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Strengthening Exercises

Information

Description of Intervention

Having adequate strength in the upper extremity is essential for normal daily functioning. Strength deficits can occur after surgery, injury, and other painful conditions, as pain and reduced mobility eventually lead to reductions in strength. Muscle strength also decreases naturally over time due to age-related changes, and frailty in older age is often a major contributor to impaired functional abilities and quality of life (QoL).

Therefore, muscle strengthening exercises are considered an integral component of treatment plans for any condition of the upper extremity involving pain, limited mobility, or strength deficits. For example, research has shown that muscle force in patients with rheumatoid arthritis is 75% lower than in that of healthy individuals, but strengthening the wrist and fingers was found to improve muscle force and performance, which in turn increased independence and improved QoL.1 For these patients, strengthening exercises for the wrist and finger flexors appeared to be essential for preventing severe deformities and helping patients re-establish some of their lost physical function.1

Traumatic musculoskeletal injuries like distal radial fractures may require surgery and a period of immobilization to allow for proper healing—6 to 8 weeks for distal radius fractures. However, strengthening exercises should be initiated immediately after the period of immobilization to help patients regain the strength that has been lost.2,3

Indications for Intervention

Strength deficits of the fingers/hand, wrist, or elbow may result from traumatic injuries, surgical procedures, neurologic disorders, or musculoskeletal conditions like rheumatoid arthritis (RA), complex regional pain syndrome (CRPS), or fibromyalgia.

Diagnosis1-3

  1. Ask for the patient’s medical history, including any recent injuries to the fingers/hand, wrist, or elbow, and any recent surgeries.
  2. Ask if the patient has any comorbidities, including smoking, diabetes, or osteopenia.
  3. Perform a physical examination of the area of interest. If range of motion (ROM) is impaired, measure the ROM of any involved joints (eg, wrist flexion/extension, wrist supination/pronation) with a goniometer and compare these measurements with the contralateral side.
  4. Assess the patient’s pain with the visual analogue scale (VAS) and disability with the Disabilities of the Arm, Shoulder and Hand (DASH) Score, or similar diagnostic scales.
  5. Measure handgrip strength with a handgrip dynamometer and pinch strength with a pinch gauge. Patients should be seated with their hips and knees flexed at 90°, feet on the floor, upper limbs in adduction, elbows at 90°, and wrists in a neutral position. Take three measurements of both the affected and non-affected extremity and calculate the mean values for each side.
  6. If sufficient data are available, diagnose the patient’s condition and determine which interventions are appropriate.

Intervention Options1,3-5

After obtaining a diagnosis, the hand therapist or physical therapist should design a personalized treatment program that addresses the impairments identified during the initial evaluation. A comprehensive treatment program should typically include both stretching and strengthening exercises, as well as patient education, pain-relieving modalities (eg, ice, heat, ultrasound), manual therapy, functional training, and sport-specific training for athletes recovering from an injury.5 The therapist may choose from a variety of strengthening exercises and should select those that the patient is capable of completing independently without provoking significant pain.6 Below are several examples of strengthening exercises for the upper extremity:

  • Elbow/forearm
    • Elbow rotations
    • Towel twist
    • Dead hang
    • Towel exercises
      • Towel dead hang
      • Towel pullups
      • Towel curl
    • Farmer’s carry
    • Dumbbell reverse curl
    • Isometric forearm pronation/supination exercises
    • Cherry pickers
    • Hand gripper exercises
  • Wrist
    • Opening and closing fist
    • Ball squeeze
    • Wrist walking
    • Fingertip high plank
    • Pole twist
    • Dumbbell or resistance band exercises
      • Wrist flexion
      • Wrist extension
      • Wrist supination
      • Wrist pronation
      • Wrist rotation
    • Rubber band strengthening exercise (entire hand)
  • Hand/fingers/thumbs
    • Isometric hooks exercises
    • Thumb extension exercise
    • Therapy ball exercises
      • Power grip
      • Thumb pinch
      • Table roll
      • Finger flexion
      • Thumb roll
      • Finger squeeze
      • Thumb opposition
    • Putty exercises
      • Fingertip pinch
      • Flat pinch
      • Finger spread
      • Finger extension
      • Full grip
    • Rubber band exercises
      • ubber band abduction exercise
      • Rubber band “C” thumb exercise

As these examples highlight, many strengthening exercises for the upper extremity involve therapeutic tools like putty, resistance bands, and rubber bands. Racquet and tennis balls are also commonly used. Isometric or isotonic exercises—or a combination of both—may be prescribed based on what the therapist deems appropriate.2,4 In one study of patients who underwent volar open reduction and internal fixation (ORIF) for distal radius fractures, rehabilitation started with light isometric strengthening exercises and then progressed to isotonic strengthening exercises four weeks after surgery.2

The duration of each exercise and number of repetitions performed will vary substantially depending on the condition present and the patient’s abilities, pain tolerance, and goals. In one study of patients with ulnar wrist pain, patients performed various exercises with a softball and resistance band for 3 sets of 10 repetition, twice per day.4 In another study of patients with RA, patients completed exercises five days per week for two consecutive months.1

Regardless of the exercises prescribed, the overall goal should always be to help the patient rebuild strength and mobility of the joints and muscles involved.7 The therapist should regularly monitor the patient’s progress and pay close attention to changes in pain levels, swelling, proprioception, and overall movement patterns. As the patient improves, the intensity, frequency, and duration of the prescribed exercises should gradually increase according to the patient’s progress. Orthotic devices may also be used.5

Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Since RA is multifaceted and often affects various components of one’s daily life, some patients may seek out other therapeutic services—like counseling—in addition to hand therapy, to assist with their rehabilitation and to discuss solutions to common obstacles.8
  • In the study of patients with distal radius fractures treated surgically with ORIF, starting strengthening exercises two weeks after surgery led to a fast return of functional abilities.2
References
  1. Cima SR, Barone A, Porto JM, de Abreu DC. Strengthening exercises to improve hand strength and functionality in rheumatoid arthritis with hand deformities: a randomized, controlled trial. Rheumatol Int 2013;33(3):725-732. PMID: 22565655
  2. Brehmer JL, Husband JB. Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study. J Bone Joint Surg Am 2014;96(19):1621-1630. PMID: 25274787
  3. Zago NN, Sande de Souza LAP, Kimura BG, Bertoncello D, Grecco MAS, et al. Serious games therapy associated with conventional physical therapy intervention accelerated hand muscles strengthening and hand functioning after complex fracture of the wrist: A case report. J Hand Ther 2020;33(4):580-586. PMID: 30853255
  4. Abdelmegeed M, Lohman E, Daher N, Kume J, Syed HM. Effect of Ulnar-Based Orthotics and Strengthening Exercises on Subjects With Ulnar Wrist Pain. J Sport Rehabil 2020;29(2):206-212. PMID: 30676202
  5. Wietlisbach C. Cooper’s Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. Third ed. St. Louis, MO: Elsevier; 2020.
  6. Aizawa J, Masuda T, Hyodo K, Jinno T, Yagishita K, et al. Ranges of active joint motion for the shoulder, elbow, and wrist in healthy adults. Disabil Rehabil 2013;35(16):1342-1349. PMID: 23826904
  7. Guzelkucuk U, Duman I, Taskaynatan MA, Dincer K. Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries. J Hand Surg Am 2007;32(9):1429-1435.PMID: 17996780
  8. Salter M, Cheshire L. Hand Therapy: Principles and Practice. Oxford, UK: Reed Educational and Professional Publishing Ltd, 2000.
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