L21: Skills Prac Muscle and sensorimotor management

Question 1

What are 6 retraining principles?

Answer 1

1. Use the principles of motor relearning- segmentation. simplification, augmented feedback
2. Precision is required
3. Exercises should be pain free
4. Exercises should be short of fatigue
5. Correct movement pattern
6. Multiple repetitions

Question 2

What are the 3 retraining principles in motor relearning of postural function of deep cervical flexors?

Answer 2

1. Segmentation:
   
   • The DCF are trained by a specific movement task of CCF
2. Simplified:
   
   • Performed in a supine position using a single plane movement
3. Augmented feedback:
   
   • Use of biofeedback
   • Use of sensory input from plinth on the back of the head (“slide head up the bed”)

Question 3

What is segmentation of retraining principles in motor relearning of postural function of deep cervical flexors?

Answer 3

The DCF are trained by a specific movement task of CCF

Question 4

What is simplified of retraining principles in motor relearning of postural function of deep cervical flexors?

Answer 4

Performed in a supine position using a single plane movement

Question 5

What is augmented feedback of retraining principles in motor relearning of postural function of deep cervical flexors?

Answer 5

1. Use of biofeedback
2. Use of sensory input from plinth on the back of the head (“slide head up the bed”)

Question 6

What are 2 characteristics of patient compliance and self help?

Answer 6

1. Sell pain control
2. Effectiveness as teacher- To do exercises well

Success depends on the skill of the practitioner

Cannot just give written HEP for patient (need to teach)

Question 7

What are 2 characteristics of schedule for formal training as retraining principles?

Answer 7

1. twice per day –am, pm
2. tonic endurance capacity – 10 x 10 sec holds
   
   • Can start with 5 x 5 sec holds

Question 8

What is a characteristic of during day as retraining principles?

Answer 8

repetitive practice throughout day - neck and scapular muscles repeatedly activated in postural correction exercise in the learning process

• 10sec every 15 mins
• Can use alarm/reminders every 15mins (outlook appointment in the morning –> snooze –> occurs every 15mins)

Question 9

What are 2 characteristics of progressions as retraining principles?

Answer 9

1. modify, add to the exercise program as the patient progresses
2. time for change is variable (CgH trial average - 4-6 weeks)
   
   • Range 2 weeks to 8-10 weeks)

Question 10

What is a characteristic of maintenance program as retraining principles?

Answer 10

consider elements of an essential maintenance program

Question 11

What are the 6 management on day 1 for the muscle system?

Answer 11

1. Explanation of evidence for presence of muscle impairment, occurs immediately
2. Explanation of evidence of efficacy of exercise
3. Constantly demonstrate the pain relieving effect of the exercise program
4. Formal training of craniocervical flexion (± extensors)
5. Formal training of scapular synergy
6. Postural re-education exercise to integrate their functional action in everyday activities
   7.

Question 12

What is the characteristics of “practice 10sec holds of correct posture every 15mins” in the training of neutral posture?

Answer 12

1. sitting, standing, walking
2. discuss reminder cues with patient

Question 13

What are 4 characteristics of “first treatment” in the training of neutral posture?

Answer 13

1. Explain how a neutral posture deloads unnecessary strain from the neck
2. Correct spinal posture from the lumbopelvic region
3. Facilitate supporting muscles (eg, multifidus, TA, longus capitis/colli; scapular synergy)
4. Teach self facilitation strategy (other feedback as required)

Question 14

What are 3 characteristics of “first or second treatment” in the training of neutral posture?

Answer 14

Once lumbar spine has been corrected, then thoracic jyphosis

• If excessive thoracic kyphosis: lift sternum
• Not enough thoracic kyphosis (too straight): relax a bit

1. Train positioning of shoulder girdle
   
   1. use instructions related to anterior chest region (easier for patient to visualise)
   2. can use analogies of elastic bands on anterior chest wall
   3. work with position of sternum (if required)
   4. If protracted: rubber bands across chest –> stretch ribber bands out to open chest
   5. Anterior tilt: stretch rubber bands up and out
   6. Downward tilt: stretch up and back
2. Maintain spinal posture**
3. Occipital lift
   
   1. “Back of skull lift off your spine”
   2. Activated deep neck flexors when doing posture correction

Question 15

What are 4 characteristics of training scapular synergy?

Answer 15

1. Low load (side lying, prone)
   
   1. Difficult in prone
   2. Easier in side lye with pillow
2. Emphasise precision and control of scapular rotation(tripartite trapezius)
   
   1. PNF, guide/facilitate movement
3. Train holding capacity at low loads used functionally in control of posture and arm movements
4. Reinforce training with repeated activation and holding in postural correction exercise

Can adjust the degree of shoulder flexion

Can do 5 sec holds

Question 16

What are 3 characteristics of training the serraus anterior?

Answer 16

Push off from wall, Prone on elbows, 4 point kneel - neutral posture

1. Maintain neutral head and trunk alignment
2. Raising and lowering thorax on scapulae with holds
3. Note: tonic endurance training of neck extensors incorporate with neck extensor training

Question 17

What are 8 characteristics of training the appropriate pattern of C-CF?

Answer 17

1. Train in supine lying (low load)
2. Facilitate with feedback from surface of bed
3. Facilitate with eye movement
4. Monitor superficial flexors with self palpation
5. Emphasise precision and control of the sagittal rotation movement of CCF (avoid retraction)
6. Use large range of motion – extension to flexion
7. Train to return to neutral position (use vision guide)
8. Train movement; introduce holding contractions if pattern is correct
   
   • Slide the back of your hair up the bed

Question 18

What are 3 characteristics of training C-CF for nerve tissue mechanosensitivity?

Answer 18

C-CF movement can be provocative if nerve tissues are mechanosensitive

1. Train C-CF pattern from extension to neutral
2. Train holding capacity by graded self resistance (thumb on mandible) in neutral
3. Progress to formal training program once sensitivity has resolved

Question 19

What are 5 characteristics of training holding capacity of the C-CF?

Answer 19

1. Once correct pattern is achieved, train CCF holding capacity starting at assessed pressure level (ensure there is no reversal to a retraction action)
2. Avoid fatigue 􀁯 substitution, incorrect pattern
3. Patient learns the ‘feeling’ of the holding contraction with feedback from the Stabiliser
4. Train with and without feedback – home no feedback
   
   1. efficiency of home exercise
   2. avoids feedback overload
   3. trains kinaesthetic sense
5. Aim for 30mmHg (10x10 sec holds) Normals - 26-28 mmHg

Question 20

What are 4 characteristics of training deep neck extensors? What are the 3 positions?

Answer 20

1. Forward reclined sitting
2. Prone on elbows
3. Four point kneeling (best position unless they have wrist, arm pain)
4. Train suboccipital muscles craniocervical extension and rotation
5. Train cervical extension pattern (semispinalis cervicis)
   
   • Can use a laser on head (visual feedback)
6. Concentrate on movement pattern and train dynamic endurance
   
   • eg. 3 sets of 5 reps initially; progressing to 10 reps
   • Twice a day

Question 21

What are 4 characteristics of co-contraction exercises? What are the 2 muscle groups in co-contraction?

Answer 21

Train deep cervical flexors in co-contraction with the deep neck extensors

• (ie training the deep muscle sleeve)

1. Neutral postural position of spine
2. 10% effort
3. Facilitate with rotation
4. Facilitate with eye movement
5. Alternating isometrics
6. 5 sec holds x 5 reps

Question 22

What is the characteristic of training interaction of deep and superficial neck flexors in movement patterns? What is the 2 progressions?

Answer 22

Once the patient has improved C-CF activation and endurance capacity (eg 10x10sec @ 26mmHg or better)

Train the neck superficial and deep flexor synergy dynamically with controlled head load (Activation eccentrically)

1. Extend to ranges that the patient can control and are painfree
2. Always ensure a correct pattern through initiation with the C-C region

Question 23

What are 3 characteristics of endurance training extensors?

Answer 23

1. Isometric training of the lower deep cervical extensors
2. Maintain neutral cranio-cervical gently push back different ranges of flexion.
3. Progressive increase in loads (20%, 50%), repetitions, and duration up to 100 seconds (At least 30 secs)

Question 24

What are 6 characteristics of training shoulder girdle control with task specificity ?

Answer 24

1. control with arm movements
2. computer work
3. lifting, carrying
4. bench work
5. gym work
6. other functional activities as required by the patient

Note importance of maintenance of neutral spinal posture in all activities

Question 25

What are 4 characteristics of training scapular synergy?

Answer 25

1. Train holding capacity at low loads used functionally in control of posture and arm movements
2. ***In the first 30-40 degrees of arm elevation there is minimal scapular motion
   
   1. There is the progressive upward rotation, posterior tilt, and external rotation as the arm elevates
3. Train control of neutral scapular posture with free arm movements: abduction< 30º, flexion< 30º, external rotation
4. Progress by adding loads eg start with 0.5Kg (Up to 5kg)
   
   1. Concentrate on: control of scapular position (ie posture of anterior chest wall) control of head and neck posture

Question 26

What are 2 characteristics of subsequent treatments in training scapular synergy?

Answer 26

1. Train scapular control throughout the range of arm elevation and lowering – manual facilitation
2. Address fatigability of upper trapezius
   
   1. 3 sets of 5 → 10 active arm abduction/flexion – free exercise
   2. Progress starting with light load (eg 0.5Kg)
   3. Ensure correct pattern is maintained throughout range

Question 27

What are 4 characteristics of functional anti-gravity holds through range in strength and endurance training?

Answer 27

C-CF activation and endurance capacity (10x10sec @ 28-30mmHg)

1. Commence at positions in the range that the patient can achieve painlessly
2. Train 5 sec holds x 5 reps
3. Progress position of extension
4. Best performed and progressed off a wall

Question 28

What are 4 characteristics of strength and endurance training?

Answer 28

1. Functional antigravity holds through range
2. graduated head lift (progressive loads)
3. Add resistance to extension
4. Train to the functional requirements of the patient

Question 29

What are 4 steps in the strength and endurance training?

Answer 29

1. 2 pillows (5 x 5 secs)
2. 10 x 10 sec holds (aim) (2 sets)
3. 1 pillow 10 x 10 sec hold (more sedentary (2 sets)
4. No pillow 10 x 10sec hold (2 sets) (more advanced)

Question 30

What are shoulder and neck exercises in the prevention in exercise intervention workers?

Answer 30

Question 31

What are 2 managements of work practices?

Answer 31

1. Functional capacity assessment
   
   1. Dependence on functional abilities needed
2. Strength and endurance training to the functional, work and sport requirements of the individual patient

Question 32

What is the cervical flexor progression?

Answer 32

Question 33

What is the cervical extensor progression?

Answer 33

Question 34

What is the scapula muscles progression?

Answer 34

Question 35

What is an example progression all muscles?

Answer 35

Question 36

What would be your approach to her management (4)?

Answer 36

1. Commence restoration of posture and formal and functional muscle function – neck flexors, extensors and scapular muscles
2. Some manual therapy but not main emphasis
   
   • Can reduce joint signs with scapula correction
3. Progress to functional tasks, strength and endurance neck and scapular muscles
4. Ergonomic advice – regular position changes, postural correction

Question 37

What is Susan’s prognosis?

Answer 37

1. There are indicators of good recovery – pain/disability levels, no other psychosocial factors
2. Should do well if adheres to exercise program, may require maintenance to prevent recurrence
   
   • Eg. posture correction or scapula exercises

Question 38

What would be your specific early physiotherapy management and home program (6)?

Answer 38

1. Ergonomics, advice modification of activities sitting, computer rest breaks – reminders for posture
2. Posture correction – lumbar and thoracic first, then scapular (upward rotation and retraction) and cervical – progress as able to maintain positions.
3. Commence neuromotor control exercises DNF – 22mmHg 10 second holds – build to 10X10 twice daily, Scapula in sidelying – palpate to ensure keep lev scap relaxed. 10x10 second holds twice daily and after work for pain relief.
4. Add lower cervical extensor work
5. Manual therapy – if required, not main emphasis
6. Self management – heat, exercises.

Question 39

How would you progress the exercise program (3)?

Answer 39

1. Progress CCFT holds pressure levels
2. Progress to:
   
   1. Scapular functional small arm movements with scapular stabilising, circles, small range flex, abd.
   2. Increase cervical extension range, add weight
   3. Neck flexor synergy- head lifts off wall, pillows
   4. Scapular small weights low range
3. Maintenance program- regular posture correction at work.

Question 40

What are 3 sensorimotor management?

Answer 40

1. Joint position error
2. Cervical movement sense
3. Eye movement control

Question 41

What are 4 characteristics of joint position sense in sitting - with laser feedback?

Answer 41

1. repositioning to neutral (eyes open, closed)
2. repositioning to points in range – eyes closed, check eyes open
3. Progress body position: sit, standing, balance
   
   1. If they are really bad, can do everything with eyes open (but try progress this)
   2. Different balance positions
4. CCF training locate target pressures, eyes open, eyes closed

Question 42

What are 2 characteristics of cervical movement sense in sitting - with laser feedback?

Answer 42

1. Follow patterns with laser- encourage accuracy first then increase speed
   
   • Can always just practice with vertical or horizontal lines
2. Increase complexity of pattern

Question 43

What are characteristics of eye follow/ smooth pursuit training?

Answer 43

Turn trunk and keep head and neck straight –> eye follow

• Compared with normal neutral position

Question 44

What is phase 1 in the exercise program? What is phase 2 (3)?

Answer 44

Phase 1: Rehabilitation of muscle control aspects, and tailored sensorimotor exercises as required

• Indications: Trauma or dizziness

Phase II: Strengthening and endurance program

1. Introduced as the disturbed muscle behaviours have been addressed
2. Progressive loaded program
3. More difficult tasks –sensorimotor- challenge balance, joint position and movement sense, eye movement control

Question 45

What are sensorimotor exercises?

Answer 45

Question 46

What are 4 characteristics of clinical assessment?

Answer 46

1. Not all patients will have all impairments
2. Axio-scapular muscle impairment is not generic to neck pain
3. Impaired cervical kinaesthetic sense
   
   1. ~ 70% in chronic whiplash
   2. < 30% in mechanical neck pain
4. Exercise prescription must be based on the assessment of the individual patient

Question 47

Exercise should not provoke_____

Answer 47

neck pain

Question 48

Precision in exercise is emphasized in the ______ process

Answer 48

motor learning

Question 49

Muscles are trained _____ and within a ____ and ____ specific context

Answer 49

specifically; functional; task

Question 50

Tailored ____ program relevant to assessment

Answer 50

sensorimotor

Question 51

_____ is essential in the learning process to establish or re- establish appropriate movement and muscle control

Answer 51

Repetition

Question 52

_____ with the exercise program is critical to the learning process

Answer 52

Compliance

Question 53

Patient’s must understand the ____ underpinning the various components and phases of the exercise approach.

Answer 53

rationale