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240 Cards in this Set

  • Front
  • Back
List the "new" 6 goals of therapeutic exercise. ***
- balance/postural control/stability
- coordination
- cardiopulmonary fitness

- mobility (flexibility)
- muscle performance
- relaxation
In the "new" goals of therapeutic exercise, what constitutes balance/postural control/stability? ***
- ability to align body segments against gravity

- to maintain or move body within available BOS without falling

- ability to hold proximal or distal body part stationary

- perform superimposed movement
In the "new" goals of therapeutic exercise, what constitutes cardiopulmonary fitness? ***
- ability to perform low-intensity, repetitive, total body movements over extended period of time

- endurance
In the "new" goals of therapeutic exercise, what constitutes coordination? ***
- correct timing and sequencing of muscle firing

- accurate, efficient movement
In the "new" goals of therapeutic exercise, what constitutes mobility (flexibility)? ***
ability of structures to move (actively or passively) to allow ROM for functional activities
In the "new" goals of therapeutic exercise, what constitutes muscle performance? ***
- ability of muscle to produce tension and do work

- strength, power, endurance
In the "new" goals of therapeutic exercise, what constitutes relaxation? ***
- ability to release tension from muscles

- conscious effort and thought

- manual techniques
Definition of flexibility ***
- ability of a muscle to lengthen, allowing the joint(s) to move through a ROM. (Bandy & Sanders)

- ability to move joint(s) smoothly through unrestricted, pain-free ROM. (Kisner & Colby)
Definition of stretching ***
- any therapeutic maneuver designed to lengthen pathologically shortened ST structures and thereby to increase ROM (Kisner & Colby)

- pathology can range from mild to severe
(all of us probably have some limited ROM.)
Definition of hypomobility ***
decreased ability to achieve ROM; or restricted motion
Definition of contracture ***

*** from her review session
- adaptive shortening of ST around joint, resulting in significant resistance to stretch and limited ROM

-- name for action of shortened muscle
Definition of adhesions ***
adherence between collagen fibers, resulting in loss of normal mobility
What are scar tissue adhesions? ***
those adherences between collagen fibers that develop in response to injury and the inflammatory response
Definition of overstretching ***
stretching beyond normal range
What is a selective stretch? ***

*** from her review session
applying stretching techniques selectively to some muscles and joints but allowing limitation of motion to develop in other muscles or joints

(e.g., tenodesis action - not attempting to extend contractures of finger flexors to allow pt to form a hook)

- also dislocation, subluxation (how??)
What is elastic deformation? ***
when ST is stretched to new length, but returns to original length when stress is removed
What is plastic deformation? ***
upon prolonged, low degree of stress ST takes on new and longer shape

(also done with heat/thermal modalities)
Describe a muscle spindle ***
- sensory organ/proprioceptor (stretch receptor)

- responds to
1) change in muscle length, and
2) velocity at which length changes

- facilitated by quick stretch
How is a muscle spindle activated? ***
- by a quick stretch of muscle

- ends of intrafusal fibers connect to extrafusal fibers

- {Type Ia and II} afferent sensory nerves of intrafusal fibers stimulated (excited)

- afferent fibers send impulses to CNS

- CNS sends impulse to muscle (via alpha motor neuron)

- muscle contracts reflexively (protectively)

(e.g., testing reflexes at the knee)
What is a Golgi Tendon Organ? ***
- sensory receptor attached to fibers in the tendon at the junction of the tendon with extrafusal muscle fibers

- responds to change in tension of muscle-tendon unit via {type Ib} afferent fibers when the muscle
1) contracts, or
2) is passively lengthened
To what actions is the GTO sensitive? ***
- active muscle contraction - low threshold (more sensitive to this)

- passive stretch - high threshold
How is a GTO activated? ***
- muscle
1) contracts, or
2) is passively lengthened
(book says if stretched for prolonged time period or during isometric contraction)

- GTO fires {via type Ib afferents}

- {Ib} afferents send impulse to spinal cord

- excitation of Ib causes inhibition of alpha motor neuron

- muscle relaxes
(e.g., losing in arm wrestling—release to avoid tearing muscle, or a "negative" in weightlifting)
What is autogenic inhibition? ***
- stimulation of a muscle that causes its neurologic relaxation

- GTO overrides excitatory impulse

- causes relaxation

(i.e., maximum and sub-max isometric contraction of muscle causes increase in tension in the GTO, leading to GTO activation, which causes the muscle to relax)
What is reciprocal inhibition? ***
- in any synergystic muscle group, a contraction of the agonist causes reflextive relaxation of the antagonist (tight muscle)

- agonist muscle contracts

- antagonist (tight) muscle is inhibited

- allows smooth motion

(e.g., contract the biceps, and the triceps relax)
What are the characteristics of ST? ***
- contractile tissue (muscle)

- non-contractile tissue (tendons, ligaments, fascia)

- both have elastic and plastic qualities
Effects of immobilization on muscle tissue (contractile ST) ***
- if muscle is immobilized for a long period of time, muscle protein and number of sarcomeres decrease

- if muscle is immobilized in a lengthened position over a prolonged time, the number of sarcomeres will increase

(thus if immobilization is absolutely necessary, better to be in lengthened position??)
What happens when a stretch is applied to noncontractile ST? ***
the collagen bonds break (fail) and length increases
What is creep? ***
the permanent deformation of noncontractile ST when low load applied over extended time
Three basic types of stretching ***
- static
- dynamic
- Proprioceptive Neuromuscular Facilitation (PNF)
Types of static stretching ***
- passive

- active
Types of dynamic stretching ***
- active

- ballistic
Types of PNF ***
- contract-relax (CR) (similar to hold-relax but with original PNF style and a concentric contraction)
- hold-relax (HR) (autogenic inhibition)
- agonist contraction (AC) (reciprocal inhibition)
- HR w/AC (combination)
What is static stretching? ***
- muscle is slowly elongated to tolerance; then prolonged holding in this position

- to the point of mild tension, not pain
Differentiate active and passive static stretching ***
muscle is slowly elongated to tolerance; then prolonged holding in this position

- if active, self-controlled
- if passive, controlled by outside force (manual or mechanical)
How does static stretching affect muscle spindles and GTOs? ***
- slow, prolonged stretch minimizes effect of muscle spindle (reduces the reflex contraction)

- may facilitate GTO because it places tension on the tendon and may spur GTO to fire, relaxing the muscle for further stretching
How long should static stretches be held for? ***

(FOOT STOMP!!)
- 30 seconds in most cases

- 60 seconds if patient is over 65

(FOOT STOMP!!)
What is dynamic stretching? ***
- uses the force production of a muscle and the body’s momentum to take a joint through full available ROM;

- stretching while moving; prepares the body for physical exertion; sports
Two types of dynamic stretching ***
- active

- ballistic
What is ballistic dynamic stretching? ***
- repetitive bouncing
- 10 - 15 bounces, each one extending farther

- potential to cause injury; causes muscle spindle to fire (thus a protective contraction prior to the next, further bounce--ouch!!)

- controversial
- appropriate for some athletes
What is PNF? ***
Proprioceptive Neuromuscular Facilitation

- Hold-Relax (Autogenic Inhibition)
- Contract-Relax (similar to hold-relax but with original PNF style and a concentric contraction)
- Agonist Contraction (Reciprocal Inhibition)
Describe performance of Autogenic Inhibition (a.k.a. Hold-Relax) ***
Hamstring stretch example:

- PTA - moves pt's leg to SLR as high as possible (max ROM)

- Pt - isometrically contracts (pushes back) against resistance provided by PTA at proximal ankle and knee for 8-10 sec

- Pt then relaxes

- PTA - moves leg into greater hip flexion, increasing length of hamstrings (facilitates GTO) and holds for 10-15 seconds

- repeat cycle 3-5 times
Describe performance of Reciprocal Inhibition (a.k.a. Agonist Contraction) ***
Hamstring stretch example:

- PTA - moves extended leg into full SLR available ROM

- Pt - actively moves leg into greater flex [PTA may add mild resistance in opposing direction or goal ("kick my hand") for cue, sort of giving the pt something to push toward/against]

- PTA - maintains leg in new position and holds 10-15 seconds

- repeat cycle 3-5 times
Describe performance of Combination PNF (a.k.a. Hold-Relax with Agonist Contraction) ***
Hamstring stretch example:

- PTA - moves extended leg to full SLR, max ROM

- Pt - isometric contraction against resistance for 8-10 seconds

- Pt - actively moves leg with agonist contraction to greater flexion ("touch your toes to my hand....")

- repeat cycle 3-5 times
What are some clinical guidelines for stretching? ***
- warm up and cool down

- stretch exactly opposite muscle restriction

- stabilize proximal

- stretch distal before proximal (puts less force/compression on joints)

- should not be painful

- be mindful of speed
---- static stretch should be slow; force gradually applied and released
---- dynamic stretch should be “mindful & aware” (Stetz)

- stretch within reason
Describe Ehlers-Danlos Syndrome ***
- inherited connective tissue disorder

- defect in synthesis of collagen – too much elasticity

- affects skin, muscles, ligaments, blood vessels, viscera

- can be mild to life-threatening

- no cure; just support
Important points for stretching geriatric patients ***
- muscle extensibility and strength decrease with age

- warm-up more important

- base stretching program on functional needs

- milder stretching

- hold stretches for 60 seconds if 65 or older
Important points for stretching pediatric patients ***
- children are more flexible than adults

- no ballistic stretching because of strain at apophyses and epiphyses
Precautions for stretching (other than pediatric/geriatric patients) ***
- recent fx
- osteoporosis
- weak muscles
- edematous tissue

- do not stretch beyond normal ROM
- be mindful of intensity (high-intensity)

- if soreness lasts > 24 hours
Duration and frequency of stretching? ***
duration
- hold for at least 30 seconds
- hold for at least 60 seconds if over 65

frequency
- 2-5 times per week
Muscle performance ***
- capacity of a muscle, or group, to do work

- 3 elements:
---- strength
---- power
---- endurance
Three elements of muscle performance ***

*** from her review session
- strength
- power
- endurance
Resistance training may incorporate.... ***
- strength
- power
- endurance

(or any combination of these)
What is "strength"? ***

*** from her review session
- maximum force a muscle or muscle group can exert during a contraction (Bandy & Sanders)

- maximal voluntary force that can be produced by the neuromuscular system, usually demonstrated by the ability to lift a maximal load one time, called the one-repetition maximum (Bandy & Sanders)

- the ability of muscle to produce tension & resultant force based on demands placed upon it (Kisner & Colby)
How is strength increased? ***
by resistance training

- heavy load
- low number of repetitions
- short time period
What is "power"? ***

*** from her review session
- rate of doing work (performing muscular contractions) over a specific amount of time

(work/time)

or
(force X distance)/time
[(mass X acceleration) X distance]/time

- related to strength and speed of movement

(example used of unloading a truck)
What is anaerobic power? ***
a single burst of high-intensity activity
What is aerobic power? ***
repeated bursts of less-intense activity
How is power increased? ***
- increasing the amount of work a muscle must perform in a given time, or

- decreasing the amount of time required to produce a given force
What is "endurance"? ***

*** from her review session
- the ability of a muscle or group to perform repeated contractions

- sometimes used interchangeably with aerobic power
With what other term is "endurance" sometimes used interchangably? ***
aerobic power
How is endurance increased? ***
- low loads
- high repetitions
- long time periods
Exercise muscle actions ***
- isometric (contraction with no change in muscle length)

- isotonic (concentric & eccentric)

- isokinetic (concentric & eccentric)
What is concentric muscle contraction? ***
shortening of the muscle against resistance

(muscle performs work on resistance)
What is eccentric muscle contraction? ***
- lengthening of the muscle against resistance

(resistance performs work on the muscle)
Production of force by concentric, eccentric, and isometric maximal contractions ***
- eccentric maximum contraction produces more force than

- isometric maximum contraction, which produces more force than

- concentric maximum contraction

E > I > C

- eccentric muscle action can produce about 30% more force than concentric actions
- concentric muscle actions take more energy to perform
- strength gains between the two types are similar, however
What is the force-velocity relationship in a(n): ***
- concentric contraction?
- eccentric contraction?
- concentric contraction - muscle tension decreases as velocity increases

- eccentric contraction - muscle tension increases as velocity increases
(theory is that this produces optimal actin-myosin overlap and creates increased muscle tension)
Is the force-velocity relationship directly proportional or inversely proportional for ***
- concentric contractions?
- eccentric contractions?
- inversely proportional

- proportional
Anatomy of a muscle fiber ***
- muscle fiber = muscle cell

- covered by endomysium

- composed of myofibrils

- myofibrils comprised of actin and myosin microfilaments
What causes muscle contractions? ***
- motor unit (the alpha motor neuron and all the muscle fibers it innervates)

- alpha motor neuron stimulates the muscle fibers and the actin and myosin microfilaments create crossbridges and shorten the sarcomeres
What is a motor unit? ***
- the functional unit of muscle

- a single motor cell (motor neuron--with body contained in anterior horn of spinal cord), plus

- its axon and terminal branches, and

- all muscle fibers supplied by the axon (5-100 or more)

(an alpha motor neuron and all the muscle fibers it innervates)
What affects strength of muscle contraction? ***
- motor unit recruitment
---- number of motor units recruited (multiple motor unit summation) and
---- frequency of stimulation (wave summation) (twitch, vermicular, tetanic)

- cross section (larger = more tension) and fiber orientation (pennate produces more force than fusiform)
Three muscle fiber types ***
Slow-twitch (Type I - red oxidative - SO)
-- Less tension, slow to fatigue
-- Primarily for endurance

Fast-twitch--fatigue resistant (Type IIa - FOG)
-- Fast oxidative glycolytic
-- Rapid contraction; slow to fatigue

Fast-twitch--fast fatigable (Type IIb - FG)
-- Fast glycolytic
-- Rapid contraction, fatigue quickly
What are some physical adaptations made by the body in response to resistance training? ***
- Neural adaptation - learned changes in the nervous system (motor unit better able to activate muscle via multiple motor unit summation and wave summation)
----- increase in strength manifests before the hypertrophy

- Hypertrophy - in 2-8 wks (Kisner & Colby, p. 158)
----- increased fiber size (vs. hyperplasia-increase in # of fibers)
----- adults with no training lose 5-7 lbs muscle per decade

- Metabolic rate increase
----- adults with no training lose 2% - 5% of metabolic rate per decade (because muscle is active tissue)

- Body composition - decreased fat with weight training

- Bone mineral density increases with weight training

- Strength of bone, tendons, ligaments and fascia increases with weight training

- Glucose metabolism increases

- Resting blood pressure decreases

- Blood lipid levels show improved profile

- GI transit time increases
Describe exercise "dosage" ***
dosage - general term for how much; can be modified in many ways

- mode (method of exercise; e.g., tubing or free weights)
- repetitions
- sets - given # of reps & rest
- duration - # of sets & rest between

- frequency - how often
- volume - reps x resistance
- rest intervals
What is overload? ***
- increase in training load that leads to adaptation in muscle

- causes fatigue; the body recovers and adapts to overcompensate and increase fitness
How are intensity and volume quantified? ***
- intensity = quality of effort - internal effort, VO2 max, lbs/lift

- volume = quantity of effort - total amt lifted, total miles run

intensity and volume of training are integrally related and depend upon each other at all times
What is specificity of training? ***
training should be specific to required activity for optimal benefits;

general training should precede specific training
Which should come first, general or specific training? ***
general training should precede specific training
What is the benefit of cross training? ***
training in one mode may provide some transfer effects, (but has limited cross-over and is inefficient for increasing performance capacity)
What is overtraining? ***
- training loads that are too demanding, leading to fatigue, substitution, injury, performance deterioration, burn-out

- can also cause depression, chronic fatigue, anorexia, weight loss, insomnia, decreased libido, increased blood pressure, muscle soreness

- can address by providing break periods, changes in routine
What is periodization? ***
- advanced resistance training

- a training plan that changes the workout sessions at regular time intervals (gradual cycling of specificity, intensity, and volume)

- helps to achieve optimal development of performance and prevent plateaus
Precautions for resistance training ***
- pain
- inflammation

- overtraining/overwork
- acute muscle soreness
- DOMS

- fractures
- cardiopulmonary disease

- incorrect breathing during exertion (in general, exhale during lift)
- substitute motions
What is DOMS? ***
delayed-onset muscle soreness

- usually occurs within 48 hours after exercise, usually resolving within 72 hours

- can last up to 1 week (eccentric mostly)

- marked by edema, loss of active ROM, decreased ability to produce force

- believed to be due to microtrauma to muscle and connective tissue
(as the lactic acid and muscle spasm theories are now out of favor)
What are the three theories behind DOMS? ***
- microtrauma to muscle & connective tissue ******

- lactic acid theory (X – old theory out of favor)

- muscle spasm theory (X – old theory out of favor)
Why is recovery time necessary after resistance training? ***
to avoid performance plateaus or deterioration
ACSM recommendations for resistance training exercise ***
- minimum of 8-10 exercises that train the major muscle groups
- perform one set of 8-12 repetitions to point of volitional fatigue
- more sets may elicit slightly greater strength gains, but additional improvement is relatively small

- perform exercises at least 2 days per week
- more frequent training may elicit slightly greater strength gains, but additional improvement is relatively small
- workouts should not be too long (> 1 hour are associated with high dropout rates)

- adhere closely to the specific exercise techniques
- perform exercises through the full ROM
- perform exercises in a controlled manner

- maintain a normal breathing pattern
- exercise with a training partner when possible (they can provide feedback, assistance, and motivation)
- elderly trainees should perform exercises in the maximum ROM that does not elicit pain or discomfort
Strength increases in both genders linearly with chronological age until.... ***
age 14
What is open kinematic chain (OKC) exercise? ***
exercise in which the terminal segment is free to move

(e.g., biceps curl)
What is isometric exercise, and when is it used? ***
- exercise in which tension is generated but the muscle remains the same length (e.g., muscle setting)

- limited carry-over in function, but can be very beneficial if no other exercises are tolerated
How is isometric exercise implemented? ***
- hold 6-10 seconds - more research needed for ideal

- for strength gains - at least 50% (of what, maximum possible contraction??) - more research needed for ideal

- multiple angle - strength gains in adjacent 30° ROM, with more ROM transfer when performed in lengthened position (thus it may make sense to exercise the muscles in the lengthened position)
What is isotonic exercise? ***
literally means, “same tension,” but this is a misnomer since tension does change as length changes through full ROM due to changes in muscle length, angle of pull, and horizontal distance from resistance to joint axis

(the weight/resistance does not change--i.e., lifting the same barbell, dumbbell) better to think of it as "same weight"

dynamic change in length
- concentric (muscle shortens during activity)
- eccentric (muscle lengthens during activity)

most functional activities use both actions
Two types of isotonic exercise ***
- same resistance - variable speed
(cuff weights, dumbbells, wall pulleys)

- variable resistance- variable speed, using:
----- equipment (e.g.,Universal, Nautilus, Body Masters)
----- elastic resistance (e.g., Theraband)

also same resistance--same speed?
How is the length-tension relationship affected through the entire ROM of a muscle contraction? ***
- strength of active tension is optimal at resting length
[muscle's active length-tension force is greatest at midrange
(e.g., 70-80 degrees of elbow flexion) and least at both extremes due to optimal crossbridge formation--see pp. 42-43 of "Essentials of Kinesiology for the PTA"]

- strength of passive tension is optimal at slightly elongated length (1.2) and decreases as muscle is shortened or lengthened

- more tension at mid-range
What is a moment arm? ***
the perpendicular distance between axis of motion and line of action of muscle
The greater the moment arm...***
the greater the force produced by the muscle
What is isokinetic exercise? ***
- same speed, variable resistance
(Kin-Com, Lido, Biodex, Ariel)
- easy quantification of pt info (peak torque, work, and power)

- protocols usually include different velocities

- stimulate maximal contraction of muscle throughout full ROM (compensates for changes in muscle length and angle of pull)
- allows high speed of contraction
Clinical guidelines for isometric exercise ***
- most often in early stages of rehabilitation
- can still be of benefit, even if done submaximally

6-10 second contractions
multiple reps
lengthened position

- can be done daily if no increase in symptoms, otherwise alternate days
What are some benefits of isotonic exercise? ***
- low cost

- varied equipment
Describe the DeLorme protocol for PRE ***
- find 10 repetition maximum

- do 10 reps of 50%
- then 10 reps of 75%
- then 10 reps of 100%
Describe the Oxford protocol for PRE ***
- opposite of DeLorme

- find 10 repetition maximum

- do 10 reps of 100%
- then 10 reps of 75%
- then 10 reps of 50%
What is closed kinetic chain exercise? ***
- terminal segment of limb is fixed while supporting some of the body weight
(e.g., squat, push-up)

OR

- joints (links) connected; and movement of one link causes motion at other links in a predictable wa.
[e.g., pull-up (Lippert)]

most activities are a combination of both
Are most exercises OKC or CKC? ***
most are a combination of or have characteristics of both types, especially those involving the upper extremity kinetic chain
What is the physiological basis for CKC? ***
- re-establish proprioception (muscle spindles, GTOs, Pacinian corpuscles)

- induce co-contraction/force couples
- improve stabilization, joint approximation

- improve reflex stabilization
- improve dynamic control

- stimulate mechanoreceptors, closing pain gate
What is a Colles'/Smith's fracture?
fracture of the distal radius
What is one of the most commonly seen wrist fractures?
Colles' (Smith's) fracture
Difference between Colles' and Smith's wrist fractures?
Colles' - distal fracture fragment displaced dorsally, wrist extended on impact; mostly older (female) patients

Smith's - distal fracture fragment displaced ventrally, wrist flexed on impact; mostly younger patients
Primary cause of Colles'/Smith's fractures?
FOOSH

fall on outstretched hand
What is RSD and how is it treated?
Reflex Sympathetic Dystrophy
- extreme sensitivity to touch
- reduced grip strength
- reduced ROM all directions
- tissue swelling
- cool, clammy skin

treated with scrub and carry protocol (alternating compression and distraction)
Physical therapy progression for treatment of Colles'/Smith's fractures
- AROM of fingers, elbow, shoulder in cast
- PROM and isometrics after cast removal, progressing to
- AROM/intrinsic hand muscle exercise
- strengthening, and
- functional activities
Outlook for Colles'/Smith's fractures
- malunion of fracture ("dinner fork" deformity) common

- stiffness and ache at joint may be permanent, especially in older patients

- full recover takes at least a year
What is adhesive capsulitis?
- joint capsule of shoulder becomes inflamed, thickened, and/or scarred and bones of shoulder unable to move freely

- pain in shoulder and loss of motion due to inflammation

- worse at night and in cold weather
Risk factors for adhesive capsulitis
- shoulder injury/surgery
- diabetes
- open-heart surgery
- hyperthyroidism
- cervical disk disease of the neck
Signs and symptoms of adhesive capsulitis
- decreased ROM in shoulder
- pain in shoulder (dull, aching)
- stiffness in shoulder
Development of adhesive capsulitis
Three stages
- painful stage - pain with any movement of shoulder; limited ROM

- frozen stage - more stiffness and more loss of ROM

- thawing stage - ROM improves
Tests for adhesive capsulitis
none specifically

- X-rays can rule out arthritis
- MRI can show inflammation
- doctor can check ROM, and move arm for you to distinguish between frozen shoulder and rotator cuff injury
Treatment for adhesive capsulitis
- stretching exercises to maintain mobility and increase ROM (therapy may be intense, but needs to be done daily)

- may include massage therapy; US, e-stim, cold packs can also be used

- joint distension - injecting sterile water into joint to stretch tissue and increase ROM

- NSAIDs, cortisone injections, OTC drugs

- surgery

- no heavy lifting, sudden jerking with that shoulder
Cause of carpal tunnel sydrome
- pressure on median nerve
What is the most common entrapment neuropathy?
carpal tunnel syndrome
Signs and symptoms of carpal tunnel syndrome
- gradual onset with burning or tingling

- fingers may feel swollen and useless

- pain at night may occur, with feeling on awakening of needing to "shake out" the wrist

- weakness in grip and fine finger coordination

- extreme chronic/untreated cases may result in wasting of muscles at base of thumb and loss of ability to distinguish hot/cold
Tests for carpal tunnel syndrome
- Tinel's sign - tap median nerve at wrist; pain shoots into hand

- Phalen's test - flex wrist completely for 60 seconds to determine if it causes numbness, tingling, or weakness

- electromyography - helps distinguish muscle weakness due to injury of a nerve from muscle weakness caused by neurologic disorder; can check nerve conduction velocity to assess damage to nerve

- wrist x-rays to rule out arthritis or other issues
Causes of carpal tunnel syndrome
- repetitive hand/wrist motions
- often congenital, some have small carpal tunnels
- prior trauma/injury to wrist
- associated with RA and thyroid disease
- pregnancy due to fluid retention

- females 3 times more likely to develop due to smaller carpal tunnels
- most common in ages 30-60
Treatment for carpal tunnel syndrome
- splints - night only at first; if not helpful, daytime as well
- workplace adjustments - reduce stress on wrist (keyboards, mouse pads, etc.)
- corticosteroids or lidocaine injections
- OTC drugs to help with inflammation (aspirin, NSAIDs)

- yoga has been shown to reduce pain and improve grip
- exercises to prevent/relieve pain (wrist circles, forearm exercises, wrist stretches)
- surgery - carpal tunnel release (cuts transverse ligament to enlarge carpal tunnel); open release surgery or endoscopic surgery
Upon what does success of carpal tunnel syndrome surgery usually depend?
- how long the nerve has been compressed

- severity of compression
Prognosis for carpal tunnel syndrome
symptoms often improve with treatment, but over 50% of cases eventually need surgery

- surgery is often successful, but full healing can take months
What is De Quervain's disease?
- degeneration and progressive stenosing tenosynovitis of tendon sheaths of APL and EPB

- often accompanied by entrapment or irritation of superficial radial nerve
What is the most common tendinitis of the wrist?
De Quervain's disease
Etiology of De Quervain's disease
- usually gradual onset of pain, but may be caused by trauma
- repetitive overuse in activities involving overexertion of thumb, radial deviation, ulnar deviation, simultaneous thumb and wrist movements (e.g., painting, golfing, fishing, typing, sewing)

- arthritis is also predisposing factor
- wristwatches and handcuffs may irritate nerve
Signs and symptoms of De Quervain's disease
- main complaint is wrist pain near radial styloid
- may radiate up forearm or into thumb
- ulnar deviation is limited and painful
- area is tender and swollen
Tests for De Quervain's disease
Finkelstein's test - pain on ulnar deviation
Treatment of De Quervain's disease
acute
- conservative PRICE
- NSAIDs
- modify ADLs, CP, PW US, iontophoresis

subacute and beyond
- mild stretching radial wrist and forearm
- soft tissue mobilization, including radial nerve stretches
- HEP to include radial nerve stretch
- education to prevent injury and aggravating positions/activities

if persistent, patient may benefit from
- corticosteroid injection or
- surgery to release roof of tendon tunnel, removing friction between tendons and tunnel
Description of lateral epicondylitis
- "tennis elbow"
- pain at lateral elbow (lateral humeral epicondyle)
- may radiate down posterior forearm
- affects muscles associated with wrist extension, supination, and radial deviation

- gradual onset
- 4-7 times more common than medial epicondylitis
Description of medial epicondylitis
- "golfer's elbow"
- pain at medial elbow (medial humeral epicondyle)
- may radiate to forearm and wrist
- affects muscles associated with wrist flexion and pronation

- usually gradual onset, but may be sudden
- 10-20% of all epicondylitis diagnoses
Etiology of lateral epicondylitis
- varus stress
- inflammation of tendons at lateral elbow
- microscopic tearing can lead to macroscopic tearing and failure of ECRB

work or physical activity
- poor technique/training/equipment
- tools > 2.2 pounds
- handling loads over 44 pounds 10+ times daily
- repetitive movement > 2 hours daily
Signs and symptoms of lateral epicondylitis
- pain at lateral elbow
- stiffness and diffuse aching
- tender on palpation (ECRB, ECRL)
- increased pain with supination, handshaking, gripping
- frequently dropping objects held in pronated position
- pain worsens with stabilizing or moving wrist with force
Etiology of medial epicondylitis
- valgus stress
- inflammation of tendons at medial elbow
- usually begins as microtear
- development of fibrotic and inflammatory granulation tissue
- most common site is between origins of FCR and pronator teres; sometimes includes palmaris longus, FCU and FDS to lesser extent
Signs and symptoms of medial epicondylitis
- pain on medial aspect of elbow and/or forearm and wrist
- inflammation
- wrist and grip weakness
- numbness/tingling into fingers (typically 4th and 5th phalanges)
- stiff elbow
Management of lateral/medial epicondylitis
- decrease inflammation/pain (cryotherapy, phono/iontophoresis, e-stim, US, NSAIDs, injection)
- promote tissue healing (PRICE, avoid painful movement, friction massage)

- increase flexibility
- increase strength/endurance
- increase functional activities and return to function
What is glenohumeral instability?
- inability to maintain the humeral head centered int he glenoid fossa

- dislocation, subluxation, or apprehension

- three types (anterior, posterior, or multidirectional)
Which form of glenohumeral instability is the most common?
anterior instability--accounts for approximately 85% of all shoulder dislocations
What is anterior glenohumeral instability?
- head of humerus displaced anterior to glenoid fossa

- main cause is trauma; combination force of abduction, extension and external rotation

- most common (85%)
What is posterior glenohumeral instability?
- humeral head displaced posteriorly, behind glenoid fossa

- main causes are seizures and electrical shock which cause forceful contractions of internal rotators

- uncommon due to frequent misdiagnosis
What is multidirectional glenohumeral instability?
- general laxity of the ligaments surrounding shoulder joint

- excessive mobility in all directions (anterior, posterior, inferior)

- also known as atraumatic shoulder instability
What is another name for multidirectional glenohumeral instability?
atraumatic shoulder instability
Etiology of glenohumeral instability
traumatic or

atraumatic
- joint laxity due to repetitive activities
- congenital - loose ligaments, abnormally shaped bones
- seizures
Signs and symptoms of glenohumeral instability
- pain
- numbness/tingling of involved arm/hand
- "dead arm syndrome" - decreased ability and/or weakness of the involved arm
- muscle guarding
- apprehension
- objective tests
- x-ray
Diagnosis of glenohumeral instability
- various tests for laxity and apprehension

- x-rays to verify dislocation
Treatment of glenohumeral instability
three phases of treatment

- protective - immobilization and physical agents

- mobility - PROM, AROM

- strengthening - chiefly of muscle groups responsible for preventing further instability (rotator cuff, horizontal abductors/adductors, scapular stabilizers)
What is a Bankart Lesion?
tearing of the labrum associated with glenohumeral instability
Description of impingement syndrome
- tendons of rotator cuff muscles or bursae are irritated, inflamed, or degenerated

- tendons insert on humerus, which does not have enough space to clear the acromion
Etiology of impingement syndrome
- subacromial spurs
- type 2 and type 3 acromions (shapes which give smaller acromioclavicular roof)
- osteoarthritic spurs of AC joint (includes subacromial spurs)
- thickened or calcified coracoacromial ligament
- loss of (balanced pull of) rotator cuff causing superior migration of humerus
- anterior or posterior capsular contractures (adhesive capsulitis)
- thick subacromial bursa
Signs and symptoms of impingement syndrome
- general achy pain in shoulder and upper arm
- weakness and pain in performing over-the-head activities (e.g., combing hair)
- pain at night that impacts sleep
What is a Neer's test?
- test for impingement syndrome

- patient internally rotates and flexes shoulder

- pain = positive test
Management of impingement syndrome
- acute: PRICE, NSAIDs, PW US, lidocaine injection, pendulums (if tolerated)

- sub-acute: pendulums, pulleys, decompression, strengthening of rotator cuff, CW US

- HEP: pendulums, pulleys, jobe's (13 shoulder exercises), towel glides
Surgery for impingement syndrome
- when non-operative treatment hasn't worked
- can enlarge space beneath acromion to allow tendon sto glide freely (acromioplasty)
- arthroscopic procedure
Muscles comprising the rotator cuff
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
Purpose of rotator cuff
provide the muscular force to keep the humeral head firmly in the glenoid fossa
Which tendon is most frequently torn in rotator cuff injuries?
supraspinatus (but others can tear as well)
Supraspinatus tendon tears frequently occur in conjunction with/due to:
impingement syndrome
How are partial rotator cuff tears treated?

Full rotator cuff tears?
partial
- tend to recur
- may be treated w/o surgery (although if > 50% torn, usually requires surgery)

full tear
- may be less painful than partial tear
- needs surgery
Etiology of rotator cuff tears
- overuse (esp overhead, e.g., painting)
- heavy lifting (esp overhead)

- trauma (sports--more youth, falling--FOOSH)

- aging (>40 - collagen breakdown; >60 - highest injury rate)
- poor posture/weak muscles
Signs and symptoms of rotator cuff tears
- shoulder pain - mild to severe during ADLs, difficulty sleeping on affected side

- weakness
- loss of motion
- crepitation (popping or grinding)
- swelling
Management of rotator cuff tears
minor - usually lasts a few days
- rest, ice, NSAIDs
- gentle stretching/ROM

pain in excess of 1 week
- 4-6 weeks PT
- HEP
- corticosteroid injection
- education

several months of pain
- surgery may be needed
Surgery for rotator cuff tears
- significant pain/dysfunction after several months of conservative treatment
- repeated dislocation of unstable joint
- complete tear
- young athlete (heal faster and more fully due better vascularity)

those over 40 usually heal better with nonsurgical intervention, unless full thickness tear

post-surgical physical therapy program until healed
What is thoracic outlet syndrome?
- a group of disorders that occur when the blood vessels or nerves in the thoracic outlet — the space between the clavicle and first rib — become compressed

- can cause pain in shoulders and neck and numbness in fingers
Three types of thoracic outlet syndrome
- neurogenic (neurological) thoracic outlet syndrome

- vascular thoracic outlet syndrome

-nonspecific-type thoracic outlet syndrome
Description of neurogenic (neurological) thoracic outlet syndrome
- characterized by compression of the brachial plexus (nerve network controlling movement/sensation in shoulder, arm and hand)

- in the majority of thoracic outlet syndrome cases, the symptoms are neurogenic
In the majority of thoracic outlet syndrome cases, the symptoms are:
neurogenic
Description of vascular thoracic outlet syndrome
one or more of the arteries and veins under the clavicle are compressed
Description of nonspecific-type thoracic outlet syndrome
- a.k.a. disputed thoracic outlet syndrome or common thoracic outlet syndrome

- some doctors do not believe it exists, while others say it is a common disorder

- patients have chronic pain in the area of the thoracic outlet that worsens with activity, but the cause of pain cannot be determined
Other names for nonspecific-type thoracic outlet syndrome
- disputed thoracic outlet syndrome or

- common thoracic outlet syndrome
Symptoms of neurogenic (neurological) thoracic outlet syndrome
- wasting in the fleshy base of the thumb (Gilliatt-Sumner hand)

- numbness or tingling in fingers
- pain in shoulder and neck

- ache in arm or hand
- weakening grip
Symptoms of vascular thoracic outlet syndrome
- bluish discoloration of the hand
- blood clot under the collarbone (subclavian vein thrombosis)

- arm pain and swelling, possibly due to blood clots
- throbbing lump near your collarbone

- lack of color (pallor) in one or more fingers or the entire hand
- weak or no pulse in the affected arm
- tiny, usually black spots (infarcts) on fingers
Causes of thoracic outlet syndrome
- anatomical defects
- poor posture

- trauma
- repetitive activity

- pressure on joints
- pregnancy
Nonsurgical treatments for thoracic outlet syndrome
- physical therapy to strengthen muscles supporting clavicle and improve posture

- NSAIDs

- weight loss
- lifestyle changes/workplace adjustments
Surgical treatments for thoracic outlet syndrome
- if physical therapy doesn't improve symptoms

- may remove a rib (or a portion of it) or specific muscles

- may reroute blood vessels around the compression
Prevention of thoracic outlet syndrome
- don't carry heavy bags over the shoulder--this depresses the clavicle and increases pressure on structures in thoracic outlet

- keep shoulder muscles strong and watch posture
Definition of loss of flexibility
a decrease in the ability of the muscle to deform, resulting in decreased ROM about a joint
Benefits of enhanced flexibility
- reduced risk of injury
- pain relief
- improved athletic performance
Differentiate between intrafusal and extrafusal muscle fibers.
- intrafusal fibers are specialized fibers within the muscle spindle

- extrafusal fibers are ordinary skeletal muscle fibers
Contrast the muscle spindle and the GTO
- spindle responds to a quick stretch and causes protective contraction

- GTO responds to isometric contraction (and prolonged passive stretch) and causes muscle to stretch/relax
Most important thing to remember with PNF
you need to know which is the antagonist (the tight muscle)

if patient is unable to flex, the extensors are tight

if patient is unable to abduct, the adductors are tight

if the patient is unable to externally rotate, the internal rotators are tight

and vice versa
Which type of stretching has the greatest potential for trauma?
ballistic
What should the patient do if, during a static stretch, the mild tension subsides (i.e., the GTO fired and the muscle has relaxed)?
change position/increase stretch to achieve a more aggressive stretch and to feel the mild pull or tension again
How can the PT/PTA enhance patient compliance with a home static stretching program?
integrate it into the patient's daily activities (on the phone, at the desk, in the car, in line at the grocery store, etc.)
If possible, the muscle to be (static) stretched should be
isolated

isolating the muscle is more effective than performing a general stretch that works 2-3 mucles (e.g., toe touch)
What can happen if the patient (static) stretches past the point of mild tension into painful ROM?
- muscles will actually tighten

- aggressively stretching tight muscles can lead to microscopic tears, which may lead to formation of inelastic scar tissue

- scar tissue will not adapt to normal demands made on the muscle, leading to injury caused by lack of blood supply and disturbed afferent input
In which portion of the body is easier to isolate muscles for more effective static stretching?
lower extremities (and neck)

stretches for the upper extremities and trunk are more generalized as it is difficult to isolate muscles
What causes age-related connective tissue stiffening?
- decrease in water content of tissue
- increase in collagen bundling
- increase in elastin crosslinks

result in decrease in distensibility and tensile strength of muscles, fascia, tendons, skin, and bones
How is strength assessed?
in terms of
- force (mass X acceleration)
- torque (rotational work)
- work (force X distance) and
- power (work/time)
What is force?
that which causes change in an object's motion

mass X acceleration
What is torque?
the concept of rotational work compared with the idea of force as linear motion

angular velocity, or displacement around an axis at the rotational speed
What is work?
force X distance
(mass X acceleration) X distance

the product of the force exerted on an object and the distance the object moves in the direction of the force
Where do muscle fibers begin and end?
they do not all run through the entire length of the muscle, or even through a fasciculus

they can
- begin in the periosteum and end in the muscle
- begin in the tendon and end in the muscle
- begin and end in the muscle
Because the muscle fibers do not run the full length of the muscle, what needs to happen to transmit the force of muscle contraction?
connective tissue sheaths (endo/peri/epimysium) must transmit the force of muscle contraction from fiber to fiber, then to fasciculi, and on to tendons which then act on bones
What makes up the contractile element of a muscle?
actin and myosin filaments
What is sarcolemma?
the membrane which encases the myofibrils
What is an innervation ratio?
the total number of motor axons divided by the total number of muscle fibers in a muscle

- muscles involved in delicate or intricate movements have lower ratios (like 1:4)

- muscles involved in larger, gross motor or postural movements have higher ratios (1:150)
How does a motor unit contract only a portion of the fibers it innervates?
it cannot

the motor unit operates on an "all or none" principle, thus all fibers contract and exert force or none of them do

they also contract completely or not at all
During submaximal efforts, muscular contraction is obtained by using a combination of:
- multiple motor unit summation
and
- wave summation
How do multiple motor unit summation and wave summation work together to produce a
- weak contraction?
- strong, but submaximal, contraction?
- only one or two motor units contract at only 2-3 times per second, with the contractions spread one after another among different motor units to achieve a tetanized state

- more motor units work simultaneously and fire more frequently
Asynchronous vs. synchronous firing of motor units
- asynchronous - fewer motor units fire out of phase and less frequently to produce weaker contraction

- synchronous - majority of motor units discharge together at maximal frequency (tetanic)
Characteristics of SO, FOG, FG muscle fibers
- diameter
- muscle color
- capillary bed
SO............FOG............FG
small .....intermed.......large
red............red.............white
dense.....dense.........sparse
Characteristics of SO, FOG, FG muscle fibers
- myoglobin content
- mitochondria
SO............FOG............FG
high.......intermed.........low
many.......many.............few
Characteristics of SO, FOG, FG muscle fibers
- speed of contraction
- rate of fatigue
SO............FOG............FG
slow...........fast............fast
slow........intermed.......fast
Characteristics of SO, FOG, FG muscle fibers
- motor unit size
- conduction velocity
SO............FOG............FG
small....intermed/lg.....large
slow...........fast.............fast
Immobilization leads to muscle atrophy, but which is more pronounced, loss of muscle mass or loss of function?
loss of function
Endurance exercise improves cardiovascular fitness, but does not prevent
loss of muscle tissue
OKC and CKC exercises produce markedly different...
- muscle recruitment and

- joint motions
Most human movements contain a combination of what types of motion?
OKC and CKC motion
To realize meaningful results while observing the law of specificity, exercises should be performed near the absolute intensity limit only....
55-60% of the total training time during preparation period

(intensity is increased to 80-90% during competitive period)
Progress for the beginner is demonstrated by a linear increase in
intensity (quality) and
volume (quantity)
At the elite level, linear increases in intensity and volume will not yield desired results and ____ ____ may be required to stimulate further improvement.
load leaping
When speed and strength are the main demands ____ must be emphasized.
intensity
When endurance is the main demand, ____ represents the principal stimulus for progress.
volume
Performance of a muscle is affected by:
- motor unit activation (multiple motor unit summation and wave summation
- cross-sectional area
- force-velocity relationship
What factors affect the amount of torque produced by a muscle contraction?
- length of moment arm (longer = more force)

- angle of muscle insertion (closer to 90 degrees = more force; greater or lesser than that and torque is lost to compression or distraction---e.g., biceps vs brachioradialis/spurt vs shunt)
Describe DAPRE
Daily Adjusted Progressive Resistance Exercise

uses previous performance to calculate following workout

- based on 5- or 7-repetition maximum; from there, do:
----10 reps with 50%, followed by
---- 6 reps with 75%, then
---- to failure with 100% and adjust per chart for 4th set
---- to failure again with adjusted weight

use 4th set to determine (per chart) starting weight for next workout and start as above with 10 reps at 50%, etc.
When starting an isotonic program, what is critical to remember, especially for patients with musculoskeletal pathology?
- low reps/high resistance (strength building) may cause injury

- must avoid causing swelling and discomfort while having patient work to maximum exercise tolerance

- high repetitions (2-3 sets of 10-12 repetitions) and low resistance (endurance) should be used initially

- patient should work submaximally (limited progressing to full ROM submaximally, then culminating in full ROM with maximum effort)
Clinical advantages of isokinetic exercise
- ability to control velocity of movement of exercising limb segment (can exercise at multiple speeds--velocity spectrum and recruit desired fibers SO, FOG, FG)

- accommodating resistance that allows for maximal muscle loading throughout ROM

- quantitative performance assessment
Most common isometric muscle sets for the lower extremities
- gluteal sets (pinch together)
- quad sets (supine - push back of knee into mat)
- hamstring sets (supine - push heel into mat to produce isometric hip extension contraction)
Describe multiple-angle isometrics
can be done with isokinetic machine or in free space

usually done with "rule of 10"
- 10-second contraction
- 10-second rest
- 10 repetitions
- 10 sets (one each at 10 different angles)
Open-chain activities are associated with _____ forces across the joint, especially parallel to the _______.
shearing

tibiofemoral joint
Although open-chain resistance training is not particularly functional, it provides a means of _______
isolating muscle groups

(e.g., can help strengthen quadriceps muscles, which, when weak, are associated with increased chair rise times and difficulties climbing stairs)
Athletes with reduced cocontraction and strength imbalances cannot appropriately dissipate....
ground-reaction forces, thus are at increased risk of knee injury because other static tissues (e.g., ligaments) are excessively stressed

CKC can help with this by providing joint compression, increasing neuromuscular control and enhancing joint stability
How are CKC exercises generally progressed?
- from static to dynamic
- from stable to unstable

- from straight planes to diagonal planes
- from single-plane to multiplane movements

- from wide base of support to narrow BOS
- from bilateral support to unilateral support

- from no resistance to resistance
- from rhythmic stabilization to resistance throughout ROM

- from fundamental movements to dynamic, challenging movements
- from consistent movements to perturbation training
Treatment for acute orthopedic syndromes

*** from her review session
rest, ice

(PRICE and isometrics?)
Treatment for subacute orthopedic syndromes

*** from her review session
- strengthening
- flexibility
- (P)ROM
Treatment for chronic orthopedic syndromes

*** from her review session
back to function
Contrast PROM and stretch

*** from her review session
PROM - move extremity through available ROM

stretch - beyond ROM, trying to stretch something that is pathologically tight
Differentiate plastic and elastic deformation

*** from her review session
- plastic deformation - soft tissue stays elongated (at least to a degree and for a bit of time)

- elastic deformation - goes back after stretch
Role of the muscle spindle

*** from her review session
- responds to quick stretch
- contracts the muscle protectively
- a reflex by a sensory receptor/proprioceptor in the muscle
Intrafusal vs. extrafusal

*** from her review session
- intrafusal - within the muscle spindle

- extrafusal - skeletal muscle fibers
Role of the GTO

*** from her review session
- also a proprioceptor (like muscle spindle)
- reflexively relaxes muscle in response to:
1) strong contraction (more effective here) or
2) passive stretch (held for a long time)
What proprioceptor does autogenic inhibition activate?

*** from her review session
GTO
Term used (somewhat) interchangeably with autogenic inhibition
hold-relax
How does reciprocal inhibition work?

*** from her review session
the agonist contracts, spurring the antagonist (tight muscle) to relax
Can muscles be transformed from slow twitch to fast twitch?

*** from her review session
no

nor is increase in size due to hyperplasia (making more fibers) it is due to hypertrophy (increased size in existing fibers)
How are muscles lengthened?***
by breaking sarcomeres

1 sarcomere splits into 2
What is the Rockwood 5?
***
a protocol of 5 shoulder exercises performed with elastic tubing

flex, extend, abduct, ER and IR
If the therapist is wanting to do PNF stretching, but the patient cannot tolerate hold-relax/autogenic inhibition, what should the therapist do?
try agonist contraction/reciprocal inhibition

it is milder and may be better tolerated