-
spedific terminology should be used but, often is used interchangably:
Flexibility:
ROM:
- Flexibility
- ability of musculature/tendinous unit to elongate
- terms used to describe: stiffness, pliable
-
it is useful to identify what is inhibiting ROM.
List (4) influences to ROM:
- swelling
- scarring: tissues (tendon, muscles, joint capsules, ligaments), soft tissues
- structures
- increased muscle tone/guarding: influence with contractions ( PNF)
-
connective tissues are made up of collagen & other fibers within a ground substance.
Collagen:
- provides strength or stiffness
- bridges: how collagen is organized provides more or less strength
-
connective tissues are made up of collagen & other fibers within a ground substance.
Elastin:
- provides extensibility
- stretch that returns to normal
-
connective tissues are made up of collagen & other fibers within a ground substance.
reticulin:
weaker temporary type III collage
-
connective tissues are made up of collagen & other fibers within a ground substance.
ground substance:
- in between fibers
- immobilization = less ground substance
-
list the structures that are dense regular connective tissues: (2)
how would you stretch dense regular conn. tissues:
- tendon (dont want tendons flexible - contractions)
- ligament
- how to stretch:
- straight: fibers run in one direction
-
list the structures that are loose regular connective tissues: (1)
connective tissue (organs)
-
list the structures that are dense irregular conncetive tissues: (5)
- joint capsules
- periostium
- aponeuroses
- dermis of skin
- fasical sheaths
- strong in multiple directions
- example: MCPJ (joint capsule, multi directions) vs. ICPJ (less motion)
-
list the structures that are loose irregular connective tissues: (1)
- subcutaneous tisses
- superficial & deep fascial layers
- nerve & muscle sheaths
- endomysium holding individual muscle fibers
more vascularity
-
one must understand mechanical properties of connective tissues to stretch and fxn properly.
list the (3) properties:
- plastic
- viscoelastic
- elastic
the extent of these vary by tissue
-
the fluid like resistance to force that provides permanent deformation is called:
viscosity
there is no potential energy, so the tissues does not return, engergy is released as heat
-
a property that allows stretched tissue to return to normal length post load is called:
elasticity
- long stretch may facilitate permenant deformation with proper stress
- ability of soft tissues to return to its pre-stretch resting length directly after a short duration stretch force has been removed
-
describe the mechanical property of visocelasticity:
- a combintation of viscosity & elasticity
- there is some return in length but not full
soft tissue initially resists deformation, such as change in length, when stretch force is 1st applied, if stretch force is sustained allows a change in length & enables the tissue to return gradually to prestretch state after stretch force has been removed
-
the property of connective tissue that allows for the ablity to undergo a permanent change in length after force is applied is called:
plasticity
change in length after force is greater than collage bridges
soft tissue assumes a new & greater length after the stretch force has been removed
-
list the (2) physical properties of connective tissue:
- creep:
- related to viscosity thus time dependent
- when load is applied long enough you may get permanet elongation
- time dependent = 15 mins +, weight or gravity
- force/stress relaxation:
- tension decreases, so may not need so much stress
- decrease muscle tone
- breaking cross bridges
- long enough stress = less force
in order to elongate connective tissue must consider both
-
the physcial property of connective tissue that describes elongation of tissues in the plastic range is called:
list (2) ways this is typically acheived:
creep
- acheived with:
- low load, long duration is most effective
- heat: destabilizes cross bridge bonds w/ least damage
- -less pain for pt.
- -to increase heat of tissues ->active exercise
how warm: 3 o TTR
-
physial properties that lead to changes beyond plastic range & failure is called:
fatigue failure-structural failure
varies with duration, repetition or magnitude
-
strain (deformation) of an object is directly related to ability to resist stress (load), as stated by:
Hooke's law
each body tissue has a unique stress strain curve
-
wavy crimp of collage is stretched 1.5-4% in which region of the stress strain curve:
toe
when stressed, initially the wavy collagen fibers straighten
-
with additional stresses, recoverable deformation occurs in which region of the stress strain curve:
elastic range
- stretches 2-5%
- feel stretch at end of this range then hits yeild point
-
once the elastic limit is reached, sequential failure of the collagen fibers & tissues occurs in the which range of the stress strain curve:
what is the result & released:
plastic range
resulting in the release of heat & a new length when the stretch is released
premanent deformation (5-10%) secondary to cross bridge breaking
-
the region of the stress strain curve in which there is considerable weakening of the tissue & less force is needed for deformation is called:
Necking
- total failure quickly follows even under smaller loads
- ultimate strength
-
the region of the stress strain curve in which each stretch increases heat allowing the next stretch to be more effective is called:
hysteresis
repetitive stretching with sub max load effectivly increases length
-
stretching techniques are based on stretch reflexes
the mechanoreceptors muscle spindles are typically sensitive to which type to stretch:
sustained stretch & quick stretch/velocity
-
strethcing techniques are based on stretch reflexes
the mehcanoreceptors golgi tendon organs are typically sensitive to which type of stretch:
tension
-
the neuromuscular afferants IA or primary afferant surround which part of the neuro fiber:
what type of stretch does the IA (primary) respond to:
- IA (primary) surrounds: middle of the spindle (nuclear bag)
- responds to: quick & sustained stretch - running, cutting, change of direction (so you dont become unstable)
-
the neuromuscular afferants II or secondary respond to which type of stretch:
static stretch
-
the neuromuscular afferants Ib send messages from which type of receptor:
which type of stretch does this respond to:
- from which type of receptor: golgi tendon organ
- responds to: tension
-
when tension develops in muscle GTOs fires and inhibits alpha motor neuron that is under tension.
why is this useful:
PNF - the pt. has muscle tightness, GTO fires & inhibits the alpha motor neuron - then decreases muscle tone
-
when a muscle is stretched (rapid or sustained) the muscle spindle responds by initiating _______ via the alpha motor neuron of the muscle stretched
reflexive contraction
-
when a stretch reflex is activated in the muscle being lengthened, decreased activity (inhibition) of the muscle on the opposite side of the joint is present which is known as:
reciprocal inhibition
-
if a stretch/tension held on a muscle is greater than 6 seconds an inhibitory impact on the muscle being held occurs which is known as:
autogenic inhibition
thus gains in flexibility may be from muscle fiber relaxation or noncontractile tissue lengthening
-
neuromuscular effects of ROM on GTO:
sensitive to which type of stretch:
located at:
which type of neuromuscular fiber:
type of inhibition:
- sensitive to which type of stretch: contraction & tension
- located at: musculotendon junctions
- which type of neuromuscular fiber: Ib afferents
- type of inhibition: autogenic inhibition - Ib sends signal to inhibit alpha motor neuron & stimulate antagonist
-
list 4 considerations of how to asses for normal ROM:
- varies from source to source (textbook to textbook)
- varies signfiiciantly by age (decreases with age)
- varies with sport &/or repetitive activity
- use contralateral however use precaution
-
immobilization is sometimes needed to provide for:
adequate healing
-
immobilization can be detrimental under which (2) conditions:
- prolonged or excessive
- (can be permanent or irreversible)
- immobilization = excessive cross bridging
- trend has been to decrease time immobilized or allow safe motion
controlled mobilization - take out of immobilization, provide ROM & immobilize again
AROM provides more stress than PROM - pulls its self away from the bone
use tissue resistance
-
immobilization of connective tissue
- changes occur within 1 week & increase with edema, trauma circulation
- loss of water & GAG content decrease ground substance
- loss of ground substance leads to decreased lubrication between fibers (increase cross bridging)
- reduction in collagen mass
- increase rate of turn over, degradation & synthesis
- with trauma collagen laid down in haphazard fashion (cross links) (proliferation phase - fibroblasts lays collagen, unorganized example: MCL injury - post 4 weeks, feels like firm lump = increased collagen)
- scar tissue formation leads to wound contraction
- binding down sheets of connective tissue (skin fascia mm ligament capsule)
- structural weakness 2ndary to decreased collagen mass
-
immobilization of muscle
- loss of strength
- can happen in just 5-7 days, most rapid initially
- decrease in mm fiber size up to (40% in 6 weeks)
- disproportionate decrease in Type I fibers
- decreased oxidative enzymes
- decreased muscle capillary density
- increased fatty tissue deposition
- decreased neural feedback
- decrease in ground substance
- shortened or lengthened position of immobilization
-
immobilization of articular cartilage
- thin covering on end of long bones 1-7 mm
- impacted length, position & WB status
- decreased chondrocyte size & ability to synthesize collagen
- softening of articular cartilage
- decreased catilage thickness
- necrosis in immobilized together (direct pressure of two long bones - arthritis)
- increased fibro fatty tissue which turns into scar in joint space
- contractures lead to further breakdown - pressure necrosis
- timeframe to become irreversible ( 30-60 days)
- intermittant loading reduces (less nutrition)
-
immobilization of ligament
- decrease in cross sectional area
- decrease in stress attenuation
- decreased GAG content
- disruption of parallel alignmen
- osteoclastic activity at bony ligament interface
-
list (2) things that must be identified for remobilization:
must identify stage of healing to base intensity & duration
- must identify limited structure
- musculotendinous
- capsoluligamentous
- myofascial
- utilize most appropriate technique based on above:
- modalities
- STM
- joint mobilizations
- PROM
- AAROM
- AROM
-
stretching techniques preformed by the patient without outside assistance is called:
what is the technique most effective for:
active stretching
elastic & possibliy some plastic changes
- effective for: prevention & minor injuries and minimal scarring
- hold 15-30 seconds 3-5 x
- reciproical inhibition
-
ballistic, static & PNF are stretching techniques known as:
passive
- short or long duration dependant on tissue & goal
- force: gravity, another person or equipment
- typically better at getting to the passive range
- should feel stretch not a lot of pain
- must take into account stage of healing (how aggressive)
- pain pattern post stretch (feels better after = good, sore for days after = not good)
- audible pops
- prolonged 10-20 mins
-
the stretching techniques based on reduction of sensory activity through spinal reflexes to cause relaxation is called:
what is the traditional technieque for this stretch:
PNF
- multiple techniques & results utilizing mechanoreceptors
- can be very effective at increasing range
traditional PNF tehcniques require working in the diagonal patterns
-
the PNF technique in which the pt. preforms end range isometeric contraction for 5-10 seconds followed by voluntary relaxation is called:
Hold-relax
- -range limiting muscle first lengthened to the point of limitation
- -pt. preforms end range isometeric contraction for 5-10 seconds followed by voluntary relaxation
- -limb is then passively moved into a new range
- -autogenic inhibition
-
the PNF technique in which the muscle contract rotation in the diagonal is allowed and all other muscle fxn's isometrically is called:
contact relax
-
the PNF technique in which the pt. concentrically contacts (shortens) the muscle opposite range limiting muscle & hold for several seconds is called:
agonist contraction
- agonist refers to the muscle oppostite the range limiting muscle
- antagonists refers to range limiting muscle
- range limited muscle is passivly moved into new range
- reciprocal inhibition
- effective with significant guarding or unstable to perform HR
- useful for intiating NM control with newly aquired range
-
list (5) precautions to be aware of while stretching:
- phase of healing
- knowledge of injury
- biomechanics of joint
- pts. rxn post tx & during
- education: how much can or cant do
-
list (5) modalities of manual therapy
- massage soft tissue mobilization
- myofasical release
- muscle engery
- joint mobilization or manipulation
- neural mobilization
-
an area of hypersensitivity, that when compressed becomes tender and if sufficiently hypersensitive gives rise to referred pain is called:
trigger point
-
skilled passive movement of a joint is called:
joint mobilization
- multiple "experts" & excellent texts
- many are doing the same things with slightly different names or slightly different techniques
- -differing legislation on what you can & cant do as an ATC (skilled passive motion)
- - performed on any joint in the body
- - requires good understanding of body anatomy
-
list the (3) effects of joint mobilizations:
- mechanical
- nutritional
- neurophysiological
-
describe the mehcanical effect of joint mobilizations:
provides movement and lubrication to articular cartilage
- -breaks adhesions
- -mitigate capsular restrictions
- -distracts impacted tissues
-
describe the nutritional effect of joint mobilizations:
- diffusion
- mobilization distracts articulation
if 2 joint surfaces are compressed, and the joint surface is not being loaded and unloaded then the joint has no way to draw nutrition.
consider an example of the joint similar to a sponge
-
describe the neurophysiological effect of joint mobilizations:
- pain gaiting: small amplitude oscillatory
- stimulates mechanoreceptors: proprioception
- inhibits nocioceptive input
-
a popping sound during joint mobilizations is thought to be:
the formation & collapse of CO2 bubbles within the joint
- advantageous for Hypomobile joints but not necessary
- contraindicated for hypermobile joints
-
list (2) contraindications for grade 1 & 2 joint mobilizations:
-
list (4) contraindications for grades 3-5 joint mobilizations:
- acute fx
- acute infections
- severe joint effusion: the joint effusion is already distending the joint, no need to mobilize it even more
- hypermobility: these grades put mechanical stress on the tissues, considering hypermobility, not going to want to stretch the tissues even more
-
list (6) precautions for joint mobilizations
- malignancy
- bone disease: osteoporosis: a vigorous joint mobilization could potentially fx
- joint replacements: end of long bones are being cut off + replaced by plastic/metal, then glued or hammered, & bone grows into replacement. be cautious with mobililzation so that replacement does not loosen replacement (doesnt usually get better), so make sure to mobilize the capsule, not the replacement
- newly formed or weakened connective tissue: after injury may be able to put some stress on the connective tissue bc you want to re-align as per stages of healing -- maturation phase---tho, light stress, not too aggressive
- R.A.
- advancing age
-
describe the...
osteokinematic motion:
&
arthrokinematic motion:
of shoulder ABD
- osteokinematic: long bone, humerus, is moving up & away
- arthrokinematic motion: head of humerus is rolling & inferiorly gliding down
-
joint motion that is under the control of the patient is called:
list (3) examples of this motion:
osteokinematic/physiologic motion
examples: flexion, ABD, ect.
the motion of the long bone
-
motion that is needed for normal joint motion but it not under voluntary control of the patient is called:
arthrokinematic/accessory motion
component motions are not capsular but accompany physiologic motions
example: humerus/ GH roll, spin,glide
-
motion that occurs in the joint capsule & is determined by its laxity is called:
joint play
-
when loss of motion at a joint is due to capsular tightness, what will the the motion be presented at:
a capsular pattern
- capsular & noncapsular patterns can be differentiated by end feels at the end of passive ROM: example decreased shoulder ER, IR, ABD (capsular pattern), but end feel with PROM is normal, then the capsular problem is ruled out, and it is likely another problem other than capsular
- -mobilization may be appropriate
-
a capsular pattern of motion loss typically indicates:
joint capsule dysfxn
-
soft tissue approximation will have what type of end feed:
give an example of soft tissue approximation:
soft end feel
example: knee flexion
-
muscular, capsular, and ligamentous all have which type of end feels:
give an example of each type of end feel:
firm end feels
- muscualr: hip flexion SLR
- capsular: MCP extension
- ligamentous: forearm supination
-
boney, elbow extension will have which type of end feel?
Hard
-
any of the normal end feels that are not appropriate to the joint motion are called:
pathologic end feels (cyriax)
-
a pathologic end feel that is a sudden,sharp arrest in 1 direction is called:
adhesion
typically occurs in joints with multiple planes of movement.. will feel un-normal in 1 direction
-
a pathologic end feel that usually occurs with rebound, usually accompanied with pain is called:
spasm
-
a pathologic end feel that presents with ligamentous laxity is called:
loose
-
a pathologic end feel that is soft, with mushy joint effusion is called:
boggy
-
a pathological end feel that presents with internal derangement and/or mechanical block is called:
springy block
-
a pathological end feel that presents with empty , no resistance to motion, with or without pain is called:
empty
-
list the (5) arthrokinematic motions that occur between bones in a joint:
- roll
- glide
- slide
- compression
- distraction
relies on joint surface shape... convex, concave, or both
-
when a new point on one surface a new point on another surface is the arthrokinematic motion called:
occurs in combination with:
- roll
- occurs in combination with: gliding and spinning
- occurs in the direction of the movement
-
when one on one surface contacts a new point on a another contact surface is the arthrokinematic motion called:
glide
- usually occurs in combination with roll & spin
- slide occurs as per concave-convex rule
- when done in tx is called a glide
-
when one bone rotates around a stationary axis is the arthrokinematic motion called:
spin
does not occur by itself
-
a decrease in space between 2 joint surfaces is the artrhokinematic motion called:
- compression
- adds stability to a joint
-
when 2 surfaces are pulled apart the arthrokinematic motion is called:
distraction
often used to stretch accessory motion
-
describe the concave-convex rule:
in which direction does the roll & glide occur:
concave surface slides in the same direction as the bone movement (mobile concave; fixed convex)
roll & glide occur in the same direction
-
describe the convex-concave rule:
in which direction does the roll & glide occur:
convex surface moves in the opposite direction of bone movement.
roll & glide are in opposite directions
- glide is in opposite direction
- roll is in same direction of bone movement
-
the plane that passes thru the joint & lies at a right angle to a line that lies perpendicular from axis of rotation (in a convex bone) to middle of contacting articular surface is called:
the treatment plane
quickly estimate the tx plane by imaging a plane that lies over the concave surface
-
small oscillations at the beginning of the range is which grade joint mobilization:
Grade I -
No tissue resistance
-
slightly larger oscillations at the beginning of the range to tissue resistance is which grade joint mobilization:
grade II
just a touch of resistace
-
a large oscillation to the end range is which grade joint mobilization:
grade III
resting to end range & back
-
a small oscillation at end range is which grade joint mobilization:
grade IV
-
a end range small amplitude high velocity is which grade of joint mobilization:
grade V
-
what 3 things can limit ROM?
once the cause has been indenified, it will be easier to tx
-
should a joint mobilization occur in a open pack or closed pack position:
open pack position
-
joint surfaces are most congruent,
ligaments and capsule are taught, and..
joint surfaces are together in which type of joint mobilization position:
closed pack position
- put in this position to stablilization
- not easily separated
- knee extension: closed pack position
- mcl stress tests at 0 and 30 degrees
- 30 degrees is open pack, allows for more motion
if there is laxity at 0 degrees of extension, then the injury is more involved because the ligament is supposed to at its tightest
-
the capsule is most lax,
least amount of congruency,
evaluation and tx occur here,
and typically occur mid range in which type of joint mobilization position:
open or loose packed position
-
the most dangerous technique,
least acceptance & understanding,
referred pain follows neural pathways, &
injury can be to nerve directly or tissue surrounding
is the type of mobilization known as:
neural mobilization
-
list 5 susceptible sites of neural mobilization
- tunnels
- neural branches
- where nerve is fixed
- high friction
- tension areas
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