Therapeutic Exercises for the Distal Upper Extremity

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194 Terms

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Therapeutic Exercise

The systematic application of exercise and movement

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What does therapeutic exercise develop or restore?

Muscular strength, endurance, and flexibility

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What does therapeutic exercise improve?

Neuromuscular coordination

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What types of therapeutic exercises are used to improve neuromuscular coordination?

Gross and fine motor exercises

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What does therapeutic exercise increase?

Cardiovascular efficiency

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What type of therapeutic exercise is used to increase cardiovascular efficiency?

Aerobic exercise

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What does therapeutic exercise target?

Health and performance factors

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2 Goals of Therapeutic Exercise

1. Rehabilitation

2. Habilitation

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Is rehabilitation or habilitation, the restoration of function lost due to injury, disease, or behavioral traits?

Rehabilitation

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Is rehabilitation or habilitation, the acquisition of age-appropriate skills and functions?

Habilitation

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Is habilitation generally used for children or adults?

Children

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Rationale for Therapeutic Exercise

Movement is needed

Trauma causes scars that can bind structures together

Inflammation, edema, and immobilization can lead to problems

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Why is movement needed?

To maintain joint mobility and tendon gliding

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What does immobilization lead to?

Joint stiffness

Restricted tendon gliding

Muscle atrophy

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What does trauma cause?

Scars

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What can scars bind?

Gliding structures together

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What can inflammation and edema lead to?

Fibrosis

Decreased tissue gliding

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What does the "stress" of movement enhance?

Normal orientation of collagen fibers to lay in a linear fashion, preventing cross links

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What does the "stress" of movement increase?

Tendon and ligament strength

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What can the "stress" of movement influence?

Collagen formation to maintain or restore tissue gliding

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What can the "stress" of movement restore?

Motion through collagen remodeling

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What type of information should clinicians incorporate in their evaluation, subjective or objective?

Objective information

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What information needs to be obtained from the evaluation?

Structures that need to be immobilized

Structures that can be moved without restriction

Structures that can be moved only under certain conditions

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How soon can a clinician move an affected body part that underwent surgery?

Immediately

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How soon can a clinician move an affected body part that was set in a cast via closed reduction?

As soon as the affected body part starts healing (callus)

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3 Purposes of Therapeutic Exercise

1. Restore function

2. Maintain mobility

3. Restore motion

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What should the clinician anticipate during the evaluation?

What limits may occur

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What should the clinician determine during the evaluation?

Reason for limitation and an exercise program to stress the correct structures

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When does the clinician determine the correct structures to stress, evaluation or assessment?

Assessment

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What can limitation occur as result of?

Pain

Edema

Atrophy

Denervation

Secondary changes in joints and soft tissues

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3 Components of Therapeutic Exercise Dosage

1. Intensity/force (active contraction vs. passive stretch)

2. Duration (how long a force should be sustained)

3. Frequency (repetitions per day/sessions per day)

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What is therapeutic exercise dosage based on?

What the client can do

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What type of motion will the clinician recommend for someone who can move their affected body part halfway, passive, active assisted, or active?

Active assisted motion

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What type of motion will the clinician recommend for someone who can not move their affected body part at all, passive, active assisted, or active?

Passive motion

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What is a sign to the clinician that they are stretching their client to much?

Blanching (white)

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Typically how long should a stretch be held for?

30 seconds

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What 2 factors is therapeutic exercise dosage based on?

1. Purpose of exercise

2. Stage of wound healing

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What is the course of action during the inflammatory stage of wound healing?

Rest and immobilization

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What position can the client rest in during the inflammatory stage of wound healing?

In a balanced position or above the heart

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Why is it important to rest an affected body part above the heart?

To minimize swelling and edema

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What is the course of action during the fibroplasia stage of wound healing?

Stress to influence collagen

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Should a low and gentle or high and hard amount of force be applied to a client in the fibroplasia stage of wound healing?

Low and gentle force

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Should a client in the fibroplasia stage of wound healing be given a few repetitions or a lot of repetitions of exercise?

Few

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How much pain should be felt during the performance of therapeutic exercises in the fibroplasia stage of wound healing?

None (perform in a pain-free range)

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When should the dosage of therapeutic exercise increase in the fibroplasia stage of wound healing?

As tensile strength increases

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What can occur during the maturation stage of wound healing?

Stiffness and decreased tendon excursion

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Why should therapeutic exercise be used in the maturation stage of wound healing?

To create changes

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How can collagen be influenced by therapeutic exercise in the maturation stage of wound healing?

By applying mild or low loads for a long duration, prolonged at the end range of joint motion

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What is the purpose of therapeutic exercises in the maturation stage of wound healing?

Stretch tissues

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What type of motion should clinicians try and get their clients back to as soon as possible?

Active (or active-assisted)

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What can be used in conjunction with therapeutic exercises in the maturation stage of wound healing?

Orthoses

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What is a general consideration of therapeutic exercise in the hand?

Restore the muscle balance between the wrist extensors and finger flexors

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Treatment Goals of Therapeutic Exercise

Manage pain

Improve posture

Increase motion, endurance, and strength

Restore function

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Passive Motion Exercise

Motion produced by an external force such as a therapist or machine

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Benefits of Passive Motion Exercise

Maintains joint/soft tissue mobility

Edema control (with elevation and muscle pumping)

Increases circulation and synovial fluid

Pain management (make sure client tells you when it hurts)

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Indications of Passive Motion Exercise

Pain with active movement

Weakness

Need to maximize range of motion

Joint replacement

Contracture management

Paralysis

Spasticity

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What does passive motion exercise not promote?

Muscle maintenance (passive motion does not prevent atrophy)

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What is the only type of exercise someone with a joint replacement can do?

Passive motion exercise

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What does pain with passive motion exercises indicate?

Soft tissue injury

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Precautions with Passive Motion Exercise (Stretching)

Mobilizing unprotected joints

Stretching wrong joint

Causing additional trauma

Osteoporosis (pressing to hard can cause a fracture)

Edematous tissues (orthosis in a balanced position)

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What are edematous tissues more susceptible to?

Injury

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Where should the client stabilize when stretching a finger?

Proximal and distal to target a specific joint

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Where should the clinician provide a passive stretch, beginning range, mid-range, or end range of motion?

End range of motion to lengthen shortened soft tissues

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What type of force should be applied when providing a passive stretch?

A slow, gentle, and sustained force

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2 Types of Muscle Fibers

1. Contractile muscle fibers

2. Non-contractile connective tissues

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What muscles fibers can a passive stretch elongate?

1. Contractile muscle fibers

2. Non-contractile connective tissues

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What do joint contractures require before a passive stretch?

Joint mobilization

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What should the clinician determine about the joint contracture before providing a passive stretch?

End feel

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What does joint distraction avoid?

Compression during stretch

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Should joint compression or distraction be used for someone who experiences pain in the joint due to a soft tissue injury?

Joint distraction

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Should joint compression or distraction be used for someone who is hypermobile?

Joint compression

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When providing a passive stretch to a finger joint, what should be isolated?

Each individual joint

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In what position should the wrist be in when providing a passive stretch to a finger joint?

Neutral

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How can a clinician instruct their client to stretch their fingers into abduction?

Slowly lace their fingers together

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What should the clinician keep in mind when passively stretching finger joints?

MCP hyperextension (return client back to THEIR normal)

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Intrinsic and Extrinsic Tightness Test

Clinician will passively flex the clients PIP joint with the corresponding MCP joint in extension and again with the MCP joint in flexion

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Positive Intrinsic Tightness Test

When the PIP joint can not be flexed when the MCP joint is extended

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Positive Extrinsic Tightness Test

When the PIP joint can not be flexed when the MCP joint is flexed

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Carpometacarpal Joint

Articulation between the distal row of carpals and the base of the 2nd - 5th metacarpals

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What 2 CMC joints are immobile?

1. 2nd CMC joint

2. 3rd CMC joint

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What does the immobility of the 2nd and 3rd CMC joints allow people to do?

Cup their hand

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What 2 CMC joints are mobile?

1. 4th CMC joint

2. 5th CMC joint

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How many degrees of flexion are available at the 4th and 5th CMC joints?

10-20°

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3 Palmar Arches of the Hand

1. Proximal transverse arch

2. Distal transverse arch

3. Longitudinal arch

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What 2 joints form the functional palmar arches in the hand?

1. Carpometacarpal joint

2. Metacarpophalangeal joint

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How can a clinician increase their clients palmar arches?

By placing their thumb in the clients palm and fingers on dorsum of hand to roll the metacarpals of the clients hand around the clinicians thumb

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What position can a clients hand end up in if the palmar arches are not supported?

Intrinsic minus

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What motion does the forearm allow?

Pronation and supination

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Passive Stretching of Forearm

Stabilize humerus (avoid internal and external rotation)

Apply force to distal forearm (not wrist or hand)

Stretch with elbow flexed and progress to elbow extended

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What may a limit in pronation be caused by?

Biceps brachii tightness

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What relaxes muscles to be elongated before stretching?

Active inhibition

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Example of Active Inhibition

Contract-relax

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Contract-Relax

An isometric contraction of a tight muscle before passive lengthening

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Passive Stretching of Intrinsic Muscles of the Hand

Put PIP and DIP joints into flexion

Gently stretch MCP joint into extension

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Passive Stretching of Extrinsic Wrist Extensors

Palm down

Flex DIP, PIP, and MCP (fist)

Then slowly flex wrist (felt on dorsal forearm)

Stretch with elbow flexed and progress to elbow extended

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What are the extrinsic wrist extensor muscles?

Extensor digitorum

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Passive Stretching of Extrinsic Wrist Flexors

Palm up

Extend DIP, PIP, and MCP

Then slowly extend wrist (felt in volar forearm)

Stretch with elbow flexed and progress to elbow extended

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What are the extrinsic wrist flexor muscles?

Flexor digitorum superficialis

Flexor digitorum profundus

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Active Motion Exercise

Active contraction of muscles

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Indications of Active Motion Exercise

Maintain joint mobility

Increase synovial fluid

Pain management

Produce tendon glide

Maintain elasticity/contractility of muscles

Stimulus for bone integrity (weight bearing exercises)

Edema control