Week 5 (parts 1, 2 and 3) Flashcards

Question

what are some exercises to improve balance

Answer 1

To improve balance, you need to challenge balance: How can we challenge balance: Reduce BOS (stand on 1 leg) Remove a balance system (vision - close eyes) Increase instability (add uneven / unstable surface) Add a movement (turn head / move arm / leg) Add a distraction (pass / throw / kick a ball) Add cognitive challenge (count back in 7s) Little and often – it is hard and can be painful

Answer 2

Ageing: Adverse effects on the musculoskeletal system: ◦ Loss of muscle mass (sarcopenia) ◦ Reduced motor units’ activation ◦ Poorer muscle quality including fat infiltration ◦ Decline in maximal strength and power ◦ Loss of bone density (osteoporosis) Functional implications Changes are directly affected by lifestyle, mainly physical activity level Power & strength are predictors of functional performance & disability Fitness components and Definitions: ◦ Strength is defined as… ◦ …the ability of the muscle to exert a maximum force at a specified velocity ◦ Forces are measured in … =…X… ◦ Newtons = Kg x gravity ◦ Power is defined as… ◦ …the force exerted multiplied by the velocity of the movement ◦ Power is measured in …. = …x… ◦ Watts = force (or torque) x velocity ◦ Endurance is defined as… ◦ …the ability to sustain an activity for extended periods of time or the ability to resist fatigue

Answer 3

 Also called resistance training or weight training.  It is based on the overload principle:  Muscles will work to overcome a resistance force when they are required to do so.  When resistance training repeatedly and consistently, muscles become stronger & larger (hypertrophy).  They may, or may not, have increased anaerobic endurance.  For this to happen, the body has to be stressed, respond to the stress and successfully return to homeostasis  Improved muscle strength and tone – to protect joints from injury  Enhanced performance of everyday tasks  Weight management and increased muscle-to-fat ratio – as you gain muscle, your body burns more kilojoules at rest  Reduce or prevent cognitive decline in older people  Increased stamina – as you grow stronger, you won’t get tired as easily  Improved sleep

Answer 4

 Increased bone density & reduced risk of osteoporosis  Improved sense of wellbeing – resistance training may boost self-confidence, improve body image & mood  Increased self-esteem  Prevention or control of chronic conditions such as diabetes, heart disease, arthritis, back pain, depression and obesity

Answer 5

o Muscle hypertrophy occurs when muscle protein synthesis exceeds muscle protein breakdown o Myogenic stem cells (satellite cells) become active when sufficient mechanical stimulus placed on muscle o Contractile elements enlarge o Extracellular matrix expands o Hyperplasia – increase in fibre numbers

Answer 6

For your strengthening to be effective and therapeutic your exercises must: Be specific to the needs and ability of your patient. Overload the muscle so the physiological effects take place to increase muscle strength. Be constantly progressed to maintain specificity, interest and effective optimise efficacy.

Answer 7

Frequency * How often is needed/ achievable Intensity * The effort * The load Time * Duration or how long * Reps * Sets Type * Mode or what kind * How complex is it? Total Volume * Sets and Reps over a time period Progression * Advancement

Answer 8

Core principles of strengthening: o Specificity o Overload o PROGRESSION How do we know when to progress? o Subjective information o Objective information Why do we need to progress our patient? o To maintain specificity. o Maintain patient interest and avoid frustration and reduced compliance o To optimise efficacy and recovery. * How can we progress exercises? o Change the exercise o Increase complexity / include kinetic chain o Increase the load o Change the lever o Increase resistance / reduce friction o Reduce stability o Increase time under tension

Answer 9

According to the ACSM and NHS guidelines: When general strength training aim for: ◦ 2-3 resistance sessions per week on each major muscle group ◦ Trained individuals can tolerate higher volumes of training. ◦ HOWEVER ◦ These are based on a 70% maximum effort load (12RM load) ◦ Consider how your patient can achieve this if they are in pain or can’t access a gym. ◦ Strengthening can be achieved at lower loads with higher volumes.

Answer 10

The effort or load needs to be considered in every exercise. Usually measured as a % of your 1RM, 40-50% equates to ~ 12RM Does anyone know their 1RM for an exercise? Calculate your intensity (in Kg) at 70% and 50% effort What colour TheraBand does that equate to? What are the effects of under loading? What are the effects of overloading?

Answer 11

Duration, Reps, Sets? Time usually depends on many factors: Your aims – strength, power, endurance Your available intensity – not everyone goes to a gym or can work at 3-5RM levels. Your patient – their needs and ability Set time / dose based on your aims but remember it is individual to your patient and will therefor rarely follow the guidelines. Avoid un-reasoned 3 sets of 10!

Answer 12

Consider: ◦ The current level of strength ◦ The equipment available ◦ The aims of your exercise ◦ The activity you are aiming to improve Types of exercise decisions: * Active assisted / Active / Resisted * Isometric / Concentric / Eccentric * Specific / functional

Answer 13

* Resistance through external forces can be applied in a variety of ways: * Gravity, friction * Manual resistance * Resistance bands – portable and can be adapted to most workouts, different strengths. * Suspension equipment – a training tool that uses gravity and the user's body weight * Body weight (mass with gravity) e.g. squats, jumps, push-ups and chin-ups. * Free weights e.g. dumbbells, barbells and kettlebells * Medicine balls or sand-bags * Weight/resistance machines – adjustable increments through weights or hydraulics Types of exercise – Isometric: o Force generation (resistance) but NO movement. o Usually utilised in the early phase of rehabilitation to minimise muscle atrophy when movement is limited or when Severity and Irritability prevent resistance through movement. o Isometric strength exercises have been found to have some analgesic effects. o During immobilization of the upper limb, strength training with maximal isometric exercise 5 days/week of the free limb may prevent atrophy of the immobilized limb! o Suggested parameters for isometric exercises include pain-free 5-10 second holds, graded to desired % of maximal contraction, 10 reps repeated several times per day with progression as indicated. o 45 second hold for 5 reps at pain free intensity can increase strength and have analgesic effects. o However - They are not functional exercises

Answer 14

o Eccentric exercises: o Result in active contractile tension WITH lengthening/passive tension of extra myofibrillar elements (esp collagen) o Can produce a greater muscle force compared with concentric and isometric types of contraction o Can create a greater effect on muscle development (than conc), resulting in extra recruitment of motor units. o They are an efficient method for muscle strengthening especially when targeting non-contractile elements. o They have been found to be more effective in treating tendinopathies. o The can result in muscle strength at length. o However o They can induce more damage to muscles when overloaded resulting in DOMS and therefor potentially worse patient compliance / adherence.

Answer 15

Like intensity, this depends on you patient, your aims, equipment, the load etc. REPETITIONS; ◦ Each stresses different physiological systems ◦ Low reps (<5) – phosphocreatine system ◦ Mod reps (6-15)– anaerobic glycolysis & maximal hormonal responses and cellular hydration Mod (>low) reps both induce hypertrophy > high reps (>15) SETS; ◦ Higher volume/multiple set protocols = ↑ hypertrophy ◦ Greatest gains are achieved with a mean training volume of 4 sets per muscle group. ◦ Multiple exercises for a specific muscle group within 1 session may maximise hypertrophic response (as opposed to lots of the same)

Answer 16

Assessment and problem list formation (where is your patient now?) Collaborative SMART Goal setting (where do they need / would they like to be?) Problem lists (What are they lacking? What do they need physiologically?) Plan your exercise programme (how you are going to get them there?) Remember specificity - every patient is different so every exercise programme will be different! Think about: ◦ Do they need any ROM first / alongside? ◦ What muscle group(s) need strengthening? ◦ What type of strengthening do they need (strength, power, endurance)? ◦ How is it best to train for this (eccentric, concentric, isometric)? ◦ What dose will you prescribe (resistance, frequency, intensity, rest FITTVP)? ◦ What can your patient achieve (consider pain, fitness, time)?

Answer 17

Aims? – General health Vs specific rehabilitation? Strength / ROM / Stability / Endurance / Power Baseline assessment? – What muscles / groups need addressing? What is current position / status? Barriers / Enablers? – Are there any barriers to rehabilitation? Are there any enablers? Goals? – Patient specific goals? Functional goals? Therapeutic / specific goals? Determine your needs assessment. Make sure you can justify your choices. 3 weeks post R THR. 2 weeks after L G2 ATFL injury 6 weeks after microdiscectomy L5/S1 3 weeks of anterior knee pain More details on the canvas page.

Answer 18

What might suggest we need to regress our exercise suggestions? How can we regress our exercises?  Reduce resistance (friction)  Reduce load  Reduce reps / sets / frequency  Change the lever  Reduce complexity

Answer 19

* Progression is essential; however, over-training can also be a problem! * Adequate time is needed to become accustomed to the stress of resistance exercise and avoid over-stress injuries in the early phases of training. * Remember individual responses vary * Long workouts / multiple sets may:  Reduce compliance and adherence to the exercise regimen.  Reduce intensity of effort due to local muscle, or total-body fatigue or psychological responses  Have negative effects on immune response

Answer 20

Can we / Should we combine exercise TYPES? Sometimes! Know your patients' NEEDS and GOALS Think about these statements see if you agree with them and if you can think of any real-world examples that exemplify them:  You can’t have Power without Strength – so start with Strength  You may need Balance in order to demonstrate Strength  You may need muscle speed and co-ordination to react with enough force  You may not be able to complete a task requiring Strength unless you have the Endurance to get their first

Answer 21

Loads will be lower in power training as it is harder to recruit muscle strength at speed for example: ◦ 30-60% of 1RM is suggested as optimal for power training in adults ◦ 20–50% of 1RM in older adults As a guide or starting point, 8–12 reps x 2-4 sets is recommended to improve power in most adults. But this will of course vary depending on your patient. What might affect the reps and sets you prescribe for your patient (remember they are aiming to increase power) ◦ Form ◦ Pain / Tolerance ◦ Age ◦ Other fitness constraints ◦ Goals / needs of the patient Plyometrics are often used when power training – rapid concentric/eccentric contractions emphasising speed of eccentric phase ◦ Hops/jumps/bounds/jump-squats ◦ The article and video relate specifically to ACL reconstruction rehabilitation but are a useful introduction into plyometric training.

Answer 22

You are aiming for <50% of the 1RM (light to moderate intensity) to improve muscular endurance. 15–20 repetitions are recommended to improve muscular endurance. ≤2 sets are effective in improving muscular endurance. Minimise rest periods between sets.

Answer 23

Hip assessment

Answer 24

Age (esp paediatric patients) Trauma Painful clicking/catching Early morning stiffness > 30 minutes Previous surgery Severe / unrelenting / night pain History of loading ++ Unclear aggs / eases

Answer 25

Cancer, previous fractures / trauma / surgery, FH early onset OA, childhood hip problems, low BMI, malaise

Answer 26

steroid use

Answer 27

hobbies/ sports, training patterns

Answer 28

Signs of non-MSK pathology or serious pathology (severe night pain, unrelenting pain, systemically unwell, weight loss, severe pain, trauma, non-mechanical pain).

Answer 29

 Posture  Pelvic position  Even weight bearing  Gait  SLS  Trendelenburg

Answer 30

P&N/numb/LBP Previous LBP

Answer 31

AROM Lx Neuro integrity tests and Neurodynamic tests

Answer 32

Isometric strength testing  Flexion  Extension  Abduction  Adduction:  0° or 45° of hip flexion (adductor magnus, adductor longus and gracilis)  90° (pectineus)  IR  ER

Answer 33

 SLS/Balance Ax – Trendelenburg? ◦ Squat – Double leg / single leg ◦ Bridge – Double leg / single leg ◦ Clam / hip abduction in SL ◦ Prone hip extension

Answer 34

◦ Hamstring – SL bridge to failure – expect 25 reps in runners ◦ Abductors / gluteal – Side lying leg lift to failure (watch for compensation)

Answer 35

◦ Tests muscle length of iliopsoas, rectus femoris and TFL/ITB Patient towards the end of the bed, opposite knee is flexed to stabilise lumber spine. Should achieve 10° of hip extension (Lx neutral) Flex knee to test rectus femoris and adduct leg to test TFL/ITB. Hamstring flexibility Supine 90-90: * Hip at 90 ° extend knee and measure distance from full knee extension Sitting: * Patient sitting in lumbar lordosis how far can they extend their knee * Patient sitting in slump how far can they extend their knee * Useful differentiation between hamstring tightness and neural dynamic issue

Answer 36

FADDIR Test – Testing for Joint Pathology:  Full flexion  Flex the hip and then adduct and internally rotate the hip  Sensitive but poor specificity.  Sensitivity 94%, specificity 8% FABER Test – Hip Joint, anterior hip muscles and SIJ:  Patient rests their foot on the opposite distal thigh.  Examiner stabilises pelvis and puts gentle downward pressure on the flexed knee. The leg should be horizontal or below.  A raised knee illustrates reduced ROM or muscle tightness, if it is painful confirm the location of pain.  Sensitivity 82%, specificity 25%. Quadrant/ Hip scour test – Testing for joint pathology: * Full flexion * Scoop into adduction and abduction maintaining flexion. * Sensitive but poor specificity.

Answer 37

Hip Palpation: Anterior: * ASIS * Greater trochanter * Adductor triangle Posterior: * PSIS * Ischial tuberosity (if appropriate) * Sacrum * Piriformis

Answer 38

Functional questionnaires ◦ Hip Outcome Score (HOS) ◦ Lower Extremity Functional Scale (LEFS) ◦ Oxford Hip Score ◦ WOMAC questionnaire ◦ The Copenhagen Hip and Groin Outcome Score (HAGOS)

Answer 39

Neurodynamics refers to the communication between different parts of the nervous system and to the nervous systems relationship to the musculoskeletal system. The nervous system needs to be able to adapt to mechanical loads, and it must be able to tolerate elongation, sliding, cross-sectional change, angulation, and compression. If these dynamic protective mechanisms fail, the nervous system is vulnerable to neural edema, ischaemia, fibrosis, and hypoxia, which may cause altered neurodynamics

Answer 40

 The application of mechanical forces to specific parts of nervous system looking for possible neural sensitivity.  Each test should be performed on the good side first.  POSITIVE RESPONSE  Reproduction of symptoms (at least some of that patient's symptoms)  A change in these symptoms with sensitising and desensitising manoeuvres

Answer 41

Contraindictions:  Malignancy  Cauda equina / cord involvement  Active inflammatory or infective disease  Bone disease  Joint instability, fracture or dislocation Precautions:  RA  Osteoporosis  Spondylolisthesis  Hypermobility  Pregnancy  Vascular disorders  Previous malignant disease  Recent trauma  Psychological issues.

Answer 42

Test the pain free side first to get a baseline. Explain to the patient what you are looking for and when they should respond – “let me know as soon as you feel any pulling, stretching, tightness or pain” Move slowly adding components on one at a time Once the sensation is reported clarify what the patient can feel and where Remove a component at a joint away from the sensation to confirm neural Document range, response and final position

Answer 43

 Passive hip flexion with the knee in extension  Sensitising tests: Dorsiflexion, hip abd, hip medial rotation, neck flexion.  Additional sensitisations:  TED – Tibial Nerve – ankle Eversion and DF  PIP – Common Peroneal Nerve – ankle Inversion and Plantarflexion  SID – Sural Nerve – ankle Inversion and Dorsiflexion

Answer 44

 Hands behind back.  Spinal slump.  Cervical flexion.  Knee extension  Desensitising test: Release neck flexion (symptoms should ease)  Sensitising tests  Dorsiflexion  Hip abduction (obturator nerve bias)  Hip medial rotation

Answer 45

 Testing the top leg  Lie on the opposite side to the one you want to test  Patient holds the lower leg to their chest and flexes neck  The uppermost knee if flexed and the hip extended.  Desensitising test: cervical extension (should ease the symptoms)

Answer 46

 Exercises are based on the tests  Aims of treatment are to reduce the mechanosensitivity of the nervous system and restore its normal capabilities for movement.  Education is essential – both nerve protection advice and information on the nature of nerve pain are important.  Consider the interfaces – treatment is likely to be multifactorial  Joint mobilisations for spinal / bony interfaces, STR for soft tissue interfaces and exercises for reducing sensitivity and increasing normal movement.  Neurodynamic exercises: Sliders Vs tensioners.  Your patient is presenting with a deep right hamstring pain which they describe as ‘burning along the bone’, VAS 3-7-10. It is aggravated by running and fast walking, driving, and sitting watching TV in the evening. When aggravated there are occasional shooting pains 8/10. PMH includes longstanding episodic LBP (currently only mildly problematic) and a G2 hamstring tear 3/12 ago.  They report feeling ‘tight’ in their hamstrings so have been doing a lot of hamstring stretches, which does ease the pain for a short time. They are not sure whether they should continue these as the benefits are short and sometimes their pain seems worse later.  On testing their slump test they have pain on the R at -40 degrees knee ext. L is tight at -20 degrees knee extension. In upright sitting they can achieve -20 degrees knee extension on both sides.  Plan your treatment for this patient  Consider the possible interfaces which might be causing problems.  Decide on 2-3 neurodynamic exercises which would be suitable.  Consider what advice / education you will give this patient.

Week 5 (parts 1, 2 and 3) Flashcards

(70 cards)