Upper Extremity Exercise Prescription Jim, Tara, Jessie, Corrin, Matt Case Study Number One

Case Study One A 35 year old male presents with difficulty raising or lifting objects over his head or elevating his arm above his shoulder with or without a load. He injured himself three weeks ago water skiing when he fell holding onto the rope too long. The shoulder has been treated for one week for soft tissue musculoskeletal injury to the right shoulder where range is limited in flexion and abduction. Also, there is muscle spasms in the neck and upper-back region. There is still discomfort on a pain scale of 6 out of 10 and range is still limited. The patient has been referred to us for range of motion testing and exercise prescription exercises for flexibility, strengthening, and retraining to return to normal activities.

Flexibility A) The pendulum exercise (Codman’s Exercise): –Used in early rehab –Detracts glenohumeral joint –Loosens and relaxes muscles around the shoulder and modulates pain. –With arm hanging at side and torso bent over at roughly 45 degree angle perform circumduction at the shoulder joint. –Repetitions: perform 15 reps for 2 sets with 10 seconds rest between sets. B) Shoulder abduction/horizontal abduction: - Grab wand with left hand in pronated position and right hand in supinated position and push towards injured side to stretch shoulder in horizontal abduction and normal abduction -15 reps on each side for 2 sets with 10 seconds rest between. C) Anterior capsular stretch: - With chest facing wall abduct arm parallel to floor, slowly turn torso away from wall stretching the anterior aspect of the deltoid and pectoralis minor. - Hold this stretch for 20 seconds. Perform 2 sets with 10 seconds rest between.

Strengthening A) Shoulder Flexion: –Perform isometric shoulder flexion until range of motion has returned. –Perform exercise five times for five seconds with 5 seconds rest in between B) Shoulder Extension: -Opposite of isometric flexion -Can perform with theraband when range of motion has returned. (Same goes for shoulder flexion) -Perform exercise five times for five seconds with 5 seconds rest C) Lateral Shoulder Rotation: -With arm flexed at 90 degrees laterally rotate arm at shoulder, pressing forearm against the wall for resistance. -Perform exercise five times for five seconds with 5 seconds of rest.

Stability Exercises A) Swiss ball stabilization: Advanced exercise for those with returned range of motion Keep ball close to body to prevent injury Roll out arms over ball into extended position. Trainer should spot the client’s torso to ensure that they do not get injured. Roll out and hold for five seconds. Repeat 3 times Do 2 sets with 30 seconds rest between each set. B) Theraband Abductions: -Place theraband underneath both feet and abduct the band until arms are parallel to the floor. -Abduct and hold for 5 seconds, repeat 5 times allow for 30 seconds of rest and then repeat one more set. C) Theraband Lateral Rotation: -Holding one end of the theraband with the left hand, laterally rotate theraband with right hand away from body as far as the client can rotate at the shoulder. -Hold the position for 5 seconds, repeat 5 times and allow for 30 seconds of rest and then repeat one more set.

Plyometric Exercises A) Slideboard: –Client should be at a fully recovered state prior to performing plyometrics. They should have a full range of motion without discomfort. –Client should perform 15 repetitions and 2 sets with at least 3 minutes of rest between sets. –Client gets down on knees and places both hands on slide board (in front of them). They proceed to abduct shoulders explosively into a semi pushup position and explosively return to the starting position. B) Power Drops with Medicine Ball -Client lies on their back while the trainer stands straddled over their body. -Trainer then drops medicine ball either to the centre of the chest or off to the side so that the client catches the ball either in front of the chest or lateral to the torso. The client then throws the ball back up to the trainer. -Client performs 5 repetitions to each positon (ie. Centre of chest, left of centre or right of centre) Rest between each set for 3 minutes.

Functional Activities A) Drinking Juice: –Perform drinking motion with arm and shoulder. Drinking from cup, waterbottle, etc. B) Placing book on bookshelf - Once in the morning, afternoon, and evening throughout the day raise a book 5 times to different heights (if possible without discomfort). - Instead of just raising books to a shelf in flexion the client should stand perpendicular to the bookshelf and raise the book in abduction to the bookshelf.

Case Study Number Two A 55 year old woman who works in a wearhouse as a clerical worker has complained of pain and discomfort above her elbow on the lateral side. She has discomfort in the area as well in the posterior aspect of her forearm and wrist. Plus loss of strength at the end of her working day and at home. In addition, she has had chronic low- order back pain for the last three years and experiences aching and pain during the course of the workday. She performs filing, mousing, and computer keyboarding and general clerical duties. As well, she is required to lift merchandise up to 5kg in and out of vans at waist height and above times a day. She is also required to drive a truck and perform deliveries from time to time. She has been diagnosed with an overuse injury and has been resting and taking anti-inflammatory medication for two weeks and is now ready to go back to work. She has been tested and prepared for work by a kinesiologist.

Flexibility A) Pronation and supination Stretch: –With arm resting on knee rotate arm in both the prone and supine position –With assistance from the non-moving arm gently rotate forearm into supination. Hold for 20 seconds and then pronate and hold stretch for 20 seconds. B) Flexion/Extension Stretch -With arm extended out to wall, allow wrist to come into extension and gently push into stretch (stretching flexor muscles), hold for 20 seconds. -For stretching the extensor muscles allow wrist to come into flexion and gently push until stretch is felt in the posterior (extensor) compartment of the forearm. Hold stretch for 20 seconds. C) Cat Crouch -While kneeling on hands and feet, keep torso as still as possible, and gently rock the pelvis into flexion and extension and hold each position for 15 seconds.

Strengthening A) Curling with opposite arm resistance Perform biceps curl with right arm while resisting with left then perform on opposite side. The opposite arm should resist at the wrist level. Perform exercise for 15 repetitions with 2 sets. (For all of these exercises rest for 30 seconds between sets.) B) Wrist flexion and extension Place forearms on top of thighs in supine position while holding a soupcan or water bottle. The client then proceeds to flex and extend wrist. The procedure is then repeated with forearms rotated into pronated position. Perform exercise for 15 repetitions with 2 sets and 30 seconds rest between sets. C) Back Extensions -While lying on floor in the prone position (face down) lift upper torso off of floor without using the hands for assistance -Perform exercise for 15 repetitions with 2 sets and 30 seconds rest between.

Stability Exercises A) Pushup Weight Transfer From a pushup position (can use knees) the client transfers weight to left arm and lifts the right arm off of ground and then repeats with the opposite side. Alternate sides on every repetiton performing 15 on each side for 2 sets with 30 seconds rest between each set. B) Exercise Ball Crunch -Client goes from being seated on the ball to rolling down the ball until their lower back rests on the peak of the ball. -In a slow and controlled fashion the client crunches their sternum towards their pelvis and then slowly returns to the starting position. -If client is not at a level where they can stay balanced on the ball while performing the exercise they may roll up a towel and slide it under the small of their back. -Perform 15 crunches with 30 seconds rest between the 2 sets. -C) Supine Hip Lift w/ exercise ball -Client lies on their back and their arms abducting to 90 degrees at their side with palms facing the floor -Position the back of the heels on the top of the exercise ball -The client then extends their hips upwards until a straight line is formed with the feet, knees, and hips and shoulders. -Perform 15 repetitions with 30 seconds of rest between 2 sets.

Plyometric Exercises A) Stress ball claw – explosively open and close hand, clenching the stress ball. –The exercise should be performed for 15 contractions for 2 sets with 3 minutes of rest between sets. B) Pushoff against wall -Client stands about 2 feet away from a wall while facing it -They then allow themselves to fall face-forward into the wall catching themselves with their hands and then explosively pushing off the wall back to the starting (standing) position.

Functional Activities A) Typing: –Typing with ergonomic wrist pad and ergonomic chair for proper posture. B) Functional lifting of boxes -Instruct the client on proper lifting techniques so that they do not create any further soft tissue injuries.

References Houghlum. P.A. Therapeutic Exercise for Musculoskeletal Injuries. Human Kinetics Earle, R.W. NSCA’s Essentials of Personal Training. Human Kinetics Anderson, M.K., Hall, S.J., Martin, M. Foundations of Athletic Training: Prevention, Assessment, and Management