Welcome

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April 29, 2004 Bethlehem, PA

Presents Building an Upper Extremity Rehabilitation Practice

Featured Speakers
Dr. Sidney M. Maycock, Jr.
1983 Graduate of Cleveland Chiropractic College, Kansas City. Inventor of the Wristiciser Featured Speaker on Television and Radio Programs Expert on Upper Extremity Rehabilitation Practices in Williamstown, NJ. Operates Cash-only Practice.

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Dr. George K. Petruska

1979 Graduate of Palmer Chiropractic College, Davenport. Lectures Nationally and Internationally in Adjunctive Procedures and Rehabilitation. Certified by OSHA in General Industry and Ergonomics Published author of Rehabilitation and Chiropractic articles. Diplomat status of the ACRB, a Fellow of the ACCRS in Rehabilitation & served on Rehab Board. Maintains a private practice in Red Hill, PA.

Todays Topics
The Better Equation for Success Anatomy as it Relates to Common Upper Extremity Conditions The Wristiciser-PROplusTM System

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Why Build an Upper Extremity Practice?

Rehabilitation & Therapy Protocols Common Billing Codes for U.E. Rehabilitation The Wristiciser One Device: Over 50 Exercises

Why Build an Upper Extremity Practice?

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Approximately 20 million people in the United

States are affected by an upper extremity disorder or injury every year.

25% of all work related injuries involve the

Upper Extremities.

35% of all acute injuries seen in an emergency

involve the upper extremities.

Each year 12 million people in the U.S. are affected by a

repetitive stress type injury to the upper extremities.

Carpal Tunnel Syndrome reportedly costs industry 100

billion dollars in lost work days.

The Better Equation for Success

Better Patient Education

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Better Tools
Better Patient Compliance

Better Results

Anatomy as it Relatives to Common Upper Extremity Conditions

Topics to be Covered:
Shoulder

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Elbow
Forearm Wrist/Hand Arthritic

Change

Shoulder Basic Anatomy

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The shoulder joint involves three bones: the shoulder blade (scapula), the collarbone (clavicle) and the upper arm bone (humerus).

Bones of the Shoulder Joint

Muscles of the Shoulder Joint

pectoralis major, coracobrachialis, subscapularis, biceps brachii

Anterior

infraspinatus, teres minor, latissimus dorsi, teres major triceps brachii, long head
deltoid, supraspinatus

Posterior Superior

Shoulder Common Disorders

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Rotator Cuff Injuries, Bursitis, Tendonitis & Impingement

Shoulder Common Disorders

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Rotator Cuff Injuries, Bursitis, Tendonitis & Impingement

Shoulder Common Disorders

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The head of the upper arm bone (humeral head) rests in a shallow socket in the shoulder blade called the glenoid. Because the head of the upper arm bone is usually much larger than the socket, a soft fibrous tissue rim called the labrum surrounds the socket to help stabilize the joint. The rim deepens the socket by up to 50 percent so that the head of the upper arm bone fits better. In addition, it serves as an attachment site for several ligaments.

Shoulder Common Disorders

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Elbow Basic Anatomy

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The elbow joint involves three bones: the arm bone (humerus), the forearm bones (ulna and radius).

Bones of the Elbow Joint

Muscles that cross the elbow can produce flexion or extension:

Muscles of the Elbow Joint

extensor carpi radialis longus

Muscles that flex the elbow joint (from attachments superior to the lateral epicondyle):
pronator teres, flexor carpi radialis, palmaris longus

Muscles that flex the elbow joint (from attachments on the medial epicondyle): Muscles that flex the elbow joint (from other sites of attachment):
biceps, brachialis, brachioradialis,

Muscles that flex the elbow joint:

triceps, anconeus

Elbow Common Disorders

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Lateral and Medical Epicondylitis

Elbow Common Disorders

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Lateral and Medical Epicondylitis

Elbow Common Disorders

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Lateral and Medical Epicondylitis

Elbow Common Disorders

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Lateral and Medical Epicondylitis

Forearm Basic Anatomy

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Muscles that cross the radio-ulnar joint can produce pronation or supination:
Muscles of the anterior forearm (pronators) pronator quadratus pronator teres flexor carpi radialis Muscles of the posterior forearm (supinators) supinator biceps (extensor pollicis longus) (extensor indicis)

Forearm Common Conditions

Nerve Entrapments
Median Nerve Ulnar Nerve Radial Nerve

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Pronator teres syndrome Anterior interosseous syndrome Carpal tunnel syndrome nerve Cubital tunnel syndrome Guyons canal compression Axilla Spiral groove Radial tunnel syndrome Posterior interosseous nerve

Forearm Common Conditions

Nerve Entrapments
Pronator Syndrome refers to a disturbance in function of the median nerve due to some mechanical abnormality at the level of the forearm. This is most often related to the path normally taken by the nerve through the middle of the pronator teres muscle, although other areas may be the site of the difficulty. Pronator syndrome may resemble carpal tunnel syndrome, but is much less common than carpal tunnel syndrome.

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With anterior interosseous nerve involvement, there is no sensory loss. and weakness is confined to the pronator quadratus.

Forearm Common Conditions

Nerve Entrapments
Cubital Tunnel Syndrome syndrome is the most common pathological entrapment of the ulnar nerve. It may be caused by constricting fascial bands, hypertrophied synovium, a tumor, a ganglion etc. Bony abnormalities like cubitus valgus as a result of previous fracture around the elbow or bony spur may also cause ulnar neuropathy. Subluxation of the ulnar nerve over the medial epicondyle with elbow flexion will also result in frictional injury to the nerve.

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Wrist & Hand Basic Anatomy

Bones of the Wrist Joint (Carpals)
Eight bones of the carpus, which occur in two rows (proximal and distal). The proximal row, consists of scaphoid, lunate, triquetrum and pisiform, and the first three of these articulate with the distal ends of the radius or ulna. The distal row, made up of the trapezium, trapezoid, capitate and hamate, articulates with the bases of the metacarpal bones.

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Bones of the Hands

Metacarpals and Phalanges

Wrist & Hand

Carpal Tunnel Syndrome

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The floor is formed by the carpal bones which are concave in its flexor surface. This bony gutter is converted into a tunnel by the flexor retinacular on the volar aspect. The median nerve and the long flexor tendons namely flexor pollicis longus, flexor digitorum profundus, and flexor digitorum superficialis together with their synovial sheaths pass through this tunnel to the digits.

Wrist & Hand

Carpal Tunnel Syndrome

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Wrist & Hand

Guyons Canal Compression
Guyon's Canal Syndrome is numbness and tingling in the ring and small fingers caused by irritation of the ulnar nerve in the Guyon's canal. Symptoms begin with a feeling of pins and needles in ring and little finger. This is followed by decreased sensation and eventually weakness and clumsiness in the hand as the small muscles of the hand are involved.

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Upper Extremity
Degenerative Joint Disease

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Osteoarthritis is one of the oldest and most common diseases in humans and the most common joint disease.

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The Wristiciser-PROplusTM System

Introducing

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Dr. George K. Petruska

Rehabilitation & Therapy Protocols
Common Billing Codes for U.E. Rehabilitation

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Case Studies
*Rehab Pearls

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Specific Adaptation to Imposed Demands Sherrington's Law Symmetrical Associated Movements Cross Reflex Physiological Overflow Awareness Functional Model

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Specific Adaptation to Imposed Demands

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The "SAID" concept is one of the underlying tenets of the strength and conditioning field. [1] It describes the observation that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bodies become stronger. And, if we practice balance and coordination skills, we improve our ability to function easier on unstable surfaces (such as on an incline, rolling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often. It has taken quite a while for those specialists in the treatment of spinal problems to incorporate the SAID concept into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As Chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that an ideal way to help our patients return to normal function is with exercises that imitate as closely as possible the real conditions under which the spine must function day after day. That certainly must include the specific stress of gravity in the upright position.

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Sherrington's Law

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One of the most important concepts in early rehabilitation is the maintenance of proper functional motor patterns. Through the use of passive and passive assistive exercises this loss can be minimized. Learned motor pattern in the functional activities of motion are ingrained or facilitated through repetition. This repetition of motor pattern reduces the resistance to this pathway as stated by Sherrington's Law of Facilitation. During an injury state, the body through conservation of energy chooses motions that are the most productive or energy efficient. Through facilitation, repetition of possible new compensatory motor patterns may alter proper mechanism eventually leading to pathological motor patterns. If not attended these dysfunctional compensatory motor patterns may develop into a seemingly unrelated new injury. Although the symptomatic treatment of this new injury may prove to be an easy task, the corrections of the true cause may be difficult without an understanding of compensatory facilitations.

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Symmetrical Associated Movements Once an injury has occurred to a limb, immobilization either through inflammation, supports, casting and/or pain during motion, rehabilitation of the injured limb can occur through "symmetrical associated movements." It involves exercising the unaffected limb in the specific motions and planes that the injured limb is unable to perform due to the injury.

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Cross Reflex

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Physiologically the injured side has similar gains/maintenance of strengths as the uninjured side, which can greatly affect prognosis time. For example, if an injury occurs in the right elbow affecting both flexion and extension exercising the left elbow in these motions will have a positive enhancement in the performance of the right elbow function. This process is labeled "cross reflex" and it has been observed dramatically in hemi-palegic rehabilitation exercise programs. (Ordet S. and Grand L., Dynamics of Clinical Rehabilitative Exercise, William and Wilkins, 1992.) Yoe G. and Cole K.J., Journal of Neurophysiology, Vol. 67, No. 5, May 1992. Study.

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Physiological Overflow

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Due to inhibitory reflex effects of pain on exercise all passive movements should be limited to pain free ranges of motion. Based on the principle of "Physiological Overflow" there is a 15 degree progression into the painful motion to each side of the exercised range of motion even though that area of the range of motion has not been exercised. (Davies G. J., Compendium of Isokinetics, S & S Publishers, 1984.)

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Awareness

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Although it is important for the patient to give attention/focus to an exercise, it is even more important for the patient to be aware (show realization or knowledge) of the exercise activity as the movement takes place. Only through awareness and knowledge is learning of motion activity obtained. Beginning the awareness component of an exercise program involves a number of questions directed to the patient. No right or wrong answer should be supplied by the clinician. The questions are designed to assist the patient in focusing on one part of the body as well as to the whole; "the feeling" experienced as muscles contract and joints move is emphasized. Once identified, the patient can then focus more specifically on where the movement is or is not occurring. The essential element in the awareness process is that the patient learns how to use their body. Learning is not accomplished if the patient is toll what is occurring by the clinician instead of feeling and sensing within. The goal in this approach of learning the movement is to reorganize the neuromuscular system with reorganization of the movement; it will hopefully become a new habit not requiring repetition, but awareness.

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Functional Model

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Functional restoration opposes the application of an injury/inflammation model when significant trauma is not present, thus focusing on softtissue healing only when appropriate. This model embraces emerging rehabilitation standards. Functional restoration addresses improper motor control (spinal instability), joint dysfunction and muscle dysfunction. Such rehabilitation focuses on the entire locomotor system, not just the area of complaint. It aims to restore function in the locomotor system involving a broad approach that uses exercise, education and manipulation.

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Carpal Tunnel Syndrome

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History

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A 32 year old right handed female presented with complaints of pins and needles in her right hand. The patient has 3 children. She is not pregnant. Her symptoms started about 1 year ago. At that time it was localized. Since the initial incident, she has had numerous episodes of symptoms. She states that each episode has become progressively worse. She wakes up at night and has to shake her hands to relieve her symptoms.

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Clinical Presentation
Carpal tunnel syndrome is a general term used to describe a myriad of conditions. It is often diagnosed when a patient complains of a feeling of 'pins and needles' in the hand and wrist. Usually occurs as a repetitive stress disorder. 1/1000 is true CTS Vibration Temperature changes Prolonged positions and actions, Occurs in women 58% of the time

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Areas of Deficit Histologic, Structural, and Neurological.

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Histologic Usually tight, overactive muscles are the forearm flexors Inhibited or weak muscles forearm extendsors.

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Structural

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Carpal tunnel syndrome (CTS) is defined as an entrapment of the median nerve in the area of the volar wrist canal beneath the flexor retinaculurn which causes neural symptoms that refer into the hand, wrist, and upper extremity (1).There are eight irregularly shaped carpal bones that articulate with one another by arthrodial joints connected by interosseous ligaments. The carpal arch and the flexor retinaculum help form the carpal tunnel. The volar carpal ligament is attached to the pisiform and hamate on one side and the scaphoid and trapezium on the other.
*Acute CTS may be caused by trauma from bums, hemorrhage, displaced fracture, unreduced dislocation of the carpal bones, or Colle's fracture

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Endocrine
Edematous conditions such as pregnancy, RSD, gout and Lupus can cause carpal tunnel-like symptoms. These conditions can be ruled out by lab test.

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Neurological

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Decreased proprioception Lack of Neuromuscular coordination. Paresthesia Dysesthesia

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OA Forms
General Health, CTS, Oswestry Neck, Elbow, Shoulder, Wrist,VAS, Pain Drawing,

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Functional Testing
Postural Analysis Proprioception Muscle ULTT1, ULTT2, ULTT3 Empty Can Test

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Findings

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Palpable band with a local twitch response (positive Jump Sign) Trigger points Decreased grip and pinch strength Impaired circulation Diminished proprioception on the involved side Tight forearm flexors; brachioradialis, carpi radialis & ulnaris, flexor pollicis longus, flexor digitorurn profundus, flexor retinacuum Weak or inhibited forearm extenders; abductor and extensor pollicis, digiti, carpi, radialis lonus and brevis

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*Tight forearm flexors, brachioradialis can lead to Tennis elbow Treatment is similar to CTS Use cryocuff compression therapy and sequential EMS to progress to rehab as soon as possible.

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Diagnosis

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CTS Abnormal Posture Muscle Imbalances Muscle Incoordination

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Prescription
Concepts

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*SAID principal *Awareness *Physiological Overflow *Symmetrical associated Movements *Sherringtons Law of reciprocal inhibition. *Neuromuscular Cross Over Effect

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Primary Focus

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*Increase strength of forearm extensors (Wristiciser) *Stretch Tight Muscles: forearm flexors (Wristerciser *Activate thenar musculature (Wristiciser) *Increase proprioception and neuromuscular coordination. *Correct Biomechanics (lunate key carpal bone) (manipulation)

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Primary focus is strengthening core and postural stabilizers.

This is the manner in which we use the joints and connective tissue during most daily, work and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance to stimulate increases in strength with the wristerciser.

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Teach correct breathing patterns beginning from the lower abdomen ending in the upper chest. (Correct breathing patterns activates postural stabilizers, facilitates a cortical response) Use stretching techniques to stretch flexors, and exercise to strengthen extensors with the Wristiciser Activate and strengthen postural stabilizers by using Wristiciser to strengthen the involved muscles.

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Once the patients progress reaches a plateau new more challenging procedures should be added utilizing the Wristiciser.

Now hand protocols can be performed on the Wristiciser.

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The home care should engage the patient in the participation of Wristiciser protocols. *This should be done until the patient functional progress reaches a plateau. *Testing should be perform every 4 to 6 weeks.

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*If the patient has Sunrise Sign surgery is necessary. Rehab is the same just longer. Rehab the surgery not the injury. Rehab the patient as if they were symptom free from conservative care.

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Evaluation, Diagnosis and treatment of Double Crush would be the similar to CTS.

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History

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A 32 year old left handed male presented with complaints of pins and needles in his left hand. His symptoms started about 1 year ago. At that time it was localized. Since the initial incident, he has had numerous episodes of symptoms. He states that each episode has become progressively worse. He wakes up at night and has to shake his hands to relieve his symptoms. Has a history of neck pain. Operates a jack hammer. Works 60 hours a week.

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The differential diagnosis is that there is C6-T3 involvement. The imbalances are on involved sided. (overactive and tight on one side, inhibited and weak on the other. (Upper Crossed Syndrome)

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Findings (additional)
Square shoulders Gothic Shoulders Military neck Tight Lower and Middle Trap Tight Neck flexors, Serratus Anterior Weak Upper Trap and Levator Scapulae, Sub Occipitals, Peck Major and SCM Myofascial trigger points in the Lower and Middle Trap, Neck Flexors

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Inhibited spinal stabilizers

eg. Mutifdus

Strength differences greater than expected values. Abnormal breathing patterns. (Shallow breathing)

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Additional Treatment
*Stretch Lower and Middle Trap, Neck Flexors, Serratus Anterior *Strengthen Upper Trap, Levator Scap, Sub Occipitials, SCM, Peck Major

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*Activate Spinal Stabilizers *Increase proprioception *Correct Spinal Biomechanics

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*Proper clearance should be obtained. PARQ should be negative for contraindication. Mirror Image exercise protocols with the Wristiciser should be performed in cervical flexion, extension and lateral bending.

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Evaluation, Diagnosis and Treatment of Reflex Sympathetic Dystrophy (RSD)

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Differential Diagnosis

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Diffuse severe pain, burning, limb guarding, temperature sensitive, and exacerbation from emotional upset. There is C6-T3 involvement. The imbalances are on involved sided. (overactive and tight on one side, inhibited and weak on the other.(upper crossed syndrome)

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Findings (additional)
Square shoulders Gothic Shoulders Military neck Tight Lower and Middle Trap Tight Neck flexors, Serratus Anterior Weak Upper Trap and Levator Scapulae, Sub Occipitals, Peck Major and SCM Myofascial trigger points in the Lower and Middle Trap, Neck Flexors

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Inhibited spinal stabilizers

eg. Mutifdus

Strength differences greater than expected values. Abnormal breathing patterns. (Shallow breathing)

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Additional Treatment
*Stretch Lower and Middle Trap, Neck Flexors, Serratus Anterior *Strengthen Upper Trap, Levator Scap, Sub Occipitials, SCM, Peck Major
*Activate Spinal Stabilizers *Increase proprioception *Correct Spinal Biomechanics

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*Proper clearance should be obtained.
PARQ should be negative for contraindication.

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Mirror Image exercise protocols with the Wristiciser were performed in cervical flexion, extension and lateral bending. *Vigorous aerobic exercise is initially difficult to perform, but eventually markedly improves the overall condition due to increased VO2 Max, circulation and scar tissue reformation.

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Evaluation, Diagnosis and Treatment of Shoulder Impingement Syndrome

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History

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A 38 year old right handed female presented with complaints of chronic shoulder pain. The symptoms occur on a intermittent basis. The frequency has increased. The patient is an assembly line worker. She works constantly over head. She was also a tennis player.

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Clinical Impression Areas of Deficit

Histologic, Structural and Neurological

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Histologic

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Usually tight, overactive muscles on the involved side. Inhibited or weak muscles on the opposite side. Backward posterior antalgic translation

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Structural

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Cervical range of motion is as follows: flexion increase, extension decrease with endpoint pain, right and left rotation WNL with discomfort on the right, right lateral flexion decreased with end point pain, left lateral flexion WNL. Gothic Shoulders, Upward rotation of the scapula.

Neurological
Decreased proprioception

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OA Forms
General Health, , Oswestry Neck, Shoulder, Copenhagen Neck Disability Index, Oswestry Headache, Headache Disability Index, VAS, Pain Drawing,

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Functional Testing
Postual Analysis Proprioception Muscle Testing

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Findings

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Square shoulders Altered arm swing Shoulder elevation with arm flexion Altered scapulohumeral rythem Military neck Tight Lower and Middle Trap Tight Neck flexors, Serratus Anterior Diminished proprioception on involved side Worse with the eyes closed.

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*Upper cross syndrome (usually present, may be the reason the condition occurred to begin with) Weak Upper Trap and Levator Scapulae, Sub Occipitals, Peck Major and SCM Myofascial trigger points was in the Lower and Middle Trap, Neck Flexors Inhibited spinal stabilizers eg. Mutifdus

Strength differences greater than expected values.

Abnormal breathing patterns. (Paradoxial breathing)

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Diagnosis

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Shoulder Impingement Syndrome Abnormal Posture Abnormal Gait Muscle Imbalances Muscle Incoordination Post Traumatic Headaches complicated by a cervicogenic component.

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Prescription
Concepts
*SAID principal

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*Sherringtons Law of reciprocal inhibition.

*Neuromuscular Cross Over Effect

*Neuromuscular Over flow (physiologic)

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Primary Focus

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*Strengthen Lower and Middle Trap, Neck Flexors, Serratus Anterior *Stretch Upper Trap, Levator Scap, Sub Occipitials, Subscapularis, SCM, Peck Major *Activate Spinal Stabilizers *Increase proprioception *Correct Spinal Biomechanics

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Stage I

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*Manipulation should be performed on a PRN basis. *Sequencial EMS should reduce the symptoms. Use PIR, PNF or FlexBuilding muscle energy technique with the Wristiciser to stretch and strengthen Lower and Middle Trap, Neck Flexors, Serratus Anterior Teach correct breathing patterns beginning from the lower abdomen ending in the upper chest. (Correct breathing patterns activates spinal stabilizers)

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Stage II

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*Manipulation should be perform on a PRN basis. *Sequencial EMS should reduce the symptoms on a PRN basis. Use PIR, PNF or Flex Building muscle energy technique with the Wristiciser to stretch and strengthen Lower and Middle Trap, Neck Flexors, Serratus Anterior

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Stage III

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*Manipulation should be perform on a PRN basis. *Sequencial EMS should reduce the symptoms on a PRN basis. Use PIR, PNF or Flexes muscle energy technique with the Wristiciser to stretch and strengthen Lower and Middle Trap, Neck Flexors, Serratus Anterior

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*Proper clearance should be obtained. PARQ was negative for contraindication.

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Mirror Image exercise protocols with Wristiciser should be performed in cervical flexion, extension and lateral bending. The patient began a specific rehabilitation program focused to functional restoration, based on the patient activities of daily living. The rehabilitation program baseline began with shoulder protocols performed to patient tolerance. Rehabilitation continued three times a week with the number of protocols increasing to patient tolerance until the patient reached a plateau.

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Home Care

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Stretching within the pain free ROM utilizing the Wristiciser stretch and strengthening protocols.

The patient should be released from treatment once their functional progress reached a plateau. They should be instructed only to return if their condition deteriorated, their function decreased or their symptoms reoccurred.

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Evaluation, Diagnosis and Treatment of Upper Crossed Syndrome

*Would be similar to Shoulder Impingement Syndrome (Winging of Scapula)

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Evaluation, Diagnosis and Treatment of Rotator Cuff Syndrome

*Would be the same except there would be a tear. (Usually the Supraspinatus) Positive Codmans

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Essentially Shoulder Impingement Syndrome is a Sloppy shoulder that progress if left untreated to Rotator Cuff syndrome.

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*Post Surgery Rotator Cuff Evaluation and treatment would be the same except that you would treat the surgery not the condition. Rehab would progress as if the patient was symptom free from conservative care.

Questions

To request additional information please contact:

Dr. Sidney M. Maycock, Jr. Dr. George K. Petruska