Exercise Therapy Lab

Question 1

Proprioceptive Retraining

Answer 1

Begin by creating a “short foot”- on the balls and heels of the foot Denote which stage your patient gets to on either foot

To retrain, have your patient practice at the level they failed at, not progressing until they can pass the level

Utilize this tool for both Lower Crossed Proprioceptive Retraining and Upper Crossed Proprioceptive retraining

Question 2

Proprioception/Balance Assessment and Retraining

Answer 2

Normal is the ability to hold each stage for 30 seconds Stage 1: Balance on one foot, arms down, eyes open Stage 2: Balance on one foot, arms crossed, eyes open Stage 3: Balance on one foot, arms down, eyes closed Stage 4: Balance on one foot, arms crossed, eyes closed

Question 3

Lower Crossed Syndrome

Answer 3

Tight/Facilitated Postural Muscles:

Hamstrings

¤ Iliopsoas

¤ Rectus Femoris

¤ Tensor Fascia Lata

¤ Thigh Adductors

¤ Piriformis

¤ Lumbar Erector Spinae

¤ Quadratus Lumborum

¤ Gastrocnemius

Weak/Inhibited Phasic Muscles:

Vastus, medialis, lateralis, intermedialis

¤ Gluteus Medius

¤ Gluteus Maximus

¤ Gluteus Minimis

¤ Rectus Abdominus

¤ Transversus abdominus

¤ Abdominal Obliques

¤ Tibialis Anterior

Question 4

Lower Crossed Special Tests

Answer 4

Pelvic Clock
Pelvic Clock with Hip Abduction
Pelvic Clock with Heel Slide
Hip Abduction Firing Pattern

Question 5

Pelvic Clock

Answer 5

Signifies inhibition or weakness of the abdominal muscles

Inhibition could be due to lumbar erector spinae or QL hypertonicity

Patient Supine, knees bent, feet on table

Physician stands on eye dominant side / Thumbs on Inferior aspect of ASIS’s- Note if they remain level

¤ Have Patient imagine ‘a clock’ or ‘bowl of soup’ on their belly

¤ Instruct patient to move their pelvis in the 4 directions below, using their abdominal muscles. Do NOT allow them to push with legs or “hip hike” on either side

Tilt Pelvis Posterior (Decrease lordosis - Umbilicus toward 12 O’Clock/ tip bowl toward face)
¤ Tilt Pelvis Anterior (Increase lordosis - Umbilicus toward 6 O’Clock/ tip bowl toward feet)
¤ Rotate Pelvis Right (Move Umbilicus toward 9 O’Clock about 1-2 inches / tip bowl toward Right)
¤ Rotate Pelvis Left (Move Umbilicus toward 3 O’Clock about 1-2 inches / tip bowl toward Left)

Fails if ASIS do not remain level

Question 6

Pelvic Clock with Hip Abduction

Answer 6

Indicates weakness of abdominal muscles or hypertonicity of adductors

Patient Supine / knees bent, feet on table

¤ Physician stands on eye dominant side / Thumbs on inferior aspect of ASIS’s to monitor

¤ Instruct patient to tilt pelvis posteriorly (toward 12 O’Clock/ tip bowl toward face)

¤ Tell patient to hold the pelvis in that position while they let their knees GENTLY fall laterally.

¤ -(The motion is passive thigh abduction, the adductors are undergoing eccentric contraction)

¤ Note if one or both ASIS moves inferiorly

¤ –signifies patient unable to maintain posterior pelvic tilt on one or both sides of pelvis

FAILS TEST IF: Unable to maintain posterior pelvic tilt on either side of pelvis while abducting thighs

Question 7

Pelvic Clock with Heel Slide

Answer 7

A failed test indicates weak abdominal muscles or facilitated and hypertonic hip flexors

Patient Supine / Both knees bent, feet on table

¤ Physician stands facing side of patient - Cephalad hand under Lumbar lordosis- note degree of lordosis

¤ From neutral, patient tilts pelvis (toward 12 O ’Clock) Note degree flattening of lordosis

¤ Instruct patient to maintain pelvic tilt while sliding their heel along table to straighten knee and hip

Monitor for any increase in lumbar lordosis

Monitor for dropping or unleveling of the ASIS

Question 8

Hip Abduction Firing Pattern

Answer 8

The normal firing pattern for proper hip ab
duction is 1. Gluteus medius, 2. Tensor fascia lata, 3. Quadratus Lumborum, 4. Lumbar erector spinae. (verified by some studies disproven by others)

Significant findings include late firing of the gluteus medius and early firing of the TFL resulting in internal rotation and flexion of the hip.

¤ The patient is sidelying on the contralateral side you wish to test

¤ Monitor at the TFL, Gluteus Medius, Quadratus Lumborum, and Lumbar Erector spinae

¤ Instruct the patient to slowly abduct their leg off the table (hip abduction)

¤ Observe for the firing pattern of the muscles.

Question 9

Lower Extremity Stretches

Answer 9

Stretch what is tight to alleviate restriction and improve inhibited weak muscles

Question 10

Thomas Test

Answer 10

To Evaluate Iliopsoas
¤ The back of the thigh should contact the table; if not psoas shortening may be present.
Stretch by having the patient hip flex, then you take it into further extension.

¤ To Evaluate Rectus Femoris
¤ Assess the flexion at the knee; if it is less than 90 degrees, rectus femoris hypertonicity is present.
Stretch by having the patient extend their knee, then you take it
into further knee flexion.

¤ Modified Thomas Test to Evaluate Tensor Fascia Lata
¤ Observe how far lateral the leg is pulled
¤ Externally rotate the femur and Internally rotate the tibia and feel for resistance

Question 11

liopsoas/ Anterior Hip Capsule

Answer 11

Pt lies prone, grasp the distal end of the femur with the knee flexed.
¤ Block pelvic motion at the IT
¤ Elevate the leg (hip extension)
¤ Normal is the ability to lift 6 inches

¤ SELF STRETCH- find yourself in a low lunge- internally rotate the femur on the side to be stretched- try for a posterior pelvic tilt- contract your gluteal muscles on the same side- stretch both sides for symmetry

Question 12

Rectus Femoris

Answer 12

Pt lies prone, grasp the distal end of the tibia and flex the knee to the barrier.
¤ Utilize isometric muscle energy to stretch
¤ Heels should be able to touch buttocks
¤ SELF STRETCH-Flex the knee to the barrier, either against a table or using an ipsilateral hand to grasp the foot- tilt the pelvis in a posterior pelvic tilt- additional stretch by flexing the opposite knee- repeat both sides for symmetry

Question 13

Piriformis

Answer 13

 Below 90 degrees- pt supine- flex hip and knee and place foot outside of the opposite
knee- stabilize the ASIS on the side being tested.
¤ Induce IR and adduction to the barrier
¤ Have the patient attempt to abduct and externally rotate and using muscle energy to treat.
¤ Above 90 Degrees- pt supine- flex hip and provide ER- knee should be able to touch the chest
¤ You can use this as evaluation or treatment utilizing muscle energy.

Question 14

Hip ADDUCTORS

Answer 14

Patient lies supine
¤ For the LONG adductors- standing in between the patients legs, use one hand to stabilize the opposite leg and the other hand to grasp the ankle and abduct the leg into the barrier.
¤ For the SHORT adductors- have the patient flex the knee and rest the foot on the table. Cephalad hand will stabilize the ASIS- Caudad hand will rest on the medial knee and slowly abduct the hip to the barrier.
¤ FOR BOTH utilize muscle energy by having the patient contract the ADDUCTORS and take up the slack, increasing the ABDUCTION of the LE.
¤ SELF STRETCH- in a seated position- bring the plantar surface of your feet together as your hips ABDUCT.

Question 15

Upper Crossed Syndrome

Answer 15

Tight/Facilitated Postural Muscles
¤ Levator Scapulae

¤ Upper Trapezius

¤ Sternocelidomastoid

¤ Pectorals

¤ Scalenes

¤ Subscapularis

¤ Flexors of the Upper Extremity

Weak/Inhibited Phasic Muscles
¤ Middle and Lower Trapezius

¤ Serratus Anterior

¤ Rhomboids

¤ Supraspinatus

¤ Infraspinatus
Deltoid
Deep Neck Flexors

¤ Extensors of the Upper Extremity

Question 16

Upper Crossed Special Tests

Answer 16

Cervical Flexion
Bilateral Shoulder Abduction
Scapular Stabilization
Pectoralis minor length assessment

Question 17

Cervical Flexion Test

Answer 17

Patient Supine and the physician sits or stands at side of table near patient’s head

¤ Ask patient to SLOWLY try to look at their feet
Incorrect
¤ Chin should tilt toward chest and
remain there as patient continues
to raise head (Forehead should be more anterior than chin throughout the range of motion)

¤ Weakness of deep cervical flexors is substituted by use of SCM and scalenes which you can see by an anterior chin thrust
Correct

Question 18

Bilateral Shoulder Abduction

Answer 18

Note symmetry of the scapula with shoulder abduction, especially looking for “winging” as well as scapular
elevation. Weakness of the supraspinatus and deltoid will result in over-recruitment of Trapezius and Levator scapulae. Overuse of these muscles leads to loss of shoulder stabilization by lower trapezius and serratus which may lead to impingement syndromes.

¤ Patient Seated, with good upright posture, physician standing behind patient, hands monitoring the scapula

¤ Instruct patient to raise their arms alongside their head, keeping elbows straight, palms facing outward

Note any winging, asymmetry in motion, early elevation or shoulder hiking

Question 19

Scapular Stabilization

Answer 19

Excessive “Winging” of the medial border of scapula occurs due to Inhibition/ weakness of Lower-mid trapezius, Rhomboids, and Serratus anterior, with resultant loss of scapular stabilization.
Subtle imbalance is often missed unless provoked by this maneuver.

¤ Patient on table – on hands & knees with elbows flexed enough to keep spine keep spine parallel (avoid spinal sagging or arching) to floor

¤ Physician stands next to patient and monitors the inferomedial border of scapula being tested.

¤ Instruct patient to support themselves with one arm while lifting the other off the table.a few inches-keeping palm parallel to the table

¤ Physician observes and palpates for any winging of scapula on support side arm

Question 20

Pectoralis Minor Length Assessment

Answer 20

Evaluate and observe the symmetry of the anterior aspect of the shoulder.
Anterior displacement
may be due to tight pectoralis minor or posterior shoulder capsule.

¤ Have the patient lie Supine

¤ Observe the anterior aspect of the shoulder to observe for asymmetry or anterior displacement.

Question 21

Upper Trapezius and SCM

Answer 21

Begin with the patient lying supine
¤ With the operator hand ipsilateral to the side being stretched stabilize the scapula and clavicle
¤ With your opposite hand stabilize the occiput and induce side bending away and rotation towards
¤ Perform muscle energy by having the patient attempt to elevate the shoulder
¤ After post isometric relaxation take the head and neck into the new barrier with increased sidebending and rotation
¤ You may address different fibers by asking the patient to tuck their chin

Question 22

Pectoralis Major and Minor

Answer 22

Extend arm on side to be stretched and stabilize at attachment at chest
¤ Modify the amount of abduction and horizontal extension to achieve the appropriate stretch
¤ Perform muscle energy by having the patient push the arm into horizontal flexion
¤ iv. After post Isometric relaxation take the shoulder into further Horizontal Extension

Question 23

Pectoralis Self Stretches

Answer 23

The patient stands facing the wall and places both hands on the wall at shoulder height
¤ Slowly the patient turns away from the side to be stretched until a stretch is felt in the pectoral region

Question 24

Posterior Shoulder Capsule

Answer 24

Begin with the patient lying in a lateral recumbent position on the side to be stretched
¤ Flex the elbow to 90 degrees and abduct the shoulder to 90 degrees
¤ From here internally rotate the arm to the barrier (normal is the ability to touch the table with the long finger)
¤ Utilizing muscle energy have the patient push back to neutral
¤ After post isometric relaxation move further into the IR barrier engaging the posterior shoulder capsule

Question 25

Deep Neck Flexors

Answer 25

Have the patient seated with a hand palpating the superficial anterior cervical muscles
¤ The patient should not their head forward utilizing the deep neck flexors (without contracting superficial muscles)
¤ Hold for 5-7 seconds completing 5-7 repetitions

Question 26

Shoulder Stabilization (Rhomboids,
Lower Trapezius)

Answer 26

A. Have the patient seated with their feet on the floor

¤ b. Bring their hands and arms in front of them interlacing the fingers in front of the sternum

c. The patient should attempt
to pull their elbows backward for 5-7 seconds and repeat 5-7 times to strengthen the Rhomboids

d. The patient may then bring their interlaced fingers
overhead and attempt to pull elbows down towards the floor for 5-7 seconds for 5-7 times to strengthen the lower
trapezius.
Lower Trapezius