exercise
what are the 3 Stages of Healing and how long does each stage last?
Phase 1: inflammation (acute)
- 1-10 days
- inflammatory response
Phase 2: proliferation (subacute)
- 2 days-6 weeks- up to 12 weeks
- fibroblastic repair
Phase 3: maturation (subacute/chronic)
- begins 3 weeks up to 12 months
- chronic is 6 months or longer
- remodelling
5 cardinal signs
1. redness
2. swelling (edema)
3. Increased temperature
4. Pain
5. Loss of function
purpose of inflammation?
1. form fibrin lattice to decrease blood loss, provide strength to wounch
2. remove damaged cells
3. recruit endothelial cells and fibroblasts in preparation for next phase
phase 1 inflammation
1. vasoconstriction - prevents blood loss
2. vasodilation - brings WBC to site, platelets adhere to exposed collagen
3. clot formation - creates a temporary plug
4. phagocytosis - macrophages remove dead tissue through phagocytosis
odema (swelling) causes
- decreased ROM
- decreased function and pain
- happens over 30 min
- fractures and ligament avulsions there is always bleeding and odema occurs in 5 minutes
chronic odema can cause:
- increased risk of infection
- cellulitis - deep bacterial infection of the skin
- ulceration - development of an ulcer
- partial limb amputation
- stasis dermatitis (eczema)
phase 2: proliferation
- purpose to cover the wound
- longer phase than inflammation (many of these things happening concurrenntly during the phase.
- steps in another que card
Steps of proliferation
1. epithelialization - creates scar to protect the tissue
2. collagen and elastin fibres - in random oder form the scar tissue which will get progressively stroger
3. wound contracture - starts around day 5, peaks after aboout 2 weeks
4. neovascularization - new blood vessels are formed for increased blood flow to the area
phase 3: maturation
- longest phase (can take up to a year)
- stress on the scar makes the collagen fibres line up parallel to the line or force
- scar rarely as strong as normal tissue
- scar usually in place 3 weeks post injury
- many factors will impede healing
steps of maturation
1. collagen systhesis
2. collagen orientation
3. healed injury
factors that affect healing (local)
- type
- size (smaller heals faster)
- location (over bone = slower)
- infection
- blood supply
- external forces (e.g. heat and cold)
- movement - may need immobilization
factors that affect healing (systemic)
- age - old=slower
- disease
- medications
- nutrition
important determinants of healing
- regenerative capacity of the tissue
- vascular supply - circulation of blood in the body
- extent of damage
typical healing timelines for healthy adult (25+ years)
(muscle, tendon, capsule, ligament)
- muscle, tendon, capsule, ligament - 4 weeks
- first week - rest
- second week - gentle painfree movement including AAROM
- week 3 - light strenghtening
typical healing timelines for healthy adult (25+ years)
(bone)
- 6 weeks healing time
- often casted for 5 weeks
- diabetic - 6 weeks casted
- recovery of movement and strength - weeks 7-12
(focus on movement first before strength)
***youth under 25 years can heal up to one week faster***
chronic inflammation
- inflammation that lasts months or longer
- caused by persistent trauma, autoimmune disease, overuse or overload cumulative microtrauma
- results in increased scar tissue
examples of chronic inflammation
- arthritis
- tendinosis
- contiuous spraining or straining
- diabetes
Which is not a local factor that affects healing?
a. Infection
b. Size of injury
c. Diabetes
d. Location of injury
c. diabetes
Which is not a sign of inflammation?
a. Increased temperature
b. Loss of function
c. Cyanosis
d. Odema
c. cyanosis
During inflammation and repair, which phase comes first?
inflammation
___ creates a scar to protect tissue and decrease risk of infection?
Epithelialization
Which option happens during proliferation?
a. Vasoconstriction
b. Neovascularization
b. Neovascularization
A left trendelenburg gait occurs when an individual has weak ___ on the left side
a. Hip flexors
b. Hip abductors
c. Hip adductors
d. Erector spinae
b. Hip abductors
True or false during gait, the toe off period is a part of the swing phase?
False - its apart of the stance phase (last step)
what does the term gait refer to?
refers to walking
- can also be called ambulation
problems with walkig can be caused by deficits in one or more oboyd systems such as;
- respiratory
- skeletal
- muscular
- nervous
- neurological
functional walking requires
1. acceptance of weight by the supporting limb
2. period of single limb support
3. advancement of the limb
what is the stance phase of gait
period of the gait cycle during which the foot or supporting limb is in contact with the ground (5 steps)
what is the swing phase of gait
this is the period of the gait cycle when the reference limb or foot is in the air and not in contact with the ground (3 steps)
what are the 5 stages of stance (gait)
1. heel strike
2. foot flat
3. midstance
4. heel off
5. toe off (push off)
what are the 3 stages of swing (gait)
1. acceleration
2. midswing
3. deceleration
elements of gait
- gait velocity (speed)
- step and stride length
- increase in single stance time
- decrease in double support time
- symmetry (equal step length and equal timing)
- time and distance
- step and stride length
- cadence (rhythm)
- width of walking base
- lateral pelvic tilt
- arm swing
- vertical displacement of COG
- horizontal displacement of COG
step length is:
the length between each step (heel of right and heel of left)
stride length is:
full cycle of steps (heel of right to the next heel of right)
what is cadence
the rhythm of walking - are both step and stride length the same time on both sides
width of walking base
- step width is an indicator of stability
- it will be a wider base if the person is less stable
- remember the runner, the mall walker and the person with trendelenburg gait on a graph
normal arm swing
- normal gait, the arm and leg on contralateral sides always move together
- this helps with overall balance
- very important when teaching someone how to use a gait aid
weakness in these muscles results in trendelenburg
hip abductors and errector spinae group
concentric muscle work
Concentric muscle work initiates the movement to move through the gait cycle
e.g. glutes and hamstring work concentrically in the acceleration of swing phase and the push off of stance phase
e.g. gastrocnemius and soleus work concentrically in push off of stance phase
eccentric muscle work
Eccentric muscle work controls the movement so that the limb moves smoothly through the gait cycle
e.g. glutes and hamstring work eccentrically in deceleration of swing phase and heel strike of stance phase
e.g. gastrocnemius and soleus work eccentrically in heel strike of stance phase
if weakness is in left L/E, which hand should the cane be used in?
right hand
how to fit a cane for someone
top of the cane should be at wrist height
15-20 degree bend should occur in the elbow
muscle grading
grade 1: muscle contraction, cannot move limb
grade 2: can move limb through range, if gravity eliminated
grade 3: can move limb through range against gravity
grade 4: can move limb against gravity with a small load
grade 5: can move limb against gravity with a heavy load
**to be able to use this grading system, a muscle must be able to contract**
how do you fit a crutch for a patient?
- 2-3 finger gap between top of crutch an armpit
- hand grip at wrist level
- elbows slightly bent at 30 degree angle when holding grips
effects of exercise on hyaline/articular cartilage
- found at the ends of bones in synovial joints and functions to provide a smooth, low friction surface
- disperses compressive and shearing forces
- pain is not felt until inury reaches subchondral bone
- no nerve or blood supply causing limited ability to heal
- goal is to provide the inured area with large amount of synovial flushing and utilize milking action to receive nutrients from the subchondral bone (movement causes milking action)
effects of exercise on fibrocartilage
- found between bones that require little motion
- e.g. meniscus, labrum, interveterbral discs
- acts as a shock absorber for large and repeated loads
- must be repaired surgically if torn/injured
- aneural and avascular (no nerve or blood supply, limited ability to heal)
- when knee meniscus or labrum injured, minimize compression via weight bearing to allow tear to heal and avoid pain
- when intervertebral disc injured, compression can be used to prevent a bluged spinal disc (can be painful)
Truth or lie?
Reducing pain is an indication for a gait aid?
No pain no gain, so you can walk on an injury into pain
Use a cane on your right side if you have a left leg injury
Use a cane on your right side if you have a right leg injury
Reducing pain is an indication for a gait aid? (truth)
No pain no gain, so you can walk on an injury into pain (lie)
Use a cane on your right side if you have a left leg injury (truth)
Use a cane on your right side if you have a right leg injury (lie)
Which fibrocartilage injury do you want to increase compression on to encourage healing?
a. Labrum
b. Intervertebral disc
c. Meniscus
b. Intervertebral disc
Which of the following things do we do to help a ligament heal?
a. Controlled stress
b. Immobilization
a. controlled stress
When a tendon is injured, what is the most conservative way to challenge it?
a. Eccentric strengthening
b. Concentric strengthening
c. Isometric strengthening
c. Isometric strengthening
Fractures bone in case for 6 weeks. Now out of cast. What treatment priority?
a. Strengthening
b. Stretching muscles
c. Mobilizing joint range
c. Mobilizing joint range
Name the saying we use to remember how to manage stairs
Good to heaven, bad to hell
True or false: A 3-point gait pattern is used primarily for those who are unable to weight bear on one lower extremity
true
Pick 2!! Someone with a right trendelenburg gait pattern, has a
a. Left hip drop
b. Right pelvis translation
c. Right hip drop
d. Left pelvis translation
a. Left hip drop
b. Right pelvis translation
adhesive capsulitis
- balance between ROM/mobilization that is painful but gaining movements vs loosing movements
- happens in the shoulder (most common) - called frozen shoulder
- can happen in other joints where there has been surgery or broken bones as well
- inflammation of the capsule
- very painful - stratum fibrosum involved
- unclear cause
- occurs in perimenopausal age (male and female)
- gross loss of motion in all directions
3 stages of adhesive capsulitis
1. freezing (4-6 weeks)
2. frozen (up to 6 months)
3. thawing (6 months to 2 years)
ligaments
- sometimes interwoven into Stratum Fibrosum and contain lots of neurosensory organs
- Poor blood supply (only from bone attachment)
- As they heal, scarring occurs
- full healing may extend to 12 to 14 weeks
- controlled stress will strengthen the repair
how do you put healthy stress on ligaments?
- Training and strengthening them by moving in normal exercise
- Exercise in off center ways to push the ligaments to strengthen them - dancing and skiing, etc.
treatment to ligamanets
- control inflammation in acute stage to provide pain-free ROM
- strengthen surrounding muscles to stabilize the area
- provide controlled stresses to help align newly laid collagen fibres in an organized and efficient direction as it heals
3 grades of sprains of ligaments
grade 1 - minor - doesn't show up in clinic <25% damaged
grade 2 - moderate - <50% of ligament is damaged
grade 3 - major - >50-100% of ligament is damaged - avulsed meaning pull or tear away
tendon
- attaches muscle to bone
- limited blood supply and neural supply
- musculotendinous junction has best blood supply (more than bony attachment)
- injuries are due to macrotrauma or microtrauma due to repetitive overload, often of eccentric nature
- you can't seperate a muscle injury from a tendon injury
treatment to tendons
- AROM pain free range 24 hours of pain onset
- ROM and pain free stretching
- when able to achieve full pain free ROM add concentric strength
- gradually start eccentric loading as healing progresses
I.C.E.
Isometric
Concetric
Eccentric
**focus on isometric at beginning stages of healing and then move on to concentric and then eccentric**
skeletal muscle
- has lots of blood supply and innervation
**muscles strains graded in accordance to the amount of tissue destruction**
grade 1: minimal tear in fibres; no palpable defect and minor loss of function
Grade 2 strain: up to half of fibres are torn and leads to painful dysfunction that limits ROM and activity
Grade 3 strain: considered a rupture of all the fibres and leads to major disability and often a palpable defect.
* this is not the same as muscle grading
treatment to skeletal muscle
- grade 2 strain, painfree ROM (PROM, AAROM or AROM) for first two weeks. Sustained stretching is allowed, but painfree. Week 3 light loaded strengthening may begin, but only if painfree.
- Grade 3 strain, approach is the same, but light loaded strengthening would not begin until week 5.
bone
- bones have good blood supply
- periosteum (outer layer of bone) has sensory nerve supply
- when injury happens to bone:
1. inflammation
2. soft callus (helps stabilize fracture)
3. hard callus (stronger stability) 3 weeks to 4 months
4. bone remodelling
- bones have longer healing time
treatment to bones
- immobilization (4 weeks youth, 5 weeks healthy adult, 6 weeks compromised healthy/elderly/multiple injuries)
- Immediately post immobilization, ROM and stretching are necessary to prevent contractures
- Strengthening begins, painfree, at 6 weeks
- Compression on bones in painfree limits helps bone growth – bones respond well to weight bearing
indication for ambulatory aids
- improve persons stability (expand BOS)
- reduce weight bearing
- compensate for lost balance, strength or coordination
- reduce pain
- promote healing
4 types of gait patterns
- 4 point - right crutch, take a step with left foot, left crutch out, take a step with right foot
- 2 point - crutch goes forward at the same time as injured foot (held in opposite hand) then unaffected leg and crutch go forward, repeat
- modified 2 or 4 point - remove a crutch and do the same thing
3 point - using crutches normally - both crutches and good foot on the floor at the same time
Modified 3 point - walking instead of hoping
non-weight bearing (NWB)
- limb cannot touch the ground
- three point gait is an example of this
Full weight bearing (FWB)
- no WB restriction ... may use a gait aid for stability
- two point gait - abulatiion aid and opposite LE move toether simultaneously
- four point gait - as per above but not simultaneous
partial weight bearing (PWB)
- Limited amount of WB permitted through LE (sometimes expressed with % BW OR amt of BW)
- Not used very often, not very realistic
- Weight is determined by surgeon
feather weight bearing (FeWB or TTWB)
- minimal WB allowed - usually for balance
- very small amount of weight bearing
weight bearing as tolerated (WBAT)
- patient determines
- ranges from minimal to full WB
- generally should not result in pain
most supportive gait aid vs least
1. STOP walker
2. rolator walker
3. 2 ctutches
4. 1 crutch
5. quad cane
6. single cane
guarding the patient... how close is too close?
- make sure you are close enough to the patient that you can catch them if they are falling
benefits of strengthening (resistance training results in)
1. decreased muscle loss
2. increased muscle mass
3. improved body composition
4. improved bone mineral density
5. improved glucose metabolism
6. improved gastrointestinal (GI) transit time
7. improved/decreased resting blood pressure
benefits of strengthening (decreased muscle loss)
- muscle mass declines with ageing and disuse
- strengthening off sets this
benefits of strengthening (increased muscle mass)
- Hypertrophy – increase in size of muscle cells/fibres (Ability to increase size of the muscle itself)
- Hyperplasia – increase in number of cells/fibres (more splitting of the muscle fibers)
- Combination of both allows muscle to exert greater force (ie stronger)
benefits of strengthening (body composition)
- Body composition changes in relationship to exercise and increase of muscle mass
benefits of strengthening (bone mineral density)
- Increases with increased muscle activity due ttension/forces on bone
- Reduces the risk of osteoporosis
- weight bearing and banging of bone on land matters with how dense your bones will be when you’re older
benefits of strengthening (glucose metabolism)
- Improves with exercise
- Reduces the risk of diabetes
- If you have diabetes, it helps manage the sugars
- type I - genetic
- type II - acquired over time
benefits of strengthening (GI transit time)
- Improves with exercise- food moves more quickly and easily through digestive system
- Helps with eliminating waste
- More waste out, less issues with constipation and less risk of cancer in colon
benefits of strengthening (resting blood pressure)
- Decreases with exercise
- Important in heart health
How does strengthening work?
1. anatomic considerations of muscle
- Muscle structure - composed of thousands of muslce fibres
- Muscle fiber structure
1. Actin and myosin make up the contractile element of the muscle
2. sarcomere is Z line to Z line, actin is bound to Z-line, myosin is bound to actin
how does strengthening work?
2. Regulation of muscle contraction
- Motor unit
- Motor unit recruitment (recruit more of the motor units)
- Cross section
- Force velocity (eccentric vs concentric)
how does strengthening work?
2. Regulation of muscle contraction (Motor unit)
- The functional unit of skeletal muscle consists of:
1. Single alpha motor neuron
2. Axon from motor unit and terminal branches
3. All the individual muscle fibers innervated by the axon via the terminal branches
how does strengthening work?
2. Regulation of muscle contraction (Motor unit recruitment)
- Strength of muscle contraction affected by:
1. Number of motor units recruited
2. Frequency of stimulation (firing of the motor neuron)
3. Comes from the Central Nervous System
how does strengthening work?
2. Regulation of muscle contraction (cross section)
- The larger the cross section of the muscle, the more tension it can produce (ie size of the muscle fibres and number of muscle fibres/myofibrils)
- the larger the muscle is, the stronger it is
how does strengthening work?
2. Regulation of muscle contraction (force velocity)
- Concentric: muscular tension decreases as velocity of the shortening contraction increases, tension increases as velocity decreases (ie muscle shortens as it contracts)
- Eccentric: muscular tension increases as velocity increases (muscle lengthens as it contracts)
**Tension = Length or Tautness and NOT Force
**speaking of the tension on the muscle, not the tendon
How does strengthening work?
1. adaptation of muscle
- 2 ways:
1. Hypertrophy/Hyperplasia: Increase in the size of muscle: increased actin and myosin in the muscle fibre
2. Neural Adaptation: Enhanced motor unit activation (e.g. Practice)
general training principles
1. overload - challenge and fatigue lead to adaptive change
2. Intensity: – strength of the stimulus per unity of time (resistance and speed)
3. Volume: - the amount of training (sum of all repetitions, sets, duration)
4. Specificity – to specific activity (e.g. point in ROM that your working a certain muscle this is where you get stronger) - e.g. Karen is really strong in the legs because she squats so much with her job
5. Cross-training – can be beneficial, but less effective and less efficient than training specifically for an activity
e.g. getting hockey players to do other things in the summer to keep strong and keep the ROM high (such as a goalie working on flexibility)
6. Overtraining – can be bad - may lead to injury
7. Precautions:
Avoid valsalva maneuver (holding breath during exertion) by breathing rhythmically or talking
Avoid DOMS*: delayed onset muscle soreness by keeping exercise intensity below the threshold of pain
fast twitch muscles
- Fast twitch: respond quickly
- takes more stimulus to fire them
- once fired they produce high tension, move quickly
- fatigue rapidly
- less blood supply (ie white in appearance)
- Peripheral musculature
- Power Muscle
- e.g. arm and legs
slow twitch muscles
- takes less stimulus to fire them
- once fired they produce less tension
- slow to fatigue
- more blood supply (ie red in appearance)
- Torso musculature
- Endurance Muscle
-e.g. everything that has to do with holding our posture (soleus is an exception)
fast twitch (power) parameters
- Work 10-30 reps alternate days
- Move slowly through full range,
- Especially in eccentric direction
slow twitch (endurance)
- Work 10-30 reps daily
- Sustained holds of 10+ seconds
- Holding posture in different ways
exercise prescription details
1. mode
- Isometric, Isotonic (OKC or CKC), Isokinetic (rarely used)
- Are you doing open kinetic or closed kinetic
exercise prescription details
2. duration
- how many times in one session
- e.g. 5 reps, 10 reps, 20 reps
exercise prescription details
3. frequency
- how many exercise sessions
- how many times a day
exercise prescription details
4. intensity
- challenge of exercise (ie load)
- e.g. poundage (how hard the exercise is)
exercise prescription details
5. warm-ups and cool downs
useful before/after sport, work conditioning, sequence training
Adult perspecitive (mode)
- Closed Kinetic chain uses fast and slow twitch
- Open Kinetic Chain uses isolated fast twitch
- Functional Activities can include both
Adult Perspective (duration)
- fast twitch/power work 0 sec holds, 10-30 reps alternate days
- slow twitch/postural work 10 sec holds repeat to fatigue once a day (take one day a week off);
Adult perspective (frequency)
a. power – done one time/day alternate days (fast twitch muscles) - working in society
b. endurance – done one time/day daily minimum with one day a week rest (slow twitch muscles) - working in society
c. work hardening – power and endurance work done daily and multiple times/day (fast or slow twitch) - not working in society because they are injured or disables (ie simulating everyday life for that patient)
adult perspective (intensity)
- exercise chosen determines intensity
- against gravity or gravity eliminated
- external load/weight/theraband
manual muscle testing grade 0-5
Grade 0: No detectible muscle contraction
Grade 1: Muscle flicker; no active movement at joint muscle contraction (no ROM)
Grade 2: Muscle able to move joint through complete ROM, gravity eliminated
Grade 3: Muscle able to move limb through complete ROM, against gravity
Grade 4: Muscle able to move limb through complete ROM, against gravity and moderate resistance
Grade 5: Muscle able to move limb through complete ROM, against gravity, full resistance (within normal limits)
manual muscle prescription
Grade 0 or 1 – use PROM to avoid contractures (no strength value)
Grade 2 – use AAROM so patient gets stronger
Grade 3 or 4 or 5– AROM and loaded isotonic OKC and CKC work.
geriatric perspectives of force contraction
Ability to generate force of contraction declines by:
- 1% per year: 30–50
- 13% per decade: 50–70
- 30% per decade: >70
Muscle strength of lower extremity declines faster than upper
pediatric perspective force contraction
- Strength increases linearly with chronologic age from early childhood in both genders until 14 years old.
- Proper strength training can improve strength without adverse effects on bone or muscle at any age
Resistance training will improve muscle strength. Strengthening will NOT do the following:
a. Decrease muscle loss
b. Increase muscle mass
c. Decrease glucose metabolism
d. Increase bone density
c. Decrease glucose metabolism
Hypertrophy is an increase in ____ of muscle cells/fibers and hyperplasia is an increase in ___ of muscle cells/fibers
size/number
Thinking of exercise parameters, which is true (can be more than one correct)
Frequency is the number of times per day
Mode is the type of exercise
Duration is the number of reps
Frequency is the number of times per day (true)
Mode is the type of exercise (true)
Duration is the number of reps (false)
True or false: delayed onset of muscle soreness (DOMS) is worse with concentric exercise and happens after every exercise session always
false
___ twitch takes more stimulus to fire/contract
fast
If you have your wrist in full flexion, and resist on the palmar side, you are working the inner range of _______
Wrist flexors
Isometric exercises should be done at multiple points in the range because of the:
a. Specificity principle
b. Volume principle
c. Overload principle
d. Overtraining principle
a. Specificity principle
therapeutic exercise
Therapeutic Exercise is the systematic performance or execution of planned physical movements, postures or activities intended to enable the patient/client to:
1. remediate or prevent impairments
2. enhance/ improve function
3. reduce risk (falls, for example)
4. optimize overall health
5. enhance fitness and well-being
what situations could be improved by exercise
Pathology: e.g. stroke, fracture, arthritis
Impairments: e.g. gait, locomotion, balance, muscle tear, back joint dysfunction
Functional limitations: e.g. self-care, home management, sitting tolerance, standing tolerance
Disability: e.g. inability to work, inability to care for yourself, inability to care for your dependents
Risk reduction: e.g. fall prevention
Health, wellness and fitness: happy peeps
procedural interventions
- flexibility exercises (stretching)
- strengthening (exercises for power and endurance)
- aerobic capacity/endurance conditioning (heart)
- balance, coordination and agility training
- body mechanics and postural stabilization/core strength
- gait and locomotion training
- neuromotor development training (paeds)
- relaxation/release
exercise considerations
Stage of Healing – tells us about when to be gentle and respect healing and when we need to add challenge to encourage healing
Pain – when to avoid it and when not to avoid it
- the majority of situations stretching and strengthening should be pain-free
- unless someone needs to be pushed to get their wrist movement back there may be a little bit of pain (strengthening should always be pain-free- only go into pain for stuck joints or ROM exercises)
Goal trying to accomplish – what are we working toward (e.g. work task, improving strength to eliminate pain, etc)
most efficient and strongest determinant of tissue healing rate
blood supply
strengthening (safe 10 rule)
- Strengthening= PAINFREE!!!
10 reps pain free, full ROM and beautiful technique
If the patient cannot do this, modify task to make easier**
30 reps (3x20) pain-free and accurate = Safe Task that is getting too easy and ready for more challenge***
Fatigue is not pain.
agonist vs antagonist
1. The agonist is working very slowly to move the limb with small or no load then the antagonist does not assist
2. if agonist is working to move the limb very fast with small or no load the antagonist will need to assit
3. if the agonist is working to life a very heavy load at any speed the antagonist will need to assist
stretching
- will elongate tissue
- muscles being stretched need to be completely relaxed
- elongation of tissue will only occur if stretched 2 min 4x a day
- pain or no pain depends on phase of healing
**stretching does not make you stronger**
stretching rules
- Day 0-10 Post Surgery or Fracture (Inflammation Stage of Healing) or Chronic Inflammation (eg tendonopathy) –
Avoid all pain. If pain comes on before stretch sensation, respect that and stop position just before the pain. “Sneak up on the length”
- 5 week Post Surgery or Post Fracture (Proliferation Stage of Healing) – Positions of sustained stretch at end range will be painful. Aiming for sustained stretch within pain tolerance (avoid spasm)
THIS IS THE ONLY TIME YOU WILL PUSH INTO PAIN
pain science
- pain is not always an accurate indicator of the health of the tissue
Pain Receptors tell us about:
a) VELOCITY
b) STRETCH
c) PRESSURE
d) THERMAL
- The body uses pain to protect us.
- We have normal thresholds of stimulus before the body defines the stimulus as painful
- However after injury the receptors can be maladapted or reset to fire too early
- people have a fear of pain
- we can educate people, provide gradual activity, and monitor peoples pain levels
when is it necessary to work into pain
during stretching post fracture or post surgery
- patient should feel recovered the nect day
- swelling should not increase
- ROM should remain the same or improve but never decrease
osteokinematic motion
- osteo=bone
- under voluntary control
- the typical amount of movement available at every joint
- direction, plane and axis of motion
Arthrokinematic Motion
- arthro=joint
- not under voluntary control
- accessory movement (rolling, sliding/gliding, spinning)
- movement of joint surfaces
true or false PROM can prevent muscle atrophy
false
True or false: AAROM can be done with equipment OR with another body part. The latter is known as AUTO ASSISTED ROM.
true
The benefits of strengthening can be achieved with:
a. PROM
b. AAROM
c. AROM
d. B and C
d. B and C
PROM does NOT do the following:
a. Improve pain control
b. Assist remodeling of joint capsule
c. Promote muscle hypertrophy
d. Prevent contractures
c. Promote muscle hypertrophy
When immobilization is necessary, it can lead to…
Joint stiffness
Muscle contractures
Muscle atrophy (weakness)
Bone density quickly becomes fragile
Cartilage becomes very fragile
Name different exercise interventions
Aerobic
Cardiovascular
Stretching
Agility training
Core training (for stabilizers)
Balance training
Bob injured his right knee, 40% of his MCL is torn. He has full knee PROM. While sitting he cannot straighten his knee fully - quad lag 20 degrees.
a. Grade 2 ligament sprain and grade 3 quad power
b. Grade 3 ligament sprain and grade 3 quad power
c. Grade 2 ligament sprain and grade 2 quad power
c. Grade 2 ligament sprain and grade 2 quad power
Typical STRETCHING parameters for injured muscle are
a. 2 min 4x per day
b. 2 min once a day into pain
c. 10-30 reps alternate days
d. 10 sec hold 10-30 reps daily
a. 2 min 4x per day
Typical strengthening parameters for fast twitch muscles are
a. 2 min holds 4x per day
b. 10 sec holds 10-30 reps daily
c. 10-30 reps alternate days
d. 10-30 reps daily
e. 10-30 reps multiple times a day
c. 10-30 reps alternate days
benfits of ROM exercise
1. MAINTAIN JOINT MOBILITY
2. NUTRITION (THINKING LUBRICATION)
3. PREVENT ADHESION AND CONTRACTURE
4. NUTRITION AND CONTINUOUS REMODELING OF CARTILAGE (CARTILAGE IS MUCH HAPPIER ITSELF WHEN MOVEMENT IS HAPPENING)
what is a closed pack position
- position in which the joint is at maximal congruence
- e.g. knee is at full extension, ankle is full dorsiflexion
benefits of AROM and AAROM
1. Increase blood circulation
2. Prevent venous stasis, clot formation
3. Slow rate of muscle atrophy
4. Increase proprioceptive input
5. Improve coordination
6. Improve motor control
what does CPM stand for?
- continuous passive motion (CPM)
- mechanical device that moves hours at a time
- promote early recovery ROM
- decrease effect of joint immobilization
- e.g. machine that moves the knee through continuous flexion/extension
benefits of PROM
1. Inhibit pain
2. Promote ligament and capsule remodeling
3. Prevent contractures forming
NOT EFFECTIVE FOR:
1. INCREASING STRENGTH
2. PREVENTING ATROPHY
Intrinsic and extrinsic factors affecting ROM
intrinsic:
- Shape and congruency of articulating bone
- Pliability of joint capsule and ligaments
- Muscle flexibility
- Muscle strength (affects AAROM & AROM)
extrinsic:
- Age
- Adipose tissue - FAT
- Disease: eg Arthritis, including RA or OA
- Injury, overuse (possibly swelling)
- Immobilization
effects of immobilization
1. loss of bone density
- results from lack of muscle pull on bone
- occurs in a few weeks and can lead to osteoporosis
2. cartilage dehydration and degeneration
- occur in a few days
- softening, reduced thickness
- decreased ability to absorb force
3. collagenous tissue fibrosis and adhesion
- stiffening and tightening of capsule, ligaments, fascia, tendons
- excessive collagen crosslink leads to decreased joint motion, and decreased tensile strength
- form adhesions
- adhesive capsulitis = frozen shoulder
4. muscle tissue contracture
- shortening of the viscoelastic properties of the muscle cell
- this allows a muscle to go back to resting length after eccentric work or stretching but with inactivity can become shortened
5. muscle atrophy
- decreased muscle size
- decreased contractile force/strength
- can occur in just days
- more specific to slow twitch
geriatric perspectives (ROM)
- ROM is progressively lost starting at age 30, with greater losses after 40.
- ROM used in activities of daily living is lost at slower rate
- E.g. trunk flexion is lost more slowly than extension.
pediatric perspectives (ROM)
- Children exhibit much greater ROM than adults.
- Newborns exhibit excessive ROM that progressively decreases through childhood.
- Maintenance of ROM is imperative in those with childhood diseases such as juvenile rheumatoid arthritis.
muscle flexibility
Muscle Flexibility is the Ability of a muscle to lengthen
- Reduce risk of injury
- Pain relief (ie reduce spasm)
- Improved athletic performance
neurophysiologic properties of muscle
- muscle spindle
- golgi tendon organ
______________________
- autogenic inhibition
- reciprocal inhibition
afferent
= sensory
- goes from body to CNS
- can sense, touch, pain, temperature, length of stretching
- stimulates muscle contraction
efferent
= motor
- info goes from brain to a muscle causing contraction
muscle spindle
- Responds to a change in muscle length
- Responds especially to the velocity at which the length changes: the quicker the stretch, the more signals and more frequent the impulses to the spinal cord
- The Muscle Spindle helps protect our muscles from injury.
- if you are stretching slowly it doesn't respond as fast
muscle spindle/quick stretch reflex arc
- Quick stretch of muscle (ex. Quadriceps/knee jerk) by hitting patellar tendon with reflex hammer
- The muscle spindle is stimulated by quick stretch
1. Afferent fibres from muscle spindle send impulses to the spinal cord (central nervous system [CNS]) after a quick stretch
2. Afferent nerve excites alpha motor neuron in the spinal cord
3. CNS (spinal cord) sends reflexive impulses to (Quadriceps) muscle via the alpha motor neuron
4. The impulse causes the (Quadriceps) muscle to contract reflexively
5. The (Quadriceps) muscle thereby resists attempts to be stretched and prevents muscle injury
golgi tendon organ
- Located at the Musclotendinous Junction
- musculotendinous junction will fire when the muscle contracts or stretches but not at resting state
- Respond to change in tension (due to contraction or prolonged stretch of at least 15 seconds)
- Prevents over-activity of the nerve fibres and the extrafusal muscle (outside muscle spindle): i.e. prevents prolonged tension in that could cause spasms, pain or damage the muscle
- Causes the muscle it is in to relax after it has contracted – so we don’t have to actively relax after every movement
Can override impulses coming from muscle spindle
golgi tendon organ and the antagonist
- GTO also can affect the antagonist muscle
- When a muscle contracts, the GTO causes the nervous system to tell the antagonist muscle to relax
- If it didn’t do this, every time we contracted one muscle, its antagonist might work against it
- Sometimes this is good (co-contraction)
- Example: trunk stabilization – flexors and extensors work at the same time
- Especially in the limbs, though, co-contraction would be exhausting and would not allow normal movement, esp flexion/extension at hip and knee during gait
excitatory vs inhibitory
1. excitatory - allows the muscle to create force
2. inhibitory - inhibit muscle from creating any force thus protecting you from injuring yourself
true or false GTo will overrule the muscle spindle
TRUE
GTO isometric hamstring contraction
- GTO fires due to tension produced in the muscle during contraction
- Afferent fibers send impulse to central nervous system
- CNS sends impulse to hamstring muscle.
- Hamstring muscle relaxes AND Quadriceps muscle relaxes
autogenic inhibition
- Muscle contracts to produce tension (or if muscle is stretched for a prolonged time: >15 sec).
- This tension in the muscle stimulates the GTO to send impulses to the CNS
- The impulse from the GTO in the muscle overrides excitatory impulse and causes reflexive relaxation of the muscle
- In normal movement, this means a muscle contract voluntarily, but we don’t have to voluntarily stop it from contracting – it relaxes by reflex
reciprocal inhibition
- Agonist muscle contraction
- Antagonist muscles are inhibited simultaneously
- When knee extends (agonist = quadriceps), knee flexors relax (antagonist = hamstrings)
- Allows smooth movement
what are the three types of stretching
1. static
2. ballistic
3. PNF - proprioceptive neuromuscular facilitation
static stretch
- Slowly elongate muscle to tolerance
Slow prolonged stretch:
- Effect from muscle spindle is minimized: Therefore muscle spindle DOESN’T cause contraction (due to low velocity)
- Effect from GTO is maximized: Therefore GTO DOES cause relaxation
- Result = More effective stretch and increased flexibility in muscle
**Most common form of stretching**
static stretch duration
> or =30 seconds: young
> or =60 seconds: over 65
- 2 min holds sustained, 4x per day when trying to change length of muscle.
- Go into first pain sensation, then back limb off of that point and wait. After one minute try to move very slightly into the stretch further. If painfree, continue. If painful, move away to previous position.
‘SNEAK UP ON MUSCLE’
ballistic stretch
- Repetitive bouncing or jerking movements
- 10 to 15 bounces, each one extending further
- Fires Muscle Spindle so muscles contract
- Important in some sports, like Olympic gymnasts
- Not commonly used unless sport demands it
static vs ballistic
static = fires GTO, if you move slowly it avaoids MS
ballistic = first MS
GTO sensory afferent speaks to CNS to inhibit muscle contractions (muscle does not contract)
MS sensory afferent speaks to CNS to inhibit muscle contraction (muscle contracts)
proprioceptive neuromuscular facilitation (PNF)
- use a brief contraction or movement before a stretch
- terminology varies (contract-relax, hold-relax, slow reversal hold-relax, contract relax with agonist contraction)
- PNF techniques
1. Autogenic Inhibition Techniques
2. Reciprocal Inhibition Techniques
3. Combination
PNF autogenic inhibition
- PTA moves the patients extended leg into a full straight leg raise
- patient pushes leg into PTA for 10 seconds isometric contraction of hamstrings
- GTO fires, hamstring relaxes (autogenic inhibition)
- PTA then moves limb into more SLR, as available, and holds for 10 seconds
- hamstring Relaxes
- then this position is held for 2 minutes
PNF reciprocal inhibition
- PTA moves extended leg into full straight leg raise
- PTA asks patient to do more SLR (hip flexion)
- during active hip flexion the hamstring relaxes via reciprocal inhibition (CTO makes its antagonist relax)
- PTA move hip into further flexion
- Sequence repeated again and after 2 cycles this point is held for 2 minutes
Combination PNF Technique
e.g. hamstring stretch
- PTA moves extended leg to full SLR
- Patient extends hip against PTA for isometric contraction (autogenic inhibition)
- After contraction, PTA asks patient to actively SLR the leg (hip flexion) more (reciprocal inhibition)
- PTA takes up slack and holds
- Sequence is repeated twice
- This position is then held for 2 minutes
geriatric perspectives of stretching
- As one age, muscle distensibility and tensile muscle strength decrease.
- Warm-ups and mild stretching are useful for the management of chronic pain.
- Base the stretching program on the client’s functional needs.
pediatric perspectives of stretching
- Children are much more flexible than adults
- No ballistic stretching because of strain at apophyses and epiphyses
stretching (adult, child, and geriatric)
children - 30 seconds
geriatrics - 60 seconds
adults - 2 minutes