Ther-Ex Final
For a (+) neurodynamic test
1. reproduce patient's symptoms (within that nerve distribution) 2. Side-side differences 3. Support exam findings 4. Sensitizing maneuvers differentiate symptoms (whether there is a nerve mobility issue)
Stimulus-fatigue-recovery-adaptation theory
An individual's performance level will initially decrease after a training stimulus is introduced and then recovery occurs in response to that training stimulus leading to an increase in performance. What happens after that is dependent upon whether a new training stimulus is introduced. If not new stimulus is introduced, then detraining can occur and performance can fall below the current baseline. If a new stimulus is introduced, the process can repeat itself
Which anatomic landmark correlates to 10% body weight when immersed in water?
C7
Does stretching prevent injuries?
Depends on what type of stretching. Dynamic warm up is shown to be effective in reducing LE injuries. Static stretching does not prevent or reduce injury risk
Stretch Intensity
Determined by the tensile load applied on the soft tissue
On the stress-strain curve, what describes the endpoint of linear region?
Elastic limit
What is an example of an external force?
Gravity
What is a typical timeline for recovery from tendinopathy?
It might take 12 weeks or more to recover; there might be pain in the first few weeks as we load the tissue
What exercises are appropriate for the advanced skill, agility, and coordination stage?
Jump/landing, planting/cutting, plyometrics (near-normal muscle performance w/o signs of tissue injury or mobility limitation *not limited to those returning to sport)
Stretch Speed
Slowly applied stretch - reduces muscle activation and reduces risk of injury to tissues and post stretch muscle soreness
What are the acute stage clinical signs?
inflammation (pain, loss of function, swelling, redness, and heat) lasts 4-6 days
Indications for AROM and AAROM exercises
pt is actually able to contract the muscles and move segment with or without assistance
Which method of resistance training exercise progression is described by decreasing the amount of resistance over three sets?
Oxford
Neurodynamic Test: Screening (active test)
PT describes a specific position and demonstrates the position for the pt. to attain. Allows PT to assess pt's willingness to move into those positions and whether or not it brings on any symptoms
Neurodynamic Test: Passive Test
PT intentionally positions the joints in a sequential manner to gradually place stress through the nervous system. Allows for differentiation in trying to determine whether or not the nervous system is involved with the issue
How should we interpret pain in the context of mechanical loading?
Pain is not a contraindication to mechanotherapy; pain is part of healing; use Traffic Light System: keep in green section; don't let pain get worse from day to day
What is the 4th phase of the Exercise Prescription Framework?
Performance Improvement
How does articular cartilage respond to mechanotherapy?
Populated by mechanosensitive cells (chondrocytes) which signal via highly analogous pathways; further research is encouraged for underlying tissue response
Which structures are primarily being stretched when the pt is seated on the plinth with leg stretched out and therapist applies an A-P force through the distal femur and proximal tibia?
Posterior joint capsule, knee flexors
What are internal forces acting on the body?
Produced from structure located within the body: Active: generated by muscle Passive: generated through tension such as a stretch of connective tissues, ligaments or joint capsules
What are the 5 main training principles?
Progressive overload Specificity Variety Reversibility Individualisation
What does POLICE stand for?
Protection Optimal Loading Ice Compression Elevation
Which is NOT characteristic of isometric exercise? Quantifies strength performance Minimizes muscle atrophy Develops postural or joint stability Develops ROM-specific strength
Quantifies strength performance
Which structures are primarily being stretch when lying supine with a cane with the right elbow on a pillow and left arm slightly off the table; using the cane for ROM pushing it into the right hand
R shoulder internal rotators
What exercises are appropriate for the tissue healing stage?
ROM and isometrics Controlled progressive mobility
Stretch Mode
ROM in that it can be manually applied or can be a self-stretching program
Precautions/Contraindications to ROM exercises
ROM should not be done when motion is disruptive to the healing process 1. early benefits and recovery 2. watch for increased pain and inflammation 3. life threatening conditions 4. PROM to major joints and AROM to ankles and feet to minimize venous stasis and thrombus formation 5. ROM considerations for medically complex patients
What exercises are appropriate for the mobility stage?
ROM, stretching, possibly eccentric exercises for lower limb mobility
Define mobility
Range of motion in terms of mobility functional activities, which is sometimes referred to as functional range of motion, or function mobility
What are examples of attentional resourcing?
Reaction time Decision-making/anticipation External perturbations Environmental distractors Dual-tasking (motor-motor vs. cognitive-motor)
What is mechanocoupling?
Refers to physical load (often shear or compression) causing a physical perturbation to cells that make up a tissue
What are the subacute tissue responses?
Removal of noxious stimuli Growth of capillary beds Collagen formation Granulation tissue Very fragile, easily injured tissue
Isometric exercises at multi-angle
Resistance is applied at multiple joint positions within the available ROM. Used when goal of exercise is to improve strength throughout the ROM when joint motion allow, but dynamic exercise might not be appropriate
Cyclic loading and connective tissue fatigue
Result of repetitive loading within a short time duration which increases heat production any may causes failure at levels lower than what's needed from a single load ex. stress fractures and overuse syndromes
Which type of balance intervention is demonstrated when the pt is standing on one foot, with their arms crossed over their chest, and eyes closed?
Sensory organization training
Which structures are primarily being stretched when pt is supine and therapist is stretching arm laterally toward the head?
Shoulder adductors
What are aquatic exercise contraindications?
Significant cardiac, respiratory, kidney concerns Concerns or bleeding Concerns for infection/pool contamination Uncontrolled seizures
Neural sliders vs tensioners
Sliders: less aggressive as the aim is to essentially slide the nerve back and forth within its container Increases tension proximally while decreasing tension distally Tensioners: greater intensity and the greatest amount of stress
What is defined as the ability of "neuromuscular system to hold the proximal or distal bodies segment in a stationary position"?
Stability
Closed Kinetic Chain (CKC)
Stationary/fixed distal segment considered more functional muscle activation proximal and/or distal to the moving joint Usually in WB
What strategy is used to monitor pain during exercise?
Stoplight system
Plastic Range
Strain goes beyond the elastic limit and causes permanent tissue deformation
What is the difference between a sprain and strain?
Strain: over-stretching of a musculotendinous unit (muscle) Grade I, II, III Sprain: over-stretching of a ligament Grade I, II, III
What exercises are appropriate for performance improvement stage?
Strength, power, endurance, hypertrophy (dependent on training goals)
You are treating a patient who sustained a right hip injury. When you evaluate the patient, you note that pain is experienced synchronous with tissue resistance (ROM). This is patient is most likely in the ____ phase.
Subacute
Which stage of tissue healing was described as moderate protection/controlled motion?
Subacute stage
What is the difference between a subluxation and dislocation?
Subluxation: incomplete or partial dislocation of the bony partners within a joint Dislocation: displacement of the two joint surfaces resulting in a loss of the normal anatomical relationship (may need reduction for bony partners to return to normal alignment)
What are some exercise adherence factors?
Supervision Credentials of supervising professional Activity monitoring and feedback # of contacts with a health provider Participation in a behavior change program incorporating motivational strategies Personal factors (ex. socioeconomic status, health status etc...)
You want to perform PROM to improve R hip flexion. The patient recently fell resulting in painful abrasions on their L side. Which would be the most optimal position to perform this exercise, keeping in mind the aim of minimal muscle activation?
Supine
You provide the door stretch exercise to progress shoulder ROM. The pt arrives at the next visit with increased pain and a 10 degree reduction in shoulder ER AROM. Which would be a logical exercise to attempt today? Supine shoulder AAROM for ER Prone shoulder overhead ER with dumbbells Standing shoulder overhead ER with cable resistance Standing shoulder overhead ER with band resistance
Supine shoulder AAROM for ER
What can joint effusion lead to?
Swelling within a joint can contribute to reduced ROM and decreased muscle activation or strength due to atherogenic muscle inhibition which is a neurological decrease in muscle activity
What is the role of integrins?
Switch that allows a signal (physical stimulus) to go from the outside of the cell to the inside; allows for repair or adaptation to handle a load; integrins can connect with the cytoskeleton (direct pathway) or they stimulate proteins (indirect pathway)
What are the two domains within FITTSBALL?
Technical domain (Type, Time, Intensity, and Frequency) Cognitive Behavioral domain (Stage, Beliefs, Ability, Limitations, and Life Satisfaction)
Plasticity
Tendency of a soft tissue to take a new and greater length after a stretch force is removed
Therapeutic exercise can be applied during the rehabilitation of which type of conditions?
Tendinopathy, joint effusion, muscle strain
What is effector cell response?
The boundary between the extracellular matrix and a single cell; this process can be harnessed by mechanotherapy to promote tissue repair and remodeling
What are the arthrokinematics for closed chain knee extension?
The concave tibia is fixed; the convex femur slides posteriorly and rolls anteriorly (roll/side in the opposite direction)
What describes the arthrokinematics of active hip abduction when functioning in an open kinetic chain?
The convex femoral head rolls superiorly and slides inferiorly on the concave acetabulum
What are the arthrokinematics for open chain knee extension?
The convex femur is fixed; the concave tibia is free to move; the tibia rolls and slides anteriorly (same direction)
What is the internal moment arm?
The distance perpendicular between the axis of rotation and internal force
As the patient goes from standing to rising onto the ball of their foot, which of the following is accurate? The gastroc-soleus is contracting eccentrically The gasroc-soleus is contracting isometrically The anterior tibialis is contracting concentrically The gastroc-soleus is contracting concentrically
The gastroc-soleus is contracting concentrically
Neural Tension
The intensity of a stretch and its influence on blood flow may depend on several factors such as the body region, rate of stretch and population being studied; we want to avoid excessive stretching or stresses to the nerve Sites of vulnerability are subjective to increased pressure or tension
Overload principle
The intensity of resistance exercises, how much external resistance is imposed on a muscle, and progressive overload is required in order to see specific adaptations; Manipulate factors such as intensity or volume of an exercise program
Which most accurately describes optimal loading?
The load applied to structure that maximizes physiological adaptation
What does the theoretical model of exercise progressional allow for?
The model allows for progression while keeping the primary task as a central component
Median Nerve Upper Lumb Neuro Test Position 1 (passive test)
The nerve is slowly and carefully elongated across each joint in succession until there is a symptom provocation or slight tissue restriction is appreciated - note final testing position It is sensitized by moving one of the joints out of the elongated position Goal is to determine if nervous system component is contributing to the pt. chief complaint
Stretch Duration/Frequency
The period of time a stretch force is applied and how often
What is the external moment arm?
The perpendicular distance between the axis of rotation and the external force
What is the external torque?
The product of the external force and the external moment arm
What is internal torque?
The product of the internal force for the muscle and the internal moment arm
DAPRE Technique
The suggested working weight is based on the maximum number of repetitions using the working weight and set #3 to determine the working weight for the next exercise session: 1 set; 10 reps; 50% 6 RM 2 sets; 6 reps; 75% 6 RM 3 sets; max possible; 100% 6 RM 4 sets; max possible; 100% adjusted working weight
Which statement is accurate regarding neurodynamic testing? The uninvolved limb is tested first Neurodynamic tests are the only tests used to assess nerve function Passive test is applied prior to the active test The test and treatment positions are typically quite different
The uninvolved limb is tested first
What is most accurate regarding rehabilitation after a lateral ankle sprain?
There is level A evidence supporting therapeutic exercise in the earlier protective motion phase of rehab after a lateral ankle sprain
What is cell-cell communication?
Thousand of cells embedded within an extracellular matrix where a stimulus in one location leads to a distant cell registering a new signal even though the distant cells does not receive a mechanical stimulus
Viscoelasticity
Time dependent property of soft tissue that initially resists deformation, such as change in length, of the tissue when a stretch force is first applied
What is the exercise prescription framework?
Tissue Healing Mobility Performance Initiation, Stabilization, and Motor Control Performance Improvement Advanced Skill, Agility, and Coordination (overlap)
Stress-Strain Curve Failure
Tissue ruptures and loses its integrity here at the end of the stress stain curve
What are strategies for pain monitoring during exercise?
Traffic Light System using the visual analog scale 0-10 Green being safe (0-2) and Yellow being acceptable (2-5) and anything above that would be excessive/high risk or Red Supervise pain during and after exercise therapy Pain should subside to baseline within 24 hours Acceptable pain is defined by the patient
Is PRP (Plasma-Rich Protein) effective for treating tendinopathy?
Trials show no benefit for PRP
During isometric contraction, the internal and external torques must be equal: T or F
True
Eccentric contractions consume less oxygen and energy stores versus concentric exercise: T or F
True
Limitations to PROM exercises
True PROM can be difficult to obtain if pt is guarding PROM does not prevent muscle atrophy or work to increase strength or endurance as compared to active or voluntary muscle contraction
Active-assistive ROM (AAROM)
Type of AROM where assistance is provided mechanically through an external force because the muscles need a little bit of help to complete the motion
Which of the following is a contraindication (vs. precaution) to aquatic therapy? Uncontrolled siezures Respiratory disorders Cardiac dysfunction Small open wounds/lines
Uncontrolled siezures
What are different types of kinetic forces on the body?
Unloading, tension, compression, bending, shear, torsion or a combo of loading (torsion and compression)
Provide examples of visual-motor training or visual disturbance training?
Using a point of visual fixation Eyes open v closed Stroboscopic eyewear
What are external forces acting on the body?
Usually due to gravity pulling on the mass of the segment, or external load (such as free weights), physical contact or resistance applied
Which balance intervention would be appropriate when aiming to address static balance deficits? Reduce visual inputs Reduce somatosensory cues Varying the support surface Stepping strategy interventions
Varying the support surface
What are the acute stage tissue responses?
Vascular changing Exudation of cells and chemicals Clot formation Phagocytosis, neutralization of irritants Early fibroblastic activity
After reading the article on dual-task interventions, which intervention includes the following: Patients were shown pictures before/after a balance intervention, and afterward had to indicate if the pictures were the same or different. Visual spatial task Visual imaginary spatial task Visual discrimination task Auditory discrimination task
Visual discrimination task
Give examples of attentional resourcing decision-making anticipation
Walk and turn R v. L upon cuing from therapist Walk and turn R v. L upon opposite cuing from therapist Walk and turn R v. L upon cue/image from therapist
How does thermodynamics play a role in aquatic therapy?
Water temp has an impact on exercise, as water retains 1000x more heat when compared to air. Water also conducts temperature 25x faster than air. Be aware of pts sensitive to temperature
Rate Dependence
When a load is applied rapidly, the slope of the stress strain curve will be much steeper vs. if its were applied slowly. The tissue will become stiffer when the load is applied at a higher rate
Stress-Stain Curve
When a tensile load is applied to a certain structure, it produces elongation. The stress-strain curve shows the strength properties stiffness and amount of energy the material can store before failure of that structure. Strength is the force per unit area of load. Strain is the amount of deformation or lengthening that occurs when an external load such as a stretch force is applied to a structure
When is self-assisted ROM typically indicated?
When aiming to protect the healing tissues after surgery or traumatic injury
2 for 2 rule
When someone can perform 2 extra repetitions on their last set for two consecutive sessions
Which anatomic landmark correlates to 33% body weight when immersed in water?
Xiphoid process
Concentric exercise
a dynamic muscle activation where a tension develops and a physical shortening of the muscle occurs as an external load is overcome by an internal force; concentric activities typically accelerate body segments
Muscle endurance
ability of the muscles t contract repeatedly against an external load generating sustained tension and resist fatigue over an extended duration
If someone experiences a small external perturbation, a/an _______ strategy would most likely be used
ankle
Exercise-induced muscle soreness
associated with repeated and rapidly progressed high intensity eccentric muscle contractions when compared to high intensity concentric exercise. This may be due to greater damage to the muscle and connective tissue when heavier load are controlled and lowered
Isometric exercsie safety precautions includ
breath holding - can cause a rapid increase in BP (strategies to avoid include rhythmic breathing and emphasizing exhalation during the contraction history of cardiac or vascular conditions
Concentric/eccentric exercise precautions
breath holding - can increase HR and arterial BP especially during the eccentric phase of exercise
Which is proposed to be a better choice for promoting improved balance? closed kinetic chain exercise open kinetic chain exercise
closed kinetic chain exercise
In arthrokinematics, what directions are the roll and slide for concave on convex?
concave rolls/slides same direction
In arthrokinematics, what directions are the roll and slide for convex on concave?
convex rolls/slide opposite direction
Muscle strength
degree that the contractile properties of the muscle can produce force
velocity of exercise
directly influences by the extra load that's applied and directly affects the force generating capacity of the neuromuscular unit. As external resistance decreases, concentric contractions can occur at a greater shortening velocity
The terms "novelty" and "complexity" are usually central to this type of intervention
dual-task training
Eccentric exercise
dynamic muscle activation and tension production is less than the level of the external load, so that the physical length of the muscle increases as it controls the load such as lowering the weight; eccentric action decelerate and absorb energy
concentric/eccentric energy expenditure
eccentric exercise is typically more efficient from a metabolic standpoint. Eccentric contractions consume less O2 and energy stores vs. concentric exercises
What is kinesiophobia?
excessive irrational fear of physical movement and activity resulting from a feeling of vulnerability to pain injury or reinjury
What is tendinopathy?
general term that refers to tendon injury affected by mechanical loading *inflammatory markers are not always present in those individuals with tendon pain (this is why we no longer call it tendonitis)
Tissue creep occurs through
gradually increasing load to encourage slow elongation of tissues
What is a common guidelines when all reps and sets can be easily completed?
increase by 5-10%
What is joint effusion?
joint swelling as a result of some injury or surgery
Constant external resistance
limb moves through ROM against constant external load; free weight, body weight or simple pulley system
isokinetic resistance
maintains the velocity of limb movement while resistance is applied
Discuss the properties of concentric and eccentric exercise
maximum concentric contraction produces less force compared to a maximum eccentric contraction under the same conditions; it is easier to lower heavy things than it is to lift them; concentric contraction requires a greater number of motor unit activation for the same load when compared to eccentric
SAID principle
notion that in order to improve a specific muscle performance component, the resistance program needs to match elements of that construct. So specificity of training or exercise suggests that the adaptive effects of training are highly specific to the training method employed
Periodization
organization and planning of a training intervention so the program is sectioned off into specific time periods. Periodization begins w/ determining the training target or goal and then the program plan is broken down into macrocycles, mesocycles, and microcycles
Stretching Alignment
positioning of a limb or body segment so that the stretch force is directed to that appropriate muscle group
What are limitations to isometric exercises?
potential for strength gains is minimal as there's no externally applied load. The aim is to slow atrophy and maintain mobility in the early phases of healing; limitations to load progression
What is hydrostatic pressures?
pressure that's exerted by water on immersed objects; pressure can help to limit effusion and also assist with venous return
Goals for AROM and AAROM exercises
provides other physiological benefits from muscle contraction when it comes to motor learning from volitional muscle action Works to maintain physiological elasticity and contractility of muscles Provides sensory feedback and stimuli for bone and joint tissue integrity Works to increase circulation and thrombus formation Helps to develop coordination and motor skills for functional activities
What is viscosity?
resistance experienced from viscosity is proportional to the velocity of movement. Viscosity creates resistance w/ all active movements and will increase as velocity increases
What is surface tension?
resistive force of surface tension will change in proportion to the size of the object moving through the water surface. So an extremity that is moving through the water surface is performing more work than if it were kept underwater.
If applying a stretch on the right wrist passively to the elbow (therapist applied stretch), where would the point of contact be located to ensure effective manual stabilization?
right humerus
What would be an appropriate exercise if strength impairments are detected during a prone hamstring MMT?
seated knee flexor strengthening against theraband resistance
Macrocycle
several months to a year
Mesocycle
several weeks to months (2-6 weeks is most typical)
Isometric exercise
static form of exercise where a muscle contracts and produces force w/o a noticeable change in length of muscle and w/o any noticeable joint motion. Muscle tension and force output are produced by the muscle through external resistance provided by a manually applied force holding in a static position, bodyweight exercises or immovable objects such as a wall; performed @ 25-50% of max voluntary contraction
What is a limitation to constant external resistance?
the muscle that's being worked is challenged maximally only at one point in the ROM where the max torque resistance matches the max torque output of the muscle
Goals for PROM exercises
to assist with circulation and synovial movement of joints for cartilage nutrition to help reduce pain and assist with healing process
Microcycle
training days and sessions
Purpose of Isometric exercises for stabilization
used to develop a submaximal but sustained level of co-contraction in order to improve postural stability or dynamic joint mobility
variable external resistance
varying levels of resistance at multiple points in ROM; weight machine, elastic bands
Manual resistance exercise
when a muscle that needs to be strengthened is weak and can only tolerate minimal-moderate resistance; resistance can be provided by the therapist or another health professional. The pt can also be taught to self apply generated manual resistance to certain muscle groups *Dependent on stage (early); patient tolerance, controlled ROM, limited by therapist strength, unable to quantify
Mechanical resistance exercise
when external load is applied through the use of equipment or some soft of other mechanical means; mechanical resistance is beneficial when greater loads are needed in order to achieve an adequate stimulus for muscle performance gains
Muscle power
work produced per muscle unit of time
Which of the following would be an example of a dual-task intervention with the aim of improving decision making? "Throw this ball back to me while standing on one leg" "Press the button as quickly as possible when you see the light on the screen" "As you walk forward, turn in the opposite direction that I point" "Keep your balance when the platform wobbles"
"As you walk forward, turn in the opposite direction that I point"
What would be a typical patient response to stretching the wrist palm down hanging off the table?
"I feel a slight pulling in my wrist and forearm"
Is it okay to have pain during exercise?
"Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence". "Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes" Check for type of pain and intensity - continue below a certain threshold
Which of the following verbal cues would promote an external cuing strategy? "Reach toward the cup on the table" "Keep your knees in line with your toes" "Lift your arm to the side" "Keep your core activated as you perform the squat"
"Reach toward the cup on the table"
Which of the following would be an example of applying an external focus of attention during a shoulder exercise? "Squeeze your shoulder blades together" "Tighten your core" "Contract your rotator cuff muscles" "Reach toward the cup on the table"
"Reach toward the cup on the table"
What is the appropriate loading progression for tendinopathy in general?
"exercise to discomfort but not excessive pain"
What are other parameters and progression besides simply adding load?
% body weight base of support support surface balance excursion of limb movement plane or direction of movement speed of movement or directional changes
A maximum ______ (a) contraction produces less force compared to a maximum _____ (b) contraction under the same conditions.
(a) concentric (b) eccentric
What is the purpose of therapeutic exercise?
- To remediate or prevent impairments of body functions and structures - To improve restore or enhance activities and participation - To prevent or reduce health related risk factors - To optimize overall health, fitness or sense of well being
What are the fundamental basics of loading?
- What activities does the pt need to return to? - How are these injured tissues loaded during that activity? - Using exercise and modalities on loading to simulate those tissues to heal and restore as close back to the original function - Physiological adaptation and restore function
What are indicators for readiness in the performance initiation, stabilization, and motor control stage?
-Should at least be in proliferative/remodeling stage of healing -Signs of inflammation are absent, decreasing, or are not worsened with the introduction of these exercises for greater than 24 hours -Do not necessarily need full mobility, but pain-free range is required
What are indicators for readiness in the mobility stage?
-Signs and symptoms of inflammation and if initial proliferation stages have occurred -Signs of inflammation have disappeared or decreasing -Inflammation is not worsened with the introduction of mobility exercises for greater than 24 hours
For untrained individuals participating in resistance training exercise, what is the recommended starting point for time under tension?
1-2 seconds
Neurodynamic Testing/Exercises Contraindications
1. Acute or unstable neuro signs 2. Cauda equina symptoms; B/B, perineal sensation 3. Spinal cord injury 4. Neoplasm or infection
What was listed as a contraindication to neurodynamic exercises?
1. Acute or unstable neuro signs 2. Cauda equina symptoms; B/B, perineal sensation 3. Spinal cord injury 4. Neoplasm or infection
What are the types of therapeutic exercise interventions?
1. Aerobic conditioning and reconditioning 2. Muscle performance exercises: strength, power, and endurance training 3. Stretching techniques including muscle-lengthening procedures and joint mobilization/manipulation techniques 4. Neuromuscular control, inhibition, and facilitation techniques and posture awareness training 5. Postural control, body mechanics, and stabilization exercises 6. Balance exercises and agility training 7. Relaxation exercises 8. Breathing exercises and ventilatory muscle training 9. Task-specific functional training
Neurodynamic Testing/Exercises Precautions
1. Be aware of other tissues/positions 2. Assess tissue irritability 3. Gradual progression 4. Cation with active disease or other pathology 5. Vascular compromise due to close proximity to nervous system
Contraindications to Stretching
1. Bony block limits motion 2. Recent fracture/incomplete healing 3. Acute inflammatory or infectious process 4. Sharp, acute pain (not normal response) 5. Hematoma or extensive tissue trauma 6. Joint hypermobility 7. Shortened soft tissues beneficial for the patient's situation in terms of providing stability to a joint
Precautions for stretching?
1. Don't force the stretch 2. Concerns for bone mineral density (ex. osteoporosis) 3. Lever arms - torque at a joint - a longer lever arm will create greater torque which will influence the force of the application in the tensile load through the target tissue 4. Prior immobilization - use cation because they lose their tensile strength after prolonged immobilization 5. Progression and muscle soreness - pain more than 24 hrs - adjust dosage; too much force or stretch being applied
What are guidelines for teaching self-assisted ROM?
1. Educate - on value of motion or exercise being prescribed 2. Teach correct alignment and stabilization 3. Observe performance and correct as necessary 4. Ensure safe and effective use of equipment 5. Provide specific guidelines/drawings for exercise + dosing - teach back technique to ensure understanding 6. Follow up visit - review exercises
Neurodynamic Tests
1. Every joints in the chain needs to be examined separately 2. Additional tests for nerve function 3. Test v. treatment positions 4. Test uninvolved side first 5. Active before passive - sense of level of irritability and willingness to move in those positions *Nerve palpation, sensation testing, reflex testing, dexterity testing, muscle testing
Signs and symptoms of impaired nerve mobility
1. History - pain is the most common symptom - monitor mobility. Pts may complain of stretch pain or paresthesias such as numbness and tingling when the tissues are in a neural stretch position 2. Neurodynamic tests - clinical tests used to detect tension or compression in the neural tissue *Both vascular and mechanical factors can contribute to nerve pathology
What are 3 ways variable loading can protect?
1. It can work to stress shield of tissues from repetitive loading 2. Provide a broader stimulation of mechanical receptors and prevention of accommodation 3. Stronger foundation that is better able to withstand a range of loading types
What are the main highlights of a resistance training program design?
1. Minimum 1 set, 8-12 reps for strengthening 2. Frequency: at least 2 days/week 3. Order: Larger, multi-joint exercises first 4. Progression: 2 for 2 Rule 5. Intensity: Borg CR-10 Scale
What are resistance training program design elements?
1. Needs analysis 2. Exercise selection 3. Training frequency 4. Exercise order 5. Training load and repetitions 6. Volume 7. Rest Period
For neurodynamic tests, what are the 4 requirements to be considered a positive test?
1. Reproduce pt's symptoms 2. Side-side differences 3. Support exam findings 4. Sensitizing maneuvers differentiate symptoms
Isometric exercise dosing
1. intensity - at least 60% of maximum voluntary contraction to improve strength 2. duration/reps - more than 6 seconds but no longer than 10 per rep (2 sec rise, 6 sec hold, 2 sec fall) 3. specificity - joint angle and mode: physiological overflow of isometrics is minimal where it occurs no more than 10 degrees in either direction from the angle in which exercise is performed 4. Sources of resistance - vary - multi angle isometrics can be performed against minor resistance or simply having the pt push against a wall or door frame
What is the rationale behind doing isometric exercise?
1. minimize muscle atrophy 2. re-establish neuromuscular control 3. develop postural or joint stability 4. alternative when dynamic resistance is contraindicated 5. develop ROM-specific strength
The physiological overflow of isometrics is minimal, where it occurs no more than ______ degrees in either direction from the angle in which exercise is performed.
10
A patient expresses they would like to train for muscle endurance, but are unsure of which training parameters to use. Which of the following would be most appropriate to help the patient reach their goal? 5 reps (85% 1 RM) X 3 sets, 2 min of rest 8 reps (70% 1 RM) X 3 sets, 30 sec of rest 10 reps (65% 1 RM) X 3 sets, 20 sec of rest 2 reps (75% 1 RM) X 3 sets, 3 min of rest
10 reps (65% 1 RM) x 3 sets, 20 sec of rest
You are using the DeLorme technique for prescribing muscle strengthening. You determined your patient has a 10 RM of 200 lbs for a squat exercise. How much resistance should be applied for the 1st set (same session)?
100 lbs
What is a typical PRE (progressive resistance exercise) program?
2-3 sets 6-12 reps 6-12 RM
What is the general recommendation for temperature range of aerobic exercise in an aquatic environment?
26-28 degrees C
For repetitions in reserve-based training, which rating would correspond with a description of perceived exertion of "3 repetitions remaining" ?
7
Which training load may be most appropriate for someone who is advanced/experienced when it comes to muscle-strengthening? 55% 1 RM 65% 1 RM 75% 1 RM 85% 1 RM
85% 1 RM
Strength Training
A systematic process that uses muscle force to raise, lower, or control heavy external loads for relatively low # of reps over a short period of time
Which anatomic landmark correlates to 50% body weight when immersed in water?
ASIS
Define muscle performance
Ability of a muscle to produce tension and do physical work which encompasses muscle strength, power, and muscle endurance
Define stability
Ability of the neuromuscular system to hold the proximal or distal body segments in a stationary position. Joint stability refers to the maintenance of proper alignment of bony segments of a joint by passive and dynamic components
Define balance
Ability to align body segments against gravity to maintain or move the body within an available base of support without falling Require the interaction between various sensory and motor systems
Define flexibility
Ability to move freely without restriction and is often times used synonymously with mobility
Define cardiopulmonary endurance
Ability to perform moderate intensity, repetitive total body movements such as walking or jogging over an extending amount of time
What are the chronic stage clinical signs?
Absence of inflammation Pain after tissue resistance (pain can continue to persist in the absence of inflammatory markers) > 6 month (months - years) Limitation of ROM or muscle function: discomfort might be felt when stressing tissues at the end of their available range (typical tissue response) Tissue will continue to remodel and respond to the stresses applied to it
Isometric knee extension would be most appropriate for which phase of tissue healing?
Acute
Which of the following is generally a contraindication to stretching? Osteoarthritis Limited joint mobility Soft tissue extensibility concerns Acute inflammatory or infection process
Acute inflammatory or infection process
Does stretching enhance performance?
Acute static stretching either has no effect or decreases muscle performance in terms of strength, power, or endurance immediately following the stretching session Some dynamic warm up programs can lead to enhanced performance
What are the stages of soft tissue healing?
Acute: inflammation Subacute: proliferation, repair, and healing Chronic: maturation and remodeling
Contracture
Adaptive shortening of the muscle tendon unit or other soft tissues that cross around the joint that contribute to significant resistance of passive or active stretching which limits ROM
How could we make a functional movement a strengthening exercise?
Add load
What phase of the Exercise Prescription Framework is initiated when an individual has near-normal muscle performance without signs of tissue injury or mobility limitations?
Advanced Skill, Agility, Coordination
Proprioceptive Neuromuscular Facilitation (PNF) Stretching
Aims to gain greater reflective muscle relaxation as a result of autogenic or reciprocal inhibition spinal processing of proprioceptive information 1. Hold-relax or contract-relax 2. Agonist contraction 3. Hold-relax with agonist contraction
Stretching
Any therapeutic intervention that increases the mobility of restricted soft tissues
Nerve is able to move without adverse stress due to:
Arrangement of the nervous system (spinal cord, nerve roots, and plexus - the movement is dissipated throughout the system and neural ischemia is avoided) Connective tissues (helps to absorb tensile forces) Perineurium (primary guard against excessive tension and allows for 18-22% strain before failure, due to its elastic properties and strength)
Doing an exercise solo v in a crowd is an example of what? or Doing an exercise stationary v. avoiding moving objects
Attentional resourcing environmental factors
What would most likely be considered a therapeutic exercise intervention? -Applying cryotherapy -Balance and agility training -Applying iontophoresis over the knee in supine -Dry needling
Balance and agility training
What is an example of a third class lever in the body?
Biceps curl - axis of rotation at the end of a bone *most common lever in the MSK system
Do biological tissues differ in how they respond to load?
Biological tissues differ in how they function and respond to load Optimal loading is tissue and adaptation specific Think: frequency, duration, magnitude, direction, and intensity to maximize adaptation that we want
How does cell-cell communication have implication for rehabiliation?
Cells communicates through small gap junctions and direct signals across to other cells to upregulate protein, make new tissue, and adapt the structure; clinical relevance is doing exercise within a certain ROM; as you are loading the tissue, the body will adapt appropriately
Elastic Range
Change in stress results in a proportional change in strain
What is the theoretical model of exercise progression?
Change of stimulus/environment over time and increase of difficulty level Goal is to see a progressive increase in performance over time Provides effective goal setting
When external torque is greater than internal torque, rotation will occur in what direction?
Clockwise (ex. seated knee flexion facing right)
What is a sensitizing maneuver for the median nerve and where should you feel the symptoms?
Contralateral cervical side flexion - changes the amount of stress placed through the nervous system; distal wrist
Define coordination
Correct timing and sequencing of muscle firing along with the appropriate intensity of muscular contraction which produces effective initiation, guiding, and grading of movement
When internal torque is greater than external torque, rotation will occur in what direction?
Counterclockwise
Hypomobility
Decreased mobility or restricted motion at a single joint or series of joints
What are the subacute stage clinical signs ?
Decreasing inflammation Pain synchronous with tissue resistance (ROM) Lasts 10-17 days (14-21 days after the onset of injury) *Depends on a number of factors including individual pt. factors, the tissue involved etc...
What has been used in the literature to guide exercise and pain?
Described 3/10 or less during exercise as "minimal" or "acceptable" pain Don't exceed 5/10 during exercise; pain should not be increased the following morning; 24-hour load response Pain should return to normal levels soon after completing the exercise Exercise volume is progressed based on response
Oxford Regimen
Determination of 10 RM 10 reps @ 100 of 10 RM 10 reps @ 75% of 10 RM 10 reps @ 50% of 10 RM
DeLorme Regimen
Determination of 10 RM 10 reps @ 50% of 10 RM 10 reps @ 75% of 10 RM 10 reps @ 100% of 10 RM
What are characteristics of optimal loading?
Directed to appropriate tissues Loading through functional ranges Appropriate blend of compressive, tensile and shear loading Variability in magnitude, direction, duration and intensity Include neural overload Tailored to individual characteristics Functional
Open Kinetic Chain (OCK)
Distal terminal segment is free to move single joint focus prime mover activation typically, NWB - resistance is applied to moving distal segment
Limitations for AROM and AAROM exercises
Does not maintain or increase strength It does not develop skills or coordination except in that motor pattern that's used
Motor task while counting backward by 3 from 100 is an example of what?
Dual tasking cognitive-motor
Doing an exercise while catching a ball is an example of what?
Dual-tasking motor-motor
Indications for PROM exercises
During acute, inflamed tissue after injury or surgery; When active ROM can be detrimental to the healing process When a pt is unable to actively move a segment such as when the pt experiences paralysis or is restricted to complete bed rest
How does tendon respond to mechanotherapy?
Dynamic mechanoresponsive tissue; major load-induced response in tendon is an upregulation of insulin-like growth factor
Which exercise would be most appropriate during the performance improvement phase of the therapeutic exercise framework?
Dynamic resistance exercise based on training goal (hypertrophy, etc..)
What exercises are appropriate for the performance initiation, stabilization, and motor control stage?
Dynamic resistance exercises: daily, high reps/low weight (<50%1RM for isotonic exercises OR 25-50% MVC for isometrics) Concentric, eccentric, or isometric exercises can be used --> specific to the individual and their needs
What is a common PT visit flow in an inpatient setting?
Evaluation/re-exam Movement intervention - therapeutic exercise/activity, neuro re-ed, gait training etc...
What is a common PT visit flow in an outpatient setting?
Evaluation/re-exam Warm up Symptom modification (if pain) - physical agents, manual therapy etc... Movement intervention - therapeutic exercise/activity, neuro re-ed, gait training etc... Cool down
"Tighten your neck muscles and tuck your chin" v. using a wall/pad as an external cue is an example of what?
External focus of attention for cervical retraction
"Don't let your knees go part your toes" v "lunge toward the target" is an example of what?
External focus of attention for lunging
"Raise arm to 90 degrees" v "reach toward my hand" is an example of what?
External focus of attention for shoulder flexion
Provide examples of perturbations
External perturbations at different body regions Anticipated v. unanticipated During static v dynamic movement Small v. larger perturbations (progression)
What neurodynamic test stresses the median nerve?
External rotation, abduction, elbow extension, wrist extension and forearm supination
Active range of motion is typically sufficient to maintain or increase strength? T or F
False
How would you progress an initial exercise?
First by increasing the exercise volume by increasing the frequency, intensity, or duration Second by changing the exercise challenge
Stretching Stabilization
Fixation of a body segment that is an attachment muscle that's being stretched
What is defined by the "ability to move freely without restriction and is oftentimes used synonymously with mobility"?
Flexibility
What is buoyancy?
Force that can provide the pt w/ a relative weightlessness and a sense of unloading by reducing the force of gravity - AROM with greater ease
Which structures are primarily being stretched with pt seated with wrist hanging off a table and therapist applying force through the palm back toward the arm?
Forearm flexors
What does FITTSBALL stand for?
Frequency Intensity Time Type Stage Beliefs Ability Limitations Life Satisfaction
What does FITTSBALL stand for?
Frequency, Intensity, Time, Type, Stage, Beliefs, Ability, Limitations, Life Satisfaction
Principles of neural mobilization treatment
Goal - neurodynamic exercise is to maximize the excursion of that nerve while minimizing the strain Intensity is dependent on irritability of the tissue, the pt's response, and the change in symptoms Technique/application of neurodynamic mobilization is performed relatively symptom free in a slow rhythmic and oscillatory motion so the therapist nudges the stretch and then backs off *not a static prolonged hold like in static stretching Link what you find from the neurodynamic testing to the neurodynamic treatment
What is an example of a first class lever in the body?
Head/neck
What is an example of a second class lever in the body?
Heel raise with axis of rotation at the MTP joints - axis of rotation is usually located at the end of one bone - the muscle or internal force has greater leverage than the external force
How does muscle respond to mechanotherapy?
Highly responsive to changes in functional demands through the modulation of loading induced pathways; overload leads to the immediate local upregulation of mechanogrowth factor and in turn leads to muscle hypertrophy via activation fo satellite cells
Stress-Relaxation
If a subfailure load is applied to a viscoelastic tissue, and kept constant, there's a gradual decrease in the force required to maintain the amount of deformation. This is due to the viscoelastic nature of the connective tissue and redistribution of water content within the tissue
Where can functional movement as an exercise fit within the therapeutic exercise framework?
In multiple phases
Where is the center of buoyancy?
In the vertical position the center of buoyancy is located at the sternum
When is isometric exercises for muscle-setting typically used?
Include low intensity isometric contraction performed against minimal or no resistance; acute stages of healing after a soft tissue injury or surgery; goal is to decrease pain and promote relaxation
What are benefits to stretching exercises?
Increased flexibility and ROM - increased muscle tendon unit extensibility in order to improve flexibility and ROM Biomechanical and neural changes in the contractile and non-contractile elements of the muscle tendon unit and surrounding fascia.
Is there a time when rest is appropriate for injury (from loading)?
Insert a day of rest or two days of rest if there is an increase in pain (exceeds green light in Traffic Light System)
Define neuromuscular control
Interaction of sensory and motor system that allow someone to either anticipate to or respond to appropriate receptive or kinesthetic input and subsequently work to create coordinated movement
What is the equation for equal torques (Internal torque = external torque)?
Internal force X internal moment arm = External force X external moment arm
Elastic
It returns to its pre stretch resting length directly after a short duration stretch force is removed
What is the FITTSBALL approach to exercise perscription?
It uses both technical and cognitive behavior domains for exercise prescription
If the internal torque of the quadriceps femoris is greater than the external toque applied, what will be the result?
Knee extension will occur
Which would be a logical regression (less challenging) for a closed kinetic chain exercise? Eyes open to closed Large to smaller excursion of limb movement Stable to unstable surface Bilateral to unilateral bas of support
Large to smaller excursion of limb movement
What is optimal loading?
Load applied to structure that maximizes physiological adaptation
What are the chronic stage tissue responses?
Maturation of connective tissue Contracture of scar tissue Remodeling of scar Collagen aligns to stress
What are the steps in mechanotransduction?
Mechanocoupling Cell-cell communication The effector response OR the mechanical trigger or catalyst the communication throughout a tissue to distribute the loading message the response at the cellular level to effect the response--the tissue "factory" that produces and assembles the necessary materials in the correct alignment
Define mechanotransduction
Mechanotransduction refers to the process by which the body converts mechanical loading into cellular responses; these cellular responses, in turn, promote structural change
What are the multidimentional components of function?
Muscle performance Cardiopulmonary/endurance Mobility/flexibility Neuromuscular control/coordination Stability Balance/Postural equilibrium
Sensory processing would be included under which category of the multi-system interaction required for balance control? MSK system Contextual factors Nervous system Environmental factors
Nervous system
What are aquatic exercise precautions?
Neurological disorders Respiratory disorders Cardiac Dysfunction Small, Open Wounds and Lines
What are the characteristics of suboptimal loading?
Non-specific generalized loading Loading through limited ranges of movement Loading exclusively in a single manner Constant, unidirectional load Minimal neural stimulus Generic, non-individualized Non-functional, isolated segmental loading
Exercise Prescription for Strength Training
Novice - Intermediate 60-70% 1 RM Advanced - Experienced >80% 1 RM Increased load will more effectively increase strength 8-12 Reps; 1-3 sets (3 sets are most effective) Rest in between sets: 2-3 min; 2-10 sec rest b/w sets may allow increased loads Velocity (slow-mod): untrained individuals start at 1-2 sec; increased tension time may increase strength gains
Where is therapeutic exercise typically documented in the SOAP note? (sets/reps, duration, etc.)
Objective
Creep
Occurs through gradually increasing external load and then is sustained. Then the tissue will continue to slowly elongate during the maintained stretch. The amount of tissue deformation depends on the amount of force and the rate at which its applied; low load, long duration stretching improve mobility
Define postural control, postural stability and equilibrium
Often used interchangeably with static or dynamic balance
When should we start loading during rehabilitation?
Optimal loading is early loading
How done bone respond to mechanotherapy?
Osteocytes are the primary mechanosensors; studies suggest increased strength and range of motion
