KIN 385

Other Computer Based Eval Tools

-Biodex stability system -Multiaxial platform allows up to 20 deg of deflection in any direction, adjustable -Patient attempts to control platform tilt, keeping it level

Other Relevant Tests & Measurements

-Body comp 1. Hydrostatic weighing 2. Bioelectrical impedance 3. BMI -Circulation 1. HR 2. BP 3. Auscultation 4. EKG, echo

Distraction

Perpendicular separation away from the treatment plane

Postural Control

-Should not use -Automatic (conscious is not required) ability to maintain control over posture

Surgical Repair knee

-Autograft 1. Bone-tendon-bone graft: 1/3rd of patella tendon a. Ipsilateral vs contralateral knee 2. Hamstring graft -Allograft: cadaver graft from patella tendon BTB or achilles tendon -Other complications 1. Unhappy or miserable triad: torn MCL, ACL, medial meniscus

Postural Control

-Automatic (consciousness is not required) ability to maintain control over posture -Postural synergies are fundamental responses to postural disturbances (perturbations) utilized to help maintain postural control -Originally investigated by Lewis Nashner (1976)

Contract Relax Agonist Contract

-Combines the 2 previous techniques -Take the limb to a point of a gentle stretch -Ask the patient to perform an isometric contraction (hold for 2-5 seconds) -Then ask the patient to relax this muscle group & contract the opposite muscle group thus moving the limb into a position of greater stretch (hold 2-5 seconds) -Repeat 2-4 times

Fiver Cardinal Signs of Inflammation

-Calor (heat) -Rubor (redness) -Tumor (swelling, edema) -Dolar (pain) -Dysfunction (loss of function)

External Forces

-Facilitate or restrict movement -Gravity, the ground, wind, other objects or people

Adhesive Capsulitis

-Stage 2 1. Goal: decrease pn, inflammation (treat joint restriction) 2. Therapeutic exercise a. Scap strengthening b. RTC strength c. AROM, PROM d. Joint mobs (grade II,III)

CKC

+End segment fixed +Stabilization via co contraction of muscles +Triplanar movements +Axial loading of joints & segments facilitates useful compression forces (decrease of sheer stresses possible) +Joint congruency maximized for stability +Kinesthetic awareness developed +Functional stresses -Compensatory /substitution possible without supervision

Active Assisted (AAROM)

-Assistance provided from external source to achieve unrestricted ROM when prime mover needs help -Achieved by: another person, gravity, pulley system, wand -Uses: weak musculature, improved movement control

Diagonals of Movement

-Combo of all 3 planes creates a single diagonal pattern -2 diagonals for each movement of a body part: head & neck, trunk, upper extremities, lower extremities -Examples: 1. Shoulder: D1 Flexion=flexion, adduction, external rotation 2. Shoulder: D1 Extension=extension, abduction, internal rotation 3. Shoulder: D2 Flexion=flexion, abduction, external rotation 4. Shoulder: D2 Extension=extension, adduction, internal rotation

Key Points of Strength

-Early: strength focus with functional consideration -Late: functional focus with strength consideration

Measurement of ROM

-Goniometry=gonia (angle) + metron (measure) -Measurement of amount of motion available at a joint

RTC Repair

-If conservative treatment is unsuccessful, or surgical repair is indicated (age, severity of tear) 1. Post operative guidelines a. Protect (0-4 weeks) i. Sling up to 6 weeks ii. Pendulums iii. Implement assisted ROM (IR/ER, flexion, extension), elevation < 70 deg. iv. Gentile isometrics after 1st week

Step 3: Implement the Plan

-Make it happen, working towards the pre stated goals -Listen to your patient/athlete. Make them responsible for telling you how treatment & exercise is affecting them (this improves their ability to listen to their own body) -Asking patient to pay attention to their body & notice differences in exercises & bodily function

Scapulothoracic Joint

-Requires movement of the clavicle on the thorax at the SC joint & motion of the scapula relative to the clavicle at the AC joint -Large array of scapula motion available & many occur concurrently -Scapulohumeral rhythm: overall ratio of 2:1 glenohumeral to scapulothoracic upward rotation motion past 30 deg. of abduction (shoulder dyskinesia)

Dynamic Stretching

-The limb is repeatedly taken through a ROM activity by the client -The individual performs movements where the primary movers take the limb through a ROM repeatedly while the antagonist muscle relaxes & elongates -Examples: lunge walking, squats to a toe raise, walking hamstring curls, hip flexions to knee extension -Increase ROM to also increase muscle/tissue temp -Doesnt seem to reduce power output the way that static stretching does, maybe even better

Limits of Stability

-The max anterior/posterior & medial/lateral angles that a subject can achieve & still keep the vertical projection of the COG within the area defined as the BOS -What happens if the COG exceeds the LOS?

Applied Musculature: Posterior

-Thoracolumbar fascia: numerous attachments on this structure make it a key area contributing to stabilization of lumbopelvic segments & transfer of forces from lower & upper body 1. Latissimus dorsi, transverse abdominis, erector spinae, gluteus maximus

Patterns Can be Performed

-Unilateral upper or lower extremity -Bilateral (combined) upper or lower extremity 1. Symmetrical 2. Asymmetrical 3. Reciprocal -Combined upper & lower extremity 1. Ipsilateral, contralateral, diagonal reciprocal

Work

-W=Force x displacement -Best represented as the area under the curve -Measured in Joules (Nm) -The longer the torque can be maintained through the ROM, the more work done -Subjects can have equivalent PT but perform less work than other -Work decreases as velocities increase

5 Goals of Therapeutic Exercise

1. Remediate or prevent impairments 2. Enhance function 3. Reduce risk 4. Optimize overall health 5. Enhance fitness & well being

Force Velocity Curve

As the velocity of a contraction increases, concentric force decreases and eccentric force increases

Golgi Tendon Organ Like Endings

Have a high treshold to mechanical stress & are slowly adapting. Silent when there is no activity in the joint. Beneficial at the end ranges of joint motion (remember GTO respond to tension)

Gamma Motor Neurons

Involved in regulating stiffness of muscles. They adjust the sensitivity of the muscle spindle so theoretically, presetting the muscle spindle may allow for a more efficient response from the muscles when reflexively responding to stretch

Gliding

Joint play movement parallel to the treatment plane

Flexion Exercises Spine

More beneficial for injuries to the posterior segment of the spine: facet pain, muscular spasm

Pacinian Corpusles

Most sensitive, found in deeper layers of joint tissues. Have a low threshold of activation but are rapidly adapting meaning they fire early but shut down over time with a constant stimulus (register accelerations/ decelerations)

Compression

Perpendicular approximation toward the treatment plane

Non Resting Position

Positions outside resting position that sometimes are used to treat subtle joint dysfunction

Physical Rehab

Rehab is a more global term that brings together all the components necessary to return the indv. to their optimal level of performance or highest possible functional capacity -Evaluation (must know your anatomy, structure function, have the ability to look globally to problem solve) -Physiology (tissue function & healing processes) -Exercise physiology -Biomechanics (how the body moves & the stresses applied to segments, joints, tissues) -Motor control (how we move as controlled by the central & peripheral nervous systems) -Motor learning (how we learn to move) -Modalities -Sport psychology

Roll & Glide

Roll without glide will result in compression/impingement on side of direction of OKM & distraction on side opposite the OKM

Traction

Separation along the lines of the long bone axis

Ruffini Endings

Slow adapting receptors that respond to pressure. Low threshold to mechanical stress meaning they fire continuously throughout stimuli. Found superficially in joint capsules & some ligaments & other joint structures

Strategies for Postural Control in the Anteroposterior Direction

Stepping Strategy: if recovery of balance is not possible with the other 2 strategies the person will step forward or backwards, in effect moving the BOS under the COG

Exercise Intolerance

-Signs & symptoms 1. Angina 2. Severe SOB 3. Abnormal diaphoresis 4. Pallor, cyanosis, cold skin 5. CNS symptoms (vertigo, ataxia, gait problems, confusion) 6. Cramps or claudication

Muscular Strength Cont.

-Strength is typically assessed using a one rep maximum (1RM) -Intensity is determined based on the 1RM -Alternative to 1RM is the 10RM

Rehab Plan Development

-Usually made in stages with specific criterion for advancement to the next stage based upon status 1. Percentages 2. Ambulatory status 3. Time frame 4. Protection

Manual Resistance

-10-15 reps to start of moderate resistance (progress with increased resistance, # of rep) -Time in contraction 2-4 seconds (should be substantial) -Keep motion smooth & accommodate resistance throughout the ROM as the mechanical advantage through the joint changes -Muscular endurance using 50% fatigue sets -Difficult to quantify intensity 1. Consider rating scale for patient 1-10 with 10 being most effort they can apply

50% Failure (Fatigue)

-1st: determine PT over 203 reps at a particular velocity -Then: perform reps at that velocity until PT is down to 50% of the max value 1. Can compare bilaterally to show how many reps it takes to reach 50% FATIGUE 2. Endurance protocol 3. Can be used to any designated fatigue value you are interested in

Step 2: Plan Development

-Are standards of performance adequate to be used for everyone? -Textbook recipes for program development with timelines vs progressions based upon functional capabilities -EX: quadricep/hamstring strength ratios or bilateral comparison of muscular strength. What is normal for that person according to their sport/position/sport maturation?

Program Design

-Assess needs, develop a plan, implement the plan, evaluate the plan, reassess needs (adjust every time you see your patient)

Normal Responses to Acute Aerobic Exercise

-BP 1. Increased SBP 2. Stable or slightly increased DBP -Pulmonary ventilation 1. Increased rate & depth

Quadratus Lumborum

-Back extensor or ipsilateral pelvis elevation & rotation 1. Major player in low back spasm following low back strain -Piriformis & obturator internis mm: external rotators of the hip joint that may shorten of tighten resulting in low back pain 1. Stabilize the pelvis during gait as well as function eccentrically during forward bending -Psoas major & iliacus form iliopsoas muscle, contributing to hip flexion or trunk flexion w/ the femur is stabilized 1. Iliacus can create anterior rotation of pelvis 2. Psoas major can create anterior translation of lumbar vertebrae, hip flexion, medial thigh rotation

Postural Equilibrium

-Balances state of forces acting on the bodys center of mass so that it moves uniformly & minimally around the bodys equilibrium point 1. Postural sway (normal) 2. When PS exceeds the ability to maintain COG within the limits of stability a strategy must be employed to maintain balance -The position of human body in relationship to the env. is determined by dynamic equilibrium 1. Combo of sensory & motor systems 2. All segments within the kinetic chain contribute to maintenance of balance

Diagonals of Movement Lower Extremity

-D1 flexion -D1 extension -D2 flexion -D2 extension

Stabilization Spine

-Decrease the microtrauma on tissue via bracing of the trunk/core 1. Beer can principle: increase pressure or support on all sides 2. Muscle fusion: Coordinating support on all sides of the core 3. Utilization of co contraction to keep core stabilized

Proprioception

-Derived form the works of Sherrington -Described the proprioceptive system afferent info from the proprioceptors located in the proprioceptive field that contributes to conscious sensation (muscle sense), total posture (postural equilibrium) & segmental posture (joint stability) -Receptors located in joints, muscle, tendons -Not equal to CNS processing

Intensity

-Directly related to load or amount of resistance (quality) -Not to be confused with perceived exertion -The more the load utilized approaches maximal force generating capacity the greater the intensity -60-100% 1RM for strength development, >80% for elite athletes -Also related to velocity of the movement: same load at a faster velocity enhances power output which is also increases intensity

Neutral Spine

-Does not mean absence of lordotic curve, rather a pain free stable position, so it may differ across patients 1. Pain free position that can be used as the basis of training exercises, always maintaining or returning to this position 2. Is it possible to keep a neutral spine in athletic events -Finding pelvic neutral: supine, seated, standing

Medial & Lateral Meniscus

-Each cover 2/3rds of the tibial plateau surface -Thicker on periphery than centrally -Different shapes 1. Medial: demilunar 2. Lateral: circular -Medial: attached to MCL ligament & more firmly to tibial plateau -Lateral: more mobile -Functions: shock absorption, increase contact between femur & tibia & distribute weight -Vascularized on the periphery

Factors Which Impede Healing

-Edema.hemorrhaging -Poor vascularity -Separation of tissue -Muscle spasm/gurading -Immobilization -Infection -health, age, nutrition, disease -Severity of injury -Corticosteroids

Neuromuscular Control

-Efferent response to sensory info -Transforming afferent info into a useful response -Reactive &/or feed back pathways 1. Continual adjustment of ongoing muscle activity 2. Speed & magnitude of perturbations during balance can effect the efficiency of these responses 3. Is there enough time to react? -Comparing afferent info against prior experiences 1. Preactivation of muscle patterns before the movement occurs (feed forward control) 2. Theorized to help compensate when external loads are large or at a speed that may not be controlled simply by reflexive responses

Strategies to Enhance Compliance

-Encourage group or partner exercise -Emphasize variety & enjoyment -Test to demonstrate & document progress -Immediate feedback & recognition of accomplishments

Computerized Dynamic Posturopgrphy

-Eval of balance via the sensory organization test on the neurocom system 1. Visual conditions modified: eyes open, eyes closed, sway referenced surroundings 2. Support conditions modified: across 3 visual conditions: sway referenced platform

SAID Principle

-Exercise selection should (eventually) be specific to posture, mode of contraction, movement, exercise type, environment, & intensity -In early stages when specificity cannot be achieved look for commonality between what you are doing & what you will be doing (+ transfer)

Maximizing the Session

-Explain the activity to the patient -Maximize patient positioning & comfort (non restrictive clothing, prone/supine/sidelying -Table height should benefit the ergonomics of the clinician (if you choose) 1. Create a stable platform with your base of support & body positioning -Provide a visual demonstration of the motion -Utilize a passive run thru initially to assure comprehension & follow up with active non resisted trials if necessary -Use consistent & useful teaching cues & reminders ("encouragement vs technique vortex") -Set a verbal level of exertion so they know what you expect 1. Adjusting with early reps if necessary according to patient's efforts -Control breathing on part of patient 1. Inhalation enhances effort 2. Exhalation enhances movement -Eye movements 1. Flexion is enhanced by looking downward 2. Extension is enhanced by looking upward 3. Has not been reproduced

Mobility of Lumbar Spine

-Extension: 20-35 deg. 1. Restricted by facet articulations 2. Posterior sagittal motion as well as posterior translation 3. LPR: return to erect posture initiated by posterior pelvic rotation to approx 45 deg. followed by extension of lumbar spine w/ posterior pelvic rotation -Lateral (side) flexion: 15-20 deg. to left, right 1. More variability across patients than F/E 2. Usually coupled w/ some degree of rotation -Rotation: 3-18 deg. 1. More variability across patients than F/E 2. Initially around an axial axis but the axis shifts to the contralateral facet joint that is being compressed 3. Usually coupled w/ lateral flexion

Coagulation Cont.

-Exudate formation -Platelets adhere to exposed collagen fibers -Release ADP to aid the process of platelets sticking to one another -Prostoglandin (PGE2) attracts leukocytes to the area -Eventually forms a leaky plug

What do we Ask About History?

-Family history 1. Sudden death 2. Myocardial infarction 3. Surgery -Lifestyle 1. Smoking 2. Activity 3. Alcohol or drug use -Personal health history 1. Hypertension 2. Dyslipidemia 3. Blood glucose

Postural Synergies

-For anteroposterior stability (strategies) -Synergy: a functional coupling of groups of muscles such that they are constrained to act together as a unit 1. Simplifies the control demands of the CNS 2. A synergy is activated as compared to indv. muscles being activated indv.

Extension Exercises Spine

-For disk injuries 1. Guideline is to find activities that cause "centralization" of pain w/o increasing symptoms in peripheral back or lower extremity a. Extreme extension may cause facet pain

Muscles Generate Force

-Force=mass X acceleration -Internal force=muscle -External force=gravity or other bodies

Resistance Exercise

-Form of active exercise in which dynamic or static muscular contraction is resisted by an outside force (gravity, manual, mechanical or other external device/object) -Serves to improve muscular strength, muscular endurance, muscular power

Density

-Frequency of a particular type of stimulus or training in a defined time period 1. Body weight squats (4 sets X 25 reps divided by 2x per week for 8 weeks=16 sessions with a volume of 1600 reps over a 2 month period) 2. Compared to (3 sets X 10 reps divided by 3x per week for 8 weeks=24 sessions with a volume of 720 reps over a 2 month period 3. What implications are there when considering volume & density (how often per week should we expose the patient to particular training stimuli during a day, week, month

Framing & Language

-Function & ability -Not dysfunction & disability -Lead your patients to positive outcomes

Strategies for Postural Control in the Anteroposterior Direction

-Hip strategy: larger perturbations in the ANT direction will be controlled by the ankle dorsiflexors, quads, & trunk flexors 1. Effectively pulling the hips backward & the trunk forward to keep the COM over the BOS when the ankle strategy is insufficient 2. Also appropriate when the ankle strategy cannot be used when force cannot be applied through the ankle plantarflexors

General Rules to Lessen the Load on the Spine During Lifting

-Hold object close to the spine -Reduce the size of the object -Bend at the hips & knees & avoid lumbar flexion/rotation

Irridiation Principle

-Importance of timing: stimulus form distal muscle groups is propagated proximally, prompting or preparing the next muscle group for conduction 1. Begin the movement sequence from distal to proximal a. Finger flexion to wrist flexion for elbow flexion to shoulder flexin

How do we Intervene?

-Improve proprioception & kinesthesic sensation -Improve dynamic joint stabilization -Improve reactive neuromuscular control -Practice functional motor programs -Exposure to tasks that activate all of these systems in order for retraining or learning how to control balance in a variety of situations

Normal Responses to Acute Aerobic Exercise

-Increased HR 220-age -Increased SV (increases linearly to 50% of aerobic capacity -Increased CO (HR x SV=CO) -Increased a-vO2 diff -Blood flow 1. Rest 15-20% of blood to skeletal muscle 2. Exercise 80-85% blood to skeletal muscle

Possible Causes of Balance Impairment

-Injury to any of the structures involved (cerebellum, basal ganglia) -Damage to proprioceptors -Injury to ankle, knee, hip, back associated with (increase postural sway & decrease balance) -Proprioception decrease with age (couple with decrease vision & impaired vestibular function)

Muscular Power ACSM

-Intensity: 30-60% of 1RM for upper body, 30-60% of 1RM for lower body -Volume: 1-3 sets of 3-6 reps -Rest: 2-3 mins for higher intensity exercises that use heavier loads, 1-2 mins for lower intensity exercises that use lighter loads

Muscular Strength ACSM

-Intensity: 60-70% 1RM for novice to intermediate, 80-100% 1RM for advanced -Volume: 1-3 sets of 8-12 reps for novice to intermediate 2-6 sets of 1-8 for advanced -Rest: 2-3 mins for higher intense exercise that use heavier loads, 1-2 mins between the lower intense exercise with lighter loads

Muscular Endurance ACSM

-Intensity: <70% of 1RM -Volume: 2-4 sets of 10-25 reps -Rest: 30-60 secs between sets

Reversals of Antagonists Slow Reversal-Hold

-Isotonic muscle action by agonists followed immediately by an isometric muscle action of the antagonist 1. Can develop at a specific point in the ROM

Hemorrhaging Cont.

-Leukocytes are delivered to the injured tissues (part of the cellular response) 1. Neutrophils (aggressive phagocytes, first line of defense) 2. Macrophages (phagocytes, second line of defense) -Function to remove tissue debris & any foreign material (bacteria), chemical & cellular transfer that comes with hemorrhaging

Delorme Regimen

-Light to heavy system, ascending pyramid 1. Determine 10RM 2. Perform 1st set at 50% of the 10RM 3. Perform 2nd set at 75% of the 10RM 4. Perform 3rd set at 100% of the 10RM -Rest is brief, warm up is built into the system -5 day per week program, retest 10RM on friday, 2 days rest

Isokinetic Movement

-Limb segment moves around a stationary axis of rotation -Constantly changing distance of the force vector (F) of the muscle from the axis of rotation (r) results in changing torque values throughout the ROM -Distance (d) from the axis at which force is produced on the through the leg cuff to the long lever does not change through the ROM

Normal Lumbar Spine Alignment

-Line of gravity (LOG), ventral to L4 -Spine is subject to constant flexion moment -Any displacement of LOG alter the magnitude & direction of moments on the spine

Factors that may Delay Wound Healing

-Local 1. Infection 2. Necrosis 3. Pressure 4. Trauma 5. Edema -Systemic 1. Older age -Diabetes -Obesity -Macro/micronutrient -Smoking -Vascular insufficiency -Disease

Resting Position

-Loose packed position -Periarticular structures are the most lax, allowing the greatest amount of joint play -Typically a very comfortable position, provides for relaxation -Shoulder: 55 deg. shoulder ABD, 30 deg. horizontal ADD -Elbow: 70 deg. FLEX, 10 deg. SUP -Knee: 25-40 deg. FLEX

Reciprocal Inhibition

-MSR also activates synergistic muscle motor neurons & inhibits antagonist muscles 1. Ia inhibitory interneuron 2. In practical terms: rapid stretch of the hamstrings facilitates hamstring muscle action & inhibits quadricep activity/tone

Static Stretching

-Method in which muscles & connective tissue are held in a stationary position at their greatest length for a specific amount of time -Self positioning/stretch, external device, assistance by gravity 1. Slowly & gently position to the point of resistance/stretch without pain 2. Hold for 15-60 seconds but control breathing (avoid holding breath) to maximize relaxation 3. Relax & repeat 2+ times (set & rep approach) 4. More than one session per day 5. Mental engagement in the activity by the patient (ownership for outcome)

Components of Pyhsical Rehab

-Minimize swelling -Control pain -Restore full ROM -Restore muscle strength, endurance, power -Re-establish neuromuscular control: postural & segmental -Regain proprioception -Restore ability to maintain balance -Maintain cardiorespiratory fitness -Consideration of the psychological effects that injury has on the indv.: education, communication, motivation, adherence all impact recovery

Isokinetics Torque

-Moment of force applied during a rotational movement (ft x lbs) 1. Torque=Fxd (moment arm) a. d=perpendicular distance from the axis of rotation to the line of application of the force

"Core Training"

-More than just abs -Lumbo pelvic region -Foundation for functional movement -Transfers forces from upper to lower

Smart Balance

-Neurocom international, Portland

Mass Movement Patterns

-PNF patterns: mass movement patterns which are characteristics of normal motor activities 1. As opposed to single plane movement MRE 2. 3 components/planes create a diagonal: a. Linear sagittal: flexion, extension b. Spiral: internal, external rotation c. Linear frontal: abduction, adduction 3. Beevors Axiom: the brain knows nothing of indv. muscle action but only knows of movement a. No single muscle is responsible for movement need synergists, stabilizers, assistors to the prime mover

Post Surgical Implications

-Painful arc syndrome: typically 60-120 deg. of abduction -Accompanies classic anterior impingement, concomitant w/ substitutive pattern: shoulder hiking

Elftman Proposal

-Principle that optimal force production is arranged in a hierarchy 1. Eccentric>isometric>concentric 2. Eccentric force/tension can be as much as 1.8 times that of isometric however ECC EMG activity is less for the same load as compared to CON -Implications in rehab 1. Is the muscle/tendon required to perform primarily CON or ECC MA 2. When can the incorporation of ECC MA be beneficial

Knee Extension Pathological Limitation

-Problems with anterior motion of concave tibia on a convex femoral surface -Restriction due to anterior structures

Shoulder Flexion Pathological Limitation

-Problems with superior & anterior motion of convex humeral head on concave glenoid fossa -Restriction due to posterior, inferior structures

Isokinetics

-Refers to a muscular action performed at a constant angular limb velocity 1. Limb segment moves at a constant predetermined velocity with accommodating resistance throughout a ROM 2. Increases in muscular output are met with increased resistance, preventing increased angular acceleration in the ROM (angular acceleration=deg/sec) 3. Isokinetic exercise & testing began in 1970's

Kinetic Chains

-Rehab exercises were traditionally OKC in nature: leg extensions, DB curls -Need to find safe way to load the extensor mechanism of the knee to protect the ACL graft resulted in surge of CKC exercises (1980) 1. Gary Gray (1992) chain reaction seminars a. CCE: combo of several joints united successfully where the end segment is not free b. OCE: combo of several joints united successfully where the end segment is free

Speed Endurance

-Repeated bouts of high speed activity with variable recovery times (analogous to a soccer player repeatedly sprinting 40-50 yards every few possessions for a 45 minute half

Power Endurance

-Repeated bouts of powerful movements in a certain period of time (basketball player performing 20-40 near maximal jumps in a single game)

Muscular Endurance NSCA + Bompa

-Reps: 10-25 -Sets: 2-3 -Rest: less than or equal to 30 sec ->20 (50+) reps

Valgus Knee

-Segment distal to the joint moves laterally 1. Mechanism of injury for MCL sprain -Varus: segment distal to the joint moves medially 1. Mechanism of injury for LCL sprain

Golgi Tendon Organ (GTO)

-Sensory receptor located in the junction between the muscle fiber & tendon 1. GTO encapsulates several muscle fibers 2. Contains collagen fibers & a single Ib afferent sensory nerve 3. Stretching GTO collagen fibers compresses the Ib nerve ending, causing it to fire 4. Ib afferents signal tension in the muscle 5. Produces inhibition of the agonist motor neurons a. Purpose is protective against overstretching or excessive contraction (decreases the tension in the muscle being stretched) b. AUTOGENIC INHIBITION

Setting up Goals for Step 2

-Should be based upon desired outcome -Measurable -Define the measures that will be taken to evaluate the goal -Use specific & or functional terms -Identify a reasonable time frame for achievement -Must be achievable for the patient -Write the goals down (document) -Discuss goals with patient -Consider the frequency of sessions (times per week) -Consider equipment availability -Develop alternatives in case of unforeseen changes/problems

Kinesthesia

-Should not be used -Portion of proprioception associated with the sensation of joint movement, either from internal (active) or external (passive) forces -Threshold to detection of passive movement: how quickly can we sense that the joint is moving

Somatosensation

-Should not use -(Somatosensory system): relaying of peripheral sensory receptor info, including mechanoreceptive (tactile & proprioceptive), thermoreceptive, & pain sensation

Neuromuscular Control

-Should not use -Unconscious efferent (motor) response to afferent (sensory) signals concerning dynamic joint stability

Proprioceptive Neuromuscular Facilitation (PNF)

-Simple definition- method of promoting or hastening the response of the neuromuscular mechanism through the stimulation of proprioceptors -History: Kabat's investigation of sister Kenny's treatment for suffers of poliomyelitis in 1940s 1. Complicated his research with the work of Dr. Sherrington (spinal reflexes & proprioceptors)

Muscular Power NSCA

-Single effort event: 1-2 reps, 3-5 sets, 2-5 mins rest -Multiple effort event: 3-5 reps, 3-5 sets, 2-5 mins rest

Muscle Spindle

-Small encapsulated sensory receptors located in the muscle that contain 1. Intrafusal muscle fibers with noncontractile central portion by polar ends that have contractile regions 2. Large diameter sensory nerve endings that spiral around the center of intrafusal fibers a. Ia, primary, involved in monosynaptic stretch reflex (MSR), sensitive to velocity of stretch b. II, secondary, provide feedback about steady state length of muscle 3. Small diameter motor nerve endings that innervate the polar ends of the intrafusual fibers (gamma motor nerves) -Oriented parallel to extrafusal fibers -SIGNALS CHANGE IN LENGTH OF THE MUSCLE

Neer: Rotator Cuff Impingement

-Stage 1: commonly affecting patients younger than 25 years, is depicted by acute inflammation, edema & hemorrhage in the rotator cuff. Usually reversible w/ non operative treatment -Stage 2: usually affects patients 25-40 years, resulting as a continuum of stage 1. Commonly does not respond to conservative treatment & requires operative intervention -Stage 3: commonly affects patients over 40 years, & most often requires surgical anterior acromioplasty & or rotator cuff repair

Facilitated Stretching Theory

-Stretching specific techniques can be applied to facilitate relaxation & improve extensibility of hypertonic muscles, muscle tendon unit, or periarticular connective tissue to improve ROM at a joint or series of joints 1. Facilitation of relaxation can occur by appropriate stimulation of the nervous system (isometric or isotonic muscle action, monosynaptic reflex, reciprocal inhibition, golgi tendon organ 2. Know your goal: static restriction due to stiffness or contracture of tissues may respond better to techniques to focus on improving creep in tissue to go beyond their resistance barrier (joint mobilization techniques, myofascial release & static stretching)

Impingement

-Structures affected 1. Subacromial bursa 2. Supraspinatus tendon 3. Biceps tendon (LH) 4. Joint capsule

Adhesive Capsulitis (Frozen Shoulder)

-Synovial inflammation-> reactive capsular fibrosis-> adhesive capsulitis 1. Rather than inflammation OR fibrosis, more of a combo -Frozen shoulder occurs: 1. After surgery or injury (insidious) 2. Most often in people 40 to 70 years old 3. More often in women (especially in postmenopausal women) than in men 4. Most often in people w/ chronic diseases

OKC

+End segment free +Isolation of muscular contraction & segment motion (predominately concentric or eccentric muscle action in isolation) +Uniplanar movements predominately -Sheer stresses, joint distraction possible -Limited improvement of kinesthetic awareness

Muscular Power Cont.

-100 lbs lifted 3 feet in 1 second -Increase power by lifting the same weight in less time (distance held constant) -Or by lifting a heavier weight in the same amount of time (distance held constant)

McKenzie back Exercises

-1981 ephasized the centralization of symptoms, particularly in those that have disk pathology 1. A more extension biased program although not entirely in the true spirit of his philosophy 2. Components: a. Prone lying w/ neck rotation, 5-10 minutes b. Prone lying w/ elbow prop, 5-10 minutes c. Prone press up, 10 reps d. Progressive extension w/ pillows, add a pillow after a few minutes of pain free position at each level e. Standing extension, hold 20 seconds, repeat f. Modifications: quadruped arch, bridging, bridging w/ limb lift

Pelvic Girdle

-5 fused sacral vertebrae form the sacrum -Superior articulation with L5 -Sacrum articulates on each side with illiac bones: sacroilliac joint (SIJ) -Small amount of motion available between the smooth hyaline cartilage of the sacral facets with the fibrocartilage surface of the illiac facets -Nutation: superior/inferior & anterior/posterior gliding of the sacrum along the innominates -Innominate bones (lateral half of pelvis with the illium, ischium, & pubic portions) 1. Amount of available motion is controversial among clinicians 2. Allows for anterior & posterior iliosacral rotation (small amount)

Lumbopelvic Region

-5 lumbar vertebrae: L1-L4 similar, L5 dissimilar -Facet orientation in the sagittal plane facilitates flexion extension motion but not rotation

Remodeling Phase

-9 days onward, will take 3 weeks to 2 years to complete, depending upon the type of tissue & extent of injury -This phase is characterized with a decrease in synthetic activity & an increase in organization -Maturation of the scar due to remodeling of the connective tissue matrix 1. Type III collagen is replaced with type I 2. Collagen is realigned along the lines of force to accommodate functional loads 3. More cross bridging occurs -Focus of treatment here=tension & loading of tissues become more important to ensure adequate orientation of tissue fibers -Active loading of tissues to realign the collagen fibers along the lines of force 1. Use lines of functional stress 2. Active contractions with resistive loads

Physiology of Balance

-A clinicians, it will be very important for you to identify the cause of a balance impairment prior to prescribing a treatment -What system is at fault? Vestibular, visual, diminished proprioception, biomechanical errors, motor systems problems

ACL Strain

-A force 1,725 newtons (387lbs) has been demonstrated to cause failure of the ACL ligament -Strain of 10-15% is necessary to cause visible failure of the ACL ligament -Variability of ACL strain according to activity 1. Weight bearing: 3.9% 2. Isometric quad set at 15 degrees knee flexion: 4.4% 3. Squatting w/ full body weight: 3.4% 4. Co contraction of quad & hamstring at 15 deg. flexion: 2.8% 5. Co contraction of quad & hamstring at 30 deg. flexion: 0.4% 6. Stair climbing: 2.7% 7. Isometric quad at 60-90 deg. flexion w/ 30N resistance: 0.0% 8. Co contraction of quad & hamstring at 90 deg. flexion: 0.0% 9. Active ROM: 2.8%, passive ROM: 0.1% 10. Biking: 1.7% -Lower ACL shear stress 90-35 deg. knee flexion but greater patella femoral contact forces -0-30 deg. causes the most ACL strain but the best quad activity 1. Utilize co contraction during this range to reduce stresses

Joint Mobilization

-A form of passive ROM -Used to restore normal accessory motion at bony articulations via: 1. Reduced capsular restrictions/adhesions 2. Distractions impacted tissues 3. Movement & lubrication for normal articular cartilage 4. Reduction of pain 5. Decreased muscular tension/spasm

Joint Position Sense

-A submodality of proprioception related to the ability to sense joint position 1. Where is the joint at in space 2. Feedback from these receptors helps regulate muscle activity through reflexive pathways 3. Reproduction of passive positioning 4. Reproduction of active positioning

Muscular Endurance

-Ability to exert repeated submaximal muscular contractions -Low intensity, repetitive or sustained activities over a prolonged period of time

Flexibility

-Ability to move a single joint or a series of joints smoothly & easily through an unrestricted, pain free ROM (Kisner & Colby) -Dependent upon elasticity of musculature, pliability of the fascia, & other connective tissues that affect the joint -ROM & flexibility are related but not equal (most individuals have similar potential for ROM at particular joints but differences in flexibility of tissues may limit maximal potential ROM

Spinal Stenosis

-Abnormal narrowing of the spinal canal of the intervertebral foramen 1. treatment should focus on: a, Poor muscle performance (intrinsic musculature) b. Short hip flexors which would contribute to anterior pelvic tilt & lumbar lordosis c. Thoracic kyphosis with overstretched & weak thoracic erector spinae d. Asymmetry of pelvic girdle & lower extremity muscle length & strength resulting in lumbar scoliosis & lateral foraminal narrowing e. Exercise w/ flexion bias should be encouraged

Muscular Strength

-Absolute strength: ability to exert force regardless of one's body weight -Relative strength: ratio between an individuals absolute strength & their body weight (RS=AS/BW) -Functional strength: ability of the neuromuscular system to produce, reduce or control forces, contemplated or imposed during functional activities, in a smooth, coordinated manner -Specific strength/special strength/functional strength: strength of only those muscles that are particular to the movement of a specific sport/activity

Proprioception

-Acquisition of stimuli by peripheral receptors, as well as conversion & transmission of afferent info to the central nervous system for processing 1. Related to the conscious & unconscious sense of joint position (joint position sense JPS) 2. Related to sensation of joint movement & acceleration (kinesthesia) 1. Threshold to detection of passive movement (TTDPM)

Ability vs. Disability

-Bio: biology, anatomy, physiology (how your different body systems interact) -Psycho: physically healthy but has psycho issues? (how an individual perceives & interprets these interactions) -Social: biology, anatomy, & physiology (how these interactions effect interactions with others

Manual Resistance Exercises

-Active resistance ROM exercise where muscular contraction is resisted by the clinician -Can be used to evaluate status of joint & related structures for bilateral strengths, weakness through a specified ROM (manual muscle testing isolate specific muscles to determine strength levels) -Criterion for use: ideally patient has full active ROM when compared bilaterally -Exception: stage of healing requires limited or protected ROM's to be respected -Applying MRE's is a skill on the part of the clinician. Attention to detail is critical to provide safety, appropriate stimulation of soft tissues & progression -MRE's also require a skill component for the patient. First sessions may result in improvements/changes as he/she learns the technique or motion 1. Improved coordination of recruitment 2. Comfort & understanding of the technique

DCER (Concentric)

-Active shortening (concentric): muscle contracts & shortens -Tension created with cross bridges overcomes resistance to shortening

Phases of Tissue Healing

-Acute inflammatory or substrate/reactive -Proliferation, repair, regeneration -Maturation/remodeling -It is a continuum -Overlap between phases, a fluid transition from one phase to the next, can also go backwards (something less than ideal happens), from any stage back & forth

Disk Herniations

-Acute stages: control pain & reduce inflammation 1. Maintain good mobility in surrounding segments 2. McKenzie patterned exercises for the spine 3. Low impact cardiovascular 4. Good shoes 5. Education on ADL's & lifting motions -Subacute & chronic stages: the treatment should focus on altering postures & movements which caused the injury

Daily Adjustable Progressive Resistive Exercise (DAPRE)

-Adaptation of Delorme but has built in system to knowing when to adjust load -Emphasis on 6RM, 4 set system 1. Sets 1, 2 progressively warm up & increase load 50% (10 reps) & 75% (6 reps) of 6RM 2. Sets 3, 4 targeted with a load that only provides 5-7 reps per set (100% 6RM) 1. If greater than 7 reps can be completed need to increase load, vice versa if <5 reps 2. Adjust load for the next days working weight

Coagulation Cont.

-Additional help to form patch comes from the conversion of fibrinogen to fibrin -Prothrombin to thrombin which stimulated fibrinogen fibrinogen to unwind individual fibrin structures -Form a lattice structure with collagen fibers (fibroblast), serves to trap platelets, RBC's & WBC's

RTC Repair

-Advanced (>12 weeks) 1. RTC strengthening 2. Progress w/ weights all exercises in all planes (sag first) 3. Restore scapulohumeral rhythm 4. Swimming at 5 months 5. Sub max return to sport or activity at end of 1 year

What is Therapeutic Exercise?

-Aerobic & endurance conditioning (cardiovascular & pulmonary) -Balance, coordination, & agility -Body mechanics & posture -Flexibility & ROM -Gait & locomotion (get from one place to another & interact with env.) -Movement pattern training (often related to sport performance) -Strength, power, & endurance training (muscular endurance, resistance training)

Dynamic Load

-All body motion increases load on lumbar spine -In a study of normal walking, the compressive loads at the L3-L4 motion segment were up to 2.5 times body weight -The loads were maximal at toe off & increased linearly with speed

Osteokinematics/Arthrokinematics

-All spinal movements involve combined action of several motion segments -Flexion: 8-13 deg. per segment -Extension: 1-5 deg. per segment -Rotation: 1-2 deg. per segment

Goniometric Measurements

-All starting positions for measurement (except some rotations) begin in anatomical neutral/reference (rotational measurement starting positions are halfway between med/lat rotation) -Reliability of goniometric measurements, amount of agreement between successive measures on the same joint 1. Intratester (same tester) 2. Intertester (different testers) -Validity of goniometric measurements, how closely does the ROM measurement equal the true/actual ROM/position

Sensory Organization

-Allows for the ability to resolve conflict when multiple sources of input conflict with each other -Resolving inaccurate input from visual input or somatosensory input by the brain in order to maintain posture/position adequately

Monosynaptic Stretch Reflex

-Also called myotatic stretch reflex -Acts to resist lengthening of the a muscle -Facilitates contraction of a muscle when it is lengthened rapidly -Ia sensory neurons from a muscle spindle excite aplha motor neurons, activating agonist muscle 1. In practical terms rapid stretch of the hamstrings facilitates hamstrings muscle activity/tone

Rotator Cuff Deltoid Force Couple

-Although the 4 rotator cuff muscles have individual functions, when functioning as a unit they create a downward force on the head of the humerus on the glenoid (compression) -Deltoid when acting alone creates an upward translatory force on the humeral head -Impairment in the complimentary relationship will result in humeral head mifration during flexion & abduction motion that produce microtrauma to joint tissues 1. Impingement of tissues between the humeral head & the acromion 2. Also consider different types of acromion orientation: Type I, II, III

Spondylolysis

-An anatomic defect in the continuity of the pars interarticularis of the vertebrae -Slippage of the vertebral body forward classified as spondylolisthesis 1. 70% occur at L5 2. 25% occur at L4 3. 4% occur higher level -Sensitive to lumbar extension & rotation -Treatment 1. Typically nonsurgical 2. Bracing, exercise, & NSAID's 3. Exercise, posture, & movement retraining 4. Lumbar extension & shearing forces should be avoided (similar to stenosis modifications) 5. Gradually get rid of brace, if used

Strategies for Postural Control in the Anteroposterior Direction

-Ankle strategy: small perturbations will be controlled by activation of the ankle plantarflexors, hamstrings, & erectors of the trunk for ANT perturbations OR ankle dorsiflexors, quads, & trunk flexors (abdominals) for a POST perturbation 1. These muscles are activated sequentially to pull the COM away from the direction of the perturbation

Cruciate Ligaments

-Anterior cruciate: functions to prevent anterior translation of the tibia on the femur 1. Passes through the intracondylar notch -Posterior cruciate: functions

Traction

-Application w/ herniated disk to increase the size of the intervertebral foramen -Intermittent intervals or rhythmic patterns -constant continuous over several minutes to 1/2 hour

Impaired Aerobic Capacity & Endurance

-Body's ability to absorb, use & deliver oxygen -Repetitive motion using large muscle groups over long duration -There are serious functional limitations w/ impaired endurance 1. Long term health 2. Many populations are inactive & becoming more so

The Injury Process

-Body's reaction to injury can be divided into 2 stages -Tissue destruction due to traumatic force: physical trauma bacterial/viral infections, heat (burns) or chemical injuries -Secondary damage due to cell death: hypoxia leads to enzymatic damage & mitochondrial failure

Kinetic Chain

-CKC movement creates (reasonably) predictable patterns of movement 1. Single leg squat results in ankle DF, knee flex, hip flex followed by triple extension a. Segments effect each other: ankle DF & knee flex effect hip flex -OKC does not result in predictable patterns of movement of all other joints in the chain 1. Segments will be subject to active & passive forces in tissues

Why do we Need to Re Train Aerobic Capacity?

-CV or pulmonary disease -Disease limited mobility -Prolonged prescribed rest -Aging -Sedentary lifestyle

Proliferation Cont.

-Capillary in budding is stimulated by a lack of oxygen (begins at periphery of wound & moves inward) -Granulation tissue is formed (one of the first things that happens, fill gap, consists of fibroblasts, collagen, & capillaries -Start to see a decrease in macrophages & fibroblasts near the end of this phase -Warmth & edema decrease (decrease in redness also, edema is the challenge)

Joint Angle Specific Strength Gains

-Carryover possible of +/- 20 degrees (greater when muscle is in a more shortened position than a longer one) -Must strengthen at several different joint angles in order to more adequately improve strength through & entire ROM -Dynamic constant external resistance (DCER)(isotonic)=muscle action in which the muscle theoretically exerts constant tension 1. Force exerted depends upon muscle length through the ROM, joint mechanical advantage 2. Reality: the external resistance remains constant but the muscle tension does not

meniscus tears

-Central tears: bucket handle -periphery tears: beak tears, posterior horn -Mechanism: impinged between femoral condyles, typically knee flexion w/ rotation -Medial meniscus frequently torn at same time as ACL -Lateral meniscus can be torn due to repeated stress due to mobility, insidious onset, may go undetected until symptomatic

Piriformis & Gluteal Pain Syndrome

-Characterized by pain &/or disability in the low back, buttocks, or posterior upper thigh due to hyperirritability of the piriformis mm which consequently puts pressure on the sciatic nerve 1. Resulting low back pain & spasm may be confused as the cause 2. Flexibility of piriformis & strength of the gluteals is critical a. Weak glutes will be substituted by hamstrings for pelvic extension, which changes the mechanics of trunk movement

Variable Contraction Velocities

-Choose a minimum of 3 velocities to work the patient at: 1. 30-60-90-120-180-240-300+ deg/sec 2. Pyramid of half pyramid sets like isotonic exercise 3. There is some indication that training velocities will help improve torque production below the training velocity but not above 4. better to initiate isokinetic exercise at submaximal effort with intermediate or slow speeds then progress to maximal effort at intermediate to fast speeds a, Improve familiarity & comfort with the type of exercise

Bilateral Comparison

-Compare contralateral limb to involved limb across same muscle actions/protocol -Differences greater than 10% are undesirable -Quick & easy but may not be best option 1. Deficits in "healthy" limb 2. Dominant vs nondominant limb differences naturally due to sport 3. Malingering?: cheating to make comparison appear closer a. Make sure to compare work values as opposed to just PT

Unilateral Muscle Ratio

-Comparison of agonist/antagonist values as a ratio or percentage -Quads/hamstring ratio CON/CON 1. As the speed increases the QH ratio approaches 1 -60 deg/sec, 60-90% -180 deg/sec, 70-79% -300 deg/sec, 80-95% -450 deg/sec, 95-100%

Shoulder Girdle

-Comprised of clavicle, scapula & humerus 1. 4 articulations a. Sternoclavicular SC b. Acromioclavicular AC c. Glenohumeral GH -Scapulothoracic (functional joint)

Step 4: Evaluate the Plan

-Continually re asses within the same session, at the end of the session, at the beginning of the next session -Is it working? -Make adjustments according to tissue response, pain, progress -Avoiding overstimulating or under stimulating tissues -Reward when short term goals are met

Contract Relax

-Contract relax: start with a static stretch by bringing the limb to the end ROM 1. Ask the patient for & resist an isometric contraction of the muscle being stretched for approx. 2-5 seconds 2. Ask patient to relax 3. Increase the stretch passively 4. Repeat 2-4 times

Shoulder Abduction

-Convex concave rule: mobilize in the direction opposite long bone movement of humerus on glenoid fossa & in same direction as the restriction caused by inferior structures -Posterior/inferior glide to increase internal rotation & flexion

Knee Extension

-Convex concave rule: mobilize in the same direction long bone movement of tibia on femoral condyles & in same direction as the restriction caused by anterior structures

Kaltenborn Grades of Translatoric Movement

-Emphasis on amount of force applied -Grade I: loosening with extremely small traction force with little appreciable joint separation -Grade II: tightening by taking up slack & then tightening the tissues. Transition zone tissues tighten & more resistance to passive movement is felt, end is termed first stop marked resistance -Grade III: stretching by applying beyond transition zone & first stop

Knee

-Femoral condyles 1. Medial extends more distally when knee is extended, larger 2. Lateral: wider -Intercondylar notch -Patellar groove -Tibial plateaus -Tibial tuberosity -Infrapatellar fat pad -Bursae -Synovial capsule/membrane

Contracture

-Fixed high resistance to passive stretch of tissue resulting from fibrous or shortened soft tissues of the joint or muscles -Concept: contracture is sometimes associated with complete loss of motion whereas shortness denotes partial loss of motion (tightness) 1. Protracted shoulder, tightness into shoulder flexion 2. Adhesion or fibrotic changes, contracture of shoulder into flexion

Glenohumeral Motion

-Flexion/extension 1. 105-120 deg/180 flex to 45 deg extension -Abduction/adduction 1. 105-120 deg/180 abd. to return to anatomic position -Scaption -Internal & external rotation 1. W/ shoulder abduction ER 80 deg., beyond 90 deg. abduction ER goes to 90 deg. & IR range up to 70 deg. -Horizontal abduction/adduction 1. 45 deg./135 deg. -Arthokinematic motion

Glenohumeral Joint

-Glenoid fossa is 1/2 as long & 1/3 as wide as head of humerus 1. Labrum provides questionable functional significance according to some researchers although it does establish improved concavity on the glenoid 2. Accepts only about 1/3 the surface of the humeral head -Ideal alignment of humerus & glenoid fossa can be affected by posture -Implications: will effect available or efficient shoulder ROM such as flexion, abduction

How Do We Define Strength?

-Goals of resistance typically revolve around desired type of adaptation -SAID principle: specific adaptation to imposed demands -Sometimes referred to as components of strength -Types of resistance training adaptations

Maitland Grades of Mobilizations

-Grade I: small amplitude movements at the beginning of the range, used for pain management -Grade II: tightening, taking up slack with large amplitude oscillations at a slow rate (1-2/sec) -Grade III: large amplitude, rapid oscillations up to the pathologic limit to ROM (2-3/sec) -Grade IV: small amplitude oscillations from the end range & beyond (2-3/sec) -Grade V: small amplitude, quick trust at end range, manipulations

Osteoarthritis: Degenerative Joint Disease

-Gradual degeneration of the chondral surfaces of the articulating surfaces in the knee: patella facets, medial & or lateral condyles of the femur 1. Surfaces of bone may have defects deep enough that full thickness chondral defects are evident 2. Dysfunction increases w/ age but young adults may also suffer chondral defects 3. Treatment: a. Injection of hyalgan (synvisc) provides a prophylactic barrier on articular cartilage b. Arthroscopic debridement & marrow stimulation techniques c. Autologous chondrocyte implantation (ACI) & osteochondral grafting d. Osteotomy to correct either the valgus or varus malalignment e. Total knee replacement -Conservative treatment & gradual return to ADL's as tolerated following replacement

Applied Musculature

-Hamstrings: insertion on ischial tuberosity allows for posterior pelvic rotation -Adductors: stabilize the femur during squatting motions -Anterior pelvic tilt: position in which the vertical plane through the ASIS is anterior to the vertical plane through the symphysis pubis -Posterior pelvic tilt: vertical plane through the ASIS is posterior to the vertical plane through the pubis symphysis

Oxford Regimen

-Heavy to light system, descending pyramid 1. 1-2 light warm up sets 2. Perform first training set at 100% 10RM 3. Perform second training set at 75% of 10RM 4. Perform third training set at 50% of 10RM -Purpose to diminish the effects of fatigue on the most important training set -Some research to support slightly better strength gains with heavy to light as compared to light to heavy protocols although may be less tolerant to the patient

Hemorrhaging

-Hemodynamic changes may occur due to: -Initial trauma=torn capillaries (vascular response) -Inflammatory mediators increase the permeability of the blood vessels (chemical response) -Pro inflammatory mediators 1. Histamines (vasodilation in arteries & increased permeability in veins) 2. Kinins (polypeptides that dilate arteries) 3. Prostaglandins (many different types)

Adaptations to Cardio Respiratory Endurance Training

-Increased a vO2 diff at max -Increased VO2 max -decreased body fat -Health benefits 1. Decreased fatigue 2. Improved performance & function 3. Improved blood lipids 4. Enhanced immune funciton 5. Glucose tolerance & insulin sensitivity 6. Improved body comp 7. Enhanced sense of well being 8. Decreased risk of chronic disease a. CAD, cancer, hypertension, diabetes, osteoporosis, anxiety, depression

Optimal Gains=Contraction Duration X # of contractions

-Increases in strength from isometric training are determined by: 1. # of contractions performed (volume should exceed 30 reps) 2. Duration of the contractions (3-10 secs, minimum of 6 secs in order to provide time for peak contraction to occur) 3. Intensity of contraction: submaximal vs maximal 4. Frequency of training

Conservative Treatment Rotator Cuff Impingement

-Initial phase: 1. Anti inflammatory medications 2. ROM: passive & active assistance a. Pendulum exercises b. T bar c. Pulley system 3. Isometric strength of RTC below 90 deg. abduction -Subacute 1. Establish normal ROM of GH joint & ST a. Scapulothoracic gliding & stability is critical -Intermediate 1. Continue ROM 2. External resistance through appropriate ROM 3. Progress from neutral to 90 & then above 90 deg. abduction -Late 1. Full pain free ROM 2. Continue strengthening: increase deceleration training of external rotators 3. Add functional activities

Acute Inflammatory Phase

-Initial reaction of body tissues to injury (mech, trauma, bacteria, burns) -First 3-5 days -Includes 3 important processes 1. Vascular response (hemorrhaging & coagulation) 2. Chemical response (changes in cellular functioning which serve to balance chemical mediators (pro inflammatory & anti inflammatory & thus inflammation) 3. Cellular response

Contributions by the CNS

-Integrates all the inputs from the sensory systems -Resolves inaccurate info from any of the 3 systems -Brain stem: all sensory & motor nerves pass thru the brain stem 1. All command signals form higher neural centers come through here 2. Integrates all postural & balance control -Cerebellum: useful during rapid & complex muscular activities like running coordination 1. makes corrective adjustments to motor activity, modulating responses to make corrections in movement 2. Involved in planning the next movement response, feed forward responses 3. Helps coordinate the intensity or sequence of muscle activation. Coordinating the responses of agonist & antagonist muscles -Basal ganglia: cerebral white matter, deep to cortex 1. Controls complex motor patterns 2. Initiates movements of repetitive nature -Supplementary motor area: active in relatively simple motor tasks with either distal or proximal limb movements. Helps organize the sequential performance of multiple movements

Using These Models to Implement Therapeutic Exercise

-Intervention (ther ex, modalities, etc) -This all comes together as our patients (health related quality of life, ultimately overall well being & wholistic quality of life)

Adaptations to Cardio-Respiratory Endurance Training

-Physiological adaptations 1. Increased heart weight & volume 2. Increased L ventricle size 3. Increased SV 4. Increased plasma blood volume 5. Decreased resting & submax HR 6. Decreased HR recovery 7. Increased max CO

Musculature & Function Shoulder

-Intrinsic musculature: attachments are only to & from the 3 bones that comprise the shoulder girdle RTC, teres major -Extrinsic musculature: attachments from the trunk or areas that extend beyond the shoulder girdle -Deltoid, pec minor & major, lats, traps, rhomboids, biceps long head, triceps long head, serratus anterior

Isokinetic Equipment

-Isokinetic dynamometers 1. Biodex system 3 a. Concentric, eccentric, isometric, CPM modes b. 0-500 deg/sec c. Only equipment still in production 2. Cybex 6000 a. Concentric, eccentric, CPM modes b. 15-500 deg/sec c. No longer in production 3. Kin-Com a. First system to provide concentric as well as eccentric modes b. No longer in production

Isokinetic Testing

-Isokinetic testing & training velocities are far below practical or real life angular velocities 1. Professional baseball pitchers demonstrate angular velocities of the shoulder between 6500-7200 deg/sec 2. Hip & knee velocities during a soccer kick may exceed 400 & 1200 deg/sec respectively 3. How much carryover effect from the training protocol do you expect to really find? -Isokinetic testing & training devices are non weightbearing & therefore not representative of functional activities for the lower extremity 1. Objective data from isokinetic dynamometers can be helpful in educating the patient & the physician about the status but consider whether these results have direct practical applicability

Rhythmic Stabilization

-Isometric muscle action of agonist followed by isometric muscle action of the antagonist (co contraction) -It is not movement, it is isometric co contractions -At 1 particular position in the range rhythmically perturb the limb in multiple directions with short isometric contractions (flex, ext, abd, add, diagnosis) 1. Plyometric muscle actions? -Dysrhythmic stabilization? -15-20-30 etc. duration -Start close to joint then as improvement occurs move further away, avoid trying to break patient

reversal of Antagonists Slow Reversal

-Isotonic contraction of the agonist followed immediately by an isotonic contraction of the antagonist 1. Used to develop active ROM of the agonists 2. Used to develop reciprocal timing 3. Can be CON/CON or ECC/ECC or a combo CON/ECC or ECC/CON

Joint Position Curve

-Joint angles used to determine at what point in the ROM that peak torque values were achieved (compare bilaterally)

Close-Packed Position

-Joint capsule & ligaments are tight or maximally tensed -Maximal contact between convex & concave surfaces -Gliding is maximally reduced & only slight separation possible

Treatment Options

-Keep the train in the track (Gary Gray) -Conservative (primary) 1. Strengthening of the VMO, hip abductors (glute medius) a. Awareness of patella femoral contact forces 2. Patella femoral McConnell taping 3. Eccentric training for patella tendonitis (Curwin & Stanish) 4.Patella joint mobilizations 5. Facilitated stretching of hamstrings, quadriceps, IT band, adductors, hip flexors, external rotators

Mobility of Lumbar Spine

-Kyphotic vs lordotic curves 1. Lordosis 2. Kyphosis (reversal of lordotic curve) -Flexion: 40-60 deg. may be variable across patients 1. 80% L4/L5 & L5/S1 articulations (primary fulcrum) 2. 20% L1/L2, L2/L3, L3/L4 articulations a. Anterior sagittal rotation as well as anterior translation 3. Forward bending bone in conjunction with pelvic rotation 4. Lumbopelvic rhythm (LPR): initial bending occurs with lumbar flexion, followed by anterior tilt/rotation of the pelvis

Intervertebral Disks (IVD)

-Largely avascular, motion & exercise may help improve transmission of nutrients to the IVD -Limited neural supply (discogenic pain) -Annulus fibrosis (AF), outer ring portion -Nucleus pulposus (NP), fluid filled inner portion, 70-90% water -Endplate, 1 mm thick & cartilaginous, for articulation with the body of the vertebrae -Allows for motion to occur between vertebral bodies

RTC Repair

-Late intermediate (8-12 weeks) 1. Goal: FROM in all planes 2. Continue joint mobilizations 3. Begin or progress resistance (bands) 4. Begin trap/serratus anterior exercises

Osteokinematic Motions (Physiologic Motion)

-Major ROM of long bones in the cardinal planes -Long lever rotational movements that can cause compression in the absence of arthokinemtic motion -Flexion/extension, abduction/adduction, internal/external rotation

Disk Herniations

-Majority of disk herniations are posterior'lateral 1. Implications of flexion or extension a. Flexion will further push the disk posteriorly, increasing pressure on nerve roots, causing neurological symptoms -Intervertebral pressure 1. Dec 75% in supine position 2. Dec 25% in side lying 3. Standing is the normalized pressure 4. Inc 40% w/ small jumps 5. Inc 150% while standing & bending forward 6. Inc 40-50% while laughing

Testing Aerobic Endurance

-Maximal graded exercise tests 1. VO2 max (specialized equipment required) a. EKG (ECG) b. Collection of expired gases -Submax graded exercise tests 1. Step, cycle, treadmill

ACL Sprain

-Mechanism typically a combination of rotation plus knee flexion (cutting to change direction when running or sudden stops with jump landings) or knee hyperextension 1. Typically a mid substance tear 2. ACL deficient copers vs non copers

Collateral Ligaments

-Medial collateral: broad, flat, deep fibers attached to medial meniscus, resists valgus stress to the knee, more commonly injured than LCL -Lateral collateral: cord like, resists varus stress to the knee

Meniscus Tears Treatment

-Menisectomy: arthroscopic procedure to remove the torn flap 1. Typical recovery 2-4 weeks: emphasis on reduction of swelling, ROM, hamstring, quadriceps & hip strengthening -Meniscal repair: suture the torn edges together 1. Typical recovery 2.5-3 months: protection from aggressive weight bearing & knee flexion early to avoid rupturing sutures & allowing tear to heal 2. Later stages same emphasis as menisectomy

Measurement of ROM

-Motion in one of three cardinal planes of the body around the corresponding axes -Sagittal/median plane (anterior/posterior) with a coronal/frontal axis=flexion/extension -Coronal/frontal plane with a sagittal axis=abduction/adduction -Horizontal/transverse plane with a longitudinal axis=internal (medial)/external (lateral) rotation

RTC Repair

-Post op guidelines continued 1. Early intermediate (4-8 weeks) a. Advance active assisted ROM b. Passive stretching c. Joint mobs: SC, AC, GH joints d. Progress isometrics & begin AROM as told e. Goal: 90 deg. flex/abd.

Passive (PROM)

-Movement at joint produced by external force with no voluntary muscular contraction 1. Achieved by another person, gravity, pulley system, wand, CPM device (continuous passive motion) -Uses 1. Assess limitation of motion (contractures, tightness, bony blockage, soft tissue approximation) 2. Decrease formation of contractures 3. Maintain/improve elasticity of muscle & other tissues 4. Improve joint nutrition by moving synovial fluid -Limitations (does not prevent atrophy, increase strength/endurance, restore motor programs for neuromuscular control

Active (AROM)

-Movement within unrestricted ROM produced by active contraction of muscles that cross the joint -Uses: 1. Facilitate muscle contraction & improve muscle function 2. Increase elasticity of related structures 3. Re education of muscles & motor skills 4. Enhance vascular dynamics (active) -Limitations: wont maintain strength in an already strong muscle

Active Lengthening (Eccentric)

-Muscle contracts & lengthens -Tension developed is less than the resistance, the muscle lengthens despite cross bridge connections -Resultant tension increases during lengthening of the musculotendinous unit -Natural portion of most human movement. Muscles that act eccentrically control segmental motion that is created by gravity or concentric MA in the agonist muscle

Role of Activating the Transverse Abdominus Muscle

-Navel to spine or "scoop" -Blood pressure cuff exercises -Avoid protrusion of abdomen w/ abdominal curls, limb lifts

Arthokinematic Motion

-Necessary movement between the articulating surfaces of a joint -Concomitant with osteokinematic motion -Difficult to measure precisely -Three distinct types of motions: 1. Spin: rotation about a stationary axis 2. Roll: non congruent joint surfaces moving on each other (convex/concave), in the same direction as the osteokinematic motion 3. Glide: two surfaces involuntarily sliding on each other

Injections

-Nerve root block (medication into the site of the inflamed nerve root) -Trigger point: local anesthetic into site of trigger point -Adjunct therapies

Needs Assessment Cont.

-Neurological examination: myotomes & dermatomes -Cardiovascular condition: know previous health status -Medications -Physician guidelines & restrictions -Psychological status of patient (stoic vs hypochondriac) 1. Tolerance to exercise 2. Motivation to return to play or work 3. Determination 4. Discipline 5. Ability to communication how they are feeling

Adhesive Capsulitis

-Non operative treatment 1. Stage 1 a. Goal: decrease pn inflammation (promote muscle relaxation) 2. Therapeutic exercise a. AAROM pnfree b. Aquatic therapy c. Gentle PROM d. Pendulums e. Joint mobs (grades I,II)

Coagulation

-Norepinephrine release (localized) (chemical) 1. Causes vasoconstriction of veins & arteries 2. Transitory (10 min or so) 3. Leads to neutrophil pavementing=attach to the endothelial lining on the vein side of the capillary -Exudate formation, fluid that contains a high concentration of cells, plasma protein & other solid matter (increases edema in area) -Fibroblasts recruited to area , collagen producing cells (by the presence of macrophages)

Adhesive Capsulitis

-Operative treatment 1. Late stage 2 or stage 3 2. ROM loss causing disability 3. Procedure (closed manipulation & arthroscopic release) 4. Post op a. CPM b. Therapeutic exercise: ROM, decrease pn, decrease inflammation, aquatic therapy (eventually strengthening per previous stages)

Extensor Mechanism: Patellofemoral Pain Syndrome

-Pain & inflammation associated w/ the patella tendon & its insertions, patella retinaculum, chondral surface of the patella, quadriceps tendon, infrapatella fat pad -Contributory factors: poor alignment of the patella or control of the knee during activity 1. Imbaances in strength of the quadriceps (weak vastus medialis oblique), tight quadriceps (rectus femoris), tight IT band, weak hip abductors, increased Q angle, foot pronation, tight external rotators, inadequate inferior patella glide during flexion, inadequate superior patella glide during extension

2 Stages of Lumbar Rehab

-Pain control (acute) 1. Typical: ice, rest, TENS, electrical stimulation initially a. Clinically when working with those more intolerant to cold you can place a hot pack on the upper back to make the ice treatment more comfortable 2. Initial goal to make ADL's more comfortable by a. Focusing on pain free movement facilitation (movement education) b. In & out of a chair, a car, out of bed, picking up objects

Special Considerations

-Patellafemoral contact area increases w/ flexion from 30-90 deg. w/ 2x the amount of surface area at 90 deg. 1. Initial patella contact at approximately 20 degrees 2. least patella femoral contact stress 0-20 degrees knee flexion

Repeated Contraction

-Patient moves isotonically against maximal resistance repeatedly until fatigue is evident -When fatigue is obvious then the clinician places a stretch at that point in the range 1. Purpose is to facilitate weaker muscles to complete a smoother movement 2. Used when the patient has a weakness either a a specific point or throughout the range 3. Make sure stretch is not contraindicated

Using These Models to Implement Therapeutic Exercise

-Patient's health condition 1. Body function & structure 2. Activity level (what types of activities that indv. engages in) 3. Participation level -Context 1. Personal (are they caregivers? Are they being cared for? Where do they live?) 2. Environmental (can they leave, 4th floor no elevator)

Data Acquisition & Interpretation of Test Data

-Peak torque (PT)- highest torque produced during contraction 1. Highest point on contraction curve, regardless of where it occurs during the ROM 2. Will differ across contraction speed a. Force velocity curve applies: faster velocities (180 deg/sec) result in smaller PT as compared to slower velocities (60 deg/sec)

Peak Torque

-Peak torque/body weight- expressing peak torque value as a percentage of body weight -Average torque-average torque produced across the entire ROM

Modes Spine

-Physio balls (swiss balls): strength & balance -Medicine balls: strength & mobility (lifts, chops) -Balance boards & external resistance: balance & strength "coordination" -Tubing systems: external resistance through a variety of ranges & planes 1. Activities a. Consider if you need to or can incorporate core stability w/ primal movements: pushing, pulling, lifting, squatting, lunging i. Progression to functional activities or ADL's ii. Coordination during functional activities & ability to transfer core stability training to the playing field or work place

PCL Sprain

-Potential risk when landing on the front of the knee: forcing tibia posteriorly (dashboard injury) -Knee hyperextension when the tibia is driven posteriorly, common cause in athletics -Rates of injury: 3-20% of knee injuries -Amount of knee laxity due to PCL tear can determine whether surgical correction is necessary. Many cope well with comprehensive rehabilitation program to strengthen quadriceps 1. Surgical replacement or repair appropriate if conservative management is unsuccessful

Muscular Power

-Power is a product of force production over a prescribed distance (work) in a particular amount of time -From a practical standpoint: 1. Power relates strength & speed of movement 2. Manipulate force or time in human movement. As a distance is a relative constant, affected by length of our segments, height, specific technique for the exercise 3. Range of effectiveness for power development is 40-80% 1RM

Isokinetics Angular Velocity

-Pre set by the clinician 1. Range: 0-500 deg/sec on average 2. Typical: 60,120,180,240 deg/sec -Muscular output is typically measured as a force (lbs) 1. How much force the machine has to use to counter the muscular output as the limb pushes against the lever arm

Progression to Impact Activity

-Prereqs 1. Adequate strength & endurance 2. ROM 3. Minimal pain & inflammation -Begin w/ low impact surface -Progress to functional surface -Progress duration & intensity -Sample progression 1. 2 foot hop 2. Alternating hop 3. SL hop 4. Sport specific skill drills (optional)

Rhythmic Initiation

-Progression of initially passive, then active assistive followed by resisted ROM through the agonist pattern 1. Slow movement 2. Used for patients unable to initiate movement & who have a limited ROM 3. Also used to teach movement patterns

Somatosensory

-Provides info concerning the orientation of the body parts to one another, & to the support surface 1. Processed very quickly as compared to visual & vestibular system info 2. Afferent input form skin (tactile), muscle, joint capsule & other soft tissues

Vestibular

-Provides info that measures gravitational, linear, & angular accelerations of the head in relation to inertial space (vestibular apparatus) 1. Head movements stimulate vestibular apparatus in the inner ear

Progressive Overload Principle

-Providing a greater stress or load on the body (systems) than it is normally accustomed to handling -Goal is to promote adaptation, occurs when the stimuli reaches an intensity proportional to the individuals threshold capacity -How do we find the level of overload in rehab that promotes adaptation but doesnt result in exacerbating the injury? Soreness due to adaptation vs soreness due to a stimulus that causes more distress to the tissue that it cannot overcome -Directly related intensity, volume, density of training

Training Spine

-Purpose is to gain core control via strengthening as well a mobility enhancement as indicated (flexibility) -Flexibility before stability? 1. Evaluation will determine which muscle groups are short & tight a. Hamstrings b. Hip flexors c. Quadratus lumborum d. Erector spinae e. External hip rotators f. Adductors g. Gastroc soleus complex (limitation in squatting motion for many)

Ballistic Stretching

-Quick movements used impose change in length of muscle & connective tissue 1. Limb is moved until gentle stretch is felt & then gentle bouncing at the end range is completed for 10-20 pulses 2. Not appropriate for all patients: production of soreness & injury are possible 3. Good in later stages of recovery when preparing patient for ballistic sport/plyometric activities 4. Benefits of warm up prior to stretching same as static

ROM

-ROM reflects osteokinematics & arthrokinematics -Osteokinematics: movement of long bones or segments & described relative to the plane of motion -Arthrokinematics: movement of joint surfaces (roll, spin, glide) -Mobility: includes osteokinematic motion, arthrokinematic motion, & neuromuscular coordination 1. Hypermobility: excessive laxity or length of tissues 2. Instability: excessive ROM for which there is no muscular control, usually due to injury of passive structures, ligaments 3. Despite hypermobility an indv. may not suffer instability: an indv with an ACL deficient knee may have anterior laxity (hypermobility) without instability 4. Conversely an indv may complain of ankle instability or giving way without measureable laxity (hypermobility) 5. Hypomobility: decreased mobility or restricted motion

Treatment Options Knee

-Re attachment of ruptured ligament on its bony attachment if appropriate -Immobilization & protection early to allow adequate formation of scarring of MCL -Gradual increase in ROM & strengthening

Applied Musculature: Anterior

-Rectus amdominus (RA): flexes the vertebral column & tilts pelvis posteriorly due to attachments 1. Contained in a sheath of aponeurosis which also serves as attachment for other AB muscles 2. RA is active when other AB muscles are active -External obliques (EO): more superficial than internal oblique 1. Acts w/ the contralateral oblique to produce trunk rotation -Internal obliques (IO): effective action resulting in flexion of the upper half of the body

Impingement Goals

-Reduce compression forces on biceps tendon, joint capsule, supraspinatus, subacromial bursa -Restore proper scapulohumeral kinematics -Strengthen: RTC (to reduce superior translation) -Lengthen: posterior capsule -Acromioplasty: surgical procedure to remove bone spurs or protruding acromion to decompress the space under the acromion process

Treatment Considerations

-Rehabilitation is fairly aggressive for ACL reconstruction 1. Generally return to full status at 6 months following reconstruction 2. Early protection in immobilizer 1-2+ weeks 3. Weight bearing as tolerable (emphasis on restoration of normal gait) 4. Restoration of normal patella mobility 5. Restoration of terminal knee extension early 6. Gradual restoration of knee flexion: 90 deg by 1 month & gradually progress to 120 deg by 2 months, avoid aggressive knee flexion early 7. Emphasis on hamstring flexibility & strengthening: hamstring is agonist to ACL, stabilizing the tibia posteriorly 8. Emphasis on hip strength 9. Restoration of quadriceps function: awareness of which positions increase tensile load on ACL a. Avoidance of open chain exercises w/ high loads (leg extensions) -Benefits of closed kinetic chain exercise -Improved neuromuscular control during activities: think of the things that are mechanisms of ACL injury & work to correct poor mechanics during activity

Importance of Cueing

-Use of verbal, visual & tactile cues is critical for the learning effect 1. Simple single commands help avoid confusion: push, pull, hold, relax, go

Power

-Represents the time it takes to do the work, expressed in watts (rate of work production) P=F x d/t -Reciprocal innervation time (RIT) represents the amount of time from termination of agonist contraction to the onset of antagonist contraction 1. Con/Con protocol 2. Delays are represented by U shaped curve rather than a V at the transition phase on the graph

Muscular Strength NSCA

-Reps: less than or equal to 6 -Sets: 2-6 Rest: 2-5 min

Hand Placement

-Resistance is applied in opposite direction of movement -Maintain solid hand position over comfortable landmarks -Distance from fulcrum/joint effects clinician effort relative to patient effort -Resistance hand vs stabilizing hand 1. Sometimes necessary to provide resistance with both hands (seated knee flexion in later stages) -Work with gravity first before working against gravity (use this change in position to make an exercise easier or harder) -Agonist muscle contraction sets before agonist/antagonist reversals

Proliferation Phase

-Resolution, regeneration, repair -Marked by the presence of macrophages -Lasting from 48 hours to 6-8 weeks (as long as 2 months) -Scar formation phase -Fibroblasts: (attracted to area by presence of macrophages), actively resorbing collagen & synthesizing new collagen (type III) -New collagen (small fibrils, disorganized, few cross bridges not linear), more brittle less elastic

Strengthening Techniques

-Rhythmic initiation -Repeated contractions -Reversals of antagonists (slow reversals, slow reversal hold) -Rhythmic stabilization

Adhesive Capsulitis (Frozen Shoulder)

-S/S: stiffness, pain & limited ROM -Dx: in stages 1. Stage 1: 0-3 months a. pn, decrease ROM b. WNL under anesthesia 2. Stage 2: 3-9 months a. Pn, significant decrease in ROM b. Loss of ROM under anesthesia 3. Stage 3: 5-9 months a. Severe decrease in ROM, less pn as previous stages b. Loss of ROM under anesthesia 4. Stage 4: 15-24 months a. less pn, progressive increase in ROM

Specific Adaptation to Imposed Demands

-SAID principle is an extension of Wolffs Law (bone remodels according to stresses placed on it) 1. The type of demand placed on the body (systems) controls the type of adaptation that will occur -Soft tissues remodel according to stresses placed on them -SAID is applied when choosing an exercise or activity throughout the stages of healing, leading to the specific needs of the patient (consider sport & position in sport, work place demands, work hardening)

Step 1: Needs Assessment

-SOAP -Subjective info: pain, when, why, how, etc -Objective info from a complete clinical eval 1. Present joint function: AROM, PROM, goniometric 2. Functional vs structural problem (prevent functional becoming structural

Erector Spinae: combo of 3 muscles: spinalis, longissimus, iliocostalis

-Spinalis & iliocostalis pull the thorax posteriorly or function eccentrically to control descent of trunk during forward bending -Longissimus not as effective in lumbar extension, rather provide a posterior sheer force on lumbar spine -Multifidi 1. Provide lever arm for segmental extension as well as provide stabilization in flexion & rotation by creating a downward force couple 2. Resist flexion during oblique contraction so that rotation can occur

Adhesive Capsulitis

-Stage 3 & 4 1. Goal: increase ROM 2. Therapeutic exercise a. Scap strengthening (force couples) b. RTC strength c. AROM, PROM specific to GH kinetics (SH rhythm) d. Aggressive stretching e. Joint mobs (grade III, IV)

Isometric

-Static form of exercise where muscular contraction occurs without a change (visible) in the length of the muscle -Tension is created in cross bridges which equals the resistance to shortening -No physical work is performed (W=F X D, D=0, therefore W=0) -Energy for physiological work can be high & force production can be high -Has been demonstrated to produce hypertrophy & neural adaptations, although not to the extent that other MA can

Steindler's Original Thesis

-Steindler defined 2 types of kinetic chains (1955) by applying concepts from mechanical engineering to the human body 1. Rigid segments are linked by flexible joints creating a kinetic motion chain 2. Distinguished by loading at the terminal joint a. Open kinetic chain (OKC) end segment is free to move b. Closed kinetic chain (CKC) end segment is met with considerable resistance which restrains free movement

Sources of Low Back Pain

-Strain or sprain 1. Low back pain is one of the largest afflictions in the country a. Substantial cost & time loss from work due to LBP b. Difficult to determine true cause of symptoms if there is no direct mechanism required i. Postural, flexibility, strength, movement mechanics all contribute ii. Sudden or abrupt movement: forceful extension, flexion, &/or rotation w/ an "unprepared trunk" iii. Adding anterior loads while in flexion greatly increase loads on spine iv. Twisting & lateral bending to not load the spine as much as forward flexion v. Changing the position of the upper extremity (raise hand overhead) or the lower extremity (unbent knees) while bending the spine will increase loads c. Consider overall strength, flexibility, & endurance when evaluating & designing rehab programs in all 3 planes of movement d. Training the patient to coordinate movements

Components of Strength

-Strength -Endurance -Power

Thapeutic Exercise

-Systematic & planned performance of bodily movements, postures, or physical activities intended to provide the patient or client with a means to: 1. Remediate or prevent impairments 2. Improve, restore or enhance physical function 3. Prevent or reduce health related risk factors 4. Optimize overall health status, fitness or sense of well being

Manual Contacts

-Tactile stimulation over a specific muscle group tends to stimulate that muscle group to hold more steady against resistance 1. Placing a hand on the quads during knee extension tends to facilitate the contraction due to afferent stimulation 2. facilitate synergists to the movement (resistance hand on the palm for elbow flexion with synergist hand placement on the biceps brachii for shoulder & elbow flexion) 3. Place hands to stimulate appropriate receptors/muscles but also consider where you want your hands to end up a. Hand placement should not impede the smoothness & coordination of the movement patterns

Exercise Prescription to Address the Specific Needs of the Individual

-Used in conjunction with various modalities & manual therapies -Performed in consideration of (type of tissue injured, stage of recovery, needs & goals of the indv.) -Goal to achieve symptom free movement & function

Sports Team Medicine Team

-Team physician (MD is ultimately responsible for the care of the patient, diagnosis & prescription of treatment, surgical intervention) -ATC (daily interaction, adherence to protocol, developing & implementation of program & plan -PT/OT (clinical setting vs athletic training clinic vs living room) -Certified strength & conditioning specialist (CSCS) key role in later stages of recovery, cooperation with ATC, PT -Patient/athlete -Coaches -Sport psychologist

Zero Position

-Technique for recording goniometric measurements by noting where zero is relative to neutral flexion/extension position 1. Shoulder ROM in sagittal plane is 60 degrees flexion & 15 degrees extension it should be recorded: 60/0/15 2. If return from flexion with extension is still short neutral or zero by 10 degrees it should be recorded: 60/10/0

ROM

-The full motion that can occur between two articulating surfaces (bones) Variability due to type of articulation & integrity of the structures associated with the joint (hinge vs ball & socket) -Can be specific joint or a group of joints (shoulder)

Factors Influencing Loads on the Spine During Lifting

-The position of the object relative to the center of motion of the spine -The size, shape, weight, & density of the object -The degree of flexion or rotation of the spine

Balance

-The process of maintaining the COG over the base of support 1. Ability to maintain a particular position (static) 2. Ability to stabilize during voluntary activity 3. Ability to react to perturbations -Requires integration of sensory info from the peripheral nervous system, CNS, & musculoskeletal systems

Kinetic Chain

-The reality of rehab is that human movement is a constant interplay between open & closed kinetic chain conditions -The exercise selection should consider both the positive & negative impact of selecting either OKC & CKC modes of therapeutic exercise -Is the segment you are targeting subject to stability in other links in the chain that need evaluation or consideration

Convex Concave Rule

-The relationship of the moving & stationary surface is based upon whether or not the moving/stationary surface is convex or concave in shape -If the moving segment is convex the roll & glide are in opposition to each other -If the moving segment is concave, the roll & glide are in the same direction

Stretch Stimulus

-The starting position is the place where the muscle group can be put on slight stretch to facilitate muscle spindle (stretch reflex) 1. Dont let the patient initiate the contraction until you have cued with tactile initiation of stretch reflex or verbal command

Scapular Force Couple

-The trapezius muscles & serratus anterior aid scapula elevation during GH motion in the frontal plane 1. Middle & lower trapezius play a very important role in aiding this force couple a. Lower trap should be active after 90 deg. abduction & early onset will interfere w/ scapula motion at the SC joint but beyond 90 very critical role w/ scapula depression b. Middle trap is a complimentary antagonist to the serratus anterior muscle & retracts scapula 2. Dominance of the upper trapezius w/out middle & lower activity will elevate the scapula inappropriately, producing a negative effect on scapula position relative to GH motion 3. Insufficient serratus anterior activation will result in winging of the scapula: medial border of scapula prominently away from the thorax

Proprioceptive Neuromuscular Facilitation (PNF)

-The use of isometric muscle action to facilitate relaxation of a muscle 1. GTO response will facilitate relaxation in the same muscle that is contracted (autogenic inhibition) 2. Reciprocal inhibition will facilitate relaxation in the muscle antagonist to the one contracted 3. Increase in ROM may also be due to changes in viscoelastic properties of the muscle/tendon 4. Three stretching techniques a. Contract relax (muscle limits desired motion) b. Agonist contraction (moves into the limited motion) c. Contract relax agonist contract 5. Benefits of warm up prior to stretching same as static

Implementation of Treatment

-The way we stimulate the muscle is more important than the resistance that is applied 1. Use of smooth, accelerated contraction through stimulation of receptors in a muscle is critical 2. Resistance should not prevent movement through a full ROM

Peak Torque

-Time to peak torque (time rate to torque development TRTD), how quickly the max torque for a contraction is achieved 1. PT usually occurs within the first 1/3 of the slope curve 2. Prolonged TRTD indicates difficulty in generating torque at the onset of contraction

Sensory Systems

-To maintain an upright posture, 3 sensory systems are utilized -Visual: measures orientation the eyes &head in relationship to surrounding objects 1. Movement of the head & neck relative to surroundings as well as info about the movement of the surroundings

Torque

-Torque=force X shortest distance between forces (which will always be the perpendicular distance) -The perpendicular difference between forces that produce a torque, or moment of force, is known as the moment arm -Torque=Force X Moment Arm

Volume

-Total amount of work over a given period of time (quantity) -Single set, session, week, month, year, quadrennial -Product of the # of repetitions & # sets & load

Applied Musculature: Anterior

-Transvers abdominis (TVA): flattens the abdominal wall & compresses abdominal viscera 1. Attaches to thoracolumbar fascia so contraction contributes to stabilization of lumbar spine a. TVA is the 1st abdominal muscle recruited for postural stabilization of upper & lower extremity when standing erect in indv. without low back pain b. Suggested that delayed onset of TVA may play a role in low back dysfunction

Disk herniation

-True herniation indicates there is a rupture of the nucleus pulposus, resulting in protrusion of all or part of the structure 1. Herniation is used universally for discogenic pain 2. Type sof disk herniation protrusion, prolapse, extrusion, squestriation

Internal Forces

-Typically think muscle but can be other tissues such as ligament, bone -Muscle forces initiates movement, other functions than just initiation?

Ability vs. Disability

-Understanding the complex interactions of health conditions & functional impairments (basic things, ROM, limit activity), activity limitations (washing hair b/c of limited functional ability), participation restrictions (limit what they can do with organized groups of people (social activities, sports)

Immobilization

-Used in some cases (pars interarticularis injuries, spondy, but no strong evidence that this improves healing) -Try to maintain mobility so that limitations in flexibility are not developed -Sleeves & back braces increase warmth & comfort but dont stabilize

Agonist Contraction

-Uses the principles of reciprocal inhibition -Take the limb to the position of a gentle stretch -Ask the patient to contract the muscle opposite the one being stretched -Hold the contraction 2-5 seconds -Repeat 2-4 times -Not worried about it being weak

Muscle Relaxants

-Usually CNS depressants which effect not only the injury site the whole person 1. Possible addiction

Static Stretching Cont.

-Variation: initial position 2 second hold, breath, new position 2 second, repeat 10-15 times. Rest & repeat cycle -Benefits of warm up prior to stretching (regardless of type) 1. Increased muscle temperature 2. Reduced viscosity of the tissues 3. Decreased muscular tension 4. Increased muscular elasticity -Detriments to performance following stretching (decrease in muscle power) -Does static stretching before activity reduce incidence of injury -Stretch once exercise more, risk of injury is probably the same -Consistent stretching will probably reduce the risk of future injury -Good in long duration but may be problematic in short duration for muscle activation & increased ROM -Stretch after then

Athletic Lumbar Rehabilitation

-Volume 1. Low: 2-5 sets of 5 reps 2. Moderate: 3 sets of 5-10 reps 3. High: 3 sets of 12-20 reps 4. Maintenance: 3 sets of 8-12 reps -Progressions 1. Flexibility followed by strength 2. 3 planes: flexion, extension, rotation 3. Supine, prone, seated, standing -Order & prioritization of exercises 1. Flexion flexibility 2. Flexion strength 3. Extension flexibility 4. Extension strength 5. rotation flexibility 6. Rotation strength

Volume & Intensity

-Volume & intensity are inversely proportional to each other -Curvilinear relationship rather than linear

Volume & Intensity Cont.

-Volume typically higher at the beginning 1. Using multiple exercises, improves connective tissue strength: ligaments, tendons in preparation for high loads of training in later stages 2. As the emphasis changes to more skill related drills in rehab the volume of strengthening exercises can decease -Avoid abrupt changes in volume & intensity

Active Resisted (ARROM)

-Voluntary muscle contraction is met with external resistance -Achieved by: another person (manual contact), thera tubing/thera band, dumbbells, machine (isotonic or isokinetic) Uses: strength assessment of a single muscle or a group of muscles (manual muscle testing, isokinetic testing), assessing status & progress -Improved muscular strength, endurance 1. Manual resistance exercise 2. Proprioceptive Neuromuscular Facilitation Techniques

Models of Function & Disability

-WHO's & Nagi's Model ICIDH: international classification of impairments, disabilities, & handicaps -Replaced with the current ICF (international classification of functioning, disability, & health

Ability vs. Disability

-WHO's biopsychosocial model of function & disability -Not strictly medical, psychological, social (includes all of these things)

Using These Models to Implement Therapeutic Exercise

-We must view our patients/clients in a comprehensive way -What is the interaction between health condition & well being & quality of life? Linked but not linked for all people (amputations, CVD), they can still have a great quality of life

Role of Strengthening Gluteals

-Weak gluteals often substituted w/ hamstring dominance -Hamstrings cannot as adequately stabilize the pelvis 1. Often seen in long distance runners 2. Lead to hip & low back pain

Muscular Endurance Cont.

-What are long term goal needs of your patient -Strength endurance: ability to repeatedly perform high load contractions (7-12 rep range) -Specific endurance: how many reps of the type of strength are required in the task/competition (a rower needs specific endurance to be able to produce near maximal force for 1500m)

Needs Assessment Cont.

-What is the present function of the injured area? establishing baseline data/status -Presence of active inflammation & swelling (decreased passive & active ROM) -Pain: source, type, intensity -ROM: goniometric measurements -Related spasm/muscle guarding -Girth measurements: knee 3, 6, 9 inches proximal & distal as well as mid joint (atrophy or swelling) -Ambulatory or non ambulatory status (functional movement assessment: gait)

Modes of Aerobic Exercise

-What should we consider when choosing the mode 1. Walking 2. Jogging 3. cycling 4. Pool/swimming 5. UBE

Joint Mobilization

-When ligament or capsule resistance is encountered -Performed at any point in the ROM -Decreases pain with increased ROM (self check) -Employs short lever techniques

Stretching

-When muscular resistance is encountered due to shortness (tightness) -Effective towards end ranges of motion -Increases in pain in muscles with increased ROM -Employs long lever techniques

Strength vs Endurance

-Which is more important for your patient -Do they engage in repetitive activity that necessitates endurance or do they need an emphasis on pure strength or both? 1. Is external resistance necessary when strengthening the abdominals or extensors

Flexion Bias or Extension Bias

-Which position is the most comfortable for the patient to decrease symptoms (centralization concept) 1. Utilize this bias initially during acute phase to make the person more comfortable

Potential Causes of ACL Injury

-Why injury rates for females are 2-8x higher compared to males across similar sport/activity 1. Biomechanical: knee valgus, increased Q angle, pronated foot, reduced knee flexion during landings & cutting maneuvers 2. Anatomical: decreased width of intracondylar notch 3. Neuromuscular (motor control): quadriceps dominant control of knee, poor technique during activity (skill practice?), poor LPHC stability 4. Hormonal?

Joint Loading

-Will be greater when a longer lever arm is used, early protection can be enhanced through use of a shorter LA -Treating ROM can be limited to accommodate for healing stages 1. Can perform shoulder IR/ER at 0 degrees, abduction in early stages & then progress to 90 degrees shoulder abduction

Impairment

Any loss or abnormality of psychology, physiologic, or anatomic structure or function: loss of ROM, decreased strength, lack of sensation

Joint Mobilizations

Appropriate when there is hypomobility in segments that may be increasing the stress on other segments (A/P mobilizations on L1/L2/L3 if L4 & L5 are extremely tender)

Most force is a high velocity eccentric contraction

High velocity low force can be concentric

Coordination

The ability to perform smooth, accurate, & controlled movements

Degenerative Cascade

There is a normal degeneration of the spine due to loads placed on it. An athlete may accelerate this process due to intense activity & training