Williams Abdominal Exercise


Williams flexion exercises (WFE) — also called Williams lumbar flexion exercises or simply Williams exercises — are a set or system of related physical exercises intended to enhance lumbar flexion, avoid lumbar extension, and strengthen the abdominal and gluteal musculature in an effort to manage low back pain non-surgically. It also stretches the erector spinae, hamstring, and tensor fasciae latae muscles and iliofemoral ligament. The system was first devised in 1937 by Dr. Paul C. Williams, then a Dallas orthopedic surgeon.


The WFEs were developed out of the Regen exercise (also called “squat exercise”), advocated in the 1930s by Eugene M. Regen, a Tennessee orthopedic surgeon, and which consist in squatting and emphasizing the convexity of the lumbar area. Williams first published his own modified exercise program in 1937 for patients with chronic low back pain in response to his clinical observation that the majority of patients who experienced low back pain had degenerative vertebrae secondary to degenerative disk disease. These exercises were initially developed for men under 50 and women under 40 who had exaggerated lumbar lordosis, whose x-ray films showed decreased disc space between lumbar spine segments (L1-S1), and whose symptoms were chronic, but low grade.


Williams believed that the basic cause of all pain is the stress induced on the inter-vertebral disc by poor posture. He theorized that the lordotic lumbar spine placed inordinate strain on the posterior elements of the inter-vertebral disc and caused its premature dysfunction. He was concerned about the lack of flexion in daily activities in the accumulation of extension forces that hurt the disc.


The goals of these exercises are to open the intravertebral foramina and stretch the back extensors, hip flexors, and facets; to strengthen the abdominal and gluteal muscles; and to mobilize the lumbosacral junctions. And also reduce pain and provide lower trunk stability.


Williams said: “The exercises outlined will accomplish a proper balance between the flexor and the extensor groups of postural muscles…”. Williams suggested that a posterior pelvic-tilt position was necessary to obtain best results.

Both flexion and extension exercises have been shown to help reduce back pain and has been demonstrated to accomplish the following: a) significantly increase the canal area, b) increase the midsagittal diameter, c) increase the subarticular sagittal diameter, and d) increase all the foraminal dimensions significantly.


These exercises were performed in the supine position on a floor or other flat surface. There were variations, but the primary maneuver is to grab the legs and pull the knees up to the chest and hold them there for several seconds. The patient then relaxes, drops the legs down and repeats the exercise again. The primary benefit is supposed to be the opening of the intervertebral foramen, the stretching of ligmentous structures, and the distraction of the apophyseal joints.

Seven of the variations of the WFEs are outlined below :

  1. Pelvic tilt – Lie on your back with knees bent, feet flat on floor. Flatten the small of your back against the floor, without pushing down with the legs. Hold for 5 to 10 seconds. Pelvic tilt exercises strengthen muscles that support your low back.


            Pelvic Tilt

2. Single Knee to chest – Lie on your back with knees bent and feet flat on the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the knee and repeat with the other knee.

      single knee chest3. Double knee to chest – Begin as in the previous exercise. After pulling right knee to chest, pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly your lower one leg at a time. Knee to chest stretches improve flexibility in your low back.


 Double knee chest

4. Partial sit-up – Do the pelvic tilt (exercise 1) and, while holding this position, slowly curl your head and shoulders off the floor. Hold briefly. Return slowly to the starting position. Partial sit-ups strengthen the upper and lower abdominal muscles at the same time.


                                                                            Partial sit up

5.Hamstring stretch – Start in long sitting with toes directed toward the ceiling and knees fully extended. Slowly lower the trunk forward over the legs, keeping knees extended, arms outstretched over the legs, and eyes focus ahead. The hamstring stretch improves flexibility of the muscles along the back of your thighs.


Hamstring stretching

6. Hip Flexor stretch – Place one foot in front of the other with the left (front) knee flexed and the right (back) knee held rigidly straight. Flex forward through the trunk until the left knee contacts the axillary fold (arm pit region). Repeat with right leg forward and left leg back. The hip flexor muscles are located at the front of your hips. These muscles are often tight, particularly if you sit a lot during the day. It improves hip flexibility.

Hip flexor stretching

7. Squat – Stand with both feet parallel, about shoulder’s width apart. Attempting to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet flat on the floor, the subject slowly lowers his body by flexing his knees. The squat exercise strengthens muscles in your hips. Perform this exercise near a sturdy surface if you have difficulty with your balance.

wall sqat

McKenzie Technique


Many people spend long periods of time in a seated position. Being seated promotes a flexed spinal posture which, according to back expert and author Stuart McGill, can cause intervertebral discs to bulge outwards resulting in pain and inhibited spinal extension. McKenzie’s exercise series is designed to encourage the displaced disc to move back into its correct position which will alleviate the pain and allow freer spinal movement.

The McKenzie method is a classification system and a classification-based treatment for patients with low back pain. A acronym for the McKenzie method is mechanical diagnosis and therapy (MTD). The McKenzie method was developed in 1981 by Robin McKenzie, a physical therapist from New Zealand.

The aims of the therapy are: reducing pain, centralization of symptoms (symptoms migrating into the middle line of the body) and the complete recovery of pain. The prevention step consists of educating and encouraging the patient to exercise regularly and self-care.


Posture syndrome

Refers to pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures.

Dysfunction syndrome

Refers to pain which is a result of mechanical deformation of structurally impaired tissues like scar tissue or adhered or adaptively shortened tissue.

Derangement syndrome

Refers to pain which is caused by a disturbance in the normal resting position of the affected joint surfaces.
This syndrome is classified in two groups:

Irreducible derangement

The criteria for derangement are present.
No strategy is capable to produce a permanent change in symptoms.

Reducible derangement

Shows one direction of repeated movement which decreases or centralizes referred symptoms / preferred direction.

Other or non-mechanical syndrome

  • Spinal stenosis
  • Hip disorders
  • Sacroiliac disorders
  • Low back pain in pregnancy
  • Spondylolysis and spondylolisthesis


McKenzie’s exercises are designed to reposition any displaced intervertebral discs. This is initially done by using gravity to draw the discs back into the spine and then actively to consolidate the effect of gravity. To facilitate disc movement, you must relax as much as possible when performing the exercises and maintain relaxed and even breathing for the duration of the exercise. McKenzie’s exercises can be categorized as either passive or active and the passive exercises should always be performed first.


1. Lying Prone

The patient takes place at the treatment table in prone position. The arms have to be parallel with the thorax, with the hands next to the pelvis. The head is turned to one side. This position creates automatically a lordosis of the lumbar spine. Although this position may be painful, the pain does not indicate the procedure is undesirable if it is felt centrally.
Patients with posterior derangement should be careful when arising from the position to standing. It is important that, while arising, the restored lordosis is maintained.
In any kind of derangement it is important to perform the exercise long enough (5-10 minutes) for the fluid to alter its position anteriorly.
For example patients with lumbar kyfosis, it is possible that the patients cannot tolerate the prone position unless they are lying over a few pillows.


   prone lying


2. Extension in Lying

The patient lies on his abdomen while the hands are placed near the shoulders. The hands are placed with the palms down. Now the patient makes a press-up movement with straight arms. The Pelvis stays near the table while the patient presses the thorax upwards. After this movement the patient returns to his starting position and repeats this exercise 10 times.
The aim of this exercise is to make the lumbar spine relax after the maximum extension, in the relaxation phase.
It is possible that there occurs central low back pain described as a strain pain, but it will gradually wear off.
This procedure is the most important and effective in the treatment of derangement as well as extension dysfunction.

extension on elbow


extention on hand








3. Standing Lumbar Extension

The patient stands up straight with his feet apart, to remain a stable position. The hands are placed on the lumbar region, in the area of the spina iliaca posterior superior. His hands fixate the pelvis while the patient leans backwards. The patient has to lean backwards as far as possible.
It is used mainly in preventing future back problems once your acute pain has resolved. It can also be used as an alternative to prone press ups if social situations don’t allow you to lie flat on the floor and exercise, but you need to extend your spine to manage your back pain.

extension in standing

4. The Flexion Rotation Exercise for Low Back Pain

To do the exercise, lie on your side (typically on the side with the most pain), and bend your knees. Straighten your bottom leg, and tuck your top foot behind your bottom knee. Slowly reach your upper hand to your shoulder blade, and rotate your spine by moving your top shoulder back and towards the floor. Repeat the exercise for 10 repetitions.
If you have tried the press up with hips off center and the standing side glide exercise and are still having symptoms, you may want to move on to the flexion rotation stretch for low back pain. This stretch can be done to treat back pain on one side or pain that is traveling down your leg.

Self-treatment exercises

Rest position for cold pack
standing back extension
Pelvic side shift

This exercise is called a “mirror exercise” and can be helpful when you have a “blocked” back and you’re leaning to one side because of it. The patient has to lean with his upper body against the wall, while his feet take same distance from the wall. Now the patient has to move his pelvis against the wall and back to the beginning position. This exercise has to be repeated 8-10 times.

Proprioceptive Neuromuscular Facilitation(PNF)


Flexibility is key for athletes and nonathletes alike. It allows you to move freely and comfortably in your daily life, and can also help prevent injury during exercise. One of the best ways to increase your flexibility is by stretching. However, research suggests that not all stretching techniques are created equal. Proprioceptive neuromuscular facilitation (PNF) stretching relies on reflexes to produce deeper stretches that increase flexibility.

Proprioceptive Neuromuscular Facilitation (PNF) is a more advanced form of flexibility training that involves both the stretching and contraction of the muscle group being targeted.

According to the International PNF Association, PNF stretching was developed by Dr. Herman Kabat in the 1940s as a means to treat neuromuscular conditions including polio and multiple sclerosis.

PNF stretching was originally developed as a form of rehabilitation, and to that effect it is very effective. It is also excellent for targeting specific muscle groups, and as well as increasing flexibility, it also improves muscular strength.


Certain precautions need to be taken when performing PNF stretches as they can put added stress on the targeted muscle group, which can increase the risk of soft tissue injury. To help reduce this risk, it is important to include a conditioning phase before a maximum, or intense effort is used.

Also, before undertaking any form of stretching it is vitally important that a thorough warm up be completed. Warming up prior to stretching does a number of beneficial things, but primarily its purpose is to prepare the body and mind for more strenuous activity. One of the ways it achieves this is by helping to increase the body’s core temperature while also increasing the body’s muscle temperature. This is essential to ensure the maximum benefit is gained from your stretching. Click here for a detailed explanation of how, why and when to perform your warm up.


While there are multiple PNF stretching techniques, all of them rely on stretching a muscle to its limit. Doing this triggers the inverse myotatic reflex, a protective reflex that calms the muscle to prevent injury.
“PNF causes the brain to go ‘I don’t want that muscle to tear’ and sends a message to let the muscle relax a little more than it would normally,” says fasciologist Ashley Black.
PNF is a stretching technique utilized to increase ROM and flexibility. PNF increases ROM by increasing the length of the muscle and increasing neuromuscular efficiency.


Revarsal of Antagonists:

A group of techniques that allow for agonist contraction followed by antagonist contraction without pause or relaxation.

  • Dynamic Reversals (Slow Reversals): Utilizes isotonic contractions of first agonists, then antagonists performed against resisitance . Contraction of stronger pattern is selected first with progression to weaker pattern. The limb is moved through full range of motion.
    Indications Impaired strength and coordination between agonist and antagonist, limitations in range of motion, fatigue.
  • Stabilizing Reversals: Utilizes alternating isotonic contractions of first agonists, then antagonists against resistance, allowing only very limited range of motion.
    Indications Impaired strength, stability and balance, coordination.

Rhythmic Stabilization (RS):

Utilizes alternating isometric contractions of first agonists, then antagonists against resistance; no motion is allowed .
Indications Impaired strength and coordination, limitations in ROM; impaired stabilization control and balance.

Repeated Contractions, RC (Repeated stretch):

Repeated isotonic contractions from the lengthened range, induced by quick stretches and enhanced by resistance; performed through the range or part of range at a point of weakness. Technique is repeated (i.e.,three or four stretches) during one pattern or until contraction weakens.
Indications Impaired strength, initiation of movement, fatigue and limitation in active ROM.

Rhythmic Initiation (RI):

Voluntary relaxation followed by passive movements progressing to active assisted and active resisted movements to finally active movements. Verbal commands are used to set the speed and rhythem of the movements. Light tracking is used during the resistive phase to facilitate movement.
Indications Inability to relax, hypertonicity (spasticity, rigidity); difficulty initiating movement; motor planning deficits (apraxia or dyspraxia); motor learning deficits; communication deficits (aphasia).


One PNF technique that Black says can trigger the reflex is commonly called “hold-relax.” This involves:

Putting a muscle in a stretched position and holding for a few seconds.
Contracting the muscle without moving (also called isometric), such as pushing gently against the stretch without actually moving. This is when the reflex is triggered and there is a “6- to 10-second window of opportunity for a beyond ‘normal’ stretch,” Black says.
Relaxing the stretch, and then stretching again while exhaling. This second stretch should be deeper than the first.


Another common PNF technique is the contract-relax stretch. It is almost identical to hold-relax, except that instead of contracting the muscle without moving, the muscle is contracted while moving. This is sometimes called isotonic stretching.

For example, in a hamstring stretch, this could mean a trainer provides resistance as an athlete contracts the muscle and pushes the leg down to the floor.


A third technique, hold-relax-contract, is similar to hold-relax, except that after pushing against the stretch, instead of relaxing into a passive stretch, the athlete actively pushes into the stretch.

For example, in a hamstring stretch, this could mean engaging the muscles to raise the leg further, as the trainer pushes in the same direction.

Regardless of technique, PNF stretching can be used on most muscles in the body, according to Black. Stretches can also be modified so you can do them alone or with a partner.

Rhythmic Rotation

Relaxation is achieved with slow, repeated rotation of a limb at a point where limitation is noticed. As muscles relax the limb is slowly and gently moved into the range. As a new tension is felt, RRo is repeated. The patient can use active movements (voluntary efforts) for RRo or the therapist can perform RRo passively. Voluntary relaxation when possible is important.
Indications Relaxation of excess tension in the muscles (hypertonia) combined with PROM of the range-limiting muscles.

To that end, PNF Techniques have broad applications in treating people with neurologic and musculoskeletal conditions, most frequently in rehabilitating the knee, shoulder, hip and ankle.










  • The PNF exercise patterns involve three components: flexion-extension, abduction-adduction, and internal-external rotation.
  • The patterns mimic a diagonal rotation of the upper extremity, lower extremity, upper trunk, and neck.
  • The pattern activates muscle groups in the lengthened or stretched positions.
  • The upper and lower extremities each have two patterns: D1 and D2 motions targeting flexion and extension.
  • The patterns are used to improve range of motion at the joint as well as introduce resistance training. This will help improve the patients strength.

Upper Extremity
D1 Flexion

  D1 Flexion

Starting Position
Shoulder extended, abducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers extended

Hand Position
Hand placed in patient’s palm so that patient can grip and flex wrist to radial side
hand on the Anterior-medial surface of the patient’s arm just above elbow

Movements to End Position 
Shoulder flexed, adducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers flexed

D1 Extension

D1 extension

Starting Position
Shoulder flexed, adducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers flexed

Hand Position
Hand over dorsal-ulnar aspect of the patient’s hand
hand on he posterior-lateral surface of patient’s arm just above elbow

Movement to Ending Position
Shoulder extended, abducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers extened

D2 Flexion

D2 flexion

Starting Position
Shoulder extended, adducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers flexed

Hand Position
Hand over dorsal-ulnar aspect of the patient’s hand
Hand on anterior-lateral surface of the patient’s arm just above elbow

Movements to End Position
Shoulder flexed, abducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers extended

D2 Extension

D2 extension

Starting Position
Shoulder flexed, abducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers extended

Hand Position
Hand placed in the patient’s palm so that the patient can grip and flex wrist to the ulnar side
Hand on posterior-medial surface of the patient’s arm just above elbow

Moving to Ending Position
Shoulder extended, adducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers flexed

Lower Extremity
D1 Flexion

D1 Flexion

Starting Position
Hip extended, abducted, and internally rotated
Ankle plantarflexed
Foot everted
Toes flexed

Hand Position
Hand on distal anterior-medial aspect of thigh
Hand on medial aspect of dorsal surface of foot

Movements to Ending Position
Hip flexed, adducted, and externally rotated
Ankle dorsiflexed
Foot inverted
Toes extended

D1 Extension

D1 extension

Starting Position
Hip flexed, adducted, and externally rotated
Ankle dorsiflexed
Foot inverted
Toes extended

Hand Position
Hand on distal posterior-lateral thigh
Hand on lateral aspect of plantar surface of the foot

Movements to Ending Position
Hip extended, abducted, and internally rotated
Ankle plantarflexed
Foot everted
Toes flexed

D2 Flexion

D2 flexion

Starting Position
Hip extended, adducted, and externally rotated
Ankle plantarflexed
Foot inverted
Toes flexed

Hand Position
Hand on distal anterior-lateral thigh
Hand on lateral aspect of dorsal surface of the foot

Movements to Ending Position
Hip flexed, abducted, and internally rotated
Ankle dorsiflexed
Foot everted
Toes Extended

D2 Extension

D2 extension

Starting Position
Hip flexed, abducted, and internally rotated
Ankle dorsiflexed
Foot everted
Toes Entended

Hand Position
Hand on distal posterior-medial thigh (wrapped around posterior aspect of femur)
Hand on medial aspect of plantar surface of the ball of the foot

Movements to Ending Position
Hip extended, adducted, and externally rotated
Ankle Plantarflexed
Foot inverted
Toes flexed

Frankele’s Co-Ordination Exercise in Ataxia :



Cerebellum And Brain 

Definition of coordination Exercises:

It is the ability to execute smooth, accurate, controlled motor responses (optimal interaction of muscle function).

Coordination is the ability to select the right muscle at the right time with proper intensity to achieve proper action.
Coordinated movement is characterized by appropriate speed, distance, direction, timing and muscular tension.
It is the process that results in activation of motor units of multiple muscles with simultaneous inhibition of all other muscles in order to carry out a desired activity

Importance of the cerebellum in coordination ;

The cerebellum is the primary center in the brain for coordination of movement.

Components of coordinated movement:

Volition: is the ability to initiate,maintain or stop an activity or motion.
Perception:in tact proprioception and subcortical centres to integrate motor impulses and the sensory feedback. When proprioception is affected it is compensated with visual feedback.
Engramformation:is the neurologica lmuscular activity developed in the extrapyramidal system. Research proved that high repetitions of precise performance must be performed in order to develop an engram
Types of coordination:

1) Fine motor skills:

Require coordinated movement of small muscles (hands, face).
Examples: include writing, drawing, buttoning a shirt, blowing bubbles

2) Gross motor skills:

Require coordinated movement of large muscles or groups of muscles (trunk, extremities).
Examples: include walking, running, lifting activities.

3)Hand-eye skills:

The ability of the visual system to coordinate visual information. Received and then control or direct the hands in the accomplishment of a task .
Examples : include catching a ball,sewing,computer mouse use.

Causes of coordination impairments , Causes of Ataxia

Degeneration, damage or loss of nerve cells in the cerebellum, which is that part of the brain that controls muscle coordination, causes ataxia. The cerebellum comprises of two small ball-shaped folded tissues present at the base of the brain near the brainstem. Diseases which damage the spinal cord and peripheral nerves which connect the cerebellum to the muscles can also cause ataxia
Other causes of ataxia include:

Stroke is a condition where the blood supply to a part of the brain gets severely diminished or interrupted, which deprives the brain tissue of oxygen and other nutrients resulting in death of brain cells.

Trauma or injury to the head, which causes damage to the brain or spinal cord, can cause sudden-onset ataxia (acute cerebellar ataxia).

Chickenpox can result in a complication in the form of Ataxia; although this is not common. Ataxia can appear during the healing stages of the infection and persist for days to weeks and gradually resolve over the time.

Transient ischemic attack (TIA) is caused by a temporary reduction in blood supply to a part of the brain. Majority of the TIAs last only for a few minutes. Some of the symptoms of TIA include ataxia, which is temporary.

Multiple sclerosis is a chronic, potentially debilitating medical condition, which affects the central nervous system.

Cerebral palsy consists of a group of disorders, which occurs as a result of damage to a child’s brain during its early development. It can be before, during or shortly after birth. It affects the ability to coordinate movements of the body.

Paraneoplastic syndromes are rare, degenerative disorders, which are triggered by the response of the immune system to a tumor or neoplasm. This tumor is commonly in the lungs, ovaries, lymph nodes or breast. Patient can experience ataxia many months or years before cancer is actually diagnosed.

Toxic reaction to some medications can also cause ataxia. Medicines, especially barbiturates and certain sedatives, like benzodiazepine, can cause ataxia as a side effect. Other things, which could cause toxic reactions, are heavy metal poisoning, alcohol and drug intoxication and solvent poisoning.

Any type of growth on the brain, either cancerous or noncancerous, can damage cerebellum and cause ataxia.

Deficiency of vitamin E or B-12 can also lead to ataxia.

No specific cause can be found for some adults who develop sporadic ataxia, also known as sporadic degenerative ataxia, which can be of many types, such as multiple system atrophy which is a progressive and degenerative disorder.

test UL
Finger to Nose Test

Examples of coordination tests:

1) In the upper limb:

A) Finger-to-nose test

The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring tip of the index finger to the tip of nose.Finger to therapist finger: the patient and the therapist site opposite to each other, the therapist index finger is held in front of the patient, the patient is asked to touch the tip of the index finger to the therapist index finger.

B) Finger-to-finger test

Both shoulders are abducted to bring both the elbow extended, the patient is asked to bring both the hand toward the midline and approximate the index finger from opposing hand

C) Finger-to-doctor’s finger test

the patient alternately touch the tip of the nose and the tip of the therapist’s finger with the index finger.

D) Adiadokokinesia or dysdiadokokinesia:

The patient asked to do rapidly alternating movement e.g. forearm supination and pronation, hand tapping.

E) Rebound phenomena:

The patient with his elbow fixed, flex it against resistance. When the resistance is suddenly released the patient’s forearm flies upward and may hit his face or shoulder.

F) Buttoning and unbuttoning test.

In any of the previous tests, we may find:

Intention tremors and Decomposition of movements
Dysmetria: in the form of hypermetria or hypometria

2) In the lower limb

A) Heel-to-knee test

heel to shin test
Heel To Knee Test in Lower Limb

B) Walking along a straight line. Foot close to foot:In case of cerebellar lesion, there is deviation of gait

C) Rom-berg test: Ask the patient to stand with heels together. Swaying or loss of balance occurs while his eyes are open or closed.

General principles of coordination exercises involve:

Constant repetition of a few motor activities
Use of sensory cues (tactile, visual,proprioceptive) to enhance motor performance
Increase of speed of the activity over time
Activities are broken down into components that are simple enough to be performed correctly.
Assistance is provided when ever necessary.
The patient there fore should have a short rest after two or three repetitions,to avoid fatigue.
High repetition of precise performance must be performed for the engram to form.
When ever a new movement is trained, various inputs are given, like instruction(auditory), sensory stimulation(touch) ,or positions in which the patient can view the movement (visual stimulation) to enhance motor performance.

Therapeutic exercises used to improve coordination:

Frenkel’s exercises
Proprioceptive Neuromuscular Facilitation
Neurophysiological Basis of Developmental techniques
Sensory Integrative Therapy


hand eye coordination
Co-ordination Exercise

Frenkel aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.

The process of learning this alternative method of control is similar to that required to learn any new exercise,

the essentials being: Concentration of the attention, Precision and Repetition

The ultimate aim is to establish control of movement so that the patient is able and confident in his ability to carry out these activities which are essential for independence in everyday life.

They are a system of slow repetitious exercises. They increase in difficulty over the time of the program. The patient watches his hand or arm movements (for example) and corrects them as needed.

Although the technique is simple, needs virtually no exercise equipment, and can be done on one’s own, concentration and some degree of perseverance is required. Research has shown that 20,000 to 30,000 repetitions may be required to produce results. A simple calculation will show that this can be achieved by doing 60 repetitions every hour for six weeks in a 16-hour daily waking period. The repetitions will take just a few minutes every hour.

The brain as a whole learns to compensate for motor deficits in the cerebellum (or the spinal cord where applicable). If the ataxia affects say, head movements, the patient can use a mirror or combination of mirrors to watch their own head movements.


Best Physiotherapy Exercises for In-Coordination–Frenkel’s Exercises :

Frenkel Exercises are a series of motions of increasing difficulty performed by ataxic patients to facilitate the restoration of coordination. Frenkel’s exercises are used to bring back the rhythmic, smooth and coordinated movements.


Dr. H S Frenkel was a physician from Switzerland who aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.

Frenkel Exercises were originally developed in 1889 to treat patients of tabes dorsalis and problems of sensory ataxia owing to loss of proprioception. These exercises have been applied in the treatment of individuals with ataxia, in particular cerebellar ataxia. The exercises are performed in supine, sitting, standing and walking. Each activity is performed slowly with the patient using vision to carefully guide correct movement. These exercises require a high degree of mental concentration and effort. For those patients with the prerequisite abilities, they may be helpful in regaining control of movement through cognitive compensation strategies. Patients with partial sensation can progress to practicing exercises with eyes closed. The main principles of Frenkel exercises are the following:

Concentration or attention

This program consists of a planned series of exercises designed to help patient compensate for the inability to tell where the arms and legs are- in space without looking.

1. Exercises are designed primarily for coordination; they are not intended for strengthening.
2. Commands should be given in an event, slow voice; the exercises should be done to counting.
3. It is important that the area is well lit and that patients are positioned so that they can watch the movement of their legs.
4. Avoid fatigue. Perform each exercise not more than four times. Rest between each exercise.
5. Exercises should be done within normal range of motion to avoid over-stretching of muscles.
6. The ?rst simple exercises should be adequately performed before progressing to more dif?cult patterns.

General Instructions for frenkel exercises

Exercises can be performed with the part supported or unsupported, unilaterally or bilaterally.
They should be practiced as smooth, timed movements, performed at a slow, even tempo by counting out loud.
Consistency of performance is stressed and a specified target can be used to determine range.
Four basic positions are used: lying, sitting, standing and walking.
The exercises progress from postures of greatest stability (lying, sitting) to postures of greatest challenge (standing, walking).
As voluntary control improves, the exercises progress to stopping and starting on command, increasing the range and performing the same exercises with eyes closed.
Concentration and repetition are the keys to success.

Frenkel exercises for lower limb

Exercises for the legs in lying

Flex and extend one leg by the heel sliding down a straight line on the table.
Abduct and adduct hip smoothly with knee bent and heel on the table.
Abduct and adduct leg with knee and hip extended by sliding the whole leg on the table.
Flex and extend hip and knee with heel off the table.
Flex and extend both the legs together with the heel sliding on the table.
Flex one leg while extending the other.
Flex and extend one leg while taking the other leg into abduction and adduction.
Heel of one limb to opposite leg (toes, ankle, shin, patella).
Heel of one limb to opposite knee, sliding down crest of tibia to ankle.

Whether the patient slides the heels or lifts it off the bed he has to touch it to the marks indicated by the patient on the plinth. The patient may also be told to place the heel of one leg on various points of the opposite leg under the guidance of the therapist.
Exercises for the legs in Sitting

One leg is stretched to slide the heel to a position indicated by a mark on the floor.
The alternate leg is lifted to place the heel on the marked point.
From stride sitting posture patient is asked to stand and then sit.
Rise and sit with knees together.
Sitting hip abduction and adduction.

Exercises for the legs in Standing

In stride standing weight is transferred from one foot to other.
Place foot forward and backward on a straight line.
Walk along a winding strip.
Walk between two parallel lines
Walk sideways by placing feet on the marked point.
Walk and turn around
Walk and change direction to avoid obstacles.


Frenkel exercises for upper limb :

Similar exercises can be devised for the upper limb wherein the patient may be directed to place the hand on the various points marked on the table or wall board to improve coordination of all the movements in the upper limb.
Some examples of Frankel exercises of upper limb in sitting position

Have patient sit in front of a table and place a number of objects on the table. The patient then touches each object with the right hand and then the left hand.
The patient flexes the right shoulder to 90 degree with elbow and wrist extended. The patient then takes his or her right index finger and touches the tip of his or her nose. This exercise is then repeated with the left hand. The exercise is performed alternating right and left index finger.
The patient taps bilateral hands on bilateral thighs while alternating palmer and dorsal surfaces as fast as possible.

Certain diversional activities such as building with toy bricks or drawing on a black board, buttoning, combing, writing, typing are some of the activities that also improves the coordination.


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