Flexion Adduction External Rotation o

The Bending Manual

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Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Anterior elevation

Serratus anterior (upper), trapezius

Shoulder

Flexion, adduction, external rotation

Pectoralis major (upper) deltoid (anterior), biceps, cora-cobrachialis

Elbow

Extended (position unchanged)

Triceps, anconeus

Forearm

Supination

Brachioradialis, supinator

Wrist

Radial flexion

Flexor carpi radialis

Fingers

Flexion, radial deviation

Flexor digitorum (superficialis and profundus), lumbri-cales, interossei

Thumb

Flexion, adduction opposition

Flexor pollicis (longus and brevis), adductor pollicis, op-ponens pollicis

Grip

Distal Hand

Your right hand contacts the palmar 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 dorsal surface.

! Caution

Do not squeeze the hand.

Proximal Hand

Your left hand grips the patient's forearm from underneath just proximal to the wrist. Your fingers are on the radial side, your thumb on the ulnar side.

Alternative Grip

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

Scapulae Abducted And Pronated

Elongated Position

Place the wrist in ulnar extension and the forearm into pronation. Maintain the wrist and hand in position while you move the shoulder into extension and abduction. The palm faces about 45° in toward the body. The traction brings the scapula into posterior depression. Continuation of the traction shortens the left side of the patient's trunk. Too much shoulder abduction prevents the trunk motion and pulls the scapula out of position. Too much internal rotation tilts the scapula forward.

Body Mechanics

Stand in a stride position by the patient's elbow, facing toward the patient's feet. The patient's motion of flexion with external rotation pivots you around so you face diagonally up toward the patient's head. Let the patient's motion pull your weight from your back to your front foot.

Stretch

Your proximal hand does a rapid traction with rotation of the shoulder and scapula. At the same time 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 extension.

Command

"Squeeze my hand, pull up and across your nose." "Squeeze and pull."

Movement

The fingers and thumb flex as the wrist moves into 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 patient's trunk with rotation toward the right.

Resistance

Your distal hand combines traction through the flexed wrist with rotary resistance to radial deviation. The rotary resistance at the wrist provides resistance to the forearm supination and to the shoulder adduction and external rotation. The traction force resists both the wrist flexion and shoulder flexion. At the end of the movement you may need to give approximation with the distal hand to stabilize the elbow in extension.

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

Use approximation at the end of the motion to resist the scapula elevation and stabilize the shoulder and elbow.

End Position

The scapula is in anterior elevation, and the shoulder is in flexion and adduction with external rotation, the humerus crosses the midline (over the pa tient's face). The forearm is supinated, the elbow straight, and the wrist and fingers flexed. Continuation of the motion will cause the patient's trunk to rotate and extend to the right.

Timing for Emphasis

You may prevent motion in the beginning range of shoulder flexion or allow the shoulder to reach the mid-position and exercise the wrist, hand, or fingers. Lock in the forearm rotation or allow it to move with the wrist.

Points to Remember

The stretch at the wrist and shoulder is done with traction, not more extension Approximate with the distal hand to stabilize the elbow in extension at end range The humerus crosses mid-line (the nose when the patient's head is not turned)

7.4.1 Flexion - Adduction - External Rotation with Elbow Flexion (o Fig. 7.9)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Anterior elevation

Serratus anterior (upper), trapezius

Shoulder

Flexion, adduction, external rotation

Pectoralis major (upper) deltoid (anterior), biceps, cora-cobrachialis

Elbow

Flexion

Biceps, brachialis

Forearm

Supination

Brachioradialis, supinator

Wrist

Radial flexion

Flexor carpi radialis

Fingers

Flexion, radial deviation

Flexor digitorum (superficialis and profundus), lumbri-cales, interossei

Thumb

Flexion, adduction

Flexor pollicis (longus and brevis), adductor pollicis

Grip

Your distal grip is the same as used for the straight arm pattern. Your proximal hand may start with the grip for the straight arm pattern. As the shoulder and elbow begin to flex, move this hand up to grip the humerus. 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 (O Fig. 7.9).

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

Your body mechanics are the same as for the straight arm pattern. Use your body weight for resistance.

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 extension.

Command

"Squeeze my hand, pull up across your nose and bend your elbow." "Squeeze and pull." "Touch your right ear."

Movement

After the wrist flexes and the forearm supinates, the shoulder and elbow begin to flex. The shoulder and elbow move at the same speed and complete their movements at the same time.

Resistance

Your distal hand resists the wrist and forearm as in the straight arm pattern. That rotary resistance plus the traction back toward the starting position gives the resistance to elbow flexion. Your proximal hand rotates and gives traction to the humerus back 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 patient's shoulder, forearm, and hand are positioned as in the straight arm pattern. The elbow is flexed, and the patient's fist may touch the right ear. The rotation in the shoulder and forearm are the same as in the straight arm pattern. Extend the elbow to check the amount of rotation.

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 where the strength of the shoulder and elbow flexion is greatest. If you work through the full range of shoulder external rotation, return to the groove before finishing the pattern.

You may lock in the shoulder flexion in mid-range and exercise the wrist, and the finger mo tions. In this position the patient can see the movements. When exercising the wrist or hand, move your proximal hand to the forearm or hand to stabilize and resist the proximal joints. Your other hand grips distal to the joints being exercised.

Points to Remember

The humerus must cross mid-line, (the nose when the patient's head is not turned)

Resistance to supination facilitates the elbow motion

7.4.2 Flexion - Adduction - External Rotation with Elbow Extension (o Fig. 7.10)

Joint

Movement

Muscles: principal components (Kendall and McCreary 1993)

Scapula

Anterior elevation

Serratus anterior (upper), trapezius

Shoulder

Flexion, adduction, external rotation

Pectoralis major (upper) deltoid (anterior), biceps, coracobra-chialis

Elbow

Extension

Triceps, anconeus

Forearm

Supination

Brachioradialis, supinator

Wrist

Radial flexion

Flexor carpi radialis

Eingers

Flexion, radial deviation

Flexor digitorum (superficialis and profundus), lumbricales, interossei

Thumb

Flexion, adduction

Flexor pollicis (longus and brevis), adductor pollicis

Grip

Distal Hand

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

Proximal Hand

Your proximal hand starts with the grip on the forearm used with the straight arm pattern. As the shoulder begins to flex and the elbow to extend, you can move your proximal hand up to grip the humerus. Wrap your hand around the humerus from the medial side and use your fingers to give pressure opposite the direction of motion. You may use the grip on the humerus from the start of the pattern.

Elongated Position

Start by positioning the limb as you did for the straight arm pattern. Maintain traction on the shoulder and scapula with your proximal hand while you use that hand to flex the elbow. Your distal hand tractions the wrist into ulnar extension. If you begin with your left hand on the humerus, your distal (right) hand flexes the elbow.

Body Mechanics

Your body mechanics are the same as for the straight arm pattern. Use your body weight for resistance.

Resisted Shoulder Abduction Table

D Fig. 7.10a-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 b a d c e

O Fig. 7.10e. Flexion-adduction-external rotation with elbow extension. Patient with right hemiplegia: the therapist's proximal hand facilitates scapula anterior elevation and trunk elongation

Resistance

Your distal hand resists the wrist and forearm as in the straight arm pattern. Added is the rotary resistance to elbow extension.

Your proximal hand rotates and tractions the humerus back 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. Give approximation at the end range to stabilize the elbow, shoulder and scapula.

End Position

The patient's shoulder, forearm, and hand are positioned as in the straight arm pattern.

Timing for Emphasis

The emphasis here is to teach the patient to combine shoulder flexion with elbow extension in a smooth motion.

Alternative Grip and Body Mechanics

The therapist can also stand on the head side of the table in the line of the motion. The distal grip is the same and the proximal grip is on the forearm on the flexor muscle group (O Fig. 7.10 c-e).

Stretch

Your proximal hand does a rapid traction with rotation of the shoulder and scapula. At the same time your distal hand gives traction to the wrist.

! Caution

Do not force the wrist into more extension.

Points to Remember

— Resistance to the elbow extension is rotary and back toward the starting position

— Normal timing: the elbow and shoulder motion occur together

Command

"Squeeze my hand, push up and across your nose and straighten your elbow." "Squeeze and push!" "Reach up across your nose."

Movement

First the wrist flexes and the forearm supinates. Then the shoulder begins to flex and elbow to extend. The shoulder and elbow should complete their motions at the same time.

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