Active Care Exam 2

What are the mobility techniques discussed in class? (6)

1) Self myofacial release

2) ELDOA

3) CARS

4) PAILS

5) RAILS

6) neuromobilization

What is the use of equipment (ex: foam roller, tennis ball) where the patient can perform a self release on a tight muscle as part of HEP to help build self-efficacy, provide relief between visits, and help progress restoration of function?

Self-myofascial release

Self-myofascial release is done _____-____s per muscle group recommended (or to your tolerance)?

30-120s

What places tension on the nerve distally and then proximally in an alternating pattern, and can be performed for any major nerves and many smaller branches of nerves?

Neuromobilization

What is the indication for neuromobilization?

Indicated when there is suspected nerve involvement in pts symptoms and the pt exhibits a positive neurodynamic test

Why do we perform nerve flossing? (5)

Nerves susceptible to entrapment and adhesion

Helps:

1) Facilitate neural gliding

2) Reduce adhesions between nerve and surrounding tissue

3) Enhances neural vascularity

4) Improves axoplasmic flow

5) May modulate central sensitization and peripheral pain mechanisms in musculoskeletal disorders

Nerves are ____% connective tissue and ____% axoplasmic fluid, so they are the same biomechanical properties as connective tissue, sensitive to mechanical load (compression & tension), and may exhibit increased or decreased length and elasticity in response.

(TQ)

Nerves = 80% connective tissue & 20% axoplasmic fluid

What is nerve flossing with the purpose to produce a sliding movement of neural structures relative to their adjacent tissues, placing tension (elongating) on one end and reduces (shorten) tension on the other end?

Sliders

What is nerve flossing with the purpose to produce an increase in tension is neural structures, relies on natural viscoelasticity of nervous system, does not pass elastic limit, and has tension on both ends?

Tensioner

What is a general recommendation for frequency and repetitions of nerve flossing?

3-5x per day or when symptoms present for 10-15 reps

T/F: Its important to note that clinicians often make the error of being too timid/light with nerve flossing techniques

FALSE

often too aggressive

What are active rotation movements at outer limits of range of motion for each individual joint in order to stimulate articular adaptations, can indicate neurological control of outer ranges for improved joint stability, and patient actively moves through range of motion (circular motion), controlled with tension and feels as if you are fighting to pull the joint through a large range of motion?

Controlled Articular Rotations (CARs)

What are the key components that differentiate CARs from other stretching/mobility techniques and assist in providing usable ROM?

CARs is controlled by tension where whip a joint through ROM without forcefully contracting it so it increases flexibility not mobility

What is progressive/regressive angular isometric loading that can be applied to any stretch to expand ROM, with this being the first contraction?

PAIL's

(Progressive Angular Isometric Loading)

Following PAILS contraction, you will stretch a muscle or joint to end range, a contraction of muscle being stretched is performed for 10-20s , with then a second contraction of the antagonist muscle called what?

RAILs

(Recessive angular Isometric Loading)

PAILs and RAILs can be applied to ANY stretch to expand range of motion, and ensures that _______ ROM is achieved

Usable

For PAILS/RAILS, the time under tension matters, not a rapid response, so one repetition involves ___ min initial hold followed by a ___-____s progressive contraction and a ____-____s regression contraction. This is repeated 2-4x

2 min initial hold

10-20s progressive contraction

10-20s regressive contraction

What is a form of myofascial stretching with postural self normalization techniques designed for widening space within a chosen articulation and correcting structural imbalances, creating facial tension to fix vertebra below and contraction in extreme range to normalize the vertebra above, with the goal of putting tension into fascia that encases muscles to normalize length and function of fascial chains??

ELDOA method

The goals of ELDOA method is to create normalization of what 3 things?

1) Fascia and connective tissue around spine

2) Space between the vertebra to increase health of disc

3) Fascia and connective tissue in the extremities

ELDOA is used commonly as an active spinal decompression to treat what 4 things?

1) Spinal mispositioning

2) Scoliosis

3) Disc pathologies (bulges, herniation)

4) Radiculopathy symptoms

What are the 4 keys to the ELDOA method?

1 -- focus on elongating spine

2 -- incorporating tension w/in fascial network

3 -- maintaining good stability/positioning throughout

4 T-- BREATH

ELDOA should be done for ____-____s

30-60s

What are the two most important components of assessment of muscles?

1) Movement = KING

2) Palpation = QUEEN

What type of palpation is a digital exam of a muscle to determine the absence or presence of palpable bands and tender trigger points using flat and/or pincer palpation?

Screening palpation

What type of palpation is like plucking a guitar string at 90 degree angle to assess taut bands and twitch response?

Snapping palpation

What type of palpation is a firm compression against underlying structure with flat contact?

Flat palpation

What type of palpation is a pincer grip between thumb and fingers where a group of muscles are rolled between the digits to detect taut bands?

Pincer palpation

What are 9 abnormal muscle palpation findings?

1) Tenderness

2) Tight cord

3) Radiating pain

4) Tender fibrous beaded chains

5) Tender nodules w/ radiating pain

6) Tender contracted muscle bundles

7) Hypertonicity

8) Spasm

9) Trigger point

What is pain in a muscle or muscles that can use to signify diffusely aching muscles due to a systemic disease such as a virus infection or a spot tenderness of a muscle or muscles as in myofascial trigger points?

Myalgia

What is a group of tense muscle fibers extending from a trigger point to the muscle attachments where the tension of the fibers is caused by contraction knots that are located in the region of a trigger point and reflex contraction of the fibers in this band produces a local twitch response?

Taut Band

What is an increased tension with or without shortening of a muscle due to non-voluntary motor nerve activity which cannot be terminated by voluntary relaxation?

(TQ)

Spasm

What is sustained intrinsic activation of the contractile elements of muscle fibers, with muscle shortening occurring in the absence of motor unit action potentials?

Contracture

What is a transient contraction of a group of tense muscle fibers (taut band) that traverse a trigger point so that the contraction of the fibers is in response to stimulation (usually by snapping palpation) of the same trigger point, or sometimes of a nearby trigger point?

Local Twitch Response

What is a myoneural unit of a muscle that is expressing aberrant neurological tone at rest where the nerve is telling the fascia to contract, sensitized neural structures produce neurogenic inflammation, causing localized vasodilation and inflammatory response around that affected motor unit?

Trigger point

Where are trigger points located?

(TQ)

In the BRAIN

(nervous system phenomenon that manifests in the innervated tissues)

What type of Trigger point is *ALWAYS TENDER,* causes pain in a referral pattern (away from the trigger point) that is not related to palpation of the muscle, with pain associated w/ movement, prevents full lengthening of the muscle, weakens the muscle, mediates a local twitch response when adequately stimulated/compressed, and produces referred motor phenomena and often autonomic phenomena, generally in its pain reference zone and causes tenderness in the pain reference zone?

Active TrPs

What type of Trigger Point is *PAINFUL ONLY WHEN COMPRESSED / PALPATED*, is clinically calm or dormant with respect to spontaneous pain, may have all the other clinical characteristics of an active trigger point and may always have a taut band that increases muscle tension and restricts ROM?

Latent TrP

How are TrP's ideally treated?

Add stabilization via stabilization / motor control exercises, restoring full pain free ROM, and manual therapies (MET, PNF, CARS, PAILS, RAILS)

What is a connective tissue that surrounds and supports the body's organs, muscles, bones, and nerves. It has many roles in the body, including:

Structure and support, Friction reduction, Force transmission, Vascular support, & Sensory organ

Fascia

What is a potent influencer of the nervous system while the biomechanical aspects surrounding it are often inaccurate and of lesser relevance, and is any technique that involves kinesthetic input and manipulation or interaction with tissue?

(TQ)

Manual therapies

What are the goals of performing manual therapies (7)?

1) Improve tissue extensibility

2) Increase ROM

3) Mobilize joints

4) Induce relaxation

5) Stabilize joint complex

6) Modulate pain

7) Reduce swelling

What are the 5 paradigms/mechanisms for explaining the therapeutic effects of manual therapies?

1) Mechanical stimulus and biomechanical effects

2) Neurophysiological mechanism

3) Peripheral mechanism

4) Spinal mechanism

5) Supraspinal mechanism

How do manual therapies influence somatoperceptual touch? (5)

(TQ)

1) Improved and more integrated pt body perception

2) Promoting reorganization of body mental representation

3) Orientation so that patients can better locate pain

4) Better discriminate

5) Strengthen of feeling "this is my body"

What facilitates reflex changes in chronic muscle holding patterns, alters spinal reflex at facilitated segment, improves soft tissue function and ROM following injury while reducing pain, can help shorten recovery period and time to return to ADL form an increase rate and amount of blood flow to and from area, increase cellular activity in the region, fibroblasts and mas cells, increase histamine response, separates/breaks collagen cross links and stretches connective tissue?

Instrument Assisted Soft Tissue Mobilization (IASTM)

What angle should an IASTM tool be held?

45 degree

What duration should IASTM treatment be performed?

60-120s

Besides passive/static treatment, what other ways can you use IASTM?

Dynamicaaly by having pt go through repetitievly ROM or functional movement pattern

What are the 6 most helpful IASTM stroke types?

1) Scanning/diagnostic

2) Warming

3) Sweeping

4) Cross Friction

5) Deep Tissue

6) Pin & Stretch

What method's objective is to increase the blood supply as well as heat and plasticity of tissues, with a protocol of 10-15min with light jogging or by using a stationary bicycle, upper body ergometer, elliptical machine, or 3-5 min w/ hot pack or US?

Warm-up

What method's objective is to remove scar tissues and facilitate synthesis and realignment of new collagen, with a protocol of 30-60 degrees with 40-120s?

IASTM

What method's objective is to correct the shortened tissue and prevent reinjury with a protocol of 3 REPs with 30s?

Stretching

What method's object is to strengthen the treated tissue and prevent reinjury with a protocol of high repetition with low load exercise?

Strengthening exercise

What method's objective is to reduce pain, control residual inflammation, and prevent secondary cell hypoxic injury with a protocol of 10-20 mins?

Cryotherapy

What technique uses Diagnosis (utilizing providers hands to identify aberrations in tissue texture, tension, and movement to determine root cause of condition) Treatment (precise touch w/ specific patient movements to restore proper function and relieve pain), and Relief?

Active Release Technique (ART)

In ART, you should use a soft contact, begin active and work __________, use active motion whenever possible, use slow motion, evaluate patient and tissue ________, work along the direction of the venous and lymphatic flow, and for frequency should ______ days.

Longitudinally

Patient and tissue tolerance

Frequency = Alternate days

Evidence supporting the use for manual therapies:

Utilizing manual therapy early in treatment (2-4 visits) is all that most individuals need to progress to more _____ care.

Manual therapy should be part of a multi-modal approach to care and is ___ effective when patient expectations are high and when patient experience is considered

Manual therapy should be considered similar to _________ : short term pain relief that allows progression to daily activities or exercise

Active care

More effective

Analgesics

T/F: Soft tissue treatments include stretching, mobility exercises, and manual therapies

TRUE

What is the goal of the first 1-4 visits?

Calm shit down (reset part)

Which types of interventions are recommended and most supported by evidence for treatment of musculoskeletal pain and injury?

Exercise!

Evidence-supported benefits of active care:

- Resolving ______ and restoring _____

- Empowering patients

- __________ patient self efficacy

- _________ fear of movement

- _________ frequency and duration of flare ups

Resolving pain & Restoring function

Increase patient self-efficacy

Decreasing fear of movement

Reducing frequency and duration of flare ups

What is the #1 predictor of successful outcomes with any exercise program?

Adherence

What type of motivation is needed to facilitate adherence?

Intrinsic motivation

How can we help our patients with intrinsic motivation and facilitating adherence?

Help w/ cognitive restricting around exercise and provide advice on building beneficial habits

What is the law of repetitive motion?

(TQ)

I = (N x F) / (A x R)

I = Insult to injury

N = number of repetitions

F = Force (% of max muscle strength)

A = Amplitude (ROM)

R = Relaxation (lack of pressure/tension on tissue)

For the Law of Repetitive Motion, if N increases what happens to I? F increases? A increases? R increases?

Increase N = Increase I

Increase F = Increase I

Increase A = Decrease I

Increase R = Decrease I

What effects does weakness have on force and potential tissue insult?

Weakness generally results in F that is high

What happens to the margin of safety as failure/tissue tolerance decrease?

Force relative to strength; person that is weak will use a higher percentage of maximum strength to accomplish a given task

The potential tissue insult is therefore likely to be higher, even if other factors are negligible

To reduce insult to tissues other factors need to be manipulated

what is the major underlying mechanism with the majority of injuries, resulting after injury to the muslces, tendons, bones, joint structures, blood vessels, fascia, and/or nerves and may result from acute injury, repetitive injury or a constant pressure/tension injury?

Cumulative Injury Cycle

Why do we care about the law of repetitive motion when assessing injuries?

Key to developing and understanding injury mechanism and properly rehabilitate injury

What factors impact the law of repetitive motion?

1) Injury Hx

2) Activity Hx and physical preparedness

3) Doing too much w/ too little rest and recovery (overload or overexertion, inadequate rest and recovery)

What is the #1 predictor of injury?

Previous injury

What results after injury that may contribute to future injury?

Poor load management (why most MSK injuries happen in the first place)

Many injuries occur in part because individuals are underprepared for the activity. What does being underprepared mean?

Not having the strength, stability, or capacity required to perform an activity

-- tissue "failure" due to being deconditioned for activity or task

What is the principle where the body will adapt to the demands placed upon it (or lack thereof)?

SAID Principle (Specific Adaptation to Imposed Demands)

What effect does too little or infrequent exposure to external load and conditioning have on tissue adaptation, margin of safety, and failure tolerance?

Tissue tolerance never raises

What effect does too much or too frequent or prolonged exposure to external load and conditioning have on the factors of tissue adaptation, margin of safety, and failure tolerance?

Adaptation can't keep pace

What affect does adequate rest/recovery have on tissue adaptation, margin of safety, and failure tolerance?

Increases these factors

What does pain generally occur in response to?

When brain sense actual or potential tissue injury

What factors influence tissue tolerance? (5)

1) Time

2) Load

3) Reps

4) Effort

5) Characteristics of a person

T/F: Nociception = pain

FALSE

Nociception does NOT equal pain -- signal body uses to tell you about annoying and maybe dangerous sensation

What happens to tissue tolerance and pain as a protective mechanism following injury; do tissues get less or more sensitive following injury?

More sensitive

-- little room for activities

Nociception does NOT equal pain

What is the average tissue healing time in general?

4-8 weeks

Why might pain persist past healing?

Misconceptions about pain

Unaddressed fears, worries, beliefs

Lack of pain education

What model has the biological part as input, psychological part as output, and social part as upstream?

Biopsychosocial model

Pathology, structural, biomechanical, biochemical, linear, input-driven way of thinking and easier to study are examples of what part of the biopsychosocial model?

Bio

Behaviors, moods, beliefs, above down descending modulation with various neurophysiologic protective (output) responses are examples of what part of biopsychosocial model?

Psycho

Socioeconomic, cultural, community, factors influencing the environment within which one's capability to alter lifestyle in a positive or negative way to optimally nudged are examples of what part of the biopsychosocial model?

Social

What is the "lens" that input (actual/perceived danger) must be interpreted through? (6)

1) Cognitions

2) Emotions

3) Attitude/Beliefs

4) Illness Behavior

5) Physical and Social Environment

6) Lifestyle factors

What are the factors including relationships, cultural beliefs, attitudes of work associates, attitudes of friends, work environment, work attitudes, or cultural settings, which can lead to disability and perception of pain, access to care, and outcomes?

Contextual Drivers

What are the factors including beliefs, expectations, perceptions of illness, fear, catastrophizing, and low efficacy?

Cognitive Drivers

What are assessment tools that allow for accurate estimates of individual, full-length psychological questionnaire scores for depressive symptoms, anxiety, anger, fear-avoidance beliefs, kinesiophobia, catastrophizing, self-efficacy, and pain acceptance?

Yellow Flag Risk Form

How is pain like an alarm?

Acts as an alarm to meant to motivate an action

-- Acute pain, nervous system takes actions to remove real or anticipated threat (achieved by motor output)

Any evidence of danger increases pain; evidence of safety decreases pain

-- this captures multidimensional nature of the persistence of pain and illustrates how multiple interventions can be of benefit

Why is pain considered multi-factorial?

All aspects of person's life can influence their sensitivity and pain

(ex: catastrophizing can influence pain and injury)

What is the relationship between hurt (pain) and harm (tissue damage)?

Even when tissue injury or inflammation appears to be linked w/ pain, there is no strong relationship between the amount of pain someone feels and the amount of tissue damage

(Pain is poorly related to damage)

How does exposure to feared or painful activities increase tolerance and facilitate return to full function?

Exposure to feared/painful activities in a slow graded manner can increase tolerance to those activities

-- ideally exposure is preceded by pain science education which mitigates this threat and can change pt views about danger associated w/ resuming meaningful activities & exercise

What are the 10 key messages related to pain?

1) Pain is an alarm meant to protect you

2) Pain is poorly related to damage

3) Pain is more about sensitivity than damage

4) Pain is multidimensional

5) Protection can be overamplified and persist past healing

6) Pain is normal, but can be weird though

7) You are strong and adaptable finding the right stimulus

8) You can respond positively to stress

9) Altered function is poorly related to pain

10) You don't need fixing no movements should be off limits forever

What does an N=1 approach to patient car mean?

Care must be individualized, treat the person not the patient

Not all pain and injury are alike

What is a certain goal of rehab? (3)

1) Restore function

2) Prevent disability

3) Maintain sustainable relationship with activity

What is the ARG principles of rehab?

1) Awareness

2) Regain control

3) *Gradually expose*

What are the 6 R's of Rehab?

1) Red flags

2) Reassure

3) Reconceptualize

4) Recalibrate

5) Robust

6) Reassess