Extension Abduction Internal Rotation o Fig 711

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Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Posterior depression

Rhomboids

Shoulder

Extension, Abduction, Internal Rotation

Latissimus dorsi, deltoid (middle, posterior), triceps, teres major, subscapularis

Elbow

Extended (position unchanged)

Triceps, anconeus

Forearm

Pronation

Brachioradialis, pronator (teres and quadratus)

Wrist

Ulnar extension

Extensor carpi ulnaris

Fingers

Extension, ulnar deviation

Extensor digitorum longus, lumbricales, interossei

Thumb

Palmar abduction, extension

Abductor pollicis (brevis), Extensor pollicis

Grip

Distal Hand

Your left hand grips the dorsal surface of the patient's 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.

! Caution

Do not squeeze the hand.

Proximal Hand

With your hand facing the ventral surface, use the lumbrical grip to hold the radial and ulnar sides of the patient's forearm proximal to the wrist.

Alternative Grip

To emphasize shoulder or scapula motions, move the proximal hand to the upper arm or to the scapula after the shoulder begins to extend.

Elongated Position

Place the wrist in radial flexion and the forearm into supination. Maintain the wrist and hand in position while you move the shoulder into flexion and adduction. Use gentle traction to bring the scapula into anterior elevation and help elongate the shoulder muscles. The humerus crosses over the patient's nose and the palm faces toward the patient's right ear. A continuation of this motion would bring the patient into trunk elongation with rotation to the right.

If the patient has just completed the antagonistic motion (flexion-adduction-external rotation), begin at the end of that pattern.

Body Mechanics

Stand in a stride position in the line of the motion facing toward the patient's hand. Start with the weight on your front foot and let the patient's motion push your weight to your back foot. Move your trunk to the right to allow the arm motion and to control the pronation with your distal grip. As the patient's arm nears the end of the range, your body turns so you face the patient's feet.

Stretch

Apply the stretch to the shoulder and hand simultaneously. Your proximal hand does a rapid traction with rotation of the shoulder and scapula. Combine this motion with traction to the wrist with your distal hand.

! Caution

Traction the wrist in line with the metacarpal bones. Do not force the wrist into more flexion.

Command

"Hand back, push your arm down to your side." "Push!"

□ Fig. 7.11a-c. Extension-abduction-internal rotation

Movement

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.

Resistance

Your distal hand combines traction through the extended wrist with a rotary resistance for the ul-nar deviation. The resistance to the forearm pronation and the shoulder internal rotation and abduc tion comes from the rotary resistance at the wrist. The traction force resists the motions of wrist and shoulder extension.

Your proximal hand combines a traction force with rotary resistance. The line of resistance is back toward the starting position.

As the patient's arm nears the end of the range of extension, both hands change from a traction to an approximation force.

End Position

The scapula is in full posterior depression. The humerus is in extension at the left side, the forearm is pronated, and the palm is facing about 45° to the lateral plane. The wrist is in ulnar extension, the fingers are extended toward the ulnar side, and the thumb is extended and abducted at right angles to the palm.

Timing for Emphasis

You may prevent motion in the beginning of the shoulder extension and exercise the wrist, hand, or fingers. This position puts the hand where the patient can see it during the exercise.

Points to Remember

Let the patient's motion do the work of pushing your weight to your back foot At the end of the range both hands change their force from traction to approximation

7.5.1 Extension - Abduction - Internal Rotation with Elbow Extension (o Fig. 7.12)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Posterior depression

Rhomboids

Shoulder

Extension, Abduction, Internal Rotation

Latissimus dorsi, deltoid (middle, posterior), triceps, teres major, subscapularis

Elbow

Extension

Triceps, anconeus

Forearm

Pronation

Brachioradialis, pronator (teres and quadratus)

Wrist

Ulnar extension

Extensor carpi ulnaris

Fingers

Extension, ulnar deviation

Extensor digitorum longus, lumbricales, interossei

Thumb

Palmar abduction, extension

Abductor pollicis (brevis), Extensor pollicis

Grip

Distal Hand

Your distal grip is the same as used for the straight arm pattern.

Proximal Hand

Wrap your hand around the humerus so your fingers can give pressure opposite the direction of internal rotation.

Alternative Grip

The proximal hand may move to the scapula to emphasize the posterior depression.

Elongated Position

The position of the scapula, shoulder, forearm, and wrist are the same as for the straight arm pattern. The patient's elbow is fully flexed.

Body Mechanics

Your body mechanics are the same as for the straight arm pattern.

Stretch

Apply the stretch to the shoulder, elbow, and hand simultaneously. The stretch of the shoulder comes from a rapid traction with rotation of the shoulder and scapula by the proximal hand. The distal hand continues giving traction to the hand and wrist while increasing the elbow supination. Stretch the elbow into more flexion if there is space.

! Caution

Traction the wrist; do not force it into more flexion.

Command

"Hand up, push your arm down toward me and straighten your elbow as you go." "Push!"

Elbow Abduction
Fig. 7.12a-d. Extension-abduction-internal rotation with elbow extension. d Different proximal grip

Fig. 7.12e-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 f

Fig. 7.12e-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 e g h

Movement

The fingers extend and the wrist moves into ul-nar extension. The shoulder begins its motion into extension-abduction, and then the elbow begins to extend. The elbow reaches full extension as the shoulder and scapula complete their motion.

Resistance

Your distal hand resists the wrist and forearm as in the straight arm pattern. Give resistance to the elbow extension by rotating the forearm and hand back toward the starting position of elbow flexion.

Your proximal hand gives traction through the humerus combined with rotary resistance back toward the starting position. When the shoulder and elbow near full extension, change from traction to approximation.

End Position

The end position is the same as the straight arm pattern.

Timing for Emphasis

Prevent elbow extension at the beginning of the range and exercise the shoulder. Prevent shoulder extension at the beginning of the range and exercise the elbow extension with pronation. Lock in the shoulder extension in mid-range and exercise both the elbow extension with pronation and the wrist ulnar extension.

Alternative Grip and Body Mechanics

The therapist can also stand at the head of the table on the opposite side. The distal grip is the same. Grip with your proximal hand around the posterior surface of the humerus from the lateral side. Face the diagonal and use your body weight for resistance.

Points to Remember

Normal timing: the shoulder and elbow extend at the same rate The rotational resistance with your distal hand facilitates the elbow and wrist extension

7.5.2 Extension - Abduction - Internal Rotation with Elbow Flexion (O Fig. 7.13)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Posterior depression

Rhomboids

Shoulder

Extension, Abduction, Internal Rotation

Latissimus dorsi, deltoid (middle, posterior), triceps, teres major, subscapularis

Elbow

Flexion

Biceps, brachialis

Forearm

Pronation

Brachioradialis, pronator (teres and quadratus)

Wrist

Ulnar extension

Extensor carpi ulnaris

Fingers

Extension, ulnar deviation

Extensor digitorum longus, lumbricales, interossei

Thumb

Palmar abduction, extension

Abductor pollicis (brevis), Extensor pollicis

Grip

Distal Hand

Your distal grip is the same as used for the straight arm pattern.

Proximal Hand

Your proximal hand may start with the grip on the forearm. As the shoulder and elbow motions begin, wrap your proximal hand around the humer-

Elbow Abduction

Fig. 7.13. Extension-abduction-internal rotation with elbow flexion

Fig. 7.13. Extension-abduction-internal rotation with elbow flexion us from underneath. Your fingers give pressure op- Body Mechanics posite the direction of rotation and resist the shoul- These are the same as for the straight arm pattern. der extension.

Alternative Grip and Body Mechanics Alternative Grip You may stand on the opposite side of the table.

You may also move your proximal hand to the scap- Face the diagonal and use your body weight for re-

ula to emphasize that motion.

Resisted Shoulder Abduction Table

Fig. 7.14a,b. Extension-abduction-internal rotation with elbow flexion: therapist at the head end of the table b a

Fig. 7.14a,b. Extension-abduction-internal rotation with elbow flexion: therapist at the head end of the table

Elongated Position

The position is the same as for the straight arm pattern.

Stretch

The stretch is the same as for the straight arm pattern.

Command

"Fingers and wrist back, push down and out and bend your elbow." "Push down and bend your elbow." If you are standing on the opposite side of the table the command is "Pull down."

Movement

The fingers extend and the wrist moves into ulnar extension. The shoulder begins its motion into extension-abduction, then the elbow begins to flex. The elbow reaches full flexion as the shoulder and scapula complete their motion.

Resistance

The distal hand gives the same resistance to the shoulder movement as in the straight arm pattern and a flexion resistance for the elbow.

At the start with the proximal hand on the forearm, it gives the same resistance as with the straight arm pattern. As soon as that hand moves to the upper arm, it gives resistance to rotation and shoulder extension. Change the traction on the humerus into approximation at the end of the movement.

End Position

The scapula is in posterior depression, the humerus in extension with abduction. The elbow is fully flexed. The wrist is again in ulnar extension and the hand open. The rotation in the shoulder and forearm are the same as in the straight arm pattern.

Timing for Emphasis

Lock in the wrist extension and elbow flexion, then exercise the shoulder in hyperextension and the scapula in posterior depression. When elbow flexion is stronger than extension, use this combination to exercise the patient's wrist and fingers.

Points to Remember

Normal timing: the shoulder and elbow complete their movements at the same time

Extend the patient's elbow, the position is the same as the straight arm pattern. Change the traction on the humerus to approximation at the end of the movement

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