Chapter 5: Interventions to Improve Prone on Elbows and Quadruped Skills

INTRODUCTION

This chapter describes activities, strategies, and techniques to improve prone-on-elbows and quadruped (all fours) skills. In addition to being functional for positional changes (e.g., bed mobility, transfers) and locomotion (crawling), these postures provide an opportunity to facilitate and progress motor control goals within the context of motor task requirements: transitional mobility, stability, controlled mobility, and skill. A description of the general characteristics of each posture is provided. Interventions are organized by specific motor control goals: acquisition of mobility, stability, and controlled mobility functions. Patient outcomes consistent with the Guide to Physical Therapist Practice¹ are described, together with clinical applications and patient examples.

Interventions to improve prone and quadruped skills typically follow interventions performed in sidelying and rolling (see Chapter 4: Interventions to Improve Bed Mobility and Early Trunk Control). Descriptions of the proprioceptive neuromuscular facilitation (PNF) principles, extremity patterns, and techniques^2,3 discussed in this chapter are presented in Chapter 3: Proprioceptive Neuromuscular Facilitation. Practice strategies critical to motor learning and achieving the motor control goals presented in this chapter as well as techniques to facilitate, activate, or inhibit muscle contraction (e.g., resistance, quick stretch, prolonged stretch, approximation, traction) are addressed in Chapter 2: Interventions to Improve Motor Function. For additional content on motor control and motor learning concepts, the reader is referred to the work of Schmidt et al.,⁴ Shumway-Cook and Woollacott,⁵ and O’Sullivan.⁶

PRONE ON ELBOWS

General Characteristics

The prone-on-elbows posture is very stable, with a large base of support (BOS) and low center of mass (COM). The patient is prone with the head and upper trunk elevated off the supporting surface, bearing weight on the elbows. The upper extremities (UEs) are in a bilateral symmetrical position with the elbows flexed to 90 degrees and positioned under the shoulders, while the forearms are in neutral position. The lower body remains in contact with the supporting surface. The prone-on-elbows posture can be used to improve control at the head/neck, upper trunk, and UEs in addition to shoulder stability, trunk mobility and stability, and hip extension range of motion (ROM). It is an important lead-up activity for independent positional changes, quadruped activities, and floor-to-stand transfers.

Despite the large BOS and low COM, the prone-on-elbows position is inherently challenging to stability and controlled mobility. In prone on elbows, weight is borne through the humerus into the glenohumeral joint, requiring stability of the glenohumeral, scapula-thoracic, and head and neck segments. Controlled mobility in prone on elbows (weight shifting side to side, weight shifting with rotation of cervical and thoracic spine) requires efficient reciprocal inhibition for agonist/antagonist control of the ...