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 patient's 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 HoldRelax with Combination of Isotonics and Dynamic Reversals.

Diagonal Motion

The upper extremity has two diagonals:

1. Flexion-abduction-external rotation and extension-adduction-internal rotation

2. Flexion-adduction-external rotation and extension-abduction-internal rotation

The shoulder and the wrist-hand complex are tied together in the pattern synergy. The elbow is free to move into flexion, move into extension, or remain motionless. Do not allow the arm to move laterally out of the groove to compensate for any limitation of shoulder motion.

Scapular motion is an integral part of each pattern. For a description of the motions making up the scapular patterns see 7 Chapter 6.

The basic patterns of the left arm with the subject supine are shown in O Fig. 7.1. All descriptions refer to this arrangement. To work with the right arm just change the word "left" to "right" in the in

Supination Radial abduction Palmar flexion Finger flexion Adduction finger

Pronation Ulnar abduction Palmar flexion Finger flexion Adduction finger

Supination Radial abduction Palmar flexion Finger flexion Adduction finger

Pronation Ulnar abduction Palmar flexion Finger flexion Adduction finger

Supination Radial abduction Dorsal extension Finger extension Abduction finger

Pronation Ulnar abduction Dorsal extension Finger extension Abduction finger

Supination Radial abduction Dorsal extension Finger extension Abduction finger

O Fig. 7.1. Upper extremity diagonals (Courtesy of V. Jung): with each of the four patterns, the elbow can flex, extend or maintain a position

Pronation Ulnar abduction Dorsal extension Finger extension Abduction finger structions. Variations of position are shown later in the chapter.

Patient Position

Position the patient close to the left edge of the table.

Support the patient's head and neck in a comfortable position, as close to neutral as possible. Before beginning an upper extremity pattern, visualize the patient's 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.

Therapist Position

The therapist stands on the left side of the table facing the line of the diagonal, arms and hands aligned with the motion.

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 therapist's position can vary within the guidelines for the basic procedures. Some of these variations are illustrated at the end of the chapter.

Grips

The grips follow the basic procedures for manual contact, opposite the direction of movement. The first part of this chapter (7 Section 7.2) describes the two-handed grip used when the therapist stands next to the moving upper extremity. The basic grip is described for each straight arm pattern. The grips are modified when the therapist's or patient's position is changed. The grips also change when the therapist can use only one hand while the other hand controls another extremity. The grip on the hand contacts the active surface, dorsal or palmar, and holds the sides of the hand to resist the rotary components. Using the lumbrical grip will pre vent squeezing or pinching the patient's hand. Remember, pain inhibits effective motion.

We recommend distal grips when the arm patterns start straight and optimal elongation or stretch is important. If the arm and elbow go from extension to flexion, change the proximal grip from the forearm to the upper arm for better shoulder control. If the arm moves from flexion to extension, we recommend starting with the proximal grip on the humerus for better elongation of all scapula and shoulder muscles. If the strong arm is used to facilitate the trunk, the proximal hand can also be on the scapula or on the active trunk muscles.

Resistance

The direction of the resistance is an arc back toward the starting position. The angle of the therapist's 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

Grip

Distal Hand

Your right hand grips the dorsal surface of the patient's hand. Your fingers are on the radial side (1st and 2nd metacarpal), your thumb gives coun-terpressure on the ulnar border (5th metacarpal). There is no contact on the palm.

! Caution

Do not squeeze the hand.

Proximal Hand

From underneath the arm, hold the radial and ul-nar sides of the patient's forearm proximal to the wrist. The lumbrical grip allows you to avoid plac 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 patient's 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.

ing any pressure on the anterior (palmar) surface of the forearm.

Alternative Grip

To emphasize shoulder or scapula motions, move the proximal hand to grip the upper arm or the scapula after the wrist completes its motion (O Fig. 7.2 d, e).

Elongated Position

Place the wrist in ulnar flexion and the forearm into pronation. Maintain the wrist and hand in position while you move the shoulder into extension and adduction. You may use gentle traction to help elongate the shoulder and scapula muscles. The hu-

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