Therapeutic Exercises for the Distal Upper Extremity

Therapeutic Exercise

The systematic application of exercise and movement

What does therapeutic exercise develop or restore?

Muscular strength, endurance, and flexibility

What does therapeutic exercise improve?

Neuromuscular coordination

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

Gross and fine motor exercises

What does therapeutic exercise increase?

Cardiovascular efficiency

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

Aerobic exercise

What does therapeutic exercise target?

Health and performance factors

2 Goals of Therapeutic Exercise

1. Rehabilitation

2. Habilitation

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

Rehabilitation

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

Habilitation

Is habilitation generally used for children or adults?

Children

Rationale for Therapeutic Exercise

Movement is needed

Trauma causes scars that can bind structures together

Inflammation, edema, and immobilization can lead to problems

Why is movement needed?

To maintain joint mobility and tendon gliding

What does immobilization lead to?

Joint stiffness

Restricted tendon gliding

Muscle atrophy

What does trauma cause?

Scars

What can scars bind?

Gliding structures together

What can inflammation and edema lead to?

Fibrosis

Decreased tissue gliding

What does the "stress" of movement enhance?

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

What does the "stress" of movement increase?

Tendon and ligament strength

What can the "stress" of movement influence?

Collagen formation to maintain or restore tissue gliding

What can the "stress" of movement restore?

Motion through collagen remodeling

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

Objective information

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

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

Immediately

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)

3 Purposes of Therapeutic Exercise

1. Restore function

2. Maintain mobility

3. Restore motion

What should the clinician anticipate during the evaluation?

What limits may occur

What should the clinician determine during the evaluation?

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

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

Assessment

What can limitation occur as result of?

Pain

Edema

Atrophy

Denervation

Secondary changes in joints and soft tissues

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)

What is therapeutic exercise dosage based on?

What the client can do

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

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

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

Blanching (white)

Typically how long should a stretch be held for?

30 seconds

What 2 factors is therapeutic exercise dosage based on?

1. Purpose of exercise

2. Stage of wound healing

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

Rest and immobilization

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

In a balanced position or above the heart

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

To minimize swelling and edema

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

Stress to influence collagen

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

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

Few

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)

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

As tensile strength increases

What can occur during the maturation stage of wound healing?

Stiffness and decreased tendon excursion

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

To create changes

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

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

Stretch tissues

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

Active (or active-assisted)

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

Orthoses

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

Restore the muscle balance between the wrist extensors and finger flexors

Treatment Goals of Therapeutic Exercise

Manage pain

Improve posture

Increase motion, endurance, and strength

Restore function

Passive Motion Exercise

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

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)

Indications of Passive Motion Exercise

Pain with active movement

Weakness

Need to maximize range of motion

Joint replacement

Contracture management

Paralysis

Spasticity

What does passive motion exercise not promote?

Muscle maintenance (passive motion does not prevent atrophy)

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

Passive motion exercise

What does pain with passive motion exercises indicate?

Soft tissue injury

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)

What are edematous tissues more susceptible to?

Injury

Where should the client stabilize when stretching a finger?

Proximal and distal to target a specific joint

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

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

A slow, gentle, and sustained force

2 Types of Muscle Fibers

1. Contractile muscle fibers

2. Non-contractile connective tissues

What muscles fibers can a passive stretch elongate?

1. Contractile muscle fibers

2. Non-contractile connective tissues

What do joint contractures require before a passive stretch?

Joint mobilization

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

End feel

What does joint distraction avoid?

Compression during stretch

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

Joint distraction

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

Joint compression

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

Each individual joint

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

Neutral

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

Slowly lace their fingers together

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

MCP hyperextension (return client back to THEIR normal)

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

Positive Intrinsic Tightness Test

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

Positive Extrinsic Tightness Test

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

Carpometacarpal Joint

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

What 2 CMC joints are immobile?

1. 2nd CMC joint

2. 3rd CMC joint

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

Cup their hand

What 2 CMC joints are mobile?

1. 4th CMC joint

2. 5th CMC joint

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

10-20°

3 Palmar Arches of the Hand

1. Proximal transverse arch

2. Distal transverse arch

3. Longitudinal arch

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

1. Carpometacarpal joint

2. Metacarpophalangeal joint

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

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

Intrinsic minus

What motion does the forearm allow?

Pronation and supination

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

What may a limit in pronation be caused by?

Biceps brachii tightness

What relaxes muscles to be elongated before stretching?

Active inhibition

Example of Active Inhibition

Contract-relax

Contract-Relax

An isometric contraction of a tight muscle before passive lengthening

Passive Stretching of Intrinsic Muscles of the Hand

Put PIP and DIP joints into flexion

Gently stretch MCP joint into extension

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

What are the extrinsic wrist extensor muscles?

Extensor digitorum

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

What are the extrinsic wrist flexor muscles?

Flexor digitorum superficialis

Flexor digitorum profundus

Active Motion Exercise

Active contraction of muscles

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