The extensors communis, indicis and minimi digiti are trained while the inter-phalangeal joints are kept flexed; the interossei are trained as extensors while the metacarpophalangeal joints are kept flexed. When sitting with the elbow flexed to a right angle the flexors receive assistance from gravity while the forearm is in pronation, resistance when it is supinated. The reverse applies for the extensors. The lateralising action of the interossei on the fingers can be trained with the hand prone on a smooth board, though at first light dorsal splints may be required on the posterior aspects of the digits to maintain full extension meanwhile. The long extensors of the metacarpo-phalangeal joints are rested by prolonging the palm piece of a short cock-up splint up to the webbing between the fingers. If these joints are to be free to move, the splint must never extend beyond the middle crease of the palm. To prolong the splint to the finger tips, in cases when only the musculo-spiral nerve is involved, is simply to ignore the action of the interossei. To rest the lumbricals a posterior plaster splint bent to a right angle is applied extending from a level slightly distal to the wrist-joint to about the level of the proximal inter-phalangeal joints (see Fig. 164, p. 468). This is usually enough also to rest the interossei. If it prove inadequate it is better to apply light posterior splints to each digit, leaving the metacarpophalangeal joints free to act. The long flexors of the inter-phalangeal joints (sublimis and profundus) are rested as a rule without apparatus. If active assistance is required, the best plan is to apply adhesive plaster, one end fixed to the dorsum of the distal phalanx and the other to the palm. There is no need to fasten the fingers down tightly. The necessity for and method of, ensuring rest for a weakened opponens pollicis has been already mentioned. A slip of adhesive plaster, passing around the thumb and fastened to the ulnar border of the palm, is all that is required. The distal inter-phalangeal joint can be left free if desired and not kept flexed as shown in Fig. 162, p. 465.

The other intrinsic and long muscles of the thumb can be trained on lines similar to those mapped out for the other digits. It is often well to rest the extensor ossis metacarpi pollicis by means of a small plaster splint inserted between the index and the thumb. The latter must, however, be kept in a position of opposition (see Fig. 165, p. 468). For some reason, which at present I cannot explain, the lumbricals will often work better when performing their function against resistance than when acting "freely."

The use of apparatus for training the muscles of the hand and fingers is, as a rule, simple. The chief point to remember is that most of us maintain the normal muscle-strength of the hand by means of countless fine movements constantly performed, rather than by any great or sustained effort. The chief element in restoring strength which has been lost is therefore constant repetition of all the finer movements of pure muscle training. As strength improves simple co-ordination work should be undertaken, and many of the ordinary kindergarten exercises will be found of value. Fastening buttons of various sizes, writing on a blackboard with chalks, tying knots and, later on, threading needles of different sizes, followed by actual needlework or knitting, will tend to do more to restore strength and co-ordination than we anticipate. When the actual apparatus is used it should be remembered that double arm work is of infinitely greater value than any amount of attention paid to the disabled member. Most right-handed people, for example, have the greatest difficulty in learning to swing an Indian club with their left hands unless they show it the way, as it were, with the right. This is, of course, true of all muscle training; but it is particularly true when training the hand. As soon as possible not only double arm work, but general exercise for the whole body such as rowing, climbing, ladder-work, parallel bars and so forth, should be used. Even the use of a skipping rope ensures that the fingers are doing their part through a countless variety of movements on the part of elbow, forearm and wrist.

MacKenzie considers the gluteus maximus and the ilio-psoas to be solely the extensor and flexor of the hip, and that they serve as antagonists one to the other. From the point of view of muscle training it is well to accept this view and to ignore all controversy as to the rotatory action of either muscle. I have never been faced with the necessity of training either muscle when recovering from paralysis; but it not infrequently happens that both suffer from disuse atrophy, in which event it is certain that the gluteus will have wasted more in proportion than its antagonist. This is particularly noticeable in patients who have used crutches for a considerable time, and the typical example is to be found in thigh amputation cases. The actual disability that results may not indeed be very great, but it leads to a lack of co-ordination in movement that can only end in a permanent limp unless muscle re-education is invoked to overcome the discrepancy. Standing, sitting (and particularly high-stride sitting) and lying trunk exercises should be chiefly relied upon. The chief point in training which helps more than anything else in strengthening the glutei is that the patient should be taught constantly to tighten up the muscles by attempting to draw the cheeks of the buttocks together at frequent intervals throughout the day, holding the contractions for increasing periods as strength is recovered.

The rotators of the hip rarely require special attention save in poliomyelitis cases; though, in prolonged illness, the patient is liable to keep the joint rotated outwards for long periods and the internal rotators suffer from disuse more than the external. It is always advisable during convalescence, therefore, to instruct a patient with this condition to practise inversion of the hip assiduously as a bed exercise. Were this made a constant law, it is probable that there would be far less foot trouble after prolonged illness - due partly to standing with the whole limb everted.