PNF in Practice-An Illustrated Guide - 3rd Edition

4.8 · Treatment Examples 445 – Rhythmic Stabilization or Stabilizing as well as specific breathing exercises work to Reversals followed by Dynamic Revers- increase endurance. al of Antagonists a) Procedure 4. Coordination and control – Stretch reflex a) Procedures b) Technique – Patterns of facilitation – Manual contact (grip) – Reversal of antagonists – Vision – Repeated Stretch and Repeated Con- – Proper verbal cues, decreased cueing as patient progresses tractions – Decreasing facilitation as the patient progresses References b) Techniques – Rhythmic Initiation Angel RW, Eppler WG Jr (1967) Synergy of contralateral mus- – Combination of Isotonics cles in normal subjects and patients with neurologic dis- – Dynamic Reversal of Antagonists ease. Arch Phys Med Rehabil 48:233–239 – Stabilizing Reversals – Replication Devine KL, LeVeau BF, Yack J (1981) Electromyographic activi- c) Combinations ty recorded from an unexercised muscle during maximal – Rhythmic Initiation, progressing to isometric exercise of the contralateral agonists and antag- Combination of Isotonics onist. Phys Ther 61:898–903 – Rhythmic Initiation done as reversals, progressing to Reversal of Antagonists Hellebrandt FA, Parrish AM, Houtz SJ (1947) Cross education, – Combination of Isotonics combined the influence of unilateral exercise on the contralateral with Stabilizing or Dynamic Reversal limb. Arch Phys Med Rehabil 28:76–85 of Antagonists Markos PD (1979) Ipsilateral and contralateral effects of pro- 5. Stability and balance prioceptive neuromuscular facilitation techniques on a) Procedures hip motion and electromyographic activity. Phys Ther – Approximation 59(11):1366–1373 – Vision – Manual contact (grip) Moore JC (1975) Excitation overflow: an electromyographic – Appropriate verbal commands investigation. Arch Phys Med Rehabil 59:115–120 b) Techniques – Stabilizing Reversals Pink M (1981) Contralateral effects of upper extremity prop- – Combination of Isotonics rioceptive neuromuscular facilitation patterns. Phys Ther – Rhythmic Stabilization 61(8):1158–1162 c) Combinations – Dynamic Reversal of Antagonists pro- Sullivan PE, Markos PD, Minor MAD (1982) An integrated gressing to Stabilizing Reversals approach to therapeutic exercise, theory and clinical – Dynamic Reversals (eccentric) pro- application. Reston Publishing Company, Reston VA gressing to Stabilizing Reversals Further Reading 6. Endurance Exercise Increasing the patient’s general endurance is a part of all treatments. Varying the activity or Engle RP, Canner GG (1989) Proprioceptive neuromuscular exercise being done and changing the activity facilitation (PNF) and modified procedures for anterior to a different muscle group or part of the body cruciate ligament (ACL) instability. J Orthop Sports Phys will enable the patient to work longer and Ther 11:230–236 harder. Attention to breathing while exercising Hellebrandt FA (1951) Cross education: ipsilateral and contra- lateral effects of unimanual training. J Appl Physiol 4:135– 144 Hellebrandt FA, Hautz SJ (1950) Influence of bimanual exercise on unilateral work capacity. J Appl Physiol 2:446–452 Hellebrandt FA Houtz SJ (1958) Methods of muscle training: the influence of pacing. Phys Ther 38:319–322 Hellebrandt FA, Houtz SJ, Eubank RN (1951) Influence of alter- nate and reciprocal exercise on work capacity. Arch Phys Med Rehabil 32:766–776 Hellebrandt FA, Houtz SJ, Hockman DE, Partridge MJ (1956) Physiological effects of simultaneous static and dynamic exercise. Am J Phys Med Rehabil 35:106–117 Nelson AG, Chambers RS, McGown CM, Penrose KW (1986) Proprioceptive neuromuscular facilitation versus weight

46 Chapter 4 · Patient Treatment 1 training for enhancement of muscular strength and ath- Spasticity 2 letic performance. J Orthop Sports Phys Ther 8:250–253 3 Osternig LR, Robertson RN, Troxel RK, Hansen P (1990) Differ- Landau WM (1974) Spasticity: the fable of a neurological 4 ential responses to proprioceptive neuromuscular facil- demon and the emperor’s new therapy. Arch Neurol 5 itation (PNF) stretch techniques. Med Sci Sports Exerc 31:217–219 6 22:106–111 7 Partridge MJ (1962) Repetitive resistance exercise: a method of Levine MG, Kabat H, Knott M, Voss DE (1954) Relaxation of 8 indirect muscle training. Phys Ther 42:233–239 spasticity by physiological techniques. Arch Phys Med 9 Pink M (1981) Contralateral effects of upper extremity prop- Rehabil 35:214–223 10 rioceptive neuromuscular facilitation patterns. Phys Ther 11 61:1158–1162 Perry J (1980) Rehabilitation of spasticity. In: Felman RG, Young 12 Richardson C, Toppenberg R, Jull G (1990) An initial evalua- JRR, Koella WP (eds) Spasticity: disordered motor control. 13 tion of eight abdominal exercises for their ability to pro- Year Book, Chicago 14 vide stabilization for the lumbar spine. Aust Physiother 15 36:6–11 Sahrmann SA, Norton BJ (1977) The relationship of voluntary 16 movement to spasticity in the upper motor neuron syn- 17 drome. Ann Neurol 2:460–465 18 19 Young RR, Wiegner AW (1987) Spasticity. Clin Orthop 219:50– 20 62 Hemiplegia Cold Brodal A (1973) Self–observations and neuro-anatomical con- Baker RJ, Bell GW (1991) The effect of therapeutic modalities siderations after a stroke. Brain 96:675–694 on blood flow in the human calf. J Orthop Sports Phys Ther 13:23–27 Duncan PW, Nelson SG (1983) Weakness – a primary motor deficit in hemiplegia. Neurol Rep 7 (1):3–4 Miglietta O (1964) Electromyographic characteristics of clonus and influence of cold. Arch Phys Med Rehabil 45:508–512 Harro CC (1985) Implications of motor unit characteristics to speed of movement in hemiplegia. Neurol Rep 9 (3):55– Miglietta O (1962) Evaluation of cold in spasticity. Am J Phys 61 Med Rehabil 41:148–151 Tang A, Rymer WZ (1981) Abnormal force – EMG relations in Olson JE, Stravino VD (1972) A review of cryotherapy. Phys Ther paretic limbs of hemiparetic human subjects. J Neurol 52:840–853 Neurosurg Psychiatry 44:690–698 Prentice WE Jr (1982) An electromyographic analysis of the Trueblood PR, Walker JM, Perry J, Gronley JK (1988) Pelvic exer- effectiveness of heat or cold and stretching for inducing cise and gait in hemiplegia. Phys Ther 69:32–40 relaxation in injured muscle. J Orthop Sports Phys Ther 3: 133–140 Whitley DA, Sahrmann SA, Norton BJ (1982) Patterns of mus- cle activity in the hemiplegic upper extremity. Phys Ther Sabbahi MA, Powers WR (1981) Topical anesthesia: a possible 62:641 treatment method for spasticity. Arch Phys Med Rehabil 62:310–314 Winstein CJ, Jewell MJ, Montgomery J, Perry J, Thomas L (1982) Short leg casts: an adjunct to gait training hemiplegics. Phys Ther 64:713–714 Motor Control and Motor Learning APTA (1991) Movement science: an American Physical Therapy Association monograph. APTA, Alexandria VA APTA (1991) Contemporary management of motor control problems. Proceedings of the II Step conference. Founda- tion for Physical Therapy, Alexandria VA Hellebrandt FA (1958) Application of the overload principle to muscle training in man. Arch Phys Med Rehabil 37:278– 283 Light KE (1990) Information processing for motor performance in aging adults. Phys Ther 70 (12): 820–826 VanSant AF (1988) Rising from a supine position to erect stance: description of adult movement and a develop- mental hypothesis. Phys Ther 68 (2):185–192 VanSant AF (1990) Life-span development in functional tasks. Phys Ther 70 (12):788–798

5.1 · 547 Patterns of Facilitation

48 Chapter 5 · Patterns of Facilitation Normal functional motion is composed of mass The PNF patterns combine motion in all three 1 movement patterns of the limbs and the syner- planes: gistic trunk muscles (Kabat 1960) (. Fig. 5.1). 1. The sagittal plane: flexion and extension 2 The motor cortex generates and organizes these 2. The coronal or frontal plane: abduction and movement patterns, and the individual cannot adduction of limbs or lateral flexion of the 3 voluntarily leave a muscle out of the movement spine pattern to which it belongs. This does not mean 3. The transverse plane: rotation that we cannot contract muscles individually, but 4 our discrete motions spring from the mass pat- We thus have motion that is “spiral and diagonal” terns (Beevor 1978; Kabat 1950). These synergis- (Knott and Voss 1968). Stretch and resistance rein- 5 tic muscle combinations form the PNF patterns of force the effectiveness of the patterns, as shown by facilitation. an increased activity in the muscles. The increased 6 Some people believe that you must know and muscular activity spreads both distally and proxi- use the PNF patterns to work within the concept of mally within a pattern and from one pattern to re- PNF. We think that you need only the PNF philos- lated patterns of motion (irradiation). Treatment 7 ophy and the appropriate procedures. The patterns, uses irradiation from those synergistic combina- while not essential, are however valuable tools to tions of muscles (patterns) to strengthen the de- 8 have. Working with the synergistic relationships in sired muscle groups or reinforce the desired func- the patterns allows problems to be treated indirect- tional motions. 9 ly. Also, the stretch reflex is more effective when an When we exercise in the patterns against resist- entire pattern rather than just the individual mus- ance, all the muscles that are a part of the synergy cle is stretched. will contract if they can. The rotational component 10 of the pattern is the key to effective resistance. Cor- rect resistance to rotation will strengthen the entire 11 12 13 14 15 16 17 18 19 20 a b . Fig. 5.1. Diagonal motions in sport: a tennis; b golf

Patterns of Facilitation 549 pattern. Too much resistance to rotation will pre- The groove of the pattern is that line drawn by vent motion from occurring or “break” a stabiliz- the hand or foot (distal component) as the limb ing contraction. moves through its range. For the head and neck, the groove is drawn by a plane through the nose, chin, The motion occurring at the proximal joint and crown of the head. The groove for the upper names the patterns, as in flexion-adduction-exter- trunk is drawn by the tip of the shoulder and for the nal rotation of the shoulder. Two antagonistic pat- lower trunk by the hip bone. Because the trunk and terns make up a diagonal. For example, an upper ex- limbs work together, their grooves join or are par- tremity diagonal contains shoulder flexion-adduc- allel (. Fig. 5.2). As discussed earlier, the therapist’s tion-external rotation and the antagonist pattern body should be in line with or parallel to the rele- extension-abduction-internal rotation. The proxi- vant groove. Pictures of the complete patterns with mal and distal joints of the limb are linked in the the therapist in the proper position come in the fol- pattern. The middle joint is free to flex, extend or lowing chapters. maintain its position. For example, finger flexion, radial flexion of the wrist, and forearm supination To move concentrically through the entire are integral parts of the pattern of shoulder flexion- range of a pattern: adduction-external rotation. The elbow, however, 5 The limb is positioned in the “lengthened may flex, extend or remain in one position. range”. The trunk and limbs work together to form – All the associated muscles (agonists) are complete synergies. For example, the pattern of shoulder flexion-adduction-external rotation with lengthened. anterior elevation of the scapula combines with – There is no pain, and no joint stress. trunk extension and rotation to the opposite side to – The trunk does not rotate or roll. complete a total motion. If you know the synergis- 5 The limb moves into the “shortened range.” tic muscle combinations, you can work out the pat- – The end of the range of contraction of the terns. If you know the pattern, you will know the synergistic muscles. When an extremity is in its ful- muscles (agonists) is reached. ly lengthened position the synergistic trunk mus- – The antagonistic muscle groups are length- cles are also under tension. The therapist should feel tension in both the limb and trunk muscles. ened. – There is no pain and no joint stress. – The trunk did not rotate or roll. – Note We can vary the pattern in several ways. 12 1 The normal timing of an extremity pattern is: 2 5 The distal part (hand and wrist or foot and 11 10 ankle) moves through its full range first and holds its position. 93 5 The other components move smoothly togeth- er so that they complete their movement al- 8 6 4 most simultaneously. 7 5 5 Rotation is an integral part of the motion and is resisted from the beginning to the end of the . Fig. 5.2. Patterns are “spiral and diagonal” [modified from motion. Klein-Vogelbach S (1990) Functional kinetics. Springer, Berlin We can vary the pattern in several ways: Heidelberg New York] 5 By changing the activity of the middle joint in the extremity pattern for function Example: First, the pattern of shoulder flexion- abduction-external rotation is done with the elbow moving from extension to flexion. The

50 Chapter 5 · Patterns of Facilitation patient’s hand rubs his or her head. The next We name the pattern combinations according 1 time, the same pattern is done with the elbow to how the limb movements (arms, legs or both) re- moving from a flexed to an extended position, late to each other: 2 so the patient’s hand can reach for a high ob- 5 Unilateral: one arm or one leg ject. 5 Bilateral: both arms, both legs, or combinations 3 5 By changing the activity of the middle joint of arms and legs (. Fig. 5.3): in the extremity pattern for the effect on two- – Symmetrical: the limbs move in the same joint muscles. pattern (e. g., both move in flexion-abduc- tion) (. Fig. 5.3 a) 4 Example: First, the pattern of hip flexion-ad- duction-external rotation is done with the – Asymmetrical: the limbs move in opposite 5 knee moving from the extended to the flexed patterns (e. g., the right limb moves in flex- position. In this combination, the hamstring ion-abduction, the left moves in flexion- 6 muscles shorten actively. Next time, the same adduction) (. Fig. 5.3 b) pattern is used with the knee staying straight. – Symmetrical reciprocal: the limbs move in This combination stretches the hamstring the same diagonal but opposite directions (e. g., the right limb moves in flexion-ab- 7 muscles. duction, the left in extension-adduction) 5 By changing the patient’s position to change 8 the effects of gravity. (. Fig. 5.3 c) Example: The pattern of hip extension-abduc- – Asymmetrical reciprocal: the limbs move in 9 tion-internal rotation is done in a side lying opposite diagonals and opposite directions position so the abductor muscles work against (e. g., the right limb moves in flexion-ab- gravity. duction, the left in extension-abduction) 10 5 By changing the patient’s position to a more (. Fig. 5.3 d) functional one. 11 Example: The upper extremity patterns are ex- ercised in a sitting position and incorporate functional activities such as eating or comb- 12 ing the hair. 5 By changing the patient’s position to use visu- 13 al cues. Example: Have the patient in a half-sitting po- 14 sition so that he or she can see the foot and an- kle when exercising it. 15 We can combine the patterns in many ways. The emphasis of treatment is on the arms or legs when 16 the limbs move independently. The emphasis is on the trunk when the arms are joined by one hand 17 gripping the other arm or when the legs are touch- ing and move together. Choosing how to combine the patterns for the greatest functional effect is a 18 part of the assessment1 and treatment planning. 19 20 1 To evaluate: to identify the patient’s areas of function and dysfunction. To assess: to measure or judge the result of a treatment procedure.

Patterns of Facilitation 551 ab cd . Fig. 5.3. Bilateral patterns. a Symmetrical: both arms in flexion-abduction. b Asymmetrical: right arm in flexion-abduction and left arm in flexion-adduction. c Symmetrical reciprocal: right arm in flexion-abduction and left arm in extension-adduction. d Asymmetrical reciprocal: right arm in flexion-abduction and left arm in extension-abduction

52 Chapter 5 · Patterns of Facilitation 1 References 2 3 Beevor CE (1978) The Croonian lectures on muscular move- 4 ments and their representation in the central nervous sys- 5 tem. In: Payton OD, Hirt S, Newton RA (eds) Scientific basis 6 for neurophysiologic approaches to therapeutic exercise: 7 an anthology. Davis, Philadelphia 8 9 Kabat H (1950) Studies on neuromuscular dysfunction, XIII: 10 new concepts and techniques of neuromuscular reeduca- 11 tion for paralysis. Perm Found Med Bull 8(3):121–143 12 13 Kabat H (1960) Central mechanisms for recovery of neuromus- 14 cular function. Science 112: 23–24 15 16 Klein-Vogelbach S (1990) Functional Kinetics. Springer, Berlin 17 Heidelberg New York 18 19 Knott M, Voss DE (1968) Proprioceptive neuromuscular facilita- 20 tion: patterns and techniques, 2nd edn. Harper and Row, New York Further Reading Bosma JF, Gellhorn E (1946) Electromyographic studies of mus- cular co-ordination on stimulation of motor cortex. J Neu- rophysiol 9:263–274 Gellhorn E (1948) The influence of alterations in posture of the limbs on cortically induced movements. Brain 71:26–33 Klein-Vogelbach S (2007) FBL Klein-Vogelbach. Functional Kinetics: Die Grundlagen, 6. Aufl. Springer, Berlin Heidel- berg New York

6.1 · 653 The Scapula and Pelvis 6.1 Introduction – 54 6.2 Applications – 54 6.3 Basic Procedures – 54 6.4 Scapular Diagonals – 56 6.4.1 Specific Scapula Patterns – 56 6.4.2 Specific Uses for Scapular Patterns – 63 6.5 Pelvic Diagonals – 64 6.5.1 Specific Pelvic Patterns – 64 6.5.2 Specific Uses for Pelvic Patterns – 72 6.6 Symmetrical, Reciprocal and Asymmetrical Exercises – 73 6.6.1 Symmetrical-Reciprocal Exercise – 73 6.6.2 Asymmetrical Exercise – 74

54 Chapter 6 · The Scapula and Pelvis 6.1 Introduction ties. The scapular muscles control or influence the function of the cervical and thoracic spine. Proper 1 The pelvic girdle and the shoulder girdle are not function of the upper extremities requires both 2 alike in their functions related to stabilization and motion and stability of the scapula. Pelvic motion motion of the extremities. In the shoulder girdle and stability are required for proper function of the 3 the scapula and clavicle work together as unit. The trunk and the lower extremities. scapula’s primary support is muscles with only one Exercise of the scapula and pelvis can have var- attachment to the axial skeleton, at the manubri- ious goals: 4 um. The shoulder girdle is dependent on muscular function and its ability to adjust to the underlying Therapeutic Goals 5 rib cage. In its normal function it is not a weight- 5 Scapula bearing structure. The scapula patterns are activat- – Exercise the scapula independently 6 ed (whether for motion or stabilization) within the for motion and stability. upper extremity patterns and all the upper extremi- – Exercise trunk muscles by using tim- ty patterns and scapula motions integrate together. ing for emphasis and resistance for facilitation. 7 The pelvic girdle, consisting of the sacrum and – Exercise functional activities such as the innominate or coxal (hip) bone, is directly at- 8 tached to the spine and is dependent mostly on ver- rolling. tebral support. It is a weight bearing structure. The – Facilitate cervical motion and stability 9 pelvic patterns do not always function in accord (by resisting scapular motion and with the lower extremity patterns because the pel- stabilization, since the scapula and vis is truly divided in its function. The sacrum is an neck reinforce each other). – Facilitate arm motion and stability 10 extension of the lumbar spine and functions in ac- cordance with spinal function. It is only involved (by resisting scapular motion and sta- 11 in lower extremity function as an extension of the bilization, since the scapula and arm innominate. The innominate bone is clearly an ex- muscles reinforce each other). tension of the lower extremity and in the efficient – Treat the lower trunk indirectly through irradiation 12 state moves with each lower extremity compo- nent. The Sacro-iliac (SI) articulation is the tran- 5 Pelvis 13 sition between the axial skeleton and the lower ex- – Exercise the pelvis for motion and tremity. Therefore, the pelvic patterns are directed stability. 14 through the sacrum to the lumbar spine while the – Facilitate trunk motion and stability. lower extremity patterns extend into the pelvic gir- – Exercise functional activities such as dle through the innominate. The lower extremity rolling. – Facilitate leg motion and stability. 15 motions are supported and complimented, wheth- er in weight bearing or non-weight bearing, by in- – Treat the upper trunk and cervical 16 nominate motions. The sacrum has the functional areas indirectly through irradiation. role in the pelvic patterns. The innominate has on- 17 ly a minor passive function unless the extremity is added. That is why, for example, it is so important to proceed to rolling as soon as the pelvic pattern is 18 developed (G. Johnson 1999). 6.3 Basic Procedures 19 6.2 Applications Diagonal Motion The scapular and pelvic patterns occur in two di- 20 agonals: anterior elevation – posterior depres- Exercise of the scapula and pelvis is important for sion and posterior elevation – anterior depression. treatment of the neck, the trunk, and the extremi- Movement in the diagonals is an arc that follows

6.3 · Basic Procedures 655 11 12 1 use of these patterns in other positions is illustrat- 10 2 ed in later chapters. 93 The procedures start with the patient in a sta- ble side lying position, the hips and knees flexed as 8 4 much as the activity needs to get an optimal result. 7 5 The patient should be positioned so that his or her back is close to the edge of the treatment table. The 6 patient’s spine is maintained in a normal alignment and the head and neck in as neutral a position as . Fig. 6.1. Diagonal motion of the scapula and pelvis possible, neither flexed nor extended. The patient’s head is supported in line with the spine, avoiding the curve of the patient’s torso. When the scapula lateral bend. or pelvis is moved within the diagonal, the patient will not roll forward or back or rotate around one Before beginning a scapula or pelvis pattern, spinal segment. place the scapula or pelvis in a mid-position where the line of the two diagonals cross. The scapula Picture a patient lying on the left side (. Fig. 6.1). should not be rotated, and the glenohumeral com- Now imagine a clock with the 12 o’clock position to- plex should lie in the anteroposterior midline. The ward the patient’s head, the 6 o’clock position to- pelvis should be in the middle, between anterior ward the feet, the 3 o’clock position anterior and the and posterior tilt. You can use a pillow between the 9 o’clock position posterior. When working with the knees when the pelvis is rotated. From this midline right scapula or pelvis, anterior elevation is toward position, the scapula or pelvis can then be moved 1 o’clock and posterior depression toward 7 o’clock. into the elongated range of the pattern. Posterior elevation is toward 11 o’clock and anterior depression toward 5 o’clock (. Fig. 6.1). Therapist Position Now imagine that the patient is lying on the The therapist stands behind the patient, facing the right side. The 12 o’clock position is still toward line of the scapular or pelvic diagonal and with arms the patient’s head but the 3 o’clock position is pos- and hand aligned with the motion. All the grips de- terior and the 9 o’clock position anterior. Work- scribed in this chapter assume that the therapist is ing with the left scapula or pelvis, anterior eleva- in this position. tion is toward 11 o’clock and posterior depression toward 5 o’clock; posterior – elevation is toward 1 In an alternative position the patient lies facing o’clock and anterior depression toward 7 o’clock. the edge of the treatment table. The therapist stands In this chapter we show all patterns being done on in front of the patient in the line of the chosen diag- the patient’s left scapula or pelvis. All references are to motion of the left scapula or the left side of the pelvis. Patient Position . Fig. 6.2. Alternative position: the therapist is in front of the patient (anterior elevation of the pelvis) We illustrate the basic scapula and pelvic patterns with the patient side lying on a treatment table. The

56 Chapter 6 · The Scapula and Pelvis onal. The hand placement on the patient’s body re- Grips 1 mains the same but the grips use different areas of The grips follow the basic procedure for manu- the therapist’s hands (. Fig. 6.2). al contact, that is opposite the direction of move- 2 The scapular and pelvic patterns can also be ment. This section describes the two-handed grips done with the patient lying on the mats. In this po- used when the patient is side lying and the thera- 3 sition, the therapist must kneel on the mats either pist is standing behind the patient. These grips are in front of or behind the patient. Weight shifting modified when the therapist’s or patient’s position is done by moving from the position of sitting on is changed, and some modification is also needed 4 the heels (kneeling down) to partial or fully upright when the therapist can use only one hand while the kneeling (kneeling up). other hand controls another pattern or extremity. 5 Resistance 6 The direction of the resistance is an arc following the contour of the patient’s body. The angle of the therapist’s hands and arms changes as the scapula 7 or pelvis moves through this arc of diagonal mo- tion (. Fig. 6.3). 8 9 6.4 Scapular Diagonals 10 6.4.1 Specific Scapula Patterns 11 Scapula patterns can be done with the patient lying on the treatment table, on mats, sitting, or standing. a The humerus must be free to move as the scapula moves. Side lying (illustrated) allows free motion of 12 the scapula and easy reinforcement of trunk activ- ities. The main muscle components are as follows 13 (extrapolated from Kendall and McCreary 1993). We know of no confirming electromyographic 14 studies. 15 Anterior Elevation and Posterior Depression (. Fig. 6.4 a–c) 16 The therapist stands behind the patient, facing up toward the patient’s head. Anterior Elevation (. Fig. 6.4 b, 6.5): 17 Grip. Place one hand on the anterior aspect of the glenohumeral joint and the acromion with your 18 fingers cupped. The other hand covers and sup- ports the first. Contact is with the fingers and not 19 the palm of the hand. 20 b . Fig. 6.3a,b. The direction of the resistance is an arc (poste- rior depression of the scapula)

6.4 · Scapular Diagonals 657 ab c . Fig. 6.4. Scapula diagonal: anterior elevation/posterior depression. a Neutral position; b anterior elevation; c posterior de- pression

58 Chapter 6 · The Scapula and Pelvis 1 . Table 6.1. Scapula movements Movement Muscles: principal components 2 Anterior elevation Levator scapulae, rhomboids, serratus anterior Posterior depression Serratus anterior (lower), rhomboids, latissimus dorsi Trapezius, levator scapulae 3 Posterior elevation 4 Anterior depression Rhomboids, serratus anterior, pectoralis minor and major 5 Elongated Position (. Fig. 6.5 a). Pull the entire Body Mechanics. Keep your arms relaxed and 6 scapula down and back toward the lower thorac- let your body give the resistance by shifting your ic spine (posterior depression) with the angulus weight from the back to the front leg. inferior rotated toward the spine. Be sure that the 7 glenohumeral complex is positioned posterior to Resistance. The line of resistance is an arc follow- the central anteroposterior line of the body (mid- ing the curve of the patient’s body. To resist the 8 frontal plane). You should see and feel that the ante- rotation component, the therapist resists the angu- rior muscles of the neck are taut. Do not pull so far lus inferior in the direction of the spine. Start with 9 that you lift the patient’s head up. Continued pres- your elbows low and your forearms parallel to the sure on the scapula should not cause the patient to patient’s back. At the end of the pattern your elbows roll back or rotate the spine around one segment. are extending and you are lifting upward. 10 Command. “Shrug your shoulder up toward your End Position (. Fig. 6.5 b). The scapula is up and 11 nose.” “Pull”. forward with the acromion close to the patient’s nose. The angulus inferior is moved away from the Movement. The scapula moves up and forward spine. In the end position, the muscular activity 12 in a line aimed approximately at the patient’s nose. moves the scapula in this direction. The scapular The inferior angle moves away from the spine. retractor and depressor muscles are taut. 13 14 15 16 17 18 19 20 a b . Fig. 6.5a,b. Resistance to scapular anterior elevation

6.4 · Scapular Diagonals 659 Functional Activities. This scapula pattern facili- tates rolling forward, reaching in front of the body, and gait-related phases. The terminal stance on the ipsilateral side and the swing phase on the contra- lateral side are related to this pattern. Posterior Depression (. Fig. 6.4 c, 6.6) Grip. Place the heels of your hands along the verte- bral border of the scapula with one hand just above (cranial to) the other. Your fingers lie on the scapula pointing toward the acromion. Try to keep all pres- sure below (caudal to) the spine of the scapula. Elongated Position (. Fig. 6.6 a). Push the scap- a ula up and forward (Anterior elevation) with the angulus inferior moved away from the spine until you feel and see that the posterior muscles below the spine of the scapula are tight. Continued pres- sure should not cause the patient to roll forward or rotate the spine around one segment. Command. “Push your shoulder blade down to me.” “Push”. Movement. The scapula moves down (caudal) and back (adduction), toward the lower thoracic spine, with the inferior angle rotated toward the spine. Body Mechanics. Flex your elbows to keep your b forearms parallel to the line of resistance. Shift your weight to your back foot and allow your elbows to drop as the patient’s scapula moves down and back (. Fig. 6.6 b). Resistance. The line of resistance is an arc following . Fig. 6.6a,b. Resistance to scapular posterior depression the curve of the patient’s body. To resist the rotation component, the therapist resists the inferior angle or line of the trunk. The vertebral border should lie in the direction away from the spine. Start by lift- flat and not wing out. ing the scapula down toward the patient’s nose. As the scapula moves toward the anteroposterior mid- Functional Activities. This scapula pattern acti- line, the resistance is forward and almost parallel to vates trunk extension, rolling backward, using the supporting table. By the end of the motion the crutches while walking, and pushing up with a resistance is forward and upward toward the ceiling straight trunk. When a patient moves from a wheel- with a rotational resistance away from the spine. chair to a bed he/she may use anterior depression of the scapula. End Position (. Fig. 6.6 b). The scapula is depressed and retracted with the glenohumer- al complex posterior to the central anteroposteri-

60 Chapter 6 · The Scapula and Pelvis Anterior Depression and Posterior End Position (. Fig. 6.8 b). The scapula is rotat- ed forward, depressed, and abducted. The gleno- 1 Elevation (. Fig. 6.7 a–c) The therapist stands behind the patient’s head fac- humeral complex is anterior to the central antero- 2 ing towards the patient’s bottom (right) hip. posterior line of the body. 3 Anterior Depression (. Fig. 6.7 b, . Fig. 6.8) Functional Activities. Rolling forward, reaching Grip. Place one hand posteriorly with the fingers forward, throwing a ball in sport activities, reach- holding the lateral (axillary) border of the scapu- ing down to the feet to take off socks and shoes. 4 la. The other hand holds anteriorly on the axillary border of the pectoralis major muscle and on the 5 coracoid process. The fingers of both hands point toward the opposite ilium, and your arms are lined 6 up in the same direction. Elongated Position (. Fig. 6.8 a). Lift the entire 7 scapula up and back toward the middle of the back of the head (posterior elevation). Be sure that the 8 glenohumeral complex is positioned posterior to the central anteroposterior line of the body (mid- 9 frontal plane). You should see and feel that the abdominal area is taut from the ipsilateral ribs to the contralateral pelvis. Continued pressure on the 10 scapula should not cause the patient to roll back or rotate the spine around one segment. 11 Command. “Pull your shoulder blade down toward your navel.” “Pull.” 12 Movement. The scapula moves down and forward, 13 in a line aimed at the opposite anterior iliac crest. The scapula moves forward with the inferior angle 14 in the direction of the spine. Body Mechanics. Let the resistance come from 15 your body weight as you shift from the back to the front leg. 16 Resistance. The resistance follows the curve of the 17 patient’s body. At the end of the pattern you are lift- ing in a line parallel to the front of the patient’s tho- rax. 18 19 20

6.4 · Scapular Diagonals 661 ab c . Fig. 6.7. Scapular diagonal: anterior depression/posterior elevation. a Neutral position; b anterior depression; c posterior el- evation

62 Chapter 6 · The Scapula and Pelvis 1 2 3 4 5 6 b a 7 . Fig. 6.8a,b. Resistance to scapular anterior depression 8 9 Posterior Elevation (. Fig. 6.7 c, . Fig. 6.9) Resistance. The resistance follows the curve of the Grip. Place your hands posterior on the upper tra- patient’s body. At the end of the pattern you are lift- pezius muscle, staying above (superior to) the spine ing around the thorax and away from top of the 10 of the scapula. Overlap your hands as necessary to patient’s head. stay distal to the junction of the spine and first rib. 11 End Position (. Fig. 6.9 b). The scapula is elevated Elongated Position (. Fig. 6.9 a). Round the scap- and adducted, the glenohumeral complex is poste- ula down and forward toward the opposite ili- rior to the central anteroposterior line of the body. 12 um (anterior depression) with the angulus inferi- or moving toward the spine until you feel that the Functional Activities. Moving backward, reach- 13 upper trapezius muscle is taut. Do not push so far ing out before throwing something, and putting on that you lift the patient’s head up. Continued pres- a shirt are activities that show these movements of 14 sure should not cause the patient to roll forward or the scapula. rotate the spine around one segment. Points to Remember 15 Command. “Shrug your shoulder up.” “Push”. 5 When doing pure scapular patterns the 16 Movement. The scapula shrugs up (cranially) and trunk does not roll or rotate. back (adduction) in a line aimed at the middle of 5 The glenohumeral complex is part of the 17 the top of the patient’s head with the angulus inferi- scapular pattern. The humerus must be or rotating away from the spine. The glenohumeral free to move along. complex moves posteriorly and rotates upward. 18 Body Mechanics. Shift your weight from the front 19 to the back foot as the scapula moves. Your fore- arms stay parallel to the line of resistance. 20

6.4 · Scapular Diagonals 663 a b . Fig. 6.9a,b. Resistance to scapular posterior elevation 6.4.2 Specific Uses for Scapular the functional activity using the stabilized Patterns scapula as the handle. – Repeated Contractions of the functional 5 Exercise the scapula for motion and stability activity will reinforce both learning the ac- (. Fig. 6.10) tivity and the physical ability to do it. 5 Facilitate cervical motion and stability (by re- 5 Exercise trunk muscles sisting scapular motion and stabilization, since – Using timing for emphasis, prevent scapu- the scapula and neck reinforce each other) lar motion at the beginning of the range – Resist the moving or stabilizing contrac- until you feel and see the trunk muscles tion at the scapula and head simultaneous- contract. When this occurs, change the re- ly to exercise the muscles that go from the sistance at the scapula so that both the cervical spine to the scapula. scapula and the trunk motion are resisted. – To stretch these muscles for increased – At the end of the scapular range of motion, range of motion, stabilize the cervical spine “lock in” the scapula with a stabilizing con- and resist the appropriate scapular motion. traction and exercise the trunk with re- 5 Facilitate arm motion and stability (by resist- peated contractions. ing scapular motion and stabilization, since the – Use Reversal of Antagonist techniques to scapula and arm muscles reinforce each other). train coordination and prevent or reduce (. Fig. 6.10) fatigue of the scapular and trunk muscles. – Scapular elevation patterns work with arm flexion patterns. 5 Exercise functional activities such as rolling. – Scapular depression patterns work with – When the trunk muscles are contracting arm extension patterns. you can extend their action into such func- 5 Treat the lower trunk indirectly through irra- tional activities as rolling forward or back- diation. Give sustained maximal resistance to ward (7 Sect. 11.5.1). Give a movement command such as “roll forward” and resist

64 Chapter 6 · The Scapula and Pelvis stabilizing or isometric scapula patterns until 1 you see and feel contraction of the desired low- er trunk muscles. 2 Points to Remember 3 5 The scapular patterns work directly on the spine as well. 4 5 When using scapular patterns for rolling, the scapula is the handle and the rolling is exercised. 5 6a 7 6.5 Pelvic Diagonals 8 6.5.1 Specific Pelvic Patterns 9 The pelvis is part of the trunk, so the range of mo- tion in the pelvic patterns depends on the amount 10 of motion in the lower spine. We treat pelvic pat- terns as isolated from the trunk if no great in- 11 creased lumbar flexion or extension occurs. Bio- mechanically, it is impossible to move the pelvis 12 b without motion in the spine because it is connected 13 with the spine. Pelvic patterns can be done with the . Fig. 6.10. Patient with right hemiplegia. a Combination of patient lying, sitting, quadruped, or standing. The scapula (posterior depression) with arm motion. b Combina- side that is moving must not be weightbearing. Side tion of scapula (anterior elevation) with arm motion lying (illustrated) allows free motion of the pelvis and easy reinforcement of trunk and lower extrem- 14 ity activities. 15 The movements and muscle components main- ly involved are as follows (Kendall and McCready 1993): 16 . Table 6.2. Pelvic movements 17 18 Movement Muscles: principal components 19 20 Anterior elevation Internal and external oblique abdominal muscles Posterior depression Contralateral Internal and external oblique abdominal muscles Posterior elevation Ipsilateral quadratus lumborum, ipsilateral latissimus dorsi, iliocostalis lumborum, and longissimus thoracis Anterior depression Contralateral quadratus lumborum, iliocostalis lumborum, and longissimus thoracis

6.5 · Pelvic Diagonals 665 Anterior Elevation and Posterior Anterior Elevation (. Fig. 6.11 b, d; . Fig. 6.12) Depression (. Fig. 6.11 a–e) Grip. The fingers of one hand grip around the crest The therapist stands behind the patient facing up of the ilium, on and just anterior to the midline. toward the patient’s lower (right) shoulder. Your other hand overlaps the first. ab a . Fig. 6.11. Pelvic diagonal: a Neutral position; b Anterior elevation; c Posterior depression

66 Chapter 6 · The Scapula and Pelvis 1 2 3 4 5 6 7 8 9 de 10 . Fig. 6.11. Pelvic patterns in function: d pelvic pattern in anterior elevation, e pelvic pattern in posterior depression 11 12 13 14 15 16 b a 17 . Fig. 6.12a,b. Resistance to pelvic anterior elevation 18 Elongated Position (. Fig. 6.12 a). Pull the crest to roll backward or rotate the spine around one of the pelvis back and down in the direction of segment. 19 posterior depression. The pelvis moves in a dor- sal convex arc backward and down (. Fig. 6.11). Command. “Shrug your pelvis up.” “Pull.” 20 See and feel that the tissues stretching from the crest of the ilium to the opposite rib cage are taut. Movement. The pelvis moves up and forward with Continued pressure should not cause the patient a small posterior tilt to follow the arc movement.

6.5 · Pelvic Diagonals 667 There is an anterior shortening of the trunk on that side (lateral flexion). Body Mechanics. Start with your elbows flexed to pull the iliac crest down as well as back. As the movement progresses your elbows extend and your weight shifts from your back to your front foot. Resistance. The line of resistance curves follow- a ing the patient’s body. Start by pulling the pelvis back toward you and down toward the table. As the pelvis moves to the mid-position the line of the resistance is almost straight back. At the end of the motion the resistance is up toward the ceiling. End Position (. Fig. 6.12 b). The pelvis is up (ele- vated) and forward (anterior) toward the lower shoulder with a small increase in posterior tilt. The upper side (left) of the trunk is shortened and later- ally flexed with no change in lumbar lordosis. Functional Activities. This movement is seen in b parts of the swing phase in gait and in rolling for- ward. . Fig. 6.13a,b. Resistance to pelvic posterior depression Posterior Depression (. Fig. 6.11 c, e; Resistance. The resistance is always upward on the . Fig. 6.13) ischial tuberosity while pushing diagonally forward Grip. Place the heel of one hand on the ischi- (anterior and cranial). al tuberosity. Overlap and reinforce the hold with your other hand. The fingers of both hands point End Position (. Fig. 6.13 b). The pelvis is down and diagonally forward. back (posterior) with a small increase in the anteri- or tilt. The upper side (left) of the trunk is elongat- Elongated Position (. Fig. 6.13 a). Push the ischi- ed with no change in the lumbar lordosis. al tuberosity up and forward to bring the iliac crest down closer to the opposite rib cage (anterior ele- Functional Activities. We see this movement in ter- vation). Continued pressure should not cause the minal stance activities, in jumping, walking stairs, patient to roll forward or rotate the spine around making high steps. one segment. Command. “Sit into my hand.” “Push.” Movement. The pelvis moves in an arc down and posteriorly. There is an elongation of the trunk on that side without a change in the lumbar lordosis. Body Mechanics. Your elbows flex as the patient’s pelvis moves downward and you shift your weight from your front to your back foot.

68 Chapter 6 · The Scapula and Pelvis Anterior Depression and Posterior Body Mechanics. Start with your elbows flexed to keep your forearms parallel to the patients back. 1 Elevation (. Fig. 6.15 a–c) The therapist stands behind the patient, facing to- Shift your weight to your front foot during the 2 ward a line representing about 25° of flexion of the motion and allow your elbows to extend. patient’s bottom (right) leg. 3 Anterior Depression (. Fig. 6.14 b, e; Resistance. At the beginning of the movement the resistance is toward the patient’s lower thorac- . Fig. 6.15 a–c) ic spine. As the motion continues, the line of the 4 Grip. Place the fingers of one hand on the greater resistance follows the curve of the body. At the trochanter of the femur. The other hand may rein- end of the pattern the resistance is diagonally back 5 force the first hand (. Fig. 6.15 a) or you may grip toward you and up toward the ceiling. below the anterior inferior iliac spine. 6 End Position (. Fig. 6.15 c). The pelvis is down and Alternate Grip. The fingers of the posterior hand forward. The trunk is elongated with no change in grip the ischial tuberosity. The anterior hand grips the lumbar lordosis. 7 below the anterior inferior iliac spine. For a grip using the leg, place your right hand Functional Activities. In daily activities we see this 8 on the patient’s anterior-inferior iliac spine and your activity in an eccentric way (going down stairs, ter- left hand on the patient’s left knee (. Fig. 6.15 b, c) minal swing, loading response). To facilitate these 9 You must move the patient’s leg until the femur is activities we place our hands as when facilitating in the line of the pattern (about 20° of hip flexion) posterior elevation of the pelvis and give resistance (. Fig. 6.15 b). to an eccentric contraction. 10 Elongated Position (. Fig. 6.15 a, b). Gently move 11 the pelvis up (cranial) and back (dorsal) toward the lower thoracic spine (posterior elevation). Be care- ful not to rotate or compress spinal joints. 12 Command. “Pull down and forward.” (“Push your 13 knee into my hand.”) 14 Movement. The pelvis moves down and anterior- ly. There is an elongation of the trunk on that side without a change in the lumbar lordosis. 15 16 17 18 19 20

6.5 · Pelvic Diagonals 669 ab c . Fig. 6.14a–e. Pelvic diagonal. a Neutral position; b Anterior depression; c Posterior elevation

70 Chapter 6 · The Scapula and Pelvis 1 2 3 4 5 6 7 8 9d e 10 . Fig. 6.14d, e. Pelvic patterns in function: d pelvic pattern posterior elevation, e pelvic pattern anterior depression 11 12 13 14 15 b a . Fig. 6.15a-c. Resistance to pelvic anterior depression. 16 The grip on the trochanter is shown in a 17 18 19 20 c

6.5 · Pelvic Diagonals 671 Posterior Elevation (. Fig. 6.14 c, d; . Fig. 6.16) Resistance. The resistance begins by lifting the Grip. Put the heel of one hand on the crest of the ili- posterior iliac crest around toward the front of the um, on and just posterior to the midline. Your other table. At the end of the motion the resistance has hand overlaps the first. There is no finger contact. made an arc around the body and is now lifting the ilia crest up toward the ceiling. Elongated Position (. Fig. 6.16 a). Gently push the pelvis down and forward until you feel and see End Position (. Fig. 6.16 b). The pelvis is up and that the posterior lateral tissues on that side are taut back. The upper side (left) of the trunk is shortened (anterior depression). Continued pressure should and laterally flexed with no increase in lumbar lor- not cause the patient to roll forward or rotate the dosis. spine around one segment. The pelvis is positioned in a direction of anterior depression. Functional Activities. Walking backward, prepar- ing to kick a ball. Command. “Push your pelvis up and back – gen- tly.” . Figure 6.17 a, b shows a pelvic diagonal used when treating a patient with hemiplegia. Movement. The pelvis moves up (cranial) and Points to Remember back (dorsal) into posterior elevation. There is a posterior shortening of the trunk on that side (lat- 5 Pure pelvic patterns do not change the eral flexion). amount of pelvic tilt. Body Mechanics. As the pelvis moves up and back 5 The pelvic motion comes from activity of shift your weight to your back foot. At the same the trunk muscles. Do not allow the leg to time flex and drop your elbows so that they point push the pelvis up. down toward the table. 5 The muscles involved in pelvic depres- sion are the contralateral pelvic elevating muscles. a b . Fig. 6.16a,b. Resistance to pelvic posterior elevation

72 Chapter 6 · The Scapula and Pelvis 1 2 3 4 5 6a b . Fig. 6.17. Patient with right hemiplegia. a Resistance to pelvic anterior elevation. b Resistance to pelvic posterior depres- 7 sion 8 6.5.2 Specific Uses for Pelvic Patterns the stabilized pelvis as the handle (7 Sect. 9 The pelvis and lower extremities facilitate and re- 11.3.1). – Use Repeated Contractions to strength- inforce each other. Pelvic depression patterns work en and reinforce learning of the function- 10 with and facilitate weight-bearing motions of the al activity. legs. Pelvic elevation patterns work with and facili- – Use the technique Combination of Isoton- 11 tate stepping or leg lifting motions. ics to teach control of the trunk motions. 5 Exercise the pelvis for motion and stability. Have the patient control trunk motion (. Fig. 6.17 a, b) with concentric and eccentric contractions while maintaining the pelvic stabilization. 12 5 Facilitate trunk motion and stability by using timing for emphasis and resistance for facili- – Use reversal techniques to prevent or re- 13 tation. lieve muscular fatigue. – Resist the pelvic patterns to exercise low- 5 The pelvis and lower extremities facilitate and 14 er trunk flexor, extensor, and lateral flex- reinforce each other. or muscles The pelvis should not move fur- – Pelvic depression patterns work with and ther into an anterior or posterior tilt dur- facilitate weight-bearing motions of the 15 ing these exercise. legs. Lock in pelvic posterior depression 1) Use Repeated Stretch from beginning then exercise extension motions of the ipsi- 16 of range or through range to strengthen lateral lower extremity. these trunk muscles. – Pelvic elevation patterns work with and fa- 17 2) Use Reversal of Antagonist techniques cilitate stepping or leg lifting motions. Lock to train coordination and prevent or re- in pelvic anterior elevation then exercise duce fatigue of the working muscles. flexion motions of the ipsilateral lower ex- 18 – Use Stabilizing Reversals or Rhythmic Sta- tremity. bilization to facilitate lower trunk and pel- 5 Treat the upper trunk and cervical areas in- 19 vic stability. directly through irradiation. Give sustained 5 Exercise functional trunk activities. maximal resistance to stabilizing or isomet- 20 – Use a stabilizing contraction to lock in the ric pelvic patterns until you see and feel con- pelvis, then give a functional command traction of the desired upper trunk and cervi- such as “roll” and resist the activity using cal muscles.

6.6 · Symmetrical, Reciprocal and Asymmetrical Exercises 673 Points to Remember 5 Pelvic motions work with and facilitate the leg motions, pelvic patterns do not correspond exactly with lower extremity patterns. 5 When using pelvic patterns for rolling, the pelvis is the handle and the rolling is exercised. 6.6 Symmetrical, Reciprocal and a Asymmetrical Exercises In addition to the exercises carried out with one b body part in one direction (the scapula moving in- to anterior elevation) and in both directions (the . Fig. 6.18a,b. Symmetrical-reciprocal exercise: the scapula scapula moving back and forth between anterior moves in anterior elevation, the pelvis in posterior depression elevation and posterior depression), both scapulae or the scapula and pelvis can be exercised simul- taneously. Any combination of scapular and pelvic patterns may be used, depending on the goal of the treatment and the abilities of the patient. Here we describe and illustrate two combinations. Use the basic procedures (grip, command, resistance, tim- ing, etc.) and techniques when you use the sym- metrical and asymmetrical pattern combinations just as when you work with single patterns in one direction. 6.6.1 Symmetrical-Reciprocal Exercise Here the scapula and pelvis move in the same di- . Fig. 6.19. Trunk extension with rotation: symmetrical re- agonal but in opposite patterns (. Fig. 6.18, 6.19, ciprocal combination of scapula and pelvis with extremity mo- 6.20). You position your body parallel to the lines tion of the diagonals. This combination of scapular and pelvic mo- tions results in full trunk elongation and shorten- ing with counter rotation. The motion is an en- larged version of the normal motion of scapula, pelvis and trunk during walking. Other function- al activities can be rolling, pushing something away from you, reaching overhead. Scapular anterior elevation-pelvic posterior de- pression (. Fig. 6.18) Scapular posterior depres- sion-Pelvic anterior elevation (. Fig. 6.20). Trunk

74 Chapter 6 · The Scapula and Pelvis 1 2 3 4 5 b a 6 . Fig. 6.20a,b. Symmetrical-reciprocal exercise: the scapula moves in posterior depression, the pelvis in anterior elevation 7 When both the scapula and pelvis move in the extension with rotation using a symmetrical com- 8 bination of scapula anterior elevation with pel- anterior patterns (forward toward each other) the vic posterior depression with extremity motion result is mass trunk flexion. (. Fig. 6.21, . Fig. 6.23) 9 (. Fig. 6.19). When both move in the posterior patterns (back- ward away from each) other) the result is mass trunk extension with elongation (. Fig. 6.22). 10 6.6.2 Asymmetrical Exercise Functional Activities. Patient can move from 11 In this combination the scapula and pelvis move in supine to prone position and backward. opposite diagonals and the diagonals are not par- . Figure 6.24 shows asymmetrical and symmet- allel. (. Fig. 6.21, 6.22) Position your body in the rical combinations used with a patient with hemi- 12 middle and align your forearms so that one is in plegia. the line of each diagonal. You cannot use your body 13 weight for resistance with this combination. 14 15 16 17 18 19 ab 20 . Fig. 6.21a,b. Asymmetrical exercise for trunk flexion: the scapula moves in anterior depression, the pelvis in anterior eleva- tion

6.6 · Symmetrical, Reciprocal and Asymmetrical Exercises 675 aa b . Fig. 6.22a,b. Asymmetrical exercise for trunk extension: the scapula moves in posterior elevation, the pelvis in poste- rior depression b . Fig. 6.24. Patient with right hemiplegia. a Mass trunk flex- ion: combination of scapular anterior depression and pelvic anterior elevation. b Trunk rotation: combination of scapular posterior depression and pelvic anterior elevation . Fig. 6.23. Trunk flexion: Asymmetrical combination of scapula and pelvis with extremity motion

76 Chapter 6 · The Scapula and Pelvis 1 Reference 2 3 Johnson G (1999) personal communication 4 Kendall FP, McCreary EK (1993) Muscles, testing and function. 5 6 Williams and Wilkins, Baltimore 7 8 Further Reading 9 10 Magarey ME, Jones MA (2003) Dynamic evaluation and early 11 management of altered motor control around the shoul- 12 der complex. Manual Ther (4): 195-206 13 14 Myers JB, Lephart SM (2000) The role of the sensorimotor sys- 15 tem in the athletic shoulder. J Athletic Training (3): 351- 16 363 17 18 19 20

7.1 · 777 The Upper Extremity 7.1 Introduction and Basic Procedures – 78 7.2 Flexion – Abduction – External Rotation – 80 7.2.1 Flexion – Abduction – External Rotation with Elbow Flexion – 83 7.2.2 Flexion – Abduction – External Rotation with Elbow Extension – 86 7.3 Extension – Adduction – Internal Rotation – 88 7.3.1 Extension – Adduction – Internal Rotation with Elbow Extension – 90 7.3.2 Extension – Adduction – Internal Rotation with Elbow Flexion – 92 7.4 Flexion – Adduction – External Rotation – 94 7.4.1 Flexion – Adduction – External Rotation with Elbow Flexion – 96 7.4.2 Flexion – Adduction – External Rotation with Elbow Extension – 98 7.5 Extension – Abduction – Internal Rotation – 101 7.5.1 Extension – Abduction – Internal Rotation with Elbow Extension – 103 7.5.2 Extension – Abduction – Internal Rotation with Elbow Flexion – 106 7.6 Thrust and Withdrawal Combinations – 108 7.6.1 Ulnar Thrust and Withdrawal – 109 7.6.2 Radial Thrust and Withdrawal – 109 7.7 Bilateral Arm Patterns – 111 7.8 Changing the Patient’s Position – 112 7.8.1 Arm Patterns in a Side Lying Position – 113 7.8.2 Arm Patterns Lying Prone on Elbows – 113 7.8.3 Arm Patterns in a Sitting Position – 114 7.8.4 Arm Patterns in the Quadruped Position – 114 7.8.5 Arm Patterns in a Kneeling Position – 115

78 Chapter 7 · The Upper Extremity 7.1 Introduction and Basic Diagonal Motion The upper extremity has two diagonals: 1 Procedures 1. Flexion–abduction–external rotation and ex- 2 Upper extremity patterns are used to treat dysfunc- tension–adduction–internal rotation tion caused by neurologic problems, muscular dis- 2. Flexion–adduction–external rotation and ex- 3 orders or joint restrictions. These patterns are al- tension–abduction–internal rotation so used to exercise the trunk. Resistance to strong arm muscles produces irradiation to weaker mus- The shoulder and the wrist-hand complex are tied 4 cles elsewhere in the body. together in the pattern synergy. The elbow is free to We can use all the techniques with the arm pat- move into flexion, move into extension, or remain 5 terns. The choice of individual techniques or com- motionless. Do not allow the arm to move laterally binations of techniques will depend on the patient’s out of the groove to compensate for any limitation 6 condition and the treatment goals. You can, for in- of shoulder motion. stance, combine Dynamic Reversals with Combi- Scapular motion is an integral part of each pat- nation of Isotonics, Repeated Contractions with tern. For a description of the motions making up 7 Dynamic Reversals, or, Contract-Relax or Hold- the scapular patterns see 7 Chapter 6. Relax with Combination of Isotonics and Dynam- The basic patterns of the left arm with the sub- 8 ic Reversals. ject supine are shown in . Fig. 7.1. All descriptions refer to this arrangement. To work with the right 9 arm just change the word “left” to “right” in the in- 10 Flex.-Add.-ER Flex.-Abd.-ER . Fig. 7.1. Upper extremity 11 Supination Supination diagonals (Courtesy of V. Jung): 12 Radial abduction Radial abduction with each of the four patterns, Palmar flexion Dorsal extension the elbow can flex, extend or Finger flexion Finger extension maintain a position Adduction finger Abduction finger 13 14 15 16 Ext.-Abd.-IR Pronation Ext.-Add.-IR Ulnar abduction Dorsal extension 17 Pronation Finger extension Ulnar abduction Abduction finger 18 Palmar flexion Finger flexion Adduction finger 19 20

7.1 · Introduction and Basic Procedures 779 structions. Variations of position are shown later in vent squeezing or pinching the patient’s hand. Re- the chapter. member, pain inhibits effective motion. Patient Position We recommend distal grips when the arm – Note patterns start straight and optimal elongation or stretch is important. If the arm and elbow go from Position the patient close to the left edge of the extension to flexion, change the proximal grip from table. the forearm to the upper arm for better shoulder control. If the arm moves from flexion to extension, Support the patient’s head and neck in a comforta- we recommend starting with the proximal grip on ble position, as close to neutral as possible. Before the humerus for better elongation of all scapula and beginning an upper extremity pattern, visualize the shoulder muscles. If the strong arm is used to facili- patient’s arm in a middle position where the lines tate the trunk, the proximal hand can also be on the of the two diagonals cross. Starting with the shoul- scapula or on the active trunk muscles. der and forearm in neutral rotation, move the ex- tremity into the elongated range of the pattern with Resistance the proper rotation, beginning with the wrist and fingers. The direction of the resistance is an arc back to- ward the starting position. The angle of the ther- Therapist Position apist’s hands and arms changes as the limb moves – Note through the pattern. The therapist stands on the left side of the table Traction and Approximation facing the line of the diagonal, arms and hands aligned with the motion. Traction and approximation are an important part of the resistance. Use traction at the beginning of All grips described in the first part of each section the motion in both flexion and extension. Use ap- assume that the therapist is in this position. proximation at the end of the range to stabilize the arm and scapula. We give the basic position and body mechanics for exercising the straight arm pattern. When we Normal Timing and Timing for Emphasis describe variations in the patterns we identify any Normal Timing changes in position or body mechanics. The thera- pist’s position can vary within the guidelines for the The hand and wrist (distal component) begin the basic procedures. Some of these variations are illus- pattern, moving through their full range. Rotation trated at the end of the chapter. at the shoulder and forearm accompanies the ro- tation (radial or ulnar deviation) of the wrist. Af- Grips ter the distal movement is completed, the scapula The grips follow the basic procedures for manu- moves together with the shoulder or shoulder and al contact, opposite the direction of movement. elbow through their range. The arm moves through The first part of this chapter (7 Section 7.2) de- the diagonals in a straight line with rotation occur- scribes the two-handed grip used when the thera- ring smoothly throughout the motion. pist stands next to the moving upper extremity. The basic grip is described for each straight arm pat- Timing for Emphasis tern. The grips are modified when the therapist’s or patient’s position is changed. The grips also change In the sections on timing for emphasis we offer when the therapist can use only one hand while the some suggestions for exercising components of the other hand controls another extremity. The grip on patterns. Any of the techniques may be used. We the hand contacts the active surface, dorsal or pal- have found that Repeated Stretch (Repeated Con- mar, and holds the sides of the hand to resist the ro- tractions) and Combination of Isotonics work well. tary components. Using the lumbrical grip will pre- Do not limit yourself to the exercises we suggest in this section, use your imagination.

80 Chapter 7 · The Upper Extremity Stretch tension on joint structure. This is particularly im- 1 In the arm patterns we use stretch-stimulus with or portant with the wrist joint. without the stretch reflex to facilitate an easier or 2 stronger movement, or to start the motion. Irradiation and Reinforcement Repeated Stretch (Repeated Contractions) dur- We can use strong arm patterns (single or bilateral) 3 ing the motion facilitates a stronger motion or to get irradiation into all other parts of our body. guides the motion into the desired direction. Re- The patient’s position in combination with the peated Stretch at the beginning of the pattern is amount of resistance controls the amount of irradi- 4 used when the patient has difficulty initiating the ation. We use this irradiation to strengthen muscles motion and to guide the direction of the motion. or mobilize joints in other parts of the body, to re- 5 To get the stretch reflex the therapist must elongate lax muscle chains, and to facilitate a functional ac- both the distal and proximal components. Be sure tivity such as rolling. 6 you do not overstretch a muscle or put too much 7 7.2 Flexion – Abduction – External Rotation (. Fig. 7.2) 8 Joint Movement Muscles: principal components 9 (Kendall and McCreary 1993) 10 Scapula Posterior elevation 11 Shoulder Flexion, abduction, external rotation Trapezius, levator scapulae, serratus anterior 12 13 Elbow Extended (position unchanged) Deltoid (anterior), biceps (long head), coracobrachialis, 14 Forearm Supination supraspinatus, infraspinatus, teres minor 15 Wrist Radial extension 16 Fingers Extension, radial deviation Triceps, anconeus 17 Thumb Extension, abduction 18 Biceps, brachioradialis, supinator 19 20 Extensor carpi radialis (longus and brevis) Extensor digitorum longus, interossei Extensor pollicis (longus and brevis), abductor pollicis longus Grip ing any pressure on the anterior (palmar) surface of Distal Hand the forearm. Your right hand grips the dorsal surface of the pa- tient’s hand. Your fingers are on the radial side Alternative Grip (1st and 2nd metacarpal), your thumb gives coun- To emphasize shoulder or scapula motions, move terpressure on the ulnar border (5th metacarpal). the proximal hand to grip the upper arm or There is no contact on the palm. the scapula after the wrist completes its motion (. Fig. 7.2 d, e). ! Caution Do not squeeze the hand. Elongated Position Place the wrist in ulnar flexion and the forearm in- Proximal Hand to pronation. Maintain the wrist and hand in po- From underneath the arm, hold the radial and ul- sition while you move the shoulder into extension nar sides of the patient’s forearm proximal to the and adduction. You may use gentle traction to help wrist. The lumbrical grip allows you to avoid plac- elongate the shoulder and scapula muscles. The hu-

7.2 · Flexion – Abduction – External Rotation 781 ab cd . Fig. 7.2. Flexion–abduction–external rotation. a Starting posi- tion; b mid-position; c end position; d emphasizing the motion of the shoulder. e Patient with right hemiplegia. Flexion–abduction–exter- nal rotation: proximal hand for scapula posterior elevation and trunk elongation e

82 Chapter 7 · The Upper Extremity merus crosses over the midline to the right and Use approximation through the humerus at the 1 the palm faces toward the right ilium. The traction end of the shoulder range to resist the scapula ele- brings the scapula into anterior depression. A con- vation and stabilize the shoulder. 2 tinuation of this motion would bring the patient in- End Position to trunk flexion to the right. 3 Body Mechanics The humerus is in full flexion (about three fingers from the left ear), the palm facing about 45° to the Stand in a stride position by or above the patient’s coronal (lateral) plane. The scapula is in posterior 4 shoulder with your left foot forward. Face the line elevation. The elbow remains extended. The wrist is of motion. Start with the weight on your front foot in full radial extension, fingers and thumb extend- 5 and let the patient’s motion push your weight to ed toward the radial side. your back foot. Continue facing the line of motion. 6 Stretch Timing for Emphasis You may prevent motion in the beginning of the Apply the stretch to the shoulder and hand simulta- shoulder flexion or in the mid-range and exercise 7 neously. Your proximal hand does a rapid traction the wrist, hand, or fingers. with rotation of the shoulder and scapula. Your dis- 8 tal hand gives traction to the wrist. Points to Remember 9 ! Caution 5 The stretch at the wrist is done with trac- Traction the wrist in line with the metacarpal tion, not more flexion bones. Do not force the wrist into more flexion. 5 Too much shoulder rotation limits the 10 scapular movement Command 5 At the end of the pattern the trunk is in 11 “Hand up, lift your arm.” “Lift!” elongation Movement 12 The fingers and thumb extend as the wrist moves into radial extension. The radial side of the hand 13 leads as the shoulder moves into flexion with ab- duction and external rotation. The scapula moves 14 into posterior elevation. Continuation of this mo- tion is an upward reach with elongation of the left side of the trunk. 15 Resistance 16 Your distal hand combines traction through the extended wrist with a rotary resistance for the ra- 17 dial deviation. Resistance to the forearm supina- tion and shoulder external rotation and abduction comes from the rotary resistance at the wrist. The 18 traction force resists the motions of wrist extension and shoulder flexion. 19 Your proximal hand combines a traction force with rotary resistance. The line of resistance is back 20 toward the starting position. Maintaining the trac- tion force will guide your resistance in the prop- er arc.

7.2 · Flexion – Abduction – External Rotation 783 7.2.1 Flexion – Abduction – External Rotation with Elbow Flexion (. Fig. 7.3) Joint Movement Muscles: principal components (Kendall and McCreary 1993) Scapula Posterior elevation Shoulder Flexion, abduction, external rotation Trapezius, levator scapulae, serratus anterior Elbow Flexion Deltoid (anterior), biceps (long head), coracobrachia- Forearm Supination lis, supraspinatus, infraspinatus, teres minor Wrist Radial extension Fingers Extension, radial deviation Biceps, brachialis Thumb Extension, abduction Biceps, brachioradialis, supinator Extensor carpi radialis (longus and brevis) Extensor digitorum longus, interossei Extensor pollicis (longus and brevis), abductor polli- cis longus Grip Alternative Position Distal Hand You may stand on the right side of the table facing Your distal grip is the same as described in 7 Sect. up toward the patient’s left shoulder. Put your left 7.2 for the straight arm pattern. hand on the patient’s hand, your right hand on the humerus. Stand in a stride with your right leg for- Proximal Hand ward. As the patient’s arm moves up into flexion, Your proximal hand may start with the grip used step forward with your left leg. If you choose this for the straight arm pattern. As the shoulder and position, move the patient to the right side of the elbow begin to flex, move this hand up to grip the table (. Fig. 7.3 d, e). humerus. You wrap your hand around the humer- us from the medial side and use your fingers to give Stretch pressure opposite the direction of motion. The re- Use the same motions for the stretch reflex that you sistance to rotation comes from the line of your fin- used with the straight arm pattern. gers and forearm. ! Caution Alternative Grip Traction the wrist in line with the metacarpal The proximal hand may move to the scapula to em- bones. Do not force the wrist into more flexion. phasize that motion. Command Elongated Position “Hand up, lift your arm and bend your elbow.” Position the limb as for the straight arm pattern. “Lift!” Body Mechanics Movement Stand in the same stride position as for the straight The fingers and thumb extend and the wrist moves arm pattern. Allow the patient to push your weight into radial extension as in the straight arm pattern. from your front to your back foot. Face the line of The elbow and shoulder motions begin next. The motion. elbow flexion causes the hand and forearm to move across the face as the shoulder completes its flex- ion.

84 Chapter 7 · The Upper Extremity 1 2 3 4 5 6 a 7 8 d 9 10 11 12 13 b 14 15 16 17 e 18 19 c 20 . 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

7.2 · Flexion – Abduction – External Rotation 785 f Timing for Emphasis . Fig. 7.3. f Patient with hemiplegia, the patient is asked to With three moving segments, shoulder, elbow and touch his head 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 rota- tion, and the supination separately from the shoul- der 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 be- fore 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 appropri- ate resistance to the wrist and hand motions. To ex- ercise 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 5 The stretch at the wrist is done with trac- tion, not more flexion Your distal hand resists the wrist and forearm as it did in the straight arm pattern. Add resistance to 5 Resist the elbow flexion with traction back the elbow flexion by giving traction in and arc back to the starting position toward the starting position. 5 Extend the patient’s elbow, the position is Your proximal hand combines rotary resist- the same as the straight arm pattern ance with traction through the humerus toward the starting position. Give a separate force with each 5 Give a functional command such as “touch hand so that the resistance is appropriate for the the top of your head” 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 pa- tient’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.

86 Chapter 7 · The Upper Extremity 7.2.2 Flexion – Abduction – External Rotation with Elbow Extension (. Fig. 7.4) 1 Joint Movement Muscles: principal components (Kendall and McCreary 1993) 2 Scapula Posterior elevation Trapezius, levator scapulae, serratus anterior 3 Shoulder Flexion, abduction, external rotation Deltoid (anterior), biceps (long head), coracobrachialis, 4 Elbow Extension supraspinatus, infraspinatus, teres minor Triceps, anconeus 5 Forearm Supination Biceps, brachioradialis, supinator Wrist Radial extension Extensor carpi radialis (longus and brevis) 6 Fingers Extension, radial deviation Extensor digitorum longus, interossei Thumb Extension, abduction Extensor pollicis (longus and brevis), abductor polli- cis longus 7 8 Grip ! Caution 9 Your distal grip is the same as for the straight arm Traction the wrist, do not force it into more flexion. pattern. Wrap your proximal hand around the hu- merus from the medial side so that your fingers Command 10 give pressure opposing the direction of motion. “Hand up, push your arm up and straighten your elbow as you go.” “Push!” “Reach up.” 11 Elongated Position The position of the patient’s scapula, shoulder, fore- Movement arm, and wrist are the same as for the straight arm The fingers and thumb extend and the wrist moves 12 pattern. The elbow is fully flexed. into radial extension as before. The elbow and shoulder motions begin next. The elbow extension 13 Alternative starting position (. Fig. 7.4 c) moves the hand and forearm in front of the face The therapist can also stand close to the pelvis, fac- as the shoulder flexes. The elbow reaches full ex- 14 ing the patient. The left hand grips the humerus tension as the shoulder and scapula complete their and triceps under the forearm and tractions the up- motion. per arm into extension, adduction and internal ro- 15 tation and the scapula into anterior depression. Resistance Your distal hand resists the wrist and forearm as in 16 Body Mechanics the straight arm pattern. Give resistance to the el- Stand in the same stride position used for the bow extension by rotating the forearm and hand 17 straight arm pattern. Shift your weight as you did back toward the starting position of elbow flexion. for the straight arm pattern. Your proximal hand gives traction through the hu- merus combined with rotary resistance back to- 18 Stretch ward the starting position. Apply the stretch to the shoulder, elbow, and hand Each of your hands uses the proper force to 19 simultaneously. Your proximal hand stretches the make the resistance appropriate for the strength of shoulder and scapula with a rapid traction and ro- the elbow and the strength of the shoulder. Use ap- 20 tation motion. Your distal hand continues giving proximation through the humerus at the end of the traction to the hand and wrist while stretching the shoulder range to resist the scapula elevation and elbow extension. stabilize the shoulder and elbow.

7.2 · Flexion – Abduction – External Rotation 787 ab c . Fig. 7.4. Flexion-abduction-external rotation with elbow extension. a, b Standard grips; c Grip variation End Position Points to Remember The end position is the same as the straight arm pattern. 5 The stretch at the wrist is done with trac- tion, not more flexion Timing for Emphasis Prevent elbow extension at the beginning of the 5 Use a rotary force back into pronation to range and exercise the shoulder. Lock in shoulder resist the elbow extension flexion in mid-range and exercise the elbow exten- sion with supination.

88 Chapter 7 · The Upper Extremity 7.3 Extension – Adduction – Internal Rotation (. Fig. 7.5) 1 Joint Movement Muscles: principal components (Kendall and McCreary 1993) 2 Scapula Anterior depression Serratus anterior (lower), pectoralis minor, rhomboids 3 Shoulder Extension, adduction, internal rotation Pectoralis major, teres major, subscapularis 4 Elbow Extended (position unchanged) Triceps, anconeus Brachioradialis, pronator (teres and quadratus) Forearm Pronation Flexor carpi ulnaris 5 Wrist Ulnar flexion Fingers Flexion, ulnar deviation Flexor digitorum (superficialis and profundus), lum- Flexion, adduction, opposition bricales, interossei 6 Flexor pollicis (longus and brevis), adductor pollicis, Thumb opponens pollicis 7 8 Grip If the patient has just completed the antagonis- 9 Distal Hand tic motion (flexion-abduction-external rotation), Your left hand contacts the palmar surface of the begin at the end of that pattern. patient’s hand. Your fingers are on the radial side 10 (2nd metacarpal), your thumb gives counter-pres- Body Mechanics sure on the ulnar border (5th metacarpal). There is Stand in a stride position above the patient’s shoul- 11 no contact on the dorsal surface. der with your left foot forward. Face the line of mo- tion. Start with the weight on your back foot and let ! Caution the patient’s motion pull your weight to your front foot. Continue facing the line of motion. 12 Do not squeeze the patient’s hand. 13 Proximal Hand Stretch Your right hand comes from the radial side and Apply the stretch to the shoulder and hand simulta- 14 holds the patient’s forearm just proximal to the neously. Your proximal hand does a rapid traction wrist. Your fingers contact the ulnar border. Your with rotation of the shoulder and scapula. thumb is on the radial border. ! Caution Do not force the shoulder into more flexion. 15 Elongated Position 16 Place the wrist in radial extension and the fore- arm into supination. Maintain the wrist and hand Your distal hand gives traction to the wrist. 17 in position while you move the shoulder into flex- ion and abduction. You may use gentle traction to ! Caution help elongate the shoulder and scapula muscles. Traction the wrist in line with the metacarpal 18 The palm faces about 45° to the lateral plane. The bones. Do not force the wrist into more extension. traction brings the scapula into posterior elevation. 19 Continuation of the traction elongates the patient’s Command trunk diagonally from left to right. Too much ab- “Squeeze my hand, pull down and across.” “Squeeze 20 duction prevents trunk elongation. Too much ex- and pull!” ternal rotation prevents the scapula from coming into full posterior elevation.

7.3 · Extension – Adduction – Internal Rotation 789 a b . Fig. 7.5a,b. Extension-adduction-internal rotation Movement right. The forearm is pronated, the wrist and fingers flexed with the palm facing toward the right ilium. The fingers and thumb flex as the wrist moves in- to ulnar flexion. The radial side of the hand leads as Timing for Emphasis the shoulder moves into extension with adduction You may prevent motion in the beginning range of and internal rotation and the scapula into anteri- shoulder extension or allow the shoulder to reach or depression. Continuation of this motion brings the mid-position and exercise the wrist, hand, and the patient into trunk flexion with neck flexion to fingers. To exercise the fingers and thumb, move the right. your proximal hand to give resistance just distal to the wrist. Your distal hand can now exercise the fin- Resistance gers, together or individually. Your distal hand combines traction through the Points to Remember flexed wrist with rotary resistance to ulnar devia- tion. The rotary resistance at the wrist provides re- 5 The stretch at the wrist and shoulder is sistance to the forearm pronation and shoulder ad- done with traction, not more flexion duction and internal rotation. The traction at the wrist resists the wrist flexion and the shoulder ex- 5 Approximate at the end range to resist the tension. scapula and stabilize the shoulder Your proximal hand combines a traction force 5 The humerus crosses mid-line with rotary resistance. The line of resistance is back toward the starting position. Maintaining the trac- tion force will guide your resistance in the prop- er arc. Your hands change from traction to approxi- mation as the shoulder and scapula near the end of their range. The approximation resists the scapula depression and stabilizes the shoulder. End Position The scapula is in anterior depression. The shoul- der is in extension, adduction, and internal rota- tion with the humerus crossing the midline to the

90 Chapter 7 · The Upper Extremity 7.3.1 Extension – Adduction – Internal Rotation with Elbow Extension (. Fig. 7.6) 1 Joint Movement Muscles: principal components (Kendall and McCreary 1993) 2 Scapula Anterior depression Serratus anterior (lower), pectoralis minor, rhom- boids 3 Shoulder Extension, Adduction, Internal Rotation Pectoralis major, teres major, subscapularis 4 Elbow Extension Triceps, anconeus 5 Forearm Pronation Brachioradialis, pronator (teres and quadratus) Wrist Ulnar flexion Flexion, ulnar deviation Flexor carpi ulnaris 6 Fingers Flexion, adduction, opposition Flexor digitorum (superficialis and profundus), 7 Thumb lumbricales, interossei Flexor pollicis (longus and brevis), adductor polli- cis, opponens pollicis 8 Grip Command 9 Your distal grip is the same as for the straight arm “Squeeze my hand, push down and across, straight- pattern. Wrap your proximal hand around the hu- en your elbow.” “Squeeze and push!” “Reach for 10 merus from underneath so that your fingers can your right hip.” give pressure opposite the direction of rotation. 11 During the starting position the therapist can give Movement resistance with the forearm against the forearm of The fingers and thumb flex and the wrist moves in- the patient on the palmar side (. Fig. 7.6 a). to ulnar flexion. The shoulder begins its motion in- to extension-adduction, and then the elbow begins 12 to extend. The hand moves down toward the op- Elongated Position 13 The humerus is in full flexion with the scapula in posite hip. The elbow reaches full extension as the posterior elevation. The elbow is flexed, and the pa- shoulder and scapula complete their motion. 14 tient’s forearm is touching the head. The wrist is in Resistance full radial extension with the fingers extended. 15 Body Mechanics Your distal hand resists the wrist and forearm, as in the straight arm pattern. Give resistance to the Your body mechanics are the same as for the elbow extension by rotating the forearm and hand 16 straight arm pattern. back toward the starting position of elbow flexion. Give approximation to facilitate the elbow exten- 17 Stretch sion. Apply the stretch to the shoulder and hand simulta- Your proximal hand gives traction through the neously. Your proximal hand does a rapid traction humerus combined with rotary resistance back to- 18 with rotation of the shoulder and scapula. Your dis- ward the starting position. Change from traction tal hand gives traction to the wrist. Usually the pa- to approximation as the shoulder and scapula pass 19 tient’s forearm is touching the head, preventing in- about halfway through their range. creased elbow flexion. Each of your hands uses the proper force to 20 make the resistance appropriate for the strength of the elbow and the strength of the shoulder.

7.3 · Extension – Adduction – Internal Rotation 791 ab . Fig. 7.6a-c. Extension-adduction-internal rotation with el- bow extension c End Position Points to Remember The end position is the same as the straight arm pattern. 5 The humerus crosses mid-line 5 Normal timing: the elbow and shoulder Timing for Emphasis Prevent elbow extension at the beginning of the motion occur together range and exercise the shoulder. Lock in shoulder extension in mid-range and exercise the elbow ex- tension with pronation.

92 Chapter 7 · The Upper Extremity 7.3.2 Extension – Adduction – Internal Rotation with Elbow Flexion (. Fig. 7.7) 1 Joint Movement Muscles: principal components (Kendall and Mc- Creary 1993) 2 3 Scapula Anterior depression Serratus anterior (lower), pectoralis minor, rhom- boids Shoulder Extension, Adduction, Internal Rotation Pectoralis major, teres major, subscapularis 4 Elbow Flexion Biceps, brachialis 5 Forearm Pronation Brachioradialis, pronator (teres and quadratus) Wrist Ulnar flexion Flexor carpi ulnaris 6 Fingers Flexion, ulnar deviation Flexor digitorum (superficialis and profundus), lum- bricales, interossei 7 Thumb Flexion, adduction, opposition Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis 8 Grip Resistance 9 Your distal and proximal grips are the same as Your distal hand resists the wrist and forearm, as in those used for extension-adduction-internal rota- the straight arm pattern. Give resistance to the el- 10 tion with elbow extension. bow flexion by rotating the forearm toward supi- nation and back toward the starting position of el- 11 Alternative Grip bow extension. After the motion begins, the proximal hand may Your proximal hand gives traction through the move to the scapula to emphasize that motion. humerus combined with rotary resistance back to- ward the starting position. Change from traction 12 to approximation as the shoulder and scapula pass Elongated Position 13 The position is the same as the straight arm pat- about halfway through their range. tern. Each of your hands uses the proper force to 14 Stretch make the resistance appropriate for the strength of the elbow and the strength of the shoulder. The stretch is the same as for the straight arm pat- 15 tern. End Position The humerus is in extension with adduction, the 16 Command scapula in anterior depression. The elbow is fully “Squeeze my hand, pull down and across and bend flexed. The wrist is in ulnar flexion and the hand 17 your elbow.” “Squeeze and pull.” closed. The rotation in the shoulder and forearm is the same as in the straight arm pattern. If you ex- Movement tend the patient’s elbow, the position is the same as 18 The fingers and thumb flex and the wrist moves the straight arm pattern. into ulnar flexion. The shoulder starts into exten- 19 sion–adduction and the elbow begins to flex. The Timing for Emphasis elbow reaches full flexion as the shoulder and scap- With the three moving segments, shoulder, elbow 20 ula complete their motion. and wrist, you may again lock in any two and exer- cise the third.

7.3 · Extension – Adduction – Internal Rotation 793 a d b e c . Fig. 7.7. Extension-adduction-internal rotation with elbow flexion. a–c Standard grips; d,e grip variations

94 Chapter 7 · The Upper Extremity With the elbow bent it is easy to exercise the in- You may prevent motion in the beginning range 1 ternal rotation separately from the other motions. of shoulder extension and exercise the elbow, wrist, Exercise this motion where the strength of shoul- hand, or fingers. In addition, you may lock in the 2 der extension is greatest. You may work through shoulder and elbow motion in mid-range to exer- the full range of shoulder internal rotation during cise the wrist and hand. This places the hand where 3 these exercises and return to the groove before fin- the patient can see it as it moves. ishing the pattern. When exercising the patient’s wrist or hand, Points to Remember 4 move your proximal hand to the forearm and give 5 With the proper rotation the humerus will resistance to the shoulder and elbow by pulling cross mid-line 5 back toward the starting position. Your distal hand 5 Resist the elbow flexion with traction back is now free to give appropriate resistance to the toward the starting position 6 wrist and hand. To exercise the fingers and thumb, 5 Normal timing: the elbow and shoulder move your proximal stabilizing hand just distal to motion occur together the wrist. 7 8 7.4 Flexion – Adduction – External Rotation (. Fig. 7.8) 9 10 Joint Movement Muscles: principal components 11 (Kendall and McCreary 1993) 12 Scapula Anterior elevation 13 Shoulder Flexion, adduction, external rotation Serratus anterior (upper), trapezius 14 15 Elbow Extended (position unchanged) Pectoralis major (upper) deltoid (anterior), biceps, cora- Forearm Supination cobrachialis Wrist Radial flexion Fingers Flexion, radial deviation Triceps, anconeus Thumb Flexion, adduction opposition Brachioradialis, supinator Flexor carpi radialis Flexor digitorum (superficialis and profundus), lumbri- cales, interossei Flexor pollicis (longus and brevis), adductor pollicis, op- ponens pollicis 16 Grip Proximal Hand 17 Distal Hand Your left hand grips the patient’s forearm from un- Your right hand contacts the palmar surface of the derneath just proximal to the wrist. Your fingers are patient’s hand. Your fingers are on the ulnar side on the radial side, your thumb on the ulnar side. 18 (5th metacarpal), your thumb gives counter pres- sure on the radial side (2nd metacarpal). There is Alternative Grip 19 no contact on the dorsal surface. To emphasize shoulder or scapula motions, move the proximal hand to grip the upper arm or the 20 ! Caution scapula after the shoulder begins its motion. Do not squeeze the hand.