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N.A.P. Exercise Program

The following introduces physiotherapeutic exercises based on the N.A.P.® therapy. These exercises can be practised alone or with the support of a therapist as well as with or without an orthosis. This text and the associated pictures present the most common mistakes and their correction.

All of the presented exercise examples are aimed to establish the best possible biomechanical situation for the patient in order to activate the muscles needed for an upright gait. For this reason, these exercises are identical for all patients despite their different gait types and orthotic fittings. 

Exercise 1: Sitting to Standing Transfer

To stabilise the lower ankle joint and the sup- porting leg.

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The patient cannot stabilise her knee when standing up. It collapses inwards.

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First, the patient has to to stabilise her foot. To do so, she needs to put it back under the chair. The therapist creates the cor- rect biomechanical situation by rotating the talus inwards with her right hand. To achieve the necessary elasticity of the calf muscles, the therapist applies lengthwise tension from the distal to the proximal direction.

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When standing up, the therapist sta- bilises the foot and supports the ventral tibial movement to allow an extension of the hip. By doing so, the plantar exors (m. peroneus longus) and m. quadriceps are activated in an eccentric way. The activity of the hip extensors and external rotators, which is needed to lift the pelvis up in a dorsal direction, is achieved by the pressure put on the tendons' origin at the tro- chanteric fossa.

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With the NEURO SWING orthosis, the patient can bring her tibia forward without help in order to extend her hip and thus bend her knee in a controlled manner.

Exercise 2: Barbell Bar

For a preactive stabilisation of the foot and the torso.

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A barbell bar forces the patient to sta- bilise her foot and torso. At rst, she cannot hold her knee in the axis.

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Pressure in the direction of the ball of the big toe and on the hip activates the entire muscle chain needed for stabilising the support- ing leg.

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The therapist’s right hand applies pres- sure in the direction of the ball of the big toe to activate the m. peroneus longus. With the ngertips of her left hand, the therapist puts the pelvis slightly up in dorsal direction. She applies pressure with her thumb via the ten- dons onset towards the acetabulum.

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When practising on her own, the patient can refer to the experience gained throughout the therapy.

Exercise 3: Ascending Sideways

To stabilise the forefoot during the transition from loading response to mid stance.

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The patient stands facing the handrail and places her a ected foot on the next higher stair tread. Due to the anterior crossing, she is forced to stabilise her forefoot. This is how she manages to bring her tibia in front of the forefoot.

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The foot stability enables her to extend her hip while ascending. This activity, plus the prolongation of the plantar exors, exerts a pull on the popliteal fossa. The patient can now extend her knee in a controlled way.

Exercise 4: Descending Sideways

To stabilise the forefoot during push off.

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The affected foot stands at the back and the patient descends, by anterior crossing of the non-affected leg, to the next lower step. This situation forces her to actively pronate her forefoot and stabilise her knee in the axis. In order to optimally activate the muscles, the therapist makes sure that the heel is lifted and the pelvis is kept centred.

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When ascending, the brain is getting a response by the precisely aimed manual tech- nique of the therapist on how to organise the forefoot stability and the controlled knee and hip extension.

Exercise 5: Descending the Stairs

To stabilise the forefoot and eccentrically control the extensor synergy.

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When descending, the mm. peronei and the long toe exors are activated by the pressure of the therapist's right hand in the direction of the ball of the big toe. The external hip rotators are activated by the therapist's left hand.

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By doing so, the patient learns to descend the stairs without any evasive move- ments of the upper ankle joint, the knee and the hip.

Exercise 6: Ascending the Stairs

To ex the knee during pre swing and initial swing.

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To avoid evasive movements when ascending the stairs, the external hip rotators are actively activated by the manual technique of the therapist. The weak knee exors are simultaneously activated by the pull applied to the lower leg.

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The hip extensors are activated by a stimulus on its tendons' onset, the ischial tuber- osity. The forward movement of the tibia to the front of the forefoot is guided by the therapist's fingertips. The control of the plantar exors is thereby enabled and a hyperextension of the knee prevented.

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Afterwards, the patient can practise descending the stairs on her own.

Exercise 7: Scooter

To achieve stabilisation during loading response, mid stance and push off.

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The affected leg stands on the scooter. The loading response of the right leg is improved by the push off of the left leg.

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The stronger leg is positioned on the scooter. The patient tries to push herself for- ward with her a ected foot.

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After the guided movement flow, the patient practises riding a scooter while the physiotherapist supports her on the handlebar.