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THERAPEUTIC EXERCISE

Presented by : Myra Leslie S. ViloriaSPT IV Therapeutic Exercise Enables the patient to : Remediate or reduce impairementsEnhance functionOptimize overall functionEnhance 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 relationshipsFatigue

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 reticulumProlonged 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 : MMTUsing a dynamometerIsokinetic 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 motionB. ROMBody positionExercise durationExercise frequency A safe progression. A safe progression is ensured if the exercises are progressed from :Slow to fastSimple to complexStable to unstableLow 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 :

HypertrophyIncrease in the efficiency of the neuromuscular system . This increased efficiency results in : Icnrease in the number of motor units recruitedIncreased in the firing rate of each motor unitIncrease 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 improvesImprove 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 : DiseaseNeurologic compromiseImmobilizationDisuseTypes 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 rangeNot all of a muscles fibers are activated there is predominantly an activation of slow-twitch There are no flexibility or cardiovascular fitness benefitsPeak 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 wallCardiovascular 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 equipmentRelying 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 techniquesAbility to limit the range Disadvantages : Amount of resistance applied cannot be measured quantitativelyAmount of resistance is limited by the strength of the clinician /family memberDifficulty with consistency of the applied forced throguhtou the range and with each repititionType 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 ofconditioning 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 activitiesThick 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 approachingeach 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 minutesTraining period20 to 30 minutes at 40%60% (low intensity), 60%70% (moderate intensity),or 70%85% (heavy intensity) of their VOmaxCool-down period 5 to 10 minutes2Guidelines for the quantity and quality of aerobic exercise programs for healthy adults as proposed bythe American College of Sports Medicine Modeany exercise that uses large muscle groups, continuous and rhythmic in naturExamples: running, swimming, walking, stair climbing. Frequency35 days/week Duration2060 minutes Intensity60%90% HR max50%85% of VOmax 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 tofive repetitions once or twice a dayTECHNIQUES TO IMPROVE FLEXIBILITY Can be done through anatomic planes of motion, combined planes of motion (similar toperipheral neuro-facilitation patterns), or through functional teaching activitiesStretching Exercises

Increase ROM by lengthening tendon and muscle beyond the available rangeInclude static stretching, static stretching with contraction of the antagonist muscle (reciprocal inhibition), static stretching with contraction of the agonist muscle, and ballistic stretchingBallistic stretchingutilizes repetitive bouncing movements with a rapid stretch. Moretension is developed, and more energy is absorbed into the muscle and tendon, which canlead 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 heldfor 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 bya 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 ROMand followed by an isometric contraction of the agonist muscle for 5 to 30 secondsEFFECTS OF EXTENDED BEDRESTIMMOBILIZATIONAND INACTIVITYMUSCLEStrengthimmobilization 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 reached25%40% of original strength. One contraction a day at 50% of maximal strength isenough to prevent this decreasStrength is lost especially in the quadriceps and extensors A decrease in fiber diameter is found affecting type I fibers (slow twitch) during earlyimmobilization. A decrease of percentage of type I fibers is noted. A decrease in oxidativeenzymes is also notedRestricted activities affect muscle strength and recruitment patterns of muscles distantfrom specific sites of injury.BONE AND JOINTS

Lack of gravitational force and muscle pull on bone cause osteopenia. As a result ofosteopenia, hypercalcemia develops. Calcium is excreted in the urine and fecesstarting at 23 days after immobilization, and peaking at 37 weeks. After activity isresumed, calcium levels remain high for 3 weeks, reaching normal values at 56 weeksWhen comparing calcium to nitrogen and protein changes in the urine, it is notedthat calcium improves last. Nitrogen loss is 2g N/day. Loss begins at 56 days afterimmobilization, peaks in the second week. After activity is resumed, loss continues for1 week, normalizes during the second week, below normal values are obtained at 4weeks, and returns to normal values in 6 weeksCalcium excretion in addition to phosphorus loss causes atrophy and a reduction infracture threshold of boneJoints show a decrease in periarticular connective tissue extensibility after inactivity.Articular cartilage begins to deteriorate due to lack of nutritional support. The hyalinecartilage in synovial joints is not supplied by vascular blood flow. It depends on nutritionfromthe synovial fluid throughloading and unloading of pressureLigaments undergo biochemical changes noted as early as two weeks after immobilization.In the case of surgically repaired ligaments, improvement in strength is affected byimmobilization.Immobilization causes ligament strengthto 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 urinarytract infections.PULMONARYDiminished diaphragmatic movement and chest expansion, due to loss ofstrength 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, decreasedvital 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 poolingoccurs 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 immobilizationtachycardia 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 INDEPENDENCEDifference between impairment, disability, and handicap: Impairmentphysical or psychological abnormality, usually the manifestation of adisease 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 impairmentand 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 safereturn home after a patient has been hospitalized One of the measurement scales used for this assessment is the FIM score (FunctionalIndependence Measure) (Figure 8-4). It documents the severity of disability as well as theoutcomes 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, andtoileting) 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 chronotropicresponse to adrenergic stimuli. Max HR = 220 agencreased 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 ismore dependent on an increased stroke volumerate 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 sedentarypatients

PULMONARY

Decreased vital capacityDecreased PO

No change in total lung capacity High incidence of pneumonINTEGUMENTARYDecreased elasticity of connective tissue leads to increased risk forpressure ulcers and skin breakdown. Decreased moisture, decreased skin sensationMUSCULOSKELETALOverall 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 andimpaired sensitivity to changes in temperature Patients are vulnerable to hypothermia and hyperthermia. Hypothermia is affected byimpaired sweating and aggravated by medical conditions, such as malnutrition, hypoglycemia,and hypothyroidism;or medications such as narcotics,ethanol, and benzodiazepinesNEUROLOGIC

Decreased short-term memory and incidental learning Slowing in the rate of central information processing tasks requiring new informationprocessing tend to decline progressively after 20 years of age Increase in choice reaction time is noted. The more complex the task, the greater the ageeffect Older adults are capable of learning but at a slower rate Decrease in proprioception and gait, leading to problems with coordination andbalance. There is associated decrease in nigrostriatal neurons with age Loss of speed of motor activitiesGENITOURINARY 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 decreasedglomerular filtration rate and decreased tubular function

GASTROINTESTINAL Impaired esophageal functiondecreased amplitude of peristaltic contractions Delayed esophageal emptying, and incomplete sphincter relaxation are associated withdisease 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 withdisease 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 InsomniaEmotional sequelaeAnxiety and confusion are common in relation to illness, prognosis, and hospitalization. Patients tend to develop depression.Many times patients are dependentfor functional activitiesDeconditioning effects include: Decreased VOmax Shortened time to fatigue during submaximal work Decreased muscle strength Decreased reaction time/balance/flexibility2Joint Mobilization\86Outlines What is Joint Mobilization?TerminologyRelationship Between Physiological & Accessory MotionBasic concepts of joint motion : ArthrokinematicsEffects of Joint MobilizationContraindications for MobilizationPrecautionsTechniques of joint mobilization 03/10/1435RHS 32287What is Joint Mobilization?Joint Mobs

Manual therapy technique Used to modulate pain Used to increase ROMUsed to treat joint dysfunctions that limit ROM by specifically addressing altered joint mechanics

Factors that may alter joint mechanics:Pain & Muscle guardingJoint hypomobilityJoint effusion Contractures or adhesions in the joint capsules or supporting ligamentsMalalignment or subluxation of bony surfacesPondering ThoughtsWould you perform joint mobilizations on someone who has a hypermobile joint?

03/10/143589RHS 322TerminologyMobilization passive joint movement for increasing ROM or decreasing painApplied to joints & related soft tissues at varying speeds & amplitudes using physiologic or accessory motionsForce is light enough that patients can stop the movement

Manipulation passive joint movement for increasing joint mobilityIncorporates a sudden, forceful thrust that is beyond the patients controlTerminologySelf-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 patientApplied in a pain-free directionTerminologyPhysiologic Movements Osteokinematics motions of the bonesmovements done voluntarilytraditional movements such as flexion, extension, abduction, rotationAccessory 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 controlEx: Upward rotation of scapula & rotation of clavicle that occur with shoulder flexionJoint play motions that occur within the jointDetermined by joint capsules laxityCan be demonstrated passively, but not performed actively92 TerminologyArthrokinematics motions of bone surfaces within the joint5 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 motionTherapist 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 preventPerformed at end of pathologic limit of the joint (snap adhesions, stimulate joint receptors)93TerminologyConcave hollowed or rounded inward

Convex curved or rounded outward94Relationship Between Physiological & Accessory MotionBiomechanics of joint motionPhysiological motionResult of concentric or eccentric active muscle contractionsBones moving about an axis or through flexion, extension, abduction, adduction or rotation

Accessory MotionMotion of articular surfaces relative to one anotherGenerally associated with physiological movementNecessary for full range of physiological motion to occurLigament & joint capsule involvement in motion95Basic concepts of joint motion : ArthrokinematicsJoint Shapes Type of motion is influenced by the shapes of the joint surfacesOvoid 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

96Basic concepts of joint motion : ArthrokinematicsTypes of joint motion5 types of joint arthrokinematicsRollSlide SpinCompressionDistraction

3 components of joint mobilizationRoll, Spin, SlideJoint motion usually often involves a combination of rolling, sliding & spinning

97RollA series of points on one articulating surface come into contact with a series of points on another surfaceBall rolling on groundExample: Femoral condyles rolling on tibial plateauRoll occurs in direction of movementOccurs on incongruent (unequal) surfacesUsually occurs in combination with sliding or spinning

98SpinOccurs when one bone rotates around a stationary longitudinal mechanical axisSame point on the moving surface creates an arc of a circle as the bone spinsExample: Radial head at the humeroradial joint during pronation/supination; shoulder flexion/extension; hip flexion/extensionSpin does not occur by itself during normal joint motion

03/10/143599RHS 322SlideSpecific point on one surface comes into contact with a series of points on another surface

Surfaces are congruentWhen a passive mobilization technique is applied to produce a slide in the joint referred to as a GLIDE.Combined rolling-sliding in a jointThe more congruent the surfaces are, the more sliding there isThe more incongruent the joint surfaces are, the more rolling there is

100Compression Decrease in space between two joint surfacesAdds stability to a jointNormal reaction of a joint to muscle contraction

Distraction - Two surfaces are pulled apartOften used in combination with joint mobilizations to increase stretch of capsule.

101Convex-Concave & Concave-Convex RuleBasic 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

03/10/1435102RHS 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 roll103RULE OF CONCAVE-CONVEX

104RHS 322Effects of Joint MobilizationNeurophysiological effects Stimulates mechanoreceptors to painAffect muscle spasm & muscle guarding nociceptive stimulationIncrease in awareness of position & motion because of afferent nerve impulses

Nutritional effects Distraction or small gliding movements cause synovial fluid movementMovement 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 105Contraindications for MobilizationShould not be used haphazardly

Avoid the following:Inflammatory arthritisMalignancyTuberculosisOsteoporosisLigamentous ruptureHerniated disks with nerve compressionBone diseaseNeurological involvementBone fractureCongenital bone deformitiesVascular disordersJoint effusion May use I & II mobilizations to relieve pain

106PrecautionsOsteoarthritisPregnancyFluTotal joint replacementSevere scoliosisPoor general healthPatients inability to relax107Techniques ofJoint Mobilization108

03/10/1435109RHS 322Maitland Joint Mobilization Grading ScaleGrading based on amplitude of movement & where within available ROM the force is applied.

Grade ISmall amplitude rhythmic oscillating movement at the beginning of range of movementManage pain and spasmGrade IILarge amplitude rhythmic oscillating movement within midrange of movementManage pain and spasm

Grades I & II often used before & after treatment with grades III & IV110Grade IIILarge amplitude rhythmic oscillating movement up to point of limitation (PL) in range of movementUsed to gain motion within the jointStretches capsule & CT structuresGrade IVSmall amplitude rhythmic oscillating movement at very end range of movementUsed to gain motion within the joint Used when resistance limits movement in absence of pain

Grade V (thrust technique) - ManipulationSmall amplitude, quick thrust at end of rangeAccompanied by popping sound (manipulation)Velocity vs. forceRequires training111Indications for MobilizationGrades I and II - primarily used for painPain must be treated prior to stiffnessPainful conditions can be treated dailySmall amplitude oscillations stimulate mechanoreceptors - limit pain perceptionGrades III and IV - primarily used to increase motionStiff or hypomobile joints should be treated 3-4 times per week alternate with active motion exercises112ALWAYS Examine PRIOR to TreatmentIf 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 limitationQuality 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 usedStretching under these circumstances is contraindicated

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

If pain is experienced AFTER tissue limitation is met because of stretching of tight capsular tissue, the joint can be stretched aggressively

03/10/1435113RHS 322Joint PositionsResting positionMaximum joint play - position in which joint capsule and ligaments are most relaxedEvaluation and treatment position utilized with hypomobile joints

Loose-packed position Articulating surfaces are maximally separatedJoint will exhibit greatest amount of joint playPosition used for both traction and joint mobilizationClose-packed positionJoint surfaces are in maximal contact to each other

General rule: Extremes of joint motion are close-packed, & midrange positions are loose-packed.114Joint Mobilization ApplicationAll joint mobilizations follow the convex-concave rulePatient should be relaxedExplain purpose of treatment & sensations to expect to patientEvaluate BEFORE & AFTER treatmentStop the treatment if it is too painful for the patientUse proper body mechanicsUse gravity to assist the mobilization technique if possibleBegin & end treatments with Grade I or II oscillations115Positioning & StabilizationPatient & extremity should be positioned so that the patient can RELAX

Initial mobilization is performed in a loose-packed positionIn 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 boneHand, belt, assistantPrevents unwanted stress & makes the stretch force more specific & effective116Treatment Force & Direction of MovementTreatment force is applied as close to the opposing joint surface as possibleThe 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 plane117Treatment 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 planeEntire bone is moved so that the joint surfaces are separated

Treatment Direction03/10/1435118RHS 322Gliding techniques are applied parallel to the treatment planeGlide in the direction in which the slide would normally occur for the desired motionDirection of sliding is easily determined by using the convex-concave ruleThe entire bone is moved so that there is gliding of one joint surface on the otherWhen using grade III gliding techniques, a grade I distraction should be usedIf 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 visitIf increased pain, reduce amplitude of oscillationsIf joint is the same or better, perform either of the following:Repeat the same maneuver if goal is to maintain joint playProgress to sustained grade III traction or glides if the goal is to increase joint play119Speed, Rhythm, & Duration of MovementsJoint mobilization sessions usually involve:3-6 sets of oscillations Perform 2-3 oscillations per secondLasting 20-60 seconds for tightnessLasting 1-2 minutes for pain 2-3 oscillations per secondApply smooth, regular oscillations Vary speed of oscillations for different effectsFor painful joints, apply intermittent distraction for 7-10 seconds with a few seconds of rest in between for several cyclesFor 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 intervals120Patient ResponseMay cause sorenessPerform joint mobilizations on alternate days to allow soreness to decrease & tissue healing to occurPatient should perform ROM techniquesPatients joint & ROM should be reassessed after treatment, & again before the next treatmentPain is always the guide121Joint Traction TechniquesTechnique involving pulling one articulating surface away from another creating separationPerformed perpendicular to treatment planeUsed to decrease pain or reduce joint hypomobilityKaltenborn classification systemCombines traction and mobilizationJoint looseness = slack

122 AQUATIC THERAPY

Intro to Aquatic TherapyAquatic 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 therapyPatients with:ArthritisHealing fractured bonesStress fracturesWho have pain only in WB activitieswho are overweight Post surgery

The Benefits of Aqua TherapyPain ControlWater 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-EsteemPeople 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 ImpactExercises in the water decreases the impact created within the joints as compared to completing exercises on land

Other BenefitsGreat for patients with:SwellingDecreased ROMDecreased strengthDecreased balance, coordination, proprioWeight bearing restrictionsCardio deconditioningGait deviations

Difficulty with land interventionArthritisHealing fractured bonesStress fracturesWho have pain only in WB activitieswho are overweight Post surgery

DisadvantagesAccess to a poolNot every clinic will be near or have a pool suitable for aquatic therapyQualified pool attendantsQualified ATs

Precautions and contraindicationsOpen woundsRespiratory dysfunctionSeizure disorders, controlled by medsFear of waterchlorine allergyaltered peripheral sensationuntreated infectious diseaseserious cardiac conditions Upper limbCan be used for treatment ofThe shoulder complexElbowWristHand

Exercises for Shoulder Complex Injuries Initial LevelStart with patient in shoulder deep water walking forwards and backwards trying to keep a normal arm swingGH movements can be done with patient back against the wall to stabilize the scapulaThe movements can be done supine or prone depending on the patients level of comfort in the water

Exercises for Shoulder Complex InjuriesIntermediate LevelAt this stage you can use equipment to increase the resistance to build on strengthKeeping with in a pain free zoneScapular 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 InjuriesFinal LevelThe goal for this level is to incorporate sport specific movements, and to make it more challengingBy bringing in sport equipment into the pool the patient can do sport specific movements

Lower LimbCan be used for treatment ofHipKneeAnkle

Exercises for Lower Limb InjuriesInitial LevelGoalsIncrease normal movementsIncrease strength of unaffected musclesIncrease ROMWalking forward, backwards and sideways help maintain a normal gaitDeep water activities help maintain cardio for patients who cant WB due to stress fractures or other injuries that require NWB activitiesExercises for Lower LimbIntermediate LevelGoalsIncrease ROMIncrease Strength Increase FlexibilityAqua belts can be used to allow for deep water runningCan do eccentric activities in shallow water by standing on a flutter board or a noodle

Exercises for Lower LimbFinal LevelBest used as a compliment to on land trainingCan have the athlete do deep water activities without a flotation beltCan do squats on noodles, dumbbells, or flutter boardsPool running

Things you can use for Aquatic Therapy Thera-band to tether them to the wall for pool running For added resistanceTennis balls on a ropea rope with knotsMilk jugs for weightsHockey sticks, old golf clubs, old tennis racquets, clothing