principles of exercising

• AROM
• PROM
• A/AROM
• Stretching

resistive exercise

progressive resistive exercise

breathing exercises

breathing during exercise

endurance-tolerance to overall activity

• -to assess the available movement at a joint
• -provides a baseline to determine where to begin with therapeutic exercise program
• -to maintain joint and soft tissue mobility & minimize the loss of tissue flexibility & contracture formation

• -systemic disease such as arthritis
• -joint, muscular or neurologic diseases
• -joint surgery
• -burns
• -inactivity that comes with any immobilization
• ex: wearing a cast

• -shortening of the length of muscle that is immobilized into the shortened position
• -atrophy
• -muscle weakness

• 1.durration of immobilization
• longer=worse
• decrease in cross sectional size of muscle fibers
• decrease in motor unit recruitment

• 2.position of immobilization-
• shortened position=worse
• sarcomere absorption
• increased production of connective tissue
• 3.composition of muscle-
• slow-twitch atrophy more quickly

• -decrease in the force muscle can produce:
• less myofibrils=decrease in size

fewer muscle fibers are recruited

sarcomeres are all in a shortened position

sarcomeres are overlapped-less functional

use goniometry to measure the specific point angles for both base line & reassessment

clues about muscle strength and potential for increasing ROM by comparing AROM and PROM

performed entirely with an external force such as a therapist or caregiver moving a joint

patient usually cannot perform PROM by themselves

used to determine if additional ROM available past what the patient can do actively

if there's acute inflamed tissue in the region-2-6 days after injury

if patient is not able or not supposed to actively move a joint

• if patient is comostose or paralzed
• following surgery and surgeon's protocol calls for "no active ROM" such as with a rotator cuff repair

cartilage degeneration

adhesion within the joint capsule

contracture formation-joint stuck in a particular position

poor circulation

1.maintain joint and connective tissue mobility

2.minimize the formation of contractures

3.maintain the elasticity of muscles

4.enhance joint lubrication via stimulating synovial fluid production and application for cartilage nutrition

5.decrease or inhibit pain

6.help maintain the patient's awareness of movement

7.assist in the healing process following injury or surgery

how far a patient can actively move their joint

sometimes demonstrates the patient's willingness to move

requires no assistance to complete the range of motion

performed by active contraction of the muscles crossing that joint

patient is able to actively contract the muscle to move the body part through all or part of the expected ROM

aerobic conditioning programs for cardiovascular health

AROM activity used above & below an injured joint to prevent contracture in the available joints

general assessment of total ROM

assistance from an outside source to assist in holding the weight of the limb while the patient moves the joint through range of motion

when a patient has weak muscles, A/AROM can be used to provide the level of assist required to move through the full available range

• if no inflammation or contraindications to AROM, goals are the same as PROM
• maintain elasticity & contractility of muscles

provide sensory feedback from the contracting muscles

provides a stimulus for bone joint tissue integrity

increase circulation & prevent/decrease thrombus formulation

used in development of coordination & motor skills

an increase in PROM that exceeds normal values for that joint

• due to laxity in soft tissue structures that normally prevent excess joint motion
• ex; gymnist

• decrease in PROM that is substantially less than normal values for that joint
• possible causes:
• 1.inflammation of soft tissue structures

• 2.abnormalities of joint surfaces
• changes due to old injuries

• normal range of motion and functional ROM may be 2 different values
• individuals can be functional even if they do not have "by the book" full ROM

ex: can still raise arms high enough to do hair but still not FROM. This is functional

need to know if the patient has a history of either hypo or hyper mobility

if pt is usually hyper-mobile they may feel their joints are stiff even though when measured goniometrically they are within normal limits

if a patient is typically hypo-mobile, you may not expect them to have full normal range

• PROM will not:
• 1.prevent muscle atrophy
• 2.increase strength or endurance
• 3.assist with circulation to the extent that AROM does

• AROM will not:
• 1.maintain or increase strength in already strong muscles

only develops skill or coordination in the movement pattern it is used in

• if motion is distuptive to the healing process.
• ex: after surgery

• ROM should not be done when the patient response or the condition is life threatening
• ex: after an accident, ICU

• joint range
• use terms like flexion, abduction, extension, etc
• measured using goniometry and recorded in the number of degrees of the angle
• Functional
• Excursion-distance a muscle is capable of moving from it's most contracted to it's most stretched

• 1.the shape of the bones or joints. end feel comes into play
• 2.what is the integrity of the joint at the end of the range
• 3.what muscles may be holding the joint back
• 4.stretch muscles opposite, prime movers

joint surface movement

how one bone moves across or around another within a joint

• the way adjoining joint surfaces move on each other
• described as:
• roll-hindge jt
• glide-slide
• spin-rotate

new points on each surface come in contact with each other throughout the movement

• rolling of one joint surface on another
• like a ball rolling on the ground

one point on one joint surface comes in contact with new points on the other joint surface

like an ice skater blade moving across the ice

the same points on each bone surface in the joint remain in contact with each other throughout the movement

ex: humerus spinning in the glenoid cavity during internal and external rotation

similar to a top spinning on a table

Convex-rounded outward

concave-caved in

most joints have one convex joint end and one concave joint end

ovoid-2 bones forming a convex-concave relationship

• ex: glenohumeral joint, hip joint, PIP
• this is the make-up of most synovial joints

• stellar/saddle shaped
• each joint surface is convex in one direction and concave in the other

ex: the CMC(carpo meta) of the thumb

motions that accompany the classical movements

essential to functional movement

• essential full ROM
• Ex:
• anterior glide of tibia on the femur during knee extension

upward rotation of the scapula with active shoulder flexion

a type of accessory motion

occurs within the joint

necessary to joint function

• can be done passively by applying external force but not actively
• used in a technique called joint mobilization
• joint mobilization is used to decrease pain and increase ROM

traction or distraction

approximation or compression

shear

bending

rotary

• also called distraction
• is the separation of the joint surfaces

an external force acting on the joint

pulls the joint surfaces apart

• also called compression
• a decrease in the space between the bones in a joint

• create approximation with:
• weight bearing
• muscle contraction

• used to provide stability
• ex: bear wt on joint the push joints together. build strength around joint by building muscles

force that occurs parallel to the joint surfaces resulting in a gliding motion at the joint

• joints that demonstrate glide
• shearing forces cause bones to be more vulnerable and can produce fracture

conbination of compression on one side of the joint and distraction on the other

• occurs when other than vertical forces are applied which result in compression on the concave side and distraction on the convex side
• Ex:

twisting forces

how closely or loosely the joint surfaces are approximated (or the quality of how the bones of the joint come together)

• 2 types of joint congruency:
• closed packed position
• open packed position

• joint surfaces have max contact with each other
• tightly compressed and difficult to distract or pull apart
• usually occurs at one extreme of ROM
• also called congruent

• also called incongruent
• the point where the joint capsule and ligaments are lax and allow for roll, spin, and glide motions (accessory motions)

the preferred position for joint mobilization techniques

a characteristic feel experienced by the examiner while performing PROM

the feel is a barrier to further motion

being able to differentiate between different types of end feels is important when assessing a joint to determine if dysfunction exists

as you visualize them you can assume the type of end feel you should be getting

by having an understanding of the joint structure, you have a better idea of what is going on inside

some joints are designed so the capsule limits ROM in a particular direction

some are structured so that the ligaments limit the end of a particular ROM

end feels will be different among patients and descriptions may vary with the examiners

it takes practice & experience to distinguish normal end feels!

• boney-hard stop. elbows and knees
• capsular-
• empty-you think you can take it further, but the patient doesn't
• springy block-feels like something isn't right, bounce
• soft tissue approximation-body builder
• soft, firm, hard

hard abrupt limit to joint motion

occurs when bone contacts bone at the end of ROM

ex: end range of elbow extension

a hard leather-like(littlegive)

limitation of motion-has a slight give

end range of full normal joint ROM of the shoulder

if a capsular end feel occurs before full normal joint ROM is achieved as compared to the other side, this is abnormal

no mechanical limitation to joint ROM

motion is likely limited by pain

could be a complete disruption of soft tissue constraints

• acute joint inflammation:
• bursitis
• abscess
• fracture
• psychogenic disorder-all in head

rebound movement(bounce) found at the end of ROM

• occurs with mechanical derangement
• ex: torn cartilage-

when soft tissue like skin and muscle prevent the joint from moving completely

ex: limited elbow or knee flexion in some who is either obese or a body builder

• same as soft tissue approximation
• firm

• muscular stretch
• stretch'capsular stretch(extension of MCPs of digits 2-5)
• ligaments stretch(forearm supination-palmar radioulnar ligament)

• bone contacting bone
• same as boney

• a capsular pattern results from a pathological condition involving the entire joint capsule which causes a particular pattern of restriction involving all or most of the PROM of the joint.
• Ex: Frozen shoulder. adhesives from surgery

a general term used to describe any therapeutic maneuver designed to increase mobiity of soft tissues and improve ROM by elongating (lengthening) structures that have adaptively shortened and have become hypo-mobile

1.increase mobility (ROM)

2.help coordination by allowing for freer and easier movement

3.prevent injuries due to strain

4.develop body awareness

5.reduce muscle tension and make the body feel more relaxed

ability of structures or segments of the body to move or be moved to allow the presence of ROM for functional activites

• ability of an individual to initiate, control or sustain active movements of the body to perform simple to complex motor skills
• ADL's

ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM

• factors that determine flexibility:
• 1.muscle length
• 2.joint integrity
• 3.extrensibility of the musculotendinous units that cross the joints

ex: the muscle we are stretching is the muscle antagonist to the movement producing

ability of soft tissue to return to its resting length after a passive stretch

think of a rubber band.

it is elastic and returns to it's normal shape once you release the stretch

tendency of soft tissue to assume a new and greater length after the stretch force has been removed

think of stretching a piece of silly putty or theraputty

the adaptive shortening of the muscle-tendon unit and other soft tissues that surround the joint

• significantly restricts passive or active stretch and motion
• ex: if there is a biceps contracture elbow extension will be limited. arm n cast

• contractile-muscle
• non-contractile-everything else
• skin
• fascia
• ligaments
• tendons
• joint capsule
• connective trissue within the muscle

• 1.mechanical properties of contractile tissue
• 2.mechanical properties of non-contractile tissue
• 3.neurophysiological properties of contractile tissue

• contractile tissue vs noncontractile tissue in muscle
• noncontractile tissue =connective tissue
• epimysium, perimysiun, endomysium
• contractile elements of muscle
• the sarcomere
• the sliding of the myofilaments, actin and myosin, over one another

• response to stretch
• myofilaments slide apart(WHEN STRETCHING)

the muscle spindle

found in the muscle among muscle fibers

stimulated by changes in the muscle length and speed of that change

if movement is quick, the response is to reflexively cause the muscle to contract

• found at the
• musculo-tendinous junction

• with slow gentle static stretching, reflexly allows muscle relaxation
• with too much stretch, initiates muscle contraction to prevent over stretching
• has the ability to override the muscle spindle
• internal mechanism to prevent injury

• stretching velocity
• quick stretch
• monosynaptic stretch reflex
• a quick stretch to a muscle causes:
• 1.the spinal cord sends info back to the muscle to contract
• 2.muscle spindle fires
• 3.slow stretch
• 4.GTO fires
• 5.slow stretch force,
• 6.GTO fires and inhibits tension in muscle allowing the muscle to relax and lengthen

do not bounce

• ex:
• put hamstring on stretch
• ask the patient to provide max isometric contraction
• GTO kicks in to protect hamstring. when isometric contraction relaxed, hamstring will more fully relax as well

neurologic mechansim

the agonist contracts to move a joint

the antagonist reflexively relaxes to allow the movement

in other words: when the agonist/ on the antagonist/off

1.manual or mechanical,passive or assisted stretching-pully

2.self-stretching-pully

3.neuromuscular inhibition techniques-contacting opposite muscles

4.joint mobilization/manipulation-

• 5.soft tissue mobilization/manipulation-rubbing a muscle can relax it (massage)
• 6.neural mobilization-

• the overall function of the patient may be improved by applying stretching techniques to some muscles and joints, but allowing other muscles and joints to remain tight
• EX: tendonesis/spinal cord injured patient
• needs trunk stability for independent sitting. tight muscle can substitute for support
• EXAMPLE: with cervical and thorcic injuries the patient loses back extensors, therefore you need to improve and maintain hamstring flexibility and allow some hypo-mobility/tightness to develop in the back extensors for stability.

• 1.the alignment and stabilization of the body during stretching
• 2.the intensity, speed, duration, mode and frequency of stretch
• 3.the integration of neuromuscular inhibition and functional activities into stretching procedures

• 1. correct alignment-patient comfort, stability during stretching, actually stretching what you think you are stretching
• 2. stabilization-fixing either the proximal or distal muscle attachment, use proximal stabilization, hold one end while muscle is being stretched
• 3. Intensity-use low intensity gentle stretch, keeps patient comfortable, less likely to contract away in pain.
• 4. Duration-choose safe, effective, and efficient stretch. lower intensity of stretch/longer duration, 30 second stretch to increase ROM

• Long duration
• static-
• sustained
• maintained
• prolonged
• Short duration
• cyclic
• intermitten
• ballistic-bounce can tear muscle

slow controlled stretch is 10-30 seconds

• most common
• muscles are lengthened to the point of tissue resistance
• held for 15-30 seconds or longer

• assume a stretching position similar to static
• as the muscle lengthens, hold the new position until further relaxation is felt

• repeated short duration stretches
• multiple repetitions, 5-10 second holds

always slow to allow for good relaxation

force used to stretch should be gradually applied and released

slow stretches are easier to control for both the patient and therapist

• how may repetitions for each stretch and how many days/week or times/day
• factors that determine frequency:
• 1.underlying cause of immobility

2.quality and level of tissue healing

3.chronicity and severity or contracture

4.use of corticosteroids(arthritis)

5.previous response to stretching-they need to trust us

manual (by therapist or caregiver)

mechanical-towel

self-stretching

passive-ROM

active-ROM

assisted-ROM

neuromuscluar inhibition

applied external force slightly beyond the point of tissue resistance and available ROM

performed for the patient by the therapist or caregiver

performed with the use of equipment

could be as simple as a cuff weight providing traction or a sophisticated device

• may be some sort of splint or brace
• devices will come with a protocol for wear and fitted to each patient individually

you stretch yourself

patient independent in doing the stretch in good form

know this before you send the patient out to do it on their own

have them do ALL the repetitions, to be sure right

• just like it sounds
• passive is force being applied into the direction of the stretch from outside the muscle

active is using active movement to produce a gentle stretch

assisted is using equipment of some sort

takes advantage of the effect the nervous system has on muscle function to help relax a muscle prior to stretching

• also known as Autogenic inhibition
• 2 types/PNF(proprioceptive neuromuscular facilitation)
• 1.hold-relax technique
• 2.contract-relax technique

• theory:
• upon contraction of the muscle the GTO(Golgi Tendon Organ) causes a reflexive relaxation of the same muscle to allow for passive elongation

PNF-advanced form of stretching that relies on the relax reflex of the muscles

uses autogenic mechanisms via GTO and Muscle spindle

1.therapist stretches the muscle to the end of the joint's natural range

2.patient performs isometric contraction x10sec

3.patient performs concentric contraction of the antagonist

4.patient relaxes

5.therapist once again stretches but this time further

6.perform 3-5 reps before moving the limb to rest

• similar to contract-relax in that
• 1.the patient also contracts the muscle being stretched
• in "hold-relax" the muscle contraction is isometric
• hold the isometric contraction for 10 seconds
• may be repeated 3-5 times before moving into resting position

use stretching to develop increased ROM and flexibility

never go for the burn

always apply pressure slowly and gently

hold a static stretch approx 15-30 sec

NEVER do a ballistic stretch-bounce

5-10 reps is plenty

if you use theraband to assist a stretching program...the only thing stretching is the theraband

muscle contraction produces increased tension in the muscle but the length does not change

muscle feels tight but the joint does not move

good for early stages of strengthening

can isolate a part of a range to address specific weakness

called for in early post surgical protocals

retards atrophy

strengthens only in part of the range

not good for overall strengthening

when the muscle contracts, the muscle length shortens, thus the joint moves

2 types of isotonic contractions: concentric/eccentric

movement produced by the agonist(prime) of that movement

shortening contraction

muscle shortens when it contracts

• insertion moves toward the origin
• ex: picking up a weight, the biceps contract concentrically

action of the antagonist in any movement

lengthening contraction

• allows for slow controlled movements
• ex: lowering a weight, the biceps contract eccentrically
• eccentric can produce greater force than concentric

• resistive exercise-wt/theraband
• progressive resistive exercise
• kinetic chains:
• open chain-distal moves
• closed chain-distal fixed(closed)-
• plyometrics-

add resistance to work muscles more against gravity

weight applied distal to the joint being exercised

can apply the weight closer to the joint to decrease the moment arm and therefore increase efficiency

when patient accommodates to the starting weights, then it's time to increase the weight(resistance) in order to progress the patient to greater strength

describes how forces occur during human motion

how segments of the body are linked together

• distal segment is free to move
• ex: elbow curl

• distal segment is fixed
• ex: push-up

• build power
• eccentric contractions immediately followed by explosive concentric contraction
• ex:
• catching/throwing weighted ball
• dribbing ball
• drop push-ups
• vertical jumps/reaches
• jumping over objects on the floor
• hopping

need special equipment-OT's not likely to use

muscle move a joint at a constant speed all the way through its range against resistance

control quality of the contraction by controlling the machine

• more for sports medicine
• control ROM
• both directions of joint movement
• isometricly,concentricly,eccentricly
• feedback from computer
• assess force output for a single point

• expensive equipment
• training to use equipment

cardiovacular strength

allows one to participate in more activity

5 minutes of sustained movement

aerobic/increase oxygen

• aerobic
• uses oxygen

• exercise can be carried on for 5 minutes of longer
• Anaerobic
• w/o oxygen

exhaustion ensues w/i 1-2 minutes

O2 cannot meet muscle demand

increases lung capacity

breath duringmovement

changes pressure in chest cavity/support lymphatic system produce relaxation,calm,anxiety