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145 Cards in this Set

  • Front
  • Back
Definitions:
Flexibility
Dynamic flexibility
Passive flexibility
Hypomobility
Flexibility - Arthrokinematics and extensibility
Dynamic flexibility - Degree which jt moved and amount tissue resistance
Passive flexibility - Extensibility
Hypomobility - Decreased mobility or restricted motion
Hypomobility may be allowed selectively to improve function
Define contracture
Contracture
Adaptive shortening – cross or surround
-significant resistance active/passive stretch, ROM
Designation of contracture by location
Contracture versus contraction
Types of contracture
-Myostatic contracture
-Pseudomyostatic contracture
-Arthrogenic and periarticular contractures
- Fibrotic contracture and irreversible contractures
Selective Stretching

Overstretching and Hypermobility
Selective Stretching
Hypomobile structures to develop to improve function
Overstretching and Hypermobility
Hypermobility improves function in some circumstances
Manual or Mechanical Stretching

Passive Stretching

Assisted Stretching

Self-Stretching
Manual or Mechanical Stretching
Utilizes an external force
Passive Stretching
No patient assistance
Assisted Stretching
Patient assistance
Self-Stretching
Patient performs the stretch
Other interventions to increase mobility of soft tissues
Neuromuscular Facilitation and Inhibition Techniques
Muscle Energy Techniques
Joint Mobilization/Manipulation
Soft Tissue Mobilization and Manipulation
Neural Tissue Mobilization (Neuromeningeal Mobilization)
Indications for stretching exercises
Adhesions, Contractures, Scar Tissue Limit ROM
Potential for Structural Deformity d/t Limited ROM
Muscle Weakness, Shortening of Muscles
Part of a Total Fitness Program
Pre and Post Vigorous Exercise

Functional limitations and/ or participation restrictions
contraindications for stretching exercises
Bony Block
Non-Union Fracture
Acute Inflammation or Infection
Sharp or Acute Pain With Elongation
Hematoma or Tissue Trauma
Hypermobility
Hypomobility Provides Stability or Neuro-muscular Control
Potential benefits/outcomes for stretching exercises
Increased Flexibility and ROM
General Fitness
Other Potential Benefits
Injury prevention
Reduced post-exercise soreness
Enhanced performance
Contractile and Non-Contractile Tissue Changes
Contractile and Non-Contractile Tissue Changes
Elasticity - Return to prestretch resting length
Viscoelasticity - Time dependent property of soft tissue
-Only non-contractile connective tissue
Plasticity - Soft tissue assumes new and greater length after stretch force removed
Contractile Elements of Muscle
Mechanical Response of the Contractile Unit to Stretch and Immobilization
Contractile Elements of Muscle
Mechanical Response of the Contractile Unit to Stretch and Immobilization
RESPONSE TO STRETCH
RESPONSE TO IMMOBILIZATION and REMOBILIZATION
Morphological changes
Immobilization in a shortened position - Sarcomere absorption
Immobilization in a lengthened position

Slow twitch muscles that are used extensively (postural control muscles, for example)
atrophy first and to a greater extent than fast twitch muscles
While studies of muscle length changes with immobilization are largely limited to animal research, it is understood that
While studies of muscle length changes with immobilization are largely limited to animal research, it is understood that
Muscle tissue is very adaptable
Sarcomere number is not fixed
Sarcomere length will adjust to generate optimal length-tension relationship in a muscle

Clinical evidence for the benefit of prolonged stretch (serial casting, bracing and splinting) supports these changes in humans as well
New length must be used to be maintained!!
Muscle Spindle:
Muscle Spindle:
Major sensory organ in muscle
Sensitive to quick stretch and to sustained stretch
Receives/conveys information about length change and velocity of length change of muscle
Lies in parallel with extrafusal fibers within skeletal muscle
Includes: afferent sensory fibers (Ia and II), efferent fibers (Gamma efferent), and intrafusal fibers that connect at ends to extrafusal fibers
Golgi Tendon Organ
Golgi Tendon Organ
Also a sensory organ
Located at musculotendinous junction, rather than in muscle
Monitors change in tension at m-t junction
Transmits sensory information via Ib fibers
Stimulated by passive stretch and active contractions
Thought to inhibit alpha motor neuron activity, thus inhibiting muscle firing
How does knowledge of muscle spindle and GTO shape the way you stretch
Muscle spindle can activate stretch reflex, causing muscle to contract when it is passively stretched.
Result is resistance to stretch
To avoid this, muscle should be stretched slowly, at a low intensity

GTO is thought to inhibit muscle tension
This should facilitate muscle relaxation during stretching
Slow, low-intensity stretch is less likely to activate the stretch reflex, in part because the GTO has a low threshold for firing
Low muscle tension promotes relaxation of sarcomeres (parallel elastic component), with muscle lengthening
Types of connective tissue
Ligaments
Tendons
Joint Capsules
Fasciae
Non-Contractile Tissue in Muscles
Skin
Composition of Connective Tissue
Composition of Connective Tissue
Collagen fibers
Elastin fibers
Reticulin fibers
Ground substance - Proteoglycans and glyocoproteins
Portion of collagen and elastin
Structural orientation of fibers
Mechanical Behavior of Non-Contractile Tissue
Collagen
Tropocollagen is basic element
Collagen microfibril
Organized
6 classes; 19 types C

Type I
Interpreting Mechanical Behavior of Connective Tissue: The Stress-Strain Curve
types of stress
Interpreting Mechanical Behavior of Connective Tissue: The Stress-Strain Curve
Stress (the load) and Strain (tissue response to load)
3 Types of stress cause strain to tissues:
Tension
Compression
Shear
Regions of the Stress-Strain Curve
Regions of the Stress-Strain Curve
Toe region
Elastic range/linear phase
Elastic limit
Plastic range
Stress-strain curve

Ultimate strength
structural stiffness
Ultimate strength
Greatest load tissue can sustain
Necking – weakening of tissue that leads to:
Failure - rupture
Structural stiffness
Slope of the elastic range, representing tissue stiffness
Steeper slope = greater stiffness, less elasticity, less elongation
More gradual slope = less stiffness, more elasticity, more elongation
Time and Rate Influences on Tissue Deformation
Time and Rate Influences on Tissue Deformation
Creep – load applied for extended period, tissue elongates and does NOT return to original length
Related to viscosity, thus is time-dependent
Stress-relaxation - load applied to stretch tissue, and length kept constant, so after initial creep, decreased force required to maintain length; tension decreases
Also related to viscoelastic properties, this is the principle applied for prolonged stretching where the same static positioning is held for hours or days
What are ways this can be done therapeutically?
Cyclic loading and connective tissue fatigue – repeated loads increase heat production and may lead to failure
Greater load = fewer cycles to lead to failure
Changes in Collagen Affecting Stress–Strain Response
Effects of immobilization
Effects of inactivity (decrease of normal activity)
Effects of age
Effects of corticosteroids
Effects of injury
Other conditions affecting collagen
Changes in Collagen Affecting Stress–Strain Response
Effects of immobilization
Tissue weakens
Adhesions form (increased cross-linkage of disorganized collagen and less effective ground substance)
Effects of inactivity (decrease of normal activity)
Decrease in size and amount of collagen (weakens tissue)
Increased predominance of elastin (increases compliance)
Effects of age
Decreases maximal tensile strength
Rate of adaptation to stress is slower

Effects of corticosteroids
Decreases tensile strength of collagen
Fibrocyte death in tissue surrounding injection site
Effects of injury
In healing, type III collagen is synthesized; this is weaker than mature, type I collagen
Remodeling begins several weeks after injury and may continue for a year, depending on severity of injury
Other conditions affecting collagen
Nutritional deficiencies, hormonal imbalance, and dialysis are examples of conditions that predispose one to connective tissue injury at lower than normal levels of stress
Immobilization increases resistance to passive stretch
Is this increased stiffness caused by changes in collagen content in the immobilized muscle?
Immobilization increases resistance to passive stretch
Is this increased stiffness caused by changes in collagen content in the immobilized muscle?
In adult mice that had hindlimb immobilization:
Increased collagen after 2 days of immobilization in a shortened position
Changes attributed to increased perimysium
After one week of immobilization, endomysium increased
Orientation of collagen fibers much more acute than in normal muscle as a result of shortening
Conclusion: Immobilization (shortened) has a direct impact on connective tissue!!
However, muscle immobilized in a lengthened position was not affected!
determinants and types of stretching exercises
Alignment and Stabilization
Intensity of Stretch
Duration of Stretch
Static stretching
Static progressive stretching
Cyclic (intermittent) stretching
Speed of Stretch
Importance of a slowly applied stretch
Ballistic stretching
High-velocity stretching in conditioning programs and advanced-phase rehabilitation
Frequency of Stretch
What effect did 3 repeated, 45-s stretches produce on viscoelastic properties in skeletal muscle?
3 repeated, 45-s stretches produced no short term effect on viscoelastic properties in skeletal muscle.
That is, there were no changes to physical properties of muscle (stiffness) after 3 stretches.
However, there was a decline in resistance to stretch within a 45-s bout
Still, no difference in resistance from 1st to 3rd stretch


The subjects’ tolerance to stretching did improve.
In healthy adult human males who underwent passive stretching of the gastrocnemius,
In healthy adult human males who underwent passive stretching of the gastrocnemius,
Tendon properties did not change
Length and pennation angle of muscle fascicles did change
It was suggested that properties of the connective tissue within muscle were altered by repetitive stretching
What's the best method for stretching hamstrings?
Methods:
Random assignment to 1 of 5 groups:
Three 1-minute stretches
Three 30-second stretches
One 1-minute stretch
One 30-second stretch
Control
4 stretching groups stretched 5 days/wk x 6 wks
Standing R hamstring stretch, calcaneus on elevated surface high enough to feel gentle stretch; forward flexion from hip, neutral spine, reaching with arms until posterior thigh stretch felt
Results:
Stretch groups had more ROM than control
No difference among stretch groups
Types of PNF Stretching
Hold–relax and contract–relax
Agonist contraction
Hold–relax with agonist contraction
Procedural guidelines for application of stretching interventions
Examination and Evaluation of the Patient
Preparation for Stretching
Application of Manual Stretching Procedures
After Stretch Procedures
Precautions for stretching
General Precautions
Special Precautions for Mass-Market Flexibility Programs
Common errors and potential problems
Nonselective or poorly balanced stretching activities
Insufficient warm-up
Ineffective stabilization
Use of ballistic stretching
Excessive intensity
Abnormal biomechanics
Insufficient information about age-related differences
Strategies for risk reduction
Adjuncts to stretching interventions
Complementary Exercise Approaches
Relaxation training
Common elements of relaxation training
Examples of approaches to relaxation training
Autogenic training
Progressive relaxation
Awareness through movement
Sequence for progressive relaxation techniques
Pilates
Heat
Methods of warm-up
Effectiveness of warm-up methods
Cold
Massage
Massage for relaxation
Soft tissue mobilization/manipulation techniques
Biofeedback
Joint Traction or Oscillation
ROM impairments can be...
(causes)
systemic
neurological
joint
muscle
surgical/traumatic
inactivity/immobilization
Functional excursion
distance a muscle can shorten after being elongated
Types of Range of Motion (ROM) Exercises
Passive ROM (PROM)
Motion produced by an external force, manual or mechanical
Active ROM (AROM)
Motion produced by active contraction of the muscles
Active-Assistive ROM (A-AROM)
Motion produced by a combination of external force and active muscle contraction (type of AROM)
Passive ROM (PROM)
Indications for PROM
Goals for PROM

Other Uses for PROM

Limitations
Passive ROM (PROM)
Indications for PROM - acute, not able or not supposed to move it
Goals for PROM - decrease complications with immobilization
Other Uses for PROM
Limitations: doesn't prevent atrophy or assist as much with circulation
Active and Active-Assistive ROM (AROM and A-AROM)
Indications for AROM
Goals for AROM
Limitations of A-AROM
Active and Active-Assistive ROM (AROM and A-AROM)
Indications for AROM: capable, assistance, adjacent joints, relieve stress (what did I mean?)
Goals for AROM - physiological elasticity and contractility, sensory feed(back?), stimulation for bone/jt., prepare for more activity, increase circulation, prevent thrombosis, develop coordination and motor skills, plus all the things from PROM
Limitations of A-AROM: still not getting strength gains from this
Precautions and Contraindications to ROM Exercises
ROM should not be done when motion is disruptive to the healing process
Follow specific precautions during early phases of healing
ROM should not be done when the patient’s response or condition is life threatening
Follow specific precautions when the patient’s condition is critical or severe
Be aware of pain, swelling, and vital signs
Examination, Evaluation, and Treatment Planning
(for ROM techniques)
Examination, Evaluation, and Treatment Planning:
Determine appropriate level of ROM
Determine safe amount of motion
Decide the pattern of motion to best meet goals
Monitor patient response to ROM intervention
Document and communicate findings
Re-evaluate and modify as appropriate
Patient Preparation for ROM
Patient Preparation
Describe the intervention to meet set goals
Free the area from restriction
Drape the patient
Position the patient for alignment and stabilization
Position yourself for proper body mechanics
Application of ROM Techniques
Application of Techniques
Control movement grasping around the joint
Support areas of poor structural integrity
Move the segment through pain-free range to the point of resistance (not beyond!)
Perform motions smoothly and slowly
Repetitions are determined in the plan of care
- generally 5-10 reps, or more, esp if immobilized
(Person with TKA comes in with pain, still needs ROM)
Thorough instructions
Application of PROM
Application of PROM
Movement of the segment by a therapist, PTA ,or mechanical device
No active muscle contraction
Motion only through the pain-free ROM without tissue resistance
Application of AROM
Application of AROM
Demonstrate the motion using PROM
Ask the patient to perform the motion
Provide assistance for smooth motion, weakness, at the beginning or end of range only as needed
Motion within available pain-free ROM
Self-Assistance-manual
Equipment
Self-Assistance-manual
Equipment
Wand (T-bar)
Wall climbing, finger ladder
Ball rolling
Overhead pulleys
Skate board/powder board
Reciprocal exercise unit
Continuous Passive Motion (CPM)
Passive motion that is performed by a mechanical device that moves a joint slowly and continuously through a pre-set, controlled range of motion
Mostly see for knee
Benefits of CPM
Prevents development of adhesions, contractures
Stimulates healing of tendons, ligaments
Enhances healing of incisions
Increases synovial fluid lubrication
Prevents degrading effects of immobilization
Quicker return of ROM
Decreases postoperative pain

But, these are acute effects, no evidence of long-term benefits
Make sure patients still do stuff to
4-8 hours a day, maybe for a week or so
General Guidelines for CPM
Device is applied immediately after surgery
Arc of motion is adjustable and determined
Rate of motion is adjustable and determined
Duration on the machine is determined
Physical therapy is included during off periods
Devices are often portable and battery operated to allow patients to be functionally active
ROM Through Functional Patterns
Assists in teaching ADLs and IADLs
Helps patient realize purpose and value of ROM exercises
Assists in developing motor patterns
3 elements of performance
(physical/muscular)
Strength, Power, and Endurance
Strength - Contractile tissue produces tension
exert force -> single max effort
Training: neural adaptation and increase fiber size
Power - force x distance/ time - rate of work, change by altering speed or work, often speed
Power training
Endurance -
Endurance training - low intensity, high reps, or sustained over time, submax (less strain), increase oxidative and metabolic capacities, often in rehab for functional capability
Overload Principle
Overload Principle
Sufficient load (over usual ability) is required to increase muscle strength
Application of the Overload Principle requires manipulation of a variable. How does volume differ????
For endurance - longer, distance
Sets or reps increase
SAID Principle
Framework of Specificity of training-mimic function
Type, intensity, duration, rate, limb position, and motion
Transfer of training carry-over to other situations, and even to the other limb
SAID Principle - Specific Adaptation to Imposed Demand
Framework of Specificity of training-mimic function
Type, intensity, duration, rate, limb position, and motion
Functional stuff - can vary lots of things to mimic function
Transfer of training carry-over to other situations, and even to the other limb
Reversibility Principle
Do older people lose more strength or more power?
Use it or lose it!
maintain
Older women after power training program -more declines in strength than power w/ detraining
“These data indicated that DT may induce larger declines in muscle strength than
“These data indicated that DT may induce larger declines in muscle strength than in power output and preserved physical independence, mediated in part by the effectiveness of high-speed power training, particularly developed for older women.”
Factors that influence tension generation in normal skeletal muscle
-Fatigue
Energy Stores and Blood Supply
Fatigue - normal process, Ca+, glycogen, O2 depleted
Muscle (local) fatigue - local
Cardiopulmonary (general) fatigue - general
Threshold for fatigue-level ex can’t be sustained
Factors that influence fatigue-disease state, lifestyle, diet, etc (patterns), anything that affects ability to oxygenate
Recovery From Exercise
Takes 3-4 min for muscle to recover (most in 1 min)
Oxygen and energy stores replenished quickly in muscles
Lactic acid and blood removed from skeletal muscle (takes 1 hr?)
Glycogen replaced over several days
Symptoms of fatigue - substitution, decreased speed and torque...
Know patient and target tissue to judge when to stop
Factors that influence tension generation in normal skeletal muscle
Age, psychological and cognitive factors
Age
Early childhood and preadolescence - lots of change through 1st year, muscle fiber number set at birth, strength and endurance increase with age, also neuromuscular, kids should do recreation and motor skills
Adolescence - 30% a year for 10-15, hormones going crazy! More traditional ex, sport specific, male strength increases 5x, female 3.5 x
Young and middle adulthood - lose 1% strength/year in 30s, ~8% a decade, but can counteract with exercise!
Late adulthood - los in 60s-70s is 15-20%/decade
80s - 30% loss
Could lose only 0.3% a year with exercise program!!
Psychological and Cognitive Factors - fear
Attention - focus
Motivation and feedback - keep journal, etc.
Influence of Muscle cross-section and size (fiber # and size) on force generation
increase diameter = increase tension-producing capacity
Influence of Muscle architecture – fiber arrangement/length on force generation
Short fibers, pinnate, multi-pinnate design in high force-producing muscles (quads, gastroc, deltoid, biceps brachii)
Long, parallel design in muscles with high rate of shortening but less force production (sartorius, lumbricals)
Influence of Fiber type distribution – type I (slow twitch) or type IIA & IIB (fast twitch) on force generation
increase% type I = low force production; slow rate of achieving max force; fatigue resistant

Increase% type II = rapid, high force production; rapid fatigue
Influence of Length-tension relationship on force generation
Greatest tension producing ability is near resting length
Influence of Motor Unit recruitment on force generation
Increase #, synchronization of MU firing = increase
Force production
Influence of Frequency of MU firing on force generation
increasing frequency = increasing tension
Influence of Type of muscle contraction on force generation
Eccentric > isometric > concentric
Influence of Speed of contraction (force-velocity) on force generation
Concentric: increase speed = decreased tension
Eccentric: increased speed = increaed tension
Muscle fiber types
Slow-twitch Red - S (slow)
(Type I)
Fast-twitch Red - FR (fatigue resistant)
(Type IIa)
Fast-twitch White - FF (fast fatiguable)
(Type IIb/IIx)
Human muscle fiber distribution
In general
Not related to age, gender

47 – 53% slow fibers (average, sedentary)

Power athletes: higher percentage of fast fibers

Endurance athletes: higher percentage of slow fibers
Neural Adaptations to resistance ex
Neural Adaptations
Neural factors dominate early changes:
Increase in strength exceeds girth change; task specific
Neural changes include:
Improved synchronization of MU firing
Improved MU recruitment – increases the # of MU firing
Increased rate of MU firing
Skeletal Muscle Adaptations
to resistance ex
Skeletal Muscle Adaptations
Hypertrophy - Inc size muscle fiber, inc myofibrillar volume both I & II
Hyperplasia - Increase number muscle fibers POOR research
Muscle fiber type adaptation
Type IIB to IIA
? No conversion I to II, none II to I
Physiological adaptation to skeletal muscle training
Depends on the type of training
Depends on the intensity of training
Physiological adaptation to resistance exercise: neural and hypertrophy factors
Neural factors most influential in the first 12 weeks, peak around 10 weeks
Hypertrophy gradual from around 8 weeks, more increase at 12 weeks, peaks around 26 weeks
Muscle hypertrophy and fiber type changes
Muscle hypertrophy
Both type I and type II fibers hypertrophy
Type II > Type I
Requires high force, short duration
Increased number, size of myofibrils
ie, increased number of sarcomeres
Increased ability to generate tension
Muscle Fiber type changes
Some remodeling of type IIB to IIA
No conversion from type I to II
Sample resistance exercise plan
5-10’ warm-up

40-60% 1RM to moderate 60-80% (I)
Permits 10-15 reps
Minimize eccentric
Reps: 8-12
Rest: 48 hrs
Freq: 2 sessions a week
Initially increase reps not resistance
More physiological adaptations to exercise
- vascular, connective tissue
Vascular and Metabolic Adaptations - strength - decreasing capillary content (percentage, more myofillaments)

Adaptations of Connective Tissues
Increased tensile strength tendons, ligaments, and connective tissue in muscle
Bone-Increase bone mineral density
But not necessarily an increase in bone mass

Elderly - minimize eccentric contractions
Resistance exercise does not promote:
does promote:
Resistance training does NOT promote:
Increased capillary density
Increased mitochondrial density


Resistance training DOES promote:
Increased stores of CP, ATP, and glycogen
Increase in related enzymes
Creatine kinase, phosphofructokinase (enzyme of glycolysis)
Study
Purpose: assess influence of strength and endurance training on muscle morphology and neural activation
All groups performed 10 weeks of trg, 3d/wk:
Strength = 3 sets, 5-7 reps (goal of 6 RM)
Endurance = 50 min cycle ergometry at 70% HRR
Concurrent = Both, 10-20 min rest between; order rotated
S and CC had similar increases in thigh extensors and flexor/adductor muscle area.
Type II increased similarly
Type I did not increase for either
A small, but significant increase in thigh extensor area was the only variable to change for E

On another note: metabolic changes occur much more rapidly in the muscle than contractile proteins can increase with training.
Therefore, endurance improves quickly (days), while speed (power) increases over weeks of continued activity.
Indications for low intensity vs. high intensity exercise
Low:
early stage of healing
after immobilization
When beginning ex program
Most children and older adults
When goal is endurance
to warm up and cool down
during slow velocity isokinetic training to minimize compressive force on joints

Near-max or Maximal:
Goals is strength, power, or size
Healthy adults in advanced rehab
Conditioning for people without pathology
Competitive lifters
Volume of resistance Ex
Volume - total # reps and sets
Repetitions
Sets
(Ave-untrained adult, load 75% of 1-RM,
completes approx 10 reps)
Training to improve strength or endurance: impact of exercise load and repetitions
To improve muscle strength
To improve muscle endurance
Exercise order, frequency, duration, and rest
Exercise Order-lrge before small; multi-jt before single-joint exercises
Frequency-# ex sessions per day/week
Duration-total # wks / months carried out
Rest Interval (Recovery Period)
Purpose of rest intervals-body recuperate
Integration of rest into exercise-per muscle group
3 min vs 2-3 min. Moderate intensity 48 hr?
Mode of Exercise
Mode of Exercise
Type of muscle contraction - concentric, iso, ecc
Position for exercise: weight-bearing or non-weight-bearing, open chain vs. closed
Forms of resistance - Manual/mechanical, constant /variable, accommodating, BW
Energy systems - anaerobic or aerobic
Range of movement: short-arc or full-arc exercise
Mode of exercise and application to function
Characteristics of periodized training
Preparation - lower loads, high reps and sets, more exercise sessions per week or day, more exercises per session
Competition - higher loads, lower sets and reps, fewer sessions per week and exercises per session
Recuperation - gradual decrease in load, additional decreases in sets, reps, exercises, and frequency
Dynamic Exercise - Constant and Variable Resistance
Dynamic Exercise-Constant External Resistance (DCER) - progressive resisted exercise, common system of loading
Variable-Resistance Exercise
Special Considerations for DCER and Variable-Resistance Exercise
Excursion of limb movement
Velocity of exercise

PRE or DCER
Implementation of resistance exercises
Warm Up
Placement of Resistance
Direction of Resistance
Stabilization
Intensity of Exercise/Amount of Resistance
Number of Repetitions, Sets, and Rest Intervals
Verbal or Written Instructions
Monitoring the Patient
Cool Down
Valsalva Maneuver
Valsalva Maneuver
At-risk patients - history of Coronary Artery Disease, Myocardial infarction, Hypertension
Prevention during resistance exercise - breathing education
Overtraining and Overwork
Overtraining and Overwork
Overtraining
Decline physical performance/capabilities
Overwork
Progressive deterioration of strength in muscles
Neuromuscular disease-NON FATIGUING EXERCISES
Exercise-Induced Muscle Soreness
Exercise-Induced Muscle Soreness
Acute muscle soreness
Delayed-onset muscle soreness (DOMS)
Etiology of DOMS - breaking bonds in belly or myotendinous jct., can last 10-12 days
Prevention and treatment of DOMS - hot/cold may feel good
Pathological fractures
(considerations for resistance exercise)
bone already weakened by disease
vertebra, hip, wrist, rib
Contraindications to resistance exercise
Pain
Inflammation
Severe Cardiopulmonary Disease
Special Considerations for Children and Older Adults
Children and resistance training
Special Considerations for Children and Older Adults
Children and resistance training
Immature thermo-regulation: children dissipate body heat less easily, fatigue quickly, need longer rest period
Older adults and resistance training
Maintain and improve functional independence
Progressive Resistance Exercise
Delorme and Oxford regimens
DAPRE regimen:
Progressive Resistance Exercise regimens
Delorme - start light and get heavier
and Oxford - start heavy, decrease resistance
DAPRE regimen: daily adjustable progressive resistance exercise - based on what they do on 3rd set (increase or decrease)
Functional Components of the Spine
Anterior - weight-bearing
Shock –absorbing portion

Posterior gliding mechanism
Lever system for muscles
Arthrokinematics
Zygapophyseal (Facet) Joint
coupled motion: consistent association of one motion about an axis with another motion around a different axis

Does this refer to - flexion is anterior rolling of occiput on atlas accompanied by posterior translation
In spine, Ipsilateral sidebend and rotation leads to...
Ipsilateral sidebend and rotation-> foraminal closure
Association between annular tears and disk degeneration: a longitudinal study
American Journal of Neuroradiology 2009
The purpose of this study was to assess whether annular tears precede nuclear degeneration and whether the evolution of nuclear degeneration is affected by presence of annular tears

CONCLUSIONS:
Annular tears occur in the early stages of disk degeneration
and are associated with a faster subsequent nuclear degeneration.
Are outer annular fissures stimulated during diskography the source of diskogenic low-back pain? An analysis of analgesic diskography data.
Pain Medicine 2009
This study aimed to clarify whether painful annular fissures stimulated during provocation diskography are the likely source of diskogenic pain

RESULTS:
80% of painful intervertebral disks as detected by provocation diskography were
sufficiently anesthetized resulting in >50% reduction in low-back pain
during analgesic diskography.
CONCLUSION:
Diskogenic pain is in varying degrees caused by the sensitized nociocepters within annular tears.
Postural stability
Role of passive and active structures
Postural stability
Passive: inert structures bone/ligament participate in stability/control
Active: muscles
Global Segmental
superficial deeper (type I)
guy wires vertebral segments
Neuro Control: Feedforward
4 cm sway in normal stance
Feedforward, communicate to brain, stabilize trunk 1st, active postural response preceding the extremities
Stability is combo of 3 factors - passive, active, neurocontrol
Muscle Control in the Lumbar Spine
Abdominal Muscles
Transverse Abdominis Stabilization Activity (major player, stops kicking in in pathological processes.)
Erector
Multifidus Stabilization Activity
Thoracolumbar (Lumbodorsal) Fascia
Global and deep segmental muscles
Global:
Rectus abdominis
Obliques
Quadratus Lumborum
Erector spinae
Ilipsoas
SCM
Lev scapulae
Upper trapezius
Erector spinae

Deep segmental muscles:
Transverse abdominis
Mulifidus
Quadratus Lumborum-deep
Rectus capitis anterior and lateralis
Longus colli

1st need segmental, then global (for stability)
Why is transversus abdominus important?
Cresswell et al. 1994
Found consistent activation of the transversus abdominis before other trunk muscles when and expected load was applied.
TrA was the first muscle activated no matter the direction of the load.
Drawing the stomach in allows for isolation of the TrA
Bracing includes activation of EO, ES, and TrA
Drawing the stomach in is better at stabilizing the SI joint than bracing

Training TrA for postural control and stability
Improves patient long term outcomes
Muscle Control in the Cervical Spine
which muscles
Mandibular Elevator Group - muscles of mastication can be factors in neck pain
Suprahyoid and Infrahyoid Group
Rectus Capitis Anterior and Lateralis, Longus Colli, and Longus Capitis
Multifidus
forward head posture - work on OA ext and other flexion
Occipital nerve behind occiput can get irritated by posture
Role of Muscle Endurance and inactivity
Inactivity has been shown to change muscle fiber composition, leading to decreased muscular endurance during sustained or repetitive activities
Different effects on stability
Neurological Control: Influence on Stability
Feedforward control and spinal stability
Effects of Limb Function on Spinal Stability
Localized muscle fatigue
Muscle imbalance
Effects of Breathing on Posture and Stability - holding breath may inhibit transverse abdominus
Effects of Intra-Abdominal Pressure and the Valsalva Maneuver
Etiology of pain
(in back mostly?)
Effect of Mechanical Stress
Effect of Impaired Postural Support from Trunk Muscles
Effect of Impaired Muscle Endurance
Pain Syndromes Related to Impaired Posture
Postural fault: no structural impairments (correct posture and fix issue, no inflammation
Postural pain syndrome: mech. Stress (end up with imbalance) -> relieved w activity (exercise)
Postural dysfunction: adapt shorten and mm weakness
Postural habits: Good to avoid abnormal stress / adaptive
Postural patterns
A
B
C
D
A - lordosis, anterior tilt, hip flexion, rely on anterior structures
B - Whole pelvis anterior, hip extension, increased lordosis, thoracic flexion,
C - decreased lordosis, poor shock absorber
D - decreased thoracic curve

important to teach patients how posture affects pain
Frontal Plane Deviations, Scoliosis, and LE Asymmetries
Frontal Plane Deviations, Scoliosis, and LE Asymmetries
Scoliosis, elevated hip
Structural
Nonstructural (reversible)
Frontal plane deviations
from LE asymmetries
Characteristic deviations - rotation toward convexity, rib hump on that side
General Management Guidelines
of Impaired posture
Awareness and Control of Spinal Postures
Posture training techniques
Axial extension (cervical retraction) to decrease a forward head posture
Scapular retraction
Pelvic tilt and neutral spine
Thoracic spine
Total spinal movement and control
Reinforcement
Postural support
Posture, Movement, and Functional Relationships
Relationship of impaired posture and pain
Relationship of impaired posture and extremity function
Joint, Muscle, and Connective Tissue Mobility Impairments
Impaired Muscle Performance
Body Mechanics
Ergonomics
Stress Management/Relaxation
Muscle relaxation techniques
Cervical and upper thoracic region
Lower thoracic and lumbar region
Conscious relaxation training for the cervical region
Modalities and massage
Healthy Exercise Habits
Lordotic Posture
Muscle impairment:
Symptoms:
Cause:
Lordotic Posture
Muscle impairment: hip flexors and lumbar extensors
Symptoms: stress anterior long ligament
narrow posterior disc and interv. Foramen
approximation of facets
Cause: faulty posture, pregnancy, obesity,
weak abdominals
Relaxed or slouched
Muscle impairment:
Symptoms:
Cause:
Muscle impairment: mobility impairment in upper abdominal muscles, internal intercostal, hip extensors, lower lumbar extensors
Symptoms: stress iliofemoral and ant longitudinal lig,
post longitudinal of upper lumbar and thoracic.
Narrow interv. Foramen in lower lumbar,
approximate facet in low lumbar
Cause: person yields to affects gravity-passive
structure provide stability.
Attitude, fatigue, weakness.
Flat lowback posture
Muscle impairment:
Symptoms:
Cause:
Muscle Impairments: mobility impairment in trunk flexor and hip extension. Impaired muscle performance due to stretched and weak lumbar extensors
Symptoms: Lack of normal physiological lumbar curve,
which reduces shock-absorbing effect on lumbar spine
and predisposes to injury. Stress post long. Lig.
Degenerative changes to disc.
Causes: continued slouching or
flexion in sitting.
Rounded Back (inc. Kyphosis) with forward head
Muscle impairment:
Symptoms:
Cause:
Muscle impairment: intercostal muscles, muscle of upper extremity originating on thorac-pect, lat, serratus. Stretched and weak lower cervical and upper thoracic and scapular retactors, ant throat, and capital flexors
Symptoms: Ant long lig anterior upper cervical, post long lig lower cervical and thoracic, fatigue thoracic erector spinae and scap retractors, irritation upper cervical facet with narrowing, impinge neurovascular bundle ant scalene or pect minor, impinge greater occipital nerve from tight upper trap-tension HA, lower cervical disc lesion, TMJ
Causes: Gravity, slouching, poor relaxed posture
Flat back and upper neck posture
Muscle impairment:
Symptoms:
Cause:
Muscle Impairment: mobility impairment anterior neck muscles, scapular protractors
Symptoms: Fatigue posture muscles, compression neurovascular bundle between rib and clavicle, decrease shock absorbing
Cause: not common, exaggerated military posture
Structural vs. non structural scoliosis
Structural scoliosis
rotation of vertebral body toward convexity. ribs rotate with vertebral body. rib hump on side of convexity
Nonstructural scoliosis
functional/postural
can be influenced/changed
Scoliosis
Impairments
Symptoms
Causes
Impairments: mobility impairment joint, muscle, fascia on concave side. Impaired muscle performance due to stretch/weakness on concave side. If hip adducted-shortened.
Symptoms: Muscle fatigue and ligamentous on convexity. Joint and nerve irritation on concavity
Causes: neuromuscular, osteopathic.
Leg-length discrepancy, muscle guard/spasms, habitual
Elevated ilium long leg
Impairments
Symptoms
Causes
Impairments: mobility impairment with dec. flexibility hip adductors LL and abductors SL.
Iliopsoas, QL, multifidus, piriformis, ES. Impaired muscle performance from stretches and weakened in general convex mm.
Symtoms: Shear force LL, deg changes LL. Lumbar, facet, foramen compress LL. Muscle tension, fatigue, spasms due to asymmetrical loading. LE overuse.
Causes: structural of functional deviations of hip, knee, ankle or foot. Additional functional unilateral flat foot or muscle imbalance.
Significance of transition areas
Cervicothoracic
Thoracolumbar
Lumbosacral
When faulty posture habits dominate, segmental mobility in these areas become exaggerated in the direction of faulty posture
Impaired muscle performance - process and treatment
Posture muscles -> succumb to gravity ->
develop stretch weakness

Exercise
Posture training
Ex muscle endurance
Environmental adaptations
Conscious Relaxation Training
for Cervical Spine
Diaphragmatic breathing
Relax jaw
Slowly flex neck
Slowly raise head inhale slowly
Feel contraction and relaxation of muscles
Part range-note feel of muscles
Tense muscles relax muscles
Patient learns to perceive tension in muscles
Definitions
Herniation
Protrusion
Prolapse
Extrusion
Free sequestration
Definitions
Herniation - bulge beyond disc perimeter
Protrusion - nuclear material contained within annulus, but bulging (fluid stasis)
Prolapse - Frank rupture vertebral canal
Extrusion - nuclear material sticking out but Still in contact
Free sequestration - nuclear material separated from disc and floating in canal
Injury and degeneration of the disc - definitions
Fatigue Breakdown and Traumatic Rupture
Axial Overload
Age
Degenerative Changes
Effect on Spinal Mechanics
Fatigue Breakdown and Traumatic Rupture - -Compression of spine. Scheuermann’s disease. -Cracked end-plate
Axial Overload - Nucleus imbibes water. 30-45 yrs of age. Annulus weakens. Annulus loses tensile strength
Age
Degenerative Changes - Strong genetic component
Effect on Spinal Mechanics - Mobility Increased, abnormal forces on facets/supporting structures
Disc Pathologies and Related Conditions
Tissue Fluid Stasis
Tissue Fluid Stasis
Symptoms may be similar to those of disc lesions
Disc, facet, and ligaments
Compressive loading on cartilage of facets
Respond to extension bias
(picture of guy sitting in chair with remote)
Signs and Symptoms of Disk Lesions and Fluid Stasis
Etiology of symptoms
Etiology of Symptoms
Pain - ligament, dura mater, blood vessels around nerves
Neurological signs and symptoms - pressure nerve roots
Variability of symptoms - depends on degree and direction
Shifting symptoms - hydrostatic mechanism
Inflammation - Nucleus pulposus in neural canal -> dural sac, neural sleeve

Onset and Behavior of Symptoms from Disk Lesions - 20-55, frequently mid 30s-40s, Pain increase w inactivity, inc with intradiscal pressure. Less w walking
Objective Clinical Findings in the Lumbar Spine
Objective Clinical Findings in the Cervical Spine

Pain, muscle guarding
Flexed posture, deviation away from symptomatic side
Neurological symptoms in dermatome / ? Myotome
INCREASED Sx’s –peripheralization
sitting, flexed postures, sit to stand, cough
straining
Limited nerve mobility
Peripheralization with flexion tests
Pathomechanical Relationships of the Intervertebral Disk and Facet Joints
Disc Degeneration
-Initial changes - Increase mobility, facet capsule strained -> irritation swelling, mm spasms
-Altered muscle control
-Progressive bony changes - Facet joints and vertebral body margins -> OA,
DJD, spondylosis….osteophytes, hypomob.
Related Pathologies
-Segmental (clinical) instability - Decreased neuromuscular stabilizing system
-Stenosis - narrowing, central or lateral
-Neurological symptoms: radiculopathy
-Dysfunction

Symptoms:
Disc protrusion
Dec disc height – DDD
Inflammatory response
Spondylosis-osteophyte growth
spondylolisthesis

Initially increased mobility, later hypomobile
Osteophytes etc. lead to narrowing. Do better with flexion (flexion bias)
Common Diagnoses and Impairments from Facet Joint Pathologies
Facets are synovial joints - respond like other joints

Facet sprain/joint capsule injury: Trauma -> effusion, dec ROM ->
mm guarding -> neurological
Spondylosis, osteoarthritis, degenerative joint disease - Degeneration of IV discs and facets joint
Rheumatoid arthritis - Degenerative changes, fragility-atlantoaxial sublux
Ankylosing spondylitis - Rheumatic disease Inflamm lig
Facet joint impingement (blocking, fixation, extrapment) - Sudden movement meniscoid of facet. No neuro
Scheuermann’s Disease
Rare congenital/degenerative weakening
T10-L2, pulposus, vertical instead of out (protrusion),
What's the problem with muscle guarding?
Mm guarding impairs function, Spinal stability
- depletes oxygen -> secondary muscle pain
How long does it take back pain to resolve?
60% resolve within one week
90% resolve within 6 weeks
Management of the spine
Examination and Evaluation
History, systems review, and testing
Stage of recovery (DEFINE THESE)
-Acute inflammatory stage
-Acute stage without signs of inflammation
-Subacute stage
-Chronic stage
Diagnosis, prognosis, and plan of care
Examination and Evaluation
History, systems review, and testing
Stage of recovery:
Acute inflammatory stage - 0-2 weeks
Acute stage without signs of inflammation - 0-4 weeks
Subacute stage - IADL’s provoke symptoms 4-12 weeks
Chronic stage - > 12 weeks Return…
Diagnosis, prognosis, and plan of care
Types of bias
flexion
extension
non-weight-bearing = feel better with traction, harness, pool

People with a bias have better outcomes
activity and movement education for everyone
General Guidelines for Managing Subacute Spinal Impairments: Controlled Motion Phase
Pain Modulation
Kinesthetic Training
Stretching/Manipulation
Muscle Performance - stabilization -> wall slides -> dynamic
Cardiopulmonary Conditioning
Postural Stress Management and Relaxation Exercises
Functional Activities
General Guidelines for Managing Chronic Spinal Impairments: Return to Function Phase
Emphasize spinal control in high-intensity and repetitive activities
Increase mobility in restricted muscles/joints/fascia/nerve
Improve muscle performance; dynamic trunk and extremity strength, coordination, and endurance
Increase cardiopulmonary endurance
Emphasize habitual use of techniques of stress relief/relaxation and posture correction
Teach safe progression to high-level/high-intensity activities
Teach healthy exercise habits for self-maintenance
Management Guidelines: Extension Bias
Principles of Management
Effects of postural changes on intervertebral (IV) disk pressure
Effects of bedrest on the IV disk
Effects of traction on the IV disk
Effects of flexion and extension on the IV disk and fluid stasis - Rest in slight forward position lessens pain b/c space potential for nucleus pulposus

Management of Acute Symptoms
Extension
Lateral shift correction
Patient education
Lumbar traction - less 15' intermittent, 10 sustained
Joint manipulation
Kinesthetic training, stabilization, and basic functional activities
- Teach simple spinal movements
Basic stab techniques
Activities, i.e., walking
SLR maintain mobility nerve roots
Effects of isometric and dynamic exercise
Effects of muscle guarding
Indications, Precautions, and Contraindications for Interventions-Extension Approach

Management When Acute Symptoms Have Stabilized
Signs of improvement
- Increased motion, negative dural mobility
- reassess movements - shouldn't peripheralize
Intervention
- Following any flexion, perform extension
Interventions to Manage a Disk Lesion in the Cervical Spine
Acute Phase
Passive axial extension (cervical retraction)
Patient education
Traction - Sustained no longer than 10’, intermittent no longer than 15’
Kinesthetic training for posture correction
Progression as Symptoms Stabilize
Disc Lesions: Postoperative Management at different phases
Maximum Protection Phase
Patient education
Wound management and pain control
Bed mobility
Bracing
Exercise
Contraindications

Moderate and Minimum Protection Phase
Scar tissue mobilization
Progressive stretching and joint mobilization/manipulation of restricted tissue
Muscle performance - Initiate segmental -> global stabilization
Gait training
Contraindications - Extension exercises, prone press-ups
Management Guidelines: Flexion Bias
Principles of Management
Effect of position - educate patient
Effect of traction
Effect of trauma and repetitive irritation
Effect of meniscoid tissue
Indications and Contraindications for Intervention: Flexion Approach
After acute, manual traction, deep neck flexor strengthening
Pelvic tilt helps (do before worrying about drawing stomach in)
From deep to global -> functional

Management of Acute Symptoms
Rest and support
Functional position for comfort
Cervical traction
Correction of lateral shift
Correction of meniscoid impingements
Management When Acute Symptoms Have Stabilized

96 pts with cervical radiculopathy 90% success  manual therapy, traction, deep neck flexor strengthening
< 54 yrs old, dominant hand not affected, look down does not worsen symptoms, mm energy, traction, dnf
Management Guidelines:
Soft Tissue Injuries
Management During the Acute Stage: Protection Phase
Management During the Acute Stage: Protection Phase
Pain and inflammation control: modalities and passive support
Muscle function: Gentle muscle setting, Muscle in shortened position
Cervical region
-Reverse muscle action
- Scapular elevation, depression, adduction, Shoulder
Lumbar region

Traction
Environmental adaptation
Management in the Subacute and Chronic Stages of Healing: Controlled Motion and Return to Function Phases
Lower Thoracic and Lumbo-Pelvic Region - management of conditions
Compression Fracture Secondary to Osteoporosis - -flexion exacerbates
Spondylolisthesis - Anterior slippage one vertebra, related to one directly below
Ankylosing Spondylitis - stretching, patient education
Scheuermann’s Disease - HNP superior or inferior
Rib Subluxation
Sacraoiliac Joint Dysfunction
Sacraoiliac Joint Dysfunction
Identification of SI impairments
Interventions
Shot-gun technique
Muscle energy technique to correct an anterior rotated innominate
Muscle energy technique to correct a posterior rotated innominate
HVT to treat an upslipped innominate (doesn't respond to muscle energy)
Cervical and Upper Thoracic Region - management of conditions
Tension Headache/Cervical Headache
Etiology - Positional, gr occipital nerve, TMJ
Presenting signs and symptoms
General management guidelines - Pain managment
mobility

Red flags:
Worst HA life
Sharp pain w/ spikes
HA’s come in bunches
Change personality

Cervical Myelopathy
Neck Pain
TMJ - Principles of Management and Intervention
Principles of Management and Intervention
Reduction of pain and muscle guarding
Facial muscle relaxation and tongue proprioception and control
Control of jaw muscles and joint proprioception
Stretching techniques
Reduction of upper quarter muscle imbalances
Fundamental interventions for the spine
Definition: Exercises or skills that all patients with spinal impairments should learn….at the time of examination and initial intervention
Kinesthetic training - head nod, pelvic tilts
Stabilization training
Axial extension w/ craniocervical flexion
Draw-in maneuver and multifidus
Functional training of basic body mechanics
Log roll, supine to side-lying, sit to stand
Patient education for spine exercise

General exercise guidelines
Active Participation
Limitations at Each Stage of Healing
Safe Self-Management Instruction
Prevention

Kinesthetic Awareness
Mobility/Flexibility
Muscle Performance
Cardiopulmonary Endurance
Functional Activities
Progression to active and habitual control of posture
Use of Reinforcement
Verbal, visual, tactile
Simple to more complex, single to multiple tasks
Identify Any Need for Postural Support
Integrate Awareness of Postural Control
Body mechanics
Functional activities

gauge ability to engage deep stabilizers before progression
Guidelines for Stabilization Training
Train safe spinal movement
Activate deep stabilizing while neutral Zone, progress through levels
Add extremity to load superficial
Increase reps and load
Isometric and rhythmic stab - incorporate deep stabilizers
Progress movement
Unstable surfaces
Swimming is extension component - evaluate whether appropriate
The ability of the patient to control the spine in a neutral
or non stressful position is paramount for all exercises
Deep segmental muscle activation and training
Cervical
lumbar
Cervical Musculature
Deep neck flexors
- axial extension
-Capital flexion
-Flattening lordosis
-Flattening upper thoracic K
Lower cervical and upper thoracic extensor
Progression - prone

Lumbar Musculature
Drawing-in maneuver (abdominal hollowing exercise) for transverse abdominis activation
Abdominal bracing
Posterior pelvic tilt
Multifidus activation and training
Stabilizer - inflatable pressure cuff
Fold in 1/3 inflate 20 mmhg
Nod & increase pressure on cuff 22# 10”
Provided successful increase 24# -> 30#
Final is one patient holds for 10”
Endurance: how many 10 second holds
Stabilization Exercises for the Cervical Region
Stabilization Exercises for the Cervical Region
Stabilization with progressive limb loading
Variations and progressions in the stabilization program
Integration of stabilization exercises and posture training
Progression of isometric and dynamic strengthening in conjunction with
functional activities

Craniocerv flexion w/ axial ext
Sh flex 90˚
Sh abd 90˚
Sh ER
Sh flex end range
Sh abduct w/ ER
Diagnol patterns
Reaching
Pushing/pulling
Stabilization Exercises for the Lumbar Region
Stabilization Exercises for the Lumbar Region
Stabilization with progressive limb loading
Variations and progressions in the stabilization program
Quadratus lumborum: stabilization exercises
Progression to dynamic exercises
Common aerobic exercises and effects on the spine
Cycling - Thoracolumbar flexion and cervical hyperextension
Walking and Running - Lumbar extension
Stair Climbing - pelvic control
Cross-Country Skiing and Ski Machines -Spinal extension
Swimming - extension
Upper Body Ergometers - Forward/backward
Step Aerobics and Aerobic Dancing
Check Biomechanics