Clinical Conversation: Alternate Grips for Upper Limb Rehab (June 2022)

This transcript includes highlights from the live, interactive session of our Clinical Conversation: Alternate Grips for Upper Limb Rehab. 

If you missed the live webinar, you can read about using alternate grips for upper limb rehab in your clinical Pilates practice, below. 

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  • Grip and Grasp Anatomy: The carpals.
    • The carpus is designed to increase the tension in the tendons of the fingers (both extensors and flexors) and optimise these movements.
    • The proximal row are functionally separate from the distal row.
    • Flexion of the wrist initially occurs between these two rows, with the scaphoid acting as a bridge, so that in the final stage of flexion the whole carpus moves as a single unit.
    • The same occurs in extension, which is the more functionally useful position for grip.
    • Wrist flexion does not play a role in any form of powerful grip.
  • Grip and Grasp Anatomy: The flexor retinaculum and finger pulleys.
    • The flexor retinaculum prevents bowstringing of the long finger flexor tendons.
    • The annular and cruciate pulleys keep the flexor tendons close to the bones and joints of the fingers, hand, and wrist, to allow for effective flexion.
    • Varying degrees of finger flexion are required for all types of grip, with wrist extension more important than wrist flexion for grip and grasp.
  • Ulnar deviation completes active elbow extension to increase the force that can be generated through that movement, transmitting load to the triangular fibrocartilage complex and thus into the carpals. 
  • Thumb Opposition.
    • This is the ability of the thumb to rotate and move independently of the other four fingers.  
    • Thumb opposition allows for precision grips to manipulate smaller objects.
  • Tenodesis Grasp.
    • Moving the wrist in extension will cause fingers to passively flex.
    • Moving the wrist into flexion will passively extend the fingers.
    • This is caused by the attachment of the flexor tendons, and the passive tension created by these muscles acting over more than one joint.
    • This phenomenon can be used to to support grip and grasp for upper limb rehab, especially in spinal cord injured patients.  
  • Grip and grasps are strongest when the wrist is held in approximately 30 degrees of extension.



  • Power grips are those with a static hand position. Adductor pollicis longus stabilises the object against the palm.

    • Cylindrical grip.
    • Spherical grip.
    • Hook grip.
    • Lateral prehension grip with thumb adduction.
  • Precision grips are those with a dynamic hand position. Muscles that oppose/abduct the thumb are active in precision grips.

    • Palmar prehension grip.
    • Tip-to-tip grip.
    • Lateral prehension grip with thumb abduction.



  • Power Grip: With your arms by your side, curl your fingers as though holding a shopping bag. 
    • Notice the work in your fingers, hand, wrist, forearm, and shoulder girdle.
    • How does the activation change if you bend your elbow?
    • How does the activation change if you pronate or supinate the forearm?
    • Add radial or ulnar deviation? Or wrist flexion or extension? 
    • Relax your grip.
    • Repeat the exercise, but this time grasp an imaginary Reformer foot bar.
    • Notice the work in your fingers, hand, wrist, forearm, and shoulder girdle as you change the position of your arm in space.
  • Precision Grip: Pinch  your thumb and first finger together. 
    • Notice the work in your fingers, hand, wrist, forearm, and shoulder girdle.
    • How does this feel different when you pinch your thumb and second finger together?
    • Thumb and fourth finger? Thumb and fifth finger?
    • How does your upper limb activation change when you add wrist flexion or extension? 
    • How does the activation change if you bend your elbow?
    • How does the activation change if you pronate or supinate the forearm?
    • Add radial or ulnar deviation? 



  • Most exercises in the Pilates studio that uses equipment use power grips.

    • E.g. When grasping the Reformer foot bar or the push through bar on the Trapeze Table, clients generally hold the bar with their thumb wrapping the bar (cylindrical grip), or with the thumb on the same side of the bar as the finger (hook grip).
    • E.g. When working with the straps and handles, clients generally hold the straps with a hook grip or with a lateral prehension grip (fingers outstretched with the thumb firmly adducted to the palm).
  • Wrist extension creates a stronger grip, so it can be useful to work with wrist extension for functional upper limb activation.

    • However, holding active wrist extension at 30 degrees, is not the same as allowing a strap to pull the wrist back into full range of passive wrist flexion.
  • Always consider the functional task requirements that your client is building to.
    • Does it require ulnar or radial deviation? How does that relate to activation up the chain?
    • Does the task require supination or pronation of the forearm? How does that impact the ability of the hand to grasp?
  •  Adding objects to the hands can help to build hand and grip strength.

    • Holding weights balls, versus hand weights will build spherical grip strength vs cylindrical grip strength.
    • Holding objects between the thumb and fingers, such as a pencil, can begin to integrate precision grips. 
    • Holding objects that are unevenly weighted can challenge the dynamic load and thus strength requirements for grip.


  • Clinical Reasoning Question One: Carpal Tunnel Syndrome.
    • Which hand or grip positions can be used to offload the carpal tunnel?
    • How can you integrate these options for any of the closed-kinetic-chain exercises on the Trapeze Table?
  • Clinical Reasoning Question Two: Medial Epicondylalgia.
    • How could a tendinopathy of the flexor carpi radialis and/or pronator terse affect the natural tenodesis of the hand/wrist?
    • Which exercises – and grips – could be used to offload the medial epicondyle and support the natural tenodesis for wrist strength?



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