Flexion Abduction External Rotation o

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Posterior elevation

Trapezius, levator scapulae, serratus anterior

Shoulder

Flexion, abduction, external rotation

Deltoid (anterior), biceps (long head), coracobrachialis, supraspinatus, infraspinatus, teres minor

Elbow

Extended (position unchanged)

Triceps, anconeus

Forearm

Supination

Biceps, brachioradialis, supinator

Wrist

Radial extension

Extensor carpi radialis (longus and brevis)

Fingers

Extension, radial deviation

Extensor digitorum longus, interossei

Thumb

Extension, abduction

Extensor pollicis (longus and brevis), abductor pollicis longus

□ Fig. 7.2. Flexion-abduction-external rotation. a Starting position; b mid-position; c end position; d emphasizing the motion of the shoulder. e Patient with right hemiplegia. Flexion-abduction-external rotation: proximal hand for scapula posterior elevation and trunk elongation b a c e merus crosses over the midline to the right and the palm faces toward the right ilium. The traction brings the scapula into anterior depression. A continuation of this motion would bring the patient into trunk flexion to the right.

Body Mechanics

Stand in a stride position by or above the patient's shoulder with your left foot forward. Face the line of motion. Start with the weight on your front foot and let the patient's motion push your weight to your back foot. Continue facing the line of motion.

Stretch

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

! Caution

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

Command

"Hand up, lift your arm." "Lift!" Movement

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.

Use approximation through the humerus at the end of the shoulder range to resist the scapula elevation and stabilize the shoulder.

End Position

The humerus is in full flexion (about three fingers from the left ear), the palm facing about 45° to the coronal (lateral) plane. The scapula is in posterior elevation. The elbow remains extended. The wrist is in full radial extension, fingers and thumb extended toward the radial side.

Timing for Emphasis

You may prevent motion in the beginning of the shoulder flexion or in the mid-range and exercise the wrist, hand, or fingers.

Points to Remember

The stretch at the wrist is done with traction, not more flexion Too much shoulder rotation limits the scapular movement At the end of the pattern the trunk is in elongation

Resistance

Your distal hand combines traction through the extended wrist with a rotary resistance for the radial deviation. Resistance to the forearm supination and shoulder external rotation and abduction comes from the rotary resistance at the wrist. The traction force resists the motions of wrist extension and shoulder flexion.

Your proximal hand combines a traction force with rotary resistance. The line of resistance is back toward the starting position. Maintaining the traction force will guide your resistance in the proper arc.

7.2.1 Flexion - Abduction - External Rotation with Elbow Flexion (o Fig. 7.3)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Posterior elevation

Trapezius, levator scapulae, serratus anterior

Shoulder

Flexion, abduction, external rotation

Deltoid (anterior), biceps (long head), coracobrachia-lis, supraspinatus, infraspinatus, teres minor

Elbow

Flexion

Biceps, brachialis

Forearm

Supination

Biceps, brachioradialis, supinator

Wrist

Radial extension

Extensor carpi radialis (longus and brevis)

Fingers

Extension, radial deviation

Extensor digitorum longus, interossei

Thumb

Extension, abduction

Extensor pollicis (longus and brevis), abductor polli-cis longus

Grip

Distal Hand

Your distal grip is the same as described in 7 Sect. 7.2 for the straight arm pattern.

Proximal Hand

Your proximal hand may start with the grip used for the straight arm pattern. As the shoulder and elbow begin to flex, move this hand up to grip the humerus. You wrap your hand around the humerus from the medial side and use your fingers to give pressure opposite the direction of motion. The resistance to rotation comes from the line of your fingers and forearm.

Alternative Grip

The proximal hand may move to the scapula to emphasize that motion.

Elongated Position

Position the limb as for the straight arm pattern. Body Mechanics

Stand in the same stride position as for the straight arm pattern. Allow the patient to push your weight from your front to your back foot. Face the line of motion.

Alternative Position

You may stand on the right side of the table facing up toward the patient's left shoulder. Put your left hand on the patient's hand, your right hand on the humerus. Stand in a stride with your right leg forward. As the patient's arm moves up into flexion, step forward with your left leg. If you choose this position, move the patient to the right side of the table (O Fig. 7.3 d, e).

Stretch

Use the same motions for the stretch reflex that you used with the straight arm pattern.

! Caution

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

Command

"Hand up, lift your arm and bend your elbow." "Lift!"

Movement

The fingers and thumb extend and the wrist moves into radial extension as in the straight arm pattern. The elbow and shoulder motions begin next. The elbow flexion causes the hand and forearm to move across the face as the shoulder completes its flexion.

Pelvis Test

□ Fig. 7.3. Flexion-abduction-external rotation with elbow flexion. a-c Usual position of the therapist; d, e alternative position with therapist on the other side of the table f

D Fig. 7.3. f Patient with hemiplegia, the patient is asked to touch his head

Timing for Emphasis

With three moving segments, shoulder, elbow and wrist, you may lock in any two and exercise the third.

With the elbow bent it is easy to exercise the external rotation separately from the forearm rotation, and the supination separately from the shoulder rotation. Do this exercise where the strength of the shoulder and elbow is greatest. You may work through the full range of shoulder external rotation during these exercises but return to the groove before finishing the pattern.

When exercising the patient's wrist or hand, move your proximal hand to the forearm and give resistance to the shoulder and elbow with that hand. Your distal hand is now free to give appropriate resistance to the wrist and hand motions. To exercise the fingers and thumb, move your proximal hand to give resistance just distal to the wrist. Your distal hand can now exercise the fingers, jointly or individually.

Prevent motion in the beginning or middle range of shoulder flexion and exercise the elbow, wrist, hand, or fingers.

Points to Remember

Resistance

Your distal hand resists the wrist and forearm as it did in the straight arm pattern. Add resistance to the elbow flexion by giving traction in and arc back toward the starting position.

Your proximal hand combines rotary resistance with traction through the humerus toward the starting position. Give a separate force with each hand so that the resistance is appropriate for the strength of the shoulder and elbow.

End Position

The humerus is in full flexion with the scapula in posterior elevation. The elbow is flexed, and the patient's forearm is touching the head. The wrist is again in full radial extension, fingers and thumb extended toward the radial side. The rotation in the shoulder and forearm are the same as in the straight arm pattern. If you extend the patient's elbow, the position is the same as in the straight arm pattern.

The stretch at the wrist is done with traction, not more flexion Resist the elbow flexion with traction back to the starting position Extend the patient's elbow, the position is the same as the straight arm pattern Give a functional command such as "touch the top of your head"

7.2.2 Flexion - Abduction - External Rotation with Elbow Extension (o Fig. 7.4)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Posterior elevation

Trapezius, levator scapulae, serratus anterior

Shoulder

Flexion, abduction, external rotation

Deltoid (anterior), biceps (long head), coracobrachialis, supraspinatus, infraspinatus, teres minor

Elbow

Extension

Triceps, anconeus

Forearm

Supination

Biceps, brachioradialis, supinator

Wrist

Radial extension

Extensor carpi radialis (longus and brevis)

Fingers

Extension, radial deviation

Extensor digitorum longus, interossei

Thumb

Extension, abduction

Extensor pollicis (longus and brevis), abductor polli-cis longus

Grip

Your distal grip is the same as for the straight arm pattern. Wrap your proximal hand around the humerus from the medial side so that your fingers give pressure opposing the direction of motion.

Elongated Position

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

Alternative starting position (o Fig. 7.4 c)

The therapist can also stand close to the pelvis, facing the patient. The left hand grips the humerus and triceps under the forearm and tractions the upper arm into extension, adduction and internal rotation and the scapula into anterior depression.

Body Mechanics

Stand in the same stride position used for the straight arm pattern. Shift your weight as you did for the straight arm pattern.

Stretch

Apply the stretch to the shoulder, elbow, and hand simultaneously. Your proximal hand stretches the shoulder and scapula with a rapid traction and rotation motion. Your distal hand continues giving traction to the hand and wrist while stretching the elbow extension.

! Caution

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

Command

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

Movement

The fingers and thumb extend and the wrist moves into radial extension as before. The elbow and shoulder motions begin next. The elbow extension moves the hand and forearm in front of the face as the shoulder flexes. 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.

Each of your hands uses the proper force to make the resistance appropriate for the strength of the elbow and the strength of the shoulder. Use approximation through the humerus at the end of the shoulder range to resist the scapula elevation and stabilize the shoulder and elbow.

Fig. 7.4. Flexion-abduction-external rotation with elbow extension. a, b Standard grips; c Grip variation

Fig. 7.4. Flexion-abduction-external rotation with elbow extension. a, b Standard grips; c Grip variation

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. Lock in shoulder flexion in mid-range and exercise the elbow extension with supination.

Points to Remember

— The stretch at the wrist is done with traction, not more flexion

— Use a rotary force back into pronation to resist the elbow extension b a c

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