Elbow And Hand: Therapeutic Exercises Flashcards
Common Sources of Referred Pain in the Elbow Region
-radicular symptoms from C5, C6 nerve roots: lateral elbow pain
-radicular symptoms from C6, C7 nerve roots: medial elbow pain
Nerve Disorders in the Elbow Region
Ulnar nerve: common sites for compression are the cubital tunnel and between two heads of Flexor
carpi ulnaris
Radial nerve: common sites for compression are under the Extensor carpi radialis brevis and distal
edge of Supinator
Median nerve: entrapment may occur between heads of Pronator tester, under Ligament of Struthers,
by the bicipital aponeurosis or deep to Flexor digitorum superficialis
Related Pathologies and Ethology of Symptoms
-rheumatoid arthritis, juvenile rheumatoid arthritis, degenerative joint disease
-acute joint reactions after trauma, dislocations, fractures
-post-immobilization contractures and adhesions develop in the joint capsule and surrounding tissues
Common Impairments of Structures and Function
Acute: joint fusion, muscle guarding, pain restricts motion, pain at rest Subacute and chronic: capsular pattern - flexion more restricted than extension
-firm end-feel, decreased joint play
Joint Hypo-mobility: Management - Protection Phase
Educate the patient
-teach methods of joint protection and how to modify ADLs
-instruct patient to avoid excessive fatigue: exercise frequently but limit repetitions
Reduce Effects of Inflammation or Synovial Effusion and Protect the Area
-intermittent or limited immobilization in a sling provides rest
-can lead to joint hypo-mobility, contractures and limited motion
-frequent periods of controlled movement within pain-free range
-gentle grade I or Il joint distractions and oscillations in resting position to inhibit pain and move synovial fluid
Maintain Soft Tissue and Joint Mobility
-passive or active assistive ROM within limits of pain
-multiple-angle sub maximal isometrics for elbow flexors, extensors, pronators, supinators
-also for wrist flexors and extensors in pain-free positions
Joint Hypo-mobility: Management - Controlled Motion Phase
Increase Soft Tissue and Joint Mobility
-intensity of stretching and mobilization techniques is dictated by the healing tissues, specific pathology, amount of pain, motion and end feel
-high intensity stretching of the elbow flexors is CI’d following trauma due to potential of heterotrophic bone formation
-incorporate passive joint mobilizations, manual and self-stretching and provide home-care instructions (self-stretch and exercise to utilize new ROM)
Improve Muscle Performance and Functional Abilities
-initiate active and low-load resistance exercises in open and closed-chain positions to develop control, muscular endurance and strength
-as patient improves, adapt exercises to progress to functional activities
Joint Hypo-mobility: Management - Controlled Motion Phase
Improve Muscle Performance
-progress strengthening exercises to joint tissue tolerance
-teach patient progressions and exercise strategies that promote return to function
-use exercises that replicate ADLs (pushing, pulling, lifting, carrying, gripping)
Restore Functional Mobility of Joints and Soft Tissues
-if restrictions remain, use more vigorous stretching and joint mobilization techniques
Promote Joint Protection
-chronic arthritic conditions may require modifications to minimize deforming stresses
Management of Overuse Syndromes - Protection Phase
Decrease Pain
-immobilization: rest the muscles
-patient instruction: keep moving and using arm but avoid aggravating activities
-cryotherapy: ice to manage pain
Develop Soft Tissue and Joint Mobility
-cross fibre frictions: at site of lesion
-neuro-mobilization
-soft-tissue mobilization: wrist flexors and extensors; decrease tightness and trigger points
-muscle mobility techniques: contract-relax techniques to wrist flexors and extensors
-passive stretch: to stretch wrist extensors - extend elbow, pronate forearm, flex and ulnarly deviate wrist, flex fingers; gently person back of hand
-passive stretch: to stretch wrist flexors - extend elbow, supinate forearm, extend and radially deviate wrist, extend fingers; gently press palm
Maintain Upper Extremity Function
-AROM to all joints of the upper extremity
-resistive exercise for shoulder and scapular stabilization (resistance applied proximal to elbow)
Controlled Motion and Return to Function Phases
Increase Muscle Flexibility
-manual stretching techniques
-self-stretching techniques
-cross fibre frictions
Improve Muscle Performance and Function
-dynamic resistance exercise: manual or elastic resistance or free weights
-initially use low-intensity resistance with multiple repetitions
-progress to more intense resistance to strengthen in preparation for functional demands
-eccentric training: comfortable wrist ROM against low-intensity load, slow speed, elbow in relatively extended position
-progressions: faster speeds before increasing resistance, then slow speed if new resistance
-functional patterns: as flexibility and strength improve and pain is controlled, incorporate exercises that simulate desired activity
-plyometric exercises: incorporate if returning to sport or occupation requiring elbow and forearm power
-activity modification to decrease chance of injury recurring
Patient Education
-advice and techniques on prevention, recognition of provoking factors and identification of warning symptoms
-how to reduce overload forces, retrain in proper techniques
-home-care: cross-fibre frictions, stretching/warm up before activity
Exercise Interventions for the Elbow and Forearm
a. To Increase Elbow Extension
• Self-Stretch: Mild Flexion Contracture
-sitting with arm supported on table, towel folded under distal humerus as a fulcrum
-use opposite hand to apply stretch force against distal forearm positioned in pronation, mid-position and supination to affect each set of muscles
• Self-Stretch: Biceps brachii
-standing at side of table, grasp edge of table and walk forward causing shoulder extension with elbow extension
b. To Increase Elbow Flexion
• Self-Stretch: Mild Extension Contracture
-prone-lying and propped up on elbows with forearms resting on floor, lower chest as far as elbow flexion allows and maintain position
-seated with elbow flexed, press against distal forearm with opposite hand to provide stretch force into further flexion
• Self-Stretch: Long Head of Triceps brachii
-flex elbow and shoulder as far as possible (so hand is reaching down back); use other hand to push on elbow to increase shoulder flexion
c. To Increase Forearm Pronation and Supination
• Self-Stretch to Increase Pronation
-grasp dorsal surface of involved forearm, heel of uninvolved hand against dorsal aspect of radius proximal to wrist, wrap fingers around ulna, passively pronate forearm and sustain stretch
• Self-Stretch to Increase Supination
-opposite to above motion
d. To Stretch Wrist Extensors
-elbow extended, forearm pronated, back of hand against wall (fingers point down), slide hand up wall until feel stretch, flex fingers for more stretch
e. To Stretch Wrist Flexors
-elbow extended, forearm supinated, place palm against wall (fingers point down), slide hand up wall until feel stretch
Exercises to Develop and Improve Muscle Performance and Functional Control
Isometric Exercises
-use manual or resistance at various positions throughout the available ROM of elbow flexion and extension and forearm rotation
-apply resistance at the distal forearm, not the hand
Dynamic Strengthening and Endurance Exercises
Elbow Flexion
-seated/standing, humerus at side of chest, hold a weight or grasp elastic band, flex and extend elbow, concentric and eccentric
-forearm supinated, pronated or neutral
Elbow Extension
-supine, shoulder flexed to 90, holding weight in hand, begin with elbow flexed and weight at either ipsilateral or contralateral shoulder, extend and flex elbow, concentric and eccentric
Forearm Pronation and Supination
-seated/standing, elbow flexed to 90 held close to thorax, rotate weight in both directions
-standing, face doorknob with arm kept at side with elbow flexed to 90, turn knob
Wrist Flexion and Extension:
-seated, forearm resting on table, hand over edge holding small weight, flex and extend wrist
