4 Ways To Improve Your Grip Strength

The Diesel Crew Nail Bending Manual

The Bending is a program created by Jedd Johnson to provide users with strength training exercises that help them get stronger hands. The guide provides people the opportunity to reduce their body fat and also regulate their breath. Being an athlete himself since 1999, Jedd understands the importance of strengths and fitness. He has taken part in many Strongman competitions and Grip Strength contests. He coaches and also talks at conferences about his strength abilities. By using the Bending program, the users learn the secret behind building their abdominal pressure and stabilization that will help turn the core into granite. One also learns to express the strength of their upper back, chest, shoulder and their hands in many innovative ways. It contains many exercise techniques, including wrist flexion, wrist extension, ulnar and radial deviation, most of which are known by very few people in the world. This program is not just for the pro, but also for the beginners wanting to learn the art. It provides a complete scheduled program to make you an expert in just a few weeks. Many people believe that nail bending is not a workout. But, Jedd thinks differently. It burns your calories and help you strengthen your entire body. Read more...

The Bending Manual Summary


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This technique may be useful in monitoring somatosensory changes induced by rehabilitation interventions. Optimal sensory feedback appears to be a pivotal requirement for motor gains in hand function and walking (see Chapter 1). Magnetoencephalography may also help researchers understand the bridge between the sensorimotor internal dynamics of the cortex and movement behavior.33

Spared Tissue And Pathways

Subcortical lesions that only partially damage the corticospinal and other motor tracts are especially likely to participate in gains (see Chapter 2). This sparing may not be appreciated by clinical examination. Predictions about improvement in hand strength and function have been made by early poststroke TMS studies aimed at detecting subclinically intact cor-ticospinal pathways.75,76 In a modest number of cases, an initial TMS response in a subject who offers no movement or twitch movement is accompanied by subsequent recovery of hand function. Transcranial magnetic stimulation in subjects with pyramidal lesions suggests 3 mechanisms in spared corticospinal pathways that cause weakness.77

Contralesional Control of the Hemiparetic Hand

Evoked responses are more commonly reported in subjects with poor recovery of the hemiparetic hand who exhibit mirror movements of the unaffected hand.109 Thus, the corticospinal projections from Ml in the unaffected hemisphere may not be a basis for functional recovery of motor control in most patients. Another fMRI study, however, using sequential finger-to-thumb movements, found that contralesional cortex in patients with subcortical lesions was more highly activated than ipsilesional cortex soon after a stroke.110 The ipsilesional cortex became more active over time, as hand function improved. In addition, the bilateral prefrontal and contralesional posterior parietal cortices shifted from greater activation acutely to lesser activation by 3 to 6 months poststroke. Six of the eight patients, however, had a plegic hand at the time of the first fMRI and showed mirror movements, so it is not so certain that the uninjured hemisphere's corticospinal tract played a primary role in...

Network and Representational Plasticity

In a series of groundbreaking studies by Weiller and colleagues, PET was performed in normal control subjects and patients who recovered hand function after a striatocapsular infarction.70 Subjects were tested under the conditions of rest, repeated thumb-to-finger opposition of the recovered hand, and the same movement for the unaffected hand. The motor task with either hand activated the contralateral motor cortices and ipsilateral cerebellum to the same degree as in healthy subjects. Subjects with recovered hand function had greater rCBF compared to the control subjects in the bilateral ventral premotor (BA 6), SMA, anterior insula, and parietal (BA 40) cortices, as well as in the ipsilateral pre-motor cortex and basal ganglia, and in the contralateral cerebellum. These nonprimary cortical motor areas apparently served a substitutive function. The bilateral recruitment may also explain the associated or mirror movements in the left hand that often accompanied a right-handed task.

Effects of testosterone replacement in older men with low testosterone levels

Several studies (Blackman etal. 2002 Ferrando etal. 1998 Kenny etal. 2001 2002 Morley etal. 1993 Sih etal. 1997 Snyder etal. 1999a 1999b Steidle etal. 2003 Tenover 1992 2000 Urban etal. 1995) have established that increasing testosterone levels of older men with low testosterone levels to levels that are mid-normal for healthy, young men is associated with a significant increase in lean body mass and a reduction in fat mass (Table 8.1). Although testosterone supplementation is associated with greater gains in grip strength compared to placebo treatment, it remains unclear whether physiologic testosterone replacement can produce meaningful changes in muscle performance and physical function. In a study by Snyder et al. (1999) testosterone treatment of older men did not increase muscle strength or improve physical function, but these men were not uniformly hypogonadal and were unusually fit for their age. In addition, their muscle strength was measured by a method (Biodex dynamometer)...

Experimental Case Study

1 month Active range of motion improved with more finger extension and adduction of the index and middle fingers. Peak grip strength was 46 lb in the left hand (30 less than the age-adjusted norm) and 16 lb in the right hand (78 less than the norm). Three-point pinch was 18 lb in the left hand and 9 lb for the right (53 of the norm). 6 months Proximal interphalangeal joint extension was limited to 20 . Finger strength was 4- 5. Finger tapping movements were slow. No chin or oral movements appreciated during hand actions. Fewer mirror movements occurred in the left hand. Peak grip strength was 42-48 lb on the left and 16-20 lb on the right 3-point pinch was 17 lb on the left and 8 lb on the right. His hand fatigued when writing, he turned a car key better, and he was able to remove objects from his pocket without dropping them.

Navicular Scaphoid Fracture 231 Clinical Presentation

Scaphoid fractures are the most common carpal bone fracture and are typically associated with a fall on an outstretched arm while the wrist is dorsiflexed. If a patient presents early, the key examination finding is tenderness in the anatomical snuffbox. This may be accompanied by swelling and loss of grip strength. A more specific clinical test for acute scaphoid fracture is pain on axial compression of the thumb toward the radius or direct pressure on the scaphoid tuberosity with radial deviation of the wrist. Since pain may improve soon after the fall, a patient may not present to a clinician until late after the injury. This late presentation puts the patient at risk for avascular necrosis. Only one small artery enters the bone, at the end that is closest to the thumb. If the fracture tears the artery, the blood supply is lost and avascular necrosis is the ultimate result.

Clinical Assessment Of S4

S4 also is usually sensitive to changes in venous return and filling of the heart. Maneuvers that reduce venous return, such as standing posture, will tend to decrease the intensity or abolish the S4 all together. Rapid volume expansion, cold pressor test, and isometric hand grip will accentuate the S4 (93). Isometric hand grip tends to raise heart rate, cardiac output, and the blood pressure (96,97). It can also raise the peripheral resistance.

Medial Elbow Tendinopathy

Figure 30-16 Medial epicondylitis may be diagnosed clinically by pain localized to the medial epicondyle during wrist flexion and pronation against resistance. There is often pain elicited after making a tight fist, and grip strength is usually diminished on the affected side.

Digital Flexor Tenosynovitis

Treatment options for digital flexor tenosynovitis include anti-inflammatory medications, modification of activities, ice, massage, stretching of the flexor tendons, and gentle-grip strength exercises, although these usually provide little relief. Corticosteroid injections are often used to relieve pain and triggering symptoms (Marks and Gunther , Peters-Veluthamaningal et al., 2009b). Symptoms may return, and repeat injections are considered if the first injection provided reasonable pain relief. However, surgery may be needed in patients with frequent recurrence.

Clinical Trials Of Functional Interventions

After reviewing 124 investigations drawn from a literature search of studies done from 1960 to 1990, Ottenbacher and Jannell carried out a meta-analysis of 36 trials.203 These studies met the criteria of including hemiparetic patients with stroke who were given a rehabilitation service in a design that compared at least two groups or conditions for change in a quantifiable functional measure. Outcomes included gait, hand function, ADLs, response times, and visuoperception. From 173 statistical evaluations recorded on the 3717 acute and chronic patients in the 36 trials, the analysis showed that the average patient who received a program of focused stroke rehabilitation or a particular procedure performed better than approximately 65 of the patients in the comparison group. Larger treatment effect sizes were associated with an earlier intervention and younger patients.

Body composition and sarcopenia

Mass (Tenover 1992), muscle strength (Morley et al. 1993 Urban et al. 1995) and skeletal muscle protein synthesis (Urban et al. 1995) However, the latter studies, besides being of short duration also included only limited number of subjects. Sih et al. (1997) observed a significant increase in grip strength in the testosterone-treated men over the age of 50 years (mean age 68 years) with low bio-available serum testosterone, in a prospective, randomized, placebo-controlled trial of 12 months' duration lower extremity muscle strength was not evaluated. Ferrando etal. (2002) observed improved leg and arm muscle strength and an increase in muscle net proteinbalance in a small number of older men treatedwith testosterone for six months a positive effect of six months testosterone treatment is seen in older men on net protein balance in the fasted state, but there is no demonstrated additive effect of testosterone when combined with amino acid feedings (Ferrando etal. 2003). Muscle...

Sensorimotor integration

Restoration of arm and hand function may offer a richer set of opportunities for functional electrical stimulation (FES). Patients present with a wide range of different disabilities, some of which are more likely to be suitable than others for a given technology. For many patients, even a modest increment in hand function could reduce reliance on expensive personal attendants (whereas locomotion can be more readily achieved by wheelchairs and accessible architectural design). The shortcomings of a primitive control system are less likely to result in physical injury in the arms than in the legs. An implanted eight-channel system called the Freehand (Neural Control Corporation, Cleveland, OH) achieved useful assisted grasp function in C6-7 quadraplegics (Smith et al., 1998 Stroh et al., 1999) but was withdrawn from the market because of the complexity and cost of its surgical implantation and fitting procedures. It relied on a relatively simple but unnatural control strategy in which...

Upper Extremity Function

In addition to the usual range of splints, or-thotic devices, and strategies aimed at improving arm and hand function, selected patients with quadriplegia benefit from some specific adaptations. For example, patients with a partial C-4 lesion with preserved elbow flexion or a C-5 injury with a functional deltoid or biceps can improve hand placement for feeding, writing, and typing activities by using a balanced forearm orthosis. If some wrist extension at the C-6 level is intact, finger flexion for a grasp will accompany extension, and finger opening will follow passive wrist flexion when the long finger flexors are allowed to become a bit tight. A wrist-driven orthosis can assist this action. A well-designed elbow extension orthosis that corrects a torque imbalance between an active biceps and inactive triceps may improve flexion and extension functions with or without the addition of FNS.182 Overhead and counterbalance slings and mobile arm supports eliminate or use the force of...

Balance Disorders Frailty and Falls in the Elderly

Of interest, poor hand grip strength, which correlates with general strength, predicts a risk for falls in older persons and, if present in midlife, predicts slow walking, difficulty arising from a chair, and limitations in ADLs 25 years later.161 Muscle weakness before age 65 years presumably lessens a person's reserve as aging-related disabilities increase. Impaired walking velocity and single-leg stance time are also associated with decreased white matter volume and a greater volume of abnormal white matter signals by MRI.162 These lesions may predispose to dysequilibrium and falls. Indeed, a prospective study of elderly patients with dyse-quilibrium complaints of uncertain cause found strong associations between falls, concerns about falling, cerebral atrophy, and white matter lesions.163

Sjogrens disease chronic urticaria

One study has examined the effects of treatment with stanozolol (10 mg daily) or placebo for 24 weeks in primary Raynaud's phenomenon and systemic sclerosis (Jayson et al. 1991). Although 43 patients (19 Raynaud's, 24 systemic sclerosis including only 4 men) entered, only 28 patients (11 Raynauds, 17 systemic sclerosis) completed the study. Compared with placebo, stanozolol significantly improved ultrasonic Doppler index as well as finger pulp and nail bed temperatures but there was no difference in reported frequency or severity of vasospastic attacks, scleroderma skin score or grip strength. The clinical significance of the changes in digital small vessel function recorded in the absence of vasospasm and without reduction in attack rates is unclear.

Forearm Wrist Thumb Splints

Wrist Ext Self Mobilization

The integrity of the wrist joint with its complex anatomic and motion architecture has been established as the key to hand function. It is uniquely vulnerable to a variety of injury and disease processes that may result in pain, stiffness, or instability, which may interfere with normal upper extremity function at all levels. The management of these wrist maladies may be substantially enhanced by proper splinting with objectives ranging from pain relief and protection to prevention and correction of deformity. In addition, wrist splinting may be used to negate or augment long extrinsic tenodesis functions in the management of digital pathologic conditions. Postoperative splinting protects healing structures while allowing predefined motion to involved and noninvolved joints. Therefore, it is imperative that careful consideration be directed toward the anatomic, kinesiologic, and functional effects of any splint created to traverse this important joint.

Allow for Optimum Sensation

Finger Tapen

A,B,D-G, Splints position key joints to improve hand function. C, Restricting full MP extension and generating IP extension through torque transmission of the extrinsic extensors, this splint for ulnar nerve paralysis allows full flexion of the fourth and fifth digits. Courtesy (A,B) Elizabeth Spencer Steffa, OTR L, CHT, Seattle, Wash. (C) Sandra Artzberger, OTR, CHT, Milwaukee, Wis. and Bonnie Ferhing, LPT, Fond du Lac, Wis. (F,G,H) Cindy Garris, OTR, Silver Ring Splint Company, Char-lottesville, Va. A,B,D-G, Splints position key joints to improve hand function. C, Restricting full MP extension and generating IP extension through torque transmission of the extrinsic extensors, this splint for ulnar nerve paralysis allows full flexion of the fourth and fifth digits. Courtesy (A,B) Elizabeth Spencer Steffa, OTR L, CHT, Seattle, Wash. (C) Sandra Artzberger, OTR, CHT, Milwaukee, Wis. and Bonnie Ferhing, LPT, Fond du Lac, Wis. (F,G,H) Cindy Garris, OTR, Silver Ring Splint Company,...

Adjuvant Pharmacotherapy

Most comparison trials show equivalency between orally given dantrolene, baclofen, and ti-zanidine after stroke. A randomized trial of 31 patients with acute stroke who did not yet have signs of spasticity looked for a prophylactic effect for dantrolene.303 The investigators started the experimental group on 25 mg of dantro-lene and built up to 200 mg over 6 weeks, then crossed the patients over the other arm of the trial. No differences were found for tone or functional outcome, but those on dantrolene developed greater weakness by isokinetic dy-namometry in the unaffected elbow and knee. An uncontrolled study of 47 patients given ti-zanidine, titrating from 2 mg per day up to 36 mg, found a significant decrease of 2 points in the Ashworth score and less pain.304 More than one side effect occurred in 89 of the subjects, as the dose exceeded 14 mg, including somnolence, dizziness, asthenia, dry mouth, and hypotension. Hand function did not change.

Splints Acting on the Wrist and Forearm

Wrist and forearm articulations are key elements to upper extremity function in that they fine-tune positioning of the distally sited hand, providing proficiency in self-care, work, and leisure activities. Essential to normal hand function, the wrist and forearm refine motion of more proximal upper extremity joints through progressive, proximal-to-distal summation of intercalated joint motion. When integrated with selective joint stabilization, this cumulative joint motion allows the hand to be positioned in a seemingly infinite number of attitudes, further maximizing its capacity for interaction within the environment. With powerful extrinsic tendon systems traversing the wrist and inserting in the hand and digits, hand strength, digital posture, and fine finger thumb motions are dependent on the integrity and positioning of wrist and forearm joints. The wrist serves as the key joint to distal hand function and influences both digital strength and dexterity. It is therefore important...

Choose the Most Appropriate Materials

Index Finger Splint Types

A, Bonding polyethylene to Plastazote produces a comfortable and extremely durable wrist immobilization splint that may be used with early return to work patients. A polyurethane foam splint (B) permits protected motion of the wrist and thumb carpometacarpal and metacarpophalangeal joints and a neoprene splint (C) positions the thumb to improve hand function. D, Splinting materials used in children's splints should be durable and nontoxic. The plastic portion of this Orthoplast and spring-wire splint is almost unrecognizable because of the patient's habit of chewing on it Courtesy (A) Theresa Bielawski, OT(C), Toronto, Ont., and Jane Bear-Lehman, PhD, OTR, FAOTA, New York, N.Y. (B) Rivka Ben-Porath, OT, Jerusalem, Israel (C) Joni Armstrong, OTR, CHT, Bemidji, Minn. A, Bonding polyethylene to Plastazote produces a comfortable and extremely durable wrist immobilization splint that may be used with early return to work patients. A polyurethane foam splint (B) permits protected motion of...

Biomedical Demography

Demographers over the past half century have increasingly become involved with the design of surveys and the analysis of survey data, especially pertaining to fertility or morbidity and mortality. Recently, various kinds of physical measurements (height and weight), physiological measurements (of blood pressure and cholesterol levels), nutritional status (assessed by the analysis of blood or urine and other methods), physical performance (hand-grip strength or ability to pick a coin up from the floor), and genetic makeup (as determined by analysis of DNA) have been added to surveys, including those conducted by Christensen, Goldman, Weinstein, Zeng, and others. Such biological measurements can be used as covariates in demographic analyses in much the same way that social and economic information is used. These kinds of analyses are an important activity of biomedical demographers (Finch et al. 2000).

Review Purpose Immobilization Mobilization Restriction Torque Transmission

Thumb Cmc Palmar

Fig. 8-12 B,C, Ring-small finger MP extension restriction IP extension torque transmission splint, type 0 (6) A-C, Combining MP extension restriction and IP extension torque transmission, this splint improves hand function by counteracting the typical MP hyperextension and IP flexion deforming forces associated with ulnar nerve paralysis. (Courtesy Peggy McLaughlin, OTR, CHT, San Bernadino, Calif.) Fig. 8-12 B,C, Ring-small finger MP extension restriction IP extension torque transmission splint, type 0 (6) A-C, Combining MP extension restriction and IP extension torque transmission, this splint improves hand function by counteracting the typical MP hyperextension and IP flexion deforming forces associated with ulnar nerve paralysis. (Courtesy Peggy McLaughlin, OTR, CHT, San Bernadino, Calif.)

Splints Acting on the Thumb

The importance of the thumb in almost all aspects of hand function cannot be overstated. The presence of an opposable thumb gives the human species a manual dexterity that is unparalleled in lower animal forms. Insurance companies assess a 40 functional loss to a hand that is missing the thumb the real loss may be substantially greater. Because of the tremendous disability resulting from thumb loss, hand surgeons have long striven to develop techniques to salvage or restore thumb function. Loss may result from congenital absence, traumatic amputation, disease, or injury.

Forearm Exercise Testing

Oxidative phosphorylation cannot occur. A simple technique for evaluating lactate production in response to ischemic forearm exercise was described by Munsat in 1970. 6i In that report, rested and fasting individuals squeezed a handheld ergometer, with a workload of 4 to 7 kg-m, at 60 Hz for 1 minute. (Alternative methods are to sustain 1.5-second contractions that are separated by 0.5-second rest periods for 1 full minute M or squeezing a hand dynamometer to 50 percent of maximum grip strength until exhaustion--usually about 10 minutes. y ) Although the serum lactate concentrations vary significantly among the studied individuals (the standard deviation approximated 60 percent of the mean), their relative change (rather than their absolute change) is fairly constant for a given individual. The serum lactate concentration peaks within 5 minutes (within 3 minutes for 90 percent of the tested individuals) of work cessation at a value that is three- to five-fold greater than the initial...

Hand Wrist and Forearm

Distal Transverse Arch

The anatomy of the hand must be approached in a systematic fashion with individual consideration of the osseous structures, joints, musculotendinous units, blood supply, nerve supply, and surface anatomy. However, it is obvious that the systems do not function independently, but that the integrated presence of all these structures is required for normal hand function. In presenting this material, I stray into the important mechanical and kinesiologic considerations that result from the unique anatomic arrangement of the hand and briefly try to indicate the problems resulting from various forms of pathologic conditions in certain areas. Surface anatomy and a description of the basic patterns of hand function are also included at the end of the chapter. distal to the wrist joint. It is important to thoroughly understand both systems. Although their contributions to hand function are distinctly different, the integrated function of both systems is important to the satisfactory...

Splinting the Pediatric Patient

Splint Wearing Schedule Form

This chapter focuses primarily on splinting for children who have developmental disabilities with subsequent difficulties in hand function. Although the splints discussed in this chapter have been observed The overall goal of splinting in the pediatric population is to maximize hand function. This can be achieved through splint use with the following goals (1) provide protection and support to weak muscles and joints, (2) provide proximal support and stability for improved distal function, (3) normalize muscle tone, (4) provide positioning of a joint, which then allows overall limb use and improved body movement and function, (5) compensate for muscle imbalance, (6) substitute for muscles that are not functional, (7) increase joint range of motion, (8) improve joint alignment, (9) decrease edema, (10) prevent or correct deformities, (11) make skin care and hygiene tasks easier, and (12) assist in task performance.

Short Opponens Hand Splint

Wrist Extension Mobilization Splint

The potential for the restoration of optimum hand function after peripheral nerve injuries of the upper extremity depends on the preservation of good passive joint motion. It is also necessary to protect periarticu-lar structures and denervated musculature by avoiding improper positioning of the partially paralyzed extremity.39,42 In the presence of existing deformity, splints may be designed to restore passive mobility to upper extremity joints. Adapted to the individual requirements of the patient, these splints range from uncomplicated rubber bands to complex multifunction splints. Once free gliding of articular surfaces has been established, maintenance and positioning splints may be used until reinnervation occurs or until tendon transfer procedures are carried out to restore balance to the hand. These positioning splints should be used in conjunction with a high-quality exercise program. Splints serve to prevent deformity that results from the unopposed antagonists of the...

Triangular Fibrocartilage Complex Injuries

One of the most common complaints about the wrist is ulnar side wrist pain. Injuries to the TFCC usually occur as the result of a hyperextension, ulnar deviation, and axially loading force and can also be found in association with distal radius fractures. However, not all disruptions of the TFCC are traumatic in nature, as inflammatory and degenerative conditions can also lead to TFCC pathology. Patients presenting with TFCC injuries may report ulnar side wrist pain, occasional clicking, loss of grip strength, and pain with pronation and supination. The mechanical symptoms may improve with rest and are worsened with loading. A complete history including any history of trauma or repetitive use injury should be taken and a complete examination of the wrist should be performed. Traumatic injuries may present with a pop and immediate pain and swelling, and chronic

Function Assessment Instruments

Normal Grip Strength Measurements

Hand function reflects the integration of all systems and is measured in terms of handedness tests, grip pinch, coordination and dexterity, and ability to participate in activities of daily living and vocational and avocational tasks. The Waterloo Handedness Questionnaire (WHQ) is a 32-item self-administered questionnaire that has high reliability46,53 and has been shown to be more specific and accurate than the traditional self-report for determining handedness.36,40 Further, when the WHQ is correlated with grip strength, it was found that in individuals with greater polarization of hand preference (i.e., always right or always left) there was a statistically significant greater difference between their dominant and nondominant grip strengths than in individuals who were less polarized (i.e., ambidextrous or nearly ambidextrous).39 Use of the WHQ has far-reaching ramifications for future clinical and research investigation in that it refines understanding of hand preference as it...

Leisure rehabilitation

When assessing leisure activities ask patients what they did before their stroke and whether they would like to return to these or try new hobbies. Using a checklist to keep a written record of what patients did before their stroke will help to identify areas of interest and plan a programme. Responses are usually more comprehensive when a checklist (such as the Amended Nottingham Leisure Questionnaire - Parker et al., 1997) is used. However, even checklists get out of date and this measure does not include computer activities such as email, Skype or on-line shopping. Look for common themes from the list of hobbies such as sporting or crafts as this may help you suggest new ones. Therapists should value more common everyday activities such as reading, walking and gardening as much as the more exciting ones. Check the most obvious limitations to participating in hobbies such as checking if patients need new glasses or hearing aid before assessing problems with hand function and...

Purpose of Application

Splints may be designed to prevent deformity by substituting for weak or absent muscle strength, as in peripheral nerve injuries, spinal cord lesions, and neu-romuscular diseases. They may be used to support, protect, or immobilize joints, allowing healing to occur after bone, tendon, vascular, nerve, joint, or soft tissue injury or inflammation. Correction of existing deformity represents another commonly encountered reason for splint application. To achieve full active joint motion potential, remodeling of joint capsular structures, tendon adhesions, or soft tissues often requires prolonged slow, gentle, passive traction that is best provided by splinting. Splints also may provide directional control for coordination problems and serve as a base for attachment of specialized devices that may facilitate and enhance hand function.

Hook of the Hamate Fracture 241 Clinical Presentation

This mechanism may also compress the terminal branches of the ulnar nerve, producing sensory and motor changes. As a result, patient symptoms include reduced grip strength, numbness and tingling in the distribution of the ulnar nerve, as well as ulnar sided wrist pain.

Physical Examination

Caveau Double

A thorough physical examination should be performed on all patients presenting with joint pain, including examination of asymptomatic joints and other organ systems that might be involved. Joints should be examined for swelling, tenderness, deformity, instability, and limitation of motion. Comparisons with the patient's contralateral side can be made in all these parameters, as well as with the physician's joints as a control. Instability can be tested by moving adjacent bones in the direction opposite to normal movement and observing for greater-than-normal motion. Serial grip strength measurements can be made by asking the patient to squeeze a blood pressure (BP) cuff inflated to 20 mm Hg and

Lateral Epicondylitis

Epicondylitis Lat

Diagnosis is based primarily on physical exam and history. Pain is elicited on palpation of the lateral epicondyle, and is aggravated by wrist extension and radial deviation. In Cozen's test (Fig. 6.1) the patient extends the wrist against resistance that is provided by the examiner at the same time as the examiner palpates the lateral epicondyle. In lateral epicondylitis, this will be very painful. In more severe cases, decreased grip strength can be noted. MRI or ultrasound can be used for diagnosis, but is usually reserved for patients who fail conservative therapy.

Functional Neuromuscular Stimulation

The first commercial surface electrode-driven device for grasping is the Handmaster (NESS Ltd. Ra'anana, Israel), which has found some use in quadriplegic patients with at least C-5 intact and in hemiplegic patients with poor hand function.11 Electrodes attached to a molded forearm orthosis that reaches across the wrist stimulates the wrist and finger flexors and extensors in synchrony. The external control unit operates from a button managed by the subject for the level of output that allows grasp, holding, or release. Uncontrolled trials of patients with a chronically hemiplegic hand showed a decrease in hypertonicity with up to 3 hours of daily stimulation for several months. A 5-week uncontrolled trial assessed subjects before and after 5 weeks of supervised home stimulation performed as they carried out a set of tasks (G. Alon, University of Maryland). The 75 patients could voluntarily flex and extend the elbow and wrist 20 and at least slightly extend the second and third...

Sensorimotor Impairment Scales

Strength is most commonly measured by the 5 grades of the British Medical Council Scale. This scale is least sensitive to change at grade 4, which describes movement against less than full resistance. This scale may be incorporated into other scales for a specific muscle group innervated by a particular root level, as in the American Spinal Injury Association Motor Score (see Chapter 10). Hand-held dynamom-etry can be performed at most muscles in a sensitive and reliable way,31,32 but limb positioning and rater experience are critical. Many devices measure grip and pinch strength, although the reproducibility and validity of these tests are often unclear.33 Grip strength, tested by a Jamar dynamometer with the elbow extended, is used to monitor diseases of the motor unit and correlates with overall strength in the elderly. The Tufts Quantitative Neuromuscular Examination34 battery uses an inexpensive, nonportable strain gauge to quantitate maximal voluntary isometric contraction of...

Motor and somatosensory deficits

Brain activity for hand grip compared to rest for individual subjects with corticospinaldamage. These fMRIstudies demonstrate that increasing corticospinal damage leads to a shift in the pattern of activation from the primary to the secondary motor system. (Modified from Ward 5 .) Figure 3.4. Brain activity for hand grip compared to rest for individual subjects with corticospinaldamage. These fMRIstudies demonstrate that increasing corticospinal damage leads to a shift in the pattern of activation from the primary to the secondary motor system. (Modified from Ward 5 .)

Allow for Optimum Function of the Extremity

The upper extremity has the unique ability to move freely in a wide range of motions, which allows for the successful accomplishment of a tremendous variety of daily tasks. The segments of the arm and hand function as an open kinematic chain, with each segment of the chain dependent on the segments proximal and distal to it. Compensation by normal segments when injury or disease limits parts of the chain often provides for the continued functional use of the extremity. Because of this adaptive ability, splinting of the upper extremity should be carefully designed to prevent needless immobility of normal joints. Often simple in design, splints that substitute for lost motion (Fig. 8-5, A,B) or control deforming substitution patterns (Fig. 8-5, C-G) enhance function by positioning specific joints in more advantageous positions. If digital joint limitation is caused by capsular pathology condition alone, the wrist may not require

Trainoffour twitch response

It is generally thought that at least three of the four twitches must be absent to obtain adequate surgical access for upper abdominal surgery. It is also preferable to reverse residual block with an anticholinesterase only when the second twitch is visible, if good recovery is to be relied upon. After reversal, good muscle tone - as assessed clinically by the patient being able to cough, raise his or her head from the pillow for at least 5 s, protrude the tongue and have good grip strength - may be anticipated when the train-of-four ratio has reached at least 0.7.

Emergence And Recovery

After completion of surgery anaesthetic agents arc withdrawn and oxygen 100 is delivered. Following removal of the tracheal tube or LMA, the patient's airway is supported until respiratory reflexes are intact. The patient's muscle power and coordination are assessed by testing hand grip, tongue protrusion or a sustained head lift from the pillow in response to command. Return of adequate muscle power must be ensured before the patient leaves theatre. Full monitoring of the patient should not be discontinued before recovery of consciousness.

Monitoring for Efficacy Outcome Evaluation

In patients with wounds (e.g., decubitus ulcers), a goal of nutritional therapy is to help facilitate wound healing. Therefore, monitoring the status of the wound becomes part of the ongoing nutritional assessment. In debilitated patients, particularly those on long-term EN, measures of functional status such as grip strength and ability to perform activities of daily living become important parts of the assessment of nutritional adequacy.

Dorsal Carpal Ganglion DCG

Wrist pain and tenderness, especially with palmar flexion, which may decrease grip strength and range of motion.45 A wrist extension immobilization splint, type 0 (1) is fabricated to reduce local area stress. A Silastic cover over the ganglion is secured with elastic wrap, allowing use for sports while protecting the DCG. If relief is not achieved with these conservative

Carpal Tunnel Syndrome

Patients typically present due to pain, numbness, par-esthesias, and loss of grip strength in the wrist and hand. Symptoms may even radiate into the shoulder region. Symptoms usually involve the radial 3 digits as supplied by the median nerve and are noted more with repetitive hand motion activities and at night. Physical examination may reveal thenar atrophy and decreased sensation over the radial 3 digits. These two clinical findings, along with a history of pain in the distribution of the median nerve, are highly suggestive of CTS and correlate to positive nerve conduction study findings (D'Arcy and McGee, 2000).

Hook of the hamate fractures

Hook of the hamate fractures can occur in direct contact sports or racquet-sport injuries as well as golf 3 . The hamate hook projects into the palm in the area of the hypothenar eminence and is vulnerable at this position. Due to the proximity of Guyon's canal any hook of the hamate fracture can be associated with neuro-vascular injury 3 . Patients present with complaints of pain in the palm aggravated by grasp. There is often loss of grip strength, and symptoms of ulnar nerve paresthesias and weakness of ulnar nerve-innervated muscles in the hand may be present 3 . On examination there is pain with direct palpation over the hook of the hamate. Standard X-rays should be obtained and if there is a possibility of fracture a CT scan may aid in the diagnosis 3 (Figs 6.7.14 & 6.7.15). Prognosis is determined by expedient diagnosis. A short arm cast is the initial treatment of choice. A delayed diagnosis may not allow for return to competition 83 . If nonunion occurs excision of the hook...

Charcot MarieTooth Disorder

Charcot-Marie-Tooth (CMT) disorders, also known as hereditary motor and sensory neuropathy or peroneal muscular atrophy, represent an inherited group of neuropathies, some of whose genetic mutations have been characterized. These disorders are associated with diffusely enlarged peripheral nerves, most commonly involving the peroneal nerve. Prevalence of CMT disorder is 1 person per 2500 in the population, or approximately 125,000 patients in the United States. Patients with CMT usually have a slowly progressive degeneration of the muscles in the foot, lower leg, hand, and forearm, and a mild loss of sensation in the limbs, fingers, and toes. The first sign of CMT is generally a high-arched foot or gait disturbance. Other symptoms of the disorder may include foot bone abnormalities such as hammer toes, problems with hand function and balance, occasional lower leg and forearm muscle cramping, loss of some normal reflexes, occasional partial sight or hearing loss, and, in some patients,...

Testing Batteries Versus Individualized Testing

Neuropsychological testing batteries provide a structured approach to the assessment of cognitive function. Although there are many neuropsychological testing batteries, two batteries are most commonly used the Halstead-Reitan Battery '131 and the Luria-Nebraska Neuropsychological Battery. '191 The Halstead-Reitan Battery is a collection of tests that Halstead found to discriminate normal individuals from patients with organic brain disease. The core of the Halstead-Reitan Battery includes six tests developed by the authors (measuring abstract reasoning, tactile performance, tactile visual-spatial memory, rhythm perception and memory, speech-sound perception, and primary motor speed) and seven tests developed by other individuals (measuring intelligence, psychomotor speed, sequencing abilities, language function, sensory function, grip strength, and personality functioning). The entire battery requires at least 6 hours for administration, not including scoring and interpretation, so...

Executive Function and Motor Performance

This test measures grip strength in each hand. Patients are given three trials with each hand, the first considered practice. Large differences between left and right grip strength may reflect lateralized hemispheric dysfunction. Adequate norms are available for this test.

Directed Neurological Examination Assessment Of Muscle Bulk

More objective measurements can be made with the use of specially designed instruments to measure force. The only one widely used in clinical practice measures grip strength. Recently an electronic strain-gauge that measures maximum isometric force has also been used in clinical research trials for the treatment of amyotrophic lateral sclerosis. y Some degree of objective measurement can also be obtained through formal assessment by a specially trained physical therapist. These semiquantitative methods (semiquantitative because they require the full cooperation of the patient being examined) are not primarily used for diagnostic purposes but rather for measuring changes that occur over time in response to some disease or treatment.

The European Myelopathy Score EMS

The European Myelophathy Score has five subscores (Table 1). The significance of the each subscore is weighted by the maximal number of points that is achieved if the subscore is normal. All of these subscores are functional criteria that do not require formal testing. They can be obtained by taking the patient's history, or even by questionnaires filled in by the patients themselves. The upper motor neuron is critical in the control of lower limb function. Gait is of major importance for judgment of cervical myelopathy. It is the only subscore that can reach 5 points. Bladder and bowel function (3 points) depend on both motor and sensory integrity. In cervical myelopathy, however, bladder or bowel dysfunction is caused primarily by a bilateral upper motor neuron lesion. Cervical myelopa-thy is generally due to degenerative changes of the middle and lower cervical spine. Therefore, impairment of hand function can be attributed mainly to lower motor neuron function (4 points), although...

Baby Buggies

Their models had names like Fleur de Lis (symbol of Bourbon Kings of France) and Silver Cross Balmoral (one of the homes of the British Queen). Observe the example at the top of 2.13a large overlapping wheels attached to enormous leaf-springs linked with leather straps to a wood-framed, hand-built carriage with hood struts and hand grip that come straight from the Hansom cab of the days of Sherlock Holmes.

Meal preparation

Some kitchen equipment such as large-handled utensils or cutlery issued by occupational therapists could be used by patients with some return of hand function to encourage further improvement or facilitate more normal movement. These could be used during meal preparation sessions in hospital or at home. Many other pieces of equipment are designed for one-handed use or to make heavy tasks lighter. Spike board, belliclamp, wall tin opener, battery-operated tin openers that fit on the can and do not require holding, ring pull cans and buttering board will enable the patient with limited upper limb function to prepare meals. A kettle tipper and cooking basket and draining spoons make dealing with boiling water safer and lighter. A trolley can be used by the more mobile patient to carry hot food.


Some of the functional relationships of these motor circuits have been visualized by autora-diography in lesion studies of animal models (Experimental Case Study 2-1). In patients studied at least 3 months after a left-sided stri-atocapsular infarction who had recovered contralateral hand function, resting rCBF by PET was still significantly lower than normal in the left basal ganglia and thalamus, the primary

Hemiparetic Stroke

The ipsilesional premotor cortex is also often activated during simple tapping with the affected fingers. Brief suppression of the dorsal premotor area by single pulse TMS contralateral to the hemi-paretic hand may prolong the simple reaction time, whereas stimulation of the ventral pre motor area does not a TMS pulse over Ml also delays the reaction time in the contralateral hand in patients and healthy contols.93 A decrease in the level of premotor activation is associated with better hand function. Thus, this region with its corticospinal projections plays an important substitutive role. the task for a subject. The contralesional dorsolateral premotor cortex and bilateral SMA participate in the acquisition of new complicated finger movement and upper extremity reaching skills. Many, but not all functional imaging studies of recovered hand movements78 demonstrate activation of these regions by the time of recovery of even simple movements. The medial wall of BA 6 contains four...

Active Movements

A few studies have examined differences in activations across hand movement paradigms. An fMRI study compared right-handed index finger tapping, four-finger tapping, and squeezing at 1-2 Hz.100 The level of activation increased across these tasks in controls. Recovered hemiparetic patients showed a larger volume of activation during right index finger tapping compared to controls in the right sensorimotor and left SMA cortices. A serial study of two hemiparetic subjects showed that simultaneous bilateral gripping soon after stroke produced a larger activation in primary sensorimotor cortex in the affected hemisphere than did use of the affected hand alone. With improved hand function, the bilateral grip activation decreased to the same level as activation induced by grip with the affected hand.101 When feasible, bilateral manual tasks may have some advantages in triggering plasticity. Some therapies do incorporate this approach.102

Monaminergic Agents

Fluoxetine 20 mg, a selective serotonin reuptake inhibitor, and fenozolone (20 mg), an amphetamine-like drug that increases monamine transmission, was given to healthy subjects during an fMRI task that compared rest to two fist closings then touching the thumb to each digit.192 The drug, compared to a placebo, focused the activity in the contralateral primary sensorimotor cortex and increased the activation of the posterior SMA, while decreasing bilateral cerebellar activation. The executive motor regions are rich in monaminergic receptors (see Chapter 1). Serotonin activates both pyramidal cells and GABAergic inhibitory in-terneurons. The neurotransmitter may inhibit Purkinje cell firing. Using the same task, another SSRI, paroxetine 20 mg, but not 60 mg, produced the same fMRI change in activation and improved hand speed modestly for the 9-Hole Peg Test.193 Other SSRIs have also improved performance time.194 A small controlled trial of fluoxetine in a single dose given to patients...

Renal disease

Pharmacological androgen therapy has been evaluated in a randomised placebo-controlled trial of nandrolone decanoate in dialysed patients (Johansen etal. 1999). Twenty-nine patients were randomised by sequential allocation to nandrolone decanoate (100 mg intramuscularly each week, n 14) or saline placebo (n 15) for 6 months. Lean body mass (measured by DEXA), timed walking and stair-climbing speed were all increased, self-reported fatigue fell but there was no change in handgrip strength. Peak oxygen consumption was also increased at three months, but not significantly so by the end of the sixth month. Larger placebo-controlled clinical studies of longer duration are needed to determine whether the impressive short-term benefits are sustainable and or improve survival.

And Disability

A useful research tool to stratify outcomes after SCI has been used by Curt and Dietz and other investigators to assess hand function and ambulation.1 For hand motor function, patients are classified as (1) being unable to make a voluntary grasp (no wrist extension or intrinsic muscle function) (2) having active hand function with wrist extension and passive grasp by a tenodesis effect and (3) having active grasp with use of the intrinsic hand muscle, allowing lateral pinch. For ambulation, patients are classified as (1) unable to stand or walk (2) able to stand or walk with physical help of 2 therapists or braces in parallel bars for therapeutic activity (3) possessing functional am-bulation with daily walking over short distances without physical help or braces other than an AFO and (4) little or no disturbance in walking.

Resistance Exercise

At least 12 studies have reported the effects of exercise in patients with neuromuscular diseases at 20 -70 of the force of their maximum single voluntary contraction. For example, a program of moderate resistance exercise that started at from 10 to 30 of each subject's maximum resistance enabled a group of patients with myotonic dystrophy, hereditary sensorimotor neuropathies, spinal muscular atrophy, and limb-girdle syndromes to modestly increase strength for hand grip, knee extension, and elbow flexion.11 Over 12 weeks, these patients gradually increased the amount of resistance and the number of repetitions during isotonic exercise of one side of the body. At follow-up, both the exercised and unexercised homologous muscles had improved, up to 20 for the knee extensors. Gains were a bit larger

Shoulder Splints

Movilizaciones Activas Hombro

Multiple secondary joint levels, allowing arm weight to be dispersed over a larger area, thus providing greater comfort than would splints that incorporate only the shoulder and humerus. The majority of these splints incorporate the elbow, forearm, and wrist as secondary joints to improve splint mechanics. For example, if the elbow is not included in a shoulder splint, control of shoulder external and internal rotation is difficult if not impossible, and destructive pressure on the distal portion of the humerus occurs as the forearm and hand are allowed to assume a dangerous, edema producing, dependent position at rest. As each successive, more distal joint is incorporated into the design of a shoulder splint, control of shoulder joint position and splint comfort increase. While finger and thumb joints frequently are free of splint material, inclusion of the wrist as a secondary joint is an important consideration in shoulder splint design. Leaving the wrist free allows better hand...

Hand Amputations

Partial Hand

Existing knowledge in biomechanics and hand function developed by hand surgeons and therapists can enhance prosthetic design today. Bunnell, the father of hand surgery, emphasized that rehabilitation of hand injuries includes custom prosthetic fitting of the partially or totally amputated hand.1,4 His comprehensive paper on surgical planning for prosthetics7 was republished in the first edition of Rehabilitation of the Hand.5,6 Moberg advocated the need for a key-pinch prosthesis. Hand surgeons understand that when muscle power is limited in reconstruction of a hand, a key-pinch is optimum over a tip-pinch for hand function.9 Moberg also suggested that proprioception of the thumb and fingers could be provided from surrounding skin areas of cutaneous sensation. Yet conventional hand prostheses continue to use a tip-pinch design, and few attempts are made to provide any sensory feedback. Even an otherwise normal hand may be of little use if it has no tactile...

Patient Satisfaction

Carlson JD, Trombly CA The effect of wrist immobilization on performance of the Jebsen Hand Function Test, Am J Occup Ther 37(3) 167-75, 1983. 28. Goossens PH, Heemskerk B, van Tongeren J, et al Reliability and sensitivity to change of various measures of hand function in relation to treatment of synovitis of the metacarpophalangeal joint in rheumatoid arthritis, Rheumatology (Oxford) 39(8) 909-13, 2000. 32. Jebsen RH, Taylor N, Trieschmann RB, et al An objective and standardized test of hand function, Arch Phys Med Rehabil 50 311-9, 1969. 39. Lui P, Fess EE Comparison of dominant and nondominant grip strength the critical role of the Waterloo Handedness Questionnaire, Submitted for publication. 49. Rider B, Linden C Comparison of standardized and non-standardized administration of the Jebsen Hand Function Test, J Hand Ther 1 121-6, 1988. 54. Stern EB Grip strength and finger dexterity across five styles of commercial wrist orthoses published erratum appears in Am J Occup Ther...

Hook Of The Hamate

The vast majority of athletes return to their previous level of sports participation following hook of the hamate excision.10,19,24 The time to return to full athletics averages 8 weeks with nearly normal grip strength regained within 3 months of fragment exci-sion.2,20 Associated nerve or tendon injury prolongs the time course for return to athletics and complicates the surgical repair and postoperative rehabilitation.22

Functional Patterns

Ergonomics Human Figure Hand

Many attempts have been made to classify the different patterns of hand function, and various types of grasp and pinch have been described. Perhaps the more simplified analysis of power grasp and precision handling as proposed by Napier8,9 and refined by Flatt4-6 is the easiest to consider. An analysis of hand functions requires that one consider the thumb and the remainder of the hand as two separate parts. Rotation of the thumb into an opposing position is a requirement of almost any hand function, whether it be strong grasp or delicate pinch. The wide range of motion permitted at the carpometacarpal joint is extremely important in allowing the thumb to be correctly positioned. Stability at this joint is a requirement of almost all prehensile activities and is ensured by a unique ligamentous arrangement, which allows mobility in the midposition and provides stability at the extremes. As can be seen in Fig. 2-31, the thumb moves through a wide arc from the side of the index finger...


Two studies have examined whether short-term pharmacological androgen therapy can improve rehabilitation in older men. The first randomised 25 men scheduled for knee replacement to receive weekly doses of 300 mg testosterone enanthate or matched placebo during three weeks before surgery (Amory et al. 2002). The second randomised 15 men admitted to hospital for general physical rehabilitation to receive weekly injections of 100 mg testosterone enanthate or placebo for 2 months (Bakhshi etal. 2000). Small improvements in Functional Independence Measure (FIM) score and strength (hand-grip dynamometry) were reported only in the latter study which, however, suffered from the limitations of small sample

Peripheral factors

Be achieved with only 20 return of diaphragmatic power, but the ability to cough remains severely impaired. If the patient is able to lift the head from the trolley for 5 s or maintain a good hand grip, it is likely that there is sufficient return of neuromuscular function for adequate ventilation and maintenance of the airway. Some more objective means of assessment are listed in Table 41.4, but these require the cooperation of the patient. In the unconscious or uncooperative patient, nerve stimulation (see Ch. 19) provides the best means of assessing neuromuscular function, although there are differences among the non-depolarizing relaxants in the relationship between their actions in the forearm and diaphragm. Grip strength Adequate cough

Wrist Finger Splints

In the ESCS, use of a colon punctuation mark ( ) in a splint's technical name indicates a torque transmission splint in which the joint immediately preceding the colon is the driver or power joint. For example, a wrist extension index-small finger MP flexion torque transmission splint, type 0 (5) uses active wrist extension to produce passive finger MP joint flexion. Splints in this group may be single-joint power-driven as noted in the example or, as is often the case, they may be reciprocal alternating multijoint powered with active wrist flexion producing MP extension and active MP flexion producing wrist extension (Fig. 13-20, A,B). The latter are sometimes used to improve hand function in radial nerve injuries. There are no secondary joints in a type 0 wrist finger torque transmission splint.

Pronator Syndrome

Treatment of pronator syndrome involves rest, modification of daily activities, NSAIDS and an elbow splint. After pain subsides the athlete can begin simple hand exercises (ball squeeze). This can progress to light wrist flexion and extension and then pronation and supination exercises. If this treatment fails for 4-6 weeks, surgical exploration can be considered and an anatomical exploration for nerve compression can be sought.

Subjective Objective

Myopathy can be a feature of hypothyroidism and manifests with proximal muscle weakness. Regardless of the cause of the hypothyroidism, weakness is observed in about one third of these patients.y Increased muscle size and firmness, which is most obvious in the limb musculature, as well as slowed muscle contraction are important features to identify. Exertional pain, stiffness, and cramps may be noted, and myoedema may be observed. Myoedema, a mounding of the muscle in response to direct percussion, is painless and electrically silent, and occurs in one third of hypothyroid patients. y Difficulty relaxing the hand grip and exacerbation by cold weather may suggest myotonia. However, unlike myotonia, hypothyroid myopathy involves a slowness of muscle relaxation and contraction, and resolves with correction of the hypothyroid state. y Although sleep apnea is usually of the obstructive type, other possibilities include a central abnormality, chest muscle weakness, and blunted responses to...

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