S2L1: Other PT Interventions Flashcards by ARIANNE YSABELLE WEE

Use of water for rehabilitation processes
Use of water that facilitates the application of therapeutic exercise.

Hydrotherapy/Aquatic Therapy

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Facilitate functional recovery by providing the environment that augments a patient’s/client’s ability to perform various therapeutic interventions.

Purpose of aquatic exercise

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Use of the different properties of water such as buoyancy, viscosity, hydrostatic pressure, and surface tension to facilitate functional recovery of our patients

Aquatic exercise

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Goals and indications for aquatic exercise (9)

Facilitates ROM exercise
Initiate resistance training
Facilitate weight-bearing activities
Enhance delivery of manual techniques
Provide 3D assess to the patient
Facilitates cardiovascular exercise
Initiate functional activity replication
Minimize risk of injury or re-injury
Enhance relaxation

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Precautions (5)

Fear of water
Neurological disorders (ataxia, MS, controlled epilepsy)
Respiratory conditions
Cardiac dysfunction
Small, open wounds and lines (waterproof dressings, clamping)

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Precautions (To do) (4)

provide an orientation period to allay the fear of water
ensure that proper medications are taken prior to the session
start with low intensity
implement close monitoring

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Contraindications of aquatic exercise

Incipient cardiac failure and unstable angina
Respiratory dysfunction (VC < 1L) (3-5 L normally)
Severe PVD
Danger of bleeding or hemorrhage
Severe kidney disease: patients unable to adjust to fluid loss during immersion
Open wounds w/o occlusive dressing, colostomy, skin infections
Uncontrolled bowel and bladder
Menstruation
Water and airborne infections
Uncontrolled seizures

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Properties of Water

Buoyancy
Hydrostatic Pressure
Viscosity
Surface Tension

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Upward force that works opposite gravity
An immersed body experiences upward thrust equal to the volumes of liquid displaced
Associated with the Archimedes’ Principle

Buoyancy

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Pressure exerted by fluid on an immersed object
is equal on all surfaces of the object
associated with Pascal’s Law
Pressure exerted by water on immersed objects

Hydrostatic Pressure

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Friction occurring between molecules of liquid in resistance to flow

Viscosity

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Measured as force per unit length
The cohesiveness of water molecules at the surface of water

Measured as force per unit

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Remember

As the density of water and depth of immersion increase, so does hydrostatic pressure.
Resistance from viscosity is proportional to the velocity of movement through liquid
Increasing the surface area moving through water increases resistance
Increasing the velocity of movement increases the resistance
An extremity that moves through the surface performs more work than if under water
Heat transfer increases with velocity

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This is important to remember and implement for patients with weight-bearing restrictions, particularly those who had lower extremity surgery, joint replacement and others.

WB with immersion

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WB with immersion on C7

10%

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WB with immersion on xiphoid process

33%

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WB with immersion on ASIS

50%

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T/F: In aquatic exercise, increasing the velocity of movement increases the resistance.

True

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T/F: Using equipment at the surface of the water decreases the resistance.

False

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T/F: Increased pressure reduces effusion, assists venous return, induces bradycardia, and centralizes peripheral blood flow.

True

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T/F: Obese patients will have increased buoyancy due to fat tissue having a lower specific gravity.

True

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T/F: Increasing the surface area moving through water increases resistance.

True

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T/F: A patient moving through the water loses body temperature faster than an immersed patient at rest.

True

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T/F: In the vertical position, posteriorly placed buoyancy devices cause the patent to lean backward.

False

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T/F: An extremity that moves through the surface performs less work than if kept under water.

False

T/F: Buoyancy provides resistance to movement when the extremity is moved downward or inferiorly.

True

T/F: Application of equipment (boot) increases drag and resistance as the patient moves the extremity through water.

True

Temperature for aquatic exercise: 0-18/32-64

Very cold to cold

Temperature for aquatic exercise: 18-26/64-79

Cool: acute inflammation

Temperature for aquatic exercise: 26-33.5/79-92

Tepid: for exercise, acute inflammation, can’t tolerate cold

Temperature for aquatic exercise: 33.5-35.5/92-96

Neutral warmth: open wounds, medically-compromised pts, ↓ tone

Temperature for aquatic exercise: 35.5-37/96-99

Mild warmth: ↑ mobility of burns

Temperature for aquatic exercise: 37-40/99-100

Hot: pain control

Temperature for aquatic exercise: 40-43/104-110

Very hot: ↑ tissue extensibility, chronic conditions

Temperature for aquatic exercise: >43/>110

Should not be used

Temperature for flexibility, strengthening, gait training, relaxation

26-35°C

Temperature for cardiovascular training, aerobic exercise

26-28 °C

Temperature if >80% HRmax to minimize heat illness

22-26°C

Temperature for acute painful musculoskeletal injuries (relaxations, elevated pain threshold, decreased muscle spasm)

33°C

General Guidelines in aquatic exercise (8)

Utilize cooler temperature for higher intensity exercise and utilize warmer temperature for mobility and flexibility exercise and for relaxation The ambient air temperature should be higher than the water temperature for patient comfort Use of maximum immersion time of 20 mins for patients with non-compromised cardiopulmonary system Always monitor vital signs to ensure patient safety The patient’s fatigue factor needs to be considered Cleaning should occur at least 2x/wk, chlorine and pH level tests 2x/day Slip-resistant walking surfaces. Safety rules and regulations and emergency procedures CPR training for staff

Pools for aquatic exercise: Group Therapy

Therapeutic swimming pools

Incorporated for safety and for proper access to the pool

Bars, rails, stairs

T/F: PT should not be in the water when leading an exercise session so that the participants can see clearly the demonstrations

True

Pools for aquatic exercise: Individual Use

Self-contained pools

T/F: Self-contained pools designs include transparent walls or sides to allow the PT to observe and analyze in 3D, the lower extremity movements of the patient

True

Special equipments for aquatic exercise (10)

Floatation belt Floatation rings Swim bars Kick boards Collar Hydro-tone boot Hydro-tone bell Hand paddle Glove Water noodle

Documentation for aquatic exercise (T, D, T, P, B, R)

Type of exercise Depth (water level) Temperature Parameters Body part Rationale

Group of systematic and scientific manipulations of body tissues that are best performed with hands “for the purpose of affecting the nervous and muscular system and the general circulation”

Massage

T/F: There should not be proper selection and execution of techniques and physiologic goal addressing the problem of a pt. Elbows, forearms, and feet cannot be used.

False for both statements.

Physiological effects of massage: Relax effects

Sedation Decrease in pain (Gate Control Theory) Vasodilation Reflex heating and muscle relaxation

Physiological effects of massage: Mechanical effects

Assist return flow circulation of blood and lymph (centripetal direction) Can mobilize soft tissue After prolonged application, make the skin tougher Increase in skin temperature

Mechanical effects for swelling, edema, and to remove waste products

Assist return flow circulation of blood and lymph (centripetal direction)

Mechanical effects to stretch adhesions in scar, fibrocystic nodule, trigger points to improve ROM

Can mobilize soft tissue

Mechanical effects for amputees, to desensitize skin in preparation for prosthesis. Amputees can have hypersensitivity, phantom limb sensation, phantom pain

After prolonged application, make the skin tougher

Indications for massage (S, M, A, S, E, P, C, P, D)

Subacute/chronic pain Muscle spasm Adhesion Superficial scar formation (trauma, burns) Edema Postural drainage Pts w/ chronic bronchitis, emphysema They tend to develop accumulation of sputum or excess phlegm in lungs Use percussion Desensitization post-surgery Pts with amputations

Contraindications of massage (I, S, A, D, M, S, H, A)

Infection (greatest CI) Skin diseases Acute inflammation DVT Malignancy Severe RA (rheumatoid arthritis) Hemorrhage Abdominal massage for pregnant patient

Precautions of massage

Burned skin

Limitations of massage (D, C, I, I, S)

Does not develop muscle strength nor improve muscle tone Cannot affect the body metabolism significantly Ineffective for weight reduction Ineffective in preventing muscle atrophy secondary to nerve damage Massage cannot be a substitute for an active exercise

General considerations in application of massage

Patient comfort (Generally gravity eliminated; gravity assisted to minimize edema) Use proper draping Use proper body mechanics Skill is required rather than strength Check the patient’s skin Start and end with effleurage Massage media (Used to reduce friction and to soften skin or scar; Unscented, removed after) (No medium used for friction massage) Massage should begin in the proximal segment of the extremity, move distally and return to proximal region (For pts with edema and swelling) Stroking movements are directed distal to proximal, esp for edema

Components of massage: For inhibition/relaxation, slow motion To stimulate, fast movement like hacking

Rhythm and rate

Components of massage: Should be even

Rhythm

Components of massage: may vary

Rate

Components of massage: Light/superficial techniques: dec pain and induce relaxation Deep techniques: to improve circulation, address adhesions & scar formations

Pressure

Components of massage: Distal to proximal

Direction

Duration and frequency: UE

10-15 mins

Duration and frequency: LE and back

15-20 mins

Duration and frequency: Entire body

45 mins - 1 hr

Massage Techniques

Stroking/Effleurage Compression/Petrissage/Kneading Friction Percussion/Tapotement

Involves gliding the palms, fingertips, and/or thumbs over the skin in a rhythmic circular pattern with varying degrees of pressure

Stroking/Effleurage

Uses of effleurage (6)

Initiates and ends treatment Used to move from one area to another & between other strokes Orients the patient with PT’s touch Used for spreading the medium Allows the PT’s fingers to feel spasm or soreness

Indications of effleurage (2)

To stimulate lymphatic drainage To relieve pain from sprain, strains, bruising, and vascular congestion related to surgery, PVD, or complex regional pain syndrome

Superficial effleurage

Light contact, results in reflexive and psychological changes Blood flow to the area is increased Relaxation with slow stroking; stimulation with fast stroking Direction of the force is not important, preferably following the direction of hair growth To dec pain & relaxation

Deep effleurage

Result in mechanical effects on the circulatory and deep myofascial systems To inc blood flow, for circulation, and stretch adhesions

Variations of effleurage: Deeper than deep effleurage

Knuckling

Variations of effleurage: Used on the back Stroking done laterally progressing up the spine; hands are removed after every stroke

Bilateral Tree

Variations of effleurage: One stroke on top of the previous stroke always keep one hand in contact with the patient

Shingles

Variations of effleurage: One hand pushes while the other hand pulls; useful for low back and muscular areas

Fulling

Involves one or both hands compressing the skin between the thumb and fingers with very little (if any) lubricant Superficial techniques promote relaxation

Petrissage/Kneading

Deeper techniques for petrissage

Increase blood flow Mobilize fluid and tissue deposits (milking effect) to remove the waste products that accumulate Loosen adhesions Increase tissue pliability

Variations of petrissage: Involves circular movements of one hand superimposed on the other; fingertips and thumb compress tissue and distract it from underlying tissues

Kneading

Variations of petrissage: Involves compression, grasping, release, and repositioning hands in more proximal area

Picking up

Variations of petrissage: Resembles picking up, except that, a shearing-type force is created by one hand pushing and the other pulling

Wringing

Variations of petrissage: Involved grabbing a small amount of tissue between the finger pads and thumb and rolling the tissue as if moving a small object under the skin

Rolling

Variations of petrissage: The tissue is grabbed and vigorously shaken between hands; the hands are then repositioned along the course of the target muscle; for chronic bronchitis to remove phlegm during exhalation

Shaking

A circular, longitudinal, or transverse pressure applied by the fingers, thumb, or hypothenar region of the hand to small areas Does not use lubricant Used to break down adhesions in scar tissue, loosen ligaments, and disable trigger points

Friction

Indications of friction

Tendonitis Tendinopathy Subacromial bursitis Plantar fasciitis Trigger points

Utilizes rhythmic alternating contact or varying pressure between hands and the body’s soft tissue The desired effect is stimulation

Tapotement

Variations of tapotement: High percussion done with the fingertips as if using a typewriter

Raindrops

Variations of tapotement: Use of fingertips (usually index & middle fingers) to percuss

Tapping

Variations of tapotement: Use of the palm and finger

Slapping

Variations of tapotement: Use of copper hand, which is percussed against the chest wall; during the exhalation phase of breathing

Cupping

Variations of tapotement: Fine, tremulous up and down movement of tissue using short, rapid, quivering motion with the hands in contact with the body part; postural drainage; soothing effect in peripheral neuritis

Vibrations

Variations of tapotement: With the palms facing each other and the fingers relaxed, use of ulnar borders of the hands

Hacking

Variations of tapotement: Clenched fist to repetitively pummel the tissue

Beating

Variations of tapotement: Same as beating, but body is struck with the medial border of the fist

Pounding

Variations of tapotement: Rapid and gentle pinching of the tissue between the thumb and index fingers

Pincemont

Documentation for massage (T, P, B, P, R)

Type of massage Parameters Body part Position Rationale

Role of taping (P, H, C, P, L, A, C)

Protect injured structure during treatment and rehabilitation Hold dressings and pads in place Compress recent injury for bleeding and swelling Protect from further injury by supporting ligaments, tendons, and muscles Limit unwanted movement — for instabilities Allow optimal healing w/o stressing the injured structures It must be clearly understood that taping is not a substitute for treatment and rehabilitation, but is an adjunct to the total injury-care programme

Objectives of wrapping/bandaging (P, P, S, S)

Provide compression to reduce effusion and swelling when treating and rehabilitating injuries Provide support and reduce range of motion when preventing, treating, and rehabilitating injuries Secure pads when preventing and treating injuries Secure dressings when treating wounds

Contraindications of taping and bandaging

Allergy to material Acute swelling (for taping) To secure position of swollen joints when applying ice packs Suspected fracture or total disruption (gr. 3 sprain) Splints should be used Pain after taping or bandaging Check the pulling and direction of tape & bandage

The process of enabling people to increase control over, and to improve their health Active participation of pts not passive by changing their lifestyles, engage in exercises Activities undertaken to encourage well-being that are directed toward actualizing an individual’s potential

Health Promotion

Is a component of health promotion Any planned combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities Reinforce voluntary behavior conducive to health Initiative and realization is a must for pts Aims to provide information to individuals and groups about health-causing actions and the impact of negative health behaviors in order to make a connection between voluntary behaviors and health

Health education

Value of patient education (I, B, M, R, E, S, I, O, S, I)

Improved adherence to exercise, diet, and medication directives Better understanding of patient’s condition More efficient communication (meaning fewer calls and emails) Realistic patient expectations especially regarding timelines Easing of fear or apprehension Safer therapy environment Increased satisfaction with the treatment plan, leading to more referrals Open environment to discuss questions and concerns Stronger relationships characterized by respect and empowerment Improved outcomes in patient’s health and well-being

Patient education (B, P, H, W, R)

Body mechanics Pain relief Home exercise programs (HEP) Wellness Risk education

PT is in a unique position to guide the patient and family in optimizing accessibility To promote independence with least amount of assistance

Environmental Modification

ITE Model: pt’s condition, cognition, balance, motivation

Individual

ITE Model: transfers, exercise

Task

ITE Model: market, church, home

Environment

Consider for environmental modifcation (E, P, C, F, C, N)

Environmental barriers Patient’s functional capabilities Cultural background Financial resources Community resources Needed assistive and/or adaptive equipment

Comprised of built and natural objects where an individual functions Home, neighborhood, community, and methods of transportation; educational, workplace, entertainment, commercial and natural settings

Physical environment

Refer to buildings and structures created by humans

Built objects

Include other humans, as well as geographical objects such as vegetation, mountains, rivers, uneven terrain, etc.

Natural objects

Environmental factors than through their presence or absence, prevent optimal function and create disability

Barriers

Home environment (U, A, U, H)

Use proper footwear Avoid using very low stools, “bangkitos” Use of firm mattress Higher toilet seat

Buoyancy is the upward force that works opposite to gravity. If a patient is standing and submerged in neck-deep water, buoyancy provides resistive force in all of the following, EXCEPT: a. knee extension from 90º knee flexion with hip in neutral position b. shoulder adduction from 90º abduction with elbow extended c. hip extension from 70º hip flexion with knee extended d. elbow flexion with the shoulder in 90º flexion

D. elbow flexion with the shoulder in 90o flexion No effect in buoyancy; Flexion happens above the water Other choices warrant inferior movement which is resisted by buoyancy

You are leading an aquatic exercise aerobic class for 5 middle-aged women. Which of the following procedures should be observed when implementing this program? a. The water temperature should be maintained in the range of 26-28ºC. b. You as their PT instructor should be on land and not in the water with them. c. There is no need for warm-up and cool-down periods when doing aerobics in the water. d. Both A and B are correct. e. Both A and C are correct.

D. Both A and B are correct. Water should be between 26-28 for aerobic exercises & instructor should be on land to see the LE movements. Middle-aged women do not need close assistance, no condition indicated also.

Your patient was referred for underwater gait training with 40% weight-bearing. The water depth should be a. at the level of the sternum b. at C7 level c. at the xiphisternal junction d. at the level of the ASIS e. above the ASIS

e. Above the ASIS Refer to provided picture in lecture

Which of the following documentation for the use of aquatic exercise as a PT intervention is correct? a. Endurance training with water at shoulder level at 36ºC X 80% HRmax for 20 mins to increase aerobic capacity. b. Strengthening exercise in waist-deep water at 28ºC using hydro-tone boots X 10 reps X 2 sets each on (B) shoulder flexors, extensors, abductors, and adductors to increase strength. c. Underwater bicycling on water noodle in chest-high deep at 28oC X 20 mins with RPE of 13-14 to increase endurance. d. Both A and B are correct. e. Both A and C are correct.

c. Underwater bicycling... Endurance training is wrong bc of too high temperature Strengthening training is wrong bc hydrotone boots were used but for UE muscles

Which of the following documentation for the use of massage as a PT intervention is correct? a. Massage using effleurage and petrissage on the (L) UE X 10 mins in supine to reduce lymphedema. b. Massage using effleurage and cupping over hypoventilated segments of the (L) lung X 5 mins each in postural drainage position to mobilize excessive secretions c. Whole body massage in supine and prone using effleurage, shingles, kneading, rolling X 20 minutes to induce relaxation d. Only A and B are correct e. All are correct

d. Only A and B are correct. - c. wrong duration

Your patient who is a bank teller has low back pain due to strain. Which of the following should be included in the Patient Education/Environmental Modification for this patient? a. Proper lifting techniques b. Home modification: use of handrails on both sides of the stairs c. Work modification: use of a stool rater than an office chair d. Both A and B are correct e. Both A and C are correct

a. Proper lifting techniques LBP is not that debilitating that pt needs handrails on both sides Stool is not recommended bc it has no back support

Your patient who is an office clerk complains of pain on the posterior aspect of the neck. Upon palpation, you noted muscle spasms and taut bands on bilateral upper traps. You decided to apply massage. Which of the following massage variation/s should you use? I. deep friction massage II. effleurage III. wringing IV. cupping a. Only I is correct b. Only II and IV are correct c. All are correct d. Only I, II, III are correct

d. Only I, II, III are correct Cupping is not included bc it’s for excessive mucous in the lungs

Your patient has back pain due to scoliosis. Which of the following should be included in the Patient Education/Environmental Modification for this patient? a. Using only one shoulder (the higher one) to carry a backpack b. Modification: use of firm mattress to sleep on c. School modification: placing the armrest on the side of convexity of the scoliosis d. Both A and B are correct e. Both A and C are correct

b. Firm mattress Scoliosis pts should carry backpack on both shoulders Arm rest should depend on the hand dominance of pt

All of the following are correct about the use of taping, EXCEPT: a. Limit unwanted movement b. Hold dressings and pads in place c. Protect a fractured structure during treatment and rehabilitation d. None of these e. Protect supporting ligaments, tendons, and muscle from further injury

c. Protect a fractured structure Splint should be used for fx, taping cannot protect a fractured bone

In modifying the environment to facilitate function of patients, the following are considered, EXCEPT: a. mode of transportation b. financial capability of the patient c. none of these d. beliefs and customs of the patient e. patient's ROM and strength

c. None of these All are considered

Case profile: A 13 y/o baseball pitcher developed (R) medial elbow tendinopathy. The following muscles could be affected in this case, EXCEPT: a. Flexor carpi ulnaris b. Pronator teres c. Palmaris longus d. Extensor carpi radialis brevis

d. ECRB It is an extensor, found laterally, and is most commonly affected in lateral tendinopathy

a. Restore Already in fxn training c minimal pain, (-) tenderness/spasm, 4⁄5 strength

Case: A 13 y/o baseball pitcher developed (R) medial elbow tendinopathy. He has been playing baseball for 1 year now. He was referred to you for functional training. He reports very minimal pain (1/10) on the area. He has no tenderness or muscle spasm, and his wrist flexors are graded 4/5. What is the MOST appropriate Long-Term Goal (LTG) for your patient? a. Pt will report dec in pain from 1/10 to 0/10 on the medial aspect of R elbow p 4 wks of PT sessions to be able to resume play. b. Pt will demonstrate inc in R wrist flexors strength from 4/5 to 5/5 p 6 wks of PT sessions to be able to pitch ball properly. c. Pt will be able to pitch ball as often as needed in a baseball game s any pain and c 5/5 strength of R wrist flexors p 6 wks of PT sessions. d. All of these e. None of these

c. Pitch ball as often as needed Other 2 are impairment level only, for STG

A 13 y/o baseball pitcher developed (R) medial elbow tendinopathy. He has been playing baseball for 1 year now. He was referred to you for functional training. He reports very minimal pain (1/10) on the area. He has no tenderness or muscle spasm, and his wrist flexors are graded 4/5. For him to return to competitive play, which of the following interventions should be part of your treatment plan? Type TRUE if intervention is correct; otherwise type FALSE. Do not consider completeness of parameters yet a. Grip strengthening using hand-held dynamometer b. Self-stretching of wrist flexors with the elbow extended and dorsum of hand against the wall c. Simulate pitching to be done against theraband resistance d. Ice massage on the medial aspect of the ® elbow until numbness e. Multiple-angle muscle sets for wrist flexors and extensors f. Gr. 1 joint oscillations on ® humeroulnar joint g. With the supinated forearm supported and hand over the edge of the table, flex wrist 10x while holding a 5-lb dumbbell

a. TRUE: Strong grip on the ball b. FALSE: Wrist extensors would be stretched c. TRUE d. FALSE: Not an acute case, no tenderness, 1/10 pain only e. FALSE: Functional training, no need for muscle sets, only for very acute and weak pts, to retard atrophy f. FALSE: Pain doesn’t originate from the joint, it’s on the tendon g. TRUE: Strengthening exercise

12. The following activities or etiologic factors may predispose an individual to develop medial elbow tendinopathy, EXCEPT: a. repetitive shuffling of book pages of librarians or accountants b. pitching baseball for 3 years for the teenager c. pulling weeds in the palace garden by hand d. swinging golf club many times per game daily e. None of these

c. Pulling weeds More for lateral elbow tendinopathy