Test 1 Review Flashcards
Therapeutic Exercise
The systematic, planned performance of body movements, postures, or physical activities intended to prevent injuries, improve/enhance/restore physical function, prevent or reduce health risk factors and optimize overall health.
Effect of Immobilization on Muscle
-Decrease in muscle fiber diameter
-Decrease in number of myofibrils
-Decrease in contractile ability due to decrease in motor unit recruitment
-Increase in fibrous and fatty tissue in the muscle
=Result: Atrophy/weakness after 2 weeks of Immobilization
Flexibility
The ability to move a single or multiple joints smoothly and easily through unrestricted PAIN FREE ROM
Elasticity
Ability to return to normal length after elongation
Extensibility
- Ability of muscle or tendon to take on a new length
- Occurs with repeated stretching for >30 seconds
Plasticity/Plastic Range
Tendency of soft tissue to assume a new and greater length after a stretch force removed
Failure
Tearing of tissue
Toe Region
Collagen wavy: where most functional activities occur
Elastic Region
Fibers stretch: complete recovery from deformation and tissue returns to its original size and shape when the stress is released = NORMAL ROM
Yield Point
Stress loads CT beyond elastic range and into plastic range
Flexibility Facts
- Individually variable
- Join-Specific
- Decreases with age
- Can be modified through training
Muscle Spindle
- Stretch Receptor
- located in parallel to extrafusal m. fibers(m.belly)
- Sensitive to changes in length and velocity
- Quick stretch=contraction(protection)
Golgi Tendon Organ
- Detects tension and sends messages to CNS for REFLEXIVE RELAXATION
- located near musculotendinous junctions(PA and DA) of extrafusal m. fibers
- Stretch >8seconds allows GTO impulses to override the muscle spindle= relaxation
- Autogenic inhibition
Duration of Stretch
Cipriani et al. stated 2x30 most beneficial
-2 min for increased flexibility
PNF: Hold-Relax
- Muscle in light stretch position
- Isometric contraction of tight muscle at end range(stim Gto = inhibition of agonist, AKA autogenic inhibition)
- Hold for 8 seconds
- Relaxation of agonist and new range is taken up
- Repeat steps 2-4
PNF: Hold-Relax with agonist contraction
- Muscle in light stretch
- Isometric contraction
- hold for 8 seconds
- Pt. concentrically contracts the opposite to move joint through increased ROM
- Repeat steps 2-4
PNF: Contract-Relax
- Muscle in light stretch
- Pt. pushes (submax) into clinicians hand extending muscle against mild resistance
- Pt. relaxes and the clinician takes up slack in new range
- Repeat steps 2-3
Factors that influence muscle force production
- Motor unit recruitment
- Cross-sectional area
- Speed of Contraction
- Angle of Pennation
- Muscle length
- Length Tension Relationship
- Pre-stretching
- Energy stores and blood supply
Sarcomere
The smallest contractile unit of a muscle
-Made of myofilaments termed actin and myosin that overlap causing cross bridging
Arrangement of Actin/Myosin
-Z line: end of actin filaments(z line to z line = sarcomere)
-I band: actin only that straddles the z line
-A band: runs length of myosin filament
-H zone: only myosin filament w/ no overlap of actin
M line: very center of myosin in the H band
All or None Principle
- When a threshold stimulus is reached, the muscle will contract
- All the muscle fibers in the unit will contract
Type I Muscle Fibers
=Aerobic/slow oxidative fibers
- Slow twitch
- slow to fatigue; used for endurance
- Use oxygen for energy
- Prevalent in postural mm.
Type II Muscle Fibers
=Anaerobic/fast oxidative fibers
- Fast twitch
- more powerful
- Capable of generating high amount of force in short amount of time
- Predominant in explosive mm contractions
Type IIa Fast-twitch fibers
=fast oxidative
- Transition between type I and IIb; uses both O2 and glycogen for energy
- Power and endurance
Type IIb Fast-twitch fibers
=Fast glycolytic
- Gylcogen for energy
- No endurance
- Power
Strength:
- Max force that a muscle can develop in a single contraction
- Functional strength = the ability of the neuromuscular system to produce, reduce, and control forces, during functional activities, in a smooth, coordinated manner
Power:
Power = Force x distance/time
-Incorporates both strength and speed
Endurance:
The ability to perform low intensity, repetitive, or sustained activities over a prolonged time (a less than max load)
- Dependent upon status of energy systems and mount of force
- Greater the force, the more quickly fatigue will occur
Goals of Training
Endurance = 15-20/set + <30 secs rest Hypertrophy = 8-12/set + 30-90 secs rest Strength = 6-8/set; no more than 10 reps + 2+ mins rest Power = 1-5/set + 2-5 mins rest
Length-Tension Relationship
-A muscle’s ability to generate tension depends on the position= Peak force production is at or near mid-range
Active Insufficiency vs. Passive Insufficiency
Active: Muscle too short to generate force
Passive: muscle too long to generate force
Isotonic Exercises(2):
Concentric: Shortening of muscle during contraction
Eccentric: Lengthening type of contraction
-More tension (2:1) can be generated than concentric
Isokinetic Exercise
=”Accommodating Resistance”
- Exercise at a constant velocity, resistance will vary
- Speed is constant no matter how much force is generated by muscle (concentric or eccentric)
Delayed Onset of Muscle Soreness (DOMS)
- Occurs 24-72 hrs post exercise
- Torn tissue: Myofibrillar disturbances 2 days post eccentric exercise(z band disturbance/disruption
- Connective tissue damage: Overstretching muscle elastic components
- No evidence for “lactic acid buildup”
- Eccentric may cause more DOMS
- Incorporate rest and also light aerobic exercise may help to relieve symptoms
SAID Principle
=Specific Adaptation to Imposed Demands
- Muscle adapts over time to stresses that are placed on them
- Exercises should mimic those of anticipated functional activities
Overload Principle
=Muscle must be challenged to perform at a level greater than what is accustomed
-PROGRESSIVE INCREASE
Reversibility Principle
- Functional gains are not maintained unless exercise consistently performed
- Occurs within 1-2 weeks (Use it or Lose it)
Delorme’s PRE: Exercise Progression
Set 1. 50% of 10 RM: 10 Reps
Set 2. 75% of 10RM: 10 Reps
Set 3. 100% of 10RM: 10 Reps
Oxford’s PRE: Exercise Progression
Set 1. 100% of 10RM: 10 Reps
Set 2. 75% of 10RM: 10 Reps
Set 3. 50% of 10RM: 10 Reps
Daily Adjusted Progressive Resistive Exercise(DAPRE) Technique:
Set 1: 50% of 6RM x 10 Reps Set 2: 75% of 6RM x 6 Reps Set 3: as many reps as possible with 6RM Set 4: adjusted working weight x as many reps as possible -Finding the adjusted weight for Set 4 by determining what happened on set 3: - 0-2 reps = decrease 5-10lbs -3-4 reps = decrease 0-5lbs -5-6 reps = keep same -7-10 reps = increase 5-10lbs ->11 = increase 10-15lbs
Duration of Training
- True strength gains take at least 6-8 weeks
- Improvements within first 2-3 weeks are neural adaptations
Janda’s Lower Crossed Syndrome:
- A short/contracted muscle inhibits/weakens it’s antagonists
- “Reflex Inhibition”
Spine ROM Exercises: General
- Cat-camel(paraspinals)
- L/S flexion in chair(paraspinals)
- Knee-Chest(paraspinals)
- Lumbar rock
- Pelvic tilt
Williams’ Flexion Exercises
- Pelvic tilt (posterior)
- Single Knee to chest
- Double knee to chest
- Hamstring stretch
- Partial sit-up
- Hip flexor stretch
- Squat
McKenzie Extension Exercises
“Theory of Centralization”
- Prone lying (pillow if uncomfortable)
- Prone on elbows
- Prone Press-ups: 10 reps 6-8x/day
- Standing extension: 10 reps, 6-8x/day
Trunk Stabilization
The most important aspect of core performance is obtaining the control that is necessary to:
- Stabilize the spine
- Maintain alignment and movement relationships between pelvis and spine
- Prevent excessive stress and compensatory motions of the pelvis during movements of the extremities
Lumbar Stabilization Exercises: The principles
Goals:
- Gain dynamic control of the spine
- Maintain “Neutral Spine” position during functional activities
- Hold posture against internal and external forces
Stabilizers:
-Lumbodorsal fascia, lats, IOA, TrA, gluteals
Lumbar Stabilization Exercises:
- Hollowing first (TrA)
- bracing (bearing down)
- Bracing with BP cuff
- Bracing + UE and LE movement
- Supine: Dead bugs - progression
- Bridging - progression (dorsiflexion on heels - LE movement - swiss ball)
- Prone: Planks - 3 levels
- Prone: Concrete lifts - swiss ball - bird dogs
- Sidelying: Side Bridges - Progression(EO and QL)
Multifidus Strengthening
- Multifidi activated with pelvic floor mm. (kegels + TrA exercises)
1. concrete lifts
2. Prone arch
3. Quadruped - Bird dogs - wts. - perturbations
4. Standing: swell the muscle
5. Standing with theraband
Lumbar Stabilization Exercises: Sitting
- Hips above knees
- On swiss ball
- Lift UE/LE
- Trunk Rotations
- Progression = add weights + perturbations
Core Stabilization: Kneeling
- Half Kneel
- Kneel on balance beam
- Kneel on balance beam with rotation
- Perturbations
Lumbar Stabilization: Standing
- Slight knee flexion to allow pelvic tilt
- Trunk rotation - Diagonal with tubing, cables, ball throwing - lunges
- Progress to a functional position
Primary Hip Flexors
Hip flexor tightness may also cause the pelvis to tilt ANTeriorly and increase lumbar lordosis:
- Iliopsoas
- Sartorius
- TFL
- Rectus Femoris
- Pectineus
- Adductor Longus
Primary Hip Extensor
- Gluteus Maxiumus
- Hamstrings
Hip External Rotators
- Gluteus maximus
- piriformis
- Obturator Internus
- Gemellus Sup&Inf
- Quadratus femoris
Hip Abductors
- Gluteus medius (all fibers)- Actions: Concentrically abducts hip; isometrically stabilizes the pelvis; Eccentrically controls hip adduction IR
- Gluteus Minimus
- TFL
Gluteus Medius Weakness
=Trendelenburg gait
-Step down test: active side
Hip Adductors
- Adductor longus, magnus, brevis
- Gracilis
- Pectineus
Hip Flexor Stretch
- Thomas Test position: Tightness will present with inability of the pelvis to be parallel to the table
- Kneeling position: rectus femoris
Hamstring stretch
- Doorway stretch
- Active stretch with hand behind knee (keep contralateral leg straight)
- Passive stretch with band around foot
- Standing with rotation of trunk
Piriformis stretch
Piriformis reverses its rotary action and becomes a hip IR as the hip is flexed past 90 degrees
- foot over knee
- quadruped stretch
Iliotibila band/Tensor Fascia Lata stretch
- Scissoring positon (Ober’s test)
- Flex, abduct, extend, and adduct the hip (clear the hip)
- standing
- supine: cross body with band on opposing foot
Hip Strengthening: Gluteus Medius
- Prone: active/resisted abduction w/ extension
- Sidelying: Hip ER (clam shells); Hip abduction with extension (hip wall slides)
- Standing: hip Abduction against cables/tubing; hip abduction/extension with t-band loop; stand in SLS; single limb squat; single limb deadliest
Best Exercise (Distefano) to strengthen hip mm.
Side-lying hip abduction exercise
Hip Strengthening: Gluteus Maximus
- Prone: hip extension with knee flexed(open chain); hip extension with knee extended(open chain)
- Quadruped: donkey kicks (open chain)
- Supine: bridging
- Standing: squats(single limb i. e. bulgarian); lunges; hip ext against tubing;
Hip Strengthening: Adduction
- Sidelying: SLR
- Standing: adduction against t-band; multi hip machine
- Seated: Nautilus machine
Hip Strengthening: Flexion
- Supine: SLR
- Prone: Walk outs/ins on swiss ball(jack knife)
- Seated: marches with ankle weights
- Standing: flexion against tubing/cables
Advantages of Manual Resistance
- Most effective during early stages of healing when muscles are weak
- allows sensory feedback for ATC
- Resistance may be adjusted
- Max muscle workout through ROM
- ROM controlled by ATC
- ATC prevents compensatory patterns
- Various positions
- Cost effective
- Direct interaction
Disadvantages of Manual Resistance
- Exercise load is subjective by ATC
- Resistance limited by ATC
- Min value for strong muscles
- May not carry over to functional activities
- Cant take home
- Labor and time intensive
- ATC possible injury
Proprioceptive Neuromuscular Facilitation(PNF): Principles
- Combines functional diagonal patters
- Improves neuromuscular control and function
- Develops: strength, endurance, stability, mobility, coordination
- May be used throughout rehab process from acute inflammatory through maturation phases
PNF Principles
- Sequence: Distal to proximal
- Verbal commands
- Visual cues
Diagonal Patterns: D1 and D2
- I.D. by motions at proximal joints
- Flexion and Extension patterns
- Flex/Ext are coupled with ABD/ADD and IR/ER
Hip Biomechanics: Gait
- Initial contact
- Loading Response
- Midstance
- Terminal Stance
- Preswing
a. Initial Swing
b. MidSwing
c. Terminal Swing
Gait: 1. Initial Contact
- 25 Degrees Hip flexion
- Hamstrings contract in reaction to hip flexion torque
- All hip extensors active in preparation for LR (glute max and hamstrings)
Gait: 2. Loading Response
- 25 Degrees hip flexion
- Glute max, hamstrings and adductor magnus contract due to flexion torque
- Glute med, min and posterior TFL contract to stabilize in frontal plane
Gait: 3. Midstance
- Hip extends to Neutral(0 degree flex/ext)
- No muscle activity in sagittal plane
- Pelvis is stabilized in the frontal plane by the hip abductor group, primarily glut med
Gait: 4. Terminal Stance
- 20 Degrees hip extension
- Ext torque keeps hip stable
- Adduction torque decreases
- TFL fires to restrain hyperextension of the hip
Gait: 5. Preswing
- 5 degrees extension
- Thigh falls forward, aided by adductor longs
- Hip ext torque diminishes
- Limb advancement begins
Swing Gait: a. Initial swing
- 15 degrees of hip flex (foot clearance)
- Iliacus, gracilis, sartorius and adductor longus are active concentrically
Swing Gait: b. Midswing
- 25 degrees of hip flex
- Iliacus, gracilis and sartorius stop firing
- Hamstrings fire eccentrically to control hip flex
Swing Gait: c. Terminal Swing
- 20 Degrees of hip flex
- Hamstrings peak to decelerate limb
- Glut max and adductor magnus prepare to stabilize at IC
Proprioception
Body’s ability to transmit afferent infer to the brain to elicit a motor response to allow for appropriate posture and movement
Components of Proprioception
- Agility to change direction
- Balance to maintain stability
- Coordination to perform the activity correctly and consistently
Functional Ankle Instability
- Following acute later ankle sprains = Chronic lateral instability develops in 20-30% of pts
- Increased risk of sprain recurrence due to delayed proprioceptive response of the peroneals
Lephart et al, 1997
- Important to understand role of proprioceptively mediated NMC after joint injury and its role during rehab
- Proprioception provides:
1. Dynamic joint stability
2. Motor control
Cutaneous(skin) Receptors
- Fast-adapting: respond to mechanical deformation such as touch, vibration, or any pressure against skin
- Slow-adapting: Respond to stretch of skin
GTO
- Detects tension
- Respons to both contraction and stretch
- Stimulation = muscle relaxation
Muscle Spindle
- Responds to stretch
- Stimulation = contraction
Joint Receptors
- Located within connective tissue of joint capsule and surrounding ligaments
1. Ruffini endings
2. Pacinian corpuscles
Ruffini endings
- Located in joint capsule on flex side of joint
- Respond to extreme ROM into ext with rotation
- Protect unstable joints
Pacinian corpuscles
- Located throughout joint capsule, joint and periarticular tissues
- Very fast adapting
- Respond more to compression forces across joint esp during high velocity changes (ex. cutting, landing)
Ligament Receptors
- Not active in mid range of motion (muscle stability)
- Stimulated when joint nears end range of motion to protect ligament
- inhibit continued agonist contraction so that stress decreases on ligament
Role of CNS in Proprioception: Spinal Cord
- Simplest form of efferent response: Spinal Reflex
- Used to adjust for minor changes in joint stress to protect joint integrity
- Occurs subconsciously
Role of CNS in Proprioception: Brainstem
- Medulla, Pons, and midbrain
- Used primarily to detect changes in posture and balance
- If spinal reflex is insufficient afferent info will travel until it reaches brainstem
Role of CNS in Proprioception: Cerebral Cortex
- Highest level of brain
- Responsible for volitional control of movement
- Movement is consciously controlled and learned before it becomes subconscious movement: i.e. repeatedly practicing an activity
Balance
Brainstem receives sensory info from:
- Vision (eyes)
- Vestibular system (ears)
- Proprioception or somatosensory system
Motor Strategies for Balance Control
- Ankle strategy - min amount of perturbations so balance is maintained distal to proximal
- Hip strategy - Rapid or large perturbations; proximal to distal
- Stepping strategy - force displaces COM
Strategies to Restor NMC
- Biofeedback - hearing when to contract muscle
- Mirrors
- Touch
- Tape
Neuromuscular Control
- Progressive: static to Dynamic
1. distracters (ball toss)
2. Surfaces
3. visual input
4. predicted vs unpredicted perturbations
Lower Extremity Techniques
- Focus on muscle groups that require attention (no wt. to wt.)
- Use of closed-chain activities is encouraged
- *Star Excursion test great predictor
