Ther-Ex Exam III

Pain affect on neuro symptoms

Parkinsons: pain rises in “off” phase

Stroke: shoulder pain and central pain cut use of arm

MS: pain drives fatigue

TBI: headache and neck pain prolong symptoms

You can help neurologic symptoms by treating orthopedic issues

Concussion treatment

Rest is no longer the treatment

light aerobic activity within 48 hours

Sub-symptom aerobic exercise: 80% of the HR that brought on symptoms

TBI interventions

Aerobic: 60-90% HRmax, 3-4x per week

Use HR not RPE, if cognition is impaired

Dual task training as attention improves

Agility, running, hopping for return to sport

Confused/agitated: short, varied, errorless practice

Glascow coma scale

mild= 13-15, lose consciousness under 30 min

moderate= 9-12, lose consciousness 30 min-24 hrs

severe= under 9, over 24 hrs

TBI

direct impact, acceleration and deceleration, penetrating, blast

Concussion= mild TBI

Multiple sclerosis intolerant to heat

Heat temporarily worsens symptoms

cooling vests, fans, cooler time of day

energy conservation, rest breaks

no exercise during a relapse

Multiple sclerosis interventions

Aerobic: 2-3x per week, 10-30 min (moderate)

Resistance: 2-3 times per week

Exercise does not cause relapses

Multiple Sclerosis

Autoimmune attack on myelin in the CNS

Types:

• relapsing-remitting

• secondary progressive

• primary progressive

Risk factors: distance from equator, genetics

Parkinsons interventions balance and agility

Challenging balance plus strength- cuts falls by 37%

Gait, lunges, boxing, agility course, tai chi

add a cognitive task as skill improves

Parkinsons interventions aerobic

treadmill training improve speed and stride length

forced cycling at 80-90 rpm

may slow progression, group exercise helps

Parkinsons interventions (amp and cues)

AMPLITUDE and CUEING

LSVT-BIG: many repetitions of large movements

External cues: metronome, music, lines on the floor

Freezing: shift weight, then take a long step

Trunk rotation and extension for posture

Exercise during the “on” medication phase

Hoehn and Yahr stages of parkinsons

1- one side of body

2- both sides, balance intact

3- balance impaired, still independent

4- severe disability

5- wheelchair

Parkinsons Disease

loss of dopamine neurons in the substantia nigra

70-80% loss of dopamine lost before motor signs

tremor, rigidity, slowness, postural instability

Risk factors: age, genetics, head injury

Interventions stroke upper extremity

REPETITIVE task specific practice

Constraint- induced movement therapy

• mitt on 90% of waking hours (make them use their affected limb)

• 3-6 hours of practice per day for 2 weeks

Strength and balance stroke interventions

Strengthening does not increase spasticity

• spasticity: strengthening the antagonist, weight bearing, stretch through functional tasks

70% 1RM

the less affected side is weak too

Walking interventions for stroke

Super important

Moderate-high intensity walking

3x per week, 30-50 min

many steps per session

DON’T assist walking, they need to just do it to get better

Aerobic interventions stroke (intensity measures)

Light intensity: under 40 %HRR, under 64% HR max, RPE under 12

Moderate: 40-60% HRR, 64-76% HR max, RPE 12-13

Vigorous: Over 60% HRR, over 76% HR max, RPE over 14

Interventions stroke chronic stage

recovery slows, fitness and strength still improve

walking, strength, and arm doses apply

Interventions stroke subacute stage

Weeks-6 months

high rate of recovery

task-specific practice, high reps, build walking tolerance

Interventions stroke acute stage

First week

Mobilize early, but not high dose within 24 hours

Positioning, ROM, sitting, standing

Fastest recovery stroke patients

1-3 months (hammer that neuroplasticity)

Stroke risk factors

hypertension, atrial fibrillation, diabetes, high cholesterol

Stroke (types)

lack of blood supply to the brain

Ischemic: about 87%

• Thrombus or embolus blocks an artery

Hemorrhagic: intracerebral about 10%, subarachnoid 5-10% (way higher fatality rate, significant more impairments)

Transient ischemic attack- warning sign

middle cerebral artery most often affected

Red flags neurologic conditions

Vital signs

• resting HR over 100 or under 50

• SBP over 200 or under 90, DBP over 110

• SpO2 under 90%

• Stop: SBP drops more than 10 mmHg or HR drops more than 15 bpm

• Use RPE w/ beta blockers or unreliable HR

Principles of Neuroplasticity

Use it or lose it

Use it and improve it

• Specificity: skill, not just use

• repetition and intensity matter

• time, salience, and age matter

• aerobic exercise primes the brain for learning

• compensation can block recovery

Lumbar ROM

most motion L4-5 and L5-S1

Flexion: 45-50

Extension: 15-20

Lateral flexion: 20 each side

Rotation: 5 each side

Acute nonspecific low back pain

No specific structure identified- about 90% of all cases

Most people improve within 6 weeks

• Early care: stay active, walk, no bed rest

• Exercise: any direction the person tolerates, low to moderate load

Recurrence is common

Chronic low back pain

Pain for more than 12 weeks

Pain new reflects sensitization, fear, sleep, mood

image explains little of pain

Exercise type matters less than doing it

• education and graded return to activity

• wide menu for exercise

Lumbar disc herniation with radiculopathy

nucleus displaces through the annulus and irritates a nerve root

symptomatic in about 1-3% of people

*Clinical findings drive decision making

Exercise: start where the leg symptoms ease, then build loading

Radicular pain peripheralization vs centralization

Peripheralization: getting worse, going away from the body, down the appendage

Centralization: go back home, good thing, calming down, returning to source

Lumbar disc herniation with radiculopathy- prognosis

90% symptom improvement in 4 wks

50% in 12 wks

60-90% resolve without surgery

Lumbar spinal stenosis

narrowed canal or foramen, degenerative at most

Neurogenic claudication: leg symptoms with standing and walking, eased by sitting

Exercise:

• flexion and neutral early, cycling, inclined treadmill

• progress to upright walking (walking tolerance is the goal)

Spondylolysis vs spondylolisthesis

lysis: pars defect, about 6% of people, more in extension sports (lineman, baseball player, gymnastics)

listhesis: vertebral slip

• isthmic listhesis: slip at L5-S1, adolescents and young adults

• degenerative listhesis: L4-5, women over 50

most are stable (no surgery)

Exercise: neutral and flexion first, extension under load last

Directional preference (lumbar spine)

One direction eases symptoms, the other provokes them.

Use the preferred direction first, then widen the menu

repeated movements in each direction reveal it

Load graded exposure

tissue tolerance grows with progressive load

increase load or range one step at a time

Acceptable pain: settles by the next session

progress when the current step feels easy for 2 sessions

Fear graded exposure

the feared task is the target

pick the activity the person avoids

• do it at a trivial load with less guarding

• confidence is the outcome, pain may not change first

• EX: pick up a pen with rounded back, then a laundry basket

Relative rest

keep training, lower the load on the sensitive tissue

not complete rest, not pushing through

lower the load, move toward neutral, shift work to another joint

same effort, different tissue takes the torque

Lumbar flexion biomechanics

Anterior disc compresses, posterior annulus and ligaments stretch

facets unload, foramina open (yay nerves)

extensors lengthen

flexion + load raises disc pressure and shear

Flexion in research

flexion exercise helps when flexion is the preferred direction

lumbar extension biomechanics

posterior disc compresses, anterior annulus stretches

facets and lamina take load, foramina narrow

extensors shorten and work hardest under load

repeated extension can move leg symptoms towards the spine

Stabilization: what is means biomechanically

trunk muscles hold the spine near neutral while something else moves

Anti flexion: hip hinge, deadlift, carry

Anti extension: plank, dead bug

Anti-rotation, anti lateral flexion: pallof press, suitcase carry, side bridge

a loading strategy

Stabilization in research

have shown to reduce pain and disability in chronic low back pain- proper education critical!

not better than other exercise long term

choose it when the person likes it and can progress it

Lateral flexion biomechanics

about 20 degrees per side (coupled with rotation)

loads facet and disc on concave side, opens convex foramen

Walking and aerobic activity (chronic low back pain)

progressive walking + education: 28% lower risk of recurrence

walking, cycling, swimming reduce pain and disability

Does condition pick exercise- lumbar spine

none prescribe a direction by diagnosis

Stenosis: walking tolerance is the goal, flexion bias as starting point

Radiculopathy: directional preference guides the start

Spondylolisthesis: stabilization is customary, evidence is small

condition sets the starting point, person sets the path