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MUHAMMED KOCABIYIK

PHYSICAL MEDICINE & REHABILITATION IV. CLASS V. GROUP

Introduction and Basic Procedures


Upper extremity patterns are used to treat dysfunction

caused by neurologic problems, muscular disorders or joint restrictions. These patterns are also used to exercise the trunk. Resistance to strong arm muscles produces irradiation to weaker muscles elsewhere in the body. We can use all the techniques with the arm patterns. The choice of individual techniques or combinations of techniques will depend on the patients condition and the treatment goals. You can, for instance, combine Dynamic Reversals with Combination of Isotonics, Repeated Contractions with Dynamic Reversals, or, Contract-Relax or Hold- Relax with Combination of Isotonics and Dynamic Reversals.

Diagonal Motion
The upper extremity has two diagonals:
1. Flexionabductionexternal rotation and

extensionadductioninternal rotation

2. Flexionadductionexternal rotation and

extensionabductioninternal rotation

Flex.-Add.-ER Supination Radial abduction Palmar flexion Finger flexion

Adduction

finger

Flex.-Abd.-ER Supination Radial abduction Dorsal extension Finger extension Abduction finger
Ext.-Abd.-IR Pronation Ulnar abduction Dorsal extension Finger extension Abduction finger

Ext.-Add.-IR Pronation Ulnar abduction Palmar flexion Finger flexion Adduction finger

Patient Position
Support the patients head

Therapist Position
All grips described in the first part of each section assume that the therapist is in this position. We give the basic position and body mechanics for exercising the straight arm pattern. When we describe variations in the patterns we identify any changes in position or body mechanics. The therapists position can vary within the guidelines for the basic procedures.

and neck in a comfortable position, as close to neutral as possible. Before beginning an upper extremity pattern, visualize the patients arm in a middle position where the lines of the two diagonals cross. Starting with the shoulder and forearm in neutral rotation, move the extremity into the elongated range of the pattern with the proper rotation, beginning with the wrist and fingers.

Resistance The direction of the resistance is an arc back toward the starting

position. The angle of the therapists hands and arms changes as the limb moves through the pattern. Traction and Approximation Traction and approximation are an important part of the resistance. Use traction at the beginning of the motion in both flexion and extension. Use approximation at the end of the range to stabilize the arm and scapula. Normal Timing and Timing for Emphasis Normal Timing The hand and wrist (distal component) begin the pattern, moving through their full range. Rotation at the shoulder and forearm accompanies the rotation (radial or ulnar deviation) of the wrist. After the distal movement is completed, the scapula moves together with the shoulder or shoulder and elbow through their range. The arm moves through the diagonals in a straight line with rotation occurring smoothly throughout the motion. Timing for Emphasis In the sections on timing for emphasis we offer some suggestions for exercising components of the patterns. Any of the techniques may be used. We have found that Repeated Stretch (Repeated Contractions) and Combination of Isotonics work well. Do not limit yourself to the exercises we suggest in this section, use your imagination.

Stretch
In the arm patterns we use stretch-stimulus with or without the

stretch reflex to facilitate an easier or stronger movement, or to start the motion. Repeated Stretch (Repeated Contractions) during the motion facilitates a stronger motion or guides the motion into the desired direction. Repeated Stretch at the beginning of the pattern is used when the patient has difficulty initiating the motion and to guide the direction of the motion. To get the stretch reflex the therapist must elongate both the distal and proximal components. Be sure you do not overstretch a muscle or put too much tension on joint structure. This is particularly important with the wrist joint.

Irradiation and Reinforcement


We can use strong arm patterns (single or bilateral) to get

irradiation into all other parts of our body. The patients position in combination with the amount of resistance controls the amount of irradiation. We use this irradiation to strengthen muscles or mobilize joints in other parts of the body, to relax muscle chains, and to facilitate a functional activity such as rolling.

Flexion Abduction External Rotation


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Trapezius, levator scapulae, serratus anterior Deltoid (anterior), biceps (long head), coracobrachialis, supraspinatus, infraspinatus, teres minor Triceps, anconeus Biceps, brachioradialis, supinator

Scapula Shoulder

Posterior elevation Flexion, abduction, external rotation Extended (position unchanged) Supination

Elbow Forearm

Wrist
Fingers Thumb

Radial extension
Extension, radial deviation Extension, abduction

Extensor carpi radialis (longus and brevis)


Extensor digitorum longus, interossei Extensor pollicis (longus and brevis), abductor pollicis longus

c
Flexionabductionexternal rotation. a Starting position; b mid-position; c end position; d emphasizing the motion of the shoulder. e Patient with right hemiplegia. Flexionabduction external rotation: proximal hand for scapula posterior elevation and trunk elongation

Hand positions
Distal Hand

Your right hand grips the dorsal surface of the patients

hand. Your fingers are on the radial side (1st and 2nd metacarpal), your thumb gives counter pressure on the ulnar border (5th metacarpal).There is no contact on the palm.

Proximal Hand

From underneath the arm, hold the radial and ulnar sides

Movements

of the patients forearm proximal to the wrist. The lumbrical grip allows you to avoid placing any pressure on the anterior (palmar) surface of the forearm.

The fingers and thumb extend as the wrist moves into radial

extension. The radial side of the hand leads as the shoulder moves into flexion with abduction and external rotation. The scapula moves into posterior elevation. Continuation of this motion is an upward reach with elongation of the left side of the trunk.

Flexion Abduction External Rotation with Elbow Flexion


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Biceps, brachialis

Elbow

Flexion

Flexion abduction external rotation with elbow flexion. ac Usual position of the therapist; d, e alternative position with therapist on the other side of the table ,f Patient with hemiplegia, the patient is asked to touch his head

Flexion Abduction External Rotation with Elbow Extension


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Triceps, anconeus

Elbow

Extension

Flexion-abduction-external rotation with elbow extension. a, b Standard grips; c Grip variation

Extension Adduction Internal Rotation


Joint Movement Muscles: principal components (Kendall and McCreary 1993)
Serratus anterior (lower), pectoralis minor, rhomboids Pectoralis major, teres major, subscapularis Triceps, anconeus Brachioradialis, pronator (teres and quadratus) Flexor carpi ulnaris

Scapula Shoulder Elbow Forearm Wrist

Anterior depression Extension, adduction, internal rotation Extended (position unchanged) Pronation Ulnar flexion

Fingers Thumb

Flexion, ulnar deviation Flexion, adduction, opposition

Flexor digitorum (superfi cialis and profundus), lumbricales,interossei Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis

a,b. Extension-adduction-internal rotation

Hand positions

Distal Hand Your left hand contacts the palmar surface of the

0patients hand. Your fingers are on the radial side (2nd metacarpal), your thumb gives counter-pressure on the ulnar border (5th metacarpal). There is no contact on the dorsal surface. Proximal Hand Your right hand comes from the radial side and holds the patients forearm just proximal to the wrist. Your fingers contact the ulnar border. Your thumb is on the radial border.

Movements

The fingers and thumb flex as the wrist moves into

ulnar flexion. The radial side of the hand leads as the shoulder moves into extension with adduction and internal rotation and the scapula into anterior depression. Continuation of this motion brings the patient into trunk flexion with neck flexion to the right.

Extension Adduction Internal Rotation with Elbow Extension


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Triceps, anconeus

Elbow

Extention

a-c. Extension-adduction-internal rotation with elbow extension

Extension Adduction Internal Rotation with Elbow Flexion


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Biceps, brachialis

Elbow

Flexion

Extensionadduction-internal rotation with elbow flexion. ac Standard grips; d,e grip variations
d e

Flexion Adduction External Rotation


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Serratus anterior (upper), trapezius Pectoralis major (upper) deltoid (anterior), biceps, coracobrachialis Triceps, anconeus Brachioradialis, supinator Scapula Shoulder Elbow Forearm Anterior elevation Flexion, adduction, external rotation Extended (position unchanged) Supination

Wrist
Fingers Thumb

Radial flexion
Flexion, radial deviation Flexion, adduction opposition

Flexor carpi radialis


Flexor digitorum (superfi cialis and profundus), lumbricales, interossei Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis

a,b. Flexionadductionexternal rotation

Hand positions
Distal Hand

Your right hand contacts the palmar surface of the

Proximal Hand

patients hand. Your fingers are on the ulnar side (5th metacarpal), your thumb gives counter pressure on the radial side (2nd metacarpal). There is no contact on the dorsal surface. underneath just proximal to the wrist. Your fingers are on the radial side, your thumb on the ulnar side. radial flexion. The radial side of the hand leads as the shoulder moves into flexion with adduction and external rotation and the scapula into anterior elevation. Continuation of this motion elongates the patients trunk with rotation toward the right.

Your left hand grips the patients forearm from

Movements

The fingers and thumb flex as the wrist moves into

Flexion Adduction External Rotation with Elbow Flexion


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Biceps, brachialis

Elbow

Flexion

a-c. Flexionadductionexternal rotation with elbow flexion

Flexion Adduction External Rotation with Elbow Extension


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Triceps, anconeus

Elbow

Extention

a-d. Flexion adduction external rotation with elbow extension. a, b The therapist is standing on the same side of the table; c, d the therapist is standing on the other side of the table
e e. Flexionadductionexternal rotation with elbow extension. Patient with right hemiplegia: the therapists proximal hand facilitates scapula anterior elevation and trunk elongation

Extension Abduction Internal Rotation


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Rhomboids Latissimus dorsi, deltoid (middle, posterior), triceps,teres major, subscapularis Triceps, anconeus Brachioradialis, pronator (teres and quadratus) Scapula Shoulder Posterior depression Extension, Abduction, Internal Rotation Extended (position unchanged) Pronation

Elbow Forearm

Wrist
Fingers Thumb

Ulnar extension
Extension, ulnar deviation Palmar abduction, extension

Extensor carpi ulnaris


Extensor digitorum longus, lumbricales, interossei Abductor pollicis (brevis), Extensor pollicis

a-c. Extension-abduction-internal rotation

Hand positions

Distal Hand Your left hand grips the dorsal surface of the patients

hand. Your fingers are on the ulnar side (5th metacarpal), your thumb gives counter-pressure on the radial side (2nd metacarpal). There is no contact on the palm. Proximal Hand With your hand facing the ventral surface, use the lumbrical grip to hold the radial and ulnar sides of the patients forearm proximal to the wrist.

Movements

The fingers and thumb extend as the wrist moves into ulnar

extension. The ulnar side of the hand leads as the shoulder moves into extension with abduction and internal rotation. The scapula moves into posterior depression. Continuation of this motion is a downward reach toward the back of the left heel with shortening of the left side of the trunk.

Extension Abduction Internal Rotation with Elbow Extension


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Triceps, anconeus

Elbow

Extention

h a

a-d. Extension-abduction-internal rotation with elbow extension. d Different proximal grip e-h. Extension-abduction-internal rotation with elbow extension. e-g The therapist on the opposite side of the table. h Patient with right hemiplegia: the therapist facilitates the scapula and trunk with her proximal hand

Extension Abduction Internal Rotation with Elbow Flexion


Joint Movement Muscles: principal components (Kendall and McCreary 1993) Biceps, brachialis

Elbow

Flexion

Extensionabductioninternal rotation with elbow flexion