Active Care Exam I

why is active care considered a complementary addition to chiropractic care

Rehab is innate drive and thus philosophically consistent with the chiropractic paradigm

Rehabilitation of the part which has long been in dis-use, this cannot be done by external manipulation, such as massage. It must be done by internal use by patient himself

what is active care

The patient is taking an active role in their treatment, typically in the form of exercise

what are the 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 characteristics

increase knowledge through education

Address underlying dysfunction and causative factors

Pain confirmation and exposure to painful movements/activities

Person-centered care focused on function and BSP approach

Promotes self efficacy and independent patients

passive care characteristics

minimal cerebral education and a patch job focused on relief

Pain avoidance behaviors and passive coping strategies

Labeled with diagnosis and disease

Promotes reliance on others to fix them

what role does movement play in general health and wellness

movement as medicine

Optimize movement, function, and performance

what role does movement play in assessment

movement screens, tests, and assessments

State assessment does not help diagnose a movement problem

Regional interdependence

what role does movement play in treatment and management

movement as part of patient care leading to better short and long term outcomes

Movement caused to movement cured

Reduced fear of movement and activity

What effect does cardio training and overall cardiovascular fitness have on health and disease? All-cause mortality?

decreased disease and increased overall health

what specific diseases may benefit the most from overall cardiovascular fitness

LBP, osteoporosis, osteoarthritis, hip fractures, obesity, non-alcoholic fatty liver, coronary artery, chronic heart failure, parkinsonism and Alzheimer's, Depression and anxiety, COPD, chronic kidney disease, breast, colon, prostate, and lung cancer

How many minutes of aerobic exercise are recommended each week?

150 minutes (30 minutes 5 days a week)

What effect does resistance training and overall strength have on health and disease? All-cause mortality?

decreased disease and increased overall health

what specific diseases may benefit the most from resistance training

Rotator cuff tendinopathy, tennis elbow, osteoporosis, T2 diabetes, stroke, chronic heart failure, parkings, COPD, kidney disease, cancers

how much resistance training is recommended each week

2 non-consecutive days each week and one set of 8-12 reps

what is the correlation between strength and all cause mortality

the greatest is in those with lowest strength

grip strength

all cause mortality and cardiovascular disease

toe strength

senior citizen falling

lower and upper body strength

all cause and CVD risk

why does movement assessment lead to better diagnostics and improved outcomes

Find the cause

Explain the source

Determine effective treatment

Shorten treatment time

in terms of pain and injury, what is the source

refers to the location the individual is feeling pain

in terms of pain and injury, what is the cause

refers to what is creating pain in the individuals system

May or may not be the same location as the source

what is the #1 predictor of injury

previous injury

how are pain, altered motor control, and injury interrelated

They are protective mechanisms

Underlying dysfunction that lead to initial injury (altered movement patterns and mobility and stability deficits)

what is motor control

Necessary input, sufficiently processed, with an acceptable output

what does altered motor control involve

Poor timing, sequencing, coordination and synergy of the neuromuscular system which manifests in dysfunctional movement

what is a mobility dysfunction

Active/passive muscle insufficiency

Neural tension

Fascial and muscle shortening

Hypertrophy

Trigger point activity

Scarring and fibrosis

Osteoarthritis

Osteoarthrosis

Uniarticular muscle spasm.guarding

Fusion

Subluxation

Adhesive capsulitis

what is the general rule for determining a MD

Active and passive movement is dysfunctional (restricted, asymmetrical, effortfull)

what is a stability/motor control dysfunction (SMCD)

Motor control dysfunction

Mechanical breathing dysfunction

High threshold (compensatory) strategy

Prime mover or global muscle compensation behavior or asymmetry

Local muscle dysfunction or asymmetry

Poor static or dynamic stabilization, alignment, postural control, asymmetry and structural integrity

what is the general rule for determining a SMCD

Active movement is dysfunctional

Passive movement is functional

how do we know when a patient is better

Patients can help us understand when their symptoms are gone but they can’t tell us when they’re functionally restored

what should your discharge criteria be

Has the patient improved and are they able to do the activities that are previously limited

Do they have the knowledge to continue care (active vs passive care)

Should we incorporate movement assessment as part of our standard operating procedure to look at patterns or parts?

patterns

When do you have justification to go look at the parts and make sure that anatomy is a supporting function?

when the pattern is dysfunctional

when should functional movement assessment be performed

1st visit baseline

Post intervention check

Ongoing assessment

why perform a functional movement assessment

Find the cause, explain the source, determine effective treatment and shorten treatment time

Improved outcomes and reduced treatment plan errors

When does our locomotor system develop?

in the first critical years of life

What happens to mobilizers and stabilizers when compensatory movement patterns occur?

Mobilizers’ increased activity (hyperactivity) and decreased flexibility

why do functional muscle imbalances occur

Disuse and lack of stimulation

Adaptation ot highly repetitive movement and stabilization patterns

Dysfunction, pain, and injury

upper crossed weak

deep neck flexors, lower trapezius, serratus anterior, rhomboids

upper cross tight

pectoralis major and minor, atlanto-occipital joint, C4-5, T4-5, glenohumeral

lower crossed weak

abdominals, gluteus maximus

lower crossed tight

thoracolumbar extensors, hip flexors

what is the kinetic chain

How the human body can be considered in terms of interrelated links or segments

What is the primary tissue/system that mediates the interconnectedness of the kinetic chain?

connective tissue

what is regional interdependence

Concept that seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with the patient's primary complaint

are joints that move primarily in 1 plane stable or mobile joints

Stable joints and prone to stability limitations

Ex. when dysfunction is present in one of these joints it is most often inadequate stability

are joints that move relatively equally in 3 planes of motion stable or mobile

Mobile joints and prone to mobility restrictions

Ex. when dysfunction is present is one of these joints it is most often inadequate mobility

Which joints/regions are meant to be mobile and are therefore most prone to mobility restrictions?

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

Which joints/regions are meant to be stable and are therefore most prone to stability limitations?

knee, lumbar, scapula, lower cervical, elbow

According to the hierarchy of movement, should management and treatment of dysfunctional movement begin by addressing mobility, motor control, or functional patterning first?

Mobility, then motor control, then functional patterning

Ex. toe touches, hip hinges, dead lift

Should active care treatment plans be based on generalized guidelines or individualized to the person/patient?

individualized

what are the primary focuses of treatment based on dysfunctional movement findings

identify relevant dysfunction movement patterns and improve them (must post check)

What techniques can help restore optimal length-tension relationship within the muscular system?

Stretching

Manual therapies

Motor control

Strengthening

What techniques can help restore optimal force-couple relationship within the nervous system?

Motor control

Exercise/loading stabilization

Regular movement

What techniques can help restore optimal arthrokinematics within the skeletal system?

Chiropractic

Repeated ERL

Regular movement

Exercise/loading

What are the goals of evidence-inspired active care?

Education and empowerment

Reduce pain and sensitivity

Determine the cause and treat the source

Restore function: mobility, stability, and overall movement patterns

Build resiliency and capacity through Load management and graded exercise/exposure

how do you know if a treatment was effective

Check and recheck

Audit and reaudit

what are the 3 Rs of active care

Reset, reinforce, retrain

what is reset

Hands on treatments and applied therapies that need to be performed by a doctor

what treatments are part of a reset

Chiropractic adjustments

Manual therapies: manipulation, mobilization, stretching, trigger point release, IASTM, active release, dry needling, massage

Passive therapies: e-stim, heat, cold, laser, shockwave, vibration, traction, rest

what is reinforced

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

what treatments are part of reinforcement

Education and advice: patient education, encourage safe movement, empowerment and self efficacy, movement modifications (load management and desensitization), ergonomics and spine sparing strategies, lifestyle adjustments

Protection and biofeedback: to reduce stress and exacerbations

Taping, bracing, splinting, footwear, orthotics, lumbar roll

what is retrain

Movement developed in patterns, not individual muscles

Block: focus on form, provide constant feedback, one exercise for a certain number of reps

Random: focus on feel, provide variable feedback, patient determines movement strategy

what are the treatments that are part of retrain

primary and secondary load management

primary load management

desensitize the pain generator, build up tolerance for load, focus on simple functional movements, address mobility and stability dysfunctions

secondary load mangement

adding load beyond pain control, returning patient ot higher tolerance than they had to begin with, building resilience, complex dynamic movement, challenging functional patterns with added load

what are the four positions of the 4x4 matrix form the neurodevelopment approach

supported

suspended

stacked

standing

In terms of progressions, which position is least challenging and which position is most challenging?

supported, suspended, stacks, and standing

hallmark patterns of supported position

spinal mobility, segmental stability, cervical patterns, shoulder flexion

hallmark patterns of suspended position

spinal curves, cross crawl patterns, pelvis to trunk disassociation, hip and shoulder flexion and extension

hallmark patterns of stacked position

beginning of single leg stance, hip and spine loaded stability, loaded hip extension

What are the four different levels of demand according to the 4x4 matrix in order from least to most difficult

feedback, demonstrate, demands, capacity

what is feedback

Anything improving the task and allowing for long term learning

What are the two ways that we can increase (or decrease) the difficulty of any exercise?

Either by changing the position or the resistance

Position: supported (non weight bearing) is the easiest

Resistance: feedback (pattern assistance with no resistance) being the easiest and capacity (resistance without pattern assistance) being the hardest

Can you determine the classification (i.e. 2x3, 1x1, etc.) of a given exercise?

1x1, 1x2, 2x1, 2x2, 3x1, 3x2, 4x1, 4x2, 1x3, 1x4, 2x3, 2x4, 3x3, 3x4, 4x3, 4x4

Can you determine the next most logical progression of a given exercise?

Can start at any level and combination that is appropriate as long as you know how to progress or regress the exercise using positions and demands

What are the primary goals in the 1st step of evidence-inspired active care?

Desensitize the pain generator

Eduction

Micro-load management through localized tissue loading

Focus on simple, functional movements

Which types of treatments are recommended or ideal during the 1st phase in order to accomplish that goal?

Pain reducing interventions followed by or combined with motor control exercises to enable more effective motor control retaining

Adjustments, manual therapies, passive therapies, pain reducing interventions

What are the primary goals in the 2nd step of evidence-inspired active care?

Restore function

Address any mobility or stability dysfunctions at this time

Utilize principles of strength and conditioning

Continue to educate and encourage self efficacy

early stage rehab goals

primary load management

late stage rehab goals

secondary load mangament

Which types of treatments are recommended or ideal during the 2nd phase in order to accomplish that goal?

active care and exercise

what is the difference between rehab and training

The goals are the same, the difference is the starting point

Rehab starts after an injury at a lower level and training starts when the body is already healthy and conditioned

what are the 3 movement principles that should guide selection of active care exercises

Movement should be within a patient's capacity or injury risk

Movement should be functional to the individual

Movement when dysfunction is present may increase risk of injury

Movement can be helpful even when pain is present

Movement can be used as a method to create an adaptation

flexibility

passive ROM of a given joint and surrounding soft tissue

mobility

ability of a joint to move through a given ROM, under neurological control of a given joint structure and surrounding soft tissue

Active ROM

what is useless flexibility

The ability to get a certain angle but not able to use the angle in daily life

active tension

nervous system tone (hypertonicity), contracture, guarding of a muscle

passive tension

muscle viscosity, fascia, nerve, joint restrictions

what happens when we have joint hyper mobility

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

People describe feeling tight all of the time

Creating stability through active stabilization system by breathing increased neuromuscular tone

What is the relationship between flexibility and injuries? (hint: U-shaped curve)

the most injuries occur at very tight and very flexible

what is seen in tight muscles

more soft tissue injuries, prone to delayed onset muscle soreness (DOMS), store and release energy better

what is seen in flexible muscles

for joint related injuries

What are the effects of age on flexibility?

Reduced flexibility as age increases

10% reduction per decade from age 20-49 y/o and continues from there

What most likely causes the feeling of muscle tightness? (summarize in your own words)

There is little evidence to support that muscle tightness is related to physical shortening of muscular tissues

It is most likely just an unpleasant subjective feeling

It is a sensitivity that comes from the nervous system and occasionally inflammation

Why do we experience tightness and stiffness? (summarize in your own words)

When we move less, there is a lack of blood flow to and in the muscles which causes them to become inactive. When we start moving again, we need to get the blood flowing and muscles moving, basically getting out of the tightness

How does neuromuscular dysfunction lead to tightness and restricted ROM?

There is nothing wrong with the tissue, but the nervous system presents issues at immobile tissues

What are the different types of treatments that are optimal for neuromuscular dysfunction?

Muscle activation stretching procedures (PNF, MET)

End rage activation techniques (CARS, PAILs, lift offs)

General movement (loaded or unloaded) or specific motor control exercises

What specific types of treatments do physically remodeled/shortened tissues require?

Stretching/loading of tissues to end rage that are sustained for 2+ minutes

8+ weeks of consistency to truly remote the tissues

What does fascia communicate and remodel in response to?

Mechanical loads such as compression, tension, strain