pnf techniques in the upper extremity 2

7/30/2019 PNF Techniques in the Upper Extremity 2

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Introduction and BasicProcedures

Upper extremity patterns are used to treat dysfunctioncaused by neurologic problems, muscular disorders or

joint restrictions. These patterns are also used to

exercise the trunk. Resistance to strong arm musclesproduces irradiation to weaker muscles elsewhere in thebody. We can use all the techniques with the armpatterns. The choice of individual techniques or

combinations of techniques will depend on the patientscondition and the treatment goals. You can, forinstance, combine Dynamic Reversals with Combinationof Isotonics, Repeated Contractions with DynamicReversals, or, Contract-Relax or Hold- Relax withCombination of Isotonics and Dynamic Reversals.


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Diagonal MotionThe upper extremity has two diagonals:

1. Flexionabductionexternal rotation andextensionadductioninternal rotation

2. Flexionadductionexternal rotation and

extensionabductioninternal rotation


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Flex.-Add.-ER

Supination

Radial abduction

Palmar flexion

Finger flexion

Adductionfinger

Flex.-Abd.-ER Supination Radial

abduction Dorsal

extension Finger

extension Abduction

finger

Ext.-Add.-IR Pronation Ulnar abduction Palmar flexion Finger flexion

Adductionfinger

Ext.-Abd.-IR Pronation

Ulnar abduction Dorsalextension

Fingerextension

Abductionfinger


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Patient Position Support the patients head

and neck in a comfortableposition, as close to neutralas possible. Before beginningan upper extremity pattern,visualize the patients arm ina middle position where thelines of the two diagonalscross. Starting with theshoulder and forearm in

neutral rotation, move theextremity into the elongatedrange of the pattern withthe proper rotation,beginning with the wrist and

fingers.

Therapist Position All grips described in the

first part of each sectionassume that thetherapist is in thisposition. We give thebasic position and body

mechanics for exercisingthe straight arm pattern.When we describevariations in the patternswe identify any changes

in position or bodymechanics. Thetherapists position canvary within the guidelinesfor the basic procedures.


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Resistance The direction of the resistance is an arc back toward the starting

position. The angle of the therapists hands and arms changes as the limbmoves through the pattern.

Traction and Approximation

Traction and approximation are an important part of the resistance. Usetraction at the beginning of the motion in both flexion and extension.Use approximation at the end of the range to stabilize the arm andscapula.

Normal Timing and Timing for Emphasis Normal Timing

The hand and wrist (distal component) begin the pattern, moving throughtheir full range. Rotation at the shoulder and forearm accompanies therotation (radial or ulnar deviation) of the wrist. After the distalmovement is completed, the scapula moves together with the shoulder orshoulder and elbow through their range. The arm moves through thediagonals in a straight line with rotation occurring smoothly throughoutthe motion.

Timing for Emphasis In the sections on timing for emphasis we offer some suggestions for

exercising components of the patterns. Any of the techniques may beused. We have found that Repeated Stretch (Repeated Contractions)and Combination of Isotonics work well. Do not limit yourself to theexercises we suggest in this section, use your imagination.


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Stretch In the arm patterns we use stretch-stimulus with or without the

stretch reflex to facilitate an easier or stronger movement, or tostart the motion.

Repeated Stretch (Repeated Contractions) during the motionfacilitates a stronger motion or guides the motion into the desireddirection. Repeated Stretch at the beginning of the pattern is usedwhen the patient has difficulty initiating the motion and to guidethe direction of the motion. To get the stretch reflex the therapist

must elongate both the distal and proximal components. Be sure youdo not overstretch a muscle or put too much tension on jointstructure. This is particularly important with the wrist joint.

Irradiation and Reinforcement We can use strong arm patterns (single or bilateral) to get

irradiation into all other parts of our body. The patients position incombination with the amount of resistance controls the amount ofirradiation. We use this irradiation to strengthen muscles ormobilize joints in other parts of the body, to relax muscle chains,and to facilitate a functional activity such as rolling.


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Joint Movement Muscles: principal components(Kendall and McCreary 1993)

Scapula Posterior elevation Trapezius, levator scapulae, serratusanterior

Shoulder Flexion, abduction,external rotation

Deltoid (anterior), biceps (long head),coracobrachialis, supraspinatus,

infraspinatus, teres minorElbow Extended (position

unchanged)Triceps, anconeus

Forearm Supination Biceps, brachioradialis, supinator

Wrist Radial extension Extensor carpi radialis (longus and brevis)

Fingers Extension, radial deviation Extensor digitorum longus, interossei

Thumb Extension, abduction Extensor pollicis (longus and brevis),

abductor pollicis longus

Flexion Abduction External Rotation


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Flexionabductionexternalrotation. a Startingposition; b mid-position; c

end position; demphasizing the motion ofthe shoulder. e Patientwith right hemiplegia.Flexionabduction externalrotation: proximal hand for

scapula posterior elevationand trunk elongation

a b c

d e

H d iti


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Hand positions Distal Hand

Your right hand grips the dorsal surface of the patientshand. Your fingers are on the radial side (1st and 2nd

metacarpal), your thumb gives counter pressure on the ulnarborder (5th metacarpal).There is no contact on the palm.

Proximal Hand

From underneath the arm, hold the radial and ulnar sides

of the patients forearm proximal to the wrist. Thelumbrical grip allows you to avoid placing any pressure onthe anterior (palmar) surface of the forearm.

Movements

The fingers and thumb extend as the wrist moves into radialextension. The radial side of the hand leads as the shouldermoves into flexion with abduction and external rotation. Thescapula moves into posterior elevation. Continuation of thismotion is an upward reach with elongation of the left side of

the trunk.


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Extension Adduction Internal RotationJoint Movement Muscles: principal components (Kendall

and McCreary 1993)

Scapula Anterior depression Serratus anterior (lower), pectoralis minor,rhomboids

Shoulder Extension, adduction,internal rotation

Pectoralis major, teres major,subscapularis

Elbow Extended (positionunchanged)

Triceps, anconeus

Forearm Pronation Brachioradialis, pronator (teres andquadratus)

Wrist Ulnar flexion Flexor carpi ulnaris

Fingers Flexion, ulnar deviation Flexor digitorum (superfi cialis andprofundus), lumbricales,interossei

Thumb Flexion, adduction,

opposition

Flexor pollicis (longus and brevis), adductor

pollicis, opponens pollicis


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a b

a,b. Extension-adduction-internal rotation

iti


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an positionsDistal Hand Your left hand contacts the palmar surface of the

0patients hand. Your fingers are on the radial side (2nd

metacarpal), your thumb gives counter-pressure on theulnar border (5th metacarpal). There is no contact onthe dorsal surface.

Proximal Hand Your right hand comes from the radial side and holds

the patients forearm just proximal to the wrist. Yourfingers contact the ulnar border. Your thumb is on theradial border.

Movements The fingers and thumb flex as the wrist moves intoulnar flexion. The radial side of the hand leads as the

shoulder moves into extension with adduction andinternal rotation and the scapula into anteriordepression. Continuation of this motion brings the

patient into trunk flexion with neck flexion to the right.


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Flexion Adduction External RotationJoint Movement Muscles: principal components (Kendall

and McCreary 1993)

Scapula Anterior elevation Serratus anterior (upper), trapezius

Shoulder Flexion, adduction,

external rotation

Pectoralis major (upper) deltoid (anterior),

biceps, coracobrachialis

Elbow Extended (positionunchanged)

Triceps, anconeus

Forearm Supination Brachioradialis, supinator

Wrist Radial flexion Flexor carpi radialis

Fingers Flexion, radial deviation Flexor digitorum (superfi cialis andprofundus), lumbricales, interossei

Thumb Flexion, adduction

opposition

Flexor pollicis (longus and brevis), adductor

pollicis, opponens pollicis


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a,b. Flexionadductionexternal rotation

a b

iti


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an positions Distal Hand Your right hand contacts the palmar surface of the

patients hand. Your fingers are on the ulnar side (5th

metacarpal), your thumb gives counter pressure on theradial side (2nd metacarpal). There is no contact on thedorsal surface.

Proximal Hand Your left hand grips the patients forearm from

underneath just proximal to the wrist. Your fingers areon the radial side, your thumb on the ulnar side.

Movements The fingers and thumb flex as the wrist moves into

radial flexion. The radial side of the hand leads as theshoulder moves into flexion with adduction and externalrotation and the scapula into anterior elevation.Continuation of this motion elongates the patientstrunk with rotation toward the right.


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Extension Abduction Internal RotationJoint Movement Muscles: principal components (Kendall

and McCreary 1993)

Scapula Posterior depression Rhomboids

Shoulder Extension, Abduction,Internal Rotation

Latissimus dorsi, deltoid (middle,posterior), triceps,teres major,

subscapularisElbow Extended (position

unchanged)Triceps, anconeus

Forearm Pronation Brachioradialis, pronator (teres andquadratus)

Wrist Ulnar extension Extensor carpi ulnaris

Fingers Extension, ulnar deviation Extensor digitorum longus, lumbricales,interossei

Thumb Palmar abduction,extension

Abductor pollicis (brevis), Extensor pollicis


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a-c. Extension-abduction-internal rotation

b ca

H nd p siti ns


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Hand positions Distal Hand Your left hand grips the dorsal surface of the patients

hand. Your fingers are on the ulnar side (5th metacarpal),your thumb gives counter-pressure on the radial side (2ndmetacarpal). There is no contact on the palm.

Proximal Hand With your hand facing the ventral surface, use the lumbrical

grip to hold the radial and ulnar sides of the patientsforearm proximal to the wrist.

Movements The fingers and thumb extend as the wrist moves into ulnar

extension. The ulnar side of the hand leads as the shouldermoves into extension with abduction and internal rotation.The scapula moves into posterior depression. Continuation ofthis motion is a downward reach toward the back of the leftheel with shortening of the left side of the trunk.

pnf techniques in the upper extremity 2

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