SPT IV Therapeutic Exercise Enables the patient to : Remediate or reduce impairements Enhance function Optimize overall function Enhance fitness and well-being Coordination of the muscular system. For motion to take place the muscles producing movement must have a sable base which to work. Muscles perform a variety of roles depending o nthe required movement. These roles include :
Prime movers/agonist : muscles that are directly responsible for producing movement
Synergist : muscles perform a cooperative function in relation nto the agonist. Stabilizers : muscles that contract statistically to steady or support some part of the body against pull of the contracting muscles against the pull of gravity
Neutralizers : muscles or muslces groups that act to preent an undesired action of one of the movers . Atagonist : muscles or muscle groups that have an effect opposite to that of the agonist. Types of muscles contraction Contraction : used to describe the generation of tension within muscle fibers conjures up an image of a shortening of a muscle fibers.
Isometric contraction : occurs when there is a tension produced in the muscle without any appreciable change in muscle length or joint movement
Concentric contraction : produces a shortening of the muscle.
Eccentric contraction : occurs when a muscle slowly lengthens as it gives it to an external force that is greater than the contractile force it is exerting.
Isotonic contraction : contraction in which the tension within the muscle remains constant as the muscle shortens or lengthens. Isokenitic contraction : occurs when a muscle is maximally contracting at the same speed throught the whole range of its related lever.
According to Cyriax, pain with contraction generally indicated an injury to them uscle or capsular structure. Factors affecting muscle performance Extensibility : the ability to be stretched or to increase in length
Elasticity : the ability to return to nornmal restign length following a strectch.
Irritability : ability to respond to a stimulus. With reference to skeletal muscle., this stimulus is provided electrochemically
Factors affecting muscle performance Muscle Fiber type
Muscle fiber size
Force-length relationships Fatigue
Age
Level of cognition Force-Length Relationship If the muscle is in a shortened position, the overlap of actin and myosin reduces the number of sites available for cross-bridge formation
Active insfuffiency : occurs when the muscle is incapable of shortening to the extent required to produced full range of motions at all joints crossed simultaneously. For ex: the finger flexor cannot produced a tight fist when the wrist is fully flexed as when it is in neutral
If the muscle is in a lengthened position compared to the resting length, the actin filaments are pulled away from the myosin heads such that they cannot create cross-bridges.
Passive insufficiency : occurs when 2 joint muscle cannot stretch to the extent required for full range of motion in the opposite direction at all joints crossed.
For ex : a larger range of hyperextension is possible at the wrist when the fingers are not fully extended. skeletal muscle blood flow increases 20-fold during muscle contraction. The muscle blood flow generaly increases in proportion to the mebaolic demands of the tissue , a relationship reflected by positive correlations bet. Muscle blood flow and exercise.
Fatigue :
Can compromise exercise tolerance and work productivity while retarding rehabilitationof diseased or damaged muscle. The development of fatigue probably involves several factors that influence force production in a manner dependent on muscle fiber type and activation pattern. Characteristic of muscle fatigue : reduction in muscle force production capability and shortening velocity, a reduction in the release and uptake of intracellular calcium by the sarcoplasmic reticulum Prolonged relaxation of motor units between recruitment. Muscle Performance Strength : the maximum force that a muscle can develop during a single contraction. Muscular strength is derived both from the amount of tension a muscle can generate and from the moment arms of contributing muscles with respect to the joint center.
Muscle strength can be measured using a number of methods : MMT Using a dynamometer Isokinetic machine Endurance : the ability of a muscle to sustain or perform repetitive muscular contractions for an extended period. The ability to perform endurance activities is based on the patients aerobic capacity
Power : the rate of performing work . Work is the magnitude of force acting on an object multiplied by the distance through wich the force acts . Improving muscle performance The promotion nad progresson of tissue-repair while exercising involves a delicate balance bet. Protection and the application of controlled functional stresses to the damaged structure. The goal of the functional exercise: is to identify the motion or motions that the patient is able to exercise into without eliciting symptoms other than post op exercise soreness.
A number of principles can be used to guide the clinician in the progression of therapeutic exercise:
Exercise prescription will vary according to the stage of healing and degree of irritability .Degree of irritability of each condition can often indicate the stage of healing to the clinician The patient is typically taught to exercise in cardinal planes before progressing as quickly as allowed to exercising in the functional planes.
The exercise protocol should intiate wih exercises that utilize a short lever arm. These exercises serve to decrease the amount of torque at the joint. Extremity exercises can be adapted to include short levers by flexing the extremity or by exercising with the extremity closer to the body. The goals should be to achieve the closed-pack position at the earliest opportunity. The closed pack position of a joint is this position of maximum stability
The prescribed exercises should repdocued the forces and laodign rates will approach the patient;s functional demands as rehabilitation progress. Variation. Variation to the exercises van be provided by altering a. the plane of motion B. ROM Body position Exercise duration Exercise frequency A safe progression. A safe progression is ensured if the exercises are progressed from : Slow to fast Simple to complex Stable to unstable Low force to high force Improving strength To increase strength, the load or resistance must be gradually increased during the muscle contraction . Strengthening of a muscle occurs when the muscle is forced to work at a higher level than to which it is accustomed.
To most effectively increase muscle strength a muscle must work with increasing effort against progressively increasing resistance. Adapative changes in improving strength :
Hypertrophy Increase in the efficiency of the neuromuscular system . This increased efficiency results in : a. Icnrease in the number of motor units recruited b. Increased in the firing rate of each motor unit c. Increase in the synchronization of motor unit firing. Improved endurance Stimulation of slow-twitch ( type I ) fibers ( when performing workloads of low intensity ) and stimulation of fast-twitch ( type II) fibers ( when performing workloads of high intensity and short duration )
Rhythmic activities increase blood flow to exercising muscles via contraction and relaxation Muscle power improves Improve bone mass ( Wolfes law) Increased in metabolism /calorie burning/ weight control / Cardoivascular benefits when using large muscle groups. Muscle can beomce weak or atrophied through : Disease Neurologic compromise Immobilization Disuse Types of Exercise Isometric exercise : Provides a static contraction with a variable and accommodating without producing a change in muscle length. It has an obious role where joint movement is restricted either by pain or by bracing Primary role : to prevent atrophy and prevent decrease of ligament, bone and muscle strength. Disadvatages of isomettic exercises : Strength gains are developed at a specific point in the ROM and not throughout the range Not all of a muscles fibers are activated there is predominantly an activation of slow-twitch There are no flexibility or cardiovascular fitness benefits Peak effort can be injurious to the tissues due to vasoconstriction and joint compression forces
There is limited functional carryover Considerable internal pressure can be generated esp. if the breath is held during contraction which can result in : Further injury to patients w/ a weakness in the abdominal wall Cardiovascular impairement ( increased bp through the valsavla maneuver even if the exercise is correctly performed ) Concentric/Isotonic Exercise :
Are commonly used in the rehabilitation process and occur frequently in acitivties of daily living the biceps curl and lifting of a cup to the mouth are examples.
Eccentric Exercises
Is important functional activities and can provide a source of shock absorption during closed-chain functional acitvities.
Functional Execises :
Functional strength is the ability of the neuromuscular system to perform the various types of contraction involved with mutijoint functional activities in an efficient manner and in a multiplanar environment. Uses combinations of concentric and eccentric contraction in the performance of activities that relate to a patients needs and requirements. Isokinetic Exercise : Requires the use of special equipment that produces an accommodating and variable resistance. The main pricinple behind isokinetic exercise is that peak torque ( the maximum force generated through the ROM ) is inversely r/t to angular velocity ( the speed that a body segment moves through its ROM ) Types of Resistance Resistance can be applied to a muscle by any external force or mass
Gravity : Can supply sufficient resistnace w/ weakned muscle. W/ respect to gravity , muscle actions may occur in : The same direction of gravity ( downward ) In the opposite direction to gravity ( upward ) In a direction perpendicular to gravity ( horizontal ) In the same or opposite direction to gravity, but at an angel Body weight : No equipment Relying on the patients body weight
Small weight : Cuff weights and dumbbells are economical ways of applying resistance. Small weights are typically used to strengthen the smaller muscles or to increase the endurance of larger muscles by increasing the number of reps. Surgical Tubing/Theraband : The amount of variable resistnace offered by elastic bands or tubing is a factor of the internal tension producedby the material
Exercise Machines : This can be used when larger muscle groups require strengthening a multitude of specific indoor exercise machines can be used. Manual Resistance : Type of active exercise in which another person provides resistance manually.
Advantages : Re-education of the muscle or extremity Critical sensory input to the patient through tactile stimulation and appropriate facilitation techniques Ability to limit the range Disadvantages : Amount of resistance applied cannot be measured quantitatively Amount of resistance is limited by the strength of the clinician /family member Difficulty with consistency of the applied forced throguhtou the range and with each repitition Type of Exercise:
Intensity : how much the effort is required to perfrom the exercise It isn ow recognized that an individual perception of effort ( relative perceivd exertion or RPE ) is closely r/t to the level of physiologic patients response to exercise Duration : Refers to the length of the exercise session. In most functional exerxcise, fatigue must be considered when doing exercises so that the patients tolerance is not exceeded.
Frequency : How often is the exercise is performed DOMS : is a type of soreness that is r/t to eccentric exercise Occurs bet. 48-72 hours. Intervention :
Conditioning, Total Body Endurance Exercises, or Cardiopulmonary Endurance Exercises
These exercises use large muscle groups, and are continuous and rhythmic, providing low intensityand high repetition, to improve overall cardiopulmonary fitness. They can be divided into aerobic and anaerobic endurance exercises. Cardiovascular effects of conditioning exercises
Decreased resting heart rate and submaximal effort Increased peak BP during maximal exercise, decreased BP at rest and submaximal effort. Muscle shortening. Tension develops to overcome resistance. Increase in stroke volume during maximal exercise Reduced myocardial oxygen consumption at rest and submaximal activities Thick and thin filaments are linked to one another via cross bridges that arise from the myosin molecule. During muscle contraction, increasing amount of myosin overlap is observed, and muscle shortening occurs. Contraction results in the Z lines approaching each other, shrinking of the H zone and I band. Aerobic endurance exercises Combination of cardiopulmonary endurance exercise with strengthening Should consist of a warm-up period, a training period and a cool-down period: Warm-up 5 to 10 minutes Training period20 to 30 minutes at 40%60% (low intensity), 60%70% (moderate intensity), or 70%85% (heavy intensity) of their VO max Cool-down period 5 to 10 minutes 2 Guidelines for the quantity and quality of aerobic exercise programs for healthy adults as proposed by the American College of Sports Medicine Modeany exercise that uses large muscle groups, continuous and rhythmic in natur Examples: running, swimming, walking, stair climbing. Frequency35 days/week Duration2060 minutes Intensity60%90% HR max 50%85% of VO max or 50%85% of HR reserve max
Anaerobic exercises
High-resistance, short-duration exercises at 80% of maximum exertion capacity. Deplete the glycolytic system, which functions during the first two minutes of exercise. Mobility exercises: exercises to improve flexibility Flexibility is defined as the ability to move body joints through their entire range of motion (ROM) Each joint of the body has a specific ROM Flexibility exercises maintain mobility within the available ROM Flexibility exercises should be done at least three times a week, should consist of three to five repetitions once or twice a day TECHNIQUES TO IMPROVE FLEXIBILITY Can be done through anatomic planes of motion, combined planes of motion (similar to peripheral neuro-facilitation patterns), or through functional teaching activities Stretching Exercises
Increase ROM by lengthening tendon and muscle beyond the available range Include static stretching, static stretching with contraction of the antagonist muscle (reciprocal inhibition), static stretching with contraction of the agonist muscle, and ballistic stretching Ballistic stretchingutilizes repetitive bouncing movements with a rapid stretch. More tension is developed, and more energy is absorbed into the muscle and tendon, which can lead to bone avulsion or muscletendon tears. High risk of injury Static stretchThe joint is moved to the end of the ROM where the position is slowly held for 5 to 60 seconds. Can be done actively or passively. Safe technique Reciprocal inhibitionThe joint is also moved to the end of ROM, and this is followed by a symmetric contraction of the antagonist muscle group for 5 to 30 seconds Static stretching with contraction of the agonistThe joint is moved to the end of ROM and followed by an isometric contraction of the agonist muscle for 5 to 30 seconds EFFECTS OF EXTENDED BEDRESTIMMOBILIZATION AND INACTIVITY MUSCLE Strengthimmobilization decreases strength by 1.0%1.5% per day. Strength can decrease as much as 20%30 % during only a week to nine days of bedrest. Five weeks of total inactivity costs 50% of the previous muscle strength. A plateau is reached 25%40% of original strength. One contraction a day at 50% of maximal strength is enough to prevent this decreas Strength is lost especially in the quadriceps and extensors A decrease in fiber diameter is found affecting type I fibers (slow twitch) during early immobilization. A decrease of percentage of type I fibers is noted. A decrease in oxidative enzymes is also noted Restricted activities affect muscle strength and recruitment patterns of muscles distant from specific sites of injury. BONE AND JOINTS
Lack of gravitational force and muscle pull on bone cause osteopenia. As a result of osteopenia, hypercalcemia develops. Calcium is excreted in the urine and feces starting at 23 days after immobilization, and peaking at 37 weeks. After activity is resumed, calcium levels remain high for 3 weeks, reaching normal values at 56 weeks When comparing calcium to nitrogen and protein changes in the urine, it is noted that calcium improves last. Nitrogen loss is 2g N/day. Loss begins at 56 days after immobilization, peaks in the second week. After activity is resumed, loss continues for 1 week, normalizes during the second week, below normal values are obtained at 4 weeks, and returns to normal values in 6 weeks Calcium excretion in addition to phosphorus loss causes atrophy and a reduction in fracture threshold of bone Joints show a decrease in periarticular connective tissue extensibility after inactivity. Articular cartilage begins to deteriorate due to lack of nutritional support. The hyaline cartilage in synovial joints is not supplied by vascular blood flow. It depends on nutrition from the synovial fluid through loading and unloading of pressure Ligaments undergo biochemical changes noted as early as two weeks after immobilization. In the case of surgically repaired ligaments, improvement in strength is affected by immobilization. Immobilization causes ligament strength to decrease, compliance to increase, and collagen degradation to increase. GASTROINTESTINAL (GI)Decreased GI motility leads to constipation and loss of appetite. GENITOURINARYUrinary stasis, leading to an increased risk of urolithiasis and urinary tract infections. PULMONARYDiminished diaphragmatic movement and chest expansion, due to loss of strength of diaphragm and intercostal muscles, leading to impaired secretion clearance. Reduced cough and bronchial ciliary activity. Patients can develop hypostatic pneumonia. Reduction in pulmonary function with decreased tidal and minute volumes, decreased vital capacity. A-V shunting and regional changes in ventilation-perfusion occur. CARDIAC Reduction in blood and plasma volumes. Redistribution of body fluids leads to postural hypotension. Venous blood pooling occurs in the legs. In addition, -adrenergic sympathetic activity is increased. Cardiovascular efficiency is decreased, increased HR, decreased stroke volume. Heart rate increases approximately 0.5 beats/minutes/day, leading to immobilization tachycardia and abnormal HR with minimal or submaximal workloads. Thromboembolism secondary to a decrease in blood volume and increased coagulability.
TEGUMENTARYskin atrophy and pressure sores develop. EVALUATION OF FUNCTIONAL INDEPENDENCE Difference between impairment, disability, and handicap: Impairmentphysical or psychological abnormality, usually the manifestation of a disease or injury. Example Cerebral Vascular Accident (CVA) Disabilityloss of ability to perform a particular activity or function, such as walking Handicapinability to fulfill a usual role or life activity as a result of the impairment and disability. Example: inability to perform a certain job due to inability to ambulate
The evaluation of functional independence is important in the process of assessing a safe return home after a patient has been hospitalized One of the measurement scales used for this assessment is the FIM score (Functional Independence Measure) (Figure 8-4). It documents the severity of disability as well as the outcomes of rehabilitation treatment as part of a uniform data system.
Consists of 18 items organized under 6 categories: Self care (eating, grooming, bathing, upper body dressing, lower body dressing, and toileting) Sphincter control(bowel and bladder function) Mobility (bed, chair, wheelchair, tub or shower, and toilet transfers) Locomotion (ambulation, wheelchair mobility, and stair management) Communication (comprehension and expression) Social cognition (interaction, problem solving, memory) Patients obtain points on each category on a scale of 1 (total assistance required) to 7 (complete independence)
PHYSIOLOGIC EFFECTS OF AGING
CARDIAC Progressive decline in maximal heart rate, possibly related to decreased chronotropic response to adrenergic stimuli. Max HR = 220 age ncreased left ventricle end systolic volume and decreased ejection fraction with exer- cise. When this is added to a decreased HR response, cardiac output during exercise is more dependent on an increased stroke volume rate of diastolic early filling is decreased;
Maximal oxygen consumption (VO max) decreases regardless of the level of activitybut more physically active patients have smaller decreases compared to sedentary patients
PULMONARY
Decreased vital capacity Decreased PO
No change in total lung capacity High incidence of pneumon INTEGUMENTARYDecreased elasticity of connective tissue leads to increased risk for pressure ulcers and skin breakdown. Decreased moisture, decreased skin sensation MUSCULOSKELETALOverall muscle mass decreases, including number of myofibrils, and concentration of mitochondrial enzymes Decreased number of motor units Increased fat15% increase at age 30, 30% increase at age 80. Patients retain more fat- soluble medications and have increased side effects Muscle endurance increases or remains stable due to muscle fiber type regrouping, increasing type II fibers with age
THERMOREGULATORY Impaired temperature regulation with decreased autonomic vasomotor control and impaired sensitivity to changes in temperature Patients are vulnerable to hypothermia and hyperthermia. Hypothermia is affected by impaired sweating and aggravated by medical conditions, such as malnutrition, hypoglycemia, and hypothyroidism; or medications such as narcotics, ethanol, and benzodiazepines NEUROLOGIC
Decreased short-term memory and incidental learning Slowing in the rate of central information processing tasks requiring new information processing tend to decline progressively after 20 years of age Increase in choice reaction time is noted. The more complex the task, the greater the age effect Older adults are capable of learning but at a slower rate Decrease in proprioception and gait, leading to problems with coordination and balance. There is associated decrease in nigrostriatal neurons with age Loss of speed of motor activities GENITOURINARY Reduction in bladder capacity Decreased urethral and bladder compliance Reduced urinary flow rate
RENAL Atrophy of the glomeruli and decrease in renal tubular cell mass, leading to decreased glomerular filtration rate and decreased tubular function
GASTROINTESTINAL Impaired esophageal functiondecreased amplitude of peristaltic contractions Delayed esophageal emptying, and incomplete sphincter relaxation are associated with disease Colondecreased force of muscle contraction with impaired rectal perception of feces. It is important to explore contributing factors for development of constipation:
GASTROINTESTINAL Impaired esophageal functiondecreased amplitude of peristaltic contractions Delayed esophageal emptying, and incomplete sphincter relaxation are associated with disease Colondecreased force of muscle contraction with impaired rectal perception of feces. It is important to explore contributing factors for development of constipation:
EFFECTS OF ACUTE HOSPITALIZATION AND DECONDITIONING IN THE ELDERL Disorientation Insomnia Emotional sequelaeAnxiety and confusion are common in relation to illness, prognosis, and hospitalization. Patients tend to develop depression. Many times patients are dependent for functional activities Deconditioning effects include: Decreased VO max Shortened time to fatigue during submaximal work Decreased muscle strength Decreased reaction time/balance/flexibility 2 Joint Mobilization \ 86 Outlines What is Joint Mobilization? Terminology Relationship Between Physiological & Accessory Motion Basic concepts of joint motion : Arthrokinematics Effects of Joint Mobilization Contraindications for Mobilization Precautions Techniques of joint mobilization 14/10/1435 RHS 322 87 What is Joint Mobilization? Joint Mobs
Manual therapy technique Used to modulate pain Used to increase ROM Used to treat joint dysfunctions that limit ROM by specifically addressing altered joint mechanics
Factors that may alter joint mechanics: Pain & Muscle guarding Joint hypomobility Joint effusion Contractures or adhesions in the joint capsules or supporting ligaments Malalignment or subluxation of bony surfaces Pondering Thoughts Would you perform joint mobilizations on someone who has a hypermobile joint? 14/10/1435 89 RHS 322 Terminology Mobilization passive joint movement for increasing ROM or decreasing pain Applied to joints & related soft tissues at varying speeds & amplitudes using physiologic or accessory motions Force is light enough that patients can stop the movement
Manipulation passive joint movement for increasing joint mobility Incorporates a sudden, forceful thrust that is beyond the patients control Terminology Self-Mobilization (Auto-mobilization) self- stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule
Mobilization with Movement (MWM) concurrent application of a sustained accessory mobilization applied by a therapist & an active physiologic movement to end range applied by the patient Applied in a pain-free direction Terminology Physiologic Movements Osteokinematics motions of the bones movements done voluntarily traditional movements such as flexion, extension, abduction, rotation Accessory Movements movements within the joint & surrounding tissues that are necessary for normal ROM, but can not be actively performed by the patient Component motions motions that accompany active motion, but are not under voluntary control Ex: Upward rotation of scapula & rotation of clavicle that occur with shoulder flexion Joint play motions that occur within the joint Determined by joint capsules laxity Can be demonstrated passively, but not performed actively 92 Terminology Arthrokinematics motions of bone surfaces within the joint 5 motions - Roll, Slide, Spin, Compression, Distraction
Muscle energy use an active contraction of deep muscles that attach near the joint & whose line of pull can cause the desired accessory motion Therapist stabilizes segment on which the distal aspect of the muscle attaches; command for an isometric contraction of the muscle is given, which causes the accessory movement of the joint
Thrust high-velocity, short-amplitude motion that the patient can not prevent Performed at end of pathologic limit of the joint (snap adhesions, stimulate joint receptors) 93 Terminology Concave hollowed or rounded inward
Convex curved or rounded outward 94 Relationship Between Physiological & Accessory Motion Biomechanics of joint motion Physiological motion Result of concentric or eccentric active muscle contractions Bones moving about an axis or through flexion, extension, abduction, adduction or rotation
Accessory Motion Motion of articular surfaces relative to one another Generally associated with physiological movement Necessary for full range of physiological motion to occur Ligament & joint capsule involvement in motion 95 Basic concepts of joint motion : Arthrokinematics 1. Joint Shapes Type of motion is influenced by the shapes of the joint surfaces Ovoid one surface is convex, other surface is concave
Sellar (saddle) one surface is concave in one direction & convex in the other, with the opposing surface convex & concave 96 Basic concepts of joint motion : Arthrokinematics 2. Types of joint motion 5 types of joint arthrokinematics Roll Slide Spin Compression Distraction
3 components of joint mobilization Roll, Spin, Slide Joint motion usually often involves a combination of rolling, sliding & spinning
97 Roll A series of points on one articulating surface come into contact with a series of points on another surface Ball rolling on ground Example: Femoral condyles rolling on tibial plateau Roll occurs in direction of movement Occurs on incongruent (unequal) surfaces Usually occurs in combination with sliding or spinning
98 Spin Occurs when one bone rotates around a stationary longitudinal mechanical axis Same point on the moving surface creates an arc of a circle as the bone spins Example: Radial head at the humeroradial joint during pronation/supination; shoulder flexion/extension; hip flexion/extension Spin does not occur by itself during normal joint motion
14/10/1435 99 RHS 322 Slide Specific point on one surface comes into contact with a series of points on another surface
Surfaces are congruent When a passive mobilization technique is applied to produce a slide in the joint referred to as a GLIDE. Combined rolling-sliding in a joint The more congruent the surfaces are, the more sliding there is The more incongruent the joint surfaces are, the more rolling there is 100 Compression Decrease in space between two joint surfaces Adds stability to a joint Normal reaction of a joint to muscle contraction
Distraction - Two surfaces are pulled apart Often used in combination with joint mobilizations to increase stretch of capsule. 101 Convex-Concave & Concave-Convex Rule Basic application of correct mobilization techniques - **need to understand this! Relationship of articulating surfaces associated with sliding/gliding
One joint surface is MOBILE & one is STABLE
Concave-convex rule: concave joint surfaces slide in the SAME direction as the bone movement (convex is STABLE) If concave joint is moving on stationary convex surface glide occurs in same direction as roll 14/10/1435 102 RHS 322 Convex-concave rule: convex joint surfaces slide in the OPPOSITE direction of the bone movement (concave is STABLE) If convex surface in moving on stationary concave surface gliding occurs in opposite direction to roll 103 RULE OF CONCAVE- CONVEX
104 RHS 322 Effects of Joint Mobilization Neurophysiological effects Stimulates mechanoreceptors to pain Affect muscle spasm & muscle guarding nociceptive stimulation Increase in awareness of position & motion because of afferent nerve impulses
Nutritional effects Distraction or small gliding movements cause synovial fluid movement Movement can improve nutrient exchange due to joint swelling & immobilization
Mechanical effects Improve mobility of hypomobile joints (adhesions & thickened CT from immobilization loosens) Maintains extensibility & tensile strength of articular tissues
Cracking noise may sometimes occur 105 Contraindications for Mobilization Should not be used haphazardly
Avoid the following: Inflammatory arthritis Malignancy Tuberculosis Osteoporosis Ligamentous rupture Herniated disks with nerve compression Bone disease Neurological involvement Bone fracture Congenital bone deformities Vascular disorders Joint effusion May use I & II mobilizations to relieve pain
106 Precautions Osteoarthritis Pregnancy Flu Total joint replacement Severe scoliosis Poor general health Patients inability to relax 107 108 14/10/1435 109 RHS 322 Maitland Joint Mobilization Grading Scale Grading based on amplitude of movement & where within available ROM the force is applied.
Grade I Small amplitude rhythmic oscillating movement at the beginning of range of movement Manage pain and spasm Grade II Large amplitude rhythmic oscillating movement within midrange of movement Manage pain and spasm
Grades I & II often used before & after treatment with grades III & IV 110 Grade III Large amplitude rhythmic oscillating movement up to point of limitation (PL) in range of movement Used to gain motion within the joint Stretches capsule & CT structures Grade IV Small amplitude rhythmic oscillating movement at very end range of movement Used to gain motion within the joint Used when resistance limits movement in absence of pain
Grade V (thrust technique) - Manipulation Small amplitude, quick thrust at end of range Accompanied by popping sound (manipulation) Velocity vs. force Requires training 111 Indications for Mobilization Grades I and II - primarily used for pain Pain must be treated prior to stiffness Painful conditions can be treated daily Small amplitude oscillations stimulate mechanoreceptors - limit pain perception Grades III and IV - primarily used to increase motion Stiff or hypomobile joints should be treated 3-4 times per week alternate with active motion exercises 112 ALWAYS Examine PRIOR to Treatment If limited or painful ROM, examine & decide which tissues are limiting function
Determine whether treatment will be directed primarily toward relieving pain or stretching a joint or soft tissue limitation Quality of pain when testing ROM helps determine stage of recovery & dosage of techniques 1) If pain is experienced BEFORE tissue limitation, gentle pain-inhibiting joint techniques may be used Stretching under these circumstances is contraindicated
2) If pain is experienced CONCURRENTLY with tissue limitation (e.g. pain & limitation that occur when damaged tissue begins to heal) the limitation is treated cautiously gentle stretching techniques used
3) If pain is experienced AFTER tissue limitation is met because of stretching of tight capsular tissue, the joint can be stretched aggressively
14/10/1435 113 RHS 322 Joint Positions Resting position Maximum joint play - position in which joint capsule and ligaments are most relaxed Evaluation and treatment position utilized with hypomobile joints
Loose-packed position Articulating surfaces are maximally separated Joint will exhibit greatest amount of joint play Position used for both traction and joint mobilization
Close-packed position Joint surfaces are in maximal contact to each other
General rule: Extremes of joint motion are close-packed, & midrange positions are loose-packed. 114 Joint Mobilization Application All joint mobilizations follow the convex-concave rule Patient should be relaxed Explain purpose of treatment & sensations to expect to patient Evaluate BEFORE & AFTER treatment Stop the treatment if it is too painful for the patient Use proper body mechanics Use gravity to assist the mobilization technique if possible Begin & end treatments with Grade I or II oscillations 115 Positioning & Stabilization Patient & extremity should be positioned so that the patient can RELAX
Initial mobilization is performed in a loose-packed position In some cases, the position to use is the one in which the joint is least painful
Firmly & comfortably stabilize one joint segment, usually the proximal bone Hand, belt, assistant Prevents unwanted stress & makes the stretch force more specific & effective 116 Treatment Force & Direction of Movement Treatment force is applied as close to the opposing joint surface as possible The larger the contact surface is, the more comfortable the procedure will be (use flat surface of hand vs. thumb)
Direction of movement during treatment is either PARALLEL or PERENDICULAR to the treatment plane 117
Treatment plane lies on the concave articulating surface, perpendicular to a line from the center of the convex articulating surface (Kisner & Colby, p. 226 Fig. 6-11)
Joint traction techniques are applied perpendicular to the treatment plane Entire bone is moved so that the joint surfaces are separated Treatment Direction 14/10/1435 118 RHS 322 Gliding techniques are applied parallel to the treatment plane Glide in the direction in which the slide would normally occur for the desired motion Direction of sliding is easily determined by using the convex-concave rule The entire bone is moved so that there is gliding of one joint surface on the other When using grade III gliding techniques, a grade I distraction should be used If gliding in the restricted direction is too painful, begin gliding mobilizations in the painless direction then progress to gliding in restricted direction when not as painful
Reevaluate the joint response the next day or have the patient report at the next visit If increased pain, reduce amplitude of oscillations If joint is the same or better, perform either of the following: Repeat the same maneuver if goal is to maintain joint play Progress to sustained grade III traction or glides if the goal is to increase joint play 119 Speed, Rhythm, & Duration of Movements Joint mobilization sessions usually involve: 3-6 sets of oscillations Perform 2-3 oscillations per second Lasting 20-60 seconds for tightness Lasting 1-2 minutes for pain 2-3 oscillations per second Apply smooth, regular oscillations Vary speed of oscillations for different effects For painful joints, apply intermittent distraction for 7- 10 seconds with a few seconds of rest in between for several cycles For restricted joints, apply a minimum of a 6-second stretch force, followed by partial release then repeat with slow, intermittent stretches at 3-4 second intervals 120 Patient Response May cause soreness Perform joint mobilizations on alternate days to allow soreness to decrease & tissue healing to occur Patient should perform ROM techniques Patients joint & ROM should be reassessed after treatment, & again before the next treatment Pain is always the guide 121 Joint Traction Techniques Technique involving pulling one articulating surface away from another creating separation Performed perpendicular to treatment plane Used to decrease pain or reduce joint hypomobility Kaltenborn classification system Combines traction and mobilization Joint looseness = slack
122 AQUATIC THERAPY
Intro to Aquatic Therapy Aquatic therapy is a therapeutic modality that involves the patient to do an exercise program in water Aquatic therapy uses the physical properties of water to assist in patient healing and exercise performance. Buoyancy (up to 90% of our body weight is removed)
Who Benefits from Aquatic therapy Patients with: Arthritis Healing fractured bones Stress fractures Who have pain only in WB activities who are overweight Post surgery The Benefits of Aqua Therapy Pain Control Water against the skin causes a sensory response which blocks pain receptors and therefore inhibits the sensation of pain from getting to the brain. Increase in Self-Esteem People who have suffered a devastating injury and need to slowly regain the movements of daily living. Once they have achieved this goal, and are not so dependent on others, they may get a psychosocial boost. Decrease Impact Exercises in the water decreases the impact created within the joints as compared to completing exercises on land
Other Benefits Great for patients with: Swelling Decreased ROM Decreased strength Decreased balance, coordination, proprio Weight bearing restrictions Cardio deconditioning Gait deviations
Difficulty with land intervention Arthritis Healing fractured bones Stress fractures Who have pain only in WB activities who are overweight Post surgery
Disadvantages Access to a pool Not every clinic will be near or have a pool suitable for aquatic therapy Qualified pool attendants Qualified ATs Precautions and contraindications Open wounds Respiratory dysfunction Seizure disorders, controlled by meds Fear of water chlorine allergy altered peripheral sensation untreated infectious disease serious cardiac conditions Upper limb Can be used for treatment of The shoulder complex Elbow Wrist Hand
Exercises for Shoulder Complex Injuries Initial Level Start with patient in shoulder deep water walking forwards and backwards trying to keep a normal arm swing GH movements can be done with patient back against the wall to stabilize the scapula The movements can be done supine or prone depending on the patients level of comfort in the water
Exercises for Shoulder Complex Injuries Intermediate Level At this stage you can use equipment to increase the resistance to build on strength Keeping with in a pain free zone Scapular stabilization can be progressed from the standing position to a supine position Over head movements can be incorporated in the program by positioning the patient in a supine or prone position ( Exercises for Shoulder Complex Injuries Final Level The goal for this level is to incorporate sport specific movements, and to make it more challenging By bringing in sport equipment into the pool the patient can do sport specific movements
Lower Limb Can be used for treatment of Hip Knee Ankle
Exercises for Lower Limb Injuries Initial Level Goals Increase normal movements Increase strength of unaffected muscles Increase ROM Walking forward, backwards and sideways help maintain a normal gait Deep water activities help maintain cardio for patients who cant WB due to stress fractures or other injuries that require NWB activities Exercises for Lower Limb Intermediate Level Goals Increase ROM Increase Strength Increase Flexibility Aqua belts can be used to allow for deep water running Can do eccentric activities in shallow water by standing on a flutter board or a noodle
Exercises for Lower Limb Final Level Best used as a compliment to on land training Can have the athlete do deep water activities without a flotation belt Can do squats on noodles, dumbbells, or flutter boards Pool running
Things you can use for Aquatic Therapy Thera-band to tether them to the wall for pool running For added resistance Tennis balls on a rope a rope with knots Milk jugs for weights Hockey sticks, old golf clubs, old tennis racquets, clothing