Lecture 5 Flashcards
What is the stage approach to rehabilitation?
- Restore biomechanical integrity
- Groove motor patterns
- Strengthen
- Functional adaptation
Describe functional and structural components of assessment?
Traditional orthopaedic medicine is influenced
by a structural approach to pathology, we
can see it thus X-ray imaging, MRI, or surgery
(damage to soft tissues or bones)
functional approach which is based on
coordinated movement of the muscle in relation
to other structures and takes into account the
stabilizing roles of muscle
An example of structural and functional assessment
A structural approach - Dx by examining structures with
MRI, Ultrasound and X rays. Eg., the hooked acromion
(type III) = structural impingement by reducing the space.
ANSWER . . . . cut it off . . .
Functional impingement presents with normal X-ray
findings, but pain and weakness are typically observed
Weakness is often in the scapular stabilizers, far from the
point of pain
Tx: restoring muscle balance through specific exercises
that work not just the glenohumeral joint but the entire
shoulder complex
Please describe muscle balance?
Muscle balance is the relative equality of
muscle length or strength between an agonist
and an antagonist; it is necessary for normal
movement and function.
Muscles may become unbalanced as a result of what?
adaptation or dysfunction. Such muscle imbalances can be either functional or pathological
Pathological muscle imbalance can result in what?
impairment of function and leads to joint dysfunction and alters movement patterns, which in turn leads to
pain
Pathological muscle imbalance is caused by what?
Cause may or may not result from an initial traumatic event. Posture related?
JUST READ
Pathological muscle imbalance may also be insidious;
many people have these muscle imbalances
without pain
What are the 2 paradigms of muscle imbalance?
Biomechanical: muscle imbalance resulting
from repetitive movements and posture thus
adaptions in muscle length, strength and
stiffness
Neurological : muscles are predisposed to
become imbalanced because of their role in
motor function. Neural control unit may alter the muscle
recruitment strategy to stabilize joints
temporarily in dysfunction
This change in recruitment alters muscle
balance, movement patterns, and ultimately the
motor program
What are 3 concepts or patterns of muscles?
Static or postural muscle tighten as they are
activated more
Dynamic and phasic muscles tend to weaken
with dysfunction
Muscles are the window to the function of the
sensorimotor system as they are labile and
vulnerable structures as the most exposed part
of the neuromuscular system
Pathophysiology of muscles
Muscle imbalance often begins after injury or pathology leads to pain and inflammation.
Imbalance may also develop insidiously from alterations in proprioceptive input resulting from abnormal joint position or motion.
These two conditions lead muscles to either tighten
(hypertonicity) or weaken (inhibition), creating localized muscle imbalance. It’s the normal response of the motor system to maintain homeostasis.
Over time, this imbalance becomes centralized in the CNS as a new motor pattern, thus continuing a cycle of pain and
dysfunction.
Janda; “muscle imbalance is an expression of impaired
regulation of the neuromuscular system that is manifested as a systemic response often involving the whole body”.
Describe Janda’s upper crossed syndrome?
It is a postural syndrome NOT a diagnosis
It explains how antagonistic muscles become imbalanced
It may result in compromised posture
This may leave the patient with altered spinal and shoulder region biomechanics
It increases the risk of associate pain syndromes
One line of the cross demonstrates
hypertrophic (tight) muscle
Other line demonstrates
hypotrophic (weak) muscle
What is the definition of JANDA
“it is an adaptation to the demands imposed upon the
musculoskeletal system, as it is the posture of the deconditioned and of the office worker. It was associated
with concurrent movement dysfunction”
Assessment & Intervention
Janda; address dysfunction in all three systems (FINO)
- First reducing any joint dysfunction or nociception in order to improve the local afferentation
- Normalize muscle imbalances with manual techniques
- Improve muscle firing patterns via sensorimotor training
- Once this was accomplished, specific therapeutic exercises designed to neutralize the chronic dysfunction and improve endurance and strength could be appropriately introduced
What does pelvic tilt tell you about a patient?
Anterior tilt = lower crossed pattern
Post tilt = loss Lx lordosis, tight hamstrings
What does head forward posture tell you about a patient?
Upper crossed pattern impact
tight; levator scaps & pecs
Weak; lower trap & deep Cx flexors
What is involved in a balance assessment?
Single leg balance test
Eyes open
Eyes Closed (+ perturbation: disturbance of motion)
Hip extension movement pattern, Watch for what?
- Lx extension and ant pelvic tilt during hip extension
2. Knee flexion during hip extension
Instructions for hip extension movement patterns
• Place patient prone on the bench
• Instruct “ raise your (right or left) leg toward the
ceiling”
• Watch for ant pelvic tilt, lumbar hyperextension
or trunk rotation in the first 10° of leg raising,
knee flexion to reduce work load
• Also watch for delayed glut max activation
(lower cross issues ?)
• While performing the motion its easy to test for
glut max strength, scale of __/5
Janda’s lower crossed syndrome means what?
tight erector spinae
tight iliopsoas
weak glut max
weak abdominals
Indications for possible Tx for HIP EXTENSION PATTERNS?
• Hip mobilization
• Stretches (PIR) of the psoas, also review rectus
femoris and hamstrings
• Femoral nerve involvement, neuromobilization?
• Sensory motor training – rocker board, balance
sandals?
• “Core” stabilization
• Bridges, squats and lunges to strengthen
Hip abduction movement pattern, Watch for?
- Flex the hip further
2. QL initiated as first movement
Instructions for hip abduction movement patterns?
• Pt side lying with lower leg flexed at the hip and
knee. Pelvis perpendicular to the table
• Instruct Pt – slowly raise your leg straight up to
the ceiling
• Fail if: on initiation of motion, cephalad shift of
pelvis, thus there is QL substitution
• Fail if in first 40°: Hip flexion (TFL substitution),
Hip ER (piriformis sub), pelvic rotation (glut med
weakness), reduced abduction then adductor
tightness
• Also check muscle strength ___/5.
Instructions for Cervical flexion movement patterns?
- patient lays supine head not on pillow
- instruct to slowly raise your head up from the table to your chest
- Fails: if chin protrudes, SCM’S overactivity, shakes from effort
Target: PIR SCM’s, check upper cervical spine, cervical spine and thoracic spine junction, endurance training, functional training, review posture
Instructions for push up movement pattern test?
• Pt in pushup position, toes or knees
• Instruct – slowly lower and then raise yourself
up again
• Fail: scapulae retract, wings or shoulder shrugs
• Targets:
- review for adj/mob T4-8, glenohumeral joint
- stretch pecs, traps, lev scaps
- proprioception – closed / open chain wall ex’s
- strengthen scap protraction
Instructions for Truck curl-up movement pattern
o Pt supine with knees slightly flexed o Ask the Pt to “curl up” until shoulder blades are off the table o Fail: feet raise up off the table before scaps come off the table, o Targets: • stretch hip flexors • core stabilization
Instructions for Trunk curl-up As an endurance test?
Pt is supported on a 50° wedge or CA Dr holds Pt feet & the wedge moved backward 10cm Pt instructed not to touch the wedge, give cues as fatigue “less than 50 secs is dysfunctional”
Please explain Vele’s Reflex stability test
o Pt to stand with feet shoulder width apart, arms by side
o Instruct: try lean forward from the ankles without bending at the waist
o Fail: delayed or absent gripping of the toes
o Target Rx:
• mob ankle/foot
• stretch calf
• strengthen intrinsic muscles of the foot
Please explain the squat test?
• Pt stands with feet hip width apart, arms straight ahead, or supported if safety issue
• Instruct them to squat until thighs are nearly parallel to the floor (less if acute or elderly)
• Fail: decrease depth of squat, knee valgus, knee
flex beyond line of toes (check hip tightness),
Lumbar hyperextension or flexion
• Target Rx:
• strengthen with side bridges
• functional with squats and lunges
Please explain the Single leg squat test
o Ask the Pt to stand with feet hip width apart o Instruct to perform a mini squat please o Fail: Inability to perform, subtalar hyperpronation, knee valgus, knee flex beyond toes, Trendelenburg sign o Target Rx: • Stretch ITB, TFL, Piriformis, • Strengthen glut med, • Sensory motor training?
Please explain the forward lung test?
o Ask: Pt to step forward and touch/kneel on the
floor, then rise back up to standing position
o Fail: inability to reach floor with back knee, poor
balance, subtalar hyperpronation, knee valgus
motion, knee flex beyond line of toes, trunk
flexion
o Target:
• anterior hip capsule
• stretch hip flexors
• sensory motor training
Please explain the side endurance bridge test?
o Ask: Pt to lay on side, then instruct to raise pelvis
from the floor until spine is aligned. Ask hold the
position as long as possible. Only the feet and
forearm/hand should be on the floor.
o Fail: Record time. Stop when for second time the
pelvis drops below peak height (touches Dr hand)
•
Muscle length testing
- Thomas / Modified Thomas for Iliopsoas, rec fem
- 90/90 SLR Hamstring test
- Ober’s test for hip abductors
- Hip Ab / Adductors - Supine
- QL – seated / standing side reach / side posture
- Piriformis
- Rectus femoris / quads – prone
- Lev scaps & traps
What is the grading score for FMS (function movement systems)?
0 – If pain is present during any part of the test.
1 – If the athlete cannot perform the test, but no pain is
experienced.
2 – The athlete can perform the test, but with modifications or visible restriction or compensation.
3 – The athlete can perform the test and meet all criteria
for the given test.
What does the FMS hurdle test assess?
Excellent indicator of running biomechanics as it evaluates hip mobility and extension of the leg during running.
Corrections here can improve sprinting explosiveness
What does the FMS shoulder mobility test assess?
Symmetrically evaluates shoulder ROM, important for
holding off players and essential to numerous goalkeeping activities
What does the FMS straight leg raise test assess?
Evaluates flexibility of hamstrings, gluteals, calves and hip flexor/quadriceps on opposite side
What does the FMS inline lunge test assess?
Evaluates stability and balance with the body in a split stance, important in acceleration
What does the FMS drop/ deep squat test assess?
Evaluates squatting mechanics and mobility of
the shoulders, hips, knees, and ankles, critical to
deceleration
What does the FMS trunk stability push-up test assess?
core stability is utilized in all aspects of the game from
running, cutting, jumping, heading, passing, shooting,
tackling, slide tackling, diving
What does the FMS rotatory stability test assess?
Evaluates core stability and ability to connect and
coordinate movements between the upper body and
lower body like running & changing directions,
jumping & heading, shooting/passing & balancing
In relation to the Y-balance test, how do you calculate the normalised reach distance?
calculated by dividing reach distance by the limb length
The Y-balance test, tests what things?
assessed absolute reach and normalized distance for each direction, asymmetry between limbs, and composite score
In the Y-balance test, how do you test for asymmetry?
absolute difference between right and left leg and is determined for each reach direction
In the Y-balance test, how do you calculate the composite score?
Reach summing the reach distance in the three directions & dividing by three times limb length, and multiplying by 100
Y1 + Y2 + Y3 ÷ 3 x limb length (x 100)
READ THIS!
o Dysfunctional, limited, or asymmetrical control
in single-leg balance tasks have been associated
with increased injury risk during participation in
sport
o Past or present injury may or may not reduce
composite scores
o Asymmetry in reach is common, one study 31%
had an asymmetry of greater than 4 cm
o Males consistently outperform females
o Age produces a bell shaped curved with a peak
at 30 years
