Theraputic exercise test 1

5 things to consider when prescribing ex

-pt's functional goals
-results of exam
-evidence for best practice
-safety
-progression of ex program

what are the 3 elements of EBP?

-knowledge from evidence
-clinical expertise
-pt's goals

what should the focus be on when progressing exercises?

performance outcomes focusing on function

criterion-based protocols

if pt can do this, they can move on to this (if they can do 10 reps, they can increase the weight)

time-based protocols

by X weeks after surgery, pt should be able to do this

SAID principle

Specific Adaptions to Imposed Demands

tissues need stress/load when healing to be prepared for future function; ex should mimic functional activity

wolff's law

bone will adapt to loads under which it is placed

davis's law

soft tissue will heal/adapt according to manner in which they are mechanically stressed

what is the acute stage of healing? when is there pain in this stage?

inflammatory; pain before tissue resistance

what PT phase corresponds to the acute stage of healing?

maximum protection

what is the subacute phase of healing? when is there pain in this stage?

proliferation, repair, & healing; pain at end-range

what PT phase corresponds to the subacute stage of healing?

moderate protection / controlled-motion

what is the chronic stage of healing? when is there pain in this stage?

maturation & remodeling; pain after tissue resistance

what PT phase corresponds to the chronic stage of healing?

minimum to no protection / return-to-function

4 signs of overload

-pain that does not resolve within 12 hrs
-increased pain from last session
-increased inflammation
-decreased functional ability

if there is no pain/swelling from previous day's exercise, what should happen?

modify 1 variable (weight, \# of reps)

if there is some pain/swelling that recedes with warmup from previous day's exercise, what should happen?

stay at same level

if there is pain/swelling that does not go away from previous day's exercise, what should happen?

decrease exercise level

what is the PT goal during the maximum protection (acute) stage of healing? (2)

-control effects of inflammation
-prevent harmful effects of rest (immobilization)

how do PTs control effects of inflammation? (4)

-selective rest
-ice
-compression
-elevation

what is the PT goal during the moderate protection/controlled motion (subacute) stage of healing? (2)

-develop mobile scar via selective stretching
-promote healing (controlled exercise)

what is the PT goal during the minimum protection/return to function (chronic) stage of healing? (2)

-increase tensile quality of scar via exercise
-develop functional independence via functional drills

contracture

fixed high-resistance to passive stretch

adaptive shortening

tissue shortening relative to normal resting length

what are the cardiovascular effects of immobilization? (3)

-sluggish circulation --\> DVTs
-decreased CO and SV (heart atrophy)
-orthostatic hypotension (result of low BP)

immobilization effect on muscle

atrophy begins after 1 week; more weakness than measured by circumference (may not be smaller, but will be weaker); atrophies more if immobilized in shortened position

immobilization effect on tendons

decreased load tolerance (due to disorganized collagen); decreased water content

immobilization effect on ligaments

decreased strength/stiffness

immobilization effect on cartilage

decreased loading --\> degeneration of joint surfaces & changes in synovial fluid

immobilization effect on bone

decreased bone marrow density; more significant in children & older adults

indications for PROM (5)

-when active movements may disrupt the healing process
-paralysis/weakness
-inability to follow directions
-pain
-used to demonstrate desired AROM activity

continuous passive motion (CPM)

device that provides PROM; sometimes used post-op to minimize immobilization effects

what is the purpose of overpressure?

determine end-feel; do NOT use when doing ROM exercises

muscle performance

capacity of muscle to do work

work

force x distance

3 elements of muscle performance

strength, power, endurance

strength

ability of contractile tissue to produce tension

what is the most common adaptation in strength training? what is this a result of?

increase in maximum force producing capacity of muscle as a result of neural adaptations & increased muscle fiber size

neural adaptation

increased recruitment in number, rate, and synchronization of motor units; make up most of muscle force capacity gains in first 6 weeks

power

rate of performing work (work / time); requires strength and speed of movement

how do you increase power?

either increase the work a muscle performs in a given amount of time or decrease the amount of time it takes to do a certain amount of work (only change 1 variable)

muscular endurance (local endurance)

ability of muscle to contract repeatedly against load and resist fatigue over time

cardiopulmonary endurance (total body endurance)

associated with repetitive, dynamic motor activities that involve large muscle groups (walking, cycling, swimming, etc)

how do muscles adapt to endurance training

increases in oxidative & metabolic capacities (better delivery/use of O2)

overload principle

load must exceed metabolic capacity of muscle to keep getting stronger

how do you change the load to accommodate the overload princple?

strength: increase resistance

endurance: increase time/reps

power: decrease time to do same work

reversibility principle

"use it or lost it"; detraining occurs after 1 week

precautions for resistance training (5)

-avoid valsalva maneuver
-substitute motions (using trap for shoulder elevation)
-exercise-induced muscle soreness
-overtraining/overwork
-pathological fx

valsalva maneuver

forced exhalation against closed glottis --\> increased intra-abdominal & thoracic pressure --\> increased BP with immediate drop after exercise

DOMS

delayed onset muscle soreness; develops 12-24 hrs post exercise; greatest with eccentric exercise

overtraining vs overwork

overtraining occurs in healthy individuals; overwork occurs in diseases pts; deterioration in muscle performance from progressing weight too quickly or inadequate rest

pathological fx

fx to bone already weakened by disease (osteoporosis)

length-tension curve

type I muscle fibers

slow twitch; low force production; resistant to fatigue (endurance)

type IIA & IIB muscle fibers

fast twitch; rapid, high force production; rapid fatigue (power)

can type I muscle fibers convert to type II and vice versa?

very hard to do this, little information

when does muscle strength peak and begin to decrease?

peaks in 20s, decreases after 30 (decrease speeds up as you age into the 80s)

muscle fatigue

decrease in amplitude of motor unit potentials due to:
-disturbance in contractile mechanism
-CNS inhibition
-decreased n-m impulses

how long does it take for O2 and energy stores to replenish after a set?

3-4 mins

how long does it take for lactic acid to leave the muscle and bloodstream after exercise?

1 hr

how long does it take for glycogen to be replaced after a workout?

several days

what is the benefit of active recovery?

results in more rapid recovery from exercise than "passive" recovery

hypertrophy

increase in cross-sectional area of muscle due to increase in myofibrillar volume; takes 4-8 weeks of training

can endurance training cause hypertrophy?

not really

hyperplasia

increase in number of muscle fibers; result of longitudinal splitting of muscle fibers; no strong evidence of existence

connective tissue adaptations to exercise

increases in tendon/ligament strength, bone density

metabolic adaptations to exercise

increased stores of ATP-PC (phospocreatine) and CPK

open kinetic chain (OKC) exercises

distal segment is free to move; usually NWB; contraction predominantly in prime mover; less joint congruency; less predictability of movement

closed kinetic chain (CKC) exercises

distal segment fixed (or moves but stays in contact with something); several joints/muscle groups move (both proximal & distal); usually WB; more joint congruency; more predictability of movement

quadriceps OKC vs CKC action

OKC: knee extension
CKC: decelerate knee flexion during loading

is the XC ski machine (for LE) OKC or CKC?

CKC

is the elliptical (for LE) OKC or CKC?

CKC

is the rowing machine (for LE) OKC or CKC?

CKC

is the rowing machine (for UE) OKC or CKC?

OKC

are step ups OKC or CKC?

CKC

dosage for ROM exercises

-2-3 times per day, every day
-10-20 reps
-move joint through available ROM, not beyond

dosage for isometric exercises

-6-10 second contraction
-multiple angles, every 15-20°
-8-10 reps each angle

dosage for resisted exercises

-1-3 sets of 8-12 reps
-once per day
-2-3 times/week
-2-3 min. rest between sets

viscoelasticity

initial resistance of collagen to deform when stretching

elasticity

ability to return to original resting length after a passive stretch

plasticity (creep)

ability to assume new, greater length in response to force applied over time

muscle spindle

primary sensory organ of muscle; responds to quick stretch

what happens when there is a quick stretch to a muscle?

intrafusal afferents in muscle spindle (Ia and II) are activated and cause efferents to fire --\> protective muscle contraction to resist further stretch

afferent vs efferent neurons

afferent: sensory

efferent: motor

golgi tendon organ (GTO)

proprioceptors in tendons; with stretch, Ib afferents fire, inhibiting muscle activation and allowing stretch (autogenic inhibition); more active with slow stretch, not as active with quick stretch

autogenic inhibition

inhibiting signal sent by GTO allowing muscle to relax and stretch rather than protectively contract

what happens during a stretch?

intrafusal fibers activate extrafusal fibers and muscle tension increases ("stretch reflex") which inhibits lengthening --\> GTOs sense increase in muscle tension after slow, prolonged stretch and relaxes muscle (autogenic inhibition), allowing it to stretch

do ligaments have elastic properties?

no; sprain when taken longer than defined length

corticosteroid effect on collagen

decreases tensile strength

stress vs strain

stress: tension, compression, shear (load)

strain: amount of deformation

elastic range

range where amount of stress applied to tissue will result in it returning to its normal length after removal

plastic range

enough stress to cause permanent changes in tissue length; will not return fully to resting length

what is the 1st surgical component performed prior to rotator cuff repair in a pt with chronic impingement?

subacromial decompression

what are the 3 elements of post-operative care after full-thickness RC tear?

-immediate/early post-op motion of GH joint
-control RC for dynamic stability
-gradual restoration of strength/endurance

after RC repair surgery, why is the shoulder immobilized in abduction?

shoulder in a more relaxed, neutral position which reduces chances of reflexive muscle contraction; reduces tension on repaired tendons & improves blood flow to site