Midterm Lecture Flashcards
1
Q
What are goals of rehabilitation?
A
Restoring mobility and functions needed to do ADLs
2
Q
Short term goal includes “increase function by …” or “decrease pain by” ___ %
“Increase aROM by” ___ %
“Increase flexibility by” ___ %
A
50% over next 2 weeks
AROM 30%
Flexibility 40%
3
Q
Long term goals regarding strength and flexibility?
*Exam Q
A
90% strength, 100% flexibility within 6 weeks
4
Q
Do you perform movement screening on acute patients/
A
No
5
Q
What is FMS?
A
Functional movement screen by Gray Cook, PT
7 movements, each exercise is a test. Some of them have clearing exams.
6
Q
What is Mag 7?
A
Magnificent Seven by Craig Liebenson, DC
Tweaked from FMS, no dowels or special equipment necessary.
7
Q
What are the 7 exercise in FMS? And which ones have clearing tests?
A
- Deep squat
- Hurdle step
- Inline lunge
- Shoulder mobility*
- ASLR
- Trunk stability pushup*
- Rotary stability*
8
Q
What are the 7 exercise in Mag 7?
A
- aROM of area of c/c
- Wall angel/T4 mobility
- Overhead squat
- Single leg stance
- Single leg squat
- Lunge to kneeling
- Respiration
9
Q
How do you score FMS and Mag7?
A
0-3
10
Q
When scoringFMS and Mag7, what does 0 mean?
A
Pain
11
Q
When scoringFMS and Mag7, what does 1 mean?
A
Can’t perform movement/>50% loss of ROM
12
Q
When scoringFMS and Mag7, what does 2 mean?
A
Performs movement with compensation (imperfect)/looks ok, but dysfunction is present
13
Q
When scoringFMS and Mag7, what does 3 mean?
A
Performs movement without compensation
14
Q
What is the goal score with FMS and Mag7?
A
To correct key fault that is causing trouble
At least 14 points (all 7 tests get at least a 2)
If there are a lot of 0s or 1s but the score is above 15, that’s not great.
15
Q
What is Lx instability?
A
Painful disorder hypothesized to result from loss of spine’s ability to maintain appropriate mechanical stiffness in neutral, midrange, or end-range movements
16
Q
Vertebrae, intervertebral discs, ligaments, joint capsules, and zygapophyseal joints are what stabilization system?
A
Passive stabilization
17
Q
Stabilizing muscles such as multifidi, trans versus abdominis, diaphragm, etc. make up what stabilization system?
A
Active stabilization
18
Q
Motor control, coordination, and proprioception make up what stabilizing system?
A
Neuromuscular control
19
Q
Structural instability is also called
A
Radiographic instability
20
Q
Radiographs are NOT indicated within the first 6 weeks of LBP if the following criteria are met
A
– No neurologic symptoms – No constitutional symptoms – No history of trauma – No symptoms of malignancy – Patient is 18 to 50 years old
21
Q
Do you do ancillary studies for structural instability? If so, what kind?
A
X-ray plain film is first choice
But its NOT indicated within the first 6 weeks of LBP if – No neurologic symptoms – No constitutional symptoms – No history of trauma – No symptoms of malignancy – Patient is 18 to 50 years old
22
Q
What are the types of spondylolisthesis?
Which one is the MC?
A
Type I dysplastic Type II isthmic **MC Type III degenerative Type IV traumatic Type V pathological
23
Q
Spondylolisthesis Type I
A
Dysplastic (congenital)
24
Q
Spondylolisthesis Type II
A
Isthmic (stress Fox in the pars-interarticularis)
25
Spondylolisthesis Type III
Degenerative (degeneration of the IVDs)
26
Spondylolisthesis Type IV
Traumatic (Acute Fx)
27
Spondylolisthesis Type V
Pathological (bone disease/infections/tumors)
28
Functional instability is also called
Clinical instability
29
What are key points from the HISTORY for a patient with functional instability?
– Complaints of “giving way” or “going out”
– Recurrent episodes
– Pain during sudden or trivial activities
– Pain during transitional activities
– Pain with sustained postures
– Difficulty with unsupported sitting
– Short term relief from manual therapy
30
What clues from PE would you see in a patient with functional instability?
```
– Aberrant movement pattern during active
trunk flexion
– Painful arc on return
– Minor’s Sign (“thigh climbing”)
– Catching or locking
– Reversal of lumbopelvic rhythm
– (+) Prone Instability Test
```
31
Describe prone instability test and (+) finding
1. Patient lays on their tummy, feet on the floor.
2. Doc applies P-A stress to SPs.
3. Patient then lifts their legs away from the floor.
(+) finding is if there is decrease pain
32
Describe passive leg extension test AND (+) finding. What does this suggest?
Both legs are lifted about 30 cm and gently tractioned to allow the lumbar spine to settle into extension
(+) test is pain or feeling of heaviness in the low back which disappears when the leg is lowered
Suggests: unstable spondylolisthesis
33
Which kind of instability do you get poor motor control? And which one do you see radiographic evidence?
Frankly, maybe both. But FUNCTIONAL speaks to the functional instability. Structural instability will have radiographic evidence.
34
In addition to having aberrant Lx flexion, what are the 3 other components that predicts patients with functional instability will have a positive response to stabilization exercises?
Those with:
1. (+) prone instability test
2. <40 yo
3. Bilateral SLR flexilbity >91˚
35
How do you manage functional instability?
- diaphragmatic breathing
- abdominal bracing/neutral pelvis
- hip hinging
- lumbar stabilization exercises
- CMT to adjacent areas
36
What are some lumbar stabilization exercises?
Quadruped track
Bridge track
Side bridge track
37
Case Presentation
Hx
* 37y.o. male office manager presents with intermittent Lx pain
* Most recent episode was initiated by bending over to pick up a pen he dropped and felt “my back go out.”
* Reports having these episodic sx’s about 2-3x/year, but are becoming more frequent
PE
• Lx aROM:
– Painful arc when returning from flexion
• Neuro Exam:
– Unremarkable L.E.: DTR’s/Lt. Touch/Mscl Testing
• Ortho. Exam:
– Decreased resistance with prone Jt. Play
– Poor Motor Control with movement
– (+) Prone Instability Test
Lumbar instability
38
Case Presentation
Hx
• 45y.o. Female presents with Cx pain of 2 weeks duration
• Sx’s began after a MVA 2 weeks ago
• Stated that she was rear-ended while at a stop light
• Since injury, has been having daily HA’s and right arm sx’s (down into her hand)
• Has been taking Ibuprofen and resting hoping that it would go away, but hasn’t.
PE
• Limited Cx aROM (very splinted)
• Ortho: (+) Cx compression/Max Compression/Shldr depression/Cx Kemps
• Feels better with Cx distraction (arm sx’s decrease)
• Neuro: (-) sharp/dull/vibration, but Lt. Touch is decreased on R side (C6).
• (-) Rapid wrist clonus
• DTR’s: +2/4 Biceps/Triceps/Brachioradialis
• Palp: Cx Jt. Dysfunctions/Hypertonic suboccipitals and Cx paraspinals.
What is on the DDX list?
Cx sprain
Cx strain
Cx disc herniation
Cx disc derangement
39
Goals in the acute phase of Cx patient (2)
Slow atrophy
| Maintain muscle memory/neuro programming
40
Cx Rehab - Acute Care interventions (4)
1 — aROM (painfree)
2 — pROM
3 — Isometric exercises w/ 20% mm contraction (painfree)
4 — directional preference (McKenzie) including end-range loading static hold vs repetitive end-range loading
41
What is the rehabilitation strategy for Cx patient?
- address postural / mm imbalances (strengthen/stretch upper cross syndrome)
- evaluate and train Cx joint dysfunction, scapular stabilizers, breathing
- retrain proprioception
- work on mm endurance
42
How do you assess posture with Cx patient? (5)
Thx extension with motion palpation (T4 mobility)
Pec evaluation with length test (esp sternal portion)
Controlled head nodding (NOT retraction) look for shaking/ratcheting = deep Cx flexor weakness
Shoulder abduction movement pattern*** gown patient so you can see hiking/imbalances side to side
Breathing/respiration - because involved mm are also postural mm
43
Faulty shoulder ABD: elevation of shoulder during 1st 60˚ of ABD.
What mm are inhibited/weak?
Middle and lower traps
44
Faulty shoulder ABD: elevation of shoulder during 1st 60˚ of ABD.
What mm are overtight/active?
Upper trap and levator scap
45
Faulty shoulder ABD: scapular winging.
What mm are inhibited/weak?
Serratus anterior
46
Faulty shoulder ABD: scapular winging.
What mm are overactive/tight?
Pecs and rhomboids
47
Faulty shoulder ABD: contra trunk flexion.
What mm are inhibited/weak?
Shoulder abductors
48
Faulty shoulder ABD: contra trunk flexion.
What mm are overactive/tight?
Opposite side QL
49
What could you do in office to manage/exercise thx extension? (7)
- Manipulation
- Bruggers relief position
- Foam rolling
- Table walks w/ foam roller
- Lat. Pull-downs
- Banded pull-a-parts
- Serratus punch w/ band
50
What could you do in office to tight postural muscles?
PIR to the suboccipitals, upper traps, levator scap
Doorway/wall corner pec stretch
51
What could you do in office to weak postural muscles? (6)
Controlled nodding
Craniocervical flexion exercise with biofeedback (BP cuff)
Chin retraction
Wall angle
Serratus punch (w/ band)
Push-up plus
52
Goal for craniocervical flexion exercise with biofeedback (BP Cuff) is ____ mm increments
2 mm
53
Mouth breathing at rest could indicate ___.
Hx of:
Not enough 02
Hx: emphysema, chronic bronchitis, asthma
54
Recurrent mid-thoracic pain could be d/t?
Faulty breathing patterns d/t lack of mobilizing effect of normal rib motion
55
What is one breathing exercise to Inhibit chest-lifting during inspiration?
Sit on chair with armrests.
| Press elbows into arm rest during deep inhalation.
56
Good ab strength w/o _________________ has been shown to lead to spine instab during challenging aerobic activities
Proper coordination b/w abs and diaphragm
57
When should you take a Brugger’s micro break?
And how long do you hold Brugger’s?
Break: 20-30 minutes
Hold: 1/2-1 minute
59
Cx Rehab strategy 1: eval and train deep neck stabilizers
How do you assess?
Hx
Observation
Julll’s test
Craniocervical test
60
Cx Rehab strategy 1: eval and train deep neck stabilizers
How do you treat?
- Cervical mobilization/manipulation
- Isometric progressions (chin tuck, ball squeeze)
- Chin retractions (seated/supine)
- Craniocervical flexion (nodding, ball roll)
- Neck extensors: Cx Quadruped track
61
Cx Rehab strategy 2: assess and treat posture and respiration
How do you treat?
Anterior head carriage
Thoracic kyphosis exercises
Respiration assessment in standing, supine, prone
Teach basic ab breathing
Ab breathing with bracing exercises
62
Cx Rehab strategy 3: address muscle imbalance of large torque producers
How do you assess/treat?
Assess: upper cross syndrome
- general long and short extensor muscles and general home stretches
- re-train scapular stabilizers (w/ wall angles, Serratus punch, push-up plus)
- pec major stretches
- strengthen large torque muscles of the neck (resistance training - Cx banded exercises)
63
Cx Rehab strategy 4: retrain sensory motor response loop
How do you Assess/treat?
Assess: Revel’s and oculomotor testing
- cervical Proprioceptive Neuromuscular Facilitation (PNF) cross patterns
- rhythmic stabilization
- head repositioning
- oculomotor training
- balance training
79
Cx Rehab - Sub-Acute Care interventions (4 step rehab strategy)
“What are the 4 main components of a cervical stabilization program?” (Dr. LeF)
1. Eval and train deep neck stabilizers
2. Assess and Tx posture and respiration
3. Address mm imbalance of large torque producers
4. Retrain sensory motor response loop
80
For the nervous system to move normally, it must execute 3 primary mechanical functions:
Withstand tension
Slide in its container
Be compressible
81
What does tension to do intraneural blood flow?
Reduces it
82
How much tension reduces intraneural blood flow?
8% elongation reduces venous
15% elongation reduces ALL blood flow
83
A __% strain held for 1 hour reduced nerve conduction by ___%
6% strain
70%
The longer the stretch, the increased likelihood of producing adverse effects
84
_____mmHg compression causes hypoxia, impairs conduction and axonal transport?
30-50 mmHg (~1 pound/square inch)
85
What is structural differentiation?
Any maneuver that affects nerve tension w/o moving the MSK tissue in the same area
E.g. ankle dorsi flexion slides lumbar nerve roots inferiorly
86
A procedure that produces increase pressure on a nerve by reducing the space around it
Closing mechanisms or a Closer
E.g. maximal IVF closing
87
A procedure that reduces pressure on a nerve by increasing the space around it
Opening mechanisms or an Opener
E.g. Maximal IVF opening
88
A procedure that creates longitudinal elongation of a nerve
Tensioner
E.g. SLR
89
Peripheral nerves system is exposed to noxious stimulation (at NR, peripheral nerve, or neural nociceptor) it can cause inflammatory response.
Inflammatory response can be not ONLY the nerve, but at the MSK tissue that is innervated by the nerve.
This sequence of events may be one mechanism for what phenomenon?
Trigger points
90
What does the IVF do in spinal extension vs flexion?
Extension: IVF compression = Closer
Flexion: IVF opening = Opener
91
The spinal canal can elongate by up to
9 cm
92
Increased Sx with spinal flexion may be d/t
Increased neural tension
E.g. tension of affected NR
93
Decreased Sx with spinal flexion may be d/t
Decreased compression
E.g. relief of central canal stenosis Sx
94
What motions gap the Right cervical facet?
Flexion
Contralateral lateral flexion
Ipsi rotation
95
During gapping, what occurs at the cervical IVF?
...it opens....
96
What are the 3 basic tissue classifications of neuro-patho-dynamics?
1 — Mechanical interface: tissues around the nervous system causing neural problems
2 — Neural: neural tissues causing neural problems
3 — Innervated tissue: tissue innervated by nerves causing neural problems
97
Know PNF patterns
:)
98
What do you do in acute care of shoulder rehab? (3)
1. passive ROM activities e.g. Codman’s pendulum, wand exercises
2. Isometric exercises
3. Postural awareness
99
How do you do cod man pendulum exercises?
- Hang 2-4 kg (4-6 pounds) from wrist to traction
| - Do 10-15 small, passive circles in each direction
100
When do you begin active ROM for shoulder rehab?
Immediately in internal and external rotation (10-15 reps 2-3x/day)
101
What instructions do you give shoulder rehab patient on isometric shoulder exercises? What is the force of contraction?
Use pillow to isometrically contract in ext/flex/internal rotation/external rotation/abd/add
10-15 reps
2-3 x/day or every hour
Hold 5-10 secs
Force of contraction: below pain threshold but at least 10-20% of MCV
102
What can you give a shoulder rehab patient if shoulder isometrics are too painful?
Ball squeeze or exercise the opposite shoulder
103
What are the 5 S’s of shoulder rehab principles?
```
Strength & endurance
Scapular stability
Stretch
Synchronize
Stimulate
```
104
In shoulder rehab, what needs to be stretched?
Subscap and ext rotators/posterior capsulE
Tight pecs
105
In shoulder rehab, what needs to be strengthened?
All rotator cuff mm starting with exercises with the arm at the side
Strengthen external rotators: infraspinatus, trees minor
106
When are tubing or weights introduced in shoulder rehab patient?
When they have >20-30 degrees of painfree AROM in flexion, ABD, scaption
107
What is the sequence of exercises for shoulder rehab?
```
FIRST
- int/ext rotation
- shoulder flex/extend
- biceps
THEN
- ABD, scaption
FINALLY
- diagonals
```
108
What are the 5 phases of tubing rehab?
Phase 1: Slow, mid range for 60 seconds or until fatigue (optional)
Phase 2: Fast, mid range for 60 seconds or until fatigue (goal: facilitation)
Phase 3: Slow full range, hold at end range up to 30 seconds, release through eccentric range in slow, controlled manner (goal: strength)
Phase 4: Fast, full range for 60 seconds or until fatigue (goal: endurance)
Phase 5. Use movements that mimic the sport or job the patient is returning to. (goal: functional training)
109
What is the goal of phase 2-5 tubing rehabilitation?
2: Facilitation
3: Strength
4: Endurance
5: Functional training
110
2 approaches to giving a patient instructions on how to to repetitions
Target number e.g. 10 and build up to 30 (for strength)
Exercise to fatigue (goal: endurance)
111
What is the most effective exercise fro infraspinatus activity with minimal strain on capsule?
External rotators: side lying ER at 0 ABD
112
When shoulder reaches about ____% strength and endurance as compared to the opposite shoulder, overhead medicine ball toss can be introduced
90%
