ACT 1 - Physio Flashcards
what is the foundation of exercise prescription?
What is the first step on clinical reasoning?
Subjective and Objective Ax
- Identify any pertinent red or yellow flags and individual safety concerns Consider the mechanism of injury
- Build rapport
- Exercise history
- Establish patient goals
- Identify impairments, Ax guide management/assess and re-assess
What is the second step of clinical reasoning?
STEP 2: Patient education and detailed planning of rehabilitation with periodisation methods (criteria are driven)
- Educationonpathology, prognosis, plan
- Adviceregardingsafeactivities
- Injuryspecificoutcomemeasures/milestones,
- Post-operativeorders
- Goalsetting: always align with patient goals (SMART)
- Collaborative process-Empower athlete/patient
Progression of rehab
Evidence and reasoning behind rehab
- management of many pain syndromes
- treatment of pain from tissue and psychological levels
- Mechanotransduction: the conversion of mechanical loads into cellular responses, and hence the structural change
- Adaptation response to exercise builds capacity which helps patient’s ability to perform task
Why do I prescribe exercise therapy?
- Prevent obesity and mitigate its risks
- Reduce development and improve management of diabetes
- Prevent and treat heart disease
- Treatment of hypertension
- Prevent osteoporosis and fractures
- Manage depression and anxiety
- Reduce risk of dementia and slow decline in cognitive impairment (Broadhouse et al., 2020)
- Manage frailty: Benefits of resistance training in physically frail elderly
- Recreational use
- Reduce risk of premature death
Components of a rehab program
Cardiovascular exercise
Any type of exercise, typically performed at moderate levels of intensity, for extended periods of time, that maintains an increased heart rate
- walking
- running
- swimming
- cycling
Muscle activation
Get the muscle working
Injury can inhibit muscle activation through:
- Pain
- Swelling
- Nerve injury
- Prolonged disuse
Muscle re-education
Get muscles working right
- Abnormal motor patterns may contribute to or be the cause of presenting injury
1. Palpate the muscle (patient and therapist)
2. Clear instruction (including demonstrations) and verbal cues
3. Verbal, visual (e.g. mirror), auditory and tactile feedback
4. Biofeedback
5. Muscle stimulation
Endurance exercise
Ability of muscle to perform repeated or sustained contractions (resist muscular fatigue), particularly when using sub-maximal resistance
- Targeted at muscle groups that are required to work at low-intensity for long periods
- Nearly all exercise programs will include endurance
- Level aligned to functional activity requirements
Hypertrophy
Increase in muscle size (CSA)
- After disuse or pain inhibited atrophy
- An important adaptation of resistance training because increase in muscle fibre size is important in improving force production
- High volume > low volume
- Working to failure (high volume) important if low load
- Balance is key when dealing with compromised tissue
- Isolated exercises often necessary early
- Periodization is key
Training load recomendation
Strength
Maximal amount of force exerted in a single attempt or Maximal force that muscle/muscle group can generate at a specified velocity
- Novice individuals = loads of 60-70%of1RMfor8-12repetition, Frequency 2 - 3 times per week, Volume 2 - 6 sets
- Experienced individuals = loads of 80-100%of1RMfor1-6repetitionsin a periodised manner, 3 - 4 times per week, Volume 2 - 6 sets
Power
Explosive power
- Ballistic (explosive) exercises: enable acceleration throughout the full range of motion
- Plyometric exercises: that involve the activation of the stretch-shortening cycle of movement and incorporate an eccentric component that is followed by a fast concentric component
- Light to moderate loading (30-60% of 1 RM) performed at an explosive velocity”
- Long rest periods
- Often restricted to late-stage rehab
3 types of muscle action
Isometric
- Muscle force generated without movement/change in length of muscle
Isotonic
- Concentric- Muscle gets shorter during active contraction. Total tension developed is sufficient to overcome an applied resistance
- Eccentric- Muscle gets longer during active contraction - More muscle tension developed
Isokinetic
- Muscle contracts while the joint moves at a constant speed throughout the range of motion
Mobilisation
Increase joint and soft tissue ROM and reduce resistance to movement
Used when:
- Deficit in ROM
- Excessive resistance to movement observed
Stretching
Increase soft tissue length and compliance
- • Tight/shortened muscles are observed
- • Warm up and cool down
- Static stretch
- stretch passively and held 15-30s, 2-4 repetitions
- Dynamic Stretching
- Involves continually moving a body apart through ROM Performed for 15-60s, or 10-20 repetitions
- Pre-contraction stretching:
- A passive stretch of the muscle, followed by isometric contraction of the muscle held 3-10s and repeated 3-7 times
Proprioception
Proprioception (position sense) is the body’s sense of position and movement, particularly limbs, which assists in the maintenance of balance and coordination
used on joint injury
Functional / sport specific
Ensure individual has met physical demands required to perform at the required functional level
How can exercise be overload
- • Increase weight (strength)
- • Increase time (endurance)
- • Increase speed (power)
Manipulation of:
- • Reps
- • Sets
- • Weight
- • Type of muscle action
- • Speed of muscle action
How to do a progresion
Change in
- Number of repetitions and sets
- Time between sets (recovery)
- Time between exercise sessions (recovery)
- Type of exercise being used (concentric / eccentric / isometric)
- Size and type of resistance being used
- Speed of exercises
- Angle of exercise
Training load recommendation summary
Gait analysis global observation
Class, age, body composition, psychology , happy, sad. have you noticed this?
Looking at the whole body.
Can you pick up a limp, a gallop , a short step, a hiked shoulder, a stiff/restricted section, ‘broken bum syndrome’ (acute low back), waddling.
Gait analysis segmental observation
Start from the feet (watch one side then the other)
- foot strike position, heel strike , toe walker , foot drop (neurological), foot position(toe in/out), over pronation, over supination
- Knees: varus , valgus , flexion/ extension
- Hip/low back: hike, drop, rotation
- Spine: Acute pain (broken bum ), rotations , Side bending
- Shoulders: Hitched
- Arm swing: Stiff arms, arms by side
Phases of gait
Capacity test for muscular endurance
- Single leg bridge (Freckleton, Cook, Pizzari, 2014) -60cm box, 20 deg Knee fl, arms crossed. 60bpm
- Single leg squat (Culvenor et al., 2016; Kemp et al., 2016) -Knee to 90 deg fl. 60bpm.
- Single leg calf raise (Mayes, 2019) -Slow, controlled vertical motion. 60bpm -Ankle alignment 2nd toe to middle of ankle -No clawing
- Hop test:
- SLhopfordistance 2. Triplehop
- Triplecrossover
How to teach a new exercise
- Name the exercise.
- Demonstrate the exercise (no verbal data)
- Identify 2-3 key aspects associated with the successful performance.
- Demonstrate the exercise again, concentrating on the 2-3 successful points.
- Individual practices and concentrates on the 2-3 aspects with minimal feedback from the clinician.
Define Periodisation?
A significant challenge for rehabilitation specialists is designing optimal training programs that facilitate neural and musculotendon adaptations whilst been mindful of biological healing constrains, and safety
What are the goals of periodisation?
Maximise training adaptations
Prevent overtraining
What is the linear periodisation?
Systematic & Predictable
- Macrocycle- 12 months
- Mesocycle- 3-4 months
- Microcycle- 1-4 weeks
What is non linear (undulating) periodisation
- volume and load altered more frequently
- More frequent changes in stimuli
- Better neuromuscular adaptations?
- Accounts for need for modifications
- Several training parameters addressed at same time Appropriateness? Power
Stages for healing
Stages of rehab
Periodisation on injury recovery based on affected tissue
What is a primary injury prevention?
Universal interventions - prevention prior to illness or injury
What is the secondary injury prevention
Diagnosis and prevention of disability
What is tertiary injury prevention?
Rehab to reduce existing injury or disability
what is the conceptual approach to injury prevention?
What are the targeted prevention programs?
Netball knee program
Smart rugby
AFL
they reduce 67% of non contact ACL injuries
Load Management
- Understand the demands of the occupation/sport/hobby
- Different tissues react to loads differently
- Establish a moderate chronic load
- Minimise large week-to-week fluctuations
- Establish ceiling and floor of safety
somatic referred pain definition
Dull, aching, gnawing and difficult to localize pain, with an inconsistent and non-dermatomal pattern Convergence of nociceptive afferents on second order neurons in the spinal cord
Radicular pain definition
Originates from irritation of the nerve root or dorsal root ganglion and surrounding meninges
Pain sharp, shooting, burning, transient, trace with finger
Radiculopathy definition
Often have both somatic referred and radicular pain
Nerve root and DRG affected in a way that changes motor and sensory nerve conduction
Loss of muscle power, skin sensation, deep sensation & proprioception associated with neural transmission through specific nerves/levels
Can have associated bladder and bowel changes (Needs immediate Medical Assessment)
Pathoanathomical summary of LBP
Whats th first line treatment for LBP - EBM
How to treat acute LBP
locate movement dysfunction
change dysfunction
treat with exercise
Lumbar flexion pain pattern proposed rehab
- • Mobility: usually extension direction preference
-
Motor control strategies
- Hinge patterns: Learn to use hip-initiate forward bend
- Lunge patterns/Squat reintegration • Work capacity- Lx extensor series
- • Strength- Hip extension exercises
- • General exercise walking, swimming
Lumbar extension pain pattern
- Mobility: Quadruped rocking, Lx flexion > rotation
- Motor control: Posterior pelvic tilt- UNLOADS Hip hinge patterning- Hip ext > Lx ext
- Work capacity- Front plank & side plank series
-
Strength- Lower abdominal strength Hip extensor strength
- Bridging progressions- Hip ext>Lx ext Compound movements RDL
- General - bike
