Fundamentals Exam 1 Flashcards
1
Q
Major CT in body includes…
A
Tendons, ligaments, cartilage, bone, muscle
2
Q
What are the major components of CT?
A
(1) FIBERS: Collagen and elastin
(2) Ground substance with associated fluid
(3) Cellular substances: fibroblast, cells specific to each CT type
3
Q
What is ground substance?
A
Non collaginous components of the extracellular matrix Ground substance is important in overall tensile strength of the tissue
4
Q
Fibroblasts are called ___ in bone and ___ in artilage
A
Fibroblasts = osteoblasts in bone, chondrocytes in cartilage
5
Q
Describe Type I collagen
A
Type I: Resistance to tension (tensile strength), found in ligaments, bone, dermis, fibrous cartilage, epimysium, perimysium, endomysium, fascia, joint capsule, meniscus, and mature scars
6
Q
Describe Type III collagen
A
Type III: Structured maintenance for organs - loosely packed, thin fibrils such as smooth muscle in CV and GI systems
7
Q
Describe Type IV collagen
A
Type IV: Support and filtration. Thin amorphous such as basement membrane
8
Q
Describe Type II Collagen
A
Type II: Resistance to intermittent pressure; loosely packed, no fibers, very thin fibrils such as hyaline and elastic cartilage, menisci
9
Q
____ molecules combine to form collagen ___, which is the smallest unit visible on electron microscope. These then combine to form collagen ____.
A
TROPOCOLLAGEN molecules combine –> collagen FIBRILS –> collagen FIBERS
10
Q
Describe collagen arrangement in tendons, ligaments, and joint capsule.
A
Tendon: closely packed, roughly parallel
Ligament: not as parallel as tendon, but more organized than a capsule
Joint capsule: loose weave of interlaced fibers
11
Q
Collagen aligns purposefully according to ____. [Early/late] movement allows for better alignment and motion of collagen.
A
Collagen aligns purposefully according to THE DIRECTION OF FORCE OR STRESS. If no activity and no stress is put on collagen, it does not align well and aligns in a disorganized fashion. EARLY movement –> better alignment
12
Q
Functions of CT
A
Support (the tissue itself and underlying tissue)
Strength
Repair
Mechanical connector between cells and other structures
13
Q
Connective tissue provides ___ strength. What does this mean?
A
CT provides TENSILE strength = amount of stress a tissue can take before it will fail. This is different in different tissues and depends on the organization of collagen, intermolecular bonds, and ground substance
14
Q
CT is weaker vs. stronger at what part of the tissue?
A
Weaker at tissue intersurface, strongest in the middle
15
Q
CT vascularity is generally [good/poor]. What’s the exception?
A
Vascularity of CT is POOR with the exception of BONE
16
Q
Neural innervations to CT are [lacking/abundant]. What’s an example? What’s the exception?
A
Neural innervations in CT are ABUNDANT! E.g. muscle spindle, GTO. Exception: cartilage is not highly innervated
17
Q
Describe elastin’s role in CT.
A
Elastin provides elastic properties by their unique cross linking. Allows for stretch and return to resting level. Gives degree of flexibility to CT
18
Q
Inflammatory Phase... # days? Is it good or bad? Cardinal signs?
A
INFLAMMATORY PHASE
- 1-6 days
- Good thing! It’s protective and kicks off healing process
- Redness, swelling, pain, loss of function, heat
19
Q
Inflammatory phase has 4 main parts. Describe each, the goal of each, and duration.
A
(1) Vasoconstriction: decrease blood loss to area. Short duration
(2) Vasodilation: increase capillary permeability. Lasts up to an hour
(3) Clot formation: platelets are first cells at site of injury. Plts bind to exposed collagen and release fibrin to stimulate clotting and prevent further blood loss.
(4) Phagocytosis: monocytes convert to macrophages when they migrate from capillaries to tissues in wound. Macrophages considered MOST important role in inflammatory phase. Macrophages produce an enzyme called collagenase which removes some of necrotic tissue
20
Q
Systemic effects of inflammatory phase may include…
A
Fever, increased WBC count, Tachycardia, increased overall metabolic rate
21
Q
List the 3 phases of healing.
A
Inflammatory phase, proliferation phase, maturation phase
22
Q
List the 4 processes that take place during the Proliferation Phase. What’s the goal of this phase?
A
GOAL: Achieve coalescence and closure of injured area
- Epithelialization
- Collagen production
- Wound Contraction
- Neovascularization
23
Q
Epithelialization:
When does it begin? How long?
Purpose?
What happens?
A
- Begins within a few hours of injury (deeper wounds may take longer to initiate)
- Wound can be clinically resurfaced in 48 hrs
- Purpose: produce a barrier to prevent fluid loss & keep contaminants out
- How? Epithelial cells are normally in contact with each other. When interrupted, they begin to migrate and eventually form a barrier across the wound
24
Q
Collagen Production. Describe how we get from fibroblasts to collagen fibers.
A
Fibroblasts generate procollagen which converts into TROPOCOLLAGEN which makes up COLLAGEN FIBRILS which make up COLLAGEN FILAMENTS which make up COLLAGEN FIBERS
25
Tissue containing newly formed capillaries and myofibroblasts is called ____. This looks ____. It gives new tissue ____.
GRANULATION TISSUE: Newly formed capillaries and myofibroblasts
Gives tissue FLEXIBILITY
Looks red, somewhat swollen
26
The new tissue formed during collagen production is [strong/not very strong]. It has a lot of collagen content, mostly type ___, giving it ~___% strength of normal tissue.
New tissue is NOT VERY strong. Lots of collagen, but mostly Type III, so strength is ~15% of normal tissue. Very weak.
27
Wound Contraction
| When does this occur? How? Can it go wrong?
Wound contraction occurs 5 days into proliferation phase, peaks at 2 weeks
Myofibroblasts are primary cells. They attach to margins of intact skin and pull it inward.
If contracts too much, can form contractures. Contractures can result from general tissue damage and muscles shortening.
28
Describe primary vs. secondary unions.
Primary union/intention: wounds rapidly closed during inflammatory stage with sutures
Secondary union/intention: wound goes through all processes and contracts on its own
29
Neovascularization occurs as a result of ___. How?
Neovascularization occurs as a result of ANGIOGENESIS. Body generates new vascular networks which ANASTAMOSE with preexisting vessels. New growth generally marked by small bud outgrowths (thin, vulnerable to stress)
30
During the proliferation phase, the scar is ____. Clinically, what does this mean?
Proliferation phase scars are red, swollen, fragile, tender.
| Tissue might be hypertrophic, scar can bind down to other tissues. Keep scar mobile, so do scar massage on incision
31
The remodeling phase lasts how long?
Remodeling phase: healing tissue can continue to strengthen over 12-24 months, but we see most strength of tissue returning in 3-4 months
32
What happens in the remodeling phase? What's the desired outcome?
Need to stress CT to strengthen it as it is healing. Goal: maximize strength of healing tissue without over stressing it (it's a balance!)
33
When you load a tissue, tensile loads are resisted primarily by ___. These respond by ____. During the elastic phase, they respond in a [linear/exponential] fashion up to ___% elongation. After the load, the tendon ___.If tensile force elongates more than that percentage, ____ changes begin to occur.
Load a tissue and loads are resisted mostly by COLLAGEN FIBERS. These STRAIGHTEN from their resting position. During elastic phase, they respond in a LINEAR fashion and elongate up to 4%. After load, they return to resting length. If tensile force elongates more than 4%, PLASTIC changes begin to occur.
34
Viscoelastic properties are exhibited by CT. This is a function of the ___. Think it out and describe why. What affects a tissue's viscoelasticity?
Viscoelastic properties are a function of the GROUND SUBSTANCE. Viscous material is RESISTANT TO FLOW and elastic material RETURNS TO ORIGINAL STATE FOLLOWING DEFORMATION and after force is removed. Viscoelasticity affected by DURATION and RATE of applied load
35
What is creep?
Characteristic of CT. When load is applied for an extended period of time, the tissue ELONGATES --> permanent deformation. Amount of deformation depends on AMOUNT of force and RATE at which force is applied
E.g. apply 10kg force to leg to stretch hamstring. Might reach 90 degrees before further movement is prevented by tissue. If load is sustained, leg would gradually “creep” a few degrees over a period of time more elongation of hamstrings
36
What is relaxation, as a characteristic of CT?
Relaxation: when a tissue is pulled to a fixed length, a certain force is required. As tissue is held at this length, the amt of force needed to maintain that length decreases
E.g. apply 10kg force to leg at 90 degrees, less force is needed over time to keep leg at 90 degrees because of relaxation of CT that occurs
37
Creep and relaxation damage the tissue. True/false?
FALSE: creep and relaxation allow CT to adapt and to fxn in a variety of loading conditions WITHOUT being damaged!
38
Define stress and strain
Stress = resistance of intermolecular bonds to physical deformation when external loads are applied
Strain = amount of DISPLACEMENT a material undergoes when a force is applied
39
The stress-strain curve illustrates how, as a force is applied, ____ will deform and in doing so will create an [internal/external] stress/tension.
Stress-strain curve: as force is applied, CT will deform and create an INTERNAL stress/tension
40
Name the 4 regions of the Stress-Strain curve
Toe region
Elastic region
Plastic region
Ultimate failure point
41
The toe region defines the part of the stress-strain curve in which soft tissue is in a ___ state and is becoming ___.
Toe region = soft tissue is in a SHORTENED state and is becoming TAUT
42
Elastic region of stress strain curve =
Tissues stretch and start to elongate, but return to resting state as soon as force is released
43
Plastic region of stress strain curve =
PERMANENT changes in length of tissue result after sustained applied force
44
Ultimate failure point of stress strain curve =
Beginning of tearing of various tissue fibers
45
Stress Strain Curve tenant:
Stiffer material = [steeper/less steep] slope of the curve
More extensible tissue = [steeper/less steep] slope of the curve
The stiffer the material, the STEEPER the slope of the curve.
The more extensible the tissue, the more HORIZONTAL (less steep) the slope of the curve.
E.g. Muscle - smallest slope
Bone - steep slope
Tendon (depends on tendon) tends to be steeper than muscle though not as steep as bone
46
Ligaments also follow the stress strain curve. They're recruited (toe range), then all fibers are tight (elastic range), and then in the plastic range, the fibers tightened [first/later] are likely to fail, before progressive fiber failure.
Summary: first fibers to tighten are the first to fail
47
An increase in temperature in a tissue increases ___.
Increase temperature to increase elasticity of tissue.
48
Low force applied slowly may cause ___.
Low force applied slowly may cause TISSUE DEFORMATION
49
High force applied quickly -->
High force applied quickly --> Tissue failure (b/c quick explosive movements)
50
Moderate force applied in a repetitive manner -->
Moderate force applied in a repetitive manner may cause tissue failure due to cumulative effect of moderate force
51
What happens to CT with aging?
Increase in tissue stiffness as well as loss of water which alters the makeup of the ground substance. This might result in increase in intermolecular bonds which leads to stickiness and adhesions. This decreases mobility and affects surrounding tissue.
52
How does immobilization influence CT?
Muscle can lose up to 80% strength after 4 weeks immobilization. Fibers become less organize, ground substance becomes dehydrated; increase in intermolecular bonding, increase in adhesion, decrease in motion
53
How does inflammation influence CT?
Inflammation --> little movement --> collagen laying down in irregular fashion, so it isn't strong
54
To prevent contractures and adhesions with immobilization, CT structures should be placed in a __ position.
LENGTHENED position (whenever possible)
55
Name 4 strategies for preventing and reducing contractures and adhesions with immobilization
(1) Place CT structures in lengthened position durign immobilization
(2) Introduce stress to immobilized limbs early
(3) Introduce stress by protected motion during healing process
(4) Control/reduce inflammation
56
Give 2 strategies for preventing and reducing contractures and adhesions (no immobilization)
Stretching and positioning
57
A slow stretch will allow ___ to more easily deform and elongate.
GROUND SUBSTANCE
58
Collagen aligns itself in the direction of ____
Aligns in the direction of the FORCE APPLIED. Give Forces in direction you want collagen laid down during remodeling
59
What is the role efficacy of myofascial techniques and soft tissue mobilization techniques to include deep friction massage to change collagen structure and viability and improve mobility, increase joint range of motion, and scar formation?
It is unproven whether these techniques can break the collagen cross links and allow lengthening and realignment
Regular mobility of affected tissue helps maintain the lubrication and critical fiber distance
Immobilization associated with increased deposition of connective tissue along with loss of water in the tissue (dehydration) and an increase in intermolecular cross linking, further restricting the extensibility of the tissue
What can we do to deter the negative affects that immobilization has on tissue/healing tissue
60
The use of ____ to increase collagen tissue extensibility, increase enzyme activity, absorb joint adhesions, and reduce fibrous tissue volume and density in scar formation is widely accepted but not proven
ULTRASOUND
61
Integumentary means ___. Its role in the body is to serve as ____.
Integumentary = pertaining to or composed of skin
Serves as a protective covering
62
What is integumentary integrity?
The health of the skin, incl. ability to serve as barrier to environmental threats such as bacteria and parasites
63
What constitutes an integumentary examination?
PT uses integumentary tests and measures to assess effects of a wide variety of problems that result in skin and subcutaneous changes. Determine BASELINE status, RATE OF HEALING/NON-HEALING, presence of EDEMA/ SWELLING/ EFFUSION
64
Integumentary changes occur due to ___, ____, ___, ___, and a number of diseases
Pressure, venous and arterial problems, ulcers, burns and other traumas
65
___ is the accumulation of an excessive amount of watery fluid in cells, tissues or serous cavities (extravascular and interstitial tissue)
EDEMA
66
___ is the escape of fluid from blood vessels or the lymphatics into tissue or cavity
EFFUSION. This is a CONTAINED edematous area (e.g. knee sprain), primarily intracapsular
67
___ is the clinical manifestation of edema.
SWELLING
68
What's the "real" term for bruising?
Eccymosis
69
Why should we examine the integument?
- Identify circulatory problems
- Assist in locating presence of adhesions (layers of tissue sticking together)
- Determine location of pain/primary problem and acuteness/chronicity of a condition
70
Steps to test the integument include...
Inspection (visual eval of skin)
| Palpation (tissue integrity, temp, moisture, elasticity)
71
In which part of the SOAP note do you document impairments?
In the OBJECTIVE Examination/Measurements section
Also, the list of impairments can be documented in the ASSESSMENT/evaluation section and considered in Clinical Impression
72
Name some integumentary changes you may see post trauma or immobilizlation
Presence of atrophy, Shiny/hairless skin (may indicate circulatory problems), Areas of Accymosis
73
___ pertains to the sheet of fibrous tissue (CT) that envelops the body beneath the skin, encloses muscles and muscle groups, and separates their several layers/groups
MYOFASCIAL
74
What are some PT indications for myofascial examinations (tests/measures)? What are non PT myofascial issues?
PT Myofascial issues: Hypomobility (secondary to immobilization/inflammation), Postural imbalance, Swelling/edema, Altered skin integrity (scar formation, poor tissue impairment)
Non PT Myofascial issues: Emotional stress pattern (e.g. tight upper traps), Disease
75
Layer palpation and skin rolls can be used to assess ___
MYOFASCIAL CT tissues
76
A muscle spasm is defined as [increased/decreased] muscle tension and [length/shortness]. It [can/cannot] be released voluntarily, thus [allowing/preventing] lengthening of muscles involved.
A muscle spasm is defined as INCREASED muscle tension and SHORTNESS. It CANNOT be released voluntarily, thus PREVENTING lengthening of muscles involved.
Summary: muscle spasm basically = muscle cramp
77
Muscle spasms [do/do not] respond to stretching
Muscle spasms DO respond to stretching!!!
78
___ is the result of some neurological problem in which there is no inhibition to contraction (nerves send continuous contraction signals).
SPASTICITY
79
Muscle spasms generally occur as a reaction to ____. Spasticity occurs as a result of ___.
Muscle spasms generally occur as a reaction to INJURY (the spasm is not the primary problem). They're sustained, involuntary contractions.
Spasticity is result of lack of neural inhibition of muscle and continuous contraction signals (NEUROLOGICAL PROBLEM)
80
Trigger points are described as hyperirritable spots in skeletal muscles associated with ___ and ___ of muscle fibers.
TP = hyperirritable spots in skeletal muscle associated with PALPABLE NODULES and TAUT BANDS of muscle fibers
81
A [latent/active] TP is a focus of hyperirritability in the muscle or its associated fascia that is clinically painful ONLY if palpated. It can have a referred pattern of pain
LATENT TP: only painful if palpated
82
A [latent/active] TP is defined as hyperirritable spots in skeletal muscle associated with palpable nodules in taut bands of muscle fibers causing muscular pain. It will refer pain and tenderness to another area of the body when pressure is applied. Pattern of pain is specific to that muscle.
ACTIVE TP: distinct pattern of referred pain, specific to that muscle. Pain is referred when pressure is applied
83
Describe 4 general TP characteristics.
(1) Tender spots in muscle: palpable tense band of muscle fibers in shortened or weak muscles
(2) Decreased muscle stretch preventing lengthening of muscle
(3) Referred pain with palpation
(4) Specific autonomic phenomena (if occurs, STOP treatment until it resolves!)
84
Trigger points respond [negatively/positively] to stretching. Summary: [stretch/don't stretch] a TP!
Trigger points respond NEGATIVELY to stretching! Don't stretch them! If you stretch and it's a positive response, likely a muscle spasm not a TP
85
A differential diagnosis of a TP includes what observations about the area? (Go for 8 total...)
(1) Focal tenderness at TP. Always present, always reproducible.
(2) Palpable taut band in muscle passing through TP. Muscle tissue in vicinity feels dense to palpation
(3) Local TWITCH response can be elicited by pressure to TP [involuntary quick contraction of muscle]
(4) Gentle sustained pressure (10+ sec) reproduces referred pain
(5) Passive or active ROM INCREASES pain
(6) Strong contraction of muscle against resistance increases pain
(7) Direction and location of skin roll is limited
(8) Altered muscle/tendon/ligament integrity
86
What are interventions for TPs?
Pressure Application (TP Release), Deep transverse friction, Spray and stretch, Injection (physicians), Dry needling
87
Describe mechanical and metabolic effects of Soft Tissue Mobilization (STM)
Mechanical: increased circulation, incr. soft tissue mobilization and potentially increased ROM, relaxation response, encourage lymphatic flow, break up scar tissue, reduce swelling/edema
Metabolic (more systemic): Increase capillary dilation (secondary to increased circulation), can help increase RBC production, increased platelets, increase urine output (b/c increased fluid movement), help with nitrogen secretion
88
Soft tissue mobilization can decrease pain via what neurological mechanism?
Gate Control Theory of Pain
89
List contraindications to Soft Tissue Mobilization
Thrombophlebitis (blood clots: don't mobilize them), Infection, open wound, New scar tissue, Edema secondary to kidney heart or lymph obstruction; fx site; acute injury [incl. hemorrhage], Autonomic effect (STOP treatment if you see increased sweating, nausea, dizziness. Seen with use in thoracic area)
90
Soft tissue mobs progresses from __ to ___
STM: progresses from SUPERFICIAL to DEEP
91
STM is generally not used alone, but can bused along with...
Tissue elongation: muscle energy techniques, stretching, proprioceptive neuromuscular facilitation; joint mobilization, therapeutic exercises, modalities, etc.
92
Deep friction massage [does/does not] use a lubricant
Deep friction massage does NOT use lubricant: you don't want to decrease the friction!
93
Commercial rubs like Bengay should/should not be used. Why?
SHOULD NOT therapeutically use Bengay. It is a skin irritant: irritates skin (Stimulates cutaneous fibers) to increase circulation. May mask sensory input, increased chance of blistering
94
Where in the SOAP note do you document soft tissue mobilization?
Under OBJECTIVE section: include patient position, treatment technique, time frame, supplies used.
Assessment: pt's response to treatment
Plan: any changes to treatment plan
95
Joint mobilization/manipulation is a manual therapy technique comprising a continuum of skilled [active/passive] movements to the ___ that are applied at varying __ and ___.
Joint mobilization/manipulation is a manual therapy technique comprising a continuum of skilled PASSIVE movements to the JOINTS and RELATED SOFT TISSUE STRUCTURES or BOTH that are applied at varying SPEEDS AND AMPLITUDES, including small amp high velocity therapeutic movement
Joint mob assesses PASSIVE, INVOLUNTARY ACCESSORY MOTION AT JOINT
96
Joint play is the assessment of ___ at a joint
Assessment of ACCESSORY MOTIONS
97
Thrust (AKA manipulation or grade __ mobilization) is a [high/low] velocity, [high/low] amplitude therapeutic movement within or at the ___ of the motion
Thrust (AKA manipulation or grade 5 mobilization) is a HIGH velocity, LOW amplitude therapeutic movement within or at the END RANGE of the motion
98
Osteokinematics describe...
Osteokinematics = physiological movements that take place at a joint; position of one BONE relative to another bone
*Due to muscle contraction or gravity
99
Arthrokinematics describe...
Arthorkinematics = Movement between 2 ARTICULATING SURFACES without reference to any force being applied at joint
100
Accessory motions are motions that occur between 2 joint surfaces that are produced by forces applied by ___. These motions [are/are not] under voluntary control.
Accessory motion = occurs between 2 joint surfaces, produced by forces applied by EXAMINER. These are NOT under voluntary control.
101
Describe a glide.
Glide = SPECIFIC point on one surface comes into contact with a SERIES of points on another surface. Does not occur in isolation during normal joint movement; we see combined rolling-gliding
102
Describe a roll.
Roll = series of points on one articulating surface come into contact with a series of points on another surface. Usually in combo with glide or spin
103
Describe a spin
One bone rotates around stationary longitudinal mechanical axis. Same point on the moving surface creates an arc of a circle as the bone spins. Spin does not occur by itself during motion
104
Compression [increases/decreases] space between 2 joint surfaces. It adds __ to the joint and is a normal reaction of a joint to muscle ___.
Compression DECREASES space between 2 joint surfaces. Adds STABILITY and is a normal reaction to muscle CONTRACTION
105
Distraction describes when two surfaces are [pushed together/pulled apart[. Often used in combo with joint mobs to increase ___.
Distraction: 2 surfaces pulled apart. Used in combo with joint mobs to increase STRETCH OF THE CAPSULE
106
Concave on convex: example and describe kinematics
Concave on convex: Arthrokinematics in same direction as osteokinematics
e.g. Tibia on Femur
107
Convex on concave: example and describe kinematics
Convex on concave: Arthrokinematics and osteokinematics are OPPOSITE
e.g. GH Joint
108
The treatment plane of a joint lies on the [concave/convex] articular surface.
Treatment plane - ConCAVE articular surface
109
Glides take place ___ to treatment plane
Glide = PARALLEL to TP
110
Distraction takes place ___ to treatment plane.
Distraction = PERPENDICULAR to TP
111
Define the zero position of a joint. Do you mobilize here?
Zero position = osteokinematic or anatomical position. GENERALLY this is the starting position for goniometry. Do NOT mobilize here!
112
Define resting position. Do you mobilize here?
Resting position = loose packed position. Arthrokinematic position where the joint capsule and periarticular structures are most relaxed, joint surfaces are LEAST congruent, and joint play is greatest. Mobilize here!
113
Define actual resting position. Do you mobilize here?
Actual resting position = position joint is placed in when you can't obtain resting position. You can mobilize here if the pt is limited in range and can't obtain true resting position.
114
Define closed pack position. Do you mobilize here?
Arthrokinematic position where joint capsule and periarticular tissues are most taut. Joint surfaces are most congruent. CONTRAINDICATED to perform joint mobilization in this position.
115
FOR OUR PURPOSES: Kaltenborn grades are for ___. Maitland grades are for ___.
Kaltenborn = distraction. Maitland = glides
116
Describe Kaltenborn Grade I. Which structures are affected?
Grade I: slow, small amplitude movement that does NOT take joitn capsule to limit of available joint motion.
Does NOT go to 1st tissue stop. Unweighting joint.
Structures: Pain fibers
117
Describe Kaltenborn Grade II. Which structures are affected?
Grade II: slow, larger amplitude movement that takes joint capsule to limit of available joint motion and into tissue resistance.
Goes UP TO 1st tissue stop.
Structures: Pain fibers and capsule
118
Describe Kaltenborn Grade III. Which structures are affected?
Grade III: slow, even larger amplitude movement that takes joint through limit of available joint motion and into tissue resistance.
Goes THROUGH 1st tissue stop.
Structures: capsule and periarticular structures
119
Describe Maitland Grade I. What structures are affected?
Mait. Gr. I: slow, small amplitude of oscillatory movements that does NOT take joint capsule to limit of available joint motion.
NOT up to 1st tissue stop, only beginning of range
Structures: pain receptors, little or no stress to capsule/ligaments
120
Describe Maitland Grade II. What structures are affected?
Mait. Gr. II: slow, large amplitude of oscillatory movements that do NOT take joint capsule to limit of available joint motion.
NOT up to 1st tissue stop, first HALF of range.
Structures: pain receptors and joint capsule and periarticular structures (but no change in length with this grade)
121
Describe Maitland Grade III. What structures are affected?
Mait. Gr. III: slow, large amplitude of oscillatory movements that take the joint up to and SLIGHTLY THROUGH the limit of available motion and into tissue resistance.
UP TO 1st tissue stop and back down into 1/2 of elastic range
Structures: joint capsule, and periarticular structures; progression glide to grade IV
122
Describe Maitland Grade IV. What structures are affected?
Mait Gr. IV: slow, small amplitude of oscillatory movements performed through the limit of available joint motion and into the tissue resistance
Up to and SLIGHTLY THROUGH 1st tissue stop; never comes back to elastic range
Structures: joint capsule and periarticular structures
123
Describe Maitland Grade V. What structures are affected?
Mait Gr. V: high velocity, small amplitude non-oscillatory movement that begins at limit of available joint motion and takes the joint into tissue resistance
STARTS at 1st tissue stop and continues. Difficult to control
Structures: joint capsule, periarticular structures, adhesions, positional faults
124
The Maitland scale includes oscillations. Are these used in exams, treatments, or both?
Oscillations are only used in TREATMENT, not in exam/evaluations.
125
How can you describe the amount of joint play at a joint?
Hypomobile (0-2), Normal (3), Hypermobile (4-6)
126
When assessing joint play, your stable hand should be positioned ____ so that you can palpate ____. Your mobile hand should be positioned close to the ___, with the forearm ___ to the bone.
Stable hand = close to joint line, palpate joint line. Generally this is the proximal bone.
Mobile hand: close to joint line, forearm perpendicular to bone (generally distal bone).
127
When assessing joint play, the therapist should be positioned [close to/farther from] the patient in order to ____ and ___.
Position CLOSE TO patient to ensure RESTING POSITION IS MAINTAINED during exam and MINIMIZE ABERRANT MOTIONS during testing and treatment
128
What's the purpose of joint mobility testing (joint play)?
- Determine if decreased ROM is due to the joint capsule or periarticular structures
- Determine mobility of joint (hypo v. hyper)
- Determine end feel of accessory motion: bony/firm
- Determine if ligaments are compromised
- Est. baseline
- Determine progress
129
Joint play is indicated in the case of [hyper/hypomobility], so, decreased joint ___ and abnormal ___. This may occur following ___ or ___. Give some reasons why.
Joint play = indicated for HYPOmobility, decreased joint EXTENSIBILITY and abnormal END FEEL. May occur following immobilization and inflammation. Possibly because joint capsule and soft tissues are affected. Decrease in H20 content in tissue, Increased in cross linkage, increase in scar tissue formation, decreased strength of the collagen.
130
Joint mobilization is thought to reverse ill consequences of immobilization and inflammation by promoting movement to help _____ and decrease the ____ that have developed.
Joint mobilization: movement to help REALIGN THE FIBERS and DECREASE THE CROSSLINKS that have developed
131
Tissues respond to external force according to the stress-strain curve. Stages of the stress-strain curve include the ___, ___, and ___. Describe each.
Elastic phase = stretched tissue returns to original state once force is released
Plastic phase/yield point: permanent elongation of stretched tissue occurs when force is removed
Failure/breaking point: separation of elongated tissue occurs
132
What is a treatment application of going to the failure/breaking point on the stretch-strain curve?
Generally you DO NOT want to go past the plastic phase and into the failure/break point phase UNLESS the goal was to BREAK THROUGH ADHESIONS
133
Factors influencing joint extensibility include ____, ___, ___, and ____.
(1) STRESS-STRAIN RULE
(2) AMOUNT of force
(3) SPEED
(4) NUMBER of REPS
134
Rapidly administered oscillations are only used in [treatment/exam] not in [treatment/exam] of joint play. These oscillations can increase the amount of ____ particularly when treating ___.
Rapidly administered oscillations are ONLY used in TREATMENT not EXAM. Can increase EXTENSIBILITY especially effective for treatment of ADHESIONS. (ie Mait. Gr. IV)
135
Creep is defined as a stretch into the ___ phase for an increased time frame to increase the amount of ____ more than one short duration. Describe the Grades necessary to obtain creep.
Creep = stretch into ELASTIC phase for increased time fraome to increase EXTENSIBILITY more than in one short duration. Involves Maitland Grades III-IV and Kaltenborn Grades II/III
136
What impairments can we treat with joint mobilization?
- Presence of positional faults
- Decreased nutrition
- Pain
- Bony compression at the joint (meniscal, labral, and capsular entrapment)
137
Articular surfaces are [vascularized/avascular], so they get their nutrition from [blood/synovial fluid]. Hypo mobility causes [increased/decreased] nutrition to joints and structures. Motion is necessary for the ____ of nutrients to occur. Normal movement allows proper joint nutrition!
Articular surfaces are AVASCULAR so they get nutrients from SYNOVIAL FLUID. Hypomobility causes DECREASED nutrition; motion is necessary for DIFFUSION of nutrients to occur
138
Joint mobilization decreases pain by stimulating joint receptors that ____ through the ___ mechanism by producing ____ in periarticular structures. Joint mob also stimulates [slow/fast] conducting [small/large] diameter proprioceptive nerve fibers that block transmission of the ____ pain fibers, decreasing transmission of pain to the brain.
Joint mob decreases pain by stimulating joint receptors that BLOCK PAIN IMPULSES through the GATE CONTROL MECHANISM by producing REFLEXIVE INHIBITION in periarticular structures. Joint mob also stimulates FAST conducting LARGE diameter proprioceptive nerve fibers that block transmission of SLOW conducting SMALL diameter pain fibers, decreasing transmission of pain to brain.
139
```
Using Maitland glides, we can treat the following with what grade glides?
Pain
Relaxation
Decreased joint nutrition
Decreased joint extensibility
Adhesions
Bony alignment
```
Maitland Scale grades (with oscillations)
Pain - Gr. I & II
Relaxation - Gr. I & II
Decreased joint nutrition - Gr. I-IV
Decreased joint extensibility - Gr. III-IV
Adhesions - Gr. III, IV, and V
Bony alignment - Gr. IV and V
140
Using Kaltenborn distractions, we can treat the following with what grade distractions?
Pain
Increased joint compression
Decreased tissue extensibility
Kaltenborn distractions
Pain: Gr. I
Increased Joint compression: Gr. I-III
Decreased Tissue Extensibility: Gr. II & III
141
Contraindications to joint mobility include... (12 total!)
- Unstable joint (hypermobility)
- Recent fx
- Over open epiphyseal plates
- Considerable joint effusion
- Ankylosing/fused joints
- Advanced diabetes (nutritional issues at skin surface --> skin tearing)
- Impaired nutrition to BONE (osteoporosis, kidney dysfxn)
- Vascular abnormalities (spine contraindication: vertebral artery test)
- Bacterial infection to the area to be mobilized
- Bony disease (osteoporosis, osteomyelitis, TB, Paget's disease)
- Undiagnosed pain
- Rheumatoid Arthritis (exacerbated stages)
142
What is Paget's Disease?
Chronic disorder that typically results in enlarged and deformed bones. Proximal bone softening of cortical bone can lead to possible fractures, bone pain, arthritis, and deformities.
143
Precautions to joint mobility include...
- Joint irritability or pain
- Protective muscle spasm/inability for patient to relax
- Irritability of adjacent joint structures
- Chronic debilitating disease
144
A distraction perpendicular to the treatment plane with the excursion slightly beyond the first tissue stop is a Grade ___
Grade III
145
All glides incorporate a slight distraction (Grade __) as a component of the technique. This serves to ___ the joint.
Glides use a slight Grade I distraction to UNWEIGHT the joint, or separate the joint surfaces
146
Capsular pattern at the knee
Loss of flexion > extension
If no limitations in extension, non-capsular!
147
Capsular pattern at the shoulder
Loss of ER > Abduction > IR
148
Capsular pattern at hip
Loss of IR > Extension > ABDuction > ER
149
Motor learning is defined as __ adaptation associated with __ and __ that lead to long term change in the ability to produce __ movement. It is the study of the ____ or ___ of movement with practice and experience.
Motor learning is defined as NEURAL adaptation associated with PRACTICE and EXPERIENCE that lead to long term change in the ability to produce SKILLED movement. It is the study of the ACQUISITION or MODIFICATION of movement with practice and experience.
150
Modern definitions of motor learning look at learning in context. It is the process of searching for a task solution that emerges from an interaction of the ___ with the __ and the ___. Includes changes to the ___ associated with practice and depends on integration and communication of the ___ including the __, __, __, and __.
Motor Learning: task solution emerging from interaction between INDIVIDUAL, TASK, and ENVIRONMENT. Includes changes to the CNS and integration/communication between the CNS parts like cortex, basal ganglia, cerebellum, and spinal cord.
151
Motor learning or acquisition of skilled movement involves 3 general concepts: __, __, and __.
Retention, generalizability, adaptability
152
What is retention?
Test skilled movement again NOT at the end of the session (that's just muscle performance improvement). Were skilled movement gains kept?
153
What is generalizability?
Similarity of learned movement to other related tasks
154
What is adaptability?
Applying learned movement to other environmental demands
155
Describe the 4 concepts of motor learning.
(1) Process of acquiring capability for skilled movement.
(2) Requires experience and practice
(3) Cannot be measured directly, but is inferred from behavior/performance
(4) Produces relatively PERMANENT changes in movement (not just performance improvement at end of session)
156
___ describes changes in behavior observed during a practice session. This may or may not reflect learning.
Motor performance
157
Performance may be affected by __, __, or __.
Fatigue, motivation, or anxiety
158
Motor learning and motor performance abilities vary widely among individuals. Rate and degree of ML and MP fall into 3 major areas: __, __, and __.
Individual
Task
Environment
159
2 types of learning and memory
Declarative (explicit) and Procedural (Implicit)
160
Describe Declarative (explicit) memory
- Conscious recall of facts/events
- Can be expressed verbally
- Awareness, attention, and reflection are needed
- REPETITION can transform declarative into procedural knowledge
- Can be practiced in other ways than how it was learned (e.g. mental practice)
161
Declarative memory includes input from what brain areas?
Medial temporal lobes, prefrontal cortex, hippocampus
162
Describe Procedural Learning (Implicit)
- Tasks that can be performed "automatically" (Habit)
- Does not require as much attention or conscious thought
- Develops slowly through repetition of at ask under varying conditions (movement schema - rules for moving)
163
Procedural memory/learning involves input from which brain areas?
Basal ganglia (striatum), cerebellum, and sensorimotor cortical areas
164
A patient with Alzheimer's Disease has damage to the medial temporal lobe. Which type of learning should be emphasized when working with this patient?
Medial temporal lobe is used in declarative memory, so use PROCEDURAL (Implicit) learning with AD patients
165
A patient has cerebellar damage. What type of learning should be emphasized when working with this patient?
Cerebellum is used in Procedural memory (implicit), so use DECLARATIVE (explicit) learning with this patient.
166
Name the 3 stages of Motor Learning (Fits & Posner).
Cognitive stage - figuring out "what to do"
Associative Stage - Deciding "How to do"
Autonomous Stage - Knowing "How to succeed"
167
In the cognitive stage of motor learning, the aim is to ____. It requires lots of cognitive processing and lots of __ as you try out multiple ___. You improve [fast/slow]. Reliance on vision is [minimal/heavy]. Learning is optimized if the environment is [open/closed]. Summary: you have [high/low] cognitive demand with [consistent/variable] performance
In the cognitive stage of motor learning, the aim is to GAIN UNDERSTANDING OF MOTOR SKILL. It requires lots of cognitive processing and lots of ERROR as you try out multiple STRATEGIES. You improve FAST. Reliance on vision is HEAVY. Learning is optimized if the environment is CLOSED. Summary: you have HIGH cognitive demand with VARIABLE performance
168
In the associative stage of motor learning, the patient knows what to do. This stage involves ____ of a selected motor strategy. Pt [is/is not] improving, but is doing so more [quickly/slowly]. The errors are [more/less] consistent. Reliance shifts away from vision and more toward ___. Learning is improved by ___. Summary: [more/less] cognitive demand with [more/less] variability.
In the associative stage of motor learning, the patient knows what to do. This stage involves REFINEMENT of a selected motor strategy. Pt IS improving, but is doing so more SLOWLY. The errors are MORE consistent. Reliance shifts away from vision and more toward PROPRIOCEPTIVE CUES. Learning is improved by OPENING THE ENVIRONMENT. Summary: LESS cognitive demand with LESS variability.
169
In the autonomous stage of motor learning, motor performance is largely ___ with [a lot of/little] error. This stage involves [minimal/maximal] cognitive monitoring, allowing patient to devote attention to ___ or ____. Performance is equally good in __ or ___ environments. Summary: almost no ____ with very [high/low] attentional demands. Attention can be shifted elsewhere with ____ effect on performance.
In the autonomous stage of motor learning, motor performance is largely AUTOMATIC with LITTLE error. This stage involves MINIMAL cognitive monitoring, allowing patient to devote attention to OTHER ASPECTS OF SKILL or A SECONDARY TASK. Performance is equally good in OPEN or CLOSED environments. Summary: almost no VARIABILITY with very LOW attentional demands. Attention can be shifted elsewhere with LITTLE DEGRADATION IN performance.
170
As you shift from the cognitive to associative to autonomous stages of learning, variability goes ___ and level attention goes ___. You start with a motor __ and end with a motor __.
Variability goes DOWN and level of attention goes DOWN. Start with a motor PLAN and end with a motor PROGRAM (automatic)
171
What factors can influence motor learning?
Instructions, practice, feedback, individual differences
172
When giving instructions, you want to first ___ the skill and highlight the ___ of the skill. Focus attention to specific aspects of movement, limiting quantity and details to match pt's ___.
Instructions: DEMONSTRATE the skill and highlight the PURPOSE/relevance of the skill. Focus attention to specific aspects of movement, limiting that to match pt's COGNITIVE ABILITIES
173
Practice can be affected by environmental factors (__ vs. ___), the practice structure (__ vs. ___), and the parsing of the task (___ vs. ___)
Open vs. closed environments
Blocked vs. random practice
Part-task vs. whole-task
174
Describe the difference between blocked and random practice. Which supports long-term learning?
Blocked: practice each task individually
Random: practice tasks in random order
RANDOM is better for long term learning
175
Describe part-task vs. whole-task. Which supports long-term learning?
Part-task: breaking task down into pieces/component parts (e.g. serial and discrete tasks can be broken up)
Whole-task: the entire task. Can be used with serial, discrete, or continuous tasks.
WHOLE-TASK practice supports long-term learning
176
___ is better during the acquisition phase with [blocked/random] or [whole task/part task] practice. BUT ___ and ___ practice support long term learning
PERFORMANCE is better d uring acquisition phase with BLOCKED and PART-TASK practice. BUT WHOLE-TASK and RANDOM practice support long term learning.
177
Mental practice can produce [large/small] positive effects on physical performance of a task. It is [not as/just as] effective as physical practice. Mental practice is limited by ___.
Mental practice can produce LARGE positive effects on physical performance of a task. It is NOT AS effective as physical practice. Mental practice is limited by COGNITIVE IMPAIRMENTS.
178
Cues/guidance/assistance can be given during a task in the form of __ or __ cues. The efficacy of guidance is mixed, but we know that eventually ___.
Verbal or tactile cues. Efficacy is mixed, but eventually we need to take away feedback for the task to continue to become automatic
179
Feedback can be ___ (e.g. ___) or ____ (e.g. ___)
```
Intrinsic feedback, e.g. sensory info
Extrinsic feedback (AKA "augmented") supplements intrinsic in the form of verbal, tactile, biofeedback, visual (mirror) cues
```
180
Extrinsic feedback can be described as knowledge of ___ or knowledge of ___. Describe each.
Knowledge of RESULTS: terminal feedback about the OUTCOME
Knowledge of PERFORMANCE: feedback related to the movement PATTERN used to achieve goal
181
Simple tasks can improve PERFORMANCE in early learning when given feedback after ___. Long term learning is best supported by giving knowledge of ___ less frequently, especially for more [simple/complex] tasks. Feedback is best given after __ (#) trials.
Simple tasks can improve PERFORMANCE in early learning when given feedback after EACH TRIAL. Long term learning is best supported by giving knowledge of RESULTS less frequently, especially for more COMPLEX tasks. Feedback is best given after 5 (#) trials.
182
Feedback can be ___, ___, ___, and given based on ____ to support long term learning
- DELAYED (gives pt time to process...best after 3 seconds!)
- Summed
- Faded (give every trial to begin with, then only every 5 or 10 trials)
- Bandwith - only given when performance deviates outside of acceptable boundaries
183
Individual difference in motor learning can be attributed to __, __, __, __, and __.
Age, cognitive ability, motivation, physical characteristics, and motor control
184
During the cognitive stage of learning, what do you do to facilitate it? (consider cues/guidance, practice schedule, feedback, etc.)
- Demonstrate/model
- Break task into parts (if possible)
- Manual guidance (reduce once safety is less of a concern)
- Stress the use of vision
- BLOCKED practice schedule
- FEEDBACK on CORRECT performance, not errors
185
During associative stage of learning, what do you do to facilitate it? (cues, feedback, practice schedule...)
- FADE verbal and tactile FEEDBACK
- Whole-task practice (to increase complexity)
- FEEDBACK given early in movement or AFTER movement (summary feedback, delayed feedback)
- Identify CONSISTENT movement errors, but allow "mistakes"
- Allow self-eval and problem solving from pt
186
What do you do to facilitate the autonomous stage of motor learning?
- Let pt correct own errors
- Vary environmental conditions
- Remove ALL verbal and tactile inputs
- Identify movement errors
187
___ is the ability to regulate or direct the mechanisms essential to movement. It involves stabilizing in space (e.g. __ and __) and movement in space (e.g. __ and __).
MOTOR CONTROL is the ability to regulate mechanisms essential to movement.
Stabilizing in space (e.g. posture and balance)
Movement in space (e.g. walking, reaching)
188
Motor control is the center of the overlap between the __, __ , and __.
Individual, task, enviornment
189
What is the value of motor control theory to practice?
Provides a framework for interpreting behavior, a guide for clinical action, new ideas, and working hypotheses for examination and intervention
190
Current theories of motor control involve ___ Theory as the foundation for many clinical applications. According to this theory, movement arises from the interaction of multiple processes including __ within the individual and interactions between the __, __, and __.
Current theories of motor control involve SYSTEMS Theory as the foundation for many clinical applications. According to this theory, movement arises from the interaction of multiple processes including PERCEPTUAL, COGNITIVE, AND MOTOR PROCESSES within the individual and interactions between the INDIVIDUAL, TASK, and ENVIRONMENT.
191
Systems theory thinks of the organism as a [constant/continuously changing] mechanical system. Coordinated movement is the mastery of redundant ___ of the moving organism. ___ help to solve this problem by constraining certain muscles to work together as a unit.
Systems theory: organism is a CONTINUOUSLY CHANGING mechanical system. Coordinated movement involves mastering redundant DEGREES OF FREEDOM. SYNERGIES help this by making muscles work together as a unit
192
In systems theory, the CNS controls the ___ sytstem. The motor system coordinates the ___ system and ___ system to impact ___ of a movement, generating ___ and an eventual ___.
CNS/central command controls NEUROMUSCULAR system. MUSCULOSKELETAL and CARDIOVASCULAR - PULMONARY systems are coordinated and together impact the DEGREES OF FREEDOM of a movement. This generates SYNERGIES and eventual MOVEMENT OUTCOME
193
What are the limitations of systems theory of motor control?
- Broadest of approaches
- Predicts behavior better as it considers muscle & skeletal systems, gravity and inertia, and nervous and sensory systems
- Does NOT consider environment as part of the system!
194
What are clinical implications of systems theory?
Movement is NOT just an output of the nervous system, but an integration of the NS with musculoskeletal/biomech. system.
Intervention must focus on interactions of impairments across MULTIPLE systems
195
What is task-oriented theory?
More recente motor control research, especially in neuro settings. Ability to use motor control is based on the SPECIFIC TASK
196
List individual constraints on motor control.
Cognition, attention, perception, arousal, sensation, flexibility, strength, tone, movement patterns
197
Movement requires the interaction of ___, ___, and ___.
Interaction of:
-MOTOR CONTROL (perception, cognition, arousal, sensation, flexibility, strength, tone, patterns of mvmt)
- MOTOR LEARNING (stages of learning, feedback, practice, indiv. learning style),
- DEVELOPMENTAL STRATEGIES (Mobility, stability, controlled mobility, skill)
198
How do you classify a TASK during motor control?
- Body Action (stability Mobility)
- Organization (discrete continuous)
- UE Manipulation (none Complex) [is interaction with an object present or absent?)
- Motor Cognitive Focus [Quality of mvmt vs. which mvmt to make?]
- Intertrial variability (movement executed same each time?)
- Environmental Predictability
199
Compare discrete, serial, and continuous tasks. These are considered ____ classifiers of a task.
Task ORGANIZATION
Discrete: beginning and an end
Serial: ordered set of discrete tasks
Continuous: No recognizable beginning/end (e.g. real life walking)
200
An open task is... (consider environment, planning, variability)
- Variable and flexible
- Changing environment
- Greater difficulty to plan movement
- Increased demand on info processing system
E.g. playing tennis or soccer. BUT you often practice/train in a closed environment first! E.g. a drill
201
A closed task is... (consider environment, planning, variability)
- Fixed, habitual patterns
- Minimal variation
- Lower demand on information processing systems
202
What are regulatory features of an environmental constraint on movement?
Regulatory features specify aspects of the environment that SHAPE THE MOVEMENT itself. Task-specific movements must conform to regulatory features of the environment in order to achieve the goal of the task.
E.g. weight, size, shape of object. Type of walking surface
203
What are non-regulatory features of an environmental constraint on movement?
Non-regulatory features of the environment may affect performance but movement DOES NOT have to conform to these features.
E.g. background noise, presence of distractions
204
List the 6 stages of movement from The Hedman Model
- Initial Conditions
- Preparation
- Initiation
- Execution
- Termination
- Movement Outcome
205
In the Hedman Model Stages of Movement, the initial conditions describe the state of condition and ___ conditions. Parameters include __, ability to interact with ___, and ___context.
In the Hedman Model Stages of Movement, the INITIAL CONDITIONS describe the state of condition and ENVIRONMENTAL conditions. Parameters include POSTURE, ability to interact with ENVIRONMENT (COGNITIVE/ AFFECTIVE), and ENVIRONMENTAL CONTEXT.
206
In the Hedman Model Stages of Movement, the PREPARATION stage describes ___ organization. It is further divided into 3 stages: __, __, and __.
Describes CNS organization. Further divided into 3 stages:
- STIMULUS IDENTIFICATION
- RESPONSE SELECTION
- RESPONSE PROGRAMMING
207
In the Hedman Model Stages of Movement, the INITIATION stage describes the instant in which ____ of ___ begins. Parameters include __, __, and __.
In the Hedman Model Stages of Movement, the INITIATION stage describes the instant in which DISPLACEMENT of SEGMENTS begins. Parameters include TIMING, DIRECTION, and SMOOTHNESS.
208
In the Hedman Model Stages of Movement, the EXECUTION stage describes the actual ____. Parameters include __, __, ____, and __.
In the Hedman Model Stages of Movement, the EXECUTION stage describes the actual SEGMENTAL MOVEMENT. Parameters include
- AMPLITUDE OF MVMT
- DIRECTION OF MVMT
- SPEED OF MVMT
- SMOOTHNESS OF MVMT
209
In the Hedman Model Stages of Movement, the TERMINATION stage describes the instant when ____. Parameters include __, __, and __.
In the Hedman Model Stages of Movement, the TERMINATION stage describes the instant when MOTION CEASES. Parameters include TIMING, STABILITY, and ACCURACY.
210
In the Hedman Model Stages of Movement, the MOVEMENT OUTCOME stage describes when ___.
In the Hedman Model Stages of Movement, the MOVEMENT OUTCOME stage describes when the GOAL of the movement was REACHED SUCCESSFULLY.
211
Summary statement for the motor control of degrees of freedom...
CNS organizes many individual muscles/joints to produce coordinated movement.
212
Open loop is AKA...
FEED FORWARD (FF) loop
213
Closed Loop is AKA
Feed BACK (FF) loop
214
What is a motor program?
Specific neural circuits (patterned motor responses) that exist for many movements
e.g. signature writing
215
Before soft tissue interventions, what do you do first?
1) Wash hands
2) Ask pt for allergies before using a lubricating medium. DOCUMENT those allergies!
3) Palpate:
- Quality of skin (palpation)
- Temperature of skin
- Skin rolls & lifting to feel for tightness
4) For most STM, warm up area using effleurage and/or exercise (e.g. arm cycling)
216
Principles of J-Stroke:
- Non-mobilizing hand
- Mobilizing Hand
- What are you targeting?
- Superficial or deep?
J Stroke:
- Non-mobilizing hand: takes up slack in skin to stretch and stabilize area
- Mobilizing hand: make "J strokes" and hook into spot
- Target area of high tissue density, restricted area, patient's chief complaint.
- Can use superficial OR deep!
217
Principles of Strumming:
- What are you targeting?
- Superficial or deep?
- Technique
Strumming:
- Target muscle contraction/tone and loss of muscle play
- Superficial OR deep
- Applied through repeated, rhythmic deformation of muscle belly, strum toward you on the side that you're strumming
218
Principles of Cross-Hand Technique:
- What are you targeting?
- Large or small muscle groups?
- Technique
- What's your goal?
- Superficial or deep?
Cross-Hand Technique:
- Targets longitudinal, large muscle groups
- Cross arms and use whole hand surface. Place hands on patient and allow them to sink into the tissue until you meet resistance. Hands then take up slack moving away from each other until you meet resistance.
- Tissue will "creep" and your hands will separate
- Goal: break up adhesions, stretch muscle into elastic range, increase blood flow
- DEEP technique
219
Principles of Deep Friction Massage:
- What are you targeting?
- Goal
- Pt Positioning
- Technique
- Superficial or Deep?
Deep Friction Massage:
- Targets soft tissue impairment at site of scar tissue, adhesions, or pain. Primarily indicated for more chronic conditions of soft tissue or accompanying resolution of acute, inflammatory disorder. Also for trigger points.
- Goal: restore/maintain mobility of structure
- Position area in relaxed, stabilized position
- Apply force perpendicular to fiber direction in localized area. Start with pressure pt can tolerate, build to 5+ mins
- DEEP technique
220
Principles of effleurage:
- Goal
- Technique
Effleurage:
- Preparatory stroke in soft tissue mobilization to warm up tissue, accustom pt to touch, relax patient
- Long gliding strokes, start light and increase depth of pressure as patient tolerates. Precedes other massage techniques. Maintain rate and rhythm of effleurage.
221
Principles of Petrissage (kneading):
| - Technique
Petrissage (kneading):
- Manipulate tissue horizontal to fibers
- Lift, wring, or squeeze soft tissue or press/roll tissue under or between hands. "Milking the tissue"
- Minimal sliding over the skin except for to move from one area to another
- Pressure to pt tolerance
222
Principles of Tapotment:
- Goal
- Technique
Tapotment:
- Promote circulation and sensory input post long-term immobilization - stimulating effect.
- Rarely used in PT
- ulnar border of hand to 'karate chop' - hands bounce off surface as they make contact, lightening impact.
223
Principles of Trigger Point Pressure Application:
- Treatment area
- Goal
- Technique
- What to do after
TP Pressure Application:
- Looking for a nodule, pain in a referred pattern in surrounding tissue, and a taut band (active = always hurting, latent = hurts on palpation)
- Apply pressure to reproduce referred pain but at a level tolerable to pt
- Use verbal feedback from pt and feedback from palpation
- Hold pressure for 10 - 60 seconds (generally 3-5 times), up to 5 minutes total time
- AFTER: Gentle PASSIVE stretch (30s), then ACTIVE CONTRACTION
224
What are potential treatments for TPs other than pressure application?
Deep transverse friction, spray and stretch, injection (physicians), dry needling
225
What is the goal of stretching?
Increase the extensibility of the muscle tendon unit and the periarticular connective tissue
226
When is stretching indicated?
- Decrease in soft tissue/joint extensibility due to adhesions, contractures, scar tissue formation
- When restricted motion may lead to structural deformities otherwise preventable
- As part of a total fitness program to prevent musculoskeletal injuries
- Prior to and after vigorous exercise to potentially minimize postexercise muscle soreness
227
When is stretching CONTRAindicated?
- Acute injury
- Unstable fx
- Untreated trigger points
- Local integument damage
- Hypermobility at that joint
228
Precautions for stretching
- Joint replacement
- Sensation deficits/proprioception
- Pain
- Active inflammation
- Unstable joint
- 2 joint muscles and affect on adjacent muscles
229
Key elements of stretching
- Align patient and specific muscles/joints to be stretched
- Stabilization of proximal or distal attachment site
- Consider osteokinematics and arthrokinematics
(1) Exam
(2) Warm up to increase blood flow and warm tissue
(3) Use any relaxation techniques
(40 Use grip that's comfy for patient
230
Describe the procedure for static stretching
(1) Position patient in comfortable position to allow relaxation
(2) Take the limb to a point at which a gentle stretching is felt
(3) Hold for 15-60 seconds (preferably toward 60sec for long term change)
(4) Relax and stretch, then repeat
231
Advantages to static stretching?
Can be more comfortable, easier for HEP, decrease injury risk. Requires less force from PT
232
Advantages/disadvantages to ballistic stretching?
Should be used on select populations (i.e. individuals preparing for plyometric activities). Higher injury risk. Not frequently used
233
Procedure for ballistic stretching
(1) Pt should be well supported and comfortable
(2) Move limb until a gentle stretch is felt, then gently bounce at end range
(3) Don't be too vigorous
234
Hold-Relax with Agonist Contraction
- Mechanism?
- How is it different from just Hold Relax?)
Mechanism: stimulating muscle spindle (reciprocal innervation)
FIRST:
Assess AROM, PROM, then...
HRAC:
(1) Move limb to point of limitation
(2) SUB-MAX isometric contraction of the AGONIST for 7-9 seconds ("Meet my resistance")
(3) Command patient to RELAX SLOWLY
(4) Patient ACTIVELY moves limb into new range independently or with assist from PT
(5) Repeat (generally 5-10 reps)
In normal Hold Relax, PT passively moves patient into new range after each stretch
235
Contract-Relax with Agonist Contraction
- Mechanism?
- How is it different from just Contract-Relax
Mechanism: stimulating GTO in antagonist, activate antagonist, direct inhibition, autogenic inhibition
FIRST: Assess AROM, PROM, then...
CRAC:
(1) Move limb to point of limitation
(2) MAXIMAL isometric contraction of the ANTAGONIST for 7-9 seconds ("Push into my hand as hard as you can")
(3) Command patient to RELAX SLOWLY
(4) Patient ACTIVELY moves limb into new range independently or with assist from PT
(5) Repeat (generally 5-10 reps)
In normal Contract Relax, PT passively moves patient into new range after each stretch
236
When testing joint play, use Maitland Grade __ for glides and Kaltenborn Grade __ for distractions.
Maitland Grade III, Kaltenborn Grade II (both go to FIRST TISSUE STOP)
237
WRIST:
- Joint name
- Resting position
- Close Pack position
- Capsular Pattern
- Treatment plane
- Exam
Wrist: Radiocarpal joint
- Resting position: slight flexion, slight ulnar deviation
- Close pack: full extension
- Capsular pattern: equal limitation in all directions
- Treatment Plane: Parallel to the surface of the distal radius
- Exam: Stabilize distal radius and ulna and wrap around the styloid processes. Moving hand distracts at carpals
238
KNEE:
- Joint name
- Resting position
- Close Pack position
- Capsular Pattern
- Treatment plane
- Exam
KNEE: Tibiofemoral joint
- Resting position: 25-40 degrees flexion
- Close pack position: full extension, lateral rotation of tibia
- Capsular pattern: Limited Flexion > extension
- Treatment plane: Parallel to the surface of the tibial plateau (proximal tibia)
- Exam: Position in resting postiion, feel for joint line, stabilize on distal femur with stabilizing hand, distract just proximal to malleoli with mobilizing hand, distraction perpendicular to treatment plane
239
SHOULDER:
- Joint name
- Resting position
- Close pack position
- Capsular pattern
- Treatment Plane
- Exam
SHOULDER: Glenohumeral joint
- Resting position: 55 degrees abduction, 30 degrees horizontal adduction
- Close pack position: Full abduction and lateral rotation
- Capsular pattern: ER > Abduction > IR
- Treatment plane: parallel to the glenoid fossa
- Stabilizing hand on acromion process, mobilizing hand on distal humerus (carefully consider angle of glenoid fossa!) When providing gliding force, force goes just distal to acromion process on humeral head.
