Musculoskeletal TEST #2

what if stretching program is not increasing flexibility?

change methods, check in HEP

connective tissue if composed of 3 types of fiber

collagen, elastin and reticulin, and nonfibrous ground substance consisting of proteoglycans and glycoproteins

as tension in the muscle increases....

discharge of the GTO's increases

what if its not increasing flexibility when stretching ?

do we need to increase the time in stretched/ positioning

Research has shown prolonged, low load stretching to be more

effective in increasing the length of tissue and decreasing inflammatory response

For endurance program, the amount of time a muscle can keep a contraction or by increasing the number of repetitions is increased compared to increasing weights. is it strength or endurance?

endurance

who benefits from strong core?

everyone

how much time can you do stretching for positive results

few times/ week

work

force x distance (torque)

Capsular tightness? what type of mobilizations

grade 3 and grade 4

when stretching the hamstring.... hamstring are the antagonist to ?

hamstrings are the antagonist to hip flexion we can activate the Golgi tendon organs in hamstrings to "relax" or turn off the hamstrings

Generally, stretches performed by PT/PTA are of

higher intensity than stretches performed by the patient

local endurance

(Muscle Endurance): the ability of a muscle to contract repeatedly against resistance, to create and maintain a contraction and to resist becoming tired over a period of time.

free weights and technique

-Cuffs, dumbbells, barbells, medicine balls, kettle bells -Technique: -Should move through full ROM -Permit no substitutions -Patient must be able to control the weight

free weights advantages

-Variety of equipment available -Easy assessment of quantitative changes -Seeing weight changes can be motivating to patient -Cuff weights can be used during functional activities

•If the patient experiences pain for more than ___________after stretches, too much force was used and the patient has an inflammatory phase occurring

24 hours

how much compression would impact the spine without muscular stabilization ? what conditions could affect this?

-10-15lbs - a lateral curvature, scoliosis

Neutral Spine (natural spine)

-A neutral spine alignment is when the pelvis is balanced between the two exaggerated anterior and posterior positions. -When the pelvis is in neutral, Posterior Superior Iliac Spine (PSIS)and Anterior Superior Iliac Spine (ASIS) are roughly level.

PNF new terminology

-AUTOGENIC INHIBITION -RECIPROCAL INHIBITION

endurance

-Ability to work over a period of time without becoming tired -Involves progressively increasing time or repetitions -Reflects the metabolic capacities of muscle

multifidi

-Atrophied in pts with chronic LBP -Responds to rehab with focus (awareness)on deep muscle activity and adding challenges

posterior oblique slings

-Consists of Latissimus Dorsi, opposite Gluteus Maximus and the Thoracolumbar fascia. -Connects from glute to opposite shoulder. -Weakness in hip muscles can cause pain into opposite shoulder during activity. - Important for throwing when foot is planted and arm posterior prior to throw..

deep longitudinal sling

-Consists of erector spinae, multifidus, TLF, sacrotuberous ligament and biceps femoris -Connect spinal muscles, SIJ ligament and hamstrings -Keeps the SIJ in a close packed position. -Commonly affected in those with regular hamstring strains and low back pain

anterior oblique slings

-Consists of external and internal oblique and opposite adductor muscles. -Connects from obliques to the groin. - Lack of trunk rotation with activity can overload the opposite groin causing injury -Important for throwing prior to when the ball is released

lateral sling

-Consists of gluteus medius, gluteus minimus, tensor fascia latae and illitibial band -Connects from lateral hip muscles to the lateral knee -Common conditions that affect this sling include ITB -syndrome Common sign of weakness in this sling include Trendelenburg gait which is common in those with hip osteoarthritis or post-operative total hip replacements.

core

-Core muscles are the main structures that support, control and move your lower spine and pelvis. -They are also the most energy efficient and ideally located muscles to do the job. -Create a link between upper and lower body.

core functions

-Decreased activity when you experience back pain/injury. -Relieve back pain when working properly. -Increase your power output . -Reduces fatigue of limb muscles. -Reduce excessive joint movement, which could injure them. -Maintains good posture. improve your arm & leg power, sport performance and ability to lift.

rubber tubing and bands advantages

-Different colors for different resistance -Advantages: -Low cost -Can be done independently -Can be done anywhere - at home or during travel -Provide progression using colors -Can be used for functional (diagonal) activities

To achieve maximum elongation of the long head of the biceps brachii during passive stretching: -Extend the elbow with the forearm in supination and then extend the shoulder. -Flex the shoulder overhead after extending the elbow with the forearm in pronation. -Flex the shoulder overhead after extending the elbow with the forearm in supination. -Extend the elbow with the forearm in pronation and then extend the shoulder.

-Extend the elbow with the forearm in pronation and then extend the shoulder.

factors affecting strength

-Improved recruitment of motor units occurs through training -The more motor units a muscle has and the greater the synchronization of motor units firing a muscle has, the greater contraction the muscle will have -The faster the muscle fires the motor units, the stronger the muscle contraction will be

overload principle

-In a nutshell, the overload principle states that if a muscle is to improve its performance, IT MUST BE CHALLENGED TO PERFORM AT A HIGHER LEVEL -If the work begins to plateau, then the performance of the muscle will plateau

manual resistance advantages

-Instruct, inform ahead of time: type, reps. -Use smooth, uniform resistance -Advantages -No equipment needed -Can establish rapport, develop trust hands-on -Can be motivating for patient -Allows immediate feedback and changes: sets, reps -Can modify speed, type of exercise through ROM -Progression easy: resistance or reps

Progression of Resistance Training

-Intensity -NWB—FWB -Repetitions -Frequency -Uniplanar-multi-planar -Slow to fast -Simple to complex, singe joint--multijoint

repetitions and sets

-Inverse relationship between weight and reps -More weight lifted, less reps capable of and vice versa -8-12 reps against moderate load -Rest and do a second set -When patient can easily do more than 8-12 reps, increase weight if goal is strengthening

overload principle focuses on the following:

-It is progressive -Intensity and volume of exercise is manipulated -Intensity is how much weight is applied to make the muscle work -Volume includes repetitions, sets, frequency of the exercise

precautions for stretching

-Know normal range of motion values-Do not passively force a joint beyond its normal ROM -Use extra caution in patients with known osteoporosis or suspected osteoporosis (those that have been immobile, are paralyzed, have been on long term Prednisone use) -Avoid vigorous stretching of muscles and connective tissue that have been immobilized for a long period of time. -Connective tissue will lose their tensile strength after prolonged immobilization -If the patient experiences pain after 24 hours after stretches, too much force was used and the patient has an inflammatory phase occurring. -Avoid overstretching weak muscles -Patients that have had multiple cortisone injections may have weakened tissue

clinical presentation of local fatigue

-Muscle discomfort, pain or cramp -A decrease in the speed of movement with each sequential contraction -A decrease in smooth coordinated muscle contraction -Inability to move the extremity through the full range of motion using the same about of weight -Increase use of substitutions -The inability to continue with a low-intensity exercises

factors that influence overall fatigue

-One's overall health -Age of the patient -Lifestyle -Diet -The characteristics of the fatigue, such as the: -Onset -Severity -Diseases -Environmental factors

manual resistance disadvantages

-One-on-one (time) required -Measures are not objective -Requires accurate judgment and awareness about amount of force

The progression and depth of the program must take in consideration the following factors:

-Pathology and health of the patient -Age of the patient -Stages of healing -Fatigue of the muscle and patient -Overall functional ability of the patient -Goals of the patient

Of the following choices, which is the most appropriate application of the hold-relax method of muscle inhibition and elongation of the gastrocnemius muscle? Extend the patient's knee, stabilize the lower leg, and: -Place the patient's ankle in as much dorsiflexion as possible; have the patient isometrically contract the dorsiflexors against resistance for 6 to 10 seconds. Then have the patient relax as you passively dorsiflex the ankle. -Place the patient's ankle in a fully plantar flexed position. Have the patient concentrically contract the dorsiflexors against your manual resistance through as much ROM as possible. -Place the patient's ankle in a comfortably dorsiflexed position; have the patient eccentrically contract the plantar flexors against your resistance through the available ROM. Then have the patient dorsiflex the ankle as far as possible. -Place the patient's ankle in as much dorsiflexion as is comfortable; have the patient isometrically contract the plantar flexors against resistance for 6 to 10 seconds. Then have the patient relax as you passively dorsiflex the ankle.

-Place the patient's ankle in as much dorsiflexion as is comfortable; have the patient isometrically contract the plantar flexors against resistance for 6 to 10 seconds. Then have the patient relax as you passively dorsiflex the ankle.

what does a strong core do?

-Prevent injuries -Greater efficiency of movement -Improved balance -Improved athletic performance -Increased power output -Improved speed and endurance

alignment and stabilization

-Prevent substitutions -Stabilization by: -Surface -External - therapist, equipment, straps, chair, holding on to something -Internal - example: drawing in maneuver to prevent pelvic motion

deep muscles role

-Provide dynamic support -Takes stress off inert structures -What does inert mean? something that does not contract

manual resistive exercise

-Provided by the therapist -Cannot be measured quantitatively -Good to use when beginning a resistive program -Limited by strength of the therapist

global muscles

-Respond to force that attempt to shift the center of mass -May add load if segmental instability present -Co-contraction of global muscles increases compression

types of resistance

-Rubber tubing and bands (Theraband and Sports Cord) -Free weights -barbells -cuff weights -medicine balls -kettle bells -Manual Resistance

machine weights advantages

-Safety -Multi-station: several people can use simultaneously -Patient may exercise without help once set up -Some are not expensive

free weights disadvantages

-Safety: risk of injury if loss of control -Requires stabilization of joints -Requires hand control -Individual must be positioned in anti-gravity positioning for weight to work.

core muscles : superficial

-Superficial -Cross multiple segments -RA: rectus abdominis -Obliques -QL: quadratus lumborum -ES: erector spinae -Iliopsoas

rectus abdominis

-The RA provides both core stability and trunk mobility. -it's the prime mover for trunk flexion

transverse abdominis and role

-The TA is the deepest of the abdominal muscles. -The TA plays a significant role in core stabilization, especially during rehabilitation. -Responds before other abdominal ms -tell them to draw in in order to activate the muscle if you are working with a patient. -Does not flex the spine or posteriorly tilt the pelvis

obliques

-The external and internal oblique muscles rotate and side bend the trunk. -These muscles also contribute to spinal stability. -Internal versus external role... -A pt rotates to the left describe how the obliques contributed....

natural curves importance

-The natural curves help cushion and protect the spine -It places the least amount of stress on the body's tissues -Like a spring.... -maintaining the lordosis

slings- muscles, fascia

-These structures work together when muscles contract to produce movement of the body. -The body consists of 4 main slings which when working effectively help us move better, produce more force and create more speed and power. -Essentially, these slings help transfer force between our upper and lower limb while providing a stable core.

progression/ regression for core exercises

-Think about strategies -Change in pt status? -Documentation

indications for stretching

-To assist with prevention of injury -Improve flexibility of soft tissue (musculotendinous structures, capsule, fascia, skin) -To help prevent post exercise muscle soreness

Which of the following statements about stretching is true? -To stretch the posterior tibialis, you dorsiflex and evert the foot and ankle. -To maximally lengthen the wrist extensors, you fully flex the wrist and flex the elbow. -To stretch the long head of the triceps brachii, you fully flex the elbow and then extend the shoulder past neutral. -To effectively stretch the tensor fascia latae, you first flex the hip to 30° and then adduct the hip.

-To stretch the posterior tibialis, you dorsiflex and evert the foot and ankle.

To maintain gains in ROM achieved as the result of a stretching program, it is recommended to: -Perform daily resistance training of the stretched muscle. -Perform daily resistance training of the muscle group opposite the stretched muscle. -Apply heat on a daily basis to the lengthened muscle groups. -Use the stretch-induced gains in ROM during functional activities as soon as able on a regular basis.

-Use the stretch-induced gains in ROM during functional activities as soon as able on a regular basis.

What is most true about Ballistic stretching? -Utilizes quick bouncing movements during the stretching maneuver, resulting in an increased chance for tissue trauma and muscle soreness. -Can be very effective because the rapid force has greater chance of reaching the plastic range, leading to tissue remodeling. -Should be used with elderly patients or patients with long-standing contractures. -Is effective only if done concurrently with joint-mobilization techniques.

-Utilizes quick bouncing movements during the stretching maneuver, resulting in an increased chance for tissue trauma and muscle soreness.

When a patient is involved in a stretching program, it is recommended that you: -Ice the muscle to be stretched before stretching. -Avoid active exercises for warm-up prior to stretching because it may increase excitability of the muscle tissue and prevent relaxation during stretching. -Warm up the tissues to be stretched by engaging in light-intensity active exercise or using therapeutic heat prior to stretching. -Stretch no more than once a week.

-Warm up the tissues to be stretched by engaging in light-intensity active exercise or using therapeutic heat prior to stretching.

contraindications for stretching

-When a bony block limits joint motion-noted as a hard end feel -After a recent fracture or a bone healing complication -During an acute inflammatory response or infectious activity: look for signs of inflammation (pain, edema, heat, redness) -Acute pain during muscle movement -Hypermobility

recovery time

-is the time needed to return to the state at which the body was prior to exercising -In order to reach 90-95% of the status of pre-exercising, the body needs 3-4 minutes of rest, with the greatest amount of recovery occurring in the first minute -Light active exercises done during the recovery period will speed up the process -If the body is able to rest appropriately and recover after each exercise, muscle performance will improve over time. Muscles not given applicable time for recovery will either level off or decrease -Muscles that are overworked or overtrained are more susceptible to injury

when performing a stretch, a force is applied to one end. If the muscle is tight, the other end will

-move -It is therefore important to stabilize the other end to prevent it from moving and to get a proper stretch.

Deep muscles

-stabilize -control motion transverse abdominis multifidus

In a patient's medical record you see "knee flexion contracture." What does it mean? •A. The patient is unable to actively extend the knee through the full range of motion (ROM) despite full passive knee extension. •B. The quadriceps muscle group is tight and limits full, passive knee flexion. •C. Full, passive or active knee extension is not possible. •D. The patient cannot actively contract the hamstrings to flex the knee.

. Full, passive or active knee extension is not possible

contract relax steps

1. PTA puts muscle in lengthened position- point of resistance-30 seconds 2. instructs patient to push into therapist ( by contracting the tight muscle-isometric) 3. patient is instructed to relax 4. patient contracts muscle opposite of tight muscle and moves extremity further into stretch, to new point of resistance- pt moves own limb 5. repeat

hold relax steps

1. PTA puts muscle in lengthened position- to point of resistance- hold 30 seconds 2. instructs patient to push into therapist (by contracting the tight muscle isometric)-6 sec 3. patient is instructed to relax 4. PTA moves extremity further into stretch, to new point of resistance- do not back off 5. Repeat

how many repetitions of stretch

3 repetitions

short duration static stretching

30 sec stretch

how long to hold a stretch ?

30 seconds

elasticity

Ability to return to original length after contraction or stretching

ballistic stretching only used in ? may lead to ?

Bouncing stretching; rapid, jerking movements in which a body part is moved with a momentum that would stretch the muscles to a maximum; during the bouncing motion, the muscle responds by contracting, to protect itself from overstretching -Only used in advanced rehabilitation phase in preparation for return to sport. -May lead to injury and activates the stretch reflex, causing the muscle to contract

extensibility (stretch ability)

Capacity of muscle to stretch beyond its relaxed length

causes of joint limitation of motion and what are they

Development of adhesions ◦Formation of collagen fibers in a cross pattern ◦Treated by joint mobilization and stretching Joint effusion ◦Increased synovial fluid may change consistency of joint and limit motion

rubber tubing and bands disadvantages and guidelines

Disadvantages: -Limited use for lower extremities compared to upper -Bands wear over time -Degradation of resistance and may break -Position Theraband directly opposite the movement -Make sure to slowly return to start position (for emphasis of eccentric contraction) -Document color of T-band

What does this describe? •Place the patient's ankle in as much dorsiflexion as is comfortable for 30 seconds •Have the patient isometrically contract the plantar flexors against resistance for 10 seconds. •Then have the patient relax as you passively dorsiflex the ankle.

hold relax PNF stretch

PNF old terminology

hold relax contract relax

In a patient's medical record you see "knee flexion contracture." What does it mean? The patient cannot actively contract the hamstrings to flex the knee. The patient is unable to actively extend the knee through the full range of motion (ROM) despite full passive knee extension. The quadriceps muscle group is tight and limits full, passive knee flexion. Full, passive knee extension is not possible.

Full, passive knee extension is not possible.

GTO versus muscle spindle sensitivity

GTO sensitive to slow build of tension (relax) -muscle spindle sensitive to quick stretch (protective stretch)

autogenic inhibition

GTO to inhibit the agonist

positioning is important when stretching because you must

In order to lengthen (stretch) a muscle, you muscle position the muscle opposite of its action PTA Competency: PTAs must know how to stretch any muscle. In order to know how to do this, PTAs must know the action of the muscle PTAs should be able to look at a stretching exercise and determine what it is being stretched

Why is lower load, prolonged stretching preferred?

Less trauma to tissue and reduced inflammatory response -Prolonged stretching allows changes to occur to the plastic component of muscle, whereas short term, higher load stretches affect elastic component of muscle.

myofascial restrictions ? what type of techniques

MFR techniques foam roller mobilizations

passive recovery

Not performing any exercises while the patient is at rest.

rules using free weights

Patient must be positioned in anti-gravity position in order for weight to resist that muscle.

serial casting and when does the cast need to changed.

Serial casting is a non-surgical approach aimed at reducing muscle tightness around a joint or resolving a contracture. -The casts need to be changed on a weekly basis until a target range of motion goal is achieved. -Often done with on ankles in children for club foot (talipes equinovarus).

usually stretches are taken to the point of resistance with a firm end feel. The more intense the stretch, the increased likelihood of an

inflammatory response -intensity should gradually increase -solicit patient feedback, observe patient response, monitor end feel to determine change of intensity

hamstring stretch are in what position

knee extension and hip flexion

what are signs of adverse effect?

sharp pain, pain lasting> 24 hours

what should patient feel when stretching?

some tension/ discomfort is normal. sharp pain is not

equipment for core exercises

sometimes just body weight but if not -Cuff weights -Theraband -Bosu ball -BAPS Board -Bodyblade -Swiss ball -Foam roller

irritability

stimulation is required to produce a response -thereshold=minimum stimulation required for a response

For strengthening program, the amount of weight that is applied to the area being treated is done in increments (such as ½ - 1 pound) and is done progressively is it strength or endurance?

strength

key elements of muscle performance are

strength and endurance

active recovery

The performance of the body doing gentle exercises during a rest to aid in the speed of recovery-cool down

What's it called? •Utilizes quick bouncing movements during the stretching maneuver, resulting in an increased chance for tissue trauma and muscle soreness.....

ballistic

reciprocal inhibition

stretch reflex to inhibit the antagonist

positioning and early ROM helps prevent tightness but after they develop,

stretching must restore motion. PREVENT WHERE POSSIBLE

-The exercise program should be developed to replicate the function that is being improved upon If the function is more relative to endurance than strength, the exercise program should be

centered around improving endurance

patient stretching and to emphasize what ?

The assistant must emphasize the importance of the home exercise program to achieving better range of motion. -Emphasize the point that if treatment is rendered by the PT/PTA 30 minutes to 60 minutes per day, and the rest of the day, the joint is held in the shortened position, the likely result will be less progress. -They need to perform their exercises for significant progress to be made.

Prolonged Stretching: Splinting

Usually ordered by physician when other interventions have not been effective. If progress is not being made, physical therapist may contact physician for order.

before and after stretching

Warm muscle up prior to stretching by application of heat. -Heat improves the extensibility of soft tissue. -Methods of application include: MHP, Continuous ultrasound, whirlpool, light activity Have patient do active exercise. Stretching is believed to more effective after active exercise than before. -Passive mobilization and soft tissue techniques should be performed prior to vigorous stretching. -Exhale during the stretch. -Have the patient perform AROM to maintain range of motion -Apply cold after stretching to decrease the inflammatory response.

Each of the following is a contraindication to stretching shortened tissues except: Sharp, acute pain during ROM. Recent fracture A bony block. When ROM is limited because scar tissue has reduced soft tissue extensibility.

When ROM is limited because scar tissue has reduced soft tissue extensibility

what is happening when I stretch? short, higher load stretched

change elastic component of muscle

In what position would the biceps be the strongest? A. With the elbow flexed to about 90 degrees and the shoulder in 0 degrees extension B. With the elbow fully flexed and the shoulder flexed to 90 degrees C. With the elbow extended and the shoulder extended

With the elbow flexed to about 90 degrees and the shoulder in 0 degrees extension

stretching

a mechanical lengthening of soft tissue

muscle spindle

a muscle receptor that lies parallel to a muscle and sends impulses to the central nervous system when the muscle is stretched

dystrophy

abnormal development of a muscle or tissue

•We instruct a patient to stretch their own gastroc. •How do we refer to this? •How long do they hold it? How many repetitions?

active 30 seconds 3-5 reps

Hyperplasia

an increase in the number of cells or fibers

hypertrophy

an increase in the size of a fiber or cell

ballistic dynamic stretching- quick stretch

applied during sporting activities-not done to restore motion but in preparation for return to activity in advanced rehab phase.

atrophy

loss of development, decrease in size

•A pt has rehabilitated a work injury but fears re-injury because the demands of the job will remain the same? •What could be done?

modify the work environment

Capsular limitation, long term contractures and significant muscle shortening will benefit from

more frequent and longer duration stretches. ◦These need to be done several times/day.

contracture examples contributing factors

more than just tightness examples: hip flexion, knee flexion, plantar flexion Contributing factors: -Disease ◦Prolonged immobility in sitting such as wheelchair bound patients ◦Post-surgical after period of immobilization ◦Muscle imbalances: if the ankle dorsiflexors are weak, the ankle will be pulled into PF.

machine weights disadvantages

most expensive and require significant space

muscle spindles are located in

parallel with muscle fibers -spindles facilitate activation of the muscle

•We have a patient relax while we stretch their gastroc. •How do we refer to this?

passive

type of stretching

passive stretching -active stretching/ self stretching -proprioceptive neurouscular facilitation stretching procedures -ballistic stretching

what is happening when I stretch? low load, prolonged stretching

plastic changes occur to the muscle structure

•What do the following muscle grades indicate to you? •Should you use AAROM, AROM or RROM to improve strength? •How would you position the patient? •Quadriceps 3/5 Biceps 5/5 •Hamstrings 3/5 •Gluteus medius 2/5 Supraspinatus 2/5

quads •Full AROM against gravity •Encourage AROM without resistance •Short seated knee extension-LAQ biceps •Can move full AROM, can tolerate max resistance. •So we would apply resistance. Make the exercise more challenging. hamstrings- •Full AROM against gravity •Encourage AROM without resistance •Hamstring curls Gluteus medius - •Cannot complete full antigravity AROM. •Here is a situation where we would perform AAROM. •Pt sidelying on contralateral side supraspinatus- AAROM

Golgi tendon organs

receptors that sense movement of the tendons, which connect muscle to bone

scar tissue formation ?

scar mobilizations (cross friction massage)

NIOSH

set the regulations that OSHA enforces

long duration positioning with overpressure

several minutes ex: when they are being laid in the table prone and they have a weight in their ankle in order to stretch their hamstring. Just remember the patient in the clinic that I would have to put the ankle weight in their ankle to promote knee extension

muscle performance

the ability of a muscle to do work

functional strength

the ability of the neuromuscular system to create, decrease or manage forces during a person's performance of functional activities, that occurs in a controlled manner.

strength

the amount of force a muscle produces. Improved by progressively adding resistance

overload

working the body or parts of the body beyond normal expected levels

To maintain gains in ROM achieved as the result of a stretching program, it is recommended to: •A. Use the stretch-induced gains in ROM during functional activities as soon as able on a regular basis. •B. Perform daily resistance training of the muscle group opposite the stretched muscle. •C. Apply heat on a daily basis to the lengthened muscle groups. •D. Perform daily resistance training of the stretched muscle.

•A. Use the stretch-induced gains in ROM during functional activities as soon as able on a regular basis.

contractility

•Ability to contract = twitch. •One contraction occurs with each stimulus •Sustained contractions: require repeated stimuli

determinants of stretching: alignment, stabilization, intensity of stretch, duration of stretch.

•Alignment: Positioning a limb or the body such that the stretch force is directed to the appropriate muscle group. •Stabilization: Fixation of a bony segment that has an attachment of the muscle to be stretched. •Intensity of stretch: Magnitude of the stretch force applied. •Duration of stretch: Length of time the stretch force is applied during a stretch cycle.

self-stretching "active"

•Any stretching exercise that is carried out independently by a patient after instruction and supervision by PT/PTA is referred to as self-stretching. •In this case forces are applied by the patient at the end of available ROM for the purpose of elongating hypomobile soft tissues. •In most instances, decreased extensibility of connective tissue is the primary cause of restricted mobility in both healthy individuals and patients after injury, disease, or surgery. •A stretched soft tissue is elastic if it returns to its pre-stretch resting length directly after a short-duration stretch force is removed. •Plasticity, or plastic deformation, is the tendency of soft tissue to assume a new and greater length after a stretch force is removed

improving muscle strength

•As a patient progresses out of the acute, inflammatory stage, restoration of muscle strength becomes a goal. •Generally, the therapist's evaluation tells the type of strengthening exercise to be completed by looking at the muscle grade.

•Extensibility and Elasticity:

•As muscle is stretched, it becomes more extensible •Inactivity produces stiffness •Stiffness can be overcome with active exercise (which increases temperature, decreases viscosity, and improves extensibility) •Activity recruits more motor units •More recruitment means greater muscle contraction •=greater strength

prior to exercise for strengthening

•Assess the patient's ROM, MMT, and functional limitations •Explain the procedure to the patient •Place the patient in the appropriate position •Demonstrate the desired motion to the patient passively •Patient should exhale on effort •Choose type of resistance- which is most appropriate •Provide stabilization •Use proper body mechanics •Provide verbal cues as needed •Establish repetitions •Some patients may not have exercised regularly in the past. •Be patient with them, provide a lot of feedback. •There may be some fear. •This can be minimized by starting the correct way.

submaximal guidelines for load or intensity considerations

•At the beginning to evaluate the pt's response •Early stages of tissue healing •After immobilization •Warm up/cool down •Repetition Maximum •1 RM-the maximum weight the patient can lift one time •Determine the 1 RM, then determine the % of 1Rm to decide weight to be lifted 8-12 times. •Beginning or sedentary 30-40% •Typical 60-70% •Elderly and children 30-50%

work conditioning

•Based on an "Industrial Athlete" model •2-6 weeks of half days (4 hour sessions) •Allows client to "build up" their physical conditioning and work on improving job specific tasks while still allowing client to work •The objective of the work conditioning program is to restore physical capacity and function to enable the patient/client to return to work.

work rehabilitation

•Broad term that encompasses many aspects of intervention, all geared toward facilitating independence at work as well as satisfactory fulfillment of the worker role •Also called Industrial Medicine.

Which of the following statements about stretching is true? •A. To effectively stretch the tensor fascia latae, you first flex the hip to 30° and then adduct the hip. •B. To maximally lengthen the wrist extensors, you fully flex the wrist and flex the elbow. •C. To stretch the posterior tibialis, you dorsiflex and evert the foot and ankle. •D. To stretch the long head of the triceps brachii, you fully flex the elbow and then extend the shoulder past neutral.

•C. To stretch the posterior tibialis, you dorsiflex and evert the foot and ankle.

excitability

•Capacity of muscle to respond when stimulated by nerve impulse

collagen fibers

•Collagen fibers are responsible for the strength and stiffness of tissue and resist tensile deformation. •There are six classes with 19 types of collagen.

contract relax

•Contract Relax : Muscle is brought to end range, isometric contraction of tight muscle, relax, stretch via contraction of opposite muscle •Reciprocal Inhibition

application for stretching

•Create an effective and efficient series of self-stretches that a person who works at a desk most of the day could incorporate into a daily home exercise routine. •Teach each self-stretching exercise to your partner.

Which of the following is a true statement about a muscle's response to stretch? •A. The muscle spindle is the motor receptor that relaxes the sarcomeres (and muscle overall) when a stretch is applied. •B. Plastic change in muscle that occurs before elastic change •C. A quick stretch of a muscle is believed to facilitate contraction of muscle fibers by means of the Golgi tendon organ (GTO). •D. The primary source of a muscle's resistance to passive stretch is the connective tissue in and around muscle

•D. The primary source of a muscle's resistance to passive stretch is the connective tissue in and around muscle

effects of injury

•Damaged tissue follows a predictable healing pattern, with newly synthesized type III collagen bridging the injury site. This collagen is structurally weaker than mature type I collagen. As remodeling progresses, the collagen eventually matures to type I. Remodeling continues for several months to a year, depending on the size of the connective tissue structure and the magnitude of the injury.

work station redesign

•Definition: physically altering the work environment to facilitate use of good body mechanics/ergonomics •The employee, employer, purchaser, and therapist should be involved •Always remember practicality

head and neck right posture for sitting shoulder elbow wrist hip knee and feet

•Flexion: less than or equal to 20 degrees •Rotation: as little as possible •Lateral Flexion: as little as possible •Shoulders in a relaxed position •Avoid cross body motions •Abduction: 15-20 degrees •Flexion: less than or equal to 25 degrees •The angle of the elbow should be approximately 85-120 degrees •For computer terminal and desk seated work, the work surface should be approximately the height of the elbow at 90 degrees •Neutral is preferred •Flexion: avoid greater than 15 degrees •Extension: avoid more than 15 degrees •Ulnar deviation: avoid greater than 15 degrees •Radial deviation: avoid greater than 5 degrees •Sitting: hips flexed 90 degrees or less Standing: hips 0-15 degrees of flexion •Knee •Approximately 90 degrees •Feet •Firmly on the floor or on a foot rest

rest interval between sets

•For a couple minutes • You could move to another muscle group and come back

work hardening

•Highly structured, goal-oriented, individualized intervention program designed to return the patient/client to work. •Work Hardening programs, which are multi-disciplinary in nature, use real or simulated work activities designed to restore physical, behavioral, and vocational functions. • Work Hardening addresses the issues of productivity, safety, physical tolerances, and worker behaviors •A goal oriented return to work program based on available job description. •Full day participation. •Integrates graded job specific work simulation and physical conditioning, biomechanics and client education to promote safety and self-management in the transition back to work.

Hold relax

•Hold Relax: Muscle is brought to end-range, an isometric contraction of tight muscle is performed, relax, passive movement to end- range •Autogenic inhibition •GTO activation

Possible Benefits of Resistive Exercise

•Improve muscle performance •Improve the strength and health of tissue: bone, muscle and tendon and other connective tissue •Decreasing the overall stress of a joint during physical activities •Improve balance •Improve one's function in ADLs, their job and their recreation activities •Change in a person's physical body composition •Decrease in body fat •Increase in muscle mass •Improvement in one's state of well-being

FACTORS AFFECTING STRENGTH

•Increase in the size of muscle •The larger the muscle, the greater the strength it has •Strength training increases the size of muscle

team of work rehab

•Injured worker •Employer •Occupational health doctor •Occupation health nurse •Therapist •Case Manager •Others

ergonomics

•Interfacing the work environment and the individual to provide increased efficiency, production and above all safety.

Reasons to Malinger in Therapy

•Job dissatisfaction •Poor treatment by employer •Financial gain •Attention

Examples of Worked Related Task Specific Training

•Lifting •Pushing •Pulling •Climbing •Stairs •Baltimore Therapeutic Equipment •Squatting

intensity for stretching low intensity vs. high intensity

•Low-intensity stretching in comparison to high-intensity stretching is more comfortable for the patient and minimizes voluntary or involuntary muscle guarding, enabling the patient to remain relaxed or assist with the stretching maneuver.

common errors and potential problems

•Nonselective or poorly balanced stretching activities. •Insufficient warm-up. •Ineffective stabilization. •Use of ballistic stretching. -excessive intensity -insufficient information about age- related differences

other conditions affecting collagen

•Nutritional deficiencies, may predispose connective tissue to injury at lower levels of loading than normal.

Key Agencies in Work Rehabilitation

•OSHA (Occupational Safety and Health Administration) •NIOSH (National Institute for Occupational Safety and Health)

OSHA

•Organization that regulates hazards in the workplace •Monitors employers compliance with safety regulations •Makes sure that employers provide a safe workplace

Discharge from a Work Rehabilitation Program

•Patient has met all of their goals •Patient is not making progress towards goals •Patient refuses to continue with POC/perform required tasks •Patient has been referred to another healthcare worker •Patient is unable to continue due to medical, psychosocial or financial complications •Payer is not willing to approve additional treatment sessions and patient is not able to continue independently of the payer •Patient has been discharged from the physician or medical provider •Patient has new injury that has occurred or the current medical condition has gotten worse and patient unable to continue with POC

physician nurse role for rehab

•Physicals •Testing/screens •Evaluations and re-evaluations of the injured worker

Role of Physical Therapy in Ergonomics

•Rehabilitation •Education! •Work site analysis •Development of exercise/stretching programming at the work site

Major Stress Factors in the Work Place

•Repetition •Force •Posture •Contact Pressure •Vibration •Cold

Proprioceptive Neuromuscular Facilitation (PNF)

•Techniques to promote or hasten a response of a neuromuscular mechanism through stimulation of the proprioceptor. -PNF can be used as a stretching and strengthening therapeutic exercise. Stretching can be performed in straight plane motions. •Methods of promoting or decreasing the neuromuscular mechanism -Response through stimulation of the proprioceptors -Can be used to muscle flexibility -For flexibility, a brief contraction prior to the stretch is the mainstay of PNF

golgi tendon organ

•The GTO is a sensory organ located near the musculotendinous junctions of extrafusal muscle fibers. The function of a GTO is to monitor changes in tension of muscle-tendon units. •These encapsulated nerve endings are woven among collagen strands of a tendon and transmit sensory information •These sensory organs are sensitive to even slight changes of tension on a muscle-tendon unit brought on by passive stretch or active muscle contractions during normal movement. •When muscle tension develops, GTO activation signals to the spinal cord inhibit activity and decrease tension in the muscle.

use what you have gained in stretching

•The most effective means of achieving permanent increases in ROM and reducing functional limitations is to integrate functional activities that use the newly gained range on a regular basis into the stretching program. •Use of functional activities to maintain mobility also lends diversity and interest to a stretching program, which may benefit patient compliance.

muscle spindle

•The muscle spindle is the major sensory organ of muscle and is sensitive to quick stretch. The main function of muscle spindles is to detect and convey information about muscle length changes and the velocity of those changes.

Reversibility principle

•The saying "if you don't use it, you will lose it", fits under this principle. •As long as the resistance exercise program is continued on a regular basis as discussed earlier, the changes in the body and/or structure will be maintained or improved

Aspects of Ergonomics

•Tool and work station design •Environment •Task Analysis •Environment •Perception •General Safety

When is Work Hardening/ Conditioning Appropriate?

•When the worker may have reached a plateau from traditional outpatient therapy, but continues to have difficulties with the physical demands that are required for work. • When unable to progress beyond a light or modified duty work assignment. • When unable to meet the full demands of the job.

Muscle needs adequate supply of energy (fuel), blood supply (oxygen) and nutrients to be able to prepare for...

•movement, to move and to recover from movement, as well as resist movement. •Along with the contraction of the muscle, the muscle also needs to remove waste products

type 11

•phasic , fast twitch fibers •Produce a large amount of tension in a short period of time •Fatigue quickly •Examples: biceps, UE muscles •Power over endurance

golgi tendon organs are activated when the

•tendon attached to an active muscle is stretched.

Golgi tendon organs are located in

•tendons near the myotendinous junction and are in series, that is, attached end to end with muscle fibers.

Type 1 fibers (slow twitch)

•tonic (static or postural), slow twitch fibers •Low muscle tension but can maintain a contraction for a long period of time. •More often used for endurance and postural maintenance •Examples: gastroc, soleus and the erector spinae group Aerobic

stretching to increase ROM

◦May involve some discomfort ◦Is performed similar to hand positioning for PROM, however, overpressure is applied at the end of the ROM into the restriction.

tightness and examples

◦Mild shortening in the muscle ◦Examples: hamstring tightness, trapezius tightness ◦May be a result of postural adaptations, for example sitting slumped contributes to forward head and prolonged sitting to tight hamstrings

Therapist/PTA stretches and mobilization techniques

◦Passive stretching ◦Passive stretching with PNF techniques ◦Muscle energy techniques ◦Grade III and IV- Joint mobilization: performed by PT

irreversible contracture

◦Permanent loss of joint motion that cannot be treated without surgical intervention ◦Physical therapy should be initiated before turning into irreversible contracture ◦Again, positioning and proper range of motion prior to the development of contracture is standard of care

mechanical stretching

◦Splinting or serial casting may be initiated if above methods not believed to be sufficient.

flexibility

◦The ability of a muscle or extremity to relax and yield to stretch and stress forces; the ROM of a joint, affected by muscles, tendons, ligaments, bones, and periarticular structures (capsule)