PNF Techniques in the Upper Extremity

PNF Techniques in

The Upper Extremity

MUHAMMED KOCABIYIK

PHYSICAL MEDICINE & REHABILITATIONIV. CLASS V. GROUP

Introduction and BasicProcedures

Upper extremity patterns are used to treat dysfunction caused by neurologic problems, muscular disorders or joint restrictions. These patterns are also used to exercise the trunk. Resistance to strong arm muscles produces irradiation to weaker muscles elsewhere in the body. We can use all the techniques with the arm patterns. The choice of individual techniques or combinations of techniques will depend on the patient’s condition and the treatment goals. You can, for instance, combine Dynamic Reversals with Combination of Isotonics, Repeated Contractions with Dynamic Reversals, or, Contract-Relax or Hold- Relax with Combination of Isotonics and Dynamic Reversals.

Diagonal MotionThe upper extremity has two diagonals:

1. Flexion–abduction–external rotation and extension–adduction–internal rotation

2. Flexion–adduction–external rotation and extension–abduction–internal rotation

Flex.-Add.-ERSupinationRadial

abductionPalmar flexionFinger flexionAdduction

finger

• Flex.-Abd.-ER• Supination• Radial

abduction• Dorsal

extension• Finger

extension• Abduction

finger

• Ext.-Add.-IR• Pronation• Ulnar

abduction• Palmar flexion• Finger flexion• Adduction

finger

• Ext.-Abd.-IR• Pronation• Ulnar

abduction• Dorsal

extension• Finger

extension• Abduction

finger

Patient PositionSupport the patient’s head

and neck in a comfortable position, as close to neutral as possible. Before beginning an upper extremity pattern, visualize the patient’s arm in a middle position where the lines of the two diagonals cross. Starting with the shoulder and forearm in neutral rotation, move the extremity into the elongated range of the pattern with the proper rotation, beginning with the wrist and fingers.

Therapist Position• All grips described in the

first part of each section assume that the therapist is in this position. We give the basic position and body mechanics for exercising the straight arm pattern. When we describe variations in the patterns we identify any changes in position or body mechanics. The therapist’s position can vary within the guidelines for the basic procedures.

ResistanceThe direction of the resistance is an arc back toward the starting

position. The angle of the therapist’s hands and arms changes as the limb moves through the pattern.

Traction and ApproximationTraction and approximation are an important part of the resistance. Use

traction at the beginning of the motion in both flexion and extension. Use approximation at the end of the range to stabilize the arm and scapula.

Normal Timing and Timing for EmphasisNormal TimingThe hand and wrist (distal component) begin the pattern, moving

through their full range. Rotation at the shoulder and forearm accompanies the rotation (radial or ulnar deviation) of the wrist. After the distal movement is completed, the scapula moves together with the shoulder or shoulder and elbow through their range. The arm moves through the diagonals in a straight line with rotation occurring smoothly throughout the motion.

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

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

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

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

Repeated Stretch (Repeated Contractions) during the motion facilitates a stronger motion or guides the motion into the desired direction. Repeated Stretch at the beginning of the pattern is used when the patient has difficulty initiating the motion and to guide the direction of the motion. To get the stretch reflex the therapist must elongate both the distal and proximal components. Be sure you do not overstretch a muscle or put too much tension on joint structure. This is particularly important with the wrist joint.

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

irradiation into all other parts of our body. The patient’s position in combination with the amount of resistance controls the amount of irradiation. We use this irradiation to strengthen muscles or mobilize joints in other parts of the body, to relax muscle chains, and to facilitate a functional activity such as rolling.

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

Scapula Posterior elevation Trapezius, levator scapulae, serratus anterior

Shoulder

Flexion, abduction, external rotation

Deltoid (anterior), biceps (long head), coracobrachialis, supraspinatus, infraspinatus, teres minor

Elbow Extended (position unchanged)

Triceps, anconeus

Forearm Supination Biceps, brachioradialis, supinator

Wrist Radial extension Extensor carpi radialis (longus and brevis)

Fingers Extension, radial deviation

Extensor digitorum longus, interossei

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

Flexion – Abduction – External Rotation

Flexion–abduction–external rotation. a Starting position; b mid-position; c end position; d emphasizing the motion of the shoulder. e Patient with right hemiplegia. Flexion–abduction external rotation: proximal hand for scapula posterior elevation and trunk elongation

a b c

d e

Hand positions Distal HandYour right hand grips the dorsal surface of the patient’s

hand. Your fingers are on the radial side (1st and 2nd metacarpal), your thumb gives counter pressure on the ulnar border (5th metacarpal).There is no contact on the palm.

Proximal Hand From underneath the arm, hold the radial and ulnar sides

of the patient’s forearm proximal to the wrist. The lumbrical grip allows you to avoid placing any pressure on the anterior (palmar) surface of the forearm.

MovementsThe fingers and thumb extend as the wrist moves into radial

extension. The radial side of the hand leads as the shoulder moves into flexion with abduction and external rotation. The scapula moves into posterior elevation. Continuation of this motion is an upward reach with elongation of the left side of the trunk.

Flexion – Abduction – External Rotation with Elbow Flexion

Flexion abduction external rotation with elbow flexion. a–c Usual position of the therapist; d, e alternative position with therapist on the other side of the table ,f Patient with hemiplegia, the patient is asked to touch his head

Joint Movement

Muscles: principal components (Kendall and McCreary 1993)

Elbow Flexion Biceps, brachialis

a b c

d e f

Flexion – Abduction – External Rotation with Elbow Extension

Joint Movement


Elbow Extension Triceps, anconeus

a b c

Flexion-abduction-external rotation with elbow extension. a, b Standard grips; c Grip variation

Extension – Adduction – Internal RotationJoint Movement Muscles: principal components

(Kendall and McCreary 1993)

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

Shoulder

Extension, adduction, internal rotation

Pectoralis major, teres major, subscapularis


Triceps, anconeus

Forearm Pronation Brachioradialis, pronator (teres and quadratus)

Wrist Ulnar flexion Flexor carpi ulnaris

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

Thumb Flexion, adduction, opposition

Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis

a b

a,b. Extension-adduction-internal rotation

Hand positions Distal HandYour left hand contacts the palmar surface of the 0patient’s

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

Proximal HandYour right hand comes from the radial side and holds the

patient’s forearm just proximal to the wrist. Your fingers contact the ulnar border. Your thumb is on the radial border.

MovementsThe fingers and thumb flex as the wrist moves into ulnar

flexion. The radial side of the hand leads as the shoulder moves into extension with adduction and internal rotation and the scapula into anterior depression. Continuation of this motion brings the patient into trunk flexion with neck flexion to the right.

Extension – Adduction – Internal Rotation with Elbow Extension

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

Elbow Extention Triceps, anconeus

a b c

a-c. Extension-adduction-internal rotation with elbow extension

Extension – Adduction – Internal Rotation with Elbow Flexion

Joint Movement



Extension-adduction-internal rotation with elbow flexion. a–c Standard grips; d,e grip variations

a b c

d e

Flexion – Adduction – External RotationJoint Movement Muscles: principal components


Scapula Anterior elevation Serratus anterior (upper), trapezius

Shoulder

Flexion, adduction, external rotation

Pectoralis major (upper) deltoid (anterior), biceps, coracobrachialis


Triceps, anconeus

Forearm Supination Brachioradialis, supinator

Wrist Radial flexion Flexor carpi radialis

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

Thumb Flexion, adduction opposition

Flexor pollicis (longus and brevis), adductor pollicis, opponens pollicis

a,b. Flexion–adduction–external rotation

a b

Hand positions Distal HandYour right hand contacts the palmar surface of the

patient’s hand. Your fingers are on the ulnar side (5th metacarpal), your thumb gives counter pressure on the radial side (2nd metacarpal). There is no contact on the dorsal surface.

Proximal HandYour left hand grips the patient’s forearm from

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

MovementsThe fingers and thumb flex as the wrist moves into radial

flexion. The radial side of the hand leads as the shoulder moves into flexion with adduction and external rotation and the scapula into anterior elevation. Continuation of this motion elongates the patient’s trunk with rotation toward the right.

Flexion – Adduction – External Rotation with Elbow Flexion

Joint Movement



a b c

a-c. Flexion–adduction–external rotation with elbow flexion

Flexion – Adduction – External Rotation with Elbow Extension



a-d. Flexion adduction – external rotation with elbow extension. a, b The therapist is standing on the same side of the table; c, d the therapist is standing on the other side of the table

c

db

a

e

e. Flexion–adduction–external rotation with elbow extension. Patient with right hemiplegia: the therapist’s proximal hand facilitates scapula anterior elevation and trunk elongation

Extension – Abduction – Internal RotationJoint Movement Muscles: principal components


Scapula Posterior depression Rhomboids

Shoulder

Extension, Abduction,Internal Rotation

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


Triceps, anconeus

Forearm Pronation Brachioradialis, pronator (teres and quadratus)

Wrist Ulnar extension Extensor carpi ulnaris

Fingers Extension, ulnar deviation

Extensor digitorum longus, lumbricales, interossei

Thumb Palmar abduction, extension

Abductor pollicis (brevis), Extensor pollicis

a-c. Extension-abduction-internal rotation

b ca

Hand positions Distal HandYour left hand grips the dorsal surface of the patient’s

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

Proximal HandWith your hand facing the ventral surface, use the

lumbrical grip to hold the radial and ulnar sides of the patient’s forearm proximal to the wrist.

MovementsThe fingers and thumb extend as the wrist moves into

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

Extension – Abduction – Internal Rotation with Elbow Extension



a-d. Extension-abduction-internal rotation with elbow extension. d Different proximal grip e-h. Extension-abduction-internal rotation with elbow extension. e-g The therapist on the opposite side of the table. h Patient with right hemiplegia: the therapist facilitates the scapula and trunk with her proximal hand

e f

b c d

g ah

a

Extension – Abduction – Internal Rotation with Elbow Flexion

Joint Movement



Extension–abduction–internal rotation with elbow flexion

ba

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PNF Techniques in the Upper Extremity