400 notecards = 100 pages (4 cards per page)
Various tissue changes occur in each stage of healing, which determines the _________?
Goal of therapy
Damage to tissue results in chemical release of histamine, prostaglandin, bradykinin, free recitals, etc., which have the following effects:
2. Increased capillary permeability
3. Secondary cell damage
What is the approximate duration of the acute/inflammatory phase?
3 to 5 days
Which type of cells are present during the acute/inflammatory phase?
PMN (polymorphonucleus neutrophils), macrophages, and fibroblasts
The fibrin clot is formed during which phase?
Which cell breaks down and removes debris from the site of injury?
What are the main signs of inflammation?
Redness (rubor), pain (dollar), swelling (tubor), hot (calor), and loss of function (laesea)
Which type of cells is predominant during the subacute/proliferative phase?
Which stage of healing do we start to see the progression of collagen type fibers from type III to type I?
What is the approximate duration of the subacute/proliferative phase?
2 to 4 weeks
_______ may form during the subacute/proliferative phase.
We can gently _______ the tissue during the subacute/proliferative phase to help the tissue become stronger.
What cells are predominately present during the chronic/maturation/remodelling stage?
Fibroblasts and myofibroblasts
Fibroblasts and myofibroblasts ______ the tissue _______.
What is the approximate duration of the chronic/remodelling/maturation phase of healing?
6 to 18 months
In the late stages of healing, contraction of a scar near a joint and adhesions around a joint can cause ________ ?
What type of fibers can become more in line with rehabilitation?
Pain leads to muscle inhibition and disuse, which can lead to _________ .
Atrophy of muscle, ligaments, and bone
Atrophy of muscle, ligaments, and bone can result in altered ________ .
Immobilized muscle can lose muscle strength at ________ .
8% per week to 5% per day
Weaker muscles, weaker connective tissues, and inefficient biomechanics can lead to?
Chronic or repeat injuries
Goals of rehabilitation try to promote?
Reduction of pain and promote function, ROM, coordination, general fitness, etc.
What are the therapeutic goals of the acute/inflammatory phase?
PRICE (protection, rest, ice, compression, elevation), prevent further injury, and control inflammation and pain
What are the therapeutic goals of the subacute/proliferative phase?
Do not aggravate healing tissue, control pain, gentle stretching (active and passive) and motion, and therapy to other adjacent areas not injured
In the subacute/proliferative phase, gentle stretching and motion helps to?
Prevent adhesions, maintain ROM, helps quality of scar being formed, and reduces congestion/swelling
What are the therapeutic goals of the chronic/remodelling/maturation phase?
Strengthen scar tissue and surrounding muscle, remove any trigger points, and to restore function, ROM, strength, muscles imbalances, coordination, and skill
The application of cold to the skin has an immediate _________ effect. Afterwards there is a long slow _______ effect.
The ________ effect of applying cold to an area of skin is helpful in the acute/inflammatory phase of healing.
With cold application to the skin of the extremities, there is the _________ reaction after about 15- 20 minutes of application.
Lewis Hunting (alternating vasoconstriction and vasodilation)
Therapeutic application of cold slows down the ________ in peripheral nerves and local _______ rate, which leads to less _______ and _______. This results in less tissue damage.
Conduction; metabolic; pain; inflammation
What can happen if tissue becomes too cold for a prolonged period of time (longer than 15 minutes)?
Ischemia leading to necrosis
What is the management of prolonged severe cold exposure?
Rapid warming in core-temperature water
What is the test that is used to determine the vascular response to a cold stimuli?
What is an abnormal initial response for the Baruch test?
You scratch the skin, the skin blanches and it remains white
What is a normal initial response for the Baruch test?
You scratch the skin, the skin blanches, but then turns red
When is therapeutic cold application contraindicated for the Baruch test?
When the skin response remains white after the initial and secondary parts of the test
When is therapeutic cold application contraindicated?
Positive Baruch test, Reynaud's test, heart disease, peripheral nerve or vascular disease, compartment syndrome, psychological aversion to cold, cold allergies, and pernio (sequel to frostbite: tissue hypersensitive to cold)
What are the indications for cold therapeutic application?
Acute musculoskeletal injuries
What can the patient expect to feel during cold therapeutic application?
CBAN: cold, burning, aching, and numbness
Methods of cold application:
Cold packs, ice (cube) massage, ice towels, immersion/ice baths
When is an ice pack application best started?
Immediately after injury during the acute phase. It is also used in the subacute phase especially after activity
Ice massage cools tissue very rapidly and should not be used longer than _______ , usually until the area is numb.
What is the approximate depth of penetration of a hot pack?
What is the approximate depth of penetration of continuous ultrasound?
5 to 8 cm
What is a caution about continuous ultrasound?
Burn: Deep tissue is not as sensitive to temperature as skin, it is possible to burn someone before they are aware. If the patient feels heat on the surface, you may have already burned deeper tissues. Never heat beyond comfortable warmth.
Examples of superficial heat applications:
Hydrocollators, microwaveable gel packs, electric heating pads
When is superficial heat beneficial?
During the chronic/remodelling/maturation phase and the late proliferation when when inflammation is no longer present
What are the physiological effects of therapeutic superficial heat?
Vasodilation, increased metabolic rate, sedative effect on nerves - less spasms and pain
Contraindications to therapeutic superficial and deep heat?
Acute/inflammatory phase, diagnosis of injury unknown, malignancy, deep infections, bleeding or clotting disorders, loss of sensation, decompressed heart disease, PVD, diabetes, inflammatory skin conditions, contact dermatitis, high fever, eyes, risk of cataracts, vascularization of cornea, burns of any kind, infants, and pregnant uterus.
What is one contraindication to therapeutic deep heat which is not contraindicated in superficial heat applications?
What are the common indications for superficial and deep heat therapeutic applications?
Neuritis/neuralgis, and the following conditions following the inflammatory phase: contusion (bruise), sprain/strain, pain or spasm, tendonitis, synovitis, tenosynovitis, fibrosis, fasciitis, myofascitis, myofibrositis, buritis, arthritis,
________ therapeutic heat application is not indicated for superficial skin infections, boil, sty (eyelids), carbuncle, furuncle, and frostbite, but these conditions are indicated for ________ therapeutic heat applications.
What is the most commonly used deep heater?
Therapeutic ultrasound (continuous)
Therapeutic ultrasound uses a ________ , which helps to make better contact with the skin and it protects the crystal ultrasound head.
When is a 100% duty cycle (continuous) method used for therapeutic ultrasound?
Later/chronic phases of healing as it produces heat
When is pulsed duty cycle (less than 100%) used for therapeutic ultrasound?
Acute/subacute phases of healing
With therapeutic ultrasound, ______ frequency produces heat deeper in the body, whereas the ______ frequency penetrates more superficially.
Lower (1MHz); higher (3MHz)
The intensity of therapeutic ultrasound is measured in?
When using therapeutic ultrasound, we would use increased intensity for?
Bigger body parts, lower frequency (1MHz), more heat desired when in the chronic phase
When using therapeutic ultrasound, we would increase the time with?
Bigger body parts, low percentage duty cycles (20%) as more time would be needed for physiological effect
Which areas of the body are contraindicated for continuous therapeutic ultrasound (produces heat)?
Over metal intrauterine device (IUD), autonomic ganglia, heart, central nervous system (spinal gutter is ok), pacemaker or other bioelectric equipment, rheumatoid arthritis, bony prominence, reproductive organs
What are the therapeutic effects of continuous ultrasound?
Vasodilation, heats up adhesions/contracture, sedation of peripheral nerves, and neuroma (a painful growth in nervous tissue)
Continuous ultrasound does not work on?
What is the effect of continuous ultrasound on fat tissue?
Little resistance, heats slowly
What is the effect of continuous ultrasound on nerves and muscles?
Well absorbed, heats well
What is the effect of continuous ultrasound on bone?
Most resistant, heats fastest
With therapeutic ultrasound at the bone:muscle interface, there is a lot of ________ and _______ . There is the potential to cause a burn at this interface due to the one tissue type ______ a lot more than the other.
Friction; heat; vibrating
Cavitation is where O2 and CO2 come out of the tissue and can coalesce and cause tissue damage with therapeutic ultrasound. In order for this to happen, we would need to use an intensity of _______ Watts/cm2.
6 to 8
What are the therapeutic effects of pulsed ultrasound?
Increased scar strength, increased rate of scar formation, increased rate of healing, does not reduce inflammation, but useful in the acute/inflammation phase
What are the contraindications to pulsed ultrasound?
Bleeding disorders, malignancy, growing epiphyses, loss of sensation, CNS, over the heart, caution with PVD
When using therapeutic ultrasound, you need to keep the ultrasound head moving at _______ cm/sec.
2.5 to 5
Underwater ultrasound is used for _______ , and you must keep the ultrasound head 1cm away from the skin surface. You can also use higher intensities from 1.0 to 2.5 Watt/cm2.
Bony prominences (hands and feet)
Therapeutic ultrasound can also be used for _________ , which helps push drug into the tissues (with an advantage of more local absorption).
Interferential Current (IFC) uses _______ frequencies (which are crossed) that create interference patterns in the body; the nerves are affected by the resulting frequency.
What are the two levels of Interferential Current (IFC) therapy?
Sensory and moror
What are the sensory level effects of Interferential Current (IFC)?
Promotes vasodilation, slows post-traumatic edema, and reduces pain (acute: lighter higher frequency; chronic stronger lower frequency)
What are the motor level effects of Interferential Current (IFC)?
Improves circulation, reduces edema (acute and chronic), and reduced muscle guarding (fatiguing muscle to reduce tension
What are the contraindications for Interferential Current (IFC)?
Pregnant uterus (lower back or abdomen), metastatic lesion, across the chest (heart), over carotid sinuses, venous or arterial thrombosis or thrombophlebitis, and/or over other currents used in body (nerve stimulator, pace maker, etc.)
With Interferential Current (IFC), moving the pads further apart creates a _______ current.
With Interferential Current (IFC), the patient will feel buzzing or tapping with the ________ level, and contraction ________ level.
What intensity is used for interferential current (IFC) to manage acute pain?
Mild sensory level
What intensity is used for interferential current (IFC) to manage more chronic cases with no muscle contraction?
Moderate sensory level
What intensity is used for interferential current (IFC) to manage muscle spasm or chronic pain?
Moderate motor level
Laser therapy only penetrates a few ________ .
Therapeutic effect of laser therapy are?
Cellular: increased ATP production, stimulation of macrophages, stimulation of fibroblasts to increase collagen production.
Altered nerve conduction and regeneration and vasodilation
Contraindications for laser therapy are?
Direct irradiation the eye, malignancy, hemorrhaging, locally to endocrine glands. Precaution with epilepsy and fever
Indications of laser therapy are?
Wound healing, fracture healing, and pain magagement
What intensity is used for interferential current (IFC) to manage acute edema (acute inflammation).
Mild motor level
Observation of the anterior posture follows the midline through the following structures:
Nose, manubrium, xiphod, and umbilicus
Asymmetry of the body contours in the standing anterior posture may indicate?
Muscle wasting, hypertrophy, nerve pathology, job related, etc.
In the anterior observed posture what is an abnormal finding of the clavicles?
The antecubital crease should face _______ in the standing anterior posture.
If the antecubital crease is pulled medially observed in the anterior posture, which muscle (s) could be responsible?
Tight pectoralis major
In the anterior observed posture, if the ribs are protruded on the concave side what could it be caused by?
In the anterior observed posture, what are the normal findings for the lower extremities?
Patella pointing straight forward and medial longitudinal arches present and symmetrical bilaterally
A pronated foot is known as?
Pes planus (flat foot)
A supinated foot is known as?
Pes cavus (arched foot)
The normal Fick angle is between _______ degrees relative to the sagittal plane and 2ndray (2ndtoe).
5 to 18
The ideal lateral postural plum line runs through the following structures:
Ear lobe, acromion, mid thorax, and slightly anterior to the hip and knee joint and lateral malleolus
A large gluteus maximus or fat over the buttock can give the false impression of _______ .
An exaggerated lordosis
Observing the posture in lateral view, knees are normally in _______ degrees flexion.
0 to 5
The ideal plumb line for the posterior observed posture should run through the following structures:
Spinous processes (C7) and gluteal cleft
Normal findings of the observed posterior posture are:
Vertical spinous processes, straight descending achilles tendons, forefoot straight (normal Fick angle), heel should be straight, other structures should be level and symmetrical (shoulders, scapula, gluteal folds, and popliteal crease).
If the palms are facing posteriorly, observed in the anterior posture, which muscle(s) could be responsible?
Tight pectorals major or forearm muscles
Uneven gluteal folds could indicate?
Muscle weakness, nerve root problem, or nerve palsy
Uneven popliteal creases could indicate?
Leg length discrepancy (LLD)
A medial bending achilles tendon if often seen with?
From an observed posterior posture, the heel angled inwards is known as _______ , and a heel angles outwards is known as ________ .
Rear-foot varus; rear-foot vulgus
The scapula is normally ____ inches from the spinous process in adults.
The scapula normally is between _______ spinous processes. Superior angle to inferior angle.
T2 to T7
The root of the spine of the scapular is at _____ level.
Winging of the scapula, with no rotation, if often due to:
Weak serratus anterior(more bilaterally) or scoliosis (more unilateral)
Elevation of the scapula, with no rotation, is due to:
Tight levator scapula/upper trapezius
Depression of the scapula, with no rotation, is due to:
Weak/long levator scapula/upper trapezius
Retraction of the scapula is often due to:
Tight rhomboids/middle trapezius
Protraction of the scapula is often due to:
Weak rhomboids/middle trapezius
Anterior tilt of the scapula is often due to:
Tight pectoralis minor
Upward rotation of the scapula is often due to:
Tight upper trapezius
Downward rotation of the scapula is often due to:
Tight levator scapula/rhomboids
What standing posture can increase spinal curves with lumbar lordosis increased?
What is genu recurvatum?
Hyperextension of the knee
From the lateral view knees are normally in 0 to 5 degrees of flexion, which muscles can cause knees flexion greater than 5 degrees?
Tight hamstrings or gastrocnemius
If knees touch but feet are apart in a standing position:
If feet together and knees do not touch (greater then 2 finger widths apart) in standing position:
One cannot easily correct their posture if
Joints are stiff or too mobile, muscles are imbalanced (in strength and length - weaker muscle is often lengthened)
Abnormal, weakened, or poor posture causes stress and wear on the _______, as well as _______ .
Articular surfaces; muscle fatigue and pain (weak and/or overly used)
Factors that are a risk to poor posture:
Muscle imbalance, excessive weight, emotional attitude, improper adolescence growth, respiratory conditions, muscle spasms, etc.
Upper and lower crossed syndrome patterns look at the pattern of:
Muscle strength in short muscles compared to the weak lengthened muscles.
Lower crossed syndrome has the following weak and lengthened (phasic) muscles:
Rectus abdominus, gluteus maximus and minimus (which is often inhibited)
Lower crossed syndrome has the following tight and short (tonic/postural) muscles:
Hip flexors (iliopsoas, psoas major, and rectus femoris), lumbar erector spinae, tensor fascia late, and quadrates lumborum.
Lower crossed syndrome can illicit pain in the lower back as well as:
Buttock pain, knee pain, and hamstring pulls (strain)
With the lower crossed syndrome, the ASIS and PSIS angle is _______ than the normal 10 degrees, resulting in an ________ tilt of the pelvis.
Weak lengthened muscles are _______ muscles, while short tight muscles are _______ muscles.
What is a solution for the lower crossed syndrome?
Strengthen the abdomen and gluteal muscles, stretch out the back and hip flexors, and do things to prevent it
The upper crossed syndrome has the following weak and lengthened muscles (phasic):
Lower and middle trapezius, rhomboids, serratus anterior, and crossed deep neck flexors
The upper crossed syndrome has the following tight and shortened (tonic/postural) muscles:
Pectoralis minor and major, sternocleidomastoid crossed with sub occipitals, upper trapezius and levator scapula
Common complaints of the upper crossed syndrome:
TMJ pain, neck pain, headaches, rotator cuff injuries, and shoulder blade pain
Phasic muscles are prone to:
Weakness, hypotonicity, inhibition, and prone to atrophy
Tonic or postural muscles are prone to:
Tightness, shortening, hypertonia, and are resistant to atrophy
What is a common cause of flat back posture (loss of lumbar lordosis)?
Weak lumbar extensors, weak hip flexors, tight hamstrings, tight rectus abdomius, and tight thoracic erector spinae
Pathological causes of thoracic kyphosis are:
Osteoporosis, compression fracture, ankylosing spondylitis, and TB
Humpback or Gibbus thoracic kyphosis is?
A localized SHARP posterior angulation, commonly from a fracture
Dowager's hump has a more _________ hump compared to a humpback or (Gibbus hump), and is commonly seen in elderly women due to osteoporosis.
In a swayback posture, the ______ is the most anterior region.
Causes of cervical lordosis (can look like lower crossed syndrome).
Lax muscles (abdominus), tight muscles (hip flexors and lumbar extensors)
Causes of lumbar lordosis:
Heavy abdomen, obesity, pregnancy, compensatory to thoracic kyphosis, spondylisthesis, and wearing high heels
There is two types of scoliosis and they are:
Structural and functional
Structural scoliosis is _______ , while functional scoliosis may be _______ .
Structural scoliosis does not _______ with forward bending or lateral flexion.
In structural scoliosis ribs are prominent posteriorly on the ______ side, and anteriorly on the _______ side.
Common causes of structural scoliosis:
Idiopathic, osteopathic, neuromuscular (spinal cord injury)
Common causes of functional scoliosis:
Leg length discrepancy, muscle spasm, pain in the back or neck, habit.
_______ cm leg length discrepancy is quite common and not necessarily pathologic.
1 to 1.5
People with leg length discrepancy will complain of more pain with ______ as compared to ______ .
When sitting with legs extended, and the patient reaches to touch their toes and can reach beyond their toes, what does this indicate?
Excessive hamstring flexibility
When sitting with legs extended, and the patient reaches to touch their toes, what can the body contour indicate?
Tightness or flexibility of the upper and lower back, hamstrings, and gastrocnemius and soleus muscles
When sitting with legs extended, and the patient reaches to touch their toes, what can be a cause of having the posterior pelvis not vertical (pelvis + back at 90 degrees) and greater than 90 degrees?
Correcting posture tips:
Self-correct every 20 minutes (military posture - 10%), less sedentary, less sitting, exercise, strengthen muscles, fix stiff joints, fix sitting posture (ergonomics), address psychological issues
What is a structural cause of knees pointing straight ahead but the toes pointing outward beyond the 5- 18 degrees Fick angle?
What could be a functional causes of toes pointing outward beyond the 5- 18 degrees Fick angle?
Tight piriformis muscle (external rotator of the hip)
In regards to the principles of exercise, what does overload mean?
Exercising in a capacity that is above “normal” on a regular basis
How does one achieve overload?
By different combinations of frequency (how often), intensity (e.g., how much weight), duration (how long), and mode of exercise (types of exercises)
What does the application of overload achieve?
It enhances physiologic function to bring about a training response
If your exercise isn’t any more than what you do on a normal daily basis, then you will probably not get much ________ from the exercise. If you lift a light weight that is not heavier than what you would normally lift on a regular basis, you will not get any _________ gains.
What does FITT stand for?
Frequency, Intensity, Time, Type
When giving an exercise prescription you need to include information about?
Examples of Frequency (FITT):
Number of times per day/week
Examples of Intensity (FITT):
Subjective descriptions “light, moderate”, 3 mph, 10 RM (amount of weight), etc
Examples of Time (FITT):
How many seconds/minutes; the “tempo” (how fast) of the movement
Examples of Type (FITT:
Active vs passive, weight-bearing, isometic vs isotonic, etc
In regards to the principles of exercise, what does specificity mean?
Depending on what your therapeutic goals are, the exercises that you prescribe should match those goals. The training effects of an exercise mat not carry over to the other activities.
Normally, range of motion (ROM) is maintained with _______ .
What happens as a result of immobilizing a limb in a cast?
Adaptive shortening of connective tissues and muscle
What is the term used to explain what happens to connective tissue and muscle as a result of immobilization over time?
Adaptive shortening can happen anytime connective tissue is not subject to regular _______ .
What can happen after 2 week of immobilization to connective tissue?
Dense connective tissue is formed reducing ROM, as well as edema due to the loss of the pumping action, which can further reduce ROM
Reduced ROM can result from ________ .
What changes begin to happen when muscle is immobilized for 5-7 days?
Atrophy and reduced mitochondrial production, and other changes such as reduced muscle fiber size, reduced capillary density, and reduced oxidative capacity (less strength and endurance)
With prolonged periods of immobilization what can happen to the muscle?
Increased fibrosis and fatty tissue within the muscle as well as neural changes that can alter proprioception
________ and prolonged ________ postures can result in adaptive shortening (shortening of the muscle and connective tissue).
What are the 4 types of stretching?
Active, Passive, Proprioceptive Neuromuscular Facilitation, and active assisted stretching
What can help improve active muscle stretching?
Heating muscle beforehand
What are some ways we can heat the muscle before we do active stretching?
Heat packs, continuous ultrasound, exercise, and/or going for a walk or run
With active stretching, if you have significant ROM loss you need to have frequent ________ sessions throughout the day.
Each active stretch should take around _______ seconds and ______ repetitions.
15 to 30; 4 to 5
Contraction of the _______ can help during active stretching.
Antagonist (opposing muscle)
Passive stretching is when that patient is _______ .
Relaxed and the therapist preforms the stretch or the stretch is preformed with the use of equipment sustaining the stretch
When is passive stretching often useful?
In the acute stage: in the pain-free ROM
Equipment that helps with passive stretching is useful when _________ .
Prolonged stretching is needed in chronically shortened (yet strong) tissues
What are the 2 techniques for Proprioceptive Neuromuscular Facilitation (PNF) stretching?
Hold-Relax and contract-relax
With Proprioceptive Neuromuscular Facilitation (PNF) stretching you use the _______ .
Agonists and antagonist to help stretch a muscle
In the hold-relax Proprioceptive Neuromuscular Facilitation (PNF) technique the muscle is _______ .
Brought to the end range, maximum isometric contraction (5-10 sec), relax, then contraction of the opposing muscle to increase the stretch of the agonist
The hold-relax PNF technique is useful for?
Muscle spasm and increasing ROM
In the contract-relax PNF technique the muscle is ________ .
Brought to end range, concentric contraction (manual resistance by doctor as muscle shortens), relax, passive movement to end range
With active assisted stretching, the body part stretches actively, but an _______ force helps.
Outside (the other arm, the therapist, using objects like a broom or towel to increase the stretch)
If a scar/muscle strain is the cause of reduced range of motion, what would help the effectiveness of stretching in the subacute/proliferative phase of healing?
Stretching in the pain-free range of motion, then ice at the end to reduce any inflammation to the site of injury
In the chronic/remodelling/phase of healing, what would be an effective treatment modality to help with stretching an injury with a adherent/mature scar?
The application of heat and then stretching the tissue to tolerance
What other modality beside stretching would be beneficial for a muscle spasm or edema?
What are the contraindications for stretching?
Recent fracture, abnormal 'bony' end feel, infection, acute inflammation, extreme sharp pain, and tight tissue that contributes to stability
After stretching, any pain beyond tenderness, especially with edema indicates?
That the stretch was too aggressive or too early in rehabilitation
What caution is given to stretching after a period of immobilization?
Risk of tearing with stretching as the tensile strength of the connective tissue has been reduced (weaker ligaments, joint, tendons). We want to increase the ROM but must be careful not to compromise the weaker tissues
What are the indications for stretching?
Tightness of soft tissues, injury to prevent reduced ROM, Abnormal alignment or postural changes, muscle imbalances or spasms
Tips for stretching when there is an injury:
Stretch slowly to the point of tension, then release the stretch slowly
Generally, we do not want to stretch in the ______ phase, stretch in in the pain-free ROM in the _______ phase, and more stretch is applied in the _______ phase.
Acute/inflammatory; subacute/proliferative; chronic/remodelling/mature
In the subacute/proliferative phase, we hold the stretch for _____ seconds, with ______ repetitions.
15; 4 to 5
In the subacute/proliferative phase, we start with _____ stretching and progress to more ________ in the pain-free ROM.
In the subacute/proliferative phase, after stretching always apply ____ to the injured area. This will reduce any inflammation that may have been caused by stretching.
Ice (unless contraindicated)
In the chronic/remodelling/mature phase of healing, we ideally want to stretch ______ to be beneficial.
Several time a day
In the chronic/remodelling/mature phase of healing, we can stretch to a ______ and hold the stretch longer than in the subacute phase of ________ seconds with 4 to 5 repetitions.
Slight discomfort; 30 to 60
In the chronic/remodelling/mature phase of healing, we can introduce _________ stretching as well as active and passive. Heat is good in this phase, as well as ice if inflammation is not contraindicated.
Proprioceptive neuromuscular facilitation
Prolonged passive stretching is good for chronic injuries with reduced ROM, and typically we use ______ tension for _______ minutes ______ a day. _______ after stretching is common, so release the stretch slowly.
Light; 15 to 20; 1 to 2; stiffness
Resistance training helps to build?
Strength and endurance, muscle mass, bone density (with heavy resistance), strength of ligaments/joints, and joint stability
Other benefits to resistant training are:
Cross education, blood sugar control, and improved confidence/self-esteem
What is cross education?
Exercising the uninjured side has some gains in strength to the injured side
Contraindication for resistance training are:
Acute injury, unstable angina, uncontrolled hypertension, uncontrolled dysrhythmias, recent congestive heart failure, severe valvular disease, and hypertonic cardiomyopathy
Lifting weights increase ______ resistance with a result increase in blood pressure.
Endurance training focuses on ________, and strength training focuses on _______ . (Both practices to muscle fatigue fit the definition)
More repetitions with less weight; less repetitions with heavier weight
With resistance training, initially there is rapid gains in ________, while long term benefits are more _______ .
Strength and endurance; gradual
Normally we have muscle _______ to certain weights, and with strength training we can turn this protective muscle _______ off, and lift heavier weight.
With initial strength training, there is a change to the number of _______ and _______ firing. We can increase these numbers, as well as our ability to synchronize _______ activation, with strength training and lift heavier weight.
Motor units; motor neurons; motor unit
The long term benefits to resistance training are:
Muscle hypertrophy (more sarcomeres with strength training, more mitochondria with endurance training) and stronger joints and ligaments
What does 1RM stand for?
1 repetition maximum (maximum weight at 1 repetition)
What does 10RM stand for?
When you can lift a maximum amount of weight of one type of exercise 10 times, but not the eleventh
What is an isometric contraction?
Muscle tension without change in muscle length, minimal movement in the joint - useful early in rehabilitation
What is an isotonic contraction?
Variable speeds/force during the movement. Consists of concentric tension (muscle generating tension while shortening - flexion) and eccentric contraction (muscle generating tension while lengthening - extension)
What is isokinetic contraction?
Constant speed with variable force, using specialized equipment
Isometric exercise are often used ________ in the rehabilitation program, as it minimizes stress the injured area.
Strength gain in isometric contraction is ______ to the position in ROM.
If you want to gain strength with isometric contraction you need to?
Exercise in 20 degree increments in the ROM
During strength training, when the muscle maximally contracts isometrically the force in the muscle prevents?
Further blood flow, and without continuous blood flow the muscle fatigues very easily. In this case hold the contraction for 5 seconds, and relax for 60 seconds.
What should you avoid doing with isometric exercises?
Valsalva maneuver: as is causes large BP fluctuations during maximal contractions (which prevent further blood flow)
Generally, with isotonic exercises, you do them 2 to 3 times weekly with a day in-between for _______ .
Isotonic exercises should be in the pain-free range of motion, with a rest of _______ seconds between sets if exercising to fatigue.
30 to 60
What is rating of perceived exertion?
A scale used by patient to determine how hard the exercise was for them (i.e., moderate level would fatigue a muscle in 10 to 15 reps)
What is DOMS?
Delayed onset muscle soreness
______ before resistance training can prevent injury.
Warm-up (not stretching)
Ensure ________ when resistance training.
Isometric contraction are often used in the _______ phase, with progression to ________ in the chronic/remodelling/maturation phase.
History taking follows the mnemonic:
What is the common quality of muscle pain?
Cramping, achy, and dull
What is the common quality of joint/ligament pain?
Dul and achy
What is the common quality of nerve root pain?
Sharp and shooting
What is the common quality of peripheral nerve pain?
Sharp, bright, and lightning-like
What is the common quality of headache pain?
Throbbing and pulsating
What is the common quality of sympathetic nerve pain?
Burning, pressure-like, stinging, achy
What is the common quality of bone pain?
Deep, nagging, boring, and dull
What is the common quality of fracture pain?
Sharp, severe, and intolerable
What is the common quality of vascular pain?
Throbbing and diffuse (PVD)
History taking: intensity is usually recored as?
On a scale of 1 to 10, 10 being the worst
What is claudication?
A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries. Pain after walking, no pain when rested, but pain again after walking again.
What common condition is characterized by progressive pain during the day?
Congestion in the joint
What common condition is aggravated by sitting and forward flexion?
Intervertebral disc lesion
What common condition is aggravated by extension and relieved by sitting and bending forward?
Facet joint pain
What common condition is characterized by periodic pain on activity?
Red flags in patient history that indicate a need for referral to a physical for cancer are:
- persistent pain at night
- constant pain anywhere in the body
- unexplained weight loss (e.g., 4.5 to 6.8 kg (10 to 15 lbs) in two weeks or less)
- loss of appetite
- unusual lumps or growths
- unwarranted fatigue
Red flags in patient history that indicate a need for referral to a physical for cardiovascular conditions are:
- Shortness of breath
- Pain or feeling of heaviness in the chest
- Pulsating pain anywhere in the body
- Constant and severe pain in the lower leg (calf) or arm
- Discoloured or painful feet
- Swelling (no history of injury)
Red flags in patient history that indicate a need for referral to a physical for gastrointestinal/genitourinary conditions are?
- frequent or severe abdominal pain
- frequent heartburn or indigestion
- frequent nausea or vomiting
- change in or problems with bowels and/or bladder function (e.g., urinary tract infection)
- unusual menstrual irregularities
Red flags in patient history that indicate a need for referral to a physical for neurological conditions are:
- changes in hearing
- frequent or severe headaches with no history of injury
- problems with swallowing or changes in speech
- changes in vision (e.g., blurriness or loss of sight)
- problems with balance, coordination or falling
- faint spells (drop attacks)
- sudden weakness
Miscellaneous red flags in patient history that indicate a need for referral to a physical are:
- fever or night sweats
- recent severe emotional disturbances
- swelling or redness in any joint with no history of injury
Yellow flag symptoms in the patient history indicate?
A more extensive examination
Some yellow flag conditions are:
With examination, one should test the _______ side first.
The mnemonic for examination is?
HIPPI - RONEL
What does HIPPI in HIPPI-RONEL examination mnemonic stand for?
History, inspection, percussion, palpation, instrumentation
What does RONEL in HIPPI-RONEL examination mnemonic stand for?
ROM, orthopaedic tests, neurological tests, X-ray, lab work
During examination, inspection can tell you about ________ , and you should look for ________ .
Behaviour, facial expression, and posture; deformities, discolouration, and signs of inflammation
If patient has a good range of motion you can add ______ to see how much further they can go.
What is the normal end feel for knee flexion?
Soft tissue approximation
What is the normal end feel for elbow extension?
Bone to bone
What is the normal end feel for finger extension?
A dislocated joint may have an _______ end feel.
Differences in ROM between AROM and PROM may be due to?
Spasm, muscle deficiency, neurological deficit, contractures, and pain
ROM hypomobility can result from:
Myofascial hypomobility or capsular/ligamenteous hypomobility
Causes of myofascial hypomobility are?
Adaptive shortening, hypertonicity of muscles (increased tension resist stretching), adhesions, and scarring
Causes of capsular/ligamenteous hypomobility are?
Adaptive shortening, adhesions of the connective tissue, scarring/fibrosis of the connective tissue, arthritis/arthrosis, capsular patterns (indicator that the joint is tight)
Hypermobility of joints are more susceptible to?
Hypermobility of joints can be caused by?
Sprains/tears, joint effusion, chronic pain, recurrent injury (leads to more stretching), paratenositis, and early osteoarthritis
What are we testing with RROM?
The muscle and nerve that supplies it. We want to see if it has good contraction (isometric) without moving the joint
Muscle testing tests the motor strength and is graded out of ______ .
When testing motor strength, what does a grade of 5+ indicate?
Normal (100%): complete ROM against gravity with maximal resistance
When testing motor strength, what does a grade of 4 indicate?
Good, (75%): complete range of motion (ROM) against gravity with some (moderate) resistance
When testing motor strength, what does a grade of 3+ indicate?
Fair+: complete range of motion (ROM) against gravity with minimal resistance
When testing motor strength, what does a grade of 3 indicate?
Fair (50%): complete range of motion (ROM) against gravity
When testing motor strength, what does a grade of 0 indicate?
No contraction palpated
When assessing pain in ROM, what indicates a ligament/capsular sprain?
Pain when stretched (AROM & PROM), but less pain with RROM
When assessing pain in ROM, what indicates a muscle sprain?
Pain when stretched (PROM) and during contraction (AROM & RROM)
When assessing pain in ROM, what indicates a articular joint dysfunction?
Pain when the joint surfaces are compressed, less pain with traction of the joint
When is a neurological exam indicated?
If the patient feels any numbness, weakness, heaviness, or tingling
Neurological testing includes?
Dermatomes (sensory), muscle tests (myotomes and peripheral nerves), deep tendon reflexes, superficial (abdominal, rooting, cremaster) and pathological reflexes (plantar reflex for UMN lesion)
Grading for deep tendon reflexes:
Sensory testing of dermatomes tests the following sensations:
Light touch, superficial pain, temperature, vibration, proprioception, and pressure
Which sensation(s) cross at the level of the spinal cord up the lateral spinothalamic tract?
Pain and temperature
Which sensation(s) cross at the level of the spinal cord up the anterior spinothalamic tract?
Which sensation(s) cross at the level of the spinal cord up the posterior column?
Proprioception, vibration, and fine touch
When should palpation be in the examination schedule?
Later in assessment, because of pain and referred pain (we may lose the sensitivity of other tests if palpation is done early)
What should we feel for in palpation?
Tissue tension (effusion/spasm), muscle tone (spastic, rigidity, flaccidity), fibrous bands, tissue thickness, swelling (gel-like = blood, softer/mobile = inflammation, boggy/spongy = synovial swelling)
What are some cautions to orthopaedic tests?
Can cause pain, apprehension, worsen stability, and can cause fracture in osteoporosis or pathological states
What are the characteristics of a lesion that should be recored to properly document a lesion found on palpation?
Location, size, shape, mobility, texture, borders, tenderness
Where is an upper motor lesion located?
In the spinal cord and higher
Where is a lower motor lesion located?
Nerve rootless, nerve root, nerve plexus, and peripheral nerves
What are the characteristics of a lower motor lesion?
Flaccid, hypotonicity, reduced or absent deep tendon reflexes, no pathological reflexes (all should be normal), and weakness at the level of injury
What are the characteristics of a upper motor lesion?
Spastic, hypertonicity, hyperreflexia/clonus of deep tendon reflexes, positive pathological reflexes (plantar reflex, etc.), and weakness below the level of injury
What is clonus?
A sign of an upper motor lesion
Characteristics of nerve root injuries:
Less weakness and less muscle wasting when compared to peripheral nerve injuries
Characteristics of peripheral nerve injuries:
More weakness, faster onset of weakness, more muscle wasting when compared to nerve root injuries
Both nerve root injuries and peripheral nerve injuries will have:
Lower motor neuron lesion signs (reduced reflexes and tone, and weakness)
When comparing nerve root injury to peripheral nerve injury, which will have upper motor neuron lesion signs and symptoms?
When comparing nerve root injury to peripheral nerve injury, which of the following is true with regards to onset and severity of the neurologic weakness?
Nerve root injuries demonstrate less weakness and have a slower onset of weakness
When the patient only has lower back pain, consider:
Mechanical lower back pain: may be a muscle strain, ligament sprain, facet joint, or sacroiliac joints
When the patient has back pain with buttock or thigh pain, consider:
Mechanical lower back pain: lumbar and SI joint often refer to the buttock and posterior leg (facet joints can refer to the thigh)
Mechanical back pain is affected by?
Posture or movement
When the patient has back pain and with pain below the knee (back of leg), consider:
Disk injury (most common cause)
If the history suggests disc injury with anterolateral leg pain, which vertebral level is affected?
L4 disc injury (L5 root)
If the history suggests disc injury with posterior/lateral foot pain, which vertebral level is affected?
L5 disc injury (S1 root)
If the patient has back pain with pain radiating to the front of the leg, it is less likely to be related to?
Sciatic nerve pain
What are the indications for an X-ray?
Upon inspection what could cause unequal crest height?
Bone length difference, pronated foot, sacroiliac joint issues, or abnormal hip/knee position
Upon inspection, when a patient has gluteal atrophy what could cause less contraction when asked to contract?
Pressure on inferior gluteal nerve or on L5 or S1 or S2 nerve roots
When a patient has low back pain and an antalgic posture that leans AWAY from the side of pain it is suggestive of:
Intraarticular lesion, and low back pain with pain radiating down the leg then nerve root compression
When a patient has low back pain and an antalgic posture that leans TOWARDS the side of pain it is suggestive of:
Articular and/or muscular causes, a disk herniation medial to the nerve root
Which nerves does the cremaster reflex test?
L1 and L2
Which nerves does the superficial abdominal reflex test?
T7 to L2
When preforming muscle testing, what is done?
What is a trigger point?
A spot or point in a muscle that refers a sensation, be it pain or weakness, to another area of the body
Where does the trigger point Iliocostalis Lumborum refer to?
Below T12 ribs lateral to spine to buttock
Where does the trigger point Longissimus refer to?
Beside spine down to gluteal fold
Where does the trigger point Multifidus refer to?
Lateral to spine, sacrum to gluteal cleft, posterior leg, and lower abdomen
Where does the trigger point Abdominals refer to?
Below xiphisternum and along anterior rib cage down along inguinal ligament to gentials
Where does the trigger point Serratus posterior inferior refer to?
Lateral to spine in T9-T12 posterior rib area
What are the common conditions that cause lower back pain?
Lumbar sprain/strain: most common, disk herniation, lumbar stenosis, spondylolisthesis, cauda equina syndrome, and sacroiliac joint dysfunction
What is a strain?
A muscle that has been abnormally stretched
What is a sprain?
Wrench or twist of the ligaments (an ankle, wrist, or other joint) violently so as to cause pain and swelling but not dislocation, can be a ligament tear
What are the risk factors for a lumbar sprain/strain?
What are the characteristics of a lumbar sprain/strain?
What are the examination findings of a lumbar sprain/strain?
What happens in degenerative disc disease?
Nucleus pulposus becomes fibrotic, sclerosis of the subcondral bone of the vertebrae, loss of disc height
Pain characteristics of degenerative disc disease?
What is the classical mechanism of injury for disc herniation?
Bending and twisting (half of the annulus fibrosis fibers are slackened when twisting)
Characteristics of disc herniation pain are:
Usually 15- 40 years old, back with leg pain (with leg pain predominating), increased pain with twisting, sitting, lifting, bending
What is the most common space occupying lesion and the most common cause of pain radiating below the knee?
With disc herniation, which level of nerve root is affected?
Usually the nerve root below, a really big herniation can affect more then one nerve root
Most disc herniations have referred leg pain (can be without neurologic findings as well). Most common lumbar disc herniation sites are:
98% of all disc lesions are L4/5 or L5/S1
Evaluation of disc herniation findings are:
When evaluating disc herniation, what are the findings of L5 neurological exam? (L5 nerve root compression)
Weakness of dorsiflexion of great toe, numbness in the lateral lower leg, and reflexes are intact
When evaluating disc herniation, what are the findings of S1 neurological exam? (S1 nerve root compression)
Weakness of foot eversion, numbness: back of calf, and lateral or plantar foot, and absent Achilles reflex
What are some special test that can help rule in/out disc herniation?
Straight leg raise (reliable, especially if leg pain is reproduced below 45⁰), Valsalva, Kemp’s test (seated or standing), Well Leg Raise, and Slump Test
With disc herniation, extension often reduces pain due to?
Centralization of pain (as compared to peripheralization of pain when in flexion or rotation)
Treatment for disc herniation can follow general rehabilitation, but avoid peripheralization. Treatment can be:
Characteristics of lumbar stenosis are:
Examination findings in lumbar stenosis are:
Treatment for lumbar stenosis is:
Lumbar stenosis can be caused by:
Bone growth, disc herniation, ligament thickening, tumour growths, and injury (fracture, dislocations)
Characteristics of spondylolisthesis are:
Examination findings in spondylolisthesis are:
Treatment for spondylolisthesis can include:
Cauda equina is a __________ .
Characteristics of caudal equina are:
What is the mechanism of sacroiliac joint dysfunction?
Characteristics of pain from sacroiliac joint dysfunction are:
Examination findings from sacroiliac joint dysfunction are: (patient need to be totally relaxed during examination)
Management of sacroiliac joint dysfunction is:
Rehabilitation goals of the spine in the acute/inflammatory phase includes:
Reduce pain, reduce spasm, reduce edema, achieve neutral posture, maintain conditioning,
Rehabilitation treatment of the spine in the acute/inflammatory phase includes:
Rehabilitation goals of the spine in the subacute/proliferative phase includes:
Increase ROM, learn pelvic neutral in different positions, restore proprioception, increase muscle endurance, maintain conditioning, decrease pain, spasm, and edema
Rehabilitation treatment of the spine in the subacute/proliferative phase includes:
Exercises that can help with ROM (subacute/proliferative phase when treating the spine are:
Knee to chest (holding abdominal contraction to stabilize spine), cat-camel, spinal twists, mechanics of lifting or bending (neutral posture, requires hamstring flexibility, core muscle strength), or Golfer's lift
Golfer's lift is used for:
Repetitive light lifting
Rehabilitation goals of the spine in the chronic/remodelling/maturation phase includes:
Rehabilitation treatment of the spine in the chronic/remodelling/maturation phase includes:
Which exercise for the lower back would help strengthen the gluteal maximums muscle?
Which exercise for the lower back would help strengthen the lumbar erector spinae in a neutral position?
Which exercise for the lower back would help strengthen abdominal muscles?
Which exercise for the lower back would help strengthen oblique abdominal and quadrates lumborum muscles?
Which exercise for the lower back would help strengthen rectus abdominus muscle?
Which action and muscle tests the L1 - L2 myotome?
Hip flexion and psoas and iliacus
Which action and muscle tests the L3 myotome?
Knee extension and quadriceps
Which action and muscle tests the L4 myotome?
Ankle dorsiflexion and tibias anterior
Which action and muscle tests the L5 myotome?
Toe extension and extensor hallucis longs and extensor digitorum longus
Which action and muscle tests the S1 myotome?
Ankle eversion and peroneus longs/brevis
For the deep tendon reflexes of the lower limb, which nerve roots are tested for the achilles tendon reflex?
For the deep tendon reflexes of the lower limb, which nerve roots are tested for the patellar reflex?
L3 and L4
What does the valsalva maneuver test for? (Increased pain is a positive test)
Increased intrathecal pressure (from a space occupying lesion like a herniated disc)
What does the Well Leg Raise test for?
Intervertebral disc protrusion, usually medially to the nerve root
What is a positive Well Leg Raise finding?
Lifting the uninjured side reproduces the radiating pain contralaterally
What does the Straight Leg Raise test for?
Mainly disc herniation, hamstring tightness, entrapment of the piriformis muscle, and SI joint pain
What are the positive tests of the Straight Leg Raise test?
What does a positive Slump Test indicate?
Tension of central nervous system or meninges
What is the positive finding of the Slump Test?
Less pain with farther knee extension with neck extended compared to knee extension with neck flexed
What does a positive Brudzinski-Kernig test indicate?
Meningeal irritation, nerve root involvement, or dural irritation
What is the positive finding of the Brudzinski-Kernig test?
Reduction in pain when the knee is flexed when hip flexion is maintained (hands are cupped behind head - chin to chest)
What are the positive findings and indications of the Nachlas test?
What does the seated/standing Kemp Test test for?
Nerve root impingement or facet joint pathology with only local pain
What is the positive finding of the seated/standing Kemp Test?
Radiating pain into the ipsilateral lower extremity
What is the positive finding of the Gapping Test?
Unilateral gluteal or posterior leg pain
What does a positive Gapping Test indicate?
Sprain of the anterior sacroiliac ligament
Note: pushing on the ASIS may illicit pain from the pressure of the doctor’s hands
What is the positive finding of the Squish Test?
Pain (loss of mobility from one side to the other)
What does a positive Squish Test indicate?
Sacroiliac joint pathology (tests the posterior sacroiliac ligaments)
How is the Gaenslen's Test preformed?
The patient is supine with the test hip off the edge of the examination table; the knee of the non-tested side is brought to the chest, then the test leg is slowly lowered into extension.
Dr: can add overpressure to the hip/sacroiliac joint extension with one hand on the bent leg and one on the extended thigh
What is the positive finding of the Gaenslen's Test?
Pain in the sacroiliac joint
What does a positive Gaenslen's Test indicate?
Sacroiliac joint pathology
Note1: this test may cause pain from hip joint pathology
Note2: the test may be done side-lying with the doctor passively extending the hip