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101 Cards in this Set
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- Back
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Historically, NMS care was DOCTOR/PRACTICE centered. The doctors' job was to find the source of the problem and fix it. Focus? Name of model?
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Focus: pathology and sx
BIOMEDICAL model |
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Modern NMS care is PATIENT-centered. The doctor's job is to foster recovery, reactivation and self-management. Core? Name?
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Core of Patient-centered is functional abilities or tolerances
BIOPSYCHOSOCIAL model |
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The WHO's ICF classification of FUNCTIONAL STATUS:
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IMPAIRMENT = ROM deficits or other (+) exam findings
ACTIVITY = walking tolerance or other ADL's PARTICIPATION = work activity levels |
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Components of the Patient centered approach
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Symptoms = pain
Dysfunction = Impairments [ROM], Functional abilities [walking - activity], Participation [work, activity] Psychosocial = distress, fear/anxiety |
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Does bed rest help LBP?
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No.
Cochrane study demo'd slightly harmfuleffects = eg, 10% loss of muscle strength and yields no improvement over 7 days |
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Can bed rest improve the life of a chiropractic student?
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Of fucking course.
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"matched" exercise prescription & reactivation effects (3)
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Gets people back to work faster
Reduces pain recurrences Prevents chronicity |
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BEST combination for matched exercise and reactivation prescription combines these two with ___________
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manual therapy
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3 R's and the S
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REASSURANCE = you don't have a serious dz and it will get better
REACTIVATION = keep moving as normally as possible. Hurt does not equal harm. RECOVERY = Adjusting, soft tissue, manual therapy, modalities SELF-MANAGEMENT = I will teach you exercises and other self care strategies to get you better and prevent recurrences. |
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Mosby's THERAPEUTIC EXERCISE definition (just try it)
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Any exercise planned and performed to attain a specific physical benefit, such as maintenance of ROM, strengthening of weekend muscles (drinking), increased joint flexibility, or improved cardiovascular and respiratory fcn.
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Goals of therapeutic exercise:
1. Resolve _______ ailments and return to full-functioning, ____-free existence. 2. Prevent recurrence of existing _________. 3. Enhance overall health, function and well being. |
ailments, pain-free
ailments |
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Name BENEFITS of therapeutic exercises
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Enhance soft tissue and joint mobility and flexibility
Improve muscle strength Improve muscle endurance *Improve balance, coordination *Enhance postural awareness and movement ability *Improve neuromuscular ability Improve cardiovascular endurance *Locomotor fcn |
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What is weird about inflammation an may alarm the patient at first?
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Inflammation increases the time it takes to get better, so if patient has inflammation, then the 'hidden' benefit of therapeutic exercise is to improve lymphatic and vascular dynamics. This hastens healing!
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TE prevents _____ that develop following injury or during a period of limited movement.
(gluing) |
adhesions
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TE modulates _____.
(ow) |
pain
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TE retrains aberrant muscle _______, the existence of which perpetuate functional loss and chronic pain.
(plaid) |
patterns
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TE restores patient _________ to perform activities of daily living or job-related tasks without fear of injury or pain.
(Enzyte) |
confidence
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Is TE applicable to spondylosis or spondylolisthesis? Stenosis? Scoliosis?
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Yes, to all the S's listed here.
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The study proved prescribed exercise was more clinically effective than traditional medical care for chronic LBP and produced more cost savings. What about Passive PT compared to exercise?
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Active exercise used to improve mobility, strength and work conditioning showed superior results. Substantial savings in days absent, etc.
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Regarding EARLY INTERVENTION of TE and LBP
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Pts with acute LBP who received exercise developed significantly less chronic LBP, utilized less health care services and reported lower pain levels.
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Estimates are that approximately ___% of all Chiropractors surveyd prescribe exercise in patient care
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96%
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Exercise has long hx in chiropractic. BJ insisted on exercise.
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WWI and WWII spurred interest and growth and now there is an athlete and sports medicine connection.
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ROM
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Range of Motion is the degree of movement at a joint and accompanying soft tissue structures.
ie, shoulder aBduction = 170% ROM |
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Degree to which patient can move (or be moved) with pain or discomfort that is TOLERABLE or manageable
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Pain TOLERABLE ROM
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Mobility of soft tissue (muscle/tendon) structures and length to which they can stretch or be stretched
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FLEXIBILITY
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TE usually places first priority on regaining ___________, followed by pursuit of other functional capacities [strength, endurance, balance, coordination].
"Window of Opportunity" |
lost ROM/flexibility
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When is FLEXIBILITY "window of opportunity"
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within 3 weeks after injury
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Muscle STRENGTH
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maximum force that a muscle or muscle group can exert with static challenges or via amount of weight lifted
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What are the risk of strength DEFICITS:
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mm weakness can:
Increase likelihood of injury Result in abnormal movement leading to COMPENSATORY changes, esp. w/ CORE strength deficits Lead to muscle imbalance, chronic mm tension and pain Increased difficulty of normal ADL's |
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Activities performed on a daily basis
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ADL's (household chores, etc.)
*hidden risk if not addressed. Must show modifications of ADLs |
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Muscle _________ is the muscle's ability to sustain a sub-maximal force in either static or repetitive activity over a period of time.
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ENDURANCE
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the muscle's ability to sustain a sub-maximal force in either static or repetitive activity over a period of time.
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Muscle ENDURANCE
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VALUE of muscle endurance?
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Enhances ability to carry out ADL's.
Prevents injuries especially 'late stage' job (aberrant way - repetitive motion), sport, recreational activities |
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POWER
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The SPEED with which a forceful mm contraction is performed.
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What is the VALUE of POWER?
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Athletes who need to perform rapid movements.
Workers (construction, factory, etc.) who perform heavy lifting or movement patterns |
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Conscious or unconscious sense of joint and body position
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PROPRIORECEPTION
*Involved in neuromuscular coordination |
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What is the VALUE of proprioreception?
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contributes to pain-free coordinated movement
reduces risk of injury or re-injury |
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What is up to the patient?
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COMPLIANCE
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The degree to which a joint and accompanying mm can be moved, NON-ACTIVELY, with the use of EXTERNAL force.
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PASSIVE ROM = PROM
This may be performed by the doctor OR the patient. This movement MINIMIZES MUSCULAR ACTIVATION. |
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What is the VALUE of PROM?
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There is none. PROMs are stupid.
Lengthen tissues to decrease mm stiffness and pain. Prevent formation of ADHESIONS following injury or immobilization Increases vascular and lymphatic drainage Allows patient to become to a participant in their care, even when they have pain. |
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The degree to which a joint and accompanying mm can be moved with a patient's own VOLITION
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ACTIVE ROM = AROM
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VALUE of AROM?
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Increases RESTING LENGTH and available PAIN FREE ROM
Enhances vascular and lymphatic drainage Provides short and long term pain relief Used as a WARM-UP method prior to exercising mm vigorously |
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ISOMETRIC mm training
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Muscle tension created WITHOUT CHANGE in mm length
*referred to as STATIC work |
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VALUE of ISOMETRIC resistance training?
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1. Effective when patient is TOO WEAK to exercise against gravity or weight
2. PREVENTS strength loss when pt unable to move actively for themselves 3. Helps MANAGE SWELLING by causing mm pumping action to REMOVE FLUID & EDEMA 4. Influences COLLAGEN ALIGNMENT during EARLY healing response 5. Enhances ability to perform ADL's safely |
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ISOTONIC resistance
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Muscle tension created when MUSCLE CHANGES LENGTH
"doing work" is moving a joint = DYNAMIC |
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Why is isotonic resistance training better than isometric (static)?
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Increases ROM up to 40% more than static pose, via 10-20% on either side.
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VALUE of ISOTONIC resistance training?
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Principle form of strengthening utilized to RESTORE STRENGTH to PRE-injury condition status.
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What types of muscle contraction is stronger: concentric or eccentric?
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ECCENTRIC is stronger 40-50%
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CONCENTRIC contraction
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Muscle SHORTENS while tension/force increases to overcome resistance = POSITIVE contraction
ie, bicep curl |
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ECCENTRIC contraction
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Muscle LENGTHENS while producing tension or force = NEGATIVE contraction
ie, bicep curl |
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Optimum contractile time ratio
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1:2 ratio
Concentric : 1, Eccentric : 2 ie, Concentric 3 seconds Eccentric 6 seconds |
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Timing
Individualization Specific sequencing Aggravation avoidance Intensity Compliance Total health |
Principles of therapeutic exercise
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TIMING principle
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Essential to begin exercising as soon as possible following onset of a problem.
Type and intensity of exercise within severity of patient's sx ie. Acute neck strain = passive range of motion PROM Chronic ankle instability - isometric/isotonic strengthening |
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INDIVIDUALIZATION principle
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Undetectable or not easily observable differences can change a patient's response to care.
Not everyone is the same! |
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Things that make a patient's response different include (individualization):
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Previous trauma
Co-morbidities Intensity of their life demands (family, job, etc.) Compliance Fear and avoidance behaviors |
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What is the main point to remember regarding INDIVIDUALIZATION principle?
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Don't assume. Pay attention to the response.
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SPECIFIC SEQUENCING principle
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Therapeutic exercise should be compatible with the STAGE of the patient's care.
It's all about PHYSIOLOGY. |
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AGGRAVATION AVOIDANCE principle
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if administered INcorrectly, TE has the potential to aggravate a patient's sx
Use sound judgement. Do no harm! Deepen your 'working' knowledge |
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TRIGGERING SYMPTOMS principle
"why a patient experiences aggravation of sx with TE" |
Exercise introduced too soon
Too challenging Other collateral damage makes it a poor fit. Unaccounted issues (degeneration, scar tissue) generate reactive responses Fear avoidance behavior Diagnosis incomplete or incorrect |
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INTENSITY principle
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Strike the ideal balance. Intense enough to produce positive change. Not so intense to aggravate sx or produce collateral damage.
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Ways to control INTENSITY
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Educate patient about what they should AND should not experience.
Early on, emphasize LOW resistance w/ more REPETITIONS. = hypervigilance! |
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TE benefits
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decrease swelling (PROM, AROM, Isometric)
decrease mm tension decrease adhesion Increase collagen alignment (isometric) Increase mm strength Increase mm coordination |
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COMPLIANCE principle
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Compliance means therapeutic exercise is performed CONSISTENTLY enough to produces an adequate stimulus-response {POSITIVE RESULT}.
Low compliance = poor results |
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Totality
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be mindful of the 'totality' of the patient's injury or condition on their whole life (physical, mental, etc.)
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The patient will enhance core stability by training ______ and/or ________ key stabilizers of the lumbar spine.
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inhibited
atrophied |
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The patient learns to maintain ______, stable lumbar spine position while performing increasingly difficult tasks involving _______ muscles.
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Guessing:
neutral stabilizing |
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Enhancing core stability by training patients to maintain a neutral spine will lead to automatic __________ and __________ control in the face of destabilizing forces.
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segmental
regional control |
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A neutral spine posture is defined as one in which the joints and surrounding tissues are in __________ ________ and thus at an angle of minimal ____ ____.
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elastic equilibrium
joint load |
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Anterior core mm
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Transversus abdominis
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Posterior core mm
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MULTIFIDUS
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Superior core mm
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DIAPHRAGM
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Inferior core mm
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PELVIC diaphragm is inferior
(vs. mm diaphragm that is superior) |
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The components of core mm ________ with the initiation of limb activity, thereby providing ________ for ballistic motions and other ADL's.
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co-contract
stabilizing |
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Regarding core function, rather than strength, we are concerned chiefly with _________ activation and __________.
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TIME & ENDURANCE
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Studies by Hodges and Richardson in the late 1990's demonstrated a change in the ________ of TRUNK mm firing in patients with ________ Low back pain.
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TIMING is off
in CHRONIC LBP patients |
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Normally, limb movement challenges the ___________ of the spine.The CNS, as a result of years of practice in movement, knows the exact time when this perturbation will occur. What is this ability to predict beforehand called?
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stability
FEED FORWARD or ANTICIPATORY mechanism of postural (core) stability |
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The first muscle to contract in response to the normal core muscle firing FEED-FORWARD/ANTICIPATORY principle of predicting motion is...?
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Transversus abdominis
It does so, when healthy, in ADVANCE of limb movement initiation, as much as 1/10 of a sec. before (as with leg movement) |
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Regarding ABNORMAL core firing, core mm can become inhibited due to ________ ________ from previous injury or long term postural strain.
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PAIN REACTION :~0
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Inhibited transverse abdominus and co-contractors still contract with limb and trunk movement when PAIN REACTION present, but?
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MORE SLOWLY, even late! AFTER global mobilizers contract.
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ABNORMAL CORE FIRING exposes spinal motion segments and SI joints to potential ________ ___________, which may result in an alarm reaction. This provokes pain and lumbar muscle spasm.
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EXCESS MOVEMENT
*This TIMING DELAY is the KEY dysfunction of the INNER core. |
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Regarding abnormal core movement and feed-forward/anticipatory mechanism distorted...
*This __________ _________ is the KEY dysfunction of the INNER core. |
TIMING DELAY
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A delay in core firing will usually not cause acute LBP right away. There is likely a buildup of ___________ leading up to an acute episode, meaning each time the patient moves, there is too much _______ in the back.
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MICROTRAUMA
TOO MUCH MOTION |
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Microtrauma that causes too much motion during an acute episode of LBP leads to premature wear and tear of tissue, including ______ and a climate of instability.
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IVD's
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What are McGill's big 3 examples of STABILIZING exercises?
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1. DEAD BUG
2. BIRD DOG 3. SIDE PLANK Other two are 4. Abdominal bracing 5. Bridging |
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Supine leg lowering and thrust
Torso raises Lunges Stork |
Examples of STABILIZATION exercises
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Regarding physioball vs. firm surface, which has more spine load during curl-ups?
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physioball
(4000 vs. 2000 Newtons) |
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Name some tools to progressively increase stability challenge
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physioball
foam roll stability pad rocker/wobble board adding elastic resistance catching ball while balancing assistant-provided perturbations |
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________ _________ further challenge core stability in a ___________ environment, in preparation fro the inevitable unplanned awkward movement.
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LABILE SURFACES
controlled |
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GOAL of increased stability challenges via tools like stability pads?
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Sudden spinal loading or unplanned, awkward movement excess, aberrant motion.
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Key to all stability challenge exercises is that they incorporate ________ __________ for the lumbar spine and find a ________ zone.
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ABDOMINAL BRACING
find NEUTRAL ZONE |
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Planned, purposeful perturbations strain _______ _________ __________ and turn stability into an unconscious motor habit.
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CORE MOTOR CONTROL
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Value/benefits of stabilization exercises:
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*Maintenance of NEUTRAL SPINE, reducing spinal loading during everyday tasks.
* Reduction of injury potential - 1st or reinjury - ...decreasing painful intolerances * Part of deconditioning prevention |
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During SPORTING activities, the core must be stable to transfer forces from the extremities to the total body for (4):
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1. Acceleration
2. Explosiveness 3. Balance 4. Power |
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Sporting activities enhance __________ and __________ ___________ of LB and trunk.
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PROPRIOCEPTION
KINESTHETIC AWARENESS |
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3 more value/benefits of stabilization exercises (circled in notes)
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Less likely to posture in provocative positions
Less likely to use inappropriate posturing and technique with lifting tasks and other functional movements Enhances maintenance of the effects of spinal adjusting |
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Name some target conditions for stabilization
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Lumbar disc syndrome
Hypermobility Spondylolisthesis Functional scoliosis The "Boomerang" patient Post-partum Failed back surgery Sprain/strain injury Myofascial pain syndrome |
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ACUTE phase exercise rx:
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FLEXION exercise I
EXTENSION exercise I Positions of COMFORT PROM ADL's "Lite" |
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SUBacute Phase exercise rx:
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FLEXION exercise II
EXTENSION exercise II AROM ISOMETRICS WALKING ADL's CAT-CAMEL for spine mobility |
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HEALING phase exercise rx
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Any previous still indicated
ISOTONICS STABILIZATION exercises |
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Factors affecting patients' ability to follow through with exercise recommendations is called?
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exercise COMPLIANCE
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What percentage of adults are not physically active on a reg basis?
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2/3
*1/4 get virtually no exercise at all |
