Edited by

Cynthia Cooper, MFA, MA, OTR/L, CHT

Owner, Cooper Hand Therapy
Scottsdale, AZ
Adjunct Faculty
Occupational Therapy
A.T. Still University
Mesa, AZ
3251 Riverport Lane
St. Louis, Missouri 63043

FUNDAMENTALS OF HAND THERAPY: CLINICAL REASONING ISBN: 978-0-323-09104-6

AND TREATMENT GUIDELINES FOR COMMON DIAGNOSES
OF THE UPPER EXTREMITY
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Copyright © 2007 by Mosby, an affiliate of Elsevier Inc.

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ISBN: 978-0-323-09104-6

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 Contributors
Sandra M. Artzberger, MS, OTR, CHT, CLT Lisa Deshaies, BS, OTR/L, CHT
Lecturer, Consultant, Clinician Clinical Specialist
Pagosa Springs, CO Outpatient Therapy Services
Certified Hand Therapist Rancho Los Amigos National Rehabilitation Center
Rocky Mountain PT and Sports Injury Center Downey, CA
Pagosa Springs, CO Adjunct Clinical Faculty
Division of Occupational Science and Occupational Therapy
Jeanine Beasley, EdD, OTR, CHT, FAOTA University of Southern California
Associate Professor Los Angeles, CA
Occupational Therapy
Grand Valley State University Kelly Droege, MOTR/L
Grand Rapids, MI Occupational Therapist
Hand Therapist Milliken Hand Rehabilitation Center
East Paris Hand Therapy Healthsouth Corporation
Mary Free Bed Rehabilitation Hospital St. Louis, MO
Grand Rapids, MI
Lori Falkel, PT, MOMT, CHT, DPT, PT, CHT
Mark W. Butler, PT, DPT, OCS, Cert. MDT Clinical Coordinator
Adjunct Associate Professor Outpatient Therapies
School of Health Related Professions Peace Health Saint John Medical Center
Rutgers University Longview, WA
Stratford, NJ
Center Manager Elaine Ewing Fess, MS, OTR, FAOTA, CHT
Novacare Adjunct Assistant Professor
Medford, NJ Department of Occupational Therapy, SHRS
Indiana University
Shrikant J. Chinchalkar, MThO, BScOT, OTR, CHT Indianapolis, IN
Hand Therapist
Hand and Upper Limb Center Sharon R. Flinn, PhD, OTR/L, CHT
St. Joseph’s Health Care Associate Professor
London, Ontario, Canada Division of Occupational Therapy
The Ohio State University Wexner Medical Center
Cynthia Cooper, MFA, MA, OTR/L, CHT Columbus, OH
Owner, Cooper Hand Therapy
Scottsdale, AZ Louann Gulick Gaub, MSA, OTR/L, CHT
Adjunct Faculty Hand Therapist
Occupational Therapy Orthopedic One
A.T. Still University Columbus, OH
Mesa, AZ
William S. Graff, EdD
Jeffrey Cowdry, BS, OT, CHT Licensed Psychologist
Hand Therapist William S. Graff, EdD, PC
Hand Rehabilitation Phoenix, AZ
Advanced Training and Rehab
St. Louis, MO Vincent Hentz, MD
Emeritus Professor of Surgery and Orthopedic Surgery
Lori DeMott, BS, OTR, CHT Robert A. Chase Center for Hand and Upper Limb Surgery
Hand Therapy Manager Stanford University
Therapy Services Stanford, CA
Orthopedic One
Columbus, OH
iv CONTRIBUTORS

Linda J. Klein, OTR, CHT Carol Page, PT, DPT, CHT

Hand Therapy Supervisor Program Director, Hand Therapy Fellowship
Therapy Department Rehabilitation
Hand Surgery, Ltd. Hospital for Special Surgery
Milwaukee, WI New York, NY
Manager, Strategic Improvement
Paige E. Kurtz, MS, OTR/L, CHT Rehabilitation
Hand Therapy Manager Hospital for Special Surgery
Advanced Orthopedics New York, NY
Richmond, VA
Adjunct Faculty Julie Pal, OTR/L, CHT
School of Physical Therapy Dept. of Occupational Therapy/Outpatient Rehabilitation
Old Dominion University Saint Lukes Hospital
Norfolk, VA Kansas City, MO

Corey Weston McGee, PhD(c), MS, OTR/L, CHT Teri Britt Pipe, PhD, RN
Assistant Professor Dean
Program in Occupational Therapy College of Nursing and Health Innovation
The University of Minnesota Arizona State University
Rochester, MN Phoenix, AZ

Joel Moorhead, MD, PhD Joey G. Pipicelli, MScOT

Adjunct Assistant Professor Occupational Therapist, Certified Hand Therapist
Environmental Health Division of Hand Therapy
Rollins School of Public Health/Emory University Hand and Upper Limb Centre, St. Joseph’s Health Care
Atlanta, GA London, Ontario, Canada
Clinical Director Lecturer
FairCode Associates School of Occupational Therapy, Faculty of Health Sciences
Marco Island, GA Western University
London, Ontario, Canada
Patricia M. Moorhead, MHCA, OTR/L
Executive Director of Professional Services Karen Donahue Pitbladdo, MS, OTR/L, CHT
WellStar Cobb Hospital Senior Occupational Therapist
Austell, GA Rehabilitation
San Francisco General Hospital
Ryan Morgan, MS, OTR/L San Francisco, CA
Senior-Level Occupational Therapist
Occupational Therapy/Hand Therapy Donald Greg Pitts, MS, OTR/L CHT
Kentucky Hand & Physical Therapy Clinical Specialist
Lexington, KY Hand Therapy
Kentucky Hand and Physical Therapy
Anne M.B. Moscony, MA, OTR/L, CHT Lexington, KY
Certified Hand Therapist Faculty
Occupational Therapy Occupational Medicine
Rothman Institute University of Kentucky
Egg Harbor Township, NJ Lexington, KY
Adjunct Faculty
Occupational Therapy - Graduate School Gillian Porter, MA, MOT, OTR/L
Philadelphia University Occupational Therapist
Philadelphia, PA SWAN Rehab
Phoenix, AZ
Brenda Nealy, PTA, BA
Certified Pilates Instructor, Master Pilates Certification Deborah A. Schwartz, OTD, OTR/L, CHT
Strength-n-Length Pilates Product and Educational Specialist
Scottsdale, AZ Physical Rehabilitation
Orfit Industries America
Leonia, NJ
 CONTRIBUTORS v

Tracy M. Shank, MS, OTR/L, CHT Jackie Wallman, OTR/L, CHT

Hand Therapist Manager
Nemours/A.I. duPont Hospital for Children Rehabilitation Services Department
Wilmington, DE Saint Luke’s Hospital
Kansas City, MO
Gary Solomon, MBA, MS, OTR/L, CHT
Director Colleen West, MS, OTR/L
Chicago Metro Hand Therapy, LLC Occupational Therapist
Arlington Heights, IL Advanced Home Care
Phoenix, AZ
Lara Taggart, MS, OTR/L Adjunct Faculty
Faculty A.T. Still University
Occupational Therapy Assistant Program Mesa, AZ
Brown Mackie College
Phoenix, AZ Christine M. Wietlisbach, OTD, OTR/L, CHT, MPA
Occupational Therapist Certified Hand Therapist
St. Joseph’s Hospital Rinker Hand Center
Phoenix, AZ Eisenhower Medical Center
Rancho Mirage, CA
Marietta Tartaglia, MS, OTR/L Assistant Professor
Occupational Therapist Occupational Therapy Program
Independent Contractor Rocky Mountain University of Health Professions
Phoenix, AZ Provo, UT

Matthew J. Taylor, PT, PhD, ERYT-500 Jason Willoughby, MHS, OTR/L, CHT
Director Clinical Specialist
Dynamic Systems Rehabilitation Clinic Hand Therapy
Scottsdale, AZ Kentucky Hand and Physical Therapy
Lexington, KY
Aaron C. Varney, BS, MOTR/L, CHT
Clinical Specialist, Occupational Therapist, Certified Hand Therapist Ranay Yarian, MA, CCRC
Outpatient Therapies Community Outreach Manager
PeaceHealth St. John Medical Center Integrative Oncology & Cancer Prevention
Longview, WA Banner MD Anderson Cancer Center
Gilbert, AZ
Rebecca von der Heyde, PhD, OTR/L, CHT Faculty Associate
Director of Occupational Therapy Department School of Social Work
Concordia University Wisconsin Arizona State University
Mequon, WI Tempe, AZ
 To my wonderful husband,
John L. Evarts
You taught me to spread my wings and allow myself to take chances.
Once again, you have provided continuous emotional support,
artistic direction and insight, and valuable technical help.
You are an amazing person, a magnificent husband,
and will always be the love of my life.
 Foreword

A
gain, Cynthia Cooper has honored me with the space to included in the science of hand therapy in the intervention
write an introduction to the second edition of her text, planned individually for each client treated. The concept of mind-
Fundamentals of Hand Therapy: Clinical Reasoning and body is not unknown to us, but putting the ideas together in one
Treatment Guidelines for Common Diagnoses of the Upper Extrem- text makes this an unusual and very relevant read for the new as
ity. By initially reviewing the Contents, the reader can see that well as older generation of hand therapists. The inclusion of chap-
this new edition, again, offers a unique and needed view of the ters related to the client-therapist relationship, offering examples
practice of hand therapy not often seen in one volume. Cynthia through narratives in hand therapy, and relating the personality
has compiled authors able to provide the basic understanding of type to how best to provide patient/client education is a unique
the fundamentals needed for understanding the anatomy and ability of Cynthia Cooper to put into conceptual thinking. The
basic fundamentals used for evaluation and treatment interven- additional chapters that incorporate dance and Pilates in hand
tions in the first section, Part One, “Fundamentals.” The chapters therapy continues to confirm this mind-body thinking along with
that were retained were updated to more current application more specific consideration to incorporate Yoga as a regular prac-
related to functional assessment, combining the mechanistic and tice. This whole section is vital to hand therapists to read and inte-
organistic concepts needed to treat the whole person. Additions grate into their clinical thinking.
to this section include chapters related to orthoses and additional Finally, Part Three, “Clinical Reasoning and Treatment
considerations of clinical reasoning and problem solving so Guidelines for Common Diagnoses of the Upper Extremity” pro-
needed for the hand therapist to provide optimal care. The addi- vides the clinician with the updated information needed in mul-
tion of the chapter by Cooper and West of “Hand Coordination” tiple diagnostic conditions found so useful in the first edition.
is filled with such relevant and useful examples illustrated so well Cynthia Cooper has added chapters in this section that begins
by the extensive figures included. with much needed information consolidated for the hand profes-
Part Two is focused on “Pain and Integrative Strategies,” which sional about wound care and ends with the addition of a topic for
is the unique and much-valued view of hand therapy from a client- “Chemotherapy-Induced Peripheral Neuropathy.” The assistance
centered point of view. The section includes concepts that are now through updated knowledge offered within this text has essential
more included and accepted in hand therapy practice, with addi- use to the hand professionals to gain and/or improve knowledge
tional evidence to support inclusions of the practices discussed. of clinical reasoning for the usual and unusual clinical conditions
The concepts included in this section have been the perspective seen in the clinic. I heartily recommend this textbook to all hand
that Cynthia Cooper has offered us over the past several years at professionals, and again, I am honored to have the chance to
various presentations and through publications. Cynthia Cooper review and write this piece on behalf of Cynthia Cooper and her
has a unique manner of ensuring that the need for occupation is original work.

Donna Breger Stanton, OTD, OTR/L, CHT, FAOTA

Associate Professor, Academic Fieldwork Coordinator
Samuel Merritt University, OT Program
Oakland, CA
 Preface

C
hanges in reimbursements are affecting health care deliv-
ery and restricting clients’ access to specialists. Even if
their health plans support specialty care, they may have
high co-pays or may live in remote locations where there are no
hand therapy specialists. Therapists who are not familiar with the
body of knowledge in hand therapy may inadvertently do more
harm than good. Therapists who are unaware of tissue tolerances
or who do not know about tissue timelines following injury or
surgery can unintentionally injure clients, sometimes irrevocably.
The purpose of this book is to educate non-specialist thera-
pists, hand therapists in training, and occupational and physical In addition, clinical pearls and precautions are highlighted
therapy students about the fundamentals of hand therapy, using throughout each chapter
didactic materials and case examples. It is also a recommended This book is unique in that it explicitly aims to teach clinical
resource for therapists who are studying for the hand therapy reasoning in hand therapy. The special features in Part Three–
certification examination. This textbook teaches reader’s how questions to discuss with the physician, what to say to clients, tips
to apply sound clinical reasoning to determine the needs of their from the field, precautions and concerns—can be used as mental
clients with upper extremity problems. In addition, it provides prompts by therapists when treating their clients. Doing this will
clear treatment guidelines for common upper extremity diagno- help them find their own clinical voices and will strengthen their
ses with content that is valuable, even for experienced hand clinical reasoning skills.
therapists. The case examples, many of which are not simple, serve two
Good clinical reasoning skills are required in order for thera- purposes. First, they demonstrate the use of clinical reasoning in
pists to move beyond therapy protocols, to think critically about treating the client. Second, they highlight the humanistic side of
their clients’ needs, and to provide safe and creative treatment. each client encounter. In reality, even a seemingly straightforward
The content of this book enables therapists to treat their clients as clinical case has its special challenges and intriguing moments.
unique people with individual needs, while applying appropriate The cases were selected to remind the reader of the human side
and safe treatment. and humane concerns in caring for a hand therapy client.
The scope of this book is broad, with content that includes I am hopeful that this book will spark therapists’ passion for
those diagnoses most typically referred to hand therapy. The hand therapy and will teach them gentle ways of touching their
book is organized into three parts. Part One lays the foundation clients’ hands and lives.
and identifies fundamentals of hand therapy treatment. In this
second edition, Part One has added new chapters on problem Acknowledgments
solving to prevent pitfalls, orthoses, and hand coordination. Part
Two has been renamed “Pain and Integrative Strategies.” In this I would like to acknowledge my mother, Delma P. Cooper, and
edition, Part Two has new chapters on how therapists’ words my twin sister, Jan Carroll, for their interest in and enthusiasm for
affect the therapeutic relationship, narratives in hand therapy, my work. I am extremely grateful to Kathy Falk, Executive Con-
personality type and patient education in hand therapy, using tent Strategist, for her support and creativity in the development
dance in hand therapy, applying Pilates concepts to hand therapy of the first edition of this book; to Jolynn Gower, Content Strate-
by connecting through the hand, and Yoga therapeutics. Part gist, and to Christie Hart, Senior Content Development Special-
Three covers “Clinical Reasoning and Treatment Guidelines for ist, for her guidance, vision, support, and expertise. I would also
Common Diagnoses of the Upper Extremity.” In this second edi- like to recognize Marquita Parker, who was the Senior Project
tion, Part Three has new chapters on wound care, wrist instabili- Manager on this book. Thanks as well to Marietta Tartaglia, MS,
ties, separate chapters on wrist fractures and hand fractures, the -
neurological hand, and hand therapy for chemotherapy-induced ond editions; and to Sarah Arnold, OTS, Siaw Chui Chai, PhD.,
peripheral neuropathy. OT, and J. Robin Janson, MS, OTR, CHT, for reviewing some
The chapters in Part Three provide diagnosis-specific infor- chapter proofs on a tight timeline. I am very grateful to Marcia
mation. Although the reader should spend time with the entire
book, the chapters in Part Three are useful as an easily accessed
resource for common diagnoses of the hand and upper extremity.
Most of the Part Three chapters use a similar organizational
format that serves as a unifying framework: me to have this wonderful opportunity.
 PART 1 FUNDAMENTALS

1 Fundamentals: Hand
Therapy Concepts and
Treatment Techniques
Cynthia Cooper

The more you know about something in detail, the less

you know about it in general.
—From The Child in Time by Ian McEwan,
Anchor Books, 1987

H
ands are visible, expressive, and vulnerable. When clients use their hands to get
dressed, eat, touch, gesture, or communicate, they are performing exquisite and
complex movements. Limitations of motion or even a small scar can affect a
person’s life in profound ways.1 When we touch our clients’ hands, we touch their lives.
Although it is very important to be knowledgeable about the details of hand anatomy
and to be structure specific in our treatment, it is equally important not to lose sight
of the whole person whose extremity we are treating. We must continuously encourage
clients to tell us about themselves and their needs so that their therapy can be relevant
and successful. While getting to know the person we are treating, we can explain how
our interventions and the client’s home programs will be helpful. As a rule, I find that if
I listen well, clients frequently tell me in lay terms or even show me exactly what motion
or function is missing. The challenge is to identify and treat clients’ specific tissues effec-
tively while not losing sight of them as people.

Hand Therapy Concepts

The anatomy of the hand is complex. Many structures are multiarticulate (that is, they
cross multiple joints), and little room is available for scar tissue or edema to develop
without affecting function. Injury in one area of the hand can result in stiffness in other,
uninjured parts. A good demonstration of this is the quadriga effect, which illustrates
the interconnectedness of the digits. If you passively hold your ring finger extended with
your other hand and then try to make a fist, you will notice how limited the whole hand
can feel when just one finger is held stiff. In this example, the flexor digitorum profundus
(FDP) tendons to multiple digits have a shared muscle belly. Restricting movement at one
finger restricts the other fingers when they try to flex. This example reminds us that clients
can be limited in motion in areas not originally injured. Therefore the therapist needs
to evaluate beyond the isolated area of injury when treating clients with hand problems.
To be competent in hand therapy, therapists must be able to do more than just note
decreased range of motion (ROM). They must be able to figure out what structures are
restricted and how these restrictions affect function (for example, the client has decreased
digital flexion due to FDP adherence, preventing him from holding the steering wheel);
they then must be able to target treatment to those particular tissues. These three ele-
ments are part of all the decisions we make as hand therapists. As treatment continues,
re-evaluation reveals new findings with different tissues to target, and appropriate modifica-
tions and upgrades are made. This chapter addresses treatment concepts and techniques of
hand therapy and concludes with some provocative thoughts to stimulate clinical reasoning.

Timelines and Healing

Tissues heal in predictable phases. However, the length of these phases varies depending
on client variables, such as age and health. The three phases of healing are inflammation,
2 PART 1 Fundamentals

fibroplasia, and maturation (also called remodeling). In the inflam- Positioning to Counteract Deforming Forces
mation phase, vasoconstriction occurs, followed by vasodilation,
with migration of white blood cells to promote phagocytosis in Predictable deforming forces act on an injured upper extremity
preparation for further healing. In this stage, which lasts a few (UE). Edema (swelling) routinely occurs after injury, creating ten-
days, immobilization often is advised, depending on the specifics sion on the tissues. The resulting predictable deformity posture is
of the diagnosis.2 If wound contamination or delayed healing is a one of wrist flexion, metacarpophalangeal (MP) hyperextension,
factor, this phase can last longer.3 proximal interphalangeal (PIP) and distal interphalangeal (DIP)
The fibroplasia phase begins about 4 days after injury and flexion, and thumb adduction.4 This deformity position occurs as
lasts 2 to 6 weeks. In this phase, fibroblasts begin the formation a result of tension on the extrinsic muscles caused by dorsal edema.
of scar tissue. The fibroblasts lay down new collagen, on which Use of the antideformity (intrinsic-plus) position is recom-
capillary buds grow, leading to a gradual increase in the tissue’s mended after injury unless it is contraindicated by the diagno-
tensile strength. In this stage, active range of motion (AROM) sis (for example, it is not used after flexor tendon repair). The
and orthotics typically are used to promote balance in the hand antideformity position consists of the wrist in neutral position or
and to protect the healing structures.2 extension, the MPs in flexion, the IPs in extension (IPs refers to
The timeline for the maturation (remodeling) phase var- the PIP and DIP joints collectively), and the thumb in abduction
ies; this phase may even last years. In the maturation phase, the with opposition (Fig. 1-1). The antideformity position maintains
tissue’s architecture changes, reflecting improved organization length in the collateral ligaments, which are vulnerable to short-
of the collagen fibers and a further increase in tensile strength. ening, and counteracts deforming forces.
The tissue is more responsive (that is, reorganizes better) if
appropriate therapy is started sooner rather than later. In this Joint and Musculotendinous Tightness
stage, gentle resistive exercises may be appropriate, and the cli-
ent should be monitored for any inflammatory responses (also Joint tightness is confirmed if the passive range of motion
known as a flare response). Dynamic or static orthoses may also (PROM) of a joint does not change despite repositioning of prox-
be helpful.2 imal or distal joints. Musculotendinous tightness is confirmed
if the PROM of a joint changes with repositioning of adjacent
joints that are crossed by that particular muscle-tendon (muscu-
lotendinous) unit.5
Joint tightness and musculotendinous tightness can be treated
with serial casting, dynamic orthoses static progressive orthoses
or serial static orthoses (see Chapter 7 and also the “Orthotics”
section later in this chapter). With joint tightness, splinting can
focus on the stiff joint, and less consideration is needed for the
position of proximal or distal joints. With musculotendinous
tightness, because the tightness occurs in a structure that crosses
multiple joints, the orthotic must carefully control the position
of proximal (and possibly distal) joints to remodel tightness effec-
tively along that musculotendinous unit.
The client in Fig. 1-2, A, had an infected PIP joint in the
index finger. He was treated with hospitalization, intravenous
FIGURE 1-1 Antideformity (intrinsic-plus) orthotic position. (From administration of antibiotics, and joint debridement. He arrived
Coppard BM, Lohman H, editors: Introduction to splinting: a clinical- for therapy 2 weeks later than his physician had ordered; he had
reasoning and problem-solving approach, ed 2, St Louis, 2001, Mosby.) no orthotic, significant edema, and a severe flexion contracture of

A B
FIGURE 1-2 A, Unsplinted, infected index finger after surgery. B, Improvement in edema and improved
extension range of motion (ROM) after 2 weeks.
 Fundamentals: Hand Therapy Concepts and Treatment Techniques CHAPTER 1 3

the PIP joint. Because the stiffness was localized to the PIP joint, proximal joint crossed by that structure. With extrinsic exten-
he needed only a digit-based extension orthosis for that joint. sor tightness, passive composite digital flexion is more limited
Fig. 1-2, B, shows his progress after 2 weeks of edema control and with the wrist flexed than with the wrist extended. With extrin-
serial static digit-based orthoses. sic flexor tightness, passive composite digital extension is more
Musculotendinous tightness can be a cause of joint tightness. limited with the wrist extended than with the wrist flexed.5
Clients with tightness of the extrinsic flexors (that is, lacking pas-
sive composite digital extension with the wrist extended) are at Lag or Contracture
risk of developing IP flexion contractures. Instruct these clients
to passively place the MP in flexion and then to gently, passively
extend the IPs to maintain PIP and DIP joint motion. In these
cases, although you should consider night orthoses in composite Clinical Pearl
extension to lengthen the extrinsic flexors, the better course may When PROM is greater than AROM at a joint, the active limita-
be to splint in a modified intrinsic-plus position with the MPs tion is called lag.
flexed as needed to support the IPs in full extension. This helps
prevent IP flexion contractures.
A client with a PIP extensor lag is unable to actively extend
Intrinsic or Extrinsic Extensor Muscle Tightness the PIP joint as far as is possible passively (which may not neces-
sarily be full extension). Lags may be caused by adhesions, dis-
Intrinsic muscles are the small muscles in the hand. Extrin- ruption of the musculotendinous unit, or weakness.
sic muscles are longer musculotendinous units that originate
proximal to the hand. Intrinsic tightness and extrinsic extensor Clinical Pearl
tightness are tested by putting these muscles on stretch. This When passive limitation of joint motion exists, that limitation
is accomplished by comparing the PROM of digital PIP and is called a joint contracture.
DIP flexion when the MP joint is passively extended and then
passively flexed. With interosseous muscle tightness, passive
PIP and DIP flexion is limited when the MP joint is passively Joint contractures can be caused by collateral ligament tight-
extended or hyperextended (Fig. 1-3). With extrinsic extensor ness, adhesions, or a mechanical block. A joint flexion contracture
tightness, PIP and DIP flexion is limited when the MP joint is is characterized by a stiff joint in a flexed position that lacks active
passively flexed (Fig. 1-4).5 and passive extension. A person with a joint flexion contracture
To treat intrinsic tightness, perform PIP and DIP flexion whose passive extension improves may progress from having a
with MP hyperextension. Functional orthotics are very helpful for flexion contracture to having an extensor lag. In your treatment
isolating specific exercise to restore length to the intrinsics while communications and documentation, it is important to identify
performing daily activities (see the “Orthotics” section). To treat such changes, to use these terms correctly, and to be joint specific
extrinsic extensor tightness, promote composite motions (that is, and motion specific. For example, you should note, “The client
combined flexion motions of the wrist, MPs and IPs) with orthot- has full PIP passive extension but demonstrates a 30-degree PIP
ics, gentle stretch, and exercise. Instruct the client that performing extensor lag.”
these exercises with the wrist in a variety of positions is helpful. When a lag is present (PROM exceeds AROM), treatment
should focus on promoting active movement. Blocking exercises
Extrinsic Extensor or Flexor Tightness (Fig. 1-5), differential tendon gliding exercises (see Fig. 1-18),
place and hold exercises (see Fig. 1-19), and dynamic or static
Extrinsic tightness can involve the flexors or the extensors. To functional orthotics can be helpful (Fig. 1-6). If a contracture is
test for tightness, put the structure on stretch by positioning the present, promote both PROM and AROM with the same exer-
cises and with corrective orthoses, which may be the dynamic,
static progressive, serial static, or casting type.

FIGURE 1-3 Interosseous muscle tightness. Proximal interphalan-

geal (PIP) and distal interphalangeal (DIP) flexion is passively limited
when the metacarpophalangeal (MP) joint is passively extended or FIGURE 1-4 Extrinsic extensor tightness. PIP and DIP flexion is
hyperextended. passively limited when the MP joint is passively flexed.
4 PART 1 Fundamentals

Hand therapy patients may have nociceptive pain or neu-

ropathic pain or a combination of the two. It is important to
address this with patients so that your treatment targets their
unique pain quality and can be most successful.

Preventing Pain
Precaution. Pain with therapy is a signal that injury is occurring.
Irreversible damage can result when clients or their families or,
worse, therapists injure tissue by using painful force and PROM.
Avoid pain in your hand therapy treatment. Being overzealous and
ignoring objective signs of tissue intolerance is inexcusable.
Teaching clients and their families that painful therapy is
counterproductive can be a challenge. Often clients come to
therapy with a “no pain, no gain” mentality. To make matters
worse, this philosophy frequently is reinforced by their physicians
and friends. Therapists have a duty to explain to their clients that
imposing, prolonging, or aggravating pain slows the healing pro-
cess, fosters more scarring and stiffness, and delays or eliminates
FIGURE 1-5 DIP blocking exercises with the MP in various opportunities to upgrade therapy.
positions.
Clinical Pearl
Never tell your clients, “Exercise to pain tolerance” or “Go to
pain.” Instead say, “Avoid pain when you exercise. It’s okay to
feel a stretch that isn’t painful, but it’s not okay to feel pain
when you exercise.”

Taking Care with Passive Range of Motion

PROM of the hand should be performed gently and with care.
Precaution. PROM can injure swollen and inflamed joints and
tissues. Colditz5 cautions that the only joints for which manual
PROM is safe are joints with a soft end-feel. Nevertheless, cli-
ents may request more aggressive therapy. They may even be
passively stressing their swollen, stiff hands at home. It is very
important that the therapist inquire about this and put a stop to
FIGURE 1-6 A dynamic MP extension assist orthosis allows the
it. Explain to your client how injurious and counterproductive it
client to perform keyboard activities at the computer.
is, emphasizing that delicate hand tissues are all too easily injured
(see Chapter 12).
Joint End-Feel Precaution. PROM can trigger inflammatory responses, causing
additional scar production, pain, and stiffness. PROM used inap-
A joint with a soft end-feel has a spongy quality at the end-range. propriately or painfully can incite complex regional pain syndrome
This is a favorable quality that indicates a potential for remodeling. (CRPS), which is also known as reflex sympathetic dystrophy (RSD).
Orthoses for soft end-feel may be the static type or the low-load,
long duration type (see the “Orthotic” section and Chapter 7).
What to Say to Clients
A joint with a hard end-feel has an unyielding quality at end-
range. This is a stiffer joint, and correcting it may require serial If the Doctor Orders “Aggressive Therapy”
casting or static progressive orthoses with longer periods of splint When a physician orders aggressive therapy for a client, I tell the
wear.2 Documenting the end-feel and explaining the implications client, “Your doctor wants you to make excellent progress. But
of your findings to the client are very important. the reality is that tissues in the hand are delicate and can easily
be injured by too much force or pressure. We will promptly
Nociceptive Pain versus Neuropathic Pain6 correct the restricted or injured tissues, and you will make the
best progress by providing controlled stress to the proper struc-
Not all pain is the same physiologically or symptomatically. tures. Painful, injurious treatment or exercise will only delay
Nociceptive pain is caused by structural dysfunction, such as or even derail your progress. What we will do aggressively is to
an arthritic wrist. Providing an orthotic to support the involved upgrade your program and encourage maximum results.”
structures reduces the pain. Neuropathic pain is caused by some Hopefully, physicians soon will realize the wisdom of re-
form of peripheral nerve dysfunction and is typically a sensory placing the term aggressive with progressive. Until that happens,
pain that is difficult for patients to describe in words. It may be explain to your clients that pain-free, controlled stretching and
burning or electrical. Providing sensory protection and minimiz- remodeling have proved to be the best course of treatment for
ing peripheral nerve irritation reduces this type of pain. the fragile hand tissues.
 Fundamentals: Hand Therapy Concepts and Treatment Techniques CHAPTER 1 5

Quality of Movement and Dyscoordinate through use of low-voltage direct current). Therapists should
Co-Contraction study these topics further. However, they also must abide by their
practice acts and the regulations of their state licensing agencies
Dyscoordinate co-contraction is a poor quality of movement regarding the use of modalities. Never use a modality for which
that can result from co-contraction of antagonist muscles. Cli- you cannot demonstrate proper education and training.
ents may demonstrate dyscoordinate co-contraction when they
use excessive effort with exercise or when they fear pain with Scar Management
exercise or PROM, or it may be habitual. The resulting motion
looks unpleasant and awkward. For example, you may feel the Scars can take many months to heal fully. Treat scar sensitivity
extensors contract as the client tries to activate the flexors. It is with desensitization. If the sensitivity causes functional limita-
important not to ignore dyscoordinate co-contraction. Instead, tions, provide protection, such as padding or silicone gel. Scars
teach the client pain-free, smooth movements that feel pleas- are mature when they are pale, supple, flatter, and no longer sen-
ant to perform. Replace isolated exercises with purposeful or sitive. Scar maturation can be facilitated by light compression
functional activities and try proximal oscillations (small, gentle, (for example, with Coban, Tubigrip [an elastic support sleeve],
rhythmic motions) to facilitate a more effective quality of move- or edema gloves).
ment. Biofeedback or electrical stimulation may also be helpful. Precaution. Always check to make sure the compression on the
Imagery offers additional possibilities (for example, ask your cli- scar is not excessive (that is, the wrap, sleeve, or glove is not too tight).
ent to pretend to move the extremity through gelatin or water).7 Inserts made of padded materials or silicone gel pads also help
Do not bark at the client to “Relax!” Instead, be gentle with your facilitate scar maturation.10 This padding is thought to promote
voice and your verbal cues. neutral warmth of the area and may decrease oxygen to the col-
lagen, thus promoting collagen maturation. Another alterna-
Adjunct Treatments tive for scar management is to use micropore paper tape applied
longitudinally along the incision line once epithelialization has
Superficial heating agents can have beneficial effects on analgesic, occurred.11 I have found this to be very effective and cost-saving
vascular, metabolic, and connective tissue responses. Analgesic for patients. In addition, paper tape helps reduce neuropathic
effects are seen in diminished pain and elevated pain tolerance. pain (see Chapter 41).
Vascular effects are evidenced by reduced muscle spasms and Instruct your clients to avoid sun exposure while the scar is
improved pain relief. Metabolic effects are related to an increased still immature (that is, pink or red, thick, itchy, or sensitive).
flow of blood and oxygen to the tissues with improved provision Sunlight can burn the fragile scar and darken its color, affect-
of nutrients and removal of byproducts associated with inflam- ing the cosmetic result when the scar is mature. Frequent use
mation. Connective tissue effects include reduced stiffness with of sunscreen is highly recommended (see Chapter 34). Although
improved extensibility of tissues.8 scar massage is often performed, it is important to monitor the
Many clients feel that heat helps prepare the tissue for exercise client’s tissue response.
and activity. The safest way to warm the tissues of hand ther- Precaution. If scar massage is too aggressive, it may cause inflam-
apy clients is aerobic exercise, unless this is contraindicated for mation and contribute to more extensive development or thickening
medical reasons. Tai chi, for example, provides multijoint ROM, of scar tissue.
relaxation, and cardiac effects. Do not encourage aggressive massage; instead, teach the cli-
Application of external heat (for example, hot packs) is a ent to perform gentler massage that does not cause a flare of tis-
popular method in many clinics. Although the use of heat is fine sues. Further research on this topic is needed.
if it is not contraindicated, be mindful that heat increases edema,
which acts like glue, and this may contribute to stiffness. Heat
can degrade collagen and may contribute to microscopic tears in Treatment Techniques
soft tissue.9 For these reasons, be very gentle and cautious if you
perform PROM after heat application. Monitor the situation to Orthoses
make sure that the overall benefits of heat outweigh any possible
negative responses. Measuring edema is a good way to objectify Orthotic Fabrication is a mainstay of therapy for UE problems.
these responses. Orthotics can provide immobilization or selective mobilization.
Cold therapy (also called cryotherapy) traditionally has been They can be used with exercise or to promote function. The topic
used to relieve pain and to reduce inflammation and edema after of orthoses exceeds the scope of this chapter (see Chapter 7). I
injury (and sometimes after overly aggressive therapy). Cryo- strongly advise readers to study more comprehensive resources
therapy typically is used after acute injury to reduce bleeding on this subject.2,12 In addition to learning about orthotic fabrica-
by means of vasoconstriction. Cold therapy reduces postinjury tion, readers should learn about strap placement for mechanical
edema and inflammation and raises the pain threshold. However, advantage and comfort.
remember: cold therapy can be harmful to tissues; be cautious with Static orthotics are used to immobilize tissues, to prevent
this modality. deformity, to prevent contracture of soft tissue, and to provide
Precaution. Do not use cryotherapy on clients with nerve injury substitution for lost motor function. Serial static orthoses posi-
or repair, sensory impairment, peripheral vascular disease, Raynaud’s tion the tissue for lengthening and are remolded at intervals. Static
phenomenon, lupus, leukemia, multiple myeloma, neuropathy, other orthotics contribute to disuse, stiffness, and atrophy; therefore
rheumatic disease, or cold intolerance. they should not be used more than necessary. Static progressive
Other modalities used in hand therapy include therapeutic orthoses (also called inelastic mobilization orthotics) apply mobiliz-
ultrasound, electrical stimulation, and iontophoresis (provision ing force using nonmoving parts such as monofilament, Velcro, or
of an agent such as an anti-inflammatory medication into tissue screws. Dynamic orthotics (also called mobilization orthotics
6 PART 1 Fundamentals

or elastic mobilization orthotics) use moving parts, such as rub- example, gripping a handful of dried beans, squeezing some out
ber bands or spring wires, to apply a gentle force. These orthotics of the hand, and then gripping further).
are used to correct deformity, to substitute for absent or impaired A scrap of thermoplastic material can be used to create a cyl-
motor function, to provide controlled movement, and to promote inder to fit the client’s available limited fist position. Sustained
wound healing or help with alignment of fractures.12,13 gripping of or holding onto this cylinder and “pumping” to flex
Forearm-based orthotics should cover approximately two- and extend the digits around the cylinder may enhance compos-
thirds of the forearm. Have the client bend the arm at the elbow, ite digital flexion.
and note the place where the forearm meets the biceps muscle.
The proximal edge of the orthotic should be ¼-inch distal to this Chip Bags
so that the orthotic is not pushed distally when the client flexes the
elbow. Flaring the proximal edges of the orthotic is also important Chip bags can be incorporated into orthotic regimens to maxi-
to ensure that the orthotic stays in place on the arm.14 Clearing mize lymphatic flow and minimize the stiffness and adherence
the distal palmar crease is extremely important. If the orthotic that otherwise would worsen as a result of the edema. A chip bag
crosses this crease, MP flexion will be impeded. When you con- is a cotton stockinette bag filled with small foam pieces of vari-
struct a dorsal forearm-based orthotic or a forearm-based ulnar ous densities (Fig. 1-11). The foam can be cut from a variety of
gutter, pad the area of the ulnar head, because this bony promi- sources, including foam exercise blocks, padding, and soft Velcro
nence can become a pressure area. Always incorporate the padding materials. Chip bags traditionally have been used in the treat-
into the molding of the orthotic; do not place it inside afterward ment of lymphedema; they are positioned over indurated areas
as an addition. With mobilization orthotics, the best approach is of edema within external compressive garments or multilayered
to provide an orthotic your client can tolerate for long periods. stretch bandages. Chip bags provide light traction on the skin,
facilitate lymphatic stimulation, and promote neutral warmth.
Clinical Pearl All these effects help reduce edema. The increased body heat
Applying low tension that is tolerable and constant over pro- under the chip bag and the light pressure exerted by the bag help
longed periods is much more effective than applying strong soften thickened or fibrotic tissue.
forces over shorter periods. In some cases, chip bags can be used alone without an accom-
panying orthotic. In such cases, they can be held in place with
stockinette or a soft Velcro strap that is not applied tightly.
The amount of safe force for the hand is 100 to 300 g.15 Cli- Sometimes a less technical approach, such as using chip bags
ents often ask that more force be used in their orthotics. These with orthotics, is a very effective option. Chip bags also can be
clients need repeated education that low load over a long dura- positioned inside or in conjunction with orthotics to maximize
tion is the safest and most effective way to remodel tissues and edema control and reduce scar adherence. Clients find chip bags
make clinical progress. very comfortable. Some refer to the chip bag as their “pillow,”
Precaution. Painful splinting can be harmful. which probably conveys the comfort they experience with it.
Skin blanching is a sign of high tension or incorrect orthotic
mechanics.3 The line of pull on the part being mobilized in a Soft Four-Finger Buddy Strap
static progressive or dynamic orthotic must be a 90-degree angle
from the outrigger (the structure from which the forces are A soft four-finger buddy strap can be made from Softstrap Velcro
directed). An outrigger can be high profile or low profile (Fig. loop to provide transverse support that promotes more efficient
1-7). High-profile outriggers have certain mechanical and adjust- primary function of the extrinsic flexors and extensors (see Fig.
ment advantages but are bulkier and less attractive.16 1-20, A-D, on the Evolve website). This strap facilitates AROM
for composite flexion and extension and for isolated extensor digi-
Orthotics Used with Exercise torum communis (EDC) and FDP tendon glide. It also stimu-
lates lymphatic flow over the volar proximal phalanges, similar to
A dorsal dropout orthotic can be used to correct digital flexion chip bags. The soft four-finger buddy strap can relieve pain and
or extrinsic extensor tightness. Mold the orthosis in a position of promote AROM when hand stiffness is present. It also is help-
comfortable stretch. Use strapping as needed to keep it in place. ful for symptom management in clients with lateral epicondylitis
The client should try to gently flex the digits away from the (tennis elbow) who have EDC involvement and pain on fisting.17
orthotic as able (Fig. 1-8). Having an object to reach for, such as
a dowel in the palm, can be helpful.
Orthoses can be used to achieve various differential MP posi-
CASE STUDIES
tions. The differential MP orthotic in Fig. 1-9 positions the long
finger MP in greater flexion than the index and ring fingers. In
this orthotic, active MP flexion of the index and ring fingers facil- CASE STUDY 1-1 ■
itates long finger flexion. Fig. 1-10 shows the opposite differential
MP orthotic with the long finger MP more extended than the A client was in an altercation with a family member, and her hand
adjacent fingers. A differential MP orthotic with the small finger was closed in a door during the argument. She was seen for mal-
MP more flexed than the ring finger might be useful for a small union of a right distal radius fracture with right ulnar joint dislocation
finger metacarpal fracture with limited MP flexion. Active PIP and extensor pollicis longus (EPL) rupture. She underwent open car-
flexion and extension within this type of orthotic at various MP pal tunnel release, corrective osteotomy of the distal radius fracture
positions also promotes PIP joint ROM and tendon gliding. This with internal fixation and bone grafting, and intercalary tendon graft-
orthotic can be used during a progressive gripping activity (for ing of the EPL tendon using the extensor indicis proprius (EIP). When
 Fundamentals: Hand Therapy Concepts and Treatment Techniques CHAPTER 1 7

FIGURE 1-7 Examples of the 90-degree angle of pull with high-profile and low-profile outriggers. (From Fess
EE: Principles and methods of splinting for mobilization of joints. In Mackin EJ, Callahan AD, Skirven TM et al, edi-
tors: Rehabilitation of the hand and upper extremity, ed 5, St Louis, 2002, Mosby.)

the client was seen in occupational therapy, her hand was extremely flexion exercise; the goals were to resolve intrinsic muscle tightness
swollen and stiff, and she had severe extrinsic extensor tightness that and promote composite digital flexion. Within 2 weeks, the client
limited full fisting. She developed CRPS and was treated successfully had made very good gains (Fig. 1-13, C).
for this with a combination of stellate ganglion blocks and hand ther-
apy. Note the dorsal scars and edema (Fig. 1-12, A). The style of chip CASE STUDY 1-3 ■
bag incorporated into her volar wrist orthosis is shown in Fig. 1-12, B.
This woman was a highly motivated client. At the time her therapy A woman who fell while hiking sustained a displaced distal radius frac-
was discontinued, she had regained very good hand function. ture that required external fixation and percutaneous pin fixation. More
than a week passed after her fall before she went to her physician. The
CASE STUDY 1-2 ■ woman explained this by noting that she has attention deficit disorder.
She came to therapy 1 day after applying an elastic bandage tightly
A client who underwent surgery for release of a Dupuytren’s contrac- and irregularly around her external fixator. Note the indentations left
ture developed a flare reaction. Note the incisional scar and fullness on her skin by the wrap (Fig. 1-14, A). Chip bags were incorporated
of the ulnar hand (Fig. 1-13, A), as well as the limitation in composite into the dressings and orthotics used in this case (Fig. 1-14, B), and the
digital flexion (Fig. 1-13, B). This client used a chip bag inside an ex- client progressed very well in therapy. She had good composite digital
ercise orthotic designed to block the MPs and promote PIP and DIP extension and flexion at the time of discharge (Fig. 1-14, C and D).
8 PART 1 Fundamentals

Exercises for Upper Extremity Therapy

Precaution. Shoulder stiffness can develop insidiously and can be
very limiting.
Check the client’s posture and proximal motion initially and
then at intervals. Incorporate proximal AROM into all home
exercise programs even if this is only a preventive measure (see
Chapter 22).
Shorter, milder sessions of exercise performed more frequently
are better than longer, intensive sessions done less often. Some
clients do well at first, performing five repetitions five times a day
and gradually building to ten repetitions hourly during the day.
Explain that exercises work well if the process is brief and frequent.
When working on isolated wrist extension, be sure to isolate
the extensor carpi radialis brevis (ECRB), and teach clients how
to extend the wrist with a soft fist that includes MP flexion. Have
FIGURE 1-8 Client performing active digital flexion in a dorsal them hold an object so that the MPs are flexed. It is critical to
dropout orthosis. retrain the ECRB to perform wrist extension. Without this iso-
lation of motion, the client may learn to extend the wrist with
EDC substitution instead of using the ECRB.

Clinical Pearl
Once established, the habit of extending the wrist with EDC
substitution can be very hard to break.

To work on wrist active/active assistive range of motion

(A/AAROM), put a towel on the table, and then place a coffee
can (no bigger than the 3-lb size) on its side on the towel. Teach
the client to place the involved hand on the can and to use the
other hand to hold the involved hand flat on the can. The client
then rolls the can using A/AAROM forward and backward. Cli-
ents like the feeling of this exercise, which also promotes proxi-
mal ROM and stimulates lymphatic flow.
In contrast to this, if extrinsic flexor tightness is a problem,
the client would perform exercises involving wrist extension with
simultaneous digital extension. Otherwise, exercises for wrist
extension should be done primarily with a fist that includes MP
FIGURE 1-9 Differential MP positioning orthosis with long finger
flexion.
MP more flexed than adjacent fingers.
Always look at the client’s wrist position when exercising the
digits. Do not exercise or coax the digits into flexion with the
wrist flexed unless you are deliberately trying to stretch the extrin-
sic extensors. It is biomechanically easier to achieve digital flexion
with the wrist in extension, to achieve PIP joint flexion with the
MP extended, and to achieve PIP joint extension with the MP
flexed. If the client cannot sustain a position of wrist neutral or
extension, use an orthosis or have the client self-support the wrist
using the other hand when digital exercises are performed.
Instruct clients always to keep the upper arm locked at the
side of the body when performing forearm rotation exercises.

Clinical Pearl
Do not perform forearm rotation exercises with the elbow on
a table or even on a pillow; this prevents isolated forearm rota-
tion and allows for substitution with humeral motions.

Teach the client that one way to do this is to keep a towel

roll pressed to the side of the body with the arm used to perform
FIGURE 1-10 Differential MP positioning orthosis with long finger forearm rotation exercises, because this requires that the elbow be
MP more extended than adjacent fingers. kept close to the body.
 Fundamentals: Hand Therapy Concepts and Treatment Techniques CHAPTER 1 9

A B
FIGURE 1-11 A, Chip bag contents consisting of small pieces of foam placed in a cotton stockinette. B, Ends
of chip bag can be folded over and taped closed.

A B
FIGURE 1-12 A, Dorsal scars and edema. B, Style of chip bag incorporated into the client’s volar wrist orthosis.

A B C
FIGURE 1-13 A, Flared incisional scar that developed after Dupuytren’s release surgery. B, Limited active
composite flexion. C, Full active composite flexion 2 weeks later.
10 PART 1 Fundamentals

A B

C D
FIGURE 1-14 A, Indentations made by a tight elastic bandage applied by the client. B, Chip bags incorpo-
rated into dressings and orthosis with external fixator and pins. C and D, Resolution of edema and active
digital extension and flexion at discharge.

In some cases, AROM through functional activity and exer- to only the DIP requires a soft quality of contraction so that the
cise may be all that is needed to enable the client to recover full effort is not overridden by other structures. The biomechanical
UE flexibility and function. When more isolated and structure- challenge to the FDP is greater when DIP flexion is performed
specific exercises are needed, the exercises discussed in the follow- with MP flexion than with MP extension. This positional pro-
ing sections may be helpful. gression can be used to upgrade the exercises.

Blocking Exercises Clinical Pearl

When a digital PIP block is used to promote MP flexion of the
Blocking exercises are exercises in which proximal support is pro- small finger, it is very helpful to stabilize the small finger meta-
vided to promote isolated motion at a particular site. They are help- carpal.
ful for clients with limitation of either AROM or PROM or both.
Blocking exercises exert more force than nonblocking exercises.
The ring and small finger metacarpals are more mobile at
Clinical Pearl their carpometacarpal (CMC) joints than are the index and long
With blocking exercises, instruct the client to hold the posi- finger metacarpals. If the metacarpal is supported by your hand
tion at comfortable end-range for 3 to 5 seconds; this allows or the client’s other hand, more effective isolated motion can
remodeling of the tissues. occur at the MP joint. This isolation and proximal support can
be very helpful for clients trying to recover MP flexion after a
small finger metacarpal fracture.
Blocking exercises can be accomplished in a variety of ways. A blocking splint with the MPs flexed helps isolate active PIP
You can use either commercially available devices or individual extension (Fig. 1-15). Extending the PIP is easier biomechanically
devices made from scraps of orthotic materials. Digital gutters or when the MP is flexed, because this position promotes central slip
cylinders that cross the IPs help isolate MP flexion and extension. function. This same blocking splint also promotes composite flex-
If the cylinder is shortened to free the DIP, then DIP blocking ion exercise and can be helpful for normalizing extrinsic extensor
exercises can be performed. These exercises can be done with the tightness. Conversely, a blocking splint with the MPs extended
MP in extension or in varying degrees of flexion. Often a client (Fig. 1-16) helps to isolate active IP flexion and FDP excursion
exerts too strong a contraction, and the PIP tries to flex within and to resolve intrinsic tightness. These types of orthotics can be
the blocking splint. Explain to the client that isolating motion used with function, or they may be used only for exercise.
 Fundamentals: Hand Therapy Concepts and Treatment Techniques CHAPTER 1 11

the client tries to sustain the exercise position. A combination of

blocking exercises and place and hold exercises can be very pro-
ductive. Also, you can try doing place and hold exercises with a
blocking orthosis in place.
When the client releases the sustained contraction, pain
sometimes may be felt in the area of a stiff joint. For instance, if
the client performs place and hold exercises for composite fisting
and then has PIP joint discomfort when releasing the fist, have
the client relax the muscle contraction but stay in the same fisted
position. While the client stays in that position, gradually provide
assistance to gently begin extending the digit or digits (minimal
joint distraction mobilization also can be helpful if not contrain-
dicated). Next, ask the client to slowly actively extend the digits
the rest of the way. This technique can be helpful for eliminating
FIGURE 1-15 Blocking orthosis with the MP flexed helps isolate PIP pain associated with end-ranges and AAROM.
extension and promotes extrinsic extensor stretch.

Resistive Exercises
After clients have been medically cleared for them, resistive exer-
cises are used for strengthening and to improve excursion of
adherent tissue. Sometimes clients want to use a greater load than
is safe for them. Teach clients that, for isolating wrist curls, they
should not use as heavy a weight as they would for biceps curls.
Precaution. Think carefully and critically about the status of
your client’s wrist if the person is recovering from a fracture, has
had tendonitis, or is at risk for degenerative joint changes. Be very
careful with wrist radial and ulnar deviation strengthening exercises,
because these may provoke tendonitis.
Generally speaking, the safest course in performing resis-
tive exercises is to use more repetitions with a lower load. This
approach promotes endurance. (A more detailed discussion of
FIGURE 1-16 Blocking orthosis with the MP extended helps isolate
resistive exercise is presented in Chapter 4.)
active PIP flexion and flexor digitorum profundus (FDP) excursion
Resistive exercise can take many forms, including progressive
and also helps resolve intrinsic tightness.
resistive exercises (PREs) and exercises performed with graded
grippers, rubber bands, squeeze balls, graded clothespins, and
putty. For example, marbles or other objects can be embedded in
A DIP cap or flexion block diverts FDP excursion to the PIP putty, requiring pinch and dexterity to remove them.
and thus promotes isolated exercise of the FDS muscle with MP
and PIP flexion and DIP extension. This blocking device may Functional Activity
also help the client exercise the flexor digitorum superficialis
(FDS) fist position more easily (see the following section). It is essential that the client incorporate the gains made from
exercising into functional UE use at home and at work. Prac-
Differential Tendon Gliding Exercises ticing or simulating relevant activities in the clinic can reinforce
this. Examples of such activities may include tying shoes, folding
Differential tendon gliding exercises are a mainstay of most clothes, manipulating coins, writing with an adapted pen, using
home programs because they are easy to perform and they pro- the involved hand for handshakes, hammering, using screwdriv-
mote motion very effectively (Fig. 1-17).18 They are a standard ers, or lifting. Putty can be used to simulate activities, such as
exercise for conservative management of carpal tunnel syndrome turning keys. Adding visualization to the simulation enhances the
and are also used after carpal tunnel release. These exercises are treatment. The scope of practice for either occupational therapy
an important option for all clients with hand or wrist stiffness. or physical therapy dictates some of these choices.
Rolling a thick highlighting pen up and down in the palm is an Ball rolling can be used for wrist AROM, composite stretch-
effective way to perform FDP gliding. ing, weight bearing, and closed chain exercise. The ball can be
dribbled or thrown for strengthening or sports simulation. Bal-
Place and Hold Exercises loons can also be thrown or batted with the hand.
Dried beans can be used for grip and release, for progressive
Place and hold exercises can be helpful when PROM is greater gripping, and for fishing other objects (for example., marbles)
than AROM (Fig. 1-18). Gently perform AAROM to position out of the beans. Instruct the client to grip the beans and then
the finger (for example, in composite flexion). Then ask the cli- to release them with full digital extension. Wrist motions can be
ent to sustain that position comfortably while releasing the assist- varied, and tenodesis can be incorporated. You also can have the
ing hand. The assisting hand may be yours or the client’s other client use opposition of the thumb to each finger to pick up one
hand. Watch for co-contraction or force that is too strenuous as bean and then release it with full digital extension.
12 PART 1 Fundamentals

A B C

FIGURE 1-17 Differential tendon gliding exer-

cises. A, Straight digits. B, Hook fist. C, Composite fist.
D, Tabletop. E, Straight (flexor digitorum superficialis
[FDS]) fist. (From Rozmaryn LM, Dovelle S, Rothman
ER et al: Nerve and tendon gliding exercises and the
conservative management of carpal tunnel syndrome,
D E
Journal of Hand Therapy 11:171-179, 1998.)

A B
FIGURE 1-18 A, Place exercises for digital flexion. B, Hold exercises for digital flexion.

Pegs of varying sizes promote tendon gliding, sensory stim- -

ulation, and joint ROM. Fine motor activities (for example, thing on the first visit.
threading beads, in-hand manipulation of marbles, and stacking
blocks) can be modified with blocking orthoses to promote iso- relaxation with a calm, slow voice.
lated ROM or tendon glide.
stiffness in another area.
Example: A client who sustained a distal radius fracture
Tips from the Field had limited AROM and PROM in wrist flexion and exten-
sion and decreased ECRB excursion (that is, passive wrist
extension exceeded active wrist extension). Stretching led to
curiosity. For example, what do you see in Fig. 1-19? improved wrist flexion. It also helped reduce ECRB adher-
ence, which resulted in improved wrist extension.
are cold, try to warm them up a bit before you touch the Example: A client had extrinsic flexor tightness after a distal
person. radius fracture with edema and decreased wrist and hand
 Fundamentals: Hand Therapy Concepts and Treatment Techniques CHAPTER 1 13

-
tinue with their home program and to celebrate small
improvements. Assist them in finding meaningful ways to
use their time (for example, find new interests and hobbies)
if participation in an enjoyable activity has been temporarily
disrupted.

needed for complicated clinical situations (see Chap-

ter 13). Give yourself a few moments to take some deep
breaths and focus on the client as a person. Try to sense
what it must be like for the client to have this injury. Care-
fully check for extensor habitus, which is habitual postur-
ing in digital extension. The index finger is particularly
prone to this response. Extensor habitus can occur after an
injury as simple as a paper cut. It is important to identify
this phenomenon and to correct it as soon as possible so
that it does not become permanent and so that joint stiff-
FIGURE 1-19 What do you see wrong with this client’s hand? ness does not occur. Buddy straps and orthotics may be
helpful.

AROM. As her extrinsic flexor tightness resolved (she recov- that you will pick up where your last session left off. Look
ered full passive composite extension), the active digital flex- at your clients with fresh eyes at each visit. Ask them what
ion also resolved because she had better mechanical function is better, what they are noticing about their hands, what
of the lengthened digital flexors. they are able to do functionally now, and what they are still
- unable to accomplish functionally.
ing painful therapy and by avoiding a flare reaction.

problem in every case. If prolonged, established stiffness is Thinking Outside the (Treatment) Box
present, if the client has highly fibrotic tissue responses, or
if client follow-through has been poor, residual limitations When to Mix and Match
may exist that are beyond our ability to correct.
- Mix and match your treatment repertoire. After reading the
tor. For example, a client was carrying a glass table that rest of this book, try to think outside the treatment box. Be
broke; the client received a laceration to his right-dominant creative, and have some fun. For example, why not perform
forearm. Several flexor tendons and the median and ulnar early protective motions (for example, place and hold teno-
nerves also were lacerated. The client missed many therapy desis motions described in Chapter 37) with most of your
visits and did not perform his Duran home program (see patients?
Chapter 30). The client returned to therapy with very poor
passive digital flexion, severe edema, and skin maceration. When Less Is More
In this case, documentation would include the follow-
ing: “The patient had been instructed to perform hourly Teaching your client the benefits of a “less is more” approach
protected passive digital flexion within his orthotic, but to UE exercises is very important. For example, a 12-year-old
he reports that he did not do so. He states that he under- girl underwent flexor tendon grafting. In therapy, when try-
stands the need to exercise as instructed. He also states that ing to isolate FDP motion at the DIP with the PIP blocked,
he understands that if he does not gain passive digital flex- she was co-contracting and eliciting PIP flexion instead. The
ion soon, he may lose the opportunity to make maximum therapist taught her to contract more softly so as to isolate
clinical gains.” If appropriate, the progress note to this cli- the FDP more effectively. The therapist used some helpful
ent’s physician should report that the patient now agrees verbal cues, such as “Don’t try so hard,” “Stop trying alto-
to increase the frequency of home exercise program (HEP) gether,” and “Stop thinking.” The therapist gave these cues
exercises, as he was previously instructed to do. in a soft, gentle voice and made sure to compliment the girl
- and smile when her isolated motion was of better quality. This
tant to investigate why this is happening and to work with activity was followed by place and hold exercises, which pro-
the client to correct the situation. Clients can have a num- gressed successfully. Even though this client was very young,
ber of reasons for failing to follow their regimen. They may she learned the quality of isolated motion well, recognizing
be uninformed about the importance of the HEP; they may that “less is more.” She also could see the improvement in her
think they can catch up and make progress later; they may capabilities.
have a secondary agenda, such as avoiding a return to work;
they may be depressed; or they may need help to assimilate When to Stop Exercising for a Few Days
the HEP into their daily routine successfully. (See Chapter
15 for more information on functional somatic syndromes Another important lesson to teach clients is when to stop exercis-
and challenging behaviors.) ing for a short time. For example, a 53-year-old, right-dominant
14 PART 1 Fundamentals

woman sustained a distal radius fracture when she fell while Summary
shopping. She developed significant, diffuse edema and stiffness
of the shoulder, elbow, forearm, and hand. This client demon- This chapter has identified fundamental hand therapy concepts
strated objective signs of a flare response after efforts were made that foster clinical reasoning. It also has highlighted treatment
to upgrade her exercises gradually. She was at risk for IP flexion techniques and provided guidelines to promote interventions that
contractures of all digits. Her sisters came to visit her, and they are safe and appropriate. Most treatment techniques are not diag-
all went to a spa for 4 days. During this time, the client stopped nosis specific, but rather can be applied to a variety of diagnoses.
performing her assigned UE exercises while she pampered herself As a hand therapist, the challenge you face is to be tissue specific,
at the spa. When she came back to therapy, she had diminished to be aware of clinical precautions, and to adapt the appropriate
flare responses, decreased edema, and improved ROM through- treatment from your toolbox of techniques to a given diagnosis.
out the upper extremity. It helped her immensely to stop trying As you continue with this book, I encourage you to ask yourself
so hard. She was then able to resume “trying,” but with a better what interventions would be most appropriate and why. I also
sense of her tissue tolerances. recommend that you return to this chapter and reread it after you
have read the rest of the book. Rereading this chapter at that time
When to Accept a Stiff Hand and Get On with Life will help you appreciate what you have learned; that, hopefully,
will be how to apply clinical reasoning in selecting safe treatment
Unfortunately, hand therapists cannot fix everything. In some choices for clients with many different diagnoses.
cases, the client’s injuries may be too severe to permit a full
recovery. In other cases, a family crisis may prevent therapy Acknowledgments to Chapter 1 in the First Edition
from continuing in a timely manner. Under circumstances such
as these, the client’s best course of action is to accept the resid- I wish to thank Sandra M. Artzberger, MS, OTR, CHT, CLT, for
ual stiffness or limitations and to resume otherwise normal liv- reviewing this chapter and for providing me the impetus to explore
ing. In such cases, therapists can perform the important role of chip bags in conjunction with upper extremity orthotics; Patricia
identifying and teaching compensatory techniques to maximize Zarbock Fantauzzo, COTA/L, for her creative ideas for using chip
the client’s function.19 Also, sometimes the therapist has the bags on clients with upper extremity problems; and Joel Moorhead,
responsibility to identify a clinical plateau and to help clients MD, MPH, John L. Evarts, BS, Lisa Deshaies OTR, CHT, and
realize that they may have achieved all that is possible at that Sharon Flinn, PhD, OTR/L, CHT, CVE, for reading and critiqu-
time. ing this chapter.

References
1. Tubiana R, Thomine J-M, Mackin EJ, editors: Examination of the hand 11. von der Heyde RL, Evans RB: Wound classification and management. In
and wrist, ed 2, London, 1996, Martin Dunitz. Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of
2. Fess EE S, Philips CA, et al, editors: Hand and upper extremity the hand and upper extremity, ed 6, Philadelphia, 2011, Elsevier.
splinting: principles and methods, ed 3, St Louis, 2005, Elsevier. 12. Coppard BM, Lohman H: Introduction to splinting: a clinical reasoning
3. Strickland JW: Biologic basis for hand and upper extremity splinting. In and problem-solving approach, ed 3, St Louis, 2008, Mosby.
Fess EE S, Philips CA, et al: Hand and upper extremity splinting: 13. Deshaies LD: Upper extremity orthoses. In Radomski MV, Latham C,
principles and methods, ed 3, St Louis, 2005, Elsevier. editors: Occupational therapy for physical dysfunction, ed 6, Baltimore,
4. S: Therapist's management of the complex injury. In Skirven 2008, Lippincott Williams & Wilkins.
TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the 14. Lashgari D, Yasuda L: Orthotics. In Pendleton HM ,
hand and upper extremity, ed 6, Philadelphia, 2011, Elsevier. editors: Pedretti's occupational therapy practice skills for physical dysfunction,
5. Colditz C: Therapist's management of the stiff hand. In Mackin EJ, Cal- ed 7, St Louis, 2013, Mosby.
linan N, Skirven TM, et al, editors: Rehabilitation of the hand and upper 15. AB, Breger-Stanton D: The forces of dynamic orthotic position-
extremity, ed 6, St Louis, 2011, Elsevier. ing: ten questions to ask before applying a dynamic orthosis to the hand.
6. Gutierrez-Gutierrez G, Sereno M, Miralles A, et al: Chemotherapy- In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation
induced peripheral neuropathy: clinical features, diagnosis, prevention of the hand and upper extremity, ed 6, Philadelphia, 2011, Elsevier.
and treatment strategies, Clin Transl Oncol 12:81–91, 2010. 16. Fess EE: Orthoses for mobilization of joints: principles and methods. In
7. Cooper C, Liskin J, Moorhead JF: Dyscoordinate contraction: impaired Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of
quality of movement in patients with hand disorders, OT Practice the hand and upper extremity, ed 6, Philadelphia, 2011, Elsevier.
4:40–45, 1999. 17. Cooper C, Meland NB: Clinical implications of transverse forces on
8. Bracciano AG: Physical agent modalities. In Radomski MV, Latham C, extrinsic flexors and extensors in the hand, Unpublished paper presented at
editors: Occupational therapy for physical dysfunction, ed 6, Baltimore, the annual meeting of the American Society of Hand Therapists, Seattle,
2008, Lippincott Williams & Wilkins. Oct. 5-8, 2000.
9. Chen J-J, Jin P-S, Zhao S, et al: Effect of heat shock protein 47 on col- 18. Bardak AN, Alp M, Erhan B, et al: Evaluation of the clinical efficacy of
lagen synthesis of keloid in vivo, ANZ J Surg 81:425–430, 2011. conservative treatment in the management of carpal tunnel syndrome,
10. Anzarut A, Olson J, Singh P, et al: The effectiveness of pressure garment Adv Ther 26:107–116, 2009.
therapy for the prevention of abnormal scarring after burn injury: a meta- 19. Merritt WH: Written on behalf of the stiff finger, J Hand Ther 11:
analysis, J Plast Reconstr Aesthet Surg 62:77–84, 2009. 74–79, 1998.
 2 Functional Anatomy
Sharon R. Flinn and Lori DeMott
Introduction
Anatomy is the study of the physical structures within the human body. The skeleton
provides the foundation for the body; muscles attach by way of bony origins and inser-
tions. Knowledge of the nervous system provides us with a practical understanding of
muscle action, tendon excursion, and joint motion. Therefore, the assessment of key
postural markers throughout the upper extremity provides an understanding of proper
skeletal alignment and balance in the neuromusculoskeletal system as well as a basis for
comparing the normal default of body conformation to that of abnormal alignment.
As hand therapy professionals, we rely on the functional anatomy of the upper extrem-
ity as the main determinant in grading the success of our client’s task performance. We
can correlate abnormal postures to a client’s functional complaints. Fundamentally and
simplistically, the observation and assessment of the body’s alignment is a measure of how
the neuromusculoskeletal system is performing. The concept of balance and movement
can provide a greater understanding of human anatomy and direct us to the contributions
of soft tissue impairment. The important issue for us is that a postural assessment gives us
the ability to evaluate the overall muscle balance and the response of the body as a whole
to disease and trauma.
During purposeful activity, a client thinks more about what they want to do and
less about how they do it. Frequently, unguarded movements lead to stressing joints and
overloading muscles without knowing the consequences of their effects on healing tissues.
When symptoms and functional limitations appear, pain is the body’s response to injury.
As the first line of defense, movement is altered unconsciously to reduce pain. Whether
the complaints are global and diffuse or pinpoint and local, we cannot be fooled into nar-
rowly interpreting the origin of their symptoms as the source of pathology to a specific
body structure. Altered body movements and imbalances in resting neuro-muscular-skeletal
alignment can cause mechanical pathology and can be the secondary complications that
result in the client’s chief complaint that is it “hurts.”
Due to a fixed time period allotted for our evaluation, it is imperative that we observe
our client’s static body postures and movement patterns to understand the etiology of
their physical impairment. Our efficiency and skill in evaluation is imperative to control
health care dollars and, above all, to direct treatments to the best outcomes for each of
our clients. During the initial interview of chief complaints and general medical his-
tory, you can simultaneously perform an assessment of posture. Observations can be
done in static, resting positions while the client is sitting, standing, and lying down as
well as during spontaneous, dynamic movements when the client first shakes your hand,
takes off his/her coat, walks, sits down, or completes paperwork. These observations are
the first quick functional anatomy screen of how the body is aligned, possible altered
responses proximally and distally, and observations of the sites related to the client’s
physical complaints.
Resting and dynamic postural assessments assist us in developing a plan of care that
provides a clear relationship between the desired improvements of the neuro-muscular-
skeletal balances and functional tasks. Self-reports are obtained every visit on the client’s
satisfaction and ease of performance in doing purposeful daily activities. For example,
the ability to wash hair will improve more efficiently and safely when scapular muscle
stabilizers are strengthened and able to support free movement at the glenohumeral joint.
Balanced scapulo-thoracic rhythm occurs at the normal starting position of retracted,
downward rotation. This allows normal gliding of the rotator cuff tendons without
impingement at the acromioclavicular joint and reduces subsequent pain. A systematic
approach to screening the functional anatomy of the core and distal joints of the body
combines the knowledge of kinematic chains, tissue imbalances, and compensatory
16 PART 1 Fundamentals

movements in the recovery of the upper extremity from disease position held against gravity, whereas dynamic posture refers
and trauma. to a series of positions that constantly change during movement
To enhance your clinical reasoning skills, this chapter will and function. Both postures require equilibrium of the muscle
review anatomy and neurophysiology principles beyond the rote system and are observed during relaxation, standing, sitting, or
memorization of origins, insertions, nerves, and actions. Instead, lying down.1
the reader will be introduced to normal postural mechanics and The neutral resting balance of our anatomy is the state of
the characteristics associated with healthy bones, joints, liga- default or the zero position of the body.2 The zero position is
ments, muscles, tendons, and the neurovascular system of the different from the anatomical position of the body. It represents
upper extremity. Then, common clinical scenarios will illustrate the normal resting balance position where the upper extremities
abnormal deviations or faults in postural mechanics resulting from align themselves in space against gravity and where movement
tissue imbalance and will provide suggestions for quick screens of ceases and loads are removed. In zero position, the upper extremi-
the functional anatomy. An extensive review of anatomic features ties are positioned in the midrange of glenohumeral and forearm
such as joint function, the lymphatic system, dermatome levels, rotation, the wrist is positioned in approximately ten degrees of
sensory distributions, and pulleys for flexor tendons, are provided extension, and the finger joints are positioned in approximately
in other chapters of the book. 45 degrees of flexion. Abnormal changes in functional anatomy
cannot be understood without knowledge of the normal resting
balance position. Fig. 2-1 illustrates zero position.
Normal Postural Mechanics The upper extremities return to this default resting position,
or zero position, in most static body postures. It is an assumed
There are observable muscle behaviors that influence our posture position of joint alignment where the tone of muscle activity is
and purposeful movements, also termed as our functional anat- minimal, where the origins and insertions are in a “resting” tone,
omy. Important distinctions should be made between anatomic and where the tension of the joint is in a relaxed, balanced posi-
characteristic of body positions, both at the initial static position tion. Tone is defined as the continuous and passive-partial con-
of a kinematic event and then the return to our neuro-muscular- traction of the muscle or the muscle’s resistance to passive stretch
skeletal equilibrium of balance.1 Static posture is the stationary during the resting state.3

Through the
lobe of the ear

Through the
shoulder joint

Midway through
the trunk

Through the
greater trochanter
of the femur

Slightly anterior
to midline through
the knee

Slightly anterior to
the lateral malleolus

Anterior view Posterior view Lateral view

FIGURE 2-1 The zero position of the body from the sagittal and coronal planes. A, Anterior view. B,
Posterior view. C, Lateral view. (Modified from Cameron MH, Monroe LG: Physical rehabilitation: evidence-based
examination, evaluation, and intervention, St Louis, 2007, Saunders Elsevier.)
 Functional Anatomy CHAPTER 2 17

Clinical Pearl the reference point for identifying imbalances that can contribute
to pain, weakness, and restrictions in movement.
If the starting position of the body differs from the zero po- The use of the two anatomic planes, axes of reference, and
sition of balance, the altered anatomy will create a disrupted mapping techniques serve as a functional anatomy screening tool
kinematic chain of movement that adds stress to areas, such that allows the hand therapy professional to compare the ideal
as the acromioclavicular joint or to the muscles that originate postural alignment to that of the assumed posture of the client.
on lateral epicondyles. The deviation from the ideal can range from slight to severe and
will guide the evaluator in understanding the problems associated
Functional anatomy, defined by postural kinematic expres- with joint and muscle functions. Next, a review of the anatomical
sions, is fundamentally based on a predictable design. Skeletal systems will be discussed in further detail including the character-
conformation is observed and analyzed by envisioning the under- istics associated with bones, joints, ligaments, muscles, tendons,
lying bone positions. By knowing the preset configuration, or and the neurovascular systems of the upper extremity and their
default design, you can visually construct the muscle anatomy the contribution to normal postural mechanics.
and its contribution to posture. The gross structure, knowledge
of fiber alignment, location, and the origins and insertions from
your human anatomy references will assist you in understand- Bones, Ligaments, and Joints
ing the natural tone and potential force of a specific muscle. The
angles and lines that are produced as well as the conformation of Bones are responsible for the rigidity and structure of the entire
our body are indications as to how synergistic muscles and periph- foundation. The joint anatomy is designed to allow transmis-
eral nerves are performing. Typically, the points of reference are sion of muscle force, at rest and during motion. Understanding
anatomical landmarks and are observed in two body planes. The the joint structure contributes to the overall whole of functional
coronal plane is vertical and divides the body into anterior and anatomy and posture configuration. The bone-to-bone connec-
posterior halves.2 From the coronal plane, we draw a linear line, tion meets to create the joint. The bone segments within the joint
or plumb line, that forms an axis of reference. From the lat- move in relation to each other. The configuration of the bony
eral view of the client, the alignment of the ear, shoulder, lateral surfaces dictates the degree of freedom of a joint and creates a
elbow, posterior hip, anterior knee, and lateral malleolus are body type of movement hinge.
landmarks that are located close to, if not directly within, the axis The joint allows freedom of movement from one to three
of reference. From the axis, you can observe the flexion, exten- planes. Two bony segments move in relationship to each other.
sion, anterior, and posterior adaptations of the body. Similarly, Usually one segment is stable while the other moves in relation
the sagittal plane is vertical and divides the body into right and to the base. At the joint there can be more than one articula-
left right halves.2 Postures viewed from all sides include obvi- tion. For example, the glenohumeral joint has scapulo-humeral,
ous body markers, such as head position, shoulder height and sterno-humeral, and clavico-humeral articulations.2 The control
glenoid orientation, clavicle angle, scapular position, antecubital and stability of the joint’s axis of rotation directly relates to the
fossa (carry angle), hand orientation, and hip height. Fig. 2-1, A articular orientation of the bones. Without rules of engagement
and B, illustrates the body in the sagittal plane and provides the for the joint, the simplest movement can become weakened by
anterior and posterior views of the body. Fig. 2-1, C, illustrates loss of mechanical advantage. This is seen in joint dislocation
the body in the coronal plane and provides a lateral view of the and a segmental bone fracture, whereby the movement is not
body with a clear view of the arm position. guided and irregular angulations are observed. Conversely, if the
A functional anatomy screen is performed by envisioning the segments of bone are not congruent and there is altered space
points at the joints, the anatomic landmarks, and the bone seg- that changes the axis of movement, the normal extrinsic muscle
ments as they create altered angles in contrast to those described pull can be offset and the movement will present with distorted
in the zero position. The differences in these angles or projections mechanics that are less than desired.
are used to hypothesize the influence of the associated muscle Throughout the body, there are many axes of rotation. In the
function. To understand postural forces of human anatomy and upper extremity there are flexion-extension, abduction-adduction,
to utilize these concepts in practice, we need to apply the nor- internal-external, radial-ulnar, and pronation-supination axes.
mal orientation of the ideal balance for the skeleton and muscles The wrist has two, the elbow joint has one at the ulnohumeral
at rest and during movement throughout the entire kinematic joint axis, and the glenohumeral joint is a ball and socket joint
chain. These “normal” default postures can then be compared to with three axes of rotation. The relationships of joint axes have
the patient who has compensatory adaptation and restrictions in a normal presentation of balance that is predictable and can be
his/her anatomical structures. assessed at rest and during movement.
Mapping is a technique of drawing using the design and angles The normal skeletal system of the upper extremity can be
of the body that create a picture of alignment. Positions of mapping mapped to determine the normal default state of zero position.
are in movement planes. The body’s coronal and sagittal planes An imaginary overlay of the skeleton on the conformation of the
produce the lines of reference in static and dynamic body postures. body creates the approximate location of the joints and bone seg-
The front and back views of the body allow the best view of sym- ments. These structures assist you in recognizing important land-
metry. Landmarks are structures that identify a feature other than marks. An example of important landmarks from Fig. 2-1 is the
a joint. Examples of landmarks are the ear, forehead creases, palm space between the arm and body. Fig. 2-2 identifies the mapping
and nail positions, the carry angle space, web spaces, and skin folds specific to the hand. Important landmarks for the hand are nail
in the back and digital creases. Once the position of the joint artic- positions, the space between the index and thumb, the cascading
ulation and landmarks are identified, the segments are drawn. The flexion of the fingers, the mass of the thenar eminence, and the
design is then analyzed using the expected functional anatomy as prominence of the ulnar head.
18 PART 1 Fundamentals

FIGURE 2-3 Mapping of a normal and pathological carpometacar-

pal (CMC) joint of the thumb. (Photo by Lori DeMott.)

the prominent head of the metacarpal. The forces from muscle

contractions are transmitted through the altered axis and with
changes in the moment arm of the tendon, the extensor becomes
B a flexor of the finger MP joint. The change in the axis of rotation
alters not only the forces applied to the MP joint but also the
kinematic chain of all joints that the muscle tendon unit controls.
The shortening or lengthening of the long tendon, in conjunc-
tion with significant joint changes, presents with a zigzag of the
fingers in proximal interphalangeal (PIP) hyperextension and dis-
tal interphalangeal (DIP) flexion joint postures.
Similar attritional changes often are observed with joint dys-
function to the carpometacarpal (CMC) joint of the thumb.
Synovitis of the joint causes bone surface erosions and ligament
laxity. Laxity of the stabilizing deep anterior oblique ligament
(DAOL), called the beak ligament, causes the joint to sublux in a
C radial and palmar direction. Over time, the degenerative thumb
FIGURE 2-2 Mapping of the hand at rest in a pronated (A), supi- CMC joint exhibits changes in appearance as seen with a promi-
nated (B), and neutral forearm position. (From Donatelli RA: Orthopae- nent ledge that extends from the radial side of the base of the
dic physical therapy, ed 4, St Louis, 2010, Churchill Livingstone Elsevier.) thumb. The loss of joint stability changes the characteristic of
the surrounding muscular anatomy. The abductor pollicis brevis
weakens and the adductor pollicis muscle contracts, unopposed.
Clinical Pearl The thumb CMC joint is drawn into adduction and rotational
An understanding of normal anatomy and the ideal positions supination. The imbalance of the thumb intrinsics change the
of balance is essential to recognize the imbalances in your cli- axis of rotation, decrease the transmission of flexion forces across
ent’s neuromusculoskeletal anatomy. the metacarpal joint, and move the resting position of the MP
joint from a flexed posture to extension. Over time, the meta-
carpal joint hyperextends as the mechanical advantage from
Altered configuration of the joint’s soft tissue matrix or bony the extensor pollicis brevis (EPB) muscle further aggravates the
constructs lead to the joint’s failure to glide and can result in adductor pull on the CMC joint and the increasing severity of
various types of joint collapses and deformities.3 With joint lax- the contracture. The interphalangeal (IP) joint compensates for
ity, the axis shifts into the direction of the weakened, degraded loss of metacarpal joint flexion and overly flexes to produce a
tissue integrity. Frequently, this is seen with attritional changes functional tip pinch. The cascading events are self-perpetuating
of the glenohumeral joint where the anterior capsulo-ligaments as the normal joint forces become pathologic. The anatomy of
are weakened and attenuated. A shift in the joint axis results in the arthritic thumb presents with imbalances, principally at the
changes in the anterior and posterior capsule and in the forma- CMC joint level, with bone erosions and capsular instability that
tion of adhesions. contribute to the distal joint changes at rest and during dynamic
Another example is seen with metacarpophalangeal (MP) loads. Fig. 2-3 illustrates mapping of a normal and pathological
joint subluxation and swan neck deformities in the hands of CMC joint. The dots estimate the joint location, the stars are the
persons with rheumatoid arthritis. A common joint change is landmarks, and the dashes are the bone segments. The dispari-
when the proximal phalanx segment shifts palmary toward the ties between the two thumbs are clear. Compared to the normal
volar plate, descending and subluxing. What is observed at rest is thumb, imbalances in the pathological thumb are identified by
 Functional Anatomy CHAPTER 2 19

three visible landmarks; increased nail rotation, MP joint hyper-

extension, and a protuberance at the CMC joint caused by the BOX 2-1 Musculotendinous Characteristics
subluxing metacarpal. that Contribute to Balance

Clinical Pearl 1. The resting length of a muscle is the relationship and

The kinematic chain of mobility is controlled and primarily proportional stretch to the fully contracted muscle fiber.
influenced proximally. 2. At rest and even during sleep, there is a tendency of the
muscle to contract and resist lengthening. This principle
is influenced by the central nervous system and the intrin-
Mapping the skeletal alignment within the body conforma- sic muscle structure and by definition is our muscle tone.
tion is a screening tool that you can utilize to assist with evalua- 3. Ordinary normal range of motion at rest or during
tion of the functional anatomy. The technique can be drawn on movement is influenced by the variability of length and
the client and, with practice, will be visualized as part of your pull of all of our contributing anatomy due to antagonist
observations during the functional anatomy screen. lengthening as well as synergistic coordination.
4. Gravity and the need for skeletal stability will change
the resting muscle tone and therefore change distal joint
Muscles and Tendons position.
5. Length and cross-section of a muscle leads to predictable
Muscles work in groups and patterns of movement. Individual excursion and levels of muscle elasticity.
muscles have lengthening, contractile, excitable, and recoil char- 6. A muscle crossing multiple joints will provide a compos-
acteristics. Contractility allows a muscle to shorten with force, to ite excursion; a proximal joint stability is necessary for
lengthen passively, and to move. Excitability allows a muscle to increased distal joint mobility.
respond to a stimulus and to maintain chemical potentials across 7. Passive joint mobility is without influence of soft tissue
its cell membranes. Extensibility allows a muscle to be stretched, elastic characteristics.
repeatedly and considerably, as needed, without being damaged. 8. Muscle balance is involuntary, and over time the resting
Elasticity allows a muscle to return to its normal length after length can change or be changed by an altered axis. As
being stretched or shortened. The end result is a force applica- the joint moves, these altered forces create imbalances and
tion. For example, a coordinated neuromuscular event occurs lead to deformity.
during the conscious decision to make a fist. The wrist extensors
stabilize the wrist in approximately 35 degrees of extension, the
extrinsic extensor digitorum communis (EDC) elongates into a site, such as the wrist joint, increase the strain at the cord level of
full extensible position as the antagonist muscle, and simultane- the brachial plexus. Similarly, contralateral flexion of the cervical
ously the extrinsic flexor digitorum profundus (FDP) and flexor spine increases the strain in the cords of the brachial plexus and
digitorum superficialis (FDS) contract in their role as agonist three major nerves in the arm.4 Under tension, the neural tis-
muscles. The coordinated muscle contractions differentiate the sue may have difficulty conducting electrical impulses, assuring
glide that allows terminal distal joint flexion. Simultaneously, adequate blood supply, and providing adequate axonal transport
contraction of the intrinsic lumbrical and interossei muscles especially during movement.5
increase metacarpal joint flexion, stabilize and control the joint, Several biomechanical properties are necessary to protect the
and allow the digits to converge into a tucked position within the nerve from tensile, shear, and compressive forces that occur across
palm. The characteristics of the musculotendinous structures that multiple joints in various postures and dynamic movements of
contribute to muscle balance are located in Box 2-1.3 the upper extremity during everyday activities.5 The properties of
the nerve protect it from the forces generated from whole body
movements resulting from everyday activities. These protections
Nervous System are due to the nerve’s capacity to change its length during move-
ment, slide or glide relative to the surrounding interfacing tissue
The peripheral, central, and autonomic nervous systems all com- during movement, and tolerate increases in pressure or compres-
bine to form one internal communication system for sensing and sion from the surrounding interfacing tissue.5 When the nerve
responding to internal and external stimuli.4 The motor and sen- does not tolerate normal stresses, a “sensitized” protective state
sory functions for the forearm, wrist, and hand are provided by may result as the upper extremity joints usually adjust by flexion
the peripheral nervous system; consisting of the median, ulnar, or extension to limit the nerve excursion. Symptoms can include
and radial nerves. Each nerve has efferent motor and afferent sen- increased pain or aberrant movements in the absence of altered
sory fibers arranged in bundles of axons. The axons are protected nerve conduction.4,5
by layers of dense connective tissues called the epineurium, peri- Observations of static and dynamic postures are essential to
neurium, and endoneurium. Each layer has a unique role to sup- evaluate the neurodynamics of the peripheral nervous system in
port the innermost structures of the nerve, modulate compressive its entirety and the changes which can result from limited excur-
and tensile forces, and allow gliding between nerve fascicles and sion or traumatized segment(s) of the nerve.4 As simply observed
the surrounding anatomical structures.5 Electrical impulses are in an acute nerve injury, the upper arm is held tightly in shoulder
rapidly conducted via the nodes of Ranvier along a neural path- adduction, internal rotation, and elbow flexion. In the presence
way, which originates at the spinal cord and brainstem and termi- of long-standing trauma to the nerve, imbalances in motor func-
nates in the fingers and toes. Due to the continuous nature and tion can be observed. For example, hyperextension of the thumb
physiology of the peripheral nervous system, motions at a distal MP joint during resistive lateral pinch can be observed in persons
20 PART 1 Fundamentals

Roots
Contribution to
phrenic nerve
Dorsal
Trunks scapular From C4
nerve C5

Suprascapular nerve C5
Subdivisions
Nerve to C6
subclavius
Cords C6
per C7
Up
ior C7
ter

t.
An dle C8

s
Mid

Po
Lateral
pectoral nerve Anterior
ior we
r
l s ter Lo T1 T1
ra Po
te
Nerves La Posterior
or r Long thoracic nerve
steri io
Po ter
An
Musculocutaneous
nerve l
dia
Me
Axillary nerve 1st rib

FIGURE 2-4 Diagram of the brachial Radial nerve Medial pectoral nerve
Medial brachial cutaneous nerve
plexus. (From Neuman D: Kinesiology of Median nerve Medial antebrachial cutaneous nerve
the musculoskeletal system: foundations Upper subscapular nerve
Ulnar nerve
for rehabilitation, ed 2, St Louis, 2010, Thoracodorsal nerve
Mosby.) Lower subscapular nerve

with ulnar nerve palsy. A zigzag deformity is observed as a result side-to-side, flexion and extension, lateral flexion to each side,
of absent function of the adductor pollicis muscle and imbalances and all the motions in between. While the locations of the struc-
created from a weakened intrinsic extensor mechanism and over- tures are designed to provide increased mobility at the cervical
powering extrinsic long flexor. level, they are also vulnerable to injuries as a result of these ana-
A neuromusculoskeletal screen of the upper extremity is criti- tomical relationships.
cal to understanding the changes that impact functional anatomy. Proper cervical alignment of vertebrae, muscle, and soft tissue
Several observations of normal postures can be made. At rest, cli- facilitates normal conduction and excursion of nervous tissue in
ents with neural tension postures will limit movement that places nerves C1 to C8. In addition, alignment of these structures also
the nerve in full excursion. The elbow joint has a high degree of provides for normal blood flow within the vertebral artery and the
contribution to nerve glide. In resting postures the elbow will vertebral and deep cervical veins, insuring adequate blood flow
flex, and the head will laterally tilt to the affected side. During and drainage for the cervical structures related to upper extrem-
movement, the head may increase the degree of tilt or the elbow ity function. Fig. 2-4 illustrates the anterior rami of nerves C5
joint increase its flexed position to offset the increased demand at to T1, which form the brachial plexus and innervate the entire
adjacent joints. upper extremity.
Now that you have a better understanding of normal postural Symptoms of cervical misalignment may appear distal to the
mechanics and the neuromusculoskeletal systems, common clini- primary injury site and present as sensory, motor, or autonomic
cal scenarios are provided to illustrate abnormal deviations, or dysfunction. For example, forward head posture can be the cause
defaults, in the postural mechanics that result from tissue imbal- of head, neck, shoulder, or mid and lower back pain as well as
ances. Quick screens will also be provided in each scenario to distal paresthesias. When the head moves forward, the axis of
assist you in applying the principles of balance. reference shifts, the cervical spine is pushed into compensatory
extension, and the neck extensors shorten. Another postural
fault is observed with the rounded shoulder posture found in
Scenario 1 many clients while sitting at their computers or while texting on
a cell phone screen. An elevated, abducted, and upwardly rotated
How does proper cervical alignment facilitate scapula influences the axis of the glenohumeral joint by chang-
normal functioning of blood vessels and nerve ing the balance of the rotator cuff muscles. The orientation of
roots? the glenoid fossa is altered, leaving the humerus in more for-
ward and internally rotated position. In time, a cascading event
Proper cervical alignment is necessary for sound neurological and of changes occurs; the pectoralis minor, serratus anterior, and
vascular function in the shoulder, arm, and hand. The normal upper trapezius muscles shorten. The extrinsic muscle origins on
relationships of bone, ligaments, disks, vasculature, and nerves the thoracic vertebrae, ribs, and scapula also contribute toward
provide the cervical spine with valuable mobility that other seg- an elevated and upward scapular position. This adaptive short-
ments of the spinal column do not possess. The cervical spine ening of soft tissue has been associated with nerve compression
supports motions of the head which consist of rotation from as the nerve plexus exits the thoracic outlet and influences the
 Functional Anatomy CHAPTER 2 21

TABLE 2-1 Common Cervical Injuries and Disorders and Resulting Impairment
Anatomic Structure Injury or Disorder Symptoms
Vertebrae Subluxation, instability, fracture; abnormal Disruption of sensory, motor, or vascular function throughout
bone development; arthritis; displacement; the UE
degenerative changes; stenosis; bony spurs
Muscle Weakness; tightness; imbalance; hypertonic- Compression of nervous tissue characteristically results in
ity or hypotonicity; spasm; overstretching; numbness, pain, paralysis, and loss of function; vascular com-
sprain or strain pression characteristically results in moderate pain and swelling3
Soft tissue Disk protrusion, lax ligament; ligament avul- ***

sion; degeneration or thickening of dura;

adhesions
Vasculature Compression; constriction; mechanical Sympathetic symptoms associated with circulation can manifest
irritation; congestion; reflex response; hem- in UE; decreased blood flow to UE tissues; temperature changes;
orrhage; stretching pain; edema; decreased healing time
Nerve root and nerves Decreased movement and elasticity; Pain at point of entrapment or along distal distribution in UE;
compression; strain, irritation, axonotmesis, decrease in or loss of sensation, motor control, or strength in UE;
severance decreased UE deep tendon reflexes; decreased UE muscle tone;
trophic changes in UE; sensation of deep pain; pain that radiates
over shoulders and arms
UE, Upper extremity.

extremity, contributing to sensory disturbances distally. Further common claviculocostal sites where increased neurovascular
postural changes ensue within the pelvic and abdominal cores pressure occurs with upper body movement. The symptoms that
and are associated with the musculoskeletal changes of the low occur at these sites are often referred to as thoracic outlet syndrome.
flat-back posture (posterior tilt), elongated and weaken hip flex-
ors, and shortened hip extensors and anterior abdominals. Table Clinical Pearl
2-1 describes other disorders that result from misalignment of Joint pathologies can be observed, and should be palpated, at
the cervical spine and can result in conditions that impair upper rest and during movements.
extremity function.

Clinical Pearl As a hand therapy professional, it is important for you to

It is important to appreciate the upper extremity as multiple remember that increased neurovascular tension over time can
parts of a complex system; the client’s complaints of pain or lead to compression. Tension will occur with normal upper body
weakness may not be the source of the pathology. movement. If the movement becomes repetitive over time, more
long-standing compression will occur. Table 2-2 describes what
occurs to the neurovascular structures with upper body move-
Observations of static postures provide valuable informa- ment. Many other upper extremity sites are prone to neurovas-
tion of the body’s resting tone and default. A quick screen of cular compression as the result of poor posture, injury, and/or
functional anatomy can be done from the sagittal and coronal muscle imbalance due to weakness or malnutrition. A thorough
planes. From the anterior view, are the eyes, ears, and shoulders understanding of the workings of the cervical spine is necessary
symmetrical? From the posterior view, does the position of the to identify the source of injury for some patients having symp-
head or shoulders deviate laterally from the imaginary plumb toms along the upper extremity. As part of effective intervention,
line? From the lateral view, does the lobe of the ear align with the educating the patient in appropriate cervical posture patterns will
imaginary plumb line and the anterior one-third of the humerus? improve the kinematic chain of the upper extremity and potential
Fig. 2-5 identifies the mapping specific to normal and forward rehabilitation outcomes.
head positions. Disparities exist between the two head positions.
Compared to the normal head position, imbalances in the patho-
logical head position are identified by three visible landmarks; the Scenario 2
position of the chin, ear, and scapula.
In addition to observations of static posture, active move- What is the relationship of the rotator cuff muscles
ments of the upper extremity are needed due to the additional to the glenohumeral joint that is intact and mobile?
tension created on the neurovascular bundle in the upper quad-
rant of the body. Common symptoms of the sensory, motor, or The glenohumeral joint depends on the rotator cuff muscles
vascular systems are localized burning, cramping, or cooler tem- for support, rather than from the bones or ligaments. Fig.
perature changes of the hand are common. When these move- 2-7 shows the relationship of the rotator cuff muscles, which
ments are repeated over time, the temporary symptoms caused include the subscapularis, the supraspinatus, the infraspinatus,
by the compression of the neurovascular bundle can become and the teres minor. The glenohumeral joint is a ball-and-
frequent or constant and somewhat unrelenting. Fig. 2-6 shows socket synovial joint that moves in multiple axes. The motion
22 PART 1 Fundamentals

FIGURE 2-5 Mapping of normal and forward head positions. (From Sahrmann SA: Movement system impairment
syndromes of the extremities, cervical and thoracic spines: considerations for acute and long-term management, St Louis,
2011, Elsevier Mosby.)

of the glenohumeral joint, provided by the rotator cuff muscles, You also need to keep in mind the impact of forces and
is related to the angle of pull for each muscle. A quick screen how they change with different positions and/or postures. For
of normal functional anatomy in a standing resting posture is instance, painting a ceiling requires glenohumeral stabilization
the parallel orientation of the hand and scapula. The hand posi- and flexion proximally. But how do the forces change when the
tion changes with the scapular position. If the hand position position is held for an extended period of time and with the cer-
is pronated, an abducted scapular position is assumed. Conse- vical spine extended? This could result in a variety of possible
quently, the abducted scapula has a direct effect upon the origin symptoms, such as dizziness, core lumbar pain, impingement
and insertion of the rotator cuff muscle actions and shortening of the rotator cuff muscles, triceps weakness, or sensory changes
or lengthening of these structures can be postulated. Table 2-3 in the thumb side of the hand. Therefore, when treating clients
identifies the locations of and motions provided by the rotator with rotator cuff injuries, you need to consider the entire kine-
cuff muscles.2 matic chain, all the forces applied to the upper quadrant, and the
context of movement, not just the isolated motion of shoulder
Clinical Pearl flexion.
The position of the hand in relation to the zero position tells A common example of a proximal upper extremity imbal-
you about the functional anatomy of the scapula and suggests ance is seen with a client who demonstrates rounded shoulders
the orientation of the scapula and its relative position on the with a forward head (RSFH) position. A functional anatomy
thorax. screen of the upper quarter can be observed while the client is
sitting at a table and reaching for a drinking cup. The upper arm
movements of a client with normal balanced shoulder position
In addition to the primary motions that the rotator cuff consists of scapular abduction and depression while the kine-
muscles have on the glenohumeral joint, they act as part of a matic expression of the arm reach is observed in neutral gleno-
force couple. Force couples are responsible for stabilizing joints humeral rotation, forward elevation, forearm in mid position
through muscle co-contractions. The forces are parallel and equal and wrist extension. In contrast, scapular adduction, glenohu-
in magnitude but opposite in direction.6 For instance, the deltoid meral internal rotation and flexion, forearm pronation, and wrist
and supraspinatus muscles work as a force couple to produce flexion occurs in an over-the-top hand orientation to grasp. Fig.
glenohumeral abduction or flexion. The deltoid and teres minor 2-8 shows the difference between the reaching patterns of an
work as a force couple to produce depression and stabilization of individual with normal balance and imbalance in the glenohu-
the humeral head. Another force couple is the deltoid muscle and meral joint. There are clear differences in the amounts of inter-
the rotator cuff muscles for depression of the humeral head and nal rotation, forearm pronation, and wrist flexion required for
flexion of the humerus.6 the default position.
 Scaleni

Cervical rib
Scalene muscles
Brachial plexus
Brachial plexus
Subclavian artery Subclavian artery

Subclavian vein
Brachial plexus Brachial plexus
Subclavian artery

Subclavian artery

Pectoralis minor

D
C
FIGURE 2-6 Common claviculocostal sites where increased neurovascular pressure occurs. A, Scalenus
anterior syndrome. B, Cervical rib syndrome. C, Costoclavicular syndrome. D, Hyperabduction syndrome.
(From Cummings NH, Stanley-Green S, Higgs P: Perspectives in athletic training, St Louis, 2009, Mosby.)

TABLE 2-2 Neurovascular Symptoms Associated with Upper Body Movement

Body Part Motion Result Symptoms
Shoulder Depression Peripheral nerve: Stretching of upper and middle trunks of Numbness and pain, particularly over ulnar
brachial plexus over scalene muscle; pulling of lower trunks distribution; pain worse at night because of
into angle formed by first rib and scalene tendon positioning; intensity fluctuates through-
out the day; arm fatigue, weakness, finger
Blood vessel: No compression of subclavian artery cramps, tingling, numbness, cold hand,
Retraction Peripheral nerve: No compression areas of hyperesthesia, atrophy, tremor,
and/or discoloration of hand
Blood vessel: Compression of subclavian vein by tendon of
subclavian muscle, not by clavicle
Abduction and Peripheral nerve: Clavicular compression on brachial plexus
retraction
Blood vessel: Clavicular compression of subclavian artery
against scalene muscle
Scapula Retraction Peripheral nerve: Compression of brachial plexus at point
where it passes between clavicle and first rib
Blood vessel: Compression of subclavian artery at point
where it passes between clavicle and first rib
24 PART 1 Fundamentals

Supraspinatus muscle

Infraspinatus muscle Subscapularis muscle

Teres minor muscle

Rotator cuff

FIGURE 2-7 Tendons of the rotator cuff muscles. (From Cummings NH,
Stanley-Green S, Higgs P: Perspectives in athletic training, St Louis, 2009,
Mosby.)

TABLE 2-3 Location and Motion of Rotator

Cuff Muscles
Muscle Location Motion
Supraspinatus Proximal attachment: Supraspi- Abduction
nous fossa of scapula and rotation
Distal attachment: Superior facet
of greater tubercle of humerus
Subscapularis Proximal attachment: Subscapu- Medial
lar fossa rotation and
Distal attachment: Lesser tubercle adduction FIGURE 2-8 Reaching capacity expected for a client with and with-
of humerus out balance in the glenohumeral joint. (Photo by Lori DeMott.)

Infraspinatus Proximal attachment: Infraspi- Lateral

nous fossa of scapula rotation system of the wrist. The palmar wrist ligaments provide support
Distal attachment: Middle facet of between the carpal bones. The dorsal wrist ligaments provide
greater tubercle of humerus support between the carpal bones and the radius. The palmar
Teres minor Proximal attachment: Superior Lateral radioscaphoid lunate ligament provides support for the radius,
part of lateral border of scapula rotation the scaphoid, and the lunate. The triangular fibrocartilage com-
Distal attachment: Inferior facet plex (TFCC) provides support between the carpal bones, the
of greater tubercle of humerus ulna, and the distal radial-ulnar joint. Each of the supporting
structures is important in stabilizing the wrist in extreme ranges
of wrist extension, flexion, radial deviation, and ulnar deviation.7
Scenario 3 Not only does stability of the joint affect mobility, but without
adequate support on the ulnar border of the wrist, the amount of
How do the ligamentous structures of the wrist and pinch strength on the contralateral side can be diminished.
hand provide stability and assist with balanced Several imbalances of the wrist can occur from pathology.
movement during normal function? How do these In the case of a displaced and angulated metacarpal fracture, the
structures change with different positions of skeletal length changes and the shortened foundations can limit
movement? Are there postural deviations from the ability of the extensor tendon to bring the MP joints into a
the normal resting balance of wrist extension and complete end range of extension. This is an important function
digit flexion that contribute to the strength and in initiating grasp for large objects, placing the hand into pockets,
movement of the hand? and for the fine manipulation of using a keyboard. Injuries to the
wrist ligaments themselves have stabilizing effects that redirect
The function of the collateral ligaments in the human body is the pull and balance of the long extrinsic tendons. This is seen
to provide joint stability while functional activities occur within in clients with distal radioulnar joint (DRUJ) instability. During
multiple planes of movement. Fig. 2-9 provides the ligamentous forearm pronation, the ulna migrates dorsally and a prominent
 Functional Anatomy CHAPTER 2 25

Deltoid ligaments

Space of Poirier
Lunotriquetral ligament

Radioscaphocapitate
ligament
Vestigial ulnar
collateral ligament Scapholunate
ligament

Ulnocarpal Radial collateral

meniscus homologue ligament

Ulnolunate ligament Radiolunate

(ulnolunate-triquetral) ligament
(radiolunotriquetral)
Radioscapholunate
ligament
(ligament of Testut
and Kuenz)
A

C Td
H

Dorsal Tm
P
intercarpal
1 Tq
ligament
S
Dorsal radiocarpal L
ligament 7
(radiotriquetral) 2 4

3
5
B
6
C
FIGURE 2-9 Ligamentous anatomy of the wrist. A, Palmar wrist ligaments. B, Dorsal wrist ligaments.
C, Dorsal view of the flexed wrist, including the triangular fibrocartilage. 1, Ulnar collateral ligament; 2,
retinacular sheath; 3, tendon of extensor carpi ulnaris; 4, ulnolunate ligament; 5, triangular fibrocartilage, 6,
ulnocarpal meniscus homologue; 7, palmar radioscaphoid lunate ligament; P, pisiform; H, hamate; C, capitate;
Td, trapezoid; Tm, trapezium; L, lunate; S, scaphoid. (From Fess EE, Gettle K, Phillips C, et al: Hand and upper
extremity splinting: principles and methods, ed 3, St Louis, 2005, Mosby.)

ulnar styloid is observed. The CMC joint of the small finger dem- observed with increased prominence of the ulnar styloid. In Fig.
onstrates mild changes but an obvious collapse proximally creates 2-10, B, the proximal elevation of the fifth metacarpal can be seen
a visual fovea, or depression. The extensor carpi ulnaris (ECU) as a result of ulnocarpal ligament laxity. This instability results
tendon that inserts onto the fifth metacarpal becomes inefficient in the disruption of the distal transverse arch. Also, you will see
and loses its ability to stabilize the metacarpal into extension dur- an atrophied hypothenar eminence and a pronounced the exten-
ing active grasp. The hand changes its appearance as the arch of sor digitorum minimi, which assists with wrist extension. Other
the small metacarpal joint ascends and over time the entire hand landmarks can be observed with abnormal depression from the
radially deviates during grasp and pinch tasks. The ligaments by metacarpal angle and prominence of the ulnar styloid; both are
virtue of disease and overload from an altered axis will eventu- indicative of possible subluxation of the wrist carpus and DRUJ
ally cascade into instability and joint collapse. Fig. 2-10 maps imbalance.
the expected imbalances from the same client with ligamentous The ligamentous structures in the fingers differ considerably
instability associated with a classical malunion of a distal radius from those of the wrist. Fig. 2-11 reviews the supporting struc-
fracture. In Fig. 2-10, A, shortening of the radius and carpal col- tures of the finger MP and PIP joints. The design of the collateral
lapse demonstrates the radial bias of the wrist. Landmarks can be ligament is to ensure lateral support. When the joint is flexed,
26 PART 1 Fundamentals

Cord portion of
collateral ligaments
Cord portion of
collateral ligaments

Accessory collateral
ligament Accessory collateral
Palmar ligaments
fibrocartilaginous Palmar
plates fibrocartilaginous
A plates

Collateral ligament
(loose in extension)

Palmar plate

Membranous portion
of palmar plate
(folds in flexion)

Collateral ligament
(tight in flexion)

FIGURE 2-10 Mapping of the expected imbalances from ligamen-

tous instability of the distal radial ulnar joint. (Photo by Lori DeMott.)

the collateral ligament lengthens to accommodate the movement

and becomes slack when the joint is in an extended position. In B
addition to the lateral support of a joint, volar reinforcement is FIGURE 2-11 A, Ligamentous structures of the digital joints. B, At
provided through strong membranous connections with the col- the metacarpal joint level, the collateral ligaments are loose in exer-
lateral ligament. The palmer (also called volar) plates are slack in tion but tighten in flexion. (A, From Fess EE, Gettle K, Phillips C, et al:
flexion but become taut when the joint is extended, thus protect- Hand and upper extremity splinting: principles and methods, ed 3, St Louis,
ing the joint from hyperextension stresses or dislocations. Com- 2005, Mosby; B, Modified from Wynn-Parry CB: Rehabilitation of the hand.
mon postural changes for ligamentous instability of the fingers In Fess EE, Gettle K, Phillips C, et al: Hand and upper extremity splinting:
may include swan neck deformity of the digits. In the static and principles and methods, ed 3, St Louis, 2005, Mosby.)
dynamic postures of the PIP joint, the palmar support attenuates
over time and the lateral bands slide anterior to the joint axis into
this new postural orientation. instability when loading the joint through tip pinch. Observa-
As expected, the thumb has ligamentous supports at the IP tional mapping of unstable bilateral RCLs at rest shows increased
joint, the MP joint, and the CMC joint. Of particular interest is angulation of the MP joints of the thumb, supination of the
the radial and ulnar collateral ligaments (RCLs/UCLs) of the MP thumb nail, and loss of muscle mass in the thenar eminences (Fig.
joint. Fig. 2-12 illustrates the importance of this strong band of 2-12, A). Similar changes can be seen with observational map-
tissue in supporting pinch, especially for tip and lateral pinches. ping of an unstable UCL with pinch to include radial deviation
Common postural imbalances can be seen with ligamentous of the MP joint and rotation of the thumb nail.
 Functional Anatomy CHAPTER 2 27

of function can be obtained when observing their influence on

multi-joint, simultaneous movements. Table 2-4 provides a list-
ing of the eight muscles, their origin, and their action.2 It is easy
to recognize that many of these muscles cross the elbow, the fore-
arm, the wrist, and in some cases the fingers. In order to ensure
full joint motion, pliability of the muscles and connective tissues,
and strength testing individual or groups of muscles that originate
from the lateral epicondyle can be useful. When testing range of
motion of the wrist and hand, the position of the elbow and the
forearm should be considered. For example, full passive stretch
of the longest musculoskeletal structure originating on the lateral
epicondyle, the EDC muscle, is obtained with elbow extension,
forearm pronation, wrist flexion, and full finger flexion.
In discussing the muscles that originate from the medial
epicondyle, a similar picture of function also can be obtained.
Table 2-5 provides a listing of the five muscles, their origin,
and their action.2 In this case, all of the muscles are innervated
by the median nerve with the exception of one, the flexor carpi
ulnaris, which is supplied by the ulnar nerve. In spite of the dif-
ferences in nerve innervations, the same principles for extensi-
bility of these muscles can apply as was suggested for the muscles
originating from the lateral epicondyle. For example, full passive
stretch of the longest musculoskeletal structure originating on
the medial epicondyle, the FDS muscle, is obtained with elbow
extension, forearm supination, wrist extension, and full finger
extension.
A functional anatomy screen of the muscles that originate
from the lateral and medial epicondyles is essential to determine
deviations from normal posture of the wrist and hand. At rest,
imbalances cause unopposed muscles from the lateral epicondyle
to change the positions of the upper arm joints. In a standing
or sitting positions the client will present with subtle increases
in the carrying angle of the elbow, the palm of the hand fac-
FIGURE 2-12 Diagram of unstable thumb MP joint collateral liga- ing forward, the wrist in radial deviation, and the MP joints of
ments in static and dynamic postures. A, Bilateral radial collateral the fingers in slight hyperextension. Similarly, the extrinsic flexor
ligaments at rest and B, ulnar collateral ligament with movement. bias of the muscles from the medial epicondyle at rest can be
(©Martin Dunitz Ltd., 2001.) observed with the back of the hand more prominent and the wrist
in ulnar deviation. During movement, the client may have diffi-
Scenario 4 culty reaching in every plane of movement and may present with
a more pronounced posture defect when carrying increased loads.
If you were to identify the muscles that originate Exaggerated movements of trunk flexion and glenohumeral rota-
from the lateral and medial epicondyles, which tion compensate for limitations in extensibility of the elbow
muscles would they be? Why would it be useful to extensors and wrist deviators.
evaluate these muscles by this grouping? As part of effective intervention for the musculoskeletal
structures originating from the lateral and medial epicondyles,
Proper balance of the musculotendinous structures that originate full extensibility is necessary to obtain multi-joint flexibility, bal-
from the lateral and medial epicondyles is necessary for positioning anced strength both proximally and distally, and full function in
the hand in tasks away from the body. Actions of elbow extension everyday life activities.
and flexion, forearm rotation, wrist extension and flexion are con-
trolled by these musculotendinous structures. Due to the length of
these tissues, their actions cross as many as five joints and can influ- Scenario 5
ence reaching and positioning of the hand. Static or dynamic muscle
imbalances can lead to pathologic joint stresses, muscle weakness, and If you were to complete a manual muscle test by
ultimately with limitations in functional reach and grasp patterns. nerve function, which muscles would be evaluated
for the median, the ulnar, and the radial nerve
Clinical Pearl distributions? What is the advantage of doing
Shortened muscles are not stronger muscles. strength testing by nerve distribution?
Functional anatomy screening can be utilized to assess muscle
Even though all of the muscles that originate from the lateral adaptations that occur with acute and chronic nerve injury.
epicondyle are innervated by the radial nerve, a different picture Changes in muscle balance, and ultimately postures at rest and
28 PART 1 Fundamentals

TABLE 2-4 Muscles Originating from the Lateral Epicondyle

Position for Full
Musculotendinous
Muscle Origin Action Flexibility
Anconeus Lateral and posterior surfaces of proxi- Extends the elbow Elbow flexion, forearm
mal half of body of humerus and lateral pronation
intermuscular septum
Brachioradialis Proximal two thirds of lateral supra- Flexes the elbow, assists with pronating and Elbow extension, forearm
condylar ridge of humerus and lateral supinating the forearm pronation or supination
intermuscular septum
Supinator Lateral epicondyle of humerus, RCL of Supinates the forearm Elbow extension, forearm
elbow joint, annular ligament of radius, pronation
and supinator crest of ulna
Extensor carpi Distal one third of lateral supracondylar Extends the wrist in a radial direction, assists Elbow extension, forearm
radialis longus ridge of humerus and lateral intermus- with elbow flexion pronation, wrist flexion in
cular septum an ulnar direction
Extensor carpi Lateral epicondyle of humerus, RCL of Extends the wrist, assists with wrist radial Elbow extension, forearm
radialis brevis elbow, and deep antebrachial fossa deviation pronation, wrist flexion
Extensor carpi Lateral epicondyle of humerus, aponeu- Extends the wrist in an ulnar direction Elbow extension, forearm
ulnaris rosis from posterior border of ulna, and pronation, wrist flexion in a
deep antebrachial fossa radial direction
Extensor digito- Lateral epicondyle of humerus and Extends the MP joints of the second through Elbow extension; forearm
rum communis deep antebrachial fossa fifth digits; in conjunction with the lumbricals pronation; wrist flexion; and
and interossei, extends the PIP joints of the sec- MP, PIP, and DIP flexion of
ond through fifth digits; assists with abduction the fingers
of the index, ring, and little fingers; and assists
with extension of the wrist in a radial direction
Extensor digito- Lateral epicondyles of humerus and Extends the MP joint of the fifth digit; in Elbow extension; forearm
rum minimi deep antebrachial fossa conjunction with the lumbricals and interossei, pronation; wrist flexion; and
extends the PIP joints of the fifth digit; assists MP, PIP, and DIP flexion of
with abduction of the fifth finger the little finger
DIP, Distal interphalangeal; MP, metacarpophalangeal; PIP, proximal interphalangeal; RCL, radial collateral ligament.

TABLE 2-5 Muscles Originating from the Medial Epicondyle

Position for Full Musculotendinous
Muscle Origin Action Flexibility
Pronator teres Medial epicondyle of humerus, common Pronates the forearm, assists with Elbow extension, forearm supination
flexor tendon, and deep antebrachial fascia elbow flexion
Flexor carpi Common flexor tendon of medial epicon- Flexes the wrist in a radial direc- Elbow extension, forearm supination,
radialis dyle of humerus and deep antebrachial tion; may assist with pronation of wrist extension in an ulnar direction
fascia the forearm and elbow flexion
Flexor carpi Common flexor tendon of medial epicon- Flexes the wrist in an ulnar direc- Elbow extension, forearm supination,
ulnaris dyle of humerus tion; may assist with elbow flexion wrist extension in a radial direction
Palmaris longus Common flexor tendon of medial epicon- Tenses the palmar fascia, flexes Elbow extension, forearm supination,
dyle of humerus and deep antebrachial the wrist, and may assist with wrist extension
fascia elbow flexion
Flexor digitorum Common flexor tendon of medial epicon- Flexes the PIP joints of the sec- Elbow extension; forearm supination;
superficialis dyle of humerus, UCL of elbow, and deep ond through fifth digits; assists wrist extension; and MP, PIP, and DIP
antebrachial fascia with MP and wrist flexion extension of the fingers
DIP, Distal interphalangeal; MP, metacarpophalangeal; PIP, proximal interphalangeal; UCL, ulnar collateral ligament.
 Functional Anatomy CHAPTER 2 29

Lateral Cords of
Lateral Cords of Posterior brachial
Cords of lateral
brachial post. Posterior brachial Medial plexus
Medial plexus
plexus med.

Radial n.
Long head of triceps
Lateral head
of triceps
Medial head of triceps
Pronator teres
Anconeus
Brachioradialis Flexor carpi radialis
Extensor carpi radialis longus Palmaris longus
Extensor carpi radialis brevis Flexor digitorum superficialis Flexor carpi ulnaris
Supinator Flexor digitorum profundus,
Extensor digitorum
radial part Flexor digitorum profundus,
Extensor digiti minimi
Abductor pollicis longus ulnar portion
Flexor pollicis longus Deep head
Extensor pollicis brevis
Extensor carpi ulnaris of flexor
Pronator quadratus pollicis brevis Hypothenar muscles: abductor,
Extensor pollicis longus short flexor, opponens, of
Abductor pollicis brevis, superficial little finger
Extensor indicis (chief) part of flexor brevis, and
opponens pollicis Palmaris brevis
All dorsal and palmar interossei
First and second lumbricals The two ulnar lumbricals
Adductor
pollicis

Axillary and radial nerves Median nerve Ulnar nerve

A B C
FIGURE 2-13 A, Axillary and radial nerves. B, Median nerve. C, Ulnar nerve. (From Jenkins DB: Hollinshead's
functional anatomy of the limbs and back, ed 6, Philadelphia, 1991, WB Saunders.)

during movement, develop in response to pain. Symptoms of discovered due to imbalances created from a diagnosis, such as
nerve pain can be reported within the cutaneous distribution peripheral neuropathy.
or throughout the entire peripheral distribution from an injury The findings of a manual muscle test can be more sensitive
to the nerve root. Unconsciously the nerve response to injury when selecting muscles innervated by various nerve distribu-
is to limit the stretch and excursion that occurs with joint tions. For example, Fig. 2-13, A, provides the distribution of
movement. The muscles of the upper extremity limit the arc the muscles associated with the radial nerve. It is important to
of motion by contracting the corresponding joint. An example note that more than finger and wrist extension can be involved,
can be seen in clients with an ulnar nerve injury. The shoul- especially with trauma to the nerve proximal to the elbow in the
der, elbow, and wrist joints will limit tension and stress to that mid-humeral or brachial plexus regions. The selection of muscles
nerve. Neural tension increases with elbow flexion greater than to be evaluated should include wrist and finger extensors as well
90 degrees and intrafascicular pressure intensifies with shoulder as those muscles that are responsible primarily for elbow exten-
abduction, forearm supination and wrist extension. The neuro- sion, elbow flexion with the forearm in neutral position, supina-
muscular system will prevent this undesirable painful posture tion, and thumb extension. In addition to wrist drop, common
by controlling joint motion in a cohesive manner. A functional postural changes for radial nerve injuries at rest may be increased
anatomy screen for the composite joints of the upper extremity forearm pronation and thumb adduction.
will find the arm bias of elbow flexion is short of 90 degrees, When identifying the muscles that are innervated by the
forearm movements range from neutral to pronation, and the median nerve, the same approach could be used. Fig. 2-13, B,
wrist is flexed. If additional tension occurs, as when the client’s provides a visual representation of the muscles innervated by the
head laterally flexes to the opposite side, the shoulder girdle and median nerve. You may notice that several extrinsic muscles,
elbow may change position to accommodate proximal nerve those muscles which originate outside of the hand, are innervated
glide without increasing neural tension. Measures are needed by the median nerve. In some cases, the musculotendinous sys-
to decrease the pain and the neuromuscular response during tem can cross the elbow, the wrist, the fingers, and the thumb.
intervention. Immobilization may be necessary, but overlook- In addition, there are several intrinsic muscles, those muscles
ing the effects of pain reduction through postural modifica- that originate in the hand, which are innervated by the median
tions may lead to an undesirable response of joint and muscle nerve and provide movements to the thumb, the index, and the
adaptation. middle fingers. In a median nerve injury at the wrist, the motor
In nerve injuries with a severe degree of conduction loss loss to the abductor pollicis brevis, opponens pollicis, and a por-
of both sensory and motor fascicules, a functional anatomy tion of the flexor pollicis brevis presents with loss of bulk to the
screening uses a more conventional assessment of imbalance. thenar eminence. The loss of muscle tone from the median nerve
Frequently, manual muscle tests are performed by evaluating innervated muscles increases the dominance of the ulnar nerve
synergistic action of muscle groups, such as wrist extensors or innervated muscles. The thumb is drawn into CMC adduction
finger flexors as a group. In reality, manual muscle testing can at rest, a posture called the ape hand position. The orientation
be a valuable tool in viewing muscle balance from other perspec- of the thumb CMC joint changes to a flat posture, the flexor
tives. Unrecognized impairments of the upper extremity can be pollicis longus is without balance at the MP joint. With this
30 PART 1 Fundamentals

FIGURE 2-14 Mapping of a hand with limited median and ulnar

nerve function. (Photo from Lori DeMott.)

loss of intrinsic abductor tension, the IP joint of the thumb is

then persuaded into flexion. Weakened tip and chuck pinch may
be present. Fig. 2-14 illustrates the mapping of postural imbal-
ances created from the absence of the median nerve at the wrist.
Important landmarks are changes in the orientation of the nail,
the prominent head of the index MP joint, and the flat space
between the index and thumb.
The muscles innervated by the ulnar nerve are identified in
Fig. 2-13, C. Motor function is supplied to a wrist flexor, finger
flexors to the ring and little fingers, and to many intrinsic muscles
of the fingers and thumb. Compression of the ulnar nerve at the
elbow can result in reduced grip from weakened FDP of the ring
and little fingers and lateral pinch from weakened adductor polli-
cis. Recognizing patterns of muscle imbalance based on the nerve
distribution provides a picture of function very different from
that picture obtained from a generalized manual muscle test.
FIGURE 2-15 Extensor tendon zones as defined by the Committee
on Tendon Injuries for the International Federation of the Society
Scenario 6 for Surgery of the Hand. (From Fess EE, Gettle K, Phillips C, et al: Hand
and upper extremity splinting: principles and methods, ed 3, St Louis, 2005,
Mosby.)
If you were to check the excursion of the extensor
and flexor tendons to the fingers, how do the
location and the type of these structures affect
movement? musculotendinous shortening, poor wrist patterns, and extrin-
sic tendon adhesions.7 In the event where normal joint range
The default position of the hand and wrist at rest is described of motion and length-tension of the musculoskeletal structures
as the “normal resting hand position.” In this posture, the wrist are present, the focus of the functional anatomy screen should
is positioned in approximately 30 degrees of extension, the MP be on the quality of tendon gliding through sheaths and the
and IP joints of the fingers are in approximately 45 degrees of expectation of fluid distal joint flexion and extension. Different
flexion, and the fingers abduct and converge towards the radius. scenarios occur when adhesions are present at different locations
At rest, the posture of the thumb joints is CMC abduction, MP in the arm and hand.
flexion, and IP extension. The balanced relationship between
the wrist, fingers, and thumb demonstrates the principle of Clinical Pearl
tenodesis. That is, the length-tension of the musculotendi- The wrist position is the key to changing the tension placed
nous structures and the ability of the extrinsic tendons to freely on the extrinsic fingers and thumb musculotendinous units.
glide within their sheaths create movements at distal joints as
a result of passive wrist repositioning. In the absence of active
muscular contraction, flexion of the fingers and thumb occurs You have learned that a muscle such as the EDC crosses the
with wrist extension and extension of the fingers and thumb elbow, the forearm, the wrist, and the fingers. In addition to
occurs with wrist flexion. A wrist-produced tenodesis can be considering the length of a musculotendinous unit, the location
beneficial in providing gross grasp, prehension, and release for of the extensor tendons is useful to appreciate the role of other
individuals who lack C7 innervation, amplitude, and tensile structures which can impact tenodesis and tendon gliding.7 Fig.
strength from tendon transfers.7 However, subtle limitations in 2-15 identifies the six locations, or zones, of the extensor tendons.
tenodesis can result from joint and soft tissue problems, such as Within an area at the wrist known as Zone VI, another important
 Functional Anatomy CHAPTER 2 31

Terminal attachment of
extensor mechanism
Lateral bands
Central band

Dorsal hood Oblique fibers

of extensor
mechanism Transverse fibers

Juncturae tendinae Extensor digiti minimi

Extensor indicis

Extensor digitorum
Extensor pollicis longus
Extensor pollicis brevis

Extensor carpi radialis longus

Extensor carpi radialis brevis Extensor retinaculum
Abductor pollicis longus

Extensor carpi ulnaris

e rcle a
Uln VI) Extensor carpi ulnaris
b
Tu

d iu s
Extensor pollicis brevis Ra
V) Extensor digiti minimi
I
Abductor pollicis longus IV) Extensor digitorum
and extensor indicis
Extensor Extensor III) Extensor
carpi radialis carpi radialis pollicis longus
longus brevis

II
FIGURE 2-16 Arrangement of the extensor tendons in the compartments of the wrist. (From Neuman D:
Kinesiology of the musculoskeletal system: foundations for rehabilitation, ed 2, St Louis, 2010, Mosby.)

contribution to the function of extensor tendon gliding is the Similarly, an appreciation of the extensor tendons to the
presence of six compartments created by the deep layers of the fingers in Zones II-IV provides a different perspective of how
dorsal fascia. Fig. 2-16 shows the tendons that are located in each location impacts tendon gliding. In Fig. 2-17, the extensor mech-
of the numbered dorsal compartments of the wrist. Testing the anism of a finger PIP joint is presented in a dorsal and lateral
independent movement of each extensor tendon by compartment view with digital MP flexion and extension. One can see the bal-
provides a clearer picture of the effectiveness of tendon excursion ance that must occur between the intrinsic and extrinsic muscle
through the dorsal pulley system and can supplement the findings groups so that full extension of a digit can occur. To assess the
of a more generic range of motion or manual muscle test. A func- contribution of the extrinsic musculature with PIP extension, the
tional anatomy screen at Zone VI for the extensor tendons may wrist and the MP joints can be stabilized in extension. In this
show changes at rest for the MP joints of the fingers with increased position, the power of the intrinsic muscles is minimized. When
extension. With movement, passive and active limitations of wrist the PIP joint is held in extension and the DIP joint is actively
flexion and exaggerated finger extension can be observed. flexed, a passive stretch to the lateral bands are completed that
32 PART 1 Fundamentals

Ulnar Radial

Triangular ligament

Lateral band

Slip of
long extensor
to lateral band
Dorsal extensor expansion

Sagittal bands
Lumbrical muscle

Long extensor tendon

Interosseous muscle

A
Long extensor tendon Sagittal bands
Dorsal extensor expansion
Interosseous muscle
Central slip of common extensor
Lateral band

Flexor profundus tendon

Lumbrical muscle
Flexor digitorum superficialis
B
Long extensor tendon
Sagittal bands

Bony insertion of
interosseous tendon on
proximal phalanx
Distal movement of
extensor expansion
Interosseous Lumbrical muscle during flexion
muscle

Lateral band

C
FIGURE 2-17 Extensor mechanism of the digits. The figure shows distal movement of the extensor expan-
sion with metacarpophalangeal (MP) joint flexion. (From Fess EE, Gettle K, Phillips C, et al: Hand and upper extremity
splinting: principles and methods, ed 3, St Louis, 2005, Mosby.)
 Functional Anatomy CHAPTER 2 33

ultimately facilitates balanced extension between the PIP and the Further considerations become evident in flexor tendon
DIP joints. Knowledge of the extensor tendon anatomy, location Zones I-II. At this level the relationship between the FDP and
by zone, and presence of surrounding structures is an important the FDS changes. Prior to entering Zone II, the FDP is deep
consideration in your assessment of the hand. to the FDS. In Zone II, the FDP passes through the decussation
At rest, a functional anatomy screen for the extensor tendons of the FDS, which can be visualized in Fig. 2-20. It becomes very
in Zone II-IV can present with imbalances in PIP and DIP exten-
sion. An injury to the palmar plate at the PIP joint results in loos-
ening of the volar supporting structures resulting in unchecked
pull of the extensor tendon, increased dorsal orientation of the
lateral bands, and hyperextension of the PIP joint. This imbal-
ance results in a change of the PIP joint axis, loss of mechanical
advantage, and flexion bias of the distal phalanx. At rest, the digit
is observed in PIP joint extension and DIP joint flexion. The
normal resting balance of flexion cascade in the MP, PIP, and
DIP joints is also lost.
The finger flexors have similarities and contrasting differences
from the extensor tendons. Fig. 2-18 illustrates the five flexor
tendon zones to the fingers and three flexor tendon zones to the
thumb. Zone IV contains the structures within the carpal tunnel,
and Fig. 2-19 provides a cross-sectional view of their anatomy.
When examining the excursion of the flexor tendons at this level,
an assessment of the structures can be performed starting with the
superficial tendons and progressing to the tendons in the deeper
compartments of the carpal tunnel. The FDS to the middle and
ring fingers would be the most superficial structure, followed by
the FDS to the index and little fingers, and finally the FDP to
all of the fingers. Two other structures are contained within the
carpal tunnel, the flexor pollicis longus and the median nerve,
as well as the synovium, which encases and lubricates the flexor
tendons. Overall, it can be useful to isolate the excursion of these
tendons by compartments as injuries that are more superficial,
such as burns, which may have more effect on the FDS compared
to injuries that are deeper—as is the case with fractures to the
distal one-third of the radius. A functional anatomy screen for
the flexor tendons in Zone IV can be exaggerated tenodesis or FIGURE 2-18 Flexor tendon zones of the hand. (From Kleinert HE,
increased finger flexion with increased wrist extension. Schepel S, Gill T: Flexor tendon injuries, Surg Clin North Am 61(2):
267-286, 1981.)

Transverse carpal ligament

Tendons Median nerve

FIGURE 2-19 Cross-sectional view of the carpal tunnel anatomy. (From Fess EE, Gettle K, Phillips C, et al: Hand
and upper extremity splinting: principles and methods, ed 3, St Louis, 2005, Mosby.)
34 PART 1 Fundamentals

important to isolate each tendon when assessing its excursion.

When testing the FDS, the effects of the FDP must be eliminated
by the examiner holding the DIPs of the non-tested fingers in
extension and allowing each individual finger to actively flex at
only the PIP joint. When testing the FDP, the PIP joint can be
supported in extension to allow only DIP flexion. In this way,
isolated range of motion exercises can facilitate the independent
function of these two important flexor tendons to the hand. A
functional anatomy screen for the flexor tendons in Zones I-II
can reveal imbalances, such as insufficient flexion of the DIP
joint with full fisting of the hand.

Summary
It is critical that hand therapy professionals understand the role
and interrelationships of joints, ligaments, muscles, tendons, and
nerves in order to appreciate normal postural mechanisms that
occur. Continued study and observations of normal anatomy
during static and dynamic movements of the upper extremity are
vital to recognizing the abnormal deviations, or defaults in pos-
ture resulting from tissue imbalance. The addition of a functional
anatomy screen during the evaluation process will enhance the
level of rehabilitation expertise needed to recognize the source of
FIGURE 2-20 The flexor digitorum superficialis (FDS) lies volar pathology and the influence of the kinematic chain at rest and
to the flexor digitorum profundus (FDP) as the tendons enter the during movements. Understanding these principles, along with
sheath. (From Schneider LH: Flexor tendon injuries, Boston, 1985, Little continued study of human anatomy, will enable you to develop
Brown.) therapeutic interventions that address the imbalances of the
upper extremity in order to help your clients recover from the
devastating effects of injury, disease, and aging.

References
1. Donatelli RA, Wooden MJ: Orthopedic physical therapy, ed 4, St Louis, 5. Topp KS, Boyd BS: Peripheral nerve: from the microscopic functional unit
2010, Churchill Livingston Elsevier. of the axon to the biomechanically loaded macroscopic structure, J Hand
2. Kendall FP, McCreary EK, Provance PG, et al: Muscles: testing and func- Ther 25:142–151, 2012.
tion, with posture and pain, ed 5, Baltimore, 2005, Lippincott Williams & 6. Rybski M: Kinesiology for occupational therapy, ed 2, Thorofare, NJ, 2011,
Wilkins. Slack Incorporated.
3. Brand PW, Hollister AM: Clinical mechanics of the hand, ed 3, St Louis, 7. Fess EE, Gettle K, Phillips C, et al: Hand and upper extremity splinting:
1999, Mosby. principles and methods, ed 3, St Louis, 2005, Mosby.
4. Walsh MT: Interventions in the disturbances in the motor and sensory
environment, J Hand Ther 25:202–218, 2012.
 3 Edema Reduction
Techniques: A Biologic
Rationale for Selection
Sandra M Artzberger

U
nlike in the past, the treatment of hand edema no longer needs to be partly a
guessing game. Modern treatment selections are more firmly grounded in ana-
tomic and biologic principles and therefore are more successful. To treat edema
effectively, the therapist must know the difference between the lymphatic and venous
systems, including the role these systems play in edema reduction. It also is essential that
the therapist understand the different types of edema. This chapter describes acute, sub-
acute, and chronic edema. It reviews vascular and lymphatic anatomy and biology, and it
describes appropriate interventions for edema, including the technique of manual edema
mobilization (MEM). Special emphasis is placed on the clinical reasoning involved in
selecting the appropriate treatment.

N
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TIO

GS
MP
DA

VA

BA
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BAN

PU

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VE
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IP

LO
TIC
VITY

CH
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LOW ST

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CP
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DR
IN

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ST D AG
AN S E
YH AS CIS
LK E M EXER
BU D
RA
OG
R ETR

Overview of Lymphatic Anatomy Related to Edema Reduction

An overview of the capillary vascular structures and their relationship to each other is
a prerequisite for a more detailed discussion of these systems. The vascular structures
include the interstitium, the arteriole, and the venule. The interstitium is the space
between cells. It contains both the smallest arterial vessel, called an arteriole, and the
smallest venous structure, called a venule.1, 2 Both the arteriole and the venule termi-
nate in capillaries, which are joined histologically (Fig. 3-1). The heart is responsible for
pumping blood through these structures.

Editor’s Note: Before the importance of Sandra Artzberger’s work on the treatment of edema was recognized, the
edema techniques that hand therapists were taught were not specific to the lymphatic system and sometimes even
damaged this delicate and amazing part of the body. Artzberger has done much to delineate the anatomy and physi-
ology of post traumatic edema. She has changed our thinking and has overhauled the treatment repertoire, creating
an approach that is based on science. Her technique of manual edema mobilization has resulted in much-improved
management of edema in clients with upper extremity injuries.
36 PART 1 Fundamentals

to spread apart. The initial lymphatic connection forms a net-

like structure.1,3
The balance between fluid moving into and out of the vas-
cular vessels on a cellular level, which was first described by
Ernest Starling in the early 1900s, is called Starling’s equi-
librium.1,2 This balanced movement of fluid functions as a
gradient system from high to low pressure. On the capillary
level, arteriole hydrostatic pressure (the pressure of the blood
fluid exerted on the arteriole vessel wall) is 30 to 40 mm Hg,
which is enough pressure to cause filtration of electrolytes,
fluid, a few small plasma proteins, and other nutrients into the
interstitium.1,2 The colloid osmotic pressure (also called the
oncotic pressure) in the interstitium is determined by the con-
centration of proteins in this intercellular space; this pressure
is approximately 25 mm Hg.2 Tissue cells in the interstitium
absorb the nutrients, electrolytes, and other substances filtered
out of the arteriole. Of the remaining substances, 90% diffuse
by osmosis into the venous system.1-3 The residual 10% of left-
over substances are large molecules, which are absorbed by the
lymphatic system.1-3 These large molecules consist of plasma
proteins, minerals, ions, hormone cells, bacteria, fat cells, and
fluid.1-5 Once the cells enter the initial lymphatic, they make up
a substance called lymph.2
As lymph enters the initial lymphatic, it causes pressure
changes that open the valve connected to the next lymphatic ves-
sels, the three-celled collector lymphatics (Fig. 3-3). Clinically,
the most important features of the tube-like collector lymphat-
ics are a middle layer of muscle cell and the presence of valves
every 6 to 8 mm along the tube.1,3 The chamber between two
valves is called a lymphangion.3 As a bolus of lymph enters a
lymphangion, the single layer muscle cell contracts against the
expanding lymphangion and pushes the bolus proximally into
FIGURE 3-1 Blood and lymph circulatory systems. (From Foldi M, the next lymphangion (see Fig. 3-3). This process continues until
Foldi E, Kubik S: Textbook of lymphology for physicians and lymphedema the bolus reaches the afferent lymphatic pathways of the lymph
therapists, Munich, 2003, Urban & Fischer Verlag.) node.

Clinical Pearl
The lymphatic system originates in the interstitium with Exercise moves lymph ten to thirty times faster through the
the smallest of the lymphatic vessels, called the initial lym- collector lymphatics and increases the rate of lymphatic uptake
phatic or lymphatic capillary, and culminates in the largest from the interstitium.1
lymphatic structure, called the thoracic duct.2 The venous sys-
tem has a continuous-loop pump system based on the heart
pumping oxygenated blood to the arteries, arterioles, venules, The pumping movement of the lymphangions resembles
veins and back to the lungs and heart. However, the lymphatic the peristaltic movement of the small intestine. The lymphan-
system does not have this continuous central pump system (see gions pump at a rate of 10 to 20 times per minute,3 and exer-
Fig. 3-1).3 Also, unlike with venous capillaries in the intersti- cise can increase this pumping motion by 10 to 30 times.1
tium, molecules do not diffuse into the lymphatic capillary. Recent theories hold that peristalsis also creates a negative pres-
Therefore the lymphatic system must be stimulated to activate sure that opens the junctions of the endothelial cells, enabling
a force pump, (external and internal vacuum stimulation that large-molecule substances to move from the interstitium into
moves lymph), creating a vacuum and drawing the lymph prox- the initial lymphatic.3
imally.3 Initial lymphatics, which are larger than venules, are Eventually the bolus of lymph moves into the afferent lym-
finger-shaped tubes that are closed on the distal end and lined phatic pathways of the lymph nodes. Lymph nodes, which per-
with overlapping, oak leaf–shaped endothelial cells. Anchor form several immunologic functions, are composed of a series of
filaments extend from the endothelial cells to the connective complex sinuses and therefore often are considered “dams” or
tissue (Fig. 3-2). Movement of the connective tissue pulls on “kinks in the hose” in the movement of lymph. Excessive swell-
the anchor filaments. This, in turn, pulls on the overlapping ing distal to the lymph nodes does not increase their rate of filtra-
flaps (junctions) of the endothelial cells, and water and large tion, but rather causes further congestion distally.4 Venous vessels
molecules are admitted into the initial lymphatic.1,2,4 Large do not connect to lymph nodes and therefore do not reflect this
molecules also enter the initial lymphatic when a change in the slowing of fluid movement. Also, venous vessels do not carry
interstitial pressure causes the junctions of the endothelial cells bacteria or tissue waste products and therefore do not pass these
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 37

FIGURE 3-2 Incorporation of the lymph capillary into the intersti-

tium. 1, Arterial section of the blood capillary; 2, venous section of
A B C
the blood capillary; 3, lymph capillary; 4, open intercellular groove-
swinging tip; 5, fibrocyte; 6, anchor filaments; 7, intercellular space. FIGURE 3-3 Structure and function of the valve segments in the
Small arrows indicate the direction of blood flow; large arrows indicate collector lymphatics. A, Arrangement of the musculature. B, Normal
the direction of intercellular fluid flow. (From Foldi M, Foldi E, Kubik S: function. C, Dilated lymph vessel with valvular insufficiency and
Textbook of lymphology for physicians and lymphedema therapists, Munich, reflux. (From Foldi M, Foldi E, Kubik S: Textbook of lymphology for physi-
2003, Urban & Fischer Verlag.) cians and lymphedema therapists, Munich, 2003, Urban & Fischer
Verlag.)

substances through the lymph nodes for cleansing. Lymph nodes diaphragmatic breathing moves lymph more proximal in the tho-
present significant resistance to the flow of lymph and must be racic duct, creating a space into which the more distal peripheral
massaged to facilitate a faster flow of the distal congested lymph.4 edema can move.
The MEM method of massaging healthy and uninfected nodes
uses MEM pump point stimulation, which is a method of simul-
Clinical Pearl
taneously massaging two groups of nodes, bundles of lymphatic
vessels, or watershed areas (anatomical drainage dividing areas), The key to successful edema reduction is to “remove the plug”
which theoretically speeds up the movement of lymph through by starting proximally at the trunk with diaphragmatic breathing
the nodes. and proximal exercise.
From the nodes, lymph can enter the venous system directly,
through lymphovenous anastomoses (areas where the small ves-
sels of the lymphatic and venous systems join), or it can continue Before they reach the thoracic duct, the deep lymphatic
on in the lymphatic vessels and empty into either the right lym- trunks share a common vascular sheath with the venous and arte-
phatic duct or the largest lymphatic vessel, the thoracic duct. The rial structures.3 Therefore exercise increases the rate of arterial
thoracic duct lies anterior to and parallel with the spinal cord from flow and passively stimulates the lymphatic vessels, increasing the
approximately L2 and empties into the left subclavian vein.2,3 The rate of lymph flow. Also, at least 200 lymph nodes are located
right lymphatic duct terminates in the right subclavian vein. centrally and around deep venous and arterial structures. Exercise
The movement of lymph in the thoracic duct is affected by of the abdominal muscles increases the pumping of blood, which
changes in thoracic pressure. Diaphragmatic breathing expands stimulates the lymph nodes, moving lymph through them more
the abdomen, causing changes in thoracic pressure that move rapidly—a force pump action.
the contents of the thoracic duct more proximally.1,3 This action “Exercise is key to lymphatic activation” is a frequently heard
creates a vacuum, drawing lymph from the more distal vessels statement. Yet therapists know that in most cases, simply exercis-
toward the thoracic duct.1,3 Treatments such as MEM, therefore, ing the edematous hand or arm in the subacute phase does not
begin with diaphragmatic breathing and trunk exercise. This is significantly or permanently reduce edema. Lymphatic structures
analogous to removing the plug from a drain or a clog from a can exceed 30 times their normal capacity before edema becomes
backed-up sink. The clog must be removed before the water can visible;1 this means that proximal to the visible edema is the
flow out. In terms of clinical application, the vacuum created by beginning of non-visible edematous congestion.
38 PART 1 Fundamentals

Exercise and light massage significantly proximal to the visible Clinical Pearl
edema create a negative pressure, drawing lymph proximally and
thus removing the “clog.” The results of research by Pecking and The anatomic differences between the lymphatic and venous
colleagues6 present a strong argument for stimulating lymphatic systems determine the anatomically-based treatment of edema.
absorption and conduction significantly proximal to visible
edema. In these researchers’ study, manual lymphatic drainage
(MLD) (the manual decongesting of lymph through activating Reduction Techniques for Acute Edema
the lymph uptake through massage, low-stretch bandaging pro-
grams, and so on) was performed exclusively to the contralateral, Bulky Dressing
normal upper quadrant on 108 women with lymphedema caused
by mastectomy; this resulted in a 12% to 38% lymph uptake in Several techniques can be used to reduce excessive fluid outflow
the hand, even without massage of the involved area.6 The con- (edema). For example, a bulky hand dressing applied at the time
tralateral massage created a negative pressure (vacuum), drawing of surgery gives counterforce to the outflow (filtration) by chang-
the lymph from the involved to the uninvolved area, where it ing the tissue pressure. It is composed of appropriate wound care
could be absorbed into the normal system. dressing, fluffy gauze sponges, and rolled-on gauze. After soft tissue
If we synthesize these findings with the theory that changes trauma, immobilization for up to a week in a bulky dressing or
in thoracic pressure move lymph proximally, and add the knowl- plaster splint facilitates healing of involved structures by preventing
edge that muscle contraction stimulates lymphatic uptake on stress on fragile tissue, which could cause microscopic rupture of
many levels, we arrive at a very strong rationale for beginning vessels with resulting edema. The therapist should check the dress-
edema reduction at the trunk even if edema is visible only in ing or splint to make sure it is not too tight and should contact the
the hand. Clinically, this means that therapists should not begin physician immediately if this is a possibility. A bulky dressing that
edema reduction treatment where edema is visible; rather, they is too tight causes vascular changes, temperature changes, increased
must begin in a normal, uninvolved area significantly proximal edema, or severe, painful compression of the fingers and can lead
to the visible edema. Appropriate treatments include diaphrag- to tissue breakdown. The capillary refill test can be used to check
matic breathing, trunk stretching and muscle contraction exer- vascular status (see Chapter 5). The therapist also must teach the
cises and activities, and MEM massage that begins in the area of client that any vascular changes (that is, changes in tissue color) or
the uninvolved axilla. (MEM is discussed in more detail later in sensory changes must be reported immediately to the physician.
the chapter.) Procedures, such as tenolysis and flexor tendon repair, involve min-
imal or no immobilization in a bulky dressing. However, even with
Acute Edema Related to the Vascular Anatomy these diagnoses, limited motion can increase edema, therefore early
motion must be balanced with rest to prevent this.
The venous and lymphatic systems have many pump-like struc-
tures that help propel the blood back to the heart. Because of the High Voltage Pulsed Current
descending gradient of hydrostatic pressures from the arteriole
capillary to the venule capillary, small-molecule substances dif- In animal studies, high-voltage pulse current (HVPC) used on
fuse easily and are reabsorbed into the venous capillary through very acute edema was reported to retard the high capillary perme-
its thin wall.2 Active muscle contraction acts as a pump as it com- ability outflow 8,9 but has not been replicated in human subjects.
presses and empties the large deep venous vessels. As this blood is Clinically, it is a frequently used modality to reduce acute edema.
propelled proximally toward the heart, a negative pressure is cre-
ated, which draws blood from the periphery into the deep veins. Elevation
Edema develops when the descending gradient of Starling’s
forces are disrupted by an interruption and an imbalance. The cas- Elevation of the hand above the heart, if not contraindicated,
cade of events that occurs after tissue laceration is a good example. also reduces outflow because it reduces the arterial hydrostatic
Initially, an outflow of water and electrolytes (transudate edema) pressure.10 Elevation in the acute stage facilitates lymphatic flow
into the wound occurs. The mast cells then release histamines, because hydrostatic gradient pressure is increased along the lym-
which greatly increase capillary permeability, and plasma proteins, phatic trunks.4 Ideally, the involved extremity is elevated in a plus
phagocytic cells, and other substances leak into the area. Plasma 45-degree “ski hill” position; this means that pillows are placed
protein fibrinogen is converted to fibrin, which plugs the endothe- so that the elbow is above the shoulder, and the hand is above the
lial cells lining the lymphatics.7 This prevents the lymphatics from elbow and wrist.
temporarily removing the large molecules as the various phagocyte Keeping the arm elevated while sleeping can be difficult.
cells perform their “cleanup” function.7 Edema results when excess Often clients use pillows on either side of them. A belt can be
fluid and plasma proteins are trapped in the interstitium. Star- fastened around the pillows to keep them together. Also, the bed
ling’s equilibrium is disrupted, because the trapping of excess pro- can be moved against the wall so that one set of pillows is pushed
teins in the interstitium increases the colloid osmotic pressure. up against the wall, preventing them from falling. For clients with
The immediate goal of treatment by physicians and therapists finger replantation, elevation no higher than the heart is recom-
is to limit the amount of outflow into the wound bed, thereby mended to avoid compromising arterial blood flow.11
preventing excessive swelling, accumulation of blood, and further Precaution. Extreme elevation of the right arm must be avoided
tissue damage. After 2 to 5 days, the swelling begins to subside as in stroke clients with right-sided heart weakness. Extreme upper
the surrounding intact venous capillaries start to absorb the tran- extremity elevation may cause fluid to flow too quickly into the right
sudate and the lymphatic vessels absorb the large-molecule plasma side of the heart, because the right upper quadrant is drained by the
proteins not phagocytized by the macrophages. right lymphatic duct that empties into the right subclavian vein.
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 39

Cold Packs developed by a Japanese-born chiropractor, Dr. Kenso Kase, in the

1970s.14 The cloth-like tape has acrylic glue applied to one side in
Cold packs, if not contraindicated for vascular and tissue ischemia a wave-like pattern, such as a finger print swirl. When the tape is
reasons or diseases such as Raynauld’s, cause vasoconstriction and applied in a specific manner it is theorized that the edema reduces
thus reduce the outflow of fluid in the acute stage. However, the because patient movement pulls the skin in the opposite direction
temperature of the cold pack is a consideration. Research shows from where the tape was applied. This movement puts a stretch
that when the temperature is lower than 59° F (15° C), proteins on the initial lymphatic structures facilitating congested lymphatic
leak into the interstitium from lymphatic structures.12 Excess absorption.15 Increasing this space, creates a pull on the connec-
proteins in the interstitium cause edema. tive tissue anchor filaments attached to the endothelial cells of the
Precaution. To prevent “ice burn” to tissue, always place a dry initial lymphatics; this separates the planted endothelial junctions,
towel between the skin and the cold pack. Cold packs should not be used thereby increasing lymph and fluid flow.
on a client with a replanted hand or digit because of the effect of vas-
cular compromise on tissue viability.13 A nerve repair may be injured Indications for Manual Edema Mobilization
by cold postoperatively. Clients should get explicit care instructions from in the Acute Stage
their physicians, including precautions on the use of cold packs.
Many wonder why MEM is not started in the acute stage. In
Retrograde Massage 1989, Hutzschenreuter and Brummer16 did a research study on
this point using sheep. They compared the results in two groups,
Light retrograde massage with elevation facilitates diffusion of one in which MLD was performed and one in which it was not
small molecules into the venous system. The elevation reduces over a defined period (that is, immediate postoperative to 3 weeks
capillary filtration (outflow) pressure, and the light pressure from postoperative). They found that both groups showed minimal
the retrograde massage aids in venous absorption of the small fluid reduction during the first week after surgery. However,
molecules (not large plasma proteins). after the first week, the MLD group had a significantly greater
Precaution. The pressure is kept light to avoid damaging the increase in fluid movement and edema reduction than the con-
single-cell initial lymphatic structures in the dermal layer of the skin. trol group.16 These results are not surprising because initially,
acute edema is transudate that is changing to exudate edema
Compression as the plasma proteins invade and are contained. Only the lym-
phatic vessels can remove excess proteins from the interstitium.1,2
Light compression, such as from an elastic glove, Coban (or simi- MEM and manual lymphatic treatment* (MLT) programs are
lar type material) lightly spiral-layered on a digit, or low-stretch designed to activate lymphatic vessels.
finger bandage wraps (see video/slides on the Evolve website),
facilitates small molecule absorption by the venous system and Exercise
absorption of large and small molecules by the lymphatic system.
A loose but compressive elastic glove generally is one in which the Some physicians prescribe proximal active motion of an extrem-
glove material can be pulled away from the hand and simultane- ity or gliding of the involved structures, or both, during the acute
ously on each side of finger at least ⅛ inch. stage of wound healing. Proximal trunk and shoulder motion is
In the early post stroke stages, hand and arm edema is a tran- excellent. It decongests the lymphatic vessels and removes tissue
sudate swelling because fluid leaks into the interstitium as a result waste products, resulting in better oxygenation to tissue and faster
of lack of muscle pumping activity on the vascular vessels. Eleva- wound healing. However, movement must be balanced with rest
tion, light retrograde massage, and light compression from an of involved structures. This is done by progressively grading the
elastic glove or elasticized arm stockinette are effective treatments exercise so as not to increase hand inflammation, pain, and swell-
that promote diffusion of leaked electrolytes and water back into ing. Always respect the fragility of healing tissue and vascular
the venous system. structures. When moving the involved structures, start with lim-
Precaution. When using an elasticized garment, observe two ited movement and check for signs of increased pain, swelling,
important precautions: (1) make sure it is not too tight (that is, it or redness. If edema increases, rest the involved hand for a day
does not cause color or temperature changes in the hand or digit) and (consider applying a static orthosis). Resume activity, but do less
(2) with elasticized stockinette, make sure it cannot roll down, caus- than previously and gradually increase the exercise over the next
ing swelling distally. treatment sessions. I usually begin with the rule of three or five:
A body garment glue can be used to prevent the elastic stocki- three (or five) repetitions of an exercise three (or five) times a day.
nette from rolling down on itself, which can cause distal swell- If this does not increase swelling, gradually increase repetitions
ing. Keep in mind that some body garment glues are latex based; or frequency, or both. Remember, edema and pain limit motion
therefore always make sure your client does not have a latex allergy and retard progress.
before using this type of glue.
Precaution. An elastic glove should be fitted to give some compres-
sion but should feel loose on the hand and fingers. If the compression is Clinical Pearl
too tight, fluid flow is restricted, which increases edema. Reducing edema is almost always the first priority; do this, and
the client will gain motion.
Elastic Taping
Elastic taping is becoming the common generic term used to des- * Manual lymphatic treatment is the generic term used to describe the massage prin-
ignate a variety of tapes similar to the original Kinesio Tex tape ciples common to all schools of lymphatic drainage.15
40 PART 1 Fundamentals

Key 2 involves external stimulation of the lymphatics to facili-

Summary of Reduction Treatment for Acute Edema tate the uptake of lymph from the interstitium by creating changes
in the interstitial pressure; by causing stretching of the anchor
filaments attached to connective tissue; and by creating nega-
postoperatively) tive pressure, which causes the opening of lymphatics through
lymphangion pumping. Appropriate treatments to achieve this
acute edema; benefit in humans not yet proven) include MEM, elastic taping, gentle myofascial release (MFR),
bombardment of tissue with fluidotherapy particles at a machine
temperature no higher than 98° F (36.7° C), active and passive
digits and/or hands. exercise and the light compression provided by elastic gloves, chip
bags, and low-stretch bandaging.
heart weakness is present (that is, post stroke client).
Contrast Baths
directed by physician)
Some therapists use contrast baths to reduce edema, although cur-
cold causes vasoconstriction. rently no research is available that supports this practice.17 If con-
trast baths are to be used, research findings on temperature need
nerve is involved. to be considered. Kurz18 states that lymph flows best at tempera-
tures between 71.6° F (22° C) and 105.8° F (41° C).18 For therapy
purposes, the hot temperature should not exceed 98° F (36.6° C)
to avoid increasing capillary permeability (which is enhanced by
on digit in spiral, distal-to-proximal pattern) heat) and thus edema. With regard to the cold temperature, as
mentioned earlier, research has shown that the initial lymphatics
actually leak protein into the interstitium at temperatures below
trunk/shoulder motion increases edema) 59° F (15° C).12 Therefore, to avoid the leakage of more plasma
proteins into the interstitium (potentially increasing edema), the
inflammation or increase in edema cold temperature should not be lower than 59° F (15° C).
Precaution. To avoid worsening the edema, set the temperatures
for contrast baths between 71.6° F (22° C) and 98.6° F (37° C).
Therapy with contrast baths commonly is performed by hav-
Reduction Techniques for Subacute and Chronic ing the client immerse the hand in warm water for 3 minutes and
Edema Based on the Lymphatic Anatomy then in cold water for 1 minute. This sequence is repeated four
times, ending on cold.
To review, the lymphatic system is an independent pump system that
works on a negative pressure gradient. When lymph vessels fill (high Electrical Modalities
pressure is created), lymph moves to an area of lower pressure.1-4
Published research regarding the use of electrical modalities,
Clinical Pearl such as transcutaneous electrical nerve stimulation (TENS), Low
The sooner lymphatic decongestion occurs, beginning at Intensity Laser Therapy (LILT), and non-thermal therapeutic
1 week post-injury even with non-visible edema, the less the ultrasound, to reduce peripheral subacute edema is inconsistent.
chances of developing tissue and scar thickening, fibrosis, and Resende, et al.19 found that TENS did not reduce edema. For
contractures. over 30 years, literature has been published regarding the mul-
tiple applications for LILT. However because of the variety of
parameters used with LILT, comparing outcomes is difficult.
The two keys to activating the lymphatic system are as follows: Studies showing the use of LILT for edema control of ankle
sprains were not positive.20,21 In 2004, a post flexor tendon
stimulated (massaged), creating a lower negative pressure to repair study using gallium arsenide (GaAs) laser therapy found
draw the most proximal edema out of the involved area. edema reduced immediately and at 12 weeks post repair.22 Clini-
cally non-thermal therapeutic ultrasound is often implemented
interstitium because only changes in the interstitial fluid pres- to reduce upper extremity edema, yet a peer-reviewed literature
sure (low to high) cause the endothelial cells lining the lym- search did not find any supporting evidence.
phatics to open. HVPC has been shown to reduce acute edema in the ani-
Key 1 is based on the theory that negative pressure causes a mal model.8,9,23 It has also been a consideration for subacute
suction effect that moves the more distal lymph proximally in and chronic edema. For instance, Griffin and colleagues24 found
the trunk and extremities.1,3 Appropriate treatments to achieve that HVPC did not reduce pre-existing edema.24 However, a
this include MEM massage that starts at the uninvolved axilla, subsequent study by Stralka and coworkers25 on employees with
diaphragmatic breathing, trunk exercise, trunk exercise combined cumulative trauma disorders who wore an orthosis that incorpo-
with breathing, proprioceptive neuromuscular facilitation (PNF) rated HVPC while working showed a reduction in edema. This
techniques combined with exhaling and inhaling, and easy yoga raises the question of whether the HVPC was reducing the acute
trunk stretching exercises. These are considered methods of inter- edema occurring while working, or reducing a combination of
nal stimulation of the deep lymphatics. acute and subacute edema. Further study is needed.
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 41

Thermal Modalities system directly below the therapist’s hands and throughout other
parts of the body. The result is elongation or softening of the
Often with subacute edema the therapist additionally has to fascia and its ground substances. Clinically, I frequently use one
address joint and tissue stiffness and decreased range of motion of several MFR techniques on a specific muscle area to reduce
(ROM). Heat will increase tissue elasticity. Heat between 71.6° the fascial restriction, and then I get a better lymphatic flow and
F (21.9° C) and 105.8° F (41° C) will increase lymph flow18 and edema reduction. Here, also, formal coursework is needed before
soften tissue due to decongestion of the lymph. However, too doing the technique.
much heat will increase capillary permeability, increasing the
swelling. Therefore, therapists are recommended to keep heat to Exercise
tissue at body temperature or just slightly above.
Clinically, the author has been able to use well-padded hot Exercise should start at the trunk to facilitate the lymphatic pump.
packs for 12 minutes on the edematous indurated (dense thick- Even low-level aerobic exercise causes thoracic pressure changes
ened) tissue area, gain tissue elasticity, and soften this edematous on the thoracic duct. The pressure changes move the lymph
indurated tissue without increasing edema. This has been accom- proximally into the venous system at the subclavian veins creat-
plished by doing a proximal MEM routine while the hot packs ing a vacuum drawing the lymph proximal from the periphery.3
are on the extremity, followed by proximal to distal exercise after Shoulder and elbow exercise, if not contraindicated, should be
removal of the hot packs. Doing the MEM stimulates and decon- done next in the sequence. This draws and moves edema proxi-
gests the proximal lymphatic system, creating the negative pres- mal toward the thoracic duct, creating a space for the more distal
sure vacuum to absorb and move the lymph from the area (see edema to move proximally. Next, exercise is completed at the wrist
Case Study 3-1). A Fluidotherapy machine set at 98° F (36.6° C) and then at the hand/fingers.
to 100° F (37.7° C) will accomplish the same benefit.
Clinical Pearl
Pneumatic Pump
Do not begin exercises at, or just, proximal to the edema
Pneumatic pumps are rarely used by hand therapists. A com- because it has to have a proximal space (decongested area) for
bination of MEM, compression bandaging, elastic tapping on the fluid to move within the lymph system.
induration areas, and exercise will usually reduce the congested
lymph. However, there might be rare instances where usage is
needed, such as a temporary case of dependent edema from a Clinical Pearl
neurological motor impairment, or extensive damage to the ini- When MEM is contraindicated (such as, for cardiac, pulmo-
tial lymphatics, such as a massive crush injury to the entire arm. nary, kidney disease reasons), some edema will be reduced by
This edema will not stay reduced unless a low-stretch bandag- doing diaphragmatic breathing. Then begin exercise at the
ing or garment system is applied to the extremity after using the trunk and proceed proximal to the edema and potentially add
pneumatic pump. Description of this type of a bandaging or gar- an elastic stockinette to the edematous area.
ment program is beyond the scope of this chapter.
When using the pneumatic pump for post trauma/surgery
chronic edema, the chamber pressures should never be greater Low-Stretch Bandages, Gloves, Massage, and Chip Bags
than 40 mm Hg because of the potential to collapse the ini-
tial lymphatics where absorption occurs “having a tourniquet Massage or compression on tissue must be light to avoid collaps-
effect”26 and because of potential calibration errors.4,27 A pneu- ing the single-celled initial lymphatics in the dermal layer. Miller
matic pump system was developed by Flexitouch in 2006, and and Seale30 reported that the initial lymphatics began to collapse
research has shown it facilitates lymphatic uptake and moves lym- at a pressure of 60 mm Hg and that they closed completely at 70
phatic fluid.28 This system mimics MLD by first decongesting mm Hg when tested on a flat surface. Eliska and Eliskova31 found
trunk edema and then proceeding to the extremity(ies) with the that a 3 minute friction massage on edematous tissue at
sequence, a rolling light chamber pressure, and the timing used 75 to 100 mm Hg caused temporary damage to the endothelial
with MLD. The therapist must follow usage guidelines and pre- linings of both the initial lymphatics and the collector lymphatics.
cautions for all pump usage. Thus string wrapping should be avoided in all stages of edema
because of the potential to damage fragile lymphatic structures and
Elastic Taping because fluid cannot be “pushed” into the lymphatic structures,
but rather it has to be absorbed due to pressure changes. Applying
Clinically I have found elastic tape to be an excellent adjunct to this same information to the application of elastic gloves, finger
MEM to soften tissue and to keep the lymphatics stimulated for and forearm wrapping, or massage means that the compression
absorbing lymph throughout the day and night. There are many has to be light to cause interstitial pressure changes and lymphatic
applications for taping, and formal course completion is recom- absorption. The movement and slight compression of a loose elas-
mended. See the Reduction Techniques for Acute Edema section tic glove or elastic stockinette causes interstitial pressure changes
for a complete description and lymphatic absorption. Clinically I have found that fingers
of elastic gloves are most effective when they can be stretched
Myofascial Release simultaneously ⅛ of an inch on either side of the digit. An elastic
stockinette must allow me to place my two hands on either side
MFR is a manual technique that entails sustaining a very light of the forearm when the patient is wearing it; otherwise it is too
gentle pressure on soft tissue that in turn impacts the fascial tight. MEM massage pressure is one half the weight of the hand,
42 PART 1 Fundamentals

or no heavier than required to feel tissue moving over muscle. (See 2. When protocol allows, exercises are performed before and af-
Reduction Techniques for Chronic Edema and the Evolve website ter the MEM session; these exercises are done in a specific
for a detailed description of bandaging and chip bags.) sequence, starting proximal to the edematous area or in the
contralateral quadrant if possible.
3. Massage is performed in segments, proximal to distal, then
Manual Edema Mobilization distal to proximal. Massage ends in a proximal direction (that
is, toward the trunk).
As mentioned in treatment for acute edema, MEM is used to 4. When possible, the technique includes exercise of the muscles
reduce persistent subacute edema where proteins are congested in the segment just massaged.
and trapped in the interstitium because of extensive tissue damage 5. Massage follows the flow of lymphatic pathways.
to lymphatic structures, fibrotic scarring, and so on. The tech- 6. Massage reroutes around scar areas.
nique reduces both visible and not yet visible edema when there is 7. The method of massage and the types of exercise do not cause
congestion of a normal, intact, but overloaded, lymphatic system. further inflammation of the involved tissue.
MEM is a modification of MLT techniques used for lymph- 8. A client home self-massage program is devised that is specific
adenectomy and/or lymph node irradiation, primary (congeni- to the pathologic condition of the hand.
tal) lymphedema, and lymphedema arising from filariasis. For 9. MEM can be adapted to various diagnoses and stages of high
those types of edemas, MLT very appropriately involves extensive plasma protein edema.
rerouting of lymph flow around missing or permanently damaged 10. Guidelines are included for incorporating traditional edema
nodes and lymphatic vessel areas. control, soft tissue mobilization, and strengthening exercises
I developed MEM after I became certified in lymphedema without increasing edema.
treatment and learned about the anatomic functioning of the lym- 11. Specific precautions are observed.
phatic system. As I studied lymphatic anatomy and physiology, 12. When necessary, low-stretch compression bandaging or other
I realized that the traditional treatments for upper extremity edema compression techniques are used.
could be improved if they were based on this knowledge. Specifi- 13. Pump point stimulation is used extensively.
cally, I realized that the subacute edema that I struggled to reduce 14. MEM is beneficial in clients whose lymphatic vessels are in-
in my surgical, trauma, and stroke clients with hand edema was a tact but overloaded from congestion.
lymphatic overloaded edema. In these cases, because the lymphatic
system, although overloaded, was still intact, extensive rerouting Contraindications
wasn’t necessary, just decongestion, starting at the trunk.
I first taught MEM in 1995, and it continues to evolve. Since The precautions and contraindications for MEM include those
then, three peer-reviewed studies (one case study, a single-subject that are common to most massage programs and others that
design study, and a randomized controlled study)32,33,34 have are specific to the movement of a large volume of fluid through
been published establishing the validity and showing outcomes of the system. Always consult a physician if you are concerned
use of the MEM technique. There are no research-based articles about the client’s current or past cardiac and/or pulmonary
for a “simple lymphatic” massage for subacute and chronic hand status. For instance, if an 80 mL volumetric difference exists
edema reduction. In other words, only MEM has been validated, between the client’s two extremities, inform the physician that
and randomly modifying MLD has not been validated. with MEM, that much fluid may be moved through the heart
MEM is a significant modification of MLT in several ways: and lungs. Ask whether this would compromise the client’s
(1) it involves only one or two trunk rerouting techniques; cardiac status.
(2) it requires exercise after each segment is massaged; (3) it has Therapists should not use MEM in the following
its own light hand massage patterns; (4) it includes scar rerout- circumstances:
ing patterns; (5) it relies heavily on client follow-through with a
self-management program; and (6) it incorporates pump point the technique.
stimulation, which is unique to MEM.
The full MEM program takes 30 minutes. The short version, may be increased; MEM should be performed proximal to the
consisting of trunk rerouting and pump point stimulation, takes inflammation to reduce the amount of congested fluid.
15 minutes. MEM can be combined with other edema reduction
techniques, but it should be done before those techniques are per- clot may be activated (that is, it may move).
formed. The reason for this is simple: MEM decongests the most
proximal edema and moves that edema proximally, creating a space potential for spreading cancerous cells. MEM should abso-
into which the more distal edema can move by means of a proximal lutely never be done if the cancer is not being medically treated.
negative pressure vacuum. The more traditional edema reduction The therapist should always seek the physician’s advice.
techniques will be more effective after MEM, because then there is -
a space cleared to which the edema can be moved proximally. lems, or pulmonary problems, because the cardiac and pulmo-
nary systems may be overloaded.
Principles and Concepts
(rationale explained previously).
MEM is grounded in the following principles and concepts:35
1. Light massage is provided, ranging from 10 to 20 mm Hg, to the edema in these cases is a low-protein edema, and the renal
prevent collapse of the lymphatic pathways and arterial capil- system may be overloaded and/or the fluid may be moved to
lary reflux. some other undesirable site.
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 43

-
ing from a mastectomy. Successful treatment of this condition
requires knowledge of ways to reroute lymph to other parts of
the body, as well as specific techniques beyond the scope of this
chapter.

Manual Edema Mobilization Massage, Drainage,

and Definitions
U’s Hand Movement Pattern
U’s are a pattern of hand movement that involves placing a flat,
but relaxed, hand lightly on the skin. The hand gently tractions
(pulls) the skin slightly distal and then circles back up and around,
ending in the direction of the lymph flow pattern. The movement
is consistently a clockwise or counterclockwise motion in a U, or
teardrop configuration. Very light pressure (10 mm Hg or less) is
used to move just the skin, thereby stimulating the initial lymphat-
ics. Clinically, this is taught by having the therapist first place the
full weight of the hand on the client’s arm; then, while the entire
palm and the digits remain in contact with the client’s skin, the
hand is partly lifted so that only half of its weight rests on the arm. FIGURE 3-4 Forearm: Clear A, B, C. Flow C, B, A. (From Mackin EJ,
MEM massage proceeds at this very light pressure, moving in a U et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis,
while tractioning (pulling), not sliding, the skin. This is a “skin” 2002, Mosby.)
massage—just enough pressure to feel the skin move over muscles.

Clearing U’s Skin Tractioning Pattern Summary of Reduction Treatment for

Subacute Edema
Clearing U’s is a pattern of skin tractioning (pulling) performed
in segments. It starts proximally and moves to the designated dis-
tal part of the trunk or arm segment (that is, upper arm, fore- stretches, trunk exercises, easy (appropriate) yoga trunk
arm, or hand). A minimum of five U’s are done in three sections stretches
for each segment. The purpose is to create interstitial pressure
changes that cause the initial lymphatics to take up lymph.

Flowing U’s Lymph Movement Pattern

Flowing U’s is a pattern of sequential U’s that starts in the distal which can cause re-inflammation of tissue)
part of the segment being treated and moves proximally past the
nearest set of lymph nodes. This could be described as “waltzing” finger wrap bandages; Coban wraps
up the arm. The process of moving one U after another from
distal to beyond the proximal node is repeated five times. After or less)
the final repetition is completed, the flowing U motion is per-
formed all the way to the contralateral upper quadrant. The pur-
pose is to move the softened lymph out of the entire segment and
facilitate its eventual return to the venous system and the heart the hand is used. Typically the therapist does 20 to 30 Us in one
(Fig. 3-4). In other words, the direction of “flow” follows the area before proceeding to the next area of pump points. After
lymphatic pathways toward the heart (that is, flowing proximally, pump point stimulation is performed in an area, MEM flow is
not distally). If not contraindicated by the diagnostic protocol, done followed by exercise either in that area or proximal to it (see
active muscle contraction is done in each segment after “flow.” the Evolve website)
This increases the rate of lymphangion contraction, which moves Therapists should not attempt MEM unless they have been
the lymph out of the area more quickly. trained in the technique. One- and two-day courses are available
and required for any therapist who would like to use MEM as a
Pump Point Stimulation treatment.

Pump point stimulation involves simultaneous, synchronous Clinical Pearl

movement of the therapist’s two hands in a U pattern over areas
Starting proximal at the trunk is the key to lymphatic decon-
of lymphatic bundles (groups of initial and collector lymphat-
gestion; this is the first technique that must be done so that
ics), watershed areas, and/or lymph nodes.35 Because nodes pose
the other edema reduction techniques are effective.
resistance to the flow of lymph, pressure from the full weight of
44 PART 1 Fundamentals

Reduction Techniques for Chronic Edema A small stockinette or powder can be put on the wrap once it is
on the finger so that the wrapped fingers do not stick together.
Chronic edema is persistent edema that lasts longer than 3 months
and is indurated (hard) and difficult to pit.35 As a result of the Clinical Pearl
long-term entrapment of plasma proteins in the interstitium, the
tissue becomes fibrotic. In part, treatment is the same as for sub- For chip bags, self-adherent wrap, or low-stretch bandaging to
acute edema, but it includes softening of the fibrotic tissue to be successful, proximal MEM, or at least pump point stimula-
facilitate uptake by the initial lymphatics. Softening of indurated tion (discussed earlier in the chapter), must be done first to de-
tissue can be accomplished with low-stretch bandaging, chip bags congest the lymph (“pull the drain plug”) and move it proximal.
(convoluted foam pieces of different densities placed in a stocki-
nette bag), foam-lined orthoses, silicone gel sheets, and elastomer
pads (see the Evolve website). Neutral warmth builds up under Summary of Reduction Treatment for
these inserts, causing an enzymatic reaction that softens the indu-
Chronic Edema
rated tissue. The varying densities of the foam chips in a chip bag
can result in tissue pressure differentiation, stimulating protein
uptake.

Low-Stretch Bandaging hardening or already hard), including chip bags, convo-

luted foam in stockinette, elastomer and elastomer-type
Low-stretch bandages are cotton, nonelastic bandages that have a products, silicone gel sheets, foam-lined orthoses low-
20% stretch because of the weave of the bandage. These bandages stretch bandages, cotton finger wraps, and loose elastic
are rolled on rather than stretched on. When a muscle contracts, stockinette and/or gloves (see the Evolve website).
it bulks up under the bandages. Because the bandages stretch only
20%, they provide a light counterforce, which is not enough to
collapse the initial lymphatics. When the muscle relaxes, the ban-
dages only collapse 20%, again not enough to collapse the initial Other Types of Edema and Appropriate
lymphatics. Thus variation in tissue pressure facilitates lym- Treatment
phatic uptake and prevents refilling of stretched tissue. Research
has shown that use of a combination of low-stretch and foam Lymphedema
bandages on the forearm, along with exercise, increases protein
uptake.36 (See the Evolve website for more information on low- Lymphedema is a chronic, high-protein edema that results when
stretch bandaging.) a permanent mechanical obstruction of the lymphatic system
Low-stretch finger wraps also soften lymph and facilitate lym- creates a lymphatic overload.37 Permanent obstruction can be
phatic absorption (see the Evolve website). These are often used caused by surgical removal of the lymph nodes, irradiation of the
when a client’s hand is so edematous that it does not fit into an nodes or skin, filariasis (an infestation of worms that destroys
elastic glove. Low-stretch finger wraps are not used to squeeze the the lymph nodes), or a congenital deficit of the lymph nodes and
edema out, because that would collapse the delicate lymphatic lymphatic vessels. Clients with lymphedema must be treated with
structures. The distal-to-proximal spiral pattern in which the a full MLT program performed by a trained and credentialed
wraps are applied, the neutral warmth maintained by the finger therapist. Treatment includes multiple rerouting of lymphatic
bandages, and the effect of finger movement all soften the indu- flow patterns around deficit areas. MEM is not appropriate for
rated tissue, improving lymphatic flow and edema reduction. these clients.
Precaution. MEM is a treatment for clients with an overloaded
Chip Bags but intact lymphatic system.
Therapists working with hand clients may see a perma-
Chip bags vary in size, depending on the area they are to cover. nent deficit of the lymphatic system, resulting in persistent,
They consist of stockinette bags filled with various densities and sustained swelling. This is seen with circumferential scars, as
sizes of foam. The ends of the bag are either taped or sewn closed. with a replanted digit. It may also occur with circumferential
Chip bags can be worn under low-stretch bandages, loose elas- skin grafting. Primary (congenital) or secondary lymphedema
tic gloves, or orthoses (see the Evolve website). Various types of (for example, from the removal of diseased nodes) causes lym-
commercially-fabricated chip bags made of foam or wheat hulls phatic congestion (slow outflow of lymph) in the subcutaneous,
are also available for purchase. epifascial tissue space38 which means that only the superficial
lymphatic vessels are affected. Therefore a client whose fingers
Self-Adherent Wrap are edematous as a result of this type of lymphedema does not
develop joint contractures (Fig. 3-5). If surgical or traumatic
Coban or similar self-adherent wrap material is used by many invasion (that is, laceration) into the deeper lymphatic structures
therapists on edematous fingers. When placed on the finger around joints has occurred, joint contractures may develop.
or digit circumferentially, it creates a squeezing effect, pushing Soft tissue contractures are caused by laceration of superficial
fluid distal or proximal, or both. Lightly overlapping spirals of and deep lymphatic capillaries, high capillary permeability that
self-adherent wrap distal to proximal down a digit facilitates the causes leakage of plasma proteins, and prolonged congestion of
absorption and movement of fluid proximally (see the Evolve plasma proteins around these joint and tendon structures leading
website). This wrap also creates a buildup of neutral warmth. to fibrosis.
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 45

Precaution. MEM and many of the edema-reduction tech-

niques are contraindicated for clients with cardiac edema, because
movement of more fluid can further overload the already compro-
mised cardiac system.

Low-Protein Edema
Low-protein edema can manifest as extremity swelling caused
by liver disease, malnutrition, or kidney failure (for example,
nephrotic syndrome).1,5 Edema results because too few plasma
proteins are present in the interstitium to bond with the water
molecule and bring fluid back into the vascular systems.
Precaution. Low-protein edema has a systemic cause and must
be treated with medication. MEM and many of the edema reduction
techniques are contraindicated because they may overload the kidneys
or liver. Also, even if these edema control techniques are used, this
type of edema will return because of its systemic cause.

Evaluation of Edematous Tissue

Edema reduces ROM both actively and passively because it increases
the size of the fingers or hand. This, in turn, can reduce functional
use and coordination of the hand. Once the edema has been reduced,
if decreased ROM persists, the therapist can effectively evaluate and
treat joint and/or soft tissue limitations. The sooner the edema is
FIGURE 3-5 Lymphedema of the hand with no loss of mobility. reduced, the less the buildup of plasma proteins in soft tissue, the
less the fibrosis of the tissue, and the less the thickening of scar tissue.
Complex or Combined Edema Precaution. Reducing edema does not reverse existing joint
contractures.
Complex or combined edema is initially a transudate edema, By taking circumferential measurements, the therapist can
such as acute flaccid stroke hand edema. With flaccidity, no determine where on the hand specifically the edema is prevalent.
muscle pump facilitates vascular flow, and water and electrolytes For consistency, always use the same measuring device; also, take
leak into the interstitium, resulting in a transudate edema. The measurements at the same time of day and after the same amount
treatment is the same as for acute edema. During this phase, of hand activity.
night orthoses might be considered to prevent shortening of the Edema rebound tests (see Chapter 5) can help determine
extensor tendons. Three months later, the edema may have a whether treatment has reduced some of the viscous congested
viscous feel, but it is relatively fast to rebound, and it does not edema. For instance, if the edema rebound time was 65 seconds
significantly or permanently reduce with elevation and/or the use before treatment and 40 seconds after treatment, this indicates
of an elastic glove. The edema now has an exudate component. that lymph was moved out. To make this subjective test more
At this point, the lymphatic system, which initially was aiding in consistent, devise a protocol for how much pressure is used and
the removal of the excess fluid (transudate edema), has reached its for how long it is applied.
maximum capacity. The lymphatic system is overloaded and has Volumeters have been shown to provide reliable, valid edema
slowed down, resulting in lymphatic congestion. The congested measurements.39 These measurements indicate whether volume
plasma protein content of the fluid makes the edema feel viscous. reduction has occurred; they do not specify the location of the
The treatment is the same as for subacute and chronic edema. reduction.
Often an orthotic program is needed to prevent or overcome The criteria for tissue quality assessment, another evaluation
joint contractures. method, are as follows:
Precaution. Overexercising or forcing joints in a flaccid or Acute edema: Tissue pits deeply, rebounds rather quickly, and
hemiparetic hand can cause microscopic rupture of tissue, resulting in can be easily moved around.
inflammation and increased hand edema. Therefore a balance must Subacute edema or early stage chronic edema: Tissue pits, is very
be attained between gentle, progressive motion and rest of structures. slow to rebound, and has a viscous quality.
Chronic edema: Tissue pits minimally and has a hard feeling.
Cardiac Edema Severe edema: Tissue has no elasticity and is shiny, taut, and
cannot be lifted.
Cardiac edema occurs with a decline in the heart’s ability to Lymphorrhea: Weeping of tissue occurs with an extremely con-
pump blood completely through the circulatory system. As a gested edematous hand or arm. Lymph, a clear, yellowish fluid,
result, fluid accumulates in the extremities, especially around the escapes from the interstitium to the outside of the skin. Tech-
ankles. Often cardiac edema manifests as bilateral ankle swelling nically, weeping tissue is considered an open wound and must
with a slight pinkish tone to the tissue. Hand therapists treating be treated as such. MEM techniques can rapidly decongest the
older adults need to look for this type of edema. lymph and stop the lymphorrhea.
46 PART 1 Fundamentals

Note: Always perform the capillary refill test if the client’s hand
CASE STUDY
has a bulky dressing or if the client is wearing finger bandages.
Precaution. Color, temperature, and sensory changes may be
signs of a problem. A purple color often indicates pooling of venous CASE STUDY 31 ■
blood, and a whitish color means that arterial blood flow to the tissue
is compromised. Immediately notify the physician of these signs. Marlene is a 58-year-old white woman from Texas who sustained a
right complex distal radius fracture, abrasions and facial fractures,
Clinical Pearl plus bruising to her right shoulder when she slipped off a chair hit-
ting her granite countertop as she climbed down from cleaning
Macrophages are less effective in edematous tissue because it
overhead light fixtures. An orthopedic surgeon and plastic surgeon
has less oxygen; phagocytic activity therefore is diminished.4
saw her in the emergency room and appropriate surgery was per-
formed on all fractures during the next week. The complex distal ra-
The therapist must be able to distinguish between congestion dius fracture was treated with open reduction and internal fixation
and infection. With an open wound, the classic signs of infec- (ORIF), casting for 4 weeks, and then a soft wrist brace for 2 weeks.
tion are redness, warmth, pain to the touch, odor, and/or cloudy At 6 weeks, Marlene saw a hand therapist for the first time. The
drainage. With a closed wound, the signs of a subclinical infec- therapist gave her the standard forearm, wrist, and hand active range
tion are a pinkish red color and slight warmth; also, the wound of motion (AROM) exercises plus an elastic edema glove. Marlene ex-
may be painful to the touch and the tissue may be hard.40 This plained they were leaving for Colorado for the summer in 2 days and
is often seen with a very edematous extremity or hand if the first would continue hand therapy there. It was another week before Mar-
course of antibiotics hasn’t fully resolved the infection. Extremely lene saw me for treatment in Colorado. An assessment revealed in part:
edematous hands often need a second course of antibiotics as significant decreased and painful shoulder ROM; forearm supination of
determined by the treating physician. 40 degrees and pronation 50 degrees; both wrist flexion and extension
Precaution. If infection is suspected, MEM should not be started 20 degrees; radial deviation 10 degrees and ulnar deviation 5 degrees;
before a full course of antibiotics has been completed and the physi- active composite finger/thumb ROM was 25% of normal range and
cian has assessed the status of the infection. passive 50% of normal range. Forearm through fingers were extremely
The signs of congestion frequently are the same as those of edematous with a total of 3½ inches greater than the circumference of
a subclinical infection. The client’s history can help determine the uninvolved left forearm/fingers. Sensation was impaired one grade
whether the condition is congestion or infection (or both). Often overall in all fingers. The patient was extremely anxious about moving
congestion (and, possibly, infection) can be prevented if the ther- her dominant right upper extremity and guarded it.
apist begins treatment of an uninfected extremity early, before Problem: I had only three visits that week to treat Marlene before
visible edema is present, with the short version of MEM. Pro- going away for a week.
longed tissue congestion can lead to infection because congestion Thus treatment priorities had to be determined for hand therapy
reduces oxygen delivery to tissue, diminishing the effectiveness of including that the patient needed to be competent with a home
the phagocytic cells. edema reduction and exercise program, patient psychological fears
Both old and new scars can create a barrier to lymph flow. needed to be addressed, and she needed to be beginning to func-
Check for proximal scars (for example, on the shoulder, back, tionally use her right upper extremity. I requested physical therapy
or axilla). Soften both old and new scars with gentle MFR tech- (PT) for shoulder issues so that I had adequate time to address the
niques, silicone gel sheets, paper tape, and/or elastic taping. hand deficit areas.
Instruct the client in MEM techniques to reroute edema around After the evaluation, she was shown how to apply heat packs to
scars and to soften scars. her shoulder and perform traditional Codman’s shoulder exercises to
Sensory testing is very important for an edematous extremity do until her PT visit. Knowing protein-rich, subacute edema is “glue”
because edema often reduces sensation. As edema is reduced, the causing pain and decreased ROM, my first priority became to reduce
degree of sensation usually improves. Sensory testing, therefore, the edema. I did the basic short MEM home program (Fig 3-6). Note
becomes an objective test that shows limitations and improve- that MEM and exercises are begun at the trunk and shoulder to re-
ments that can be related to function. duce hand edema. For Marlene if MEM was just started at the elbow,
Coordination often is diminished by edema in the hand. the distal edema would have had no proximal lymphatic space for
A nine-hole peg test can become a repeated, scheduled test for congested forearm edema to move into and out of the area. Also,
assessing hand function. Reducing hand edema should improve the shoulder exercises as part of the MEM treatment facilitate prox-
coordination, unless an underlying problem exists. imal muscle pumping of the lymphatic system. I chose to do the
Pain assessment is very important. As edema declines, pain MEM home program on the patient rather than a full therapist treat-
usually diminishes. Clinically, pain reduction often is noticed ment, because I could teach the patient her home program while
before ROM shows improvement. Keep in mind that pain can I was doing it. It was imperative for her to follow through three to
have many sources. For example, in a client with a Colles fracture, five times a day. This also got her used to using and touching the
edema reduction can relieve the pain caused by the pressure of right upper extremity. The AROM program previously given to Mar-
edema on the nerve receptors; however, the client still may have lene was reviewed and incorporated into her daily routine. I loaned
chronic pain specifically related to the fracture site. Therefore Marlene a 3½ inch ball to use for wrist/arm ROM exercises (see the
other, appropriate methods must be used to reduce that pain, Evolve website).
which differs from edema-related pain. Even during treatment During the first treatment visit, we reviewed her MEM program
for a different cause of pain, the client should follow a MEM that she had done two of the five recommended times a day. I took
home program twice daily to eliminate any new, not yet visible 30 minutes and did the entire therapist version of MEM to her right
congested edema. upper extremity and reduced the hand edema by 50%. Marlene
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 47

was excited to see the edema reduction, plus her pain reduced session with a slight edema reduction noted. I performed MFR and
from 6/10 at rest to 3/10 at rest. She also had a slight increase in joint mobilization. This session began with the use of mirror therapy
active and passive ROM. During the last 15 minutes of the MEM to improve her hand/wrist ROM exercises and improve patterns of
treatment, I placed her forearm/hand between two hot packs in composite and spontaneous movement. Marlene was instructed in
an effort to facilitate induration softening and elongation of tis- a simple mirror therapy home program to do two times daily. Her
sue to increase ROM. I added a 6 oz weight hammer for supina- colored pencils were also built up for easier gripping, and I encour-
tion/pronation exercises and wrist flexion/extension to her home aged her to do sketching activities.
program. She was also given sponges to carry around to do fin- While I was on vacation, Marlene continued her home pro-
ger/wrist exercises multiple times a day. The use of a heat pack for gram but apprehension on her and her husband’s part limited
10 minutes four times a day was encouraged along with continu- the frequency. There was neither further loss nor gain in edema.
ing the ball exercises, which she like to do because “it makes my The remaining 25% of the increased edematous girth compared
wrist and arm feel good.” to the uninvolved extremity was reduced by my treatment in two
During the second treatment visit, Marlene was in full compli- subsequent 15 minute MEM sessions. More vigorous progressive
ance with her home program because she experienced decreased strengthening exercises were started after the edema reduced (If
pain and had started to use her hand for assistive light tasks, such started too soon and vigorously, this will cause an inflammatory
as folding clothes and dusting. MEM was again 30 minutes as noted response and increased edema.) and her upper extremity ROM
above with the hot pack placed 15 minutes on hand/forearm indu- started to significantly increase. It took a few more sessions for Mar-
rated tissue. Edema was reduced about 15% further. This was fol- lene to lose her apprehension of using the right hand, and then she
lowed up by forearm/wrist MFR, grade one wrist joint mobilization, began again doing and enjoying her volunteer activity at a thrift
and instruction in scar massage. The forearm and wrist were elastic store sorting and marking. She also felt she could safely enjoy long
taped for edema reduction. Marlene loved to do color pencil sketch- mountain hikes again.
ing. She was asked to bring her tools to the next session. Post note: Ideally I would have preferred seeing Marlene for treat-
During the third treatment visit, Marlene continued to be com- ment the first week post casting for a shoulder ROM program and an
pliant with MEM and the exercise part of her home program, but edema or preventative edema reduction program. If there were no
she still was apprehensive about using her right upper extremity for complications (such as, blood clots or other MEM contraindications),
routine light activities of daily living (ADLs), and so on. Between visits, then I would have begun shoulder/elbow ROM, dealt with patient
the patient’s hand edema had reduced another 10%. MEM with the psychological apprehension and ADL issues, and started a MEM
usage of the hot pack was only 15 minutes during this treatment home program addressing trunk to cast.
48 PART 1 Fundamentals

Breathing - 2 Diaphragmatic Axillary - 1 One at a Time

Inhale through nose making navel move out towards hands.

Exhale through puckered lips, hands follow navel in.
Using full weight of flat hand with flat fingers at center
Repeat ______
3 times. Rest ______
10 seconds between repeats. of uninvolved armpit, make ______
20 in-place circles.
5
Do ______ times per day. 5
Repeat at involved armpit. Do ______ times per day.

Shoulder - 5 Chicken Wings Arm/Hand - 2 Elbows: Cubital Crease Nodes

Palm across involved

elbow’s crease, pressing
slightly harder on inside of
20 in-place
elbow make ______
circles.

With thumbs in armpits and elbows at sides, lift elbows

toward ears then lower to sides. 2
Repeat ______ times.
5
Repeat ______ 5 times per day.
times. Do _____ 5
Do ______ times per day.

Arm/Hand - 4 Arm Anterior Elbow to Should ñ Sweep Shoulder - 1 Roll

On involved arm, sweep Inhale and bring

20 times from elbow
______ shoulders up, back,
crease over biceps, to then exhale and
top of shoulder. relax shoulders
down.

5
Repeat ______ times.
5
Do ______ times per day. 5
Do ______ times per day.

FIGURE 3-6 Marlene’s manual edema mobilization (MEM) home program. (From Visual Health Information
(VHI) kits, used with permission.)
 Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 49

Arm/Hand - 6 Arm: Volar Elbow to Wrist ñ Clear Arm/Hand - 7 Arm: Volnar Wrist to Elbow ñ Sweep

Involved hand palm side up, 20 times from

Sweep _____
make _____
10 in-place circles involved arm wrist crease
at elbow crease proceeding to elbow crease.
in sections to wrist.

Repeat ______
2 times.
5
Do ______ times per day. 5
Do ______ times per day

Wrist/Finger - 3 Wrist: Curl to Shoulder Arm/Hand - 3 Hand: Dorsum of Hand to Axilla Sweep

Involved palm down, fingers in web spaces, sweep

Palm side of arm up, bend wrist toward elbow, bend elbow ______
10 times over top of hand and forearm, back of
so hand rest on shoulder. upper arm, shoulder, chest front to uninvolved armpit.
5 times. Do _____
Repeat _____ 5 times per day. 5 times per day.
Do _____

Arm/Elbow - 1 Upper Arm: Make Fist Overhead

With involved arm

above head and straight,
open and close hand
5 times.
_____

2
Repeat ______ times.
5
Do ______ times per day.

FIGURE 3-6, cont’d

50 PART 1 Fundamentals

References
1. Guyton A, Hall J: Textbook of medical physiology, ed 9, Philadelphia, 22. Ozkan N, et al: Investigation of the supplementary effect of GaAs laser
1996, WB Saunders. therapy on the rehabilitation of human digital flexor tendons, J Clin Laser
2. Hole JW: Human anatomy and physiology, ed 4, Dubuque, IA, 1987, Med Surg 22:105–110, 2004.
William C Brown. 23. Snyder AR, et al: The influence of high voltage electrical stimulation on
3. Kubik S: Anatomy of the lymphatic system. In Foldi M, Foldi E, Kubik S, edema formation after acute injury: a systematic review, J Sport Rehabil
editors: Textbook of lymphology for physicians and lymphedema therapists, 19:436–451, 2010.
Munich, 2003, Urban & Fischer Verlag. 24. Griffin JW, Newsome LS, Stralka SW, et al: Reduction of chronic post-
4. Casley-Smith JR: Modern treatment for lymphedema, ed 5, Adelaide, traumatic hand edema: a comparison of high voltage pulsed current,
1997, The Lymphoedema Association of Australia. intermittent pneumatic compression and placebo treatments, Phys Ther
5. Chikly B: Silent waves: theory and practice of lymph drainage therapy with 70(5):279–286, 1990.
applications for lymphedema, chronic pain, and inflammation, Scottsdale, 25. Stralka S, Jackson J, Lewis A: Treatment of hand and wrist pain,
AZ, 2001, International Health & Healing Publishing. AAOHN J 46(5):233–236, 1998.
6. Pecking A, et al: Indirect lymphoscintigraphy in patients with limb 26. Grieveson S: Intermittent pneumatic compression pump settings for the
edema: progress in lymphology, Proceedings of the Ninth International optimum reduction of oedema, J Tissue Viability 13(3):98–100, 2003.
Congress of Lymphology201–296, 1985. 27. Segers P, et al: Excessive pressure in multichambered cuffs used for
7. Bryant WM: Wound healing, Clin Symp 29(3):1–36, 1977. sequential compression therapy, Phys Ther 82:1000–1008, 2002.
8. Reed BV: Effect of high voltage pulsed electrical stimulation on microvas- 28. Adams K, et al: Direct evidence of lymphatic function improvement
cular permeability to plasma proteins, Phys Ther 68(4):491–496, 1988. after advanced pneumatic compression device treatment of lymphedema,
9. Snyder AR, Perotti AL, Lam KC, et al: The influence of high voltage Biomed Opt Express 1:114–125, 2010.
electrical stimulation on edema formation after acute injury: a systematic 29. Giudice M: Effects of continuous passive motion and elevation on hand
review,, J Sport Rehabil 19:436–451, 2010. edema, Am J Occup Ther 44:10, 1990.
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revascularization of the hand. In Hunter JM, Schneider LH, Mackin EJ, pressure manual massage? Lymphology 28(1):21–30, 1995.
et al: Rehabilitation of the hand: surgery and therapy, ed 4, St Louis, 1995, 32. Roenhoej KK, Maribo T: A randomized clinical controlled study
Mosby. comparing the effect of modified manual edema mobilization treatment
12. Lievens P, Leduc A: Cryotherapy and sports, Int J Sports Med with traditional edema technique in patients with a fracture of the distal
5(Supplement):37–39, 1984. radius, J Hand Ther 24:184–193, 2011.
13. Villeco JP, Mackin EJ, Hunter JM: Edema: therapist’s management. 33. Priganc V, Ito M: Changes in edema, pain, or range of motion following
In Mackin EJ, et al: Rehabilitation of the hand and upper extremity, ed 5, manual edema mobilization: a single-case design study, J Hand Ther
St Louis, 2002, Mosby. 21:326–333, 2008.
14. Kase K, Stockheimer KR: Kinesio taping for lymphoedema and chronic 34. Howard SB, Krishnagiri S: The use of manual edema mobilization
swelling, Albuquerque, NM, 2006, Kinesio USA. for the reduction of persistent edema in the upper limb, J Hand Ther
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clinical trial, Arch Phys Med Rehabil 79:1415–1420, 1998.
 4 Tissue-Specific Exercises
for the Upper Extremity
Lori Falkel

T
issue-specific exercise progressions can be thought of as the science of prescribing
an accurate dosage of exercise. Tissue-specific exercise allows us to use our knowl-
edge of exercise physiology to address the specific pathologic tissue conditions.
When physicians prescribe medicine, they do not arbitrarily select a medication from the
pharmacy and administer it. They prescribe medicine based on the pathologic condition.
With proper knowledge, exercise is the therapist’s area of expertise. For optimal
outcomes, exercise dosage must not be assigned arbitrarily; it should be dosed accu-
rately according to the physiology of the tissue(s) involved. When designing an exercise
program effectively to promote the recovery of the target tissue, the therapist needs to
consider multiple variables. Some of these variables are the appropriate resistance; the
repetitions and sets that will promote the desired response; the speed, frequency, breaks,
and duration of exercise; the appropriate positioning of the limb and/or client; and the
precise range of motion. Proper exercise equipment, to provide support, can be critical
for restoration of physiologic motion. The types of muscle work (for example, concentric,
eccentric, and isometric) are also important considerations.
The Ola Grimsby Institute developed Scientific Therapeutic Exercise Progressions
(STEP), which is a concept of dosing exercises according to the specific pathologic condi-
tion and tissue tolerance of each client. STEP is based on principles of medical exercise
therapy. It was developed in Norway and has been practiced throughout Europe for many
years with excellent results. STEP addresses musculoskeletal dysfunctions with respect to
their histologic, biomechanical, and neurophysiologic significance.*

Joint Dysfunction
Joint dysfunction occurs because of a compromise in connective tissue integrity. This
may result from capsular, ligamentous, or cartilaginous causes. In cartilage, symptoms
of joint dysfunction present as an inability to withstand compressive forces. If the joint
dysfunction is capsular, joint swelling will be present. A ligamentous injury has point ten-
derness. The end result is altered mobility. Joint dysfunction can be labeled as a hypomo-
bility, a hypermobility, or an instability. A joint is considered to be hypomobile when
movement takes place about a physiologic axis but is less than normal. A hypermobile
joint has greater than normal motion around a physiologic axis. Joint instability is motion
around a nonphysiologic axis.1 All synovial joints can be categorized by a joint mobility
grading system1 (Table 4-1).

Musculoskeletal Dysfunctions
The two main causes of musculoskeletal dysfunctions are acute trauma and cumulative
trauma. Acute trauma is associated with an excessive contraction (muscle strain) or an
externally applied force. Chronic overload, or cumulative trauma, is associated with pro-
longed static work, stress, and often reduced aerobic activity.

Clinical Pearl
A large percentage of clients who have cumulative trauma injuries are deconditioned
because of a fairly sedentary job or lifestyle.

* The Ola Grimsby Institute offers courses on a range of subjects pertaining to exercise and physical therapy if more
information is needed.
52 PART 1 Fundamentals

TABLE 4-1 Joint Mobility Grading Scale BOX 4-1 Traits That Have Been Shown to Increase
Grade Joint Mobility Treatment Risk for Fractures
0 Ankylosed Surgery/no mobilization treatment
Slender build
1 Considerable Articulation/ avoid exercise and Fair skin
limitation manipulation Family history of osteoporosis or osteoporotic fracture
2 Slight limitation Joint mobilization/self-mobilization Small muscle mass
3 Normal No treatment needed Sedentary lifestyle
Small peak adult bone mass (approximately age 35)
4 Slight increase Postural correction/ADLs and ANLs/ Low calcium intake
check for hypomobility/taping/self-
stabilization Cigarette smoking
Excessive consumption of protein, sodium, and alcohol
5 Considerable Postural correction/bracing/taping/
One or more osteoporotic fracture(s)
increase self-stabilization/ADL and NDL/
check for hypomobility/dry nee- A situation that increases the likelihood of falling (that is,
dling/sclerosing injections wet floor, throw rugs, or small pets)
6 Pathologically Surgery/no mobilization treatment
unstable
ADLs, Activities of daily living BOX 4-2 Common Age-Related Changes
Affecting Bone Loss
Comorbidities Associated with Increased Prevalence
of Musculoskeletal Dysfunction Gradual increase in parathyroid hormone secretion as a result
of chronic calcium deficiency
The vast majority of clients who present for treatment in a hand
clinic do not have only a hand injury. The therapist must be Decreased intestinal absorption of elemental calcium
aware of the client’s comorbidities and provide comprehensive Lower circulating calcitonin
treatment that addresses the client as a whole, rather than just an Decreased sunlight exposure and dietary vitamin D intake
extremity. Some of the more common diseases that are associated Decreased ovarian function causing altered estrogen balance
with lowered tolerance of the musculoskeletal system are diabetes,
hypothyroidism/hyperthyroidism, gastric ulcer, chronic/recurrent
infections, colitis, and cardiovascular and respiratory diseases. Exercise Considerations
Diabetes causes the production and use of insulin in the body
to be impaired. This results in an abundance of sugar in the blood- Always use caution and discretion when prescribing the inten-
stream. With diabetes, the pancreas secretes little or no insulin (type sity of exercise. A thorough evaluation provides the necessary
I diabetes) or the body becomes resistant to the action of insulin information regarding cardiovascular compromise or risk fac-
(type II diabetes). If the disease is not treated, the level of sugar tors, pulmonary disease, diabetes mellitus, hypertension, obesity,
in the bloodstream builds up and leads to diabetic complications. peripheral vascular disease, arthritis, and renal disease.5
The thyroid gland affects all aspects of metabolism. The thy- Precaution. An exercise program may not be recommended for
roid releases hormones that regulate heart rate, the strength of uncontrolled diabetes. A rigorous strengthening or aerobic exercise
bones, how quickly calories are burned, and sensitivity to heat/ program, in this case, may cause a hyperglycemic effect because cel-
cold. If the thyroid gland is underactive or overactive (hypo- lular absorption of glucose is restricted. Insulin-dependent diabetic
thyroidism/hyperthyroidism), medical treatment is necessary to clients may need to decrease insulin or increase carbohydrate intake
avoid complications.2 when exercising. They should monitor their glucose more frequently
A gastric ulcer is an open sore that develops in the lining of when starting an exercise program. For this client population, the
the stomach. The ulcer may result from diet, stress, medication, exercise should be dosed at a lower level of intensity and duration
or bacterial infection. initially and should progress at a much slower rate.2
Infections can occur when the immune system is suppressed
or comes in contact with an organism to which it does not have
resistance. Bones and joints become susceptible to chronic infec- Osteoporosis
tions that originate elsewhere in the body and are passed to them
via the bloodstream.3 An estimated 30 million Americans have osteoporosis. This dis-
Colitis is a painful and debilitating chronic inflammation ease is responsible for 1.5 million individuals sustaining bone
of the digestive tract.4 Symptoms include bloating, cramping, fractures per year (200,000 wrist fractures, 300,000 hip fractures,
abdominal pain, and loss of appetite. Cardiovascular and respira- and 300,000 non-wrist extremity fractures). Osteoporosis costs
tory disease includes any of a multitude of problems involving the more than $18 billion per year in health care expenses and lost
heart, lungs, and blood vessels. Some of these disease processes productivity. Bone mass attains a peak in males and females at
are preventable and are acquired over a lifetime; others are con- approximately 30 to 35 years of age, with total bone mass begin-
genital. Cardiovascular disease is more prevalent than all of the ning to decline 5 to 10 years later. Boxes 4-1 and 4-2 list traits
previously mentioned diseases combined.5,6 and age-related changes associated with osteoporosis.7,8
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 53

BOX 4-3 Some Considerations for Exercise BOX 4-4 Contraindicated Exercises for Advanced
Selection Osteoporosis

Vigorous aerobic workout

for bone stimulation. Exercises that require twisting or bending
Abdominal machines
of falls. Biceps-curl machines
Rowing machines
and repetitive.
Tennis
Golf
are less effective than walking.
Bowling

Males are less affected by osteoporosis than females. Males sufficient lighting, and use of handrails decrease the risk of a
usually ingest more calcium and have higher levels of calcito- fall or fracture.
nin. They also produce testosterone into the seventh and eighth Precaution. Avoid forceful, unguarded motions, such as opening
decades of life as opposed to the decline in hormone production a stuck window or bending forward to lift a heavy object. Instead,
that females experience with menopause in the fourth or fifth teach clients how to squat when lifting.
decade. The increased calcium and hormone levels reduce the
loss of bone mass, which in turn reduces the potential for devel-
opment of osteoporosis. Histology of Collagen, Bone, and Cartilage
Several factors can affect bone resorption levels. A lack of
weight bearing and of activity in antigravity muscles changes the Collagen
resorption rate, as does excessive thyroid and parathyroid hor-
mones. Corticosteroids also have an impact. Collagen is the fundamental component of the connective tis-
Determinants of bone mass and loss are genetic, mechanical, sues of the body, including fascia, fibrous cartilage, tendons, liga-
or hormonal. Genetics can cause large-boned individuals to gain ments, bones, joint capsules, blood vessels, adipose tissue, and
a relative immunity to osteoporotic fractures. The mechanics of dermis. Collagen is the most abundant protein in the human
bone density can aid in the prevention of fractures, but they also body. It accounts for approximately 30% of all protein. Before
can be a possible cause. Increasing loading yields lead to increased 1970, researchers believed that all collagen was identical. Now,
bone mass, and decreased loading yields lead to decreased bone nineteen types of collagen are known that are differentiated by
mass. their protein composition. Type I and type II together compose
approximately 90% of human connective tissue. Type III collagen
Exercise for Prevention/Treatment of Osteoporosis is produced first, in the initial reparative phase, before type I col-
lagen. Type III collagen also is found in arteries, the liver, and
Exercise can help prevent or slow down bone loss, improve pos- the spleen.8
ture, and increase overall fitness. For clients who are at risk of Type I collagen constitutes about 90% of total body collagen.
osteoporosis, a bone density test before beginning an exercise Type I collagen is found in bone, tendon, fascia, fibrous cartilage,
program is recommended. Box 4-3 lists factors to consider when derma, and sclera. This collagen is synthesized by fibroblasts,
selecting an exercise.7 osteoblasts, and chondroblasts. Its primary function is to resist
Although walking is the best of all of the options listed in tension.
Box 4-3, those clients who are unable to tolerate walking because Type II collagen is found in hyaline and elastic cartilage and
of comorbidities or advanced osteoporosis have other options. intervertebral disks. Type II collagen is synthesized by chondro-
These options provide benefit by generating muscle tension, blasts. Its primary function is to resist intermittent pressure.
which provides needed stress to bone. To prevent injury to those Fibroblasts produce type I collagen fibers that are found in
with advanced osteoporosis, clients absolutely should avoid the tendons, ligaments, and joint capsules. Procollagen, the precur-
exercises listed in Box 4-4. sor of collagen, is produced in the endoplasmic reticulum and is
made up of polypeptide chains of lysine, glycine, and proline.
Client Education for Osteoporosis Tropocollagen is the basic molecular unit of collagen fibrils and
is found in the interstitial spaces; this collagen is the building
Education of the client on what impact osteoporosis will have block of collagen. The bonds of procollagen and tropocollagen
on his or her life and what the client can do to prevent frac- are weak and easily deformed or ruptured. One must understand
tures or falls is important. Teach clients about proper body that collagen bonds are remodeled from mobilization or exercise.
mechanics by demonstrating proper posture. When teaching Fibroblasts also produce glycosaminoglycans. These are pro-
lifting and carrying techniques, show the client how to hold teoglycans, the fundamental components of connective tissue,
loads close to the body. Explain that strengthening exercises which make up the extracellular matrix of tendons, ligaments,
improve balance and decrease the risk of falling. Address fall and articular cartilage. Imbibition is the primary nutritional
prevention. Wearing of proper shoes, removal of throw rugs, source for avascular tissues, such as tendons, ligaments, cartilage,
54 PART 1 Fundamentals

and vertebral disks. When tension/pressure increase, fluid is Optimal Stimulus for Regeneration of Collagen,
forced out of tissue and the volume of the tissue decreases. This Bone, and Cartilage
causes an increase in the concentration of proteoglycan sub-
stances and an increase in osmotic pressure, which in turn pro- Collagen
duces imbibition. Glycosaminoglycans provide the fibers with
nutrition via imbibition and lubrication. They allow space for The optimal stimulus for fibroblastic function in the regenera-
elastic deformity of the tissue.8 The half-life of glycosaminogly- tion of collagen is modified tension along the line of stress. This
cans is 1.7 to 7 days. Immobilization for more than 1.7 to 7 days modified tension is not to exceed the level of tension that the
causes a 50% decrease in glycosaminoglycans. Therefore lubrica- newly formed polar bonds of tropocollagen can withstand. The
tion is decreased and the elastic range of collagen is decreased. tropocollagen is an immature precursor to the stronger, more
A decrease in glycosaminoglycans causes a decrease in nutrition, resilient collagen. Once a certain level of tension is exceeded, tis-
which damages the tissue. sue breakdown will occur instead of proliferation.
Precaution. If tension exceeds this critical level, the signs and
Bone symptoms will be pain, inflammatory reaction, muscle guard-
ing, decreased range of motion or loss of flexibility, and secondary
Bone is the protective and supportive framework that has rigid scarring.8
and static, elastic and dynamic properties. The properties and
geometry of bone can be altered in response to internal and exter- Bone
nal stress and also in response to mineral demands. Bone has
plastic qualities; it absorbs and stores compressional forces and The optimal stimulus for osteoblastic production in the regenera-
transmits tensile forces. Bone also has elastic qualities. Long bone tion of bone is modified compression in the line of stress. Wolff’s
can deform up to 5%. The ability of bone to deform decreases law states that bone will change its internal architecture according
with age. to the forces placed upon it.
Bone is composed of approximately 5% water and approxi- Precaution. Abnormal shear force may cause a pseudarthrosis.
mately 70% minerals (calcium hydroxyapatite, phosphate, Pseudarthrosis or “false joint” occurs at the site of nonunion.
magnesium, sodium, potassium, and fluoride carbonate); Osteophytes are bony outgrowths that develop as the body
approximately 20% organic compounds, mostly type I collagen; attempts to provide stability or to repair itself. Shearing force
and approximately 5% noncollagenous proteins. Osteoblasts stimulates undifferentiated mesenchymal cells to produce carti-
are the functional building blocks of the osteoid matrix; they lage, and a false joint may be created at the fracture site.9
are located only at the surface of bone tissue. Osteocytes are
mature osteoblasts. Osteoclasts are responsible for bone dis- Cartilage
solution and absorption. Bone homeostasis balances synthesis,
dissolution, and absorption with the forces that are applied on The optimal stimulus in the regeneration of cartilage is intermit-
the skeleton.9 tent compression/decompression with glide. Joint movement
(shear) is necessary to distribute synovial fluid over the cartilagi-
Cartilage nous surface and provide oxygen and other necessary nutrients.
Intermittent compression forces the extracellular fluid within
Cartilage is a semirigid connective tissue that is less dense and the joint to be compressed into the cartilage matrix. With joint
more elastic than bone. The functional unit of cartilage is the immobilization, an alteration in joint mechanics and a decrease
chondrocyte. Chondroblasts are immature chondrocytes, and in the normal contact areas of cartilage occur. This eventually
they produce the ground substance or extracellular matrix of leads to joint dysfunction, hypomobility or hypermobility, and
cartilage. This extracellular matrix consists of glycosaminoglycans muscle guarding.
and type II collagen. Water composes 65% to 80% of articu- Precaution. The body responds to the stresses placed upon it.
lar cartilage. Like fibroblasts, chondroblasts synthesize collagen With abnormal stresses, there will be dysfunctional remodeling.
and glycosaminoglycans when stimulated by mechanical tension. This manifests as joint degeneration, osteophytes, bone spurs, or
Mature cartilage is avascular and lacks nerve supply. Cartilage pseudarthrosis.9
gets nutrition through imbibition. The mechanical forces of
motion stimulate imbibition and removal of waste products.
The three types of cartilage are the following: Effects of Immobilization versus Early
1. Hyaline cartilage: The most common and found on articular Mobilization
surfaces of peripheral joints, sternal ends of the ribs, nasal sep-
tum, larynx, and tracheal rings
2. Elastic cartilage: Found in the epiglottis, laryngeal cartilage, Clinical Pearl
walls of eustachian tubes, external ear, and auditory canal Early mobilization within a pain-free range of motion pro-
3. Fibrocartilage: Found in intervertebral disks, some articular motes faster healing of connective tissue, stronger collagen
cartilage, the pubic symphysis, dense connective tissue in joint bonds, reduced scar tissue adhesions, and improved collagen
capsules, ligaments, and the union of tendons to bone fiber orientation.
The two primary functions of articular cartilage are to pro-
mote motion between two opposing bones with minimal friction
and wear and to distribute the load applied to the joint surfaces After 9 weeks of immobilization, there is 14% loss of total
over as great an area as possible.10 collagen, and by 12 weeks there is a 28% loss. The half-life of
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 55

BOX 4-5 Home Exercise Program Golgi Tendon Organs

Golgi tendon organs (GTOs) are proprioceptors that are located
The home exercise program should do the following: in the tendon adjacent to the myotendinous junction. They are
1. Provide modified tension in the line of stress. Initially, this arranged in series with the extrafusal muscle fibers. They are sen-
will be accomplished by performing light muscle contrac- sitive to stretch but are activated most efficiently when the muscle
tions to move the joint through the full available pain-free shortens. The GTO transmits information regarding muscle ten-
range of motion. sion as opposed to length. Neural input from the GTO causes
2. Avoid re-injury. Any exercise or activity that causes pain is an an inhibition of muscle activation. This provides a protective
indication of tissue trauma. mechanism to avoid development of excessive tension.11
3. Provide the proper dosage. Give specific instructions about
the number of repetitions, sets, breaks, positioning, and Joint Mechanoreceptors
speed of exercises.
4. Indicate the frequency of exercise. This depends on healing Four types of mechanoreceptors are found in the synovial joint
time frames, intensity, volume, comorbidities, and the tol- capsules. Mechanoreceptors have a significant effect on muscle
erance to stress of the tissue. Be clear in the instructions to tone and pain sensation locally and distally along segmental
the client about the frequency of exercise. Initially this may innervations. The number of mechanoreceptors decreases with
be three or more times per day, but with increased exercise age. By age 70 the total number of receptors has decreased by
stress, there will be a decrease in frequency. about 50%, depending on factors such as genetics and activity
5. Supply adequate nutritional support. Explain the impor- level.12
tance of eating a balanced diet and drinking a sufficient Type I mechanoreceptors are found in the superficial layers of
amount of water to stay hydrated. A well-balanced diet the joint capsule between the collagen fibers. A large percent-
combined with exercise promotes healthy tissue. age of the type I mechanoreceptors is found in the joints of the
neck, hip, and shoulder. They have a great effect on the coor-
dination of the tonic muscle fibers. They are slow-adapting
and inhibit pain. They fire during movement and for about
glycosaminoglycans is 1.7 to 7 days. The half-life of collagen is 1 minute after movement stops. They provide postural and kin-
300 to 500 days. For this reason, under normal physiologic con- esthetic awareness (awareness of the position of the body or body
ditions, it takes between 1 to 2 years for full healing to occur. part in space). They are active in the beginning and end-range of
Immobilization of cartilage causes a decrease in thickness and collagen tension.
number of collagen bundles, a decrease in proteoglycan con- Type II mechanoreceptors are found in deep layers of joint cap-
tent, an increase in water content, a decrease in load-bearing sules. A high concentration of the type II mechanoreceptors is
capacity, softening of the articular surface, decrease in tensile found in the joints of the lumbar spine, hand, foot, and tem-
strength of cartilage, and a decrease in oxygen content. To poromandibular joint. They are fast adapting and pain inhib-
decrease these adverse effects of immobilization, one should iting. They fire during movement and continue to fire until
institute an exercise model of high repetitions with low to no about ½ second after movement stops. They do not respond to
resistance. This model increases the oxygen content within the stretch but are activated in beginning and midrange of collagen
tissues by improving blood flow and imbibition. For maxi- tension. They have more effect on the phasic muscle fibers and
mal benefit, mobilization exercises should be performed sev- kinesthesia.
eral times a day.8 A home exercise program helps accomplish Type III mechanoreceptors are located in the deep and super-
these goals. Box 4-5 lists the qualities of a good home exercise ficial layers of the joint capsules and ligaments. They are slow
program. adapting and inhibit muscle tone in response to stretch at the
extreme end-range of tension. They provide kinesthetic infor-
mation, but their role is less understood than the type I and II
Neurophysiology mechanoreceptors.
Type IV mechanoreceptors are located in joint capsules, blood
Muscle Spindles vessels, articular fat pads, anterior dura mater, ligaments of the
spine, and connective tissue. They are not found in muscle. They
Muscle spindles are proprioceptors that consist of intrafusal fire when excessive levels of tension are reached in the collagen,
muscle fibers enclosed in a sheath (spindle). They run parallel and they warn of tissue trauma. They function as pain-provok-
to the extrafusal muscle fibers and act as receptors that provide ing, nonadapting, high-threshold receptors. They fire continu-
information on muscle length and the rate of change in muscle ously until the injurious stimulus is removed. They are provoked
length. The spindles are stretched when the muscle length- by excessive stretch, inflammation, high temperature (38° C to
ens. This stretch causes the sensory neuron in the spindle to 42° C or 100.4° F to 107.6° F), or respiratory and cardiovascular
transmit an impulse to the spinal cord, where it synapses with distress.12
alpha motor neurons. This causes activation of motor neurons Pain has been defined by the International Association for
that innervate the muscle. The muscle spindles determine the the Study of Pain as an unpleasant emotional disorder evoked
amount of contraction necessary to overcome a given resistance. by sufficient activity in the nociceptive system and associated
When the resistance increases, the muscle is stretched fur- with real or potential tissue damage.13 The irritation causing the
ther, and this causes spindle fibers to activate a greater muscle pain may be due to immobilization, physical trauma, infection,
contraction.11 or emotional tension.
56 PART 1 Fundamentals

Precaution. Pain is a protective mechanism. Pain is not a Stages of Repair

warning that something is about to go wrong; it has already gone
wrong! Pain is the way the body alerts the brain that an irritation to The stages of repair can be categorized into three phases: inflam-
the tissue has occurred. For this reason, one must remember to exercise mation, repair, and remodeling. During the inflammatory phase,
within a pain-free range of motion. In this case, feeling bad is a good the white blood cells/macrophages destroy cellular debris, synthe-
thing because it is how your body communicates. Listen to the body. size fibronectin, and produce protein and fiber. During the repair
stage, collagen is produced, and during the remodeling stage,
the fibroblasts orient longitudinally within 28 days and repair is
Traumatology complete between 128 to 135 days. Myofibroblasts (involved in
tissue reconstruction) are active from 5 to 21 days after trauma
The response of the body to trauma is predictable and consis- to up to 9 months. During the initial remodeling, a random con-
tent, regardless of the tissue involved or the mechanism of injury. figuration of collagen fibrils occurs. This arrangement provides
Trauma sets off a highly organized response involving chemical, minimal strength. During the maturation phase, the mechani-
metabolic, permeability, and vascular changes at a cellular level in cal strength increases with remodeling and organization of fibers
preparation for tissue repair. with modified tension in the line of stress.8

Phases and Time Frames of Healing

Muscle Physiology
The initial response to a traumatic event is irritation. This lasts
for 5 to 6 hours. Vasomotor constriction occurs in the first few
seconds. An immediate release of chemical vasodilators occurs. Clinical Pearl
These dilators are also transmitters for the nociceptive (pain) sys- Strength is related to fiber diameter, not fiber type.
tem. The vasodilation increases the hydrostatic pressure because
of increased capillary permeability. Clinicians rarely can influ-
ence this phase because of its immediate occurrence. Type I muscle fibers are smaller in diameter than type II mus-
The next stage of healing is the acute stage, which lasts for cle fibers. Muscle recruitment progresses from smaller to larger
1 to 3 days depending on the vascularity of the tissue. During diameter. Tonic muscles fire first because they are the primary
this time frame, a migration of the larger cell bodies through the dynamic joint stabilizers. Their nutrition mainly comes from the
wall of the vessel occurs. Subsequently, blood flow increases to delivery of oxygen. They are predominantly type I or slow-twitch
the area, increasing hydrostatic pressure and increasing bleeding. muscles and are responsible for sustaining proper joint arthro-
The large proteins leak out of the capillary, causing a shift in kinematics over time.14
osmotic pressure with resultant pulling of fluid out of the cap-
illary. Venous stasis occurs distal to the traumatized area, and Tonic versus Phasic Muscles
edema results (see Chapter 3).
The third stage of healing is the subacute stage. The subacute Tonic muscles initiate the easy work; they are better adapted
stage begins with the settled stage, where muscle spasming occurs for endurance exercise than phasic muscles because they have
over the next 3 to 5 days. Bleeding is no longer present. Oxy- more capillaries, mitochondria, and metabolic enzymes (Table
gen and macrophages are present. Walling off of the capillary 4-2). With long-distance running the tonic muscles are primarily
occurs, which makes waste removal difficult. This leads to sec- responsible for work because they are adapted for aerobic activ-
ondary healing or scarring. Externally applied heat in the settled ity. The phasic muscles are recruited to participate if the load is
stage promotes stasis and inflammatory exudates. The preferred too great or if it is increasing. They are better suited for short-
method of heating tissue is internally. Initiating movement with duration activities that are of higher intensity. They also begin
low resistance exercise produces friction and naturally generates to participate if the light work has lasted for 2 to 3 hours, as seen
heat. This promotes increased blood flow. with marathon runners who sprint when approaching the finish
The final stage is the chronic stage. Tissue becomes line. Phasic muscles are anaerobic and contract at a higher speed
strongly chemical bonded (covalent bonds) and mature at 9 to
12 months. At this stage the tissue becomes nonelastic and can-
not be deformed. Mature scar tissue may cause pain. Clinically,
TABLE 4-2 Comparison of Tonic and Phasic
concentrate on increasing the tolerance of the tissue to tension
Muscle Fibers
about the scar by use of controlled stress through properly dosed Tonic Phasic
exercises.
Red: High myoglobin White: Lower myoglobin
Tissue-specific exercise in the subacute stage provides the
concentration concentration
optimal stimulus for the removal of metabolites, which are
products of metabolism, from the tissue. Muscle contraction is Slow twitch: 10 to 20 impulses Fast twitch: 30 to 50 impulses
necessary to transport metabolites from the cell and provide oxy- per second per second
gen/nutrition to the area. Increased vascularization accomplishes Type I Type II
this goal. This is achieved through many repetitions of properly
dosed exercise with minimal resistance while avoiding excessive Arthrokinematic Osteokinematic
tissue tension. In other words, the muscle contractions with Bipenate Fusiform
proper exercise facilitate formation of capillaries, blood flow, and
Antigravity —
removal of metabolites.
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 57

and with greater force of contraction; they fatigue more quickly Endurance is the capacity to maintain an intensity of exercise
than tonic muscles. for a prolonged period. Endurance requires continuous restoration
The tonic muscle fibers atrophy almost immediately when of energy sources. Tonic muscles primarily require oxygen from
immobilized after injury because they depend primarily on oxy- the vascular system for their nutrition. Phasic muscles require glu-
gen for metabolism. Therefore exercise to improve vasculariza- cose and body fat for their nutrition. Because the tonic system is
tion provides the oxygen necessary to nourish the tonic system. the first to atrophy, because of muscle guarding and decreased
Habitually overloading a system will cause it to respond and motor recruitment, endurance is the quality that will increase
adapt. The rate of protein synthesis in a muscle is related directly nutrition through vascularization. Endurance exercise also pro-
to the rate of amino acid transportation into the cell. Amino acids motes removal of waste products and prevents continued firing
transported into the muscle are influenced by the intensity and of the type IV mechanoreceptors caused by an abnormal chemical
the duration of the muscle tension. Conversely, muscle atrophies environment. Exercise dosage for endurance and vascularization
as a result of disuse, immobilization, guarding associated with requires many repetitions (three sets of 24) with low resistance.17
pain, or starvation.14,17 Speed is the time it takes to cover a fixed distance. Speed equals
distance divided by time. With an increase in speed of movement
Types of Muscle Work and Training Effects is an increase in inertia, and overcoming this inertia requires a
higher level of coordination. Speed of movement ultimately must
Isometric muscle contraction is the production of muscle tension be functional. During the initial phases of healing, coordination
without a change in muscle length or joint angle. The tension in is not sufficient to exercise safely at a fast/functional speed.18
the cross-bridges (the portion of myosin filament that pulls the Volume refers to the total amount of weight lifted in a work-
actin filaments toward the center of the sarcomere during muscle out. The weight per repetition determines the appropriate vol-
contraction) is equal to the resistive force, thereby maintaining ume per set. Heavy weights cannot be lifted for many repetitions
constant muscle length. in a set. Volume can be determined by multiplying the number
Concentric muscle contraction is muscle shortening as the of repetitions by the number of sets times the weight lifted per
muscle produces tension while the insertion moves toward the repetition. Three sets of 25 repetitions with 5 pounds would be
origin. Movement occurs in the same direction as the tension calculated as 3 × 25 × 5 lbs = 375 lbs of volume. If other sets also
and joint motion because the contractile force is greater than are performed with different amounts of weight, the volumes per
the resistive force. Based on the sliding filament theory, the set are calculated and then all are added together to obtain the
cross-bridges on the myosin filament attach to the active site total workout volume.19
on the actin filament. When all of the cross-bridges in a muscle Strength is the maximal force that a muscle or group of mus-
shorten in a single cycle, the muscle shortens by approximately cles can generate against a resistance at a given speed. Strength
1%. Muscles have the capacity to shorten up to 60% of their can be tested as a measure of 1 RM (resistance maximal; see
resting length; therefore the contraction cycle must be repeated the following discussion for more on this topic). Strength train-
multiple times.15 ing is performed at a percentage of 1 RM. For strength training,
Eccentric muscle contraction is muscle lengthening as the the number of repetitions decreases as the resistance increases.
muscle produces tension and the insertion moves away from the Increased resistance produces an increase in tissue tension and a
origin. The net muscle movement is in the opposite direction decrease in blood flow to the capillaries during the muscle con-
of the force of the muscle because the contractile force is less traction, as well as an increase in blood flow when the exercise is
than the resistive force. Eccentric contractions require less energy over. Therefore only a few repetitions are performed. For pure
than concentric contractions and are thought to be responsible strength gains, 85% of 1 RM (three sets of six) are performed.
for some aspect of postexercise muscle soreness. The cross-bridges However, when there is muscle atrophy, after immobilization,
of myosin stay attached to the active sites while the resistance is strength gains are realized at 30% to 40% of 1 RM.18-21
lowered. It may be the actual “tearing” away of the cross-bridges Power is the ability to overcome resistance over a specific
while resisting the lowering of a heavy resistance that results in distance in a fixed time frame. Work equals force multiplied
the delayed-onset muscle soreness.15,16 by distance. Power equals work divided by time. Power lifting
is generally not a functional requirement for clients. However,
increased power is necessary to perform a task at a faster rate.
Exercise Power is therefore a critical component of exercise for clients.22

Functional Qualities of Exercise Dosing

Coordination refers to quality of motion. With atrophy of the Exercise initially is dosed based on the physiology of the type
tonic system, coordination is the first functional quality to be lost I muscle fibers and their depletion of nutrients in a state of
because the tonic muscles are the primary dynamic stabilizers of guarding.
the joints. Therefore coordination must be the first functional
quality to be restored. With an increase in speed or an increase in Clinical Pearl
resistance comes a need for increased coordination. Normaliza- Clinically, the first goal of dosing exercise is to deliver oxygen
tion of a reflex disturbance, which is abnormal action of the cell, to the muscles, elicit no pain, and perform many repetitions.
tissue, organ, or organism caused by overstimulation or under-
stimulation, requires 5000 to 6000 repetitions. The repetitions
are necessary to regain optimal coordination of movements about Initially, focus on sustaining slow, coordinated movement
a physiologic axis.17 around a physiologic axis. Ultimately, progress toward a fast/
58 PART 1 Fundamentals

functional speed while maintaining coordination and provid- energy reserve that is so necessary for tissue synthesis and repair
ing optimal stimulus for regeneration of the specific tissue(s) in (Fig. 4-2).
lesion.17 Resistance should be objective and measurable, physi- Precaution. With an older client population, take care not to
ologic, and adjusted to the tissues participating. (See later in the overexercise, or the risk for breakdown of collagen tissue and prob-
chapter for explanations of these concepts.) Training with free lems, such as tendonitis, will increase.17
weights or a pulley system is easier to quantify and provides a
more specific resistance throughout the entire range of motion Calculating Dosage
than elastic bands.
In 1948, DeLorme defined the term resistance maximal (RM).
Starting Positions This is the resistance that a group of muscles can overcome
once. RM was used as a measure of strength. In the 1950s the
Determining a starting position depends on tolerance of the Norwegian, Oddvar Holten, developed a curve that estimated
specific tissues to stress. Gravity assists, resists, or is eliminated, guidelines for dosing repetitions/resistance for concentric work
depending on what the tissue can tolerate while working in a (Fig. 4-3).17,23
pain-free synergy about a physiologic axis.
Precaution. If there is pain while exercising against the force of Calculating Resistance by Percentage of 1 RM
gravity, position the limb in a posture that eliminates the effects of
Repetitions of Exercise
gravity.17
If necessary, to complete a pain free arc of motion, the limb Because 1 RM is the maximum resistance that can be overcome
can be positioned so that the motion to be performed is assisted once, this resistance has a high risk of causing further injury to
by gravity. This way, the antagonists, muscles that work in the already compromised tissue. When dosing an exercise pro-
opposition to the prime movers, generate motion instead of the gram initially, the first functional qualities desired are to promote
painful agonists, or prime movers. vascularization and endurance while maintaining coordination.
For this to be accomplished, according to the Holten diagram,
Range of Motion the exercise should be dosed at 30 repetitions (Fig. 4-4).17,23

Initially, localize motion to a specific joint in a specific direc-

tion with controlled range of motion maintained throughout the OGI
Stress Effects
arc. Monitor the tension on noncontractile tissues. Watch for
controlled, normal physiologic motion, and educate the client Energy
to avoid compensatory motion while exercising. Adjust the resis- At 20 years 100
tance to allow for acceleration toward maximal length-tension of age 1 of
80
range and deceleration away from it. Quality of motion, while 10 persons Reserve
avoiding pain-provoking end-ranges, dictates quantity.18 are affected. 70%
60 Half Energy
At 60 years
40 Reserve
Work Capacity/Effects of Aging of age 3 of
30 Same Daily 70%
10 persons Workout
An individual’s sustainable work capacity is approximately 30% are affected. 20
of that person’s available energy. The remaining 70% of the
stored energy in the body is needed for protein synthesis and 10 20 30 40 50 60 years old
maintenance of tissue (Fig. 4-1). The amount of energy avail- FIGURE 4-2 Effects of age on energy requirements. (Used with
able for maintenance, repair, and regeneration of tissue decreases permission from the Ola Grimsby Institute.)
with age. With age, it takes less activity to dip into the 70% of

OGI
OGI
Daily Requirement Concentric Curve (Holten)
vs. Reserve
100% 1 Rep.
95% 2
100% 90% 4 Strength
Reserve
75% 85% 7

50%
70% 80%
75%
11
16 Strength/Endurance
Work Capacity 70% 22
25%
30% Demand 65% 25 Endurance
60% 30

FIGURE 4-1 Total daily energy requirements. (Used with permission FIGURE 4-3 Holten diagram. (Used with permission from the Ola
from the Ola Grimsby Institute.) Grimsby Institute.)
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 59

The client is given a weight that the therapist predicts will the weight of the limb for proper dosage are to position it in a
cause fatigue in less than 30 repetitions. The client then performs gravity-eliminated position or even a gravity-assisted position.17,23
as many repetitions as possible before the onset of fatigue, pain,
or loss of coordination. As an example, the client is provided Length-Tension Relationship and Implications
with a 3-pound weight and is able to perform 16 repetitions to Exercise
with this weight before becoming fatigued or experiencing pain
(16 repetitions correlates to 75% of 1 RM according to the Blyx,24 a Swedish physiologist, defined muscle fiber length
Holten diagram). equilibrium as the length the muscle will maintain when it
Therefore is unaffected by outside forces. Muscle force production var-
ies depending on the angle of the muscle in the arc of motion.
The length/tension curve identifies the length at which a muscle
generates the most contractile tension (Fig. 4-5). This length is
influenced by histologic, biomechanical, and neurophysiologic
factors. Histologically, the overlap of actin and myosin filaments
is most extensive toward the midrange of motion. Biomechani-
cally, the angle of the tendon insertion into the bone dictates
. where the greatest tensile strength will occur. The greatest
amount of force is achieved when the moment arm for a muscu-
This client should be able to perform 30 repetitions with 2.4 lar force is perpendicular to the lever arm. Neurophysiologically,
pounds.

Speed of Exercise LENGTH-TENSION CURVE

Speed of exercise is another component that may change the dos-
age. Increased speed causes an increase in inertia and requires
more coordination to execute. Oxygen debt is also important to

h
Blix curve

ion
Tension

stretc
avoid during exercising so as to provide the type I muscle fibers

Resting length

Co
ns
te

ntr
with nutrition while they are in a state of guarding.

al

ac
t
Precaution. If the client’s respiratory rate is increasing during
To

tile
e
the exercise, then the speed of exercise must be decreased or there must siv

for
s
Pa

ce
be a longer break between sets or both.
To increase the total number of repetitions while maintaining Length
an accurate dose, increase the number of sets. It has been deter-
mined that to go from one set to three sets without changing the
resistance, the number of repetitions must be decreased by 15%
Total tension
to 20%. By doing this, one set of 30 repetitions now becomes
three sets of 24 to 25 repetitions. The amount of time between
sets is determined by how long it takes the client to return to a Total tension
Blix curve
Resting length

steady state respiratory rate (equilibrium of the respiratory sys- composite pair tch
Co

of muscles modified by
stre

tem). This is necessary to avoid oxygen debt.

ntr

Brand
ac

When using pulleys to exercise the upper extremity, if the

tile

e
weight of the limb alone exceeds 60% of 1 RM, then a counter- s siv
for

Pa
weight may be used to de-weight the arm. Other ways to decrease
ce
us h
m retc
e
cl
ng t
si e s

How to Calculate lb. from % R.M. OGI

po siv
op as
P

If the patient obains 11 repetitions

with 2lb., then 60% of 1 R.M. =
100% 1 Rep. X 2 lb.
Step 1: =
% of 1 R.M. # of Repetitions 60% 80%

80% 11 Rep. Step 2: X = 120 Normal functional

80 region

Step 3: X = 3
60% 30 Rep. 2

Step 4: X = 1.5 lb.

60% of 1 R.M. = 1.5 lb.
FIGURE 4-5 Length-tension curve. (From Brand PW, Hollister A: Clini-
FIGURE 4-4 Example for calculating exercise dose. (Used with per- cal mechanics of the hand, St Louis, 1993, Mosby. In Trumble, Principles of
mission from the Ola Grimsby Institute.) hand surgery and therapy, St Louis, 2000, Philadelphia.)
60 PART 1 Fundamentals

the joint mechanoreceptors influence muscle facilitation around

the joint. Type I and type II mechanoreceptors fire at the begin- BOX 4-6 Considerations for Exercise Program
ning of range. Type II alone fires at midrange, and type I fires at
the end-range of capsular tension.12 Equipment: Consider using pulleys, benches, bolsters, and
The clinical importance of the length/tension concept can be wedges for positioning; straps, free weights, and de-
discussed in terms of concentric and eccentric aspects. weighting devices.
Ropes: Consider the range of motion, and set the rope per-
Concentric Aspects pendicular to the lever arm and parallel to the muscle fiber.
When working concentrically with pulleys, set the rope perpen- Pulley: Should be single, double, concentric, or eccentric.
dicular to the lever arm at 20% into the lengthened range of the
Starting positions: Consider recommending supine, prone,
muscle that is going to do the work. If using free weights, position
side-lying, sitting, standing, non–weight bearing, weight
the limb where it is perpendicular to the force of gravity, when
the lever arm is at 20% into the lengthened range of motion. bearing, arm supported, or unsupported.
Movement range: Consider recommending full range of mo-
Eccentric Aspects tion; inner, outer, or mid range of motion.
When working eccentrically, have the maximal resistance set per- Weight: Consider the functional quality that is desired and
pendicular to the lever arm at 20% to 30% into the shortened what percentage of 1 RM is needed to accomplish that.
range of the muscle that is going to do the eccentric work. The (In this case, the functional qualities most likely would be
length/tension concept reveals that muscle produces the least endurance and vascularization.) Also take into account the
amount of power at the beginning and end-ranges. When acti- body/limb position, gravity, and quality of motion when
vated, the muscle contraction accelerates toward the midrange determining weight.
and decelerates away from it. The variability of speed is an impor-
Dosage: The number of repetitions and sets is determined by
tant component of all activities of daily living. Because activity is
the desired functional qualities. These include coordina-
task specific, the variables of speed and resistance throughout the
range of a contraction are important for fiber recruitment and tion, vascularization, endurance, strength, and power.7,23
physiologic coordination.25,26 Speed: This will vary, but early in the rehabilitation, when
working on vascularization and endurance, it is important
Formulation and Progression of an Exercise Program to follow respiratory rate at steady state to avoid oxygen
debt. Speed should increase as coordination and function
When formulating an exercise program for treatment of hypomo- increase.
bility or hypermobility, you should start by identifying the specific Rest: Breaks between sets are determined by respiratory rate.
problems that exist. Examples of these problems are the following: As the client starts to increase strength (x resistance + x
repetitions), the rest breaks will increase. As resistance
increases, the frequency of exercise decreases as well (three
times per week).
rotation [ER] > abduction [ABD] > internal rotation [IR])
Education: Instructions to the client must be specific. Dem-
onstration of the exercise first or even guiding the client’s
limb through the arc of motion that is desired is often
helpful. Use verbal, visual, and tactile cues as necessary.
Once an examination has been completed, establish func-
tional or measurable goals that address the identified problems.
The following suggestions are several possible goals for the client: Consider client and equipment needs before starting exer-
cises. Box 4-6 outlines different aspects of an exercise program.
Consider precautions and contraindications when implementing
with functional work/avocation activities (time) an exercise program.
Precaution. Comorbidities (such as, cardiac or pulmonary dis-
accomplish functional activities) ease, specific physician protocol, and other medical/surgical consider-
ations) must dictate exercise decisions.
improved arthrokinematics of the glenohumeral joint (at work,
with activities, time frames) Progressions of Hypomobilities
Decrease pain and guarding: Distraction of the joint to fire Progressions of hypomobilities has four stages (Table 4-3).
type I mechanoreceptors
Increase joint mobility: Compression/decompression with Stage I
gliding for cartilage, modified tension in the line of stress Stage I begins with many repetitions to address coordination.
for joint capsule Following the Holten diagram, 60% of 1 RM promotes vascu-
Hydrate/lubricate cartilage: Compression/decompression larization. This is dosed at three sets of 25 repetitions. Fifty per-
with glide cent of 1 RM helps decrease joint edema. Beginning with 40% of
Increase proprioception: Modified tension in the line of 1 RM may be necessary when the amount of muscle fiber atro-
stress phy present is significant. Start at a slow speed with minimal
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 61

TABLE 4-3 Progression of Hypomobilities TABLE 4-4 Progression of Hypermobilities

Stages I to IV Stages I to IV
Stage Procedures Goals Stages Procedures Goals
Stage 1 Many repetitions Increase endurance Stage I Many repetitions Increase endurance
Low speed Increase circulation Low speed Increase circulation
Minimal resistance Increase exercise ability Minimal resistance Increase exercise
ability
Outer range of motion Avoid overexertion
Beginning or midrange of Avoid overexertion
Stage II Increase repetitions Increase endurance motion
Increase speed Increase fast coordination Stage II Increase repetitions Increase strength
Do not increase resistance Include isometric contrac- Increase sensitivity to
Stage III Stabilizing exercise in the Increase strength in the tions in inner range of motion stretch
gained range of motion gained range of motion Stage III Submaximal (80% RM) Increase dynamic sta-
Concentric and eccentric resistance concentrically and bility in the gained
eccentrically range of motion
Stage Coordinate tonic and Functional stability
IV phasic function through- Include isometric contractions
out physiologic range of in the full range of motion
motion (except the outer range)
Stage IV Coordinate tonic and phasic Functional stability
function throughout physi-
resistance to maintain coordinated movement and help decrease ologic range of motion
inflammation. Work into the outer, pain-free range of motion
RM, Resistance maximal.
to promote stimulation of fibroblasts and production of glycos-
aminoglycans. This stage of exercises stimulates joint mechano-
receptors and GTOs to inhibit pain and guarding. Begin with facilitation patterns. Add isometric contractions in the newly
the joint in a resting position and provide support of bolsters or gained end-range of motion to promote strength.
other equipment as needed to promote quality of motion around
a physiologic axis. Start with concentric contractions initially to Stage IV
increase vascularity.25 Have the client progress to stage IV when the client is able to
increase the speed of exercise and still maintain coordination.
Stage II Absence of delayed-onset muscle soreness is also an indication
Have the client progress to stage II when the functional quality of that it is time to progress to the next level. Stage IV emphasizes
coordination and vascularization is achieved. Signs for progress- functional exercises and retraining for activities of daily living,
ing to this stage are a decrease in complaint of pain, increased essential job functions, and sport-specific activities. Exercises are
range of motion, increased speed of exercise, decreased muscle performed through a full range of motion at up to 80% to 90%
guarding, and less fatigue experienced by the client. of 1 RM at a functional speed in order to achieve the functional
The goal of stage II is to increase endurance and speed. This quality of power.18
is accomplished by increasing the number of sets and the number
of exercises. With increased coordination, increase the speed of Progressions of Hypermobilities
exercise. Do not increase resistance. At this point, remove the
supportive bolsters so that the client can begin stabilizing proxi- Exercise progressions for hypermobilities have four stages
mally while improving the mobility of the hypomobile joint. His- (Table 4-4).
tologic changes that take place in stage II are improved nutrition
to the joint cartilage through decreased viscosity of synovial fluid Stage I
associated with the increase in speed.25 Stage I for hypermobilities is identical to stage I for hypomobili-
ties with one major exception. With a hypomobility the exercises
Stage III are dosed to promote increased mobility, whereas with a hyper-
Have the client progress to stage III when pain has resolved, full mobility the goal is to increase stability. Therefore exercises for
range of motion is regained, and when speed and coordination hypermobility are performed in the beginning and midrange of
have increased. For the newly gained range of motion, there must motion so that coordination can be maintained while developing
be dynamic stability. This means that the musculotendinous units stability.
are strong enough to maintain controlled, physiologic mobility.
Concentric and eccentric contractions in the newly gained range Stage II
of motion promote functional stability. In stage III the resistance In stage II, increase repetitions, number of sets, and number of
is increased to 60% to 80%, and the repetitions are decreased exercises. Add closed kinetic chain and slow plyometric exercises
to 10 to 15 repetitions to promote strength/endurance. Begin to increase sensitivity to stretch. Continue to perform exercise in a
triplanar motions by exercising in proprioceptive neuromuscular single plane of motion, and increase speed as coordination permits.
62 PART 1 Fundamentals

Stage III
TABLE 4-5 Borg Rate of Perceived Exertion Scales
In stage III, increase resistance to 80% of 1 RM and decrease
the number of repetitions to promote strength. Perform con- Borg Scale Newer Scale
centric and eccentric contractions for increased stability in the
6 0 Nothing at all
physiologic range of motion. Add a set of one isometric con-
traction at 75% to 85% of 1 IM (isometric maximum). This 7 Very, very light 0.5 Very, very weak
contraction should be held for 15 seconds. Fast plyometrics 8 1 Very weak
(when an eccentric contraction is immediately followed by a
concentric contraction) for recruitment of the muscle spindle 9 Very light 2 Weak
helps increase sensitivity to stretch and aids in stability. Tripla- 10 3 Moderate
nar motion can start in stage III for promotion of functional
stability. 11 Fairly light 4 Somewhat strong
12 5 Strong
Stage IV
13 Somewhat hard 6
Hypermobility progression in stage IV is equivalent to that for
hypomobilities. The exercises become more functional, and you 14 7 Very strong
should focus more on retraining for a job, activities of daily liv-
15 Hard 8
ing, and sport. Increase the resistance to improve the qualities of
power and speed.18 16 9
17 Very hard 10 Maximal
Monitoring of Vital Signs
18
Monitoring of vital signs is a reliable, valid, and meaningful way 19 Very, very hard
of measuring clients’ response to exercise. It takes practice to
become accurate with monitoring vital signs and to understand 20
the significance of these values. Taking a resting heart rate, blood
pressure, respiratory rate, and oxygen saturation (SpO2) only
measures the body systems at rest. To get baseline measurements, Training Modes
take vital signs before, during, and after exercise. Doing this pro-
vides critical information about how the body is responding to Cardiovascular warm-up not only gets the heart and lungs pre-
the exercise loads placed upon it, as well as how well it recovers pared for exercise, but it also is the healthy, natural way of pre-
from the stress of exercise. paring tissue for more vigorous, tissue-specific exercise. The
Precaution. Proper dosing of exercise can improve the efficiency warm-up may consist of 5 to 15 minutes of walking on the tread-
of the cardiovascular system, whereas overdosing may cause irrevers- mill or riding on a stationary bike or upper body ergometer. This
ible damage. type of warm-up increases blood flow, heart rate, deep muscle/
Heart rate/pulse may be altered by many medications and tissue temperature, and respiratory rate and decreases joint syno-
diseases. When this is the case, as in clients who are taking beta- vial fluid. This means of increasing circulation may be the wise
blockers or are in congestive heart failure, monitoring of the heart choice as opposed to the passive hot pack application for tissue
rate in response to exercise may provide inaccurate or misleading warming.
information. In such cases, one must use other forms of measur- Core/proximal stabilization exercises are essential components
ing the response of the body to exercise.5,6 of all phases of exercise and activities of daily living. For normal
physiologic movement to take place, there must be distal mobil-
Rate of Perceived Exertion ity on proximal stability.
Precaution. Increased mobility at the expense of proximal sta-
Gunner Borg established the Borg scale (rate of perceived exer- bility equates to compensatory or nonphysiologic movement.
tion, or RPE) in 1962. The RPE is a subjective measurement Therefore proper posturing and core stabilization exercises
of how hard clients think they are exercising. The RPE has are an appropriate component of the hand therapist’s repertoire.
been proved to be a valid and reliable way of measuring exer- Concentric exercise requires three times as much energy as
tion during exercise and functional activities. The original scale does eccentric exercise. Most of the energy of the body is stored
was based on numeric values that ranged from 6 to 20, with 6 in muscle mass. Seventy percent of the stored energy is used to
being a perception of minimal effort, as in relaxing in a chair, maintain all vital organ function. Thirty percent of the stored
and with 20 describing maximal effort, as in running up a steep energy is used to carry out functional daily activities. If a person
hill. Target RPE is between 11 and 13 (fairly light to some- regularly exceeds the 30% of energy reserved for activities of daily
what hard). This is a pace that could be maintained for at least living and dips into the 70% reserved for vital organs, pathologic
a 15-minute workout. Breathing would be labored; one could conditions of the collagen will result. This may be manifested as
carry on a conversation but likely would prefer not to do so. In a tendonitis, for example. To promote healing, when dosing ini-
more recent years, a modified RPE scale has become popular. tially for concentric exercise, it is best to require many repetitions
This newer version is based on a 0 to 10 value system. Zero is with light resistance. Doing so will increase oxygen to the injured
equivalent to work at rest, and 10 is maximal exertion. Some tissue by increasing its blood flow (Fig. 4-6).14
find this modified scale easier to use. Table 4-5 gives the Borg Isometric exercise occurs when a muscle contracts without
RPE scales.5 joint motion. A strengthening effect for the muscle occurs at the
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 63

during exercises and throughout the day and night will result in
Oxygen Consumption OGI optimal health. Encourage clients to keep a journal of their activi-
ties and home exercise program. This is often helpful for account-
of Musc les ability and guidance for upgrades.

100% Concentric CASE STUDIES OF EXERCISE PROGRESSIONS

Work
75%

50%
75% CASE STUDY 41 ■

Eccentric
25% Work History
25% TP is a 36-year-old left-hand dominant female secretary who spends
8 hours a day working on the computer and talking on the tele-
FIGURE 4-6 Oxygen consumption of muscles. phone. She also is attending night school and studying nursing.
Because of limited free time, she reports that she has not been par-
ticipating in any regular exercise program. She admits that she has
angle the joint assumes during the contraction and at 20 degrees gained quite a bit of weight over the last year. TP often studies in bed
on either side of that angle. For example, if the biceps are iso- at night, propped up by pillows, until she falls asleep. She presents
metrically contracted with the elbow at 90 degrees, a strengthen- to therapy reporting that her right lateral elbow has been painful for
ing effect will result from 70 to 110 degrees. This is a safe way to approximately 3 months. She does not recall sustaining any injury.
begin strengthening after an injury if the isometric exercises are She notes that the pain in her elbow becomes more intense over the
performed in a pain-free range. Isometric exercises can be per- course of the workday. Upon questioning, she does recall that she
formed at varying angles and can be dosed at different intensi- often awakens during the night with numbness and tingling into
ties. The amount of force that can be maintained by an isometric the “whole hand.”
contraction for 1 second is 1 IM. In rehabilitation, therapists
dose isometric contractions at a percentage of 1 IM. Percentage Clinical Evaluation Findings
of isometric resistance is dosed in relation to holding time. For TP reports frustration because she has had 1 month of therapy for
example, 60% of 1 IM can be held from 50 to 60 seconds; 80% her elbow, and she feels that it has not improved but rather has got-
of 1 IM for 20-30 seconds; 90% of 1 IM can be maintained for ten worse. She states that her therapy has consisted of hot packs,
10 seconds.14 ultrasound, and stretching exercises. She also was provided with a
Open and closed kinetic chain exercises play an important role wrist orthosis and tennis elbow strap.
in rehabilitation of the upper extremity. Most functional activi- Her evaluation was remarkable for rounded shoulder with a
ties of the upper extremity are open chain. Movement occurs forward head (RSFH) posture, sixth cervical vertebra–facilitated seg-
from muscle origin to insertion, and the terminal joint is free. ment (causing increased tone along the C6 distribution), pain to
With closed chain exercises, movement occurs from muscle palpation at the origin of the extensor carpi radialis brevis, pain at
insertion to origin, and the terminal joint is constrained in a fixed end-range elbow extension, decreased grip on the right (because
position.27 of pain), and pain with resisted wrist extension. After explaining the
findings and outlining the treatment plan, the therapist established
Client Education goals for therapy with TP, and she agreed to comply.
An ergonomic evaluation of the workstation was performed.
To increase compliance with exercise programs, it is essential to Recommendations for computer monitor, keyboard height, and
educate clients on why they are doing each component of the chair adjustments were made. New mouse placement and style
exercise program and what is being accomplished. were reviewed. A phone headset was ordered.
TP was instructed in some postural exercises, including pectora-
Clinical Pearl lis stretches, chin tucks, neck stretches, and gentle brachial plexus/
peripheral nerve glides. The postural strengthening exercises in-
Explain that the exercises that are dosed at high repetitions are
cluded wall letters and scapular retraction and depression exercises.
to improve vascularization and endurance.
TP agreed to perform these exercises during breaks at work and at
home.
Movement is life, and conversely lack of movement will lead TP agreed to start walking daily, beginning with 15 minutes a day
to tissue destruction. Many repetitions in a pain-free range of at a comfortable pace while maintaining good posture. Duration of
motion help to increase blood flow, which in turn brings more the walks is to increase by 2 minutes a week over the next 2 months,
oxygen to the injured tissue. The body gets nutrition through the as she is able. Speed of gait is also to increase as TP becomes more
oxygen in the blood. comfortable and acclimated to her walking program.
Precaution. Avoid pain because pain indicates that the tissue is The first therapy treatment was spent evaluating TP, and edu-
being irritated. With tissue irritation there will be more pain, which cating her on the different components of her present complaints.
leads to muscle guarding, inflammation, and a decrease of blood Explanations were provided on how posture, work, and exercise
flow/nutrition to the area. habits contributed to the elbow pain and how she could address
Emphasize quality of motion. The body responds to the stress this responsibly. She was provided with the foregoing home exercise
placed upon it. Maintaining proper posture and body mechanics program and was dosed for her clinical elbow exercise program.
64 PART 1 Fundamentals

The first stage of exercise was dosed with the physiology of the that she could continue with her independent exercise program and
tonic muscle fiber of the elbow in mind. Three months of muscle make upgrades appropriately.
guarding resulted in some tonic muscle atrophy, degeneration of
collagen, and alteration in joint mechanics leading to a decrease in CASE STUDY 42 ■

normal contact areas of cartilage. The optimal stimulus for regenera-

tion of collagen is modified tension in the line of stress, and the op- History
timal stimulus for regeneration of cartilage is compression/decom- RJ is a 42-year-old right-hand dominant male carpenter who sus-
pression with glide. Following the stage I protocol for hypomobility, tained an injury to his left shoulder 3 weeks before presenting for
it was determined that TP could tolerate 21 repetitions of concentric therapy. He reports that when unloading his truck at the job site
wrist extension against gravity before pain set in. early one morning, he lost his footing and started to fall backward off
On the second visit, treatment commenced. All exercises were the truck. At the time, he was holding his toolbox in his right hand.
dosed at three sets of 25 repetitions to promote vascularization and As he was falling, he reached out with the left hand and grabbed on
endurance while maintaining coordinated movement around a to a long 4×4 that was sticking out of the bed of the truck. He reports
physiologic axis throughout a full pain-free arc of motion. TP warmed that “it happened so fast,” but he is sure that he did not actually fall
up on the upper body ergometer for 12 minutes at 120 rpm, forward onto the shoulder or bump it on anything. Over the next 2 hours,
and backward to avoid fatigue. Please refer to the Evolve website for he found it difficult to do his job because of left lateral and posterior
illustrations of the following exercises: shoulder pain. He decided to go to the nearby urgent care facility
1. Concentric wrist flexion, with forearm supported on a table (see when the pain did not resolve over the course of the day. X-ray films
Evolve for Fig. 4-7, A) were taken, and no fracture was noted. Over the next 2 weeks, RJ
2. Concentric wrist extension, with forearm supported on a table tried to persevere at work and apply ice to the shoulder whenever he
(see Evolve for Fig. 4-7, B) could. He returned to the physician because his shoulder “just wasn’t
3. Pronation, with forearm supported on a table (see Evolve for Fig. getting any better.”
4-8, A)
4. Supination, with forearm supported on a table (see Evolve for Fig. Clinical Evaluation Findings
4-8, B) Magnetic resonance imaging confirmed a near full-thickness tear
5. Elbow flexion/extension, with forearm supported on a table (see of the supraspinatus and partial tear of the infraspinatus. Therapy
Evolve for Fig. 4-9) evaluation ruled out any cervical spine involvement. Manual muscle
After finishing the foregoing 375 repetitions, the home exercise testing of the left shoulder revealed 3/5 grade strength of the supra-
program was reviewed to ensure that the exercises were being per- spinatus and 4/5 grade strength of the infraspinatus. There was a pos-
formed correctly. Treatment concluded with an ice massage. TP re- itive sulcus test at zero degrees, positive Hawkins-Kennedy sign, and
ported fatigue but no pain. positive external rotation lag sign with the supraspinatus at greater
TP returned to therapy 2 days later reporting that she had been than 10 degrees and with the infraspinatus at less than 10 degrees.
compliant with her home exercises, walking program, and working The evaluation confirmed the magnetic resonance imaging findings,
on proper posture throughout the day/night. Her complaint of pain and it was determined that RJ had a right shoulder impingement
had decreased approximately 25%, and the “numbness and tingling” with an underlying hypermobility because of the rotator cuff tear.
in the hand had resolved. TP went through the foregoing exercise
program again and then was scheduled for one visit per week in Goals of Therapy
therapy to make upgrades in the program as necessary. She also The goals of therapy were as follows:
agreed to add the dosed exercises to her current home exercise pro- 1. Decrease pain.
gram. 2. Resolve muscle guarding.
One week later, she returned to the clinic and reported com- 3. Restore functional range of motion around a physiologic axis.
pliance and denied any problems with her exercises. She stated 4. Increase endurance/strength of the rotator cuff.
that the exercises were taking much less time now than they were
originally. TP described minimal complaint of elbow pain during the Initial Treatment
workday and no more symptoms at night. The exercises were up- Exercises were selected for stage I hypermobilities:
graded because she now could tolerate 30 repetitions. Please refer 1. Start with a warm-up exercise, such as the upper body ergometer
to the Evolve website for illustrations of the following exercises: for 10 minutes at 120 rpm.
1. Wrist extension against gravity (see Evolve for Fig. 4-10) 2. Dose with many repetitions initially to increase endurance and
2. Wrist flexion against gravity (see Evolve for Fig. 4-11) circulation to the type I muscle fibers of the rotator cuff (three sets
3. Pronation with 1 lb (see Evolve for Fig. 4-12, A) of 25).
4. Supination with 1 lb (see Evolve for Fig. 4-12, B) 3. Begin with slow speed to promote coordinated movement about
5. Elbow flexion—recumbent seated position flexion with 2 lbs (see a physiologic axis.
Evolve for Fig. 4-13) 4. Choose starting positions that are in the inner range of motion to
6. Elbow extension in prone with 2 lbs (see Evolve for Fig. 4-14) maintain stability from inner to mid range of motion.
TP agreed to continue with her home exercise program, adding 5. Support the limb with equipment, as necessary, to aid with pre-
the new upgrades with the three sets of 25 each. serving proper joint arthrokinematics.
The following exercises were selected for Robert’s shoulder rehabili-
Result of Care tation. Please refer to the Evolve website for illustrations of the fol-
On the following week, TP called to cancel her future therapy ap- lowing exercises:
pointments. She reported that she had not had any elbow pain in 1. Scapular retraction (see Evolve for Fig. 4-15)
the previous 4 days and that because of time constraints she felt 2. Internal rotation (see Evolve for Fig. 4-16)
 Tissue-Specific Exercises for the Upper Extremity CHAPTER 4 65

3. External rotation (see Evolve for Fig. 4-17) On the fifth visit, RJ began stage II for hypermobility. Slow
4. Abduction (see Evolve for Fig. 4-18) plyometrics were added with a 1-pound ball tossed against a wall,
5. Lateral pull downs (see Evolve for Fig. 4-19) catching it with the left hand. Closed chain exercises were initiat-
6. Triceps (see Evolve for Fig. 4-20) ed by performing wall pushups. He started to perform (two sets of
7. Biceps (see Evolve for Fig. 4-21) 25) concentric contractions and one set of isometric contractions
RJ’s first treatment was spent evaluating and testing to de- in the inner to mid range of motion. The isometric contractions
termine the appropriate resistance to achieve the functional were dosed at 60% to 70% of 1 IM, which is a 40- to 60-second
qualities of vascularization and endurance while maintaining co- hold.
ordination and quality of motion without eliciting pain. The outer By the eighth visit, RJ was able to progress to stage III. Exercises
range of motion initially was avoided because of instability. On re- were upgraded to include concentric contractions at 80% of 1 RM for
turn visits, he performed three sets of 25 repetitions for all of the two sets of ten repetitions and one set of isometric contractions in
foregoing exercises. He took rest breaks between sets. For each the mid to outer (stable) range at 85% of 1 IM for a 10- to 15-second
exercise the pulley rope was set perpendicular to the lever arm hold. Fast plyometrics were performed to recruit the muscle spindle.
at 20% into the lengthened range of motion and parallel to the He started to incorporate diagonal (proprioceptive neuromuscular
muscle fiber. Concentric contractions were performed initially, facilitation) patterns into his exercise routine as well.
and between each repetition, the weight stack was let down to
remove tension. Result of Care
In the fourth week, Robert’s rehabilitation introduced some retrain-
Continuing Care ing of some of his essential job functions. At that time, he was re-
RJ was scheduled for therapy three times per week for 4 weeks. On leased back to full duty and was discharged from therapy. He de-
his third treatment, he was noted to be moving through his exercise cided to join a local gym and continue with his established exercise
program more quickly, maintaining coordination, and reporting no routine.
pain with exercise and decreased pain overall. He then was dosed for
four more exercises. Please refer to the Evolve website for illustrations Acknowledgments
of the following exercises:
1. Horizontal adduction (see Evolve for Fig. 4-22) I would like to give special thanks to Ola Grimsby and the Ola
2. Horizontal abduction (see Evolve for Fig. 4-23) Grimsby Institute for the invaluable education I received from
3. Extension (see Evolve for Fig. 4-24) them and the permission to share this knowledge with other
4. Flexion (see Evolve for Fig. 4-25) clinicians.

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ential diagnosis for physical therapists: screening for referral, ed 4, St Louis, 15. Cipriani DJ, Falkel JE: Physiological principles of resistance training
2007, Saunders Elsevier. and functional integration for the injured and disabled. In Lee AC,
7. Carmona RH, Beato C, Lawrence A: Bone health and osteoporosis: a report Quillen WS, Magee DJ, et al: Scientific foundations and principles
of the surgeon general, Rockville, Md, 2004, Department of Health and of practice in musculoskeletal rehabilitation, St Louis, 2007, Saunders
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8. Grimsby O, Rivard J, Kring R: Exercise for collagen repair. In Grimsby 16. Cheung K, Hume P, Maxwell L: Delayed onset muscle soreness:
O, Rivard J, editors: Science, theory and clinical application in orthopaedic treatment strategies and performance factors, Sports Med 33:145–164,
manual physical therapy: applied science and theory, Vol 1, Taylorsville, 2003.
UT, 2008, The Academy of Graduate Physical Therapy, Inc., pp 33–65. 17. Grimsby O, Rivard J, Kring R: Exercise prescription. In Grimsby O,
9. Grimsby O, Rivard J: Exercise for bone repair. In Grimsby O, Rivard J, Rivard J, editors: Science, theory and clinical application in orthopaedic
editors: Science, theory and clinical application in orthopaedic manual physi- manual physical therapy: applied science and theory, Vol 1, Taylorsville,
cal therapy: applied science and theory, Vol 1, Taylorsville, UT, 2008, The UT, 2008, The Academy of Graduate Physical Therapy, Inc.,
Academy of Graduate Physical Therapy, Inc., pp 19–31. pp 347–392.
66 PART 1 Fundamentals

18. Grimsby O, Rivard J, Kring R: Functional qualities and exercise dosage. 22. Harman E: The biomechanics of resistance exercise. In Baechle TR,
In Grimsby O, Rivard J, editors: Science, theory and clinical application Earle RW, editors: Essentials of strength training and conditioning, ed 3,
in orthopaedic manual physical therapy: applied science and theory, Vol 1, Omaha, 2008, Human Kinetics, pp 73–78.
Taylorsville, UT, 2008, The Academy of Graduate Physical Therapy, 23. Medical exercise therapy, Oslo, 1996, Norwegian MET Institute.
Inc., pp 325–344. 24. Blyx M: Blyx curve, Scand Arch Physiol, 93–94, 1892.
19. Baechle TR, Earle RW, Wathen D: Resistance training. In Baechle TR, 25. Grimsby O, Rivard J, Kring R: Exercise progression. In Grimsby O,
Earle RW, editors: Essentials of strength training and conditioning, ed 3, Rivard J, editors: Science, theory and clinical application in orthopaedic
Omaha, 2008, Human Kinetics, pp 405–407. manual physical therapy: applied science and theory, Vol 1, Taylorsville, UT,
20. Peterson MD, Rhea MR, Alvar BA: Maximizing strength development in 2008, The Academy of Graduate Physical Therapy, Inc., pp 431–472.
athletes: a meta-analysis to determine the dose-response relationship, 26. Ratamess NA, et al: Progression models in resistance training for healthy
J Strength Cond Res 18:377–382, 2004. adults, Med Sci Sports Exerc, 687–708, 2009.
21. Wolfe BL, LeMura LM, Cole PJ: Quantitative analysis of single vs mul- 27. Brumitt J: Scapular-stabilization exercises: early-intervention prescription,
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2004.
 5 Evaluation of the Hand
and Upper Extremity
Linda J. Klein

T
he client’s initial evaluation sets the stage for successful rehabilitation. Evalua-
tion establishes rapport, determines areas of functional deficit, and serves as the
foundation for treatment and recovery. Only with an accurate assessment can the
therapist determine the best course of treatment for the client’s condition. A number of
assessment processes and clinical assessment skills are needed to perform a thorough eval-
uation (Fig. 5-1). The main areas of assessment for the injured hand include pain, wound
and scar status, vascular status, range of motion (ROM), swelling, sensation, strength,
current and previous use of orthotics, and functional limitations. A screening of proximal
motion, strength and posture are important to have a full understanding of deficits in the
distal upper extremity. Periodic re-evaluations are necessary to show progress, identify
new or remaining problems, and redirect goals.
Using an evaluation summary form is helpful (see Appendix 5-1). The form will
guide you through each step of the assessment, ensuring that you do not forget any areas.
Defer areas of an evaluation when it is not appropriate to perform them at a certain
time in the tissue healing process or if the client simply cannot tolerate these procedures.
Sometimes an additional specific form is needed for an assessment. For example, the
evaluation summary form should have an area listed as sensation even though a separate
form is used for sensory tests, including the Semmes-Weinstein monofilament test or
two-point discrimination test. On the evaluation summary form, give a brief description
that indicates where the client perceives altered sensation, including numbness, tingling,
burning, or hypersensitivity. Then use the Semmes-Weinstein monofilament, two-point
discrimination, or other sensation forms for more specific and objective information.
The evaluation summary form promotes clinical reasoning and assists the therapist’s
organization of thoughts and communication with a thorough and logical progression of
categories.

Initial Interview
Obtaining a History
Before assessing the function of the client’s hand, obtaining a history of the injury or
symptoms that bring the client to the therapy clinic is essential. Understanding the onset
of symptoms (for example, trauma versus gradual) is essential. Next, ask about any prior
medical intervention. Has there been surgery? An injection? X-ray, magnetic resonance
imaging, or computed tomography scan? Nerve study? Cast immobilization? Use of
orthotics? Medication? Manual tests by the physician? Or has there been no interven-
tion by the physician except to send the client to therapy for the therapist’s expertise in
evaluation and treatment? Understanding previous care that the client has experienced
helps in a number of ways. It gives the client confidence that you understand what has
been done, and it builds trust because in many cases you can explain what the physician
was attempting to determine with various tests. Having clients develop trust in you leads
to gaining their full cooperation and participation in the evaluation and rehabilitation
process. In addition to the history of the injury or condition, you must understand the
individual’s pertinent medical history, because many medical conditions, such as diabetes
or peripheral vascular disease, affect the healing process.

Observation
During the initial process of meeting new clients and discussing their history and symp-
toms, use your observation skills. Observe the client’s nonverbal communication, including
68 PART 1 Fundamentals

Observation
Interview Posture
Pain Spontaneous use
Use of orthoses Guarding
Functional use Scar
Establish Rapport
Wounds
Trophic status

EVALUATION

Palpation
Gentle approach
History
Pain
Specific Testing Adhesions
ROM Pitting/brawny edema
Medical History of current Edema Provocative tests
history condition Vascular
Sensation
Strength
Coordination

FIGURE 5-1 Summary of the evaluation process. ROM, Range of motion.

facial expressions and body language, as well as how the client holds
and uses the injured extremity and trunk. The client often guards BOX 5-1 Pain Scales
the injured extremity at the time of initial evaluation, possibly as
a subconscious protection from pain. I also have seen situations in Numeric analog scales: A line with equal markings from 0
which the client guards the extremity or exaggerates limitations, to 5, 0 to 10, or 0 to 20 is used to indicate the perceived
such as strength or motion, during the evaluation to be sure that level of pain at the initial evaluation compared with
the therapist recognizes and appreciates the extent of deficit. In periodic re-evaluations.
these cases, it is sometimes possible to observe them function better Visual analog scale: Provide the client with a 10-cm line
during a spontaneous situation than during the formal assessment. drawn vertically on paper with one end labeled “no pain”
For example, a client with an elbow injury who lacks 40 degrees of and the other end labeled “pain as bad as it could be.”
elbow extension during formal assessment may be seen extending The client marks the location and level of pain, and the
the elbow significantly further while removing or putting on his examiner later divides the line into twenty equal portions to
or her coat. Another example is the client who guards the hand determine the distance from zero to the client’s pain mark.
by holding it close to the body during the assessment but uses the Verbal rating scale: Client describes their pain with four
hand more freely with gestures during informal discussion. to five descriptive words (for example, mild, moderate, or
Observe differences in posture and use of the upper extrem- severe).
ity in spontaneous situations compared with formal assessment. Graphic representation: The client marks his or her pain
This gives clues regarding the client’s comfort with the extremity. location and type on a body chart.
Use different approaches to elicit the best response from clients Pain questionnaire: Written pain questionnaires are
who are not comfortable moving freely (see Chapter 15). In my available that obtain more information about the client’s
experience, most clients with abnormal posturing (guarding) are pain, such as the McGill Pain Questionnaire.2 These
unaware of their upper extremity positioning and are eager to questionnaires are probably used most in specialty centers
change. In contrast, facilitation of positive involvement by clients dealing with management of pain, but the knowledge
who may be consciously controlling their responses in therapy is of the content of specific questionnaires may be helpful
more challenging. I have had some success by reminding these to develop your skills in discussing pain during an
clients that continued therapy is contingent on their showing evaluation.
progress. I have found that use of a nonjudgmental approach,
pointing out inconsistencies between formal testing and observa-
tion is the most effective approach in this situation. Reinforcing
that your goal is to work with the client toward recovery will Assessment of Pain
maximize the client’s positive involvement in the rehabilitation
process. Equipment
In discussing each section of the evaluation, I will describe
the tools and process of the evaluation, followed by inconsisten- No equipment is necessary, but you may choose to use a pain
cies and difficulties to be aware of, and when that portion of the scale during initial evaluation to summarize the client’s overall
evaluation should be deferred. perception of pain. Numerous pain scales are available (Box 5-1).1
 Evaluation of the Hand and Upper Extremity CHAPTER 5 69

Methods develop. Many clients are apprehensive about attending therapy,

concerned that the therapist may perform painful, provocative
Obtain a verbal or written description by the client regarding the tests, might touch or grasp a sensitive or tender area or move the
level of pain, location, type of pain, frequency or cause, and dura- extremity beyond comfort. Knowing that the therapist is aware
tion of pain. Also document when pain occurs during other parts of the pain helps the client relax and participate in the rest of the
of the evaluation, such as with active range of motion (AROM) or evaluation process.
passive range of motion (PROM), strength testing, or palpation:
Level of pain: Using a pain scale, have the client describe the Clinical Problem Solving
pain at its worst on the scale and then at its best, and also obtain
an average pain level. Most often, I use the 0-to-10 pain scale At times, the therapist is not given a firm diagnosis by the refer-
or the verbal rating scale of mild, moderate, or severe. Docu- ring physician and may be instructed to evaluate and treat for
mentation can then be done accordingly; for instance, “Pain is hand, wrist, elbow, or shoulder pain. The location of pain and
described as varying from mild at best to severe at worst.” whether pain occurs with active or passive motion can give the
Location of pain: Have the client point to the area(s) of pain. therapist clues as to the cause of the pain. Use provocative test-
For clients with a more diffuse pain that may involve more of ing for specific conditions with the goal of reproducing the pain
the upper extremity, I use a body chart on which the client can complaint for nerve compressions and tendonitis or tendinopa-
circle the areas that hurt and rate each area if desired. When a thy (see Chapters 24 and 28).
client has referred pain—for instance, when palpation of one Consider the following:
area results in pain in another area—this is best documented on
a body chart as well. Referred pain can occur for a number of is caused by a problem with the muscle or tendon.
reasons, such as following a nerve injury where pain may be felt
proximal or distal to the site of injury of the nerve. as tightness of the joint structures, ligament injury, cartilage
Type of pain: Ask the client to describe the pain as throbbing, injury, or inflammation (pain may be present equally with
aching, sharp, stabbing, shooting, burning, or hypersensitive to AROM in these situations).
light touch.
Frequency or cause of pain: Determine whether the pain is con- is present with distraction of the joint but not compression of
stant or intermittent. Have the client describe when the pain the joint, pain is most likely due to a ligament or joint capsule
occurs and what seems to cause the pain. This information is being stretched with distraction and relieved with compression.
helpful in determining a diagnosis if the physician has not pro-
vided a firm diagnosis. with distraction, pain is more likely due to a problem at the
Duration of pain: Determine how long the pain has been joint surface, such as thinning or loss of cartilage, inflammation
present. within the joint or other abnormality, such as a bone spur.
Precaution. Aggressive clinical problem-solving methods can
Clinical Pearl be used safely only when the physician has allowed AROM and
Pain in an area for longer than 6 months often is classified as PROM as part of treatment. These methods are not appropriate
chronic pain, as opposed to acute pain experienced following in the acute phase following a tendon, nerve, or ligament repair
a recent injury. or tendon transfer.

Chronic pain: Chronic pain often is associated with depres- Wound Assessment
sion, anxiety, and other psychological involvement and may be
helped best by a team approach with specialists in the area of Open wounds can be intimidating. Breaking the assessment
chronic pain management. down to wound size, depth, color, drainage, and odor is helpful
Pain levels: Note pain levels that occur during the evaluation, (see Chapter 21). When wounds are closed, it is appropriate to
such as pain during AROM, PROM or strength testing. For skip this section and go on to scar assessment.
instance, my evaluation might state, “Strength: Grip strength Consider the following:
right hand 100#, left hand 50# with moderate pain identi- Size: Measure length and width with a ruler. Make a tracing of
fied in left volar wrist with grip.” I may have a goal to reflect the wound for future comparison, or use transparent calibrated
this in my initial evaluation note, such as “Increase left hand grids. Do not touch the wound with the ruler or other measur-
grip strength to 75# without pain.” Tendonitis is more often ing device unless the item is sterile.
associated with pain on AROM than PROM in the direction Depth: Wound depth may be measured with a sterile cotton
of motion of the involved muscle/tendon. Thus distinctions swab if the client and therapist are comfortable with this proce-
about pain during evaluation become part of the clinical rea- dure.
soning and treatment process. Color: Open wounds are referred to as red, yellow, or black.3,4
Many wounds have a combination of these colors, and wounds
Discussion progress through stages of these colors.
Red wound: Wound may be a superficial wound, second-
I usually begin my assessment of a new client’s injury by discuss- degree burn, acute fresh wound, surgical wound, or a
ing the client’s pain and reassuring the client that the evaluation wound left open to heal by secondary intention, which
is not intended to worsen the pain. As soon as the client has the is the process by which an open wound heals with granula-
opportunity to tell me about his or her pain, I see a level of relief tion and new blood vessel formation.
70 PART 1 Fundamentals

Yellow wound: Semiliquid to liquid slough (exudate) is along the third metacarpal, with a thickened area under the skin
present. Color ranges from cream to yellow. Pink or red of 3 mm in height and 2 to 3 mm in width surrounding the scar).
granulation tissue usually is seen at the edges of or under Adhesions: Assessment of adhesions of surface scars to underly-
the yellow tissue. Yellow tissue may facilitate infection. Yel- ing tissue is done by observation and palpation. Some adhesions
low wounds are often in the late inflammatory phase or can be seen during active motion. When the adhesion is on the
early fibroplasia phase and include exudates. dorsal hand or wrist or the volar wrist/forearm, the scar is often
Black wound: Wound characterized by necrotic black, seen to dip deeper, or dimple, when active motion is attempted
brown, or gray tissue or thick eschar (layer of necrotic col- because of adhesions from the superficial scar to underlying fascia
lagen over a wound). Pus may form at the edges because and tendons. Also assess adhesions of skin to underlying tissue
of macrophage (cell that assists in cleaning the wound of by palpation. Attempt to slide or lift the scar tissue in a man-
necrotic tissue and debris) activity. New granulation tissue ner similar to the surrounding uninjured tissue, and describe the
forms under the eschar. If bacterial infection forms under level of adhesion as mild, moderate, or severely adherent.
the eschar, the wound edges can become red, painful, and Precaution. Respect the level of healing of a new scar and the
swollen. The wound may be in all stages of wound repair, tissue to which it may adhere. Avoid aggressively attempting to move
with inflammation present while macrophages remove scar tissue within the first week following suture removal or when
necrotic debris, fibroblasts lay down new collagen under a portion of the wound is still open. Doing so may cause damage to
the eschar, angiogenesis (new vessels in the tissue of a heal- fragile, healing tissue or possibly may reopen the wound. Avoid strong
ing open wound) begins to occur, and the wound tries to scar manipulation during assessment or treatment over a tendon in
contract despite being blocked by eschar. the early phase of healing.

Clinical Pearl
Wounds almost always have more than one color present at Vascular Status Assessment
one time. Treat the worst stage first; that is, progress from
treatment of black to yellow and then yellow to red. A basic vascular evaluation of the hand can be done by obser-
vation (color or trophic changes, pain level), palpation (pulse,
capillary refill assessment, modified Allen’s test), and temperature
Drainage: Attempt to quantify the amount of drainage (mild, assessment. Blood flow to the hand can be affected by proximal
moderate, heavy) and color of drainage. Clear, pink, or white injury or diagnoses, such as thoracic outlet syndrome, injury to
drainage does not indicate presence of infection. Exudate may the hand itself, or conditions like Raynaud’s phenomenon. Proxi-
have a yellow color and may or may not indicate infection. mal conditions, such as thoracic outlet syndrome, are discussed
in the Chapter 22.
Clinical Pearl
If there is any question of the possibility of infection, have the Observation
drainage examined by a physician.
Observation includes assessment of color and trophic changes
in the hand. Increased levels of white (pallor), blue (cyanosis),
Odor: Odors often indicate infection. Note any odor emanat- or red (erythema) coloration of the skin are the most common
ing from the wound, and have the wound assessed by a physi- changes noted.
cian for potential infection.
Temperature: Surface thermometers or temperature tapes can Clinical Pearl
be used to compare temperature of an area near the wound Arterial interruption usually produces a white or grayish discol-
with an unaffected area. oration of the affected area (pallor), whereas venous blockage
produces a congested, purple-blue color.5 Dusky blue may in-
dicate chronic venous insufficiency. Redness may indicate loss
Scar Assessment of outflow of blood from the hand or a venous problem, but it
also may be an indication of a normal inflammatory phase of
The characteristics to assess for scar status include color, size, wound healing or the presence of infection.
whether it is flattened or raised, and the presence of adhesion
(attachment) to underlying or surrounding tissue.
Consider the following: Trophic changes refer to the texture of the skin and nail.
Color: Scars usually begin as deep red and gradually become Changes in the trophic status can occur from sympathetic nerve
lighter as time progresses. or vascular changes. Note the presence of increased dryness or
Size: Use a ruler to measure the length and width of the scar. moisture of the skin of the involved hand and the presence of
Flat/raised: Use observation and palpation to assess how far the open wounds or necrotic tissue at the initial evaluation. Reevalu-
scar is raised above the skin level, and describe it using terms like ate these items frequently for improvement.
mild or moderate. Sometimes the superficial scar may be flat, but Pain is present in two-thirds of clients with upper extrem-
there may be a lump under the skin. This happens most com- ity vascular disease.6 Pain may be described as aching, cramping,
monly on the dorsum of the hand or wrist with a lump under the tightness, or cold intolerance. Pain may be associated with activ-
surface scar that is a thickening composed of a combination of ity that includes exposure to vibration, cold, or repetition.
scar and fluid. This lump of scar and fluid can be described by size Precaution. Close monitoring of color and temperature change
and height (for example, dorsal incisional scar is 3 cm in length is important, and communication with the referring physician is
 Evaluation of the Hand and Upper Extremity CHAPTER 5 71

recommended if abnormalities are worsening or not improving. available and have resulted in the effort by the American Society
Causes of vascular abnormalities are numerous, and in-depth evalu- of Hand Therapists to standardize this process.9 This method
ation and testing by the physician may be indicated. is discussed later in this chapter; however, variations exist that
are acceptable, and we should refer to recognized ROM refer-
Palpation Tests of Vascular Status ences10,11 when becoming familiar with ROM testing. All ROM
of the forearm, wrist, and hand is performed with the client in
Capillary Refill Test
the seated position. Clinical problem solving that interprets the
To perform the capillary refill test, place pressure on the distal cause of the limited ROM (for example, joint stiffness, intrin-
portion of the volar finger or over the fingernail of the digit until sic tightness which limits simultaneous MP extension and IP
tissue turns white.5,6 Capillary refill time is the number of sec- flexion, and extrinsic tendon tightness which limits composite
onds it takes for the color to return to normal after the pressure wrist and digit motion in the same direction) is important for
is released. Normal capillary refill time is less than 2 seconds, and determining the most appropriate treatment.
the time can be compared with the same digit on the opposite
hand or with uninjured digits. Methods

Peripheral Pulse Palpation Passive Range of Motion

Place light pressure over the radial artery or ulnar artery just prox- PROM is the ability of a joint to be moved through its normal
imal to the wrist crease to gain information about the strength arc of motion while relaxed, with motion being performed by an
of the pulse or blood flow to the hand.7 If the pulse is weaker in outside source, such as the therapist’s hand, the client’s opposite
one wrist than the other, there may be a potential problem with hand, or gravity. Limitations in PROM indicate a problem within
blood flow proximal to the wrist. Palpation of peripheral pulse is the joint (for example, stiffness caused by capsular or ligamentous
used frequently for assessing proximal vascular diagnoses, such tightness, decreased joint space, or bone spur). PROM also may
as thoracic outlet syndrome. Check the pulse before and after be limited by tightness of the muscle/tendon group opposing the
exercise in certain positions to determine whether position or passive motion (for example, a tight or adherent extensor muscle/
exercise diminish blood flow to the distal upper extremity. Refer tendon will prevent full passive or active flexion).
to Chapter 22 for more information on specialized testing. Precaution. Traumatic injuries to the bone or joint in the
acute phase of healing, or as determined by the physician, are lim-
Modified Allen’s Test ited to AROM, with no PROM allowed. PROM by an outside
The modified Allen’s test assesses the status of the blood sup- source may be performed too strongly, reinjuring the healing bone
ply within the hand through the ulnar and radial arteries of the or ligament. Following a tendon repair in the early phase of tendon
wrist.5-8 To perform the test, place firm pressure over the radial healing, PROM in the direction that would stretch the tendon is
and ulnar arteries just proximal to the wrist crease. Instruct the not allowed.
client to make a tight fist and then open the fingers repeatedly
until the palm turns white. Then instruct the client to relax the Active Range of Motion
fingers to a partially opened position. Release the pressure from AROM is motion of a joint caused by musculotendinous con-
one side of the wrist, allowing blood flow through one of the traction, most often from a voluntary muscle contraction. Limi-
arteries. Record the time it takes for the color to return to normal tations in AROM can result from a number of causes. Some of
in the hand. Repeat the process, releasing pressure from the artery these causes include weakness of the muscle, loss of tendon conti-
on the opposite side of the wrist. Record the time it takes for the nuity, adhesions of the tendon preventing its motion, inflamma-
color to return to normal in the hand. A normal response is 5 tion or constriction of the tendon, decreased tendon mechanical
seconds or less and can be compared to the opposite extremity to efficiency because of loss of pulley (bowstringing), and disrupted
confirm a normal response time for that individual. nerve supply to the muscle.
Precaution. AROM using a repaired tendon (that is, contract-
Surface Temperature Assessment ing a repaired muscle/tendon) is not allowed following some tendon
Surface thermometers can be used to compare forearm tempera- repairs or tendon transfers in the acute phase of tendon healing.
ture to fingertip temperature. If the forearm is at least 4° C (39° This restriction lasts for approximately the first 4 weeks after the
F) warmer than the fingertip surface, it may indicate vascular repair unless the type of repair performed by the surgeon allows use
compromise. Assess Raynaud’s phenomenon with a tempera- of an immediate active-motion protocol. Please refer to Chapters
ture assessment that measures the temperature of the involved 30 and 31.
fingertip(s) after being in a warm room (24° C [75° F]) for 30 You must recognize that AROM or PROM also may be lim-
minutes and then after being immersed in ice water for 20 sec- ited by pain. If the client describes pain during ROM testing,
onds. Record the time it takes to return to the baseline tempera- note this on the evaluation form.
ture. The normal time for return to body temperature is within When there is no medical limitation regarding use of AROM
10 minutes, but clients with Raynaud’s phenomenon may take and PROM, it is important to do the following:
20 to 45 minutes.7
determine the cause of limitation.

Range of Motion Assessment that individual.

-
Assessment of ROM in this chapter is limited to the forearm, ment session (for example, before or after exercise) for a more
wrist, fingers, and thumb. A variety of ways to assess ROM are accurate reading of improvement.
72 PART 1 Fundamentals

A B
FIGURE 5-2 A, Pronation as measured with a standard 6-inch goniometer, demonstrating axis of motion on
the dorsal distal ulna. B, Supination as measured with a standard 6-inch goniometer, demonstrating axis of
motion on the volar distal ulna.

Clinical Pearl
instance, it is more difficult to perform finger flexion when
the wrist is flexed compared with when the wrist is extended. When flexor tendon gliding is limited by adhesions, TPM will
When the extensors are adherent, each individual digital joint be better than TAM.
measured alone or independently will flex further than when all
three finger joints are flexed at the same time.
Standard plastic goniometers work well for measurement.
Total Active Motion Large goniometers (12¼ inches) are recommended for the larger
Total active motion (TAM) is used to describe the full arc of elbow and shoulder joints. Standard goniometers (6 to 7 inches)
active motion of the digit(s). TAM is measured as the total flex- are used for measuring the forearm and wrist (Figs. 5-2 and 5-3).
ion of all three finger joints, subtracting any loss of full extension They can be cut down in length to measure finger ROM (Fig.
at all finger joints: 5-4). Metal finger goniometers are available at a higher cost and
do not have the benefit of transparency when lateral placement
(MP + PIP + DIP flexion) - (MP + PIP + DIP extension loss) = TAM is needed. Electronic and computer system goniometers are avail-
able at a much higher cost. For the wrist, I prefer the 6-inch
where MP is metacarpophalangeal, PIP is proximal interpha- goniometer with rounded ends because it allows dorsal placement
langeal, and DIP is distal interphalangeal. on the wrist for flexion and extension (Fig. 5-5).
Hyperextension of the fingers is recorded with a plus sign (+),
Clinical Pearl loss of full extension with a minus sign (−). When standard place-
ment of the goniometer is not used because of scar, swelling, or
Use TAM when reporting ROM in situations where tendon ad- wound, document the modified placement of the goniometer for
hesions limit motion and composite motion is more limited future reference to allow for accurate comparative measurements.
than individual joint motion.
Forearm Range of Motion
Total Passive Motion Consider the following for forearm ROM:
Total passive motion (TPM) is the same process as TAM but is
measured passively. This can be helpful to document the pres-
ence of adhesions. flexed to 90 degrees, forearm and wrist neutral.
 Evaluation of the Hand and Upper Extremity CHAPTER 5 73

A B
FIGURE 5-3 A, Wrist flexion measured dorsally over the central wrist with a standard 6-inch goniometer. B,
Wrist extension measured along the volar surface over the central wrist with a standard 6-inch goniometer.

A B

C
FIGURE 5-4 Finger flexion measured dorsally with a standard 6-inch goniometer that has been cut down in
length. A, Demonstrates metacarpophalangeal (MP) flexion; B, demonstrates proximal interphalangeal (PIP)
flexion; and C, demonstrates distal interphalangeal (DIP) flexion. Note the placement of the goniometer arms
to allow DIP flexion to be measured in a composite flexion position.

arm of the goniometer stays in contact with the dorsal dis-

pronation, and along the volar surface for supination. tal forearm as it moves into pronation. The stationary arm
- of the goniometer, which stays in the starting position, is
ometer across the distal forearm, dorsally with axis placed at now straight up and should be aligned with the humerus
the lateral edge of the dorsal ulna for pronation, and along the if the client has maintained the correct starting position of
volar surface of the distal forearm, with axis placed at the lateral the trunk and arm. The moving arm of the goniometer is to
edge of the volar ulna for supination. stay flat on the dorsum of the distal forearm, flush with the
center of the distal forearm, between the ulna and radius (see
place in the starting position (straight up), while the other Fig. 5-2, A).
74 PART 1 Fundamentals

A B
FIGURE 5-5 A, Alternate goniometer for wrist flexion, measured dorsally over the central wrist. B, Alternate
goniometer with rounded ends used for wrist extension measured dorsally over the central wrist.

place in the starting position (straight up), while the other

arm stays in contact with the volar distal forearm as it moves
into supination. The stationary arm of the goniometer, which
stays in the starting position is now straight up and should be
aligned with the humerus if the client has maintained the cor-
rect starting position of the trunk and arm. The moving arm
of the goniometer is flush on the center of the volar forearm on
the flattest portion of the midvolar forearm (see Fig. 5-2, B).
-
position, I prefer to align the stationary arm of the goniometer
with the humerus. This will provide an accurate measurement
of forearm motion in relation to the humerus. It is important
to perform the test in the same manner on retest.
- FIGURE 5-6 Wrist ulnar deviation measured dorsally.
nation by allowing the goniometer to overturn and measure
more along the distal radius or under-turn and measure more
along the distal ulna, rather than correctly on the middle sec-
tion of the distal forearm. Other common errors are to allow table surface, place the goniometer flat on its side, one arm of
the client to lean or move the arm away from the starting posi- the goniometer on the dorsum of the forearm, axis at the center
tion of humeral adduction against the side of the body. Feed- of the wrist, and the other arm of the goniometer along the
back from an experienced therapist is helpful when learning to third metacarpal (Fig. 5-6).
measure forearm motion. Volar placement of the goniometer on the palm to measure
wrist extension may be difficult because the goniometer does
Wrist Range of Motion not lay flat on the many curves in the palm. A goniometer with
rounded ends (see Fig. 5-5), which is available in many therapy
Consider the following for wrist ROM: supply catalogs, allows dorsal placement of the goniometer to
measure flexion and extension of the wrist.
and ulnar deviation.
Digital Range of Motion
The MP, PIP joints, DIP joints of the fingers, and MP and inter-
of Hand Therapists recommendations are along the volar sur- phalangeal (IP) joints of the thumb are measured with the same
face for extension, dorsally for flexion, and dorsally for radial procedure and are described together next:
deviation and ulnar deviation. Lateral placement is appropriate -
when scar or swelling make dorsal or volar placements inaccu- ion and extension. The MP joints of the fingers also perform
rate. abduction and adduction, and although this can be assessed
with goniometric measurements,11 a tracing of the hand with
the dorsum of the forearm and the other arm along the third the fingers fully abducted is also an effective way to show
metacarpal on the dorsum of the hand (see Fig. 5-3, A). change over time.

the volar forearm and the other arm along the third metacarpal digit is extension. Neutral wrist is recommended for consis-
on the palmar side of the hand (see Fig. 5-3, B). tency in procedure.
 Evaluation of the Hand and Upper Extremity CHAPTER 5 75

A B
FIGURE 5-7 A, Thumb carpometacarpal (CMC) radial abduction measured dorsally with a standard 6-inch
goniometer. B, Thumb CMC palmar abduction measured radially with a standard 6-inch goniometer.

demonstrated by measuring the distance, during a composite fist,

measured. from the fingertip pulp to the distal palmar crease of the hand.

the dorsal surface. The MP joint is measured with one arm Thumb Carpometacarpal Joint
of the goniometer along the metacarpal, and the other arm of
the goniometer along the proximal phalanx, with the axis at Consider the following:
the dorsal MP (see Fig. 5-4, A). Placement of the goniometer -
for the PIP joint is with one arm of the goniometer on the tion, and opposition.
proximal phalanx and the other arm on the middle phalanx
(see Fig. 5-4, B). Placement for the DIP joints is with one arm first and second metacarpals on the dorsal radial aspect of the
of the goniometer on the middle phalanx and the other arm hand.
on the distal phalanx (see Fig. 5-4, C). Alternate placement of
the goniometer is laterally along the finger if there is a lump or on table for radial abduction or with the ulnar side of the hand
other abnormality preventing dorsal placement. on the table, forearm neutral for palmar abduction or opposi-
tion. The thumb is adducted to be flat along the side of the
and when moving into flexion, move the distal arm of the goni- index finger.
ometer to maintain its position on the dorsum of the finger
section noted before. Note the degree of flexion attained. If second metacarpal and the other arm placed along the first
loss of full extension is present, record it with a minus sign (−); metacarpal, dorsally for radial abduction and radially for pal-
for example, −25 to 50 degrees MP motion means there was a mar abduction. The axis of the goniometer will be located at
loss of 25 degrees of extension and the joint was able to flex to the first carpometacarpal (CMC) joint, where the first metacar-
50 degrees of flexion. For hyperextension, use a plus sign (+): pal articulates with the trapezium and trapezoid.
+25 to 50 degrees MP motion means there is 25 degrees of
hyperextension at the MP joint and the joint was able to flex to the second metacarpal is stationary, and the goniometer arm
50 degrees of flexion. placed over the first metacarpal moves, staying in alignment
Hyperextension is difficult to measure with the standard over the first metacarpal as the thumb moves into radial abduc-
6-inch goniometer or 6-inch goniometer cut down in length, and tion (Fig. 5-7, A).
lateral placement is necessary for this measurement. The goniom-
eter style with rounded ends described in the discussion section of the radial side of the second metacarpal is stationary, and the
wrist ROM (see Fig. 5-5) can be used to measure hyperextension goniometer arm placed on the dorsal first metacarpal moves,
of the digit joints with dorsal placement. staying in alignment over the first metacarpal as the thumb
moves into palmar abduction (see Fig. 5-7, B).
Clinical Pearl
Measurement of each digit in composite flexion and extension recommends using a ruler to measure the distance from the
(TAM) is important during the initial evaluation. volar IP joint of the thumb to the third metacarpal with the
nail parallel to the plane of the palm when the thumb is in
opposition.9 Other sources suggest measuring opposition as
Each joint may be near normal if measured in isolation, the distance between the thumb tip and the base of the small
but significant limitation in ROM may be evident when total finger.10 Still others suggest having the patient touch the tip
active flexion and extension are measured, due to tendon glid- of the small finger with the thumb and assessing whether the
ing or scar tissue limitations. The TAM of the digit measured in nail of the thumb is perpendicular to the nail of the small fin-
composite flexion and extension indicates the functional limita- ger and parallel to the plane of the metacarpals.11 This is the
tions of motion. Functional limitations of motion also can be method that I prefer to use. Because there are a number of
76 PART 1 Fundamentals

different ways to assess opposition, it is important to define the include applying heat over the hand that is placed in a composite
method used in the documentation and be consistent when flexion position with a wrap that supports the flexed fingers in a
retesting. comfortable stretch. Following the heat treatment with the tis-
Thumb CMC joint ROM testing is difficult to perform con- sue in its lengthened position, manual techniques would include
sistently because placement of both arms of the goniometer is massage to the dorsal scar that is adherent to the extensor tendons
done using visual judgment of the therapist. Placing the goni- and ROM exercises emphasizing composite flexion of the fin-
ometer arms correctly over the first and second metacarpal with gers distal to the site of adhesion. I would not choose to do joint
the axis at the CMC joint can be difficult, and practice with an mobilization or individual joint stretches, ultrasound, or heat to
experienced therapist is recommended. an individual joint. However, if the assessment shows individual
joint stiffness, my treatment choice would include joint mobiliza-
Clinical Problem Solving tion (when passive motion is allowed), modalities to the limiting
joint structures, as well as AROM and PROM of the individual
When ROM of the digits is limited, it is important to determine joint and composite motion to encourage functional use of the
whether the limited ROM is due to joint stiffness, extrinsic ten- injured hand.
don tightness or adhesions, or intrinsic tightness. Perform this
type of assessment as soon as active and passive motion is allowed
because it dictates the most appropriate type of treatment by Swelling
determining the limiting structure(s).
Follow these steps: Swelling of the hand occurs after every surgery or injury to some
Step 1: Measure and record composite flexion and composite extent and is the normal response of the body to injury, bring-
extension of the digits with the wrist in neutral to slight exten- ing cells that are important for healing to the injured area. Nor-
sion. mal reduction of swelling begins within 2 weeks of the injury or
Step 2: Compare composite flexion and extension of the fin- surgery but may take a number of months to complete. Exces-
gers with the wrist fully extended and fully flexed (to determine sive edema or edema that is not decreasing gradually but instead
whether extrinsic tendon tightness or adhesions are present). remains in an area longer than 2 weeks can become problematic
Step 3: Screen ROM of each finger joint separately with the because it becomes more like gel, interfering with joint and ten-
proximal joints supported in neutral (to determine whether don motion and functional use of the hand.
limited motion is isolated to the joint, regardless of the posi- Precaution. Awareness of edema and assessment of the amount
tion of the proximal joints). and characteristics of edema present are critical.
Step 4: Perform passive motion of the digits. Comparison of As discussed in Chapter 3, numerous types of swelling occur
passive motion to active motion provides information regard- in the extremity. Inflammatory edema that occurs after injury,
ing tendon adhesions that may be limiting active motion. surgery, or other insult is initially fluid but over time may become
The following is a description of the causes of finger joint spongy and eventually fibrotic and thus more resistant to meth-
motion limitations in each of the screened positions: ods aimed at reducing the swelling.

the same regardless of the position of proximal joints, the limi- Amount of Swelling
tation is due to joint stiffness.
The amount of swelling in the hand and wrist is assessed most
flexion is due to weak or paralyzed flexor muscles, or flexor often using circumferential and volumetric measurements. The
tendon adhesion or rupture. characteristics of edema typically are evaluated by observation
and palpation.
active extension is due to weak or paralyzed extensor muscles,
or extensor tendon adhesion or rupture. Volumetric Displacement
Equipment
with the proximal joint(s) in extension than with the proximal The volumeter kit available in supply catalogues includes the
joint(s) in flexion, the limited flexion is due to extrinsic exten- volumeter tank, a collection beaker, and graduated cylinder for
sor tendon tightness or adhesions. measuring the displaced water. A hand volumeter and arm volu-
meter are available.
with the proximal joint(s) in flexion than extension, the limited
extension is due to extrinsic flexor tendon tightness or adhe- Method
sions. Always use the same level surface for each test. The client’s hand
must be free of jewelry or other objects. If jewelry cannot be
the MPl joint flexed than when the MP joint is extended, the removed, document such.
limitation is due to intrinsic tightness. Follow these steps:12
Treatment choices can be made accordingly. For example, Step 1: Fill the volumeter with room temperature water to the
when limited flexion is due to tight or adherent extensor tendons, point of overflow, to allow an accurate starting point. Allow
treatment should address the extensor tendon length and ability excess water to flow out into a beaker, and then empty the
to glide, not the motion at individual joints. This type of situ- beaker.
ation occurs frequently following an open reduction and inter- Step 2: Position the hand so that the palm faces the client and
nal fixation of a metacarpal fracture with scar tissue adhesions the thumb faces the spout of the volumeter. Keep the hand
to underlying extensor tendons. My treatment choice would as vertical as possible; avoid contact with sides of volumeter
 Evaluation of the Hand and Upper Extremity CHAPTER 5 77

A B
FIGURE 5-8 A, Edema measurement using the volumeter. The water that is displaced by immersion of the
hand and distal forearm into the volumeter overflows into a collection beaker. B, Volumeter measurement
is completed when the water from the collection beaker is poured into a graduated cylinder for accurate
reading.

(surfaces that are too high prevent the client from placing the forearm at the edge of the water when it is lowered into the
the arm straight down into the volumeter). water on the first trial. When swelling is reduced, it is possible
Step 3: Lower the hand slowly into the volumeter until the for the hand and forearm to be lowered further into the volu-
dowel in the volumeter is firmly seated between the middle meter because the web space between the fingers that is used as a
and ring fingers. Collect the displaced water in the beaker. stopping point against the dowel may deepen as swelling reduces.
Hold the hand still in the volumeter until water stops drip- Thus there are times when I see a significant decrease in edema of
ping into the collection beaker (Fig. 5-8, A). the hand; however, because the forearm is lowering deeper into
Step 4: Pour the displaced water from the beaker into the gradu- the volumeter, there is little if any change in the volumeter read-
ated cylinder for final measurement (see Fig. 5-8, B). ing. Ensuring that the hand and forearm are lowered to the same
Step 5: Repeat the previous steps if you would like to average depth on each repeat test minimizes this variable.
results for increased accuracy.
Step 6: Compare the volume to the other hand to determine a Circumferential Measurement
relative normal for the individual and to determine whether Equipment
a systemic increase in volume is occurring. The difference Tape measure or tape measure/loop for finger circumference is
between the two extremities is the most valuable informa- available in catalogs. When measuring circumference, identify
tion because there is a normal daily variance in volume, even the area being measured in relation to anatomic landmarks, and
in uninjured extremities. This test has been determined to use the same amount of tension on the tape measure for each test.
be accurate to 5 mL, or 1% of the volume of the hand.
Therefore a 10-mL difference is considered a significant Method
change from one measurement to the next.13 Follow these steps:
Precaution. Volumetric measurement should not be performed Step 1: Apply tape measure around area to be measured.
with open wounds, with an unstable vascular status, casts, exter- Step 2: Tighten lightly (Fig. 5-9).
nal fixators, percutaneous pins, or other nonremovable supports or Step 3: Record the circumference. Be sure to note exactly
attachments to the extremity. where tape was placed; for example, 4 cm proximal to
radial styloid, around radial styloid and distal ulna, proxi-
Discussion mal phalanx, or PIP joint. Note positioning, such as elbow
To increase reliability with volumetric testing, it has been helpful flexed or extended, wrist neutral, or fingers relaxed or
in my experience to use a waterproof marker to mark the spot on extended.
78 PART 1 Fundamentals

Discussion tissue that can be displaced by pressure, leaving a pit that slowly
Consistency of repeat measurements with a tape measure is fills back up when the pressure is removed14 (Fig. 5-10).
difficult because the tightness with which the tape measure is As the edema becomes more spongy and gel-like, it will refill
applied can vary with each application. Having the same thera- more slowly than fluid edema. As time goes on, if the edema
pist perform repeat measurements can help decrease variability becomes very firm, it will decrease the ability of the fluid to move
of tightness. out of the way with pressure and no longer will be pitting. The
more firm edema is characterized as brawny edema and usually
Characteristics of Edema is caused by the interstitial fluid becoming clogged, preventing
it from moving easily.12 The terms mild, moderate, and severe
Observation can be used to quantify the extent of the pitting or brawny char-
The skin becomes shiny and more taut with loss of wrinkles or acteristic; however, this is a subjective observation made by the
joint creases when there is an increase in swelling. A description examiner.
of the appearance of the skin may be documented. The evaluation
form may have a checklist to choose from a variety of options,
such as shiny, dry, and partial or full loss of joint creases. The Sensation
color of the skin is also helpful to document and can be described
as having increased redness (erythema), bluish tinge (cyanosis), or Static Two-Point Discrimination
pallor (loss of normal color).
The static two-point discrimination test measures innervation
Palpation density (the number of nerve endings present in the area tested).
Pressure with the examiner’s finger into the swollen area may Flexor zones I and II are tested (the area between the distal pal-
allow an indent into the swelling and may provide feedback as mar crease and the fingertips). Two-point discrimination deter-
to the firmness of the swelling. If the examiner’s finger is able to mines the ability to discern the difference between one and two
push into a soft edema fairly quickly, it is characterized as pitting points and relates to clients’ ability to determine not only if they
edema, which is made up of large amounts of free fluid in the can feel something but also what they are feeling.

Equipment
The device used for this test is the Disk-Criminator, also known
as the Boley gauge, and is available in therapy supply catalogs.

Method
Follow these steps:15,16
Step 1: Instruct the client to respond to each touch, with vision
occluded, by saying “one point” or “two points.”
Step 2: Support the client’s hand to avoid movement of fingers
when touched by the point(s). Putty commonly is used as a
support for the fingers.
Step 3: Occlude the client’s vision. Begin at 5 mm. Touch the
client’s fingertip with one or two points, randomly applied
(Fig. 5-11).
Step 4: The force of the touch pressure is just to the point of
FIGURE 5-9 Edema measured using circumferential finger tape blanching, in a longitudinal direction to avoid crossing digi-
available in therapy supply catalogs. tal nerve innervation in the finger, perpendicular to the skin.

A B
FIGURE 5-10 A and B, Pitting edema is seen when pressure from the examiner’s finger leaves an indent, or
“pit,” when removed.
 Evaluation of the Hand and Upper Extremity CHAPTER 5 79

Step 5: Increase or decrease the distance between the two points. Step 3: Occlude the client’s vision.
If the client is unable to discriminate two points correctly at Step 4: Instruct the client to respond with either “one” or “two”
5 mm, increase the distance between the points. If the client to the stimulus provided.
is able to discriminate two points correctly at 5 mm, decrease Step 5: Application is from proximal to distal on the volar distal
the distance, and continue until you have determined the phalanx of the fingertip. The points are longitudinal to the
smallest distance the client can discriminate as two points. axis of the finger and are placed perpendicular to the skin.
Step 6: Begin distally and work proximally from fingertips to Move the points along the fingertip only, from proximal to
distal palmar crease. distal. Speed has not been addressed.
Step 6: Begin with a distance of 5 to 8 mm, and increase or
Discussion decrease as needed.
Seven out of ten correct responses in one area are required for Step 7: Lift the points off the tip of the finger. Do not allow the
a correct response. Box 5-2 describes two-point discrimination points to come off the tip of the finger separately because
scoring. this gives the client information that it was two points.

Moving Two-Point Discrimination Discussion

Seven of ten correct responses are needed for an accurate
According to Dellon,17 moving two-point discrimination always response. Two millimeters is considered normal moving two-
returns earlier than static two-point discrimination after nerve point discrimination. A common error is to press too hard dur-
laceration, and it approaches normal 2 to 6 months before static ing the testing process, and inconsistency in amount of pressure
two-point discrimination. This test is used to determine progress placed on the device and skin is the main problem with reliability
in return of sensation following nerve injury. of this test.

Equipment Touch/Pressure Threshold Test (Semmes-Weinstein

The device used for this test is the Disk-Criminator, or Boley Monofilament Test)
gauge.
This test determines light touch thresholds. The test is effective
Method in identifying impairments in nerve compression injuries.
Follow these steps:17
Step 1: Describe the test to the client. Equipment
Step 2: Fully support the client’s hand. The Semmes-Weinstein Pressure Aesthesiometer Kit is available
in catalogs with 5 or 20 monofilaments. The monofilaments are
color-coded with green monofilaments indicating light touch
within normal limits, blue monofilaments indicating diminished
light touch, purple monofilaments indicating diminished protec-
tive sensation, and red monofilaments indicating loss of protec-
tive sensation. If only the largest monofilament is felt, it indicates
deep pressure sensation only; and if the largest monofilament is
not felt, it indicates that light touch sensation is “untestable”
(Table 5-1).15 The 5-monofilament screening kit contains the
largest monofilament in the categories of normal, diminished
light touch, diminished protective sensation, and the small-
est and largest monofilament in the loss of protective sensation
category.

TABLE 5-1 Semmes-Weinstein Monofilament

FIGURE 5-11 Two-point discrimination test is performed with the Categories/Scoring15
points placed longitudinally onto the skin of the fingertips with pres-
sure just to the point of blanching. Monofilament
Color Code Definition Size Range
Green Normal light touch 1.65 to 2.83
threshold
BOX 5-2 Static Two-Point Discrimination
Scoring15,16 Blue Diminished light touch 3.22 to 3.61
Purple Diminished protective 3.84 to 4.31
1-5 mm = Normal sensation
6-10 mm = Fair Red Loss of protective 4.56 to 6.65
11-15 mm = Poor sensation
One point perceived = Protective sensation only
Untestable Unable to feel largest —
No points perceived = Anesthetic monofilament
80 PART 1 Fundamentals

Step 2: Provide a light touch stimulus to an area. Place a dot on

the hand map where the stimulus was placed.
Step 3: Following the client’s response, if touch is felt in another
place than given, draw an arrow pointing to the location the
client felt touch from the location given. If the client did
feel touch where given, draw the dot alone.

Additional Tests
Additional tests for assessing sensation are the following:15
Ninhydrin test: Used to evaluate sudomotor or sympathetic ner-
vous system function. It does not require a voluntary response
from the client and therefore can be used for children or indi-
viduals with cognitive impairments. Ninhydrin spray is a clear
FIGURE 5-12 Semmes-Weinstein monofilament test measures agent that turns purple when it reacts with a small concentra-
touch force threshold. tion of sweat. The individual’s hand is cleansed and air dried
for at least 5 minutes. The fingertips are then placed on bond
paper for 15 seconds, and traced. The paper is sprayed with
Method the ninydrin spray reagent and dried according to directions.
Follow these steps:15 The prints are then sprayed with the ninhydrin fixer reagent,
Step 1: Describe the test to the client. and areas where sweat is present will appear as dots. The test
Step 2: Support the client’s hand on a rolled towel to prevent identifies areas of distribution of sweat secretion after recent,
the fingers from moving with the touch. complete peripheral nerve lesions. No sweat will be present in
Step 3: Occlude the client’s vision with a screen or folder. a particular nerve’s innervation area after a complete nerve lac-
Step 4: Instruct the client to respond with “touch” each time a eration.
touch is felt. O’Riain wrinkle test: Used to evaluate sympathetic nervous sys-
Step 5: Begin with the largest monofilament in the normal cat- tem function or recovery following a complete nerve lesion.
egory (2.83). Proceed to larger monofilaments if there is no Denervated palmar skin does not wrinkle when soaked in 42°
response. C (108° F) water for 20 to 30 minutes, as normal skin will.
Step 6: For the smaller monofilaments, sizes 1.65 to 4.08 (green Vibration: Used to determine frequency response of mechano-
and blue categories), the filament needs to be applied for receptor end organs. Tuning forks of 30 and 256 cps are most
three trials. One correct response to the three trials is con- frequently used. It has been noted that there is currently no
sidered a correct response. All larger monofilaments are equipment that controls for force and technique at this time.15
applied only one time for each trial. Moberg’s pick-up test: Used to determine tactile gnosis, or func-
Step 7: Begin testing distally and move proximally. tional discrimination. Using specific small objects, the client
Step 8: Apply the monofilament perpendicular to the skin until picks the objects up with each hand and is timed, with vision
the monofilament bends. Apply it slowly (1 to 1½ seconds) and without vision. The time to place the objects in the box
to the skin, hold for 1 to 1½ seconds, and then lift slowly (1 with and without vision is recorded, and the quality of move-
to 1½ seconds) (Fig. 5-12). ment and use or disuse of specific digits is observed.
Step 9: Record on a hand map the monofilament size that the
client correctly perceives. Discussion
Localization of Light Touch Although it is helpful to be aware of the battery of sensory evalu-
ations described, a standard screening of sensation is limited to
The localization of light touch test is used to determine func- one or two assessments. I recommend use of the Semmes-Wein-
tional ability to locate touch on the hand.15 The ability to local- stein monofilaments for nerve compressions (such as, carpal tun-
ize light touch returns after light touch threshold and can cause nel or cubital tunnel syndrome), and monofilaments, two-point
significant problems following a nerve repair. discrimination testing, and functional test (such as, Moberg
pickup test) following a nerve injury or laceration. Following a
Equipment nerve laceration, touch threshold (Semmes-Weinstein monofila-
The equipment needed is the Semmes-Weinstein monofilament ments) will show an improvement before the ability to discrimi-
(the smallest monofilament to be determined intact on threshold nate touch (two-point discrimination).
testing described previously). If monofilaments are not available,
a cotton ball or pencil eraser has been used. It is important to use
the same item for retests. Coordination
Method Coordination is the ability to manipulate items in the environ-
Follow these steps: ment. This ranges from gross coordination to fine coordination
Step 1: Describe the test to the client. The client is to open his tasks. A large number of standardized coordination tests are
or her eyes and point to the location the touch was felt after available with methodology available for each test. Standardized
the stimulus is given. coordination tests include O’Connor Dexterity Test, Nine-Hole
 Evaluation of the Hand and Upper Extremity CHAPTER 5 81

Peg Test, Jebsen-Taylor Hand Function Test, Minnesota Rate determined to be accurate and reliable. Annual calibration is rec-
of Manipulation Test, Crawford Small Parts Dexterity Test, and ommended and should be done more often in high-use settings.
the Purdue Pegboard Test.18 A simple test for a quick screen- Do not ignore calibration. Pinchmeters are commercially avail-
ing of coordination is the Nine-Hole Peg Test.18,19 This test is able; however, no one specific type is endorsed by the aforemen-
standardized yet allows use of a low-cost homemade board and tioned associations.
pegs. The Jebsen-Taylor Hand Function Test assesses functional
tasks, such as writing, as well as the ability to manipulate large Method
and small items.18,20 The methodology is available with each test The client is seated with shoulder adducted, elbow flexed to 90
and will not be specified in this chapter because of the number of degrees, and forearm and wrist neutral. The therapist places the
tests available. Use of a standardized test is helpful particularly for dynamometer in the client’s hand while gently supporting the base
clients whose injuries might affect their coordination. of the dynamometer, and he/she instructs the client to squeeze as
hard as possible. Grip force should be applied smoothly, with-
out rapid jerking motion. Allow the wrist to extend during the
Strength Testing grip.18,21
Consider the following:
Grip and Pinch Strength Testing Standard grip test: Three trials on the second handle-width
setting.
Grip and pinch strength testing is the standard method used Five-level grip test: One trial on each of the five handle-width
for decades to determine functional grasp and pinch strength. settings. This test is used to determine a bell curve when
The tests are used initially and in periodic retests to demonstrate graphed. The strongest grip is almost always on the second or
improvement in the strength available to grasp or pinch. Contra- third handle-width setting. The weakest grips normally occur at
indications are noted in the following discussion. the most narrow and widest settings with scores on the middle
three handle settings falling between the strongest and weakest
Contraindications scores, assimilating a bell curve. Lack of maximal effort may be
a possibility when the five handle setting scores show a flat line
Do not perform these tests when resistance has not yet been when graphed, where readings at all handle settings are almost
approved by the referring physician. Grip and pinch strength the same, or when there is an up/down-up/down type of curve.
testing are maximally resistive tests. Testing is contraindicated Rapid exchange grip test: The examiner rapidly moves the dyna-
before full healing following a fracture, ligament repair, tendon mometer, alternating from the client’s right to left hands, for
laceration, or tendon transfer of the forearm, wrist, or hand, or as ten trials to each hand. This test had been thought to prevent
determined by the referring physician. voluntary control of grip strength by the client, making it more
Precaution. An acute joint, ligament, or tendon injury or sprain difficult for a client to self-limit the grip response or provide
of a digital joint or wrist are contraindications for maximal grip or less than maximal effort.22 More recently, Schectman and col-
pinch strength testing until resistive exercises are appropriate. leagues23-25 have articulated well-founded concerns about the
For any traumatic injury, I defer testing of grip or pinch methods with which clinicians interpret sincerity of effort of
strength until resistive exercises or strengthening have been grip tests. Their work provides some thought-provoking find-
approved by the referring physician. For a gradual-onset condi- ings on the topic.
tion or injury (such as, tendinopathy or carpal tunnel syndrome),
I will test strength at the time of initial evaluation, even though Discussion
my initial treatment plan may not include strengthening until the Normative data exists for grip and pinch strength testing.26 In
level of pain decreases. At the time of initial evaluation for this addition, the American Society of Hand Therapists recommends
type of condition, I modify the instructions and tell the client that you compare readings with the client’s opposite extremity if
to stop grasping when mild pain occurs to prevent an increase it is uninjured.
in pain following use of the test, and I document when pain
does occur with the test. Determination of initial grip and pinch Pinch Strength Test
strength for tendinopathy or nerve compressions is important to
determine future progress.
Equipment
The device used is the pinchmeter (styles vary).
Clinical Pearl
Method
The question to always ask yourself before performing
With the client seated, elbow flexed to 90 degrees with arm
strength testing is whether there are any healing tissues that
adducted at side, and forearm neutral, proceed as follows:18
can be damaged by this test.
Lateral pinch (key pinch): Place the pinchmeter between the
radial side of index finger and thumb, and instruct the client to
pinch as hard as possible.
Grip Strength Test Three-point pinch (three jaw chuck pinch): Place the pinchme-
ter between the pulp of the thumb and pulp of the index and
Equipment
middle fingers. Instruct the client to pinch as hard as possible.
To assess grip strength, the Jamar dynamometer is recom- Two-point pinch (tip to tip pinch): Place the pinchmeter between
mended by the American Society for Surgery of the Hand and the tip of the thumb and tip of the index finger, and instruct
the American Society of Hand Therapists.18,21 The test has been the client to pinch as hard as possible.
82 PART 1 Fundamentals

Discussion Functional Use

Repeat each test three times and calculate an average. Calibrate
equipment at least annually. Functional use is an area that should be assessed as part of every
evaluation. This portion of the evaluation is important to deter-
Manual Muscle Test mine functional goals with the client and to document them for
the insurance company. Determining difficulty in daily activities
Manual muscle strength is essential to test and document for helps you set goals in conjunction with the clients’ perception
improvement when there is weakness related to a nerve injury or of their needs. This area often is forgotten or bypassed in a busy
compression. Identifying the strength of various muscles along clinic situation. Discussing functional limitations and goals helps
a specific nerve distribution helps determine the level of nerve clients recognize that the therapist is aware of the ways that their
injury and improvement over time. Measurement of manual injury affects their life and gives them confidence that they are
muscle strength also is helpful in order to document improve- working together toward common and meaningful goals.
ment when weakness is present because of disuse, such as after
prolonged immobilization. Equipment
Equipment A checklist to help the client think of areas in which they are suc-
Manual muscle testing is a form of strength testing that measures cessful or in which they have difficulty may be helpful. Categories
the client’s ability to move the body part being tested against such as self-care skills, home management (outdoor and indoor),
gravity and, if able to move fully against gravity, to maintain the and vocational tasks can be included. The evaluation summary
position against the examiner’s resistance. Thus the only equip- form (see Appendix 5-1) may include a list of common tasks,
ment needed is a reference book and a form on which to record such as opening containers or performing fasteners. Some thera-
the results. pists prefer to take notes about specific functional tasks that the
client describes as difficult. Please see Chapter 8 for more about
Method functional assessments.
Manual muscle testing is performed according to methods docu-
mented in numerous sources. Strength is graded according to Method
normal, good, fair, poor, and trace strength definitions—with
fair strength defined as the ability to move the body part through Functional use is assessed through discussion with the client or
its full available range against gravity, although not able to toler- simulation of activities. The extremity may be completely non-
ate any additional resistance. Also acceptable is a number grading functional because of the presence of a cast and/or limitations
system where 5 corresponds to normal, 4 to good, 3 to fair, 2 to due to the injury, such as a flexor tendon repair in the early
poor and 1 to trace strength. Description of the method of apply- stage of healing, a complex injury, inability to move the digits to
ing resistance to each muscle of the hand, wrist, and forearm is grasp an object, loss of muscle innervation, or loss of sensation.
beyond the scope of this chapter. An excellent reference for spe- In these cases, to list all the functional tasks that are limited is
cific testing procedures for each muscle is found in Muscles: Test- impossible, and it may be more appropriate to state the limita-
ing and Function by Peterson Kendall, et al.27 I recommend use tions such as, “Unable to use the right upper extremity for any
of a form designed for manual muscle testing with the muscles functional tasks other than support of a light object using the
listed in relation to their nerve innervation, as described in this forearm, as the hand is unable to grasp.” At the other extreme
reference. may be a client with a single digit injured with hypersensitivity
that limits fine coordination. In this case, it may be possible to
Discussion list specific task limitations. I prefer to include the category of
Manual muscle testing is contraindicated in the same situations functional use as the last section of the evaluation documenta-
as for grip and pinch strength testing, or when pain prevents full tion. Following documentation of the status of pain, wounds/
effort by the client. Because manual muscle testing is a maximally scars, ROM, sensation, and strength, the functional use state-
resistive test, any injury with healing tissues (bone, ligament, and ment becomes a reflection of the way that the previously noted
tendon) that could be reinjured should not be tested until deter- deficits affect the client’s daily life.
mined to be safe by the referring physician or the appropriate In some situations, time limitations may preclude an in-depth
time after surgery allows resistance. assessment of all areas of the upper extremity in one session. A
Precaution. Finger or thumb tendon repairs are not sufficiently screening of some sections may be done with a full assessment
strong to test until 14 weeks after surgery. deferred to the next session. For instance, I may screen the area
of sensation by asking about the client’s sensation and may defer
monofilament or two-point discrimination testing to the next
Use of Orthotics visit.

Many clients have obtained their own orthotic or have been given
a prefabricated orthotic by their primary or referring physicians. Summary
Determine the use of any orthotics and the amount of time and
activities during which they are worn. This information is help- Awareness of the areas to include in a thorough evaluation is
ful in determining the client’s functional limitations and allows enhanced by use of an evaluation summary form (see Appendix
you to offer insight into the appropriate use of orthotics for the 5-1), which facilitates the logical progression through the steps of
client’s condition (see Chapter 7). the evaluation.
 Evaluation of the Hand and Upper Extremity CHAPTER 5 83

Precaution. Awareness of situations in which it is unsafe to per- also by listening as the client attempts to communicate verbally
form certain assessments is essential. and nonverbally. The information gained during the assessment
Much evaluation is done by observation. Effectiveness as a process is the foundation upon which treatment choices rest, and
therapist is enhanced when the therapist takes the time to com- the connection the therapist makes with each new client is the
municate well with a new client during the evaluation. This foundation upon which the client’s confidence in the treatment
occurs not only by describing the process of the assessments but rests. Both are equally important.

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 Evaluation Summary
Appendix 5-1 Form

History of Injury/Condition __________________________________________________________________________

_____________________________________________________________________________________________________
Pertinent Medical History: __________________________________________________________________________

Pain Level