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CHI442: Physical Rehab 1 > Week 4 Prague School > Flashcards

Flashcards in Week 4 Prague School Deck (21):

Whar is the 4 stage approach to rehabilitaion?

  1. Restore biomechanical integrity
  2. Groove motor patterns
  3. Strengthen
  4. Functional adaptation


what is the difference between a stuctural or functional problem?

Structural: "if something is affecting the normal structure it is removed- if pain is originating from a certain region only that arrea is assesed"

  • traditional ortho med = xray, MRI, surgery

Functional: coordinated movement of the muscle in relation to other structures and takes into account the stabilizing roles of muscle

  • looks at musculature - tightness, weakness, coordination/motor control


Why is muscle balance so important and how can it become unbalanced?

  • relative equality of muscle length or strength between an agonist and an antagonist; it is necessary for normal movement and function.
  • Unbalanced: as a result of adaptation or dysfunction = can be functional or pathological
  • Pathological = impaired function because of pathological disease >>>> joint dysfunction and altered movement patterns >>> pain
    • can be insidious - no pain
    • traumatic event?
    • Neurological: neural control unit may alter the muscle recruitment strategy to stabilize joints temporarily in dysfunction
  • Functional:
    • Biomechanical: imbalance as a result of repetitive movements, incorrect posture >>> adaptations in muscle length, strength and stiffness


Describe the pattern of dysfunction in Static and Dynamic muscles

  • Static muscles (postural): tighten as they are activated more
  • Dynamic/phasic muscles: tend to weaken with dysfunction


Describe the pathophysiology of muscle imbalance

  • Mc begins after injury or pathology >>>>  pain and inflammation.
  • can have insidious onset
  • This leads to hypertonicity or inhibition (weakness) - creating localized muscle imbalance.
  • Over time, this imbalance becomes centralized in the CNS as a new motor pattern, thus continuing a cycle of pain and dysfunction.

Janda; "muscle imbalance is an expression of impaired regulation of the neuromuscular system that is manifested as a systemic response often involving the whole body".


Clinically describe Janda's Upper Crossed Syndrome

(proximal or shoulder girdle crossed syndrome)

  • It is a postural syndrome NOT a diagnosis = pattern used to explain inappropriate loading
  • joint dysfunction: particularly at the atlanto-occipital joint, C4-C5 segment, cervicothoracic joint, glenohumeral joint, and T4-T5 segment
  • It may result in compromised posture
    • Tight = Traps/letator scap + pecs
    • Weak = deep neck flexors + rhomboids/serratus anterior
    • anterior head tilt
    • increased cervical lordosis and thoracic kyphosis
    • elevated and protracted shoulders
    • rotation and winging of the scapulae.
  • = altered spinal and shoulder region biomechanics

decrease glenohumeral stability as the glenoid fossa becomes more vertical due to serratus anterior weakness leading to abduction, rotation, and winging of the scapulae. This loss of stability requires the levator scapula and upper trapezius to increase activation to maintain glenohumeral centration - janda


Clinically describe Janda's Lower Crossed Syndrome

(distal or pelvic crossed syndrome)

Tight = erector spinae (thoracolumbar extensors) + iliopsoas/rec fem (hip flexors)

Weak = abdominals + glut max/min

  • dysfunction:  L4-L5 and L5-S1 segments, SI joint, and hip joint.
  • Specific postural changes:
    • anterior pelvic tilt,
    • increased lumbar lordosis,
    • lateral lumbar shift ?
    • external leg rotation
    • knee hyperextension

If the lordosis is deep and short, then imbalance is predominantly in the pelvic muscles; if the lordosis is shallow and extends into the thoracic area, then imbalance predominates in the trunk muscles


What are the 3 steps for addressing muscle/joint dysfunction?

  1. First reducing any joint dysfunction or nociception in order to improve the local afferentation = get rid of pain
  2. Normalize muscle imbalances with manual techniques
  3. Improve muscle firing patterns via sensorimotor training


Once this was accomplished, specific therapeutic exercises designed to neutralize the chronic dysfunction and improve endurance and strength could be appropriately introduced


Balance Assessment

Single leg balance test

  1. Eyes open
  2. Eyes Closed (+ perturbation)

Age (Bohannon 1984)

  • 20-49 y = 24-29 s
  • 50-59 y = 21 s
  • 60-69 y = 10 s
  • 70-79 y = 4 s

Note: Patient safety when testing. Be mindful of where you stand and your office surroundings. often used in geriatric population assess risk of falls

What to look for: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=57098

  • Elevating the rib cage when breathing / holding breath during test at any stage = poor intrinsic core stabilization. Assess the diaphragm for dysfunction.
  • Stance-leg toes gripping the ground = instability of the foot; poor stability in the stance leg / glute max inhibition.
  • Rotated shoulder or pelvis = poor patterning in the AOS and POS.
  • Flexion at the waist = decreased extension in the stance-leg hip or inhibition of the contralateral psoas.
  • Trendelenburg sign = inhibition of the stance-leg glute medius or contralateral quadratus lumborum.
  • Eyes look anywhere other than straight ahead = eye muscle facilitation (very common in post-traumatic neck injuries).
  • Head tilt / rotation = sternocleidomastoid / scalene dysfunction.


How do you perform a Hip Extension Movement Pattern and what are you watching for?

  • Place patient prone on the bench - ensure foot is off end of bench to prevent recruitment
  • Instruct " raise your (right or left) leg toward the ceiling" 10-20°
  • Watch for ant pelvic tilt, lumbar hyperextension or trunk rotation in the first 10° of leg raising, knee flexion to reduce work load
  • Also watch for delayed glut max activation (lower cross issues ?)
  • While performing the motion its easy to test for glut max strength, scale of __/5


How do you perform a Hip Abduction Movement Pattern and what should you watch for?

  • Pt side lying with lower leg flexed at the hip and knee. Pelvis perpendicular to the table
  • Instruct Pt – slowly raise your leg straight up to the ceiling
  • Fail if: on initiation of motion, cephalad shift of pelvis, thus there is QL substitution
  • Fail if in first 40°: Hip flexion (TFL substitution), Hip ER (piriformis sub), pelvic rotation (glut med weakness), reduced abduction then adductor tightness
  • Also check muscle strength ___/5.


Describe the Cervical Flexion Movement Paterrn test

  • Pt lays supine without pillow
  • Instruct to slowly saise your head up from the table to your chest
  • Fail = chin protrudes, SCM overactivity, shacking with the effort (weak deep cervical flexors)
  • Targets:
    • PIR SCM
    • Check upper CS and CT junction and T4-8
    • Endurance training + Functional training
    • review posture


Describe the Push up movement pattern test

  • Pt in pushup position, toes or knees 
  • Instruct – slowly lower and then raise yourself up again 
  • Fail: scapulae retract, wings or shoulder shrugs 
  • Targets: 
    • review for adj/mob T4-8, glenohumeral joint 
    • stretch pecs, traps, lev scaps 
    • proprioception – closed / open chain wall ex’s 
    • strengthen scap protraction 


Describe the Truck Curl- Up movement Pattern

  • Pt supine with knees slightly flexed keep arms out straight paralel to the trunk
  • Ask the Pt to “curl up” until shoulder blades are off the table 
  • Fail: feet raise up off the table before scaps come off the table, 
  • Targets: 
    • stretch hip flexors 
    • core stabilization 


How is the Trunk Curl-Up done as an endurance test?

  • Pt is supported on a 50° wedge or CA 
  • Dr holds Pt feet & the wedge moved backward 10cm 
  • Pt instructed not to touch the wedge and hold that poition at 50° (cross arms over)
  • give cues as fatigue 
  • “less than 50 secs is dysfunctional” 


Describe Vele's Reflex Stability Test

  • Pt to stand with feet shoulder width apart, arms by side 
  • Instruct: try lean forward from the ankles without bending at the waist 
  • Fail: delayed or absent gripping of the toes 
  • Target Rx: 
    • mob ankle/foot 
    • stretch calf 
    • strengthen intrinsic muscles of the foot 


Describe the Squat Test

  • Pt stands with feet hip width apart, arms straight ahead, or supported if safety issue 
  • Instruct them to squat until thighs are nearly parallel to the floor (less if acute or elderly) 
  • Fail: decrease depth of squat, knee valgus, knee flex beyond line of toes (check hip tightness), Lumbar hyperextension or flexion 
  • Target Rx: 
    • strengthen with side bridges 
    • functional with squats and lunges 


Describe a Single Leg Squat

  • Ask the Pt to stand with feet hip width apart 
  • Instruct to perform a mini squat please 
  • Fail: Inability to perform, subtalar hyperpronation, knee valgus, knee flex beyond toes, Trendelenburg sign 
  • Target Rx: 
    • Stretch ITB, TFL, Piriformis, 
    • Strengthen glut med, 
    • Sensory motor training? 


Describe the correct and incorrect way to perform a Forward Lunge

  • Ask: Pt to step forward and touch/kneel on the floor, then rise back up to standing position 
    • knees shouldn't go past toes, 90, 90
  • Fail: inability to reach floor with back knee, poor balance, subtalar hyperpronation, knee valgus motion, knee flex beyond line of toes, trunk flexion 
  • Target: 
    • anterior hip capsule 
    • stretch hip flexors 
    • sensory motor training 


How do you perfom a Side Bridge Endurance test

  • Ask: Pt to lay on side, then instruct to raise pelvis from the floor until spine is aligned. Ask hold the position as long as possible. Only the feet and forearm/hand should be on the floor. 
  • Fail: Record time. Stop when for second time the pelvis drops below peak height (touches Dr hand) 
  • <45 secs is dysfunctional, no greater than 5% difference btwn sides. 
  • Target Rx: stretch hip flexors & anterior hip 


What is more important

  • Muscle strength?
  • coordinated movement?