Final Review Flashcards
Progression of movement. Lumbar extension strengthening
1) Basic lumbar stabilization with progressive limb loading emphasis on abdominals:
- Patient position hook lying knees 90°. Place the pressure cuff under the lumbar spine and inflate to40 mmhg. Begin each exercise drawing in maneuver to activate deep segmental muscles. Determine the level at which a patient can maintain pressure constant(stable pelvis) while performing either A , B or C limb load activity. For endurance, decreased load and perform repetitive motion for one minute or longer. For strength, progress load.
2) Basic lumbar stabilization with progressive limb loading emphasis on trunk extensors:
- Patient position quadruped in or prone. Patient assumes a neutral spine and lumbar and cervical region (keeping eyes focused towards the floor or exercise mat), performs drawing in maneuver, and moves extremities. Motions are repeated or alternated from side to side.
Greater the ratio of disc thickness to the vertebral height, the greater the mobility
C/S - 2:5 most mobile (6/15)
L/S - 1:3 (5/15)
T/S - 1:5 Least mobile (3/15)
Action of Internal and External Obliques
Trunk Rotation
Transverse abdominis most active during?
Flexion
-Drawing in maneuver strengthening
Scoliosis right side curve
lat flex to right, stretch over head
Dynamic Strengthening exercises for Lumbar muscles
Progressively gest more difficult
1) Trunk flexion exercises:
- Supine: Curl-ups • Curl-downs • Double knee to chest • Pelvic lifts • Bilateral straight leg raising • Bilateral straight leg lowering ▪
Prone: Planks • Roll out on Gym ball • Pike on Gym ball • Advanced planks with push-up
2) Extension exercises:
- Prone: Thoracic elevation • Leg lifts
3) Trunk side bending exercises
- Standing: Side bends ▪
- Sidelying: Antigravity side bends • Progressed antigravity side bends
Valsalvas
internal and external oblique
ligaments stabilize the spine
ALL prevents hyperextension,
PLL prevents hyperflexion.
Superspinius ligaments limits forward flexion
Run parallel blending together longitudinally with the tendon They don’t generate as much tension (strength) as penniform arrangements Many muscles of the upper extremities have longitudinal arrangements which reflects the increased ROM the upper extremities have versus the lower ones Examples of longitudinal arrangements include: o Strap like (parallel), Rhomboidal, Triangular, Fusiform
Longitudinal Fibres
Don’t line up with the tendon Very strong A lot of penniform arrangements are found in the lower extremities to generate the strength needed for support and ambulation Examples of penniform arrangements include: o single penniform, bipenniform, multi penniform
Penniform Fibres
Both have secondary actions but cant do inversion without each other
Tibialis Post
Tibialis Ant
The voluntary isometric contraction of opposing muscle groups to “” a joint in a position, usually after it’s been injured, in an attempt to protect it
Fixation (Fixator Muscle)
Decreases circulation which slows healing
Fixating Joints
This is seldom seen vs. stabilizing synergist activity
Voluntary fixation
Vertebral bodies and intervertebral discs. The function is weight bearing and shock absorption
Anterior Pillar
Vertebral arch (pedicles, lamina, articular processes, facet joints, transverse processes and spinal processes). The function is to provide mechanism for movement, also used for muscle attachment which provides mobility and stability.
Posterior Pillar
Acute phase – Maximum Protection Phase,
1) Pain and or neurological symptoms
2) Inflammation
3) Guarded posture( prefers flexion, extension, or non weight bearing
4) Limited ability to perform ADL and IADLs
Subacute – Moderate Protection/Controlled phase
1) Pain: only when excessive stress is placed on vulnerable tissues
2) Impaired posture/postural awareness
3) Impaired mobility
4) Impaired muscle performance: poor neuromuscular control of stabilizing muscles; decreased muscles endurance and strength
5) General deconditioning
6) Limited ability to perform IADLs for extended periods of time
7) Poor body mechanics
Chronic phase – No Protection/Return to function phase
1) Pain: only when excessive stress is placed on vulnerable tissues in repetitive or sustained nature for prolonged periods
2) Poor neuromuscular control and endurance in high-intensity or destabilized situations
3) Flexibility and strength imbalances
4) Generalized deconditioning
5) Limited ability to perform high-intensity physical demands for extended periods of time
Describe Muscle Setting, when is there an indication to use muscle setting?
- Gentle isometric contractions intermittent/low intensity which improves circulation.
- May be performed in several pain free positions.
- Does not improve strength but decreases atrophy maintains muscle fiber mobility and the joint immobilized
Describe the process of a joint mobilization, what are the indications for a joint mobilization?
Techniques used to decrease pain and to restore, maintain or treat joint dysfunctions that limit ROM by specifically addressing the altered mechanics of the joint.
Describe the 5 process of a joint mobilization
- Pain, Muscle Guarding and Spasm: Can be treated with gentle joint-play techniques to stimulate neurophysiological and mechanical effects: Neurophysiological effects: Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of pain to spinal cord or brain stem levels. Mechanical Effects: Small-amplitude distraction or gliding movements and gentle joint play of the joint are used to cause synovial fluid motion thus bringing nutrients to avascular cartilage.
- Reversible Joint Hypomobility: Progressively vigorous joint-play stretching techniques to elongate hypomobile capsular and ligamentous connective tissue.
- Positional Faults/ Subluxations: A faulty position of one bony partner with respect to its opposing surface may result in limited motion or pain. Ex: Pulled elbow, capitate-lunate subluxation
- Progressive limitation: Diseases that progressively limit movement can be treated with joint play to maintain available ROM or slow down progressive mechanical restrictions.
- Functional Immobility: Immobile joints can be treated with non-stretch distraction or gliding to prevent degenerating and restricting effects of the immobility.
Mechanical Effects:
Small-amplitude distraction or gliding movements and gentle joint play of the joint are used to cause “synovial fluid”
Neurophysiological effects:
mall-amplitude oscillatory and distraction movements are used to “stimulate the mechanoreceptors that may inhibit the transmission of pain to spinal cord or brain stem levels”
If a client presents signs and symptoms of inflammation which grade of joint mobilizations would be safe and effective?
Grades 1
Grade 2 is for assessment
Which grade of joint mobilizations would you perform for a client who has a decrease in GH flexion?
Posterior glide
What are some of the contraindications to stretching?
1) A bony block limits joint motion
2) Recent fracture and bony union is incomplete
3) Acute inflammatory or infectious process (heat & swelling) or soft tissue healing could be disrupted in the restricted tissues and surrounding region
4) Sharp acute pain with joint movement or muscle elongation
5) A hematoma or other indication of tissue trauma is observed
6) Joint hypermobility already exists
7) Shortened soft tissues provide necessary joint stability in lieu of normal structural ability or neuromuscular control
8) Shorted soft tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills otherwise not possible.
How would you perform a stretch for the Gastrocnemius and the soleus muscle? What makes these stretches different?
A stretch for soleus would just have a bend in the knee.
A form of dynamic muscle activation in which tension develops and physical shortening of the muscle occurs as an external resistance is overcome by an internal force as when lifting a weight.
Concentric
Involves dynamic muscle activation and tension production that is below the level of external resistance to that physical lengthening of the muscle occurs as it controls the load, as when lowering a weight.
Eccentric
What direction will the slide occur if the surface of the moving bone is concave? Convex?
If the joint surface of the moving bone is CONCAVE the slide of the joint will be in the SAME direction as the swing of the bone.
If the joint surface of the moving bone is CONVEX, the slide of the joint will be in the OPPOSITE direction as the swing of the bone
Ability of contractile tissue to produce tension The greatest measurable force exerted by a muscle or muscle group to overcome resistance during a single maximal effort
Muscle strength
The ability of the neuromuscular system to produce, reduce or control forces encountered during normal functional activities
Functional strength
What exercises are effective when you are teaching a client postural control of a cervical hyperlordosis?
Axial extension (cervical retraction) to decrease a forward head posture: - Patient position and procedure: Sitting or standing, with arms relaxed at the side. Lightly touch above the lip under the nose and ask the patient to lift the head up and away as if a string was pulling their head upward Verbally reinforce the correct posture and draw attention to the way it feels. Have the patient move to the extreme of the correct posture and then return to midline.
Scapular retraction
- Patient position and procedure: Sitting or standing. For tactile and proprioceptive cues, gently resist movement of the inferior angle of the scapulae and ask the patient to pinch them together (retraction). Suggest that the patient imagine “holding a quarter between the shoulder blades’ ‘ or imagine “putting their elbows in their back pockets’ ‘ The patient should not extend the shoulders or elevate the scapulae (Fig. 14.21 B).
Posterior curves (present at birth) - Convexity is posterior - These curves are named kyphosis curves - Found in the thoracic and sacral regions
Primary curve
“Compensatory” curves that develop as infants lift their head & eventually stand. - Convexity in anterior - These curves are named lordosis curves - Found in the cervical and lumbar regions
Secondary curves
Curves named Lordosis Curves
Secondary Curves
Curves named Kyphosis Curves?
Primary Curves
What will influence the movement of the lumbar spine?
Facet joint orientation movement
Strengthen Abdominals
Joint Mobilzations
What is the progression of core strengthening?
1) Deep Neck Flexors - Activation and Training
2) Lower Cervical & Upper Thoracic Extensor Activation & Training
3) Drawing in Maneuver for Transverse Abdominis Activaton
4) Abdominal Bracing
5) Posterior Pelvic Tilt
6) Multidifus Activation & Training
Describe Feed forward mechanism?
The CNS activates the trunk muscles in anticipation of the load being imposed by limb movement to maintain stability of the spine
Kind of opposite of “feedback” system
“This happens in anticipation NOT in response”
What conditions have an extension bias?
1) Patient often assumes a flexed posture or flexed with lateral deviation
2) Sustained or repetitive extension maneuver reduce or relieve their symptoms
Examples: IVD lesion, Fluid stasis, mm imbalance, flexion injury
What conditions have a flexion bias?
1) Patient may present with a flexed posture and be unable to extend because of increased neurological symptoms and decreased mobility
2) The flexed position reduces or relieves the symptoms
Examples: FJI, Spondylosis, Extension load injury, Disc Lesions
How would you differentiate a stretch for levator scapula, SCM, Scalenes?
Levator Scapula:
- Contralateral Flexion, Contralateral Rotation, Inferior Rotation (Look down to armpit), Hand under leg to depress scapula
SCM:
- Contralateral Flexion and rotation with extension
Ant Scalene:
- Contralateral flexion & Ipsilateral Rotation
Middle and Post Scalene:
- Contralateral Flexion
What structures are affected with a client who has a flat back posture?
1) Flat upper back and neck
2) Potential Muscle Impairments: Mobility impairment in the anterior neck muscles, thoracic erector spinae, and scapular retractors, and potentially restricted scapular movement, which decreases the freedom of shoulder elevation. ▪ Impaired muscle performance in the scapular
3) Flat low back - Decreased lumbosacral angle with decreased lumbar lordosis
4) Posterior pelvic tilt
5) Flat upper back o Decrease in thoracic curve
6) Depressed scapula/ depressed clavicle
7) Exaggeration of axial extension due to flexion of occiput on atlas and flattening of cervical lordosis
What are the actions of the obliques? How do they work together?
internal & external obliques
Bilateral: trunk flexion
Unilateral: trunk rotation and lateral flexion
What is the purpose of the thoracolumbar fascia?
- Restricts end range flexion and provide stabilization forces in the lumbar region
- Surrounds erector spinae, multifidi and quadratus lumborum, thus providing support to these muscles when they contract.
What exercise is effective to develop the strength and coordination of the transverse abdominis?
1) Drawing-In Maneuver for Transverse Abdominis Activation
2) Patient positions: Training may be easiest in the quadruped position in order to use the effects of gravity on the abdominal wall. Hook-lying (with knees 70° to 90° and feet resting on an exercise mat), prone-lying, or semi-reclined positions may be used if more comfortable for the patient. It is important to progress training to sitting and standing as soon as possible
3) Procedure: Teach the patient using demonstration, verbal cues, and tactile facilitation. Explain that the muscle encircles the trunk, and when activated, the waistline draws inward. Palpate the TrA muscle just distal to the ASIS and lateral to the rectus abdominis
What is the primary function of the muscles of rectus abdominis
Trunk flexion
hat is the primary function of internal & external obliques
Bilateral: trunk flexion
Unilateral: trunk rotation and lateral flexion
transversus abdominis
Stabilization (acts like a girdle of support). • Active with both isometric trunk flexion and extension
What is the primary function of quadratus lumborum
Pelvic hiking & trunk side bending
What is the primary function of erector spinae
Bilateral: trunk extensors
Unilateral: lateral flexion
Antagonist to gravity and prevents trunk from falling over
What are the important guidelines to keep in mind for your client who has an acute spinal concern in the protection phase?
1) Educate Patient
2) Decrease Acute Symptoms
3) Teach awareness of neck and pelvic position and movement
4) Demonstrate safe postures
5) Initiate neuromuscular activation and control of stabilizing muscles
6) Teach safe performance of basic ADLs, progress to IADLS
Which structure limits forward flexion of the spine?
Posterior longitudinal Supraspinous Ligamentum nuchae Interspinous Ligamentum flavum Capsular ligaments
Describe nutation and counternutation
Nutation is anterior movement of the base of the sacrum. Counternutation is posterior.
What direction of a glide would you perform to assist a client in increasing their hip flexion?
Posterior glide of hip
Your client presents with a hyperlordosis, how do you strengthen the abdominal muscles?
Flexion forward, Curl-ups, Situps, Crunches
What exercise would assist with pain that is centralized in nature due to a disc herniation?
Mild isometic stengthening of back
Drawing in maneuver
First Class Levers
Their axis located between the line of force application and the line of resistance The line of force application (F) in humans is located at the muscles insertion point on the bone and the direction of this force is the line with the direction of that muscle The line of resistance (R) is the direction the resistance is applied to the lever/bone First class levers can overcome large resistances or produce great speed of movement depending where the axis lies in relation to the force and resistance
Examples include: - pliers - triceps acting at the elbow - scissors - gastrocnemius/soleus at the ankle - pry bars - cervical extensors acting at the sub occipital joint
Second Class Levers
The resistance located between the axis and the line of force These are strong levers because of their mechanical advantage
Examples include, wheelbarrow, nutcracker o fireplace bellows There are not many convincing examples of second class levers in the body however it has been argued that the foot when rising on the toes (metatarsophalangeal joints) is an example of a second class lever The axis in this case is considered to be the MTP joints, the force is applied at the heel where the Achilles tendon attached and the resistance is located at the ankle where the weight of the body is transferred to the foot
Third Class Levers
Third class levers have the force located between the axis and the line of resistance These are fast levers at the expense of being strong Third class lever arrangements are designed for speed at the distal segment and a moving small resistance over a large distance A small amount of shortening of a muscle like brachialis results in a large arc of movement
Examples include: - The spring closes a screen door - Using a shovel - Golf clubs/baseball bats - Pectorals acting at the shoulder - Deltoids at the shoulder - Psoas major at the hip - Infraspinatus at the shoulder - Biceps brachii at the elbow - Hamstrings at the knee
Goals of stabilization, strength, and endurance training for the spine
1) Activate and develop neuromuscular control of core and global spinal stabilizing muscles to support the spine against external loading
2) Develop endurance and strength in the muscles of the axial skeleton for functional activities
3) Develop control of balance in stable and unstable situations
Specific guidelines for muscle performance of the spine (Know order)
1) Begin training awareness of safe spinal motions and the neutral spine position or bias
2) Have patient learn to activate the deep (core) stabilizing musculature while in the neutral position
3) Add extremity motions to load the global musculature while maintaining a stable neutral spine position (dynamic stabilization).
4) Increase repetitions to improve holding capacity (endurance) in the stabilizing musculature; increase load (change lever arm or add resistance) to improve strength while maintaining a stable neural spine position.
5) Use alternating isometric contractions and rhythmic stabilization techniques to enhance stabilization and balance with fluctuating loads
6) Progress to movement from one position to another in conjunction with extremity motions while maintaining a stable neutral spine
7) Use unstable surfaces to improve the stabilizing response and improve balance
Understand Fulcrum on Levers (Look at notes)
-
Which lever is most common?
3rd Lever
Mobilize the tibial nerve
Ankle dorsiflexion with eversion
Contraindications of nerve mobilizations
1) Acute or unstable neurological signs
2) Cauda equine symptoms related to that spine including changes in bowel or bladder control and perineal sensation:
3) Spinal cord injury or symptoms
4) Neoplasm and infection.
science of “the science of movement”
Kinesiology
Active insufficiency
Unable to reach the contraction force because of hte limit of muscle length
Passive insufficiency
Unable to reach full range of motion because of the limit of muscle length
Newton’s 1st law (Keeps moving - Car)
A body remains at rest or in a state of uniform motion in a straight line until acted upon by an unbalanced or outside force when a body is at rest, the forces acting upon it are completely balanced when the body or part is in motion it will continue to move until some force causes it to stop the force necessary to overcome the inertia of the body depends on the weight of the body and the rate at which it is moving, which is the reason why it is more difficult to put a shot than to throw a baseball an object does not move unless a force has been applied that is greater than the object’s inertia
Newton’s 2nd law (Law of Attraction)
The acceleration of a body is proportional to the force imparted to it and inversely proportional to its mass: acceleration = force mass the application of the same amount of force to a golf ball and a 12 lb shot will cause the golf ball to accelerate more because of its smaller mass by rearranging the formula this law can be stated differently where: force = mass x acceleration the force generated by a body is directly proportional both to its acceleration and to its mass, therefore this equation tells us that if the golf ball and the 12 lb shot are made to accelerate equally, the shot because of its greater mass will make a larger dent where it lands
Newton’s 3rd law (Trampoline)
When one body exerts a force on a second body, there is an equal but opposite force exerted by the second body on the first forces are always on pairs that are equal in magnitude but opposite in direction usually in biomechanics, internal body forces are referred to as “actions” and external forces applied to the body are known as “reactions” (i.e. weights, the floor/ground) when an individual pushes against or lifts up any object, the object pushes against the person or pulls down with equal force in a line directly opposite that of the individuals force
Ability to perform low intensity repetitive or sustained activities over a prolonged period of time
Endurance
Two types of Endurance:
1) Cardiovascular endurance: Total body endurance Repetitive dynamic motor activities like walking/cycling
2) Muscle endurance: Local endurance The ability of a muscle to contract repeatedly against an external load, generate and sustain tension, and resist fatigue over an extended period of time.
Ability of contractile tissue to produce tension The greatest measurable force exerted by a muscle or muscle group to overcome resistance during a single maximal effort
Muscle strength
Strength and speed of movement
Defined as the work (Force X Distance) produced by a muscle per unit of time (Force X Distance/Time) “the rate of performing work”
Power
Two aspects of power
1) Anaerobic power work produced over a very brief period of time single burst of high intensity activity
2) Aerobic power work produced over an extended period of time repetitive burst of less intense activity
Power enhanced by?
increasing the work a muscle must perform in a specified period of time o the greater the intensity of the exercise and shorter the time period taken to generate force, the greater the muscle power
Open chain exercise?
1) Non weight bearing position/exercise
2) Distal segment (hand/foot) moves freely during exercise
3) Most effective in isolating or training individual muscles/groups
4) Open chain tend to allow more control and are probably safer in the early phase of rehabilitation
Closed chain exercise?
1) Weight bearing position assumed and the body moves over a fixed distal segment
2) Tend to have more substitute motions
3) Closed chain increase joint congruency/approximation which increases stability
4) Less joint shear forces, results in less friction/wear and tear
5) Closed chain tends to provide greater proprioceptive/ kinesthetic feedback
6) Best choice for balance or postural control
The ability of structures to be moved freely, without restriction.
Can be used interchangeably with mobility
Flexibility
The tendency of the force to produce rotation around the axis
Torque
If a force is exerted in a body that can rotate about some pivot or fulcrum point, the force is said to generate?
Torque
1) Elbow flexors cause the forearm to rotate around its fulcrum (the elbow joint) creating torque
torque equals the product of the force magnitude and its perpendicular distance from the direction of force to the point or axis of rotation
- This perpendicular distance is called the moment arm or torque arm
2) torque or turning effect at the elbow when holding a 5 lb weight (neglect the weight of the forearm) with the elbow flexed at 90 degrees is the product of the weight times its perpendicular distance or moment length from the elbow joint
3) If this 5 lb weight is held at 1 ft away from the elbow joint then the moment arm is considered to be 1 ft (remember at 90 degrees of elbow flexion the forearm is parallel to the ground and the moment length will be the actual length of the forearm)
The application of mechanics to the living human body
Biomechanics
Subacute Spinal Problems Plan of Care
1) Educate patient in self-management and how to decrease episodes of pain
2) Progress awareness and control of spinal alignment
3) Increase mobility in restricted mm/joint/fascia/nerve
4) Teach techniques to dvlp neuromuscular control, strength, endurance
5) Dvlp cardiopulmonary endurance
6) Teach techniques of stress relief/relaxation
7) Teach safe body mechanics and functional adaptations
Chronic Spinal Problems Plan of Care
1) Emphasize spinal control in high-intensity and repetitive activity
2) Increase mobility in restricted mm/joint/fascia/nerve
3) Improve mm performance, dynamic trunk and extremity strength, coordination and endurance
4) Increase cardiopulmonary endurance
5) Emphasize habitual use of techniques of stress relief/relaxation/ posture control
6) Teach safe progression to high-level/high-intensity activity
7) Teach healthy exercise habits for self-maintence
What are Links?
What are Pivots?
Links are Bones
Pivots are Joints
Are Fast Levers Strong?
No
- Fast levers are not strong and strong levers are not fast
Do Levers Rotate?
Levers rotate around a Fulcrum (Fixed point or joint), or an axis that is opposite to the plane of motion
Axis is between the line of Force and Resistance (MA is Greater or Less than 1)
1st Class Levers
Resistance between Axis and Force (MA Greater than 1)
2nd Class Lever
Force between Axis and Resistance (MA less than 1)
3rd Class Lever
What direction glide to increase flexion are the hip?
Posterior
Is swelling a CI to stretching?
Yes
How to stretch Gastrocnemius
Dorsiflexion and Extend the Knee
How to give eccentric Bicep Stretch?
Elongating at the elbow (extended)
Rotating to Left - what is happening at Facet Joint?
Left move posteriorly and right moves anteriorly
What is considered extension bias?
Disc Herniation
Flat Low Back Characteristics
Posterior Tilt of Hip Hip Flexors (Quad) Lengthened Hip Extensors (Hammys) are Contracted Abdominals are Contracted
Sway Back Characteristics
Thoracic shift posterior Hip Extension (Pelvis Shift Anterior) Flexion of Thorax @ Upper Lumbar Intercostals Shortened Thoracic Stretched
Which glide to decrease in Hip Extension
Anterior Glide
Example of Penniform Muscle
Rectus Femoris
Which Lever is Axis between Load and Force
1st Class
Management Guidelines during Acute Stage
1) Patient Education
2) Protection of Injured Tissue
3) Prevention of Adverse Effects of Immobilization
Management Guidelines during Subacute Stage
1) Patient Education
2) Management of Pain and Inflammation
3) Initiation of Active Exercise
4) Initiation and Progression of Stretching
5) Correct Contributing Factors
Management Guideline for Chronic Phase
1) Patient Education
2) Progression of Exercise
3) Progression of Stretching
4) Progression of Muscle Performance Exercise
5) Return to High Demand Activity
Application of mechanics to the living human body?
Biomechanics
What are the 2 basic types of movement?
1) Linear motion
2) Angular motion
What 4 movements do muscles produce?
1) Prime Mover (Agonist)
2) Antagonist
3) Fixator
4) Synergist
Property of matter that causes it to resist any change of motion in either speed or direction (Ball rolling down a hill)
Inertia
Nervous system has considerable mobility to adapt to wide range of movements imposed on it by daily activities
- Nerve compressed as it passes a bony structure in confined space
Neural Tension
Points to note when Neural Tension testing?
1) Every nerve examined separately b/c every position elongates nerve
2) Test position to detect nerve mobility same as treatment position
3) Test unaffected side first
If SI joints are not free to move, the stride length is decreased and vertical limp is present
Gait
