Therapeutic exercises (copy)

What are the 3 goals for Therapeutic Exercises?

• Achievement of symptom-free movement and function

• Carefully graded stresses and forces applied to body (certain tissues can only deal with certain stresses in certain phases of healing ex) post op pts

• Applied in controlled, progressive and appropriately planned manner

What are the 4 parts of the NAGI Model?

• Pathology

• Impairment

• Functional Limitation

• Disability

What is Pathology in the NAGI Model?

Disease, Disorder, Condition (Rotator Cuff tear)

What is Impairment in the NAGI Model?

consequence of pathology, any loss or abnormality of psychological, physiologic or anatomic structure or function ( ROM, nerve mobility, coordination, balance, muscle power loss)

What is Functional Limitation in the NAGI Model?

a limitation from an impairment that is not disabling, yet interferes with daily function (Thing pt is having trouble doing in daily life) ( postal worker cant lift up bags of mail)

What is Disability in the NAGI Model?

an inability to undertake normal activities of daily living (ADL's), or tasks at home, work, recreation or in the community

What does the NAGI Model also encompass?

Societal function or lack thereof

What is a PT Diagnosis?

It is the relationship of a patient's impairment to their functional limitations (

(Ex. Decreased Right Glenohumeral ROM (Shoulder flexion 95 deg) resulting in inability to stack boxes on top shelf at work.)

(Ex. Decreased Right Glenohumeral ROM (Shoulder flexion 95 deg) resulting in inability to stack boxes on top shelf at work.) Of this example, what is the impairment and what’s the functional limitation?

• impairment: the ROM

• Functional limitation: unable to stack boxes on top shelf at work

What does a pt Subjective consist of? And why do you need to capture all the basic info?

• "Body chart", case history, description of symptoms (pt SINS)

• capturing all the basic info that’s helping drive the pattern recognition

What is an Objective? And the concept

• Systematic administration of test or movements to define impairments and its relationship to the functional limitation

  • systematically do some tests and movement to help pick out impairments (remember the triangle!= and march up that triangle and determine if all systems are good or which of these systems are normal and you will target that system and you will see if that will affect the pts asterisk sign or the functional movement that is painful

What else do you do in objective ?

• Observation and Inspection

• Provocation

• Motion-pain relationship

• Resistance Testing

• Joint Mobility Testing

• Hypothesis Testing

Regarding objective, what does motion - pain relationship mean?

We are trying to decide if pt is pain dominant meaning pain limited, they are irritable or are they resistance limited in their movement which means they are stiff more so than painful

Give an example of hypothesis testing?

ex) is think the pts limited ROM is the cause of their pain, so, I want to restore that” then restore that and see if the functional limitation has improved

What is a Prognosis? A prediction of what? It’s the anticipated length time of what?

• A prediction of the patient's optimal level of function expected at the end of treatment

• Anticipated length of time needed to reach the specified functional outcome

What are 6 factors that can influence Prognosis?

• Complexity, severity, acuity or chronicity of proble (More impairments/pain/inflammation etc means longer it will take for it get better)

• General health ( how it affects how active they can be and how quickly their tissues recover)

• Patient goals

• Patient's motivation

• Safety issues ( protocols like early stages of post op)

• Extent of support (physical, emotional, social) (more support the better they recover)

What are 6 factors influencing decision when developing a plan?

• Impairments, functional limitations or disabilities

• Psychological status of patient (pt motivation towards PT)

• Socioeconomic and cultural factors

• Home environment/ Family support

• The patient's and employer's vocational plan (getting them back to work and how physically demanding it is)

• Ethical considerations ( how long you will be able to treat them if their are having true impairments unless they are faking it) ex) workers comp has a history of this

What is a Long Term Goal?

how treatment will affect the functional limitations or disability at the conclusion or rehab

Ex) carpal tunnel: returning to a job like typing and using their hands which will cause the reoccurrence of the issue and they should think if they would want to return to that job

What is Short Term Goal?

measurable behavioral objectives affecting the documented impairments

What can Short Term Goals reflect?

May reflect component abilities or skills to achieve functional goals (Ex. Increase strength and ROM)

What are 2 things PT should do when evaluating a plan?

1. Compare original data with current data at frequent intervals

   1. its important to measure everything in the eval and you’re going to want to reassess the rom and such to see if the pt is getting better or not

2. Identify goals that have been met, change those that need further modification

What is Strength/Muscle Performance?

The ability of a muscle or muscle group to produce tension

How is Strength/Muscle Performance assessed? (2)

MMT OR Functionally by having pt lift and equivalent weight as in their functional limitation

What are 7 factors that can influence strength?

1. Cross sectional size

2. Length-tension relationship

   1. If its Optimal, too short = active insufficiency, too long = passive insufficiency

3. Recruitment of motor units

4. Type of muscle contraction (Iso/Con/Ecc)

5. Fiber type (Type I vs Type II)

6. Energy store and blood supply

7. Speed of contraction -greater torque at lower speeds

8. Motivation of patient

What are 3 ways to increase Neuromuscular strength?

• Hypertrophy

• Possible Hyperplasia( more cells)

• Increased recruitment of motor units ( physically tap that muscle to teach pts to turn it on)

Early strength gain is often due to what?

motor learning (meaning because they are learning to activate those muscles)

What is Hypertrophy? Increased amount in what 3 things?

• Tissue protein

• Density of capillary beds

• Size of Type 2 Fibers

What are 3 types of non-contractile tissue?

Bone, Tendon, Ligament (these benefit from resistance training)

Skeletal tissue strength can increase help with what else? And how?

can help with osteoporosis (muscle pulling on the bone is stress/loading on the bone)

Where can Ligament and Tendons gain strength?

Musculotendinous Junctions and Ligament Bone Interfaces (due to increased load/stress)

What are the 3 guidelines for increased strength?

• Overload Principle

• High loads, low reps- performed to fatigue

• Varying type and structure of exercise program

Don’t give ________ dosages!

random

Regarding varying type and structure of exercise, What type of muscle contraction can you start with?

You can start with isometrics initially then onto eccentric/concentric

What is the Overload Principle?

A load that exceeds metabolic capacity

What is Endurance necessary for?

Necessary for performing repeated motor task in daily living

What are the 2 types of endurance?

Muscle and general body endurance

What is Muscular Endurance? ****

Ability of muscle to contract repeatedly or generate tension, sustain it and resist fatigue over a prolonged period

What is General Body Endurance?****

Ability of a individual to sustain low intensity exercise such as walking; jogging over an extended period

Why is aerobic conditioning/general body endurance very important ? Indicated for what? Helpful for who? How about the people that cant put too much weight?

indicated for LBP likely and helpful for pts that have degenerated issues in their hips and knees…. People that cant put too much weight on their extremities then you can put them on the exercise bike

What is General Body Endurance AKA?

Aerobic conditioning

What are 5 Muscular/ Cardiovascular/ Pulmonary immediate changes?

• Inc. blood flow to muscle

• Inc. HR

• Increased arterial BP due to inc. stroke vol and cardiac output

• Increased O2 demand and consumption

• Increased respiratory rate and depth

What are long term adaptive strength changes in Muscle?

Capillary bed density increase

What are long term adaptive strength chances in Cardiac and Vascular Changes? What increases and what decreases ?

• Cardiac output and stroke volume increase

• Resting HR decreases and return to resting from exercise quicker

Guidelines for Developing Endurance: Muscular Endurance

Active exercise performed repeatedly against a moderate load to the point of fatigue

Guidelines for Developing Endurance: General Body Endurance

• directly exercising large muscle groups (walking, running, swimming, cycling)

  • Exercise prolonged > 20 minutes

  • Exercise every other day

To maintain healthiness its recommended to get some type of what daily???

exercise - josh

Regarding mobility and flexibility, mobility of what is important for what?

Mobility of contractile and non-contractile tissue is important for normal function

What is Normal Motion of muscle?

constant elongation and contraction of tissues

What is Restricted Motion of muscle?

Adaptive shortening

Give an example of adaptive shortening, how did it happen? What could it create in the capsule ?

which means they have had a TKA and no one has helped straighten that knee out, all that swelling which could lead to fibroplasia (more cells being produced) which might allow a contracture in the capsule… so it’s important to reduce this adaptive shortening to increase flexibility and mobility

What is considered a Diseased or Trauma motion of muscle?

Pain, weakness or inflammation which can decrease mobility and result in adhesions and contractures

What do muscles do when stimulated? Relaxes after what? Can be what? Immobilization results into what?

Shortens <<

• Relaxes after contraction

• Can be passively stretched

• Immobilization results in adaptive shortening

Connective Tissue Characteristics (3)

• Non-Contriactile

• Adaptively shortens

• Supple and can be lengthened by passive stretch

Regarding connective tissue, can it contract or relax? How can you lengthen them?

• No it cant

• With just passive stretching and end range stretching

Scar Tissue Characteristics, does not yield to what? Non what for 2 things, what do you need to avoid?

• Does not yield to stretch

• Non-resilient

• Non-elastic

• Avoid prolonged immobilization

Immobilization is _____ and very _____….. when do you want to get them moving by?

• Common and very ciritical

• Want to get them moving as soon and as safely as possible

Regarding skin, what’s suppleness important??? And what else is important??

• it must be stretch for joint motion to occur

• Early mobilizations is important

How can skin develop motion limitations?

After burns, trauma, surgeries

What is Stability?

Synergistic co-ordination of neuromuscular system to provide a stable base for superimposed functional movements (Stable base for movement to occur)

What structures is Stability very important for?

Proximal Structures <<

• Trunk

• Hip

• Shoulder Girdle

What can decreased stability proximally cause?

Excess stress on certain structures w distal mobility

How can a pt develop Stability? Control what? Maintain what? (2)

• Pt. must learn to control proximal area

• Must maintain stable, well aligned posture

How can they control the proximal area??

by strengthening the muscles in the h proximal area and cure the muscles to fire at the right times

How can a pt develop stability while carrying out a functional task? (4)

• Start in single plane motions (be able to maintain stable and well aligned posture while doing functional tasks)

• Progress to controlled diagonals (multiple plane motions)

• Endurance must be developed in stabilizers (glute med, glute max, mid&low traps)

• Work in components then progress to full functional activity (work in short arcs of movement and then progress to full functional activity)

What is Relaxation?

conscious effort to relieve tension in muscles

What occurs after active contraction of muscle?

Reflex Relaxation occurs

What can decrease muscle tone?

• Conscious thought

  • Biofeedback

  • Transcendental meditation

What are 4 guidelines for Relaxation?

• Place patient in comfortable position

• All body parts well supported

• Pt. taught to progressively contract and relax musculature

• Use deep breathing

Give an example of relaxation

What are Coordination, Balance, and Functional Skills dependent on?

• Sensory system

  • Somatosensory and proprioception

What is Coordination?

• Ability to use the right muscles at the right time

  • w/ appropriate sequencing and intensity

What is Coordination the basis of?

Smooth and efficient movement

What is Balance?

Ability to maintain the center of gravity over the base of support; usually when upright

What is Balance a combination of? Give an example

• Stability and mobility

  • Hips need to be strong enough to stay in the right place

  • Need to have joint motion in ankles and knees for the movement strategies

Where is Balance needed?

Needed to hold a position in space or move in a controlled- coordinated manner

What is Functional Skills?

Refer to varied motor skills necessary to function independently in all aspects of daily living (includes balance, coordination, and stability.)

What are 6 Guidelines of Developing Coordination, Balance, and Functional Motor Skills? Constant repetition of what? Use what type of cues? Progress from what to what? Emphasize Stability before what? Simulate real what? As what improves, what should increase?

1. Constant repetition of simple → more complex motor activities

   1. Have pt do a mini squat, tap on glute med to prevent pelvis from tipping or off balance, make sure it’s aligned

2. Use of sensory cues (tactile, visual, proprioceptive, verbal)

   1. Mirrors

3. Progress from single straight plane to combined motions and diagonals

4. Emphasize proximal stability before distal mobility

5. Simulate real specific functional activities

   1. Instead of jumping then go to squats and eventually into deeper squats then short jumps and then full jumps

6. As quality of motion or motor skill improves, speed and timing should be increased

How can a PT prepare for Exercise Instruction? Do what ahead? What type of relationship (2) ? Identify what 2 things for the pt ?

• Plan ahead

• Positive therapist/patient relationship

• Collaborative relationship (help them understand why your re giving these exercises and don’t give too many)

• Identify patient's learning style (decide if they need a vid of themselves or a printed list of exercises)

• Identify patient's attitude towards exercise (some pts love to exercises so you need to slow them down, some ppl hate it so you need to give them little by little)

What is Motor Learning? (3) what type of processes? What type of acquisition and retention ? Involves what?

• Complex set of internal processes

• Relatively permanent acquisition and retention of a skilled movement/task

• Involves practice

What are the 3 types of Motor Tasks?

Discrete, Serial, Continuous

What is Discrete Task? Example?

Movement w recognizable beginning and end

Ex. Push up, lifting weights

What is Serial Task? Example

• Composed of series of discrete tasks combined in a particular sequence

• (Ex. Eating w fork = appropriate grasp, proper positioning scoop up food, move fork to mouth)

What is Continuous Task? Example

• Repetitive, uninterrupted movement w NO distinct beginning or end

• (Ex. Cycling, walking up and down stairs)

What are the 3 Stages of Motor Learning?

Cognitive, Associative, Autonomous

What is Cognitive Stage? (5) Requires a great deal of what? Patient thinks about what? What’s common? Pts are easily what? Requires a lot of what?

• 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

What is Associative Stage? (6) Pt makes what ? Concentrates on what? Tries to become more what? Use of what type of skills? Modifies activities depending on what? Decrease in need for what ?

• 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

What is Autonomous Stage? (5) movements are what? Pt can do what ? Easily adapts to what? Very little what is required? Pts are often what before this stage?

• Movements are automatic

• Patient can do multiple tasks at once

• Easily adapts to variations in task demand

• Very little feedback or instruction required

• Patients often discharged before this stage...*****

What are 3 Variables that influence Motor Learning?

• Pre-Practice Considerations

• Practice

• Feedback

What is Pre-Practice Considerations? (4) Understanding why what? Ability to do what? Demonstration of what? Pre - practice what that is clear and succinct ?

Understanding why they are doing it

Ability to pay attention

Demonstration of task for patient

Pre-practice verbal instruction that is clear and succinct

What is the MOST important part of Motor Learning?

PRACTICE

What are the 3 Types of Practice?

• Part v Whole Practice

• Blocked v Random v Random Blocked

• Physical v Mental

What is Part v Whole Practice?

whole practice is a jump ( From a deep squat all the way to a full jump). Part practice is just a mini squat (make sure our knees dont drive in or go over our toes

What is Blocked v Random v Random Blocked Practice?

• blocked: ask a pt do a sit to stand from a plinth at a fixed height(cue to lean fwd, keep feet underneath them and extend at the hips)…. They are doing the same thing over and over again

• Random: ask pt them to do a STS from a chair then stool then a table and a plinth

• Random blocked: you are going to do 10 STS from the plinth then 10 more at this chair

What is Mental v Physical Practice?

• mental: asking them to picture and think of the alignment in their knees and legs

• Physical: actually doing it yourself

What is feedback? What’s being received and by who? When do you give feedback?

• Sensory information received by learner

• Either during or after performance of task

What 3 things must a PT decide when providing feedback?

• Type of feedback

• Amount of feedback

• Timing of feedback (Before/after)

What are the 6 types of feedback?

• Intrinsic

• Augmented

• Concurrent

• Terminal

• Immediate

• Delayed

• Summary

What is Intrinsic Feedback? (3)

• Sensory cue inherent in task

• Arises from performance of task

• Usually proprioceptive, kinesthetic, tactile, visual, audio