Interventions to Improve UE Skills

Question 1

Closed chain movements for UE rely on?

Answer 1

performed in weight bearing positions

Question 2

Open chain movements for UE are for?

Answer 2

ability to move in space (reaching). These movements rely on the coordination of the scapula, shoulder, elbow, forearm, wrist, hand, and fingers.

Question 3

Tx of the hemiparetic UE is extremely important why?

Answer 3

b/c of it’s influence on functional movements such as bed mobility, transfers, postural control, standing, walking, etc.

Question 4

If you find tightness in certain movements, you can use __________ in sitting. How would you modify these techniques?

Answer 4

Scapular mobilizations.

Modify to side lying position.

Question 5

What is the progression of mobilizations?

Answer 5

Lumbar first, Thorax, then Scapula

Question 6

During Scapula elevation mobilization, what is the alignment and primary muscles being mobilized?

Answer 6

Alignment: Facilitate pt into neutral/slight APT by pressing leg around back of pt where knee is at L-spine

PT firmly holds position and asks pt to slump into PPT*

Primary Muscles: Lower Trap, Lats Dorsi

Question 7

During Scapula Depression mobilization, what is the alignment and primary muscles being mobilized?

Answer 7

Alignment: Facilitate pt into neutral/slight APT by using leg behind back

PT instructs pt to slump slightly (don’t allow scapula to move upward) Then holds position and instructs patient to come back up into APT

Primary Muscles: Upper Trap, Levator Scap, Pec Minor

Question 8

During Scapula mobilization into Adduction, what is the alignment and primary muscles being mobilized?

Answer 8

Alignment: facilitate pt into APT

Hand Placement: one hand on scap with thumb and Thenar Eminence on axillary border of scap, the other hand comes around to stabilize the lateral ribs to make sure it does not rotate

Facilitation: put pt into APT with knee.
Instruct pt to weight shift away from you (relative adduction*).
Then hold scap in new range and have pt weight shift back to neutral as PT holds scap in new range, which increases ROM

Primary Muscle: Serratus Anterior

Question 9

During Scapula mobilization of abduction, what is the alignment and primary muscles being mobilized?

Answer 9

Alignment: Place pt in slight APT with knee

Hand Placement: one hand on scap with fingers (PIP’s) on vertebral border.
Instruct pt to weight shift towards you(relative abduction)
*Can help unweight the contralateral hip by placing foot under hip and DF foot
Hold scap in New range and have pt weight shift back to neutral, while PT holds new range increasing the ROM

Primary Muscles: Rhomboids, Middle and Lower Trap

Question 10

You have a patient that has increased tone in the hand, which results in a fisted position. What will this affect?

Answer 10

• ROM
• Skin on hand
• Increased sweating and skin breakdown

Question 11

What is the sequence of opening a hand with increased tone?

Answer 11

1. Start by rocking limb
2. Align the wrist to the forearm
3. Align the carpal bones to the radius and ulna by lifting and spreading
4. Support the wrist alignment with one hand
5. Move your other hand to fingers and keeping MP flexion, extend DIP’s and PIP’s (*Don’t touch palm!)
6. Use traction at the MP’s and bring them into extension
7. Lower hand to a weight bearing surface and place the hand down from the ulnar side first and work towards the thumb side

Can put hand on cloth or towel to preserve arches. Maintain arches and provide approximation over the thumb and little finger to get weight down into the thenar and hypothenar eminences

Question 12

What are the purposes of UE weight bearing? FORCED USE

Answer 12

• To support the weight of the upper trunk and body
• To lift or move the body mass during transitional movements
• To stabilize objects against a work surface for task performance

Question 13

What are the requirements with UE weight bearing?

Answer 13

• Movement in the trunk over the stable arm

- Arm muscle activity to maintain arm on the supporting surface while simultaneously supporting body weight

Question 14

Two Common Patterns of WB for UE in Sitting is?

Answer 14

• Forearm weight bearing-forearm and hand supported to bear weight
• Extended arm weight bearing- support body weight on hands when the arms are extended at the side of the body

Question 15

What is forearm weight bearing look like?

Answer 15

Easiest task.
Trunk and shoulder girdle actively “depress” into table.
This position is utilized often for stabilizing items during table top activities.
Use bedside tables- they can be raised or lowered to the appropriate height
Maintain arches Weight is taken through thenar and hypothenar eminences*

Question 16

What is forearm WB position utilized for?

Answer 16

• If pt can’t do prone on elbows
• For pt’s with poor muscular control of the trunk and a flaccid UE- help retrain trunk movements with weight shifts and support flaccid arm
• Activate muscles in the involved limb to take on WB
• Can be used to increase mobility of the scapula
• Can be used to lengthen tight muscles b/t the trunk and arm
• Can decrease flexor hypertonicity
• Can assist with opening a tightly fisted hand

Question 17

What happens during a lower trunk initiated weight shift while in forearm WB during an Anterior Pelvic Tilt? (*Seated wide grip row)

Answer 17

Trunk: Trunk extension
Scapula on WB Side: Depression, retraction,Downward rotation
Humerus on WB side: Extension & ER
Elbow/FA on WB side: Flexion, supination

Question 18

What happens during a lower trunk initiated weight shift while in forearm WB during an Posterior Pelvic Tilt? (Over hand bent over row in starting position*)

Answer 18

Trunk: Trunk flexion
Scapula on WB side: protracts, upward rotation, and elevation
Humerus on WB side: IR & Flexion
Elbow/FA on WB side: Pronation/Ext

Question 19

What happens during a lower trunk initiated weight shift while in forearm WB during an Lateral WB side (WS to convex side)?

Answer 19

Trunk: Elongation
Scapula on WB side: Elevation, ABD, Upward rotation
Humerus on WB side: ADD & ER
Elbow/FA on WB side: Supination

Question 20

What happens during a lower trunk initiated weight shift while in forearm WB during an Lateral NWB side (WS to decrease WB)

Answer 20

Trunk: Shortening
Scapula on WB side: Depression, ADD, downwardly rotate
Humerus on WB side: ABD & IR
Elbow/FA on WB side: pronation

Question 21

If you wanted to work on ER on a patient, which motion(weight shift) will improve ER?

Answer 21

Anterior Pelvic Tilt

Question 22

Which motion(weight shift) promote forearm WB for IR and Flexion of the humerus?

Answer 22

Posterior Pelvic Tilt

Question 23

If you wanted to work just on Elbow/FA pronation specifically, which motion(weight shift) will improve pronation?

Answer 23

Lateral NWB side (WS to decrease WB)

Question 24

What can extended arm weight bearing be utilized for?

Answer 24

• Increasing the stability of the body when balance is challenged
• It is a means of trunk support when sitting without a back support
• It can be used to transition from sitting to standing or sidelying to sitting
• One arm can be in WB and one arm can be free to perform a functional activity
• It is a good position to increase extension in the thoracic spine*
• It can assist in gaining strength of the adductors and upward rotators of the scapula
• It works to activate elbow extension and wrist extension in pattern of forward reach*
• It can lengthen hypertonic muscles in the shoulder, elbow, wrist, and fingers
• It can increase mobility of the scapula and shoulder joint through active movements
• It is more difficult than Forearm WB*

Question 25

First position that is used in extended arm WB: Sitting on edge of mat with fingers over the edge, Laterally along the thighs can help with?

Answer 25

* Most stable position - Can assist in the transfer of sit to stand - The shoulder is aligned in front of the hips & is IR - The thoracic spine is in slight flexion - The scapula is abducted and elevated - Can be used when patient has muscle tightness which limits ROM or when function calls for this position

Question 26

First position that is used in extended arm WB: Sitting on edge of mat with hands placed back towards the hip joint can help with?

Answer 26

* Least stable position - This will take the spine out of flexion and provide more extension - The scapula will adduct - The shoulder is in more abduction & ER

Question 27

First position that is used in extended arm WB: Sitting on edge of mat with hands behind the hips can help with?

Answer 27

* 2nd most stable position - This gives the most spinal extension and scapular adduction - The spine, scapula and shoulder need good mobility and range to attain this position*

Question 28

Weight bearing is important b/c it?

Answer 28

- Helps contribute to shoulder girdle stability and extension of the trunk - Establishes a reference point for midline - Starts to develop a ratio of tone in the UE - Helps develop balance reactions - *Co-contraction/normalization of tone * The UE has less of an opportunity to be in a WB position than the LE

Question 29

What would be a good object to use if your patient does not have full wrist movement?

Answer 29

A ball or inverted bowl

Question 30

If your patient has high tone in the UE, what type of surface will you use? What if your patient has low tone?

Answer 30

- Firm surface for high tone | - Form or soft surface for low tone

Question 31

How do you place the hand in WB?

Answer 31

- Ulnar surface first then lower and roll hand down radially into WB along thenar & hypothenar eminences - Withdraw your hand toward fingers, last thing you do is let go of the thumb - Position arm in slight flexion, ABD, & ER - Make sure scapula is stable on thorax

Question 32

*Guidelines for Building Control into the UE: Body on arm is used for?

Answer 32

Stability- Arm is stable, body moves. Hand is stable on surface, some part of body is moved on the arm while the arm stays stable. *This helps get a baseline of tone and improve graded movement

Question 33

*Guidelines for Building Control into the UE: Arm and Body is used for?

Answer 33

Mobility- Movements together This is more challenging, may have pt move trunk and arm forward together by moving table or cart forward

Question 34

*Guidelines for Building Control into the UE: Arm on body is used for?

Answer 34

Skill- Body is stable, and arm moves around body. 1st: start with UE in weight bearing position on surface. Want to progress to functional UE activities with UE movement on the body without a distal contact.

Question 35

Weight bearing on a STABLE surface- | Body on Arm movement on the midline is performed how?

Answer 35

APT/PPT: maintaining shoulder alignment over the hip joints Rotation of the head and trunk (initiated from the lower trunk) AWAY from the involved arm Rotation of the head, trunk, and uninvolved arm AWAY from the involved side.

Question 36

Weight bearing on a STABLE surface- | Body on Arm movement with movement AWAY from midline is performed how?

Answer 36

- Lower trunk weight shifts right and left | - Lower trunk weight diagonal weight shifts toward involved side

Question 37

Weight bearing on a STABLE surface- | Body on Arm movement with movement ACROSS midline gets?

Answer 37

*Most WB/Forced WB Reach the uninvolved arm across midline using a functional object or task to facilitate reaching. Be sure there is active WB on the involved side

Question 38

Weight bearing on a UNSTABLE surface- | Body on Arm movement would be performed how?

Answer 38

Moving the arm and trunk together - May use clipboards, small balls(10-12') or cylindrical objects (3-4'). The trunk moves with the arm forward, back, diagonal, while maintain alignment - Selective movement of the involved arm on an unstable surface-the arm is moving on an unstable surface (ball, cylinder) while the trunk is stable - *Consider progression of activity: Isometric to eccentric to concentric Work in a functional environment, facilitating normal alignment and normal movement patterns

Question 39

When it comes to protecting the hemiplegic shoulder, what are you able and not able to do?

Answer 39

- do NOT pull on affected arm: utilize trunk or pelvis for repositioning - Utilize lap trays or arm troughs for UE support in a w/c - Avoid using slings since they encourage IR & ADD - Do NOT use overhead pulleys - Shoulder flexion & ABD ROM performed ONLY when humerus is ER - When performing shoulder ABD greater than 90 degrees, you MUST assure scapular gliding and upward rotation * Sidelying on hemiparetic side is good for WB. *Make sure scapula is protected

Question 40

How could you activate the Lower Trap as a tx idea for the UE?

Answer 40

Prone on elbows position and raising chest up