Ther-Ex Final
What would be a typical patient response to stretching the wrist palm down hanging off the table?
"I feel a slight pulling in my wrist and forearm"
A maximum ______ (a) contraction produces less force compared to a maximum _____ (b) contraction under the same conditions.
(a) concentric (b) eccentric
For untrained individuals participating in resistance training exercise, what is the recommended starting point for time under tension?
1-2 seconds
Neurodynamic Testing/Exercises Contraindications
1. Acute or unstable neuro signs 2. Cauda equina symptoms; B/B, perineal sensation 3. Spinal cord injury 4. Neoplasm or infection
What was listed as a contraindication to neurodynamic exercises?
1. Acute or unstable neuro signs 2. Cauda equina symptoms; B/B, perineal sensation 3. Spinal cord injury 4. Neoplasm or infection
Neurodynamic Testing/Exercises Precautions
1. Be aware of other tissues/positions 2. Assess tissue irritability 3. Gradual progression 4. Cation with active disease or other pathology 5. Vascular compromise due to close proximity to nervous system
Contraindications to Stretching
1. Bony block limits motion 2. Recent fracture/incomplete healing 3. Acute inflammatory or infectious process 4. Sharp, acute pain (not normal response) 5. Hematoma or extensive tissue trauma 6. Joint hypermobility 7. Shortened soft tissues beneficial for the patient's situation in terms of providing stability to a joint
Precautions for stretching?
1. Don't force the stretch 2. Concerns for bone mineral density (ex. osteoporosis) 3. Lever arms - torque at a joint - a longer lever arm will create greater torque which will influence the force of the application in the tensile load through the target tissue 4. Prior immobilization - use cation because they lose their tensile strength after prolonged immobilization 5. Progression and muscle soreness - pain more than 24 hrs - adjust dosage; too much force or stretch being applied
What are guidelines for teaching self-assisted ROM?
1. Educate - on value of motion or exercise being prescribed 2. Teach correct alignment and stabilization 3. Observe performance and correct as necessary 4. Ensure safe and effective use of equipment 5. Provide specific guidelines/drawings for exercise + dosing - teach back technique to ensure understanding 6. Follow up visit - review exercises
Neurodynamic Tests
1. Every joints in the chain needs to be examined separately 2. Additional tests for nerve function 3. Test v. treatment positions 4. Test uninvolved side first 5. Active before passive - sense of level of irritability and willingness to move in those positions *Nerve palpation, sensation testing, reflex testing, dexterity testing, muscle testing
Signs and symptoms of impaired nerve mobility
1. History - pain is the most common symptom - monitor mobility. Pts may complain of stretch pain or paresthesias such as numbness and tingling when the tissues are in a neural stretch position 2. Neurodynamic tests - clinical tests used to detect tension or compression in the neural tissue *Both vascular and mechanical factors can contribute to nerve pathology
What are the main highlights of a resistance training program design?
1. Minimum 1 set, 8-12 reps for strengthening 2. Frequency: at least 2 days/week 3. Order: Larger, multi-joint exercises first 4. Progression: 2 for 2 Rule 5. Intensity: Borg CR-10 Scale
What are resistance training program design elements?
1. Needs analysis 2. Exercise selection 3. Training frequency 4. Exercise order 5. Training load and repetitions 6. Volume 7. Rest Period
For neurodynamic tests, what are the 4 requirements to be considered a positive test?
1. Reproduce pt's symptoms 2. Side-side differences 3. Support exam findings 4. Sensitizing maneuvers differentiate symptoms
For a (+) neurodynamic test
1. reproduce patient's symptoms (within that nerve distribution) 2. Side-side differences 3. Support exam findings 4. Sensitizing maneuvers differentiate symptoms (whether there is a nerve mobility issue)
The physiological overflow of isometrics is minimal, where it occurs no more than ______ degrees in either direction from the angle in which exercise is performed.
10
A patient expresses they would like to train for muscle endurance, but are unsure of which training parameters to use. Which of the following would be most appropriate to help the patient reach their goal? 5 reps (85% 1 RM) X 3 sets, 2 min of rest 8 reps (70% 1 RM) X 3 sets, 30 sec of rest 10 reps (65% 1 RM) X 3 sets, 20 sec of rest 2 reps (75% 1 RM) X 3 sets, 3 min of rest
10 reps (65% 1 RM) x 3 sets, 20 sec of rest
You are using the DeLorme technique for prescribing muscle strengthening. You determined your patient has a 10 RM of 200 lbs for a squat exercise. How much resistance should be applied for the 1st set (same session)?
100 lbs
What is a typical PRE (progressive resistance exercise) program?
2-3 sets 6-12 reps 6-12 RM
For repetitions in reserve-based training, which rating would correspond with a description of perceived exertion of "3 repetitions remaining" ?
7
Which training load may be most appropriate for someone who is advanced/experienced when it comes to muscle-strengthening? 55% 1 RM 65% 1 RM 75% 1 RM 85% 1 RM
85% 1 RM
Strength Training
A systematic process that uses muscle force to raise, lower, or control heavy external loads for relatively low # of reps over a short period of time
Which of the following is generally a contraindication to stretching? Osteoarthritis Limited joint mobility Soft tissue extensibility concerns Acute inflammatory or infection process
Acute inflammatory or infection process
Does stretching enhance performance?
Acute static stretching either has no effect or decreases muscle performance in terms of strength, power, or endurance immediately following the stretching session Some dynamic warm up programs can lead to enhanced performance
Contracture
Adaptive shortening of the muscle tendon unit or other soft tissues that cross around the joint that contribute to significant resistance of passive or active stretching which limits ROM
Proprioceptive Neuromuscular Facilitation (PNF) Stretching
Aims to gain greater reflective muscle relaxation as a result of autogenic or reciprocal inhibition spinal processing of proprioceptive information 1. Hold-relax or contract-relax 2. Agonist contraction 3. Hold-relax with agonist contraction
Stretching
Any therapeutic intervention that increases the mobility of restricted soft tissues
Nerve is able to move without adverse stress due to:
Arrangement of the nervous system (spinal cord, nerve roots, and plexus - the movement is dissipated throughout the system and neural ischemia is avoided) Connective tissues (helps to absorb tensile forces) Perineurium (primary guard against excessive tension and allows for 18-22% strain before failure, due to its elastic properties and strength)
Elastic Range
Change in stress results in a proportional change in strain
What is a sensitizing maneuver for the median nerve and where should you feel the symptoms?
Contralateral cervical side flexion - changes the amount of stress placed through the nervous system; distal wrist
Hypomobility
Decreased mobility or restricted motion at a single joint or series of joints
Does stretching prevent injuries?
Depends on what type of stretching. Dynamic warm up is shown to be effective in reducing LE injuries. Static stretching does not prevent or reduce injury risk
Oxford Regimen
Determination of 10 RM 10 reps @ 100 of 10 RM 10 reps @ 75% of 10 RM 10 reps @ 50% of 10 RM
DeLorme Regimen
Determination of 10 RM 10 reps @ 50% of 10 RM 10 reps @ 75% of 10 RM 10 reps @ 100% of 10 RM
Stretch Intensity
Determined by the tensile load applied on the soft tissue
Limitations for AROM and AAROM exercises
Does not maintain or increase strength It does not develop skills or coordination except in that motor pattern that's used
Indications for PROM exercises
During acute, inflamed tissue after injury or surgery; When active ROM can be detrimental to the healing process When a pt is unable to actively move a segment such as when the pt experiences paralysis or is restricted to complete bed rest
On the stress-strain curve, what describes the endpoint of linear region?
Elastic limit
What neurodynamic test stresses the median nerve?
External rotation, abduction, elbow extension, wrist extension and forearm supination
Active range of motion is typically sufficient to maintain or increase strength? T or F
False
Stretching Stabilization
Fixation of a body segment that is an attachment muscle that's being stretched
Which structures are primarily being stretched with pt seated with wrist hanging off a table and therapist applying force through the palm back toward the arm?
Forearm flexors
What does FITTSBALL stand for?
Frequency Intensity Time Type Stage Beliefs Ability Limitations Life Satisfaction
Principles of neural mobilization treatment
Goal - neurodynamic exercise is to maximize the excursion of that nerve while minimizing the strain Intensity is dependent on irritability of the tissue, the pt's response, and the change in symptoms Technique/application of neurodynamic mobilization is performed relatively symptom free in a slow rhythmic and oscillatory motion so the therapist nudges the stretch and then backs off *not a static prolonged hold like in static stretching Link what you find from the neurodynamic testing to the neurodynamic treatment
Stress-Relaxation
If a subfailure load is applied to a viscoelastic tissue, and kept constant, there's a gradual decrease in the force required to maintain the amount of deformation. This is due to the viscoelastic nature of the connective tissue and redistribution of water content within the tissue
What are benefits to stretching exercises?
Increased flexibility and ROM - increased muscle tendon unit extensibility in order to improve flexibility and ROM Biomechanical and neural changes in the contractile and non-contractile elements of the muscle tendon unit and surrounding fascia.
Elastic
It returns to its pre stretch resting length directly after a short duration stretch force is removed
Which would be a logical regression (less challenging) for a closed kinetic chain exercise? Eyes open to closed Large to smaller excursion of limb movement Stable to unstable surface Bilateral to unilateral bas of support
Large to smaller excursion of limb movement
Exercise Prescription for Strength Training
Novice - Intermediate 60-70% 1 RM Advanced - Experienced >80% 1 RM Increased load will more effectively increase strength 8-12 Reps; 1-3 sets (3 sets are most effective) Rest in between sets: 2-3 min; 2-10 sec rest b/w sets may allow increased loads Velocity (slow-mod): untrained individuals start at 1-2 sec; increased tension time may increase strength gains
Creep
Occurs through gradually increasing external load and then is sustained. Then the tissue will continue to slowly elongate during the maintained stretch. The amount of tissue deformation depends on the amount of force and the rate at which its applied; low load, long duration stretching improve mobility
Which method of resistance training exercise progression is described by decreasing the amount of resistance over three sets?
Oxford
Neurodynamic Test: Screening (active test)
PT describes a specific position and demonstrates the position for the pt. to attain. Allows PT to assess pt's willingness to move into those positions and whether or not it brings on any symptoms
Neurodynamic Test: Passive Test
PT intentionally positions the joints in a sequential manner to gradually place stress through the nervous system. Allows for differentiation in trying to determine whether or not the nervous system is involved with the issue
Which structures are primarily being stretched when the pt is seated on the plinth with leg stretched out and therapist applies an A-P force through the distal femur and proximal tibia?
Posterior joint capsule, knee flexors
Which is NOT characteristic of isometric exercise? Quantifies strength performance Minimizes muscle atrophy Develops postural or joint stability Develops ROM-specific strength
Quantifies strength performance
Which structures are primarily being stretch when lying supine with a cane with the right elbow on a pillow and left arm slightly off the table; using the cane for ROM pushing it into the right hand
R shoulder internal rotators
Stretch Mode
ROM in that it can be manually applied or can be a self-stretching program
Precautions/Contraindications to ROM exercises
ROM should not be done when motion is disruptive to the healing process 1. early benefits and recovery 2. watch for increased pain and inflammation 3. life threatening conditions 4. PROM to major joints and AROM to ankles and feet to minimize venous stasis and thrombus formation 5. ROM considerations for medically complex patients
Cyclic loading and connective tissue fatigue
Result of repetitive loading within a short time duration which increases heat production any may causes failure at levels lower than what's needed from a single load ex. stress fractures and overuse syndromes
Which structures are primarily being stretched when pt is supine and therapist is stretching arm laterally toward the head?
Shoulder adductors
Neural sliders vs tensioners
Sliders: less aggressive as the aim is to essentially slide the nerve back and forth within its container Increases tension proximally while decreasing tension distally Tensioners: greater intensity and the greatest amount of stress
Stretch Speed
Slowly applied stretch - reduces muscle activation and reduces risk of injury to tissues and post stretch muscle soreness
Plastic Range
Strain goes beyond the elastic limit and causes permanent tissue deformation
You want to perform PROM to improve R hip flexion. The patient recently fell resulting in painful abrasions on their L side. Which would be the most optimal position to perform this exercise, keeping in mind the aim of minimal muscle activation?
Supine
You provide the door stretch exercise to progress shoulder ROM. The pt arrives at the next visit with increased pain and a 10 degree reduction in shoulder ER AROM. Which would be a logical exercise to attempt today? Supine shoulder AAROM for ER Prone shoulder overhead ER with dumbbells Standing shoulder overhead ER with cable resistance Standing shoulder overhead ER with band resistance
Supine shoulder AAROM for ER
Plasticity
Tendency of a soft tissue to take a new and greater length after a stretch force is removed
As the patient goes from standing to rising onto the ball of their foot, which of the following is accurate? The gastroc-soleus is contracting eccentrically The gasroc-soleus is contracting isometrically The anterior tibialis is contracting concentrically The gastroc-soleus is contracting concentrically
The gastroc-soleus is contracting concentrically
Neural Tension
The intensity of a stretch and its influence on blood flow may depend on several factors such as the body region, rate of stretch and population being studied; we want to avoid excessive stretching or stresses to the nerve Sites of vulnerability are subjective to increased pressure or tension
Overload principle
The intensity of resistance exercises, how much external resistance is imposed on a muscle, and progressive overload is required in order to see specific adaptations; Manipulate factors such as intensity or volume of an exercise program
Median Nerve Upper Lumb Neuro Test Position 1 (passive test)
The nerve is slowly and carefully elongated across each joint in succession until there is a symptom provocation or slight tissue restriction is appreciated - note final testing position It is sensitized by moving one of the joints out of the elongated position Goal is to determine if nervous system component is contributing to the pt. chief complaint
Stretch Duration/Frequency
The period of time a stretch force is applied and how often
DAPRE Technique
The suggested working weight is based on the maximum number of repetitions using the working weight and set #3 to determine the working weight for the next exercise session: 1 set; 10 reps; 50% 6 RM 2 sets; 6 reps; 75% 6 RM 3 sets; max possible; 100% 6 RM 4 sets; max possible; 100% adjusted working weight
Which statement is accurate regarding neurodynamic testing? The uninvolved limb is tested first Neurodynamic tests are the only tests used to assess nerve function Passive test is applied prior to the active test The test and treatment positions are typically quite different
The uninvolved limb is tested first
Viscoelasticity
Time dependent property of soft tissue that initially resists deformation, such as change in length, of the tissue when a stretch force is first applied
Stress-Strain Curve Failure
Tissue ruptures and loses its integrity here at the end of the stress stain curve
Eccentric contractions consume less oxygen and energy stores versus concentric exercise: T or F
True
Limitations to PROM exercises
True PROM can be difficult to obtain if pt is guarding PROM does not prevent muscle atrophy or work to increase strength or endurance as compared to active or voluntary muscle contraction
Active-assistive ROM (AAROM)
Type of AROM where assistance is provided mechanically through an external force because the muscles need a little bit of help to complete the motion
Rate Dependence
When a load is applied rapidly, the slope of the stress strain curve will be much steeper vs. if its were applied slowly. The tissue will become stiffer when the load is applied at a higher rate
Stress-Stain Curve
When a tensile load is applied to a certain structure, it produces elongation. The stress-strain curve shows the strength properties stiffness and amount of energy the material can store before failure of that structure. Strength is the force per unit area of load. Strain is the amount of deformation or lengthening that occurs when an external load such as a stretch force is applied to a structure
When is self-assisted ROM typically indicated?
When aiming to protect the healing tissues after surgery or traumatic injury
2 for 2 rule
When someone can perform 2 extra repetitions on their last set for two consecutive sessions
Muscle endurance
ability of the muscles t contract repeatedly against an external load generating sustained tension and resist fatigue over an extended duration
Which is proposed to be a better choice for promoting improved balance? closed kinetic chain exercise open kinetic chain exercise
closed kinetic chain exercise
Muscle strength
degree that the contractile properties of the muscle can produce force
Tissue creep occurs through
gradually increasing load to encourage slow elongation of tissues
What is a common guidelines when all reps and sets can be easily completed?
increase by 5-10%
SAID principle
notion that in order to improve a specific muscle performance component, the resistance program needs to match elements of that construct. So specificity of training or exercise suggests that the adaptive effects of training are highly specific to the training method employed
Periodization
organization and planning of a training intervention so the program is sectioned off into specific time periods. Periodization begins w/ determining the training target or goal and then the program plan is broken down into macrocycles, mesocycles, and microcycles
Stretching Alignment
positioning of a limb or body segment so that the stretch force is directed to that appropriate muscle group
Goals for AROM and AAROM exercises
provides other physiological benefits from muscle contraction when it comes to motor learning from volitional muscle action Works to maintain physiological elasticity and contractility of muscles Provides sensory feedback and stimuli for bone and joint tissue integrity Works to increase circulation and thrombus formation Helps to develop coordination and motor skills for functional activities
Indications for AROM and AAROM exercises
pt is actually able to contract the muscles and move segment with or without assistance
If applying a stretch on the right wrist passively to the elbow (therapist applied stretch), where would the point of contact be located to ensure effective manual stabilization?
right humerus
What would be an appropriate exercise if strength impairments are detected during a prone hamstring MMT?
seated knee flexor strengthening against theraband resistance
Macrocycle
several months to a year
Mesocycle
several weeks to months (2-6 weeks is most typical)
Goals for PROM exercises
to assist with circulation and synovial movement of joints for cartilage nutrition to help reduce pain and assist with healing process
Microcycle
training days and sessions
Muscle power
work produced per muscle unit of time