Summer lectures Flashcards
Goal of therapeutic exercises
- achievement of symptom-free movement and function
- carefully graded stresses and forces applied to body
- applied in controlled,progressive and appropriately planned manner
Prognosis
- a prediction of the patient’s optimal level of function expected at the end treatment
- anticipated length of time needed to reach the specified functional outcome
factors that influence prognosis
-complexity, severity,acuity or chronicity of problem
-general health
-patient goals
Patient’s motivation
- safety issues
- extent of support
3 types of motor tasks
- discrete task
- serial Task
- continuous task
Discrete task
movement with a recognizable beginning and end
Ex: doing a push up, lifting a weight
Serial task
-composed of a series of discrete tasks combined in a particular sequence
Ex: eating with a fork = appropriate grasp, proper positioning, scoop up food, move fork to mouth
Continuous task
repetitive, uninterrupted movements with no distinctive beginning or end
Ex: cycling, walking up and down stairs
stages of motor learning
cognitive stage
associative stage
autonomous stage
Cognitive stage of motor learning
requires a great deal of thinking
- patient thinks about sequence or each component
- errors in performance common
- Pt easily distractible
- requires a lot of feedback
associative stage of motor learning
- patient makes infrequent errors
- concentrates on fine-tuning the motor task
- patient tries to become more efficient and consistent
- use of problem solving skills
- modifies activities depending on environment
- decrease in need for feedback
autonomous tsage of motor learning
- movements are automatic
- patient can do multiple tasks at once
- easily adapts to variations in task demand
- very little feedback or instruction requires
- patients often discharged before this stage…
What affects ROM?
structure of joint
integrity of tissue
flexibility of soft tissue
Joint range
amount of motion usually measured in degrees that can occur at a joint, the junction between two bones
muscle Range
Functional excursion of a muscle or the distance a muscle can shorten from full elongation
active vs. passive insufficiency
relates to multi joint muscles
- active: no power because too short
- passive: no power because too long
What are the 3 types of ROM?
- passive
- active
- active-assistive A-AROM
why do PROM?
acute inflamed tissue where soft tissue is too weak coma paralysis complete bed rest
Why do AROM?
patient has enough muscle strength to go through available range
aerobic condition
maintain mobility above and below immobilized region
Why so A-AROM?
when the muscles are too weak to make it through the full range
attempts to achieve the same goals as AROM
Limitations of PROM
will not prevent muscle atrophy
will not increase strength or endurance
will not assist circulation as much as AROM
Limitation of AROM
for strong muscles, it will not increase strength or maintain strength
limited development of skill or coordination
General guidelines for Continuous Passive motion CPM
- can be applied after surgery
- establish available ranges
- start with low arc 20-30 degrees
- increase arc 10-15 degrees per day as tolerated
- rate of 1 cycle per 45 sec or per 2 min depending on patient tolerance
- Duration: 24 hours or 1 hour 3x/day
- initiate muscle setting and AAROM during off times from CPM
- usually used for less than 1 week
which form of range of motion testing gives you more precise information about joint mobility as compared to muscle pathology?
PROM
AROM,A-AROM, and resistive range of motion all involve the use of contractile tissue.
in normal function, muscles must be able to:
Produce
sustain
regulate muscle tension
Muscle strength
ability of contractile tissue to produce tension and a resultant force based on the demands placed upon the muscle
muscle power
related to strength and speed of movement
muscle endurance
ability of a muscle to contract repeatedly against a load, generate and sustain tension
how would you increase strength?
systematic approach use muscle groups to lift/ lower, control heavy loads -low reps -short duration -no more than 10 reps -minimum of 66% of 1RM - recovery time 1 min for isotonic and isometric ---2-4 min for isokinetic
How to increase power?
- muscle strength needs to be available already
- increase work performed over a specific period of time
- or reduce the period of time the worj is done in (pIyometrics)
How to increase endurance?
muscle endurance- ability to repeatedly contract against load, sustain tension and resist fatigue
- important for postural control
- low load
- high reps 20-50 for 2-3 sets
- prolonged duration
SAID principle
Specific Adaptation to imposed Demands
- extension of Wolff’s law
- helps therapist determine exercise prescription
- helps therapist to best meet functional goals and needs
Concentric vs eccentric
concentric: requires more O2, more energy, more motor units. less mechanical efficiency. increase velocity , force decrease
eccentric: less O2, less energy required, less motor units, more mechanically efficient. increase velocity–> initial increase in force production, then levels off
Why choose concentric or eccentric?
depends of functional activity pt. is trying to achieve
- if patient very weak (<3/5) use eccentrics
- eccentrics for activities that require high intensity deceleration or quick direction changes
- late stage of rehab- eccentric @higher speeds and loads
precaution for use of eccentrics
increased cardiovascular demand –> no Valsalva
- increased incidence of DOMS
- progress slowly and decrease freq as intensity increases
isometric exercises
no visible joint motion
no appreciable change in muscle length- used for postural or joint stability
- used for protecting joint or tissue in acute stage of healing by activating muscles
-if functional activity uses isometric contractions
types of isometric exercises
muscle setting: low intensity, little/no resistance, promotes relaxation and pain relief, retards atrophy
stabilization exercises: sub-maximal co-contractions, decr intability, usually done in mid range of joint, usually done in weight bearing
multiple angle: isomterics @ multiple joint postions, improve strength throughout ROM, used if dynamic full ROM resistance exercises are painful or contraindicated
limitation of isometrics
strength improvements limited to the joiny angle in which exercise was done
little carry over to dynamic function
not very effective for endurance
Resistance in pounds of theraband at 100% elongation
Yellow 2.9 red 3.9 green 5 blue 7.1 black 9.7 silver 13.2 gold 21.6
Why use isokinetics?
Pt. can generate max force output @ varying angles
during concentric isokinetics- increase velocity= decreased force, thus less joint compression forces
- can accommodate painful arc
- co-activation of muscle at higher velocities for improved stability
energy systems when doing exercise
anaerobic exercise- high intensity and low reps
aerobic exercise- low intensity of larger muscle groups for extended periods
full arc exercises-
resistance through full available range
- strengthens thru full AROM
short arc exercises
- limited range of motion resistance application
- avoids arc of pain
- unstable position of joint
- protect healing tissue
force velocity relationship
concentric- velocity of contraction increase, force generation decr
eccentric- velocity of muscle lengthening increase, muscle force generation increases initially then levels off
Traction grade 1
(loosen)
- small amplitude distraction,no stress on capsule
- equalizes tension of muscle, cohesive forces and atmospheric pressure
- used with all mobilizations and for pain relief
traction grade 2
(tighten)
- “taking up the slack”
- enough distraction to tighten tissues around joint
- maintain joint play when ROM is not allowed or for pain relief
traction grade 3
(stretch)
- stretch on joint capsule and on surrounding periarticular tissues
- stretch structures to increase joint play
Grading accessory mobility stiffness–> super mobile
0: complete bony ankyloses
1: significant joint stiffness
2: moderate hypomobility
3: normal
4: moderate hypermobility
5: significant joint laxity
6: completely unstable
effects of joint mobilization
moves synovial fluid, enhances joint nutrition
maintains extensibility and tensile strength of the articular and periarticular tissues
provides sensory input
3 typesof stress
tension
compression
strain
Toe-region
considerable deformation
not much force required
most of function occurs here
elastic range and limit
range: strain directly proportional to tissue ability to resist stress
- tissue at EROM with gentle over pressure
complete recovery takes place
limit: beyond this point, tissue does not return to original shape or length
plastic range
extends to point of rupture
permanent change occurs
sequential failure of bonds between collagen fibrils and eventually collagen fibers
-necking-considerable weakening and failure is near
effects of corticosteroids
results in decrease in tensile strength
fibrocyte death nextto injection site
- up to 15 weeks to recover
effects of injury on type of collagen
lay down of type III collagen
weaker than type I mature collage
usually takes place around 3 weeks after injury
3 types of neural inhibition stretch
- hold relax or contract relax
- agonist contraction
- hold relax with agonist contraction
contract-relax
take shortened muscle to its end range
perform a endd-range isometric contraction 7-10 sec
-voluntary relaxation to follow
-passively move limb into new range
agonist contraction
patient concentrically contracts muscle opposite to range limiting muscle
-lowlevel resistance or AROM with no resistance
results in reciprocal inhibition
contract relax with agonist contraction
- pre-stretch isometric contraction
- followed by concentric contraction of muscle opposite to range limiting muscles
4 phases of scar formation
inflammatory
granulation
fibroplasia
maturation
inflammatory phase of scars
immediately after trauma
- 24-72 hours
- blood clotting begins almost instantly
- followed by migration of microphages to start debriding area
granulation phase of scar
- uncharacteristic increase in relative vascularity of tissue
- needed to meet metabolic needs of repairing tissue
- the more vascular the tissue, the quicker the scar forms
- – movement is helpful in this stage
fibroplastic stage of scars
lasts 3-8 weeks
- fibroplastic cells increase in number
- increase in rate of production of collagen fibers and ground substance
- binds to itself with weak hydrostatic bonds
- therefore tissue elongation is easier
- window of opportunity for shaping scar!
maturation phase of scar
- collagen matures, solidifies
- maximal stress can be placed on tissue without fear if tissue failure
- significant remodeling can still take place
absolute contraindications of passive movement-manipulation
-joint hypermobility
- malignancy
-tuberculosis
-active osteomyelitis
severe osteoporosis
-unstable fracture
-acute ligamentous rupture
3 stages of disk degeneration
dysfunction
instability
stabilization
capsular pattern for lumbar spine
side flexion, rotation equally limited then extension
Derangement 1
central or symmetrical pain across L4/5
- with or without buttock or thigh pain
loss of full extension range
no deformity
derangement two
central or symmetrical pain across L4/5 with or without buttock or thigh pain loss of full extension range deformity of lumbar kyphosis easily converted into a derangement 4
derangement three
unilateral or asymmetrical pain across L4/5
with or without buttock and / or thigh pain
loss of full extension range
no deformity
derangement four
unilateral or asymmetrical pain across L4/5
with or without buttock and / or thigh pain
loss of full extension range, flexion range, or both
with deformity of lumbar scoliosis
derangement 5
unilateral or asymmetrical pain across L4/L5
with or without buttock and /or thigh pain
with leg pain extending below the knee
no deformity
derangement 6
unilateral or asymmetrical pain across L4/5
with or without buttock and/or thigh pain
with leg pain extending below the knee
with deformity of sciatic scoliosis and reduced lordosis
neurologic deficit commonly occurs
derangement 7
symmetrical or asymmetrical pain across L4/5
with or without buttockand /or thigh pain
with deformity of accentuated lumbar lordosis
loss of flexion range of movement
sudden onset of pain
treatment D1
prone lying
sustained extension/prone on elbows 30-40 reps
EIL
mainatnce of reduction
postural re-ed
HEP- prone on elbows 10/hr for next 24 hr
treatment D3
initially same as D1 first 24 hrs prone lying. POE,EIL if patient improves continue D1 day 3, if no improvement - prone lying with hips laterally shifted away from painful side -EIL with shifted position
treatment of D2
use pillow technique to gradually reduce kyphosis until prone lying achieved
-start with 3-4 pillows under belly prone
-remove 1 pillow every 10-15 minutes
Time is key
-once the patient is able to lie prone, treat as D1
goal is to reduce lumbar kyphosis
treatment D4
examination to make sure shift is present correction of primary lateral shift teach self correction of lateral shift recovery of extension as in D2 then progress to D1
treatment of D6
look for a position of comfort
instruct patient to maintain this position for as long as possible
treatment should be tried along the line of D4 and D5
if symptoms increase, then modify
treatment D7
in flexion, if there is a marked deviation use flexion in step standing
“if deviation in flexion is to the right, left leg should be on chair”
- return to full upright standing with lordosis after each of 10 reps
-once centralized, stop flexion in steo standing, commence to FIL
Delorme regimen
Determine 10 RM
10 reps @50% 10RM
10 reps @75% 19RM
10 reps @100% 10RM
Precautions for resistance exercise
Valsalva Substitue motions Overtraining Overworking Avoid resistance distal to unheal fracture or unstable joint
Stop if pt. Experiences dizziness, pain or SOB that is unusual
Containdications for massage
Malignancy Inflammation Fracture Active hemorrhage Edema Infections Aneurysm Acute RA Osteomyelitis Osteoporosis Advanced diabetes Fibromyalgia in inflammatory state Symptoms get worse when applied STM
