For Test 2 -424

•*How long do these exercise help with pain?

*3-5 hours after exercise for MS*

Closing thoughts NSLBP

-Main reason for low back pain reoccurrence is due to exercise *nonadherence* -The root cause of back pain is hard to diagnose -Most will get it at sometime in their life

effects on exercise response

•Exercise positions involving standing and sitting may trigger pain (do back flexion/extension testing) •Limiting factors (biopsychosocial factors) -Physical, Psychological (fear!), Sociological •LBP may not in of itself limit exercise but pain usually moderates loads

Gross Motor Function Classification System (GMFCS) is a widely used method to class and describe the level of mobility in cerebral palsy.

•Level 1 good •Level 5= compromised movement a lot •Exercise testing for levels 1,2, 3 (anything is valid with any needed modifications) •Levels 4, 5 don't try to exercise test because it will be invalid •Submax test for all conditions

MS definition

•MS is an inflammatory autoimmune disease of the CNS -Characterized by *nerve demyelination* -Plaques *(sclerosis)* in brain and spinal cord. Develop into permanent scars -Impaired nerve transmission •Symptoms of weakness, fatigue, and impaired motor function

Clinical Considerations -Contraindications to consider:

Follow ACSMs contraindications: •*Resting BP 200/110 mmHg* •Unstable angina (chest pain that comes and goes for no reason (not just exercising))

What is the best method of measuring body comp in people with SCI

Four-compartment model

Which statement true regarding signs or symptoms of stroke

The resulting brain damage causes paralysis and complications on the contralateral side of the body

There are approximately 2.8 million cases worldwide of MS -Northern latitudes have higher prevalence *Risk factors:*

•*Risk Factors: Initial diagnosis is typically between ages 20 and 50 yr* -*Women affected about two times the rate for men* •Susceptibility is complex: Related to genetic, infectious, and environmental factors •>50% disabled within 10 yr of diagnosis •Lifetime medical costs can top $1 million

Exercise programming -self study: •Exercises NOT to do: -standing toe touches -sit-ups -double leg lifts

•exercise TO DO: -partial crunches, supine hamstring stretches -wall sits -press-up back extensions -bird dogs -pelvic tilts -bridges •also maintain - 3-4 days of walking - 2 days of other strength work

What is the speed of reps for MS?

Slow. Balance it out with faster and heavier motions though

Causes of low back pain -These are not NSLBP because these have specific causes of pain

•Disk breakdown •Spasms •Tense muscles •Ruptured disks •Back pain can also occur with some conditions and diseases, like: Scoliosis, Spondylolisthesis, Arthritis, Spinal stenosis, Pregnancy, Kidney stones, Infections, & Fibromyalgia. •*In up to 80%-90% of cases, pain cannot be attributed to a recognizable, known, specific cause*

Closing thoughts for MS •*There are no specific exercise training guidelines for those with MS. It depends!*

•Evidence exists that exercise can limit physical disability and ameliorate symptoms •*Goal is to enhance or maintain ADLs, improve QOL, reduce symptoms of MS* •Make adjustments to prevent excessive neurological fatigue or danger as disease progresses - can you go too hard? •Exercise is safe and does not exacerbate symptoms

Treatment -Consider: •Can exercise during a flare up ** •*Cognitive - improve memory, relax, reduce stress. Symptoms are worse when someone is stressed*

•Exercise •Physical therapy •Occupational therapy •Speech pathology •Cognitive remediation specialists •Complementary treatments (e.g.,Chinese medicine, relaxation, naturopathy) •Assistive devices—canes, crutches, orthoses

Clinical considerations •Classify by *Kurtzke Functional Systems* -Can assist in objectively rating an individual's ability to perform certain exercises

•Exercise testing (very useful; should be done, strength, balance, aerobic) -Useful to establish baseline measures for future comparisons (Assesses the effectiveness of exercise training) -Provides information on individual responses to submaximal and maximal exertion -Establishes criteria from which an appropriate exercise prescription can be created -May suffer from *autonomic dysfunction* (HR doesn't increase or increase weirdly) -test *every* time coming out of a flare up

acute and early sub-acute aerobic treadmill walking posture -extensor intolerant and flexor intolerant

•Extensor intolerant = *Don't do decline* because back is in extension. Incline walk if flat is troublesome. Do elliptical or recumbent cycling too. No static posture (brings stress to back; do dynamic resistance training) •Flexor intolerant = decline and flat treadmill is good. cycling is good. Nothing that causes leaning over or lifting legs (*don't use incline treadmill*)

Exercise Prescription cont. -Cardiorespiratory exercise:

•Following ACSM's guidelines for frequency, intensity, and duration is an appropriate approach in patients having suffered a stroke •Suggested modes of activity: -Walking on ground or on a treadmill (balance, coordination, gait abnormalities) -Cycle ergometry (to improve stair-climbing ability) -Water-based exercise (to improve isokinetic strength)

Other barriers:

•General lack of energy •Little self-confidence •Limited disease-specific knowledge of fitness center staff •Fear of falling due to balance problems

Exercise testing

•Graded exercise testing is not indicated for back pain, BUT may be indicated if there are other comorbidities •*Avoid testing during acute flare-up* •Flexibility (all scored with ROM and pain rating): Straight single leg raises (compare sides), Back Flexion, & Back Extension •Mobility: gait analysis (heel/toe walking) •Strength: trunk isokinetic trunk strength

exercise prescription -special considerations

•If there is concern about stumbling during walking on a treadmill, supported treadmill exercise can be suggested, allowing the patient to exercise at higher velocities without the risk of falling •Data suggest that progressively increasing intensity over the course of a 6-mo training program showed greater benefits than increasing duration performed at lower intensities

Fibrinogen •A plasma protein from the liver involved with *blood clotting* -*Coagulation* factor -Test used to investigate disorders of coagulation (blood clot)

•Makes blood more viscous (thick) -Interferes with blood flow -Increases workload of heart (increases TPR) -Promotes *excessive platelet clumping* -Elevated levels with pregnancy, acute infection, CVD, stroke, trauma, cancer -*normal: 2.0-4.0g/L*

SCI disease definition •Spinal cord injury (SCI) affects conduction of neural signals across the site of the injury or lesion •Classified by the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body.

•May be defined as: - Complete =without sensory function in the lowest sacral segment (no function) - Incomplete =partial preservation of sensory or motor function below the neurological level (partial function) •SCI patients have deficits in: Motor, Sensory, & Autonomic

Spinal Cord Injury (SCI) -Scope:

•Worldwide, more than *2* million people are living with SCI •About 40% die before reaching the hospital •About 17,000 Americans will survive a new SCI per year •Following rehab, about *90%* will return to private residence and be able to walk again •Men are affected *four* times more than women •Traumatic •Nontraumatic •Average direct health care cost from age 25 exceeds $3.5 million.

Classifications of LBP -The person presenting with NSLBP may complain of localized or generalized lumbosacral region pain of variable intensity, duration, and frequency -Radiating pain with sensory changes, numbness, or lower-extremity weakness can be associated with more serious pathology and can indicate specific tissue involvement

•acute: pain lasting <6 weeks •subacute: pain lasting 6-12 weeks •Chronic: pain lasting longer than 12 weeks (in general)

Exercise training review

•flexibility= likely increased to similar degree as in healthy individuals -may reduce spasticity •improves body comp and balance too

Fibrinogen

Too low= free bleeding. Too high= makes blood more viscous (thicker), interferes with blood floor and elevates chance of stroke

MS Quiz : The primary disease process of multiple sclerosis occurs within what area of the body?

central nervous system

You are about to prescribe aerobic exercise to a patient with multiple sclerosis and a Kurtzke expanded disability status score of 6.5 to 7.0. Your choice of exercise modality should be 1) treadmill 2) cycle ergometer 3) Nordic track 4) running

cycle ergometer

more harm than good exercises:

don't do *double leg stuff*, like standing and touch toes, pull knees to chest -no twisting of the spine,

Low back anatomy and common pain points: -deeper level:

erector spinae

A complete SCI results in the patients having partial preservation of sensory or motor function below the neurological lesion T/F

false

CP - pain is not a significant problem with this disease T/F

false

Exercise testing in patients with multiple sclerosis is not recommended and provides little clinical value to the care team.

false

Exercise testing with MS is not recommended and proves little clinical value T/F

false

NSLBP pain results from a mechanical abnormality of muscle and joint function and not typically included by psychosocial factors such as emotional distress job dissatisfaction, or poor self-related health T/F

false

Static exercise stretching is contraindicated in patients with multiple sclerosis because it has been found to cause spastic "flare-ups."

false

Although NSLBP is common, 75-90% of patients recover within a few weeks with very little recurrence over the next decade

false ("within a few weeks with very little recurrence over the next decade" is false)

Low back anatomy and common pain points: -most superficial level:

lower back -sacrum area near bone where tendons and muscles insert

STIM exercise therapy

makes muscles contract a little to retain muscle mass -grip aids

Reduced strength seen in patients with multiple sclerosis may be due to all the following except 1) reduced central nervous system activation 2) lower motor unit discharge rate 3) progressive deconditioning associated with the disease process 4) metabolic insufficiencies that affect protein metabolism

metabolic insufficiencies that affect protein metabolism

Other comorbid conditions -Autonomic dysflexia, Syringomyelia

•*Autonomic dysflexia* =knee jerk reaction goes too far, HR increases (autonomic systems go too high) •*Impaired thermoregulation* =blood doesn't go to skin, they overheat •*Syringomyelia* =spinal cord cysts (*only progressive condition**) have to have surgery to get it taken out

MgGill 3 exercises stretches pt 1. (*for sub acute and chronic*)

•*Cat-camel/cow* exercise to lose up spine: *3-4 seconds cycle, 7-8 reps* •*Child's pose*

Clinical considerations -Associated conditions to ask about:

•*Epilepsy*: If present, increases the prevalence of intellectual disability (seizure meds) •*Visual and speech impairments* are common •*Scoliosis*: May need surgical correction in those severely affected •*Dental issues* •*Fatigue* and reduced ability to perform ADLs over time •*Contractures*: Decrease ROM and alter posture -alignment issues •*Chronic Pain* (high rates)

primary barriers to exercise:

•*Fear of worsening symptoms* •Fear of promoting disease progression

The ____ is a widely used method to classify and describe the level of mobility in CP

Gross motor function classification system

what is Crouch gait in CP

Loaded walks on the treadmill can help improve this by strengthening muscles and joints. When walking normally, entire walking pattern were improved making them less likely to fall and less joint damage - 50% of people with CP can't walk after 30 years old, which is why this is important to make people walk longer and better

pathology pt 3 • Hemorrhagic stroke: -Hemorrhagic strokes can be further broken down into intracerebral and subarachnoid.

•*Hemorrhagic*: *Hypertension is the major risk factor* for hemorrhagic stroke. Hemorrhagic strokes can also be caused by *aneurysm*, drug use, brain tumors, *congenital arteriovenous malformations*, and anticoagulant medication •*Intracerebral*: bleeding inside the brain •*Subarachnoid*: bleeding in and arounds paces that surround the brain

Neurogenic osteoporosis, Spasticity, Hyperreflexia:

•*Neurogenic osteoporosis* =decline in BMD due to inactivity •*Spasticity* =velocity-dependent increase in muscle *"tone"* from damaged stretch reflex. Varies in presentation. (often involves increased levels of pain) •*Hyperreflexia* =exaggerated reflexes.

Treatment -there is no cure for MS

•*Overall goal is to enhance or maintain ADLs by reducing or slowing the effects of MS and reduce fatigue* •There is only one FDA-approved disease-modifying drug (for secondary progressive MS): -Corticosteroids are used to ameliorate inflammation

McKinzie exercises. (for *acute*) pt 1 -Evaluation and treatment technique -Exercises based on the evaluation --(Extensor or flexor weakness) -Lumbar extension - extensor weakness is most common

•*Prone press up* -Lie prone and extend back while pressing up on the hands on elbows. Come down, repeat, hold in an up position for *about 5 seconds, then lower. 10 reps every 1-2 hours during acute phase*

McKinzie exercises. (for *acute*) pt 3

•*Standing Lumbar Extension* -stand and elongate your spine, place hands just above butt, and lean back as far as it's comfortable, lean back, *hold for 5 seconds, and come back to normal - 10 reps. Every 1-2 hours for acute phase*

McKinzie exercises. (for *acute*) pt 2

•*Sustained extension* -Lie prone but prop yourself up on the elbows, keep shoulder blades down and back, hang out in this position. *stay in position from 1-5 minutes*, don't over do this exercises (can cause issues like herniated disks)

exercise prescription

•*The major goal is to improve functional capacity (FC)* •The average FC of a stroke patient is near 14.4 mL/kg/min, whereas 20 mL/kg/min is the minimum for independent living •Typically, standard therapy does not provide enough of an aerobic stimulus to achieve an increase in cardiorespiratory fitness

MgGill 3 exercises stretches pt 2. (*for sub acute and chronic*)

•*The psoas stretch*: Back pain can tighten this muscle more, pulling hips to anterior position. Hip flexor stretch traditional lunge does NOT stretch psoas. Do: one leg, forward, raise opposite arm overhead, bend to side, drop shoulder back and stretch it back. *Hold 2 seconds, lunge and repeat. 6 reps per side* •*Hip airplanes*: Rotate torso forward, kick back leg behind you, rotate hips in then out, avoid twisting upper body *3 sets of 3 reps*

pathology pt 2 -Ischemic strokes can be further categorized as thrombotic or embolic:

•*Thrombotic*: (clot starts in the *veins* usually) Occlusive thrombus develops in or outside an ulcerated plaque •*Embolic*: (clot starts in the *arteries*) Emboli that cause embolic strokes are typically from plaques in the carotid or other arteries that travel to the brain and lodge into a smaller cerebral artery or arteriole

CP - Postnatal events usually occur before the age of 2 yrs and are a result of all the following except -Sarcomas -Anoxic event -Traumatic brain injury -Epilepsy -Viral or bacterial meningitis

Sarcomas

Which exercise hits the quadratus lumborum most effectively? Side plan

Side plank

Homocysteine -levels: •An *amino acid formed from methionine* break down •Rarely accumulates because it is converted into cysteine or back into methionine •Some people lack the enzyme that converts homocysteine (genetic)

•high= >15 umol/L •Excess homocysteine is terrible! -*Damages arteries, Promotes cholesterol build up*, Interferes with clotting factors •Lowering homocysteine levels in those with the enzyme deficiency decreases cardiovascular disease risk (take these: *B6, folic acid, B12*)

American Spinal Injury Association (ASIA) Impairment Scale

Know that A is the worst and E is normal

•Disorders linked by disturbances to the brain, resulting in motor disorders

-Disturbances of sensation, perception, cognition, communication, and behavior -Secondary musculoskeletal problems

Clinical considerations SCI •Cardiovascular management issues:

-*Relative bradycardia* attributable to impaired sympathetic nervous system in SCI above T6; occasionally requires pacemaker placement -*Functional Electrical Stimulation (FES)* Muscle stimulators: Increase local blood circulation, Can relax spasms for several hours, & For disuse atrophy

Clinical considerations pt 2 •Functional mobility issues could cause injury:

-*Upper extremity range of motion*, strengthening, and endurance within limitations of orthotics and medical management -*Bed mobility* (including side to side, supine to prone to supine, supine to sit) -*Wheelchair mobility* (including forward and backward propulsion, turning, uneven terrain, curbs, ramps, hills) -*Transfers* (including wheelchair to bed, toilet, bath, car, etc)

Exercise prescription •Range of motion exercise

-*perform daily* -focus on all major joints, with importance in maintaining shoulder ROM to decrease injury risk (external rotation of the humerus, retraction and upward rotation of the scapula) -*Particularly focus on joints with contracture or spasticity* -Consider care for those with osteopenia

Which of the following would be considered a primary preventions strategy for NSLBP -Limit bed rest as a general rule -Avoid aggressive spinal loading -Address negative lifestyle choices -Encourage compliance with therapies

-Avoid aggressive spinal loading

A hemiplegic stroke recovery patient is working with you, what is one exercise you would not perform with them -One-legged squats -Barbell squat -Overhead dumbbell press -Planks

-Barbell squat (unilateral exercises are ok, but since one side of body is weak, don't do bilateral exercises)

Which statement is true for MS -MS affects more men than women -Southern latitudes appear to be associated with higher prevalence -Genetics plays no role -50% percent of patients are unemployed within 10 yr of diagnosis

-50% percent of patients are unemployed within 10 yr of diagnosis

The CEP should do the following when performing a graded exercise test on patients with a history of NSLBP -Select a mode of activity that does not exacerbate NSLBP -Avoid testing during a acute flare up -Consider submax testing to reduce the risk of aggravating the condition -All of the above

-All of the above

Exercise prescription -Resistance exercise:

-All patients do scapular stabilization and rotator cuff exercises -*Initially 2 sets of 10 reps for all exercises, 60-70% 1RM or RPE 12-13* -prescribe isometric contractions for shoulder (6 sec) --protractors and retractors, elevators and depressors, internal and external rotators -bands are useful avoid overload of wheelchairs, and always set brakes

Exercise prescription •Cardiorespiratory exercise: -Aerobic exercise appears to be an important therapeutic intervention for reducing comorbidities such as CVD, type II diabetes, and obesity (main goal of exercise for SCI)

-Empty bladder before exercise -Intensity: Method of monitoring intensity is controversial --HR responses are variable (level of injury); in many, 30-80% HRR correlates to 50-85%peak VO2 --*RPE* is often used and preferred; RPE of *11 to 14* is likely best, corresponding to 60-90% of peakVO2

Flint Rehab article

-Flexibility is important -Movement patterns (hips, trunk, arms...) -Quadriplegia = chair exercises, bands, use grip aid

Contraindications to exercise testing in patients who have suffered stroke would include all except -Gait -Resting hypertension of over 200 SBP or more 110 DBP -Unstable chest painAltered mental state

-Gait

autonomic dysfunction in MS

-HR doesn't increase or increases weirdly -MS patients can't sweat/ have impaired thermoregulatory function, so use a fan, AC, and frequent rest when exercising

Which statement regarding SCI and resistance training is false? -Rotator cuff specific exercise -If you have stage 1 ulcer should not resistance train -Isometric contractions for the shoulders concentrating on the protractors, retractors, elevators, depressors, internally and externally rotate should be considered

-If you have stage 1 ulcer should not resistance train

Alcohol and CP article

-Increased post neonatal acquired CP following any alcohol-related diagnosis were found for non-aboriginal children *(7.9 more odds for CP)* -Heavy alcohol consumption while pregnant there is a direct cause for CP (or maybe if alcoholic beforehand)

Which statement is false for CP? -Its a genetic disorder linked to an autosomal recessive maternal gene affecting mostly the caucasian population -Defined as a group of permanent disorders of the development of movement and posture -It causes activity limitations attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain -Associated with disturbances of sensation, perception, cognition, communication, and behavior, with secondary musculoskeletal problems

-Its a genetic disorder linked to an autosomal recessive maternal gene affecting mostly the caucasian population

Pathophysiology of NSLBP

-Lifetime prevalence is 58-70% -Yearly prevalence is 15-37% -Estimates suggest that 28.4% of adults ≥ 18 yr have experienced NSLBP in the past 3 mo -Up to 85% of NSLBP has no identifiable cause. -The most common presenting diagnosis of low back pain is not really a diagnosis but a symptom -Risk of recurrence within a year is 60-75% -Recovery from NSLBP is relatively high (75-90% within a few weeks)

Which of the following is not indicated to stop the exercise program and re-evaluate for -Back pain is severe enough that the person wants to stop the exercise -Moderate muscle soreness occurs following exercise and goes away an hour later or appears the next day but is non limiting

-Moderate muscle soreness occurs following exercise and goes away an hour later or appears the next day but is non limiting

Common signs and symptoms for MS include all the following except -Optic neuritis -Paresthesia -Cognitive dysfunction -Osteoporosis

-Osteoporosis

Closing thoughts SCI -A team approach to evaluation, exercise prescription development, and exercise programming isr ecommended for patients with SCI

-Patients with SCI present with obstacles and considerations that the CEP must be familiar with to provide safe and optimal exercise testing and training oversight -People with SCI tend to be sedentary and can garner significant health benefits from increases in physical activity

Types of lower back pain -chronic (>3 months) tissue injury is not used a guide

-Should address inappropriate fears that more activity will cause more pain -should get client to resume activities as soon as they are able (strongly recommended)

What is a true statement treatment strategies -There is no cure for MS; treatments are designed to reduce or slow the effects of the disease while minimizing exacerbations -Targeted treatments facilitate destruction of the scars that impair nerve transmissions -There are multiple FDA-approved medications

-There is no cure for MS; treatments are designed to reduce or slow the effects of the disease while minimizing exacerbations

Which statement about SCI is false? -They are progressive in nature -Affect conduction of neural inquiry or lesion -Classified by the lowest segment of the spinal cord -Incomplete or complete

-They are progressive in nature

What is the highest impaired function that could be affected when there is a spinal cord lesion affecting the brachial plexus? -Affects dorsiflexion -Total paralysis of the wrists -Little or no control of bowel or bladder -Loss of function in hips

-Total paralysis of the wrists

common medications for stroke patients

-Warfarin Avoid exercise that could cause injury so they don't bleed out -Aspirin for anti-platelet

Kurtzke Expanded Disability Status Scale (EDSS)

0-10 scale - 0 is good. As number increases, gets worse and death occurs at 10 -*Half a point to one point can increase on the scale with exercise and treatment focusing on QOL*

What are the most common symptoms of multiple sclerosis? (select all that apply) 1) balance problems 2) visual impairments 3) muscle weakness 4) hypertension

1) balance problems 2) visual impairments 3) muscle weakness

Unilateral CP vs bilateral CP Classification

-monoplegia and hemiplegia = *unilateral* -other 3 = *bilateral CP*

stroke-related *modifiable* risk factors

-smoking -hypertension -high blood cholesterol -obesity and overweight -high blood LDL levels -high homocysteine, C-reactive protein, and fibrinogen levels

Special exercise considerations

1. Patients experience a fear-avoidance behavior pattern when they believe that movement and activity will further damage or injure the spine 2. the exercise specialist should monitor for red flag findings

Common signs and symptoms of MS include all the following except 1) visual impairments (optic neuritis, nystagmus) 2) motor function difficulties and paresthesia 3) cognitive dysfunction, emotional changes, and possibly depression 4) increased muscle strength

4) increased muscle strength

Multiple sclerosis is thought to be what type of disease? (select all that apply) 1) infectious 2) autoimmune 3) inflammatory 4) congenital

2) autoimmune 3) inflammatory

3. deconditioning may be greater in these patients than in sedentary healthy individuals. This may be more severe in smaller phasic muscle groups than in larger tonic muscle groups

4. the exercise specialist should use caution if loading through the spine and should consider unloading in some cases for pain management 5. Progression should be slow and initial exercise levels low, avoiding overtraining and over stressing 6. Smokers may need a slower progression.

Risk factors and endothelial dysfunction: Mediator role of oxidative stress

5 risk factors: -hypercholesterolemia -hypertension -diabetes -smoking -heart failure

Define athetosis

A motor symptom characterized by slow, involuntary, writhing movements of the fingers, hands, and toes

Which statement about multiple sclerosis (MS) is false? 1) MS is an inflammatory autoimmune disease of the central nervous system. 2) MS is characterized by nerve demyelination. 3) Although progressive in nature, MS can be cured with aggressive treatment and therapy. 4) MS involves the formation of plaques in the brain and spinal cord that develop into scars and impair nerve transmission.

Although progressive in nature, MS can be cured with aggressive treatment and therapy.

Treatment for MS -No cure exists, so treatment focuses on managing current symptoms and slowing progression -Progression can be slowed with medications -Symptoms are managed with Physical therapy, Occupational therapy, Exercise, Diet

Assess/Testing: -Vision and cognition -Need for a support person -Endurance, strength, and flexibility -Balance and gait abnormalities

what segment do you get autonomic, sensory, and motory issues?

At T6 and above, you will have autonomic issues -do they have a pacemaker? If yes = autonomic issues

biofeedback therapy

Biofeedback therapy at MUSC. raises self-efficacy of if you are doing it right

functional assessments

Cognitive and physical function assessments; need specific scale -Modified Fatigue impact scale (MFIS) for MS, for the general population use FSS (fatigue severity scale) -time 25 ft walk = MS functional composite (MSFC)

An ischemic stroke that occurs when a clot from the carotid or other artery affected is...

Embolic

Which of the following is true regarding hemorrhagic strokes

Excessive bleeding in the cerebral arteries prevents blood from flowing to brain

Unifying model: Endothelial dysfunction to CVD/Stroke due to Nitric Oxide (NO) Bioavailability

FMD (flow mediated dilation) - can measure direct oxidative stress - decreased NO, increased local mediators leads to thrombosis, inflammation, vasoconstriction, and plaque rupture

People with multiple sclerosis are believed to have the same life expectancy of those without multiple sclerosis.

Factors that predispose one to this disease have not been identified

Research suggests that progression of the endurance program should focus in increases in duration and not intensity (stroke)

False. Intensity first (for stroke people only)

Types of lower back pain -acute:

If LBP is acute (flare-up stage) injury and pain may be related -Ice -Analgesics (muscle relaxants, NSAIDS) -General movement - no bed rest

When working with patients with CP, why should the CEP pay close attention to the Gross Motor Function Classification System?

It classifies the individual's motor impairments to make more safe and appropriate exercise testing and prescriptions

Why is it important to consider impaired thermoregulation during exercise in an individual with multiple sclerosis?

It may cause exacerbation of symptoms.

Types of lower back pain - sub-acute:

LBP sub-acute -Exercise guided by pain when restarted -NSAIDS or medication as needed

Nonspecific low back pain (NSLBP) -disease definition:

NSLBP is the leading cause of disability, with 59.1 million Americans affected; 540 million worldwide -Confounding variables are age, depression, and obesity -One-quarter (*25%*) of U.S. adults reported having LBP lasting at least 1 day in the past 3 months -LBP accounts for more lost workdays than any other musculoskeletal condition

What is the best predictor of whether an individual will experience an episode of NSLBP?

Previous history of back pain episodes

Which type of MS steadily gets worse with no signs of recovery phases

Primary progressive

The 4 courses (types) of MS -Primary progressive MS (PPMS)

Primary progressive MS (PPMS) -a steady increase in disability without attacks

The 4 courses (types) of MS -Progressive-relapsing MS (PRMS)

Progressive-relapsing MS (PRMS) -steady decline since onset with super-imposed attacks -The worst one to have - end up in wheelchair sooner (least common)

Which of the following interventions has been found to be consistently ineffectual or harmful for clients with acute low back pain

Prolonged bed rest

The 4 courses (types) of MS -Relapsing-remitting multiple sclerosis (RRMS):

Relapsing-remitting multiple sclerosis (RRMS) is the *most common* form of MS -Relapses can occur, and damage still gets worse each time. Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission

The 4 courses (types) of MS -Secondary progressive MS (SPMS)

Secondary progressive MS (SPMS) -initial relapsing-remitting MS that begins to have decline without periods of remission -initial relapsing and flare-ups but then they stop

Body comp- different models

The more compartments that are measured, the smaller the error in body composition estimates

A patient with multiple sclerosis presents with ataxia of the arms. What modification would you recommend for this individual's strength training program?

Use machine weights instead of free weights.

Which of the following is not a special consideration when a patient with multiple sclerosis is exercising? 1) balance 2) thermoregulation 3) osteoporosis 4) fatigue

osteoporosis

when should you not exercise with pressure ulcers?

pressure from sitting too long, develops ulcers. Don't exercise with stage 2 or above ulcers (depends on how bad stage 2 is, may be able to just wrap it)

Low back anatomy and common pain points: -deepest level:

quadratus lumborum -(can't really massage it out (do strength exercises))

MS is noncurable, but it is

treatable

Although the resistance training can prove positive benefits in people in NSLBP, specific exercise for core strengthening (back and abdominal muscles) should be the focus T/F

true

As part of the physical exam performed in someone who has suffered a stroke, it is advisable to obtain a resting ECG to assess symptoms of ischemia and CVD

true

Depressive is experienced by most people in the poststroke period

true

Despite research examining the effects of exercise on multiple sclerosis, no specific training guidelines exist for this population of patients.

true

During the acute phase of a SCI, mechanical management issues take priority over fitness concerns T/F

true

Epilepsy is common in CP, with seizures occurring in almost half of children T/F

true

For sub-acute NSLBP, the physical examination should include spinal and abdominal muscle strength training T/F

true

Level B or impairment is more limiting than a C level of impairment T/F

true

Multiple sclerosis is most common in women.

true

The majority of CP cases are a result of prenatal events T/F

true

The most common approach when prescribing ROM exercises for patients with NSLBP is to evaluate for areas of tightness and design the exercise prescription to include stretches to correct any impairments noted T/F

true

The timed 25 ft walk, nine-hole test, and paced auditory serial addition test are used to evaluate lower leg function and ambulation, arm and hand function, and cognitive function is the MSFC assessment

true

MgGill 3 exercises for strength and stabilization. pt 1 (*for sub acute and chronic*)

•*partial crunch* -lie on back, put hands under back, bend one knee, raise upper back off of table and hold *10 seconds*. Don't round spine. *2 reps, rest 20-30 seconds in between*. switch legs and repeat •*Side plank on knees*: *4 reps, hold for 10 seconds* to start (build up to 30 seconds). Progress to side plank on elbow and feet. Obliques, transverse abdominis, quadratus lumborum •*Bird-dogs*: hold for *10 seconds, 4 reps, rest 20-30 seconds in between*. Glute complex and erector spinae

C-Reactive protein •levels: •Combination of inflammation. Only get tested when you feel not sick, and if you have underlying inflammation in the body it will tell you if you have chronic level inflammation

•A plasma protein made in the liver that indicates inflammation •Levels rise in response to inflammation resulting from coronary artery disease, cancer, infection, or trauma •CRP levels independently predict risk for MIs •*Low risk = 0-1, moderate risk = 1-3, high risk = 3+*

Stroke -Diseases of the Cardiovascular System Stroke (starvation of blood to the brain)

•A stroke or "brain attack" occurs when a blood clot or rupture limits blood flow to the brain -1. *Ischemic stroke* (vessel in brain blocked: permanent) 87% of all strokes (*most common*) -2. *Hemorrhagic stroke* (vessel in brain bursts: permanent) -3. *TIA* (vessel in brain temporarily blocked, temporary damage)

Alternative treatments

•Acupuncture •*Biofeedback therapy* •Chiropractic •Hypnosis •Massage •Meditation •Relaxation techniques •Tai chi •Yoga

Pharmacology for NSLBP -Aspirin and ibuprofen over a long time is kidney damage/dysfunction -Narcotics can cause dizzy, drowsiness, -Don't have them on a treadmill or obstacle course activities if they are on these. Note other side effects

•Acute -NSAIDS all the time, Muscle relaxants every day, No bed rest / light activity of ADL. Don't be sedentary, walks (no running). Don't do resistance training •Subacute -NSAIDs as needed. As tolerated exericse intensity to pain •Chronic -As needed medication but less likely to need it. Aerobic, resistance = anything is good

Exercise testing for specific phases

•Acute: -Avoid (don't do it). But can do a little flexibility testing (single leg raises only). Where does the pain start in the measurement? •Subacute: -Do strength testing (*most valuable here* to see where deficits are), flexibility testing (straight leg raises, back flexion, back extension), & gait analysis •chronic -not really done here but could be done

Pathophysiology factors of NSLBP

•Age (more common the older you get: 30-40+ years old) •Previous back pain episodes •Poor flexibility in hamstrings/back extensors, lower trunk muscular strength •Poor physical fitness / being obese •Heredity (such as ankylosing spondylitis, a form of arthritis) •Some types of arthritis and cancer •Being sedentary/inactive •Posture and your job (if you have to lift, push, or pull while twisting your spine, if you work at a desk all day) •Smoking (body may not be able to get enough nutrients to the disks in your back, smoker's cough may also cause back pain)

Clinical Considerations -History and physical exam:

•Assess for *hemiplegic gait*. - testing implications •Screen for frequently present risk factors for CVD such as hypertension and diabetes •Resting electrocardiogram (ECG) and symptoms of ischemia should be assessed, as coronary artery disease often presents in stroke patients •Psychological assessment may be warranted, as many stroke patients develop mental *depression* during the post stroke period

Pathology stroke

•Atherosclerotic process causes cerebrovascular disease, and ultimately an ischemic stroke •Proceeds in the same fashion as plaque progression in CAD.

Diagnostic Testing

•Blood tests -lipid profiles -HbA1c and fasting glucose •Body comp analysis -DXA is NOT gold standard for SCI. Can use DXA to assess BMD (or radiographs) -*use four-compartment body composition modeling* -other: BIA ?

Pathophysiology of SCI

•Cardiovascular -*Circulatory hypokinesis*: Lowering of BP, SV, CO, and eventually BP too far •*Venous stasis, deep venous thrombosis (DVT)* (develop clots in legs when sit too long), and subsequent pulmonary embolus may occur •Increased risk of *orthostatic hypotension* (too low BP in any change of position or posture, gets dizzy)and *exertional hypotension* (when exercising, BP drops very low)

Cerebral Palsy (CP) -Disease definition

•Cerebral palsy is "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain"

Precautions during exercise

•Debilitating fatigue •Muscle spasticity •Muscle weakness, poor balance, and incoordination •Sensitivity to heat •Pain •Incontinence (pee before exercise) •Consider cycle ergometer if ambulatory impairment exists

conclusion CP

•Deconditioning is common in individuals with CP •Innovation is required for safety and effectiveness of exercise training in those with CP •Optimizing exercise protocols across the severity spectrum and changing physical activity behaviors long-term are future needs

Exercise Prescription cont. -Resistance exercise: •Resistance training is an important part of a patient's exercise prescription because of the neuromuscular compromise following a stroke •ACSM's recommendations for strength training could easily be followed with some modifications in the mode of training

•Depending on the degree of muscular strength and endurance deficit, consider low-resistance modalities, such as elastic bands, body weight exercises, and sandbags •For extremely weak individuals, consider exercises against gravity •It is important to focus on completing activities of daily living (e.g., stair climbing, chair stands, walking through obstacles)

Nonspecific low back pain (NSLBP) -disease definition:

•Discomfort and pain, localized below the costal margin and above the inferior gluteal folds, with or without leg pain •Experienced in the lumbosacral region in the absence of major identifiable pathology •Not a single entity but rather a syndrome with pain and disability as the *most important symptoms*

Exercise Programming •The focus of exercise in patients with NSLBP should be to reduce risk factors and minimize recurrences •Evidence is growing in this area and is the focus of many practices, PT, Spine centers, etc

•Muscle strength, muscle coordination, flexibility, core trunk strength are all targeted •Specific back/trunk exercises and stretches should be performed: (no one type of training is superior (Mckenzie extension exercises vs Williams flexion exercises)) •Gradual progression should be used (most likely back specific exercises every other day)

CP pathophysiology

•Noxious events (congenital or acquired CP) lead to damage of brain tissue, resulting in *90%* of CP cases •Remaining 10% result from abnormal brain development (brain malformations): -White matter damage, gray matter lesions -Lesions to the corticospinal tracts -Lesions to the basal ganglia, thalamus, and related extrapyramidal pathways •~75% caused by prenatal events.

Symptoms of MS cont.

•Numbness, tingling •fatigue •muscle spasms •walking difficulty •pain

Pathophysiology of SCI. pt 2

•Pulmonary -*Ventilation impairment* (autonomic, lungs can't expand or contract well, vital capacity lower) •Bowel and bladder function •Endocrine -*Glucose intolerance* •Musculoskeletal -*Marked muscular atrophy* (need STIM for this) -Increased risk of *pressure ulcers*

Benefits of exercise •Stretching and flexibility - working GTO putting strain on it.

•Reduced risk for certain chronic diseases •*Reduces muscle spasms/ spasticity with varying rep speed* (turns off some motor spasticity and pain) •Reduced perception of fatigue •Improved muscular strength, muscular endurance, flexibility, and balance •Improved mood and confidence

Scope -Gender and Ethnicity:

•Risk Factor: *Women* have a higher life time risk of stroke than men. This larger number of women is mainly due to *longer life span and increased risk of CVD associated with menopause.* •Risk Factor: Incidence highest in *African American Males* then Females followed by Caucasians (large drop)

Other terminology -know: (check worksheet oaks)

•Spasticity •Dyskinesia • Dystonia • Choreoathetosis • Athetosis • Chorea • Ataxia • Dysarthria • Aphasia • Hindfoot valgus

What are the types of CP? •The brain damage that causes cerebral palsy will not worsen or heal over time •Luckily, the brain has neuroplasticity, which is its ability to rewire functions affected by brain damage to healthier areas of the brain.

•Spasticity= cerebral cortex •dyskinesia= basal ganglia •ataxia= cerebellum

Stroke treatment

•Standard rehabilitation for stroke patients usually includes physical therapy, occupational therapy, and speech therapy •Peripheral treatments may include registered dietitian and psychological counseling •*Primary aim of all rehabilitation is to restore balance, movement, coordination, and improve QOL to engage in ADLs and remain independent*

Scope of Stroke

•Stroke is the *second* leading cause of death among cardiovascular disease, accounting for 17% of CVD deaths •Fifth leading cause of death (*top 5*) in the US. •*26% of survivors are institutionalized and 30% are unable to walk without assistance 6months after stroke* •The estimated annual financial burden is $184 billion by 2030.

Exercise Prescription cont. -Flexibility:

•Stroke patients can perform traditional flexibility exercises as outlined by the ACSM •Focus should be on all major joints, with special attention given to paretic limbs, especially muscle groups that are experiencing a large degree of muscle spasticity •A raised platform can be very useful because it assists the stroke patient's ability to lie down and return to a standing position after exercising

conclusion stroke

•Stroke remains a significant cause of death and disability •Exercise testing and training are important in both prevention and treatment after stroke •There is increasing demand for CEP involvement in the care of patients at risk for stroke or after stroke. This is especially true for post stroke patients with only minimal related loss of motor function •Exercise appears to be a crucial component, as physical therapy alone is not sufficient to increase functional capacity after stroke

types of stroke

•TPA medicine given to break up clots within 3-4.5 hours

What is tetraplegia (quadriplegia) and paraplegia?

•Tetraplegia (quadriplegia) involves dysfunction of the arms. trunk, leg •Paraplegia involves trunk and legs but arms are fully functional •Height of injury and completeness of the injury is important

Characteristics of MS

•The process is likely initiated by autoreactive T cells that initiate an immune response against myelin -Cross blood-brain barrier and begin myelin damage •As myelin sheath deteriorates, plaques result in axonal destruction •Impairment of nerve conduction leads to symptoms and inability to perform ADLs

treatment for NSLBP -Traction device stretches out ligaments or tendons (back extension circle thing on ground)

•There is a wide range of medical management strategies, depending on thes everity of NSLBP -Medications, Exercise, Passive modalities (heat, massage, spinal traction), Facet joint injections, Surgeries (spinal discectomy, spinal decompression, and spinal fusion) •Surgical intervention is questionable except for unequivocal disc herniation •Education on safe exercises, lifestyle choices, limit bed rest, avoid aggressive spinal loading

Symptoms of MS -Major Signs:

•Visual impairments -Optic neuritis (blindness) -Nystagmus (blurred vision/ eye shaking) •Motor function difficulties -Paresthesia (numbness, tingling) -Spasticity -Falls •Psychological effects -Impaired cognition -Memory loss -Depression -*Symptomatic fatigue*

Can a Child Acquire Cerebral Palsy After Birth? •Stable incidence -May be slowly rising because of survival of more prematurely born babies •Lifetime cost of persons born with CP was estimated at $11.5 billion •Motor disabilities in childhood (typically up to 0-5 years) are only diagnosed as cerebral palsy if the brain damage occurs to the developing brain, if not then it is a traumatic brain injury

•While most people (up to *80%*) are born with *congenital cerebral palsy*, it is also possible to get cerebral palsy after birth. This is called *acquired cerebral palsy*: infection (meningitis, encephalitis, etc.) and poisoning (heavy metals), traumatic brain injury (from events that inflict excessive force to head like a car accident), blood clotting, seizures, tumors, surgeries, *anoxia* (near drowning)

Diagnosis of back pain -Massaging only works if pain is superficial, not deep -Focus on specific items that you may need to refer out -Rule out any serious issues (slipped discs, etc) -Then use goniometer to measure back, legs, etc

•palpate on common superficial anatomical landmarks to determine soft tissue irritability •initial focus should be on exclusion of any serious neurological problem -ex: sensation, motor function, reflexes / x rays, MRI, CT scan •if no serious neurological problems, screening can include ROM and flexibility testing (hamstring and hip flexor tightness, spinal flexion) •ideally the examination should include aerobic testing and spinal and abdominal muscle strength testing (assuming the patient is not having a flare-up of pain)