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145 Cards in this Set
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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 |
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Define contracture
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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 |
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Selective Stretching
Overstretching and Hypermobility |
Selective Stretching
Hypomobile structures to develop to improve function Overstretching and Hypermobility Hypermobility improves function in some circumstances |
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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 |
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Other interventions to increase mobility of soft tissues
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Neuromuscular Facilitation and Inhibition Techniques
Muscle Energy Techniques Joint Mobilization/Manipulation Soft Tissue Mobilization and Manipulation Neural Tissue Mobilization (Neuromeningeal Mobilization) |
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Indications for stretching exercises
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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 |
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contraindications for stretching exercises
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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 |
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Potential benefits/outcomes for stretching exercises
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Increased Flexibility and ROM
General Fitness Other Potential Benefits Injury prevention Reduced post-exercise soreness Enhanced performance |
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Contractile and Non-Contractile Tissue Changes
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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 |
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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 |
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While studies of muscle length changes with immobilization are largely limited to animal research, it is understood that
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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!! |
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Muscle Spindle:
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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 |
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Golgi Tendon Organ
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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 |
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How does knowledge of muscle spindle and GTO shape the way you stretch
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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 |
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Types of connective tissue
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Ligaments
Tendons Joint Capsules Fasciae Non-Contractile Tissue in Muscles Skin |
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Composition of Connective Tissue
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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 |
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Collagen
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Tropocollagen is basic element
Collagen microfibril Organized 6 classes; 19 types C Type I |
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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 |
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Regions of the Stress-Strain Curve
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Regions of the Stress-Strain Curve
Toe region Elastic range/linear phase Elastic limit Plastic range |
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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 |
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Time and Rate Influences on Tissue Deformation
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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 |
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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 |
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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! |
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determinants and types of stretching exercises
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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 |
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What effect did 3 repeated, 45-s stretches produce on viscoelastic properties in skeletal muscle?
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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. |
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In healthy adult human males who underwent passive stretching of the gastrocnemius,
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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 |
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What's the best method for stretching hamstrings?
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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 |
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Types of PNF Stretching
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Hold–relax and contract–relax
Agonist contraction Hold–relax with agonist contraction |
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Procedural guidelines for application of stretching interventions
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Examination and Evaluation of the Patient
Preparation for Stretching Application of Manual Stretching Procedures After Stretch Procedures |
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Precautions for stretching
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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 |
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Adjuncts to stretching interventions
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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 |
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ROM impairments can be...
(causes) |
systemic
neurological joint muscle surgical/traumatic inactivity/immobilization |
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Functional excursion
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distance a muscle can shorten after being elongated
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Types of Range of Motion (ROM) Exercises
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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) |
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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 |
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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 |
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Precautions and Contraindications to ROM Exercises
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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 |
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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 |
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Patient Preparation for ROM
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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 |
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Application of ROM Techniques
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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 |
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Application of PROM
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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 |
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Application of AROM
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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 |
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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 |
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Continuous Passive Motion (CPM)
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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 |
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Benefits of CPM
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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 |
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General Guidelines for CPM
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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 |
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ROM Through Functional Patterns
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Assists in teaching ADLs and IADLs
Helps patient realize purpose and value of ROM exercises Assists in developing motor patterns |
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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 |
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Overload Principle
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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 |
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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 |
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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 |
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“These data indicated that DT may induce larger declines in muscle strength than
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“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.”
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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 |
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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. |
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Influence of Muscle cross-section and size (fiber # and size) on force generation
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increase diameter = increase tension-producing capacity
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Influence of Muscle architecture – fiber arrangement/length on force generation
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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) |
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Influence of Fiber type distribution – type I (slow twitch) or type IIA & IIB (fast twitch) on force generation
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increase% type I = low force production; slow rate of achieving max force; fatigue resistant
Increase% type II = rapid, high force production; rapid fatigue |
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Influence of Length-tension relationship on force generation
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Greatest tension producing ability is near resting length
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Influence of Motor Unit recruitment on force generation
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Increase #, synchronization of MU firing = increase
Force production |
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Influence of Frequency of MU firing on force generation
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increasing frequency = increasing tension
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Influence of Type of muscle contraction on force generation
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Eccentric > isometric > concentric
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Influence of Speed of contraction (force-velocity) on force generation
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Concentric: increase speed = decreased tension
Eccentric: increased speed = increaed tension |
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Muscle fiber types
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Slow-twitch Red - S (slow)
(Type I) Fast-twitch Red - FR (fatigue resistant) (Type IIa) Fast-twitch White - FF (fast fatiguable) (Type IIb/IIx) |
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Human muscle fiber distribution
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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 |
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Neural Adaptations to resistance ex
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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 |
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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 |
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Physiological adaptation to skeletal muscle training
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Depends on the type of training
Depends on the intensity of training |
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Physiological adaptation to resistance exercise: neural and hypertrophy factors
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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 |
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Muscle hypertrophy and fiber type changes
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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 |
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Sample resistance exercise plan
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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 |
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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 |
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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) |
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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. |
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Indications for low intensity vs. high intensity exercise
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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 |
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Volume of resistance Ex
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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 |
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Exercise order, frequency, duration, and rest
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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? |
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Mode of Exercise
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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 |
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Characteristics of periodized training
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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 |
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Dynamic Exercise - Constant and Variable Resistance
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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 |
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Implementation of resistance exercises
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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 |
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Valsalva Maneuver
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Valsalva Maneuver
At-risk patients - history of Coronary Artery Disease, Myocardial infarction, Hypertension Prevention during resistance exercise - breathing education |
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Overtraining and Overwork
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Overtraining and Overwork
Overtraining Decline physical performance/capabilities Overwork Progressive deterioration of strength in muscles Neuromuscular disease-NON FATIGUING EXERCISES |
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Exercise-Induced Muscle Soreness
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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 |
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Pathological fractures
(considerations for resistance exercise) |
bone already weakened by disease
vertebra, hip, wrist, rib |
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Contraindications to resistance exercise
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Pain
Inflammation Severe Cardiopulmonary Disease |
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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 |
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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) |
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Functional Components of the Spine
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Anterior - weight-bearing
Shock –absorbing portion Posterior gliding mechanism Lever system for muscles |
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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 |
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In spine, Ipsilateral sidebend and rotation leads to...
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Ipsilateral sidebend and rotation-> foraminal closure
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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. |
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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. |
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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 |
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Muscle Control in the Lumbar Spine
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Abdominal Muscles
Transverse Abdominis Stabilization Activity (major player, stops kicking in in pathological processes.) Erector Multifidus Stabilization Activity Thoracolumbar (Lumbodorsal) Fascia |
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Global and deep segmental muscles
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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) |
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Why is transversus abdominus important?
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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 |
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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 |
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Role of Muscle Endurance and inactivity
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Inactivity has been shown to change muscle fiber composition, leading to decreased muscular endurance during sustained or repetitive activities
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Different effects on stability
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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 |
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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 |
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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 |
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Frontal Plane Deviations, Scoliosis, and LE Asymmetries
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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 |
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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 |
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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 |
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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. |
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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. |
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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 |
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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 |
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Structural vs. non structural scoliosis
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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 |
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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 |
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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. |
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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
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Impaired muscle performance - process and treatment
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Posture muscles -> succumb to gravity ->
develop stretch weakness Exercise Posture training Ex muscle endurance Environmental adaptations |
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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 |
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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 |
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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 |
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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) |
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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 |
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Pathomechanical Relationships of the Intervertebral Disk and Facet Joints
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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) |
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Common Diagnoses and Impairments from Facet Joint Pathologies
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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 |
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Scheuermann’s Disease
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Rare congenital/degenerative weakening
T10-L2, pulposus, vertical instead of out (protrusion), |
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What's the problem with muscle guarding?
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Mm guarding impairs function, Spinal stability
- depletes oxygen -> secondary muscle pain |
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How long does it take back pain to resolve?
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60% resolve within one week
90% resolve within 6 weeks |
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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 |
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Types of bias
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flexion
extension non-weight-bearing = feel better with traction, harness, pool People with a bias have better outcomes activity and movement education for everyone |
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General Guidelines for Managing Subacute Spinal Impairments: Controlled Motion Phase
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Pain Modulation
Kinesthetic Training Stretching/Manipulation Muscle Performance - stabilization -> wall slides -> dynamic Cardiopulmonary Conditioning Postural Stress Management and Relaxation Exercises Functional Activities |
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General Guidelines for Managing Chronic Spinal Impairments: Return to Function Phase
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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 |
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Management Guidelines: Extension Bias
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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 |
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Interventions to Manage a Disk Lesion in the Cervical Spine
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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 |
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Disc Lesions: Postoperative Management at different phases
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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 |
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Management Guidelines: Flexion Bias
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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 |
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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 |
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Lower Thoracic and Lumbo-Pelvic Region - management of conditions
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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 |
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Sacraoiliac Joint Dysfunction
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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) |
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Cervical and Upper Thoracic Region - management of conditions
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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 |
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TMJ - Principles of Management and Intervention
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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 |
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Fundamental interventions for the spine
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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 |
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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 |
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Progression to active and habitual control of posture
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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 |
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Guidelines for Stabilization Training
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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 |
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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 |
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Stabilizer - inflatable pressure cuff
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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 |
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Stabilization Exercises for the Cervical Region
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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 |
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Stabilization Exercises for the Lumbar Region
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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 |
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Common aerobic exercises and effects on the spine
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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 |