Functional Mobilization Upper Extremity Flashcards
1
Q
Upper extremities Evaluation
A
- Cervical Rotation
- Upper T-spine Rotation
- First and second rib mobility
- Shoulder Abduction
- Shoulder Horizontal Adduction
- Shoulder Internal Rotation
- Testing of Automatic setting of humeral head
- Postural Evaluation/Vertical Compression Test
- Elbow Flexion test
- Upper Limb Neural Tension
- Disinhibition series
- Impact test
- Arm pull at side
- T1-2 flexion extension
2
Q
Cervical Rotation
A
Lateral border of hand at A/C joint and fingertips on the posterior neck
- 1st point of contact (to 1st knuckle) = 70%
- Middle knuckle/2nd knuckle = 80%
- Proximal knuckle/3rd knuckle = 90%
- Chin touching hand 100%
70% from cs 30% from ts
3
Q
Upper T-Spine Rotation
A
Palpate the spinous processes to access rotation (move opposite direction of the head)
a. Same level- noting the decree of motion that occurs during cervical rotation
b. Level above or below - note the amount of rotation occurring between thoracic levels
4
Q
First and Second Rib mobility
A
- evaluate end feel of 1st ribs
- asses mobility with cervical motions (diagonal and side bending motions)
Efficient state, the rib drops inferiorly as the head moves towards it.
Repeat with 2nd rib
5
Q
Shoulder Abduction
A
Efficient shoulder= close to 180 degrees AAROM abd with shoulder fixed in PD.
palm facing downward
evaluate range and quality of motion
Limitation indicates dysfunction of capsule, AC joint or neural tension
Arm heavier on dysfunctional side
6
Q
Hypermobility end range
A
when feels like will move (excessive joint i.e. pt reports joint drop)
Stop prior to “hyper”
7
Q
Hypermobility and stabilization
A
Apprehension with hypermobility is normal. Cue to relax apprehension before stabilizing.
8
Q
Shoulder Horizontal Adduction
A
stabilize shoulder
note ROM in the arc of flexion add down to extension adduction
9
Q
Shoulder Internal Rotation
A
Evaluate HBB reaching upwards to head
Note range where humeral head translates anteriorly (hand on humeral head)
10
Q
Testing of automatic setting of humeral head/VCT
A
ability of shoulder to have stabilizing contraction while resisting flexion/approximation at 90 degrees
Straight arm/elbow
Stagger stance (see what stagger is weaker each side and retest using same stance)
Hand on inferior prox. humerus vs scapula
11
Q
Elbow Flexion test
A
Stability of GH and scapula
Efficiency of connection to core
12
Q
Postural evaluation
A
lateral view for overall postural alignment
13
Q
Stabilizing shoulder girdle options for Upper Limb Neural Tension Test
A
Therapist positioned
- SUPERIORLY depressing shoulder girdle assessing for tension subjectively and objectively (initial take up of nerve and check for immediate NT)
- INFERIORLY with hand under posterior shoulder and depress the shoulder girdle
-Can utilize strapping belt to stabilize the shoulder
- Can add cervical side bending and rotation to further challenge the neurovascular structures
14
Q
Most common nerve tension
A
Median
15
Q
If tension with initial shoulder depression
A
Treat above the clavicle
16
Q
Areas of nerve tension
A
Carpal tunnel
Aponeurosis
Neck
Elbow
Pronator Teres
17
Q
Localization with ULTT
A
Drop head to same side: Increase in ROM = treat Soft tissue and fascia
No change with head to same side: Think joint
18
Q
Upper Limb Neural tension for brachial plexus and median nerve
A
Arm at side, extend the elbow with forearm in supination and progress to slowly extending the wrist testing for tension. Further progress to shoulder abduction up to 90 degrees
Add increased demand on neural mobility by side bending head away from side being tested
Evaluate if tension felt in any cervical vertebrae
*Note ROM of wrist and shoulder ABD at first sign of tension or symptom provocation
19
Q
Upper Limb Neural tension for Radial nerve
A
Position like Median nerve with forearm in pronation and wrist flexion (palm down)
20
Q
Upper Limb Neural tension for Ulnar nerve
A
Flex arm and place hand next to face (circle between thumb and first finger). Slowly horizontally abduct arm testing for tension
21
Q
Neural tension caution
A
Avoid stretching neural tissues (exacerbation of symptoms). Only test tissues to initiation of tension - therapist or patient perception
22
Q
Disinhibition series identifies
A
-Evaluate initiation (ACE), strength, ability to hold (not push), ability to produce irradiation, and endurance
-Means of identifying if there is a cervical component to peripheral weakness
-Identify what type of cervical position or upper quadrant stress will inhibit
-Develop home program and body mechanics strategies
23
Q
Disinhibition series
A
- Evaluation of CPM
- Pivot Prone (shoulder girdle and upper extremity response)
- Peripheral Strength (supine and sitting. compare bilaterally)
4.Segmental Eval - Treatment in supine/sitting
- Retest weak muscles
- Impact test
- Treatment strategies
- HEP training
24
Q
Peripheral muscle weakness connected too
A
Disinhibition of FFM/ACE
Check Impact test/ core
25
CPM
Evaluate diagonal direction for flexion/extension for ACE, Initiation, Strength, Endurance, And irradiation
26
Pivot prone
Identifies inhibition of muscular response
Caution with manual contact To front/lateral surface with testing
Feel scapula
ER not hand facing forward
Ask self: where is breaking point? GH, Scapula, Serratus posterior, neck?
27
Peripheral Strength tests
1. Thumb add & opposition (C8-T1)
-arm at side elbow at 90 mid range supination and pronation
2. Wrist flexors (C7)
-Same as Thumb add
3. Wrist extension (C6)
-Same as Thumb add
4. ER/IR (C5-6)
-Same as Thumb add
5. Elbow flexion (C5-6) and Extension (C7)
-at side forearm in supination
6. Forearm pronation
-Pronator teres (C6) and Quadratus Teres (C8-T1)
-Palm down at side, PT hand in hand thumbs interlocked
7. Shoulder flexion (C5-6)
-PNF upper extremity patterns (optional)
8. Problematic function motion or pattern
*Break test score not MMT
28
Disinhibition Segmental eval
1. Evaluated in supine or sitting
2. perform axial elongation (lengthening and posterior motion of cervical spine and tucking of the chin)
3. Pressure on transverse processes, assess ability to hold each level
4. Deep neck flexors: resist under chin with chin tucked
29
What muscle is the primary deep cervical stabilizer?
Longus coli
30
Disinhibition Treatment (inhibited segments)
1. into axial extension
2. General resistance PA resistance
3. Specific segmental faciliatory treatment
a. Prolonged hold to specific transverse process of identified inhibited segments
b. Unilateral enhanced facilitation: add cranial rotation towards weak side
c. Irradiation- Discover what will assist using 1) resisted chin tucking 2) LE or UE resistance to facilitate inhibited segments
d. Resistance to cranial elongation through pressure on top of head or behind occipital ridge
31
Axial extension should
Lengthen not buckle
32
Disinhibition HEP
1. Train patient: perform self-resisted axial elongation one hand behind neck to resist posterior motion one hand under chin to resist short neck flexors. Tip of tongue on rugae of hard palate. Maintain contraction until an enhanced contraction is achieved.
2. Resisted home program- resistance to specific weak segments with TheraBand or belt. Progressively increase length of hold time. Perform on regular basis up to 10x daily; finding target muscle weakness and whenever inadvertently utilize agg. activities.
3. Progression: to sitting and prolong axial extension in functional postures
4. Elongation: TheraBand resist
33
Primary thoracic girdle structures
1st and 2nd Thoracic vertebra
1st and 2nd ribs
Manubrium
Sternoclavicular joints
34
Upper T/S manipulations can improve
Cervical, shoulder, and elbow functions
35
Disinhibition retesting muscles
No change: prognosis is guarded
Strength and initiation improved: central involvement or inhibited state and mechanism to facilitate improvement
36
Thoracic girdle Evaluation
1. VCT and EFT
2. Thoracic girdle
3. Mobility
1st and 2nd rib
4. Extension hypomobilities of upper T/S
37
EFT assesses what in the shoulder?
Watch for GH stabilization
Meet contraction
Shoulder winging
ACE/CFS
38
Impact test
In supine or sitting
*teach patients to test themselves
1. Prolonged cervical flexion -most often inhibitory motion
2. Other cervical motions- Extension (looking up), Side bending (phone), forward head posture, rotation (backing up car)
3. Axial compression-compression on top of head (wearing a hat)
4. Arm pull- carrying objects (Thoracic outlet)
5. Any motion or activity pt reports aggravates symptoms
39
Shoulder girdle VCT Assessment
Test both foot position strategies and find which weakest vs strongest
Test flexion vs approximation stabilization
Can shoulder girdle push to engage?
40
Sources of prolonged C/S flexion
Watching TV, Cell phones, Sleeping with multiple pillows under head
41
Therapist mechanics for 2nd rib
Weight shift through hips
42
Disinhibition treatment strategies
1. identify positive activities (inhibitory)
2. Train to avoid those activities or motions. Most reintroduce within several weeks.
3. Retest patient in more demanding ways as they improve
43
Thoracic girdle mobility
Breathing
Folding and lengthening of ribs and manubrium with flexion / extension
T1-2 with flexion / extension / rotation hands interlocked behind neck (lift elbows to create T/S extension)
44
1st and 2nd rib
1. First rib
a. Side bending
b. Rotation
2. Soft tissue
a. Deep fascia, levator, upper traps
b. Posterior superior Serratus
3. 2nd/3rd ribs side lying
4. First rib A/P-P/A
5. First rib depression
6. Anterior and medial scalenus mobility
45
1st rib movement with Right Cervical movement
Right Rib posterior superior
Left Rib anterior inferior
46
1st rib to assessment
Glide Inferior/anterior vs posterior
47
1st rib mobility aspects
AP/PA
Depression
48
1st rib mobilization ideas
Snowman with a hat
Knuckle
49
FMP for 1st rib ideas
LTR
Breathing
Head rotation
50
FMP for 2nd rib idea
Breathing
Basking seal
Press feet into the table
51
Deep C/S fascia mobilization ideas
Fist
Round side of Fascia freer
52
Accessory muscle of breathing that gets Confused with trap tightness
Posterior superior serratus
53
Extension hypomobilities of upper T/S
1. POE
a. STM grove of spine
b. joint mobilization
2. Upper Thoracic backward bending
a. Evaluation- hip hinge 20 degrees lift elbows superiorly. Note end-feel.
b. Treatment sitting on supporting surface or PT knees
3. Localize restriction flex/ext then R/L. Increase hip flexion with lower T/S
54
Mobilization options for Thoracic extension
1. Cervical rotation or side bending (active, passive, assisted)
2. Cover Position
3. Active or resisted shrugging
4. Lower trunk rotation
5. BOS - opposite leg into underlying surface
55
Scaleni
Anterior: c3-6
Medial: 2-7
Posterior: 5-7
56
Extension Hypomobilities Upper T/S
Prone on elbows
Upper Thoracic backward bending
- elbows on supporting surface
- elbows on therapist's knee
*Spring test
*Try and drop T/S forwards
*Assess how moves to R vs L, side bend, C/S rotation
*If painful at end range, then back side bend to loose pack
*Hand behind head: beware of shoulder issues but good for fusion
57
Extension Hypomobilities Upper T/S mobilization strategies
Snowman with a hat
Dycem
Breathing
weight shifts
oscillations
Feet into the floor
Pull arms down
Push hands together
Lift arms-NMRE
- hold vertebra into range then resist rotation
- vertebra resist and arm irradiation
58
Form Closure
Form (structures) allow it to have stability
59
Form closure of shoulder girdle
Clavicle forwards
scapula down and back
60
Example of limited Shoulder girdle form closure
Pull from neck preventing colure on rib cage
61
Force closure
Muscle contraction creates stability
62
Shoulder Girdle Evaluation
1. Shoulder position
a. Anterior/Posterior Superior/Inferior
b. Humeral Head position
c. Shoulder girdle Vertical Compression
d. Pull on UE
e. UE ROM
-does the weight go to the foot?
63
Shoulder positioning manual evaluation
Hand on scapula and clavicle
64
Clavicle mobility with ROM
moves posteriorly on acromion with Horiz add
moves Anteriorly with Horiz abd
Downward glide with flexion
Upward glide with extension/shoulder girdle depression
65
Big ben
Shoulder Clock
66
Shoulder clocks (Big Ben)
Evaluate passive and active movement of scapula looking for mechanical and motor control problems
Asses range, end-feel, quality of motion in AE/PD/AD/PE
assess soft tissues, AC and SC movements
Trace and isolate then retrain in new range
67
AC joint PA mobility in sidelying
anterior fingers on posterior clavicle
posterior hand gripping anterior humerus
68
AC joint AP mobility sidelying
Anterior hand on posterior humerus
Posterior fingers fingers acromion
69
AC joint percussion
Kong while resisted shrugging
70
SC movements with posterior scapula patterns
Proximal end of clavicle distracts away from manubrium
71
SC movements with anterior scapula patterns
Proximal end of clavicle Compresses against the manubrium
72
SC movements with elevation scapula patterns
Proximal end of clavicle moves inferiorly (Caudally)
73
SC movements with depression scapula patterns
Proximal end of clavicle moves superiorly (cranially)
74
Clavicle distraction
Patient move from anterior position posteriorly to mobilize
*Dycem can assist in grip and reducing tenderness
75
Scapula thoracic articulation mobilization
Side lying
Roll pt toward you
use zyphoid/sternum on shoulder to compress scapula into fingers
Can use dycem for better grip
76
Latissimus pocket
Assess if accessing latissimus pocket with unilateral EFT
Train stability through prolonged holds to shoulder girdle and UE
77
Sitting AC mobilization
Elbow resting on table at restricted motion in scaption
Access AC and SC
78
FMUE functional tests
Impact test
Pivot prone
VCT
EFT or arm pull
79
UE force couples
BAD: Pec Minor and Subscap (Internal rotators)
GOOD: Serratus anterior, Rhomboids, and RC
80
CoreFirst application to shoulder
Establish BOS
Align over effective BOS
PNF to engage core/deep stabilizers of joint
Weight shift within BOS
WS out of BOS and WA into new BOS
Vary BOS
Speed and automatic engagement
81
Shoulder Girdle Mobilization
A/C joint
S/C joint
Scapular thoracic pocket
Latissimus pocket
82
GHJ Evaluation
VCT
CS ROM
Shoulder girdle position
First rib mobility
Shoulder ROM
Approximation
83
GHJ mobilization
-Posterior translation
-Gapping distraction of GH articulation
-Caudal translation of head of humerus
-Downward (caudal) glide of humerus
-Humeral Posterior shear
-Internal Rotation in Abduction
84
Primary shoulder off axis
Shoulder sitting anteriorly
85
Purpose of Posterior translation
Getting humeral head on axis in glenoid fossa
86
Purpose of distraction of GH articulation
Improving space between the humeral head and glenoid fossa
*essential intrinsic accessory motion
87
Purpose of Caudal translation of humeral head
Decompression of subacromial space
88
Purpose of downward (caudal) glide of humerus
Improving ability for humeral head to glide caudally
89
Shoulder capsule can be treated with
Caudal glide
90
Caudal glide in sitting
Arm placed in scaption
mobilize with down ward force through shoulder
Retrain with hands in axilla
91
Capsule is
60% tendon type tissue
Remainder is capsule type tissue
92
Posterior capsule is made of which tendon
Infraspinatus
93
90% of dislocations occur
anteriorly
94
Posterior shear mobilizes
posterior capsule
95
Muscles to assess with soft tissue mobilizations Flex Abd ER/Ext ADD IR (PE/AD)
Superficial fascia
Pectoralis major tendon and muscle
pectoralis minor
inferior capsule
subscapularis
neurovascular structures
teres major and minor
infraspinatus
latissimus
serratus
deltoids
triceps
head of triceps
bicipital groove
supraspinatus body
supraspinatus tendon
upper trapezius
levator
deep cervical fascia
posterior superior serratus
96
Muscles to assess with soft tissue mobilizations Flex Add ER/Ext ABD IR (PD/AE)
Superficial fascia
pectoralis
pectoralis tendon folding
pectoralis minor
coracoid process
anterior deltoid
biceps
biceps tendon
inferior capsule
subscapularis
teres major and minor
infraspinatus
latissimus
serratus
posterior deltoids
triceps
upper trapezius
levators
deep cervical fascia
supraspinatus
supraspinatus tendon
97
Roll on it mobilization with sidelying restroom request (flexion horiz add)
Mobilizing humerus for IR, flexion, Horiz add
evaluate humeral motion
98
Roll on it Internal rotation (Jackie Gleason)
good home exercise for internal rotation
99
Round about
Arm circles
100
Prayer pose palm down
emphasis on lower traps
101
Prayer pose Thumb up
Lateral muscles like latissimus
102
Prayer pose Thumb down
Medial muscles of Rhomboids
103
Increased UE nerve tension that does not maintain associated with
Previous Concussion (especially loss of consciousness)
Hyper sympathetic
104
Thrust nerve mobilization
Isolate
deep breath and holds
muscle contraction
Trust (not a big motion, just quick)
105
Nerve treatment motions
Wrist
Elbow
Cervical side bending
Shoulder Horiz. add and abd
106
Areas of nerve mobility
*primary restrictions
Cervical foramen
Anterior scalene
First rib
Superior and inferior clavicle*
Coracoid process
Pectoralis minor*
Axilla region
Course of arm, forearm (Pronator teres)*
Wrist retinaculum*
Aponurosis of palm
107
Passive arm circles
Big spin
108
Elbow Mobilization
Extension of Olecranon process and radial head
Olecranon and radial distraction
Olecranon mobility
Radial head mobility
Radial head gapping
Anterior glide of humerus
Weight bearing
Flexion supination and pronation
109
Olecranon efficient positioning
Should "Disappear" with supinated extension and maintain with pronation without shifting
110
Lateral Tendonitis?
Think radial head distraction and on axis
111
Forearm elbow resistance
Straight flexion/extension in supination or pronation
flexion with supination
flexion with pronation
Extension with supination
Extension with pronation
112
Supported flexion is...
Pivot of elbow in PNF pattern
113
Wrist and Forearm mobilization
Circumduction
Distal radius and ulnar mobility
Superior (Proximal) metacarpals
Inferior (Distal) metacarpals
Lateral Shear wrist
proximal to distal rows of carpals and metacarpals
Medial to lateral columns of carpals and metacarpals
Wrist flexion
Weight bearing wrist extension
114
Fingers Mobilization
Palm fold and lenthen ability
Weight bearing hand spreading
Circumduction of MCP
Articulation Diagonals and rotation
MP flexion and extension
115
Thumb Mobilization
Opposition
Radial extension
Palmar abduction
Adduction
Resisted Mass grasp and release
116
PNF hand placement
inside hand always on the hand
outside on the forearm
Radial pattern: inside hand fingers pointing towards thumb
outside on radius
Ulnar pattern" inside hand fingers toward pinky side
outside hand on ulna
117
PNF body mechanics
Table midthigh height
use WS and hinging for resistance rather than arms
Switch pelvis direction to other diagonal @ 90 degrees shoulder flexion
* make use you get full rotation at head of table
118
Flexion Abduction External Rotation Irradiation (PE)
Scapular PE or PD
Bilaterals
Elbow flexion
Radial extension
lifting pattern hold at end range
Resist extremity through full flexion abduction pattern
dowel resist bilateral flexion abduction
119
Extension Adduction Internal rotation Irradiation (AD)
Scapula AD
Elbow extended or flexion
Wrist ulnar flexion
Bilateral UE
Chopping
Resist extremity through full extension adduction pattern
Dowel
120
Extension abduction Internal Rotation Irradiation (PD)
Scapular PD
Wrist Ulnar extension
Bilateral UE
Resist extremity through full extension abduction pattern
Chopping
Dowel
121
Flexion Adduction External Rotation Irradiation (AE)
Scapula AE
Elbow flexion
Wrist radial flexion
bilateral UE
Lifting
Resist extremity through full flexion adduction pattern
Dowel
122
Dowel PNF
Different hand positions change what hand is doing more work
Great for shoulder patients and helping get core to engage
