Shoulder: Flexion and Extension (Fig. 3.1)
Hand Placement and Procedure
Grasp the patient’s arm under the elbow with your lower hand.
With the top hand, cross over and grasp the wrist and palm of the patient’s hand.
Lift the arm through the available range and return. N O T E : For normal motion, the scapula should be free to rotate upward as the shoulder flexes. If motion of only the glenohumeral joint is desired, the scapula is stabilized as described in the chapter on stretching (see Chapter 4).
A
B
FIGURE 3.1 Hand placement and positions for (A) initiating and (B) complet- ing shoulder flexion.
FIGURE 3.2 Hyperextension of the shoulder (A) with the patient at the edge of the bed and (B) with the patient side-lying.
A
B
Shoulder: Extension (Hyperextension) (Fig. 3.2)
Alternate Positions
Extension past zero is possible if the patient’s shoulder is at the edge of the bed when supine or if the patient is posi- tioned side-lying, prone, or sitting.
Shoulder: Abduction and Adduction (Fig. 3.3)
Hand Placement and Procedure
Use the same hand placement as with flexion, but move the arm out to the side. The elbow may be flexed.
Scapula: Elevation/Depression, Protraction/Retraction, and Upward/Downward Rotation (Fig. 3.6)
Alternate Positions
The patient should be prone, with his or her arm at the side, or side-lying, with the patient facing the therapist and the patient’s arm draped over the therapist’s bottom arm (see Fig. 3.6B).
N O T E : To reach full range of abduction, there must be external rotation of the humerus and upward rotation of the scapula.
Shoulder: Horizontal Abduction (Extension) and Adduction (Flexion) (Fig. 3.5)
Patient Position
The patient’s shoulder must be at the edge of the table to reach full horizontal abduction. Begin with the arm either flexed or abducted 90⬚.
Hand Placement and Procedure
Hand placement is the same as with flexion, but turn your body and face the patient’s head as you move the patient’s arm out to the side and then across the body.
48 ROM TECHNIQUES
FIGURE 3.5 Horizontal (A) abduction and (B) adduction of the shoulder.
FIGURE 3.4 The 90/90 position for initiating (A) internal and (B) external rotation of the shoulder.
A B
A
B
Shoulder: Internal (Medial) and External (Lateral) Rotation (Fig. 3.4)
Patient Position
If possible, the arm is abducted to 90⬚, the elbow is flexed to 90⬚, and the forearm is held in neutral position. Rotation may also be performed with the patient’s arm at the side of the thorax, but full internal rotation is not possible in this position.
Hand Placement and Procedure
Grasp the hand and the wrist with your index finger between the patient’s thumb and index finger.
Place your thumb and the rest of your fingers on either side of the patient’s wrist, thereby stabilizing the wrist. With the other hand, stabilize the elbow.
Rotate the humerus by moving the forearm like a spoke on a wheel.
Hand Placement and Procedure
Cup the top hand over the acromion process and place the other hand around the inferior angle of the scapula. For elevation, depression, protraction, and retraction, the clavicle also moves as the scapular motions are directed at the acromion process.
For rotation, direct the scapular motions at the inferior angle of the scapula while simultaneously pushing the acromion in the opposite direction to create a force cou- ple turning effect.
FIGURE 3.7 Elbow flexion and extension with the forearm supinated.
FIGURE 3.6 ROM of the scapula with the patient (A) prone and with the patient (B) side-lying.
A
B
A
B
Elbow: Flexion and Extension (Fig. 3.7)
Hand Placement and Procedure
Hand placement is the same as with shoulder flexion except the motion occurs at the elbow as it is flexed and extended.
N O T E : Control forearm supination and pronation with
your fingers around the distal forearm. Perform elbow flex- ion and extension with the forearm pronated as well as supinated. The scapula should not tip forward when the elbow extends, as it disguises the true range.
Elongation of Two-Joint Biceps Brachii Muscle
Patient Position
To extend the shoulder beyond zero, position the patient’s shoulder at the edge of the table when supine or position the patient prone lying, sitting, or standing.
Hand Placement and Procedure
First pronate the patient’s forearm by grasping the wrist and extend the elbow while supporting it.
Then extend (hyperextended) the shoulder to the point of tissue resistance in the anterior arm region. At this point, full available lengthening of the two-joint muscle is reached.
Elongation of Two-Joint Long Head of the Triceps Brachii Muscle (Fig. 3.8)
Alternate Positions
When near-normal range of the triceps brachii muscle is available, the patient must be sitting or standing to reach the full ROM. With marked limitation in muscle range, ROM can be performed in the supine position.
Wrist: Flexion (Palmar Flexion) and Extension (Dorsiflexion); Radial (Abduction) and Ulnar (Adduction) Deviation (Fig. 3.10)
Hand Placement and Procedure
For all wrist motions, grasp the patient’s hand just distal to the joint with one hand and stabilize the forearm with your other hand.
N O T E : The range of the extrinsic muscles to the fingers affect the range at the wrist if tension is placed on them. To obtain full range of the wrist joint, allow the fingers to move freely as you move the wrist.
Forearm: Pronation and Supination (Fig. 3.9)
Hand Placement and Procedure
Grasp the patient’s wrist, supporting the hand with the index finger and placing the thumb and the rest of the fingers on either side of the distal forearm.
Stabilize the elbow with the other hand.
The motion is a rolling of the radius around the ulna at the distal radius.
Alternate Hand Placement
Sandwich the patient’s distal forearm between the palms of both hands.
N O T E : Pronation and supination should be performed
with the elbow both flexed and extended.
P R E C A U T I O N : Do not stress the wrist by twisting the hand; control the pronation and supination motion by moving the radius around the ulna.
50 ROM TECHNIQUES
FIGURE 3.10 ROM at the wrist. Shown is wrist flexion; note that the fingers are free to move in response to passive tension in the extrinsic tendons.
FIGURE 3.9 Pronation of the forearm.
FIGURE 3.8 End ROM for the long head of the triceps brachii muscle.
Hand Placement and Procedure
First, fully flex the patient’s elbow with one hand on the distal forearm.
Then flex the shoulder by lifting up on the humerus with the other hand under the elbow.
Full available range is reached when discomfort is expe- rienced in the posterior arm region.
Hand: Cupping and Flattening the Arch of the Hand at the Carpometacarpal and Intermetacarpal Joints (Fig. 3.11)
Hand Placement and Procedure
Face the patient’s hand; place the fingers of both of your hands in the palms of the patient’s hand and your thenar eminences on the posterior aspect.
Roll the metacarpals palmarward to increase the arch, and dorsalward to flatten it.
Alternate Hand Placement
One hand is placed on the posterior aspect of the patient’s hand, with the fingers and thumb cupping the
metacarpals.
N O T E : Extension and abduction of the thumb at the
carpometacarpal joint are important for maintaining the web space for functional movement of the hand. Isolated flexion-extension and abduction-adduction ROM of this joint should be performed by moving the first metacarpal while stabilizing the trapezium.
FIGURE 3.12 ROM to the metacarpophalangeal joint of the thumb.
FIGURE 3.11 ROM to the arch of the hand.
Joints of the Thumb and Fingers: Flexion and Exten- sion and Abduction and Adduction (Fig. 3.12)
The joints of the thumbs and fingers include the metacar- pophalangeal and interphalangeal joints.
Hand Placement and Procedure
Depending on the position of the patient, stabilize the forearm and hand on the bed or table or against your body.
Move each joint of the patient’s hand individually by sta- bilizing the proximal bone with the index finger and thumb of one hand and moving the distal bone with the index finger and thumb of the other hand.
Alternate Procedure
Several joints can be moved simultaneously if proper stabi- lization is provided. Example: To move all the metacar- pophalangeal joints of digits 2 through 5, stabilize the metacarpals with one hand and move all the proximal pha- langes with the other hand.
N O T E : To accomplish full joint ROM, do not place ten- sion on the extrinsic muscles going to the fingers. Tension on the muscles can be relieved by altering the wrist position as the fingers are moved.
Elongation of Extrinsic Muscles of the Wrist and Hand: Flexor and Extensor Digitorum Muscles (Fig. 3.13)
General Technique
To minimize compression of the small joints of the fingers, begin the motion with the distalmost joint. Elongate the muscles over one joint at a time, stabilize that joint, then elongate the muscle over the next joint until the multijoint muscles are at maximum length. This is particularly critical is there is restricted flexibility in the extrinsic musculature.
Hand Placement and Procedure
First move the distal interphalangeal joint and stabilize it; then move the proximal interphalangeal joint. Hold both these joints at the end of their range; then move the metacarpophalangeal joint to the end of the available range.
Stabilize all the finger joints and begin to extend the wrist. When the patient feels discomfort in the forearm, the muscles are fully elongated.
52 ROM TECHNIQUES
A
B
FIGURE 3.14 (A) Initiating and (B) completing combined hip and knee flexion.
Hip: Extension (Hyperextension) (Fig. 3.15)
Alternate Positions
Prone or side-lying must be used if the patient has near- normal or normal motion.
Hand Placement and Procedure
If the patient is prone, lift the thigh with the bottom hand under the patient’s knee; stabilize the pelvis with the top hand or arm.
If the patient is side-lying, bring the bottom hand under the thigh and place the hand on the anterior surface; sta- bilize the pelvis with the top hand. For full range of hip extension, do not flex the knee full range, as the two- joint rectus femoris would then restrict the range.
FIGURE 3.13 End of range for the (A) extrinsic finger flexors and (B) extensors.
B A