1. 11-1 Kinesiology for Manual Therapies Chapter 11 Unwinding the Soft Tissues of the Forearm: Dimensional Massage Techniques for the Muscles of the Hand and Wrist McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

2. 11-2 Learning Outcomes o 11-1 Define key terms. o 11-2 Describe the difference between entrapment and compression. o 11-3 Discuss how posture and sleep positions can contribute to soft-tissue conditions. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

3. 11-3 Learning Outcomes (cont.)  11-4 List several potential causes of carpal tunnel syndrome.  11-5 Determine safe treatment protocols and refer clients to other health professionals when necessary.  11-6 Review general pathologies and conditions of the muscles of the hand and wrist. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

4. 11-4 Learning Outcomes (cont.)  11-7 Develop a treatment protocol for conditions of the lateral and medial epicondyle areas.  11-8 Demonstrate safe body mechanics.  11-9 Practice specific techniques on the hand and wrist muscles.  11-10 Incorporate dimensional massage therapy techniques in a regular routine or use them when needed. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

5. 11-5 Introduction  The anatomy of the forearm, hand, and wrist is a compact package.  Repetitive activities come with a price of soft-tissue dysfunction. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

6. 11-6 Injuries and Overuse Syndromes  Sprains are injuries that often tear ligaments and soft tissue and bruise nerves.  Strains are injuries to the soft tissue, such as a stretch or tear to a tendon or muscle.  Both injuries have levels of severity. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

7. 11-7 Injuries and Overuse Syndromes (cont.)  Fractures and lacerations are frequent traumatic results to hand and wrist injuries.  Tendonitis is defined as an inflammation of a tendon.  Different types of tendonitis could include a partial tear from the bone or a lesion in the body of the tendon. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

8. 11-8 Injuries and Overuse Syndromes (cont.)  An adhesion may be a painful scar.  Tendonosis is defined as a breakdown in collagen fibers in the tissue.  Collagen is made up mostly of protein and is composed of the white fibers of connective tissue. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

9. 11-9 Injuries and Overuse Syndromes (cont.)  Tenosynovitis is an inflammation of a tendon sheath.  Tendon sheaths are Saran-wrap-like connective tissue that surround individual groups of tendons. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

10. 11-10 Other Soft-Tissue Issues  A wrist ganglion is a cyst that usually protrudes on the dorsal side of the wrist.  Dupuytren’s contracture is a debilitating hand condition that can inhibit normal hand and finger function. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

11. 11-11 Nerve Complaints  Carpal tunnel syndrome is an inflammatory condition of the median nerve.  Causes include: small tumors and/or ganglion, fluid retention in pregnancy, shape of the tunnel, a depressed capitate bone, tenosynovitis, and flexed wrist positions. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

12. 11-12 Nerve Complaints (cont.)  The median nerve can be entrapped outside of the carpal tunnel by the pronator teres or pectoralis minor.  Bony compressions of the brachial plexus can reduce innervation to the median nerve and produce distal symptoms. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

13. 11-13 Nerve Complaints (cont.)  The radial nerve can become entrapped by the triceps brachii or by the supinator.  Ulnar nerve entrapment in the arm and flexor carpi ulnaris can cause weakness of grip.  The cubital tunnel can compress the ulnar nerve. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

14. 11-14 Sleep Positions and Posture  Question clients about sleep positions.  Upper extremities above the head in sleep can help the pectoralis minor to entrap the brachial plexus.  A fetal sleep position encourages rounded shoulder postures. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

15. 11-15 Arthritis, Osteoarthritis, Degenerative Disk Disease, and Cervical Subluxations  Arthritis is an inflammation of a joint and is common in the aging process.  Osteoarthritis is a degenerative joint disease common in the spine.  Spurs are bony growth on the side of the vertebrae. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

16. 11-16 Arthritis, Osteoarthritis, Degenerative Disk Disease, and Cervical Subluxations (cont.)  Degenerative disk disease is the depletion of the disk space between the vertebrae.  It is often present with osteoarthritis.  A subluxation is a joint that is slightly ajar that a chiropractor could align or adjust. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

17. 11-17 Unwinding the Forearm Muscles  Probable muscles involved in lateral epicondylitis: brachioradialis, extensor carpi radialis longus, extensor digitorum, extensor carpi ulnaris, extensor digiti minimi, triceps, anconeus, supinator, and compensating biceps and brachialis. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

18. 11-18 Unwinding the Forearm Muscles (cont.)  Probable muscles involved in medial epicondylitis: pronator teres, flexor carpi ulnaris and radialis, flexor digitorum superficialis, and flexor digitorum profundus.  Do not overlook the biceps and brachialis in the arm. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

19. 11-19 Unwinding the Forearm Muscles (cont.) Treatment protocol McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

20. 11-20 Dimensional Massage Therapy for the Hand and Wrist Muscles McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved  Not all hand and wrist pain is from repetitive action of the forearm muscles.  Check infraspinatus, subscapularis, scalenes, and pectoralis major and minor.  Relax the shoulder girdle muscles first and work down to the forearm.

21. 11-21 Dimensional Massage Therapy for the Hand and Wrist Muscles – Supine Compression of the Forearm Muscles McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

22. 11-22 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Jostle the Brachioradialis McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

23. 11-23 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Elliptically Move the Forearm Muscles McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

24. 11-24 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Myofascial Stretch of the Brachioradialis McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

25. 11-25 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Parallel Thumbs on the Brachioradialis McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

26. 11-26 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved  Locate and palpate forearm tendons.  Check for hypertonicities, tenderness, and pain tolerance levels at attachment sites.

27. 11-27 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Compressive Effleurage McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

28. 11-28 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Alternating Petrissage of the Forearm McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

29. 11-29 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Broadening of the Forearm Muscles McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

30. 11-30 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Myofascial Humeral Twist McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

31. 11-31 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Petrissage Elbow Joint with Distraction McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

32. 11-32 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Elliptically Move the Carpals and Metacarpals McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

33. 11-33 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Short Cross Stroke to the Antebrachial Fascia McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

34. 11-34 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Thumb Stripping to the Antebrachial Fascia McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

35. 11-35 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Thumb Stripping to the Flexor Retinaculum McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

36. 11-36 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Strip the Forearm Tendons McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

37. 11-37 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Flex, Extend, and Strip Tendons McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

38. 11-38 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Treat Lateral Origins McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

39. 11-39 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Treat Medial Origins McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

40. 11-40 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Broaden with Active Engagement McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

41. 11-41 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Lengthen with Loose Fist McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

42. 11-42 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Lengthen with Thumbs McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

43. 11-43 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Light Hacking McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

44. 11-44 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Flipping Hand McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

45. 11-45 Dimensional Massage Therapy for the Hand and Wrist Muscles (cont.) – Supine Ulnar and Radial Flexion Shake McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

46. 11-46 Chapter Summary  This chapter discussed the vulnerability of the forearm, hand, and wrist structures.  Injuries and overuse syndromes including fractures and dislocations, tendonitis, tendonosis, and tenosynovitis were reviewed. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

47. 11-47 Chapter Summary (cont.)  Soft-tissue issues and nerve complaints were explored.  Arthritis, osteoarthritis, degenerative disk disease, and cervical subluxations were reviewed. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

48. 11-48 Chapter Summary (cont.)  Treatment protocol and sequence of the forearm, hand, and wrist areas were outlined for unwinding the forearm muscles. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

49. 11-49 Chapter Summary (cont.)  Dimensional Massage Therapy techniques for the muscles of the forearm, hand, and wrist were depicted for the supine position. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

50. 11-50 Chapter Review  The Chapter Review is divided into true and false, short answers, and multiple choice questions.  The questions are designed for the students to test their knowledge. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

51. 11-51 Explore and Practice  Activities in this section are for practice and demonstration.  Every opportunity should be utilized to locate muscular attachments on as many different bodies as possible to support kinesthetic learning. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

52. 11-52 Explore and Practice  Use the muscle cards and book in technique classes, for log hours, or for case studies for reference purposes. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved