Active Care - Exam 1

Benefits active care is intended to provide

reduce pain

restore biomechanics and function

improve strength, stability, and coordination

improve mobility and flexibility

improve proprioception and balance

Active care also involves

patient education and advice

Difference btw passive and active care

passive care = short term

Three roles movement plays in patient care

general health and wellness

assessment

treatment and management

ACSM guidelines for Aerobic training

150min/wk (at least 30min of 5+ days)

ACSM guidelines for Resistance training

2 non-consecutive days/wk

_____ is an independent predictor of all-cause mortality and cardiovascular disease

grip strength

The single best predictor of senior citizen falling is

toe strength (leg strength 2nd)

Why movement assessment leads to better diagnostics and improve outcomes

shorten treatment time

Source of pain

refers to the location the individual is feeling pain

Cause of pain

refers to what is creating pain in the individual’s system

#1 predictor of injury

previous injury

Motor control

necessary input, sufficiently processed, with an acceptable output

Altered motor control involves

poor timing, sequencing, coordination, synergy of the neuromuscular system that manifests in dysfunctional movement

Mobility Dysfunction (TISSUE)

decreased AROM

decreased PROM

Mobility dysfunction takes

time (repetitive, disuse)

Stability/Motor Control Dysfunction (BRAIN/SKILL)

decreased AROM

functional PROM

Does a parts-based movement model work

NO!

• should start with MVNT PATTERNS first

When do we have justification to look at parts first

when the pattern is dysfunctional

When should functional movement assessments be performed

1st visit baseline

post-intervention check

ongoing assessment

Why should we perform functional movement assessments

find the cause, explain the source, determine effective tx, and shorten tx time

improved outcomes and reduced tx plan errors

When a compensatory mechanism is triggered, what happens

the stabilizing function is overtaken by the mobilizing muscles

• mobilizers increase activity and decrease flexibility

Functional muscle imbalances occur as a result of

disuse and lack of stimulation

adaptation to highly repetitive movement and stabilization patterns

dysfunction, pain, injury

Upper crossed syndromes weak vs tight muscles

Weak = deep neck flexors (ant) and lower traps, serratus anterior, rhomboids (post)

Tight = pectoralis major and minor (ant) and upper traps, levator scap, suboccipitals (post)

Lower crossed syndromes weak vs tight muscles

Weak = abdominals (ant) and gluteus maximus (post)

Tight = hip flexors (ant) and thoracolumbar extensors (post)

Primary tissue/system that mediates the interconnectedness of the kinetic chain

connective tissue

Regional interdependence

unrelated impairments in a remote anatomical region may contribute to (or be associated with) the patient’s primary complaint

Mobile joints

produce movement in 3 planes

prone to mobility dysfunction

Stabile joints

produce movement in 1 plane

prone to stability dysfunction

Mobile joints examples

ankle, hip, thoracic, glenohumeral, upper cervical, wrist

Stabile joints examples

knee, lumbar, scapula, lower cervical, elbow

Hierarchy of movement - Management and Treatment

mobility → motor control → functional patterning

Hierarchy of movement - Movement evaluation

Functional patterning → motor control → mobility

Rehab plans incorporating active care exercises should be

specific to the individual and adaptable

Primary goal of dysfunctional movement findings

identify relevant dysfunction movement patterns and improve them (must post-check to know if improved)

Techniques that help restore optimal length-tension relationship (Muscular system)

stretching

manual therapies

motor control

strengthing

Techniques that help restore optimal force couple relationship (Nervous system)

motor control

exercise/loading

stabilization

regular movement

Techniques that help restore optimal Arthrokinematics (Skeletal system)

chiropractic

repeated ERL

regular movement

exericse/loading

Goals of evidence-inspired active care

education and empowerment

reduce pain and sensitivity

determine the cause, treat the source

address dysfunctional movement patterns

restore function

build resiliency and capacity

How do we know if a treatment was effective

check and re-check (audit and re-audit)

Three R’s of active care

reset

reinforce

retrain

Treatments part of Reset

passive therapies (E-stim, head/cold, laser, traction)

manual therapies (manipulation, stretching, dry needling, massage)

Reinforce

what we did with out reset - reducing the likelihood of recurrent episodes and making sure that we don’t have a regression

Treatments part of Reinforce

education and advice

protection and biofeedback (taping, bracing, splinting, lumbar roll)

Treatments part of Retrain

motor control retraining (neurodevelopment perspective, block vs random)

loading strategies (primary and secondary)

Primary vs Secondary load management (Retrain)

primary - desensitize pain generator, build up tolerance for load, simple movements

secondary - adding load beyond pain control, building resilience, complex dynamic movements

4 X 4 Matrix Positions

1 - Supported (least challenging)

2 - Suspended

3 - Stacked

4 - Standing (most challenging)

4 X 4 Matrix Demands

1 - Feedback (least difficult)

2 - Demonstrate

3 - Capacity w/feedback

4 - Capacity (most difficult)

Turkish Get-up example of 4×4

What is the development in Supported position

spinal mobility (flex/ext/rot)

segmental stability

cervical patterns

shoulder flexion

What is the development in Suspended position

spinal curves

cross-crawl pattern

pelvis to trunk disassociation

hip and shoulder flexion/extension

3 - Stacked is the first aspect of

axial loading

What is the development in Stacked position

beginning of single leg stance

hip and spine loaded stability

loaded hip extension

Feedback

anything improving the task and allowing for long term learning

4×4 Matrix Guidelines - two ways to increase the difficulty of any exercise

the position (supported easiest, standing hardest)

the resistance (feedback easiest, capacity hardest)

Progression of a given exercise

1×1 → 2×1 → 2×2 → 3×1 → 3×2 → 4×1 → 4×2 →

1×3 → 1×4 → 2×3 → 2×4 → 3×3 → 3×4 → 4×3 → 4×4

Primary goals of the 1st step of evidence-inspired active care

calm shit down

• put out the first and stabilize the foundation before you rebuild the house

• desensitize the pain generator

• education

• micro load management through localized tissue loading

• focus on simple functional movements

Primary goals of the 2nd step of evidence-inspired active care

build shit back up

• restore function

• early stage rehab (primary load management)

• late stage rehab (secondary load management)

The goals and principles of rehabilitation and training are the _____ the difference is the _______

same; starting point

Movement Principles

mvnt should be within a pt’s capacity or injury risk

mvnt should be functional to that individual

mvnt when dysfunction is present may increase risk of injury

mvnt can be helpful even when pain is present

mvnt can be used as a method to create an adaptation

What is gamefication based on

dynamic systems theory (DST) - by modifying environment, task, or individual

Flexibility

PROM of a given joint and surrounding tissue

Mobility

ability of a joint to move through AROM under neurological control

Useless flexibility

ability to get to a certain angle/ROM but not be able to use that angle/ROM in daily life

• great PROM but can’t express it actively (AROM)

Two types of tissue tension restricting ROM

active tension

passive tension

Active tension

nervous system tone (hypertonicity)

contracture

guarding

Passive tension

muscle viscoelasticity

fascia

nerve

joint restriction

What happens when we have joint hypermobility

the brain sense instability in the passive stabilizing system through afferent feedback from the joint structures

• responds by creating stability via active stabilization (inc muscle tone)

People that have joint hypermobility often describe feeling

very tight all the time

What is the relationship btw flexibility and injuries

U-shaped curve

• very flexible = joint injuries

• very tight = soft tissue injuries

Tight muscles are more prone to

DOMS

store and release energy better

Aging and Flexibility

experience reduced flexibility as we age (10% per decade)

What causes the feeling of muscle tightness

fascial and neurological tension

Why do we experience tightness and stiffness

prolonged posture causes ischemia

lack of movement causes adaptation to imposed demands

weakness causes overload

Treatments for neuromuscular dysfunction

muscle activation stretching procedures (PNF and MET)

end range activation techniques (CARS, PAILs, lift-offs)

general movement loaded or unloaded

Neuromuscular dysfunction is a ____ issue (dec AROM only)

brain

Treatments that physically remodeled/shortened tissues (dec AROM + PROM) require

stretching/loading tissues to end range and sustained for 2+ min

Fascia communicates and remodels in response to

mechanical loads (compression, tension, strain)

What major structure in the body provides a significant amount of afferent feedback necessary for allowing proper movement expression

somatosensory cortex

Neurological inhibition

if joint is functioning properly =

• gamma motor tone is reduced

• spindles become less excitable

• greater motion around articulation can occur (smoother)

Neurological facilitation

if cortex receives poor afferent info from the joint =

• gamma motor tone is increased

• muscle spindles become hyperexcitable

• less motion allowed

Why is performing an adjustment before active care exercises recommended

allows for a short window of neurological inhibition of muscles = more effective

Indications to stretching

restricted motion will lead to structural deformities otherwise preventable

muscle weakness and shortening of opposing tissue

may be used as part of a total fitness program

prior to vigorous exercise to minimize soreness

ROM limited due to loss of extensibility (adhesions, contractures, scare tissue)

Contraindications to stretching

bony block limits motion

recent fracture

acute inflammatory or infectious process

soft tissue healing could be disrupted due to stretch

sharp acute pain with joint movement or muscle elongation

What does stretching actually do

affect change in the NS through facilitation or inhibition of neuromuscular tone

fascial tension/contraction and viscoelasticity

How long do the effects of stretching endure

after 5-30min the gains are significantly reduced

What is most important to modify in order to counter the short-term effects of stretching

repetition (frequency) and consistency

What causes the acute increase in ROM seen with static stretching

analgesic response (inhibited nervous system tone)

The majority of increased ROM associated with stretching occur in the first

15sec of a stretch

Static stretching should be performed for

3-4 sets of 15-30sec

Ideal frequency for stretching

multiple times a day for 6-10wks

What is the primary factor for increasing tendon flexibility

plyometric loading

gentle stretches held up to 10min

Stretch-induced strength loss

stretching cause an acute inhibition of maximal force produced by the muscle

Stretch-induced strength loss is more pronouced in activities performed at relatively

slow/low velocities (bench press and deadlift)

Maximal contraction of the muscle ____ to static stretch minimizes stretch-induced strength loss

prior

What causes DOMS

neural feedback

free radicals

swelling

Different categories of stretching techniques

static stretching

dynamic stretching (active and ballistic)

muscle energy technique (PIR and RI)

PNF stretching (contract-relax, hold-relax, CRAC)

Static stretching

passive (relaxing into a ROM)

slow and constant

with a partner or individually (bands or supported)

What is the reason behind the push against performing ballistic stretching

increased injury risk

does not result in sustained increases in ROM

Active dynamic stretching

controlled movement through a full range

start slow and gradually pick up speed and increase ROM

use sport/task-specific

prepares and warms up the body