Therex 2 (Davies part 1) Flashcards
1
Q
How old is evidence based practice?
A
about 10 years
2
Q
what is a major trend types of rehab exercises right now?
A
Functional exercises
3
Q
what is Ockham’s razor?
A
It is a problem-solving principle devised by William of Ockham (c. 1287–1347), who was an English Franciscan friar and scholastic philosopher and theologian. The principle states that among competing hypotheses that predict equally well, the one with the fewest assumptions should be selected. Other, more complicated solutions may ultimately prove to provide better predictions, but—in the absence of differences in predictive ability—the fewer assumptions that are made, the better.
4
Q
explain the house-building analogy
A
building an exercise program is like building a house. You want to start with a solid foundation (which is making sure each link in the kinematic chain is strong) before you billd the walls (which is more functional and plyometric exercises that could be a goal but must come after each link is strong).
5
Q
In order to build a strong foundation by making sure all the links in the kenematic chain are strong, do you have to test each link before proceeding?
A
no
you don’t even have to test each link. Just strengthen all of them first
6
Q
What is the order that we should use to build an exercise program?
(important slide)
A
- Muscle activation/motor control/learning
- Muscle strength, power, enduranace
- Neuro-muscular dynamic stability (proprioception)
- Functional specificity
7
Q
Draw the Rehabilitation Phases chart
A
8
Q
Rehabilitation phases: Acute phase
Task Charecteristics
A
dscrete
9
Q
Rehabilitation phases: Subacute phase
Task Charecteristics
A
discrete/Serial
10
Q
Rehabilitation phases: Chronic phase
Task Charecteristics
A
Discrete/Serial/Continuous
11
Q
Rehabilitation phases: Acute phase
Practice Schedule
A
blocked
12
Q
Rehabilitation phases: Subacute phase
Practice Schedule
A
Blocked
13
Q
Rehabilitation phases: Chronic phase
Practice Schedule
A
Random or Random/Blocked
14
Q
Rehabilitation phases: Acute phase
Skill
A
Part/Progressive-Part
15
Q
Rehabilitation phases: Subacute phase
Skill
A
Part/Progressive-Part
16
Q
Rehabilitation phases: Chronic phase
Skill
A
Part to whole
17
Q
Rehabilitation phases: Acute phase
Feedback
A
KP and KR
18
Q
Rehabilitation phases: Subacute phase
Feedback
A
KP and KR
19
Q
Rehabilitation phases: Chronic phase
Feedback
A
Intrinsic Feedback
20
Q
do we always have to train skill re-aquisition?
A
yes!
things are always different for a pt after an injury or surgery
21
Q
If a muscle cannot function in an isolated muscle pattern, then . . . (finish the sentence)
A
. . . there is no way it can function normally in functional patter!!!
22
Q
What is the idea behind integrated functional rehab?
A
It is important to develop isolated muscle function before progression to more complex multi-planar functional exercises. It provides the patient with a firm base to build on.
23
Q
what are three problems that can occur if functional exercises are focused on without strengthening each link in the kinematic chain?
A
- When perforiming functional “composite exercises”, muscles proximal & distal to the specific muscles oftentimes compensate
- When performing functional “composite exercises” when there is a weak link in the kinematic chain, creates abnormal motor synergy patters.
- Because of the synergistic co-contraction of other muscles, functional training prevents the optimum activation of teh specific muscle to create a training effect
- (remember the muscle must be contracted at at least 60% of MVC to get a training effect)
24
Q
What is almost the same as MVC?
A
1RM
MVC = maximal volitional contraction
1RM = 1 rep max
25
who is the scapular guru guy?
Kibler, WB
26
What is a positive use of multi-joint exercises early in rehab?
They are useful if you want to "stress-sheild" a muscle early in rehab
because surrounding muscles compensate for the injured muscle so the foce demand on the injured muscle is relatively less.
27
What are the tree justifications fo rnot doing functional exercises early in rehab?
(know this!)
1. Ablnormal pteerns of movment/muscle activity happen
2. Muscle compensation
3. Low MVCs of muscle
28
In the recent ACL study by Freddie Fu, what was found about ACL strength in an ACL reconstruction at 6 months vs 1 year?
An MRI showed that
* at 6 months the quality of the graft went down
* at 1 year the quality of the graft was good again.
This shows that the extra-articular tissue of the graft needs time to adapt to being inside of the joint in synovial fluid. There is a rejection phase first, then the graft must progress through the phases of healing with an extra phase (the ligamentization phase) following the proliferation phase.
Also, blood flow is lost at first so it takes time for revascularization of the graft before it can properly heal.
Eventually the tendon will take on the characteristics of a ligament (ligamentumization).
This may not be apparent from PT testing. The person may look ready to return to play, but the graft tissue is still compromised.
29
what is ligamentumization?
Eventually a ligament graft derived from a tendon will take on the characteristics of a ligament.
The ligamentization phase follows directly after the proliferation phase and involves the ongoing process of continuous remodeling of the ACL graft toward the morphology and mechanical strength of the intact ACL. A clear endpoint of this phase cannot be defined because certain changes still occur even years after ACL reconstruction. It is still a matter of debate whether a full restoration of the biological and mechanical properties of the intact ACL is possible or whether it is more of a transformation of graft tissue that resembles but not does not fully replicate the properties of the intact ACL.
30
Ligamentization Phase of Graft Healing
The ligamentization phase follows directly after the proliferation phase and involves the ongoing process of continuous remodeling of the ACL graft toward the morphology and mechanical strength of the intact ACL. A clear endpoint of this phase cannot be defined because certain changes still occur even years after ACL reconstruction. It is still a matter of debate whether a full restoration of the biological and mechanical properties of the intact ACL is possible or whether it is more of a transformation of graft tissue that resembles but not does not fully replicate the properties of the intact ACL.
http://www.expertconsultbook.com/expertconsult/op/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-1-4160-5332-3..10055-6--s0030&isbn=978-1-4160-5332-3
31
List Davies' Exercise Progression Continuum (14)
(know this inside and out)
this is the long version from fall semester
1. Multiple angle isometrics, sub-maximal intensity, pain-free
2. Multiple angle isometrics, maximal intensity, pain-free
3. "Dynamic" isometrics
4. Short Arc (limited ROM) eccentric dynamic exercises, sub-maximal intensity, pain-free
5. Short Arc (limited ROM) concentric dynamic exercises, sub-maximal intensity, pain-free
6. Short Arc (limited ROM) eccentric dynamic exercises, maximal intensity, pain-free
7. Short Arc (limited ROM) concentric dynamic exercises, maximal intensity, pain-free
8. Long arc (full ROM) eccentric dynamic exercises, sub-maximal intensity, pain-free
9. Long arc (full ROM) concentric dynamic exercises, sub-maximal intensity, pain-free
10. Long arc (full ROM) concentric dynamic exercises, maximal intensity, pain-free
11. Long arc (full ROM) eccentric dynamic exercises, maximal intensity, pain-free
12. Neuromuscular dynamic stability exercises
13. Plyometrics
14. Functional Exercises
32
5 questions we need to ask about patient progression:
1. How?
2. What?
3. When?
4. Where?
5. Why?
33
what is patient progression dependant on?
signs & symptoms
34
Three criteria categories commonly used to decide whether to progress a patient in a rehab program
1. Subjective Criteria (Symptoms)
2. Objective Criteria (Signs)
3. Functional Performence Testing
35
Three Subjective criteria commonly used to decide whether to progress a patient in a rehab program
1. Pain
2. Stiffness
3. Changes in function
36
Eight Objective criteria commonly used to decide whether to progress a patient in a rehab program:
1. Anthropometric Measurements
2. Goniomentric Measurememtns
3. Palpable Cutaneous Temperature Changes
4. Redness
5. MMT
6. Isokinetic Testing
7. Kinesthetic Testing
8. KT 1000 Testing
37
How could you assess pain to determine if you should progress a patient?
VAS
| (visual analog scale)
38
What does Dr. Davies like to use best and second best as an objective measurement to determine whether to progress a pt or not?
When to use them?
He likes to use anthropometrics
If that doesn't work, then use goinio
(Anthropometrics for small joints, Gonio for larger joints)
39
Would you progress pt if they are objectively better but subjectively worse?
Can progress
It is okay to let them go up one pain number
40
Would you progress pt if they are objectively worse but subjectively worse?
Do not progress
possibly regress back to last level
41
Would you progress pt if they are objectively better and subjectively better?
Yes!
42
How long should Isometrics be performed?
6 seconds
This is very clear since 1953
any longer or shorter wastes our and patient's time
However, 10 seconds gives us 2 seconds for ramp-up and 2 seconds for ramp-down, so 6 seconds is how long the full force should be applied but it should take 10 seconds per rep to perfomr
43
Why is a 2 seccond ramp-up & 2 second ramp-down reccomended for isometric exercises (making the total time per rep 10 seconds)?
To minimize pain
If you have a patient create a maximum volitional contraction, starting and ending it too quicily can cause pain, effusion, etc.
Fluid in a joint can cause a rebound effect where fluid pushes against mechanoreceptors that cause pain.
44
What is the Rule of Tens for Isometrics?
10-second contraction (2 sec ramp, 6 sec contraction, 2 sec ramp) x 10-second rest x 10 reps x 10 sets x 10 positions (multiple angles)
\*These are all things to consider, not perform all at once
45
What does the abbreviation MAI mean?
* *
Multipule Angle Isometrics
(this is an abberviation that can be found in rehab protocols)
46
Eight things about Isometrics that we are suppostd to know:
(the slide that was missing that Dr. Davies said to KNOW!)
Isometric Contractions:
1. Creates muscle activation
2. Prevents atrophy
3. Increases strength
4. Decreases pain
5. Neuromodulation to prevent reflex dissociation
6. Self mobilization (ex.-PF joint)
7. Mechanical pump decrease effusion
8. Physiological overflow through ROM
(this is exactly what was on the slide)
47
What is the physiological overflow ROM?
The amount of ROM past the endpoints of a movement that experience a training effect even though there was no actual work done in that ROM.
48
What is the physiological overflow for Isometric Exercises?
10 degrees on each side
for a total of 20 degrees
49
how can we apply our knowledge of physiological overflow when doing isometric exercises?
We can get pain-free strengthening of the painful arc ROM if we do isometric exercises on either side of the painful arc as long as the isometric positions are no more than 20 degrees from each other on both sides of the painful arc
50
What is the physiological overflow ROM for short arc excercises?
Implications
30-40 degrees
(120 degrees past resisted ROM in both directions)
We can do short arc exercises every 30 degrees
again, we can strengthen painful arc ROM without pain by taking advantage of overflow
Example: shoulder painful arc syndrome: sip the painful arc
80-120 degrees is usually where the painful arc is found.
Do short arcs up to painful point (get 20 degree overflow)
Do shorts above painful arc (get 20 degreees overflow)
strengthening happens in painful arc iwhtout ever exercising in the arc
51
What is the Elftman Proposal?
Principle that states that the optimal force production of different modes of contraction is arranged in a predictable hierarchy as follows:
Force:
Eccentric \> Isometric \> Concentric
Eccnetric generates more force tha isometrics
Isometrics generate more force than concentric
52
Citation for Elftman Proposal:
Elftman, H. Biomechanics of Muscle. JBJS 48:363, 1966
(dr davies said to be able to cite)
53
Compare muscle force generated by Eccentric vs Concentric contractions
Eccentric \> Concentric
(10-40%)
10- 40% more force can be applied with eccentrics vs concentrics
54
How to you tweak the Elftman Proposal for optimal training progression?
Start (as per Ex. Progression Continuum) with isometrics for muscle activation
Then to start dynamic exercises, use Elftman sequence
Eccentrics
Isometrics
Concentrics
Functional Eccentrics
( don't understand how we are using Isometrics in the dynamic exercises, but this is what the slide says and I have no other notes on it).
55
What is DOMS?
* Delayed Onset Muscle Soreness
* DOMS is the sensation of discomfort or pain in the skeletal muscles that occurs following unaccustomed muscular exertion
* Pretty much everyone is susceptible to DOMS (Highly trained athletes are an exception)
* It usually peaks 24-48 hours after exercises and lasts 7-10 days.
* It is not caused by lactic acid, but by microtearing in the muscle tissue
* It is more of a good thing. It can signal that person is working the correct muscles
56
Is there a diffreence between eccentric vs concentric muscle contractions in ability to produce DOMS?
yes
Eccneric contractions produce DOMS more easily than Concentric contractions
57
Why is DOMS more common with Eccentric actions than Concentric contractions?
1. During Concentric contraction, the Muscle-Tendon unit is the only component generating force
2. During Eccentric action, the Muscle-tendon unit is generating force along with the SEC (series elastic components) and PEC (series elastic componenets)
1. this is also probably why more force can be generated with eccentric contraction vs concentric
58
How long does DOMS last?
about 7-10 days
It is self-limiting chemical response
59
Details on mechanism of how DOMS occurs (the chemicals don't matter much for the exam, but I want to know)
Micro-trauma occurs to the SEC and PEC, it releases hydroxyproline which creates a noxious stimulation to the surrounding tissues, therefore creating the generalized muscle soreness.
60
SEC stands for
Series elastic component
(a "mysium"
61
PEC stands for
parallel elastic component
| (a "mysium")
62
Implications of DOMS?
* since pain peaks 24-28 hours after the exercise bout that generated the pain, do not do the same exercises with the pt when then come in 2 days after first appointment. Add different exercises and
* don't re-test too early (they will be worse than the first time because of pain ihibition
* by 7-10 days the issue will resolve and you can re-test
63
4 specific Clinical Recomendations in regards to DOMS:
1. Educate the pt that they will get worse (general DOMS) before they get better - but is okay because it demonstrates they are really working
* If they do not get DOMS they are probably not working hard enough
* Predicting something that happens builds trust
2. Do not exercise the same muscle groups 2-3 days later after starting a rehab program
3. Do not exercise the same muscle groups more than 3-4 times per week
4. Do not re-test a patient for muscle strength for at least 2 weeks following the start of a new rehab program
64
Do we want the pt to do the same exercises at home in HEP as we do in clinic?
No!
When the pt is with you, do the most important exercises (and the ones that need your skill the most). Have the pt do the less important (complimentary) exercises at home.
\*It is still important for them to do the exercises at home, but it is not as critical if they don't and you don't spend your limited time on exercises that are not as important when you are more needed for the most important exercises
65
Where do we pull our infomration when designing Therapeutic Exercise Programs?
Because ther are not spceific rehab programs for different pathologies, then we need to draw from the basic sciences, exercise physiology, biomechanics, EMGs, outcome studies, evidence based practice, clinical experience, and experties with "your patients"
## Footnote
Level I and II evidence are not available for all the components, so we must pull from weaker sources.
66
Training Methods: FOUNDATION
How many sets are optimal?
1-3 sets
UE: Untrained: 1 set for 1st month, then add sets; Trained: start with multiple sets
LE: start with multiple sets with trained and untrained
67
Training Methods: FOUNDATION
How many reps?
10 (specificity)
| (ACSM reccomends 8-12)
68
Training Methods: FOUNDATION
What intensity?
Test 10 RM (MVC) at beginining and at 4 weeks to establish and adjust working weights
Train at 60-80% of 10 MVC (can use OMNI Scale)
example: Start with 60% of 10 MVC of contralateral arm
69
Training Methods: FOUNDATION
What format?
Super-set format
70
Training Methods: FOUNDATION
Rest intervals (between sets)?
Isotonics: 30-60 sec (main one to remember)
Isometric exercises: ~ 1 minute
Isokinetic exercises: 2-4 minutes
71
Training Methods: FOUNDATION
Frequency?
3-4 times/week (sometimes it says 2 times/week)
(no less than 2 times/week)
)do not train same muscle group more than 4 times/week)
72
Training Methods: FOUNDATION
progression?
3-10% progression per week
| (based on s/s of course)
73
Training Methods: FOUNDATION
how many exercises?
10 different exercises to start (foundation)
74
How do you adjust sets for trained vs untrained individuals IN THE UE?
* Untrained: 1 set is as effective as multiple sets for the first month
* then you must increase sets to continue advancing
* Trained: multiple sets from day 1
75
How do you adjust sets for trained vs untrained individuals IN THE LE?
need to start with multiple sets in the LE for both trained and untrained
76
Two other names for Eccentric MM action
Lengthining MM Contraction
Negative Work
77
what are Super Sets?
Super sets are when there are reciprocal exercises for the agonist and then followed immediately by the antagonist
for example: Do a set of 10 biceps curls followed by a set of 10 tricep dips
(alternating working antagonistic muscle groups as you go to each set)
78
5 Advantages to using super sets
1. Saves time in the clinic
2. provides muscle with recovery time increasing efficientcy of workouts
3. efficiency in developing exercise program
4. work on muscle balance
5. focus on one muscle group to create a dominant muscle group
79
How do you decide what weight to start with?
* Can test 1 or 10 rep MVC (1-10 RM) - Use 10 MVC since training program includes 10 reps
* At beginning and at 3 or 4 wks or periodically to establish and adjust working weight
* can test contralateral side and start at 60% of that if we cannot test involved arm
* Omni resistance scale- he puts this up on the scale (keep them at 6-8 on the scale)
80
how long should a rehab program be?
minimum 6 weeks
(because it takes this long to get change in the size of muscle fibers - true strengthening)
81
What is the OMNI scale?
A 0-10 visual scale that can help pts train at the correct intensity
The key is to make sure they work between 6-8 on the scale
It is a good idea to print the scale and bring it to clinic with you so you can ask pt how hard they feel they are working and adjust the intensity as needed
82
What is a common problem with intensity in rehab?
PTs often say they don't have time to determine 1 or 10 RM for pts.
Consequently we overdose or underdose the patient's exercise prescription
This is an area where we can do better!!
Try using the other options if we don't have time to test every muscle. (OMNI scale, etc).
83
What does ACSM reccomend about frequency of strength training the same muscle group?
3-4x/week (about every other day) is appropriate
more than 4x/week often leads to overtrining in the same muscle group
84
does a muscle get bigger, better, stronger, faster, etc, during the workout or rest/recovery phase?
The rest and recovery phase
that is why overtraining effects can easily develop if you strength train the same muscle group more than 4x/week - there is not enough rest time for the muscles to heal and grow.
85
What are the implications or clinical practice in regards to frequency reccomendations:
Make sure to split sessions - alternate muscle groups or specific activities
take HEP exercises into this consideration when deciding what to do in clinic and for HEP.
86
What was the study by Moritani and DeVries about?
It is the seminal study that looks at neural vs hyprotrophic response to strength training.
published in 1979
* it shows that when we begin an exercise program, over the first four weeks any improvements that we see are almost exclusively a neuro-physiological response
* After 4 weeks of training, we get a hyprotrophic contribution and anything after that is mostly from hypertrophic adaptation
* Therefore, it will be 4 weeks before we can expect to see any ahnthropometric changes due to hypertrophy
87
Draw the Moritani & DeVries chart
88
how long does it take to plateu if you continue doing the exact same exercises without mixing up the training program?
about 6 weeks
89
novel vs standard skill: which one is more dominated by neuro-physiology?
What progression does this support?
The more novel the skil, the more the neuro part dominates (such as jumping backwards)
That is why we start we have the progression through therapeutic exercises:
1. Muscle activation/Motor control/Learning
2. Muscle strength, power, endurance
3. Neuro-muscular dynamic stability
4. Functional specificity
90
What causes the first four weeks of neurological change?
(just need to know a few examples)
Just say that it is very complicated and multifactorial (but probably need to know a few examples)
It could be any and/or all of the following **Neural Factors:**
1. motor learning
2. neuro-chemical changes
3. sensorimotor changes
4. muscle pre-activation
5. muscle activation
6. increase in amplitude of SEMG (increase in neural drive)
7. Increases magnitude of efferent neural output from CNS
8. Motor unit firing
9. Increased doublet firing in individual motor units (boublet is a short inter-spike interval in a motor unit train, and occurs at the onset of a muscular contraction)
10. Recruitment
11. Rate coding
12. Motor unit synchronization
13. Training related increases in TRTD
14. Central control of training related adaptions
15. Increased excitability of cortical areas
16. Disinhibition which creates increased muscular force
17. Decreases in antagonistic co-activation
91
what is a common concern for pts when you are trying to implement a rehab program that is at least 6 weeks long?
Insurance or financial concerns might limit the amount of visits a patient can attend.
Try to space out the visits that the pt has in order to get the 6 weeks and give the pt more to do at home. This works best with a motivated pt who understands the exercises well and is not a "motor-moron"
92
What is Periodization?
Planned manipulation of training variables in order to maximize training adaptations and to prevent the onset of the over-training syndrome
Often used with athletes and by strength and conditioning coaches, but not often used in PT
(maybe this should change or maybe it should be considered more in the PT setting)
PTs do it some by setting STG and LTGs
93
What are the names of three types of cycles that are commonly used in periodization?
1. macro-cycles (often years - example: olympic athletes every 4 years)
2. meso-cycles (often weeks - months)
3. Micro-cycles (often days-weeks)
94
What are two main types of peirodizations?
Linear: continue increasing intensity gradually
Undulating: manipulate intensity of different components of training program so that intensity undulates throughout cycle. Goal is to peak in skill and strength when person reaches competition
95
what is "super-compensation effect"?
Something that happens when a person starts training again after a planned break as part of a periodization program
96
Should we pregress our patient during the week?
No. Once a week is enough
(3-10% each week)
Too much progression could cause overtraining
97
What does the 3 - 10% increase each week to progress a pt refer to? (aka increase of 3-10% of what?)
TOTAL VOLUME OF WORK!
Volume = resistance X reps X sets for each exercise performed. Then the amount for all exercises performed are added together
per session or week
98
how do you decide what exercises to use
It is wide open
Pick your favorite
the options are almost unlimetd
BUT remember that when you build a house, you want to have a solid foundation. Work each link in the kinetic chain!
Davies' TOPT 10 Exercises for Shouldr Complex Rehab are a good place to start for shoulder
99
What are Davies' TOP 10 Exercises for Shoulder Complex Rehab?
Four Scapulo-thoracic Exercises:
1. **Scaption with the thumb up**
2. **Press downs**
3. **Rowing**
4. **Push up with a plus**
Four GH Exercises
1. Scaption with the thumb up (no need to repeat)
2. Press downs (no need to repeat)
3. **Prone ER with horizontal extension**
4. **Flexion**
Two RTC Exercises
1. **External Rotation**
* start in 30/30/30 position, progress to 90/90 position
2. **Internal Rotation**
* start in 30/30/30 position, progress to 90/90 position
Two TAS (total arm strength( exercises
1. **Elbow flexors**
2. **Elbow estensors**
After these you may go on to advanced neuromuscular dynamic stability exercises
100
"Specificity" Functional Exercises (4)
1. Dynamic Stability
2. Proprioceptive/Kinesthetic training
3. Neuromuscular reactive training
4. Functional rehabilitation
101
What are some other training considerations? (6 examples)
1. Pain
2. Fear Avoidance (includes Kinesiophobia)
3. Kinesiophobia
4. Pain inhibition
5. Effusion
6. Reflex Inhibition
102
What is a really big deal for athletes returning to sports that we may easily overlook?
Kinesiophobia!
103
draw the "Training Methods: FOUNDATIONS" chart:
a similar chart has minium frequency set at 2/week
104
What does KP stand for?
Knowledge of performance
105
what does KR stand for?
knowledge of results
106
what is knowledge of results?
Knowledge of results is a form of feedback in which verbal information is given to a subject at the end of the performance of a task or skill. The feedback is provided about the outcome of the performance, rather than about the movements which brought about the performance.
http://psychology.wikia.com/wiki/Knowledge\_of\_results
(I think Dr. davies used it more as feedback after a skill is completed)
107
what is knowledge of performance?
Knowledge of performance is a form of feedback which gives subjects not only knowledge of results but also of the processes and movements that helped to achieve the outcome
http://psychology.wikia.com/wiki/Knowledge\_of\_performance
(I think Dr. davies used it more as feedback during a skill)
