The manual resistance exercise techniques described in this section are for the upper and lower extremities, performed concentrically in the anatomical planes of motion. The direction of limb movement would be the opposite if manual resistance were applied to an eccentric contraction. The exercises described are performed in non-weight-bearing positions and involve movements to isolate individual muscles or muscle groups.
Most of the exercises described below are performed with the patient in a supine position. Variations in the therapist’s position and hand placements may be necessary, depending on the size and strength of the therapist and the patient. Alternate positions, such as prone or sitting, are described when appropriate or necessary. Ultimately, a therapist must be versatile and able to apply manual resistance with the patient in all positions to meet the needs of many patients with significant differences in abilities, limitations, and pathologies.
Opposite motions, such as flexion/extension and abduction/adduction, are often alternately resisted in an exercise program in which strength and balanced neuromuscular control in both agonists and antagonists are desired. Resistance to reciprocal movement patterns also enhances a patient’s ability to reverse the direction of movement smoothly and quickly, a neuromuscular skill that is necessary in many functional activities. Reversal of direction requires muscular control of both prime movers and stabilizers and combines concentric and eccentric contractions to decrease momentum and make a controlled transition from one direction to the opposite direction of movement.
Hand Placement and Procedure. Apply resistance to the anterior aspect of the distal arm or to the distal portion of the forearm if the elbow is stable and pain-free. Stabilization of the scapula and trunk is provided by the treatment table.
Hand Placement and Procedure. Apply resistance to the posterior aspect of the distal arm or the distal portion of the forearm. Stabilization of the scapula is provided by the table.
Hyperextension of the Shoulder
The patient may be in the supine position, close to the edge of the table, side-lying, or prone so hyperextension can occur.
Hand Placement and Procedure. Apply resistance in the same manner as for extension of the shoulder. Stabilize the anterior aspect of the shoulder if the patient is supine. If the patient is side-lying, adequate stabilization must be given to the trunk and scapula. This can usually be done if the therapist places the patient close to the edge of the table and stabilizes the patient with the lower trunk. If the patient is lying prone, manually stabilize the scapula.
Abduction and Adduction of the Shoulder
Hand Placement and Procedure. Apply resistance to the distal portion of the arm with the patient’s elbow flexed to 90°. To resist abduction, apply resistance to the lateral aspect of the arm. To resist adduction, apply resistance to the medial aspect of the arm. Stabilization is applied to the superior aspect of the shoulder, if necessary, to prevent the patient from initiating abduction by shrugging the shoulder (elevation of the scapula).
PRECAUTION: Allow the glenohumoral joint to externally rotate when resisting abduction above 90° to prevent impingement.
Elevation of the Arm in the Plane of the Scapula (”Scaption”)
Hand Placement and Procedure. Same as previously described for shoulder flexion. Apply resistance as the patient elevates the arm in the plane of the scapula (30° to 40° anterior to the frontal plane of the body).
NOTE: Although “scaption” is not a motion of the shoulder that occurs in one of the anatomical planes of the body, resistance in the scapular plane is thought to have its merits. The evidence is inconclusive as to whether the torque-producing capabilities of the key muscle groups of the glenohumeral joint are greater when the arm elevates in the plane of the scapula versus the frontal or sagittal planes; however, the glenohumeral joint has been shown to be more stable, and there is less risk of impingement of soft tissues when strength training is performed in the scapular plane.
Internal and External Rotation of the Shoulder
Hand Placement and Procedure. Flex the elbow to 90° and position the shoulder in the plane of the scapula. Apply resistance to the distal portion of the forearm during internal rotation and external rotation. Stabilize at the level of the clavicle during internal rotation; the back and scapula are stabilized by the table during external rotation.
Alternate Procedure
Alternate alignment of the humerus. If the mobility and stability of the glenohumeral joint permit, the shoulder can be positioned in 90° of abduction during resisted rotation.
Horizontal Abduction and Adduction of the Shoulder
Hand Placement and Procedure. Flex the shoulder and elbow to 90° and place the shoulder in neutral rotation. Apply resistance to the distal portion of the arm just above the elbow during horizontal adduction and abduction. Stabilize the anterior aspect of the shoulder during horizontal adduction. The table stabilizes the scapula and trunk during horizontal abduction. To resist horizontal abduction from 0° to 45°, the patient must be close to the edge of the table while supine or be placed side-lying or prone.
Elevation and Depression of the Scapula
Hand Placement and Procedure. Have the patient assume a supine, side-lying, or sitting position. Apply resistance along the superior aspect of the shoulder girdle just above the clavicle during scapular elevation.
Alternate Procedures: Scapular Depression
To resist unilateral scapular depression in the supine position, have the patient attempt to reach down toward the feet and push the hand into the therapist’s hand. When the patient has adequate strength, the exercise can be performed to include weight bearing through the upper extremity by having the patient sit on the edge of a low table and lift the body weight with both hands.
Protraction and Retraction of the Scapula
Hand Placement and Procedure. Apply resistance to the anterior portion of the shoulder at the head of the humerus to resist protraction and to the posterior aspect of the shoulder to resist retraction. Resistance may also be applied directly to the scapula if the patient sits or lies on the side, facing the therapist. Stabilize the trunk to prevent trunk rotation.
Flexion and Extension of the Elbow
Hand Placement and Procedure. To strengthen the elbow flexors, apply resistance to the anterior aspect of the distal forearm. The forearm may be positioned in supination, pronation, and neutral to resist individual flexor muscles of the elbow. To strengthen the elbow extensors, place the patient prone or supine and apply resistance to the distal aspect of the forearm. Stabilize the upper portion of the humerus during both motions.
Pronation and Supination of the Forearm
Hand Placement and Procedure. Apply resistance to the radius of the distal forearm with the patient’s elbow flexed to 90° to prevent rotation of the humerus. Do not apply resistance to the hand to avoid twisting forces at the wrist.
Flexion and Extension of the Wrist
Hand Placement and Procedure. Apply resistance to the volar and dorsal aspects of the hand at the level of the metacarpals to resist flexion and extension, respectively. Stabilize the volar or dorsal aspect of the distal forearm.
Radial and Ulnar Deviation of the Wrist
Hand Placement and Procedure. Apply resistance to the second and fifth metacarpals alternately to resist radial and ulnar deviation.Stabilize the distal forearm.
Motions of the Fingers and Thumb
Hand Placement and Procedure. Apply resistance just distal to the joint that is moving. Resistance is applied to one joint motion at a time. Stabilize the joints proximal and distal to the moving joint.
Lower Extremity
Flexion of the Hip with Knee Flexion
Hand Placement and Procedure. Apply resistance to the anterior portion of the distal thigh. Simultaneous resistance to knee flexion may be applied at the distal and posterior aspect of the lower leg, just above the ankle. Stabilization of the pelvis and lumbar spine is provided by adequate strength of the abdominal muscles.
PRECAUTION: If, when the opposite hip is extended, the pelvis rotates anteriorly, and lordosis in the lumbar spine increases during resisted hip flexion, have the patient flex the opposite hip and knee and plant the foot on the table to stabilize the pelvis and protect the low back region.
Hand Placement and Procedure. Apply resistance to the posterior aspect of the distal thigh with one hand and to the inferior and distal aspect of the heel with the other hand. Stabilization of the pelvis and lumbar spine is provided by the table.
Hyperextension of the Hip
Patient position: prone.
Hand Placement and Procedure. With patient in a prone position, apply resistance to the posterior aspect of the distal thigh. Stabilize the posterior aspect of the pelvis to avoid motion of the lumbar spine.
Abduction and Adduction of the Hip
Hand Placement and Procedure. Apply resistance to the lateral and the medial aspects of the distal thigh to resist abduction and adduction, respectively, or to the lateral and medial aspects of the distal leg just above the malleoli if the knee is stable and pain-free. Stabilization is applied to the pelvis to avoid hip-hiking from substitute action of the quadratus lumborum and to keep the thigh in neutral position to prevent external rotation of the femur and subsequent substitution by the iliopsoas.
Internal and External Rotation of the Hip
Patient position: supine with the hip and knee extended.
Hand Placement and Procedure. Apply resistance to the lateral aspect of the distal thigh to resist external rotation and to the medial aspect of the thigh to resist internal rotation. Stabilize the pelvis.
Patient position: supine with the hip and knee flexed.
Hand Placement and Procedure. Apply resistance to the medial aspect of the lower leg just above the malleolus during external rotation and to the lateral aspect of the lower leg during internal rotation. Stabilize the anterior aspect of the pelvis as the thigh is supported to keep the hip in 90° of flexion.
Patient position: prone, with the hip extended and the knee flexed.
Hand Placement and Procedure. Apply resistance to the medial and lateral aspects of the lower leg. Stabilize the pelvis by applying pressure across the buttocks.
Resistance to knee flexion may be combined with resistance to hip flexion, as described earlier with the patient supine.
Patient position: prone with the hip extended.
Hand Placement. Apply resistance to the posterior aspect of the lower leg just above the heel. Stabilize the posterior pelvis across the buttocks.
The patient may also be sitting at the edge of a table with the hips and knees flexed and the trunk supported and stabilized.
Alternate Patient Positions. If the patient is lying supine on a table, the hip must be abducted and the knee flexed so the lower leg is over the side of the table. This position should not be used if the rectus femoris or iliopsoas is tight because it causes an anterior tilt of the pelvis and places stress on the low back.
If the patient is prone, place a rolled towel under the anterior aspect of the distal thigh; this allows the patella to glide normally during knee extension. If the patient is sitting, place a rolled towel under the posterior aspect of the distal thigh.
Hand Placement and Procedure. Apply resistance to the anterior aspect of the lower leg. Stabilize the femur, pelvis, or trunk as necessary.
Dorsiflexion and Plantarflexion of the Ankle
Hand Placement and Procedure. Apply resistance to the dorsum of the foot just above the toes to resist dorsiflexion and to the plantar surface of the foot at the metatarsals to resist plantarflexion. Stabilize the lower leg.
Inversion and Eversion of the Ankle
Hand Placement and Procedure. Apply resistance to the medial aspect of the first metatarsal to resist inversion and to the lateral aspect of the fifth metatarsal to resist eversion. Stabilize the lower leg.
Flexion and Extension of the Toes
Hand Placement and Procedure. Apply resistance to the plantar and dorsal surfaces of the toes as the patient flexes and extends the toes. Stabilize the joints above and below the joint that is moving.
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