Intro to Eval and Treatment Exam 2

What may cause the deficit?

Pain

Swelling

muscle guarding/ spasm

Joint injury

Surgery

Inactivity

shortening of connective tissue and muscle

Combination

ROM exercises or manual interventions

joint capsule tightness doesn’t allow proper motion

Stretching/flexibility exercises

muscle tightness restricts motion

Strengthening

weakness causes decreased motion

Restriction/lack of ROM

Pain

Inflammation

Joint Capsule Tightness

Joint Injury

Muscle tightness/shortening

Muscle weakness

JOINT MOBILITY

The ability of a joint to move through its full available range

JOINT MOBILITY Affected by:

Joint surfaces (arthrokinematics/ accessory motion - Roll, spin, and glide)

Muscle flexibility

MUSCLE FLEXIBILITY

The ability of a muscle or muscle groups to lengthen passively through its full available range

MUSCLE FLEXIBILITY Affected by:

Joint mobility

Active Insufficiency

muscular limitation occurring when a multi-joint muscle shortens over all its joints simultaneously, becoming too slack to generate effective tension or force

Passive Insufficiency

occurs when a multi-joint muscle is stretched to its maximum length over two or more joints simultaneously, preventing further movement and restricting full ROM

When you improve muscle flexibility

joint range of motion will also increase

When you improve joint range of motion

muscle flexibility may NOT be affected

Active Range of Motion

movement of body part through an arc of motion by active muscle contraction

When patients can exercise without assistance

Patients move their limbs themselves

Assisted Active Range of Motion

Mvmt of a body part through an arc of motion with a combination of active muscle contraction and external force

When muscles are weak or when jt motion causes pain

Patients move their limbs, but outside force helps with the movements (clinician, machine, self, etc.)

Passive Range of Motion

Movement of body part through an arc of motion by an external force

No effort exerted by the patient

When patients cannot actively participate

When contraindicated for muscle to contract

Start with AROM if

patient can perform w/o pain or inflammation (not contraindicated)

Start with AAROM if

patient cannot perform AROM

Start with PROM if

cannot perform AAROM or if muscle contraction contraindicated

Anatomical Limits to Flexibility

Same for healthy and injured?

Muscles, tendons, surrounding fascial sheaths

Connective tissue

Bone

Adipose tissue

Skin

Neural tissue

All (except bone, age, gender) can be altered to increase jt ROM

Efferent

motor; away from spinal cord

Afferent

sensory; towards spinal cord

Facilitatory

excites; increases; makes easier

Inhibitory

depresses; decreases; makes more difficult

Muscle Spindle

sensory receptors found in the muscle fibers; sensitive to stretch; facilitates contraction

Golgi Tendon Organ

sensory receptors found in the muscle tendons; sensitive to increased tension (muscle contraction); inhibits further contraction

When a muscle stretched…

• m spindles & GTOs send afferent impulses to SC

• synapse w/ motoneuron at SC… informs m being stretched

• efferent impulses come back to same m, contract & resist stretch

GTO responds to both

changes in length and tension

stretch held for pd of time (6s),

GTO sends afferent impulses back to SC (senses increase in tension) (All of this occurs w/o having to send impulses to brain)

Signals synapse w/ a m neuron at SC,

efferent impulses back to m causes reflex relax. of m being stretched (the

antagonist) (All of this occurs w/o having to send impulses to brain)

Autogenic inhibition

Relaxation of the muscle that is contracting

Contr. during “push” phase causes increase tension

stimulates GTOs to produce reflex relaxation before m placed on stretch

Reciprocal inhibition

contraction of agonist causes a reflex relax. in antagonist muscle, allowing it to stretch

M & tendons composed largely

of non-contractile collagen and elastin (Both components (w/contractile components) determine muscle’s capability of deforming and recovering)

M also has active contractile components

actin and myosin myofilaments (Both components (w/ non-contractile components) determine muscle’s capability of deforming and recovering)

Both components resist

deform % of ea. depends on degree m is stretched & velocity of deform

non-contractile primarily resist

degree of stretch. stretch, more these components contribute

contractile elements limit

high velocity deform

Stretches held long enough allow for

viscoelastic & plastic changes to occur in collagen & elastin fibers

The > the vel. of deform., the >

the chance of exceeding tissue’s capability to undergo viscoelastic & plastic changes

To most effectively stretch a m during rehab,

intramuscular temp should be increased before stretching + effect on collagen and elastin enhances ability of GTO to inhibit (39º C or 103º F)

Low intensity warm-up or modalities

Cold: helpful to decrease m guarding that might be limiting ROM

Stretching Techniques Goal

improve active ROM by altering extensibility of mt units over time, mt units will increasing ROM possible

Dynamic Stretching

repetitive contraction of agonist to create quick stretch of antagonist

Many sports stretch

ballistic (high-intensity, dynamic technique that uses rapid, bouncing, or jerking movements to force muscles beyond their normal range of motion)

Functional

late stages healing

Tail end of warm-up

resembles dynamic activity

Static Stretching

to pt of discomfort; hold 3 – 60 s 15-30s most effective 3-4x

contraction of agonist, passively use BW, partner, clinician, t-bar, towel, etc

Proprioceptive Neuromuscular Facilitation

alternating isometric/isotonic contractions of ag & antag 10s push/ 10s rest 3 different techniques. contract relax hold relax slow reversal-hold-relax

no evidence one better/worse

Contract Relax

beneficial when ROM ltd by m tightness. Uses a combination of passive stretching with isotonic (concentric) muscle contractions of the muscle being stretched. Each lasts for 10 sec Immediately transition between contracting and relaxing (no delay) Repeated 2 to 3x

Hold Relax

approp when m tension on 1 side of jt. Combination of passive stretch and isometric muscle contractions of the muscle being stretched. Each held for 10 sec Immediately transition between contracting and relaxing (no delay) Repeated 2 to 3x

Slow-Reversal-Hold Relax

useful for increasing ROM when primary limiting factor is antagonistic m group. Combination of active concentric contraction of the agonist (not the muscle being stretched) with gentle overpressure, followed by isometric contraction of the muscle being stretched. Starts with active contraction. Ends with passive stretch. Most challenging for the patient to perform 10 seconds each. Repeat 2-3x

Recommendations for Stretching

Between 3-6x/week Muscle must be maximally relaxed May need to help pt attain proper relaxation

Location of treatment – quiet, low lighting

Deep breathing

Visualization

Conscious relaxation

Precautions

Overload necessary however always keep stage of healing in mind; avoid re-injury

Educate patient, discomfort OK, pain is not

Stretching with acute injury OK as long as tissue stretched is not injured

If your patient had poor accessory motion into knee extension, which direction would you mobilize the tibia?

anterior

The joint position in which there is maximal joint play, poor bony congruency, maximal joint volume, and most separation between bones is the position we place our patient in when performing joint mobilizations. What do we call this position?

open packed

On the Maitland scale of joint mobilizations, which grades are used to primarily treat pain?

grade 1 and grade 2

What are the 2 primary indications for choosing to integrate joint mobilizations into your treatment plan?

hypermobility and pain

You have determined that joint mobilizations are necessary for your patient who is lacking shoulder abduction. Which of the following would help you determine which way to mobilize the humerus?

convex-concave rule

Your patient has joint capsule tightness that is limiting both accessory and physiologic motion. What therapeutic intervention is best suited to help this patient improve their range of motion?

joint mobilizations

The two fascia that are vital to proper core functioning are the

thoracolumbar and abdominal fascia

Poor stability, weakness, or dysfunction at any level has been linked to which of the following issues? (select all that apply)

low back pain, ankle instability, knee instability, ankle instability, knee instability, patellofemoral pain

The ideal position for exercise, activity, and performance in in which the pelvis is neither anterior or posterior tilted, is called

lumbopelvic neutral

At what tempo should you teach your patient to perform a standard PRE exercise, such as an open can as shown in this picture?

2 seconds concentric, 4 seconds eccentric

During progressive, resistive exercise, the muscle must be trained eccentrically because of...

the need to decelerate the limb, especially during high velocity dynamic activities

In order to prevent low back pain and other compensations or injuries, it is vital for your patient to activate their global muscles before the local muscles (T/F)

false

Which type of exercise uses a constant velocity rather than a constant resistance?

isokinetic

Mobilization techniques are performed parallel to the treatment plane and traction is performed perpendicular to the treatment plane (T/F)

true

The SAID principle stands for

Specific Adaptations TO Imposed Demands

global or local: multifidus

local

global or local: transverse abdominis

local

global or local: rotatores

local

global or local: rectus abdominis

global

global or local: external oblique

global

global or local: erector spinae

global

Which of the following would be considered benefits for including isometric exercises in the rehabilitation program

they are thought to be safe for the patient, strength gains are specific to the angle exercised

Training to increase [A] must include components of both strength and speed

power

Having your patient complete 2 sets of 15 reps of this horizontal abduction exercise, would be representative of targeting improvements in what specific goal of rehab?

muscle endurance

Which of the following anatomic "groups" of muscles make up the core?

pelvic/ hip muscles, lumbar spine muscles, abdominal wall muscles

Hypermobile

joint moves beyond anatomical limits (due to laxity). Treat w/ strengthening & stability exercises, bracing, taping, splinting

Accessory

Motion of joint surfaces relative to one another not under voluntary control. Can be hypo-, normal, or hypermobile

Hypomobile

stops short of the anatomic limit. Mobilization used to correct tight inert tissues

Shoulder Capsular Pattern

ER more limited than abduction

Abduction more limited than flexion

Flexion more limited than IR

Knee Capsular Pattern

Flexion more limited than extension

Talocrural (ankle) Capsular Pattern

PF more limited than DF

Passive, manual techniques applied to joint and related soft tissues to

decrease pain or increase range of motion

Mobilization

Slower speeds, occurs throughout the range, may be a small or large amplitude mvmt

Manipulation

Always at end of range, small amplitude, quick thrust

Concave-Convex

If concave joint moving on stationary convex surface – glide occurs same direction as roll

Convex-Concave

If convex surface moving on stationary concave surface – gliding occurs opp direction to roll

Compression

decreased jt space

Improved jt stability

Associated with WB activities or muscle contraction around a joint

Important for joint nutrition

Abnormally high loads problematic

Distraction

when jt surfaces are separated

Helpful to relieve joint pain

Most commonly used

Precedes most manual therapy techniques (including joint mobs)

Open/Loose-packed or Resting position

Max. jt play - position in which jt cap/ligs most relaxed

Articulating surfaces maximally separated

Position used for joint mobilization

Close-packed position

Max contact of articulating surfaces

Effects of Joint Mobilizations

decreased pain/pain perception due to stimulation of joint mechanoreceptors

increased joint proprioception

decreased muscle spasm, guarding, & increased muscle relaxation

Maintenance of tensile strength and extensibility of articular structures

increased joint nutrition

Grade I

Small amplitude mvmt at beginning of range. Used to treat pain

Grade II

Large amplitude mvmt w/in midrange. Used to treat pain

Grade III

Large amplitude mvmt up to the pt of limitation (PL) in range. Used to treat ROM deficits

Grade IV

Small amplitude mvmt at very end of range. Used to treat ROM deficits

Grade 5

Manipulation

Small amplitude, quick thrust at end of range

Accompanied by popping sound

Velocity vs. force

Requires training

If concave moving on fixed convex

mobilization occurs in SAME direction as desired motion