Exam 1 Flashcards
Active vs. Passive Warm Up (which is better?)
Active- muscles are active
Passive- muscles are not active
Active is better for performance = increase to same level of temperature for activity
Physiologic Reasons for Warm Ups
Increase Body Temp: -O2 dissociates from hemoglobin -vasodilation -Q10 enzymatic reaction effect -increase muscle contraction speed -decrease muscle relaxation time -extensibility of connective tissue -nerve conduction velocity -muscle thixotropy (time dependent viscosity) -actin myosin bonds -
Warm Up Recommendations (Parts of Warm Up)
Aerobic/Callisthenic –> Stretching –> Activity Specific
- gradual
- not too intense
- general –> specific
- sweat
- increase HR
Consequences of Immobility
- Joint contractures
- Muscle atrophy
- Thrombus formation
Passive ROM (Define, Indications, Goal, Limitations)
Define: segment moved by device or therapist, no active contraction, through pain free ROM without tissue resistance
Indications: acute inflammation, inability or contraindication to move
Goal: decrease complications of immobilization
Limitations: no change in muscle size/strength/endurance, limited improvement in circulation
Active ROM (Define, Indications, Goals)
Define: patient performs motion, provide assistance if needed to control movement/weakness/beginning & end range, move within pain free ROM, helping assist initiation or change of direction & keepings smooth motion
Indications: able to move, early strengthening, movement above and below immobilization
Goals: decrease consequences of immobility, maintain elasticity of structures, sensory feedback, maintain bone/joint integrity, prevent thrombus, coordination, motor skills
Active Assisted ROM (Define, Indications)
Define: patient performs movement but assistance is provided throughout by pulley/T bar/therapist, move through pain free ROM
Indications: able to move but not attaining full range, same as AROM
PROM, AROM, and AAROM Limitation
does not improve strength!!!
ROM Application & Preparation
- Free up work area, Drape & position patient, Position yourself, Remember gravity
- Control mov’t (support jt and areas of poor structural integrity), MOVE THROUGH PAIN FREE RANGE TO POINT OF RESISTANCE, smooth and slow, patterns best meet patient goals, 5-10 reps based on goals
Define: functional ROM, functional mobility, hypomobility, flexibility, goal of strethcing
- functional ROM: comfortable ROM needed to perform an ADL
- functional mobility: incorporates NS and motor control needed to perform ADL
- hypomobility: restricted ROM due to immobilization, sedentary, postural alignment, muscle weakness, inflammation, deformity
- flexibility: ability to move a single joint or series of joints smoothly & easily through an unrestricted, pain free ROM
- goal of stretching: improve extensibility of contractile & noncontractile components of muscle-tendon units and periarticular structures
Types of Contractures
- myostatic- shortened/tight musculature, no specific pathology
- pseudomyostatic- hypertonicity, muscle spasm, NM inhibition
- arthrogenic (in jt) and periarticular (around jt)- cartilage damage, osteophyte formation
- fibrotic- scar tissue, adhesive capsulitis, heterotopic ossification
Hypomobility
- decreased extensibility of CT (not contractile elements)
- stretch induced gains in ROM: neural changes first and biomechanical changes, increased extensibility & length, decreased stiffness, not changing length of sarcomeres
Guidelines for Stretching
- at least 3x/week for ROM increases
- at least 1-2x/week to maintain
- slow elongation and hold at low force TO THE POINT OF MILD DISCOMFORT
- 15-30 second hold (better than shorter holds/as good as longer holds)
- 3 to 5 different stretches for each different muscle group
- no consensus on repetitions or speed for dynamic stretching
Stretching in Chronic Contractures
- may need longer duration stretch
- prolonged static stretch with splints or casting
- LLPS: low load, prolonged duration stretch
Proprioceptive Neuromuscular Facilitation Stretching
- takes advantage of stretch reflexes to increase range: GTOs and muscle spindles
- reciprocal inhibition***- when agonist contracts then antagonist relaxes
Stretch Rflexes
- muscle spindles: embedded in muscle, cause muscle to contract when stretched too quickly, antagonist relaxes
- GTOs: causes relaxation before tension gets too high
- reciprocal inhibition
- spinal level reflexes- only goes to spinal cord
Review the Literature for PNF
- hold contraction for 3 seconds
- may not be result of muscle spindle/GTO
- alters stretch perception with neural distraction
Stretching and Athletic Performance
- acute stretch does not improve performance and may be detrimental
- regular/chronic stretching improves force, jump height, running speed
Stretching and Injury Risk
- no link shown to prevent injury
- analgesic (desensitizing) effect in muscle that could predispose you to injury
- beneficial to maintain normal ROM
Contraindications to Stretching
- PAIN WITH MOVEMENT!!! (4 or less)
- bony block
- recent fracture
- acute inflammation or infection
- fragile tissue, tissue trauma
- hypermobility
- contracture is helpful to patient
Spine Stabilization- What is it? Basic Motor Learning?
- proximal stability for distal mobility
- deep segmental muscle activation
- basic motor learning: awareness, control with simple movements, control with complex movements, automatic maintenance of stability
- tension on thoracolumbar fascia is increase with muscle contraction (internal weight lifting belt)
Tripodism- loads change between flexion and extension
tripodism- defined as the load relationship between the vertebral bone-disc interface and facet joints (and lamina)
- with flexion: compressive load to facets decrease, load to discs increase
- with extension: compressive load to facets increase, load to discs decrease
- force from abdominal muscles counteract shear forces
Guidelines for Training
- awareness (neutral positions)
- activation in neutral
- add extremity motions
- reps to improve endurance
- alternate isometric contractions
- move from one place to another
- challenge with unstable surface
Deep Segmental Muscles
- neck: longus colli
- lumbar spine: transverse abdominus (does not hypertrophy but will improve activiation), multifidus
Deep Neck Extensor Activation
- craniocervical flexion: nod
- axial extension: double chin
- supine with pressure feedback
- prone lift head while looking down
Deep Lumbar Musculature Activation
- fine neutral spine
- belly button to spine (draw in): no pelvic movement, normal breathing, different than bearing down
- pressure feedback: abdominal draw in
- quadratus lumborus: side plank
Pressure Feedback
- use standard blood pressure cuff
- cervical: under neck –> increase pressure with contraction
- lumbar: under belly prone –> decrease pressure with contraction
- lumbar: under low back supine –> increase pressure with contraction
Physical Activity Guidelines
- Department of Health and Human Services
- First published in 2008
Committee Report: Health Outcomes
All cause mortality cardiorespiratory health metabolic health energy balance musculoskeletal health functional health cancer mental health*** youth adverse effects other populations***(people with disabilities, pregnancy, racial/ethnic groups)
Why We Need PA Guidelines
- Americans are largely inactive & engineered out of our environment
- Physical activity is repeatedly shown to improve health, lifestyle change accessible to nearly everyone
- prevention oriented
- previous “guidelines” said some is good, more is better
- guidelines address specific groups
Major Research Findings
- regular activity reduces risk of many adverse health outcomes
- some activity is better than none
- added health benefits generally occur as amount of activity increases
- most health benefits require at least 2 hours and 30 minutes a week of mod intensity PA
- benefits from aerobic and muscle strengthening
- beneficial for all people: age, disability, gender
- benefits far outweigh risks
How Much Activity?*******
- 150 minutes per week of mod intensity to substantially reduce risk of chronic disease
- additional benefits seen at 5 hours per week
Children and Adolescents (age 6-17)
- 1 hour per day of mod intensity
- vigorous intensity at least 3 days per week
- obesity prevention
- bone strengthening
- motor development
Adults (age 18-64)
- 150 min per week of mod aerobic activity
- OR 75 min of vigorous aerobic activity
- muscle strengthening activities 2 or more days/week of all major muscle groups
- 10 min or greater bouts
Older Adults (> 65 yrs)
- follow adult guidelines
- as active as possible (if less than adult guidelines)
- include balance activities
- if no symptoms: don’t need to consult a health care provider
Getting Started
- look for ways to do more
- pick something enjoyable and feasible
- establish support
- build up over time
- Be Active Your Way Guidebook
Gauging Exercise Intensity
- rating of Perceived Exertion: scale of 6 to 20
- heart rate
- metabolic equivalents: 1 MET is rest
- talk test
Moderate and Vigorous Physical Activity
Moderate: -RPE 11 to 14 (on a scale of 6 to 20) -50 to 69% of Max HR -3 to 5 METs -can talk, but not sing Vigorous: -RPE of 17-19 - > 70% of Max HR -6 METs or higher -cannot talk without taking extra breaths
The best type of exercise, is…
the type of exercise you’re actually going to do.
Stretch Shortening Cycle
- muscle contraction isn’t just a muscle contraction
- muscle spindles stretch–>tell brain to contract
- elastic potential especially in tendons
- 4 Steps: Preparation, Eccentric, Transition, Concentric
- Always remember: position, biarticular muscles, one muscle can do more than one thing, gravity
Principles of Manual Muscle Testing (Resistance, Break Test, Active Resistance Test)
Resistance: concentric force in line with line of pull of muscle and in opposition to contracting muscle (remember anatomy)
Break Test: end of available ROM and patient holds while therapist tries to “break”, most common MMT procedure
Active Resistance Test: apply progressive resistance until motion stops, not recommended because scores equal to break test
Principles of Manual Muscle Testing (application of resistance, one joint muscles, biarticular muscles)
Application of Resistance: length tension relationship, joint mechanics
One Joint Muscles: apply resistance at end range
Biarticular Muscles: apply resistance at mid range with most favorable length-tension postion
Where do you apply resistance? What do you do if there is any variation in procedure?
- apply resistance at distal end of segment the muscle attaches to (EXCEPT weak knee joint during hip testing = 4 or lower, scapular muscle assessment)
- apply gradually over 2 to 3 seconds
- if variation is noted, DOCUMENT, JUSTIFY, and REPEAT IN SAME WAY
MMT Grading Scale
1 = no activity
2 = trace activity
3 = poor
4 = good
5 = normal
testing (get baseline and compare) vs. screening (find weakness)
represents performance of all muscles in that motion
Grade Zero Muscles
muscle is completely inert on palpation and visual inspection
Grade 1 Muscles
- visible or palpable contractile activity (1 or more muscles in mov’t group, tendon tension)
- move limb into testing position –> ask patient to hold and then relax –> compare
Grade 2 Muscle
- completes full ROM in gravity minimized position
- reduce friction
Grade 3 Muscle
- can complete full ROM against gravity & any additional resistance leads to break
- **functional threshold for upper extremity because need to be able to move limb against gravity
- check that joint is not locked during testing
Grade 4 Muscle
- complete full ROM against gravity & “yields” or “gives” with maximum resistance at end range
- must document if break is due to pain or weakness
- says it is “Good”, but it is NOT “Normal”= not endpoint for rehab
- clinical observation very important (ex: getting up from chair)
Grade 5 Muscle
- able to complete full ROM & therapist cannot break at end range
- compare bilaterally
- consider how much force the muscle functionally producess
Using + and -
-discouraged from general use because too subjective
Exception!!!!- plantar flexors
-pt who is walking, do not assess PF strength in supine
-2+ if partial weight bearing heel raise or max resistance in supine
-2 if full ROM with no resistance
-2- if partial range in supine
Practical Considerations for Grading
- ordinal scale
- jump between 1 and 2 then jump between 4 and 5 (fuzzy)
- smaller increments between 0-1, 2-3, 3-4
Practical Considerations for Testing
- optimize patient comfort
- quiet, non distracting test area
- testing surface is adequate size, firm but not too firm
- organize testing order to minimize position changes
- knowledge and skill will determine the usefulness of results
Required Practitioner Knowledge for MMT
- location and anatomical features of involved muscles (O, I, LOP)
- consistent test application: method and positioning
- identify patterns of substitution
- detections of minimally contracting muscle
- able to identify bilateral differences & deviation from normal
Continued Required Practitioner Knowledge for MMT
- do not grasp muscle belly
- innervations: weakness in one group requires testing of all
- definitive vs. confirmatory (diagnosis specific)
- modify without impacting test results
- consideration of fatigue
- effect of sensory loss on movement
Things to Look Out For:
- open wounds
- tubes, monitors, wire, ostomes, traction, ventilators
- patient cannot assume test position
- don’t take shortcuts: **don’t assign lower grade without testing that grade first
- listen to your patient
Influence of the Patient on MMT
- effort
- willingness to endure pain
- ability to comprehend instructions
- motor skills
- cultural implications
Usefulness in Various Settings: Acute Care, Acute Rehab, Long Term, Home Health
Acute Care: post surgical assessment, transfer safety, discharge plans
Acute Rehab: baseline, plan, changes (not always due to increase muscle strength, could be neural)
Long Term: progression, assessments, plan of care
Home Health: community mobility requirements, CMS requires home bound to be considerable and taxing effort in leaving the home
Usefulness of MMT in Outpatient Setting
- origin of pain
- quality of contraction
- symmetry
- weakness in kinetic chain
- assessment**- due to ceiling effect
Limitations of MMT
- population variation
- objectivity and some subjectivity
- validity and reliability
- sensitivity and diagnostic validity
- Ceiling Effect: not recommended to use as progress measure over grade 3, bilateral comparison as instrumented assessment
- tester’s strength
Method of MMT
- position patient
- assume they are weaker than you think
- determine LOP
- use good body mechanics
- stabilize surrounding joints
- patient moves limb into position
Alternatives to MMT
- repetition max tests
- isokinetic dynamometer
- hand held dynamometer
- biodex
- throwing tests
- jumping tests
- body weight testing
Medical Evaluation
- useful and important prior to starting exercise program (baseline)
- can identify high risk individuals that should only exercise under medical supervision
- can be used to help motivate a person to adhere to program (BP, body fat, blood lipid)
- periodic med evals can identify dangerous conditions earlier
- not everyone needs an eval
- med eval target moderate to high risk individuals
Pre participation Health Screening
- Physical Activity Readiness Questionnaire
- Signs and Symptoms
- CVD Risk Factors
- Med Eval including physical and stress test
Purposes of Preparticipation Screening and Risk Stratification
- ID individuals w/ med contraindications that require exclusion from exercise program until conditions abated or controlled
- recognize individuals w/ clinically significant diseases or conditions who should participate in a medically supervises exercise program
- detect individuals who should undergo a med eval and/or ex testing as part of screening process before initiating exercise program or increasing frequency/intensity of current program
Risk Stratification Steps
- Assess presence of previously diagnosed disease (cardiovascular, pulmonary, metabolic) –> HIGH RISK
- Assess presence of signs and symptoms of disease (1 or more –> HIGH RISK)
- No disease or S&S, determine total number of CAD risk factors present (2 or more –> MODERATE, 0 or 1 –> LOW)
Signs or Symptoms of Disease (9)
- pain/discomfort in chest, neck, jaw, arms, or others that may result from ischemia
- shortness of breath at rest or w/ mild exertion
- dizziness or syncope (fainting)
- orthopnea (SOB lying down relieved by being upright) or paroxysmal nocturnal dyspnea (same but occurs 2-5 hrs after going to bed)
- ankle edema
- palpitations or tachycardia
- intermittent claudication (pain in muscle with inadequate blood supply, walking upstairs/hill causes cramp & gone in 1-2 min)
- known heart murmur
- unusual fatigue or SOB with usual activities
CVD Risk Factors (8)
- Age: men great or equal to 45, women 55
- Family History: MI, coronary revasc, death before 55 of male 1st degree or 65 female 1st degree
- Smoking: current, exposed to environmental, quit within previous 6 months
- Hypertension: SBP greater or equal to 140, DBP greater or equal to 90, or on meds
- Dyslipidemia: LDL greater or equal to 130, HDL less or equal to 40, total greater or equal to 200, or on med (subtract 1 if HDL greater or equal to 60)
- Prediabetes Fasting Glucose: fasting blood glucose greater or equal to 100 but less than 126, or determined by oral glucose 140-199
- Obesity: BMI greater or equal to 30, waist greater that 40 in for men or 35 in for women
- Sedentary: not in 30 min mod intensity (40-60% VO2R or 3-6 METs) on at least 3 days per week for at least 3 months
If presence or absence of CVD risk factor is not disclosed or is not available…& prediabetes.
- …that CVD risk factor should be counted as a risk factor EXCEPT prediabetes:
- age greater or equal to 45 and BMI greater or equal to 25kg/m2
- age less or equal to 45 with BMI greater or equal to 25 and additional CVD risk factor for diabetes (family history of DM)
Low Risk Individuals
- low risk of acute CV event
- exercise may pursued safely without the necessity for med exam or clearance
Moderate Risk Individuals
- risk of acute CV event is increased
- in most cases, individuals may safely engage in low to moderate intensity PA without needing med exam for clearance
- advised to have med exam and exercise test before vigorous intensity exercise
High Risk Individual
- extreme risk of acute CV event
- thorough med exam should take place & clearance given before initiating exercise or PA of any intensity
