Final Exam Flashcards
Physiological Effects of Message
-increase circulation
-reactive hyperemia
-increase lymphatic flow
-disperse waste, 02, increase lactic acid
Reflexive Massage
-stimulates receptors in skin and fascia
-decreases pain
-ANS response (increase parasympathetic tone)
-GTO activation
-Gate control theory
-release of opiates
Mechanical Massage
-performed after reflexive to decrease pain and guarding
-deeper tissues
-loosens adhesions, scar tissue, trigger points
-realigns cartilage
-increase ROM
Indications for Massage
-decrease SNS, muscle tone, prottective spasms
-evaluate restrictions
-realign cartilage
-reduce edema
-circulation
-increase ROM
Containdications for Massage
-skin infections/open
-thrombosis/embolism or phlebitis, severe varicose veins
-new tendon transplant
-fracture/non union
-acute inflammation
-cellulitis
-synovitis
-absesses
-cancer
-fever
Skin Rolling
-evalutes skinn conectivity and underlying restrictions
-no lotion
-lifting skin
Light Effleurage
-warm up and cool down
-light, continuous pressure
-get used to contact
Deep Effleurage
-medium, continuous pressure distal (light) to heart (deeper)
-promotes relaxation
-decreases pain
-searching for spasms
Petrissage
-kneading, deeper
-grasp and lift muscle and skin toward heart
-push waste to increase lymphatic and venous return
-loosen tissue and increase elasticity
Effect:
-spreads fibers
-tension of connective tissue
-proprioceptive input
-reduce collagen cross-linking
Friction
-deep, circular or transverse mmts
-no skin mmt, move underlying tissues
-where a trigger point, adhesion or scar is felt
-realign collagen fibers
Transverse Friction
-intense perpendicular to tendon
-should be painful, explain
-used for chronic tendon inflammation
Percussion or Tapotement
-brisk, rapid blows with relaxed hands
-increase circulation
Myofascial Trigger Points
-hyperirritable locus: taught band of tissue
-reffered pain, lump, decreased ROM, jump sign
Trigger Point Massage
-related to acupressure
-find point until pain or jump sign
-press on point and maintain pressure (will increase pain then lessen)
Myofascial Release
-mid pressure and stretch
-move in direction of restriction
-superficial to deep
-relieves soft tissue from abnormal grip of tight fascia
Active Release Technique
-deep tissue to break down fibrotic adhesions that restrict movement and scar tissue
-apply pressure in direction of fibers while pt actively elongates muscle
Sprains
Grade 1: ligament stetched
Grade 2: incomplete or partial tear, most pain, most common, reduced strength
Grade 3: complete tear, no pain, loss of function
Strains
Grade 1: Microtearing of muscle, mild pain and swelling
Grade 2: partially torn muscle, moderate pain, affecting activity
Grade 3: complete or avulsion, severe pain initially, defect, loss of function
Acute Stage of Healing
-inflammatory
-pain early in ROM
-0-10 days
-chemicals irritate nerve endings
PT:
-prevent negative effects of rest
-reduce inflammation, edema, pain
-protect area
Teqniques:
-soft tissue
-estim: tens, IFC
-cryo
-joint mobilizations (I-II)
-ultrasound
Subacute Stage of Healing
-proliferation and repair
-pain at endfeel
-2-22 days
-growth of capillaries, collagen formation, wound is covered, granulation tissue
PT:
-mobilize scar
-promote healing and function (PROM>AAROM>AROM)
-develop neurmuscular control
-pt education about 6w healing
Teqniques:
-soft tissue: Cross friction, TP, MFR, AR
-estim: tens, IFC
-heat: increase circulation
-joint mobilizations (III-IV)
-stretching
-Isometrics, AROM, endurance, WE exercises
Chronic Stage of Healing
-maturation and remodeling
-pain at overpressure
-12 days -1+ yr
-new collagen (type 2) to align with stress
-scar formation
PT:
-return to function
-increase tensile quality of scar
- develop functional independence
-mobilize scar
-improve neurmuscular control
Teqniques:
-soft tissue: Cross friction, TP, MFR, AR
-estim: russian, NMES
-deep heat: increase circulation
-joint mobilizations (III-IV)
-stretching
-increase strength
Ligament Injuries
-trauma, mechanical stress, gender differences
-3-6weeks
-85% type I collagen, turn into type III
-30-50% weaker
Laxity:
-3 weeks= mild tension
-6 weeks= resume normal activities
-12 weeks= almost max tensile strength
Tendon Injuries
-singular incident or cumulative
-patial tear or rupture @ junction
-surgical repair essential for full return if >50% diameter
Healing:
-limited blood supply, 7.5x lower than muscle
-type III collagen aligned randomly (proliferative)
-increase in type 1 lonngitudianlly (remodeling)
Tendon Healing Precautions
-AROM 3 weeks across repair site results in poor outcomes
-should be exposed to limitted motion-PROM
-slow progression from PROM->AAROM->AROM->Resisted
Rehab lasts: 6m-2 years
Causes of Muscle Injury
Mechanical Forces:
stretch, contraction, contusion
Thermal Stresses:
heat or cold
Nerve Injury
Myotoxic Agent:
lidocaine, corticosteroids, venom
Prolonged Ischemia:
compartment syn, tourniquet
Management of Muscle Injury
Short term mobilization (2-5 days)
-manage inflammation and hemorrhage
Cautious mobilization
-2-3 weeks= tissue extensibility & protection
-4-6 weeks= gentle AROM < full range
After 6 week:
-warm up period and endurance activities to reduce reinjury
-avoid eccentric
Fracture Healing
- Hematoma (6-12h): Blood clot forms and inflammation
- Proliferation (1-2d): granulation tissue and fibrocartilage
- Callous Formation (1-3w):
Soft callous - Ossification (6w): Soft callous replaced by bony callous
- Remodeling (4m-1y): restoration of medullary canal
Factors to Hinder Fracture Healing
-inadequate blood supply
-poor nutritional status
-poor apposition
-infection
-diseases
-corticosteroid
-soft tissue damage
Bone Healing Prognosis
Children: 4-6w
Adolescents: 6-8w
Adults: 10-18w
-distal faster than proximal
Joint Mobilization
Direction: traction or gliding
Technique: oscillation or sustained
Grade I: early joint play
Grade II: further joint play close to tissue resistence
Grade III: joint play past resistence
Grade IV: passed resistance toward anaotmical limit
Signs of Excessive Exercise
-soreness not relieved in 24h
-pain increased or comes on early
-increased stiffness
-inflammation
-weakness
-decreased function
Fuctional Excursion
-entire length of a muscle
-max elongation
Range of Motion
-used for examination of movement
PROM
-motion produced by external force (PT)
-no active contraction
-motion only through pain free range
Indication:
-Don’t disrupt repair
-pain
-neurological inability to activate muscles
Goals:
-avoid stiffness
-mainstain mobility
-mitigate pain
-avoid contracture
AROM and A-AROM
-motion produced by active contraction or a combination
-demonstrate using PROM
-movement in pain free range
Indication:
-move against gravity
Goals:
-restore AROM
Limitations:
-not enough to sustain strength
ROM Contraindications
-disruptive to healing process (precautions)
-response or condition is life threatening
Continuous PROM
-CPM
-mechanical device that moves joint slowly and continuously through controlled ROM
-for pt unable to move themselves
Benefits:
-prevents contractures
-stimulates healing structures
-increases synovial fluid lube
-prevents degrading from immobilization
-quicker return of ROM
-decreases postop pain
Functional Patterns
-asssits teaching ADLs and IADLs
-help realize value and purpose
-motor patterns
-meaningful exercises
Acute ROM
PROM
-3-5 reps w/in pain tolerance
-several times a day
Subacute ROM
-PROM to AAROM to AROM
-gravity eliminated to antigravity
10-15 reps with brief hold w/in pain free range
-2-3x per day
Chronic/Functional ROM
-AROM
->30 reps for maintenance of ROM
-stretching to gain ROM
Dynamic Flexibility
-flexibility of muscle due to active mmt
-how high you can kick your leg
Passive Flexibility
-flexibility of muscle due to a passsive force
-PROM usually greater
-how far someone can bend your leg
Hypomobility
-limited arthrokinematic mmt of a joint
-motion you can feel
Arthrokinematics
-movement at the joint
-can be improved to improve osteokinematics
-can treat glides not rolls
Active Insufficiency
-muscle comprimises movement from being too contracted to produce movement
Ex: triceps in full ext and shoulder hyperext
Passive Insufficiency
-muscle comprimsies movement from being too lengetthend to produce movement
ex: finger extensors in full wrist flexion
Myostatic Contracture
-MT unitt is adaptively shortended
Pseudomyostatic Contracture
-hypertonicity due to CNS lesion
Arthrogenic and Periarticular Contractures
-adhesions, synovial proliferation, joint effusion, osteophytes
Fibrotic and Irreversible Contractures
-fibrous changes in connective tissue leads to adhesions
-difficult to re-establish normal tissue length
Selective Stretching
-purposeful stretch certain muscles and joints while letting others become hypomobile to improve function
Overstretching/Hypermobility
-purposefully overstretch certain muscles or joint to increase function
Interventions to Increase Mobility
Manual Stretching
-external force to perform a passive stretch
Passive Stretching
-no active contraction of contractile unit
Assisted Stretching
-patient assistance by themselves, machine or another person
-self stretching
Neuromuscular Fasciltation and Inhibition
-PNF
-increase or decrease msucle tone
Muscle Energy Techniques
-hold-relax-repositon techniques
Joint Mobilization/Manipulation
-passive techniques to restore arthrokinematics
Soft Tissue Mobiliation
Neural Tissue Mobilization
Indications for Stretching
-adhesions, scars, scar tissue limit ROM
-potential deformity due to ROM limitations
-muscle weakness, shortening
-part of training
-pre/post exercise
Contraindications for Stretching
-bony block
-non-union fracture
-acute inflammation
-infection
-sharp pain
-hematoma or tissue trauma
-hypermobility
-hypomobility provides stability or control
Mechanical behaviors: toe region
-Laxity in tissue/collagen begins to straighten
Mechanical behaviors: elastic region
Can return to original shape and size after being deformed
Mechanical behaviors: elastic limit/yield point
Following elastic region, the yield point signals, the point of no return for the tissue
Mechanical behaviors: plastic range
Residual deformations of the tissues will be permanent
Mechanical behaviors: failure point
Tear or break of tissues
Mechanical behaviors: Necking
-ultimate strength
-warning for failure
Creep
-load applied for extended time to elongate
-PROM
Hypertrophic Scar
-rasied scar within bounds of injured region
Keloid Scar
-extends beyond boundary of the injured site
Scars
-inelastic
-dependent on 02
-prolonged pressure can limit scar by limiting 02
Chronic Inflammation
-repeated stress/trauma
-immune responce
-low grade inflammatory responses
-increased fibroblast, immature collagen, decredattion of mature collagen= weak tissues
Ampere
-rate of current flow
Current
-net mmt of electrons
-high to low
-can be increased by increasing pulse duration and frequency
Voltage
-force of current flow
Good Conductors
-nerve
-muscle
-blood**
Resistance/Impedance
-opposition to electron flow
-skin and fat are highest
-increases as electrode disease increases
-decreases as frequency increases
Ohm’s Law
I= V/R
-more resistance=less current
Good Insulators
-skin
-fat
-bone
-nerve sheath
-tendon
Current Flow: Skin
-insulator
-need more voltage to penetrate skin and layers
Current Flow: Fat
-insulator
-most resistance
Current Flow: Nerve
-conductor
-6x better than muscle, but surrunded by fat and sheath (insulator)
Current Flow: Blood
-best electrical conductor
Current Flow: Tendon
-poor conductor
-most resistance
Current Flow: Muscle
-good conductor
Current Flow: Bone
-Poorest conductor
-most resistance
Frequency vs Impedence
-increased frequencies decreases impedence
Biphasic/Alternating
-goes positive and negative
-pain relieving
-continous flow, changing directions
-no chemical reactions
ex: TENS, IFC
Monophasic/Direct Current
-uninterupted flow of electrons toward positive pole
-can be reversed
-chemical changes: electrolysis
-muscle contraction when meeting threshold
Ex: ionto
Pulsatile
-2+ pulses grouped together
-discontinuous
-most nerve/muscle stimulation
ex: Russian and High Volt
Accommodation Phenomenon
-a fiber subjected to constant depolarization will become unexcitable at the same intensity
Frequency
-cycles per second Hz
-can determine the type of muscle contraction elicited
-Tetany: 50Hz
Intensity
-amplitude/volatge/intensity
-increasing the stimulation or amplitude to reach deeper tissues, more nerves, stronger contraction
-knob on top
Pulse Duration
-pulse width
-targets specific structures
Capacitance
-ability of a tissue to store electricity
-higher capacitance= more time before a response
-capacitance can be reduced by increasing frequency
-larger diameter= smaller capacitance
Muscle: most
Nerve: least
Pulses
-individual waveforms
-monophasic current
Symmetric, asymmetric, balanced, unbalanced
Cycle: biphasic
Cathode
-negative
-site of depolarization
-most electrons
-usually black
-where muscle contraction happens
IONTO
-alkaline effects
-repels neg/attrac pos
Anode
-positive
-least electrons
-usually red
IONTO:
-repel pos/ attract neg
-acidic effects
Alpha Beta Nerve
-sensory nerves
-100usec chronaxie
-tingling sensation
-TENS, IFC
-largest diameter
Motor Nerve
-contraction and tingling
-200-250usec chronaxie
-TENS, Russian, NMES
Alpha Delta Nerve
-sharp pain
-300-700usec chronaxie
-noxious paresthesias, strong muscle contraction
-TENS
C FIbers
-dull pain
-noxious paresthesias, strong muscle contraction
-1.0msec
Denervated Muscle
-thinnest
-minimizes atrophy and edema
-10msec
Neuro Muscular Electrical Stimulation (functional electric stimulator)
-NMES/FES
Russian Currents
-muscle strengthening*
-muscle re-education*
-increasing ROM
-Slow atrophy
-Edema control (via muscle)
-2,000-10,00z frequency
-burst mode
-fast oscillating AC current, burst
Interferential Currents
-IFC
-pain control*
-muscle stimulation
-2 bipolar configurations (relief where they cross)
-4000-4100Hz frequencies
-120usec pulse width
Sweep Mode: frequencies modulated to avoid accommodation
Scan Mode: amplitude can be modulated
-for poorly localized pain
Target Mode: move with finger
High-Volt Pulsed Current
-HVPC
-reducing edema
-muscle pump 1:1
-wound healing
-twin peaked monophasic
-unequal electrodes, small over treatment
Transcutaneous Electrical Nerve Stimulation: Conventional
-TENS
-acute pain relief; surgical, labor*
-gate control theory; A-Beta*
-asymmetric biphasic
-tingle with no contraction*
Settings:
-75-150msec Duration/Width
-80-125pps Frequency
-continuous*
- Starting: 100p/100f*
-30mins, til pain is gone*
Iontophoresis
-low volt, continuous direct current
-drive ions into body
-medicine
-less than 30min on big machines
-longer with home devices
Doses:
-40mA-min= 4.0 current x 10min
-40mA-min= 2.0 current x 20min
Meds:
-Acetate, -, calcium depositis
-Dexamethasone, -, tendonitis/bursitis
-Lidocaine, +, trigeminal neuralgia
Wound Care
HVPC:
-promotes faster healing
-Negative Polarity: inflammatory phase of healing
-Positive Polarity:
proliferattion phase of healing (bacterial)
Transcutaneous Electrical Nerve Stimulation: Low-Frequency/Acupuncture/Motor-Level
-TENS
-chronic pain relief*
-Descending Pain control theory: modulation; enkephalin*
-asymmetric biphasic
-tingle AND contraction*
Settings:
-100-600msec Duration/Width
-<20pps Frequency
-Duty cycle: 30-60s*
- Starting: 180p/18f*
-15-60min*
-over motor point
Gate Control Theory
-increase A-Beta afferents triggers release of enkephalin to inhibit 2nd order neuron to block pain
Descending Pain Control: Modulation
-activate opiate receptors in PNS of nociceptive afferent fibers
Transcutaneous Electrical Nerve Stimulation: Noxious- Level
-TENS
-hyperstimulation analgesia
-chronic pain relief*
-Endogenous opiate pain control theory*
-asymmetric biphasic
-high intensity to noxious level; muscle contraction acceptable*
Settings:
-100-1000msec Duration/Width
-1-5pps Frequency
-Duty cycle: 30-45s
- Starting: 250p/2f*
-15-60min*
-over trigger point, until pain is no longer percieved
Endogenous Opiate Pain Control Theory
-peripheral blockage and extrasegmental analgesia
-stimulation of small afferents to release endorphins
Transcutaneous Electrical Nerve Stimulation: Brief Intense
-TENS
-fast pain relief during procedure*
-Descending: peripheral and central anagelsia theory*
-asymmetric biphasic
-muscle fasciculation to sustain contraction*
Settings:
-100-600msec Duration/Width
-100 pps Frequency
-Duty cycle: 30-45s
- Starting: 250p/100f*
-15min*
-around wound
Descending Pain Control: Peripheral and Central Analgesia
-serotonergic efferents from thalamus to activate enkephalin interneurons
Premodulated (Bipolar)
-2 currents switch within the device
-only 2 electrodes
-pain control
-muscle stimulation/reeducation
-slow atrophy
-2 bipolar configurations (relief where they cross)
-duty 10:10, ramp 1-2s, 10-20min
-200-400usec pulse width
E-stim Indications
-pain
-contraction
-muscle reeducation
-slow atrophy
-strengthening
-increasing ROM
-decrease edema
-decrease spasms
-healing
-regenerate tissues
-stimulate PNS
-protein synthesis
E-Stim Contraindications
-pacemaker/defib
-internal stimulators
-chest or heart area
-carotid
-thrombosis/vascular or arterial disease
-confusion
-seizure
-infection
-open wounds (unless treatin)
-cancer
-pregnancy
-high level SCI
Muscle Re-education
-Russian, NMES
-following surgery
-CNS inhibition of muscle
-improve motor control
-200-600 usec/ 35-55 pulse
-15min
-Duty 1:1
Muscle Pump Contractions
-HVPC, Russian, NMES
-increase circulation
-mimic normal contractions
-200-600usec/ 35-55 pulse
-comfortable muscle contraction
-20-30min
-duty 1:1
-elevatte the body part (can use AROM)
Edema Control
-HVPC
-elevate extremity*
-space electrodes far apart*
-negative polarity distal to swelling*
-driving forve to move plasma away
-30min
-best results immediately after injury
-80-120Hz/ low frequency*
-intensity as needed >60*
Muscle Strengthening
-Russian, NMES
-200-600usec/ 50-85pps
-gradual ramp
-duty 1:5
-to muscle fatigue 60% MVIC
-pt working with estim
Increasing ROM
-Russian, NMES
-200-600usec/ 35-55pps
-strong contraction
-interrupted current with gradual ramp
-antagonist muscles to joint contracture
-90min
-duty 1:1
-pt passive
Denervated Muscle
-lost peripheral nerve supply
-if reinnervation doesnt occur in 2 years connective tive replaces contractile elements so recovery not possible
-1st week <1ms duration
-2 weeks >10ms duration
-NMES
Slow Muscle Atrophy
-Russian, MNES, HVPC
-200-600usec/ 50-86pps
-15-20mins
-duty 1:5
-to muscle fatigue
-pt working with estim
IONTO Indications
-analgesia
-bone spurs
-ulcers
-edema reduction
-fungal infections
-sweating
-muscle spasms
-tendonitis
IONTO Contraindications
-estim rules
-impaired skin sensation
-allergy
-recent scar
-broken skin
-metal
Ultrasound Indications
-acute conditions
-calcium deosits
-chronic inflammation
-delayed healing
-ulcers
-contractures/spasms
-trigger points
-pain
-scar
-warts
Ultrasound Contraindications
-active bleeding
-decreased sensation to temp
-decrease circulation
-DVT
-infecion
-malignancy
-breast implants
-carotid
-epiphyseal plates in young
-heart, eyes, genitalia
-cement or plastic
-pelvic and thrunk of pregnant
-pacemaker
-vascular insufficiency
Ultrasound Function
-deep heating 5cm
-piezoelectric crystals vibrate to produce sound waves into tissues through transucer
-most waves reflect, need gel or water
Attenuation
-decrease in energy intensity due to absorption in tissues and dispersing of waves
Ultrasound Absorption
-penetration and absorption inversely related
-absorption increases with frequency
-high protein=high absorption
Bone: highest
Blood: least
ERA
-effective radiating area
-energy output is greatest at center, small than transducer
Treatment area= 2-3x ERA
Collimation
-focus of the beam
-larger tranducer and higher frequency=more collimation
Bean Nonuniformity Ratio
-BNR
-peak intensity:average intensity
-lower is better
-better BNR=less risk foor hot spots
Non-Thermal Ultrasound
Acute Injury, Edema, Healing Ultrasound
-superficial and deep (3-1MHz)
-non-thermal and pulsed
-20% Duty Cycle
-1 Intensity/ 8-10mins
Mid Thermal Ultrasound
Subacute Injury or Hematoma Ultrasound
-increase 1deg C
-continuous
Superficial (3MHz)
-0.5 in/ 3 mins
Deep (1MHz)
-1 in/ 5min
Moderate Thermal Ultrasound
-chronic injury, inflammation, pain, trigger points
-increase 2 degree C
-continuous
Superficial (3MHz)
-0.5 in/ 6min
Deep (1MHz)
-1 in/ 10min
-1.5 in/ 6min
-2 in/ 5min
Vigorous Thermal Ultrasound
-stretching collagen, joint contractures
-increase 4 deg C
-continuous
Superficial (3MHz)
-1 in/ 6min
Deep (1MHz)
-2 in/ 10 min
Ultrasound Cautions
-tissue damage at 45 deg
-continue only improvement
-placebo
BFR
-Blood flow restriction
-4 sets of 30/15/15/15 (75reps) with 30s breaks
-10-30% 1RM
Arms: 200mmHG, red cuff or 50%
Legs: 300mmhg, yellow cuff or 80%
Contraindications:
-severe HTN
-Compromised circulation
-Varicose veins
-IV drug use
-swelling
-trauma
-open fractures
-skin gradt
-direct nerve injury
-uncontrolled DM
-sickle cell
Heat Types
Conduction:
-contact with source
-hot/ice pack, cold spray
-1cm penetration (cold>hot)
Convection:
-air of liquid transfer
-whirlpool or cryotherapy
Radiation:
-no physical contact needed
-laser, UV
Conversion:
-energy changes when contact is made
-US
Cold
Uses:
-decrease inflammation/swelling/pain (gate control)
-decrease muscle activity
-decrease BF, temp, metabolic rate, nerve confuction
Contraindications:
-impaired circulation
-hypersensitivity
-skinn anesthesia
-open wounds/infections
-joint pain
-dont lay on top
Biofeedback
-used to measure motor unit action and pressure
-can be used to assess or to self educate pt
-Myotrac and Pressure cuff (neck=20, back=70)
Uses:
-relaxation
-neuromuscular re-ed
-coordination
Sensitivity:
-start low then progress for NMR
-start high for relaxattion
Physiological Responses to heat
Increased:
-CO, metabolism, pulse, breathing, vasodilation, BF, permeability, edema
Decreased:
-BP, muscle activity, SV, BF to resting structures, joint stiffness, spasms, pain
Heat Preparation/Contraindications
-40-45 celcius
-subacute to chronic
-less than 2cm of depth
-lot for long term outcomes
Contraindications:
-acute/subacute inflammation
-decresed circulation/sensation
-DVT
-cognitive
-cancer
-eldery/very young
Heat Modalities
Hot pack:
-160-170deg
-6-8 layers protection
-check skin @5
Parafin:
-dipping odd shaped parts
-126deg
-6 layers
-15-20min
Fluidotherapy:
-tank of warm air and corn husks
Whirlpool
Hyrdrotherapy
-immersion baths mixed with air
-Whirlpool and Aquatic Therapy
Effects:
-decreased tone
-increased BF, temp
-pain relief/relaxation
-vasodilation
-debridement
Contraindications:
-advanced Cardiopulm disease
-bleeding
-less sensation or circulation
-gangrene/infection
-maceration
-Peripheral vascular disease
Physiologic Response to Cold
-Cold
-Burning
-Aching
-Numbness
-redness, vasocontriction
Cold Modalities
Ice Pack:
-acute to subacute
-muscle spasms and inflammation
Cold Spray:
-acute or subacute
-pain, spasms
Cryo Cuff:
-provides cold and compression
-moves water/ needs 1 layers
Contrast Bath:
-subacute
-alternating hot and cold
-edema, DOMS, desensittation
Postural control
Controlling body position for stability and orientation
Postural orientation
Maintain relationship between segment and body and
Environment
Posture stability (balance)
Control COM in relationship to BOS with balanced forces
Center of mass
Center of the body mass, average of body segments
Center of mass on Adults
S2
Center of gravity
Vertical projection of COM, changes with environment
Center of pressure
Center distribution of total force, sum of all forces on the floor
Base of support
Body part in contact with support surface, usually feet
Vertical line of body alignment: Standing
Mastoid process, anterior to shoulders, hip joints, anterior to knee joints, anterior to ankle joints
Ankle strategy
Small perturbation, reactive balance training
-rotation around ankle joint
Post Displacement:
-dorsiflexors, quads, abs
Ant Displacement:
-plantarflexors, gastroc, hamstring, errectors
Hip Strategy
Larger, faster perturbation, ankle motion limited
Post Displacement:
-quads, abs
Ant Displacement:
-hamstring, errectors
Stepping Strategy
Largest, fastest
Reach strategy
Arms engage, similar to stepping strategy
Normal Postural Sway
Ant/Pst: 12deg
Lateral: 16deg
MSK Components of Balance
-joint ROM, spine flexibility, muscle tone, segmental mmt
Neuro Components of Balance
-sensory processes
-hihger level integration
-Neuromuscular
Vertical line of body alignment: Sitting
-head balanced on level shoulders
-upper body erect
-shoulders over hips
-deett and knees apart
Semicircular Canals
-angular acceleration
-sensitive to fast movements
-slips, falls, trips, gait
Otolith Organs
-linear position and acceleration
-head in space
-respond to slow head movements
Causes of Balance Impairments
-injury to inner ear, SC, peripheral receptors, cerebellum, basal ganglia, proprioceptors, MSK
-lesions to neuro
Spatiotemporal Compensations
Change BOS:
-widen, shuffling feet, shifting onto stronger leg
Restriction of mmt:
-stiffening, moving slowly
-Standing Reaching forward: flx hips instead of DF ankles
-Standing Reaching sideways:
flex trunk instead of lat moving hips
-Sitting Reaching Sideways: flexing forward and not to side
-In standing: not ttaking step when needed
Using hands for support
-holding onto things
Balance Guidelines
-cannot be trained in isolation
-stand/sitt, static/dynamic
-double/single limb
-postural adjustments are action specific
-should progress
-include external cues that require stepping
Safety:
-gait belt
-stand behind and to the side
-near railing, no sharp edges
-check equipment
-clean floor
Balance Training: Mode
-weight shift w/ increasing sway
-speed
-surface challenges
-weight distribution on chairs (balls and leaning)
Balance Training: Postural Training
-awareness of posture
-modified position
-increase varietty of BOS and arm positions
-unstable sessions
-visual cues and mirros
-static and dynamic posture
-Change environment
Balance Training: Movements
-movment patterns (PNF)
-trunk rotations
-head movements
-stepping
Balance Training: Progression
-BOS: wide to narrow
-Posture: stable to unstable
-Visual: closing
-COG: distrupitions
-Unable surfaces
-environments
-REPETITION
Balance PNF Techniques
Stability:
-rhythmic stabilization
-alternating isometrics
Enhance Dynamic Balance:
-Isotonic contractions
-Slow and quick reversals
What is PNF?
-proprioceptive neuromusclular fascilitation
-functional diagonal and neuro facilitation to improve control and function
Improve: stabilization, strength, endurance, control, agonist/antagonish, trains nerves
D1 UE
-putting a seatbelt on
Flexion: reaching for seatbelt
-Shoulder: add, ER
-Scap: UR, abd
-Forearm: sup
-Wrist: flex, rad dev
-Fingers: flx, add
Extension: buckling it
-Shoulder: abd, IR
-Scap: DR, add
-Forearm: pronation
-Wrist: ext, ulnar dev
-Fingers: ext, abd
D2 UE
-Sword and waiter
Flexion: waiter holding a tray
-Shoulder: flx, abd, ER
-Scap: elevat, UR, abd
-Forearm: sup
-Wrist: ext, rad dev
-Fingers: ext, abd
Extension: reaching for sword
-Shoulder: ext, add, IR
-Scap: depress, DR, add
-Forearm: pronation
-Wrist: flex, ular dev
-Fingers: flx, add
D1 LE
-hacky sack and ballet
Flexion: hackey sack
-Hip: flx, ER, add
-Knee: flx
-Ankle: DF, inv
-Toes: extension
Extension: Ballet
-Hip: ext, ITR, abd
-Knee: ext
-Ankle: PF, ev
-Toes: flx
D2 LE
-dog peeing and curtsey
Flexion: dog peeing
-Hip: flx, IR, abd
-Knee: flx
-Ankle: DF, ev
-Toes: extension
Extension: curtsey
-Hip: ext, ER, add
-Knee: ext
-Ankle: PF, inv
-Toes: flx
Rhythmic Initiation
-PT guiding through ROM
-for pts with difficulting initiating
-improves controlled mmts
-AROM, PROM, AAROM
Repeated Contractions
-jerking motions
-PT stretches in jerks pt while going through the RROM
-strengthens weak agonists
-need AROM and RROM
Slow Reversal
-kind of reversal of antagonist
-function changes in agonist to antagonist mmt
-contant resistance applied through ROM
-strong concentric of agonist followed by less strong eccentric of antagonist
Slow Reversal Hold
-kind of reversal of antagonist
-function changes in agonist to antagonist mmt
-contant resistance applied through ROM with isometric hold at end of range
-better detection of joint/space tension
Alternating Isometrics
-most common
-isometric hold of agonist then antagonist
-alternatting resistance to opposite muscles
-no ROM, inproves stabilization
Rhythmic Stabilization
-isometric hold of agonist AND antagonist (co-contraation)
-simultaneous multidirectional resistance to opposite muscles
-no ROM, inproves rotary stabilization
Stretching Time
10-30s hold
Stretch: Upper Traps
Postition: Supine
Stabilize: Shoulder
Movement: LSB, flexion away
Home:
-flex head and rotate away with one hand
Stretch: Levator
Postition: Supine
Stabilize: Shoulder
Movement: Flex, LSB, Rotate away
Home:
-flexion and rotation away with one hand
-ipsi scap upward rotation and depression with other hannd
Stretch: SCM
Postition: Sitting up
Stabilize: Clavicular head
Movement:
-Stand behind pt
-Pt actively Ext, LSB away and Rotate toward
Hold-Relax
-stretch msucle and maintain stretch
-isometrically contract against stetch
- Stretch muscle
- Isometrically Contract same muscle (being stretched)
- Hold and go into further stretch
Contract-Relax
-stretch muscle and maintain stretch
-isotonically contract against stetch, moving
- Stretch muscle
- Isotonically Contract same muscle (being stretched)
- Hold and go into further stretch
Hold-Relax w/ Agonist Contraction
- Stretch muscle
- Isometrically Contract same muscle (being stretched)
- Hold and go into further stretch
- Concentrically contract antagonist (move in opposite direction)
Stretch: Quadratus Lumborum
Postition: Side lying
Stabilize: Ribs and iliac crest with forearms
Movement:
-Stand in front of pt
-break the bread
Home:
-cat stretch with LSB away, ipsi shoulder abducted
Stretch: ITB
Postition: Sidelying
Stabilize: Ribs
Movement:
-Stand behind pt
-extend and adduct leg off of table
Home:
-extend and adduct leg off of table
-use roller
also for QL
Home Stretch: Scalene
-Cervical extension, rotation towards, and 1st rib depression
Home Stretch: Adductors
-ipsi side proped up while standing on contra leg
-drop ipsi pelvic for more stretch
or
-crossing legs and stretch
Stretching Contraindications
-hypermobile
-hypomobility provides stability
-bony block
-non union fracture
-inflammation
-pain
-tissue trauma
-
Daily Adjustable Progressice Resistive Exercise
-DAPRE
-pt perform max reps during 3rd and 4th sets
-uses last reps tto guide future reps
-each side worked independently for fucntional goals
-Increase weight and decrease reps
Set 3= Set 4
0-2=dec 5-10
3-4= dec 0-5
5-7=same
8-12= inc 5-10
13+= inc 10-15
DeLorme- Walking Training Progression
-determine 10RM
-do 3 sets
-increase percentage of 10RM each set (50%, 75%, 100%)
SAID Principle
Specificity of training: training specific groups, patterns and energy systems
Trransder of Training: improve applicability of program for caryover value
FITT Principle
-Frequency
-Intensity
-Time
-Type
Adaptations to Resistance
Neural:
-1st adaptations (2 weeks)
-motor learning
-not true muscle adaptations
Skeletal Muscle Adaptations:
-2nd adaptations (1 month)
-hypertrophy/hyperplasia
Determinant of Resistance
Alignnment & Muscle action: done within lines of muscle force
Alignment & Gravity: limb in antigravity for max
Stabilization:
-muscle groups are synergistic stabilizers
Reversibility Principle
-detraining after 1-2 weeks
-must maintain
Acute/Post Surgical Exercise
Isometrics:
-multiple angles, stability, msucle recruitment
-no weightbearing
-alter time, angle, reps
-3-5s hold, 10s for endurance
Isotonics:
-slow eccentrics (more force)
-Concentric (less force needed)
-gravity only
-use available ROM
-3-5 reps
Subacute Phase Exercise
Isometrics:
-multiple angles, weight bearing
-increase time, angle, reps
-3-5s hold, 10s for endurance
Isotonics:
-slow eccentrics (more force)
-Concentric (less force needed)
-resistance
-reps determined by goals
Concentric
-less force
-acceleration
Isometric
-no change in length
-balance of eccentric and concentric
-stabilization
-power
Eccentric
-more force
-deceleration, shock absorbtion, changing directions
-tissue healing
Strength Prescription
8-12 reps
Power Prescription
2-6 reps
Endurance Prescription
12-20 reps
BFR Mechanism of Action
Hypertrophy Theory: blocks venous outflow
Lactate Theory: limited o2 forces use of fast twitch
Muscle Recruitment Theory: lactate forced larger muscle recruitment
Growth Hormone Theory: lactate and lactic acid increases growth hormone release
Chronic Phase Exercise
-specifc muscle group
-total body conditioning
-integrate power, strength, function, speed, endurance
Order:
-multi joint/complex
-single joint, less complex
Dynamic Exercise-Constant External Resistance
-DCER
-same external load applied to mmt
-external load doesn’t move during mmt
-aka isotonic
Variable-Resistance Exercise
-same external load applied to mmt
-extternal load accomidates to the changes in muscle
-strengthen all parts of ROM
Elastic Resistance Training
-therabands
-(stretch length - rest length)/ (rest length x 10)
Precautions of Resistance Exercise
-valsalva
-substitutions
-overtraining: decreased performance
-overworking: decreased strength
-Acute Muscle soreness: decreased bf and increased metabolites irritating nerves
-DOMS: unacustomed vigorous exercise; microtrauma
Contraindications of Resistance Exercise
-pain
-inflammation
-severe CP disease
PEACE & LOVE
Protection
Elevation
Avoid anti inflammatories
Compression
Elevation
Load
Optimism
Vacularization
Exercise
Stress Shielding
-absolute stability
-held together by plates/compression
-NWB
Stress Sharing
-allows callous formation
-partial load transmission
-screws, pins, wires
-WBAT
Indication for Spinal Surgery
-cauda equina or failure of 3 months treatment
Posterior Hip Precautions
-add, flx, IR
Anterior Hip Precautions
-abd, ext, ER
MC Shoulder Replacement
-reverse
-most severe
-more stable for those who glenoid and cuff are torn
