Important themes from lectures Flashcards
KISS Principal (keep it simple stupid)
Keep It Simple Stupid
- Don’t overcomplicate
- Get basics right first
- Then get creative
Link to diagnosis and predisposing factors
Then…
- Identify areas lacking flexibility (is stretching appropriate?
- Identify areas with excessive movement (does it need strengthening?)
*usually occur in combination across a joint (control, proprioception and order of firing)
Stages of rehab (brukner and khan)
- Acute phase
- From the time of injury to almost pain free ‘normal ROM’
- PRICE is increasingly replaced by POLICE
- Treatment and management focused on soft tissue and joint mobility and pain relief - Restore ADLs
- Aim is to allow the patient to return to normal ADLs and basic sport specific technical movements.
- Progress from single joint controlled actions to complex tasks through several biomechanical planes.
- Exercises progressed by reps, increasing velocity of the movement, or the frequency (rate) of the exercises.
- Main goals are related to addressing functional limitations in activity and improving performance of semi-complex sport-specific movement patterns.
- Returning to sports activities
- ADL’s should produce no symptoms.
- Proprioceptive, agility and functional work should all be performed without any adverse effects.
- More traditional strength and conditioning can be incorporated with increased focus on higher complexity and velocity.
- Emphasis on higher rate of force development.
- Muscle conditioning now becomes completely sport specific. ie. power/speed for sprinters, Endurance distance runners/ cyclists.
- Decisions regarding return to play are made in collaboration with all stake holders.
The following criteria can be used when deciding on a full return to sport:
- Time constraints for soft tissue healing observed
- Pain free ROM
- No persistent swelling
- Adequate strength and endurance
- Good flexibility and proprioception
- Adequate cardiovascular fitness
- Skills regained
- No biomechanical abnormality – structural or skills based
- Psychologically ready
- Coach satisfied with training form
- Rehab is not over when you return to sport/work
Return to sport focus
- Progression of activity: jog to stride to hop to agility with increasing
- complexity.
- Slow integration activities (individual to team mate , to full training)
- Assessment of athlete’s performance and structural biomechanics
- What caused the original injury? Work with skills coach - technique must be corrected here.
- Has the athlete adopted a guarding / protective mechanism?
- Has this created altered movement patterns?
- Perform 70%-90% of normal training load
- CONFIDENCE– essential to restore. Athlete maybe hesitant to perform the activity that caused the original injury, fear injury reoccurrence, lack of full return of skills.
- Prevention of reinjury
- All injuries with tissue disruption will render the patient more susceptible to re-injury.
- Interventions should be aimed at impairments and functional limitations known to exist as a result of injury.
- These include altered muscle activation patterns, inadequate landing and cutting strategies.
Basic strategies
- High reps = trains strength-endurance and used with short recoveries
- Low reps – trains strength power and req longer recoveries
(dependant on Pt.)
Open vs Closed chain
An open kinetic chain exercise often involves single joint movement performed in a non weight bearing position where the distal extremity moves freely through space.
A closed kinetic chain exercise involves multiple joints and is performed in weight bearing positions with a fixed distal extremity. These are thought to be more functional, provide more propriceptive feedback and cause less shear forces than open kinetic chain ex’s.
Pros and cons OKC Advantages - Decreased joint compression - Can exercise in non-weight bearing positions - Able to exercise through increased ROM - Able to isolate individual mm Disadvantages - Increased joint translation - Decreased functionality CKC Advantages - Decreased joint forces in secondary joints (eg PTFJ in squat) - Decreased joint translation - Increased functionality Disadvantages - Increased joint compression - Not able to exercise through increased ROM - Not able to isolate individual mm.
Healing times
Brukner and khan chap 3.
Stages of change
Summary of stages:
1. PRECONTEMPLATION STAGE. We enter the stages of change from a state of precontemplation– during which the idea of change is not seriously considered.
o Denial
o Education but no belief or desire for change
o Cant see the solution or the problem
- CONTEMPLATIVE STAGE Secondly we contemplate the need for change; but take no active steps.
o Thinking about change
o Learning what outcomes of change will be for the individual
o Personally specific info
o Charting pros and cons helpful in this stage - DETERMINATION STAGE Thirdly we determine to take action. eg we buy walking shoes, join a gym or discover a local swimming pool, but we take no action.
o Making the decision to change
o Combination of intention and behavioral change - ACTION STAGE Then action is initiated. We walk regularly; go to that gym, have eggs instead of muesli for breakfast ……
o Doing it
o Transition stage
o Patient has begun to establish goals which meet individual needs and values
o Any change is good, don’t have to have an all or nothing approach
o Modification of behavior, environment and lifestyle is key in order to overcome habits
o Requires time and commitment - MAINTENANCE STAGE Finally the action is maintained for several weeks. But most having maintained the change, whether in diet, smoking habit, exercise or whatever, will sooner or later fail and revert to the first or second stage. Then comes the verdict that is most helpful; namely
o Living it
o Work to prevent relapses and consolidate gains
o Maintenance is a continuation not an absence of change
o Need to have practiced you new lifestyle for some time so it becomes automatic
o Allow slip ups as they take the pressure off
o Stabilizing change and avoiding replaces is key
Techniques
o Stimulus control – recognises triggers for addictive behaviour.
o Predict environments.
o Talk Back urges.
o Talk Back negative thoughts.
o Learn to cope with pressures from others, inform friends and family of your decision to change.
o Lifestyle enhancement – what are you going to do without your addictive behaviour, try and make life exciting. - RELAPSE +/- TO FAIL IS NORMAL!!! We should not engage in self-recrimination but instead discover WHY WE FAILED.
o Oops start over
o Slips and setbacks are a part of learning take it on board and get back into the cycle
o It takes 3-4 times before a smoker succeeds at quitting
Stabilisers vs Mobilisers
Stabilisers:
- Closely associated with cervical spine, lumbar spine and gleno-humeral joint.
- Lower neural threshold.
Eg deep neck flexors, rotator cuff, multifidus.
Mobilisers:
- Away from Cx spine, GH jt, Lx spine
- Higher neural threshold.
- Can dis locate joints without stability in case of sh.
- Mainly over trained in gym and sports.
Eg Delts, SCM, biceps, pecs, ?upper traps, abdominals
Mirror Muscles……….
Clinical joint stability
In 1992, Panjabi proposed a model of spinal stability that involved three separate, but integrated mechanisms.
These include:
• The Control System which is neural based.
• The Passive Subsystem which comprises the spinal column.
• The Active Subsystem which comprises the muscles.
Panjabi’s model involves the ability to maintain a neutral lumbo-pelvic position during functional daily activities.
This model has been used as the basis of other studies investigating segmental stability (Cholewicki, Cresswell, and in the last two decades Hodges).
Stage 1
• Local Segmental Control
• Develop segmental control via activation and training of the local muscle system.
• Goal is to improve kinaesthetic awareness and muscular control.
Stage 2
Closed Chain Segmental Control
Goal here should be to re load the weight bearing muscles and unload the non weight bearing muscles whilst maintaining control of the local muscle system.
Progression in this stage should also be made to include closed chain.
Stage 3
Open Chain Segmental Control
• The goal here is to continue to develop segmental control whilst maintaining control of adjacent segments.
• Completion of this stage will see the patient able to integrate control of weight bearing and non weight bearing muscles in functional movements.
• What we are looking for here is the ability to be able to achieve functional segmental control.
Clinical joint instability
- A dysfunction in any one of the subsystems may lead to clinical joint instability.
- This in turn may result in the compression of pain sensitive joint structures or nerve roots.
- Instability can occur in most joints.
- It may stretch or compress joint structures such as ligaments or capsules.
- It is always an increase in the neutral zone or joint translation movements.
SAIDS principal
Specific Adaptation to Imposed Demand
Training program must be adapted to the individual and the demands of their performance
Think of this in all individuals, from athletes to elderly
Specificity of function across all demographics
What is strength? (6 qualifiers)
- Maximum strength
highest force capability of the neuromuscular system produced during slow eccentric, concentric, or isometric contractions. - High-load speed-strength
highest force capability of the neuromuscular system, produced during dynamic eccentric and concentric actions under a relatively heavy load (>30% of max) and performed as rapidly as possible. - Low-load speed-strength
highest force capability of the neuromuscular system, produced during dynamic eccentric and concentric actions under a relatively light load (<30% of max) and performed as rapidly as possible. - Rate of force development (RFD)
the rate at which the neuromuscular system is able to develop force, measured by calculating the slope of the force-time curve on the rise to maximum force of the action. - Reactive strength
ability of the neuromuscular system to tolerate a relatively high stretch load and change movement from rapid eccentric to rapid concentric. - Skill performance
ability of the motor control system to coordinate the muscle contraction sequences to make the greatest use of the other 5 strength qualities such that the total movement best achieves the desired outcome.
In sports that involve repeated maximal efforts, such as sprinting or swimming, an additional quality termed ‘power endurance’ should also be included.
Power vs Strength
Strength
Initially high repetitions, low resistance
Progress to higher resistance with less repetitions
As function and strength improve, progressions into faster, functional and eccentric exercises are performed
Progression: (very important!)
1. Passive mobilisation
2. Passive exercises
3. Active exercises
4. Active resisted exercises
5. Functional/ Sports Specific
Power
‘Maximum amount of work an individual can perform in a given unit of time’ B&K CSM 4th Edn
- Training for power has long been known to be critical for athletic performance.
- Emerging evidence of the importance of muscular power for all populations including the elderly.
- It is important to initiate all movements as quickly and explosively as possible.
- Volume - relatively low.
- Intensity – depends on the type of exercise eg. Jump squat and Bench Press Throw (30- 60% of 1 RM)
- Olympic Type Exercises (80- 90% of 1 RM, 3-6 RM)
- Rest Periods (5 minutes)
Basic exercise program
- Warm up
- Strength and conditioning
- Cardio
- Warm down and static stretching
Initially high repetitions, low resistance
Progress to higher resistance with less repetitions
As function and strength improve, progressions into faster, functional and eccentric exercises are performed
Motor control and neural strategies
- Motor control training aims to optimise tissue loading to prevent injury (or further injury) and reduce nociceptive afferent discharge.
- Training aimed to restore activation of transversus abdominis is more effective for individuals found to have poor activation on ax at baseline.
- Recovery of symptoms is related to recovery of function of this muscle in these individuals. (Unsgaard-Tondel 2012, Ferreira 2010)
- Evidence is emerging for poor control across this stiffness-mobility spectrum in people with lumbopelvic pain.
- This can present as excessive motion (Schneider G ‘05), or excessive stiffness (Hodges ‘09), or elements of both.
Involves 3 main neural strategies
- Reactive control– nervous system activates a pattern of muscle activation in response to sensory input. System unexpectantly disturbed.
- Preparatory control– activation initiated in advance of the disturbance. Only used when demands are predicted.
- Ongoing tonic muscle activation–low percentage of contraction to maintain a state of preparedness.
Power vs Strength
Strength Initially high repetitions, low resistance Progress to higher resistance with less repetitions As function and strength improve, progressions into faster, functional and eccentric exercises are performed Progression: (very important!) 1. Passive mobilisation 2. Passive exercises 3. Active exercises 4. Active resisted exercises 5. Functional/ Sports Specific Progressions 1. Activation 2. Less than body weight 3. Body weight 4. Two legs 5. Single leg 6. Small reps 7. High reps 8. Plyometrics / High Weight Low Res 9. Sport Specific
Power
‘Maximum amount of work an individual can perform in a given unit of time’ B&K CSM 4th Edn
- Training for power has long been known to be critical for athletic performance.
- Emerging evidence of the importance of muscular power for all populations including the elderly.
- It is important to initiate all movements as quickly and explosively as possible.
- Volume - relatively low.
- Intensity – depends on the type of exercise eg. Jump squat and Bench Press Throw (30- 60% of 1 RM)
- Olympic Type Exercises (80- 90% of 1 RM, 3-6 RM)
- Rest Periods (5 minutes)
Functional capacity testing
“set of tests, practices and observations that are combined to determine the ability of the evaluated to function in a variety of circumstances, most often employment, in an objective manner”
A variety of physical skills and tests to determine:
- One’s ability to participate at the desired level in sport, occupation, and recreation or to return to participation in a safe and timely manner without functional limitations; and
- One’s ability to move through up to three planes of movement as determined via non-traditional testing that provides qualitative and quantitative information related to specialized motions involved in sport, exercise, and occupations.
7 Steps
- basic objective testing eg pain and rom
then
- proprioception and balance testing
- then strength testing (CKC OKC)
- then DL functional tests
- then SL functional tests
- then lower extremity functional tests (or upper extremity)
- then sports specific functional testing
Limitations
• Standardisation needed
• Most tests have not undergone validity and reliability testing = weakens use as re- assessment tools.
• Normative data unknown, especially between population groups.
Example of some tests used
Single leg bridge test
Supine on floor, heel on a box or plinth at 60cm.
• Knee of the test leg is slightly bent at 20deg.
• Opposite leg is bent to 90deg hip and knee flexion, arms crossed over chest.
• Subjects elevate the hips as high as possible and the assessor places a hand at this height.
• Repeat action as many times as possible touching the assessors hand each time.
• The test concludes when the subject is unable to bridge to the original height (assessors hand).
Single leg hop test
• Subjects stand on one leg and hop as far forward as possible and land on the same leg. The distance is recorded with a tape measure which is fixed to the ground.
• A limb symmetry index is calculated
Star excursion balance test
• The SEBT is performed in the anterior, posterolateral, and posteromedial directions.
• A composite score for all 3 directions is obtained for each leg. A limb symmetry index is then caculated.
• Can also compare forward results >4cm = increase chance of injury.
• Highly representative non-instrumented dynamic balance test for physically active people.
• Reliable measure and valid dynamic test to predict risk of lower extremity injury, to identify dynamic balance deficits in patients with lower extremity conditions, and to be responsive to training programs in healthy participants and those with lower extremity conditions.
• >4cm difference in forward result between sides = 2.5 x incidence of lower extremity injury (Plisky et al 2006 Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players)
Loading error scoring system
• Subjects jump off a 30cm high box onto the ground (at a distance from the box of 50% of their height) and immediately jump vertically upward as high a possible.
• Subject performs this task multiple times until the assessor has observed and marked all items/errors on the criteria.
Progressions employed after levels of motor control, strength, power, endurance, flexibility and proprioception achieved
Tendinopathies
Most common in:
Older populations – Achilles, RC, LE, Gut med
Younger populations – Patella, Adductor, Hamstring, Achilles
Occurs after a sudden increase in load (exercise), which may have been a result of volume, intensity or frequency of training. Can result in pain, decreased exercise tolerance and reduction in function.
SSX:
- Focal localised pain approx. 1cm in diameter
- Pain is load dependant, i.e. Greater load = more pain
- Pain worse 24 hours after load
- Injury usually occurs at the point of the tendon with least blood supply (e.g. 2cm above insertion of Achilles) or the musculotendinous junction.
If no load involved can be due to CVD factors
If its bad for your heart its bad for your tendons i.e. T2 diabetes
Stages of tendon pathology
Stage 1 Reactive tendinopathy
– Refers to non-inflammatory response of tendon cells and matrix proteins to an acute tensile or compressive overload.
– Short term thickening an attempt to reduce stress’
– More common in younger person
– Also arises with direct trauma to tendon
Stage 2 Tendon dysrepair
– Worsening tendon pathology with greater matrix
breakdown.
– Seen clinically in overloaded tendons, difficult to detect transition from stage 1 without imaging.
– Disorganized matrix leads to ingrowth of blood vessels and nerves
– Further thickening
Stage 3 Degenerative tendinopathy
– “end stage” of tendon overuse
– With long term failed response to loading, cells give up and die (apoptosis)
– If left untreated leads to rupture
Treatment
If you identify the injury in the early stages (reactive tendinopathy or early tendon dysrepair) then:
• Load management/reduction will allow the tendon time to adapt and recover. This will result in lower levels of pain.
• In these stages if aggravating activities are continued and eccentric exercises are added without sufficient recovery, poorer outcomes will result.
In degenerative stages:
• Exercise is a positive stimulus for tendon restructuring.
• Pain does not affect the overall outcomes.
• Eccentric exercise treatments, despite pain response, is important.
• Possible adjunct treatments, such as frictions, ultrasound, and shock wave therapy may be useful at this stage of pathology as their rationale is to stimulate cell activity.
• Prolotherapy, aprotinin, sclerosing therapy, glyceryl trinitrate and injection itself may all have theoretical implications in degenerative tendinopathy.
Stages of treatment
Identify and adjust the load that is causing the problem.
Stage 1. Isometric exercise
• Shown to immediately relieve patellar tendon pain more than isotonic exercise and sustained for 45min. (Rio et al)
• 3 – 5 sets of 30-60sec up to 5/day.
• Primary goal is to reduce morning stiffness and pain during tensile load. Approx 2 weeks in reactive on degenerative tendon but may take 6-8/52 in purely reactive tendon.
Stage 2. Isotonic exercise
• Pain is stable at low level. Intro of slow heavy isotonic (concentric/eccentric) exercise (ratio 3:4), 4 x 6-8 reps. Every 2nd day, retain stage 1 exercises.
• Should be performed for every muscle in kinetic chain that has a deficit – particularly anti-gravity mm such as calf, quad, gluts.
• Can take up to 12/52 for good strength in musculotendinous unit.
• Eg >25 calf raises (achilles) or 1.5X BW leg press (patella).
Stage 3. Energy storage exercise
• Once mm stronger, the tendon can be loaded with energy storage exercises.
• To store energy in a tendon you need to do faster eccentric exercises, initially with a slower release (concentric phase), but building to quick storage and fast release.
• High loads so only 2-3/7. Monitor 24-48hr response.
• Retain phase 1 & 2 ex.
Stage 4. Sport-specific energy storage and release
– Once the tendon can tolerate high-energy storage loads.
– Functional activity-specific exercises.
– Retain stage 1-2 exercises, stage 4 replaces stage 3.
– Again, only every 3rd day as high load exercises.
– Controlled training environment and then competition.
Load management
LOW LOAD= Slow strength movements, Cycling, Rowing, Swimming
MODERATE LOAD= Straight line running, Slow skipping
HIGH LOAD= Plyometrics, Agility and Change of direction, High speed running
