Therapeutic Exercise- Moving Toward Function.pdf

THERAPEUTIC EXERCISE

Moving Toward Function Second Edition

Carrie M. Hall, PT, MHS Physical Therapist Owner, Movement Systems Physical Therapy Clinical Faculty University of Washington Seattle, Washington

Lori Thein Brody, PT, MS, SCS, ATC Senior Clinical Specialist, Sports and Spine Physical Therapy University of Wisconsin Hospital Research Park Clinic Madison, Wisconsin Graduate Program Director Orthopaedic and Spo-rts Physical Therapy Rocky Mountain University of Health Professions Provo, Utah

with contributors

4~ liPPINCOTT WILLIAMS & WILKINS •

A Wolters Kluwer Company

Philadelphia • Baltimore • New York • London Buenos Aires • Hong Kong • Sydney • Tokyo

Preface to the Second Edition

In the years since the first edition of Therapeutic Exercise: Jlodng Toward Function, much has happened in the field of physical therapy. In this past year, the Medicare Pre­ cription Drug, Improvement, and Modernization Act was passed, including several provisions that positively affect our ability to provide crucial rehabilitation services to \I edicare beneficiaries. We continue to achieve direct ac­ cess in more states across the country. Over 1,000 entries ,lie available through Hooked on Evidence, APTA's online database , to enhance clinical deCiSion-making and practice. _•ew strategies are being developed to combat the reemer­ .!ence of physician-owned physical therapy services PO PTS). The PT Evaluation Tool (PTET) was launched, -hich makes DPT programs much more accessible. Through APT A efforts, consumers ,vere educated about hildhood obesity via an online chat through washington­ st. c:om. It surely is an exciting time for physical therapy, Ac­ rding to the APTA [HOD 06-00-24-35]' by the year - 20, physical therapy will be provided by physical thera­ t who are doctors of physical therapy and who may board-certified specialists. Consumers will have direct 'Cess to physical therapists in all environments for pa­ ent/client management, prevention, and wellness ser­ ces. Physical therapists will be practitioners of choice for dividuals with conditions that affect movement, function, d health and wellness, and will hold all privileges of au­ • omous practice. Physical therapists may be assisted by ~ ical therapy assistants who are educated and licensed provide physical therapist directed and supervised com­ ents of interventions. It was within this context that we developed the second 'tion of Therapeutic Exerc-ise: MO-ving Toward Function. - owing terminology used in the APTA's Guide to Phys­ T herapy Practice, this text was written for physical rapy students entering DPT programs and practicing nici ns as the primary audience. Howe\er, other health fessionals will certainly gain valuable inSight from this as well. The importance of therapeutic exercise as a fundamen­ rvice provided by physical therapists will only ren hen as our profession moves toward autonomous ·ce. Although physical therapists provide a variety of - n' ntions , therapeutic exercise is the most widely used "en'ention by physical therapists . The premise of this text , t therapeutic exercise, with an emphasis on functional ~rom es, is a fundamental intervention necessary to re­ 'ate movement dysfunction, and that the prescription therapeutic exercise requires expeltise found uniquely • e profession of physical therapy. Our inimitable knowl­ _ in basic biomedical and physical sciences, applied and 'cal research evidence regarding specific movement-

related conditions, knowledge of human behavior derived from the social and behavioral sciences, and specialized clinical skills in the prescription of therapeutic exercise dis­ tinguishes us among other exercise providers. Organized into seven distinctive units, Therapeutic Ex­ ercise: Moving Toward Function provides a conceptual framework for making clinical decisions regarding the pre­ scription of therapeutic exercise and restoring function.

NEW CONTENT Although the general organization of units has not changed from the first edition, a review of the table of contents will reveal the addition of Chapter 4: Prevention, and the Pro­ motion of Health, Wellness, and Fitness, and the addition of Impaired Aerobic Capacity to the chapter on Impaired Endurance (Chapter 6). The inclusion of this new matelial underscores the importance of the role of physical therapy in the promotion of health and wellness as a means of im­ proving the quality of life of our patients and clients. As members of a health profession, physical therapists have a responsibility to promote wellness in its entirety. While physical therapists are uniquely qualified to develop and prescribe exercise programs that help prevent injury, promote fitness, and enhance athletic performance, we also recognize the importance of integrating the psychoso­ cial, emotional, spiritual, and intellectual dimensions of the individual in promoting health and wellness. Additionally, substantial new coverage of jOint mobiliza­ tion was added to Chapter 7: Impaired Range of Motion and JOint Mobility in response to student and faculty re­ quests . JOint mobilization is introduced in Chapter 7 and expanded upon ,vith detailed techniques in Units 5 and 6.

PEDAGOGICAL FEATURES Educational features such as illustrations, tables, displays, key pOints, critical thinking questions, lab activities, and selected interventions remain consistent with the first edi­ tion but have been improved and revised in the second edition. Additional and revised illustrated self-manage­ ment boxes provide step-by-step exercises written directly for the client, demonstrating to the reader how to write clear instructions. Patient-related instruction boxes ad­ dress patient education issues, with tips on enhancing communication and compliance. Case studies are linked to lab activities and critical thinking questions to foster clinical deCiSion-making. To encourage a thorough under­ standing of the importance of encompaSSing the total body when prescribing therapeutic exercise, we have pro­

xiii

xiv

Preface to the Second Edition

vided a sample com plete intervention for a case with interconnected upper and lower quarter impairments to complement selected interventions found in tbe first edition. To remain consistent with APT A's "grassroots" effort to develop a database containing current research and to pro­ vide learning tools to foster evidence-based practice in physical th erapy, we have updated the literature revi ew and evidence-based data in all chapters. It is our hope that with these changes, \Ve are providing a text consistent with a DPT curriculum .

We have worked diligently to incorporate feedback from cliniCians, students, faculty, and reviewers into th e second edition of Th era.peutic Exercise: lHovin g Toward Function. Although we believe we have accomplished this task, we are already preparing for the third edition with the goal of accommodating the needs of our changing profes­ sion. We welcome feedback from the health care commu­ nity at large to assist us in this endeavor. Carrie Hall, PT MHS, Lori Thein Brody, PT , MS, SCS, ATe

Brief Contents

UN IT

1

•

Foundations of Therapeutic Exercise PTER

1

1

-PTER

CHAPTER

10

3

CHAPTER

CHAPTER

evention and the Promotion of Health, Wellness,

d Fitness 47

13

14

Therapeutic Exercise in Obstetrics

259

UNI T 4

2

Sample Specialties of Therapeutic

Exercise Intervention 283

siologic Impairments and

erapeutic Exercise 51

CHAPTER

_5

15

Closed Kinetic Chain Training

aired Muscle Performance

57

CHAPTER

-6

283

16

Proprioceptive Neuromuscular Facilitation

j red Aerobic Capacity/Endurance

87

CHAPTER

7

9

5

Functional Approach to Therapeutic Exercise

of the lower Extremities 349

CHAPTER

167

330

113

UN IT 149

309

17

Aquatic Physical Therapy

. ed Range of Motion and Joint Mobility

. ed Posture

229

Therapeutic Exercise for Fibromyalgia Syndrome and

Chronic Fatigue Syndrome 244

4

JNIT

207

12

Therapeutic Exercise for Arthritis

"nciples of Self-Management and

ercise Instruction 35

ER

11

Soft Tissue Injury and Postoperative Treatment

2

atient Management

3

Special Physiologic Considerations in

Therapeutic Exercise 207

CHAPTER

Introduction to Therapeutic Exercise and the

Expanded Disablement Model 1

PIER

UNIT

18

The Lumbopelvic Region CHAPTER

349

19

The Pelvic Floor

402

xvii

xviii

Brief Contents

CHAPTER

20

The Hip 436

CHAPTER

21

The Knee 488

CHAPTER

22

25

CHAPTER

The Thoracic Spine 610

26

CHAPTER

The Shoulder Girdle 643

CHAPTER

27

The Elbow, Forearm, Wrist, and Hand 698

The Ankle/Foot 524

• •

UNIT

6

Functional Approach to Therapeutic Exercise

for the Upper Extremities 555

UN IT

7

Case Studies APPENDIX

739

1

Red Flags: Recognizing Signs and Symptoms 759

CHAPTER

23

The Temporomandibular Joint 555

CHAPTER

APPENDI X

2

Red Flags: Potentially Serious Symptoms and Signs in

Exercising Patients 764

24

The Cervical Spine 582

IND EX

771

Contents

UNIT

1

Foundations of Therapeutic Exercise 1

1

::H APTER

Introduction to Therapeutic Exercise and the

Expanded Disablement Model 1

CARRIE HALL

Definition of Physical Therapy

The Disablement Process 2

Purpose of Defining the Disablement Process Evolution ofthe Disablement Model 3

Modified Disablement Model 4

Patient Management 10

CARRIE HALL

42

4

Prevention and the Promotion of Health, Wellness,

and Fitness 47

2

JANET BEZNER

The Context for Primary Prevention 47

Definitions 47

Measurement of Wellness 50

10

Patient Management Model 10

Examination 10

Diagnosis 15

Prognosis and Plan of Care 16

Intervention 17

Outcome 19

Clinical Decision Making 20

Therapeutic Exercise Intervention 20

Therapeutic Exercise Intervention Model Exercise Modification 27

Adjunctive Interventions 30

Physical Agents 30

Mechanical Modalities 30

Electrotherapeutic Modalities 31

CHAPTER

39

Health Promotion and Wellness-Based Practices 50

From Illness to Wellness 52

The Use of Screening as an Examination Tool within a

Wellness-Based Practice 52

Starting a Wellness-Based Practice 52

2

Introduction

Home Exercise Prescription 42

Considerations in Exercise Prescription Determining Exercise Levels 43

Formulating the Program 44

CHAPTER

1

Therapeutic Exercise Intervention 2

uHAPTER

Issues in Home Exercise Program Prescription Understanding Instructions 39

Proper Exercise Execution 40

Equipment and Environment 41

3

Principles of Self Management and

Exercise Instruction 35

LORI THEIN BRODY

Teaching in the Clinic 35

Safety 35

Self-Management 36

Adherence and Motivation 36

Health Behavior Models 36

Applications 36

Clinician-Patient Communication

38

UNIT

2

Physiologic Impairments and

Therapeutic Exercise 57

21

CHAPTER

5

Impaired Muscle Performance

57

CARRIE HALL AND LORI THEIN BRODY

Definitions 58

Strength 58

Power 58

Endurance 58

Muscle Actions 58

Morphology and Physiology of Muscle Performance 59

Gross Structure of Skeletal Muscle 59

Ultrastructure of Skeletal Muscle 60

Chemical and Mechanical Events During Contraction

and Relaxation 60

Muscle Fiber Type 61

Motor Unit 61

Force Gradation 61

Factors Affecting Muscle Performance Fiber Type 62

Fiber Diameter 62

Muscle Size 62

62

xix

xx

Contents

- - ---.

Muscle Architecture 64

Force-Velocity Relationship 62

Length-Tension Relationship 63

Training Specificity 64

Neurologic Adaptation 64

Muscle Fatigue 64

Lifespan Considerations 65

Cognitive Aspects of Performance Effects of Alcohol 67

Effects of Corticosteroids 67

Lifespan Issues 108

Guidelines for Cardiovascular Endurance Training in the

Young 108

Guidelines for Cardiovascular Endurance Training

in the Elderly 108

67

70

Examination/Evaluation of Muscle Performance 72

Therapeutic Exercise Intervention for Impaired

Muscle Performance 73

Activities 73

Dosage 78

Dosage for Strength Training 80

Dosage for Power Training 81

Dosage for Endurance Training 81

Dosage for Training the Advanced or Elite Athlete 81

Precautions and Contraindications 82

CHAPTER

6

Impaired Aerobic Capacity/Endurance 87

JANET BEZNER

Physiology of Aerobic Capacity and Endurance 87

Definitions 87

Energy Sources Used During Aerobic Exercise 88

Normal and Abnormal Responses to Acute

Aerobic Exercise 90

Physiologic and Psychological Adaptations to

Cardiorespiratory Endurance Training 93

Causes of Impaired Aerobic Capacity/Rehabilitation

Indications 94

Examination/Evaluation of Aerobic Capacity 96

Patient/Client History 96

Systems Review 96

Screening Examination 96

Tests and Measures 97

Therapeutic Exercise Intervention Mode 100

Dosage 101

7

Impaired Range of Motion and Joint Mobility 113

Causes of Decreased Muscle Performance Neurologic Pathology 67

Muscle Strain 68

Disuse and Deconditioning 70

Length Associated Changes 70

Physiologic Adaptations to Training Strength and Power 70

Endurance 72

CHAPTER

66

100

Precautions and Contra indications 105

Graded Exercise Testing Contra indications and

Supervision Guidelines 106

Supervision During Exercise 106

Patient-related Instruction/Education and Adjunctive

Interventions 107

LORI THEIN BRODY

Morphology and Physiology of Normal Mobility

114

Causes and Effects of Decreased Mobility 114

Effects on Muscle 115

Effects on Tendon 115

Effects on Ligaments and Insertion Sites 116

Effects on Articular Cartilage 116

Effects on Bone 116

Effects of Remobilization 117

EffectsonMuscle 117

Effects on Tendon 117

Effects on Ligaments and Insertion Sites Effects on Articular Cartilage 118

Effects on Bone 118

Mobility Examination and Evaluation 119

118

Therapeutic Exercise Intervention for Decreased Mobility 120

Elements of the Movement System 120

Activities to Increase Mobility 120

Exercise Dosage 137

Precautions and Contraindications 138

Causes and Effects of Hypermobility 139

Therapeutic Exercise Intervention for Hypermobility 140

Elements of the Movement System 140

Stabilization Exercises 140

Precautions and Contra indications 142

Lifespan Issues

143

Adjunctive Agents 143

Superficial Heat 143

Deep Heat 144

CHAPTER

8

Impaired Balance 149

LORI THEIN BRODY AND JUDY DEWANE

Definitions 149

Physiology of Balance 149

Contributions of sensory systems 150

Processing Sensory Information 151

Generating Motor Output 151

Motor Learning 152

Causes of balance impairment 152

Effects of training on balance

153

Examination and evaluation of impaired balance

154

Therapeutic exercise intervention for impaired balance Mode 155

Posture 156

155

xxi

Contents Movement 156

Dosage 158

.

Precautions and Contra indications

CHAPTER

163

Special Physiologic Considerations in

Therapeutic Exercise 207

9

CHAPTER

Impaired Posture 167

CARRIE HALL

Introduction

LORI THEIN BRODY Physiology of Connective Tissue Repair 207

Microstructure of Connective Tissues 207

Response to Loading 208

Phases of Healing 209

Principles of Treating Connective Tissue Injuries 211

Restoration of Normal Tissue Relationships 211

Optimal Loading 211

Spec ific Adaptations to Imposed Demands 212

Prevention of Complications 212

Causes of Impaired Posture and Movement 172

Range of Motion 173

Muscle length 173

Joint Mobility 173

Muscle Performance 173

Pain 174

Anatomic Impairments and Anthropometric

Characteristics 176

Psychological Impairments 176

Lifespan considerations 177

Environmentallnfluences 178

Examination and Evaluation Posture 178

Movement 179

Management of impairments associated with connective

tissue dysfunction 212

Sprain: Injury to Ligament and Capsule 213

Stra in: Musculotendinous Injury 213

Tendinitis and Tendon Injuries 215

Cartilage Injury 219

Management of impairments associated with localized

inflammation 219

Contusion 219

178

Intervention 180

Elements of the Movement System Activity and Dosa ge 181

Management of impairments associated with fractures Classification of Fractures 220

Application of Treatment Principles 220

180

Management of impairments associated with joint

arthroplasty 226

10

Pain 185 CHAPTER

_ORI THEIN BRODY

Defin itions 185

Physiology of Pain 185

Pain Pathways 186

Pain Theory 187

Therapeutic exercise intervention for pain Acute Pa in 190

Chronic Pain 190

Adjunctive Agents 202

Transcutaneous electrical nerve stimulation Heat 203

204

~edication

204

12

Therapeutic Exercise for Arthritis 229

KIMBERLYBENNETT Review of Pertinent Anatomy and Kinesiology 229

Examination and Evaluation 188

Pa in Scales 188

McGill Pain Questionnaire 189

Disability and Health-Related Quality of Life Scales

Cold

220

Management of impairments associated with bony and soft

tissue surgical procedures 221

Soft Tissue Procedures 222

Bony Proced ures 224

Patient-Related Instruction and Adjunctive

Interventions 182

APTER

11

Soft Tissue Injury and Postoperative Treatment 207

167

Definitions 168

Posture 168

Sta nda rd Posture 168

Deviations in Posture 169

Movement 171

~

UN IT 3

190

202

Pathology 230

Osteoarthritis 230

Rheumato id Arthritis 190

231

Exerc ise Recommendations for Prevention and Wellness Therapeutic Exercise Intervention for Common

Impairments 233

Pain 234

Impaired Mobility and Range of Motion 234

Impaired Muscle Performance 235

Impaired Aerobic Capacity 237

Special Considerations in Exercise Prescription and

Modification 239

Ligament or joint capsul e laxity precautions 239

233

xxii

Contents Restoring muscle balance 240

Normalizing specific joint movement patterns 241

Exercise modifications in response to pain or

fatigue 241

Pacing treatment 241

Patient Education

.

UN IT 4

Sample Specialties of Therapeutic Exercise

Intervention 283

241

CHAPTER

CHAPTER

13

Therapeutic Exercise for Fibromyalgia Syndrome

and Chronic Fatigue Syndrome 244

KIMBERLY BENNEn

Pathology 244

Fibromyalgia syndrome 244

Chronic fatigue syndrome 246

Therapeutic exercise intervention for prevention and

wellness 247

Therapeutic exercise intervention for common

impairments 247

Impaired muscle performance 248

Impaired aerobic capacity 249

Impaired range of motion 250

Impaired posture 250

Impaired response to emotional stress 251

Pain 252

Precautions/contraindications 252

Adjunctive interventions and patient-related

instruction 253

CHAPTER

14

Therapeutic Exercise in Obstetrics 259

M.J STRAUHAL

Physiologic Changes Related to Pregnancy - Support

Element 259

Endocrine System 259

Cardiovascular System 260

Respiratory System 262

Physiologic Changes Related to Pregnancy-Base

Element 262

Musculoskeletal System 262

Therapeutic Exercise Intervention for Wellness 263

Precautions and Contraindications 263

Exercise Guidelines 263

Exercise Intensity 266

Exercise Classes 266

Therapeutic Exercise Intervention For Common

Impairments 266

Adjunctive Interventions 266

Normal Antepartum Women 266

High Risk Antepartum 272

Postpartum 274

Therapeutic Exercise Intervention For Common

Impairments 276

Nerve Compression Syndromes 276

Other Impairments 277

15

Closed Kinetic Chain Training 283

SUSAN LYNN LEFEVER

Physiologic Principles of Closed Kinetic Chain Training Muscular Factors 284

Biomechanical Factors 284

Neurophysiologic Factors 286

284

Examination and Evaluation 287

Standardization Tools 287

Therapeutic Exercise Intervention 287

Elements of the Movement System 288

Activity or Technique 290

Dosage 290

Application of Closed Kinetic Chain Exercises 291

Lower Extremity Examples & Progression 291

Upper Extremity Examples & Progression 292

Precautions and Contraindications 306

CHAPTER

16

Proprioceptive Neuromuscular Facilitation

309

CHUCK HANSON

Definitions and Goals 309

Basic Neurophysiologic Principles of proprioceptive

neuromuscular facilitation 309

Muscular Activity 309

Diagonals of Movement 310

Motor Development 314

Examination and Evaluation 314

Impaired range of motion and muscle length 314

Impaired muscle performance (power) 314

Impaired muscle performance (endurance) 314

Impaired balance 314

Impaired posture 314

Impaired motor control 314

Pain 314

Treatment Implementation 316

Patterns of Facilitation 316

Procedures 317

Techniques of Facilitation 320

Patient-related instruction 326

CHAPTER

17

Aquatic Physical Therapy 330

LORI THEIN BRODY

Physical Properties of Water 330

Buoyancy 330

Hydrostatic Pressure 330

Viscosity 330

Contents Physiologic Responses to Immersion 334

Effects of Water Temperature 336

Physiologic Responses to Exercise and Immersion

CHAPTER

336

Examination and Evaluation for Aquatic Rehabilitation

337

Therapeutic Exercise Intervention 337

Mobility Impairment 337

Balance Impairment 340

Aquatic Rehabilitation to Treat Functional Limitations 343

Coordinating Land and Water Activities 343

Patient-Related Education 344

Precautions/contraindications 344

UNIT

5

Functional Approach to Therapeutic

Exercise of the Lower Extremities 349

:::HAPTER

18

The lumbopelvic Region 349

~AR RIE

HALL

Review of Anatomy and Kinesiology 350

Lumbar Spine 350

Pelvic Girdle 353

Myology 354

Gait 357

Examination and Evaluation 357

Patient History 357

Screening Examination 358

Tests and Measures 359

Therapeutic Exercise Intervention for Common

Physiologic Impairments 364

Aerobic Capacity Impairment 365

Balance and Coordination Impairment 365

Muscle Performance Impairment 366

General Disuse and Deconditioning 375

Range of Motion, Muscle Length, and Joint Mobility 378

Pain 383

Posture and Movement Impairment 386

Therapeutic Exercise Intervention for Common

Diagnoses 389

lumbar Disk Herniation 389

Examination and Evaluation Findings 389

Treatment 390

Spinal Stenosis 391

Examination and Evaluation Findings 391

Treatment 391

Spondylolysis and Spondylolisthesis 392

Examination and Evaluation Findings 393

Treatment 393

Adjunctive Interventions 393

Bracing 393

Traction 394

xxiii

19

The Pelvic Floor 402

ELIZABETH SHELLY Review of Anatomy and Kinesiology 403

Skeletal Muscles 403

Pelvic Diaphragm Muscles 403

Related Muscles 404

Pelvic Floor Function 404

Physiology of Micturition 405

Anatomic Impairments 405

Birth Injury 407

Neurologic Dysfunction 407

Psychological Impairments 408

Motivation 408

Sexual Abuse 408

Examination/Eva Iuati on 408

Risk Factors 409

Screening Ouestionnaires 409

Results of the Internal Examination 409

Patient Self-Assessment Tests 410

Therapeutic Exercise Interventions for Common

Physiologic Impairments 411

Impaired Muscle Performance 411

Active Pelvic Floor Exercises 412

Pain 414

Joint Mobility and Range of Motion (including muscle

length) Impairments 415

Posture Impairment 418

Coordination Impairment 418

Clinical Classifications of Pelvic Floor Muscle

Dysfunction 419

Supportive Dysfunction 419

Common Impairments 420

Hypertonia Dysfunction 421

Incoordination Dysfunction 422

Visceral Dysfunction 422

Therapeutic Exercise Intervention for Common Diagnoses 423

Incontinence 423

Organ Prolapse 426

Chronic Pelvic Pain 426

Levator Ani Syndrome 426

Coccygodynia 427

Vulvodynia 427

Vaginismus 428

Nonrelaxing puborectalis syndrome 428

Dyspareunia 428

Adjunctive Interventions 428

Biofeedback 428

Basic Bladder Training 429

Scar Mobilization 429

Externally Palpating the Pelvic Floor Muscles 431

CH APTER

20

The Hip 436

CARRIE HALL

Anatomy And Kinesiology 436

Osteology and Arthrology 436

xxiv

Contents

Muscles 438

Nerves and Blood Supply 438

Kinematics 438

Kinetics 440

Kinetics and Kinematics of Gait 441

Anatomic Impairments 441

Angles of Inclination and Torsion 441

Leg Length Discrepancy 443

Examination and Evaluation 444

History 444

Lumbar Spine Clearing Examination 444

Other Clearing Tests 444

Gait and Balance 446

Joint Mobility and Integrity 446

Muscle Performance 446

Pain and Inflammation 447

Range of motion and Muscle Length 448

Work, Community, and Leisure Integration or

Reintegration 448

Special Tests 448

Therapeutic Exercise Interventions For Common

Physiologic Impairments 450

Impaired Muscle Performance 450

Range of Motion, Muscle Length, Joint Mobility, and

Integrity Impairments 459

Balance 467

Pain 468

Leg Length Discrepancy 470

Therapeutic Exercise Interventions For Common

Diagnoses 471

Osteoarthritis 471

Iliotibial Band-Related Diagnoses 474

Nerve Entrapment Syndromes 478

CHAPTER

21

The Knee 488

LORI THEIN BRODYAND ROB LAN DEL

Review of Anatomy and Kinesiology 488

Anatomy 488

Kinematics 491

Kinetics 492

Anatomic Impairments 492

Genu Valgum 493

Genu Varum 493

Examination and Evaluation 493

Patient/client History 493

Tests and Measures 493

Therapeutic Exercise Intervention for Physiologic

Impairments 494

Mobility Impairment 494

Impaired Muscle Performance 496

Therapeutic Exercise Intervention for Common

Diagnoses 500

Ligament Injuries 500

Fractures 506

Meniscallnjuries 508

Degenerative Arthritis Problems 509

Tendinoplasties 512

Patellofemoral Pain 514

CHAPTER

22

The Ankle/Foot 524

JO HN P MONOHAN, RYAN HARTELY, CARRIE HALL. AND STAN SMITH

Review of Anatomy and Kinesiology 524

Osteology 524

Arthrology 525

Myology 526

Neurology 526

Foot and Ankle Kinesiology 527

Gait Kinetics 529

Gait Kinematics 530

Anatomic Impairments 533

Subtalar varus 533

Forefoot Varus 533

Forefoot Valgus 534

Examination and Evaluation 534

Patient/Client History 534

Joint Integrity and Mobility Examination 534

Muscle Performance 534

Pain 534

Posture 534

Range of Motion 535

Other Examination Procedures 535

Therapeutic Exercise Intervention for Common Physiologic

Impairments 535

Balance and Coordination Impairment 535

Muscle Performance 536

Pain and Swelling 537

Posture and Movement Impairment 538

Range of Motion and Joint Integrity Impairment 539

Therapeutic Exercise Intervention for Common Ankle and

Foot Diagnoses 543

Plantar Fascitis 543

Posterior Tibial Tendon Dysfunction 545

Achilles Tendinosis 545

Functional Nerve Disorders 545

Ligament Sprains 547

Ankle Fractures 549

Adjunctive Interventions 549

Adhesive Strapping 549

Wedges and Pads 550

Biomechanical Foot Orthotics 550

Heel and Full Sole Lifts 550

UNI T

6

Functional Approach to Therapeutic

Exercise for the Upper Extremities 555

CHAPTER

23

The Temporomandibular Joint 555

DARLENE HERTLING

Review of Anatomy and Kinesiology 555

Bones 555

Joints 556

Muscles 557

Nerves and Blood Vessels 560

Kinetics 560

Contents

xxv

Examination and Evaluation 561

Subjective Data 561

Mobility ImpairmeRt Examination 561

Pain Examination 561

Special Tests and Other Assessments 562

Therapeutic Exercise Interventions for Common Physiologic Impairments 620

Impaired Muscle Performance 621

Impaired Range of Motion and Muscle Length 623

Impaired Posture and Motor Function 629

Therapeutic Exercise Interventions for Common Physiologic Impairment 562

Mobility Impairment 562

Posture and Movement Impairments 568

Therapeutic Exercise Interventions for Common Diagnoses 633

Parkinson's Disease 633

Scoliosis 635

Kyphosis 637

Thoracic Outlet Syn.drome 637

TheraP!lutic Exercise Interventions for Common

Diagnoses 572

Capsulitis and Retrodiskitis 572

Degenerative Joint Disease 573

Derangement of the Disk 573

Surgical Procedures 575

Adjunctive Therapy 575

~,",APTER 24

The Cervical Spine 582

_AROL N. KENNEDY

Review Of Anatomy And Kinesiology 582

Craniovertebral Complex 582

Midcervical Spine 584

Vascular System 585

Nerves 585

Muscles 586

Examination and Evaluation 587

History and Clearing Tests 587

Posture and Movement Examination 588

Muscle Performance, Neurologic, and Special

Tests 588

Therapeutic Exercise Interventions For Common Physiologic

Impairments 588

Impaired Muscle Performance 588

Mobility Impairment 593

Posture Impairment 600

Therapeutic Exercise Interventions For Common

Diagnoses 605

Disk Dysfunction 605

Cervical Sprain and Strain 605

Neural Entrapment 606

Cervicogenic Headache 607

PlER

25

The Thoracic Spine 610

"~B

LANDEL. CARRIE HALL. MARILYN MOFFAT, AND SANDRA

S AK·SMITH

Review of Anatomy 610

Osteology/Arthrology/Myology 610

Kinetics 611

Anatomic Impairments 614

Kyphosis 614

Scoliosis 617

Examination and Evaluation 618

History 618

Systems Review 618

Tests and Measures 619

CHAPTER

26

The Shoulder Girdle 643

CARRIE HALL

Review of Anatomy and Kinesiology 643

Sternoclavicular Joint 643

Acromioclavicular Joint 644

Scapulothoracic Joint 645

Glenohumeral Joint 645

Scapulohumeral Rhythm 646

Myology 647

Examination and Evaluation 649

Patient/Client History 649

Clearing Examination 650

Motor Function (Motor Control and Motor Learning) 651

Muscle Performance 651

Pain 651

Peripheral Nerve Integrity 652

Posture 652

Range of Motion, Muscle Length, Joint Mobility, and Joint

Integrity 652

Work (Job/School/Play). Community, and Leisure

Integration or Reintegration (Including Instrumental

Activities of Daily Living) 653

Therapeutic Exercise Interventions For Common Physiologic

Impairments 653

Pain 653

Range of Motion and Joint Mobility Impairments 661

Impaired Muscle Performance 666

Posture and Movement Impairment 672

Therapeutic Exercise Interventions For Common

Diagnoses 673

Rotator Cuff Disorders 673

Adhesive Capsulitis 680

Adjunctive Interventions: Taping 685

Scapular Corrections 686

Prevention of Allergic Reaction 687

Prevention of Skin Breakdown 690

CHAPTER

27

The Elbow. Forearm. Wrist. and Hand 698

LORI THEIN BRODY

Anatomy Elbow Wrist Hand

698

and Forearm 700

702

698

xxvi

Contents

Regional Neurology 702

Musculotendinous Disorders 719

Bone and Joint Injuries 723

Complex Regional Pain Syndrome 729

Stiff Hand and Restricted Motion 732

Kinesiology 705

Elbow and Forearm 705

Wrist 706

Hand 706

Examination and Evaluation 708

History 708

Observation and Clearing Tests 708

Mobility Examination 708

Muscle Performance Examination 709

Pain and Inflammation Examination 709

Other Tests 709

Therapeutic Exercise Interventions for Common Physiologic

Impairments 709

Impaired Mobility 709

Impaired Muscle Performance 711

Impaired Endurance 713

Pain and Inflammation 714

Posture and Movement Impairment 714

Therapeutic Exercise Interventions for Common Diagnoses 715

Cumulative Trauma Disorders 715

Nerve Injuries 716

UNIT

7

Case Studies 739

APPEN DIX

1

Red Flags: Recognizing Signs and Symptoms 759

APPENDI X

2

Red Flags: Potentially Serious Symptoms and

Signs in Exercising Patients 764

INDEX

771

chapter 1

Introduction to Therapeutic Exercise and the Modified Disablement Model CARRIE HALL

Definition of Physical Therapy Therapeutic Exercise Intervention The Disablement Process Purpose of Defining the Disablement Process

Evolution of the Disablement Model

and revised in March 1995. The author has further revised the language used in this definition to remain current. Physical therapy, which is the care and senices pro­ vided by or under the direction and superdsion of a physi­ cal therapist, includes 1. Examining patients with impairments, functi onal

limitations, and disahility or other health-related conditions to determin e a diagnosis, prognOSiS, and Pathology/pathophysiology intervention. Examinations within the scope of phys­ Impairments ical therapy practice include, but are not limited to, Functional Limitations, Disability, and Quality of Life tests and measures of four categories of conditions ; Risk Factors and Interventions musculoskeletal (e.g., range of motion , muscle per­ Prevention and the Promotion of Health, Wellness, and form ance, joint mobility, posture) , neuromu scular (e.g., reflex integrity, cranial nerve integrity, neuro­ Fitness motor development, sensory integration ), cardiovas­ Summary cular/pulmonary (e.g. , aerobic capacity/endurance, ventilation and respiration , circulation), and integu­ mentary (e.g., integumentary integrity). .-\mong the many interventions available to physical thera­ 2. Alleviating impa irments and functi onal limitations pists, therapeutic exercise has been shown to ,!>e funda­ by designing, implementing, and nwdifying thera­ mental to imp roving function and disability.l- I It is the peutic interventions. Interventions include, but are premise of this text that , through carefully prescribed ther­ not limited to, procedural interventions such as ther­ apeutic exercise intervention, an individual can make sig­ apeutic exercise; manual therapy techniq ues; pre­ niJicant changes in functional performance and disability, scription , fabrication, and application of' assistive, and that physical therapists have the unique educational adaptive, supportive, and protective devices and training to be the preferred clinician for prescribing thera­ equipment; airway clearance techniques; physical peutic exercise. agents and mechanical and electrotherapeutic modalities; and functional training in self-care, home DEFINITION OF PHYSICAL THERAPY management, work (job/school/play), community, and leisure activities. The Guide to Physical Therapist Practices has defined 3. Preventing injury, impairments, fun ctional limita­ physical therapy as follows: tions, and disability , including the promotion and maintenance offitness, health, and quality of life in Physical therapy includes diagnosis and management of move­ all age populatiOns ment dysfunction and enhancement of physical and functional 4. Engaging in consultation, education, and research. abilities; restoration, maintenance, and pronwtion of optimal

Modified Disablement Model

physical function, optimal fitn ess and wellness, and optimal It is evident from these two definitions that phYSical quality of life as it relates to movement and health; and pre­ therapists examine, evaluate, diagnose , and intervene at vention of the onset, sympt()ms, and progression of impair­ the level of impairment, functional limitation, and disabil­ ments, functional limitations, and disabilities that may re.sult ity in the disablement process. The most critical message from diseases, disorders, conditions, or injuries.

The Model Definition of Physical Therapy for State Practice Acts 9 was adopted by the American Phys ical Ther­ apy Association (APTA ) Board of Directors in March 1993

promoted by these definitions is that physical therapists are primarily concerned with using knowledge and clinical skills to prevent, reduce, or eliminate impairment, func­ tionallimitation, and disability and enable individuals seek­

2

Therapeutic Exercise: Moving Toward Function

ing their services to achieve the most optimal quality of life possible. In the past, the focus on measuring and altering impair­ ments superseded the goals of improving function and dis­ ability. This text focuses on altering those impairments re­ lated to improving function and disability through the use of therapeutic exercise. Instead of considering "which ex­ ercise can be prescribed to improve impairment," the ther­ apist should consider "what impairments are related to re­ duced function and disability for this patient and which exercises can improve functional perfonnance and disabil­ ity by addressing the appropriate impairments ." To understand the relationships among disease, pathol­ ogy, impairment, functional limitation , and disability, and to avoid confusion caused by misunderstood terminology, a detailed description of the disablement process is neces­ sary and is provided later in this chapter. The model pro­ posed is based on two conceptual models and their modifi­ cations. The reader is encouraged to use this model to think about the complex process of disablement and how the dis­ ablement process relates to decisions regarding therapeu­ tic exercise intervention.

THERAPEUTIC EXERCISE INTERVENTION Therapeutic exercise intervention is a health service pro­ vided by physical therapists to patients and clients. Pa­ tients are persons with diagnosed impairments or func­ tional limitations. Clients are persons who are not necessarily diagnosed ,vith impairments or functionallimi­ tations but who are seeking physical therapy services for prevention or promotion of health, wellness, and fitness . Interventions for clients of physical therapy can include ed­ ucation regarding body mechanics provided to a group of persons involved in strenuous occupational activity, early education and exercise prescription geared toward preven­ tion for persons diagnosed with a musculoskeletal disease such as rheumatoid arthritis , or exercise recommended for a group of high-level athletes to prevent injury or enhance performance. Therapeutic exercise is considered a core element in most physical therapy plans of care. It is the systematic per­ formance or execution of planned physical movements , postures, or activities intended to enable the patient/client to (1 ) remediate or prevent impairments, (2) enhance func­ tion, (3) reduce risk, (4) optimize overall health, and (5) en­ hance fitness and well-beingS Therapeutic exercise may include aerobic and en­ durance conditioning and reconditioning; balance, coordi­ nation , and agility training; body mechanics and posture awareness training; muscle lengthening; range of motion techniques; gait and locomotion training; movement pat­ tern training; or strength, power, and endurance training. Although therapeutic exercise can benefit numerous systems of the body, this text focuses primarily on treat­ ment of the musculoskeletal system. Concepts of thera­ peutic exercise intervention specifically for the cardiovas­ cular/pulmonary, neurologic, and integumentary systems are not covered in this text, except as they relate to impair­ ments of the musculoskeletal svstem. ;

Decisions regarding therapeutic exercise intervention should be based on individual goals that provide patients or clients .vith the ability to achieve optimal functioning in home, work (job/school/play), and communitylleisure ac­ tivities. To implement goal-oriented treatment, the physi­ cal therapist must • Provide comprehenSive and personalized patient management • Rely on clinical deciSion-making skills • Implement a variety of therapeutiC interventions that are complementary (e.g. , heat application before joint mobilization and passive stretch, followed by active exercise to use new mobility in a functional manner) • Promote patient independence whenever possible through the use of home treatm ent (e.g., home spine traction , home heat or cold therapy) , self-manage­ ment exercise programs (e.g., in the home, fitness club, community-sponsored group classes, school­ sponsored or community-sponsored athletics ), and patient-related instruction. Care must be taken to prOvide intervention sufficient to meet functional goals, avoid providing extraneous inter­ ventions , promote patient independence, and promote health care cost containment. In some cases, patient inde­ pendence is not possible, but therapeutic exercise inter­ vention is necessary to improve or maintain health status or prevent complications. In these situations, training and ed­ ucating family, friends , significant others, or caregivers to deliver appropriate therapeutic exercise intervention in the home can greatly reduce health care costs by limiting in­ house physical therapy intervention .

THE DISABLEMENT PROCESS PhYSical therapists intervene at the level of impairment, functional limitation, and disability of the disablement pro­ cess. The concept of disablement refers to the "various im­ pact(s) of chronic and acute conditions on the functioning of specific body systems, on basic human performance, and on people's functioning in necessary, usual, expected, and personally desired roles in society."lO,ll A practitioner's un­ derstanding of the process of disablement and the factors that affect its development is fundamental to achieving the goal of restoring or improving function and redUcing dis­ ability in the individual seeking physical therapy services. This ,viII become evident as the disablement process is de­ fined and described. The speCific relation to therapeutic exercise intervention is discussed throughout the explana­ tion of the disablement process.

Purpose of Defining the Disablement Process The purpose of defining the disablement process in a text on therapeutic exercise is to provide the reader with an un­ derstanding of the complex relationships of pathology and disease, impairments, functional limitation, and disability and to prOvide the conceptual basis for organizing elements of patient/client management that are provided by physical therapists. This text will use an expanded disablement

Chapter 1: Introduction to Therapeutic Exercise and the Modified Disablement Model model that provides both the theoretical framework fO.r .un­ derstanding physical therapist practice and the classIfIca­ tion scheme by which physical therapists make diagnoses. Tl'te accepted definitions of imp
:. e direction of flexion and low back p
;"'exion postures and movement patterns associated with

~petitive flexion. A passive or active stretch technique may

.

chosen to apply to the hamstrings. tretching the hamstrings is an intervention at the Im­ -.wrment level of the disablement process. Improving the D!rth of the hamstrings can increase hip range of motion d consequently improve mobility to bend forward at the before streSSing the low back in a flexion movement ttern. ChOOSing to treat this imp
E olution of the Disablement Model previous example is ~n oversimplifi~~tion of the use of disablement process m making deCISIOns about thera­ . tic exercise. The relationships of the components along t:

3

INTERNATIONAL CLASSIFICATION OF IMPAIRMENTS, DISABILITIES, AND HANDICAPS (ICIDH) "DISEASE" -

IMPAIRMENT -

DISABILITY -

HANDICAP

NAGISCHEME JACTIVE PATHOLOGY -

IMPAIRMENT -

FUNCTIONAL _

LIMITATION DISABILITY

FIGURE 1-1 . Two conceptual models fo r the disablement process_ the continuum of disability are quite complex. The disable­ ment process can be better understood by examining the evolution of the disablement model. The most frequently presented models of the disable­ ment process are the World Health Organization's (vVHO ) International Classification of Impairments, Disabilities, and Handicaps (ICIDH) 10 and a model developed by soci­ ologist Saad Nagill in the 1960s (Fig. 1-1). In both disable­ ment models, the central theme is the description of a pro­ cess from disease or active pathology toward functional limitations and the factors limiting a person's ability to in­ teract as a normally functioning person in society .

Active Pathology Dr Disease There is general agreement between the l'\agi and ICIDH models in the definition of the first two concepts of dis­ ablement (see Fig. 1-1 ). For Nagi, active pathology in­ volves the interruption of normal cellular processes and the efforts of the affected systems to regain homeostasis. Active pathology can result from infection, trauma, metabolic im~ balance, degenerative disease process, or another cause. I~ ICIDH uses the term disease to refer to the biomechanical, phYSiol0f,iC, and anatomic abnormalities of the human or­ ganism. ,10,13 Examples of actIve pathology and drsease common to both models are the altered cellular processes found in osteoarthritis, cardiomyopathy, or ankylosing spondylitis.

Impairment Both models refer to the next stage in the continuum as im­ p
4

Therapeutic Exercise: Moving Toward Function

decreased endurance) can also be detected , usually as se­ quelae of the musculoskeletal system impairments (i.e., secondary impairments, which are explained later in this chapter).

Functional Limitation, Disability, and Handicap The I\ agi and ICIDH models diverge at the next two levels of the disablement model (see Fig. 1-1). Nagi Model The next level in the disablement model is functional limitation. For Nagi, this term represents a limitation in peJiormance at the level of the whole organism or person. It appears he is referring to components of more complex tasks of basic activities of daily living (BADL) (e.g., per­ sonal hygiene, feeding, dreSSing) and instrumental activi­ ties of daily living (IADL) (e.g., preparing meals, house­ work, grocery shopping). Examples of functional limitations for Nagi might include gait abnormalities, re­ duced tolerance to sitting or standing, difficulty climbing the stairs, or inability to reach overhead. Disability is the final element in Nagi's model. Nagi de­ scribes disability as any restriction or inability to peJiorm socially defined roles and tasks expected of an individual within a sociocultural and physical environment. Activities and social roles associated with the term disability in­ c1ude 13

• BADLs and IADLs • Social roles, including those associated with an occu­ pation or the ability to perform duties as a parent or student • Social activities, including attending church and other group activities, and socializing with fri ends and rela­ tives • Leisure activities, including sports and physical recre­ ation, reading, and travel Nagi reserves the term disability for social rather than individual functioning. In considering Nagi's definition of disability, not all impairments or functional limitations re­ sult in dis ability. For example, two person s diagnosed with the same di sease with similar levels of impairment and functional limitation may have two different levels of dis­ ability. On e person may remain very active in all aspects of life (i.e., personal care and social roles ), have support from family members in the home , and seek adaptive methods of continuing vvith his or her occupational tasks, whereas the other individual may choose to limit social contact, depend on others for personal care and household responsibilities, and have a job where it is not possible to use adaptive meth­ ods to partiCipate in work tasks. Nagi describes the distinction between functionallimi­ tation and disability as the difference between attributes and relational concepts . Attributes are defined by Nagi as phenomena that pertain to characteristics or properties of the individual. A functional limitation is primarily a reflec­ tion of the characteristi cs of the individual person. It is therefore unnecessary to go beyond the individual to mea­ sure a functional limitation. Disability, however, has a rela­ tional characteristic in that it describes the inwvidual's lim­ itation in relation to society and th e environment. As the

previous example demonstrated, persons with similar attri­ bution profiles (e.g., pathology, impairments , functional limitations) can present "vith different disability profiles. Factors such as age, general health status, personal goals, motivation, social support, and physical environment influ­ ence the level of disability the person experiences. International Classification of Impairments. Disabilities. and Handicaps Model The ICIDH model (see Fig. 1-1) does not discriminate betvv'een fun ctional limitation and disability. According to ICIDH, the term disability describes any restriction or lack of ability to perform a task or an activit)' in the manner con­ sidered normal for a person, such as a disturbance in gait, BADLs, or IADLs. Handicap is the term used to describe the final element of the ICIDH model. It is a disadvantage resulting from an impairment or disability that limits or prevents fulfillment of an individual's normal role . The WHO stipulates that a handicap is not a classification of in­ dividuals but is a classification of circumstances that place such individuals at a disadvantage relative to peers when judged by the norms of society. The handicap represents the social and environmental consequences for the individ­ ual stemming from the presence of impairments and dis­ abilities. 10 A criticism of the ICIDH model is that it does not dif­ ferentiate between limitations in performing societal roles and the cause of these limitations . The cause of societal limitations is clear in Nagi's model in that it is broken down into functional limitations (i.e., attributes relating to the in­ dividual) and disability (i.e. , relational characteristics to so­ ciety). In understanding the disablement process, it is im ­ portant to identify the extent to which disability results from the social and physical environment or from factors vvithin the individual. It is believed that the Nagi model does this more SUCCinctly than does the ICIDH model.

MODIFIED DISABLEMENT MODEL The previous two disablement models de monstrate that much of the discrepancy between the Nagi and ICIDH models is semantic and that neither model completely ful­ fills the deSCription of the complexity of the disablement process. Several modifications of the two basic models of Nagi and ICIDH have been proposed and each has impor­ tant contributions8.13-16 The model described and used in this text combines elements from each basic model and their modifications to prOVide a model for physical therapy practitioners (Fig. 1-2).

Pathology/pathophysiology The first element of the modified model remains the same as in the N agi model, vvith a revision to the definition. Pathology/pathophysiology (disease, disorder, or condi­ tion) refers to an ongOing pathologic/pathophysiologic stat that is (1) characterized by a particular cluster of signs and symptoms and (2) recognized by the patient or the practi­ tioner as "abnormal." Pathology/pathophysiology is primal'­ ily identified at the cellular, tissue, and organ levels and i

Chapter 1. Introduction to Therapeutic Exercise and the Modified Disablement Model

5

risk factors

P~'i=:::::":t~/· ~ secondary conditions

GURE 1-2. Modified disablement model.

Prevention and promotion of heath, weliness, and fitness

• n the physician's medical diagnosis. It is, however, -thin the scope of physical therapy practice to diagnose thology at the tissue level using clinical tests and mea­ ciT • such a~ those outlined by Cyria'\ (e.g., supraspinatus donitis),u FUlthermore, the complexity of the in terre­ io nships among the components of the disablement del is indicative of the knowledge of pathology and th ophysiology necessary to perform optimal patient agement. For example, in the case of a patient referred a physical therapist with shoulde r pain , the physical therj t performs an examination/evaluation to diagnose the ndition. It is imperative for the physical therapist to be owledgeable in the numerous possible causes of the pa­ nt's pain. The physical therapist's knowledge that differ­ t cluste rs of si.gns and symptoms are consistent with thology at the tissue (e.g. , tendonitis) , organ (e.g., my­ lrdial infarction), or cellular (e .g., lung cancer) level is '!itical for the diagnosis and management of the patient's , ndition. If the clinical findings on examination suggest a thologic or pathophysiologic condition that is not within - e scope of physical therapy practice (e.g., myocardial in­ Mction, lung cancer) that has not been addressed by the p ropriate practitioner, an immediate referral is neces­ SdI)' (see Appendix l). In many instances, the pathology can not be dj~gnosed and the physical therapist must rely n clusters of impairments to formulate a diagnosis and in­ ~rve ntion. A pathology-based diagnosis does not, by itself, elineate the impairments, functional limitations, or dis­ bility that will guide the physical the rapy intelvention (see Chapter 2, Patient Management). Therefore, the therapist must acknowledge the compTex multidirectional and cyclii­ al nature of the disablement model and the fact that in­ 'e rvention can be introduced at any component of the model (e.g., pathology, impairment, functional 1mitation, lisability) , but that the more data collected regarding indi­ i dual components, the more accurate the patient manage­ men t will be. A

Impairments Similar to the Nagi and ICIDH models , impairments are defined as losses or abnormalities of physiologic, psycho­ logiC, or anatomic structure or function. Active pathology results in impairment, but not all impairments originate from pathology (e.g. , congenital anatomic deformity or loss, immobilization , faulty movement patterns). Through­ out this text, phYSiologic, anatomic, and psychologic im­ pairments are differentiated (Display 1-1).

Physiologic Impairment Physiologic impairment can be defined as an alteration in any phYSiologic function such as aerobic capacity, mus­ cle performance (strength, power, endurance), joint mobil­ ity (i.e., hypomobility/hypermobility), balance, posture, or motor function (Fig. 1-3). Physical therapy interventions can most Significantly modify phYSiologic impairments. Unit 2 of this text provides a more thorough discussion of each of these phYSiologic impairments and examples of therapeutic exercise interventions to remediate or prevent these impairments.

Anatomic Impairment

Anatomic impairment is an abnormality or loss of struc­

ture, such as hip anteversion, structural subtalar varus,

structural genu varum, or congenital or traumatic loss of a

DISPLAY 1-1

Impairments Physiologic impairment: an alteration in any physiologic function Anatomic impairment: an abnormality or loss of structure Psychologic impairment: any abnormality related to the psychologic system

6

Therapeutic Exercise: Moving Toward Function

ment process is not a unidirectional process, but one that is much more complex, interrelated, and cyclical. The term applied to this concept and used in the modi­ fied dis::lhlement model is secondary conditions (see Fig. 1­ 2).13 Secondal), conditions occur as a result of a prim ar; disabling condition. A secondary condition may be a type of pathology or impairment, as exemplified earlier, and it can deSignate additional functional limitations and disability. By definition , seconda,), conditions only occur in the pres­ ence of a plimal)' condition. Other commonly encountered secondal), conditions include pressure sores, contractures. urinary tract infection, cardiovascular deconditioning, and depreSS ion. Each of these secondary conditions can lead to additional functional limitations and disability.

Functional Limitations, Disability, and Quality of Life FIGURE 1·3. The patient exhibits a loss of medial rotation at the gleno­ humeral joint, a physiologic impairment in range of motion and joint mobility limb. Anatomic impairments cannot be remedied with physical therapy intervention, but modifications can be made to function in light of anatomic impairments. The physical therapist should be aware of the presence of anatomic impairments to be able to prOvide an appropliate prognosis and determine the best plan of care. Therapeu­ tic exercise intervention in the presence of anatomic im­ pairments will be discussed in selected chapters in Units 5 and 6.

Psychologic Impairment

The final two elements of the main pathway, function limitation and disability, remain unchanged from the defi­ nitions proVided in the description of?\agi's model (Fig. 1­ 4). Beyond the main pathway of pathology toward disabJ ment, a final outcome-health-related quality of Ii (HRQL)-has been added. HRQL has been defined generally corresponding to total well-being, encompassi 7 three major components: 18 ,19 • Physical function component, which includes BADu and IADLs Psychologic component, which includes th e '\'an cognitive , perceptual, and personality traits of a son"; and • Social components, which involves the interaeti, the person "within a larger social contE'xt or ture. " f)

Psychologic impairment is any abnormality related to the psychologic system. Although most persons with any degree of disability are affected to some extent psycholog­ ically, it is beyond the scope of physical therapy practice to treat psychologic impairm ents directly. It is the responsi­ bility of the physical therapist to recognize when a psycho­ logic impairment is reducing the effectiveness of a physical therapy intervention and therefore requires referral to an appropriate health care practitioner. Because physical therapy intervention can greatly affect psychologic impair­ nwuts , it is important that the physical therapist under­ stand basic psychologic paradigms. However, it is not within the scope of this text to proVide the details war­ ranted for a thorough understanding of the topic. Proper screening for psychologic impairments is the responsibility of the physical therapist, as is working vvith other members of the health care team to provide a consistent philosophic approach to the person's psychologic impairment and disability.

Primary and Secondary Impairments Primal), impairments can result from active pathology or disease. A secondary impairment results from plimary impairments and pathology. Primary impairments can cre­ ate secondary impairments, and primal)' impairments can lead to secondary pathology (see Fig. 1-2). The disable­

FIGURE 1-4. The functional limitation related to impa.rE'::~" - ­ and joint mobility is the patient's limited ability to rea~- ,:,,­ The patient's disability is the inability to periorm \\":i:E­ safely.

Chapter 1. Introduction to Therapeutic Exercise and the Modified Disablement Model

Assessments of quality of life attempt to capture how limitations in function affect physical, psychol09,ic, and so­ cial roles as well as perceptions of health status.-O- 22 A peron may argue that issues related to quality of life are not di tinct from disability, but quality of life is considered broader than disability, encompassing more than well be­ ing related to health such as education and employment. Other "non-health" -related factors contribute to an indi­ i dual's sense of well being and overall quality of life. Such actors include economic status, individual expectations .md achievements, personal satisfaction with choices in life, d sense of personal safety as depicted in the model (see Fig. 1-2). The model (see Fig. 1-2) displays HRQL as a ·mall palt of quality of life and that general quality of life ·erlaps with components of the main pathway.

isk Factors and Interventions The main pathway from pathology to disability, including uality of life, can be modified by a host of factors such as gender, education, income, comorbidities, health bits, motivation, social support, and physical environ­ ent. Proper medical care and timely rehabilitation also .m eliminate or reduce the impact of each component's af­ ts on one another. Conversely, improper medical care or "E'habilitation along with other aforementioned factors can nify the impact of each component in relation to the ).-t or accelerate the disablement process. Education, age, _ender, disease severity, duration of illness and treatment, d comorbidity modify the disablement grocess in per­ diagnosed with rheumatoid arthritis,2 24 and anxiety, pression, and coping style have been related to func­ nal limitations in individuals with hip or knee os­ hritis.25 The model exhibits these components as risk tors and interventions (see Fig. 1-2). Risk factors are predispOSing in that they exist before onset of the disablement process. There are several s of risk factors: ~e.

• DemographiC, social, lifestyle, behavioral, psycho­ logiC, and environmental factors • Comorbidities (e.g. , coexisting conditions ) • Physiologic impairments (e.g. , short hamstrings, weak abdominal muscles, lengthened lower trapezius ) • Anatomic impairments (e.g. , congenital scoliosis , shallow glenoid fossa, hip anteversion ) • Functional performance factors (e.g. , less than opti­ mal work station ergonomics resulting in poor posture at the work station, faulty gait kinetics or kinematics, inappropriate lifting mechanics ) The physical therapist must be aware of these factors for h individual, because they can greatly alter the individ­ . disablement profile. With respect to therapeutic exer­ intervention, many of these factors can directly influ­ e the choice of activities or techniques, dosage , and cted functional outcome. An example is the scenario of individuals involved in a motor vehicle accident and di­ o ed vvith an acceleration injury to the cervical spine th resultant sprain or strain to the cervical soft tissues. "'Ie individual is a sedentary, 54-year-old male smoker th diabetes who has a significant forward head and tho­

7

racie kyphOSiS and must return to a data entry job (which he dislikes ) at a poorly deSigned workstation. The other indi­ vidual is an active and otherwise healthy, 32-year-old man who enjoys his job as a salesman and is engaged in activities such as sitting, standing, and walking throughout the day. The disablement profiles of these two individuals are quite different, and the prognoses, therapeutic exercise inter­ ventions, and functional outcomes differ accordingly. In addition to the risk factors present before disability, interventions (see Fig. 1-2) can alter the disablement pro­ cess at each juncture. Interventions may include extra-in­ dividual factors (i.e., outside of the individual) such as med­ ications, surgery, rehabilitation, suppOltive equipment, and environmental modifications or intra-individual factors (i.e., self-induced) such as changes in health habits, coping mechanisms, and activity modifications. The expected out­ come is that interventions modify the disablement process in a positive manner. However, interventions occaSionally serve as exacerbators to the disablement process. Exacer­ bators may occur in the folloWing ways: • Interventions may go awry. • Persons may develop negative behaviors or attitudes. • Society may place environmental or attitudinal barri­ ers in the path of the individual.

Prevention and the Promotion of Health, Wellness, and Fitness Physical therapists may prevent impairment, functional limitation, and disability by identifYing risk factors during the diagnostic process. Three major types of prevention in­ clude: 8 • Primary preIJention, which is the prevention of dis­ ease in a susceptible or potentially susceptible popu­ lation through specific measures such as general health promotion efforts, • Secondary prevention, which includes efforts to de­ crease duration of illness, severity of disease, and se­ quelae through early diagnosis and prompt interven­ tion,and • Tertiary prevention, whieh includes efforts to de­ crease the degree of disability and promote rehabili­ tation and restoration of function inpatients with chronic and irreversible diseases.

Therapeutic exercise as an intervention intends to pro­ mote primary, secondary, and tertiary prevention as well as health , wellness, and fitness. Prevention, health, weIlness, and fitness must be considered critical foundational con­ cepts of therapeutiC exercise intervention (see Chapter 4).

Summary The modified disablement model (see Fig. 1-2) exhibits the complexity of the relationships among pathology, impair­ ments, functional limitations, disability, risk factors, inter­ ventions, quality of life, and prevention , wellness, and fit­ ness. A practitioner's understanding of this model is critical to developing a therapeutic exercise program that is effec­ tive , efficient, and meaningful for the individual seeking

8

Therapeutic Exercis e: Moving Toward Function

physical the rapy services. Th e amount of data that can be collected during an initial examination or evaluation of an individual can be irnmense and often overwhelming. This model (see F ig. 1-2) allows the physical therapist to orga­ nize data pertainin g to the patie nt's impairments, func­ tionallimitations, and disability. It also allows the physical therapist to categorize pertinent aspects of the patient's IlistOlY, the effect of prior treatm ent, and the presence of risk factors. Most important, the clinical presentation can be classified in a way tbat identifies the impairments im­ peding tile performance of certain functional tasks and ac­ tiviti es, thereby focusing the treatment on only those im­ painn e nts directly related to functional li mitation and disability. It aho enables the practitioner to clarify risk fac­ tors and interventions that may serve as impediments to improved functional performance, reduced disability, and improved quality of life, thereby serving the role of pre­ vention, and promoting health, wellness, and fitness. With this analysis, the practitioner can develop goals that are rel­ evant to the individual's daily life and promote health, well­ ness, and fitness at any level of ability.

KEY POINTS • Physical therapists examine patients with impairments, functional limitations, and disabilities or other health-re­ lated conditions to determine a diagnosiS, prognOSiS, and interve ntion. • Physical therapists are involved in alleviating and pre­ venting impairments, functional limitations, and disabil­ ity by deSigning, implementing, and modifying thera­ peutic interventions. • Therapeutic exercise intervention engages the individ­ ual to become an active participant in the treatment plan. • Therapeutic eXf~ rcise should be a core intervention in most physical therapy treatment plans. • As the health care industry continues to change , the practitioner must recognize that the third-party reilll­ burser for medical care is seeking health care services that are efficient and cost-effective. Prudent us e of ther­ apeutic exercise can reduce health care costs by pro­ moting patient independence and self-responsibility. • A thorough understanding of the disablement process can assist the practitioner in developing an effective, ef­ ficient , and cost-contained therapeutic exercise inter­ vention, meaningful to the person seeking physical ther­ apy services.

CRITICAL THINKING Develop a case defining each feature of the modified dis­ ablement model. Given a patient with low back pain, pro­ vide a probable history of the condition. Include a brief de­ scription of each of the follOwing features: • Risk factors • Pathology • Impairments (anatomic, psycholOgiC, physiologic) • Functionallimitations

• Disahility • Secondarv conditions • Previous 'inte rve ntions (intra-individuaL ual , and exace rbators) How would these elements ch ange if the pati ferent age, had a different lifestyle, or a difTe­ tion';:>

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6. Weiss A, Suzuki T , Bean J. High intensity

improves strength and functio nal perfo

Arch Phys Med RehabiI1999 ;79:36~i6

7. Hiroyuki S, Uchiyama Y, Kakurai S. Spec

ance and gait exercises on physical function

elderlv. Clin Rehuhil 2003;17:472--li9.

8. Guicl~ to Physical Therapist Practice. Ph~ 9. American Physical Tlwrapy Association. A _

therapist practice, I: a des cliption of

Phvs Ther 1995;75:709-764.

10. Internati onal Classification of Imp ainnen Handicaps. (;e neva, Switzerland: " 'orld H ti on, 1980. 11. Nagi SZ. Disability and Rehnbilitation. State Uni versitv Press, 1969. 12. VerbruggE' L, J~;tt l' A. The disablement p 1994;38:1- 14. 13. POpE' A, Tarlov A, eds. Disability in :\ mer-""lc tion al Agencla for Prevention. \ \'ashin'!: Academy Press, 1991. 14 . National Advisory Board on \Iew Research, Draft V: Report Plan for \Ie.!· Research. Bethesda, MD: National 1­ 1992. 15. Cuccionn E' .I\.A. Arthritis and th e prOl. ..., " Ph)s Ther 1994;74:408-414. 16. Guccionne AA. Physical tlwrap\' diagn . ship betwcpn impairm ents and r 1991 ;71499-504. 17. Cyriax J. Textbook of Orthopedic \ Iedid tissue lesions. 8th E d. London: Bailliere TI 18. Jette AM. Using health-related qualih physical th erapy outcomes 1993;73:528-537. 19. Jette AM. Physical disablement concept< for~~ research and practice . Phys Ther 199-1:- ~.'.)St'20. DeHaan R, Aaronson ~, Limburt >1 , et cl. Mea::::::::::: of life in stroke. Stroke 1993;24:320-321.

Chapter 1: Introduction to Therapeutic Exercise and the Modified Disablement Model IIollbrook M, Skillbeck CE. An activities index for use ""ith stroke patients . Age Ageing 1983;12:166-170. \litchell DM , Spitz PW, Young DY, et al. SUlvival, prognosis and cause of death in rh eumatoid althritis. Arthritis Rheum 1986;29:706-714. _) Sherrer YS, Bloch DA, Mitchell, et al. Disability in rheum a­ toid arthritis: comparison of prognostic factors across three populations. J RheumatoI1987;l4:705-709.

ft in r

py tty

9

24. Mitchell JM , Burhouser RV, Pincus T . The importance of

age, education , and comorbidity in the substantial earnings

and losses of individuals \\~th symmetlic: polyarthlitis. Arthri­

tis Hheum 1988;3 1:348-357.

25. Summers M~, Haley WE , H.eville JD , et al. Rauiographic as­

sessment and psycholo~c variables as predictors of pain emu functional impairment in osteoarthritis of the knee or hip. Arthritis Rheum 1988;31 :348-357.

chapter 2

Patient Management CARRIE HALL

Introduction Patient Management Model Examination Evaluation Diagnosis Prognosis and Plan of Care Intervention Outcome

Clinical Decision Making Therapeutic Exercise Intervention Therapeutic Exercise Intervention Model Exercise Modification

Adjunctive Interventions Physical Agents

Mechanical Modalities

Electrotherapeutic Modalities

INTRODUCTION An understanding of the disablement process presented in Chapter 1 enables the clinician to provide optimal patient management by understanding the relationships among pathology, impairments, functional limitations, disabilities, yuality of life, risk factors, and the effects of intra-individ­ ual and extra-individual interventions. Knowledge of the disablement process enables the clinician to • Develop comprehensive yet efficient examinations and evaluations of impairments and functionallimita­ tions relatiJlg to the patient's unique disability profile. • Reach an accurate diagnosis based on logical classifi­ cation of pathology, impairments, and functional lim­ itations. • Develop a prognosis based on the evaluation and the patient's goals. • Create and implement effective and efficient inter­ ventions. • Reach a desirable functional outcome for the patient as quickly as pOSSible. Each patient presents with unique anatomic, physio­ logic, kineSiologic, psychologic, and environmental charac­ teristics. Consideration of all these variables is necessary to develop an effective plan of care , but it can be overwhelm­

ing even for the experienced clinician. This chapter pre­ sents two additional models to assist in organizing the data and making the clinical decisions that are necessary to de­ velop an effective and efficient therapeutic exercise inter­ vention: the patient management model proposed by the American Physical Therapy Association 1 and a therapeutic exercise intervention model.

PATIENT MANAGEMENT MODEL The physical therapist's approach to patient management is described as the patient management model in Fig. 2-l. The physical therapist integrates these five elements of care in a manner designed to maximize the patient's out­ come, which may be conceptualized as patient-related (e.g. , satisfaction with care) or associated with service de­ livery (e .g., efficacy and effiCie ncy) The current model of patient management intends to involve the patient in deci­ sion making, which should in turn result in higher satisfac­ tion with care. In addition, in a responsibility-focused health care system, the clinicians are called to identify and justify the hypotheSiS that underlie interventions, which should in turn result in improved efficiency of care and prOvide payers with better justification for interven tion.

Examination

t Evaluation

•

Diagnosis

t Prognosis

t Intervention

~

(

outcome )

FIGURE 2·1. Patient management model.

10

Chapter 2 Patient Management

Examination Examination is required before the initial intervention and is performed for all patients/clients. Examination is de­ Sned as the process of obtaining a history, performing a rel­ evant systems revie'vv, and selecting and adm inistering spe­ cific tests and measures to obtain data. 1 The history is e),.p ected to provide the physical therapist with peltinent in formation about the patient: • Demographic profile and social history • Occupation • Living and working environm ents • General health history • Past and current history of the physical condition • Past and current functional status • Extra-individual and intra-individu al interventions These data can be obtained from the patient, family, sig­ nificant others , caregivers, and other interested persons through interview or self-report forms , by consulting with th r members of the health care team , and by reviewing e medical record. Display 2-1 summarizes the data gen­ n ted from the history. The syste ms review is a screening process that provides

information about the bodily systems involved in the pa­ tient's current disability profile. Data generated hom the systems review may affect tests performed during subse­ quent examinations and choices regarding interventions. The systems review also assists the physical therapist in identifying possible problems that require consu ltation with or referral to another provider. Several major systems should be screened for involvement: cardiovascular/pul­ monary, integumentalY, musculoskeletal, and neuromus­ cular. In addition, comm unication abi lity, affect, cognition, language, and learning style of the patient shou ld be as­ sessed. Display 2-2 summarizes the data generated from a systems review. Depending on the data gathered from the history and systems review, the therapist may use one or more exami­ nations in whole or in part. The examination may be as brief or as lengthy as necessary to generate a diagnosis. For exarnple, after taking the history and concluding a systems review, the physical therapist may determine that further examination is not appropriate and that the patient should be referred to another health care practitioner. Conversely, the physical therapist may determine that a detailed exam­ ination of several bodily systems is required to develop a thorough diagnosis The specific tests and measures

DlSPLAV 2·1

Data Generated From Client History1 nlual Demographics Age Sex Race Primary language ocial History Cultural beliefs and behaviors Family and caregiver resources Social interactions, social activities, and support systems Occupation Current or prior work (e.g., job, school, play) or community activities owth and Development Hand and foot dominance

Developmental history

living Environment Living environment and community characteristics

Projected discharge destination(s)

Liistory of Present Condition Concerns that led the individual to seek the services of a physical therapist Concerns or needs of the individual requiring the services of a physical therapist Onset and pattern of symptoms Mechanism(s) of injury or disease, including date of onset and course of events Patient's, family's, or caregiver's perceptions of the patient's emotional response to the present clinical situation • Current thera peutic interventions

o

11

• Patient's, family's, or caregiver's expectations and goals for the therapeutic intervention Functional Status and Level of Activity • Prior functional status, and self-care and home management (i.e., activities of daily living and instrumental activities of daily living) • Behavioral health risks Sleep patterns and positions Medications • Medications for present condition • Medications for other conditions Other Tests and Measures • Review of available records • Laboratory and diagnostic tests History of Present Condition • Prior therapeutic interventions • Prior medications Medical or Surgical History • Endocrine/metabolic • Gastrointestinal • Genitourinary • Pregnancy, delivery, and postpartum • Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions Family History • Familiar health risks Social Habits (past and present) • Level of physical fitness (self-care, home management, community, work [e.g ., job, school, play) and leisure activities)

12

Therapeutic Exercise: Moving Toward Functi on

OISPLAY2-2

Systems Review Data 1 The systems review includes the following: • Cardiopulmonary: assessment of heart rate, respiratory rate, blood pressure, and edema ~ Musculoskeletal: gross symmetry, gross range of motion, gross strength, height, weight • Neuromuscular: gross coordinated movement (e.g., balance,locomotion, transfers, transitions) ~ Integumentary: skin integrity, skin color, presence of scar formation • Communication ability, affect, cognition,language and learning style: includes the assessment of the ability to make needs known, consciousness, orientation (person, place, and time), expected emotional/behavioral responses, and learning preferences (e.g., learning barriers, educational needs)

included in each examination generate data about the pa­ tient's impairments and functional limitations. Implemen­ tation of the examination is based on a prioritized order of . tests and measures that depend on medical safety, patient comfort, and medical treatment priorities; the patient's physiologic, emotional, functional, social, and vocational needs; and financial resources. The most relevant examina­ tions to this text tllat are performed by a physical therapist include:l • Aerobic capacity/endurance • Anthropometric characteristics • Assistive and adaptive devices • Circulation (arterial, venous , lymphatic) • Cranial and pelipheral nelve integrity • Environmental, home, work (job/school/play) barriers • ErgonomiCS and body mechanics • Gait, locomotion , balance • Integumentary integrity • JOint integrity and mobility • Motor function (motor control and motor learning) • Muscle performance (strength, power, endurance) • Orthotic, protective, and supportive devices • Pain • Posture • Range of motion (including muscle length ) • Reflex integlity • Sensory integrity • Ventilation and respimtion/gas exchange • Work (job/school, play), commullity, and leisure inte­ gration or reintegration Other information may be required to complete the ex­ amination process; • Clinical findings of other health care professionals • Results of diagnostic imaging, clinical laboratory, and electrophysiologic studies • Information from the patient's place of work regard­ ing ergonomic, posture, and movement requirements. The examination is an ongoin g process throughout the patient's treatment to determine th e patient's response to

intervention. Based on re-examination findings (e.g., new clinical symptoms or failure to respond in the expected manlier to the intervention), the intervention may be ter­ minated or modified. Exercise modification is discussed later in this chapter.

Evaluation Evaluation is the dYllamic process in which the physical therapist makes judgments based on data gathered dUJing the examination. To make appropriate clinical decisiops re­ garding the evaluation, the physical therapist must • Determine the priority of problems to be assessed based on the medical history (and any other pertinent data collected through medical records or interac­ tions with other health care providers ) and systems review. • Implement the examination. • Interpret the data. Interpretation of the data constitutes the evaluation. In­ terpretation of the examination findings is one of the most critical stages in clinical decision making. In interpreting the data to understand the sources or causes of the patient's impairments, fundionallimitations , and disabilities, all as­ pects of the eX{lmination must be considered and analyzed to determine the follmving: • P rogreSSion and stage of the signs and symptoms • Stability of tll e condition • Presence of preexisting conditions (j.e., comorbidJties) • Relationships among involved systems and sites To remain consistent with the language of the disable­ ment process and to link the patient management model with the disablement model, tlle following sections provide the reader witll examples of examinations and evaluations for each element of tlle disablement model.

Pathology Laboratory tests, radiologiC studies, and neurologiC exam­ inations are used to assess the presence and extent of the pailiologic process at the organ, tissue, or cellular level. Because some biochemical and physiologic abnormalities may be beyond the scope of medical testing, detection of­ ten relies on the examination/evaluation of impairments. One of the frustrations for physical therapists follOWing the disablement model is that underlying pathology asso­ ciated with the impairments, functional limitations, and resulting disabilities often cannot be identified. Radio­ lOgi C, neurologic, or laboratory study results commonly are negative despite tlle presence of clinical signs and symptoms. H owever, the lack of an identifiable pathology should not lead the physical therapist to believe that an organic reason for the individual's impairments , func­ tional limitation, or disability is not present. Even with a diagnOSiS of pathology, the physical therapist should con­ centrate on examination and evaluation of impairments, functionallirnitations , and disabilities, because the pathol­ ogy diagnosis may not provide much gUidance for physical therapy intervention.

Chapter 2 Patient Management

Impairments Medical procedures to evaluate impainllents include clini­ cal examinations, laboratory tests, neurologic tes ts , illlaging procedures, and the patient's medical histOlY and symptom re ports. Physical therapy procedures to examine and eval­ uate impairmen ts should be based on bodily systems most treated by physical therapists including the musculoskele­ tal, neuromuscular, cardiovascular, pulmonary, and integu­ mentary systems (F ig. 2-2A ). Many bodily systems are not within the scope of thorough and de finitive examination by a physical therapist (e.g. , metabolic, renal , circulatory). However, if peliinent to the physical therapy intervention , this information should he gathe red from the patit~ llt , other medical and llC'ulth caw profc>ssionals, or medical r('cords. Specific tests (e.g. , pulse. hlood pressme ) inclicating system impairments that are \;vitltin the scope of therapists should be performed (Fig 2-2B). Examinations ma)' reveal a list of impairments that may or may not be amenahle to physical therapy treatment. It is tempting to evaluate and treat lists of impairments, but this type of practice may not be the most effective or efficient use of health care dollars. It is therefore prudent to make simultaneous decisions about whether testing or measuring anyone impairment is pertinent to determining the cause of the functional limitation and disability. T o facilitate this decision-making process, ask the follOwing questions: • Is the impairment related directly to a functional lim­ itation? For example, reduced shoulder girdle mobil­ ity (i.e., impairment ) can be directly related to an in­ ability to reach upward (i. ., functional limitation). • Is the impairm ent a secondary condition of the pri­ maty pathology or impairment? For example, a pa­ tient has complaints of shoulder p ain and loss of mo­ bility (i.e. , impai rments) resulting in reduced fun ction of the upper extremity (i.e., fundionallimitation ) for the activities of daily living ( D Ls). However, the source of the shoulder pain is cervical disk disease

(i.e., primary pathology ). Los s of mobility of th e shoulder is a secondalY impairment, and retlnced USt' of the upper ('xtr >mity during ADLs is a secondary func tional limitation, both of which dewloped be­ cause of pain in the shoulder originating from the pri­ mary conwtion of celvical degenerative disk disease. • Can the impairment be related to future functional limitation? Studies have shown that a relationship can exist betwee n current impairment findings and future functional limitations. 2.3 F or example , 10 " of shoul­ der range of motion (RO M ) in the absence of fllIlC­ tionallimitation [)lay lead to functional limitation in the future from exaggeration of the impairment or the existing impairment leading to other impairm ents. • Is the impairm e nt unrelated to the fu nctionallimita­ tion and disability and tlw r(O fore should not be as ­ sessed or treated? F or example, a patient complains of shoulder pain (i.E> ., impairment) and reduced use of the shoulder girdle during ADLs. Hypomobility of the shoulder girdle may be an obvious impairment, but it may not be related to the functional limitation or disability. T h patient's pain may occur in the midrange and be a result of impaired scapulohumeral rhythm, not hypomobility. In summar)" not all impairments result in functional limitations , and not all functional limitations resnlt in dis­ ability. For the clinician to provide effective care that will ultimately affect function and reduce the potential for dis­ ability, therapeutic interventions should, in theory, target only those impairments that are related to the functional limitations. Indeecl, it has been suggested that through the examination process, the clinician determines the interre­ latiollships among impairments, functional limitations, and disability for a patient with a given diagnosis and that this information then guides treatme nt. 4 Examples of cervical spine impairments include reduced range of cervical spine motion and deep cervical muscle performance, whereas a

A

FIGURE 2-2. (A) Measurement of range of motion and muscle length impa irment. The patient shows signs of limited hamstring extensibility. (8) Measure­ me nt of aerobic capacity impa irment. The clinician takes the patient's blood pressure.

13

B

14

Therapeutic Exercise Moving Toward Function

functional limitation might be a driver's inability to rotate the head and neck to be able to see behind when driving an automobile in reverse. If an individual is then unable to work because his or her occupation requires automobile use, that person could be considered to have a disability.

Functional Limitations Rarely does the patient seen in the physical therapy de­ partment, clinic, or office describe specific complaints of weakness , loss of muscle length, or loss of jOint mobility (i.e., impairments). For example, the patient is probably more concemed about his or her ability to climb a flight of stairs (j.e., functional outcome ) than the adequate knee ROM and quadriceps force or torque production needed to climb the stairs (i.e. , impairments ). Improved knee ROM and quadriceps force production may not result in the ability to climb a flight of stairs. The inability to climb stairs may be related to other impairments, such as weak gluteal musculature, lack of ankle mobility, or psychologic impairments (e.g. , fear). One question must be addressed in daily practice and in physical therapy research: \Vhich and to what degree are impairments linked to functional limitations? More studies are attempting to establish the relationships among pathol­ ogy, impairments, and functional limitations because this question is clinically impOltant to physical therapists. For example, the information gained from a deSCriptive study of individuals ,vith arthritis indicates correlations among pathology (i.e. , arthritis ), impairments (i.e. , knee ROM , pain and joint stiffness, reduced muscle performance ), and functional limitations (j.e., performing ADLs including getting down to and up from the floor and ascending/de­ scending stairs ) 5 This study indicates that quadriceps mus­ cle performance, joint pain dUling the activity, perceptions of functional ability, and body weight combined can predict betvveen 39% and 56% of the variance in time to perform four fun ctional tasks in adults with osteoarthritis of the knee. These findings appear to indicate that interventions that improve quadriceps muscle performance, reduce joint pain and body weight, and facilitate perceptions of func­ tional ability may have a positive impact on the ability to get down to and up from tbe floor and ascend/descend stairs in adults with osteoarthritis of the kn ee. Improving the impairments related to the functional out­ come is necessary, but the measure of success is in the abil­ ity to achieve a functional outcome such as climbing the stairs. To determin e success in achieving functional out­ come, valid, reliable, and sensitive tests must be used to measure functional performance . \Vith standardized tests, no single assessment instrument can measure the full range of potential impairments, functional limitations, and dis­ abilities. Adequate evaluation usually must rely on a battery of appropriate instruments. It is beyond the scope of this text to discuss the various stanJardized tests, but a literature search on the speCific population you are testing can offer explicit tests and measures for your Jesired purpose. 6-- 11; Tests and measures of physical functional limitations have various formats: • Self-reports or proxy reports (e.g. , spouse, parent, personal physician ) of the level of difficulty perform­

ing tasks (e.g. , no difficulty, some difficulty, much dif­ ficulty, inability)19,2o • Observation of performance of functional tasks, rat­ ing the level of difficulty (e.g. , fully able, partially able , unable ), such as measuring distances, weight lifted, number of repetitions, or quality of motion based on kineSiologic standards 21 • Clinical tests of physical mobility (e.g., Six-Minute Walk Test, Berg Balance Scale, Timed & Go Test, gait speeds, Timed Movement Battery)2 - 24 • E1uipment-based evaluation of performance (e.g., usc of a hand dynamometer to examine grip strength, ' computer-assisted assessment of balance, use of spe­ cialized grids to measure performance of closed chain activities)25-29

Ur

Disability Improvement in functional outcome may not be the only or most important measure of the positive effects of physical therapy intervention . Disability, as defined in the disable­ ment model introduced in Chapter 1 (see Fig. 1-2), entails the social context of functional loss. Social function encom­ passes three domains: social interaction, social activity, and social role. 30 Each of these domains requires a certain de­ gree of physical ability. For example, functional limitation in going up and down stairs may limit 1. A person's social interaction because of the inability to go outside the home to visit friends. 2. A person's social activity because of the inability to go to church ,vith stairs to the front door. 3. A person's social role because of the inability to go to work and perform tasks that require going up and down stairs.

Successful performance of complex instrumental ADLs such as personal hygiene, housekeeping, and dreSSing re­ quire integration of physical, cognitive, and affective abili­ ties. As a result, measurement of disability requires tests that consider the complexity of variables that affect the per­ son's ability to interact in society. The standard and most economic procedure for measuring disability is self-repOlts or proxy reports, which include simple ordinal or interval scoring of the degree ofdifficulty in performing roles within the person's milieu. Questions regarding functionallimita­ tions, disability, and quality oflife are included in many self­ reports used by phYSical therapistsy ·l 1 , 15 ,26,27 ,.1 1 ~3') Similar to tests and measures of functional limitation , no one self­ repOlt can encompass all aspects of disahility from a physi­ cal therapist's perspective, and it is important to be aware of numerous reports pertin ent to specific areas of practice. The appropriate self-report can offer comprehensive, con­ cise information peltaining to functional limitations, dis­ ability, and quality of life, which can guide the physical ther­ apist's evaluation and intervention. Results of a disability measure often reveal aspects of the disability that are beyond physical impairments and functional limitations. Refer the patient to the appropriate health care profeSSional if aspects of his disability are be­ yond your knowledge , expertise, or experience. Decide whether further physical therapy intervention is appropri­

Chapter 2: Patient Management

ate or physical therapy should be deferred until other as­ pects of disability are adequately dealt with. For example, a patient with low back pain may have a high level of anxi­ ety or depression associated with the loss of function and the disability. Physical therapy may not be effective until the patient is treated for the anxiety or depression, or phys­ ical therapy concurrent with counseling may be deter­ mined to be most effective. The time it takes to complete and interpret the self­ report forms has been described as a methodologic and practical barrier to using self-reports. However, self-reports assist in determining whether functional limitations and dis­ ability exist beyond the scope of physical therapy practice and result in a referral to health care providers educated to evaluate and treat components outside the physical thera­ pist's domain. This information may save financial resources and time spent attempting to treat physical impairments or functional limitations that cannot be resolved without more comprehensive intervention involVing other health care practitioners, family members, or significant others. The tim e and cost savings to the patient and the health care sys­ tem justifies the time spent completing and interpreting the for m. It is beyond the scope of this text to discuss all of the andardized tests of disability. The Medical Outcomes rudy 36-Item Short-Form Health Survey (SF-36)36 is a m ultidimensional generic measure designed to assess both physical and mental health status. The SF-36 is a good choice for a baseline and can be complemented by a more patient population speCific disability questionnaire ~uch_ as .L . t e d relerence [' I'IS.t 1819.2S.3L31.38 ill e prov1'de d'lI1 t h e assocla . . nderstanding the relationships among physical impair­ ments, functional limitations, and disabilities is relevant to evaluation and treatment of a person seeking phYSical therapy services. In 2003, Rothstein and Echtemach pub­ .li.shed a revised algOrithm designed to meet the needs of contemporary practice. 39 They present a patient manage­ ment system that involves the patient in decision making and can be used to provide payers with better justification for in­ en-entions. Compatible with the Guide to Physical Thera­ ist Practice'sl patient management model and terms of the - blement model presented by Nagi,40 this algorithm calls the clinician to identifY the impairments, when appropri­ ; to examine how these impairments relate to functional ficits; and to examine whether interventions designed to 4IJleliorate or reduce impairments can result in changes in -unction and levels of disability. In addition, the revised ver­ non calls on the clinician to identify hypotheses that under· . interventions used for prevention. The reader is strongly ed to review this article in that it is believed that by ap­ _ing the hypothesis-oriented algorithm for clinicians II on individual patient basis, therapists will be ideally posi­ ned to apply evidence to patient care and to defend their terventions to colleagues and to third-party payers?9

me

Diagnosis ia211 0sis is the next element in the patient management el. Diagnosis is the process and end result of inform a­ n obtained in the examination and evaluation. The diag­ tic process includes analyzing the information obtained

15

DISPLAY 2-3

Definitions of Terms Cluster: A set of observations or data that frequently occur as a group for a single patient. Syndrome: An aggregate of signs and symptoms that characterize a given disease or condition. Diagnosis: A label encompassing a cluster of signs and symptoms commonly associated with a disorder, syndrome, or category of impairment, functional limitation, or disability. Adapted from American Physical Therapy Association. A guide to physical therapist practice. I: a description of patient management. Phys Ther

1995.75.'749-756.

in the examination and evaluation and organizing it into clusters, syndromes, or categories (see Display 2-3 for def­ inition of terms) to help determine the most appropriate intervention strategy for each patient The diagnostic pro­ cess includes the folloV\ring components;l • Obtaining a relevant history (i.e., examination) • Performing a systems review (i.e., examination) • Selecting and administering speCific tests and mea­ sures (i.e., examination) • Interpreting all data (i.e., evaluation) • Organizing all data into a cluster, syndrome, or cate­ gory (i.e., diagnosis) The end result of the diagnostic process is establishing a diagnosis. To reach an appropriate diagnosis, additional in­ formation may need to be obtained from other health care professionals. In the event that the diagnostic process does not )rield an identifiable cluster, syndrome, or category, in­ tervention may be gUided by the alleviation of impairments and functionai limitations. Caution should be taken in ran­ domly treating impairments not associated with functional outcome. The purpose of a diagnosis made by a physical therapist is not to identify all of the patient's impairments, but to focus on which impairments are related to the pa­ tient's functional limitations and therefore should be ad­ dressed by the physical therapist To ensure optimal pa­ tient care, the physical therapist may need to share the diagnosis determined from the physical therapy examina­ tion and evaluation process with other profeSSionals on the health care team. If the diagnostiC process reveals that the condition is outside of the therapist's knowledge, experi­ ence, or expertise, the patient should be referred to the ap­ propriate practitioner. Diagnosis in the physical therapy patient management model is synonymous with the term clinical classification and is not to be ~onfused with the term medical diagnosis. 41 Medical diagnosis is the identification of a patient's pathol­ ogy or disease by its signs, symptoms, and data coll~cted from tests ordered by the physician. Diagnosis establIshed by a physical therapist is related to the primary dysfunction toward which the physical therapist directs treatment 41 --43 The ability to diagnose clusters, syndromes, or categories can foster the development of efficient treatment interven­

16

Therapeutic Exercise Moving Toward Function

bons and facilitate reliable outcomes research to present to the pubHc. medical community, and third-party payers. For example, a common medical diagnosis of patients referred to outpatient physical therapy practices is low back pain, which is nothing more than a location of pain. If an out­ comes study Was performed that included all patients with the diagnosis oflow back pain in a given practice, the results would not shed ligl1t on the best approach for treating low back pain because of the diverse causes, stages and severity of the condition, and comorbidities involved. Subclassifica­ tion of patients based on diagnostic classification paradigms is necessary to provide more efficient patient management strategies aml more meaningful outcome data . Technologic advances (e .g., diagnos tic imaging) for identifying pathology have not necessaJily decreasecI the peliod in which symptoms resolve nor do they always guide physical therapy treatment. Medical diagnosis (e.g., hemi­ ated nucleus pu lpos\ls, spondylolisthesis) has not been shown to be helpful in direCtin~ successful rehabilitation of patients 'vvith low back pain. 4 . Identifying the patholosry should not be the goal of diagnosis made by a physical ther­ apist. The medical diagnOSiS , in most cases, does not pro­ vide the physical therapist with enough information to pro­ ceed ,;vith intervention. The physical th erapist's diagnosis is reached only after performing a thorough examination and evaluation combinecL jf Jlecessarv, v'Vith th e results of tests and measures ordered and pe/fornwd by professionals from· other disciplines and with the medical diagnosis. Physical therapy is in the early stages of developing im­ pairm ent-based, functional li mitation-based, ancI treat­ ment-basecI cIiagnostic classiflcations. After classifications are developed, much work regarding validity, reliability, and sensitivity of diagnostic classifications needs to be done. Formulation and develogment of a useful classifica­ tion design require the use of: • Measure ment theory and advanced stati~tical tech­ niques (i.e., facto r and cluster analyses) to validate clinical observations and systematize the compleXities of clinical findings. • Advanced technology that enables simultaneous col­ lection, storage, and repeated acqUisition of data that characterize multiple eleme nts of movement. Many leaders in the physical therapy community hope in the future to correlate effective and efficient treatment v'Vith the cunica] diagnosis made by physical therapists to estab­ lish more efficient ancI cost-effective outcomes 4 J .43,46-51 Only then can physical the rapists promote the efficacy of the profeSSion in today's responSibility-focused health care environmen t.

Prognosis and Plan of Care After a diagnosis has been es tablish ed, th e physica] thera­ pist determ ines the prognosis and develops the plan of care. Prognosis is the process of determining the level of optimal improvement that may be obtained from interven­ tion , and the amount of time reqUired to reach that level. l For example, an expected short-term outcome for an oth­ erwise healthy 65-year-old person after a hip fracture treated with open reduction and intemal fLxation may be

the ability to walk 300 feet with paltial weight bearing, us­ ing a walker, in 3 days; an expected long-term outcome may be the abi lity to walk independently without a gait devia­ tion in 12 to 16 weeks. The plan of care consists of statements that specify the interventions to be used and the proposed duration and frequency of the interventions that are required to reach the anticipated goals and expected outcomes 1 The plan of care is the culmination of the examination, diagnostic, and prognostic processes. The prognosis and plan of care should be based on the follm;ving factors: • The patient's health stat us, lisk factors , and response to previous interventions • The patient's safety, needs, and goals • The natural history and th e expected clinical course of the patholos,ry, impairment, or diagnosis • The results of the exam in ation , evaluation, and diag­ nostic processes To ensure the prognosiS and pian of care are based on the patient's safety, needs, and goals, the physical therapist should confer v'Vith the patient and establish patient goals ..'52 DUling this discussion , th e patient must be informed of th e diagnosis or prioritized impairment list if a diagnosis can­ not be developed. The patient should also be proVided v'Vith an explanation of tlle relationship between the diagnos is or impairments and the function al limitations and dis ability. This information can assist the patient in developing realis­ tic goals and understanding the purpose of th e selected in­ terven tions. Agreement between the patient and therapist on the long-term and short-term goals is imperative for successful treatment outcom es . When the physical thera­ pist determines that physical therapy intervention is un­ likely to be beneficial, the reasons should be discussed with the patient and other individuals concerned and docu­ mented in the medical record . To ensure the prognosiS and plan of care are based on the natural history and the expected clinical courses of the pathology, impairment, or diagnosis, the physical therapist must rely on textbooks, lectures from instructors, literature reviews, research articles, evidence-based clinical practice gUidelines, and clinical experience. 53 Straus SUCCinctly out­ lined the steps necessary to pract~ce evidence based patient management in her 1998 article:"" • Convert the need for information into clinically rele­ vant, answerable questions • Find, in tbe most efficient way, the best evidence with which to answer these questions (whether this evi­ dence comes from clinical examination, published re­ search, medical tests , or oth er sources) • CliticaUy apprais e the evidence for its validity (close­ ness to the tlllth) and usefulness (clinical appkabil­ ity) • Integrate the appraisal v'Vith clinical expertise and ap­ ply the results to clinical practice • Evaluate your performance. FollOWing th ese steps can assist the clinician in develop­ ing a sound prognosis and plan of ca re based on finding the best evidence available in a practical time frame.

Chapter 2: Patient Management

Intervention Intervention is defined as the purposeful and skilled in­ teraction of the physical therapist with the patient using various methods and techniques to prod lice changes in the patient's condition consistent with th e evaluation, diagno­ sis, and prognosis 1 Ongoing decisions regarding interven­ tion are contingent on the timely monitoring of the pa­ tient's r sponse and the progress made toward achieving outcomes. The three major types of intervention are listed in Display 2-4. This text focuses on one aspect of direct in­ te rvention (i.e., therapeutic exercise) and patient-related instruction as it relates to therapeutiC' xercise. The key to a successful intervention and patient out­ co me is to do the right thin gs well ..5.5 To determine the right t11ings, the physical therapist must have a thorough under­ tanding of the patient's disahlement process and sound clinical deCision-making skills.

Clinical Decision Making for Intervention T he physical therapist is educated and trained to effectively and effiCiently treat phYSiologiC and certain anatomic im­ pairments related to functional limitations and to arrive at desirable functional outcomes for the patient. In designing the plan of care, the physical therapist analyzes and inte­ grates the clinical implications of the severity, complexity, and acuity of pathology/pathophysiology, the impairments, the functional limitations, and disabilities. Recall that the ulti mate functional goal of physical therapy is the achieve­ ment of optimal movement and functioning. Physical ther­ apists generally develop treatment interventions with the in tention of restoring function and reducing disability. However, strictly impairment-based interventions often do "lot achieve functional goals because the focus may not be n the right impairment. Treating the "Right" Impairments

An important clinical decision in the patient management process is to determine the impairment that most closely re­ tes to a functional limitation or disability. Physical thera­ p' ts are often tempted to include impairments that do not _ rrelate in their intervention plan because they assume that :.he reduction of any or _all impairments leads directly to imTovement in function. 56 In reality, the treatment of impair­ ents can only lead to improvement in function if the im­ '1airrnents contribute to a functional hmitabon. - There is one instance, however, in which physical ther­ ists must treat impairments that do not contribute to an

DISPLAY 2.-4

Types of Physical Therapy Interventions Direct intervention (e.g., therapeutic exercise, manual therapy techniques, debridement. wound care) Patient-related instruction (e.g., education provided to the patient and other caregivers involved regarding the patient's condition, treatment plan, information and training in maintenance and prevention activities) Coordination, communication, and documentation (e.g., patient care conferences, record reviews, discharge planning)

17

identified functional limitation or disability. In this in­ stanc , an impairment may not correlate with a functional limitation or disahility, but if le ft: untreated. it may lead to future func tional lim itation. In this instance, the physical therapist may treat the impairment as a preventive mea­ sure. For example, a patient has been preSCribed a prone hip extension exercise to improve gluteal strellgth for treat­ ment of hip pain. However, wh ile the patient is extending the hip , his or her lumbar spine is moving into excessive ex­ tension . If the faulty movement pattern is [eft: untreated, low back pain may develop. E xe rcises need to be pre­ scribed to improve the stahility of the low back to prevent the possibility of future episodes of low back pain. If an impairment seems to be linked to a functional lim­ itation or disability, the therapist mllst question whether the impairment is amenable to physical therapy interven­ tion. To help determine the answer, the physical therapist should ask several questions: • \Vil! the pati ent henefit from the intervention (i.e., can treatment improve functioning or prevent func ­ tionalloss)? • Are there any possible negative effects of the treat­ ment (contraindications )? • What is the cost-benefit ratio? If the treatment cannot be justified, the physical thera­ pist should consider other options such as the fo llOWing: • D iscussing the decision to decline intelvention with the patient to ensure patient agreement and under­ standing of the decision • Referring the patient to an appropriate practitioner or resource • Assisting in modifying the environment in which the individual lives, goes to school, or works to ensure maximal performance despite the impairment, func­ tionallimitation, or disability • Teaching the individual to appropriately compensate for the impairment, functional limitation, or disability

If the impairment is amenab le to treatment, decide whether to treat the impairment, functional limitation , or both . For example, a 72-year-old man , after total knee re ­ placement, may present with weakness of the quadJiceps and reduced mobility of the knee. The therapi st may choose to treat the impairments with speCific exe rci se in­ struction to increase quadJiceps muscle performance and tibiofemoral joint mobility or to teach the patient the func­ tional task of sit to stand that can resolve the impairments and restore function to the patient's satisfaction. The added benefit of chOOSing to focus on function rather than on spe­ cific exercise is that patient compliance may improve, be­ cause incorporating function al exercise into daily life is eas ­ ier than finding time for speCific exercise. However, the impairments may be too profound to allow adequate per­ form ance duJing a functional activity. For example, if the quadJiceps strength in the previous example is less than fair, specific quadriceps strengthening may be necessary to achieve enough force or torque production to participate in a functional activity without compromising tl1e quality of movement. Caution must be applied in prescribing func­ tional activities prematurely to improve impairments.

18

Therapeutic Exercise Moving Toward Function

Selecting and Justifying Treatment Interventions

After a decision has been made to treat a specific im­ pairment or functional limitation, the next step is to select an appropriate treatment approach or combination of com­ plementary approaches (e.g., moist heat before joint mobi­ lization, which is followed by stretching and ends with a functional task that employs the new mobility). The clini­ cian must select and justifY the chosen intervention. Physical therapists may select an intervention from among the following possibilities: 1 • Therapeutic exercise (including aerobic condi tioning) • Functional training in self-care and home manage­ ment (including basic ADLs and instrumental ADLs ) • Functional training in community or work reintegra­ tion (including instrumental ADLs, work hardening, and work conditioning) • Manual therapy techniques (including mobilization and manipulation ) • Prescription, fabrication , and application of assistive, adaptive, supportive, and protective devices and equipment • Airway clearance techniques • Integumentary repair and protection techniques • Physical agpnts and mechanical modalities • Electrotherapeutic modalities Numerous patient factors must be taken into considera­ tion to determine which of the described interventions are correct. This information is obtained from the history and systems review (see Displays 2-1 and 2-2). An awareness of the physical environment for living, working, or participat­ ing in recreational activities to which the patient wishes to return is important in developing functional activities and achieving functional outcomes. For example, a successful outcome may not be reflected in increased strength in the physical therapy office by a hand-held dynamometer, but may be observed in the use of that strength in a functional manner in the patient's environment, such as walking up a flight of stairs with 20 pounds of groceries The process of selecting and justifying treatment inter­ vention must include knowledge of research literature and the ability to interpret the literature as reliable and valid. The most credible source of justification is based on rele­ vant research literature. Use caution when making deci­ sions based on theory of pathophysiologic mechanisms and expert opinion not substantiated by credible clinical evi­ dence. Knowledge of the literature combined with an ac­ cumulation of clinical experience facilitates the most in­ formed choice.

person, even when educating the patient is possible, can promote compliance by teaching the support person to in­ tervene in an appropriate manner and encouraging the dis­ play of appropriate attitudes toward the patient's functional limitations and disabilities. Patient-related instruction is critical to enhance com ­ pliance in follOwing through with interventions and pre­ venting future disability. Imparting your knowledge of the patient's disablement process enables the patient to gain confidence in your skills, which fUliher enhances compli­ ance. Patient-related instruction may include the follOWing: • Education pertaining to the • pathologic process and impairments contributing to functional limitation and disability; • the prognosiS; • and the purposes and potential compli cation s of the intervf'ntion • Instruction and assistance in making appropriate de­ cisions about management of the condition during the ADLs (e.g., work station ergonomiC modifica­ tions, altered movement patterns and body mechan­ ics, altered sleep postures) • Imtruction and assistance in implementing interven­ tions under the direction of the physical therapist (e.g., training a support person in techniques of ther­ apeutic exercise in the event that cognitive, phYSical, or resource status of the patient requires assis tance to perform a home management program) Patient-related instruction confers several benefits: • Increased patient, Significant other, family, and care­ giver knowledge about the patient's condition, prog­ nosis, and management

Patient-Related Instruction Patient-related instruction is the process of impaliing information and developing skills to promote indepen­ denc(' and to allow care to continue after discharge 1 It must be an integral part of any physical therapy interven­ tion (Fig. 2-3 ) and will be featured in this text to enhance the t)wrapeutic exercise intervention. When patient education is not possible (e.g., the patient is an infant, comatose, or has a head injury), educating fam­ ily members, Significant others, friends, or other caregivers is essential. Patient-related instruction offered to a support

FIGURE 2-3. Patient-related instruction is an integral part of physical therapy intervention. By helping the patient understand his impairment and functional limitations. the clinician promotes patient compl iance with the therape utic intervention program. In addition. patient satisfaction is pro­ moted by taking the time to educate the patient regardi ng the cause(s) of his cond ition, self-management techniques. and prevention

Chapter 2: Patient Management • Acquisition of behaviors that foster healthy habits, wellness, and prevention • Improved levels of performance in employment, recreational, and sports activities • Improved physical function , health status, and sense of well-being • Improved safety for the patient, sign ificant others, family, and caregivers • Reduced disability, secondary conditions , and recurrence • Enhanced decision making about the use of health care resources by the patient, significant others, fam­ ily, or caregivers • Decreased service use and improved cost containment Patient-related instruction represents the first and most important step toward directing responsibility for treat­ ment outcome from the phYSical therapist to the patient. A thorough understanding of the individual's disablement process and the factors that may impede improved func­ tional outcome are necessary to proviJe comprehensive and personalized patient-related instruction . The success­ ful practitioner is one who is skillful in the delivery of an ac­ tive treatment approach based on treatment speCific to the individual's disablement profile and on eJ ucation that places the patient (or caregiver) in the position of taking re­ sponsibility for the outcome.

Outcome As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions on the fol­ lOWing domains: l • Pathology/pathophysiology • Impairments • Functional limitations • Disabilities • Risk reduction/prevention • Health, wellness, and fitness • Societal resources • Patient/client satisfaction An outcome is considered successful when the follOWing conditions are met: • Physical function is improved or maintained when­ ever pOSSible. • Functional decline is minimized or slowed when the status quo cannot be maintained. • The patient is satisfied. At each step of the patient management process, the physical therapist considers the possible patient outcomes. This ongoing measurement of patient outcomes is based on the examination and evaluation of impairments , functional status, and level of disability. To evaluate the effectiveness of the intervention, the physical therapist must select crite­ lia to be tested (e.g. , impairments , functional limitations) and interpret the results of the examination. Outcomes can

19

be measured through outcome analysis. This is a systematic examination of patient outcomes in relation to selected pa­ tient variables (e.g., age, sex, diagnosis, interventions, pa­ tient satisfaction). It can be part of a quality assurance pro­ gram, used for economic analysis of a practice, or used to demonstrate efficacy of intervention. Although positive outcomes are not synonymous with improved impairment measures , rneasurement of impair­ ments and functional status should be performed to deter­ mine the efficacy of the intervention plan. By measuring both variables , the therapist can determine whether changes in the im,gairment are associated with changes in functlonal status,'>J If functlOnal status has not changed, consider modifying the intervention plan. Modification of intervention is based on the status relative to the expected outcome and the rate of progress. Modification of an inter­ vention is also based on the follOwing considerations : • Medical safety • Patient comfort • Pati e nt's level of independence with the interven ­ tion (especially related to therapeutic exercise inter­ vention) • Effect of the intervention on the impairments and functional outcome • New or altered symptoms due to interve ntion by other health care providers • Patient finances, environment, and schedule con­ straints The intervention may be modified by one of the follow­ ing actions: • Increasing or decreaSing the dosage of the interven­ tion, espeCially in the case of therapeutic exercise in­ tervention (see the section on exercise modification in this chapter) • Treating different impairments • Changing the focus to functional limitations • Consulting or referring to a more e>"'Perienced physi­ cal therapist • Referring the patient to a more appropriate health care prOvider • Improving physical therapy techniques , verbal cues, and teaching skills Prudent clinical reasoning assists the clinician in deter­ mining the need for modification and the best adjustments to implement. In determining and implementing revised goals and interventions, the clinician uses the additional data gathered from the re-evaluation. This re-evaluation and modification process continues until the decision to stop treatment is reached. Physical therapists have a responsibility to demonstrate to patients and third-party payers that physical therapy is efficient , cost effective, and prOvides patient satisfaction. In daily practice, physical therapists should adhere to the same principles of measurement used in research . Changes should be carefully documented in an effOlt to demonstrate that physical therapy intervention is related to successful outcomes in an efficient and cost-effective manner.

20

Therapeutic Exercise Moving Toward Function

DISPLAY 2-5

DISPLAY 2-6

Patient Management Conceots

Clinical Decision-Making Tips for Patient Management

• Develop an examination or evaluation schema pertinent to the patient. Diagnose the patient's impairments, functional limitations, and disabilities. Develop a prognosis based on the patient's individual disablement process. Develop a plan of care designed to improve function (i.e., the right things). Apply appropriate judgment and motor skills to provide the appropriate intervention. Continually use clinical reasoning to modify the intervention as needed for a positive outcome.

In the current health care environment, physical thera­ pists are faced with the challenge of practicing in an in­ creasingly competitive marketplace. As marketplace com­ petition continues to grow, patient satisfaction with physical therapy is emerging as an outcome variable of crit­ ical importance. The results of one study show that patient satisfaction with care is most strongly correlate_~ with the quality of patient-care provider interactions."1 This in­ cludes the care provider spending adequate time \\lith the patient, demonstrating strong listening and communica­ tion skills, and offering a clear explanation of treatment and prevention strategies. Successful patient management entails many aspects of clinician and patienUclient interaction. Display 2-5 sum­ marizes patient management concepts.

CLINICAL DECISION MAKING At each juncture in the patient management model, clini­ cal decisions are made. Appropriate decisions are crucial for a successful outcome. However, the clinical reasoning process involved in patient management presents the greatest challenge to the physical therapiSt. The following aspects are found to be most difficult in the clinical deci­ sion making process: • Organization of evaluation findings into a diagnosis • Development of a prognOSiS based on the patient's functional limitations and disabilities • Development of realistic patient-based goals • Development and implemelltation of an intervention that is effective and efficient Display 2-6 summarizes clinical deCiSion-making tips in relation to patient management to help the physical thera­ pist address some of these challenges. The effectiveness of clinical decision making is based on obtaining pertinent data. The physical therapist must possess • Knowledge about what is pertinent • The skill to obtain the data • The ability to store, record, evaluate, relate, and in­ terpret the data. These actions require knowledge of the disablement process; clinical experience in treating impairments and

Examination: Prioritize the problems to be assessed and the tests and measures to be implemented. Evaluation: Consider and analyze all examination findings for relationships, including the progression and stages of the symptoms, diagnostic findings by other health care professionals, comorbidities, medical history, and treatment or medications received. Diagnosis: Segregate findings into clusters of symptoms and signs by common causes, mechanisms, and effects. Prognosis and Plan of Care: Develop long-term and short­ term goals based on patient safety, needs, and goals and on information regarding the natural history and expected clinical courses ofthe pathology, impairment, or diagnosis. InterventIOn: Determine whether impairments correlate with a functional limitation or disability and are amenable to physical therapy treatment. Select and justify a method of intervention. The most credible source of justification is based on relevant research literature. Outcome: Measure the success ofthe intervention plan according to functional gain and make appropriate modifications when necessary.

functional limitations; and disciplined, systematic thought processes. Common to those who strive to excel in clinical decision making are the following characteristics: • Wide range of knowledge • Ongoing acquisition of knowledge • Need for order or a plan of action • Questioning unproven conventional solutions • Self-discipline and persistence in work Information regarding clinical decision making and the process involved warrant their own text. However, this text strives to include theoretic information and pertinent is­ sues related to clinical decision making. This information empowers the physical therapist with some of the neces­ sary tools to make appropriate clinical decisions regarding the design and application of treatment plans.

THERAPEUTIC EXERCISE INTERVENTION Of the three components of physical therapy intervention (see Display 2-4), this text presents information regarding the direct inte rvention of therapeutic exercise and patient­ related instruction associated with therapeutic exercise in­ tervention. After a thorough examination and evaluation has been performed; a diagnosis and prognOSiS have been devel­ oped; and the clinician understands the relationships be­ tween the pathology, impairments, functional limitations, and disability, a plan of care is determined through the clin­ ical deCiSion-making process. Therapeutic exercise may be the basis of the intervention or may be one component of the intervention, but it should be included to some extent in all patient care plans. Therapeutic exercise includes ac­ tivities and techniques to improve physical function and

Chapter 2: Patient Management health status resulting from impa.irments by identifying specific performance goals that allow a patient to achieve a higher functional level in the home , school, workplace, or community. It also incorporates activities to allow well clients to improve or maintain their health or performance status for work, recreation, or sports and prevent or mini­ mize future potential functional loss or health problems. To develop an efficient, effective therapeutic exercise intervention, consider these variables: • Which elements of the movement system (defined subsequently) need to be addressed to restore func­ tion? • Which activities or techniques are chosen to achieve a functional outcome, including the sequence within a given exercise session and the sequence of gradation in the total plan of care? • \Vhat is the purpose of each specific activity or tech­ nique chosen? • What are the posture, mode, and movement for each activity or technique? • What are the dosage parameters for each activity or technique?

21

DOSAGE Type of contraction Intensity Speed Duration Frequency Sequence Environment Feedback

Posture

Mode

The follOwing section presents a therapeutic exercise in­ tervention model to assist in organizing all the details neces­ sary to prescribe an effective, efficie nt exercise prescription. Movement

Therapeutic Exercise Intervention Model A three-dimensional model has been developed to assist the clinician in the clinical decision-making process re­ garding exercise prescription (Fig. 2-4). Three axes are used to visualize three components of exercise prescription and their relationships: 1. Elements of the movement system as they relate to the purpose of each activity or technique 2. The specific activity or technique chosen 3. The specific dosage

Elements of the Movement System To prescribe the appropriate exercise, factors regarding the patient's disability profile must be considered. The most critical factor is the patient's functional status. Each exercise prescription has one common goal: to restore functional movement as best as possible and prevent or minimize functional loss in the future. Sahrmann describes movement as a system that is made up of several elements, each of which has a unique basic function necessary for the production and regulation of movement. 5S The optimal actions and interactions of the multiple anatomic , phYSiologic, and psychologic systems involved in movement must be considered. Ideal move­ ment can be thought of as the result of a complex interac­ tion of several elements of the movement system as defined by Sahnnann 58 and modified for the purposes of this model:

• S-upport element: the functional status of the cardiac, pulmonary, and metabolic syste ms. These systems play an indirect role in that they do not produce mo­ tion of the segments, but provide substrates and

ACTIVITY FIGURE 2-4. Therapeutic exercise intervention model. Note the three­ dimensional model indicating the relationship between elements of the movement system, activity, and dosage.

metabolic support required to maintain the viability of the other systems. Examples of components in­ cluded in this element would be cardiovascular status, breathing patterns, and hormonal factors . • Base eleme nt: the functional status of the muscular and skeletal systems. This element provides the basis for movement, including components such as range of motion, extensibility/stiffness properties of muscle, fascia, and periarticular tissues; joint mobility and in­ tegrity, muscle performance, and muscle length-ten­ sion properties. • Modulator element. the phYSiologic status of the neu­ romuscular system. This element is particularly re­ lated to motor fUIlction, including components such as patterns and timing of muscle recruitment and feed-forward and feedback systems . • Bio1Tlechanical element: the functional status of static and dynam iC kinetics and kinematics. The biome­ chanical element is an interface between motor con­ trol and musculoskeletal function , the reby affecting the pattern of muscle use and the shape of bones and jOints. Components of the biornechanical ele ment in­ clude static forces affecting alignment and muscle re­

22

Therapeutic Exercise Moving Toward Function cruitment, and dynamic forces affecting arthrokinet­ ics, osteokinetics, and kinematics. • Cognitive or affective element: the functional status of the psychologic system as it is related to movement. Components of this element include learning ability, compliance, motivation, and emotional status.

(Note: The cognitive element is not an original element of the movement system as defined by Sahrmann. 58 ) The elements of the movement system are along the hor­ izontal axis of the therapeutic exercise intervention model (see Fig. 2-4). The diagnostic process can determine the im­ pairments that are related to the patient's functionallimita­ tions and disability. To begin plann.ing the therapeutic exer­ cise intervention, the impairments should first be related to the elements of the movement system. This process not only illustrates the complex interaction of the elements of the movement system, but also guides the clinician toward the most appropriate activities ot techniques, the sequence of ex­ ercise, and the specific dosage to treat the impairments re­ lated to the functional limitations and disability. For example, a person with knee pain with a posture impairment of genu valgus will require orthotic intervention to correct the biome­ chanical element before muscle performance (base element) or motor control (modulator element) training. Changing the alignment at the knee is prerequisite to effective base or mod­ ulator element training. It may then be decided that muscle performance training is prerequisite to motor control train­ ing due to the fact that the patient's strength, power, or en­ durance are below functional levels. Muscle performance dosage parameters are different from motor control dosage parameters (See Dosage in a subsequent section of this chap­ ter). Understanding the sequence of intervention based on a prioritization of the elements of the movement system, and that dosage parameters are different for the different ele­ ments of the movement system, can assist in organizing the complex data collected during the examination. After evaluating a patient, it may be apparent that one, a few, or all elements of the movement system are involved. Most often, the interaction of the elements is critical, but one or two elements usually are pivotal to effect change. First, determine which element(s ) is/are involved to choose the appropriate activity or technique, the proper dosage related to the element for which the exercise is pre­ scribed, and in what order the exercises should be pre­ scribed to be most efficient at restoring normal movement. The follOwing simplified case is prOVided for a detailed ex­ ample of this clinical deciSion-making sequence:

FIGURE 2-5. Thoracic kyphosis with excessive scapular anterior tilt.

fails to posterior tilt during upper extremity flexion (Fig. 2­ 6). As a result, the glenohumeral joint mechanically im­ pinges under the acromion process, and tissues in the sub­ acromial space (e.g., bursa, biceps tendon , rotator cuff tendons ) undergo microtrauma resulting in pain (Le. , im­ pairment), inflammation (i.e., pathology), and the inability

History

A 42-year-old female graphiC deSigner presents with a diagnosis of impingement syndrome of the shoulder. She spends a large part of her day at a monitor creating design documents. She has two children ages 1 and 3. She likes to garden and cook. A functional limitation is an inability to raise the arm to groom her hair or lift her small children without pain.

'­

/

Evaluation

A pivotal impairment is determined to be a thoracic kyphosis that results in the scapula resting in an excessive anterior tilt (Fig. 2-.5). The scapula, resting in anterior tilt,

FIGURE 2-6. Lack of scapular posterior tilt leads to glenohumeral im­

pingement.

Chapter 2: Patient Management

23

to raise the arm 'without pain (i.e., fUIlctionallimitation). If left untreated, loss of mobility of the upper extremity may ensue, further affecting function and potentially leading to disability (e.g., inability to pick up children, inability to per­ form work-related duties , inability to participate in desired recreational activities ). Impairments can be listed and categorized by the ele­ ments of the movement system, as exhibited in Display 2-7. As can be seen from this example, different impainnents are correlated with each element of the movement system. A specific exercise can be prescribed to address each im­ pairment associated with an element of the movement sys­ tem (e.g. , stretching the pectoralis minor to address the base element). Most often, the interaction of elements is critical; therefore, one exercise may address numerous ele­ ments of the movement system. For example, wall slides (Fig. 2-7) can improve several features: • Extensibility of the pectoralis minor (i.e., base element) • Muscle performance (i.e., base element) and recruit­ ment (i.e., modulator element) of lower trapezius • Thoracic extension mobility to reduce th e thoracic kyphoSiS (i.e., biomechanical element ) When instructing a patient in the performance of this exercise, provide verbal , visual, or tactile feedback to focus on the correlating ele ment of the movement system, or prOvide instruction to the patient regarding the interaction of elements. For example, tactile feedback into the lower trapezius during a speCific exercise (See Self-Management 26-2: Facelying Arm Lifts in Chapter 26 ) can assist in re­ cruitment (modulator element). The sequence in which each exercise is presclibed is based on prioritizing which elements are pivotal to restoring function and which ele­ ments must be improved for other elements to follow. For example, it may be decided that the patient needs to take measures to improve her emotional status (i.e., cognitive/affective element) to assist in addressing the slumped posture that correlates with sadness, and combine this vvith exercise to improve postural habits (i.e. , biome­ ch anical element), before any other intervention. DISPLAY 2·7

Elements of the Movement System Related to Impairments Support element impairment: Using accessory muscles of respiration versus diaphragm for breathing pattern, potentially leading to overuse and shortening of pectoralis minor • Base element impairment: Short pectora lis minor and short head of biceps pulling coracoid process anterior and inferior, lengthened and weak lower trapezius not providing sufficient counterforce • Modulator element impairment: Reduced recruitment of lower trapezius and serratus anterior • Biomechanical element impairment: Thoracic kyphosis contributing to the anterior tilt of scapula Cognitive and affective element impairment: Patient is clinically depressed, and the physical manifestation is a slumped posture contributing to the thoracic kyphosis. a

FIGURE 2-7. This exercise illustrates a patient performing a wall slide. The patient moves from the position shown here to the end position of the shoulders in full elevation. Note the arms are positioned in the scapular plane, slightly fONvard of the wall. Attempts should be made to prescribe exercise that will address the complex interaction of the elements of the movement system. For example, to restore normal shoul­ der girdle movement, diaphragmatic breathing (i.e. , sup­ port element) may be pivotal to reduce the activity of the pectoralis minor (modulator element), improve thoracic spine alignment (biomechanical element), and increase thoracic spine mobility (base element). Another example is to design an exercise that will concurrently stretch the pec­ toralis minor and strengthen (in the shortened range ) the lower trapezius (j.e., base element) (Fig. 2-7). Optimizing the recruitment strategy (i.e., modulator element) during speCific exercise and during functional movement is always necessary to achieve the best functional outcome. Display 2-8 summarizes the factors to consider before determining the relevant and prioritized list of the ele­ ments of the movement system.

DISPLAY 2·8

Considerations in Clinical Decision Making Relevant to the Elements of the Movement System • Identify the functional limitations and related impairments to be treated . • Relate functional limitations and impairments to be treated with the appropriate elements of the movement system. • Prioritize elements of the movement system.

24

Therapeutic Exercise Moving Toward Function

Activity or Technique Along the vertical axis is the activity or technique chosen to ultimately achieve the functional goal. Therapeutic exer­ cise activities and techniques include the following: • Stretching (passive and active) • ROM exercises (e.g. , active assisted ROM , active ROM) • Strengthening (e.g. , active assistive, active, and resis­ tive exercise using manual resistan ce; pulleys, weights, hydraulics , elastics, robotics; mechanical or electromechanical devices) • NeuromusculaF re-education • Developmental activities • Breathing exercises • Aerobic or muscular enduran ce activities using cy­ clf's , treadmills , steppers, pools, manual resistance:' , pull eys, wei'ghts, hydraulics, elastics, robotics , and mecbanical or electromechanical de\,1ces • Ar]uatic exercise • Gait training • Balance and coordination training • Posture awareness training • Body mechanics and ergonomics training • Movement training To be successful in chOOSing the proper activity or tech­ nique , first determine the elpment of the lIlovcment sys­ tem associated vvith the impairment or fum:tional limita­ tion. Each element is associated with spcciflc therapeutic exercise interventions. For example, the biomechanical el­ ement is associated with posture awareness training, the modulator element is associated with speCific neurOITHlSCU­ lar re-education, the support element is associated vvith breathing exercises and aerobic endurance activities , and the base element is associated with stretching and strengthening activi ties. After identifYing the elements of the movement system , the physiolOgiC status of the impairments or functional lim ­ itations must be considered. This information assists in de­ termining the activity or technique, posture, movement, and mode parameters. For example, if muscle performance (i.e. , base element ) is pivotal to a successful functional out­ come, the chosen activity or technique may depend on the force or torque capahility of the affected muscles. If the force or torque capability is)ess than fair in muscle strength, as determined by Kendall,,,g a gravity-lessened position ac­ tive ROM activity or an against-gravity active assisted tech­ nique may be chosen. Another example may be related to reduced muscle recru itment from prolonged immobiliza­ tion (i.e., modubtor element) or muscle amnesia. If the abil­ ity to recruit is poor, a graVity-lessened active ROM activity may be chosen with tactil e feedback or against-gravity ac­ tive HO M with neuromuscular electrical stimulation as an adjunctive intervention (discussed later in this chapter), both of which are chosen to augment muscle re-education. Stage of Movement Control

Another factor to consider in chOOSing an activity is the stage of movement control (Display 2-9). Mobility is defined as the presence of a functional range through which to move and the ability to initiate and sustain active movement

DISPLAV2-9

Stages of Movement Control Mobility: A functional range through which to move and the ability to sustain active movementthrough the range Stability: The ability to provide a stable foundation from which to move Controlled mobility: The ability to move within joints and between limbs following the optimal path of instant center of rotation (PICR) Skill: The ability to maintain consistency in performing functional tasks with economy of effort

through the range .50 A person with musculoskeletal dys­ func tion may exhibit impairments in either or both parame­ ters of mobility. For example, after total knee arthroplasty, a person may e>:perience passive mobility restrictions caused by pain , swelling, and soft-tissue stiffiless or shOliness and have decreased ability to initiate knee motion as a result of reduced muscle force or torque production or reduced re­ cmitment capability. The cause of the mobility restriction must be determined on a case-hy-case basis to determine the most appropliate exercise intervention (see Chapter 7). Stability in the construct of stages of movement control is defined as the ability to prOvide a stable foundation from which to move 60 A precursor to achieving the stability nec­ essary for lll ove ment, or dynamiC stability, is optimal pos­ ture. The inruvidualmust be able to maintain optimal pos­ ture without a load before optimal posture can be maintain ed during movement of a limb. Mobility and sta­ bilityare not mutually exclusive. Achieving mobility before addreSSing stability is unnecessary; the two stages of move­ ment control can occur concurrently. For example, as mo­ bility after total knee arthroplasty is achieved paSSively, ac­ tive motion must be prescribed. For optimal active motion, the knee requires a stable proximal base from which to move (i.e ., pelvis and trunk) and distal base for weight bearing (i.e. , foot and ankle). Stability must be achieved at these regions for optimal active motion to take place. Controlled mobility is defined as the ability to move within joints and between limbs, follOwing the optimal path of instant center of rotation (PICR) (See Chapter 9 for clar­ ity on the definition of the PICR. ) This requires proper re­ cruitment of synergists that perform movement (i.e., sta­ bility within a segment during movement ) and proper length and recruitment, if necessary, of muscles providing a stable foundation for movement. The previous example would progress from exercises improving knee mobility, as well as pelvic-trunk and foot-ankle stability, to functional movement patterns. To walk, th e knee must flex and ex­ tend at proper stages in the gait cycle. The trunk, pelVis, ankle, and foot must move into proper position at each stage of the gait cycle and provide proximal and distal sta­ bility for optimal knee function. The activity may involve the swing phase of gait, which requires a stable pelvis from which to swing the lower limb (Fig. 2-8A ), or the stance phase of gait (Fig. 2-8B) , which requires a stable foot for optima! knee loading. The final progression in the stages of movement con­ trol is skill. Skill implies consistency in performing func­

Chapter 2: Patient Management

A

25

B

FIGURE 2-8. (A) Swing phase of gait requires a stable pelvis. (B) Stance phase of gait requires a stable foot.

tional tasks with economy of effort 61 Skill in the upper extremities most often requires freedom of movement in space in a coordinated manner within and between the hand, wrist, forearm, elbow, shoulder girdle, trunk, and pelvis (e.g., grasping a cabinet door) (Fig. 2-9). Occasion­ ally, closed chain (weight-bearing) movements are re­ quired in the upper extremity (e.g. , gymnast performing a handstand on the balance beam) (Fig. 2-10). Skill in the lower extremities requires coordination of open chain (non-weight-bearing) movements (e.g., svving leg in kick­ ing a soccer ball) (Fig. 2-11) and closed chain movements (e.g., stance leg in kicking a soccer ball) within and be­ tween the foot, ankle , tibia, femur, pelvis, and trunk for movement on varied surfaces. For total body movement to be optimal, coordinated movement must occur vvithin and between each segment involved in the movement (e.g., the tennis serve) (Fig. 2-12). Commonly, patients are asked to perform skill-level ac­ tivities without first developing proper foundations for

functional movement control. Conversely, patients may be prescribed exercises developing the other stages of move­ ment control without finalizing the intervention with skill­ level activities during functional movements. Skill is a nec­ essary stage of movement control despite the prognosis of the patient (e.g" walk 10 feet vvith a walker versus run a marathon ), which must be worked toward by achieving op­ timal function at each prior stage of movement control. In summary, an activity can be as simple as performing a dynamlc knee extension movement in supine (i.e" mobil-

URE 2-9. Grasping a cabinet door requires freedom of movement in _ in a coordinated manner within and between the joints of the upper -"mity. trunk, and pelvis.

FIGURE 2-11. Skill in lower extremities requires coordination of open and closed chain movement. The swing leg performs an open chain movement as the stance leg performs a closed chain movement.

FIGURE 2-10. A gymnast performing on the balance beam represents an upper extremity closed chain movement.

26

Therapeutic Exercise: Moving Toward Function

narrow base of support) need to be determined. Included in this information is proper hand placement and angle of ap­ plication of the force if the activity is performed manually. When using elastics, pulleys, mechanical, or electrome­ chanical devices , proper equipment placement and angle of application of force must be determined. These descrip­ tions must be included in the heginning and ending posture information. The movement needs to be specifically defined (e.g. , paltial squat through a 30-degree arc, unilateral arm raise through full-range , proprioceptive ne uromuscular fa­ cilitation diagonal of th e upper extremity to chest height). The quality of performance of the exercise is critical to the outcome (i.e. , modulator element of the movement sys­ tem ) In relation to base or modulator elements , an obvious but often neglected concept is that a mllsde cannot be strengthened if it is not recruited. Even if the correct ac­ tivity is ch osen , and the mode, posture, and movement are carefully selected, proper execution of the exercise is nec­ essary to ensure a successful outcome. For example, hip abduction while sidelying can be performed ,vith at least five different recruitment patterns (Fig. 2-13 and Display 2_11 )sa Attention to preciSion of movement and recmit­ ment patterns is vital and always must be promoted to the best of the illdivi dual's capabi lity. Modify the exercise to achieve the best performance pOSSible.

FIGURE 2-12. A tennis serve represents a total body movement, whi ch is coordinated within and between each segment involved in the movement ity) or as difficult as an integrated movement pattern such as walking on an uneven surface (i.e., skill). An under­ standing of th e level of involvement of the support, base, modulator, and cognitive/affective elements of the move­ ment system help to determine the complexity or the task and the stage of movement control in which to intervene. Display 2-10 summ arizes the factors to consider before de­ termining the activity or technique. Mode, Posture, and Movement After choosing the activity or technique , further break­ down of the activity is necessalY for precise prescription. The mode, which is the method of performing the activity or technique, must be chosen. For example, if aerobic exer­ cise is chosen, the mode can be cycling, swimming, walking, or a similar activity. If strengthelling is chosen, the mode can be weights, manual resistance, or active assisted exer­ cise. If ba1an ce and coordination training is chosen, the mode can be a balance board, balance beam, or computer­ ized balance device. The initial and ending postures (e.g. , standing, sitting, supine, prone, wide base of support,

Dosage The third axis is related to dosage parameters (see Fig. 2­ 4). When determining dosage, anatomic sites, and the physiologic status of the affected elements of the move­ ment system , the patient's learning capability must be con­ sidered. The anatom ic site comprises the speCific tissues involved (e.g., ligament, musdc , capsule, faSCia). The phys­ iologiC status of the affected elements of the movement system includes the severity of the tissue damage (e.g., par­ tial versus complete tear) , the irritability of the condition (e.g., easily provoked and difficult to resolve versus difficult to provoke and easy to resolve), the nature of the condition (e.g., chemical versus mechanical mediated pain), and the stage of the condition (e.g. , acute, subacute, chronic). For pati ents recovering from an injury, the dosage parameters are modified aceording to the tissues involved and the prin­ ciples of tissue healing. In the early stages of healing, tis-

DISPLAY 2·10

Considerations Involved in Clinical Decision Making Related to Choice of Activity or Techniaue • Determine the element of the movement system related to the impairment or functional limitation to be treated. • Consider the physiologic status of the movement system. Determine the stage of movement control.

FIGURE 2-13. Hip abduction in the sidelying position. Optimal execution is with the pelvis and femur in the frontal plane and the movement of hip abduction occurring in the fro nta l pla ne. This requ ires recruitment of al l of the hip abductors in synergy.

Chapter 2: Patient Management

DISPLAY 211

Variations in Performing Side lying Hip Abduction 1. Sidelying with pelvis in frontal plane and abducting the hip with all of hip abductors in synergy (see Fig. 2-13) 2. Sidelying with pelvis rotated backward and femur rotated laterally, causing the movement to move toward the sagittal plane and resulting in recruitment of hip flexors 3. Sidelying with pelvis in frontal plane with femur rotated

medially and flexed, resulting in recruitment of tensor

fascia lata

4. Sidelying with pelvis in frontal plane, but movement is at the pelvis (hip hike). resulting in recruitment of lateral trunk muscles 5. Sidelying with pelvis in frontal plane, but movement is

abduction of opposite hip, resulting in recruitment of

opposite hip abductors

sues tolerate low-intensity passive or active activities, but in the later stages, tissues tolerate more aggressive resistive activities (see Chapter 10). The patient's ability to learn , or learning capability, in­ fluences the schedule and the amount of reinforcement , feedback, or sensory input needed to perform the activity successfully. If a patient has difficulty learning a motor task, the dosage may be altered according to the principles of learning (see Chapter 3). For example, various forms of feedback (e.g., verbal, visual, tactile) combined with nu­ merous , lOW-intensity repetitions may be required initially for optimal performance of an activity. As skill is acquired, feedback and repetitions may be reduced and a more com ­ plex activity eventually may be prescribed. After the anatomic and phYSiologic elements and the learning capabilities are understood, specific dosage pa­ rameters can be determined. Display 2-1 2 summarizes the factors to consider before determining dosage parameters. Parameters related to dosage include • Type of contraction (i.e. , eccentric , concentric, iso­ metric, dynamic, or isokinetic) • Intensity (i.e., amount of assistance or resistance re­ quired ) • Speed of the activity or technique • Duration tolerated (i.e ., number of repetitions or number of sets, particularly related to endurance and stretching activities) • Frequency of exercise (i.e., number of exercise ses­ sions in a given period)

DISPLAY 2-12

Considerations Involved in Clinical Decision Making Related to Choice of Dosage Parameters Determine the anatomic sites involved in the current

condition.

Determine the physiologic status of the tissue(s) involved.

Consider the patient's learning capability.

27

• Sequencing of the exercise prescription (i.e., stretch before strengthen, low intensity warm-up before moderate or intense aerobic activity, or Single jOint uniplanar movement before multijoint mu ltiplanar movement) • Environment in which the exercise is performed (i.e., quiet, controlled environment of a private room in a physical therapy clinic versus a loud, chaotic, uncon­ trolled, outside environment ) • Amount of feedback necessary for optim al perfor­ mance of the activity

Summary In sum mary. numerouS variables in this model must be considered in prescribing an exercise, and variables often overlap (e.g. , learning capabilities under dosage is similar to stages of movement control under activity, vvhich is sim­ ilar to modulator and cognitive/affective elements for the movement sys tem ). The task of organizing this data can be overwhelming. The three-dimensional model may help to visualize the relationships among the components of exer­ cise prescription. It is the goal of this text that this model assists in organizing the data necessary to develop an effec­ tive, efficient therapeutic exercise intervention.

Exercise Modification When the desired patient outcome is not met in a reason­ able time frame , modification is based on evaluating how the following possibilities affeCt the lack of progress achieved vlith the therapeutic exercise intervention: • The physical therapist may choose the wrong activity, dosage of exercise, or both. • The physical therapist may not be able to effectively implement or teach the exercise. • The patient may not be able to learn the exercise well enough or misunderstand or forget the instructions or dosage. • The patient may not follow through with the pre­ sCliption. To be most effective and efficient with exercise pre­ scription, constant re-exam ination and evaluation of changes in impairments and function are required. The ex­ ercises must be continually modified to increase or de­ crease the difficulty to ensure continual progress is being made 'Nith minimal setbacks. Numerous parameters can be modified to render an exercise more or less difficult. Four general parameters can be varied in an exercise prescrip­ tion: biomechanical, phYSiologic, neuromuscular, and cog­ nitive or affective. Display 2-13 outlines parameters that can be varied and provides examples for various types of ex­ ercise. Th e reader is strongly encouraged to review Display 2-13 before continuing further in the text. If you've paid careful attention to these basic methods and principles, but the patient is not responding to the in­ tervention, you must realize that all has been done within the scope of your therapeutic knowledge, expertise, and ex­ perience and that the patient should be discharged if you feel maximum improvement has been attained. If not, the

28

Therapeutic Exercise Moving Toward Fu nction

DISPLAY 213

Exercise Modification Parameters Biomechanical Stability • Size of base of su pport Example : It is more difficult to balance with feet close together or in tandem than feet wide apart, and in sidelying rather than supine. Height of center of mass Example: Sit-ups may be done first with hands at the sides, progressed to forearms folded across the chest, progressed to hands clasped behind the neck. This upward shift of arm weight moves the center of mass toward the head by stages, progressively increasing the difficulty of the exercise. • Support surface Example: The stability of the support surface can be progressed from a static or stable surface to a mobile base, such as foam, a balance board, or a trampoline. 8 .ternal Load • Magnitude Example: Increased magnitude of resistance alters the weight of the segment and thereby increases the difficulty of movement; however, it may also increase feedback from muscle and joint receptors and enhance the response. Gravitational forces Example: The force of gravity on a segment is maximal when the part is horizontal and diminishes as it moves toward the vertical. Knee flexion in prone is more difficult at the beginning of the movement and becomes easier as the motion progresses. Hip abduction is gravity reduced in prone or standing and against gravity in sidelying. Speed (see Chapter 5) Example: A medium rate is usually easier than very

rapid or very slow.

• Length of lever arm Example: In prone exercises for scapular adductors (middle and lower trapezius)' raising the arms with the elbows flexed gives less resistance than if the arms are nearly or completely straight. Point and ang le of application of manual or mechanical resistance Example: A muscle pulling at or near a right angle to the long axis of the segment exerts its force more effectively than when its angle of pull is very small. Number of Segments Involved • Fewer segments may not always be easier than more segments, especially as in fine motor control. Length of Muscle A muscle is better able to exert active tension when it is in a lengthened state than after it has undergone considerable shortening. When it is desirable to limit the participation of a given muscle in a movement, it is placed in a shortened position, or · put on slack." The active tension exerted by a muscle spanning more than one joint at a given joint depends on the position of the second joint over which it passes, because this determines the length of the muscle. For instance, the hamstrings are more effective as knee flexors when the hip is flexed and less effective when the hip is extended. Similarly, if the goal is to isolate the gluteus maximus during hip extension, the participation of the

hamstrings is reduced if hip extension is done with the knee flexed compared with the knee extended. Passive TensIOn ofTwo· Jomt Muscles The hip can be flexed to only 70 to 90 degrees with the knee extended but considerably more if the hip and knee are flexed. Similarly, the ankle can dorsiflex more when the knee is flexed than when the knee is extended. These considerations are particularly important in planning effective stretching activi­ ties and in analyzing stabilization of body segments in all types of exercise. Altering joint positions or the use of external sup­ ports such as pillows can reduce or increase the tension of two-joint muscles based on the goal of the exercise. Open Vp,rsus Cosed Kinetic Cham The kinetic chain is related mostly to specificity of exercise. If the desired activity is in the closed kinetic chain, this position should be used for training whenever possible. However, the closed kinetic chain often cannot isolate muscle function as well as a specific open kinetic chain exercise. Stabilization (External or Within) • If stability is required for a movement, use of external straps or pre positioning a limb may assist stabilization if the patient is unable to stabilize with proper patterns internally. For ex­ ample, in supine, the trunk can stabilize with greater ease if the hip and knee are flexed and held in place by the hands while the other limb slides down and back during an abdomi­ nal strengthening exercise (Fig. 2-14). This is an example of pre positioning to offer external stability. Physiologic Durat~on

• Duration of activity in seconds, minutes, or hours • Number of repetitions or sets performed Frequency • Number of exercise sessions in a given time period Speed • Slower is not necessarily easier (see earlier) Intensi'.y of ContractIOn or ExtLrnal Load • Percentage of maximum voluntary contraction Type of Musc e Contract.on • Eccentric, isometric, concentric Seouence o' Exercise • May require beginning with less complex tasks or less strenu­ ous activity in early stages of learning or healing and pro­ gressing to less need for "warm-up" activities as skill is achieved and tissues are in more advanced stages of healing Rest Between RepetitIOns and Sets • As strength or endu rance improves, less rest is necessary between repetitions and sets. Be cautious of overtraining, espec ially in presence of neuromuscular disease or injury. Neuromuscula Sensory mput Visual, proprioceptive, and tactile inputs can be manipulated. If the eyes are closed, visual input is eliminated, leaving the vestibular, proprioceptive, and tactile receptors to detect any disturbance. The tactile input can be varied by standing on soft foam. The proprioceptive input can be varied with head movement. (continued)

Chapter Z: Patient Management

DISPLAY 2·13

Exercise Modification Parameters (Continued)

FIGURE 2·14. Leg slide movement for strengthening deep abdomi­ nal muscles. The hip and knee are flexed and held closer to the chest as the other limb slides down and back. (A) Starting position is actu­ ally with both knees fully bent and both feet positioned off the floor. This photograph illustrates the mid position of the exercise. (A) End­ ing position.The patient should end with the extremity as close to full extension as the length of the hip flexors wil l allow.

Sensory Facilitation or Inhibition • Techniques such as cutaneous and pressure input, approximation, and traction can alter muscle responses. Prolonged pressure on the long tendons such as the quadriceps, biceps, hamstrings, or finger flexors seems to inhibit responses. The placement of manual contacts is critical to facilitate the desired response. Contacts are placed in the direction toward which the segment is to move. Approximation or compression into or through a joint stimulates the joint receptors and may facilitate extensor muscles and stability around a joint. Traction separates the joint surface and is incorporated if increasing range of motion around a joint is desired.

Cognitive or Affective Frequency and Duration of the Activity • Increased frequency and duration of the activity increases the practice schedule to enhance learning . Initial Information ProVided Care should be taken to provide enough information to perform the activity with the correct strategy, but not to give too much information, which may overwhelm the learner. Accuracy Provided As skilll is acquired, increased accuracy of cues is provided to "fine tune" a movement.

Number of Segments Involved • In weight-bearing postures, joint involvement usually refers to the weight-bearing segments; for example, prone on elbows does not require participation of the forearm and hand or the lower body compared with quadruped. The placement of manual contacts or other external forces also influences the number of segments involved. For example, contacts placed on the scapula and pelvis in sidelying involve the entire trunk, whereas contacts positioned on the lumbar spine and pelvis result in more isolated activity of the lower trunk.

Complexity of Activity • Number of steps involved; as in breaking down components of gait into single tasks and then uniting them into the integrated complex motor task of gait with numerous steps

Stage of Movement Control • Mobility, stability, controlled mobility, skill (see Display 2-9 for the definitions of stages of Movement Control)

Anxiety Level • Initially, greater focus on the activity is combined with the least emotional distractions to enhance early learning.

Variability of Environmental Conditions • Initially reduced number of external distractions is provided with increasing external distractions toward a functional environment as skill is acquired.

29

30

Therapeutic Exercise : Moving Toward Function

patient should be referred to another practitioner for fur­ ther treatment.

ADJUNCTIVE INTERVENTIONS To complete this chapter on patient management, adjunc­ tive interventions were chosen to be included in this sec­ tion to provide insight into the complementary role they play in therapeutic exercise prescription. The interventions presented in this section are considered adjunctive to ther­ apeutic exercise in that they are not regarded as essential to achieving a functional outcome. When choosing to use an adjunctive intervention , a de­ cision must be made regarding the benefit of its use in con­ junction v.rith therapeutic exercise. The clinician should be reasonably sure that combining the adjunctive intervention with the therapeutic exercise would produce more rapid or optimal functional recovery. Make it clear to the patient that the adjunctive intervention is being used to augment the exercise and that the exercise and modified posture and movement habits v.rill ultimately change the impairments and functional limitations for long-term improvement. There are conditions for which physical agents, mechanical and electrotherapeutic modalities, and orthotics are imper­ ative to achieve improved physical function and health sta­ tus, in which case these intelventiollS are not considered adjunctive (e.g., significant soft-tissue inflammation, severe pain disorders, skin conditions, nerve injUl)', impaired mo­ tor function, structural abnormalities). Physical agents, mechanical modalities, and electrother­ apeutic modalities are presented in this section because of their effective adjunctive role in therapeutiC exercise. Ad­ ditional adjunctive interventions such as taping and or­ thotic presCliption are presented in Units 5 and 6.

Physical Agents Physical agents use ice, heat, sound, or light energy to in­ crease connective tissue extensibility, modulate pain, or re­ duce or eliminate soft-tissue inflammation and swelling caused by musculoskeletal injUl)' or Circulatory dysfunc­ tion. In addition, physical agents increase the healing rat of open wounds and soft tissue, remodel scar tissue, or treat skin conditions. Examples of physical agents include ultra­ sound, moist heat, paraffin baths, cryotherapy (Fig. 2-15), and hydrotherapy. Heat com bined with stretch is an example of using phys­ ical agents as an adjunct to therapeutiC exercise. Because connective tissue is a major factor in joint contracture, a method for elongating or stretching this tissue is important in changing a jOint mobility impairment. Connective tissue is a viscoelastic structure capable of plastiC and elastic changes. The viscous properties of connective tissue allow it to go through a permanent change in structure 62 .63 Elas­ tic properties refer to the connective tissue's ability to re­ gain its original length. When an applied stretch to a con­ nective tissue is removed, the elastic components recover their orikrinallength and the viscous components remain de­ formed. )2 The amount of elastic and viscous deformation can vary conSiderably, depending on the amount of applied force, duration of appli ed force , and tissue temperatmc 64

FIGURE 2-15. The clinician ices the patient's knee as an ad junct to ther­ apeutic exercise.

Theoretically, stretchi ng protocols produce deformational changes that lengthen the connective tissue and increase . joint ROM. Thermal agents also playa role in determining the amount of elongation obtained from a static stretch. EI­ <,vating the temperature of conn ective tissue has been sho,vn to increase its extensibility; when combined ,vith stretching procedures, it can produce permanent elonga­ tion. The combined application of heat and stretching was found to be more effective in prodUCing permanent in­ crease in length than heat or stretching alone 65 When mo­ tion is limited by connective tissue crossing the joint, the combined application ofheat and stretch may be a useful in­ tervention if the follOWing considerations are observed: 66 • Stretch should be combined with the highest tolera­ ble therapeutic temperature that can be achieved in the area to be treated. • The application of stretch should be at least 30 seconds. • Moderated forces should be used to take advantage of the viscous nature of the tissue. • The tissue temperature should be elevated before ap­ plying stretch to reduce tissue damage . • The tissue elongation achieved should be maintained while the tissue is allowed to cool. This takes approx­ imately 7 minutes. Infrared radiation , electromagnetic radiation, and ultra­ sound are three sources of energy used for therapeutic heating. The choice of energy source depends on the treat­ ment objective, because each of the three sources produces a different heating pattern in tissue. Please refer to the ap­ propriate reference for further information regarding the choice of physical age nt. 67

Mechanical Modalities Mechanical modalities i.nclude a broad group of proce­ dures (e.g., traction, continuollS passive motion , tilt table, vasopn eumatic compression devices, compression, taping) to modulate pain, stabilize an area that requires tempo­ rary support, increase RO M. , or apply distraction, approx­ imation , or compression. C andidates for mechanical

31

Chapter 2 Patient Management

modalities include patients with pain disorders , disk dis­ orders, nerve compression or entrapm e nt, sprains or strains, hypomobility or hypermobility, and hemodynamiC: impairments. Although many mechanical modalities can assist thera­ peutic exercise in achieving functional outcome, taping is discussed in more detail because of its potential direct ef­ fect on enhancing the outcome of therape\ltic exercise. The clinical indications for taping have expanded bcyond the traditional taping to imm obilize and protect a sprained or strained tissue. There are several indications for taping: • Improvement of contact areas for weight-bearing car­ tilage • Improvement of initial alignm ent. thereby assisting in restoration of normal movement patterns • Alteration of length-tension prope rties of muscle tis­ sue; progreSSive stretching of shortened tissue and shortening of lengthened tissue • Unloading of inflamed or injured tissue Specific techniques for taping are included in the r levant regional chapters. The techniques illustrated include hip jOint taping (see Chapter 20 ), patellofemoral joint taping (see Chapter 21 ), plantar fascia taping (see Chapter 22) , and scapulothoracic taping (see Chapter 26).

Electrotherapeutic Modal ities Electrotherapeutic modalities include a broad group of physical agents that use electricity to modulate pain, reduce or eliminate soft-tissue inflammation, decrease muscle spasm, and assist in muscle re-education. Electrotherapeu­ tic modalities include alternating direct and pulsed current , neuromuscular electrical stimulation (NME S), transcuta­ neous electrical nerve stimulation, and surface electromyo­ graphy (S E M G ). Although many el ctrotherapeutic modal­ ities deal with the treatment of pain, inflammation , and soft-tissue healing, this discussion focuses on the use of NMES and SEMG for treatment of muscle re-education.

Neuromuscular Electrical Stimulation

.I

NMES is a versatile modality that can be integrated into treatme nt plans for a variety of patient proble ms. MES can be a safe and effective adjunct to treahnent of disuse atrophy, ROM deficits , and muscle re-education. M S has even been sho\\'l1 to improve muscle performance in basketball playe rs' jumping ability.58 NMES can be deliv­ ered via commercial house power-driven or portable elec­ tJical stimulators. Wavdorm ruther than the source of the stimulator appl'ars to be more important in g@e rating strong muscle contractions with the least fati gue 6 \J It should be possible to establish hom e treatment protocols \'lith battery-operated stimulators providing monophasic or biphasic waveforms, which could be just as e ffective as the more expensive treatment with a clinical stimulator 70 Although studies have not shown ME S to be effective in preventing disuse atrophy, there is some evidence that it can retard the effects of immobilization and disuse and in­ crease muscle force. 71 - 73 Treatment protocols reported to decrease the effects of disuse atrophy vary conSiderably. The patient's diagnosis and pre-injury condition influence the initial parameter settings and rate of progression . Table

2-1 illustrates suggested parameters for initiating a NMES program for patie nts with various degrees of atroph y 74 Wheneve r possible, involve the patient in active exercise combined with NMES . For example, a patient with mod­ erate disuse atrophy of th e vastus medialis oblique (VMO) with patellofemoral pain may use NMES in conjunction with a closed chain isometric exercise for the VMO. The decision to discontinue a NMES program for disuse atro­ phy should be based on the patient's recovery of fun ction. When the patient is able to voluntarily exercise effectively against res istance, NMES may be discontinued. Patients who are weak or experience pain and joint swelling have difficulty moving a joint through its available ROM. In the absence of a fracture involving the joint itself, early motion is desirable to accelerate rehabilitation and prevent loss of motion. NMES may be used for p atients with orthopediC or .neUl:ol~~c dysfunction to promote full return of Jomt moblhty. 15- 1 Most patients who have difficulty regaining or maintain­ ing ROM have been immobilized or have Significant weak­ ness and disuse atrophy, and similar guidelines with regard to disuse atrophy may be followed for frequency and duty cycle selection. NMES is ideally suited as an adjunct to ac­ tive ROM exercises because of its cyclic, repetitive nature. NME S is not intended to replace passive stretching, active, or active assistive ROM exercises or functional retraining of ne"" ROM gained. NMES can be used for muscle re-education and facili­ tation to re-establish voluntary control of body pOSitions and movements after injury or disease h as affected the mo­ tor control mechanism or when less than optimal move­ ment patterns have been learned because of repetition of faulty movement patterns dUling ADLs, sport, recreation, or work. Improvemen t in motor control has been docu­ mented afte r ~MES was used at a current intensity suffi­ cient to evoke a muscle contraction (i.e., motor thresh­ old) .' 0 When using NMES for muscle re-education and facilitation, the patient should attempt to perform a desired movement or contraction along with the stimulation. That way, NMES is used to augment the voluntary movement, not replace it. Use of N MES for muscle re-education and facilitation is limited only by the therapist's creativity.

Surface Electromyography SEMG is increaSingly recognized by physical therapists as a tool to augment evaluation and treatment of a variety of musculoskeletal and neuromuscular conditions 81 - S::; Appli­

~ggested Treatment Parameters for Patients Wltti Disuse Atrophy

Frequency (pps) On

time (s)

Off time (s) Session length (min) Se sions per day

SEVERE ATROPHY

MODERATE ATROPHY

MINIMAL

ATROPHY

3-10 5 25-50 .5-10

10-30 5-10 20-30 15

3---4

3---4

30-50 10-15 10-30 15 1-2

pps, pllises per second; s, seconds

32

Therapeutic Exercise Moving Toward Function

cations have heen proposed for numerous comjjtions in which inapproplinte patterns of muscle activity are thought to be contributory. SEMG can be used as a form of biofeedhack to augment relaxation-based training, tension recognition trailling, postural training, body mechanics in­ struction, tllerapeutic exercise, and functional activity or work station modification. It can serve as an online biofeed­ back technique to ensure the desired response is elicited at the df:sired time. For example, it can Hllgment a stretching technique hy placing th e electrodes on the muscle to be stretched and Illaintaining low or no activity during the stretch. It CJn be used uuring a specific exercise to ensure isolated recmitmel1t of a muscle. For exalliple, one elec­ trode can be.: pi8ccd over the tensor fascia lata and one over the glutellS ll1C'dius during prone hip abduction. If the de­ sired mlIscle for recruitme nt is the gluteus medius, activity in the gluteus medius is expected wiili relative quiescence in the tensor fascia lata. SFMG also can be used to ensure the desired synergy and timing of muscles acting in a force cO\lple during a functional movement pattern. For exam­ ple, one electrode is placed over the upper trapezius, one over the lower trapezius, and one over the serratus anterior during upper extremity flexjon. The proper recruitment pattern and timing of the muscles can be correlated with the path of motion at the scapula. If the scapula appears to be elevating, more activity is required under the lower trapezius and serratus anterior; likewise , if the scapula is not elevating enough , more activity is needed under ilie upper trapezius and serratus anteJior. Appropriate use of SEMG requires a thorough knowl­ edge of instrumentation, set-up, and interpretation of data. Please refer to recommended reading on the topic. 86-88

Surface Electromyography-Triggered Neuromuscular Electrical Stimulation Combining SEM G with N MES can more;owerfully facil­ sl itate muscle than eitller modality alone In SEMG-tlig­ gered NMES , NM E S is delivered to a target musclc after a prescribed electromyography threshold is exceeded. The benefit of com hilling the two mocialities is th8t the patient must actimte the llluscle to a predetermined threshold, the re by serving as an active partiCipant in the process, which may not happen during traditional 1\.\1ES. This modality is particularly useful for muscles in which voli­ tional control is difficult (e.g., gluteus medius, VMO, serra­ tus antelior, lovver tr
KEY POINTS • The physical therapist integrates five elements of care­ examination , evaluation, diagnosis, prognosis , and inter­ vention-in a manner deSigned to maximize the pa­ tient's outcome. • An understanding of each component of the patient management model assists tlle clinician in maximizing

patient satisfaction and in delivering tl1e most effective and efficient sClvices pOSSible. • The clinician's knowledge, expertise, experience, and ongOing acquisition of knowledge and e.\'Perience are the determinants for successful patient management. • Critical clinical decisions are those involveu in deter­ mining which impairments from the list generated from the examination are most closely related to func­ tional limitation and disability anu thcrefore warran t intervention. • Patient-related instruction must be an integral part of any physical ilierapy intelvention. • The three-dimensional therapeutic l'wrcise interven­ tion model is deSigned to help organize the data neces­ sary to make clinical decisions regarding therapeutic ex­ ercise intervention. • Exercises must be continually monitored to determine the need for modification to increase or decrease diffi­ culty to ensure continual progress is being made with minimal setbacks. To be most effective with exercise modification, the clinician must possess thorough un­ derstanding of the parameters that can be modified. • Therapeutic exercise can be complemented wiili adjunc­ tive interventions if ilie additional intervention can lead to a higher level of functional outcome in a shorter period.

CRITICAL THINKING QUESTIONS _ _ _ _ _- - 1 1. Read Case Study #2 in Unit 7. a. List the phYSiologic, anatomic, and psychol ogic im­ pillrments. b. List the functional limitations. c. Correlate the impairments to the functional lirnitil­ tions. d. Choose ilie impillrments and functional limitations you feel warrant treatment. e. Correlate ilie impillrments and functional limitations you have chosen to treat vvith the elements of the movement system. f. Prioritize the elements of the move ment system. 2. Still using Case Study #2, you have decided to prescribe exercises to improve knee mobility, because you know the patient requires 70 degrees of knee flexion to per­ fonn simple ADLs. You would like to use a sit to stand movement to work on knee mobility. Recall that she re­ quires moderate assistance with sit to stand transfers. a. Describe the posture, mode, and movement of the activity. b. Describe all pertinent parameters of dos
Chapter 2: Patient Management

REFERENCES 1. Amelican Physica'l Therapy Association. Guide to physical therapist practice . 2nd Ed. American Physical Therapy Asso­ ciation. Phys Ther 2001:81:9-746. 2. lette AM, Branch LG , Berlin J. Musculoskeletal impairments and physical disablement among the aged J Gerontol 1990: 45: YI203-M208. 3. Bradley EM , 'Wagstaff S, Wood PHN. Measures of func­ tional ability (disability) in arthritis in relation to impairment of range of joint movement. Am Rheum Dis 1984:43: 563-569. 4. Rothstein JM , Echte rnach JL. HypotheSis-oriented algo­ rithm for clinicians. Phys Ther 1986:66:1388-1394. 5. Topp R, Wooley S, Khuder S, et al. Predictors of four func­ tional tasks in patients with osteoarthriti s of the knee. Orthop Nul'S 2000;19:49--59. 6. Atlas SJ, Deyo RA, Van Den Ancker M, et a!. The Maine­ Seattle back questionnaire: a 12-item disability questionnaire for evaluating patients with lumbar sciatica or stenosis: results of a derivation and validation cohort analysis. Spine 2003;28: 1869-1876. 7. Beaton DE, Schemitsch E. Measures of health-related qual­ ity ofhle and physical function. Clin Orthop 2003;413:90-105. 8. Takken T, van der Net J, Helders PJ. Relationship between functional ability and physieal fitness in juvenile idiopathic arthritis patients. Scand J Rh cumatoI2003 ;32: 174-178. 9. Hazes JM . Determinants of physical function in rheumatoid arthritis: association with the disease process. Rheumatology (Oxford) 2003;42: 17-21. 10. Hazes JM. Determinants of physical function in rheumatoid arthritis: association with the disease process. Rheumatology (Oxford). 2003;42:17-21. 11 . Mason JH, Anderson JJ, Meenan RF, et al. The Rapid As­ sessment of Dis ease Activity in Rheumatology (RADAR ) Questionnaire: validity and sensitivity to change of a patient self-report measure of joint count and clinical status. Arthri­ tis Rheum 1992:35:156-162. 12. Meenan RF, Mason JH, Anderson JJ, et a!. AIMS2: the con­ tent and properties of a revised and expanded Arthlitis Im­ pact Measurement Scales health status questionnaire. Artlui­ tis Rheum 1992:35:1-10. 13. Jette AM , Davies AR, Cleary PO, et al. The functional status' questionnaire: reliability and validity when used in primary care. l Gen Intern Med 1986:1:143-149. 14. Haley SM. Motor assessment tools for infant and young chil­ dren: a focus on disability assessment. In: Forrsberg H, ed. Treatment of Children with Movement Disorders: Theory and Practice. Basel, Switzerland: S Karger, 1992. 15. Frey WD. Functional outcome: assessment and evaluation. In: Deli sa JA, ed. Rehabilitation Medieine: Principle and Practice. Philadelphia: JB Lippincott, 1888. 16. Haley SM , Coster "VJ, Ludlow LH. Pediatric functional out­ come measures. In: Jaffe KM , ed. Pediatric Rehabilitation. Philadelphia: WB Saunders, 1991. 17. Law M. Evaluating aetivities of daily living: directions for the future. Am J Occup Ther 1993:47:233-237. 18. Heinemann W , Linacre JM, Wright BD , et al. Relationships between impairment and physical disability as measured by the Functional Independence Measure . Arch Phys Med Re­ habil1993 :74:566-573. 19. Mahoney FL, Barthel OW. Functional evaluation: the Balthel index. Md State Med J 1965:14:61- 65. 20. Hamilton BB, Laughlin JA, Fiedler RC, at al. Interrater reli­ ab ility of the 7-level functional independence measure (FIM ). Scand J Rehabil Med. 1994;26: 115-119. :21. Berg K, Wood Dauphinee S, \Villiams JI, et al. Measuring balance in the elderly: validation of an instrument. Can J Pub­ lic Health 1992:2:S7-S11.

33

22. Keith RA, Granger CV. The functional independence mea­ sure: a new tool for rehabilitation. In: Eise nberg MG , Greysiak Re, eds. Advances in Clinical Rehabilitation . New York: Springer Publishing, 1987. 23. Butland RJA, Pang J, Gross ER, et al . Two, six, and twelve minute walking test in respiratory disease. I3MJ 1982:284: 1604-1608. 24 . Steffen TlvI, Hacker TA , Mollinger L. Ag(~ - and gender-re­ lated test performance in community-dwelling elderly peo­ ple: S L\:-~vIinute Walk Test, Berg Balanee Scale , Timed Up & Co Test, and gait speeds. Phys Ther 2002;82:128-137. 25. Creel GL, Light KE, Thigpen MT. Concurrent and construct validity of scores on the Timed Movement Battery. Phys Ther 2001; 81:789--798. 26. Granger CV, Cotter AC, Hamilton RB, et al. Functional as­ sessment scales: a study of persons after stroke. Arch Phys Med Rehabil1993:74:l33--138. 27. Gresham GE, Labi ML. Functional assessment instruments currently available for documenting outcomes in rehabilita­ tion medicine . In: Granger C\!, Gresham GE , eds. Func­ tional Assessment in Rehabilitation Medicine. Baltimore: Williams & Wilkins, 1984. 28. Shields RK, Enloe LJ, Evans RE, et al. Reliability, validity, and responsiveness of functional tests in patien ts with total joint replacement. Phys Ther. 1995:75:169-176. 29. Stewart A, Ware JE, eds. Measuring Functioning and \Vell­ Being: The Medical Outcomes Study Approach. Durham , NC: Duke University Press, 1992. 30. Guccione AA, Cullen KE, O'Sullivan SB. Functional assess­ ment. In: Sullivan SB , Sehmitz TJ, cds. Physical Rehabilita­ tion: Assessment and Treatment. 2nd Ed. Philadelphia: FA Davis, 19S8. 31. Guccione AA. Arthritis and the process of disablement. Phys Ther 1994:74:40S-414. 32. Bergner M, Babbitt RA , :arter WB, et a!. The sickness im­ pact profile: development and final revision of a health status measure. Med Care 1981: 19:787-805. 33. Roland M, Morris RA. A study of the natural history of back pain, part I: the development of a reliable and sensitive measure of disability in low back pain. Spine 1983:8: 141-144. 34. Fairbanks JCT, Couper J, Davies JB, et at The Oswestry low back pain disability questionnaire. PhYSiotherapy 1980:66: 271-273. 35. Wadde'll G, Main CJ, Morriss EW, et al. Chronic low back pain , psychological distress, and illness behavior. Spine 1984:9:209--213. 36. Lawliss GF, Cuencas R, Selby 0, et al. The development of the Dallas pain questionnaire: an assessment of the impact of spinal pain on behavior. Spine 1989:14:512-515. 37. Ware J E , Sherbourne CD . The MOS 36-item short-form health survey (SF-36), 1: conceptual framework and item se­ lection. Med Care 1992;30:473-483. 38. Davidson M, Keating JL. A comparison of five low back dis­ ability questionnaires: reliability and responsiveness. Phys Ther 2002;82:512-515. 39. Sehuling J, de Hann R, Limbu rg M, et a!. The Frenchay ac­ tivities index: ass essment of functional status in stroke pa­ tients. Stroke 1993:24:1173--1177. 40. Rothstein JM , Echtemach JL, Riddle DL. The hypothesis­ oriented algOrithm for clinicians II (HOAC II): a guide for patient management. Phys Ther 2003;83:455-470. 41. Nagi S. Disability concepts revis,ited: implications for preven­ tion. In: Pope AM , Tarlov AR, eds. Disability in America: Toward a National Agenda for Prevention. Washington DC: National Academy Press, 1991. 42. Sahrmmlll SA. DiagnOSiS by the physical therapist-prereq­ uisite [or treatmellt: a special communication. Phys Ther 1988:68: 1703-1706.

34

Therapeutic Exercise: Moving Toward Function

43. Rose SJ. Physical therapy diagnosis: role and function. Phys Ther 1989:69:535-537. 44. Delitto A, Synder-Mackler L. The diagnostic process: exam­ ples in orthopedic physical therapy. Phys Ther 1995:75 203- 210. 45. Van Dillen LR, Sahrmann SA, Norton BJ, et a1. Movement system impairment-based categories for low back pain: stage 1 validation. J Orthop Sports Phys Ther 2003;33:126-142. 46. Rose SJ, Description and classification: the cornerstone of pathokinesiological research. Phys Ther 1986:66:379-381 . 47. Fritz JM, \"ainner RS, Examining d.iagnostic tests: WI evi­ dence-based perspective. 1'hys Ther 2001 ;81:1546- 1564. 48. Fosnaught M, A critical look at diagnosis. Phys Ther 1996: 4:4il-53. 49. Balla JL. The Diagnostic Process: A Model for Clinical Teach­ ers. CambliJge, England: Cambridge University Press, 1985. 50. Guccione AA, Physical th erapy diagnosis and the relationship bC' t\\'een impairments and fUllction, Phys Ther 1191:71: 499- 503. 51. Dd,ker J, Van Baar ME , CUlfs EC , et al. Diagnosis and treat­ ment in physical therapy: an investigation of their relation­ ship. Phys Ther 1993:73:568-577. 52. Jette AM . Diagnosis and classification by physical therapists: a special communication . Phys Ther 1989:69:967- 969. 53. Baker SM , Marshak HH , Rice GT, et al. Patient partiCipation in physical therapy goal setting, Phys Ther 2001;81:1118­ 1126, 54. Straus SE , Sackett DL. Using resc'arch findings in clinical practice. BMJ 1998;317:339-342. 55. Kan e R. Looking for physical therapy outcomes. Phys Ther 1995:74:425-429. 56, Rothstein JM. Outcome assessment of therapeutic exercise. In: Bajmajian JV, Wolf SL, eds. Therapeuti c Exercise . 5th Ed , Baltimore : Williams & Wilkins, 1990, 57. Oermann MH, Templin T. Important attributes of quality health care : consumer perspectives. J Nurse Scholarsh 2000;32:167-172, 58, Salumann SA. Diagnosis and Treatment of Movement Im­ pairment Syndromes , St. Louis: Mosby, Inc" 2002, 59, Kendall FP, McCreary EK , Provance PG, Muscles Testing and Function , 4th Ed. Baltimore: Williams & Wilkins, 1993, 60. Sullivan PE, Markos PO, Clinical Decision Making in Thera­ peutic exercise, Norwalk, CT: Appleton & Lange, 1995. 61. Gentile AM . Skill Acquisition: Action, Movement, and Neu­ romotor Processes, In : Carr JH , Shephard RB , eds. Move­ ment Science: Foundations for Physical Therapy in Rehabil­ itation, 3rd ed. New York, NY, Aspen Publishers, Inc. 2000, 62, Hardy M, Woodall W , Therapeutic effects of heat, cold, and stretch on connective tissue. J Hand Ther 1998;11:148-156. 63. Culav EM , Clark CH, Merrilees MJ . Connective tissu es: ma­ trix composition and its relevance to physical therapy. Phys Ther 1999;79:308-319, 64, Chen SS , Humphrey JD , Heat-induced changes in the me­ chanics of a collagenous tissue: pse udoelastic behavior at 37 J egrees C. J Biomech 1998;31:211-216. 65. Knight CA, Rutledge CR, Cox 'viE , et al. Effect of superfiCial heat, deep heat, and active exercise warm-up on the extensi­ bility of the plantar fl exors. Phys Ther 2001;81:1206-1214, 66. Warren CG, Lehmann JF, Koblanski IN. Elongation of rat tail tendon: effect of load and temperature. Arch Phys Med Rehabil 1971:.52:465-474,484. 67. Hecox B, Tsega A, \""eisberg J, Physical Agents: A Compre­ hensive Text for Physical Therapists. Norwalk, CT: Appleton and Lange , 1994. 68. Maffiuletti NA, Cometti G, Amiridis IG, et al. The effects of electromy stimulation training and basketball practice on muscle strength and jumping ability , Int J Sports Med 2000;21:437-4A3 .

69. Marqueste T , Hug F, Decherchi P, et al. Changes in neuro­ muscular function after training by functional electIical stim­ uhltion. Muscle Nerve 2003 ;251:181-188. 70. Talbot LA, Gaines JM, Ling SM, et al. A home-based proto­ col of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the kne e. RheumatoI2003;30:1571-1578, . 71. Wiggerstad-Lossing I , Grimby G, Jonsson T, et al. Effects of electlical muscle stimulation comhined with voluntary con­ tractions after knee ligument surgery. Med Sci Sport Exerc 1988:20:93-98. 72. Morrissey MC, Brewster CE , Shields CL Jr, et al. The effects of electrical stimulation on the quadriceps during postopera­ tive knee immobilization. Am J SPOlts Med 1985: 1.3:40-45. 73. Bohannon RW, Effect of electIical stimulation to th e vastus medi alis in a patient with chronically dislocatin g patelhie . Phys Ther 198363:1445-1447. 74. DeVahl J, :'\e uromuscular electrical stimulation (NMES) in rehabilitation , In: Gersh MR, ed. Electrotherapy in Rehabil­ itation . Philadelphia: FA Davis , 1992. 75. Cannon NM , Strickland ,TW, Therapy follOWing flexor tendon surgery, Hand Clin 1985:1:147-165. 76. HaugJ, Wood LT. Efflcacyof neuromuscular stimulation of the quadriceps femOlis during continuous passive motion following total lmee arthroplasty. Arch Phys Med 1988:69: 42.3-424. 77. Baker LL, Yeh C, Wilson D , et al. E lectrical stimulation of v\'fist and fingers for hemiplegiC p atients. Phys Ther 1979:59149.5-1499, 78, Carnstam B, Larsson LE, Prevec TS . Improvement of gait follOWing functional electrical stimulation. Scand J Rehabil Med 1977:9:7-13. 79, Gracanin F. Functional electrical stimulation in control of motor output and movements. In: Cobb WA, Van Duijn H. eds. Contemporary Clinical NeurophYSiology (EEG Suppl), Amsterdam: Elsevier, 1978, 80 . Marqueste, Marqueste T, Decherchi P, et al, Effect of mus­ cle electrostimulation on afferent activities from tibialis ante­ rior muscle after nerve repair by self-anastomosis. Neuro­ science 2002;113 :257-271. 81. Coffey SW, Wilder E, Majsak MJ, et al. The effects of a pro· gressive exercise program with surface electromyographic feedback on an adult with fecal incontinence. Phys Ther 2002;82:798-811. 82. Pauliina A, Jonna P, Paula L, et al. Intravaginal surface EMG probe design test for urinary incontinence patients. Acupunct Electrother Res 2002;11 :23-31. 83, Nord S, Ettare D, Drew D , et al. Muscle learning therapy­ efficacy of a biofeedback based protocol in treating work­ related upper e}.tremity disorders, J Occup Rehabil 2001 ;11: 23-31. 84. Glazier DB, Ankem MK, Ferlise V, et al. Utility of biofeed­ back for the daytime syndrome of urinary frequency and ur­ gency for childhood. Urology 2001 ;57:791-793. 85. Gross MD , Ormianer Z, Moshe K, et al. Integrated elec­ tromyography of the masseter on incremental opening and clOSing with audio biofeedback: a study on mandibular pos­ ture, Int J Prosthodont 1999;12:419-425. 86. Soderberg GL, Knutson LM . A guide for use and interpreta­ tion of kinesiologic electromyographic data, Phys Ther 2000;80:485-498, 87, Cram JR, Kasman GS. Introduction to Surface Electromyog­ raph y. Bethesda, YlD: Aspen , 1998 , 88. Kasm an GS , Cram JR, Wolf SL. Clinical ApplicatiOns in Sur­ face El ectromyography: Chronic Musculoskeletal Pain. Bethesda, MD: Aspen, 1998. 89. Fields RW. Electromyographically triggered electric muscle stimulation for chronic hemiplegia, Arch Phys Med 1987:68: 407-414 .

r

chapter 3

Principles of Self-Management and Exercise Instruction LORI THEIN BRODY

Teaching in the Clinic

Safety

Self-Management

Adherence and Motivation

Health Behavior Models

Applications

Clinician-Patient Communication Issues in Home Exercise Program Prescription

Understanding Instructions

Proper Exercise Execution

Equipment and Environment

Home Exercise Prescription

Considerations in Exercise Prescription

Determining Exercise Levels

Formulating the Program

Patient education has become a more critical component of patient care in the last decade. Changes in the structure of the medical system, reimbursement issues, and an increase in the prevalence of chronic problems require more patient education about their condition and self-management trategies. Patient-related or client-related instruction is de fined as the "process of informing, educating, or training patients/clients, families, significant others, and caregivers \\i th the intent to promote and optimize physical therapy ,ervices."l Instruction , education, and training of the pa­ tient or client includes information on their current condi­ 'on, the diagnosis, prognosis and plan of care, health and vellness issues , and risk factors for pathol ogy, impair­ ents, functional limitations, and disability. Teaching in th e clinic can take many form s. Serving as a .jnjcal mentor for a physical therapy intern or teaching ents how to assist their child in stretching exercises are \lOUS examples of teaching in the clinic. Clinicians also h patients during the evaluation and treatment ses­ ns . A study of the perceptions of physical therapists re­ •...rdi.ng their involvement in patient education showed that rapists educate 80% to 100% of their patients. 2 These rapists primarily recognized teaching range of motion ~l) techniques, home exercise programs, and treat­ t rationales. Clinicians recognize but may underesti­ the importance of educating their patients on impor­ . sues such as the relationship between symptoms and r patients' daily routines and the e>"'Pected response to ..;ercise program. Patients' satisfaction with treatment

and willingness to adhere are often based on the fulfillment of their expectations. The more time spent educating the patient on prognosis and expectations from the rehabilita­ tion program, the more likely the patient is to adhere to and be satisfied "vith the tre atment program. Gahimer and Domholdt 3 found that therapists educated their patients primarily in the areas of information about illness, home exercises, and advice and information. Moreover, the pa­ tients reported attitudinal or beha\lo ral changes ranging from 83.8% to 86.5% as a result of this education. Health education and stress counseling were addressed less fre­ quently during the treatment session.

TEACHING IN THE CLINIC Teaching in the clinic is a constant and ongOing process. As changes in health care occur, many clinicians are finding that their role has changed from full-time, hands-on prOviders of rehabilitation services to part-time educators, administrators , and c1inicians. 3 Clinical teaching, parti cu­ larly in the area of the home exercise program, is espeCially important, because in-house supervised physical therapy is often inadequate to achieve the patient's goals. For exam­ ple, performing stretching exercises three times per week for 30 minutes under the clinician 's supervision probably will be insufficient to produce a change. The development of a thorough, complementary home exercise program is essential. Exercise prescription for the bome, workplace, or school can prove to be an interesting challenge for the clin­ ician and patient. H e lping the patient establish a daily exercise program as a routine can be a positive lifelong influence.

Safety Depending on the speCific circumstances, provision of re­ habilitation services may be limited to a few visits. In this situation, the patient may be carrying out the rehabilitation program at home or at a local health club with intermittent rechecks for status and progreSSion of the program. To en­ sure safety during exercise and improvement in the pa­ tient's symptoms, the exercise program must be executed properly. Frequently, the patient appears to understand proper performance of the exercises, but he or she subse­ quently forgets the instructions, resulting in improp er techniqu e. This p ro blem can result in a lack of improve­ ment and potentially in exacerbation , or worsening, of the symptoms. The patient should understand which signs and

35

36

Therapeutic Exercise Moving Toward Function

symptoms predict an exacerbation so he or she can modify the exercise program appropriately. This education can prevent an exacerbation and potential reinjury.

Self-Management In addition to increasing the safety of the exercise pro­ gram, educating the patient about the effects of the exer­ cise program on specific symptoms can empower him or her to self-manage the situation. The more clearly pa­ tients understand the relationships among various activi­ ti es (including the exercise program) and their symptoms, the better able they ,,,,,ill be to regulate their activity lev­ els. This makes the patient a partner in the rehabilitation program. The patient still looks to the clinician for gUid­ ance' and education regarding the physical problem, but tlIP clinician give.~ the patient some responsibility in the deci~ion-making process. This approach gently gUides tlw patie nt in the se lf-managt~ lllent process. Holmes et at! successfully used a self-manage ment approach in the treatment of a woman with impingement syndrome and adhesive capsulibs. She was seen for six visits over 10 weeks and followed for 1 year. The authors felt that the intensive patient education allowed the patient to develop an internal sense of control and prevented the develop­ ment of an external focus in which the patient depends on the therapist for management of the condition. Motiva­ tion exhibited hy patients may be a manifestation of their locus of control beliefs.s

ADHERENCE AND MOTIVATION Patient compliance 'vvith a treatment regimen is the subject of a great deal of research. The terms compliance, adher­ ence, and therapeutic alliance are often used to discuss the extent to which a patient's behavior coincides with medical advice." Some feel that the term compliance is too dictato­ rial on the part of the caregiver, and seems to neglect the philosophy of "patient as partner" ill determining the plan of care. The term adherence will be used throughout this chapter. The best-designed rehabilitation program achieves little if the patient is not compelled to participate. A study by Sluijs et aL 6 demonstrated a complete adher­ ence rate of only 35%, with 76% of the patients "partly" compliant "vith their rehabilitation program. The factors related to nonadherence were barriers that patients perceived, lack of positive feedback, and the degree of helplessness.

Health Behavior Models Clinicians spend a great deal of time designing what they believe to be tlle best plan of care for their patients. How­ ever, even t1w best intclvention plans will fail in ilie ab­ sence of patient participation. The factors associated with compliance with medical professional recommendations have been well-studied. Some studies focus on eliminat­ ing unhealthy behaviors (smoking, excessive alcohol use), whereas others focus on initiating healthy behaviors (good eating habits , exercise, compliance with medication

schedules).·5-7 A number of behavior change models have been put forth. For example, the Health Belief Model stresses a reduction of environmental barriers to healthy behaviors includin~ ~erceived barriers, benefits , self-effi­ cacy, and severity. ' Other models include the Healili Locus of Control, Self-Efficacy and Transtheoretical, or stages of change model./i· 10 Of these models, ilie Trans­ theoretical model has been applied to many aspects of ex­ ercise behaviors. The Transtheoretical model emphaSizes the temporal aspect of a behavior change, underscoring the ability to change a behavior over a valiable length of time. lndividu­ als may spend varying lengths of time in the different stages as they slowly make changes, or they may get stuck in one stage. Additionally, the patient may move through some of the stages several times before completing the behavior change.!O The stages identified in iliis model include: pre­ contemplation, contemplation, preparation, action, and maintenance. In the precontemplation stage, the individual has no in­ tention of changing or does not see any need for change. Prochaska II quantifies this stage by a person stating he or she did not intend to change \vithin the next 6 months. A person in this stage will be reluctant to begin any rehabili­ tation program and generally does not see the need or ben­ efit of it. The individual may feel forced to corne for reha­ bilitation by some outside party (physician, family member, employer), and no amount of explanation or information 'vvill improve adherence. Individuals in the contemplation phase are seriously considering change but have not yet initiated it. Individu­ als in this stage state that they are planning to make a change witllin tlle next 6 months. Those in the preparation stage indicate that they are planning to change in the next month or had made some changes, but had not fully achieved the change . Individuals in the action stage have reached some criterion level of change (such as quitting smoking or exercising three times per week) within the past 6 montl1s. Those in the maintenance stage had reached the criterion level of behavioral change more tllan 6 months earlier.ll

Applications The patient will be more willing to adhere to a rehabilita­ tion program if attention is ~ven to the stage of readiness to begin such a program.7,lo. 2 The first step is truly listen­ ing to the patient to identify clues as to their state of readi­ ness for change. This can be done by using open-ended questions to explore issues related to adherence and to fa­ cilitate the patient's personal involvement. Help the pa­ tient identify potential barriers to participation and request input as to how these barriers can be removed or mini­ mized. Patients need to believe that ilie pros of participa­ tion outweigh the cons, and that they are capable of achiev­ ing ilie e>"'Pected outcomes if they participate. ll ,13.14 Help the patient in the precontemplation phase to identify per­ sonal goals that might be achieved by participation in the rehabilitation program. Build rappOlt through regular ap­ pointments and reflective conversation. 14 For the patient in the contemplation phase, build motivation through en­

Chapter 3: Principles of Self-Management and Exercise Instruction

I"

I­

t 1-

courageJllent and the provision of information. Review the pros and cons of participation, reflecting the patient's own personal goals. Enhance adherence by educating the pa­ tient regarcling the relationships among the injury or pathology, the exercise program, and the expected out­ come. The c1iniciall may purposefully link the exercise to the patient's speciflc problem or goals, but the patient may not understand this relationship. He or she should under­ stand this relationship to ensure active partiCipation in the treatme nt program. Brus et a1. 15 found that compliaBce with physical exercise, en ers'Y conservation, and joint pro­ tection was increased by patient education in a group of pa­ tients with rheumatoid alihritis. For those in the action phase, actively engage the patient in plan of care formula­ tion and provide support for the plan. H elp identify barri­ ers to implementation and address these in the treatment plan . Patients in the action and maintenance phases need positive reinforcement to continne partiCipation and pre­ vent relapses. Motivation is a key factor in exercise adherence. Every person experiences various influences on motivation. What motivates one person is unlikely to motivate an­ other. The clinician should attempt to determine which factors motivate the patient to adhere with the exercise program and use these as the "carrot" or reward. These factors vary tremendously and may include return to ac­ tivities the patient enjoys (e.g., gardening, sports, leisure, recreational activities), return to work, return home (e.g., from hospital or intermediary care facility), ability to shop or carry out instrumental activities of daily liVing, or the ability to care for a child. After the motivators are identi­ fied, 'the exercise program should be tailored to those ac­ tivities. Inability to participate in these activities is often one of the primary reasons the patient sought medical at­ tention initially. When designing the rehabilitation program with moti­ vation and adhe rence in mind, use caution when using "ex­ e rcise files." If' the exercise program seems nonspecifIc or unrelated to the patient's functional needs , adherence could become a problem. In the early rehabilitation phases, some exe rcises may not seem particularly "functional" to the patient, but they are important aspects of the treatment program. Explaining the importance of the exercis e edu­ cates the patient about the condition, asslires the patient of the clinician's understanding of the problem and the po­ tential solution, and treats the patient as an educated par­ ticipant in the rehabilitation process. Further explanation of how the exercises will progress to more functional activ­ ities or how a specific exercise is related to the motivatin a activity validates the importance of that activity and verifies that this is important to the patient. As the exercise program progresses, it should reflect more and more close ly the activity to which the patient will be returning. The same physical th erapy goals can be achieved while increasing motivation and function by us­ ing functional activities as the exercise program. For ex­ ample , for the individual recovering from shoulder surgery who is unable to unload the dishwasher, transfer­ ring dishes of increasing weight from the counter to shelf for progressively longer periods is more motivating and interesting than lifting a 1-pound weight (Fig. 3-1) This

37

FIGURE 3-1. Choose home exercises reflective of the patient's usual activities.

type of activity has the added ben efit of requiring distal muscle function that more closely replicates the actual important activity than lifting a weight or using resistive tubing. \i\ie ights and tubing are useful adjuncts to the re­ habilitation progranl and , wh en possibl e, should be used in a way that duplicates the functional activity. Rather than performing a series of cardinal plane shoulder exer­ cises, miIIlicking activities such as a tennis svving, raking, sawing, or throwing a ball can increase stre ngth and rein­ force important motor programs . An exercise pro gram requiring the fewest lifestyle changes increases the patient's adherence to it. Rather than trying to add more activities to the pati ent's day (o~ten ask­ ing that exercise be performed several times per day), choose exercises that can be incorporated into her day. If an exercise program requires a 15- or 30-minute time block carved out of a person's busy day once or twice daily, ad­ herence is difficult despite the patient's desire to partici­ pate. If the exercises can be blended into activities that the patient already does during the day, adherence becomes much easier. A study by Fields et a1. I6 examined the rela­ tionships among self-motivation or apathy, perceived exer­ tion, social support, scheduling concerns, clinical environ­ ment, and pain tolerance to adherence to sport injury rehabilitation in college-age recreational athletes. Of the variables under consideration, significant differences were seen between adherers and nonadherers in self-motivation , scheduling concems, and pain tolerance; of these factors, scheduling concerns contributed most to the overall group difference. In another study, Slu,ijs et a1. 6 found that the strongest factor in nonadherence was the barriers patients perceived. The most frequent complaint was that the exer­ cise program required too much time and that the exercises did not fit into the patient's daily routine. An example of an

38

Therapeutic Exercise: Moving Toward Function

DlSPLAV 3-1

Home Exercise Program for Office Worker with Adhesive Capsulitis Impairments

1. Decreased range of motion in all directions in a capsular

pattern 2. Decreased strength tested by manual muscle tests in all major shoulder muscle groups 3. Resting pain at 4 on 0-10 (0 = least; 10 = most pain); activity pain at Band 0-10. Functional Limjtations

1. Unable to use arm for activities of daily living 2. Unable to lift weight with arm held away from the body 3. Unable to get arm over head for work and daily activities Disability

1. Unable to fulfill all roles at work because of limitations 2. Unable to participate in leisure activities Home Exercises 1. Stretching for shoulder elevation while in warm shower 2. Active use of arm for personal hygiene, including

showering, combing hair, dressing, eating, pendulum

exercises during dressing

3. Scapular retraction exercise with abduction in front of mirror during grooming three times per day, looking in the mirror each time 4. Shoulder flexion or abduction stretch on desk when

talking on the phone

5.. Passive shoulder external rotation stretch at file cabinet every time 6. Isometric exercise while reading morning mail 7. Walk with large arm swings during lunch hour B. Supine overhead stretches on couch during the evening news 9. Use arm as much as possible for cooking, dishwashing, housework, and yardwork 10. Resistive tubing exercises sometime during the day; patient's choice.

exercise program for a patient with adhesive capsulitis can be found in Display 3-l. Fitting exercise into the patient's daily routine estab­ lishes a conditioned response that may cany over after therapy is concluded. For example, if a patient needs to in­ crease the length of the gastrocnemius-soleus complex by stretching several times each day, instructing that person to stretch for 20 to 30 seconds each time he or she ascends the stairs is less burdensome than doing this as part of an exer­ cise routine at the day's end. For the individual needing to increase shoulder flexion ROM , leaning al1ead with his or her arm forward and flexed on the desk or kitchen counter before making a phone call is a productive use of time. This may beco me a conditioned response, and whenever the phone rings, the individual associates that activity with stretching his or her shoulder, or when ever the patient climbs the stairs, he or she thinks of calf stretching. This technique works particularly well with postural re-educa­ tion exercises (Fig. 3-2).

CLINICIAN-PATIENT COMMUNICATION Individual differences Sign ificantly affect the patient-clini­ cian relationship. Fundamental personality differences, values , and teaching and learning styles influence com mu­ nication and may ultimately affect adherence and outcome. Possessing important skills to assess the patient's willing­ ness and style of communication and learning can enhance the rehabilitation program. These skills include the ability to actively listen and reflect t~e patient's re~orts and to provide appropJiate feedbackY.l S Sluijs et al. found lack of positive feedback to be one of the primary factors related to lack of adherence ,vith a rehabilitation exercise program, Cameron 5 suggests improving the quality of the interaction by showing sensitivity to the patient's verbal and nonverbal communications , and understanding of and empathy with the> patient's feelings. Patient education implies a willingness to partiCipate by the patient and the clinician. The patient's readiness to

FIGURE 3-2. The clinician should prescribe exercises that can be performed during other home or work activities.

Chapter 3 Principles of Self-Management and Exercise Instruction

learn depends on many factors, including the relationship \-vith the health care provider. The clinician must be able to assess the patient's readiness and willingness to learn. The relationship is based on how the patient is coring with the particular situation. Schwenk and Whitman l described a control scale in which the control level of the patient and clinician were inversely related. As the clinician uses less controlling or assertive behaviors, the patient's control of the situation increases. The converse is also true; the active and assertive clinician is likely to push the patient into a more passive role. If the patient is unwilling to be in such a role, conflict "rill ensue, or the clinician will become more passive, relinquishing some control to the patient. The clinician's attention to the patient's needs can guide the appropriate communication style. In the initial visits, a more passive listener role gives the patient an opportunity to explain his or her needs. This gives the clinician an op­ portunity to hear the patient's concerns, expectations, and goals. Fundamental skills necessary for active listening in­ clude close observation of the patient's words, intonation, and body language. Eye contact, along "rith affirmation and reflection of the patient report, can clarify what the clini­ cian heard and validate the patient report (Fig. 3-3). This gives the clinician an opportunity to discuss the recovery prognosis given adherence to the treatment program, which, along "vith discussion of the clinician's expectations of the patient, can enhance communication and the reha­ bilitation process. Several studies have shown the "Pygmalion effect" in a variety of settings in which the instructors' eXf-ectations were matched by students' achievements. 1 -22 Although communicating the expectations of all in­ volved participants is important, it is equally important to prOvide realistic expectations in the form of short-term and long-term goals. Setting reasonable and achievable goals can provide one form of positive feedback for the patient. Occasionally, the patient's motivation can be improved by

FIGURE 3-3. In appropriate cultural situations. eye contact can enhance communication.

39

education about reasonable goals. The ability to perform the same level of exereise or acthrity at a lower level of pain is a reasonable short-term goal. The patient may only see that he or she is performing at the same level and perceive this as a lack of progress. ClaJification on how progress is defined and reasonable expectations regarding progress can improve patient adherence and satisfaction. Some ad­ vocate a contract approach in which the specific obligations of each party in the attainment of the therapy goals are set forth and a timeline determined. 5

ISSUES IN HOME EXERCISE PROGRAM PRESCRIPTION The home exercise program is an increasing component of the overall treatment program for most patients. In some cases, the patient performs the exercises independently, whereas, in other cases, a family mem ber or other health care provider assists in the exercise program. In either sit­ uation, clarity in goals and exercise procedures is essential to ensure an optimal outcome.

Understanding Instructions One of the fundamental steps in ensuring a positive out­ come after initiation of a rehabilitation program is the pa­ tient's ability to understand the therapist's instructions. Many variables affect this aspect of patient care, including language or cultural barriers, reading or comprehenSion levels , hearing impairment, and clarity of instructions. The best-deSigned rehabilitation program may fail be­ cause it has not been carried out well. Do everything pos­ sible to ensure that your instructions are clear and easy to understand.

Cultural Barriers Identify any cultural barriers to understanding early in the rehabilitation course. Language differences may hinder the use of even the Simplest terminology. Although an indhrid­ ual may appear to understand many words in English, communicatin,~ thoughts about medically related issues is likely to be dillicult. Use of an interpreter, whether a pro­ fessional or a family member, can minimize communica­ tion difficulties in this area. Other cultural barriers to adherence may exist and should be identified to the best of your ability. Religious or other cultural customs may prevent individuals from exer­ Cising on certain days or from wearing clothing that allows a body part to be visualized or palpated during exercise. In major metropolitan areas, a multitude of cultures exist. It is difficult to know all the intIicacies of many cultures and customs. Do your best to know the times and meanings of your patient's ethnic or religiOUS holidays. Seek informa­ tion on cultural or religiOUS customs related to eye and phYSical contact, including the appropriate type of greet­ ing. This includes not only appropriate eye contact (avoid­ ing eye contact is a sign of respect in some cultures), but how the patient is addressed, and if any physical contact (i.e., handshake) is appropriate. 23 Although these speCific instances are difficult to know ahead of time , be alert to

40

Therapeutic Exercise Moving Toward Function

signs during the appointm ent that the patient is unwilling or hesitant to participate. Ask for permission to perform ex­ amination procedures in advance, or explain what needs to be done and determine what the patient needs to feel com­ fortable in the situation. In many cases, the patient feels most comfortab le being examined by a therapist of the same sex. To the best of your ability, these issues should be addressed when scheduling the patient.

Clarity of Instruction Simple aspects of the exercise program such as clear de­ scriptions and legible writing are also important for adher­ ence. Although written exerci.se programs may provide a personalized touch to the program, it may prove detrimen­ tal if the patient is unable to read your writing. Busy sched­ ules and too little time contribute to hastily written patient instructions. The specific exercise descriptions may make perfec t sense to the clinician but confuse the patient. Base­ line knowledge assumed by the therapist may be too much for th e patient and may result ill incorrect exercise perfor­ mance. Although the patient may be extremely bright and appears to grasp many aspects of medical care, clarity about which direction is "forward" or "up" is still necessalY- Di­ rections should be lengthy enough to be comprehenSive vvithout overburdening the patient with details, Full sen­ tences are unnecessary, but key phrases or bulle ted points can improve clarity. Pictures of the exercises should be included and ideally demonstrate the exercise in the start and finish pOSitions. Communicating a three-dimensional movem en t on a Single sheet of pape r at a stationary point in time is difficult. Showing starting and eflding positions or shO\lVing pictures from different angles helps clarify the three-dimensional nature of the movemen t. Arro'vvs shOWing the direction of movement with marks clearly indicating the start and end positions are helpful. Often, exercise pictures show posi­ tions midway through the exercise and the patient is un­ clear as to the full excursion of the movement. Throughout this book, Self-Managcmcnt boxes present examples of ex­ ercise instructions. Many clinics provide picture files or computer­ generated exercises with pictures, descriptions, and exer­ cise prescriptions included. These are helpful for tJle clini­ cian , but lise caution with these for the foll OWing reasons . First, the therapist frequently needs to modi~' the exercise in some way to adapt it to the speCific patient needs. These modifi cations should be made on the patient's exercise record, not just verbalized. Do not assume that because an exercise is prOvided in one of th ese formats, that it is Ule bes t or only way to perform the exercise. Second, the exer­ cise prescription should be individualized based on the pa­ tient's needs and ability to self-manage the problem, not necessarily prescribed as a certain number of sets and rep­ etitions per day. This type of prescliption may confBct \vith the goal of teaching the patient self-management skills. Ex­ erc.ises that appear to be "canned" or Ulf' standard sheet of exerci sE'S that is given to every patient with a certain diag­ nosis minimizes the individuality of the exercise program. Lack of individualization minimizes the skills of the thera­ pist and may affect adherence if the patient feels his or her needs are not being met.

Communication with the patient regarding the exercise program should be written and verbal. Simply handing a pa­ tient the exercise program without having the patient per­ form each of the exercises increases the likelihood of non­ adherence and incorrect pelformance. A study by Friedrich et al. 24 found that patie nts who received a brochure of ex­ ercises rather than supervised instruction had a lower rating of "correctness" of exercise performance. A strong correla­ tion between the quality of exercise performance and a de­ crease in pain was found. 24 Although patients may say they can remember their exercises, it is best to document the ex­ ercises with a written description that is reinforced \¥ith ver­ bal cueing as the exercises are performed. Organize the exercises to follow a lOgical sequence. An exercise program requiring frequent position changes is time-consuming and burdensome for the patient. Cluster exe rcises of a similar nature for ease of understanding and ease of performance. For example, cluster all exerci ses per­ formed in a supine position to minimize position changes and group together shoulder rotation exercises because of their similar nature . Be sure to organize the exercises to simplify th eir performance and minimize the impact on the patient's lifestyle.

Proper Exercise Execution Although the patient may appear to follow the exercise in­ structions, he or she may still perform the exercise incor­ rectly. The patient may understan d Ule instructions, but the instructions may be incomplete, the patient may read things into the instructions, or the patient may simply be unaware that he or she is not doing what the instructions call for. For example, the patient may think he or she is performing a trunk curl but raUler is doing a full sit-up, or pelforming a straight leg raise without the necessary quadriceps set first. Ensure proper performance by having the patient per­ form each of the exercises under your direction and guid­ an ce, with verbal and tactile cueing for proper perfor­ mance. Encourage the patient to take notes during these sessions to enhance participation , responsibility; and un­ derstanding of the exercise program. Although written and verbal instructions help ensure proper performance, more instruction is occasionally necessary. Other options include haVing a famil y member observe the clinician instructing the pati ent, so that this individual may gUide the patient's home exercise performance. Videotaping the exercise ses­ sion allows the patient to see himself or herself performing the exercise, along with hearing the clinician's verbal cues and observing tactile cues for proper performance . The pa­ tient can replay this tape at home if a question regarding the exercise program exis ts. When the patient returns for follow-up, ask him or her to demonstrate the home exercise program. If the patjent has been performing th e exercises on a daily basis, the exercises should nearlv be committed to memo!'v. The ability of the patient to qu'ickly recall the exercises with or without the as­ sistance of the handout may provide a due about adherence. Moreover, this shows preCisely how the patient has been ex­ ecuting the exercise. Frequently the exercise has been changed somewhat from the clinician's original intended performance, and this may affect the patient's progress since

Chapter 3 Principles of Self-Management and Exercise Instruction

41

A B FIGURE 3-4. The exercise program must be reviewed at fol low-up visits to ensure correct performance. (A) Incorrect position-substituting scapular movement for glenohumeral movement and incorrect degree of rotation . (8) Correct position-clinician corrects exercise performance.

the last visit. Occasionally, the incorrect exercise perfor­ mance can have negative consequences, such as increasing the patient's symptoms or hindering progress (Fig. 3-4).

t'

r

a a t.

Equipment and Environment

to

res

ne

n

ed IC

Along with determining what motivates the patient, deter­ mine the motivation derived from use of exercise equip­ ment. Performing exercises using body weight, objects at the home or office, or work tools may be more functional; however, the patient may feel like this is not really exercise if it does not involve weights or resistive bands. Patient ed­ ucation is necessary to ensure the patient of the impOltance of these activities. However, preconceived ideas about ex­ ercise are frequently difficult to overcome, and adherence may be improved by use of some equipment. The financial cost of purchasing some equipment for home use may in­ crease or decrease adherence. If money mllst be spent to carry out the exercise program, the patient may decline participation. However, some patients feel obligated to use equipment that they have purchased. Assess the patient's position on this issue before issuing or recommending pur­ chase of equipment. When designing an exercise program "vith some specific equipment, ensure that the patient has a place to use the equipment (Fig. 3-5). Depending on the region of the coun­ trY, homes mayor may not have stairs. Other accommoda­ tions may be necessary if exercises require the use of a step. \\ l1en prescribing exercises to be performed in a supine or ro ne position, a surface of the appropriate height and firm­ ness must be available. Exercises often are easy to perform n the plinth in the clinic, but the quality or the ability to per­ orm the exercise is negated at home because of the patient's

environment. The patient must be able to comfOltably tran­ sition positions to and [rom that surface. If the only available firm surface to carry out the exercise program is the floor, the patient must be able to easily get up and down from the floor. If not, the exercise program should be modified to in­ crease the ease of participation in the program. A final aspect of the environment that the clinician has little control over but should consider is the presence of a

FIGURE 3·5. The clinician should choose equipment that can be easi ly used by the patient at home.

42

Therapeutic Exerci se: Moving Toward Functi on

supportive family. Social support is an importan t factor in patient adherence to a treatment regimen. Social support includes both the medical community and the patient's family and immediate community. Social isolation has been determined to be a major factor in nonadherence to a med­ ication regimen. Lack of social support has contributed to dropping out of treatment in a number of studies. 25 Social support is particularly important when managing chronic disease, due to the ongoing nature of the problem . Be sure to evaluate the role of the family and other sup­ port systems in the patient's immediate community. The family or work co mmunity can provide support, or poten­ tially have a negative effect. A supportive family can maxi­ mize the patient's opportunity to participate in medical care by being physically and emotionally supportive. Fam­ ily members who take over duties normally carried out by the patient and advocate participation in the exercise pro­ gram can enh ance the patient's opportunity for improve­ ment. A nonsupportive family who criticizes the patient for being injured or unable to carry out expected roles can cre­ ate barriers to improvement. If possihle, involve the family in the patient's care to en­ sure an understanding of the plan of care and prognosis. This vvill help them understand realistic goals and the plan to achieve them. If family members are nonsupportive, do your best to minimize their negative impact by providing additional support to your patient. Always be alert to signs of this situation and make referrals as necessary to ensure optimal participation in the rehahilitation program.

HOME EXERCISE PRESCRIPTION Prescribing exercises for a home program is challenging. These exercises are performed vvi thout supervision , and patient edu cation is critical to a successful home exercise program. Frequently, limited patient visit time further challenges the clinician to teach the patient all the neces­ sary components of the self-management program. Provid­ ing a short, safe home exercise program is better than be­ ing too broad and overwhelming the patient vvith information on the first visit.

Considerations in Exercise Prescription Exercise prescription can be difficult for several reasons. Determining the number of exercises and the quantity of repetitions, sets, bouts, and intensity is challenging. Too lit­ tle exercise may not produce the desired result, but too much exercise may overwork the patient, resulting in a de­ cline in progress. Many factors influence choices regarding the exercise prescription: • Stage of healing • Tissue irritahility and symptom stability • Patient's time and willingness to participate • Time between physical therapy visits

Stages of Healing The acuity or chronicity of the injury affects the exercise prescription , including the regularity of supervised physical therapy and the time between visits. In the early stages , give the patient a few things to do at home bet\.veen closely

scheduled supervised visits. In the early phase, appoint­ ments may be more frequent because of the rapidity ,'lith which the patient's symptoms, impairments, and function are changing. The exercise program changes more fre­ quently as goals are met and new goals established. In the early stage, the symptoms may be new to the patient, mak­ ing determination of the appropriate exercise level diffi­ cult. Close follow-up of response to treatment is necessary to ensure forward progress. Conversely, in the intermedi­ ate to later stages, changes in the patient's symptoms and function occur more slowly, and the exercise program may be more extensive. The patient is often instructed in self­ progression of activities.

Tissue Irritability and Symptom Stability Tissue irritability has a significant effect on the rehabilita­ tion program choices. This factor is somewhat subjective and is determined through a complete subjective examina­ tion. Questions regarding the patient's symptoms prOvide the clinician \'lith the best information on this issue (Dis­ play 3-2). Before deCiding on tlle choice or intensity of the exer­ cises, understand what kinds of activities or pOSitions worsen the patient's symptoms. These activities or posi­ tions mayor may not need to be avoided. If the patient can tolerate the activity or position for some time, is able to de­ tect the prodromal signs that the symptoms are going to worsen , and understands that stopping the activity or changing position can alleviate the symptoms, use these ac­ tivities or positions therapeutically. For example, if a pa­ tient with carpal tunnel syndrome enjoys knitting and this is one of the patient's functional goals , knitting may be used as part of the rehabilitation program. The patient must be able to recognize the onset of synlptoms and be able to al­ leviate them by taking a rest period or discontinuing the knitting. Similarly, if a patient \vith back pain enjoys and is able to tolerate some walking, this activity can be a compo­ nent of the exercise program. The patient must be able to detect the onset of symptoms and be able to relieve them by discontinuation, stretching, icing, or some other self­ management intervention. Conversely, if the patient re­ ports an unmanageable, inevitable worsening of symptoms once irritated, the exercise program should expressly avoid any position or activit)' that may exacerbate symptoms. Be sure to consider the stability of the patient's symp­ tom s as a component of tissue irritability. Individuals may

DISPLAVJ·2

Questions Assessing Tissue Irritability 1. What activities or positions increase your symptoms? 2. How much time can you spend in that activity or position

before your symptoms begin?

3. When you start feeling these symptoms, will they continue to progress despite discontinuing the activity or changing positions? Will changing the activity or position alleviate the symptoms? 4. After you begin experiencing your symptoms, how long do they last? How long until you return to "baseline"? 5. Is there anything you can do to relieve your symptoms?

Chapter 3 Principles of Self-Management and Exercise Instruction

have significant unpredictable Huctuations in their symp­ toms over the course of the day or week. If symptom changes cannot be associated with the time of day, position, or any specific activity, th e exercise prescription can be dif­ ficult. If the patient is unable to determine what kinds of things make him or her better or worse, assessing the effects of the exercise program becomes yet another variable in the symptomatology. Deciding whether a specific exercise pre­ scription is beneficial or deleterious is challenging if the pa­ tient's symptoms fluctuate randomly. When possible, it is best to proceed with fevver exercise interventions until a sta­ ble baseline of symptoms is achieved. This baseline then serves as a gauge of the effect of the exercise program. Th e patient's other daily activities affect the exercise pre­ scription. Understanding the behavior of a patient's symp­ toms over a 24-hour period and how his or her normal daily routine affects the symptoms helps the clinician to gauge appropriate exercise levels . Frequently, the patient is un­ aware of the im pact of certain routine activities on his or her problem, or the patient must perform some activities that worsen his or her symptoms (such as sitting or walking). For example, the individual with patellofemoral pain should be counseled about the importance of good shoes , particularly if standing for a large portion of the day. Despite the fact that standing behind a cash register for 8 hours may exacer­ bate the patient's symptoms, this work may be necessary to provide financial support for the family. The individual with back pain may need to lift a child out of a crib several times each day, despite the fact that this activity is painful. The clinician must educate the patient about the impact of these activities on symptoms and provide suggestions to minimize their negative effects. Moreover, the clinician must educate the patient regarding modification of the exercise program based on the symptoms related to participation in these ac­ tivities. On days when the patient's symptoms may be in­ creased because of excessive standing, working, or lifting, he or she may need to decrease the rehabilitation exercise level. Failure to recognize the impact of daily activities on symptoms may cause the clinician to erroneously assume that a change in the patient's symptoms was caused by the exercise program alone.

Time Between Physical Therapy Visits The time between follow-up visits affects the exercise pre­ scription. For the patient attending supervised physical therapy one or more times per week, the clinician may be more willing to give the patient more challenging exercises for the home program, knOwing that the patient will be monitored more closely in the clinic. For those patients who live some distance away or who have longer intervals between supervised visits for other reasons , the clinician should provide exercises less likely to overwork the pa­ tients. This program is supplemented with instructions on how to progress exercises jf they become too easy (e.g., in­ rease time, repetitions, intensity) or an intermediate phone follow-up can take place.

Patient's Time and Willingness The amount of time the patient has available to exercise is an important factor affecting exercise prescliption. If the pa­ tient claims to have little time available for the home exercise

43

program, educate the patient about the importance of the program, but make conscious choices about priority exer­ cises. Make an effort to select exercises considered to be the most important for the exercise program. More is not always better, and giving thoughtful consideration to the core exer­ cises is beneficial for the clinician and the patient. Choosing exercises that have the greatest impact for the least time commitment can minimize the time requirement and maxi­ mize the benefits. The patient will probably appreciate your concern and attention to his or her needs. Couple this ap­ proach with education regarding the importance of the home exercise program to achieve the determined goals in as expedient and efficient a time frame as possible. Emphasize the patient's responsibility in achieving those goals.

Determining Exercise Levels Determining the appropriate level of exercise can be diffi­ cult, particularly when the patient has had little or no ex­ perience vvith the specific problem previously or little pre­ vious experience with exercise. Although many individuals exercise regularly, many others have little experience with exercise. Knowing how to respond to different sensations felt during the rehabilitation exercises can prove frustrating to the patient. Many patients ask whether to continue ex­ erciSing if the exercise produces pain. Despite the fact that pain is a subjective symptom, acknowledge this sensation. Consider pain in the context of change from the patient's baseline symptom level and how the symptoms behave over the subsequent 24-hour period. Curwin and Stanish 26 provide guidelines originally de­ signed to help determine readiness to return to a sport. However, these same gUidelines are nicely adapted to eval­ uation of the patient's exercise program (Table 3-1). The column in Table 3-1 entitled "DeSCription of Pain" refers to the level of pain during rehabilitation exercise perfor­ mance, and the categOlY "Level of Sports Performance" could be retitled "Level of Exercise Program Perfor­ mance. " Activity levels that keep the patient 'v\Jjthin his or her optimal loading zone are generally levels 1 through 3. Occasionally, some patients may be able to tolerate exer­ cise at level 4 vvithout any residual effects. In these cases, progress may need to be reassessed on a weekly basis rather than on an exercise session to exercise session or a daily basis. Patients with adhesive capsulitis often experi­ ence pain at level 4, but this level of pain does not interfere with their overall function or progress. Th ese gUidelines prOvide the patient and the clinician com mon criteria " Jjth which the exercise program prescription is evaluated. Despite the clinician's best efforts, some patients expe­ rience an exacerbation of their symptoms, which mayor may not be related to the exercise program. Although the first response of the clinician and the patient may be some level of distress, an exacerbation is not always a negative expe rience. Valuable lessons can be learned from an exac­ erbation. At some pOint, whether days , weeks, months, or years later, most patients experience some type of symp­ toms related to the current problem. The patient with patellofemoral pain may experience a milder level of pain after a hiking vacation , or the individual 'v\Jjth low back pain may notice some back discomfort after a long plane flight.

44

Therapeutic Exercise: Moving Toward Function

Curwin and Stanish Classification for Determining the Appropriate Level of Discomfort Associated with.HomeExercise Prescription LEVEL 1 2 3

4

5 6

DESCRIPTION OF PAIN

LEVEL OF SPORTS PERFORMANCE OR ACTIVITY

[\0 pain Pain only with extreme exertion Pain with extreme exertion and 1-2 hours afterward Pain during and after any vigorous ac:ti\ities Pain during activity and fordng termination Pain during daily activities

N ormal Norma] Norma] or slightly decreased Somewhat decreased Markedly decreased Unable to perform

F rolll Curwin S, Stallish WD: Tendinitis: Its Etioi o,)..,'Y and Treatment. Lexington, MA: DC Heath und Co., 1984:64.

Some patients expelience a complete exacerbation of their symptoms at some future pOint. Patients must learn how to manage the exacerbation. Frequently, seve ral weeks have pas.~ed by the tilllc the patient seeks medical attention and gets an appointment with the physician and a subsequent appointment v.rith the therapist. The optimal time for intervention has passed, and the patient may be struggling v.rith secondary problems resuJting from compensation, or movement changes made because of pain or other impairments. One of the best ser­ vices the clinician can offer the patient is instruction on how to manage a return of symptoms. Instruction may in­ clude the use of modalities such as ice, appropriate activity modifications or rest, changes in the maintenance exercise program, or education regarding when to seek medical at­ tention. In addition to possibly preventing reentry to the medical system tl1rough immediate, appropliate symptom manage­ ment, self-management has the added benefit of enhancing patient<;' confidence in their ability to resolve tllC symptoms The exacerbation experience coupled with instruction in ap­ propriate management under tlle clinician 's guidance can greatly decrease the patient's anxiety. Patients are often fear­ ful about palticipating in activities tl1at may provoke their symptoms, afraid that they v.rill be "back where they started" in the early stages of their injury. Learning that an exacerba­ tion does not necessarily send them back to the initial phase and tllat they can successfully manage the problem empow­ ers patients to make appropriate activity choices. Eventually, patients may choose to participate in activities they enjoy at the expense of getting a little sore, knov.ring that they can successfully manage the symptoms independently.

Formulating the Program When pOSSible, forrnu]ate the exercise program after the paticnt's baseline level of symptoms has stabilized and the preViously mentioned factors (e.g., tissue initability) have been determined. EnsUling the patient's understanding of what the "baseline" feels like aJJows better communication between the clinician and patient regarding the behavior of their symptoms and the effects of the exercise program. Symptoms that are unstable or fluctuating \\rithout deter­

minable cause make assessing the effects of intervention difficult. Ask the patif~ nt to articulate his or her "normal" level of symptoms to assist in determining the stability of symptoms. If patients have difficulty determining the sta­ bility of their symptoms, slow progression is necessary. 'When the patient is able to perform the sallle exercise pro­ gram for tl1fee consecutive sessions without an increase in symptoms, progression is appropriate. If intervention needs to be implemented before the es­ tablishment of a stable baseline, give the patient as few ex­ ercises as pOSSible. This minimizes the impact of the exer­ cise program, thereby lowering the possibility of exacerbating the symptoms. If the patient's symptoms do worsen, you'll have an easier time determining ilie cause, and changes can be made more appropriately. As symp­ toms resolve and the baseline stabilizes, increase activities systematically and gradually. Do this by increasing the time and repeti tions or by adding new exercises slowly. Dow the exercise program is progressed depends on each person 's stage of injury, speCific goals, and stability of symp­ toms. F or the individual who is in the intermediate to late healing stages and has demonstrated stable symptoms, sev­ eral exercises can be progressed Simultaneously. For those with unstable symptoms and frequent exacerbations, only one change in the rehabilitation program should be made at a time. In this way, any positive or negative response to the change can be more easily identified and remedied. Teach patients how to modify their exercise program based on their activity level on any given day. Put exercises in the context of their daily routine. On days when the pa­ tient is more active (e.g., working overtime, child care, shopping, yard work), modify the home exercise program to prevent overload . On days when the patient is more sedentary (e.g., bad weather, day off from work), increase the exercise program. In this way, the patient begins to un­ derstand the impact of his or her overall acthrity level on his or her symptoms. This assists the patient in the self-man­ agement of symptoms in the future. ChOOSing exercises that can be incorporated into activi­ ti es already performed durin g the clay should be a funda­ mental aspect of tl1e exercise program. This type of exer­ cise prescription results in short bouts of exercise performed several times throughout the day, thus improv­

Chapter 3: Principles of Self-Management and Exercise Instruction

ing motivation and adherence. In this case, the patient is unlikely to overwork in any single session, resulting in a lower chance of an exacerbation of symptoms. Moreover, the likelihood of exacerbation is decreased despite a greater volume of exercise than can be performed in any single session. For example, the individual with Achilles tendinitis may tolerate only two repetitions of 30 seconds of calf stretching at a time. If that individual performs those two repetitions six times spread out over the course of her day, the stretch has been performed 12 times. In contrast, if the patient tried to carry out the home exercise program in the evening after work and dinner, chances are only two repetitions would be performed that day. Finally, teach the patient that some exercise is better than none, and if time limitations exist, a couple of key ex­ ercises should be performed. Occasionally, other life events prevent completion of the full home exercise pro­ gram despite the patient's willingness to adhere. Prioritize the exercises, highlighting those that are most important to complete if time does not permit completion of the entire program. Emphasize the importance of finishing all of the exercises when time permits, while suggesting that some exercise is better than none.

KEY POINTS • Changes in health care delivery systems require more patient education and self-management. • Patient safety is the primary issue when designing a home exercise prescription. • The best-designed treatment program is of little value if the patient does not adhere to the clinician's recom­ mendations. • The clinician must determine the patient motivators to enhance likelihood of adherence. • Exercises requiring the fewest lifestyle changes and im­ posing changes that mimic the patient's usual activities can increase adherence. • Patient-clinician communication is enhanced by deter­ mining the patient's willingness to learn and listening ac­ tively to the patient's needs.

l...­_ _

11­

_

_

• Wlitten and verbal instructions should be included in a home exercise program. Written exercises should include beginning and ending positions and any precautions. • On subsequent visits, the patient should demonstrate the home exercise program to ensure correct perfor­ mance of all exercises. • Home exercise choices are affected by the acuity of the injury, tissue irritability, stability of symptoms, time available for exercise, and factors affecting the length of follow-up. • A symptom exacerbation can be a learning experience for the patient if educated properly about the experi­ ence. • Patients must be taught how to modify their home exer­ cise program based on other activities and symptoms. • Understanding the typical behavior of their symptoms allows patients to more easily recognize an exacerbation and be able to guide activity choice and intensity. • Any cultural, language, education, visual, or hearing bar­ riers should be identified early and appropriate accom­ modations made. • Prioritize exercises so that the patient may perform at least some of her exercises on busy days .

CRITICAL THINKING QUESTIONS 1. How would your home exercise instruction differ for patients who were a. Visual learners b. Auditory learners c. Kinesthetic learners 2 . Consider the patient in Lab Activities question 1. How would you prOvide this patient with a home exercise program if he or she were blind? 3. A patient returns to see you and reports that the home exercise was not done because of a lack of time. How do you respond? What is your strategy and rationale? 4 . A patient returns to see you and reports that the home exercise program was not done because the exercises hurt. How do you respond? What is your strategy and rationale'?

LAB ACTIVITIES

1. Refer to Case Study 6 in Unit 7. Design a home pro­ gram for this patient. Include written instructions and diagrams for all exercises. Teach your patient this home program while relaying the follOWing emo­ tions: a. Empathy b. Disinterest c. Hurry d. Insecurity 2. Using the exercises developed for the first question, modify each exercise to be performed throughout the da)" incorporating the exercises into the patient's c1ailv routine. /

45

3. Using the exercises developed for the first question, plioritize the exercises for the patient, and explain your rationale for the priOlitization to the patient. Use language the patient can understand. 4. Your patient desires to return to several sporting ac­ tivities. Choose two of the exercises you have given the patient, ancll11odif)' them to mimic a spolting ac­ tivity to which the patient woulcllike to return. S. Teach someone else in the class who does not know how to tie a necktie how to do this without looking at each other and without using the words yes or 110.

46

Therapeutic Exercise: Moving Toward Function

REFERENCES 1. Cuide to physical therapist practice. 2nd ed. Phys Ther 2001; 81(1):Sl-S738. 2. Chase L, Elkins JA, Readinger J, et al. Perceptions of physi­ cal therapists toward patient education. Phys Ther 1993;73: 787-796. 3. Calumer JE , Domholdt E. Amount of patient education in physical therapy practice and perceived effects. Phys Ther 1996; 76: 1089-1096. 4. Holmes CF, Fletcher JP, Blaschak MJ , et al. Management of shoulder dysfunc tion. J Orthop Sports Phys Ther 1997;26: 347- 354. 5. Cameron C. Patifmt compli ance: recognition of factors in­ volved and suggestions for promoting compliance with thera­ peutic regim e ns. J Adv Nurs 1996;24:244-250. 6. Sluijs EM , Kok GJ, van der Zee J. Correlates of exercise com­ pliance in physical therapy. Phys Ther 1993;73:771-787. 7. Marcus BH, Simkin LR. The stages of exercise behavior. J Sports Med Phys Fitness 1993;33:83-88. 8. Chen CY, Neufeld PS, Feely CA, et al. Factors influencing compliance with home exercise programs among patients \vith upper-extremity impairme nt. Am J Occup Ther 1999; .53:171-180. 9. Elder JP, Ayala GX, Harris S. Theories and intervention ap­ proaches to health-behavior change in primary care. Am J Preven ivied 1999;17:275-284. 10. Marcus BH, Simkin LR. The transtheoretical model: applica­ tions to exercise behavior. Med Sci Sports Exerc 1994;26: 1400-1404. 11. Prochaska JO. Strong and weak prinCiples for progressing from precontemplation to action on the basis of tvvelve prob­ lem behaviors. Health PsychoI1994;13:47-51. 12. Peterson TR, Aldana SG. Improving exercise behavior: an ap­ plication of the stages of change model in a worksite setting. Am J Health Promotion 1999;13:229-232.

13. Bandura A, Adams ~E, Beyer J. Cognitive processes mediat­ ing behavioral change. J Personality Social Psychol 1977;35: 125-139. 14. Nolan RP. How can we help patie nts initiate change? Can J CardioI1995;1l(Suppl A):16A-19A. 15. Brus HL, van de Laar MA, Taai E, et. al. Effects of patient ed­ ucation on compliance with basic treatment regimens and health in rece nt onset active rheumatoid arthritis. Ann Rheum Dis 1998;57:146-151. 16. Fields J, Murphey M, Horodyski MB , et al. Factors associated with adherence to spo rt injury rehabilitation in college-age recreational athletes. J Sport Rehab 1995;9: 172-180. 17. Gieck J. PsycholOgical considerations for rehabilitation. In: Prentice W, ed. Rehabilitation Techniques in Sports Medici ne. 2nd Ed. St. Louis: Mosby-Year Book, 1994. 18. Schwenk TL, Whitman N. The Physician as Teacher. Balti­ more: Williams & Wilkins, 1987. 19. Brophy J. Research on the self-fulfilling prophecy and teacher expectations JEd PsychoI1983;75:631-661. 20. Fisher A. Adherence to sports injury rehabilitation pro­ grammes. Sports Med 1990;9: 151-158. 21. Hom T. Expectancy effects in the interscholastic athletic set­ ting: methodolOgical concerns. J Sport PsychoI1984;6:60-76. 22. Wilder KC. Clinician's expectations and their impact on an athlete's compliance in rehabilitation. J Sport Rehab 1994;3: 168--175. 23. Spector RE. Cultural Diversity in Health and Illness. Upper Saddle River, NJ: Pren tice-Hall , Inc. , 2000. 24. Friedrich M, Cermak T , \1aderbacher P. The effec t of brochure use versus therapist teaching on patients perrorm­ ing th erapeutic exercise and on changes in impairme nt status. Phys Ther 1996;76:1082-1088. 25. Becker MH, Green LW. A family approach to compliance \,vith medical treatment: a selective re\1eW of the literature. Int J Health Educ 1975;18:173-182. 26. Curwin S, Stanish WO. Tendinitis: Its Etiology and Treat­ ment. Lexington , MA: DC Heath , 1984.

chapter 4

Prevention and the Promotion of Health, Wellness, and Fitness JANET R. BEZNER

The Context for Primary Prevention Definitions

Measurement of Wellness

Health Promotion and Wellness-Based Practices From Illness to Wellness The Use of Screening as an Examination Tool Within a Well­ ness-Based Practice Starting a Wellness-Based Practice

The function of protecting and developing health must rank even above that of restoring it when it is impaired.-­ Hippocrates

Interventions aimed at preventing injury and illness are among the many tools physical therapists use on a daily ba­ sis to address the health needs of the patients we serve. In­ deed, prevention, health promotion, and wellness efforts have recently garnered increased attention as the nation struggles to control escalating health care costs and to stop the progression of chronic diseases that have reached epi­ demic proportions. 1,2 It has been estimated that 50% of premature deaths in the United States are related to mod­ ifiable lifestyle factors,3 so there is clearly a need for effec­ tive prevention programs and efforts aimed at reducing risk factors and improving health and wellness. Traditionally the physical therapist's role in prevention and wellness has been narrowly focused on preventing a re­ currence of the injury or illness a patient already has experi­ enced, or identifYing risk factors and preventing escalation into disease. For example, when treating a patient recover­ ing from an ankle sprain, some rehabilitation activities are di­ rected toward preventing a recurrence of that injury. The approach may include direct interventions such as balance exercises or indirect interventions such as patient education. ome physical therapists perform biomechanical analyses such as running gait analysis or ergonomiC workstation anal­ ysis to identify risk factors predisposing clients to injury. Al­ though appropriate and worthwhile, these efforts do not produce the signuicant outcomes that primary prevention programs might, because they are applied after the onset of li sk, illness, or injury. Contemporary physical therapist prac­ tice includes a role for the physical therapist in primary pre­ \'ention-that is, interacting with clients to promote health and improve wellness before they become patients.

Physical therapist efforts in health and wellness promo­ tion require an expanded view of health beyond the biomedical or disablement models. Additionally, it is im­ portant to recognize that clients may not be motivated to participate in health-causing behaviors until they become symptomatic or ilL The purpose of this chapter is to explore the concepts of prevention, health promotion, and wellness. Because the remainder of this book discusses interventions aimed at injured or ill patients, this chapter will focus on pri­ Tnan} prevention and the services that physical therapists can provide to clients before they become patients.

THE CONTEXT FOR PRIMARY PREVENTION Numerous physical therapy profeSSional references sup­ port a role in health promotion and wellness. The Guide to Physical Therapist Practice, which defines the physical therapy scope of practice, discusses the physical therapist's role in prevention and the promotion of health, wellness, and fitness. 4 The American Physical Therapy Association's vision statement, goals, and objectives and several policy statements reference the role of the physical therapist in the provision of health and wellness services. 5 Numerous state licensing acts include within the definition of physical therapy a reference to promoting and maintaining fitness, health, or wellness in all age groupS.6 The accreditation cri­ teria for physical therapy educational programs state that graduates of accredited programs are prepared to identify and assess health needs and provide approflriate preven­ tion and well ness information and programs. 7 Thus the expectation that physical therapists participate actively in health and wellness practice exists in many pro­ fessional documents. To provide such services, the physical therapist must first understand and differentiate the many terms used to describe these concepts.

Definitions Prevention, Health Promotion, and Health Education There are many terms used ""fjthin the context of "preven­ tion" within the US health care system. Differentiating these terms proVides a valuable perspective for the delivery of appropriate sef\fjces by physical therapists. Figure 4-1 il­ lustrates the prevention to intervention continuum, rang­ ing from health promotion services to rehabilitation. The

47

48

Therapeutic Exercise Moving Toward Function

Prepathogenesls Period Health Promotion

Health Protection

Primary Prevention

Preventive Health Services

Period of Pathogenesis Early Diagnosis and prompt treatment

Disability Limitation

Secondary Prevention

associated pathologic state of the patienUclient at each stage of prevention is shown across the top of the diagram . Prevention is divided into primary and secondary preven­ tion services. Also referred to as public health, primary prevention includes health promotion, health protection, and preventive health services . Primary prevention takes place in the "prepathogenesis" period before the onset of disease. Secondary prevention services take place after the onset of illness or injury, in the presence of pathology, and include screening for the purpose of early diagnosis and treatment of disease , as well as disability limitation. Secondary prevention includes efforts to ide~tify disease early hy recognizing either the physiologic changes that precede illness or signs of subclinical illness. Examples in­ clude breast and prostate cancer screening, osteoporosis screening, medical preplacement evaluations, and accident reportingt-l Also included within secondalY prevention are efforts to limit disability for those with chronic diseases such as diabetes (i.e ., a foot care educational program) or spinal cord injury (i.e., a program to prevent skin break­ down ). Tertiary care, or rehabilitation , is the category that encompasses most of traditional physical therapist ser­ vices. Although the physical therapist may use health edu­ cation methods to provide information in the case of a sec­ ondary prevention effort, the health status of the patienUclient dete rmines whether this information falls under primary, secondary, or teliiary care. For example, providing information about how to be physically active for a client without injury or illness might be classified as pri­ mary prevention, whereas providing the same information to a client with diabetes would be considered secondary prevention , and including physical activity in an interven­ tion plan for a diabetic client who is receiving rehabilitation for an amputation would be considered tertiary care. In terms of primary prevention, health promotion is the most significant component for the physical therapist to understand. Health promotion can been defined as a combination of educational and environmental programs or actions that are conducive to health. 9(p. 17)Three terms in this definition are worth exploring to understand the con­ cept. They are: combination, educational, and endronmen­ tal. The term "combination" suggests that a variety ofleam­ ing experiences are necessary to influence behavior change. It is rare that a Single intervention can make a pro­ found change. For example, in instituting an osteoporosis prevention program, it would be appropriate for the physi­ cal therapist to consider factors beyond the exercise pro­ gram. Other health care providers on the program team might be enlisted to ensure that important factors such as

Rehabilitation

Tertiary

FIGURE 4·1. Differentiation of primary, sec­ ondary, and tertiary prevention.

nutrition and hormone status are addressed , 'vvhich will re­ inforce the need to partake in physical activity, as well as provide valuable information about other useful interven­ tions. The word combination also suggests that interven­ tions should be matched to specific behaviors. In the case of the osteoporosis program , interventions should be planned to increase the quantity of weight bearing activity the participants experience. Education within the definition of health promotion refers to health education, which is "any combination of learning experiences designed _to facilitate voluntary ac­ tions conducive to health. " 9 (p l /) Health education activi­ ties are planned out, rather than incidental experiences (e.g., designed) and facilitate behavior change without co­ ercion (e.g., voluntmy). Examples of health education ini­ tiatives include counseling a patient on the risks of smok­ ing, providing an osteoporosis prevention class for a corporate wellness program, and teaching children how to carry and load their backpacks safely. The word "environmental" in the definition is meant to encompass the myriad of social forces th at influence health, including social, political , economic, organizational, policy, and regulatory issues 9 It is critical to recognize that health promotion is broad and includes both individual and social/regulatory activities. For example, a physical thera­ pist working for a large manufacturing company may want to begin a smoking cessation program to improve overall worker health. However, if the employer does not have a nonsmoking policy, efforts to stop smoking at the individ­ uallevel will most likely be ineffective. Other illustrations of the broad net of health promotion include programs to increase the activity levels of youths or the elderly, corpo­ rate policies that provide release time to exercise , and funding to support or build public parks and trails. Based on these definitions , it is apparent that the term health education falls under the umbrella of health promo­ tion, and often the activities that would define each are overlapping 9 More recently, it has been suggC'sted that the terms health prol1wtion and health education are not sig­ nificantly different, and , in fact , are often used inter­ changeably.9 The bottom line is that both health promotion and health education refer to the "broad and varied set of strategies to influence both individuals and their social en­ vironments, to improve health behavior, and to enhance health and quality of life." IO(plO) The terms health promotion or health education are the most relevant aspects of primary prevention for the physi­ cal therapist. Health protection refers to strategies deal­ ing with engineering the physical environment such as wa­

Chapter 4 Prevention and the Promotion of Health, Wellness, and Fitness

te r fluoridation, whereas preventive health services refers to traditional medical system efforts to prevent in­ jury and illness-for example, immunizations.

WeI/ness and Lifestyle Wellness is defined in the Guide to Physical Therapist Practice, 2nd edition, as "concepts that embrace positive health behaviors and promote a state of physical and men­ tal balance and fitness."4 Since H.L. Dunn conceptualized wellness in 1961 and offered the first formal definition of the term ("an integrated method of functioning which is riented toward maximizing the potential of w\~ich the in­ dividual is capable."ll(p.j)), wellness has been explained by n l.rious models and approaches l2 - W Although the litera­ tu re is full of definitions of, references to, and information about wellness, a universally accepted definition has failed to emerge. Several conclusions can be drawn, however, from the abundance of literature about wellness. For many people, including the public, health and well­ ness are synonymous with physical health or well-being, and commonly consists of physical activity, efforts to eat nutri­ tiously, and adequate sleep, Research has indicated that when the publlic is asked to rate their general health, they nan owly focus on their physical health status, and do not consider their emotional, social, or spiritual health. 20 R'fer­ ring back to the definitions introduced earlier, it is obvious that wellness includes more than just physical parameters. The common themes that emerge from the various models and definitions of wellness suggest that wellness is multidimensional, 1113- 19,21 .22 salutogenic or health caus­ ina 11,13,16,17,19,23,24 and consistent with a systems view of peb;sons and their environments. 11,25-27 Each of these char­ acteristics will be explored, First, as a multidimensional concept, wellness is more than simply physical health . Among the dimensions in­ cluded in wellness are physical, spiritual, intellectual, psy­ cholOgiC. social, emotional, occupational, and community or environmental, 2.'} Adams et al, 28 proposed six dimensions of wellness based on the strength and quality of the theo­ retical support in the literature, The six dimensions and their corresponding definitions are shown in Table 4-1. -~-I

--.

l­

-

Definitions of,the Dimensions ~ of ;yv~~ness .. _ __ __ _

Phvsica] PsycholOgiC

ociai

I

f

49

E motional piritual Intellectual

' ____

Positive perceptions and expectancies of physical health A general perception that one will expelience positive OutCOlllPS to the events and circull1stances of 'life The perception that family or friends are available in times of need, and the perception that one is a valued suppOli provider The possession of a secure sense of self-identity and a positive sense of self-regard A positive sense of meaning and purpose in life The perception that one is internally energized by the appropliate amount of intellectually stimulating activity

\ dam s et al., 1997)

FIGURE 4-2. The Wellness Model. The second characteristic of wellness is that it has a salu­ togenic fo cus in contrast to a pathogeniC focus in an illness mode1. 24 E mphasizing that which causes health is consis­ tent with Dunn's original dellnition.! l It suggests that well­ ness involves maximizing an individual's potential, not just preventing an injury or maintaining the status quo. Well­ ness involves choices and behaviors that emphaSize optimal health and well-being beyond the status quo. Third, wellness approaches me a systems perspective, In systems theory each element of a system is independent and contains its own subelements, in addition to being a subele­ ment of a larger system. 21,25,2(; Further, the elements in a s,Ys­ tem are reciprocally interrelated, indicating that a disruptlOn ofhomeostasis at any level of the system affects the entire sys­ tem and all of its subelements. 2.S,2fi Therefore, overall well­ ness is a reflection of the state ofbeing within each dimension and a result of the interaction among and between the di­ mensions of welJness. Figure 4-2 illustrates a model of well­ ness reflecting this concept. Vertical movement in the model occurs between the wellness and mness poles as the magni­ tude of wellness in each dimension changes (see blaek arrow above), The top of the model represents wellness because it is expanded maXimally, whereas the bottom ofthe model rep­ resents illness. The size of each dimension (a subelement in systems theory) represents how much wellness an individual pos­ sesses in that dimension. As wellness fluctuates in each di­ mension an erred is aenerated on all of the other dimen­ sions (r~ciprocal interrelation), see red arrow above, According to systems theory, movement in every dimen­ sion influences and is influenced by movement in the other dimensions. 28 As an example, an individual who experi­ ences a knee injury and undergoes surgery to repair the an­ terior cruciate ligament will probably e)<,.-perience at least short-term decreased physical wellness (the size of the physical dimension on the diagram will decrease), Applying systems theory and according to the model, this individual may also experience a decrease in other dimensions, such

50

Therapeutic Exercise Moving Toward Function

---------------------------------------------------------

as emotional or social wellness, in the postoperative period resulting from the connectedness or interrelatedness of all of the dime nsions. The overall effect of the changes in these dimensions will be a decrease in overull wellness, which anecdotally we know occurs when patients e>..'peri­ ence a physical illness or injury. In other words , they also experience a change in their emotional or social states. Fur­ ther applying the model in terms of an intervention plan, focus on a nonphysical state, such as the emotional or social dimension , can positively affect the physical dimension and result in improvf'd wdlness during recovery from an injury or illness. The word lifestyle differs from wellness and thus is also important to consider, because many Significant causes of disease , such as obeSity and diabetes, involve lifestyle choices. 29 The Simplest definition of lifestyle is perhaps "the consciously chosen, rersonal behavior of individuals as it may relate to health.,,9(p3) A more complex notion of lifestyle recognizes that personal behaviors are Significantly influ enced by social and cultural circumstances, indicating that behavioral choices may not be entirely under volitional control. For example, there is a great deal of controversy over tobacco advertising and its influence on celtain popu­ lations. Consideration, therefore, of an individual's behav­ iors related to health and wellness , is most appropriately done \,vithin the context of social and cultural influences , and, more importantly, interventions deSigned to change behaviors should recognize the important influence of so­ ciety and culture. This understanding of lifestyle is congru­ ent "vith defiinitions of wellness, because it acknowledges that there are multiple influences on behavior.

Measurement of Wellness As a result of the varied way that wellness has been defined and unde rstood, a variety of wellness measures exist. A good well ness measure should reflect the multidimension­ edity and systems orientation of the concept and have a salutogenic focus. In the literature and in daily practice, clinical, phYSiologiC, behavioral, and perceptual indicators are all touted as wellness measures. Clinical measures in­ clude blood lipid levels and blood pressure; physiologic in­ dicators include skin fold measurements and maximum oxy­ gen uptake; behavioral measures include smoking status and physical activity frequency; perceptual measures in­ clude patient/client self-assessment tools such as global in­ dicators of health status ("Compared to other people your age, would you say your health is excellellt, good, fair, or poor,?,,)30 and the SF-.36 Health Status Questionnaire. 31 Although clinical, phYSiologiC, and behavioral variables are useful indicators of bodily wellness and are commonly used to plan individual and commuHity interventiOns, they are incomplete measures of wellness.:1':2 Clinical and physi­ ologiC measures assess the status of a single system, most commonly within the physical domain of wellness. Overall, behavioral measures are a better reflection of multiple sys­ tems due to the influence of motivation and self-efficacy on th e adoption of behaviors, but they do not describe the wellness of the mind. On the other hand, perceptual mea­ sures are capable of assessing all systems and have been shown to predict effectively a variety of health out­

comes.28.30.33-35 Perceptual measures can complement the information prOvided by body-centered measures. 32 Although some perceptual measures assess only Single system status (e.g., psychologiC well-being, mental well-be­ ing), numerous multidimensional perceptual measures ex­ ist and can serve as wellness measures. Perceptual con­ structs that have been used as wellness measures include general health status,31 subjective well_being,36.37 general well_being,38,39 morale,40.4'1 happiness ,42.4:t' life satisfac­ tion ,44-46 hardiness , 47.4'1 and perceived wellness. 2s , ~9.,)U Ex­ ample questions from a few of these perceptual tools are listed in Table 4-2. The influence of perceptions on health and well ness has been demonstrated repeatedly in a variety of patient/client populations and a variety of settings. Mossey and Shapir0 30 demonstrated more than 20 years ago that self-rated health was the second strongest predictor of mortality in the el­ derly, with age being the strongest predictor. Numerous other researchers have replicated these findings in other populations, lending support to the value of perceptions in understanding health and wellness and indicating that how well you think you are may be more important than how well you actually are. Patient's perceptions are critical in understanding and explaining quality of life.:32 Health per­ ceptions prOvide an important link betvveen the biomedical model with its focus on "e tiological agents, pathological processes, and biological, phYSiological, and clinical out­ comes" and the quality of life model, with its focus 011 "di­ mensions of functioning and overall well-being. ',;)2;p59) (Fig. 4-3). Health perceptions "are among the best prediC­ tors of general medical and mental health services as well as strong predictors of mortality, even after controlling for clinical factors. "30..31:p62) Physical therapists assess perceptions as a part of the pa­ tient/client history, as recommended in the Guide to Phys­ ical Therapist Practice. 4 Some of the kinds of perceptions that can be assessed include perceptions of general health status, social support systems, role and social functioning, and functional status in self-care and home management activities, and work, community, and leisure activities. Al­ though a few of these categories are included in overall wellness, such as general health status and social and role functioning, measuring wellness perceptions speCifically can proVide additional and more complete information about the patient that the physical therapist can use to for­ mulate a plan and that can be insightful to the patient/client. Therefore, perceptual tools should be in­ cluded when measuring weliness for primary prevention and when examining patients/clients for secondary or ter­ tiary prevention.

HEALTH PROMOTION AND WELLNESS­ BASED PRACTICES Establishing a wellness-based practice or offering health promotion and wellness services requires that the physical therapist or prOvider modify the traditional approach used to treat patients. Creating a successful weliness-based prac­ tice involves changing the focus from illness to weliness ,

Chapter 4 Prevention and the Promotion of Health, Wellness , and Fitness

51

Sample Items from Perceptual Measurement Tools INSTRUMENT

PERCEPTUAL CONSTRUCT

SAMPLE ITEMS (RESPONSES)

SF_363 l

General health perceptions

Satisfaction with Life Scale 44

Life satisfaction

Perceived Well ness Surver8

Perceived well ness

NCHS General Well-Being Schedule39

General well-being

Philadelphia Geriatric Center Morale Scale 40

Morale

Memorial University of Newfoundland Scale of Happiness 43

Happiness

"In general , would you say your health is:" (excellent, very good , good, fair, or poor) "Compared to one year ago, how would you rate your health in general now?" (much better than one year ago, somewhat better, about the same, somewhat worse, much 1I"0rse) "In most ways my life is close to my ideal" "I am satisfied \\lth my Life" (7-point Likert scale from stroll gly disagree [lJ to strongly agree [7]) "I am always optimistic about my future" "I avoid activities that require me to cuncentrate" (6-point Likert scale from very strongly disagree [1] to vely strongly agree [6]) "How have you been feeling in genera r~" (In excellent spirits , In very good spirits , In good spirits rnostly, I have been up and down in spirits a lot , In low spirits mostly, In ve ry low spirits ) "H as your daily life been full of things that were interesting to you?" (All the time, Most of the time, A good bit of the time, Some of the time, A little of the time, None of the time ) "Things keep getting worse as I get older" "I am as happy now as \vhen I was younger" (yes, no) "In the past months have you been feeling on top of the world?" "As I look back on my life, I am fairly well satisfied" (yes, no, don't know)

Characteristics of the Individual

Symptom

L--

/ AmPlif/ication

1

-

~

- -- - - - - - - ' \ 1

Values p\references ~

Personality Motivation

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e \'

n

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Biological and

Physiologic Variables

Symptom Status

-

\

Psychological Supports

\

Functional Status

t

Social and Economic Supports

th ~d

c­

'S,

General

Health

Perceptions

-

Overall Quality of Life

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/

p ppo,, Social and Physiologic

I Characteristics of the Environment

FIGURE 4·3. Health-related Quality of Life Conceptual Model.

al

-

32

Nonmedical Factors

I

52

Therapeutic Exercise Moving Toward Function

being a role model of well'ness, incorporating wellness measures into th e examination , considering the client within his or her system, and offering services beyond the traditional patient-pro\iiuer relationship.

From Illness to Wellness The types of services provided in a physical therapist well­ ness-based practice can be varied and are influenced by the population served, the skills and eJ..'Pertise of the phys­ ical therapist, and the setting in which the services are provided. Based on the definition and characteristics of wellness provided earlier in this chapter, wellness services can be provided in any setting and to any population-it just requires changing the approach to consider patients as clients who have the potential and opportunity to be more well. The most common weJJness-based practices are inte­ grated within a tradition al physical tl1erapy setting in which patients convert to "members" after uischarge from physi­ cal therapy services for a specific diagnosis. These pa­ tients/clients use the clinic or fitness faCility to continue their exercise program. In this case, the client would have access to the faCility to perform an individually or group prescribed exercise program and to the physical therapist who would be available to answer questions and progress the client's program. Additionally, to truly address "weJJ­ ness ," the prOvider must consider offering services beyond only the physical domain. Establishing a well ness-based practice within an exist­ ing physical therapy setting requires several features. The facilitv should be available and staffed at convenie1lt hours for '~lie nts and the staff should have expertise in exercise prescription as well as awareness and knowl­ dge of wellness. For exa mple, opportunities can be cre­ ated to acknowledge the influence of social connections on wellness by offering group classes and group interac­ tion among clients. The intenectual aspect of wellness can be tapped by providing educational resources and challenges for clients. For example, offering an educa­ tional class on topics such as progressing an exercise pro­ gwm or nutrition, then testing understanding of an ex­ ercise prescription or the content of a class are activities that would use and challenge the intellectual dimension. Additional staff with expertise in mental and spiritual health can be retained as consultants to provide services in th ese uilllensions when indicated or requested by clients. Some facilities provide an integrated experience, vvith mental and spiritual health as a component of the wellness program. E stablishing a well ness-based practice also requires that the prOVi de r assume the role of a facilitator or part­ ner rather than that of an authority figure. 51 'When a pa­ tient is ill it is often appropriate for the health care prOvider to act as the exp ert because the patient has lim­ ited ability to prOVide self-care and is relying on the provider for information and sblls to recover and im­ prove. In a wellness setting the best approach ]S to believe that the client knows best i.n terms of maximizing his or her potential; therefore, assuming a partner or facilitator role is more appropriate and will create a relationship in

which the client feels empo\Vered to take control. Rath er than "making" the client well , the provider can view the client as a whole person within a biopsychosocial context and consider teaching the client how to achieve wellness. Being a role model and fulfilling the role of facilitator will establish a relationship and environment in which clients can attain greater wellness.

The Use of Screening as an Examination Tool within a Wellness-Based Practice The Guide to Physical Therapist Practice defines screening as determining the need for further examination or consul­ tation by a ph:sical therapist or for referral to another health profeSSional. Screening is important and applicable in a health promotion context because it enables identification of the health status, personal goals, and available resources of the client. Within a physical therapist's scope of practice and a health promotion/wellness context, clients can be screened in numerous ways. Wellness programs routinely screen for osteoporosis, physical activity level, balance/risk for fall s, muscle strength and endurance, flexibility, per­ ceived wellness and quality of life, and motivation to change health-related behaviors or adopt new behaviors. A number of tools have been developed and are available in the litera­ ture for use in scree ning clients. Example perceptual screening tools that can be used in a wellness or primary prevention context and tlleir uses are listed in Table 4-3. Screening tools can be used to identify whether or not a client has risks that should be investigated before partici­ p ating in an intervention program. The physical therapist can also use the screening information to identify who should perform further examination and intervention, and the conditions under which the intervention should be per­ form ed (e.g., with or without supervision, the need for a medical diagnostic test). Screening tools can also identify a baseline from which progress can be assessed and docu­ mented. Depending on specific state law, screens may be performed on existing clients or can be used to identify those who would benefit from services.

Starting a Wellness-Based Practice The mechanics of starting a specific wellness-based prac­ tice do not differ from starting or e}..'Panding any type of practice. The first step should include verifying that "well­ ness" or "health promotion " is included within the defini­ tion and description of pbysical therapy in the state prac­ tice act. Second, the liability pohcy should be checked to ensure coverage for wellness type activities. As with any new endeavor, physical th erapists should spend time iden­ tifyi ng and understanding the potential risks involved in the provision of wellness services. Although great strides have been made in the area of in­ surance coverage for health promotion and wellness ser­ vices, most in surers do not reimburse health care providers for these services. However, the public understands the value of these services and is becoming more and more willing to pay directly for them. 52 In the case of populatiOns that are unable to afford these types of services, consider prOViding more affordable group and community pro­

Chapter 4: Prevention and the Promotion of Health, Wellness, and Fitness

~ _

53

Perc,eptual Screening Tools

PERCEPTUAL SCREENING TOOL

USE

RESOURCE/REFERENCE

Physical Activity Readiness Questionnaire (PAR-Q)

General activity screen for ages 15-69

Canadian Society for Exercise Physiology www.csep.ca

Self-efficacy for Exercise Questionnaire

Assesses the beliefs one has regarding success with phySical activity

Marcus, Selby, Niaura, et al. (1992) 53

Physical Activity Enjoyment Scale (PACES )

Assesses how enjoyable a client finds exercise

Kendzierski , DeCarlo (199 1) 54

Motivational Readiness for Change Scale (Trans theoretical Model)

Assesses a client's readiness to change for any behavior (exercise, smoking, etc.)

Marcus , Simkim (1993)55; Prochaska, DiClemente (19S3) 56

Short Form 36 (SF -36)

General perceptual health status and outcomes q uestionnai re

Medical Outcomes Trust www.outcomes-trust.org

Perceived'Vellness Survey (P'VS)

General perceptual well ness survey

Adams, Bezner, Steinhardt (1997)

Risk for falls

Assesses a client's risk for falling

Computer Workstation Checklist

Identi fies clients at risk for injury as a result of computer use

Balance Self-Test www.balanceandmobility. com/patienUnfo/ printout.aspx Ww\v.os ha.gov/S LTC/etools/ com pu terworksta tions/ checklist .htm l

!rrams, applying for state and federal grants to support pro­ grams, or providing pro bono services that offer recognition through positive public relations. Other activities that should be well thought out and planned include marketing and advertising the program and evaluating program success. Although speCifics of rhese activities are outside the scope of this chapter, they Me key to overall program effectiveness. Whether you are

28

PHYSICAL THERAPY APPLICATION Indicates whether or not an individual should seek further medical consultation before beginning an aerobic exercise program. Provides the physical therapist ~tith information about perceptions of success with physical acti\tity, which can be a barlier to adopting an activity habit if not addressed. Provides information about how enjoyable a cl.ient finds exercise, Researchers have found that enjoyment is related to adherence to physical activity, so when enjoyment is low it should be addresse d in the exercise prescription. Provides information from which the physical therapist can tailor the intervention for a speCific behavior. For example, if a client is not ready to change, the intervention ,viII be very different compared to a client who is ready to make a change. Provides information about perceptions in e ight health concepts, including physical functioning, role limitations resulting from physical health problems , bodily pain, social functioning, g('neraimentalll('al th, role limitations resulting from emotional problelll s, vitality (c nC'f)"''Y/fatigue), and generall1('alth perc('ptions . Can be used to determine the relative burden of an injury or illness and to document the relative benefits/outcomes of an intervention or interven tions. Provid('s information about general well ness perceptions ill six diml'nsions , including phYSical, emotional, social , psycholOgiC, spilitual , and intellectual. Can be used to determine the relative burden of all injury or illness and to docume nt the effect of an intervention on overal l we llness. Indicates an individual's lisk for falling and thus the need for further examination and intervention. Identifies speCific areas "'tithin a computer works tati on wlwre problems may exist that wou ld benefit the worker to be addn:ssed. Includes the areas of posture. seating, keyboarcl!input devi(;(" mon itor, work area, accessories, and general issues.

stalting a speCific wellness-based practice or program or are adopting a wellness approach within an existing health care setting, shifting from a medical to a biopsychosocial fo­ cus, recognizing that, as impOltant as they may be, there is more to wellness than physical parameters, and adding the assessment of perceptions to your examination toolbox are both approaches that will provide a strong basis for a well­ ness program.

54

Therapeutic Exercise: Moving Toward Function

KEY POINTS • Prevention is classified as primary, secondary, or tertiary • Health promotion and wellness fall into the realm of pri­ malY prevention, whereas most rehabilitation is sec­ ondary or tertiary prevention • The terms health promotion and health education are often used interchangeably • Well ness is multidimensional, salutogenic, and requires a systems perspective • \Vellness extends beyond only the physical domain to in­ clude many other dimensions such as spiritual, intellec­ tual, psychosocial, and emotional • Perceptual measures are often better predictors of gen­ eral well-being than physiolOgiC measures • Wellness requires a vision beyond just the physical do­ main and the biomedical model

REFERENCES 1. u.s. Department of Health and Human Services. Healthy People 2010. Washington DC: U.S. Department of Health and Human Services, 2000. 2. HealthierUS Initiative. Available at: http://www.health­ ierus.govlindex.html. Accessed December 18, 2003. 3. McGinnis JM , Foege WHo Actual causes of death in the United States. JAMA 1993;270:2207-2212. 4. Guide to physical therapist practice . 2nd ed. Phys Ther 2001 ;81:471-593. 5. American Physical Therapy Association. House of Delegates Policies. Available at: http ://wvw/.apta.orgigovernanceIHOD/ poliCies. December 18, 2003. 6. Federation of State Board of Physical Therapy The Model Practice Act for Physical Therapy. 3rd ed. Alexandria, VA: Federation of State Boards of Physical Therapy, 2002. 7. The Commission on Accreditation of Physical Therapy Educa­ tion. Evaluative criteria for accreditation ofeducation programs for the preparation of physical therapists . Alexandria, VA, 1996. 8. Stave GM. The Glaxo Wellcome health promotion program: the contract for health and wellness. Am J Health Promotion 2001;15:359-360. 9. Green LW, Kreuter MW. Health promotion planning. An educational and environmental approach. 2nd Ed. Mountain View, CA: Mayfield Publishing Company, 1991. 10. Glanz K, Rimer BK, Lewis FM. Health behavior and health education. 3rd ed. San Francisco: Jossey-Bass , 2002. 11. Dunn HL. High Level Wellness. Washington DC: Mt. Ver­ non, 1961. 12. Wu R. Behavior and IUness. New Jersey: Prentice-Hall , 1973. 13. Lafferty J. A credo forwellness. Health Ed 1979;10:10-11. 14. Hettler W. Wellness promotion on a university campus. J Health Promotion Maint 1980;3:77-95. 15. Hinds We. Personal paradigm shift: a lifestyle intervention approach to health care management. East LanSing, MI: Michigan State , 1983. 16. Greenberg JS. Health and wellness: a conceptual differentia­ tion. J School Health 1985;55:403-406. 17. Ardell DB. High Level \Vellness. Berkeley, CA: Ten Speed Press, 1986. 18. Travis JW, Ryan RS. Wel1ness Workbook. 2nd Ed . Berkeley, CA: Ten Speed Press, 1988. 19. Depken D . Wellness through the lens of gender: a paradigm shift. Wellness Perspectives 1994;10:54--69. 20. Ratner PA , Johnson, JL, Jeffery B. Examining emotional, physical, social, and spiritual health as determinants of self-

rated health status. Am T Health Promotion 1998;12: 275--282. . 21. Nicholas DR, Gobble DC, Crose RG, et al. A systems view of health, wellness and gender: implications for mental health counseling. J Ment Health Counsel 1992;l4:8- 19. 22. Whitmer JM , Sweeney TJ. A holistic model for wellness pre­ vention over the life span. J Counsel Develop 1992;71: 140-148. 23. World Health Organi za tion. Basic Documents. 15th Ed. Geneva, Switzerland: WHO , 1964. 24. Antonovsky A. Unraveling the Mystery of Health: How Peo­ ple Manage Stress and Stay Well. San Francisco: Jossey-Bass, 1988. 25. Jasnoski ML, Schwartz GE. A s)~lchronous systems model for health. Am Behav Scientist 1985;28:468-485. 26. Seeman J. Toward a model of positive health. Am Psychol 1989;44:1099-1109. 27. Crose R, Nicholas DR , Gobble DC, et al. Gender and well­ ness: a multidimensional systems model for counseling. J Counsel Develop 1992;71:149-156. 28. Adams T, Bezner J, Steinhardt M. The conceptualization and measurement of perceived wellness: integrating balance across and within dimensions. Am J Health Promotion 1997;11:208-218. 29. Mokdad AH , Ford ES, Bowman BA, et al. Prevalence of obe­ sity, diabetes , and obeSity-related health risk factors, 2001. lAMA 2003;289:76--79. 30. Mossey JM , Shapiro E. Self-rated health: a predictor of mor­ tality among the elderly. Am J Public Health 1982;72: 800-808. 31. Ware JE , Sherbourne D. The MOS 36-item short-form health survey (SF-36). Med Care 1992:30:473-483. 32. Wilson IB , Cleary PD. Linking clinical variables with health­ related quality of life. JAMA 1995;273:59-65. 33. Idler E, Kasl S. Health perceptions and survival, do global evaluations of health status really predict mortality? J Geron­ toI1991;46:S55-S65. 34. Stewart A, Hays R, Ware J. Health perceptions, energy/fa­ tigue , and health distress measures. Measuring functioning and well-being: the Medical Outcomes study approach. Durham , NC : Duke UniverSity, 1992. 35. Eysenck H. Prediction of cancer and coronary heart disease mortality by means of a personality inventory. Results of a 15­ year follow-up study. Psychol Rep 1993;72:499-,516. 36. Andrews F, Robinson J. Measures of subjective well-being. In: Robinson J, Shaver P, Wrightsman L, eds. Measures of Personality and Social Psychological Attitudes. Vol. 1. San Diego: Academic Press, 1991. 37. Diener E. Subjective well-being. Psychol Bull 1984;95: 542-575. 38. Campbell A, Converse P, Rodgers W. The Quality of Ameri­ can Life. ::\ew York: Russell Sage Foundation, 1976 . 39. Fazio A. A concurrent validational study of the NCHS gen­ eral well-being schedule. DHEW Publication Number (HRA) 1977;2:78--1347. 40. Lawton M. The Philadelphia geriatric center morale scale: a revision. J GerontoI1975;30:85- 89. 41. Morris J, Shenvood S. A retesting and modification of the PGC morale scale. JGerontoI197.5;30:77--84. 42. Fordyce M. The PSYCHAP inventory: a multi-scale to mea­ sure happiness and its concomitants . Soc Ind Res 191)6;18: 1--33. 43. Kozm a A, Stones M. The measure ment of happiness: devel­ opmen t of the lvlemorial University of Newfoundland scale of happiness (MUNSH ). JGerontoI1980;35:906--912. 44. Diener E , Emmons R, Larsen R, et al. The satisfaction with life scale. JPers Assess 1984:49:71-75.

Chapter 4 Prevent'ion and the Promotion of Health, Wellness, and Fitness

4.5. Neugarten B, Ha\ighurst R, Tobin S. The measurement of life satisfaction. J CerontoI1961;16:134--143. 46. "Tood V, Wylie M, Sheafor B. An analysis of a short self-re­ port measure of life satisfaction: correlation with rater judg­ ments. J CerontoI1969;24:465-469. 47. Kobasa S. Stressfuil life events, personality, and health: an in­ quiry into hardiness. J Pers Soc 1'sychoI1979;.'37:1-11. 48. Williams P, Wiebe D, Smith T. Coping processes as media­ tors of the relationship benveen hardiness and health. J Be­ hav .\ied 1992;15:237-255. 49. Adams TB, Bezner JR, Drabbs ME, et a1. Conceptualization and measurement of the spiritual and psychological dimen­ sions of wellness in a college population. J Am Coli Health 2000;48:165-173. 50. Bezner JR, Hunter DL. Wellness perceptions in persons \\ith traumatic brain injury and its relation to functional indepen­ dence. Arch Phys Med RehabiI2001;82:787-792.

r

r

a

e

:h

55

51. Ferguson T. "Vorking \\ith your doctor. In: Coleman D, Curin J, eds. Mind Body Medicine. New York: Consumer Reports Books, 1993. 52. Eisenberg DM, Da\is RB, Ettner SL, et al. Trends in alter­ native medicine use in the United States, 1990-1997. JAMA 1998;280:1.569-157.5. 53. Marcus BH, Selby VC, Niaura RS, et al. Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport 1992;63:60-66. 54. Kendzierski D, DeCarlo KJ. Physical activity enjoyment scale: two validation studies. J Sport Exerc Psychol 1991; 13:50-64. 55. Marcus BH, Simkim LR. The stages of exercise behavior. J Sports Med Physical Fitness 1993;33:83-88. 56. Prochaska JO, DiClemente CC. The stages and processes of self-change in smoking: towards an integrative model of change. J Consult Clin PsychoI1983;5l:390-395.

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Physiologic Impai~ments

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chapter 5

Impairment in Muscle Performance CARRIE HALL AND LORI THEIN BRODY

Definitions Strength

Power and Work

Endurance

Muscle Actions

Morphology and Physiology of Muscle Performance Gross Structure of Skeletal Muscle Ultrastructure of Skeletal Muscle Chemical and Mechanical Events During Contraction and Re­ laxation Muscle Fiber Type Motor Unit Force Gradation

Factors Affecting Muscle Performance Fiber Type

Fiber Diameter

Muscle Size

Force-velocity Relationship

Length-tension Relationship

Muscle Architecture

Training Specificity

Neurologic Adaptation

Muscle Fatigue

Lifespan Considerations

Cognitive Aspects of Performance

Effects of Alcohol

Effects of Corticosteroids

Causes of Decreased Muscle Performance Neurologic Pathology

Muscle Strain

Disuse and Deconditioning

Length-associated Changes

Physiologic Adaptations to Training Strength and Power

Endurance

Examination and Evaluation of Muscle Performance Therapeutic Exercise Intervention for Impaired Muscle Performance Activities to Increase Muscle Performance Dosage Dosage for Strength Training Dosage for Power Training Dosage for Endurance Training Dosage for Training the Advanced or Elite Athlete

Precautions and Contraindications

Physiologic, anatomic, psychologic, and biomechanical factors affect muscle performance. Pathology/pathophysi­ ology and disease affecting the cardiovascular, en­ docrine/metabolic, integumentary, musculoskeletal, neu­ romuscular, or pulmonalY systems can also affect muscle performance. Muscle performance impairment can be fur­ ther classified by impairments in strength, power, or en­ durance. These impairments must be related to a func­ tional limitation or disability, or promote prevention, health, wellness, and fitness , to justify therapeutic exercise intervention. For example, an individual lacking the muscle performance to carry a bag of groceries into the house re­ quires intervention to achieve this instrumental activity of daily living. A worker lacking the muscle performance to maintain efficient posture and safe movem ent patterns throughout the workday requires intervention to prevent work disability. Although not all scientific and clinical information on streIlgth, power, and endurance production can be cov­ ered in this text, this chapter provides a strong foundation for this element of therapeutic exercise intervention. Fun­ damental terms and concepts are defined, the essential morphology and physiology of skeletal muscle relative to muscle performance are reviewed, and clinical applica­ tions are presented.

57

58

Therapeutic Exercise: Moving Toward Function

DEFINITIONS Strength Impaired muscle performance is commonly treated by clinicians and is usually described as a strength deficit. However, strength is only one of three components of muscle performance (i.e., strength , power, and en­ durance ). Strength is defined as the maximum force that a muscle can develop during a Single contraction, and is the result of complex interactions of neurologic , muscular, biomechanical, and cognitive syste ms. Strength can be as­ sessed in terms of force , torque , work, and power. If ap­ propriate decisions are to be made regarding these impair­ ments , operational definitions are necessary. Force is an agent that produces or tends to produce a change in the state of rest or motion of an object. I For ex­ ample, a ball sitting stationary on a playing field remains in that position unless it is acted on by a force . Force, de­ scribed in metric units of newtons or British units of pounds, is displayed algebraically in the follOwing equation: force = mass x acceleration Kinetics is the study of forces applied to the body. Some of the factors influencing muscular force production include the neural input, mechanical arrangement of the muscle , cross-sectional area, fiber-type composition, age, and gender. I All human motion involves rotation of body segments about their joint axes. These actions are produced by the interaction of forces from external loads and muscle activ­ ity. The ability of a force to produce rotation is torque. Torque represents the rotational effect of a force with re­ spect to an axis:

torque = force x moment arm The moment arm is the perpendicular distance from the line of action of the force to the axis of rotation. The metric unit of torque is the newton-meter; the foot-pound is used in the older British system of units. Clinically, the word strength is often used synonymously with torque. Large amounts of torque are produced by the musculoskeletal system during everyday functional activi­ ties such as walking, lifting, and getting out of bed. It is in­ correct to conclude that a person is "strong" only because his muscles generate large forces. It would be just as erro­ neous to conclude that a person is strong only because he has large moment arms. Torque can be altered in biomechanics through three strategies: • Changing the force magnitude • Changing the moment arm length • Changing the angle between the direction of force and momentum In the human musculoskel e tal system , changing the force magnitude (i.e. , tension -producing capability of mus­ cle) can be altered by training, the moment arm can be de­ creased by positioning a load closer to the body, and the an­ gle between the force and moment arm may be changed by altering joint alignment through postural education.

Power and Work Power is the rate of performing work. Work is the magni­ tude of a force acting on an object multiplied by the dis­ tance through which the force acts. The unit used to de­ scribe work is the joule, which is equivalent to 1 newton-meter (the foot-pound unit is used in the British system ). Work is algebraically expressed in this equation:

work = force x distance The unit of power in the metric system is the watt, which is equal to 1 joule/second (foot-pound/second in the British system ). Power can be determined for a Single body move­ ment, a series of movements , or for a large number of repetitive movements, as in the case of aerobic exercise. Power is algebraically expressed as: power = ,,,ork / time For the simple movement of lifting or lowering a weight, the muscle must overcome the weight of the limb and the weight (force ), acting some distance from the axis of rota­ tion (torque) through a range of motion (work) during a speCific time frame (power). This example summarizes the practical aspects of force, torque, work, and power in resis­ tance training.

Endurance Endurance is the ability of muscle to sustain forces re­ peatedly or to generate forces over a certain period. It is of­ ten measured as the ratio of the peak force that can be gen­ erated by a muscle at a given point in time, relative to the peak force that was possible during a Single maximum con­ traction. Muscle endurance can be examined by isometric contractions, repeated dynamiC contractions, or repeated contractions on an isokinetic dynamometer.

Muscle Actions Poorly defined muscle actions can be a source of confusion and inaccuracy. Resistive exercise uses various types of muscle contraction to improve impaired muscle perfor­ mance. Muscle actions can be divided into two general cat­ egories: static and dynamic. A static muscle action, tradi­ tionally referred to as isometric, is a contraction in which force is developed without any motion about an axis , so no work is performed. All other muscle actions involve move ment and are called dynamiC or isotonic. An isotonic contraction is a uniform force throughout a dynamiC muscle action. No dy­ namic muscle action uses constant force because of changes in mechanical advantage and muscle length. Iso­ tonic is therefore an inappropriate term to describe human exercise performance, and the term dynamic is preferred. Dynamic muscle action is further described as concen­ tric or eccentric action . The term concentric describes a shortening muscle contraction, and the term eccentric de­ scribes a lengthening muscle contraction. Eccentric con­ tractions differ from concentric and isometric contractions in several important ways. Per contractile unit, more ten­ sion can be generated eccentrically than concentrically and

59

Chapter 5: Impairment in Muscle Performance at a lower metabolic cost (j.e. , less use of ATP-derived en­ ergy).2 Eccentric contractions are an important component of a functional movement pattern (e.g., required to decel­ erate limbs during movement), are the most energy-enl­ cient form, and can develop the greatest tension of the var­ ious types of muscle actions. The term isokinetic refers to a concentric or eccentric muscle contraction in which a constant velocity is main­ tained throughout the muscle action. A person can exert a continuous force by using an isokinetic device, which pro­ vides a resistive surface that restricts movement to a set, constant velocity Some acceleration and deceleration oc­ curs as the individual accelerates the limb from a resting po­ sition to the preset velocity and decelerates the limb to change directions. By constraining the speed of the isoki­ netic device, the limb moves at a constant velocity. Because the device cannot be accelerated beyond the preset speed, any unbalanced force exelted against it is resisted by an equal and opposite force. This mu scular force may be mea­ sured, displayed, recorded , or used as concurrent visual feedback. Although the isokinetic device may be moving at a constant velocity, it does not guarantee that the user's muscle activation is at a constant velocity. Despite this inac­ curacy, the terms isokinetic and isotonic to describe muscle action are likely to be employed for pragmatic reasons. During functional movement patterns, combinations of static and dynamiC contractions occur. Tnmk muscles con­ tract isometrically to stabilize the spine and pelvis during movements of the extremities such as reaching or walking. Lower extremity muscles are subjected to impact forces requiring combinations of concentric and eccentric con­ tractions, sometimes within the same muscle acting at two different joints. Muscles commonly perform eccentric con­ tractions against gravity, as in slowly lowering the arm from an overhead position. Muscles often act eccentrically and then contract con­ centrically. The combination of eccentric and concentlic actions forms a natural type of mu scle action called a stretch-shortening cycle (SSC).3,4 The SSC results in a final action (i.e., concentric phase) that is more powerful than a concentJic action alone. This phenomenon is called elastic potentiation.4 The SSC is discussed in more detail later in this chapter.

MORPHOLOGY AND PHYSIOLOGY OF MUSCLE PERFORMANCE a

~f

1­ !Il

~

a

e­ fl­

ns fl ­ ~d

Improving muscle performance often translates into im­ provements in functioning by the patient. A thorough un­ derstanding of muscle morphology and phYSiology is re­ quired to prescribe an appropriate exercise program that proceeds to the ultimate goal of a functional outcome for each patient.

Gross Structure of Skeletal Muscle Each of more than 430 voluntary muscles in the body con­ sists of various layers of connective tissue. Figure 5-1 illus­ trates a cross-section of a muscle consisting of thousands of muscle cells called muscle fibers (Fig. 5-lA-B). These

Muscle A.

Myofibril myofibril

C. Z ",Zs=-a-rc-o-m-e-re-

Sarcomere

z = zline A = A-band I = I-band

D.

E. Thick filament: myosin Myosin filament ~

Thin filament: actin

~ ••• ~ Actin filament

"e • . • • F

.:~:~:~:.

• ••••••

• • •

Cross section at level of A-band

FIGURE 5-1. Schematic drawing of the structura lorganization of skeletal muscle. (AI A fibrous connective tissue, epimysium surrounds the muscle, which is composed of manyfascicles. The fa scicles are encased in a dense connective sheath, the perimysium. (8) The fascicles are composed of muscle fibers surrounded by capillaries and covered by a loose connective tissue called the endomysium. Each muscle fiber is composed of numerous myofibrils (C) Myofibrils consist of sma ller filaments that form a repeat­ ing banding pattern along the length of the myofibril One un it of this seri­ ally repeating pattern is called a sarcomere . (O-FJ The banding pattern of the sarcomere is formed by the organization of thick and thin filaments, actin and myosin

multinucleated muscle fibers lie parallel to one another and are separated by the innermost layer of connective tis­ sue, called the endomysium. As many as 150 fibers are ar­ ranged into bundles called fasciculi. Fasciculi are sur­ rounded by perimysium, the next layer of connective tissue. The entire muscle is encased by the outermost layer of connective tissue, the epimYSium. This connective tissue sheath tapers at the ends as it blends into and joins the in­ tramuscular tissue sheaths forming the tendons. The ten­ dons connect to the outermost covering of the bone, the periosteum. The force of muscle contraction is transmitted directly from the muscle's connective tissue to the point of attachment on the bone. Beneath the endomysium and surrounding each muscle fiber is a thin , elastic membrane, called the sarcolemma, enclOSing the fiber's cellular contents. The aqueous proto­ plasm or sarcoplasm contains the contractile proteins, en­ zymes, fat and glycogen particles, the nuclei , and various

60

Therapeutic Exercise: Moving Toward Function

specialized cellular orga ne lles . E mbedded in the sar­ coplasm is an extensive network of interconnecting tubular channels kllown as the sarcoplasmic reticulum. This highly specialized syste m provides the cell with structurall in­ tegrity and also serves important functions in muscular contractions.

Ultrastructure of Skeletal Muscle The ultrastructure of skeletal muscle consists of different levels of subcellular organization (see F ig. 5-1). Each mus­ cle fiber consists of smail fibers called myofibrils (see Fig. 5-1C). Myofibrils are composed of even smaller threads caJled myofilaments (see Fig. 5-1D-F). Th e myofilaments are composed pri marily of two proteins, actin and myosin. Six other proteins have been identified that have a struc­ tural or physiologic purpose. The contractile unit of the en­ tire myofibril is known as the sarcomere.

The Sarcomere The sarcomere is the functional unit of the contractile sys­ tem in mu scle, and the events that take place in one sar­ comere are duplicated in the others. Various sarcomere build a myofibril, myofibrils build the muscle fiher, and muscle fibers build a muscle. Th e sarcomere is composed of thin filaments (approximately 5 nm in diameter) formu­ lated from the protcin actin and the thick filaments (ap­ proximately 15 11111 in diameter) formulated from the pro­ tein myosin. Figure 5-1C illustrates the structural pattern of myofila­ mcnts witHn a sarcomere. The lighter area is referred to as the I band and contain s the portion of the thin filaments that do not overlap with the thick filam ents. The darker zone is known as the A band and is the region where actin and myosin overlap . T he Z line bisects the I band and adheres to the sarcolemma to give the entire structure sta­ bility. The repeating unit between two Z lines represents the sarcomere. The actin and myosin filaments within the sarcomere arc primarily ]nvoh-ed in the mechanical process of muscular contraction and therefore in force develop­ ment. E ach myosin cross-bridge is an independent force gent'rator.

Actin-Myosin Orientation Figu re 5-2 illustrates the actin-myosin orientation within a sarcomere at res ting and contracted lengths. Actin , the chief component of the th in filament. has the shape of a double helix and app ears as two strands of beads spiraling around each other. Two additional proteins, troponin and tropomyosin, are important ('onstituents of the actin helix becaus e they appear to regulate th e making and breaking of contacts between the actin and myosin filaments dUling

Sarcomere relaxed

Thin filament (actin)

J

Thick filament (myosin)

Contraction

J Sarcomere contracted

FIGURE 5-2. Actin-m yosin relationsh ips in relaxed and contracted position.

contraction. Tropomyosin is a long polypeptide chain that lies in the grooves behveen the helices of actin. Troponin is a globular molecule attached at regular intervals to the tropomyosin (Fig. 5-3).

Intracellular Tubule System The sarcoplasmic reticulum and transverse tu bu le (T ­ tubule) system within the muscle fiber can be seen in Fig. 5-4. The sarcoplasmic reticulum lies parallel to the myofib­ rils , whereas the T-tubule system runs perpendicular to the myofibril. The lateral end of the sarcoplasmic reticulum terminates in a saclike vesicle that stores calcium . The T­ tubule system appears to function as a micro transportation network for spreading the action potential (i.e., wave of de­ pol arization ) from the fiber's outer membrane inward to the deep regions of the cell.

Chemical and Mechanical Events During Contraction and Relaxation The most widely held theory of muscle contraction is the sliding filament theory. According to this theory, active shortening of the sarcomere, and hence of muscle, results from the relative movement of tlle actin and myosin fila­ ments past one another whiJe retaining its onginallength . Excitation-contraction is th e phYSiologic mechanism whereby an electric discharge at the muscle initiates the chemical events that lead to contraction. Wh en a muscle fiber is stimulated to contract there is an immediate in­ crease in tile intracell!ular calcium concentration . Arrival of tbe action potential at the T-tubules causes calcium to be released from the lateral sacs of the sarcoplasmic retic-

Tropon

FIGURE 5·3. The re lationship of actin, troponin, and tropomyos in.

Tropomyosin

Chapter 5: Impairment in Muscle Performance

61

Myofibrils

DISPLAY 5-1

Sequence of Events in Muscular Contraction Sarcolemma .:...o!It=;r--~_ Sarcoplasmic

reticulum "-;r,pf---f'+-+

T-tubule

FIGURE 5-4. Relationships of the sarcoplasm ic reticulum, T-tubule sys­ tem, and myofibrils. ulum. The inhibitory action of troponin (i.e., preventing actin-myosin interaction) ceases when calcium ions bind rapidly with troponin in the actin filaments. The globular head of the myosin cross-bridge provides the mechanical means for the actin and myosin filaments to slide past each other. During contraction, each cross-bridge under­ goes many repeated but independent cycles of movement. Thus at any given moment on ly approximately half of the cross-bridges actively generate force and displacement, and when these detach, others take up the task so that shortening is maintained. Display 5-1 summarizes the vents during excitation, contraction, and rela;i:ation of the muscle.

Muscle Fiber Type Skeletal muscle is not a simple homogenous group of fibers \vith similar metabolic and functional properties. Distinct . fiber types have been identified and classified by their con­ tractile and metabolic characteristics. Slow-twitch fibers, or type I fibers, are characterized by slow speed of contraction, low activity of myosin ATPase, and glycolytic capacity that is less well developed than that of their fast-twitch counter­ parts. Slow-twitch fibers are well suited for prolonged aer­ obic exercise. Fast-twitch fibers are divided into fast oxidative­ glycolytiC. or type IIA, and fast-glycolytic. or type IIB , fibers. Generally, fast-twitch fibers have a high activity level of myosin ATPase associated with their ability to generate energy rapidly for quick. forceful contractions. Fast oxida­ tive-glycolytic fibers are a hybrid between slow-twitch and fas t-glycolytic fibers. These fibers combine the ability to produce quick, forceful contractions and sustain them for longer than fast -glycolytic fibers (though not as long as slow­ twitch fibers ). Compared vvith fast oxidative-glycolytic fibers, the fast-glycolytic fibers possess a greater anaerobic potential. A third fast-nvitch fiber, type IIC, has been iden­ tified. The type IIC fiber is normally a rare and undifferen­ tiated fiber that may be involved in reinnervation or motor W1it transformation. s

The following is a list of the main events in muscular contra ction and relaxation. The sequence begins with the initiation of an action potential by the motor nerve. This impulse is propagated over the entire surface of the muscle fiber as the cell membrane becomes depolarized. 1. Depolarization of the T-tubules causes release of calcium from the lateral sacs of the sarcoplasmic reticulum. 2. Calcium binds to the troponin-tropomyosin complex in the actin filaments, releasing the inhibition that prevented actin from combining with myosin. 3. Actin combines with myosin-activated myosin ATPase, which splits ATP. The energy that is created produces movement ofthe cross-bridge, and tension is created. 4. ATP binds to the myosin cross-bridge, breaking the actin­ myosin bond and allowing the cross-bridge to dissociate from actin. 5. Cross-bridge activation continues as long as the concentration of calcium remains high enough to inhibit the action of the troponin-tropomyosin system. 6. When stimulation ceases, calcium moves back into the lateral sacs of the sarcoplasmic reticulum. 7. Removal of calcium restores the inhibitory action of troponin-tropomyosin . In the presence of ATP, actin and myosin remain in the dissociated, relaxed state.

Motor Unit The motor unit consists of the motor neuron . its axon, and the muscle fibers supplied by the motor neuron . The num­ ber of muscle fibers belonging to a Single motor unit can vary from ,5 to 10 to more than 100. As a general rule, small muscles responsible for precision tasks (e.g., intrinsic hand muscles) are composed of motor units supplying few mus­ cle fibers, whereas trunk and proximal limb muscles con­ tain motor units supplying a large number of muscle fibers. Human motor units with the following characteristics tend to be classified as tonic motor units: long contraction times , low-twitch tension, high resistance to fatigue, small­ amplitude action potentials, and slow conduction velocities. Conversely, phasic motor units tend to be recruited at high levels of voluntalY contraction, display short contraction times and high-tvvitch tensions, are not fatigue-resistant, and show large-amplitude action potentials and fast con­ duction velocities.

Force Gradation Motor units are activated to increase force production or deactivated to decrease force produ ction. Force gradation can be likened to a rheostat, through which more motor units are brought on line as the need for force increases or taken off line as the need for force decreases. Force increases can occur by increasing the rate of discharge (j.e., rate coding) or by graded recruitment of higher threshold motor units (i.e ., size principle)6 Rate coding implies high-frequency discharge when high forces are needed, and low-freq,uency pulses are delivered when low forces are necessary. I The size prinCiple states that, dur­

62

Therapeutic Exercise Moving Toward Function

ing activation of motor neurons , those with the smallest axons have the lowest thresholds and are reclllited first, followed by larger cells with higher thresholds. In most voluntary everyday contractions, slow (type I) motor units are the first to be reclllited. \"lith increasing power output, more fast (type II) units are activated. Trained persons can activate all the motor units in a large limb muscle during a static, maximal , voluntary contrac­ tion, whereas this is not possible for untrained persons . The fastest (type lIB ) motor units are preferentially activated in fast corrective movements and reflexes. Explosive maximal contractions are thought to activate fast and slow motor units Simultaneously. Violations of the size prinCiple do occur. Two departures occur through neural adaptations related to the specificity of velocity and movement pattern in strength training. High-threshold, fast-twitch motor units are preferentially activated during brief, r~id concentric actions in which the intent is to relax qUickly. It has also been demonstrated that fast-twitch motor units are preferentially reclllited in ec­ centric actions performed at moderate to high velocities. 9

FACTORS AFFECTING MUSCLE PERFORMANCE The total force a muscle can produce is influenced by nu­ merous factors. When prescribing therapeutic exercise in­ tervention for muscle pelformance, knowledge of princi­ ples regarding muscle morphology, phYSiology, and biomechanics are critical. The follOwing text discusses the primary factors influencing force production and, hen ce, muscle performance.

Fiber Type Sedentary men and women and young children possess 45 % to 55% slow-twitch fibers .10 Persons who achieve high levels of sport profiCiency have the fiber predominance and distributions characteristic of their sport. For example, those who train for endurance sports have a higher distri­ bution of slow-twitch fibers in the Significant muscles, and sprint athletes have a predominance of fast-twitch fibers. Other studies show that men and women who perform in middle-distance events have an approximately equal per­ centage of the tvvo types of muscle fibers l l Any resistive rehabilitation program should be based on the probable distribution of fiber type of the individual. Clear-cut distinctions between fiber type composition and athletic performance are tllle for elite athletes. A per­ son's fiber composition is not the sale determinant of per­ formance. Performance capacity is the end result of many phYSiolOgiC, biochemical, and neurologic components, not simply the result of a Single factor such as muscle fiber type. 12

Fiber Diameter Although the different fiber types show clear differences in contraction speed, the force developed in a maximal static action is independe nt of the fiber type but is related to the fiber's cross-sectional diameter. Because type I (slow )

fibers tend to have smaller diameters than type II (fast) fibers, a high percentage of type I fibers is believed to be associated ,vith a smaller muscle diameter and therefore lower force development capabilities. J3

Muscle Size When adult muscles are trained at intensities that exceed 60% to 70% of their maximum force-generating capacity, the muscle increases in cross-sectional area and force pro­ duction capability. The increase in muscle size may result from increases in fiber size (i.e. , hypertrophy), fiber num­ ber (i.e., hyperplaSia), interstitial connective tissue, or some combination of these factors. 14 . 15 Although the major mechanism for increased muscle size in adults is hypertrophy, ongoing controversy sur­ rounds evidence of hyperplaSia. Mammalian skeletal mus­ cle does possess a population of reserve or satellite cells that, when activated, can replace damaged fibers with new fibers .16 .17 A mechanism exists for the generation of new fibers in the adult animal. Scientific models of exercise and stretch overload have shown Significant increases in fiber number. 14 The mechanisms for fiber hyperplasia probably are the result of satellite cell proliferation and longitudinal fiber splitting. 14 Despite few investigations of the effect of strength train­ ing on interstitial connective tissue, it appears that, because interstitial connective tissue occupies a relatively small pro­ portion of the total muscle volume, its potential to con­ tribute substantial changes in muscle size is limited 1 8

Force-Velocity Relationship Muscle can adjust its active force to preCisely match the ap­ plied load. This property is based on the fact that active force continuously adjusts to the speed at which the con­ tractile system moves. When the load is small, the active force can be made cOlTespondingly small by increasing the speed of shortening appropriately. When the load is high, the muscle increases its active force to the same level by slowing the speed of shortening (Fig. 5-5) .19

400

300

E

t

III ::l

200

cr

~

100 -,

MV

0+1-.-------,----~4-~----,_----_._,

360° Eccentric

180°

60° 0° 60°

180°

360° Concentric

FIGURE 5-5. Relationship between the force and velocity of eccentric muscle contractions. (Adapted from Herzog W. Ait-Haddou R. Mechanical muscle models and their application for force and power production. In: Komi PV, ed. Strength and Power in Sport, 2nd ed. Malden, MA: Blackwell Sc ientific Publications, 2003. p. 176).

63

Chapter 5: Impairment in Muscle Performance

Slowing the speed of contraction allows a patient time to develop more tension during concentric contractions. 1I.mvever, during eccentric contractions, increased speed of lengthening produces more tension. This appears to pro­ vide a safety mechanism for limhs excessively loaded. In­ creasing the speed of a concentric contraction significantly lowers the amount of concentric torque developed. In con­ trast, increasing the speed of an eccentric contraction in­ creases the amount of torque developed until a plateau speed is reached.

3000

Lengthened position "' ... /

Casts removed

I , . . ...

Adult muscles immobilized

,,

(/) Q)

Q; E o

Casts removed

~

co

(f)

,, \ ' Shortened position

1000

Length-Tension Relationship

1­

e

1­

-e

e

"

A muscle's capacity to produce force depends on the length at which the muscle is held with maximum force delivered near the muscle's normal resting length (Fig. 5-6). The re­ lationship between strength and length is called the length-tension property of muscle. The number of sar­ comeres in series determines the distance through which the muscle can shorten and the length at which it produces maximum force. Sarcomere number is not fixed and in adult muscle, this number can increase or decrease' (Fig. 5­ 7 ).20 Re?;Ulation of sarcomere number is an adaptation to changes in the functional length of a muscle. Length-associated changes can be induced by postural malalignment or immobilization. 21 ,22 In muscles chronically maintained in a shortened range because of faulty posture or immobilization, sarcomeres are lost, and the remaining sar­ comeres adapt to a length that restores homeostasis; the new length enables maximum tension development at the new immobilized, shortened posibon. 23 In muscles immobilized or posturally held in a lengthened position, sarcomeres are added, and maximum tension is developed at the new in­ creased length. When a cast is removed or posture restored, the sarcomere number returns to normal. The stimulus for sarcomere length changes may be the amount of tension along the myofibril or the myotendon junction, with high tension leading to an addition of sarcomeres and low tension to a subtraction of sarcomeres. 24 . The clinical implication of the length-tension relation­ ship is that the evaluation of muscle "strength" must be reconsidered. Muscles that tend to be shortened (e.g., hip flexors ) may test as strong as normal-length muscles, be­

Time (weeks)

FIGURE 5·7. Changes in the number of sarcomeres in various conditions. cause the manual muscle test position is a shortened po­ sition. zs Conversely, the lengthened muscle (e.g., gluteus medius on the high iliac crest side) tests weak, because the manual muscle test occurs at a relatively shortened range, which is an insufficient position . Accordin a to ani­ rnaI studies, 26hh t e s ort muscles should develop bthe least peak tension , followed by the normal-length muscle and the lengthened muscle, which develops the greatest peak tension (Fig. 5-8). This finding reflects the number of sar­ comeres in series. The lengthened muscle may be inter­ preted as weak although it is capable of producing sub­ stantial tension at the appropriate point in the range. This phenomena is called positional strength. A muscle should be tested at multiple points in the range to determine whether the muscle is positionally weak or weak through­ out the range. The emphaSiS of therapeutic exercise intervention should be on restoJing normal length and tension develop­ ment capability at the appropriate point in the range, rather than just strengthening the muscle. The positionally weak muscle should be strengthened in the shortened range, and the weak muscle should be strengthened dy­ namically throughout the range. 10

100

8

,,

, -----,

6

~ SO

-

~

C .ri c cal . In: , ell

2

Control

- - . Lengthened ......... Shortened

110 OL...L---'---'----'----'----'---~'--

1.0

2.0 2.S 1.S Sarcomere length

3.0

3.S

(~m)

FIGURE 5-6. The length·tension curve depicts the relationship between muscle length and force development.

% Muscle belly length of control

FIGURE 5-8. Changes in the length·tension relationship caused by length changes associated with immobilization. (Modified from Gossman, Sahrmann SA. Rose SJ Review of length·associated changes in muscle. Experimental evidence and clinical implications. Phys Ther 1982;62:1799.)

64

Therapeutic Exercise: Moving Toward Function

Muscle Architecture The arrangement of the contractile components affects the contractile properties of the muscle dramatically. The more sarcomere lie in series, the longer the muscle will be, the more sarcomere lie in parallel, the larger the cross­ sectional area of the muscle will be. These two basic archi­ tectural patterns affect the contractile properties of the muscles in the folloWing ways: • The force the muscle can produce is directly propor­ tional to the cross-sectional area. • The velocity and working excursion of the muscle are proportional to the length of the muscle . Generally, muscles with shorter fibers and a larger cross-sectional area are designed to produce force, whereas muscles with Ismg fibers are designed to produce excursion and velocity.21 For example. the quadriceps muscle con­ tains shorter myofibrils and appears to be specialized for force production , whereas the sartorius muscle has longer fibers and a smaller cross-sectional area and is better suited for high excursion.

Training Specificity Training specificity suggests that "you get what you train fOL" This spe~ifi~i~ i~ particularly si~n.ifican t in terms ~f trammg veloclty._8,_9 1 he greatest tramlIlg effects are eVI­ dent when the same exercise type is used for testing and training, although this principle varies by muscle contrac­ tion types. A study of concentric and eccentric quadriceps training found that specificity was rel ated to eccentric training but not concentric training ao Concentlic training showed increases only in concentric an d isometric strength a1 Studies have shown bilateral transfer; training one limb resulted in strength gains in the contralateral limb a2 Further studies of bilateral versus unilateral train­ ing have shown improved bilateral scores when training bi­ laterally and improved unilateral scores when training uni­ laterally. These findings were consistent for upper extremity and lower extremity training.·1:, ROM specificity also exists ; stren~h improvements are greatest at the joint angles exercised.- h A study of eccentric training showed isometiic strength gains that were joint an­ gle-specific; a similar study of COIH:entric training showed improvements throughout the range .32 The effects of posture on the specificity of training was assessed using squat and bench press lifts as the training tool. A variety of tests followed an 8-week training session that included skills such as veliical jump, 40-meter sprint, isokinetic tests, and a 6-second bout on a power bicycle. The authors found results to support the concept of pos­ ture specificity, because the exercise postures similar to the training postures enabled the greatest improvements. 34

Neurologic Adaptation Muscle performance is determined by the type and size of the involved muscles and by the ability of the nervous sys­ tem to appropriately activate muscles. Activities requiring high force development require coordinated input from

the neurologic system. The muscles responsible for pro­ ducing the large force in the intended direction, called ag­ onists, must be fully activated. Muscles that assist in coor­ dinating the movement, called synergists , must be appropriately activated to ensure precision of rotating parts. Muscles prodUCing force in the opposite direction of the agonists, called antagonists, must be appropriately activated or relaxed. For example, during a squat or step­ up, the jOint alignment and muscular recruitment patterns at the trunk, pelvis, hips, knees, ankles, and feet can alter which muscles are trained. The nervous system control for resistive exercises such as the squat is complex. When an unfamiliar exercise is introduced into the resistive ex­ ercise program , the early increase in strength partially re­ sults from adaptive changes in the nervous system control. The clinician must ensure appropriate nervous system control over the movement pattern for the desired out­ come. Inappropriate instruction or failure to monitor the exercise can render it ineffective or detrimental to th e ex­ pected outcome. DeLorme and Watkins 3.5 hypotheSize that the initial in­ crease in strength after progressive resistance exercise oc­ curs at a rate greater than can be accounted for by muscle morphologic changes. The initial rapid increases in strength probably result from motor learn ing. When a new exercise is introduced, lleural adaptation predominates in the first several weeks of training as the individual masters the coordination necessary to perform the exercise effi­ Ciently. Subsequently, hypertrophic factors gradually dom­ inate over neural fa ctors in the gain in muscle perfor­ mance. 36 Although neurologic auaptations were once thought to dominate i£l the first few weeks of training, Staron and colleagues 3( found that morphologic changes begin to occur in the second week of training. Other adaptations, such as the ability to fire motor units at very high rates to develop power, may require a longer period of training to attain and be lost more rapidly during detraining. 38 In the long term , further improvement in per­ formance Critically depends on the way the muscles are ac­ tivated by the nervous system dUling training. 39

Muscle Fatigue Muscle fatigue may be defined as a reversible decl'E:'C1se in contractile strength that occurs after long-lasting or re­ peated muscular activity.4o Human fatigue is a complex phenomenon that includes failure at more than one site along the chain of events that leads to muscle fiber stim u­ lation. Fatigue involves a central component, which puts an upper limit to the numberof command Signals that are sent to the muscles , and a peripheral component. Peripheral changes in cross-bridge function associated with fatigue in­ clude a slight decrease in number of interacting cross­ bridges , reduced force output of the individu al cross­ bridge, and reduced speed of cycling of the bridges dUling muscle shortening. When the patient is performing resistive training, be alert for signs of fatigue. Fatigue can lead to substitution or injury. The dosage for resistive exercise is often limited to form fatigue, th e point at which the individual must dis­ continue the exercise or sacrifice technique.

Chapter 5: Impairment in Musc le Performance

65

FIGURE 5-9. Two phases of a sit-up (A) Trunk curl phase, (B) Hip flexion phase, NOTE Refer to chapter 18 for IndlcatlOns/contralndlcallOns for bent-knee versus straight-leg sit-up

i­

,­

r­ 'e ~.

E'f

g f­

e-

in

re ­

lex lit

u­ an en t ~fal

in­ )

­

~s s-

ng be Of

d to dis-

Quality of motion usually is the most important factor in prescribing any exercise, Although this seems quite obvi­ OlIs , it is a concept that is often neglected, With resistive ex­ ercise, the patient cannot expect gains in force or torque production unless the muscle is recruited during the move­ ment pattern, Because synergists can readily dominate a movement pattern, take care to ensure precision of motion during all exercise prescription, After the form is compro­ mised (i.e" form fatigue), stop the exercise. Continuing to exercise with poor technique compromises the outcome and may be detrimental, An example of the importance of technique is the tradi­ tional sit-up and the effect of holding the feet dO'wn while the trunk raises forward. Kendall 25 prOvides a detailed anal­ ysis of muscle function during the Sit-up. For the curled­ tllJnk sit-up to be used as a technique or test of abdominal strength , the ability to flex the trunk must be differentiated from the ability to flex the hips, The trunk flexion phase must precede the hip flexion phase in the trunk raising movement (Fig, 5-9), When the feet are not held down, the abdominal muscles tilt the pelviS posteriorly as the head and ' shoulders are raised, With the feet held do\:vJ1, the hip flex­ ors are given distal fixation , and the trunk raising may be­ come a hip flexor activity (Fig, 5-10), The trunk flexion phase is bypassed, and the motion is primarily hip flexion, Recruitment of the abdominal muscles is minimized, and recruitment of the hip flexors is maximized, When per­ forming abdominal curls, the individual may exhibit proper technique for a few repetitions but then slip into faulty tech­ nique, or form fatigue, as the abdominal muscles fatigue, With the feet free, abdominal muscle fatigue results in an inability to complete the trunk curl. The feet raise in an at­ tempt to use the hip flexors, but \Nithout distal fLxation, they are rendered insufficient and unable to lift the trunk up­ ward, To ensure testing or training of the abdominal mus­ cles, do not hold the feet dUling the trunk flexion phase, As in the previous example, the proper exercise may be prescribed but performed incorrectly, therefore not achieving the desired result of increased abdominal strength, It is not good enough to perform the exercise; it must be performed correctly and with the appropriate re­ cruitment pattern, A person cannot strengthen a muscle

that is not being recmited.

Lifespan Considerations Prepuberty Only about 20 % of a newborn child's body mass is l1111sl'k tissll~, The infant is weak, and muscular strengthening in the first months takes place by spontaneous movem nts . These movements should not be limited by tight clothes or constant bundling of the newborn, However, the infant and toddler should not be burdened with sys tematic resistive training; normal developmental progression provides an appropriate stimulus for the development of an optimal amount of muscular strength In the prepubertal phase, muscle mass increases paral­ lel to body mass. Children are able to make strength gains above and beyond growth and maturation, Benefits of ex­ ercise in this age group include improved muscle perfor­ mance, increased motor performance, improved body composition, an enhanced sense of well-being, and a posi­ tive attitude toward fitness. 10d!2rate stretlgth training is acceptable , but heavy resistan ee should be avoided be ­ cause of the sensitivity of joint structures , especially at the epiphyses of bones. R sistive training at th is age should focus on technique and the neurologiC asp cts of training. Maximum lifts are contraindicated, and submaximal resis­

FIGURE 5-10. Improperly performed sit-up, with only a hip flexion phase. NOTE Refer to chapter 18 for indications/contraindications for bent-knee versus straight-leg sit-up

66

Therapeutic Exercise: Moving Toward Function

tive training focused on form is preferred (8 to 12 repeti­ tions per set or more) . During prepuberty, there are no dif­ ferences between girls and boys ,vith respect to trainability for strength. Boys have a small genetic advantage, which is completely compensated by the developmental advantage of girlS. 41 There is no biologic basis for a sex-dependent dif­ fere nce in strength performance. Any difference in the strength between girls and boys, particularly in the shoul­ ders and arm s, appears to result from social expectations and gender roles in SOCiety. Muscle perform an ce training should always be superVised by knowledgeable staff to avoid risk of injury.

Puberty The ability to improve strength increases rapidly dUling puberty, particularly in boys. The increase in male sexual hormones is Significant because of their anabolic (i.e., pro­ tein-incorporating) com ponent. During maturation, the propOltion of musc:le in boys increases from 27% to 40% of body mass .41 With the onset of puberty, the strengths of girls and boys diverge markedly. On average, the strength of girls is 90% that of boys at 11 to 12 years of age, 85% at 13 to 14 years , and 75% at 15 to 16 years 4 1 Although this gender difference has a biologiC basis, it does not com ­ pletely account for the differences seen, suggesting contin­ ued societal influences. General strength training is recommended during this phase. Optimal strength and muscular balance is critical for the quickly growing skeleton. Some precautions dur­ ing strength exercise are still warranted. The epiphyses remain sensitive and liable to injUlY. Avoid heavy loads, unilateral burdens, or faulty techniques to prevent epi­ physeal damage.

Early Adulthood Stren~h

potential is at its highest in the 18- to 30-year pe­ liod. 4 The competent biologiC structures show a state of good adaptability, the jOints tolerate high loads , and the so­ cial situation makes specific use of strength necessary. Most individuals are actively involved in physical activity without the responsibility of working long hours. During this period, emphaSiS should be placed on a balanced fit­ ness program for cardiopulmonalY fitness , muscle perfor­ mance , and flexibility.

Middle Age The decrement of strength during this phase oHife must be differentiated according to training activities, gender, and body area. Trainjng for as little as 2 hours or more each week is sufficient to pOSitively influence strength. A small amount of training increases the difference between active an d inactive persons with increasing age. Persons from white-collar profeSSions have the same or even more strength than persons from blue-collar profeSSions; leisure time activities account more for existin g strength than pro­ fessional demands 43

Advanced Age The body can adapt to strengthening exercise throughout th e lifespan. It is possible to reverse existing muscular weakness in old age. 44 Strength increases result from rela­ tively low stimuli because of the marked atrophy present at

the onset of training in many elderly individuais. A study of older men (mean age, 70 years) de monstrated that the training-induced strength gains resulted from neural fac­ tors , as indicated by the increases in maximal integrated electromyography in the absence ofhypertrophy.45 Neural factors are a significalQt mechanism by which older subjects increase strength in the absence of any signjficant evidence of hypertrophy. In general, fatigability increases \vith ad­ vancing age, and older muscles require a longer period of recovery after strenuous exeltion. There is also a significant increase in the collagen content of muscle with advanc:ing age . This is associated ,vith thickening of the connective tis­ sue and increased muscle stiffness. The decrease in muscle performan ce with advancing age affects men and women differently. The absolute de­ cline in strength is less steep in women than in men. Palts of the body are also affected differently. The arms are more affected than the trunk and legs, probably because of less use of the upper extremities in strength-related activities. Active elderly women surpass inactive men with respect to trunk muscle strength. Adequate muscle strength helps to preven t or moderate the symptoms of degenerative changes of the joints. Resis­ tive exercise by the elderly should be directed toward the muscles susceptible to atrophiC changes. 46 Priority should be given to the deep neck flexors , scapular stabilizers, ab­ dominal muscles, gluteal muscles, and quadriceps. Unjus­ tifiably, little attention is paid to strength of the ventilatory muscles (i.e. , diaphragm ) and pelvic floor muscles. Train­ ing should include both multiple joint and Single joint ex­ ercises, performed at moderate loads for 1 to .3 sets of 8 to 12 repetitions. Additionally, the elderly should consider training for power, not just strength. Leg power has been shoWQl to sig­ nificantly influence the;,hysical performance of mobility­ limited elderly people. 4 Fielding et al 48 found high veloc­ ity resistance traini ng to increase muscle power more effectively than low velOCity training in older wom en. Power training in this group should include light to moder­ ate loads performed for 6 to 10 repetitions with high veloc­ ity. See Chapters 18 through 27 for resistive exercises for the spine, shoulder, arm , hip, knee , and pelViC floor. With advanCing age, the social needs and individual mo­ tivation fo r the use of strength lessen ; the atrophy reflects the effects of disuse , not mere age-related changes. The voluntary and deliberate use of the motor system in daily life activities and intentional resistive training are able to counteract the loss of muscle mass with increasing age . The vigorous use of muscles, particularly among old persons, improves their health and sense of well-being.

Cognitive Aspects of Performance The cognitive or mental aspects of strength and perfor­ mance are most easilv seen in elite athletes. The use of mental imagery techniques such as visualization and posi­ tive self-talk has been suppOlted by sport psycholOgists and athletes alike. Positive cognitive strategies can enhan ce strength and performance, an d negative strategies may have a negative or negl igible impact. A study of different mental preparation techniques (i.e., arousal, attention, im­

Chapter 5 Impairment in Muscle Performance

If

67

gery, self-efficacy, and control-read conditions) showed that preparatory arousal and self-efficacy techniques pro­ nced greater ~osttest strength performance than in the control group. 9 A similar study showed no difference IDl ong the mental preparation conditions, but all per­ onned significantly better than a control group.50 Some types of mental preparation can have a negligible o · negative impact on strength performance. A study of relaxation-visualization training by non-strength-trained men showed poorer knee extensor measures for them than a control group. The investigators suggested that this training dive~ted their full concentration away from the exercise task.") A mental task requiring subjects to imag­ ine situations making them angry or fearful produced increased levels of arousal but no change in strength per­ £ rmance. 52 A study of the impact of imagery, preparatory arousal, and counting backward on hand grip strength found im­ ery to enhance grip strength in older and younger sub­ jects. 53 Gould and coworkers 54 found that imagery and preparatory arousal improved strength pelformance. Dif­ ferent kinds of imagery and their impacts on power and en­ durance activities (i.e., seated shot-put and push-ups to ex­ haustion) have been studied. Results show that all imagelY techniques have a positive impact and that using metaphors is particularly effective in improving power and endurance measures.s5 The knowledge of results of isokinetic peak torque out­ put (i.e., visual feedback) provides an important error-cor­ rection function. This type of training may help patients de­ velop cognitive strategies that can be used to guide performance in clinical and nonclinical settings. 56 Studies u a est that mental preparation and the current mental tate can affect strength performance. Consider this when performing and interpreting the results of resistive tests.

sition, deranged elements of the sarcoplasmic reticulum, and abnormal mitochondria. Type II fiber atrophy has also been attributed to chronic alcohol abuse. 50 Type II atrophy suggests that alcoholic patients may exhibit speCific deficits in muscle performance, such as an inability to generate ten­ sion rapidly and to produce power. For many patients, ab­ stinence leads to full recovery of muscle function, but for others, the injury may be more severe and resistant to treat­ ment, and this must be considered as a comorbidity when projecting the prognOSiS .

Effects of Alcohol

Muscle performance can be impaired for a variety of rea­ sons. Central or peripheral neurologic pathology decreases an individual's ability to effectively recruit and functionally use his muscles. Injury to the muscle from a strain or con­ tusion decreases performance, as does disuse or decondi­ tioning for any reason. The goal of examination/evaluation of muscle performance is to determine the cause of the im­ pairment to develop the most efficient and comprehensive intervention plan. The follOWing section discusses the po­ tential factors that can cause impaired muscle perfor­ mance, examination/evaluation results of each potential cause, and general intervention concepts for each speCific cause.

The deleterious effects of alcohol abuse on muscle have been well documented. 57 The myopathic changes seen in the alcoholic patient have at times been attributed to mal­ nutrition or disuse. Experiments have demonstrated that, even \vith nutritional support and prophylactic exercise, normal subjects can develop alcoholic myopathy if they in­ gest large amounts of ethanol. 58 Alcoholic myopathy has two clinical phases: an acutely painful presentation that follows "binges" and a chronic phase that consists of morphologic and functional alter­ ations in muscle. 59 Acute alcoholic myopathy has morpho­ logic features, such as fiber necrosis , intracellular edema, hemorrhage, and inflammatory changes, that can be seen under light microscope . Binges by chronic alcoholics can 'esult in an acute myopathy characterized by muscle cramps, muscle weakness, tenderness, myoglobinuria, re­ d uced muscle phosphorylase activity, and decreased lactate response to ischemic exercise. Exercise is contraindicated for persons with acute myopathy and those with myo­ O'lobinuria, because it may stress an already compromised 'stem. Changes seen in chronic alcoholic myopathy include in­ tracellular edema, lipid droplets, excessive glycogen depo­

Effects of Corticosteroids The \videspread use of oral corticosteroid agents as anti­ inflammatory and immunosuppressant agents has led to cases of steroid atrophy.61 The primary biopsy finding in patients treated with prednisonelike steroids (e.g., pred­ nisone, prednisolone, methylprednisolone) is type II fiber atrophy61 This reduction is thought to be most pro­ nounced in type lIB fibers 52 and is believed to occur more often in women than men 63 Corticosteroids are a potent catabolic stimuli, and the atrophy caused by prolonged cor­ ticosteroid use occurs as protein degradation exceeds pro­ tein syntheSiS. Goldberg 5 believes that the constant use of the type I fibers during normal voluntary movement pro­ vides these fibers with a protective or sparing influence from the catabolic effects of steroids. Exercises recruiting type II muscle fibers may protect them from steroid­ induced atrophy. Normal function can be expected to re­ turn \vithin 1 year or, more often, \vithin several months af­ ter steroid use has stopped. 53

CAUSES OF DECREASED MUSCLE PERFORMANCE

Neurologic Pathology NeurologiC pathology can affect the contractile capacity of muscle as a result of pathology in the central or peripheral nervous system. The peripheral nervous system can be af­ fected at the nerve root or peripheral nerve level. Individuals \vith nerve root pathology may present \-vith muscle performance impairments in the nerve root distri­ bution. Examination will discover muscle performance impairment associated with a specific nerve root distribu­ tion. For example, nerve root compression at the LA-L5

68

Therapeutic Exercise: Moving Toward Function

spinal level can produce quadriceps femoris weakness, and nerve root compression at the C5-C6 spinal level can result in deltoid and biceps weakness. Sensory changes usually precede muscle performance changes , but individuals with more severe patholob'Y may have se nsory and motor changes. Therapeutic exercise intervention depends on the prognosis for the nerve root involvement. If the changes are relatively recent and resolution of the nerve root com­ pression is expected through conservative or surgical man­ agement, preventive and protective measures are taken. The goal of therapeutic exercise intervention is not only to promote optimal muscle performance of the muscles in­ nervated by the affected spinal segment (pending progno­ sis) but also promote spine stability and optimal movement patterns to alleviate any mechanical cause of nerve root pathology incurred by the spinal segment(s) (see chapters 18 and 24). Peripherally, resistive exercise can be used to maintain/improve current strength levels, whereas training inner lumbar or cervical core and girdle muscles provide proximal stability. CentraDy, use resistive exercise to train inner core muscles (i.e. , longus coli , transversus abdominis, lumbar multifidus, pelvic floor; see Chapters 18, 19, and 24 for detailed muscle performance training) to effectively stabilize the spine and relieve mechanical nerve root irri­ tants. After the mechanical or chemical cause of nerve root injury is remediated, speCific, localized resistive exercise of the involved musculature is often indicated to restore pre­ cise recruitment patterns. NeurologiC weakness may also result from a peripheral nerve injmy. Compromise of the median nerve at the carpal tunnel, the radial nerve at the cubital tunnel , or the common peroneal nerve at tIle fibular head are examples of such injmy. The pattern of sensory loss and wcakness de­ pends on which nerve and where along the nerve's course the damage occurs. Some peripheral nerve entrapments have only a motor component, others have only a sensory component, and some are mixed. Examination results will demonstrate sensOlY changes and weakness consistent with the peripheral nerve innervation pattern. As in nerve root involvement, attention should be focused on remediating the mechanical cause of the peripheral nerve injury. For example, a depressed shoulder girdle may contribute to traction on the long thoracic nerve, causing motor changes in the serratus antelior. Exercise and posture education to elevate the shoulder girdles may alleviate the traction on the long thoracic nerve and ultimately restore normal in­ nervation to the serratus anterior. Resistive exercise should also focus on maintaining and increasing the strength of the unaffected motor units in the involved musculature, and progreSSively strengthening motor units on reinnervation. Caw must be taken to not focus too much on strengthen­ ing muscles that are intact for fear of creating Significant muscle imbalance. Exercise should try to maintain muscle balance and efficient movement patterns \:vi.thout develop­ ing a dominant muscle group that overrides other muscle action. Splinting, braCing, taping, or other supportive mea­ sures may be necessary to maintain balance. Other neurolOgiC conditions include neuromuscular dis­ ease such as multiple sclerosis, postpolio syndrome, and Guillain-Barre syndrome, and muscular paralYSis or paresis resulting from spinal cord injuIJ' or cerebral vascular acci­

dent (CVA ). Resistive exercise programs must consider the prognosis and tailor the exercises appropriately. In situa­ tions such as Guillain-Barre syndrome, certain cases of spinal cord injury and e VA, and progreSSive stages of mul­ tiple sclerosis, some recovery is expected. Examination re­ sults will distinguish more global patterns of weakness or tone changes. E xercise programs focus on maintaining strength in intact m usculature and gently strengthening weakened muscles as recoveIJI and remission advances. Take care to avoid fatiguing these weakened muscles dur­ ing strengthening exercises. D osage pararneters generally include several short exercise sessions of a few repetitions interspersed throughout the day. Duling quiescent periods of diseases such as multiple sclerosis, a general condition­ ing program of balanced strengthening and mobility exer­ cises is appropriate. When recovery is not expected, resis­ tive exercise programs emphaSize functional strength of remaining musculature. This includes strength for func­ tional activities such as self-care, transfers, and mobility. Take care to avoid overworking these muscles. Unlike per­ sons with full innervation who use their muscles efficiently, the individual with paralysis uses th e few innprvated mus­ cles they have for nearly all their activities. The potential for overuse injuries is very high.

Muscle Strain Muscle strain occurs along a continuum from acute macro­ traumatic injury to chronic microtraumatic overuse injuries (see Chapter 11). Examination results will distinguish this form of \Veakness by pain with resistance, typically in the lengthened ranges of the muscle where the cross-bridges are most separated. Resistive exercise in the treatment of muscle strain injuries depends on where along this contin­ uum the injury occurs. Resistive exercise that neither over­ loads nor underloads the tissue is optimal. Determining this resistance dosage is the challenge. Acute traumatic injulies occur when a muscle is rapidly overloaded or overstretched and the tension generated ex: ceeds the tensile capability of the musculotendinous unit. 60 These injuries occur near the musculotendinous junction and at random areas within the muscle belly. The ham­ string muscle is a common site of muscle strain injury. A combination of insufficient strength, reduced extenSibility, inadequate wann-uf' and fatigue has been implicated in hamstring injuries 6 (see Patient-Related Instruction 5-1: Preventing Musc:le Strain ). Strength, extenSibility, and fa­ tigue resistance protect a muscle from strain injUly. Eccentric loading is a common mechanism of muscle strain injury, and a muscle prepared for eccentric loading is less likely to sustain an injury. E ccentric loading should be an integral part of any resistance training program (see Selected Intervention 5-1: Lateral Kicks for an example of eccentric loading). A program to prevent muscle strain in­ juries should include dynamiC resistive exercises \:vi.th a strong eccentric component, flexibility exercises, an appro­ priate \Varm-up before activity, and attention to fatigue lev­ els. The rehabilitation program after injury should also fo­ ellS on these factors. ~v[uscles may also be strained from chronic overuse. For example, extensor digitorum longus (EDL) strain is com­

Chapter 5: Impairment in Muscle Performance

Preventing Muscle Strain Although some muscle strains are not preventable, prec autions can reduce your risk of inju ry. 1. Warm-up before a vigorous activity; 5 to 7 minutes of a large muscle group activity such as walking, jogging, or cycling should suffice. This should be enough activity to break a sweat. 2. Stretch stiff and short muscles after your general warm-up. Stretch each muscle for 15 to 30 seconds for four repetitions. 3. Balance your sports or other leisure activities with strengthening exercises. Your clinician can help you focus on muscles susceptible to injury. 4. Avoid fatigue during the activity. Fatigue can increase your risk of injury. 5. Strengthen underused muscles to prevent overuse to susceptible muscles. Your clinician can help you determine which muscles these are and what specific exercises you need to perform to maintain muscle balance.

mon in workers performing continuous repetitive elbow, wrist, and hand activities as a result of using the EDL for wrist extension and elbow flexion. Training the individual to use the biceps for elbow flexion whenever possible (i.e. , keep the hand supinated versus pronated during elbow

t::::\ ~

f

Lateral Kicks

Although this patient requires comprehensive intervention as described in other chapters, only one exercise related to resistive training is described . This exercise would be used in the late phase of this patient's rehabilitation.

ACTIVITY: Resisted hip abduction and ankle eversion PURPOSE: To increase the muscle performance of the ankle eve rtor and hip abdu ctor muscles. STAGE OF MOTOR CONTROL: Controlled mobility MODE: Resistive band POSTURE: Standing with one foot on the resistive band and th e band around the other foot. A SUppOlt should be readily available for balance as needed.

~

of ll ­

a '0 ­

fo-

flexion) can alleviate the overuse strain to the EDL. A thorough evaluation can determine the cause of the overuse problem. Ergonomic assessment and appropriate work site modification is also necessary to prevent a recur­ rence of the strain if ergonomics are at the root of undesir­ able posture or movement patterns. If left untreated, this impairment can quickly lead to disability. Strain resulting from muscle dominance overuse is man­ aged by reducing the loads imposed on the strained mus­ cle. When the tensor fascia latae dominates over the ilio­ psoas during hip flexion and gluteus medius during abduction, the tensor fascia latae is at risk for an overuse strain. Improving the strength and recruitment patterns of the iliopsoas and gluteus medius can reduce the load on the tensor fascia latae and allow it to recover. Postural habits (e.g. , standing in medial rotation ) and movement patterns (e.g. , hip flexion or abduction with medial rotation) must al so be modified to improve recruitment of the underused synergists. A potential risk factor of muscle strain is gradual, contin­ uous overstretching, which occurs when a muscle is contin­ uously placed in a relatively lengthened, tension -producing pOSition. For example, the lower trapezius in a person with forward shoulders is subjected to continuous tension and has adapted to a lengthened state. It may not take much force to produce a strain injury in a muscle that is already overstretched. This type of strain puts the muscle at risk for two fo rms of muscle weakness , one from length-tension changes and the other from overstretch strain.

SELECTED INTERVENTION 5-1

See Case Study #1

g

MOVEMENT: Standing on the uninjured leg, abduct the hip in the frontal plane, and eve It (pronate ) the ankle. ~'Iaintain good spinal posture throughout the exercise. Do not hike pelviS . Move only at the hip joint. Avoid moving out of the frontul plane. Moving toward flexion results in th e motion performed by the flexor abductor group. Return to the start position.

69

DOSAGE: Two to three sets per day to form fatigue . If patient does not fatigue by 20 repetitions, increase the resistance of the bane!. EXPLANATION OF PURPOSE OF EXERCISE: This exercise increases muscle performance in tile hip abductors ,lIlel ankle evertors in a synergistic fashion. Abductors are strengthe ned in both concentric and eccentric modes. It may be progressed to a higher speed to challenge stability.

70

Therapeutic Exercise: Moving Toward Function

Patient education is a key component of the rehabili ta­ tion program in the case of muscle strain associated with continuous overstretch. In the lower trapezius example, educate the patient about optimal postural habits to re­ duce tension on the lower trapezius. Improving postural habits and reducing tension on the lower trapezius with bracing or taping (see Chapter 26 ) will allow the muscle to heal more rapidly. In addition, it ,vill promote adaptive shortening and therefore ultimately achieve a more opti­ mal length-tension relationship and reduce the risk for future reinjury.

Disuse and Deconditioning Muscle performance may be impaired because of disuse or deconditioning for a variety of reasons. Illness , surgery, specific physical conditions (e .g., pregnancy ,vith twins), or injury may necessitate a period of decreased activity. Sub­ tle muscle imbalances can lead to overuse of one muscle and to disuse and deconditioning of another. Illness and injury are common causes of deconditioning. For example, illness such as pneumonia or an injury such as a herniated disk can result in a period of decreased activity . and subsequent deconditioning. In these situations, total­ body deconditioning occurs, and general conditioning is necessaly. However, specific exercises also may be neces­ sary to improve muscle performance and prevent sec­ ondary impairments. For example, an elderly individual may have relatively asymptomatic osteoarthritis until a bout with pneu monia produces general deconditioning. Subsequently, knee osteoarthritis becomes symptomatic because of impaired muscle performance in the lower ex­ tremity muscles involved in gait and other functional activ­ ities. Specific resistive exercises to recondition those mus­ cles are necessary to restore proper biomechanics and prevent further disability. Reduced activity levels can impair muscle performance in a similar manner. Multiparous pregnancies, exacerbation of a musculoskeletal injury, an episode of colitis, or social factors such as major life changes (e.g., job, school , divorce, family illness, death ) can reduce activity levels and result in impaired muscle performance. For example, regular exer­ cise may keep a woman's patellofemoral malalignment from becoming symptomatic. When her activity level decreases in the late stages of pregnancy, the combination of de­ creased activity, weight gain, and hormonal changes pro­ duces symptoms at the patellofemoral joint. Selective resis­ tive exercises combined with patient education can prevent this exacerbation. Resistive exercises in the case of overall decreased activity must consider the muscles most likely to be affected , the patient's desired activity level and prefer­ ence, and any underlying or residual medical conditions. An overlooked source of deconditioning or disuse is a subtle muscle imbalance. vVh en activating muscles for a functional movement, the body chooses the most efficient muscular and motor unit activation pattern. Certain motor units in a muscle may be preferentially recruited when a muscle is engaged in a particular task()f For example, mo­ tor units in the lateral portion of the long head of the biceps are preferentially activated when this muscle is engaged in elbow flexion, whereas motor units in the medial portion

are preferentially activated in forearm supination. The re­ cruitment thresholds of motor units in a muscle are also in­ fluenced by the type of mu scle actions associated \\lith a movement. In elbow flexion, biceps motor units have a lower threshold in slow concentric and eccentric actions than isometric actions; the reverse is true for the brachialis 68 The recruitment thresholds of motor units of a muscle active in a movement may also be affected by changes in jOint angle. 69 Some muscles or portions of a muscle may be overused while other muscles or portions are disused, and the resistive rehabilitation program must acknowledge this imbalance. In the previous example, in­ struction in general resisted elbow flexion may exacerbate the imbalance whereas speCific training of the vveaker re­ cruitment pattern can restore muscle balance.

Length-Associated Changes The principle of the length-tension curve affects muscle performance when a muscle is adaptively lengthened from prolonged posture and repetitive movement patterns of the muscle in the lengthened state. Examination of postural alignment controlled by the muscle suggests that the mus­ cle is longer than ideal as in depressed shoulders or hip ad­ duction and medial rotation. Muscles ,viJi test weak in the short range when compared ,vith synergists, paired muscle of the other extremity, or other half of the axial skeleton (i.e., posterior gluteus and tensor fasciae latae, right and left posterior gluteus medius, or right and left external oblique muscles, respectively). As previously mentioned, this is referred to as positional weakness. Intervention should focus on strengthening the muscle in the shortened range, optimizing posture to reduce lengthening tension 011 the muscle , and altering movement patterns to recruit the muscle in the shortened range.

PHYSIOLOGIC ADAPTATIONS TO TRAINING Strength and Power The benefits of resistive exercise extend beyond the obvi­ ous improvements in muscle performance to include posi­ tive effects on the cardiovascular system, connective tissue, and bone. Moreover, these effects translate into fun<:tion. Individuals perform their daily activities \\lith more ease because they are functioning at a lower percentage of tbeir maximum capacity. Improved functioning also enhances the patient's sense of well-being and independence.

Muscle The most obvious benefits of resistive training are for th muscular system. Regular resistive exercise is associated with several positive adaptabons, most ofwhich are dosagp.­ dependen t (Tahle 5-1). The cross-sectional area of th muscle increases as a result of an increase in th e rnyofiblil volume of individual muscle fibers, fiber splitting, and po­ tentially an increase in the number of muscle fibers. This cross-sectional area increase primarily results from prefer­ ential hypertrophy of type II fibers. Changes in the muscle

Chapter 5: Impairment in Muscle Performance

~

. Physiologic.Adaptations to Resistance Training ~_. _ _

VARIABLE Performance Muscle strength Muscle endurance .'\erobic capacity Ylaximal rate of force production Vertical jump Anaerobic power Sprint speed Muscle Fibers Fiber size Capillary density Mitochondrial density Enzyme Activity Creatine phosphokinase Y1yokinase Phosphofructokinase Lactate dehydrogenase Metabolic Energy Stores Stored ATP tored creatine phosphate Stored glycogen Stored triglycerides Connective Tissue Liaament strength T ndon strength Collagen content Bone density Body Composition Percentage of body fat Fat-free mass

' RESULT AFTER RESISTANCE TRAINING

Increases Increases for high power output No change or increases slightly Increases Increases Increases Improves Increases No change or decreases Decreases Increases Increases Increases No change or vmiable Increases Increases Increases May increase May increase May increase May increase Increase Decreases Increases

-\dapted from Falkel JE, Cipriani DJ. Physiological principles of . tance training and rehabi.litation. In: Zachazcwski JE , \,1agee DJ, -Quille n WS. eds. Athletic Injuries and Rehahilitation. Philadelphia: WB.

:runders, HJ96.

i­

L

e ,d ee

ril

pend on fiber type and the stimulus. Hypertrophy of ..tSt-twitch fibers occurs when all or most of the fibers are in recruited and is considered an adaptation for in­ a~ed power output. Slow-twitch fibers hypertrophy in ponse to frequent recruitment. In repetitive, low-inten­ .' activity, fast-twitch fjbers are rarely recruited, and e fibers may atrophy while the slow-twitch fibers hy­ rtrophy. A study by Staron and colleagues 37 examined differences in the proportion of muscle fiber types in tance runners, weight lifters, and sedentary controls. investigators found the weight lifters had a greater portion of type IIA fibers and had a greater ~e IIA r area than the controls or distance runners 7 Spec i­ ty of resistive training exists and must be considered n designing a training program. Other changes occur on cellular and systemic levels. capillary denSity is unchanged or decreases, and the :ochondrial denSity decreases. Some of these changes .tit from their number relative to total muscle volume.

71

Although protein volume and cross-sectional area increase in response to resistive training, some of the cellular or sys­ temic factors may remain unchanged, giving the percep­ tion of a decrease, although the decrease is only relative. Energy sources necessary to fuel muscle contraction in­ crease after resistive training. In general, levels of creatine phosphate, ATP , myokinase, and phosphofructoJ.<:in~se in­ crease in response to a resistive exercise ~rogram.ll- 14 Lac­ tate dehydrogenase is variably changed. Z Neural adaptations occur with resistive training. Studies have shown increases in the muscle's ability to produce torque and increased neural activation, as measured by electromyography (EMG)38 Increases in muscle activity were also seen after resistive training that consisted of ex­ plOSive jumping. Increased EMG values associated "vith greater power and maximal contraction were attributed to a combination of increased motor unit recruitment and in­ creased firing rate of each unit. 75

Connective Tissue Although disuse and inactivity cause atrophy and weaken­ ing of connective tissues such as tendon and ligament, physical training can increase the maximum tensile stre'2r,!l and the amount of energy absorbed before fail­ ure. I Physical activity returns damaged tendons and liga­ ments to n~~mal tensile strength values faster than com­ plete rest. I I Physical training, particularly resistive exercise, may alter tendon and ligament structures to make them larger, stronger, and more resistant to injury.

Bone

Weightlessness 78 and immobilization 79 can cause profound loss of bone denSity and mass. Weight-bearing activities that recruit antigravity muscles can maintain or enhance bone denSity and mass. 80 Weight training, paliicularly with a weight-bearing component, can substantially alter bone mineral denSity. Individuals in sports requiring repeated high-force movements such as weight lifting and thrO\ving events have higher bone densities than distance runners and soccer players or swimmers. sl Those who play tennis regularly have higher bone denSity in their dominant fore­ arms, and professional pitchers have greater bone denSity in the dominant humerus 8z A 5-month study of weight training compared with jogging found that weight training produced Significantly better increases in lumbar bone denSity than the aerobic exercise 83 These studies suggest that regular exercise, speCifically exercise such as resistive training, can maintain or improve bone density. Resistive training to improve bone denSity is important for women of all ages. A study of adolescent fe­ male athletes found runners to have higher total body and site-specific bone mineral denSity than swimmers or cy­ clists, and that knee extension strength was an independent predictor of bone mineral denSity in this population. 84 Fi­ nally, a study of bone mass and exercise dosage found that daily loading regimens broken down into four sessions with recovery time in between improved bone mass Significantly over a loading schedule that gerformed the training in a Single, uninterrupted session. Thus smaller exercise ses­ sions separated by recovery periods may be a better pre­ scription when increased bone mass is the goal.

72

Therapeutic Exercise Moving Toward Function

Cardiovascular System Resistive training benefits the cardiovascular system. The idea that strength training causes hypertension is erro­ neous. Most reports show that highly strength-trained atll­ !etes have average or lower tilan average systolic and dias­ tolic blood pressures .86 When performed properly and heeding the proper precautions, strength training can have a positive effect on the cardiovascular system. Increased intrathoracic or intra-abdominal pressures may affect cardiac output and blood pressure during resis­ tive exercise. In the classic model, increased intratiloracic pressures are thought to decrease venous return to the heart and decn~ase cardiac output. Intrathoracic pressure is inversely related to cardiac output and stroke volume and directly related to systolic and diastolic blood pressure our­ ing resistive exercise. Increased intrathoracic pressmes may limit venous return and decrease cardiac output while causing an accumulation of blood in the systemic circula­ tion that may increase blood pressure. Performing resistive exercises with a Valsalva maneuver, which elevates in­ trathoracic pressure, leads to a greater blood pressure re­ sponse than yenormance of the exercise without a Valsalva maneuver 8 1 Instructing the patient to breathe properly during exercise may reduce the increase in blood pressure sometimes seen during exercise. Increased intramuscular pressure during resistive exer­ cise may result in increased total peripheral resistance and increased blood pressure . Mechanically induced increases in peripheral resistance probably are the cause of higher blood pressures during isometric and concentric exercise compared with pressures during eccentric exercise S8 Iso­ metric or concentric exercise combined witil a Valsalva ma­ neuver can produce the greatest increase in blood pres­ sure. This combination should be avoided, espeCially by individuals at risk for elevated blood pressure (see the Pre­ cautions and Contraindications section). Resistive exercise does result in a pressor response that affects the cardiovascular system by causing hypertension through exciting the vasoconstrictor center, which leaos to increased pelipheral resistance. If precautions are taken to ensure proper breathing and avoid isometric contractions in persons at risk for a pressor response, resistive exercise's benefits outweigh the risks. Long-term performance of resistive exercise can result in positive adaptations of the cardiovascular system at rest and during work. Cardiovas­ cular adaptations to resistive training are su lllmarized in Display 5-2.

DISPLAY 5-2

Benefits of Strength Training on the Cardiovascular System • • • • • • •

Decreased heart rate Decreased or unchanged systolic blood pressure Decreased or unchanged diastolic blood pressure Increased or unchanged cardiac output Increased or unchanged stroke volume Increased or unchanged maximal oxygen consumption Decreased or unchanged total cholesterol

Endurance The muscle's response to endurance training is different from its response to strength or power training. This re­ sponse is expected because of the differences in training dosage. Muscular endurance depends on oxidative capac­ ity, and training increases the muscle's metabolic capacity. Muscular endurance is often limited by a local accumula­ tion of lactate, \Vitll glycolysis inhibition and a failure to re­ generate ATP in tile working muscle.~~ During prolonged activities, depletion of intramuscular glycogen reserves may contribute to impaired muscular endurance. Muscles trained for endurance demonstrate cells with increased mitochondrial size , number, and enzymatic ac­ tivity, as well as increased penusion 9o Increased enzymatic activity allows the muscle to better use the oxygen deliv­ ered, encouraging use of fats as a fuel and sparing glycogen. Muscles that are stronger use a smaller portion of the max­ imum voluntary contraction force with activity, thereby de­ laying the onset of muscular fatigue. Muscles trained for endurance also demonstrate in­ creased local fuel storage. Glycogen stores may be in­ creased twofold, and when endurance training is combined with appropriate carbohydrate intake, stores may increase as much as threefold 90 In addition to increasing fuel stores, the endurance-trained muscle also increases fatty acid use and decreases tlle use of glycogen as a fuel. This alteration allows more exercise before fatigue. Endurance muscle training improves the m.ygen delivery system by increasing the local capillary network, producing more capiUaJies per muscle fiber. 90 Increased perfUSion slows the accumulation of lactate in the working muscles.

EXAMINATION AND EVALUATION OF MUSCLE PERFORMANCE Decreases in muscle performance may occur for a num­ ber of reasons. A thorough examination is necessal)' to de­ termine the cause of impaircd muscle performance and the link betv.reen impaired muscle performance and func­ tional limitations or disabilities. After that relationship is established, the intervention must be matched to the cause of impaired muscl e pelformance. The muscle test is only one small part of the examination process and must be used "vith additional information (e.g. , range of mo­ tion, joint mobility, balance, sensory and reflex integrity) to determine the speCific cause of impaired muscle perfurmance. The tests and measures recommended by the Guide to PhljsiC(J/ TheTapist Practice9 J ensure comprehensive as­ sessment of the patient's impairments, functional limita­ tions, and disability. Within the examination is a subset of measures speCific to the penormance of the muscle, These tests include an analysis of functional muscle strength, power, or endurance; manual muscle tests; dynamometry; and electrophysiologic testing. Manual muscle testing is the most fundamental of all strength tests. Length-tenSion relationships, muscle imbal­ ance, and positional weakness must be considered when choosing manual muscle test positiOns. Close attention to

Chapter 5 Impairment in Muscle Performance

substitution patterns and testing in a variety of positions minimizes the chance of erroneous results. ""hen used re­ liably, hand-h eld dynamomete rs can provide muscle per­ formance information that is more reliable than that of tests using the traditional clite ria of 0 through 5. Isokinetic dynamometers are commonly used to assess muscle performance, Computerized systems provide trem e ndous data reduction capabilities, Tests can be pe r­ formed at a variety of speeds and comparisons made with antagonists, the contralateral limb, normative standards , or previous test results. These tools provide reliable data that can be used to assess progress , as a motivator, or as criteria for progression to more advanced rehabilitation phases. A variety of mus cle actions can be ass essed using this equipment. Dynamic strength can also be de termined using the rep­ e tition maximum (RM ) mctll od, For example, a 10 RM is the maximum amount of we ight that can be lifted 10 times , and a 1 RM is the maximum amount of weight that can be lifted once. The amount of weight that can be lifted for a given number of repetitions can be determined and com­ pared vvith that for the antagonist, the opposite limb , or to a previous test result. The magnitude of measured increases in force or torque depends on how similar the test is to the training exercise,92 For example, if athletes train their legs by doing the squat exercise, the increase in strength measured as maximal s(luatting is much greater than the strength increase mea­ sured in isometric leg press or knee extension tests. Tbis specificity of movement pattern in strength training ~roba­ bIy reflects the role of learning and coordination. 3 Im­ proved coordination takes the form of the most efficient ac­ tivation of all of the involved muscles and the most efficient activation of motor units within each muscle in volved, Testing force production in the manner in which the mus­ cle has been trained reflects the morphologic and neuro­ lOgiC adaptations,

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n

THERAPEUTIC EXERCISE INTERVENTION FOR IMPAIRED MUSCLE PERFORMANCE

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Therapeutic activities to enhance muscle performance are at the core of the intervention program for man)' patients. The dinician is faced vvith a multitude of variables to con­ ider when designing this program. These variables are found in the intervention model in Chapter 2, Prioritizing and balancing all these variables to achieve the best patient outcome requires both knowledge and experience. The fol­ 10vving sections vvill highlight the key variables to consider when designing a resistive exercise program. Be sure to consider another impOltant variable: the ini­ tial training status of the patient. Realize that recomm en­ d tions about the intervention model variables vvill change with the training status of the individual patient. Two p a­ tients vvith identical impairments may present vvith an in­ flammatory shoulder condition , one who is a regular exer­ ciser, lifting we ights 5 days per week and working construction, whereas the other is a sedentary individual, "'orking at a desk job , The initial exercis e prescription and progression plan will differ based on the diffe rence in their mitial training status,

73

The American College of Sports Medicine (AC M ) de­ fines a no-dee as someone vvith no training experience , in­ termediate as someone vvith 6 months of consistent resis­ tance training expelience, and advanced as someone vvith years of resisti ve training experience,al Elite individuals are highly competitive athletes, Strength gains vary con­ siderably among these training groups . You can e;..-pect muscle strength gains of approximately 40% in untrained individuals, 16% to 20% gains in intermediate , 10% in ad­ vanced, and 2% in elite athletes. 94 These gains can be x­ pected over the course of 4 weeks to 2 years, with the ma­ jority of gains (espeCially in the untrained) occurring in the first 4 to 8 wee ks, For untrained individuals, thc' re­ sponses to just about any training program will be pro­ found , whereas making gains in intermediate, advanced, or elite athletes is much more difficult. E xercise prescrip­ tion will ne d to be mOre creative and variable in these individ uals,

Activities to Increase Muscle Performance The specific activities and dosage chosen to improve mus­ cle performance d pend on many factors, including the in­ dividual's age and medical condition, muscles involved, ac­ tivity level, current level of training, goals (i.e ., str ngth, power, and endurance), and cause of decreased muscle perform ance. The folloV\ing sections describe the activities used to increase muscle performance and their relative risks and benefits, Be sure to match the appropriate train­ ing mode to the patient's goals,

Isometric Exercise Isometric exercise is commonly used to increase muscle performance. Although no joint movement occurs, isomet­ lic exercise is considered functional because it provides a strength base for dynamiC exercise and because many pos­ tural muscles work primarily in an isometric fashion (see Self-Manage ment 5-1: Cl~ rvical Spine Extension for an ex­ ample of isometric exercise for postural muscles ). Isomet­ ric exercise is a valuable rehabilitation tool when joint mo­ tion is uncomfortable or contraindicated, du ri ng immobilization, or when weakness exists at a specific point in the ROM. Isom etric exercise is used as a special tech­ nique in proprioceptive neuromus cular facilitation to en­ hance stability and strengthen muscles in a weak portion of the range, This resistive mode is easy to understand and perform correctly, requires no equipment, and can be per­ formed in almost any setting, Isometric exercise is most ef­ fective when individuals are in a low state of training, be­ cause the benefits of isometric exercise decrease as the state of training increases. Most gains_are made within the first 5 weeks of the onset of training D , Some factors are important in chOOSing isom etric exer­ cise for rehabilitation , Isom etric strength is specific to the joint angle. Studies have demonstrated isometric joint an­ gle specificity, noting that strength gained at one joint an­ gle did not predictably carry over to other joint angles% Keuromuscular changes accoun ted for the joint-angIe-de­ pendent effects, and obtaining generalized strength gain~ required multiple-angle training programs. Whitlel '

74

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 5-1

Cervical Spine

Extension Purpose: Position:

Movement technique:

To strengthen cervical extensors. Lying on your stomach with fists positioned under your forehead and a pillow under your trunk; a small towel roll under your chin may be necessary to keep your head in neutral. Remove your hands from your forehead and hold your head in a proper neutral position. Hold for 10 seconds.

Dosage Repetitions: ___ per set sets Frequency __ sessions per day, __ sessions per week

found significantly increased strength at all joint angles af­ ter 10 weeks of training at specific jOint angles. Others have found this gen eral transfer, although only after training was well advanced. 96 In the beginning training phase , the strength gains were transferred only when the muscle ,vas at shorter than resting length. Beeause of the angle specificity, mu ltiple-angle isomet­ ric training is recommended whenever possible. Sample dosage parameters for isometric exercise prescription are as follows: • Perform isometric contractions every 15 to 20 de­ grees thro ughout the ROM . • Hold each contraction approximately 6 seconds (the first few seconds of the first maximum contraction ap­ pears to trigger the major training effect-after the first few seconds, the ability to maintain a maximal contraction drops off dramatically). • Hold the contraction long enough to fully activate all motor units, and repeat it frequen tly throughout the day. • Isometric contractions have their greatest effect near maximal contraction, although this may not be possi­ ble in many clinical situations. Isometric exercise is used for purposes other than mus­ cle strength training. One of the benefits of isometric exercise is the ability to perform repetitive submaximal con­ tractions as "reminder" or reeducation exercises. Quadri­ ceps sets are used after injUly or surgelY to reeducate the person on how to activate the quadriceps. This prepares the

patient for more advanced dynamic activities. Quadriceps and gluteal sets are also used to enh ance circulation throughout the lowe r extremity during periods of bed rest. Use caution wh en prescribing isometric exercise for pa­ tients with hypertension or known cardiac disease. Isomet­ ric exercise can produce a pressor response , increasing blood pressure. Perform isometric exercise without breath holding or a Valsalva maneuver. Individuals with hyperten­ sion may benefit from simple, repeated contractions held only 1 to 2 seconds.

Dynamic Exercise Dynamic resistive exercise can be performed in a variety of modes, postures, and dosages , as well as with a variety of contraction types (i. e., concentric, eccentric). Body weight, resistive bands, free weights, pulleys, and weight machines are a few modes of dynamic resistive exercise (see Patient­ Related Instruction 5-2: PurchaSing Resistive Equipment). Manual resistance applied by the cliniCian, the patient, or a family member is another form of dynamic resistive exer­ cise. Concentric and eccentric contractions can be used in different combinations depending on the mode of exercise chosen (i.e., free weights uses concentric and eccentric contraction of the same muscle groups whereas manual re­ sisted exercise can use concentric contractions of opposing muscle groups). As with isometric exerCise, each type of dy­ namic exercis e has risks and bene fits, and the training mode must be matched to the speCific needs of the indi­ vidual . The ACSM reco mm ends that for novice and inter­ mediate training, both free weights and machines be used, whereas the advanced and elite athletes' emphaSis should be primarily with free weights94 Weight Machine Exercise

"Weight machines are commonly found in rehabilitation clinics and health clubs. Most of these machines work in a similar fashion, although some differences exist. Histori­ cally, most weight machines were deSigned to isolate a spe­ cific muscle group such as the quadriceps femoris or biceps brachii. Some equipm ent trains multiple muscle groups in combination patterns such as a leg press or pull-up machine.

Patient-Related Instruction 5-2

Purchasing Resistive Equipment Before purchasing resistive equipment for home use, the following information should be considered: 1. Is the equipment safe? Is it approved by a reputable organization? 2. How easy is the equipment to use? How long will it take to learn how to use it? 3. Is the equipment versatile? Can it be used to train a number of different muscle groups? 4. Will the equipment suit your needs as your training progresses? Before purchasing equipment, consider joining a health club for a month or two to see: 1. Which equipment you tend to use regularly 2. What features you like about some equipment 3. What features you dislike or seem to be lacking

Chapter 5: Impairment in Muscle Performance

n

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These machines usually have stacks of plates weighing 5 to 20 pounds each. The weight stack configuration varies vvith the specific muscle action trained. A pin placed in the weight stack selects the amount of weight to be lifted. An important weight machine valiable is the pulley or cam system used. A simple pulley system provides relatively constant resistance through the ROM. Other machines con­ tain an elliptical cam that varies the resistance through the ROM. The cam is an attempt to account for changes caused by varying length-tension relationships, and the machine is called a variable resistance machine. Less resistance is pro­ vided at the beginning and end of the ROM. Weight machines also differ in their adjustability. Lever arms and seat positions should be adjustable for a variety of body sizes. This ensures the ability to align the joint axis with the axis of the machine and prevent injury from poor posture or exercise mechanics. Stops and range-limiting devices should be available and easily adjustable. An advantage of weight machines over free weights is safety. Patients are stabilized effectively by the equipment, and the risk of falls or injury resulting from instability is minimized. It takes less time to learn weight machine exer­ cises. After the adjustments are learned, the equipment is relatively easy to use, and novice weight lifters are less in­ timidated by the equipment. vVeight machines are also rel­ atively time efficient because the machines are already set up. Only a few simple adjustments are necessary, and the patient is ready to begin. One of the disadvantages of weight machines is their ex­ pense. An expensive machine may train only biceps, whereas this could be done inexpensively vvith a couple of free weights and a bar, With the weight machines , the in­ creases in weight are restricted to fLxed increments (Le., weight plates), Smaller changes of 1 or 2 pounds are not possible on most machines. Despite the many size adjust­ ments on weight machines, they still do not fit everyone. \lost also have a fixed , two-dimensional movement pat­ tern. Because the machine gUides the patient through the ROM, little proprioception , balance, or coordination is . learned from the experience. Most machines are deSigned to perform bilateral exercise. In some cases, performing un ilateral exercise is difficult, if not impOSSible. Free-Weight Exercise

Free-weight training is the resistive exercise technique of choice for body builders and power lifters. Free-weight Lraining usually is done with a bar and weight plates , al­ though smaller hand-held weights are available. ReSistive b nds , tubing, and pulleys are used in a similar fashion to •ree weights. One benefit of bands and pulleys over free \'eights is the ability to position the patient vvithout regard -0 gravity (see Self-Management 5-2: Supine Shoulder Flexion). Free weights, resistive bands, and pulleys have dle advantage of movement in a variety of three­ Jimensional patterns without fixed movement patterns. This allows highly specific training that matches individual eeds . For example, resisted lunging patterns forward, ackward, laterally, or diagonally can be performed with resistive bands, pulleys, or free weights. These movement patterns can be performed in whatever range is necessary or the individual, rather than in ranges dictated by a

-eight machine.

75

SELF-MANAGEMENT 5-2 Supine Shoulder

Flexion

Purpose: Position:

To increase the strength of the shoulder muscles, especially serratus anterior. lying on your back with the band tied around your foot. Hold the band in the ipsilateral hand with the arm next to your side and elbow bent to 90 deg rees.

Movement technique: Level 7:

Level 2:

Keeping your elbow bent, punch your hand towa rd the ceiling until your elbow is straight, then move your straight arm upward toward your head. Press backward into the surface you are lying on or pillow(s) as needed to support you at the end of your range of motion. Push back with an isometric contraction for 10 seconds. Return arm in reverse movement pattern. Repeat as prescribed. Perform level one with a straight arm.

Dosage Repetitions: _ _ per set, _ _ sets Frequency __ sessions per day, __ sessions per week

10"£

Free-weight training allows more discrete increases in resistance, and resistance can differ from one side to the other (see Self-Management 5-3: Standing Biceps Curls). For example, reCiprocal biceps curls can be performed 'vvith 10 pounds on the injured side and 15 pounds on the uninjured side. Incremental increases of 1 to 2 pounds or less are available , allOwing a more gradual overload. The free-weight equipment is affordable, and a multitude of ex­ ercises can be pe rformed vvith the same free weights . These exercises c:an include simple strengthening and en­ durance activities or power training techniques. One of the biggest advantages of free-weight training is the neural component of balance. Compared with the ex­ ternal stabilization prOvided by a weight machine, the free weight usually has little external stabilization. These exer­ cises require postural muscle stabilization beyond the work required to move the weight. The individual lifting vvith free weights must understand proper posture and spinal stabilization to prevent injmy to the back. If bal­ ance is a rehabilitation goal , free weight exercise may be indicated.

76

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 5-3

Standing Biceps

Curls

Purpose: Position'

To strengthen the biceps muscles Standing position, with shoulder girdles, spine, and pelvis in neutral. Hold a weight in each hand, palms facing sideway toward your thighs.

Movement technique: Levell:

Level 2:

Alternately bend your elbows, tu rning your palms upward as the weights clear your hips; and straighten your elbows, turning your palms sideways again as yo u move toward your hips. Do not alter your neutral shoulder, spine, or pelvic position as you lift and lower the weight. Bend and straighten your elbows simultaneously. Hold __ pounds in each hand

Dosage Repetitions: ___ per set. ___ sets Frequency __ sessions per day. __ sessions per week

Level 2

A I

The neural demands of free-weight exercise are a disad­ vantage for some. It takes longer to learn free-weight exe r­ cise, because the free-weight tasks usually are more com­ plex than those with weight machines. Novice lifters may be at greater risk for injury because of poor technique (Fig. 5-11 ). Spotters are necessary for many of the free­ weight lifts, increasing the personnel demands of this resis­ tive technique. Because of the time required to load and unload bars, free-weight training is less time efficient. Safety tips for individuals training with free weights in­ clude working with a knowledgeable partner who can spot safely. Collars should always be used to lock the weights on the bar and prevent movement of the plates on the bar. Proper form and technique should be acquired before lift­ ing with any weight. Plyometric Exercise

Functional activity seldom involves pure forms of iso­ lated isometric, concentric, or eccentric actions , because the body is subjected to impact forces (Fig. 5-12) , as in run­ ning or jumping, or because some external force , such as gravity, lengthens the muscle. In these move ment patterns, the muscles are acting eccentrically and then concentrically. By definition of eccentric action , the muscle must be active during the lengthening phase. The SSC is the combination of an eccentric action followed by a concentric action. Training techniques that employ the SSC are called plyo­ metrics. Examples of plyometric exercises include hopping, skipping, bounding and jumping drills for the lower ex­ tremity, and plyometric ball or elastic resistive exercises for the upper extremity. However, not all jumping or resistive band exercises are plyometric Plyometrics are done \vith a specific goal in mind: to increase power and speed. Plyometrics are qUick, powerful movements that are used to increase the reactivity of the nervous system. Plyo­ metJics enhance work performance by storing elastic en­ ergy in the muscle during the stretch phase and reusing it as mechanical work during the concentric phase. Bosco and colleagues98 found that the amoun t of elastic energy stored in a muscle during eccen tric work determines the recoil of elastic energy during positive work. Part of the de­ veloped tension during the stretching phase is taken up by the elastic elements arranged in series with sarcomeres (i.e., series elastic component or tendon). This mechanical work is stored in the sarcomere cross-bridges and can be

B

FIGURE 5-11. (A) Front arm raise performed with poor technique with exce ss ive scapula elevation and (B) front arm raise performed with improved scapula stability.

Chapter 5: Impairment in Muscle Performance B

77

DlSPLAYS-3

Sample Plyometric Activities Shortening

Easy

• Ankle bounces in place Ankle bounces side to side • Ankle bounces with SO-degree turn • Ankle bounces in stride • Single leg push ofts from box • Lateral hopping over cones • Forward hopping over cones Intermediate

GURE 5-12. The stretch-shortening cycle in dally activities. At contact muscle is stretched and contracts in a lengthening action [eccentric) AI- The stretch phase is followed by a shortening [concentric) action [B) - e figure demonstrates the SSC. which is the natural form of the muscle -.nction.

r

""eused during the folloV\rjng pos itive work if the muscle is -ontracted immediately after the st retch. The muscle's .iliility to use th e stored energy is determined by the timing f the eccentric and concentric con tractions and by the ve­ ocity and magnitude of stretch. A quick transition from ec­ :entric to concentric (Le., undamped landings) along V\rith high-velocity stretch of high magnitude produces the -rreatest benefits. The transition time between the eccen­ tric and concentric contractions is called the amortization phase, and the distinction between plyometrics and other mpact activities is the goal of decreasing this phase as much as possible. Plyometrics are high- level activitie s. Because of the tored energy in the series elastic component, the tendon is usceptible to overuse injury when performing plyometrk exercises. The individual should be in an advanced training tage before these techniques are employed . In an ad­ \-anced exercise program, these techniques develop power and speed, the key muscle performance elements of ath­ I tics. Jumping from or to different heights, bounding (i.e. , jumping for distance), progressive thro\\rjng programs, and throV\rjng for speed or distance are methods of using sse for e nhancing speed or power performance. Before per­ forming lower extremity plyometrics, the individual must be able to squat hi s or her body weight , perform a standing long jump equal to his or her height, and balance on a sin­ erIe leg \'1rjth eyes closed. Programs should be well-planned and progressed slowly and appropriately for the individual and the goals. An example of a plyometric program can be fo und in Display 5-3. See Additional Reading for more ply­ ometric materials.

Isokinetic Exercise Isokinetic dynamom eters provide maximum resistance through the entire ROM. The first isokinetic dynamome­ ters performed resisted concentlic contractions at speeds fixed by the clinician. The dynamometer was passive in that the machine was unable to move independently; the pa­ tient was required to move the dynamometer ann. The new isokinetic devices are active compu terized training and testing devices that are capable of actively moving tlle

• • • • • • •

Jump ups on box Side jumps on to box Tuckjump Multiple jumps forward Multiple jumps sideways Split squat jump Cone hops with turn Cone hops with land and sprint

Advanced

• • • • • • •

Multiple box jumps with single leg land Squat jumps to multiple boxes Depth jumps with ball catch Standing long jump with SO-degree turn and sprint Depth jump with SO-degree turn and sprint Single leg bounding Bounding and vertical jump combination

patient's limb for him or her. These dynamometers provide reCiprocal concentlic resistance at fixed speeds, and they provide multi-angle isometric resistance, fixed resistance concentric and eccentric con tractions, passive motion, and fL'{ed speed concentlic and eccentric contractions. The re­ mainder of this discussion focuses on th e isokinetic capa­ bilities of th ese devices. The major advantage of isokine tic resistive training is its ability to fully activate more muscle fibers for longer peri­ ods. Because the machine matches the torque provided by the patient, it "accommodates" th e patient's changing abil­ ities throughout the ROM . In contras t, free weights (i.e., fLxed resistance training) overload only the weakest portion of the range , but the stronger portion (usually the middle third ) is not overloaded. Isokinetic devices allow training at a variety of speeds. The positive effect of fast-speed training on performance is highlighted \vith isokinetic training. Training at faster speeds can assist the return to functional activities that require less muscle torque devclopment but faster speeds of contraction . Speeds that more closely match the patient's function can be chosen to match functional velocities. Higher speeds can de­ crease joint compression forces in areas such as the patellofemoml joint, decreasing the pain and discomfort of­ ten seen with heavy resistance exercis es. Although less torque is generated at high speeds, the decrease in pain and more functional speeds may produce better results. Studies assessing the speed variable favor slow-speed isokinetic trainin~ over fast-speed training for the develop­ ment of strength. 9 High muscular tension is necessary for generating strength gains and is achieved when the isoki­

78

Therapeutic Exercise: Moving Toward Function

DISPLAY 5-4

Dosage Variables for Individuals with Muscles of Various Stren.!l!h Grades Muscles Fair or Below Progressing to Muscles Above Fair

1. Gravity lessened or against gravity 2. Active assistive, active, or resisted 3. Range of motion 4. lever arm length (bent elbow to straight arm) Muscles Above Fair Strength Grade

1. Type of contraction (e.g., isometric, concentric, eccentric, isokinetic, plyometric) 2. Weight or resistance 3. Sets or repetitions 4. Frequency of training sessions (be cautious of overtraining) 5. Speed of movement (slower speed increases amount of force or torque generated during concentric exercise) 6. Distance (E.g., running, jumping, throwing) 7. Rest interval between sets

netic speed is slow enough to allow full recruitment and generation of a high resisting force. Isokinetic resistive training also has disadvantages. These devices are expensive to purchase and maintain. They require trained personnel for setting up patient train­ ing programs, testing, and data interpretation. From a biomechanical perspective, most training is done in a single plane, with a fixed axis at a constant velocity in an open ki­ netic chain. Testing and training in a Single plane improve test reproducibility but do not necessarily carry over to function. We rarely move at a constant velocity in func­ tional activities, although this feature prOvides for maximal

loading through the ROM. Newer isokinetic devices have some closed-chain components, which have the advantage of testing a functional movement pattem but the disadvan­ tage of being unable to tell where the muscle performance impairment lies.

Dosage The exercise dosage can be altered in a variety of ways. In­ creasing the intensity or amount of weight is the most ob­ vious means; changing the relationship to gravity, increas­ ing the lever arm length, increasing sets and repetitions , decreasing the rest interval, and increasing the frequency are others. The dosage parameters of intensity, duration , and frequency are related and considered as training volume, and all must be considered when designing a resistive exercise program. The resistive exercise must be progressed to a functional activity to transition intervention at the impairment level to a functional situation (Fig. 5-13). Choose appropriate dosage parameters based on the needs of the patient (Display 5-4). Determine whether the goal is to develop muscuLr strength, power, endurance or some combination of these muscle performance parameters. Patients 'vvith low levels of function often require resis­ tive exercise prescriptions. Examination of many patients presenting with functional limitations reveals a less than fair grade of muscle strength. Patients ,vith fair or lower muscle grades are unable to initiate resistive exercise against gravity with proper recruitment and movement pat­ terns. When resistive exercise is prescribed against gravity, the patient is forced to train a faulty movement pattern . For example, a patient may be unable to lift his or her arm overhead without pain. The patient is evaluated and is found to have a physiologic impairment of a muscle strength grade of fair for the lower trapezius and serratus

FIGURE 5-13. Progression of exercise. (A) Squat progressed to (B) squat with a bag of groceries

Chapter 5 Impairment in Muscle Performance

e

anterior. The exercise prescription then is to dynamically lift a free weight in the sagittal plane through a full arc of motion. Because of the lack of strength of the lower trapez­ ius and serratus anterior, the patient lifts the arm with ex­ cessive scapular elevation, recruiting the upper trapezius instead of the preferred scapular upward rotation force couple of the upper, middle, lower trapezius, and serratus anterior. This faulty pattern strengthens the upper trapez­ ius and reinforces the faulty osteokinematic motion at the scapulothoracic joint. The patient's functional limitation does not change (i.e., still has pain with overhead lifting) even though the straight arm lift gets "stronger" over time. To resolve the functional limitation of pain with overhead lifting, the impairment of the specific strengths of the lower trapezius and serratus anterior must be addressed. Because these were tested at grades of fair or lower, resistive exer­ cise against gravity is an in appropriate initial exercise pre­ sCription. Give this patient an initial exercise program in a gravity-lessened plane for the lower trapezius and serratus anterior (see Self-Management: Serratus Anterior Progres­ sion in Chapter 26). Lever arm length and ROM can be al­ tered as needed pending the muscle test results. To ensure concentric contraction during elevation and eccentric con­ traction during lowering in a gravity lessened position, use resistive bands at the appropriate resistance. To ensure that an eccentric contraction of the upward rotators occurs dur­ ing the lowering phase, take care to ensure adequate resis­ tance throughout the entire lowering phase; if resistance is lost, the contraction becomes concentric movement of the scapular downward rotators. After the muscle strength is

79

above a grade of fair, initiate active exercise against gravity (e.g., bent arm progressed to straight arm ) and progress to resistive exercise against gravity. Dosage parameters can be manipulated for maximum gains in strength , power, and endurance through a system of training called periodization. Periodization systemati­ cally varies the training dosage to prevent "plateaus" in training gains , to maintain interest, and to provide a well­ balanced program. Varying the training program is essential to making long-term gains in training. Periodization breaks the training program down into cycles of a specific length and goals (i.e., hypertrophy, basic strength, power, and en­ durance ). The cycles can vary from "minicycles" of 1 week to mesocycles of several months. Often a training program comprises a variety of cycles ofvariable lengths. Further dis­ cussion of periodization is presented later in this chapter in relation to training the advanced or elite athlete.

Intensity Extensive strength training research has been performed on individuals without injury. Dosage parameters to increase strength began ,vith DeLorme's classic paper in 1945. 100 He proposed a 10 RM, 10-set regimen. Later, De­ Lorme and Watkins 35 modified this regimen to a 10 RM , three-set regimen with loads increasing progress ively for each set from one half to three fourths to a full 10 RM set. DeLorme called this regimen progressive resistance exer­ cise, a term still used today (Table 5-2). DeLorme's three­ set progreSSive resistance program has served as a control

TABl£5..2 BASE REPETITION MAXIMUM (RM)

TECHNIQUE DeLorme

10

Oxford

10

6

DAPRE

SETS 1. 50lk of 10 RM 2. 75 % of 10 RM 3. 100% of 10 RM 1. 100% of 10 RM 2. 7Y 7c of 10 RM 3. 50% of 10 RM 1. 50% of6 RM 2. 75% of6 RM 3. 100lk of6 RM 4. Adjusted weight based on number of reps performed in set 3"

NUMBER OF REPETITIONS

ADJUSTED WORKING

ADJUSTED WORKING

Pe Iformed in Set 3° 0-2

Weight for set 4° D ecrease 5-10 lb Decrease 0-5 lb Keep weight the same Increase 5- 191b Increase 10-15lb

Weight for next day" Decrease 5-10 lb Same weight Increase 5-10 lb Increase 5-15 lb Increase 10-20 lb

3-4 5-6 7-10

11

• djustments for the Daily Adjustable Progressive Res istive Exercise (DAPRE) program.

NUMBER OF REPETITIONS 10 10 10 10

10 10 10 6 As many as possible As many as possible, this number of reps is used to determine the working weight for the next day"

80

Therapeutic Exercise: Moving Toward Function

condition by which the effectiveness of other methods has been judged. In 1951, an alternative to the DeLorme regimen was proposed by Zinoviefflo l at Oxford. He suggested adjusting the intensity of the load to allow for progressive fatigue. This was achieved by selecting an initial load that was just enough to permit each set to be completed. This regimen was called th e Oxford ted1l1 ique. McMorris and Eikins l02 compared the DeLorme and Oxford techniques and found the Oxford technique to be slightly better, but the differ­ ences were not statistically significant. The daily adjustable progressive resistive exercise (DAPRE ) technique has been proposed as a more adapt­ able progressive exercise program than the Oxford or De­ Lorme approaches (see Table 5_2).103 This program elimi­ nates arbitrary decisions about the frequency and amount of weight increase. The DAPRE program can be used "vith free weights or with weight machines. A 6 RM is used to es­ tablish the initial working weight. Thereafter, weight in­ creases are based on the performance during the previous training session. These gUidelines have been based on studies of unin­ jured subjects. When treating a patient with s~ecific im­ pairments, the resistive exercise dosage varies. I 4 Exercise should be performed to substitution or form fatigue , the point at which substitution or alterations in form occur.

Duration and Volume Duration of resistive training can be considered the num­ ber of sets or repetitions of a specific exercise session and the amount of rest in between sets. Intensity and duration are inversely related. The greater the intensity, the fewer repetitions are performed. Volume is the total number of repetitions performed during a training session multiplied by the resistance used. When training at a low RM (near the 1 RM or maximum amount of weight that can be lifted), very few repetitions are performed, and strength gains are the chief goal. When training at 10 RM or higher, many repetitions are per­ formed , and the goals are endurance and other aspects of muscle perFormance. Very little stimulus is necessary to make strength gains in the beginner. In untrained individuals, one set of 10 RM , two to four times per week, may be adequate. In advanced or elite athletes , multiple set routines , three times per week, will be necessary to achieve strength and power gains. For this group, performing one set of an exercise is less effective for increasing strength than performing two or three sets, and there is evidence that three sets are more effective than two sets.l05 However, multiple sets pose higher risk for injury; the refore, careful technique must be employed to avoid injUl)'­ The rest interval between sets is another important vari­ able. Rest intervals will vary from less than 1 minute to 2 to 3 minutes depending on the intenSity of the lift and the purpose of the training. Muscles can be overloaded by de­ creasing the rest interval between sets.

Frequency Training frequency depends on the rehabilitation goals. Isometric exercise is performed several times per day, and

heavy dynamiC exerc ise may be performed every other day. F requency of one exercise is related to the exercise goal, in­ tensity, duration, and other exercises in the patient's reha­ bilitation program. Individuals training for power lifting or body bUilding lift daily or twice daily, whereas individuals in rehabilitation programs may perform resistive exercise 3 days per week and cardiovascular exercise on alternate days. Be sure to allow adequate time for recovery bet""'een training sessions. Shortening the recovery period between training sessions can produce perSistent fatigue. 106 Studies prOVide a variety of frequency recommenda­ tions, and these need to be balanced with intensity, dura­ tion , initial training status, and the goals of the training. Progressive resistive exercise training one time weekly with 1 RM for one set increases strength Significantly after the first week of training and each week up to at least the sixth week los Significant increases have occurred for beginners training 1 to 5 days per week

Sequence The sequence of training muscles can affect the develop­ ment of strength. In general, multijoint exercises are advo­ cated for strength and power gains. However, speCific iso­ lated muscle training is often necessary when rehabilitating individuals with impaired muscle performance. These ex­ ercises should be performed first before the patient gets fa­ tigued. Follow these exercises with multijoint functional movement patterns. For training novice, intermediate, and advanced individuals wanting to increase strenph, the ACSM prOvides the following recommendations: 9 • exercise large muscle groups before small and per­ form multijoint before single-joint activities • when training all major muscle groups in one training session, rotate upper body and lower body activities • when training upper body and lower body muscles on different days, alternate agonist and antagonist exercises • when training individual muscle groups, perform higher intensity exercises before lower intensity exercises

Dosage for Strength Training For strength development, the ACSM recommends that novice and intermediate lifters train at an intenSity of 60% to 70% of 1 RM for 8 to 12 repetitions. 94 Novices should train the entire body 2 to 3 days per week whereas inter­ mediate lifters should train similarly, unless desiring to progress to split workouts (upper body one day and lower another). In this case, the frequency should be 3 to 4 days per week, allOWing training of each muscle group 1 to 2 days/week The volume prescription should include either Single or multiple sets initially (such as the DeLorme or DAPRE ) and progressed to periodized training using mul­ tiple sets . Advanced lifters should train at 80% to 100% of 1 RM in a periodized plan. 94 Apply an approximately 2% to 10% increase in load based on the muscle group and activ­ ity to progress training. For general training purposes, it is important to train both concentric and eccentric muscle actions unless one type of action is preferred based on the pathology, impair­

81

Chapter 5: Impairment in Muscle Performance

ments, or functional limitations. For example, patients who have difficulty descending stairs because of poor quadri­ ceps contro l, but no trouble ascending stairs, should em­ phaSize eccentric muscle actions. Slow to moderate velocities are recommended for novice trainers unless the patient has difficulty generating torque or controlling movement at a speCific functional speed. The ACSM recommends moderate velocities for in­ te rmediate training, and a spectrum of velocities from un­ intentionally slow to fast to maximize training gains in the advanced and elite ath lete. 94 For novice, intermediate, or advanced training, the .·\CSM recommends rest intervals of 2 to 3 minutes for multijoint exercises using heavy loads 94 For other exer­ cises (including weight machines) they recommend a horter rest interval of 1 to 2 minutes. This recommenda­ tion is the same for developing both strength and power.

Dosage for Power Training Power requires a combination of strength, speed, and skill and the training program should reflect these variables. Ef­ fI ctive use of power requires baseline strength at both fast and slow speeds, the ability to generate force quickly, effi­ cient use of the SSC, and good neuromuscular coordination. For power development, one to three sets of30% to 60% f IRM for three to six repetitions should be incorporated 'n to the intermediate training program 94 ProgreSSion hould use various loads planned in a periodized fashion. \d anced training should include a 3 to 6 set (1-6 repeti­ tions/set) power program incorporated into the strength program. ProgreSSion ofpower training requires both heavy ding (85% to 100% of 1 RM) for force development, and "g;ht to moderate loading (30% to 60% of 1 RM) performed 'high velOCity for increasing fast force production. 94 Focus oly on heavy loading may actually decrease power output not accompanied by quick, explosive-type exercises such the loaded jump squat. 94 Rest period recommendations the same as for strength training.

osage for Endurance Training I 'cle endurance is necessary for a valiety of activities and

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uscle groups. For example , postural muscles must pro­ . e sustained or repetitive contractions for long periods, h as during prolonged standing, walking, or work activ­ . Many lower extremity muscles need endurance for Jiletic endeavors such as distance running, tennis, or er sports and leisure activities . Repetitive work activities eb as carpentry, factory work, or other manual labor re­ e local muscle endurance to fulfill job requirements _.mng 8- to 12-hou r work shifts, For development of muscular endurance in novice and .:ennediate training, the ACSM recommends relatively loads with moderate to high volume (10 to 15 repeti­ ). For advanced training, various loading strategies d be used for multiple sets per exercise (10 to 25 rep­ . ns) using a periodization scheme,94 L shorter rest periods such as 1 to 2 minutes for high tition (15 to 20 repetitions) and less than 1 minute for erate (10 to 15 repetitions) sets 94 The training fre­

quency is the same as for strength training, and the training velOcity should be slow 'vvhen doing a moderate (10 to 15) number of repetitions , and moderate or fast velocities when performing higher numbers of repetitions (15 to 25 or more).

Dosage for the Advanced or Elite Athlete The follo'vving techniques are used by those who train com­ petitive athletes. These techniques can be used to provide variety, increase resistance, or maximize the workout time in daily workouts. These speciflc: techniques are not well­ studied, but do provide the recommended variability nec­ essary for training the advanced or elite athlete. They are introduced to familiarize the therapist with the terminol­ ogy used in training these ath letes. Use good judgment based on scientific prinCiples when using these techniques. A superset consists of two sets of exercise involving op­ posing muscles that are performed in sequence without a rest between sets (e.g. , a biceps curl followed by a triceps extension , without rest, proceeding to the re maining sets). Supersets can reduce workout time or allow more exercise to be performed during the same period. A triset is a group of three f'xercises, each done after the other with little rest between muscle groups. Trisets can be used to exercise three different muscle groups or three an­ gles of a complex muscle (e.g. , flat , incline, decline bench press for the different fiber directions of the pectoraliS major). Pyramid training is a modification of the DeLorme train­ ing program. The regimen stalis with a high number of rep­ etitions and low weight (to warm-up), but instead of main­ taining the repetitions constant and increasing the weight, the repetitions are reduced and weight is increased. After the series is completed, the individual works backward, tak­ ing off weight and adding repetitions. The number of repe­ titions and sets is arbitrarily established as long as the high­ repetition, low-weiaht progreSSion to a heaVier-weight, low-repetition regimen is followed (Table 5-3). A typical split routine consists of a series of exercises that usually emphaSize two or three major muscle groups or body parts. This allows the individual to train on 2 con­ secutive days \vithout overtraining muscle groups, because one muscle group is resting while the other is exerCising. Body builders often follow a double-split routine, in which two sessions ar~ performed on each day (Table 5-4). MatveyevlO I described the basic ideas of periodized training programs for these athletes . A program is peri­ odized when it is divided into phases, each of which has pri­

SalT!ple Pyramid Training for a Squat Exercise for a H!ghly Trained Individual SETS

REPETITIONS

WEIGHT

1 1 1 1 1 1

12 8

100 135 185 225 250 275

6 4

2 1

82

Therapeutic Exercise Moving Toward Function

Example of a Split Routine for Total­

Body Resistive Training

FOUR-DAY PROGRAM* Monday: upper body Tuesday: lower body Wednesday: rest Thursday: upper body Friday: lower body Saturday: rest Sunday: repeat sequence

SIX-DAY, TWO SESSIONS PER DAY PROGRAM* Monday AM: chest Monday P~I: back Tuesday AM: shoulders Tuesday PM: upper legs Wednesday AM: triceps Wednesday PM: biceps Thursday AM: chest Thursday P~I: back

•Abdominal and calf muscles are exercised each day.

mary and secondary goals. The program is based on the premise that maximum stl"ength gains are not made by con­ stant heavy training but are made possible by different training cycles or periods. These cycles allow the athlete to reach maximum performance level at a predesignated time, usually the day of competition. In his original model, Matveyev l07 suggested the initial phase of a strength-power program should contain a high volume (Le., many repetitions) with lower intensity (i.e., low average weight lifted relative to maximum possible in each movement). Typical high-volume phases for weight lifters contain more training sessions per week (6 to 15), more ex­ ercises per session (3 to 6), more sets per exercise (4 to 8), and more repetitions per set (4 to 6). As weeks pass, the vol­ ume decreases and intensity increases. The resulting higher intensity and lower volume represent the characteristics of a basic strength phase of training. Typical high-intensity phases for weight lifters contain fewer training sessions per week (5 to 12), fewer exercises per workout session (l to 4), fewer sets per exercise (3 to 5), and fewer repetitions per set (1 to 3). A third, optional phase may include low volume (low repetitions) with high intensity (heavyweights) to work on power. The final phase is considered an active rest phase 'vvith very low volume and very low intensity. Each phase may be several weeks to several months long. Two or more complete cycles may fit into a training year. Stone and colleagues l08 proposed and successfully tested a periodized model of strength-power training with sequential phases that change rather drastically. An exam­ ple is a phase to increase muscle size (five sets of 10 RM in core exercises), a phase to improve specific strength (three to five sets of 3 RM), and a phase to "peak" for competition (one to three sets of one to three repetitions). The use of 10 RM is higher than typically recommended in the early preparation phase but has proved to be successful in a number of studies. 108

PRECAUTIONS AND CONTRAINDICATIONS Be sure to consider certain precautions and contraindica­ tions when prescribing resistive exercise. Avoid using the Valsalva maneuver during resistive training, especially by

patients with cardiopulmonary disease or after recent ab­ dominal, interveliebral disk, or eye surgery. Educate pa­ tients to breathe properly during exercise, typically exhal­ ing on exertion. Use isometric exercise with caution by persons at risk for pressor response effects (e.g., high blood pressure after an aneurysm). During resistive training, especially in an untrained state, minor lesions of the muscle structure and inflamma­ tion resulting in muscle soreness are common. Soreness may be caused by myofibrillar damage localized to the Z band, membrane damage, or inflammatory processes. The serum or plasma level of creatine kinase is elevated and is an indicator of muscle damage, because the enzyme is found almost exclusively in muscle tissue. Delayed sore­ ness, clearly linked to eccentric activity, usually peaks about 2 days after exertion. Muscle function deteriorates, and muscle strength may be reduced for a week or more af­ ter intensive eccentric exercise. However, an adaptive pro­ cess reduces the soreness after repeated training ses­ sions. lOD Even during the soreness period, moderate activity is advised, because the adaptation response occurs before full recovery and restoration of muscle function. Pa­ tients should be cautioned that eccentric training may lead to muscle soreness 24 to 48 hours after exercise, but that moderate exercise should continue during the recovery pe­ riod. A somewhat different type of soreness and reduced muscle function may occur during very long and intense ex­ ercise bouts. It is probably related to the total metabolic load, not muscle tension development. lOg Overwork phenomena may exist even at moderate train­ ing regimens over an extended period. Overtraining may lead to mood disturbances and reduce the effect of training by a decrease in performance. Avoid fatigue and overtrain­ ing by patients 'vvith metabolic diseases (e.g., diabetes, al­ coholism), neurologiC diseases, or severe degenerative joint diseases because of the risk of further jOint damage. Over­ training may be the reason for a lack of progress, decreased performance, or development of joint pain and swelling. Care should be taken when developing resistive exercise programs for prepubertal and pubertal children and ado­ lescents. Minimize stress to epiphyseal sites and develop balanced exercise programs to avoid muscle imbalances. An absolute contraindication to resistive exercise is acute or chronic myopathy, as occurs in some forms of neuromuscular disease or in acute alcohol myopathy. Re­ sistive exercise in the presence of myopathy may stress and permanently damage an already compromised muscular system. Scientific knowledge and common sense should be ap­ plied in prescribing resistive exercise. Caution should be taken with exercise in the presence of pain, inflammation, and infection. Although resistive exercise may be indicated. the mode and dosage should be carefully chosen.

KEY POINTS • The term muscle pe1formance includes strength, power, and endurance. • The term strength should be clarified in terms of force, torque, and work.

r

I

..

Chapter 5 Impairment in Muscle Performance

• Muscle actions are static and dynamic. Static muscle ac­ tions are called isometric. • A thorough knowledge of muscle morphology is neces­ sary for effective/efficient therapeutic exercise prescrip­ tion to improve muscle performance. • Dynamic action is the preferred term over isotonic. Dy­ namic actions can be further divided into concentric and eccentric actions. • The sliding filament theory describes the events that oc­ cur during muscle contraction. • Basic muscle fiber types are slow oxidative, fast gly­ colytic, and fast oxidative glycolytic. • Force gradation occurs by rate coding and the size prin­ Ciple. • Overload training produces changes in the size of the musde primarily through hypertrophy but also through hyperplasia. • :\1uscle strength must be evaluated relative to the mus­ cle's length because of length-tension relationships. • :\1uscle architecture can Significantly affect muscle force production. • Specificity of training exists, especially relative to train­ ing velocity. • Adaptations to resistive training are partially neurologic ill that changes in performance often precede morpho­ logiC changes. • Form fatigu e is the point at which the individual must discontinue the exercise or sacrifice technique. • . lthough dosage and goals differ, resistive training is beneficial from late childhood through old age.

• Impaired muscle performance can result from neuro­ logiC pathology, muscle strain, muscle disuse, or length associated changes. • Adaptations to resistive training extend beyond the mus­ cle to include connective tissues , the cardiovascular sys­ tem , and bone. • Activities to improve muscle performance include iso­ metric, dynamiC, plyometric, and isokinetic exercise. • Dynamic exercise can be performed with a variety of modes , including free weight, resistive bands, pulleys, weight machines, or body weight; including various com binations of concentric and eccentric contractions. • Plyometric activities use the stretch-shortening cycle to enhance muscle performance. • The dosage of exercise to improve muscle performance depends on the goal (i.e., strength , power, and en­ durance) as well as the initial fitness level of the individ­ ual (i.e., novice, intermediate, advanced, and elite ). • Precautions and contraindications to resistive exercise must be known to ensure safety to the patient/client.

CRITICAL THINKING QUESTIONS ----1. Consider each of the questions in the Lab Activities in the next section. How would your dosage differ if you were training for a. strength b. power c. muscle endurance

LAB ACTIVITIES

----~~~------~~~~~~~

1. A series of musculoskeletal conditions is listed from i to viii. For each condition, perform the following:

a.

b.

c.

d.

Determine which muscles are involved. In­ clude possible underused synergists that may lead to overuse of the muscle involved. List each muscle and describe its specific: action. Design and perform one exercise for each mus­ cle (group) given the manual muscle test grade of fair minus (3-/5). Include complete dosage parameters. Design and perform two exercises for each musde (group) given the manual muscle test grade of good (4/5). Use an elastic band for one and a free weight for the other, and include complete dosage parameters. Progress the exercises in question lc to two functional activities.

83

Musculoskeletal and neuromuscular conditions i. ii. iii.

iv. v. vi. vii. viii.

Achilles tendinitis Iliotibial band fascitis Patellar tendinitis Hamstring strain Peroneal nerve palsy (i.e. , common peroneal nerve) (list muscles innervated) Supraspinatus tendinitis Middle trapezius strain resulting from over­ stretch Lateral epicondylitis

2. Using free weights or a weight machine, determine the 1 Ri\lI , 6 RM , and 10 RM for a bench press and leg extension . Determine the dosage for Oxford. De­ Lorme, and DAPRE programs. 3. Pick three muscle groups throughout your body (one upper quarter, one lower quarter, and one trunk). Design two different resistive exercises for each mus­ cle group using a variety of equipment, including elastic bands, free weights, and pulleys and weight machines if available. Determine the dosage for a DeLorme program .

84

Therapeutic Exercise: Moving Toward Function

2. Design a muscle performance program for a woman confined to bed rcst for 3 weeks after an acute lumbar fracture without neurologic involvement. Include dosage parameters for strength and endurance. 3. Consider Case Study #5 in Unit 7. List muscles with impaired muscle performance. Determine whether the muscle requires strength, endurance, or power training. Decide on one activity for each muscle and determine the dosage relative to the goal (i.e., strength, power, and endurance) and initial fitness level for this patient. Develop the sequence of exercise for each session and include the frequency in the dosage parameters.

REFERENCES 1. Enoka RM . Force. In : Enoka RM , ed. Neuromechanical Basis of KineSiology. Champai\!;n, IL: Human Kin e ti cs Books, 1988. 2. Abbott BC, Bigland B, Hitchie JM. The physiologieal cost of negative work. J Physiol (Lond) 1952;117:380--390. 3. :'-lorman RW, Komi pv. Electromyographic delay in skele­ tal muscle under normal movell1ent conditions. Acta Phys­ iol Scand 1979;106:241. . 4. Komi PV . Stretch-shortcning cycle. In: Komi PV, ed. Strength and Power in Sport. Oxford: Black-vcfl Scientific Publications, 1992. 5. KOllli PV. Physiological and biomechanical correlates of muscle fUlletion: effeds of muscle structure and stretch­ shortening cycle on force and spC'cd. In: Teljung RL, ed. Ex­ ercise and Sport Science Reviews, vol 12. Lexington , MA: Collamore Press, 1984. 6. Henneman E, Somjen G, Carpenter DO. Functional signif­ icance of eel! size in spinal motoneuron. J Neurophysiol 19f),');28:560-580. 7. Liebe r RL. Skeletal Muscle Structure and Function. Balti­ more: \Villiams & Wilkins, 1992. 8 . Grimby L, Hannerz J. Firing rate and recruitment order of toe extensor motor units in diffe rent modes of voluntary contraction. J PhysioI1977;264:865-879. 9. l\ardone A, Romano C, Schieppati M. Selective recruit­ ment of high-threshold human motor units dUIingvoluntary isotonic lengthening of active muscles. J Physiol 1989; 409:451-471. 10. Bell RD, MacDougall JD , Billeter R, et al. Muscle fiber

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well Scientific Publications. 1992..

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Med Sci Sports Exerc 1993;25:1333-1345.

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16. Bischof R. Analysis of muscle regeneration using Single my­

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17. Schultz E, Jarysza k DL, Gibson MC, et al. Absence of exogenous satellite cell contlibution to regeneration of frozen skeletal muscle. J Musclc Res Cel! MotiI1986;7: 361-367. 18. MacDougall JD , et al. Muscle fiber number in biceps brachii in body builders and control subjects. J Appl Physiol 1984;57: 1399-1403 . 19. Herzog W, Ait-Haddou R. Mechanical muscle models and their application for force and power production. In: Komi PV, ed. Strength and Power in Sport, 2nd ed. Malden, ~"lA: Black-veil Scientific Publications, 2003. 20. TabaI)' JC, Tabary C, Tardieu C, et al. PhYSiolOgical and structural changes in the eat's soleus muscle due to immobi­ lization at different lengths by plaster cast. J Physiol 1972; 224:231-244. 21. Oude t CL, Petrovic AG. Regulation of the anatomical length of th e lateral pterygoid muscle in the growing rat. Adv Physiol Sci 1981;24:115-121. 22. KendalJ 1-10, KendaH FP, Boyn ton DA. Posture and Pain . Baltimore: WilUams & Wilkins, 1952. 23 . Williams P E, Goldspink G. Longitudinal growth of striated muscle fibers. J Cell Sci 1971;9:751-767. 24 . Herring SW, Grimm AF, Grimm BR. Regulation of sar­ comere number in skeletal muscle: a comparison of hy­ potheses. Muscle Nerve 1984;7:161- 173. 25. Kendall FP, McCreary KE, Provance PG. Muscles Test­ ing and Function . 4th ed. Baltimore: Williams & Wilkins, 1993. 26. Williams PE, Goldspink G. Changes in sarcomere length and physiological propeliies in immobilized muscle. .r Anat 1978;127:459-468. 27. Josephson RK . Extensi ve and intensive factors determining the performance of striated muscle. J E1.ll Zool 1975;194: 135-154. 28. \-/orrissey MC, Harman EA, Johnson MJ. Resistance train­ ing modes: specifidty and effectiveness. Med Sci Sports Ex­ erc 1995;27:648-660. 29. Kanehisa H, Miyashita M. Specificity of velOCity in strength training. Eur J Appl PhysioI1983;52:104-106. 30. Higbie EJ. Effects of concentric and eccentric isokinetic heavy-resistance tmilling on quadriceps muscle strength, cross-sectional area and neural activation in women. Doc­ toral Dissertation, University of Georgia, 1994. 31. Weir JP, Housh DJ , Housh TJ, et al. The effect of unilateral concentric weight b'aining and detraining on joint angle speCifiCity, cross-training, and the bilateral deficit. J Orthop Sports Phys Ther 1997;25:264-270. 32. Weir JP, Housh DJ, Housh TJ, et al. The effect of unilateral eccentric weight training and detraining on joint angle specificity, cross-training, and the bilateral deficit. J Orthop Spolis Ph)'s Ther 1995;22:207-215. 33. Taniguchi Y. Lateral specificity in resistance training: the ef­ fect of biJateral and unilateral training. Em J Appl Physiol 1997;75:144-150. 34. V\·'ilson GJ, 1I·1urphy AJ, Walshe A.The specificity of strength training: the effect of posture. Eur J Appl Ph),siol 1996;73: 346-.352. 35. Delorme TL, Watkins AL. ProgreSSive Resistance Exercise. l\ew York: Appleton CentUlY, 1951. 36. Moritani T, DeVries HA. Neural factors vs. hypertrophy in time course of muscle strength gain. Am J Phys Med Reha­ biI1979;58:l1.'5-130. 37. Staron RS, Karapondo DL, Kraemer WI. et al. Skeletal mus­ cle adaptations during early phase of heavy-resistance train­ ing in men and women. J Appl PhysioI1994;76: 1247-1255. 38. Hakkinen K, Komi PV. E lectromyographic changes during strength training and detraining. Med Sci Sports Exerc 198,3;15:455-460.

Chapter 5: Impairment in Muscle Performance

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la

rc

39. Sale D. " -e ural adaptation to strength training. In: Komi PV. Stre n?;th and Power in Sport. Oxford: Blackwell Scientific Publications, 1992. 40. Edman f'K. Contractile performance of skeletal muscl e fibers. In: Stre ngth and Power in Sport. In: Komi PV, ed. Oxford: Blackwe ll ScientifiC' Publications , 1992. 41. Crasselt W , Forchel I. Kroll M, et al. Zum Kinder- und Ju­ gendsport-Realitaten, Wunslw und Tenden zen. [Sport of Children and Adolescents- Reality, Expectations , and Ten­ dencies.] Leipzig: Deutsche Hochschule fur Korpe rkultur , 1990. 42. Hettinger TH. Isometrisches Muskeltraining. [Isometric Muscle Training.] Stuttgart: George Thie me Verlag, 1968. 43. Yokomizo YI. Measureme nt of ability of older workers. Er­ gonomics 1985;28:843-854. 44. Grimby G, Danneskiold-Samse W , Hvid K, et al. Morphol­ ogy and enzymatic capacity in arm and leg muscles in 78--81­ year-old men and women. Acta Physiol Scand 1982;115: 125-134. 45 . Moritani T. Training adaptations in th e muscles of older men, In: Smith EL, Serfass RE, eds, Exercise and Aging: The Scientific Basis, New Jersey: Enslow Publishers, 1981. 46, Janda v, Muskelfunktionsdiagnostik. [Functional Diagnos­ tic Tests for Muscles, ] Berlin: Verlag Volk & Gesundheit, 1986, 47. Bean JF, Kiely SK, Herman S, et al. The relationship be­ tween leg power and physical performance in mobility-lim­ ited elderly people, JAm Ger Soc 2002;50:461-467, 48. Fielding RA , LeBrasseur NK, Cuoco A, et al. High-veloCity resistance training increases skeletal muscl e> peak power in older women. JAm Ger Soc 2002;50:655-662, 49. Wilkes RL, Summers JJ, Cognitions , mediating variables, and strength performance, J Sport PsychoI1984;6:351-359. 50. Weinbe rg R, Jackson A, Seaboune T. The effects of spe­ cific vs . nonspecific mental preparation strategies on strength and endurance performance. J Sport Behav 1985;7: 175-180. .51. Tenenbaum G, Bar-Eli M, Hoffman TR, et a!. The effect of cognitive and somatic psyching-up techniques on isokinetic leg strength performance, J Strength Condit Res 1995; 9: 3-7. 52. Murphy SM, Woolfolk RL, Budney AJ. The effects of emo­ tive imagery on strength performance, J Sport Exerc Psy- . choI1988;10:334-345. 53. Elko K, Ostrow AC. The effects of three mental preparation strategies on stre ngth performance of young and older adults. J Sport Behav 1992;15:34-41. 54. Gould D , Weinberg R, Jackson A. M ental preparation strategies, cognition and strength performance. J Sport Psy­ choI1980;2:329-339, 55, Gassner GJ. Comparison of three different types of imagery on performance outcome in strength-related tasks with col­ legiate male athletes. Dissertatio n thesis, Temple Univer­ sitv, 1997. 56. H~bbel SL, Rose Dr. The relative effectiveness of three forms of visual knowfedge of results on peak torque output. J Orthop Sports Phys The r 1993;18:601-608, 57, Rubin E . Alcoholic myopathy in heart and skele tal muscle, N Engl J \lIed 1979;301:28-33. .58, Song SK, Rubin E , Ethanol produces muscl e damage in hu­ man volunteers, Science 1972;175:327-328. 59 . Rubin E , Perkoff GT, Dioso NM , et a!. A spectrum of my­ opathy associated \-vith alcoholism . Ann Intern Med 1967; 67:481-492. 60. Hanid A, Slavin G, Main, et al. Fiber typ e changes in striated muscle of alcoholics, J Clin Pathol 1981;34: 991-995.

85

61. MastagLia FL, Ar?;ov Z . Drug-induced neuromuscular dis or­ de rs in lllan . In: \Valton J, ed. Disorders of Voluntary Mus­ cl e . 4th ed . Edinburgh: Churchill Livingstone, 1981. 62. Stern LZ, Fagan JM. The endocrine myopathies . In : Vinken pJ, Bnl)'ll GW, Rin?;el SP, eds, Handbook of Clillical ~ e u­ rological Disease of Muscle: Part 2. Amsterdam : North Hol­ land Publishing, 1979, 63. Bunch TW, W~Jihingham JW, Combs et al. Azathioprine with predn,i sone for polym YOS itis : a controlled clinical trial, Ann Intcrn Med 1980;92:356-369, 64 , Go tdberg AL, Coodman HM. Relationship between cOlii­ sone and muscle work in dete rmining muscle size. J Physiol (Land) 1969;200:667-675, 65, Malone TR , Garr,e tt E , Zachazewski JE, Muscle: de forma­ tion, injury, repair. In: Zachazewski JE , Magee DJ , Quillen WS, eds. Athletic Injuries and Rehabilitation. Philadelphia: WB Saunders, 1996. 66. Worrell TW, Perrin DH . Hamstring muscle injury: the in­ fluence of strength, flexibility, warm-up and fatigue, J Or­ thop Sports Phys Ther 1992;16:12-18. 67. Desmedt JE, Godaux E, Spinal moton e uron recruitment in man : rank de ordering ,vith direction but not with speed of voluntary movement. Scie nce 1981;214:933-936, 68. Tax AM, Denier van der Gon JJ, Gielen C AM, et al. Dif­ ferences in central control of m, biceps brachii in move­ me nt tasks and force tasks . Exp Brain Res 1990;79: 138-142. 69, Van Zuylen EJ, Gielen CAM , Denier van der Gon JJ. Coor­ dination and homo?;enous activation of human ann muscles during isometric torques . J Neurophys 1988;60:1523-1548 . 70, Staron R, Hikida RS , H agenllan FC, et a!. Human muscle skeletal muscle fiber type adaptability to vaJious workloads. J Histoche m Cytochem 1984;32:146-152, 71. Costill DC, Daniels J, E vans, e t al. Skeletal muscle enzymes and fiber composition in male and female track athletes. J Appl PhysioI1976;40 :149-154. 72, Tesch PA, Komi PV, Hakkinen K. Enzymatic adaptations consequent to Ion?; term strength training. Int J Sports Med 1987;8(Suppl) 66-69. 73. MacDougall JD, Sale DG , Moroz JR, et al. Mitochondrial volume denSity in human skeletal muscle follOWing heavy resistance training. Med Sci Sports 1979;11:164-166. 74. Thorstensson A, Spokin B, Karls son J. Enzyme activities and muscle strength after "sprint training" in man. Acta Physiol Scand 1975;94:313-316, 75 . Hakkinen K, Komi PV, Alen M, Effect of explOSive type strength training on isomet ric force and relaxation time , electromyographic and muscle fibre characteristics of leg extensor muscles. Acta Physiol Scand 1985;125:587-600. 76. Stone MH . Implications for connective tissue and bone al­ terations resulting from resistance exercise training, Med Sci Sports Exerc 1988;20:S162-S168. 77. Tipton CM , Mattes RD , Maynard JA, et a!. The influence of physical activity on ligaments and tendons, Med Sci SpOliS 1975;7:165-175. 78. Voge l IM , Whittle MW. Proceedings : bone mine ral co ntent change s in the Skylab astronauts, AJR Am J Roentgenol 1976;126: 1296-1297. 79. Hanson TH, Roos BO, Nachemson A, Development of os­ teopenia in the fourth lumbar vertebrae during prolonged bed rest after operation for scoliosis . Acta Orthop Scand 1975;46:621-630, 80. White MK, Martin RB , Yeater RA, et al, The effects of ex­ ercise on postmenopausal wome n. Int Orthop 1984;7: 209-214, 81. Nilsson BE , Westlin ~1 E. Bone densi ty in athletes, Clin Or­ thop 1971 ;77:179-182.

n,

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82. Jones HH, Priest JS, Hayes WC, et al. Humeral hypeltrophy in response to exercise. J Bone joint Surg Am 1977;59: 204-208. 83. Lane N, Bevier W, Bouxsein M, et al. Effect of exercise intensity on bone mineral. Med Sci Sports Exerc 1988;20:S51. 84. Duncan CS, Blimkie CJ, Cowell C, et al. Bone mineral den­ sity in adolescent female athletes: relationship to exercise type and muscle strength. Med Sci Sports Exerc 2002: 34:286-294. 85. Robling AG, Hinant FM, Burr DB , et al. Shorter, more fre­ quent mechanical loading sessions enhance bone mass. Med Sci Sports Exerc 2002;34:196--202. 86. Fleck SJ. Cardiovascular adaptations to resistance training. Med Sci Sports Exerc 1988;20:S146--S151. 87. Fleck SJ, Henke C, Wilson \V. Cardiac MRI of elite ju­ nior OlympiC weight lifters. Int J Sports Med 1989;10: 329-333. 88. Miles DS, Gotshall RW. Impedance cardiography: noninva­ sive assessment of human central hemodynamics at rest and during exercise. Exerc Sports Sci Rev 1989;17:231-264. 89. Shephard RJ. Muscular endurance and blood lactate. In: Shephard RM, Astrand P-O, eds. Endurance in Sport. Ox­ ford: Blackwell Scientific: Publications, 1992. 90. Lash JM, Sherman WM. Skeletal muscle function and adap­ tations to training. In: American College of Sports Medicine: Resource YIanual for Guidelines for Exercise Testing and Prescription. 2nd ed. Philadelphia: Lea & Febiger, 1993. 91. Interactive Guide to Physical Therapist Practice, vol 1.0. Alexandria, VA: American Physical Therapy Association, 2002. 92. Sale DG, MacDougall D. SpeCificity in strength training: a review for the coach and athlete. Can J Appl Sports Sci 1981;6:87-92. 93. Rutherford OM, Jones DA. The role of learning and coor­ dination in strength training. Eur J Appl Phys 1986;55: 100-105. 94. Kraemer vVJ, Adams K, Cararelli E, et al. Amel1can College of Sports Medicine position stand. ProgreSSion models in re­ sistance training for healthy adults. Med Sci Sports Exerc 2002;34:364-380. 95. Atha J. Strengthening muscle. Exerc Sport Sci Rev 1981; 9:1-73. 96. Muller EA. Influence of training and of inactivity on muscle strength. Arch Phys Med Rehabil1970;51:449--462.

97. Whitley JD. The influence of static and dynamiC training on angular strength performance. ErgonomiCS 1967;10: 305-310. 98. Bosco C, Tihany J, Komi PV, et al. Store and recoil of elas­ tic energy in slow and fast types of human skeletal muscles. Acta Physiol Scand 1982;116:343-349. 99. Gettman LR, Ayres J. Aerobic changes through 10 weeks of slow and fast-speed isokinetic training [abstract). Med Sci Sports 1978;10:47. 100. DeLorme TL Restoration of muscle power by heavy resistance exercises. J Bone Joint Surg Am 1945;27: 645-667. 101. Zinovieff AN. Heavy resistance exercise: the Oxford tech­ nique. Br J PhysioI1951;14:129-132. 102. Iv1cMorris RO, Elkins EC. A study of production and evalu­ ation of muscular hypertrophy. Arch Phys Med Rehabil 1954;35:420--426. 103. Knight KL Knee rehabilitation by the daily adjustable pro­ gressive resistive exercise technique. Am J Sports Med 1979;7:336--337. 104. KlUsen EM. Functional improvement produced by resis­ tance exercise of the biceps muscles affected by polio-myeli­ tis. Arch Phys Med 1949;30:271-278. 105. Clarke HH. Muscular strength and endurance in man. En­ glewood Cliffs, NJ: Prentice-Hall, Inc., 1966. 106. Busso T, Benoit H, Bonnefoy R, et al. Effects of training fre­ quency on the dynamiCS of performance response to a Single training bout. J Appl Physiol 2002;92:572~80. 107. Matveyev LP. Periodisienang das Sportlichen Training. Berlin: Beles Wernitz, 1972. 108. Stone MH , O'Bryant H, Garhammer J. A hypothetical model for strength training. J Sports Med Phys Fitness 1981;21:342-351. 109. Friden J, Seger J, Sjostrom M, et al. Adaptive response in human skeletal muscle subjected to prolonged eccentric training. Int J Sports Med 1983;4:177-183.

ADDITIONAL READING Chu DA. Jumping into Plyometrics. Champaign, IL: Human Ki­ netics Publishers, 1992. Gans C, Bock WJ. The functional Significance of muscle architec­ ture-a theoretical analysis. Ergeb Anat Entwickel Gesch 1965;38:115--142.

Chapter 6

Im paired Aerobic Capacity/Endurance JANET R. BEZNER

Physiology of Aerobic Capacity and Endurance Definitions Energy Sources Used During Aerobic Exercise Normal and Abnormal Responses to Acute Aerobic Exercise Physiologic and Psychologic Adaptations to Cardiorespira­ tory Endurance Training

Causes of Impaired Aerobic Capacity/Rehabilitation Indications Examination/Evaluation of Aerobic Capacity Patient/Client History

Systems Review

Screening Examination

Tests and Measures

LI

n

c

Therapeutic Exercise Intervention Mode

Dosage

Precautions and Contra indications Graded Exercise Testing Contraindications and Supervision Guidelines Supervision During Exercise

i-

Patient-related Instruction/Education and Adjunctive Interventions

h

Lifespan Issues Guidelines for Cardiovascular Endurance Training in the Young Guidelines for Cardiovascular Endurance Training in the Elderly

Cardiovascular endurance is the ability of the cardiovascu­ lar system (i.e., heart, lungs, and vascular system) to take in, l'xtract, deliver, and use m.:ygen and to remove was te prod­ ucts. Cardiovascular endurance, or aerobic capacity, sup­ ports the performance of repetitive activities using large muscle groups for extended peliods. Clients and patients who work at home or on the job, participate in athletic endeavors of all levels, skill, and type, and who perform physical activity for fun or leisure, require adequate aero­ bic capacity. Concurrently, these activities also improve impairments in a robic capacity, and are thus useful thera­ peutically in a rehabilitation setting. The literature contains convincing evidence that the regular performance of cardiorespiratory endurance activ­ ities reduces the risk of developing disease, such as coro­

nary healt disease, and is associated with lower mortality rates in both older and younger adults. l-3 Despite this evi­ dence, recent surveys of exercise trends among inhabitants of the United States (U.S.) illustrates that apprOXimately 15% of U.S. adults perform vigorous physical activity (3 times per week for at least 20 minutes) during leisure time, approximately 22% partake in sustained physical activity (5 times per week for at least 30 minutes) of any intensity dur­ ing leisure time, and about 25% of adults perform no phys­ ical activity in leisure time. l Adolescents and young adults (ages 12 to 21) are similarly inactive and approximately 50% regularly participate in vigorous physical activity.l Because of the widespread prevalence of physical inac­ tivity among the U.S . population, the U.S . Public Health Service has created goals for exercise participation in the Healthy People 2000 and the Healthy People 2010 docu­ ments, aimed at im~~oving the quality and increasing the years of healthy life. ' ·J In addition , the U.S. Department of Health and Human Services, the Centers for Disease Con­ trol and Prevention, the National Center for Chronic Dis­ ease Prevention and Health Promotion, the President's Council on PhYSical Fitness and Sports, and the American College of Sports Medicine (ACSM ) recommend that all adults should accumulate 30 minutes or more of moderate­ intensity physical activity on most, and preferably all, days of the week. I .6 Tovvard this end, health care profeSSionals have an opportunity to contlibute to the overall well-being of the patients and clients we serve by prescribing mean­ ingful exercise programs based on the most contemporary sci en tific evidence. In this chapter, the scientific basis of aerobic training \vill be presented along with guidelines for prescribing and supervising aerobic exercise.

PHYSIOLOGY OF AEROBIC CAPACITY AND ENDURANCE Definitions There are many terms used in relationship to aerobic ca­ pacity and exercise that require clarification. Physical ac­ tivity has been defined as any bodily movement produce~ by skeletal muscles that results in energy expenditure. ( Similarly, exercise is a type of physical activity that is planned, structured, repetitive, and is purposely aimed at improving physical fitness. 7 Physical fitness is a set of at­ tributes that people have or achieve and includes compo­ nents of health-related (cardiorespiratOlY endurance, body composition, muscular endurance, muscular strength ,

87

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Therapeutic Exercise: Moving Toward Function

flexibility) and athletic-related skills.' Being physically fit thereby enables an individual to perform claily tasks vvith­ out undue fatigue and with suffici ent en ergy to enjoy leisure-tim e activities and to respond in an emergency sit­ uation , if one arises. Cardiorespiratory endurance training, or repetitive movements of large muscle groups fueled by an adequ ate> response from the Circulatory and respiratory systems to sustain physical activity and eliminate fatigue, is designed to achieve physical fitness.! Said another way, cardiorespi­ ratOlY endurance is the ability of the whole body to sustain prolonged exercise." Another term for cardiorespiratOlY endurance training is aerobic training, indicating the role of oxygen in the performance of this type of exercise . Anaerobic training, on the other hand, involves exercise performed in short bursts that does not require an ongOing supply of oxygen, such as strength training. s The highest rate of m:ygen that the body can consume during maximal exercise is termed aerobic capacity , maxi­ mal oxygen uptake, or V0 2 max 8 V0 2 max is considered the gold standard measurement of cardiorespiratory endurance and aerobic fitness and can be measured in absolute (liters/minute) or relative (milliliterslkilograms/ . minute) terms. s

Energy Sources Used During Aerobic Exercise To base exercise prescription on sound scientific princi­ ples, it is important to understand and differentiate the fuel sources and the metabolic pathways used during the per­ formance of aerobic exercise. The performance of aerobic exercise requires readily available energy sources at the cellular level. Ingested food, comprised of carbohydrate, fat , and protein, is converted to and stored in the cell as adenosine triphosphate (ATP) , the body's basic energy source for cellular metabolism and the performance of muscular activity. Each food source has a unique route whereby it is converted to ATP. There are three methods, or metabolic pathways, by which ATP is produced. s

Fuel Sources Carbohydrate, including sugars, starches, and fibers, is the preferred energy source for the body, is the only fuel capa­ ble of being used by the central nervous system, and is the only fuel that can be used during anaerobic metabolism. Carbohydrates are converted to glucose and stored in mus­ cle cells and the liver as glycogen, ,"lith approximately 1,200 to 2,000 kcal of energy stored in the form of carbohydrate. Each gram of carbohydrate ingested produces approxi­ mately 4 kcal of energy8 Fat can also be used as an energy SOurce and is the body's largest store of potential energy, about 70,000 kcal in a lean adult. s However, the basic storage form of fat use­ ful as an energy source, triglyceride, must be broken down into free fatty acids (FFA) and glycerol before FFAs can be used to form ATP by aerobic oxidation. The process of triglyceride reduction, termed lipolYSiS, requires Significant amounts of oxygen, thus carbohydrate fuel sources are more efficient than fat fuel sources 9 and are thus preferred during high-intensity exercise. From each gram of fat 9 kcal of energy is produced.

Protein is us ed as an energy source in cases of starvation or extreme energy depletion and it provides approxi mately 5% to 10% of th e total energy needed to perform en­ durance exercise. Protein yields approximately 4 kcal of en­ ergy per gralll and is not a preferred energy source under normal conditions 8

Metabolic Pathways ATP-PCr System

The first pathway is anaerobic, meaning th at it does not require m.ygen to function, although it also can occur in the presence of oxygen. This pathway is called the ATP­ PCr system, where PCr stands for phosphocreatine Or cre­ atine phosphate. s As vvith ATP , PCr is a high-energy com­ pound found in skeletal muscle cells that functions to replenish ATP in a working muscle, extending the time to fatigue by 10 to 20 seconds. 9 Thus energy released as a re­ sult of the breakdown of PCr is not used for cellular metabolism , but rather to prevent ATP levels from falling. One molecule of ATP is produced per molecule of PCr. This simple energy system can produce 3 to 15 seconds of maximal muscular work8 and requires an adequate recov­ ery time, genera]]y three times longer than the duration of the activity. Glycolytic System

The production of ATP during longer bouts of activity, such as that required to address an aerobic capacity im­ pairment, requires the breakdown of food energy sources.'s In the glycolytic system, or during anaerobic gly­ colysiS, ATP is produced through the breakdovm of glu­ cose, obtained from the ingestion of carbohydrates or from the breakdovm of stored liver glycogen. Anaerobic glycolysis also occurs ,vithout the presence of oxygen, but is much more complex than the ATP-PCr pathway, re­ quiring numerous enzymatic reactions to break dovm glu­ cose and produce energy (Fig. 6-1). The end product of glycolysis is pyruvic add , or pyruvate which is converted to lactic acid in the absence of oxygen, and the net energy production from each molecule of glucose used is two molecules of ATP, or three molecules of ATP from each molecule of glycogen . Although the energy yield from the glycolytic system is small, the combined energy produc­ tion of the ATP-PCr and glycolytic pathways enables mus­ cles to contract ,vithout a continuous ~».ygen supply, and thus provides an energy source in the first part of a high­ intensity exercise until the respiratOlY and Circulatory sys­ tems catch up to the sudden increased demand placed on them. FUliher, the glycolytic system can only prOvide en­ ergy for a limited tim e because the end product of the pathway, lactic acid , accllll1ulates in the muscles and in­ hibits further glycogen breakdown and eventually im­ pedes muscle contraction. 8 Oxidative System

The production of ATP from the breakdown of fuel sources in the presence of oqgen is termed aerobic oxida­ tion or cellular respirationS ATP is produced in the mito­ chondria, cellular organelles conveniently located next to myofibrils, the contractile elements of individual muscle fibers. The oxidative production of ATP involves several complex processes, including aerobic g~colySiS, the Krebs cycle, and the electron transport chain. (Fig. 6-2)

H

OH

@--J-,

Glucose

@~ • glucose

hexokinase

6-~lhosp~latEl

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8

.._ _ _ _ _~,lIjill phosphorylase

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fructose

6-phosphate

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f) phosphofructo­ kinase

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fructose 1, 6-diphosphate

•

.H'0H

Aldolase

HO

H

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..J.

Isomerase 3-phosphoglyceraldehyde

3-phosphoglyceraldehyde

., 7°

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- - J lglyceraldehyfJ! 3-phosphate dehydrogenase

r

1, 3-diphosphoglycerate

....

3-phosphoglycerate

fDl

3-phosphoglycerate

11 phoSPhogrtm~.

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't-(~, ,~., +

enolse

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phosphoenolpyruvate

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lactate dehydrogenase

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Lactate

lactate dehydrogenase

FIGURE 6-1. The derivation of energy (ATP) via glycolysis An overview of the breakdown of glucose (a six-car­ bon molecule) and glyco gen (a chain of glucose molecules) to two three-carbon molecules of pyruvic acid. Note that there are ro ughly 10 separate steps in thi s anaerobic process. (From McArdle W, Katch F, Katch V. Exercise Phys iology: Energy, Nutrition, and Human Performance, 5th ed . Baltimore Lippincott Williams & Wilkins, 2001)

90

Therapeutic Exercise: Moving Toward Function

Carbohydrate or glycogen is broken down in aerobic glycolysis, Similarly to the breakdown of carbohydrate in anaerobic glycolysis, but in the presence of oxygen pyru­ vic acid is converted to acetyl coenzyme A (acetyl CoA).s Acetyl CoA undergoes a number of complex chemical re­ actions in the Krebs (citric acid ) cycle, producing two molecules of ATP (Fig. 6-2). The end result of the Krebs cycle is the production of carbon dioxide and hydrogen ions , which enter the electron transport chain, undergo a series of reactions, and produce ATP and water. Thirty­ nine molecules of ATP are produced from one molecule of glycogen or .38 molecules of ATP from one molecule of glucose (one ATP is used in the conversion of glucose to glycogen )8 The presence of oxygen thus enables signifi­ cantly more energy to be produced and results in the abil­ ity to perform longer periods of work without the impedance of muscle contraction created by the build up of lactic acid. Figure 6-3 summarizes and compares the energy production capabilities of the three metabolic pathways.

Metabolic Pathway and Fuel Source Selection During Exercise High-intensity, brief-duration exercise (efforts of less than 15 seconds ) is accomplished using stored ATP in the muscle for energy created via the ATP-PCr pathway. High-in tensity, short-duration exercise (efforts of 1 to 2 minutes' duration ) relies on the anaerobic pathways, including the ATP-PCr and glycolysis systems for the provision of ATP. High­ intensity, brief-duration and high-intensity, short-duration exercise thus use carbohydrate or glucose as the fuel sources Submaximal exercise efforts use carbohydrate, fat, and protein for energy. Low-intensity (less than 50% of maxi­ mal oA),gen consumption) exercise performed for long du­ ration uses both FFA and carbohydrate fuel sources "vithin the aerobic oxidative pathway to produce ATP. 9 As exercise duration increases or intenSity decreases, and in the pres­ ence of an abundant supply of oxygen, the body will use a higher level of FFA oxidation compared with carbohydrate fuel sources for ATP production . During work loads of moderate to heavy intensity (greater than 50% of maximal oxygen consumption), the proportion of carbohydrate used for ATP production increases and the proportion of FFA used decreases. This same relative proportion of carbohy­ drate and FFA use continues as workload approaches max­ imal exercise capaCity. Above maxim al levels, exercise is anaerobic and thus can only be performed for a short tirrie. 9 As noted earlier, protein partiCipates as an energy source only in eAiremely deficient situations (e.g. , starvation) and minimally during endurance exercise. To summarize, carbohydrate is the preferred fuel source for the production of ATP to supply the body with energy during exercise. Exercise can occur anaerobically, via the ATP-PCr or anaerobic glycolYSiS pathways, or aero­ bically, via the aerobic oxidative pathway. The oxidative pathway has the greatest ATP yield and enables exercise to continue for prolonged periods without the fatigue caused by lactic acid buildup. To support the aerobic needs of pro­ longed exercise, numerous changes occur in the cardiovas­ cular and respiratory systems, which "vill be discussed in the follOwing section.

Normal and Abnormal Responses to Acute Aerobic Exercise Normal Responses to Acute Aerobic Exercise To assess an individual's response to exercise, it is impor­ tant to understand the normal phYSiologic changes that oc­ cur as a result of the performance of physical activity. The ability to sustain aerobic exercise depends on numerous cardiovascular and respiratory mechanisms aimed at deliv­ ering oxygen to the tissues. The follOwing changes would be eA'Pected during aerobic exercise and would be consid­ ered normal responses.8-12 Heart Rate

There is a linear relationship between heart rate (HR), measured in beats/min, and intensity of exercise, indicating that as workload or intenSity increases, HR increases pro­ portionally. The magnitude of increase in HR is influenced by many factors, including age , fitness level, type of activity being performed, presence of disease, medications , blood volume, and environmental factors such as temperature and humidity. Stroke Volume

The volume or amount of blood ejected from the left ventricle per heart beat is termed the stroke volume (SV), measured in mLibeat. As workload increases, SV increases linearly up to approximately 50% of aerobic capacity, after which it increases only slightly. Factors that influence the magnitude of change in SV include ventricular function, body pOSition, and exercise intensity. Cardiac Output

The product of HR and SV is cardiac output (Q ), or the amount of blood ejected from the left ventricle per minute (Llmin ) (Q = HR X SV). Cardiac output increases linearly with workload because of the increases in HR and SV in re­ sponse to increasing exercise intenSity. Changes in Q de­ pend on age, posture, body size, presence of disease, and level of physical conditioning. Arterial-Venous Oxygen Difference

The amount of oxygen extracted by the tissues from the blood represents the difference between arterial blood oxygen content and venous blood oxygen content and is referred to as the arterial-venous oxygen differ­ ence (a-v02 diff) , measured in mLidL. As exercise in­ tenSity increases, a-v02 diff increases linearly, indicating that the tissues are extracting more oA),gen from the blood, decreaSing venous oxygen content as exercise progresses. Blood Flow

The distribution of blood flow (mL) to the body changes dramatically during acute exercise. Whereas at rest, ap­ proximately 15% to 20% of the cardiac output goes to mus­ cle, during exercise approximately 80% to 85% is dis­ tributed to working muscle and shunted away from the viscera. During heavy exercise, or when the body starts to overheat, increased blood flow is delivered to the skin to conduct heat away from the body's core, leaving less blood for working muscles.

Chapter 6: Chapter Impaired Aerobic Capacity/ Endurance

i n

U r-

p­ ~e

to to ~d

FIGURE 6-2. After glucose and glycogen have been reduced to pyruvate, IPhase I) pyruvate is catalyzed to acetyl CoA, which can enter the Krebs cycle or citric acid cycle, where oxidative phosphorylation occurs. Hydro­ gen released during the Krebs cycle then combines with two coenzymes that carry the hydrogen atoms to the electron transport chain IPhase 11). IFrom McArdle W, Katch F, Katch V. Exercise Physiology Energy, Nutrition, and Human Performance, 5th ed . Baltimore Lippincott Williams &Wilkins, 2001)

91

92

Therapeutic Exercise Moving Toward Function

ATP-P~~ • •

. . ..... ...... ..

~ 100

.!

FIGURE 6·3. Energy producti on capabilities of the three metabolic pathways. This figure depicts the actions and interactions of the ATP­ phosphocreatine, glycolytic, and oxidative metabolic pathways. High-in­ tensity, brief duration exercise is fueled by the ATP-phosphocreatine pathway, whereas high-inten sity, short-duration exercise relies on the glycolytic pathway, both of which are anaerobic . The aerobic oxidative pathway provides energy for muscular contraction during prolonged ex­ ercise of low to mode rate intensity. (From Bezner J Principles of aero­ bic conditioning. In: Bandy WD, Sanders B, eds. Therapeutic Exercise. Techniques for Intervention. Baltimore Lippincott Williams & Wilkins, 2001)

Bl ood Pressure

The two components of blood pressure (BP), systolic (SBP) and diastolic (DBP) pressure, respond differently during acute bouts of exercise. To facilitate blood and oxy­ gen delivelY to the tissu es, SBP increases linc<.lrlywith work­ load. Because DBP represents the pressure in the arteries when the heali is at rest, it changes little during aerobic ex­ ercise, regardless of intensity. A change in D BP ofless than 15 mm Hg from the resting value is considered a normal re­ sponse. Both SBP and DBP are higher during upper ex­ tremity aerohic activi.ty, compared to lower extremity aero­ bic activi.ty. This increase is thought to be due to increased resistance to blood How and a resulting increase in blood pressure to overcome the increased resistance as a result of the smaller !l1usde mass and vasculature of the upper ex­ tremities compared to the lower extremities s Pulmonary Ventilation

The respiratory system responds during exercise by in­ creasing th e rate and depth of breathing in order to in­ crease the amount of air exchanged per minute (Umin ). An immediate increase in rate and depth occurs in response to exercise and is thought to be facilitated by the nervous sys­ tem, initiated by th e movement of the body. A second, more gradual, increase occurs in response to body temper­ ature and blood chemical changes as a result of the in­ creased oxygen use by the tissues. Thus both tidal volume, or the amount of air moved into and out of the lungs dur­ ing regular breathing, and respiratory rate (RR) increase in proportion to the intensity of exercise.

Abnormal Responses to Aerobic Exercise Individuals with suspected cardiovascular disease or any other type of disease that may produce an abnormal re­ sponse to exercise should be appropriately screened and tested before th e initiation of an exercise program. This topic will be discussed in greater Q(;taillater in this chapter. However, abnormal responses may occur in individuals without known or docllmented disease and thus routine monitoring of exercise response is important and can be used to evaluate the appropriateness of the exercise

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prescription and as an indication that further djagnostic testing may be indicated. In general, responses that are inconsistent ,vith the nor­ mal response gUidelines described previously are consid­ ered abnormal responses. Of the parameters described, HR and BP are most commonly assessed dUling exercise. The failure of HR to lise in propOliion to exercise intensity, a failure of SBP to rise or a decrease in SBP 2: 20 mm Hg dur­ ing exercise, and an increase in DBP 2: 15 mm Hg would all be examples of abnormal responses to aerobic exercise l l Signs and symptoms of exercise intolerance should also be recognized und include those usted in Display 6-1. Ab­ normal exercise responses, such as failure of HR to rise, of­ ten occur with exercise intolerance, defined as patient­ related signs and symptoms; however, they can occur independently so the clinician should be familiar "vith both. Knowledge of the normal and abnormal phYSiologic and symptom responses to exercise will enable the clinician to prescribe and monitor exercise safely and confidently and to minimize the occurrence of untoward events during exer­ cise. Regular exposure to aerobic exercise results in changes to the cardiovascular and respiratOlY systems that can also be assessed by monitoring basic phYSiolOgiC variables durin& rest and exercise. These adaptations will be discussed next. L

Angina, typically manifested as chest, left arm, jaw, back or lower neck pain or pressure • Unusual or severe shortness of breath • Abnormal diaphoresis • Pallor, cyanosis, cold and clammy skin • Central nervous system symptoms such as vertigo, ataxia, gait problems, or confusion • Leg cramps or intermittent claudication Physical or verbal manifestations of severe fatigue or shortness of breath ACSM Resource manual for Guidelines for Exercise Testing and Prescription, :rd Edition

Chapter 6 Chapter Impaired Aerobic Capacity/ Endurance

Physiologic and Psychologic Adaptations to Cardiorespiratory Endurance Training In healthy individuals, cardiovascular training produces profound changes throughout the cardiorespiratory and vascular systems. The documented benefits of aerobic ex­ ercise are a result of the adaptations the oxygen delivery system undergoes secondary to the performance of regular activity. These adaptations, considered chronic changes, enable more efficient performance of exercise and thus af­ fect cardiorespiratory endurance and fitness level. These chronic adaptations occur in the cardiovascular and respi­ ratory systems and affect the values of both V0 2 max and body composition (see Display 6-2).

Cardiovascular Adaptations

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Factors involving the heart that adapt in response to a reg­ ular exercise stimulus include heart size, HR, SV, and CO. The weight and volume of the heart and the thickness and chamber size of the left ventIicle increase in trained indi­ \riduals. As a result, the heart pumps more blood out per beat (SV) and the force of each contraction is stronger. SV is thus increased at rest, as well as duIing sub maximal and maximal exercise, because of more complete filling of the left ventricle duIing diastole compared with an untrained heart and an increase in plasma blood volume, discussed in the follov\ring section. Changes to HR include a decreased resting HR and a decreased HR at sub maximal exercise lev­ els, indicating that the indhridual can peIform the same amount of work v\rith less effort after training. Maximal HR typically does not change as a result of training. The amount of time it takes for HR to return to resting after exercise de­ creases as a result of training and is a useful indicator of progress towards better fitness. Because Qis the product of

n. d a

DISPLAY 6-2

~o

Physiologic Adaptations to Cardiorespiratory Endurance Training

[ k l~

• Increased heart weight and volume • Increased left ventricle size • Increased stroke volume Increased plasma blood volume • Decreased resting and submaximal heart rates • Decreased time required for heart rate to return to resting after exercise • Increased maximum cardiac output • Increased total hemoglobin • Decreased systolic and diastolic blood pressure in hypertensive clients Increased peripheral capillary formation • More efficient blood distribution to active muscles • Increased tidal volume during maximal exercise • Decrease resting and submaximal respiratory rates • Increased respiratory rate during maximal exercise • Increased pulmonary ventilation during maximal exercise • Increased pulmonary diffusion during maximal exercise • Increased a-v02 difference during maximal exercise • Increase in V0 2 max • Decreased body fat

93

HR and SV (Q = HR X SV), it does not change much at rest or during submaximal exercise because HR decreases and SV increases. However, because of the increase in maximal SV, maximal Q increases considerably.811 .12 Adaptations also occur in the vascular system and inc.:!ude blood volume, blood pressure, and blood flow changes. Aer­ obic training increases overall blood volume, pIimaIily be­ cause of an increase in plasma volume . The increase in hlood plasma results from an increased release of hormones (an­ tidiuretic and aldosterone) that promote water retention by the kidney and an increase in the amount ofplasma proteins, namely albumin. A small increase in the number of red blood cells may also contribute to the increase in blood volume. The net effect of greater blood volume is the delivery of more oxygen to the tissues. Resting blood pressure changes with training are most noteworthy in hypertensive or bor­ derline hypertensive individuals, in whom aerobic training can decrease both SBP and DBP up to 10 mm Hg . During the performance of submaximal and maximal exercise, there is little change, if any, in blood pressure as a result of train­ ing. Several adaptations are responsible for the increase in blood flow to muscle in a trained individual , including greater capillarization in the trained muscle (s), greater opening of existing capillaIies in trained m uscle(s), and more efficient distIibution of blood flow to active muscles 8 ,11,l2

Respiratory Adaptations The capacity of the respiratory system to deliver oxygen to the body typically surpasses the ability of the body to use oxygen, thus the respiratory component of performance is not a limiting factor in the development of cardiorespiratory endurance. Nevertheless, adaptations in the respiratory sys­ tem do occur in response to aerobic training. The amount of air in the lungs, represented by lung volume measures, is unchanged at rest and during submaximal exercise in trained individuals. However, tidal volume, the amount of air breathed in and out dUling normal respiration , increases during ma'<.imal exercise. Respiratory rate (RR) is lower at rest and duIing submaximal exercise and increases at maxi­ mal levels of exercise. The combined increases in tidal vol­ ume and RR during maximal exercise of trained indhriduals produce a substantial increase in pulmonary ventilation, or the process of movement of air into and out of the lungs. Pulmonary ventilation at rest is either unchanged or slightly reduced and during submaximal exercise is slightly reduced follOwing training. The process of gas exchange in the alve­ oli, or pulmonary diffusion, is unchanged at rest and at sub­ maximal exercise levels, but increases duIing maximal exer­ cise because of the increased blood flow to the lungs and the increased ventilation as discussed previously. These two factors create a situation that enables more alveoli to par­ ticipate in gas exchange, and thus the perfusion of oxygen into the arteIial system is enhanced dUling ma'<.imal exer­ cise. Finally, a-v02 diff increases at maximal exercise in re­ sponse to training as a result of increased oxygen distraction by the tissues and greater blood flow to the tissues because of more effective blood distIibution. 8 ,ll,12 One net effect of these cardiovascular and respiratory adaptations on aerobic capacity is an increased V0 2 max af­ ter endurance training. A typical training program consist­ ing of three times per week, 30 minutes per session exer­

94

Therapeutic Exercise Moving Toward Function

cise at 75% of VO z max, as discussed in a later section of this chapter, over the course of 6 months can improve VOz max 5% to 30% in a previously sedentary individual. Rest­ ing V0 2 max is either unchanged or slightly increased fol­ lOwing training, and submaximal VO z is either unchanged or slightly reduced, representing greater efficiency 8 The second net effect relates to body composition changes that have been documented as a result of aerobic exercise train­ ing. Whether caloric intake stays the same during training or is decreased, individuals lose fat mass as a result of train­ ing. Several mechanisms have been postulated to produce a loss of body fat secondary to training, including appetite suppression, an increase in the resting metabolic rate, and increase in lipid mobilization from adipose tissue and thus the burning of fat for energy.8

Psychologic Benefits of Training In addition to the myriad of cardiovascular, respiratory, and metabolic improvements that occur after aerobic training, psychologiC benefits have also been documented, although are less weil understood. An overall assessment of the litera­ ture in this area indicates tllat depreSSion, mood, anxiety, psychologic well-being, and perceptions of physical function and well-being imgrove in response to the performance of physical activity. 1, ' The finding that exercise can decrease symptoms of depreSSion and anxiety is consistent witll the fact that individuals who are inactive are more likely to have depreSSive symptoms compared to active persons, Improve­ ments in depreSSion and mood have been found in popula­ tions with and witllOut clinically diagnosed psychologic im­ pairment, as well as in those with good psychologic health, although the literature is less conclusive in this specific area, A number of factors have been postulated to explain the beneficial effects of aerobic training on psycholOgiC func­ tion , including changes in neurotransmitter concentrations, body temperature, hormones, cardiorespiratory function , and metabolic processes, as well as improvements in psy­ chosocial factors such as social support, self-efficacy, and stress relief. Further research is needed to verify the pote n­ tial contribution of changes in these factors resulting from aerobic training to improvement in psychologiC function. 1 Despite the inability to explain why psycholOgiC param­ eters improve in response 1:..0 training, the effect on overull quality of life is positive. J4.\.o Improvement in quality oflife as a result of physical activity has been demonstrated in in­ dividuals without 1&-19 and v\lith disease, including coronary heart disease patients who are obese,20 coronary heart dis­ ease patients who are elderly,Zl patients with chronic heart failure,z2 patients after coronary bypass graft surgery,23 and patients with multiple sclerosis24 and cancer. 25

Dose-Response Relationship The amount of physical activity associated vvith decreased risk for cardiovascular disease and death has been the topiC of numerous studies recently.2&-30 Authors agree that an in­ verse linear dose response exists between the amount of physical activity performed and all-cause mortality.2&-28 Al­ though the minimal effective dose of physical activity is un­ clear, expenditure of 1,000 kcalJweek is associated vvith a Significant reduction in all-cause mortality.26,28 It is less clear whether additional benefits are achieved from the

performance of vigorous physical activity compared with moderate intenSity activity, such as the current guidelines to accumulate 30 minutes of moderate intenSity activity daily,2/j- 3o Until additional research is performed clarifying this association, it appears that an exercise prescription based on an individual client's motivations and desires is the best approach to follow, with the aim of performing consistent with current recommendations to accumulate 30 minutes or more of moderate-intenSity phisical activity on most, and preferably ail, days of the week. ,6 The dose-response relationship relative to improve­ ments in quality of life has also been examined, The ob­ served improvement in quality of life in individuals who participate in regular exercise is achieved from quantities of exercise considered to produce health-related (versus fitness-related ) benefits. Fitness-related benefits include those resulting in Significant changes in physical fitness level, as measured by cardiorespiratory endurance and body composition changes, SpeCific recommendations for fitness-related changes usually include vigorous, continu­ ous activities vvith a focus on the specific parameters of ex­ ercise (intenSity, mode, duration, frequency). Health­ related benefits can be achieved through the performance of moderate intensity, intermittent activity wherein the fo­ cus is on the accumulated amount of activity performed. 6 The documented health-related benefits from the perfor­ mance of regular exercise are shown in Display 6-3. Although improvement in fitness level is a worthwhile goal and also results in the health-related benefits listed previously, exercise to achieve health-related benefits ap­ pears to be easier for most people to incorporate into their lifestyle and thus prOvides a valuable exercise option .3l<>3 The specific parameters necessary to achieve both fitness­ related and health-related benefits of aerobic exercise are presented later in this chapter.

CAUSES OF IMPAIRED AEROBIC CAPACITYIREHABILITATION INDICATIONS The ability of the body to use oA)'gen can be limited by dis­ ease and is affected by aging and inactivity, A systems re­

DISPLAYS·3

Health-Related Benefits from the Performance of Regular Exercise • Decreased fatigue • Improved performance in work- and sports-related

activities

• Improved blood lipid profile • Enhanced immune function • Improved glucose tolerance and insulin sensitivity • Improved body composition • Enhanced sense of well-being • Decreased risk of coronary artery disease, cancer of the

colon and breast, hypertension, noninsulin-dependent

diabetes mellitus, osteoporosis, anxiety, and depression

1­

.r

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance

view, conducted as a part of the examination, discussed in the next section, can identify the presence of or risk for pathology/pathophysiology, impairments, functional limi­ tations, or disabilities that impact aerobic capacity.34 Al­ though injury to or diseases of the heart, lungs, and vascu­ lar system-the primary tissues involved in cardiovascular endurance-are the most obvious causes of impairment or functional limitation, diseases and conditions of other body systems also affect aerobic capacity. There are three categories of diseases that directly affect the heart, including conditions of the heart muscle, diseases affecting the heart valves, and cardiac nervous system condi­ tions.:)'3 Heart muscle conditions include coronary artery dis­ ease (CAD), myocardial infarction , pericarditis, congestive heart failure, and aneurysms. 35 The pathologic processes in­ volved in the impairment of aerobic capacity in these heart muscle conditions involve obstruction or restriction of blood flow, inflammation, or dilation or distension of one or more heart chambers?5 Aerobic capacity is impaired because the heart is weakened as a result of the disease or condition or blood flow is impaired, resulting in ischemia and necrosis of heart muscle and an inability to pump enough blood in re­ 'ponse to increased demand from activity. The heart valves can become diseased by rheumatic fever, ndocarditis, mitral valve prol&pse, and various congenital deformities. Valve defects increase the workload of the heart, as the heart must work harder to pump blood through a mal­ fu nctioning valve, resulting in impaired aerobic capacity.35 The nervous system that controls cardiac muscle contraction, when diseased, produces arrhythmias such as tachycardia nd bradycardia. Arrhythmias impair aerobic capacity by causing changes in circulatory dynamics becat,:?e the heart is beating too slow or too fast, or skipping beats. x' There are numerous types of peripheral vascular disease , including arterial, venous, and lymphatic disorders, such as atherosclerosis, embolism, Buerger's disease, Raynaud's dis­ ease, deep venous thrombosis, venous stasis, and lymph­ edema?5 Because aerobic capacity is determined by the condition and capacity of both the heart and the peripheral . circulation, these conditions also produce impairments. The " ascular system is used to transport oxygen to exercising muscles so that diseases of the peripheral vascular system disrupt circulation to peripheral muscles , prodUCing a loss of nction at rest and during exercise, impairing aerobic ca­ pacity. The most common disease of the vascular system is h)pertension, considered a major risk factor for myocardial in farction, stroke, and cardiovascular death. Conditions affecting the pulmonary system influence the ability of the lungs to bring in and absorb oxygen and expel carbon dioxide from cells in the body. These pro­ 'esses are of primary importance to cardiorespiratory en­ urance; therefore, diseases affecting ventilation and respi­ ration impact aerobic capacity. Diseases affecting the lungs . c1ude lung tumors , chronic obstructive pulmonary dis­ ase (including bronchitis, bronchiectasis, emphysema), thma, pneu monia, tuberculosis, cystic fibrosis , and vari­ us occupational lung diseases (pneumoconiosis ).35 Disease of the neurologiC, musculoskeletal, en­ . Dcrine/ metabolic, and integumentary systems may also egatively affect aerobic capacity. Conditions such as ancer, neuromuscular disease, cerebrovascular attacks ,

95

traumatic brain injury, spinal cord injury, osteoporosis, arthritis , and AIDS either directly or indirectly impair aer­ obic capacity and thus limit cardiovascular endurance. Any medical condition necessitating hospitalization or bed rest can result in deconditioning of the cardiovascular system. Surgical procedures for the gallbladder, appendix, uterus, or other internal organs require a period of de­ creased activity. Accidents resulting in multiple system in­ juries can limit activity for long periods of time , resulting in deconditioning. The effects of aging on the cardiovascular and respira­ tory systems are numerous, resulting in an overall decrease in aerobic capacity. Some of the factors that have been at­ tributed to the decline in aerobic capacity documented "vith age include decrements in central and peripheral cir­ culation including a decrease in maximal HR , SV, and a­ V02 difference; increases in body fat and decreases in lean body mass; and lung function decline including a d crease in vital capacity and forced expiratory volume, an increase in residual volume, and a loss of elasticity in the lung tissue and chest walL 8 Because the elderly respond to cardiovas­ cular training with impressive improvements in aerobic ca­ pacity, it is difficult to differentiate between biolOgiC aging and phYSical inactivity as the primary cause of the decline in aerobic capacity that occurs with age. A sedentary lifestyle, or physical inactivity, impairs aer­ obic capacity and is considered a modifiable risk factor for cardiovascular disease (Display 6-4). ConSidering that ap­ proximately 40% of the U.S. adult population is sedentary, physical inactivity is more prevalent than the diseases dis­ cussed previously that cause impairment in aerobic capac­ ity, and thus is a major public health concern. s On the pos­ itive side, as a modifiable risk factor, physical inactivity is mutable and can and should be addressed when identified during the examination of a patient.

DISPLAY 6-4

Risk Factors for Corona

Heart Disease

Major Risk Factors-Nonmodifiable Increasing age Male gender Heredity (including race)

Ma,or Risk Factors-Modifiable Tobacco smoke High blood cholesterol levels High blood pressure Physical inactivity Obesity and overweight Diabetes mellitus

Contributing Factors Individual response to stress Peripheral vascular disease Personality Hormonal status Alcohol consumption Goodman and Snyder. p. 96; http.!/americanheart.org/presenter.jhlml?identifier= 235, accessed November 27, 2002

96

Therapeutic Exercise: Moving Toward Function

EXAMINATION/EVALUATION OF AEROBIC CAPACITY With the exception of clients with cardiovascular and pul­ monary diseases, most clients who are referred to physical therapy do not have as their primary diagnosis impaired aerobic capacity. Because aerobic capacity influences any exercise a client may perform as a part of an intervention, and thus the outcomes that client will achieve, it is impor­ tant that examination and evaluation of the cardiovascular and respiratOlY systems be included as a part of the exam­ ination and evaluation of all clients. The tests and mea­ sures described in this section are aimed at identifying the presence of disease, describing baseline aerobic capacity, and measuring change in aerobic capacity as a result of in­ tervention(s). The clinician is assumed to have the knowl­ edge and skill to perform the basic tests necessary to diag­ nose impairments and functional limitations in aerobic capacity; however, detailed information will be provided for the more advanced tests of aerobic capacity because many clinicians may not have experience performing these tests on a regular basis. Additional information may be . obtained from the ACSM texe 6 on exercise testing and prescliption.

Patient/Client History Specific portions of the general data generated from a pa­ tienUclient history as defined in Chapter 2 are important to note when attempting to identify the presence of an im­ pairment in aerobic capacity that either should be directly addressed in the intervention or that may influence the clinician's ability to set and achieve goals related to other impairments. Knowledge of the risk factors for coronary heart disease provides a basis for collecting the most rele­ vant information regarding impaired aerobic capacity. As shown in Display 6-4, general demographic information such as age, gender, and ethnicity is very important to con­ sider. Social/health habits such as smoking and physical ac­ tivity are important behaviors to inquire about during the histOlY. Assessm ent of general health status in terms of phYSical, role, and social functioning as well as functional status and activity level can provide additional indication of limitations in cardiovascular endurance. Clinical tests of blood cholesterol are useful to identify clients at risk for coronalY heart disease. Other factors that should be noted from the history include personalitylbehavior, pregnancy, and breast-feeding status, factors that also may modify the exercise prescIiption .lI \1edication histOlY is of primary importance to review, espeCially for clients with documented cardiovascular and pulmonary disease, but also for those ,vith risk factors for disease. \1a1lY cardiac and pulmonalY system drugs affect aerobic capacity, and thus clients using these drugs should be carefully monitored during any intervention that affects the cardiovascular and pulmonalY syste ms , including therapeutic exercise, functional training, airway clearance techniques, integumentary repair techniques, electrother­ apeutic modalities, and physical agents and mechanical modalities.

Specific questions that should be posed during the pa­ tienUclient history to identify the presence of cardiovascu­ lar and pulmonary disease and the relevant aspects of the client's overall status that may affect aerobic capacity as dis­ cussed above can be found in Goodman and Snyder's text 35 on differential diagnOSiS.

Systems Review After, and based on, the patienUclient history, a systems re­ view is conducted as a brief or limited examination of the status of the other major body systems (integumentary, musculoskeletal, neuromuscular) , and the communication ability, affect, cognition, language, and learning style of the patient. 34 The systems review helps to identify impair­ ments in other areas that may affect the performance of an activity or task within the plan of care. FUlther, the systems review may identify potential problems that require refer­ ral to another provider. Because the primary intervention used to address aero­ bic capacity impairments, therapeutiC exercise, requires adequate musculoskeletal, neuromuscular, and integu­ mentary function, it is espeCially impOltant to perform a tl10rough systems review in clients with cardiovascular and pulmonary impairments. Failure to do so could result in prescribing an intervention that the patient either cannot perform or that compromises the safety of the patient. At a minimum, skin integrity, muscle strength, joint range of motion, balance, gait function , and assessment of the abil­ ity to make needs known should be assessed.

Screening Examination Before the initiation of an exercise program, individuals should be assessed to ensure safety and minimize risksl l The ACSM 36 has created guidelines delineating who should be medically evaluated before participation in vig­ orous exercise (defined as in tensi ty > 60% VOz max ). Those who do not require medical evaluation includ asymptomatic (Display 6-5) apparently healthy women younger than age 50 and men younger than age 40 wbo have fewer than two CAD risk factors (family history of CAD, Cigarette smoker, hypertenSion, hypercholes­ terolemia, diabetes mellitus, sedentary lifestyle) .;)G In addition, asymptomatic apparently healthy men and women , regardless of age or CAD risk factor status, who wish to begin a moderate exercise training program (de­ fined as intenSity between 40% and 60% VO z max) do not need medical evaluation. For individuals who do not re­ quire medical evaluation , preparticipation screening can be performed using a self-report questionnaire, such as the Physical Activity Readiness Questionnaire or PAR-QI J,:1R.37 (see Appendix 3). Based on the answers to the seven ques­ tions on the PAR-Q, individuals between the ages of 15 and 69 can either appropriately partiCipate in exercise or be re­ ferred to a physician for further evaluation before begin­ ning an exercise program. All individuals who fall outside of the boundaries described should be referred to a physician for medical evaluation before participating in exercise training.

Chapter 6: Chapter Impaired Aerobic Capacity/Endurance

DISPLAY 6-5

Asymptomatic is Defined as Without: • pain in the chest, neck, jaws, or other areas suggestive of ischemia • shortness of breath at rest or with mild exertion • dizziness or syncope • orthopnea (difficulty breathing in any position other than

sitting upright)

• ankle edema • palpitations or tachycardia • intermittent claudication • known heart murmur • unusual fatigue or shortness of breath with usual activities ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed.

Tests and Measures The examination categories directly relevant for the client "vith aerobic capacity impairment include tests and measures of aerobic capacity/endurance, anthropometriC characteristiCS, and circulation. There are numerous tests . nd measures in each of these categories and often the most difficult task for the clinician is selecting the most appropriate test. Tests and measures should be selected based on data collected from the history, systems review, and screening, the means the client has available for fol­ lOwing through with a program of aerobic exercise, client goals , and the equipment and monitoring equipment available.

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The development of an appropriate and useful exercise prescription for cardiorespiratory endurance depends on an accurate assessment of V0 2 max, which is most com­ monly achieved through the performance of a graded exer­ cise test (GXT). Exercise tests can be maximal, in which an. individual performs to his or her phYSiologic or symptom limit, or submaximal, in which an arbitrary stopping or lim­ iting criterion is used. Maximal Graded Exercise Tests The most important characteristics of a maximal GXT are that it has a variable or graded workload that increases gradually and that the total test time equal approximately 8 to 12 minutes a6 In addition, individuals undergoing maxi­ mal GXT testing are usually electrocardiogram (ECG) monitored. The direct measurement of V0 2 max requires the analysis of expired gases, which requires speCial equip­ ment and personnel and is thus costly and time-consum­ ing. 36 V0 2 max can be estimated from prediction equations after the individual exercises to the point of volitional fa­ tigue , or it can be estimated from submaximal tests. For most clinicians, maximal exercise testing is not feasible be­ cause of the special equipment required and the ECG monitoring, although it is the most accurate test of aerobic capacity. Additionally, it is recommended that maximal graded exercise testing be reserved for research purposes, testing of diseased individuals, and athletic populations. II

97

Thus submaximal testing is most commonly us ed, espe­ cially \vith low-risk, apparently healthy individuals, and "viII be further described in this section. Individuals who wish to conduct maximal graded exercise testing are referred to the ACSM Guidelines for Exercise Testing 36 or th ACSM Resource Manual l l for more detailed information. Submaximal Graded Exercise Tests Submaximal exercise tests can be used to estimate V0 2 max because of the linear relationship bet\veen HR and V0 2 , and HR and workloadY That is, as workload or V0 2 increases, HR increases in a linear, predictable fashion. Therefore, the clinician can estimate max V0 2 by plotting HR against workload for at least t\vo exercise workloads and extrapolating to age-predicted maximal heart rate (220 - age) to estimate V0 2 max (Fig. 6_4 ). 36 Submaximal exer­ cise testing is based on several assumptions , as shown in Display 6-6. Failure to meet these assumptions fully, which is usually the case, results in errors in the prediction ofV0 2 max. Therefore, submaximal testing typically results in less accurate V0 2 max estimations. Submaximal tests are ap­ propriately used to document change over time in response to aerobic training and, given the time and money saved, are very useful clinically. ACSM 36 provides recommendations for physician super­ vision during graded exercise testing. For women younger than age 50 and men younger than age 40 who are without Iisk factors or symptoms (Display 6-5), physician supervi­ sion is not deemed necessary duling maximal or submaxi­ mal testing. Individuals in these age ranges who have t\vo or more Iisk factors but no symptoms or disease can unde rgo submaximal testing 'Arithout phYSician supervision. Physi­ cian supervision during submaximal and maximal testing is recommended for any individual with CAD or with symp­ toms of CAD. Last, during maximal testing for men older than age 40 and women older than age 50 "vith t\.vo or more risk factors but no symptoms, physiCian supervision is rec­ ommended a6 Therefore, submaximal testing can be per-. formed safely by physical therapists 'Arith any age individual who is symptom or disease free , as defined by ACSM. 36 Numerous testing protocols have been gubJished and are available for submaximal exercise testing. 6 Because of the requirement of reproducible workloads, treadmills, bicycle ergometers, and stepping protocols are most commonly used. Test selection should be based on safety concerns, fa­ miliarity \vith and knowledge of the testing protocol, equip­ ment aVailability, and clienUpatient goals, abilities, and con­ ditions (e.g. , the presence of orthopediC limitations).

Bicycle Ergometer Tests The t\vo most common bicycle ergometer tests are the YMCA protocol and the Astrand-Ryhming test. 36 In the YMCA protocol, the client performs two to four, 3-minute stages of continuous cycling, deSigned to elevate the HR to bet\veen 110 and 150 beats/ min dming t\vo consecutive stages. The client begins cycling at 50 revolutions/min at a resistance of 150 kgm/min or 0.5 kg and progresses to greater resistance in subsequent stages based on HR recorded during the last minute of the first stage according to Table 6-1. For example, if HR = 85 at the end of the first stage, the second stage workload wOlllJ be 600 kgm/ min and the third stage workload would be 750 kgm/ min.

98

Therapeutic Exercise: Moving Toward Function 180 ---, estimated maximal HR

extrapolated ~ /

to max HR //

/ /

~

c:

{ //

160

E

•

U5 cr; 140 Q)

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&120 ro

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Individuals pedal at SO revolutions/min and HR is measured during the fifth and sixth minutes. The two HR measures must be within 5 beats of one another and the HR between 130 and 170 beats/min for the test to be completed. If the HR

100

I I

80

---i

:estimated I V0 2max

YI

I 50

100

150

200

Exercise Intensity (watts) 900

1500 Estimated

2100

2700

\/0 2 (ml/min)

FIGURE 64 Heart rate (HR) obtained from at least two (more are prefer­ able) submaximal exercise intensities may be extrapolated to the age­ predicted maximal HR. A vertical line to the intensity scale estimates max- . imal exercise intensity from which an estimated V0 2 max can be calculated. (From Kenney WL ACSM's Guidelines for Exercise Testing and Prescription. 5th Ed . Baltimore Williams & Wilkins, 1995)

The test is terminated \vhen two consecutive stages yield a HR reading between llO and 150 beats/min. The two HR measures and corresponding workloads are plotted on a graph and the line generated from the plotted points is ex­ tended to the age-predicted maximal HR and an estimation ofYO z max is obtained. 36 The Astrand-Ryhming test involves a single 6-minute stage, with workload based on sex and activity status: • unconditioned females, 300 or 450 kgm/min (SO or 75 watts) • conditioned females , 450 or 600 kgmlmin (75 or 100 watts) • unconditioned males , 300 or 600 kgm/min (50 or 100 watts) • conditioned males, 600 or 900 kgrnlmin (100 or 150 watts).

DISPLAV6·6

Assumptions for Submaximal Exercise Testing • The workloads used are reproducible. • Heart rate is allowed to reach steady-state at each stage of the test. • The age-predicted maximal HR is uniform (220 - age) with

a prediction error of 10% to 15%.

• A linear relationship exists between HR and oxygen uptake, • Mechanical efficiency is the same for everyone (e.g., V0 2

at a given work rate),

ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed; American

College of Sports Medicine Resource Manual for Guidelines for Exercise

Testing and Prescription 3rd Ed. Baltimore: Williams & Wilkins, 1998.

3.4

3.5

L..-_--'-, 1.500

AGURE 6-5. The Astrand-Rhyming nomogram. A nomogram used to calcu­ late aerobic capacity (V0 2 max) from pulse rate during submaximal work. ThE clinician must know the pulse rate, sex, and work load from the bicycle er­ gometer test performed on the client to determine absolute V0 2 max. Va: max values obtained from the nomogram should be adjusted for age by a cor­ rection factor (Table 6-2), (Reprinted with permission from Astrand PO, Ry~ · ming LA nomogram for calculation of aerobic capacity [physical fitness] fro pulse rate during submaximal work. J Appl Physiol1 954;721 8-221)

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance

99

E?_·~~~y~glsu~~~ ~ ~iEycle Ergometer Test Protocol-Workload Settings

Second Stage

Third Stage

Fourth Stage

HR < 80

HR 8!H19

HR 90-100

HR > 100

750 kgmlmin (2.5 kg ) (125 watts) 900 kgmlmin (3.0 kg) (150 watts ) 1050 kgmlmin (3.5 kg) (175 watts)

600 kgmlmin (2.0 kg) (100 watts) 750 kgmlmin (2.5 kg) (125 watts) 900 kgmlmin (3.0 kg) (150 watts)

450 kgmlmin (1.5 kg) (75 watts) 600 kgmlmin (2.0 kg) (100 watts) 750 kgmlmin (2.5 kg) (125 watts )

300 brm/min u (l.0 kg) (50 watts ) 450 kgm/min (1.5 kg) (75 watts) 600 kgm/min (2.0 kg) (100 watts)

Resistance settings shown apply to ergo meters \\~th a 6 meter/revolution flywheel. )

. less than 130 beats/min , the resistance should be increased b SO to 100 watts and the test continued for another 6 min­ utes. The test may be terminated when the HR in the fifth and sixth minute differs by no more than S beats and is be­ tween 130 and 170 beats/min. An average of the HRs is cal­ culated and a nomogram is used to estimate VO z max (Fig. 6­ 5).36 The value determined from the nomogram is corrected or age by multiplication of a correction factor (Table 6-2).

Treadmill Tests ubmaximal treadmill tests are also used to estimate VO z max. A single-stage submaximal treadmill test has been de­ "eloped for assessing VO z max in low-risk individuals. 38 It involves beginning with a comfortable walking pace be­ ,\'een 2.0 and 4.S mph at 0% grade for a 2- to 4-minute warm-up, designed to increase HR to within 50% to 7S% of ae-predicted (220 - age) maximum HR, followed by 4 minutes at S% grade at the same self-selected walking ;peed. HR is measured at the end of the 4-minute stage .md VO z max is estimated using the following equation: V0 2 max (mUkglmin) = lS.l + 21.8 X speed (mph) - 0.327 X HR (bpm ) - 0.263 X speed X age (years) + 0.00S04 X HR X age + S.98 X sex (0 = F , 1 = M)

Step Tests

--

e er­ ~2

tor­ rom

Correction Factor.foi'J\ge for Astrand­ Nomogr~I11 , --

-

-

AGE

CORRECTION FACTOR

15 25 35 40 45 50 55 60 65

1.10 1.00 0.87 0.83 0.78 0.75 0.71 0.68 0.65

m ill p . 223 Bandy and Sanders, which was reprinted from American .ollege of Sports Yiedicin c. Guidelines for Exercise Testing and re- cription. 5th Ed. Media, FA: vViili ams & Wilkins , 1995.

Females: V0 2 max (mUkglmin) = 6S.81 - [0.1847 X recovery HR (beats/min)] Males : V0 2 max (mUkglmin) = 111.33 - [0.42 X recovery HR (beats/min)]

Field Tests

tep tests were developed based on a need to test large umbers of individuals expeditiously and represent another

. R.l1yming

mode of submaximal exercise testing. Several protocols have been developed,39 but only one \-vill be presented. The Queens College Step Test requires a 16.2S-inch step (simi­ lar to the height of a bleacher).:39.4o Individuals step up and down to a 4-count rhythm (on Count 1 subject places one foot on step, on Count 2 subject places the other foot on the step, on Count 3 the first foot is brought back to the ground, on Count 4 the second foot is brought down). A metronome is useful to maintain the prescribed stepping beat. Females step for 3 minutes at a rate of 22 steps/min, whereas males step at a rate of 24 steps/min. At the end of the 3 minutes, a recovery IS-second pulse is measured, starting at S seconds into recovery while the individual remains standing. The pulse rate is attained and is converted to beats/min by mul­ tiplying by 4. This value is termed the recovery HR. The fol­ lOwing equations are used to estimate VOz max.

-

Field tests refer to exercise testing protocols derived from events performed outside, or in the "field ." They are also submaximal tests and, as with the step test, are more prac­ tical for testing large groups of people, appropriate when time or equipment is limited, and when assessing individu­ als older than age 40 a9 A variety offield tests exist,39 but only the Cooper 12-minute test and the I-mile walk test will be discussed. In the Cooper 12-minute test, individu­ als are instructed to cover the most distance possible in 12 minutes , preferably by running, although walking is ac­ ceptable. The distance covered in the 12 minutes is recorded and VO z max estimated according to the follow­ ing equation?9 V0 2 max (mUkglmin)

= 3S.97 (miles ) - 11.29

A I-mile walk test is another option in the field test cate­ gory41 Individuals walk 1 mile as fast as possible without running and the average HR for the last two complete min­ utes of the walk is recorded . A HR monitor is necessary to record and average the HR over the last 2 minutes. If a HR monitor is not available, a IS-second pulse can be mea­ sured immediately on test completion. VO z max is esti­ mated from the follOwing equation: 41

100

Therapeutic Exercise Moving Toward Function

V0 2 ma;\ (mLlkglmin ) = 132.85 - 0.077 X body weight (pounds ) - 0.39 X age (years) + 6.32 X sex (0 = F, 1 = M) - 3.26 X elapsed time (min) - 0.16 X HR (beats/min) All clients should be closely monitored during exercise test performance. Vital signs should be assessed before, during each stage or workload of the test, and after the test for 4 to 8 minutes of recovery. 11 In addition, the rating of perceived exertion (RPE) is commonly used to monitor exercise tol­ erance 42 RPE refers to the "degree of heaviness and strain experienced in physical work as estimated according to a specific rating method,,42.p9 and is an indicator of overall perceived exertion. The Borg RPE scale and instructions for use are shown in Fig. 6-6.

Anthropometric Characteristics Body composition is important to assess in individuals par­ taking in an aerobic exercise program because of the changes e>"'Perienced in fat mass as a result of chronic train­ ing discussed earlier in this chapter. In addition, body com-

RATING

DESCRIPTION

6

None at all

7

Extremely light

8 9

Light

10 11

Light

12 13

Somewhat hard

14

15

Hard (heavy)

16 17

position is an important examination tool in the presence of obesity and is considered superior to simple measures of height and weight. The gold standard measure of body composition is hydrostatic or unde[\l1/ater weighing that re­ quires speCialized equipment and the patient to tolerate to­ tal body immersion. Because of these limitations, several reliable measures of body composition estimation have been developed and are used widely, including body mass index, bioelectric impedance, near-infrared interactance; skinfold measurements, and waist to hip ratio. Bioelectric impedance, near-infrared interactance, and skinfolds re­ quire speCialized equipment and, in the case of skinfolds, specialized training; whereas the body mass index and waist-to-hip ratio can be measured using height, weight, and circumferential measurements. The clinician is re­ ferred to ACSM 's Guidelines for Exercise Testing and Pre­ scription 36 for additional information about performing these tests.

Circulation Assessment of blood pressure; heart rate, rhythm , and sounds; and respiratory rate , rhythm, and pattern is impor­ tant to establish a baseline and to determine impairments. In addition, these measures can be assessed over time to determine the effect of aerobic training on the cardio­ vascular and pulmonary systems and ' to document improvement.

THERAPEUTIC EXERCISE INTERVENTION Impaired aerobic capacity/endurance involves the support element of the movement system , and as such is the under­ lying impairment for num erous functional limitations and disabilities and is thus a priority to address with the inter­ vention plan. A wide variety of aerobic endurance activities exist and are the most efficient techniques to achieve the goal of improved aerobic capacity. The modes and dosage specifics used when establishing an aerobic endurance ex­ ercise prescription will be presented. A primary objective of the exercise prescription is to assist in the adoption of regu­ lar physical activity as a lifestyle habit and thus should take into consideration the behavioral characteristics, personal goals, and exercise preferences of the individuaP6

Mode Very hard

18 19

Extremely hard

20

Maximal

FIGURE 6-6. The rating of perceived exertion scale. (From Bezner J. Prin­ ciples of aerobic conditioning. In: Bandy WD, Sanders B, eds. Therapeutic Exercise. Techniques for Intervention. Baltimore: Lippincott Williams & Wilkins, 2001. Data from American College of Sports Medicine. The rec­ ommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 1990;22:265-274.)

Several modes of cardiovascular endurance training are available. Any activity that uses large muscle groups and is repetitive is capable of prodUCing the desired changes. Such activities include walking, jogging, cross-country ski­ ing, bicycling, rope jumping, rowing, swimming, or aerobic dance (see Selected Intervention 6-1 ). Although lap swim­ ming is the most common aquatic cardiovascular exercise, water jogging, cross-country skiing, and water aerobics are also effective aquatic training methods. An upper body er­ gometer is a good cardiovascular training tool and is espe­ Cially well suited for individuals unable to use their legs (see Fig. 6-7). The choice of exercise mode depends on the patient's goals and speCific physical condition . Performing an activ­

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance

t'::\ \::.J

101

SELECTED INTERVENTION 6-1

Cross-Country Ski Machine

Refer to Case Study #10

Although this patient requires comprehensive intervention, only one exercise is described:

ACTIVITY: Cross-country ski machine PURPOSE: To increase cardiovascular endurance and musculoskeletal muscle endurance of quachiceps, gluteals , and spine and arm extensors ELEMENTS OF THE MOVEMENT SYSTEM: Base, suppOli

DOSAGE: Ten minutes, adding 5 minutes every three ses­ sions

RATIONALE FOR EXERCISE CHOICE: When the arm move­ ment is included, cross-country skiing is a total body exer­ cise. Aerobic conditioning can be achieved, along \\~th shoulder, trunk, hip, and leg extensor muscle endurance training.

EXERCISE GRADATION: This exercise can be progressed by increasing the frequency, intenSity, or duration of acti\~ty.

STAGE OF MOTOR CONTROL: Skill POSTURE: Standing posture, maintaining proper pelvic and spine posture. Arms are resting on the machine for balance or can paliicipate by performing altemate ann extensions with attached pulleys (with or without resistance) MOVEMENT: Alternate hip flexion and extension in a walking pattern \\~th minimal knee motion is pelformed. The patient/client must be sure to transfer weight completely li'om leg to leg during the activit\', rather than shuffling or sliding the feet while bearing weight bilaterally. The arms can move in an alternate fashion \\~th the legs. Bange of motion may be limited by individual needs.

1­

rt

r­

Id

SPECIAL CONSIDERATIONS: (1 ) All precautions to cardiovascular endurance exercise must be considered. (2) Individuals with balance and coordination difficulty should he assessed for ability to perform the activity safely.

Used with the permission of Kordie Track, Inc. , Chaska. MN.

r­

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lis e.

ki­ bic Pl­

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er­

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ity that is convenient, comfortable, and enjoyable increase s the likclihood of adherence. The amount of impact is also an important consideration when choosing the exercise mode. For the individual ~th lower extremity degenera­ tive jOint disease or the overwe ight indi~dual , impact ac­ ti~ties should be avoided. The pool is a better choice for those who need to minimize weight bearing or impact. Weight bearing can be completely negated by exercising in the deep end of the pool. For those desiring to return to impact acti~ties, gradual impact progression can prepare the body for the demands of this type of lo ading (see Patient-Related Instruction 6- 1). Variety and cross-training in the cardiovascular en­ durance program are imperative. Alternating moell's of aC­ ti~ty can allc~ate boredom and prevent overuse injuries resulting from repetitive activity. Many individuals have such low muscular endurance th at they are incapable of performing the sa me repetitive ac tivity for more than a few minutes. The acti~ty mode can be alternated within the training session and among sess ions. Although one individ­ ual may bicycle 2 days per week, swim 2 days, and walk 2 days, another may bike , walk, and stair step for 10 minutes each daily.

'<\' ithin one mode of exercise, several postures or equip­ ment types are available. For example , during bicycling, the trunk postllfe selected depends on the goals. Bicycling may be performed on a recumbent bike (Fig. 6-8A), ~th the hips flexed 90 degrees or more and the low back sup­ ported , or it may be performed in a upright position with the anTIS moving (Fig. 6-8C ), or in a fOlward leaning posi­ tion (Fig. 6-8B ). The optimal posture for maximal exercise benefit should be emphaSized (see Patient-Related In­ struction 6-2).

Dosage Type The training session itself may be performed using a variety of training techniques, from continuous activity to interval training. Continuous training relies on the aerobic energy system to supply energy for the exercise session and can be carried out for prolonged periods. The individual exercises continuously, without rest, at a steady exercise rate. Al­ though continuous in nature , several different activities can be combined ~thin the same session, such as tread mill and bicycle or s\:vi.mming and deep-water running.

102

Therapeutic Exercise: Moving Toward Function

FIGURE 6-7. Upper body ergometer. An upper body ergometer is an exercise mode that provides an aerobic exercise alternative for those with sig­ nificant lower extremity impairments or to provide variety in an exercise prescripti on. Because the smaller upper extremity muscles perform the exer­ cise, lower heart rates are experienced. In addi­ tion, it is difficult to monitor vital signs during ac­ tivity. The seat on the device should be adjusted to allow slight elbow flexion in the outstretched po­ sition of the arm while the back maintains contact with the seat. and the seat height position should ensure that the shoulder is even with the axis of the crank arm. (From Bezner J Principles of aero­ bic conditioning. In Bandy WD, Sanders B, eds. Therapeutic Exercise. Techniques for Intervention. Baltimore: Lippincott Williams & Wilkins, 2001. Courtesy of Henley Healthcare, Sugar Land)

Interval training incorporates rest sessions between bouts of exercise. This technique is useful for clients who are unable to maintain continuous exercise for the optimal length of time (e.g., 30 minutes) and for those recuperating from an orthopedic injury or who are deconditioned. When presclibing interval training, the ratio of the rest period to the training period determines the activity intensity and the energy system used. The aerobic energy syste m is used to a greater extent vvith longer training intervals and shorter rest periods. For example, performance of three bouts (in­ tervals) of activity at an inten sity of 50% of V02. max or greater for 10 minutes with a 2-minute rest period in be­ tween each bout would use the aerobic energy' system. The rest periods can be true rest (i.e., no activity) or a work-relief interval , during which light activity such as walkjng may be performed. High-intensity activity usually is combined vvith longer complete-rest intervals, and low to medium intensities are combined with shorter rest in­ tervals or work-relief intervals. F or example, a training session might inc:lude a set of 10 100-meter sprints, in which each sprint may only take 10 to 20 seconds to com­ plete, with a 10-minute complete rest inteJ-val between each sprint. Because high-intensity exercise of short dura­ tion uses the ATP-PCr and glycolysis systems for the pro­ vision of ATP , a longer rest period is required to allow musc:le energy stores to be replenished. Less intense exer­

C\lBE)(

cise, concomitantly, relying on the aerobic oxidative path­ way, can be performed adequately from an energy avail­ ability standpoint for longer periods of time with shorter rest intervals that may consist of complete-rest or work-re­ lief intervals. Circuit training can be continuous or interval. Circuit training is a training technique in which the individual ro­ tates through a series of exercise stations. A variety of up­ per extremity, lower extremity, core, and cardiovascular training exercises tYl)ically are included. The individual performs the activity at each station for a specified time (i.e., 30 seconds ) ann then moves on to the next station . The activity choices, activity intensity, and rest between stations determine the energy system used and whether the . activity is interval or continuous. This type of training pro­ vides the opportunity for a well-balanced exercise program with valiety. Multiple individuals can be trained simultane­ ously if there are adequate stations (see Patient-Related In­ struction 6-3).

Sequence Cardiovascular endurance training may be performed as pali of a comprehellsive relwhilitation program that in­ cludes mobility. stretching, and strength ening activities. Gen(.;' ral warlll-up activities should he performed initially, followed by stretching ann the cardiovascular training ses­

Chapter 6: Chapter Impaired Aerobic Capacity/Endurance

Return to Impact Activity Any return to impact activities such as jogging, impact aerobics, or sports requiring running or jumping should be preceded by impact progression. This approach ensures readiness to return to the activity and decreases the likelihood of setback. Prerequisites for impact progression include the following:

1. Adequate muscle strength and endurance 2. Full range of motion in the joints 3. No swelling A suggested progression is as follows:

1. 2. 3. 4.

Two-footed hopping Alternate-footed hopping Single-footed hopping (optional) Skill drills (optional)

This progression should be implemented as follows: 1. Begin on a low-impact surface (e.g., pool, minitramp, shock-absorptive floor). 2. Subsequently progress to the terrain you will be using. 3. Begin with 5 minutes, and increase by 2- to 5-minute increments when you are able to complete three consecutive sessions without pain, swelling, or technique compromise. 4. Return to your full activity is determined 'by the criteria set by your clinician.

uit ro­

sion. The warm-up period should last 5 to 10 minutes to prepare the body for exercise. Large muscle group activ­ ity such as walking, calisthenics, or bicycling should be performed with gradually increasing intensity. T he warm­ up session may be a lower-intensity version of the cardio­ vascular training activity. Walking at a slower speed for 5 minutes may be used as a warm-up activity for fast rvvalk­ ing or jogging. The warm-lip activities incr ase muscle blood flow, muscle temperature, and neural conduction. These changes , along with mental preparedness, can decrease the risk of muscle injury during exercise. After the warm-up, stretching exe rcises are performed, fol­ lowed by the more vigorous cardiovascular endurance ses­ sion . The cardiovascular training session should be concluded with cool-down activities, which often consist of lower-intensity versions of the training sessio n and stretching exercises. The exercise session should be concluded with a cool­ down period of 5 to 10 minutes to allow redistribution of blood flow that has chang d with exercise, including pre­ vention of lower extremity pooling of blood by enhanCing venous return to the heart. Activ mllscle contraction by continued walking, cycling, or low-level calisthenics assists with blood flow redistribution. Stretching should conclude the session to ensure maintenance of the working muscle's optimal length.

Frequency The frequency of cardiovascular training should be deter­ mined through consideration of the patient's goals, the in­ tensity and duration of exercise, and the patient's base line fitness level. The optimal frequency for most individuals is

103

three to flve times per week,s.:l(; with those initiating a pro­ gram beginnina at three to four times per week and pro­ gressing to fiv . The ov rload principle in tCrIllS of the in­ teraction alDong inte nsity, duratio n, and frequency is importan t to consider when prescribing exercise. Individu­ als with very low functional capacities can perform daily or twice daill)' exercise because the total amount of exercise , considering intenSity, duration , and frequency , is so 10\v.36 In a highly trained individual, exercise at a greater fre­ quency may be necessary to produce overload, depending on the exercise intenSity.

Intensity As with frequency and duration, setting the intensity of exercise shollid be bas d on the overload plinciple and consideration should be given to the fun ctional limita­ tions , goals, and fitness level of the individual. Exercise in­ tensity indicates how much exercise should be performed or how hard one must ex rcise and is typically presclibed on the basis of H R max, H R reserve, VO z m ax, RPE, or METS (metabolic equivalents) . Prescribing exercise in­ tensity using HR is considered the preferred method be­ cause of the correlation between HR and the stress on the heart and because it is readily accessible for monitoring during exerciseS Several methods involving HR can be used. vVhen prescribing exe rcise as a percentage of maximum HR , either directly measured or on the basis of age-pre­ dicted maximum HR, the training range sho uld be be­ tween 55% and 65% to 90% of HR max 36 A second method involves the use of the HR reserve or Karvonen formula: Target HR range = [(HR max - HRrest) X 0.60 and 0.80] + HRrest 36

If exercise is prescribed using VO z max, 5.5 clc to 7.5% is also used as a training range and V0 2 max should be stated in relative terms (mUkg/ min), which accounts for the indi­ vidual's body weight. The HPE can also be used to pre­ scribe exercise intensity, \vithin the range of 12 to 16 on the RPE scale shown in Fig. 6-7. RPE is espeCially useful for prescribing intensity for individuals who are un able to pal­ pate pulse or when HR is altered because of the influence of medication and should be considered an adjunct to mon­ itoring HR in all other individuals. 36 M E TS may also be used to prescribe activity intensity. METS are used to estimate the metabolic cost of physical activity relative to the resting state. One MET is equal to 3.5 mL of oxygen consumed per kilogram of body weight per minute (mUkglmin).36 Therefore, when V0 2 is known, the intensity can be prescribed in METS by dividi ng rela­ tive VO z by 3.5 mL/kg/min. In general, walking at 2 mileslhr is the equivalent of approximately 2.0 METS , and walking at 4 miles/hr is the equivalent of apprOximately 4.6 METS. Selection of an appropriate training range versus a spe­ cific training value has been recommended to prOVide greater flexibility in the exercise prescription, yet ensure that a training respon se will be achieved. For example, an individual who is starting an exercise program might be given a target HR range between 60% an d 70% of HR max

104

Therapeutic Exercise: Moving Toward Function

FIGURE 6-8. (A) Exercise on a semirecumbent bike positions the individual differently from ex­ ercise on a traditional bike, (B) Bicycling in a tra­ ditional position places more weight on the up­ per extremities, challenging the postural muscles more than in a recumbent position, (C) Exercise on an upright bike with moving arms places dif­ ferent loads on the patient.

instead of being told to keep target HR at a value equiva­ lent to 60% of HR max. Intensities between 70% and 85% HR max or 60% and 80% HR reserve are recommended for most people to ex­ perience improvements in cardiorespiratOlY endurance. 36 Health-related benefits can be realized at lower intensities, and thus lower intensities may be appropriate if the goal of exercise is to improve health rather than fitness. 43 In the pool, the heart rate is decreased when exercising while immersed to the neck because of the Starling reflex and is therefore a poor gauge of workload. The heart rate of deep-water exercise is 17 to 20 beats/ min less than that of the comparable land-based activity 44 Increase exercise intensity by adding resistance, in­ creasing speed, changing terrain (e.g" up hills ), removing stabilization , or adding upper extremity activity. The method for increasing intensity is goal-specific and may be limited by other medical or physical conditions (e.g. ,

rotator cuff tendinitis limiting the use of upper extremi­ ties). The intensity necessalY to achieve a workload in the target training zone varies among individuals and usually correlates with the previously determined conditioning level.

Duration Exercise duration can be manipulated to produce overload and a resultant cardiovascular training effect. Duration de­ pends on the frequency, intensity, and the conditioning level of the patient. In general, exercise of greater intensity is performed for a shorter duration and exercise of lower intensity can be performed for a longer duration. Manipu­ lation of these variables is goal-dependent. If the patient is required to perform an activity for a long duration (i.e" continuous walking as part of a job or recreation), progres­ sion of the rehabilitation program should focus more on in­ creasing the duration and less on increasing the intensity.

Bicycling Guidelines The following guidelines will keep your bicycling experience healthy and safe: 1. Seat height The seat should be set so that your knee is slightly bent in the down-most position. If you place your heel on the pedal in the down position, your knee should be perfectly straight. When you place the ball of your foot on the pedal, your knee should be bent at the correct angle (15 to 20 degrees of knee flexion with the ankle in 90 degrees of dorsiflexion). 2. Cadence: Your pedal cadence should be high, at least 60 rpm or more. Your clinician may have other recommendations, depending on your specific situation. 3. Resistance: The resistance should be low enough to allow a higher cadence. Resistance too high can place extra stress on the knee. Keeping the resistance low and the cadence high produces the desired benefits without hurting your knees. 4. Safety: If riding outside, always wear a helmet, and obey your local bicycle laws.

The optimal duration recommended for aerobic train­ ing is between 20 and 30 minutes per session of exer­ cis e .8 ,36 For individuals who are unable to perform 20 minutes of continuous exercise , discontinuous exercise can be prescribed. That is , several 10-minute bouts can be performed, for example, until eventually exercise can be tolerated for 20 to 30 minutes continually. Duration can be progressed up to 60 min utes of continual activ­ ity.36 The same activity or different activities may be per­ formed in each of these sessions (see Patient-Related Instruction 6-4).

Setting Up a Circuit Your regular exercise routine can be enhanced and made more enjoyable by breaking up a continuous activity with stations of alternative activities. A circuit can be created outside along a normal walking or running route, or at your indoor exercise location. For example, a walking or jogging program through the neighborhood or on the treadmill can be broken up with the following activities performed at certain intervals throughout the session: 1. Toe raises 2. Abdominal curls 3. Push-ups 4. Squats 5. Dips 6. Lunge walks 7. Quadriceps, hamstring, and calf stretches

High-risk patients also show disregard for appropriate warm-up and cool-down , consistently exceed prescribed training heart rate , are more likely to be male , and to smoke cigarettes. Although this profile is helpful, it is important to note that a Significant number of patients with one or more of these characteristics will never experience an exe rcise­ related cardiovascular complication , and others without any of these characteristics ma)' experience a complication Therefore, the wise clinician will follow the recomnlt'nua­ tions in Display 6-7 when prescribing and monitoring aer­ obic exercise to reduce the incidence and severity of com­ plicatiolls during exercise. Endurance exercise places a significant load on the car­ diovascular and musculoskeletal systems. Consideration should be given to any injury or disease affecting either of these sys tems. Individuals with degenerative joint disease should be encouraged to partiCipate in non-weight-bearing

PRECAUTIONS AND CONTRAINDICATIONS

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In addition to the signs and symptoms of exercise intoler­ ance described in the physiology of aerobic capacity and e ndurance section an d Display 6-1 , clinicians should be aware of the risks associated "vith exercise, as well as mon­ itoring and supervision gUidelines. The incidence of car­ diovascu lar complications during exercise has been docu­ mented to be extremely low for individuals without Significant cardiac disease':16 For persons with cardiovascu­ lar disease, the incidence of cardiovascular complications during exercise is conSiderably greater; however, the over­ all absolute risk of cardiovascular complications during ex­ ercise is low when considered in light of the health benefits associated with chronic exercise. A profile has developed of individuals at gr atest risk for cardiovascular complications du ring exercis ,36 The prom includes those with a history of multiple myocanlial infarc­ tions, impaired left ventricular function with an ejection fraction of less than 30%, rest or unstable angina pectoris, se riou s arrhythmias at rest, significant multivessel atherosclerosis on angiography, and 10\.\/ serum potassium .

Frequency, Intensity, and Duration Determining how often (frequency), how hard (intensity), and how long (duration) to exercise can be difficult. These parameters are related and must be balanced to find the right quantity of exercise for you. The following broad guidelines can be refined by your clinician: 1. Frequency: Generally, if you exercise more frequently (more times per day or days per week), the intensity and duration of those sessions should be lower. This recommendation allows adequate recovery before the next session. If the intensity and duration are high, you may not be fully recovered before the next session. 2. Intensity: The more intense the exercise, the shorter is the duration. Intense exercise cannot be sustained very long by most people. 3. Duration: Exercise that is lower in intensity can be sustained for longer periods . For example, sprinting can be sustained for seconds, but jogging can be sustained for up to several hours. The intensity and duration are inversely related; as one increases, the other must decr ease .

106

Therapeutic Exercise Moving Toward Function

DISPLAY 6-7

DISPLAY 6-8

Recommendations to Reduce the Incidence and Severity of Complications During Exercise

Contraindications to Exercise Testing

• Ensure medical clearance and follow-up • Provide on-site medical supervision, if necessary • Establish an emergency plan • Promote participant education • Initially encourage mild-to-moderate exercise intensity • Use continuous or instantaneous ECG monitoring for selected participants • Emphasize appropriate warm-up and cool-down procedures before and after vigorous exercise, including stretching • Modify recreational game rules and minimize competition • Maintain supervision during the recovery period • Take precautions in the cold • Consider added cardiac demands in the heat ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed.

exercises such as bicycling and water ~xcrcise, and those \-vith low buck pain should participate in activities that sup­ port or safely strengthen the back (e.g. , semireclllllbent biking, water activities ). Individuals with osteoporosis should be encouraged to participate in weight-bearing ac­ tivities. Positions and postures should be chosen that mini­ mize the risk of fracture.

Graded Exercise Testing Contraindications and Supervision Guidelines There are numerous contraindications to exercise testing, and guidelines for supervision of graded exercise tests. Dis­ play 6-8 lists the absolute and relative contraindications to exercise testing. The relative contraindications should be considered in light of the potential bene fits of exercise and a less vigorous prescription created for individuals in this category. All clients should be closely monitored during exercise test performance. Vital signs should be assess ed before, during each stage or workload of the test, and after the test for 4 to 8 minutes of recovery.lI In addition, the RPE is commonly used to monitor exercise tolerance (Fig. 6-7 )Y' Finally, individuals should be monitored for signs and symptoms of exercise intolerance, The guide­ lines for stopping an exercise test are presented in Dis­ play 6-9.

Supervision During Exercise A thorough screening or medical evaluation is critical for determining which individuals may require supervision durin g exercise ,36 Apparently healthy individuals do not require supervision during the performance of aerobic ex­ ercise , Those individuals "vith two or more risk factors for CAD (Display 6-4, plus family history of myocardial in­ farction/coronary revascularizationlsudden death before

Absolute A recent significant change in the resting ECG suggesting significant ischemia, recent myocardial infarction (within 2 days) or other acute cardiac event Unstable angina Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise Severe symptomatic aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Suspected or known dissecting aneurysm Acute infections

Relative Left main coronary stenosis Moderate stenotic valvular heart disease Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia I Severe arterial hypertension (i.e., systolic BP > 200 mm Hg and/or a diastolic BP > 110 mm Hgl at rest Tachyarrhythmias or bradyarrhythmias Hypertrophic cardiomyopathy and other forms of outflow tract obstruction Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise High-degree atrioventricular block Ventricular aneurysm Uncontrolled metabolic disease (e.g., diabetes) Chronic infectious disease (e,g" mononucleosis, hepatitis, AIDS) ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed.

age 55 in fath er or male first-degree relative or before age 65 in mother or female first-degree relative), or who have documented CAD should be supervised during exercise.,16 Additionally, individuals mth the follOWing signs or symp­ toms should be supervi sed during exercise: pain or dis-

DISPLAY 6-9

Guidelines for Cessation of Graded Exercise Testing • Onset of angina or anginalike symptoms • A significant drop (20 mm Hg) in SBP or a failure ofthe SBP to rise with an increase in exercise intensity • Excessive rise in SBP > 260 mm Hg or DBP > 115 mm Hg • Signs of poor perfusion (lightheadedness, confusion, ataxia, pallor, cyanosis, nausea, cold or clammy skin) • Failure of HR to increase with increased exercise intensity • Noticeable change in heart rhythm • Client requests to stop • Physical or verbal manifestations of severe fatigue • Failure of the testing equipment ACSM's Guidelines for Exercise Testing and Prescription, 5th Ed.

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance

comfort secondary to ischemia, shortness of breath at rest or with mild exertion, dizziness or syncope, orthopnea or paroxysmal nocturnal dyspnea, ankle edema, palpitations or tachycardia , intermittent claudication , known heart murmur, or unusual fatigue or shortness of breath with usual activities.

PATIENT-RELATED INSTRUCTION/EDUCATION AND ADJUNCTIVE INTERVENTIONS

P"lP­ dis­

Patient education regarding cardiovascular endurance training is a critical component of the program. Endurance training should be canied out daily or several times per week, and some of the program may be carried out without the clinician's supervision. Clinicians should recall the re­ cent recommendation of the U.S . Department of Health and Human Services, the Centers for Disease Control and Prevention, the !\ational Center for Chronic Disease Pre­ vention and Health Promotion, the President's Council on Physical Fitness and Sports, and the Amelican College of Sports Medicine that all adults accumulate 30 minutes or more of moderate-intensity physical activity on most, and preferably all , days of the week l ,6 Patient education should include the "why" and the "how to" of the warm-up, training session, and cool-down phases. The patient should be alerted to signs or symptoms neces­ sitating early cessation of the activity (including those in Display 6-1) These symptoms may be musculoskeletal (e.g., joint pain, muscle pain, cramps ) or cardiovascular (e.g., shortness of breath, chest pain, lightheadedness), or they may be specific to the patient's particular problem (.i.e., reprodUCing the patient's original symptoms ). The patJ~nt should be counseled regarding modifications in the exercIse program based on fatigue level and other activities that day. As the patient is prepared for discharge, education re­ garding a maintenance program is critical to continued ad- . here nce with the exercise program. ProgreSSion through a conditioning program should be individualized and is de­ pendent on the client's functional capacity, pre morbid state, health status, age, and individual preferences, goals, and tol­ erance of the training. 36 The client's objective and subjective training res~onses should most heavily influence t.raining progreSSion. 1 Signs and syn1ptoms of overtrammg mclude exercise and nonexercise fatigue, reduction in maximum performance, decreased interest in training compared with nonnal decreased HR and RPE values at the same work­ load, ~d increased complaints of aches and pains. 45 Emphasizing the importance of continued exercise in lona-term health maintenance can assist the patient in making exercise a lifelong commitment. Information about safe progression, exercise dosage , and signs and symptoms of overload can assist the patient in making appropriate ex­ ercise choices. The documented success of programs deSigned to en­ courage the adoption of a regular exercise habit is similar to the success of changing other health-related behaviors such as smoking and weight reduction, in that approxi­ Inately 50% of those who initiate the behavior will develop

107

a lifelong habit. 46 Factors that have been found to be most predictive of exercise dropout or noncompliance include personal, program, and other characteristics. Personal characteristics that predict dropout include being a smoker, being sedentary during leisure tim , having a sedentary occupation, possessing a Type A personality, be­ ing employed in a blue-collar occupation, being overweight or overfat, possessing a poor self-image, b~ ing depressed or anxious , and having a poor credit rating 4 , Program factors predicting dropout include inconvenient time or location , excessive costs, the prescription of high-intenSity exercise, lack of exercise variety, exercising alone, lack of positive feedback, inflexible exercise goals, and poor exercise lead­ ership.47 Additional factors that have bee n identified to predict dropout are lack of spouse support , inclement weather, excessive job travel, injury, medical problems, and job change or move 4 7 These factors in sum indicate that programs and individuals prescribing exercise can and should adopt speCific strategies to enhance comphance with exercise prescription. Examples of these strategies are shown in Display 6-10. The use of behavior change theOlies to enhance the adoption of exercise has received increased attention re­ cently in the literature, specifically the application of the stages of change model, as discussed in Chapter 3. After identifying the stage the patient is currently in , the ll1ter­ vention can be tailored to enhance compliance and movement towards a lifelong habit. For example, an in­ dividual in contemplation is not quite ready for an exer­ cise prescription. Efforts in this stage should focus on the provision of information about the costs and benefits of exercise, strategies to increase activity within the present lifestyle, and the social benefits of activity, for example 48 Those in the preparation stage would benefit most from a thorough examination and exercise prescription. Whereas , those in the action or maintenance stage would benefit from learning about strategies to prevent relapse, making exercise enjoyable, and diverSifying the exercise

DISPLAY 6·10

Strategies to Enhance Compliance With Cardiovascular Endurance Training Programs • Minimize musculoskeletal injuries by adhering to the principles of exercise prescription Encourage group participation or exercising with a partner • Emphasize mode variety and enjoyment in the program • Iincorporate behavioral techniques and base prescription on theories of behavior change • Use periodic testing to document progress • Give immediate feedback to reinforce behavior change • Recognize accomplishments • Invite spouse or significant other involvement and support of the training program Ensure that the exercise leaders are qualified and enthusiastic Reprinted, by permission, from B.A. Franklin, 1988, "Program factors that influence exercise adherence" in Exercise adherence, edited by R. K. Dishman (Champaign, IL Human Kinelil;sl, 242-249.

108

Therapeutic Exercise Moving Toward Function

prescription to include more variety. Given the difficulty most peoplp encounter when changing health-related be­ haviors, it seems prudent to use documented hehavior change theori es when possible, such as the stages of change model.

LIFESPAN ISSUES Guidelines for Cardiovascular Endurance Training in the Young Adolescents and children receive health-related benefits from reg\llar exercise and should be encouraged to partici­ pate in regular activity because adopting an active lifestyle early in life may increase the likelihood-of participating in physical activity in adulthood." There are several key phys­ iologic differe nces between children and adolescents com­ pared with adults that the clinician should be aware of when prescribing aerobic exercise in young people. Resting and submaximal exercise blood pressure values are lower in children than in adults, with a progressive increase with age seen until late adolescence when the values are similar to that of adults. s Children have smaller hemis and less total blood voluiTJe compared with adults, so stroke volume is lower at rest and during exercise. To maintain cardiac out­ put, hccart rate is higher in childmn compared with adults. Overall cardiac output in children is lower than adults for the saIlle ahsolute rate of work , so a-v02. difference in­ creases to compensate for the lower stroke volume 8 Aero­ bic capacity, when expressed in Umin, is lower in children because of a lower maximal cardiac output capaCity. How­ ever, as children develop and their pulmonary and cardio­ vascular function improves, aerobic capacity improves as well. s Children lose more energy during exercise compared with adults when p<:rfonning the same activity at the same intensity. In addition, children are less effiCient at dissipat­ ing heat during exercise because tl1l'y generate more metaholic heat per unit body size, sweat at a lower rate, and hegin sweating at a higher core body temperature com­ pared with adults. Taken together, these factors indicate that children exercising in hot environments should do so at a lower intensity and they will need more time to accli­ matize compared with adults. The recommendations for adults to accumulate at least 30 minutes of moderate intensity physical activity on most and preferably all days of the week apply to chil­ dren and adolescents over the age of 6. 1 .6 Regular partic­ ipation in physical activity will result in gains in strength, endurance, bone formation, self-esteem and self-efficacy, and skill development. 36 A program of activity will also minimize risk factors for cardiovascular disease, manage weight, reduce anxiety and stress, provide social interac­ tion , and can be a great source of fun and enjoyment. 36 Children are at low lisk for cardiovascular disease and are able to adjust exercise intensi~' to tolerance, so do not need a heart rate prescription? Fitness-based games and activities should be used when prescribillg exercise for children because they are fun and children are more

'h

likely to partiCipate in activities that are fun versus highly structured. As children age, they can progress to league and team sports. Adolescents can benefit from league sports as well as cardiovascular exercise such as s\vim­ ming, bicycling, and jogging. If desired, prescribing exer­ cise using the parameters recommended for adults is safe for adolescents. Children and adolescents are susceptible to overuse injuries; therefore, clinicians and parents should be aware of the signs and symptoms of overtraining. It is also important to recognize that children and adolescents should balance cardiovascular training with muscle strength and endurance training and activities to address flexibility.

Guidelines for Cardiovascular Endurance Training in the Elderly Several factors affect the decline in phYSiologic function and physical performance that has be en documented to occur with age. Tl~chnologic advances that require hu­ mans to expend less physical effort, decreased motivation levels and lC'ss energy, and the effects of aging all may contribute to the changes seen in the elderly and are sometimes difficult to differentiate. Maximum o)..')'gen consumption decreases approximately ]0% per decade 'with aging, beginning in the middle of tIle third decade in men and toward the end of the second decade in women. Maximum heart rate, stroke volume, cardiac out­ put, and peripheral blood flow also decrease with ageS In the lungs , residual volume increases with age but total lung capacity remains unchanged , so less air can be ex­ changed with each breath. The lungs and chest wall also lose elasticity with aging.s Body composition changes seen with aging include an increase in relative body fat and a decline in fat-free mass s All of these changes doc­ umented in the elderly can be slowed by partiCipation in regular physical activity. The sam e exercise testing prinCiples presented earlier in this chapter apply to the elderly population. In addition to the tests listed, the 6-minute walk test is used often as a measure of aerobic capacity in elderly patients and in el­ derly clients without disease 4 !),50 To peIform the test, pa­ tients walk as qUickly as they can along a level surface for 6 minutes. The outcome measure of interest is the distance walked in feet or miles. The 6-minute walk test is a practi­ cal alternative to other exercise testing means in the elderly because it is easy to perform, patients can stop and rest any­ time during the test, assistive ambulation devices may be used to perform the test , and it has been shO\VIl to be a re­ liable indicator of functional ability. 49,51 The exercise prescription gUidelines discussed in this chapter can be applied to the elde rly population , who should be encouraged to meet the recommendation to ac­ cumulate at least 30 minutes of moderate-intensity exer­ cise on most and preferably all days of the week. The ef­ fects of cardiovascular endurance training in the elderly include decreased blood pressure, increased high-density lipoprotein cholesterol, improved cardiovascular mortal­ ity rates, increased bone denSity, and maintenance of oxy­

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance

gen consumption values. 52 Endurance training is a safe activity, and as for other populations at risk (e.g., the un­ fit, obese, cardiac patients), it should be implemented slowly. Chosen activities should minimize impact on the joints, emphasizing activities such as water exercise, bicy­ cling, or stair climbing. As is true for all ages, exercise need not be vigorous and continuous to be beneficial. Se­ lect activities that are accessible, convenient, enjoyable, and safe for the participant. Progress the prescription by increasing exercise duration rather than intensity.36 To maintain muscle strength and endurance and to improve mobility, balance, and agility, the elderly should be en­ couraged to participate in strength training and activities to maintain flexibility, in addition to a program of aerobic exercise."fi

v ke

Ie 1'1 ­

KEY POINTS

a

el­

• Physical fitness is defined as a set of attlibutes that peo­ ple have or achieve and includes cardiovascular en­ durance, or the ability of the whole body to sustain pro­ longed exercise. • Aerobic capacity or maximal oxygen uptake (V0 2 max) is the highest rate of oxygen the body can consume during maximal exercise. • Carbohydrates are the preferred energy source for the body during aerobic exercise. • The oxidative metabolic pathway produces the most ATP and enables exercise to be performed for pro­ longed periods. • During acute exercise, HR, SV, Q, a-vOz diff, BP, and RR increase proportionally to the exercise worldoad. • Benefits of cardiovascular endurance training include positive changes in the cardiovascular and respiratory systems that prOvide protection from disease, and im­ proved psychologic well-being and quality of life. • Impaired aerobic capacity can occur as a result of pri­ mary cardiovascular and pulmonary disease, diseases of other syste ms that limit mobility, prolonged bed rest, ag­ ing, and a sedentary lifestyle. • Areas of the patient/client history that the clinician should pay special attention to during the examination of individuals with impaired aerobic capacity include risk factors for cardiovascular disease, social/health habits such as smoking and physical activity, functional ability, and medication history. • Patients/clients should be appropriately screened prior to the initiation of a cardiovascular training program to ensure safety and minimize risks, thus the clinician should be aware of general screening gUidelines. • Tests and measures used to examine patients/clients with impaired aerobic capacity include graded exercise tests, body composition , and tests and measures of cir­ culation such as blood pressure. • Exercise prescription should be based on the results of an appropriate exercise test administered before the ini­ tiation of a cardiovascular training program. • Cardiovascular endurance training can be performed us­ ing a variety of exercise modes and training techniques.

109

• Exercise prescription should be based on the individ­ ual's needs and interests and should take into considera­ tion comorbidities that may affect activity performance. • Cardiovascular endurance training is on e aspect of a well­ balanced exercise program including muscle strengthen­ ing and endurance activities and flexihility exercises. • The clinician should be aware of the signs and symptoms of exercise intolerance and shoulcl be able to identify the contraindications for graded exercise testing. • Supervision requirements for graded exercise testing and for the performance of aerobic exercise are based on the patient/client's history, risk factors, and abilities and the clinician should be able to appropriately determine the level of supervision reqUired. • Education about the specifics of the exe rcise prescrip­ tion, including progreSSion, and the implementation of strategies to enhance compliance will increase the likeli­ hood of the patient/client adopting cardiovascular exer­ cise as a lifelong habit.

CRITICAL THINKING QUESTIONS

------------------------~ l. Consider Case Study #1 in Unit 7. a. "What activities to maintain cardiovascular endurance would you recommend for Lisa as she recovers from her ankle sprain? Be sure to consider the demands of her sport. b. What activities would you recommend if she were a long-distance runner? A hockey player? A wrestler? 2. Consider Case Study #2 in Unit 7. a. Assuming the patient has met the short-term goals, to plan an intervention program to achieve the long­ term goals, what test and measure would you select to assess aerobic capacity? What tests and measures to assess circulation would you monitor during the test of aerobic capacity? b. To design a long-term aerobic exercise program for Sarah, determine the best strategies to incorporate to enhance compliance and increase the likelihood that she will adopt exercise as a lifelong habit. 3. Consider Case Study #3 in Unit 7. a. Design an inte~ention program to improve this journalist's cardiovascular endurance, including techniques to enhance compliance. b. According to the Transtheoretical Model of Behav­ ior Change, what stage of change would you place Cathy in and what strategies are appropriate to in­ corporate to move her to the next stage? 4. Consider Case Study #8 in Unit 7. a. Recommend a graded exercise test for George, con­ sidering the examination findings and his premorbid condition. b, Make recommendations for a cardiovascular exer­ cise program, considering George 's examination findings and his job. c. How would your intervention plan be different if George worked as a long-distance truck driver?

110

Thera peutic Exercise Moving Toward Function

Refer to Case Study #9 in Unit 7

PROGNOSIS This patient with iliotibial band fllscitis and intermittent plantar fascitis has limited functional ability to walk and work because of musculoskeletal impairment. The short- and long­ tenn goals set for her arE' aimed at decreasing disability and returning the patient to a pain free level of functioning. As the patient progresses and her pain , posture, muscle strength , Aexibility, and move ment patterns improve, it would be approPJ;ate to perform an exercise test 011 her to assess aerobic capacity and then to prescribe an exercise program for her that would be safe, personalized, and motivating.

TESTS AND MEASURES OF AEROBIC CAPACITY The patient expressed an interest in returning to walking as a IItness activity. It was dete rmined that she was in the "preparation" stage, meaning that she was getting some ex­ e rcise, but not regularly since she became inJured. To fa­ cilitate the creation of an exercise prescription , the most appropriate test and measure, then , would be one that uses walking as a mode. In selecting an appropri ate test, the first step is to determine whether or not the patient requires medical screening before the initiation of a vigor­ ous or mode rate activit:>; program . According to the guide­ lines set forth by ACSM , asymptomatic apparently healthy women younger than age 50 who have fewer than two risk factors for CAD do not require medical examination be­ fore participation in vigorous exe rcise (see Display 6-5 and the Screening Examination section of this chapter). Fur­ ther, asymptomatic women, regardless of age, do not need

,3

t.1D ,I ufil3 ill mnrmnmU! 9M GW lJ1I.Dimrlrm

STAGE

TREADMILL SETTINGS

Rest \Varm-up

NIA 3.0 mph 0% grade 3.0 mph 5% grade :2.0 mph 0% grade

"'lain Cool down

medical screening be fore the initiation of moderate inten­ sity exercise. Because the patient is asymptomatic and without risk factors , she c10es not need medical screening. It would be appropriate to administe r the PAR-Q as rec­ ommended. The patient's answers to the questions on the PAR-Q will determine her readiness for an exerci se pro­ gram . The clinician should e nsure that the patie nt does not possess contraindications for exercise testing. Review­ ing the absolute ann relative contraindications in Display 6-8 \v;1I ellsure that the patient is ready for exercise testing. Assuming the screening examination did not reveal any contraindications to exercise testing, the clinician should next consider what equiplllent is available to conduct the test. I f a treadmill is available, any of the maximal or submaximal treadmill protocols might be appropliate. If a treadmill we re not available, :my of the fi eld walking tests would be a good option. Because this patient desires to participate in a walIGng program for fitness , because her cardiovascular risks are lo\\', and because a treadmill is available, a submaximal treadmill test was selected. To perform this test, the patient self-selects a comfortable walking pace between 2.0 and 4.5 mph at 0% grade for a 2­ to 4-minute warm-up. The goal lor the warm-~p is to increase HR to within 50% to 75'k of age-predicted (220 ­ age ) maximum HR. The patient's age-predicted max HR is 220 - 47 = 173. The HR range between 50% and 75 % would be 87 bpm to 130 hpm. After the patient's HR reaches this range, progression is made to the next stage of the test. This stage lasts 4 minutes at 05% graJe at the same self-selected walIGng speed. Vital signs (BP, HR) should be measured and recorded hefore. dUling, and after the test. Ttlhle 6-3 details the patient's vital signs.

DURATION N/A

3 minutes 1,5 seconds 4 minutes 4 minutes

The HR measured at the end of the fourth minute of the main stage is reqUired to ente r into the equation used to estimate V0 2 max. Using the equation given in the chapte r: V0 2 max (mUkg/min ) = 15.1 + (21.8 X :3.0mph ) - (0.:3:27 X 135 bpm) - (0.263 X :3.0mph X 47 years) + (0,00504 X 1.35 bpm X 47 years ) + (5.98 X 0) (0 = F, 1 = M), the estimated V0 2 max is calculated to be 31 mUkglmin.

- ._.­ HEART RATE

BLOOD PRESSURE

85 10:2

1:32186 140/84

None :'\Jone

135

14.5/80

None

90

130/80

None

SIGNS AND

SYMPTOMS

EXERCISE PRESCRIPTION The recommended training intensity using V0 2 max for this patient is behveen ,5.5% and 7.'5% of V0 2 max, or behveen 17 and 2:3 mUkg/min. If the clinician has a table available that proVides a guideline for walking intensity equivalent to the V0 2 mao,; or METS (V0 2 maxl3 ..5 ) training range, an exercise prescription could be easily created using the walIGng intensity from the table equivalent to 17.5 to 24 mUkg/min. (contillued )

I

S

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance

IMPROVING AEROBIC CAPACITY­ A CASE STUDY (Continued)

111

walk 45 minutes at 4.0 mph, progress the frequency to 4

days per week.

Education: The patient was instructed to identif), the signs and symptoms of exercise intolerance, including thost: for the musculoskeletal system. It was also recommended that she find a walking pminer to decrease boredom and increase accountabili ty, enjoyment, and, thus, compliance.

The equivalent MET values for this patient's VOl training range would be between 4.8,5 and 6,,5 METS. The patient should perform activities within this MET intensity range during the aerobic training portion of the exercise program. Because walking at 4.0 mph is appro:dmately 4.6 ~\IETS, and the patient desired to walk around her neighborhood, the follmdng exercise prescription was created.

FOLLOW-UP

"'arm-up: 5 minutes of slow walking or gentle stretching Mode: walking on level or uphill smface Intensity: 4,0 mph (l.'5-minute mile) on level surface or 3.0 to 3,,5 mph (17- to 20-minute mile) on uphill surface Duration: :30 minutes per day Frequency: 3 days per week Cool-down: Stretching and strengthening exercises as prescribed Progression: After 2 weeks without pain or discomfort, add 2 minutes per week up to 40 to 45 minutes. After you can

The patient should be able to follow this exercise prescription for 4 to 6 months, contacting the clinician when she has questions or concerns. At approXimately 6 months, the patient should undergo another exercise test to assess progress and adjust the exercise prescription. A 6-month program with these parameters can improve aerobic capacity between 5% and 30%.111.J A new exercise prescription can be created based on the results of the second exercise test and the dosing parameters adjusted to proVide adequate stimulus for continued progression or maintenance of aerobic capacity. based on the patient's goals.

REFERENCES 1. u .s. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. At­ lanta: u.S. Department of Health and Human Services, Cen­ ters for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 2. Blair SN, Kohl HW, Paffenbarger RS, et al. Physical fitness and all-cause mortality. JAMA 1989;262:2395-2401. .'3 Paffenbarger RS, Hyde RT, Wing AL. Physical activity and physical fitness as determinants of health and longevity. In: Bouchard C, Shephard RJ, Stephens T, eds. Physical Activity, Fitness, and Health: International Proceedings and Consen­ sus Statement. Champaign, IL: Human Kinetics, 1994. -1. Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. vVashington DC: U.S. Department of Health and Human Services, 1990; DHHS pub. no. (PHS) 91-50212. 5 . U,S. Department of Health and Human Services. Healthy People 2010 (conference edition, in two volumes). Washing­ ton DC, January 2000. 6. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health, JAMA 1995;273:402--407. - Caspersen q, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985)00: 126-131. S. Wilmore JH, Costill DL. Physiology of sport and exercise. 2nd Ed. Champaign, IL: Human Kinetics, 1999. ~ . Hasson SM. Clinical Exercise Physiology. St. Louis: Mosby, 1994. 10. Berne RM, Levy MN. Cardiovascular physiology. 7th Ed. SI: Louis: Mosby, 1997. I L American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and Prescription. 3rd Ed. Baltimore: Williams & Wilkins, 1998. 1:2 . Bezner J. Principles of aerobic conditioning. In: Bandy WD, Sanders B, eds. Therapeutic Exercise. Techniques for Inter­ vention. Baltimore: Lippincott Williams & ''''ilkins, 2001. McAuley E. Physical activity and psychosocial outcomes. In: Bouchard C, Shephard RJ, Stephens T, eds. Physical Activ­ ity, Fitness, and Health: International Proceedings and

Consensus Statement. Champaign, IL: Human Kinetics, 1994. 14. Caspersen CJ, Powell KE, Merritt RK. Measurement of health status and well-being. In: BOllchard C, Shephard RJ, Stephens T, eds. Physical Activity, Fitness, and Health: In­ ternational Proceedings and Consensus Statement. Cham­ paign, IL: Human Kinetics, 1994. 15. Rejeski WJ, Brawley LR, Shumaker SA. Physical activity and health-related quality of life. Exerc Sport Sci Rev 1996; 24:71-108. 16. McMurdo MET, Burnett L. Randomised controlled trial of exercise in the elderly. Gerontology 1992;38:292-298. 17. Ruuskanen JM, Ruoppila I. Physical activity and psycholOgi­ cal well-being among people aged 65 to 84 years. Age Ageing 199.5;24:292-296. 18. Woodruff SI, Conway TL. Impact of health and fitness-re­ lated behavior on quality of life. Soc Ind Res 1992;2.5: 391-405. 19. Norris R, Carroll D, Cochrane R. The effects of aerobic and anaerobic training on fitness, blood pressure, and psycholOgical stress and well-being, J Psychosomatic Res 1990;34:367-375, 20. Lavie q, Milani RV. Effects of cardiac rehabilitation, exer­ cise training, and weight reduction on exercise capacity, coro­ nary lisk factors, behavioral characteristics, and quality of life in obese coronary patients. Am J CardioI1997;79:397-401. 21. Lavie q, Milani RV. Effects of cardiac rehabilitation and ex­ ercise training programs in patients 2: 7.5 years of age. Am J CardioI1996;78:675-677. 22. Kavanagh T, Myers MG, Baigrie RS, et al. Quality of life and cardiorespiratory function in chronic heart failure: eHc'C,ts of 12 months' aerobic training. Heart 1996;76:42--49. 23. Kurlansky PA, Traad EA, Galbut DL, et al. Coronary bypass surgery in women: a long-term comparative study of quality oflife after bilateral internal mammary artery grafting in men and women. Ann Thorac Surg 2002;74:1.517-1.525. 24, Petajan JH, Gappmaier E, White AT, et aL Impact of aerobic training on fitness and quality of life in multiple sclerosis. Ann NeuroI1996;39:432--441. 25. Smith SL. Physical exercise as an oncology nursing interven­ tion to enhance quality of life. Oncol Nurs Forum 1996; 23:771-778.

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26. Haennel RG, Lemire F. Physical activity to prevent cardio­ vascular disease. How much is enough? Can Fam Physician 2002;48:65-71. 27. Lee 1M, Sesso HD, Oguma Y, et a1. Relative intensity of phys­ ical activity and risk of coronary heart disease. Circulation 2003;107:1110-1116. 28. Lee 1M, Skerrett Physical activity and aU-cause mortality: what is the dose-response relation? Med Sci Sports Exerc 2001 :33:S459-S:±71. 29. Manson JE, Greenland P, LaCroix AZ, et al. Walking com­ pared with vigorous exercise for the prevention of cardiovas­ cular events in women. 1\ Engl J Med 2002;347:716-725. 30. Yu S, Yarnell JW, Sweetnam PM, et al. What level of physical activity protects against premature cardiovascular death? The Caerphilly study. Heart 2003;89:.502-506. 31. \1anson JE, Hu FB, Rich-Edwards JW, et al. A prospective study of walking as compared vvith vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999;341:650-658. 32. Andersen RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic exercise in obese women. JAMA 1999;281:335-340. 33. Dunn AL, \1arcus BH, Kampert JB, et al. Comparison of lifestyle and structured interventions to increase physical ac­ tivity and cardiorespiratory fitness. JAMA 1999;281:327-334. 34. Guide to Physical Therapist Practice. 2nd Ed. Phys Ther 2001;81:471-593. 35. Goodman CC, Snyder TEK. Differential Diagnosis in Physical TI1f'rapy 3n1 Ed. Philadelphia: WB Saunders Company, 2000. 36. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 6th Ed. Philadelphia: Uppincott Williams & Wilkins, 2000. 37. Amelican Association of Cardiovascular and Pulmonary Re­ habilitation. Guidellines for cardiac rehabilitation and sec­ ondary prevention programs. 3rd Ed, Champaign, IL: Hu­ man Kinetics, ] 999. 38. Ebbeling CB, Ward A, Puleo EM, et al. Development of a single-stage submaximal treadmill walking test. Med Sci Sports Exerc 1991;2:3:966-973, 39. Maud PJ, Foster C. Physiologica,l Assessment of Human Fit­ ness. Champaign, IL: Human Kinetics, 1995.

pr

40. McArdle WD, Katch FI, Pechar GS, et al. Reliability and in­ terrelationships between maximal oxygen intake, physical work capacity and step-test scores in college women, VIed Sci Sports Exerc 1972;4:182-186, 41. Kline GM, Porcari JP, Hintermeister R, etal, Estimation of V0 2ma\ from a one-mile track walk, gender, age, and body weight. Med Sci Sports Exerc 1987;19:2,53-259. 42. Borg G. Borg's Perceived Exertion and Pain Scales. Cham­ paign, IL: Human Kinetics, 1998. 43. American College of Sports Medicine, The recommended quantity and quality of exercise for developing and maintain­ ing cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 1990;22:265-274. 44. McArdle WD, Katch FI, Katch VL. Exercise PhYSiology: En­ ergy, Nutrition and Human Performance. 3rd Ed. Philadel­ phia: Lea & Febiger, 1991, 45. Lehmann M, Foster C, Keul J. Overtraining in endurance athletes: a brief review, Med Sci Sports Exerc 1993;25:854­ 862. 46. Dishman RK. Exercise Adherence. Champaign, IL: Human Kinetics, 1988, 47. Franklin BA. Program factors that influence exercise adher­ ence: practical adherence skills for the clinical staff. In: Dish­ man RK, ed. Exercise Adherence. Champaign, IL: Human Kinetics, 1988, 48, Marcus BH, Banspach SW, Lefebvre RC, et al. Using the stages of change model to increase the adoption of physical activity among community participants, Am J Health Promot 1992;6:424-429. 49. Bean JF, Kiely DK, Leveille SG, et al. The 6-minute walk test in mobility-limited elders: what is being measured? J Geron­ tol A Bioi Sci Med Sci 2002;57:M751-M756. 50, Lord SR, Menz HB. Physiologic, psychologiC, and health pre­ dictors of 6-minute walk performance in older people, Arch Phys Med RehabiI2002;83:907-911. 51. Hamilton DM, Haennel RG, Validity and reliability of bhe 6­ minute walk test in a cardiac rehabilitation population. J Car­ diopulm RchabiI2000;20:156-164. 52. Pollock ML, Lowenthal DT, Graves JK et al. The elderly and endurance training. In: Shephard RJ, Astrand PO, eels. Endurance in Sport. Boston: Blackwell Scientific, 1992.

chapter 7

Impaired Joint Mobility and Range of Motion LORI THEIN BRODY

Morphology and Physiology of Normal Mobility Causes and Effects of Decreased Mobility Effects on Muscle

Effects on Tendon

Effects on Ligaments and Insertion Sites

Effects on Articular Cartilage

Effects on Bone

Effects of Remobilization Effects on Muscle

Effects on Tendon

Effects on Ligaments and Insertion Sites

Effects on Articular Cartilage

Effects on Bone

Mobility Examination and Evaluation -herapeutic Intervention for Decreased Mobility Elements of the Movement System

Activities to Increase Mobility

Exercise Dosage

Precautions and Contra indications

Causes and Effects of Hypermobility Therapeutic Exercise Intervention for Hypermobility Elements of the Movement System

Stabilization Exercises

Exercise Dosage

Precautions and Contra indications

lifespan Issues djunctive Agents Superficial Heat

Deep Heat

lost patients with orthopaedic conditions need mobility ti\'ities during the rehabilitation program. The clinician ust provide hands-on rehabilitation techniques and in­ ':ructions for a home exercise program. The execution of obility activities is not as difficult as choosing the appro­ riate level of assistance and ensuring that the patient is rforming the exercise with the correct level of assistance. ear instruction and supervised practice in the clinician's re ence can prevent misunderstandings about exercise -.erformance. Ylobility exercises may be initiated early in the rehahili­ tion program and done throughout the rehabilitation pro­

gram on a maintenance basis. Some individuals need pro­ gressive mobility exercises throughout the rehabilitation course, progressing from passive to active assisted to active range of motion (ROM). The choice of mobility activities depends on the stage of healing, length of immobilization, number and kind of tissues affected , and the specihc injury or surgery. Understauding of the effects of decreased mo­ bility and remobilization is the key to making appropriate mobility exercise choices. The clinician also must realize that immobilization is relative; it can be externally imposed by a brace or cast, or the patient may "self-immobilize" by discontinuing the Ilse of the limb . When consid ring mobility, the terms arthmkinematic and osteokinematic motion must be differentiated. Arthrokinematic motion refers to movements of the joint surfaces. Roll, spin, and glide are terms used to describe arthrokinematic motion. Arthrokinematic motion is a nec­ essary component of osteokinematic motion that refers to movement of the bones. Osteokinematic motion is de­ scribed in terms of planes (e.g., elevation in the sagittal plane) or relative movements (e.g., flexion, abduction). Mobility can be impaired by alterations in arthrokinematic motion, osteokinematic motion, or both. Although decreased mobility is the most obvious mobil­ ity impairment encountered, the concept of mobility is rel­ ative, with the degree of mobility occurring along a contin­ uum. That continuum encompasses hypomobility, or decreased mobility, and hyperrnobility, or excessive mobil­ ity. Hypermobility should not be confused 'with instability. Instability is an excessive range of osteokinematic or arthrokinematic movement for which there is no protective muscular contro!.l For example, someone may have exces­ sive arthrokinematic antelior, postelior, and inferior glide at the shoulder (j.e., hypermobility) that is asymptomatic. Loss of dynamic muscular control at the shoulder produces instability and symptoms . At the hypomobility end of the continuum, the con­ cepts of con tracture and adaptive shortening are impor­ tant for understanding hypomobility. A contracture is a condition of fixed high resistance to passive stretch of a tissue ['t~su lting from fllbrosis or shortf'l1ing of the soft tis­ sues around a joint or of the muscles. 2 Contractures occur after injury, surgery, or immobilization and are the result of the re modeling of dense connective tissue. Imm obi­ lization of a tissue in a shortened position results in adap­ tive shortening, which is shortening of the tissue relative to its normal resting length. Adaptive shortening also can result from holding a limb in a posture that shortens the tissues on one side of the jOint. For example, protracting 113

114

Therapeutic Exercise: Moving Toward Function

the shoulders in a rounded posture results in adaptive shortening of the pectoral muscles. This shortening can be accompanied by stiffness, or a resistance to passive movement. Somewhere between the ideas of hyper mobility and hy­ pomobility lies the concept of relative flexibility. Relative flexibility considers the comparative mobility at adjacent joints. Movement in the human body takes the path ofleast resistance . If one segment of the spine is hypo mobile be­ cause of injury or disease , the segment is stiffer and has more resistance to movement than adjacent joints. ""hen fle xion , extension , or rotation is necessary, the adjacent joints produce most of the movement because of the resis­ tance to motion at the hypomobik joint. Likewise, stiffness in the halllstrings is often compensated by lumbar spine motion , placing more load on the spine. Lengthening the hamstrings minimizes the stress placed on the spine and is the basis for hams tring stretching, an approach used by some persons to remedy back pain. Relative flexibility is not aJways an impairment. For ex­ ample, because of its biomechanicaJ and anatomic proper­ ties , L5 is more adapted to produce rotation than any other lumbar segment. It is relatively J1wre flexihle in the direc­ tion of rotation . This is a clinical problem (i.e., impairment) only if the motion becomes excessive and is not muscularly controlled. This problem may occur because of relative stiffness at other spinal segments (above or below L5) or at the hips. For example, golfing requires a Significant amount of total body rotation. If the hips, knees, and feet are relatively more stiff in rotation than the spine, the dis­ crepancy may impose excessive rotation in the spine. If the thoracic spine or upper lumbar segments are stiff in rota­ tion, the difference may impose excessive rotation on the L5 segment. L5 is the site of relative flexibility in the di­ rection of rotation .

MORPHOLOGY AND PHYSIOLOGY OF NORMAL MOBILITY Normal mobility, in its broadest definition, includes os­ teokinematic motion (movement of bones ), arthrokine­ matic motion (moveme nt of joint surfaces ), and neuromus­ cular coordination to achieve purposeful movement. Normal mobility requires adequate tissue length to allow flll1 ROM (i.e., passive mobility) and the neuromuscular skill to accomplish movement (i.e., active mobility). Structures involved in passive mobility include the joint's articular surfaces and interposed tissues (e.g., ml'nisci, labrum , synovial lining), jOint capsule, ligaments and tendons (including insertions sites), muscles, bursae, fascia, and skill. Toints must have normal arthrokinematic motion, or the ability of an articular surface to roll , spin, and glide across another. The ability to accomplish active mobility reqUires an intact, functioning nervous system in addition to the structures necessary to allow passive mobil­ ity. Mobility is maintained in most individuals by routine, daily use of their limbs and jOints in normal daily activities. However , adaptive shortening can occur in those who spend long periods in single postures (e.g., sitting most of the day), and mobility can be lost.

Normal mobility includes adequate joint ROM and mus­ cle ROM. JOint ROM is the quantity of motion available at a joint or series of jOints in the case of the spine. In contrast, muscle ROM is the functional excursion of the muscle from its fully lengthened position to its fully shortened position. Examination and treatment techniques for joint ROM im­ pairments and muscle ROM impairments differ. JOint ROM impairments are examined using accessory or "joint play" motions (arthrokinematic motions ) and are treated with joint mobilization, whereas muscle or other soft-tissue ROM impairments are examined using flexibility tests and treated with ROM or stretching exercises.

CAUSES AND EFFECTS OF DECREASED MOBILITY Individuals can lose mobility at a joint for several reasons. Trauma to soft tissue, bone, or other joint structures can di­ minish mobility. Operations such as total jOint replace­ ments, reconstructions, debridements, arthroplasties, os­ teotomies, and tendon transfers can reduce mobility, as can surgery for nonorthopaedic conditions. Mastectomy or other chest procedures may result in shoulder immobility, and bed rest after cardiac, gynecolOgiC, or other surgical procedures may result in immobility in many jOints. Joint disease such as osteoarthritis or rheumatoid arthritis and prolonged immobilization or bed rest for any reason fre­ quently produce immobility. The inability to move a joint because of neuromuscular disease or pain can also result in mobility loss , and pain that inhibits movement can signifi­ cantly alter 1110bihty. Immobility at a joint produces a self-perpetuating cycle that can be interrupted by several physical therapy inter­ ventions, including ROM modalities, resistive exercises, or mobilizations. ProgreSSive adaptive shortening of the soft tissues occurs as the body responds to decreased loading. This shortening limits mobility and function, redUCing the patient's ability to carry out normal activities of daily living, work, or leisure activities. The patient accommodates these limitations by substituting other joints or limbs to achieve functional goals, thereby contributing to the disuse. Pain results from disuse and progreSSive shortening of the joint capsule (a highly pain-sensitive structure) , adding to the disuse. Weakness ensues because of changes in the length­ tension ratios, furthering the patient's disinclination to use the limb. Decreased mobility has profound effects on bone and soft tissues, reflecting the body's ability to adapt to various levels of loading. The plastic nature of these tissues works in positive and negative ways. The specific adaptations to imposed demands principle is based on Wolff's Law and as­ serts that tissu es remodel in accordance to the stresses placed on them. Th e effects of overload, or tissue load greater than its normal usage , and its resulting hypertro­ phy, the enlargement of a tissue because of an increase in the size of its constituent cells, are well known , but the find­ ings associated with underloading are less well kno\llm . Findings such as muscular atrophy, or wasting away of a tis­ sue, and loss of jOint motion are evident, but cellular changes, articular cartilage changes, and weakening of liga­

Chapter 7: Impaired Joint Mobility and Range of Motion

t t

ments and their insertions are less obvious alterations. The clinician must prevent these effects when possible and con­ sider them when implementing a rehabilitation program. The following sections review the consequences of im­ mobilization or decreased mobility on various tissues. Gen­ erally, the effects reviewed are caused by immobilization of healthy, uninjured tissues (this is how most studies are done ). This raises two important issues. First, immobiliza­ tion usually is initiated in the presence of an injury (although tissue-lengthening procedures are exceptions), and the structural and mechanical properties of the injured tissues probably will be further compromised. The stages of healing can be found in Chapter 11 and should be considered in concert with the immobilization issues. Second, it is tempt­ ing to focus only on the injured tissue after immobilization. However, all surrounding tissues also are immobilized, and understanding the immobilization effects on these tissues ensures a safe and effective rehabilitation course.

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The atrophying effects of immobilization on muscle have been well documented . These effects are time-, muscle composition-, and position-specific. The longer the immo­ bilization, the greater is the atrophy, "vith significant struc­ tural and functional properties deteriorating during the first week. 3 ,4 The functional loss is greater than the loss of muscle mass or circumference, probably because of addi­ tional neurologic inactivity. Studies of electromyographic activity after immobilization demonstrate a decrease in electrical activity that is disproportionate to the amount of atrophy.s-7 Circumferential measures do not reflect the fu nctional loss; quadriceps changes after 6 weeks of immo­ bilization include a 30% to 40% strength loss , a 20% to 30% cross-sectional area decrease, and a thigh circumference loss of 10% to 20%3,4,8,9 (Fig. 7-1 ). Along with muscle fiber atrophy, a concurrent increase in connective tissue occurs that may confound circumferential measureslO Moreover, immobility results in a greater depOSition of subcutaneous fat, and circumferential measures provide no information bou t the composition of the underlying tissue.

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115

Muscle composition affects the degree of atrophy, Mus­ cles composed primarily of slow-twitch fibers atrophy to a greater extent than muscles composed primarily of fast­ twitch fibers 7 ,1l This difference may reflect the use pat­ tern , with the higher-use slow-twitch fibers showing a greater relative decrease. Lieber suggests the most impor­ tant factors in atrophy from decreased use to be the degr e of immobilization (Le., number of joints crossed), followe d by the degree of change relative to normal function ,] l For example, calf muscle atrophy is greater when the ankle and knee are immobilized. Atrophy is greater in the soleus (static postural muscle) than the gastrocnemius (relatively lower-use muscle). The position of immobilization Significantly affects the structural and mechanical properties of muscles. Muscles may be immobilized in a shortened position after injury or surgical repair, as for an Achilles tendon rupture or a rota­ tor cuff tear. Long-term immobilization in a shortened po­ sition results in changes in sarcomere length and number as the body attempts to restore the original sarcomere length. 12 Immobilization results in a net loss of sarc:omeres, although the remaining sarcomeres are longer. Th e muscle is stiffer, and less energy is absorbed before faih1[e. A shift to the left in the length-tension ratio occurs. Muscles may also be immobilized in a lengthened pOSition, as in serial casting done to lengthen the muscle. This results in an in­ crease in the number of sarcomeres, "'li th less atrophy oc­ cuning than "vith immobilization in the shortened position. The elastic and connective tissue are reorganized such that the muscle adap ts to its new immobilization length 1 2 . 11 The length-tension ratio shifts to the right with immobi­ lization in a lengthened position. The sarcomere changes associated with immobilization take place at the myotendi­ nous junction.

Effects on Tendon Immobilization of any collagenous tissu e has signiflcant ef­ fects on that tissue , even in the absence of direct injury. Im­ mobilization-related decreases in the size and number of collagen fiber bundles reduce the load tolerance. D e­ creased water content , decreased total glycosaminoglycans, and increased synthesis (i.e., production of a chemical compound) and degradation (i,e., breakdown to a less com­ plex compound ) of collagen are coupled with profound dis­ organization of flber orientation. 14 The metabolic turnover in tendon is much lower than in muscle, and the tendon is more refractory to immobiliza­ tion-induced changes. However, the tensile strength, elas­ tic sti ffness, and total tissue weight aU decrease with im­ mobilization. 3 The collagen fib ers become thinner and less organized, and cross-li~ks are reduced 3 ,14 Enwemeka 15 studied the effects of various tim es and positions of cast im­ mobilization on rabbit Achilles tendons. Limbs were im­ mobilized 3 to 8 weeks. Two groups of limbs were placed first in a shOitened position and then in a lengthened posi­ tion for 2 or 4 weeks of the immobilization peliod. Results demonstrated progressive, profoundly disorganized colla­ gen fibrils, with some sections totally devoid of collagen. By week 8, the cross-sectional area and collagen fibril diame­ ter of im mobilized tendons decreased by -50%. In the Cwo

116

Therapeutic Exercise: Moving Toward Function

groups that were subsequently immobilized in a length­ ened positioll, a reversal in this progressive decline was ob­ served aFter 2 weeks. However, this same reversal was not Foulld in the group immobilized in a lengthened position For 4 wccks , suggesting the benefits of the lengthening were negated by or adapted to by the additional immobi­ lization time.

Effects on Ligament and Insertion Sites As with other primarily collagenous tissues, ligament tissue responds to immobilization at a slower rate than tissues with higher metabolic activity. The total collagen mass decreases in a time-dependent manner, with a concomitant decrease ill the ligament's mechanical properties. The ligament's strength and stiFFness decrease, and the joint's stiffness in­ creases.l(i This difference probably results from adhesion and pannus formation and from decreased lubrication in the joint 17 Ligaments devoid of stress Jemonstrate shortening, as measured by a decrease in the distance betw!.'cn sutures placed in the ligament 18 The shortening may be an active process; shortening has been inhibited by electrical poten­ tials Simulating mechanicalloadillg. The effects 0]' immobilization and remobilization on the medial collateral ligament (MCL) have been studied ex­ tensively. In a classic study, Laros et al. 19 found a signifi­ cant loss of ligament strength in dogs after as little as 6 weeks ' immobilization. Woo et al. 20 compared the effects of surgical repair of the MCL followed by 6 weeks of im­ mobilization with the effects of no repair and no immobi­ lization at 6, 1.2, and 48 weeks postoperatively. At 6 weeks, the varus-valgus instability was similar in the two groups, but by ]2 weeks and at 48 weeks, the varus-valgus laxity in the nonrepaired and nonimmobilized group was similar to normal subJects. The tensile properties of thi s group were also superior to the repaired and immobilized group at all interva.ls. The mechanical and structural properties of the repaired and immobilized group remained lovver than con­ trols and lower than the nonrepaired and nonimmobilized group even at 48 weeks, high.lightil~g the long-ten'.l nega­ tive effects of this treatment. Noves-'t studied the effects of an A-week immobilization on ;nterior cruciate ligament (ACL) complex failure in primates, finding a 39% decrease in complex load to failure. The extent of immobilization-induced weakness ap­ pears to be time-uependent in a nonJinear fashion . De­ creases in \ICL collagen mass accelerated when immobi­ lization was extended from 9 weeks to 12 weeks. 16 ,22 Decreased mass is a result of collagen degradation exceed­ ing collagen syntheSiS. Moreover, this pattern produces a disproportionate quantity of young, immature collagen laid dov-'Il in a random , disorganized fashion. The clinician must consider these changes when a joint is immobilized for any reason , Gentle loading, even duling t.l1e immobilization pe­ riod , can minimize or negate these changes, As with other soft tissues, loading is necessary to main­ tain the integrity of the insertion sites. Loading can include jOint motion, muscular action, or weight bearing, providing the clinician with numerous options to maintain the health of this tissue. Because it is more metabolically active than the ligament or tendon, the inSf'liion site can be expected

to demonstrate greater changes. The ligament-bone inse r­ tion site uemonstrates bony resorption and subsequent weakening from immo'bilization, z3 Noyes et al 24 studied failure rates of the 'bone·ACL unit failure in monkeys after 8 weeks of immobilization, finding an increased <1\1111sion rate companod with control values. The researchers thought a loss of cortex at the attachment site was the mechanism offailure. Woo et al.i'S added to these data, sug­ gesting that immobilization has a greater impact on indi­ rect inseliion sites (i.e., soft-tissue junction with bone is more gradual and diffuse ) than on direct insertion sites. Subperiosteal resorption of bone accounted for the in­ creased a\l111sion rate of the femur-MeL-tibia complexes, suggesting that the bone is the weakest portion of the in­ sertion site.

Effects on Articular Cartilage The harmful effects of immobilization on atiicular cartilage must be considered by the clinician rehabilitating individu­ als after injury or surgery. Articular cmiilage requires load­ ing to maintain its integrity. Decreased loading and motion leaus to degeneration of the articular surface. Immobiliza­ tion results in increased water content and decreased pro­ teoglycans and alters the proteoglycan organization. These changes precede softening and fragmentation of the chon­ dral surfaces, Decreaseu proteoglycans (i. e. , glycoprotein­ binding materials) may result from increased degradation or decreased syuthesis. 26 Subsequent decreases in cartilage stiffness and thickness may make the caliilage more \l11lner­ ahle to injury. As with a partially torn ligament, loss of ma­ trix proteoglycans places an increased load on the remain­ ing tissue. Progressive deterioration occurs with chondrocyte (i.e., mature caliilage cell) loss, collagen fiber splitting, and fibrillation and with subchondral bone sclero­ sis 3 ,4 If immobility continues, bony proliferation results in osteophyte formation. The position of the joint during im­ mobilization also affects the degeneration seen, Knee im­ mobilization in full extensjon results in irreversible, pro­ gressive osteoarthritic jOint changes because of the compressive forces betwee n articular surfaces. 26--28 These changes are thought to result from the articular hypoxia from uecreased synOvial fl uid, increased compression of the aliicular surfaces, and increased intra-articular pressure.2~J Studies of cartilage changes after immobilization in dogs produced decreases in glycosaminogly<:an concentrations, cartilage thickness, uronic acid content, and proteoglycan synthesis,30 The type of fixation affects t.l1e stimulus to the articular cartilage. Comparisons of rigid immobilization with external fixation to long leg casting (permitting 8 to 15 degrees of motion) demonstrated more severe proteogly­ can loss and prolonged recovery in the joints with rigid fJ.;x­ ation. 31 Decreased weight bearing, even in the presence of normal joint motion, appears to be harmful to the articular cartilage. 32 ,33

Effects on Bone Immobilization leads to profound changes in bone, which, unchecked , can lead to osteoporosis (i.e., a'bnormal decreased denSity of the 'bone). Bone resorption (i. e.. loss

Chapter 7 Impai red Joint Mobility and Range of Motion

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of substance) occurs in the early phases, with a decrease in bone mass relative to volume. Bone mineral loss may be as high as 8% per month while on bed rest. 3 ,4 The total loss is accounted for by approximately a 30% increase in resorp­ tion and a 70% decrease in formation. 34 The decreases are most dramatic in the first 6 weeks, followed by a slowin,~ until equilibrium is reached, usually after 5 to 6 months. " In trabecular bone, the volumes of haversian canals and re­ sorption areas increase, but the trabecular bone volume de­ creases. 35 Trabecular bone appears to be more sensitive to loading changes because of its rapid remodeling. 36 In cor­ tical bone, the bone loss occurs more slowly, but over time, it contributes si~nificantl)' to the fragility associated with immobilization. ,4,35 Subchondral bone changes are also seen with immobilization, but they appear to be related to alterations in overlying articular caliilage rather than the cancellous bone.37 Bone loss depends on the location , normal use patterns, bone composition, and prior status of the bone. Greater loss occurs in weight-bearing bones than in upper extrem­ ity bones. For example, bone loss may appear only after 8 months in individuals \vith upper extremity paralysis.)9 Be­ cause of the high turnover rate in children, the effects of immobilization are more profound. The various mechanical stresses contributing to bone health must be considered in rehabilitation. Bone loss from immobilization must be differentiated from bone loss caused by weight-bearing limitations. Complete bed rest \·\lith immobilization or immobilization combined with weight -bearing restrictions has the greatest impact on bone health. 3,s Weight bearing and muscular contraction are the two mechanical forces responSible for bone de velop­ ment. 36 Space flight studies of bone loss emphasize the im­ portance of gravity and weight bearing on bone health 36 .:39 Studies of individuals immobilized ,vith poliomyelitis , mus­ cular dystrophy, and paraplegia have demonstrated rates of bone loss approaching 1O/C per week. 33 Muscular pull on the bone can produce a mec:hanicalload to stimulate os­ teoblast activity. Osteoblast calls are associated with the production of bone. Bone denSity studies of handicapped, nonambulatory children have demonstrated a 30% deficit in bone denSity compared \vith age -matched controls 40

117

10 weeks, followed by a 4-week remobilization period during which normal activity was permitted. At 4 weeks, a 30% deficit in slow- and fast-twitch muscle fibers re­ mained (Fig. 7-2). Although the atrophy resulting from immobilization was muscle- and fiber-sp ecific, the recov­ ery was not. The increased extracellular connective tissue seen after immobilization had returned to normal levels after remobilization suggests a decrease in stiffness. The mechanism for fiber regeneration is unclear, although ev­ idence su~~ests satellite cell activation and myotube formation . ' ,7

Effects on Tendon Few studies have looked at the effects of remobilization on uninjured, immobilized tendon, but maGY researchers have examined the results of remobilization after tendon injury with or without repair. Karpakka et alY found that remo­ bilization of rat tendon resulted in acceleration of collagen synthesis. Enweme ka l 3 .42 studied the remobilization of healing tendon after surgical repair. Limited mechanical stress such as passive mobilization promotes the normal gliding and soft-tissue relationships necessary for optimal healing after tendon repair. In a study of Achilles tenotomy in rabbits, the immobilization was removed at 5 days post­ operatively, and the tendons were examined at 12, 18, or 21 days postoperatively. I S Early remobilization was found to Significantly improve the tendon 's tensile strength and en3000

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Effects on Muscle .vI uscular strength deficits after immobiJization often re­ quire long and tedious rehabilitation for full recovery. H owever, remobilization studies are lacking, as is a con­ ensus on the parameters for rehabilitation and return to ac:tivity. Factors affecting the rate and end pOint of recov­ ery include predom~nantly the position and time of im­ mobilization. Lieber ' immobilized canine quadriceps for

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remobilized dog quadriceps muscles. The magnitude of muscle atrophy was muscle-type specific. (8) Graph of slow fiber area from control and im­ mobilized dog quadriceps muscles. (From Lieber RL. Skeletal Muscle Struc­ ture and Function. Baltimore Williams & Wilkins, 1992219)

118

Therapeutic Exercise: Moving Toward Function

ergy absorption capacity over those of immobilized con­ trols at days 12 and 18, and increases in mean cross-sec­ tional are,; were found at 12 and 21 days. No rerupture was evident, and no differences in tensile strength and energy absorption capacity were found at 21 days postoperatively. The investigator concluded that, despite no cLfferen ces be­ tween the two groups at 21 days , the morbicLty associated with immobilization counterbalances the possibility of rerupture . The effects of remobilization after flexor tendon repair have been systematically studied. Tendons receiving early protected mobilization after repair did not form significant adhesions, nor was there Significant repair site de[orma­ tion. 4345 The mechanism for improved healing was pro­ posed to be a cell ular re sponse from the tendon and epitenon resulting from the mechanical motion. T he load at failure of immediately mobilized tendons tested at 3 weeks was found to be twi.ce that of the immobilized ten­ dons. Early mobilization of tendon repairs appears to result in a strong repair without excessive scar formation. The precise parameters for immobilization and remobilization are unknown 46

hone-ligament complex remained inferior, with failures continuing to occur at the insertion site. T he results of these studies and others suggest that changes at the inser­ tion site that occur because of immobilization are re­ versible with remobilization 19.21.23.4, The length of remo­ biU zation relative to the length of immobilization necessary to restore th e original strength levels at the insertion re­ mains undefined. Any lengthy immobilization (6 weeks or longer ) appears to require remobilization periods of 4 months or longer to restore the mechanical and structural properties of th e tissues. Tissue immobili7.ed for shorter periods probably requires less time to return to preimmo­ bilization levels. Although the effects of immobilization and the benefits of early remobilization are indisputable, clinicians and re­ searchers are beginn ing to identify a subgroup of patients who may need to be protected longer. The healing rate and quality of tissue vary along a continuum from stiffness and arthrofibrosis to hyperelasticity. Those presenting with stiffness and decreased motion should be mobilized early, and those with hyperelasticity and hypermobility should be protected longer.

Effects on Ligament and Insertion Sites

Effects on Articular Cartilage

Rcm obilization can restore the mechanical and structural properties ofliga1l1ent tissues , although the time needpd for this reparation has not beell established. Because of its low metabolic activity, th e re1l10hilization period necess ary to restore mechanical properties of the ligament substance generally exceeds the immobilization period. Although the extern al measures after immobiJization may indicate recov­ ery, restoration of the ligament complex mechanical prop­ erties lags behind our measurement ahility. Clinical exami­ nation procedures such as ligament laxity testing, instahility testing, and palpation are unlikely to detect residual weak­ ness after immobilization or during the remobilization period. An understanding of the recovery process at the cel­ lular level must gUide the rehabilitation program. Studies of ACL immobilization have found valiable re­ sults regarding remobilization periods. Larson et al. 23 found that 6 weeks of svvimming retraining was needed to restore the separation force and elastic stiffness of the ACL after 4 weeks of immobilization. In contrast, 5 months of reconditioning did not fully restore the ACL failure load af­ ter 8 weeks of immobilization. 21 The site of failure re­ tumed to control values, with evidence of bone formation at the insertion site. Continued conditioning for 1 year af­ ter th e immobilization period still left the failure load at 91fc; less than that of controls. Similar results were observed for energy absorbed to failure. 2 1 Inseliion sites of ligament and tendon into bone and the myotendinous junctio~ respond favorably to loading after immobilization. 23.21.4 1 The b021P-liga lllent complex be­ comes stronger with exercise .'J, Re mobilization after im­ mobili zation appears to restore the properties of the inser­ tion site and the ligament substance itself at different rates. 2H9 This finding is supported by the study of Woo et al.,47 who found a rehml of the mechani cal propelties of the MCL with 9 weeks of remobilization after 9 weeks of immobilization. However, the structural properties of th e

Remobilization and prevention of immobilization­ associated cit'generation can pwnmt degradation of articu­ lar caltilnge and progression to osteoarthritis. The response to remobilization depends on the length of im mohilization, the associated injury or pathology, the status of the articu­ lar cartilage before immobilization, available jOint motion, and load distribution . Activity that is too vigorous can harm the joint surface. Activities that maintain loads within the optimal loading zone should he chosen. Signs of overload include pain, swelling, warmth , and tenderness. Osteoarthritic changes th at occur as the result of joint immobilization have poor reparative eapabilities. Immobi­ lization for more than 4 weeks probably results in irre­ versible changes in the articular cartilage, even 'with remo­ bilization. 12 Articular cartilage changes and connective tissue adhesions after immobilization often persist despite remobilization periods of equal or longer duration. 37 How­ ever, these changes may not progress in the presence of ap­ propriate remobilization techniques (Le., avoiding over­ load ), joint stability, equitable load distribution, and freedom of motion .49 Persons with inadequate joint stahil­ ity may continue to overload their articular cartilage through excessive shearing forces , and those with in­ e(luities in load distribution (i .e., varus knee ) may overload one compartment and unclerload the other. Both situations can lead to progressive osteoarthritic changes. Th e individ­ ual who lacks full joint motion after immobilization in­ creases loads on the alticular cmiilage within his or her lim­ ited range. RestOling full active ROM after immobilization is critical for optimizing joint healtll.

Effects on Bone The rate of bone's response to remobilization exceeds that of most other biologiC tissues. As with other tissues, the re­ sponse is related to the metabolic activity of the tissue, and

Chapter 7 Impaired Joint Mobi lity and Range of Motion

T

d d h

;'ounger persons have greater response rates, probably be­ cause of the high rate of bone turnover. 3 ,.J. Although bone may return to normal at a faster rate than soft tissues, the effects of immobilization usuaUy are more profound in bone, In contrast to other tissues, bone changes resulting from immobilizatiun may not be reversible with remobi­ lization,12,3G, Studies of the os calcis of Skylab crew me m­ bers found decreased bone mineral content 5 years after the flights. :l8 Immobilization periods longer than 12 weeks are likely to result in permanent changes, with the recovery pe riud xceeding the immobilization period many times over.32 ,36,50 The outcome of remobilization depends on the bone quality before immobilization and on the immobilization period, Restoration of the mechanical forces on bone (i.e., gravity and muscular stress and strain) reverses bone loss. n resumption of weight bearing, trabecular bone in­ creases at about 1% per month and mayor may not return to its preimmobilization statusY

MOBILITY EXAMINATION AND EVALUATION

I­

I­

ot:"

1_

I­ I_

11

Ie

td

It i­

P rform a thorough examination before chOOSing a physi­ cal therapy intervention. This ensures appropriate indica­ tions and goal setting for the speCific mobility technique chosen. 1vloreover, the evaluation , including subjective ex­ amination and history takin g, informs decisions about exer­ cise dosage, activity type, and elements of the movement vstem specific to the individual. The concepts of joint ROM and muscle ROM were clar­ ifIed earlier. Examination procedures must identify the ource of decreased mobility to effectively direct the treat­ ment. Joint ROM is usually measured in the cardinal planes with a goniometer. Goniometric measurem ents are per­ formed actively or passively, although the reliability of measurement i~ greater for active measures than for pas­ ive measures.~l Isolated motions such as elbow flexion , .

knee extension, and ankle dorsifleAion are most commonly measured, Functional goniometric measurements with less stabilization and control can also be taken. Goniometric measurement of fOlward reach is a common function al as­ sessment. Standards for normal goniometric mobility at each joint are publ,i shed and provide a guidelin for assess­ ing mobility. When assessing joint R01vl, the clin ician must ensure proper patient positioning to avoid apparent joint motion limitabions caused by poor muscle ext nsibility. or example, hip joint fleAion ROM shonkl he performed with the knee flexed to prevent limitations from hamstring ex­ cursion (Fig. 7-3). Assessment of joint ROM with a goniometer does not identify the cause of limited motion. Joint ROM can be limited by capsular tightn ess , extrinsic soft-issue tightness , intrinsic joint blockage (i,e., knee meniscus tear blocking motion) or pain. Selective tissue tension testing assists the clinician in iden tifying the tissue at fault. Loss of joint mo­ tion in a capsular pattern or "vith a capsular end feel su ­ gests that the joint capsule is the tissue at fault , and the treatment focus is joint mobilization. However, tIle clini­ cian should remember that end-feel assessment is not a highly reliable measurement and that the pattern of capsu­ lar limitation does not always exist.·;2 Limitations in arthrokinematic motion decrease a pa­ tient's mobility, and increases in arthrokinematic mohil'ity cause hypennobility. Artbrokinernatic mobility is assessed through joint play maneuvers. JOint play is the mOVen1PIlt of one aliicular surface on another and is not usually under voluntary control. JOint play is assessed by stabilizing one aliicular surface (by stabiliZing the bone) am1 applying ex­ ternal pressure on the other to produce Illovement. For ex­ ample, applying an anteroposterior glide at the proximal in­ terphalangeal joint of the index finger [('(Illires stabilization of the proximal phalanx while the distal phalanx is moved in an anteroposterior direction. In some cases, stabilization of one segment is prOvided by the surrounding bony and soft­ tissue structures and the suppoliing surface. For example, when pelforming posteroanterior unilateral vertebral pres-

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tl­ n­

o­ n

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FIGURE 7·3.

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11 9

(A) Joint range of moti on at the hi p. The knee is flexed to minimize effects of hamstring tension . (8) Muscle rang e of motion for the hamstrings. The same hip flexion activity is done with the knee extended .

120

Therapeutic Exercise Moving Toward Functi on

Elements of the Movement System

FIGURE 1-4. Assessment of ha mstring flexibility goniometricaliy using the 90-90 straight-leg raise. The hip is flexed to 90 degrees, and the kn ee gradually extended from flexio n to extension. The final ang le of knee flex­ ion is measured.

sure , the patient is stabilize d in a prone position on the table while unilate ral postcroantcorior pressure is applied to the transverse process, producing rotation of the vertebral body that should be compared "vith th e contralatnal side'.l Assessme nt of joint play can identify hypomohil e , normal, or hypermobile conditions. T hese tests direct intervention for increasing capsular mob ility, looking for oth er sourct'S of mobility loss , or stabilization activities, respectively. Unidirectional loss of motion suggests some other soft tissue (muscle-tendon un it, skin, fascia, neurologic tissue ) is at fault , and other RO M techniques may be e mployed. Muscle HOM is generally assessed using flexibility tests, a few of which are quantified. F or example. hamstring ex­ tensihility can be assessed ~oniom e trically usin g th e 90-90 straight-leg raise (Fig. 7-4). The T homas te st for Jlip flexor extcnsibility and the BUlln el-Little r test for hand intrillsic or joint capsul e exte nsibiLty are examples of flexibility tests . These tests, when p erformed correctly, can direct in­ terve ntion for decreased musculote ndinous exte nsibility as the cause of decreased mobility.

THERAPEUTIC INTERVENTION FOR DECREASED MOBILITY A variety of interve ntions are available to treat decre ase d mohility, After th e tissues limiting mohility have been iden­ tified , appropriate HO\-I , stretching, or joint mobiliz.ation techniques should be applied. Adjullctive agents e nh ance the dfectiVC'ness of exercise interventions.

Although any of the ele ments of the movement system may contribute to decreased mobility, most problems with mo­ bility aris e from base elements , or the extensibility and mo­ bility of the soft tissues. For example, 10SS of normal hip ex­ te nsio n RO M may contribute to low back pain by tran sfe ning the extension mobility requirement from the hip to th e low back (j.e., relative flexibility). In this case, de­ creased mobility (i.e. , impairment) in the hip contributes to low b ack pain (i.e ., impairment). The pain arises from com­ pression of the posterior ele ments of the spine and subse­ quent inflammation around the nerve roots (i ,e., pathol­ ogy) and an inability to sit for long periods (j.e. , functional limitati on), If left untre ated, this condition may lead to dis­ ability, such as the inability to work at a desk, partiCipate in recreational activities, or sit in car. In this example, the base elements are the shortened hip flexors and hip jOint capsule pulling the pelvis into anterior tilt and the lengthened and weak abdominal muscles that are unable to provide sufficient counterforce. The biome­ clwllical elem ents are the increased anterior pelvic tilt and ilH.Tl,ased lumbar lordosis contributing to post e rior ele­ lilent compression in the spine. The modulator element is an inahility to rc cmit the abdominal muscles to improve tl1C' hiomechani cal elements, The cognitive or affective el­ e men t is depreSSion related to chronic low back pain. The elements of the movement system involved must be prioritized and those ebnents amenable to physical ther­ apy inte rve ntion determined. In this situation, intervention to increase the length of the hip flexors, decrease stiffness in the hip JOint capsule , and improve the neuromuscular filing and musclllar endurance of the abdominal muscles should be instituted.

Activities to Increase Mobility T he clinician has many opti ons for treating decreased mo­ bUity. JOint mobilization , RO M exercises, and stretching are the more common interventions applied. ROM activi­ ti es or joint mobilization can be used to increase joint RO M, and stretching techniques can be used to H' medy limitations in muscle RO M . JOint mobilization is a tech­ nique that prese rves or increas es arthrokin el1latic motion. It is a necessary prerecluisite for normal osteokinematic mobility. Attemptillg to p erform ROM activities in the ab­ sence of normal arthrokine matic motion at the joint surface does not improve the impaired mobility and may increase' the pati ent's S),lIlpt01l1S. Self-mobilization activitiC's such as lateral distraction at the glenohumeral joint or 10ng-cLXis tnlction at the hip llIay preced e ROM exercises. When applying interventions to increase mobility, the clinician must conside r the continuum of hypomobility to hypermobility and the concept of relative flexibility. Hypo­ mobility call be mistreated if the possibility of adjacent hy­ pemlobility is ignored. For example, if a stiff segment ex­ ists at L4- L5 and treatm e nt is directed at d ecreaSing stiffness the re without stabilizing intelventi ons directed at hype rmobil e segments above amI below, symptoms of in­ stability at these segnl ents may in crease. Treatment must in cl ude a comprehc'llSivc program to improve the mobility

r

Chapter 7 Impaired Joint Mobility and Range of Motion

121

at the relatively more stiff segments or regions and to in­ crease the stiffness at the relatively more mobile segment. Because motion always occurs along the path of least resis­ tance, mobility occurs naturally at the stiff s gment only if it is of equal mobility or more mobile than other segments. It is important to increase the stiffness at the site of relative flexibility. This is done by improving neurolTluscular control, muscle performance capability, and length-tension relationships of the stabilizing muscles around the site of relative flexibility. These techniques are coupled with pa­ tient education , postural training, and movement patterns that improve the distribution of mobility.

Range of Motion Mobility activities at a joint or series of joints and articula­ tions can offset some of the deleterious effects of immobi­ lization. Movement about a joint, whether passive, active assisted, or active, produces a load in the soft tissues. This loading can maintain the integrity of the tendon, ligament and bony attachments, articular cartilage, and muscle. The benefit is determined by the exercise and immobilization parameters and by the status of the tissues before immobi­ lization. Mobility activities are specific exercises or func­ tional activities performed to improve functional ROM about a jOint. Mobility activities usually are pe rformed through a jOint ROM and can be performed in cardinal planes or in multiple planes using functional movement patterns (e.g., reaching, squatting). These activities can be performed actively, paSSively, or \vith active assistance. Passive Range of Motion

Noncontractile tissues potentially limiting passive mo­ bility about a jOint include the joint capsule, periarticular connective tissue, and overlying skin. Surgical incisions prodUCing adhesions between the skin and underlying fas­ cial layers limit their ability to glide during joint motion. hortening, spasm, or contractures of the musculotendi­ nous unit can also limit the passive motion at a joint. Short­ ening of musculotendinous tissue should be differentiated [rom stiffness of the connective tissues. Stiffness in soft tis- ' ues is felt as an increased resistance to movement and can alter movement patterns paSSively and actively, resulting in musculoskeletal pain. Bone-on-bone approximation in the presence of degenerative joint disease, loose bodies, and pain can similarly limit passive mobility. Passive ROM exercises are mobility activities performed \i thout any muscular activation (Fig. 7-5). These exercises .U' performed within the available ROM. Any overpressure .1t the end of the range would be categorized as stretching, ot passive ROM. Passive ROM and stretchi?g can be com­ ined to increase the ROM around a joint.·,3 The exercise :hosen should allow full available excursion. Several modes Me available for the performance of passive ROM or -tretching. Pulleys, continuous passive motion devices, amily members, or various household objects such as the oor, counters, or chairs can be used to perform passive OM. Holding the position at end range adds a stretching ~ mponent to the passive ROM activity. Using pulleys to :a.in shoulder flexion can be helpful if performed properly ithout scapular or spinal substitution patterns (Fig. 7-6). -rhe Sdme can be said for self-mobilization activities such as tching the arm forward on a counter (Fig. 7-7). Passive

AGURE 7-5. Self·range activity for wrist flexion.

knee flexion can be eaSily performed using a towel and a smooth floor , by sitting on a chair, or while in a pool. Passive ROM is used when active movement may dis­ rupt the healing process, when the patient is phYSically or cognitively unable to move actively, or when active move­ ment is too painful to perform. Passive movements also are used to teach active or resistive exercises and to produce relaxation. Goals related to the prescription of passive ROM depend on the patient and the setting. In an or­ thopaediC setting, passive ROM is often used to prevent the deleterious effects of immobilization after an injllly or surgery. Prevention of joint contractu res ancl soft-tissue stiffness or adaptive shortening, maintenance of the normal mobile relationships between soft-tissue layers, decreased pain, and enhancement of vascular_dynamics and synovial diffusion are goals of passive ROM. v3 These goals are diffi­ cult to measure and to document. The clinician must rely on his understanding of the pathologic process to provide the rationale for this intervention. Yl easurable outcomes related to passive RO M as prevention intervention may in­ clude decreased pain , expeditious restoration of motion and strength, and earlier return to function after activity is allowed (see Self-~vlanagement 7-1: Ankle Passive Range of Motion) . vVhen the patient is comatose, paralyzed, on complete bed rest, wheelchair bound, or cognitivel)' unable to main­ tain joint ROM, passive ROM is used to achieve the same goals as the orthopaedic setting. Because of the long-stand­ ing nature of these problems and the profound effects of long-term immobility, prevention assumes even greater importance. The patient usually requires passive ROM ex­ ercise two or more times each day, necessitating provision of services by family members or other assistive personnel. The clinician's skill in performing passive ROM can sig­ nificantly alter the response. The clinician's handling tech­ niques can affect the patient's comfort and ability to relax during treatment. 'When active muscle contraction is con­ traindicated, positioning and handling should allow the pa­ tient to fully relax. Any apprehension could result in pro­

122

Therapeutic Exercise: Moving Toward Function

B

FIGURE 7-6. (A) Incorrect performance of should er flexion using pulleys. (B) Correct performance using proper posture and movement kinematics

tective muscle contraction and possible injury. Proper po­ sitioning allows adequate stabilization while the clinician's hand control provides stabilization and command of the af­ fected limb. The clinician should use a grip that provides control but considers the patient's condition. Avoiding painful areas or excessively tight grips that produce dis­ comfort assures the patient of the clinician's control. ROM should be performed at a smooth and steady pace, avoiding abrupt movements or excessive speed that may cause pro­

A

tective muscle cont raction . The clinician should always monitor the patient's response and be flexible enough to modifY the technique when necessary. The hand position, ROM , and speed must be tailored for each patient. Active Assisted Range of Motion

Active assisted ROM can be defined as mobility activi­ ties in which some muscle activation takes place. In this sit­ uation, the patient is unable or not allowed to fully activate

B

FIGURE 7-7. (A) Incorrect performance of passive shoulde r flexi on on a countertop. (B) Correct performance using proper posture and movement kinematics.

Chapter 7 Impaired Joi nt Mobility and Range of Motion

SELF·MANAGEMENT 7·' Ankle Passive

Range of Motion

Purpo :

To increase ankle motion in all directions

Position:

In a sitting position with the ankle crossed across the knee, with a comfortable grip at the forefoot.

Movement technique:

Move the ankle in upward and downward directions. Move the ankle in and out. Stay in a comfortable range of motion. Hold briefly at the end of the range in each direction.

Dosage Repetitions: _________ Frequency: _________

posed by the disease or injuly, changing le ngth-tension ra­ tios , or synergist action. Active assisted exercise is indicated for patients who are unable to complete the ROM actively because of weakness resulting from trauma, neurologic injury, muscular or neu­ romuscular disease, or pain. The weight of the limb may impede active movement using proper mechanics, and as­ sistance may be prOvided to ensure proper exercise perfor­ mance. Some injuries or operations necessitate limitations in active muscle contraction in the early phase of healing (see Self-Yfanage ment 7-2: Kn ee-to-Chest Stretching). The expected goals \\lith active assisted ROM interven­ tion are the same as those accomplished with passive ROM. Prevention of the negative effects of immobilization , pre­ vention of joint contractures and soft-tissue tightness , de­ creased pain, and e nhancement of vascular dynamiCS and synovial diffusion can be accomplished with active assisted ROM. The benefits of active muscle contraction extend be­ yond those of passive ROM. Active muscle contraction sig­ nificantly enhances circulation. The pull of muscle on its bony attachments is a stimulus for bone activity while elic­ iting muscle activity. Active muscle contraction also assists in proplioception and kinesthesia, enhanCing the individ­ ual's awareness of his position in space. Muscle contraction in this situation has little impact on true strength gains in most patients, but it teaches the patient how to actively fire the muscle. For example, individuals with rota tor cuff in­ juries require assistance to activate these muscles after

SELF·MANAGEMENT 7·2 Knee-to-Chest

Stretching the muscle. Active assisted ROM is indicated when some muscle activation through the ROM is allowed or desired. :\ctive assisted ROM is frequently used to initiate gentle m uscle activity after musculotendinous surgical proce­ d ures such as rotator cuff or Achilles te ndon repairs . The a mount of assistance throughout the ROM may vary. Some dividuals may require assistance throughout the entire ange, but others may require minimal or no assistance in ome ranges but nearly maximal assistance in other ranges. This variation may result from a painful are, limitations im-

Purpose:

To increase the mobility of the lumbar spine and hips in flexion

Position:

Lying on your back, with your knees bent and feet flat on the floor

Movement technique:

Slowly bring one knee to your chest while grasping behind your knee. Bring the second knee to your ch est. Hold for 15 to 30 seconds. Slowly lower one leg to the starting position, followed by the other leg.

Dosage DISPLAV 71

Considerations When Performing ROM • ensure patient comfort and safety • ensure clinician safety by using good body mechanics • support any areas at risk of injury resulting from

hypermobility, fracture, etc.

• perform ROM slowly and rhythmically • move through as full a range as possible • avoid an excessively tight grip by grasping over as large a surface area as possible • use cardinal plane motions, combined motions, or

functional movement patterns

123

Repetitions: _________ Frequency: _ _ _ _ _ _ _ __

124

Therapeutic Exercise: Moving Toward Function

FIGURE 7-8. Active assisted shoulder flexion can be accomplished with assistance from the therapist

injury or surgery (Fig. 7-8). Morp()Ver, active assisted exer­ c.is(' involves the patient in his rehabilitation, rather than acting as the recipient of a passive technique. Hand placement and cueing during active assisted ROM are important for optimal patient participation. When possible, tactile cueing should be on one side of the joint rather than using a glip on the flexor and extensor sur­ faces. This action cues the patient for the direction of assis­ tance or resistance. This is particularly important when performing a technique such as active assisted ROM when some ranges are assisted but others are not.

quirements, active exercise requires more muscle coordi­ nation because of the lack of assistance or guidance through the ROM. As with active assisted exercise, the strength gains are minimal in many patients. Only those "vith fair (3/5 ) strength or less can be expected to have their strength challenged. However, many patients can expect to be chal­ lenged proprioceptively and kinesthetically. For example, after knee inju ry or surgery, many individuals have diffi­ culty activating the quadriceps femoris. Quadliceps setting exercises show patients how to activate the quadriceps, a prerequisite for functional activities. Although little or no tibiofemoral movement occurs, patellofemoral active ROM occurs, with superior glide of the patella on the femur. Active exercise should follow any passive technique to reinforce proper movement patterns and to overcom e mal­ adaptions to tissue stiffness. As new mobility is achieved, active exercise ensures the ability to use the new range ef­ fectively. For example, as hip flexion ROM improves from joint mobilization and stretching techniques, hand-knee rocking can be used to facilitate hip flexion ROM (see Chapter 18, Fig. 18-26). As shoulder flexion mobility in­ creases after stn~ tching exercises, initiate active shoulder flexion exercises. Similarlv, as knee flexion ROM increases after stretching, active kn~e flexion should follow (see Self­ Management 7-3: Active Range of Motion for Shoulder Flexion and Self-Management 7-4: Active Knee Flexion). Active exercise enhances the vascular benefits of ROM, with activities such as ankle pumps (i.e., repetitive dorsi­ flexion and plantarflexion) used postoperatively to prevent deep vein thromboses.

Active Range of Motion

Active mobility can be limited by the same noncontrac­ tile and contractile tissues that limit passive mobility. Shortening, stiffness, spasm, or contracture limit the joint's ability to move through a RO M. The strength and en­ durance of the muscle or muscle group can limit active mo­ tion. Strength below a fair (3/5) muscle grade implies an in­ ability to complete the ROM against gravity. Poor neuromuscular coordination and balance, such as the in­ abiuty to stand on a single leg, may limit active mobility. Strength in an agonist may be adequate to complete the ROM, but antagonist firing because of neurologic pathol­ ogy or faulty neuromuscular control patterns may limit mo­ tion. The patient may lack adequate speed of movement or agonist or synergist coordination to achieve purposeful movem ent. Cardiovascular endurance limitations in pa­ tients with chronic obstructive pulmonary disease, emphy­ sema, or other cardiovascular conditions can hinder the performance of active exercise. Active ROM is defined as mobility activities performed by active muscle contraction. These activities can be per­ formed against gravity or in a gravity-minimized position, depending on the individual's strength and the physical therapy goals (Fig. 7-9). Motions in cardinal planes, combi­ nation movem ent patterns, or functional activities such as reaching or combing one's hair are all examples of active ROM. The expected goals or outcomes associated with ac­ tive ROM intervention include those associated with pas­ sive ROM plus the beneflts of muscle contraction. These goals parallel those of active assisted ROM, although the results are greater. In addition to the greater strength re­

FIGURE 7-9. (A) Active hip flexion in a gravity minimized position (8) Active hip flexion against gravity.

Chapter 7 Impaired Joint Mobility and Range of Motion

SELF-MANAGEMENT 7-3 Active Range of Motion for Shoulder Flexion

Purpose:

To increase active mobility in a forward and overhead direction

Position:

In a sitting or sta nding position keeping your trunk in good alignment

Movement technique:

Reach your arm forward and up overhead. Reach as far overhead as is comforta ble.

Dosage Repetitions: _________ Frequency: _________

r

what sequence can best resolve the impairments and func­ tionallimitations of each patient. Stretching is contraindicated in the case of acute in ­ flammation or infection in the tissues being stretched. Use caution in patients with recent fracture , osteoporosis , the elderly (because of increased stiffness), those who have been in prolonged immobilization, or those 'Nith vely weak muscles. Posture is a key aspect of any stretching activity per­ formed. The starting and ending positions and the proper posture of associated jOints are based on physiologic and ki­ nesiologic factors. Physiologic factors such as the stage of healing affect the starting and ending positions for ROM and the position for stretching. For example , if a patient has just sustained an acute musculotendinous injury, ROM avoids the extreme position of the muscle range that would place too much stretch on the injured tissue. Kinesiologic factors include the normal osteokinematics and arthrokinematics at the joint. For example, proper per­ formance of shoulde r flexion requires normal arthrokine­ matic motion at the glenohum eral, sternoclavicular, and acromioclavicular joints and requires norm al osteokine-

SELF-MANAGEMENT 7-4

I.

Active Knee

Flexion

i­

.r

Purpose:

To increase active range of knee flexion and to initiate muscle activity

Position:

Movement technique: As with active assisted ROM , active exercise is indicated wh en active muscle contraction is desired. Many exercise ' programs begin with a regimen of active exercise to ensure proper exercise performance before the addition of resis­ t nce. In some situations, the weight of the limb alone pro­ duces optimal loading and makes a good starting point for the rehabilitation program. An additional benefit of active exercise is independence. After the patient learns the cor­ "ect exercise technique, that exercise can be performed in variety of modes that suit the patient's preferences (see elected IntelVention 7-1: Active Range of Motion to Im­ rove Mobility).

Stretching tr tching techniques are used to increase the extensibility of the muscle tendon unit and the periarticular connective . sue. Stretching is used to increase flexibility, which de­ ?€ nds on joint ROM and soft tissue extensibility. Stretch­ 00' techniques fall into three broad categories: static 'lretching, ballistic stretching, and proprioceptive neuro­ uscular facilitation (PNF) stretching. Specific stretching .. 'ercises and methods \.vithin these broad cat~J].?ri~s can 'ncrease muscle extensibility and jOint ROM." .o4-tb The linician must determine which stretching methods and

125

Standing on your uninvolved leg on the floor or on a small step, with your involved leg hanging down next to the step, hold onto a sta ble objectfor support. Slowly bend your involved knee up behind you, then lower it slowly and in a controlled fashion . Be sure to keep your knees in line with one another.

Dosage Repetitions: _________

Frequency: _________

126

1"::\

\!I

Therapeutic Exercise Moving Toward Function

SELECTED INTERVENTION 7-1

Active Range of Motion to Improve Mobility

See Case Study #4

ACTIVITY: Wand elevation exercise PURPOSE: To increase shoulder mobility in abduction , scaption, and flexion

RATIONALE FOR EXERCISE CHOICE: This exercise passively assists motion into a runctional, frequently limited range. The intensity of stretch is easily modified by changing water depth. EXERCISE GRADATION: The patient should discontinue use of wand and progress to active then resisted movements,

RISK FACTORS: Ensure appropIiate stabilization and arthrokinematic motion to prevent substitution HEMENTS OF THE MOVEMENT SYSTEM: Biomechanical STAGE OF MOTOR CONTROL: Mobility POSTURE: The patient is standing in chest-deep water, with a wand in the hands.

.-/

MOVEMENT: The patient allows the buoyancy of the water and the assistance of the uninvolved arm to lift the arm in the frontal , scapular, or sagittal plane. Rela.xation of the shoulder muscles allows passive stretch into abduction, scaption. or flexion. DOSAGE: Sets of 3 to .5 repetitions \vith 30-second holding at the end of the range.

matic motion and associated arthrokinematic motion at the scapulothoracic articulation and thoracic spine. If motion is limited at any of these locations, substitution and faulty movement patterns occur. If an individual lacks gleno­ humeral arthrokinematic motion that limits glenohumeral flexion , scapulothoracic elevation or lumbar spine exten­ sion may substitute. Attempts to stretch the shoulder into further flexion can impinge subacromial soft tissues, cause substitution by adjacent jOints , or both. The patient can learn an effective substitution pattern that prohibits nor­ malization of movement patterns and the eventual pro­ gression to normal arthrokinematic and osteokinematic motion. Be sure to use joint mobilization techniques in this situation. Another important kineSiologic factor is the stabilization of one attachment site of the muscle (usually proximal) or limb during stretching. For example, appropriately stretch­ ing the hamstring muscles requires proximal stabilization through proper lumbar and pelvic positions. Failure to sta­ bilize proximally results in lumbar spine flexion , posterior pelvic tilt, and movement of the hamstring origin closer to the insertion, thereby minimizing the stretch. Maintaining correct posture th at appropriately stabilizes is essential for effective stretching. General procedures for stretching include a thorough examination to ensure stretching of the appropriate tissues . Before beginning the stretching perform a gen eral warm­ up to increase local blood flow and warm the tissue to be

Wand shoulder abduction

stretched. Active exercise for warm-up is preferable to lo­ cal heat application , but hot packs can be used before stretching to warm local tissues. Use any relaxation tech­ niques necessary to enhance the stretching procedure. As with ROM techniques, use a grip technique that is com­ fortable for the patient or use family members or equip­ ment such as pulleys, towels, or bands, or the pool for stretching. Stretching can be performed using equipment or steps, walls, or bars in the pool (Fig. 7-10). The buoyant atmosphere and water's warmth often make stretching more comfortable (see Chapter 17). As always, listen to the patient and modify techniques as necessary to ensure opti­ mal outcomes. Neurophysiology of Stretching

In addition to the mechanical factors affecting stretch­ ing (see Chapter 11 ) the neurophysiology of the gamma system must be considered in exercise prescription. The muscle spindle and Golgi tendon organ (GTO) play impor­ tant roles in the modulation of stretching. The muscle spindle is a specializell sensory organ comprising intrafusal (nuclear bag and nuclear chain fibers ) muscle fibers that lie in parallel with the extrafusal muscle fibers. Because they lie in parallel, stretching the extrafusal muscle fiber stretches and activates the intrafusal muscle fiber. The muscle spindle is sensitive to both changes in length and the velOCity of these changes in the extrafusal muscle fiber. Type Ia and type II afferent nerve fibers arise from the

Chapter 7: Impaired Joint Mobility and Range of Motion

AGURE7-10. Knee flexion stretching can be performed in the pool, using buoyant equipment.

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intrafusal fibers. The primary afferent nerve fiber from the nuclear bag intrafusal muscle fiber is principally sensitive to the rate of change of stretch 66 If a muscle is stretched quickly, the la fiber will facilitate contraction of the muscle being stretched. The la receptor from the nuclear chain in­ trafusal muscle fiber responds to a maintained stretch and produces a maintained contraction. It is primarily affected by changes in muscle length , rather than velocity. Stimula­ tion of la fibers facilitates activation of the muscle being stretched. As with the type la fibers arising from the nu­ clear chain fibers, type II endings also alise primarily from the nuclear chain fibers and respond to maintained stretch with a maintained contraction. The eTO (type Ib fiber) attaches to the muscle tendon in series with the extrafusal muscle fibers and is sensitive to tension in the muscle caused either by stretching or by ac­ tive muscle contraction 66 Its function is protective, to pre­ vent overstretching or excessive contraction of the muscle. When stimulated, the eTO inhibits its own muscle and fa­ cilitates its antagonist . This decreases the tension in the muscle being stretched. Thus the eTO can override the timulus from the muscle spindle, facilitating relaxation of the muscle being stretched rather than contraction. The e TO is primarily responsible for the autogenic inhibition mechanism.

Static Stretching DeVries 55- 57 is credited with the initial research on the use and efficacy of static stretching and ballistic stretching. tatic stretching is a method of stretching in which the muscles and connective tissue being stretched are held in a tationary position at their greatest possible length for me period. When using static stretching on a clinical ba­ .' , stretches should be held a minimum of 30 seconds in

127

younger patients , and 60 seconds in older patients for opti­ mal results 67- 69 A study of individuals age 65 and older found that holding stretches for 60 seconds produced greater HOM gains that persisted 19nger than the gains for stretches held for 15 or 30 seconds. (0 A study of younger in­ dividuals found that holding stretches for 30 or 60 seconds produced greater benefits than stretches held 15 seconds, but there was no difference between the 30-second and 60­ second stretches.67 Static stretching offers advantages of using less overal'l force , decreasing the danger of exceeding the tissue extensibility limits, lower energy requirements, and a lower likelihood of muscle soreness.:>6 Static stretch­ ing also has less effect on the la and II spindle afferent fibers than ballistic stretching, which would tend to in­ crease a muscle's resistance to stretch and facilitate the eTO, thereby decreasing the contractile elements' resis­ tance to deformation. When performing static stretching, position the pa­ tient to allow complete relaxation of the muscle to be stretched. This position requires a comfortable, support­ ive surface or other external stabilization. Take the limb to the point at which a gentle stretching sensation is felt , and hold the stretch for 15 to 60 seconds_ Relax the stretch and then repeat. Proper limb alignment ensures that the proper tissues are being stretched with­ out causing injury to adjacent structures (see Self­ Management 7-5: Hip Stretching).

SELF-MANAGEMENT 7-5 Hip Stretching

Purpose:

To increa se the flexibility of the lateral hip and thigh muscles

Position:

Standing with the involved leg out on the surface (e.g., table, step) in front of you

Movement technique:

Keeping your hips square (do not rotate your hips), bring your leg across in front of you a few inches; next, roll your entire leg in the same direction (across your body), Hold 30 to 60 seconds.

Dosage Repetitions: _ _ _ _ _ _ _ __ Frequency: _ _ _ _ _ _ _ __

128

Therapeutic Exercise Moving Toward Function

Ballistic Stretching

Ballistic stretching uses qUick movements that impose a rapid change in the length of muscle or connective tissue . Initiated by active contraction of the muscles antagonistic to the muscles and connective tissue being stretched, these movements appear to be jcrh)' in nature. Although ballistic stretching has been effective for increasing flexibility in athletes, there may be a greater chance of muscle soreness and injury ·56 Injury may result from excessive uncontrolled forces during ballistic stretching and proposed neurologic inhibitory influences (activation of Ia afferent fibers ) asso­ ciated with rapid-type stretching. s9 ,71-76 For these reasons, ballistic stretching should be used only with selected patients, such as individuals preparing for plyometric activities. The patient performing ballistic stretching should be well stabilized and comrortable. Move the limb until a gen­ tl e stretch is felt , ami then gentl), "bounce" at the end range. Take care to avoid ballistic stretching that is too vig­ orous, because it can produce muscle injuty and pain. Proprioceptive Neuromuscular Facilitation Stretching

PNF stretching techniques are vvidel)' used by the phys­ ical therapy community. These techniques seek to capital­ ize on the use of the neurophysiologic concept of stretch activation . PNF stretching techniques use a contract-relax (CR) sequence, an agonist contraction (AC), or a contract­ relax-agonist contraction (CRAC) sequence. 77 Using PNF stretching techniques , the clinician seeks to facilitate the stretch by using the principles of reciprocal and autogenic inhibition. CR stretching begins as does static stretching: support the patient and bring the limb to the end ROM until gen­ tle stretching is felt. At that point, ask for and resist an iso­ metric contraction of the muscle being stretched for ap­ proximately 2 to 5 seconds and then ask the patient to rela.x the muscle. Then increase the stretch and repeat the pro­ ceuure two to four times. AC stretching uses the principle of reCiprocal inhibition. Take the limb to the position of gentle stretch and ask for a contraction of the muscle opposite the muscle being stretched. This facilitates the stretch and inhibits the mus­ cle unuergoing stretch. For example, when stretching the hamstring muscles , a simultaneous contraction of the quauriceps muscles can facilitate the stretch. Hold the mus­ cle contraction for 2 to 5 seconds and repeat the technique two to four times. CRAC is a technique that combines the CR and AC stretches. Take the limb to the point of gentle stretch, and perform a CR sequence (i.e., resistance applied against the muscle being stretched). After contracting the muscle be­ ing stretched, ask the patient to relax this muscle while con­ tracting the opposing muscle group, thus facilitating the stretch. For example, when stretching the ham string mus­ cles, they are brought to a position of stretch. The ham­ string muscles are contracted against resistance and then relaxed, and the quadriceps are contracted. Each of these stretching techniques requires constant communication with the patient to ensure that neither overstretching nor excessive resistance produce muscle in­

jury. These techniques can be performed independently with a family member or alone using a towel or other sim­ ple objects to provide resistance or assistance. Effects of Stretching

Stretching is one of the most accepted interventions in rehabilitation. Stretching has been studied to determine the effects of different stretching techniques. The effects of stretching are divided into acute effects and chronic ef­ fects. Acute effects are the immediate, short-term results of stretching and are the result of elongati'ng the elastic component of the musculotendinous unit (see Chapter 11, Figs. 11-2 through 11-4). The effects of routine stretching exercises are acute in nature. Chronic effects are the long­ term results of prolonged stretching and are the result of adding sarcomeres (usually because of immobilization in a lengthened position ). Stretching is used to lengthen short­ ened tissue and to decrease muscle stiffness. Contractile and noncontractile elements of muscle contribute to its res ting tension and resistance to elongation 76 Potential sources of stiffness are adhesions, epimysium, pe rimy­ sium , endomysium, sarcolemma, contractile elements within the muscle fiber, and associated tendons and their insertions 76 The relative contribution of the contractile el­ ements to resistance to stretch appears to be velocity­ related, ,'lith increased resistance to stretch occurring at higher velocities. 78 The farther the muscle is stretched, the greater is the relative contribution of noncontractile elements. 76 The mechanism for short-term gains in flexibility after stretching techniques is unclear. Magnusson et al. 79 found that static and cyclic stretches both produce decreases in resistance to stretch , and that the increases in range of mo­ tion were due to increased tolerance to the stretch, not to changes in the viscoelastic properties of the muscle. When comparing flexible versus inflexible individuals, the authors found that flexible subjects attained a greater angle of stretch 'with greater tensile stress and energy than inflexi­ ble individuals, appare nt~ because of greater tolerance to the stretching sensation. 0 Additionally, strengthening ex­ ercises increased muscle stiffness that was unaltered by daily stretching S1 There is no _agree me~t about which stretching tech­ nique is best. 5o •54 ,o8--6Z,6-l,60 According to some researchers, PNF techniques may be better than static or ballistic tech­ niques for producing acute , short-term improvements in ROM 82 These short-term improvements may result from contraction of antagonistic muscles while performing CRAC stretchin?, '-Yhich is based on the principle of reCip­ rocal inhibition. 1-13 Muscle stiffness has been decreased by performing a conditioning isometric or eccentric muscle action. 83 This muscle contraction causes a change in vis­ cosity and resistance to molecular deformation, decreasing stiffness and resistance to stretch. Prestretch conditioning through active or passive movements (i.e., passive oscilla­ tions or active repetitive eccentric actions) may 100s e2~ actin-myosin bonds and increase stretching effectiveness. However, in the absence of continued activity, the short­ terms gains in flexibility may be lost. DePino et al s4 found that improvements following four consecutive 30-second hamstring stretches were lost within 6 minutes of complet­ ing the last stretch. i'

Chapter 7: Impaired Joint Mobility and Range of Motion

c

Regardless of the type of stretching method used, flexi­ bility gains made may be retained even after the individual has stopped stretching for some time, Zebas and Rivera 65 demonstrated retention of gains from 2 to 4 weeks after the cessation of a 6-week stretching program. Feland et al. 70 found retention of gains 4 weeks after cessation of a 5 times per week, 60-second hamstJing stretching program in el­ derly individuals. Participating in a flexibility exercise pro­ gram three to five times per week can produce gains. For individuals with Significant flexibility deficits, stretching should be part of their daily routine. After the goal is achieved, stretching once each week may be sufficient to maintain gains.

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Joint Mobilization \1anual therapy techniques such as jOint mobilization are used to improve the mobility of joints. The Guide to Physi­ cal Therapist PracticeRS defines mobilization/manipulation as a "continuum of skilled passive movements to the joints ancl!or related soft tissues that are applied at varying speeds Jnd amplitudes, including small-amplitudelhigh velocity therapeutic movement." Manipulation is a type of mobiliza­ ti n that is generally penormed at a high velocity through a mall amplitude. Various models of manual therapy exist, each with its own definitions and classification of mobiliza­ tion/manipulation. For example, Maitland86_ describes five levels of mobilization, whereas Kaltenborn 8 1 speCifies only three (Fig. 7-11 ). Regardless of the classification system, these schools of thought all focus on increasing joint mobil­ i .' by increasing the joint pIa)', or motion bet'vveen the Joint unaces, Use of mobilization/manipulation techniques re­ quires an understanding of the normal joint architecture, Mthrokinematics , and the specific pathology to determine \-hich intelventions are appropriate. Researchers have examined the ability of joint mobiliza­ tion techniques to increase jOint ROMsb,HUHsu et al 88 ex­ mined the effects of anterior and postelior translational obilization performed in the resting position and at end , duction on shoulder rotation and abduction ROM in ca­ laver specimens. Both anterior and posterior glides at end

range increased abduction ROM , whereas these same glides penormed in the resting position were less effective. Small increases in lateral rotation were found after anterior glides in the resting position and in medial rotation after posterior glides at end range. Roubal et al 8 9 found that inferior and posterior mobi­ lizations after a brachial plexus block in patients with adhe­ sive capsulitis increased motion in flexion, abduction , in­ ternal rotation, and external rotation. Range increased in all four directions despite no antelior mobilization treat­ ment, suggesting that mobility was limited more by capSLl­ lar tension than joint geometry. In a series of case studies , Vermeulen et al. 90 found increased ROM in all directions, increased joint capsule volume, and increased function in a group of patients with adhesive capsulitis treated with end­ range joint mohiIi7,ation. Biomechanics of Joint Mobilization

Movement occurs at a joint when one jOint surface moves on another relatively fixed joint surface. Roll , spin, and glide (or slide ) are the major categOlies of arthrokine­ matic motion found in human jOints. Roll occurs when new points on one joint surface meet new pOints on the oppos­ ing joint surface. Spin is a pure rotational movement in which rotation occurs about a fixed axis. Motion of the ra­ dial head during pronation and supination is an example of spinning. Gliding or sliding occurs when one point on a moving surface continually comes in contact with new points on the opposing surface. Sliuing is the predominant motion used in joint mobilization techniques. In most arthrokinematic motion, a combination of these move­ ments occurs. In addition to roll, spine, and glide, com­ pression and distraction of the joint can occur. Compres­ sion techniques are often used to facilitate mu scular cocontraction and Joint stabilization, whereas distraction is used in conjunction with joint mobilization to increase joint mobility or decrease pain. Some jOint play must exist for arthrokinematic motion to proceed normally as the limb moves through the ROM (osteokinematic motion). The type and direction of arthrokinematic motion is determined in part by the rela-

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Available Joint Play

129

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130

Therapeutic Exercise: Moving Toward Function

tive shape of the jOint surfaces. Most joint surfaces are clas­ sified as either ovoid or sellar. In an ovoid jOint, one joint surface is concave, whereas the other is convex. For exam­ ple, at the glenohumeral jOint, the glenoid fossa is concave, whereas the humeral head is convex. In a sellar joint, both surfaces are both concave and convex. The car­ pometacarpal joint of the thumb is an example of such a jOint. The convex-concave rule dictates the direction of gliding of one joint surface on the other and forms the ba­ sis for joint mobilization techniques. When a convex sur­ face is moving on a fixed concave surface (such as the humeral head moving on the stationary glenOid) the move­ ment of the convex bone is in the direction opposite the convex articulating surface. In this case , the convex humeral head glides inferiorly as the humeral shaft moves superiorly. The opposite is true when a concave surface moves on a stationary convex surface. For example, move­ ment of the concave tibial jOint surface on the stationary concave femoral condyles is in the same direction as the tibial movement. Thus the tibial joint surface \vill move posteriorly as the tibia moves into flexion . However, the human body does not always follow our rules, and the convex-concave rule is one of these. Follow­ ing this rule at the shoulder would suggest that an anterior glide is used to increase mobility in external rotation, hori­ zontal abduction, and extension, whereas a posterior glide is used to increase motion into internal rotation, horizontal adduction, and flexion. A study by Howell et al. 91 found that when the arm was placed in a maximally cocked position (abduction, extension, and lateral rotation) the humeral head was actually resting approximately 4 mm posteriorly. Additionally, Harryman et a1. 92 found anterior humeral head translation with glenohumeral flexion and h0l1zontai adduction and posterior translation "vith extension and lat­ eral rotation . These apparent violations of the convex-con­ cave rule may be the result of joint capsule tightening dur­ ing rotation that is unique to the glenohumeral jOint. Thus applying a Single rule to all jOints may mislead the clinician. The primary indication for jOint mobilization is a limitation in active and passi\'e ROM at a joint. This is especially true in the case of a capsular end feel and loss of RO M in a capsular pattem. Remember that a number of stllJctures can limit ROM at a joint; joint mobilization is most effective when the tissue limiting ROM is the jOint capsule. This is generally as­ sessed via jOint play or joint accessory motion testing. Small amplitude jOint mobilization may be used for the reduction of pain. These oscillations stimulate joint recep­ tors and decrease the perception of pain by the central ner­ vous system. JOint traction or distraction is used to relieve the compression of painful joint surfaces and is used along with most mobilization techniques to separate jOint sur­ faces during the mobilization procedure. Joint mobilization is contraindicated in the case of joint infection, neoplasm, acute inflammation, or recent frac­ ture. Caution must be used in cases of connective tissue disease, osteoporosis, hypermobility, or edema. Mobilization Grades

Manual therapists use diffe rent mobilization grades de­ pending upon their background and training. The two most commonly used grading systems are those developed by

Kaltenborn and by Maitland. 86,s7 They are distinguished by the number_ of grades and the criteria for each grade. Kaltenbom 81 defines three grades of mobilization by the amount of force applied, whereas Maitiand B6 describes his grades by the amplitude and position in the range. Kaltenborn 's techniques are a sustained translation, whereas Maitland's are an oscillation. Kaltenborn's87 grades are: Grade I: a low level distraction force Grade II: a greater force that takes up the available joint play Grade III: a force that stretches the joint tissue after the available jOint play has been taken up. Maitland's s6 grades are as follows: Grade 1: small amplitude rhythmic movements near the beginning of the range of motion Grade 2: large amplitude rhythmiC oscillations per­ formed 'vvithin the available range, but not reaching the limit Grade 3: large amplitude rhythmic oscillations per­ formed to the limit of the range and into the tissue resistance Grade 4: small amplitude rhythmic movements per­ formed at the limit of the range and into the tissue re­ sistance Grade 5: small amplitude, high-velocity thrust tech­ niques performed at the end of the range of motion for the purpose of breaking adhesions Maitland86 emphaSizes not only the amplitude of the os­ cillations, but the rhythm and amount of pressure as well. He suggests that grade I oscillations for pain must be ex­ tremely gentle using a very light touch. The rhythm of os­ cillations can be varied from quick staccato movements into a stiff range, to smooth, rhythmic oscillations into and out of the painful or stiff region. When using grade II os­ cillations, the greater the pain, the slower and smoother should be the oscillations. Sustained stretch positions can be used as well, and the techniques should vary within the treatment session. General Procedures

Be sure your patient is relaxed and positioned com­ fortably on the treatment table. Muscle guarding result­ ing from discomfort or apprehenSion will interfere with the treatment and place undue stress on both the patient and therapist. Position yourself to optimize body me­ chanics, making use of body weight and leverage to min­ imize your energy expenditure. Use external devices sucb as the table, positioning, belts, and wedges to stabilize and minimize therapist efforts. Be sure your grip is firm. using as large and wide a portion of your hand as possi­ ble. This will minimize painful pinching or a painful lo­ calized force application. Grasp as close to the joint line as possible 'with both the mobilizing and the stabilizing hand. Provide gentle traction to the jOint while perform­ ing mobilizations. Understand the joint anatomy and arthrokinematics to minimize chances of painful joint compression forces. Oscillations are performed at a rate

Chapter 7: Impai red Joint Mobili ty and Range of Motion

131

DISPLAY 7-2

Shoulder Joint Mobilization

------------------------------------------------------------

Glenohumeral Anterior Glide Purpose' to increase shoulder external rotation and extension Position: patient is prone with shoulder at edge of table and abducted to 90 degrees, elbow flexed to 90 degrees; mobilizing hand on posterior humeral head while stabilizing hand holds mid-humerus Mob"lization: anterior force applied by mobilizing hand to humeral head while stabilizing hand applies gentle traction

Glenohumeral Posterior Glide Purpose: to increase shoulder flexion and internal rotation Position: patient is supine with the shoulder at the edge of the table, scapula stabilized by the table or towel roll; abducted to 45 degrees and elbow slightly flexed ; mobilizing hand on anterior humeral head and stabilizing hand supporting elbow Mobilization: posterior force applied by mobilizing hand to humeral head while stabilizing hand applies gentle traction G enohumeral 'nferior Glide Purpose: to increase shoulder abduction and flexion Position: patient is supine with the arm in 30 degrees to 45 degrees abduction; stabilizing hand supports scapula in axilla while mobilizing hand grasps distal humerus obilization. inferior force applied by mobilizing hand while stabilizing hand holds scapula steady

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Acromioclavlcul r Joint Ante io Glide Purpose. to increase joint mobility

Position: patient is positioned sitting; stabilize the scapula with thumb along the scapular spine and fingers along acromion; mobilizing hand placed on posterior clavicle near joint line Mobilization: mobilizing hand imposes an anterior force on the clavicle

Sternoclavicular Joint Superior/lnferior and Anteriorl Posterior Glides Pur ose: superior glide increases depression, whereas inferior glide increases elevation; anterior glide increases protraction, whereas posterior glide increases retraction POSitIOn: patient is supine with the stabilizing hand on the sternum and the mobilizing thumb or thumb and index finger on the proximal clavicle Moblllza 'on: superior glide: the index finger applies a superior force to clavicle inferior glide: thumb applies an inferior force to clavicle anterior glide: thumb and index finger lift the clavicle posterior glide: thumb applies a posterior force to clavicle Scapular Mobilization Purpo e to increase mobility at the scapulothoracic articulation Po 1110 patient is in prone; superior hand is along scapular spine while inferior hand grasps inferior angle of the scapula MOillliz8tlon: mobilize the scapula in elevation, depression, adduction, abduction, or rotation by pushing the appropriate direction

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of 2 to 3 per secon d for approximately 1 minute. Reeval­ uate the joint and repeat, or choose anoth er grade or di­ rection as necessary. Kaltenbom ll7 suggests beginning the mobilization in the resting position if the purpose of the treatment is pain relief. The resting position valies from one individual to another. Find the position allowing the greates t ease of movement by trying gentle traction in a variety of positions. This position " the resting position. If the p urpose of the mobilization is ' to stre tch the tissue, then perform the mobilization nearer the li mit of mobility. Performing the mobilization closer to

the end range has proven more effective in increasing mo­ tion than performing mobilizations in mid-range . Applications to Specific Joints

Selected mobilization techniques for the spine and ex­ tre mities will be d escribed. Realize th at this is only an overview of techniques and is not comprehensive . Addi­ tionally, many modifications are available, and the specific positioning will vary with available res ources and patient and therapist preferences. The deSCriptions can be found in Displays 7-2 to 7-8 and F igures 7-12 to 7-29.

DISPLAY 7·3

Elbow Joint Mobilization

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Purpose: to increase elbow joint mobility in flexion or extension osition: patient is supine with the elbow flexed to approximately 70 degrees, wrist resting on the therapist's shoulder; both hands grasp proximal ulna obilizatlon. a distal force applied against the proximal ulna Elbow Humaror dial Anlerior or os erior Glide Pu 0 anterior glide to increase flexion, posterior glide to increase extension Position. supine with the elbow extended and supinated as far as possible; stabilizing hand grasping the medial distal humerus; proximal palm of stabilizing hand on anterior radial head with fingers on the posterior aspect

Mobilization: a posterior glide force provided by the palmar aspect of the hand, or an anterior force provided by the fingers Elbow Radioulnar Anterio and Posterior Glide Purpose: anterior glide to increase supination, posterior glide to increase pronation Posllio,!' patient sitting or supine with the elbow in extension and supination for posterior glide or extension and pronation for anterior glide; stabilizing hand grasps proximal ulna with thenar eminence on anterior aspect and fingers on posterior aspect; mobilizing hand is in same ,position over the proximal radius Mobilization: posterior force on radial head for posterior glide; anterior force on radial head for anterior glide, both while stabilizing hand holds ulna steady

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(text continues on page 137)

132

Therape utic Exercise: Moving Toward Function

DISPLAY 7-4

Wrist and Hand Mobilization Interphalangeal or metacarpal palmar end dorsal glide Purpose: palmar glide to increase flexion, dorsal glide to increase extension Position: patient's palm faces down with joint in resting position; stabilizing hand holds proximal bony segment while mobilizing hand grasps distal bony segment Mobilization' with mobilizing hand, move distal segment toward the palm to increase flexion or toward dorsum to increase extension while applying gentle traction

Thumb metacarpal-carpal dorsal and palmar glides Purpose. palmar glide to increase adduction; dorsal glide to increase abduction Position: patient's hand is positioned with the palm down, joint in a resting position; stabilizing hand grasps distal forearm with grip around trapezium while mobilizing hand grasps first metacarpal Mobilization: with mobilizing hand, glide metacarpal toward palm to increase adduction, or toward dorsum to increase abduction while applying gentle traction

Thumb metacarpal-carpal radial and ulnar glides

Wrist palmar and dorsal glides Purpose: palmar glide to increase extension, dorsal glide to increase flexion Position: patient's forearm rests on table or wedge with the carpal joint at the edge; forearm is pronated for palmar glide and supinated for dorsal glide; stabilizing hand steadies the distal forearm against the table or wedge; mobilizing hand grasps the distal wrist Mobilization: apply a downward force with mobilizing hand while applying gentle traction

Purpose: ulnar glide to increase flexion; radial glide to increase extension PosItIon: patient's hand is positioned with the ulnar side down, joint in a resting position; stabilizing hand grasps distal forearm with grip around trapezium while mobilizing hand grasps first metacarpal Mobilization: with mobilizing hand, glide metacarpal toward radius to increase extension, or toward ulna to increase flexion while applying gentle tra ction

DISPLAY 1-5

HiJ! Joint Mobilization Hip Distraction/Distal Traction Purpose: pain relief and general mobility Position: patient is supine or prone on the table, with the pelvis stabilized with a belt; therapist grasps either the distal thigh or the distal calf, depending upon whether or not you want distraction through the knee joint; a belt can be used around your waist and hands to reinforce the grip and allow use of body weight Mobilization: a distal traction force is applied to the leg by shifting your body weight backwards

Mobilization: lean backward to apply a lateral traction force to the hip Hip Anterior Glide Purpose: increase extension and external rotation Position: patient is prone with knee flexed to 90 degrees and a firm wedge or towel roll placed under the anterior pelvis; mobilizing hand just distal to posterior hip, and stabilizing hand grasps ankle to stabilize leg Mobilization: anteriorly directed force through mobilizing hand via forward weight shift

Hip lateral Traction Purpose: pain relief and general hypomobility Position: patient is supine with pelvis stabilized with a belt; the hip may be in any degree of flexion to extension depending upon the direction of hypomobility; mobilizing belt is placed around your pelvis and the patient's proximal thigh

Hip Posterior Glide Purpose: increase flexion and internal rotation Position: supine with hip near full flexion, knee flexed, pelvis stabilized on table or with additional wedges or support; mobilizing hands on patient's knee Mobilization: a posteriorly directed force through the long axis of the femur

Chapter 7: Impa ired Joint Mobility and Range of Motion

133

DISPLAY 7-6

Knee Joint Mobilization Tibiofemoral Anterio Glide Purpose: increase extension Position: patient is prone with the knee at the edge of the table; mobilizing hand is just distal to knee joint and stabilizing hand supports anterior ankle MobilizatIOn. anteriorly directed force downward through mobilizing hand while stabilizing hand applies gentle distal traction Tibiofemoral Posterior Glide Purpose: increase flexion PositIon: patient is supine or sitting with the knee at the edge of the table; mobilizing hand is just distal to the knee joint and stabilizing hand supports posterior ankle

Mobilization: a posteriorly directed force through mobilizing hand while the stabilizing hand applies gentle distal traction Patellofemoral Jomt Mobilization Purpose: increased general patellar mobility; and superior glide for increased extension, inferior glide for increased flexion Position, supine with knee supported by table, wedge, or towel roll; mobilizing thumb and index finger placed along patellar border oriented to direction of mobilization MobilizatIon apply a medially, laterally, superiorly, or inferiorly directed force to the patella

DISPLAY 7 7

Foot and Ankle Mobilization Ankle Anterior Glide Purpo e, increase plantarflexion Position, prone with foot hanging just over the edge of the table; stabilizing hand under the anterior distal tibiofibular joint; mobilizing hand on the posterior calcaneus, just distal to joint line Mobilization: apply a downward, anteriorly directed force to the calcaneus while applying gentle traction

Ankl Traction Purposa' pain relief and general mobility Position: supine with leg stabilized by a strap and foot just over the edge of the table; both hands grasp the foot, one posterior on the calcaneus and the other anteriorly over the midfoot Mobilization: lean backwards to produce a distal traction to the talocrural joint

Ankle Posterior Glide Purpose: increase dorsiflexion Position: supine with foot just over the edge of the table; stabilizing hand under the posterior distal tibiofibular joint; mobilizing hand grasps anterior ankle just distal to joint line Mobilization: apply a downward, posteriorly directed force to the ankle while applying gentle traction

Metatarsal and Phalanges Glide Purpose' increase mobility of toes Position, supine with foot over the edge of the table; stabilizing hand grasps metatarsal while mobilizing hand grasps phalanges Mobilization: apply dorsal and ventral mobilizations while applying gentle traction

DISPLAY 7-8

Spine Mobilization Cervical and Thoracic Spine Posterior to Anterior Glide Purpose increase segmental mobility and pain relief Position' patient is prone with towel under forehead or on mobilization table; therapist's thumbs placed one on top of the other, directly over the spinous process to be treated; spread hands over the adjacent neck or back area, keeping shoulders directly above treatment area obilization: apply a direct posterior to anterior force to the spinous process; this technique can also be performed with thumbs on the transverse processes unilaterally or bilaterally CervIcal and Thoracic Spine Lateral Glide Purpose' increase general mobility and unilateral pain relief Position patient is prone; therapist's thumbs placed one on top of the other, directly over the lateral side (right or left) of the spinous process to be treated; spread hands over the adjacent neck or back area obilization: apply gentle pressure to lateral border of spinous process

Lumbar Spine Posterior to Anterior Glide Purpose' increase segmental mobility and pain relief Position' patient is prone; therapist's ulnar border of the hand over the spinous process to be treated; the other hand reinforces the mobilizing hand by resting on top of it and grasping the radial border of the wrist with the fingers; keep your shoulders directly over your hands; this technique can be modified to provide unilateral pressure to the transverse process using your thumbs adjacent to one another MobIlization: a gentle rocking motion provides an anteriorly directed force over the spinous process Lumbar Lateral Glide Purpose: increase segmental mobility and pain relief Position: patient is prone with the therapist's thumbs (one on top of the other) on the lateral side of the spinous process to be mobilized MobilizatIon: apply a horizontal pressure to the lateral border of the spinous process

134

Therapeutic Exerc ise Moving Toward Function

FIGURE 7-12. Glenohumera l anterior glide.

FIGURE 7-13. Glenohumeral posterior glide.

FIGURE 7-14. Scapular mobi lization.

FIGURE 7-15. Humeroradial anterior glide.

FIGURE 7-16. Rad ioulnar posterior glide.

FIGURE 7-17. Interphalangeal pal mar glide.

Chapter 7 Impaired Joint Mobility and Range of Motion

FIGURE 7·19. Wrist dorsal glide. FIGURE 1·18. Thumb metacarpal-carpal dorsa l glide.

FIGURE 1·20. Hip distraction.

FIGURE 1·21. Hip anterior glide.

AGURE 7·22.. Tibiofemoral anterior glide.

FIGURE 7·23. Tibiofemoral posterior glide.

135

136

Therapeutic Exercise: Moving Toward Function

FIGURE 7-24. Ankle anterior glide.

RGURE 7-25. Ankle posterior gl ide.

RGURE 7-26. Metatarsal glide.

FIGURE 7-27. Cervica l spine posterior to anterior glide.

FIGURE 7-28. Thoracic spine la tera l glide

FIGURE 7-29. Lumbar spine posterior to anterior glide.

Chapter 7 Impaired Joint Mobility and Range of Motion

Exercise Dosage The stage of healing (see Chapter 11 ) and the tissue re­ sponse to loading relative to the patient's examination find­ ings determine the dosage of mobility exercises. Each pa­ tient should be cons idered on an individual basis, with the dosage matched to the patient's needs. These needs extend beyond the physical impairments to include psychosocial and lifestyle issues.

Sequence Mobility activities can be performed as part of warm-up ex­ ercises before aerobic or strengthening activities or as in­ dependent rehab ilitative exercise s. Use passive or active assisted ROM to teach active ROM exercises, and usc ac­ tive ROM as a teaching tool for resistive exercise. The se­ quence of exercise depends on the purpose of the ROM ac­ tivity. ROM exen:ise as preparation for more difficult exercise should occur before that activity. When mobility exercises are being performed for the benefits of ROM in­ creases, they should be performed in a sequence of easier to more difficult. ?vIost exercises performed paSSively can also be per­ formed actively or with active ass istance. This makes an asy progressive sequence for the patient to follow. For ex­

ample , a Single knee flexion exercise can be eaSily pro­

O'ressed by changing instructions. Progress knee flexion

" i th a towel to active assisted by using some muscle activ­

'ty and some passive ass istance from the towel (Fig. 7-30).

\ 5 the patient improves, the same exercise can be per­

ormed without assistance. The same is true for shoulder

. exion exercises with a pulley or counter; the exercise can

performed with some level of assistance or completely ctively. The concept of active stretching is impoliant when se­ uencing mobility activities. Active stretching is the use of tive movement to stretch the agonist or to use the agon ist n .its new range. Stretching a short muscle should always be :omplemented with active stretching by strengthening the pposing muscle in the shortened range. Based on scien­ .ilk studies of length-tension propeliies of skeletal muscle,

URE 7·30. Active range of motion at the knee using a towel for assis· -- e as needed.

137

it is hypothesized that a stiff or short soft-tiss\le stmdme cannot remain lengthened until opposing soft-tissue stnlc­ tures shorten. r):J The opposing muscle nlllst be strength­ ened because its length-tension properties have been dis­ rupted because the short muscle is in need of stretch. It cannot generate slIfficient tension in the short range to op­ pose the pull of the short muscle. By str ngthen ing the lengthened muscle, particularly in the short range, its length-tension properties can improve, anu it can provide a counterbalancing force to the shOli muscle. Stretching a short muscle can be done passhrely through a self-stretch or manual stretch, but it should always be accompanied \\ith active stretching through strengthening the opposing mus­ cle in the shorte ned range. Active contraction of the antagonist in a shortened posi­ tion is used to strengthen this muscle while Simultaneously actively stretching the agonist. For example, after static stretching of the hamstrings, the patient can extend the knee in a sitting position while the paraspinal muscles sta­ bilize the spine to prevent lumbar flexion. The quadriceps actively stretch the hamstrings into the new range. This re­ peated activity enhances mobility in the new range . This same sequence concept can be applieu throughout the body, as in the treatment oflow back and pelvic muscle im­ balance. After static stretching of short hip flexor muscles, the patient should extend the hip in a walk stance position while the abdominal muscles stabilize the spine and pelviS (see Self-Management 7-6: Active Stretch for the Hip Flexor Muscles ).

Frequency, Intensity, and Duration The frequency of a therapeutiC exercise program is often inversely related to the intensity and duration. Exercises of high intensity and duration are performed less frequently and vice versa. ROM activities, because of their purpose and goals , are generally a lower intensity exercise per­ formed for a shorter duration. These exercises can be per­ formed more frequently and usually take place in the home or work environment. Choose exercises that can eaSily and effectively be performed independently by the patient or vvith the assistance of a family member. The exercise frequency is related to the purpose of the exercise, which can be considered relative to physiologic, kinesiologic, or learning factors. Physiologic purposes are those that enhance fluid dynamiCS, support articular carti­ lage nutrition, and maintain the integlity of the periarticu­ lar connective tissues. KineSiologic purposes include main­ tenance of normal arthrokinematic motion and are closely tied to learning factors or chOOSing the correct motor pro­ gram. Exercises to teach postural set, appropriate sequenc­ ing, and patterning of muscle contraction or to teach a complex motor skill af(' examples of ROM as a tool for learning. Exercises performed for phYSiologiC or kineSiologiC purposes are perform ed t".lO to five or more times each day. The number of times depends on the environment and availability of exercise vvithin that environment. If it is nearly impossible for an individual to perform exercises during the workday, asking him or her to carry out an ex­ ercise program five times each day is unreasonable. Simi­ larly, if the ROM activities require the assistance of an­

138

Therapeutic Exercise: Moving Toward Function


'V"

SELF-MANAGEMENT 7-6 Active Stretch for

the Hip Flexor Muscles

Purpose:

To stretch and use hip flexor muscles in the new range. This activity should follow hip-stretching exercises.

Position:

In a stride position, with the leg to be stretched behind and with the opposite foot forward as in taking a step. Be sure to keep the back straight and abdominal muscles tightened.

Movement technique:

Shift your weight forward onto your front foot while maintaining proper hip and back position. Hold 30 to 60 seconds. Be sure that the hip of your back leg is being stretched as shown by the highlighted area in the illustration below.

Dosage

Repetitions: _ _ _ _ _ _ _ __

Frequency: _ _ _ _ _ _ _ __

otber, availability of that help dictates the frequency of the exercise program. As discussed in Chapter 3, an exer­ cise prescription should fit within the con text of the indi­ vidual's day. Exercises performed as learning tools are usually per­ formed more frequently duling the day. Examples of these exercises are postural reeducation activities such as scapu­ lar retraction and depression, chin tucks while sitting at a desk, and knee extension while dliving without postelior pelvic tilt or lumbar flexion (Fig. 7-31). These kinds of ex­ ercises are often put "on cue" so that a speCific stimulus can elicit the postural response, such as performing postural ex­ ercises every time the phone lin gs , every time a new page is started on a computer document, or every time an in­ structor poses a question. This type of programming places the exercise in the appropliate functional context, within the environment or situation where the exercise most needs to be performed. With time and repetition, individ­

uals should find that, when the stimulus elicits the re­ sponse, they are already in the appropliate posture, The in­ tensity of this type of exercise is low, and the frequency is therefore increased. The number of sets and repetitions depends on the fre­ quency and the number of exercises performed. When sev­ eral exercises are being performed to maintain ROM dur­ ing a period of bed rest or in the early healing stages of an injury, the sets and repetitions may be fewer as multiple components of the jOint and periarticular connective tis­ sues are being mobilized. Conversely, when only a few ex­ ercises can be performed because of healing constraints or other medical conditions, more sets and repetitions of those exercises can be performed. When exercises are be­ ing performed frequently throughout the day, fewer sets and repetitions are performed during each session. When active exercise is being used to increase endurance, more repetitions and longer duration rather than greater fre­ quency is the rule. The guiding principle in ROM pre­ scription is understanding the physiologic, kinesiologic, and learning factors associated with each exercise in rela­ tion to the patient and exercise goals. The length of time a stretch must be held to facilitate an increase in muscle flexibility remains a point of dis­ agreement among clini cians. The clinical literature states that stretches should be held for a minimum of 30 sec­ onds in young individuals and 60 seconds in older indi­ viduals. There does not appear to be an)' advantage to holding a stretch longer than those peliods.67...(j!J However, the tim e that a patient or an athlete wants to hold a stretch may be based on the individual's perceived need or comfort level. When in doubt , a stretch should be held for a longer peliod rather than a shorter peliod. Although short-term flexibility improvements can be seen in one stretching session, studies on the length of stretching time necessary to effect long-term increases in muscle flexibil­ ity are still lacking. The intensity of stretching should be low to medium to prevent reflexive contraction. This con­ traction occurs in response to discomfort duling stretch­ ing. The stretch should be comfortable enough to be eas­ ily held for 30 seconds.

Precautions and Contraindications Passive ROM and stretching are not benign processes and are contraindicated when motion could disrupt the healing process. For example, passive motion into fu!! sbouTder ex­ ternal rotation may disrupt the healing process after a cap­ sular shift procedure. Passive motion into hip adduction. flexion past 90 degrees, and internal rotation past neutral may result in dislocation of a recent total hip arthroplasty Use caution to ensure that the activity is passive when ac­ tive muscle contraction is contraindicated, such as after a tendon transfer procedure. Ensure that the activity is pro­ ducingjoint ROM in the case of passive ROM and muscle ROM in the case of stretchin g. Moreover, control tilt" speed and patient comfort to prevent inadve rte nt muscl e contraction to oppose the passive exercise. Active muscle contraction in response to fear or pain could disrupt the healing process. Be aware of local anatomy, arthrokinemat­ ics, and the effects of passive ROM on these tissues . For ex­

Chapter 7: Impaired Joint Mobility and Range of Motion

139

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FIGURE 7-31. Chin tucks, pelvic tilts, and quadriceps setting can be performed while sitting on an unstable sur­ e

face. (A) Poor posture. (8) Good posture with proper pelvic posture and chin tucks.

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-ffiple, passive shoulder ROM into full overhead flexion i thout adequate humeral head depression may compress recent rotator cuff repair under the coracoacromial arch, roducing pain and disrupting the healing process. .\s with passive ROM, active assisted ROM is con­ :raindicated when motion or contraction may disrupt the ealing process or affect the individual's health status. For . mple, individuals 'vyith unstable cardiac conditions are t candidates for active assisted exercise. When perform­ g exercise with an active component, ensure that the type muscle contraction performed (e.g., concentric, eccen­ c, isometric ) is indicated and that the amount of tension _ nerated is appropriate. The indications and contraindi­ 'ons for these contraction types are described in Chap­ r 4. Emphasize the importance of muscle relaxation be­ ~en exercise repetitions to ensure adequate blood flow to working muscles. Contraindications and precautions for active ROM are ame as those for active assisted exercise. tvluscle con­ tion that may disrupt the healing process or affect the li...idual's health status are contraindications to active . 1. The type of muscle contractions being performed uld be safe for the specific situation, and the clinician uld allow musde relaxation between repetitions.

USES AND EFFECTS OF PERMOBILITY

rex-

ough most clinicians are familiar with the treatment of ns vvith decreased mobility, many patients have prob­ related to excessive mobility. Most individuals do not - medical attention primarily for possessing excessive

mobility about a joint or throughout the body. More fre­ quently, patients seek medical attention for pain, fatigue , or tendinitis. These pathologies, impairments, and func­ tionallimitations often result from the hyper mobility. Hypermobility should be differentiated from instability. Hypermobility is excessive laxity or length of a tissue, and instability is an excessive range of movement, osteokine­ matic or arthrokinematic, for which there is no protective muscular control. Despite hypermobility, the individual may experience no symptoms of instahility. For example, individuals "vith ACL-deficient knees may have measur­ able antelior laxity (i.e., hypermobility) at the tibiofemoral joint with no symptoms of instability. Conversely, individu­ als may have complaints of instability or "giving way" with no measurable laxity. Hypermobility can be broadly categorized as excessive jOint mobility resulting from trauma or a genetic prediSpo­ sition or as excessive tissue length. Patients with traumatic or atraumatic hypermobility may seek medical attention for a number of complaints, which mayor may not include frank instability . Hypermobility at a joint caused by traumatic injury can lead to true instability, particularly at the glenohumeral joint, where a traumatic anterior inferior dislocation can re­ sult in recurrent dislocation . Similarly, sprains to the lateral ankle ligaments or medial knee ligaments can result in hy­ permobility and instability. Atraumatic hypermobility is common at the glenohumeral joint; persons \vith multidi­ rectional instability often seek medical attention for symp­ toms of rotator cuff tendinitis. At the knee, hypermobility can result in secondary patellofemoral pain. Hypermobility can develop in response to a relatively less mobile segment or region. In a multijoint system with common movement directions (e.g., spine), movement oc­

140

Therapeutic Exercise Moving Toward Function

curs at the segments providing the least resistance. Abnor­ mal or excessive movement is imposed on segments with the least amount of stiffness. With repeated movements over time, the least stiff segments increase in mobility, and the stiffer segments decrease in mobility. A thorough ex­ amination , seeking to ullderstand the iJllpairment con­ tributing to the hypermobility, is necessary.

THERAPEUTIC EXERCISE INTERVENTION FOR HYPERMOBILITY Treatment techniques for hypermobility should be di­ rected at the related impairments and functional limita­ tions and at the underlying causes of hyper mobility. For ex­ ample, a patient with hypermobility at the spinal level probably has pain and decreased mobility at adjacent seg­ ments. These impairm ents must be treated along with the underlying hypermobile segment. Although it is important to address the patient's current complaints, failure to rec­ ognize hypermobility as the underlying cause ensures the retum of symptoms. Hypermohility should be treated only if it is associated with instabihty or is producing symptoms elsewhere (i.e ., hypomobile segment) because of relative flexibility.

Elements of the Movement System The elements of the movement system are important in di­ recting treatment of hypermobility. For example, a patient with spondylolysis at L4 (j.e., anatomic impairment) demonstrates faulty dynamic posture with increased lum­ bar lordosis during movement (i.e. , impairment). This re­ sults in pain (i.e. , impairment) and an inability to run and jump (i.e., functional limitation) and to participate in high school SPOIts (i.e., disability). In this situation, the spondylolysis is the base element, and the faulty dynamic posture is the biomechanical ele­ ment. The spondylolysis is not amenable to physical ther­ apy intervention, although the biomechanical ele ment must be resolved to allow healing and prevent recurrence of the spondylolysis. The intervention should address the biomechanical element through stabilization exercises and postural exercises to be incorporated into daily activities.

Stabilization Exercises The concept of stabilization exercises gained popularity in the treatment of conditions of the spine. Stabilization exer­ cises are dynamiC activities that attempt to limit and control excessive movement. These exercises do not imply a static position, but rather describe a range of movement (i.e., the neutral range ) in which hypermobility is controlled. Stabi­ lization activities include mobility exercises for stiff or hy­ pomobile segments, strengthening exercises in the short­ ened range for hypermobile segments, postural training to ensure movement through a controlled range , and patient education. Supportive devices such as taping or braCing may be necessary initially to keep movement within a range where stability can be maintained. This range is different

for every patient and condition. Patient education focuses on helping the patient find the limits of stability and work within those limits. As mobility exercises to decre
Closed-Chain Exercise Closed-chain exercise has been advocated for those with joint instability or hypermobility. For the lower extremity, exercises such as squats, lunges, or step-ups with the foot fixed are commonly used closed-chain activities. For the upper extremity, any weight-bearing exercise performed in the push-up or modified push-up position is conside red to be closed-chain. Weight bearing with thc hands against the wall or on a table or counteltop is also an effective closed­ chain pOSition for the upper extremity. The rationale for this exercise is muscular co-contraction, decreased shear forces, and increased joint compression. Some of this the­ ory is supported by scientific and clinical research. 94 ,g5 Other studies dispute some aspects of this rationale, such as muscular co-contraction with a closed-chain posi­ tion. 96 ,97 Particularly for the lower extremity when the foot spends a lot of time in contact with the floor, using closed­ chain exercise for hypermobility makes good clinical sense. However, for the upper extremity, the closed-chain posi­ tion is rarely the pOSition of function. The closed-chain po­ sition remains an effective position for upper extremity training for individuals "vith hypermobility, but open ~chain stabilization techniques should be incorporated as well.

Chapter 7 Impaired Joint Mobility and Range of Motion

141

\[ore information on the effects of closed-chain exercise can be found in Chapter 16.

Open-Chain Stabilization pen-chain stabilization activities are availab le for the lower and the upper extremities. PNF techniques such as rh:1hmic stabilization and alternating isometrics can be u ed effectively to facilitate co-contraction about a joint (see Ch apter 15). These techniques are particularly effective in the latter stages of rehabilitation when performed in the po­ 'tion of instability, such as abduction and external rotation ' 0 1' treating anterior glenohumeral instability (Fig. 7-32). Stabilization exercises for the spine are difficult to cate­ ~orize, because the spine is often ftxed at one end and open t the other end. It is not a true closed or open system. Sta­ ilization exercises for the spine are often initiated in a upine position with abdominal braCing exercises and pro­ :ressed to sitting and standing positions. A variety of stabi­ .uation exercises can be performed on unstable surfaces uch as a gymnastiCS ball or foam rollers to improve stabil­ ry within a comfortable range. Sitting, prone, and supine tivities combined with arm reaching and leg lifts can be d from early to advanced stages of stabilization training Fig. 7-,33). Many of these same activities can be used to im­ rove stability throughout the upper and lower extremities.

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Ballistic Exercises

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Ballistic exercise has been shown to produce co-contrac­ on about a joint through triphasic muscle activation. tIiuh-speed ballistic activities result in different patterns of ~o n ist- antagonist muscle contractions from those of lower activities. Rapid ballistic movements result in syn­ hronous activation of agonists and antagonists6.9R99 In ntrast, the same move ment pattern at a slow speed

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FIGURE 7-32. Rhythmic stabilization performed in a position of appre­ ~

sion .

FIGURE 7-33. Sitting on a gymnastics ball while performing simultaneous arm and leg exercises is an example of an advanced spine stabilization ex­ ercise.

demonstrates only agonist muscle contraction, with brak­ ing provided by passive viscoelastic propelties 6 Although the viscoelastic properties also restrict movement at faster speeds, these propelties are inadequate to halt fast move­ ments H8 These rapid ballistic movement patterns can be used with resistive tubing, balls, or inertial exercise equip­ ment (Fig. 7-34). Th e amount of antagonist activity needed to halt a movement is rel ated to the velOCity of the activity. 98 Sub­ jects were asked to produce fast flexion movements of the thumb and fast extension movements of the elbow over three distances and at a variety of speeds. All movements resulted in biphasic or triphasic muscle contraction. A lin­ ear relationship was found between peak velOCity and the amount of antagonist activation needed to halt the move­ ment. Movements made through large angles (i.e., large amplitude) showed less antagonist activity than those made through small angles at the same speed, and fast, small­ amplitude movements demonstrated an earlier onset of an­ tagonist activity. The dis tance during fast movements is controlled primarily by the first agonist muscle contraction, and increasing antagonist torque is associated with de ­ creasing distance, ultimately controlling the movement time. 99 ProdUCing fast movements requires large agonist torque production, followed by an equally large or large r antagonist torque. One study concluded that qUick movements through small distances result in a large, qUick antagonist burst and that slow movements over a long distance result in small and late antagonist bursts. 88 The antagonist burst timing is not speCified solely by size; it is also a function of the move­ ment amplitude. Timing and amplitude are regulated by

142

Therapeutic Exercise Moving Toward Function

FIGURE 7·34. (A) Performance of rapid alternating shoulder flexion and extension at end range of motion us­ ing impul se inertial exercise system . (B) Simi lar activity performed with tubing .

the central nervous system . For example, flexing and ex­ tending the hip rapidly tbrough a very small range elicits co-contraction of agonist and antagonist musculature, but fl exing and extending slowly through a large range elicits reciprocal activation of the agonists and antagonists . If hip and pelvic stabilization is the goal, small-amplitude, fast movements are more likely to elicit co-contraction than slow, large-amplitude movements. Anoth er factor that affects antagonist activit)' is the sub­ ject's knowledge of the necessity for such a contraction. On study provided a mechanical stop for preventing further movement in some elbow flexion and extension tasks 98 When the subjects knew that the stop was in place, the an­ tagonist burst disappeared after two or three trials. This re­ sulted in a faster movement, suggesting that the antagonist activity brakes and slows the motion. Some cognitive con­ trol over the braldng mechanism exists. This research supports the use of rapid, alternating movem ents , moving qUickly through a short distance. Large-amplitude movement does not produce the same muscular coactivation as small-amplitude move ment.

Exercise Dosage Dosage parameters depend on the pUipose of the exercise and the patient's tolerance for the activity. Any time rapid, alternating movements are used , fatigue can alter the proper performance and thus the outcome of treatment. Watch for signs of fatigue that result in substitution pat­ terns or loss of the desired stabilization. For rapid move­

ments , sets for time often work better than a set number of repetitions. Patients can try to increase the number of rep­ etitions of an exercise within the timed set. As v;-ith " I other exercise prescription, peJform the ex­ ercise to fati ,ue v\-ithout lOSing control. Monitor the time or number of repetitions, and , as the patient improves. change the exercise parameters to continue increasing the challenge. This may include increasing tbe resistance , rep­ etitions, or speed, or decreaSing the rest interval.

Precautions and Contraindications An important precaution when treating areas of hypermo­ bility is to ensure that areas of relative fleXibility are identi­ fled. Stretching techniques to improve mobility in a hypo­ mobile area may increase hypermobility in an adjacen t area. Reinforce correct dynamic stabilization to ensure that intervention is isolated to the correct segment. For exam­ ple, failure to stabilize the peh-is during hip flexor stretch­ ing increases lumhar extension, potentiaUy increasing hy­ permohility in this area. Any time dynamic stabilization activities are being per­ formed at the limits of stability (e.g. , resisted shoulder rota­ tion at 90 degrees abduction and full external rotation in a hypermobile shoulder), be sure that the individual has ade­ quate control to prevent instability or dislocation. Progress activities according to th e patient's ability to control the lim­ its of stahiJity. Fatigue of dynamic stabilizing musculatur places the patient at risk for injury, and the fatigue level should be monitored throughout the exercise session.

Chapter 7: Impaired Joint Mobility and Range of Motion

Many stabilization exercises use eccentric muscle con­ traction to provide stability. Eccentric contractions are as­ sociated with delayed onset muscle soreness (see Chapter 5l. fatigue, loss of control, and substitution. Consider this in the exercise dosage. Watch the patient closely for signs of tigue and loss of control because the patient could be in­ red or develop excessive muscle soreness. Any time activities are performed on a single limb, use _ ution to prevent falling and ensure that Single-leg stance indicated. Individuals vvith degenerative joint disease at the primary or adjacent joint may experience a symptom cerbation due to excessive loads on the limb. A pool can "1linimize the quantity of weight bearing while performing merle-leg stance activities (see Chapter 17).

FESPAN ISSUES

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Sure to consider that most studies on stretching and bility exercises have been performed on young and mid­ -age adults, and few have been performed on children ~ the elderly. However, because of the aging of the popu­ . n, more and more studies are being carried out on the erly to determine how their responses to treatment dif­ f from that of younger individuals. As noted in the section Stretching, the elderly benefit from holding their tches for a longer time than do younger individuals. As with many adults, children exhibit variable degrees of bility, from shortened and tight muscles to hypermobil­ In general, flexibility remains relatively stable throu&l : ,and then declines until about the ages of 11 to 15. 0 - .is decline is probably because of the adolescent growth rt . As with adults, flexibility in children can be improved . the stretching techniques outlined in this chapter. JOint mobilization techniques are not commonly used in - dren, although there may be special cases in which this hnique is indicated. JOint mobilization has been consid­ ~ for children with central nervous system disorders ~h as cerebral pal sy lOl As with adults, the primary indi­ 'on for use in this population is joint hypomobility re­ ...:.tin from capsular tightness. However, use caution when g joint mobilization in any child. It may be contraindi­ ed in some situations, such as Down's syndrome in which t hypermobility secondary to jOint laxity is generally the . Additionally, in any child with open epiphyses, the po­ nal damage to the growth plate must be balanced against _ potential benefits of joint mobilization. Alternative in­ "".-entions to increase mobility may be safer choices. ther issues exist at the older end of the lifespa~. JOint bility and muscular flexibility decline with aging. 'a Con­ 've tissue changes occurring with aging impact the use _ int mobilization and stretching exercises. Aging muscle _ eases in stiffness as measured by passive length-tension t , and the amount of muscle area occupied by connec­ 102 t:' tissue also increases Feland et al. (0 suggest using 'c stretching over PNF stretching because the muscles the elderly are more susceptible to contraction-induced ill)' and have decreased capacity to recover from such in­ ~-. Older individuals have demonstrated greater muscle :JIness and a lower tolerance for stretching. Rl

143

Additionally, jOint ROM decreases with aging. Declines of 20% in hip rotation and 10% in wrist and shoulder mo­ tion have been reported. 10" Vlalker 104 showed declines in the lower e.\.iremity joint ROM of up to 57%. A 25% de­ crease in trunk side bendin; between the ages of 20 and 60 have also been reported, 10 Before performing joint mobi­ lization in the elderly population, consider their decreased joint capsule tensile strength, diminished articular cartilage water content, and increased bone fragility, Joint mobiliza­ tion should be approached cautiously because of all these connective tissue changes,

ADJUNCTIVE AGENTS Clinicians often use various treatments or techniques to enhance the effects of another treatment. Forms of tissue heating are the most common adjunctive agents used in combination with ROM exercises to increase mobility, The ability of collagen to be easily and safely deformed or stretched is enhanced by increasing the temperature of the collagen, Because muscle is primarily composed of colla­ gen, the ability of the muscle to be stretched may be en­ hanced by increaSing the temperature of the muscle 40 The critical temperature for benefici,al effects appears to be ap­ proximately 39°C or 103°F. 10 ,lo.:>-108 Intramuscular temperature may be increased by heating modalities or through exercise. The therapeutic tempera­ ture reqUired may be effiCiently achieved for the time nec­ essary to complete a flexibility pro@mm using a deep­ heating modality such as ultrasound 1 9,110 PhYSiologically, the easiest and most appropriate way to increase intramus­ cular temperature is through the use of exercise, Active, submaximal resistive exercise of the muscle groups to be stretched should be performed before stretching. This type of exercise is capable of prodUCing temperature increases to approximately 39°C after 10 to 15 minutes. Heating techniques may prepare the tissue for mobility activities by increasing the tissue temperature, promoting relaxation and pain reduction, and increasing the local cir­ culation, Forms of heat other than exercise can be catego­ rized broadly as superfiCial-heating and deep-heating agents. Although heat can increase local circulation and temperature, it is not a substitute for warm-up exercises before a planned activity. A warm-up exercise such as walk­ ing, bicycling, upper body ergometry, or active ROM exer­ cise should take place before any therapeutiC ROM activi­ ties. This approach increases core temperature and prepares surrounding tissues for the forthcoming activity,

Superficial Heat The most common superfiCial heating agents include hot packs, paraffin, and warm whirlpools. These agents pri­ marily increase skin temperature, with little penetration of heat to deeper tissues. Skin temperature increases are the greatest within the first 0.5 cm from the surface, with some increase in muscle temperature at 1 to 2 cm and less heat­ ing at 3 cm,l1l To achieve temperature elevations at in­ creaSing depths, a treatment time of 15 to 30 minutes is

144

Therapeutic Exercise Moving Taward Function

nec('ssalyIll The depth of penetration is significantly af­ fected by the tissue composition. Areas with less soft tissue heat deeper than areas with greater subcutaneous fat. For example, superficial heat applied to the hands can increase tissue temperature to the jOint, but heat applied to the thigh has only shallow penetration. Hot packs are frequently used over larger surface areas such as the low back, thigh, and knee. Smaller areas such as the hand are more amenable to warm paraffin. The pa­ tient usually sits qUietly while the treatment is applied. This produces relaxation but may leave the individual un ­ prepared for Vigorous exerc ise. In contrast, a warm whirlpool can provide superficial heating while simultane­ ously allowing exercise to be performed. Active, passive, or resistive ROM exercises can be performed while in a warm whirlpool, thereby extending the benefits of this heating modality.

!Deep Heat Ultrasound is the most common form of deep heat used in the clinic. The effects of ultrasound are mechanical and thermal, although in this context, the thermal effects are emphasized. The specific effects and depth of penetration are affected by the tissue type, the ultrasound wavelength or frequency, and the intensity. Ultrasound has the ability to elevate tissu e temperatures to depths of 5 cm or more. llJ The temperature elevation in tissue has been as­ sociated with increases in collagen ell.iensibility, changes in nerve conduction veloCity, and increases in the paih threshold. Ultrasounu intensities necessalY to achieve tis­ sue temperatures to a range of 40°C to 45°C range from 1.0 to 2.0 W /c m 2 delivered continuously for 5 to 10 minutes. lll Th e effects of ultrasound on tissue healin~ and tissue eX­ tensibility have been studied. Reed et al. ll examined the effects of continuous ultrasound on knee medial collateral ligament extenSibility. The authors found that ultrasound did not increase extenSibility beyond the effects of stretch­ ing. Although heating the tissue may not affect its extensi­ bility, low-intensity ultrasound may facilitate healing. En­ wemeka et al. 1 13 found that nine treatments oflow-intensity ultrasound to the rabbit Achilles tendon resulted in signifi­ cant increases in tensile strength , tensile stress, and energy absorption caracity compared with sham ultrasound . Ramirez et al. 1 4 expanded these results , shOWing that low­ intensity ultrasound to rat Achilles tendons stimulated col­ lagen syntheSiS in tendon fibroblasts. Additionally, ultra­ sound stimulated cell division during periods of subsequent rapid cell proliferation. Superficial heat such as a hot pack commonly is used in combin ation with ultrasound to enhance the effects of treatment. The hot pack promotes relaxation and therefore increases the patient's tolerance for stretching, and the deep heat produces changes in the collagen elastiCity, preparing it for subsequent stretching. If extensibility gains are to be maintained after the heat and stretching session, stretching should be performed as the muscle cools to its preheated temperature. Ideally, this new length should be maintained for an extended period

after the therapy session. This can be done by the use of splints or continuous passive motion devices .

KEY POINTS • The effects of immobilization on the injured and unin­ jured soft tissues are profound. All tissues are affected, including insertion sites and bone. • These effects are the result of the speCific adaptations to imposed dem ands prinCiple; tissue responds to loads placed on them . When und erloaded, the tissu e weakens. • The period needed to restore normal structural and me­ chanical properties to immobilized tissue can be two or more times the immobilization period. • JOint ROM should be differentiated from muscle ROM. The specific goal dictates the type of mobility activity prescribed. • A variety of contractile and noncontractile tissues can limit mobility at a jOint. • Passive ROM exercise is a mobility activity performed without muscle contraction. Active assisted ROM is a mobility activity in which som e muscle activity takes place, and active ROM exercise uses active muscle con­ traction to perform the exercise. • To increase flexibility , stati c, ballistic, and P!\f stretching techniques can be used. The type of stretch chosen depends on the individual's impairments ami lifestyle. • Joint mobilization is an integral component of a com­ prehenSive mobility program when capsular restriction is a key finding. • Pulleys, machines, the pool, or objects found in the home or office can be used to perform mobility exercises. • Mobility exercise prescription depends on the speCific goal of the activity and the environment in which it will be performed. • Hypermobility can be as disabling as hypomobility. Sta­ bilization exercises such as closed-chain and rapidly al­ ternating movements may be incorporated. • Adjunctive agents such as heat can be used to enhance mobility activities.

CRITICAL THINKING QUESTIONS

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1. Consider Case Study #2 in Unit 7. a. Although the patient needs to increase knee range of motion in both flexion and extension, which direc­ tion would you emphaSize first and why? b. Discuss the advantages and disauvantages for variou exercise modes to increase this patient's active knee range of motion. 2. Consider Case Study #4 in Unit 7. a. How would your treatment differ if the patient were an elderly woman with severe osteoporoSiS? b. How would your treatment differ if the patient were 25 years of age and the joint accessory motion testin result indicated hypermobility?

Chapter 7 Impaired Joint Mobility and Range of Motion "I ~

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LAB ACTIVITIES

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Perform the following activities with your partner. Not all positions are optimal for performing each of the ex­ ercises, but the clinician occasionally is unable to change the patient's position . If not the optimal position, which position would be better and why? 1. With your patient in supine, perform the following: a. Passive ROl\·I shoulder flexion b. Active assisted ROM shoulder abduction c. Passive ROM shoulder internal and external rotation d. Contract-relax stretching for pectoralis major e. Passive ROM hip and knee flexion f. Contract-relax-contract stretching of the ham­ stling muscles g. Passive ROM lumbar flexion h. Passive ROM lumbar rotation .~ With your patient sitting, perform the following: a. Passive ROM hip internal and external rotation b. Active assisted ROM knee extension c. Contract-relax stretching hip internal rotator muscles d. Active assisted ROM shoulder flexion e. Active ROM shoulder abduction 3. VVith your patient in a sidelying position, perform the following: a. Passive ROl\'I shoulder extension b. Active assisted ROM shoulder abduction c. Contract-relax stretching shoulder internal rota­ tor muscles d. Active ROM shoulder t1e;..ion .t. With your patient in a prone pOSition, perform the following: a. Active assisted ROM elbow extension b. Passive ROM hip internal and external rotation

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145

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c. ARO~I shoulder flexion d. Contract-rela, stretching hip flexors e. Contract-relax-contract stretching for gastroc­ nemius f. Contract-relax-contract stretching for soleus Decide how to best position your patient for the fol­ lowing: a. Active ROM shoulder external rotation in a grav­ ity minimized position b. Active ROM scapular elevation c. Active ROM wrist extension in a gravitv-minimized position ' / d. Contract-relax stretching of hip adductor muscles e. Active ROM shoulder abduction in a gravity-min­ imized position f. Passive ROM cervical rotation g. Static stretching of the tJiceps muscle Choose five of the previous exercises and write a description of those exercises for a patient in a home exercise program. Include a picture of the exercise. Consider Case Study #6 from Unit 7. Instruct your patient in the first phase of the exercise program. Ex­ plain and demonstrate. The clinician is treating a postal worker v.ith rotator cuff tendinitis resulting from hyperrnohility. This man sorts mail all day at eye level. The rotator cuff tendinitis has resolved with intelvention. Instruct this patient in an exercise program to treat the insta­ bilit:y. E;"'Plain and del11onstrate.

Instruct a patient in a self-stretching program for the quadriceps, hamstrings, and iliotibial band. Explain and demonstrate three different stretches for each muscle group.

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fFERENCES ~. Magee

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Chapter 7 Impaired Joint Mobility and Range of Motion

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52. Hayes KW, Peterson C, Falconer J. An examination of Cyr­ iax's passive motion tests with patients having osteoarthritis of the knee. Phys Ther 1994;74:697-709. .53. Frank C, Akeson WH, Woo SL-Y, et al. Physiology and ther­ apeutic value of passive joint motion. Clin Orthop 1984;185:113-125. 54. Cornelius W, Jackson A. The effects of cryotherapy and p, F on hip extensor flexibility. J Athletic Training 1984; 19:183-184. .).5. deVries HA. Prevention of musc ular distress after exercise. Res Q 1961;32:177-185. 56. deVries HA. E valuation of static stretching procedures for improve ment of flexibility . Res Q 1962;33:222- 229. -7. deVries HA . The "looseness" factor in speed and oxygen consumption of an anaerobic 100 yard dash. Res Q 1963; 34:305-313. ') Loudon KL, Bolier CE, Allison KA , et aI. Effects of two stretching methods on the flexibility and retention of flexi­ bility at the ankle joint in runners. Phys Ther 1985;65:698. 59. Moore M, Hutton R. Electromyographic investigation of muscle stretching techniques. Med Sci Sports Exerc 1980;12:322-329. 60. Prentice WE. A comparison of static stretching and PNF stretching for improdng hip joint fl exibility. J Athletic Training 1983;1S:56-59. l. Sady SP, Wortman M, Blanke D. Flexibility training: ballis­ tic, static or proprioceptive neuromuscular facilitation? Arch Phys Med RehabiI1982;63:261-263. 62. Tanigawa MC. Comparison of the hold relax procedure and passive mobilization of increasing muscle length. Phys Ther 1972;52:725-735. 63. Voss DE, Ionta MK, Myers GJ. Proprioceptive Neuromus­ cular Facilitation: Patterns and Techniques. 3rd ed. Philadelphia: JB Lippincott, 1985. Wallin D, Ekblom B, Grahm R, et aI. Improvement of mus­ cle flexibility: a comparison between nvo techniques. Am J Sports Med 1985;13:263- 268 . - Zebas CJ, Rivera ML. Retention of flexibility in selected joints after cessation of a stretching exercise program. In: Dotson CO , Humphrey JH , eds: Exercise PhYSiology: Cur­ rent Selected Research Topi cs New York: AMS Press, 1985. 66. Crutchfield CA, Barnes MR . The NeurophYS iological Basis . of Patient Treatment. Voir. The Muscle Spindle, 2nd ed. West Virginia: Stokesville Publishing Co., 1972. , . Ban dy WD , Irion JM. The effect of tim e of static stretch on the flexibility of the hamst ring muscles. Phys Ther 1994;74: 845-852. Lentell G, Hetherington T , Eagan J, et al. The use of thermal agents to influence the effectiveness of a low-load prolonged stretch. J Orthop Sports Phys Ther 1992;5: 200-207. 9. Madding SW, Wong JG , Hallum A, et al. Effects of duration of passive stretching on hip abduction range of motion. J Or­ thop Sports Phys Ther 1987;8:40~16. - 0. Feland JB , Myrer JW, Schulthies SS , et. al. The effect of du­ ration of stretching of the ham string muscle group for in­ creasing range of motion in people aged 65 years or older. Phys Ther 2001;81:1110-1117. 71. Entyre BR, Abraham LD . Antagonist muscle activity during stretching: a paradox reassessed . Med Sci Sports Exerc 1988;20:285-289. - 2. Entyre BR, Abraham LD . Ache-reflex changes during static stretching and two variations of proprioceptive neuromus­ cular facilitation techniques . Electroencephalogr Clin Neu­ rophysioI1986;63:174-179.

147

73. Entyre BR , Lee EJ. Chronic and acute fleXibility of men and women using three different stretching techniques. Res Q 1988;222:228 . 74. Shindo M, Harayama H, Kondo K, et aI. Changes in reCip­ rocal Ia inhibition during voluntary contraction in man. Exp Brain Res 1984;53:400-408. 75. Zachazewski JE. FleXibility for sport. In: Sanders B, ed. Sports Physical Therapy. Norwalk, CT: Appleton & Lange, 1990. 76. Zach azewski JE . Improving flexibility. In: Scully RM, Barnes MR, eds. Phys ical Therapy. Philadelphi a J.B. Lip­ pincott, 1989. 77. Hutton RS . ~euromu sc lliar basis of stretching exercises. In: Komi P\', l,d. Stre ngth and Power in Sports. Boston: Black­ well Scientific, 1992:29-38. 78. Tillman LJ , Cummings GS. Biologic mechanisms of con­ nective tissue mutability. In: Currier DP, Nelson RM , ed. Dynamics of Human BiologiC Tissues. Philade lphi a: FA Davis , 1992. 79. Magnusson SP, Aagard P, Simonson EB , et al. A biome­ chanical evaluation of cyclic and static stretch in human skeletal muscle. Int J Sports Med 1998;19:310-316. 80. Magnusson SP, Aagard P, Simonson EB , et al. Passive ten­ sile stress an d energy of the human hamstring muscles in vivo. Scan J Med Sci Sports Exerc 2000;10351- ,).'59 8l. Magnusson SP. Passive properties of human skelE'tal lIl11scJe during stretch maneuvers . A review. Scan J Med Sci Sports E xerc 1998;8:65-77. 82. Stopka C , Morley K, Siders R, Schuette J, et al. Stre tchin g techniques to improve fleXibility in Special OlympiCS ath­ letes and their coaches. J Sport Rehab 2002;11 :22-34. 83. H agbarth KE , Hagglund ]V, Nordin M, et al. ThLxot ropic behavior of human finger flexor muscles ,vith accompanying changes in spindle and reflex responses to stretch. J Physiol 1985:368:323-342. 84. DePino GM , Webright WG, Arnold BL. Duration of main­ tained hamstring flexibility after cessation of an acute static stretching protocol. J Athletic Train 2000;35:56-59. 85. Guide to Physical Therapist Practice. 2nd Ed. 2001;81: S680. 86. Maitland GD. Vertebral manipulation. 5th ed, Buston: But­ terworth , 1986. 87. Kalte nhorn FM . The spine: basic evaluation and mobiliza­ tion techniques. MinneapoliS : Orthopedic Physical Therapy Products, 1993. 88. Hsu AT, Hedman T , Chang JH, et al. Changes in abduction and rotation range of motion in response to simulated dor­ sal and ventral translational mobilization of the gleno­ hume ral joint. Ph)'s Ther 2002;82:544- 556. 89. Roubal Pl, Dobritt D, Placzek JD . Glenohumeral gliding manipulation follOWing interscalene brachial plexus block in patients ,vith adhesive capsulitis J Orthop Sports Phys Ther 1996;24:66-77. 90. Vermeulen HM, Obermann WR, Burge r BJ, et al. End­ range mobilization techniques in adh esive capsuLitis of the shoulder joint: a multiple-subj ect case report. Phys Ther 2000;80:1204-1213. 9l. Howell SM , Glainat BJ, Renzi AJ, et al. Normal and abnor­ mal mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint Surg 1988;70A:227-232. 92. Harryman DT II, Sidles JA, Clark JA, et aI. Translation of the humeral head on the glenOid with passive glenohumeral motion. J Bone Joint Surg 1990;72A:1334-1343. 93. \Villiams PE , Golkspink G. Changes in sarcomere length and phYSiolOgical properties in immobilized muscle. J Anat 1978: 127:459-468.

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104. Walker JM , Sue D, Miles-Elkousy N, et a!. Active mohility of the extremities in older subjects. Phys Ther 1984;64: 919-923 105. Lehmann JF, Masock AJ, Warren CG, et al. Effect of ther­ apeutic temperatures on tendon extensibility. Arch Phys Med Reh abil 1970;51:481-487. 106. Rigby JF, Hirai N, Spikes JD, et al. The mechanical proper­ ties of rat tail tendon. J Gen PhysioI1959;43:265-283. 107. Rigby JF. The effect of mechanical extension upon the ther­ mal stabi'lity of collagen. Biochem Biophys Acta 1964;79: 334-363. 108. Warren CG, Lehmann JF, Koblanski JM , et al. Elongation of rat tail tendon: effect of load and temperature. Arch Phys Med RehabiI1971;.52:465-474. 109. Draper DO , Ricard MD. Rate of tempf'rature decay in human muscle follovving 3 MHz ultrasound: the stretch­ ing windo w revealed. J Athletic Training 1996;30: 304-307. 110. Rose S, Draper DO, Schulties SS, et al. The stretching \.\~n­ dow part two: rate of thermal decay in deep muscle follOwing I-MHz ultrasound. JAthletic Training 1D96;31:139-143. 111. Michlovitz S, ed. Thermal Agents in Rehabilitation. 2nd ed. Philadelphia: FA Davis, 1990. 112. Reed BV, Ashikaga T, Fleming Be, et al. Effects of ultra­ sound and stretch on knee ligament extensibility. J Orthop SPOIiS Phys Ther 2000::30:341-347. 113. Enwemeka CS , Rodriguez 0, Mendosa S. The biomechani­ cal effects of lOW-intensity ultrasound on healing tendons. Ultrasound Med BioI 1990;16:801-807. 114. Ramirez A, Schwane lA, McFarland C, et a!. The effect of ultrasound on collagc~ synthesiS and fibroblast proliferation in vitro. Med Sci Sports Exerc 1997;29:326-332.

chapter 8

Inlpaired Balance LORI

THEI~I

BRODY and JUDY DEWANE

Definitions Physiology of Balance Contributions of Sensory Systems

Processing Sensory Information

Generating Motor Output

Motor Learning

auses of Impaired Balance Effects of Training on Balance xamination and Evaluation of Impaired Balance ctivities for Treating Impaired Balance Mode

Posture

Movement

Dosage

recautions and Contra indications atient Education ...ance is an important consideration when rehabilitating ents with a variety of disorders, and balance training is reasingly being integrated into clinical practice.l~4 De­ e the increased clinical application of this training, the .mitions of many terms remain unclear. "Vhen impaired ility or muscle performance cannot account for an in­ dual's disability after an injury or surgery, the disability - meti mes attributed to a "lack of proprioception." Neu­ ~c specialists may describe uncoordinated movement cl\ kinesia in a patient after head injury or stroke. Or­ paedic and neurologic clinicians describe increased rural sway and poor balance in elderly patients or pa­ with osteoarthritis. Sports specialists report that elite etes lack proprioception or kinesthesia, resulting in in­ _'. Are all of these persons talking about the same thing?

INITIONS rdination is the ability to perform smooth, accurate, controlled movements. 5,6 Coordination is necessary for .,. execution of fine motor skills such as writing, sewing, ing, and the manipulation of small objects. Coordina­ i also necessary when performing gross motor skills as walking, running, jumping, occupational tasks, and 'c and instrumental activities of daily living. Coordi­ ecl movements involve proper sequencing and timing of

synergistic and reciprocal muscle activity, and they require proximal or "core" stability and maintenance of a posture .·5 The concept of coordination includes balance. Balance is the ability to maintain equilibrium or the ability to main­ tain the center of gravity (COG) over the base of support (BOS).6 Postural stability rom sway is the normal, contin­ uous shifting of the body's COG over the BOS. When a person is able to keep sway within the limits of stability, balance is maintained (postural stability). When sway ex­ ceeds these limits, a corrective strategy is necessary to prevent falling. 7 Balance requires the person to maintain a position, to stabilize durin~ voluntary activities, and to react to external perturbations. ,9 Despite the simplicity of this definition, the ability to maintain balance requires effective and effI­ cient coordination among multiple sensory, biomechanical, and motor systems. Vestibular dysfunction, visual impair­ ment, or diminished proprioception can impair balance. Treatment of impaired balance requires a detailed exami­ nation to determine the system at fault.

PHYSIOLOGY OF BALANCE Identifying causes of and prescribing treatment for balance impairment requires an understanding of the systems en­ gaged in balance control and their normal interactions . These systems prOvide input into the central nervous sys­ tem. The information must be processed and an appropri­ ate motor strategy chosen and executed. The syste ms model of motor control defines postural stability as the ability to maintain the COG within stability limits.7,lO These limits are the spatial area in which the individual can maintain eqUilibrium without changing his or her BOS. A certain amount of anteroposterior and lateral sway nor­ mally occur while maintaining balance. This sway envelope defines the limits of stability in anterior, posterior, and lat­ eral directions. Normal anteroposte rior sway in adults is 12 degrees from the most posterior to the most anterior position. l l Lateral stability limits vary with foot spacing and height. An average-height adult with 4 inches between the feet can sway apprOximately 16 degrees from side to side. II This stability limit is often characterized by a cone of sta­ bility (Fig. 8-1A and B). As long as the individual's swayen­ velope stays vvithin the limits of stability, balance is main­ tained. When the COG is aligned in the middle of the sway envelope, 12 degrees of anteroposterior sway and 16 de­ grees of lateral sway can easily occur. If sway exceeds these limits, some strategy must be employed to regain balance. 149

150

Therapeutic Exercise: Moving Toward Function

A

B

c

FIGURE 8-1. Relationships of the limits of stability, the sway envelope, and the center of gravity (COG) alignment. (A) The li mits of stability are described by a cone-shaped sway envelope. (8) When the COG is aligned in the center, the sway envel'ope rema ins within the limits of stabil ity (e) When the COG is offset. as in a forward leaning posture, the sway en­ velope exceeds the limits of stabi lity, and a balance restoration strategy must be implemented to regai n balance.

If an individual's COG is aligned more ante rior, posterior, or late ral than center, a small er sway envelop is tolerated before losing balan ce (see Fig. B-IC) ll F or example, a pa­ tient with Parkinson's disease or a patien t with a significant thoracic kyphosis may have a static or dynamic anterior posture, decreaSing the tolerance for anterior sway.

Contributions of Sensory Systems Three sensOlY systems contribute to the maintenance of upright posture: visual, vestibular, and somatosensory. They are considered to be thc se nsory triad of postural con­ trol (Fig. 1)-2). The systems model suggests inte ractions among the individual, the pnvironment, and the functional task, with a circular nel:\vork of subsyste ms interacting to maintain stability and produce move ment. 6 Any of these systems may dominate , and all are context dependent. No single sense directly determin es the position of the body's COG; the combined feedback from each svstem must be integrated. The visual and somatosensory ~ystems gather information from th e environment (e.g. , position relative to other objects , stability of the surface), and the vestibular system provides an internal refe rence, proviuing informa­ tion about the head's orientation in space] :2

adapting endings are angle-specific and fire continuously as long as the joint is held at a specific angle , providing infor­ mation about jOint pOSition. Pacini form cOl1Juscl es signal joint movem e nt, but they give littLe information about the final joint position. i :3 They are rapidly adapting stmctures with a low threshold to mechanical stress. These receptors are activated primarily by acceleration and deceleration. T b e Golgi-Mazzoni corpuscles are slow-adapting receptors sensitive to joint capsule compression in a plane p erpen­ dicular to its surface , The Golgi l'igament endings are also slow-adapting receptors that are se nsitive to ligament ten­ sion or stretch. Free nerve endings are th e articular noci­ ceptive system that are activated by mechanical deforma­ tion or chemical irritation. 14 These receptors work togeth er 'with varying functions and features to provide information about movement and jOint position , I nformation from these re ceptors is relayed to the medulla and brain stem th rough th e dorsal column me­ uial-Iemniscal pathway.13 T his infom1ation assists in coor­ dinating eye, head, and neck movements to stabilize th e vi­ sual system and in maintaining postures amI coordinate d move ment patterns 1 4 JOint afferent information does not . contribute to a conscious sense of pOSition, 14. 15 This con­ clusion is base u on studi es in which local allesthetization of jOint tissues failed to reduce joint position aware ness and total joint replacement did not diminish jOint pOSition se nse. 16 The gamma system (see Chapter 7) may be bettf'r suited than the alpha system for delivery of complex information needed for the regulation of m ove ment. T he gamma sys­ tem regulates stiffn ess in the muscles supporting the joint. By maintaining muscle tone , appropriate posture, and stiff­ ness in the muscles, adjustments in prep aration fo r move­ ment can be made. T he gamma motor syste m is aided by the joint afferent system and provides both additional posi­ tion sense information and preparatory muscle stiffness ad­ justments. The joint afferent information assists the muscle spindle afferent fibers during unexp ected postural pertur­ bations. Stretching ligam ents about the joint (thereby stim­ ulating joint receptors ) increases the firing frequency of primary spindle affere nts. Remembe r that firing the pri­ mary spindle aHe rents facilitate s contraction of the agonist muscle. The muscle spindle fibers appear best suite d for providing joint position sense , and tIle role of jOint affe r­ ents may be regulation of muscle stiffn ess, rather than fUllctioning as mechanical restraints or uetectors of motiOll

Somatosensory Neurophysiology T he somatosensory system provides information ahout the relative location ofhody parts. The te rm proprioception re­ flects the static position , and kin esthesia r efers to the posi­ tions during moveme nt. F or example, when a person steps onto a rug that slips be ne ath his or her foot , the accele ra­ tion of the slipping limb provides the first information to the system, Information from the somatosensory syste m arises from peripheral sources such as the muscle, join t capsule, and other soft-tissue structures. Free nerve endings, Huffini endings, and paciJ1iform corpuscles are found in the jOint capsule. Ruffini endings are encapsulated endings that re­ spond to passive and active movement. 13 These slowly

Visual

Somatosensory

FIGURE 8-2. The triad of balance control.

Vestibular

Chapter 8: Impaired Balance

limits. Intrinsic muscle stiffness is always present and may be the first line of defense against perturbations. The somatosensory system plays an important role in regulating posture. Information must be detected periph­ rally and transmitted centrally for processing. The periph­ ral receptors are an important source of that information.

Visual and Vestibular Neurophysiology The visual and vestibular systems contribute Significant in­ fo rmation about th e body's position and movement in space. The visual system provides information about the position of the head relative to the environment and orients the head to maintain level gaze. This system contributes 'unificantly to head and neck posture. The visual system o provides information about the movement of sur­ rounding objects , thereby providing information about the peed of movement. Information entering the visual sys­ em travels through the optic nerve to the lateral geniculate llcleus of the th alamus to the superior colliculus and ouah a few fibers to the inferior olivary nuclei. The lat­ ra.l ge niculate nucleus receives the large'st projection and e first center where information from the retina is rep­ nted,17 From here, neurons project to the primary vi­ :al cOliex in the occipital lobe (Brodmann's area 17). The vestibular system provides information on orienta­ n of the head in space and on acceleration, Any move­ nts of the head, including weight shifts to adjust posture, 1Ulate the vestibular receptors, The vestibular nerve pro­ to the vestibular nuclei and to the cerebellum, The tibular nuclei also receive input from other sensory sys­ . including the visual system, From the v stibular nu­ L two vestibulospinal tracts descend to the spinal cord for tll ml control. 17 Ascellding projections include fibers to .trol eye movements and fibers to the thalamus, From thalamus, projections ascend to tl1e head of the caudate . eus and to the palietai association area, where the in­ -mation is integrated with other sensory information,

ocessing Sensory Information pr information arrives from peripheral receptors , the in­ ation must be analyzed, The relative contributions ach system and integration of each system's infor­ 'on are critical. Integration and processing of incoming rmation occurs in the cerebellum, basal ganglia, and pi mentary motor area. J ,) The time required to process in formation is important, particularly when a qUick re­ e is n cessary, Generally, the somatosensory system rmation is processed bstest, followed by the inform a­ from the visual and vestibular systems JH nsory organization is ilie process of resolving conflict­ _ input; it is necessary because incoming information a system may be inaccurate, For example, consider g stationary on a train in a station when an adjacent b gins moving forward. The visual1nput is unable to ct whether that train is moving forward or your train is mg backward, The brain must resolve inaccurate input the visual system with the accurate information from omatosensory and vestibular systems, Inform ation the visual system (e ,g" moving'visual fields) and th e tosensory system (e,g" moving sidewalks, compliant

151

surfaces) is susceptible to error. If an injury decreases the inform.ation processing rate, balance may be impai red, Other systems may adequately compensate for impair­ ments in one system, and this concept is the basis for many treatment programs,

Generating Motor Output After the sensory information is transmitted centrally, tlle information is processed, and a response is selected, the re­ sponse output must be executed. This response program­ ming is influenced by the movement and is the stage most often manipulated in treatment. 19 Complex movements take longer to process and program than simple tasks, Al­ though a multitude of postural responses are available when someone is destabilized, three automatic responses are common, These preprogrammed synergies are the funda­ mental movement unit engaged when balance is dis­ turbed,6,9 Ratl1er than determining which muscles to acti­ vate and when, the brain only needs to know which synergy to engage, when to engage it, and at what intensity to re­ spond, This is an example of feedforward control, or open­ loop con trol. In feedforward control, movement occurs too fast to rely on sensory feedback. Responses are prepro­ grammed and automatic, In contrast, feedback control, or closed-loop control, movement relies on feedback. It is used to learn preCision movements, Treatment procedures focus on these preprogrammed synergies to maintain postural control. However, remember that the motor output is situ­ ation dependent. The response to a stimulus will vary de­ pending on the environment in which it is elicited, Be sure to vary the treatment environment; this allows the patient to develop movement strategies in a variety of situations, Three fundamental movement strategies to maintain equilibrium have been identified: the ankle strategy, the hip strategy, and the stepping strategy,20 These strategies depend on the intensity of the disruption , the subject's awareness, and the subject's posture at the time of pertur­ bation. The ankle strategy is the most commonly used, par­ ticularly when displacements are small. The ankle synergy displaces the COG plimarily by rotation about the ankle joint (Fig, 8-3), Posterior displacement of the COG results in dorsiflexion at the anklle, with contraction of the anterior tibialis , quadriceps , and abdominals to control the back-

FIGURE 8-3. Ankle strategy in response to small perturbations,

154

Therapeutic Exercise Moving Toward Function

The ancient art of T' ai Chi Chuan has been studied ex­ tensively for its effects on impairments in the elderly, Lan 41 studied the effects of Tai Chi on knee extensor muscle strength and endurance and found increases in concentric and eccentric peak torque and the knee extensor en­ durance ratio in both men and women. Additionally, im­ provements in resting heart rate, 3-minute step test heart rate, modified sit and read, total body rotation testing, and Single leg stance with eyes closed were found in a Tai Chi group compared with a control group.42 The effects ofTai Chi directly on balance have been analyzed. Tai Chi was found to reduce the risk of multiple falls by 47.5%43 Yan 44 found that Tai Chi partiCipants Significantly reduced their vertical pressure variability compared with a walking or jogging group. Significant improvements have been found in posturography testing, self-reported physical function­ ing, general health status, arthritis symptoms, Sensory Or­ ganization Testing, and the Dizziness Handicap Inventory following Tai Chi training. 4.5-48 However, others have found computerized balance training to produce greater improvements in balance measures than Tai Chi, suggest­ ing that Tai Chi may delay the onset to first or multiple falls by improving confidence without actually changing sway measures. 49 This is consistent with others who found sig­ nificant self-reported benefits of Tai Chi training (im­ proveme nts in daily activities) compared with individual­ ized balance training. 50

EXAMINATION AND EVALUATION OF IMPAIRED BALANCE Evaluation of balance impairment can range from the sim­ ple to the complex, Simple clinical measures such as the ability to maintain a Single-leg stance ,vith the eyes closed or the Romberg test are commonly used in the clinic. Com­ puterized balance testing systems are increaSingly incorpo­ rated into the clinical evaluation and treatment. The Inter­ active Guide to Physical Therapist Practice.51 describes three categories of balance assessments. They are: • Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetiC devices or equipment (i.e., activities of daily living scales, instrumental activities of daily living scales, and observations ) • Balance (static or dynamic) with or \vithout the use of assistive, adaptive, orthotic, protective, supportive, or prosthetiC devices or equipment (i.e., balance scales, dizziness inventories, dynamiC posturography, fall scales, motor impairment tests, and mobility skill profiles) • Safety during gait, locomotion, or balance (i.e., confi­ dence scales, diaries, fall scales, and logs ) Because balance impairment can arise from many sources, evaluation should differentiate biomechanical, motor, and sensory causes. For example, the clinician com­ monly attempts to disturb the patient's balance by trying to push the subject with instructions such as , "Don't let me push you over." The patient's response is to tighten all mus­ cles in an attempt to resist the clinician's push. This tests '

the ability to tighten postural muscles , not balance reac­ tions . "\That determines a positive test, and how would this test subsequently direct treatment? This test, as with the Single-leg stance and Romberg tests, is a static test, and tells little about the individual's ability to maintain balance while moving. However, this test is a relevant indicator in crowd situations, in which a patient may get pushed. This highlights the importance of an organized, thoughtful ex­ amination process deSigned to sequentially and speCifically test the various systems involved in balance. Evaluation ofbiomechanical causes of imbalance can be readily performed in the clinic. Crutchfield6 emphasizes the importance of distinguishing among a normal neuro­ logiC system working with an abnormal musculoskeletal system , an abnormal neurologiC system working with a normal musculoskeletal system, or a combination of both. Joint range of motion , muscle length imbalance, impaired muscle performance, pain, or other postural abnormalities (e.g., kyphOSiS ) can contribute to balance impairment. Loss of motion at a jOint or series of jOints (e.g. , ankle, knee, spine ), decreased accessory motion, and muscle length im­ balance alters posture and movement strategies. Likewise , muscle impairments such as weakness or loss of endurance alter movement strategies. For example, gluteus medius weakness results in a predictable alteration in gait known as a gluteus medius limp. This weakness may prevent normal hip or stepping strategy use. Pain often produces changes in movement that, if continued, can produce secondary strength and mobility impairments. Limited ankle range of motion prevents use of an ankle strategy, requiring the pa­ tient to use a hip strategy. This may be interpreted as fault) balance, although the hip strategy may be the best strategy available for that patient. Many of these impairments can be assessed using simple clinical measures such as goniom­ etry and manual and functional muscle testing, Impairment of the se nsory system can result in balano impairment. Testing for sensory organization requires more elaborate testing systems such as the visual-conflict dome and rotating platform. The Postural Dyscontrol Test combines and isolates information from the visual, vestibu­ lar, and somatosensory systems 9 Systematically studyin the contributions of each of these systems requires diffe r­ ent testing situations, including standing with the ey open on a fixed platform; standing blindfolded on a fixe d platform; sway-referenced vision with fixed support; nor­ mal vision with sway-referenced support; absent vision with sway-referenced support; and sway-referenced vision and support (Fig. 8-5)11 Blindfolding the eyes provides in­ formation on the contribution of the visual system. In the situation with sway-referenced vision with fixed SUppOit. the visual box moved as the subject swayed, presenting a sensory conflict: movement took place, but the eyes did not register movement. JOint receptors sensed the movement. but the eyes did not. The vestibular system provided the re­ solving information, indicating that movement had taken place. During this testing, normal subjects sway very little. The situation of normal vision with sway-referenced support presents a different conflict. In this case, the plat­ form rotates in conjunction with the body sway. The visual system records movement, but the joint receptors do not. The vestibular system presents the resolving information.

Chapter 8 Impaired Balance i Normal vision. Fixed support.

2 Absent vision. Fixed support.

3 Sway-refer­ enced vision. Fixed support.

155

meters , turn around, return to the chair, and sit again. 55 The reliability of this tes! is high, and it correlates well with th e Berg Balance Test:~6 The clinician should choose an evaluation battery that taps the multiple aspects of balance, including sensory, musculoskeletal, psychologic, and per­ formance factors,

ACTIVITIES FOR TREATING IMPAIRED BALANCE A

J

I.

j

Normal vision. Sway-refer­ enced support.

B 5 Absent vision. Sway-refer­ enced support.

C 6 Sway refer­ enced vision and support.

d

aI

F o E RE 8-5. The six balance testing situations: (A) standing quietly, eyes

= . (8) standing quietly, eyes closed; (e) standing with a visual box, '. open; (O)standing, and body rotates with body sway; (E)standing, ro­ "'1 platform, eyes closed; (F) standing on a rotating pla tform with a vi­ box.

l'e

~ T-

ten

e. ted lat­ al at. pn .

rater sway occurs in this situation than in the previous ee situations. The greatest sway is observed in situations ent vision with sway-referenced support and of sway­ r nced vision and support, for which inaccurate infor­ n is furnished from more than one source. Platform tion provides inaccurate information to the visual and thetic systems in the situation of absent vision with \ -referenced support. The rotating platform and visual provides inaccurate visual and somatosensory informa­

in the situation of sway-referenced vision and support,

. e tests suggest that individuals rely primarily on the

atosensOlY system for orientation and postural control

that, when somatosensory and visual information are

ved or inaccurate, the vestibular system is left to pro­

postural contro\.6 everal clinical tests of balance have been developed. F unctional Reach Test, Tinetti's balance and mobility roent, Timed Get Up and Go , and Berg Balance Test u d frequently in the clinic to give objective and func­ al measures of balance 7 ,H 5z The Berg Balance Test performance from 0 (unable to pe rform) to 4 (nor­ for 1'4 different tasks and has a 53% sensitivity. Older Jts who scored higher on the test were less likely_~o fall those who scored below 45 of the 56 points :o-> The ctional Reach Test is an upper extremity balance test - assesses postural a_djustments that anticipate upper ex-mity movement. 5Z ,;,4 The Timed Up and Go Test re­ es the patient to stand up from sitting in a chair, walk 3

The most important factor in treating balance impairment is determining the cause of the impairment. Remember that balance problems can result from musculoskeletal, neuromuscular, sensory, or cognitive impairments. Repet­ itive quadriceps strengthening exercises do little to im­ prove balance if the underlying problem is a movement dis­ order. Conversely, the patient must have adequate strength to maintain balance. Many individuals lack "core" strength, or strength in the trunk and pelvis, which pro­ vides a stable base for subsequent movement. A concurrent strength program is often necessary for treating balance impairment. For discrepancies benveen actual stability limits and perceived stability limits, use postural sway ac­ tivities within the actual stability limits, For patients with sensory organization problems, design an exercise program requiring the patient to maintain balance during progres­ sively more difficult static and dynamic activities. Vary the sensory emphasized \vith the different activities, Systemat­ ically eliminate, minimize, or alter the visual, vestibular, or somatosensory input, requiring the patient to reconcile in­ put from the different systems. If strength is a significant component of the balance problem, then it would be considered a base element of the elements of the movement system. If the problem lies in the status of the neuromuscular system (motor control, sensory organization), then it would be considered a mod­ ulator element. For those whose primary problem is a fear of falling, the element of the movement system may be cognitive/affective. The follmving treatment suggestions must be matched to the underlying problem and patient. The foc us of these interve ntions is on the central nervous system and the peripheral mechanisms it controls; for indi­ viduals with primary peripheral vestibular system prob­ lems, alternative interventions exist that are beyond the scope of this textbook.

Mode A variety of modes can be used to treat balance impair­ ment. Any musculoskeletal (base elem ent) problem such as impaired muscle performance or mobility, or pain, should be treated first , with reevaluation for continued balance impairment after resolution of the musculoskeletal prob­ lems. Chapters 4, 7, and 10 provide speCific activities to treat these impairments. Use a stable surface such as a hard floor or rigid chair for initiating standing, kneeling, or sitting balance activities, For patients who need to train an ankle synergy, begin \vith weight shifts on a firm surface, with gradually increasing sway. As the patient improves, increase the compliance of

156

Therapeutic Exercise: Moving Toward Function

the support surface. Use rehabilitation balls, foam rollers, and foam surfaces to provide uneven or unstable surfaces (Figs. 8-6 and 8-7). More challenging surfaces such as a minitramp can also provide a variety ofbalance experiences (see Self-Management 8-1 ). Train sitting balance, trunk stability, and weight distribution on a chair, table, or thera­ peutic ball (see Self-Management 8-2 and 8-3 and Fig. 8­ 8). Similarly, balance beams, lines drawn on the floor, bal­ ance boards, and scales can be used for balance training (Fig. 8-9). Balance beams are particularly useful for pa­ tients needing to train a hip synergy because they prevent the use of an ankle synergy as a substitute. More sophisticated balance testing and training devices are also available . Any mode used for testing balance can be used for training. The pool is also an ideal place to train bal­ ance, because the water's movement causes perturbations , and the water's viscosity slows balance loss, giving individ­ uals more time to respond (see Self-Management 17-3 in Chapter 17).

Posture Awareness of posture and the position of th~ body in space is fundamental to balance trai ninp'. Maki 5 , suggests that training include mimicking the v,;~ied and unpredictable events that preCipitate falls in the elderly, and that activities include not only COG displacements, but BOS compen­ satory movements. KineSiologiC factors such as achieving and maintaining proper COG control and learning factors such as internalization of balance strategies provide the structural framework for the treatment postures chosen. For those needing work on core trunk stability first , train­ ing may be initiated in a sitting pOSition , which provides an opportunity to develop a sense of trunk posture and equity of weight bearing while sitting. Use a variety of arm posi­ tions , such as forward or lateral reaching, to change the

AGURE 8-7. Tai Chi exercise to improve single leg balance.

postural challenge. Maintaining equitable weight distribu­ tion and trunk posture on an unstable sUlface such as a therapeutic ball creates an interesting and useful balanc challenge. Use static postures such as half kneeling, talllmeeling. and standing alone or in combination with foam surfaces to alter the challenge to the patient. Use force platforms or scales while standing to train the patient to distribute weight equally on each lower extremity. Simple weight shifting is a good introductory activity. More challenging static pos­ tures, such as standing heel to toe or a Single-leg stance. should be included when the patient is ready. This posture minimizes ankle strategy use and facilitates a hip synerg)'_ For the athlete, postures encountered in sport should be duplicated and system atically challenged in the clinic. Lunge pOSitions, Single-leg stance 'vvith a vaIiety of trunk postures, and squat positions are commonly encountered in spOli. After stability and optimal posture are achieved in static positions, dynamiC movement should be superim­ posed on the activity (see Selected Intervention 8-1).

Movement

FIGURE 8-6. Foam rollers are used in bilateral stance when the person practices weight shifting while catching a ball.

A variety of movement patterns superimposed on stabl postures can increase the balance challenge. Adding an­ teroposterior and lateral sway assists the patient in deter­ mining and increasing his or her stability limits. Perform these in a variety of modes (e.g., supportive chair, thera­ peutic ball, firm floor, foam roll, foam pad , balance board. pool) and in a variety of postures (e.g., sitting, half kneeling. tall kneeling, standing, Single-leg stance) using varying arm postures or movements. Trunk rotations \vith the arms in a variety of positions (e.g., abducted, forward flexed, arm

Chapter B: Impaired Ba lance

SELF-MANAGEMENT 8-1 Minitrampoline

Balance Purpose: To improve stability in single leg stance Movement technique: Levell.

While standing on the minitramp with a stable object at hand. practice standing on one leg. Make sure that your knee is slightly bent. Use the stable object for balance only if necessa ry.

Level II:

Close your eyes.

Level III:

Perform a minisquat.

Level IV:

Add resistance to the knee.

Level V:

Add movement to the arms.

Dosage

Repetitions: _________

Frequency: _ _ _ _ _ _ _ __

157

them across the chest or overhead can make the exe rcise extremely difficult for a person with poor trunk and hip stability. More advanced balance exercises include hopping, skip­ ping, carioca, slide board, and rope jumping (see Self­ Management 8.4). Perform these xe rcises in a v,uiety of patterns , with exaggerated step length or knee lift. .'.1any can be performed backward, "vith a variety of step tech­ niques incorporated. The "hop and stop" can be performed on a firm surface or a soft surface such as foam or minitramp (Fig. 8-13) . The patient is asked to hop Single or double footed and to "stick" the landing 'without losing his or her balance . Exercise equipment such as a stepper can also challenge balance if performed without hand support, backward, or with the eyes closed. For athletes, reproduc­ ing movement patterns found in their sports can prepare them for the return to activity. Many traditional sports drills can be modified for use in a clinical setting. The pool provides an ample supply of balance move­ ment patterns. The viscosity and movement of the water constantly challenge posture and balance. Any arm or leg movement can potentially disrupt the patient's balance . For example, performing bilateral shoulder horizontal ad­ duction and abduction results in posterior and anterior dis­ placement of the body, respectively. Perform this exercise with th e feet in stride , in normal stance , in a narrowed

SELF-MANAGEMENT 8-2 Sitting Balance on

a Stable Surface Purpose.

To increase awareness of and expand stability limits

Movemel ( techniqu While sitting on a sta ble surfa ce such as a Level 3

chair, practic e reaching forward, overhead, and to the side. You may you look in the direction you are reaching or in a different direction, as recommended by your therapist.

Level 4

Dosage chest ) with changes in head position (e.g. , rotated, ~ ly flexed ) to alter vestibular input can be combined multitude of ways. Proprioceptive neuromuscular fa­ tion techniques in trunk rotation, called chops and are excellent dynamic movement patterns. These pat­ includ arm , trunk, and head rotation; flexion ; and ex­ on (see Chapter 15) (Fig. 8-10). epping exercises such as lunges provide an opportu­ to control balance as the client first moves outside the litv limit and then restabilizes when his or her foot ground. Starting "vith small steps and progressing ill lunges (Fig. 8-11) increaSingly challenges the pa­ _-\dding a concurrent arm activity can further chal­ _ balance. For example, reciprocally swinging the during stepping can make the task easier, but per­ ing a proprioceptive neuromuscular facilitation chop tching a ball can make it more difficult (Fig. 8-12). pletely eliminating the arms for balance by holding

::he

Repetitions:_________ Frequency: _ _ _ _ _ _ _ __

158

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 8-3 Sitting Balance on

an Unstable Surface Purpose. To increase postural stability and trunk balance

Movement technique: While sitting on the therapeutic ball. practice reaching forward. overhead. and to the side. You may look in the direction you are reaching or in a different direction. as recommended by your therapist.

Dosage Repetitions: _ _ _ _ _ _ _ __ Frequency: _ _ _ _ _ _ _ __

stance, or in single-leg stance for progressively increasing difficulty (see Self-Management 8-5).

Dosage Environment The environment for balance training depends on the pa­ tient's situation. For the frail elderly or those with signifi­ cant balance impairment, most of the training activity takes place in the clinic . Be alert for correct posture, avoidance of substitution , proper performance, and safety. Simple activities such as postural awareness exe rcises may be performed safely at home. Realize that the clinic envi­ ronment is designed for maximum patient safety, and may not reflect real-world situations. Lighting, noise, cars , weather factors , and a multitude of other external envi­ ronmental conditions may overload the patient's sensory system , increasing the risk of a fall. Be sure to progress pa­ tients to balance training in the types of environments they will encounter when they leave the clinic. This may re­ quire short "field trips" outside the clinic to reproduce these situations. For athletes or other active individuals with muscu­ loskeletal causes of balance impairments, balance activities may be carried out independently at home, at a local health club, or in a local pool. Safety is the key factor when mak-

FIGURE 8-8. A variety of balance activities can be performed on a thera­ peut ic ball (A) single-arm lateral reach, (8) bilatera l reaching, (e) as sis­ tance for balance whi le lifting one leg.

ing choices about the exercise environment. A stable sup­ port should always be available for regaining lost balance. This support should be placed such that it does not inter­ fere vvith the exercise and does not cause injury during an attempt to regain balance.

Chapter 8: Impaired Balance

FIGURE 8-9. (A) Latera l movement on a balance beam on foam rollers. (8) Adding a soccer ball to drill activi­ ties increases the chal lenge .

1':::'\ 1

\.:::;J

SELECTED INTERVENTION 8-1

Single-leg Balance on a Foam Roller

CTIVITY: Single-leg balance OIl foam roller with added activity

J~11amic

.

PURPOSE: To increase stabilitv limits and dmamic balance /

ECAUTIONS: Patient safety: ens ure readiness for activity

nd safeguards in case of balance loss; adequate tnlllk control OSTURE: Standing on a foam roller with dynamic control of ad, spine, and lower extremity post m e OVEMENT: ~vlaintain balance while moving a ball into a ariet)' of positions or while playing catch with ball OCEOURE: Isometric, concentlic, and eccentric muscle mtractions of th e spine extensors, flex ors , and abdominal lique muscles . The closed-chain nature of the activity will roduce co-contraction of lower extremity musculature .d uding, but not limited to, the gastroc-soleus, quadriceps , mstrings, and gluteal muscles. OSAGE: Three to six sets of :30-second intervals

FUNCTIONAL MOVEMENT PAmRN TO REINFORCE GOAL OF EXERCISE: A variety of Single leg instability situations is encountered in sports. The indiviclualleam s to control posture through core muscle contraction while performing a dynamic activity on an unstable smface.

159

160

Therapeutic Exerci se Moving Toward Function

FIGURE 8-10. Proprioceptive neuromuscu lar facilitations of chop and lift in half-kn eeling position: (A) starting position and (B) ending position.

e.

FIGURE 8-11. (A ) Minilung es are progressed to (B)fu iliunges.

Chapter 8 Impaired Balance

FIGURE 8-12. Catching a ball in a variety of situations increases task complexity (A) on a balance board, (8) combined with lateral lunges, and (C) on a slide board.

161

162

Therapeutic Exercise Moving Toward Functi on

Sequence SELF-MANAGEMENT 8· 4

Purpose:

Slide Board

To increase balance and coordination during a functional activity

Movement technique: Leve/I.

Laterally glide on a slide board.

Leve/II:

Continuously catch and toss a ball.

Level III:

Increase speed.

Level IV:

Increase the number of balls tossed.

Dosage

Repetitions: _ _ _ _ _ _ __

Frequency: _ _ _ _ _ _ _ __

FIGURE 8-13. Hop and stop for dynamic balance . (A)The pa­ tient starts from a small stool. hops down, and (8) "sticks" the landing.

Progression of exercise from simple to complex involves changes in mode , posture, and movement. Base of support is advanced from a wide to a narrow base, and then from a stable surface to a more unstable surface. Similarly, posture progressed from stable posture (e.g., sitting) to more un­ stable posture (e.g., single-leg stance) exemplifies appro­ priate sequencing. For example, performing postural sway in all directions ,vith the arms folded across the chest while sitting on a firm chair is a good precursor to adding arm movements or for performing the same exercise on an un­ stable therapeutic bal!. Closing the eyes is a simple and ef­ fective means to increase the difficulty of any exercise. Vary displacements from those generated by the patient to an external force, and from an anticipated displacement to an unanticipated one. While standing, start with simple sway activities that elicit an ankle strategy. Reinforce this strategy by verbal or tactile cuing and ensuring proper posture and firing pat­ terns to prepare the patient for larger perturbations. En­ courage the patient to gradually increase the stability limits by reaching or swaying farther. Progress to greater disrup­ tion of the COG to elicit a hip strategy or a stepping strat­ egy. After these responses are established, progress to more dynamiC activities, unstable surfaces, and complex movement patterns. Beginning with simple tasks on a stable surface and moving to progressively more unstable surfaces and com­ plex tasks is the sequence plan, regardless of the age or con­ dition of the patient. For the athlete, progression to a bal­ ance board, minitramp, slide board, or computerized balance training system may occur rapidly. Although train­ ing the individual in postures or activities encountered in

Chapter 8: Impaired Balance

SELF-MANAGEMENT 8-5

Shoulder Level

163

PRECAUTIONS AND CONTRAINDICATIONS

Claps in the Pool Purpose: To increase upper back and chest strength and to challenge balance

Movement technique:

Levell:

While standing in good postural alignment with your arms to the side at shoulder level, bring them forward and back to the starting position.

Level II: Level III: _eve/IV: evel V:

Bring your feet closer together. Stand on a single leg. Close your eyes Add resistance to the hands.

Dosage Repetitions:_ _ _ _ _ _ _ __

Frequency: _ _ _ _ _ _ _ __

The most important precaution in balance training is the patient's safet),. B)' definition, balance training challenges the patient's balance. Because the potential for falls is high, choose activities that are appropriate for the patient's skill level. A well-performed evaluation and initiation of activi­ ties at a lower level than determined by the examination can ensure appropriate exercise choice. It is safer to start the patient with tasks that are simpler and safer and progress to more complex exercises than to misjudge and place the patient in an unsafe situation . The surrounding environment should have maximum safety as the principal design factor. Eliminate obstacles or unsafe objects from the exercise area and provide addi­ tional stabilization for the patient. A gait belt, hand contacts from the clinician, parallel bars, or other stable external ob­ jects for the patient to hold should be immediately available. Balance training is contraindicated for persons who are inherently unsafe in balance-challenged positions. For ex­ ample, those with cognitive impairments may be unable to understand the purpose and mechanics of the activit)'.

PATIENT EDUCATION

or her sport can prepare the patient for those situations, }' unpredictable situations occur, and unpredictable rturbations should be included in the training program teach the nervous system how to respond to novel . tions.

- edback ...ming factors are essential in planning the activity mode treating balance impairment. Early in the treatment gram, simple balance challenges with external feedback n cessary. This allows the patient to develop gross te9ies to manage the perturbation. As the patient learns develops these gross strategies, increasing the balance enge while decreasing the external feedback allows in­ rna.! strategies to develop. In the case of balance training, ming is the ultimate goal. ~ lirrors can provide postural feedback regardless of the ·tion of exercise. This allows visual feedback (i.e., exter­ feedback about position), which must be removed at e poin t to allow internalization of the balance strategies.

Patient education is an ongoing process for the patient with balance impairment. Safety is the most important area of education. Counsel the individual with significant balance impairments regarding use of assistive devices to maintain stability. A walker, one or two crutches, or a cane can \viden the BOS, thereby increasing the stability limits. Evaluate the home fo r potential balance hazards . Loose rugs, slippery floors or bathtubs, uneven doorway thresh­ olds, and stairs without railings can be hazards. Footwear can affect balance. Shoes that slip on the foot or on the fl oor or shoes ,-,,,ith rubber bottoms that stick on the floor can cause a fall. Include patient education on balance limitations. Fac­ tors include time (e.g., walking more than 20 minutes) , dis­ tance (e.g. , after walking more than four blocks ), tim e of day (e.g. , better in the morning than in the evening), and environment (e.g., crowds, nois e, lights). Understanding the situations that place the patient at risk can help him or her make appropriate, safe choices while still participating in desired activities. The patient should be taught strategies to maximize bal­ ance in compromised situations. For reasons beyond their control, patients may find themselves in situations in which their balance is at risk. For example, when coming out of a movie, a person may have difficulty adjusting to the light, noise, and crowds in the lobby. Patients should be coun­ seled in strategies to optimize balance, which may include using an assistive device (when the patient normally does not use one ), using a friend's arm for balance and escort through the lobby, sitting and planning a path where stable objects may provide some extern al ass istance, or asking someone for assistance.

164

Therapeutic Exercise: Moving Toward Function

KEY POINTS • Balance is one component of coordination, which is a more global concept that includes fine motor skills. • Aging is associated with balance impairment and places the elderly at risk for falls. • Some musculoskeletal disorders or injuries are associ­ ated with balance impairment. Balance training should be incorporated into the treatm ent program. • Balance is a function of the interaction of visual, vestibu­ lar, and somatosensory systems. • Ankle strategies are used in response to small perturba­ tions , and hip or stepping strategies are used to counter larger perturbations. • Measurement of balance impairment should include biomechanical, sensory system , and motor strategy as­ sessme nts. • Treatment should be aimed at the cause of the problem , whether biomechanical, sensorimotor, or both.

CRITICAL THINKING QUESTIONS 1. Consider Case Study #1 in Unit 7. Design a progressive balance program for this basketball player. How would your treatnlPnt program differ if she were a a. Gymnast b. Figure skater c. Wrestler d. Cross-country runner 2. Consider Case Study #5 in Unit 7. Design a progressiv balance program for this woman. Indude sitting, stand­ ing, and transitional postures and movements. What other interventions probably are necessary to improv, her balance? 3. vVhat aspects of home design can maximize an individ­ ual's independence if balance is impaired?

LAB ACTIVITIES

1. With a partner, perform the folloWing activities.

Which balance strategy is elicited and why? a. With the patient's feet shoulder-width apart, at­ tempt to gently disrupt the patient's balance. b. With the patient's feet shoulder-width apart, at­ tempt a larger disruption of the patient's balance. c. With the patient standing heel to toe, attempt to gently disrupt the patient's balance. d . With the patient standing on a balance beam, at­ tempt to gently disrupt the patient's balance. e. Restrict the patient's ankle mobility with a brace or tape. Attempt to gently disrupt the patient's balance. f. Repeat steps a through c on a soft foam surface. 2. Compare the length of time balance can be main­ tain ed in the following situations. Which muscles are working, and how are changes in COG compen­ sated by postural changes? What do the arms attempt to do? a. Single-leg stance with eyes open (left and light) b. Single-leg stance with eyes closed (left and right) c. Single-leg stance, performing tubing-reSisted shoulder horizontal abduction, unilateral and bilateral d. Single-leg stance, performing tubing-reSisted shoulder flexion from 120 to 180 degrees of over­ head flexion, unilateral and bilateral e. Single-leg stance, performing tubing-reSisted hip extension f. Single-leg minisquats \vith the contralateral knee flexed

g. Single-leg minisquats with the contralateral knee extended and hip flexed h. Single-leg minisquats on a minitramp i. Single-leg toe raises from a level surface j. Single-leg toe raises from the edge of a step 3. Compare muscle activity in the folloWing situations: a. Single-leg minisquats on a minitramp, with tubing around the posterior knee pulling the knee into flexion b. Single-leg minisquats on a minitramp, with tubing around the medial k'l1ee pulling the hip into ab­ duction c. Single-leg minisquats on a minitramp, with tubing around the anterior knee pulling the knee into ex­ tension d. Single-leg mini squats on a minitramp, with tubing around the lateral knee pulling the hip into ad­ duction 4. Perform the folloWing activities. Which activity is the most challenging to your balance? a. Repetitive Single-leg hopping with arms free b. Repetitive Single-leg hopping with arms across the chest c. Repetitive Single-leg hopping with arms overhead d. Rope jumping on altemate feet e. Rope jumping on a Single foot f. Single repetition of a Single-leg hop, controlling and stopping the landing as quickly as possible (i.e., hop and stop) g. Hop and stop on a minitramp

Chapter 8 Impaired Balance

REFERENCES L Swanik C B. Lephart SM , Giannantonio FP, et al. Relcstah­ lishing proprioception and neuromuscular control in the ACL-injured athlete. j Sport RehabiI1997;2182-206. _. Barrett DS, Cobb AG, Bentley G. JOint proprioception in normal, osteoarthritic, and replaced knees. J Bone JOint Surg Br 1991;73:S3-56. 3. Corrigan JP, Cashmen YVF, Brady MP. Proprioception in the cruciate deficient knee. J Bone joint Surg Br 1992;74:247­ 250. . Lamb K, Miller J, Memadez M. Falls in the elderly: causes and prevention. Orthop .'\ urs 1987;6:45-49 . 5 chmitz TJ. Coordination assessm e nt. In: O'Sullivan SB , chmitz TJ, eds. Physical Re habilitation: Assessment and T reatment. Philadelphia: F A Davis , 1994.

C rutchfield CA, Shumvvay-Cook A, Horak F B. Balance and

coordination training. In: Scully RM , Barnes MR, eds. Phys­

ical Therapy. Philadelphia: JB Lippincott, 1989:825--843.

- Berg KO, Wood-Dauphinee SL, Williams JT, et al. Measur­ ing balance in the elde rly: validation of an instrument. Can J Pu blic H ealth 1992;83:S7-S11. Berg KO , Maki BE , Williams JI. e t al. Clinical and laboratory measures of postural balance in an e ldprly population. Arch Piws Med RehabiI1992;73:1073-lOS0 h ~m\Vay- Co()k A, llorak RB. ,\ss(:ssin cr th e inflll(,lIce of sen­ "(1)' inte~action on balancf' . Phys T he r ] 986 : lS4S,lS.'50 . \lcCollum G, Leen T. Form and exploration of IJl echanieal tability limits in erpct stance. J Motor Behav 1%9;21:225­ _38. :\ashn c r LM. Sensory, neuromuscular, and biomechanical

contributions to hum an halance. In : Balance: Proceedings of

.he American Physical The rapy Association Forum;

"ashville, TN, June 1:3-15, 1989 .

. 'ashner LM. Adaptation of human movement to altered en­

iro nments. Trends .'\ eurosci 1982:5:358-361.

te rn EB. The somatosensory syste ms. In: Cohen H, ed .

e uros cience for Rehabilitation. Philadelphia: JB Lippincott ,

993. Rowi nski MJ . Affen'nt neurobiology of the joint. In : Could ,\. Davies GJ, eds. Orthopae dic and Sports Physical Ther­ .p\'. 2nd eel. St. Louis: CV \-tosby, 1%·5. - Jrigg P. Articular n!,llfophysiology. In: ZaC'hazewski JE , leGee' OJ, Quillen \VS , eds. Athletic Injury Rehabilitation. ?hiJadelphia: 'VVB Saunders, 1996. ";riucr P, Finerman GA, Riley LH . Joint-pOSition sense after tal hip replac ement. J Bone Joint Surg Am 1973;55:1016­ 025.

ox CR, Cohen H. The visual and vestibular systems. In: Co­

en H, ed . j le uroscience for Rehahilitation. Philadelphia: JB

..ippincott, 1993. " rnstein C, Mitz AR. The motor system Il: higher centers. n : Cohen H , ed. Neuroscience for Rehabilitation . PhiladeJ­ . bia; JB Lippincott, 1993. ;.j ht KE. Information processing for motor performance in _'ng adults. Phys Ther 1990;70:820--826. . . 11l1er L , McCollum G. The organization of human postu­ ,...d moveme nts: a formal basis and experimental syntheSiS. Bellav Brain Sci 1985;8:l.35-172. yl ;' ., Sinnott PL. VaIiations in halance and body sway in ridd le-aged adults Spine 1991;16:325--330. \'egene r L, Kisner C, l\'ichols D . Static and dynamic balance ponses in persons \vith bilateral knee osteoarthritis. J Or­ p Sports Phys Ther 1997;25 :13--18. reeman .vI. Instability of the foot afte r injUlies to the lateral gament of the ankle. J Bone JOint Surer Br 1965;47:669-677. ornwall M, Murrell P. Postural sway follo'yvil1g inversion rain of the ankle. J Am Podiatr Med Assoc 1991;81:243--247.

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25. Barrack RL, Skinner HB, Cook SO, et al. Effect of alticular disease and total knee arthroplasty on knee joint-position sense. J NeurophysioI1983;50:684-687. 26. Sattin RW. Falls among older persons: a puhLc health per­ specti ve. Annu Rev Public Health 1992;13:489--508. 27. Lichtenstein MJ , Shields SL, Shiavi RG, et al. Exercise and balance in aged women: a pilot controlled clinical trial. Arch Phys Med RehabiI1989;70:138-143. 28. Jamlo GB , Thomgren KG. Standing balance in hip fracture patients. Acta Orthop Scand 1991 ;62:427-434. 29. Bohannon Rv\', Larkin PA, Cook AC, et a!. Decrease in timed balance test scores with aging. Phys Ther 1984;64:1067­ 1070. 30. Judge JO, Lindsey C, Underwood M, et al. Balance improve­ ments in older wom en: effects of exercise training. Phys Ther 1993;73:254-265. 31. Hasselkus BR, Shambes GM. Aging and postural sway in wo men. T GerontoI1975;30:661-667. 32. Ekdahl C, Jarnlo GB, And ersson SI. Standing balance in healthy subjects. SC'and J Rehabil Med 1989;21:187-195. 33. Era P, Heikkinen E. Postural sway during standing and unex­ pected disturbance of balance in random samples of men of diffl' rent ages. J GerontoI1984;40:287-295. 34. Maki BE, Holliday PH , Topper AK . A prospective study of postural halance and risk of hLlling in an ambulatory and inde­ pendent {' lderly population. J GerontoI1994;49:M72--M84. :15. Legtt' rs K. Fear of falling. Phys Ther 2002;82:264-272. 36. Maki BE. Gait changes in older adults: predictors of falls or indicators of fear. J Am Geriatr Soc 1997;45:313-320. 37. Myers AM, Powell LE, Maki BE, et al. PsycholOgical indicators of halance confidence: relationship to actual and perceived abilities. J Gerentol A BioI Sci Med Sci 1996;51:M37- M43. 38. Liu BA, Topper AK, Reeves FA, et al . Falls among older peo­ ple: relationship to medication use and orthostatic hypoten­ sion . T Am Geriatr Soc 1995;43:1141-1145 . 39. \"/olfson L, Whipple R, Derby C, et al. Balance and strength training in older adults: intervention gains and Tai Chi main­ tenance. J Am Ger Soc 1996;44:599-600. 40. Gillpspie LO , Gillespie WJ, Roberts on MC, et al. Interven­ tions for preventing falls in elderly people . Cochrane Database Syst Rev 2001;3:CD000340. 41. Lan C , Lai JS , Chen SY, et al. Tai Chi Chuan to improve mus­ cular strength and endurance in elderly individuals: a pilot study. Arch Phys Med Rehabil2000;81:604--607. 42. Hong Y, Ll IX, Robinson PD. Balance control , flexibility, and cardiorespiratory fitnes s amo ng older Tai Chi practitioners. Br J Sports Med 2000;34:29-34. 43. Wolf SL, Barnhart HX, Kutner NG, et a!. Reducing frailty and falls in older persons: an investigation of TaUChi and compute rized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Ger Soc 1996;44:489-497. 44. Yan JH. Tai chi practice reduces movemen t force valiabiLity for seniors. J Gerentol A Bioi Sci Med Sci 1999;S4:M629­ M634. 45. Hain TC . Fuller L , \Veil L, et al. Effects of Tai Chi on bal­ ance. Arch Otolar),11 Head Neck Surg 1999;125:1191-1195. 46. Wong AM, Lin YC, Chou SW, et al. Coordination exercise and postural stabi lity in elderly people: e ffect of Tai Chi Chuan. Arch Phys Med Reh abil 2001;82:608-612. 47. Li F, Harme r P, McAuley E, et al. An evaluation of the effects ofTai Chi exercise on physical function amo ng older persons: a randomized controlled trial. Ann Behav Med 2001;23:139­ 146. 48. Hartm an CA, Manos TM, Winter C , et al. Effects of Tai Chi training on function and quality of life indicators in older adults with osteoarthritis. T Am Ger Soc 2000;48: 1553-1559. .

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49. Wolf SL, Barnhart HX, Ellison GL, et al. Th e eflect of Tai Chi Quan and computeri zed balance training on postmal sta­ bility in older subjects. Atlanta FICSIT Group. Frailty ilnd Injuries: Cooperative Studies on Intervent.ion Techniques. Phys Ther 1997;77:371-381. 50. Kutner NG , Barnhart H, Wolf SL, et al. Self-report benefits ofTai Chi practice by older ad ults . J Gerentol B Psych Sci Soc Sci 1997;52:P242-P246. 51. Interactive Guide to Physical Therapist Practice, V. 1.0. Alexandri a, VA : American Ph ysical Th erapy Association, 2002. 52. Duncan PW, Weiner DK, Chandler J, et a!. Functional reilch: a new clinical measure of balance. TGerontol 1990;45: M Hl2­ M197. . 53. Bogle Thorhalm LD , Newton RA . Use of tlle Berg Balance Test to predict falls in tlle elderly. Phys Ther 1996;76:576­ 58.5. 54. Fishman M N, Colby LA, Sachs LA, et al. Comparison of up­ per-extremity balance tasks and force platform testing in per­ sons Witll hemiparesis. Phys Ther 1997;77:1052-1062. 55. Mathias S, l\'ayak USL, Isaacs B. Balance in elderly patients : the "get-up and go" test . Arch Phys Med Rehabil 1986;67: 387-389.

56. DiFabio HI', Seay R. Use of the "fast evalu ation of mobili ty. balance and fear" in elderly w mmunity dwellers : \'alidity and reliability. Phys Ther 1997;77:904-917. 57. Maki BE , Yfdlroy WE. Postural control in the older adu lt. Clin Geriatr M ed1996;l2:63~65H.

ADDITIONAL READING Dietz V, Hurstmann GA, Berger W. Significance of propriocep­ tive mechanisms in tlle regulation of stance. Prog Brain R 1989;80419-423. Era P, Heikkinen E. Postural sway during standing and unex­ pected disturbance of balance in random samples of men di f­ ferent ages. J Gerontal] 9S5;40:287-295. Hageman HA, Leibowitz JM , Blanke D. Age and gender effect· on postural cuntrol measures. Arch Phys Med Reh ahil 1995;76:961-96.5. Lichtenstein :V1J, Shields 51., Shiavi RG, et al. Exercise and bal­ ance in aged women: a pilot controlled clinical trial. Arch Ph!, Med RehabiI1989 ;70:131:i-143. Province MA, Had ley EC. Hornbrook MC, et al. The effects exercise on falls in elderly patients. JAMA 1995;273 :1341­ 1347.

chapter 9

Impaired Posture and Movement

t

CARRIE HALL

troduction

efinitions

Posture Standard Posture Deviations in Posture Movement 1­

~auses

of Impaired Posture and Movement

Range of Motion Muscle Length Joint Mobility Muscle Performance Pain Anatomic Impairments and Anthropometric Characteristics Psychologic Impairments lifespan Considerations :nvironmentallnfluences

= amination and Evaluation Posture

Movement

- .ervention Elements of the Movement System

<\ctivity and Dosage

atient-Related Instruction and Adju nctive

terventions

TRODUCTION airments in posture and movement are the basis of :ly regional musculoskeletal pain syndromes (MPS).l arc localized, painful conditions arising from irrita­ of myofascial, periarticular, or articular tissues. l Pain ':Jl trauma, such as a fracture or dislocation , or pain d by systemic disease, such as rheumatoid arthritis or er, cloes not fall into this category. However, impair­ ts of posture and movement can contribute to perpet­ ng pain associated with trauma or systemic disease. eaional MPS are often the result of cumulative micro­ Jn1 a imposed on musculoskeletal tissue. Microtrauma occur from overuse, which is defined as repetitive, sub-

maximal stress that exc:eec\s the tissue's ability to atlapt and repair. 2 ,3 Overuse can occur during a relatively short pe­ riod, such as playing the first volleyball game of the season, or over a longer period, such as performing data entry tasks 8 hours a day, S days a week, for many years. Microtrauma can also be caused by movements repeated during activi­ ties of daily living \vith less than optimal starting alignment or faulty osteokinematic motion. Pain indicates that a mechanical deformation or chemi­ cal process has stimulated the nociceptors in the symp­ tomatic structures. However, desc:ribing the mechanisms that signal pain is not the same as identifying the cause of pain. The premise of this chapter is that mechanical stress related to sustained postural habits or repeated movement patterns: (1) is the primary cause of pain , (2) contlibutes to the recurrence of a painful condition, and (3) is associated with the failure of the condition to resolve. Intervention, therefore , focuses on correcting the fac­ tors predisposing or contributing to the sustained postures or repetitive movement. When correction is not possible (e.g., anatomic impairments, pathology, disease), modifica­ tion of the posture or movement is indicated. Display 9-1 summarizes the factors influenCing impairments of posture and movement. This chapte r defines the terms lIsed in the evaluation and treatment of impairments of posture and movement, discusses factors influenc:ing impairments of posture and movement, and outlines the principles of therapeutic exer­ cise intervention for correction of posture and movement impairments.

DEFINITIONS Posture Posture is often considered to be a static func:tion rather than being related to movement. However, posture should not only be considered a static function, but also in the con­ text of the position the body assumes in preparation for movement. Traditionally, posture is examined in standing and sitting positions, but posture should be examin ed in

167

168

Therapeutic Exercise Moving Toward Funchon

DISPLAY 9-1

Factors Influencing Posture and Movement Impairment • Physiologic impairments Range of motion Muscle length/extensibility Joint integrity and mobility Muscle performance Motor control Balance and coordination Pain • Anatomic impairments (i.e., structural scoliosis, hip anteversion, structural limb length discrepancy) • Anthropometric characteristics • Psychologic impairments • Developmental factors (e.g., age) • Environmental influences • Disease or pathology

numerous positions, paliicularly postures in which the pa­ tient frequently assumes and positions related to fre­ quently performed movements. For example, standing on one leg is 85% of the gait cycle and th erefore should be considered a typi cal posture to be examined. 4 A useful definition of posture was provided by the Pos­ ture Com~littee of the American Academy of Orthopaedic

treated, this chapter considers only the upright standin, posture. The standard posture refers to an ideal postur rather than an average or norm al posture. This standard should be used as a basis for comparison; deviations from the standard are called impairments (~f posture. An evaluation of postural faults necessitates a standard by which individual postures can be judged. The standing posture is used as the standard in this chapter and is illus­ trated from the back and side (Fig. 9-1 ). In the back view. a line of reference represents a plane that coincides with the midline of the body. It is illustrated as beginning mid­ way between the heels and extending upward to midwa\ bet\veen the lower extremities, through th e midline of tll pelvis, spine , and skull. The right and left halves of th£" skeletal structures are essentially symmetric . Hypotheti­ cally, the two halves of the body are in equilibrium . In the side view, the vertical line of reference represent• a plane that divides the body into front and back sedion Around this line of re feren ce, the body is hypothetically in a position of equilibrium. From a mechanical standpoint, it may be logical to a5­ sume that a line of gravity should pass through the centel" of weight-bearing joints of the body. However, the on­ center position is not considered stable, because it can be held only momentalily in the presence of normal extem ru stresses. 9 . 10 For example, when the ce nter of the knee joi n.'

Surgeons :'~

Posture is usually defined as the relative arrangement of th e paIis of the body. Good posture is the state of muscular and skeletal balance that protects the suppoIiing structures of the body against injury or progressive deformity irrespective of the attitude (e .g., erect, lying, squatting, stooping) in which these structures are working or resting. Under such conditions, the muscles function most eflIciently, and the optimum positions are afforded for the thoracic and abdominal organs. Poor pos­ ture is a faulty relationship of the various parts of the body, which produces increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support.

Most people are trained to consiJer the relationship be­ t\.veen posture and the musculoskeletal systems, but an im­ pOliant message delivered by this definition is the interac­ tion bet\veen posture, musculoskeletal tissues , and organ systems (e.g., lungs, abdominal organs, pelvic organs ). This definition suggests that, without optimal support, organ systems may not fun ction optimally. For example, respira­ tory insuffiCiency can result from kyphosis (increased tho­ racic flexion ) or kyphoscoliosis (kyphosis superimposed lat­ eral curve ).6 These postural hwlts can reduce mobility of the thorax and thereby in crease the work of breathing.' Chronically altered respiratOl)' mechanics have been cited as a contributing factor to cardiopulmonat), pathology (e.g. , pulmonary hypertenSion, right heart failure )s

Standard Posture Although any posture a patient or client assumes for sus­ tained periods on a daily basis should be evaluated and

FIGURE 9-1. The back and side views of standard posture. The su rfa~­ and anatomic landmarks that coincide with these views are listed Table 9·1.

Chapter 9: Impaired Posture and Movement

d

n

d

h 1-

1\

f'

Ie

i-

I

Anatomic Structures and Surface l andmarks That Coincide With the line of Reference for the Side View of Posture SURFACE LANDMARKS

TOMIC STRUCTURES

Slightly anterior to the lateral malleolus Slightly anterior to a midline through the knee Through the greater trochanter Midway between the back and the abdomen Midwav between the front and back of the chest Through lobe of the ear

ugh the calcaneocuboid iut ::btlv anterior to the center -fthe knee jOint ghtly posterior to the center the hip jOint rough the sacral promontory -rough the bodies of the .:mbar veliebrae "Ough the dens ugh the external auditory eatus _ tl; posterior to the apex the coronal sutures

The pelvis is the link that transmits the weight of the head, arms, and trunk to the lower extremities, and it is considered key to the alignment of the entire lower body. Because of structural variations of the pelvis (i.e., women tend to have a shallow pelvis, \'lith the anterior superior il ­ iac spine (ASIS) inferior to the posterior superior iliac spine), it is not appropriate to use an anterior landmark in relation to a posterior landmark. The pelvis is considered to be in a neutral position when the AS IS and the symphysis pubis are in the same vertical plane (see Fig. 9-2A). The anatomic structures and surface landmarks that coincide 'vvith the line of reference for the side view are listed in Table 9-1. Specific alignment of the upper extremity is summarized in Display 9_2.1

Deviations in Posture The follOWing terms denote deviations in alignment 'vvith reference to segments of the body:ll

~

HO, Ke ndall F P, Boyn ton DA. Posture and Pain. Huntington, Rob rt E. Krieger Publishing, 1970.

ides 'vvith the line of gravity, there are equal tenden­ fo r the joint to flex and to hyperextend. The slightest e exerted in either direction causes it to move off cen­ If the body must calion muscular effort at all times to t knee flexion , muscular effort is unn ecessarily ex­ ed. To offset this necessity, the line of gravity is conred to be slightly antelior to the joint center. Ligamen­ tructures and ideal muscl e length res train the knee moving freely posteriorly. At the hip joint, the same 'ples apply, but the hip is most stable when the line of ity is slightly posterior to the center of the joint. The ligaments of the hip anteriorly prevent additional extension.

A

169

B

c

RE 9·2. (A) The neutral position of the pelvis is one in which the an­ peri or iliac spines are in the same transverse plane and in which they . e symphysis are in the same vertical plane. (8) An anterior pelvic tilt 'COs ition of the pelvis in which the vertical plane through the anterosu­ : iliac spines are anterior to avertical plane through the symphysis pu­ C) A posterior pelvic tilt is a position of the pelvis in which the verti­ ane through the anterosuperior iliac spines is posterior to a vertical ethrough the symphysis pubis.

• Lordosis is an increased anterior curve of the spine, usually of the lumbar spine, but it can affect the tho­ racic or cervical spine. If used without a modifying word, it refers to lumbar lordosis (Fig. 9-3 ). • Kyphosis is an increased posterior curve, usually of the thoracic spine but sometimes of the lumbar spine. If used 'vvithout a modifying word, the term refers to the thoracic spine (Fig. 9-4).

DISPLAY 9-2

Alignment of the Upper Extremity Side view • Humerus No more than one third of the head of the humerus protrudes in front of the acromion.

Proximal and distal humerus in line vertically

• Scapula The inferior pole is held flat against the thorax (if the thorax is in ideal alignment), 30 degrees anterior to the frontal plane (i.e., scapular

plane)

Back and front view • Humerus Antecubital crease faces anterior; olecranon faces posterior, • Forearms Palms face the body • Scapula The vertebral border of the scapula is parallel to the spine and is positioned approximately 3 inches from the spine. The root of the scapula (where the spine of the scapula meets the vertebral border of the scapula) is at the levelofT3. The vertebral border of the scapula is held against the thorax (if the thorax is in ideal alignment).

170

Therapeut,ic Exercise Moving Toward Function

B A FIGURE 9-5. (A) This person has marked structural genu valgum,

G

knock-knees. (B) Postural genu valgum results from a combination of la-­ eral rotation of the femurs, supination of the feet, and hyperextension ~ the knees. With lateral rotation, the axis of the knee joint is oblique to tI; ~ coronal plane, and hyperextension results in adduction at the knees. FIGURE 9-3. Marked anterior pelvic tilt and an exaggerated anterior curve of the lumbar spine This curve IS called a lordosis. Note that accompany­

ing the anterior pelvic tilt and lordosis is flexion of the hip joint

• Anterior pelvic tilt refers to a position in which the vertical plane through the ASIS is anterior to a verti­ cal plane through the symphysis pubis (Fig. 9-2B). • Posterior pelvic tilt refers to a position in which the veliical plane through the ASIS is posterior to a verti­ cal plane through the symphysis pubis (Fig. 9-2C). • The normal angle bel:\veen the tibia and femur in the frontal plane is about 170 to 175 degrees and is called the physiologic valgus angle of the knee. 12 If the val­ gus angle is less than 165 degrees, genu valgum (i.e.,

knock knees) exists. 12 Structural genu valgum can iJ._ associated with pronated feet, medially rotated fe ­ murs, anteverted hips, and coxa varum (Fig. 9-5A) (5 Chapter 20). Postural genu valgum results from combination of lateral rotation of the femurs, supina­ tion of the feet, and hyperextension of the knees ( Fig. 9-5B).11 Conversely, if the tibiofemoral angle ap­ proaches or exceeds 180 des;rees, genu varum (i.e bow legs) exists (Fig. 9-6A)1 Structural genu valUl'" can be associated with coxa valgum (see Chapter 2

j

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/' ~''-\ 1 I

,... . .-\, . '>, \

r

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/

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If

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A

B

FIGURE 9·6. (A) Mild degree of structural genu varum, or bow legs I

FIGURE 9-4. This person exhibits an exaggeration of the normal posterior curve of the thoracic spine. This is called a kyphosis

Postural genu varum results from a combination of medial rotation of :­ femurs, pronation of the feet, and hyperextension of the knees. When ': murs medially rotate, the axis of motion for flexion and extension is oblic to the coronal axis. From this axis, hyperextension occurs in a postera ;: eral direction, resulting in separation at the knees and apparent bowi ~ the legs.

Chapter 9: Impaired Posture and Movement

171

• Winging ofthe scapula or medial rotation is a position or movement about a vertical axis in which the verte­ bral border of the scapula moves posteriorly and lat­ erally away from the rib cage and the glenoid fossa moves in an anterior and medial direction (see Fig. 9­ 8 ),13 Lateral rotation of the scapula is the converse movement. 13

Movement

~

e

u

, B

URE 9-7. Moderate genu recurvatum, or hyperextension of the knees.

Postural genu varum results from a combination of medial rotation of the femurs, pronation of the feet, and hyperextension of the knees (see Fig. 9-6B).1l • In the sagittal;,lane, the tibiofemoral angle should be 180 degrees. l' If the angle exceeds 180 degrees . genu recurvatum (i.e., hyperextension) exists (Fig. 9-7)Y • Scapular adduction is a rest position or movement in which the scapula is positioned or moving toward the vertebral column (see Fig. 9-9)Y Scapular abduction is a rest position or movement in which the scapula is positioned or moving away from the vertebral column (Fig. 9-8).11 The clinician should avoid using "retrac­ tion" for scapular adduction and "protraction" for scapul~r abduction. 11 The arm may be protracted by abduction of the scapula, but the scapula is not pro­ tracted; the same concept applies to arm retraction and scapular adduction. • ("pward rotation of the scapula is a position or move­ ment about the sagittal axis in which the inferior an­ gle moves laterally and the glenoid fossa moves cra­ nially (see Fig. 9_8).11 Downward rotation of the capula is a position or movement in which the infe­ rior angle moves medially and the glenoid fossa moves eaudally.ll • nterior tilt of the scapula is a position or movement about a frontal axis in which the coracoid process moves in an anterior direction. 11 Posterio-r tilt of the 'capula is a position or movement in which the cora­ coid process moves in a posterior and cranial direc­ tion, whereas the inferior angle moves in an anterior and eaudal direction (see Fig. 9-8).11 • Elewtion of the scapula is a position or movement about a vertical axis in which the scapula moves cra­ nially, and depression of the scapula is a position or movement in which the scapula moves caudally (see Fig. 9-8)11

Movement is the action of a physiologic system that pro­ duces motion of the whole body or of its component parts. 1'1 Evaluating active movement requires precise ob­ servatlOn and palpation skills and extensive knowledge of kinesiologic principles. A useful criterion for assessing precise or balanced mov~ment is observing the path of instantaneOliS center of rotatwn (PIeR) during active motion. 1 The instant center of rotation desclibes the relative uniplanar motion of two adjacent segments of a body and the direction of displace­ ment of the contact points between these segments (Fig. 9­ 9).15 The instant center of rotation changes over time be­ cause of altered joint configurations and external forces. The PIeR is a trace of the sequential instant centers of ro­ tation for a joint in different positions throughout the range of motion (ROM ) in one plane (Fig. 9-10). Efficiency and longevity of the biomechanical system reqUlres mamtenance of precise movement of rotatin¥ seg­ ments; the PIeR must meet a kinesIologIc standard. D e­ viations in the PIeR from the ideal for a given joint imply that the arthrokinematic jOint motions have become al­ tered, even if the osteokinematic motion is within the nor­ mal range. The quality or precision of the osteokinematic motion is affected. Various investigators have shown that PIeR deviations provide a noninvasive means of identifY­ ing pathomechanics. 13 ,15 However, because the radiologic methods used to determine the PIeR are not available to physical therapists , clinically reliable tools for measuring the PIeR need to be established. Techniques used to qual­ itatively examine uniplanar, multi planar, and total body

Elevation Upward rotation

~Ienoid ~fossa

Adduction ~

rotation

Depression

FIGURE 9-8. The positions and movements of the scapula.

172

Therapeutic Exercise: Moving Toward Function

- - - - - ­ Upper trapezius

V!'2', \ \ Lower

FIGURE 9-9. A normal knee with a Iine drawn from the instant center of the tibiofemoral joint to the tibiofemoral contact point (line A) forms a right angle with a line tangential to the tibial surface (line B) . The arrow indi­ cates the direction of displacement of the contact points. Line Bis tangen­ tial to the tibial surface, indicating that the femur glides on the tibial condyles during flexion-extension motion .

movement patterns include precise observation, palpation of joint osteokinematics and arthrokinematics, and palpa­ tion or the use of surface electromyography to detect mus­ cle activation patterns. The clinician relies on a thorough knowledge of kinesiologic principles to differentiate ideal from impaired movement patterns. A major determinant of the PICR during active motion is the muscular force-couple action on the joint. Force couple is defined as two forces of equal magnitude but op­ posite direction with parallel lines of application. 10 The re­ sult of the forces is zero , meaning the body is not displaced (i.e. , the body is in translatory equilibrium ). The force cou­ ple causes the body to rotate around an axis perpendicular to the plane of the forces (Fig. 9-11 )10 In biomechanics, the instant center of rotation changes as the joint moves; consequently, the force-couple parameters change as the instant center of rotation changes.

FIGURE 9·10, Semicircular path of instant center of rotation (PICR) for the tibiofemoral joint in a normal knee.

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Upper serratus anterior Lower serratus anterior

FIGURE 9-11. The action lines of the upper trapezius, lower trapezius, up­ per serratus anterior, and lower serratus anterior combine in a force-cou­ ple action to produce almost pure upward rotation of the scapula.

Deviation of the PICR from the kineSiologic standard can be an indication of faulty muscle synergy in the force couple. Muscle dominance is defined as one muscle of a synergistic group of muscles that exceeds the action of it counterparts , causing a deviation of the PICR and potential disuse of the other synergists. 1 The factors that affect force­ couple balance are discussed later in this chapter.

CAUSES OF IMPAIRED POSTURE AND MOVEMENT Pathokinesiology is defined as the study of anatomy and phYSiology as they relate to abnormal movement. 16 Pathokinesiology emphasizes abnormalities of movemen as a result of pathologiC conditions. For example, in hemi­ paresis, the abnormal movement is the result of patholog:. involving the nervous system 1 However, the reverse can also occur-pathology can be the result of abnormal move­ ment. This can be defined as kinesiopathology.l When movement deviates from the kineSiologic standard, the cu­ mulative effect of repetitive movement can be patholog:.' Therefore, it is reasonable to assume that maintaining pre­ cise movement patterns can minimize abnormal stress. Ki­ nesiopathology can also result from repetitive J1lovemen~ and sustained postures associated ,vith activities of daily li,'­ ing including recreational, fitness , and sports activities Clinicians use sustained postures and repetitive move­ ments therapeutically to increase ROM , jOint mobilit~· muscle performance, and coordination. Most often, adap­ tations such as these are considered advantageous; ho\\'­ ever, they can also be detrimental and contribute to move­ ment impairments. Everyday activities can change muscle performance, ROM, jOint mobility, and motor control which in tum can alter the relative partiCipation of syner­ gists and antagonists and eventually movement patterns. The follOwing sections describe the relationship b tween posture and movement and phYSiologic, anatomic. and psychologic impairments, lifespan considerations, and environmental factors.

Chapter 9: Impaired Posture and Movement

Range of Motion

c-

d e

The normal limitation of joint motion in certain directions as postural significance in relation to the stability of the hody, particularly in standing. For example, dorsiflexion at the ankle with the knee straight is normally about 10 to 15 rees. This means that when standing barefoot vvith the t:et nearly parallel, the lower leg should not sway anteriorly n the foot more than about 10 degrees. The knee jOint has p to 10 degrees of hyperextension . In the standing posi­ n, the femur and lower leg relationship should not ex­ eed 10 degrees of postural deviation posteriorly. The hip joint also has about 10 degrees of hyperexten­ on, and, in standing, the joint motion of the pelvis on the mur is restricted to about 10 degrees of postural devia­ m anteriorly. Excessive joint ROM can allow prop or­ nal postural deviations in the corresponding directions. Conversely, jOint limitation also can affect postural !!11 ment. Ankle, knee, or hip flexion contractures can e deviations ofposture in the corresponding directions. " ith respect to movement, ROM impairment can con­ ute to movement dysfunction in that normal movement ot occur at a joint with limited ROY[ and excessive \1 can allow extremes of movement that are detrimen­ t the joint, periarticular structures, and associated mus­ _. TY11ic;ally, limited ROM at a joint encourages faulty - ment at another segment. For example, a common tty movement pattern seen associated with adhesive ulitis of the shoulder is excessive scapula elevation. A re thorough discussion of this concept will be presented r in this chapter. Finally, normal ROM at a joint does ensure accuracy of the PICR during active movement. :nember that precise active movement is dependent on ...anced force couples acting on the jOint.

scle Length pairment of muscle length can affect both posture and \-ement. Prolonged posture alterations can result in cle length changes. The time a muscle spends in the rt ned range and the amount a muscle is contracted in h ~rtened range determines whether it becomes short­ "(J.l t-l 9 Conversely, the stimulus for lengthening a mus­ the amount of tension placed on the muscle over a nged period. 17­ 19 ustained postures, particularly those postures that are ltained in faulty alignments, can induce changes in the I sand suppOlting tissues that can be injurious, espe­ ~ when the joint is at the end of its range. zo clinical example can prOvide a better understanding of e concepts. Consider a person with thoracic kyphosis , scapula positioned in abduction, downward rotation, anterior tilt. The lower trapezius muscle can experi­ sustained tension , resulting in lengthening, from a pectoraliS minor coupled with gravity and the weight ·m b. These forces act to tilt the scapula anteriorly. The oralis minor expeliences little to no counterbalancing on from the lengthened lower trapezius and is assisted :ra\ity and the weight of the limb to remain in the short­ position. If the pectoralis minor contracts repeatedly _ e shortened range (e.g. , as an accessory muscle of res­ n on), it can develop adaptive shortening.

173

These alterations in the muscle length not only con­ tribute to perpetuating the faulty posture but also con­ tribute to altered length-tension properties and subsequent force couple action of the muscles, thereby ultimately af­ fecting the PICR during active motion (see ~'luscle Perfor­ mance in a subsequent section for more details).l

Joint Mobility A joint can only move through a standard PIeR if the joint has the available passive range in osteokinematic and arthrokinematic; motions. However, normal passive joint mobility does not guarantee precise PICR during active motion. Impairments in joint mobility rarely occur in isolation. Active motion is usually affected by a combination of fac­ tors such as ROM, muscle length , muscle performance, joint mobility, and motor control. For example, during ac­ tive shoulder medial rotation in the prone pOSition with the arm abducted to 90 degrees, the shoulder should medially rotate 70 degrees vvithout an associated anterior glide of the head of the humerus. The active ROM can be limited by short lateral rotators , stiff periarticular structures (par­ ticularly the posterior capsule), and weak medial rotators. In some c;ases, the quality of motion is affected. For ex­ ample, during medial rotation , one deviation of the PICR that may be observed or palpated is an althrokinetic mo­ tion of the head of the humerus gliding excessively anteri­ orly. This movement may result from one or a combination of factors, such those previously mentioned , combined with specific weakness of the subscapulariS; dominance of the pectoralis major, latissimus dorsi, and teres major mus­ cles; and excessive extensibility of the ante rior capsule . JOint mobility, whether limited or excessive, can affect ac­ tive motion, particularly when combined "vith other physi­ ologiC impairments.

Muscle Performance A long-held belief is that deviations in posture reflect mus­ cle weakness. However, the relationships between postural deviation and muscle strength have been questioned,21 and the literature instead sugges ts that the relationship be­ tween muscle length and strength may contribute to pos­ tural deviation. 1 Stretch weakness is a term used by Florence Kendall to describe the effed of muscles maintained in an elongated condition beyond neutral phYSiologic rest position. J I This definition is based on the results of manual muscle strength testing, at which Kendall is an acknowledged expert. 11 For example, when the shoulders are maintained in a forward position and the scapulae are elevated and abducted, tl1e lower and middle trapezius muscles are positioned in an elongated rest position. The manual muscle test would demonstrate weakness (Fig. 9-12). However, the apparent weakness of the posturally lengthened muscle ma), be an indication of altered length-tension properties such that the elongated muscle cannot produce tension in the short­ ened range (i.e., the manual musde test position)17-20 Length-tension properties of muscle are also discussed in Chapter 5.

174

Therapeutic Exercise Moving Toward Fu nction

FIGURE 9-12. Manual muscle test position for the lower trapezius. Note that the arm is in elevation, positioning the scapula in upward rotation. The test positionfor the scapula is upward rotation, adduction, and depression. Failure to hold the test position indicates weakness.

If the elongated middle and lower trapezius muscles are tested in a relatively lengthened range , the force produc­ tion capability is greater than in the traditional manual muscle tes t position. This ghenomenon can be called a length-associated change. 2 For the muscle to become lengthened, it adds sarcomeres in series and, therefore, is capable of producing greater peak force than a normal­ length or shortelleo muscle whe n tested at its optimal length. However, if the lengthened muscle is placed in a shortened position for manual muscle test, the filaments would overlap and be less efficient at prodUCing force than a short or normal-length muscle. This is similar to flexing the "'nee to test the gluteus maximus in hip extension and thereby lessening the contribution of the hamstrings . When testing muscles in the shortened range, a more ap­ propriate description may be positional strength, because it indicates only the force the muscle can create in the short range. l One form of stretch weakness may be positional weakness. Testing the muscle at multiple points in the range and comparing findings with those for the opposite extre mity (or half of the body when examining axial mus­ cles ) can help to differentiate positional weakness from weakness resulting hom strain , disuse , or neurologic in­ volvement. The muscle with length associated changes tests weak in the short range and strong in the lengthened range, whereas the other sources of weakness should test weak throughout the range. The length-tension properties of the muscle correlate di­ rectly with the partiCipation of the muscle in the force cou­ ple. The hne of pull of its Hhers determines the speCific func­ tiOll of each muscle. No two muscles in the body have exactly the same line of pull. Whenever muscle weakness exists, the performance of some movement is affected or the stability of some part of the body is impaired. A muscle that becomes elongateo over tim e exhibits positional weakness relative to the same point in tl1e range of normal length or shortened synergists. Compared with its normal-length or shortened synergists, its paIticipation in the force couple is lessened until it can achieve its optimal length-tenSion relationship. The result is a deviation of the PICR, which may contribute to microtrauma and eventually to macrotrauma, pathology, further impairment, and disability.

A clinical example may illustrate the relationship be­ tween length-tension properties and movement. In an in­ dividual with a functional limb length discrepancy \vith a high iliac crest on the light, the right hip is in postural ad­ duction , which places the gluteus medius on stretch. Dur­ ing gait, the gluteus medius partiCipates in the hip abduc­ tion force couple to decelerate hip adduction from the initial contact to midstance phase (see Selected Interven­ tion 9-1 ). The tensor fascia lata does not necessarily en­ counter the same stretch stimulus as the gluteus medius when the hip is in postural adduction (particularly the an­ teromedial fibers ) and therefore can create better tension for abduction at initial contact when the hip is in more rel­ ative adduction. However, because the tensor fascia lata is also a hip flexor and medial rotator, without strong coun­ terbalance from the gluteus medius (particularly posterior gluteus medius), the PICR of the hip can deviate in the di­ rection of flexion and medial rotation . The overstretched gluteus medius can generate greater counterbalancing ten­ sion only after the hip is adducted , flexed, or medially ro­ tated, which places the muscle on stretch. The posturally lengthened muscle affects the force-couple action and ulti­ mately affects active movement patterns. The theory of"core strength" is another key concept that certainly pertains to optimal posture and movement. Chap­ ter 18 discusses the theory of core strength in detail along with therapeutiC exercise descriptions to develop core strength. The reader is referred to the section on Muscle Performance in Chapter 18, The Lumbopelvic Region for the literature review, and detailed discussion of this topic . With respect to the endurance component of muscle performance, the fatigability of a muscle affects its partiCi­ pation in a force couple, particularly in repeated move­ ments. Muscle fatigue affects movement, but muscle en­ durance often is not a factor in perpetuating optimal resting alignment; the length of the muscles and periarticular struc­ tures support optimal alignment. Little muscle activity is re­ quired to maintain a relaxed standing position. 22

Pain Pain, posture, and movement are inextricably linked. Pain can induce abnormal movement, abnormal movement can induce pain, and it is often difficult to differentiate cause from effect. When a mechanical defect perpetuates th symptom or prevents resolution of the painful condition. the mechanical cause must be diagnosed and treated. Ulti­ mately, the posture habits and movement patterns con­ tributing to the mechanical cause of pain must be modified. Pain mayor may not alter a given posture or movement. depending on the severity of the symptom and tl1e magni­ tude or intensity of stress imposed by the posture or move­ ment. However, pain that is associated ""ith posture and movement can lead the clinician to an understanding of th kinesiopathologic factors contributing to the pain. For ex­ ample, if a patient has pain during a medial shoulder rota­ tion movement, such as is used in swimming, it must be de­ termined what impairments are associated with the pain experienced during this movement pattern and how to alter the movement pattern to reduce or eliminate th pain. For example, during movement testing, the move­ ment of the head of the humerus is found to be associated

Chapte r 9 Impaired Posture and Movement

I

t:::\

SELECTED INTERVENTION 9-1

\;!;J

Prone Hip Abduction

See Case Study #9 .-\lthough this patient requires comprehensive intervention, one critical exercise is described:

ACTIVITY: Prone hip abduction through full range of motion PURPOSE: Strengthen 2+1.5 gluteus medius through full mnge (need to increase the muscle's ability to create tension ;:hrough full range ) RISK FACTORS: No appreciable risk factors

EFFECT OF PREVIOUS INTERVENTIONS: :-.Jone

ELEMENTS OF THE MOVEMENT SYSTEM: Base

STAGE OF MOTOR CONTROL: Mobility

ODE: Resisted exercise in a gravity-lessened position OSTURE: Beginning ancl ending position-prone, with a ilIow under stomach, hip slightly laterally rotated, elastic ..round the ankle (Fig. A) SPECIAL CONSIDERATIONS: Ensure that the gluteus medius is contracting throughout the entire activity (concentric and eccenttic) and that the tensor fascia lata (TFL) is mllumally relaxed. Ensure that full end-range motion is achieved and that the abdominalllluscies are stabilizing the spine against extension and the pelvis against anterior tilt and side-bendillg forces imposed by motion of the hip. Be sure motion is isolated to the hip and that no Illotion occurs in the spine or pelviS. DOSAGE Special Considerations: Anatomic: Gluteus medius Ph)'siologic: No strain , 2+15 manualmusc!e test (M \1T) grade Learning capability: Difficulty isolatillg gluteus medius over TFL may require tactile facilitation or surface electromyography with biofeedback on gluteus medius for better isolation. Type of Contraction: Concentric during abduction motion and eccentric during adduction motion Intensity: Light-resistance elastic tied around the ankle and taut in hip-neutral position Speed of Activity: ,Vloderate on cOllcentric portions ; slow eccentric pOition

011

Duration: To forIll fatigue for two sets (ma.xirnuIIr of :30 repetitions ) Frsquency: Daily

OVEMENT: The hip extends just enough to clear from the .uppOiting surface, abducts through the full available range concentric), rests on the supporting surface, retul11s to a Jiahtly extended position, and slowly adducts to the starting position (eccentric) (Fig. B).

Environment: Home Fesdback: Initially tactile facilitation or surface electromyography with biofeedback, tapered after isolated contraction is achieved (contil/lled)

175

176

t:::\

\!I

Therapeutic Exercise: Moving Toward Function

SElECTED INTERVENTION 9-1

Prone Hip Abduction (Continued)

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to increase the strength of the gluteus medius in isolation from the TFL. Because the MMT grade is 2+/5, a gravity­ lessened position was chosen to allow full range of motion. Elastic was used to ensure concentric contraction of the gluteus medius during the abduction motion and eccentric contraction on the return from abduction in a gravity­ lessened position. Full range of motion is expected to work on length-tension properties of the gluteus medius (Le ., ability to create force throughout the range, including the shortened range ). EXERCISE MODIFICATION/GRADATION: As strength through a full range is developed, the exercise should be progressed to an against-gravity position (Le., sidelying). After a 3+/5 MMT grade is achieved, standing functional activities should be in­ troduced (Le., stability and controlled mobility). After proxi­ mal stability and controlled mobility are achieved, the exer­ cise can be progressed to functional gait activities (i.e. , skill). Within each activity level, specific dosage parameters can be manipulated to progress the exercise and prepare for

with excessive anterior translation. When the humerus is manually prevented from moving anteriorly during the mo­ tion by the clinician, the pain is relieved. The anterior translation can be assumed to be the mechanical cause of the pain. The clinician must perform additional tests to de­ termine the specific impairments that contribute to the an­ terior displacement of the head of the humerus such as a weak or overstretched subscapularis coupled \vith a domi­ nant and short teres major. Treatment is based on resolving the impairments associ­ ated with the kinesiopathologic pattern. By treating these impairments, the pain often resolves vvithout necessarily re­ quiring direct treatment of the tissue that is the source of pain.

Anatomic Impairments and Anthropometric Characteristics Anatomic impairments can predispose persons to impair­ ments of posture and movement that can result in MPS. In­ dividuals with anatomic impairments (e. g ., scoliosis, kypho­ sis from Scheuermann's disease , hip anteve rsion ) are predisposed to develop MPS because of altered posture habits and movement patterns. For example, an individual with Scheuermann's disease typically has moderate to marked kyphOSiS. This patient is prone to even more exag­ gerated kyphOSiS beyond the anatomic impairment because of the effect of grc1\ity and the weight of the upper extrem­ ities on the kyphotic posture. Increased thoracic kyphOSiS can give rise to thoracic, neck, shoulder, low back, or lower quadrant pain because of compensatory spinal , shoulder girdle, pelvic girdle , and lower extremity alignments. The patient may adopt movement patterns that perpet­ uate the kyphotic posture. For example, during forward bending, instead of initiating the movement \vith concen­

gradation to the next level. At each level, care must be taken to ensure synergy between the gluteus medius and TFL in stabiliZing the hip in the frontal plane by obse[\.ing the pelvic and femur positions and preventing antelior peh.i c tilt, Trendelenburg gait, or femur medial rotation. In closed chain positions, neutral pelvic, tibial, and foot alignment about all three axes complement the hip position.

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF SPECIFIC EXERCISE:

Posture: Educate the patient about asymmetiic postures that reinforce a weak, lengthened gluteus medius (i.e. , standing with weight shifted to the involved side, resulting in a high iliac crest). Movement During gait, think of contracting gluteal musculature at heel strike to prevent a Trendelenburg gait.

tric phaSiC activity from the rectus abdominis and control­ ling the lowering ,vith eccentric spinal and hip extensors. the bending movement may be produced by tonic concen­ tric rectus abdominis activity and phaSiC eccentric deceler­ ation from the spinal and hip extensors. The latter move­ ment pattern would contJibute to greater kyphotic force on the thoracic spine than the former pattern. Anthropometri c characteristics can also contribute to impairments ofposture and movement. Consider a tall mar 'with broad shoulders and a tall, narrow pelvis. Ideal lu m­ bopelvic rhythm is such that motion at the lumbar spi n should be accompanied by motion of the pelvis rotating on ' the hips.23 The tall man with broad shoulders and a tall, nar­ row pelvis has a higher center of mass than an ave rage­ height woman with a relatively broader pelviS. ,""hen th man bends fOIWard, the fulcrum point is more likely to bo in the lum bar spine than at the hips because of the high cen­ ter of mass. The man therefore has a greater tendency bend vvith excessive lumbar flexion and limited pelvic rotA­ tion (Fig. 9-1:3). With repeated forward bending using tlu. strategy over a lifetime, the hip joint is at risk for developin _ hypomobility in the direction of flexion , and the lumbar seo ­ ments are at risk for becoming hypermobile in the djrecti of flexion . The hn)ermobility of the lumbar spine into fl e\­ ion may be carried through other postures and movem patterns such as sitting, leaning fOlward in sitting, and th follow-through phase in sening the ball in tennis. Relat impairments of muscle length and performance can res from impairments of movement and contribute to perpe ating and further exaggerating faulty movement.

Psychologic Impairments Emotional factors can affect posture and movement. Fa instance, a person 's posture at the funeral of a loved one b

Chapter 9 Impaired Posture and Movement

=A

177

B

=

Flexible tissue

-

"Stiff" tissue LB = Low back HE = Hip extensors

FIGURE 9-14. Severe developmental deviation. This amount of lordosis in an 8-year-old child is considered a severe developmental deviation neces­ sitating intervention. A corset to support the abdomen is needed along with therapeutic exercises.

GURE 9-13. This illustration depicts faulty lumbopelvic rhythm with less ement of the pelvis relative to the hips. In men, this could result from anthropometric characteristics of a heavy upper body relative to the " er body ".e

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different from that at a celebration of a happy occasion. A person v.rith significant negative stresses (e.g., divorce, death, illness) may develop profound changes in posture d movement. It is beyond the scope of physical therapy ctice to deal v.rith profound or complex psycholOgic im­ pairments. Nonetheless, the physical therapist must be sensitive to the contribution emotional factors can have on posture and movement. If the physical therapist deter­ ~es that the emotional state of the patient is inhibiting ~cover)', referral to an appropriate mental health practi­ . ner is indicated, Physical therapy intervention may need _D stop until the emotional state improves, or it can proceed it is determined that continued intervention is beneficial _ psychologic recovery Improved emotional status often 'll proves posture and movement, and improved posture !ld movement can improve emotional status.

"fespan Considerations

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<7e affects posture and movement. Children are not ex­ "JeCted to conform to an adult standard of posture and vement, primarily because the developing individual ..:oxhibits much greater mobility and flexibility than the ult. 24 Developmental deviations appear in many chil­ ::.ren at about the same age and improve or disappear 'lthout any corrective treatment, despite unfavorable en­ rronmental influences?4 However, developmental devia­ ns are perpetuated by habit in some children. Repeated b e rvation (not a single examination) can determine e ther a developmental deviation is being perpetuated habit. If the condition remains static or if the deviation CTeases, corrective measures are indicated. A young ..1Iild (younger than 5 years) is not likely to have habitual ults and can be harmed by corrective measures that are t needed. Any deviations considered severe require im­ ediate attention, regardless of the age of the indhridual f ig. 9-14). Developmental changes occur in the feet, ees, hips, pelvis, trunk, and shoulder girdle. Display 9­ ~ Ls ts the common developmental deviations in children

DlSPLAV9·3

Developmental Deviations in Posture Feel • Flat arches are normal in the small child. • By age 6 or 7, expect good arch formation. Knees • Genu valgum is normal in a small child (about 2 inches between ankles is normal for an average-height child). • By age 6 or 7, genu valgum should be diminished or gone. • Postural genu varum in the school-age child is not acceptable, and corrective measures should be taken, because it is difficult to change in the young adult. • Genu varum may be compensatory for genu valgum by hyperextension of the knees. Hips • Femur medial rotation is the most common and often result from hip anteversion, foot pronation, knee hyperextension, postural genu va rum, and, less often, genu valgum. Check for structural sources and treat with the appropriate corrective measures. • By adolescence, the femur should be in near-neutral alignment. • Femur lateral rotation is more common in young boys. • Persistent lateral rotation should be treated, because it can be detrimental in adulthood, Lumbopelvic Region • A protruding abdomen is normal for a child, • By the age of 10to 12, the abdomen should no longer be protruding, • Lordosis peaks at age 9to 10 and should gradually diminish thereafter. • Handedness patterns emerge in school-age children, most commonly with the hip high and shoulder low on the dominant side. This should be monitored if it is borderline or excessive. Shoulder Girdle • Scapular tilting is normal in school-age children, • The prominence should diminish as the child approaches adolescence. From Kendall HO, Kendall FP, Boynton DA. Posture and Pain. Huntington, NY Robert E Krieger Publishing, 1970.

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Therapeutic Exercise Moving Toward Function

that should gradually diminish as the child reaches ado­ lescence and adulthood. One particular anatomic impairment that is not consid­ ered a normal developmental posture occurs dUling ado­ lescence. Physical therapists working with preadolescent and adolescent populations should be routinely screening for the onset of scoliosis. After scoliosis is diagnosed, the adolescent can be referred to a physician specializing in the treatment of scoliosis and a comprehensive management plan can be developed. The aging process can induce many postural and move­ me nt changes, primarily because of pathology or disease. The aging process manifests in minor neuromuscular changes, but in the absence of disease, the resulting im­ pairments of posture and movement usually are no more exaggerated than in middle age. Vigilant attention to pos­ ture anclmovement patterns should minimize the effect of aging in an otherwise healthy individual.

Environmental Influences The activities in which an individual partiCipates and the surrounding environment may have favorable or adverse effects on posture and movement. The nature of the activ­ ities and the time spent doing them and whether the effect of habitual postures and movements during one activity are reinforced or counteracted by habitual positions or re­ peated movements in other activities determine the overall postural and movement effect. Stresses are put on the ba­ sic structures of the human body by increaSingly speCial­ ized and limited or repetitive activity (e.g., working endless hours at a computer display terminal , going home ex­ hausted, sitting most evenings in a recliner chair in front of a television ). The activities of an individual must be considered as a whole in gauging their postural or movement effects. Con­ centration on one type of activity can ensure muscle imbal­ ance, but a combination of activities may be almost as un­ favorable if each involves the same kind of movement or position. For l'xample, a person working at a video display terminal who engages in piano playing in her leisure time has no real change in the type of activity. Several environmental factors, such as workstations, beds, pillows, car seats, school chairs and desks, and footwear, influence posture and movement. These envi­ ronmental influences should be made as favorable as possi­ ble. When major adjustments cannot be made, small ad­ justments often help conSiderably. A discussion of environmental influences is not complete without refer­ ence to body mechanics related to lifting and carrying. These strategies should be examined and favorably modi­ fied as much as possible I()f the individual's circumstances.

determine if the points of reference of the individual being tested are in the same alignment as the corresponding pOints in the standard posture. The amount of deviation of the various points of reference from the plumb line reveal the extent to which the subject's alignment is faulty. When deviations from plumb alignment are evaluated, they are desclibed as slight, moderate, or severe l l Additional align­ ment tests can be performed in several positions, such as sitting, recumbency, and single-limb stance. Deviations from acceptable standards can be noted. Posture can assist the clinician in generating hypotheses regarding muscle length. For example, anterior pelvic tilt can suggest short hip flexors and elongated abdominal muscles. Specific muscle length tests are necessary to de­ termine actual muscle length. D efinitions of terms regard­ ing muscle length are as follows: • Tautness is defined as muscles or ligaments put on tension. It implies a state in which slack is taken up in the muscles or ligaments. • A short muscle limits the ROM as it relates to the ki­ nesiologic standard. • An elongated muscle is longer than the kinesiologic standard; tautness appears after the motion has cx­ ceeded the normal joint range. • The term tight often is used interchangeably with short or taut, but these terms do not have equivalent meanings. On palpation , a muscle that is short an d drawn taut feels tight. A muscle that is elongated and drawn taut also feels tight on palpation. Because the word tight implies that a muscle should be stretched. the terms short and elongated are preferred to de-

EXAMINATION AND EVALUATION Posture The lines and pOints of reference discussed under standard alignment are put to practical use in plumb line tests for postural alignment (Fig. 9-15). A plumb line test is used to

AGURE 9·15. For the purpose of testing, the client steps up to a s u ~ ­ pended plumb line. For the back or front view the subject stands with feei equidistant from the line; for side view, the point just in front of the latera malleolus is in line with the plumb line. The base point should be the fixed reference point, because the base is the only stationary or fixed part of thE standing posture.

Chapter 9: Impai red Posture and Movement

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179

scribe muscle length to ensure that stretching is ap­ plied only to short muscles. • Stiffness is defined as the change in tension per unit change in length. 25 When passive motion of a joint is assessed , all the tissues crossing the joint contribu te to the resistance, which can be referred to as jOint stiffness.! For the purposes of this text, stiffness refers to the resistance present during the passive elonga­ tion of muscle and connective tissue, not during ac­ tive muscle contraction or at the end of ROM .

ovement .:..u mination of movement in the clinical setting can be allenging, because sophisticated computerized move­ nt analysis equipment is costly and is not user-friendly the typical physical therapy setting. The clinician must refore rely on the follOwing test procedures for singleTIt movement analysis: • Palpation skills and precise observation of basic movement patterns at a single joint are used to deter­ mine how closely the movemen t pattern replicates the kinesiologic standard PICR for a given limb for that movement (e. g. , observing or palpati ng the lenohumeral or scapulothoracic joints while raising the arm in flexion ; or the spine, pelviS, knee , ankle, or foot during standing hip and knee flexion ). • Palpation or surface electromyography is used to de­ termin e the pattern and synchronization of muscle < ctivity for a given movement , which is compared with known kinesiologic standards. clinician should rely on the follOWing test proce­ for analysis of multiple-segment movement: • :\s in gait analYSiS , break the movement into phases, nd look at each segment or component (i.e., group of egments ) during each phase and relate the segmen­ tal movements to the process of movement. For ex­ ample, the step-up can be broken into a swing and tance phase (Fig. 9-16). Each segment can be ana­ lyzed and relationships can be determined . For in­ tance, a hip-hike strategy in the lumbopelvic region - related to insufficient hip and knee flexion and an­ kle dorsiflexion in the swing phase, and a T rendelen­ burg position (pelvis is dropped on the side opposite to the weak hip abductors) in the stance phase is re­ lated to similar abnormal movement patterns (i.e ., hip adduction occurs in a hip-hike and Trendelenburg position ). • imilar movement pattern deSCriptions can be devel­ oped for each basic movement required for activities of daily living (e.g., rising from sit to stand, step-down, bed mobility, reaching). By describing movement p ttern strategies, the variations in movement pat­ e ms and deviations from efficient and healthy pat­ ems can be determined. The reader is referred to a 'TIore complete re ference on this topic for specific re­ :jonal movement impairment syndromes .! rutional examination techniques can offer clues to ex­ ou tcomes. By compiling results of ROM , muscle

A B FIGURE 9·16. The step can be bro ken into two phases. (A) The swing phase in which the hip and knee are flexed to bring the foot to the surface of the step and (B) the stance phase in which the body is raised onto the step.

length, joint mobility, and muscle performance tests, the clinician can hypothesize about the quality of the PICR and the muscle recruitment patterns during active movement. Th e minimal essential tests of muscle length that should be included in any posture or movement examination of the lower and upper q uadrant are listed in Display 9-4. The minimal essential tests of positional strength that should be

DISPLAY 9-4

Essential Muscle Length Tests Lower Quadrant • Hamstring: This test should distinguish between the medial and lateral hamstrings. • Gastroc-soleus: This test should distinguish between the gastrocnemius and soleus. • Tensor fascia lata and iliotibial band • Hip flexors: This test should discriminate among the tensor fascia lata, rectus femoris, and iliopsoas. • Hip rotators: This test should distinguish between the medial and lateral rotators. Upper Quadrant • Teres major and latissimus dorsi • Rhomboid major and minor and levator scapula • Pectoralis major • Pectoralis minor • Shoulder rotators: This test should distinguish between the medial and lateral rotators.

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Therapeutic Exercise: Moving Toward Function

DISPLAY 9-5

Essential Positional Strength Tests Trunk • Abdominal muscles: separate tests should be performed for the rectus abdomin is and internal oblique,10 external oblique,l and, if possible, transversus abdominis.29 Lower Quadrant • Iliopsoas • Gluteus medius • Gluteus maximus • Hamstrings • Quadriceps • Tensor fascia lata Upper Quadrant • Serratus anterior • Upper, middle, and lower trapezius • Infraspinatus and teres minor • Subscapularis 1

included in any posture or movement examination for the trunk, upper quadrant, or lower quadrant are listed in Dis­ play 9-5. Reexamination of the movement after additional tests have been performed can enable the clinician to bet­ ter understand the complexity of movement.

INTERVENTION Healthy, effective, and efficient posture and movement are an integral part of general well-being. Efficiency and longevity of the human biomechanical system requires maintenance of precise movement of the rotating seg­ ments. 1 Good posture and movement are considered fundamental to health of the biomechanical system. Ide­ ally, posture and movement instruction and training should become an integral part of any therapeutic intervention. Although posture and movement alterations can each be considered as one type of impairment, they cannot be con­ sidered in the same way as impairment of muscle perfor­ mance, RO\1 , or joint mobility. Impairment in posture and movement can be the result of many factors, including physiologic, anatomic, and psychologic impairments. To develop an efficient, effective intervention for the treat­ ment of posture and movement impairment, all the func­ tional limitations and the related impairments resulting from and contributing to posture and movement impair­ ment should be understood. The effect of predisposing risk factors, previous interventions, and environmental influ­ ences should also be taken into consideration. This chapter has presented a foundation for developing therapeutic exercise interventions to treat posture and movement impairments. The remainder is devoted to de­ scribing therapeutic exercise intervention for posture and movement according to the intervention model described in Chapter 2.

Elements of the Movement System Any or all elem ents of the movement system can be in­ volved directly or indirectly in the development of posture and movement impairment and therefore should be dealt with in treatment. Base and biomechanical elements usu­ ally require direct intervention for the correction of pos­ ture and movement impairments, whereas modulator ele­ ments are more critical to movement impairments than posture impairments. Impairments of the cognitive or af­ fective element can limit the progress of an individual ,vith posture or movement impairments. If this is the case, ap­ propriate referral to a mental health practitioner may be­ required to reach the desired fun ctional outcome. Impair­ ments of the support element can affect posture and move­ ment directly (Le., faulty breathingpattems or reduced en­ ergy for movement) or indirectly through o>..ygen transpo deficits in systemic disease that contributes to further faults in posture and movementS Display 9-6 prOvides exampl e~ of impairments of the elements of the movement system associated with posture and movement. Other bodily systems may be involved directly or indi­ rectly and should be considered if necessary to impron' posture or movement. For example, a patient presents with posture and movement impairm ents about the hip with the comorbidity of urinary incontinence caused by pelvic HOOT

DISPLAY 9-6

Elements of the Movement System and Factors Contributing to Impairment of Posture and Movement Biomechanical Factors • Anatomic impairments such as scoliosis or hip anteversion • Physiologic impairments such as postural genu varum • Anthropometric characteristics Base • Overstretched gluteus medius, contributing to high iliac

crest and functional limb length discrepancy

• Easily fatigued serratus anterior, contributing to reduced

scapular rotation with repetitive overhead activities

• Muscle strain, contributing to reduced activity level and

altered movement patterns

Modulator Factors • Reduced or loss of innervation of the gluteus maximus

associated with hip hyperextension

• Tensor fascia lata dominance during hip flexion,

contributing to hip flexion with medial rotation

• Latent timing of the vastus medialis oblique, contributing to patellofemoral movement impairment Support Factors • Inappropriate breathing patterns associated with abnormal rib cage alignment and with rib and thoracic spine movement patterns Cognitive or Affective Factors • Depression associated with slumped posture or shuffling

gait

• Upright posture associated with feeling proud • Increased muscle tension associated with stress

Chapter 9 Impaired Posture and Movement

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weakness and estrogen depletion. Full correction of pos­ ture and movement impairments about the hip may not be achieved without attention to the pelvic floor dysfunction, which is caused by impairments of'the movement, urogen­ Ital, and endocrine systems. The link between the move­ ment system and urinary incontinence is discussed in Chapter 19. In this case, without considering the associated rogenital problems and hormonal imbalances, the pelvic • oor problem may not resolve, preventing optimal function f the pelvic floor muscles. Because two of the pelvic floor ""luscles are also used for hip function (i.e., obturator inter­ us and piriformis), dysfunction of the pelvic floor may ontribute to posture and movement impairment of the 'p, which may contribute to further pelvic floor dysfunc­ n, and so on as the cycle continues. All the systems in­ lved must be addressed to resolve the posture and move­ ent impairment at the hip.

ctivity and Dosage -wnerous activities or techniques can be chosen to restore althy and efficient posture and movement:

• Stretching short muscles and improving extensibility of stiff myofascial tissues • Improving muscle performance in muscles exhibiting weakness , strain, or poor endurance • Supporting, strengthening, and shortening elongated muscles • Optimizing body mechanics , ergonomics, and pos­ ture a\ovareness • Optimizing balance and coordination • Training appropriate breathing exercises • Improving aerobic condition This list is not conclusive in that all therapeutic exercise -erventions can affect posture and movement. Because tu re and movement are components of the intervention el, evely activity or technique should promote optimal ture and movement. No activity or technique should ' npromise kinesiologic standards of posture and move­ nt unless modification is necessary as a result of the dis­ e . pathology, or anatomic impairment.

Id ntifying and priOlitizing the elements of the move­

nt Y5tem, combined with knowledge of the physiologic

'. of the component impairments, can help to deter­ ~e the activities or techniques needed, including the ture, movement, and mode param eters. Dosage param­ depend on the component impairment (e.g., ROM, de le ngth , joint mobility, muscle performance), stage "llotor control, and phYSiologic status of the tissue being Jressed. To illustrate these points, consider a patient with a mild -er trapezius strain with abducted and downwardly ro­ ed scapulae at rest (Fig. 9-17) and excessive scapular ab­ _tion and anterior tilt dUling fOf\vard-reaching activities. 'ention of these impairments is preferable, and there uld be careful scrutiny of any posture, activity, or tech­ e that allows further stretching of the lower trapezius. ideal length of ligaments and muscles helps to main­ ideal posture alignment with a minimum of muscular ..Irt , and when muscles and ligaments become over-

FIGURE 9·17. Although minimal, this figure illustrates abduction and downward rotation of the left scapula relative to the right

stretched, they fail to offer adequate support, the jOint ex­ ceeds the normal range, and the posture becomes faulty or muscular effort increases to maintain ideal alignment. In this case, it is possible that the lower trapezius is strained by overstretching, and that posture and movement patterns perpetuate this condition. Treatment of base (i.e., shorten­ ing and strengthening of the lower trapezius) and biome­ chanical elements (i.e., reduced thoracic kyphosis ) is indicated. In addition to posture awareness training and er­ gonomic modifications to address the biomechanical ele­ ment, taping can be used to support the scapula in im­ proved alignment (see Chapter 26). This approach also affects the base element by supporting the lower trapezius in the short range, thereby alleviating tension to allow heal­ ing and improve length-tension properties. Combining attention to base and biomechanical ele­ ments is more powerful than fOCUSing on either technique alone. With respect to the base element, the goal is to im­ prove muscle performance by altering length-tension properties of the lower trapezius. This component of mus­ cle performance impairment is often overlooked but is critical to achieving muscle balance to restore healthy and efficient posture and movement. The tendency Ill::!y be to stretch the opposing short pectoralis minor and major (also contlibuting to impairment of scapula posture and movement). However, if attention is focllsed only on stretching the short muscle without shortening and strengthening the lengthened muscle , equilibJium about the joint cannot be achieved. Another example of this principle is in the case of a person with an anterior pelvic tilt and lumbar lordosis. If the hip flexors are stretched without adaptively shortening the abdominal muscles (see Chapter 18), the pelvis does not assume a neutral position in relaxed standing. One activity that may be useful in this situation is to strengthen the adaptively lengthened muscles in the short­

182

Therapeutic Exercise: Moving Toward Function

ened range. The premise of this intervention strategy is to improve the strength of the lengthened musc.:le in the shOli range, where it has the greatest difficulty creating tension. If the focus of the exercise is on stTengthening without at­ tention to th e ability to create tension in the shortened range, the exercise may reinforce the muscle imbalance by increasing the strength in the lengthened range. Careful decisions must be made regarding the stage of motor con­ troJ, posture, mode, movement, and dosage parameters to provide the optimal stimulus for strengthening without overloading the target ll1usc.:lc or promoting substitution of a dominant synergist (i.e., upper trapezius) or antagonist (i.e., pectoralis minor or major). The physiologic status of the tissue (i.e., le ngth-associate d changes or degree of strain) must be considered when determining each of these parameters. Stability may be the starting point for the stage of motor control becau se strengthening is the chosen activity and specificity is critical. Often, the lengthened muscle is un­ able to hold the limb against gravity when positioned in the short range. Shortening the lever arm or exercising in a gravity-lessened position may be necessary for optimal strengthening (see Fig. 26-20 in Chapter 26). As the mus­ cle becomes stronger in the shortened range, lengthening the lever arm and exercising against gravity can modify the exercise. Submaximal isometric contractions in the short range may be ideal initially, moving toward concentric­ eccentric contractions throughout the range as the muscle heals , length-tension propeJiies improve, and muscle per­ formance can substantiate participation in the force cou­ ple. After stability is attained, the exercise can be pro­ gressed to controlled mobility and skill, with ultimate progression to functional movement patterns involving the total body as the final goal. Dosage should follow the gUidelines for strength train­ ing to improve muscle performance capability and gener­ ate hypertrophy of the lower trapezius to provide coun­ terb alancing stiffness to the antago nists , the pectoralis major and minor. Eventually, endurance dosage parame­ ters can be applied as more functional movements are incorporated. Simultaneous stretching of the pectoralis minor an d ma­ jor can be preSCribed to augment the improved posture and movement change s. It may also be necessary to address breathing pattems if it is determined that the pectoralis mi­ nor is stiff because of overuse as an accessory muscle of res­ piration. Stretching addresses the base element, and breathing addresses the support element. Both of these in­ terventions can begin at the mobility stage of motor con­ trol , progressing somewh at parallel to that for the lower trapezius toward controlled mobility an d skill. Ultimately, the isol ated joint function of optimal move­ ments of the scapula must be incorporated into total-body movement patterns (i.e., controlled mobility and skill). When this stage is appropriate, movement impairme nts of related areas may emerge. Perhaps the scapula abducts during forward-reaching movements because of a lack of hip fl exion during reaching patterns or a lack of thoracic or hip rotatjon during cross-body reaching patterns. The re­ lated areas may reguire interven tion to restore no rmal function to the shoulder girdle.

FIGURE 9-18. The use of pillows under the head, under the waist, and be­ tween the knees can position the spine in optimal alignment in sidelying.

Patient-Related Instruction and Adjunctive Interventions Education regarding attention to postural alignment in fre­ guently held or prolonged occupational or recreational po­ sitions is key to (1) optimizing joint position for rest ancl function, (2) reducing the tension placed on elongated muscles, and (3) increasing the tension placed on short­ ened muscles to restore muscle balance. Photographs of the patient in a typical rest posture and corrected posture can serve as powerful feedback for indUCing change. Er­ gonomiC modifications may be necessary to improve th patient's environment. If an on-site visit to the workplace is not feasible , a photograph of the workstation can be ana­ lyzed to provide suggestions for change. Othe r posture habits, including recumbent positions, can be analyzed ancl suggestions offered. Pillows under the head , under or be­ tween the knees , or under the waist in sidelying (Fig. 9-18 ) can be suggested to offer optimal support to body regions while in recumbent positions. Footwear is another topiC' about which the physical therapist can prOVide recommen­ dations (see Chapter 22). Adjunctive interventions such as supportive device (e.g., corsets, bracing, orthotics, taping) can be used te m­ porarily to assist in creating length-associated and proprio-

FIGURE 9-19. Taping along the thoracic spine can serve as biofeedback to discourage excessive thoracic flexion. The tape is best applied with the patient in a quadruped position, with the thoracic spine in a flat position.

Chapter 9 Impaired Posture and Movement

tive chang s or used permanently to provide partial or mplete corredion of anatomic impairments. For exam­ . taping can b used te mporarily in the thoracic region provide proprioceptive input for a patient about his or r k-yphotic posture (Fig. 9-19 ). Every time the patient 've into excessive thoracic flexion , the tape serves as a "'1inder. Conversely, a permanent supportive device such corrective orthotic may be necessary to improve align­ nt throughout the kinetic chain and gait kinetics and matics in an individual \.vith structural forefoot varus.

183

niques and stage of motor control, and accurate pre­ scription of dosage parameters for a successful outcom e. • Successful treatment of impaired posture and move­ ment can directly affect the kinesiopathologic factors re­ sponsible for the development, perpetuation, or recur­ rence of MPS.

CRITICAL THINKING QUESTIONS

1. How are posture and movement impairments related to

KEY POINTS tany physiologic impairments can contribute to and 1erpetuate impairments in posture and movement. \·aluation of posture and movement impairment re­ uires identification of deviations in posture and move­ lent hom acceptable standards and assessment of con­ 'b uting factors such as physiologic impairments and mironmental, structural, developmental, and emo­ onal factors. Th rapeutic exercise intervention for posture and move­ e nt impairment involves prioritization of the elements the movement system and related impairments, care­ at determination of the appropriate activities or tech-

LAB ACTIVlnES :\ssess your laboratory partner's posture from the si.de and back views. Given your partner's alignment, which muscles would you predict to be too long or shOlt? _ Design an exercise program that stretches muscles that may be too short and strengthens muscles that are too long. Assess your paltner's strategy of rising from sit to stand, Break the movement into component parts. Assess the feet, ankles, knees, hips, pelvis, and lum­ bar, thoracic, and cervieal spine about all three axes of motion during each component of the movement.

ENCES ahrmann SA. Diagnosis and Treatment Of Movement Im­ pairment Syndromes. St. Louis: Mosby, 2002. - He rring SA, Nilson KL. Introduction to overuse injuries. Ciin p orts Med 1987;6:225-239. Leadbetter WB. Cell-matrix responsE' in tendon injUly. Clin ports Med 1992;11:53:>-578. Janda V. On the concept of postural muscles and posture in man. Aust J Physiotller 1983;29:8:3--84. - Posture Committee of the American Academy of Or­ thopaedic Surgeons. Postur and its relationship to Olthope­ die disabilities: a report of the Posture Committee of the American Academy of Orthopedic Surgeons. Evanston , IL: ,\merican Academy of Olthopedie Surgeons; 1947: 1.

MPS? 2, Define ideal posture as it relates to surface landmarks from a side view. 3, Consider Case Study #9 in Unit 7. a. Given this patient's posture alignment, what muscles would you predict to be too long? What muscles would you predict to be too short? b. List the base, modulator, and biomechanical ele­ ments of the movement system that contribute to this patient's movement impairment. c. Develop an initial list of exercises, posture educa­ tion , and movement retraining for this patient. Progress one of the listed exercises with respect to the stages of motor control.

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4. How would you prOVide feedback to change your partner's motor control strategy in rising from sit to stand? What verbal, tactile, and visual cues would you prOVide? What base element impairments may be contributing to the movement impairment? .5. Assess your partner's strategy of balancing on one limb. How does your partner move his or her center of mass over the base of support? What happens at the foot , knee, hip. pelViS, and spine? Do you think your partner uses a correct strategy? If not, what is faulty? Is one side different from the other? What contributing factors may be responsible for the faulty movement strategy?

6. Hobson L, Hammon WE. Chest assessment. In: Frownfelter D , ed. Chest Physical Therapy and Pulmonary Rehabilita­ tion. St. Louis Mosby, 1987:147-197. 7. Bates DV. Respiratory Function in Disease. 3rd ed . Philadel­ phia: WB Saunders, 1989. 8. Dean E. Oxyge n transport deficits in systemic disease' and im­ plications for physical therapy. Phys Ther 1997;77:11:;7-202. 9. Johnson F, Leitl S, Waugh W. The distribution of the load across the knee: a comparison of statie and dynamic mea­ surements. J Bone JOint Surg Br 1980;62:346--.349. 10. Nordin M, Frankel VH. Basic Biomechanics of the Musculo­ skeletal System. Malvern, PA: Lea & Febiger, 1989. 11. Kendall FP, McCreary EK, Provance PC. Muscles Testing and Function . Baltimore: Williams & \,vilkins, 1993.

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Therapeutic Exercise Moving Toward Function

12. Nork.in C, Levangie P. Joint Structure and Function. 2nd ed. Philadelphia: FA Davis, 1992. 13. Bagg SD, Forest WJ. A biomechanical analysis of scapular ro­ tation during arm abduction in the scapular plane. Am J Phys Med Rehabil1988;67:238-235. 14. Stedman's Concise Merucal Dictionary. Baltimore: Williams & Wilkins, 1998. 15. Frankel VH, Burstein AH, Brooks DB. Biomechanics of in­ ternal derangement of the knee. J Bone Joint Surg 1971;53: 945-962. 16. Hislop H. The not-so-impossible dream. Phys Ther 1975;55: 1069-1080. 17. Williams PE, Goldspink G. Changes in sarcomere length and physiological properties in immobilized muscle. J Anat 1978; 127 :459-468. 18. Tabary JC, Tabury C, Taradiew C, et al. Physiological and structural changes in the cat's soleus muscle due to immobi­ lization at different lengths by plaster casts. J Physiol 1972; 224:231. 19. Goldspink G. Development of muscle. In: Goldspink G, ed. Growth of Cells in Vertebrate Tissues. London: Chapman & Hall, 1974:69-99.

20. Gossman MR, Sahrmann SA, Rose SJ. Review of length­ associated changes in muscle, experimental and clinical implications. Phys Ther 1982;62:1799-1808. 21. vValker ML, Rothstein JM, Finucane SD, et al. Relationships between lumbar lordosis, pelvic tilt, and abdominal perror­ mance. Phys Ther 1987;67:512-516. 22. Basmajian yv, DeLuca CJ. Muscles Alive. Baltimore: Williams & Wilk.ins, 1985. 23. Caillet R. Low Back Syndrome. Philadelphia: FA Davis. 1981. 24. Kendall HO, Kendall FP, Boynton DA. Posture and Pain. Huntington, NY: Robert E. Krieger Publishing, 1970. 25. Sternheim MM, Kane JW, Elastic properties of materials. General Physics. Toronto: John Wiley & Sons, 1986.

RECOMMENDED READING Salwmannn SA. Diagnosis and Treatment of Movement Impair­ ment Syndromes. St. Louis: Mosby, 2002. Kendall FP, McCreary EK, Provance PG. Muscles Testing ancl Function. Baltimore: Williams & Wilk.ins, 1993.

chapter 10

Pain LORI THEIN BRODY

Definitions Physiology of Pain

Sources of Pain

Pain Pathways

Pain Theory

Examination and Evaluation

Pain Scales

McGill Pain Questionnaire

Disability and Health-Related Quality of Life Scales

Therapeutic Exercise Intervention for Pain

Acute Pain

Chronic Pain

Activity and Mode

Dosage

Adjunctive Agents

Transcutaneous Electrical Nerve Stimulation

Heat

Cold

Medication

Pain is a psychosomatic experience th at is affected by cul­ tural , historiC, environmental, and social factors. The prevalence of chronic pain increases from ages 18 to 70; and approximately 23% of patients in their seventh decade report chronic pain.! It is more common in women than in men. Unlike impairments such as motion or strength loss that can be observed and measured v\lith tools such as go­ niometers and dynamometers, pain is elusive. Although limited motion produces observable functional limitations or disability, pain produces functional limitations and dis­ ability that are not always observable by the outsider. This situation produces anxiety for the patient and can be a source of conflict with spouses, famUy members, friends, and coworkers. The clinician must recognize the impact of pain on the patient and provide him or her with strategies to manage the pain.

DEFINITIONS Pain is a component of most musculoskeletal conditions seen in the clinic. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated ,\lith actual or potential

tissue dam age, or described in terms of such dam age."2 Acute pain is associated with muscle strains, tendinitis , contusions, surger)" or ligament injuries. Although it is im­ portant to acknowledge and treat acute pain , pain is usually short-lived. Most individuals can tolerate this type of pain because they know that it is temporary. Acute pain is often successfully treated with nonnarcotic analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs ) and agents such as ice. Chronic pain is pain that perSists after the noxious stim­ ulus has been removed. It includes persistent pain after healing of an acute injury and pain ,\lith no known cause. It is not simply acute pain that has persisted too long. There may be no relationship between the extent of pathology and the intensity or anatomic location of the pain. Chronic pain is not short-lived and produces profound changes in the physical, psycholOgiC, and social aspects of the patient's life. Chronic pain typically is a major component of prob­ lems such as fibromyalgia , chronic fatigue syndrome, my­ ofascial pain syndrome, rheumatoid arthritis, and low back pain. Physical therapy focuses on treating the pain, the mo­ tion and muscle impairments, and the functional limita­ tions and disability that result. Referred pain is pain felt at a site far distant from the lo­ cation of the injury or disease. Although the pain is felt elsewhere, the pain is still very real . Examination and eval­ uation can become difficult in the absence of understand­ ing common pain referral patterns. Be sure to consider other distant sources of pain when examining the patient with acute or chronic pain.

PHYSIOLOGY OF PAIN Pain is a complex sensory experience. The phYSiology of pain is far too complex to be covered in detail in this text. However, this brief overview provides an understanding of the phYSiology of pain and the scientific basis of interven­ tions used to treat it.

Sources of Pain Acute pain results from microtraumatic or macrotraumatic tissue injury. Microtrauma is defined as a long-standing or recurrent musculoskeletal problem that was not initiated by an acute injury. Microtrauma is exemplified by the overuse injury in which repetitive activity exceeds the tissue's ability to repair and remodel according to the imposed loads. The athlete playing in a weekend tennis tournament and the 185

186

Therapeutic Exercise Moving Toward Function

worker putting in overtime are prone to microtraumatic in­ juries. Macrotrauma is defined as an immediately notice­ able injury involving sudden, direct, or indirect trauma 3 Macrotrauma can produce pain through direct injury of tissues. Joint dislocations injure the jOint capsule and peri­ articular connective tissue , and ligament or tendon injuries damage the respective collagenous tissues. Microtrauma and macrotrauma result in an inflammatory response that secondarily produces pain. Macrotrauma also produces pain directly through damage to the nociceptors, or pain receptors. Chronic pain can arise suddenly or come on very gradu­ ally. It has strong psychologic, emotional, and sociologic effects. Individuals with chronic pain tend to have signifi­ cant sleep disturbances , depressive symptoms, appetite changes, and decreased activity and socialization. Theories about the source of chronic pain suggest increased sensiti­ zation of nociceptors and spinal level changes that perpet­ uate positive feedback loops in the pain-spasm cycle 4 Pain from inflammation in conditions such as osteoarthritis and rheumatoid arthritis sensitizes dorsal h0111 neurons to the inflammation. After inflammation of a joint or muscle, af­ ferent input to the spinal cord increases the activity of the dorsal horn , sp inothalamic tract, and thalamic neurons. The elevated activity increases the frequency of back­ ground firing of dorsal hom neurons and increases sensi­ tivity to noxious and nonnoxious peripheral stimulation and joint motion. Repetitive stimulation with progressive bUildup of the response in th e dorsal horn neurons is termed "wind-uR" and is a critical concept in understand­ ing chronic pain ..~ When damage to the central nociceptive system occurs, nonnOCicertive afferent activity becomes capable of eliciting pain. Stimuli th at we re previously innocuous become painful. This is referred to as non­ nociceptive pain (NNP ). These non nociceptive afferents are not abnormal, but are working with a sensitized cen­ tral nervous system (CNS). Bennett5 describes four clini­ cal features of NNP. They can be found in Display 10-I. The pathophysiology of NNP includes central sensitization of ongoing or past nociception, convergence of nociceptive and nonnociceptive inputs on the same secondary neuron in the dorsal horn , the experience of pain on wide dynamic range neuron s (WDR), and an expansion of the recep­ tive fields , extending pain beyond the original boundaries. 5 The peripheral receptive field of dorsal horn neurons in­ creases in response to chronic pain. ? The pain seems to spread from the Originally painful area to adjacent areas.

DISPLAY 10-1

Characteristics of Nonnociceptive Pain 1. pain appears to be inappropriate compared with tissue pathology, or no tissue pathology may be evident 2. hyperalgesia, where pain is greaterthan expected given the stimulus 3. allodynia, where normally nonnoxious stimuli produces pain 4. painful region extends beyond expected based on original tissu e pathology

The basis for some of these changes may be an increased sensitization of WDR neurons from nocicep tive input, causing them to respond more intensely to more nonnoci­ ceptive input and to afferent input from a larger area. 6 Af­ ter being sensitized to nociceptive input from periph eral nerves, the WDR will respond to nonnoxious stimuli as in­ tensely as they had to other stimuli before sensitization. s The increase in receptive field area, increased background firing, and increased sensitivity to mechanical stimuli after acute or chronic inflammation may set the stage for chronic pain that seems to spread along a limb or to adjacent areas. Referred pain is considered to be an error in perception. For example, pain originating from deep visceral tissues may refer to the cutaneous region with the same segmental innervation. Pain originating from the genitourinary system may refer to the low back because of the common Tll-L2 segmental origin. Cardiac pain refers to the shoulder be­ cause of the common T1-T2 segments. As afferent input from the visceral receptors synapse in the dorsal horn , in­ formation is also incoming from skin afferents. Conver­ gence of this incoming information in the dorsal horn re­ sults in the sense that the pain is originating from the skin. This same principle underlies the use of electrical stimula­ tion at remote sites to decrease visceral pain.

Pain Pathways Pain is transmitted from nOCiceptor and non nociceptor af­ ferents in the periphery. Nociceptors are defined as pain receptors that transfer impulses to the spinal cord an d higher CNS levels. Nociceptors in the periphery are acti­ vated by mechanical stimuli such as strong pressure, irri­ tants such as chemicals (e .g., bradykinin, substance P, hi<­ tamine), or noxious elements such as heat and cold. Nociceptors in peripheral tissues transmit pain infor­ mation through A-delta and C fibers. A-delta fibers ar small, myelinated fibers carrying information about pain and temperature. The information is carried to the spinal cord at an approximate speed of 15 m/s8 The A-delta fibers are most responSive to mechanical stimuli and probably are responsible for the sensation of pain in acut injuries. Type C fibers are slow, unmyelinated fibers car­ rying information about dull aching or burning pain fro m polymodal receptors. Polymodal receptors are recep­ tors that respond to a variety of stimuli such as tempera­ ture and pressure. Type C polymodal fibers are found in the deeper layers of skin and in virtually all other tissues except the nervous system itself. They are also known as "free nerve endings" and are responSive to thermal, chem­ ical, and mechanical stimuli. C fibers probably are re­ sponsible for the con tinued sensation of pain after the noxious stimulus has been removed . Transmission speed to the spinal cord is approximately 1 m/s. At the spinal cord level , A-delta fibers enter the dorsal roots sending collateral that ascend and descend several segments before entering the gray matter. These fibers ter­ minate on the cells of laminae I and V. The slower C fibe rs also enter the dorsal root and then enter the gray matter and synapse at the level of ently or ascend or descend a level or two before entering the substantia gelatinosa at laminae II and III. Some processing of information OCCll rs

Chapter 10 Pain

the spinal cord before the information is transmitted to uher levels. Important receptors at the termination of the . lary nociceptive afferents in the dorsal horn have been and, in particular N-methyl-D-aspartate, which are acti­ ed and placed in a state ready for activation. \) They are a '"lIIlary mechanism in the development of windup, central itization, and changes in peripheral receptive fields . Three types of interneurons found within the dorsal m are categorized by their response to pelipheral stim­ bon: low-threshold mechanosensitive, responding only innocuous stimuli such as touching the skin; nOCiceptive ific, responding only to high-threshold noxious stimuli; J WDR , responding to a wide variety of noxious and noxious stimuli. Changes in the firing patterns of the "D R interneurons are suggested as an underlying cause of nic pain, and convergence of stimuli from various re­ tors in the dorsal hom is the theoretic basis underlying • e;ate control theory. This convergence also may be the ..;rc of referred pain. Substance P is a neuromodulator \ )1 to be responsible for th~ transmission of noxious in­ "lJ1
187

noxious stimulus-elicited dorsal horn neuron activity4 Other neurons descending from the midbrain use no~a­ drenaline as their transmitter and provide an analgesic ac­ tion through direct inhibition of dorsal horn nociceptive neurons , rather than through the enkephalinergic in­ terneurons s Continued research in the area of descend­ ing influences may provide more effective pain control in­ terventions in the future.

Pain Theory Melzack and Wall proposed the gate theory of pain in 1965, \:\lith revisions added in 1982 4 This theOlY replaced previ­ ously held pain theories such as the specificity and pattern­ ing theories 4 The cornerstone of the gate theory is the convergence of first-order neurons and associated second­ order neurons \:\lithin the substantia gelatinosa (Fig. 10-1). The system has four components consisting of afferen t neu­ rons , internuncial neurons within the substantia gelatinosa, transmission cells (T cells ), and descending control from higher centersY The activity ofT cells is regulated by the balance of large- and small-diameter fiber input from the periphery and by descending control from higher cells. This balance regulates the transmission of pain information. The substantia gelatinosa modulates incoming informa­ tion (Le., regulates position of the gate) presynaptically, be­ fore information is passed to second-order neurons. When incoming information increases substantia gelatinosa activ­ ity, presynaptic inhibition occurs, closing the gate. Infor­ mation is not passed from first- to second-order neurons for further transmission to higher centers. If peripheral re­ ceptors associated \:\lith large-diameter myelinated fibers are stimulated, activity in the substantia gelatinosa may close the gate to the slower C fiber pain information trans­ mission. This theory provides the rationale for interventions to "close the gate" to pain transmission. Several peripheral stimuli can close the gate to pain Input from thermal modalities such as heat and cold can successfully decrease pain. When thermal impulses are transmitted, the input can "block" pain transmission from slower fibers at the substan­ tia gelatinosa. Electrical impulses from transcutaneous electrical nerve stimulation (TENS ) application can prefer­ entially block pain impulse transmission (discussed in the Adjunctive Therapies section ). Exercise can successfully decrease pain by stimulation of joint afferent receptors. These Signals travel along A-beta fibers , which have larger

Touch Receptor

A·Beta

FIGURE 10-1. The gate control theory of pa in T cells = central transmis· sion cells; SG = substantia gelatinosa

188

Therapeutic Exercise:

Movi~g

Toward Function

diameters and carry information at higher speeds (30 to 70 m/s) than the slower pain fibers. This same mechanical stim­ ulation of peripheral receptors can be achieved through tis­ sue massage. Further revision of the gate theory ofpain con­ tinues, because descending control from higher centers also influences the transmission of pain information.

EXAMINATION AND EVALUATION A variety of tools helps the clinician assess and monitor the patient's pain level. Tools such as the McGill Pain Ques­ tionnaire (Iv! PQ) assess affective qualities of pain, and the visual analog scale (VAS) is a nominal scale assessing pain intensity. Because of the multifaceted nature of pain , as­ sessment should include information on the pain's inten­ sity, location, and pattern over a 24-hour period (i.e., quan­ tity of pain) and descriptors assessing the affective aspects (i.e., quality of pain). The impact of pain (Le., functional limitations and disability) on the patient's life should be de­ termined. Frequently tools such as the Beck depreSSion and Beck anxiety questionnaires are used to assess the psy­ chologic aspects of the patient's pain. Clinicians perform examinations to determine the source of the patient's pain. This examination directs the subsequent treatment program to the source of pain. Structures ,vithin the musculoskeletal system have differ­ ent levels of pain sensitivity. The periosteum of the bone is a highly pain-sensitive structure, whereas the joint capsule, ligaments, tendons, and muscle are less pain sensitive. In­ terestingly, research has found that isometric muscle con­ traction normally increases the pain threshold, whereas in patients vvith fibromyalgia, the pain threshold actually de­ creases. J2 Additionally, compared with skin receptors , sen­ sory input from muscle is a more potent catalyst of central sensitization. 5 Fibrocartilage and articular cartilage are not pain-sensitive structures, although injury or damage to these structures can produce a synovitis that results in pain. Perform a thorough evaluation to determine the source of the pain and to assess the characteristics of that pain. How­ ever, remember the pathophysiology of chronic pain and realize that the pain region and intensity may extend be­ yond discernible tissue pathology.

type of measurement. This type of scale presumes equal in­ tervals between each level (i.e., the difference between a 1 and a 2 is equal to the difference between a 3 and a 4), and this may not be the case for the patient. The VAS can be administered in several differen! forms (Fig. 10-2). A line with words placed at intervals along the line commonly is used. A Single word may b used at each end, such as "no pain" and "worst pain," or several words may be placed along the continuum. Th more words and lines dividing the continuum , the more the patient is likely to recall previous answers. As vvith th simple 0 to 10 scale, the VAS is easy to administer and is not limited by cultural or language barriers, but it pro­ vides a minimal amount of information. Improve the reli­ ability of a VAS by eliminating division marks and onl_ marking both ends of the scale. The patient then places mark along the scale corresponding to her current pair level. The distance from the left or right can be measur to assess progress. The direction of the scale should be lti­ tered occasionally. Reverse the "no pain" and "worst pain sides of the scale or tum the scale from horizontal to ver­ tical to minimize patient recall. 13 Combine these scale vvith other assessments, such as the location of pain (usin_ a body diagram) and subjective descriptions of the quali of pain (see Fig. 10-2). _________________________________ ~ o

Worst

p

pain

No

pain

------------------------------------Mild

Moderate

Worst

pain

0 I 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20

Pain Scales Worst

The VAS and a 0 (least pain) to 10 (worst pain) scale are used to assess pain intenSity. The simplest clinical tool consists of asking the patient to rate her pain on a 0 to 10 scale and recording this in the medical record. Follow-up visits ask the same question to determine the response to treatment. This type of scale has advantages and disadvantages. The clearest advantage is the ease of use. The patient is not bur­ dened vvith forms to fill out or multiple questions to answer. Language and cultural barriers do not affect the use of this simple scale. The disadvantage is the minimal information acqUired vvith such a tool. Only pain-intensity information is gathered. Information regarding the affective aspects of pain, pattern of pain, and the impact of the pain on the pa­ tient's life are absent. The patient is likely to remember the previous pain score, which reduces the reliability of this

pain

No

pain

\\

Se\'ere

AGURE 10-2- Variations of avisual analog scale.

1\ pai.­

189

Chapter 10: Pain

In­

t

nd

be or

cGiII Pain Questionnaire

tient is allowed to choose only one word from each subcat­ egOlY and is not required to select an item from every cate­ gory. The values are summed and the mean determined; the mean is the PRI score. The total number of subcategories selected is summed as the NWC score (Fig. 10-3). The PPI is determined by use of a 5-point scale, asking about the current pain level and the level of pain when it is at its worst and at its best. The PPI is the current pain level. Part two categorizes the pattern of pain as constant, peri­ odic, or brief and asks about activities that increase or re­ lieve pain . A body diagram allows the patient to mark where the pain is located. The patient marks E for external pain and I for internal pain and then uses a VAS to docu­ ment the quantity of pain. The MPQ better assesses the many dimensions of pain \vith greater sensitivity than a VAS. The disadvantage is the time required to complete the questionnaire. A short form of the MPQ has been developed to address this issue .

e MPQ is one of the most widely used tests for the mea­ ement of pain, and several forms of the questionnaire -e been developed. 14-16 This pain questionnaire consists -..marily of three classes of word descriptors to assess the bjective aspects of pain. The MPQ also contains an in­ ity score, a body diagram, and an assessment of pain tive to activities and pain patterns. The three major ures are the pain rating index (PRI), the number of rds chosen (NWC), and the present pain intensity (PPI ). Part one contains word descriptors classified as three cat­ _ ties (i.e., sensory, affective, and evaluative ) and 20 sub­ £Orrories _Subcategories contain nvo to sLx words that are 'tatively similar but of increasing intensity. For exam­ _ one subcategOlY assesses the thermal aspects of pain ugh the descriptors "hot," "burning," "scalding," and .tring." Each word is assigned a numeric value. The pa-

McGill- Melzack Pain Questionnaire Patient's Name _ _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ _ _ _ Time _ _ _ _ am/ pm Analgesic(s)

Dosage Time Given _ _ _ _ _ _ _ _ Dosage _ _ _ _ _ _ _ TimeGiven

Analges ic Time Difference (hours): PRI:

S

1 FLiCKERI NG QUIVERING PULSING THROBBING BEATING POUNDING 2 JUMPING FLASHING SHOOTING 3 PRICKING BORING DRILLING STABBING LANCINATING

(II-IS)

-

-

-

+2

-

5 PINCHING PRESSING GNAWING CRAMPING CRUSHING

-

6 TUGGING PULLING WRENCHING

-

-

-

7 HOT BURNING SCALDING SEARING

-

8 TINGLING ITCHY SMARTING STINGING 9 DULL SORE HURTING ACHING HEAVY

-

TENDER TAUT RASPING SPLITIING

-

-

­

­ -

-

EXHAUSTING 12 SICKENING SUFFOCATING

GRUELLING CRUEL VICIOUS KILLING

­

(16)

13 FEARFUL FRIGHTFUL TERRIFYING 14 PUNISHING

+3 M(S) _-::-,...,.,.-_ M(AE) _ _ _ _ M(D _ _ _ PRT(D _ _ (17-19) (20) (17-20) (1-20)

II TIRING

-

4 SHARP CUTIING LACERATING

o

+1

A --:-:-:-:-::--E (I-tO)

RE 10-3. The McGill-Melzack uestionnaire (From Melzack R. cGill Pain Questionnaire: major ~rti es and sourcing methods. 975;1:277-299 )

+4

am/pm am / pm

I COMMENTS:

PPI

-

-

-

15 WRETCHED BLINDING

-

16 ANNOYING TROUBLESOME MISERABLE

-_

INTENSE UNBEARABLE 17 SPREADING RADIATING PENETRATING PIERCING

--

18 TIGHT NUMB DRAWING SQUEEZING TEARING

-

19 COOL COLD FREEZING 20 NAGGING NAUSEATING AGONIZING DREADFUL TORTURING

-

_

-

­

-

-

-

-

a

PPI

No pain

1 2 3 4 5

MILD _

DISCOMFORTING

DISTRESSING ­ HORRIBLE EXCRUCIATING

-

-

ACCOMPANYING SYMPTOMS: NAUSEA HEADACHE DIZZINESS DROWSINESS

~~~!~:~TION COMMENTS:

SLEEP'

-

GOOD FITFUL CAN'T SLEEP COMMENTS:

-

= ­

FOOD INTAKE: GOOD SOME LlTILE NONE

-

COMMENTS:

COMMENTS:

ACTIVITY: GOOD SOME L1TILE NONE

-

-

190

Therapeutic Exercise Moving Toward Function

Disability and Health-Related Quality of Life Scales A variety of tools has been developed to assess pain and the impact of pain and resulting disability on patients' lives. Most tools broadly assess physical, social, and psychologic function. Some tools assess health perceptions, satisfaction, and various impairments. Each tool taps into these do­ mains in a different way and at a different level. The tool must be matched to the population of interest. The scales are classified in several ways but are broadly categorized into disease-specific and generic measures. Disease-specific scales are specific to a particular disease and are more responsive to issues of that population. Generic tools are applied across a variety of disease categories; the information has little relevance to a specific disease, and other important issues may not be tapped. However, use of these tools allows comparisons among dis­ ease or injury categories. Commonly used generic tools are the Quality of Well­ Being scale (QWB), the Sickness Impact Profile (SIP), the Duke Health Profile (DUKE), and the Short Fonn-36 (SF­ 36). The QWB taps five health concepts (i .e., phYSical func­ tioning, mental health including psychologic distress, social or role functioning, mobility or travel, and physical or phys­ iologiC symptoms) , and the SIP measures 12 concepts. Nei­ ther of these tools assesses pain directly. The DUKE mea­ sures seven health concepts, including self-esteem , health perceptions, and pain. The SF-36 is a derivative of the Medical Outcomes Study-149, a 149-item tool used as a generic assessment. The SF-36 is a 36-item tool measuring seven health concepts, including pain. Use caution when chOOSing a generic health assessment tool to ensure that critical parameters are being measured. The tool's range must allow for improvement or decline in the patient's sta­ tus without exceeding the upper or lower limits of the mea­ sure (Fig. 10-4). One way to minimize some of the potential problems associated with generic tools is to use a disease-specific tool in combination with a generiC measure. The Oswestry Low Back Disability Questionnaire, the Waddell Disabil­ ity Index, and the Disability Questionnaire are used for individuals with back pain, and the McMaster-Toronto Arthritis Patient Reference Disability Questionnaire, the Arthritis Impact Measurement Scales (AIMS) , the Health Assessment Questionnaire, and the Functional Capacity Questionnaire are used for individuals with arthritis. As with generic tools, disease-specific tools must match the population tested. Reliability of the tool must be deter­ mined for the population being evaluated. For example, if the AIMS reliability has been established for Caucasian women who are 65 or older, this tool may not be reliable or valid when applied to men between the ages of 40 and 60 (Fig. 10-5). Generic and disease-specific tools can be administered together to strengthen the information obtained. For ex­ ample, the SF -36 may be combined \vith the Oswestry Low Back Disability Questionnaire for individuals with low back pain. A major concern about combination application is the burden placed on the patient who must fill out a number of questionnaires.

THERAPEUTIC EXERCISE INTERVENTION FOR PAIN Although many commonalities exist, the approaches to treating acute pain differ from the approaches to chronic pain. Application of acute pain interventions in the case of chronic pain will lead to frustration for the caregiver and the patient. Some combination of exercise and modalitie are used; specific choices depend on the patient's circum­ stances. The treatment program should be tailored to each patient and be responsive to the pain pattern. For example. muscle stretching exercises are advocated for treating pa­ tients \vith myofascial pain resulting from shortening of sar­ comeres found with sustained muscle fiber tension. How­ ever, resistive exercises are contraindicated in the earh phases because of the early fatigue and lengthy recovery i;l muscle \vith active trigger points. 17

Acute Pain The typical patient with acute pain has recently sustained an injury or undergone a surgical procedure. The pain is re­ lated to the acute trauma of an initial injury or an exacer­ bation of a preexisting injury. Pain medication may be taken for a short time after the injury or surgery. Acute pain is expected to resolve substantially over the course of a fe\\ days. Although some residual pain may continue for weeks after the injury or surgery, most pain is expected to resolve with only minimal discomfort remaining. Acute pain of this type is treated \vith a combination o · medication (i.e., prescription or over-the-counter drugs at the patient's discretion), gentle exercise, and ice. Ice is pre­ ferred over heat in the first 24 hours , and may be changed to heat thereafter depending upon the injury acuity and pa­ tient preference. Exercise is preSCribed based on the spe­ cific injury or surgery and is directed at restoring the mo­ tion, strength, and function of the injured body part. Rehabilitation of the injured area is the prime focus and proVides the framework for exercise prescription. Exercise in this phase is directed toward the primary joint and at prevention of injury at adjacent joints because of compen­ sation. The clinician should include patient educatio about pain-relieving postures and skills to fulfill the acthi­ ties of daily living and the instrumental activities of dail~ living (see Patient-Related Instruction 10-1).

Chronic Pain Treatment of chronic pain requires a team approach be-­ cause of the multidimensional nature of the pain. Chron" pain is disabling and interferes with all aspeccs of the per­ son 's life. The clinician must work closely with the physi­ cian, psychologist, vocational counselor, alternative healtl care providers, and the patient. In this way, a comprehen­ sive treatment program can be established to ensure all aspects of the pain are being addressed. TherapeutiC exer­ cise is a major component of the treatment plan,I8-20 bu many adjunctive treatments and alternative therapies ar, often explored by the patient. Herbal remedies, acupunc­ ture, reflexology, and other therapies are often part of a pa­ tient's complete treatment program. An open dialogue (te'x t continues on page 194)

191

Chapter 10: Pain

SF-36 HEALTH SURVEY

tructions: This survey asks for your views about your health. This information will help keep track of how you feel and how well you are to do your usual activities.

eEl

D­

- - :;wer every question by marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer __ can.

h e

n general, would you say your health is:

iT­

(circle one)

in

2. Compared to one week ago, how would you rate your health in general now? (circle one)

lIent ................. . ........... .... .......... ...... .. .. .. .. ... .. .. .

Much better now then one week ago .. ...... ..... .. .. ............ 1

;-y good ... .. .... ... .. .. ...... .. ...................................... 2

Somewhat better now than one week ago ......... .. .... ........ 2

.. ...... ..... ........ .. ................................................ 3

About the same as one week ago ........ ... .. . .... .......... ... 3

... ... .. . . .. ... .... . . .... . .... ...... . .. ........ ....... ......... .. .... . 4

Somewhat worse now than one week ago ....... ............. ... 4

....... .... .. .. ... .. ............ ... .... ...... .. .... .............. ..... 5

Much worse than one week ago ........ .. ....... .. ...... ... .... ... 5

- e following items are about activities you might do during a typ ical day. Does your health now limit you in these activities? If so, how much? (circle one number on each line)

I Yes, Limited A Lot

Yes, Limited A Little

No, Not Limited At AI!

Vigorous activities such as running , lifting heavy objects, participating in strenuous sports

1

2

3

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

1

2

3

-. lifting or carrying groceries

1

2

3

d. Climbing several flights of stairs

1

2

3

Climbing one flight of stairs

1

2

3

• Bending, kneeling , or stooping

1

2

3

• Walking more than a mile

1

2

3

· Walking several blocks

1

2

3

· Walking one block

1

2

3

j. Bathing or dressing yourself

1

2

3

ACTIVITIES

~.

.l I

,,C

I

l

3.

.1

,1

.1

JRE 10-4. The SF-36 assessment tool. (FromMedical Outcomes Trust; Boston, MA, 1992.) (continued)

192

Therapeutic Exercise Moving Toward Function

4, DUring the past week, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (circle one number on each line) Yes

No

a, Cut down on the amount of time you spent on work or other activities

1

2

b, Accomplished less than you would like

1

2

c, Were limited in the kind of work or other activities

1

2

d, Had difficulty performing the work or other activities (for example, it took extra effort)

1

2

5, During the past week, have you had the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Circle one number on each line)

a, Cut down on the amount of time you spent on work or other activities b, Accomplished less than you would like c, Didn't do work or other activities as carefully as usual -­

--­

-

Yes

No

1

2

1

2

1

2

- ­

6, During the past week, to what ex1ent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? Not at all "", .. " ... ,,"""

,"" " "."" .... ,, .. ....... " .. "" .. "" .. ... .. ,,",

(circle one) 1

Slightly."" ... " ... ................. ,, ' " .. ''' ,'', ' " .. " ... " " " ... . ",''', ,, .. " .... " "." .... 2

Moderately", .... ... , .... ... .. " .' " ... , .. ..... .. .. ... " ..... , ... .. ... ' .. ... .... ". , " ... " ..... 3

Quite a bit... ... ..... .. ........ .. ". "." ....... " .. .. . " .... .. " ........... " ... " ......... 4

Extremely"""" .. " .. ,,' """" " .. . , ....... ", ",' " ......... ... .... ,' '' , .... " , .. .. .. ,." ... ,.5

7, How much bodily pain have you had du ri ng the past week? None ...... .... . ..

(circle one) "." .......... " ..... .. ... ........ .. " .. " .......... " " ....... " .. .... ...... 1

Very mild .. " ....... .. " .... ......... " .. .. ... " .. " .... . .. ... " .. ", .... .. " .. "" .. "",,,,,,2

Mild ... "

" " " , . • "" ",,,., ,,., ,,. " ' . ,', .. , " ' ,, .. , ... " ' .' , ',, ..... ,,, . ' " " , ,, .,, ,,,3

Moderate "" ... ... """""" ' " " ", .. ", .. ,.. .. " " ", ... ... . ","', .. "'" ,,, ., ",' ,.. .. .. ,' 4

Severe '" Very severe

' ' ' ' ' ' ' ' ' ' ' " ... " ' ' ' ' ' ' ' ' , .. .. " ......... , ,, .. ,,'', .. .. .. ,,, .. ,,'''' ' ,, . ,,,,,.5

.. , .. " .. .. " .. " " ",, " "", .. ", .. " " .... """ .. ,.,, ........ ,,' ",6

8, During the past week, how much did pain interfere with your normal work (including both work outside the home and housework)? (circle one) Not at all .... " " .... .. ... .. " .. " ..... ", .. " . " ... ... " .. ... " .... .. .... .. ........ " ............ 1 A little bit .. .... " ...... ' ... """ ...... " .. " .. " ..... " ...... " .. " ... " .. " .......... " ...... 2 Moderately" .. , ... , .. . , "" " " '" .... .. ','" ". , " .. , " ", .. ", .. " .. ', .. , , .. "" ,.. ,.. ,. ''',' 3 Quite a bit.. " .. "" ........ " ... "."" ....... "". """ " . ", ... . "., .. ,, " . .. " ... " .. ,4 Ex1remely., ... " ." .. ' ",,' .. " . " ...... ," , ... " .. '.,'''' '" " ... " .... .... , ' .. ' .. ' " .... " .. ,.. , 5

FIGURE 10-4. (CONTINUED)

193

Chapter 10 Pain

questions are about how you feel and how things have been with you during the past week . For each question, please give the one

.r that comes closest to the way you have been feeling. How much of the time during the past week­ (circle one number on each line)

All

you feel full of pep?

of the Time

Most of the Time

A Good Bit of Time

Some of the Time

1

2

3

4

5

6

Some of the Time

None of the Time

-3VE)

you been a nervous person?

1

2

3

4

5

6

-

you ever felt so down in the dumps

1

2

3

4

5

6

- Z>19 you felt calm and peaceful?

1

2

3

4

5

6

-

1

2

3

4

5

6

1

2

3

4

5

6

you feel worn out?

1

2

3

4

5

6

e you been a happy person?

1

2

3

4

5

6

1

2

3

4

5

6

Ie

:at nothing could cheer you up?

you have a lot of energy?

-.ave you felt downhearted and blue?

-

:: 0 you feel tired?

_ _ g the past week, how much time has your physical health or emotional problems interfered with your social activities (like visiting with -"'Ids, relatives, etc.)? (circle one)

All of the time ................................ ........ .......... .. ... ....... ....... .. .. ... ....... 1

Most of the time ................ .. ...... .. .... .. ......... ... ........ .. .......................... 2

Some of the time ........ . ............ ... ................... ................ ... ...... .... ... . 3

A little of the time .... .......................... . ..... ... ... . ... .. ........ .... .. .. .. ... .. .. ... . 4

None of the time ..... .. ... .. ....... .... .. ................... .. .. .... .. .. . ....... .. .. .. .... ..... . 5

TRUE or FALSE is each of the following statements for you? (circle one number on each line) Definitely True

Mostly True

Don't Know

Mostly False

Definitely False

2

3

4

5

_ I am as healthy as anybody I know

2

3

4

5

: I expect my health to get worse

2

3

4

5

:: My health is excellent

2

3

4

5

:. I seem to get sick a little easier than other people?

RE 10-4. (CO NTIN UED)

194

Therapeutic Exercise: Moving Toward Function

Health Concepts, Number of Items and Levels, and Summary of Content for Eight SF-36 Scales and the Health Transition Item No. of Items

No. of Levels

10

21

Role Functioning Physical (RP)

4

5

Bodily Pain (BP)

2

11

Intensity of pain and effect of pain on normal work, both inside and outside the home

General Health (GH)

5

21

Personal evaluation of health, including current health, health outlook, and resistance to illness

Vitality (VT)

4

21

Feeling energetic and full of pep versus feeling tired and worn out

Social Functioning (SF)

2

9

Extent to which physical health or emotional problems intertere with normal social activities

Role Functioning Emotional (RE)

3

4

Extent to which emotional problems interfere with work or other daily activities, including decreased time spent on activities, accomplishing less, and not working as carefully as usual

Mental Health (MH)

5

26

Concepts

Physical Functioning (PF)

Reported Health Transition (HT)

5

Summary of Content

Extent to which health limits physical activities such as self-care, walking, climbing stairs, bending, lifting, and moderate and vigorous exercises Extent to which physical health interteres with work or other daily activities, including accomplishing less than wanted, limitations in the kind of activities, or difficulty in pertorming activities

General mental health, including depression, anxiety, behavioral-emotional control, general positive affect Evaluation of current health compared to one year ago

FIGURE 10-4. (CO NTI NUED)

with the patient ensures a thorough understanding of all therapies occuning simultaneously. A critical component of chronic pain treatment is a real­ istic understanding of the goals of the treatment plan. Pa­ tient education is a key component; the clinician explains the likely source of pain, activity modifications or postures to minimize pain, and the expected outcomes of interven­ tion . Ultimately, the goal is a return to the highest level of function while managing the pain. Interventions to inhibit pain input or to facilitate non­ nociceptive input are incorporated while Simultaneously addressing associated impairments and functional limita­ tions . Therapeutic exercise is used to affect the pain di­ rectly through endogenous opiates and indirectly through facilitation of nonnociceptive input and to treat the associ­ ated impairments and functional limitations. Exercises chosen may have very different goals. Exercise may be un­ comfortable for the individual with chronic pain, and this

discomfort may be necessary to achieve pain inhibiti through endogenous opiates . This type of intervention T' quires extensive education regarding the purpose of th ercise and alternative options. It is essential to ensure co munication and program adherence. The goals of the therapeutic exercise program exte beyond treatment of impairments. Functional limitati and disability related to depreSSion, sleep, and appetite " also of concern . Improvements in sleep patterns, men; state, and appetite may be the first markers of success, intervention, improving before any change in impairme measures (see Patient-Related Instruction 10-2). When designing the therapeutic exercise program, ca sider the current physical and psycholOgiC status of th tient and take into account potential secondary proble that must be prevented17 Direct the therapeutic exerc.. program toward the source of the pain, musculoskeletal l pairments, or functional limitations and toward any

Chapter 10: Pain

195

INSTRUCTIONS

Check only one box in each section which best applies to you. We realize you may consider that two of the statements in anyone section relate to you, but please just mark the box which most closely describes your problem. SECTION I - PAIN INTENSITY

o I can tolerate the pain I have without having to use pain killers. o The pain is bad but I can manage without taking pain killers. o Pain killers give complete relief from pain . o Pain killers give moderate relief from pain . o Pain killers give very little relief from pain. o Pain killers have no effect on the pain and I do not use them . SECTION II - PERSONAL CARE ( Washing, Dressing, Etc. )

o I can look after myself normally without causing extra pain. o I can look after myself normall y but it causes pain. o It is painful to look after myself and I am slow and careful. o I need some help but manage most of my personal care. o I need help every day in most aspects of self care. o I do not get dressed , wash with difficulty and stay in bed . SECTION III - LIFTING

o I can lift heavy weights without extra pain. o I can lift heavy weights but it gives extra pain. o Pain prevents me from lifting heavy weights off the floor , but I can manage if they are conven iently positioned, e.g., on a table. o Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. o I can lift only very light weights. o I cannot lift or carry anything at all. SECTION IV - WALKING

CJ Pain does not prevent me from walking any distance.

o Pain prevents me from walking more than 1 mile. o Pain prevents me from walking more than 1/2 mile. o Pain prevents me from walking more than 1/4 mile . o I can only walk using a stick or crutches. o I am in bed most of the time and have to crawl to the toilet. SECTION V - SITTING

o I can sit in any chair as long as llike . o I can only sit in my favorite chair as long as I like.

Pain prevents me from sitting for more than 1 hour.

Pain prevents me from sitting for more than 30 minutes.

o Pain prevents me from sitting for more than 10 minutes . o Pain prevents me from sitting at all. URE 10-5. The Oswestry Low Back DisabilityQuestionnaire. (Adapted from Fairbank JCT, Davies JB, Couper Oswestry Low Back Pain Disability Questionnaire Physiotherapy 1980:66:271-273) (continued)

o~ al. The

rei e

im ­ ec­

196

Therapeutic Exercise: Moving Toward Function SECTION VI - STANDING

o I can stand as long as I want without extra pain. o I can stand as long as I want but it gives me extra pain. o Pain prevents me from standing for more than 1 hour. o Pain prevents me from standing for more than 30 minutes. o Pain prevents me from standing for more than 10 minutes. o Pain prevents me from standing at all. SECTION VII - SLEEPING

o Pain does not prevent me from sleeping well. o I can sleep well only by using tablets. o Even when I take tablets I have less than six hours sleep. o Even when I take tablets I have less than four hours sleep. o Even when I take tablets I have less than two hours sleep. o Pain prevents me from sleeping at all. SECTION VIII - SEX LIFE

o My sex life is normal and causes no extra pain. o My sex life is normal but causes some extra pain. o My sex life is nearly normal but is very painful. o My sex life is severely restricted by pain . o My sex life is nearly absent because of pain . o Pain prevents any sex life at all. SECTION IX - SOCIAL LIFE

o My social life is normal and gives me no extra pain. o My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc.

o Pain has restricted my social life and I do not go out as often . o Pain has restricted my social life to my home. o I have no social life because of pain. SEcnON X - TRAVELING

o I can travel anywhere without extra pain. o I can travel anywhere but it gives me extra pain. o Pain is bad but I manage journeys over two hours. o Pain restricts me to journeys of less than one hour. o Pain restricts me to short necessary journeys under 30 minutes. o Pain prevents me from traveling except to the doctor or hospital.

I

FOR OFFICE US

Total Score

Therapist's Signature and Date

e AGURE 10-5. (CONTINUED)

Patient's Signature and Date

e

e

Chapter 10 Pain

Management ofAcute Pain increase in acute pain is a sign of doing too much. This ay disrupt the healing process. In this situation, you S ould do the following: 1. Find a position of comfort that decreases or eliminates your pain. Your clinician can help you learn what these positions are. 2. Use a pain-relieving treatment such as ice for 10 to 15 minutes every hour. 3. Use an assistive device such as crutches, a cane, or a walker if your leg is involved, a sling or splint for your upper extremity, or a corset for your back. These devices red,uce the stress on the injured area. 4. Take your medications as prescribed.

-ar:-' preventable problems identified dUling the evalua­ process. Identify the elements of tJle movement sys tem ked in the production of pain in order to facilitate pri­ !:ization of interventions (see Selected Intervention 10-1).

ctivity and Mode activity chosen to treat the individual with chronic pain nds on the source of the pain and results of the evalu­ n process. In addition to the specific interventions cho­ to treat the source of the pain, other activities can help patient.

I I

G:\

Why You Should Exercise When You Have Chronic Pain You should exercise when you have chronic pain, because exercise can: 1. Improve problems such as inflexibility, loss of mobility, or weakness, which contribute to your pain. 2. Decrease pain by inhibiting transmission of pain

impulses.

3. Improve your sleep at night. 4. Control weight gain, which often occurs from inactivity and can have negative physical and psychologic consequences. 5. Prevent secondary musculoskeletal complications of pain such as further weakness, immobility, and flexibility at other joints. 6. Prevent secondary cardiovascular changes such as increases in blood pressure, elevated cholesterol levels, or diabetes complications. 7. Enhance your sense of well-being, self-esteem, and accomplishment.

The patient with chronic low back pain resulting from a herniated disk should receive treatm ent speCific to the im­ pairments and functional limitations associated with that injury, and several adjunctive measures can be used to treat the associated pain. Patients with chronic low back pain who were randomly aSSigned to active rehabilitation com-

SELECTED INTERVENTION 10 -1

'\;!;J Treatment of the Patient With Fibromyalgia See Case Study #7 Uthough this patient requires comprehensive intervention, as described in the patient management model, one exercise is described.

ACTIVITY: Hand to kTlee pushes PURPOSE: To increase abdominal and hip flexor muscle strength ; imprm'e Single-leg balance and trunk stability; and increase upper qualter strength through closed chain activity RISK FACTORS: No appreCiable risk factors ELEMENTS OF THE MOVEMENT SYSTEM: Base

SPECIAL CONSIDERATIONS: Ensure proper posture of the trunk, pelviS, and weight-bearing limb. Cue for an abdominal muscle contraction, using palpation as necessary. This exercise is contraindicated when an isometric muscle contraction is contraindicated. DOSAGE: Hold (''Olltraction for 3 to 6 seconds at a comfOItable intensity that does not cause hip flexor or shoulder fatigue. Repeat on the opposite side. TYPE OF MUSCLE CONTRACTION: Isometlic Intensity: Su bmaximal Duration: Hold for up to 6 seconds Fraquency: DUling each pool session

STAGE OF MOTOR CONTROL: Stability POSTURE: Standing position on a Single leg. The opposite hip and knee are fl exed to 90 degrees. The opposite hand of the l1exed leg pushes isometrically against the movement of hip fl exion. A neutral spine is maintained, and concentration on abdominal muscle contraction is emphaSized,

MOVEMENT: Isometric contraction of the abdominal, l'lip flexor, and contralateral upper quarter muscles.

197

RATIONALE FOR EXERCISE CHOICE: This exercise addresses the many components of fibromyalgia, including hunk stability, Single-leg stance stability, abdominal muscle endurance, and upper and lower qnarter muscle endurance. EXERCISE GRADATION: This exercise is progressed to greater intensity and more repe titions. More advanced stabilization exercises incorporating upper and lower extre mity movements with resistance are then added.

198

Therapeutic Exercise: Moving Toward Function

pared with passive (massage and heat) treatment had sig­ nificantly improved back pain intensity, functional disabil­ ity, and lumbar endurance measured at a I-year follo'vv­ Up.21 Individuals in pain, particularly those with chronic pain, are susceptible to changes in posture and movement patterns. These changes can perpetuate the original symp­ toms or cause secon dary impairments or function allimita­ tions. Regardless of the activity chosen, the therapeutic fo­ cus should be on awareness and use of proper posture and movement patterns. Movement therapies such as Feldenkrais are helpful in restoring appropriate movement pattern s. Total-body movement patterns are often more succPssful than isolated joint movement when treating individuals with chronic pain. Rhythmic activity of large muscle groups should be the activity of choice. This activity should be balanced with specific exercises to address the impairments and func­ tionallimitations (Fig. 10-6). Diagonal patterns used in proprioceptive neuromuscu­ lar facilitation (PNF) techniques (see Chapter 16) are use­ ful for teachin g the patient position and posture awareness while still using multisegmental movement. In addition to aSSisting in movement awareness , PNF patterns can in­ crease mobility and muscle performance. These patterns can ensure proper muscle recruitment during movement. Substitution patterns often are difficult to observe but are easily palpated during PNF exercises. The posture and movements chosen for PNF should address the speCific impairments and functional limitations determilled during the evaluation. Bilateral, symmetric patterns are paliicu­ larly helpful when one side is involved and needs re training

through the uninvolved side. Bilateral patterns that em­ phaSize trunk fl exion and extension or rotation and sidebending are effective for normaliZing specific move­ ment patterns. The upper extremity diagonal patterns can be performed in a vari ety of posture:; and positions, de­ pending on the patient's needs. Upper and lower extremit:· patterns can be combined for total-body movement pat­ terns. These same patterns can be performed in a pool (se Self- Management 10-1). Aerobic exercise is effective for treating chronic pain an d is frequently recommended in the treatm ent of condition such as fibromyalgia. The pool can be used for aerobic ex­ ercise, although consideration must be given to th e water' resistance (see Self-t·,IIanagement 10-2 and 10-3). This re­ sistance can produce muscle fatigue before reaching aero­ bic exercise level s. Walking is a simple form of continuous exercise that can be performed by many persons (Fig. 10­ 7). Walking is particularly effective because it can be per­ formed for several short bouts several times each day. A sta­ tionary bicycle such as a recumbent bike is also an effedh'e tool, although less available. Other exercises enjoyed by th individual, such as aerobic dance , recreational dance, or tra­ ditionallap s'vvimming, should be incorporated. Activities such as yoga, Tai Chi, or using a therapeutic ball allow a variety of large muscle group activities to carried out while increasing posture awareness (Fig. 10-8 Many of these activities are done in a group setting or indi­ vidually at home, providing fl eXibility to suit the needs (J each patient (see Self-Management 10-4). Group treat ­ ment of patients with fibromyalgia resulted in improv, function and decreased tender pOints. 22

FIGURE 11)-6. (A) A pelvic tilt exercise is a simple exercise for trea chronic low back pain. (8) Bridg ing is an advanced exercise for streng­ ening the abdominal and gluteal muscles. (C) Knee-to-chest stretch complements hip and low back strengthening.

Chapter 10: Pain

Proprioceptive Neuromuscular Facilitation Postural Technique

SELF-MANAGEMENT 10-1

Purpose.

To improve postural control while moving the arms and sitting on an unstable surface

Position:

Sitting on a therapeutic ball,with both feet flat on the floor, grasp wrist or a resistive band with both hands over one shoulder (A).

Movement techniquf;.

Levell:

Keeping your arms straight, and rotate your trunk and shoulders down past your opposite hip (B and C).

Level 2:

Increase the resistance.

Level 3:

Perform with one foot off the floor.

Dosage

Repetitions _________

Frequency--------­

199

to pain at the spinal conllevd. A disadvantage of pool use in treating chronic pain is the difficulty in determinjng proper muscle recruitment and movement patterns. The water's refraction causes distortion , and the clinician cannot ob­ serve movement and posture. Actual palpation and tactile cuing in the pool can overcome this problem. A second dis­ advantage for some individuals with conditions such as fi­ bromyalgia or myofascial pain syndrome is th e water's resis­ tance. The viscosity of water provides enough resistance to exacerbate some chronic pain conditions. Choose pOSitions and movement patterns to minimize resistance caused by turbulence (i.e., controlling the speed of movement) and viscosity (i.e. , minimizing the surface area) (see Self-Man­ agement 10-8).

Dosage As with the activity chosen, the dosage depends on the spe­ cific component of the movement system being treated and the purpose of the exercise, but some generalities about ex­ ercise and pain should be considered. The exercise dosage should not increase the pain. The chosen speed, repeti­ tions, intensity, and duration should not increase pain within the exercise session, nor should symptoms increase after exercise. If the water's resistance is a concern in aquatic exercise, the first session should be kept brief (5 to 7 minutes) to assess the response to this intervention. As

Supine Kicking With Optional Arm Movements

SELF-MANAGEMENT 10-2

Purpose

To increase strength and endurance ofthe neck, trunk, hip, and leg extensor muscles and to increase cardiovascular endurance

Position.

Supine with arms in a comfortable position

overhead or at the side

Movement

technique.

B

c

The pool is a useful tool in the application of therapeutic . rcise for those with chronic pain (see Chapter 17). The vantages include unweighting from the buoyancy and the rmth and contact of the water on the skin. Unweighting e sore limb or painful back allows movement with less pain and provides the opportunity for correct posture and ovement patterns during activity or stretching (Fig 10-9) e Self-Management 10-5, 10-6, and 10-7). Movements :hat are too painful to perform on land are performed with ;reater ease and less pain in the water (Fig. 10-10). The wa­ ~r's warmth and skin contact may function to close the gate

Levell:

Rhythmic, repetitive kicking, keeping knees relatively straight. and kicking from the hips; large or small fins may be used.

Level 2:

Add arm movements in an underwater backstroke pattern. Bring arms up along the sides of your body to the shoulders, extend them straight out to the sides, then pull back down toward your sides.

Dosage

Repetitions _________ F~quency---------

200

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 10-3

Jumping Jacks

Purpose. Increase strength in shoulder and hip abductor muscles, initiate gentle impact, and initiate exercise using large muscle groups

Position: Start in chest-deep water, with feet together and arms at sides.

Movement technique: Bring both feet out to the sides while simultaneously bringing arms out to the side. Return to the starting position.

Dosage Repetitions _ _ _ _ _ _ _ __ ffequency _______________

FIGURE 10-7, Walki ng on a track is a si mple, continuous aerobic exerciSE ava ilable to most patients.

FIGURE 10-8, Therapeutic ba ll exerc ises such as pelvic rocking ca n be performed at home and in the cli nic. (A) Start pos ition . (8) End pos ition

Chapter 10 Pain

SELF-MANAGEMENT 10-4

Yoga Exercise

,.,..

~

~ !!! ~ SELF-MANAGEMENT 10-5

"

201

Hip External

Rotation Stretch

Purpose: To promote relaxation and pain relief and to increase mobility in the low back and hips

Position: Lying supine, with legs elevated on the wall IA).

Purpose: To increase mobility of the hips Position: While facing the ladder, set the foot of the hip to be stretched on a step of the ladder. Slide the foot across to the edge of the step. Keeping your foot there, let your knee roll out. Hold for 10 to 15 seconds.

ovement chnique: Let the knees and hips bend, sliding the leg down the wall to a comfortable position (8). Hold 10 to 15 seconds, and return to the starting position.

Oos8ge

Movement

technique:

Levell:

Assume the position described above until you feel a gentle stretch in your hip.

Level 2:

Assume the position described above until you feel a gentle stretch in your hip. Use your hands to push your knee farther into rotation.

Repetitions _ _ _ _ _ _ _ __

Frequency _________

00s8ge Repetitions _ _ _ _ _ _ _ __

Frequency _ __________

A

FIGURE 10-9. Deep water bicycling.

tolerance is demonstrated , the intensity or the duration may be increased (see Patient-Related Instruction 10-3). The frequency is determined by the activity type and purpose and by the quantity of exercise performed before pain is experienced. For example, if only a few repetitions of activity at a low intensity for a short duration can be performed before experiencing pain, the exercises may be performed with greater frequency. Availability also affects frequency. A pool may not be available more than once each day or even less often. The frequency must be bal­ anced against the intensity and duration of an activity. Some exercise should be performed daily, and matching a land-based exercise program to complement the pool pro­ gram is necessary. After the pain-free dosage is determined , progress the exercise parameters to those best suited to treat the pa­ tient's und erlying pathology, impairment, or functional limitation. Advance the activity to a functional progression aimed at returning to previous activity levels.

202

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 70-6

Deep Water

March With Barbell Purpose.

To increase mobility through the low back, hips, and knees

Position:

In water depth equal to your height or deeper, use a barbell or other buoyant equipment to support yourself.

Movement technique: Levell:

March in place through a comfortable range of motion at a comfortable speed.

Level 2:

Add buoyant equipment to feet and ankles, increase the speed of marching, or do both.

Dosage

Transcutaneous Electrical Nerve Stimulation TENS has been proven useful in the treatment of som e types of pain .23 Stimulation of the posterior tibial nerve and sciatic nerve was performed to see the effect on WDR neu­ rons in the spinal cord. Results showed that electrical stim­ ulation of peripheral nerves lead to inhibitory input to the pain pathways at the spinal cord. 24 One mechanism of pain relief with the application of an electric current is based on the gate theory of pain. Appli cation ofTEr\S selectively ac­ tivates large A-alpha and A-beta fibers, which are stinlU­ lated at lower thresholds than the smaller C fibers. These impulses travel to the dorsal horn of the spinal cord, where facilitation of the small interneurons of the substantia gelatinosa inhibit pain transmission through presynaptic in­ hibition. Activation of these large-diameter fibers closes the gate to small-diameter fiber transmission.

Repetitions _ _ _ _ _ _ _ __ Frequency __________

'VI

SELF-MANAGEMENT 10-7

Elbow Flexion

Extension Purpo

To increase mobility in the elbows, increase muscle strength and endurance in the upper extremities, and increase trunk stability

Position

Standing in shoulder-deep water, with your feet in a comfortable sta nce and arms at the sides

Movement

techniqu Levell:

Flex and extend the elbows with thumbs pointing up.

Level 2:

Turn your palms up.

Level 3:

Add gloves or other resistive equipment.

Dosage

ADJUNCTIVE AGENTS Adjunctive agents are essential in the treatm en t of pain. In the case of chronic pain, more agents are used. The dis­ abling nature of chronic pain leads individuals to seek out any other potentially pain-relieving therapy such as medi­ cations, chiropractic, massage therapy, relaxation tech­ niques , acupuncture , biofeedback, and psychologic care. 17 Acupuncture , herbal remedies, dietary changes, and a host of other therapies may be employed. In particular, real acupuncture has proven better than sham acupuncture for relieving pain , improving global ratings, and decreaSing morning stiffness. 17 It has been recommended as an adjunctive treatment in the management of fibromyalgia, chronic low back pain, myofascial pain, and osteoarthritis. Continuous communication with the patient ensures opti­ mal team treatm ent and avoids conflicting interventions. Remain open-minded and su pportive as the patient searches for solutions to his or her pain .

Repetitions _ _ _ _ _ _ __

Frequency _ _ _ _ _ _ _ __

Chapter 10 Pain

203

According to the gate theory, heat application can de­ crease pain directly. Thermal sensations are carried to the dorsal horn of the spina! cord through large-diameter myelinated fibers. These impulses can dose the gate, blocking the tra.llsmission of pain impulses through small­ diameter fibers. The therma!l sensations are transmitted to conscious levels preferentially over pain sensations. The in­ creased circulation resulting from heat application de­ creases pain through two mechanisms. First, pain res ulting from ischemia de creases as the local circulation is in­ creased. The increased circulation may break the pain­ spasm cycle as pain decreases and the muscle is provided with oxygenated blood. Second, the increased circulation

me

omd leu-

SELF-MANAGEMENT 10-8

Water Walking,

Forward and Sideways

GURE 10-10. Knee-to-chest stretching can also be performed comfort­ " Iy in the pooL

Other theories suggest that TENS may function rough antidromic (i.e., conducting impulses in a direc­ n opposite to normal) stimulation of afferent neurons. \ntidromic stimulation may decrease pain by blocking the ociceptive input to the spinal cord, and it may stimulate release of substance P, resulting in vasodilation. Vasodila­ 11 can decrease pain by increasing local circulation, -hich removes metabolic waste products and supplies oxy­ :enated blood for healing. The increased local circulation ':Day decrease local ischemia enough to decrease pain. 11 TENS may effect the opiate pain-modulating system. -\ ending projections from small-fiber afferents reach the P.\G, which is rich with opiates. The PAG prOVides de­ cending input to the dorsal hom, which probably is opiate­ ~ diated. TENS may provide some analgesia through opi­ te-mediated activation of tile brain stem. The parameters for TEl\"S application are varied . Con­ . ult any appropriate textbook for discussion of the benefits [)f different parameter settings.

Purpose.

To increase mobility throughout the trunk, arms, and legs; increase trunk stability; and increase muscular strength and endurance in the arms, legs, and trunk

Position;

Stand in water between waist and shoulder deep; deep water provides more resistance to walking.

Movement technique' Level T:

Step sideways, raising your arms out to the sides as you step and bringing back down to the sides as you bring your feet together,

Level 2.

Walk forward with the opposite arm and leg reaching forward together. Be sure to walk normally using a heel-to-toe pattern.

Level 3:

Add resistance gloves to hands.

Dosage Repetitions _________ Frequency ________________

Heat H at is comJllonly used as a primary or adjunctive agent to Jecrease pain. Trauma can produce a pain-spasm cycle that activates Ilociceptors. The nociceptors detect pain that pro­ tIuces refl.'x muscle activity that, if prolonged, results in muscle ische mia. The ischemia excites muscle nociceptors that perp tuate the muscle spasm. Chemical releas e at the time of injury or resulting from inf1ammation can also stim­ ulate nociceptors. Vasoconstriction associated "vith a sym­ pathetic response or vasoconstriction resulting from mus­ cle spasm can produce pain. The application of heat can decrease pain from any of these sources.

Forward walking

Sideways walking

204

Therapeutic Exercise Moving Toward Function

With Chronic Pain 1. Ideally. you should do something every day. at least on ce per day. Your clinician can give you further guidelines. 2. Many people do well by performing several short bouts of exercise spread throughout the day. These sessions may be only 5 to 10 minutes long. 3. Any aerobic activity should be continuous. working up to 10 to 20 minutes over time. 4. Stretches should be intense enough to feel a gentle pulling sensation. 5. Other exercises should be performed slowly until slight fatigue is felt or as otherwise instructed by your clinician. 6. If you feel any sharp. stabbing pain or numbness or tingling as a result of the exercise. discontinue the exercise. Use your pain-relieving measures, and tell your clinician. 7. You may feel some discomfort during or for a short time after exercise. This discomfort should not be confused with the pain that brought you to the clinic. Avoid exercises that increase this pain, but you may continue to exercise with some ofthe discomfort. 8. Ask your clinician if you are unsure about what to feel with your exercise program,

may remove noxious chemicals associated with injUly or in­ flammation, thereby decreasing pain, SuperfiCial heat in the form of hot packs is commonl), used in the clinic and home to decrease pain and as a pre­ cursor to therapeutic exe rcise, Local heat application in­ creases the extensibility of tissue, preparing it for subse­ quent exercise, Immersion in a warm pool or whirlpool can also decrease pain , although the water temperature is sig­ nificantly lower than that of a hot pack because of the size of the area heated. The warmth and buoyancy effects of the water combine to decrease pain sensation, Ultrasound or diathermy can increase the heat's depth of penetration, Any of these modalities can provide valuable assistance in the reduction of pain,

'Cold Cold treatments are commonly used to decrease pain, Cold decreases pain through some of the same mechanisms as heat. Cold sensation is carried to the dorsal horn of the spinal cord through large-diameter afferent fibers and is capable of closing the gate to pain signals through smaller­ diameter fibers. The drop in tissue temperature blocks synaptic transmission of any input, rendering the gate inac­ tive, The decrease in pain may help to break the pain­ spasm cycle. In acute injury, the vasoconshiction produced by cold may prevent edema that produces pain, Because the application of cold is somewhat noxious, the afferent in­ put to the brain stem through the PAG could cause the re­ lease of endorphins at the spinal level; the decrease in pain would be modulated b)' higher centers.

Cold usually is applied by means of ice in the form of packs, bags, or ice massage, The length of application de­ pends on the size of the area to be cooled, the area of the bod)' to be cooled , the mode of application, local circula­ tion, and patient sensitivity,

Medication Dlllg therapy is commonly prescribed for individuals with acute or chronic pain, Many medications are available and act through different mechanisms and at different sites to relieve pain. Medications are administered orally, by intra­ muscular injection, by injection into other structures, or bv intravenous infusion, The dosage necessary to produce analgesia varies among indrviduals and for various medica­ tions, Acting p e ripherally, NSAIDs are commonly prescribed, Several chemical classes exist, all of which inhibit the syn­ thesis or release of prostaglandins.25 AnalgeSia generally occurs within 24 hours of NSAID administration, and anti­ inflammatory responses occur with continued administra­ tion. The major side effect of NSAIDs is gastrointestinal . upset. Many NSAIDs are enteric coated and long acting. decreaSing the frequency of administration. Local injec­ tions of anesthetic agents can provide relief from pain in lo­ calized areas. Trigger-point injections with an anesthetic agent are commonly performed in individuals with chronic pain, particularly pain arising from myofascial tissues, Re­ cently, botulinum toxin type A has been effective in reduc­ ing pain as measured by VAS, palpable muscle firmness. and pressure pain th~esholds when compared with saline (placebo) injections, 11 Cyclooxygenase (COX)-selective drugs are another clas­ sification of nonopioid analgeSiC medications. The COX-2 selective drugs (e.g" celecoxib, rofecoxib ) work by inhibit­ ing the synthesis of prostaglandins, These medications ma~' decrease pain and inflammation with less gastric irritation . At the spinal cord and higher levels , a variety of medica­ tions can be administered. Antidepressant medications have analgeSiC effects, and administration may relieve pain at levels below those necessary to achieve antidepressant effects, These medications may be used at levels that have analgeSiC and antidepressant benefits , At these same levels. muscle relaxants such as benzodiazepines also act as anal­ geSics. Moreover, they help patients relax and sleep , which Significantly improves their quality of life. Narcotics actin at opioid receptors are used to treat pain, Side effects ot opioids include postural hypotenSion, sedation, and confu­ sion. These effects may lead to a risk of falls , which should be considered in an y rehabilitation program, Morphine and other strong narcotics are commonly ~sed to relieye end-of-life pain and cancer pain, Bennett" suggests that opiates are the most effective medications for managin chronic pain and should not be withheld because of fear 01 addiction, Addiction is the use of medication for its mind­ altering properties with manipulation of the medical sys­ tem to acquire them, This is very different from the physi­ cal dependence seen in patients who need these medications to obtain pain relief. Some patients receive inadequate pain control from tra­ ditional administration methods because of individual dif­

Chapter 10: Pain

erences in absorption and metabolism of drugs or because . fluctuating plasma levels of the drugs or their metabo­ tes. In this situation, patient-controlled analgesia (PCA) y be indicated. The PCA system infuses a drug in a de­ J ed location on demand or at a continuous rate.2.6 pioid analgesic drugs such as morphine, meperidine, and romorphone are commonly used 26 In an on-demand tem, a small button on the PCA system releases a preset e of medication. The constant-rate infusion delivers a all but continuous dose to maintain steady plasma levels the analgesic. A variety of safety features (i.e. , the pump programmed to prevent an overdose) are included in the "Stem. Chronic pain from cancer, surgery, or labor and de­ ry is a common reason for the use of PCA. o

KEY POINTS Pain impairment occurs with most musculoskeletal con­ ditions and must be treated as a primary impairment along with any secondary limitations that may result. ~ociceptors, or p~n receptors, transmit impulses from the periphery to the dorsal hom of the spinal cord and higher CNS levels. Pain information is transmitted through A-delta and C fi bers, which are small, unmyelinated neuronal fibers. Information is processed within the spinal cord and then cends through the contralateral spinothalamic tract to the thalamus. The gate theory of pain states that incoming information from non-pain receptors (e.g., thermal, mechanical) can dose the gate to pain information. Chronic pain may result from increased sensitization of Ilociceptors and spinal level changes that perpetuate positive feedback loops in the pain-spasm cycle. D escending impulses can influence pain perception hrough several mechanisms, including endogenous opiates. Pain can be assessed through direct measurement tools such as the VAS or MPQ questionnaires or through quality of life scales such as the SF-36. • Therapeutic exercise is a cornerstone of treatment for chronic pain. It can remedy pain (through gating mech­ anisms and descending influences), secondalY limita­ tions caused by pain, and associated impairments and functional limitations. TENS , he at, cold, and medications are key components of a comprehensive pain treatment program.

CRITICAL THINKING QUESTIONS Consider Case Study #5 in Unit 7. a. This patient has pain with standing and walking. vVhat interventions may improve this patient's ability to stand and walk without pain? b. This patient has pain with lumbar extension. How does your therapeutic exercise intervention address this problem? c. What suggestions can you give this patient to allow her to participate in social activities without pain?

205

2. Consider Case Study #7 in Unit 7 . a. Design an exercise program to preve nt further de­ cline of her aeneral deconuitioning, with considera­ tion of her ov rail fatigue and daily demands . b. Provide this patient with suggestion s for energy­ reducing measures to allow her to complete daily tasks without increasing pain or fatigue .

REFERENCES 1. Wolfe F , Ross K, Andreson J, et al. The prevalence and char­ acteristics of fibrom yalgia in the general population . Arthritis Rheum 1995;38:19-28. 2. Merskey H, Bogduk N, eds. Classification of Chronic Pain: Descliptions of Chronic Pain Syndromes and Definiti ons of Pain Terms. 2nd ed. Seattle: IASP Press , 1994:210-211. 3. Quillen WS, Magee OJ, Zachazevvski JE. The process of ath ­ letic injury and rehabilitation. In: Zachazewski ]E, Magee OJ , Quillen 'A'S, eds. Athletic Injuries and Rehabilitati on. Philadelphia: WB Saunders, 1996:3-8. 4. Newton RA. Contemporary views on pain and the role played by thermal agents in managing pain symptoms. In: Michlovitz S, ed. Thermal Agents in Rehabilitation. 2nd ed. Philadel­ phia: FA Davis, 1990. o. Bennett RM. Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensOIY processing in fi­ bromyalgia. Mayo Clin Proc 1999;74:385-398. 6. Kramis RC, Roberts W], Gillette RG. Non-nociceptive as­ pects of persistent musculoskeletal pain. ] Orthop Sports Phys Ther 1996;24:255-267. 7. Sluka KA. Pain mechanisms involved in musculoskeletal dis­ orders. J Ortbop Sports Phys Ther 1996;24:240-2.54. 8. Bowsher D. Nociceptors and peripheral nerve fibers. In: Wells PE, Frampton V, Bowsher 0, eds. Pain Management in PhYSical Therapy Norwalk, CT: Appleton & Lange 1988. 9. Siddall PI. Cousins M]. Spinal pain mechanisms. Spine 1997;22:98-104. 10. Werner ]K. Neuroscience: A Clinical Perspective. Philadel­ phia: WB Saunders, 1980. 11. Hanegan JL. PrinCiples ofnociception. In Gersh MR, ed. Elec­ trotherapy in Rehabilitation. Philaqelphia: FA Davis, 1992. 12. Kosek E, Ekholm ], Hansson P. Modulation of press ure pain thresholds during and follo\ving isometric contraction in pa­ tients with fibromyalgia and healthy con trols. Pain 1996;64: 415-423. 13. Scott], Huskisson EC GraphiC representation of pain . Pain 1976;2: 175-184. 14. Melzack R. The McGill Pain Questionnaire: major properties and scoling methods . Pain 1975;1:277-299. 15. Melzack R. The short-form McGill Pain Questionnaire. Pain 1987;30:191-197. 16. Melzack R, Katz ] , Jeans ME . The role of compensation in chronic pain : analysiS using a new method of scoring the McGill Pain Questionnaire. Pain 1985;23:101-112. 17. Borg-Stein]. Simons DG . Myofascial pain. Arch Phys Med RehabiI2002;83:S40-S47. 18. Frost H, Klaber Moffett ]A, Moser JS , et al. Randomised con ­ trolled trial for evaluation of fitness programme for patients \vith chronic low back pain. BMJ 1995;310:151- 154. 19. Geiger G, Todd DO, Clark HB , et al. The effects offeedback and contingent reinforcement on the exercise behavior of chronic pain patients. Pain 1992;49:179-] So. 20. Minor MA. Exercise in the management of osteoarthlitis of the knee and hip. Arthritis Care Res 1994;7:198-204. 21. Kankaanpaa M, Taimela S, Airaksinen 0, et a!. The efficacy of active rehabilitation in chronic low back pain. Effect on

206

Therapeutic Exercise: Moving Toward Function

pain intensity, self-experienced disability, and lumbar fatiga­ bility. Spine 1999;24:1034-1042. 22. Bennett RM, Burckhardt CS , Clark SR, et al. Group treat­ ment of fibromyalgia: a 6 month outpatient program. J Rheum 1996;23:521~528. 23. Robinson AJ. Transcutaneous electrical nerve stimulation for the control of pain in musculoskeletal disorders. J Orthop Sports Phys Ther 1996;24:208-226.

24. Hanai F. Effect of electrical stimulation of pelipheral nerves on neuropathic pain. Spine 2000;25:1886--1892. 25. Baxter R. Drug control of pain. In: Wells PE, Frampton V, Bowsher D, eds. Pain Management in Physical Therapy. Norwalk, CT: Appleton & Lange, 1988. 26. Nolan MF, Wilson MCB. Patient-controlled analgesia : a method for the controlled self-administration of opioid pain medications. Phys Ther 1995;75:374-379.

chapter 11

Soft-Tissue Injury and Postoperative Treatment LORI THEIN BRODY

Physiology of Connective Tissue Repair

Microstructure of Connective Tissues

Response to Loading

Phases of Healing

Principles of Treating Connective Tissue Injuries

Restoration of Normal Tissue Relationships

Optimal Loading

Specific Adaptations to Imposed Demands

Prevention of Complications

1anagement of Impairments Associated With Connective Tissue Dysfunction

Sprain: Injury to Ligament and Capsule

Strain: Musculotendinous Injury

Tendinitis and Tendon Injuries

Management of Cartilage Injury

anagement of Impairments Associated With

ocalized Inflammation

Contusion

~anagement of Impa irme nts Associated With I=ractures

Classification of Fractures

Application of Treatment Principles

1anagement of Impairments Associated With Bony 'lnd Soft-Tissue Surgical Procedures

Soft-Tissue Procedures

Bony Procedures

~anagement

of Impairments Associated With Joint

Arthroplasty

lost musculoskeletal problems resolve with conservative anagement. Patients who develop overuse injuries, or 'e mild sprains, strains, or contusions can expect to re­ ":lm to full function within a matter of days or weeks. For mmple, most patients with acute low back pain recover thin 12 weeks without surgery. 1 However, some muscu­

loskeletal problems do not resolve ,vith conservative man­ agement alone. In these cases, surgical intervention may be necessary to return the patient to optimal function. Understanding the fundamentals of connective tissue physiology and response to stress forms the basis for re­ habilitation programs designed for both conservative and postoperative management. Be sure to consider this in­ formation in the context of interventions used to improve mobility and muscle performance, as discussed in Chap­ ters 5 and 7.

PHYSIOLOGY OF CONNECTIVE TISSUE REPAIR Soft tissues, including ligament, tendon, cartilage, and other connective tissues, respond to injury in a relatively predictable fashion. The repair process is similar in all connective tissues, although some variability between tis­ sues (e.g., bone) exists. Healing is also affected by age, lifestyle, and systemic factors (e.g., alcohol abuse, smok­ ing, diabetes mellitus, nutritional status, general health ) and local factors (e.g., degree of in~ury, mechanical stress, blood supply, edema, infection).2, An understanding of the healing phases helps the clinician choose treatment procedures that are appropriate at various pOints in the healing process .

Microstructure of Connective Tissues Tendon, ligament, cartilage, bone, and muscle are some of the major connective tissues in the body. The three main components of connective tissue are fibers (i.e. , col­ lagen and elastin ), ground substance with associated tis­ sue fluid (i.e., glycosaminoglycans such as proteoglycans ), and cellular substances (Le., fibroblasts , fibrocytes, and cells specific to each connective tissue).3 The function of the various connective tissues is based on the relative pro­ portions of intracellular and extracellular components such as collagen, elastin, proteoglycans, water, and con­ tractile proteins. At least 15 types of collagen (types I through XV) are known and differ fundamentally in the

207

208

Therapeutic Exercise: Moving Toward Function

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Small amounts « 20%). F rom W alker JM. Cartilage of hum an jOints and related structures. In: Zachazewski JE, Magee DJ, QUillen WS, e ds: Athldic Injuri es and Rehabilitation. WB Saunders, 1996:123.

acid amino sequence of their constituent polypeptide chains (Table 11_1 ).4,5 Water makes up nearly two thirds of the weight of nor­ mal ligament, and collagen makes up 70% to 80% of the ligament's dry weight. 6 \learly 90% of that collagen is type I, and 10% or less is type III collagen. Elastin is found in tiny quantities in ligam ents , making up less than 1% to 2% of the total weight. Proteoglycans, another important solid found in ligaments, comprise less than 1% of the ugament's weight, but they are essential because of their water­ binding properties. 2 Tendon is a collection of closely packed collagen fibers that connect muscle to bone. Collagen forms 70 % of the dry weight of tendon , and the overalilroportions are 30% collagen, 2% elastin, and 68% water. The low proportion of elastin accounts for the low elasticity of tendon. If ten­ don were more elastic, the tendon would elongate with muscle contraction, rather than transmitting the force to the bone. Muscle contraction would fail to move its inser­ tion toward the origin, and no movement would take place. The structure provides some information about the func­ tion of this tissue. Articular cartilage is composed of similar components, with nearly 80% of its weight from water. The high water content in aI1icuiar cartilage, as in other viscoelastic tissues , is responsible for the mechanical properties of the tissue. The collagen makeup is primarily type II collagen , with small proportions of other collagen types,s Proteoglycans (ie., glycosaminoglycans ) are water-loving, or hydrophiliC, molecules. Proteoglycans are responsible for the water­ binding capabilities of articular cartilage, and proteoglycan loss results in a decreased \vater content and loss of the tis­ sue's mechanical properties. When a person bears weight on a limb, the compression causes fluid to be squeezed out of the tissue , and unweighting pulls fluid back in because of the hydrophiliC nature of the proteoglycans. This action prOVides nutrition and lubrication for the articular carti­ lage . Thus weight beatirig is important for the health of

articular cartilage. As proteoglycans are lost with degener­ ative joint disease, the abiuty to resorb fluid is impaired, decreasing the ability to absorb shock or transmit loads. As with the other soft tisslJes of the body, bone is com­ posed of solid and fluid components. Organic compounds such as type I collagen and proteoglycans constitute ap­ proximately 39% of the total bone volume. 8 Minerals con­ tribute nearly half of the total bone volume , and fluid fUls the vascular and cellular spaces comprising the remaining volume. The primary minerals found in bone are calcium hydrm.,),apatite crystals. These minerals differentiate bone from other connective tissue and provide bone with its dis­ tinctive stiffness.

Response to Loading When connective tissues are loaded, the amount of fo ro per unit area (j .e. , stress ) can be plotted against the change in length per unit length (i.e., strain ) providing much infor­ mation about the material properties of the tissue. The rel­ ative contributionS of composite materials determine th mechanical properties of the specific tissue. However. some general concepts about connective tissue response" can be determined . Tensile loads are resisted primarily by the collagen fib­ rils, which respond first by straightening from their restin climped state. This straightening requires little force (Fig. 11-1 ). In the elastic portion of the curve, the collagen fiber respond to the load in a linear fashion up to 4% elonga­ tiol1. 7 .9 After the load is removed, the tendon returns to its original length, a characteristic of the elastic range only up to the elastic limit. Beyond this pOint, removal of the stress does not result in a return to the tissue's original length. If the tissue is elongated beyond approximately 4%, plastiC' changes begin to occur (i.e. , plastiC range) as the cross-lin begin to fail. Permanent deformation is the chief ch arac­

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209

Chapter 11: Soft-Tissue Injury and Postoperative Treatment

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. tic of the plastic range. After some fibers fail, the load the remaining fibers is increased, accelerating tissue ure. The yield pOint is the pOint at which an increase in , 'n occurs without an increase in stress; here, the curve teaus or even dips. The ultimate strength is the greatest d the tissue can tolerate, and rupture strength is the jnt at which complete failure occurs. The area under the curve represents the amount ofstrain rgy stored in the tissue during loading. The viscoelastic e of connective tiss ue results in an imperfect recovery er deformation , known as hysteresis . This difference be­ e n the loading curve and the unloading curve represents ergy lost. This energy is lost primarily in the form of heat. tretched tissue becomes warm in the process. ther tissue qualities related to the load deformation lye are resilience and toughness. Resilience reflects a ma­ ri 1's ability to absorb energy within the elastic range. As silient tissue is loaded quickly, work is performed, and ergy is absorbed . When the load is removed , the tissue 'ckly releases energy and returns to its original shape. IIghness is the ability of a material to absorb energy within plastic range. A critical quality of connective tissues is ir ability to absorb energy without rupturing. :\ relationship exists between stress and strain called the . tic modulus. The elastic modulus is the ratio of the Te s divided by the strain and reflects the amount of stress eeded to produce a given strain (i.e., deformation). The _ ater the stress necessary to deform the tissue, the stiffer the materiaL For example. bone has a higher elastic mod­ Ius than meniscus and deforms less \vith a given load. CycliC loading alters the load deformation curve. Heat cumulates in the area of loading, disrupting the collagen ~ro ss-bridges. Cyclic loading produces microstructural mage that accumulates with each loading cycle. Damaae cumulates faster at higher intensities of cyclic 10ading!O Failure as a result of cyclic loading, called fatigue failure, is .he phYSiologiC basis underlying stress fractures. En­ urance limit or fatigue strength is the stress below which tigue cracks do not begin to form lo Connective tissues also demonstrate viscoelastic proper­ es that prOvide these tissues with their uniquely mutable h aracteristics. These properties are creep and relaxation. When a tissue is held with a constant force, it begins to engthen until equilibrium is reached or until the tissue rup­ tures , depending on the magnitude of the force. This prop­ e rty is called creep. When a tissue is pulled to a fixed length, certain force is required. As the tissue is held at this length, th e amount of force necessary to maintain that length de­ creases. This property is called relaxation. These properties low connective tissues to adapt to and function in a variety of loading con ditions without being damaged. Tissues pulled into tension (i.e. , stretched) lengthen and relax, vhich prOvides the rationale for stretching exercises to lengthen shortened soft tissues (Figs. 11-2 through 11-4).

Phases of Healing The clinician must understand the phases of healing to for­ mulate a plan of care matching the tissue's loading capabil­ ities. The phases of healing provide a framework into which the rationale for physical therapy interventions fit. U nder-

j Increased loading rate

Strain

FIGURE 11 -2. Three stress-strain curves for cortical bone tissues tested in tension at three different loading rates As the testing rate increases. the slope (the elastic modulus) of the initial straight line portion increases. (Adapted from Burstein AH. Wright TM. Fundamentals of Orthopaedic Biomechanics. Baltimore Williams & Wilkins. 1994:120.) standing the healing process gives the clinician the tools to treat a variety of injury and surgical conditions. Injury to the soft tissues arises from a number of sources. Physical traumas such as a sprain , strain, or contu­ sion are most common, whereas injuries can also occur from bacterial or viral infections, heat, or chemical injury. Trauma causes direct damage to the cells in the immediate area of the injury, causing bleeding into the inters titial spaces. The bleeding initiates a cascade of events that pro­ motes healing of the injured tissue. The process can be considered in phases, although the continuum is an over­ simplification of a very complex process. 400 A

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Deformation (mm) FIGURE 11-3. Stress-strain curve for ligament. As the ligament is dis­ tracted. fibers become progressivelyrecruited into tension (A) until all the fibers are tight (B). The parts of the ligament that are tightened first are likelyto be the first to fail (e) as the ligament reaches the yield point. Pro­ gressive fiber failures quickly result in ligament failure (D). (Adapted from Frank CB. ligament injuries pathophys iologyand healing. In Zachazewski JE. Magee DJ . Quillen WS. eds. Athlet ic Injuries and Rehabilitation. Philadelphia WB Saunders. 199615.)

210

Therapeutic Exercise Moving Toward Function

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AGURE 11-4. Effects of cyclic loading. When bone tissue is loaded cycli­ cally to 90% of its tensile yield strength, nonreversible behavior (ie, dam­ age) is seen. By the 350th loading cycle, the elastic modulus has changed appreciably. (Adapted from Burstein AH, Wright TM. Fundamentals of Or­ thopaedic Biomechanics. Baltimore Williams & Wilkins, 1994125)

Any of four outcomes may result from the inflammatory process: (1 ) resolution when the injUly is mild and transi­ tory. (2) replacement of the normal cell with fibrosis, (3) abscess formation in the presence of an infection, or (4) progression to chronic inflammation resulting from persis­ tent injury or individual factors. 11 These factors include di­ abetes, corticosteroid lise, and hematologic diseasell How the soft-tissue injury is managed is often responsible for the outcome of the injUiy.

Phase I: Inflammatory Response Healing of acute injuries passes through three major phases, beginning with the acute vascular-inflammatory re­ sponse (Fig. 11-5). The purpose of the vascular changes is to mobilize and transport cells (white blood cells and lellko­ cytes ) to the area to initjate healing. When connective tis­ sue is damaged , injured cells in the area release chemical substances (e.g. , prostaglandins, bradykjnin ) that initiate the iuflammatory response. The gap in the torn tissue is filled vvith erythrocytes and platelets. l The platelets form a plug to contain the bleeding and provide a scaffold for sub­ stances that will stabilize the clot. Local bleeding is a strong chemotactic stimulus, attracting white blood cells such as neutrophils and mononuclear leukocytes that help lid the site of bacteria and cellular debris through phagocytosis. Concurrently, in adjacent uninjured vessels, vasodilation occurs to increase local blood flow while capillary perme­ ability is altered to allow greater exudation of plasma pro­ teins and white blood cells. This produces swelling and edema in the area. In this phase, the damaged tissues and microorganisms are removed, fibroblasts are recruited, and some wound strength is provided by the weak hydrogen

FIGURE 11-5. Changes in components of rabbit med ial collateral liga­ ments at various stages of healing. Values are normal ized to that of unin­ jured ligament (normal = 1) (Adapted from Andriaacchi T, Sabiston P, De­ Haven K, et al. I-,gament injury and repair. In Woo SL-Y, Buckwalter JA. eds. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL American Academy of Orthopaedic Surgeons, 1988115)

bonds of collagen fibers12 The inflammatory phase is es­ sential in initiating the healing process, This phase is initi­ ated immediately and lasts 3 to 5 days.l2 Signs and symptoms observed in this phase are pain. warmth, palpable tenderness, and swelling. Pain and ten­ derness are caused by mechanical and chemical stimuL­ tion of nociceptors, and warmth and swelling are caused by acute inflammation. Limitations in joint or muscle range of motion (ROM) from pain or direct tissue damage are like l~ to occur. ROM testing usually reveals pain before the end of the ROM is reached. Focus treatment procedures in this phase at decreasing pain and edema while preventing a progressive cbronic in­ flammation. Ice is effective at reducing pain and edema. Compression also controls edema by forcing fluid to areas of lower hydrostatic pressure in the capillalies and lymph vessels. 11 Maintain the mobility and strength of adjacent joints and soft tissues while the acutely injured areas ar rested (see Patient-Related Instruction ll-l).

Phase II: Repair and Regeneration The second phase, lasting from 48 hours to 8 weeks, is th repair-regeneration stage, marked by the presence in tissu of macrophages directing the cascade of events occurring in this proliferative phase. Fibroblasts are actively resorb­ ing collagen and synthesizing new collagen (plimarily typ III), The new collagen is characterized by small fibrils , dis­ organized in orientation and deficient in cross-linking. J~ Consequently, the tissue !aid down in this phase is suscep­ tible to disruption by overly aggressive activity. As thi phase progresses, a gradual decrease in tissue macrophage_ and fibroblasts occurs, and a grossly visible scar filling til gap can be seen.l.l

Chapter 11 : Soft-Tissue Injury and Postoperative Treatment

ake the following steps when an acute musculoskeletal ury or a tlare-up of a preexisting injury occurs: 1. Ice the area for 10 to 15 minutes using cold packs or ice. Do this as often as possible throughout the day. 2. If possible, elevate the part to decrease swelling. 3. Apply compression in the form of an elastic sleeve or bandage. Remove the compression at night for sleeping. 4. Use a supportive or assistive device (e.g., sling, splint. cane, crutches, walker) to rest the injury. 5. Contact your clinician or physician regarding the need for further evaluation. 6. Resume previous program of care when instructecl or able.

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The warmth and edema resolves during this phase. Pal­ e tenderness decreases, and the tissue can withstand _- tie loading. Pain is felt concurrent with tissue resistance tretch of the tissue. Treatment procedures in this phase include ROM exer­ , joint mobilization, and scar mobilization to produce a ile scar. These interventions are most effective during . stage of healing. Gentle resistance may be applied to .J.intain mobility and strength of the musculotendinous -t. [n bone, this phase is referred to as the callus phase_Os­ .:>clasts perform a function analogous to the macrophages oft tissue. These cells debride the fracture ends and repare the area for healing_ The infrastructure for healing sembled, including a capillary structure supporting cal­ - formation. This callus bridges the gap be1:\veen the frac­ ends. The callus is an unorganized scaffold of cartilage t is easily deformed. Although the bone repair is rela­ ely weak at this pOint, limited activity is allowed. This ding promotes remodeling and maturation. Treatment goals focus on applying light loads that will rovide a stimulus for the tissue to remodel. Keep these ds within the tolerance of the newly formed tissue by onitoring signs and symptoms closely. Any increase in "'3in, warmth, or edema is a Signal that the loads are ex­ _eeding tissue capabilities. Loads can be in the form of retching, joint mobilization, range of motion activities, or -eight bearing.

hase III: Remodeling and Maturation healing progresses to the third phase, the remodeling­ "TJaturation stage, a shift is made to the depOSition of type I collagen. This phase is characterized by de<:reased synthetic activity and cellularity, with increased organization of extra­ eellular matrL'(. The collagen continues to increase and be­ lTins to organize into randomly placed fibrils with stronger eovalent bonds. At this pOint, tension becomes important in providing orientation guidance to the organizing collagen. The new collagen must orient and align along the lines of stress to best accommodate the functional loads required. This tension can be imposed by stretching, active contrac­ tion (in the case of the musculotendinous unit), resistive

211

loads, or electrical stimulation. The end of tissue remodeling is unknown and may take months to years for completion. As with the remodeling-maturation phase in soft tissues , loading is important in the final phase of bone healing. In this phase of bone healing, woven bone (i.e. , immature bone) is replaced by well-organized lamellar bone. l Nor­ mal loading is necessary to remodel the bone in accordance to the stresses that it will bear (i.e., Wolff's law). The link­ age of electrical charges with mechanical loading is called the piezoelectric effect. 3 Piezoelectric effects in the cal­ cium hydroxyapatite crystals resulting from loads orient the crystals along lines of stress. In long, weight-bearing bones, activity differs on the concave and convex sides. On the concave side, osteoblasts lay down more bone where bone is subject to compression (i.e., negative charge). On the convex side, osteoclasts digest bone that is subject to ten­ sion (i.e. , positive charge ). Imposition of normal functional loads are necessary for the final remodeling of bone. Elec­ trical stimulation is used to enhance bone healing using the same piezoelectric effect.

PRINCIPLES OF TREATING CONNECTIVE TISSUE INJURIES A variety of procedures are available to achieve physical therapy goals. Although detailing every situation the clini­ cian may encounter is difficult, speCific prinCiples guide the decision-making process. These principles proVide a framework and rationale for intervention choices.

Restoration of Normal Tissue Relationships After connective tissue injury, the relationships of a variety of tissues are altered. After injury or immobilization, the tendon may fail to glide smoothly through the tendon sheath, the nerve may be adhered to surrounding tissues, folds of joint capsule may become adhered to one another, the skin may bind to underlying tissues, or fascial layers may fail to glide on one another. These normal relation­ ships must be restored , or painful and restricted movement may result. Interventions such as active muscle contrac­ tion , passive joint motion or mobilization, modality use, or massage restore those relationships . Begin these preven­ tive interventions as early as the healing process allows , of­ ten within the first 48 hours. Additionally, the normal length-tension relationship of the muscle must be recov­ ered to ensure optimal function. Muscles damaged by con­ tusion , disrupted by surgical procedures, or placed in a shortened pOSition during immobilization are susceptible to these alterations. Use stretching techniques to restore the normal length-tension properties. For example, the Achilles tendon should be stretched regularly while a pa­ tient recovers from an ankle sprain or fracture.

Optimal Loading After a connective tissue II1Jury, a cascade of events facilitates the body's healing process. If this cascade is

212

Therapeutic Exercise: Moving Toward Function

Specific Adaptations to Imposed Demands Weakness

Destructive force

Too much

Optimal loading

Too

little

FIGURE 11-6. Optimal loading Choose a load that neither overloads nor underloads the tissue of interest. (From Porterfield JA. DeRosa C Me­ chanical Low Back Pain. Philadelphia WB Saunders, 199113)

interrupted, healing is disrupted, and chronic inflamma­ tion may ensue. During each of the healing phases, choose treatment procedures that aid the healing process without disrupting the normal chain of events. This requires opti­ mal loading or choosing a level of loading that neither over­ loads nor underloads the healing tissue (Fig. 11-6). Effec­ tive application of optimal loads requires a thorough understanding of the mechanism of injured tissue loading, including which planes of movement place the greatest loads on the healing tissue. Consider the biomechanical effects of daily activities and therapeutic activities in the context of the stage of heal­ ing, and individual factors such as age, quality of the tissue, nutritional status, and fitness level. A stress that underloads a tissue in the remodeling phase probably overloads the tis­ sue in the inflammatory phase. An exercise that underloads a young athlete after an acute fracture would probably overload an elderly individual after a pathologic fracture. The medial collateral ligam ent of the knee is loaded most in the frontal plane "vith the knee near terminal extension. Avoid activities that load the knee in the frontal plane near full knee extension during the acute phase. However, in the late phases, when remodeling of the ligament is necessary, frontal plane loading is preCisely the stimulus needed. De­ signing the treatment program requires consideration of all of the factors in the intervention model within the injury framework (see Patient-Related Instruction 11-2).

The following signs and symptoms suggest that exercise or activity is too much and should be decreased or modified: 1. Increased pain that does not resolve within the next 12 hours 2. Pain that is increased over the previous session or comes on earlier in the exercise session 3. Increased swelling, warmth, or redness in the injury area 4. Decreased ability to use the part

Although the concept of optimal loading guides the quan­ tity of activity (e.g., volume, intensity), the specific adap­ tations to imposed demands (SAID) prinCiple expands to include the type of activity chosen. The SAID principle is an extension of Wolffs law, which states that a bone re­ models according to the stresses that are placed on it. The SAID prinCiple implies that soft tissues remodel accord­ ing to the stresses imposed on them . Exercise is specific: to the posture, mode, movement, exercise type , environ­ ment, and intensity used. For example, an exercise mar be chosen to prepare the quadriceps muscle for weight bearing. The quadriceps muscle contracts eccentrically in a closed chain through the first 15 degrees of knee flexion during the loading response of gait. A closed chain eccen­ tric quadriceps exercise such as a short-arc (0 to 15 de­ grees) leg press is a better choice than concentric isoki­ netic exercise. This is an example of the SAID plinciple guiding the activity choice. The SAID principle also gUides exercise prescription parameters. For example, in the late stage of healing, a pa­ tient returning to tennis should increase the speed and in­ tensity of exercise, whereas the patient returning to marathon training should increase the exercise duration . When the stage of healing and optimal loading parameters allow, training should as closely as possible reflect the spe· cific demands of the patient's functional task.

Prevention of Complications Be sure to consider the effects of the connective tissue injury on surrounding tissues . For example, immobilization imposed while a fracture is healing is unhealthy for the joint's articular cartilage, ligamen ts, and surrounding mus­ culature, although it is necessary for bone repair. Muscle atrophy and weakening of the immobilized ligaments en­ sue during the immobilization period. Use any available in­ terventions that might minimize these effects. For exam­ ple, electrical stimulation or isometric muscle contractions can be used to retard strength losses in the muscle, tendon. and tendon insertion sites. Active muscle contractions also prevent thrombus formation after surgery. ROM exercises at joints above and below injury sites may preserve som soft-tissue relationships and prevent loss of mobility. Weight bearing loads the articular cartilage and lessen degradation caused by immobilization.

MANAGEMENT OF IMPAIRMENTS ASSOCIATED WITH CONNECTIVE TISSUE DYSFUNCTION Patients with acute soft-tissue injuries such as sprains and strains are commonly treated by physical therapy cliniCians. Management of these injuries is discussed together be· cause of the many similarities, and any differences are highlighted.

Chapter 11: Soft-Tissue Injury and Postoperative Treatment

213

Sprain: Injury to Ligament and Capsule an[lap­

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_\ sprain can be defined as an acute injury to a ligament or int capsule without dislocation. Sprains occur when a joint extended beyond its normal limit, and the ligament or cap­ 'Ule tissues are stretched or tom beyond their limit. Sprains e common at the ankle (i.e., anterior talofibular and calca­ ofibular ligaments), knee (i.e., medial and lateral collat­ rnlligaments, anterior and posterior cruciate ligaments), list , and spine. A sprain may resolve with short-term im­ bilization, controlled activity, and rehabilitative exercises, t other sprains may require surgery to stabilize the joint.

prain Classification rain severity occurs along a continuum from microscopic ..aring and stretching of ligament or capsule fibers to com­ te disruption of the ligament. Sprains are classified by ~"'e rity based on clinical examination or special testing _<7 . , magnetic resonance imaging, arthrometer testing). mde I sprains are mild sprains in which the ligament is tched, but there is no discontinuity of the ligament. A _ de II sprain is a moderate sprain in which some fibers tretched and some fibers are tom. This produces some 't)' at the joint. A grade III , or severe sprain, is a CO!l1­ tete or nearly complete ligament disruption with resultant 'ty (Table 11-2).

: amination and Evaluation ~:tam ination

techniques for the individual with a ligament rain iucludes observation to assess ecchymosis and rna. Observe functional range of motion such as gait in \-er extremity problems and forward reaching in upper re mity injUlies. Perform active and passive ROM , mus­ performance testing, and pain assessment to obtain in­ '1ll ation regarding impairments associated with the in­ _. Assessment of joint integrity and mobility by manual instlUmented laxity testing provides a baseline measure joint laxity, whereas instability or apprehension testing ,ides information about the instability associated with t laxity (Fig. 11-7). Palpation identifies the specific loca­ n of the primary and any secondary injuries. Evaluate nts proximal and distal to the primary joint injury to de­ -mline associated injuries. Determine functional limita­ and identify the relationship beh.veen impairments tl10se functional limitations.

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DESCRIPTION

CHARACTERISTICS

de I

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de II

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Fibers are stretched without loss of continuity Some fibers are stretched, and some are tom. Some laxity observed on examination Ligament completely or nearly completely torn; laxity results.

-de III

Severe

American Acade my of Orthopaedic Surgeons. Athle tic Training ports Medicine. Park Ridge, IL: American Acade my of :hopaeclic Surgeons, 1991.

FIGURE 11-7. KT-1 000 testing for anterior or posterior cruciate ligament laxity

Strain: Musculotendinous Injury A strain is an acute injUly to the muscle or tendon from an ablUpt or excessive muscle contraction. Strains are usually the result of a quick overload to the muscle-tendon unit i~ which the tension generated exceeds the tissue's capacity. Strains occur when a contracting muscle is excessively or abruptly stretched in the opposite direction. The person who reaches quickly to catch a falling object or the individ­ ual who suddenly stops or changes direction when walking or running is susceptible to a muscle strain. Strain injuries are difficult to claSSify and can 'be graded as mild, moderate , or severe based on clinical examination findings such as pain , edema, loss of motion, and tender­ ness. Muscle strains can be complete or incomplete , al­ though complete tears are less common. Most strain injuries occur at the mvotendinous junc­ . 14 / . tlOn. Structural features of the sarcomeres and connective tissues in this area suggest that load transmission occurs across the musculote ndinous junction. As -witll many other structures in the body, transitions from one tissue type to an­ other are areas of increased stress and risk of injury_ In this case, the transition zone from contractile to noncontractile tissue creates an area of increased stress that is susceptible to injury. Factors that may contribute to muscle strain in­ juries include poor flexibility, inadequate warmup exercise , insufficient strength or endurance, and poor coordination. 14

Examination and Evaluation A thorough histOlY provides the clinician with clu es to the examination of the muscle strain . An abrupt decele rating movement, change of direction , or quick stretch may pre­ cipitate a muscle strain. The musculotendinous junction or the muscle belly are painful. Muscle injuries can be repro­ duced clinically by active or resistive contraction of the muscle and by stretching it. For example , a quadriceps strain is reproduced by stretching the knee into flexion and by resisting active knee extension. The muscle may need to be put on stretch during the active or resistive muscle con­ traction to stress the lesion. Occasionally, localized swelling and warmth may be observed.

214

Therapeutic Exercise Moving Toward Function

FIGURE 11-8. Clinician instructing patient in isometric biceps curl.

Application of Treatment Principles Phase I

Treatment principles in the early phase include optimal loading and prevention of secondal), complications. As the inflammatory response initiates the healing response, an

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environment conducive to healing must be established. The appropriate balance of rest and loading ensure loads within the optimal loading zone for the patient's age, medical con­ dition, and injury severity. Overload may perpetuate bleed­ ing or the inflammatory response beyond its useful purpose. and underload may result in complications such as motion loss, scar tissue adhesions, or ectopic ossification. Modality use in this phase usually includes cryotherapy and compression with elevation to decrease bleeding and swelling. Most injuries allow passive or active ROM in a pain-free range, although exercise may be contraindicated in some severe cases. Isometric muscle contraction, in the absence of moderate or severe muscle strains, can lessen at­ rophy and serve as a learning activity, reminding the patient how to contract involved muscles (Fig. 11-8). Because the muscle is the primary tissue involved in a strain, active mus· cle contraction capability may be limited or reduced signif­ icantly. When treating lower extremity injuries, assistive de­ vices, immobilizers, and weight-bearing restrictions can maintain tissue loading within the optimal loading zone. Treatments that impose rest or restriction must be balanced with activity that offsets the negative effects of immobility (see Selected Intervention 11-1: Isometric Ankle Eversion for the Patient FollOwing Ligament Reconstruction). Phase II

As healing progresses to the repair and regeneration phase, treatment principles focus on restoration of normal

SELECTED INTERVENTION 11 -1

Isometric Ankle Eversion for the Patient After Ligament Reconstruction

See Case Study #1 Although this patient requires comprehensive intervention as described in the patient management model, one speCific exercise is described.

ACTIVITY: Isometlic ankle eversion PURPOSE: Increased ability to produce torque in the peroneal muscles without excessivelv loading the acutel" ;" injured tissue

RISK FACTORS: No appreCiable risk factors

sure eversion is not substituted with tibial external rotation, hip abduction, or external rotation.

OOSAGE TYPE OF MUSCLE CONTRACTION: Isometric

Intensity: Subrnaximal Durstion: To fatigue, pain, or 20 repetitions Frequency' Hourly or as frequently as possible during the day

Environment H ome

ELEMENTS OF THE MOVEMENT SYSTEM: Base STAGE OF MOTOR CONTROL Mobility POSTURE: Any comfOltable position such as sitting or supine. The lateral border of the foot is stabilized against a stationary object. MOVEMENT: Patient performs an isometlic ankle eversion contraction against a stationalY object. SPECIAL CONSIDERATIONS: Ensure that mnscle contraction is at a submaximallevel during the acute phase. Ivla.ximal muscle contraction can overload recently injured tissues. Be

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen Ito begin retraining the peroneal muscles. Isotonic exercises can overload the muscle in the acute phase, but subm,cximal isometlic contraction maintains loading within the optimal loading zone. Gentle isometric activation "reminds" the muscle how to contract, proViding a foundation for fUlther strengthening in later phases. EXERCISE MODIFICATION OR GRADATION: As healinab progresses, isometric contractions may be performed at multiple angles. Isometric contractions should be progrcssed to isotonic exercise through a range of motion. Closed chain exercise should be incOlvorated as weight bearing allows.

Chapter 11 Soft-Tissue Injury and Postoperative Treatment

relationships, optimal loading, and prevention of '
21 5

T

FIGURE 11-10. Active quadriceps co ntraction faci litating a hamstring stretch.

tions chosen (Fig. 11-11). The goal in the final phasp is to "fine tune" or convert that baseline strpngth and mobility into functional movement patterns and activities that ad­ dress the patient's functional limitations and disability. The exercises generally consist of more whole-body patterns and functional activities related to the patient's lifestyle. At the same time, consider the status of healing tissue and the loads placed on it as you choose activities. For example, re­ peatedly throvving a fastball on a repaired elbow medial col­ lateral ligament excessively loads that repair at this pOint. A graded, progressive functional exercise is necessary to re­ sume activities with such loads (Fig. 11-12).

ase III

the patient returns to activity, the guiding principles ptimalloading and SAID. The type and magnitude of ncountered in the patient's daily routine, including rl- , nd leisure activities, determine the specific interven-

Tendinitis and Tendon Injuries Tendon failure can occur as a result of macrotrauma or mi­ crotrauma. Tendons are able to withstand high loads, but if

FIGURE 11-11 . Example of impact loading in a horizontal position as a transitional activity between strengthening and impact loading in a verti­ cal position.

216

Therapeutic Exercise: Moving Toward Function

FIGURE 11-12. A soccer drill performed by soccer coach is an example of a graded, progressive study.

these loads become repetitive, injury may result. Injury oc­ curs on a microscopic or macroscopic level, with damage to the structural proteins and the blood supply. Adequate time must be allowed for healing to take place or tendinitis will develop. As the understanding of tendinitis has pro­ gressed, new classification schemes of tendon injUly have been developed . In addition to the global categories of acute and chronic, tendon injuries have been subclassified as paratenonitis, tendinosis, tendinitis, and paratenonitis \-vith tendinosis 15 Each of these subcategOries has treat­ ment ramifications. Although tendon injuries are discussed in the context of connective tissue injuries, some of these injuries may be more suitably treated in a localized inflam­ mation pattern. This will vary with classification . However, all tendon injuries will be discussed together for clarity.

Classification of Tendon Injuries Acute macrotraumatic injUlies occur as a result of a sudden contraction , often decelerating in nature, and they are fol­ lowed by a lengthy but predictable outcome. 15 Loads dur­ ing normal activities generally do n~t exceed 2.5 % of the tendon's ultimate tensile strength. 16 . 1 ' However, loads dur­ ing high-level activities, such as kicking, have been found to exceed this average level. For example, loads estimated in a weight lifter at the time of patellar tendon rupture were 17 times body weight. 18 Most acute injuries occur at the musculotendinous junction and result in a profound in­ flammatory reaction. 18 This reaction initiates the phases of healing outlined previously. Microtrauma without adequate recovery time can also result in injury to the tendon. Paratenonitis is an inflam­ mation of the outer layer of the tendo!] (i.e., paratenon), whether lined with synovium or not. l .o . 20 Histologically,

inflammatory cells are found in the paratenon or peritendi­ nous areolar tissues , and, clinically, the cardinal signs of in­ flammation such as pain , crepitation, swelling, and palpa­ ble tenderness occur. Treatment procedures, including anti-inflammatory measures, are indicated. Tendinosis is an intratendinous degeneration witho\'lt an inflammatory response. It is generally caused by atrophy from aging, microtrauma, or vascular trauma. Histologic findings include fiber disorientation, hypocellularity, scat­ tered va:;cular ingrowth , and occasional necrosis or calcifi­ cation 1 .o . ZO Because there is no inflammatory respons e. none of the cardinal signs of inflammation is present, and anti-inflammatory measures are ineffective. A nodule may be palpable but non tender. Tcndinosis may also occur with paratenonitis, in which paratenon inHammation accompa­ nies intratendinous degeneration. Symptoms in this cas(~ may be confUSing, combining signs of inflammation 'vvith a palpable tendon nodule . Histologically, scattered vascular ingrowth may be present, although no true intratendinou;i inflammation exists . The term tendinitis is used to desCiibe a tendon strain or tear and is defined as synlptornatic degeneration of the ten­ don witI:, vascular disruption and an inflammatory repair 1"(;'­ sponse. iO .20 Histologically, tendinitis is classified into thre subgroups, each witIl different findings , from purely inflam­ mation to inflammation superimposed on preexisting degen­ eration to calcification and tendinosis changes in chronic conditions. The chronic stage is furtller categorized: 1. 2. 3. 4.

Interstitial microinjury Central tendon necrosis Frank partial rupture Acute complete rupture 15

The SYlilptoms ill this group are proportional to the va,,· cular disruption or atrophy and can be inflammatory, dp­ pending on the duration (Table 11-3).

Examination and Evaluation In examining the individual with a tendon injury, histor: and subjective symptoms are of primary importance be­ cause of the differences in classification and treatm en The global classification of acute versus chronic injury usuarly easily clarifi ed by injUly profile. Distinguishing be tween various types of chronic injuries and deCiding to cla.'­ siry the problem as primarily a connective tissue probJel or a localized inflammation can be more difficult. Tl eVCl1ts leading up to the onset of pain in the chronic COb are significant in that th e predispOSing factors may be icler. ­ tified. Modifying the components that may have COII­ tributed to the problem is essential to recovery. Trainil' _ errors , inappropriate equipm e nt, environmental factor excessive fatigue , or an apparently small inj ury without equate recovely can preCipitate tendon injury. 'Nork training res trictions or modification of the home or woo environment may be neceSSalY to give the body an ad~­ quate opportunity for recovery (Fig. 11-1:3). PhYSical examination follows traditional orthopaedi c sessment procedures and includes observation, RO~d muscle performance testing, postural assessment, and jOi integrity and mobility tests. Observe for any structural postural abnormality that may have predisposed the pati

Chapter 11 : Soft-Tissue Injury and Postoperative Treatment

EW Paratenonitis

OLD

DEFINITION

HISTOLOGIC :FINDINGS

CLINICAL SIGNS AND SYMPTOMS

Tenosynovitis, tenovagi nitis, peritendinitis

An inflammation of only the paratenon, lined by synovium or not Paratenon inflammation associated with intrate ndinosis degeneration

Inflammatory cells in paratenon or peri tendinous areolar tissue

Cardinal inflammatory signs : swelling, pain, crepitus, local tenderness, warmth , dysfunction Same as above, \.vith often palpable tendon nodule, swelling, and inflammatory signs

aratenonitis with tendinosis

Tendinitis

endinosis

Tendinitis

Intratendinous degeneration resulting from atrophy (aging, microtrauma, vascular compromise)

enciinitis

Tendon strain or tear

Symptomatic degeneration of the tendon with vascular disruption and inflammatory repair response

-r

217

Same as above, with loss of tendon collagen , fiber disorientation , scattered vascular ingrowth , but no prominent intratendinous inflammation Noninflammatory intratendinous collagen degeneration with fiber disorien tation, hypocellularity, scattered vascular ingrowth , occasional local necrosis , or calcification Three recognized sub­ groups; each displays variable histology, from pure inflammation to inflammation superimposed on preexisting degeneration in chronic conditions: (1) acute, (2) subacute, (3) chronic

Often palpable tendon nodule that is asymptomatic; no swelling of tendon sheath

Symptoms are inflammatory and proportional to vascular disruption, hematoma, or atrophy-related cell necrosis. Symptom duration defines each group: (1) <2 weeks, (2) 4 to 6 weeks , (3) 6 weeks

- "Om American Academy of Orthopaedk Surgeons. Athletic Training and Sports Medicine. Park Ridge, IL: American Academy of Orthopaedic .ugeons, 1991.

to tendinitis. Use speCific ROM and mobility testing to de­ termine the tissue at fault and use muscle testing to assess muscle length and functional muscle imbalances. Use pal­ pation skills to determine the precise areas of tenderness and isolate the tendon injury's location. Document any nodules, palpable defects (in acute trauma), and crepitus, because this provides the therapist with valuable informa­ tion for classification.

Treatment Principles and Procedures

con ­

. nt

AGURE 11-13. A tennis elbow strap can be used to decrease loads on the •'irist extensor musculature during drills.

Treatment of tendinopathies is based on the speCific ten­ don injury, framed within the context of the tendon's role in function. Restoring the tendon to optimal length, cellu­ larity, and ability to withstand loads is fundamental to com­ plete rehabilitation. The optimal loading zone is the foun­ dation principle for chOOSing loading techniques. Educate the patient about outside activities that maximize symptom resolution and minim ize harmful effects. Rehabilitation should be of appropriate intenSity, frequency, and duration such that, when combined with essential activities of daily living, it keeps loading within the optimal loading zone. When inflammation is a component of the tendinopathy, anti-inflammatory measures are helpful. If you are treating inflammation as the primary problem, the injury may be treated in the localized inflammation practice pattern. Physical agents such as ultrasound and cold packs, as well as electrotherapeutic modalities such as electrical muscle stimulation and iontophoreSiS, can reduce inflammation .

218

Therapeutic Exercise: Moving Toward Function

Use other physical agents or modalities as necessaly to re­ duce the pain associated with inflammation, allowing greater participation in the therapeutic exercise program. Incorporate stretching if muscle length is inadequate for the demands placed on the musculotendinous unit. In cases of recovery from an acute tendon injUl)', stretching is critical for restoring the normal length of the tissue. More­ over, in the early stages, stretching is a stimulus for the proper alignment of healing collagen. In healing tissue , gentle stretching to provide a stimulus for fiber orientation without disruption of the immature collagen facilitates the remodeling process. In the chronic tendon injury, stretch­ ing increases the tissue's resting length, allowing loading through a greater range and force dispersion over a larger surface area. Changes in resting length may affect the mus­ cle spindle, altering its sensitivity and resultant muscle stiffness. As "vith resistive exercise, stretching should be prescrihed according to intensity, frequency, and duration parameters. Too often, these prescriptive factors are ne­ glected, leading to overload. For example, patients often believe that a strong stretching sensation is necessary to adequately stretch the muscle. However, a strong stretch can be just as damaging to an injured muscle-tendon unit as too much resistance. Patients should feel a "low" to "medium" stretching sensation during the stretch without an increase in symptoms after the stretching session. Eccentric muscle contractions have been implicated in the development of tendinopathies. Eccentric contractions allow the series elastic component (SEC) to contribute to force production. Tendon forms p<.ui of the SEC 9 Other connective tissue proteins in parallel with the muscle fiber also contJibutc to force production. Eccentric contractions usually precede concentJic contractions in activities such as jumping, allOWing the SEC to contribute to force produc­

tion. The force generated in the tissue during eccentric contractions depends on the velocity of the stretch, the dis­ tance moved, and the amount of load placed on the tissue (e.g., body weight , external loads). These parameters are used in the rehabilitation of tendon injuries. Curwin and Stanish 9 outlined a progressive resistive ex­ ercise program in an attempt to strengthen the tendon tis­ sue. Because eccentric muscle contractions allow the SEC to contribute to force production and because eccentric muscle contractions are frequently associated with the de­ velopment of tendinopathies, this muscle contraction type is emphaSized. Before an effective eccentric contraction can be performed , the individual must first be able to iso­ metrically hold at the starting position. Thus the first ap­ propriate resistive exercise may be a submaximal isometric contraction. As the individual progresses, an eccentric pro­ gram is initiated , vvith a progression of speed built into the program. The resistive eccentric program is performed slowly for the first 2 days, progressed to a moderate speed for 3 days, and then to a fast speed for 2 days. The resis­ tance is then increased, and the speed progreSSion insti­ tuted again. This program is easily performed at home, and intensity, frequency, and duration are clearly outlined to prevent overload (Fig. 11-14). Be sure to begin and end each session with stretching. As with any soft-tissue injury, rehabilitation activitie must mimic the demands placed on those tissues on return to activity. The prescription parameters are framed around the functional outcome. For the individual returning to a work, leisure, or home environment that places him or her at risk for reinjUlY, appropriate modifications to the envi­ ronment or to the individual (e.g., technique, adaptive or supportive devices ) must be made as part of the prevention and long-term care program.

FIGURE 11-14. Eccentric quadriceps work with an ankle we igl-o is performed by the patient. (A) Uninvolved leg lifts the relaxed iT · volved leg. (8) Uninvolved leg is then lowered eccentrically by 111= involved leg

Chapter 11: Soft-Tissue Injury and Postoperative Treatment

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anagement of Cartilage Injury Classification of Cartilage Injury Damage to the articular cartilage can occur from mechanical mjury or from other non mechanical trauma. Nonmechanical traumas include infection, inflammatory conditions, or pronged joint immobilization and can result in loss of proteo­ gl~lcans. Proteoglycan degradation or suppression of synthe­ sis from these conditions results in articular cartilage damage ;hat may be irreversible. Mechanical damage to the articular ~'artilage (i.e., chondral injury) or to the mticular cartilage -md underlying bone (i.e., osteochondral injury) can happen a result of blunt trauma, frictional abrasion, or excessive ,'eierht-bearing forces. 21 Knee hyperextension injuries or an­ . e rotational injuries can result in chondral or osteochondral :Djuries and ligamentous injuries. In addition to classification by cause of damage (me­ hanical or nonmechanical), articular cartilage injury is I ssified by whether it is partial or full thickness and by the iz of the lesion. Depth and diameter of the lesion also ave implications for treatment, and classification systems r these lesions have been developed.

Examination and Evaluation

h

.0

-

':Jlportant clinical information relative to rehabilitation in­ udes the cause of the damage (i.e., mechanical or non­ ,cchanical), area of damage (e .g. , weight-bearing surface ), ssification of damage , and other factors that may affect ealth of the articular cartilage, such as general health, estyle factors, body weight, joint alignment, and stability.

• urgery was performed, the status of the alticular carti·

O'e and the associated soft tissues should be available

the chart. Patient goals should be determined and a

alistic prognosis determined based on available inform a­ On. For example, an individual with an articular carti­ O'e lesion on the weight-bearing surface of the me­ al femoral condyle in a varus-aligned anterior cruciate 'lament-deficient knee will have difficulty when returning high-demand activities . Other assessment procedures of merit include posture, M, muscle performance, and jOint integrity and mobil­ examinations. Assessment of swelling and pain influ­ - ces intervention choices and progreSSion of the treat­ nt program. A swollen and sore knee indicates that the int is inflamed, which is unhealthy for the articular calti­ lTe. Resolution of the swelling and inflammation as uickly as possible is imperative for the joint's health.

-reatment Principles linimum requirements for healthy articular cartilage are eedom of motion , eqUitable load distribution, and stabil­ .12 Initiate treatment focused on restoration of motion as primary goal. The aggreSSiveness of other interventions eh as muscle performance exercises is dictated by the !her factors and the medical treatment. The articular car­ ere has a better chance of recovery after injury or surgery the presence of equal load distribution (i.e., medial and e ral compartments in the knee) and joint stability. A ee with sianificant varus or valgus alignment excessively ,"l ds the medial and lateral compartments, respectively. :-his loading is the rationale for tibial osteotomy proce­

219

dures , which attempt to balance load distribution medially and laterally. An unstable knee (anterior or posterior cruci­ ate deficient) also places greater loads on the articular car­ tilage, and rehabi'litation after alticular cartilage injury or surgery in an unstable knee must proceed cautiously. Restoration of motion in a compromised jOint allows loads to be distributed across a greate r jOint surface area, decreaSing peak focal loads. Mobility activities enhance fluid dynamics in the joint, assisting INith lubrication and nutrition of the joint. Active and passive ROM activities are important for the recovery of articular cartilage lesions. In addition to the restoration of motion, normalization of gait and increased muscl performance decreases loads on the articular cartilage. Effective eccentric muscle forces dur­ ing the loading response of gait can minimize articular carti­ lage and subchondral bone loads, Strengthening activities play an important role in the protection of articular cartilage.

MANAGEMENT OF IMPAIRMENTS ASSOCIATED WITH LOCALIZED INFLAMMATION Contusion A contusion occurs as the result of a blow and can occur in any area of the body to a variety of tissues. No break in the skin occurs, although blood vessels below the skin may be injured, causing ecchymOSiS in the area. If the damage is more extensive and large blood vessels in the area are disrupted, a localized area of blood may accumulate in deeper tissues , forming a hematoma. When a deep-tissue hematoma occurs, ecchymOSiS mayor may not be seen on the skin surface. For example, quadl1ceps femoris contu­ sions frequently result in hematoma formation. This hematoma is easily palpable wi.thin the muscle, but it is rarely accompanied by ecchymosiS. The severity of this type of injury can be deceptive, and if left untreated , may progress to myositis ossificans. Myositis ossificans is the formation of heterotopiC bone ,-"rithin the muscle. Bleeding in the area of the contusion initiates the inflammatory re­ sponse and healing process.

Examination and Evaluation The history of a blow proVides the best information for evaluation of a contusion , The size, location, and direction of the blow prOVide the clinician vvith valuable clues about the location and extent of soft-tissue injUl1es. After obser­ vation and palpation of the area for localized swelling or hematoma, assess joint mobility, muscle performance, and flexibility and function. A diagnosis and prognOSiS based on the evaluation guide treatment procedures. Muscle contu­ sions at risk for ectopic bone formation (e.g., quadriceps femoriS , biceps brachii) are treated more cautiously than simple subcutaneous tissue contusions, and the evaluation process must clarify the extent of tissue involvement.

Treatment Principles

Simple contusions generally resolve in a timely manner with­

out ~ e condary complications or long-term consequences.

However, this will he determined by the extent and location

220

Therapeutic Exercise Moving Toward Function

of the contusion. Be sure to consider the many layers of soft tissue comprising most injured areas. Contusions that occur in areas of high loads or poor blood supply may eventually result in a chronic inflammation. For example, a blow to the Achilles tendon may result in secondary Achilles tendinitis. Also, deep muscle contusions are at a high risk for long-term complications. Quadriceps contusions left untreated may re­ sult in myositis ossificans or ectopic bone formation within the muscle. This bone results in significant impairments such as loss of motion and muscle performance, as well as functional limitations relative to gait. These impairments and functional limitations can result in disability in those who are physically active as part of their lifestyle. Treatm ent principles are therefore grounded in an un­ derstanding of the consequences of the specific contusion. Range of motion must be restored as quickly as possible, al­ though in the case of a deep muscle contusion, aggressive mobility early on can increase bleeding. Thus a balance must be struck between treating the impairments and causing fur­ ther damage. In the case of a quadriceps contusion where the risk of myositis ossificans is high , this balance can be dif­ ficult. Use ice to control swelling and local inflammation as necessary. Use measures of pain, muscle length, and muscle performance to gUide the aggressiveness of treatment for this condition. When these measures decline, the pace of the program is too aggressive, potentially causing further dam­ age. Muscle performance measures must be restored, and these activities progressed to functional skills such as walk­ ing, stair climbing, and upper extremity work tasks . Submax­ imal isometric contractions can be safely initiated in the early phases, and these exercises progressed to more challenging muscle performance activities as healing progresses.

MANAGEMENT OF IMPAIRMENTS ASSOCIATED WITH FRACTURES A fracture can be defined as a break in the continuity of the bone.23 Most frac tures are the result of an acute injury (i.e. , macrotrauma), although stress fractures can occur as the result of microtrauma. Fractures are categorized by whether the skin is broken (i.e., open or closed), the amount of disruption (i.e., displaced or nondisplaced), and the type of fracture (e.g., greenstick, comminuted). The type and degree of force required to fracture a bone usu­ ally injures the surrounding soft tissue as well. Most frac­ tures are treated in the practice pattern of impairments as­ soci ated with fracture . However, patients undergOing surgical stabilization may be more appropriately treated in the bony and soft-tissue surgical procedures pattern. All fractures "'rill be discussed together for clarity.

Classification of Fractures Classification is first determined by whether the fractured hone is protruding through the skin. Fractures breaking the skin surface are considered open fractures; those that do not break the skin are classified as closed fractures. The conti­ nuity of the ends of the fracture is then considered. If the hone on all sides of the fracture remains in anatomic align­ ment, th e fracture is considered non displaced. Nondis­ placed fractures are more difficult to diagnose and require

Transverse

Spiral

Oblique-transverse or butterfl y

Oblique

Comminuted

Metaphyseal compression

~ rn

~ ~U ~~ ~ °0°

o

1)0

FIGURE 11·15. Types of fractures. (AI transverse, (81 spiral , (e) obliqUE (0) comminuted, and (f) metaphyseal fracture.

special studies such as radiography to verify. Fractures iT: which the ends of the bones are not in anatomic alignm ent ,vith each other are considered displaced fractures. Fractures are described by the type of break or disrup­ tion (Fig. 11-15). A greenstick fracture is an incomplet fracture that occurs in children. It is so named because a its resemblance to a green stick or t\vig that partially break3 when bent. Epiphyseal fractures also occur in children aIle are fractures through the growth plate. Salter and Harris: subclassified epiphyseal frac tures into five different typ depending on the extent of fracture affecting the epiph)' and metaphysis. Children are also susceptible to avulsio fractures , in which a tendon or ligament is separated fro r its attachment by a small piece of bone. Because of the rel­ ative strength of the collagenous tissues compared wi bone in this population, it is not uncommon to see YOUll_ persons avulse structures such as anterior cruciate lig, ments or the proximal origin of the hamstring muscle fror the bony attachments. Comminuted fractures break into more than two frat. ments and are often the result of Significant trauma, such ­ a fall or motor vehicle accident. PatholOgiC fractures oce in damaged or diseased bones, as in the elderly "'rith oster~ porosiS. These fractures are produced v.rith SUrpriSiIl minimal force. Stress fractures are overuse injuries in whk the bone's ability to remodel is incapable of keeping up \\; the breakdown resulting from activity. Stress fractures Ol­ cur in persons involved in repetitive activities such as rur ­ ning and jumping and in those \\rith decreased bOJ1e del1sit>

Application of Treatment Principles When designing the rehabilitation program, consider as ciated soft tissues that have been injured and subsequen immobilized. For example, which soft tissues should considered in the injury and management of a proxim humeral fracture? Depending on the location of the frac­

Chapter 11. Soft-Tissue Injury and Postoperative Treatment :'Jre, the joint capsule, rotator cuff insertions, long head of ;:he biceps or triceps muscles may be involved. Although ~ e fracture may be of primary importance from the physi­ . n 's perspective, rehabilitation of the associated soft :ISSues may be more challenging than the healing of the cture. These soft tissues may have been injured at the ~ e of fracture, they may impaired because of the resul­ t immobilization, or both. Be sure to relay this inform a­ n to the patient so realistic expectations after fracture atment can be developed. Often patients believe that en the fracture is healed that the limb should be func­ nal . Soft tissues can take longer to recover than bone, cl ensuring that the patient understands this is important r prognosis and adherence.

mobilized Fractures

e

e fracture site and joints above and below the fracture ually are immobilized for some time to allow healing. For 'ents with external fL'(ation (e.g., cast, splint), physical n lpy treatment focuses on rehabilitating the soft tissues t were damaged at the time of fracture and that were bsequently immobilized. The effects of immobilization soft tissues are described in Chapter 7 and consist of ening of the articular cartilage, shortening and atrophy musculotendinous units, decreased mobility of the joint ule and periarticular connective tissues, and decreased rculation. Consider these changes when initiating reha­ Itation after immobilization. Optimal loading and 'ito ration of normal tissue relationships are the goals en rehabilitating patients after fracture immobilization. Initially, joint mobilization, stretching, and other gentle bility activities can begin to restore ROM and normal -tissue relationships without overloading the tissues. n tle strengthening in the form of isometrics or gentle tonics stimulates increases in muscle performance. se same activities and controlled weight beafing load 'cular cartilage to reverse the changes resulting from im­ bilization. Electrical stimulation or biofeedback may be ssary in treating significant muscle atrophy. As impair­ n ts improve, initiate activities to alleviate any remaining -Ilctional limitations to facilitate the patient's return to Irk, leisure, and community activities.

rgicallv Stabilized Fractures

nm-

- actures of the hip and femur are examples of fractures t are frequently treated vvith surgical stabilization. The athy immobilization and significant lifestyle restrictions --Ike conservative treatment of some fractures unrealistic. n reduction and internal fL'(aticm (ORIF) provides im­ ctuate fixation of the fracture \vithout the deleterious ef­ 15 of immobilization. " 'hen treating the individual who underwent surgical tion of an acute fracture, treatment principles in the l~· phase focus on recovery from the traumas of the orig­ injury and of surgery. The principles are the same as ose for treating soft-tissue strains, sprains, and contu­ ns when addressing postfracture and postoperative pain. "hen chOOSing exercises, be sure to consider the effects of magnitude and direction of loading on the fracture site. e stability of the fracture and fixation gUide exercise oice, and this information should be obtained from the

221

chart or from the physician. For example, a patient with a fixated patellar fracture may avoid weight bearing to pre­ vent distraction loads at the fixation site, but a patient vvith a fixated tibia fracture may be allowed to bear weight to compress the fracture. Activities that address impairments and functional limitations while keeping loads vvithin the optimal loading zone can then be safely chosen.

Stress Fractures Stress fractures are a type of overuse injury in which the os­ teoblastic activity cannot keep pace vvith osteoclastic activ­ ity. This occurs when repetitive loading vvithout adequate recovery is imposed. The metatarsal bones, tibia, and spine are common sites of stress fractures. The most important aspect of stress fracture care is de­ creasing loading to allow healing to occur. This may range from leisure activity limitation to short-term immobiliza­ tion. During this phase, rehabilitation procedures include treating any impairment of mobility, muscle balance, or movement patterns that may have predisposed the individ­ ual to a stress fracture. If decreased bone mineral denSity is suspected as an underlying problem, institute education or referral for proper evaluation and testing. After loading at the fracture is allowed, determine the pa­ tient's optimal loading zone. The patient must learn which exercise or work parameters (e.g., intensity, repetitions, du­ ration, frequency) keep vvithin the optimal loading zone. Choose activities that duplicate the activities to which the patient will be returning. If possible, the activity should be used as a component of the rehabilitation program. Use the functional activity, whether work, leisure, or recreational ac­ tivities, as the measure of progress, and allow full return when the fracture has healed and is no longer painful to load.

MANAGEMENT OF IMPAIRMENTS ASSOCIATED WITH BONY AND SOFT­ TISSUE SURGICAL PROCEDURES Surgical procedures necessitating rehabilitation can be broadly categorized into soft-tissue procedures and bony procedures. Soft-tissue procedures are operations primar­ ily directed at the soft tissues, such as tendons, ligaments, or joint capsules. In contrast, bony procedures are opera­ tions primarily directed at bone and adjacent tissues. These categories are not exclusive, because surgery often includes soft tissues and bone. However, the primary procedure may predominantly affect one or the other, and rehabilita­ tion follows those guidelines. Not all surgical procedures can be discussed here, and as new surgical techniques are employed, the rehabilitation may change. The physical therapist should focus on the principles of treating patients vvith different categories of procedures, rather than on spe­ cific diagnosis-based protocols. Frequently, a course of conservative management, in­ cluding physical therapy, precedes surgery, and follow-up therapy is provided in the postoperative period. This gives the physical therapist the opportunity to participate in the patient's care in two critical perioperative periods. Many specific physical therapy outcomes can be achieved when the therapist has the opportunity for a preoperative visit.

222

Therapeutic Exercise: Moving Toward Function

This visit allows positive interaction and development of a good rapport between the therapist and pabent. Instrucbon in the postoperative exercise program occurs at a time when full attention can be given to the rehabilitation program, without the complica tions of postoperabve pain and nausea. Teach the pabent crutch training, wound care, bed mobility, precautions and contraindications to certain movements , and use of any immobilization or supportive equipment so the pabent is not overburdened with multiple instrucbons after surgery. Emphasize the importance of adhering to the prescribed exercises in the postoperative program. Consult with the patient about expected outcomes and return to function to reinforce realisbc e>"}Jectabons after surgery.

Soft-Tissue Procedures A multitude of soft-tissue procedures are routinely per­ formed by surgeons and include transfer, reattachment or realignment of tendons , ligament reconstrucbons , capsular tightening, debridement and synovectomy procedures, and stabilization techniques. Regardless of the speCific proce­ dure, consider the stages of healing and the effects of im­ mobilization and remobilization on soft tissue . In addition to the specific tissues involved in the surgery, consider ad­ jacent tissues that may be affected in d irectly by the surgery. These tissues may include supporting muscula­ ture, tissues at adjacent joints, articular cartilage, and asso­ ciated joint structures. Some soft-tissue procedures often require a longer re­ covery period than bony procedures because of the diffi­ culty in obtaining fL'Cation in soft tissue. Capsular reefing or tightening surgeries in which soft tissue is sutured to soft tissue or tendon transfer or repair procedures in which soft tissue is attached to bone require adequate heali ng time to ensure fixation. Most important, be sure to understand the surgical procedure and communicate with the surgeon to ensure optimal rehabilitation for the patient. The goals of therapeutic exercise in the perioperative period are to restore motion, strength, and function and to reduce pain. The principles of opbmal loading and SAID prOvide the framework for intervention choices. Be sure to observe for and educate the patient about potential post­ operative complications such as infection or deep vein thrombosis. Prevention of these complications by early de­ tection minimizes the risk of and protracted course of care associated with these problems. The re habilitation pro­ gram should include exercises and modality treatments to be performed at horne to reinforce self-management of the condition.

Ligament Reconstructions The most common sites ofligament reconstllJcbons are the ulnar collateral ligament at the elbow, the late ral ankle ligaments, and the anterior and posterior cllJciate (ACL, PCL) and medial collateral ligamen ts (MCL) of the knee . Ligament reconstruction should not be confuseJ with a primary ligament repair. Ligament reconstructions gener­ ally use other tissues (e.g., tendon ) to create a new liga­ ment, rather than repairing the original ligament. Commu­ nication with the surgeon regarding the specifics of the procedure provides the clinician \\lith information critical to proper patient care.

Not all individuals with ligament injuries are candidates for reconstructive procedures. Ample evidence exists sup­ porting the conservative management of knee MCL in­ juries in the presence of an intact ACL. Many individuals are able to return to their previous activity levels after ACL injury without surgical reconstruction . Decisions regarding the appropriateness of reconstructive procedures are based on the patient's activity level, clinical signs and symptoms, and the natural history of the injury. The postoperative rehabilitation course after ligament reconstructions depends on factors such as the graft mate­ rial, fixabon, quality of the tissue, status of the jOint sur­ faces, comorbidities, and associated injuries. In the knee. bone-patellar and tendon-bone ACL reconstructions have solid, bone-to-bone fixation, whereas use of hamstring or il­ iotibial band tissues may have soft-tissue fixation. Fre­ quently, associated injuries or procedures affect the reha­ bilitation (e.g., meniscus injury or repair, ulnar nervE­ transposition ). Comorbidities such as diabetes or degene r­ ative joint disease may alter the typical postoperative pro­ cedures by accelerating some aspects (e.g. , mobility), but in other cases, it may slow do\'IJl elements of the rehabilitation program (e.g. , weight bearing). EvelY individual should bE­ considered in light of the specific situation. Impairments after ligament reconstructive surgeries in ­ clude loss of mobility an d strength, pain, and swelling. Weight bearing and all weight-bearing activities are ini­ paired after lower extremity procedures. These impair­ ments may result in functional limitations, including inabil­ ity to perform activities of daily living such as bathing. dressing, and household chores or an inability to partici­ pate in leisure activities. Associated disabilities may includ an inability to fulfill expected roles as worker, student, or spouse (see Selected Intervention 11-2).

Tendon Surgery SurgelY to repair or transfer te ndons is commonly per­ formed in orthopaediCS. Whether a tendon has been to acutely or has undergone a degenerative process over protracted period, surgery to repair or debride the inju . can maximize the outcome. Common areas of tend~r surgery include the tendons of the hand and the rotato cuff, and Achilles and patellar tendons. As 'vvith ligament injuries, not all tendon ruptures need to be treated surgi­ cally. Many individuals return to a high level of functio despite an unrepaired rotator cuff tear or conservatiYE' management of an Achilles tendon rupture. The specific rehabilitation program depends to a grea' extent on the location and function of the musculotendi­ nous unit, the location and extent of damage within th musculotendinous unit , the quality of tlle tissue , and th ability of the su rgeon to effectively repair the damage. AI­ eas of poor blood supply, inferio r tissue quality, extensi\', damage, or comorbiclities can deleteriously affect the sur­ gical outcome. Communicate with the physician to enSllfi an understanding of the quality of the surgical repair tc avoid overtreating or undeltreating the patient. Key issues after a tendon injllly are the prevention of l11 u­ bility impairment without overloading the tendon repair and prevention of excessive atrophy. Immobilization resul in loss of normal tenJon gliding \vithin the tendon shead

Chapter 11. Soft-Tissue Injury and Postoperative Treatment

ate

rup-

~

SELECTED INTERVENTION 11 · 2

~

o.uadriceps Setting for the Patient With a Knee Injury

See Case Study #6 Although this patient requires comprehensive intervention as descIibed in the patient management model, one speciflc exercise is described.

!len

late­

ACTIVITY: QuadIiceps setting

sur­ nee.

PURPOSE: To increase superior glide of the patella, to teach activation of the quadIiceps, and to maintain or increase strength in the quadIiceps muscle

h
Dr il­

RISK FACTORS: No appreciable risk factors

Fr eh ­

en n r­

ELEMENTS OF THE MOVEMENT SYSTEM: Biomechanical and

pro­

STAGE OF MOTOR CONTROL: Mobility

neuromuscular

uti

POSTURE: A variety of positions sLlch as long sit, supine, or

10 be

standing. The knee is fully extended.

MOVEMENT: isomettic contraction of the quadIieeps muscle

_ in­

:lin _

SPECIAL CONSIDERATIONS: Ensure nOlTnal tracKing of the

im ­ pair­

patella. Avoid substitution with hip extensor musculature.

:xl the associated soft-tissue and jOint adl1esions because of restrictions placed on muscle-tendon stretch and con­ de tion. Unlike ligament reconstruction surgery, after ich strengthening exercises can be initiated early, these me exercises may overload the repaired tendon.

per-

-ebridement T . cal deblidement is performed alone or combined with lIer procedures at a number at joints. Deblidement refers the removal of tissue from an area until healthv tissue is osed. The purpose is to remove potential sourc~s of pain irritation and, in some cases, to stimulate a healing re­ nse. For example, in osteoarthritic knees, debridement \" remove osteophytes and loose bodies , shave or trim ar­ of roughened articular cartilage, and trim or remove ar­ of tom meniscus. When performing a ligament recon­ ction, the remains of the tom ligament are debrided ore the reconstruction is performed, and the tom ends tendon are debrided before tendon repair. Because of the variety of situations in which this proce­ re is used, rehabilitahon is dictated by the primary pro­ ure. Rehabilitation after debridement that accompanies don or ligament repair follows the repair guidelines. De­ ,dement performed primarily (e.g., arthritis) is guided by underlying pathology. Understanding the extent of dede ment and the status of the jOint (e.g. , location , extent, depth of articular cartilage changes, meniscus tears) en­ S appropriate pacing of the rehabilitation program. r

'1ovectomy n ovectomy, the removal of the synovial lining of the t, is a procedure performed primarily in the case of

223

Check quadriceps muscle contraction by attempting to mobilize the patella. With an effective quadriceps set, the pateUa should not be mobile.

DOSAGE TYPE OF MUSCLE CONTRACTION: IsometIic

Intensity: Submaximal to maximal Duration: Hold for up to 6 seconds for up to 30 repetitions Frequency: Hourly or as frequently as possible RATIONALE FOR EXERCISE CHOICE: QuadJiceps setting is a key exercise to maintain the health of the extensor mechanism. This activity lubIicates the patellofemoral jOint, increases superior glide of the patella (necessary for full knee extension), and increases or maintains quadliceps muscle strength. Full knee extension with quadIiceps activation is necessary for a normal gait.

EXERCISE GRADATION: Quadriceps setting is a foundation exercise that serves as a precursor to other exercises. This activity is progressed to more difficult exercises that require quadriceps muscle activation (i.e., any closed chain exercise).

rheumatoid arthritis and other diseases such as pigmented villonodular synovitis. The purpose of synovectomy in the case of rheumatoid arthritis is to remove the inflamed syn­ ovium and thereby relieve pain and swelling and perhaps retard the progressive jOint destruction associated vl'ith chronic inflammation. 2.5 This procedure is perfomled only after conservative measures to control the pain and swelling have failed. Rehabilitation after synovectomy is gUided by the pri­ mary pathology, such as rheumatoid arthritis. Because this procedure has been performed as a last resort to control pain and svvelling, every effort should be made during re­ habilitation to restore motion and strength without in­ creaSing pain or swelling. These two factors guide the pace of the rehabilitation program and prOvide the clinician vvith the parameters for optimal loading.

Decompression Decompression procedures are used to relieve pressure in an area and are commonly performed at the shoulder to re­ duce pressure on the subacromial soft tissues and in the spine to reduce pressure on the spinal cord. Surgery in the wrist to relieve pressure in the carpal tunnel and fas­ ciotomies in the leg to reduce compartment pressures may be considered forms of decompression. The excessive pres­ sure in these areas may result from bony or soft-tissue ar­ chitecture, and decompression involves the release or re­ moval of these soft tissues and shaving or removal of bony sources of pressure. Rehabilitation after a decompression is guided by the primary pathology and the status of the tissues decom­ pressed, which depends on the amount and duration of

224

Therapeutic Exercise Moving Toward Function

compression and on the type of tissue compressed. For ex­ ample , if excessive pressure on a nerve has caused neuro­ lOgic changes, rehabilitation focuses on recovery of nerve function. If pressure has caused poor muscle function (e.g., rotator cuff), rehabilitation focuses on recovery of muscle function. As rehabilitation progresses, avoid using activities or positions that may excessively compress the tissue just decompressed.

Soft-Tissue Stabilization and Realignment Procedures Soft-tissue stabilization procedures are performed in the case of jOint instability resulting fro m capsular laxity. This proceJure is performed most frequently to correct an un­ stable shoulder and may be combined with other stabiliza­ tion procedures (e.g. , bony stabilization). A variety of sur­ gical techniques can stabilize a jOint with capsular laxity. Likewise , soft-tissue realignment procedures are per­ formed to redirect the pull of soft tissues that mayor may not be the result of instability. For example, proximal patel­ lar realignment is used to enhance the effective pull of the vastus medialis obliques on the patella. Regardless of the procedure , the fixation usually is soft tissue to soft tissue , vvithout bony stability. Because of the lack of ligid fixation and length of time necessary for soft tissue to heal, the loads placed on the re­ pair site are controlled for some time after stabilization. For example, when stabilizing the shoulder for anterior in­ ferior glenohumeral instability, external rotation is limited for a short time after surgelY to allow the anterior capsule to heal. Because the repaired tissue is noncontractile, mus­ cle activation is usu ally allowed early in rehabilitation, as long as ROM precautions are considered. As rehabilitation progresses into the range that stresses the repaired tissue , be alert for signs of progressive loosening of the repair, such as complaints of slipping or instability. Mobility re­ covery should be full, without the return of instability symptoms.

Meniscal and Labral Repairs The meniscus of the knee and the labrum of the shoulder are two common sites of fibrocartilage repair. Tears of the glenoid labrum are more difficult to identify, and repair techniques lag behind those for the menisci. Labral tears are often a diagnosis of exclusion, after other types of in­ juries have been ruled out. They tend to be less symp­ tomatic because of the non-weight-bearing nature of the joint; therefore, surgery for repair is less common. When repairs are performed, they are often in the superior aspect of the joint, where the superior labrum and long head of the biceps attachment meet. Repair of tom menisci of the knee is commonly performed alone or in combination with other procedures such as ACL reconstruction. In the knee in particular, the repair is of a soft tissue with an inferior blood supply. Healing may be enhanced by associated pro­ cedures to increase the blood supply to the area. Important issues during rehabilitation include under­ standing the loads placed on the repair when the jOint is in a variety of positions. These positions should be avoided in the early stages when the repair is still fragile. For example, full overhead positions may be avoided early after labral re­

pairs in the superior zone. Full knee flexion in weight bear­ ing is limited for several weeks after meniscal repair, be­ cause this position places high loads on the meniscus. Re­ turn to activities such as impact loading, jogging, deep knee flexion, and pivoting should be approached cautiously, par­ ticularly in the early postoperative phase. Communicate with the surgeon regarding the location and extent of tissue repair. Th e type, location, and extent of tear provide important information about the rehabilitation protocol. At the knee, the margins of a longitudinal tear will be approximated with weight bearing, whereas the margin of a radial tear will be disrupted. Tears located in the pe­ lipheral one third , or vascular zone, have a better prognosi than those in the central one third, or avascular zone. HO\\,­ ever, surgical techniques have improved and meniscus tear in the avascular zone are repairable vvith good success.26 Meniscal allografts are being used in situations in which patients have undergone a complete meniscectomy, and are generally young and active, have a varus alignment, and tibiofemoral arthrosis. The goal is to perform the surgen early before extensive articular cartilage damage occurs. T' In fact, meniscal allograft transplantation is co ntraindi­ cated in patients with Significant arthrosis .

Bony Procedures Rehabilitation is often necessary after bony surgical proce­ dures to restore motion at adjacent joints, strengtl1en relatt>G soft tissues, and increase general endurance. Some interven­ tions have a direct effect on the bone and can enhance th healing process. The specific procedure, tissue damage, an patient's general health, balanced vv'ith the optimalloadin_ and SAID plinciples, guide intervention choices.

Debridement/Abrasion Chondroplasty Surgical procedures to remove loose fragments and oth mechanical or chemical irritants may provide some tempo­ rary relief to jOint pain in the degenerative joint. Simpl arthroscopic irrigation along with removal of loose bodi or other tissue fragments can produce improvement i many patients. Patients with good joint space, a short dura­ tion of symptoms, good alignment, and a stable knee m
Chapter 11. Soft-Tissue Injury and Postoperative Treatment

lear­ . be­ Re­ knee par­

abon ·ntof ation Twill rgins ~ p ­ nosts

-lQ\.\ ­

tar ~6

'hich . and '. nd

I1!ery o

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LJrs. - '

Linw­

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the mechanical properties of the replacement fibrocarti­ larre are significantly inferior to the original tissue. Rehabilitation after abrasion chondroplasty varies with the extent and location of the articular cartilage lesion. Large lesions on weight-bearing surfaces have a poorer rognosis than small lesions on non-weight-bearing sur­ ces. The joint with extra loads from excessive body weight, alalignment, or instability is likely to require a longer re­ bilitation course, with a greater likelihood of overloading :he new fibrocartilage. These individuals may have weight­ aring and exercise limitations for up to 8 weeks after rgery. Restoration of motion and strength as qUickly as ssible without disrupting the healing process provides the 5t opportunity for healing of this fresh injury (Fig. 11-16).

225

days. The patient undergoes a second surgical procedure in which a periosteal flap is harvested from a different site and sutured over the lesion , leaving a small opening. The cul­ tured chondrocytes are injected under the periosteal flap and the flap sealed with fibrin glue. Rehabilitation after autologous chondrocytes implanta­ tion is similar to that of other articular cartilage procedures. Full unloaded PROM is allowed early on, and the patient ,viII be non-weight bearing for the first 2 to 4 weeks, ,vith progreSSive weight bearing over the next 2 to 4 weeks. Iso­ metrics that do not engage the lesion are initiated and pro­ gressed to short-arc isotonic exercises, again , in positions that do not engage the lesion. Return to activity is any­ where from 6 to 12 months depending upon the lesion , pa­ tient factors, and type of activity.

steochondral Autograft Transplantation (OA T) ew surgical techniques attempt to restore and preserve .rticular cartilage. The OAT procedure, or mosaicplasty, "'"ansfers articular cartilage tissue from areas of low loading ;) reas of high loading. This procedure is performed most ften at the knee, where bone plugs are removed from hlea and intercondylar notch and placed on the articu­ urface lesions. Problems with this procedure are re­ ed to limitations in the graft size, obtaining good con­ .:roity of the graft and adjacent articular cartilage, and graft tion. Rehabilitation after an OAT procedure will vary 'th the size and location of the lesion and fixation stabil­ . The general rules about rehabilitating any articular car­ rre lesion apply here, and are modified based on individ­ patient factors. General gUidelines allow unloaded RO M as tolerated, whereas AROM varies depending on size, location, and fixation of the lesion. Patients are , nerally non-weight bearing for 3 to 4 weeks, followed by gradual progression of weight bearing over the next 3 to -eeks. Muscle performance activities include isometric tractions in pain-free ranges and short-arc resistive ex­ ises in ranges that do not engage the lesion after 3 to 4 ks after surgery.

tologous Chondrocyte Implantation e autologous chondrocytes implantation procedure is d in cases in which the lesion is up to 15 cm in diame­ . The lesion is generally of the femoral condyles or x-hlea. Prerequisites include good alignment, ligamen­ stability, and good ROM .28 In this procedure, two to "ee full-thickness samples of healthy articular cartilage harvested from the patient and cultivated from 11 to 21

URE 11-16. Using activities in a gravity-minimized environment can _"ressively load the lower extremity.

Open Reduction and Internal Fixation ORIF of a fracture is commonly performed when closed reduction is impossible or when fracture healing would be protracted if treated without fixation. Goals of ORIF are to stabilize a fracture while allmving early motion and activity, to decrease the chances of nonunion, and to decrease the effects of immobilization on the limb. Surgical fi.xation may use plates, screws, wires, or other forms of hardware to sta­ bilize the bone and fragments. In most Situations, the hard­ ware is left in permanently, although it may be removed if superficial location causes discomfort. Rehabilitation after ORIF is directed at any impair­ ments or functional limitations associated with the injury. Any force great enough to fracture a bone is likely to have produced some local soft tissue damage, which must be treated as well. Restrictions (e.g. , weight bearing, motion) are specific to the location and severity of the fracture and to the extent of associated soft-tissue injury. In general, surgical fixation stabilizes the fracture, and treatment fo­ cuses on associated soft-tissue damage and restoration of full function.

Fusion Fusion is the operative formation of an ankylOS iS or arthrodesis. 29 Fusions are performed most commonly in the spine, although some joints in the extremities are fused . Spinal fusions are used to treat problems such as instability, facet pain, and disk disease. Glenohumeral joints are fused in cases of severe pain, espeCially in the presence of neuro­ logic injury (e.g. , axillary nerve, long thoracic nerve) that severely restricts functional use of the arm. Knee jOints are fused when severe arthritis produces pain and disability and total joint replacement is not a treatment option. Fusions about the ankle are used to treat hind foot pain and arthritis. The postoperative rehabilitation program must consider the mechanical changes that occur as a result of the fusion. Because mobility is limited at a jOint (or series of joints in the spine), adjacent joints compensate to restore the presurgical mobility. How effectively these joints compen­ sate or overcompensate has a profound impact on the re­ sult. If the hip and ankle are unable to adequately com­ pensate for a fused knee , the patient has difficulty getting in and out of a car, a chair, and on and off the floor. Because the spine is a series of joints, adjacent segments can often compensate for fusion at one or more levels . However, ad­

226

Therapeutic Exercise: Moving Toward Function

jacent segments may become hypermobile in response to the fusion, creating pain above or helow the fusion . An im­ portant aspect of postoperative rehabilitation is focused on the adjacent joints and procedures necessary to ensure the long-term health of these joints. The muscles must be re­ trained to function in a new movement pattern.

Osteotomy Osteotomy, the surgical cutting of a bone, is a procedure performed to correct bony alignment. This procedure is performed most commonly at the knee to correct excessive genu varus or valgus. Excessive varus or valgus places in­ creased loads on the medial and lateral compartments of the knee, respectively. This may result in degeneration of the articular cartilage in that compartment. The purpose of performing an osteotomy is to redistribute weight ofT the compromised compaliment and to disperse the load over a larger area. To correct for excessive varus, a high tibial os­ teotomy (or valgus osteotomy) is performed at the proximal tibia. To correct for excessive valgus, a distal femoral os­ teotomy is performed. These procedures remove a wedge of bone from the respective site, and the "fracture" is fix­ ated with hardware. RehabJitation focuses on the precipitating issues that led to surgery (usually degenerative joint disease) and the preservation or restoration of motion and strength. An im­ portant consideration is the change in loading patterns on the articular cartilage. One compmiment that has been ex­ ceSSively loaded wJl have decreased loading; the other com­ partment that has been underloaded will have increased loading. How well a compartment adapts to the increased load depends on many factors. The health of the miiclllar cartilage in this compartment is probably the most important factor. Weight bearing and weight-bearing activities may have to be restricted until the joint can adapt to this change.

MANAGEMENT OF IMPAIRMENTS ASSOCIATED WITH JOINT ARTHROPLASTY Joint replacement surgery is performed to remedy signifi­ cant degenerative jOint disease after other conservative or surgical measures have been exhausted. Joint replacement is performed in many jOints, including the hip, knee, shoul­ der, elbow, wrist, and hand. The chief goal of joint arthro­ plasty is pain relief. Generally, the clinician cannot expect in creased joint motion , strength, or function other than that resulting from a decrease in a patient's pain. JOint replacement is categOrized by component design (i.e., constrained, ul1constrained, or semiconstrained), fixa­ tion (i.e. , cement or cementless), and materials (i.e. , cobalt­ chrome alloy, titanium alloy, or high-density polyethylene). A constrained design allows motion in only one pl'ane; an unco l/strained design allows motion in any axis. A semicon­ strained allows full motion in one plane and some motion in other planes. Fixation is achieved with cement or with some type of biologic fixative. Biologic fixation may include a porous coat or similar surfaces that allow bony ingrowth into open areas on the surface. Recovery of components with this type of fixation is difficult in the patient in need of

revision alihroplasty. Materials usually are a combination of rnetah and plastic. Rehabilitation issues are jOint- and prosthesis-specific. In general , restoration of motion, strength, and function and consideration of the underlying cause of the surger: constitute the rehahilitation framework. Consideratio n must also be given to the adjacent joints, which may b compromised by tlte same disease process and the exces­ sive loads placed on them in the perioperative peliod . Af­ ter recovery from the operation, the patient general ly feels much better than before the surgery, with less pain in the affected joint. Education regarding the long-term health of the joint replacement and the adjacent joints is a large com­ ponent of the patient care program.

KEY POINTS • The composition and structure of connective ti.ss u(" proVide information about each tissue's mechanica properties and function. • The unique viscoelastic characteristics of connective ti~ ­ sues are the result of their fluid and solid constituen· materials. • When connective tissues are loaded, the stress (i.e­ force per unit area relative to the strain) or change in til length per unit length prOVides information about till tissue's ability to withstand loads. • The viscoelastic properties of relaxation, creep, and h};>­ teresis are the phYSiologiC basis for changes seen wid stretching. • The stages of healing along with knowledge of the spe­ cific injury provide the clinician with gUidelines for in­ tervention selection throughout the episode of care. • Restoration of nonnal tissue relationships , optimal load­ ing, the SAID principle, and prevention of secondaJ" complications are broad rehabilitation principles th . guide treatment. • Acute soft-tissue injuries such as sprains, strains, an contusions necessitate early intervention to avoid sec· ondalY complications. • Management of tendon injuries and prognosis varies at · cording to the injury classification. • Interventions used in the treatment of bony or surgic: procedures should have a solid foundation in basic sc ­ ence and require an understanding of the anatomy ar kineSiology of the area.

CRITICAL THINKING QUESTIONS 1. Consider Case Study #2 in Unit 7, before her total 1m replacement surgery. Presu me she came to your c:linic_ years earlier in an attempt to delay surge ly. At that ti m her motion was decreased hv 15% . and her over; strength was decrc'ased by 20(70. Describe her exerci program. Provide the rationale for restoration of h joint motion and strength in the case of osteoarthritis the knee. 2. a. The patient in the first question is given a hom e ercise program to carry out for 2 weeks, after whic

Chapter 11: Soft-Tissue Injury and Postoperative Treatment

i

m­

u

i.e 1

tht>

~

r in-

load­

227

she returns to the clinic for reevaluation and pro­ gression, Explain to this patient how to differentiate the discomfort associated vvith some exercise from pain that may be related to harming her knee, b, The patient in the first question is given a home ex­ ercise program to carry out for :2 'weeks, after which she returns to the clinic for reevaluation and pro­ gression. Compared with her previous visit, her knee is more swollen and warm to the touch. She has lost ,5 degrees of knee extension and 10 degrees of knee fll'xion. Her gait is significantly impaired. What are your recommendations at this time? When should you see her again and why?

3. Why are repeated eccenbic muscle contractions associ­

ated with tendinitis?

4. If eccentric muscle contractions contribute to tendini­

tis, why are they used to treat tendinitis?

5. Consider Case Study #6 in Unit 7. How would your acute-phase mobility program differ if the patient a. Were generally hypermobile, demonstrating elbow hyperextension, knee recurvatum, and thumb to volar forearm? b. Were generally hypomobile, with a history of exces­ sive scar formation?

1. A patient comes to the clinic Monday morning with acute Achilles tendinitis after a weekend tennis tournament. a. Instruct your patient in a home exercise program, including dosage, to be performed until he re­ turns in 4 days. b. Explain to your patient about adjunctive agents and give any special instructions. :') The patient returns 4 days later and is in a subacute phase of injury. a. Demonstrate five stretching techniques for the Achilles tendon. b. Instruct the patient in a home stretching pro­ gram, including dosage. c. Demonstrate three ways to strengthen this mus­ cle group, including dosage, using i. Concentric only

Isometric onlv

Eccentric oniv

:3. This patient has imp'roved with the exercise program and desires to return to basketball. Demonstrate the final phase of the rehabilitation program to prepare the patient for this activity. 4. Instruct each of the follmving patients in five exer­ cises to increase k-nee f1exion mobility: a. A 19-year-old student:2 weeks after a grade II me­ dial collateral ligament sprain of the right knee with a 0- to 90-degree ROM b. A 75-year-old woman who is unable to get up and down off the Hoor :2 weeks after a total right knee replacement with a 0- to 60-degree ROM II.

Ill.

l~

th

, an I ec­

EFERENCES 1 Andersson GB. Epidemiological features of chronic low-back

rgi

,C

\' an

Ikn

linie ::

, tim

I\·era!.

erci to of h r ritis 0

ne ex­

\\'hid

pain. Lancet 1999;354581-585. " Frank C, Woo S-L, Andriacchi T, et al. Normal ligament: Structure, function and composition. In: vVoo SL-Y, Buck­ walter JA, eds. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1988:45-10l. :3, Riegger-Krugh C. Bone. In: Malone TR, McPoil T, Nitz AJ, eds. Orthopaedic and Sports Physical Therapy. 3rd ed. St. Louis: Mosby, 1997. -I. Walter JB. Principles of Disease. 2nd ed, Philadelphia: WB Saunders, 1982. J. Walker JM. Cartilage of human joints and related struc­ tures. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Ath­ letic Injuries and Rehabilitation. Philadelphia: WB Saun­ ders, 1996, 6, Woo SL-Y, Maynard J, Butler D, Lyon R, et al. Ligament, tendon and joint capsule insertions into hone. In: Woo SL-Y, Buckwalter J A, eds. Injury and Repair of the Musculoskeletal Soft Tissues, Park Ridge, IL: American Academy of Or­ thopaedic Surgeons, 1988:133-167. 7, O'Brien M. Functional anatomy and phYSiology of tendons. Clin Sports Med 1992;11:.505-520.

8, LOitz-Ramage B, Zernicke RF, Bone biology and mechanics, In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic In­ juries and Rehahilitation, Philadelphia: WB Saunders, 1996. 9. Curwin S, Stanish WD. Tendinitis: Its Etiology and Treat­ ment. Lexington, MA: DC Heath, 1984, 10. Burstein AH, Wright TM, Fundamentals of Orthopaedic Biomechanics. Baltimore: Williams & \,Vilkins, 1994. 11, English T, Wheeler ME, Hettinga DL. Inf1ammatory re­ sponse of synovial joint structures, In: Malone TR, McPoil T, Nitz AJ, eds. Orthopaedic and Sports Physical Therapy. 3rd ed, St. Louis: Mosby, 1997, 12, Leadbetter \VB, An introduction to sports-induced soft-tis­ sue inflammation. In: LeadbettC'r WB, Buckwalter lA, Gor­ don SL, eds. Sports-Induced Iuflammation. Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1990:3-24, 13. Andriaacchi T, Sabiston P, DeHaven K, et al. Ligament: in­ jury and repair, In: Woo SL-Y, Buckwalter JA, eds, Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge IL: American Academy of Orthopaedic Surgeons, 1988:103-132, 14. Malone TR, Garrett WE, Zadwzcwski JE, Muscle: deforma­ tion, injUly, repair. In: Zachazewski JE, Magee DJ, Quillen WS, eds, Athletic Injuries and Rehabilitation, Philadelphia: WB Saunders, 1997:71-91. 15. Leadbetter WB. Cell-matrix response in tendon injury. Clin SPOJts Med 1992;11:533-57S.

228

Therapeutic Exercise: Moving Toward Function

16. Elliot DH. Structure and function of mammalian tendon. BioI Rev 1965;40:392-421. 17. Walker LB, Harris EH , Benedict JV. Stress-strain relation­ ships in human plantaris tendon: a preliminary study. Med Elect BioI Eng 1964;2:31-38. 18. Zernicke RF, Garhammer J, Jobe F\,y. Human patellar ten­ don rupture. J Bone JOint Surg Am 1977;59:179-183. 19. Nicholas JA. Clinical observations on sports-induced soft­ tissue injuries. In : Leadbetter WB, Buckwalter JA, Gordon SL, eds. Sports-Induced Inflammation. Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1990: 129-148. 20. Clancy WJ. Tendon trauma and overuse injuries. In : Lead­ better WB, Buckwalter JA, Gordon SL, eds. Sports-Induced Inflammation. Park Ridge, IL: American Academy of Or­ thopaedic Surgeons, 1990:609-618. 21. Buckwalter J, Rosenberg L, Coutts R, et al. Articular carti­ lage: injury and repair. In: Woo SL-Y, Buckwalter JA, eds. In­ jury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1988:465-482. 22. Arnoczky S, Adams M, DeHaven K, et al. Meniscus . In: Woo SL-Y, Buckwalter JA, eds. Injury and Repair of the Muscu­

loskeletal Soft Tissues. Park Ridge , IL: American Academy of Orthopaedic Surgeons, 1988:465-482. 23. American Academy of Orthopedic Surgeons. Athletic Train­ ing and Sports Medicine. Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1991. 24. Salter RB . Textbook of Disorders and Injuries of the M uscu­ loskeletal System. 2nd ed. Baltimore: Williams & Wilkins, 1983. 25. Insall IN. Surgery of the Knee. New York: Churchill Living­ stone , 1984. Rubman MH, Noyes FR, Barber-Westin SO. Arthroscopic repair of meniscal tears that extend into the avascular zone. Am JSports Med 1998;26:87-95. 26. Noyes FR , Barber-Westin SO. Arthroscopic repair of menis­ cus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy 2000;16:822-829. 27. Stollsteimer GT, Shelton WR, Dukes A, et al. Meniscal allo­ graft transplantation: A 1- to 5-yea r follow-up of 22 patients. Arthroscopy 2000;16:343-347. 28. Gillogly SO, VOight M, Blackburn T. Treatment of articu­ lar cartilage defects of the Imee with autologous chondrocyte. implantation. JOrthop Sports Phys Ther 1998;28:241-251. 29. Dorland's Illustrated Medical DictionalY, 26th ed. Philadel­ phia: WB Saunders, 1981.

L chapter 12

Therapeutic Exercise for Arthritis KIMBERLY BENI\JETT AND BASIA BELZA

Review of Pertinent Anatomy and Kinesiology Pathology Osteoarthritis Rheumatoid Arthritis

Exercise Recommendations for Prevention and Wellness Therapeutic Exercise Intervention for Common 'TIpairments Pain

Impaired Mobility and Range of Motion

Impaired Muscle Performance

Impaired Aerobic Capacity

Special Considerations in Exercise Prescription and \1odification Ligament or Joint Laxity Precautions Restoring Muscle Balance Normalizing Specific Joint Movement Patterns Exercise Modifications in Response to Pain or Fatigue Pacing Treatment ~atient

Education

lore than 43 million people in the United States have rthritis ,1,2 with the expectation that the number \.vill in­ _--ease to 60 million by 2020. 3 Nearly one third of adult lericans have signs or symptoms of arthritis 4 Of all the ronic conditions causing disability in the United States, -rthritis is most prevalent. The economic impact of arthritis ignificant. Total costs (including medical care and lost ges) for arthritis represent 38% of the cost of all muscu­ keletal conditions, \.vith lost wages representing 74% of . COSt. 5 ,6 Hidden in these numbers are the personal ef­ ts of rheumatic diseases on individuals and their families d employers. Pain and decreased ability to fu nction influ­ nee parenting and spousal roles, community involvement, d work performance. These issues affect self-image, es­ eem, and the quality of life. Declines in muscle strength, ardiovascular endurance, range of motion (ROM), and exibility are well documented in children and adults with .rthritis.'-15 These factors underlie the extent of physical tness in an individual , and physical fitness can be a critical dicator of the capacity to function. l6 Previous treatment strategies, espeCially for the treat­ ent of inflamed joints, favored rest. However, more re­ e ntly, studies suggest that patients with rheumatic condi­

tions who participate in regular exercise programs improve flexibility, strength, cardiovascular status, and physical functioning with
REVIEW OF PERTINENT ANATOMY AND KINESIOLOGY SynOvial joints are the primary sites of althritis. Their dys­ function can affect the ability of the entire organism to function. In a normal synovial joint (Fig. 12-1 ), ligaments, muscles, tendons, capsule, cartilage, and subchondral and trabecular bone provide stabilizing, shock-transmitting, and shock-absorbing structures to cope \.vith the consider­ able stress on the joint that occurs with movement and weight bearing. Fo~ example, in running, the tibiofemoral jOint experiences forces 2.5 to 3 times body weight. 25 In deep knee bends, the patellofemoral joint experiences forces 10 times body weight. 26 StabiliZing forces are prOvided by balanced alignment of soft tissue, including muscle, ligament, and tendon around the joint; by the congruity of the jOint surfaces in thei r con­ tact "vith one another; and by the surface tension prOvided by synovial fluid in the joint. Another protective component is the shock-absorbing and shock-transmitting properties of articular cartilage and of subchondral and trabecular bone.

229

230

Therapeutic Exercise Moving Toward Function Periosteum Subchondral bone plate Arti cul ar

cartilage

Muscle Joint capsule

Synovium Tendon Ligament

FIGURE 12-1 . Normal joint function depends on the integrity of all the joint structures. IAdapted from AHPA Arthriti s Teaching Slide Collection. American College of Rheumatology, Atl anta, GAl

The neuromuscular system plays an important role as well. Stretching slightly stretched muscle absorbs energy and sp reads force temporally and spatially across the articular surface (i.e. , compare jumping ofT a height with locked knees and with flexible, slightly bent knees). This mecha­ nism reqUires an inta<;:t neuromuscular reflex arc and good jOint proprioception. 21

tionallimitations, and disabilities (see Chapter 1). This ap­ proach necessitates an understanding of the pathology and its relation to broader functional effects. For osteoarthritis and rheumatoid arthritis, treatment plans should be designed based on a knowledge of the pathologic processes of the diseases. This knowledge guides the choice of interventions, observation of precau­ tions, and formulation of rational goals. Understanding the relation of this pathology to broader functional effects h1­ cilitates design of a program that can address the deficits, Arthritis literally means joint inflammation, but there are approximately 100 different forms of arthritis (inflam­ matory and noninflammatory, affecting not only joints but soft tissue). Osteoarthritis and rheum atoid arthritis , two of the most common forms of arthritis , are discussecl in thi chapter. Because these two diseases have distinctly differ­ ent pathologic mechanisms, some of the exercise design considerations vary, Osteoarthritis ~epresents a type of nonsys temic, mostl) noninflammatory, localized pathology, Rheumatoid arthli­ tis is a systemic, inflammatory disease that usually involve multiple joints and often affects organ systems, Under­ standing the basic processes involved in these forms of arthritis can help the physical therapist in designing appro­ priate treatm ent plans. Because the same principles of de­ generative and inflammatory processes are encountered in the less common forms of arthritis , similar thought pro­ cesses can be applied to developing exercise approaches for patients with these diseases. Effects of the two diseases on jOints and related structures are listed in Table 12-1.

PATHOLOGY

Osteoarthritis

An impOliant principle of therapeutic intervention is that treatment should take into consideration the underlying causes of the disease and the resul ting impairments , func-

Osteoalihritis is characterized by the breakdown of artic­ ular cartilage under load and by bony hypertrophy leadin_ to jOint margin bone spur formation (i.e" spurring), It C'cU:

EtiologV

STRUCTURE

FUNCTION

EFFECTS OF OSTEOARTHRITIS

EFFECTS OF RHEUMATOID ARTHRITIS

Caltilage

Shock absorption, joint congmence Secretes synOVial fluid for nutrition of cartilage, lubricatio n, and stability Stability, rein force capsule and limit movement, guide movement Reinforce joint capsule, reflex jOint protection, move joints

Thickl'ning to softening to thinning to loss Secondal), involvement occaSionally

Erosion of caltilage

Synovium

Liguments

Muscles

Bone

Extraarticular system

Stmctural support

Abnormal joint alignment stresses Immobility shortens pain , causes guarding and re flex inhibition , leading to weakness Subchondral bone remodeling changes shock-absorbing properties , joint margin spUrlin g leads to bony blockade and pain Increased energy expenditure from abnormal movement patterns

Microvascular lirung cells activated by inflammatory process, pannus formation Erosion weakens

Joint deformity interferes \vith peak torqu generation; immobility shortens; myositi weakens; pain and effusion cause guardir._ and reflex inhibition le
Myositis, anemia, sleep dismption , fatigu e. increased energy expenditure fr0111 abnorma.l movement patte rn s

Chapter 12 Therapeutic Exercise for Arthritis a -

and

caused by excessive loading of normal cartilage (i.e.,

e large or many small forces ), or the application of rea­

nable loads to abnormal cartilage. Ahnormal caItilage

y be of genetically poor quality or may result from the :xly's attempt to repair normal cartilage that has been ...1Jl1aged. 26 steoarthritis can be idiopathic, but there are several disposing factors, including obesity, trauma, hypermo­ 'ty from ligament laxity or damage, overuse, infection, lammation (including rheumatoid arthritis), and genetic 'tors. 26 ,28 The view that osteoarthritis is the result of pas­ 'e wearing of cartilage with time is being replaced with an ~reased understanding of the complexity of the regula­ : ' events controlling cartilage synthesis at a molecular 'el. The interaction of biomechanical and molecular ts to produce osteoarthritic changes is the subject of ~o ing research. 29 Incidence is highly correlated with ag­ _: the disease affects about 50% of those older than 65 J 0% of those older than 75 26

flical Manifestations

p

teoarthritis typically affects weight-bearing jOints, luding hips, knees, spine, and me tatarsophalangeal llts as well as the first metacarpophalangeal, first car­ me tacarpal, proximal interphalangeal joints (i.e. , chard's nodes ), and distal interphalangeal joints (i.e., berden's nodes). The disease is usually unilateral, often cling only one joint compartment, and has no direct -em ic effects. The pathologic changes of osteoarthritis reflect damage ill articular cartilage and the joint's reaction to that age . Cartilage damage is accompanied by decreased k-transmitting and shock-absorbing capacities of sub­ ndral and trabecular bone, which diminish the joint's 'ty to withstand loading forces. This condition further e es the articular cartilage, resulting in cartilage failure chondrocyte death. Tissue damage leads to proteolytic z\,me release and low-grade synovial inflammation. If ''{mic, inflammation can lead to fibrosis of the joint cap- . . limiting movement and adding to joint pathology. Hy­ ~ophic bone formation at joint margins (i.e., marginal rring) , often asymmetrically within the joint, leads to t deformity and pain (Fig. 12-2) . Ex traarticular soft-tissue structures are affected by ~nmetric joint deformity. Uneven pull on muscles and _ m nts can lead to shortening of stmctures on one side lengthening on the other, further changing normal t alignment. The muscle length imhalances lead to -ngth changes and force couple imbalances, which can acre the joint by altering active joint mechanics. .\ com mon example of this imbalance is seen in the os­ m h ritic knee. Lateral compartment cartilage loss results \'alg1'ls deformity of the knee, which stretches muscles ligaments mediaEy and shortens soft-tissue structures mlly. In addition to affecting alignment of the knee and zht bearing through the joint, the deformity changes the (·hanical advantage of medial and late ral muscl groups the stability of the jOint as stretched ligaments become JOint pain and swelling, together "vith splinting and ding, can lead to muscle disuse atrophy and loss of this rtant component of the shock-absorbing system

Early Stages of Disease

231

Late Stages of Disease

Degeneration of cartilage

Reactive

FIGURE 12-2.. Osteoarthritis starts with asymmetric cartilage loss, which leads to abnormal forces on the joint. Soft-tissue imbalance, joint malalignment, and bony hypertrophy can result. Inflammation is not the major component of the osteoarthritis process. (Adapted from AHPA Arthritis Teaching Slide Col lection. American College of Rheumatology, Atlanta. GAl

Although cartilage failure may be the primaly event in osteoarthritis, the disease can be regarded as failure of the entire joint complex. Cartilage failure disrupts the protec­ tive system of the joint, which compounds the effects of the initial cartilage damage in an ongoing process. The overall effect of the disease is rarely confined to the involved joint. 3o Minor lo cites studies of patients with osteoarthritis in the lower limb that showed joints adjacent to the af­ fected joint can have limitations in ROM and strength and that contralateral joints also can be affected in ROM and in functional use. In attempting to improve overall function, the exercise program should focus on impairments at the affected jOint and on secondary impairments and func­ tionallimitations at associated joints caused by the primary impairments and by inactivity.

Rheumatoid Arthritis Etiology Rheumatoid arthritis is a disease characterized by chronic, erosive synovitis. Immunologic events are triggered when synovial vascular lining cells are "activated," causing the transformation of svnovial membrane cells. These cells proliferate, resulting in thickening and inflammation of the synovial membrane. The new cedi layers become an inva­ sive, fibroblast-like cell mass called pannus , which is capa­ ble of eroding cartilage and bone. Synovial fluid accumu­ lates , and the joint swells, distending the capsule, pulling on its peliosteal attachment, and causing paill and potential rupture. Ligaments and muscles around the inflamed ioint are also subject to weakening alld potential rupture. .

Clinical Manifestations Loss of cartilage and hone integrity, soft-tissue disruption , and swelling lead to joint dysfunction as they do in os­ teoarthritis, but often the deformities are more severe, and

232

Therapeutic Exercise: Moving Toward Function

usually the entire Joint is affected rather than just one joint compartment (Fig. 12-3). Most commonly th e disease be­ gins insidiously with slow progression of symptoms over weeks to months. The number and severity of jOint in­ volvement is highly variable. As the disease becomes more chronic, contralateral joints are affected. The Joints of the hands, wrists, elbows , shoulders, feet , ankles , and cervical spine are most likely to be affected. The joint changes are usually reversible if the disease remits within 1 year and no structural deformity has occurred. Early intervention with an emphasis on education regarding jOint protection strate­ gies is important. Irreversible changes usually occur be­ tween the first and second year in more chronic forms of rheumatoid arthritis a1 Unlike osteoarthritis, rheumatoid arthritis has systemic effects such as fatigue , malaise, anemia, and sleep disorders (i.e. , pain and abnormal sleep cycles ). Organ systems, in­ cluding lungs and the cardiovascular system , may also be affected. Medications used to treat rheumatoid arthritis may contlibute to mYOSitis, gastrointestinal distress , and sleep disruption. These systemic effects should be consid­ ered in designing exercise programs for the patient "vi.th rheumatoid arthritis. 31 .32 Early Inflammatory Response Periarticular

osteoporosis

Inflammation

of synovium

Erosion

Increased

synovial

fluid

Natural History of Rheumatoid Arthritis The course of rheumatoid arthritis is variable and charac­ terized by exacerbations and remissions. The patient with rheumatoid arthritis may experience an exacerbation and remission with no furth er occurrence; exacerbations and remissions that gradually decrease over time; or a fast­ progreSSing disease state with few remissions. During an exacerbation, jOints are hot and swollen, morning stiffness is present and often lasts longer than 60 minutes, and sys­ temic effects may be more obvi.ous. This is considered an acute phase of the disease . As the pain, swelling, systemic effects, and morning stiffness decrease, the disease state is considered to be subacute. Between exacerbations, the dis­ ease state is considered chronic. The clinician needs to consider the phase of rheumatoid arthritis when designing an exercise program. However. prolonged inflammation during the acute stage contributes to difficulty in determining the phase of the disease. After prolonged inflammation, synovial membranes fibrose , de­ creaSing the vasculature such that jOints may not appear hot and swollen. These are referred to as burned-out joints. Although it may appear that the disease has gone into re­ mission (i.e., the subacute or chronic phase ) and has ceased to damage the joint, the joint destruction and systemic effects continue ,31 and the disease state remains active. Because symptoms wax and wane, the type and intensih of appropriate exercise also vary. The clinician must con­ sider the phase of rheumatoid althritis when designing an exercise program , and patients must be taught to modif, the program to match the phase of their illness. Various classifications have been useful in guiding exercise pre­ scription and in teaching patients to monitor aud appropli ­ ately modify their home programs and activities of daily Ii\­ ing (ADLs ). In the classification of functional statu proposed by the American College of Rheumatology, pa­ tients are divi.ded into four groups based on their ability t perform self-care, vocational activi.ties , and avocational ac-­ tivi.ties (Display 12-1). Most exercise program studies tha looked at exercise effects considered patients in functiona class I , II, and, occaSionally, III.

Post-Inflammatory Response

Degeneration

of cartilage

Periarticular osteoporosis Erosion of bone

,V..LlL--- Fibrosis

of synovium Ligament laxity

FIGURE 12-3. Early inflammatory joint response to rheumatoid arthritis includes pannus formation and erosion of carti lage and bone. Pos­ inflam matory irreversible joint changes include destruction of carti lage. bone. and soft tissues and fibrosis of the joint capsule. Damage affects joint alignment. stability. and range of motion . IAdapted from AHPA Arthritis Teach ing Slide Collection . American College of Rheumatology, Atla nta, GAl

DISPLAY 12-1

Classification of Functional Status of Patients With Rheumatoid Arthritis* Class I: Completely able to perform usual activities of daily living (self-care, vocational, and avocational)* Class II: Able to perform usual self-care and vocational activities, but limited in avocational activities Class 11/: Able to perform usual self-care activities, but limited in vocational and avocational activities Class IV: Limited in ability to perform usual self-care, vocational, and avocational activities • Usual self-care activities include dressing. feeding, bathing. grooming. and toileting. Avocationallrecreation, leisure) and vocationallwork, schOOl, homemaking) activities are patient desired and age- and sex-specifiC. From Hochberg MC. Chang RW, Dwosh I, et al. The American College of Rheumatology 1991 revised criteria for the classification of global functiona, status in rheumatoid arthritis. Arthritis Rheum 1992.35:498-502

Chapter 12: Therapeutic Exercise for Arthritis

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Another classification scheme that may guide the thera­ t in exercise program design examines the radiologic and .ilnical evidence of disease progression (Display 12-2). Ex­ rcise should be tailored to impairments at each stage. The ree of activity of the inflammatory event should espe­ ..illy be taken into account. It is also necessary to accom­ date or anticipate joint structural integrity problems so at the affected joint is not unduly stressed. A clearer pic­ Ie of the jOint pathology being addressed allows a safer , d more specific exercise design. D isplay 12-2 summarizes the effects of rheumatoid hritis on joint and extra-articular structures and func­ n . In addition to the local pathologic changes caused by lese diseases, the resulting pain and effusion trigger pro­ t'ctive and reflex spasm and immobility. Immobility . ds to further muscle atroRhy and loss of normal protec­ \. reflex responses. 2.5 .1, . 4 Immobility combined ,\lith n-weight bearing has been shmvn in animal models to Dntribute to cartilage breakdown, aggravating the condi­ 32 !lon ,33 Diminished joint complex integrity can also lead '0 movement pattems that are energy inefficient, limiting tivity. When a joint is abnormally aligned, muscles can no nger generate peak force , contributing to strength Jeficits. For these reasons and because of the effects of v-dose steroids on muscle 3s and the destructive effect of yositis in rheumatoid arthritis , muscles often atrophy sig­

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DISPLAY 12-2

Classification of Progression of Rheumatoid Arthritis Stage I. Early *1. No destructive changes on roentgenographic examination 2. Roentgenologic evidence of osteoporosis may be present Stage II. Moderate *1. Roentgenologic evidence of osteoporosis, with or without slight subchondral bone destruction; slight cartilage destruction may be present *2. No joint deformities, although limitation of joint mobility may be present 3. Adjacent muscle atrophy 4. Extra-articular soft-tissue lesions, such as nodules and tenosynovitis, may be present Stage III. Severe *1. Roentgenologic evidence of cartilage and bone destruction in addition to osteoporosis *2. Joint deformity, such as subluxation, ulnar deviation, or hyperextension, without fibrous or bony ankylosis 3. Extensive muscle atrophy 4. Extra-articular soft·tissue lesions, such as nodules and tenosynovitis, may be present Stage IV. Tenninal *1. Fibrous or bony ankylosis 2. Criteria of stage III • The criteria prefaced by an asterisk are those that must be present to permit classification of a patient in any particular stage or grade. From Schumaker HR Jr, ed. Primer on the Rheumatic Diseases. 10th ed. Atlanta: Arthritis Foundation. 1993>188-190.

233

nificantly. Type II fiber deficits occur inoyatients with rheumatoid arthriti s and osteoarthritis,16,." and isomet­ ric strength deficits have been regorted for these pa­ tients compared with controls, 12,19 .:)1,. S These impairments underlie the development of functional deficits as patients find it more difficult, painful, and less efficient to move . Exercise correctlypresclibed can address impairments and functional deficits.

EXERCISE RECOMMENDATIONS FOR PREVENTION AND WELLNESS There is no direct way to prevent rheumatoid arthritis. On the other hand, the literature suggests that certain factors including obesity, trauma, hype r mobility, and inflamma­ tion correlate with the development of osteoarthritis. 3 1,33 An appropriate exercise regimen aimed at maintaining ap­ propriate body weight, sustaining good postural alignment, developing good muscular strength and length, and cor­ rectly using joints in ADLs may be logical and desirable for joint protection. It has been demonstrated, for example , that a 10-pound weight loss was correlated ,vith a 50% de­ crease in the likelihood of knee osteoarthritis developing in women. 39 But to the extent that osteoarthritis has a genetic basis in some persons, and in some cases is correlated \-vith trauma, infection, and inflammation, exercise is not a guar­ antee against developing osteoarthritis. A major goal of treatment is to limit the progression of arthritic damage in the affected joint and in the joints showing adaptive changes to pathology at the primary joint. Intervention in­ cludes assessing and treating impairments and resulting functional losses in an attempt to avoid disablement.

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON IMPAIRMENTS In osteoarthritis, the goal of treatment is to decrease pain and any inflammation present, restore normal Joint flexibility, and reestablish balance between muscle length and strength around the joint. Any adaptive changes in joints proximal, distal , or contralateral to the affected joint and its surrounding structures must also be addressed. Per­ formance of basic functional tasks (e.g., sit to stand to sit, balance, timed walking, performance of household, voca­ tional and recreational activities ) and optimization of car­ diovascular fitness are the tasks of an exercise program de­ signed for a patient with osteoarthritis. For patients with rheumatoid arthritis, exercise program considerations are largely those outlined for osteoarthritis, but because of the variability of its course and because of the possible systemic involvement of the disease, careful monitoring by the physical therapist and the patient is nec­ essary, Patients must be taught to recognize symptom de­ velopment and the stage of the illness and to modify activ­ ity appropriately . The patient with arthlitis typically presents with pain , mobility impairment, imbalances in muscle length and movement patterns contributing to impaired muscle per­ formance, and cardiovascular endurance impairment.

234

Therapeutic Exercise Moving Toward Function

These factors should be evaluated bilaterally throughout the entire extremity joint chain and the trunk. It is equally important to look at functional movement patterns, includ­ ing gait, stairs, sit to stand to sit, and manipulation of tools and the environment when hands are involved. The exercise program must carry the effects of therapy beyond treatment of a localized joint problem to issues of function in an attempt to reverse the disablement process. In planning an exercise regimen, the impairment at the af­ fected joint and secondary impairments and functional lim­ itations must be addressed. Limitations may occur along a continuum of function, ranging from deficits in high-level athletic performance to an inability to perform self-care ac­ tivities. The aims of treatment are to decrease impairment while improving function. Functional improve ment includes per­ formance of ADLs and improved muscle and cardiovascu­ lar conditioning. Functional activities should be incorpo­ rated into the exercise routine to ensure that functional skills are mastered and carried into daily life in an attempt to reverse the disablement process. JOints should be pro­ tected during exercise and dUling functional activities.

Pain It is important to address and minimize pain during thera­

peutic intervention, because pain may lead to other impair­ ments. Joint pain and swelling together "vith splinting or guarding can inhibit peliarticular muscle function and lead to disuse atrophy, suppress the normal protective reflex re­ sponse, and cause further cartilage breakdown. 25 ..13 ,4o.41 These changes can lead to inefficient movement patterns, thereby decreaSing cardiovascular endurance and further limiting activity. The changes may also disrupt the soft­ tissue balance around the jOint, affecting its stability, align­ ment , and active motion. When a joint is abnormally aligned, muscles can no longer generate peak force, con­ tributing to strength deficits. The use of exercise to restore muscle balance and joint range for cardiovascular conditioning and to improve func­ tional status was associated with no increase in 16ain in some studies on the effect of exercise on arthlitis 17 · and with a decrease in pain in otbers. h .19 Patients often present with some degree of pain in the affected joints, which may pre­ vent exercise to the full extent possible or signal the pres­ ence of an inf1ammatory process . In either case, helping to control the pain dUling and after exercise can maximize pos­ sible exertion and help to control inflammatOl), processes. Tlwrmal modalities and electrical stimulation to control pain can be applied in conjunction with exercise in the clinic. When possible, the patient should be taught to apply them at home and be instructed about sources for these modalities. The patient should learn how to apply these treatments , because the chronic condition mandates a con­ tinued need for them, at least episodically. Heat applica­ tion to muscl es may be appropriate for the patient with rheumatoid arthritis before exercise. Ice applied to joints after exercise may also be appropriate for the patient \'lith osteoarthritis and for the patient with rheumatoid arthritis , if tolerated. Transcutaneous nerve stimulation may be use­ ful in conjunction with other modalities in managing pain.

Transcutaneous nerve stimulation should be used with cau­ tion with exercise, because it could mask symptoms of overexertion. It has been suggested that regular exercise be scheduled for late morning or early afternoon, especially for patients with rheumatoid arthritis "vith stiffness early in the day and fatigue later in the day42

Impaired Mobility and Range of Motion Osteoarthritis and rheumatoid arthritis often contribute to mobility impairment. ROM can be diminished by several factors: • Stiffness and shortening of muscles or tendons from spasm, guarding, or habitual postures • Capsular stiffness or contracture • Loss of joint congruity because of bony deformity A thorough musculoskeletal evaluation should indicate which of these factors are present. Cartilage maintenance depends in part on joint move­ ment 4 0 .41 Passive, active, and active assisted ROM exer­ cises are deSigned to ensure that affected jOints move through the full range available to them. Passive ROM is rarely necessary, except in cases of acute joint exacerbation and of severe muscle weakne and inf1ammation in rheumatoid arthritis. These patient probably are in functional status classes III and IV and of­ ten need to be at rest. To avoid contracture and to ensur, maintenance of full ROM , one or two repetitions of gentle passive movement through full available range each day i< reqUired. Repetitive passive ROM movements may in­ crease joint inflammation 42 For patients with rheumatoid arthritis who are in functional status classes I and II or wh have osteoarthritis, active ROM exercises should be per­ formed daily for affected joints. When weakness prevents the patient from attaining fuI ROM, assistance from another person or another limb m a~ be required to achieve full available range. Typically, pa­ tients start with 1 to 5 repetitions and progress to 10 ead day. When muscle shortening is the cause of range limita­ tions, passive stretch controlled by the patient or clinician may be provided as long as the joint is stable. Considera­ tions outlined in Chapter 7 regarding stabilization of prox­ imal and distal attachment sites to avoid streSSing .ioi n~ above and below the target muscle are especially importalI: in this population. In patients with rheumatoid 31illlitis fi whom the integrity of muscle, ten.don, or ligament is i question (especially in smaller joints), gentle active RO ~ exercises are preferable . As a safety measure, it is impor­ tant that patients be safely positioned while performing ac­ tive ROM exercises to ensure they do not fall, lose contr, of a limb, or apply more force than is intended (Fig. 12-1 Ligament laxity can occur in the cervical spine of pa­ tients with rheumatoid arthritis, and special consideration especially for stretching exercise, apply. A more detail deSCription of these precautions is given in the section Ligament or Joint Capsule La,ity Precautions. Patients who have rheumatoid arthritis with prolong­ morning stiffness or osteoarthritis with the brief stiffn e~ (less than 0.5 hour) common in the morning may benel~

Chapter 12 Therapeutic Exerci se for Arthritis

235

SELF-MANAGEMENT 12-1 Self-Mobilization

of the Shoulder Joint

Purpose:

To stretch the tight capsule and muscles around the shoulder, which are limiting movement

Position:

Sit on a straight-back chair as shown, with a folded towel padding your arm.

Movement

technique: let your arm hang down.

Grasp it just above the elbow.

Repeat a gentle, rhythmic series of downward

tugs, trying to keep your shoulder muscles

relaxed.

Dosage Repetitions _ _ _ _ _ _ _ __ Frequency _ _ _ _ _ _ _ __ GURE 12-4. The patient performs an active range of motion exercise 5t extension) with he r arm and wrist firmly stabilized on the table for -'ety.

m instruction in a ROM and stretching routine targeting stiff areas. This exercise can be done before retiring at ght, in the morning after a warm shower, or during both

riods .

I nstruction of the patient in self-mobilization tech­

ques as part of a home exercise program may be useful in -es of osteoarthlitis in which capsular restriction limits \- ment but no acute joint irritation or bony block exists ee Self-Management 12-1: Self-Mobilization of the _ oulder Joint)n Capsular stiffness in patients with e umatoid arthritis often results from jOint distention, and ..rther distractive forces on this inflamed and often weak­ ed tissue should be avoided . When stability is good, pas­ e application of graue 1 oscillations by a skilled therapist relax periarticular spasm be fore passive or active ROM ti\'ities lllay be beneficial (see Chapter 7).

paired Muscle Performance _ engthening of weakened muscles is an important part of ::> 'ning muscle balance around the joint. It can be done metrically, isotonically, or isokinetically (see Chapter 5). _ ch form of exercise has its place in rehabilitation of the :thritic joint, depending on the state of the jOint. Isoki­ tic equipment is most readily available in a clinical set­ a and is not likely to be practical for independent exer­ -e programs; it is not discuss ed here . Isometric exercise is t appropriate for acute exacerbations in osteoarthritis d rheumatoid arthritis , but precautions to avoid in­ -eased inflammation should be observed.

heumatoid Arthritis tients suffering acute exacerbations of rheumatoid !'thritis are primarily at rest, are pOSitioned to prevent de­ rmity, and may have one or two daily applications of pas-

sive ROM applied to large jOints and active ROM applied to small joints. In this stage, the prevention of muscle atro­ phy is important. Muscle strength declines 3% each week in a patient at rest. 43 Because it appears that isometric con­ tractions are associated with the least joint shear and intra­ articular pressure increases,44 this form of exercise is often prescribed in the acute and subacute phases of uisease. A single isometric contraction at two thirds of m
236

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 72-2 Brief Isometric

Exercise-Isometric Quadriceps Contraction

Purpose: To maintain or slightly increase strength of quadriceps muscles during acute knee joint inflammation when the joint is otherwise held at rest and to avoid increasing blood pressure when this is a consideration

Position: Sit with the ba ck supported or in a supine position; bend one knee and straighten the other.

Movement technique: Tighten the quadriceps of the straight leg. Hold 3 to 6 seconds. Rest 20 seconds.

Dosage Repetitions _ _ _ _ _ __ _ _ Frequency ____________

Q

~

FIGURE 12-5. Squeezing a wet towel is an example of an isometric exer­ cise that can strengthen an arthritic hand. The patient avoids movement into painful ranges or applying pain-causing pressure. Using warm water soothes Joints

Osteoarthritis In the osteoarthritic joint that is acutely painful, especially if there is significant inflammation and swelling, intra­ articular pressure and shear should be limited while pre­ . ven ting muscle atrophy. Isome tric contractions are often the exercise of choice in this stage (Fig. 12-5). The sam considerations apply as for the patient with rheumatoi d arthritis . Blief intense isometric exercises are appropliat when controlling blood pressure is an issue (see Selected Intervention 12-1: Hand-to-Knee Pushes ). For the patient with an acu te arthritic jOint, the home program should start with five repe titions of 6-second con­ tractions and assessment of the response . The patient can gradually increase repetitions to two se ts of 15 if symptoms are not exacerba ted. As acu te pain, swelli ng, and inflam­ mation resolve, movem en t into an isotonic routine is ap­ propriate.

SElECTED INTERVENTION 12 -1

Hand-to-Knee Pushes

See Case Study #11 Although this patient requires comprehe nsive intervention as described in other chapters, only one exercise ,,,ill be described. This exercise would be used in the early to intermediate phases of this patient's rehabilitation .

ACTIVITY: Standing hand-to-knee pushes PURPOSE: To increase the muscle performance of the hip

abductor (stance limb) and abdominal muscles

STAGE OF MOTOR CONTROL: Stability

MODE: Aq uatic em,i ronment

POSTURE: Standing on one leg with yom back against a wall, maintain ing a proper lumbar nlignment by pelVic tilting.

Bend the opposite knee and flex the hip to approximately 90

degrees.

MOVEMENT: With the hand opposite your flexed hip, press

isometJically against your kn ee. Maintain good spinal posture

throughout the exercise. Hold for a count of three. Retum to

the start position .

DOSAGE: Perform 5 to 7 repetitions with each knee, 2 to .3

sets to form fatigue.

EXPLANATION OF PURPOSE OF EXERCISE: Hip abductors on

the stance limb are trained to main tain transverse plane

peJ"ic position, while the abdom inaJs work to maintain pelviC

tilt agai nst the isometric exercise. This exercise is performed

in the upright position to enhance carryover to claily

activities, but is performed in a gravity-lessened environment

to reduce weight bearing on the Single-stance limb.

Chapter 12: Therapeutic Exerci se for Arthriti s

Dynamic Training

Dynamic muscle strengthening occurs when muscles ntract as thev shorten (i.e., concentric contractions) or n(>then (i.e., ~ccentric contractions ), resulting in move­ ent of the joint they cross. The advantages of dynamic ex­ rcise include increased movement of the joint, resulting in aintenance of capsular, ligament, and muscular flexibility d increased cartilage nutrition. Muscle strengthening oc­ M S in all the joint ranges achieved during the exercise and ults in a functionally more efficient muscle-joint com­ e. . JOint stress and intra-articular pressure are higher an with isometric exercise. 44 Dynamic training is there­ re appropriate for patients with chronic, subacute - eumatoid arthlitis of class I and II and for most patients i th osteoarthritis. In prescribing an exercise regimen, th e use of low resis­ ce and high repetition (to fatigue) in a motion arc that s not irritate the joint is preferred to high-load, low-rep­ 'tion routines in which increased joint loacling may cause 'n t inflammation. 42 The use of free weights, machines, resistance tubing, and y weight in closed chain activities can be appropriate .i~'s to apply resistance, but their limitations and advan­ ..,es must be considered in relation to the individual needs the patient. For example, resistance tubing is less likely get out of control and torque a joint out of alignment than free weight , but tubing resistance increases when it is retched, just as end-range movement is achieved and the rcising muscle is out of range of its mechanical advan­ ,..,e. Used correctly, machines offer the advantage of stabi­ ..in the body and exercised joint but rarely offer a low lough resistance to allow a very deconditioned patient to them. Closed chain exercises, which can range from . 'squats to single-leg squat reaches , offer movement pat­ ~ms that are the basis of function . Closed chain exercise \' also be introduced through functional activities such as .Jking, stair climbing, sit to stand, bending, and squatting. elusion of these activities in the strengthening routine \ides the clinician with an opportunity to confront safety ues involving balance and body mechan ics while ad­ ressing daily activities. Bracing, assistive devices, and ex­ -eise intensity can then be considered in this context as U. The choice of resistance modality depends on the pa­ -nt's presentation and the goal of treatmen t. In general, start with low enough weight to allow ap­ . ~ ximately three sets of 10 repetitions , with rest between ts and no resulting joint pain or swdling. The patient uld gradual1y progress to 30 repetitions without rest and i thout symptom exacerbation and then increase the resis­ ...nce and start the protocol again.

mpaired Aerobic Capacity ~

e effec ts of osteoarthritis and rheumatoid arthritis joint structure can lead to a loss of functional ove ment patterns and affect cardiovascular fitness. atients affected with either disease have decreased ardiovascular endurance, strength, walkin/? time , and to­ work capacity compared with controls l ,19,20.38 Addressing the cardiovascular endurance impairment of tients "vith arthritis has several benefits, including im­ "1

237

proved cardiorespiratOlY status and endurance,47 improved sense of well-heing. 17 .;ls and improved walk distance Jb Cardiovascular training should be a major part of therapy programs for patients with osteoarthritis and chronic func­ tional class I and II (possibly class III) rheumatoid arthritis. Cardiovascular programs for patien ts with osteoarthritis or rheumatoid arthritis of the lower extremity weight­ bearing joints need to be deSigned to minimize joints stress and shock, to encourage calcium uptake into bone , and to account for any balance difficulties. Several options are available, but adherence to a program is likely to be better when patients are able to pursue activities they find plea­ surable. 49 Accessibility and cost factors may also be impor­ tant for some people. Patient input into this aspect of the program design is important. Water is a good medium for exercise and has demon­ strated positive effects on ~i'~D,_ muscle strength, flexibil­ ity, depression, and anxiety. ,.,,0.01 Water provides a means of unloading jOints; in waist-Ieve~ water, the body weight is 50% of that on lanel and in neck-level water, the body weight is 10%.52. Water provides a medium that can resist or facilitate movement. Its benefits include: • Allowing performance of movement patterns that may not be possible on land because of balance or strength deficits • Providing muscle relaxation • Modifying pain perception through sensory stimu­ lation Aquatic therapy can facilitate social interaction in class settings or during family recreation. This aspect may be an added benefit for a population that may be socially lim­ ited from active partiCipation in physical activities (see Chapter 17). Cardiovascular work can come from walking in the shal­ low end of a pool, from the use of a foam noodle or float belt (e.g., an AquaJogger, which allows walking or running in deeper water), water exercise classes, or swimming (Fig. 12-6). Swimming is best done by skilled persons with good form so that abnormal movement patterns of the back, neck, and shoulders are prevented. Use of a snorkel and swim mask can be beneficial for patients with cervical spine disorders. Pool temperatures should be 82°F to 86°F for active ex­ ercise or 92°F to 98°F for pain relief and gentle ROM ac­ tivities:32 Local Althritis Foundation offices prOvide a list of regional pools that meet requirements regarding such factors as temperature and accessibility. The Arthritis Foundation also sponsors water exercise classes taught by certified instructors. These classes are available to arthritis patients for a nominal fee. Information about these pro­ grams is availahle on The Arthritis Foundation web page (www.arthritis.org). Stationary or recreational bicycling is another form of lOW-impact exercise that can improve strength and cardio­ vascular conditioning. Bicycling is more effective than brisk walking or swim ming for weight loss by obese patients needing to decrease the load on weight-bearing joints S3 In an article on the use of biking in arthritis programs, Namey cliscusses frame types , fit, and progression of exercise pro­ grams. 54 He suggests an upright position on the bike with

238

Therapeutic Exercise Moving Toward Function

FIGURE 12-6. Wa lking in shallow water with a foam noodle allows the patient to improve cardiovascular endurance while unweighting arthritic joints. The deeper the water, the more unweighting. handle oars that are flat or that curve upward. He suggests that the seat should be high enough to allow the rider to have only a very mild bend in the knee at the bottom of the pedal stroke. It is worthwhile to have the rider take the bike to a bike store so that frame adjustments can be made for correct length from trunk to liandlebars and for correct seat horizontal alignm ent (i.e. , angled to allow neutrallum­ bar alignment unless the patient has a posterior element problem requiring lumbar flexion). Initial outings should be on level, low-traffic streets or trails , and they should be well within the ability of the tider in terms of strength and endurance. A helmet is a must. A walking program can improve cardiovascular en­ durance. Several studi es have shown additional benefits of a walking program for patients with arthritis including re­ duction of pain, increase in flexjbility and strength, and im­ provemen t of function. 17 . I ~ Assessment for balance, safety, and current levels of fun ction combined vvith advice re­ garding suppOltive footwear, acceptable walking surfaces, and progreSSion of activities are necessary. Most neighbor­ hoods have high schoo] tracks that make an ideal exercise arena became of shock-absorbing level surfaces, easily cal­ ibrated distances, freedom from traffic hazards , and easy accessibility to a car to return home when the person be­ comes fatigued . Many shopping malls make tlh eir hallways available before 110urs for mall walking. This is ideal in bad weather or as a social opportunity, and it provides frequent opportunities for resting if necessary. In both settings, it is safer to use headphones for music or inspirational tapes thall it is in public tJ'affic areas where the patient must at­ tend to vehicular traffic . This form of exercise, however, is not vvithout risk, because falls are always possible,14 and an assistive device might he considered where balance is a problem. The use of treadmills, cross-country ski machines , or re­ bounders (i.e., mini trampolines ) offers options for low-

impact, weight-bearing activity. This equipment requires more agility, balance, and coordination than outdoor or mall walking. Whichever form of exercise is chosen, cross­ training can prevent boredom , stimulate different muscle groups , and alternate joint stress from session to session. To modify exertion during training sessions, patients should be taught to monitor their heart rates or reliably apply the Borg perceived exertion rating technique (see Chapter 6) ..55 They must also kno"v their training parame­ ters. Based on results of a study on aerobic exercise by pa­ tients with rheumatoid arthritis and osteoarthritis, Minor 1o suggested that disease-related cellular changes in the mus­ cle tissue of rheumatoid arthritis patients might contribute to low aerobic capacity. At similar preSCribed heart rates, a patient with rheumatoid arthritis might be working at a higher percentage of aerobic capacity than a patient vvith osteoarthritis. Both patients, however, might be working at a higher capacity than a younger or more fit individual. Mi­ nor, in the same article, pointed out that high-intensity ex­ ercise is neither required nor appropriate for effective con­ ditioning of deconditioned subjects. Another useful form of monitoring for patients with . rheumatic disease is the training index. Originally devel­ oped by Hagbert6 for determining minimal beneficial car­ diovascular fitness levels in cardiac patients, this tool was adapted by Burkhardt and Clark for use in patients witb rheumatic disease. In this technique, the pulse during ex­ ercise is divided by the maximum heart rate (i.e. , 220 mi­ nus the person 's age) and multiplied by the number of min­ utes of exercise to yield the training index for that session of exercise. At the end of a week of exercise, daily trainillg

Determining the Training Index to Track the Level of Exertion This is a simple way for you to keep track of how much exercise you are doing and whether you are (1) progressing in the amount you are doing and (2) whether you are gradually reaching a level of exertion that helps your heart and lungs stay healthy. Always pay attention to your symptoms. and modify exercise appropriately. Remember. every little bit you do adds up! Your training index (TI) goal is 42 to 90 each week. As time goes on. this number may rise. You and your therapist will discuss this. Max Heart Rate (MHR) = 220 minus your age. Intensity = pulse with exercise divided by MHR. Example: A 40-year-old woman who exercises 3 times each week: • Session 1: pulse = 100 for 10 minutes of exercise • Session 2: pulse = 110 for 15 minutes of exercise • Session 3: pulse = 110 for 20 minutes of exercise Her MHR = 220 - 40 = 180. • Session 1: 100/180 = 0.55; 0.55 X 10 min = 5.5 • Session 2: 110/180 = 0.61; 0.61 X 15 min = 9.2 • Session 3: 110/180 = 0.61; 0.61 X 20 min = 12.2 Her total TI = 26.9

Chapter 12 Therapeutic Exerc ise for Arthritis

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dex values are added to give the total for the week The om mended number of units is 42 to 90 per week to Jintain cardiovascular fitness, This is a useful monitoring I for trac\Qng the level of activity and to coach patients pacing exercise when needed (see Patient-Related In­ auction 12-1: Determining the Training Index to Track e Level of Exertion), The training index can have motivational value because can serve as a tangible sign of progress, Tracking the ..-:llning index may be especially motivating for patients o view aerobic exercise primarily as a means to weight • which is generally slower than most persons need for ·tive reinforcement. The training index may also be use­ ~ for motivating patients who are at a very low level of ac­ i ty, because they can see evidence of accumulated effort -er time in a quantified manner. Introducing the training dex in conjunction with a discussion of the benefits of robic exercise may be one more way to help the patient '"t'IDain motivated. \ Vhatever form of cardiovascular exercise is chosen, it uld be fun and satisfying for the patient. This is an im­ rtant link in maintaining or regaining function, because more closely training fits with patient goals, the more ective it is.

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PECIAL CONSIDERATIONS IN

ERCISE PRESCRIPTION AND

DDiFICATION

e impairments common to the patient with arthritis can e specific challenges in designing a safe, effective exer­ e routine. The possibility of joint inflammation, laxity, d deformity in rheumatoid and osteoarthritis and of sys­ e rnic effects in rheumatoid arthritis necessitate precau­ ns during exercise, Pain in both conditions can interfere i th function and therapeutic exercise, and it must be dealt i th , All positive findings from the initial evaluation should be onsidered when identifying the specific impairments to be dressed with exercise, These findings guide decisions out the prescription variables and necessary precautions d may suggest other options:

239

Muscle strengthening around these joints can increase sta­ bility without external support, but it is undesirable to load these joints in a way that aagravates the instability, F or ex­ ample, in medial or lateral collateral ligament LL\ity of the knee, dynamiC abductor or adductor strengthening without increased joint stress may be performed by placing the weight proximal to the knee joint rather than at the <w kle, Other protective approaches may include braCing of the knee during exercise or the use of a closed chain pattern if proximal muscles are adequate to stabilize the knee in good alignment and the loading forces are tolerated by the joint. In the small joints of the hand and foot, ligament la\ity caused by the erosive effects of rheumatoid arthritis or asymmetric joint deformity from cartilage destruction and marginal spurring resulting from osteoarthritis need to be considered as carefully in exercise prescription as they are in instructions for joint protection during ADLs, The use of ring and wrist splints and foot orthotics helps stabilize and align joints in neutral positions under stress (Fig, 12-7), Ligament integrity during ROM activities is a crucial safety issue for the upper cervical spine, Rheumatoid arthri­ tis can affect the ligaments of the upper cervical spine and middle spine segments (i,e" C5 and C6 areas) and can cause erosion of the dens 31 Any patient presenting with upper cervical spine instability or long tract signs should be re­ ferred to the phYSician for consideration of immobilization, Patients with a histOlY of rheumatoid arthritis who do not have objective signs of cervical instability should be warned that any cervical spine ROM exercise that results in upper extremity pain or parestheSia or dizziness should be d~scon­ tinued and that they should consult their physicians 51 Joiht protection can be approached through mecha­ nisms that unload the joint, attenuate shock, and maximize neutral Joint alignment. In addition to use of splints and braces, the follmving approaches may be implemented to decrease joint forces: • U nweighting joints through the use of assistive de­ vices (e,g., in hip osteoarthritis, use of a cane on the

• Protect joints during strengthening when ligament or capsular laxity exists, • Restore muscle balance when splinting, postural habit, or pain inhibition has selectively weakened muscle groups around one or more joints, • Normalize specific joint movement patterns, • Restore functional activities, • Treat pain during and after exercise, Take into account systemic variables such as fatigue lev­

I irritability of joints, and cardiovascular fitness, espe­ _ially in the patient with rheumatoid arthritis,

igament or Joint Laxity Precautions Joint instability caused by ligament laxity, muscle atrophy, or bony joint deformity can affect arthritic joints (see Figs, 1:2-2 and 12-3) and must be assessed during evaluation.

FIGURE 12·7. The patient uses a wrist brace to stabil ize joints during exercise,

240

Therapeutic Exercise: Moving Toward Function

contral ateral side to reduce joint reaction forces as much as 50 % )5h • Attenuating shock forces in weight-bearing joints (e.g., viscoelastic insoles decreased impact vibration by 42% in tibias of experimental subjects) 'i9 • Using a water medium 52 or unloading equipment in a clinic settingfiO Weight reduction is an important goal of exercise for pa­ tients "vith pathologic joints and is often a major goal of ex­ ercise programs. The Framingham studies indicated that obesity was a major predictor of the development of os­ teoarthritis 61 and that loss of as little as 10 pounds de­ creased the risk of developing knee osteoarthritis by 50% in women. 39 Reduction of jOint loading forces by weight loss decreases one of the stresses acting on the joint. Strength­ ening and recovery of jOint reflex mechanisms offers in­ creased joint protection , and normalizing joint alignment to as nearly neutral as possible distributes forces more sym­ metrically through the joints. 26 Choosing exe rcise equipment that does not stress joints (e.g. , cuff weights for upper extremity strengthening rather than free weights when there is wrist or finger jOint insta­ bility) , that can be oflow enough resistance to ensure con­ trol of the joint by the patient (i.e. , some machines do not start at a low enough weight setting for deconditioned indi­ viduals), and that encourages movement in phYSiologic pat­ terns (e.g., shoulder abductor strengthening should be done in shoulder external rotation) contributes to patient safety during exercise. By understanding the factors neces­ sary for good joint health , the therapist is able to design an

exercise program that protects the unhealthy jOint from forces it is unable to resist while helping the patient achieve muscle balance around the affected joint in an effort to im­ prove joint phYSiology.

Restoring Muscle Balance Disuse atrophy from guarding, pain inhibition , or postural habit can be addressed with ROM and strengthening exer­ cise for patients with osteoarthritis, chronic rheumatoid arthritis, and to some extent, subacute rheumatoid arthri­ tis . These conditions lead to muscle imbalances that can initially limit joint range and lead to joint contractures and muscle weakness affecting the entire limb and eventually affecting the whole body. The therapist must be aware of the muscle groups most typically affected by osteoarthritis and rheumatoid arthritis i\l speCific joints. Muscle shorten­ ing leads to weakness and joint malalignment. For exam­ ple, in hip osteoarthritis, hip flexor shortening and hip flexor and extensor weakness are common (Table 12-2). To modify the processes leading to muscle atrophy, a combination of medications (for pain and reduction of in­ flammation ), therapeutic modalities, posture and body me­ . chanics instruction , external bracing, and other support de­ vices are often necessary. For example, a patient with osteoarthritis of the hip may be requested to temporaril~' use a cane to unload the painful joint; instructed in stretch­ ing of hip flexors and strengthening of weak hip abductors and extensors; educated in correct rest postures and lower extremity alignment with walking; and required to undergo joint mobilization to restore capsular mobility.

Common Patterns of Joint Restriction in Osteoarthritis and Rheumatoid Arthritis JOINT

RESTRICTION

STRETCH

STRENGTHEN

Hip (ONRA)

• All planes, espeCially internal rotation and extension

• • • • • • • • • •

Flexors Extensors Internal and external rotators Tensor fascia lata Hamstrings (quadriceps ) Ankle dorsiflexors and plantarflexors Tarsal invertors and evertors Toe flexors and extensors Careful in deranged joints PROM , AAROM , AROM

• Abductors • Extensors

• • • • •

Careful in deranged joints PROM, AAROM, AROM Careful in deranged joints ROM wrist daily Stretch wrist flexors and extensors, forearm pronators and supinators, hand intrinsics

Knee (ONRA)

Ankle and foot (RA)

Shoulder

(RA )

Elbow

(RA)

Hand and wrist (RA)

Extension Ankle dorsiflexion MTP flexion PIP extension Abduction Flexion External and internal rotators • Extension lost early it

• • • • • •

• MCP extension • Wrist extension • First web space

• Quadriceps • Toe extensors and fl exor· • Tibialis posterior • Abductors • External rotation • Biceps • Triceps • Biceps • Triceps • Finger extensors • ""rist extensors

AARO\-I, adive ass isted range of motion; ARO\-I , active range of motion; MCP, metacarpophalangeal joint; MTP, metatarsophalangeal jOint; OA,

osteomthritis; PIP, proximal interphalangeal joint; PROM , passive range of motion; RA, rheu matoid arthritis; ROM, range of motion.

Data from Hicks JE . Exe rcise in patients with inflammatory arthritis and connective tissue disease. Rheum Dis C lin North Am 1990;16:845-870 and

from Moskowitz RW, Goldberg V,\1. Osteoarthritis : clinical features and treatment. In : Schumaker HR Jr, ed. Primer on the Rheumatic Diseases. 10th

ed. Atlanta: Arthlitis F oundation . 1993:188-190.

Chapter 12: Therapeutic Exercise for Arthritis

ormalizing Specific Joint ovement Patterns

m-

In ­

ne--­

de-

lid 10th

bservation of the functional use of affected joints (i.e., rim ary sites of disease and those vvith adaptive responses) dicates where abnormal movement pattC'rns exist. Ab­ rmal movement patterns can result from irreversible in t surface deformity or erosion of the capsule or liga­ ents. External support in the form of bracing or splinting ay be required. Abnormal movements also can be caused . muscle imbalance around joints earlier in the course of : ease or in jOints undergoing adaptive response to disease a distant joint. Assessment of muscle balance between llergist and agonist or antagonist muscles (e.g., in the hip tween iliotibial band and iliopsoas, in the shoulder be­ . n the deltoid and rotator cuff muscles) may be useful Jr designing a program aimed at restoring a muscle bal­ ce that allows the joint to function as close to the kinesi­ ogic standard as possible. This approach decreases the eIlergy required to function and contributes to healthier int alignment. Restoration of function in hand, foot, and knee joints can difficult in this context because of the relatively long \'er forces of muscles crossing these joints where ligament xity often is present. Intervention \vith exercise aimed at anction in these joints vvill often have to be done in con­ nction vvith bracing, foot orthotics and special shoes, med­ ettion, therapeutic modalities, and the use of adaptive ~uipment. Functional use of pens, kitchen utensils, levers, d buttons (including keyboards) in hand rehabilitation, or example, provides opportunities for a combination of trengthening and safe functional training (Fig. 12-8).

Exercise Modification in Response to Pain and Fatigue ~)'stemic

deconditioning, muscle and joint irritability, and possibly anemia characterizes patients vvith inflammatory arthritis. Evaluation of the patient's response to treatment allows appropriate and timely modification of the exercise prescription. Irreversible changes such as cartilage loss, hony deformity, or ligament laxity, together 'Nith systemic

241

symptoms such as fatigue or reduced cardiovascular capac­ ity, require modification of exercise to avoid aggravation of joint irritation or undue fatigue. In the pagt, exercises that increased pain for longer than 2 hours after exercise were modified, It is now accepted that any exercis e that in­ creases joint pain should be modified or avoided, 57 The pa­ tient should be taught to differentiate bet'l'/een muscle re­ action to exercise and joint pain, Undue fatigue after exercise in de conditioned patients vvith osteoarthritis and rheumatoid arthritis and in patients with rheumatoid arthritis who may be functioning at a lower aerobic capac­ ity indicates a need to further modify the exercise prescrip­ tion. It is necessary to keep in mind that fatigue can be ei­ ther systemic or exercise-induced or both. Instructions to the patient with a rheumatic disease might include sleep and rest gUidelines 62 Compliance vvith exercise programs increases when ex­ ertion and pain are within acceptable limits for the pa­ tient] {.'33,38 The patient's reaction to exercise should be carefully monitored, and self-monitoring skills should be taught as part of the therapy program.

Pacing Treatment A patient vvith more advanced or complicated arthritis may have a team consisting of a rheumatologist, orthopedic sur­ geon, psychologist, vocational counselor, orthotist, nurse, podiatrist, nutritionist, occupational therapist, and physical therapist. Demands made on the patient's time, energy, and financial resources by individual team members must be considered. Duplication of services should be avoided, whereas teamwork to provide positive functional outcomes should be practiced.

PATIENT EDUCATION Chronically affected patients should be educated about their conditions during treatment and given self-help liter­ ature and information about community resources such as the Arthritis Foundation, Some treatments may be appro­ priately applied by family members or caregivers, and their involvement in treatment sessions to learn these tech­ niques and to ask questions can be an efficient use of treat­ ment time. Working vvith patients with arthritis can be an exciting challenge to the physical therapist. This is a chance to ap­ ply the principles of exercise prescription in a situation de­ manding knowledge of joint and muscle pathology, the ability to do careful and complete assessment, the ingenu­ ity to modify treatments to fit the determined require­ ments, and the ability to motivate patient cooperation. The benefit to the patient of this successful process can be an improvement in the quality of his or her life.

I<EY POINTS FIGURE 12-8. It is important to incorporate functional activilties into the treatment plan. Here, the patient with arthritic fingers practices writing skills.

• Exercise can mitigate impairments that lead to func­ tional deficits in patients vvith rheumatoid arthritis and osteoarthlitis and has a positive effect on quality of life.

242

Therapeutic Exercise Moving Toward Function

• The stability and mobility of a normal diarthrodial joint depend on the integrity of its anatomic parts. The dis­ ease processes of osteoalihritis and rheumatoid arthritis attack these anatomic parts and affect jOint integrity and function. • The pathology of one diarthrodial joint in a kinetic chain can adversely affect joints proximal and distal in that same chain and the contralateral jOints. Exercise pre­ scription should consider these joints when assessment indicates the need. • Pain is a common impairment in patients with os­ teoarthribs or rheumatoid arthritis. Management of pain with therapeutic modalities, safe alignment, bracing, and pacing is a necessary component of exercise pre­ scription. • JOint movement is necessary for maintaining joint health. Passive, active assisted, and active ROM exer­ cises are appropriate , and the choice depends on the severity of involvement of the jOint. • Isometric exercise is useful in maintaining strength of the muscles around an affected joint. It can be done without aggravating an inflamed joint and without rais­ ing blood pressure in patients when this is a considera­ tion by using BRIMEs. • Dynamic training offers the advantage of strengthening periarticular musculature through full joint range and increasing cartilage nutrition. Certain precautions must be followed, especially in strengthening muscles around unstable jOints. • Cardiovascular conditioning is frequently necessary for patients \.yith osteoarthritis or rheumatoid arthritis. It has a positive effect on the quality of life . FollOWing specified gUidelines , it is possible to prescribe exercise that does not aggravate existing jOint pathology. • Because of inflammation and joint instability, exercise prescription must include special precautions such as joint bracing, nonjarring movements, conjunctive thera­ peutic modality use, and pacing. • Patients' adherence to an exercise program often de­ pends on their belief in the program and on sharing common goals with the therapist. For this reason , the therapist must be aware of patients' beliefs and goals during the treatment program.

CRITICAL THINKING QUESTIONS 1. In Case Study #3 (see Unit 7), decide which joints should be addressed in a rehabilitation program. 2. Formulate an exercise prescription for the patient's right hip , including exercise type , intensity, progression param eters , precautions, and adaptation. 3. Decide which outcome measures would indicate that the patient had reached her goals and which would in­ dicate she had reached goals you feel are important. Are there disparities you may have to reconcile?

REFERENCES 1. Henderson B, Edwards CWoThe SynOVial Lining in Health and Disease. London : Chapman and Hall , 1987.

2. Knight AD , Levick JR. Morphometry of tbe ultrastlllcture of tIle blood-joint barrier in th e rabbit knee. Q J Exp Physiol 1984;69:271- 288. 3. Benjamin M, Ralphs JR. Fibrocartilage in tendons and liga­ ments-an adaptation to cOlllpressivp load. J Anat 1998;193: 481-494. 4. Lawrence RC, Helmick CG, Arnett FC, et a!. E stimates of the preva lence of artlllitis ano selected musculoskeletal disorders in the United States. Arthritis Rheum 1998;4l:77S- 799. 5. Yelin E , Callahan LF. The economic cost and social and psy­ chological illlpact of musculoskeletal conditions. ArtbIitis Rheum 199,'5;38:13.51-1362. 6. Prae me r A, Furner S, Rice D. rVlusculoskeletal conditions in the United States. 2nd ed. Ros e mont, IL: Am e rican Academ\' of Orthopedic Surgeons , 1999. ­ 7. Ekdahl C, Eberhardt K, Andersson SI, et a1. Assessi ll
Chapter 12 The rapeutic Exerc ise for Arthritis

r-

r

la -

R

1\

n­

pro­

gram in women with rheum atoid arthritis taking low dose prednisone, J Rheumatol 2000;27:1674-1680, ':,1. Bunning RD, Materson RS, A rational program of exercise for patients with osteoarthritis, Semin Arthritis Rheum 1991;21(Suppi2):33--43, _5, Allen ME, Arthritis and adaptive walking and running, Rheum Dis Clio North Am 1990;16:887-914, Brandt KD, Slemenda CW, Osteoarthritis epidemiology, pathology and pathogenesis, In : Schumacher HR Jr, ed, Primer on the Rheumatic Diseases, 10th ed, Atlanta: Arthri­ tis Foundation, 1993:184-187, Kessler RM , Hertling D, Management of Common Mus­ cllloskeletal Disorders, Philadelphia: Harper & Row, 1983 : 10-50, Mease p, Rheumatologic issues, In : Agostini R, Titus S, eds, Medical and Orthopedic Is sues of Active and Athletic Women, Philadelphia: Hanley & Belfus, 1994:230-246, _ J. Bere nbaum F, Osteoarthritis epidemiology, pathology and pathogenesis, In: Primer on Rheumatic Diseases 2001, \tIinor MA, Exercise in the management of osteoarthritis of the knee and hip, Arthritis Care Res 1994;7:198-204, ..\nderson RJ. Rheumatoid arthritis clinical features and lab­ ora tory, In: Schumacher HR .II', ed, Plimer on the Rheumatic Diseases, 10th ed, Atlanta: Arthritis Foundation , 1993:90-95, _ Gerber L. Rehabilitation of patif'nts lvith rheumatic diseases, In: Schumacher HR Jr, ed, Primer on the Rheumatic Dis­ eases, 10th eel. Atlanta: Arthritis FOllndation, 1993:90-95, JokI p, Prevention of disuse muscle atrophy in chronic arthli­ tides, Rheum Dis Clin lorth Am 1990;16:837- 844, Fahrer H , Rentsch H U, Gerber N J, et ai, Knee effusion and re Oe:>; inhibition of the quadriceps, J Bone JOint Surg Br 1988;70:635-638, Dannes kiold-Samsoe B, Crimby G, The relationship be­ tween the leg muscle stn'ngth and physical capacity in pa­ be nts with rhenmatoid arthritis wit.h reference to the influ­ ence of corticosteroids, Clin RheumatoI1986;5:468-474, E dstrom L, Nordemar R, Differentia! changes in type I and type II muscle fibers in rheumatoid arthritis, Scand J Rheumatol 1974;3: 155-160, irca A, Susec-Michiel M, Select.ive type II fiber muscular at­ rophy in patients \vith osteoarthritis of the hip, J :\feurol Sci 1980;44:149-159, Lankhorst GJ, van de Stadt RJ , Van der Korst JK. The rela­ tionship of functional capacity, pain and isometric and isoki­ netic torque in osteoarthrosis of the knee, Scand J Rehabil \tIed 1985;17:167-172, Felson DT, Zhang Y, Anthony JM , et ai, Weight loss reduces the risk for symptomatic knee osteoarthritis in women, Ann Intern Med 1992;117:535-539, _ Bland JH, Cooper S\t!' Osteoarthlitis: a review of the cell bi­ ology involved and evidence for reversibility, Management ra tionally related to known genesis and pathophysiology, Semin Arthritis Rheum 1984;14:106-132, Roy S, Ultrastructure of articular cartilage in experimental immobilization, Ann Rheum Di s 1970;29:634-642,

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42, Hicks JE. Exercise in patients with inflammatory arthritis and connective tissue disease, Rheum Dis Clin North Am 1990; 16:845-870, 43, Muller EA, Influence of training and of inactivity on muscle strength, Arch Phys Med Rehabil1970;5l:449--462, 44, Jayson MIV, Dixon SJ, Intra-articular pressure in rheumatoid arthritis of the knee, Part III: pressure changes during jOint use Ann Rheum Dis 1970;29:401--408, 45, Machover S, Sapeeky AT, Effect of isomctlic exercise on the quadriceps muscle in patients \\ith rheumatoid arthritis, Arch Phys Med Rehabil1966;47:737-741. 46, Gerber L , Hicks J, Exercise in the rheumatic diseas~s , In : Basmajian,.TV, ed , TherapeutiC Excrcise, Baltimore: Williallis & 'Wilkins, 1990:333, 47. McCubbin JA. Resistance exercise training for persons with arthritis. Rheum Dis Clin 1\orth Am 1990;16:931-943, 48, Danneskiold-Samsoe K, Lyngberg K, Risum T , et all The ef­ fect of water exercise therapy given to patients with rheuma­ toid arthritis, Scand J Rehabil Med 1987;19:31-35, 49, Jensell G\,I, Lorish CD, Promoting patient cooperation with exercise progrums, Arthlitis Care Res 1994;7:181-189, 50, Basia B, Topolski T, Kinne S, et al. Does adhe rence make a djfference? Results from a community-based aquatic exercise program, Nurs Res 2002;.'51285-29l, 51. Patrick DL, Ramsey SO, Spencer AC, et al. Economic evalu­ ation of aquatiC exercise for persons lvith osteoarthritis, Med C are 2001:39:413-424, 52, McNeal RL. Aquatic therapy for patients with r he llmatic dis­ ease, Rheum Dis Clin :\forth Am 1990;16:9 15-929, 53, Gldnup G, W iO'ht loss without dietary res triction : efficacy of different forms of aerobi c exercise, Am J Sports Med 1987; 15275-279, 54, Name), T C , Adaptive bicycling, Rheum Dis Clin 1\ortl1 Am 1990:16:871- 886, 55, Borg GAV, Psychophysical basis of perceived exe rtion, Med Sci Sports Exerc 1980;14:377-381. 56, H agberg f M, Central and peripheral adaptations to training in patients with coronary artery disease, Biochem Exerc 1986;16:267-277. 57, Lorig K, Fries JF, The Arthritis Help Book. 4th ed, Reading, MA: Addison-Wesley, 1995:124, 58, Neumann DA. Biomechanical analysis of selected princi­ ples of hip joint protection, Arthritis Care Res 1989;2: 146-155 , 59, Voloshin A, ''''osk J , Influe nce of artificial shock absorbers on human gait, Clin Orthop ReI Res 1981;160:52-56, 60, Essenberg VJ Jr, Tollan M, Etiology and 'treatment of fi­ bromya lgia synd rome, Orthop Phys Ther Clin North Am 1995;4:443--457. aimark A, et ai, ObeSity and knee 61. Felson DT, Anderson osteoarthritis the Framingham study, Ann Intern Med 1988; 109:18- 24, 62, Minor MA, Westby MD, Rest and Exercise in Clinical Care in the Rheumatic Diseases, 2nd ed, Atlanta: American Col­ lege of Rheumatology, 2001:179-184,

n,'\

chapter 13

Therapeutic Exercise for Fibromyalgia Syndrome and Chronic Fatigue Syndrome KIMBERLY BEI\I1\1 ETT

Pathology

Fibromyalgia Syndrome

Chronic Fatigue Syndrome

PATHOLOGY

Therapeutic Exercise Intervention for Prevention and Wellness

The causes of FMS and CFS are not clear despite research looking at many different physiologic systems for evidence of involve ment. Treatment depends on outcome studies for validation.

Therapeutic Exercise Intervention for Common Impairments

Fibromyalgia Syndrome

Impaired Muscle Performance Impaired Aerobic Capacity Impaired Range of Motion Impaired Posture Impaired Response to Emotional Stress Pain

Precautions and Contra indications

Adherence

Clarity of Instruction

Pacing

Considerations in the Application of Exercise

Adjunctive Interventions and Patient-related Instruction Pharmacologic and Psychologic Intervention Patient-related Instructions

Significant impairments exist in patie nts with fibromyalgia syndrome (FMS), including widespread pain, 1 decreased joint range of motion,2 and impaired respiratori and car­ diovascular status. 4 P~ltjents frequ e ntly decrease work hours and change tasks"-I and they develop significant con­ flicts about life roles. s Twenty-five percent of patients 'with chl'Onic fatigue syndrome (CFS) patients are bedridden or unable to work. 9 These disabilities have negative economic and qual.ity of life effects. Patients with FMS and CFS are being seen increasingly in the physical therapy clinic be­ calLlse carefully prescribed exercise has been shown to be of value in improved aerobic performance, tender joint pain, well-being, pain levels, and self-efficacy.lo- l U nfortu­ nately, these conditions are poorly unde rstood by the pub­ lic and many health professionals. An understanding of the problems these patients encounter will provide a basis for a solid rehabilitation program .

The cause of fibromyalgia is uncertain. FMS is character­ ized by widespread body pain (in all four quadrants and the axial skeleton) and tenderness, fatigue, and morning stiff­ ness. 1 FMS tends predominately to affect females (80% to 90% of patients ). Pati ents typically are between 20 and 60 years of age, 17 though the re have been reports of children being affected. 18,19 Persons with FMS are estimated to compose about 7% of the patients seen in general medical practices and up to 20% of the patients in general rheuma­ tology practices 17 ,20

EtiologV One of the characteristics of FMS is the absence of consb­ tent, positive laboratory findings. 1 Because its symptom mimic those of other diseases (e.g. , rheumatic diseases. multiple sclerosis, malignancies, hypothyroidism, anemia' . a thorough medical evaluation is necessary to exclude other possible causes of the presenting complaints. 21 Onset of FMS can be insidious; it may occur after a viral in fec­ tion 22- 24 or trauma. 23- 25 It also may be related to stress 26: sleep disruption such as occurs in sleep apnea, sleep my­ oclonus, and alpha-delta sleep 27,28; or be related to centl:a1 nervous system (CNS) mechanisms. 29 It seems likely that multiple factors contlibute over time until a threshold i~ reached such that a final event appears to be the precipi­ tating factor 30 Many researchers have attempted to identify the causative factors of FMS , but the pathomechanics remain elusive. Historical references to FMS-like s)'T!l,ftoms are found as far back as Hippocrates. 31,32 Straus3~ cites the treatise of an 18th century physician who describes such disorder found predominately "among women ... who arl sedentary and studiOUS ," and that he felt was "preCipitated by antecedent causes including grief and intense thoughts.­ In the 1800s and early 1900s, muscle inflammation (giving rise to the te rm fibro sitis) was considered a cause. The

244

Chapter 13: Therapeutic Exercise for Fibromyalgia Syndrome and Chronic Fatigue Syndrome

te nn fibrositis has generally been disregarded based on the lack of histologic evicl8nce of inflamm ation in the muscles of patients with FMS. 3 .1 .:34 Later research on the possible causes ofFNIS has focused on peripheral (muscle physiol­ o . ) and central (eNS function ) phenome na. Peripheral Origin

Aggressive exercise is not well tolerated by patients with F\1S and often results in increased perception of pain and fatigue. 35- 38 Mtlsde adaptation to decreased activity has been hypothesized to be at least partially responsible for th adverse reaction to overexertion, and muscle morphol­ gy and rhYSiology in patients vvith FMS have been inves­ ·uated. 3 No muscle morphologic changes speCific to FMS ve been found. 34 In a very few muscle samples , evidence uggesting a mitochondrial disorder and pOSSibly microcir­ _ .Iation compromise was documented, but these changes 'ere not \.videspread in the muscle. 33 ,40-12 \'either muscle energy metabolism 43 .4 4 nor enzyme levels.36 vary from :hose of controls, though a recent study showed decreased • e of phosphorous metabolites at maximal work levels. 45 eports of decreased exercise-induced muscle blood flow patients vvith FMS 46 were not, however, accompanied by . e expected decrease in capillary denSity that this finding u ggested:n It is not dear whether localized metabolic or orphologic changes in muscle can account for the pain d fatigue associated with FMS . Epidural blockade does reduce FMS tender pOints,47 d there is evidence of increased nociceptor reactivity in b ents with FMS,48 which suggests that the pain may be peripheral origin. Muscles of patients with FMS do not ow a drop in surface electro myographic activity during ort pauses between muscle contractions, which may be a -espo nse to perceived pain and fatigue. 49 Studies found . t patients with FMS or CFS do not sustain repe~te_d uscle contractions at the same)n_tensity as controls.,,0-02 Other studies show that they do .,,3.,,4 However, when elec­ . I stimulation of muscles accompanied repeated con­ ctions, the contraction intensity and duration matched ose of controls ss This finding suggests that the muscle it­ ·if is capable of normal \-vork but that there may be a cen­ mechanism limiting that work by producing symptoms MS and CFS, which the patient interprets as pain and QUe.

Central Nervous System Origin

Pain modulation may be disrupted in FMS at the spinal

ord level or in higher CNS centers. Although endorphin . 'els have been found to be normal ,56.57 lowered levels of ' ru m tryptophan 58 and elevated levels of substance pS9 a. amplify pain perception. Pituitary hormone secretion changes have been found in tients \vi.th FMS. 60- 62 Growth hormone is adversely af­ ected by sleep deprivation. 63 The production of an FMS­ e state in healthy volunteers through alpha-delta sleep .nduction 64 may point to a role for abnormal @rowth hor­ one secretion in FMS symptom production. 3 Another hypotheSiS in which CNS regulation is pro­ posed to be aberrant suggests that the level 'vvhere control lost is the limbic system. This area affects sensory gating ..nd processing of sensory input. 65 Autonomic nervous sys­ em dysfunction has also been suggested by the results of

244

245

several studies. 3G .fiG An inverse relationship between sym­ pathetic reactivity and pain sensitivity has been found. Stress and anxiety associated with FMS would be xpected to increase sympathetic tone, but the expected commensu­ rate increase in plasma and urinary catcchotamin('~ were not found. iii A lowered level of sympathetic activation has been postulated, LInd may be a source of increased pain sensitivity in patients with FMS hH The ro le of psychiatric and behavioral disorders in FMS is controversial. In one study, 20% to 40% of people with FMS in a tertiary care center were found to have current mood disorders and a lifetime incidence ranging from 40% to 70%. However this was felt to reflect health care-seeking behavior in that population because lower lifetime incidences are noted to occur in patients with FMS in the general population. 3o A hypothesis unifying many of the theories about FMS pathophys iology has been proposed by Yunus. z9 This mode l emphasizes the possible role of neurohormonal dys­ function resulting in aberrant central pain mechanisms , which are proposed to lead to fatigue, depreSSion, anxiety, and mental stress, further altering sympathetic activity and amplifying pain perception. He also suggests that physical deconditioning, trauma, spinal stress from poor posture, and environmental stimuli may further amplify pain. There may be a genetic predisposition to FMS because first-degree relatives of patients with F.\1S have a hi~h~r than expected frequency ofFMS. It has been proposed 9.,0 that FMS can occur with exposure of genetically suscepti­ ble individuals to anyone or a combination of the triggers associated \vi.th FMS onset. 17-19.21 The variety of triggers and variety of symptom, some of which predominate over others for given individuals, suggest there may be subgroups of patients with FMS. It may be that treatment must be tailored to individual patients.71. 72 Signs and Symptoms

FMS is a chronic condition in which symptoms wax and wane but are typically unrelenting. In addition to pain and fatigue, this population experiences lowered respiratory function ,3 joint ranae , and muscle endurance and has strength impairments ~,7:3 and below average cardiovascular fitness levels 4 FMS is listed in the American College of Rheumatol­ ogy (ACR) classification of rheumatic disease as an extra­ articular disorder. In a multicenter study,1 which estab­ lished the 1990 ACR criteria for definition of FMS, the most common symptoms of patients \vi.th FMS were fa­ tigue, sleep disturbance, and morning stiffness (73% to 85% of patients ). Pain allover, parestheSia, headache, and anxiety affected 45% to 69% of patients. Less common, but still Significantly more frequent than in controls, were findings of irritable bowel syndrome, sicca syndrome (i.e. , dry eyes and mouth) , and Raynaud's phenomenon «35%). In this same study, factors found to affect the musculoskeletal symptoms of patients with FMS included cold, poor sleep, anxiety, humidity, stress, fatigue, weather changes, and warmth, as they did to a lesse r de­ gree in control subjects. The diagnostic criteria for FMS were developed from this study (Display 13-1 ). The diagnOSiS is based on

246

Therapeutic Exerc ise: Moving Toward Function

DISPLAY 13-1

Classification of Fibromyalgia 1. History of widespread pain. Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. Low back pain is considered lower segment pain. 2. Pain in 11 of 1Btender point sites on digital palpation. Definition. Pain on digital palpation must be present in at least 11 of the following 1Btender point sites: Occiput bilateral, at the suboccipital muscle insertions low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7 Trapezius: bilateral, at the midpoint of the upper border Supraspinatus: bilateral, at origins, above the scapula spine near the medial border Second rib: bilateral, at the second costochondral junction, just lateral to the junctions on upper surfaces lateral epicondyle: bilateral, 2 cm distal to the epicondyles Gluteal: bilateral, in upper outer quadrants of buttocks in the anterior fold of muscle Greater trochanter: bilateral, posterior to the trochanteric prominence Knee: bilateral, at the medial fat pad proximal to the joint line Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive," the subject must state that the palpation was painful. Tender is not to be considered painful. * For classification purposes, patients are said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present: for at least 3 months. A second clinical disorder does not exclude the diagnosis of fibromyalgia. From Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 7990 criteria for the classification of fibromyalgia. Arthritis Rheum 7990,33 760-772.

finding at least 11 of 18 ten der points (Fig. 13-1 ) in the presence of Widespread pain (i.e. , pain in all four quad­ rants of the body, including at least part of the axial skele­ ton) persisting for at least 3 months' duration. Tender points were deflned as anatomically discrete and repro­ ducible areas of heightened pain perception in patients with FMS. Diagnosis may also be made when the full 11 of 18 tender points are not present but other features commonly found in the study areYo Functional Limitations

Several studies have examined the effect of FM S on ev­ eryday life. Fifty-five percent of working patients were fou.nd to have changed work tasks and to work shorter hOlm than before the illness. Motor tasks were reported as being more difficult to perform than before FMS onset, and 67% reported no or short pain-free periods. 5 The lack of objective findings in light of the patients' perception of their illness is stressful and can lead to feel­ ings of rejection and of being misunderstood or disbe­ lievecJI. These feelings compromise the patient's ability to deal with the inness . Daily routines are disrupted, conflicts

about life roles emerge and lead to further stress, and loss of physical fitness and loss of future opportunities occur. Patients need early and adequate infonnation , along with acknowledgment of the conditions to minimize psychoso­ cial consequences 8

Chronic Fatigue Syndrome CFS is characteJized by profound fatigue. Descriptions of similar illnesses are found throughout the medical litera­ ture.31 ,32 Th ese disorders include neurasthenia, myalgic encephalomyelitis, and chronic Epstein-Barr virus infec­ tion (i .e., "yuppie flu"). With an estimated incidence of

Occiput: - - - - - - - - - - - - - - + ­ suboccipital muscle insertions Trapezius: midpoint of the upper border

Supraspinatus : above the medial border of the scapular spine

­

/

Gluteal: upper outer quadrants of buttocks

/'

Greater trochanter: / posterior to the trochanteric prominence

Low cervical : - - - - - - - - - - - + anterior aspects of the intertransverse spaces at C5-C7 Second rib: second costochondral junctions

• •

,/ ~

~

Lateral epicondyle: 2 cm distal to the epicondyles

Knee: medial fat pad proximal to the joint line

FIGURE 13-1. Location of 1Btender points.

. '

~

Chapter 13 Therapeutic Exercise for Fibromyalgia Syndrome and Chronic Fatigue Syndrome

10 leur.

\ith

o

.1 %, CFS is much less prevalent than is FMS , and studies -uggest that CFS affects both sexes and oc<.:urs a<.:ross al­ 'n~~t all ra<.:es and ethni<.: groupS.74

DISPLAV 13-2

The Centers for Disease Control and Prevention Working Case Definition of Chronic Fati ue S ndrome

0­

o l ra­ Wgic

~fec­

!e of

Etiology \'arious studies have looked for the causes of CFS. Im­ mune system changes have been reported in patients with CFS. Early reports of viral markers have not been con­ nned in later studies. The Epstein-B arr virus is not thought to be a causative agen!_in CFS onset, though some i ral trigger may be involved. (0) Neuroendocrine changes,

e pecially in hypothalamic hormone production or relea~e

Jf corticotrophin- releasing hormone, have been found. 16

F S does not appear to be a form of depression, because

urohormonal and sleep-cycle findings characte ristic of

epression are not found in patients with CFS , though ill­ 5s-related depression may occur, as it does in FMS.'4 Up

70% of patients with CFS simultaneously present with

' \>1S .20

Signs and Symptoms The onset of CSF is typically sudden, and the fatigue is pro­ ::lund. Twenty-five percent of patients with CFS are d ridden or unable to work, and 33% can work only part­ me.9 Patients with CFS may tolerate exeltion at first, but to 24 hours late r, symptoms often increase. This must be nsidered by the clinician when designing and teaching an rcise program. In 1994, the Centers for Disease Control and Preven­ n (CDC) publi~~ed a working case definihon of chronic ligue syndrome (, (Display 13-2). Unexplained, debilitat­ fa tigue of at least 6 months' duration that is unalleviated . rest and four of eight listed symptoms are required for e definition. Symptoms include impairment in memory concentration, sore throat, tender ceMcal or aXillary m ph nodes, muscular pain, multijoint noninflammatory

hralgia, new or different headaches, nonrefreshing

ep, and prolonged (at least 24 hours) generalized fatigue

!'fer previously tolerated exercise.

, mong the eight symptoms detailed by the CDC, sleep

ruption is reported by about 95% of patients with CFS.

~ther common complaints include neurocognitive diffi­ illties, muscle weakness, frequent need for naps, dizzi­ e s, shortness of breath, and adverse responses to stress. 7 -Omparison of the diagnostic criteria for FMS and CFS

oW a broad overlap, and their exact relationship is in

o.lestion. 74

(J

?

THERAPEUTIC EXERCISE INTERVENTION FOR PREVENTION AND WELLNESS ecause the causes of FMS and CFS are UnkllOWll, it is dif­

cult to know how to prevent the onset of these conditions ler than to encourage a life of balanced activity, rest, and tress management and to encourage family practitioners regard evidence of imbalances in these areas or of sleep . orders as worthy of early intervention. After FMS and ~FS are present, an exercise routine in conjunction with ") armacologic and psychologic interventions seems to be ~e most effective treatment strategy.

247







Fatigue criteria and four of eight symptom criteria must be present to fulfill the case definition.

Fatigue criteria I

1. Persistent or relapsing fatigue that a. Has been clinically evaluated b. Is of definite onset c. Is not the result of exertion d. ResLllts in substantial reduction in activity 2. Other conditions that explain the fatigue have been

excluded, including:

a. Active medical conditions (e.g., untreated

hypothyroidism)

b. Previously diagnosed medical condition whose resolution has not been clinically documented (e.g., treated malignancies) c. Past or present psychotic or melancholic depression, bipolar disorder, schizophrenia, delusional disorders, dementia, anorexia nervosa, bulimia d. Alcohol or substance abuse within 2 years of the onset of fatigue or anytime thereafter

Symptom criteria Persistent or recurrent symptoms lasting more than 6 consecutive months: 1. Self-reported impairment in short-term memory or

concentration, which causes substantial reduction of

occupational, educational, social, or personal activities

2. Sore throat 3. Tender posterior cervical, anterior cervical, or axillary

lymph node pain

4. Muscle pain 5. Multijoint noninflammatory arthralgias 6. New or different headaches 7. Un refreshing sleep 8. Prolonged (at least 24 hours) generalized fatigue after

previously tolerable levels of exercise

From Buchwald D. Fibromyalgia and chronic fatigue syndrome. Similarities

and differences. Rheum Dis Clin North Am 1996,22.219--243

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON IMPAIRMENTS Clinical manifestations of FMS and CFS include evidence of impairments that affect functioning. Studies carried out over the past 10 years 10- 1Z,71l-S2 and reviews of treatment approaches for FMS and CFS 13 ,74,83 support the need for multidisciplinary intervention in the treatment of these im­ pairments. Pharmacology, psychotherapy, education, and physical medicine (including exercise and manual therapy) are used and are largely empiric with ongoing outcome studies. Pharmacologic and psychotherapeutic approaches are discussed with adjunctive interventions. Physical medicine is an important part of treatment for patients with FMS or CFS. Evidence of deconditioning,4

248

Therapeutic Exercise Moving Toward Function

lowered respiratory function,3 decreased joint range, depleted muscle endurance, and reduced muscle perfcJr­ mancp2.7l has been found in these patients. Abnormal joillt alignment and posture may contribute to peripheral stresses and amplify pain. 12 .1:3.29 Deconditioning may make muscle more vuln e rable to physiologic changes (h~'ifl ot~)esi zed by some researchers to underli e ~~J:ipberal pam 26 .. L ) and aHect neurohormonal regulatIOn : .-., Stress is an exacerbating factor fo r some patients with these conditions. Carefll l prescIiption of an exercise program depends on si gnificant findings during the initial evaluation. The clinician working with a patient "vith FMS or CFS should assess posture, strength, joint play, and cardiovascular conditioning to design a treatment program. Therapeutic exercise can address six main areas of impairment: Impaired muscle performance Impaired aerobic capacity Impaired range of motion (ROM) Impaired posture 5. Impaired response to emotional stress 6. Pain 1. 2. 3. 4.

It is important to introduce exercise slowly, progressing intensity and duration as symptoms allow. The regimen de­ pends on good communication between the clinician and patient. For consistency with the format being used in this textbook, exercises to address impairments are listed in the order used in other chapters, but this may not be the order in which they are introduced to the patient. The skillful therapist will choose interventions based on impairments found during evaluation and will structure them in a way that allows the patient to progress most smoothly toward functional goals. There will be overlap in the impairments addressed within any given session (e.g., impaired response to stress and impaired aerobic capacity) but it is advisable to start with an emphaSiS on the less demanding regimens (e.g., re­ laxation and stretch) early in the course of treatment to build patient confidence in exercise and a greater accep­ tance of more aggreSSive exercise later. As treatment pro­ gresses increase the intensity and difficulty of the interven­ tion, monitoring patient response and adjusting (and teaching the patient to monitor and adjust) appropriately, working toward functional goals. In general follovving the order outlined in Table 13-1 should help progress treat­ ment with less likelihood of an adverse response to treat­ ment and an increased confidence and willingness to par­ ticipate on the patient's part. Therapeutic intervention for a structured return to physical activity is suggested for patients with CF_S because complete inactivity appears to promote fatigue. 14 Although little literature exists on the effect of exercise for CFS,42 one study showed improvement in global self­ assessment scores for patients with CSF after aerobic exercise training S2 Treatment of FMS-like symptoms of CFS could follow the F\lIS protocols suggested in the next sections, and physical symptom exacerbation should guide progression of the program.

Exercise for Patients with

Fibromyalgia

Early Phase (Week 1-on) Goal: stress and pain management Rcln:;ation Progressive rela'{ation Autoge nic deep breathing Visualization Deep breathing Stretch Midphase (Week 2-on) Goal: Musculoskeletal balance Fluoromethane spray and stretch Self-mobilizations Neuromuscular techniques: hold and relax, contract and relax Strai n -cou nterstrain Muscle system balance exercises (Sahrman) Neutral spine (±: tubing) Closed chain eccelltric exercise Early aerobic exercise: supine bike, unloading equipment, ell5 exercises in water Late Phase Goal: Ivlaintenance Stretch, cont. Musculoskeletal balance, cont. Gelleral strength: resistance tubing, machines, closed eh eccentric exercise Aerobic exercise: non-weight-bearing to weight-bearing an nonjarring activities (ski machine, seated sitationary bike treadmill) and water exercises (aerobics, flotation belt)

Impaired Muscle Performance Muscle performance in patients with FMS declines com­ pared with controls. This loss does not appear to res from metabolic or morphologic changes in the muscl patients "vith FMS; it is caused by some change in centr. control. Perception of pain and fatigue may limit produc­ tion of muscle contraction force and eventually affect fu nv tional activities of the patient because of resulting decond.­ tioning. When inSignificant muscle imbalances are fo up. or existing imbalances are being successfully addressed, p;.­ tients can begin to direct their energy toward gEmer: strengthening routines for conditiOlling, especially if th... goal is a priority for them. Strength training is initiated the middle phase of treatment and for maintenance pur­ poses. There is evidence that increasin~ general strengtl levels affects FMS symptoms pOSitively. 6 The same conditions apply to exercise prescription fi general strengthening as apply to treatment of specif/. movement faults. The program should start with 10\\ resistance and low-repetition work, avoid static holdi I1;:­ monitor symptoms, and progress slowly. Allowing the pa. tient to choose the form of exercise may increase enjoyme and compliance. Exercise can be isometric or isotonic. If iso­ metric activities are chosen, avoidance of prolonged stan holding is important. Contractions should not be held longe­ than 3 to 5 seconds, "vith three to six repetitions of the exer­ cise performed three times each week. a level that has bee demonstrated to increase peri31ticular muscle strength,s4

Chapter 13: Therapeutic Exercise for Fibromyalgia Syndrome and Chronic Fatigue Syndrome

249

In dynamiC exercise, slow move ment through full range i th return to the lengthened range allows a slight muscle etch between contractions. Resistance tubing and, fur­ er into the program, resistance machines, which are de­ aned to provide good body alignment and smooth resis­ ce, seem preferable to free weights, perhaps because ey allow more complete muscle relaxation between rep­ l ions than free weights, which depend on static muscle ntraction of the forearm and fingers. Closed chain, ngthening exercis es of the Pilates type (a form of exercise \'eloped and used with dancers , emphasizing strength d flexibility over bulking) are useful when the patient is ~ady for active movement . If no prior weight training has en done by the patient, calibrating the response by start­ g \vith three to five repetitions of three to five exercises at j lightest weight and monitoring the response over 24 to - hours can provide the baseline of the patient's tolerance. atienl:e is important in introducing exercise to decrease e tbacks. Table 13-2 prOvides a sample program.

paired Aerobic Capacity

cb

cause aerobic exercise may have a positive effect on some the impairments seen in patients 'with FMS, including en­ urance, pain, and fl exibility, it should be introduced as I()n as possible. Initially, only a few minutes of the activity ould be allowed (2 to 5 minu tes, un less the patient is al­ ady active for longer periods without symptom flares ). is allows the gradual bUild-up of tolerance. By the late ase of rehabilitation , the patient may be ready to work on evation of the heart rate to 50% to 60% of the maximum art rate. Monitoring techniques including the training in­

__ " ~

Sample St~engthening Program

ater Program: 3 Davs/Week • Warm-up: slow wal kin g forward , backward, Sideways: with or without arm movement depending upon upper extrem­ ity involvement (approximately 5 minutes) • Slow-speed arm movements with short lever arm and de­ creased surface area (5 to 10 repetitions) • Flexion/exte nsion • HOlizo ntal ab duction/adduction • Abduction/adduction • Rotation • Slow speed leg kicks into flexion and abduction (5 to 10 repetitions ) • Squats or stepping exercise • Bicycling with legs • Gentle stretching and walk for cool down

nd Program: 3 OaysJWeek • Walking in home or
FIGURE 13-2. For FMS or patients wi th CFS, it is important to introduce exercise gently. Early exercise phase cardiovascu lar trai ni ng can beg in with the patient lying on the floor behind a stationary bicycle. The patient should peda l for approximately 2 to 3 minutes in the first training session. By late phase of treatment the patient may have progressed to 15 minutes of cycling vvhile lying on the floor and then to seated cycl ing, reducing time initially and gradually increasing aga in to 20 min.

dex, ~~dse determination, and use of the pe rceived exertion scale " should be discussed so pacing and progress can be monitored. The patient should keep a record ofexertion and symptoms to facilitate this assessment. During th e first session, it may be a good idea to make a contract '.''lith the patient to start preaerobic activitif"S of daily walking, even if on ly one half of a block. For the pa­ tient who is able to walk more than one fourth of a mill', a high schoo! track offers sevl'ra! advantages. Typically, it has a shock-absorbing surface; it is a safe place to use head­ phones without worrying about traffic, which may make it more enjoyable; accurate distance estimates are possible so progress in distance and rate can be tracked; and the pa­ tient who fatigu es part way through can usually walk back to a car rather than all the way home or have to ask some­ one to come for him or her. It is important to consider the patient's interests and goals in designing a walking program and in suggesting a particular environment. Initially, the rate of walking should be sIo'vv and comfortable until toler­ able levels, without a flare of symptoms, can be established. Another approach to introducing exercise gently is to have the patient lie behind a stationalY bike supported in a spinal-neutral position with the feet on the pedals of the bike (Fig. 13-2). During the first session, th patient should pechl about 2 to 3 minutes; 1 to 2 minutes can be adcled each session (at first not more than once a day) until, by the late phase of treatment, the patient may reach 15 minutes. At thi s pOint, the patient probably can tolerate sitting on the bike seat to pedal, but time should he decreas ed to 7 to 10 minutes and slowly advanced until the patient reaches 20 to 25 minutes. After this level is reached. it should be possible to ullow the patient to choose some other form of nonjarring aerobic exercise that is personally enjoyable.

250

Therapeutic Exercise Moving Toward Function

More gradual introduction of aerobic exercise may solve some of this problem, and the knowledge that this is a com­ mon finding may help the clinician and the patient perse­ vere beyond this point in conditioning, In introducing aerobic exercise routines, the therapist should let the patient know that continuous monitOring and pacing are impOliant. During periods of symptom flares. the patient should be encouraged to modify exercise inten­ sity appropriately through trial and error of symptom re­ sponse to exercise level over time, It is easy for patients to become discouraged and stop a program. Their records and the encouragement of the clinician may help the m push through this difficult time and allow them to complY \,vith what appears to be one of a few treatment approaches with a positive impact on FMS.

Impaired Range of Motion

FIGURE 13-3. Unweighting eq ~ ipment supports part of the patient's body weight. This decreases joint stress and body weight resistance, enabling the patient to do cardiovascular exercise with less physio log ic stress.

In some clinics, unweighting equipment (e.g., harness) is available anJ has been used successfully in introducing patients to aerobic cxcrcisc b6 (Fig. 13-3). Water exercise is another form of reduccJ weight-bearing exercise. The pa­ tient can walk in the shallow end, move rhythmically, or participate in exercise classes, Community pool programs, such as the ones offered by the Alihritis Foundation and the YMCA, have instructors trained to work with persons with various disabilities. These programs have the added benefit of social contact. For some patients with FMS, so­ cializing has been markedly decreased because of fatigue and pain. The Arthritis Foundation has a list of pools with this program in many areas, and having this list in the clinic for patients may help them initiate contact. Nonjarring sources of aerobic exercise for slightly more advanced patients may include a treadmill, ski machine, seated push-pull arm and leg machines, and mini tramp. For patients who enjoy the water or who were avid runners, there are specially designed flotation belts that allow the user to walk or jog in the deep end of the pool and that some patients with FMS tolerate well after they learn pac­ ing techniques. In several studies of the effects of aerobic exercise on FMS, the first 10 to 12 weeks were problematic for muscu­ loskeletal symptom flares and for adherence. 1D ,15 A system­ atic review of exercise in FMS 87 reports adherence to exer­ cise and attrition in study subject numbers (25% average in the studies cited) was a problem. Some patients com­ plained of a flare of pain or fatigue during and after exer­ cise, and it is pOinted out that positive findings reported ,vith exercise in these studies might be due to attrition bias. Mengshoel,15 however, maintains that patients can per­ form low-intensity dynamiC exercise without a flare of symptoms.

Restrictions in joint ROM may exist at any joint held for pro­ longed periods in abnormal alignment. JOints particularly af~ fected by static poor posture can include craniovertebntl. cervicothoracic, scapulothoracic, glenohumeral, radio­ humeral, midthoracic, lumbopelvic and pelvofemoral, and subtalar joints. Intervention \vith soft-tissue and joint mobi­ lization techniques where deemed appropriate should always be supported with exercises deSigned to balance muscles around the affected jOints. Patient efficacy and re­ sponsibility with self treatment in this chronic condition is an important part of patient education for self management. Where jOint hypermobility or poor proximal stability i ~ present, concurrent use of stabilization training (e.g., in craniovertebral flexion during self stretch of suboccipital muscles, uptraining of longus capitis and down training of scalenes and sternomastoid muscles) is necessary for the preservation of good joint alignment. Flexibility exercises should be graded for exertion and time. The typical 20- to 30-second hold during stretching may be too long when effort is required to hold a limb. Pas­ sive support or decreased time may be necessaly. Stretch­ ing should never be painful. Breathing instruction durin training is important as breath holding can be a character­ istic of patients with FMS,'

Impaired Posture The biomechanical faults resulting from poor postural alignment can contribute to FMS pain,1:1,29 and poor pos­ tural alignment can play into the reduced respiratory ca­ pacity of patients. Postural assessment in all postures typi­ cal for the patient (standing, sitting, resting, and static or repetitive work postures) is impOliant in this regard. Pa­ tient education regarding the importance of normal pm ­ ture is often needed. Instruction regarding appropriat adaptation of standing, sitting, and lying surfaces wi th shock-absorbing pads, suppOlis, and equipment realign­ ment may be needed. And, often, help training for corree muscle recruitment and endurance to maintain good aliQJ1­ ment is necessary. Along with stretching, strengthening for muscle balance around affected joints is necessary. The Sabrman approa& to muscle balance in joint or movement Jysfunction (s

Chapter 13 Therapeutic Exercise for Fibromyalgia Syndrome and Chron ic Fatigue Syndrome

hapter 9) appears to be an especially effective and well­ I rated approach to treating patients with FMS. These rcises are specific and can be progressed slowly, allow­ _ pacing and monitoring of symptoms, ideally short of . 19 overexertion flares. Most do not require resistance pment and are easily related to functional tasks (e.g., rung overhead without shoulder or back pain, standing out back or hip pain). -t tic posture is a starting point for return to function re dynamic activity against gravity is required. Stabi­ 'on exercises for trunk and proximal limb girdle muscles I eful when muscle weakness or joint hypermobilit:y im­ "'TTlents exist and proximal control during functional tasks the limbs is compromised. This is especially true for -1l segmental dysfunction . An approach that has been a essful for patients is the use of graded-resistance tub­ ached to the wall or door, with the performance of ex­ j t\. proprioceptive neuromuscular fac ilitation diago­ while neutral trunk alignment is maintained during ted limb movements (Fig. 13-4). This exercise can be ::-ressed in difficulty by adding movement of the entire . e.g., lunging) against resistance while holding a neu­ ~ nment. cc ntric control is an important part of functional ac­ . introducing control and balance to move ment pat­ . and one that is frequently lost in deconditioned pa­ + • Closed-chain activities and movement th erapies , ding Tai Chi Chuan, Feldenkrais , and low-level ther­ :.ttic ballet classes are exercise strategies that may help re periarticular muscle balance and fun ction and stim­ e vestibular balance (Fig. 13-5). They may be more in­ -ting and fun for patients, and the patient's desire to be Iv d with one or the other of these forms of exercise ald guide the choice. Introduction of these strategies :ad be slow, probably after successful introduction of _"en tric forms of exercise, and always according to the nt's tolerance and carefully monitored for progreSSion tensity, duration, and frequency.

A

B

E 13-4. The use of graded-resistance tubing attached to the wall. :~rf o r mance of upper extremity proprioceptive neuromuscular facili­ - diagonals provides a nonstressful stabilization exercise. (A) Holding a tubi ng, the patient crosses her wrists with her palms faci ng down· (B) Maintaining her hand at wai st level, the patient bends her el­ _as she turns her palms upward.

251

FIGURE 13-5. Tai Ch i is an excellen t exercise strategy to help restore con· trol and ba lance to the movement patterns of deconditioned patients The teacher shou ld have experience working with patients with joint problems or chronic illness.

Impaired Response to Emotional Stress If the evaluation indicates a need for stress management, it should be initiated in the early phase of treatment, proba­ bly within the first or second visit. Stress management may include an exercise program with relaxation, deep breath­ ing, and stretch exercises. These are unlikely to be stressful to most patients and usually provide benefits that are im­ mediately obvious and typically pleasurable. This approach can provide a positive introduction to the benefits of exer­ cise and offer an opportunity to demonstrate that exercise does not have to mean maximal exertion to be beneficial. Progressive relaxation, autogenic deep breathing, and visu­ alization e ercises (see Chapter 25) can be taught, or tapes can be made available to pati nts for use at home. In addi­ tion, patients may benefit from referral to an appropriate mental health profeSSional for related services. Instruction in diaphraamatic and lateral costal expan­ sion breathing (see Chapter 25) can help respiratory func­ tion and is a good adjunct to any treatment requiring soft­ tissue or jOint mobilization of the thoracic cage. General stretching followi.ng accepted gUidelines (see Chapter 7) can be prescribed if no Joint instahility has been found. It is often necessary to make the patient aware of the distinction between stretch and pain, which can be difficult 'vvhen gen­ erali zed pain and aching is chronic and patients have learned to disregard these Signals. Limiting stretches to specific areas of restriction ensures a more manageable program, modeling the concept of pacing and prioritizing for the patient. In introducing these exercises, it may be useful to sug­ gest that the patient choose a pleasurable place at a time when interruptions are minimal. Enjoyable background music can be played Defining this experience to the

252

Therapeutic Exercise: Moving Toward Function

patient as a pleasurable and relaxing one that can have a positive impact on symptoms of FMS allows clinicians to reinforce success through an achievable task, builds patient confidence in the use of exercise therapeutically, and may help modify unrealistic beliefs about exercise.

Pain The patient with fibrornyalgia by definition has widespread pain and tenderness. During the intake evaluation the pa­ tient may also discuss isolated areas of jOint pain. It is help­ ful to assess both the fibromvalgia and biomechanical as­ pects of the patient's sYl11pt~l11~ and treat biomechanical faults (which may be postural, traumatic, or from some co­ existing medical condition) as part of the whole approach. Elimination of pain ofbiomechanical origin (e.g. , shoulder impingement resulting from abducted and downwardly ro­ tated scapulae ) by using hands-on or muscle balancing techniques will contribute to a decrease in emotional and phYSical stress, increase the sense of control, possibly elim­ inate a source of sleep disruption , and may better allow participation in an exercise routine aimed at the FMS symptoms without fUither exacerbating the fault. Although aerobic and strengthening exercise have been shown effe ctive in decreasing pain and tenderness in FMS, a systematic review of studies 87 has also shown that adherence and increased symptoms are problematic to some patients with FMS. Careful monitoring and adjust­ ing of the exercise program for each patient, together with ongOing teaching about the rationale for exercise, may be useful in managing pain and apprehension, and maximiz­ ing adherence. Transient relief of pain can be gotten from thermal and electrical modalities (see discussion in "Adjunctive Thera­ pies and Patient-related Instruction" later in the chapter), and patients can be taught self application techniques. However, because pain may be central in origin, it is un­ likely these will prOvide any long-term relief, but may offer the patient an increased sense of control over pain. Cognitive behavioral therapy and neuropharmacologic approaches are useful in pain management, and the physi­ cal therapist who works wi.th patients wi.th FMS should be familiar with the outlines of these therapies in order to sup­ port efforts being made by otl1er providers in conjunction 'v\lith exercise therapy.

PRECAUTIONS AND CONTRAINDICATIONS Exercise can be a two-edged sword for patients with FMS or CFS. Overexertion can lead to a relapse or exacerbation of symptoms. lO . ].'5,42 ,nS l Because most persons with FMS or CFS have experienced this phenomenon, they may re­ sist the idea of exercise, and adherence to an exercise pro­ gram may be difficult.

Adherence In a helpful article that reviews factors influencing,gatient adherence to an exercise routine , Jensen and Lorish high­

light the importance of the patient's beliefs about the nature of the disease and the benefits of exercise. They point OUi that the process of negotiating for mutual therapeutic goal is an impOItant part of treatment. Although the therapb: may be modeling goals on a pathophysiologic concept of th. disability, the patient's view is probably different. The pa­ tient's view is shaped by his or her perception of the dis ability and its effects, what he or she perceives to he help ful, and treatment goals and activities that are impOIt personally, The therapist has the opportunity to influen these beliefs and pOSitively affect treatment and adheren with the program through a process of mutual informatim. sharing, listening, trust building, and negotiation. Adherence with exercise programs may be problematit Patients with FMS and CFS may feel as if their energy rt>­ serves are nearly depleted and may want to avoid exerci Patients may fear exercise based on past experience \\; exacerbations after overexertion, As more is being learn about the treatment of these conditions, patients may see. exercise prescription based on the encourage ment of th physician or knowledge gained from support groups, litt:­ ature, or word of mouth. Patients may hope for the cJm'­ cian to reconcile the apparent discrepancy between th experiences and what they are told is helpful, making it ea' ier for the clinician to convince the patient about tl1e be efits of exercise. One function of the initial assessment is to proVide opportunity for exchange of information. Another is to mutual goals. During the assessment, the clinician show. listen to and attempt to understand the patient's pOint view. In this way, the patient can develop confidence in br· ing part of a team. These are important processes in prc­ moting the patient's adherence to an exercise program (5 Chapter 3).

Clarity of Instruction Mental fog and poor memOIY are frequent complaints patients witl1 FMS and CFS, Clear written and drawn i structions should be given the patient, and the patient performance of the exercise based on these instructio should be reviewed periodically. A checklist of all pr.­ scribed exercises may be useful for selected patients.

Pacing Pacing is crucial for patients who are chronically fatigued.' For many persons, exercise conjures up images of a we know11 athletic clothing company's famous exhortation ~ "just do it." This is one patient belief that may be useful ~ explore. A patient may fear that exercise means jogging Ii 3 miles. For people who have been active exercisers befo the onset of the disease, the inability to meet this expect. tion may be a source of grief or frustration. The concept therapeutic exercise and the importance of pacing needs be carefully explained. Another frequently encountered expectation is th ~ exercise can help control weight. It is common [I weight gain to occur with these conditions , partially be­ cause of inactivity and the effects of some medications. I is important for the patient to understand that therapel ­

Chapter 13 Therapeutic Exercise for Fibromyalgia Syndrome and Chronic Fatigue Syndrome ~.

rcis e must be sluwly introduced to monitor reac­ and to teach pacing. The initial disparity of goals lead to nonadherence to the program, whereas a er mutual understanding of goals may prevent frus­

to be ready to discuss its importance if the patient is cuncerned.

n.

ADJUNCTIVE INTERVENTIONS AND PATIENT-RELATED INSTRUCTIONS

tost patients have experienced symptom flares with "e_·ertion . Initiating an exercise routine requires start­ _ Jowly, with few repetitions (three to five may be uh the first tim e), light resistance (none to very mini­ . and a limited number uf exercises (usually, three is :lah). Feedback 24 to 48 hours after exercise is neces­ - fo r pacing the progression of the program. Sometimes, tient who is progressing the intensity and duration of . 'vity has a setback unrelated to exercise and needs to porarily drop back to earlier levels of performance. .oonition and applause from the patient and the clini­ or efforts to pace and avoid overexettion and avoid helps in redefining the value of exercise for the ent. The training index is one form of monitoring that can ~ ed to help the patient in pacing. The training index originally introduced for use with cardiac patients by ..berg 90 and modified by Clark91 for use with patients F\1S. This is a quantitative measure of exertion on simple calculations using pulse rate and the du­ of exercise. The training index provides target val­ for basic cardiovascular fitness, which may be used by ents to track their progress toward these goals (see Pa­ t-Related Instruction: Determining the Traihing In­ to Track the Level of Exertion in Chapter 12). Some -ents may find it helpful to keep a diary of daily activi­ _ to monitor possible correlations between symptoms ctivity levels, and this may also be a useful pacing

nsiderations in the Application Exercise

p

253

piric findings suggest that exercise approaches requir­ .: high numbers of repetitions or static holding should a\' ided by patients with FMS. Exacerbations of FMS triggered in one study that looked at the effects of titive dynamic muscle contraction and sustained 'c muscle contractions in patients with FMS and in entary, healthy control subjects. It was found that, 24 rs after exercise, exercise-induced extremity pain not returned to preexercise levels in patients \-vith f .38 In the past, eccentric exercise was avoided by patients th FMS because muscle pain in FMS was believed to .- caused by unrepaired muscle fiber damage with exer­ and because normal muscle eccentric exercise was wn to create more muscle damage HI However, evi­ !lce suggests that patients with FMS are not more sus­ -ptible to activity-induced muscle damage than healthy bjects 43 In one study in which exercise-induced pain monitored in patients with FMS, insignificant differ­ ces in self-assessed pain were found in response to con­ entric and eccentric forms of exercise. 15 Unfortunately, e avoidance of eccentric exercise has become a "rule" r many people with FMS, and the therapist may need

Treatment of FMS and CFS typically is multidisciplinary, and the therapist shuuld be aware of other intervcntion strategies that are being used. The list of caregivers for a patient with FMS or CFS may include an internist. rheumatologist, acupuncturist, occupational therapist, massage therapist, naturopath, psychologist, biofeedback therapist, and physical therapist. Planning an exercise routine for a fatigued patient who is seeing multiple prac­ titioners requires care, con sideration , and commu­ nication. DUling physical therapy, interventions adjunc­ tive to exercise are useful. Some of these include myofascial techniques , massage, and other manual ther­ apy techniques.

Pharmacologic and Psychologic Intervention Pharmacologic therapy is based on findings of neurohor­ monal alterations and sleep disruption in CFS and FMS and on treating associated symptoms (e.g., fever in CFS, muscle pain and gastrointestinal irritation in CFS and FMS) . Low­ dose tricyclic medications, which in much larger doses act as antidepressants, may be beneficial in addreSSing pain and sleep disruption. Selective serotonin-uptake inhibitors may help the fatigue component. 83 Buchwald 74 points to anec­ dotal reports of antiviral and immunomodulating drugs in the treatment of CFS. Simms 8.1 offers a complete review of the pharmacologic treatment of FM S. The association of pain, fatigue, and disordered sleep of FMS and CFS with psychologic status is controver­ sia1. 31 ,92-94 This controversy is stressful for many patients. h As Hendriksson's studies pOint out, the effects of these chronic, long-term conditions can be profound. 5 ,s Aside from the question of any possible causal relationship be­ tween psychopathology and CFS or FMS, various types of psychotherapeutic and educational interventions aimed at teaching coping strategies and at adjustment to lifestyle changes have been found to be beneficial. One studl5 showed a 63 % rate of return to work by pa­ tients with CFS after 1 year of cognitive behavioral ther­ apy, and a study by Buckelew and coworkers 96 correlated higher self-efficacy with less pain and impairment in phys­ ical activities for patients with FMS . Self-efficacy can be defined as a belief that one can successfully do a thing . Self-efficacy has been shown to impact behavior, motiva­ tion , thoughts , and emotions .96 A meditation-based stress­ reduction program was also shown to be effective in im­ proving physical symptoms. 97 Because CFS and FMS may be long-term, life-changing conditions, individual and group psychotherapy may be beneficial. In a review of pro­ grams using education for self-management of FMS , Burkhardt and Bjelle 98 concluded that self-efficacy and life quality can be enhanced for patients who undergo even short-term intensive treatment , with improvement

254

Therapeutic Exercise: MovingToward Function

SELF-MANAGEMENT 13-1 Neuromuscular Relaxation of Suboccipital Muscles

Fibromyalgia Syndrome and Chronic Fatigue Syndrome For information about fibromyalgia or chronic fatigue syndrome, contact one of these organizations: The Arthritis Foundation is an excellent source of information, has support groups, and provides leadership training. Phone numbers of local chapters can be found in phone books. Fibromyalgia Alliance of America provides patient information and support group resources. FMAA P.O. Box 21990

Columbus, OH 43221-0990

(614) 457-4222 Chronic Fatigue Immune Deficiency Syndrome Association of America, Inc ., provides patient information, support group resources, and data on research, treatment, and conferences. CFIDS Assoc. P.O. Box 220398

Charlotte, NC 28222-0398

800-848-7373

lasting beyond the end of the program. Several organiza­ tions sponsor support groups and education classes throughout the United States and Canada (see Patient-Re­ lated Instruction 13-1 : Organizations for Information About Fibromyalgia Syndrome and Chronic Fatigue Syn­ drome ).

Patient-related Instructions The use of ice, heat, and electrical stimulation to modify the pain of FMS and CFS may help with general patient comfort and with adapting to the effects of exercise. It is important to teach patients to apply the therapeutic modal­ ity so they can use it independently in coping with these conditions . Moist heating packs (rice bags that can be made for less than a dollar and heated in the microwave ), ice cups or probes and ice packs, and fluoromethane spray and stretch are all effective treatments. Their use is covered in an ex­ cellent self-help book by Penner. 99 Alpha Stirn (form of microcurrent stimulation) is ap­ proved for use in helping with sleep and pain. It tends to be tolerated well by people with CFS and FMS compared with transcutaneous nerve stimulation. Temporomandibular joint, shoulder, craniovertebral joints, rib , lumbar spine, and patellofemoral pain resulting from jOint malalignment, headache, and periarticular spasm are encountered by patients with FMS and CFS. It is important to teach these patients self-mobilization or neuromuscular techniques to use in conjunction with ex­ ercise aimed at balancing the muscles around the affected joints (see Self-Management 13-1 : Neuromuscular Relax-

Purpose:

To restore normal length to one group of suboccipital muscles and to decrease craniovertebral compression and possibly relieve headache Lie on your back with your knees bent and Position: neck supported on a small pillow or towel roll. Movement r"1 ." :.",. Gently tuck your chin without lifting your head. Hold for 6 seconds. Relax.

Dosage

Repetitions ________ Frequency ________

ation of Suboccipital Muscles ; Self-Management 13-': Neuromuscular Relaxation of a Second Set of Suboccipit Muscles; Self-Management 13-3: Neuromuscular Rela;.­ ation of a Third Set of Suboccipital Muscles ; and Sel­ Management 13-4: Neuromuscular Relaxation of Tigl Rib Joints ). This helps to make them independent in co ing with the effects of their conditions and may help the· progress in their strengthening routines because the; less interrupted by pain.

-1(~_YJPJil~~-

.,..~-OO •

• FMS and CFS are increasingly recognized in clinic p tient populations , have Widespread effects, and li m functioning. • The cause of FMS is unclear; CFS may be viral in ori • Exercise appears to be one of a few effective treatme for FMS and possibly for CFS. • Because of the fatigue and ease of symptom exacerh lion with exertion, exercise prescription must be dar carefully and thoughtfully, tracking responses cantin ously. • Exercise for the treatment of FMS and CFS can be e pected to address stress, posture, and mobility impai­ ments; impaired muscle performance; and cardiovas lar endurance. • Exercise should be introduced slowly and progress from exercises likely to lead to success to those that m

Chapter 13 Therapeutic Exerci se for Fibromyalgia Syndrome and Chronic Fatigue Syndrome

flar

Neuromuscular Relaxation of a Third Set of Suboccipital Muscles

SELF-MANAGEMENT 13-3

Neuromuscular Relaxation of a Second Set of Suboccipital Muscles

SELF-MANAGEMENT 13-2

rpo e.

Ition:

255

Purpo e:

To restore normal length to a second set of suboccipital muscles and to decrease craniovertebral compression and possibly relieve headache Lie on your back with your knees bent and neck supported on a small pillow or towel roll.

Position: Movement

technique:

vement hnique:

Glide your head to the right without bending your neck. ith one finger tip on the bone behind your right ear, gently _wsh your head to the right, but resist isometrically with ur neck muscles. ~ Id for 6 seconds. - "peat on the opposite side.

age Repetitions _ _ _ _ _ _ __

Frequency _ _ _ _ _ _ __

To restore normal length to a third set of suboccipital muscles and to decrease craniovertebral compression and possibly relieve headache Lie on your back with your knees bent and neck supported on a small pillow or towel roll. Lift your chin about one·eighth of an inch,

so your head tips back. Bring your right ear toward your right shoulder one-eighth of an inch, so your head tips to the right. Turn your head one-eighth of an inch to the right, so your heads rotates to the right. With one fingertip on the right temple, gently push your head back to the left, but your neck muscles resist so no motion occurs.

Oosage Repetitions _ _ times on each side (do not alternate) Frequency _ _ _ _ _ _ __

be Jlpair­

e e.­ II rna

more stressful. Relaxation, breathing, stretching ex­

reises, and gentle, limited walking exercises can

rogress to strengthening and to slowly progressing aer­

ie exercises. hysical therapy treatments should always attempt to -nodel the concepts of pacing and limiting overexertion m d overcommitment as they apply to daily activities of the patient and in therapeutic exercise. The physical therapist should attempt to encourage ~ood communication and establish mutually acceptable goals in an attempt to contribute to the patient's adher­ ence to the exercise program. _-\ robic exercise should be progressed slowly, be non­ jarring, and be pleasurable if possible. During physical therapy treatment , patients often are undergoing adjunctive treatments from other medical diSCiplines, which may stress them in tenm of energy, ti me, and money. The therapist should be aware of the ther commitments and help the patient prioritize real­ istically. The use of physical agents for pain control should be taught as self-treatment techniques, because using clinic time for their application may not be the best use of the patient's resources. Patients should be taught appropriate self-mobilization

or neuromuscular techniques to cope with chronic biomechanical faults so that they have tools to manage their condition independently.

CRITICAL THINKING QUESTIONS 1. Outline the questions you would ask in the subjective

2. 3. 4.

5.

portion of an evaluation of a patient with FMS. Be sure you cover the areas of their presentation that may affect development of the condition and that may contribute to its exacerbation. What physical tests and measurements would you per­ form in the objective portion of the evaluation? What forms of exercise would you need to introduce over time to the patient with FMS? List the order in which you would probably introduce the various types of exercise over the course of treat­ ment of the FMS patient. Discuss speci al considerations for in troducing exercise.

256

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 73-4 Neuromuscular

Relaxation of Tight Rib Joints

Purpose: Position:

Movement technique:

To decrease tightness atthe rib joints and decrease posterior costovertebral pain With help of your therapist or after you are experienced, push on the rib in the front that corresponds with the level of pain on the back. Even though this might not have seemed painful to you until you touched it, it will almost feel like a red-hot type of pain if it is the correct level. The place you push in front is on the same side as the back pain and near where the rib attaches to the sternum. After you have located the spot, place the fist ofthe same-side hand flat against the spot. Press the opposite hand on top of your fist; your elbow on the side of the pain sticks out.

Stand next to a wall or have a partner gently resist that elbow as it starts to elevate from your side. Hold for a slow count of 6. Be very gentle with resistance.

Dosage Repetitions _ _ times on each side (do not alternate) Frequency ________

6. List the functional goals of physical therapy treatment that would be appropliate for this clinical population .

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Chapter 13: Therapeutic Exercise for Fibromyalgia Syndrome and Chronic Fatigue Syndrome

R

~l oldofsky H. Sleep and fibrositis ~o rth Am 1989;15:90-103.

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257

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Therapeutic Exercise Movi ng Toward Function

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84 . Hicks JE. Exercise in patients \vith inflammatory arthritis and connective tissue disease. Rheum Dis Clin NOlth Am 1990 16:84,5-<')70. 85. Borg GAV. Psychophysical basis of percC'ived exertion. M Sci Sports Exerc 1980;14:.377-381. 86. Essenherg VJ Jr, Tollan MF. Etiology and treatment of fl ­ bromyalgia syndrome . Orthop Phys Ther Clin North Ar. 1995;4443-457. 87. Busch AJ Schachter CL, Peloso PM , Bombardier C. ExerciS< for treating fibromyalgia syndrome (Cochrane revi ew). Th Cochrane Library, issue 3. Oxford , UK: Update softwan 2002. 88. Jensen GM, Lorish CD. Promoting patient cooperation \\it exercise programs. Arthritis Care Res 1994;7:181-189. 89. Lorig K, Fries HF. The Arthritis Helpbook 4th Ed. Readiu_ MA: Addison-Wesley, 1995. 90. Hagberg JM. Central and pelipheral adaptati'ons to train L _ in patients with coronary artery disease. Biochem Exe 1986;16:267- 277. 91. Clark SR. Prescribing exercise for fibromyalgia patien Arthlitis Care Res 1994;7:221-225. 92. Goldenbe rg DL. PsycholOgical symptoms and psychiatric agnosis in patients with fibromyalgia. J Rheumatol 19 16(SuppI19):127-l30. 93. Goldenberg DL. PsycholOgiC studies in fibrositis. Am J \ 1 1986;81:67-70. 94 . Yunus MB , Ahles TA, Aldag JC, et a!. Relationship of clini features with psycholOgical status in primary flbromyab Arthritis Rheum 1991;34:1.3-21. 95. Shaq:>e M, Hawton K, Simkin S, et al. Cognitive beha\i therapy for the CFS: a randOlll controlled trial. BMJ 19'­ 312:22- 26. 96. Buckelew SP , Murray SE, Hewett JE, et al. Self-effie-a:. pain, and physical activity among FM subjects. Arthlitis Res 1995;8:43-.50. 97. Kaplan H, Goldenberg DL, Galvin-Nadeau M. The impa a meditation-based stress reduction program on fibromyal", Gen Hosp Psychiatry 1993;15:284-289. 98. Burkhardt CS , Bjelle A. Education programs for fibromyaL patients: description and evaluation. Baillieres Clin Rhe Ul tol 1994;8:9:35-955. 99. Penner B. Managing Fibromyalgia: A Six-Vleek Course Self-Care. Helena, MT: Capital Physical Therapy, 1997.

c:..

chapter 14

Therapeutic Exercise in Obstetrics M.J. STRAUHAL

ysiologic Changes Related to Pregnancy­

pport Element

Endocrine System

Cardiovascular System

Respiratory System

ysiologic Changes Related to Pregnancy­ ase Element

Musculoskeletal System

erapeutic Exercise Intervention for Wellness

Precautions and Contraindications

Exercise Guidelines

Exercise Intensity

~xercise Classes

- erapeutic Exercise Intervention for Common pairments Adjunctive Interventions ormal Antepartum Women

High-risk Antepartum

Postpartum

- erapeutic Exercise Intervention for Common "'pairments Nerve Compression Syndromes Other Impairments

the moment of conception, pregnancy profoundly al­ a woman's physiology. Every system in her body O'es during the childbearing year to provide for the di­ needs of fetal growth and development, meet the tabolic demands of pr-,nancy, and protect her normal iologic functioning. 1 By cons idering the, e changes, physical therapist can carefully implement a therapeu­ e.·ercise program that is safe for the mother and fetus. _rapeutic exercise may be prescribed to pregnant "llen for several reasons: • Primary conditions unrelated to pregnancy • Disorders related to the physiologic changes of preg­ nancy, such as back pain, faulty posture, or leg cramps • Physical and psychologic benefits • Preventive measures (Display 14-1 ) Women are usually healthy and highly motivated at this e of their lives, and the physical therapist has the op­ :tunity to introduce important lifestyle changes. Thera-

DISPLAY 14-1

Possible Benefits of Prenatal Exercise • Preservation or increase of maternal metabolic and cardiopulmonary capacities Hitness) • Facilitation of labor, endurance for labor and delivery, possible decreased perception of pain, and improved relaxation • Promotion of faster recovery from labor • Promotion of good posture and body mechanics • Prevention of injury and protection of connective tissue at risk because of laxity • Prevention of low back pain, diastasis recti, and urinary incontinence • Psychologic benefits-improved mood, body image, and self-esteem and reduction of postpartum depression • Assistance in the management of gestational diabetes • Prevention of excessive weight gain • Improvement of muscle tone • Decreased risk of venous stasis, deep vein thrombosis, varicose veins, edema, and leg cramps • Decreased risk of bone loss because of high circulating estrogen levels • Reduction of postdate deliveries Data from references 5, 6, 40, 50, and 60.

peutic exercise during this phase in life can play an impor­ tant role in immediate intervention and in prevention of dysfunction and disease in the future.

PHYSIOLOGIC CHANGES RELATED TO PREGNANCY-SUPPORT ELEMENT Physiologic changes related to pregnancy include signifi­ cant alterations in the maternal endocrin e. cardiovascular, respiratory, and musculoskeletal systems.

Endocrine System The endocrine system orchestrates the hormones that me­ diate changes in soft tissue and smooth muscle. Various lev­ els of relaxin, estrogen, and progesterone cause fluid re­ tention, grovvth of uterine and breast tissue , greater extensibility and pliability of ligaments and joints, and a re­ duction in smooth muscle tone. Hormonal changes and structural adaptations alter gastrointestinal function. 3 Nau­ sea, vomiting, changes in appetite, constipation , heartburn, 259

260

Therapeutic Exercise Moving Toward Fu nction

and abdominal pain may interfere with a pregnant woman 's ability and motivation to perform an exercise program. The thyroid gland enlarges moderately during preg­ nancy because of hyperplasia of the glandular tissue and in­ creased vasculal'itv.'3 The basal metabolic rate increases during a normal p~egnancy by as much as 15% to 30% by term (i.e.:. bilih occurring bet\veen 38 and 42 weeks of ges­ tation)l -,) The pregnant woman requires approxim ately 300 kilocalories (kca!) more per day to meet this increased metabolic need,l,2,4 Metabolic need is increased further (up to 500 kcal per day) in pregnant women who regularly exercise and with lactation (i. e., secretion of milk by the breasts) . 1.2,6,7 The thermoregulatory abilities of the body are affected by endocline changes. Increased metabolism results in ex­ cess heat that is dissipated hy peripheral vasodilation and acceleration of sweat gland activity. The pregnant woman may experience heat intolerance and many complain of fa­ tigue after only min imal exertion.

Gestational Diabetes Mellitus The pancreas adapts to the increased nutrient demands of the moth er and fetl!ls. There is a progressive rise in insulin levels during pregnancy into the third trimester. The rise in the serum insulin level, which peaks at about 32 weeks' ges­ tation, is a result of pancreatic islet hypertrophy.s Specific hormones promote maternal glucose production or de­ creased peripheral use of glucose to provide more fuel for the fetus 6 Approximately 1 % to 12% of pregnant women experience a failure of the pancreas to secrete insulin in sufflcient quantity to take care of this glucose or they expe­ ri ence a failure of the body to properly use insulin, result­ ing in hype rglycemia (i.e. , high blood sugar).8,9 Thjs is called gestatio nal diabetes mellitu.s (COM ) and is consid­ ered the most common medical complication of preg­ nancy6 The highest ~revalence of COM occurs at 24 to 40 weeks' gestation. All pregnant women should be screened for diabetes, because it can occur even when no risk factors or symptoms are present. Management consists of diet, careful monitoring of glucose levels , and possibly insulin therapy6 Because cardiovascular conditioning exercise facilitates glucose use and reduces the amount of insulin needed to keep blood glucose levels normal, it may play an important role in th e management of COM.fi,lo-in One study docu­ men ted th at women with COM training with arm ergome­ try lowered le,:els of glycemia better than \,.,ith dietary changes aloney.,,16 Physical training may help avoid or de­ lay insulin tberapy.20 Further research is needed, because some studies show that prolonged strenuous exercise may induce hypoglycemia (i.e. , low blood sugar) faster in the pregnant than in the nonpregn ant woman. 21 Hypoglycemia metlns that levels of glucose in the bloodstream are too low to meet th e body's energy needs. In pregnancy, hypo­ glycemia may develop in women whose bodies cannot ad­ just to the increased glucose requiremen ts of the fetus, with or without exe rcise 22 Some pregnant women feel bet­ ter when they eat frequent, small, high-protein meals with an emphasis on complex carbohydrates (ie., whole grains,

fruits, and vegetables ) rather than simple sugars (i.e., S\Neets). 23

\Vhether or not maternal glucose control improves, ex­ ercising three to four times each week for 30 minutes does improve cardiorespiratOlY fitness in pregnant women with COM l l Because overt diabetes mellitus develops in ,50%: or more of women ",vith COM , they are at greater risk for cardiovascular complications 6 Pregnancy prOvides an ex­ cellent opportunity to educate these patients, instruct them in an exercise program, and st res~ the importance of con­ tinuing exercise after delivery.2'1,20

Cardiovascular System Maternal hemodynamic changes include a blood volum~ increase of 30% to 50% that peaks in the middle of thE' third trimester. 3 ,6,2fi The increase in maternal blood vol­ ume varies with the size of the fetus and ",vith multiple fe­ tus es (e.g., t\vins, tIiplets ) 6 In normal pregnancy, one sLxtb of the total maternal blood volume is within the uterin vascular system. 3 An increase in kidney blood flow im­ proves removal of metabolic waste associated with fetal growth resulting in increased urine production and fre­ quency. Increased skin blood flow helps with heat dissip"­ tion but makes the pregnant woman appear flush ed.

Anemia Hemoglobin levels fall progressively because of a great increase in plasma than of red blood cells,l,2,4-fi A dE'v­ ciency in red blood cells, hemoglobin, or both is called Ollt­ mia and during pregnancy has been called phYSiologic d'­ lutional anem,ia (i.e., 15% below nonpregnant level~ Many cases of anemia are caused by iron deficiency, Ix­ cause the body uses iron to produce hemoglobin. In pre£:­ nancy, iron stores are heavily called on to increase bloo volu :!le and to provide hemoglobin for the placenta and fE-­ tuS .21 - 2fJ Women are usually prescribed supplemental ir to prevent anemia during pregnancy and during breas;. feeding. Symptoms of mild iron defiCiency may be exp enced early in pregnancy and include fatigue, lighthead~ ­ ness, and decreased tolerance for exercise. Hemoglobin conce ntration determines the oxyge carrying capacity of the blood. The amount of oxygen tra ferred across the placenta is influenced by maternal and tal hemoglobin concentrations. 6 The relative difference ' t\veen red blood cell volume and plasma volume does i interfere \vith oxygen distribution to various organs durn_ pregnancy as might be expected. Changes in cardiac 0 " put, stroke volume, and heart rate contribute to an incre' in oxygen distribution 6 When a pregnant woman exerc' many of the variables that determine the transfer of ox)'g' across the placenta are affected. Physiologic adaptations . pregnancy and to exercise appear to be complement and fetoprotective. 30-33 Contributing to oxygen distribution is an increase in cc diac output by 30% to 50% and an increase in resting p by 8 beats per minute (bpm ) in the early weeks of pre . nancy to a plateau of about 20 bpm at 32 weeks. 1-3,6 D ing normal pregnancy, cardiac output is influenced b~' creased maternal weight, basal metabolic rate, and bl

Chapter 14 Therapeutic Exercise in Obstetrics

_e __ e ­

lem

olume and by decreased arterial hlood pressure and vas­ -ular resistance. Hormonal chal1ges inf1uence the decrease in total sys­ emic vascular resistance by 25% and in total peripheral scular resistance by 30%. This helps to balance the .bange in cardiac output and produces an arterial blood ressure decrease of 5 to 10 mm Hg for the duration of the regnancy.l.2,4.5 Peripheral vasodilation keeps the blood ressure within normal limits despite the increase in blood u lume during pregnancy.3

""upine Hypotensive Syndrome dy position also inf1uences hemodynamic changes. As regnancy progresses, supine hypotension or inferior vena d\'a syndrome may develop when the backlying position is urn d.34 The aorta and inferior vena cava may be oc­ uded by the increased weight and size of the uterus (usu­ y after the fourth month of pregnancy). The obstruction '-enous return and subsequent hemodynamic adjust­ nts from aortic compression decrease cardiac output l -4 esearch suggests a variety of factors involved in deter­ ;ning the possible severity and significance of supine hy­ tensive syndrome (SHS).34 Signs and symptoms of SHS presented in Table 14-l. The American College of Ob­ etriciaJ1s and Gynecologists (ACOG) recommends that Q'Tlant women avoid the supine position after the first "1ITlester>") A physical therapist with a thorough under­ ..mdin a of SHS and the rationale behind position changes take a f1exible approach to treatment and exercise in 'upine position and reduce the alarm and paranoia oc­ ionallv associated with SHS. ome' women are asymptomatic during documented se­ re supine hypotension (arterial pressure of 80/40 mm ! or report symptoms before or after the hypotenSive . ode. The vaJiability in signs and symptoms may ref1ect erent degrees of ref1ex autonomic activation.·34 As many 60 % of women may experience symptoms at some time

during pregnancy, but the incidence of true SHS is about 8%, with risk peaking at 38 weeks' gestation 3 + Cappe and

Surks 'G estimated the incidence of severe cases of SHS to be less than 1(lc of the 2,000 women they studied. Other studies report that there is sufficient uteroplacental perfu­ sion even if aortocaval circulation is diminished over time. 36 The earliest sign of impending SHS is an increase in ma­ ternal heart rate and a decrease in pulse pressure. Sponta­ neous recovery usually occurs vvith a change in maternal position, even if very slight. 3•4 ,.'J4 Maximum venous return and cardiac output are obtained in the left lateral recum­ bent position, but the right lateral recumbent position also reduces symptoms. 1.2 ,4,:t4 SHS is confined almost exclusively to the supine posi­ tion, although anatomic anomalies (e.g., bicornuate uterus, whid, has two horns or horn-shaped branches) may predis­ pose a small number of women to symptoms in sidelying positions. Prolonged and motionless standing also can oc­ clude the inferior vena cava and the pelviC veins during pregnancy, decreaSing cardiac output, increasing venous pressure, and contributing to edema and varicosities in the lower extremities. 3 Awareness of hemodynamic changes and SHS becomes important to the physical therapist when perform ina man­ ual therapy techniques or prescribing exercises that require supine positioning or prolonged standing. Accommodating to a more upright or sidelying position (espeCially in the third trimester) or frequent position changes may be ap­ propriate when working with patients at risk for SHS. Sug­ gestions for position changes include placing a small wedge or pillow under the right hip in supine, raising the head and shoulders 20 to 30 degrees, semisitting, prone (on a speCial SUppOlt orwith use of pillows or wedge to decrease abdom­ inal compression and ensure patient comfort), or quadruped (i.e., all-fours position). Changing positions from lying to uplight should be done cautiously to decrease

Supine Hypotensive Syndrome SIGNS

SYMPTOMS

SIGNS IN SEVERE CASES

Pallor or cyanosis Muscle tWitching Shortness of bre ath Hyperpnea Yawning

Faintness Dizziness Re stlessness Nallsea and vomiting CI-wst and abdominal discomfort or pain Visual disturbances Numbness or paresthesias in the limbs Headache Cold legs \,Veakness T innitus Fatigue Desire to flex hips and knees Anguish

Unconsciousness Incontinence Impalpable pulses A lifeless appearance Convulsions

Diaphoresis Cold, clammy skin A vvild expression SyncopC'

Data fro m refe rences 34 and 36.

261

Cheyne-Stokes respiration

262

Therapeutic Exercise: Moving Toward Function

symptoms of orthostatic hypotension. Symptoms of SHS have disappeared with manual displacement of the uterus to the left or with lifting of the uterus in supine. 34 Con­ versely, SHS has been induced by abdominal pressure, which should be considered when positioning a patient in prone or when prescribing a maternal external support that may put pressure on the abdomen. 34 The physical therapist should encourage the pregnant woman to shift pOSitions fre­ quently during exercise, work, and treatment to avoid stasis and hypotension. Because supine positioning during labor has been associated with a lower fetal m.:ygen saturati~m , po­ sition changes apply to the laboring woman as we1l 31

Respiratory System The respiratory system also adapts to the many changes of pregnancy. Hormonal changes produce increased mucus in the respiratory tract with associated increases in sinus and coldlike symptoms. 1 .4 The upper respiratory tract may become predisposed to coughing and sneezing, increasing the likelihood of stress urinary incontinence in the preg­ nant woman \vith weak pelvic floor and abdominal muscles. The diaphragm is displaced upward about 4 cm, but diaphragmatic excursion is increased. 1, .4,6 An increased pulmonary ventilation rate (i.e., the total exchange of air in the lungs measured in liters per minute) during pregnancy is achieved by the woman breathing more deeply, increas­ ing tidal volume (i.e., the amount of gases exchanged \vith each breath).1 -3,6 The respiratory rate increases only slightly (approximately 2 bpm), but there is an associated increase in respiratory minute volume , which is the amount of air inspired in 1 minute. 1-4,6 Lung compliance increases, and airway resistance decreases from the relaxing effect of progesterone on smooth muscles,6 This has been referred to as hyperventilation of pregnancy. Although arterial blood gases reflect an increase in m.:ygen and a decrease in carbon monoxide, causing mild respiratory alkalosis, this is not true hyperventilation. This mild maternal alkalosis pro­ motes placental gas exchange and prevents fetal acidosis. 6 It may be perceived as dyspnea at rest and dUling exercise or as a decrease in the tolerance for exercise and exertion. In early pregnancy, it is unrelated to the encroachment of the uterus on the diaphragm. Later, as the lower costal girth is increased, greater breathing movement takes place at the middle costal and apical regions compared ,vith the abdomen .38 Pregnancy is characterized by a 10% to 20% increase in oxygen consumption that, combined with a reduction in functional residual capacity, results in a lower oxygen re­ serve 6 ,39 Exercise produces an increased demand for OJ..),­ gen and risks the possibility of blood now being shunted from the uterus to the active skeletal muscles , although re­ search has not proven this to be true 6 Some studies show this increase in oJ..)'gen demand to be more dramatic dUling weight-bearing exercises, which are more ener~ costly in pregnancy because of the extra body weight. 6, With in­ creasing body weight, more oJ..)'gen is required to exercise, and a woman reaches her maximal exercise capacity at a lower level of work. 40 Maximal exercise capacity of most pregnant women declines by approximately 20% to 25% in the second and third trimesters of pregnancy.6 Pregnant

bl

women should be advised to decrease workloads later in pregnancy, when fetal demand is at its greatest. 38

PHYSIOLOGIC CHANGES RELATED TO PREGNANCY-BASE ELEMENT Musculoskeletal System The physical therapist is perhaps best suited to deal \vith the multiple musculoskeletal changes that occur in re­ sponse to pregnancy. Many of these changes may make the childbearing woman more vulnerable to injury and pain" Although the physiologic and morphologic changes in pregnancy are normal, musculoskeletal symptoms should not be considered normal despite the fact that they are common. Optimal weight gain by the mother during pregnancy i important to pregnancy outcome, but a wide range i weight gain is compatible with good clinical outcomes ,l The pattern of weight gain may also have important impli­ cations. Birth weight of the infant parallels maternal weigh< gain , and overwe ight and underweight women face in­ creased risks during pregnancy. There are potential haz­ ards for the mother and the infant when weight gain is re­ stricted, and exercise should not be used to decre
Chapter 14 Therapeutic Exercise in Obstetrics

-! cm of elevation of the diaphragm. 1--4 Chest circumference

increases by 5 to 7 cm. In the last himester, the tnmk may rotate to the right as the growing uterus rotates to the right On its long axis. This dextrorotation most likely occurs be­ cause of the position of the rectosigmoid (Le., lower portion of the sigmoid colon and upper portion of the rectum) on the "eft side of the pelvis. 1,2.6 Changes in hormones contribute to joint laxity and subsequent hypermobility. This joint laxity contributes to creased foot pronation during pregnancy. Poor foot 'gnment affects the mechanics of the lower kinetic ~hain. Unlike other jOints in the body that return to their normal prepregnancy position, the foot may not. 3 The postpartum woman may notice a permanent increase in hoe size. Because laxity and weight gain change foot liomechanics, pregnant women should be advised regard­ ng proper footwear and possibly orthotics for support ~ e Chapter 22). Postural changes in response to pregnancy can be fur­ • er exagge rated by work, activities of daily living (ADLs), -ecreation, and exercise. Hormonal changes facilitating aamentous laxity, softening of cartilage, and prolifera­ on of synovium also influence postural changes and pos­ ibly contribute to injuries during more strenuous move­ ent. Because these mechanical changes may aggravate reexisting conditions, it must not be assumed that a _regnant woman's complaints of aches and pains are al­ 'ays a result of the pregnancy. There may be reluctance .0 give credence to musculoskeletal complaints of preg­ ancy and postpartum. The consequence may be under­ ~e ferring to physical therapy and limited function in this population.

HERAPEUTIC EXERCISE INTERVENTION FOR WELLNESS [ \. ry pregnant woman adapts differently to the physio­ !tic changes of pregnancy. Age , level of fitness, previous .illd current exercise history, and concurrent adaptations to the changes of pregnancy must be considered when the hysical therapist designs a therapeutic exercise program r the childbearing client. Research focused on physical activity in the workplace as identified four physical stressors that are associated ith an increased incidence of prematurity and low birth \'eight, both factors of poor pregnancy outcome : quiet tanding, long hours, protracted ambulation , and heavy lift­ ' ng.41 It is beiieved that these activities cause intermittent hut protracted reductions in uterine blood flow. Research ocuse? on recreational exercise during pregnancy has not identified similar associations but rather indicated an over­ .ill positive impact on pregnancy outcome.42A :3 The interac­ tion between the phYSiolOgiC adaptations to exercise and pregnancy appear to improve maternal cardiovascular re­ e rve, maternal heat dissipation, placental growth, and fu nctional capacity.42 Women who engage in active exer­ cise during pregnancy have fewer of the common discom­ forts associated "vith pregnancy, such as swelling, leg (Tamps , fatigue, and shortness of breath 44 .4 .5 Some studies ave shown a reduction in the duration of labor and inci­

263

dence of obstetric complications during delivery associated with maternal exercise.'*5--48 Current research suggests that moderate aerobic exer­ cise, carefully preSCribed and monitored during pregnancy, is safe and benefiCial for the mother (even if previously sedentarl 9 ) and the fetus. 5,6.26,30-33,42-58 Healthy, well­ conditioned women can participate in a moderate or high­ intenSity exercise program during pregnancy without ad­ verse fetal or maternal outcomes. ag However, concerns about exercise during pregnancy ex­ ist (Table 14-2). Althoucrh many of these concerns are not substantiated by researcK the guidelines for exercise err on the side of conservative management. Precautions and con­ traindications should be considered, and prudent guide­ lines should be followed in the initiation of an exercise pro­ gram for a pregnant woman.

Precautions and Contraindications Pregnant and postpartum women should be advised to seek the approval of their health care providers (e.g., phYSician, mid"vife) before engaging in an exercise program. They should be screened for contraindications or risk factors for adverse maternal or perinatal outcome. Displays 14-2 and 14-3 detail the absolute and relative contraindications to exercise in pregnancy. Limitations or modifications of the exercise program may be recommended at any time during " the pregnancy..)"- 6 40 .0-0 For example, a pregnant woman with preexisting pulmonary disease may be able to exercise, but her intensity level may vary as pregnancy-induced changes affect the respiratory system. In the presence of a speCific relative contraindication, decisions regarding exer­ cise are made in conjunction with the patient's physician and guidelines referenced in Displays 14-4 and 14-5.

Exercise Guidelines ACOG and the Melpomene Institute for Women's Health Research have published guidelines for exercise during

Exercise Risl(s During Pregnancy MATERNAL

FETAL

Hypoglycemia

Hypoxia-possibility that blood flow will be shunted from the uterus in favor of exercising muscles Distress Intrauterine grovvth retardation from alterations in energy and fat metabolism

Chronic fatigue Musculoskeletal injury from repetitive mechanical stress, changes in balance , and soft-tissue laxity Cardiovascular complications Spontaneous abortion

PreteI'm labor

Malformations Hyperthermia secondary to maternal hyperthermia, increaSing risk of neural tube defects and preterm Ilabor Prematurity Red1lced birth weight

Data from rdr'rcllc('s 5-7. 40. 50, ancl 60.

264

Therapeutic Exercise Moving Toward Function

DISPLAY 14-2

Absolute Contra indications to Exercise During Pregnancy

1. Pregnancy-induced hypertension (blood pressure >140/90 mm Hg) 2. Diagnosed cardiac disease (ischemic, valvular, rheumatic, or congestive heart failure) 3. Premature rupture of membranes (i.e., risk of prolapsed cord), leaking of amniotic fluid (especially important if exercising in

water)

4. Placental abruption 5. History of preterm labor during current pregnancy (initiation of labor before the 37th week) 6. History of recurrent miscarriage (no exercise in first trimester, but may be able to exercise after that) 7. Persistent vaginal bleeding 8. Fetal distress 9. Intrauterine growth retardation 10. Incompetent cervix 11. Placenta previa (i.e., partial or complete covering ofthe cervix by the placenta) 12. Thrombophlebitis or pulmonary embolism 13. Acute infection 14. Preeclampsia or toxemia (i.e., hypertension with proteinuria or edema) and eclampsia (i.e., hypertension, proteinuria, and edema associated with convulsions and possible loss of consciousness and cardiac arrest) 15. Polyhydramnios (i.e., amniotic fluid volume >2,000 mL) 16. Oligohydramnios (i.e., abnormally low amount of amniotic fluid) 17. Severe isoimmunization 18. No prenatal care Data from references 6, 7, 50, and 109.

pr~§~lancy and after delivery (Displays 14-4 and 14­

5)." 0.60 ACOG recommends that women who are accus­ tomed to aerobic exercise before pregnancy continue but cautions against starting a new aerobic exercise Erogram (other than walking) or intensifying training levels. i A gen­

tle-paced water aerobics class may be appropriate for th beginner. Exercise in water offers ;everal physiologic ad­ vantages to the pregnant woman.61.6~ The hydrostatic forc€' of water, proportional to the depth of immersion, produces an increase in central blood volume by pushing extravascu-

DISPLAY 14-J

Relative Contraindications or Limitations to Exercise During Pregnancy 1. Diabetes 2. Anemia or other blood disorder 3. Thyroid disease 4. Dilated cervix 5. History of preterm labor during previous pregnancy 6. Uterine contractions that last several hours after exercise 7. Sedentary lifestyle 8. Extreme obesity or underweight (including eating disorders, poor nutrition, and inadequate weight gain) 9. Overheating-high maternal core temperature may be associated with abnormal fetal development (teratogenesis) in the first trimester Swimming pool temperatures should not exceed 85°F to 90°F (29.4°C to 32.2°CI • Avoid Jacuzzi temperatures above 101°F (38.5°C) • Avoid exercising in hot, humid weather or with fever 10. Breech presentation during the third trimester 11. Multiple gestation 12. Pulmonary disease (e.g., exercise-induced asthma, chronic obstructive pulmonary disease) 13. Peripheral vascular disease 14. Hypoglycemia 15. Cardiac arrhythmias or palpitations 16. Pain of any kind with exercise 17. Musculoskeletal conditions (e.g., diastasis recti, pubic symphysis separation, sacroiliac dysfunction) 18. Medication that alters maternal metabolism or cardiopulmonary capacity 19. Smoking, alcohol, recreational drug, and caffeine consumption Data from references 6, 7, 50, and 60.

Chapter 14: Therapeutic Exerci se in Obstetrics

265

DISPLAY 14-4

General Exercise Guidelines • Exercise regularly, at least three times per week. • Avoid ballistic movement, rapid changes in direction, and exercises that require extremes of joint motion. Include warm-ups and cool-downs. Avoid an anaerobic (breathless) pace. Strenuous activity should not exceed 30 minutes; 15- to 20-minute intervals are recommended to decrease the risk of hyperthermia. Ketosis and hypoglycemia are more likely to occur with prolonged strenuous exercise. Discourage vigorous exercise or exertion in high heat and humidity, with high pollution levels, and during febrile illness. • Frequent change of positions may be required to avoid supine hypotensive syndrome, but be careful of sudden changes in posture to reduce possible orthostatic hypotension. Avoid prolonged periods of standing, especially in the third trimester. • Modify the intensity of exercise according to symptoms and stage of pregnancy. • Do not exercise to exhaustion or undue fatigue. Adequate rest is important. Rest after exercise in the left lateral recumbent position for maximum cardiac output. Exercising to the point of fatigue or exhaustion may compromise the function of the uterus, with a detrimental effect on the fetus. • Maintain metabolic homeostasis by adequate caloric intake. Increase to 300 kcal/day for pregnancy alone, 500 kcal/day more for exercising during pregnancy, and 500 kcal/day more for lactation (may vary based on prepregnancy weight). • Fluids should be taken before, after, and possibly during exercise to avoid dehydration. • Avoid gastrointestinal discomfort by eating at least 1-1/2 hours before an exercise workout. "No pain, no gain" does not apply to exercise during pregnancy. • low-resistance and high-repetition exercise is recommended. Avoid Valsalva maneuvers and encourage proper breathing during exercise. • Maternal adaptations favor non-weight-bearing exercise instead of weight-bearing exercise. Postpartum progression into prepregnancy exercise routines should be gradual. • Stop exercise or activity if unusual symptoms occur (see Display 14-5). ~ ala

from references 1-7 and 60.

~ fl uid (edema) into the vascular spaces 6 3 This may lead

increased uterine blood flow and keeps the maternal .-art rate and blood pressure lower than with land exer­ . The buoyanci of water is supportive, and water is nnoregulating.6 --64 The ~i0elin~s offered here are for the general popula­ ,3.6.1.40,.,0.60.6,,--67 These differ from those given to the 'e or professional athlete, whose risks and precautions DISPLAY 14-5

Signs and Symptoms That Signal the Patient to Stop Exercise and Contact Her Physician 1. Pain of any kind 2. Vaginal bleeding 3. Uterine contractions that persist at 15-minute intervals or more frequently and are not affected by rest or change of position 4. Persistent dizziness, numbness, tingling 5. Visual disturbance 6. Faintness 7. Shortness of breath 8. Heart palpitations or tachycardia 9. Persistent nausea and vomiting O. leaking amniotic fluid 1. Decreased fetal activity ' 2. Generalized edema (rule out preeclampsia) 3. Headache (rule out hypertension) 4. Calf pain or swelling (rule out thrombophlebitis) :31a from references 1-7 and 60.

are similar but whose training level may be more intense if closely supervised. 6.'J:3.6S,69 Several activities should be dis­ couraged or avoided during pregnancy.3,6.40.50 The preg­ nant woman should be dissuaded from participating in competitive or contact sports, and activities that have the potential for high-velocity impact that may cause abdomi­ nal trauma should be discouraged: • Horseback riding • Snow and water skiing • Snow boarding • Ice skating • Diving • Bungee jumping • Heavy weight lifting • High-resistance activities HyperbariC conditions, as in scuba diving, and activities that may promote extreme Valsalva maneuvers , as in weight lifting, should be avoided. The pregnant woman should not partake in activities that pose an increased risk to damage of jOints, ligaments, and disks secondary to hor­ monal changes (e.g., positions in which free weights may put joints into traction or stress the ligaments ). The shift in the center of gravity along with increasing weight gain puts the pregnan t woman at a hi~her risk for injury in sports that require balance and agility. 0 The pregnant woman should avoid activities and exercises in which loss of balance is in­ creased (e.g., mountain climbing, gymnastics, downhill ski­ ing, sliding into base ), espeCially in the third trimester. Caution should be used when exercising at high altitudes during pregnancy35,70

266

Therapeutic Exercise: Moving Toward Function

Exercise Intensity Exercise prescription regarding target heart rate or work­ out intensity, duration, and frequ ency during pregnancy rem ains controversial. There are drawbacks \'lith using the target heart rate formula for th e aerobje portion of an ex­ ercis e session during pregnancyf'i,26,)O It usually is ex­ pressed as 60% to 90% of an individual's age-predicted maximum heart rate. Wisewell et al 6 reported that the maximum l1ealt rate in pregnant women is lower than this estimated value. In pregnancy, the maternal resting heart rate is elevated over nonpregnant values by 15 to 20 bpm. 4,G y!itral valve prolapse occurs more frequently dur­ ing pregnancy and may be aggravated by healt rates above 140 hpm. G,.50 With this in mind , recommendations for the general population include the reduction of exercise inten­ sity during pregnancy by approximately 25%. A maximal heart rate of 60% to 75% is considered safe: a maximum maternal heart rate of 140 bpm for those just stalting an ex­ e rcise program and 160 bpm if previously exercising 6 ,50 Exercise intensity may also be determined by the degree of respiratory distress or rate of perceived exertion 6 These levels correlate with maximal heart rate percentages: Light: 40% to 50% of heart rate maximum Moderate: 51 % to 65% of heart rate maximum Heavy: 66% to 80% of heart rate maximum Conversing with ease during exercise indicates that the woman is exercising at the light to moderate intensity that is optimal for pregnancy6 E ndurance exercises have the additional benefit for pregnant women of preparing them for the increased exer­ tion of labor and delivery. With the fluctuation in the hor­ monal milieu , aerobic exercise is an excellent mood eleva­ tor. HO'wever, if the key postural muscles, especially those of the pelvic floor, are weak, aerobic exercise can be detri­ mental because of the added stress to those stru ctures. Wa­ ter aerobics or bicycling are appropriate forms of cardio­ vascular fitn ess that may decrease stress on weak muscles and vulnerable joints. Gl ,52

Exercise Classes Prenatal wellness can be greatly enhanced by prenatal ex­ ercise classes. Physical th e rapists ' understanding of the musculoskeletal system make them ideal instructors. An in­ dividual approach and the focus on essential muscles af­ fected by pregnancy make th ese classes different from other community-based classes . SpeCial celtification is not required to teach classes, but special continuing education in this area is recommended. Prenatal exercise classes should address the phYSiologic changes that occur during pregnancy and the therapeutiC exercises that prepare the body for these changes. Compli­ ance with exercise is enhanced when clients understand that muscIIloskeletal dysfunction and associated discomfOlt may be prevented. Many women return to these classes af­ ter delivery for continued socialization and support (see Chapter 4). Because women who have had one or more vaginal de­ Iivelies are at increased lisk for chronic back pain, classes

that target back pain prevention might be a cost-effective way to reduce disability and health care costs in the fu­ ture. 71 ·72

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON IMPAIRMENTS Focusing on the balance of muscle length and strength in key postural muscles in pregnant and postpartum women i5 extremely important. These muscles are most affected by the biomechanical changes of pregnancy. Length-associ­ ated changes ariSing from the typical kyphOSis-lordosis pos­ ture can be prevented by addreSSing the posterior neck muscles, the middle and lower trapezius muscles , the transversus abdominis (TA), external and internal oblique;; (EO and 10, respectively), hip extensors , and the pelvic floor. Adaptive shOltening is common in the anterior shoul­ der muscles , lumbar paraspinals, and hip flexors. Appro­ priate active and passive stretches should be prescribed h ­ these areas. Lumbar, sacroiliac, and pubic symphysis prob­ lems may be greatly relieved by lumbopelvic stabilization exercises and by the use of external supports during preg­ nancy.

Adjunctive Interventions Pregnancy restricts the use of many modalities, especial]. ones that increase body heat. This is especially importalI over tl1e abdomen or uterus. Hot packs are generally safe to use on the back, neck. and extremities. Ultrasound may be considered at site.~ away from the uterus, especially when treating nonpre a ­ nancy related concerns (e.g., whiplash , peripheral joint muscular injury)73 Continuous shortwave or microwa\ diathermy should not be applied to the low back, abdom·­ nal, or pelvic regions of the pregnant wo~nan because of th possible thermal effect on the fetus. 73- /S This finding only been documented in pregnant laboratory anima and , for obvious reasons, the approach has not been test on pregnant women. Ice , when properly applied , should be encouraged f muscular and joint pain and inflammation during pr__ nancy. Electrical stimulation is contraindicated duriI, _ pregnancy, except for the use of trallscutaneous electlir stimulation (TENS ) during labor and delivery. Studi have shO\vn that electrical stimulation applied to vari parts of the body may induce labor. Manual therapy ' muscle energy techniques should be used \-vith caution cause of soft-tissue laxity. Heavy traction techniques vigorous manipulations with pregnant patients should avoided 40

Normal Antepartum Women For the pregnant woman , postural awareness is \-ital \\ considering accommodations resulting from the shift in center of gravity, weight gain, and possible joint byp biJity. Frequent attention to spine and pelvis alignm (see Chapte rs 9 and 18), scapular pOSition (see Cha' 26 ), inn e r core facilitation (see Chapter 18),

Chapter 14 Therapeutic Exercise in Obstetri cs

267

h in ~nG

;lb i­

A

B

FIGURE 14-1. Th e pregnant women is performing (A) chin tucks and (B) small knee bends to minimize length­ associated changes.

patellofemoral function (see Chapter 21) can be effective in preventing le ngth associated changes in key muscles

n _

t"

Pre-!­

In

Fig. 14-1). Postural faults may be perpetuated into the postpartum period, espeCially when caring for the new in­ fant. Proper body mechanics and joint protection should be b'essed to decrease abnormal forces on joints that are at increased risk of injury because of hormonally induced laxity.

Sample musculoske letal evaluations that incorporate adaptations for manual muscle test,ing and limit the num­ be r of body position changes for the pregnant client can be found in Obstetric and GYl1 ecologic Care ill Physical Ther­ apl/ 9,76 and Clinics in Physical Therapy: Obstetric and Gy­ ecologiC Physical Therapy. 40

Impaired Muscle Performance Abdominal Strength

in

Goals for petforming abdominal exercises during preg­ nancy include improve lllent of muscle balance and pos­ tu re, support of the growing ute rus, stabilization of the tnmk and pehis , and maintenance of function for more rapid recovery ahe r delivery. Most pregnant women can perform abdominal exr,rcises in supine with frequ ent posi­ tion changes . Exerciscs such as supine hip and knee flcxion ' ith hip abduction and laterul rotation (sec Self ~dalluge­ In ent 18-.'3) and pro?,n~ ssive leg slides (see Self Manage­ ment 18-1) are appropriate as long as the neutral spine po­ i tion is maintained. In the case of an anterior pelvic tilt and lumbar lordosis , the client can be tallght to use the abdom­ inalmuscles (particularly the EO) to tilt the pelvis in a pos­ terior direction. This activity can be performed in a variety f positions (eg. , sitting, standing) and can be used to ac-

tively stretch the low back extensors and while strengthen­ ing the abdominal muscles. Bilateral straight-leg raising and leg-loweting exercises should be avoided during preg­ nancy hecause of the vulnerability of the vertebral joints and excessive pull on an overstretched abdomen. When the woman has SHS , the supine position should be avoided, and the us e of side lying, sitting, standing, and quadruped posit,ions can be creatively llsed to train the patient in ab­ dominal facilitation and neutral spine. The quadruped po­ sition i. excellent for pe rforming concentric and eccentric contractions of the abdominal muscles (see Self-Manage­ ment 14-1: Quadruped Abdominal Exercise). Pelvic Floor Strength

The pelvic floor muscle may undergo length-associated changes from the long-standing pressure of the growing uterus . Hormonall), softened tissue further complicates the increased load on the pelvic floor. A vaginal birth or a lengthy and unproductive second stage of labor (i.e., push­ ing phase) b fore cesarean section poses its problems for a vulne rable pelViC floor. There is the potential for direct trauma to the muscles with an epiSiotomy (i.e., incision in the pelvic fl oo r made during childbirth to enlarge the vagi­ nal opening and allow faster delivery), tears, or lacerations . In addition, pudendal or obturator nerve stretch injuries may occur during delivery. The importullce of pelvic floor muscle strength cannot be overemphaSized (see Chapter 1g). It plays a vital role in supporting the internal organs \e.g., rectum, vagina, uterus) by preventing dovvnward displacement (i.e., pro­ lapse or pelVic relaxation ). Pregnancy and postpartum pelvic floor dysfun ction may manifest as pelvic organ pro­ lapse, utinary or fec al incontinence, pelvic pain from mus­

268

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 14- 1

auadruped

Abdominal Exercise

Purpose:

Position: Movement technique:

To train the patient in abdominal facilitation when backlying is uncomfortable or not possible (e.g., supine hypotensive syndrome) On hands and knees 1. Concentric contraction a. Inhale, allowing the abdomen to expand. b. While exhaling slowly, pull tummy in while maintaining neutral spine. (To stretch back extensors, push lower back up and tuck chin down.) 2. Eccentric contraction a. Slowly relax your tummy, and return to the starting position.

Dosage Repetitions Frequency

cle spasm, painful episiotomy, or tears, or jOint malalign­ ment (i.e., sacrococcygeal involvement). A strong, coordi­ nated pelvic floor may demonstrate improved control and relaxation during the second stage of delivery and in post­ partum recovery. Attention to the pelviC floor muscles should occur early in the pregnancy and should continue throu~hout the duration of the pregnancy and postpartum phase 0.17 (see Chapter 19).

Impaired Joint Integrity and Muscle Length Joint Hypermobility

During pregnancy there is a greater degree of jOint lax­ ity throughout the body. Studies looking at .this in relation­ ship to serum relaxin levels are conficting. is There are no studies reporting a higher i~cidence of exercise-induced injuries du ring pregnancy. 31. ill Abdominal Muscle Length Diastasis Recti

Modifications to exercise for abdominal muscles are necessary for a woman with diastasis recti,77.79.S0 In stand­ ing, the abdominal wall supports the uterus and maintains its longitudinal axis in relation to the axis of the pelvis. 2 The muscles of the abdomen that must lengthen to accommo­

date the enlarging uterus and growing fetus in pregnancy are the external and internal obliques, transversus abdomi­ nis , and rectus abdominis . The linea alba is formed by the crossing fibers of the aponeuroses of these muscles , mak­ ing a tendinous seam from the sternum to the symphysis pubiS. Hormonal changes and the increasing mechanical stress placed on these structures during pregnancy may re­ sult in a painless separation of the linea alba. 40 The rectus muscles separate in the midline, creating a diastasis recti. The rectus muscles are normally about 2 em apart above the umbilicus and are in contact with each other below th e umbilicus. A separation.&reater than this is considered to be a diastasis recti.40.77 .1 . .130 If severe, the anterior uterine wall may be covered by only skin, fascia, and peritoneum. If extreme, the gravid uterus drops below the level of the pelvic inlet when the woman stands. The pelvic inlet is bound posteriorly by the body of the first sacral ve rtebra (promontory), laterally by the linea terminalis, ,md anteri­ orly by the horizontal rami of the pubic bones and symph­ ysis pubis.2 Descent of the fetal head below this point i called engagement and occurs normally during the last few weeks of pregnancy or during labor. Upright exercis .should be restricted if engagement occurs at any other tim during the pregnancy. 2 The presence of a diastasis recti potentially reduces the ability of the abdominal wall muscles to contribute to their role in trunk and pelvic girdle alignment, motion, and stabil­ ity; support of pelviC viscera; and by way of increasing intra­ abdominal pressure, forced expiration, defecation , urina­ tion , vomiting, and the second stage oflabor (i.e. , pushing) 4o Checking for a diastasis recti should be done beginning in the second trimester and continuing throughout the rest of the pregnancy and into the postpartum phase. To evaluat the abdominal wall for a diastasis, the pregnant woman should lie in the supine hooklying position. With chin tucked and arms extended to the knees, she should raise her head and shoulders until the scapulae clear the surface. The ther­ apist checks for a central bulge in the abdomen and, with fin­ gers placed cephalocaudally, measures the amount of sepa­ ration between the rectus muscles 2 inches above, 2 inches below, and at the level of the umbilicus. 40 •8o Each finger rep­ resents approximately 1 em (Fig. 14-2). A diastasis correction exercise can be pelfonned to main­ tain alignment and discourage further separation. This i~ performed with the woman in supine hooklying if she toler­ ates backlying (i.e., exclude SHS ). With arms crisscrossed over the abdomen, the patient manually approximates thE recti muscles toward midline, performs a posterior pelvic tilt. and slowly exhales while lifting her head . The scapulae should clear the surface77 (see Self-Management 14-2: Cor­ rection of Diastasis Recti). Exhalation prevents an increaSE­ in intra-abdominal pressure, engaging the TA first with a neutral spine 40 The additional support of a large sheet folded lengtll'wise under the patient's back may be helpful as pregnancy progresses. The two ends of the sheet are brought up and crisscrossed over the abdomen to simulate support of the abdominal wall. The patient can grip each end of thE sheet and pull outward to support the recti muscles toward the midline (see modification in Self-Management 14-2: Correction of Diastasis Recti). If diastasis is detected, pa­ tients are usually encouraged to avoid unsupported curl-ups. trunk rotation exercises, and sitting straight up from a supine

Chapter 14: Therapeutic Exercise in Obstetrics

Normal

269

B

Separated

FIGURE 14-2. (A) Comparison of a normal abdomen with a diastasis recti abdominis. (8) The therapist :hecks for a central bulge in the abdomen and measures the amount of separation between the rectus uscles.

'hon (i.e., jackknifing), because these activities may en­ .lrage further separation. ..\ an adjunct to therapeutic exercise, an external support the form of an abdominal binder, lumbopelvic support, or roiliac belt can assist the patient in achieving improved oy mechanics and postural alignment. When a diastasis is -esent, the eAiernal support helps to reestablish and main­ , normal alignment of the abdominal wall and support the _ i\id uterus to prevent further stretch weak'11ess. These pports are worn during upright exercises and ADLs. Pelvic Floor Muscle length If coccyx pain is associated with pelvic floor tension nllgia, pelviC floor relaxation or "inversed command" u t be emphasized 8 1 After ruling out the possibility of re­ ed pain from LS-S1 , the patient can be taught a self nagemen t technique to relax the pelviC floor muscles. patient is instructed to place her hand over the anal ft, plaCing the middle finger in the cleft and the other nuers on the buttocks. As she pretends to "pass gas" gen­ without straining or bearing dmVJ1, she should feel the al cleft bulge out against the middle finger. 52 This mrthens the pelvic floor and should be practiced several ~ es each day to recall the sensation. The use of a donut hion or sitting with layers of towels under the thighs y be useful in keeping pressure off the cocc)'x. 40 ,82 If pelvic floor muscle tension has caused sacrococcygeal alalignment, direct mobilization of this articulation may performed to reduce pain. 83 This technique also is ap­ ropriate for a subluxed coccyx after childbirth. 39

'TIpaired Posture-Biomechanical Element -l-- :.

pa­

pine

Lumbar lordosis may result from pregnancy, or pregnancy lay exaggerate a preexisting lordosis. Ideal postural align­ ment, as defined by Kendall,h4 involves a minimal amount of stress and strain and is conducive to maximal efficiency

of the body (refer to Chapter 9 for the definition of ideal alignment of the spine and pelvis ). During pregnancy, the center of gravity shifts anteriorly which may result in ante­ rior rotation of the ilium. This accentuates and increases the normal anterior curve of the lumbar region, creating a lordosis (Fig. 14,3) (see Patient-Related Instruction 14-1: Postural Correction). Muscle weakness resulting from length-associated changes in the abdominal muscles and the hip extensor muscles results in poor control of the pelvis (in this case, an anteriorly tilted pelvis). However, adaptations to biomechanical changes during pregnancy vary from woman to woman. Anterior pelvic tilt and lumbar lordosis have not been conSistently observed and are not necessarily associated with reports of pain.72.hl Frequent inner core activation (see Self-\llanagement 18-1) in various positions enhances muscular control and strength and the postural awareness required throughout the day to relieve pain and fatigue in the low back. A lordosis at the thoracolumbar junction may cause me­ chanical stress on the muscles and ligaments, prodUcing foraminal narrOwing. The result may be radicular irritation manifesting as pain along the course of the iliohypogastric and iliOinguinal nerves anteriorly and posteriorly-a com­ mon referral source of pain for prepartum and postpartum women. 40 Radicular symptoms may also be experienced in the upper extremities, chest, and neck because of a com­ pensatory thoracic kyphOSiS and increased cervical lordosis. Changes in the transverse diameter of the chest may me, chanically aggravate preexisting costovertebral or thoracic joint dysfunction. Thoracic kyphOSiS may develop during pregnancy and persist postpartum. Wall slides with the back to the wall (see Fig. 26-23) faCilitate strengthening to scapular upward rotators, thoracic erector spinae, and stretch to the pectoral muscles . This exercise can reduce thoracic kyphOSiS and lift

270

Therapeutic Exercise: Moving Toward Function

Head shifted forward

SELF-MANAGEMENT 74-2 Correction of

Diastasis Recti Purpose;' Position: Movement

technique:

Thoracic kyphosis

To correct a diastasis recti and improve the length-tension relationship of abdominals (rectus abdominis) Backlying with knees bent and feet flat. Cross hands over the midline.

Scapular abduction Humerus in medial rotation

Lumbar lordosis Anterior pelvic tilt

1. Inhale.

2. As you exhale (engaging TAl, rock your pelvis back (engaging RA), flattening your lower back. 3. Tuck your chin, and slowly raise your head off the surface while pulling the belly muscle toward the midline. 4. Slowly lower the head and relax.

Hyperextended knees,

possibly with

associated femoral

internal rotation

and tibial lateral rotation

Dosage Repetitions

Pronated feet

Frequency

Modification: Fold sheet lengthwise under your low back. Cross sheet over the midline, holding the opposite ends in each hand. As you tuck your chin and slowly raise your head, pull outward on the ends of the sheet. As you lower your head and relax, release your grip on the sheet.

Starting position

FIGURE 14-3. Incorrect posture during pregnancy.

and at work apply to the pregnant woman and the no pregnant woman (see Chapter 18).

Gait Gait should be assessed for adaptations or muscle imb ances resulting from pregnancy. Three-dimensional m tion analysis techniques inves tigating alterations in g during pregnancy suggest that alterations in kinetic paral ; ~ eters may lead to overuse of various lower extremity mne cle groupS.86 Increases in hip moment and power in coronal and sagittal planes and increases in ankle mome and power in the sagittal plane may be due to increased U' of hip abductors , hip extensors, and ankle plantar flexo Although this appears to reflect co mpensations used ' maintain normal gait, they may contribute to lumb pelviC, and hip pain, as well as muscle cramps in the 10\\ extremities and overuse impairments, especially in the derconditioned woman.

Pain Action

the lib cage off the uterus by promoting balance in length and strength of the antelior and posterior upper quarter muscles. Performing this exercise frequently throughout the day can reduce postural pain and discomfort. Another useful exercise to improve posture during pregnancy is a wall abdominal isometric (Fig. 14-4). This exercise helps to maintain tone in the abdominal region and normal length of hip flexors , both of which support the lumbar curve and pelvic position. Frequent changes of position, proper pos­ ture , and body mechanics during daily activities at home

Approximately 50% to 90% ofwomen experience back pa. during pregnancy4.6.38.72.85,87 Many women \vith chron back pain link the onset to pregnancy.72,1l8,89 Back pain m occur at any time throughout the pregnancy, but most co monly occurs between the fourth and seventh month.­ Back pain causes include: • Biomechanical strain from increases and imbalanre in jOint loading resulting from increased body m and dimension . • Postural changes, such as lum bar lordosis creating iJT­ creased stress on the facet jOints, posterior ligamen and intervertebral disks. • Postural changes that aggravate preexisting spond: ­ lolisthesis, degenerative facet joint disease, later: stenosis, and muscle imbalances .

Chapter 14 Therapeutic Exerci se in Obstetrics

271

• Muscle fatigue from overload on key muscles includ­ ing back extensors, abdominals, and pelvic floor.

Postural Correction To correct posture during pregnancy, follow the steps below. Perform these steps simultaneously as often as you can-at least six times per day. Try them during different daily activities such as brushing your teeth, washing the dishes, or standing in line. Maintain them while performing exercises in the standing position. 1. Elongate the neck by drawing the chin back and

keeping eyes level.

2. Lift your breastbone, ribs, and head without arching your lower back, as though you are trying to be taller. Breathe normally; do not hold your breath. 3. Pull your lower abdominal muscles in by pulling your belly button toward your spine. The pelvis should be in neutral position. 4. Unlock your knees, squeeze your buttock muscles to separate your knees, and turn your thighs slightly outward so that the kneecaps face the middle of your feet. 5. Pull "up and in" with the pelvic floor muscles. 6. Shift your weight slightly so half of your weight is on your heels and half is on the balls of your feet. Slightly lift the arches of your feet without rolling out on the sides of your feet.

The relationship between postural changes during preg­ nancy and back pain is unclear 8 5 Back pain is not entirely explained by biomechanical changes that can be measured by postural assessment. The source of pain is likely to be multifactOrial, but there are common patterns of presenta­ tion. These are: lumbar pain (LP), posterior pelviC pain (PPP ), and nocturnal pain n ,Il8.90 Evaluation and exercise prescription for pregnancy back pain must be individualized. Although higher levels of prepregnancy fitness seems to decrease the risk for LP, it does not appear protective for ppp .72 ,RH,90 Patients may need to be advised to adjust their exercise habits as the pregnancy progresses, Back pain and other pregnancy-related discomforts may be minimized b~ re­ ducing the duration and intensity levels of exercises,5. 0 Lumbar Pain

LP is described as pain in the lumbar spine with or with­ out radiation into the leg, It is aggravated by prolonged standing or sitting, or repetitive lifting, LP responds to treatment focused on posture, body mechanics for ADLs, and exercise similar to the nonpregnant population (see Chapter 18). Posterior Pelvic Pain

PPP is four times as prevalent as LP but is not limited to the sacroiliac (51) area which has been described as the most com mon location of pregnancy back pain,72R'i,8H,91 It

• Ligamentous laxity affecting the sacroiliac jOints, pu­ bi c symphysis, and sacrococcygeal joint.

FIGURE 14·4. Wall abd ominal isometrics, Standi ng with feet about 3 inches from the wall. bend hips and knees to put hip flexors on slack. Pull belly button in towa rd the spine, Slowly straighten hips and knees while keeping low back in neutral (not flat back) positi on, Stop when low back moves into extension,

272

Therapeutic Exercise Moving Toward Funct io n

is described as deep pain below L5 and over the SI jOint and posterior superior iliac spine. Pain is unilateral or bi­ lateral and may radiate to the posterior thigh or knee. It is aggravated by extremes of hip and spinal movement and asymmetrical loading of the pelvis as in stair climbing, sin­ gle leg stan ding, and rolling in bed. Seve ral tests have been described to distinguish be­ tween LP and PPp.n ,/;'l5l2- 94 The PPP provocation test is performed by applying veltical pressure through the flexed thigh on the affected side of the supine patient. Pain in the sacroiliac joints may occur very early in preg­ nancy, possibly because of circulating hormones. Although the lumbar spin e and the hip may refer pain into the sacroiliac region, a valiety of alterations in sacroiliac joint configuration and movement may produce impairment and functional limitations. Vlanual therapy techniques may be used to reduce asymmetry and abnormal motion. Muscle imbalances in the major muscles influenc]ng SI joint sta­ bility must be addressed (see Chapter 18). Stretching tech­ niques must be performed gently and cautiously because of possible joint hypermobility or true articular instability. An external support or belt may be appropriately applied to enhance stabili ty of this region and the pubic symphysis. Th e pubic symphysis is the only b~_ny junction in what Noble calls the "vulnerable midline .''' I This area includes the abdominal and pelvic floor muscles that are c:onnected in midline by a tendinous seam . There is marked '..videning of the pubic symphysis by 28 to 32 weeks of gestation, from apprOximately 4 to 7 mm .l This widening facilitates vaginal delivery but can lead to pelViC discomfort and gait un­ steadiness in late pregnancy. Wide leg motions or reCipro­ cal movement of the lower extremities such as stair climb­ ing or turning in bed may cause pain in a lax pubic symphysis. If such pain occurs, leg exercises may need to be eliminated until the joint is stabilized. Vigorous stretch­ ing of the hip adductor muscles should be avoided, because go thi s exercise may result in pubic symphysis separation. Nocturnal Back Pain

Nocturnal back pain is described as "cramplike" and is thought to be linked to increased blood volume and pres­ sure on the inferior vena cava 96 Decreasing venous flow could result in hypoxia of neural tissues. Position changes during sleep are recomm ended. The round ligaments are two rounded cords that run from the superior angle of the uterus on either side to the labia majora. During pregnancy, these ligaments must stretch vvith the growing uterus and may intermittently spasm, causing sh arp pain in the grOin . This is espeCially true with sudden position changes. Gentle side stretching in tailor or regular sitting positions \vith arms overhead may re­ lieve this discomfort (Fig. 14-5). This stretch may also help relieve heartburn and the feeling of shortness of breath as it lifts the rib cage upward and away from the pelviS. Transient osteoporosis (TO) during pregnanct _is self­ limiting and spontaneously resolves postpartum. 1.98 De­ spite the rarity of fractures, pregnant women with TO m~ develop pain in the back, grOin, hip, or lower extremities. 9 Careful attention should be paid to medical and family his­ tory because preexisting osteo~enia and genetiCS playa role in the degree of bone loss.lOa-: 02 Exercise history is vital in the djfferential diagnosis because a woman vvith compro­

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FIGURE 14·5, Gentle side stretching in tailor sitting. mised skeletal integrity, such as an amenorrheic ath lete may be at a higher risk for osteoporosis and fracture durin\:. pregnancy and lactation. 103.10 4 Immobilization and inacti\ ­ ity are risk factors for TO and should be considered wh treating a woman on bedrest for a high-risk pregnancy. Recovery time is stated in the literature to vary betwe 2 and 12 months postpartum and is compromised by lacta· tion. l05 ,106 Profound detrimental effects on matemal bo mineral density during lactation are due to the cumulati\~ effects of prolonged estrogen deficiency and calcium 10 Studies have not been able to show that lactation-induCt'L bone loss is less in exercising women. More research needed to address types of exercise (high im~act and sj~t: specific) and exercise duration postpartum. l 3 Lactatior­ induced osteopenia is reversible with cessation of breas­ feeding.

High-risk Antepartum When the outcome of pregnancy is adversely affected " mater~al or fetal factors, the pregnan cy is identified as hie risk. 1O , , 108 Bed rest is used in nearly 20% of all pregnanci to treat a \vide variety of conditions. Bed rest may be pn­ scribed when a pregnancy becomes complicated at cor · ception, when preexisting matemal disease such as hen disease is present, or as the pregnancy advances. It is e mated that approximately one of four complicated pr. _ nancies leads to the birth of a premature baby. 109

Lifespan Considerations More women are chOOSing to delay childbearing until th fourth or fifth decade . Their decision may be influenced a career, new marriage , financial security, and infertili problemsYo Women who delay childbearing may exp good pregnanc~ outcome but higher incidence of obstetn complications . 11-117 These include preeclampsia, placen~ previa, placental abruption, breech presentation, preten­ delivery (before 32 weeks), and low birth weight. There increased risk of operative delivery, including USe of fo; ­ ceps, vacuum extraction, and cesarean section. Althou pregnant women with diabetes and hypertenSion are at i ~

1

Chapter 14 Therapeutic Exercise in Obstetrics

creased risk for adverse perinatal outcome irrespective of ge, these complications increase almost linearly with a e.

118

The detrimental effects of inactivity in the form of bed rest vary according to the duration of bed rest, the patient's prior state of health and conditioning, and activity per­ formed during bed rest. Much has been Wlitten about the effects of bed rest, many of which occur within the first 3 days. These effects include decreased work capacity, or­ thostatic hypotension, increased urine calcium (possibly leading to bone loss), and increased risk of deep venous th rombosis (DVT). The theoretical basis for bed rest dur­ mg a high-risk pregnancy is to promote uterine and pla­ (''ental blood flow and to reduce gravitational forces that may stimulate cervical effacement (Le., obliteration of the ce rvix in labor, when only the thin external os remains) and dilationY9- 122 The left lateral recumbent or Trendelen­ burg position may be recommended. Bathroom privileges may be restricted. Typically, these patients report muscu­ skeletal, cardiovascular, and psychosocial complaints. Even modest activity can reduce detrimental effects of bed rest. 107,108 Therapeutic exercises for this patient popu­ tion focus on several features: • Improvement of circulation • Promotion of rela,xation • Avoidance of increased intra-abdominal pressure by minimizing abdominal contractions during exercise, basic ADLs, bed mobility, transfers, and self-care • Avoidance of Valsalva maneuvers • Prevention of decreased muscle tone and decondi­ tioning effects • Prevention of musculoskeletal discomfort Activity guidelines for the high-risk antepartum patient
Impaired Muscle Performance General strengthening and toning exercises help prevent or reduce decreased muscle tone and the deconditioning ef­ fects of bed rest, Frequent position changes in bed should be encouraged to avoid SHS and prevent musculoskeletal discomfort. Discomfort may be experienced because of static positioning, joint stiffness, and decreased circulation. These strengthening and toning exercises can be done in the supine position: • Neck rotation and side bending • Gentle isometric neck extension into a pillow • Shoulder presses dO\vn and back into a pillow • Unilateral heel slides, hip internal rotation and exter­ nal rotation, hip abduction and adduction, and termi­ nal knee extension off a pillow • Graded pelvic floor contractions if performed cor­ rectly (with minimal abdominal muscle activation or breath holding) in-

273

DISPLAY t4·6

Activity Guidelines for the High-Risk Antepa rtum Patient 1. Obtain approval from the health care provider before any exercise. 2. Tell the patient not to lift legs against gravity (including kicking off covers). Lower extremity movement may increase symptoms (e.g., increased bleeding, contractions, blood pressure, leakage of amniotic fluid). If symptoms increase, lower extremity exercises should be deferred first. Active assisted or passive range of motion exercises for the lower extremities may be appropriate. 3. Do not perform resisted lower extremity exercise. 4. Do unilateral exercises, except for ankles and wrists, to avoid stabilization by abdominal muscles. 5. Progress the number of exercises and repetitions

gradually.

6. Do not overdo. Exercises may become more difficult as pregnancy progresses and fatigue increases or when medicated with tocolytics (medications used to stop or control preterm labor). You may need to modify exercises if tocolytics increase fatigue or give the patient the "jitters." Timing exercise further from dosage time is helpful. 7. Avoidance of abdominal contractions during exercise is necessary to help eliminate expulsion forces and uterine irritability, especially with preterm labor. 8. Avoid Valsalva maneuvers. Valsalva maneuvers are bearing-down efforts accompanied by holding the breath without exhalation (closed glottis). This increases the intra abdominal pressure and pressure on the uterus. Valsalva maneuvers may be performed by a patient with abnormal respiratory rate and rhythm and mayor may not include an abdominal contraction. A Valsalva maneuver must be avoided during bed mobility, transfers, exercises, or bowel movements to avoid irritating the uterus. The therapist instructs the patient to exhale on any effort. 9. Comfort measures include body mechanics and positioning in bed to support the spine and abdomen in proper alignment. In sidelying, pillows between the legs, under the abdomen, and behind the back and shoulders may be helpful. Frequent changes of position should be encouraged. 10. If symptoms increase with bed rest exercises, stop and report to the physician.

These strengthening and toning exercises can be done in the sidelying position: • Unilateral shoulder circles (downward and back­ ward), arm circles, hand and wrist active ROM, knee extension with hip flexed, partial knee to chest, and hip external rotation • Unilateral resistive band (or light weights) for upper extremities only: biceps curl, triceps press, shoulder press, diagonal lift, shoulder extension, and horizontal abduction and adduction (avoid proprioceptive neu­ romuscular facilitation pattern D2 upper extremity extension with or without resistive band because it fa­ cilitates the abdominal muscles) • Graded pelvic floor contractions

274

Therapeutic Exercise Moving Toward Function

The support of a spouse, famil y, and fri ends can greatly reduce the anxiety and stress the high-risk antepartum pa­ tient may experien<.:e . Bed rest places the patient in the dif­ ficu]t position of limiting simple ADLs and limiting her roles as mother (if she has other children ), spouse, and provider (un less she can work from her bed) . The physio­ logic effects of stress can take its toll, and the patient and caregivers must understand the ration ale for bed rest and importance of therapeutic exe rcise to enhance fetal and maternal outcomes. Most patients are hom e for this bed rest, although some women are hospitalized. A home visit to teach the patient and family proper exercise perfor­ mance may he appropriate (see Self-M anagement 14-3: Sidelvil'lg Exercises for the Pati en t on :Bed Rest and Pa­ tient: n elated Instruction 14-2: Bed Mobility). One stlldy wported noncompliallce of 33.8% for bed rest in the high-risk antepartum wom en the), studied. 123 Reasons for noncompliance included not feeling ill child care responsibi lities, householo demands , lack of support, having to work, and discomfort whUe on bed rest. Preg­ nancy outcomes were similar for women wh o did and did not adhere to bed rest recommendations. Further research is needed to address the validity of the Rractice of bed rest as treatment for high-risk preg;lancies. ~3-1 27 Because many high-risk pregnancies end in cesarean section deliveries, it may be an appropriate time to prepare the patient for cesarean recovery and rehabilitation. Dis­ cussion of cesarean section is provided later in this chapter.

Impaired Mobility Circulation Exercises

Supine or sidelying circulation exercises should be done every waking hour. If allowed, these exercises may be per­ form ed while sitting at the edge of the bed. This reduces the likelihood of lower extremity DVT. Ankle pumps and circles irllprove circulation by facilitating a pumping action in the muscles of the lower extremiti es. Gentle lower ex­ tremity isom etlics may also help. However, the therapist must be extremely careful that the patient avoids increas­ ing intra-abdominal pressure or blood pressure. E xamples of 10vver extremity isom etrics include quadriceps , gluteal, and adductor muscle exercises.

Pain (Stress) Relaxation Exercises

Th ere ~re several ways of instructing relaxation exer­ cises. 38,39,!7 Two meth ods of relaxation require conscious recognition and release of muscle tension. Th e Mitchell method involves contrac tion of the opposing Illuscle groups to release stress-induced tension in 1ll1lscles 128 The Jacobson method, also knowil as progressive rehxation , in­ volves alterllatcl), contracting and r;~laxing muscle groups progressively throughout the body. L9 Visualization techniques or meditation may be helpful as a way to withdraw from the stress-producing situation temporarily. Diaphragmatic breathing and bod)' aw.?nmess during exercises or ADLs also improve relaxation 7 , Biofeedback and stretch ing are more activt' forms of re­ laxation. The patient is required to be mentall'y attentive to

SELF·MANAGEMENT 14·3 Side/ying Exercises for the Patient on Bed Rest

Purpose: Position: Movement technique:

Precaution:

To maintain strength ofthe lower extremities while on bed rest restrictions Side lying. Place a pillow under your head and between your knees. 1. Knee extension with hip flexed. Begin with the hip partially flexed . Bend and straighten the knee as shown in Fig. A. 2. Knee extension with hip extended. Begin with the hip in a straight position. Bend and straighten the knee as shown in Fig. B. 3. Knee-to-chest exercise. Slowly draw knee up to the chest and then slide it back shown as shown in Fig . C. Stop exercising if contractions or pain are experienced.

Dosage Repetitions Frequency (A) Knee extension with hip flexed. (B) Knee extension with hip extended. (C) Knee to chest.

L ~\

A

"

\

I I

\

\

I

I

'...~

L~\



L~\



B

c

purposefully reduce a state of tension and rccognize a state of relaxation .

Postpartum Impaired Muscle Performance Postpartum exercise is \ital for restoration of normal mus­ cle function. Pelvic floor alld abdominal contractions could

Chapter 14 Therapeutic Exercise in Obstetrics

Sed Mobility For moving from side to side: 1. Keep your head on the pillow. 2. Roll like a log. For moving from lying to sitting using the "bed rest pushup." 1. Roll to one side. 2. Keeping your back stra ight, use your arms to push up to sitting while you swing your legs over the edge of the bed. 3. Reverse to lie back down. Be sure to breathe and keep your stomach muscles relaxed. This helps avoid Valsalva maneuvers. Never jackknife to sit. Bed-rest pushup

started within the first 24 hours after delivery to restore )ne, Even if a rectus diastasis was not present during preg­ ~ cy, a separation could have developed during the sec­ d stage ofIabor. A diastasis does not always resol ve spon­ aneously after delivery and may persist well into th e tpartum phase, It should be evaluated and reduced be­ re aggressive abdominal strengthening begins, H owever, o me tric activation and facilitation of these muscles in var­ us positions is appropriate, Remind the patient that these uscles may not provide adequate support initially for the nk and low back, which are more vulnerable to injury. In me cases, the temporary use of an abdominal binder is 'sable, Pelvic floor contractions immediately after delivery are ~_ ential in restoring muscle tone, reducing edema, facili­ ling circulation, and relieving pain, especially if an epi­ 'otomy has been performed or the perineum was torn , e perineum comprises the pelvic floor and associated tructures occupying the pelvic outlet; the area is bound teriorly by the pubic symphysis, laterally by the ischial Jberosities , and posteriorly by the coccyx, Th e patient lOuld be instructed to contract or "brace" the pelvic floor uscles ,vith coughing, sneezing, or laughing; avoid VaJ­ \'a maneuvers when lifting the infant; and initi ally sup­ rt the sutured perin eu m manually during defecation ,

275

Pelvic floor strengthening should continue in the post­ partum phase and beyond to restore muscle tone and to en­ hance normal bowel, bladder, and sexual function, The supportive function of the pelvic floor is additionally chal­ le nged by lifting and carrying th e infant and various pieces of child care equipment (e,g" stroller, infant seat, diaper bag) (see Chapter 19), Wo men with back p ain during pregnancy are at high risk for back pain postpartum, 130-134 Studies sugcrest that atte n­ tion be paid to muscles that influence spinal and pelvic sta­ bility including transversus abdominis, pelvic floor, lumbar multifidus, hip rotators, and gluteus maximusJ 35- 137 (see Chapter 18 and 19), Cesarean Recovery A cesarean section (i,e" C-section ) is the surgical deliv­ ery of the baby through the wall of the abdomen and the uterus after a horizontal (most preferred in the United States ) or vertical incision has been made, The horizontal, or transverse, incision extends from side to side, just above the pubic hairline , This incision is preferred because there is less blood loss , it heals with a stronger scar, and is less likely tore~\llt in complications in a subsequent vaginal de­ Iiveryl-U JS V p.rtical incisiollS an : so metimes n('vded be­ cause of certain positions of the Laby or placenta, The rate for cesarean births in the United States is ap­ proxi mately 10% to 25 %111; About 25% to 30% of these are performed because the pregnant woman has had a previ­ ous cesarean section 139 \"'omen may be encouraged to try a vaginal birth after cesarean (VBAC) delivery, Reasons to cons ider VBAC are less risk (this is controversial), shorter recovery time, an d more involvement in th e birth pro­ cess ,1:39,1 40 Th e cesarean procedure may be planned for reasons such as placenta previa (i,e" placement of the placenta be­ low the fetus and over part or all of the cervix) , breech pre­ sentation (Le" presentation of the buttocks or feet of th e fe­ tus in the birth canal), or maternal illn ess, or emerge nt for reasons such as fetal distress (i,e" condition of fetal diffi­ culty in utero detected by electronic fetal monitoring and fetal scalp sampling), prol apse of the umbili cal cord, or failure to progress in labor, In childbirth classes, all women should be prepared for the possibility of a cesarean section birth, Some health care facilities have group classes before delivery for planned cesarean section patients, This class prOvides an excellent oppOltunity to educate and instruct patients in recovery after the procedure, They experience many of the same phYSical discomforts associated with ma­ jor abdominal surgery but h ave the additional respon sibil­ ity of caring for the newborn, Exercises may begin ,vithin 24 hours afte r delivery but shouls! be graded and base d on the patient's comfort level. {i, HI Breathing exercises are important to keep lungs clear of mucus, Coughing may be painful, and "huffing" (by pulling the abdominals up and in ) is recommended while splinting the incision , Pelvic rocking or bridging with a gen­ tle twist from side to side may assist in al leviating discom­ fort from decreased intestinal motility, Lower extremity ex­ ercises h e lp prevent DVT and orthostatic hypotension before early ambu lation, Despite the absence of a vaginal delivery, the pelvic floor has undergone dramatic changes

276

Therapeutic Exercise: Moving Toward Function

during the pregnancy, or there may have been a lengthy and unprod uctive trial of pushing. Pelvic floor exercises should be continued or initiated imm ediately. Gentle ac­ tivity of the abdominal muscles stimulates healing of the in­ cision and facilitates the return of muscle tone. Progress with abdom inal exercises as tone increases and tissues tolerate added stress. Scar mobilization after su­ tures are removed (usually 3 to 6 days ), or as comfort al­ lows , assists proper healing, and reduces adhesion forma­ tion. Postpartum precautions and exercises apply, but exercise is progressed more slowly. Attention to balanced upright posture is important, because pain and discomfort at the incision may prompt a protective flexed posture. TENS may be helpful in alleviating incisional pain.

Impaired Mobility and Muscle Length The patient must accommodate to multiple body changes that occur rapidly. Weight loss and a change in the center of gravity produce postural readjustments. Ligaments and connective tissue may remain under hormonal influ ence for up to 12 weeks. 6 If the mother is breastfeeding, the neck and upper back muscles are affected by the increased weight of the lactat­ ing breasts and by the pOSitions assumed by the mother during nursing. Exercises that improve postural awareness and the length-tension propeliies of the anterior and pos­ terior neck muscles (see Chapter 24 ) and scapular muscles, such as the lower and middle trapezius , are appropriate (see Chapter 26). Certain exercises may be uncomfortable for a nursing mother to penorm because of breast tender­ ness (e.g., prone positioning). Attention should be paid to sitting posture and positioning of the baby during breast­ feeding. The breastfeeding moth er requires adequate caloric intake, fluids , and plenty of rest to produce milk for lactation. Caring for an infant is phYSically demanding and in­ volves repetitive lifting, feedi ng, and carrying. Proper body mechanics and attention to key postural muscles (See Chapter 9) vvill prevent repetitive strain injuries.

Impaired Aerobic Capacity When a woman has maintained good phYSical condition during pregnancy, her postpartum fitness is improved. If labor and delivery are uncomplicated, exercise can usually be resumed before the 6-week checkup.40 Return to exer­ cise should be gradual and based on her comfort level. Postpartum exercise guidelines are listed in Display 14-7.

Pain If muscle tension in the pelvic floor is increased as a result of pain from an infected or poorly healed epiSiotomy or tear, the inversed command may be initiated. Modalities in the form of superfiCial heat, ultrasound, ice, TENS , and perineal massage may help to reduce discomfort.;3s Al­ though pregnancy itself may be a factor in the development of lumbar disk disease, second-stage labor may markedly increase intradiscal pressure. 40 A disk protruSion may de­ velop, or a preexisting protruSion may be exacerbated. This is treated with posture, body mechanics, exercise, manual therapies, and modalities as in the general population , keeping in mind that hormonal changes persist for several weeks after delivery.

DISPLAY 14-7

Postpartum Exercise Guidelines 1. Gradua"y return to exercise but exercise regularly (3 times/wk). The process of reversal to the prepregnant state is thought to take 6 to 8 weeks (although the anatomic effects of relaxin may persist as long as 12 weeks). 2. Correct anemia before engaging in moderately strenuous activities. Stop exercising if vaginal bleeding increases or bright red blood appears. 3. Avoid moderately strenuous activities if excessive vaginal bleeding occurs or soreness of an episiotomy persists. 4. Avoid exercises that raise the hips and pelvis above the chest, such as bridging, knee-chest positions, and inverted postures, until postpartum bleeding has stopped completely. These positions put the body at risk for a rare but fatal air embolism through the vagina. 5. Avoid ballistic movements, extreme stretching, and heavy weight lifting for 12 weeks or longer if joint laxity persists. 6. Use the same precautions as in pregnancy to prevent musculoskeletal injury, for approximately 12 weeks. 7. Provide good support to the breasts during exercise, especially if nursing. Nursing mothers should feed the infant before exercising to avoid discomfort. B. Target heart rates and limits should be established in consultation with a physician and may be based on the fitness level during and before pregnancy. Data from references 6,40, 50, 77, 142, and 143.

Stress- Cognitive Element A transient depreSSion (i.e., postpartum depreSSion or post­ partum blues) may occur because of phYSiolOgiC readjust­ ments and endocrine upheaval. New responsibilities as a parent may be overwhelming. These may initially intenere with exercise performance but should level out within a fe\\' days to weeks. Support and involvement of the spouse and family members can make a difference in th e new mother's desire to exercise after delivery.144 Group classes for post­ partum exercise encourage mothers to exchange experi­ ences and work thorough problems together. Many classes incorporate exercises that include the infant and the mother.

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON IMPAIRMENTS Nerve Compression Syndromes Nerve compression syndromes may arise during pregnanc: because of fluid retention, edema, soft-tissue laxity, and ex­ aggerated postural changes . SpeCial attention should be paid to blood pressure in these patients because these syn­ dromes may be the first sign of increasing fluid resulting from preeclampSia (a condition of hypertension, edema. and proteinuria).

Intercostal Neuralgia Intercostal neuralgia is the term used to describe unilateral, intermittent pain in the rib cage or chest from flaring of the rib cage. Exercises to relieve this discomfort include spinal

Chapter 14 Therapeutic Exercise in Obstetrics

longation with arms overhead in supine, sitting, or stand­ g positions and trunk side bending away from the pain.

ry,oracic Outlet Syndrome muscle support is inadequate, spinal curves may become more pronounced as the center of gravity changes and the 'oman gains weight, especially in the breasts. The forward ead and shoulder posture rna)' lead to thoracic outlet syn­ drome (TOS), with compromise of the brachial plexus and bclavian vessels. A variant of TOS, called acroparesthe­ ia, occurs when the neurovascular bundle becomes tretched over the first rib, which may be elevated in preg­ :aIlcy. The woman may complain of pain, numbness, and . gling in the hand and forearm. 4o Strengthening of the upper back and scapular muscles d lengthening of the pectoral muscles may assist in re­ e\"ing symptoms (see Chapter 25). Support for the upper ck and breasts in the form of a good brassiere and man­ actured supports may be appropriate to decrease the d. 84 This is especially important after delivery for the ur ing mother.

...,arpal Tunnel Syndrome Carpal tunnel syndrome ofpregnancy usually disappears af­ 'er delivery but may persist or develop in the postpartum hase if the woman is breastfeeding. It is addressed much e same as in the nonpregnant client (See Chapter 27), i th a decrease in hand and wrist flexion activities, night use resting splints, and exercises to keep fingers mobile and :mprove movement of fluids. Unlike patients with cumula­ j\'e trauma-type carpal tunnel syndrome, pregnant and reastfeeding clients typically have bilateral symptoms. ~ateral Femoral

Cutaneous Nerve Entrapment

Lateral femoral cutaneous nerve entrapment (i.e., meralgia paresthetica) occurs in pregnancy when the nerve is com­ pressed as it emerges from the pelviS at the inguinal liga­ ment adjacent to the anterior superior iliac spine or where ranches enter the tensor fascia lata. Adequate length is eeded in the tensor fascia lata, iliopsoas, and rectus ' emoris muscles. Exercises to balance the hip muscles may appropriate (see Chapter 20). Lying on the unaffected -ide draws the uterus away from the compressed area. Soft­ ti sue techniques to reduce the stiffness of the iliotibial and may also be helpful.

Tarsal Tunnel Syndrome T. rsal tunnel syndrome (i.e., posterior tibial nerve compres­ ~ion) occurs with edema in the tarsal tunnel just posterior to the medial malleolus. Compression of the posterior tibial nerve produces numbness and tingling in the medial aSfect of the foot and possibly weakness of the flexor muscles 0 the oes. 6 Elevation and active foot and ankle exercises help to decrease edema and relieve compression. A posterior splint may be used to immobilize the ankle at night.

Peroneal Nerve Compression The peroneal nerves wrap around the neck of the fibula nd supply the muscles that dorsiflex the ankle. Prolonged -quatting may compress these nerves and cause foot drop 6 Pregnant women should be discouraged from prolonged quatting during exercise and during delivery.

277

Other Impairments Other impairments that may result from pregnancy include t mporomandibular joint (TM]) dysfunction. patdlofemoral dysFunction, joint discomfort or dysfunction, and varicosis. Exercise interventions are presented in other chapters for some of these impairments, but guidelines for precrnancy should be carefuIly followed. n .

Temporomandibular Joint Dysfunction TM] dysfunction may be related to pregnancy. TMJ dys­ function is caused by hypermobility resulting from in­ creased laxity or may appear after delivery because of ex­ cessive tension in the face during the "pushing" phase of delivery 3lJ (see Chapter 23). Differential diagnosis for TOS and TMJ dysfunction would include appropriate tests for cervical dysfunction.

Patellofemoral Dysfunction Patellofemoral dysFunction and pain may occur from the added stress of weight gain and fluid retention, especially \vith preexisting muscle weakness. Knee hyperextension and foot pronation are common in pregnancy, possibly be­ cause of the change in the center of gravity. This results in additional stress on the knees . Kinematic studies show that patellofemoral force increases by 83% in a pregnant woman rising from a chair without the use of her upper ex­ tremities 6 Enlargement of the uterus causes a reduction in hip flexion and repositions the center of mass falther from the axis of rotation. Greater muscular effort is therefore re­ quired. This muscular effort is reduced if the pregnant woman uses her arms to rise from a chair or avoids low seat­ ing (see Chapter 21).

Jo;nt Discomfort or Dysfunction 'iVeight gain in pregnancy increases stress in weight-bear­ ingjoints, causing discomfort in normal joints or potentially increasing dysfunction in joints \vith preexisting althritis or instability. Stair climbing produces forces of three to five times the body weight in the hip and knee joints In a woman who increases her weight by 20% in pregnancy, forces on her weight-bearing joints may increase by 100%40 (see Chapters 20 and 21).

Varicosis Venous pressure in the lower body increases with advanc­ ing pregnancy. Venous distention and stasis contribute to varicosities of the lower extremities and vulvar region 4 Frequent foot and ankle exercises help to alleviate edema and muscle cramps, especially if the patient is sedentary or sits on the job. They also help reduce the likelihood of lower extremity DVT. Patients should be advised to elevate the lower extremities higher than the heart to assist venous circulation (Fig. 14-6). The quadruped position reduces stress on the lower extremity vascular structures , and side­ lying positions decrease compression of the inferior vena cava. Because long periods of static standing increase com­ pressive forces of the weight of the fetus on the vascular system, the patient should sit instead of stand when she has the option. Immersion in water has been shown to mobilize extravascular fluid and reduce edema 63 ,l45 Compression stockings should be considered.

278

Therapeutic Exercise: Moving Toward Function

CRITICAL THINKING QUESTIONS

~

1. The pregnant woman is positioned in supine for a man­ ual therapy technique. Her face begins to lose color, and she complains of faintness. a. Should you continue with the technique but move very gently? b. Should you offer the patient a glass of water? c. Should you have her lie on her side until the symp­ toms resolve? d. Would you proceed with the technique after the symptoms resolved? e. What are some possible position changes you could make other than sidelying that could alleviate symptoms? f. Can you treat th e patient in pOSitions other than supine? 2. A 32-year-old woman, 6 weeks after delivery of her sec­ ond child, experienced severe lower quadrant pain while lifting a stroller into the trunk of her car. a. List possible causes for her pain. b. What specific muscle groups would you assess, and what treatment options would you consider? 3. The pregnant patient is being instructed in an exercise program to improve her posture. She begins to e»''Peri­ ence contractions. a. Should you stop the exercise and send the patient home? b. Should you have the patient lie in left lateral recum­ bent position until the contractions stop? "Vould you then proceed? c. Should you call the patient's doctor immediately? d. What is your advice to the patient regarding perfor­ mance of her exercise program?

1

AGURE 14-6, Elevation of feet to reduce varicosis. NOTE The feet are higher than the heart to assist venous circulation. Place a wedge under right hip to prevent SHS.

KEY POINTS • The many physiologic changes that occur during preg-· nancy affect a woman's ability and motivation to exercise. • By follOwing precautions, contraindications, and guide­ lines, a safe therapeutic exercise program may be estab­ lished for pregnant women. • Exercise du'ing pregnancy has many benefits and may preven t or assist in the treatment of common impair­ ments. • The rapeutic exercise during pregnancy focuses on key postural muscles most affected by the biomechankal changes of pregnancy. • A high-lisk pregnancy may require bed rest; however, specific exercises may be performed and are beneficial. • Therapeutic exercise is beneficial for postpartum recov­ ery, even if a cesarean section has been performed .

0­

LAB ACTIVITIES 1. Your patient is 20 weeks' pregnant and complains of

sharp pain in the right sacroiliac jOint with transi­ tional movement. 'Vith your partner perform tests and measures to assess her dysfunction. 2. Discuss adjunctive interventions that may be appro­ priate and safe to use on this patient. ,3. Demonstrate positioning for treatment and exer­ cise. Make appropriate modifications if SHS is present.

REFERENCES 1. Cunningham FG, MacDonald PC, Gant NF, et a!. Williams Obstetlics. 20th Ed . Stanford, CT: Appleton & Lange, 1997. 2. Cunningham FG, MacDonald PC, Gant NF. Williams Ob­ stetrics. 18th Ed. Norvvalk, CT: Appleton & Lange, 1989. 3. Bobak 1M, Jensen MD , Zalar MK. Maternity and Gyneco­ lOgiC Care. 4th Ed. St. Louis: CV Mosby, 1989. 4. Scott JR, DiSaia PI , Hammond CB, et a!. , eds. Danforth 's Obstetrics and Gynecology. 7th Ed. Philadelphja: J.B. Up­ pincott, 1994.

....

~O~

4. 'Vith your partner, demonstrate evaluation of the ab­ dominal muscles for a diastasis recti and the appro­ priate corrective exercise. Discuss other treatment options for a diastasis recti and the advice you would give to the postpaltum patient \-vith a diastasis recti regarding basic ADLs. ,5. Discuss possible reasons for a pregnancy becoming high risk. Demonstrate exercises that could be taught to a pregnant woman on bed rest.

5. Wolfe LA, Amey MC, McGrath MJ. Exercise and preg­ nancy. In: Torg JS, Separd R} , eds. Curre nt Therapy in Sports Medicine. 3rd Ed. St. Louis: Mosby, 1995. 6. Artal Mittelmark R, Wisewell RA, Drinkwater BL, eds. Ex­ ercise in Pregnancy. 2nd Ed. Baltimore: Willi ams & Wilkins, 1991. 7. AmeJican College of Obstetricians and GynecolOgists. Exer­ cise dUling pregnancy and the postpartum period . ACOG Technical Bull 1994;189. 8. Avery MD, Rossi MA. Gestabonal diabetes. J Nurse Nlid­ wife 1994;39:9S~19S.

Chapter 14: Therapeutic Exercise in Obstetrics

9. Weller KA. Diagnosis and management of gestational dia­ betes. Am Fam Physician 1996;53: 2053-2062. 10. Bung P, Artal R. Gestational diabetes and exercise: a sUlvey. Semin PerinatoI1996;20: 628-633. 11 . Avery MD, Leon AS, Kopher RA . Effects of a partially home-based exercise program for women with gestational diabetes. Obstet GynecoI1997;89:1O-15. _. Jovanovic-Peterson L, Peterson CM. Exercise and the nu­ tritional management of diabetes during pregnancy. Obstet Gynecol Clin :'-lorth Am 1996;23:75-86. 3. Jackson P, Bash DM. Management of the uncomplicated pregnant diabetic client in the ambulatory setting. Nurse Pract 1994;19:64-73. -I. Bung P, Artal R, Khodiguian N, Kjos S. Exercise in gesta­ tional diabetes: an optional therapeutic approach? Diabetes 1991;40(SuppI2):182-185. 5. Jovanovic-Peterson L, Peterson CM. Is exercise safe or use­ ful for gestational diabetic women? Diabetes 1991;40(Suppl 2):179-181. . Jovanovic-Peterson L, Durak E, Peterson CM. Randomized trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes. Am J Obstet Gynecol 1990;162:754-756. - Horton ES. Exercise in the treatment of NIDDM: applica­ tions for GDM? Diabetes 1991;40(SuppI2):175-178. Bung P, Bung C, Artal R, et al. Therapeutic exercise for in­ sulin requiring gestational diabetics: effects on the fetus­ results of a randomized prospective longitudinal study. J Perinat Med 1993;21:125-137. Winn HN, Reece EA. Interrelationship behveen insulin, di­ etary fiber, and exercise in the management of pregnant di­ abetics. Obstet Gynecol Surv 1989;44:703-710. Garcia-Patterson A, Martin E, Ubeda J, et al. Evaluation of Ii ht exercise in the treatment of gestational diabetes. Dia­ betes Care 2001;24: 2006-2007. Bessinger RC, McMurray RG, Hackney AC. Substate uti­ lization and hormonal response to moderate intensity exer­ cise during pregnancy and after delivery. Am J Obstet Gy­ ecol 2002;186: 757-764 . Field .lB. Exercise and deficient carbohydrate storage and intake as causes of hypoglycemia. Endocrinol Metab Clin )iorth Am 1989;18: 155-161. Carlson KJ, Eisenstat ST , Zipporyn T, eds . The Harvard Guide to Women's Health. Cambridge, MA: Harvard Uni­ \'ersitv Press , 1996. Clapp J. Effect of dietaIY carbohydrate on the glucose and insulin response to mixed caloric intake and exercise in both nonpregnant and pregnant women. Diabetes Care 1998; 2J( SuppI2):B107-B112. - Carpenter MW. The role of exercise in pregnant women \\1 th diabetes mellitus. Diabetes Care 2000;43:56-64. Shangold M, Mirkin G, eds. VVomen and Exercise: Physiol­ ogy and Sports Medicine. Philadelphia: FA Davis, 1994. - Lops VR, Hunter LP, Dixon LR. Anemia in pregnancy. Am Fam Physician 1995;51:1189-1197. - E ngstrom JL, Sittler CPo Nurse-mid\vifeIY management of iron-deficiency anemia dUling pregnancy. J Nurse Midwife 1994;39:205-345. choU TO, Hediger ML. Anemia and iron-deficiency ane­ mia: complication of data on pregnancy outcome . Am J Clin . -utr 1994;59: 4925-5005. Wang TW, Apgar BS. Exercise during pregnancy. Am Fam Physician 1998;57:1846-1852. Clapp JF. Exercise during pregnancy: a clinical update. Clin ports Med 2000;19:273-286. Heffernan AE. Exercise and pregnancy in primary care. \" urse Pract 2000;25:42-60.

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33. Clapp JF, Stepanchak W, Tomaselli! J, et al. Portal vein blood flow-effects of pregnancy, gravity and exercise. Am J Obstet Gyneco12000; 183:167-172. 34. Kinsella SM, Lohmann G. Supine hypotensive syndrome. Am J Obstet GynecoI1994 ;83: 774-787. 3.5. The American College of Obstetricians and GynecolOgists. Exercise during pregnancy and the postpartum period. ACOG Committee Opinion No. 267. 2002;99:171-173 . 36. Kotila PM, Lee SN. Effects of Supine Position During Preg­ nancy on the Fetal Heart Rate [thesis]. Forest Grove, OR: Pacific University, 1994. 37. Carbonne B, Benachi A, Leeque ML, et al. Maternal posi­ tions during labor: effects on fetal oxygen saturation mea­ sured by pulse oximetry. Obstet GynecoI1996;88:797-800. 38. Polden M, Mantle J. Physiotherapy in Obstetrics and Gyne­ cology. Oxford: Buttenvorth-Heinemann, 1990. 39. O'Connor LJ, Gourley RJ. Obstetric and GynecolOgiC Care in Physical Therapy. Thorofare, NJ: Slack, 1990. 40. Wilder E, ed. Clinics in Physical Therapy, vol. 20. Obstetric and GynecolOgiC Physical Therapy. New York: Churchill Livingstone, 1988. 41. Heckman JD , Sassard R. Musculoskeletal considerations in pregnancy. J Bone Joint Surg Am 1994;76:1720-1730. 42. Clapp JF. Pregnancy outcome: physical activities inside ver­ sus outside the workplace. Semin PerionatoI1996;20:70-76. 43. Clapp JF. A clinical approach to exercise during pregnancy. Clin Sports Med 1994;13:443-458. 44. Horns PN, Ratcliffe LP, Leggett JC, et al. Pregnancy out­ comes among active and sedentary primiparous women. J Obstet Gynecol Neonat Nurs 1996;25:49-54. 45. Sternfeld B, Quesenberry CP Jr, Eskenazi B, et al. Exercise dUling pregnancy and pregnancy outcome. Med Sci Sports Exerc 1995;27: 634-640. 46. Botkins C, DIiscoll CE. Maternal aerobic exercise: newborn effects. Fam Pract Res J 1991; 11:387-393. 47. Clapp JF 3rd. The course of labor after endurance exercise during pregnancy. Am J Obstet Gynecol 1990;163:1799­ 1805. 48. Beckmann CR, Beckmann CA. Effects of a structured an­ tepartum exercise program on pregnancy and labor out­ come in primiparas . J Reprod Med 1990;35:704-709. 49. Marquez-Sterling S, Perry AC, Kaplan TA, et al. Physical and psychological changes \vith vigorous exercise in seden­ tary primigravidae. Med Sci Sports Exerc 2000;32:58-62. 50. Kulpa P. Exercise during pregnancy and postpartum. In: Agostini R, ed. Medical and Orthopedic Issues of Active Athlet.ic Women. Philadelphia: Hanley & Belfus , 1994. 51. Wolfe LA, Walker RM, Bonen A, et al. Effects of pregnancy and chronic exercise on respiratory responses to graded ex­ ercise. J Appl PhysioI1994;76:1928-1936. 52. Zeanah M, Schlosser SP. Adherence to ACOG guidelines on exercise during pregnancy: effect on pregnancy outcome. J Obstet Gynecol Neonat Nurs 1993;22:329-335. 53. McMurray RG, Mottola MF, VVolfe LA, et al. Recent ad­ vances in understanding maternal and fetal responses to ex­ ercise. Med Sci Sports Exerc 1993;25:1305-1321. 54. Wolfe LA, Mottola MF. Aerobic exercise in pregnancy: an update. Can J Appl PhysioI1993 ;18: 119-147. 55. Clapp JF 3rd. Exercise and fetal health . J Dev Physiol 1991;15:9-14. 56. Sady SP, Carpenter MW. Aerobic exercise during preg­ nancy: special considerations. Sports Med 1989;7:357-375. 57. Clapp JF 3rd. The effects of maternal exercise on early preg­ nancy outcome. Am J Obstet GynecoI1989;16l:l453-1457. 58. Hall DC, Kaufmann DA. Effects of aerobic and strength conditioning on pregnancy outcomes. Am J Obstet Gynecol 1987;157:1199-1203.

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59. Kardel KR, Kase T. Training in pregnant women: effects on fetal development and hirth. Am J Obstet Gynecol 1998; 178:280-286. 60. The Melpomene Institute for "Vomen's Health Research. The Bod'y'\vise Woman. New York: Prentice Hall Press, 1990. . 61. Ruoti RG, Monis DM, Cole AJ. Aquatics Rehabilitation. Philadelphia: Lippincott-Raven Publishers, 1997. 62. Katz VL. Water exercise in pregnancy. Semin Pelinatol 1996;20:285-291. 63. Kent T, Gregor J, D eardoff L, et al. Edema of pregnancy: a comparison of water aerobics and static immersion. Obstet GynecoI1999;94: 726-729. 64. McMurray RG, Katz VL. Thermoregulation in pregnancy. Sports Med 1990;10: 146-158. 65. Bell R, O'Neill M. Exercise and pregnancy: a review. Birth 1994;21:85-95. 66. Yeo S. Exercise guidelines for pregnant women. Image J Nurs Sch 1994;26:265-270. 67. Treyder Sc. Exercising while pregnant. J Orthop Sports Phys Ther 1989;10358-365. 68. Hale RW, Milne L. The elite athlete and exercise in preg­ nancy. Semin PerinatoI1996;20: 277-284. 69. Wiswell RA. Applications of methods and techniques in the study of aerobic fitness during pregnancy. Semin Perinatol 1996;20:213-221. 70. Huch K. Physical activity at altitude in pregnancy. Semin PerinatoI1996;20:304-314. 71. Levangie PK. Association of low back pain with self-re­ ported risk factors among patients seeking physical therapy services. Phys Ther 1999;79:757-766. 72. Perkins J, Hammer RL, Loubert PV. Identification and management of pregnancy-related low back pain. J Nurse Midwifery 1998;43: 331-340. 73. Michlovitz SL, ed. Thermal Agents in Rehabilitation. 2nd Ed. Philadelphia: FA Davis, 1990. 74. Edwards MJ. Congenital defects in guinea pigs: prenatal re­ tardation of brain growth of guinea pigs following hyper­ thermia during gestation. Teratology 1969;2:329. 75. Smith DW, Clarren SK, Harvey MAS. Hyperthermia as a possihle teratogenic agent. J Pediatr 1978;92:878. 76. Stephenson RG, O'Connor LJ. Obstetric and Gynecologic Care in Physical Therapy. 2nd Ed. Thorofare, NJ: Slack, 2000 77. Noble E. E ssential Exercises for the Childbearing Years. Harwich , MA: New Life Images, 199.5. 78. Schauberger CW, Rooney BL, Goldsmith L, et al. Periph­ eral joint laxity increases in pregnancy but does not correlate I.vith serum relaxin levels . Am J Obstet Gynecol 1996;174: 667-671. 79. Boissannault J, Blaschak M. Incidence of uiastasis recti ab­ dominis during the childbearing years . Phys Ther 1988;68:1082. 80. Bursch S. Interrater reliability of diastasis recti abdominis measurement. Phys Ther 1987;67: 1077. 81. Sinaki M, Merrit JL, Stillwell GK. Tension myalgia of the pelvic floor. Mayo Clin Proc 1977;52: 717-722. 82. Mayo Clinic. Home Instructions for Relief of Pelvic Floor Pain. Rochester, MN: Mayo Foundation for Medical Edu­ cation and Research, 1989. 83. Hansen K. Sacrococcygeal instability in pregnancy. Obstet Gynecol Phys Ther 1993;17:5-7. 84. Kendall FP, McCreary EK, Provance PG. Muscles Testing and Function . Baltimore: Williams & Wilkins, 1993. 85. Franklin ME, Conner-Kerr T. An analysis of posture and back pain in the first and third trimesters of pregnancy. J Or­ thop Sports Phys Ther 1998;28: 133-138.

86. Foti T, D avids JR, Bagley A. A biomechanical analysis ofgail during pregnancy. J Bone JOi nt Surg 2000;82-A:625-6:32. 87. Kelly-Jon es A, McDonald G. Assessing musculoskelet back pain during pregnancy. Prim Care Update Ob/G)TI 1997;4:205- 210. 88. Ostgaard HC, Zeth erstrom G, Roos-Hansson E , Svanberr B. Reduction of back and posterior pelvic pain in pregnanC\ Spine 1994;19: 894-900. 89. Sihvonen T, Huttunen M, Makkonen M, et al. Functiona. changes in back muscle activity correlated with pain inten· sity and prediction of low back pain during pregnancy. Arc. Phys Med Rehabil1998;79:1210-1212. 90. Colli ton J. Back pain and pregnancy. PhYSician Sports Me\. 1996;24:89-93. 91. Berg G, Hammar M, Moller-Nielson J, et al. Low back pair during pregnancy. Obstet GynecoI1988;71:71-75. 92. Ostgaard HC, Zetherstrom G, Roos-Hansson E. The poste· rior pelvic pain tes t in pregnant women. Eur Spine 1994;3:258-260. 93. Mens JMA, Vleeming A, Snijders q, et al. Reliability an validity of the active straight leg raise test in postelior peh pain since pregnancy. Spine 2001;26:1167-1171. 94. Vleeming A, DeVries HJ, Mens JMA, et al. Possible role the long dorsal sacroiliac Ligament in women II~th pelipar­ tum pelvic pain . Acta Obstet Gynecol Scand 2001 ;81:430­ 436. 95. Callallan J. Separation of the symphysis pubiS. Am JObst: GynecoI1953;66:281-293. 96. Fast A, Weiss L, Parich S, et al. Night backache in pr~· nancy-hypoth etical pathophYSiological mechanisms. Am­ Phys Med Rehab 1989:68: 227-229. 97. Fingeroth RJ. Successful operative treatment of a displace subcapital fracture of the hip in transient osteoporosis (l' pregnancy. A case report and review of the literature. J Bo Joint Surg 1995:77:127-131. 98. Samdani A, Lachmann E, Nagler W . Transient osteoporo. of th e hip during pregnancy: a case report. Am JPhys M: RehabiI1998;77: 153-156. 99. Smith R, Athanasou NA, Ostlere SJ, et al . Pregnancy-associ­ ated osteoporosis. Q J Med 199.5;88:865--878. 100. Dunne F , ""'alters B, Marshall T , et al . Pregnancy associat, osteoporosiS. Clin EndocrinoI1993 ;39:487~90. 101. Carbone LD , Palmiere GM, Graves SC, et al. Osteopor: of pregnancy: long-term follow-up of patients and their 0,,­ spring Obstet Gynecol ] 995 ;86:664-666. 102. Khastgir G, Studd IW, King H, et al. Changes in bone d<, ­ sity anu biochemic,ll markers of bone turnover in pre _. nancy-associated osteoporosis. Brit J Obstet Gyne 1996;103:716-718. 10.3. Little KD, Clapp JF . Self-selected recreational exercise no impact on early postpartum lactation-induced bone I Med Sci Sports Exerc 1998;30:831--8.36. 104. Keen AD, Drinkwater BL. Irreve rsible bone loss in fon amenorrheic athletes. OsteoporoSiS lnt 1997;7:311- 315. 105. Funk JL, Shoback DM , Genant HK. Transient osteopor of the hip in pregnancy: natural history of changes in bo mineral denSity. Clin EndoclinoI1995;43 :373-382. 106. Sowers M. Pregnancy and lactation as risk factors for sub quent bone loss and osteoporosis. J Bone Min eral R 1996;11: 1052-1060. 107. Pipp LM. The exercise dilemma: considerations and guid£-. lines for treatment of the high risk obstetric patient. JObst; Gynecol Phys Ther 1989;13:10-12. 108. Frallm J, Davis Y, Welch RA . Physical therapy managem of the high risk antepartum patient: physical and occu~. tional therapy treatment objectives and program, part II Clin Manage Phys Ther 1989;9:28-33 .

Chapter 14 Therapeutic Exerci se in Obstetrics Gilbert ES , Harmann JS. Manual of High Risk Pregnancy and D elivery. St. Louis: Mosby, 1993. O. Barnes LP. Pregnancy over 35: special needs. MCN Am J Matern Child Nurs 1991;16:272. I. Kozinszky Z, Orvos H, Zoboki T, et al. Risk factors for ce­ sarean section of primiparous women aged over 35 years. Acta Obstet Gynecol Scand 2002;81:313-316. 2. Astolfi P, Zonta LA. Delayed maternity and risk at delivery. Paediatr Perinat Epidemiol 2002;1667-72. 13. Seoud. MA, Nassar AN, Usta 1M, et al. Impact of advanced maternal age on pregnanc), outcome. Am J Perinatol 2002;19:1-8. -t. Ziadeh S, Yallaya A. Pregnancy outcome at age 40 and older. Arch Gynecol Obstet 2001;265: 30-33. 5. JoLly M, Sebire ~ , Hanis J, et a1 The risks associated with pregnancy in women aged 35 years or older. Human Reprod 2000;15: 2433- 2437. Abu-Heija AT, Jallad MF, Abukteish F. Maternal and peri­ natal outcome of pregnancies after the age of 45. J Obstet Gynaecol Res 2000;26: 27-30. - . Cilbert WM, ~ es bitt TS , Daniplsen B. Childbearing be­ yond age 40: pr gnancy outcome in 24,032 cases. Obstet GynecoI1999 ;93:9-14. . Vankatwijk C, Pepters LL. Clinical aspects of pregnancy af­ ter the age of 35 years: a review of the literature. Hum Re­ prod Update 1998;4: 185- 194. Goldenberg RL, Cliver SP, Bronstein J, et al. Bed rest in pregnancy. Obstet Gyneco11994; 84:131. ..:. J. Yl alon i JA, Kasper CE. Physical and psychosocial effects of antepartum hospital bed rest: a review of the literature. Im­ age J Nurs Sch 1991;23:187-192. : 1. Maloni JA, Chance B, Zhang C, et al. Physical and psy­ chosocial side effects of antepartum hospital bed rest. Nurs Res 1993;42: 197-203. __. ~'laloni JA. Home care of the high-risk pregnant woman re­ guiling bed rest. J Obstet G)'11ecol ~eonat Nurs 1994;23 696- 706. ~'l Josten LE, Savik K, Mullett SE, d al. Bed rest compliance for women \vi th pregnancy problellls. Birth 1995;22:1-12. _4. Schroeder CA. Women's expt'lience of bed rest in high-risk pregnancy. Im
281

134. Mens JMA, Snijders CJ, Starn HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys Ther 2000;80:1164-1173. 135. Hides JA, Richardson CA, Jull GA. Multifidus muscle re­ covery is not automatic after resolution of acute, first­ episode low back pain. Spine 1996;21:2763-2769. 136. Sapsford RR, Hodges PW. Contraction of the pelvic floor muscles dUling abdominal maneuvers. Arch Phys Med Re­ habiI2001;82: 1081-1088. 137. Sapsford RR, Hodges PW, Richardson CA, et a!. Co-activa­ tion of the abdominal and pelvic floor muscles during vol­ untary exercises. Neurourol Urod)'11 2001;20:31-42. 138. American College of Obstetri cians and Gynecologists. Ce­ sareaIl Birth . ACOG patient education pamphlet AP06. Washington, DC: Amel;can College of Obstetricians and GynecolOgists, 1983. 139. American College of Obstetricians and G)'1lecologists. Vagi­ nal Bilth After Cesarean Delively. ACOG patient education pamphle t AP070. 'vVashington , DC : American College of Obstetricians and GynecolOgists, 1990. 140. Rangelli D , Hayes SH. Vaginal birth after cesarean: the role of the physical therapiSt. J Obstet Gynecol Phys Ther 1995;1910-13. 141. Gent D , Gottlieb K. Cesarean rehabilitation . Clin lvlanage Phys Ther 1985:5: 14--19. 142. Knee- chest ex('rcises and maternal death [comments). Med J Aust 1973;11127. 143. N('lson P. Pulmonary gas embolism in pregnancy and the puerperium. Obstet Gynecol Surv 1960;15:449-481. 144. Hinton PS , Olson CM. Postpartum exercise and food intake: the importance of behavior-specifiC self efficacy. J Am Diet Assoc 2001;101: 1430-1437. 145. Katz VL, Ryder RM, Cefalo RC, et al. A comparison of bed rest and immersion for treating the edema of pregnancy. Obstet G)'1lecoI1990;75: 147-151.

RECOMMENDED READING Clapp JF. Exercising Through Your Pregnancy. Champaign, IL: Human Kinetics, 1998. Myers RS, ed. Saunuers Manual of Physical Therapy Practice, chapters 22 and 23 Philadelphia: WB Saunders, 1995. Nobd E. Essential Exe rcises for the Childbearing Year. 4th Ed. Harwich, MA: New Life Images, 1995. Nobel E. Marie Osmond's Exe rcises for Mothers-To-Be. New York: New American Library, 1985. Nobel E. Marie Osmond's E xercises for Mothers and Babies. New York: New American Library, 1985. Pauls JA. Therapeutic Approaches to Women's Health. Gaithers­ burg, MD: Aspen Publishers, 1995. Simkin P, Whalley J, Kepler A. Pregnancy, Child Birth and tile Newborn : The Complete Guide. Deephaven , MN: Meadow­ brook Press, 1991.

RESOURCES American College of Obstetricians and GynecolOgists (ACOG), 409 12t11 Street, SW, Washington , DC 20024-2188; (202) 638­ 5577. American College of Sports Medicine, P.O . Box 1440, Indianapo­ lis, IN 46206; (317) 637-9200. American Physical Therapy Association , Section on Women's Healtl1, P.O. Box 327, Alexandria, VA 22313; (800) 999-2782 ext. 3237. Melpomene Institute for Women's Health Research , 1010 Uni­ versity Avenue, St Pau l, MN 55104; (612) 642-1951.

chapter 15

Closed Kinetic Chain Training SUSAN LYNN LEFEVER

ysiologic Principles of Closed Kinetic Chain Training Muscular Factors Biomechanical Factors Neurophysiologic Factors

amination and Evaluation Standardization Tools

erapeutic Exercise Intervention

Elements of the Movement System

Activity or Technique

Dosage

plication of Closed Kinetic Chain Exercises

Lower Extremity Examples and Progression

Jpper Extremity Examples and Progression

ecautions and Contraindications rically, the concepts and principles involving the dis­ 'ne s of hum an kinesiology and the biomechanics of me nt have been inextricably woven into the study of hanical engineeling. The kinetic chain concept origi­ in 1955, \vhen Stcindler 1 used mechanical engineer­ : theories of closed kinematic and link concepts to de­ be human kinesiology. In the link concept, rigid r1apping segments are connected in a series by movable •. This system allows for predictable movement of one based on the movement of the other joints and is con­ re [ a closed kinematic chain. 2 .3 In the lower extremity e human body, each bony segment can be viewed as a link; bones of the foot, lower leg , thigh , and pelviS are as rigid links. Similarly, the subtalar, talo crural, fe moral, and hip synOVial joints act as the connecting pplying these concepts to human movemen t, dlerl observed that two types of kinetic chains exist, nding on the loading of the "terminal joint." Stcindler HIed th ese as an open kinetic chain (O KC ) and a d kinetic chain (C KC). He observed that muscle re­ ment and joint motions were different when the foot

or hand was free to move or met considerable resistance .

An OKC was described when the end segment is free to

move (e.g., swi ng limb during gait, wavi ng the hand)l In

the CKC, "the terminal joints meet considerable external

resistance which prohibits or restrains its free motion"

(e.g., des cending stairs, upper extremity during crutch

walking)l Display 1,'5-1 summarizes characteristics com­ mon to OKC and CKe. The use of CKC exercises in rehabilitation began in the 1980s, when physicians began looking for safe ways to re­ habilitate the quadriceps mechanism in patients after ante­ rior cruciate ligament (ACL) reconstruction. During the 1960s and 1970s,4,5 documentation in the biomechanics lit­

erature demonstrated an increase in the anterior shear

forces during the last 30 degrees of OKC knee extension.

Numerous researchers 6 - 10 thought that this increase in an­

terior shear placed a detrimental strain on the healing graft

that could compromise the surgical result.

U sing cadaveric experiments, Grood an d associates 8 documented increased anterior tibial translation with OKC knee extension and subsequently suggested exercising in an upright posture to use the "forces of weight bearing" to minimize anterior tibial translation. Stability is enhanced in the weight-bearing position because of increased joint compressive forces, improved joint congruency, and mus­ cular co-contraction. Henning and colleagues 9 supported this hypothesis by the findings of an in vivo ACL strain study. By placing a strain gauge in the ACL of two volunteers , the amount of strain across the ACL was measured during various exer­ cises, including isometlic knee extension at 0 and 22 de­ grees and such daily activities as walking and stationary bik­ ing. It was found that isometric knee extension at 0 and 22 degrees placed more strain on the ACL than walking or sta­ tionary biking. Although most of the scientific literature concerning CKC activities is focused on quadriceps rehabilitation after ACL reconstruction , cont rasting research by Hungerford and Barryll evaluated patellofel1loral contact pressure areas dur­ ing OKC and CKC exercises. The investigators believed an OKC extension exercise, performed in the 0- to 30-degree

283

." I

,.

""

284

Therapeutic Exercise: Moving Toward Function

DISPLAY 15-1

Characteristics Common to CKC and OKC Activities

-------------------------

The following characteristics are common to CKC activities: • Interdependence of joint motion (i.e., knee flexion depends on ankle joint dorsiflexion) • Motion occurring proximal and distal to the axis of the joint in a predictable fashion (e.g., knee flexion is accompanied by hip flexion, internal rotation, and adduction and by ankle joint dorsiflexion and internal tibial rotation) Recruitment of muscle contractions that are predominantly eccentric, with dynamic muscular stabilization in the form of co-contra ction • Greater joint compressive forces resulting in decreased shearing • Stabilization afforded by joint congruency • Normal posture (weight bearing) and muscle contractions • Enhanced proprioception because of the increased number of stimulated mechanoreceptors The following are characteristics common to OKC activities: • Independence of joint motion (e .g., knee flexion is independent of ankle joint position) • Motion occurring distal to the axis of the joint (e.g., knee flexion results with motion of only the lower leg) • Muscle contractions that are predominantly concentric Greater distraction and rotary forces • Stabilization afforded by outside means • Activation of mechanoreceptors limited to the moving joint and surrounding structures

range oflmee flexion, resulted in high patellofemoral contact pressures because of the decreasing patellofemoral contact area with an increasing length of the moment ann as the limb assumed a more horizontal position. They concluded that OKC extension exercises against resistance produce non­ phYSiologic loading of patellar articular cartilage. Even rela­ tively small loads, which are commonly used in phYSical ther­ apy departments , produce pressures far in excess of normal activities, such as stair climbing or squatting. 11

PHYSIOLOGIC PRINCIPLES OF CLOSED KINETIC CHAIN TRAINING Three major phYSiolOgiC prinCiples supporting the use of CKC training include muscular factors , biomechanical fac­ tors, and neurophysiologic factors.

Muscular Factors CKC exercises stimulate muscular co-contractions, thereby enhanCing stability in the weight-bearing posi­ tion 3-,U.13 For example, weight-bearing activities de­ crease the amount of anterior shear across the ACL5-9,14 as a result of co-contraction of the hamstring musculature. This prOVides dynamiC stabilization that results in im­ proved gostural holding and additional support for the joint. l 5- The type of muscular contractions in the closed chain setting is predominately eccentric in nature followed by co-contractions and finally concentric muscle function.

Stretch Shortening Cycle One method of training the neuromuscular system to per­ form this sequence of muscle contractions ,is referred to ru plyometric training. Plyometric training is a method of tnun­ ing the neuromuscular system to increase power (i.e., wo per time ). This is accomplished combining speed an strength of muscular contractions. 1 21 The increased powe occurs from storing energy during the eccentric phase an using this stored energy during the concentric phase. Plyc-. metric exercises involve rapid closing and opening of the ki­ netic chain:) and are routinely preSCribed as part of the reh'"­ bilitation of at111etes after orthopedic injuries. A frequent goal of rehabilitation of athletes is to retu their ability to change forward energy into vertical height as in blocking a volleyball or dunking a basketball. The b..­ sic premise is that a muscle can perform more posith (concentric ) work if it is stretched (eccentrically loaded immediately before shortening. This is referred to as stretch-shortening cycle (SSC )1 1l,21,22 Mechanically, tL elastic components of the muscle and tendon (i.e ., myosir actin, and other proteins ) that are arranged in series ar. stretched during the eccentric portion, thereby storing e ergy. During the concentric portion, this energy is releaSE-> as the elastic components return to their restir.. _ length. 2,18,21,22 This is similar to the way a spring stores et­ ergy as it is stretched and releases the energy as it retufT' to its resting length. It is believed that activation of d­ muscle spindle, inhibition of the Golgi tendon orga through the stretch reflex, and a marked increase in t~ chemical energy enhance muscular contraction.17.21 -2:3 TI result is improved neural effiCiency and neuromuscul control with increased tolerance to stretched loads (i.e. ,
bl

Biomechanical Factors Biomechanical factors conhibuting to joint stability inclu the geometry of the joint surfaces, joint approximation, at! stimulation of joint receptors. For example , t1le geom e of the jOint surfaces appears to aid in t1le decrease of antt"­ rior tibial displacement in the loaded knee joint. 17,24 Add.­ tionally, CKC activities at the talocrural jOint increase an joint approximation, enha~c ing joint congruency and co tributing to joint stability,20

Joint Surface Geometry Understanding the geometry of the joint surfaces also ....­ lows the clinician to more fully understand the osteokin~­ matics associated with CKC function . Osteokinematic the distal segment moves through a greater range of m ­ tion (ROM ) more rapidly than the proximal segm ent. 26 F example, lmee flexion is associated with obligatory intem tibial rotation. Understanding the influence of foot and ankle biom ­ chanics on the entire kinetic chain is essential to ensure at curate prescription ofCKC exercises. A brief description how motion of the subtalar joint can influence the kin chain is provided to illustrate proper CKC training. Closed­ chain pronation of the subtalar jOint results in calcaneal f!'­

'f -

Chapter 15 Closed Kinetic Chain Training ersion and talar plantar flexion and adduction 27 (Fig. 15-1). The alignment of the talus in the ankle mortise dictates that

in a CKC setting motion of the lower leg must follow the

motion of the talus. That is , as the talus plantar flexes and

adducts, the lower leg internally rotates as the fibular head

translates superiorly and anteriorly. This results in talocru­

ral jOint dorsiflexion and knee flexion vvith a valgus stress

Fig. 15-2). Motion occurring up the chain continues with

fe moral adduction and internal rotation as the hip moves

into flexion. z8 --30 The pelvis tilts anteriorly and internally

rotates in phase \vith the limb (the tibia, femur, and pelvis

all internally rotate, vvith the distal segment moving faster

and through a greater ROM ) as the lumbar spine extends

and counterrotates.z9

Jackson z9 describes the pelvis as the next triplane joint

::hat has an intimate relationship ,vith the subtalar joint. He

reels that the pitch of the subtalar joint axis dictates the

.unount of transverse and frontal plane rotation occurring

the pelviS and throughout the lower limb. The average x:is of the subtalar joint is 42 degrees midway bet\veen the gittal and transverse planes (see Chapter 22), thus pro­ noting fairly equal amounts of transverse and frontal plane otion. A high subtalar joint axis results in increased trans­ erse plane motion of the pelvis and entire lower extremity. This configuration results in subtalar joint supination and e predictable movements of the entire lower extremity. the subtalar joint supinates, motions up the chain in­ lude tibial external rotation, knee extension, femoral ex­ -emal rotation, and abduction and external rotation of the ·um.Z7 ,Z9 The clinical significance of a high subtalar jOint xis is that the limb has difficulty vvith shock attenuation. 28 ~his lack of shock attenuation should alter the type and _ sage of CKC exercises the clinician prescribes during ver extremity rehabilitation. A low subtalar joint axis re­ alts in more frontal plane motion of the pelvis and lower '" remity.29 Excessive subtalar pronation results in an in­ •..-ease in the frontal plane motions of femoral adduction ad an increased valgus stress on the knee . The clinical re­ It is a limb that is inefficient during propulsion 28 When ' rescribing eKC exercises for the patie nt vvith a low subta­ joint axis, the clinician should position the foot in subta­ joint neutral (see Chapter 22) before beginning the ex­ rd se and have the patient maintain that foot position wing the exercise. Foot and ankle motion influences hip , 'nee, and pelViC motion ; therefore, initiation of exercises in e segment of the lower extremity kinetic chain results in

J GURE 15-1. Closed-chain pronation: calcaneal eversion. talar plantar ·on. and adduction .

~

285

\\ \)

( FIGURE 15-2. Closed-chain pronation internal rotation of the lower leg and flexion with valgus stress at the knee.

predictable movement of the other segments. The distal segment moves through a g,~e ater ROYI and more rapidly than the prmumal segment.­ The following example illustrates the influ ence of mo­ tion on the kinetic chain. A patient reports to physical therapy vvith the diagnosis of posterior tibialis tendinitis. During the evaluation, she displays prolonged subtalar jOint pronation during the midstance phase of the gait cycle. This prolonged pronation has resulted in an overuse injury to the posterior tibialis tendon. One of the goals of rehabilitation is to teach this patient to supinate the subtalar joint. To control the amount of weight bearing through the injured tissue, the patient should begin the exercise in a seated position and ac­ tively raise the arch in the foot. Dorsifl exing the hallux can be used to assist with raising the arch. As the arch rises , external rotation of the lower leg can be seen and felt. Progress the exercise to standing; external rotation of the lower leg results in knee extension and external rotation of the hip. Dorsiflexing the hallux can be elimi­ nated after the patient begins fu[) weight bearing. An ad­ ditional method to encourage supination of the subtalar joint reverses this exercise. Begin with tightening of the posterior gluteus medius, hip lateral rotators , and glu­ teus maximus musde groups. Tihis muscle contraction results in external rotation of the hip, which leads to knee extension, external rotation of the lowe r leg, plan­ tar flexion of the t.alocrural joint, and supination of the subtalar jOint. The resulting movement raises the medial longitudinal arch of the foot. Electromyographic (EMG) studies by Perry31 shoyv that the gluteus medius and, to a lesser extent, the gluteus maximus and posterior tib­ ialis are active in the stance leg during midstance of the gait cycle. Because hip external rotation effects foot supination , these findings suggest that clinicians s!hould encourage the patient to contract the !hip musculature during stance phase of gait to enhance supination of the subtalar joint.

286

Therapeutic Exercise: Moving Toward Function

Wolff's Law Additional sUppOJt for using CKe exercises in rehabilitation is provided by the constant remodeling of tissues. 2 Wolffs law states that bone remodels according to the stresses placed on it. Areas of increased stress result in bone depo­ sition. Related research in the field of osteoporosis has shown that early pubertal girls placed on a jumping program for 7 months had an increase in bone cross-sectional area in the femoral neck and inteltrochanter regions. 32 This theory has been extended to the remodeling of soft tissues. Collagen fibers organize themselves along lines of mechanical stress. 2 This is of particular impor­ tance when rehabilitating patients after ligamentous in­ juries. A gradual change in the mechanical stress through the injured tissue along biomechanically consistent lines can help strengthen the injured tissue and help it to resist reinjury.2 It is important to place gradual mechanical stress on healing soft tissues by placing them in functional positions throughout the rehabilitation process. For ex­ ample, when rehabilitating a patient vvith a medial deltoid ligament sprain to the ankle , the position of the foot during CKC exercises is important for controlling the amount of stress placed on the healing tissue. Allovving the subtalar joint to excessively pronate during the exer­ cise places an undesirable stress on the healing medial deltoid ligament.

Neurophysiologic Factors Neurophysiologic support for using CKC activities in reha­ bilitation is prOVided by stimulation of the proprioceptive system. Proprioception is a specialized form of touch and is composed of the sensation of joint movement (i.e. , kines­ thesia) and of joint position (i.e ., jOint position sense).33 The sensOJY receptors consist of mechanoreceptors and nociceptors found in muscles, joints, periarticular struc­ tures , and skin. Four major types of jOint receptors , the muscle spindle, the Golgi tendon organs, and cutaneous re­ ceptors have been identified as structures providing sen­ sory input to the central nervous system (CNS).34 Defor­ mation and loading of the soft tissues surrounding a joint trigger the mechanoreceptors to convert this mechanical energy to electrical impulses. 33 .1.5 The electrical impulses are transmitted to and integrated by the CNS to produce a motor response. 34 ,35 Mechanoreceptors can be classified as rapidly or slowly adapting, depending on the type ofstimulus. Rapidly adapt­ ingjoint mechanoreceptors such as Pacini's corpuscles emit a rapid burst of impulses that declines quickly:'4 .3fl These rapidly adapting receptors are believed to detect a sudden chan~e in joint motion (i.e. , acceleration or decelera­ tion). 3,34 Slowly adapting mechanoreceptors emit a sus­ tained levelof il~pulse and are believed todetec.t .t he :posi­ tIon of the lImb m space and slow changes m posItion ..J,"4 CKC activities use the force of gravity to stimulate these receptors. Borsa hypothesized that a loss of mechanorecep­ tor feedback after jOint injUly results in the loss of protec­ tive muscular co-contraction, conhibuting to a cycle of re­ peated ligamentous injury and further joint instabilit:y37 The use of CKC activities durin~ rehabilitation can stimu­ late these mechanoreceptors?U By encouraging muscular

co-contractions through CKe exercises, the cycle of re­ peated ligamentous injury may be disrupted. 38

Balance The goal of restoring balance mechanisms after a joint injury provides additional neurolOgiC support for the use of eKe activities. Balance (i.e., postural control) is the ability of the body to maintain the center of mass over the base of SUppOit without falling?9 This is an impOitant motor skill. An indi­ vidual senses body position relative to gravity by combining visual, vestibular, and somatosensOJY (i.e., proprioceptive) inputs 39 Small adjustments in the ankle, hip, and knee are used to maintain the line of gravity over the base of sup­ port. 38,40.41 In a CKC movement, indirect forces from mus­ cles of adjacent segments are transferred to and received from adjOining segments. The position of an adjoining seg­ ment of the kinetic chain can assist with proprioceptive in­ put, helping to maintain equilibrium. 39 CKC activities focus­ ing on balance and postural control should be an impoltant part of any upper or lower extremity program, particularly one \'lith the goal of restoring normal kinesthesia.

. Neural Adaptation Neural adaptation involves changes in the ability of the ner­ vous system to recruit the appropriate muscles to obtain a desired result. 42 \Vhen beginning a new exercise program. the strength gains that occur in the first few weeks can be attributed to improved coordination from neural adapta­ tion as the ~erson becomes more efficient in performing the activity. 2 In evaluating the aspects of neuromuscular reeducation, understanding the three levels of CNS influ­ ence on motor control is helpful. The Simplest level in­ volves the .:'pinal reflex and is responsible for reflex muscl splinting.31 The second level of motor control involves in­ teraction at the brain stem for control of posture and equi­ librium. In the highest level of CNS involvement, th mechanoreceptors interact vvith cognitive awareness. Continued practice of patterned motion requires les and less cognitive awareness, until it eventually becom autom atic or habitual and can be performed with ease. 12.2~ Using functional CKC activities enhances the nervous sys­ tem's ability to recruit groups of muscles to work together. Neural pathways are created that closely replicate fun c­ tional demands. Proponents of motor learning describe tbe process oflearning a new movement as beginning on a con­ scious cognitive level and, with repetition , moving to a more subconscious level. Rehabilitative programs should enhance functional outcomes by including functional CK activities. For example , a quadriplegiC patient must learn to use his or her upper body to perform transfers from the wh eelchair to the bed. Therefore, a new neural pathway of using the upper extremity in a closed fashion becomes nee­ essaly. Seated eKC triceps dips would be an appropriate activity to include in this patient's rehabilitation program t enhance development of this pathway.

Specificity of Training CKC trail~ing relies on the prinCiple of the specificity of training. 1oA0 ,42 Studies involVing strength training have shown a greater increase in strength was measured whe the test activity was similar to the actual training exer­

Chapter 15 Closed Kinetic Chain Training

cise. 42 ,43 This approach involves the use of the specific daptations to imposed demands (SAID) principle 44 ,45 Changes in the neuromuscular system can be accom­ plished by applying a specific type of mechanical stress i,e" imposed demands) to that system. In response to the tress, the body makes specific adaptations in muscle re­ cruitment patterns, Using CKC training helps to replicate the imposed demands of activities of daily living and uses a more natural recruitment pattern of an eccentJic muscle contraction to decelerate or control a movement, followed by a concentric muscle contraction. Using a 4-inch step to rform step-up exercises to gain the lower extremity hip d thigh strength needed to improve the functional per­ fo rmance of ascending stairs is an example of using the ~ AID principle with a CKC activity.

EXAMINATION AND EVALUATION The evaluation of functional activities and documentation f improvements in function are critical issues faCing the physical therapy profession, Many insurance companies e reimbursement of physical therapy services on docu­ ented improvements in function, Testing of CKC activi­ 'es can be both static and dynamic.

Standardization Tools ~

the Lower Extremity Functional Profile, Gray and Team eaction 46 attempted to set standards for the measurement d documentation of functional testing in a CKC setting, The tests are deSigned with a set of rules using clear and :.-onsisten t terminology and standards that can be eaSily doc­ .lD1ented. The tests evaluate the functional movements of , tic and dynamic balance, amount of motion (i.e., excur­ on), and distance moved in a CKC environment. 46 Tests or the sfort activities of step, hop, and jump also are pre­ nted. 4 Other researchers have devised functional tests ':or both the upper and lower extremity to determine the . -e diness of an athlete to return to recreational activi­ e .47-50 A few CKC submaximal tests can indicate the etyof performingplyometric exercises,lS,23 For example, fore initiation of plyometric activities, Albert 18 and the _'ational Strength and Conditioning Coaches Association 23 "ecommend that a person should be able to longjump his or er height in distance. Evaluation of patients from a CKC ..:pproach is useful when dealing with adolescents to ensure . at their immature muscular and skeletal systems can han­ Jle the stress of increased loads. Comparative results of nctional testing can be obtained from pretest and posttest alues or by comparing right and left values 46 CKC training has the unique advantage of"becoming the t"; the test becomes the exercise, and consequently, the 'l:ercise becomes the test. An example is testing of static :.aiance. The patient presents with difficulty in Single-limb ance during gait. The patient is asked to balance with oes off, eyes open, on one limb. Measurement is taken of e amount of time balance is achieved. The test ends when ..Jl alteration in position of the stance limb, the non-weight­ aring limb touches , or after 30 seconds. If less than opti­ lal performance occurs, this activity becomes part of the

287

patient's home exercise program. After the 30-second limit is reached, the difficulty of the test can be enhanced,46 Another example of an exercise is an excursion test in Single-limb stance, Excursion tests are deSigned to mea­ sure the amount of motion that can be controlled at a joint. 46 For example, consider a patient who presents 'vvith decreased stride length on the left during gait. Beginning on the left leg, the patient is asked to extend the left hip with a successful return to the standing position while maintaining the Single-limb stance, The degree of hip ex­ tension in the sagittal plane is measured, If limited hip ex­ tension is measured, this activit;r becomes part of the pa­ tient's home exercise program. 4 Another potential examination tool , the ProWedgeIt (Biomechanical Services Corporation) (see Fig.15-3), has become available permitting the evaluation of CKC activi­ ties by altering the position of the foot in the frontal plane. This type of examination tool can be used to assess im­ provement in the patient's function with their foot held in a celtain posture. For example, a patient that demonstrates excessive subtalar joint pronation during stance may have a reduced medial reach. When retested using the ProWedgelt "vith the subtalar less pronated, an improve­ ment in the medial reach should be evident. This may be helpful when deCiding if any frontal plane assistance in the form of a function foot orthosis would be helpful (Fig.L5-4).

THERAPEUTIC EXERCISE INTERVENTION CKC training is a valuable form of exercise for enhanCing patients' ability to function in their work, home, or recre­ ational environments , Rehabilitation of muscular strength and neuromuscular coordination must take into account the position and function of the entire kinetic chain. The position of an adjacent segment directly affects the muscu­ lar contraction and applied force throughout the involved region. No longer is there rehabilitation of a "knee patient." A study by Bullock-Saxton 51 supports this concept. The re-

FIGURE 15-3. Posterior view using ProWedgelt.

288

Therapeutic Exerci se Moving Toward Function

FIGURE 15-4. Medial reach using ProWedgelt.

searcher compared two groups: an injured group who had sustained severe unilateral ankle sprains and a matched un­ injured, control group. Changes in sensor), perception (i.e., vibration) and motor response (i.e., hip extensor firing pat­ tern) \vere found . The results showed significant delays in gluteus maximus recruitm ent on the ipsilateral and con­ tralateral sides in the injmcd group.'Sl Rebabilitation of a patient with a knee injury focuses on functional limitations and rehabilitation of the entire limb. Resolving these functional limitations includes weight­ bearing activities under task-speCific conditions. The flexi­ bility, simplicity, and creativity associated with CKC train­ ing afford countless possibilities for exercises to be included in a home exercise program. To assist the clinician in prescribing appropriate CKC exercises , this section is divided into elements of the move­ ment system, activity or technique, and dosage guidelines.

Elements of the Movement System Base Element Impairments in the base element of the movement system (e.g., muscle performance, range of motion, muscle flexi­ bili!:)" joint mobility and integrity) can be dealt with quite well \\ith CKC exercise.

Muscle performance must be at least at a functional level in the target muscles to partiCipate in upright closed chain activities. The higher the demand for muscle performance. the higher the muscle grade must be to perform the activi!:)' with precision. Clinicians should be cautious in prescribing CKC activities when the muscle performance cannot sup­ port optimal performance of the activity. OKC activities, in gravity-aSSisted, gravity-reduced, or gravity-eliminated po­ sitions, may be necessary until the muscle perfonnance im­ proves to a functional level. For example, if gluteus mediu strength is less than 3/5, a step-up or step-down activity ma~ be performed with a faulty Trendelenburg pattern. In thi case, a better choice may be to perform prone hip abduction (see Chapter 20) until 3 to 3 +/5 muscle grade is achieved before prescribing a step-up or step-down activity. Eventu­ ally performing the step-up or step-down with a leve~ pebs is more important than compromising the quali!:)! of the ex­ ercise for the sake of performing a CKC exercise. ROM , muscle length , and joint mobility and integri!:) impairments can also be treated quite well with CKC ac­ tivities. When chOOSing a specific type of CKC exercise the clinician must take into consideration the relationship be­ tween the movement of the proximal and distal segmen The relationship of the proximal and distal segments affects the movement of the limb as a whole. In a CKC function al activity, the proximal segment is moving on a more station­ ary distal segment. For example, closed-chain knee exten­ sion is performed by the medial aspect of the femur 111 0\' ­ ing posteriorly, "vith an internal rotation component, over fixed tibia . Similarly, in a closed-chain setting ankle join~ dorsiflexion is accomplished by the tibia and fibula movill_ over the talus. Because motion occurs both prOximally and distally to the axis of rotation, ankle joint dorsiflexion is of­ ten accompanied by subtalar joint pronation. Osteokinematically, the distal segment moves through greater ROM more rapidly than the proximal segl11ent. ~ For example, knee flexion is coupled with obligatory inter· nal tibial rotation. To perform CKC knee flexion, the tib must internally rotate more than the femur. If this rotatio does not occur, the knee is unable to flex. The concept the proximal segment moving over the distal segment be­ comes important when mobilizing joints after periods immobilization. Standard mobilizat~on techniques descri mobilization of the distal segment. ,2 During function, tJ proximal segment is moving over the distal segment. Mob­ lizing jOints, palticularly those of the foot and ankle, in a('­ cordance with this prinCiple can enhance function. 53 .54 Ip · corporating CKC activity after joint mobilization should considered to ensure proper CKC kinematics and recrui°­ ment patterns in newly gained ROM (Fig.15-5 ).

Modulator Element Impairments in the modulator element (e.g., neuromUSCl:­ lar control) can be effectively managed "vith CKC activitie­ For example, controlling knee flexion in a CKC position re ­ quires muscular control of rotation of the tibia from beJo. and of the femur from above . The tibia internally rotate­ through a larger excursion while the femur remains reL.­ tively laterally rotated as the knee flexes . If the femur an tibia rotated the same amount with the same speed, no re­

Chapter 15 Closed Kinetic Chain Training

289

Open

Closed

FIGURE 15-7. The center of mass is located directly over the knee.

URE 15·5. Incorporating closed kinetic chain activity to improve range ~ Jtion

for the first metatarsal phalangeal joint

-e motion would have occurred (Fig. 15-6). Coordinated flexion is accomplished by controlling the rate and unt of subtalar joint pronation by eccentric contraction the deep posterior calf muscle group and excessive hip m al rotation by eccentric contraction of the hip lateral tors.

-mechanical Element biomechanical element of the movement system is ably the element most affected by CKC training. To full advantage of the benefits of CKC activities, some 'Ilechanical elements to consider include: • Placement of the center of mass • Placement of the foot Performing a knee flexion-extension exercise in a closed . position can strengthen different muscle groups, de-

JRE 15-6. Relative rotation of the distal and proximal segments.

pending on where the center of mass is placed relative to the knee. Figure 15-7 shows an example of a minisquat with the center of mass placed directly above the knee. The knee extensors must work to control the movement. In Fig. 15-8, the center of mass is located behind the knee, result­ ing in more stress placed on the hip extensors to control the movement. Figure 15-9 shows a knee flexion-extension ex­ ercise in which the pelvis is forward relative to the knee. In this example, the gastrocnemius must work to control the knee movement. This is tll.le in the daily activities of stair climbing, sit to stand movement, and forward progression of the body over the stance limb during the gait cycle. When prescribing these CKC activities, placement of the center of mass can directly influence muscle recll.litment. Placement of the foot can also influence the efficiency of performing CKC exercises. \Vhen the subtalar joint is per­ mitted to pronate excessively, internal rotation of the entire lower limb occurs "vith a resultant increased valgus stress at the knee.28.55 This may contribute to patellofemoral pain or interll.lpt the healing of a medial collateral ligament strain. External devices can be used to position the foot and con­ sequently the entire lower extremity in a better position. The use of an external device to support the subteJarjoint in a neutral or slightly supinated position when stretching the gastrocnemius in a CKC position can be used to limit sub­ talar pronation and enhance dorsiflexion of the talocll.lral jOint (Fig. 15-10, Fig.15-3).

FIGURE 15-8. The center of mass is located behind the knees.

290

Therapeutic Exercise: Moving Toward Function

Dosage

FIGURE 15·9. The center of the mass is located in front of the knee of the back leg.

Activity or Technique When choosing rellubilitabve activities, it is important to consider the mode or method, postures , and th e specific movement pattern necessary for the patient to achieve his or her optimum function. Differe nt modes can be used while performing diJferent types of kinetic chain exercises. Conversely one cou ld look at CKC training as a mode in and of itself For example, CKC training could be the mode used to rehabilitate ROM , balance, or muscle pe rformance impairments. If proprioceptive training is chosen, the mode can be a balance board, foam pad, or dynamic Single limb stan ce; however, the mode will he applied in a CKC posture . The initial and ending postures might include am­ bulating with a \-vide base of suppoli ending with a narrow base of support. The movement should be speCifically de­ fined through a given range.

There are a number of dosage param eters that can b changed to evoke an appropriate outcome using CKC ac­ tivities . These include type of contraction, inten sit: speed, duration , frequency, sequence, environment, and feedback. Different types of muscle contractions can be used dur­ ing different types of kinetic chain exercises. For example if concentric muscle strength of the quadriceps muscle was the goal of rehabilitation and CKC training was the mode of activity, stationary cycling would be an appropriate ac­ tivity. StationalY cycling employs the use of a CKC move­ ment ; the foot is fixed to a pedal, and the foot meets resis­ tance , but the foot is free to move , resultin~ in predominan ce of concentric mu scle contraction.ll,.J' Addi­ tional examples of similar types of CKC exercises usi n concentric muscle contraction of the hip and knee exten­ sors include the use of a stair-climbing machine and knet­ extension using the seated leg press. If, on the other hand, eccentric quadriceps muscle strength was a goal of rehabilitation and stepping exercis were the mode of the activity, a step-down would be a gOOl. choice. When analyzing functional activities such as walk­ ing, descending stairs, or sitting from standing, determm­ ing the type of muscle contractions and joint motions nee ssary to complete the task should help gUide th deCiSion-making process about the type of kinetic chain ercise to prescribe. The variables of force (intensity), speed, duration fre· quency, sequence, and environment mu st be considere
FIGURE 15·10. Supporting the subtalar Joi nt in a neutral or slightly supinated posi tion enhances ankle-talocruralJo int dorsiflexion.

)e

.c­

t\ _

~d

Ir­

Chapter 15 Closed Kinetic Chain Training

creases. is Plyometric exercises are demanding and should be performed no more than twice weekly. The ability to sequence complex movements in multiple directions is required in activities of daily living and athletic Activities. Initiation of CKC exercises should begin in a sin­ gl plane and then progress to include all three cardinal body planes. An example of challenging the frontal plane tiUling Single-leg stance is lateral reach (Fig. 15-11 ). An ex­ mple of challenging the transverse plane during single-leg tance is reaching with trunk rotation to the right (Fig. 15­ 1). Additional activities using an external object (e.g., Jribbling a basketball) should be incorporated to further ~hallenge patients according to their functional needs . Se­ uencing of plyom etric exel'cises should begin with jumps place and progress through bounding, skipping, and , fi­ :ally, depth jumping. is Acquiring good postural control is important for effi­ -ent function and safety. The use of full-length mirrors to Ip the patient maintain good biomechanical alignment is !!;ood source of biofeedback to e nsure proper pe rfor­ .an e. Additionally, the patient may initially need the use en external support mechanism while performing bal­ c-e and postural control. Gradation of the activity occurs . O'radually removing the external support. For example, proving static Single-limb balance can be performed in a IOrway with the shoe on and touching the doorvvay with Ah hands. As balance and the patient's confidence im­ ,,'e, the activity is progressed and the extemal support is ·'llOved. The shoe is removed, followed by touching the Tway with only one hand, progressing to not touching doorway during the exercise. ClOSing the eyes contin­ _ to remove external support, as does altering the sup­ mng surface by placing a foam pad beneath the foot. foam pad alters the mechanoreceptor input and the nd reaction force to the limb (Fig. 15-13).

291

FIGURE 15-12. Reaching with trunk rotation to the right during a single­ leg stance challenges the transverse plane.

APPLICATION OF CLOSED KINETIC CHAIN EXERCISES Selected techniques of both lower extremity and upper ex­ tremity CKC exercises are presented to demonstrate the treatment principles and stimulate creativity when using CKC activities as an integral part of a home exercise prescription.

Lower Extremity Examples and Progression

E15-11. A lateral reach during a single-leg stance challenges the "" plane

Research in the field of sports medicine has focused on fac­ tors leading to the increased incidence of ACL injuries in female athletes in,Yolved in jumping and cutting sports. Re­ search by Hewete 8 evaluated landing techniques of female athletes and found a decrease in the knee flexor moment, increase in the abduction/adduction stress at the knee, and an increase in peak landing forces. A 6-week jump training program using plyometric exercises was designed to de­ crease landing forces by teach inK ~e1!romuscular control of the lower limb dUling landing.·JJ,oS,og These training pro­ grams resulted in a decrease in ACL injuries of female ath­ letes. A sample of the jump training program is shO\Vl1 in Display 15-2. The decision to increase the progression is based on the athlete's profiCiency in landing the jumps. All closed-chain exercises are not functional . Similarly, all open-chain exercises should not be dismissed because they are non-weight-bearing activities 2 A more pragmatiC approach to chOOSing rehabilitation activities should be investigated; it is som etimes appropriate during rehabili­ tation to prescribe non-function CKC exercises 60 For

292

Therapeutic Exercise: Moving Toward Function

FIGURE 15·13. (A) Balan ce exercise using external support. (B) By altering the su rface (use of a foam pad), the exercise becomes more cha llenging .

example, consider a patient who is unable to stand from a seated position . The patient presents with concentric quadriceps and hip extensor muscle weakness , mild ante­ lior knee joint laxity, moderate tibiofemoral arthritis, and limited ankle dorsiflexion. Exercise could include station­ ary cycling because it requires concentric quadriceps, and hip extensor muscle contraction affords jOint stability, de­ creases jOint compressive forces, and allows the ankle to move freely. Sample exercises for ROM, joint mobility, balance, and muscle performance impairm ents are shown in Fig. 15-10 and 15-13 and in all of the Self- Manage ment displays in this chapter.

DISPLAY 15-2

Sample Jumping Program Exercises Phase I: Basic Mechanics 1. Vertical jumps 2. Tuck jumps 3. Broad jumps 4. Squat jumps 5. Skipping in place Phase II: Training 1. Vertical jumps 2. Tuck jumps 3. Jump jump jump 4. Squat jumps 5. Skipping for distance Adapted from Hewett et al. 58

Repetitions! amount of time Week 1 Week 2 20 sec 25 sec 20 sec 25 sec 5 reps 10 reps 10sec 15sec 20 sec 25 sec Week3 Week4 30 sec 30 sec 30 sec 30 sec 5 reps 8 reps 20 sec 20 sec 1 run 2 runs

Upper Extremity Examples and Progression Research has been done to evaluate the necessity to per­ form CKC exercises for the upper extremity. Intramuscu­ lar EMG data have shown that a number of closed or par­ tially closed activities should be incorporated into shoulder rehabilitation program. 5 l. 52 CKC activities ha\ been shov\ln to improve neuromuscular control of the up­ per extremities 63 Additional studies have evaluated the ill" portance of having a "stable base" for performing skill ae­ tivities.G).ri! The results of these studies confirm th findings of Sullivan and coUeagues 12 concerning the co cepts of the stages of motor control. First, stahility is n essary in the form of cocontraction around the glen humeral and scapulothoracic joints, progressing t controlled mobility 'with proper scapulothoracic rhyth m Consider the patient who presen ts with left arm hemiple­ gia and with a subluxated hum eral head with anterior liga­ mentous laxity, poor stability of the humeral head in til< glenOid fossa, poor scapulothoracic rhythm, and aiter, kinesthesia. Exercise should include upper extremil:' weight bearing with weight shifting to improve stability an enhance kinesthesia. The progression of this exe rcise coul go as follows. Begin with a standing weight shift: exercise i.: the sagittal, frontal, and transverse planes with both hand on the table and eyes open. Duration could be for 10 se r ­ onds increasing to 1 minute. Progression of this exerci fro m eyes open to eyes closed and adding propriocepti\ neuromuscular facil itation manual techniques to stimulatr co-contraction and rhvthmic stabilization of the musd around the glenohume'ral joint after the patient could mas­ ter an effective cocontraction changing the surface to a I stable base (standing on a wobble board in both the fron ta. and sagittal planes) would make this a more challenging ae­

Chapter 15: Closed Kinetic Chain Training

SELF-MANAGEMENT

rpos .

'5-'

293

Improving Hip Mobility-Backward Lunge

To improve backward movement of your hip

tec utions 8nd nlr8indicstions: Pain on exertion, acute injury, lumbar spine anteroposterior instability

Position: ol/sment chnique:

Standing with feet shoulder width apart, knees over second toes Maintain arch height. Lunge backward, and mainta in a neutral spine position. Extend the hip.

Hold for seconds.

Slowly return to the start position .

osage Repetitions Frequency

SELF-MANAGEMENT 15-2 Foot Intrinsic

Muscle Strengthening

Purpose: Precautions and contr8indications. Position: Movement

technique:

To improve foot strength through the arch of your foot Pa in on exertion, acute injury Begin seated; progress to single·leg stance Maintain arch height.

Tighten the muscles in your arch. Do not push the ball of your foot into the floor. Hold for

seconds.

Dosage Repetitions Frequency

(text continues on page 306)

294

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 15-3

Purpose: Precautions and contraindications: Position: Movement technique:

Hip Strengthening-Saginal Plane

To strengthen the muscles in the front part of your thigh Pain on exertion, acute injury Single-leg stance on _ -inch box Maintain arch height. Step forward with the non-weight-bearing limb. Control hip and knee flexion of the stance limb. Take _ seconds to complete the exercise. Slowly return to the start position.

Dosage Repetitions Frequency

SELF-MANAGEMENT 15-4

Purpose: Precautions and contraindicatjons: Position: Movement technique:

Dosage Repetitions Frequency

Hip Strengthening-Transverse Plane

To strengthen your hip rotator muscles.

Pain on exertion, acute injury, lumbar spine rotational instability

Single-leg stance on _-inch box

Maintain arch height.

Externally rotate the non-weight-bearing limb.

Control internal rotation of the stance limb.

Take _ seconds to complete the exercise.

Slowly return to the start position.

Chapter 15 Closed Kinetic Cha in Traini ng

SELF-MANAGEMENT 75-5

Hip Strengthening-Frontal Plane

Purpose:

To strengthen your outside hip muscles

Precautions and contraindications:

Pain on exertion, acute injury

Position: Movement technique:

Single-leg stance Maintain arch height. Place Thera-Band around waist and anchor securely. Laterally lunge on the non-weight-bearing limb. Control adduction of the stance limb. Take _ seconds to complete the exercise. Slowly return to the start position.

Dosage Repetitions Frequency

SELF-MANAGEMENT 75-6

Purpose: recautions and contraindications: Position: ovement chnique:

Quadriceps Strengthening >30 Degrees (Wall Squats)

To strengthen the muscles around your knee and in the front part of your thigh Pain on exertion, acute injury of posterior cruciate ligament (should consider supine leg press)

Standing approximately 2 feet from the wall, feet shoulder width apart,

knees over second toes

Maintain arch height.

Stand with the back against the wall.

Slowly slide down the wall, bending the knees, stopping at degrees.

Maintain knees over second toes.

Hold for 6 seconds.

Take 4 seconds to complete the exercise.

Slowly return to the start position.

Dosage Repetitions Frequency

295

296

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 75- 7 Quadriceps Strengthening 0 to 30 Degrees (Retro-walking)

Purpose: Precautions and contraindications: Position: Movement technique:

To strengthen the muscles around your knee and in the front of your thigh and to improve your balance Pain on exertion. acute inju ry. ba lance difficulties Standing on the treadmill with feet at the normal angle and base of gait. holding onto the side railing

SELF-MANAGEMENT 15-8 Calf Strengthening-Single-Leg Heel Raise

Purpose: Precautions and contrB;ndications: Position: Movement technique:

Walk backward. extending the right hip and landing on the ball of the right foot. Extend the right knee. pressing the right heel into the bed of the treadmill. Repeat the sequence by extending the left hip.

Positioning on treadmill

Pain on exertion. acute injury. severe balance disorders Single-limb stance Maintain arch height. Place a ball or rolled-up sock between the ankles. Keeping your knee straight. squeeze the sock. and raise the heel off the floor. Try to keep the weight evenly distributed over the first and fifth toes. Take seconds to raise heel off the ground. Take _ to slowly return to the start position.

Dosage Repetitions Frequency

To strengthen your calf muscles and improve your balance

Dosage Repetitions Frequency

Chapter 15 Closed Kinetic Cha in Training

297

SELF-MANAGEMENT 15-9 Quadriceps Strengthening > 30 Degrees (Forward Lunge)

To strengthen the muscles around your knee and in the front part of your thigh

Precautions and contraindications: Position: Movement technique:

Pain on exertion, acute injury Standing with feet shoulder width apart, knees over second toes Maintain arch height. Lunge forward. Keep the knee over the second toe, and behind the ankle. Bend the knee forward until the thigh becomes parallel to the ground. Hold for 6 seconds. Take 4 seconds to perform the exercise . Slowly return to the start position.

Dosage Repetitions Frequency

SELF-MANAGEMENT 15-to Quadriceps Strengthening 0 to 30 Degrees (Closed Kinetic Chain Short

Arc Quads)

Purpose:

To strengthen the muscles around your knee

Precautions and contraindications: Position:

Movement technique:

Pain on exertion, acute injury Standing with feet shoulder width apart and with the affected knee over the

second toe, place the ball behind the knee and the heel against the wall.

Starting position

Maintain arch height Try to straighten your knee by pushing the back of your knee into the ball. Hold this position for 6 seconds. Slowly return to the start position.

Dosage Repetitions

Frequency

Ending position

SELF-MANAGEMENT 15-' 7

Purpose: Precautions and contraindications: Position: Movement technique:

Lumbar Spine Strengthening

Pain on exertion, acute injury Kneeling on hands and knees Maintain neutral spine. Slowly extend your _ _ arm and _leg.

Starting position

•

4""O~

Dosage Repetitions Frequency

Ending position

SELF-MANAGEMENT 75-12

Purpose:

Stabilize the pelvis on the weight­

bearing limb.

Stabilize the shoulder girdle with the

weight-bearing arm.

Hold seconds.

Slowly return to the start position.

To strengthen your lower back and buttock muscles

Hip Strengthening-Backward Lunge With Tubing Place Thera-Band around the waist.

Lunge backward, and maintain a

neutral spine position.

Extend the hip.

Hold for seconds.

Slowly return to the start position.

To strengthen your hip and buttock muscles

Precautions and contraindications: Pain on exertion, acute injury, lumbar spine anteroposterior instability

Position: Movement

technique:

Standing with feet shoulder width apart, knees over second toes Maintain arch height.

Starting position

Dosage Repetitions Frequency

Ending position

Chapter 15 Closed Kinetic Cha in Training

299

SELF-MANAGEMENT 15-13 Hip Strengthening-Backward Squat

Sit backward into the chair, pivoting

around your knees.

As you sit back, move your arms

forward to counterbalance the sitting

motion.

Slowly return to the start position.

To strengthen your hip and buttock muscles eccentrically Pain on exertion, acute injury Standing with feet shoulder width apart, knees over second toes

ovement chnique:

00S8g8

Maintain arch height. Place a tall chair directly behind you.

Starting position

Repetitions

Frequency

Ending position

300

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 15-14 Calf Strengthening-Forward Lean

Purpose: Precautions and contra;ndicat;ons: Position: Movement technique:

Keeping your knee straight, lean forward, leading with your waist Use your gastrocnemius muscle to control the forward motion. Slowly return to the start position.

To strengthen your calf muscles and to improve your balance Pain on exertion, acute injury 8to 10 inches from a wall, single-limb stance Maintain arc h height. Place hands in front of your chest to catch yourself.

Starting position

Dosage Repet;tions Frequency

Ending position

Chapter 15 Closed Kinetic Chain Tra ining

First Ray Stability-Windlass Mechanism SELF-MANAGEMENT 75-75

Purpose:

To strengthen the muscles supporting the arch of your foot

SELF-MANA GEMENT 15-16 Subtalar Joint and Midtarsal Joint Pronation

Purpo e:

To improve controlled movement of your heel and the arch of your foot

Precautions and contraindic8tions: Pain on exertion, acute injury

PrecBution ani contraindicatiof . Pain on exertion, acute injury

Position:

Position:

Movement technique:

Dosage Repetitions Frequency

Begin seated, progress to normal walking stride Maintain arch height. Extend only the hallux. Gently push the knuckle of your big toe into the floor. Hold seconds.

301

Movement technique:

Dosage Repetitions Frequency

Starting position Starting position

Ending position Ending position

Begin seated, progress to normal

walking stride

Extend only the lateral four toes in a smooth and controlled manner. Gently try to lift the lateral border of your foot off the floor. Take _ seconds to complete this exercise.

302

Therapeutic Exe rcise Movin g Toward Function

SELF-MANAGEMENT 15-17

Subtalar Joint Pronation

To promote controlled movement of your heel and improve your balance

Precautions and contraindications:

Pain on exertion, acute injury, severe balance disorder

Position:

Single-leg stance

Movement technique:

Place Thera-Band around the outside of the foot, and attach it to an immovable object. Raise the heel off the floor. As you return equalize the heel to the floor. control the motion of the Thera-Band pulling the subtalar joint into a pronated position. Take _ seconds to complete this exercise.

Starting position

Dosage Repetitions Frequency

SELF-MANAGEMENT 15-18

Purpose: Precautions and contraindications: Position: Movement technique:

Hip Strengthening-Transverse Plane

To strengthen your hip rotator muscles Pain on exertion, acute injury, lumbar spine rotational instability Single-leg stance; place non-weight-bearing limb on a wheeled stool Maintain arch height. Externally rotate the non-weight-bearing limb. Control internal rotation of the stance limb. Take _ seconds to complete this exercise. Slowly return to the start position .

Dosage Repetitions Frequency

Starting position

Ending position

Ending position

Chapter 15: Closed Kinetic Chain Traini ng

303

SELF-MANAGEMENT 15· 19 Quadriceps Strengthening 0 to 30 Degrees (Standing Stationary Cycling)

To strengthen the muscles around your knee and in the front part of your thig h

Precautions and contraindications:

Pain on exertion, acute injury, balance difficulties

Position:

Standing on the pedals of the bike

Movement technique:

Begin pedaling in an upright position. Use the quadriceps muscle to control the knee as it moves into extension.

Dosage Repetitions Frequency

SELF-MANAGEMENT 15·20 Glenohumeral Co-Contraction

To stabilize the muscles around your shoulder when it is newly injured and painful

Movement technique:

Precautions and contraindications:

Pain on exertion, balance difficulties

Dosage

Position:

Standing hands supported on a table

Starting position

Weight shift sagittal, frontal, and transverse planes. Use co-contraction of the muscles surrounding the glenohumeral joint.

Repeat _ _ _ _ _ _ _ sec/min Frequency

Ending position__

304

The rapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 15-21

Glenohumeral

Dynamic Stability Purpose: PrecButions Bnd contraindications.' Position: Movement technique:

To stabilize the muscles around your shoulder as your shoulder pain lessens Pain on exertion, acute injury

SELF-MANAGEMENT 15-22

Scapulothoracic Stability Purpose: PrecButions Bnd contraindications; Position:

Quadruped injured hand weight bearing on soft 6" ball Weight shift on to injured arm and move ball in sagittal, frontal, and transverse planes Enhance dynamic stability with controlled mobility by using axial compression and a moveable boundary.

Dosage Repeat _ _______ sec/min Frequency

Movement technique:

Pain on exertion Standing injured arm in scapular plane at shoulder height elbow extended push into the wall encouraging scapular protraction Straight arm push up against the wall with a "plus" Recruitment of serratus anterior to promote scapulothoracic stability while using axial compression.

Dosage Repeat ________ sec/ min Frequency

Starting position Starting position

Ending position

Ending position

To improve the function of your scapular muscles

Chapter 15: Closed Ki netic Chain Training

SELF-MANAGEMENT 15·23

Glenohumeral

Internal Rotation Purpose: Precautions and contrsindicstions: Position: Movement technique:

To improve the stability of your shoulder and gain internal rotation mobility Pain on exertion Standing with injured side towa rd the wall, injured arm in scapular plane at shoulder height elbow extended

305

SELF-MANAGEMENT 15-24 Thoracic Spine Extension Glenohumeral Joint Stability

Purpose: Precautions Bnd contraindications: Position: Movement technique:

To improve the mobility of your thoracic spine and stability of your shoulder to improve your posture Pain on exertion Quadruped Tighten abdominal muscles Push into the floor spreading the area between your shoulder blades Bring the top of your head and tailbone toward each other Hold for 15 to 30 seconds Reverse the movement squeezing the shoulder blades together sinking in the area between your shoulder blades Lengthen through the top of your head and tailbone Hold for 15 seconds to 30 seconds Repeat the exercise trying to move one vertebra at a time

Push into the wall with _ hand Tighten abdominal muscles Reach beneath injured arm with opposite hand Hold for 15 seconds to 30 seconds

Dosage Repetitions Frequency

Dosage Repetitions Frequency

Starting position

Starting position

Ending position

Ending position

306

Therapeutic Exercise Moving Toward Function

tivity, The addition of making the weightbearing arm resist a more challenging environment would follow in sequence with the addition of moveable boundary (weight bearing onto a ball) external axial load, Additional studies have demonstrated the necessity of an efficient kinetic chain to accomplish these complex skill movements by generating, transferring, and regulating forces created in the legs and trunk to the hand,

PRECAUTIONS AND CONTRAI NDICATIONS When choosing CKC training as a method of rehabilitation, the patient's safety is a primary concern, A rehabilitation program should begin subma'(imally and progress to func­ tional goals the patient can tolerate , To safely progress a pa­ tient through the rehabilitative process, it is necessary to in­ corporate criteria for gradation of th e exercise, When substitution of another component in the chain occurs and the intended link is unable to perform the activity, the ex­ ercise should be altered to an easier leveL33 For example, a patient could perform a lateral step do\VJ1 from a 6-inch step \-vith the instruction to keep his or her knee over the second toe and could continue until a substitution occurred, In­ ability to keep the knee over the second toe or an increase in symptoms would result in modif)'i ng the step-down, The exercise should be stopped on a 6-inch step and continued

LAB ACTIVITIES 1. Choose three closed- or partially closed-chain exer­

cises (one for each segment of the lower extremity) and adapt each exercise to patients with the follOWing injuries. Be prepared to demonstrate the exercises, give written home instructions (including dosage and precautions ), and eA'}Jlain the scientific basis of your selection. a, Subacute extensor mechanism dysfunction in a college athlete b. Extensor mechanism dvsfunction in a 70-vear­ old, sedentary woman ~ ~ c. Acute, excessive pronation of the subtalar joint in a 15-year-old recreational athlete d. Chronic, excessive pronation of the subtalar jOint and excessive pronation in a diabetic, hyperten­ sive, slightly obese, 60-year-old Illan who is mod­ erately active e. ACL-deficiellt knee in a 45-year-old firefighter who is preparing for return to work in 2 weeks f. ACL-reconstructed knee with medial collateral ligament strain 6 weeks after surgery 2. Choose three CKC exercises for th e upper extremity. Incorporate at least two proprioceptive neuromuscu­ lar facilitation elements in your treatment for the fol­ 100ving patients: a. A 17-year-old high school senior softball player with an anterior instability of the glenohumeral

on a 4-inch or 2-inch step, Proper performance of th e exer­ cise should be stressed over the number of repetitions , Additional precautions \vhen using CKC exercises in­ clude pain, joint effUSion, and the inability of joints to han­ dle the compressive forces, Environmental condition must be evaluated so the activities are performed on a fl at. hard surface with appropriate footwear.

KEY POINTS • CKC exercises use the forces of weight bearing and tl effect of gravity to simulate functional activities, • Common characteristics ofCKC activities include inter­ dependence of joint motion, motion occurring proxi m ~ and distal to the axis of rotation, greater joint compres­ sive forces , stabilization afforded by joint congru en c~_ recruitment of muscle contractions, and eccentric fol ­ lowed by concentric muscle contractions to provide a more normal functional pattern, • Proximal segments move over more fL,ed cUstal segment • CKC training of the lower extremity involves movemen of the foot , ankle, knee, hip, and pelvis in a predictabl sequence, • The success of using C KC activities in the rehabilitatio of patients begins with unde rstanding the kinetics and kinematics of the jOints and subsequent kineSiology wher the distal segment is attached to a supporting surf~lce ,

-----..---------

_-=---:..:.. __L_

~

,.. 1 -

.:--

I

-

I

joint, who has a good chance for a college scholar­ ship if she performs well this season b. Chronic faulty movement pattern of the gleno­ humeral joint with dominance of the axiohumeral rotators (pectoralis major and latissimus dorsi) over the scapulohumeral rotators in a 48-year-old carpenter 3. Using the principle of the proximal segment moving over a fixed distal segment, mobilize the tibiofemoral joint to gain knee extension and talocrural joint to ob­ tain dorsiflexion. Develop one CKC activity to be used as a home exercise to maintain mobility of each joint. 4. Develop an activity changing the center of mass over the base of support to alter muscle recruitment of the hamstrings, quadriceps and gluteals, and gastrocne­ mius and soleus in squat, sit-to-stand, and step-up activih!. .3. Analy~e the influence of forcing an excessively toed­ in pOSition of a patient with a naturally toed-out stance position on th e ACL at the knee. 6. Develop five activities for each plane to enhance movement in th e frontal, transverse, and sagittal planes during Single-limb stance. 7. Describe th e effect of subtalar joint supination on the osteokinematics of the ankle and hip.

Chapter 15: Closed Kinetic Cha in Training

CRITICAL THINKING QUESTIONS ----------------~ 1. Consider Case Study #6 in Unit 7. a. Describe the relationship between this patient's knee mobility impainnent and its effect on the ipsi­ lateral hip, ankle, and subtalar jOints. b. Choose a specific goal and design a treatment pro­ gram using three diffe rent CKC exercises . Include modulator and biomechanical factors. c. If this patient was returning to play basketball, de­ sign a plyometric exercise program to return this pa­ tient safely to his sport. Consider Case Study #4 in Unit 7. a. Describe three CKC exercises to improve his im ­ pairm ents Discuss four characteristics unique to CKC training that most aptly apply to the patient ,"vith an: a. Unstable knee b. Unstable L5 segment c. Unstable talocrural joint d. Anteriorly unstable glenohumeral joint

EFERENCES I. Steinclier

A. Ki nes iology of the H uman Body Under Normal and Pathological Conditions. Springfield , IL: Charles C Thomas , 1973. _. Snyder-Mackler L. Scientific rationale and physiological ba­ sis for the use of closed kinetic chain exercise in the lower ex­ tremity. J Sport RehabiI1996;5 :2-12. , Wilk KE. Naiquan Z. Glenn SF. et al. Kinetic chain exercise: implications for the anterior cruciate ligament patient. J Sport RehabiI1997:6:125-140. Lindal 0 , Movi n A. The mechanics of the knee joint. Acta Or­ thop Scand 1967;38: 226--234. . - Smidt GL. Bio mechanical analysis of knee flexion and exten­ sion. J Biomecharucs 1973;6:79-92. Paulos L, Noyes FR, Grood ES, et al. Knee rehabilitation af­ ter antelior cruciate ligament reconstmction and repair. Am J Sports Med 1981;9:140-143. - Arms SW, Pope MH , Johnson RJ, et al. The biomechanics of the anterior cmciate ligament rehabilitation and reconstruc­ tion. Am J Sports i\'[ed 1984;12:8-18. Grood ES, Suntay WT, Noyes FR, et al. Biomechanics of th e knee-extension exercise. Effect of cutting the anterior cruci ­ ate liaament. JBone j oin t Surg 1984;66A:725-734. Henning CE, Lynch MA, Glick KR . An in vivo strain gauge tu dy of elongation of the anterior cruciate ligame nt. Am J ports Med 1985;13:22-26 . Renstrom P, Anns SW, Stanwyck TS , et al. Strain within the ante rior cruciate liga m{'nt during hamstri ng and quadliceps activity. Am J Sports Med 1986;14:83- 87. Hungerford OS , Barry M. Biom echanics of th e patellofemoral joint. Clin Orthop 1979;144:9-15. _ Sullivan PE, Markos PO , Minor MAD. An Integrated Ap­ proach to Therapeutic Exercise Theory and Clinical Applica­ ti on. Reston , VA: Res ton Publishing Company, 1982. Knott M, Voss DE. Proprioceptive Neuromuscuhlr Facilita­ tion. 2nd Ed. New York: Harper & Ro\\', 1968 . - Wozniak-Timmer CA. Cycling biomechanics: a literature re­ \i ew. J Orthop Sports Phys Ther 1991;14:106-113 . _ Palmitier RA, An KN , Scott SG , e t al . Kinetic chain exe rcises in knee reh abilitation . Sports Med 1991 ;11:402-413 . - L utz GE , Palmitier RA, An KN , et al. Comparison of tibiofemoral joint forces during open-kinetic-chain and

307

closed-kinetic-chain exercises . J Bone Joint Surg Am 1993; 75 :732-739. 17. Yack HJ, Collins CE, Whieldon TJ . Compalison of closed and open kinetic chain exercise in th e an telior cmciate ligame nt­ deficient knee. Am J Sports Med 1993;21:49--53. 18. Albert M. E cce ntri c Muscle Training in Sports an d Or­ thopaedics. New York: Churchill Livi ngstone. 1991. 19. VOight ML, Cook G. Clinical application of closed kinetic chain exercise J Sport Rehabil 1996;5:25-44. 20. Komi P\!, Bosco C. Utilization of stored elas tic energy in leg extensor musclps by men and women. Med Sci Sports E xerc 1978;10 261-26R. 21. Eno ka R. Neuromechanical Basis of KineSiology. Cham­ paign, IL: Human Kineti c Books, 1988 . 22. Bosco C , Komi P. Potentiation of the mechanical behavior of the human skple tal muscle through prestretching. Acta Phys­ iol Scand 1979;100:467-472. 23. National Strength and Conditioning C oaches Association (N SCCA). PlyometIi c Train ing: Cnd rstanding and Coach­ ing Power Developm e nt fo r Sports [video tape]. Lincoln , NE: National Strength
308

Therapeutic Exercise Moving Toward Function

apy Home Study Course, Sports Physical Therapy Section of the American Physical Therapy Association, 1994. 41. Guskiewicz KM, Perrin DH. Research and clinical applica­ tions of assessing balance. J Sport RehabiI1996;5:45-63. 42. Sale DG. NeurolOgical adaptation to strength training. In: Komi PV, ed. Strength and Power in Sport. Oxford: Blackvvell Scientific Publications, 1992. 43. Sale DG, MacDougall D. Specificity in strength training: a review for the coach and athlete. Can J Appl Sports Sci 1981; 6:87-92. 44. Kegcrreis S. The construction and implementation of func­ tionall progressions as a component of athletic rehabilitation. J Orthop Sports Phys Ther 1983;5:14-19. 45. Roy S, Irvi n R Sports Medicine: Prevention, Evaluation, Man­ agement and Rehabilitation. New York: Prentice-Hall, 1983. 46. Gray GW. Team Reaction. Lower Extremity Functional Pro­ file. Adrian, MI: Wynn Marketing, 1995. 47. Mangine RE, Kremchek TE. Evaluation-based protocol of the anterior cruciate ligament. J Sport Rehabil 1997;6: 1.S7- 1H1. 48 Lcphart SM, Perrin DH, Fu FH, et al. Functional perfor­ mance tests for the anterior cruciate insufficient athlete. J Athletic Training 1991;26:44-49. 49. Risberg MA, EkelaJl.d A. Assessment of functional tests after anterior cruciate ligament surgery. J Orthop Sports Phys Tlwr 1994: 19:212-217. .50. Goldbeck TG, Davies GJ. Test-retest reliability of the closed kinetic chain upper extremity stability test: a clinical field test. J Sport Rehabil 2000;9:35--45. 51. Bullock-Saxton JE. Lom! sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther 1994;74:17-31. 52. Kaltenbom FM. Mobilization of the Extremity Joints, Exam­ ination and Basic Treatment Techniques. Oslo: Olaf :\lorlis Bokbandel, Universitetsgaten Oslo, 1980. 53. Mulligan BR. Manual Therapy "NAGS", SNAGS", "MWMS", etc. YVelhngton, l\ew Zealand: Plane View Ser­ vices Ltd., 1999. 54. Hoke BR, Lefever-Button S. When the Feet Hit the Ground ... Take the Next Step. Toledo, OR: American Physical Re­ habilitation Network, 1994.

55. Silvers HJ, Mandelhaum BR. Are ACL tears preventable ill the female athlete? Medscape Orthopaed Sports Med 2002;6(2); www.medscape.comiviewarticle/439586. 56. Jorge ivl, Hall ML. Analysis of EMG measurements duri n'! bicycle pedalling. J Biornech 1986;19:683-694. 57. Curwin S, Stanish W. Tendinitis: Its Etiology and Treatmenl Lexington, MA: Collamore Press, 1984. 58. Hewett T, Stroupe A, :\lance T. Plyometric training in fem all" athletes. Am J Sports Med 1996;24:765-773. .59. Hewett TE, Lindenfeld TN, Riccobene JV, et aI. The efTed of neuromuscular training on the incidence of knee injury iI: femal e athletes. Am J Sports Med 1999;27:699-706. 60. Snyder-Mackler L, Delitto A, Bailey SL, et al. Strength of t.h quadriceps femoris muscle and functional recovery after n'­ construction of the anterior cruciate ligament. J Bone Joire Surg Am 1995;77:1166--1173. 61. Townsend H, Jobe FW, Pink M, et al. Electromyographk analysis of the glenohumeral muscles during a basebalJ reha­ bilitation program. Am J Sports Med ! 991;19:264-272. 62. Moseley JB, Jobe FW, Pink M, et al. EMG analysis of th scapular muscles. Am J Sports Med 1992;20:128-134. 63. Ubinger ME, Prentice WE, Guskiewicz KM. The effect closed kinetic chain training on neuromuscular control ill the upper extremity. J Sport Rehabil1999;8: 184-194. 64. Glousman R, Jobe FW, Tibone JE, et al. Dynamic elee · tromyographic analysis of the throWing shoulder wi glenohumeral instability J Bone Joint Surg Am 1988;'j( 220~226.

RECOMMENDED READINGS Beckett ME, Massie DL, Bowers KD, et al. Incidence of hyper. pronation in the ACL injured knee: a clinical perspective. Atlll Training 1992;27:58--60. DeCarlo M, Shelboume KD, McCarroll JR. Traditional verSll accelerated rehabilitation follOWing ACL reconstruction: a 0 year follow-up. J Orthop Sports Phys Ther 1992;15: 309-3 J6 Irrgang JL Whitney SL, Cox ED. Balance and propriocepth training for rehabilitation of the lower extremity. J Sport TIp· habil1994;3:68-83.

chapter 16

n

d

Proprioceptive Neuromuscular Facilitation CHUCK HANSON

Definitions and Goals Basic Neurophysiologic Principles of Proprioceptive euromuscular Facilitation Muscular Activity

Diagonals of Movement

Motor Development

Examination and Evaluation ~ reatment

Implementation

Patterns of Faci Iitation

Procedures

Techniques of Facilitation

Patient-related Instruction ... the late 1940s, Dr. Herman Kabat, a neurophysiologist

d physician at the University of \1innesota, began to an­

n e the work of Sister Elizabeth Kenny and her treatment

pproach for patients with anterior poliomyelitis. Dr. Ka­ t found that the Kenny method was lacking in neuro­ ySiologic principles. He then looked to classic research neurophysiology for the basis of his treatment approach neurologic disability. He coupled the work of Sir Charles herrington regarding facilitation and faciUtation patterns the nervous system with his own observations of func­ nal human movement, as witnessed in sports and the rk of Sister Kenny. These Ibuilding blocks became the undation for what is now internationally reco~nized as roprioceptive neuromuscular facilitation (PNF). -4 \1aggie Knott, a young, ambitious physical therapist, Iped to further develop Dr. Kabat's basic patterns and rinciples. Together, Maggie Knott and Dr. Kabat created e basis of the handling skills, techniques , and principles t are applied vVidelytoday. \1aggie Knott is recognized as pioneer in manual therapy. By the early 1950s, Dorothy - s, director of physical therapy at George Washington -niversity Hospital in \t\'ashington , DC, joined Maggie -nott. Dorothy Voss contributed her skills and background therapeutic exercise and motor lcarnin a theory to the ba­ patterns and handling skills in place at that time. l -4 The llaboration of these two extraordinary therapists and the ic work of Dr. Kabat created this functional approach to rapeutic exercise and rehabilitation. The purpose of this chapter is to present a foundation in practical application of P F. Practice suggestions ac­ mpany each section to transform written concepts into .ll1ual experience. As with all manual techniques , PNF is

only as powerful as the skill with which it is applied. Inten­ sive practice is essential for best results.

DEFINITION AND GOALS PNF is best defined by first defining the individual terms.

Propnoceptiue refers to stimuli aroused within an organism through the movement of its tissues ." Ncuromusculm- per­ tains to the nerves and muscles . Facilitatioll is the Ihasten­ ing of any natural process. This results from reduC'ing nerve resistance through one stilllulus, allOWing a second stimu­ lus to more easily evoke a rt~spons('. As a whole, PNF is de­ fined as methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptor. 1 PNF is initiated when a deficient neuromuscular mecha­ nism results in altered or inefficient patterns of motion or posture. There may be severa.! goals ofPNF treatment. One major goal is to restore or enhance postural responses or nor­ mal patterns of motion. Specific demands are used to facili­ tate a direct effect on the target muscle group or an indirect effect on the synergists or antagonists of the target group.

BASIC NEUROPHYSIOLOGIC PRINCIPLES OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION Muscular Activity Muscle groups are classified as agonists, antagonists , neu­ tralizers, supporters, and fixators. Within a movement pat­ te rn, several muscle groups may work in synergy to create a specific move ment. Agonists work to produce movement, whereas an tagonists relax to allow moveme nt to occm. Neutralizers inhibit a muscle from pc rf{mning mort' than one action. Supporting muscles stabilize the truTl~ and proximal extremities, and fi xators hold bones steadyY Muscle contractions are classified as dvnamic (i.e., iso­ tonic) or static (i.e. , isometric). With isOtO~lic contractions, the intention of the patient is to move; with isometric con­ tractions, the intention is to hold a position or stabilize. Dy­ namic contractions are concentric (i.e., active shortening of a muscle), e centric (i.e. , active lengthening ofa muscle) , or maintained isotonic (a P!'-:F term ) in which the patient's in­ tention is to move, but no motion occurs. Static contractions are those in which no motion occurs.:3 For a more complete discussion of muscular activity, see Chapter 5 .

309

310

Therapeutic Exercise Moving Toward Function

Diagonals of Movement Three planes of movement occur simultaneously during normal-functioning motor activity. Because of the agonist­ antagonist relationship of the nervous system, each compo­ nent is associated with an antagonistic motion: • Flexion versus extension • Abduction versus adduction in the extremities and lateral movement in the trunk • Internal rotation versus external rotation

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Combinations of these components work together to produce the diagonals of rrwvement (i.e., innate path in which maximal response of the trunk and extremities can be facilitated) .1-3,7-9 There are two diagonals of movement for each major body part: the head, neck, and upper trunk; tJlI~ lower trunk; the upper extremities; and the lower extremi­ ties (Table 16-1). Although the diagonals of movement ha\'l:" been isolated for ease of description, the diagonal pattern of the head, neck, and trunk occur Simultaneously with th diagonal patterns of the extremities .

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II.LUSTRATION

Head and Neck A: F leKion with rotation to right (D fl, H) B: Extension with rotation to left (D ex, L)

A: Flexion with rotation to left (D fl, L) B: Extension with rotation to right (D ex, R)

B continued

Chapter 16: Proprioceptive Neuromuscular Facilitation

:0

Movement (Continued)

n

J­

311

DIAGONAL PATTERN

ILLUSTRATION

Upper Trunk .-\: Flexion with rotation to

right (D fl, R)

B: Extension with rotation

to left (D ex, L )

A

B

A

B

FI xion with rotation to left (D fl, L ) Extension -with rotation o right (D ex, R)

continued

312

Therapeutic Exerci se: Moving Toward Fun cti on -_

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Diagonals ofMov~m<en((¢o~~!!lI~~dJ; DIAGONAL PATTERN

I

ILLUSTRATION

Upper Extremities A: Flexion-adduction-external rotation (D 1 fl) B: Extension-abduction-internal rotation (Dl ex)

A

B

A

B

A: Flexion-abduction-extern al rotation (D2 11) B: Extension-adduction-internal rotation (D2 ex)

contin/l l:

Chapter 16 Proprioceptive Neuromuscu lar Facil itation

ILLUSTRATION

DIAGONAL PATTERN lower Extremities " Flexion-adduction-external

rotation (D 1 £1)

B: Extension-abduction-inte rnal rotation (Dl ex)

A

B

A

B

Flexion-abduction-external ro tation (D2 f1) Extension-adduction-intemal tation (D2 ex)

flexion goes external rotation, supination , and wrist radial ·on. e.~te ns iun gues internal rotation , pronatiull, and wris t ulnar ·on. abduction goes wrist E'x ten sion. clduetion goes \Vlist fl exion. wrist extension goes fingl' r exte nsion.

W ith Witl, With With With W ith With

wrist fl exion goe s fi nger fl exion.

ahduction goe s internal rotation and foot eve rsion.

adduction gues external rotation anc.l fuut invcrsion.

hip fkxion goes I(lot dorsiflC':.\ion.

hip c' xte nsion goes foot plantarflexion.

pJantllrflexion goes toe fl exion.

c.lorsillexion goes toe extension.

31 3

314

Therapeutic Exercise: Moving Toward Function

Normal coordinated patterns of motion, which facilitate the strongest output, are diagonal in direction with spiral components. These patterns reflect the functional relation­ ship of the trunk and extremities in sports and work activi­ ties (Fig. 16-1)4 While looking at the component motions in a diagonal sit-up exercise, try to observe or "feel" the spi­ ral, diagonal movement pattern of the body. As the arms move diagonally across toward the right knee, the trunk be­ gins to flex , rotate, and sidebend. Diagonals of mOWll1ent are useful during treatment. The tllE'rapist lllay rely on these normal functional move­ ment patterns to identify quality of contractions, range of motion (ROM), and functiona.l impairments or limitations. Altered movement patterns may he modified through the use of pattems of facilitation , which are discussed in the Treatment Ilnplementation section.

Motor Development PNF is based on 11 basic principl es drawn from the fields of neurophYSiology, motor learning, and motor behavior. 1 These principles have been relied on to guide the direction of the patient-therapist interaction, setting the tone and character of the approach. Current neurophYSiology theo­ lies reflect a different model of central nervous system con­ trol thall that used to develop PNF. 10 .11 The 11 original principles are summarized in Display 16-1 to provide a his­ torical perspective and to promote a basic understanding of the theory behind PNF .

EXAMINATION AND EVALUATION Success in physical therapy is measured by improving physical function. A thorough subjective and objecti\·c examination or evaluation enables the therapist to diag­ nose impairments and functional limitations. During thE examination, the patient's capabilities are assessed in the following areas:

Impaired ROM arul muscle length • JOint and soft-tissue ROM: Sufficient jOint and soft­ tissue ROM in the trunk and extremities for fun c­ tional activities

Impaired muscle peiformance (power) • Tone: Sufficient postural tone to provide stability iT the trunk and proximal lim b segments, but not so ex­ treme as to prevent smooth, coordinated purposefu. movement (see Chapter 4) • Recruitment: Sufficient motor unit recruitment oc­ curring during functional activity

Impaired muscle peiformance (endurance) • Adequate cardiovascular conditioning, attentio span, and neuromuscular force potential to complet. repetitive or sequenced activity

Impaired balance • Presence of proper balance, lighting, and equiliblilll reactions • Able to start, stop, accelerate, decelerate , or reveL motion as necessary to perform skillful functions

Impaired Posture • Stability: Adequate trunk stability to maintain po, · tures

Impaired motor control • Bed mobility, transfers, and gait: EqUilibrium an righting reactions to allow for transition betwe postures, including advanced developmental posture in which the center of gravity is displaced higher over a smaller base of support and moves through larger excursion • Mobility: The ability to initiate and stop movement 0 command • Controlled mobility: Proper timing and balanced n:· cruitment of trunk and proximal or distal extremit> muscle groups to allow for smooth and coordinate. movement in functional ranges of motion • Proper proximal to distal timing

Pain • Pain as an inhibitor: Must consider tactile sensitivih joint or soft-tissue ROM, and weight-bearing tol e~ ­ ance

FIGURE 16-1. A baseball pitch exemplifies the spiral, diagonal movement pattern of the body. (© Stock Boston/ Peter Southwick)

A customized treatment plan maximizes the patient" strengths and minimizes his or her weaknesses. Throngl­ examination and evaluation, the therapist must judge

Chapter 16 Proprioceptive Neuro muscu lar Facil itation

DISPLAY 16-1

Principles of Proprioceptive Neuromuscular Facilitation 1. All human beings have potentials that are not fully developed. Motor activity is limited to the individual's physical ability and inherent and previously learned neuromuscular responses. However, the normal person has a vast and untapped neuromuscular potential, which may be developed through environmental influences and voluntary decisions or tapped during stressful episodes. Based on this philosophy, the therapist always strives to treat function, motivate the patient to achieve higher levels, and uses the patient's strengths to minimize his or her weaknesses. 2. Normal motor development proceeds in a cervocaudal and proximodistal direction.* Development of motion occurs first in the head and neck, then in the trunk, and finally in the extremities. Motion develops from proximal points to distal points. During treatment, the head and neck are treated first because they influence the movement pattern of the body. Next, the trunk is treated, because it provides the foundation of function. After adequate control of the head, neck, and trunk is established, fine motor skills may be developed. 3. Early motor behavior is dominated by reflex activity. Mature motor behavior is reinforced or supported by postural reflex mechanisms. During treatment, reflexes may be facilitated to support weak muscles by choosing a specific developmental posture, initiating part of a functional activity or pattern, or involving the head and trunk with extremity patterns . . The growth of motor behavior has cyclic trends as evidenced by shifts between flexors and extensor domi­ nance. During functional activity, movements alternate between flexion and extension. This reciprocal relation­ ship leads to stability and balance of postures. In treat­ ment, the reciprocal relationship of flexors and extensors may be facilitated to reestablish stability and balance. =_ Goal-directed activity is made up of reversing movements. Normal movements are rhythmic and reversing. Reversing movements establish an equilibrium among activities and establish a balance and interaction between antagonists. Treatment must facilitate movement in both directions to enhance functioning. Normal movement and posture depend on "synergism" and a balanced interaction of antagonists. Functional movement relies on a balance of reflex activity, flexor­ extensor dominance, and reversing movements. During treatment, imbalances among these factors are corrected to restore normal patterns of motion and postural responses. This may be achieved by performing ransitions between postures (e.g., rolling reversals, supine to or from sitting, performing reciprocal or reversing patterns). - Developing motor behavior is expressed in an orderly sequence of total patterns of movement and posture. Motor behavior develops in a specific sequence. During development, early milestones provide the basis for more complex function. Motor behavior progresses in an orderly fashion from mobility to stability to controlled mobility and into skill or function, creating a diverse repertoire of motor behavior. Combined movements of the neck, trunk, and extremities also progress in a specified sequence (Fig. 16-2). Treatment must progress

Combined Movements of Paired Extremities Symmetrical: perform like movements at the same time Asymmetrical: perform movements toward one side at the same time Reciprocal: perform movements in opposite direction at the same time Combined Movements of Upper and Lower Extremities Ipsilateral: extremities of same side move in same direction at same time Contralateral: extremities of opposite sides move in same direction at same time Diagonal reciprocal: contralateral extremities move in same direction at same time while opposite contralateral extremities move in opposite direction

Symmetrical

Asymmetrical

Ipsilateral

Reciprocal

Contralateral

Diagonal reciprocal

fiGURE 16-2. Interact ion of segments.

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Therapeutic Exercise Moving Toward Function

DISPLAY 16-1

Principles of Proprioceptive Neuromuscular Facilitation (Continued)

in a similar fashion. More fundamental developmental levels often are used initially to emphasize proximal stability, enhance balance, and encourage a greater sense of security. As success is achieved, the sophistication of the task is progressed within the same developmental level or to a more advanced developmental posture. B. Normal motor development has an orderly sequence but lacks a step-by-step quality (overlapping results).* Although development of motor behavior is sequential, one activity is not perfected before another more advanced activity is initiated; overlapping occurs. In treatment, this overlapping may be used to facilitate progress. More difficult activities may be performed at lower developmental postures, whereas easier tasks may be performed at more advanced developmental postures. 9. Improvement of motor ability depends on motor learn­ ing. Motor learning is enhanced through the use of mul­ tisensory inputs. Auditory, visual, and tactile stimuli are used to progress learning. Visual cues help coordinate and guide movement. Various tones of auditory cues may influence muscle reaction . Verbal cues influence the quality of the patient's response. Tactile cues may provide direction and encouragement. Treatment that uses these multisensory inputs may optimize learning opportunities, thereby maximizing the patient's progress toward more complete functional ability.

what postures, contacts, cues, and goals are most effec­ tive. The evaluation should therefore take into account several factors: • The patient's short-term and long-term goals • The patient's receptive potential for language, vision, and manual contacts to promote appropriate cuing • The patient's strengths (e.g., what the patient does well; which body half, quadrant extremity, or joint is most sound, strong, and usable for irradiation; at ,vbich developmental level the patient has a spec­ trum of neuromuscular capabilities to practice transi­ tions; what motivates the patient, such as sports par­ ticipation or task completion without aSSistance) • The patient's weaknesses (e.g., postures that cause the patient difficulty in functioning because of me­ chanical disadvantage, incoordination, or exceSSively high postural tone; body palts that are less functional or-painful ) Because treatmeut is dynamiC, requiring continuous re­ assessm ent of results and restructuring of inputs , goals, and tasks , this examination or evaluation process is ongOing.

TREATMENT IMPLEMENTATION Functional capabilities are described as a product of envi­ ronmental , social, psycholOgiC, medical, and physical fac­ tors.7 Treatment interventions that address the proper im­ pairment may include these features :

10. Frequency of stimulation and repetition of activity are used to promote and retain motor learning and for the development of strength and endurance. The motor learning process requires repetition or practice of the task to be learned. Therapeutic tasks need to offer transfer appropriate processing, the process of putting the learner into a problem-solving mode most comparable with later performance. In this way, learning is enhanced through repetitive tasks, and through a repetitive therapeutic exercise program. Variations of repetitive exercises may include retrieval of a certain motor sequence, performance of a particular action in a variety of environmental contexts, and performance of ar. anticipatory mode of control as opposed to a reactive mode of control. 11. Goal-directed activities coupled with techniques of facilitation are used to hasten learning of total patterns of walking and self-care activities. Realistic functional goals are continually set for the patient throughout treatment. The patient's goals are included in decision making to establish a closer bond for meeting a common target. Activities that have meaning for the patient are more effectively integrated into motor learning. * Current thought contradicts these two principles. Although true for infants studies have found that adults do not necessarily follow these patterns.

• Modification of the environment • Education and compensation for the impairment • Treatment directed at changing the individual's n romuscular capabilities PNF is an invaluable tool in this final strategy. Succes implementation depends on the therapiSt's thorou _ understanding of the prinCiples of anatomy, biomechani exercise philosophies , and theories of motor control : motor learning. The therapist can then choose to apply patterns of faCilitation, procedures, and techniques of fat. tation. The patterns of facilitation, the most fa miL hallmark of PI\F, prOVide the framework for educatr _ movement. The procedures define the methods of mam hanelling and facilitating inputs. The techniques offad tion are applied to the agonist-antagonist muscle group addlress particular neuromuscular impairment. Display 16-_ summarizes the PNF treatment process.

Patterns of Facilitation Knowledge of the normal functional movement patte of the body allows the therapist to identify altered terns of motion. During treatment, the therapist may C" and resist the spiral, diagonal patterns of the neck, tl'UI'.; or extremities (i.e., the diagonals of movement) to p mote a maximal response from muscle groups and . move the patient toward functional gains. 12 VOSS l ar Adler3 have thoroughly described this approach. Patter.: of facilitation are manually resistive exercises that cre the diagonals of movement by coupling pairs of antag

Chapter 16 Proprioceptive Neuromuscular Fac ilitation

317

DISPLAY 16-2

Proprioceptive Neuromuscular Facilitation Treatment Planning Process 1. Diagnose impairment or functional limitation. Based on a thorough subjective and objective examination, diagnose impairments and functional limitations. Set short- and long­ term goals. 2. Choose the pattern or function. Make a decision about whether to treat the functional limitation directly (e.g., through resisted gait, bed mobility) or to identify a component impairment that, when addressed, will result in greater gains toward the functional goal. 3. Choose the task. The task needs to be "transfer appropriate." Make a decision to have the patient perform one of the following: • The full pattern or function • A "part task" or limited range pattern, which is a natural subset or portion of the targeted task ~ An "adaptive training" task, in which an easier version of the targeted function is performed

tic patterns , providing a path for reversing motio ns

J us ing the agonis t-antagon ist relationship of the ner­

4. Apply a technique: Choose a technique to target the observed impairment or functional limitation. Apply the technique to the movement pattern. 5. Reevaluate responses and adjust inputs. As the patient's response is observed, the facilatory inputs are adjusted to maximize their effect. Varying the task also has proven to be beneficial to learning. This can be achieved by changing the developmental level of the task to progress its difficulty. Another task, which addresses the same or another related impairment, may also be chosen. 6. Integrate into function. The final step is to integrate the gains from the technique into function. Whether a stretching, strengthening, or coordinating task has been performed, give the patient a chance to use the gains in a functional manner.

Body Positioning and Mechanics

ocedures

Be positioned "in the diagonal"' or treatment plane when­ ever possible l3 (F ig. 16-4). Shoulde rs and hips face toward the direction of movement. Having your forea rm s in th is plane is espeCially important. This positioning provides the best mechanics for manual cuing. The desired effects of manual contacts and resistance may be altered by even a sligh t deviation from this position.

. F is a manual therapy approach to fun ctional rehabilita­ with specific ~uide lines regarding the procedures of 'ent handling.l -~ Basic procedures of facilitation include Jy positioning and mechanics, manual contacts, manual 1 maximal resistance, irradiation, verbal and visual cu­ • traction and app roximation, stretch, an d timing.

The therapist uses contacts overlying the agonist muscle group to strengthen contractions or direct movement. Re­ search indicates that the afferent input of co ntact over a muscle group is facilitating to that muscle th rough a polysy­ naptic pathway. 14 Movemen t requires a dynamic response

system as techniques are applied. Figure 16-3 illus­ a sample pattern of facilitation. Voss et aLl have c}\i ded a pictorial descliption of the various patterns of ilitation. I

Manual Contacts

RE 16-3. Pattern of facilitation. (A) Sta rting point for 02 extension pattern with elbow straight. nt for 02 extension pattern With elbow straight.

u

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Therapeutic Exercise: Moving Toward Function

FIGURE 16-3. (CONTI NUED) (e) Starting point for D2FL pattern with elbow stra ight. (0) Endi ng poi nt for D2FL pattern with elbow straight. Note that the starting po int or "lengthened range" for one pattern in the di­ agonal is the end point or "shortened range" for the antagonist pattern. A pract ical tip for find ing the correct manual contacts and body mecha nics for the therapi st is to start by positi oning the patient at end range of the pattern to be performed, making certain your handholds will be effective at tha t point and to "wind up " the ex­ tremity to the lengthened range. from the trunk an d proximal and distal limb segments in synergy; therefore , manual contacts can be applied to any of these areas to prOvide facilitation . T o provide the con­ tact, the therapist often uses the lumbrical glip (Fig. 16-.'5), a hallmark of PNF. This aids in keeping contacts and ene's unidirectionaL The point of man ual contact is slightly differe nt in each individual because of variations in anatomic stru cture and

neuromus cular co ntroL The therapist needs to identify tl specific p oint of man ual contact. This location is the p oi at which a maximal response in the correct direction is L­ cilitated. The m;.lllual contacts used to facilitate these ind­ vidnal pattC' l'Ils vary in tTeatme nt, depending on the desi move me nt n.'sponse and need for e mphasis in the facili tion. The con tacts need to proviue the patient "vith a sen of security and th e therapist \vith proper leve rage to app

A

B

FIGURE 16-4, Therapist positioned in the diagonal or trea tment plane, with the forearm s, shou lders, and hips facing toward the direction of movement.

Chapter 16: Proprioceptive Neuromuscular Facilitation

• propriate resistance and cuing throughout the desired O\·ement. The therapist may plan for a direct effect, contacting the et group, or an indirect eff ct, contacting the synergist an tagonists to the targeted group. The therapist then J 4l.\ ' apply the proper inputs for the desired response ere eire other variations:

• ROM within a pattern • • • •

Speed of contraction Type of muscle contraction Number of repetitions Direction and quantity of resistance for emphasis 1-.1

anual and Maximal Resistance -1- ssic therapeutic exercise prinCiple, de monstrated by

onne,14 is tltat resistance to motion enhances muscle ·\ aticJl1. In PNF, the dir 'ction, quality, and quantity of . tance are adjusted to prompt a smooth and coordi­ ~ d response, whether for stability (i. e. , holds) or for , smoothness, and pace of moveillellt. The resistance uld be appropriate to prompt proper irradiation and fa­ ate function. The amount of n'sistallce applied to a dy­ nic (isotonic) contraction should be no greater than the . t· nce that allows full ROM to occur. For a static (iso­ ric) contraction, the thC'rapist should gradually build to greatest amount of resistance tolerated without defeat­ _ or breaking the patient's hold. I When applying resistance, consider the treatnwnt goal: • Power or endurance • Quality of movemf'nt • Presence of spasticity

diation iation, also callC'd overflow, is the spread of clingy the primC' agonist to co~nplen1f'JltaJy agonists and an­ _ nists within a pattern. ]v Irradiation can occur from 'nIal to distal muscle groups, distal to proximal, upper k to lower trunk (a nd vice versa), and from one mity to another. \Veaker muscle groups bellefit from irradiation they gain while working in synergy with e;er, more normal partncrs 9 . lh P~F is based Oil the f that contacting and applying the proper inputs to the rgists or antagonists of a target group is more effective (;onve ntional resistance ('xcrcises , which target a ~inlm cle group. . 1

319

The therapist may stimulate irradiation through the use of resistance. Aceording to _Sherrington, the response can be excitatory or inhibitory.l i The increase in effort to over­ come "esistance changes the excitation of motor neurons. As motor neurons respond, it is thought that they create a spread of energy from the agonists to "coagonists" at distant sites to assist with task completion. As the amplitude of the agonist contraction increases, antagonists that are usually reciprocally inhibited at low levels of resistance may be­ come facilitated in cocontraction. I II Another explanation is that excitation in stabilizers or fixators enhances the biomechanical advantage of the agonist group.19-2l The therapist learning the PNF approach is often in­ structed to "treat the good extremity first ," creating an ir­ radiation pattern from the contralateral side and a motor template for the desired task. 22 Combined movements of extremity patterns have predictable irradiation patterns within an intact neIVOUS system; Figure 16-2 reviews com­ bined movement patterns . The bilateral combinations of extremity motion have different effects on the trunk. Sym­ metric movements promote trunk flexion or extension, whereas reciprocal movements promote trunk rotation. Asymmetric movements combine trunk flexion or exten­ sion with rotation and lateral bending. Cross-diagonals use opposite limb movements to produce a stabilizing force in the tnmk. 23 The therapist can selectively choose the ap­ propriate type of pattern or movement to elicit the desired response from the trunk for a function.

Verbal Cuing The timing and tone of verbal cues are chosen carefully by the therapist and are a hallmark of PNF. Effective verbal cues coordinate the therapist's efforts with the patient's. Cues should be clear, concise, and appropriate to the pa­ tient's individual needs and comprehension. l-3 Commands frequently start off by detailing a particular patient re­ sponse ("lift your toes and pull up and across") and then change to more simple cues for subsequent repetitions ("and pull ; good ... again") Verbal cuing during treatment becomes goal-depen­ dent. A skilled therapist uses a quiet voice to promote con­ centration or inhibit hypertonus and a progreSSively louder voice to encourage greater recruitment or progreSSively greater ROM in a task or pattern. Cues can also prompt the initiation of movement ("squeeze and pull up and across"), the timing of reversals or reciprocal movements ("push and pull and push ..."), or remind the patient of a functional task that facilitates an es tablished motor pattern or engram ("reach to touch my face").

Approximation and Traction Handling techniques are deSigned to maximize the output or response by the patient. Approximation (i.e., compres­ sion ), as evidenced in weight-bearing joints, stimulates re­ ceptors to facilitate cocontraction and stability around the joint. 24 The effects of approximations are employed by the therapist through the use of weight-bearing developmental postures or by adding manual force into gravity. For example, a young athlete with a recent medial meniscus strain has difficulty ,vith vastus medialis oblique recruitment during straight-leg raises. By coupling light

320

Therapeutic Exercise: Moving Toward Function

compression through the knee with the limb in an un­ locked extended position with verbal cues to "hold," co­ contraction of vastus medialis oblique and hamstrings can be facilitated. This can be an effective technique in which full weight in gravity creates pain and inhibition. Traction separates joint surfaces, provides a stretch stimulus, and enhances movem ent by elongating the adja­ cent muscles 1b Commonly used with pulling movements, traction can be used selectively in the presence of pain to inhibit excessive compression . For example, physiologic mobilization in grades I and II of spinal joints are tradi­ tionally suggested to inhibit pain. 2.s If mi ld distraction is added, the amplitude of such mobilizations can frequently be increased, enriching mechanoreceptor stimulation and hasten ing progression toward functional ranges of motion in treatment.

Stretch Whenever appropriate, the therapist promotes reflexive activity that is faCilitatin g. Stretch is frequently performed at the starting position of a pattern or movemen t (i.e, length ened range ) and produces further muscle elonga­ tion. The resulting reflex activation is then synchronized with volitional effort through verbal cues ("pull") . Resistance through the entire available range provides continued stretch through tension. Stretch can be repeated at the start of the range or superimposed during a pattern to redirect or strengthen a patient's response. 1,:;) Because th e muscle spindle is sensitive to microns of motion, be careful to keep the amplitude and vigor of the stretch stim­ ulus app ropriate . To rely on this reflex response , the targeted muscle group must possess tone at rest and not be flaccid.

Timing Timing describes the sequencing of motion. Normal timing requires proper coordination and proportion al contribu­ tion from proximal and distal muscle groups. Timing for emphaSiS suggests that, to facilitate an enhanced muscular response , the therapist can intentionally interrupt the nor­ mal timing sequence at specific points in the ROM and ap­ ply speCific contacts to promote an optimal response 1 -J

Techniques of Facilitation With its basis in the neurophYSiologic work of Sherring­ ton,18 the PN F techniques of facilitation wel'e developed to tap into the "circuitly" of the nervous system . Whether ap­ plied to formal patterns or to functional movement, reflex responses and the predictable patterns of facibtation and inhibition are skillfully manipulated by the therapiS t. These techniques are based on SherringtoFl's principles of: • Irradiation: Energy is channeled from stronger to weaker muscle groups or patterns. • Successive induction: An increased response of the agonist results after con traction of its antagonist. • ReCiprocal inn ervation: Facilitation of the agonist re­ sults in simultaneous inhibition of the antagonists. 18 These techniques are proving to be valuable adjuncts in other treatment approaches SUdl as jOint mobilization,

myofascia1 release, and stabilization exe rcises. They are be­ ing adapted also in aquatics, sports medicine, and oth er therapeutic environments. The techniques include: 3 • RhythmiC initiation • Repeated stretch and repeated contractions • Reversals of antagonists: dynamiC reversals, stabiliz­ ing reversals, rhythmiC stabilization • Hold and relax • Contract and relax • Combination of isotonics Techniques directed at facilitating the agonist musd t group follow the next fevv sections. Information regardill_ the basic goals of the techniques are accompallied by a cli n­ ical example of how it Jllay be put to use. Each examplt" con tains a description of how to use patient positionint verbal commands, manual contacts, stretch, repetition , an timing and how to make conscious choices to I11mdmally ["" cilitate the desired outcome. .

Rhythmic Initiation The goal of rhythmiC initiation is to improve the ability the target agonis t to direct and begin movement. By start­ ing with passive movement in a chose n direction pattern, encouraging gradual patient partiCipation, an resisting the patient as performance improves, the ther;,­ pist can cue the direction, rate , and sense of the mo\' ment while bUilding motor output. In many cases, this a proach also promotes a subsequent reflexive relaxati response. In deciding on the ROM in an exercise, the therapi must decide if the full or a partial range of a pattern or tas is to be attempted to maximally facilitate the agonist. B this repetitive approach, a weak or paralyzed patient inin. ates rolling by '"pumping up" the nervous system. Do not overly concern ed with the detail of the pattern if the fU Jl( . tional goal is being achieved with good quality. Rhythmic initiation also helps set a selected rate movement. This application is particularly helpful \\1 patients who suffer from rigidity (e.g., parkinsonism ) severe spasticity. For exalllple, standing behind a subj holding two canes, it is possible to facilitate upper trll ~ rotation by grasping the canes and facilitating anTI SWU1_ Try this before and then dllring walking, and remem the power of verbal cuing ("reacb, and reach , and rea ... and reach I"). Display 16-3 prOVides a sample exer that uses rhythmiC initiation. Rhythmic initiation may used to: • Initiate movement • Define the direction or pattern of movement • Set the appropriate rate of movement • Improve coordination and sense of motion • Promote general relaxation

Repeated Contractions

Temporal and spatial sllmlnation are key to facilitation ,

movement reeducation. Spatial summation results [r

overlapping multiple facilitating inputs simultaneollsl~

promote excitation of a maximal response (i.e., positionID_

contracts, resistance, stretch, and verbal cuing), In tem

Chapter 16 Proprioceptive Neuromuscular Facil itation

z-

321

DISPLAY 16-3

DISPLAY 16-4

Sample Exercise Using Rhythmic Initiation

Sample Exercise Using Repeated Contractions

Goal

Goal

Joe Newman complains of shoulder pain while throwing a ball. The goal of treatment may be to improve the following: 1. Faulty timing of trunk or scapula (proximal) and extremity (distal) motions 2. A flat plane of arm motion during delivery 3. Poor follow through

Anna Lewis presents with glenohumeral dysfunction. Scapular stabilizer weakness has been identified by many researchers as a deficiency contributing to glenohumeral dysfunction. The goal of treatment in this example is to initiate lower trapezius function from the lengthened range.

plemenlation • Standing slightly to the right of Joe, a right-handed thrower, start your reeducation with your right hand cuing his right hand and your left hand on his right anterior shoulder. With a cue of "Let me move you," demonstrate passively the desired diagonal path, directing the motion of the limb and trunk in an efficient pattern. • Focus on the elements of range for follow through, staying in the upright path and keeping appropriate timing of the proximal and distal components. Repeating your passive movement pattern, instruct Joe and his proprioceptors about your desired results. Next, ask Joe, "Help me a little." Maintain the timing, range, and path while transitioning to active assistive movement. • Redirect the timing, path, or range if Joe's efforts do not match yours . As Joe responds appropriately, add resistance and say, ~ Now pull down and across, and again!" Progressively build your resistance to reinforce the weight shift, the trunk flexion with rotation, and proper contributions of the proximal and distal components. Try to maintain appropriate resistance throughout the 110vement.

' ummation, facilitation occurs by grouping repeated ts close together in time to promote the de sired rponse17 The technique of repeated contractions repeatedly elon­ the agonist muscle groups to reintroduce reflexive ut. The therapist must resist the response to stretch. timing of the verbal cues is also critical to success. Yhen the therapist's stretch occurs in the fully length­ -d range , the technique is called repeated stretch. When restretch occurs within the active RO:Vl, it is called re­ f'd contractions. v"hen performed midrange, this tech­ Je can help to redirect the patient's movement pattern. w range is achieved, the therapist may want to facilitate :.iliilizing dynamiC (isotonic) contraction by adding slight roximation and telling the patient to "hold." The tech­ e can commence again after the hold with a restretch . " lay 16-4 provides a sample exercise that uses repeated tractions. Repeated contractions may be used to: • Help to initiate movement • Strengthen the agonist movement pattern from lengthened range • Strengthen the agonist movement pattern from within the available active ROM • Redirect motion \vithin a pattern or task

Implementation • Try starting with the prone-on-elbows position. • Stand or kneel in front of Anna, placing your hands over the inferior half of each scapula, below the scapular spine. • Passively pull or glide the left scapula into elevation, elongating the scapula depressors. • With a gentle additional stretch and coupled cue ("Pull!"), stretch the lower trapezius, and resist its reflexive response as soon as it is felt. • As you feel the resisted response start to wane, immediately restretch to the lengthened range and repeat the cue ("Pull again!"). • This input can be repeated as long as it proves effective in increasing muscle recruitment. Repetitions can be dosed to increase strength and endurance. • Follow-up with a functional motion requiring the lower trapezius to function as a stabilizer and use of manual cues to maximize its response are recommended .

Reversals of Antagonists Reversing movement patterns that afford the body balance and postural stability are key to many functional tasks. The reciprocal activity of the limbs in the swing compared with stance phases of walking (i.e. , flexion adduction [swing] and extension abduction [stance] ) demonstrate this. Additional examples include sawing, chopping wood, rowing a boat, running, and grasping and releasing objects. The principle of successive induction provides that th~ agonist is facilitated after contraction of the antagonist I I To promote facilitation of the agonist, a better balance be­ tween the agonist and its antagonist is needed. To facilitate static and dynamic postural balance, reciprocal movements of the antagonistic groups are facilitated with static (iso­ metric ) or dynamiC (isotonic) contractions . When move­ ment is the intention, dynamiC reversals of antagonists use push-pull type dynam iC (isotonic) contractions. Holds can also be added as appropriate ("push, now pull, 1I0W push, and hold that push"); this is a dynamiC reversal hold. By us­ ing altern ati ng dynamic (isotoniC) contractions, during which the therapist's resistance prevents the motion, stabi­ lizing reversals are performed. 3 The patient's intention in this case is to move only if static (isometric) contractions are used; stability is the focal goal. The technique is called rhythmic stabilization .

Dynamic Reversals of Antagonists ReCiprocal or reversing motions are enhanced by the tech­ nique of dynamiC reversals. In this technique, dynamic (isotonic) contractions of antagonistic movements are facil­ itated reciprocally in a range appropriate to the goal of the

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Therapeutic Exercise Moving Toward Function

exercise. The movements can be cued to increase range as strength and control improve or scaled down through re­ peated reversals to enhance stahility. These techniques can be applied to the activities of daily living, self-care activities, and isolated pattems of move­ ment. Rolling is an exa mple of one such applicatioll. Al­ though the speCific impairments limiting the ability to roll may vary, the therapist may use reversals in rolling to max­

imize independence. Display 16-5 prOvides a sample exer­ cise that USE'S dynamic reversals of antagonists. Dynami reversals an-' used to: • • • •

Increase Improve Improve Improve

active ROM strength in the available ROM balallce and coordination of antagonists endurance of antagonistic patterns

DISPLAY 16-5

Sample Exercise Using Dynamic Reversals of Antagonists

Goal Bob Desmond has trouble rolling in bed. He is recovering from a mild stroke and has difficulty with coordination and fine motor control in his right upper extremity. The goal is to improve independence in rolling to the left in bed and proximal control of the right upper quadrant to increase upper extremity function . Implementation For a better understanding of this example, refer to Fig. 16-6.

• Biomechanically, rolling from supine to prone typically requires head and upper trunk flexion, with rotation in the direction of the roll. From sidelying left, for example, the motion of the head and right scapula to the left can be resisted as the patient initiates rolling . (Contacts: The therapist's right hand is over the anterior deltoid and humeral head. The left hand contact consists of fingertip pressure over the left brow, with the fingers pointing in the direction of the roll to gently cue neck flexion and rotation .)

FIGURE 16-6. (A) Reversing patterns of neck flexion with scapular anterior depression (8) Transition be­ tween motions. Here the therapist's forehead contact continues to facilitate roll ing toward prone, while the other hand is positioned on the scapula to reverse into rolling toward supine. (e) Neck extension with scapu­ lar posterior elevation. (0) Preparing to reverse motion; note change in scapular contact

Chapter 16: Proprioceptive Neuromuscular Facilitation

-r-

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DISPLAY 16-5

Sample Exercise Using Dynamic Reversals of Antagonists (Continued)

• The cue is "Tuck your chin and roll left!" This midrange starting position is selected to benefit from the effects of gravity and decrease the inhibitory effects of tonic reflexes from the supine position. • As the power begins to fade, release the scapular contact while still cuing at the head. By placing the right palm over the supraspinatus fossa and posterior aspect of the acromion process, a gentle stretch can be applied to the scapula, accompanied by a succinct verbal cue to "Push back and roll ... look at me!" As the reversal of the roll begins to take shape, seize the opportunity to quickly and accurately replace the left (head! hand to resist neck extension and rotation or side

abilizing Reversals ance and stability are enhanced by stabilizing reversals. . is achieved by applying alternating resistance to an ago­ t-antagonist pair and seeking a maximal dynamic (iso­ 'c) contraction. The therapist grades the resistance to fa­ litate a unidirectional hold, preventing the patien.t's .empts to move. This technique is similar in many ,"vays rhythmic stabilization, but it can also be used when a pa­ :Ilt is u.nable to perform a true static (isometric) contraction. This technique facilitates stability in a new or difficult \ J!. During a treatment session in which the patient sfers to a new posture, range, or weight-bealing status, implementation of stabiliZing reversals may prove valu­ to integrate the new abilities into function. Display 16­ rovides a sample exercise that llses stabiliZing reversals antagonists . Stabilizing reversals are used to: • Improve balance and stability • Improve strength • Integrate a new posture or RO~'I into function

bending right as its power builds. This placement should be posterolateral to the crown of the head. • As the roll returns the patient to sidelying, switch your "scapular" hand again to the position over the anterior del­ toid, restretching into a relative position of posterior eleva­ tion (the lengthened range for any motion is the shortened range of its antagonist). Lighttraction applied through the movement can help to "jumpstart" the agonist group. ~ Repeat the process, attempting to build the range and strength of the roll to the left. • Take care to select the optimal point for cue reversals. Effective stretch and secure contacts are key elements of fa cilitation.

Rhythmic Stabilization 'ocontraction of antagonists is the goal of rhythmic stabi­ lization. The teclll1i(lue can be performed at any point in a given ROM. The keys are to slowly build resistance; make smooth, coordinated transitions between antago­ nists; and ensure that the resistance promotes stability and does not break the patient's hold. RhythmiC stabiliza­ tion is used to: • Improve strength of antagonists • Improve balance of antagonists • Improve stability • Increase active and pas sive RO M following the technique • Decrease pain by reflexive relaxation Display 16-7 provides a sample exercise that uses rhyth­ mic stabilization.

DISPLAY 16-6

Sample Exercise Using Stabilizing Reversals al Illiam Tavish, age 68, is status post total hip arthroplasty. The goal of treatment is to improve decreased range of motion (ROM) in p extension and lack of stability in late stance phase of gait. lementation While in the parallel bars, have William stand in a staggered stance position with the involved extremity a small distance ahead. His

'lands should be on the bars and open, not grasping.

You can effectively resist the forward weight shift to the involved leg by a manual contact at the pelvic crest, with pressure aimed

downward toward the heels. Your verbal cues are, "Push into my hands. Stand tall!"

fter William has come as far forward as his hip joint flexibility and hip, and trunk strength allows, tell him to "Keep pushing your 'lips here; don't let me push you back!" Build your resistance to recruit gluteals and trunk extensors, watching for excessive lordosis. Then, release one of your hands from the pelvis and place it over the patient's scapula on the same side to resist the trunk from ehind. "Now, don't let me pull you forward!" After he responds to the new resistance, you can change the second hand to the posterior surface of the trunk with a pelvic or scapular contact, whichever gives you the best stabilizing response. ontinue sequencing the reversals as you build the patient's balance and stability in this late stance position. When used after joint mobilization and muscle stretching techniques, this technique is effective in integrating the new ROM into >Unction.

324

Therape utic Exercise Movi ng Toward FUllction

DISPLAY 16-7

Sample Exercise Using Rhythmic Stabilization Goal Elizabeth Curtis became a C5 quadriplegic after a spinal fracture sustained in a motor vehicle accident. She has fair balance in long sitting. The goal is to improve trunk control and upper extremity strength while increasing stability in long sitting. Implementation An excellent strategy in rehabilitation is to try to treat the patient in his position of function. Compared with the able­ bodied population, a person with a spinal cord injury often spends more time in long sitting (for dressing, bed mobility, and transfers). (See Fig. 16-7.1

A

• Slowly build your resistance with appropriate vigor at each hand to promote a maximal response. " Hold; don't let me twist you!" is your cue. - While maintaining your contact at the weaker side, reverse the contact at the free hand and start to build the new direction of resistance there. Be certain to maintain the hold through the transition: "Keep holding." Your intonation should be encouraging but not excitatory, which may break the hold. • Reverse the second hand, gradually decreasing its input before removing it and then gradually rebuilding its input as it shares the manual cuing in the new combination. Simultaneous switching of both hands often causes the

B FIGURE 16-7. Example of rhythmic stabil ization performed in long sitt ing. Therapist slowly changes resistance from flexor to extensor surface while maintaining resistance on opposite side.

• Kneel behind Elizabeth, who is positioned in long sitting, with arms extended. • Allow Elizabeth to chose a hand position forward of or behind the greater trochanter, whichever promotes the best sta bility to start. • Place one of your hands anteriorly over the humeral head and the other over the scapular spine on the other shoulder. • Add a bit of approximation through both hands to promote stability.

hold to be lost. Take care to keep the manual contacts pure and unidirectional from each hand. • By altering Elizabeth's hand position after initial success with this technique, it is possible to progress the difficulty of this exercise and further integrate the sitting balance into function. • By having Elizabeth lift an arm and continue to stabilize, progression can be made up the developmental ladder and toward greater functional independence.

Chapter 16: Proprioceptive Neuromuscular Fac il itation

325

DISPLAY 16-8

Sample Exercise Using the Hold-Relax Technique Goal Mary Brown presents with a diagnosis of lumbar sprain, which occurred as a result of a lower back injury 3 weeks ago. Your objective Tests and Measures include active range of motion assessment, palpation, a neurologic exami­ nation, and passive intervertebral motion testing. You deter­ mine that Mary has pain with passive extension mobilization in prone and flexion in sidelying, with the focus on the dys­ function and pain at the L5-S1 segment. Mary has been un ­ able to make headway with the lumbar flexion exercises prescribed by the physician, and says, "I'm just too tense and in too much pain." The goal is to mobilize the L5-S1 seg­ ment to promote relaxation, reduce the pain, and improve spinal mobility.

mplementation • You position Mary in a prone position with a pillow under the abdomen to maintain the lumbar spine in a neutral position. • You notice that a grade I PIA (posterior to anterior) glide of L5 is pain-free, and you can increase it to a slightly larger excursion, but less than 50% of normal accessory range. You maintain your pressure just below the pain threshold and tell Mary, "Hold." The goal is for Mary to try to isometrically tighten or co-contract. avoiding pain . After about a 6-second hold, you tell Mary, "Take a deep breath .. ., and relax." As the patient exhales, you can perform PIA mobilization in the new pain-free range of L5 on the sacrum (Fig. 16-8). Repeat this process to increase the pain-free range of motion. This passive technique should be followed by an agonist contraction to integrate the new pain-free range. In this case, a gluteal set or bridging will irradiate to the lumbar extensor and provide this integration function .

_Id and Relax 1 x relaxation is the goal of the hold and relax technique. la"(ation may allow an increase in passive RO\l and may p to decrease pain related to excessive tension. Sher­ ~on' s concepts of reciprocal innervation and successive uction call for inhibition of the antagonist during an ag­ t contraction and inhibition of a muscle group immedi­ \' after its contraction. 17 By using this phenomenon, the -relax and contract-relax techniques are valuable ad­ ·ts to muscle stretching. In the hold-relax technique, after reaching the end -ge of the agonist pattern, a "hold" (static) con traction rfonned against . radually building resistance. The is a maximum pain-free response. After the ensuing ,. phase, the new agonist range is achieved, and the ess is repeated . This technique is helpful when th e nt is experiencing pain. In faCilitating the hold phase, Cart' to avoid pain and not break the patient's holding raction.

elaxation techniques are effective when used in con­

h Oll with formal joint mobilization and manual ther­

~5 Display 16-8 demonstrates the use of the hold-relax

FIGURE 16-8_ Example of posterior to anterior mobilization of L5 on the sacrum using hold-relax.

technique with a common manual therapy technique. Hold and relax may be used to: • Improve passive ROM • Provide relaxation • Reduce pain

Contract and Relax

The goal of the contract-relax technique is relaxation of the

antagonist to a desired motion. A dynamiC (isotonic) con­

traction of the antagonist is perforn1ed, allowing only the ro­

tation component to occur against maximal resistance. After

the contract phase, ask the patient to relax; the passive mo­

tion into the agonist pattern is achieved. As with the hold-re­

lax technique, a key component in integrating the new range

is resistance of the agonist after the relaxation phase.

Many acquired ortho£5dic conditions surface as a result of muscle im balances 2 () The rapeutic intervention with these problems must focus on reestablishing a balance be­ tween agonists and antagonists and reeducate their recruit­ me nt patterns in function. This is accomplished by short­ ening the lengthened group and lengthening the shortened

326

Therapeutic Exercise: Moving Toward Fu nction

DISPlAY 16-9

Sample Exercise Using the Contract-Relax Technique Goal Holly Carson presents with chronic plantar fasciitis, which presents a challenge in controlling the inflammatory process and modifying pathomechanics. Physical therapy treatment usually involves antiinflammatory modalities, control of forces borne on the fascia, and stretching exercises. Myofascial release can be used effectively as an adjunct in this process. Muscle biasing results in part from stimulation of stretch receptors situated in the fascia . Releasing undo tension in that tissue can amplify the effects of selected therapeutic exercises by speeding tissue adaptation. Myofascial release to the plantar flexor or long toe flexor groups can be used during stretching and in conjunction with postural and gait retraining exercises to establish better muscle balance in the limb. Implementation • Ask Holly to lie prone on a treatment table with her toes approximately 6 inches past the table edge. • Stand atthe foot of the table with the plantar aspect of Holly's foot resting against your thigh. By rocking forward, Holly's ankle can be brought into graded dorsiflexion. • To perform the myofascial technique, place both hands palm down on the distal calf, near the end of the Achilles tendon. • Leaning from the trunk and using a stacked lumbrical grip, exert deep pressure into the posterior calf and apply a massage stroke, moving proximally. • Progress very slowly, as if moving a wave of tissue in front of your finger pressure. • When a thickening or increased tension in the contractile elements of the calf is noted, exert mild dorsiflexion by leaning forward from your lower trunk. At the point where moderate passive tension is noted, tell the patient, "Push your foot into my thigh; keep pushing . . . and relax." • The contraction phase should last about 3 to 6 seconds.

group. Display 16-9 provides a sample exercise that uses contract and relax. The contract-relax technique is used to: • Improve passive ROM • Provide relaxation

Combination of Isatonics The techniques of rhythmic initiation and repeated stretch are designed to facilitate the concentric component motion of a given movement pattern. However, many activities re­ quire a mix of concentric, eccentric, and maintained dy­ namic (isotonic) contractions. The goal of a combination of isotonics is to integrate the movement by varying the type of agonist contraction reqUired for function. It is solely an agonist-direction technique, but like all other techniques, it is rarely used alone during treatment (see Self-Manage­ ment 16-1: Bridging Sequence). Display 16-10 provides a sample exercise that uses a combination of isotonics. The combination of isotonics is used to: • Integrate the components of dynamiC (isotonic) con­ tractions, concentric, ecce ntric, and maintained

FIGURE 16-9. Coupling contract-relax with myofascial release . As the relaxation response is noted, pick up the slack created in the fascial tissue and the ankle dorsiflexion (Fig. 16-91. Commonly, extreme tightness can be noted in the region of the musculotendinous junction of the gastrocnemius. After a set of multiple repetitions (10 to 151. tell the patient. "Now, push your heel at me!" This integrates the new range of motion with an agonist contraction to the end range. Try to resist a sustained hold at maximum stretch. Follow-up should include closed-chain exercises that encourage talocrural dorsiflexion while controlling pronation.

• Increase strength of agonist • Increase active ROM • Teach functional control

PATIENT-RELATED INSTRUCTION From the initial interaction with the patient, the therapis must be working toward independence and the develop­ ment of an effecti ve home program of care. This i.: achieved by providing education and training directly t: the patient or to family members and aides. When carri over to the home , manual handling and exercise techniqu progress and prolong the benefits of clinical care, jOint an soft-tissue mobility, strengthening, improved stabi lity, an safety in self-<.:are and activities of daily living. Carefully choose exercise postures to challeng strength and stability at a level appropriate for the patien Resistance is provided by gravity, manually, by addi n free weights, or by using resistive tubing or bands. Th quantity of resistance, range and rate of movement, rep'· ­

Chapter 16: Proprioceptive Neuromuscular Faci lita tion

SELF-MANAGEMENT 16-1 Bridging

Sequence Purpose: Position:

To strengthen the glutea l muscles and

lower trunk, while maintaining a neutral

position of the lower back.

Start by lying on your back with knees bent

and feet flat, shoulder-width apart.

Movement

Technique:

Lift the pelvis off the floor by tightening the

buttock muscles.

Raise to a comfortable height, being sure

notto arch the lower back.

Hold this position 2 to 3 seconds.

Slowly lower halfway down, again holding

this new position for 2 to 3 seconds.

Return to the "up" position, again focusing

on preventing the arching tendency of the

lower back.

For greater strength demands, try the same motion while

holding a resistance band (supplied) across the pelvis

during the exercise (see diagram). Be certain to monitor the

position of the lower back during the exercise to prevent

arching and pain. Progress to higher raises of the hips only

as your strength and flexibility allow.

327

DISPLAY 16-10

Sample Exercise Using a Combination of Isotonics Goal Tom Dewey is a 64-year-old man who fell 12 weeks ago and sustained a fracture to the right proximal femur. He currently shows decreased stance stability on the right in gait and some difficulty with coming to stand from lower chairs and the commode. The goal of treatment is to improve lower extremity strength, independence with sitto stand from low surfaces, and stance stability in gait.

Implementation Bridging is a bilateral, symmetric, lower extremity pattern, typically incorporating hip extension, abduction, and knee extension. The most effective manual contact to resist bridging is over the anterior rim of the iliac crest, adjacent to the anterior superior iliac spine. • The initial phase of the bridge is concentric, and the cues

are a light manual stretch into further hip flexion while

vocalizing, "Push up into my hands."

• As the maximum response begins to taper, change the cue: "Keep it there. Don't let me push you down!" The intention of the patient is to continue pushing up against a true hold. If you feel restretching from this hip-extended position could yield further facilitation, coordinate a manual cue with "Push some more, and again!" • To control the eccentric phase, continue the resistance, and say to the patient, "Make me work to push you down ... slowly." The sequence of the combination is determined by the output of the patient and your specific goals. The sequence could be bridge-side shift right-slowly lower-bridge-side shift left to center-slowly lower-bridge-side shift left-slowly lower, and so on. In this particular pattern, the goals may be 1. Increased endurance (16 to 20 repetitions, less

strenuous holds and combinations)

2. Improved hip extension range of motion (few repetitions with multiple repeated contractions; holds at maximum range) 3. Improved bed mobility (add a side scoot to the task)

ns and sets, and duration of the exercise session are

eel to meet the patient's physical and medical profile. tive home programs combine speCific patterns to iso­ impairments with progression into functional tasks to :note transfer processing toward function. Techniques as contract and relax, reversals of antagonists , and -Ilg holds can be used to enhance more basic move­ patterns.

l EV POINTS "XF is a manual therapy approach that applies postures, \·ement patterns , contacts , cues , and goals , all of wch are maximally faCilitating. -reatment is based on improving function and using ctions that are possible to reach those that are attain­ Le as goals.

• PNF is not a treatment per se; it is a philosophy that lends itself to us e as an adjunct to other treatment ap­ proaches in most therapeutic environments.

1. Consider Case Study #8 in Unit 7. Describe PNF tech­ niques indicated to improve this patient"s a. Scapula posture b. Cervical spine mobility c. Lengthened rhomboids and lower trapezius d. Abdominal weakness 2. Consider Case Study #5 in Unit 7. Describe PNF tech­ niques indicated to improve this patient"s a. Standing balance b. Balance during gait c. Trunk posture during gait

328

Therapeutic Exercise: Moving Toward Function

Rhythmic Stabilization Start with your partner seated on the edge of his or her chair and with his or her feet on the floor. In this exer­ cise, manually challenging your partner's sitting balance, a. Try resisting at one shoulder and then both. b. Resist at the pelvis; then try the l1ead. Tl)' a com­ bination. c. TI)' varying the rate at which you apply resistance. d. Tl)' resisting in the sagittal plane and then on a di­ agonal. e. Resist at both shoulders pushing from the front. Resist at both shoulders pulling from the rear. Try pulling with one and pushing with the other. f. Try adding approximation through the shoulders. Then tl)' traction at the shoulders as if lifting the scapulae. 1. \Vhich rate of resistance application facilitated strength and stability? 2. \Vhich muscles were recruited from resistance at the different locations, with the different combinations? 3. Did straight or diagonal resistance promote the greatest recruitment of strength and stability? 4. What influences did anterior, posterior, and anterior­ posterior pressures provide? 6. What happened by adding traction and approxima­ tion?

Irradiation Start witb your partner supine, close to you on the right side of a high treatment table. a. Resist your partner's right hip flexion and adduc­ tion through active HOM. Your left hand is Oil your paliner's thigh and your right hand on the dorsu m of his foot. h. Have your pClliner roll to sidelying, and repeat the ll10vemen t. c. Hepeat the sidelying task with your partner hold­ ing on to the far side of the table. d. Let your partner place the sole of his left foot against your thigh or pelViS for stability and have your partner repeat the resisted movement. 1. In which position could your partner tolerate the greatest resistance'? Why? 2. In what part of the full ROM did your partner toler­ ate the strongest resistance? \·Vhy'? :3. What influence did holding the table proVide? What about pl'acing your partner's opposite foot against you'? 4. What happens in your partner's strongest part of the range if you focus your resistance on the dorsi flexing foot') What if the focus is on the hip fleXing? Have your partner practice rolling from siclelying to­ ward prone to his or her left on a treatment table or mat. Next, make your partner work a bit harder to roll by

holding back over his or her anterior right shoulder. You should be positioned in line with the rolling motion of your partner's shoulders. • As your partner rolls into gravity what happens to his or her ability to overcome your resistance? • What do you notice happening if you exert strong re­ sistance against your partner's shoulders rolling for­ ward? Do other areas come in more strongly in an at­ tempt to succeed in overcoming your resistance? • \Vhat happens if you exert strong resistance as your pmtner tries to initiate rolling from the supine posi­ tion toward prone? • Notice the effect on your partner's ability if you change your position relative to his or her shoulders. Try changing the direction of your resistance off of your partner's line of movement. What happens to his or her strength?

PNF Approach 1. List the advantages of PNF as a therapeutic exercise approach. 2. List the disadvantages of PNF as a therapeutic exer­ cise approach. Patient Problem A 30-year-old man hus complaints of chronic shoulder pain. His diagnosis is impingement syndrome. Your findings include • Painful arc from 90 to 110 degrees of flexion • PROM limited to 12.5 degrees abduction • Fair middle and lower trapezius strength • Functionallv unable to undress overhead • Unable to ;Ieep on the shoulder at night hecause of pain Coals: scapulothoracic stability, glenohumeral mo­ bility, functional needs for dressing, positioning for im­ proved sleep at night, and decreased pain. Devise a treatment plan or progression , including your response • Treatment postures with their rationale • Techniques of facilitation to be applied • \Vhich pattern or movement • Range to be emphaSized Techniques Which techniques would you consider if your patient demonstrates poor stance stability because of 1. Tight hip flexors 2. Weak gluteals 3. Hip pain 4. Ataxia Demonstrate your choices of treatment postures, techniques, and handling skills with a laboratory part­ ner. Discuss your thoughts.

Chapter 16: Proprioceptive Neuromuscular Facilitation

REFERENCES 1. Voss D, Ionta M, Myers B. Proprioceptive Neuromuscular Facilitation, Patterns and Techniques. 3rd Ed. Philadelphia: Harper & Row, 1985. 2. Knott M, Voss D . Proprioceptive Neuromuscular Facilita­ tion, Patterns and Techniques. 2nd Ed. Philadelphia: Harper & Row, 1968. 3. Adler S, Beckers D , Buck M. PNF in Practice: An Illustrated Guide. l'<ew York: Springer-Verlag, 1993. 4. Murphy W. Healing the Generations: A History of Physical Therapy and the American Physical Therapy Association. Lyme, CT: Greenwich Publishing Group, 1995. 5. Webster's Collegiate Dictionary. 10th Ed. Springfield, MA: Merriam Webster, 1995. 6. Roberts S, Falkenberg S. Biomechanics: Problem Solving for Functional Activity. St. Louis : Mosby-Year Book, 1992. I . Sullivan PE, Markos PD. Clinical Decision Making in Thera­ peutic Exercise. Norwalk, CT: Appleton & Lange, 1994. Sullivan PE, Markos PD. An Integrated Approach to Thera­ peutic Exercise: Theory and Clinical Application. Reston , VA: Reston Publishing, 1982. 9. Kabat H. Studies on neuromuscular dysfunction , XI: new principles on neuromuscular reeducation. Permanente Found Nled BuIl1947:5:111-123. O. Umphred D. Neurological Rehabilitation. 3rd Ed. St Louis: Mosby, 1995. 1. Shumway-Cook A, Woolacott M. Motor Control: Theory and Practical Application. Baltimore: Williams & Wilkins, 1995. 2. Shimura K, Kasai T. Effects of proprioceptive neuromuscu­ lar facilitation on initiation of voluntary movement and motor evoked potentials in upper limb muscles. Hum Movement Sci 2002;21:101-113. 3 . Mangold ML, Harper L. Proprioceptive neuromuscular fa­ cilitation residency program. Vallejo, CA: 1981. 4. DeLorme TL, Watkins AL. Techniques of progreSSive resis­ tive exercise. Arch Phys Med 1948:29:263. 5. Knutsson E . Propriocepti ve neuromuscular facilitation. Scand J Rehab Med SuppI1980:7:106-112. 6. Hildebrandt FA. Application of the overload pIinciple to muscle training in man. Arch Phys Med Rehabil 1958: 37:278-283.

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17. Sherrington C. The integrative action of the nervous system. 2nd Ed. New Haven , CT: Yale University Press; 1947. 18. Loofburrow GN, Gellhorn E . Proprioceptively induced re­ flex patterns. Am J PhysioI1948:l.'54:433-438. 19. Hellebrandt FA, Parrish AM , Houtz SJ. Cross education, the influence of unilateral exercise of the contralateral limb. Arch Phys Med 1947:28:76-85. 20. Markos PD. IpSilateral and contralateral effects of propIio­ ceptive neuromuscular facilitation techniques on hip motion and electromyographic activity. Phys Ther 1979:.59: 1366­ 1373. 21. Pink \1. Contralateral effects of upper extremity propriocep­ tIve neuromuscular facilitation patterns. Phys Ther 1981: 61:1158-1162. 22. Arai M, Shimizu H , Shimizu ME, et al. Effects of the use of cross-education on the affected side through various resistive exercises on the sound side and settings of the length of the affected muscles. Hiroshima J Med Sci 2001;50:65-73. 23. Winstein CJ. Designing practice for motor learning: clinical implications. Proceedings of the II STEP Conference, Nor­ man , OK; 1990. Alexandria, VA: Foundation for Physical Therapy; 1991:65-76. 24. Wyke BD. Articular neurology: a review. Physiotherapy 1972:58:94-99. 25. Maitland GD . Vertebral Manipulation. 5th Ed. London : But­ terworth , 1986. 26. Sahnnann SA. Diagnosis and Treatment of ~1usde Imbal­ ances and Musculoskeletal Pain Syndromes. Course handout. St. Louis , MO: vVashington University Program ill Physical Therapy, 1994. 27. Davies GJ, Dickoff-Hoffman S. :'-Jeuromusl;ular testin a and rehabilitation of the shoulder complex. J Orthop SportsOPhys Ther 1993;18:449-458. 28. Jobe FW, Pink M. Classification and treatment of shoulder dysfunction in the overhead athlete. J Orthop Sports Phys Ther 1993;18:427-432. 29. Wilk KE, Arriga C . Current concept in the rehabilitation of the athletic shoulder. J Orthop Sports Phys Ther 1993;18:365-378. 30. Kendall HO , Kendall FP, Boyton DA . Posture and Pain. Bal­ timore: Williams & Wilkins, 1952.

chapter 17

Aquatic Physical Therapy LORI THEIN BRODY

Physical Properties of Water Buoyancy Hydrostatic Pressure Viscosity

Physiologic Responses to Immersion Effects of Hydrostatic Pressure Effects of Water Temperature

Physiologic Responses to Exercise and Immersion Examination and Evaluation for Aquatic Rehabilitatio n Therapeutic Exercise Intervention

Mobility Impairment

Muscle Strength/Power/Endurance Impairment

Balance Impairment

Aquatic Rehabilitation to Treat Functional Limitations Coordinating Land and Water Activities Patient-related Education Pre cautions/Contraind ications Although water has been used therapeutically for cen­ turies, only recently has its use become widespread in the . ehabilitation community. Traditionally, water therapy has been limited to whirlpools used to debride ""ounds or to apply heat or cold treatments. However, the unique buoy­ ant and resistive properties of water make it a useful tool for therapeutic exercise. The advantages of unloading and of immersion in a resistive medium are well recognized, and the use of water as a rehabilitative medium continues to grow. As a result, the body of knowledge surrounding aquatic rehabilitation has expanded tremendously. As with land-based exercises, different techniques, schools of thought, and approaches have been developed. The Halli­ wick method, the Bad Ragaz Ring Method , Watsu , and Ai Chi are all examples of approaches to rehabilitation in the water. Further information on resources for these tech­ niques can be found in the Additional Resource section at the end of the chapter. As with other approaches to therapeutic exercise, it is important to realize that the water is a tool, with advantages and disadvantages. Not all patients are appropriate candi­ dates for aquatic rehabilitation. The strengths and weak­ nesses of each treatment modality must be matched to the needs of the patient. Because water is such a unique envi­ ronment, the clinician should get in the pool and experi­

ence the effects of different exercises before prescribin ~ them for patients . Often, aquatic exercises that appear to be simple can be quite difficult , and exercises that are dif­ ficult on land are easy to perform in the pool. The trunk stabilizing muscles are challenged with most arm and Ie,:: exercises and represent a very different task from the same activity performed on land. Aquatic physical therapy can be defined as the use of an aquatic medium to achieve physical therapy goals. The' purpose of this chapter is to acquaint the reader with the fundamental prinCiples of therapeutic exercise in the \/;'a­ ter. It is intended to provide the framework for integratio of water-based and land-based exercise to treat impair­ ments, functional limitations, and disabilities.

PHYSICAL PROPERTIES OF WATER The physical properties of water proVide countless option for rehabilitation program design. Be familiar with the properties and the intended or unintended effects that m a~ result from their interaction . For example, the effect ot buoyancy on gait is that of unweighting, thereby reducin~ the amount of physical work of walking. However, this re­ duction may be offset by the frontal resistance encounterea because of the water's resistance. As such, the clinician and patient should clearly define the goals of any given exercise in the pool to ensure progress toward overall functiona:. goals.

Buoyancy Archimedes' prinCiple states that an immersed body at re expeliences an upward thrust e1ual to the weight of tl same fluid volume it displaces. As such , rather than downward force resulting from gravity and body weight. in· dividuals in the pool experience an upward force (i. e buoyancy) related to water depth and specific gravity. Tht." specific gravity of an oblect (or an individual) is its densi . relative to that of water. The speCific gravity of water is al­ most exactly 1 g/cm 3 ; therefore, anything with a spe cjfi gravity greater than 1 g/cm 3 sinks, and anything less floats This property forms the scientific basis for underwate weighing to determine body composition. The speCi fic gravity of a person is determined by the relationship be­ t"veen lean body mass and body fat . Individuals with higher relative lean body mass are more likely to sink, an those with a higher relative body fat have a tendency t float. These differences can be balanced by the appropriate

330

Chapter 17 Aquatic Physical Therapy

e of water depth, flotation equipment, and waterproof -eight eyuipment. Buoyancy acts through the center of buoyancy, which is e center of gravity of the displaced liquid. If the body 'eight and the displaced fluid weights are unequal, a rota­ n about the center of buoyancy occurs until equilibrium reached. The moment of buoyancy is the product of the ree of buoyancy and the perpendicular distance from ce nter of buoyancy to tllf' axis of rotation. As on land, greater the distance, the gre
- sition and Direction of Movement with gravity, patient position and direction of movement reatly alter the amount of assistance or resistance. Ac­ ties in the water can be buoyancy-assisted, supported, or ted (Fig. 17-1). Movements toward the surface of the e r are considered to be buoyancy-assisted exercises and - imilar to gravity-aSSisted exercises on land. In this case, movement is assisted by the water's buoyancy. In the ding pOSition, shoulder abduction and flexion, as well .he ascent phase of a squat, are considered buoyancy­ - ted exercises. In a prone position, hip extension can be ~-ancy-assisted. ~ [ovements parallel

to the bottom of the pool are con­ red buoyancy supported and are similar to gravity­

331

minimized positions on land. These movements are nei­ ther resisted nor assisted by buoyancy. In a standing po­ sition , horizontal shoulder abduction is an example of sllch an activity. Hip and shoulder abduction in a supine position are also examples of buoyancy-supported acti,itics. Movements toward the bottom of the pool an-: buoy­ ancy-resisted exe rcises. In a supine pOSition, shoulder and hip extension are buoyancy-resisted activities, and tlw de­ scent phase of a squat is resisted in a standing position. The ability of the clinician to position the patiellt a number of ways allows for a multitude of assisted, supported, and re­ sisted activities.

Water Depth The water's depth is another variable that can alter the amount of assistance or resistance offered. For example, performing a squat in waist-deep water is easier than hip­ deep water. L ss support is provided by buoyancy in the shallower water. Walking can b e easier or harder in deeper water, depending on the individual's impairment or disability. Som eone \vith pain because of degenerative joint disease may find walking in deeper water easier be­ cause of the additional unlo,tding of buoyancy, and some­ one "vith muscular or cardiovascular weakness may find the additional frontal resistance of deeper water more difficult. Estimates of percentage weight bearing at vari­ ous depths have been obtained by Harrison et al. 2 The amount of weight bearing depends on the body composi­ tion of the patient, the water's depth, and the walking speed. Fast walking can increase the loading over the static condition by as much as 76%.2 Occasionally, water depth options are limited by the available facilities.

FIGURE 17-1. (A) Buoyancy-assisted knee extension. In a sta nding position with the hip flexed, knee extension s assisted by buoyancy. (8) Buoyancy-supported knee extension. In a sidelying position, knee extension is neither assisted nor resisted by buoyancy, but moves through a range perpendicular to buoyancy. (continued)

332

Therapeutic Exercise Moving Toward Function

of edema control. Pascal's law states that the pressure of a fluid is exerted on an object equally at a given depth l The pressure increases vvith the density of the fluid and vvith its depth . HydrostatiC pressure is greatest at the bot­ tom of the pool because of the weight of the water over­ head. As such, the pool may be a good exercise option for individuals with lower extremity edema or joint effusion. The hydrostatic pressure also produces centralization of peripheral blood flow, which alters cardiac dynamiCS. Thi ' is discussed later in this chapter under Physiologic Re­ sponses to Immersion.

Viscosity The viscosity of a fluid is its resistance to adjacent fluid la~­ ers sliding freely by one another.l This friction causes a re­ sistance to flow when moving through a liqUid. Viscosity is of little Significance when stationary. The viscous quality 0 '

c FIGURE 17-1, (Conti nued ) (e) Buoyancy-resisted knee extension. In a standing position with the knee flexed, the moti on from flexion to exten­ sion becomes resisted by the water's buoyancy.

Water level

B3

Modifications can be made by adding buoyant equipment to unload or by adding resistive equipment to increase frontal resistance.

B2

Lever Arm Length

B1

Just as "vith exercise on land, the lever arm length can be adjusted to change the amount of assistance or resistance. Performing buoyancy-assisted shoulder abduction in a standing position is easier with the elbow straight (i.e., long lever) than with the elbow flexed (i.e., short lever). Con­ versely, buoyancy-resisted shotIider adduction is more dif­ ficult with the elbow extended because of the long lever arm (Fig. 17-2).

A

Buoyant Equipment To further increase the amount of assistance or resistance, buoyant equipment can be added to the lever arm (Fig. 17­ 3). Additionally, as the buoyancy of the equipment in­ creases, the resistance also increases. A buoyant "bell" in the hand during shoulder abduction increases the assis­ tance from buoyancy while increasing resistance to the ad­ duction return motion. Buoyant cuffs can be added any­ where along the lever arm to adjust the quantity and location of assistance or resistance (Fig. 17-4). Buoyant equipment is also used to SUppOlt individuals in supine or prone pOSitions as they perform exercises. Because buoy­ ancy works in the direction opposite that of gravity, any land activity that would be resisted by gravity is assisted by buoyancy and vice versa.

Hydrostatic Pressure The pressure exerted by the water at increasing depths (i.e., hydrostatic pressure) accounts for the cardiovascular shifts seen with immersion and for the purported benefit

x

Water level

B

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B1 B

B

FIGURE 17-2. (A) The effect of buoyancy on shoulder abduction witr shortened lever arm (elbow bent) (8) The effect of buoyancy on sholJlac abduction with a long lever arm (elbow extended) Increasing the lever a­ increases the distance from the center of rotation , thereby increa sing i;­ resistance or assistance. (Adapted from Skinner AT, Thomson AM, e­ Duffield 's Exercise in Water. 3rd Ed. London Bail liere Tindall, 1983)

Chapter 17: Aquatic Physical Therapy

I Water level

X

A~

~

~

b"'"

B2

~

~

~

0

9

~ ~

""=
- --d 1 ---

CB B

GURE 17-3. The effect of buoyancy with the addition of a float in the d. The distance from the axis of rotation is further increased, thereby - :reasing the resistance or assistance. (Adapted from Skinner AT, Thom­ ~ AM, eds. Duffield's Exercise in Water. 3rd Ed. London Bailliere Tindall, =83 )

te r allows it to be used effectively as a resistive medium ause of its hydrodynamic properties. Turbulent flow is 'Uduced when the speed of movement reaches a critical IOcity.3 Eddies are formed in the wake behind the mov­ g object, creating drag that is greater in the unstream­ ed object than in streamlined objects (Fig. 17-5). In tur­

bulent flow, resistance is proportional to the veloCity squared, and increasing the speed of movement signifi­ cantly increases the resistance. When moving through the water, the body experiences a frontal resistance propor­ tional to the presenting surface area. Resistance can be in­ creased by enlarging the surface area. The clinician has two variables to alter resistance produced by viscosity: the ve­ locity of movement and the surface area or streamlined na­ ture of the object.

Velocity of Movement Turbulence and resultant drag are created when move­ ment reaches a critical velOCity. Slow nlOVell1ent through the water produces little drag. and resistance is minimal. Buoyancy may be a more Significant resistive or assistive property than viscosity during slow movement. However, when moving rapidly through the water, much resistance can be encountered that is proportional to the speed of movement. Individuals can progress resistance incremen­ tally by gradually increasing the speed of exercise. This al­ lows multiple gradations of an exercise rather than finite in­ creases in weight, as is frequently necessary in land programs. A study comparing shoulder muscle activation at 30 de­ grees/sec, 45 degrees/sec, and 90 de~rees/sec in the water and on land highlights this property. The percent of max­ imal voluntary contraction of the shoulder muscles \.vas consistently higher on land at 30 degrees/sec and 45 degrees/sec, \.vhereas those values were higher in water at

.

f A

333

B

AGURE 17-4. (A) Buoyant cuff added to the knee provides some assistance to hip flexio n. (8) A buoyant cuff added at the ankle provides greater hip flexion assistance.

334

Therapeutic Exercise Moving Toward Function

Surface Area

FIGURE 17-5. USing aplow while walking increa ses the su rfa ce area, cre­ ating eddies and drag.

In addition to alteling the speed of movement, resistano can be modified by changing the object shape to provid more or less turbulence. The body can be positioned to al­ ter turbulence, or equipment can be added. For example. less resistance is encountered in sidestepping than in for­ ward or backward walking because or the more streamlined shape in frontal plane movement. Performing shoulder in­ ternal and external rotation with the elbows bent to 90 de­ grees with the forearms pronated produces much less resis­ tance than performing this exercise with the forearms in neutral (Fig. 17-6A,B ). Adding resistive gloves fmiher in­ creases the resistance (Fig. 17 -6e). Changing the pitch of the hand slightly behveen neutral and pronation alters the surface area and resultant resistance. This provides a multi­ tude of resistive positions. A study of the Hydro-Tone ( H~ ­ dro-Tone Fitness Systems, Inc. , Huntington Beach, CAl re­ sistive bells found th at their OIientation and water velocii:' both had a significant effect on force production. 5 Approxi­ mately 50% more force is produced when the bell is ori­ ented at 45 degrees compared with 0 degrees at fast speeds At slow speeds, the orientation made little difference ir force production. Other equipment to increase the surfae area and resultant turbulence are fins for the feet, a plo-w fo­ resistive walking or other pushing and pulling activities , re­ sistive bells and boots, and paddles or pinwheels (Fig. 17- 'j'

PHYSIOLOGIC RESPONSES TO IMMERSION 90 degrees/sec (Table 17-1 ). This finding suggests that as the speed of movement through the water increases, so does the resistance. Slow movements produce muscle acti­ vation that is below those levels achieved against gravity on land, whereas fast movements exceed the muscle activation of comparably paced land-based movements.

Significant physiologic changes occur with immersion various depths. Be aware of th e changes that occur despi changes known to occur with exercise. These respol1 S may produce desirable effects (e .g. , con trol of lower tremity edema ) or undesirable effects (e.g., limitation

Shoulder Muscle Activation (Electromyographic) During Arm Elevation in the Scapular Plane on Land and in Water. Data are Mean Percentage of Maximal Voluntary Contraction MUSCLE

Supraspinatus Infraspinatus Subscapularis Anterior deltoid Middle deltoid Posterior deltoid

TEST CONDITION

Land Water Land Water Land Water Land Water Land Water Land Water

• P < .05 land versus wa ter. From reference 4.

30 DEGREES/SEC

45 DEGREES/SEC

90 DEGREES/SEC

16.68° 3.93 11.10· 2.28 5.96° 1.49 15.88" 3.61 6.22' 1.60 2.25" .75

17.46" 5.71 10.76 ' 2.89 6.1;:3 2.26 18.8:2" 43.49 7.64 2.53 2.24 .91

22.79 27.32 15.03 21.06 7.4.5 10.73 22.09 32.83 10.07 17.39 4.23 6.56

0

Chapter 17 Aquatic Physical Therapy

A

335

B

FIGURE 17-6. The amount of shoulder internal and external rotation re­ si stance is less with (A) forearm pronation than with (8) forearm neutral. (C) Resistance can be further increased by the addition of gloves.

g expansion ). Choose the appropriate water depth d on the specific health status of the patient and on the ent's physical therapy goals.

ects of Hydrostatic Pressure nersion alone is not a benign action . The hydrostatic m e encountered results in changes in cardiovascular Imics even before exercise is initiated (Display 17-1). rsion to the neck results in centralization of periph­ blood f1ow.6-LO Ri sch et al. 9 found that immersion to diaphragm raised heart volum e by approximately 130

mL, and further immersion to the neck increased heart vol­ ume by another 120 mL. Intrapulmonary blood volume in­ creases 33% to 60%, and vital capacity has been shown to decrease 8%.9 Immersion to the neck also increased cen­ tral venou s pressure at the height of the right atrium from 2.5 to 12.8 mm H g 9 The blood volume shift results in in­ creased right attial pressure of 12 to 18 mm Hg and in­ creased left ventricular end-diastolic volume (i .e., cardiac preload).7,8, ]O The cardiac preload produces a stroke vol­ ume (SV) in crease through the Frank-Starling reflex. Stud­ ies have shown a SV increase of 35% and a cardiac output (CO ) increase of32% while immersed to the neck, 6,l OThe

336

Therapeutic Exercise: Moving Toward Function

tremity edema are lIegated. The clinician should match the needs of the patient (e.g., prevention of edema, cardiac his­ tory) with the risks and benefits of the various treatrneu: modalities. For example, a patient with no significant car­ diac history and ankle swelling would benefit from immer­ sion in deeper water, whereas a patient with known cardiac disease and no lower extremity edema should be treated iJ: more shallow water.

Effects of Water Temperature

FIGURE 17-7. A variety of equipment is available to increase the surface area of movingl limbs.

heart rate (HR ) remains unchanged or decreases because of the relationship of HR , SV, and CO such that HR X SV 9 = co. Risch et al. demon strated that raising the water depth from the symphysis pubis to the xiphOid decreased the HR 159<: . These HR changes depend on the depth of immersion, the individual 's comfort level in the water, wa­ ter temperature, and type and intensity of exe rcise. The cardiovascular changes resulting from centraliza­ tion of blood flow are graded, and they occur with simple immersion before the ons et of exercise. This accounts for much of the variability in HR changes with water exercise reported in the literature. The hydrostatic indifference point (HIP) is located approximately at the diaphragm and represents the point at which the increase in hydrostatic pressure in the lower extremities and abdomen is precisely countered by the hydrostatic pressure of the water. Y The effect of hydrostatic pressure on cardiovascular changes depends on the depth of immersion and on body position . For example, when the wate r level drops below the sym­ phYSis pubis, the positive e ffects of prevention of lower ex-

DISPLAY 11-1

Physiologic Changes With Immersion 1. Decreased:

Peripheral blood flow Vital capacity 2. Increased: Heart volume Intrapulmonary blood volume Right atrial pressure Left ventricular end-diastolic volume Stroke volume Cardiac output 3. Decreased or unchanged heart rate

Water temperature , as with hydrostatiC pressure, alters tht' cardiovascular challenge to the immersed subject in depth-related fashion . \Vater that is too warm or too col can add a significant thermal load to the cardiovascular s\ tern. Chouk~oun and Varene l1 found co to be unchang from 25°C to 34°C (77°F to 93 C F) but Significantly in· creas ed at 40°C (104°F); oxygen consumption was signi.6. cantly increased at 25°C (77°F). Several studies have fo un a decreased HR in subjects exercising in cold water, and ex­ ercising in very warm water can increase HR 1 2- 16 Ther­ moneutral temperature is suggested to be approximate~ 340C. 14-16 Most pool temperatures range from 27° to 35C ­ (81°F to 95°F ). Know the current pool temperature an pote ntial effects on the patient.

PHYSIOLOGIC RESPONSES TO EXERCISE AND IMMERSION In addition to the effeds of immersion alone on cardiovas­ cular dynamiCS , the clinician must consider the comhiJla­ tion of changes res ulting from immersion and change resulting fro111 exercise. Training in water produces physi­ ologiC adaptations similar to training on land, and aquati training can b_e used to increase or maintain cardiovascular condition. ID,1 ,-21 Deep-water running has been shown t maintain an individu al's maximum oxygen consul1lpti aI1ld 2-mile run time over a 6-week training period. 2 Th pool can be used as a cardiovascular training tool alone in combination with land-hased training, proViding the in­ dividual recovering from injUly with alternative trainin mediums. When training in th e pool, th e cardiac preload resultin~ from central volume increases perSists clespite the vascul;c­ shifts JulOWIl to occur with exercise 7 Despite the increast­ in blood flow to the working muscles (i.e., peripheralizatio, of blood flow), the increased cardiac load resulting frOJli hydrostatic pressure (i.e. , centralization of blood flow) still occurs. Most studies have found the HR to be lower or un­ changed compared ,\lith similar cardiovascular activity 0 land. 1'>.2z-1' The depth of immersion aflects the degree cardiac changes, ,"vith increasing depth prodUCing greater cardiovascular changes. Subjects studied while walking and jogging in ankle-, knee- , thigh-, and waist-deep water ''''ere found to work harder "vith increasing immersion up to the waist , at which point the increased resistance (resulting from i,!lcreased surface area) was partially offset by buo~'­ ancy.2<> Water running and jogging in waist-deep water pro­ duces the same H~ and oxygen consumption changes a exercise on land. 26,2 1 However, exercise while immersed to

Chapter 17 Aquatic Phys ica l Therapy

the neck will produce a HR of 8 to 11 beats per minute lower than similar land-based exercise. 28 Both shallow-water running and deep-water running can be used for cardiovascular training. As with on land , a linear relationship between HR and cade nce exis ts for deep-water running.29 Mechanically, shallow-water run­ ning more closely resembles land-based running because of the foot contact on the bottom, but contact may also cause impact or friction problems. When perform ing resistive exercise in the pool, be sure ~o realize that most muscle contractions are concentric be­ l-ause of the negation of gravity. Eccentric contractions can generated if the water is shallow enough to minimize the e ffects of buoyancy, by manually resisting the force of uoyancy in an eccentric fashion , or by using a lot of buoy­ .illt equipment. For example, performing a squat exercise n thigh-deep water requires eccentric contractions in the wering phase, but peJforming the same exerc.:ise in waist­ ep water negates most of gravity's effects. If enough otation equipment is used, an exercise can require eccen­ T}C resistance against buoyancy. With large flotation de­ ces in the hand, the motion of shoulder abduction be­ mes an eccentric contraction of the shoulder adductors, isting the upward force of buoyancy.

MINATION AND EVALUATION FOR

QUATIe REHABILITATION

~e

clinician must perform a fuHland-based examination.

rusis the same evaluation the clinician performs when de­

-gning a land-based program. As always , choose tests and easures based upon the patient history and systems re­ w . Additionally, be sure to consider the physical proper­ of the water and the phYSiolOgiC effects of immersion en determining the appropriateness of aquatic physical erapy for the patient (see Display 17-2). \Vill the patient nent from the properties of buoyancy or hydrostatic ressure (Le., relief of weight bearing or swelling control)?

DISPLAY 17-2

Patient Screen for Aquatic Rehabilitation 1. Basic safety Ability to enter/exit the pool safely Comfort in the water Ability to put face in the water Rhythmic breathing/bobbing Ability to supine and prone float and recovery Turning over 2 Precautions to aquatic environment Cardiac history Fear of the water Any precautions to land exercise (i.e., diabetes) Limited lung capacity 3. Contraindications to aquatic environment Fevers, infections, rashes Open wounds without Bioclusive dressing Incontinence without protection Unstable cardiac conditions

337

Will the centralization of blood now place the patient at risk? Look for impairments that might alter the patient's relative denSity and ability to float. For example, a patient with paraparesis may need flotation to keep her legs from sinking when supine. Identify pathology or impairments that might affect the patient's ability to tolerate the hydro­ static pressure against the chest wall. Patients \vith de­ creased lung capacity may have difficulty breathing result­ ing from this pressure. Watch for sensory impairments that might alter the patient's ability to tolerate the touch of the pool floor, walls or water, or the visual or auditory sensory stimulation found in a pool. Be sure to assess the patient's safety in the pool envi­ ronment. Will the patient be able to traverse a wet shower room and pool deck? Will he or she be able to don and doff a swim suit? Are there safe mechanisms for transfer in and out of the pool, given the patient's physical capabilities? What is the patient's comfort level in the pool? Is he or she able to float and recover, blow bubbles, and immerse the face in the water? Is the patient able to regain balance com­ fortably if he or she loses it in the water? The patient's safety is paramount in the pool, just as on land.

THERAPEUTIC EXERCISE INTERVENTION After determination of the appropriateness of aquatic physical therapy with the patient, specific physical therapy goals must be developed. These goals should be written to address the speCific impairments and functional limitations identified. Aquatic exercise has been shoVl'l1 to improve im­ pairmen ts and functional limitations in individuals with variou s diseases and to improve the fitness of older women ao ,31 Patients with rheumatic disease showed signif­ icant improvement in premean and postmean scores of ac­ tive jOint motion and the Functional Status Index. 30 The decreased pain and difficulty with daily activities con­ tributed significant'ly to the overall increased functional status and active jOint motion. Elderly women participating in a 12-week water exercise class demonstrated significant improvements in oxygen consumption, muscular strength, agility, skin-fold thickness, and cholesterol as compared with a control group.31 Improvements in impairments and functional limitations such as these are reasonable rehabil­ itation goals. The follOwing sections describe prinCiples of aquatic phYSical therapy to treat common impairments.

Mobility Impairment Exercises to improve joint mobility and range of motion (ROM) are easily performed in the water. The general muscular relaxation, support of buoyancy, and hydrody­ namic forces occurring in water interact to provide an en­ vironment conducive to mobility activities. Be aware of the potential for overstretching while in the water. \Vhen de­ signing a mobility program in the pool, the primary consid­ erations are the fol!owing: l. The force of buoyancy and its effect on the desired motion (assisting, supporting, or resisting) 2. The available RO,M at the joint 3. The direction of the desired motion 4. The need for any flotation or weighted equipment

338

Therapeutic Exercise: Moving Toward Funct ion

Progress simple ROM exercises addressing impair­ ments to activities directed toward functional limitations and disabilities as qUickly as possible. For exa mple , progress exercises to increase hip and knee motion to nor­ Illa] ambulatiol1 as soon as pOSSible. Buoyancy is the physical property used most often to fa­ cilitate ROM. Use lever arm length and buoyant equipment to increase or decrease dIe amount of assistance from buoy­ ancy. For example, hip flexion , shoulder fl exion, and shoul­ der abduction are motions assisted by buoyancy in a vertical position. High marching steps can be performed with the knee flexed or extended, witll or v"ithout flotation equip­ ment to improve hip fl exion ROM . As soon as motion and weight bearing al1ow, progress this activity to normal walk­ ing, running, or bicycling, depending on the patient's needs. Perform traditional stretching using static structures in the pool such as steps, pool sides, and bars (Fig. 17-8). Be aleli to the me of proper technique when perform­ ing any exercise in the pool. Because of tbe water's refrac­ tion, it may be difficult to see the patient's posture and me­ chanics during excrcise. The maintenance of proper spine position and osteokinematics during ROM activity is essen­ tial for the progression to functional exercises. Observe the patient's exercise mechanics on land to ensure proper prr­ fonnance before pool exercise. Selected Interventions 17­ 1 and 17-2 present examples of aquatic exercises that may be prescribed for clients with mobility impairment.

Muscle Strength/Power/Endurance Impairment Altll0ugh buoyancy is tlle primary tool used to increase mobility, viscosity and hydrodynamic properties provide the greatest challenge to strength and endur::mce. The turbulence created during motion produces the greatest

resistance and is influenced by the surface area, object shape, and speed of movement. The strength trainin a principles and progressions used in water-based activiti are the same as those used on land. These include vari ­ ables such as frequency, intensity, and duration. As \'\lith techniques to increase mobility, progres s tradition al strength and endurance training exercises to address func­ tional limitations and disabilities as qUickly as pOSSible. For exampTe, progress simple viscosity-resisted hip exten­ sion and knee extension exercises to normal gait or risil1: from a chair as qUickly as pOSSible. Calisthenics, open kinematic chain, closed kinematic chain, diagonal pat­ terns, and motor control exercises can be performed ef­ fectively in the pool. Because the patient is immersed in a resistive medium. exercise in any direction can be resistive if given a critil:aJ velocity. A rf'sistive motion in any direction reqtlire counterforce to stabilize against the turning effects of t11 center of buoyancy. For eX~1 mpl e , an individual standing ir shoulder-deep water performing bilateral sholl,lde r fl exior from neutral to gO-degree flexion is pushed back\;vard . the force generated with the arms (see Self-Managem e n~ 17-1: Bilateral Shoulder Flexion ) The leg and trunk stabi­ lizers must fire to counte ract and kr'ep the individual fron falling over. This can be an effective technique to trai trunk stabilization. It is easy to overlook the additional mus­ cular work necessary to prOVide stabilization against resb· tive mOVC'lllellts in th e pool, and this demand probably con­ tributes to th e overwork experienced by many patients. B aware of which muscle groups are providing stability, th quantity of stabilization necessary, and the position or pos ­ ture of the joints being stabilized. In the absence of cxteor­ nal support (e.g, hand hold, wall support), nearly any up­ per or lower extremity exercise places Significant demancL on the hip and trunk stabilizers.

FIGURE 17-8. Stretching exercises for (A) hamstring muscles and (B) shoulder extensors can be performed us­ ing bars or the pool edge .

t'::\

SELECTED INTERVENTION 17-1

~

Aquatic Therapy to Improve Upper Extremity Mobility I

See Case Study #4

ACTIVITY: Shoulder internal rotation stretching PURPOSE: To increase mobility in internal rotation and extension

comprehensive mobility, strength, and endurance program performed in the pool. This program is balanced with a home exercise program.

FUNCTIONAL MOVEMENT PATIERNS TO REINFORCE GOAL OF SPECIFIC EXERCISES: Reaching behind the back for hygiene, tucking in shirt, and hooking brassiere

ELEMENT OF THE MOVEMENT SYSTEM: Base STAGE OF MOTOR CONTROL: Mobility POSTURE: Standing in waist deep water holding a buoyant barbell behind the back MOVEMENT: Squat slightly to increase the stretch SPECIAL CONSIDERATIONS: Substitution such as forward trunk flexion or scapular protraction must be avoided. The patient should feel a medium to moderate stretching sensation . DOSAGE: Patie nt should hoId stretch for :30 seconds EXPLANATION OF CHOICE OF EXERCISE: This exercise was chosen to increase shoulder mobility as one component of a

t:::\

v:;J

Starting position

Ending position

SELECTED INTERVENTION 17-2

Aquatic Therapy to Improve Lower Extremity Mobility

See Case Study #6 :\.!though this patient requires comprehensive intervention as desclibed in previous chapters, one speCific exercise related to aquatiC therapy will be described.

ACTIVITY: Lunge walking PURPOSE: To increase mobility in the hip, knee and ankle, and force or torque generation and endurance in the lower extrem ities RISK FACTORS: No appreciable risk factors

DOSAGE: Repetitions to form fatigue; performed two to three times per week EXPLANATION OF CHOICE OF EXERCISE: This exercise was chosen to improve mobility at the hip, kn ee, and ankle , as well as dynamic muscular control at these joints. This movement was chosen to emphasize the knee flexion component in the loading response phase of gait. FUNCTIONAL MOVEMENT PATIERN TO REINFORCE GOAL OF EXERCISE: Normal gait, ascending and descending stairs, and getting in and out of chair

ELEMENTS OF THE MOVEMENT SYSTEM: Base STAGE OF MOTOR CONTROL: Controlled mobility MODE: Mobility and resisted activity in a gravity lessened environment POSTURE: Maintain an upright trunk throughout the exercise MOVEMENT: Walking in a normal heel-toe gait pattern , exag­ gerating the knee flexion of the loading response to 60 to 80 degrees of flexion, followed by full extension at midstance. SPECIAL CONSIDERATIONS: Ensure an upright trunk voiding forward lean. Avoid h.llee flexion beyond 80 degrees of flexion, and maintain a vertical tibia during the knee exion component.

Starting position

Ending position

340

Chapter 17 Aquatic Physical Therapy

Therapeutic Exercise Movinq Toward Function

----------------------------- -- ---------------- ---------------

SELF·MANAGEMENT 17-1

Purpose:

Position: Movement technique:

346

Bilateral Shoulder Flexion

Increased muscular strength and endurance in shoulderflexors and extensors Increased trunk stability Standing with the feet in stride, arms atthe side, and pa lms facing forward Levell: Bring arms forward together; then turn palms facing backward and push arms backward. Turn palms forward and repeat. Level 2: As Level 3: As equipment Level 4: As Level 5: As

above, but with feet in stance above, with addition of resistive above, but standing on one leg above, with eyes closed

Dosage Repetitions: Frequency: _________

As with exercises to increase mobility, equipment can be used to enhance resistive exercise. Buoyant cuffs or bells can be used to increase the resistance against buoyancy, and paddles, gloves, and other surface area-enhancing equipment can increase the resistance resulting from tur­ bulence. It is important that the quality of the exercise not be sacrificed for an increase in resistance (see Self-Man­ agement 17-2: Bell Push-Downs). As resistance is in­ creased, patients may alter their technique or posture to ac­ commodate the resistance change. For example, adding gloves to bilateral shoulder horizontal abduction and ad­ duction can increase the postural sway so much that the pa­ tient cannot maintain balance. Cardiovascular endurance can be increased in several ways, relying on the same principles of overload and pro­ gression used in land-based programs. The activity must be of sufficient intensity and duration, use primarily large muscle groups, and should be performed three to five times per week. Deep-water activities are especially useful for individuals with weight-bearing limitations. Deep­ water running, bicycling, cross-country skiing, and vertical kicking are only a few of the activities that can be per­ formed continuously or as intervals. Traditional s\vimming strokes complement these lower extremity dominant exer­

cises. Shallow-water running makes an excellent cardiov, cular conditioning exercise if impact is tolerated. Appropr. ate aquatic footwear must be worn when shallow-wate running for any length of time. This can include an in£" pensive surf shoe or a more expensive aquatic exercjs· shoe. This minimizes the likelihood of impact injuries ar friction injuries to the bottom of the foot.

Balance Impairment The supportive medium of the water and its destabilizi.. _ forces provide an ideal environment for balance trainiu _ Other individuals in the pool create turbulence and crear destabilizing forces. These forces can also be created by individual's own movements. For example, kicking on~ le-_ forward produces a force pushing the individual backwar (see Self-Management 17-3: Single-Leg Kicks). The for­ ward movement must be countered with balance re­ sponses. The increased reaction time makes these types training movements especially useful for individuals \ \ 1 poor balance. Movements occur more slowly in the pool ft'­ suIting from the water's viscosity. As such, when balal1c lost, the fall is slowed dramatically, giving the individ time to react and respond.

Therapeutic Exercise: Moving Toward Function

Chapter 17 Aquatic Physical Therapy

SELF-MANAGEMENT 17-2 Bell Push-Downs

Purpose:

Position:

In creased abdominal strength

Increased trunk stability

Increased shoulder and arm strength

Standing in chest deep water, arms

straight out in front with hands on a

Styrofoam bell

Movement technique:

Levell: Tighten abdominal muscles and

pull bell straight down toward legs.

Control the bell on the way ba ck up.

Level 2: Move to deeper water.

Level 3: Increase size of buoyant bell.

Dosage Repetitions: Frequency: _ _- - - - - -

Starting position

Ending position

SElF-MANAGEMENT 17-3 Single-Leg Kicks

Purpose:

Position:

Increased hip mobility Increased hip and knee muscl e strength and endurance Increased single-leg balance Standing on one leg in a neutral spine posture with abdominal muscles tightened. The non-weight-bearing leg should be straight at the knee and flexed at the ankle. If working primarily on balance, stand near the edge, but do not hold on to steady yourself. Otherwise, hold on to the side for support.

Movement

technique:

Levell: Kick leg forward and back, ensuring proper spine position. Avoid arching your back as your leg comes back, and avoid letting your trunk sway. Level 2: Add resistive equipment to foot or ankle.

Starting position

Dosage Repetitions:

Frequency: _ _ _ _ _ _ __

Ending position

341

342

Therapeutic Exercise: Moving Toward Function

A variety of balance activities performed on land can be adapted to the pool. Any single-leg stance exercise with concurrent movement of the arms, opposite leg, or both can provide a wealth of balance exercise. Single-toe raises, step-ups, and simple single-leg balan ce exercises can be

performed \vith and without equipment (see Self-Managc-­ ment 17-4: Three-step Stop). Selected Interventi on 17-3' Aquatic Therapy to Improve Balance presents a sample 0 an aquatic exercise that may be prescribed for the clien with balance impairment.

SELF-MANAGEMENT 17-4 Three-step Stop

Purpose:

Position: MOllement technique:

Increased dynamic balance Increased trunk stability Increased lower extremity strength Increased single-leg balance Standing on both legs in a neutral spine posture, abdominal muscles tightened. Take three steps forward beginning with your right leg, then stop and balance on your right leg. Step back with the left leg for three steps, stopping to balance on the left leg. After several repetitions, switch to stepping with the left leg first. Levell : Use your arms as needed for balance. Level 2: Place your arms across your chest. Level 3: Close your eyes.

00s8ge Repetitions: Frequency: _ _ _ _ _ _ __

l

Chapter 17: Aquatic Physical Therapy ~e ­

-3'

i I

t:::\

SELECTED INTERVENTION 17-3

~

Aquatic Therapy to Improve Balance

343

n See Case Study #1

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF SPECIRC EXERCISE: Single-leg stance of gait cycle

ACTIVITY: Single-leg balance in chest deep water PURPOSE: Train single-leg balance through entire lower extremity and trunk without full weight on the limb. RISK FACTORS: No appreciable lisk factors ELEMENT OF THE MOVEMENT SYSTEM: Modulator STAGE OF MOTOR CONTROL: Stability OSTURE: Single-leg stance with arms in a comfOltable position; lumbope hic region in neutral and knee in slight l1exion OVEMENT: None; simply maintain balance Level 1

Progression

OSAGE: Repetitions to form fatigue or pain; attempt to hold ~.

long as possible

QUATIC REHABILITATION TO TREAT CTIONAL LIMITATIONS n tional limitations represent restrictions in perfor­ ce at the level of the whole person. Impairments in­ -e losses at the tissue, organ, or system level but mayor ~ not contribute to functional limitations. As the patient -es improvements in impairments , activities in the pool lid be modified to emphasize the functional limitations. ctionaJI limitations related to posture or position can be essed in the pool. If prolonged sitting is a functional itation, a variety of sitting activities can be performed in ::' pool. Many pools contain steps where the patient can \-ith various levels of depth (Le., unloading) . Chairs can ubmerged in the pool, and buoyant equipment for sit­ = is available (Fig. 17-9). As sitting tolerance increases , depth of water should be decreased , thereby more ::ely representing land situations. This same prinCiple be applied to deficiencies in prolonged standing or r positional limitations. ~ unctionallimitations related to speCific movement pat­ (e.g., gait, forward reaching) respond well to aquatic bilitation. Unloading the lower extremity or spine e is frequently adequate to normalize gait mechanics. al or tactile cuing may be necessary if gait changes t' existed for some time. Any impairments such as limi­ ns in motion , endurance, or strength must be ad­ ed concurrently. As normal pain-free gait mechanics chieved, the water depth should begin decreasing to icate the land-based environment. Similarly, other _tionallimitations in movement can be addressed in the manner. For the individual with difficulty performing rd reaching, this acthity can be assisted by buoyancy,

which is progressed to buoyancy-supported and to buoy­ ancy-resisted activity. Repetitive hunk flexion and exten­ sion, lifting, pushing, pulling, and squatting can be pro­ gressed in the same fashion (Fig. 17-10). Components of basic activities of daily living and instlllmental acthities of daily Ihing can also be reproduced in the pool.

COORDINATING LAND AND WATER ACTIVITIES One of the questions frequently asked by clinicians con­ cerns the integration of water- and land-based activities. How much acthity should be performed in the water, and when should land-based activity be incorporated? The ad­ vantages and disadvantages of aquatic rehabilitation and land rehabilitation should be matched to the needs ofthe in­ dividual patient, keeping in mind that humans function in a gravity environment. Because it is difficult to reproduce lower extremity eccentric muscle contractions in the pool, the patient should be progressed to land-based activities as quickly as tolerated. Early on, the patient may tolerate little land-based acthity because of pain. Aquatic rehabilitation occupies most of the program at this time. As the patient is able to tolerate land-based activity, these exercises should be incorporated into the program . The quantity of water­ based activity may remain unchanged, increase if tolerated, or decrease as the quantity ofland-based exercise increases. The exact proportion and quantity of both land and water activity is determined by the needs and response of the pa­ tient. Occasionally, individuals respond better to alternate days in the pool, but others can progress to daily land-based exercises and discontinue pool exercise. The exercise

344

Therapeutic Exercise: Moving Toward Function

FIGURE 17-9. Posture exercises and reaching activities can be performed whi Ie sitting on flotation equipment.

program should be matched to the needs of the patient, with the goal of progressing to land-based exercise.

PATIENT-RELATED EDUCATION

anticipated experience in the water. Identify the areas entry and exit from the pool, the water's depth, and an­ other important safety features (e.g., drop-offs, gutters bars). Also familiarize the patient with the exercise pro­ gram on land before entering the water to ensure prape­ exercise performance. As the patient enters the water and the rehabilitati program proceeds, use this time as an opportunity to teac. the patient about the expected benefits of the exercise. Fer example, when performing activities in single-leg stance the patient frequently complains of an inability to maintai' balance. Emphasize that developing balance is the purpo of the exercise and that any modification of the exercise t, further destabilize the person is a progression of the exer cise. When surface area-enhancing equipment is add explain to the patient that it will increase the difficult} ( the eXf'rcise. This also educates the patient on appropriat, exercise program progression, and when the program continued independently, the patient is able to self-mana!! and progress his or her own exercise program. -

PRECAUTIONS/CONTRAINDICATIONS Some absolute and relative contraindications to exercise 1 the water exist. Individuals with excessive fear of the wate. open wounds, rashes, active infections, incontinence, c.­ tracheostomy should not be admitted to the pool. H O\' ever, some physicians allow patients with open wounds participate in aquatic rehahilib,tion with use of a BioclllSi\ drf'ssing. This is commonly seen in patients with postop ative incisions. r

As with land-hased exercise, patient education is a key component of the aquatic physical therapy program. The education program bf'gins before entry into the water with a discussion of' the fundamental properties of the water and the patient's expectations. Ensure patient comfort in the water; this is enhanced by educating the patient about the

A

B

FIGURE 17-10. Work conditioning exercises such as (A) pushing and (8) lifting can be reproduced in the pool.

Chapter 17 Aquatic Physical Therapy

Be aware of precautions to exercising in the water. The ardiovascular changes occurring with immersion should of concern for the patient with a cardiac history. The . drostatic pressure also ' limits chest expansion in those mersed in neck-deep water. This can create breathing 'ffi culties for patients with pulmonary impairments or nctional limitations. The hydrostatic pressure against chest wall also can cause a sensation of an inability to "eathe in persons who are uneasy in the water. The drostatic pressure produces diuresis , which can be ided by emptying the bladder before entry to the I. Be alert to medical emergencies in the pool. It may be re difficult to respond to an emergency in the water, and action plan must be in place. Be sure to know and prac­ e safe removal of the patient from the water, and know lide1ines for implementing cardiopulmonary resusci­ n in the pool. Because of the sense of mobility experienced when ex­ j ing in the pool, many patients tend to ovef\vork. rexercise may occur because of the reduced gravity en­ nment, the support of buoyancy, and the muscular re­ ..tion associated with immersion, hydrostatic pressure, water temperature. Frequently, the signs and symp­ of oveJWork do not manifest until later in the day or next day. It therefore is better to err on the conserva­ ide and underestimate the appropriate amount of ex­ . -e rather than overestimate.

l EV POINTS he pool prOvides a unique environment for the reha­ wtation of individuals with a variety of impairments, ..nctionallimitations, and disabilities. e properties of buoyancy and viscosity can be used in number of ways to achieve physical therapy goals.

LAB ACTIVITIES 01Activities Upper extremity a. Using a variety of pOSitions (e.g. , supine, prone, standing) and equipment (e.g., buoyant, resistive, wall, railings) , develop an exercise program to in­ crease a patient's shoulder, elbow, forearm, and wrist range of motion in all available ranges. Do this for a variety of motion limitations (i.e. , mini­ mal loss to Significant motion loss). b. Using a variety of positions and equipment, de­ velop an exercise program to increase a patient's shoulder, elbo'vv, forearm, and wrist strength and function. Progress from isometric exercise

345

• The effects of hydrostatic pressure and water tempera­ ture on the phYSiologic responses to activity must be considered to ensure patient safety. • The water's viscosity prOvides much resistance and can be fatiguing for deconditioned individuals. • Because a range of activities, from mobility and stretch­ ing to resistive and cardiovascular exercise can be per­ formed in the pool, aquatic therapy can progress from the early stages through functional progression. • Balance is challenged with nearly every arm and leg movement in the pool, and the effects of exercises on the trunk and leg stabilizers must be considered when de­ signing the exercise program. • The pool program must be balanced by a well-deSigned land-based program to ensure proper transition back to the land environment.

CRITICAL THINKING QUESTIONS 1. How can the difficulty of the first selected intervention exercise (Single-leg balance) be increased using the follOWing? a. Arms b. Legs c. Equipment d. Other sensory systems 2. "\That factors might limit the patient's ability to perform this exercise? 3. How is this exercise changed in different water depths? a. Waist deep b. Neck deep 4. How is the exercise in Self-Management: Bell Push Downs changed in different water depths? a. Chest deep b. Neck deep 5. How can mobility in internal rotation be improved while keeping the shoulders immersed?

-. -

L..

•

_

through a functional progression to activities of daily living, work, or sports. Perform open- and closed-chain exercises. 2. Lower extremity a. Using a variety of positions (e.g., supine, prone, standing) and equipment (e.g., buoyant, resistive, wall, railings) develop an exercise program to in­ crease a patient's hip, knee, and ankle range of motion in all available ranges. Do this for a variety of motion limitations (Le., minimal loss to signifi­ cant motion loss). b. Using a variety of positions and equipment, de­ velop an exercise program to increase a patient's (continl/ed)

346

Therapeutic Exercise Moving Toward Function

LAB ACTIVITIES (Continued) lower extremity strength and function . Progress from isometric exercise through a functional pro­ gression to activities of daily living, work, or sports. Perform open- and closed-chain exercises. 3. Trunk a. In an upright position, establish a neutral spine position and ambulate forwan], backward, Sidestepping, and braiding patterns . Vary step length. and observe resultant changes in range of motion. b. In an upright position, pelform a vaJiety of upper extremity exercises, and observe the challenges to the tnmk stabilizers. Perform exercises with a wide stance, narrow stance, and standing on one leg. c. In an upright position, perform a vadety of lower extremity exercises, and observe the chaflenges to the trunk stabilizers. Notice the differences be­ tween sagittal plane and frontal plane motions.

Land Activities Develop lanu-based and aquatic rehabilitation pro­ grams for the follOWing patient problems. Progress the program from the acute phase through to a functional progression. PATIENT #1

A 54-year-old man has L4-L5 discogenic back pain . The patient has had recurrent episodes of pain over sev­ eral years but has always been able to self-treat with a home exercise program designed by a physical therapiSt. Two weeks ago, the patient took a vacation requiring a long plane flight , followed by sleeping in a bed with a poor mattress. This patient has been unable to relieve the symptoms with self-treatment. His primary com­ plaint is low back pain with occasional radicular pain to the left knee. Symptoms do not extend beyond the knee. The patient desires to return to walking as exercise and recreational golf. He works at a desk job. Examination reveals an eaSily correctable lateral shift

REFERENCES 1, Beiser A, PhYSics, 2nd Ed , Menlo Park, CA: The Be n­ jamin/Cummings Publishing Co., Inc., 1978. 2, Harrison RA , Hillman M. Bulstrode S. Loading the lower limb when wal king partially immersed : implications for clini­ cal practice. Physiotherapy 1992;78: 164-166. 3. Skinner AT, Thomson AM , eds. Duffield's Exercise in Water. 3rd Ed , London: Bailliere Tindall, 1983, 4. Kelly BT, Roskin LA, Kirkendall DT, et al. Shoulder muscle activation during aquat ic and dry land exercises in nonim­ paired su bjects. ] Orthop Sports Phys Ther 2000;30:204-210. 5. Law LAF, Smidt GL. l.:nderwater forces produced by the Hy­ dro-Tone bell. ] Orthop Sports Phys Ther 1996;23: 267-271. 6. Arborelius M , Balldin CI , Lilja B, et a!. Hemodynamic changes in man during immersion with the head above water. Aerospace Med 1972:43:582-598,

to the light, with decreased active and passive ROM in extension, left sidebending, and left rotation . Active mo­ tion is limited in flexion. Dural signs are positive for radicular symptoms, but deep tendon reflexes and sen­ sation are intact throughout. The low back is diffllsel~' tender, with a protective muscle spasm in the left erec­ tor spinae. Lower extremity strength is .5/.5 to Single rep­ etition testing throughout. PATIENT #2

A 60-year-old woman presents after a right proxima, humeral fracture , which was cared for with sling immo­ bilization for 6 weeks. She has a history of mild degen­ erative joint disease at the acromioclavicular joint. She b right-handed and complains primarily of an inability to perform her daily activities because of motion loss and shoulder pain . Her goals are to return to activities 0 daily living, golf, and gardening. Examination reveals loss of motion in an shoulder Illotions in a capsular pattern. Elbow, 'mist, and hand motions are normal. Strength tests are limited by shoul­ der pain. Accessory motion is slightly decreased CO Ill­ pareu with the left in anterior, posterior, and inferior di­ rections. Strength and sensation are normal throughoU! the rest of the right upper extremity. PATIENT #3

A 17 -year-old girl is seen 6 weeks after abrasi o chondroplasty for an acute osteochondral lesion on the weight-bearing surface of her right knee medial femorai condyle. Her goals are to return to basketball, softball and volleyball. She is partial weight bearing (.50%) ana can be progressed by 25% every 2 to 3 weeks until f weight bearing is achieved. Active motion of the knee is S:0-1O-90 and passh motion is S:0-5-100 with an emptyendfeel. She main­ tains a 1+ effusion and has 4+/5 strength to manua: muscle test, with visible atrophy of the quadriceps Hamstring muscle testing is 4+1.5, gluteus maximus is 4+/5, and gluteus medius 415. She ambulates ,vith aT' antalgic gait pattern with bilateral axillary crutch Overall, she has a varus knee alignment.

7. Ch11stie fL, Sheldahl LN! , Tristani FE , et aI. Cardiovasc regulatia'n dUling head-out water immersion exercise. J . PhysioI1990;69:657-664, 8. Green GH , Cable NT, Elms N. Heart rate and m:ygen I.: sumption during walking on land and in deep water. ] SP' Med Phvs Fitness 1990;30:49-52. 9, Risch WD, Koubenec H], Beckmann U, et aI. The eITe<' graded immersion on heart volume, central venous pre pulmonary blood distribution , and heart rate in man. Pllu_ Arch 1978;374:115-118, 10. Sheldahl LM, Tristani FE, Clifford PS, et al. Effect of hi out water immersion on response to exercise training. J-". Phys ioI1986;60:1878-1881, 11. Choukroun \!fL, Varene P. Adjustments in o,),:ygen tran during head-out immersion in water at different tem tures. ] Appl PhysioI1991;68:1475-1480.

Chapter 17 Aquatic Physical Therapy _ Craig AB , Dvorak M. Thermal regulation of man exercising during water immersion. J Appl PhysioI1968;25:28-35. Craig AB, Dvorak M. Compiuison of exercise in air and in wa­ ter at different temperatures. Med Sci Sports Exerc 1969;1: 124-130. olden C, Tipton MJ. Human thermal responses during leg­ onlv exercise in cold water. J PhvSioI1987;39l:399-405. Golden C, Tipton MJ. Human 'adaptation to repeated cold im mersions. J PhysioI1988;396:349-363. agawa S, Shiraki K, Yousef MK, et al. \Vater temperature d intensity of exercise in maintenance of thermal equilib­ ri um . J Appl PhysioI1988;2413-2419. - :hellini BA, Shapiro Y, Pando If KB. Cardio-respiratory phys­ ical training in water and on land . Eur J Appl PhysioI1983;50: 255-263. Hamer PW, Morton AR. Water running: Training effects and pecifieity of aerobic, anaerobic, and muscular parameters fo llOWing an eight-week interval training programme. Aus­ tralian J Sci Med Sport 1990;21:13-22. \"ickpry SR, Cureton KG, Langstaff JL. Heart rate and energy expe nditures during aqua dynamics . Physician Sports Med 19 3; 11:67-72. \\'hitley JD , Schoene LL. Comparison of heart rate re­ ponses: water walking versus treadmill walking. Phys Ther '987;67: 1501-1504. Eyestone ED, Fellingham G, George J, et al. Effect of water "Uf1ning and cycling on maximum oxygen consumption and 2Jile run performance . Am J Sports Med 1993;21:41-44. Connelly TP, Sheldahl LM , Tlistani FE , et al. Effect of in­ 'reased central blood volume with water immersion on 'ma catecholamines during exercise. J Appl Physiol 1990; 9:651--656 . . [c \,l, urray RG, Beny :\1J, Katz VL, et al. Cardiovasculrtr re­
347

24. Town GP, Bradley SS. Ylaximal metabolic responses of deep and shallow water running in trained runners. Med Sci Sports Exerc 1991;2,3:238-241. 25. Gleim GW, Nicholas JA. Metabolic costs and heart rate re­ sponses to treadmill walking in water at different depths and temperatures. Am J Sports Med 1989;17:248-252. 26. Evans BW, Cureton KJ, Purvis JW. Metabolic and circulatory responses to walking and jogging in water. Res Q 1978;49: 442-449. 27. Yamaji K, Greenley M, Northey DR, et al. Oxygen uptake and heart rate responses to treadmill and water running. Can J Sports Sci 1990;15:96-98. 28. Svedenhag J, Seger J. Running on land and in water: com­ parative exercise phYSiology. Med Sci Sports Exerc 1992;24: 1155--1160. 29. 'W ilder RP, Brennan D , Schotte DE. A standard measure for exercise prescription for aqua running. Am J Sports Med 193;21:45-48. 30. Templeton MS , Booth DL, O'Kelly WO. Effects of aquatic therapy on joint flexibility and functional ability in subjects with rheumatic dis ease. J Orthop Sports Phys Ther 1996;23: 376-381. 31. Takeshima N, Rogers ME, Watanabe E , et al. Water-based cxercise improves health-related aspects of fitness in older women. Med Sci Sports Exerc 2002:33:544-551.

ADDITIONAL RESOURCES Aquatic Physical Therapy Association: [email protected] Aquatic Resources Network: www.aquaticnet.com Halliwick Method: www.halliwick.net Ruoti R, Morris D, Cole AJ. Aquatic Rehabilitation . Philadelphia, PA: Lippincott Williams and Wilkins, 1997.

chapter 18

Therapeutic Exercise for the Lumbopelvic Region CARRIE HALL

Review of Anatomy and Kine siology

Lumbar Spine

Pelvic Girdle

Myology

Gait

Examinatio n and Evaluation

Patient History

Screening Examination

Tests and Measures

Thera peutic Exerc ise Intervention for Common P ysiologic Impairme nts

Aerobic Capacity Impairment

Balance and Coordination Impairment

Muscle Performance Impairment

Range of Motion, Muscle Length, and Joint Mobility

Pain

Posture and Movement Impairment

Therapeutic Exercise Intervention for Co mm on

Diagnoses

Lumbar Disk Herniation

Spinal Stenosis

Spondylolysis and Spondylolisthesis

Adj unctive Interventions

Bracing

Traction

espite tremendous research on the topic of low back pain LBP), the optimal treatment for patients with LBP re­ mains largely enigmatic. Randomized clinical trials have w ed to find consistent evidence for improved treatment utcomes with many treatment approaches commonly used ~' physical therapists and other practitioners including ex­ ercise, manual therapy, and traction 1 Underlying the diffi­ culty in demonstrating the treatment effects of conservative

management is the lack of consensus about classification of patients with lumbopelvic syndromes. vVithout a valid and reliable classification system, guidelines regarding conser­ vative management for the patient 'vvith lumbopelvic syn­ drome-related signs and symptoms r~ !l1ain incxact. 2 Vari­ ous classi fication systems for lumbopelvic syndromes have been developed, but no consensus has 'been reache(..l.3-Ll The clinician therefore must base intervention, and morC' specifi c to this text-therapeutic exe rcise ,int~Tvenbon--{)1I a thoughtful and systematic examination and evaluation process and diagnose the co,me(s) of the prese nting func­ tionalliIllitations and disability. Diagnosis requires taking a thorouglt history, performing a ll1cticulous examination, evaluating phYSiolOgiC impai rments and functional limita­ tions, and combining the data gathered from any physical medicine examinations. The impact of a psychologic im­ pairment on the presenting condit,ion and prognOSiS must not be underestim ated, but treatment of this impairment is beyond the scope of this text and is discussed only as pmt of the overall intervention. Although it is tempting to develop an intervention based on a pathoanatomic diagnOSiS, this type of practice is not recommended. Diagnostic imagery, such as radiog­ raphy, magnetiC resonance imaging, and computed to­ mography scans, produces substantial numbers of false positive findings , indicating pathology in asymptomatic in­ dividuals. 12 Effective intervention cannot be limited to treatment of pathology, disease, or anatomic impairm ents; it must also addrpss the phYSiologic and psychologic im­ pairments most closely associated with the underlying cause of the pati ent's functional limitations and disability. Exercise prescription should be based on individual and ongOing assessm e nt of th e disability, functional limita­ tions, and related impairments. Despite the \vide variety of exercises that are prescribed for the low back, evi­ dence-based data to justif)! choices are not as complete as one may think or expect. Thus clinical decisions regarding exercise prescription require the blend of knowledge, ex­ perience, and research. The profeSSional challenge for us all is to make ,vise decisions by balancing knowledge , clin­ ical experience, and research.

349

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Therapeutic Exercise: Moving Toward Function

REVIEW OF ANATOMY AND KINESIOLOGY Prerequisite to sound clinical decision making in the patient management process (see Chapter 1) is an extensive knowl­ edge of ..m atomy and kinesiology. The anatomy and kinesi­ ology of the lum bopelvic ret~n have received considerable attention in the literature,!' 1 1 which has enhanced clinical understanding of the function of the lumbopelvic region and emphasized the integrated nature of normal movement between the trunk and extre mities. To properly examine, evaluate, diagnose , and treat the lumhopelvic region, in­ depth knowledge of all aspects of th e movement system in­ volved in LBP is essential. It is beyond the scope of this text to proVide a complete review of the anatomy and kinesiol­ ogy of the lumbopelvic region , thus the review will be lim­ ited to content pertinent to this chapter.

Lumbar Spine The lumbar spine consists of five lumbar veltebrae. LI-L3 vertehrae have a similar structure (Fig. 18-1), and L4-L5 vertebrae have sim ilar structure (Fig. 18-2).

Arthrology The lumbar motion segment has distinct posterior and an­ terior elements. The plimary features of the posterior ele­ ment are the zygapophyseal joints (ZJ) and muscle attach­ ments and the primary features of the anterior element are the vertebral bodies and intervertebral disks (IVDs) . The ZJs have a distinctive shape and orientation in the lumbar spine. The angle that each ZJ makes with respect to the sagittal plane determines the amount of resistance of­ fered to motion in the sagittal and transverse planes. The more the joint is oliented in the frontal plane, the more it resists sagittal plane motion, but the less it can resist trans­ verse-plane motion ; the converse is true for joints oriented in the sagittal plane (see Figs. 18-1 and 18-2). From Ll-L3, the ZJ lies primalily in a sagittal plane, and the shape of the joint surface is in a variable J or C shape when viewed from above. From L4-S1 , the orienta-

Superior facet Lateral aspect

A Inferior facet Spinous process

B

IGURE 18-1. (A) Lateral view of a lumbar vertebrae. (B) Superior view of a typical lumbar vertebra shows the sagittal-plane orientation of the zy­ gapophyseal joints. Sagittal-plane orientation resists rotation but not for­ ward displacement

Superior facet

Superior aspect

FIGURE 18-2. Superior view of a typical fifth lumbar vertebra . Note tilt more frontal plane orientation of the zygapophyseal joints. Fwntal-pla c = orientation better resists forward displacement than rotation.

tion of the ZJ is more frontal and therefore resists antel; shear more effectively than rotation. The frontal plane OJ; · entation resists the tendency of L5 to migrate forward or the anteriorly tilted sacral base. The fibrous capsule of the ZJ has poste rior, supe lior and infelior components, with fibers OIiented more or I transversely from one articular process to the other. T anterior part of the capsule is formed entirely by the liga­ mentum flavum. 18 Some of the deep fibers of the posteri" capsule attach directly into the outer edge of the articul cartilage. Posteriorly, a portion of the lumb ar multifid (LM) inserts directly into the capsule. 19 The pull of the L. may prevent entrapment of the capsule between the arti"­ ular surfaces during movement. The ZJs typically demonstrate changes "vith aging. _ birth, the joints are primarily oriented in the frontal plan and they assume their more typical curved appearance du ing the first decade. The change may result from forces n­ lated to the development of bipedal gait in early childhoo Side-to-side joint asymmetry is common in adults and I to articular tropism (i.e., developmental alteration in tl­ joint's shape) in a certain percentage of the population ';' Some investigators feel that tropism may alter the biom..... chanics and increase the forces on some f.ortions of IVDs, thereby predisposing them to injury. " ,21 ,22 The IVD connects the body of one vertebrae to that adjacent superior and inferior vertebrae. This joint, co monly referred to as the interbody joint,15 transmits vert cal load while allowing movement and resisting torsion ar. shear. The IVD is made up of an annulus fibrosus (AP . nucleus pulposus (NP), and an end plate. The collag. fibers of the AF are arranged in concentric rings arou the NP. These concentric rings are called lam.ellae. E al lamellae has an alternating orientation of collagen Abe such that the fibers in adjacent lamellae are at 90 degr to each other. This orientation effectively resists com p re sion, but horizontal translation and rotation are resisted only a portion of the fibers 15 The NP is 70 % to 90% wat depending on a person's age. 15,23 Because of its fluid ture and its complete containment \vithin the AF and plates, the NP exerts a force in all directions against the . and end plate when pressure is increased through co

Chapter 18 Therapeutic Exercise for the Lumbopelvic Region

A

B

c GURE 18-3. (A) Vertebral movement during flexion. Flexion of the lum­ :- spine involves a combination of anterior sagittal rotation and anterior - slation. (B) As sagittal rotation occurs, the zygapophyseal joints sepa­ -~ permitting the translation movement to occur (C) Translation is lim­ - _by compression of the inferior zygapophyseal joint of one vertebra on :: su perior zygapophyseal joint of the vertebra below.

sion or weight bearing. This force braces the annulus m the inside, reducing its tendency to buckle under pressive loading. This structure also facilitates force mission through the end plates. The end plate is situ­ on the superior and inferior part of the IVD and is the akest part of the IVD in compression.

Changes occur within the IVD with age. The most sig­

Kant include loss of water (palticularly in the NP) , in­ ing collagen content, and an increasing similarity in ~ composition of the AF and NP. The result is a less effi­ nt hydrodynamic bracing mechanism , which places in­ ·jng stress on the AF. The IVD is essentially avascular with the exception of outer AF.I.5 However, it is metabolically active at a rel­ el slow rate.15 The nutrition of the disk depends on dif­ ion. It receives its supply from the two closest vessel Tees , which are those beneath the vertebral end plate those at the periphery of the AF.24 Although the ~ri­ .. mechanism of transport is thought to be diffusion , 4 a -,ond mechanism may exist in which nutrients are ex­ .mged along with the water that is routinely squp.ezed out .uld drawn into the IVD during compressioll and de­ -npression. Certain movements, possibly those in and . of flexion , may facilitate nutrition of the disk. 2'5.26 Alh the metabolism is slow, it does result in turnover of e of the constituent structures of the IVD. When IVD ary occurs, healing transpires , but complete healing e months to years. One of the direct benefits of exercise y be to facilitate the nutrition of the IVD.l3,27

351

pendently because all spinal movements involve the com­ bined action of several motion segments. Skeletal struc­ tures that influence motions of the lumbar spine are the rib cage, which limits motion of the thoracic spine, and the pelvis and hip, which augment trunk motion by movement of the pelvis over the femoral heads. The amount of flexion varies at each interspace of the lumbar spine, but most of the flexion takes place between the LA and Sl levels. Rotation is minimal from Ll to L4 and greatest at the lumbosacral level. Flexion is a combination of anterior sagittal rotation (i.e. , osteokinematic motion) and a small amount of anterior sagittal translation (i.e., arthrokinem atic motion ) (Fig. 18­ 3). It varies between 8 and 13 degrees per lumbar segment 28 and is limited primarily by the posterior ligamentous system and posterior IVDs, the ZJ capsules, and compression of the anterior IVDs. Extension is a combination ofposterior sagit­ tal rotation and a small amount of posterior sagittal transla­ tion. It varies between 1 and S degrees per lumbar seg­ ment l6 and is limited by bony contact of the posterior elements. Rotation is limited to ap~roximately 1 to 2 de­ grees per segment in each direction. 6 Initially, rotation oc­ curs about a vertical axis, followed by a shift in the axis to the contralateral compressed ZJ (Fig. 18-4). Rotation is limited primarily by bony engagement of the contralateral ZJ , by tension of the capsule of the ipsilateral ZJ capsule, and by approximately half of the annular fibers as they are elon­ gated. Rotatio~ is usually coupled "vith side flexion in vari­ ous patterns. l ( Likewise, lateral flexion does not occur in isolation in the lumbar spine but is coupled with rotation. The coupling of motions in the lumbar spine, apalt from LS-Sl, where ipsilateral coupling of rotation and side flex­ ion is known to occur,15 is not consistent. Individual pat­ terning of mo!ion coupling varies with sagittal position of the segment. l ( Because there appears to be a diversity of possible motion coupling, rules pertaining to coupled rota­ tion and lateral flexion do not exist. Biomechanics must be assessed for each patient. DUling flexion movements, the anterior AF and NP are compressed, the posterior AF is stretched, and the poste­ rior NP is compressed on to the postelior wall. The poste-

eokinematics and Arthrokinematics range of motion (ROM) of the lumbar spine differs at ous levels and depends on orientation of the facets of intervertebral joints (see Figs. 18-1 and 18-2). Motion "een two vertebrae is small and does not occur inde­

FIGURE 18-4. Vertebral movement during rotation. (A) Initially, rotation occurs around an axis within the vertebral body (B) The zygapophyseal joints compress (C) Further rotation causes the vertebra to pivot around a new axis at the point of compression.

352

Therapeutic Exercise: Moving Toward Function

rior portion of the AF is the thinnest part, and the combi­ nation of stretch and increased pressure in this area may cause AF damage, causing the NP to bulge or herniate through the AF. Because of the alternating direction of the fibers of the AF, only half of the fibers are stretched during rotation while half relax. This stretch pattern may be one reason why the disk is more vulnerable to injury during combined flexion and rotation movements. In a standing position, the lumbar spine moves in concert 'with the thoracic spine and pelvic-hip complex to produce motion in the sagittal, frontal, and transverse planes. For­ ward bending from a standing position is the motion that is most commonly used in activities of daily living (ADLs). During fon.vard bendillg, the initial motion is the posterior sway of the pelvis as the hips flex, which allows the center of gravity to remain \vithin the base of support. As the hips start to flex, the lumbar spine beginS to reverse its inward curve and, on completion of the reversal of the lumbar curve, the rest of the motion is hip flexion. The lumbar spin e shou ld not complete more than 50510 of its motion into flexion be­ fore hip flexion is initiated." At completion of flexion there should be a straightening or flattening of the lumbar spine. During the return from forward bending, ideally the initial part of the motion should be hip extension, followed by the hips and spine concurrently completing extension until the upright position is resumed 5

Innervation Th e outer one third to one half of the AF has a nerve sup­ pl/ !5 and is therefore capable of being a source of pain from the lumbar spine. The ZJs and LM are supplied by the medial branch of the dorsal ramus of the spinal nerv(-':. The capsu le and synovial folds contain nociceptive fibers.2') The ven tral dura mater is il1Iwrvated, but the dorsal is not. Ax­ ons from segmen ts LA to S2 innervate the sacroili ac joint (S I} ). The superior gluteal nerves, the obturator nerves, the posterior rami of SI and S2, and branches of the sacral plexus prOvide articular innervation.

Kinetics The lumbar spine is a major load-bearing region of the body. Dynamic loads usually are higher than static loads because almost all body motion increases lumbar spine loads, from a slight increase during slow walkin g to signifi­ cant increases during vigorous physical activity. A sampling of postures and movements are examined in the follovving sections. Statics

In upright stance, the line of gravity of the trunk passes ventral to the cen ter of the fourth lumbar vertebral body (Fig 18_5)ao It falls ventral to the transve rse axis of motion of the spine, amI the motion segmen ts are subjected to a fonvard-bending moment, which mllst be coun terbalanced by passive force s from the ligaments and erector spinae muscle and by active erector spinae muscle forces. Any dis­ placement of the line of gravity alters the magnitude and direction of the moment on the spine, which must be coun­ terbalanced by passive or active forces to maintain equilib­ rium . For the body to return to eqUilibrium, the moment can be counteracted by increased muscle activity, which causes postural sway. The erector spinae, abdominal mus­

FIGURE 18-5. The line of gravity for the trunk (solid line) is usually ven.­ to the transverse axis of motion of the spine, and the spine is subjecteo a constant flexion moment.

cles, and psoas are intermittentk active in maintaining Ii upright pOSition of th e trunk. I However, small adj us­ ments in the position of the head, shoulders, pelvis, kne or ankles can decrease or abolish the need for muscle tivity by restoring eqUilibrium. Though not desirable. person can rely solely on passive tension from ligament muscles being pulled taut to maintain equilibrium (e._ swayback posture). Body position affects the magnitude of the loads on spine. These loads are minimal during well-supported, dined positions; remain low during relaxed, upright stan ing; and rise during sitting. During relaxed, unsuppOltl sitting, the loads on the lumhar spine are greater than dr' ing relaxed, upright standing.:,2 During erect sitting, Ii ward tilting of the pelViS and an increase in the lumbar I dosis reduce the loads on the lumbar spine (Fig. I B-6 ), I these loads still exceed those produced during relaxed, \. right standing. The loads on the lumbar spine are 10\\ during supported sitting than during ull supported si tti n~ hackward inc:lination of tl1C backrest amI the use of a III har support further reduce the loads (Fig. IB_7)a:l Loads on the spine are at their minimum when a per. assumes a supine position with the hips and knees bent l supported. A further decrease in these loads is achieved the application of traction.,4 Conversely, the highest 10 on the~rine usually are external loads that are produced lifting.'­ Dynamics

Almost all motion in the body increases the loads on lumbar spine. This increase is modest during activities s as slow walking or easy twisting, but it can hecome stantial durillg various exercises. 32 In a study of norIl' walking at four speeds, the compressive loads at thE' L3-L­ motion segment ranged from 0.2 to 2.5 times b weight. '·" The loads were maximal at toe-off and incre linearly with walking speed. Lifting and carrying an object over a distance is a co mon task reqUired by any individual for work or as palt ADLs, such as lifting groceries from the car and carr)1: _ them into the Rouse, lifting a child from the floor or clib. lifting the laundry basket from tlle floor to the washing m chine. Several factors influence the loads on the spine du:­

•

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

353

cle contraction. Form and force closure mechanisms pre­ vent excessive motion of a joint system. For example, in an SIJ with normal form and force closure mechanisms, a 400­ to 2,600-pound force is necessary to disrupt stabiUty of the joint system. 41 An inherent disruption in form or force clo­ sure mechanisms must exist for instability to occur,

Pelvic Girdle Osteology and Arthrology

B

c

URE 18-6, (A) Compared with relaxed upright standing, (B) the line of =, 'ty for the trunk, already ventral to the lumbar spine, shifts further ven­

during relaxed, lumbar-flexed sitting . This shift creates a longer level - (Lw) for the force exerted by the weight of the upper body (C) During __ sitting with the pelvis in anterior pelvic tilt and the lumbar spine in .= sion, the line of gravity shifts dorsally, reducing the lever arm, but it " II slightly longer than during relaxed upright standing. (Adapted from -cjin M, Frankel H. Basic Biomechanics of the Musculoskeletal System - Ed. Philadelphia Lea & Febiger, 1989)

lifting such as the position of the object relative to the ter of motion of the spine; the size, shape, weight, and sity of the object; and the degree of flexion or rotation the spine. However, following some general rules about y mechanics can lessen the load on the spine:

The shape of the SIJ is highly variable. In the skeletally ma­ ture individual, SI, S2, and S3 contribute to the formation of the sacral surface, and each part can be oriented in a dif­ ferent vertical plane. The sacrum is wedged anteroposteri­ orly. These factors provide resistance to vertical and hori­ zontal translation. In the young, the wedging is incomplete, and the SIJ is planar at all three levels and is vulnerable to shear forces until ossification is complete in the third decade.42 The articular cartilage lining the SIJ is unusual. The sacral surface is lined with smooth hyaline cartilage, whereas the iliac surface is lined with a rough type of fi­ brocartilage. The conclusion of one study examining the friction coefficient of the SIJ suggested that the coarse car­ tilage texture contributes to the ability of the joint to resist translation. 39 ,4o The coarseness of the iliac cartilage in­ creases with age. 42 }he complementary ridges and grooves in the mature SIJ"HO also increase friction and thereby contribute to form closure , The SIJ is surrounded by some of the strongest Uga­ ments in the body. The dorsal sacroiliac ligament tightens when the sacrum counternutates (see Table 18-1 for def­ inition) relative to the inominate,43 and the dorsal sacroil­ iac ligament is thought to control this motion. The sacro­ tuberous and interosseous ligaments tighten during sacral nutation (see Table 18-1 for definition) and control this

• Holding the object close to the body reduces the flex­ ion moment on the spine, • Reducing the size of the object can reduce the lever arm for the force produced by the weight of the ob­ ject, lessening the load on the spine. • Bending the hips and knees and keeping the back rel­ atively straight (avoidance of flexion and rotation) re­ duces the load on the spine.

In considering transference of load through the pelvic _ ~e , passive and active mechanisms appear to contribute pelvic girdle stability.36 The passive mechanism con­ ~hutes to stability because of the articular relationship of e ly fitting jOints, where no extra forces are needed to ..lintain the state of the system; this is called form clo­ e,14,.37-40 Three factors contribute to form closure of any t:

• The shape of the joint surface • The friction coefficient of the articular cartilage • The integrity of the ligaments that approximate the joint The other mechanism is called force closure,14,37-40 and involves passive and active mechanisms to stabiUze the i t. Force closure requires extra forces to keep the jOint place , such as that provided by ligaments and active mus­

A

B

c

o

E

FIGURE 18-7, Influence of backrest inclination and back support on loads on the lumbar spine in terms of pressure on the third lumbar disk during supported sitting. (A) Backrest inclination is 90 degrees and disk pressure is at amaximum. (B) Addition of a lumbar support decreases disk pressure. (C) Backward inclination of the backrest to 110 degrees but with no lum­ bar support reduces disk pressure further. (D) Addition of lumbar support with same degree of backrest inclination further decreases pressure. (E) Shifting the support to the thoracic region pushes the upper body forward, moving the lumbar spine into flexion and increasing disk pressure. (Adapted from Andersson GBJ, Ortengren R, Nachemson A. Lumbar disc pressure and myoelectric back muscle activity during sitting. I. Studies on an experimental chair. Scand J Rehabil Med 1974;6104-114)

354

Therapeutic Exercise Moving Toward Function

Definitions of Nutation and Counternutation TERM

DEFINITION

SACRAL MOTION

Nutation

Sacral Flexion

Counternutation

Sacral Extension

Base moves anteriorly and inferiorly Apex moves posteriorly and superiorly Base moves posteriorly and inferiorly Apex move's anteriorly and superiorly

motion 44 ,45 The ventral sacroiliac ligament is the weakest of the group and is supported anteriorly by the pubic symphysis. These ligam ents contribute to form and force closure.

Osteokinematics/Arthrokinematics The amount of movement that is available at the articula­ tion between the innominates and the sacrum is quite small and undoubtedly is the basis for much of the histOlic.:al con­ troversy regarding existence of movement of this joint and the axis through which motion occurs. n .46- 52 This contro­ versy may reflect the individual variability in joint anatomy and the variation that occurs in the early, middle, and ex­ treme ranges of movement. Although SIJ mobility is normally limited, research has shown that movement does occur throughout life,14,37-39,53,54 The most widely accepted movement is that of nutation and counternutation (see Table 18_1)55 Side bending and rotational movements have also been studied,56,57 although the existence of these motions re­ mains controversial. ~o definitive model exists to define the path of instant center of rotation of the joint, and the amount of Illotion present remains controversial. 5 S,59 Movements of the innominates wi th respect to the sacrum occur primarily in the sagittal plane and are called anterior and posterior iliosacral rotation. 49 A small amount of posteroanterior translation of the innominate occurs with anterior rotation, and a small amount of anteroposte­ rior translation occurs with posterior rotation. Anterior and posterior rotations of the innominate occur as normal os­ teokinematic motions during the gait cycle (see the Gait section), Depending on the anatomic configuration of the innominate and sacral surfaces, a small amount of super­ oinferior translatory shear motion occurs 60--B2 The vertical movement occurs with limb loading and is most pro-

nounced "vith static standing on_ one leg, especially if mcW.' , tained for a prolonged period 4 i

Kinetics Stability of the pelvic girdle is important, because it m transmit forces from the weight of the head, trunk, and up­ per extremities and forces from the lower extremities up ­ ward. The pelvic girdle can be divided into posterior an anterior arches by a frontal plane passing through the a(­ etabular fossa. Body weight is transferred from the L5 ver ' tebra to the first sacral segment. The weight is then dis­ tributed equally along the sides of the sacrum across th arcuate line to the acetabulum. Ground reaction fore which travel up the lower extremity, are transmitted supe­ riorly through the same bony trabeculae and across the Pli.' bic rami to cou nterbalance the ascencLng forces from tbt'" contralateral li mb. Superincumbent body weight tends force the sacral base anteroinferiorly. The components the anterior arch act as a tie beam to prevent separation the SIJ. If the pubic symphysis is unstable , there is a ten­ dency for the two innominate bones to separate, allowil. _ sacral tilting in an anteroinferior direction, The angle of inclination of the articular surface of sacrum is a Significant factor in the stability of the SIJ,52 T anatomic impairment of vertically oriented SIJs subject ligaments to greater stress because less of the load is bo by the osseous structures of the posterior arch. Asymme loading may occur with asymmetry of the angle of inclir_ tion or postural asymmetry (e.g., limb length discrepan c\

Myology Optimal function of the lumbopelvic region requires an i tegration of the musculature of the posterior and anteri aspects of the spine, pelvis, and hips. In addition, the lati ­ Lumbar multifidus Erector spinae

Intermuscular septum

Posterior layer

Quadratus lumboru m Lateralrap.·,

Latissimus

dorsi~j

FIGURE 18·8. Cross-section of the lumbar spine showing layers of the trunk musculature. (Adapted from Porterfield JA. DeRosa C Me­ chanical Low Back Pain Perspectives in Functional Anatomy 2nd Ed. Philadelphia WB Saunders, 1998)

Anterior layer

Psoas major

Transversus abdominis

Internal oblique abdominis

Chapter 18 Therapeutic Exercise for the Lumbopelvic Region

355

FIGURE 18-10. The attachment of the superficial erector spinae to the GURE 18-9. When viewed from the side, the superficial erector spinae ~

be seen to course superiorly and posteriorly from its point of origin at ::: pelvis to its attachment to the ribs. Elongation of the muscle occurs -"0 the thorax (on the same side as the superficial erector spinae) is .!ght even further posterior, or the iliac crest on the same side is brought ard. Shortening of the superficial erector spinae occurs with thorax or . • s movement opposite those just described. (Adapted from Porterfield eRosa C Mechanical Low Back Pain Perspectives in Functiona l s:omy 2nd Ed. Philadelphia WB Saunders, 1998) us dorsi influences lumbopelvic mechanics, Because of integration of musculature spanning the lumbopelvic jon, myology is addressed in an integrated format for entire region.

sterior Lumbopelvic Myology thoracolumbar fascia (TLF ) and its powerful muscular ments play an in1f0rtant role in stabilization of the bopelvic region. 63 ,6 Numerous muscular attachments the TLF have been described, including attachments of sversus abdominis (TrA) and some fibers of the internal .i ues (10) into the lateral raphe portion of the TLF, and hments of gluteus maximus, latissimus dorSi, erector _;nae, and biceps femoris into the posterior layer of TLF <7. 18-8), This pattern suggests that the hip, pelvic, and ; muscles interact with arm and spinal muscles through '" TLF,63 The gluteus maximus and latissimus dorsi may duct forces contralaterally through the posterior layer of - TLF, and the action of these two muscles may be linked prOvide support to the SIJ and lumbar spine during gait rotation of the trunk This integrated system has also n proposed as a method of load transference between pine and hips, in which the TLF is a centrally placed cture for the interaction of muscles from each region. The spinal extensors may be broadly categorized as su­ rficial muscles (i.e., iliocostalis) , which travel the length the spine and attach to the sacrum and pelvis, and deep 'd es (j.e. , longissimus and LM) , which span the lumbar _ lents. Even though the superfiCial spinal extensors do • attach directly to the lumbar spine, they have an opti­ lever arm for lumbar extension by virtue of their at­ ents (Fig. 18-9). By pulling the thorax posteriorly, _. can create an extension moment at the lumbar spine. y function eccentrically to control descent of the trunk .;ng forward bending and isometrically to control the po­ n of the lower thorax with respect to the pelvis during ctional movements 65 .66 The attachment of the superfi­ pinal extensors also influences SIJ mechanics. Be-

sacrum provides a potential force for sacral nutation (sacral flexion) Be­ cause nutation increases sacral stability, the superficial erector spinae may playa role in force closure of the sacroiliac joint. (Adapted from Porter­ field JA, DeRosa C Mechanical Low Back Pain Perspectives in Functional Anatomy 2nd Ed. Philadelphia WB Saunders, 1998) cause of the attachment of the erector spinae aponeurosis to the sacrum, the pull of the erector spinae tendon on the dorsal aspect of the sacrum induces a flexion moment (i.e. , nutation ) of the sacrum on the ilium (Fig. 18-10). The deep erector spinae have a poor lever arm for spine extension but are aligned to provide a dynamiccounterforce to the anterior shear force imparted to the lumbar spine from gravitational force (Fig. 18-11). The attachment of the LM to the spinous process provides a strong lever arm for spinal extension (Fig 18-12). During forward-bending mo­ tions, this muscle contributes to controllin rr the rate and magnitude of flexion and anterior shear 6, Because of its deep location, short fiber span, and oblique orientation, the LM is thought to stabiliz against flexion and rotation forces on the lumbar spine. 68 ,69 Several studies have illuminated its relationship with the vertebral segment 7 0-72 The effect of dysfunction of this muscle, which is discussed in a later section, further emphasizes its important role in spine sta­ bilization. The LM also contributes to dynamiC stability of the SIJ. Because it is attached to the sacrotuberous liga­ ment, tension on the ligament imparted as a result of LM

FIGURE 18-11. Because the deep erector spinae attach close to the axis

of lumbar motion, the muscle group provides a dynamic posterior shear and compression force (arrows) . This muscle can provide a force to prevent an­ terior translation . (Adapted from Porterfield JA, DeRosa C Mechanical Low Back Pain: Perspectives in Functional Anatomy 2nd Ed. Philadelphia: WB Saunders, 1998)

356

Therapeutic Exercise Moving Toward Function Multifidus

Sacrotuberous

Gluteus maximus

FIGURE 18-12. Because of the LM insertion, there is a large vertical vec­ tor for extension, with a small horizontal vector indicating it is a stabilizer of rotation rather than horizontal rotation being its primary function . The primary vector is to provide posterior sagittal rotation. The primary rotators of the trunk are the oblique abdominals that. by virtue of their vertical vec­ tor, cause a flexion moment as well as rotation, which is stabilized by the LM. (Adapted from Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine Edinburgh Churchill Livingstone, 1987)

muscle contraction potentially increases the ]jgamentous stabilizing mechanisms of the SIJ (Fig. 18-13)

Anterior Lumbopelvic Myology One of the most important muscle groups contlibuting to mobility and stability of the lumbopelvic region is the ab­ dominal wall mechanism. The abdominal wall consists of, superficial to deep, the rectus abdominis (RA), external oblique (EO ), 10, and TrA . The RA, EO, and 10 appear to serve a relatively more dynamiC role than the TrA. The TrA is circumferential, situated deeply, and has at­ tachments to the TLF, the sheath ofRA, the diaphragm , il­ iac crest, and the lower six costal surfaces. 73 Because of its unique anatomic features, such as its deep location, its link to fascial support systems, its fiber type distribution, and its possible activity against gravitational load during standing and gait, the TrA is an important stabilizing muscle for the lumbar spine 74 -J>2 The TrA activates before the onset of limb movement in persons without LBP, but this function is lost in those with LBP.74 ,'<;;1 Current theory suggests that this muscle is a key background stabiliZing muscle for the lumbar spine and that the emphasiSof speCific exercises for the abdominal wall should involve specific recruitment of the TrA instead of general strengthening or endurance. Ex­ ercises of this nature are described in detail in a subsequent section of this chapter. The oblique abdominal muscles working synergistically prOVide an anterior oblique sling and, together with the posterior oblique sling (i.e., TLF and associated struc­ tures), they assist in stabilization of the lumbar spine and pelViS in an integrated system of myofascial support 37 ..38 The right EO works synergistically with the left 10 to pro­ duce rotation to the left and to prevent excessive rotation when necessary. The LM must synergically contract to pre­ vent fle>..ion imposed by the obliques so that pure rotation or transverse-plane stabilization can occur. The inferior and medial direction of the fibers of the EO are positioned

FIGURE 18-13, Anatomic relationship of lumbar multifidus to the saw; iac joint, sacrotuberous ligament, and gluteus maximus. The LM atta ch~ to the TLF primarily through a raphe separating the multifidus and gl utei­ maximus. The anterior border of the raphe is anchored to the SIJ capsi ­ and the posterior border of the raphe becomes part of the TLF. Tendin slips of the multifidus pass under the long dorsal Slligament to joint w­ the sacrotuberous ligament; these connections are thought to integrate ~­ LM into the ligamentous support system of the SIJ (Adapted from Po ~ field JA, DeRosa C. Mechanical Low Back Pain: Perspectives in Functior Anatomy 2nd Ed. Philadelphia WB Saunders, 1998.)

to prevent anterior pelvic tilt and anterior pelvic shea: With respect to the SIJ, the oblique abdominals provi compressive forces between the t""o pubic bones and at SIJ posteliorly (Fig. 18-14).

Associated Pelvic, Hip, and Upper Extremity MyologV Twenty-nine muscles originate or insert into the pel Twenty of these link the pelvis with the femur, and I ­ link the pelvis with the spine. This implies that signifi forces can be generated through the pelviS and sub,­ quently through the lumbar spine by various combinati, of knee and hip muscle activity. The iliacus and psoas major have Significant attachmel1' to the spine and pelvis . If not counterstabilized by the dominal muscles , the iliacus can exert an anterior rotati

Abdominal obliques

Restraining ligaments

FIGURE 18-14, Contraction of the abdominal oblique muscles acting 0' the fulcrum of the interosseous ligament increases sacroiliac joint stab and pubic symphysis compression. (Adapted from Porterfield JA, DeRu: C. Mechanical Low Back Pain Perspectives in Functional Anatomy 2nd : ' Philadelphia WB Saunders, 1998)

Chapter 18 Therapeutic Exercise for the Lumbopelvic Region

rce on the pelvis. If not counterstabilized by the deep erector spinae, lumbar multifidus, and abdominal muscles , :he psoas major can exert an anterior translational force on um bar segments. The fibers of the gluteus maximus muscle run perpen­ .ticular to the plane of the SIJ and blend with the TLF and -he contralateral latissimus dorsi. 14 Compression of the SIJ curs when the gluteus maximus and the contralateral tissimus dorsi contract. This oblique system crosses the idline and is believed to be a Significant contributor to d transference through the Ee~vic girdle during rota­ n al activities and during gait. 4.31 The TLF is tensed by ntraction of gluteus maxim us, latissimus dorsi , and erec­ lr spinae muscles. In addition to the attachment to the ischial tuberosity, e long head of the biceps femoris attaches to the sacro­ b rous ligament. Contraction of the biceps femoris in­ . eases tension of the sacrotuberous ligament and pulls the crum against the ilium, effectively increaSing the stability the SIJ.i8 In standing and walking, the pelvic girdle is stabilized on e femur by the coordinated action of the ipSilateral glu­ us medius and minimus and by the contralateral adduc­ r muse:les. Indirectly, by maintaining a relationship be­ ·een the hip, pelvis , and lumbar spine in the frontal plane, gluteus medius, gluteus minim us , and adductors con­ -bute to lumbar spine stability. Although these muscles ~ not directly involved in force closure of the SIJ, they ava significant role in pelvic girdle function. The piriformis is considered to be part of the deep hip ral rotator group and pelvic floor. It appears to playa vi­ ..J role for stabilization of the SIJ. The piriformiS attaches the sacrum , the anterior surface of the sacrotuberous lig­ ent, and the medial edge of the SIJ capsule. This Il1US­ anchors the apex of the sacrum and controls sacral nu­ ilion. The link of pelvic floor function and lumbopelvic .nction should not be underestimated. One investigator JU nd that some patients with chronic low back pain L BP) were unable to recruit the TrA \vithout prior con­ action of the pelvic floor.'\)

ait ~ait is an important functional activity. Table 18-2 displays

e biomechanics and muscle function of the gait cycle of e lumbopelvic region.

MINATION AND EVALUATION ~b e purpose of any examination/evaluation is establish a di­

gl1 0sis of the SOll rce, if possible , and the cause of the pre­ nUng ~igns , symptoms, functional limitations , and dis­ ility. However, the speCific source of symptoms riginating in the lumbopelvic region is difficult to diag­ se. A pathoanatomic diagnosis is possible for approxi­ tely 70% of patients with CLBP if those patients with ocumented ~sychologic aggravation of their symptoms e excluded. 4 Even when a pathoanatomic diagnosis is rovided, it cannot, in and of itself, guide decisions regard­ g intervention in the management of lumbopelvic condi­

357

tions. Structural changes do not nece~sarily correlate with or predict levels of pain or disability.s,) Removal or correc­ tion of structural abnormalities of the lumbar spine may fail to cure or even worsen painful conditions.86 Without a. di­ agnOSis that can gUide patient management, use of a tradi­ tional pathoanatomic model (i.e., one that implies symp­ toms should be proportional to organ pathology) is limited. The goal of the physical therapy examination is to deter­ mine the pathomechanical cause(s) of the patient's func­ tional limitations and disability. However, that being said, examination can lead the examiner to a pathoanatomic di­ agnosis for the small percentage of patients in whom a pre­ cise structural fault can be ascribed. A pathoanatomic diag­ nosis can only be made by correlating the phYSical examination findings with the history and medical findings (i .e. , radiographic, neurologiC , and laboratory study re­ sults) . A pathomechanic approach to diagnosis of LBP is valu­ able for several reasons:

• It reveals to the examiner and the patient the type and direction of the mechanical stress that correlates \'lith symptoms. • It reveals phYSiologiC impairments that correlate with the mechanical stress. • It screens for pathology and anatomic and psycho­ logic impairments that affect the prognosiS. • It becomes the basis for a therapeutic exercise pro­ gram and for posture and movement retraining. The key to pathomechanical testing of the lumbopelvic region is determining the postures and movements that correlate 'vvith the patient's signs or symptoms. It can then be deduced what type and direction of forces exceed the tissue tolerance or adaptability and lead to mechanical or chemical stimulation of the nociceptive system. If the ex­ aminer is unable to correlate the history and physical ex­ amination findings with a mechanical cause , the source of the symptoms may be non mechanical, an d referral to a medical practitioner is indicated for further diagnostics (sec Appendix 1) The clinician examining a patient \vith a lumbopelvic syndrome has the responsibility of answering three critical questions by the end of the initial examination:

l. Is there a systemic or visceral disease underlying the pain (see Appendix I)? 2. Is there evidence of neurologiC compromise that represents a surgical emergency (e.g., cauda equina symptoms)? 3. Are there mechanical findings that guide conserva­ tive management? Data collected from the history and physical examina­ tion should provide an answer to all three question s.

Patient History The patient's history is a critical component of the lum­ bopelvic examination. In addition to the general data col­ lected from a patient/client history as defined in Chapter 2, special questions regarding symptoms related to the low back can begin the clinical reasoning process toward diag­

358

Therapeutic Exercise Moving Toward Function

Kinematics and Mus~.le . J\sny.lty of the Gait Cycle in the Lumbopelvic Region PHASES OF THE GAIT CYCLE

RANGE OF MOTION LUMBAR SPINE

RANGE OF MOTION PelVIC GIRDlE*

MUSCLE ACTIVITY LUMBAR SPINE**

MUSCLE ACTIVITY PelVIC GIRDlE***

Initial Contact

Sidebending ipsilateral! rotation

Small c ranial!caudal shear; ipsilateral innominate rotates posteriorly/

Bilateral erector spinae

Hamstring, Gluteus maximus"" (Inman VT, Ralston HJ. Todd F. Hum an Walking Baltimore: Williams & . Wilkins, 1981.)

contralateral Loading Response Midstance

As at Initial

Contact

As at Initial

Contact

Terminal Stance

Preparing for Initial Swing

Pres\ving

Preparing for Initial Swing Contralateral side­ bend/ipsilateral rotation As Initial Swing As Initial Swing

Initial Swing

Midswing Terminal Swing

contralateral innominate rotates anteriorly

Ipsilateral innominate rotates anteriorly toward neutral; contralateral innominate rotates posteIiorly toward neutral Ipsilateral innominate rotates anteliorly past neutral; contralateral innominate rotates posteriorly

Bilateral erector spinae (Battye CK, Joseph J. An investigation by telemetering of the activity of some muscles in walking. Med BioI 1966;4:125-135. )

• The mo tion of the sacrum betwee n the two innominates and adjacent fifth lumbar vertebra has been descri bed as a complex, polyaxial, torsional movc me nt that occurs about the oblique axes. (Greenman PE. PrinCiples of Manual Medicine. Baltimore: \Villiams & vVilkins, 1989.) (Beal Me. The sacroiliac problem: review of anatomy, mechanics and diagnosis. J AIlI Osteopath Assoc 1982;81:667-679 .) •• Discrepancy exists regarding activity of rectus abdominis and obliqui extern us and internus, perhaps because of speeds of walking dUling testing conditions. (Waters RL, Morris JM . Electrical acth~ty of muscles of the trunk during walking. J Anat 1972;111:191-199. Sheffield FJ. Electromyographic study of the abdolllinalmllsdes in walking and other movements. Am J Phys Med 1962;41:142-147.) Transversns abdominis and lumbar mu ltifidu s appear to be linked with the control of stability of the spine against the perturbation produced by the movement of the limbs and should be considered as active dming the gait cycl e . (Hodges PW, Richardson CA. Contraction of the abdominal muscles associated \vith moveme nt th e lower Limb. Phys Ther 1997;77:132-144.) '" Mil ch of the muscle activity occurring across the pelvic girdle during gait is discussed in Chapter 20. Additional information regarding the link between the hip, the lumbopelvic r('gioll, and the IIpper extremity are provid('d in this table . • , 0' Hamstring activity im:reases the tension in the sacrotuberous ligame nt and contributes to the force closure meehanism of the pelvic girdle ,vith loading of the limb. (Wingarden JP, Vleeming A, Snidjers q , et al. f\ functional-anatomical approach to the spine -peh~s mechanism: interaction betw, th e biceps femoris muscle and the sacrotuberous ligament. Eur Spine J 1993;2:140. Snijders q, Vleeming A, Stoeckart R. Transfer of lumbosacral load iliac bones and legs. Part 1: biomechanics of self-bracing of the sacroiliac joints and its significance for treatmen t and exercise. Clin Biomech 1993;8;285-300. Vleeming A, Stoeckart R, Snijders CJ. The sacrotuberous ligament: a conceptual approach to its d)~lamic roh·· in stabilizing the sacroilia:. joint. J Clin Biomech 19089;4:201-203.) Gluteus maximus becomes active ,,~tb eounterrotation of the trunk and aml s\\~ng fOlwarcl, resulting in lengthening of the contralateral latissimus dorsi muscle . Shortly thereafter, the arm swings backward, causing contraction of the contralateral latissim us dorsi . Lengthening and contraction of the latissimus dorsi contributes to increased tension in the TLF and tllereby contributing to further force closure mechanism of the SIJ. (Lee D. Instability of the sacroiliac joint and the consequellces to gait. J Manual Manipulative Ther 1996;4:22-29.) Gluteus maxim us activity is key to force closure stabilizing mechanisms within the pelvis; loss of function of the gluteus maximus can hinder stabiLity of the SIJ .

nosis. Research on validity of histOlY findings with respect to LBP generally uses a pathoanatomic classification sys­ tem. The research presented in Display 18-1 uses diagnos­ tic labels of disk disease, ZJ syndrome, SIJ syndrome, cauda equina syndrome, and stenotic syndrome For detailed list of questions, please refer to Magee's text. S7

Screening Examination Symptoms originating in the lumbopelvic region often are experienced elsewhere in the lower quadrant and symp­

toms mimicking lumbopelvic origin dysfunction can oribe nate in visceral tissues (see Appendix 1). It is for these r"'~­ sons that a lumbopelvic screen is recommended before lumbopelvic or lower quadrant examination. The purpo of the screening examination is to determine whethe symptoms experienced in the lower quadrant are origina<­ ing in the lumbopelvic region, If it is determined tb symptoms are stemming from the lumbopelvic region. more thorough lumbopelvic examination and evaluation indicated, Display 18-2 lists the tests that should be i eluded in any lumbopelvic screening examination,

Chapter 18: Therapeutic Exercise for the Lumbopelvic Reg ion

359

DISPLAY 18-1

History Items in Patients With LBP or SIJ Syndrome Disk dis8ase'80 • Low back pain • Burning, stabbing, "electrical" pain down the leg • Numbness or paresthesia (sensitivity 30% to 74% for paresthesia)* • Aggravated by increased intradiskal pressure or specific movements .. Substantial but not complete relief with rest ~ Radicular distribution pain (sensitivity of 95% for sciatic distribution of pain)'2 • Leg pain greater than back pain • Pain superficial and sharp rather than less well-defined, dull, aching • Sensitivity for sciatic distribution of pain of 79% to 95%* ZJ syndrome • ZJs do not cause referred pain exclusively in the central lumbar spine** • ZJs may refer pain into the leg below the knee possibly due to segmental facilitation as a result of nociceptive input from a painful structure elsewhere in the affected segment*** SIJ syndrome • Groin pain** • Pain inferior to the PSIS**** • Radicular symptoms may occur as a result of extravasation ot inflammatory mediators through a capsular recess or tear to adjacent neural structurest Cauda equina syndrome '90 • Sensitivity of 95% for urinary retention '2

ests and Measures :be follOwing sections describe, in alphabetical order, the ts and measures highlighted in any lumbopelvic exam i­ bon/evaluation. The tests and measures must be individ­ -.ilized based on the data collected from the history, sys­ ms review, and screening examination. Additional tests measures may be included on a case-by-case basis. The older is referred to the Guide to Physical Therapist Prac­ for a detailed list of physical therapy tests and mea­ rres 88

'1thropometric Characteristics "l thropometric characteristics may be of interest, whereas individual's unique anthropometric characteristics can a risk factor in developing certain types of lumbopelvic n dromes. For example, the anthropometric characteris­ of a male with broad shoulders, narrow pelviS, and high nter of mass promotes lumbar flexion versus hip flexion Iri nher forward bend movements. This may pose as a risk ·tor in cleve loping a disk-related injury. In addition , he y have difficulty returning to a job requiring bending d lifting vvithout careful attelltion to body mechanics lim­ ng lumbar flexi on forces.

:'gonomics and Body Mechanics assessment of a patient's job-related duties and physical mands should include ergonomic and boJy mechanic as­

~ Sensitivity

higher than 80% for motor weakness and decreased sensation in the legs '2 • LBP • Bilateral or unilateral sciatica • Sensitivity of 75% for saddle area hyperesthesia 12 • Sexual dysfunction (decreased sensation during intercourse, decreased penile sensation, and impotence) • L5-S1 central disk herniation may cause no motor or reflex changes inthe legs Stenotic syndrome'2 • 60% sensitivity for neurogenic claudication • 85% sensitivity for leg pain • 60% sensitivity for neurologic abnormalities 'Van den Hoogen HMM. Koes BW, Van Eijk JTM. et al. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in general pradice. Spine 7995;79: 7132-7737 "Schwarzer AC, April CN, Derby R. et al. Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Spine

7994; 79.7132- 1737 "'Mooney V, Robertson J The facet syndrome. Clin Orthop

7976, 775.'749-756 Dwyer AP, West S, et al. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique, part I. asymptomatic volunteers. Spine 7994;19:7483-1489. FortinJD, PierJ, FalcoF. Sacroiliac joint injectIOn: pain referral mapping and arthrographic findings. In: Vleeming A. Mooney V, Dorman T, et al.. eds. Movement, Stability & Low Back Pain New York, NY.' Churchill Livingstone, 7997. tFortl1J JD, Pier J, Falco F Sacroiliac joint injection: pain referral mapping and arthrographic findings. In: Vleeming A. Mooney V. Dorman T, et al., eds. Movement, Stability & Low Back Pain. New York, NY.' Churchill Livingstone, 7997. .~. ' Fortin JD,

sessment. This may include assessing material hallJling ca­ pabilities, such as lifting incrementally increasing weights at different heights . Assessment of non-material hand1ng capabilities include tasks such as sitting or standin.g toler­ ance , or work station ergonomics . These kinds of assess ­ ments are often termed functional capacity evaluations

DISPLAY 18-2

Lumbopelvic Scan Evaluation Observation: Posture scan in standing and sitting,local signs of skin color, texture, scars, soft-tissue contours Active range of motion (with overpressure if indicated): in

standing, flexion, extension, lateral flexion; in sitting,

rotation

Stress tests: Supine lumbar compression and distraction,

supine sacroiliac joint compression and distraction,

sidelying sacroiliac joint compression, prone lumbar

torsion stress

Provocative test: Prone posteroanterior pressure to the lumbar spine Palpation: Palpate related lumbar-pelvic-hip musculature. assessing for tone changes. lesions, and pain provocation Dural mobility tests: Slump test, straight-leg raise, prone knee flexion Neurologic testing: Key muscles (see Table 18-3). reflexes, dermatomes

360

Therapeutic Exercise: Moving Toward Function

(FCEs). FCEs can be purchased or designed in the clinic and may use expensive mechanical devices interfaced \vith computers, or inexpensive handmade boxes, crates, and push/pull sleds. One important point to maintain conceJ1l­ ing the validity of a FCE is that an FCE, conducted from 2 to 4 hours over 1 to 2 days of a person 's life at a given point in time, cannot predict a person's capacity to work for 8 to 10 hours per day, 4 to 6 days per week, 52 weeks per year. At best, the FCE may simulate certain skills and capacities needed to perform the job. The FCE should be used as one aspect of the injured person's examination, not as a com­ plete evaluation in and of itself.

Gait/Balance Gait is a complex functional movement pattern that can in­ dicate pathomechanical fadors contributing to lum­ bopelvic signs or symptoms, palticularly if the patient re­ ports that walking increases or decreases symptoms. The relationship of other regions to the lumbopelvic region is important in ascertaining the mechanical stre~s imposed on the lumbar spine. For example, a hypomobile supinated foot that does not adequate ly pronate during the stance phase of gait may increase compressive stress on the lum­ bar spine, whereas a hypennobile pronated foot may in­ duce a transverse-plane stress on the lumbar spine by cre­ ating a short limb during the stance phase of gait. Video analysis can be an efficient tool to evaluate the complex in­ teraction of multiple regions on the lumbar spine during walking or running.

Muscle Performance The ability for the abdominal , spinal extensor, and pelvic girdle muscles to carry out functions of mobility and stabil­ ity must be carefully assessed to ascertain the pathome­ chanics of the lumbopelvic region. Muscle performance testing includes tests of strength, power, and endurance adequate for each individual to carry out his or her de­ sired controlled mobility (basic activities of daily living) [BADLsJ and skill-level activities (instrumental activities of daily living [IADLsJ). Assessment of the force- or torque-generating capability of the spinal extensor and abdominal muscle groups can be perfonned 'vvith traditional manual muscle testing proce­ dures as described by Kendall and colleagues. 1i8 Because of the nume rous details regarding accurate assessment of the abdo minal muscles, Kendall's work should be reviewed to ensure optimal manual muscle testing results. Although objective information about muscle force or torque production can be gathered from isokinetic testing, gross strength testing by this method may not be sensitive to the function of the deeper musculature surrounding the spine. Whereas many studies demonstrate an unequivocal relationship bet'vveen impaired function of the deep ab­ dominal and LM muscles and LBP, studies comparing gross trunk strength in normal or LBP patients ha;,:e not conSistently demonstrated such a relationship.90-9" This difference may reflect the inherent limitations in conclu­ sions that can be ascertained from studies examining maxi­ mal trunk strength in persons with LBP. For example, pain can hinder maximal effort, and a test of a patient with LBP may be more a test of the patient's tolerance to pain. This design problem may be responsible for the varied and

seemingly contradictory results of trunk muscle stren2:th reported in the literature. Isokinetic testing of trunk muscle strength also focus e largely on the assessment of muscles primarily involved in and capable of prodUCing large torques about the spine (e.g., RA, thoracolumbar erector spinae) rather than on muscles considered to provide stabilit)' and fine contro (e.g. , transversus abdominis and LM).!J6,97 Most studies fo­ cus on maximal voluntary contractions, which are rareh carried out during the ADLs. In the CLBP population sudden, unexpected , and insignificant movement at 10\1 load can exacerbate symptoms just as commonly as tasks in­ gg volving maximal exertion. mJ . Isokinetic and traditional manual muscle testing may n be sensitive enough to assess the muscle performance o. the deep trunk muscles (i.e. , TrA and LM). Te~ting trunk muscle strength should also consider the function tlle deeper musculature. Tests tllat examine the ability tlle deep trunk muscles to stabilize against various dir tional forces during active extremity movement can provi the cli12ician with an indication of their muscle perfor­ mance:01OO High repetitions can provide an indication the endurance of the trunk muscles . 'When tlle spine is un­ able to remain stable against a specific direction of force. can indicate a lack of force or torque production or fati (depending on the focus of the test) of tlle associated tJUllj muscle(s ). In theory, resisted testing of the trunk muscles can ab provide information about the integrity of the trunk mil: des relative to imposed strain. However, resisted testin, the trunk muscles can also provoke other pain-sensiti, structures and result in a weak and painful test, makin difficult to use resisted testing as a differential diagn o test for trunk muscle strain. Muscle strength testing of pelvic girdle and pelvic flo. muscles can provide pertinent information about fact that may contribute to lum bopelvic dysfunction. For exarr pIe, weakness in the gluteus medius results in excessive lL adduction and pelvic drop in the Single-limb support ph of gait, which can impose frontal or transverse plane s on the lumbopelvic region and thereby contribute to lu.--­ bopelvic impairment or pathology. Chapters 19 and 20. spectively, provide recommendations for pelvic floor Cll pelViC girdle muscle performance testing.

Neurologic Testing: Tests for Motor Function and Sensory and Reflex Integrity A thorough neurologiC examination for the lumbopelvic gion consists of three parts. An uppel- motor neuron sere, ing is indicated when cord compression is suspected.. upper lumbar central herniation may result in spinal co compression. A central herniation in the lower lum spine can cause compression to the cauda equina therefore should not result in upper motor neuron sign" Sufficient compression on the nerve root may result decreased conductive function of the nervous system; 11 roeonduetive testing may reveal segmentally related 5 sory chan?es , motor changes, and deep tendon re changes. 1O Testing motor function can indicate a patte of muscle weakness from a specific disk level or peripbe nerve. Table 18-3 indicates the key muscles with the corre­ sponding nerve root and peripheral nerve innervation.

Chapter 18: Therapeutic Exercise for the Lumbopelvic ,Region

Key Muscles and Corresponding

Nerve Root and Peripheral Nerve in the

Lumbop.elvic Region

KEY MUSCLE

NERVE ROOT

PERIPHERAL NERVE

~)()a s

L2 (3) L3 (4 ) L4 (5) LS (SI)

L5 (SI )

L5 (Sl )

LS (SI)

Sl (S2)

SI

SI

S2

Femoral nerve Femoral nerve Deep Peroneal Deep Peroneal Supelior Gluteal Superficial Peroneal Sciatic Tibial Superficial Peroneal Sciati c Inferior Gluteal

driceps - -bialis Anterior ~ rtensor Hallucis uteus Medius

neii erJI H
S4

The third part includes neurodynamic tests that examine movement and tensile abilities of the nelVOUS system. - \IDT1ples of neurodynamic tests include the straight leg e (SLR), prone knee bend (PKB ), and slump maneuver. e clinician administeling these tests should be skilled in specialized features of handling and sequencing the mponents of the test and must understand what is con­ ered to be a normal or acceptable response. Butler 102 deJibes the technique and rationale for neurodynamic tests tI e lumbopelvic region. Deyo et aI. 12 noted a sensitivity 0% and specificity of 40% for the SLR in diagnosis ofIow mbar disk herniation. The SLR test is most appropriate r testing the L5 and S1 nerve roots. Irritation of the higher mbar roots is tested by the PKB or femoral nerve stretch 12 t; reliability and validity of the PKB are unknown.

ain e clinician examines pain in the lumbopelvic region with pect to many variables: • Measurement of pain with respect to the level of dis­ ability it imposes on an individual with LBP, and therefore can be used as an indicator of outcome

361

• Examination techniques used to diagnose whether the pain is originating in the lumbopelvic region and, if possible, determine the potential source(s) of the pain • Examination techniques to determine the potential cause(s) of pain • Examination techniques and clinical reasoning to de­ termine the impact of pain on the physiologic func­ tion of the lumbopelvic region Because the United States, in common with other West­ ern nations, is trying to restrain the costs of health care, it is more important than ever for clinicians to demonstrate that the care they deliver is both efficient and effective. Pain scales are a common method for assessing patient out­ come in back ~ain. At least 22 scales have been reported in the literature. 03 However, the presence of pain alone is a narrow definition of health outcome that correlates poorly with physical function 104 Waddell and Main 105 stated that in evaluating the severity of LBP, three recordable , clinical components must be differentiated: pain, physical impair­ ment, and disability [See: Work (Job/SchoolJPIay), Com­ munity, and Leisure Integration or Reintegration (Includ­ ing Instrumental Activities of Daily Livin ) for further discussion regarding measures of disability). Efficient allocation of health care resources can be aug­ mented by an outcome measure that can predict those pa­ tients whose outcomes are likely to be poor. Those individ­ uals can be redirected to more appropliate intervention. Waddell developed a list of nonorganic signs that can be used as a predictor of ~utcome for patients wit~ lum­ bopelvic disabilities. 106.10 1 vVaddell and coworkers 10 1 iden­ tified five nonorganic signs, and each can be detected by one or two tests. The tests assess a patient's pain behavior in response to certain maneuvers (Table 18-4). A patient presenting with a high Waddell score (Le., 3-5 of 5 positive non organic signs ) is believed to have a clinical pattern of non mechanical, pain-focused behavior. The patient has significant enough psycholOgiC impairments that interven­ tion focused on physiologic and anatomic impairments alone probably cannot produce a successful outcome. A high V/addeII's score can be used as a predictor of func­

Waddell's Signs TEST

SIGNS

- enderness

Superficial-the patient's skin is tender to light pinch over a wide area of lumbar skin :\onanatomic-c!eep tenderness felt over a wide area, not localized to one structure Axial loading-light vertical loading over patient's skull in the standing position causes lumbar pain Acetabular rotation-back pain is reported when the pelvis and shoulders are passively rotated in the same plane as the patient stands; considered to be a positive test result if pain is reported within the first 30 degrees Straight-leg-raise discrepancy-marked improvement of straight-leg raising on distraction compared with formal testing Double-leg raise-when both legs are raised after straight-leg raising, the organic response is a greater degree of double-leg raiSing; patients with a nonorganic component demonstrate less double-leg raise compared with the single-leg raise Weakness, cogwheeling, or giving way of many muscle groups that cannot be explained on a neurologic basis Sensory disturbance-diminished sensation fitting a "stocking" rather than a dermatomal pattern Disproportionate verbalization, facial expression , muscle tension and tremor, collapSing, or sweating

lffiulation Tests ~istraction

~egi onal

Tests

Disturbances

~\'e rreaction

]:"rom Karas R, McIntosh G, Hall H, et a!. Th e relationship between nonorganic signs and ce ntralization of symptoms in the prediction of t.he return to u rk for patients with low back pain. Phys Ther 1997;77:356. Reprinted with permission of' the American Physical Therapy Association.

362

Therapeu tic Exercise: Moving Toward Function

tional outcome, as indicated by a low rate of return to work. IOB However, the practitioner must interpret this finding with caution 106 A high Waddell score only indi­ cates a high degree of nonorganic or psychologic impair­ ments. It does not signify malingering, which is a judgment, not a medical or psychologic diagnosis.I06.109 Patients with a high Waddell score should be referred to the appropriate practitioner for treatment before or in conjunction with further physical therapy intervention. In addition to measurement of pain in relation to out­ come data, the clinician should also attempt to determine whether or not the lumbar spine or pelvis is indeed the source of the pain. After it has been determined that the lumbopelvic region is the source of pain , even if the exact source of the pain cannot be diagnosed, attempts must be made to determine the mechanical cause of the pain. The complexity of understanding the causes or mechanisms of pain is beyond the scope of this text. Much controversy ex­ ists about whether chemical or mechanical mechanisms initiate and perpetuate pain and about exactly what neuro­ physiologic and biochemical processes are responsible for pain. The role of the therapist is to determine whether me­ chanical interventions can alter pain. During the examina­ tion process , the therapist can observe precise stabilization and movement patterns and correlate faulty patterns with thc onset of or increase in pain. If altering the pattern of stabilization or movement reduces or eliminates the pain, the speCific faulty movement pattems responsible for the pain can be diagnosed .5

Posture The therapist should perform a cursory evaluation of the pa­ tient's standillg or sitting postures during the history portion of the examination. Posture also is examined formally as part of the evaluation process. The patient is aware of the scrutiny dUling the formal exami nation and may assume what he or she considers to he proper posture or posture that depicts the painful or emotional state he or she wishes to portray. The posture pOiirayed during this examination may be unconscious or intentional, and the motivation is not always easily discerned. Observation of posture \vithout the patient's kno'vvledge can be more revealing of the true con­ tribution of posture to his or her signs and symptoms. More speCific examination should include standing, sit­ ting (supported and unsupported), and recumbent pos­ tures. Several things should be observed, including head pOSition, shoulder girdle pOSition, spine curves (Le., cervi­ cal, thoracic, and lumbar), and lumbopelvic, hip, knee , an­ kle-foot alignment should be examined about all three planes. In standing, the examiner is looking for asymmetry and possible relationships between segmental regions (e.g., foot pronation and genu valgum on the side of a low iliac crest and apparent short limb). Bony landm arks are as­ sessed to visualize the position of the pelvis , including the iliac cres t, posterior supelior iliac spines (PSISs ), anterior supeJior iliac spines (ASISs) , and pubic symphysis. Ideal pelviC alignment is best visualized through the ASIS and pubic symphysis in the frontal plane 88 A hypotheSiS can be developed regarding the contribu­ tion of faulty lumbopelvic alignment to the pathomechani­ cal cause of symptoms and the relationship of other body

regions in perpetuating the faulty lumbopelvic alignment. Correction of alignment can reduce pathomechanical stress in the lumbopelvic region and therefore reduce or eliminate symptoms. This is an early step toward the diag­ nosis of a pathomechanical cause oflumbopelvic functional limitations and disability. However, posture is not always a good indicator of the pathomechanical stress causing lum­ bopelvic symptoms. For example, a person with spinal stenosis may have a flat lumbar spine and yet incur symp­ toms with extension forces on the lumbar spine due to th narrowed spinal canal or lateral foramina. Another hypotheSiS can be developed about mus cle lengths. Assumptions can be made regarding muscle­ fascial structures that are too long based on joillt position such as a long EO in an anterior pelvic tilt (Fig. 18-15 Muscle length testing is indicated to determine whethe­ muscles are short because of joint position (e.g., specificaTh which hip flexors are short in anterior pelvic tilt). Addition­ ally, the results of positional strength tests should correia \vith muscle length hypothesis.

Range of Motion, Muscle Length, and Joint Mobility RO M tests of the lum bopelvic region should not only asses the ROM of the lumbar spine , but also the pelvic-fe mo~ complex and the relationship between the ROM of the b and lumbar spine. The interrelationship of ROM \ \ i. other regions of the body (e.g., thoracic spine and upper tremity) is also of interest. Muscle length testing of t spine, upper, and lower quarters should also be includ Mobility tests of the lumbopelvic region determine th e i; . tervertebral mobility/stability (passive intervertebral m tion testing or passive intervertebral motion [PIVM]) of spine and mobility/stability of the SIJ. ROM testing is performed in standing for flexion and tension, lateral flexion , and quadrant movements; it is pt."

AGURE 18-15. The lordotic posture and anterior pelvic tilt elongate ­ external oblique.

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

rmed in sitting for rotation. Overpressure can be used to produce symptoms. The intent of HOM testing is fOUlfold: 1. To determine the patient's vvilIlngness to move

:2. To reproduce symptoms

3 . To detern1ine the quantity of lTIotion in the lUlnbar­ pelvic-hip complex 4. To determine the quality of movement by assessing the relationship between the various regions of the spine and the pelvic-hip complex.

Chapter 20 describes hip ROM testing. The purpose of • HOM testing is to determine reduced HOM in the hip t may contribute to compensatory spine motion, ("reby imposing a pathomechanical stress on the lumbar .;ne. For example, a hip that has reduced HOM in exten­ n may cause compensatory spine extension, paliicularly n ng the terminal stance phase of gait or in the final e of return from a forward bend. \.ctive hip ROM testing can be used to assess movement ems of the hip and stabilization patterns of the lum­ elvic region. s Faulty patterns can induce a pathome­ ic~ stress on the lumbar spine and provoke symptoms . rrectron of faulty patterns of lumbopelvic stabilization uld reduce symptorns if the faulty pattern is contribut­ ~ to pathomechanical stress on the affected structures. In way, these tests can also be used to clear the hip joint ~y possible involvement. If correction of lumbopelvic IhzatlOn reduces symptoms, it is unlikely that the hip is source of symptoms. Thoracic ROM testing is described in Chapter 25. The -!pose of thoracic ROM testing is to determine whether uced ROM of the thoracic spine is contributing to com­ atory motion in the lumbopelvic region (e.g., reduced _tiff thoracic spine rotation could induce increased stress the lumbar spine during transverse plane movement ems). Tests ~f mU:cle extensibility across the pelvis and hip descnbed rn Chapter 20. Data obtained from these provide the clinician with additional information ut potential causes of pathomechanical stress on the bar spine. For example, dUling forward bending, stiff . tnngs can restrict pelvic fOlw,lrd rotation, resulting in 'Oon stress (FIg. 18-16B) on the lumbar spine. :\..lthough not direct measures of trunk muscle extensi­ i~', lumbopelvic forward bending, backward bending, J lateral flexion can test for posterior, anterior, and lat­ ~runk extensibility, respectively. Assessment of postu­ alignment can lead to a hypotheSiS about excessive trunk de length (see Posture Examination section). One type of ROM testing unique to the lumbar region developed by McKenzie. llo This method is based on assumption that sustained or repeated movements may 'ect n~cl~ar pOSition, resulting in centralization or pe­ _ beralrzatron of symptoms. McKenzie defined the cen­ .Jization phenomenon as "the situation in which pain aris­ ~ from the spine and felt laterally to the midline or distally, "educed and transferred to a more central or near midline -ition when certain movements are performed. "llo Pe­ ~e ralization is the opposite phenomenon wl1l'reby pain . ncr from the spine and felt proximally and to the midline .ncreased and transferred laterally and distally when cer­

363

tain movements are performed. McKenzie's theol), pre­ SUlnes that as long as the annulus and disk are intact, an off­ set load on the disk in a lesion-specific direction of spinal movement may apply a reductive force on a displaced nu­ clear fragment , directing it toward a more central location (i.e" "centralization"), thereby redUCing symptom-gellerat­ rng stress on neural or other nociceptive structures,l ro JOint mobility tests of the lumbDr region , or PIVM tests come in three categories: passive phYSiologiC intervertebral motIon (PPIVM), passive accessory intervertebral motion (PAIVM) , and segmental stability tests. PIVM testing is used to deterI~linE' relative mobility (e .g. , hypermobility ver­ sus hypomoblhty) and to stress the related spine and pelviC JOll1ts 111 an attempt to determine end feel , assess irritability, assess st~bility, and provoke symptoms. Meadows prOvides descnptlOns of these tests and defines PAIVM as the passive assessment o~ an intervertebral joint through its glides, whereas stabIlIty tests attempt to examine segmental trans­ latory mobility.lol Research shows at best moderate in­ tI~arater reliability and poor interrater reliability.lll Relia­ bIlIty lInproves when a positive response includes both perceived changes in ROM and provocation of symptoms rather than just decreased mobilityy z,1l3 A combination of PPIVM and PAIVM tests correctly identified dysfunctional levels diagnosed vvith intra-articular infiltration. 114 Regarding the SI}, a battery of tests has been suggested to rulisout o,r confirm a suspected diagnosis of SIJ dysfunc­ tlOn. A cnte?a of at least three of four tests vvith positive results IS reqUIred to determine the presence of SIJ dys­ functIon: standing flexion, PKB, supine-to-long sitting, and palpatron of the PSIS in sitting. Passive physiologic motion (PPM) tests of the pelvis include anterior and posterior in­ nominate rotation 10l Passive accessory motion (PAM) te:ts refer ,to the passive assessment of a joint b~ way of rrhdes and 111 the SIJ can be used to test stability. I 6 All ROM, muscle length, and mobility/stability tests should assess the effect that altered motion of the exam­ ;ned region has on lumbar spine and SIJ. For example, an II1creased extension moment may be imposed on the L5 segmental level during active movement patterns because

A

=

B

= -

=

Flexible tissue Stiff tissue

FIGURE 18-16. (A) Normallumbopelvic rhythm (LPR) (B) Reduced exten­ sibility of the hamstrings (HS) can alter lumbar-pelvic range of motion. Stiffness from the HS slows the rate and can potentially restrict the range of pelVIC motion. resul ting in excessive flexion stress of the lumbar spine . (Adapted from Cai llet R. Low Back Pain. 3rd Ed. Philadelphia FA Davis 1981) .

364

Therapeutic Exercise: Moving Toward Function

Please mark on the line below how much pain you have had from your back on average over the past week,

o

2

3

4

5

7

6

8

10

9

No pain at all

Maximum pain possible Please tick the answer which most closely describes you on each of the following six sections, At present are you working Full time at your usual Job Full time at a lighter job Part time Not working/unemployed Disability benefit Housewife/student/retired

0 9 0 6 0 3

00 00 0 score as for chores

At present can you undertake household chores or odd jobs Normally 09 As much as usual but more slowly ::::J 6 A few, not as many as usual C3 Not at all 00 At present can you undertake sports or active pursuits (e,g, dancing) As much as usual Almost as much as usual Some, much less than usual Not at all Do you have to rest during the day because Not at all A little Half the day Over halfthe day

09 06 0 3

00 of pain? 06 0 4 0 2

00

How often do you have a consultation with a doctor or have any treatment (e,g, physiotherapy) for your pain? Never Rarely About once a month More than once a month

06 04 0 2

00 06 0 4 0 2

DO

Please tick the box that best describes how much your back pain affects the following activities,

No Effect Sex life Sleeping Walking Traveling Dressing

0 6

0 0 0 0

3 3 3 3

Mildly/ Not Much

Modera tely/ Difficult

Severely/ Impossible

04 0 2 0 2 0 2 0 2

0 2 0 1 01 01 0 1

DO DO DO DO DO

FIGURE 18-17. The Low Back Outcome Score (LBOS) Pain scale rea dings are equivalent to the following scores: 0-2 = 9; 3-4 = 6; 5--6 = 3; 7-10 = 0, Patients are placed in one of four outcome categories based on over­ all scores: 65 or higher (excellent), 50 or higher (good). 30 or higher (fair), and lower tha n 30 (poor), (Adapted from Holt AE. Shaw NJ. Shelly A. et al. The reliabil ity of the Low Back Outcome Score for Back Pain, Spine, 2002;

27206- 210)

Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living) This category of tests and measures includes the measurr­ ment of disability, Waddell and Main 105 proposed that evaluating the severity of LBP, three recordable clinical ' ness components must be differentiated (See Pain ca' gory), one of those being disability, The following list is Ii ited to validated functional questionnaires that \\'e designed by selecting items relevant to back pain: Oswestry Low Back Disability Score l17

Million Visual Analogue Scale 1l8

Roland Morris Disability Questionnaire 1l9

Waddell Disability Index 10.;

5, Clinical Back Pain Questionnaire (Aberdeen

Back Scale)103

6, Low Back Outcome Score (LBOS )104.120

1. 2, .3. 4.

Descriptive information for the selected measure­ given in Table 18-5. Problems in the assessment of come for patients with LBP have been subject to co erable recent investigation with little agreement in tJl erature concerning which outcome measure to use. few re~o~ts using the same criteria for assessing tients. Ll 1-2 A recent study demonstrated the LBO compare favurably with other established measur, LBP in terms of both internal consistency and test­ reliability, even wh ('n tested more ligorously.l04 T fore, it is believed that the LBOS is a reliable instru for clinical use (Fig. 18-17),

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON PHYSIOLOGIC IMPAIRMENTS

How often do you have to take pain killers for your pain? Never Occasionally Almost every day Several times each day

of relatively less extension mobility available at the hip. B~ determining which spinal segmental levels, what anatomiC' regions, and the sources of structural limitation (e,g" mus­ cle, capsule, b one), a specific intervention plan can be de­ veloped to address the related impairments ,

It is not usually possible or desirable to set up a par::.. exercise regimen for the lumbar spine and srJ based on the pathology or medical diagnosis. The choice cise intervention therefore must be based on the p' and the physiologi.c, psychologic, and anatom ic ments that are most closely related to the patient tionallimitations and disabiLty. Because this text is not presenting a treatment related to a specific classification system, the exerc based on tlle phYSiologic impairments detailed in t; are presented in alphabetical order. Physiologic imp;:..:!~ have been separated for clality of presentation, thoU'§' ality, patients most uften present with a complex i:n:~a of pathology and anatomic, psychologic, and pl1\'Si pairments. The exercise examples are not meant tl strate a comprehenSive approach to the treatment lugic impairments; they were chosen to illustrate ...,..,...,....­ and a rew;onable approach to the use of exerci bopelvic region, Ptinciples related to work-conditioI:::.;: .~ grams. althuugh often used in addre function are not L'Q\'ered in

Chapter 18 Therapeu tic Exercise for the Lumbope lvic Region

365

~ ptive Information for Selected Back-Specific Functional Instruments

_w stly Low Back Disabili ty Score

llion Visual Analogue ale d Morris Disability uestionnaire ..dde Jl Disability Index \. Back Outcom e Score

CONTENT

SCORING

COMPLETION TIME

Pain intensity, interference with sleep , self-care, walking, sttting, standing, lifting, sex life , trav­ eling, social life. Pain inten sity, interferellce with physical activities, interference with work, ove rall handicap. Physi cal activities . housework, mobility, dressing, ge tting help, appetite. irritability, pain severity Heavy lifting, si tting, walking, standing, social life, travel, sex life, sl ep, footwear. Current pain, employment, domestic and sport activities, use of drugs and medical services, rest, sex life , five daily activities.

0-100

5 min

0-100

.5-10 min

0-24

.5 min

0-9

.5 min

0-7.5

.5 min

ed from Kopec KA. Measuring functional ou tcomcs in persons with back pain. Spine 2000;25:3110--3114.

robic Capacity Impairment ro bic capacity impairment can be considered a sec­ ifV condition resulting from the incapacitation associ­ \~th CLBP or a risk 'factor contributing to the devel­ e nt of CLBP. Research supports the fact that aerobic rcise alone is not enough to prevent recurrence of LBP, ough aerobic exerci.?~ is beneficial for patients with bopelvic syndromes. ,,) Aerobic exercise enhances heal ­ ~. helps weight loss , and has favorable psychologiC ef­ ,', such as reduction of anxiety and depression. T~'Pically, the patient is limited by musculoskeletal pain ~ orking at the optimal target heart rate necessary for pro­ ing aerobic gains. Aerobic exercise is initially prescribe? tolerance" and is progressively increased as the patient s _ and symptoms improve. The mode of exercise (e.g., g, swim ming, walking, jogging) should be based on the 'e nt's desires and the postures and movements that re­ 'e symptoms. For example, if walking relieves pain, but 'ling increases pain, walking should be encouraged, and .dng should be discouraged. If weight-bearing aerobic ex­ . e is chosen, the physical therapist may need to counsel patient in choosing proper footwear to ensure the best juht-bearing dynamiCS possible Orthotic prescription " be necessary to optimize ground reaction forces (see lapter 22). If weight-bearing exercise is unbearable, waT i ofte n a well-tolerated medium for aerobic exercise by person with lumbopelvic dysfunction (see Chapter 17). other option is to walk 'vvith some type of unloading echanism either through harness apparatus or the use of m tches, walker, grocery cart, or stroller.

strategies for balance. 124 LBP patients have a tendency to fulcrum about the hips and low back to maintain upright postures during balance tasks; persons ;vithout LBP tend to fulcrum abou t the ankle. Authoritics 36 ackn owledge the necessity of balance work in the rehabilitation of lum­ bopelvic patients, particularly when deaLng with hypermo­ bility and instability impairmen ts. Gym balls, wobble boards, slide boards, and foam rolls can be used to enhance proprioception and teach optimal balance strategies (e.g., ankle versus back), Aspects of pro­ prioceptive training can be incorporated at any stage of re­ habilitation, as illustrated by examples fOCUSing on balance and coordination discussed in other sections of this chap­ ter. After an activity can be performed correctly on a stable surface, the patient can be positioned on a moving base of support, such as a gym ball (see Fig. 18-18) or foam roll

alance and Coordination Impairment The functional importance of proprioceptive trainin¥ has e n emphaSized during rehabilitation of the spine,12. Pro­ -.ection of the musculoskeletal system relies in part on ade­ _uate proprioception and reaction time of the neuromuscu­ .ar system. This requires fine adjustments in neuromuscular JCtivation patterns in response to a fluctuating load. True sta­ ilitv of the spine at the skill level requires precise and rapid ~sponses to perturbations in the load imposed on the spine. There is evidence that LBP patients may be prone to ex­ cessive postural sway, poor balance reactions, and altered

AGURE 18-18. Sitting on a gym ba ll can add an element of difficulty to the stability phase of lumbo-pelvic exercise. Care must be taken to ensure quality of recruitment strategy as dominant strategies may emerge on the unstable surface.

366

Therapeutic Exercise Moving Toward Function

(see Fig. 18-19). Any activity challenging balance and proprioception must be performed vvith precision, empha­ sizing correct body position and recruitment strategies. The rate of movement is progressed wh ile accuracy is maintained. One example of a high-level exercise challenging bal­ ance and coordination is standing on a half or full foam roller (the latter is the mos t difficu lt ). The patient is in­ structed to shift his or her weight from side to side and for­ ward to back from the ankles as trunk stab ility is main­ tain ed. Another va riation is performance of squatting motions or upper extre mity motions individually and then combined after proper trunk stabilization is accomplished. The ankles, knees, and hips are used as the fulcrum points for balance instead of the low back.

Muscle Performance Impairment Treatment of general muscle performance impairments in the lumbopelvic reglon has limitations. Evidence suggests that muscul ar dysfunction in the presence of lumbopelvic syndromes does not so much affect the strength of the trunk musculature as Jt influences the patterns of trunk muscle recruitment.I~. )-1 2\ Sub tle shifts in the p atterns of muscle recruitment result in some muscles being relatively underused in the force couple, whereas other muscles rel­ atively domillate the force couple. 5 The cause and effect relationships of these subtle shifts in muscle recruitm ent patterns cannot be determined and should be thought of as part of a cOlltinuous cycle of altered recruitment strategies and mOVelllt'nt patterns.

Lack of muscle endurance has been shown to also be prime impairment in muscle performance. Many investiga­ tors have reported diminished trunk muscle endurance and increased rates of muscular fatigue in LBP patients com­ pared with individual s without LBP , even "vhen stren r>tl measures testing results are within normallimits H4 ,!)5, 126'E Sophisticated electromyographic testing using a techniqu called power spectrum analys is has identified that the L \ I is th e back extenso r most susceptible to enduran cl;' changes. 12G ,130 These studies indicate the need to providt" an endurance training component in the course of a total re­ habilitation program. N o special exercise recommendatioll are needed, because the dosage can be modified for exer­ cises preSCribed for force or torque production to satisf)! en­ durance goals (j.e., higher repetitions with lower loads). Mechan isms such as muscle strain, p ain , inflammation neurologic pathology, or general deconditioning can con­ tribute to muscle performance impairment. The clinici must consider the possible mechanisms contlibuting to tlh­ more dramatic as well as subtle changes in muscle recrui,­ ment patterns to develop the appropriate exercise inter­ vention. After the underlying mechanism(s) are identifi, precise exercise can be prescribed to activate, restore, improve muscle control and performance of the trunk lll u '­ cles. The follOWing section describes exercises to establi. control over specific trunk muscles. Subsequent sectio investigate the various causes of reduced muscle peJ-for­ mance around the lumbar spine and recommend activiti and techn iques to alleviate individual causes of muscle per­ formance impairment.

Exercise for Muscle Control Research has establis hed a link between lumbar dysfUll," ­ tion and altered base (i.e. , muscle perform ance) and 111 ulator (i.e., neuromuscular con trol) function of the in n core muscles defined to include the TrA, LM, and peh floor. 12S- 1.11 General strengthening programs for the trunk musd may not adequately recruit o r improve the muscle perfor­ mance of the <.leep and often underused trunk muscles. calized and speCific exercise aimed at training neuro mu.,­ cular control of the inner core may be critical to imprmi. _ subtle patterns of muscle recru itment necessmy for opt ­ mal segmental stability in the lumbar spine.1 3~ . 133 Si rr­ larly, speCific exercises aimed at training neuromuscu) control and muscle perform ance of the inner core plus t1 gluteus medius , gluteus muximus, hip lateral rotators, ar latissimus dorsi may be critical for optimal SlJ stability ar load transference from the upper and lower quarter to t low back. A pelvic floor contraction, in particular (s. Chapter 19), is indicated for the chronic, unstable SlJ l cause of the shared muscle of the piriformis and obturat internus and the import an t supportive function of t pelvic floor to the pelViC girdle. Before presenting the exerci se recommendations for ~ inner core, three additional concepts must be addressed. FIGURE 18-19. Standing on two foam rolls is easier than standi ng on one foam rol l. For the stabil ity phase, the goal is to rea ch to the side th rough ro­ tation of the hip with the spine in neutral. For control led mobility, the goa l is to move the hips, thoracic. and lumbar spine in a combined rotational movement pattern. However, movement should be emphasized at the hips and thoracic spine. with very little rotation occurring in the lumba r spine.

• Exe rcis es chosen should prom ote optimal length­ sian properties of the trunk and pelvic girdle m The affected muscles should be trained at th e le ngtl sired for fun ction. Too ofte n, the inner core IllUs c\ strengthened in the lengthened range because of

•

Chapter 18 Therapeutic Exercise for the Lumbopelvic Region

a Valsalva maneuver, resulting in abdominul distension or "pooching," lumbar fl exion ,- and bearing down on the pelvic floor (see Fig 18-20). A disadvantage to strength­ ening the muscles in a lengthened range is the contribu­ tion this may have toward altered length-tension proper­ ties. The inner core muscles need to be of the right le ngth to support the spine and pelvis in good static alignment and have the correct length-tension proper­ ties to continue to support the spine and pelvis during dynamic activities. • A second important principle is specificity of training or the prinCiple of specific adaptation to imposed de­ mands (SAID principle ). For example, although a sit­ up is a functional activity, it is not the primary function of all the abdominal muscles for ADLs and IADLs. It has been proposed that the inner core muscles are linked with the control of stability of the spine against the perturbation produced by movement of the limbs 69 The primary role for the deep trunk muscles is to pro­ vide static stability to the trunk during movements of the extremities and dynamic stability during trunk movements. • A third principle governs exercise progression. The stages of motor control (Le., mobility, stability, con­ trolled mobility, and skill) can be used to progress lum ­ bopelvic exercise. Mobility and stability usually occur together in the lu m bopelvic region. Stability is often a problem at the dysfunctional segmental level, and mo­ bility is more likely to be a problem at an adjacent lum­ bar level or in some associated region (e.g., hip, tho­ racic spine, shoulder girdle ). To be most effective, simultaneous reconciliation of mobility and stability im­ pairments is desired. When developing a program fo­ cusing on stability, the chosen direction of force must be based on the directions in which the spine is most -usceptible to motion and the directions most corre­ lated with symptom reproduction ,s·'·H After adequate mobility and stability are achieved, the patient is pro­ rressed to controlled mobility (BADLs) and then to skill-level activities (IADLs). 'According to a study by Richardson and Jull,75 patients who followed a graded program of exercise to improve the muscle perfor­

367

mance and neuromuscular control of the inner core ex­ perienced pain resolution within 4 weeks , with only a 29% recurrence rate at 9 months. These results were compared with a control group of LBP patients who exercised aerobically by jogging and s'vvimming. They too were pain-free at 4 weeks, but they had a LBP re­ currence rate of 79% at 9 months. Specificity seems to be the key to the proper prescription of the exercises that correspond with improved neuromuscular control and muscle performance of the deep trunk muscles. This treatment approach demands a high level of skill by the instructor in teaching the exercise and a high level of patient compliance and attention to detail. Con­ tinual reassessment of muscle recrUitment capabilities and muscle performance is necessary to progress or modify the exercise for optimal results. Patient-related instruction is the first step to establish awareness over the individual inner core muscles. The clin­ ician must first determine the presence or absence of the inner core synergy by palpating the TrA, LM, and external palpation of the pelvic floor if necessary (see Chapter 19). Although it is not necessary to facilitate the inner core in this manner, often the easiest component of the inner core to activate is the pelvic floor (see Chapter 19 and Patient­ Related Instmction 18-1). After the patient has contracted the pelvic floor , the therapist can palpate the other compo­ nents of the inner core. The TrA can be palpated medially and deep to the AS1S. Contraction of the TrA should feel like taut fascia under the fingertips , whereas contraction of the 10 will push the fingertips out superfiCially. Toning down the force of contraction will assist in isolating the TrA. An­ other indication that the TrA has contracted is that the waist will pull inward laterally like the function of a girdle, and the umhilicus will be gently pulled in toward the spine. The umbiliclls pulled upvvard toward the libs cou­ pled with rib cage depression indicates dominance of the RA and is a common mistake. The LM can be palpated best at the L5 level just me­ dial and deep to the spinous process. If the LM is not contracting, the therapist can provide an explanation to

FIGURE 18-20. (A) Use of the abdominal muscles in a leng thened range. Note protrusion of the umbi licus. (8) Use of the oblique abdominal muscles and transversus abdominis in the short range.

368

Therapeutic Exercise Moving Toward Function

What are the inner core muscles? The inner core refers to a group of deep muscles that, under normal circumstances, work together to provide stability to the lower back and pelvis. In normal function they should contract automatically and simultaneously before any upper extremity,lower extremity, or trunk movement-in effect, before any movement you make. The inner core muscles include: • The diaphragm-your primary breathing muscle • The pelvic floor-attached to the bony ring of the pelvis from the tailbone to the pubic bone • The lumbar multifidus-the deepest layer of the back muscles • The transversus abdominus-the deepest layer of the abdominal muscles

How do you activate them? This section describes inner core awareness activities. These activities must be mastered before using the inner core with more advanced self management activities and activities of daily living. NOTE: Your physical therapist will work with you individually to identify the best strategy to initiate your inner core. You may only need to contract one of these muscles to get them all to activate. • To contract the pelvic floor: Think of slowly and gently pulling the tip of your tailbone toward your pubic bone. Try not to contract the rectal portion of your pelvic floor, but rather more of the portion closer to your pubic bone . To see if you are using the correct muscles, the next time that you urinate, let out half the volume of your bladder and then stop the flow of urine with the least amount of effort possible. Be aware of which muscles you are using. NOTE: This testis notto be used as a daily exercise. It is simply a method for you to identify which muscles make up the pelvic floor. Anothe ~ image is to think about an elastic cord anchored between your

the patient as to the function of this muscle with respect to sacral nlltation, lumbar extension, and stabi liza tion against rotational forces. Visually, show the patient mod­ els and pictures of th e regioll and LM muscles. Cue for tactile input by palpating directly over the LM at the af­ fected level. Key to isolation of the LYi is to facilitate a submaximal isometric contraction . Patients often have ini­ tial difficulty in facilitating a LM contraction in a home exercise program. This is particularly tru e for patients with a chrbnic: condition and for postoperative patients. Manual techniques can be used to help facilitate recruit­ ment in the early stages of neuromuscular training. Figure 18-21 illustrates a manual technique for faCilitating re­ cruitment of LYi musculature. After a consistent LYi con­ traction can be elicited , ask the patient to perform a body check and detcnnine whether fO CUSing on contraction of the LM facilitated a pelvic floor contraction. You as th e

feet and extending up toward your umbili cus. Think about pulling the cord tight from the anchor point upward toward your umbilicus. • To contract the lumbar multifidus: Think of initiating a very tiny tilt of the sacrum (moving the tailbone away from your body as if to arch your back). The contraction should be isometric (the muscle contracts but the joint does not move). Another image is to think about an elastic cord running between your "dimples" in your low back. Think about tightening the cord between your dimples. This may help you to feel the contraction of the lumbar multifidii. • To contract the transversus abdominis: Slowly and gently pull your lower abdomen inward. Imagine trying to "zip up" a slightly tight pair of pants. You can feel the tension in the muscle under a finger placed one inch inward from the front pelvic bones. You should feel a tensing of the deep muscle, not a bulging of the more superficial muscles. Another image is to think about an elastic cord running between the two prominent pelvic bones (called' the ASIS). Think about tightening the cord between these two bones. This may help you to isolate your transversus abdominis ,from the other abdominal muscles. • To activate the inner core synergy: Your physical therapist will help you to identify which inner core muscle best activates the entire inner core group. Next, take a deep diaphragmatic breath, allowing your ribs to expand to the front, sides, and back. Allow the air to exhale naturally. Before you take anothe r breath, slowly and gently contract your inner core. Next, resume normal breathing while maintaining contraction of your inner core . Your physical therapist will instruct you how to proceed from this step. • Positions to activate your inner core : __ back lying __ stomach lying __ sidelying __ quadruped __ sitting __ standing

__ squatting __ walking

clinician can palpate the TrA to det<:rmine whether it I contracted in synergy with the LM and pelvic floor. Y can ask the patient to vary the illitialmuscle activatioll [1'­ cus from the pelvic floor, to the LM , to the TrA to ensu the synergy is intact. Contraction of the inner core should occur in conjunc­ tion "vith good breathing habits. Ask the patient to per­ form a deep diaphragmatic breath and assess the quali: of the inhalation and exhalation teehniqu e . If the quali:. is poor, teach the patient diaphragmatic breathing as cill cussed in Chapter 23. Next, ask the patient to take a dee diaphragmatic breath 'vvith a relaxed, not forced, exhak­ tion. Before the next breath, ask the patient to slOtcly am. gently contract the inner core synergy, then resume nor­ mal relaxed breathing. After relaxed breathing can be per­ formed wh ile sustain ing an inner core contraction, th e i~ ­ ner core supine progression (see Self-Management 18-1

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

369

FIGURE 18·21. Sidelying manually resisted lumbar mullifidus exercise. Restoration of lumbar multilfidus activity may need to begin by facilitating the muscle at the specific level of spinal pathology with a manual technique. Low-load rotary res istance is applied to the affected segment in a side lying position as if testing for passive physiologic intervertebral movement. The patient is encouraged to ma intain the submaximal contraction against the therapist's resistance into rotalion. The therapist palpates the segmental level to ensure multifidus activity. EMG reveals that the multifidus is active in rotation both ips ilateral and contralateral as a stabilizer. 15 The primary role of the multifidus is to oppose the flexion moment assoc iated with rotation.

SELF·MANAGEMENT 18·' Supine Inner Core Progression

Purpose:

Starting position."

TIP: •

A back lying activity to strengthen and improve muscle control over your deep trunk muscles includi ng your lumbar multifidus, tra nsversus abdominis, and pelvic floor. Use of progressively more difficult leg movements challenge your inner core muscles. Highe r levels will require use of more su perficial muscles, but the inner core should still be activated as the local stabilization strategy. You can think of this progression as strengthening from the "inside out."

Lie on your back on a firm surface, such as the floor, with knees bent, feet flat on the floor, and shoes off. To feel the transversus abdominis, place your fingertips deep to the inside of your front pelvic bones (your physical therapist will show you the exact location). Refer to the Patient-Related Instruction sheet that teaches how to contract each muscle of the inner core. Take a deep diaphragmatic breath in (your physical therapist will teach you the correct technique for diaphragmatic breathing). Allow the exhalation to occur naturally, do not force the exhalation. Before you take your next breath, activate your inner core. Resume normal breathing. After normal breathing has been established, you can begin the prescribed level of this exercise. The abdominal muscles must be pulled in, not poached or distended. The pelvic floor must be pulled up, not pushed downward. These

•

Movement technique:

errors in strategy often occur as increased strain is placed on the abdominal and pelvic floor muscles from the progressively difficult leg moveme nts. The lumbar spine must remain in a neutral position with a slightforward curve-just enough to fit your hand between your back and the floor-and not move into further forward curve or excessively flat. If needed, you may use a small hand towel rolled under the small of your back to provide feedback as to the position of your spine. Your physical therapist will check off the level(s) you are to perform with the appropriate dosage.

Levell:

While keeping your inner core activated, s/ow/yslide one leg down to a straight position followed by sliding the other leg down so that both are in a straight position. If your back is arched, you may need to limit your heel slide so that your pelvis is not pulled out of a neutral position. Next, slide one leg up the table to a flexed hip and knee position. After you have completed this movement, slide the same leg back t o a straight position. Repeat with the opposite limb.

TIP:

The pelvis must remain in neutral and not rotate. The spine must remain in neutral and not flatten, arch, or rotate. To keep your spine and pelvis stable you must be sure to keep your inner core activated, especiall'y during the initiation of the heel slide because this.is the moment when the neutral' position is often lost. (continued)

370

Therape utic Exercise Moving Toward Function

SELF-MANAGEMENT 18-' Supine Inner Core Progression (Continued)

Dosage Sets/repetitions

Frequency

Level II: Assume the start position. Lift one leg off the floor until your hip is at a SO-degree angle with the floor. Next, slide the other leg down to a fully extended position while keeping the opposite leg elevated off the floor. Slide the leg back to the same position as the nonmoving limb. Repeat with the other leg.

TIP:

As soon as you are unable to stabilize the pelvis and lumbar spine with your inner core, stop and rest for a minute before continuing. If your hip flexors (front thigh muscles) are short, you will not be able to fully extend your leg without moving your spine or pelvis out of neutral. In this case, stop sliding your leg when you notice your spine or pelvis moving from the neutral position. Eventually, your hip flexor muscles will lengthen as your ab­ dominal muscles shorten and become stronger.

Level f1J:

TIP:

Repeat level II, but instead of sliding your leg down and back, glide your leg down and back. The nonmoving leg should remain in a flexed position off the floor. It is easy to transition from a flat abdomen to a poached abdomen and from keeping the pelvic floor pulled upward to pushing it down­ ward at this level. Keep the inner core acti­ vated and continue to breathe.

Dosage Sets/repetitions

Frequency

Level IV: Begin from the start position, and lift both legs off the floor at the same time to the SO-degree position. Return to the start position by lower· ing both legs at the same time. Slide both legs simultaneously to the fully extended position, and slide both legs back to the start position.

Dosage Sets/repetitions

Frequencv

Level V: Repeat level IV, but glide both legs down and back to the start position.

Dosage Sets/repetitions

Frequencv

and inner core series (Self-Management 18-2) can be prescribed. When prescribing the supine inner core progression (see Self Management 18-1) the individual should be aware that isolated use of the inner core is not possible tl1rougb­ out all the levels of the exercise. Beyond level II, most in­ dividuals will require recruitment of more tban the inner core for stabilization. The exercise is progressed from level I to level V through a combination of progressively longer lever arms in th e form of hip and knee extensions and in­ creased loads in the form of moving one limb advanced to moving both limbs simultaneously. The direction of forces imposed on the spine also must be considered in advanCing the exercise, particularly from level III to level IV. Level III and level IV may be interchanged with respect to diffi­ culty, depending on which direction of force the patient has most difficulty controlling. Level III combines sagittal­ and transverse-plane forces because of th e unilateral limb movement, whereas level IV induces a strong sagittal-plane force because of the bilateral1imb movement. If an indi­ vidual has difficulty controlling rotational forces , progres­ sion from level n to level IV may be easier than to levelEr. These factors , combined ,vith patient skill at accomplishing the criteria described previously, can gUide the clinician in advanCing the exercise.

Dosage Sets/repetitions

Frequencv

It is important that the exercise is not progressed to next level unless the prescribed number of repetition the previous level can be achieved and the follovving crit, ­ ria have been met:

• The lumbar spine should not deviate from the ini starting pOSition, which should be in a neutral sp' pOSition (Table 18-6). • The trunk muscles should be functioning at opb lengths (i .e., not lengthened). • Th e RA should not De dominating the Sj1wrgy, an Valsalva maneuver is discouraged. Self Management 18-2: Inner Core Series challen ... the inner core muscles in a variety of positiolls and m control levels. Similar to the supine inner core progressi as the difficulty of the exercise is progressed, the inner cc ,.viII not be sufficient for proper stabilization and more s perficial muscles will need to assist in the stabilization p cess . However, the patient needs to be cautioned to co tinue to recruit the inner core, thereby strengthenil _ "from the inside out." Another exercise fOCUSing on the ability of the in core muscles to stabilize the spine and pelvis is i1Justra in Self-Management 18-3: Bent-Knee Fall-Out. Similar level II and III illustrated in Self-Management 18-1, ~

~

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

371

SELF-MANAGEMENT 18-2 Inner Core Series

Purpose:

The purpose of this series of activities is to progressively recruit your inner core, aided by your more superficial trunk muscles as needed, in a variety of positions. Be su re to activate your inner core prior to and during these various activities to strengthen ufrom the inside out. n Your physica l therapist will check off the positions you are able to perform with good technique and will teach you appropriate variations and progressions ofthese activities.

Back lying:

You can perform the back lying inner core progression in this position. Refer to the back lying inner core progression handout.

Side lying:

Start position'

Lie on your side with your hips and knees bent about 45 degrees. Place one or two pillows between your knees. You may need to place a small towel under your waist. Place your hand on your pelvis to monitor the position of your pelvis.

TIP:

Movement technique:

Slowly rotate your hip so that your knee cap rotates slightly upward. Do not allow your pelvis to move. You can advance this activity to a straighter hip position and add a lifting movement with your thigh. Your physical therapist will teach you this progression and provide you with a more d'etailed handout.

TIP:

Quadruped:

Start positIOn'

TIP:

Movement technique:

TIP:

Stomach lying:

Repetitions _ _ Frequency _ _

Sitting: Start position: Sit on a chair with a straight seat pan and straight back. Hips and pelvis should be at a right angle with the seat pan. Shoulders should be centered over hips.

Movement technique:

Start position: Lie on your stomach with a pillow positioned vertically under your chest and hips. Bend your elbows and rest your hands on the back of your head.

Movement technique:

TIP:

Lift your elbows only about 1/2 inch off the surface. Hold the position for 5 to 10 seconds. Return your elbows to the start position. You can advance this exercise by changing your arm positions and movements or by adding leg movements. Your physical therapist will teach you the appropriate progression and provide you with a more detailed handout.

Dosage Repetitions _ _ Frequency _ _

Lift one arm off the table top surface. It is not important to lift the arm fully overhead. Return your hand to the supporting surface. Do not let your spine and pelvis move from the start position when lifting your hand. Your physical therapist will teach you how to advance this exercise with variations in the start position or by adding arm and leg movements together.

Dosage

Dosage Repetitions _ __ Frequency ___

Assume a positi on on your hands and kne es, centering your hips over your knees and your shoulders over your hands. Rotate your pelvis so that your hips are at a SO·degree angle with your thigh, spine straight. and head in line with the rest of your spine. Do not round your spine upward, drop your head, or arch your low back excessively.

TIP:

Slowly straighten one leg as far as possible without letting your spine or pelvis move out of the start position. Return to the start position and repeat with the other leg. Do not let your spine or pelvis move back­ ward (slump) or rotate. Your physical ther­ apist can advance this exercise with com­ bined arm and leg movements.

Dosage Repetitions _ _ Frequency _ _

Activities of daily living:

Your physical therapist win teach you how to engage your inner core with various movements used in your daily activities such as squatting" stair stepping,liftlng, reaching, or walking.

372

Therapeutic Exercise: Moving Toward Function

Neutral and Functional Spine Positions SPINE POSITION

DEFINITION

CLINICAL JUDGMENT OF POSITION

Neutral

L\lmbar spine in slight extension, ASIS and pubic symphysis in the same vertical plan e'

Functional Spine

Position of greatest stability, least stress, fewest symptoms for an individua,l for any given activity

In supine , enough lumbar ex tension curve that the clinician can palpate the lumbar spinous processes, but not so much lumbar extension so as to pass hand through to the other side Varies 'with pathology, activity, and symptoms

' Maitland GD, Vertebral Mallipu la tion, 4th Ed, London: Butterwo rth, 1977,

exercise challenges the inner core ability to stabilize against extension and rotabon forces, An increased meas ure of difficull:\! can be introduced to any of th ese exercises by using half full foam rolls or gym balls. Foam rolls and gym balls are believed to facilit ate re­ cruitment of the deep trunk muscles and stimulate the pro­ prioceptor2 and balance reactions that are necessary for functionJ.1,o Care must be taken to introduce this variation when the patient is capable of using subtle recruitment pat-

0;'

terns and does not fall into muscle dominance strategies to balance on the roll or ball. Progression to a higher stage of motor control often suffices, unless the speCific goal is to challe nge balance and propri oception, As shown in the inner core selies, exercises emphasiziu!! stability through in creased neuromuscular control and muscle performance can be progressed to sitting or stand­ ing, In sitting, extremity movements can be used in much the same 'Nay as in supine positions to challenge the spin

SELF-MANAGEMENT 18-3 Bent-Knee Fall-out

Purpose:

To train you to move your thigh independently of your pelvis, lengthen your inner thigh muscles, strengthen and shorten weak and overstretched abdominal muscles, and train your inner core to stabilize against rotational forces

Before beginning the movement, engage your inner core. Be sure to keep it en­ gaged throughout the entire movement and continue to breathe in a relaxed manner.

Movement

Slarting

position:

TIP:

Back lying with one leg straig ht and the other hip andknee bent with the foot flat on the floor. Place your hands on your pelvis as indicated by your physical therapist to monitor pelvic motion. Your physical therapist may ask you to place _ _ pillows under the outside of the bent knee to letthe knee fall into something,

technique:

let the bent knee fall out to the side. Do not allow motion to occur in the pelvis, Relax the inner thigh muscles completely before returning to the start position.

Dosage Repetitions __ Frequency __

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region to stahilize against various directional forces , with the em­ phasis on using the entire lumbopelvic stabilizing system in )'nergistic manner. For example, sitting while raising the .mns in the sagittal plane can challenge the spine to stabi­ lize against sagittal forces , and changing the movement to a nilateral arm raise or to a diagonal direction challenges e spine to stabilize against a transverse plane force. Sit­ ting 011 a gym ball (see Fig. IS-IS ), making the base of sup­ "lOrt unstable, can further challenge sitting. The patient is ncouraged to use the appropriate inner core strategy arned in previous localized exercises by presetting the _'Ontraction before arm or leg movem ents. Stabilization regreSSions can also be developed in standing. Standing n a half or full foam roll can further challenge a standing roaression (see Fig. lS-19 ). After neuromuscular control and adequate muscle per­ rmance are established to stabilize the spine against lOve ments of the extremities and further strength is re­ .u ired from an occupation or recreational activity to . lieve a functional outcome, higher forces are required an can be supplied by the extremities alone. Dumbbells, eighted balls, or ankle weights can be used to progress the reviously described exercises. Pulleys or elastic tubing can o be used to increase the force requirements of the trunk usculature to stabilize the spine. For example, the patient be challenged to maintain trunk stability with an iso­ etric contraction while pulling the weight up or down Fig. lS-22A ), side to side or in a rotary motion. The em­ asis initially is on dynamiC motion at the hips, (Fig. lS­ -')B ), while avoiding motion through the trunk (i.e., stabil­ . level of stages of motor control) . This exercise requires fTective stabilization of the trunk through the inner core uscles and active recruitment or more superfiCial trunk uscles and latissimus dorsi , gluteus maximu s, gluteus edius, adductors, and hip rotators. All of these muscles e important in stabilization of the lumbar spine and _ lvic girdle through the posterior, anterior, and oblique uscular systems. The load is increased as tolerated, and :he speed is maintained at a low level.

B

Tubing can be used to add isometric resistance to create ~ upright stability activity The goal is to maintain the spine in neutral . rough isometric contractions of the trunk musculature while the upper 2uarter, trun k, or lower quarter is moving in sagittal or transverse planes. thi s example, the primary motion is occ urring at the hips in the (A) sag it­ :al or (B) transverse plane while the trunk remains in neutral alignment via sometric contractions of the inner core and more supe riicial trunk muscles

373

FIGURE 18-23. A progression from Fig 18-22 is controlled mobility. In­

stead of holding the trunk in neutral alignment, the lumbar spine is incor­ porated into combined movement patterns with the remainder of the spine, hips, knees, ankles, and feet Controlled mobility activities can be per­ formed about separate planes of movemen t leg, sagittal , transverse, frontal plane) Caution must be practiced when moving in multiple complex planes of movement leg, combined flexion/rotation) resulting from the po­ tential injurious stress to the lumba r spine Re sistance can be applied through pulleys, elastic tubing, or weig hted balls. The patient can periorm these activities on an unstable surface such as foam rolls or high-density foam squares. With all controlled mobility drills, the motion can occur in the lumbar spine , but most of the motion should occu r in the thoracic spine and hips, withthe least occurring in the lumbar spine

Preparation for high-level functional return requires more advanced strength training that incorporates spine motion as part of the total movement pattern (i.e., con­ trolled mobility and skill stages of motor control). Programs of this nature may include spine motions involVing concen­ tric and eccentric work with variable resistance in all planes, such as controlled mobility in th e sagittal plane and in combined planes (Fig. lS-23 ). At this stage, the various isokinetic machines (e.g. , Medex, medical exe rcise rotation trainer) and any pulley apparatus or elastic resistance can be useful. The chosen movem ent pattern should be tai­ lored to those required for the patient's occupational or recreational activities. Rotation is often not well tolerated by those with a true articular instability of the lumbar spine or S1J, particularly when the pelvis is fixed in an apparatus or in sitting. Pa­ tients with true articular instability should avoid motion in the affected region and should train strictly in isometric modes. Vocational counseling or recreational modification may be necessary for those with true articular instability. Counseling focuses on chOOSing activities that avoid rota­ tional movement patterns. As with all resistive exercise, after the muscle perfor­ mance has reached a functional level, functional activities must be added to the program. However, it is unnecessary to wait until the end of the rehabilitation program to train functional activities. These should be considered from the beginning in designing the plan of care. For example, a min­ imal expectation for a patient in acute pain is to perform hip and knee flexion (see Self-Management lS-1: Level I) and

374

Therapeutic Exercise Moving Toward Function

bent-knee fall-outs (see Self-Management 18-3) in a supine position vvithout pain . These duplicate movements are nec­ essary for pain free bed mobility. The definition of a successful functional outcome varies. Success for one person may be to perform light housework; for another, success may mean resuming heavy lifting, playing a racket sport, or running long distances. The abil­ ity to return to desired functional activities, regardless of the level, requires neuromuscular skill to control motion of the trunk and pelvic girdle in relation to the other extrem­ ities. This requires interactive stabilization and movement strategies during total-body movement patterns. Exercises addressing force or torque generation of the trunk muscles should he part of a comprehensive rehabilitation program addressing other physiologic impairments. To achieve the neuromuscular skills necessary to return to function at any level, functional exercises must be practiced with precise movement and recruitment patterns and for many repeti­ tions frequently throughout the day. This requires a high level of commitment on the pali of the patient. The exer­ cises used to progress to a functional outcome are based on the postures and move ment patterns used during ADLs and occupational and recreational activities. No two func­ tional retraining programs should be the same, because each program is tailored to the individual's functional goals. Examples of functional activities are prOvided in the Pos­ ture and Movement Impairment section.

Neurologic Impairment and Pathology Mechanical (e.g., compression, traction) and biochemical (e.g., inflammatory response) factors ariSing from lum­ bopelvic dysfunction can result in nerve root pathology. For example, a herniated nucleus pulposus (HNP) at the LS-S1 revel can cause mechanical and hiochemical irritation to the LS nerve root and medial branch of the dorsal rami, result­ ing in weakness in the gluteus medius and same-level LM , respectively.1 16 The underlying pathology or impairment causing the mechanical or biochemical irritation must be treated, if possible, to affect the efferent input into the cor­ responding musculature. Exercise to improve force or torque capability of the affected musculature without treat­ ing the underlying neurologiC dysfunction \vill prove futile. Nonetheless, exercise ll1 <1)' be a large part of th e solution. For example, excessiye mobility at ~ segmental level can read to dege nerative disk disease,13i which can result in l1erve root compression and reduce effcrent input into the associated musculature. Exercises to improve the stability of the offending segment coupled with exercises to improve the mobility of other segments or regions (e.g., thoracic spine rotation, hip joint flexion) can reduce the mechanical stress on the nerve root, tl'lereby contributing to restoration of neurologiC input into the affected musculature. Appro­ priate strengthening exercises for the affected musculature (see Display 18-3) can be more effective after the neuro­ lOgiC compromise is resolved. Anoth er neurologiC cause of impaired muscle perfor­ mance is nerve injury resulting in muscle paresis or paraly­ sis, which can occur as a complication of surgery or from a traction injury to the nerve. LM segmen tal atrophy at the surgical site has been reported in the CLBP population af­ ter surgic,d intervention 138 It is thought to be the result of

iatrogenic lesions of the dorsal rami and innervation failur. of the low back muscles after surgery. This finding is higt- ­ lighted as a possible cause of "postoperative failed bac syndrome" and is supported by histologiC evide nce .1 Other investigators have reported denervation of segmer­ tal paraspinal musculature in patients with the radiolog; diagnosis of segmental hypermobility.130 These chang­ were thought to result from traction injury of the posteri primary rami segmentally supplying the muscle at the h_, . permobile segment. The ability for exercise to reverse th. effects of denervation is related to the neurophysiologic re­ covery of the damaged nerve. Nonetheless, sustained me­ chanical stress from segmental instability delays or inhibi healing, and exercise targeted toward increasing segmen stability can reduce mechanical stress on the segment an augment healing. If nerve regeneration occurs, specific e.1­ ercises focused on improving force or torque generati are necessary to "reeducate" the previously denervat muscle. 140 SpeCific exe rcise recommendations "vin be dis· cussed subsequently.

Muscle Strain Muscle strain can result from a variety of mechanisms: • Trauma (e.g. , spinal extensors and LM after a mot vehicle accident) • Overuse (e.g., one diagonal EO and 10 muscles in competitive rowing team member) • Gradual continuous stretch (e.g., EOs in a swayba. or lordotic posture) Strain to lumbopelvic musculature, particularly ; caused by trauma, is difficult to diagnose, because it oft occurs ,vith injury to other tissues in the motion segment If a strain is suspected, the activity or technique, startin_ pOSition, and dosage depend on the severity of the strair the stage of healing, and the mechanism of injury. Sever­ strains in early stages of recovery and chronic strains \' . long-term disuse must start with low-intensity isometric ex­ ercises. Strains resulting from chronic stretch must be sup­ ported in a short range and exercised with low initialloacL and gradual progreSSions ,vith a focus on generating ten ­ sion in U1e short range and avoiding the overstretch range For example, in the case of an EO strain res ulting frOJ marked lordosis and anterior pelvic tilt, llse of an abdomi­ nal binder combined with low-load exercises in a neutriL spine and pelvis position may be indicated in the earl. stages of recovery (see Patient-Related Instruction 18-1 and Self-Management 18-1 and 18-2). If the strain is the result of overuse, ultimate recoveT\ must involve improving the force or torque production and recruitment patterns of the underused synergist(s). For ex­ ample, strain to one diagonal oblique abdominal muscle is a common injury among members on a rowing team. It . caused by repetitive flexion and unilateral rotation. Chang­ ing the movement pattern to greater flexion and rotation occurring at the hips, and improving the force and torque capabibty of the postelior spinal muscle group (to minimize the flexion component during unilateral rotation ) and op­ posite oblique abdominal muscle group, may be indicated. Rarely does a patient progress from a trunk muscle strain in the expected time frame, primaruy because of frequen t

Chapter 18 Therapeutic Exercise for the Lumbopelvi c Region

375

DISPLAY IB-3

Resisted Exercises for the Lumbopelvic System Stability Activities for the Anterior Aspect

Stability Activities for lumbopelvic Synergy

• Inner Core activation (see Patient-Related Instruction 18-1) • Leg slides (see Self-Management 18-1) • Prone knee bend (see Self-Management 18-5) • Hip and knee flexion, hip abduction and lateral rotation (see Self-Management 18-3)

• Inner core activation (see Patient Related Instruction 18-1) • Sitting upper extremity flexion, abduction, rotation (Figs. A and B) • Quadruped arm lift (Fig. C) • Self Management 1'8-2

Stability Activities for the Posterior Aspect

Controlled Mobility Activities for lumbopelvic Synergy

• Inner core activation (see Patient Related Instruction 18-1) • Manual lumbar multifidus facilitation (see Fig. 18-21) • Sidelying small-range hip abduction • Prone small-range hip extension Isee Self-Management 20­ 1: Stomach Lying Hip Extension in Chapter 20) • Prone neutral spine isometric

• Trunk curl sit-up (see Self-Management 18-4) • Trunk sagittal and transverse plane motion in standing (see Fig. 18-23)

Skill Activity for Lumbopelvic Synergy • Monitor performance of recreational or occupational skills

B

~injuI)' of the

muscle. ReinjuI)' is most likely a result of poor rotection of the injured area during postures and move­ nt pattems the patient is unaware he or she is performing. - ' the responsibility of the therapist to educate the patient avoid postures and movement pattems most likely con­ ..-muting to delayed healing and to use improved postures rid movement pattems to promote the healing process.

;jenera! Disuse and Deconditioning ~ neral disuse and deconditioning of the trunk and pelvic zirdle muscles can result from the previously described ,-auses. However, the trunk and pelvic girdle muscles also e susceptible to deconditioning as a result of general de-

creased activity level. Trunk and pelvic girdle decondition­ ing may be a leading cause of lumbopelvic sYlldromes and therefore are critical areas to address in prevention . Indi­ viduals \'lith general deconditioning require a careful ex­ amination so that a conditioning program is focus ed on the specific muscles in need of strengthening and that the program is initiated at the appropriate level of difficulty. The dilemma with most trunk-strengthening exerc ises per for med to improve fitness (e.g. , bent-knee sit- ups, crunches, roman chair hyperextensions, abdom inal or back strengthening machines) is that the exercise is often per­ formed at a higher level than that at which the muscles can safely and preCisely execute the movement. When one syn­

376

Therapeutic Exercise Moving Toward Function

FIGURE 18-24. The sit-up can be cons idered atwo-phase activity. (A) The first phase is the trunk curl. As trunk flexion is slovvly initiated by raising the head and shoulders form a supine position, the rib cage depresses an­ teriorly (rectus abdominis) and the ribs flare outward, increasing the in­ frasternal angle (internal oblique) The pelvis tilts posteriorly simultane­ ously with the head and shoulders raising (8) As the trunk is raised in flexion on the thighs, the sit-up enters the second or hip-f1lexion phase. As the hip flexors exert a strong force to ti lt the pelvis anteriorly, the external oblique maintains the spine in flexion and the pelvis in posterior rotation. The infrasternal angle decreases, as evidence of the external ob'l ique ac­ tivity. (Adapted from Kendall FP, McCreary EK, Provance PG. Muscles Test­ ing and Function. 4th ed. Baltimore Williams & Wilkins, 1993)

ergist of a group is relatively weak, the other synergists of­ ten produce the necessary force or torque required to per­ form the desired movement, thereby reinforcing the mus­ cle imbalance and increasing the risk of injury to the lumbopelvic region. It is beyond the scope of this text to analyze all the com­ mon fitness exercises used to strengthen the trunk muscles. Because the ability to curl up to a sit-up should be consid­ ered a normal ADL and because various forms of the sit-up are still commonly performed, a concise analysis of this ex­ ercise is prOvided, The sit-up can be considered as two distinct phases of one movement: trunk flexion followed by hip flexion (Fig. 18-24), The RA and 10 produce t11e tnll1k flexion phase, as indicated by rib cage depression (RA) and rib angle widen­ ing (r0), and the hip flexors produce the hip-flexion phase,s9 The role of the EO is to otfset the anterior force on the pelvis and lumbar spine exerted by the hip flexor muscles as evidenced by a narrowing of the rib angle dur­ ing the sit-up phase. s8 Although hip flexors may exhibit some weakness associ­ ated with postural problems (e.g., weak hip flexors in the swayback posture), it rarely interferes with performing the hip-flexion phase of the Sit-up. The problem in accurately performing a straight leg sit-up is usually vveakness of the abdominal. muscles, speCifically the RA and IO in complet­ ing the trunk curl phase and the EO during the hip-flexion phase As a result, because of a premature hip flexion phase, the lower portions of the RA and 10 do not get a dy­ namic stimulus and the lumbar spine is vulnerable to the extension forces exerted by the hip flexor muscles lifting a longer lever arm. Instruction in proper execution of the Sit-up requires a complex level of analysis and decision making considering the performance of the abdominal muscles in relation to the hip flexor muscles and structural factors. Self-Manage­ ment 18-4: Sit-Up offers a detailed deSCription of the sit-

up. It is important to teach the client to complete th e trunk-curl phase before the sit-up phase for proper execu­ tion of this exe rcise , The lower extremities constitute about one third of th body weigh t. H 1 This means that the force exerted by th tnJDk in the supine position is greater than that of the lower extremities, and the feet need to be held down during the hip-flexion phase. However, if the spine flexes sufficientl\ as the trunk raises and the center of mass moves downward toward the hips, the tnJDk, in many persons, can be raised in flexi on without having the feet held down. Most adol e~ ­ cents and women can perform the sit-up vvithout havin their feet held doWlil because of a combination of body pro-­ portion (e .g., upper body less mass relative to lower bod; and segmental trunk flexion lowering the center of mass. II: contrast, many men may need to have some added force applied (usually very little) at the point where the trunl. curl is completed and the hip flexion begins because mas ­ of the upper body is greater than that of the lower bod\ This rnav also be tnJe for women vvith a stiff trunk becaus( of the il{ability to segmentally flex the spine, which creat a longer lever arm and may require the feet to be hel down during hip flexion, If it is necessary to stabilize th feet during the hip-flexion phase, the feet should be hel down only during the hip-fleXion phase to ensure full tnm flexion before tho hip-flexion phase begins. If the feet arr held down prematurely or throughout the sit-up, the hir flexors are given fixation, and the tnmk can be raised by hir flexion instead of trunk flexion. Elevation of the feet during the sit-up can indicate a domina] muscle fatigue. For example, all individual may able to curl the trunk through a speCified arc of moti without requiring the feet to be 11eld down (or held dow only during hip flexion) for the fIrst few sit-ups. How'ew:' in subsequent sit-ups, the feet begin to rise before th specified arc of motion is completed. With the onset of ab­ dominal fatigue, the feet elevate when previously elevati was not observed or rise earlier in the range if fixation is re­ qUired during the hip-flexion phase, because the abdom­ nal muscles are no longer prodUCing enough torque to n the trunk through the speCified arc of motion. Therefo the hip flexors act earlier in the range to raise the trun with the fee t rising as a result. For many years, sit-ups were performed with the L_ straight, but the emphaSis has shifted to doing the exerc" in the bent-knee position. For this reason, the bent-kn position is compared with the hip-extended position. TI bent-knee sit-up has long been advocated as a mean minimizing or eliminating the action of the hip fl exo placing them "on slack" during the sit-up. This idea, W ruL has persisted for many years among profeSSionals and tl. public, is false and misleading. The abdominal muscle not cross the hip joint and can therefore only flex the tmD:; The sit-up, whether the hips are extended or flexed , is strong hip flexor exercise; the difference is the arc of L joint motion through which the hip flexors act (i.e., hip~ tended: 0 to 80 degree s flexion; hips flexed: 50 to 125 ci grees flexion). Because the hip joint moves to completi of hip flexion ROM with the hips and knees flexed, hL repetitions of this type of sit-up may be more conduch"e the development of short hip flexors than the sit-up \\~. the hips extended.

Chapter 18: Therapeutic Exercise for the Lumbopelvic Regi on l

377

_

9

SELF-MANAGEMENT 78-4

Sit-Up

Purpose: To strengthen the abdominal muscles and hip flexor muscles necessary to sit up from a supine position

you come to a full sitting position. Slowly reverse the curl and resume the start position.

Starting

position: Back lying with hips and knees straight. Your physical therapist will determine if you are to begin this exercise in a supine position with hips and kn ees stra ight or with pillows under your knees. Your physical therapist will also determine if you will require fixation of your feet during the sit-up phase of this exercise. To perform this exercise with proper technique, follow the tips listed:

Start with an inner core contraction and hold

this contraction throughout the entire sit-up

and return to the start movement.

Do not push your abdomen out or your pelvic

floor down.

Curl your trunk to the same spine level with

the selected arm position.

Maintain lumbar flexion and posterior pelvic

tilt during the hip flexion phase.

If you require fixation for your feet, do not use

the fixation until the sit-up phase.

TIP:

If you did not require fixation for 'eve", you

should not require fixation at any level of the

exercise. Ask your physical therapist if you

have trouble keeping your feet down during

the sit-up phase of level II or III. Premature

Ilifting of your feet can be an indication of

abdominal fatigue.

Movement technique: Levell: With your arms in front of your body, bring your chin to your chest, and slowly curl your trunk as

Although normal flexibility of the back is desired, exces­ -e flexibility is not. A contraindication to performing a !:>ent -knee sit-up is excessive flexibility of the lum bar spine. n th the hips extended, the center of mass is slightly ante­ rior to the first or second sacral segment. With the hips and ..:nees bent, the center of mass moves cranially. The lower extremities exert less force in counterbalancing the trunk du ring the sit-up with the hips and knees flexed than \-vith the hips extended . To sit up from the bent-knee pOSition, the feet must be held down , or the trunk must flex exces ­ ively to move the center of mass downward. As the curl pro­ gress es, the center of mass moves distally toward the hip joint. In the hip-extended position, by the time the hip-flex­ ion phase arrives , the center of mass has moved toward the hips, which encourages the hips (not the lumbar spine ) to £lex during the sit-up phase. With the hips flexed. the cen­ ter of mass may not reach the axis of motion of the hips by the hip-flexion phase, thereby imposing a flexion moment on the lumbar spine versus the hip jOints. The persons most

Dosage Sets/repetitions

Frequency

Leve/II. Perform as in level', but place your arms fold ed across yo ur che st.

Dosage Sets/repetitions

Frequency

Leve/III: Perform as in 'eve", but place your hands on top of your head with your elbows open.

Dosage Sets/repetitions Frequency

in danger of being adversely affected by repeated bent-knee sit-ups are children and young adolescents because of their tendency toward excessive flexibility. Adults with LBP as­ sociated \-vith excessive flexion flexibility of the low back may also be adversely affected by this exercise . A precaution to performing a straight-leg Sit-up is short hip flexo rs. In the supine position with the legs straight, a person with short hip flexors lies in anterior pelVic tilt and lumbar extension. The danger \vith performing the sit-up from this position is that the multijoint hip flexors (i.e. , teIl­ sor fascia lata [TFLj and rectus femoris) pull the pelViS into more anterior pelvic tilt and subsequently the spine into further extension during the hip-flexion phase. The bent­ knee position releases the downward pull of the short hip flexors, allOWing the pelviS to tilt posteriorly and the lumbar spine to relatively flex. This relieves the extension stress on the low back. However, the hips and knees should be bent only as much as needed to allow the pelvis to reach neutral in the supine position. This position should be maintained

378

Therapeutic Exercise Moving Toward Function

passively by using a large enough roll or pillow under the knees. Prescribing bent-knee sit-ups (even in a partially bent-knee position) to individuals with short hip flexors is not the final solution, and this position should not be used indefinitely. Short hip flexors often accompany lengthened EO muscles because of the anterior pelvic tilt posture in­ duced by the short hip flexors. The bent-knee sit-up nei­ ther addresses the short hip flexors nor the lengthened EOs. 'Vorking toward a goal of being able to lie supine with the pelvis in neutral is accomplished by minimizing and gradually decreasing the amount of hip flexion permitted in the start position. Consequently, it is important to perform exercises to stretch the short hip flexors (see Self-Manage­ ment 18-5: Prone Knee Bend), to strengthen and shorten the EO muscles (see Self-Management 18-1), and to attend to undesirable postural habits (e.g., avoiding excessive an­ terior pelvic tilt and lumbar lordosis) . A contraindication to either bent lG1ee or straight leg sit­ up techniques is concern about compressive loading of the spine. Lumbar compressive loads greater than 3,000 N were

SELF-MANAGEMENT 78-5

Prone Knee Bend

Purpose: To lengthen the hip flexors and quadriceps, improve the strength of the inner core, and train the pelvis and spine to remain still during knee bending movements

Starting position:

Options:

Facelying with both lower limbs straight and knees together. You may need _ _ pillows under your hips, as indicated by your physical therapist. You may need to position your thigh out to the side.

Movement technique: Before moving your legs, engage your inner core. Maintain this contraction as you bend one knee as far as possible without movement

in the pelvis or spine

Options:

Bend both knees at the same time while keeping knees and ankles together. Correct: pelvis remains still

predicted for both straight-leg and bent-knee Sit-up tech­ niques. 142 In the presence of an HNP, for example, the issuE' of using straight-leg or bent-knee sit-ups is not as important as the issue of whether or not to prescribe sit-ups at an. A trend in abdominal strengthening is a trunk curl OI "crunch" performed without the hip-flexion phase. If the EO muscle is weak, making the lumbar spine vulnerablE during the hip-flexion phase of the sit-up, performance only the trunk-curl phase should be safe and effective fe­ strengthening the abdominal muscles. There is less in­ tradiskal pressure in performing the trunk curl than in a fuL sit_ up 32 However, the trunk curl focuses primarily on pro­ ducing torque for movement rather than force or torq for stabilization of lumbar segments. This preferentially r, cruits the RA and 10 over the EO. Moreover, the trur curl is contraindicated for any person with a thorac kyphosis because of the stress thoracic flexion exerts on tl. kyphosis. Alternative exercises should be suggested for f sons with poor lumbar stabilization and thoracic kypho (see Self-Management 18-1 and 18-2). If the trunk curl is chosen, the therapist should dete-­ mine the position in which the patient should start­ small towel roll under the knees, a wedge-shaped pill under the head and shoulder, or a pillow under the knee­ Before any trunk movement, an inner core contracti should be initiated (see Patient-Related Instruction: With the arms extended forward, the patient should the chin toward the chest and continue to curl the upp trunk as far as the spine can flex (see Self-Management ! 4). If the subject cannot perform the curl to completion his or her spine flexion because of abdominal weakne wedge-shaped pillow can be placed behind the head shoulders to limit the range and the decrease the effeCl gravity. As abdominal muscle strength improves, sequ tially smaller pillows can be used. If the hip flexors short, temporary use of a pillow under the knees can used to decrease the pull of the hip flexors on the spine· allow the individual to lie in supine with the pelvis spine in neutral. Table 18-7 summarizes features relatoo the prescription of the Sit-up and its variations.

Range of Motion, Muscle Length, and Joint Mobility Clinical decisions regarding exercise prescription ROM, muscle length, and jOint mobility must be con ered in relation to other regions of the spine, upper q ter, and lower quarter.

Hypermobility

Dosage Repetitions Frequency

Diagnosis of hypermobility and true articular instab' can be made from careful examination J0 1. 116 The exar­ iner should also seek to discover the impairments COl"­ tributing to the hypermobility or articular instabili ~ ~ Four factors can be responSible for the development of hypermobile segment: trauma (e.g., motor vehicle ace'­ dent resulting in an acceleration injury), pathology (e.g rheumatoid arthritis , degenerative jOint change anatomic impairment (spondylolisthesis, HNP, asymmet­ ric tropic changes in the ZJ ), or repetitive movement pat­

Chapter 18 Therapeutic Exerci se for the Lumbopelvic Region

------------------------------------------------~--------~----

Summary of Indications.

Contra indications. and Precautions in Prescribing

Sit-ups and Sit-up Variations

EXERCISE

INDICATIONS

Bent-knee Sit-up

Lordosis

emporary Use of Pillows U ncler Knees for Sit-up traight-leg it-up

ru nk Curl (only) t'tl1porary Use o fWeclgc

CONTRAINDICATIONS AND PRECAUTIONS Sholt hip fle xors. excessive tmnk flexi on fle\ihility, thoracic kyphosis

Short hip flexors

At least good strength of all abdom inal muscles and hip fl exors Weak external obliques, disk pathology \Veak int!:'ll1al obliques and rectus abdominis

Disk pathology

Thoracic kyphosis

ems. With repetitive movement, hypermobility can de­ elop within the lumbopelvic region in response to a rel­ tively less mobile segment or region. Theoretically, in a ultijoint system with common movement directions, any ';ven movement follows the segments providing the least re istance, resulting in abnormal or excessive move ment If segments with the least amount of stiffness 5 With re­ ted movements over time, the least stiff segments in­ rease in mobility, and the more stiff segments decrease ill mobility. Sahrmann has termed the site of abnormal or excessive motion the site of relative stiffness or fleXibility. 5 The term elative is key to this concept. For example, the fifth lum­ ar vertebra, because of its biomechanical and anatomic properties, is more adapted to produce rotation than any other lumbar segment. It is therefore relatirely more flexi­ ble in the direction of rotation. This becomes a clinical problem or impairment only if the motion becomes exces­ j\·e . A contributing fac:tor is the relative stiffness at other 'pinal segments and regions in the upper aud lower C),uar­ ers that are deSigned for rotation. For example, playing golf involves a significant amount of total-body rotation to chieve a proper golf swing. If the hips , knees, or feet are relatively stiff in rotation, this pattern may impose excessive rotational stress on the spine. If the thoracic spine or upper lumbar segments are stiff in rotation, this pattern may im­ pose excessive rotation on the L5 segment. The cause-and-effect relationship of relative flexibility c n be addressed through a comprehensive program of im­ p roving mobility at the relatively more stiff segments or re­ cions and improving stiffness at the relatively more mobile egment. Stiffness should be increased at the site of relative

379

flexibility by improving neuromuscular control , muscle performance (i. e., hypertrophiC changes), and length-t n­ sion relationships of the stabilizing muscles (see the \1us­ cle Performance Impairment section) around the site of relative f1 >.:ibility coupled \-\lith educating the patient and training postures and movement patterns (see the Posture and Movement Impairment section ) that improve the dis­ tribution of mobility between associated regions and the lurnhopelvic region. Exercises to reduce hypermobility at a segmental level or within the pelViS can be progre sed according to tradi­ tional stages of motor control: mobility, stability, controlled mobility, and skill. The stage of mobility can be thought of as improving mobility at relatively stiff or hypomobile seg­ ments or regions in the specific: directiun (s) susceptible to move1llent, or DSM, a term developed by Sahrmann s Ac­ tivities and techniques to improve mobility are presented in the Hypomobility section. The stage of stability can be thought of as improving mo­ tor control, musc:le performance (particularly hypertrophiC changes ), and length-tension properties of the affected muscles to increase stiffness at the site of relative flexibil­ ity. SpeCifiC activities and techniques chosen to promote stiffness and stability at a site of relative flexibility should be based on the direction the segment is susceptible to exces­ sive or abnormal flexion, ext nsion, or rotation (Le ., DSM ). To stimulate adaptive shortening in a lengthened muscle, exercises must be performed with the spine in neutral or functional positions with the muscles in the corresponding length. The patient must be educated to avoid habitual pos­ tures that place a lengthening stress on the muscle (e.g. , avoid standing in a swayback in the presence of lengthened EO ). In some cases, immobilization in the short range (e.g., use of an abdominal binder) mav be neces sary to facilitate adaptive sh.ortening. To stimul~te hypertrophic changes that lead to increased stiffness, prescribe dosage levels for specific muscles appropriately. Controlled mobility focuses on the ability of the lum­ bopelvic region to move dynamically in all three planes with appropriate distribution of move ment and forces \v:ithin the lumbar region and between associated regions of the upper extremities, thoracic spine, SI], hip , knee, an­ kle, and foot. Skill is reached when the patterns of muscle activation become automatic and internalized by the pa­ tient during functional activities. Display 18-3 prOVides recommendations for exercises to develop stability through the stages of motor control. To be most effective in reduC:ing hypermobility with exercise, the therapist should educate each patient to use appropriate spine positions during all xercises and func­ tional activities. There is no particular IU11lbopeivic func­ tional position that is best for all patients and for all activ­ ities. Although the standard is the neutral position (see Table 18-7), it may not be achieved by all patients and for all activities, in which case the functional position of the spine should be used. The functional position (see Table 18-7) varies with phYSiologiC status and stresses from ADLs and IADLs. It varies among individuals and cir­ cumstances. For example , to avert exacerbation of symp­ toms, patients with spinal stenosis must avoid extension. The functional position may vary with the patient's activ­

380

Therapeutic Exercise Moving Toward Function

ity. For example, flexion should be avoided during heavy lifting from the floor to the waist. Some authorities argue that the spine should be held in end-range extension for maximal protection and efficiency of motion in lifting. 143 However, end-range extension should be avoided during lifting from waist level to overhead, and the functional po­ sition may be biased toward flexion to avoid injury to the spine with this activity. Functional spinal posture may vary with the patient's behavior of symptoms. The more severe, irritable, and acute the condition, the more lim­ ited the functional position of the spine becomes to avoid symptoms.

Hypomobility To be most effective, activities or techniques to reduce hy­ permobility must occur simultaneously with activities or techniques to increase mobility. Many activities or tech­ niques can be used to increase mobility, such as manual tech niques (e.g., articular jOint mobilization, muscle en­ ergy techniques, soft-tissue mobilization); passive self­ stretch or self-mobilization; or active assisted, active, and resisted exercise. There are multiple justifications for the use of manual therapy including (see Chapter 7): • PsycholoiliC effects as a result of patient-therapist in­ teraction. ~4 • Mechanical effect (e.g., aJtering positional relation­ ships or mobiliZing joints thr~ugh stretching or rup­ turing restrictive structures )l4.) • Neurophysiologic effect (e .g., activation of the gate control mechan~sm , reflexogenic decrease of muscle hypertonicity) 14.) Research does not support the use of rotatory manual techniques for reduction of herniations in contained or un­ contained disks14R- 14H; in fact, rotatory techniques seem contraindicated in diskogenic dysfunctions and tensile strain to annular fibers as a result of rotation may further wf'aken nuclear containment.149 Research also does not support the rationale that manual therapy can affect the positionaJ relationship in the SIJ and thus decrease com­ plaints llS NeurophysioIogic mechanisms may offer a bet­ ter explanation of the effects of manual therapy. Clinical outcome studies demonstrate better results ,vith manual therapy techniques when pati ents with nonsJiecific LBP are classified using clinical gUideline indices.i" Prrssive intervention in the form of manual therapy or manual exercise without some form of active exercise is dis­ couraged. One potential hazard in providing purely passive intervention is that the patient may not participate actively in the rehabilitation process. This may prevent the patient from achieving ful] recovery or contribute to recurrence, because the patient is unable to manage the condition in­ dependently. Whenever possible, active participation in the form of patient-related education and self-management ex­ ercise is encouraged. Active assisted ROM , active ROM , proprioceptive neu­ romuscular facilitation techniques (see Chapter 14), and passive stretching can also be used to increase mobility (see Chapter 7). This discussion focuses on self-management exercises, emphasizing passive and active stretching.

Passive stretching may be necessary, particularly for muscle groups with adaptive shortness. Careful muscle length testing determines which trunk and pelvic girdle muscles require stretching. SuperfiCial trunk muscles, such as the RA, quadratus lum borum, and lum bar erector spinae. and multijoint hip muscles, such as tensor fascia lata/iliotib­ ial band (TFUITB), semitendinosus or semimembranosus (medial hamstrings ), biceps femoris (lateral hamstrings ). hip adductors , and rectus femoris, are susceptible to adap­ tive shortening. Care must be taken when stretching muscles crossing th hip joint in individuals with lumbopelvic dysfunction, be­ cause the SIJ or lumbar spine often becomes the site of rel­ ative flexibility when the hip becomes hypomobile. Stabi­ lization of the pelvic attachment wIllie the distal attachment moves requires special attention in lumbopelvic patients be­ cause the spine or SIJ becomes the path of least resistance and therefore eaSily moves before the feeling of a stretch. An example of proper stabilization for a diarthrodial muscle with attachments on the pelvis is the supine passl\'e hamstring stretch. The hamstrings may be passiveh stretched in supine with one hip flexed and the ipSilateral knee extended (to the point of mild hamstring tension) and the foot against a wall while the contralateral hip and kne are extended. The lumbopelvic region is stabilized in part by the appropriate recruitment of the inner core muscl and by the underlyi ng surface. The length of the ham­ strings determines the distance from the wall and angle or SLR. Certain criteria are used for proper stabilization to fa­ cilitate the optimal stretch: • The ipSilateral knee must be extended (not hyperex­ tended) • The spine and pelvis must be in neutral with respect to flexion , lateral flexion, and rotation • The opposite hip and knee must be in full extension • Active proximal stability (inner core synergy) must be present to achieve the most effective stretch (i. e. proximal stability before distal mobility). Incorrect technique will result in any number of com­ pensations, including posterior pelvic tilt, lateral pelvic tilt pelvic rotation , spine flexion or rotation (Fig. 18-25A), or opposite hip flexion (Fig. 18-25B). Medial or lateral hamstrings can be isolated by rotatio of the hip (i.e., hip lateral rotation increases the stretch t, the medial hamstrings and vice versa for the lateral ham­ string). The position is held until the feeling of mild tension disappears (usually up to 30 seconds ). The patient ther. moves slightly closer to the wall to increase hip flexion and again creates mild tension. This action may be repeated up to three or four times. The goal is to achieve an appreciable increase in hamstring extenSibility ,vitbin one session. Simple active movements can also be used to stretch muscles (see Display 18-4) and is routinely recommended after a passive stretch. For example, an individual with lumbopelvic pain who was diagnosed with lumbar hyper­ mobility in the direction of extension and rotation may han" worse symptoms after prolonged walking. During the stance phase of gait, it is observed that the lumbar spine moves exceSSively into extension and rotation instead of the stance hip moving into extension. The impairments con­

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

381

B AGURE 18-25. Incorrect technique during the supine passive hamstring stretch. (A) Spine flexi on and rotation. n this example. the pelvis rotates right with relative left spine ro tation. (8) Al lowi ng the opposite hip to flex 10es not stab ilize the pelvis rendering the hamstring stretch less efficient

..;b uting to the relative flexibility of the lumbar spine in the Y! of exte nsion and rotation may include poor muscle rformanc e of the inner core muscle s combined with ort diarthrodi al hip flex ors. Self-Man agement 18-1 monstrates an exercise progress ion targeting the illlpair­ nts in the inner core simultaneous with lengthening the t hrodial hip flexors. While the inner core muscles con­ et in the short range , the hip flexor muscles elongat(~ . If patient allows the hip fle xors to pull the pelvis and spine

out of alignment, the exercise becomes detrimental to al­ tering the site of relative Oexibility. In a patient with a hy­ permobile 51}, the site of relative flexibihty may be at the innominate rather than th e lumbar spine . The exercise must be monitored , focllsin on stabilizing the innominate rather than the lumbar spiIle by monitoring and preve nting move ment of the ASIS in an ante rior inferior di rection. In conjunction with this exe rci se, the patient can work on the same r(,lationship in other pOSitions, such as prone

DISPLAY 18-4

Exercises to Improve Hip Flexion Mobility and Decrease Lumbar Flexion Mobility :Xercises to improve hip flexion mobility • Hand-knee rocking (see Self-Management 20-6: Hand-Knee Rocking in Chapter 20) Supine hip flexion without lumbar flexion or rotation (Fig. A)

Exercises to reduce lumbar flexion mobility Seated knee extension (see Self-Management 20-7: Seated Knee Extension in Chapter 20)

• Standing hip flexion (Fig. B)

Instruction to alter posture and movement patterns Corrected Sitting Posture (see Patient-Related Instruction

19-4: Proper Sitting Posture in Chapter 19)

Improved lumbar pelvic movement (see Patient-Related

Instruction 18-3)

382

Therapeutic Exercise: Moving Toward Function

(see Self-Management 18-5). The lumbopelvic region is stabilized through appropriate inner core reclllitment, and the knee is flexed to the pOint of mild tension and before the loss oflumbopelvic stabilization. Emphasis is placed on relaxation of the rectus femoris and TFL simultaneously with stabilization of the spine against the extension force imposed by the short diarthrodial hip flexors. These active movements prepare the patient for the ultimate goal of sta­ bilizing the lumbar spine during the stance phase of gait.

Neuromeningeal Hypomobility Loss of mobility of the nervous system can occur as a result of congenital disorders, trat:ma, surgical complications , or degenerative changes.3.102.1bl There are two types of neu­

romeningeal hypomobility: the tethered cord syndrome an d the nerve root and dural movement dysfunction. Th tethered cord syndrome forms a con traindication to physi­ cal therapy intervention; however, nerve root and dural movement dysfunction can respond quite well to neural mobilization techniques. 102 Before intervention , neu­ romeningeal mobility should be assessed and its influeno determined. Specific exercises may be prescribed that are designed to improve mobility of the neural system (see setf­ Management 18-6: Neuromeningeal Mobilization). The re­ lated anatomy, physiology, and application principles mus: be well understood for the effective and safe use of this t)'pe of treatment. This topic is worthy of more extensive cover­ age. Detailed information is provided by Butler. 102

QII

~

SELF-MANAGEMENT 18-6

Purpose:

Neuromeningeal Mobilization

To improve the mobility of your sciatic nerve and its branches into the calf and foot and to reduce the pain coming from a loss of mobility in the sciatic nerve

Assessment: Before beginning this exercise, you must first assess the status of your neural mobility. Slump in your low back and pelvis as far as

possible.

Bring your chin toward your chest.

Flex your foot as far as possible.

Slowly extend the knee on the side of

symptoms as far as possible.

Stop at the onset or worsening of symptoms.

Notice the angle of your knee. You will

recheck this angle after performing the

exercise. You should be able to extend your

knee further if you are successful with

mobilizing your nerve.

If the angle is less, you have exacerbated

your nerve and should repeat the series,

reducing the range of motion of each

movement in the series. Recheck the knee

angle. It should be back to the original

assessment position or may be improved.

Knee mobilization

Starting position:

Slump in your low back, and roll your pelvis back as far as possible. Slightly flex your neck to take the stress off the forward head positionthe slumped posture placed your head in.

Movement

technique: Repeat each activity up to 15 times.

Knee mobilization Keeping your ankle relaxed, extend your knee until you feel mild tension behind your knee. Relax back to the start position. Ankle mobilization. Extend your knee about three fourths of the distance you found during the assessment. Flex and extend your ankle. Neck mobilization: Extend your knee three fourths of the distance you found during the assessment. Flex your ankle toward your head about three fourths of the distance of its full range of motion. Actively flex your chin toward your chest and release to the start position. Reassess after the first cycle. If you have been successful as described under the assessment, repeat the cycle_ times.

Ankle mobilization

Neck mobilization

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

Pain Pain is the most common reason persons with lumbopelvic Tldromes seek health care. Pain is often perceived to be e cause of limitations in function and disability by indi­ iduals with lumbopelvic syndromes. The sources of pain ithin the lmnbopelvic region are numerous ,md often dif­ ult to diagllose because of the complex interaction of pe­ lpral and central mechanisms responsible for the expe­ nee of pain. The phYSiologic and psychologic impact that bopelvic pain has on the person can create profound ability. It is often difficult to determine the individual ntribution of phYSiologic and psychologic impairment, -essitating treatment that deals with both categories of pairment. However, this section deals with the treatment ain hased solely on phYSiologic musculoskeletal factors. Treatment of the phYSiologic musculoskeletal compo­ l of pain can include interventions along a vast spec­ of choices, ranging from pharmaceutical intervention form of oral medications, skin patches, or injections hysical therapy to surgery-applied individually or in combination. The choice of intervention must be tai­ to each case, ideally vvith input from all practitioners Ived in the case. This section discusses therapeutic ex­ as one type of intervention for the treatment of mus­ keletallumbopelvic pain. Although the exercises sug­ d in this section were chosen to demonstrate activities 'echniques to treat diffe rent causes of pain, many are d to treat other impairments, such as those of mobility, de performance, posture, and motor function. Conse­ ·ntly, they may be referred to in other sections of this p t r, illustrating the complex interaction of impair­ n ts and the diversity and versatility of the exercises. To make informed decisions about the exercises chosen treat pain, the clinician should understand the physio­ '!ic impact that pain has on the structures of the lum­ pelvic region . There is evidence of segmental changes tbin the deep low back musdes in the presence of ....Bp 70.l40.1'52-15'1 Atrophy has been found on the ipSilateral de and at the corresponding c1inieally determined level of lnptoms in the LM, whose potential segmental stabilizing lie in the lumbar spine is beeoming increasingly well rec­ ~ ized97155 Histologic changes have been found in the p e I fihers of the LM in patients with herniated IVDs and 'LBP. I '5:3,1'iIi- lS9 The changes identified in the type I fibers ay result from pain-provoked, low-tension muscle con­ action , which is not strong enough to stimulate type II bers.71 Others have hypothesized. that the atrophy is con­ i ·tent with pain-induced disuse , I."). Although the physio­ !Tic changes are not well understood, they do occur and -ontribute to impairments in muscle performance and 'leuromuscular control, particularly in the LM. A patient with CLBP and poor segmental control over the stabiliZing and movement functions of the affected mo­ tion segment(s) is caught in a cycle of pain and dysfunction. Reducing the mechanical or ehemical causes of pain is crit­ ical to breaking the cycle and allOWing the structures af­ fI ted by pain and inflammation to recover if prOvided with the appropriate stimulus. Most structures in the lumbar spine can be a source of pain at some time under the right circumstances, making it

383

difficult or impossible to diagnose a specific source of pain. The nerve root, disk annulus, facet joint, and muscle seem to be the most acceptable candidates for sources of pain. 160 The mechanisms of pain production are described as a combination of mechanical and chemical irritation of the nociceptive receptors within the tissues. It is not clear whether mechanical stresses lead to chemical irritation, which sensitizes the tissue, or chemical irritation makes tis­ sue more sensitive to mechanical stress. The t\,yo mecha­ nisms most likely coexist in the vast majority of cases. In the spinal eanal, the HNP is a strong candidate for the cause of inflammation and irritation of nerve roots and nerve endings, Because of the juxtaposition of disk and nerve roots in the spinal canal, sciatica (j,e., pain radiating from the low back into the buttock, posterior thigh , and leg) is likely to rise from compression of the dorsal root ganglion and inflamed nerve roots, When a painful condi­ tion is set in peripheral tissue, the consequent barrage of noxious Signals into the spinal cord can sensitize so­ matosensory neurons in the dorsal hOIll. These sensitized neurons can contribute to a condition of CLBp 161 The physical therapist is most interested in the mechani­ cal cause of pain as it relates to movement. A systematic physical examination often reveals postures, stabilization, and movement strategies that contribute to the onset of pain, worsen existing pain, or convers~l('., reduce or abolish pain. One philosophICal approach)' 14 to treatmg mechal1ical causes of pain related to posture or movement is to teach the patient to avoid the posture or movement that is associated with the onset or worsening ofpain. The therapist should in­ struct the patient in more desirable posture and movement patterns and treat the associated physiologic impairments contributing to the undesirable posture and movement strategies (e.g., ROM, joint mobility , muscle performance, neuromuscular control). This approaeh is believed to inter­ vene mechanically by avoiding the postures and movements that are associated with pain, and chemically by allOWing the painful structures to "rest" and reduce or halt the inflam­ matory process. For example, in the patient who reports worsening of pain during forward bending, the lumbar­ pelvic relationship is faulty, with excessive motion in the low back relative to the hips. If the pain is reduced or abolished when the patient is instructed to bend vvith a greater con­ tribution of movement from the hips and less movement from the low back, this information can be used to devise an exercise intervention. Examples of exercises to include in such a program are listed in Display 18-4. In many cases, redUCing the mechanical stress on the affected structures by improving mobility in adjacent regions, improving stability in the affected region, and making associated changes in posture and movement patterns are sufficient steps to resolve the episode of pain "vithout need for other interventions. In other in­ stances, complementary interventions (e.g., joint mobi­ lization , physical agents , pharmaceutical intervention, psy­ chologic counseling) by the physical therapist or other practitioners involved in the case may be necessary to treat additional mechanical, chemical, or psychologic con­ tributions to pain. McKenzie developed another the rapeutic exercise ap­ proach for the treatment of pain. 161 , l()2 A Simplified exam­

384

Therapeutic Exercise Movi ng Toward Function

pie of this approach is the use of movem ents that reduce or abolis!J symptoms. Self-reports of postures relnted to pain , observation of posture, and uniplanar movements (e.g., flex­ ion , extension, lateral flexion ) are used to assess the effect of posture and movement on SymptOlTlS. During the examina­ tion , each movement is rated according to terms used to de­ scribe a change in status (e.g., improve, worsen, status quo). After the movement, or repeated lllovements, th e patient is asked to compare his or her sylnptoms "ith the baseline:. The concepts of peripheralization (i.e., pain or paresthe­ sia that moves distally away from the spine) and cClltralizo­ ['ion (i.e., pain or parestl-Jf'sia that is abolished or moves from th e periphery toward the lumbar spine) are used to deter­ mille which movements should be used in self-treatment. For exampl e, if repeated fOf\vard bending peripheralizes symptoms and extension centraIiZE'.s symptoms, extensiOll­ related exercises would be used In self-mana£1:emen t to

modulate symptoms (see Self-Management 18-7: Pran Press-Up Progression ). Thi s approach to the treatment of acute LBP has been effecti ve in restoring function , 163 par­ ticularly if used in conjunction with a treatment-based clas­ sification approach to low back syndrome. 4 In a retrospec­ tive studyof87 patients with leg and LBP, Donelson et al. l ~ found that all p,ltients witl1 excellent outcomes of McKen­ zie-based diagnosis and treatment showed centraljzation during the initial evaluation. McKenzie's conceptual model for treatment of disko­ genic dysfunctions theorizes tl1at with annular fibers pres­ ent to exert force on the NP, the NP vvill move fosteriorh during flexion and anteriorly during extension .. 149 Other rationales include effects related to activating gate control mechanisms , neural tissue relaxation, decreasing mechanj­ cal stim ulation of nerve roots and other nociceptive tissues. and disk hydration. 149. lA.'5 - JG9

SELF-MANAGEMENT 78-7 Prone Press-Up Progression

Purpose:

TIP:

Starting position: Movement technique:

TIP:

Levell:

To improve the mobility of your low back into backward bending, stretch the front trunk muscles, move your leg pain toward your back or abolish it completely, and/or progressively relieve the pressure on your lumbar disk. Your physical therapist may ask you to perform special exercises to reduce any shift you exhibit in your spine before the execution of this exercise. Face lying with legs straight. Your physical therapist will inform you of the levels of this exercise you are to perform and the duration of time you should spend at each level. You should not progress to the next level if your pain does not change in intensity or position (i.e., does not move toward your spine) or moves further down your Ileg. Remain on your stomach with your hands supporting your forehead.

Dosage Range of motion Sets/repetitions Frequency

Dosage Duration Frequency

Leve/II

Dosage Duration Sets/repetitions Frequency _ _ Levell/I Place your hands next to your shoulders. Press your upper trunk upward with your arms through the presc ribe d range of motion. Be sure the muscles in your back are fully relaxed .

Prop up onto your forearms. Be sure you relax the muscles in your back.

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

Positional techniques can also be used to modulate pain. For example, a patient can be taught to use positional trac­ tion if the goal is to separate joint surfaces to expedite re­ lief of pain (Fig. 18-26). The theory behind positional trac­ tion is similar to that for other types of traction (see Traction in a later section of this chapter) in that the tech­ nique is used to affect the mechanical causes of pain. 170 Self-mobilization or "prescriptive articular exercise," '~an be prescribed to correct articular dysfunction, particu­ larly that which relates to the SIJ. For example, a patient who presents with recurrent sacroiliac articular dysfunc­ tion (e.g., anterior innominate rotation) that is mechani­ cally contributing to his or her pain should be able to self­ treat the articular dysfunction rather than relying solely on the therapist to restore articular function .171 An example of a prescriptive articular exercise is illustrated in Self-Man­ aO'ement 18-8: Self-Mobilization for an Anterior Innomi­ nate Dysfunction. For this type of technique to be suc­ .::essful, the patient must learn to evaluate his or her dy. function and to pelform the appropriate technique with precision only until correction is achieved. It also must be emphaSized to the patient that these techniques are not nsidered part of the regular exercise regimen ; they hould be used only for articular dysfunction that con­ tributes to the patient's symptoms. Although pain is the ost common symptom , paresthesias and weakness are ...Iso symptoms related to articu lar dysfunction and should be used as indications for this treatment technique. For patients with CLBP, posture and movement inter­ 'ention may be preSCribed to improve activity tolerance, ,·hich is the ability to tolerate a specific posture or move­ ment deemed safe or necessary for function. The clinician hould encourage patients to gain activity tolerance but not o completely ignore pain , because increased pain can rve as an impediment to progress. A chemical process such as inflammation often domi­ ates the clinical picture, and attempts at altering mechan­ causes may not lessen the pain . The clinician must treat mflammation with the appropriate adjunctive modalities e .g. , cryotherapy, electrotherapy), protective measures e.O'., corset, SIJ belt), and controlled rest, but strict bed rest .hould be avoided (see Chapter 7). Moreover, the patient's phYSician should be alerted so that, if necessary, appropri­ e pharmacologic agents may be preSCribed or modified. Exercise is not con traindicated in the treatment of hemical causes of LBP. However, the primalY goal is to

AGURE 18-26, Positional traction . The use of a foam wedge allows max­ 1lal lateral flexion at a desired segmental level because of its sharp apex ~od ability to accommodate to the bony pelvis The wedge easily can be "'lade at a business that specializes in the manufacturing or design of foam • oducts. The re commended density is CO-80. The preferred dimensions are 0 X 8 X 8 X 18 inches (small) and 0 X lO X lO X 18 inches (large)

385

SELF-MANAGEMENT 18-8 Self-Mobilization

for an Anterior Innominate Dysfunction

Purpose: Starting position:

To normalize the position and motion of your pelvis Backlying on a firm surface.

Movement

technique:

Keep your __ hip and knee straight. Pull your __ knee toward your chest until you feel a mild barrier. Gently squeeze your __ gluteal muscles against an unyielding force exerted by your hands keeping your knee to your chest. Hold your contraction for 8to 10 seconds. On relaxation, flex your hip and rotate your pelvis posteriorly until you feel a new barrier. Repeat this process three to four times.

Dosage Repetitions Frequency

reduce the inflammatory process, which is typically achieved in physical therapy by reducing mechanical stress in the region. Exercises encouraging controlled rest are prescribed to enable the patient to perform basic move­ ments without causing pain. To move without inducing an increase in baseline pain , motion must be prevented at the affected lumbar spine segment Or SIJ. Exercise may in­ volve low-intenSity isom etril: re<.:ruitment of the stabilizing muscles of the lumbar spine and SIJs with simultaneous small-range movements of the extremities. Altering the length of lever arms, limiting the ROM , and adjusting the position of the exercise to a gravity-lessened position are examples of altering the exercise to reduce the stress on the inflamed segments. Prophylactic ROM exercises for associ­ ated regions and neuromeningeal mobility exercises 102 (see Self-Management 18-6) also may be used to prevent un­ necessalY loss of movement. As the acute pain reduces in intensity and irritability and as functional movement improves , more advanced exercises may be introduced, fOCUSing on impairments in muscle per­ formance , ROM, muscle extensibility, joint mobility, bal­ ance, and relatively more advanced postures and movement patterns. Transition to more advanced stages of care is rarely simple; it is often necessary to revert to more specific treat­ ment of acute pain because of the difficulty in prescribing the optimal dosage for more advanced exercise. The dosage

386

Therapeutic Exerci se Moving Toward Function

often stresses any given element of the movement system beyond its tolerance, resulting in increased pain and inflam­ mation. Exercise gradation should therefore err on U1e con­ servative side to avoid exacerbation of symptoms. Patients should be educated about when to modify or stop exercise in light of in creased symptoms (e.g., numb­ ness, paresthesia, pain ) beyond accer)table time frames (e.g., if symptoms are increased for more than 24 hours ). Continuing to exe rci se when symptoms increase signifi­ cantly or when increased symptoms exceed acceptable time frames can be counte rproductive to progress. Educat­ ing the patient to heed the body's warning signs and to modif)' exercises appropriately (e.g., decrease lever anTIS , work in graVity-lessened pOSition, decrease repetitions, de­ crease frequency , longe r rest pe riods ) can prevent the complications of excessive stress on healing tissues. The musculaJ changes that occurred as a result of lum­ bopelvic pain (e .g. , muscle performance capabilities, cross­ sectional area, neurumuscular control) may not improve naturally after the pain has ceased and the patient resumes functional activiti es.71.172 Specific localized exercises as de­ scribed in this chapter can restore the ideal lumbopelvic muscle control and performance. A clinical example may prOvide inSight into the complex relationships between pain and the development of hyper­ mobility as well as other phYSiologic impairments in the Illmbopelvic region. A patient presents with LBP. During the examination, the physical therapist notices that the pelvis and lumbar spine rotate during the initiation of active hip flexion and that this movement provokes LBP. When the patient is properly cu ed to recruit the inner core mus­ cles; pelviS and spine rotation is reduced, and symptoms are eliminated. Other tests throughout the examination con­ firm that the LS-S1 segmental level is the site of relative flexibility in the direcbon of rotation. The examination should determine all contributing phYSiologic impairments. In this scenario, it is possible that the patient presents with asymmetric trunk and pelvic girdle muscle performance, poor neuromuscular control, and easy fatigability in the deep trunk muscles. The patient may present with unilat­ eral shOJi hip adductors, positional weakness of the gluteus medius, and foot pronation ; functional limb length discrep­ ancy; and a history of using a repetitive rotation movement pattern at work. To develop a program to improve the stiff­ ness at the site of relative fl eXibility, each of the correlating impairments must be addressed . The program emphaSizes achieving quality of total-body movement and training kinesthetic awareness to control spinal postures and move­ ments in the direction associated \vith symptoms. An earlier se ction (see Myology and Muscle Perfor­ mance Impairment) discussed the role of the TrA, LM , and pelvic floor in the stabilization of the lumbopelvic region . SpeCific stabilization exercises aim ed at improvin g motor control and muscle performance of the inner core muscles appear effective in reverSing atrophiC changes in the LM muscles in patients with acute LBp J72 and may reduce re­ currence rates after first episode of acute LBp173 In a sub­ group of patients with structural abn ormalities prediSpos­ ing them to. segm ental illstability, speCific stabilization exercises reduced long-term pain ~n d disability levels when compared wi th general exerci se l l .J.

Posture and Movement Impairment Effective education in the area of posture and movement i essential to recover from and prevent recurrence of 111m­ bopelvic syndromes. Educ ation regarding posture an d muvcment should be initiated at the time of the first visit. By the end of the initial examination , the clinician should be aware of the postures and movements that exacerbate symptom s175 and therefore be able to instruct the pabent in simple recommendations regarding sitting, standing. and recumbent postures. Basic movement patterns can instructed, such as bed mobility (see Patient-Related In­ strucbon 18-2: Bed Mobility), sit to stand, and bending (see Patient-Related Instruction 18-3: Lumbar-Pelvic Move­ ment ) and liftin g man euve rs. The specific postures and movem ent patterns chosen to teach the patient should be based on the patient's pathology, impairments, function~ limitations, and disability. For example, a person with a di­ agnosed HNP at LA may have different sitting recomm en­ dations than a person with spinal stenosis. The former b advised to avoid sustained end-range flexion, while the lat­ ter is advised to avoid sustained, end-range extension. In addition to education regarding posture and mon'­ ment during ADLs, the clinician must consider specific posture and movement patterns for each prescribed exer· cise to be 1110St effective . For example , allOWing a patien with disk pathology to sit or move in lumbar flexion durin!: a sitting knee extension exercise not only reduces the ef­ fectiveness of the hamstring stretch, but also places addi­ tional stress on the disk. The initial and ending posture , the spine and pelvis during the movement of Imee exten­ sion must be emphaSized. Similarly, allOWing a patient witi:

Sed Mobility To reduce the stress on your low back, your physical therapist may ask you to get out of bed in a specific manner. The following instructions pertain to safe bed mobility. • Activate your inner core and slide one foot at a time up the bed until your knees are flexed and your feet are flat on the bed. Be sure to prevent your back from arching or rotatin g by using your inner core. • If you are not close to the side of the bed, you must bridge and slide until you are close to the side of the bed. Be sure to keep your inner core activated while bridging and sliding. • Roll your body as one unit until you are lying on your side. Do not lead with your upper body or pelvis because this will result in a rotational stress on your spine that is detrimental to the healing process. • Gently let your feet slide off the bed while simultaneously pushing yourself into the upright position with your hands. • TIP: Be sure to maintain an inner core contraction during all components of this maneuver. You should be able to perform this skill without increase in symptoms. Talk to your physica'i therapist if you are unable to transfer from back lying to sitting' without increased symptoms.

Chapter 18 The rapeutic Exerci se for the Lumbopelvic Region

387

Lumbar-Pelvic Movement Return From Forward Bend (0 to G) • Lead with your hips and pelvis by contracting your gluteal muscles. • Your low back should only extend after your pelvis has achieved its neutral position. • At the end of the range, you may need to pull in with your abdominal muscles to achieve your neutral pelvic position. (Adapted from Calliet R. Low Back Pain. 3rd Ed. Philadelphia: FA Davis, 1981.)

When you bend forward to pick up a light object, such as a shirt or a pencil. you can practice moving with the appropriate relationship between your low back and pelvis. The following are key points to keep in mind while bending forward:

Bending Forward (A to C) • Leading with your head, slowly curl your spine as you bend forward. • Think about relaxing at each vertebral segment. • Try to keep your knees straight and minimize the backward shift of your hips. • After you have reached the level of your low back in your forward bend, try to rotate your pelvis. • Do not flex your low back further after your pelvis has stopped rotating. • If you need to bend more to reach the desired distance, bend your hips and knees instead of flexing your low back beyond the rotation of your pelvis. • At the end of the forward bend, relax your low back.

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pondylolisthes is to move into segmental anterior trans la­ n of the affected spinal level during level II of the supine ler core progression (see Self Management 18-1) can ex­ rbate symptoms related to the spine pathology. Atten­ n to posture and movement during all exercises pre­ ribed enhances their effectiveness. The ultimate goal of each individual seeking treatment to achieve a desired functional outcome. This involves . I in total-body posture and movement patterns that use ti mal stabilization and dynamic recruitment patterns. "i entire therapeutic exercise intervention plan is geared ward this final goal. To achieve skill in posture and move­ lent , the individual must pay close attention to precision : move ment during speCific fun ctional exercises (e .g. , heel :ides to improve bed mobility skills ), during ADLs (e.g., Juatting maneuve rs), and during IADLs (e .g., playing _ lO. The clinician should teach or "coach" the patient in roper stabilization and movement strategies usin g the undation of neuromuscular control, muscle perfor­ nce, mobili ty, and proprioception that the impairment­ ed exercises have provided . Aspects of posture and movement retraining can be in­ rporated into any stage of rehabilitation. Training begins

by splitting complex movements into a numbe r of simple component sequences. The choice of activity is de termined by the functional require ments of the individual. At each progreSSion of the program, 1110re advanced posture and movement strategies are introduced. For example, an in­ troductory postural strategy may be to teach the individual to sit properly in an e rgonomic chair. Later, the patient may be progressed to sitting in a standard ch air or on a soft surface such as a gym b all. The follmving are examples of moveme nt patterns used in ADLs that require education and training in proper performance: 1. 2. 3. 4. 5.

Simple bed mobility and sit-tn-stand transfers Small bends and squatting milne UVe rs Gait (Fig. 18-27A ) ilnd stair stepping (Fig. 18-27B ) Occupational activities, such as lifting mechanics Recreational activities, such as baseball (Fig. 18-28 )

The 1110re advanced the move ment pattern, the more the task needs to be broken into Simplified components to ensure that the proper amount of move me nt occurs in the segments where movement is desired and that stabilization occurs where no movem e nt is desired . After skill is achieved at each component, simple movements are linked

388

Therapeutic Exercise Moving Towa rd Function

FIGURE 18-27. Controlled mobility and skill must be reinforced at the lumbar spine about al l planes of motio n and during all phases of gait. A few of the critical aspects necessary to reduce stress or compensatory lumbar movements include (A) hip extension duri ng terminal sta nce, thoracic rotation during swing, and hip abductor stabilization during initia l contact and loadi ng. During svving phase, the inner core must contract to form a sta­ ble base to prevent lumbar extens ion or rotation. During stance phase, hip abductor muscles must contract to prevent lateral pelvic tilt. Generally, the trunk muscles, and especially the inner core, must work to prevent com­ pensatory spinal sagittal, transverse, or fro ntal plane movements. (8) Stability is necessary in the lumbar spine fo r proper execution of a step-up. During the swing phase of the step-up, the inner core muscles contract to cre­ ate a stable base for efficient hip flexor contraction. During the stance phase of gait, hip abductor muscles con­ tract to prevent lateral pelvic tilt. Inner core muscles again contract to provide a stable base for hip and knee musculature.

FIGURE 18-28. Skill is required for performing a b.aseba ll throw. Duri ng transverse plane movements, th e emphasis shou ld be on motion at the hips and thoracic spi ne. Du ring sagittal-plane movements, emphasis should be on hip and knee mOlion

together to form the total activity sequence. Teaching ski=:. in movement requires high levels of motivation and com­ pliance from the patient and in-depth knowledge of cor. · cepts of motor learning and movement analysis by the clir ician. Chapter 9 further addresses exercise prescription fl the treatment of posture and movement impairments. Specific exercises may be linked together in a circlli.­ training format. Examples of functional circuits include lift­ ing circuits to retrain occupational functional outcomes an sport- or technique-specific circuits to retrain recreationa. activity functional outcomes. The lifting circuit may include a variety of manual handling procedures, such as single- am.. double-handed lifts with a variety of different shapes an; weights, pushing and p ulling activities, and reaching to hje: and low levels. A sport-specific circuit for soccer, for exarr. . pIe, may include trapping, passing, dlibbling, and shoobu _ skills. With each movement, the aim is to maintain spina. stability dttring extremity motions so that the moveme patterns become automatic or reach skill level. Almost any piece of equipment, whether designed for specific exercise, sport, or work activity, can be adapted fit the prinCiples of 11lmbopelvic functional movement re­ training. Only imagination limits the exercise program after the principles are understood. Exercises can be adapted meet the demands of the patient's work and recreation The clinician must be careful not to progress the patie

Chapter 18: Therapeutic Exercise for the Lumbopelvic Region

389

faster than he or she can learn to control motion with the optimal strategies. Diligence displayed by the patient and clinician is rewarded with fewer setbacks and higher gains n functional return.

pain felt in disk herniation . Clinically, disk herniation can be divided into the following subsets:

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON DIAGNOSES

H:\'P without neurologiC deficit has signs and symptoms similar to those of an annular tear but is slower to recover and imparts slightly more disability. No encroachment on the nerve root has occurred with this condition. HNP vvith nerve root irritation has signs and symptoms, including sci­ atica, paresthesias , and positive SLR, but no neurologiC deficit is diagnosed. HNP with nerve root compression has signs of nerve root irritation plus neuroconductivity changes. A massive midline disk herniation may cause spinal cord or cauda equina compression, requiring imme­ diate surgical referral. Fortunately, the cauda equina syn­ drome occurs in only 1% to 2% of all lumbar disk hernia­ tions that result in surgery. 176

The following section discusses three of the most common Jiagnoses of the lumbopelvic fE'gion. Although SIJ syn­ ome is not discussed, it should be evaluated and treated _:ombining concepts related to both the lumbopelvic region d hip joint (see Chapter 20). The reader is challenged to velop a comprehensive lumbo-pelvic-hip therapeutic ex­ rcise prescription for each individual SIJ syndrome pa­ nt encountered.

mbar Disk Herniation

• HNP with ou t neurologiC deficit • HNP with nerve root irritation • HNP with nerve root compression

The peak incidence of herniated lumbar disks is in adults

Examination and Evaluation Findings

I:\veen the ages of 30 and 55 years. 176 Disk herniation i thout trauma can be thought of as one factor in a contin­ 1m of the spinal degenerative process. The degenerative rocess can progress from minor muscular or soft-tissue in­ ries to abnormal spinal biomechanics, vvhich ultimately break down the underlying jOint structure and create et arthritis, disk degeneration, herniated disk, spinal - nosis, neurologic entrapment, and severe permanent ability177 A patient who suffers a spinal annular tear uld develop sp inal stenosis 10 years later. The primary of therapists involved in the treatment of lumbopelvic lldromes is to assist in the diagnostic process early, treat ~ sources (if known ) and causes of dysfunction appropri­ eh', and prevent severe pathologic conditions from devel­ . mg. Unfortunately, the initial low back injury is often II ht of as a benign muscular or ligamentous injury and not heralded as the first sign of a process that can lead to ere pathoanatomy and disability. The beginning of the degenerative process is an annu­ tear resulting in a disk protrusion or annular bulge. 'ith a disk protrusion, the :\P does not herniate from the k it is confined by the annular fibers. This may be the ieal "back sprain" that res ults from be nding, lifting, d frequent twisting. It often gives a person LBP with e or no pain radiation into the legs. The pain is usually lieved quite rapidly with rest or curtailment of most nding or lifting activities for several days. Patients are 'Ualiy fairly comfortable when on their feet, but when y change from a lying to a sitting position or from sit­ g to standing, the pain can be acute and disable them m fully standing. The probable cause of the pain is flexion or torsion forces imposed on the disk during ese movements. These episodes, if not treated appro­ riately, can recur and become more frequent as time :,rogresses. Eventually, they can lead to the more dis­ ling disk herniation. If the annular tear progresses to full annular disruption , HNP results. Penetration of the nuclear material into pe­ ._ heral areas that are highly sensitive to mechanical and emical stimulation may be the source of the disabling

Sciatica is a symptom of nerve root irritation that could be caused by a HNP. Sciatica is defined as a sharp or burning pain radiating dowu the posteri or or lateral aspect of tl1e leg, usually to the foot or ankle, often associated with Dumbness or paresthesia. Coughing, sneezing, or the Val­ salva maneuver often aggravates the pain. Sciatica caused by disk herniation is worsened by prolonged sitting and im­ proved by walkin~, lying supine, lying prone, or sitting in a reclined position. 2 The absence of sciatica makes a clini­ cally impOltant lumbar disk herniation unlikely. 1 76. 1 7~- 1 1l1 The estimated incidence of disk herniation in a patient without sciatica is 1 in 1,000. 12 The SLR test can be used as a factor in diagnOSing a HNP. A symptomatic disk hemiation tethers the affected nerve root. Pain results from stretching the nerve by straight-leg raising from the supine or sitting position. In the supine SLR test, tensioll is transmitted to the nerve roots after the leg is raised beyond 30 degrees, but after 70 degrees , fllrther movement of the nerve is negligi­ ble 1S :2. A typical SLR sign is one that reproduces the pa­ tient's sciatica between 30 and 60 de frees of eleva­ · 176.IH3 ,184 "fh e Iower th e ang Ie prod ' .. t Ion. ucmg a positive result, the more speCific the test becomes, and the larger is the disk protruSion found at surgery185.186 Care must be taken to differentiate hamstring tension from sciatica. Sensitizing techniques (e.g., neck fle xion, ankle dorsi­ flexion) can be used to determine whether the pain expe­ rienced is originating from hamstring tension or nerve irritation. Straight-leg raising is most appropriate for testing the lower lumbar nerve roots (L5 and 51), where most herni­ ated disks occur176 Irritation of higher lumbar roots is tested with femoral nerve stretch (i.e., flexion of the knee with the patient prone). About 98% of clinically important lumbar disk hernia­ tions occur at the L4-L5 or LS-Sl intervertebral level,176,186,187 causing neurolOgiC impairments in the mo­ tor and sensory regions of the LS and 51 nerve roots. The most common neurolOgiC impairments are weakness of the ankle and great toe dorsiflexors (LS ) or ankle and foot plan­

390

Therapeutic Exercise Moving Toward Function

tar flexors (Sl), diminished ankle reflexes (Sl), and sensory loss in the feet (L5 and Sl) .17A.l R6 .lH7 In a patient with sciat­ ica and suspected disk herniation , the nemolog1c examina­ tion can be concentrated on these functions. Among pa­ tients with LBP alone (no sciatica or neurologic symptoms), the prevalence of neurologic impairments is so low that ex­ tensive neurologic evaluation is usually unnecessary. J 2 Higher lumbar nerve r_~ots ac~ount for only about 2% of lumbar disk herniations. J I b . lilh . l·~ I They are suspected when numbness or pain involves the anterior thigh more promi­ nently than the calf. Testing inc:ludes patellar tendon . re­ flexes , quadriceps strength, and psoas strengthy6 . ISbJf)~ Quadriceps weakness is virtually always associated with im­ pairment in the patellar tendon reflex . J S~ The most consistent finding ,vith a low lumbar midline disk herniation, calrled cauda equina syndrome, is urinaJY retention.12> 190-19~ Unilateral or bilateral sciatica, sensOlY and motor defieits, sexual dysfunction (i.e., decreased sen­ sation during ]ntcreourse, decreased penile se nsation and impotence), and abnormal SLR also are common examina­ tion findings.190-192 The most common sensOJY deficit (i.e., hyperesthesia or anesthesia) occurs over the buttocks, pos­ terosuperior thighs, and perineal regions. lD O--192 Finally, de­ creased anal sphincter tone can be a neurolo&iC sequelae of cauda equina syndrome .I!'lO Kostuik et al. lD warns that a central disk lesion, especially at the L5-S1 disk, can pose a diagnostic challenge because it affects only the lower sacral roots and causes no motor or reflex changes in the legs. There is a growing consensus that plain roentgenograms are unnecessary for every patie nt \vitl1 LBP because of a low yield of useful flndings, potentially misleading results, substantial gonadal irradiation , and common inte rpretive disagreements. 12 The Quehec Task Force on Spinal Disor­ ders suggests that early roentgenography is necessary only under the follOWing conditions: • • • • •

Neurologic deficits Patient older than 50 or younger than 20 years of age Fever Trauma Signs of neoplasm 193

Magnetic resonance imaging and computed tomogra­ phy can be used e ven more selectively, usually for surgical planning. 12 The finding of herniated disks and spinal steno­ sis in many asymptomatic individuals 19'U ~5 indicates that imaging results alone can be misleading. Valid decision­ making requires correlation with a comprehensive history and physical examination.

Treatment There is no recipe approach toward the exercise manage­ ment of LBP, even if u specific structural diagnosis, such as HNP \vith nerve root irritation , is offe red. Determining which interventions to use depends on diagnostic informa­ tion regarding the pathoanatomic process and the phYSio­ logic impairments contributing to the pathomechanical process and on the psychologic impairments, patient dis­ ability proffle, and desired functional outcomes. The fol­ 10vving concepts of care for speCific stages of disk hernia­ tion can guide management of the degenerative disk process.

Acute Stage In the acute stages of any injury, the immediate goals ar often to relieve pain and to reduce or halt the inflammatoI! process so that the healing process can occur unimpeded. Early intervention and patient adherence to the recom­ mendations addressing pain and inflammation in the case of HNP are essential for achieving a rapid recovery and for preventing chronic pain and disability. Along with physical therapy intervention, the patient' physician usually prescribes steroidal or nonsteroidal anti­ inflammatory medications and may suggest epidural steroid injection. The use of epidural steroid injection, performed by experienced physicians who have shown competence ie the technical aspects of this procedure, has produced favor­ able outcomes, particularly if used in conjunction ,vith ph)'''­ ical therapy. J96 . Controlled rest is often recommended and may take tht­ form of posture and activity modification (i.e., avoidance 0 flexed postures, sitting, and bending or lifting activities) 0 local support (e.g., corset, abdominal binder, tape). It is im­ portant to teach the patient to avoid flexed and asymmet . postures , flexion and rotation movements , and sittin _ (which elevates disk pressures ) to enhance healing an prevent reinjury to the healing disk. The clinician also car teach the patient how to use clyotherapy at home to conb-, inflammation. Traction also may be beneficial to relie\ nerve root compression and radiculopathy or paresthesi; in the acute phase (see the Adjunctive Intervention section). Exercise can playa vital role in the treatment of pain an inflammation. For example, careful prescription of exer· cises based on the McKenzie diagnostic classification S\ tem may be useful in the early treatment of disk-relat, signs and symptoms (See Examination and Evaluatio Range of Motion, Muscle Length, and JOint Mobility a Therapeutic Exercise Intervention for Common Physi. ~ logiC Impairments: Pain and Self-Management 18_7).lGLl As with any mechanically induced injury, the cause. muscle or soft-tissue injury must be avoided. In the acu phase of disk he rniation , it is often difficult to determiI' the postures and movements associated vvith segment dysfunction. However, it is useful to teach the patient b . movements such as supine heel sHdes (see Self-Mana!:, . ment 18-1) and bent knee fall-outs (see Self-Manageme 18-3) to assist with bed mobility and transfers. In the acute phase of disk herniation , the patient is ofte susceptible to the effects of immobilization as a result . the protective nature of this phase of care. Treatment · maintain or improve mobility of adjacent segments with the lum bar spine and thoracic spine and the extensibiUty , lower extremity muscles is vital for redUCing stress on th injured segment and reducing the effects of immobilizati that may playa role in recurrence of the condition. For e~­ ample, joint mobilization of the thoracic spine and se;­ ments above and below the affected segmental level, alon ~ with soft-tissue mobilization of the erector spinae groul can maintain joint mobility during the acute phase. Pir ­ formis spasm is a common secondalY effect of lower lu n: ­ bar disk herniation. Soft-tissue mobilization and passh stretching to this muscle can decrease pain associated wit the spasm.

Chapter 18 Therapeutic Exercise forthe Lumbopelvic Region

Treatment to maintain or improve mobility in the neu­

ral tissues also is critical in the acute stages. Adverse neural tension is a common sequela of HNP. It can affect muscle performance and lumbopelvic mobility. Neuromeningeal mobility should be assessed and its influence determined. pecific exercises may be prescribed that are designed to improve mobility of the neural system (see Self-Manage­ ment 18-6). Initially, tolerance is usually very low, and neu­ omeningeal mobility exercises must be performed with caution, usually in recumbent positions to prevent exacer­ . ting symptoms. Neuromeningeal mobility exercises per­ ormed during the acute stage may prevent chronic com­ plications from increased neural tension. The related .anatomy, phYSiology, and application prinCiples must be 'ell understood for the effective and safe use of this type of treatment. This topic is worthy of more extensive cover­ O'e; further gUidance in ~rescribing these exercises has been provided by Butler 1 2 The clinician should encourage the patien t to maintain me activity level, such as sv,rjmming or walking, during the acute stage. Swimming can be employed v,rjth the use f a kick board to minimize unwanted spinal motion while romoting aerobic fitness and lower extremity motion. " alking with a corset, wearing good shock-absorbing oes, and walking on a soft surface (e.g., gravel) may re­ uce disk pressure enough to tolerate the stress of walking. n addition to the benefits of movement, the benefits of v-level aerobic exercise are gained. Subacute and Chronic Stages

\fter the acute pain has subsided and the patient has more 'reedom of movement, the treatment should focus on tering postures and movements and the associated im­ oairments that produce symptoms. The ultimate goal is the -('turn to the highest possible level of function with the .Jest and most desirable postures and movement patterns IOssible. Review the sections on treatment of impairments to un­ rstand the concept of exercise intervention for mobility, uscle performance, balance, coordination, posture, and ovement impairments and the progression through tradi­ nal stages of motor control. This information prOvides basis for developing a progressive program of interven­ 'on for a patient with disk pathology beyond the acute ages of care. Education is considered to be the most impoltant inter­ ~n tion to prOVide the patient with troubleshooting and de­ . ion-making tools to protect against developing chronic , ability experienced by many persons with disk disease. The patient must be taught self-management techniques to :-ain control over the pathology and remain les s reliant on the health care system for ongOing treatment. The clinician -nust teach the patient to temporarily manage acute exac­ erbations \vith cryotherapy, positional techniques, or re­ peated shift correction and extension movements 162 In­ truction in body mechanics, ergonomics, and ongOing tness activities are equally important in preventing recur­ rence. Evaluation of the home and work environment, work-station ergonomics, and the development of fitness programs are preventive strategies the clinician may imple­ ment. Perhaps the most important outcome of patient ed­

391

ucation is the sense of confidence gained by the realization that back problems can be managed while the patient con­ tinues to function and lead a productive life.

Spinal Stenosis Spinal stenosis is defined as an abnormal narrowing of the spinal canal (cen tral) or the intervertebral foramen (lat­ eral).197 Central stenosis can result from osteophyte en­ largemen t of the inferior articular process or vertebral bod­ ies , congenitally decreased anteroposterior or mediolateral diameters of the spinal canal, hypeltrophy of the ligamen­ tum flavum, spondylolisthesis, or neoplasm that impinges on the cauda equina. Lateral stenosis is typically caused by subluxation of the facets as a result of disk narrov,rjng. Ex­ tension and rotation positional faults of the segment pro­ duce further narrowing. Symptoms are usually segmental because of entrapment of the nerve root.

Examination and Evaluation Findings The characteristic history of persons with spinal stenosis is that of neurogenic claudication (j.e., pain in the legs) and, occasionally, neurologiC deficits that occur after walking. In contrast to arterial ischemic claudication, neurogenic claudication can occur on standing (v,rjthout ambulation), may increase with cough or sneeze, is associated with nor­ mal arterial pulses,190 and is relieved by flexion of the lumbar spine, One often-used test to discriminate be­ tween ischemic and neurogeniC claudication is stationary biking. The patient is positioned in lumbar flexion and asked to pedal. This test will likely reproduce symptoms if the source is ischemic claudication, whereas with the spine positioned in flexion, neurogenic claudication is less likely . Increased pain on spine extension is typical of stenosis. Although flexion is usually painful with herniated disks, it can be a position of relief for patients "rjth spinal stenosis. Patients feel more comfortable walking in a stooped posi­ tion , cycling, walking behind a shopping cart or lawn mower, or walking up an incline or stairs, rather than walking on a flat surface, down an incline, or down­ stairsYlg,200

Treatment Treatment of spinal stenosis is based on symptoms related to postures and movements. If the patient has mild symp­ toms that fluctuate \\rjth mechanical, postural, and move­ ment changes, he or she can be accommodated \\rjth ap­ propriate patient-related education, exe rcise, external lumbar support, (i.e. corset), and nonsteroidal anti-inflam­ matory medication. Although nonoperative measures can­ not reverse a true anatomic impairment, they can accom­ modate it by increasing the foraminal or spinal canal diameter. Exercise should focus on phYSiologiC impairments that may contribute to foraminal or spinal canal narro"rjng: • Poor muscle performance from the inner core (TrA, LM , and pelvic floor) resulting in insufficient SUppOlt to the lumbar spine

392

Therapeutic Exercise: Moving Towa rd Function

Limited ambulation is a frequent functionallimitatio among patients with spinal stenosis. Harness-support treadmill ambulation or use of crutches for patients \\i leg pain brought on by walking can be used as a progressh return to walking without symptoms. The amount of u loaded force can be progressed until unloading force i longer required to relieve pain during ambulation. 201 Patients should be instructed in recreational activiti th at do not produce symptoms. Exercise biased towa: fl exion should be encouraged, such as walking on a tre. mill v.rith a slight incline, cycling, or walking while pushit _ a stroller. Exercise biased toward extension should be . couraged, such as walking on a flat surface, walking do hill , or swimming.

• Short hip flexors contribu ting to ante rior pelvic tilt and lumbar lordosis • Thoracic kyphosis with overstretched and weak tho­ racic erector spinae accompanying lumbar lordosis • Asymmetry of pelvic girdle and 10'vver extremity mus­ cle length and strength resulting in lumbar scoliosis and lateral foramin al narro'vving Canal or fOl-aminal narrOwing is typically associated \vith spine extension, combined extension and rotation, or ante­ rior translation. Postures associated \vith relative extension (i.e., kyphOSiS and lordosis), combined extension and rota­ tion (j.e., kyphOSiS and lordosis and limb length discrep­ ancy) , or anterior translatio n (i.e., swayback) should be avoided, and the patient should be instructed in postural

correction to remedy these postural habits.

The clinician should teach the patient to avoid move­

ment patterns that require repeated extension, rotation, or shearing and to develop control over th ese fo rces when un­ avoidable. For example, a common movement that repro­ duces symptoms in patients with spinal ste nosis is the re­ turn from forward be nd resulting from the exte nsion forces placed on the spine. To reduce the extens ion forces , the pa­ tient should be taught to lead with hip extension and re­ cruit hip extensors to return from a fonvard-bending posi­ tion and, at the e nd of the extension cycle, to recruit abdominal muscles to avoid late lumbar extension (Fig. 1829B ) or anterior pelvic shift (Fig. 18-29C).

Spondylolysis and Spondylolisthesis Spondylolysis , a bilateral defect in the pars interarti occurs in 58% of adults.zo2 Approxi mately 50% of never progress to any degree of spondylolisthesis, a co tion of fonvard subluxation of the body of one veliebrat­ the verte brae below it. 202 Spondylolisthesis is not limit any specific segment of the spine. However, it occurs I commonly at the L5-S1 segmental level, primarily bee of the angulation of the L5 segment with respect to th tical plane. De fects or impairment of any of the support' structures can lead to subluxation of the superior seg

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II tension. (A) Depicts proper simu ltaneous resumption of the lumba r curve with pelvic rotation. The pelvic rotation leads the reextension phase. followed by lumbar exten­ sion after ful l pelvic rotation to neutral has been achieved. The result is neutral pelvic position and a normal lumbar B extension curve. (8) Ea rly lumbar extens io nwithout pe lvic rotation creates an extension moment on the spine. The pelvis does not achieve neutral on standing, resulting in lumbar lordosis. Thispattern should be avoidedin an indi­ vidual with stenosis or spondyloli sthesis. (e) Another fau lty re extension strategy, often used by the individual II with a swayback posture. At the end of the range, the IIII 1/ pelvis excessively posteriorly rotates and sways fo rwa rd, imposing an anterior translation moment on the lumbar spi ne, which shou ld be avoided in an individual with stenosis or spondylolisthesis. [Adapted from Calliet R.

c Low Back Pain . 3rd Ed. Phi ladelphia FA Davis. 1981.)

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Chapter 18 Therapeutic Exercise for the Lumbopelvic Region

393

n the inferior segment. Spondylolisthesis has been classi­ fieJ 203 by cause into five types: l. Type I, isthmic: A defect in the pars interarticularis

may be caused by a fracture or by an elongation of the pars without separation. 2. Type II, congenital: The posterior elements are anatomically inadequate because of developmental deficiency. This occurs rarely. 3. Type III, degenerative: The facets or the supporting ligaments undergo degenerative changes, allowing listhesis . There is no pars defect, and the condition worsens with age. 4. Type IV, elongated pedicle: The length of the neural arch elongates to allow listhesis. This is essentially an isthmic type. Traction forces are apparently contributory. o. Type V, destructive disease: Metastatic disease, tu­ berculosis, or other bone disease may change the structure of the supporting tissues.

Examination and Evaluation Findings ~h e

patient may complain of backache, gluteal pain, lower mb pain or paresthesias, hyperesthesia, muscle weakness, tennittent claudication , or bladder and rectal distur­ .ances. The physical examination may reveal that symp­ ms worsen on return from forward bending that is ac­ mpanied by lumbar extension. If the patient is cued to - d with the gluteal musculature and recruit the inner re, symptoms are reduced. The clinical diagnosis is sus­ cted if this finding is accompanied by inspection and pal­ tion of the spine in which a depression at the listhesis vel is noticed. Percussion over the segment may elicit "'
-reatment creneral, treatment of spondylolysis or spondylolisthesis nonsurgicaP9 Treatments include bracing, exercise, and nsteroidal anti-inflammatory medications. In children d adolescents , immobilization in a thoracolumbosacral race, activity modification, and exercise e;-,:pedite healing f the defect. 204 ,20.') Exercise, posture and movement retraining, and activity odification are the cornerstones of the rehabilitation pro­ :ram. As for the patient with spinal stenosis, lumbar exten­ on and shearing forces should be avoided. Exercises fo­ used on resolving the impairments associated with 'tension or shearing forces should be prescribed, and rang emphasis should be placed on inner core strength­ rung and posture and movement retraining. Figure 18-30 - a good position to activate the inner core without the an­ - rior force from the hip flexors as in Self-Management 18­ 1. Self-Management 18-2: Inner Core Series can prOvide milial exercises to stimulate the stability necessary for re­ very from spondylolisthesis. If a brace is used in con­ _unction with physical therapy, the physical therapist hould communicate \vith the physician regarding the pre­ cribed immobilization period and weaning program. Most often , the patient can continue to participate in sports dur-

FIGURE 18-30. Sitting posterior pelvic tilt. This activity can be used by in­

dividuals with lordosis. anterior pelvic tilt, weak and overstretched ab­ dominal muscles (particularly external oblique and transversus abdominis). and short hip flexors , The supine inner core progression is often con­ traindicated for this type of patient due to the anterior translation force ex­ erted by the iliopsoas and anterior pelvic ti lt force exerted by the TFL and rectus femoris. The patient sits with her back against a wall and is in­ structed to pull the umbilicus toward the spine to reduce the lordosis, Sit­ ting takes the stretch off the hip flexors , and the pelvis should be able to move posteriorly with greater ease than in standing with the hip flexors on relative stretch, Use of a gluteal contraction over an abdominal contraction is discouraged This exercise can be progressed to standing in slight hip and knee flexion (to release tension on the hip flexors) and then to stand­ ing upright once the abdominal muscles are strong enough and the hip flexor muscles are of sufficient length to attain a neutral pelvic position The advantage of this exercise is that it can be performed frequently throughout the day.

ing the immobilization period and is encouraged to do so, However, activity modification also may be advised. Activ­ ities such as volleyball and gymnastics are associated \vith Significant extension movements and shearing forces im­ posed on the lumbar spine. If movement patterns cannot be modified enough to reduce symptoms dUling these ac­ tivities, the patient may need to be counseled to seek an­ other form of recreation or athletic endeavor.

ADJUNCTIVE INTERVENTIONS Bracing Some form of motion restriction for excessive motion at a segmental level may be necessary in patients with hil'e r= mobility or instability in the lumbopelvic region,20 ,2(l, Bracing is indicated when exercise alone, used to improve segmental stability and relative flexibility, has failed to pro­ duce a desirable functional outcome. Support proVided to the segmental levels with proper braCing can improve stiffness locally and encourage move­ ment at segments requiring more relative mobility. For ex­ ample, use of a lumbosacral corset can stabilize the lum­ bosacral region while promoting movement in the hips . Bracing theoretically should be able to improve length-ten­ sion relationships in affected trunk and pelviC girdle mus­ culature, For example, overstretched abdominal muscula­ ture that often accompanies lumbar lordosis and anterior

394

Therapeutic Exercise Moving Toward Function

pelvic tilt is supported in the short range in a properly fit­ ting lumbar support. With consistent use of a properly fit­ ting support over time , the overstretched musculature may adaptively shorten. If accompanied by exercise, improved muscle performance by the overstretched musculature may occur at a faste r rate than ,vith exercise or bracing alone. If the lumbar support stabilizes the spine during functional movement, it also can encourage movement across the hip joints in the desired directions, which can affect the extensibility of tissues surrounding the pelvic girdle. Bracing is intended as an adjunctive measure to a comprehensive approach to the treatment of lumbopelvic syndromes. The choice of brace depends on the region re­ quiring motion restriction (i.e. , upper lumbar, lum­ bosacral, or sacroiliac region ) and the amount of immobi­ lization required (i.e., abdominal binder for minim al support to the abdomen versus a thoracolumbosacral corset with rigid stays for maximal support). The clinician must encourage the patient to continue with appropriate levels of function al activity and prescribed exercise while using the brace to improve strength , endurance, and mo­ bility impairments and to prevent th e undesirable effects of immobilization.

Traction Lumbar traction is the application of forces to stretch the periarticular tissues and mus culature ,41.206,207 decrease compressive forces and thus circulatory compromise to neural structures,20o; reduce intradiskal pressure,209,210 and retract herniated disk material.206.211 It is indicated when decompressive forces reduce symptoms and the patient is unable to provide sufficient support to the spinal segments to prevent onset of symptoms with postural changes, self­ administered unloading techniques, or exercise. In this light, it is considered adjunctive to a comprehensive exer­ cise program. Traction can be applied to the lumbar spine manually or mechanically; in supine, prone, or inverted position; in dif­ ferent degrees of trunk flexion or extension; and using a con­ ventional or split table .149 When lumbar traction is applied, the movement that occurs at the spinal segments is thought to be a combination of distraction of the vertebral bodies and gliding of facet joint surfaces. Results of research on traction use and effectiveness is mixed, but numerous au­ tllOrities claim traction is an effective and beneficial method of treatment when used appropriately.170,206,211-215 Otl1ers have shown poor results with treatment or found that the positive effects of traction were of limited or marginal value. 216,2 17 Results of these studies must be considered ju­ diCiously, because most have studied traction as an isolated treatment. This puts unrealistic demands on a Single treat­ ment modality. Traction is intended as an adjunctive inter­ vention to a total plan of care, including patient-related ed­ ucation and exercise instruction. Research that examines the use of traction in conjunction with a well-planned treat­ ment regimen would help in defining the effectiveness of this form of treatment. The type of lumbar traction used and the parameters of use can contribute to a rapid functional outcome, The types

of lumbar traction include continuous, manual, positional, mechanical, and graVity-aSSisted. Autotraction is another type that h as been useful in the treatment of acute LBP.21 With this technique, the patient lies on an adjustable table and grasps bars at the head of the table, A traction belt is applied to the pelvis. Traction is performed by the patient pulling ,vith the anns or pushing with the legs, allOWing constant control of the force applied. The table can be ma­ nipulated three-dimensionally and moved from horizontal to vertical. The choice of which type of traction device to use i based on a thorough understanding of the phYSiolOgiC ef­ fects of each type of traction coupled with the speCific im­ pairments related to the patient's condition. Several pa­ rameters can be controlled ,vith traction . The degree to which these can be modulated depends on the type of trac­ tion being used. Generally, a benefit of mechanical traction is that it has the most variables that can be manipulated. However, it must be performed in a clinical setting. Home traction (a form of mechanical traction ) and positional trac­ tion do not have the benefit of manipulating several vari­ ables for the best patient prescription, but they can be per­ formed independently at home. Ideally, research should guide the type of treatment Se ­ lected for given patient conditions. Unfortunately, few data are available to help clinicians select treatment parameter and it is necessary to rely on theoretical arguments for parameter selection, tempered by common sense and clin­ ical experience. Theoretical arguments regarding type 0 traction , intenSity, patient position, direction of pull treatment duration, and unilateral versus bilateral tractio have been prOvided by Saunders.21g Table 18-8 prOvides guidelines for selecting treatment parameters for four clin ­ ical conditions.

Traction Treatment Parameters DIAGNOSIS HNP

DDD/DJD

Hypom obility Limited Flexion Limited Extension Facet Impingement

PATIENT/STRAP POSITION

TYPE OF TRACTION

DURATION

Prone/ anterior pull Supine/ posterior pull; Prone/ anterior pull

Sustained

8-10 min

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10-15 miI:

Supine/ posterior pull Prone/ anterior pull Patient comfort! unilateral pull

Intermittent

10-15 min

Intermittent

10-15 min

Sustained or Intermittent

10-15 mill

Chapter 1B Therapeutic Exerci se for the Lumbopelvic Region

KEY POINTS • A thorough understanding of the anatomy and biome­ chanics of the lumbopelvic region is prerequisite to ap­ propriate therapeutic exercise prescription for this re­ Mon. Exercise must be based on a thoughtful and systematic examination process identifying the physiologic and psy­ chologic impairm ents most closely related to the indi­ vidual's functional limitations and disability. Therapeutic exercise intervention for cornmon physio­ logic impairments must be coordinated to address as­ sociated impairments and plioritized to address those most closely related to functional limitations and dis­ ability. Exercise management of common pathoanatomic diag­ nos es must not follow a recipe approach, but rather re­ I te to the patient's unique impairments, func tional lim­ itations, and disability.

LAB ACTIVITIES 1. Pick up two loads of equal weight but diffe rent sizes . Which is easier to pick up , th e larger or smaller size? 2. Analyze your partner's osteokinematic motions and muscle activity across the lumbar-pelvic-hip com­ plex during each phase of gait about all three planes of motion. How does your partner deviate from the standard? :3. Analyze your paltn er's LPR. Howwould you retrain the pattern if th e lumbar spine was relatively Jllore flexible in the flexion phase? How would you retrain the pattern if the lumbar spine was re lative ly more Hexible in the extension phase? 4. Teach your partner how to activate the inner core. Be sure to palpate the LM and TrA to ensure acti­ vation at the proper level. Teach you partner how to incorporate the inner core activation into the supine inner core progression and inner core series. \Vhat is the difference be r-veen level III and IV of the supine inner core progress ion? Instruct your part­ ner to perform level II of the supine inner core pro­ gression on a half or full foam roll. Is it Jllore or less difficult on a foam roll? .:J. On your paltner, pe rform manual resistance to the lumbar multifidus in sidelying. Can you palpate ac­ tivity of the lumbar multifidus at the L5 level'? 6. Analyze your partner performing bent-knee and straight-leg sit-ups. Does your partner require fixa­ tion of his or her feet during the hip-flexion phase of the bent-kn ee or straight-leg sit-up? During a straight-leg sit-up, how man)' sit-ups can your part­ ner perform with arms straight be fore his or her feet lift up (or lift earlier in the range)'? Arms crossed across the chest'? Arms behind the head? What does lifting of the feet or li fting prematurely indicate'?

395

CRITICAL THINKING QUESTIONS 1. Prioritize postures from the most to the least stress­ ful on the lumbar spine . 2. Describe the principles fo r the use of optimal body mechanics during lifting. 3 . D escribe the biomechanical diff!:'rences ber-veen the bent-knee and straight-leg sit-up. What would be the best abdominal exercise for an individual with a H)jP? Spinal stenosis or spondylolisthesis? How would you modify the sit-up for a person with a kyphosis/lordosis pos ture type? 4. How can exercise impact chemical causes of pain? 5. What postures place the E O in a lengthened posi­ tion , making it susceptible to strain resulting from overstretch? 6. Given the following activities: flexion phase of forward bending, sidelying hip abduction, and seated rotation. Describe the optimal site and direction of relative

I

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7. Teach your partner how to passively stretch the hamstrings and hip flexors without lumbopelvic mo­ tion. Teach your partne r an active movement to stretch these muscles using hip mobility 'vvithout trunk mobility. What muscles must your partner use to stabilize the spine while actively stretching the hip flexors or hamstrings'? 8. Teach your pmtne r to stabilize against extension, flexion , and rotation forces (separately) while sitting on a flat surface <md on a gym ball. \Vhich one is eas­ ier? What would be the effect of sitting on a gym ball with your feet on a slippelY surface (e .g., slide board) while performing upper extremity move­ ments? 9. Teach your partner to stabilize against extension forces in standing on a flat surface and on a half and full foam roll. What type of balance strategy does your partner use (ankles, knees, or hips )? 10. Teach your paltner controlled mobility activities in standing that challe nge the spine to stabilize against Hexion forces, extension forces, and rotation forces . Even though you are encouraging move ment in the lumbar spine, wh ere should most of the movement occur during total-body move ments? 11. Teach your partne r to perfiwm a golf swing with ap­ propriate motion occuning at the ankle-foot com­ plex, knee , hip , pelViS, and spine. \Vhe re in the spine should most of th e rotation occur? 12. Develop and teach your partner an exercise to im­ prove th e coordinated function of the latissimlls and gluteus maximus to improve force closure of the pelvic girdle. (Hint: a step and elastic tubing are useful props. ) \Vhat other muscles are involved in force closure of the SIJ? Are you engaging all mus­ cles at the appropIiate length with the activity you

396

7. 8. 9. 10. 11. 12.

13.

14. 15.

Therapeutic Exercise Moving Toward Function

--~~-----------------------------------------------------------

flexibility during these movements. (Hint: during the return from fonvard bending, the optimal site of rela­ tive flexibility is the hip in the direction of extension versus the lumbar spine in the direction of extension. ) 'What is the conceptual basis for treatment of a rela­ tive flexibility or stiffness problem? Define the anatomic injury that occurs with disk pro­ lapse and the three subsets of disk herniation. Define the three clinical categories of signs and symptoms associated with HNP. Define the broad categOlY of spinal stenosis and the two types of stenosis. Discuss the difference between spondylolysis and spondylolisthesis. What is the common posture and movement that a person with either stenosis or spondylolisthesis should avoid? How would you instruct a patient with stenosis or spondylolisthesis in inner core strengthening? (Hint: you want to avoid forces that produce extension or anterior translation on the lumbar spine. ) Discuss the musculature involved in force closure of the SIJ. Refer to Case Study #5 in Unit 7. a. Based on her history and physical examination findings , what is the likely medical diagnosis for this patient? b. What are the faulty posture and movement pat­ terns associated with onset of her symptoms? c. What are the correlating phYSiologic impair­ ments? List them under the headings used in this chapter (e.g. , mobility, muscle performance). d. Develop an exercise program addressing all perti­ nent impairments related to her functionallimita­ tions and disability. e. Be sure to include patient-related instruction tips.

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Movements, Maneuvers, and Exercises. Stockholm:

Almqvist & \Viksell, 1970.

Ande rsson GBJ, Ortengren R, Nachemson A. Lumbar disc

pressure and myoelectric back muscle activity during sitting.

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Paris SV. Differential diagnosis of lumbar back and pelvic pain. In: Vleeming A, Mooney V, Dorman T , et aI., eds. Movement, Stability & Low Back Pain. New York, NY Churchill Livingstone, 1997. 209. Nachemson A, Elfstrom G. Intradiskal dynamic pressure measurements in the lumbar discs. Scand J Rehabil IvIed 1970;51:10--40. ':10. Bridger RS, Ossey S, Fourie G. Effect oflumbar traction on stature. Spine 1990;1.5:522-524. _11. Gupta R, Romarao S. Epidurognlphy in reduction oflumbar disc prolapse by traction. Arch Phys Med Rehabil 1978; 59:322-327. _12. Crisp E. Discussion on the treatment of backache by trac­ tion. Proc R Soc Med 1955;48:805- 808. _13. Frazer E. The use of traction in backache . Med J Aust 1954; 2:694-697.

401

214. Hood L, Chrisman D. Intermittent pelViC traction in the treatment of the ruptured interveltebral disc. Phys Ther 1968;48:21-30. 215. Matthews JA. DynamiC discography: a study of lumbar trac­ tion. Ann Phys Med 1968;9:275-279. 216. Christie BGB. Discussion on the treatment of backache by traction. Proc R Soc Med 1955;48:811-814. 217. 'Weber H , Ljunggren AE, Walker L. Traction therapy in pa­ tients with hemiated lumbar intervertebral discs. J Oslo City Hosp 1984;34:62-70. 218. Larsson U, Choler U, Lidstrom A, et 31. Autotraction for treatment of lumbago-sciatica: a multicentre controlled in­ vestigation. Acta Orthop Scand 1980;51:791-798. 219. Saunders HD, Beissner KL. Lumbar Traction. LaCrosse, WI: Orthopedic Section, American PhYSical Therapy Asso­ ciation, 1994.

chapter 19

The Pelvic Floor ELIZABETH SHELLY

Review of Anatomy and Kinesiology Skeletal Muscles

Pelvic Diaphragm Muscles

Related Muscles

Pelvic Floor Function

Physiology of Micturition

Anatomic Impairments

Nonrelaxing Puborectalis Syndrome Dyspareunia

Adjunctive Interventions Biofeedback Basic Bladder Training Scar Mobilization Externally Palpating the Pelvic Floor Muscles

Birth Injury

Neurologic Dysfunction

Psychologic Impairments Motivation

Sexual Abuse

Examination/Evaluation Ri sk Factors

Screening Questionnaires

Results of the Internal Examination

Patient Self-Assessment Tests

Therapeutic Exercise Interventions for Common Physiologic Impairments Impaired Muscle Performance Active Pelvic Floor Exercises Pain Joint Mobility and Range of Motion (incl uding muscle length) Impairments Posture Impairment Coordination Impairment

Clinical Classifications of Pelvic Floor Muscle Dysfunction Supportive Dysfunction

Common Impairments

Hypertonia Dysfunction

Incoordination Dysfunction

Visceral Dysfunction

Therapeutic Exercise Intervention for Common Diagnoses Incontinence

Organ Prolapse

Chronic Pelvic Pain

Levator Ani Syndrome

Coccygodynia

Vulvodynia

Vaginismus

PhYSiologic impairments of the gynecologic, urinary, an gastrointestinal systems are often treated with medication or surgery. However, physical therapists have become ir. ­ creasingly involved in the rehabilitation of these patien Pelvic floor muscle (PFM) rehabilitation involves th skeletal muscles located at the base of the abdominal ca\ ity. The pc/dc floor refers collectively to tissues that sp, from the pub ic bone to the coccyx. This area includt­ skeletal muscles under volunta1Y control, which respon to the same training techniques as other skeletal muscl th e body. This chapter introd\lces students to the anatomy and nesiology of the pelvic floor , phYSiology of mictUlition , ar anatomic and physiologic impairments of the pelvic Hoc Management of common phYSiologic impairments of tI pelviC floor, pelvic floor-related diagnoses, and their i pact on other areas of the body are described , and clini applications are provided. All physical therapists should screen patients for pel\ floor impairments and provide basic instruction in stren ening these skeletal muscles. This chapter provides scree ing and evaluation tools that do not require internal vagi& evaluation or surface electromyography (EMG ) of pelvic floor and explains how to teach pelvic floor exercis (PFEs ), which strengthen the PFMs and speCifically dress impaired muscle performance. Arnold Kegel was obstetrician \ovho pioneered PFM strengthening in 1940s. 1 The Kegel (pronounced "kagel") exercise, as i­ commonly known , is a contraction of the PFMs arou nd object, preferably a pressure biofeedback device. Pati often use Kegel exercises and PFE synonymously. T chapter also discusses pelvic pain associated with pe floor impairment. A working knowledge of normal fune of th e 11l1l1bopeivie and hip stmctures is necessaJY to ac, rately treat PFY[ spasm (see Chapters 18 and 20). The the rapis t must know ho\V to evaluate all of . stmctures of the pelvic floor to understand the medical agnoses and treatment interventions for PFM dysfun c"

Chapter 19 The Pelvic Floor

403

.\ complete evaluation of this area often requires intravagi­ nal palpation and surface EMG evaluation, These evalua­ tion skills are usually not considered entry-level skills, Post­ araduate study is recommended for therapists interested in directly treating the PFMs,

REVIEW OF ANATOMY AND KINESIOLOGY The many inconsistencies in labeling the structures of the pelvic floor found in the medical literature can make the study of these mu scles confusing, This section outlines the terminology used by most clinicians, Because most pa­ ·ents with pelvic floor dysfunction are female , female anatomy is discussed in this chapter, but the pelvic di­ aphragm layers and intrapelviC hip rotators are essentially ate same in both sexes.

Puborectalis

Internal anal sphincter

External anal sphincter

Skeletal Muscles The skeletal muscles of the pelvic floor (Fig, 19-1) can be divided into four layers, from superficial to deep: (1) the anal sphincter, (2) superficial pelineal muscles , (3 ) urogen­ ital diaphragm, and (4) the pelvic diaphragm, The anal sphincter (Fig, 19-2) is the most superficial keletal muscle, The anal sphincter includes the internal anal sphincter (i.e" smooth muscle ) and the external anal sphincter (i,e" skeletal muscle) These sphincters fuse su­ periorly 'with the puborectalis component of the pelvic di­ phragm muscle, These three muscles function together to provide fecal continence, Neurologic innervation is pro­ \ided from the fourth sacral nerve and inferior branch of the pudendal nerve , The superficial perineal muscles (Fig, 19-3) aid in sexual functioning of the pelvic floor , and the urogenital di­ aphragm (Fig, 19-4) is part of the continence mechanism.

Pubic symphysis

anal sphincter

Puborectalis

Transverse section

FIGURE 19-2. Anal sphincter,

The three superficial perineal muscles are the bulbocaver­ nosus, the ischiocave rnosus, and the superficial transverse pelineal, The three muscles of the urogenital diaphragm are the urethrovaginal sphincter, the compressor urethrae (formerly known together as the deep transverse perineal), and the sphincter urethrae (Table 19_1),2-4

Pelvic Diaphragm Muscles Coccyx

Pelvic

diaphragm

Anal sphincter

FIGURE 19-1. Pelvic floor muscle layers

Urogenital diaphragm

The pelvic diaphragm (Fig, 19-.5) is the largest muscle group in the pelvic floor and is responsible for most of the function or dysfunction of this area, This layer is divided into the coccygeus muscle and the levator ani muscles, The coccygeus muscle originates at the spine of the is­ chium, inserts on the anterior portion of the coccyx and S4, and is innervated by the ventral rami of sacral nerves 4 and .5, In other mammals, this muscle controls tail movement. In humans , the coccygeus flexes the coccyx and may help stabilize the sacrum through its sacrococ­ cygeal attachments 4 The levator ani muscle is further divided into the iliococ­ cygeus and the pubococcygeus muscles, The iliococcygeus originates from the pubic ramus and arcus tendentious

404

Therapeutic Exercise: Moving Toward Function Round ligament

Pubic symphysis

Urethral meatus

Vaginal ing (Introitus) Bulbocavernosus muscle

Pubic rami ~_);;••. _Ioo....lo,,----

Transverse perineal muscle

Gluteus maximus muscle

FIGURE 19-3. Female pelvic floor muscles- inferior view.

ligament (run extension of the obturator internus fascia) and inseIis onto the coccyx. The pubococcygeus muscle is di­ vided into the pubovaginalis and puborectalis muscles. The pubovaginalis originates at the posterior aspect of the os pubis and inserts on the perineal body and vaginal walls, forming a sling around the vagina. The puborectalis origi.­ nates from the pubic bone and obturator internus fascia and inselis onto the coccyx and lateral walls of the rectum, simi­ larly forming a sling around the rectum. The innervation of the levator ani musdes is from the inferior rectal branch of the pudendal nerve of S2 through S4 and ventral rami of S2 through S4 (Table 19-2). The function of the levator ani muscles is to support the pelvic viscera. The pelvic diaphragm muscles are approximately 70% slow-twitch muscle fib ers (type 1) and 30% fast-twitch muscle fibers (type 2) .2 Both types of muscle fibers have specific functions in the pelviC floor, and a complete exer­ cise program should train both types of muscle fibers. The phYSiology of these muscles is similar to that of other skele­ tal muscles. Sensation in the region is limited and may be decreased with surgery or childbirth. The PFM responds to qUick stretch and has extensive fascia throughout the muscle layers (see Table 19-2). The PFMs contract as a unit to achieve various func­ tions. Impairments can occur in a Single layer or through­ out the entire skeletal muscle layers.

Ischiocavernosus muscle

Anal opening

Pelvic diaphragm

Coccyx

Anal sphincter

internus muscles often contribute to PFM impairmen ts and vice versa. Hip function may need to be considered "vith pelvic floor dysfunction and pelvic floor dysfunction "vith hip dysfunction. The adductor muscle group also may participate in PF !'. f pain syndromes. The muscle originates at the pubic ram and ischial tuberosity, inserts on the posterior femur and medial femoral condyle, and is innervated by the ohturator and sciatic nerves. Adductor fascia at the pubic rami is in close proximity to the superficial perineal muscle fascia. The psoas minor and major muscles originate from ver­ tebral bodies and disks ofT12 through L5 . The iliaeus mus­ cle originates at the medial iliac fossa. Both muscles fuse and travel in an anteroinferior direction under the inguin a: ligament to insert onto the lesser trochanter of the femur The iliopsoas muscle is innervated by the L2 through U spinal nerves. It is a key muscle to treat in lumbopelvic d~'S ­ functions. Travell and Simons 5 call it the hidden prankste~ and stress its importance in pelviC dysfunctions.

Pelvic Floor Function Kegel 7 defined the pelviC floor functions as supporth-e sphincteric, and sexual. The foHowing sections discuss ea of these three functions in detail.

Supportive Function

Related Muscles The piriformis and the obturator intern us (the intrapelviC hip rotators ) are located within the pelvis and can affect the functioll of th e PFMs. The piriform is originates on the an­ telior surface of Sl to S4 (Fig. 19_6). 5,6 Its inferior border is close to the superior border of the coccygeus muscle and it inserts at the greater trochanter of the femur (Fig. 19-7). The obturator internus originates at the inner rim of the obturator foramen and inserts onto the greater trochanter. The levator ani muscles attach to an extension of the obtu­ rator internus fascia (i.e. , the arcus tendinous, also called the white line). This muscle is best envisioned three di­ menSionally. Impairments in length, strength, endurance, and patterns of recruitment of the piriformis and obturator

The pelViC floor provides support to the pelvic organs. D~ ­ Lancey and Richardson 3 stated that normal pelvic or, support is achieved by ligamentous support from above an PF M function from below. They also observed that reco\ ­ ery oforgan support requires attention to restoring ligamen support (i.e. , surgery) and restoring pelviC floor fUllctio (i.e., pelvic floor rehabilitation ). At rest, the PFMs maintair.. a minimal resting tone. The muscle activity increases \vi increased intra-abdominal pressure, The forces of gravi . and increased intra-abdominal pressure (e.g. , laugh, cough sneeze, vomit, lift, strain ) encourage prolapse or protrusio of the pelvic organs. Strong PF~ls help to support tht­ organs against increased intra-abdominal pressure and eo­ hance normal functioning. The supportive function is pri­ marily performed by the tonic, slow-twitch muscle fibers.

s.

t.ir E~

Chapter 19: The Pelvic Floor Vagina

405

not a pathologiC condition. Intervention should be aimed at the impairments that contribute to the syndrome of incontinence.

Sexual Function

com pressor _ ethrae

The vagina has very few sensory nerve fibers s The PFMs provide proprioceptive sensation that contributes to sexual appreCiation. Hypertrophied PFMs provide a siI1aHer vagina and more friction against the penis during intercourse. This results in stimulation of more nerve endings and provides pleasurable sensation during intercourse. Strong pelvic f100r contractions occur during orgasm. Patients with weak PFMs often cannot achieve orgasms. s In men, the PFMs assist in achieving and maintaining an erection.

---+-H7<-f--J..,...-==", """-11'=""

us

" al ~Dh incter

Physiology of Micturition A

Vagina Internal smooth

Pubic symphysis Sphincter urethrae Urethrovaginal sphincter Compressor urethrae

B

AGURE 19·4. Female urogenital diaphragm (A) Inferior view. (B) Side iew. (Schussler B, Laycock J, Norton P, Stanton S, eds. Pelvic Floor Re­ education Principles and Practice. New York Springer-Verlag, 19941.

Sphincteric Function The PFMs provide closure of the urethra and rectum for continence. During normal function, quick closure of the orifices is prOvided by the phaSiC, fast-twitch fibers of the pelvic f100r. Closure during rest (i.e. , static resting tone) is provided by the slow-twitch muscle fibers. Conti­ nence is preserved when the pressure in the urethra (provided by several structures including the PFMs) is higher than the pressure in the bladder. Loss of sphinc­ teric function may lead to incontinence. The medical literature commonly points out that incontinence is a symptom and not a disease; based on the terminology used in this book, incontinence results from impairments,

Micturition refers to the physiolOgiC process of urination and involves a complex set of somatic and autonomic re­ f1exes. An explanation of micturition is provided in Display 19-1. This information is included so the therapist can ex­ plain the basics of normal bladder function to the patient and assist with basic bladder retraining. Urine is produced steadily at about 15 drops per minute. Bladder filling is constant, except in the presence of bladder irritants, which increase urine production . There is always urine in the bladder. Urine continues to collect, and the bladder passively expands until approxi­ mately 150 mL fluid is collected. Stretch receptors in the bladder then Signal the brain that it may be necessary to get to the bathroom soon. This is called the first sensation to void. The detrusor muscle (i.e., muscle of the bladder) remains quiet, and the PFMs maintain normal resting tone. Filling continues until 200 to 300 mL, "vhen a stronger sensation of urgency is felt from increased acti­ vation of stretch receptors The detrusor and PFMs re­ main unchanged. A severe urge to void usually occurs at 400 to 550 mL.
ANATOMIC IMPAIRMENTS Many factors contribute to normal function of the PFMs. Some of these factors cannot be changed by phYSical ther­ apy interventions. The two major causes of anatomic im­ pairments are birth injury and neurologiC dysfunction.

406

Therapeutic Exercise Moving Toward Function

Muscles of the Urogenital Triangle MUSCLE Superficial perineal Bulbocavernosus Ischiocavernosus Superficial transverse perineal Urogenital diaphragm Urethrovaginal sphincter Sphincter urethra Compressor urethra

ORIGIN

INSERTION

INNERVATION

FUNCTION

Corpus cavernosum of the clitoris Ischial tuberosity and pubic rami Ischial tuberosity

Perineal body

Perineal branch of pudendal S2-S4 Pelineal branch of pudendal S2-S4 Perineal branch of pudendalS2-S4

Clitoral erection

Crus of the clitoris Central perineal tendon

Vaginal wall

Urethra

Upper two thirds of urethra Ischiopubic rami

Trigone ring

Perineal branch of pudendalS2-S4 Perineal branch of pudendal S2-S4 Perineal branch of pudendal S2-S4

Urethra

Clitoral erection Stabilizes perineal body Compression of urethra Compression of urethra Compression of urethra

Urethra Pubovaginalis Vagina

Puborectalis

Rectum Coccygeus

lIiococcygeus

Coccyx

FIGURE 19-5. Female pelvic diaphragm-superior view.

Coccygeus Muscle and levator Ani Muscles MUSCLE

ORIGIN

INSERTION

INNERVATION

FUNCTION

Coccygeus muscle Levator ani muscles

Spine of the ischium

Anterior portion of the coccyx and S4

Ventral rami, S4, and S5

Flex the coccyx

Inferior rectal branch of the pudendal nerve, S2-S4, ventral rami, S2-S4

Support of the pelvic viscera, continence mechanism

Pubococcygeus Pubovaginalis Puborectalis

Iliococcygeus

Posterior os pubis Pubic bone, arcus tendineus Pubic rami, arcus tendineus

Perineal body, vaginal walls Anterior coccyx, lateral rectum Coccyx

Compression of the vagina and urethra Compression of the rectum

Chapter 19: The Pelvic Floor

GURE 19-6. The anterior sacrum. Origin of the piriformis (A) and coc­ 1 8 US

(8).

irth Injury 'aginal delivery may result in tears, overstretching, or

:rush injury of the PFMs (i.e., between baby's head and

ubic rami) or may cause complete or partial denervation

. unilateral or bilateral pudendal nerves (i.e., stretch in-

my or avulsion of the nerve).

407

Birth injuries account for a significant percentage of PFM dysfunction. 9 Mild and moderate injuries can be ef­ fectively treated with behavioral intelventions (see the Im­ paired Muscle Performance sedion). However, severe trauma may result in severe muscle damage (usually uni­ lateral) and decreased sensory or motor innervation suffI­ cient to render the muscle ineffective. This type of trauma occurs in a very small percentage of births. Very fast deliv­ eries do not allow time for tissue stretch and may result in a "burst" effect, extensively teming the tissue. Deliveries \vith a pushing phase longer than 2 hours may result in stretch injury to nerves and muscles. Use of forceps to as­ sist delivery may resu1lt in increased trauma to the muscles. Many other factors during delivery may inHuence PFM outcomes, including the woman's positioll, leg position, size of the baby, medical interventions, and medications given. However, most women with vaginal deliveries sus­ tain only minor, temporary dysfunctions and recover fully. To maximize birth recovery, all women of childbearing age should receive accurate preventive education on PFM health. 10

Neurologic Dysfunction Many central and periphera!l nervous system dysfunctions affect PFM function. Peripheral nervous system condi­ tions, such as disk herniation and spinal cord injury, may

Sacrotuberous ligament

Piriformis

muscle

Coccygeus

muscle (cut)

Sacrospinous ';jament .sacrotuberous ligament

~--I--r"-----t- Sciatic nerve

Iliococcygeal portion of levator ani muscle (cut)

internus muscle Pubococcygeal portion of levator ani muscle

Urinary bladder of levator ani Iliococcygeal portion of levator ani muscle

FIGURE 19-7. Piriformis and pelvic area-superior view.

408

Therapeutic Exercise: Moving Toward Function

DISPLAY 19-1

Micturition Facts • The bladder's job is to store urine and empty fully at the appropriate time and place. • It is necessary to allow normal filling of the bladder for normal bladder function. A person should not go to the bathroom "just in case." • It is important to drink six to eight a-ounce glasses of fluid per day. Decreasing fluids does not decrease incontinence and may make urgency worse because concentrated urine is a bladder irritant.42 • It is normal to urinate six to eight times in a 24-hour period with normal fluid intake. More than eight times per day is called urinary frequency. In rare cases, the physician instructs patients to empty more frequently. • The normal voiding interval is 2to 5 hours. • Normal nocturnal voiding frequency (after the patient has gone to bed for the eveningl is zero to one time per night for children and adults younger than 65 years of age and one to two times per night for adults older than 65 years of age. • Each urination stream should last a to 10 seconds. If· urination is completed in 2to 3 seconds, the voiding interval could have been longer. • Hovering over the toilet may result in incomplete emptying of the bladder. Dverflow from the adductors and gluteals to the pelvic floor muscles (PFMI results in increased tone in the PFM and decreased urine flowing out. • Many fluids can irritate the bladder, causing urgency and increasing urine production. The most common bladder irritants are caffeine (e.g., coffee, tea, cola, medications, chocolate!. alcohol, carbonated beverages, and nicotine. Many other substances can be irritants, including artificial sweeteners, citrus, and some over-the-counter and prescription medications. Eliminating or limiting bladder irritants decreases symptoms of urgency and urge incontinence. • Women should always clean well after using the toilet by reaching around behind and wiping from frontto back. This ensures that fecal matter is not introduced into the urethra and decreases the incidence of infection.

result in SenSOl)' or motor dCllcrvation of the PF\1s. Dia­ betes may result in sensory or motor denervation of the PFMs and autonom ic neuropathy "vith disruption of blad­ der function. The pelvic plexus includes many small nerves that are often not visible during surgeI)'. These nerves arc not located in a consistent pattern in all pa­ tients. Radical pekic operations, such as total hyste rec­ tomy and radical prostatectomy, may ]"(' sult in inadvertent disruption of the senso1)' and motor nerves to the bladder and PFMs. Patients may be able to strengthen the re­ maining innervated muscle to achieve full supportive and sphinctelic function. Central nervous system (CNS) dis­ eases such as cerebrovascular accidents, multiple sclero­ sis, and Parkinson's disease may affect cognitive control of bladder and PFMs. These conditions may also affect the patient's ability to get to the toilet or to recognize the toilet and may affect the patient's social awareness of continence.

PSYCHOLOGIC IMPAIRMENTS

Motivation PFM strengthening requires motivation and persistence Improvement in muscle function with PFM therapy can be quick and dramatiC, but it is more often slow and gradual. Some patients do not have enough motivation to complete therapy and find it easier to wear incontinence pads. In­ continence affects patients' lives differently. Some patient are devastated and severely limited by a small amount of urine leaki ng two or three times per week. Other patients view large leaks two or three times per day as a mild incon­ venience. The perceived severity of the condition helps de­ termine motivation. Ask the patient, "On a scale of 0 to 10. how severely does your condition affect your life (0 = no effect; 10 = severely limiting)." Therapists must strongl~ encourage patients th roughout therapy to maintain motiva­ tion. Depression and poor motivation may limit a patient's progress with PFE.

Sexual Abuse An estimated one of three girls has been abused before the age of 14. Only one of five cases is repOlted. Some studie5 show that there is a higher incidence of incontinence, pehi c pain, and fibromyalgia among sexual abuse survivors. therapists should be aware of symptoms of sexual abuse (Display 19-2) and should have some e»:posure to techniqu to facilitate rehabilitation of these patients (Display 19-3). ) is espeCially important to be sensitive to these issues whe­ treating PFM dysfunction and pelViC pain. Therapists are en­ couraged to seek addi tional information on sexual abu survivors (see the Recommended Reading section ).

EXAMINATION/EVALUATION All patients could benefit from screening for PFM d: ,­ function . Understanding the risk factors for PFM dysfunr . tion helps the therapist identify patients who may bene from in-depth guestioning. Screening tools are prOvided t

DISPLAY1~2

Symptoms of Sexual Abuse • Low self-esteem, feelings of loss of control • Poor body awareness, often not trusting their own physical or emotional feelings • Difficulty with anger and violence • Difficulty with sexuality and intimacy; may avoid sex completely or compulsively seek sex • Denies and forgets instructions or appointments • Self-mutilating or addictive behaviors • Controlling of environment, treatment, or your time • Multiple personalities • Dissociation (Le., avoidance of eye contact, distant look!. an unconscious defense mechanism to separate the mind from the body and protect the mind from impending trauma; may occur during the treatment sessions

Chapter 19 The Pelvic Floor

DISPLAY 19-3

DISPLAY 19-4

Guidelines for Therapy With Known or Suspected Sexual Abuse Survivors

Risk Factors for Supportive Dysfunction and Hypertonia Dysfunction

• Give the patient control over as much as you can in the environment and in therapy. • Offer names of community support services and psychologists skilled in the treatment of sexual abuse survivors. • Do not touch the patient without permission, and avoid hugging or other nonessential physical contact. • Never allow the patient to disassociate. • Be honest with the patient about your ability and knowledge lor lack of) in this area.

entify PFM impairments and dysfunctions. Therapists re cautioned that questionnaires can be misleading Li and ..Jj urol<)<1ic o workup is indicated if conservative treatment ot successful. This section also outlines the information at is gathered by specialized th erapis ts from internal 'linal examinations and from patient self-evaluations.

isk Factors ~

brief screening questionnaire shou ld be given to all pa­ nts. Patients with medical histories that include many k factors may be screened using a more detailed form. k factors are related to the causes of various dysfunc­ ns (see Display 19-4).

Screening Questionnaires \ '0 types of screening questionnaires can be used to de­ nnine whether patients have dysfunctions of the pelvic ~oor. Questions should be clear and direct . A broad ques­ n such as "Are you incontinent?" usually results in a .Jse-negative response.

-

409

Supportive Dysfunction • • • • • •

• • • • •

Vaginal childbirth Pregnancy Obesity Chronic or prolonged coughing, as with pulmonary diseases Severe bulimia with chronic vomiting Long-term incorrect lifting or straining with a Valsalva maneuver Ii.e., increased intraabdominal pressure with bearing down), including incorrect straining with exercise Chronic constipation Pelvic congestion or swelling Neurologic dysfunctions that may affect peripheral nerves of the pelvis and many central nervous system diseases Decreased awareness of pelvic floor muscles (PFM) with disuse atrophy Pelvic surgery

Hypertonia Dysfunction • Back and pelvic pain with joint dysfunction, especially if related to a direct fall on the buttock or pubic bone • Muscle imbalance ofthe hip muscles, abdomen or pelvis, or lumbar spine, including shortened muscles or connective tissue in the trunk and pelvis • Habitual PFM holding le.g., excessive emotional stress) • Abdominal adhesions and adhered scars in the pelvic region • Deep episiotomy or perineal tearing with childbirth • Pelvic surgery • Pelvic inflammatory conditions, such as endometriosis or irritable bowel • History of or current fissures or fistulas • Connective tissue disease such as fibromyalgia • History of sexual abuse • History of or current sexually transmitted disease or recurrent perineal infections, including yeast infections • Dermatologic conditions such as lichen sclerosis and lichen planus

Brief Screening Questionnaire E:\'aluation of all patients, especially those with the risk fac­ '>f listed in Display 19-4, should include three questions: • Do you ever leak urine or feces? • Do you ever wear a pad because of leaking urine? • Do you have pain during intercourse?

Detailed Screening Questionnaire Therapists must understand the dysfunctions of the pelvic ocr and their diagnostic classifications and the types of in­ _ ntinence to fully understand interpretation of the results f this screening tooL A detailed screening questionnaire hould be given if the patient responds affirmatively to the uestions of the brief screening questionnaire. The longer ersion should be administered to a patient with pelviC, trunk, or back pain who is recovering slower than expected see Display 19-5). Questions 1 through 14 (see Display 19-5) may indi­ te a PFM supportive dysfunction or urgency that may ole treated using PFEs. A positive response to questions 1 ~rough 3 indicates symptoms of stress incontinence. A

positive response to questions 4 through 8 indicates symp­ toms of urge incontinence. A positive response to ques­ tions 13 and 14 may indicate organ prolapse. Questions 13 through 19 may indicate hypertonia, incoordination, ob­ struction, or urinary re tention. The PFM should relax during urination. Poor relaxation or incoordination may result in symptoms of obstruction (i.e., positive responses only to questions 15 through 17). These patients may also need evaluation by a physician to rule out mechanical ob­ struction. If the patie nt has symptoms of hypertonia (i.e., positive response to questions 13 through 19), proceed with full evaluation of the sacroiliac, hip girdle, and pelvic fascia.

Results of the Internal Examination A complete PFM evaluation is necessary to prescribe an appropriate exercise program for the PFMs. It includes an extensive history, symptom documentation, identification

410

Therapeutic Exercise Moving Toward Function

DISPLAY 19-5

Detailed Pelvic Floor Screening Questionnaire The patient should respond with never, sometimes, or often to the following questions: 1. Do you leak urine when you cough, laugh, or sneeze? 2. Do you lose urine when you lift heavy objects such as a basket of wet clothes or furniture? 3. Do you lose urine when you run, jump, or exercise? 4. Do you ever have such an uncomfortable, strong need to urinate that you leak if you do not reach the toilet? Do you sometimes leak with this strong urge? 5. Do you develop an urgent need to urinate when you hear running water? 6. Do you develop an urgent need to urinate when you are nervous, under stress, or in a hurry? 7. When you are coming home, can you usually make it to the door but then lose urine just as you put the key in the lock? 8. Do you have an urge to urinate when your hands are in

cold water?

9. Do you find it necessary to wear a pad at any time

because of leakage?

10. Does your bladder awaken you from sleep? How many times each night? 11. How often do you leak urine or feces? 12. How often do you inadvertently leak gas? 13. Do you ever feel as though you are "sitting on a ball" or that there is something "in the way" when you are sitting? 14. Do you ever feel as though something is "falling out" of your perineal area? 15. Do you find it hard to begin urination? 16. Do you have a slow urinary stream? 17. Do you strain to pass urine? 18. Do you have pain during vaginal penetration, including intercourse, insertion of a tampon, or vaginal examination? 19. Do you have pelvic pain with sitting, wearing jeans, or bike riding?

of associated factors, internal vaginal or rectal examina­ tions, and surface EMG or pressure biofeedback eval­ uation. The speCialized therapist obtains the followin$ information from the internal examination of the PFMs: L Muscle performance is assessed in the form of power, and endurance. Power is defined as the ability to contract (manual muscle grade of 0 through 5). This grade pro­ vides information on how much lift (i.e., supportive func­ tion) and closure (i.e., srhincteric function ) the PFMs have. The muscle bulk 0 the PFMs can be palpated to help determine possible duration of rehabilitation and re­ habilitation potential. Patients 'with a small, thin PFM require a longer rehabilitation time and generally have less rehabilitation potential than those \ovith good PFM bulk. Endurance is defined as the ability to hold a slow­ twitch muscle contraction and repeat the contraction. Clinicians also determine how many fast-twitch muscle contractions can be done. The quality of the contractions is also evaluated. Resting tone between contractions is assessed, looking speCifically for altered tone impairments. Coordination of the PMFs and the relationship with as­ sociated muscles is assessed. Muscle dominance patterns

or inappropriate contractions of the gluteal muscles. adductor group , and abdominal muscles are assessed. Other impairments , such as pelvic floor trigger pOints. decreased sensation, and scars or myofascial adhesions. may limit strengthening. Internal examination of the PFMs is the gold standard evaluation. However , internal examinations cannot or should not be performed in some cases ( see Display 19-6).

Patient Self-Assessment Tests When an internal evaluation cannot 'be performed , self­ assessment tests can help patients and th e therapist iden­ tify some of the impairments of the PFMs. Therapists can use the results of self-assessment tests to prescribe PFE with some accuracy. A possible evaluation tool used when an internal evalu­ ation cannot be performed is the digital vaginal self-exam­ ination (i.e., finger in the vagina test). Begin \ovith patien education, as outlined later in the Teaching Pelvic Floor Exercises section. This section also includes informatio about verbal cues for the proper contraction of PFMs. ter a brief introduction to the PFMs and the exercise, the patient should be instructed in the digital vaginal self. examination test (see Patient-Related Instruction 19-1 Testing Your Pelvic Floor Muscle Ability by Performin_ the Digital Vaginal Self-Examination [Finger in the Vagin.. Test]). Digital vaginal self-examination is often accepted b female patients and can be taught to male patients (i.e., fin· ger in the rectum test) in the same manner if they are ha\ · ing trouble le arning the correct contraction with oth e­ methods. Many factors influence continence and PF \ function. Some practitioners use the stop urine test to de· termine PFM function. Current literature does not suppor the value of this test 1 3 The finger in the vagina test cannot evaluate all aspec.: of muscle function , but can give some indication of thl muscles' abilities and provide gUidance in prescribing ext'" cises. Patient progress is judged by decreaSing symptOJT

DISPLAY 19-6

Contraindications to Internal Evaluation of the Pelvic Floor Muscle • Pregnancy • Within 6 weeks of vaginal or cesarean delivery • Within 6 weeks after pelvic surgery • Atrophic vaginitis, a condition of fragile skin seen in cases of estrogen deficiency • Active pelvic infection • Severe pelvic or vaginal pain, especially pain during

penetration or intercourse

• Children and presexual adolescents • Lack of informed consent • Lack of therapist's training (The therapist should obtain specialized training in performing internal evaluations of the pelvic floor muscle. Training can be obtained in postgraduate courses or through individual instruction from a midwife, physician, nurse, or trained physical therapist.)

Chapter 19 The Pelvic Floor

Testing Your Pelvic Floor Muscle by Performing the Digital Vaginal Self-Examination The following test can help you monitor your re covery. Perform this test before beginning your pelvic floor exercise program and then periodically thro ughout the training period, approximate ly every 2we eks. Fluctuations in muscle ability occur in response to fatigue, medications, hormones, and other factors. The pelvic floor muscles are more likely to be weak at the end of the day, when you are sick, and just before menstruation. s For an accurate comparison, repeat the test at the same time of the day and the same time of the monthly menstrual cycle as the original test. Any exercise program takes time and dedication. As with other muscles, the pelvic floor muscles may take 4 to 6 months to strengthen. After you have performed the test, report the following information to your therapist: how many seconds you can hold the contraction, how many ofthese long-hold contractions you can do, how many quick contractions you can do.

Digital Vaginal Self-Examination (Finger in Vagina or Rectum)

411

TH ERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENTS This section outlines the phYSiologic impairments and pos­ sible treatments of the PFMs and related structures. Sev­ eral types of impaired PFM function are possible: • Impaired muscle performance of the PFMs, abdomi­ nal muscles, and hip muscles • Pain and altered tone of the PFMs, hip muscles, and trunk muscles • Mobility impairments causing PFM dysfunction as a result of adhesions, scar tissue, and connective tissue disorders • Posture impairments • Coordination impairments of the PFMs, PFMs dur­ ing activities of daily living (AD Ls) , PFMs with the abdominal muscles, and abdominal muscles alone

Impaired Muscle Performance Pelvic Floor Muscles

Place your finger into the vagina or rectum up to the level of the second knuckle. Pal'pate the muscle on either side of the vagina or rectum while you contract the pelvic floor muscle, pulling the muscles up and in. You should feel the muscles contract around your finger and pull your finger up and in. If you feel tissues pushing out of your body or bulging, ask your health care professional to evaluate the area. Determine how long you can hold the pelvic floor contraction and how many times you can repeat that contraction. Then perform quick maximal contractions (1­ second hold). Count the number [)f quick contractions you can perform before the muscle tires.

Impaired muscle performance (impairment in strength, power, or endurance) is the most commonly treated im­ pairment of the P FMs. PFM performance may be im­ paired by trauma during vaginal delivery, CNS or periph­ eral nervous system (PNS) neurologic dysfunction, surgical procedures, decreased awareness of PFMs, disuse, pro­ longed increased intra-abdominal pressure, pelvic conges­ tion or swelling, and back or pelvic pain. Impaired muscle performance is usually the primary impairment in the sup­ portive dysfunction diagnostic c.:lassification.

Patients can perform the test at home and report to the therapist, or the test can be done in the c.:linic if sufficient privacy is available (i.e., closed-door treatment room with a pli nth or recliner is suggested). In the clinic, the therapist can briefly step out of the room \vhile the patient performs the test or can remain in the treatment room with the pa­ tient adequately draped. The patient should prOvide the follmving information:

This test is used only to evaluate pelvic floor muscle strength under physical stress. Do not perform this test until you can stop the urine flow at least once during urination. To begin, empty your bladder, and then perform five jumping jacks. If no urine leaks out, wait one-half hour, and do five more jumping jacks. If no leakage occurs, wait one-half hour, and repeat the five jumping jacks. The test proceeds until leakage occurs. Make a note of how long after urina­ tion and how many jumping jacks you could do before urine leakage occurs. There are no normative values forthis test, but some therapists feel a patient should be able to do 5to 10 jumping ja cks 2to 3 hours after urination without leaking. Circle the number jumping jack at which urine leakage occurs:

Jumping Jack Test

• Duration (in seconds) of slow-twitch muscle contrac­ tion hold • Number of repetitions of slow-twitch muscle contractions • N umber of repetitions of fast-twitch muscle contractions .\ second self-assessment test, the jumping jack test, is a test of advanced strength (see Patient-Related Instruction 19-2: Jumping Jack Test). It is usually not given to seden­ tary, incontinent patients. It is helpful for athletes and other active individuals who know how to do the PFE well. Patients may use this test to judge continued progress after active therapy has ended.

Immediately-1 2345 1/2hr-12345 1 hr-1 2345 1-1/2 hr-1 2345 2hr-12345 2-1/2hr-12345 3hr-12345 3-1/2hr-12345 4hr-12345

412

Therapeutic Exercise: Moving Toward Function

The PFMs are 70% slow-twitch muscle fibers with the critical role of providing support to pelvic organs against gravity in all upright positions. PFMs are postural muscles and must be able to maintain some baseline tone for long periods. Weak, easily fatigued , saggy muscles do not sup­ port the pelvic organs and result in supportive dysfunction of the PFMs. Lengthened muscles may result in pain and pressure in the perineum because structures "hang" on the ligamentous supports and stre tch the nerves. Poor en­ durance of the PFMs is a common finding in many women without symptoms of PFM dysfunction. Most women probably have endurance impairment of the PFMs long before functional impairments of leabng urine or prolapse occur. Teaching PFEs to all adults may help to prevent PFM dysfunctions in the future. This is especially true with prenatal and postpartum women and women after menopause or gynecologic surgery. The treatment for impaired muscle performance is ac­ tive PFEs. 14 - 16 These strengthening exercises are ex­ plained later in the Active Pelvic Floor Exe rcises section.

Abdominal Muscles Impaired abdominal muscle performance often results in a pendulous abdomen and can contribute to PFM dysfunc­ tion , especially incontinence. Restoring abdominal wall length and strength and avoiding Valsalva maneuvers are the goals of PFM dysfunction treatment. Treatment of impaired abdominal muscle performance is described in detail in Chapter 18. Patients with PFM dys­ function should be taught not to bear down (j.e ., Valsalva maneuver) during exercises and ADLs. Valsalva maneuvers can contribute to incontinence and may increase the chance of pelvic organ prolapse.

Hip Muscles Hip impairments (see Chapter 20) are often underlying causes of hypeltonia dysful1ctions of the PFMs. The piri­ formis, obturator internus, and adductors are the most likely muscles involved because of their proximity to the PFMs. Any muscle impairment affe cting the sacroiliac joint may also contribute to hypertonia dysfunction of the PFMs (see Chapter 18).

Active Pelvic Floor Exercises PFEs specifically address impaired muscle performance of the PFMs. Proper contraction and relaxation of the PFMs are necessary for normal function and are the focus of treatment for most PFM impairments. Correct technique is essential.

Dosage The therapist uses the results from the patient's self-evalu­ ation (i.e., stop test and digital vaginal self-examination test) to prescribe an individualized exercise program for PFM strengthening. The therapist also should consider the follOWing parameters, even when prescribing PFE 'vvithout the benefit of an internal examination . The therapist should remember the basic principles of overload (i.e., the muscle must be challenged to its fullest capacity to improve strength) and specificity (i.e., patients should exercise the

muscle correctly in isolation ). Patients can be taught these ideas and can learn to progress their own programs. 17 PFEs must be individualized for the patient to reach his or her full rehabilitation potential. Many well-intentioned publi­ cations give "cookbook" exercise programs that are too hard for the average incontinent patient (e.g., hold for 10 seconds and repeat 10 to 15 times). Patients try to follow these instru ctions, realize that their symptoms are not changing, and ultimately abandon the exercises. These same patients have achieved good results with careful in­ structions and individualized programs. Duration

How many seconds should the patient hold the slow­ twitch muscle contraction? If the evaluation reveals that the patient can hold the contraction for 3 seconds (not un­ common for weak muscles ), the therapist asks the patient to hold the pelvic floor contraction (i.e. , Kegel contraction for 3 to 4 seconds before resting and repeating the exercise. Sustained PFM contractions are progressed to a maximuJll of 10 seconds. 1B This parameter shows the endurance of the muscles. Endurance impairments of PFMs ar common. Rest

How long should the patient rest between slow-twitch muscle contractions? Increased resting tone (i.e., hyperto­ nia) and weak muscles require longer rest times. Twice as. much rest time as hold time is advised for a weak muscle (e.g., 3-second hold, 6-second rest, and repeat). Rest time is decreased as strength increases (e.g., 10-second hold, 10­ second rest, and repeat) . A quality PFM contraction re­ quires complete relaxation at the end of each exercise. In­ complete relaxation does not train a muscle in its full rang' of motion and may result in hypeltonia and pain . Complett; relaxation between contractions produces a more fune-­ tional muscle. Slow-Twitch Repetitions

How many slow-twitch contractions should the patier,~ do in one set before fatigue? For the patient previously de­ scribed, the therapist would determine how many 3-secon contractions the patient can complete. The average patier; ~ with an endurance impairment is able to perform only 5 tr 10 repetitions before fatiguing. The exercise program m be individualized for maximum benefit. Fast-Twitch Repetitions

How many fast-twitch contractions should the patie do in one set? A complete PFE program includes fo tvvitch and slow-twitch muscle contractions. The therapis prescribes the number of fast-twitch muscle contraction.: based on how many can be done at the initial evaluatio Fast-twitch muscle contractions involve quick, maximal re­ cruitment of the PFMs , followed by qUick relaxatio These contractions are usually held for less than 2 second. Sets

How many sets should the patient do in 1 day? Patien with weak PFMs should do a set of contractions (as deter­ mined previously) several times during the day. The se­ should be spaced throughout the day and performed up ­ four or five times per day, with a total of 30 to 80 peh­ floor contractions per day.1B

Chapter 19: The Pelvic Floor

Activity Posture

Gravity pulls down on the pelvic floor in upright posi­ Patients \vith very weak PFMs should therefore do their exercises in the horizontal position (Le., gravity neu­ n l). Patients with moderately strong PFMs can perform xercises in the sitting position (Le. , against gravity) and ad­ -ance to the standing position as they feel stronger. Results the manual muscle test (MMT) using an internal exami­ tion of the PFMs provide the basis for prescribing exer­ e positions accurately. All patients should eventually .rogress to doing PFEs while standing, because it is neces­ for the muscles to function well in this position (i .e., st incontinence occurs while standing). Some publica­ . ns recommend that women practice PFEs while driving r waiting in line. However, patients should learn these -ercises in a quiet place so they can concentrate and per­ rm the exercises correctly. After the exercises are arned well, patients can do them while waiting in line or tehing TV. ·O IlS.

Accessory Muscle Use

Contraction of the abdominal, adductor, and gluteal uscles can result in overflow to the PFMs.19 The princi­ of overflow are used to facilitate strengthening of weak F ~s. Simply stated, overflow is the intentional contrac­ n of associated muscles to increase recruitment of very ak muscles. This technique is usually reserved for pa­ nts vvith an M MT result of 1/5 or 0/5. Some patients with _ .) results need facilitation , but most therapists begin atment without facilitation and add it later if the patient ot progressing as expected. Conversely, if the patient an MMT result of 3/5 or higher, the therapist discour­ the use of accessory muscles. Eventually, all patients uld learn to contract the PFtvls \vithout accessory mus­ . Several studies 2o ,21 have shown the close synergy of e abdominal muscles (particularly the transversus) and e PFM (see Chapter 18). Therefore it is neither neces­ -0' nor desirable to keep the abdominal muscles com­ etely silent during a PFM contract. Patients who are mpletely unable to slow the urine stream may benefit m facilitation, but if symptoms do not improve \-vithin 2 3 weeks , the patients should be referred to the phYSician, therapist with specialized training in PFM rehabilitation, both. Movement

Teaching PFE without internal palpation or biofeed­ ck is diHlcult for the therapist and the patient. However, "s section gives the therapist a comprehensive plan for aching effective PFE, including patient education, verbal es for proper PFM contraction, home exercise programs, cl methods for putting the exercise program together. e rapists use the treatment dosage information in con­ ction with th e patient self-assessment and awareness ex­ '"eises to prescribe an individualized PFE program. Patient Education

Before teaching patients how to do the PFEs , they auld be educated about the location and function of the -F ~s, and the importance of normal PFM function should e>"'Plained.

413

There are many commercially available charts, posters , and handouts that give a two-dimensional view of the loca­ tion of the pelvic floor. However, many patients find three­ dimensional models more helpful. Pelvic models that have the PFMs and obturator internus muscles in place help in explaining the proximity of the PFMs to the muscles of the buttocks and hips. Alternatively, the therapist can use a standard pelvic bone model and place her hand from the coccyx to the pubic bone to signify the muscles. The patient should understand that the PFMs are internal (approxi­ mately 2 inches into the vagina) and are in close proximity to the hip muscles. However, it is neither necessary nor de­ sirable to contract the hip muscles while exerCising the pelvic floor, unless the therapist is using overflow principles. An explanation of Kegel's three functions of the PFMs (the three Ss ) is usually sufficient for the patient: • Supportive: They hold the pelvie organs in . • SphincteriC: They stop urine, feces, and gas from es­ caping until the person reaches the toilet. • Sexual: They help women grip the peniS and increase sexual feelings. They help men form and maintain an erection. The therapist should to teach the differences in function between fast- and slow-twitch muscles. The analogy of sprinters and marathoners helps to explain the fast- and slow-twitch properties of the muscle. Sprinters depend on the fast-twitch muscle fibers, which are mainly responsible for the sphincteric function. The fast-twitch fibers contract quickly before a sneeze or cough. The marathoners are the slow-twitcb muscle fibers , which provide the supportive function and hold up the organs A combination of fast- and slow-twitch fibers assists sexual function. The follOWing points are examples of the importance of normal muscle function. The information can be individu­ alized for each patient: A well-exercised muscle has a good blood supply and may recover better from trauma such as childbilth or surgery. PFEs started during pregnancy result in less incontinence and pain after delivery. 22.2:, It is easier to learn these exercises before changes oc­ cur from surgery, pregnancy, childbirth , or aging. All women should have a basic knowledge of the PFMs and how they should be exercised (especially if they have any of the risk factors revealed by the screening questionnaires). PFEs should be a part of a woman's basic self-care, such as brushing her teeth and showering. As stated earlier, incontinence is a symptom not a dis­ ease. It is not an inevitable sequel of pregnancy, surgery, or aging, and 87% of patients can signifi­ cantly reduce or eliminate incontinence with pelvic muscle exercises 1 Exercising these muscles before and after bladder sus­ pension surgery may enhance the operative results. 24 Some patients still have symptoms after bladder surgery or become incontinent several years late r. Strengthening the PFMs may reduce the likelihood of recurring symptoms. The normal PFM function is helpful in the treatment of low back and pelvic pain. zs Weakness or spasm in this

414

Therapeutic Exercise Moving Toward Function

muscle group may result in stress to adjacent hip muscles and perpetuate functional limitations. Hip, buttock, and leg pain may not resolve unless this muscle group is functioning normally. About 49% of patients verbally instructed in PFEs are do­ ing them incorrectly26 A~rroximately 25% are pushing do"v11 on the pelvic floor. ) This makes the dysfunction worse. The therapist must descl;be the exercises correctly and encourage patients to use the home exercises de­ scdbed in the next section. Display 19-7 provides verbal cues that can be used to instruct a patient how to penorm a pelvic floor contraction. Home exercises are an essential aspect of PFM strengthening. Before patients begin to perform these ex­ ercises on their OwTl at home, they must have a complete understanding of their muscles and how to exercise them. The therapist should be aware of a patient's comprehen­ sion of the following exercises. Many patients nod and agree just to end the discussion of an embarrassing subject. The therapist should address this form of exercise vvith the same professionalism and completeness as she does for any other exercise. This approach can place the patient at ease, and it emphaSizes the importance of the exercises. Follow-up of the home exercise program is important. At subsequent sessions, ask patients how many, how long, and in what position they are doing the exercises, if they feel the contraction, if the muscles are getting stronger, and if the symptoms are decreasing. To improve compli­ ance, it may be helpful for patients to keep a diary of the ex­ ercise routine and list how many times per day inconti­ nence occurs. These home exercises are used in conjunction with the self-assessment test descdbed in the evaluation section of this chapter (see Self-Management 19-1: Home Awareness Exercises ). After going over the self-assessment test and home awareness exercises with the patient, this informa­ tion may be copied and given to the patient to take home with her. The patient should perform the tests and aware­ ness exercises at home and then report to the therapist for documentation of results and development of an individu­ alized PFE program.

Putting It All Together- The Exercise Program The exercises described in Self-Management 19-1: Home Awareness Exercises are designed to help the patient iden­ tify and effectively contract the PFMs. However, it is

DISPLAY 19-7

Verbal Cues Used to Teach Pelvic Floor Contractions • Tighten and lift the muscles around your vagina, and pull them up and inward, as if to stop urine flow. • Tighten the muscles that you would use to stop gas from escaping at an embarrassing time. • Pull your muscles up and in, as if you had the urge to urinate and could not stop to use the toilet • Gently push out, as if to pass gas, and then quickly pull the muscles back up and in.

impOliant to create an exercise program that challenges th PFMs of each patient. For example, if a patient's self-assessment test (e.g., di e­ ital self-examination ) shows that the PFM contraction Wali held for 5 seconds and repeated five times and that H qUick contractions were penormed, her evaluation result would be as follows: • Duration of slow-twitch muscle contraction hold: J seconds • Repetitions of slow-twitch muscle contractions: .J times • Repetitions of fast-twitch muscle contractions: H times With this information, the therapist could prescribe the fol· lmving exercise prescription (see Display 19-8). Five P F ~ contractions are held for 5 seconds with a 10-second re between (double rest is given to patients with poor P F ~ ~ function). Remind the patient to relax completely in be· tVv'een contractions. Ten quick PFM contractions are done to train the fast-twitch function of the muscle. Repeat set four to six times per day; weak muscles need to exerci_ short sessions many times during the day. Exercises shout, be penormed lying doWTl. The patient should contract t:hr PFMs before and dudng stressful activities, such as cough­ ing, sneezing, lifting, and straining. All patients should given functi0I2al training activities such as "squeeze befo you sneeze ."Zi Self-assessment and modification of the exercise pIT'­ gram continues periodically throughout rehabilitation. Re­ member to ask the patient how often and how many PF) exercises she can do. Ask if her symptoms are improyin (i.e., decreasing incontinence ).

Pain Pelvic Floor Muscles PFM spasm with or without muscle shortening occurs i: response to many situations outlined in the Hyperto ­ Dysfunction section of this chapter. Pain and altered to impairments may be caused by lumbopelvic or hip impair ­ ments, tonic holding patterns of the PFMs, abdominal ad­ hesions and adhcred scars in the trunk and perineum , fh ­ sures, and fistulas. Pain and altered tone impairments ar usually the primary impairments of hypertonia dysfun tions. Coccyx pain is rarely a result of sacrococcygealjo' mobility impairment, but it usually is caused by referr, pain from spasm and trigger points in the surroundL__ muscles. The PFMs, obturator internus, and piriformis ell.; refer pain to the coccyx (Fig. 19-8). Treatment of PFM spasm includes manual soft-tissul­ manipulation of PFM vaginally, rectally, or extern al] around the ischial tuberosities and coccyx. Surface E M biofeedback and PFEs may also help restore the norm tone of the PFMs. In some cases, the PFMs beco m.. "frozen" and cannot relax or contract effectively (see Patient­ Related In struction 19-.3: Importance of Rel axing tht" Pelvic Floor Muscles). Modalities such as electrical stimula­ tion , ultrasound, hot, and cold are being used on th peIineum to treat spasm. The therapist should learn the logistics of applying the modality on to the perineum.'::

15

Therapeutic Exe rcise Moving Toward Function

Chapter 19 The Pelvic Floor

415

SELF·MANAGEMENT 19·' Home Awareness Exercises

These exercises are used to help you understand what you should be doing during the Kegel or pelvic muscle exercise. Try the exercises at home, and report the results to your physical therapist. Remember that this is an intern al muscle, and you should try not to contract the leg or buttock muscles. During these exercises try to identify: 1) If you are doing the exercises correctly,

Finger Into Vagina or Rectum:

2) How long you can hold the contraction (in seconds) up to 10 seconds, 3) How many repetitions you can perform holding the contraction for the previous length of time, 4) How many quick contractions you can perform.

Index Finger on Perineal Body: Place your index finger on the perineal body (i.e., the skin between the vagina or penis and the rectum) or lightly over the anus. This can be done over your underpants in some cases. Contract the pelvic floor muscles, and feel the perineal tissue moving away from your finger, up and into the pelvic cavity. If the pelvic floor is very weak, you may not feel much movement. However, you should never feel the anus or perineal tissue moving toward your finger or bulging. If you feel tissues moving toward your finger, stop exercising, and ask your physician, midwife, physical therapist, or other health professional to instruct you in the proper pelvic floor muscle contraction.

Visual Exercise: Women

Men

Place your index finger into the vagina or rectum up to the level of the second knuckle. Palpate the muscle on eithe r side of the vagina or rectum while you contract the pelvic floor muscles, pulling them in and up. You should feel the muscles contract around your finger and pull your finger up and in. If you feel tissues pushing out of your body or bulging, ask your health care professional to examine the area.

Lie on your back with your knees bent and your head resting on several pillows. Hold a mirror so that you can see your perineal body and rectum. Contract the pelvic floor muscles up and in, and watch the perineal tissues moving up into the body. It may be difficult to see the movement if the muscles are very weak. Seek further professional instruction if any tissue comes toward the mirror or bulges outward. Stand in front of a long mirror, and watch the penis as you contract the pelvic floor muscle up and in. The penis should move slightly upward during the contraction .

Sexercise­ (for Women): Contra ct the pelvic floor muscles around the penis during intercourse.

lodality parameters and other treatment considerations are he same as those used for spasm in other areas of the body.

'lip Muscles -\Ily muscle imbalance at the hip and trunk may contribute o hypertonia dysfunctions of the .r'FMs through sacroiliac int impairments. It is often difficult to pinpoint the origin f pain in the lower pelvic region. Muscle spasm and trigger points are a common cause of pain in the perineum, groin, .md coccyx areas. Travell and SimonS describe referred pain atterns originating from trigger points in the adductors, PFMs, obturator intemus, and piriformis (Figs. 19-8 and 19-9). Spasm and trigger points in these muscles may be pri­ mary or secondary impairments and should be treated in all patients with PFM dysfunction. Treatment for hip muscle pasms includes soft-tissue manipulation, modalities (i.e., .utrasound, electrical stimulation, hot or cold packs), thera­ p utic exercise for stretching and strengthening, and pa­ tient education abou t body mechanics and postures .

Trunk muscles Iliopsoas and abdominal trigger points and spasm may be the primary muscular impairment in pelvic pain conditions. Iliopsoas spasm may irritate the pelvic organs that overlie them and vice versa, making iliopsoas altered tone impair­ ments an important condition to treat in cases of visceral dysfunction. Treatment of these muscles is essential to full recovery.

Joint Mobility and Range of Motion (including muscle length) Impairments Spasms of the PFMs are often related to sacroiliac, sacro­ coccygeal, pubic symphysis, and lumbar joint mobility im­ pairments . These impairments may be primary or secondary and include hypomobility or hypermobili ty (see Chapter 7). Mobility restriction of scar tissue and connective tissue in the perineum and groin can also affect PFM function greatly.

416

Therapeutic Exercise Moving Toward Function

tion • Duration of slow-twitch muscle contractions: 5 seconds • Rest between slow-twitch muscle contractions: 10

seconds, double rest • • • • •

Repetitions of slow-twitch muscle contractions: 5 times Repetitions of fast-twitch muscle contractions: 10 times Sets per day: 4 to 6 sets per day Position: gravity eliminated-lying down on back or side Accessory muscle use: not at this time

Joint Integrity and Mobility Impairments of the Lumbopelvic Region Resulting in PFM Dysfunction Hypomobility or hypermobility of the sacroiliac, pubic symphysis, or sacrococcygeal joint may cause the secondary impairment of PFM altered tone (i.e., spasm).29 Pain from lumbopelvic-hip joint integrity or mobiljty may lead to a tonic holding pattern of the PFMs similar to that seen in th e ce rvical muscles after an acce leration injury (i.e., whiplash). Sacroiliac mobility impairments may also cause pain-induced PFM weakness. Any malalignment of the

pelvis can alter the origin and insertion alignment of th PFMs and impair function by causing spasm or weakness. Significant jOint integrity and mobility impairments in all PFM dysfunctions should be treated to achieve full heal­ ing. Joint mobilization, positioning, soft-tissue mobiliza­ tions, therapeutic exercise, and other modalities treat joint integrity and mobility impairments. The hypogastlic plexus (TlO through L2) provides sym ­ pathetic innervation to the pelvic and perineal area. :-.Jor­ mal joint mobility in the TIO through L2 region may nor­ malize sympathetic nerve output to the perineum and decrease pelvic pain symptoms. These hypotheses are based on clinical findings and have not been researched in experimental trials.

Lumbopelvic Joint Mobility Impairments Resulting From PFM Dysfunction Unilateral PFM spasms may contribute to and perpetuate pelvic joint mobility impainllents. In some cases, untreated PF~ spasm may be the reason for continued mobility im­ pairments. This is seen comm only in the sacroiliac joint and less frequ en tly in the sacrococcygeal joint. Because ofPF~ 1 attachrnent onto the sacrum , unilateral PfM spasms can result in torque of the sacrum similar to the torque created by a unilateral piriformis spasm. Unilateral PFM spasm

Sphincter ani, levator ani,

and coccygeus

(view from below)

~

FIGURE 19·8. Trigger points (xl and their referral pain patterns (shaded areas;'

/'

Obturator internus

~

Chapter 19: The PelvIc Floor

of abdom inal adhesions and organs can enhance organ function and may be the necessary link in maintaining nor­ mal mohility in the pelvic jOints.

Importance ofRelaxing the Pelvic Floor Muscles Pelvic floor muscles must be completely relaxed for normal function. For example, if you hold a brick in your hand all day and at the end of the day are asked to throw the brick 10 feet you would probably not be able to throw it, because your a;m muscles would be cramped and tired. ~onic holding of the pelvic floor muscles often results In a c!"ampy pain in the groin or tail bone area. If you hold the pelvIc floor muscles tense ali day, you cannot contract the muscles more when you need them during coughing or sneezing. This may result in leaking urine. One goal of recovery is to be able to contract and relax the pelvic floor muscles well.

an occur as a result of trauma, such as adductor strain with sertion injury, birth injury, or a fallon the pubic rami. PFM spasni can be caused by sacroiliac joint rr:obility im­ pairment and then become the reason for contmued J~mt d\'sfunction. Whether it is the primary or secondary Im­ p~rment, release of PFM spasm is needed to restore and 'Tlaintain normal sacroiliac jOint mobility in these cases.

J...umbopelvic Joint Mobility Impairments Resulting From Adhesions

.. .

Yisceral adhesions may cause sacroiliac jOint mobJiIty Im­ painnents, especially if unilateral adh~sions fro~ organ to sacrum are severe. Specialized therapIsts use VIsceral mo­ bilization techniques to manipulate organs and abdommal ascial tissue. These techniques are used to stretch adhe­ sions and restore normal movement of lumbopelvic joints nd pelvic organs. For example, in :ndometrios.is, en­ dometrial tissue implants in the abdommopelVIc cavIty out­ side the uterus. As with the tissue inside the uterus, the ex­ planted tissue responds to hormones during the menstrual . -de causing irritation, inflammation, and :v~ntually scars and adhesions. Adhesions from endometnosls can be ex­ tensive throughout the abdomen and are often treate~ with , paroscopic laser surgery. Adhesions can pull on .the JilUm , coccyx, or sacrum and constrict bowels .or fallopl~n tu?es, altering joint and organ function. Soft-trssue mobtllzatlOns

TrP 1

Scar Mobility Restrictions Episiotomy is a common obstetric procedure that involves making a cut in the perineal body imme~iately befor; vagi ­ nal delivery, usually to ease delivery (FIg: 19-10). \.agl~al tissue may tear as an extension of an epIsIotomy or 111 heu of an episiotomy at the time of delivery. EpiSiotomies and tears may result in adhesions and pain wherever the scar tissue occurs-at the perineal body, tissue inside the vagina, and even toward or into the rectum. Adhesion pain usually occurs in the immediate postp artum stage an~ abates in most women after 4 to 6 weeks . However, thIS pain persists in some women and can be so severe that in­ tercourse is impossible and every bowel movement hurts. Sitting may be impossible, or sitting tolerance may be hm­ ited. Muscle spasm and adhesions are the most common impairments. Conversely, some patients demonstrate fall1­ inhibited PFM weakness. Treatment includes soft-tissue manipulation and friction massage of scars externally and internally. Modalities, such as ultrasound, mterferentlal electrical stimulation, hot paeks, and cold packs also are used. PFEs and biofeedbaek are important in restoring the normal contraction and relaxation of muscles.

Connective Tissue Mobility Restrictions Muscle strains often result in irritation to connective tis­ sues and shortening of fascia and tendons. Groin inju.ri~s commonly traumatize the adductor muscle group. T~IS IS a very large muscle group that inserts onto the pubIC ra­ mus and ischial tuberoSity. Physical therapists often treat the distal adductor muscle and fascia, whereas restrictions in connective tissue mobility and muscle spasms of the proximal adductor muscles are often left untreated, Ti~­ sue at the insertion of the adductor muscles to the pubiC arch should be evaluated and treated in patients with per­ sistent groin pain , A similar condition may occur i~ the hamstring muscles, The hamstring tendo~ sends a shp of connective tissue to the sacrotuberous lIgament, which eventually fuses with the posterior sacroiliac ligaments. Impaired mobility of connective tissue at the proxH~ al hamstrin Ie>a muscle may be related to persisten t sacrOlitac

Crowning

baby's head

Midline episiotomy

Mediolateral epiSiotomy

*

AGURE 19·9. Trigger points (TrP) of the hip adductors (x) and their refer· al pain patterns (shaded areas).

417

FIGURE 19·10. Possible sites of epi siotomy.

418

Therapeutic Exercise: Moving Toward Function

joint dysfunction. These conditions may occur with spasm of the PFM s. Treatment of connective tissue mobility im­ pairment includes soft-tissue mobilization, therapeutic ex­ ercise, and modalities (i.e. , ultrasound, electrical stimula­ tion , hot packs).

Posture Impairment Poor posture and body mechanics are commonly associ­ ated v\lith joint mobility impairments. Education about proper posture and body mechanics is included in the treatment of all patients with jOint dysfunction of the lu m­ bopelvic area. Sitting posture demands special attention to PFM impairments (see Patient-Related In struction 19-4: Proper Sitting Posture ).

• Proper sitting posture is essential for relief of perineal and tail bone pain. • Weight should be shifted forward on the two "sit bones" and thighs. • There should be no pressure on the tail bone. • Push your buttocks back in the chair so there is no space between your very low back and the chair. • Use a small towel roll at your waist to maintain the inward curve if needed. • A firmer chair can support your posture better and decrease pressure on the tail bone. • Poor sitting posture places weight on coccyx.

Coordination Impairment Coordination impairm ent is related to inappropriate pat­ terns of timing and recruitment of the PFMs and abdomi­ nal muscles. This impairment includes incoordination of the PFM contraction, incoordination of the abdominal contraction, incoordination of the PFMs during ADLs, and incoordination of the PFMs with the abdominals.

Pelvic Floor Muscles oordination impairment of the PFMs is the in ability of all of PFMs to contract and relax at the appropriate times. Manual evaluation of the PFMs and biofeedback training may reveal the patient's inability to create and hold a syn­ chronous contraction. This problem is usually related to decreased awareness of the PFMs. In non-neurologic con­ ditions, the patient can usually leam the correct sequenc­ ing and timing of contraction through some form of biofeedback (e.g., surface EMG; pressure; contrac ti n around a finger, penis, or similar object).

Pelvic Floor Muscles During Activities of Daily Living Coordination impairment of the PFMs during ADLs i observed in stress incontinence, with urine leaking during lifting, coughing, and sneezing In some cases , leaking re­ sults from impai red performance of th e PFMs. However. some patients have fairly good PFM strength but do not contract the PFMs at the proper time dUling the activit;,. All patients must learn to contract the PFM s before and during increased intra-abdominal pressure (e .g., cough lift , sneeze) (see Patient-Related In struction 19-5 Squeeze Before You Sneeze ). One study showed that this type_of training alone can decrease urine leakage up to 70%.2 1,30

Pelvic Floor Muscles With Abdominal Muscles Loss of lumbar lordosis __

Poor weight

distribution onto coccyx

1/

I

Co rrect...J.-..-I----­ lordosis

Nee dle EMG studies show that the abdomin al muscles partiCipate in a synergy with the PFM s. 20 .21 The therapist should understand proper contraction of the PFMs with the abdominal muscles to correctly instruct the patient For example, the therapist can instruct the patient to sit u tall in a chair and to pouch the abdominal muscles outward As the patient keeps the abdomen pouched out and COD­ tracts the PFMs, she should notice the amount of effor. needed and the force generated by the PFMs. Next, she should sit up in the chair and pull the abdominals inward supporting the abdominal contents and the back. \l\l hile sh

Squeeze Before You Sneeze Coccyx

Proper sitting posture places weight on the ischial tuberosities and posterior thigh .

Practice contracting the pelvic floor muscles immediately before sneezing, coughing, laughing, lifting, or straining. This is similar to training yourself to bring your hand to your mouth before you sneeze. By voluntarily contracting the pelvic floor muscles before increases in abdominal pressure, you will eventually create a habit, and the pe1lvic floor muscle will contract automatically.

Chapter 19 The Pelvic Floor

holds the abdominal contraction gently and contracts the PFMs, she notices the effort needed and the force gener­ ated by the PFMs. Most persons feel a stronger PFM contraction when the abdominals are pulled inward properly. This is especially evident in the presence of PFM weakness. The PFMs can­ ot contract effectively when the abdominals pouch out, while bearing down, or during a Valsalva maneuver. In PF:\II training, it is especially important not to bear down and bulge the abdominals outward with the PFM contrac­ tion. All patients must learn to isolate the PFMs from the abdominal muscles at some point in the treatment. Bearing down is associated with PFM relaxation during bowel movement. PFM contraction during defecation is an example of PFM coordination impairment. This results in difficulty passing feces and often causes constipation and pain, which may be diagnosed as obstructed defecation. The patient must learn how to relax the PFMs at the proper time in association ,vith the proper abdominal contraction fo r defecation (Table 19-3).

Abdominal Muscles Coordination impairment of the abdominal muscles result in dll inability to pull the muscles inward. These impairments ')'lust be treated before considering PFM timing with the abdominals. See Chapter 18 for specific training techniques.

CLINICAL CLASSIFICATIONS OF PELVIC FLOOR MUSCLE DYSFUNCTION Pelvic floor dysfunctiOns have four clinical claSSifications, ,'hich are used nationally by specialized physical thera­ pists . Clinical classifications are intended to guide the ther­ pist in treatment planning. However, the type and sever­ t:' of phYSiologic impairments within the dysfunction vary, :lIld treatments must be individualized. Each classification as a blief description of t11e syndrome and a discussion of • e cause , common impairments, and functional limita­ , ns. There are many possible causes for these dysfunc­ ons, which often result from a combination of pathologiC nditions and comorbidities. In many cases , the primary a use is unknown. Therapists should have some under­ anding of the causes and comorbidities of the dysfunction they are treating, although it is not always necessary to pin­ point the cause for effective treatment. It is necessary to de ntify the correct impairment for effective treatment.

419

Much of the information on PFM dysfunctions is based on the clinical observations of gynecologiC physical thera­ pists around the country. Unfortunately, few studies have been performed on the physical therapy treatment of these patients. All four clinical classifications are presented to provide a complete view of the dysfunctions treated by physical therapists. The medical diagnoses associated with supportive and hypertonia dysfunctions are discussed later in this chapter. There are four clinical classifications: 1. Supportive dysfunction 2. Hypertonia dysfunction 3. Incoordination dysfunction 4. Visceral dysfunction

Supportive Dysfunction Supportive dysfunction results from the loss of strength and integrity of contractile and noncontractile tissues; this dysfunction is wealmess and sagging of the PFMs. Com­ mon medical diagnoses often associated with suppOliive dysfunction are stress incontinence , mixed incontinence, and pelviC organ prolapse (see Patie nt-Related Instruction 19-6: Boat at the Dock-Role of Pelvic Floor :\IIuscies in Organ Prolapse). The supportive role of the PFMs in con­ tinence was discussed earlier in this chapter.

Etiology and Comorbidities Severe birth injury may result in anatomic impairments of the PFMs and nerves in the area. More commonly, the trauma of vaginal delivelY results in moderate or mild mus­ cle impairments. Altered muscle length or tension may oc­ cur with stretch during delivery. Stretching of connective tissue or muscle beyond its elastic capacity renders the tis­ sue permanently long . The increased length of connective tissue means that the muscle must generate more force to accomplish the same function. Functional weakness and impaired muscle performance result. Hypertrophy of the remaining muscles often produces the desired effect of im­ proved support of the PFMs. Muscle atrophy can result from central and peripheral nervous system dysfunction, including nelve damage from pelvic surgery. Temporary neurologic dysfunction, such as mild stretch to the pudendal nerve during delivery often responds well to PFE. In conditions of mild or incomplete nerve damage, the remaining PFMs often become hyper­ trophied and produce good functional outcomes. One

Coordination of the Pelvic Floor Muscle ACTIVITY

NORMALPFM ACTION

NORMAL ABDOMINAL ACTION

DYSFUNCTIONAL PFM ACTION

RESULT OF DYSFUNCTIONAL ACTION

Lifting

Contraction Relaxation

Relaxation or weak contraction Contraction

Leaking urine

Bowel movement

Inward contraction by obliques Bulging contraction by rectus abdominis with Vaisalva maneuver

Difficulty passing feces, constipation, pain

• In training of pelvic floor muscle (PFM) function, the patient must learn the coordinated functions ofli/bng and bowel movement and the isolated PFM contraction for training and strengthening.

420

Therapeutic Exercise: Moving Toward Function

Boat at the Dock-Role of Pelvic Floor Muscles in Organ Prolapse • Imagine there is a boat tied to a dock (A). The pelvic organs (Le., bladder, uterus, and rectum) are the boat. The ropes holding th e boat to the dock are the ligaments that support the organs from above. The water is the pelvic floor muscle. • If the water level drops (B) (Le., loss of support or weakness of the pelvic floor muscles), the boat (organs) hangs on the ropes (ligaments). Eventually the ropes stretch out and break, resulting in the boat (organs) falling down (i.e., prolapse). • If you pull the boat back up by replacing the ropes O.e., organ suspension surgery) without raising the water level (i.e., pelvic floor muscles strengthening) (e), the boat will continue to hang on the ropes and eventually falls down again (Le., prolapse). Falling happens quicker if you jump on the boat O.e., increase pressure in the abdomen from cough, sneeze, lift, or improper exercise). • Long-lasting results are more likely if you raise the water level (i.e., pelvic floor muscles strengthening) and stop jumping on the boat O.e ., reduce unnecessary increases in abdominal pressure). In this case, the ropes (ligaments) mayor may not need to be replaced (i.e., ligament and pelvic organ surgery).

while patients are on prolonged bed rest. These restrictions may result in disuse atrophy and impairment of PFM per­ formance. Prolonged increased intra-abdominal pressure may re­ sult in stretching of the PFMs or their tendons and may contribute to pelvic organ prolapse. Repeated, incorrect lifting or straining \vith Valsalva maneuvers and chronic or prolonged coughing or vomiting perpetuates incontinence and prolapse symptoms and slows recovery of PFM strength. These chronic increases in intra-abdominal pres­ sure may initiate PFM impairment. Pregnancy and ab­ dominal obesity increase intra-abdominal e essure. Obe­ sity correlates with increased incontinence. ,:32,1, Pelvic congestion or swelling of the PFMs can occur during pregnancy and in some lymphedema conditiom . Swelling in and around a muscle may inhibit its action sufficiently to cause impaired muscle perrormance. Hor­ mones released during pregnancy loosen the connecth' tissue of PFM tendons, which causes the muscles to sag. Because pregnancy is a temporary condition, most physi­ cians and therapists are not concerned about symptoms of supportive dysfunction during pregnancy. However, 9 months of prolonged intra-abdominal pressure, especiaU \vith improper lifting at work, during exercise and ADLs , 0 in lifting another child, and prolonged, hormone-indue lengthening may result in sig~iflcant postpartum SurfOJi­ Ive PFM dysfunction , even WIth a cesarean delivery.

Pelvic ligaments

Pelvic organs

L

Common Impairments

PFM

B

A

c

study reported 15% to 20% of patients undergOing radical pelvic surgery had permanent voiding dysfunctions. , 1 Pelvic surgery may result in complex anatomic changes that affect PFM function 9 Many young children are taught not to touch or look at the perineum. In some cases, this early training results in adults with decreased awareness of the PFMs. Decreased awareness does not necess arily result in PFM weakness, but disuse atrophy may occur when decreased awareness is combined 'with other risk factors, such as menopause and bed rest . Decreased awareness of PFM contraction often exists conculTently with other impairments and makes re­ habilitation more challenging. Many patients 'with severely decreased awareness can benefit from biofeedback in­ struction to identify the correct muscle contraction. The PFM s are used less when a Foley catheter is in place and

The most common phYSiologic impairments of sUPPOlti\­ dysfunction are impaired PFM performance, includin _ PFM weakness, increased PFM length, increased connec· tive tissue length, and muscle atrophy; endurance impair. ment of the PFMs; and impaired abdominal muscle per· formance , including weakness and increased length of th abdominals. The less common phYSiologic impairments associat, with supportive dysfunction should also be treated for recovely. Coordination impairm ent of the PFMs duri _ ADLs often exists to some degree in supportive dysfun: . tions; coordination impairments of the abdominal mus also occur with supportive dysfunction . When the PF ~ are fairly strong and incoordination is Significant, the r tient is given the diagnOSiS of incoordination dysfuncti Pain impairments of the PFMs may be a concurrent p lem that may lead to pain-induced weakness. In this c the origin of pain must be treated to reach maximum m cle strength. JOint mobility impairment of the lumbopel region may also affect the PFMs. A summary of impa. ments and suggested interventions for supportive dysfu. tion is provided in Display 19-9,

Functional Limitations Patients may exhibit symptoms of stress incontin en mixed incontinence, and organ prolapse. Loss of urin e \\­ coughing, sneezing, laughing, lifting, or exercising often quires the use of absorbent products (i.e. , incontine pads or diapers ). Some patients limit or modifY acti\; for fear of leaking urin e.35 Patients may avoid shopp_ _ trips , overnight vacations, outdoor activities, and spOli

Chapter 19 The Pelvic Fl oor

DISPLAY 19-9

Summary of Impairments and Suggested Interventions for Supportive Dysfunctions • Impaired performance and endurance of the PFM: weakness, increased length, atrophy PFE with facilitation, overflow, biofeedback or vaginal cones Electrical stimulation (NMES) • Coordination of the PFM: decreased awareness of how to contract correctly PFE with biofeedback and during ADLs • Coordination and impaired performance ofthe abdominals Therapeutic exercise for the abdominals Proper contraction of abdominals with function • Pain in PFM and mobility of pelvic joints

Soft tissue mobilization, scar mobilization

Joint mobilization, muscle energy techniques

Modalities such as heat, cold, ultrasound, and electrical

stimulation

~DLs, ~FE,

activities of daily living; NMES, neuromuscular electrical stimulation; pelvic floor exercises; PFM, pelvic floor muscles.

use of incontinence. Urinary frequency is urination more lan seven times in a 24-hour period, and Ulination some­ mes occurs as often as cvery 30 to 40 minutes. Frequency .... conjunction with urinary urgency may require modifica­ n of ADLs, because patients usually do not venture far rom the toilet. Lack of PFM support may be p ainful and t' lilt in decreased ability to ambulate or exercise.

vpertonia Dysfunction H\pertonia dysfunction is a complex category related to in and spasm of the PFMs. Common medical diagnoses sociated with hypertonia dysfunction include levator ani . n drollle , pe lvic floor tension myalgia, coccygodynia, vul­ 'odynia, vestibuiitis, vaginismus , animus , chronic pelvic in, and dyspareunia. Hypertonia dysfunction may result J a m p elviC joint dysfunctions, hip muscle imbalance, and ..bdominope lvic adhesions and scars affecting the PFM ction.

Etiology and Comorbidities The cause of hypertonia dysfunctions is often more diffi­ cult to identifY than the cause of other dysfunctions. Lum­ opelvic joint mobility impairments or pathology is one of <.he most common impairments found in patients with hy­ pertonia dysfunction. Injuries, such us a fall onto the coccyx or pub ic ramus, are common for thes e patients. LUIl1­ bopelvic jOint dysfunction may result from PFM dysfunc­ 'on or may directly or indirectly cause PFM spasm. Tonic holding patterns and spasm may result from the proximity of muscles to traumatized pelvic joints. Hip joint integrity and mobility, pain, and muscle per­ rOflnan ce impairments contributes to hypertonia dysfunc­ tion through its effect on the pelvic jOints. Spasm of the as­ ociated muscles, particularly the obturator internus and piliformis, can directly initate the PFMs , causing holding and spasm.

421

Abdominal or perineal adhesions and scars can cause hypertonia dysfunction. Pelvic organs must slide freely during phYSiologiC functions such as peristalsis , bowel movement, or vaginal penetration during intercourse. Ab­ dominal adhesions can restrict pelvic organ movement and cause pain and spasm of PF\tls dUling bowel movement or intercourse. Severe adhesions of the uterosacral ligaments may restrict sacroiliac joint mobility. Adhesions may be a result of pelvic or abdominal surgery or an inflammatory condition of the abdomen, such as endome triosis. Perineal scars (often found in third- or fourth-degree episiotomies) can cause adhesions to the rectum and vaginal wa!lls. These scars can be so painful that patients dread every bowel movement. Other painfu l conditions such as in terstitial cystitis, endometriosis, fissures, and fistulas may also cause holding pattems in response to pain. H olding pattems of the PFMs may occur as a response to excessive gene ralized stress or reflect an emotio nal connec ti on to the per­ ine um .:36 Excessive holding of the PFM s because of pain or stress often leads to trigger points, ischemic changes, and tissue shortening. Connective tissue diseases such as fibromyalgia are as­ sociated with hypertonia dysfunctions, particularly vulvo­ dynia. Pelvic pain, as discussed earlier, may be a problem for sexually abused individuals. The exact connection is un­ known, but emotional holding of the PFMs und physical trauma to the pe rineum may plu)' a part in the eventuul de­ velop ment of hypertonia dysfunction .

Common Impairments The re are many possible plirnary phYSiologiC: irnpcunnen ts in hypertonus dysfunctions . Careful eval uation is necesscuy to determine the most signific:ant impairments in each pa­ tient. The most common impairlllents of hypertonus dys­ function are altered tone of the PFMs, including spasm and tri?;.,~er pOints; altered tone (e.g., trigger points, spasm) of associated muscles of the hip, buttock, and trunk; impaired muscle performance and coordination impairments of the hip, leading to musc:le imbalance around the hip; jOint mo­ bility impairments of lumbopelvic joints, particularly the sacroiliac, pubic S)'111physis , and lower lumbar facet joints; mobility impairments of scar and connective tissue; and posture impairment, contributing to pelViC joint dysfunc­ tion. Pain impairment because of hypersensitivity of the pelineal skin is common in vulvodyn ia, but it is not typical of other hypertonia dysfunctions. A summary of impair­ ments and suggested interventions are prOvided in Display 19-10.

Functiona l Limitations Hypertonia dysfunctions of the PFMs have functional lim ­ itations similar to other pelvic pain syndromes, such as low back and pelviC girdle pain. The ability to work (e.g. , lift, sit, push, drive , clean house ), recreate, ambulate, sleep, and perform ADLs may be limited. Functional limitations unique to PFM hypertonia may result in a decreased abi l­ ity or inubility to sit because of severe perineal pain. Some patients cannot wear jeans or ride a bike. Routin e pap smears can be painful or impOSSible. The affected woman often has a decreased ability or an inabi lity to have sexual intercourse or sexual contact of any kind.

422

Therapeutic Exercise: Moving Toward Function

DISPLAY 19-10

Summary of Impairments and Suggested Interventions for Hypertonus Dysfunctions • Altered tone of the PFM: muscle spasm and trigger points Biofeedback for training the PFM to relax Rhythmic contract and relax of the PFM (quick PFE) Soft-tissue mobilization, vaginally or rectally Electrical stimulation on the perineum, vaginally or rectally Relaxation training, autonomic nervous system balancing Vaginal or rectal dilators Ultrasound atthe insertion of the PFM atthe coccyx Heat or cold over the perineum • Altered tone of the associated muscles of the hip, buttock and trunk-muscle spasm Soft-tissue mobilization Therapeutic exercises for stretching Modalities such as ultrasound, electrical stimulation, heat, and cold • Muscle impairments and coordination impairments of the associated muscles of the hip, buttocks, and trunk: muscle imbalances around the trunk and hip joint Therapeutic exercises for strengthening and stretching Coordination training of muscles around a joint (i.e., around the hip) or between several areas (hip and abdominals) • Mobility impairment of scar and connective tissue of the perineum, inner thighs, buttocks, and abdominals Soft-tissue mobilization, scar mobilization Visceral mobilization Modalities such as ultrasound, heat, and microcurrent • Mobility impairments (e.g., hypermobility, hypomobility) of pelvic joints: sacroiliac, pubic, lumbar, hip and sacrococcygeal Joint mobilization, muscle energy techniques, strain and counterstrain, craniosacral therapy Posture and body mechanics education Therapeutic exercises for muscle imbalances Modalities such as ultrasound, heat, cold, electrical stimulation, and TENS • Faulty posture leading to undue stress on the pelvic

structures

Instruction in proper sitting and standing posture and

body mechanics Use of cushions, lumbar rolls, and modified chairs • Pain in the perineum with hypersensitivity of the skin and mucosa Modalities such as cold, heat, ultrasound, and electrical stimulation

Education on avoiding perineal irritants

PFE, pelvic floor exercises; PFM, pelvic floor muscles; TENS, transcutaneous electrical nerve stimulation

Many women and men are embarrassed to talk to their doctors, family, and friends about pelvic, perineal, or geni­ tal pain. It is difficult to explain the reasons for functional limitations if you are unable to tell someone the location or the nature of the pain. This creates emotional stress. Chronic pelViC pain patients often suffer in silence for many years before they find a medical professional who is able to treat them effectively.

Incoordination Dysfunction Incoordination dysfunction can be divided into neurologic and non-neurologic syndromes. Detrusor sphincter dyssynergia is a type of incoordination resulting from a neurologic lesion in the spinal cord between the brain stem and T10. The PFMs and smooth muscle internal sphincter contract during a bladder contraction so that urine is unable to be expelled. This condition should be monitored by a physician. Symptoms of neurolOgiCincoordination are similar to the obstructed voiding symptoms listed in the screening evaluation questionnaire. The therapist should refer the patient to the physician if neurologic incoordina­ tion or obstructed voiding is suspected. Incoordination dysfunction may be a minor dysfunction with supportive or hypertonia dysfunctions, or it may occur as the primary dysfunction. Non-neurologic incoordination dysfunction is characterized by absent or inappropriat pattems of timing and recruitment of the PFMs. Common medical diagnoses associated with incoordination dysfunc­ tion include stress incontinence, constipation with ob­ structed defecation, and pelvic pain.

Etiology and Comorbidities of Non-Neurologic Incoordination Dysfunctions The cause of pure non-neurologic incoordination dysfunc­ tion is often related to disuse and decreased awareness 0 the PFMs and abdo minals . Muscle atrophy is not signifi ­ cant in this dysfunction. Decreased awareness may refle an emotional condition or social conditioning. Pain i th e pelViC or abdominal area may disrupt recruitmen patterns . Surgical intervention may result in inhibitiol of the muscles-the muscles forget what to do, when tr do it, and how it should be done. Some patients ha\ ­ never been aware of the PFMs and have developed poo­ recruitment patterns.

Common Impairments of Non-Neurologic Incoordination Dysfunctions PFM weakness may be a minor impairment. Most of th patients are found to have good PFM strength on the M~I T Coordination impairment- is the primary phYSiolOgiC ir: ­ pairment. Coordination impairment of the PFMs were dis­ cussed previously in the Coordination Impairment secti

Functional Limitations of Non-Neurologic Dysfunctions The most common functional limitation of incoordinati dysfunction is stress incontinence with urine leaking dU rin_ increased intra-abdominal pressure, such as during coug ing, sneezing, or lifting. Patients also may have obstruct defecation with constipation and rectal pain.

Visceral Dysfunction Visceral dysfunction is a pseudo-PFM dysfunction. It is disease or abnormality in mobility or motility of the , dominopelvic visceral tissues that leads to pain and muse loskeletal impairments. Detrusor instability, often foun d patients with urge incontinence, is the most widely 51 visceral dysfunction directly related to the PFMs. It

Chapter 19 The Pelvic Floor

characterized by irritated detrusor contractions and is often related to PFM impairments . Urge incontinence responds well to supportive dysfunction treatments. The causes , im­ p airments, and treatment of urge incontinence are dis­ c ussed later in the Therapeutic Exercise Intervention for Common Diagnoses .

Etiology and Comorbidities \'isceral dysfunction encompasses several medical diag­ noses: endometriosis, pelvic inflammatory disease , dys­ menorrhea, surgical scars , irritable bowel syndrome, and mterstitial cystitis. These conditions may result in impair­ me nts whose primary origin is abdominopelvic pain or ad­ hesions caused by organ disease. Knowledge of the causes and medical management of these diseases is necessary to tre at the resulting impairments. A multidisciplinary ap­ proach is optimal when dealing with visceral dysfunction. T reatment of comorbid musculoskeletal impairments often results in decreased pain and increased function.

Common Impairments Weakness of the abdominal muscles , especially the oblique and transversus layers, may occur in response to pain in the abdomen, causing a pendulous abdomen v\lith poor visceral .md lumbar support. Secondary lumbopelvic joint mobility Lmpairment and posture impairments may result. Altered one (e .g. , spasm) or impaired muscle performance (e.g., \'eakness ) of the PFMs may also occur as a result of pain in e lower pelvic organs. Chronic pelvic pain postures often cur with long-standing abdominopelvic pain, These pos­ res result in posture impairment; mobility impairments f pelvic and lumbar jOints; altered tone, pain, and trigger points in trunk and lower extremity muscles; and impaired performance of the hip muscles with length and tension ·h anges. Abdominal adhesions and scar mobility restric­ 'ons may result in decreased mobility or motility of ab­ ominal and pelvic organs and pelvic joints. When organ mobility is restricted, cramping, pain, and altered organ w1ction may result. For example, abdominal adhesions may form around parts of the bowel , constricting the bowel u me n and making passage of feces painful. Mobility impairments playa major role in visceral dys­ unctions. Visceral mobilization techniques are used by phYSical therapists to restore normal mobility of organs.

Functional Limitations Functional limitations vary greatly in cases of visceral dys­ function. In the case of dysmenorrhea (i.e. , painful men­ truation ), patients may have 2 to 3 days each month of in­ 'e nse abdominal pain that confines them to bed. Other 'on ditions result in constant abdominopelvic pain and cause functional limitations such as those of patients vvith nk or back pain, who have a decreased ability to work , _it, walk, lift, have intercourse , play sports, exercise, or per­ 'orm daily ADLs. Functional limitations may be directly re­ ted to organ dysfunction. For example, interstitial cystitis causes the person to urinate as often as every 15 minutes. I rri table bowel syndrome may result in alternating diarrhea and constipation, with many patients experiencing abdom­ inal pain and bloating. These functions are unpredictable and often force patients to remain near the toilet for fear of evere cramping or incontinence of feces.

423

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON DIAGNOSES This section describes the most common medical diag­ noses for the pelvic floor region and suggests physical ther­ apy interventions. The diagnostic classifications gro up physiologic impairments into common syndromes . The medical community uses a different classification syst m, and phYSical therapists should be aware of the medical clas­ sifications, testing, and medical treatme nt of these condi­ tions to enhance their ability to provide effective physical therapy intervention. The associated medical diagnoses discussed here are commonly associated with supportive and hypertonia dys­ functions. Medical diagnoses associated "vith supportive dysfunction usually fall into nyo categories-incontinence and organ prolapse. Both can be extremely complex condi­ tions vvith many associated impairments and comorbidities. Some conditions associated vvith supportive dysfunctions are anatomic impairments and cannot be changed vvith physical therapy intervention. The most common medical diagnoses associated with hypertonia dysfunction include chronic pelvic pain, levator ani syndrome, coccygodynia, vulvodynia, vaginismus, anis­ mus, and dyspareunia. The most common phYSiologic im­ pairments for each diagnosis are discussed \.vith the diag­ nosis. Any impairment may be Significant, and failure to address all significant impairments may limit the patient's progress. Any and all combinations of impairments listed for hypertonia dysfunction can be associated with these di­ agnoses. Each patient should be evaluated thoroughly, im­ pairments identified , and treatment plans developed based on the severity and significance of each impairment.

Incontinence Incontinence is defined as the ~omplaint of any involuntary leakage of luine, feces , or gas 3 1 More than 1.3,000,000 per­ sons in the United States have urinary incontine nce. This fig­ ure includes apprOximately 50% of nursing home patients. Careful evaluation of these patie nts often reveals PF\1 weakness and treatable comorbidities. Approximately 80% of these incontinent patie nts can be Significantly helped \.\Tith noninvasive behaviora[ techniques used by physical thera­ pists, occupational therapists, and registered nurses. is Incontinence can be a limiting condition. It may occur durin sports activities and cause embarrassment. 3H Ny­ gaard -" conducted a questIOnnaIre study of women who ex­ ercised. She found that 47% had incontinence during exer­ cise . Twenty perce nt of those women modified their exercise routines solely because of incontinence. Some women even stop exercising because of incontinence. This disruption in exercise ability may have a Significant effect on physical therapy for other areas of the body. The thera­ pist may encounter poor compliance vvith exercises that cause incontinence. The instructions included in this chap­ ter may be enough to correct or minimize symptoms so that the patient can return to active exercises. Incontinence also may limit elderly persons' activity lev­ els. In some cases, incontinence causes embarrassment and

9_

424

Therapeutic Exercise: Moving Toward Function

may result in seclusion from social activities , family func­ tions, and work. 39 PFM strengthening can help these pa­ tients retun) to an active lifestyle without fear of embar­ rassing leakage. 40 Incontinence also may result in secondary conditions such as skin breakdo\Vl1, which can be a serious medical consequence for the elderly patient. All physical therapy patients should be questioned about leakage, and, if appropriate, instructioJlS should be given to help remedy the situation. Understanding the most common types of inconbnence assists tlherapists in developing treatment plans. Physicians broadly categorize bladder dysfunctions as the failure to store urine and the failure to empty urine. Stress, urge, and mixed incontinence a1'e examples of a failure to store urine. Overflow incontinence is the failure to empty urine . The full screening questionnaire provided earlier helps to identify the type of incontinence. Stress and mixed incontinence are the t'I:vo types directly related to supportive dysfunctions. rge incontinence is a viJsceral dysfunction. Overflow and functional incontinence are usually not related to support­ ive dysfunction of the PFMs (see Tahle 19-4).

Stress Incontinence Stress incontinence is defined as involuntary leaking of urine on effort or exertion_ such as during coughing, laugh­ ing, sneezing, and lifting 3 ' Continence is maintained when the pressure in the urethra is higher than the pressure in the bladder. Strong PFMs help to increase the pressure in the urethra . The urogenital diaphragm muscles playa large role in the closure of tr,e urethra (see Fig. 19-4). In stress incontinence, the patient coughs, and pressure in the abdominal cavity is increased, pressing do\Vl1 on the

Cough

Sneeze

Laugh

Jump

Urine

L

d6b

Bladder

" PFM

d()l)b d

FIGURE 19-11. Stress incontinence.

bladder. If urethral pressure is low (usually because the PFMs are not strong enough ), the urethra is forced open slightly, and a small amount of urine leaks out (Fig. 19-11 ), The causes of stress incontinence are similar to the cause of supportive dysfunction. Physiologic impairments in­ clude impaired PFM performance, shOitened endurance. and coordination impairments. Treatment for pure str incontinence includes PFM exercises, vaginal weights, and electrical stimulation. 15 .16

Urge Incontinence Urge incontinence is defined as leaking urine associate with a strong urge to urinate?7 The normal urge to urinate is a result of activation of stretch receptors in the detl1lSCY muscle. During this urge, the detrusor remains stable ani does not contract. In some patients, a very strong urge tr urinate is associated with inappropriate detrusor contra"·

Tvpes Of Incontinence, Symptoms, and Possible Treatments TYPE OF INCONTINENCE

SYMPTOMS

DIAGNOSIS CLASSIFICATION

POSSIBLE TREATMENT

Stress incontinence

Small urine leak with cough sneeze, exercise

Supportive dysfunction, PFM weakness

Urgc incontinence

Moderate or large uline If:
Visceral dysfunction, may have PFM weakness also

Overflow incontinence

Small amounts of urine leaking constantly with cough and sneeze, straining to start urination, feeling of incomplete emptying

Functional incontinence

Long or difficult trip to the toilet with leaking on the way

Possible incoordination dysfunction (PFM contraction dUling Ulination), visceral dysfunction (atonic bladder) , hypertonia dysfunction (PFM spasm or pain) Mobility impairment of decreased ambulation ability, poor transfer ability, decreased finger coordi nation

PFE, biofeedback, vagin' cones, electlical sti m ulation Bladder training, PFE if needed, biofeedback electrical stimulation Bladder training, PFE biofeedback vaginal cones, electrical stimulation Medical evaluation mav be needed, advanced PFM rehabilitation with biofeedback electrical stimulation , MFR, PFE , bladder training

Mixed incontinence

Supportive dysfunction , PFM weakness, visceral dysfunction

MP H. myofascial release; PF E , pelvic floor exercises; PFM , pelvic floor muscl e.

Gait training, strengthe exercises for lower and upper extremiti e~ . environmental modifications

Chapter 19 The Pelvic Floor

·ons . Unstable detrusor contractions are contractions of the bladder muscle at incorrect times (e.g., when not posi­ 'oned over the toilet to void). Strong, unstable detrusor rontractions, as seen in overactive bladder or detrusor in­ . tability, increase bladder pressure and may result in in­ o ntinence. The volume of urine leaked is usually larger :han that with stress incontinence and may include the en­ dee contents of the bladder. In some cases, urge inconti­ ence may occur without unstable detrusor contractions ,.e. , sensory urgency). The underlying cause of urge incontinence is often un­ ~ ear and may include PNS or CNS nerve damage. It is u pected that poor bladder habits (especially going to the throom too frequently) and bladder irritants (such as affeine, nicotine, and alcohol) contribute to the condi­ ·on. PFM weakness with impaired muscle performance d endurance impairment is often found in patients with !Tge incontinence. Coordination impairment of the PFM s llring detrusor contraction may also be present. In this . tuation, the PFMs do not contract in response to the rge to urinate, and a small increase in bladder pressure ay cause urine leakage . Prim ary treatment for urge in­ _ontinence can include bladder retraining, avoiding blad­ er irritants, PFE , low-frequency electrical stimulation, ..nd medications.

425

ists may include biofeedback, electrical stimulation, my­ ofascial release, PFEs, and bladder training.

Functional Incontinence Functional incontinence is defined as the loss of urine be­ cause of gait and locomotion impairment. Incontinence is a secondary condition in pure functional incontinence; the primary impairment is a gait and locomotion impairment­ an inability to get to the toilet quickly enough. It is not un­ usual for an elderly or disabled patient to require oS to 10 minutes to rise from a chair, ambulate ,-,vith a walk r to the toilet, maneuver in front of the toilet , lower his or her clothes, and sit down. Elderly patients often have les s abil­ ity to store urine because of PFM weakness and less ability to defer the urge to urin ate than you nger persons. The mobility-impaired patien t may leak urine on the long jour­ ney to the toilet. Patients may also have PFM dysfunction or anatomic impairments. However, treatment of gait and locomotion impairments and adjustments to the environ­ ment can improve function, and phYS ical therapists are well suited to help these patients. Some ideas for helping these patients are detailed in Display 19-11.

DISPLAY 19-11

Wixed Incontinence fixed incontinence is a combination of stress and urge in­ symptoms. These patients report leaking urine ith increas es in intra-abdomin al pressure and with a illong urge to urinate. The causes of mixed incontinence e similar to the causes of supportive dysfunctions. The PF Ms are usually weak. Treatment of this condition is sim­ to treatment for urge incontinence: bladder training, "oiding bladder irritants, PFM exercises , electrical stimu­ tion, vaginal weights, and in some cases, medications. ~ntinence

!1verflow Incontinence 'erflow incontinence results from a failure to empty the

I dder fully. Obstruction of the urethra by tumor, scar

. sue around the urethra, an enlarged prostate, hypertonia

)[ the PFM, or other mechanical blockage may prevent

the bladder from emptying. D ecreased contractility of

the bladder from a neurolOgiC de ficit, such as peripheral

erve injury associated with radical pelvic surgery, cauda equina injUly , or diabetes, also may contribute to overflow mcontinence. In overflow incontinence , the bladder does not empty ully, and high volumes of urine are maintained in the blad­ der. When the bladder pressure is higher than the urethral pressure, small amounts of urine "spill out." This small but nstant leaking mayor may not be related to increased in­ tra-abdominal pressure and is characteristic of overflow in­ continen ce. Physical therapy impairm en ts may include pain and altered tone from spas m of the PFMs. Mobility mpairment may be caused by adhered scars. Many cases . volve neurologic incoordination of the PFMs or primary \iscercd dysfunction and require medical intervention . A ull medical evaluation is essential. Therapists should refer le patien t to the doctor if overflow incontinence is sus ­ pected. Physical therapy treat ment by pelvic floor special­

HelpingPatients With Functional Incontinence • Improve the speed of the sit-to-stand transfers by raising the height of the chair, providing a chair with arms, improving shoulder depression and elbow extension strength, and improving lower extremity strength in the quadriceps and gluteals. • Improve the speed of ambulation to the bathroom by providing appropriate assistive devices, clearing obstacles from the pathway to the toilet, bringing the patient's chair closer to the toilet (e.g ., move the sitting room to the side of the house nearest the toilet) or bringing the toilet closer to the patient (e.g., place a commode or urinal near the bed or sitting room), and improving balance and coordination, strength, and endurance of the lower extremities. • Improve the speed of ambulation in the bathroom by clearing obstacles (especially rugs) and providing grab bars for ambulation without assistive devices ifthe bathroom is too small for the device to fit easily. • Improve speed of lowering clothes by providing patient with Velcro-open pants, suggesting that women wear skirts and dresses, and improving finger coordination and dexterity to manage buttons and zipper more quickly. • Improve stand-to-sit transfer onto the toilet by providing a raised toilet seat and handrails and by improving lower extremity function. • Consider cognitive impairments in a patient's ability to recognize the bathroom. It may be helpful to place a picture of a toilet on or near the door or to leave the door open. In severe cases, even when patients are brought to the toilet, they may still not understand what to do. • Absorbent garments (i.e., diapers and pads) are available for men and women in a variety of sizes. Helping patients and caregivers to choose appropriate garments may allow increased participation in work, social, and recreational activities. Always make sure that the physician has been informed of the patient's incontinence and that conservative treatments have been tried .

426

Therapeutic Exercise Moving Toward Function

Organ Prolapse Organ prolapse is the second largest categoq of medical di­ agnosis associated "vith supportive dysfunctions. The cause of prolapse may be complex and is often associated with PFM supportive dysfunction and prolonged increases in intra-abdominal pressure. A simple explanation of prolapse and PFM function is presented in the Patient-Related In­ stmction 19-6: Boat at the Dock. The most common types of organ prolapse (Fig. 19-12) are cystocele (j.e., protrusion of the bladder into the anterior vaginal vault ), uterine pro­ lapse (i.e. , displacement of the uterus into the vaginal canal), and rectocele (i. e. , protrusion of the rectum into the posterior vaginal vault). Common symptoms include a sensation of organs "falling out," feelings of pain or pressure in the perineum 37 that may limit functional activities in standing, feeling that thcre is something bulging in the vagina, sensations of sit­ ting on a ball, difficulty defecating (j.e., rectocele), diffi­ culty urinating (i.e. , cystocele), or painful intercourse (j.e ., uterine prolapse). All patients should learn how to protect the PFMs from undue stress. However, it is essential that patients with organ prolapse learn how to avoid increas ed intra-abdominal pressure. Physical therapy treatment in­ volves educating patients on decreasing intra-abdominal pressure (see Patient-Related In struction 19-7: Decreas­ ing Intra-abdominal Pressure) and PFM exercises.

Chronic Pelvic Pain Chronic pelvic pain is the most widely seen diagnosis asso­ ciated "vith hypertonia dysfunction. It is analogous to the diagnosis of low back pain-it does not give specific infor­ mation about what type of impairments may be present. The most common impairments are altered tone and per­ formance impairments of the associated muscles of the Rectum

nPr-7

Bladder

~~ B

A

nO

~

~'? c

• Avoid constipation, and do not strain with defecation (i.e., bowel movement). Drink lots of fluids to help avoid constipation and soften stools. Consult with a dietitian or physician about dietary changes and medications to avoid constipation. • If you have difficulty getting out of the chair, scoot to the edge ofthe chair, lean forward, and push up with the arms. Avoid bearing down and breath holding. Instead, contract the abdominals inwardly, breathe out. and contract the pelvic floor muscles (PFM) while you stand up. • Lift properly with inward contraction of abdominals and outward breath on effort. Avoid bulging the abdominals outward and bearing down. • Exercise correctly using an inward abdominal contraction. Avoid bearing down and pouching the abdominal muscles outward. Unnecessary increases in intra-abdominal pressure may occur while lifting weights that are too heavy and with abdominal exercises that are too advanced. Curl-ups or sit-ups commonly cause the abdominals to bulge. Avoid curl­ ups if you have organ prolapse. You should advance to weight lifting, advanced abdominal exercises, and jogging slowly and carefully if you have PFM weakness. • If you are a postpartum woman, it is especially important to restore adequate PFM strength before returning to high-impact aerobics, jogging, and advanced weight lifting. The jumping jack test (see Patient-Related Instruction 19-2: Testing Your Pelvic Floor Muscles by Performing the Digital Vaginal Self­ Examination) can be used to determine the ability of the PFM to withstand stress. You should be able to do five jumping jacks one-half hour after urinating before returning to exercises that repeatedly increase pressure on the PFM. It is important to continue active rehabilitation of the PFM during your return to vigorous exercise. If incontinence persists or worsens, you may have to delay the return to vigorous exercises until more strength of the PFM is gained. • It is important to seek medical treatment for chronic coughing or vomiting and to contract the PFM during coughing or vomiting . You can counterbrace the PFM by contracting during coughing and vomiting. Support the perineal tissue with gentle upward pressure of the hand over the perineum during coughing and vomiting spells.

o

FIGURE 19·12. Common types of organ prolapse. (A) Normal organ posi­ tion s. (8) Cystocele. (C) Rectocele. (D) Uterine prolapse.

trunk and hips , poor posture, and mobility impairme nts the pelvic and lumbar jOints. Therapists should remem the roll of the PFMs in sacroiliac dysfunctions. All patie with chronic pelvic pain should be screened for PFM function, evaluated, and treated if needed.



Levator Ani Syndrome Levator ani syndrome is another diagnosis that m a~' used universally for patients with vaginal or rectal pain. . tients report pain in the coccyx, sacrum, or thigh. Le\ ani syndrome refers to spasm and trigger points in

Chapter 19 The Pelvic Floor

pelvic diaphragm layer of the PFMs. Patients often report pain with defecation and increased pain ,vith sitting. Some patients say they feel like they are "sitting on a ball" (this can also be a symptom of organ prolapse ). Pelvic floor tension myalgia is pain in th e PFMs that is usually associated with spasm or chronic tension . This di­ a!!nosis is simil ar to levator an i syndrome , and many practi­ tioners use the two names interchangeably.

Coccygodynia Coccygodynia indicates pain at the coccyx bone. Pain at the coccyx is usually not related to the sacrococcygeal joint. _lore often, it is related to trigger points of the PFM s, ob­ turator intern us, or piriformis. Patients often have sacroil­ iac joint mobility impairments and less freyuently have acrococcygeal joint mobi lity impairments. Coccygodynia is a common sequel of falls directly on the buttocks. Pa­ li nts report pain with sit-to-stand transfers , possibly be­ cause of gluteal muscle con traction or sacroiliac dysfu nc­ tion. Coccygodynia patien ts have pain that limits sitting. The most common impairments associated v'lith levator ani, tension myalgia, and coccygodynia include altered tone of the PFMs and associated muscles; mobility impairmen ts of scars, connective tissue, and pelvic joints; and faulty pos­ tu re, especially in sitting. All patients ,vith this diagnosis must leam to sit ,vith their weight balan ced on the ischial tuberosities and not on the tail bone (see Patient-Related In­ struction 19-4: Proper Sitting Posture). Some patients need to use a special cllshion to relieve pressure on the coccyx. The most effective cushion is a seat wedge apprOximately 2.5 inches tall with a small cut out in the posterior aspect (Fig. 19-13) A typical donut-shaped cushion places direct pres­ ure on the coccyx and is therefore not recommended.

Vulvodynia \-ulvodynia is a broad diagn osis of pain in the external O'enitalia and vestibule. It can be a severe, often idiopathic condition that mayor may not be associated with PFM dys­ functions. Patients report stabbing pai n in the vagina and less commonly the rectum . Urin ation usually in creases pain. Many patients are completely unable to have vaginal penetration of any kind (e.g., intercourse, speculum evalu-

abon , tampon insertion ). Symptoms are increased ,'lith sit­ ting and by wearing tight pants. The causes of vulvodynia are complex and can include hyperton ia dysfunction; metabolism of calcium oxalate, and other substances; infection by bacterial ane! viral or­ ganisms (j.e., yeast infections are common); pelvic surgery; environmental irritants or reactions; dennatologic condi­ tions; and neoplas tic conditions. Vulvodynia is a difficult condition to treat. A multidisciplinary approach is best. All impairments shou ld be considered, especially mobility im­ pairments of the pelvic and lumbar joints, mobility impair­ men ts of scars, and altered tone of the PFMs and associ­ ated muscles. These patients need special in structions in avoiding perineal irri tants (see Patient-Related Instruction 19-8: Avoiding Perineal Irritants) and may benefit from

Avoiding Perineal Irritants Avoid unnec essary irritation to the vaginal tissue to encourag e healing of the area. The vaginal tissue is like the tissue in your mouth. It needs to stay moist and should not be vigorously cleaned with harsh soaps. Here are some suggestions to decrease the irritation of the vaginal tissue:

Clothing Avoid tig ht clothes, especially jeans and pantyhose. It is also helpful to avoid bike riding, because pressure and rubbing on the perineum can increase irritations. Wear 100% cotton white underpants that are washed separately in hot water with a mild detergent; avoid bleach and fabric softeners.

Hvgiene Use white, unscented toilet tissue and pat dry after urination. Some women spray the vaginal area with a fine mist of plain water then pat dry. Wash the vaginal area gently with mild soap (Le., natural glycerin-based soaps without deodorants or fragrances). Do not douche unless it is suggested by your doctor. Avoid dripping shampoo or other soaps on the vaginal area while in the shower. Soak in the tub with clear water-no bubble bath, bath beads, or other fragrance additives. Do not wash yourself in the tub; wash in the shower.

Menstruation

T ~l

13"

t-------17~"-----1

-r 2~"

-L " -_ _ _ _ _ _ __ __ _

FIGURE 19-13. Coccygodynia seat cushion .

427

Avoid tampons if possible. Avoid pads with fragrances. Consider trying cotton washable menstrual pads. Do not douche, unless suggested by your doctor.

Medications Speak to your doctor before using any prescription or over-the-counter cream on the perineum. Many creams can be irritating and make the situation worse. Do not self-medicate for yeast infections. Some contraceptive creams or jellies and lubricants can irritate . Speak to your doctor about an appropriate contraceptive method . Pure vegetable oil can be used as a vaginal lubricant without irritation by many women.

428

Therapeutic Exercise: Moving Toward Function

pain-reducing modalities such as transcutaneous electrical nerve stimulation at the sacral nerve roots.

Vaginismus Vaginismus is defined as a spasm of muscle around the vagina, usually the superficial muscle layer or urogenital di­ aphragm. It may be associated with vulvodynia. Patients re­ port symptoms similar to those of vulvodynia, although to a lesser degree. Dyspareunia (i.e. , painful intercourse) is a common symptom of vaginismus. Muscle spasms may be a secondary impairment in response to a medical condition, such as atrophic vaginismus or fistula (i.e., a small opening in the skin similar to a small cut at the corner of the mouth). Prim ary dyspareunia may occur with vaginismus as a result of fear of penetration.

The skilled practitioner can employ various modalities and techniques to enhance the effect of active PFE for the treatment of supportive dysfunctions, including the diag­ nosis of incontinence. Modalities and techniques are cho­ sen based on the patient's degree of muscle weakness . For a manual muscle grade of 0 to 2, the practitioner can in­ clude the follO\-ving modalities or techniques : • Facilitation with muscle tapping of the PFMs • Overflow exercises of the buttocks, adductors, and lower abdom inals • Biofeedback with pressure or a surface EMG device • Electrical stimulation • Bladder training • Coordination of PFMs during ADLs

Nonrelaxing puborectalis syndrome or anismus is a spasm of the anal sphincter. It is similar to vaginismus in that it may be a secondary impairment caused by trauma, fissure , fistula, or hemorrhoids at the anal opening. Patients report severe pain "vith defecation, which often leads to constipa­ tion because patients delay defecation . The levator ani may or may not spasm .

For manual muscle grade of 3 to 5, the practitioner can in­ clude weighted cones inserted into the vagina and PFEs in more stressful activities, such as weight lifting. These pa­ tients continue to benefit from bladder training and biofeedback but should be weaned away from facilitation . overflow, and electrical stimulation . Many other interventions are used in conjunction with exercise for the treatment of hypertonia dysfunctions (see Display 19-10). Interventions used for muscle spasms in other areas of the body can be used with PFM spasms well. Later sections describe perineal scar mobilization and a method for externally palpating the PFMs.

Dyspareunia

Biofeedback

Dyspareunia is the symptom of painful penetration and can be associated \\lith all of the cliagnoses previously described. It can be divided into tvvo categories: pain at initial penetra­ tion or pain with deep penetration. Pain with initial pene­ tration may be caused by superficial muscle spasm (j.e., vaginismus ), skin irritation (i.e., vulvodynia), or adhered, painful episiotomy. Deep penetration dyspareunia may be related to spasm of the PFMs (e.g. , levator ani syndrome, tension myalgia) or organ prolapse with visceral adhesions. The most common impairments found in vaginismus, anis­ mus , and dyspareunia are altered tone of the PFMs and as­ sociated muscles and mobility impairment ofscars and con­ nective tissue .

It is necessary to give all patients some form of feedback. whether it is with the finger in the vagina, a mirror, or witt. biofeedback machines during PFEs. Some practitioneI'" use biofeedback machine evaluation and treatment with :L: PFM dysfunction patients. Surface EMG and pressure biofeedback are two methods of machine biofeedbacl. This type of biofeedback is especially helpful if the patiem has decreased sensation or decreased motivation. Pressure biofeedback involves an air chamber con­ nected to a manometer, which records pressure changes The air chamber is inserted into the vagina, and the pati contracts the PFMs around it. The PFM contraction cre­ ates increases in pressure in the vagina that is recorded an.. displayed for the patient and therapist. Some pressure de­ vices collect specific data on pressure changes; others an. used only for immediate feedback to the patient. Thera­ pists must be careful to instruct PFE correctly, beca bearing down increases pressure and may be misinte r . preted as proper PFM contractions. Surface EM G can prOvide even more information abo the muscle contraction, patterns of recruitment, and restin_ tone . It is a powerful tool in treating PFM dysfunction. 41 : internal vaginal or rectal probe or surface electrodes used to pick up the electrical muscle activity of the PFM that it can be displayed. Stand-alone surface EMG un!' provide feedback in the form of a bar graph or line ofligh This gives information about one part of the contraction a time. The units are helpful for home training. Compute'­ assisted surface EMG units can show the electrical muse activity of the entire PFM contraction or several contr-,., ­ tions in a row on one screen (Fig. 19-14). This allows

Nonrelaxing Puborectalis Syndrome

ADJUNCTIVE INTERVENTIONS Many patient-related instructions have been included throughout this chapter. Education is essential for this pa­ tient population. When was the last time someone talked \-\lith you about how to urinate? Take time and make sure your patients understand anatomy and good bladder health, because they are often too embarrassed to admit that they do not know. Physical therapy for the PFMs applies the same princi­ ples of treatment used for other weak and painful muscles. Therapeutic exercise principles are the same, and modali­ ties are used for the same reasons . This section lists the modalities used in supportive and hypertonia dysfunctions. Several techniques are explored in more detail to enhance the therapist's ability to treat PFM impairments.

Chapter 19 The Pelvic Floor EMGA - ­ 1000.---------------------------------.1000 500 500

200 ~ 100

200 100

~o

o

~

Seconds FIGURE 19·14. Print out of computer-assisted surface electromyographic :reatment showing elevating baseline. (From Shelly B, Herman H, Jenkins

T. Methodology for Evaluation and Treatment of Pelvic Floor Dysfunction. Dover, NH The Prometheus Group, 1994)

429

interval by 0.5 hour every week. Do not increase the void­ ing interval if incontinence or urgency is worse or un­ changed. Patients do not follow the bladder training sched­ ule at night. Nocturnal voiding gradually improves as the daytime voiding interval increases. The goal is a voiding in­ terval of 2 to 5 hours, ""ith seven or fewe r voids per day. Urge deferment is taught to allow pabie nts to maintain the voiding interval. If the urge arrives heforp the pre­ scribed voiding interval, patients are enco uraged to Llse the techniques in the Patient-Related Instruction 19-9: Urge Deferment. Patie nts need to practice several different techniques to find the most effective technique for them. After the urge has passed, patients should try to wait until the correct time to urinate . Patients un able to complete a bladder diary have been shown to have less success with behavioral the rapy for urinary incontinence. 15

Scar Mobilization therapist to compare recruitment at different times in the con traction. Surface EMG is the idea! method of feedback in down training (i.e. , relaxation training) for patients with hypertonia dysfunction of the PFMs. Biofeedback therapy fo r patients with stress , urge, or mixed incontinence is given an A rating by the Agency for Health Care Policy and Re­ earch §uidelines on the management of urinary inconti­ nence. 1 This mean s that properly designed research stud­ i s support t11e effectiveness of biofeedback for the treatment of these patients.

Basic Bladder Training Bladde r training is scheduled voiding to regain normal void­ in!> patterns. It is used in cases of urge ncy, frequency, urge incontinence, or mixed incontinence. Have the patient rewrd the time of day he or she urinates in the toilet, the time of urine leakage (i.e. , incontinence ), and why urine leaked (eg. , cough, sneeze, lift). It is also helpful for the pa­ tient to record amount and type of fluid intake. Information hould be collected for 3 to 6 days. This type of record is called a bladder diary (see Fig. 19-1.3). Bladder diaries can be simple or complex. The purpose of the simple bladder diary is to determine the feature s shown in Table 19-5. The cause of t11e acciden ts he lps identify the type of in­ continence. Total fluid intake and the numher of bladder irritants can be used to counsel patients on appropriate fl uid intake. Bladder irritants must be limited for success­ ful treatment of urge incontin ence . However, limiting overall fluid intake does not decrease incontinence ei­ ther. 42 Patients should be encouraged to drink 6 to 8 cups of fluid per day The average VOiding interval (i.e .. average time between urinations) is the most important piece of information gained from the bladder diary for bladder retraining. Ask the patient to urinate in the toilet at the average voiding in­ terval you determined from the blad der diary, whether they need to urinate or not. For example, if the average voidin a interval was 1 hour, ask the patient to void in the toilet ~~ery 60 minutes-no sooner and no later. The blad­ der eventually becomes accustomed to the schedule, and urgency decreases. Most patients can increase the voiding

Adhesion of perineal scars can cause pain with intercourse (i.e. , dyspareunia), pain vvith bowel movement and weak­ ness of PFMs. The goal of scar mobilization is to lengthen connective tissue and scar adhesions, allowing fasciullayers to slide easily over one another. Complete scar manage­ ment includes internal myofascial release of sca rs, mobi­ lization of scars by patients or their partners, ultrasound , PFE, and heat if needed. One method for teaching mobi­ lization of scar tissue is described in Patie nt-Related In­ struction 19-10: Self-Mob ilization of Scar Tissue. The therapist can describe the technique using the pa­ tient's web space between the thumb and first finger as the posterior vagina (Fig. 19-16). This allows the therapist to give the patient the experience of the amount of pressure that is appropriate and to show how to perform the oscilla­ tions. Oscillations are similar to friction massage in that the goal is to slide the skin over the second laye r of fascia , thereby breaking adhesions and restoring mobility.

Features Determined From A Bladder Diary MEASURE

PURPOSE

Average voiding int('rval Fref[uency of voids il124 h Nocturnal voiding frequency Number of incontinence episodes in 24 h Cause of accidents Total fluid intake

Determine bladder schedule Bladder hab its and outcome data Bladder habits and outcome data Outcome data

Number of bladder irritants per day

' _

Stress or urge symptoms Counsel on normal fluid intake Counsel on decreasing bladder irri tants

Abrams P, et aJ. Th e standardization of' term inology of lower urinary tract functi on: J'( 'port from the stlmoardization sub-committt:c of the IntcrJl ati onal Continence SOCiety. .\Jeurourol Urodynam 2002;21: 167- 17ii.

430

Therapeutic Exercise: Moving Toward Function

Column # Directions Urination in toilet: check, measure, or count # of seconds.

2 Make a check if a urine leak occurs, note small or large.

3 Note the reason for the accident (jump, sneeze, lift, water, urge).

4 Note type and amount of fluid intake.

Fill in the day and date at the top of each column. Name___________________________________

Acct.#______________________________

DAY toilet

leak

reason

fluid

toilet

leak

reason

fluid

toilet

leak

reason

fluid

6am 7am Bam 9am lOam llam 12am Ipm 2pm 3pm 4pm Spm 6pm 7pm Bpm

9pm

I

IOpm Ilpm

I

12pm

I

lam

I

2am

1

3am

I

4am

I

Sam

TOTAL # of pads Stop Test Results ___________________________ Type of pad used_ _ _ _ __ _ _ _ _ _ ___

FIGURE 19-15. Bladder diary.

Patient's Signature.__________________________________

Chapter 19 The Pelvic Floor

• Sit down; pressure on the perineum helps calm the bladder. • Relax and breathe; nervousness and anxiety contribute to urgen cy. • Sm all pelvic floor muscle contractions help to reflexively relax the bladder. • Keep the mind busy; attend to a task involving a lot of attention. Tell yourself you cannot stop to go to the bathroom, count backwards, or pretend you are in the car, and there is no bathroom available. • Practice mind over matter; the mind has great influence over the bladder. For example, you are on a 2- or 3-hour car ride, and you feel the urge to urinate. If you say to your bladder, "Not now; calm down; I'll go later," the urge goes away. The bladder may become conditioned to produce the sensation of urgency and bladder contractions with certain activities (e.g., before leaving home, before a speech, walking past the bathroom, arriving home, while unlocking the door). It is important to break these habits and establish control over the bladder. (Rather than the bladder controlling your actions.)

431

• Wash your hands thoroughly before beginning • Choose one of the following positions: Lying on the bed with pillows to prop the head up Sidelying on the bed In the tub • Use your index finger to reach around from the back while sidelying, or use your thumb to reach the vagina from th e front. • Apply firm, downward pressure on the scar, usually located on the posterior vaginal wall. This probably feels uncomfortable but should not be extremely painful. Constantly holding pressure results in softening of tissue, similar to the feeling of your thumb sinking into a stick of butter. • Maintain downward pressure for 1 to 3 minutes; then begin gentle oscillations in all directions. Do not allow your finger or thumb to slide over the skin; take the skin with you as your thumb oscillates. Continue these oscillations for several more minutes. • Move on to another area of the scar, or finish the session. • Use a hot towel on the perineum or soak in a hot tub to help dissipate any residual soreness.

Tolerance to scar mobilization varies with the severity of adhesions. Most women find that pain with deep myofas­ cial release of scars decreases as the adhesions loosen. Dys­ pareunia usually decreases as scars loosen. Some women fi nd it difficult to effectively massage their own vaginal scars. It may be difficult to reach the vagina, or it may be

Episiotomy scar massage.

Patient's hand

difficult to cause self-inflicted pain. In this case, partners can be trained in a similar manner to assist with treatment. Scar mobilization before intercourse can help decrease dyspareunia. Scar mobilization should not be performed in the presence of open wounds, rash, or infection. Postpar­ tum women should wait at least 6 to 8 weeks after delivery and should check with the physician if questions arise. .

Give downward pressure on t h e ) web space

Externally Palpating the Pelvic Therapist's hand

FIGURE 19-16. Describing self-mobilization of a vaginal scar using the patient web space

Floor Muscles It is possible to palpate the PFMs externally at the insertion to the coccyx and along the length of the muscle at the medial ischial tuberosity. The benefits of this palpation are limited, but it is helpful in palpating and treating trig­ ger points in some parts of the levator ani and obturator

432

Therapeutic Exercise: Moving Toward Function

DISPLAY 19-12

Externally Pal,eating the Pelvic Floor Muscles • Patient position: Place the patient in sidelying with the top leg in approximately 60 to 80 degrees of hip flexion and the knee comfortably bent. Put two or three pillows under the top leg to provide stability in neutral abduction or adduction, and allow the patient to relax the leg fully. Total patient relaxation is necessary for deep PFM palpation. • Therapist's position: The therapist is positioned behind the patient and finds the tip of the ischial tuberosity on the uppermost ilium. • Therapist's preparation: This palpation may be done through underpants but is more effective if the fingers are on bare skin. The therapist should wear a latex or vinyl glove on the palpating hand because it will be close to the anus and perineum. • Hand position: The most effective hand position is supination, and with all four fingers adducted in full finger extension. Keep the hand parallel to the table, and place the fingertips on the skin between the ischial tuberosity and the anus (just medial to the ischial tuberosity). • Technique: Apply gentle inward pressure, directing your fingertips toward the anterior-superior iliac spine (AS IS) of the top ilium. Closeness to the ischial tuberosity results in the skin pulling taught and restricting deep palpation. In this case, reposition the fingers more medial toward the rectum, taking up some skin slack (see Figure). The levator ani muscles are rather deep, being the third layer in the pelvic floor. Depth from the skin varies greatly and can be more than 1.5 inches. When a firm resistance is felt, ask the patient to contract the pelvic floor muscles (PFMs). You should feel a firm PFM contraction pushing your fingers outward. With the PFMs at rest, assess for pain, hypertonia, and

connective tissue restriction in the usual manor. Angling

the fingers anteriorly and posteriorly can give information

about different areas of the levator ani muscle group. The

obturator internus is a little more difficult to palpate. A

review of anatomy is necessary to orient yourself to the

location of the muscle in the sidelying position. Keep the

intern us muscles . This method does not give access to all areas of the pelViC floor. This palpation requi res ski ll ed in ­ struction and practice to perfect. Patie ll t pOSition , therapist preparati on, therapist position , hand pOSi ti ons, and tech­ nique are descri bed in D isplay 19-12.

KEY POINTS • The pelvic floor tissues include four skeletal muscle lay­ ers: ~lJlal sphin cte r (co ntin e nce ), supe rfiCial perineal muscles (sex ual fun ctioning), urogenital d iaphragm (contin ence), and pelvic diaphrJ.gm (continence, pelviC suppori). • T he pelvic diaphragm includes the coccygeus and the le­ vator ani muscles (pubococcygeus and i1iococcygeus), the largest muscle group in the pelvic floor. These mus­ cles are skele tal muscles un der voluntary control and have 70 % slow-twitch and 30% fast -twitch muscle fibe rs. They span from the pubic bone to the tai l bone

palpating hand in the position described previously, and gently change the angle of the hand so that the wrist and elbow drops and the fingers move upward into the tissue above. The obturator internus is located in this area. The muscle should feel somewhat soft. Have the patient contract the muscle to ensure correct location. External rotation can be tested by asking the patient to lift the top knee upward toward the ceiling while keeping the foot on the supporting surface. The therapist resists this motion with a hand on top of the knee. A small isometric contraction should result in palpable muscle tension . The palpation depth is important. Shallow palpation results in palpation of the medial ischial tuberosity. In this case, continue straight, inward pressure until the tissue releases to a deeper level, and then angle the wrist down and the fingers upward. Myofascial release of muscle or connective tissue can be carried out in this position if impairments are identified.

External palpation of pelvic floor muscles. (Adapted from Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts. 1976.)

and betvveen the ischial tuberosities. The pelvic floor ~ close to many hi p muscles (i.e. , obt urator internus an piriformis), but it is neither necessary nor desirable t( move th e legs while contracting the PFM s. • The th ree functions of the pelvic floor are supporth (i .e ., preve nts pelviC organs from prolapsing), sp hint ­ telic (i.e., preve nts involuntary loss of urine, feces , an gas from the urethra and rectu lll ), and sexual (i.e., iI ­ creases sexual app reciation and mailltains erection ). • All patients shoul d be screened for PFM dysfunctio with these simple questions. Do yo u ever leak uri ne feces') D o you ever wear a pad because of leaking UIi n l ­ Do you have pain during intercourse ? If indicated. more comprehensive questionn aire can be given to ar , tempt to identi fy the type of in continence and other )j,.,..~ iting factors. • Patients can be given self-assess ment tests an d tauo-' self-awareness exercises: jumping jack test, digital se ­ examination (finger into the vagina), index finge r on t!: peri neal body, visual exercise, sexercise, and squeezi. _

Chapter 19 The Pe lv.ic Floor

around an object. These home exercises help to develop the exercise program and ensure the patient is contract­ ing the PFM correctly. • Through home self-assessment, the patient reports the number of seconds a PFM contraction can be held, rep­ etitions of holding contractions, and repetitions of quick contractions. • Impairments that affect PFM function include perfor­ mance impairments of the PFMs, abdominals, and hip muscles; pain and altered tone of the PFMs, hip mus­ cles, and trunk muscles; lumbopelvic joint mobility im­ pairments; posture impairments; and coordination im­ pairments of the PFMs and the abdominal muscles. • PFM dysfunctions have four clinical classifications that are used by gynecologic physical therapists across the United States: supportive dysfunction (i.e., loss of sup­ port usually as a result of impaired PFM performance); hypertonia dysfunction (i.e., pain and altered tone im­ pairment in the PFMs); incoordination dysfunction (i.e., coordination impairment with poor timing and recruit­ ment of PFMs); and visceral dysfunction (i.e., dysfunc­ tions of the pelvic viscera with possible PFM involve­ ment). PFM dysfunctions can result in Significant functional limitations and affect the quality of life. • Incontinence is the most common result of suppOliive dysfunction. The most common types of incontinence are stress incontinence (i.e., loss of urine and increased intra-abdominal pressure with a cough, sneeze, laugh, or lift), urge incontinence (i.e., very strong urge to urinate, usually associated with a bladder contraction, which re­ sults in leaking urine), mixed incontinence (i.e., com­ bined stress and urge incontinence), overflow inconti­ nence (i.e., obstruction at the urethra or a flaccid bladder that allows high volumes of urine to collect in the bladder and spill over), and functional incontinence (i.e., leaking of urine because of an inability to ambulate to toilet quickly). • Organ prolapse is another common diagnosis resulting from PFlvl weakness. Forms include cystocele (i.e., bladder prolapse into the vagina), uterine prolapse (i.e., uterine displacement into the vagina), and rectocele (i.e., rectal prolapse into the vagina). • With the results of screening questionnaires, the physi­ cal therapist should be able to develop an exercise pro­ gram, including the duration of slow-twitch contraction, rest between slow-l:\vitch contractions, repetitions of slow-twitch contractions, repetitions of fast-l:\vitch con­ tractions, number of sets per day, exercise pOSition, need for overflow facilitation from accessory muscle, and other treatments that may be helpful. • All physical therapists should be aware of the PFMs and be prepared to give generalized strengthening in­ structions. • Teaching PFEs involves educating the patient on the lo­ cation and function of the PFMs and the importance of normal PFM function, providing accurate verbal clues, and teaching home assessment and awareness exercises. The most effective verbal cue seems to be "Pull your sphincter muscles up and in as if you do not want gas to come out." Many patients become discouraged and abandon PFEs. Therapists must continue to monitor the

433

patient's progress and to actively encourage pmiicipa­ tion in the PFE program.

CRITICAL THINKING QUESTIONS 1. Develop a PFE program for the followin g patients. In­ clude the duration of slow-twitch muscle contractions, duration of rest bel:\veen slow-l:\.vitch muscle contrac­ tions, and number of repetitions of slow-l:\vitch muscle contractions, number of repetitions of quick contrac­ tions, number of sets per day, exercise position, whether to use accessory muscles or not, and any other treat­ ment that may be helpful. Indicate which type of incon­ tinence the patient may have and any risk factors that may limit her progress. a. A 64-year-old woman, a mother of three children, has a 10-year history of gradually worsening urinary leak­ ing with coughing, sneezing, walking, lifting, and laughing. She wears three panty liners each day and leaks a small amount of urine an average of six ti mes per day. The patient does not report a strong urge to urinate or difficulty urinating, and she has no com­ plaints ofpain. She does have a 5-year history of adult­ onset diabetes. She expresses concern about the odor of her leaking and admits avoiding overnight trips, long car rides, and social activities that involve physi­ cal activity such as walk-a-thons or exercise classes. After the initial evaluation, the patient was taught the finger in the vagina test, \vith these results: Duration of hold: 3 to 4 seconds Repetitions of holding contractions: 3 times Repetitions of quick contractions: 6 times Develop an exercise program. b. A 25-year-old woman is the mother of a 12-month­ old baby, who weighed 9lb 2 oz at bilih and was de­ livered vaginally after a long labor. Delivery required the use of forceps and a deep episiotomy. The woman presented with the primary complaints of having a strong urge to urinate and needing to uri­ nate every 1 to 2 hours, and she occasionally leaks urine before reaching the toilet. She is an emergency room nurse in a major hospital and admits to very small amounts of leaking with lifting patients in and out of bed. Other significant medical history in­ cludes right sacroiliac pain since pregnancy and sacroiliac pain with intercourse. The patient reports voiding 10 to 14 times each day (!:\vo to three times each night), which Significantly interferes with her work. She wears maxipads (!:\vo per shift) to work be­ cause she is unsure whether she will be able to leave a patient to urinate. The urologist has tried medica­ tion without success and feels the patient may have a permanent dysfunction. After the initial evaluation, the patient was taught the finger in the vagina test, "vith these results: Duration of hold: 7 seconds Repetitions of holding contractions: 10 times Repetitions of quick contractions: 15 times Develop an exercise program.

434

Therapeutic Exerc ise Moving Toward Function

LAB ACTIVITIES 1. Practice administering the screening questionnaire. 2. Develop a case study in which a patient needs to be instructed in PFEs. Practice explaining the location and function of the muscles and the importance of PFEs using words, posters, and models. 3. Explain the appropriate self-assessment test and home awareness exercises to the patient. 4. Perform the self-assessment test and self-awareness exercises at home, and develop an appropriate exer­ cise program for yourself. Exercise programs should include the following: a. Results of jumping jack test h. The number of repetitions and amount of hold time per contraction c. The amount of rest that should be taken hetween contractions d. Th e number of fast-twitch muscle contractions per set e. The number of sets per day

2. Irnagine you or someone you love is the patient in ques­ tion lb, and ~xamine how you would feel about your sit­ uation. Describe the impact on your life (i,e., work, fall1­ ily, social interactions, emotions). List some things you would be forced to change because of your condition. 3. You are treating a 30-year-old man who fell off a ladder onto his right buttock. After 3 weeks of quality treatment, he has experienced Significant decrease in low back and sacroiliac pain, but he can only sit for one-half hour and experiences pain with sit to stand transfers and when go­ ing up stairs. He finally admits that his tail bone hurts and that it feels as though he is "sitting on a ball, " Your evalu­ ation shows no dysfunction in the lumbar spine, and per­ sistent hypomobility of the right sacroiliac. Which mus­ cles should you assess for dysfunction , and how would you treat them? Think about how YOll would explain to the patient that his pain may be related to the PFMs.

REFERENCES 1. Kegel A. Progres s i\'(~ resistance exe rcises in the functional restoration of the perineal muscles. Am J Ob stet Gynecol 1948;.56:238. 2. Schussle r B, Laycock J, Norton P , Stanton S, eds. Pelvic F loor Re-education Principals and Practice, New York: Springe r-Verl ag, 1994. 3. DeLancey J, Richardson A. Anatomy of genital support In: Benson T, ed. F e male Pelvic Floor Disorders. New York: Norton Medical Books, 1992. 4. Walters M, Karram M. Clinical Urogynecology. St. Louis: Mosby-Ye'lr Book, 1993. .5. Travel! J, Simons D, Myofascial Pain and Dysfuncti on: The Triggpr Poiut Manual, vol 2. BultimorC': Williams & Wilkins, 19\)'2

!.....~.

=-~':--f'

f. Suggested position of exercises (i.e., lying down or upright ) g. Other methods of strengthening that should be considered 5. Practice palpating the PF1vls externally at the ischial tuberosity. Evaluate for pain, trigger pOints, spasm , and connective tissue tension . ~'!ake sure you are on the correct muscle by having the patient contract that muscle. 6. Sit up tall in the chair, and push yom abdominal mus­ cles ouhvard. Keep the ahdomen distended, and con­ tract the PFMs . Notice the amount of effOlt needed and the force generated by the PFMs. Next, sit up in the chair, and pull the abdominals inward, support­ ing the abdominal contents and the back. Hold the abdominal contraction gently and contract the PFMs. ~otiC'e the effort needed and the force gen­ erated by the PF\>!s. Next, try to contract the PFMs and bear down, pouching out th e abdominals. Try to contract the PFMs ancl then pull tbe abdominals in­ ward correctlv .' .

6, Mcminn R, Hutchings R. Color Atlas of Human AnatOIm Chicago: Year Book Medical Publishers, 1977, 7, Kegel A. Sexual functi on of the pubococcygeus muscle. vVest J Surg Obste t Gynccol ] 9.52;10521. 8 . C hiarelli P. Women's Waterworks-Curing fncontinence Snohomish , \VA: Khcnl Publi cations, 199.5. 9. Sherburn M, Guthri JR, Dudley EC , et aJ. Is incontinence as­ soci,ltcd \\'ith lllclwpause:) Ohste t GynecoI 2001;98:628-633 10. \1eyer S, Hohlfeld P, Achtari C, et aJ. Pelvic floor educatior after \'aginal delivery. Obstet Gynecol 2001;97:673-677, 11. James :VI, Jackson S, Shepherd A, et at. Pure stress lea ka~ symptomatology: is it safe to discount detrussor instabili ~"~ Br J Obstet GynecoI1999;106:12,j,5-1258. 12. Laycock J, Haslam J, ed. TherapeutiC \![anagement of Incon· tinence and Pelvic Pain. London: Springer-Verlag, 2002 . 13, Sampselle C, DeLancey J. The urine strea m interruption te.~ and pelviC mllscle function, Nurs Res 1992;41:73-77. 14. Pages I, Jabr S, Schaufele ~1K , et al , Comparative analysis biofeedback and pbysi cal th erapy for treatment of urinary i eOlltine nce in women. Am J Phys Med Rehabil 2001 ; 494- .502, 1.5. Bo K, Talseth T, Hulme I. Single blind, randomized co trolled trail of pekic 1100r exercise, electrical stimulati ou vaginal cones and no treatrne nt in manage ment of genu i stress incontinence in women . BMJ 1999;:318:487--493. 16. Arvonen T, Fianu-Jobnson A, Tyni-Lenn e R. Effectiveness two conservative modes of physical therapy in women \\itt urinary stress incontinence . \'eurourol Urodyn 2001 :2(: .591--599. 17. Woman's Hospital Physical Therapy Departnwnt. The BO{· tom Line on Kegels. Baton Rouge, LA : A Woman's Hospiti!. Publication, 1997. 18. Urinary Incontinence Guidelines Panel. Urinary Inconti· nence in Adults: Clinical Practic(' Cuideline, A.HCPR PuL 1\0.92-0038, Rockville, MD: Agency for Health Care Polk" and Resear ch , Public Health Se rvice, U.S, Departm ent Health and Human Services, March 1996,

Chapter 19: The Pelvic Floor 19. Bo K, Stien R. Needle ElviG registration of striated urethral wall and pelvic floor muscle activity patterns dUJing cough, V<11­ salva, abdominal, hip adductor and gluteal contractions in nul­ liparous healthy females. Neurourol Urodyn 1994;13: 35--41. 20. Neumann P, Gill V. Pelvic floor and abdominal muscle inter­ action: EMG activity and intra-abdominal pressure. lnt Urogynecol I 2002;13:125-132. '21. Saps ford RR, Hodges PW, Richardson CA, et al. Co-contrac­ tion of the abdominal and pelvic floor muscles during volun­ tary exercise. !'\eurourol Urodyn 2001;20:31-42. ;:):2. l\'ielsen C, Sigsgaard I, Olsen M, et al. Trainability of the pelvic floor-a prospective study during pregnancy and after delivery. Acta Obstet Gynecol Scand 1988;67:437-440. 23. Sampselle C. Changes in pelvic muscle strength and stress urinary incontinence associated with childbirth. J Obstet Gy­ necol Neonatal Nurs 1990; 19:5:371--377. '2-t Sueppel C, Kreder K. See W. Improved continence out­ comes with preoperative pelvic floor muscle strengthening exercise. Croll\urs 2001;21:201-210. 25. Lee D. The Pelvic Girdle. 2nd Ed. Edinburgh Churchill Liv­ ingstone, 2000. 26. Bump R, Hurt G, Fantl A, et al. Assessment of Kegel pelvic muscle exercises performed after brief verbal instruction. Am JObstet GynecoI1991;165:322-329. 27. Miller JM , Ashton-Miller JA, Delancey J. A pelViC muscle pre-contraction can reduce couch-related urine loss in se­ lected women with mild stress urinary incontinence. J Am Geriatric Soc 1998;46:870--874. 25. American Physical Therapy Association. Women 's Health Gynecological Physical Therapy Manual. Alexandria, VA: APTA, 1997. 1-800-999-APTA, ext. 3237. 29. Herman H. ConseIVative management of female patients \vith pelvic pain. Urol Nurs 2001;20393-417. 30. Miller JM , Perucchini D , Carchidi LT, et al. Pelvic floor mus­ cle contraction during a couch and decreased vesical neck mobility. Obstet Gynecol 2001;97:255-260. 31. Weih AJ, Barret DM . Voiding Function and Dysfunction : A Logical and Practical Approach. Chicago: Year Book Medical Publishers, 1988. 32. Elia G, Dye TD , Scarlati PD. Body mass index and U1inary in­ continence symptoms in women . Int Urogynecol J 2001;12: 366--369. 33. Subak LL, Johnson C, Whitcomb E , et al. Does we ight loss improve incontinence in moderately obese women? Int U rogynecol J2002;13:40-43. 34. Rortvent G, Hannestad YS , Daltl eit AK, et al. Age-and type- dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study Obstet Gynecol 2001;98: 1004-1010. 35. Nygaard I, D eLancey J, Arnsdorf L, e t al. Exercises and in­ continence. Obstet GynecoI1990;75:848--851. 36. Van der Velde J, Laan E, Everaerd W. Vaginismus , a compo­ nent of a general defense reaction. An investigation of pelViC floor muscle activity dUling exposure to emotional-inducing

435

film excerpts in women with and without symptoms of vagi n­ ismus. Int Urogynecol J 200l;l2 :3:28~'331. 37. Abrams P, Cardozo L, Fall M, et al . The standardization of terminology of lower urinary tract function: report from the standardization sub-committee of th e Inte rna­ tional Continence SOCiety. Am J Obstct Cynecol 2002 ;21: 167-178. 38. Bo K, Sundgot Borgen J. Prevalence of stress urinary incon­ tinence among phYSically active and sedentalY female stu­ dents. Scand JSports Sci 1989;11:113-116. 39. Meade-D'Alisera P, Meniweather T, Wentland M, et al. D e­ pressive symptoms in women with Urinal)' incontinence: a prospective study. Urol Nurs 2001;21:397-.'399. 40. Burgio KL, Locher JL, Roth DL, et al. PsycholOgical impair­ ments associated with behavioral and drug treatment of urge incontinence in older women. J Geron tol B Psychol Sci Soc Sci 2001;56:46--51. 41. Herndon A, Decambre M, McKenna PH. Interactive com­ puter games for treatment of pelvic floor dysfunction. J Urol 2001; 166: 1893- 1898. 42. Pearson B. Liquidate a myth redUCing liqUid intake is not ad­ visable for elderly with urine control problerns. Urol Nurs. 1993;13:86--87.

RECOMMENDED READINGS King P, Myers C, Ling F, et al. Muscu1loskeletal factors in chronic

pelvic pain. J Psychosom Obstet GynecoI1991;l2(Suppl ):87-98.

Sahrmann SA. Diagnosis by the physical therapiSt. Phys Ther

1988;68:1703-1706.

PATIENT EDUCATION

Bass E, Davis L. The Courage to Heal: A Guide for Wome n Sur­

vivors of Child Sexual Abuse. 3rd Ed. New York: Harper & Row,

1994.

Burgio K. Staying Dry. Baltimore: John Hopkins UI~iversity Press,

1989.

Wise D, Anderson R. A Headache in the Pelvis. OCCidental, CA:

National Center for Pelvic Pain Research, 2003.

PHYSICAL THERAPY BOOKS Adams C, Frahm J. Genitourinary system. In: Myers R, ed. Saun­

ders Manual of Physical Therapy. Philadelphia: WB Saunders ,

1995.

Polden M. PhYSiotherapy in Obstetrics and Gynecology. Stone­

ham, MA: Butterworth-Heill('Illann Publishers, 1990.

Schussler B, Laycock J, NOlton P, Stanton S, eds. Pelvic Floor Re­

education PrinCiples and Practice. New York: Springer-Verlag,

1994.

MEDICAL BOOKS Benson T, ed. Female Pelvic Floor Disorders. New York: Norton

Medical Books, 1992.

Wall L, Norton P, DeLancey J. Practical Urogynecology. Balti­

more: Williams & Wilkins, 1993.

chapter 20

The Hip CARRIE HALL

Anatomy And Kinesiology Osteology and Arthrology Muscles Nerves and Blood Supply Kinematics Kinetics Kinetics and Kinematics of Gait

Anatom ic Impairments Angles of Inclination and Torsion Center Edge Angle Leg Length Discrepancy

Examination and Eval uation History Lumbar Spine Clearing Examination Other Clearing Tests Gait and Balance Joint Mobility and Integrity Muscle Performance Pain and Inflammation Posture and Movement Range of Motion and Muscle Length Work, Community, and Leisure Integration or Reintegration Special Tests

Therapeutic Exercise Interventions for Common Physiologic Impairments Impaired Muscle Performance Range of Motion, Muscle Length, Joint Mobility, and In­ tegrity Impairments Balance Pain Posture and Movement Impairment Leg Length Discrepancy

Therapeutic Exercise Interventions for Common Diagnoses Osteoarthritis Iliotibial Band-Related Diagnoses Nerve Entrapment Syndromes

The primary roles of the hip joint are to support the weight of the head, arms, and trunk during erect standing postures and dynamic weight-bearing activities such as walking, run­ ning, and stair climbing and to provide a pathway for trans­ mission of forces between the lower extremities and pelvis.

The structure and function of the hip affect the function of the entire lower kinetic chain and the upper quadrant through its articulation with the pelvis proximally and th femur distally. Neither structure nor function of the hip joint can be ex­ amined vvithout considering the weight-bearing function of the joint and the interdependence ,vith the other joints of the lower extremity and lumbopelvic region . These issues are examined in this chapter, which also provides a review 0 the anatomy and kinesiology of the joint. Common anatomic impairments and the components of examination and eval­ uation of the hip joint also are described. Therapeutic exer­ cise interventions are suggested for the treatment of physi­ ologic impairments and selected diagnoses of the hip joint.

ANATOMY AND KINESIOLOGY The hip joint is composed of the head of the femur and the acetabulum of the pelvis (Fig. 20-1). The construction 0 this joint allows for th e wide range of functions required for the activities of daily living (ADLs ), such as sitting, squat­ ting, walking, and stair climbing.

Osteology and Arthrology The concave component of the hip joint is the acetabulum. The acetabulum is located on the lateral aspect of the pelvis, which is formed by the fusion of the ilium , ischium and the pubis (see Fig. 20-1A). The acetabulum fonTIS a true hemisphere, but only a horseshoe-shaped portion 0 the hemisphere is covered with articular cartilage. I A pe­ ripheral rin g of fibrocartilage called the acetabulu l1 labrum (see Fig. 20-1B) deepens the entire socket. The cavity of the acetabulum faces obliquely anteriorly, later­ ally, and caudally. The femoral head is the convex compo­ nent of the hip joint. The shape of the head of the fem ur varies among individuals, ranging from just slightly larger than a true hemisphere to almost two thirds of a sphere The femoral neck angulates the head such that the head faces medially, superiorly, and anteriorly. The femoral neck has t"l0 angular relationships witl1 the femoral shaft that are important to hip jOint function. The exact angulation of the femoral head varies among person and even from side to side in the same individual. The an­ gle ofinclination is the angle formed between the neck and shaft of the femur in the frontal plane (Fig. 20-2).2 The an­ gle oftorsion is formed as a projection of the long axis of th femoral head and the transverse axis of the femoral condyles (Fig. 20-3 ).

436

Chapter 20 The Hip Ilium

Acetabulum

Lateral condyle

437

Head

Axis of head and neck

Greater sciatic notch "''''''''t--~- Acetabular fossa

Lesser sciatic notch

A

Obturator foramen

Axis of femoral condyles

Head of femur

FIGURE 20-3. The normal angle of torsion of the right femur. In adults this

B

angle averages about 12 to 15 degrees but varies widely with age and sex 2

FIGURE20-1. (A) Articulating surface of the acetabulum. (B) Lateral view of the hip joint shows the relationship of the acetabular labrum and femoral head.

The head of the femur is covered vvith articular carti­ lage, except for a small central portion called the fovea. The cartilage covering is thickest in the medial central region and thinnest toward the periphery.2 Variations in the carti­ lage thickness correlate with different strengtb and stiff­ ness properties in various regions of the femoral head. 3 The hip joint capsule, in conjunction vvith the bOlly com­ ponents of the hip joint, functions to constrain translation between the head of the femur and the acetabulum. 4 The most important and anatomically consistent ligaments of the ca~sule are the iliofemoral and ischiofemoral liga­ ments. The iliofemoral ligament, known also as the Y-liga­ ment of Bigelow, originates between the anterior inferior iliac spine and the acetabulum and spirals medially to its in­ sertion along the intertrochanteric line anterior to the hip joint (Fig. 20-4A). It functions to restrict extension of the hip. The ischiofemoral ligament originates from the ischial rim of the acetabulum, follows the spiral of the iliofemoral ligament as it crosses the joint, and inserts around the pos­ terior aspect of the femoral neck (Fig. 20-5B). Because of its posterior location, it restricts medial rotation but also adduction when the hip is flexed. 6

Because all the capsular ligaments are coiled around the femoral neck in a clockvvise direction, combined extension and medial rotation of the hip tighten the ligaments, and combined flexion and lateral rotation uncoil the ligaments. Consequently, extension and medial rotation is the position of greatest stability for the hip, and flexion and lateral rota­ tion is the position of least stability for the hip, particularly if combined with adduction, as in sitting cross-legged. A strong force up the femoral shaft toward the hip joint, with the hip in the latter position, may push the femoral h~ad out of the acetabulum resulting in hip joint dislocation. i The internal architecture of the femur reveals trabecu­ lae systems that accommodate the mechanical stresses and strains created by the transmission of forces between the fe­ mur and pelvis. The medial trabeculae system (Fig. 20-5) closely parallels the joint reaction force on the head of the femur during single-limb support. 1,2 The lateral trabeculae system (Fig. 20-5) probably resists the compressive force on the femoral head produced by contraction of the abductor muscles (i.e., gluteus medius, gluteus minimus, and tensor fascia lata [TFLJ).2 With aging, the femoral neck gradually undergoes de­ generative changes. The cortical bone is thinned, and the trabeculae are gradually reabsorbed. s These changes may predispose the femoral neck to fracture, which is the most common fracture site in elderly persons. 29

Axis of head and neck Head

~ Axis of femoral shaft

Iliofemoral ligament

inclination

I I I

------+-- : I I I I I

I I

FIGURE 20-2. The axis of the femoral head and neck form an angle with the axis of the femoral shaft called the angle of inclination. The angle of in­ clination offsets the femoral shaft from the pelvis laterally and in most adults is about 125 degrees 2

Ischiofemoral ligament

FIGURE 20-4. (A) Anterior view of the hip illustratinQl the iliofemoral and

pubofemoral ligaments. (B) Posterior view of the hip illustrating the is­

chiofemoralligament.

438

Therapeutic Exercise Moving Toward Function

FIGURE 20-5. Femur showing the medial trabeculae and lateral trabecu· lae systems.

Muscles Numerous muscles cross the hip joint. Tahle 20-1 lists the muscles according to their function at the hip in an open ki­ netic chain. Review of Table 20-1 should be aided by an at­ las of anatomy to help visualize the muscular relationships. Coordinated muscle function in the kinetic chain is dis­ cussed in the Gait section.

In considering the musculature that crosses the hip, the practitioner must consider the relationship of the hip mus­ cles to the muscles of the trunk and the roles they play in moving or positioning the pelvis and spine. For example, dynamically, both hip extensors and abdominal musc:les posteriorly rotate the pelviS. Postural hip flexion may result from a combination of short hip flexors, elongated anterior trunk musculature (i.e., lower rectus and ex ternal obliques), and shortened postelior trunk musculature (i.e., lumbar erector spinae and latissimus dorsi). The relation­ ship between low back pain (LBP) and hip function has been established in female athletes. 9 This research sup­ ports the need for the assessme nt and treatm ent of hip muscle imbalance in individuals with LBP. Musculature of the lower extrem ity acting at the kn e ~, ankle, and foot affects the function of the hip and vice versa. For example, chronic hyperextension of the knee re­ sulting from weak quadriceps and short ankle plantar fl ex­ ors transmits an anterior force up to the head of the femur. TI1is anterior force may contribute to anterior compression of the head of the femur in the acetabulum . Likewise. stretched and weak hip lateral rotators can lead to the hip functioning in chronic medial rotation, which may result in excessive pronatory forces at the foot.

Nerves and Blood Supply ..1

•.•

\, M.~scles of the Hip Joint

FLEXORS

EXTENSORS

Iliopsoas Tensor fascia lata Rectus femoris

Gluteus maximus Hamstrings Posterior fibers of gluteus medius Piriformis

Sartorius Adductor magnus , longus, brevis Pectineus Gracilis

ABDUCTORS

ADDUCTORS

Gluteus medius Tensor fascia lata Superior gluteus maximus Gluteus minimus

Adductor magnus, longus, brevis Quadratus femoris Pectineus Obturator externus/internus Gracilis Medial hamstrings

MEDIAL ROTATORS

LATERAL ROTATORS

Tensor fascia lata Gluteus minimus AnteJior fibers of gluteus medius Adductor magnusllongus Semimembranosus/ semitendinosus

Pirifornlis Obturator internus/externus Superiorlinferior Gemelli Quadratus femoris Gluteus maximus Posterior fibers of gluteus medius Biceps femoris

From "1orkin C, Le\'angic P. Jo int Structure and Function. Philadelphia: FA D avis, 1983.

Branches of nerves derived from the lumbosacral plexus in­ nervate the hip joint and the rest of the lower extremity. The hip joint receives branches from the obturator an d femoral nerves (lumbar plexus [Ll-L4]) and the superior gluteal nerve and the nerve to the quadratus femoris (sacral. plexus [L4-S3 ]) . Because of the innervation from the femoral nerve , pain expelienced in the knee can be the re­ sult of pathology in the hip. The blood supply to the head of the femur is of particu­ lar importance because of its Significance in com mon pathologiC conditions at the hip , including fractures , osteo­ chondrosis (Lcgg-Calve-Perthes disease ), and avascular necrosis of the femoral head. The head of the femur re­ ceives its vascularization from two sources: the artery of the ligament of the head of the femur (ligamentum tel'es) and branches of the medial and lateral circumflex arteries that ascend proximally along the neck of the femur. Because of the relation of the medial and lateral cir­ cumflex arteries to the neck of t11e femur, they are subject to injury in the case of a femoral neck fracture. These ar­ telies are intracapsular; therefore, pressure caused by jOint effusion may stop blood flow . This mechanism is thought to be a factor in osteochondrosis of the head of the femur and. in some cases, idiopathic avascular necrosis of the head.

Kinematics Osteokinematics Hip motion takes place in all three planes: sagittal (flexiolil and extension ), frontal (abduction and adduction), and transverse (medial and lateral rotation ). When not influenced by tension of th e diarthrodial hip muscles (e.g., hamstrings , rectus femoris ), motion is great­ est in the sagittal plane, where the range of f1exion is 0 to

Chapter 20 The Hip

approximately 120 to 135 degrees (or soft-tissue approxi­ mation ), and the range of extension is 0 to 15 degrees. With the knee in extension, placing passive tension on the ham­ strings, the range of flexion is considerably less, approxi­ mately 90 degrees. The range of extension is notably less than that of flexion and is limited by the tension of the il­ iofemoralligament. Ranges of fle xion and extension can ap­ pear greater than actual if pelvic and lumbar motion is al­ lowed to take place. For this reason, care must be taken to stabilize the pelvis when measuring the range of motion (ROM) at the hip. The range of abduction is 0 to 30 degrees, whereas ad­ duction is somewhat less , 0 to 25 degree~. :Movement be­ yond physiologic abduction and adduction is accompanied by tilting of the pelvis and side bending the lumhar spine. The~e associated move ments must be controlled when measuring frontal plane hip ROM . Discrepancies exist in the literature concerning rotation ROM , probably because of the method of measurement, age differences , and structural differences between men and women. The most acceptable method for measUIing hip rotation ROM is ,"lith the patient in the prone position with the hips extended to tighten the anterior capsule.lO If the ROM is tested in sitting, the hip is flexed and the ante­ rior capsule relaxed, which allows a slightly greater range of lateral rotation. Hip rotation ROM varies with the age and sex of the in­ dividual. Children younger than 2 years of age usually have a lateral rotation contracture of the hip resulting from an in­ trauterine position in which the hips are flexed and laterally rotated. 11 Standing prOvides the stimulus for the hips to ro­ tate medially, redUCing the lateral rotation contracture to the point where medial and lateral rotation ROM is roughly comparable throughout childhood. Later in life, lateral ro­

tation becomes greater than medial rotation in men, but in women , they remain about equal , or in many instances, me­ dial rotation is slightly greater. 12 In a study of 500 subjects, spanning 22 age-groups from younger t11an 1 year old to 70 and older, medial rotation was greater in female subjects than in male subjects by a mean of 7 degrees. 13 The clinician should be aware of ROM recluirements necessary to perform ADLs to assist the patient in devel­ oping appropliate functional goals. ROM values for gait are addressed in a subsequent section. The average ranges of motion required for basic ADLs are summarized in Table 20-2. Maximal motion in all planes is required for tying the shoe and squatting to pick up an object from the floor. The values obtained for these common activities indicate that hip flexion of at least 120 degrees and abduction and lateral rotation of at least 20 degrees are necessary for carrying out activities in a normal manner. If these values are not avail­ able at the hip joint, the consequence may be for another joint to move exceSSively or abnormally to attain the de­ sired movement. For example, during squatting, if 120 de­ grees of hip flexion is not available in one hip, the lum­ bopelvic region may compensate "vith excessive flexion or rotation motions. If this faulty movement pattern is used repeatedly, microtrauma may be imposed on the compen­ satory lumbar segments, potentially leading to pathology. In the closed kinetic chain , movement of the pelvis oc­ curs over the head of the femur about all three axes of mo­ tion. The osteokinematic ROM and arthrokinematic rela­ tionships remain unchanged, regardless of the status of the kinetic chain (i.e. , open versus closed). Anterior and poste­ rior pelvic tilting occurs in the sagittal plane about a frontal axis (Fig. 20-6 ). Lateral pelvic tilt occurs in the frontal plane about an anteroposterior axis (Fig. 20-7). Pelvic rotation oc­ curs in the transverse plane about a vertical axis (Fig. 20-8).

Mean Values for Maximum Hip Motion in Three Planes During

Common Activities

ACTIVITY Tying shoe with foot on Hoar

Tying shoe \-vith foot across opposite thigh

Sitting down on chair and rising from sittin g

Stoo ping to obtain object from floor

Squatting

Ascending stairs

439

PLANE OF MOTION

RECORDED VALUE (DEGREES)

Sagittal Frontal Transve rse Sagittal Frontal Transverse Sagittal Frontal Transverse Sagittal Frontal T ransverse Sagittal Frontal Transverse Sagittal Frontal Transverse Sagittal

124 19 15 110 23 33 104 20 17 117

21 18 122 28 26 67 16 18 36

. Smidt. GL. Hip lilf'aSllfe lll e nts fClr se lected ac tivities of daily living. Clin Orthop

440

Therapeutic Exercise: Moving Toward Function

FIGURE 20-6. Relationship of movements in the sag ittal plane of the pelvis and hip. (A) Normal position. (8) Motion of the pelvis in a posterior direction (ie, posterior pelvic tilt) produces hip extension and lumbar flexion. (e) Motion of the pelvis in an anterior direction (ie, anterior pelvic tilt) produces hip flexion and lumbar extensi on.

Arthrokinematics

Statics

shifts in all three planes, prodUCing moments about the h ip that must be counterbalanced by muscle forces. The mag­ nitude of these forces depends on spinal alignm ent; the po­ sitions of the non-we ight-hearing leg, trunk, upper e\­ tremities, and we ight-bea ring leg; and especially til" inclination of the pelvis J ..! Fig. 20-9 de monstrates how the line of gravi ty in the frontal plane shifts \:v:ith three different positions of the pelvis and upper body. The shift of the gravity line and resulting change in the length of the gravitatio nal force lever arm (GFLA, the per­ p endicular distance between the gravity line and the center of rotation in the femoral head), influences the magnitude of the moments about the hip joint (F ig. 20-10). The hi abductors must counterbalance the moment created bv the GFLA. The GFLA and joint reaction force are minin;izeci. when the trunk is tilted over the hip joint (see Fig. 20-9B Patie nts \\lith hip pain may adopt this type of gait pattern with maximal trunk tilt over the ipsilateral side, to redu joint reaction forces and decrease pain. Patients with weal. abductors may present \:v:ith a Trendelenburg sign (see Fi e: lO-ge) because of the inability of the hip abductors to gen­ e rate enough force to counterbalance the GFLA,

DUling double-limb support, the line of gravity of the body passes poste rior to the hip joint, creating an extension mo­ ment. The strong iliofe moral ligament restricts extension, providing static restraint with full hip extension . Th ough not desired as a postural strategy, the iliofemoral ligament allows erect posture to be maintained without constant muscular action 4 ,6 When a p erson moves from double­ limb support to single -limb support, the line of gravity

Many investigators have studied loads imposed on the hiF joint dUling dynamiC act,ivities. J'5~25 In vivo loads acting the hip jOint have demonstrated the average patient loacb the hip jOint ,vith 238% body weight (BW) when walking abu t 4 km/h , while climbing upstairs increases joint conta force to 251 % BW, going dO\l\fI1stairs to 260% BW.:2:2

Because of the inheren t structural stability of the hip joint, the arthrokinematic motion accompanying hip flexion and extension is nearly a pure rotation. The head rotates poste­ riorly in flexion, accompanie d by a slight posterior glide, and the head rotates anteriorly in extension , accompanied by a slight antelior glide. The motions of hip abd uction and add1!lction and of medial and late ral rotation also include combinations of rotation and gliding, which occur opposi te to the motion of the distal end of the femur (when the fe­ mur is the moving segm ent).

Kinetics Kinetic studies have demonstrated that substantial forces act on the hip joint during simple activities. The factors in­ volved in prodUCing these forces must be understood if ra­ tional rehabilitation programs are to be developed for pa­ tients \",ith functional limitations and disability due to hip pathology and impairments.

Dvnamics

n.

FIGURE 20-7. Relationship of movements in the frontal plane of the pelvis and hip. In lateral pelvic tilt. one hip jOint serves as the axis for motion, and the opposite iliac crest elevates or drops about that pivot point. The hip on the high iliac crest side is in relative adduc­ tion, whereas the hip on the low iliac crest side is in relative abduction.

A

B

!\

441

Chapter 20: The Hip

Right

AGURE 20-S. Relationship of movements in the transverse plane of the pelvis and hip. Rotation of the pelvis in a clockwise direction results in left hip lateral rotation and right hip medial rotation, and rotation of the pelvis in a counterclockwise direction results in right hip lateral rotation and left hip medial rotation. (From Norkin CC, Levangie PK. Joint Structure and Function A Comprehensive Analysis. 2nd Ed. Philadelphia FA Davis, 1992)

Kinetics and Kinematics of Gait The pelvis, hip, knee, ankle, and foot work in synergy to produce the ideal gait pattern. Table 20-3 summarizes ki­ netics and kinematics of the gait cycle at the hip. This in­ :ormation is provided so that deviations from the norm are

Abductors Abd = 2" HAT = 4"

Abductors Abd = 2" HAT=1"

Left

FIGURE 20-10. In right unilateral stance, a moment is created around the right hip joint that tends to produce aclockwise rotary force about the right hip. Activity of the right hip abductors is necessary to counteract the grav­ itational moment. The arrow indicates the action line of the right hip ab­ ductors in right unilateral stance. The distance from the action line to the right hip joint axis is about half the distance from the right hip joint axis to the body's center of gravity. The right hip abductors must be capable of ex­ erting a force almost tvvice as great as the gravitational force to prevent lateral drop of the pelvis on the left.

appreciated, and appropriate specific and functional exer­ cises can be developed to treat impairments in movement patterns associated with gait Because motions at the ankle, knee, and hip in the sagit­ tal plane are the most important in contributing to the crit­ ical events that occur in gait, they are the focus of the sum­ mary information in Table 20-3. Other more subtle motions occur in all three planes at the foot, k-nee, hip, and pelvis. These motions should also be understood to analyze the gait cycle and appropriately treat pathologic gait More detailed kinesioloSic information about the gait cycle is provided by Perry.' 6

ANATOMIC IMPAIRMENTS

A B Abductors Abd = 2" HAT = 3"

c FIGURE 20-9. (A) In right unilateral stance, the weight of the head, arms, and trunk (HAT) act 4 inches from the right hip, producing an adduction torque around the right hip joint. The abductors, acting 2 inches from the right hip joint, generate a large force to produce an abduction torque suffi­ cient to counterbalance the torque produced by HAT. (B) When the trunk is laterally flexed toward a stance limb, the moment arm of the HAT is sub­ stantially reduced, whereas that of the abductors remains unchanged. The result is a substantially diminished torque from the HAT and a correspond­ ing decreased hip abductor force to counterbalance the HAT torque. (C)The pelvis drops on the opposite side of the stance limb when the abductor force cannot counterbalance the torque produced by HAT. This is called apositive Trendelenburg sign, and is discussed in more detail in the text.

Four anatomic impairments of the hip joint are worthy of consideration because of the impact they have on hip func­ tion: angle of torsion, angle of inclination, center edge an­ gle, and leg length discrepancy (LLD). Each anatomic im­ pairment, independently or in combination with other impairments (anatomic or phYSiologic), warrants careful consideration about the impact on hip jOint function and the function of joints proximal or distal to the hip.

Angles of Inclination and Torsion As discussed earlier, angles of inclination and torsion are normal anatomic relationships of the femur. However, the degree of inclination or torsion can become abnormal when the values are greater or less than normal. Abnormal angulations of the femur are considered anatomic impair­ ments. These anatomic impairments of the femur can sig­ nificantly alter hip joint mechanics, which can alter the me­ chanics of adjacent segments proximally and distally in the kinetic chain. In early infancy, the angle of inclination is about 150 degrees because of the abducted position of the femur in

442

Therapeutic Exercise Moving Toward Function

Kinetics and Kinematics of the Gait Cycle at the Hip PHASES OF THE GAIT CYCLE Initial contact

Loading response

Midstance

Terminal stance

MOMENT Rapid, high-intensity flexion moment

Flexion torque persists, second highest torque demand; adduction moment begins

Decreased flexion moment; adduction moment continues Adduction moment ends; hip extension moment keeps hip stable

RANGE OF MOTION

MUSCLE ACTIVITY

MUSCLE CONTRACTION TYPE

25 degrees of hip flexion

Hamstrings

Eccentric

All hip extensors are active in preparation for loading response All of the hip extensors to counteract the flexion moment

Eccentriclisometric

25 degrees of hip flexion

Posterior tensor fascia lata, gluteus medius, gluteus minim us, upper gluteus maximus to stabilize the pelvis in the frontal plane Hip abductor group is active as above

Extends to neutral

Hip extends to 20 degrees (a portion of this apparent hip extension may come from pelvic rotation posteriorly 5 degrees) Moves toward neutral

Initial swing

Hip extension moment diminishes to 0 degrees Not measured

15 degrees of hip flexion

Midswing

Not measured

25 degrees of hip flexion

Terminal swing

Not measured

Unchanged from midswing

Preswing

Eccentric

Isometlic/eccentric

Isometric/eccen tric

Anterior tensor fascia lata

Eccenttic

Adductor longus, rectus femoris Iliacus, gracilis, sartorius, adductor longus Iliacus, graCilis, sartorius cease Hamstting begins Hamstrings

Concentric at the hip Eccentric to the kn ee Concentric

Lower fibers of gluteus maximus and adductors

Concentric Eccentric Eccentric Isometric/eccentric

Adapted from Rancho Los Amigos Medical Center. Observational Gait AnalYSiS, Downey, CA: Los Amigos Research and Education Institute, 1993,

utero, The angle decreases with age to the normal adult value of 125 degrees, with further decreases to the normal older adult angle of 120 degrees.! The angle is somewhat smaller in females and somewhat larger in males. A pathologic increase in the angle is called coxa valga (Fig. 20-11A), and a pathologic decrease is called coxa vara (Fig. 20-11B). The position of the greater trochanter influences the mechanical stress of the hip joint, the extent of contrac­ tion of the gluteus medius and minim us muscles, and the mechanical stress of the femoral neck. 27 A normal neck­ shaft angle appears to achieve a maximum lever arm of the abductor muscles and the best compromise betvv'een a!ticular pressure and bending stress on the femoral neck. A very high position of the greater trochanter (coxa vara) can result in shortening of the lever arm of the abductor muscles and high bending stress of the femoral neck. Conversely, in a valgus hip, bending stress is lower, but articular pressure is higher. The newborn infant has a maximum angle of torsion of approXimately 40 degrees. This decreases to an average of 32 degrees at the age of 1 year and further decreases

to 16 degrees by the age of 16 years28 The angle i normally about 12 to 15 degrees in the adult, but it m,l\ range from 8 to 30 degJ-ees and, as with the angle of in­ clination, varies between sexes and among persons 1 .2 \) A pathologic increase in the angle of torsion is called anteAxis of

~ head and neck

/

/

\ (

/

>125°0

///

/ Angle of inclination

\

/

<: )

Axis of

-+--- femoral shaft

1--+--

Angle of inclinatior

Axis of femoral shaft

FIGURE20-11. Abnormal angles of inclination, (AjA pathologic increa:.:: in the angle of inclination is called coxa va lga, (8j A pathologic decre a ~:: in the angle of inclination is called coxa vara

Chapter 20 The Hip

443

Center edge angle

Axisof--~

head Angle of torsion

Axis of condyles

~~--

Acetabular labrum

Acetabular fossa

A Anteversion

Acetabular labrum

FIGURE 20-13. The center edge angle or angle of Wiberg . Retroversion

FIGURE 20-12. (A) A pathologic increase in the angle of torsion is called anteversion. (8) A pathologic decrease in the angle of torsion is called retroversion. (From Norki n CC, Levangie PK. Joint Structure and Function : A Comprehensive Analysis. 2nd Ed. Philadelphia FA Davis; 1992)

"ersion (Fig. 20-12A), and a decrease is called retrover­ sion (Fig. 20-12B ). Anteversion and retroversion can be . cree ned for during a clinical examination (see Examina­ tion/Evaluation). Because the hip joint can only tolerate a limited amount f torsion (12 to 15 degrees) without jeopardizing the con­ aruence of the hip jOint, a pathologic increase (> 15 de­ rees) or decrease « 12 degree s) in the angle of torsion is manifested distally at the femoral condyles. In the standing position, the femoral condyles of an individual with femoral anteversion are oriented medially, and in femoral retrover­ ion, they are oriented laterally when the femoral head is in mu,ximum congruence. The individual with femoral ante­ "ersion functioning with the femoral condyles faCing later­ ally risks lOSing congruence of the femoral head in the cetabulum. Similarly, the individual \-vith femoral retro­ \'ersion functioning with the femoral condyles facing medi­ 11y also lisks lOSing congruence of the femoral head in the cetabulum. The practitioner must be aware of these anatomic impairments when guiding femoral alignment dUling exercise and function.

Center Edge Angle or Angle of Wiberg A. line connecting the lateral rim of the acetabulum and the e nter of the femoral head forms an angle ,vith the vertical I.."11own as the center edge angle, also called the angle of " iberg (Fig, 20-13). The center edge angle for the average adult is 22-42 degrees. 2u Although this is a normal angle, \ liations in the angle can lead to altered stability of the fe moral head , in which case it would be considered an anatomic impairment. A smaller center edge angle (i,e" more vertical OIienta­ tion) of the acetabulum may result in decreased congru­ encv of the head of the femur and the acetabulum , plaCing the I head of the femur at increased risk of supelior disloca­ tion of the head of the femur. Children arc at greater risk fo r th is type of dislocation than adults, because the center edge angle normally increases with age 30 It may be for this reason that congenital dislocation is more common at the hip than any other joint in the body.31

Leg Length Discrepancy LLD , when measured from one common bilateral point of reference proximally to another common bilate ral point of reference distally, is a unilateral difference in the total length of one leg compared with the other. LLD is com­ monly thought of as resulting from a structural fault in the anatomic length of the long bones, Iwmipelvis. or asym­ metric structural development of the spine (i.e, scoliosis), in which case it would be considered an anatomic impair­ ment. Howeve r, LLD often is the resu lt of the functional relationships of the spine , pelvis, long bones, and hones of the feet about all three axes of motion. For example, an in­ diviclual standing in a neutral subtalar pOSition, measured bilaterally from the tip of the medial malleolus to the hori­ zontal plane (i.e., flat surface), should have equal measure­ ments of both limbs. If the individual is allowed to pronate one foot, the medial malleolus of the pronated foot moves closer to tbe gro und. The difference in height may be as much as 1/4 to % of an inch . This would be considered a physiolog'ic impairment as opposed to an anatomic impair­ ment, resulting in LLD. Structu ral and functional LLDs are common clinical terms used to describe the two types of LLDs.32,33 Table 20-4 summarizes definitions of the clinical terms used to describe LD. LLD has been associated with hip pain , knee pain, LBF, and with lower extremity stress fractures 3 4-J7 Stud­ ies have shown increased bip joint forces of up to 12% in the r latively short and long limbs with LLDs of 3.5 to 6.5 cm. 38 In ge neral, an LLD of more than 2.0 em results in asymmetry in contact time , first and second force peaks, and loading and unloading rates of the vertical ground re­ action force in gait. 39 The most common mechanism for dealing with minor degrees of Limb length discrepancy is the induction of pelviC tilling in the coronal plane. In nor­ mal individuals, pelvic obliqUity of 6.1 degrees can totally accommodate for a LLD of 2.2 cm 40 With LLD greater than 2 cm, th e coronal plane mechanism is necessarily augmented by changes in the sagittal plane, which occur at the ankle and knee in standing. The knee responds with flexion of the lo ng limb , where as the long leg ankle demonstrates increased dorsiflexion at terminal stane and the short lea ankle produces early heel rise and greater degrees ~~f plantar flexion during stance: lO The combination of these chanaes have th effect of shOlten­ ing the functional length of the long limb both in the stance and swin g phases while lengthening the shorter

444

Therapeutic Exercise Moving Toward Function

Definitions of Structural and Functional leg length Discrepancies TERM

TYPE OF IMPAIRMENT

DEFINITION

MEASUREMENT TECHNIQUE

Structural

Anatomic

Standing anteroposterior x-ray film or ultrasound imaging39

Functional

PhYSiologic

Actual osseous length difference between the hemipelvis , femur, and tibia Position of osseous structures as they relate to each other and to the environment during weight-bearing function

limb during the stance phase. Because of the changes in forces incurred at the hip and gait asymmetries , it appears that more than 2 cm of LLD can significantly affect ki­ netics and kinematics throughout the kinetic chain and therefore should be addressed. LLD of less than 2 cm af­ fect pelvic alignment and may need to be addressed de­ pending on the associated impairments and pathology. Evaluation and treatment of LLD is addressed in later sections.

EXAMINATION AND EVALUATION Examination and evaluation of the hip can be isolated to the hip in the case of specific hip pathology (e.g., rheuma­ toid arthritis , osteoarthlitis [OAl, avascular necrosis of the femoral head). However, even for a diagnOSiS isolated to the hip, evaluation of the knee, ankle-foot, and lum­ bopelvic regions may prOvide useful information. Similarly, the hip is commonly included in the examination and eval­ uation of other regions to assess anatomic or phYSiolOgiC impairments of the hip that may be contributing to dys­ function in the affected region (e.g. , a stiff hip contributing to lumbar hypermobility). The descliptive examination and evaluation information presented in this section is not intended to be comprehen­ sive or reflect any speCific philosophical approach ; it simply serves as a general review of pertinent tests performed in most hip examinations.

History In addition to the general data generated from a patienU client history as defined in Chapter 2, the follOwing infor­ mation is important to obtain from a patient with impair­ ment, functional limitation , or disability involving the hip jOint. Of particular importance is a history of congenital hip dysfunction (e .g. , congenital hip dysplaSia) , childhood hip conditions (e .g. , slipped capital epiphYSiS, severe antever­ sion treated with bracing), or a family history of OA or rheumatoid arthritis. Although the hip can become injured as a result of trauma, the clinician is more likely to en­ counter hip dysfunction as a result of cumulative micro­ trauma. In the latter case, it is important for the practi­ tioner to gain an understanding of the ADLs, recreational, and occupational activities with which the patient is in­ volved on a repetitive basis and which activities seem to provoke symptoms. Much of this information can be

Actual difference between two pair, of identical reference points (e.g. , greater trochanter and medial malleolus)

obtained through self-report forms (Display 20-1 ) and the formal interview can clarify subjective information.

Lumbar Spine Clearing Examination The prevalence of lumbopelvic conditions in the genera. population, combined with the fact that pathology in the lumbopelvic region can manifest in referred pain pattern into the hip (e.g., posterior buttock) and cause neurolOgi­ cally mediated weakness of hip joint musculature (particu­ larly the gluteal musculature), supports routine lumba: screening during any hip examination. A typicallumba= clearing examination is outlined in Chapter 18. Althougl this scan may seem extensive, excluding or diagnOSing lurr..­ bar or sacroiliac joint involvement is critical to accurate di­ agnOSiS of lower quadrant symptoms. Positive test res~ for the lumbar clearing examination can indicate a need fo­ a more thorough lumbar or sacroiliac jOint examination.

Other Clearing Tests The practitioner should examine and evaluate associ at regions. Although the hip may be the source of sympto it is common for multiple regions to be involved , partiL-. ­ larIy in patients \vith long-standing impairments , function limitations, and disability. A thorough examination of all iI·­ volved regions permits the clinician to develop an in tl­ grated and comprehenSive plan of care. For example, iT'­ pairments of the pelvic floor may affect function of the h i Screening for pelvic floor dysfunction can alert the pr2 tioner to any associated pelvic floor conditions ( Chapter 19). Visceral involvement or serious disease or disorde should be excluded. Pain in the hip and pelvic region c. also result from visceral sources (see Appendix 1). A tb ough history and physical examination and evaluation . alert the practitioner to visceral involvement or serious ill­ ease or pathology. The hip must be excluded as the source of symptoms to ­ perienced in other regions. Because the hip is largely IT­ nervated at the L3-L4 level, hip pathology occasional causes pain to be referred to the knee .41 ,42 This is well dOl­ umented in children, in whom any examination for kn pain must include a hip examination,43 but this must not forgotten as a source of knee pain in the adult. A patient any age complaining of knee pain without apparent kn pathology or impairments should have the hip examined a potential source of pain.

Chapter 20: The Hip

445

DlSPLAV20-1

Self-Report Form J I can manage only a single step or curb.

..J I am unable to manage even a step or curb.

Functional Index Walking

.:.J Pain does not prevent me walking any distance.

...J Pain prevents me walking more than 1 mile.

:. Pain prevents me walking more than

1/2

mile .

:J Pain prevents me walking more than 1/4 mile .

.J I can only walk using a stick or crutches.

:i I am in bed most of the time and nave to crawl to the toilet.

Work (applies to work in home and outside)

':J I can do as much work as I want to.

..J I can only do my usual work, but no more.

':i I can do most of my usual work, but no more.

I cannot do my usual work.

..J I can hardly do any work at all (only light dUty).

~ I cannot do any work at all.

.::r

Personal Care (washing, dressing, etc.)

:J I can manage all personal care without symptoms. :i I can manage all personal care with some increased symptoms. ..J Personal care requires slow, concise movements because of increased symptoms. :. I need help to manage some personal care. :J I need help to manage all personal care . :. I cannot manage any personal care . Sleeping ..J I have no trouble sleeping . ..J My sleep is mildly disturbed (less than 1 h sleepless). :J My sleep is mildly disturbed (1-2 h sleepless). .J My sleep is moderately disturbed (2-3 h sleepless). J My sleep is greatly disturbed 3-5 h sleepless). .J My sleep is completely disturbed (5-7 h sleepless). Recreation/Sports (indicate sport if appropriate

-------) .J I am able to engage in all my recreational/sports activities without increased symptoms. :i I am able to engage in all my recreational/sports activities with some increased symptoms . ..J I am able to engage in most, but not all of my usual recreational/sports activities because of increased symptoms. ..J I am able to engage in a few of my usual recreational/sports activities because of my increased symptoms. ..J I can hardly do any recreational/sports activities because of increased symptoms. ..J I cannot do any recreational/sports activities at all.

Acuity (answer on initial visit) :J How many days ago did onset/injury occur? _ _ _ _ _ days Stairs .-1 I can walk stairs comfortably without a rail.

:::J I can walk stairs comfortably, but with a crutch, cane, or rail. ..J I can walk more than one fl ight of stairs, but with pain or

weakness . ..J I can walk less than one flight of stairs.

Uneven Ground ..J I can walk normally on uneven ground without loss of balance or using a cane or crutches. ..J I can walk on uneven ground, but with loss of balance or with the use of a cane or crutches . .J I have to walk very carefully on uneven ground without using a cane or crutches . ..J I have to walk very carefully on uneven ground even when using a cane or crutches . :::J I have to walk very carefully on uneven ground and require physical assistance to manage it. ..J I am unable to walk on uneven ground. Standing

.J I can stand as long as I want without pain .

..J I can stand as long as I want, but it gives me extra pain.

.J Pain prevents me from standing for more than 1 hour.

.J Pain prevents me from standing for more than 30 minutes.

..J Pain prevents me from standing for more than 10 minutes.

..J Pain prevents me from standing at all.

Squatting

..J I can squat fully without the use of my arms for support.

,..J I can squat fully, but with pain or using my arms for support.

..J I can squat 3/ 4 of my normal depth, but less than fully.

':J I can squat 1h of my normal depth, but less than %.

.J I can squat 1/ 4 of my normal depth, but less than 1/2 .

.J I am unable to squat any distance due to pain or weakness.

Sittmg

':i I can sit in any chair as long as I like.

':J I can only sit in my favorite chair as long as I like.

..J Pain prevents me sitting more than 1 hour.

.J Pain prevents me sitting more than 1h hour.

..J Pain prevents me sitting more than 10 minutes.

..J Pain prevents me from sitting at all.

Pam Index Please indicate how much pain you feel at this time on the scale below

I_

_

_ _ _ _----~~--

No Pain

Worst Pain Imaginable

--PlEASE COMPLETE ON LAST VISIT ONLV-­ Improvement Index Please indicate the amount of improvement you have made since the beglnnmg of your phvslcal therapy treatment on the scale below. 1_ _ _ _ _ _-

No Improvement

- - -- - - ­

Complete Recovery

Work Status 1. No lost work time 2. Return to work without restriction 3. Return to work with modification 4. Have not returned to work 5. Not employed outside the home Work days lost because of condition: _ _____ days

Adapted from Therapeutic Associates Outcome System. Therapeutic Associates, Inc. 75060 Ventura Blvd., Suite 240, Sherman Oaks, CA 97403­

2426.

446

Therapeutic Exercise Moving Toward Function

Gait and Balance Gait evaluation is an important component of the examina­ tion of a person with a hip dysfunction. Analysis of gait should include observation of the hip along with the rest of the kinetic chain about all three planes of motion during each critical event in gait (e.g., initial contact, loading response, midstance). Of particu lar importance are the relationship of pelvic and hip motion (i.e., amount oflateral pelvic tilt and hip adduction [TrendeJenburg's sign: see Fig. 20-9C]) and the relationship of hip and lower extremity mo­ tion (i.e. , hip medial rotation, tibial medial rotation, and foot pronation). Because the hip functions interdependently with other regions in the body, the relationship of distal and proximal segments to the hip must also be evaluated. Video analysis can assist in this complex examination procedure, because the video can be taken from any angle and can be viewed in slow motion to allow precise observa­ tion of the components of gait. Hypotheses can be gener­ ated about the cause of any observed gait deviation that can be confirmed or negated as a result of the additional data collected. Balance tests are often included in hip examinations be­ cause of the high incidence of falls resulting in hip injury and fracture. Balance testing should identify intrinsic (i.e. , related to the individual ) and extrinsic (i.e. , associated with environmental factors) factors related to the risk of falling. Low-tech balance assessments can identify risk factors for falls 44 Strong correlations have been found among per­ formance-based measures and fall risk, as well as between performance-based measures and self-report measures. Five variables are significantly related to fall risk: 44 1. Berg Balance Scale score 45

2. Dynamic Gait Index score 46

3. Balance Self-Perceptions Test score 47 4. History of imbalance 5. Type of assistive device used for amblliation High-tech, computerized, force-platform balance devic~" commonly meas ure the ability to maintain the center 0 pressure within the base of support against progressive per­ turbations. This information is highly objective and is oft used to track progress in developing postural balance.

Joint Mobility and Integrity Althrokinem atic motions are relatively limited at the hir joint in comparison to osteokinematic motions . Arthrokine­ matic tests of the hip should include: lateral/medial transla­ tion, distraction and compression, and anteroposterior/ pos­ teroanterior glides 48 The quantity of motion, the end fee and the presence/location of pain should be noted. Tests fo. joint integrity should assess for jOint stability and pain prO\'1 cation. Lee has developed arthrokinetic tests for joint stabil­ ity at the hip. These tests are desclibed in Table 20_5. 4S

Muscle Performance Impairments in muscle performance can result from nu­ merous sources , and tests of muscle performance combin with results of other tests should attempt to determine the presence and cause of reduced muscle performance, The follOWing discussion highlights speCific types of muscle per­ formance testing procedures used to diagnose the presenCt: and source of impairment of muscle performance. SpeCific manual muscle testing (MMT) of muscles SUI, rounding the hip joint can provide information regarclin_ muscle performance capability of each muscle or fib e:r direction of a Single muscle (e.g., anterior versus posteli

Hip Arthrolcinetic Tests of Stabilitv TEST

INDICATION

DESCRIPTION

Proprioception! arthrokinetic stability

Tests integrated neuromuscular function

Torque test

Global tests of passive stability and pain provocation. Intends to stress all the ligaments simultaneously. Differentiates inferior band of iliofemoral liga ment Differenti ates iliofemoral ligament

Patient standing in front of plumb line, shifts weight to stan on one Jeg with eyes closed, Exami ner observes the degT' of lateral shift of the center of gravity from the plumb lin Bilateral comparison is made, Patient in supine, ipsilateral femur is extended until anteli rotation of the inominate begins, The femur is mediall rotated to end range, Apply a slow steady posterolater, force along the line of the neck of the femur.· If passive femoral extension elicits pain, this ligament may the etiologic factor. Patient is positioned as in the torque test, but the femur adducted and laterally rotated, The same force is appli as in the torque test.·· Patient is positioned as in the torque test, but the femur L abducted and fully laterally rotated, The same force i applied as in the torque test.·· With the patient in supine, the ipsilateral femur is slightl, extended, abducted, and fully medially rotated, The samt' force is applied as in the torq~e tes t,· ·

Inferior band of the iliofemoral liga ment I1iotrochantelic band of the iliofemoral ligament Pubofemoral ligame nt

Differentiates the pubofemoral ligament

Ischiofemoral ligament

Differentiates the ischiofemoral ligament

• If this test is pdinl t,ss, the subsequcnt differf'll tiuting tes ts art' not required, If pain is elicited, this ligament may bc an etiologica l factor. Adapted from Lee D, The Pelvic Girdle , Churchill Livingstoll e, 19!-l9; p, 103-104, 00

Chapter 20 The Hip

uluteus medills)49,,so Comprehensive MMT of the hip musculature also can determine the relationship of muscle performance capability of synergist and antagonist muscu­ lature around the hip (e,g" postelior gluteus medius versus TFL as hip abductors), Positional strength testing can determine the length­ tension properties of the relevant muscle (see Chapter 5), It is often of interest to the examiner to determine length­ associated changes in muscles within a synergy, Manage­ ment of a muscle functioning weakly resulting from length­ 'sociated changes is different from a weak muscle resulting from strain or disuse, For example, a lengthened postelior gluteus medius with positional wealmess should be carefuIly strengthened in the short range (Le" abduc­ tion, extension, lateral rotation), Selective tissue tension tests combine active and passive ROM with resisted tests of muscles around the hip joint complex, Results of these tests can assist the examiner in the differenti~ diagnosis of a contractile versus non-con­ tractile lesion."l The major muscle groups (i.e" hip flexion, extension, abduction, adduction, and rotation) should be tested one by one if a contractile lesion is suspected. Care­ ful positioning of additional resisted tests can identify which synergist is at fault. For example, if the hip flexor group is implicated, it is possible through careful position­ ing to further differentiate the TFL from iliopsoas, If a selective tissue tension test is positive, interpretation f the resisted test can indicate the severity of tissue lesion. Table 26-4 in Chapter 26 explains diagnostic findings with respect to resisted tests. Resisted tests can also screen for a neurologic cause of reduced force production, particularly in refe;~nce to the fatigability of the muscle being tested, Hip musculature is innervated by the lumbar and sacral plexus; consequently, low back dysfunction often results in neurologic wealmess around ilie hip. In addition, numerous peripheral nerves c n be involved in nerve entrapment syndromes around the hip, which can result in motor changes (see Table 20-6 for an overview of these syndromes. This topic will be dis­ cussed in more detail in a subsequent section of this chap­ ter). Careful neuroconductive screening can diagnose pe­ ripheral versus spinal nerve-mediated weakness,

Pain and Inflammation Examination for pain and inflammation is done concur­ rently with other tests to determine the source, Inflamma­ tion is difficult to examine in the hip joint, because it is deep within the pelvis and cannot be readily palpated. Pos­ itive findings for a capsular pattern51 (defined in Display 20-2) of hip mobility and end-feel assessment (i.e., pain be­ fore limitation of motion is reached) indicate former or ac­ tive inflammation, Examination of the pain level should be incorporated into the subjective and objective portion of the examina­ tion, The patient should answer questions regarding pain level by using a visual, numeric, or verbal analog scale over a 24-hour cycle in relation to specific activities and in gen­ era1. 52 Duling the physical examination, the patient should be questioned about the onset, location, and intensity of pain with respect to each test performed,

447

Regional Approach to Nerve

Entrapment Syndromes

REGION

SUBREGION

NERVE

Anterior

Inguinal

Ilioinguinal nerve Genitofemoral nerve Iliohypogastric nerve Tllff12!Ll nerve root Genitofemoral nerve Iliohypogastric nerve Tllff12!Ll nerve root Lateral femoral cutaneous nerve of thigh Genitofemoral nerve Femoral nerve Obturator nerve Ilioinguinal nerve Iliohypogastric nerve Lateral cutaneous nerve of thigh T12 nerve root Lateral cutaneous nerve of thigh Posterior cutaneous nerve of thigh Posterior rami of the lumbar, sacral, and coccygeal nerves Iliohypogastric nerve Lateral cutaneous nerve of thigh Posterior cutaneous nerve of thigh Tl2 Lateral cutaneous nerve of thigh Inferior medial and lateral cutaneous nerves Posterior cutaneous nerve of thigh

Suprapubic

Thigh

Lateral

Buttock

Thigh

Posterior

Buttock

Thigh

The specific source of syn1ptoms may not be diagnosed without additional tests that are beyond ilie scope of phys­ ical therapy practice (i.e" radiolOgiC, electrodiagnostic, and laboratory studies). However, ilie mechanical contribution to ilie development or fortitude of the symptoms can be di­ agnosed through careful examination and evaluation of the impairments that contribute to increased biomechanical stress to the hip joint.

DISPLAY 20-2

Established Capsular Pattern S1 1. 2. 3. 4. 5.

50 to 55 degrees of limitation of femoral abduction 0 degrees of femoral medial rotation from neutral 90 degrees of limitation of femoral flexion 10 to 30 degrees of limitation of femoral extension Femoral lateral rotation and adduction are fully maintained

448

Therapeutic Exercise Moving Toward Function

Posture and Movement Specific lumbopelvic and lower quadrant alignment should be examined in all three planes. Hypotheses can be devel­ oped regarding the contribution of faulty alignments at the ankle, foot , knee, and lumbopelvic regions to the alignment of the hip. The pwctitioner can also create hypothesis re­ garding muscles that are too long based on joint position, but muscle length testing is indicated to determine whether muscles are too short due to joint position. Initial screening for LLD should be performed by evaluating:

1. iliac crest heights 2. spine, pelvic, femur, tibia, and foot alignments 3. bony landmarks of the pelviS, knee , and ankle In addition, the specific alignment about all three planes of motion , of the spin e, pelvis, hip, tibia, and fooUankle com­ plex should be noted during simple ADLs such as squat­ ting , ascending and descending stairs, and sit-to-stand transfers. Hypothesis regarding the interrelationships of the lower limb segments can be generated (i.e. , foot prona­ tion, genu valgum, femur medial rotation, and lateral pelViC tilt on the short side)

Range of Motion and Muscle Length RO M testing of the hip jOint includes several assessments. Quick tests are functional movements that are used to as­ certain the patient's willingness and ability to move and the requisite extent of the examination to follow. Such tests for the hip include flexing the hip and knee while putting the foot on a standard step height, forward bending, squatting, and sitting "vith one leg crossed over the other. Active and pass ive open chain osteokinenwtic ROM should be carefully measured . It is impOltant to determine osteokinetic mobility of the hip joint along the continuum of hypermobility to hypomobility about all three axes of motion by carefully stabilizing the spine and pelvis during passive ROt"I examination techniques. Qualitative assessment of active and passive ROM com­ bined with clinical reasoning can supply speCific diagnos tic information: • A firm ovel})ressure applied to a motion is used to ex­ clude or diagnose joint pathol ogy. Overpressure can also be used to determine the hip end-feel and there­ fore the structures prOViding the barrier to further motion. • Assessment of the sequence of pain and limitation can grade the irritability ~f the condition and guide the in­ tensity of treatment."1 • The pattern of restriction indicates the presence of a capsular pattern (see Display 20-2). This is an indica­ tion of joint inflammation. 51 • The combined results of passive and active movem ent testing can implicate a contractile or inert structure S1 For exa mple, the findings of passive movement painful in one direction and active movement painful in another implicate a contractile structure. Tests of muscular extensibility are also important in assess­ ing ROM of the hip. Common extensibility tests include determining the length of sevenll muscles:

• Medial and lateral hamstrings (hamstring len gth should be examined as a group and individually as medial and lateral hamstrings) • Hip flexors (hip flexor length should be assessed indi­ vidually for the iliopsoas, rectus femoris , and TFL) • Hip adductors/abductors (particularly TFL) • Hip rotators The examiner should assess for a lack of extensibilitv and for excessive extenSibility. A hypotheSiS should be devel­ oped regarding what impact a lack of extensibility or ex('Ps­ sive extenSibility will have on the funct ion of the hip and re­ lated regions.

Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living) Although measures of phYSiologic impairments are impor­ tant for diagnOSiS , prognOSiS, and treatment planning, fWll'­ tional ~bility and quality of life are better indicators of OUl ­ co me .'~ 3 Functional ability can be measured direct! through observation of functional tasks or by the use of sei:- ­ report measures. Display 20-1 illustrates a general self-re­ port measure with a specific section devoted to the llir The Harris Hip Function Scale is another, but it is sped to degenerative conditions of the hip (Display 20-3) . T Harris Hip Function Scale was Originally deSigned to ass~ patient status after the onset of traumatic arthritis of tl h ip s4 This scale combines a patient's report of pain and I or her capacity for ambulation and self-care. These tas, account for 91 o/c of the score, and deformity and hip RO ~ account for 9% of the score. The advan tages of this sc< are that it is heavily weighted toward function, is eas.' administer, and is familiar to most clinicians.

Special Tests Numerous special tests are used to confirm or lie symptoms or suspected diagnoses of the hip. For the COl monly used special tests discussed in this section, sped information regarding the technique of application can found in the related references. The Tren delenburg test is used to evaluate the fu r tional force or torque capability of the hip abductor mllS group. During gait, the patient may exhibit a positive T re delenburg sign (see Fig. 20-9<;:) or compensated Tren len burg sign (see Fig. 20-9B ).41 However, other gait de\­ tions of the hip indicate hip abductor torque impairme such as excessive hip medial rotation , pelvic counter-rot tion , or excessive lateral pelvic shift. These other gait df" ­ ations, although not traditi onally called Trendelenb __ _ signs, are also indicators of reduced hip abductor mu performance and are particularly related to positio weakness of the gluteus medius. If the examiner suspects that one of a patient's legs Tr.. be shOlter than the other, speCific tests are indicated to dr termine whether a structural or functional LLD exists_R diographs or other imaging techniques should be u when accuracy is critical. Ultrasound me as urement of L

Chapter 20: The Hip

449

DISPLAY 20·3

Harris Hip Function Scale (Circle one in each group) Pain (44 points maximum) None/ignores Slight, occasional, no compromise in activity Mild, no effect on ordinary activity, pain after unusual activity, uses aspirin Moderate, tolerable, makes concessions, occasional codeine Marked, serious limitations Totally disabled

3. Leg length discrepancy less than 11/4 inch 4. Pelvic flexion contracture <30 44 40 30 20 10

o

Range of Motion (5 points maximum) Instru cti 0 ns Record 10° of fixed adduction as "-10° abduction, adduction to 10°"

Similarly, 10° of fixed external rotation as "-10° internal

rotation, external rotation to 10°"

Similarly, 10° of fixed external rotation with 10° further

external rotation as " - 10° internal rotation, external rotation

to 20°"

Function (47 points maximum) Gait (walking maximum distance) (33 points maximum) 1. Limp: None 11 Slight 8 Moderate 5 Unable to walk 0 2. Support: None 11 Cane, long walks 7 Cane, full time 5 Crutch 4 Two canes 2 Two crutches 0 Unable to walk 0 3. Distance walked : Unlimited 11 Six blocks 8 Two to three blocks 5 Indoors only 2 Bed and chair 0 Functional Activities (14 points maximum) 1. Stairs: Normally Normally with banister Any method Not able 2. Socks and tie shoes: With ease With difficulty Unable 3. Sitting: Any chair, 1 hour High chair, 1/2 hour Unable to sit 1/2 hour any chair 4. Enter public transport Able to use public transportation Not able to use public transportation

4 2 1 0 4 2 0 5 3 0 1 0

Absence of Deformity (requires all four) (4 points maximum) 1. Fixed adduction <10 4 0 2. Fixed internal rotation in extension <10

Range

Index Factor

Permanent flexion A. Flexion to (0-45°) (45-90°) (90-120°) (120-140°) B. Abduction to

Index Value*

1.0 0.6 0.3 0.0 °

(0-15°)

(15-30°)

(30-60°)

0.8 0.3 0.0

C. Adduction to (0-15°) (15-60°)

0.2 0.0

D. External rotation in extension to (0-30°) (30-60°)

°

E. Internal rotation in extension to (0-60°)

°

0.4 0.0

0.0 *Index Value = Range x Index Factor

Total index value (A

+ B + C + D + E)

Total range of motion points (multiply total index value x 0.05) Pain points: Function points: Absence of Deformity points: Range of Motion points: Total points (100 points maximum) <70 = poor,70-80 = fair, 80-90 = good, 90-100

= excellent

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: Treatment by mold arthroplasty. J Bone Jt Surg 1969:51A:

737- 755.

450

Therapeutic Exercise: Moving Toward Function

offers a_Jeliable, noninvasive, and easily performed metlloci.oD This technique is superior to ~linical measuring methods and radiologic examinations .',6 In general, al­ though imaging techniques are considered to be tlle most accurate method for deterlllining LLD, they are costly, ti me consumjng, and, in the casE' of radiographs and COlll­ puted tomography (CT), the patient is exposed to radiation. As a result, alternative clinical methods have been devel­ oped. Two methods have emerged over the years: (1) an "indirect method" performed in standing using lift blocks under the short leg and visually examining the level pelviS, termed the "iliac crest palpation and book correction" method (ICPBC)57,58 and (2) a "direct method" done in supine measuring the distance of fixed bony landmarks with a measuring tape. Two commonly used tape measure methods (TMM ) include measuring the distance behveen (1) the anterior inferior iliac spine (ASIS) and tlle lateral malleolus 57 and (2) the ASIS and the medial malleolus,sg T here is still disagreement regarding the validity and relia­ bility of both the clinical methods. The average of hvo mea­ sures between the ASIS and the medial malleolus and th e ICPBC method both appear to have acceptahle validity and reliability when used as a screening toOI .''lS/iO The clinical determination of the angle of torsion is commonly called the T rochanteric Prominence Angle Test (TPAT) (Fig. 20_14)Gl The developers of this test demon­ strated that this measurement correlutes well \vith intraop­ erative measurements, and it is considered to be more ac­ curate than radiographic techniques. G! Yet, a more recent study concluded that clinical application of the TPAT is limited by both the variable anatomy of the proximal femur and examiner difficulties related to the soft tissues sur­ rounding the hip joint 62 III the hands of a single, expeJi­ enced clinician, the TPAT perform ed poorly, underesti­ mating or overestimating the f<; !11oral anteversion by more than 5 to 10 degrees 62 Nonetheless, this method may be acceptable if the goal of the test is to screen for the pres­ ence of abnormal angles of torsion. If accuracy is desired, two- or three-dimensional CT imaging is thought to be the

most frecise method for determining femoral antever­ sion. 6 Differences in hip rotation RO~1 can also indicat abnormal femoral torsion. To predict an abnormally hjgh anteversion angle (above mean + 2 standard deviations [SD]) , the difference behveen medial and lateral rotation (measured in hip extension) must be 45 degrees or more. whereas an abnormally low anteversion angle (lovver th an mean - 2 SD) could be predicted when lateral rotation is at least 50 degrees higher than medial rotation. 64

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENTS After examination and evaluation of the hip and all related regions, the clinician should have a thorough understand­ ing of the functional limitations affecting the patient and the related impairments. The diagnosis and prognOSis arE' formulated, and an intervention is planned. The decision to treat any impairment lies in its relation­ ship to the functional limitation and disability. PlioritizatiOl of impairments is critical to effective and efficient interven­ tion. Exercise intervention should be kept as functional ~ pOSSible. Ho\I,'ever, if the impairm ent is profound, spe<.:i fi exercise may be necessary to improve the level of perfor­ mance until it can be incorporated into a functional activi~ SpeCifiC exercise and functional activity examples are p ro­ vided in the discussion of exercise intervention for commo phYSiologic impairments affecting the hip.

Impaired Muscle Performance The section on kinetics described the powerful forces re ­ quired from the musculature surrounding the hip jOint fi accomplishing ADLs. The force-generating capabihty any muscle around the hip joint may be compromised fl one of the follOWing reasons: • NeurologiC pathology (e.g. , peripheral nerve, nel\ root, neuromuscular disease) • Muscle strain • Altered length-tension relationships (either resul ti from anatomic or phYSiolOgiC impairments ) • General weakness from disuse resulting from mu se. imbalance, general deconditioning, or reduced mu,­ de torque production for a speCific performance le\ (e.g., high-level athlete in training) • Pain and inflammation

FIGURE 20-14. TPAT test. The TPAT presumes that when the subject is prone, with the hi p in extension, and the most prominent portion of the greater trochanter is rotated into maximum lateral position, the femoral neck will be para llel to the floor. The angle of rotation of the shank seg­ ment relative to vertical at this poi nt rellects the overall angle of torsi on.

Endurance impairments at the hip must be thought of i:: light of the tremendous force-generating requirements (. the gluteal musculature during functi0l1al activities. Er. durance is required to meet the repetitious demands walking, jogging, running, and so on. Proper synergy am oc _ all muscles involved in the gait cycle keeps the intensit:· muscle action at an aerobic level. When one muscle in a S\T­ ergy group reduces its function, it imposes greater deman on othe r muscles, potentially rendering them anaerobic (ffi, therefore far less energy dficient ,(j·5or causes compcnsato strategies, such as rehance on the iliotibial band (!TB ) fc stability or a compensatory Trendelenburg pattern

Chapter ZO The Hip

reduce the need for muscle force to keep the center of mass \Vithin the base of support. Dosage parameters depend on the performance level desired by the individual (e.g., walk­ ing 50 feet vvithout pain, running a marathon in the best ti me possible) , with an emphasis on high repetitions instead of maximal force production.

Neurologic Pathology To develop the appropriate plan of care, it must be de­ termined whether the cause of the neurologically induced " 'eakness is neuromusculoskeletal (e.g., nerve root, pe­ ripheral nerve ) or neuromuscular (e .g., multiple sclerosis) III origin. If the clinician has determined that the cause is neuro­ muscu loskeletal in origin , it must then be determined whether the pathology is at the level of the nerve root or in a peripheral nerve . A dysfunction at the level of the lumbar pine can induce nerve root pathology that can manifest as weakness of the muscles innerva ted by the affected seg­ mentallevels.66 The clinician must thoroughly screen the lumbopelvic region to confirm or negate the hypothesis of pinal influence on the reduced force-generating capability of muscles surrounding the pelvic girdle. Numerous peripheral nerves surro und the hip . The sec­ tion on Nerve Entrapment Syndromes vvill discuss the po­ tential pelipheral nerve injuries affecting the hip region. After a thorough examination and evaluation process, the neurologically ind uced hip joint weakness must be treated. Whether the source of the neurologiC involvemen t is from the nerve root or peripheral nerve, the origin of the problem must be treated appropriately for the affected muscle torque production to improve . Despite alleviation of neurologiC factors, weakness con­ ributing to functional limitation may still exist. The level of weakness depends on the degree and duration of neuro­

451

logic involvement. Display 20-4 provides a clinic.:al example to illustrate this point.

Muscle Strain Force-generating capability may be compromised by an in­ jury to the muscle in the fo rm of muscle strain. Hamstring muscle strains_ are among the most common muscle injuries in athletes 6 (.68 Factors c.:ausing hamstring strain include poor flexibili ty, inadequate muscle strength or endurance, dyssynergic.: contraction, inadequate warm ­ up, and return to aC tivi ~'- before complete rec.:overy,67JiD-71 Sahrmann proposed hamstring overuse as another etiology for hamstring strain 72 The hamstrings partic.:ipate in force couples around the lumbopelvic-hip complex, contJibuting to posterior pelviC rotation , hip extension, and, indirectly, hip medial and lateral rotation. During gait, all portions of the hamstring are active from midswing to early loading response (see Table 20-3). From midswing to initial con­ tact, the role of the hamstrings is to decelerate the hip. At initial contact and loading response, the bic.:eps femoris is thought to decelerate tibial medial rotation that occurs with foot pronation 65 Because of the multiple roles of the hamstrings , it is quite possible to sustain an overuse injury. Display 20-5 describes possible mechanisms of hamstring overuse. Treatment of a hamstring strain should follow the gUide­ lines for tissue healing outlined in Chapter 11. H owever, for the hamstrings to fully recover, treatment must be fo­ cused on the cause of the strain. I f the cause of the strain is overuse, the load must be reduced on the hamstrings dur­ ing meaningful functional activities. I mproving the muscle performance and neuromuscular control of the under'Used synergists and correcting for any biomechanical factors (e.g., foot orthotic to correct for forefoot varus) constitute a recommended course of action.

DISPLAY 20-4

Case Example of Neurologic Factors Contributing to Weakness at the Hip Case Presentation: A 13-year-old gymnast has had a 5-month complaint of pos­ terolateral hip pain. At the time of her initial evaluation, she was diagnosed with a gluteus medius strain. Appropriate treatment of her gluteus medius strain did not improve her condition after 3 months. Atthattime, her physician per­ formed athorough lumbar screen. Radiologic reports indi­ cated a grade II L5-S1 spondylolisthesis with slight L5 nerve root compression occurring with end-range lumbar extension. As a result of the additional diagnosis of spondylolisthesis, she was treated with lumbosacral bracing and exercise to correct impairments related to the spine instability. During the next 3 months, her hip pain began to resolve, although only af­ ter a dual program was developed for treatment of the spondylolisthesis and gluteus medius strain. Explanation of outcome: The L5 nerve root innervates the gluteal musculature. Irritation of the nerve root at the unstable spinal level could interrupt the motor function of the L5 nerve root, resulting in neurologically induced weakness of the gluteus medius. 66 Without full afferent input into the gluteus medius, it may be

vulnera ble to strain, especially at the level of this patient's activity. Effective healing could not occur until afferent input into the gluteus medius was fully restored, which could not occur until the stability of L5-S1 segmental level was sufficient for her activity level. After the L5-S1 level became more stable and normal afferent input was restored to the affected musculature, a gradual conditioning program for the gluteus medius muscle was necessary to restore muscle performance to the functional level desired by this patient. Sample exercise program: An example of a progressive strengthening program for the gluteus medius is illustrated in Self-Management 20-1 : Gluteus Medius Strength Progression. This progression begins in prone for the muscle with a 3/5 or lower MMT grade 49 and progresses to sidelying with increasing lever arms to increase the load on the muscle. As muscle performance improves, transition to functional positions and movements can be introduced. Self-Management 20-2: Walk Stance Progression can be progressed to a leap (Fig. 20-15), with the focus on controlling frontal and transverse plane forces at the hip on landing.

452

Therapeutic Exercise: Moving Toward Functi on

DISPLAY 20-5

Mechanisms of Hamstring Overuse • Subtle imbalances in force or torque production and endurance between the hamstrings and gluteus maximus may lead to excess demand on the hamstrings to decelerate hip flexion during late midswing and hip medial rotation at initial contact. • Significant forefoot varus (see Cha pter 22), combined with length-tension alterations and reduced force or torque production of the deep hip lateral rotators, may lead to overuse of the biceps femoris. Without optimal foot mechanics and hip lateral rotator function, the biceps femoris load is exaggerated because of the increased role it must play in decelerating femoral and tibial medial rotation at initial contact through the midstance phase of gait. • Underuse of the oblique abdominal muscles may lead to overuse of the hamstrings because of the increased role they must play to exert a posterior rotational force on the lumbopelvic region .

Two commonly underused synergists involved in the cause of hamstring overuse strain are the gluteus maximus and deep hip lateral rotators. Examples of therapeutic intervention for progressive strengthening of the gluteus maximus and deep hip lateral rotators are shown in Self­ Management 20-1: Stomach-Lying Hip Extension . The exercises illustrated are considered specific, nonfunctional exercises. There are two reasons to prescribe this type of exercise instead of more func tionally relevant exercise. First, the force-generating capability of the muscle is

SELF-MANAGEMENT 20-1

Stomach-Lying

Hip Extension Purpose:

To strengthen the seat muscles, train you to move your hip independent of your pelvis and spine, and stretch the muscles on the front of your hip

Start position:

Lie on your stomach on a firm surface, and place _ _ pillows under your torso.

Movement technique

o

o

o

Preset your spine and pelvic position by activating your inner core and squeezing your seat muscle. Use your seat muscles to barely lift your thigh off the floor. Return your thigh to the floor and repeat the lift with the other leg.

Dosage Sets/repetitions ________ Frequency ________

inadequate to allow it to fully partiCipate in a functio nal task. Second, the kinesthetic awareness of the muscle may be such that the patient's ability to selectively recruit {t during a functional task may be insufficient. After force-generating capability and kinesthetic aware­ ness of the proximal posterior hip musculature are im­ proved sufficiently, graded functional activities can be initi­ ated. Self-Management 20-2: Walk Stance ProgreSSion and Self-Management 20-3: Step-Up, Step-D own illustrate functional progreSSions of specific exercises that use the gluteus maximus, quadriceps, deep hip lateral rotators in sagittal-plane kinetic chain activities. The clinician must be concerned with the recruitment of the underused synergis ts during each exercise. Subtle changes in lower quarter kine­ matics can affect muscle recruitment strategies.73 For ex­ ample, keeping the trunk more vertical during a step actiy­ ity can diminish the use of gluteus maximus relative to the quadriceps versus inclination of the trunk toward a mor horizontal position can increase the use_of gluteus maximu relative to the quadriceps (Fig. 20-15 ) 14 Display 20-6 de­ scribes the role of various muscles during these exercises. Overstretch can also be a contributing factor to muscle strain. For example, the gluteus medius muscle is suscep­ tible to strain resulting from length-associated change which can occur in an individual with an ~rparen t LLD and resulting iliac cres t height asymmetry. 1 On the side of the high iliac crest, the hip is adducted, and the gluteus medius is in a chronically lengthened position . As a result. this muscle is at risk for strain. Treatment of this type of strain must involve exercises that resolve the contributing factors to the LLD in conjunction with treatment to improve the length-tension properties , muscle perfor­ mance , and neuromuscular control of the gluteus medius. In the early stages of recovery, taping (Fig. 20- 16) can unload the muscle and support it at an appropriate length. providing a positive environment for healing. Severe strains may require use of a cane in the contralateral hand to unload the muscle enough to induce healing. Exercise to progressively strengthen the gluteus medius ar depicted in Self-Management 20-4: Gluteus Medius Strength ProgreSSion and Self-Management 20-2.

Disuse and Deconditioning Disuse and deconditioning of the hip joint musculaturE'. particularly of the abductor muscles, is quite common. Disuse or deconditioning can result from injury or patho­ logy affecting the hip and surrounding structures or fro m acquired movement patterns that promote disuse. For example , weakness in the gluteal musculature in hip jOint OA is a common finding, but research has not determined whether it is the cause or the result of hip jOint pathology.' '; Atrophy and pain both contribute to the decrease of muscle strength in hip OA 76 Because hip muscles participate in gait, sit to stand, squatting, and ascending/desce nding stairs, weakness of hip muscles can affect the performance of basic ADLs. It is reasonable to consider that acquired posture and movement habits can contribute to altered length-tenSion properties and disuse of the hip musculature. For example. a slightly high iliac crest, as commonly occurs in a handed­ ness pattern on the dominant side, contlibutes to length­

Chapter 20 The Hip

453

SELF-MANAGEMENT 20-2 Walk Stance Progression Purpose:

To teach the correct pattern to move your body over your hip, teach a good strategy to balance on one leg, and strengthen your hip and other lower extremity muscles to support your lower extremities in good alignment for activities you perform in standing

Levell

Start position

Movement technique

• Stand in a staggered stance position with your involved leg in front of your uninvolved leg. • Check the position of your feet, knees, hips, and pelvis. • Feet should be facing straight ahead with arches in neutral. • Knees should be facing straight ahead without turning in or out excessively lif you have anteverted or retroverted hips, the knee position may be modified). ~ Hips and pelvis should be facing forward and level. • Slowly bend your front hip and knee whi le leaning slightly toward your front leg. • Do not bend your knee further than the length of your foot. Hold this position for 10 seconds. • Activate your inner core (Note: activate your inner core in preparation for all the levels of this exercise). • Squeeze your seat muscle. • Tighten your quadriceps. • Hold the arch of your foot up while you keep your big toe down.

Levell

Dosage Sets/repetitions Frequency

A

Leve/II

Dosage Sets/repetitions Duration Frequency Level III: Split SqUBt

Start position •

Position yourself in a staggered stance with your involved leg forward. Lean toward your front limb as in l evel I. • Keeping your spine, pelvis, hips, knees, and ankles steady, slowly lower yourself until you see or feel your pelvis tilting or rotating out of the start position. • The movement should be occurring at your hip and knee. Your front knee should only bend as far as the length of your foot. (Note: a good rule of thumb is to keep your lower leg bone parallel to your torso throughout the entire maneuver.) .. Most of your weight should be over your front limb; if you feel your back limb straining, shift your weight onto your front limb. • Slowly rise upward while keeping your weight shifted forward. • Repeat up and down while remaining in a forward position over your front foot.

Level II: Single limb stance

Start position • The start position for this exercise is the end position of level I.

Movement technique

.. Progress from the walk stance position by lifting your back heel upward as you straighten your front knee and hip (A). • Be sure your feet. knees, hips, pelvis, and spine are in good alignment. • Hold this position for 3 seconds. • Slowly bring your back thigh forward by bending the hip and knee (as if to take a step forward) (B). • Balance for up to 30 seconds. (continued)

454

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 20-2 Walk Stance Progression (Continued)

Leve/III

Dosage Sets/repetitions Frequency Level/V: Lunge

Start position • Stand with both feet on the floor and weight equally distributed between both limbs. • Take a step forward and watch your pelvis, hip, knee, ankle, and foot position as in level I. Do not let your back arch. • This is a ballistic exercise. Be extra careful about your position.

Level IV

Dosage Sets/repetitions Frequency

FIGURE 20-15. (A) Side view of step-up exercise with good spine, hip, knee, and ankle/foot relationships Note the forward incl ination of the trunk. A good rule of thumb is to teach the exerciser to keep the trunk parallel to the tibia during the entire phase of vertical to lower­ ing and the return motion. This will best ensu re proper balance be­ tween the gluteus maximus, hamstrings, and quadriceps during closed chain activities. (8) Side view of step-up exercise with de­ creasedhip flexion and center of massposterior to the axis of rotation of the hip and knee . Step-up from this start position promotes use of a hamstring and soleus strategy to pull the hip and knee into exten­ sion to raise the center of mass upward. Relative to the quadriceps and gluteus maximus recruitment, th is position favors use of the quadriceps primarily because of the lack of hip flexion.

SELF·MANAGEMENT 20·3 Step-Up, Step-Down Purpose:

Variation: You can step off the back of the step. Do not step down fully, but merely touch your toe on the floor and step back up again so as not to fully unload the weight of your body through the stance leg. This makes the stepping leg work harder. This variation places more stress on your quadriceps.

To strengthen your spine, hip, knee, ankle, and foot muscles and to improve your balance in single limb stance

Step-Up

Start posItion. Stand facing a step. Movement technique • Lift your leg onto the step, keeping your thigh in midline and your pelvis level. • After your foot is on the step, check its position. The arch should be up with the big toe down. • Lean toward the step, being sure that your knee is in line with your foot (Note: this may vary if you have anteverted or retroverted hips) and your pelvis is level. • Looking at your body from the side, a good rule of thumb is to flex your knee no further past the length of your foot and to keep your lower leg bone parallel to your torso throughout the entire step up and down maneuver. • Step-up while keeping your pelvis level, knee over toes, and arch up. Be sure to lean into your hip, but do not let your pelvis tilt. • Variation: You can stand to the side of a step and step-up sideways. This variation places more stress on your outside hip muscles. Be sure to keep your pelvis level.

B

Dosage Sets/repetitions

Resistance (step height)

Frequency

Step-Down

Start position Stand on a step that is higher than you can control during a step-down movement.

Movement Flex the foot of the leg you are stepping down with. Bend the hip and knee of the foot remaining on the step as you lower your flexed foot tow ard the floor. Lean forward so as to bend at your hip. Do not let your knee bend further than the length of your foot. o Do not completely step down, but stop just short of the floor and hold this position for up to 10 seconds. • Be sure that your pelvis is level, your knee over your toes (Note: this may va ry if you have antev­ erted or retroverted hips), and your arch up as you lower your leg. Do not deviate from this position . • Variation: You may need to use an external device to assist you in your balance _ _ Hold a ski pole, dowel rod, or upside down broom in each hand. _ _ Hold a ski pole, dowel rod, or upside down broom in the opposite hand from which you are balancing. _ _ Hold a weight in the hand of the hip on which you are balancing. • Variation: After you can balance well during the lowering phase, you can further challenge your bal­ ance by using arm movements. When you have lowered yourself as far as you can control, raise the arm on the same side or opposite side of the leg on which you are balancing. _ _ Raise it up and down to the side. _ _ Raise it up and down to the front. _ _ Raise it toward and away hom the midline of your body.

Dosage Sets/repetitions

Assistance (amount of weight in hand)

Resistance (step height)

Frequency

456

Therapeutic Exercise: Moving Toward Function

DISPLAY 2.0-6

Role of lower Extremity Muscles During Closed Chain Exercises • The gluteus maximus muscle decelerates hip flexion in the lowering phase of the split squat, lunge, and step-down and accelerates hip extension during the rising phase of the split squat, lunge, and step-up. • The quadriceps muscle decelerates knee flexion during the lowering phase of the split squat, lunge, and the step-down and accelerates knee extension during the rising phase. • The deep hip lateral rotators are recruited to control hip medial rotation during all phases of each exercise. • The posterior tibialis and peroneus longus muscles control foot pronation during the stance phase of each exercise, which assists in controlling tibial and femur medial rotation up the kinetic chain .

FIGURE 20-16. Taping to support a strained gluteus medius.

c O ~

SELF-MANAGEMENT 20-4

Purpose:

Gluteus Medius Strength Progression

To strengthen the hip muscles that keep your hip and pelvis in good alignment when you walk (highest level of this exercise [level Vj helps to stretch the band on the outside ofthe thigh)

Level I-Prone Hip Lift

Start Position • Lie on your stomach on a firm surface.

Leveill-Prone Hip Lift With Elastic Perform as in level l, but attach a _ _ piece of elastic around your ankles.

Dosage Sets/repetitions Frequency

Place pillows under your torso as indicated in the illustration. • Your legs should be in line with your hips and rotated slightly outward.

Movement technique

• First you must activate your inner core to stabilize your pelvis. • Squeeze your buttock muscle. R Slightly lift your leg and move it sideways through as much range as your hip allows. The indication that your hip has moved through its full available range is that your pelvis begins to tilt sideways and your spine side bends. Do not move your hip any further after you feel your pelvis or spine move. Hold this position for 10 seconds. • Return your hip to a start position.

Dosage Sets/repetitions Frequency

Level II: Prone hip abduction with elastic

Levellll-Sidelying hip rotation Start position • Lie on your uninvolved side, with your hips and knees bent and _ _ pillows between your knees.

Chapter 20: The Hip

SELF-MANAGEMENT 20-4

Gluteus Medius Strength Progression

(Continued)

• Be sure you are on your side, with your head and neck in line with your spine and your spine in neutral, not rotated forward or backward.

Movement technique

• Keep your trunk still by activating your inner core. Slowly turn your hip outward (like opening a clam shell). Hold this position for 10 seconds. • Sl owly return to the start position.

Dosage

Level III: Sidelying hip lateral rotation

Leve/ V-Side/ying Full RRoge Hip Lih

Start position •

As in Level IV, but with your hips and knees straight in line with your torso. • It is helpful to lie against a wall, positioning your pelvis such that your pelvis is against the wall and both "cheeks" are touching the wall. In addition, your therapist may ask you to position a small towel behind your upper buttock to ensure your hip is in extension when it slides up the wall.

Sets/repetitions Frequency

Movement technique Level IV: Sidelying hip abduction-short lever arm

LeveIIV-Side/ying hip lift

Start position • Movement technique

As in level III, but your knees should be only slightly bent.

• Turn out your hip without letting your pelvis or spine tilt backward or forward by activating your inner core level III. • Lift your thigh upward and slightly backward through a full range of motion. Your pelvis will tilt and your spine will bend when you reach the end of your hip range. Do not move your pelvis or spine. Hold this position for 10 seconds. • Keeping your hip turned outward, slowly lower your thigh to the start position .

Dosage Sets/repetitions Frequency

As in level IV, but slide your heel up the wall through a full hip range of motion. Do not compensate by tilting your pelvis or sidebending your spine. Hold this position for 10 seconds. • Keeping your hip turned outward, slowly lower your leg to the start position.

Dosage Sets/repetitions Frequency

Level V: Sidelying hip abduction-long lever arm

457

458

Therapeutic Exercise Moving Toward Function

ening of the ipsilateral gluteus medius,49 w~~ch affects its force-generating capability during function. " The muscle tends to function at its relat~vely lengthened state during gait (with the hip adducted). , Q Eventually, this movement pattern may become more exaggerated, contributing to ex­ cessive hip adduction during the stance phase of gait and furth e r reliance on stability from passive tension of the ITB.il! As the hip increases its use of the ITB for passive stability, gluteus medius participation ma), decrease. Sub­ sequently, the gluteus medius is subject to furtber decon­ ditioning. This imbalance has been de monstrated in dis­ tance runners with iliotibial band syn drome (ITBS )80 Long-distance runners with ITBS have weaker hip abduc­ tion strength in the affected leg compared with their unaf­ fec ted leg. After 6 weeks of training with speCial attention directed to strengthen the gluteus medius, hip abductor torque increased 34(7c to 51 % and 22 of 24 athletes were pain-free and able to return to running. The iliopsoas is active in the initial swing phase of gait and presumably in ascending stairs 80 Its activity probably is related to the lateral rotation and hip flexion, which ac­ companies the inibal swing phase of gait. Faulty patterns of hip flexion can indicate underus e of the iliopsoas and overuse of another synergist. The follOwing examples de­ sClihe L:lUlty hip flexion patterns: • Hip bike during the swing phase of gait or stair climb­ ing suggests recruitment of lateral trun k musculature to hike tbe hip instead of using the iliopsoas to flex the hip (Fig. 20-17). • Hip fl exion with medial rotation (Fig. 20-18 ) suggests use of TFL as the predominant hip flexor instead of the iliopsoas.

FIGURE20-17. Use of a hip-hike strategy on the left to ascend the stairs.

FIGURE 20-18. Medial femoral rotation of the left femur accompanyin; hip flexion during stair climbing.

Salmnann states that repetitive alteration in the optim a. path of instant center of rotation of the hip during flexi o and the resulting compensatolY hip and lumbopehic movement patterns predispose the hip and lumbopehic region to further impairments and pathologiC conditions.-~ SpeCifiC exercises to improve the force-generating capabi­ lity of the iliopsoas (see Self-Management 20-5: Iliopso Strengthening) and gradual movement re-education in hir flexion patterns during function (i.e. , s'wing phase of gai­ and stair climbing) are indicated to improve iliopsoa muscle performance and participation in the hip fl exior force couple. Reduced participation of the gluteus maxi,:1Us pr, foundl y affects gait and the ability to ascend stairs fi) Gluteu maximus activity is related to Jeceleration of hip flexion a. terminal swing and isometric extensor support of the flexed hip at in~tial contact and during the loading response phase of gait. 55 Squatting, step-ups, step-dmVIls, and sit-to-st~md exercises are functional methods for improving the gluteus maximus force-generating capability and its recruitmen dUIing functional movement patterns , prOvided the proper kinematics are promoted (See Fig. 20-19). Hip lateral rotators are active from the initial contact tl midstance of gait, presumably to decelerate tbe medi al femoral rotation occurring as a result of foot pronation Signs of excessive hip medial rotation during weight accep­ tance and the Single-limb support phases of gait need to bE examined to determine the contributing impairments (e.g..

Chapter 20 The Hip

SELF- MANAGEMENT 20-5

Iliopsoas

Strengthening Purpose:

To strengthen the muscle deep in the front of your pelvis that lifts your leg and controls the forward rotation of your hip joint St8rt position: Sit with your feet flat on a firm surface, back straight. pelvis erect, and arms resting at your sides.

459

Range of Motion. Muscle Length, Joint Mobility, and Integrity Impairments ROM and joint mobility impajrments of the hjp can span the continuum of hypomobility to hype rmobility. The ex­ tre me clinical manifestation ofhypo molhility is the arthritic hip with a capsu lar pattern of limitation . The extreme din­ ical manifestation of hypermobiLity is eongenital dyspbsia of the hip, ereating chronic instability in the hip joint Ben",een these extreme conditions, more subtle mobillity impai rments can affect the fu nction of the hip.

Movemellt technique

Hypermobility

Levell-PassIve lift, nold, lower • Use your hands to lift your knee toward your chest as far as possible without letting your lower back round or #slump" backward. • Hold this position for the prescribed number of seconds. • Lower your leg to the start position.

Because of the inhere nt stability of the hip, hypermobility is not commonly thought of as an impairme nt in the adult hip , but rather as an impairment in th e developing hiph2 or complication in total hip arthroplas ty. With the increasing use of arthroscopy at the hip, sur­ geons have discovered labral tears to be more common than thous:ht 81 /,s Observations in the study reported by McCa rthy -'I suggest that acetabular labrallesions may be a contributory factor to the evolution and progression of OA of the hip, The \\lorking hypotheSiS is that a primary ante­ rior labral tear disrupts the stability of the hip , espeCially at the extremes of joint motion. This leads to abnormal glid­ ing of the alticular surfaces under dyn amiC torsional load­ ing conditions. In this sense, it is plaUSible that loss of the presumed stabi.lizing and weightbearing roles of the labrum at the extremes of motion (where the labrum would be anticipated to eXl~rt its most Significant effect) could pre­ dispose the hip to additional degeneration. Alternatively, lesions of the anterior labrum may represent a final com­ mon pathway of deterioration in hips with a wide variety of primary disorders. Hip joint hypermobility has been shovlI1 to be associated with OA in numerous studies and warrants careful atten­ tion for the preven tion of hip dege nerative joillt dis­ ease 86--88 Treatment of the unstable developin a hip usually consists of positioning, braCing, or sur cr ery/,9:90 wh('n~as trcatnwnt of the hypennobile (rarely unstable) adult hip usually consists of th~'l"apeutie exercise and posture and .. movem ent retnunmg. ,­ The etiology of hypermobility can be eithe r arthrokine­ matic or osteokinematic. Arthrokinematie hypermobility is defined as linear translation that is excessive, whereas os­ teokinell1atic hypc rmobility is angular translation ,t hat is considered excessive . These \\vo types o~~l)'Permobi lity can exist separately or togethe r. Sahrmann' ~ describes a syn­ drome in the hip (fe moral ante rior glide syndrome) in which abnormal anterior glide of the hip accompanies hip flexion resulting from stiffness in the posterior capsule and exces­ sive l'xtel~ sibility of the antelior capsule, yet hip flexion ROM may be norlllal or restricted. Anoth e r syndrome (femoral adduction with mewal rotation ) is desc ri bed in wbi Ii excessive hip adduction and medial rotation occur in combination, without the presence ofexcessive linear trans­ lation of the hip joint.':2 F e moral adduction syndrome can become exaggerated to the point that lateral glide mobility becomes excess ive, thus involving both osteokinematic and arthroki~ e ll1atic hypermobility ( ~ moral lateral glide syn­ drome ) 12. A person with femoral addu ction or lateral glide

Level /I-Resisted hIp flexion • Perform as in Levell, but push against your knee in a down and slightly outward direction for the prescribed number of seconds. Lower your leg to the start position.

Dosage

..)

Sets/repetitions Duration Frequency

hip anteversion , genuvalgllm, foot pronation, hip medial rotation). Use of orthotic support as the exclusive remedy for hip medial rotation shonld be avoided. There is evi­ dence that the kinematic effects of orthotic intClvention ar' small and not systematic bJ Instead, spec ific E'xe rcise and fun ctional retraining of the hip lateral rotator func­ tional control should be emphasized (Fig. 20-20 and Fig 20-21; see Self-Management 20-2). Eve n in the presenc . of foot- and ankle-related impairments and orthotic inter­ vention, isolated hip lateral rotator muscle strengthening is indicated to assist in pronation control.

460

Thera peutic Exercise Moving Toward Function

FIGURE 20-19. Chair squats. Note the forward inc lination of the trunk and parallel lines of the trunk and tibia. (A) Chair squats ca n be made easier with the use of pillows. (8) Gradually taking away the pillows can make the exercise more difficult.

syndrome typically has a broad pelvis, an apparent LLD (the high side being symptomatic), femur medial rotatiOIl. genu valgum, and foot pronation. These alignment faults contribute to stretch to the abductor and lateral rotator muscle groups and lateral capsule allowing excessive ad­ duction, medial rotation, and lateral glide patterns. Patterns of sustained postures and repetitive movements can predis­ pose an individual to a variety of syndromes because ofsoft­ tissue extensibility changes in the myofascial or periarticu]s:r

FIGURE 20-ZO. Prone hip lateral rotation with elastic. The patient is in­ structed to stabilize the pelvis in the sagittal and transverse planes with in­ ner core recruitment while rotating the hip from medial rotation to midline or slight latera l rotation. The slow release back to media l rotation empha­ sizes eccen tric control of the latera l rotators.

FIGURE 20-21. Single-limb balance challenges hip lateral rotators b adding torsional destabilizing stress through resisted movement of the up­ per extremities into horizontal adduction.

Chapter 20 The Hip

tis sues leading to hypermobility in osteokin ematic or aIthrokinematic patterns. Careful examination should distinguish between os­ teokinematic and arthrokinematic hyper mobility; the diag­ nosis of the latter being more difficult to resolve than the former. The primary objective of any therapeutic exercise intervention for the treatment of hyper mobility, regardless of etiology, is to promote joint stability and prevent contin­ ued stress on the overstretched or tom tissues (myofascial or periarticular) via postural and movement pattern changes and improving length. tension properties and mus­ cle performance of all muscles involved. Given the exam­ ple of the person with a femoral adduction syndrome, cor­ rection of postural habits such as sitting with his or her legs crossed, or standing 'with the affected leg in adduction, is indicated. Protecting the lateral structures from excessive treteh in the sidelying position with pillows between the legs is imperative. All movements should be performed \\ith the focus on avoiding femur adduction and medial ro­ tation patterns. Hip adductor stretching may be indicated reduce the adductor moment on the hip joint (see Fig. :20-22). Dosage for strengthening hip abductor and lateral rotators should prioritize muscle hypertrophic changes to enhance joint stiffness. Vilhenever excessive medial rotation ROM is measured, care must be taken to screen for anteversion. A common as­ oeiated finding with hip anteversion is weakness of the hip lateral rotators (i .e., deep hip rotators, gluteus maximus, posterior fih ers of gluteus medius ). In the presence of ex­ cessive medial rotation RONI , with or without anteversion, exercise to improve muscle performance of the lateral ro­ tators is indicated. Lateral rotator strengthening exercises, to be most effective , should be coupled with educat·ion about altering postural habits (e.g. , reduce the incidence of tanding with the femur in excessive medial rotation ) and movement training to improve recnritment of lateral rota­ tors during closed chain function. See Patient-Related Instruction 20-1: Standing Knees Over Toes and Patient­ Related Instruction 20-2: Walking With Knees Over Toes ' for examples of posture and gait education and training. aution must be taken when strengthening hip lateral ro­ tators in the presence of anteversion so as not to push the individual into too much lateral rotation , which will induce

FIGURE 20-22. A method of stretching hip adducto rs . The patient is in­ structed in maintaining a neutral pelvis (sitting with the back against the wal l can help prevent posterior pelvic tilt) and increasing the range of hip abduction versus trunk forward bend ias is commonly depicted in adductor stretches)

461

Standing Knees Over Toes Your neutral hip position may vary depending on the structure of your hips. Your physical therapist will instruct you as to your neutral position if you have a structural variation in your hips.

From the Front • Your weight should be distributed equally between both feet. • Your pelvis should be level from side to side • The left side of your pelvis should be in line with the right side of your pelvis (Le., your one side of your pelvis should not be in front of the other side) • Your knees should be in line with your feet; if you bent your knees, your knees would be directed over the midline of your feet. • Your feet should be hip-width apart and slightly turned outward. • The arch of your foot should be slightly elevated, with your big toe down.

Ideal alignment

From the Side • Your pelvis should be in neutral, with the front pelvis bones in the same plane as your pubic bone. • Your knees should not be bent or locked. • Your ankle should fall below your 'knee, with your lower leg at a 90-degree angle with respect to your foot.

462

Therapeutic Exercise : Moving Toward Function

Walking With Knees Over Toes When you walk • Do not let your knee lock back as you bring your weight over your foot. Your knee should be slightly bent when your heel contacts the floor and should slightly straighten as your body weight moves over your foot. • At the time your heel hits the ground. think of squeezing your buttocks to prevent your knee from turning in as your body weight moves over your foot. • Think of using your foot muscles to prevent your arch from dropping too low as your body weight moves over your foot. • Keep your inner core activated to prevent your pelvis from tilting forward. This is particularly important as your body weight moves in front of your foot and your hip must extend. If you do not hold your abdominal muscles tight. your pelvis may tilt or rotate instead of your hip extending.

Correct

Incorrect

tion ROM limitations. The therapist may need to counse the individual to seek a recreational activity that does no require Significant lateral rotation ROM. / Another common movement impairment that develop in the individual with anteverted hips is to achieve Jate rotation ROM by laterally rotating the tibia on the fem ur (See Fig. 20-23).% The person with this compensator: alignment should also be educated about his or her uniqut" lower extremity biomechanics and hip lateral rotatio ROM limitations to prevent rotational hypermobility p rob­ lems at the tibiofemoral joint and potential knee jOin pathology.u2,rm. !00

Hypomobility HypomobiLity impairments, particularly in the djrection flexion and medial rotation , can be found in the youm: middle-age , and elderly adult hip joint. Subtle losses i flexion and medial rotation may indicate early arth ri"' changes5l or hypomobility caused by chronic lack of us a result of altered movem ent patterns. A fully estahlish capsular patte rn (s ee Di~~play 20-2) can be a hallmark fin· ·­ ing for the alihritic hip. "

Correct

arthrokinematic hypermobility (see the follovving section for further explanation ). Individuals \vith hip anteversion can present with two unique hypermobility problems related to attempts to compensate for the anatomic impairment. Persons with hip anteversion may engage in activities that promote extreme hip lateral rotation, such as ballet or soccer. The anteverted hip is forced to function in extreme lateral rotation for ac­ curate performance of the activity. The head of the femur can be forced to translate excessively anteriorly and laterally to achieve the laterally rotated femur position,91 often resulting in anterior groin pain. Hip joint hypermo­ bility subsequently develops in an anterior and lateral di­ rection 9 ! Mounting evidence suggests _a link between in­ creased anteversion angles and OA. io.I2-9i It is possible that the anterolateral hypermobility may be a predispOSing fac­ tor in the development of OA. To prevent or alleviate this impairment, the patient should be educated about his or her unique lower extremity biomechanics and lateral rota­

FIGURE 20-23. Excessive tibiofemoral rotation associated with hip=­ teversion in an individual who has participated extensively in ballet. ~ ture shows ind ivi dual vo lunta rily laterally rotating the tibia, [Fr:' Sahrmann, Diagnosisand Treatment of Movement Impairment SyndJo rr, ~ SI. Louis: Mosby. 2002)

Chapter 20 The Hip

Pain need not be an essential component of early arthritic changes and hypomobility findings. For example, OA (confirmed radiologically) leading to considerable restriction of range in the capsular pattern may no~ cause pain, even when the capsule is stretched quite hard."l This is a typical finding in middle-age men with a capsular pat­ tern of restriction at the hip. Commonly, they have no com­ plaints of hip pain or related functionallirnitation, but they may complain of LBP because of the movement imposed on the back as a result of decreased hip mobility. Hip joint hypomobility may result from altered lum­ Lopelvic movement patterns because of a combination of anthropometric (e.g., high center of mass), occupational, and environmental (e. rr ., sports, recreation, hobbies) fac­ tors. It is hypothesized that, ultimately, as hip mobility de­ creases, lumbar mohility increases. This finding has been demonstrated in measyring lumbopelvic rhythm during t()Jward bending,IOl-lo" particularly in the early phase of forward bending.l06 The investigators of these studies found a Significant relationship between a relative loss of hip flexion mobility and relative increased lumbar flexion mo­ bility. Knowledge of this relationship is critical for the clin­ ician prescribing exercise and retraining movement pat­ terns. Functional activities such as bending forward to brush one's teeth, making th e bed, and reaching into the re­ frigerator involve moderate amounts of hip and lumbar flex­ ion. Hip stiffness resulting from reduced extensibility in capsule, ligament, or myofascial structures may impose ex­ cessive motion on the lumbar spine during forward-bending activities, which may ultimately lead to microtrauma and macrotrauma of the lumbar spine. Exercises to increase hip flexion mobility and lumbar stability, combined with re­ training lumbopelvic rhythm during forward-bending activ­ ities, are impOItant to mitigate impairments associated with the cause of LBP in this palticular patient subset. A useful exercise to retrain hip and lumbar movement is illustrated in Self-:\1anagernent 20-6: Hand-Knee Rocking. The hamstrings have been implicated as a potential source of hip stiffness. lo6 A common stretch for the ham­ strings is illustrated in Fig. 20-24. A selective medial or lateral hamstring stretch can be induced by rotating the hip in the medial direction to stretch the lateral hamstrings and lateral direction to stretch the medial hamstrings. Because the hamstrings are a diarthrodial muscle, knee extension must be maintained while the hip flexes to ensure optimal stretch stimulus. After the hamstrings have been stretched paSSiveLy, an active exercise should be performed to ensure the new length is used during function. One exercise that uses hamstring length during an active movement pat­ tern is illustrated in Self-Management 20-7: Seated Knee Extension. Another joint in the kinetic chain that may become stressed because of a relative loss of mobility in the hip joint is the knee. During squatting movements, loss of hip flexion ROM may impose increased motion on the lumbar spine and the knee joint (Fig. 20-25). Loss of hip joint mobility is a common finding in persons complaining of overuse-re­ lated knee conditions such as patellofemoral dysfunction and patellar tendinitis or tendinosis. Improved hip joint ROM and muscle pelformance of the gluteus maximus cou­ pled vvith improved squatting movement patterns can re-

463

SELF-MANAGEMENT 20-6 Hand-Knee

Rocking Purpose:

To improve the ran ge of motion of your hips, stretch the posterior hip muscles, and train independent movement between your hips, pelvis, an d spine Start position • Position yourself on your hands and knees so that your hips are directly over your knees and hands are directly under your shoulders. • Knees and ankles should be hip width apart with feet pointing straight back Your spine should be flat with a slight curve downward in your low back and your pelvis tilted so that your hip joint is at a 90-degree angle.

Movement technique:

Rock backward at the hip joint only. Stop at any sensation of movement in your back.

Rock backward slightly Back stays straight Hip joint angle decreases

Dosage Sets/repetitions Frequency

duce the stress on the knee Joint. Progressive squatting ex­ ercises with optimal kinematics at the hip and knee are rec­ ommended to decrease exressive forces at the low back and knee (see Self-Management 20-8: Progressive Squat). Emphasis has been placed on hip flexion and medial ro­ tation hypomobility impairments, but loss of hip extension ROM is another common finding, particularly in patients with end-stage hip mthritis. With myofascial or periarticu­ lar stiffness across the anterior hip, the pelvis may rest in a relative anterior tilt in relaxed stanchng. This posture may contribute to a relative increase in anterior pelvic tilt and lumbar extension to achieve an upright position (see Fig. 20-6C). During gait, hip extension is unable to be achieved, which may result in excessive lumbar extension or rotation. On return from the forward bend, the pelViS does not achieve a neutral position, and excessive lum bar extension

464

Therapeutic Exercise: Moving Toward Function

FIGURE 20-24. (A) Supine passive hamstring stretch with proper proxi­ mal stabilization (B) pelvic rotation is a common faulty technique during this stretch (C) Posterior pelvic tilt is another common faulty technique as­ sociated with this streich.

is imposed on the lumbar spine (Fig. 20-26) to achieve an upright position. A common finding associated with loss of hip extension ROM is positional weakness in the external oblique mus­ cles, lower rectus abdominis, and transversus abdominis because of the chronically anterior tilted pelvis. Treatment of this impairment requires careful stretching of the af­ fected hip flexor muscles concurrent with positional strengthening of the appropriate abdominal muscle groups (see Chapter 18). Specific muscle length tests reveal which hip flexor mus­ cles are contributing to the lack of hip extension ROM. Of­ ten, the diarthrodial hip flexors (i.e., rectus femoris and TFUITB) are stiff or short. Traditional stretches for the di­ arthrodial hip flexors do not follow the basic guidelines for optimal stretching because proximal stability is often not maintained (Fig. 20-27). Alternative stretches are recom­ mended for optimal results. Self-Management 20-9: Hip Flexor Stretch illustrates an isolated passive diarthrodial hip flexor stretch. For maximal effiCiency with this stretch,

it is critical to maintain the stability of the pelvis and spinE' while maintaining the femur and tibia in a neutral positio during knee flexion. To isolate the stretch to the TFL slight lateral rotation and adduction of the femur at end­ range is suggested. Compensatory tibia lateral rotation n1a\ occur as the ITB is stretched. The patient must be cau­ tioned to maintain tibiofemoral alignment by medially f(}­ tating the tibia during the stretch. Self-Management 18-5: Prone Knee Bend in Chapter 18 illustrates an active diarthrodial hip flexor stretch. Thi stretch uses active movement of knee flexion in an ex­ tended hip position to place repeated stretch 011. the eli­ arthrodial hip flexors while contracting the abdominal mus­ cles to stabilize the pelvis. As the abdomina'! muscles are recruited to stabilize the pelvis in this stretch, simultaneous elongation of the diarthrodial hip flexors and abdominal strengthening in the shortened range occurs. To ensure that gains in hip extension mobility are used in a functional context, the clinician must confirm that proper movement patterns are being used during fune­

Chapter 20 The Hip

,

. . . .J..

465

SELF-MANAGEMENT 20-7 Seated Knee

Extension·

Purpose:

To stretch the hamstring and calf muscles and train independent movement between your low back and pelvis and your hip and lower leg Start position: Sit with your back straight, pelvis erect, and arms resting at your sides.

Movement technique:

A

• Activate your inner core with particular attention to the lumbar multifidus. • Slowly straighten your knee, being sure not to let your pelvis rock ba ckward. Stop when you feel tension developing behind your knee. Hold this position for the prescribed number of seconds.

• Variations __ After your knee has moved as far as possible. move your ankle so that your foot points upward toward your knee. __ Rotate your hip and knee outward before you begin the stretch. __ Rotate your hip and knee inward before you begin the stretch.

FIGURE 20-25. Squat (A ) Fau lty squat technique performed with in­ creased lumba r flex ion as compensation for dec reased hip fl exion . (8) Faulty squat technique pe rformed with increased knee flexion as compen­ sation for decreased hip fl exion.

Dosage Sets/repetitions Duration Frequency

Bending With a Neutral Pelvis ) is necessary to ensure the specific ROM improvements are carried into ADLs.

Balance tional activities. Precise performance of functional move­ ment patterns requires hip extension mobility and abdom­ inal control to prevent anterior pelvic rotation and to achieve full hip joint extension. Achieving control over hip extension and pelvic position during functional activities such as the late stance phase of gait (see Patient-Related Instruction 20-2: Walking With Knees Over Toes), sit to stand, hip extension phase of squatting, and the return from forward bending (see Pa­ ti ent-Related Instruction 20-3: Return From Forward

Approximately 25% to 35% of persons older than 65 yt'ars experien ce one or more falls each yeaL I07.lOS Falls are a leading cause of morbidity and mortality of persons older than 65 years,lO~) .l lO and many of the falls result in hip frac­ tures which are a leading cause of mortality and morbidity among older people in the United States. II In 1995, hip fracture was the 10th leading reason for hospitalization for Medicare beneficiarie~, 111 and the prevalence and costs of hip fracture are expected to grow as the older population increases. ] 1.3 .114 The hip fracture rate in the ~nited States is about twice as high for women as for men,11".116 and res­

466

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 20-8

Purpose: Stsrt position:

Progressive Squat

To progressively strengthen your hip girdle muscles and train independent movement between your hips and spine Stand with weight equally distributed between both feet with your pelvis and spine in neutral. Your neutral hip position may vary depending on the structure of your hips. Ask your physical therapist for instructions on your neutral hip position.

Movement technique: Levell: Small knee bend o Slowly bend your hips and knees. • Do not bend your knees farther than the length of your feet. Think of sitting back slightly. o Be sure that your feet are facing ahead, with knees over toes and pelvis level as you bend. • A good rule of thumb is to keep your lower legs parallel to your torso during the lowering and raising phase of this, and subsequent levels, ofthis maneuver. • Return to the upright position by using your seat and front thigh muscles. Be sure to complete the rising phase by returning to the neutral spine and pelvic position.

Level II Leve/ /1/: Partia/squat Perform as in Level II, but do not use a cha ir as a stopping point; instead, lower yourself as far as is comforta ble. o As you move deeper into the squat, you will need to bend your hips more (remember that your knees should not bend further forward than the length of your feet) to keep your balance. o

1

Small knee bend

Level III

Level I Level": Chair squat ~

Perform as in Levell , but lower yourself to a chair with _ pillows. o Try not to collapse into the chair, but rather slowly lower yourself. • Re turn to the upright position by using your seat and front thigh musc les. Be sure to comp lete the ri sing phase by returning to the neutral sp ine and pe lvic position.

• Variation

Perform Level III with a dumbbell in each hand.

Perform Level III in a squat rack with a barbell.

Dosage Sets/repetitions Frequen cy Weight

Chapter 20 The Hip

467

SELF-MANAGEMENT 20-9 Hip Flexor

Stretch To stretch the front thigh muscles Purpose: Start position • Sit on the edge of a table so that you r thigh is halfway off. Lie back while bringing both knees towa rd your chest. • Pull your knees toward your chest until your low back just touches the ta bletop surface.

o

Movement technique FIGURE 20-26. On the retu rn from forward bend. if the pe lvis stops rotat­ ing posterior before it reaches a neutral position. excessive lumbar exten­ sion is imposed on the spine to achieve an upright posture.

• While grasping behind your knee, lower your other leg toward the floor, keeping your knee bent to 90 degrees. • Keep your thigh in the midline; do not let it drift to the side. • Do not let your thigh rotate inward

idents of nursing homes have been reported to have a 3 to 11 times greater risk than nonnursin? ):lome residents of hip fracture in the United States , 11 Netherlands,1l8 France, llB and Finland. 120 Hip fracture has a high impact on patients' health and medical costs. A high risk for hip fracture is predicted by low bone density, prior fragility fractures, and a high Iisk of falling. 121-124 Improved postu­ ral stability and balance can improve fear of falling and de­ lay the onset of fall events for older adults. 12.5-128 Tai chi has bee n valuable in promotin% Rosture stability and balance control in the well elderly. l2 - 32 The Tai chi • Variation: Let your thigh drop out to the side instead. Turn your lower leg inward. Gently pull your thigh toward midline until you feel slight tension in your iliotibial band. • Hold for seconds.

Dosage Sets/repetitions Frequency

FIGURE 20-21. Traditional stall ding hip flexor stretches do not eHectively stabilize the spi ne and pelvis Note the anterior pelvic tilt and hip flexion in this individual attempting to perform this commonly used hip flexor stretch.

progression (i.e ., bipedal weight shifting to uniped posi­ tions) focuses less on centeIing the center of mass within the base of support and more on learning corrective strate­ gies for instability. The advanced forms serve the pmposes of destabilizing the indiviJual in a controlled fashion, en­ gaging new movement strategies and facilitatiIlg the confi­ dence level of the participant. Force-platform biofeedback systems can also be used to train posture stability and balance control. However, the focus of force-platform biofeedback systems is different than that of Tai chi balance training. The former is typi­ cally concerned with learning to enhance center of mass or center of pressure movement within the limits of stability, and the latter is concerned with learning controlled mo­ tions as those limits ar passed. Controlled clinical studies have not demonstrated a reduction in falls or delays in fall occurrences among older persons using force-platform

468

Therapeutic Exercise Moving Toward Function

Return From Forward Bending With a Neutral Pelvis When you come up from bending forward • Lead with your hips by activating your seat muscles. • Do not arch your back. Avoid this by activating your inner core and gently pulling your belly button toward your spine. • Complete the motion by bringing your pelvis back to neutral before finishing the spine movement.

ance must focus on the intrinsic and extrinsic factors re­ lated to the balance disorder. This requires extensive ex­ amination and evaluation of muscle performance, ROM. joint mobility, vestibular function, balance reactions, and environmental factors. Clinicians trained in balance­ related rehabilitation have shown that compliance with a multidimensional, individualized exerci.se program that ad­ dresses the impairments and fUl1ctionallil11itations associ­ ated with bahmce deficits can improve balance and mobil­ ity function and reduce the likelihood of fallsY Display 20-7 lists general guidelines that can assist the practitioner in developing balance training activities for the hip, and Display 20-8 describes a sample progression of balance tasks.

Pain

When You Rise Upward From a Squatting Malian • Be sure to complete the motion by fully extending.your hips until your pelvis reaches neutral. • Activate your inner core to ensure your pelvis remains in neutral.

biofeedback systems. 133 This may be because the ability to control the center of pressure during quiet standing or with the added provision of random but moderate perturba­ tions, used dming typical machine-based postural training, may not translate well into a functional situation, thereby not resulting in decreased fear of falling or delayed onset of fall events for older adults. The ability to effectively treat patients with balance dis­ orders can be enhanced by a clearer understanding of the problems underlying balance. Treatment of impaired bal­

Pain is undoubtedly the most common reason persons seek physical therapy for hip-related dysfunction. The preva­ lence of hip pain in the elderly is 14.3% for those 60 year) of age and older. 134 The most important aspect of therapeutic exercise inter­ vention for hip pain is the differential diagnosis of 'the etiol­ ogy as well as the mechanical cause of the pain. TraumatiC' and overuse soft-tissue injuries include muscular, bursal tendinous, or ligamentous inflammation, contusions, strains. and sprains. Skeletal injuries can involve the physis or apophysis in children, and skeletal disorders include frac­ tures, subluxations, dislocations, stress injuries, infections. and avulsions. Patients with nontraumatic hip pain from sys­ temic conditions such as rheumatoid arthritis, juvenile arthritis, ankylosing spondylitis, tumors, and metabolic bone disease should be suspected when the severity or course of the injury is atypical. Persistent hip pain can Oliginate from intramiicular disorders such as avascular necrosis, OA, loose bodies, labral tears, or pyalthrosis. Hip pain also may be sec­ ondary to a lumbar spine disorder. Nerve entrapment sYTI­ dromes involving the ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve of the thigh may present as hip pain or paresthesias (to be discussed in more detail under Nen Entrapment Syndromes). Pain from the hip joint can be referred anteriorly to the groin, referred laterally in the region of the greater trochanter, or radiate do\vn the anterior and medial thigh to the knee. Occasionally, referred knee pain can occur with little or no pain in the hip. Pain posterior to the hip or in the buttock is frequentl~ associated with lumbar spine pathology, but it can also arise from the hip. Pain from the spine commonly radiates down the posterior thigh, occasionally to below the knee, but hip pain rarely radiates below the knee. Severe synovitis or acute arthritis can produce pain in the entire hem ipelvis. Pain related to HE fascitis is experienced in the lateral thigh and can be mistaken for lumbar radiculopathy. Be­ cause this condition occurs commonl\' in the elderlv, spinal stenosis can be incorrectly implicated as the sour~e of .tIl< lateral thigh pain. \Vhether or not the source of the pain is diagnosed, the biomechanica! cause should be establis l1 ed. Treatme nt must work toward alleviating impairments related to the source and cause of pain and inflammation for long-term

Chapter 20: The Hip

469

DISPLAY 20-7

Guidelines for Balance Training Activities In treating balance impairments with training programs, in­ cluding T'ai chi, progressive drills, and computerized bal­ ance devices, the specific demands of compensatory step­ ping or grasping reactions that are found to cause difficulty (e.g., lateral weight transfer, rapid foot or arm movement, crossover steps) should be addressed. These skills can be addressed through unpredictable exercise conditions, such as the use of dense foam or having an outside perturbation such as a partner pushing or pulling the patient off balance. Cautious progression toward uniped motions is indicated, especially because this position is experienced by most older persons before falling. When training balance control, stepping and grasping reactions are not just strategies of last resort. These strategies can be initiated very early, well before the center of mass is near the stability limits of the base of support. 133 One goal of balance training may be to reduce the incidence of stepping and grasping strategies as posture stability and balance are increasingly challenged. Display 20-8 provides examples of progressive uniped balance tasks. The goal of the exercise would be to balance on one limb, with the progressive self-induced perturbations (e.g., arm movements), without using a grasping or stepping strategy to prevent a fall. • For anteroposterior perturbations, the fixed-support ankle strategy (i.e., ankle muscular response to arrest the motion of the center of mass) may provide an early defense against destabilization, followed by a stepping or grasping

strategy.133 When using an anteroposterior destabilizing force (e.g., uniped with sagittal arm movements), expect the ankles to provide the stabilizing force to maintain postural stability. o A fixed-support hip strategy (i.e., hip muscular response to arrest the motion of the center of mass) may be limited to a special task condition that precludes the option of stepping or grasping. 133 Use of a fixed-support hip strategy would be inappropriate under normal conditions. • Lateral destabilization complicates the control of compensatory stepping because of anatomic or physiologic restrictions on the lateral lower extremity movement and the associated prolonged uniped balance demand. Aging appears to be associated with increased difficulty in controlling lateral postural stability, which may be of specific relevance to the problem of lateral falls associated with hip fractures. 134 Exercises designed to provide frontal­ plane destabilizing forces (e.g., uniped with frontal-plane arm movements) would especially be indicated in the aging population. Side-stepping strategies for recovery to prevent a fall are important skills for this population to learn. o Assistive devices can aid the individual in balance control before developing functional balance control through a comprehensive training program. Use of a cane in the nondominant hand has reduced the rate of falls by up to fourfold. 161 Cutaneous information from fingertip contact, through a cane, and from a stable surface is more powerful than vision in stabilizing sway in stance.161

resolution. Treatment of the cause of the pain and inflam­ mation often relieves symptoms without specific treatment of the source. Several examples of treatment of the cause of pain and inflammation are presented throughout this chap­ ter. Treatment of potential sources of hip pain and possible

contributing factors can follow the general guidelines illus­ trated in Display 20-9.

DISPLAY 20-8

Examples of Progressive Balance Tasks • Balance on one leg on a firm surface is progressed to an unstable surface such as dense foam. o Balance on one leg while rotating the head on a firm surface is progressed to dense foam. o Balance on one leg with frontal, sagittal, or transverse plane arm movements on a firm surface is progressed to dense foam. • Perform the previous balance task, but follow the arm movements with the eyes and head. • Balance on one leg and move the trunk and upper body into contralateral flexion and rotation (i.e., reach for inside of ipsilateral ankle and foot) and ipsilateral extension and rotation (i.e., reach for object superior, lateral, and posterior to the head). and follow the arm movements with the eyes and head. • Perform the previous three exercises while holding a weighted ball.

Posture and Movement Impairment Posture and movement training of the hip is used to opti­ mize kinetics and kinematics at the hip joint as well as to in­ fluence the kin etics and kinematics of other jOints in the ki­ netic chain. Similarly, posture and movement training of other jOints in the kinetic chain can influence the kinetics and kinematics of the hip. Intervention focusing on posture and movement is pivotal to all therapeutic exercise inter­ veritions. Exercise should not be taught without attention to details of posture and movement. All patients should be provided with instruction in avoiding posture and move­ ment habits that contribute to the cause of symptoms and in developing alternative habits that will reduce or elimi­ nate symptoms. With respect to hip alignmen t, it is important to under­ stand that pelviC tilt is not always an accurate measure of hip jOint angle. Knee jOint angle can also affect hip joint an­ gle . For example, when the knees are flexed, the hips are flexed, even if the pelvic tilt is near neutral, and when the knees are hyper-extended, the hips will be extended, even if the pelvic tilt is slightly anterior (Figure 20-28). Be sure to correct for pelviC tilt and knee joint angle when treating posture impairments at the hip. This holds true for trans­ verse and frontal plane posture impairments as well.

470

Therapeutic Exercise Moving Toward Function

DISPLAY 2D-9

Guidelines for Pain Relief Involving the Hip Joint Activity modification: Initially, the clinician should encourage patients to maintain muscle performance and ROM of the hip while avoiding risk activities, such as running, carrying heavy loads (especially contralateral to the painful hip 162 1, or prolonged standing. • Physical agents or electrotherapeutic modalities: The use of cryotherapy, moist heat, or electrotherapeutic modalities may help modulate pain or decrease inflammation. Because of the anatomic position of the hip, these modalities may have limited effectiveness in treating intraarticular inflammation or sources of pain. • Manual therapy: Appropriate use of joint and soft-tissue mobilization can improve physiologic impairments related to pain and inflammation, such as joint mobility and tissue extensibility. Joint mobilization can also be used to modulate pain (see Chapter 163 • Therapeutic exercise intervention: Gentle active ROM exercises in the pain-free range can be used to modulate pain, similar to the grade III joint mobilizations described by Maitland. 163 • Assistive devices: When a person has a limp caused by pain, use of an assistive device in the contrarateral

n

Movement impairments at the hip, as with posture im­ pairInents, can be affected by impairments at other seg­ ments. The cause of any given hip movement impairment must be diagnosed from the data collected during the examination of the patient. For example, limited hip flex-

r

hand is necessary to reduce the load on the hip. A cane in the contralateral hand of a patient can reduce the joint reaction force by as much as 30%.139 Patients often are reluctant to use an assistive device for fear of "giv­ ing in to the condition." Patient-related instruction must include an explanation that temporary use of an assis­ tive device will reduce the load at the hip and allow the pain and inflammation to resolve. Exercise to improve mobility and force- or torque-generating capability of the appropriate musculature is required to discontinue use of the assistive device without risk of recurrence of symptoms. Weight loss: Overweight persons must work diligently on weight loss through proper nutritional counseling and aerobic activity tolerated by a painful hip, including non-weight-bearing activity such as aquatic activities or cycling. It is possible that cumulative exposure to excessive body mass may increase the risk of developing hip OA164,165 and the worsening of the disease,166,167 • Biomechanical support: Carefully prescribed foot orthotics can improve skeletal alignment and potentially influence contact forces at the hip,168

ion during a step-up activity may result from a loss of hip flexion ROM, reduced joint mobility, weakness in the hip flexors, or limited knee or ankle mobility. Only a thorough examination can reveal the cause of the movement impair­ ment. Once the cause(s) is established, an appropriate in­ tervention can be developed to manage the associated impairments (i.e., muscle stretching, joint mobilization. muscle strengthening) Although posture and movement retraining are ultimate goals in most physical therapy interventions, changes in pos­ ture and movement patterns require basic: skills in mobility. muscle performance, and motor control. To affect a posture or movement change, mobility, length-tension properties. and muscle performance must be at functional levels, and kinesthetic awareness about joint position, joint motion, or a specific muscle recruitment pattern must be developed. The initial focus of any intervention should be on im­ proving phYSiologic impairments to a functional level. After phYSiologic impairments have achieved a functional level of capacity, gradual transition from specific exercises address­ ing physiologic impairments to greater emphasis on pos­ ture and movement patterns used during functional exer­ cise, and activities should occur until the primary emphasis is on functional retraining. Examples of exercises to im­ prove posture and movement of the hip joint are presented throughout this chapter.

Leg Length Discrepancy

FIGURE 20-2B. Note the slight anterior pelvic tilt. When the knees are hyperextended, the hips will be extended, even if the pelvic tilt is slightly anterior.

Although LLD is not considered a postural impairment iso­ lated to the hip, it is discussed here because of its func­ tional implication at the hip as the transmitter of forces from the ground and lower extremities to the trunk and up­ per extremities. Functional LLD is the most difficult form

Chapter 20 The Hip

to diagnose and treat. Nearly any movement of an osscous segment out of its normal plane of reference in relation to other bones can create a shorter or longer distance be­ tween proximal and distal reference points. Altered os­ seous pOSitions can occur about any ~\is of motion and in any segment. \tlinor alterations in position in anyone se 1­ ment, when added to minor alterations in position of other segments, can lead to a substantial LLD . To furth er complicate matters , functional LLD can co­ exist with stmctural LLD-someti I11CS exaggerating the LLD and sometimes compensating for the LLD . For ex­ ample, a stmcturally longer limh may compensate for its l~ngth with lateral pelvic tilt, knee flexion, or foot prona­ tion . After the type of LLD aml the segments involved are accurately diagnosed as functional, struchlral, or combined LLD, appropriate intervention must be determined. Treatment of LLD ranges from posture and movement training to shoe inserts to various surgical techniques in­ cludi~g limb Lengthening and shortening and epiphys­ IOdeSIS. After it has been determined that the LLD is not completely amenabl to posture and movement training, other nonsurgical or . urgical interventions are indicated. There is disagreement regarding the correct treatment in reg:lrds to l1lag~itude of LLD. Reid and Smith 135 suagest dlVldmg LLD I11tO three categorie , mild (0-30 mm) , moderate (30-60 mm), and severe (>60 mm), in which !TIlld cases should either go untreated or treated nonsur­ rically, moderate cases should be dealt with on a case-by­ case basis and sOllie should be dealt with surgicully, and 'evere cases should be corrected surgically. Moseley sug­ O'ests a similar breakdown: 0-20 mm requiring no treat­ ment, 20-60 mm requiring a shoe lift, C'piphy~iodesis, or shortening, 60-200 mm requiring le ngthening that lIlay or may not be combineu witl1 other procedures. and >200 !TIm prosthetic fitting.136

Structural Leg Length Discrepancy The most common treatment for mild structural LLD is the use of shoe lifts , which consists of either a heel lift, shoe insert, or building up the sole of the shoe on the shorte r I g. In general, up to 20 mm of correction can be made \vith an insert, whereas further corrections shuuld be uone on the 'ole of the shoe./.3713~ If an equinus anatomic impairment exists, a heel lift is more appropriate than a full-sole lift. The amount of lift preSCribed depends on the limb lenlTth difference and the patient's phYSiologic tole rance b to change. Individuals with long-standing, significant stmc­ tUfal discrepancies generally do not tolerate siO'nificant . ~ 0 ' rapid change because of the osseous and soft-tissue adap­ tatIOns that have developed over tim e. NfinimaJ bei(Yht ad­ justments at infrequent intervals should be maue ugti! the maximal necesscuy change has occurred.

Functional Limb Length Discrepancy

T reatment of functional LLD should consider th e physio­

lOgiC impairments at each invol ed segment and the inter­

actions between levC'ls. for example, a function ally short

l.imb caulsed by femoral and tibial medial rotation and by

'loot pronation could have associated impairments of:

• Lengthened or weak posterior gluteus medius and deep hip lateral rotators

471

• Lengthened or weak foot supinators • Forefoot or readoot vams Appropriate exercises, biomechanical support, and posture and movement training are necessary to alleviate the re­ lated impairm ents. Patients with functional LLD related to ~ower extremity kinetic chain pronation (i.e., femur medial rotation, genu valgum, and foot pronation) may benefit from temporary or permanent foot oltbotics to assist in controlling pronation throughout the kinetic chain. However, caution must be used in prescribing Olthotics to remeuy phYSiologiC impair­ ments up ~he kinetic chain. Exercises to alleviate physio­ logiC Imp[illl111ents contlibuting to pronation should be at­ te mpted irst. If performance demands exceed the ability to control pron ation , use of orthotics may be a usef~l adjunct. . Cautious use of sole or heel lifts to compensate for a f~nctio.nal LLD is recommended. The faulty strategy of displacmg the center of mass over the base of support used by a patient vvith a function al LL D does not necessarily al­ ter vvith a lift. The more common scenalio is for the indi­ vidual ~o continue with the same faulty strategy, thereby enhancmg the functional LLD. For example, during initial contact phase of gait, the shOlt limb may be functionally short as a result of positioning th e hip in adduction \vith minimal displacelllent of the center of mass over the base of S~ppOlt. After adding a lift , a similar gait strategy may continu e to be us ed, causing fmther exaggeration of tl'le L.LD. Often, training tl1e patient to properly position the hlp and accurately displace the center of mass over the base of support alleviates tbe LLD without the need for orthotic correction (see Self-Management 20-2: levels I and II).

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON DIAGNOSES Although it is b yond the scope of this text to present a comprehensive description and intervention plan for all di­ agnoses affecting the hip joint, a few selected diagnostic categones are presented. A brief overview of the etiology, examination/evaluation findings, and proposed interven­ tion, with emphasis on therapeutic exercise, is presented for each diagnOSis.

Osteoarthritis Osteoarthritis is the most common form of arthritis, affect­ ing Illi." ions of people in the niteu States. Among US adults .30 years of age or older, symptomatic disease in the hip occurs in approxi mately 3%.139 OA increases with age, anu sex-specific diffe rences are evident. 140- 143 Became OA is a disease whos e prevalence increases with age, it will be­ com . even more prevalent in the future as the bulging co­ hort of baby boomers grows older. OA is a complex disease whose etiology bridges biome­ chanics and bioch mistr\'. Evidence is bfTrowin ba for the role , / of systemic fa 'tors (s uch as genetics, dietary intake, estro­ gen lISe, and bone denSity) and of local biomechanical fac­

472

Therapeutic Exe rc ise: Moving Toward Functi on

tors (such as muscl e weakness, obesity, and joirrt ]
Diagnosis Proper diagnosis of a patient with hip OA requires a care­ ful history, physical examination , and review of appropriate radiographic and laboratory studies. The prese nce of ra­ diographic changes (e.g. , joint space narrowillg, moderate malalignment, osteophytes at the mar~nal aspects of the joint) should correlate ""rith positive examination findings at the hip joint to arrive at a diagnosis of hip OA. A positive radiographic finding alone does not indicate that the hip OA is the source of symptoms, because many other muscu­ loskeletal and nonmusculoskeletal sources can mimic hip joint pain. Hlp OA is a common sequelae of aging and is not always symptomatic. Many people "vitll pathologic and ra­ diographiC evidence of OA have no symptoms. 14il Laboratory tests may not detect serum abnormalities unless their presence is related to another disease process. The rheumatoid factor tes t is generally negative. If the rheumatoid factor is found in the serum of older patients, its presence may be unrelated to the arthritis because false-positive results for rhe un:,atoid factor increase with age in the normal population . 1 ~'J Gradual, progressive, chronic pain can be associated with ~A. Intraarticular pain is usually described as deep, aching pain and can be experienced in the groin, around the greater trochanter, medial knee, and posterior buttock. The patient may induce or aggravate pain \.\Iith moderate to vigorous activity and experience relie f of pain \vith rest. Long periods of rest, however, may resu lt in joint stiffness. The stiffness of OA is not as seve re as that of rhe umatoid arthritis. Mild activity mually dissipates tlle stiffness . Com­ mon clinical findings of a patient \~.ith hip OA are described in Display 20-10.

Treatment Major advances in management of OA to reduce pain and disability are yielding an impressive array of available treat­ ments ranging from acupuncture to chondrocyte trans­ plantation, new oral anti -infl ammatory medications, and

DISPLAY 20-10

Common Clinical Examination Findings of a Patient with Hie OA • Alignment: anterior pelvic tilt. hip flexion, and hip lateral rotation • Gait: positive Trendelenburg sign, but more commonly a compensated Trendelenburg or antalgic gait (see Fig. 20­ 9B) • ROM: restricted ROM in a capsular pattern with associated myofasciallength changes • Muscle performance:weakness in all muscles surrounding the joint, but most notably in the gluteus medius and maximus

DISPLAY 20-11

Nonoperative Treatment of OA • Systemic and topical treatments (i.e., nonopioid analgesics, NSAlDs, opioid analgesics, chondroitin and glucosamine, and topical analgesics)148.169-175 • Acupuncture 176.177 • Intra-articular injection of corticosteroids 178.179 • Assistive devices180.181 • Patient education182-184 • Exercise18~187

patient-related instruction. Evide nce for the efficacy 01 commonly used oral the rapies , alternative therapies_ biomechanical intervention s, such as exercise, and behm-­ ioral interventions directed toward enhanCing self-manage­ ment is mounting (See Display 20-11). In the vast majOlit\ of cases, surgical treatment of OA is considered onlv after failure of non surgical treatments. J :37 Recently, biologiC ap­ proaches to the surgical treatment of OA have be explored.J 38.146 Th e folloVlring sections Vlrill review concepts related tl therapeutic exercise intervention for the treatment of im­ pairments related to hip OA.

Pain and Inflammation Management of pain and inflammation for hip OA car follow the general gUidelin es discussed in a pre\rious sec­ tion (see Display 20-9). Activity modification may be one 0 the most significant aspects of treatment for pain and in­ flammation. The changes may include modification of bd­ sic and instrum ental ADLs. The patient should be in ­ structed in joint protection techniques during prolong postures (i.e. , standing \~rith efjual weight bearing on bot! feet , using an assistive devi ce ) and common movement pat ­ terns (i.e, carrying heavy loads in the hand on the invo[Y, side or in botll hands equaIly) J :39 The patient car:! COll\'er' vigorous weight-bearing activities (e.g., running, tennis) t non-weigh t-bearing activities (e .g. , biking, s\vimming, \ \ '!I _ ter aerobics ). SpeCific to hip OA, treatm ent addreSSing the caus the pain should focus on altering the biomechanics of the hip. Th e degeneration in OA is caused by a hreakdo""ll chondrocytes, which are an essential element of articular cartilage. This breakdown may be initiated by biomechani­ cal stress. A primary goal of the intervention should be tl alter biomechanical forces acting on the joint. Restorin _ joint ROM and tissue extensibility in flexion, extension medial rotation, and abduction and restoring muscle per­ formance of gluteus medius and maximus enables the join, to function in improved alignment and movement pattern This in tum can reduce the biomechanical stress to the fo­ cal area of DJD and result in decreased pain.

Range of Motion and Joint Mobility Specific exercises to improve ROM and jOint mobilit\­ may include passive (Figure 20-29 and Figure 20-30) and active stretching (Self-Management 20-6) and mobilizatiOf) in the affected directions (see Chapter 7). However, actin~ exercises should be employed whenever pOSSible. Actiq~ exercises improve ROM and joint mobility ""rith the added

Chapter 20 The Hip

473

FIGURE 20-29. Passive range of motion to the hip in (A) flexion. (8) extension. (C) abduction. (D) medial rotation, and (f) lateral rotation. Note the stabil iza tion of the pe lvis to make certain that movement occurs at the hip in isolation. In the case of hip flexion. a simultaneous posterior-i nfe­ rior glide of the head of th e femur can reduce an­ terior hip impingement that occurs with a stiff posterior joint

bonus of recruitment of the muscles necessary to move the joint in the desired direction during function. Examples of ctive exercises to improve hip mobility in persons with hip A are shown in Self-Management 20-4 and Self-Manage­ ment 20-8. Another useful technique to teach the patient \\ith OA in the hip is self-traction (Fig. 20-31 ).

Self-Management 20-4). Whenever possihle, functional ex­ ercises should be employed. For example , standing on the involved hip in neutral hip joint alignment and lifting the un­ involved hip onto a step can stimulate hip abductor recruit-

Muscle Performance

The patient can be instructed in specific exercises to im­ prove muscle perrormance (see Self-Management 20-1 and

FIGURE 20-30. Prone hip medial rotation stretch wi th elastic. The patient is instructed to stabilize the pelvis in sagittal and transverse planes via in­ ner core contraction. It is important to keep the femur in contact with the floor to ensure a precise rotational stretch. If the hip flexors are short, use of a pillow under the hips can allow the knee to flex 90 degrees with min­ Imal compensatory hip flexion. This exercise is contraindicated in the pres­ ence of knee pathology

AGURE 20-31. Self-traction of the hip The involved limb is given traction by the use of abelt or other stiff material around the ankle wh ich is secured in a door jam, whereas the contralateral limb pushes off a surface as shown. This technique can provide a decompression stress to the joint and stretch the joint capsule.

474

Therapeutic Exercise Moving Toward Function

ment on the weight-bearing side. However, weight-bearing exercises on a hip with OA may exacerbate symptoms, par­ ticl.llarly if the alignment is faulty. Adjunctive use of a cane, walking stick, ski pole, or dowel rod in the contralateral hand during weight-beming exercise can reduce the amount of work necessary for the ipsilateral hip abductors . This ap­ proach reduces the jOint reaction force ,md joint pain and in­ creases tolenHlce to weight-bealing exercise. Another method to reduce the jOint reaction force enough to allow weight-healing exercise is to hold a weight in the hand on the involved side. 139 TIle amount of weight can be graded to use the least amount necessarv to reduce pain and allow optimal alignment during the step~up activity. Regardless of the method llsed to unload the hip, the ap­ propriate strategy for unilateral balance must reinforced. The gluteus medius and TFL are synergist hip abductors. H is COlllmon for the TFL to dominate the stance recruitment pattern, particularly if the hip is in flexion or medial rota­ tion . Education regarding the neutral position of the hip and gluteus medius recruitment is critical to the optimal out­ come of this exercise. This may require additional activity from the inner core muscles to control anterior pelViC tilt. Step-up acti~ties stimulate hip extensor recruitment of the stance limb ,:.> and faci litate hip flexion mobility, partic­ ularly if emphasis is placed on hip flexion during the step­ up (Fig. 20-32), and ..s_tep-down activities stimulate gluteus medius recruitment. 10 Care must be taken during stepping activities to prevent Trendelenburg patterns and to rein­ force proper length-tension properties of the gluteus medius (i.e., hip should not adduct more than 5 to 8 de­ grees , and femoral medial rotation should be kept to a minimum ). All stepping activities can be graded by altering

the step height or adding weight. A small step height (4 inches) and carrying a weight in the involved side hand re­ duces the force-gen erating requirements of the hip exten­ sors and abductors. Conversely, larger step heights (8 to 12 inches) and carrying a weight in the contralateral band in­ crease the force-generating requirements. Dosage parameters regarding repetition for these exer­ cises depend on whether the goal is to improve force/torqu e or endurance capabilities. Higher repetitions with a de­ creased load focus on endurance, and lower repetitions witI: a higher load focus on force production. Balance

Injury to a joint and musculotendinous structures, as i hip OA, probably results in altered somatosensOlY infor­ mation that can adversely affect motor control. 147 Progre<­ sive balance training can have a positive effect on functio' of the arthritic hip. SelPdanagement 20-2: levels I and I can be useful in training an iridividual to balance on on. limb with correct form. After the patient is able to stand one limb with appropriate muscle recruitment and joi loading strategies v. i th reduced pain, balance activities (:a; be added to th e program. Progression should be take slowly to prevent an inflammatory reaction in th e hi which would 'be counterproductive to improved functio n Posture and Movement

Patient-related instructions regarding improved weigh ­ bearing habits are critical to the long-term effectiven es therapeutic exercise. The person \\ith hip OA must be cau­ tioned to avoid positioning the involved limb in the cap~"­ lar pattern (i.e. , hip flexion and lateral rotation). Instructi ,in use of the inner core should not be overlooked becau of its effect on improving pelvic position. Small ROM \ squats can be useful to proVide a stretch to the anterior IT ­ ofascia I structures simultaneous ,vith inner core stren ening (see Figure 14-4). During function , use of assi'-" devices such as canes, crutches, or walkers can be quit fective in reducing jOint stress during ambulation, and CO 1­ sequently decre ase antalgic gait patterns. Problem sohi:' _ to develop improved posture and movement patterns to c...­ low continued participation in social and occupational !.l._ tivities is time well spent with a patient. Adjunctive Interventions

Because the hip is a weight-bearing joint, it is import that the individual maintains optimal weight through pro nutrition and aerobic activity. Non-weight-bearing aeroL activities are recommended for persons with hip OA.14 Use of a statiol1my bike with the seat relatively high c. serve as means of maintaining aerobic activity with mini lT. weight-bearing stress on the joint. Aquatic exercise pr grams have been shown to be effective for the treatment OA.149 Swimming, non-weight-bearing exercise with . flatable supports, or weight-bearing exercises in a pool ( Chapter 17) minimize stress on the hip joint.

Iliotibial Band-Related Diagnoses FIGURE 20-32. Side view of astep-up exercise with exaggerated hip flex­ ion to focus on hip flexion mobil ity and gluteus maximus recruitment.

The extensive deep fascia that covers the gluteal regi and the thigh like a sleeve is called the fascia lata. It is ...­ tached prOXimally to the external lip of the iliac crest,

Chapter 20: The Hip

sacrum and coccyx, the sacrotuberous ligament, the is­ chial tuberosity, the ischiopubic rami, and the inguinal lig­ ament. Distally, it is attached to the patella, the tibial condyles, and the head of the fibula. The dense portion of the fascia lata situated laterally is designated th ITB. The TFL and three fourths of the gluteus maximus insert into the ITB so that its distal attachment serves as a conjoint tendon of these muscles. The TFL can be functionally dif­ ferentiated into anteromedial and posterolateral fibers. The anteromedial fibers have a greater mechanical advan­ tage for hip flexion , and the posterolateral fihers have a greater mechanical advan tage for hip abduction and me­ dial rotation (Fig. 20-33).14() During walking, the anteromedial fibers generally are quiet, where~s the posterolateral filw rs are active near ini­ tial contact. 1.)0 "\lith sequentially in creased locomotor ve­ lOCity, anteromedial fiber activity increases near preswi.ng and initial swing, presumably to decelerate the extending hip and accele rate flexion of the thigh, and posterolateral ctivity increases at initial co_ntact, pres1l1nahly to deceler­ ate the adduction moment. L,U The posterolateral fibers of the TFUITB complex have also been implic~te d in provid­ in g stability against varus stress at the knee. hl T he antero­ medial fib ers are active during the hip flexion phase of the tep-up, and the posterolateral fibers are active during the loading phase of the step-up. Because of the vast functional roles of the TFU ITB complex, it is prone to overuse injuries (sec Display 20­ 12) 12 The follo wing sections proVide etiologic and treatment information for the most common ITB-related diagnoses

Iliotibial Band Fascitis \ condition, sometim s mistakenly diagnosed as sciatica, is that of pain associated with inflammation of the fascial band from overuse of the TFL, commonly called ITB fasci­ tiS .72 Pain may be limited to the area covered by the fascia

B

A

C

FIGURE 20-33. (A) The anteromedial fibers of the TFL have a greater me· chanical advantage for hip flexion . (8) The posterolateral fibers of the TFL have a greater mechanical advantage for hip abduction and (C) medial roo ation. (From Pare EB, Stern JT. Schwartz JM. Functional differentiation within the tensor fascia latae. J Bone Joint Surg Am 1981 ;63A 1457)

475

DISPLAY 20-12

ITB-related Diagnoses

• ITB fascitis: Inflammation ofthe ITB resulting from overuse of ITB for stability. • Trochanteric bursitis: In trochanter bursitis, the bursa becomes inflamed because of the pressure exerted by a short ITB moving back and forth over the greater trochanter during movement. • ITB friction syndrome (also known as ITB syndrome): In ITB friction syndrome, pain and tenderness are localized to the lateral femoral condyle because of a short ITB exerting pressure over the lateral femoral condyle, • Patellofemoral dysfunction: Shortness of the ITB can contribute to patellofemoral dysfunction because of its insertion into the lateral retinaculum of the patellofemoral joint and its tendency to dominate over the quadriceps for knee stability (see Chapter 21). • TFL strain: TFL strain can occur from overuse of a short TFl../ITB or a stretched TFl../lTB complex. The former is more common, but there are instances of strain of the stretched TFl../ITB. The TFl../ITB on the side of the adducted hip (usually the high iliac crest). if there are no associated hip medial rotation or hip flexion alignment or movement faults, is subject to continuous tension and therefore strain. • Faulty movement patterns at the hip and tibiofemoral joints: Faulty movement patterns of the hip and tibiofemoral joints related to the TFl../lTB are critical to understanding the effect of muscle imbalance on the function of these joints. Sahrmann provides more information on this subject. 72

along the lateral surface of the thigh or may extend upward over tht' buttocks and involve the gluteal fascia . Painful symptoms may extend below the knee, with associated symptoms of paresthesia in the region of the lateral calf. A review of the anatomy of the lateral aspect of the knee demonstrates the relationship of the pe roneal nerve to the muscles and fascia in this area. Peroneal nerve irritation call result from pressure from rigid bands of fascia in a short ITB or from the effect of traction from taut bands of fascia in an overstretched ITB. Peroneal nerve irritation can manifest as symptoms in the lateral calf. 49 Symptoms are similar to plantar fascitis; often worse in the morning and improve with minimal weight bearing, but they then worsen vvith continued weight bearing. Tests to differentiate ITB fascitis from sciatica are summarized in Display 20-13 . Presumably, this condition results from overuse of the TFUITB . Concurrent with any overuse syn­ drome is underuse of the related synergists about any axis of motion in which the affected muscle functions. The more deconditioned the underused synergists become, the greater the force-producing requirements become for the TFUITB complex. until finally the force-producing re­ quire ments exceed the muscle and bs cial capability, and inflammation results. Display 20-14 summarizes the syner­ g,ist relationships that may become imbalanced, leading to TFUITB overuse.

Iliotibial Band Friction Syndrome Although iliotibial band friction syndrome (also known as il­ iotibial band syndrome ) manifests at the knee, it is pre­

476

Therapeutic Exerc ise: Moving Toward Function DISPLAY 20-13

Key Tests for Differential Diagnosis of Iliotibial Band Fascitis from Sciatica Kev Tests • Palpation over the length of the fascia lata may elicit tenderness, especially over the greater trochanter or near the point of insertion lateral to the patella. • Hip flexion, abduction, and medial rotation (TFL manual

muscle test) may test painful.

• The 0ber test (test for ITB length) reveals shortness of the TFI../ITB, and further stretch may elicit pain. Paresthesias along the peroneal nerve distribution may worsen with ankle inversion. • Lumbar spine clearing test results are negative for

reproduction of the patient's symptoms.

Associated Findings Hip rotation ROM may reveal excessive medial rotation

relative to lateral rotation ROM.

o Positional weakness of the synergistic muscles of the

gluteus medius, gluteus maximus, iliopsoas, and

quadriceps.

o Hip anteversion. • Excessive medial rotation, positive Trendelenburg sign, or limited hip extension in gait. o

sen ted here because therapeutic exercise intelvention is fo­ cused at the imbalances in flexibility and muscle perfor­ mance at the hip. ITB syndrome is an overuse syndrome first described by Colson and Armour. 151 The ITB lies an­ terior to the lateral femoral condyle with the kn ee in exten­ sion and moves posterior to the lateral epicondylar promi­ nence with knee flexion. Biomechanical research of ITB syndrome has demonstrated that friction occurs near foot­ strike, predominantly in the foot contact phase, between the postelior edge of the iliot~bial band and the underlying lat­ eral femoral epicondyle.102 The posterior fibers of the ITB are more problematic in this syndrome than the anterior fibers. This is supported by the surgically known fact that the posterior fibers of the ITB are tighter against the lateral

epicondyle than the anterior fibers .153 Repetitive knee flex­ ion and extension causes the posterior edge of the ITB to rub across the lateral epicondyle, which gives rise to an in­ flammatory reaction in the tissue deep to the ITB. ITB syndrome is quite common in long distance run­ ners, cited as the second most common injury, with a s ~'\ discrepancy prevalence of 38% male and 62% female.] "" ITB syndrome in runners results from a complex of train­ ing errors, muscle imbalances in performance and flexibil­ ity, inappropriate surface and terrain, lower extremit\ alignment, and inappropriate footwear. The clinical symptoms of ITB syndrome include lateral knee pain and occasional snapping laterally. The area i tender over the lateral condyle and pain can be provoked be exerting pressure o_ver th e lateral epicondyle duril,? a~­ tlve knee f1exlOn , partIcularly at 30 degrees f1exlOn L5 It 1 not uncommon for this syndrome to be misdiagnosed as an­ other condition that causes lateral knee pain such as later meniscal tear, lateral collate ral ligam ent sprain, or poplitea. tendinitis.]53 Coronal magnetiC resonance imaging can ht­ usefill to determine a differential diagnosis 154

Other ITS-Related Syndromes Similar causes exist for the remaining ITB diagnoses , al­ though with slightly different symptoms. Although some o' these diagnoses manifest at the knee , treatment must foc on the cause of the condition, which is TFUITB overuse at the hip.

Treatment Therapeutic exercise intervention for each of the IT B­ related diagnos es should take into consideraUon th e biomechanical factors causing the syndrome and the re­ lated anatomic and phYSiologic impairments. Pain and Inflammation In the acute phase, treatment should be directed towar alleviating the pain and inflammation with medication (i. e. nonsteroidal anti-inflammatory drugs ), physical age nt<_ (i.e. , cryotherapy), electrotherapeutic modalities, and un­ loading (e.g. ,. use of a cane, taping, proper ~ositi07ni~ at I11ght WIth pIllows between knees If sldelymg).1-.h­ acute symptoms subside, succeeding treatments should be directed toward resolving the impairments and func tiona. limitations associated with the condition.

DISPLAY 20-14

Potential Synergist Relationships With TFUITB Overuse The anteromedial TFL can dominate the hip flexion force couple, contributing to underuse of the iliopsoas. • The posterolateral TFL can dominate the hip abduction and medial rotation force couples, contributing to underuse of the gluteus medius, upper fibers of the gluteus maximus, and gluteus minimus. ~ Because the ITB can provide stability to the knee, overuse of the ITB may contribute to underuse of the quadriceps. • The hip tends to function in medial rotation patterns, thereby contributing to underuse ofthe hip lateral rotator force couple, including the deep hip rotators, posterior fibers of the gluteus medius, and lower fibers of the gluteus maximus.

Range of Motion ROM impairments are most often associated with a stiff or short TFLlITB complex. 156 Stretching the TFUIT B complex is indicated but can pose a challenge to the clini­ cian and patient. The TFUITB has many actions at the hi p. For an optimal stretch, the TFUITB must be elongated si­ multaneously in all directions opposite its actions. It is crit­ ica1 that the stretching be speCifically directed to the area in need of stretch , and some commonly prescribed TFUITB stretches do not meet these criteria (Fig. 20-34). An assisted stretch emphasizing the posterolateral fibers is shown in Fig. 20-35. This stretch ensures the most precise positioning for the best outcome . The obvious disadvantage of this stretch is that rarely can an individual self-stretch in this position. Over time, he or she may be able to master the control required after a series of hip abduction exercise

Chapter 20: The Hip

A

B

dro p pelvis to adduct

l

FIGURE 20-34. Commonly prescribed TFL/ITB stretch that does not stretch the TFL/ITB in al l directions opposite its actions. (A) Crossing the legs commonly places the hip joint in med ial rotation. (8) Swaying later­ ally, wi,th the hip medially rotated, stretches the gluteus medius and lateral capsu le more than the TFL/ITB

with the emphaSiS on eccentric control of the gluteus medius (see Self-MaIlagement 20-4). This exercise also em­ phaSizes improving th~ force-generating capability and kinesthetic aWLlreness of the gluteus medius-a critical, un­ derused synergiSt. A self-stretch exercise for the TFUITB is shown in Fig, 20-36. This stretch is directed more toward the anterolateral fibers and is considered an active stretch because of the activation of the abdominal muscle group and gluteus max..imus to rotate the pelvis posteriorly. TFUITB stretching should not be used in isolation with the hope that the stretch ,vill permanently improve the I ngth. The clinician must seek the related impairments and functional limitations that perpetuate the shortness. F or example , short posterolateral fibers of the TFUITB do not remain stretched if the person stands and moves ,vith the hip in excessive medial rotation. Improvements in mus­ cl e performance of the underused synergists coupled with education r garding postural habits and neuromuscular training of new movement patterns are essential to restor­ ing length to the ITB on a more permanent basis.

FIGURE 20-35. Assisted Ober stretch position. The hip must be in concur­ rent hip extension, lateral rotation, and adduction without lateral pelvic tilt This is difficult to perform without assistance.

477

opposite hip

FIGURE 20-36. ITB stretch to the extended hip. In the half-kneel stretch position, the patient is asked to maximally drop the contralate ral pelvis to adduct the ipsi lateral hip. The patient also is asked to extend the hip by means of posterior pe lvic tilt (usi ng the gluteus maxi mus and abdominal muscles) A slight hip lateral rotation can be added to stretch the PL fibers. This technique is best used for hip conditions as weightbearing on the knee can be uncomfortable in patients with knee conditions.

Muscle Performance

Correction of muscle performance deficits of the hip abductor muscles has been shown to be correlated with recovery from ITB syndrome 80 Perhaps progressive strengthening of additional underused synergists such as the iliopsoas, gluteus maxim us , and quadriceps can further assist in reducing the phYSiologic and biomechanical re­ quirements of the TFUITB. After functional muscle per­ formance is achieved, attention to biomechanical elements to ensure recruitment of these synergists/antagonists dur­ ing function is essential to full recovery. The initial exercise prescription depends on the posi­ tional strength of these muscles. For example, the iliopsoas may require active assist initially, progressing to active holding, resistive holding, and finally functional exercises (see Self-Management 20-5 and the swing phase of Self­ Management 20-3). The emphasis initially is on end-range isometrics, followed by eccentric, and finally concentric contractions to ensure the improvement of the positional strength of the iliopsoas at end range. The goal with this ap­ proach is to improve the length-tension relationships of the relatively lengthened, weaker synergist to the TFUITB in hip flexion, An example of a functional movement recruit­ ing the iliopsoas may include repeated swing phase of a step-up with avoidance of hip medial rotation or hip hike accompanying the hip flexion pattern.

478

Therapeutic Exercise: Moving Toward Function

fiGURE 20-37. Taping techniques to unload the ITB. (A) Unloading the TFL/ ITB with lateral longitudinal tap­

ing using a technique develo.ped by Florence Kendall. (B) Unloading the TFL/ ITB with anterior to posterior

strips positioned proximally over the TFL and placed ev­ ery 2 to 3 inches distally. The patellofemoral joint may need to be taped medially to prevent lateral displace­ ment from the stretch placed on the ITB distally

A

Adjunctive Intervention

For a strained TFUITB due to continuous tension, use of taping as illustrated by Kendall 49 (Fig. 20-37A) can un­ load the strained structure. Because the femur must not function in excessive medial rotation , taping the hip in a slight amount oflateral rotation may be indicated. An alter­ native taping technique is illustrated in Fig. 20-37B. Apply­ ing firm pressure over the TFL while applying tape over this area may unload the TFL and therefore encourage more gluteus medius palticipation dUling functional activities.

Nerve Entrapment Syndromes Although nerve entrapment syndromes represent a rela­ tively small group of conditions causing hip, groin, or but­ tock pain, an understanding of the etiology of these syn­ dromes can facilitate a precise diagnosis and promote efficient management of the condition. Display 20-15 lists the possible nerve entrapment syndromes that can be a source of hip , groin, or buttock pain. The anatomic possibilities for nerve entrapment syn­ dromes in this region arise from the lumbosacral plexus and its branches (figure 20-38). Unless nerve entrapment syndromes produce "hard" neurologic signs of lDotor weak­ ness, sensOlY loss, or change in tendon reflexes, specific di­ agnosis may be difficult. This is particularly true of nerve entrapments around the pelvis where the cutaneous sen­ sory dermatomes overlap considerably and many of the nerves have no motor inne rvation that can be easily tested, resulting in nonspecific and poorly localized pain com­ plaints. A thorough knowledge of the anatomy of the region is necessary to diagnose nerve entrapment syndrom es at the hip. Table 20-6 assists the reader with differential diag­

nosis by providing a regional approach to the diagnosis of nerve entrapment syndromes. For the purposes of this text, the discussion of entrap­ ment syndromes will be focused on symptoms in the region of the buttock and posterior thigh. The piriformis syn­ drome has been described as a form of sciatic nerve en­ trapment causing buttock and posterior thigh pain and the piriformis muscle has been implicated as a potential soure of sciatica symptoms J '; ! The original description of thi condition dates from 1928 when Yeoman stated that insuf­ ficient attention had been pajd to the piriformis muscle as a potential cause of sciatica. 108 Although there may be numerous cases in which sciati pain is ass_ociated with a short piriformis, Kenda1l 49 and Sahrmann 12 describe a variation of this syndrome in which the piriformis is lengthened.

DISPLAY 20·15

Specific Nerve Entrapment Syndromes as a Cause of Pain in the Hip. Groin. and Buttock • • • • • • • • • •

Iliohypogastric nerve Ilioinguinal nerve Genitofemoral nerve Obturator nerve lateral cutaneous nerve of the thigh Femoral nerve Pudendal nerve Posterior cutaneous nerve of the thigh Superior and inferior gluteal nerves Sciatic nerve

Chapter 20: The Hip

479

Ilioinguinal nerve

Genitofemoral nerve

+----~11

Obturator nerve

Pudendal nerve

Sciatic nerve

Posterior cutaneous nerve of the thigh

The length of the piriformis must be carefully assessed before planning an intervention for this syndrome. For ex­ 'unple, in a faulty standing position with the femur ill ad­ duction and medial rotation and the pelvis in anterior pelvic tilt, the piliformis muscle is placed on stretch. The piriformis muscle is pulled taut, potentially entrapping the sciatic nerve. Pressure on the sciatic nerve mav result from tension from the adjacent taut piriformis m~scle. If the nerve pierces through the piriformis, an injurious tension may be imposed on the sciatic nerve along with the stretched muscle. Because the piriformis is actively used during gait, abnormal gait patterns can impose stress on the piriformis and relateo sciatic nerve. "Vith a stretched piri­ formis, repetitive movements of the hip in medial rotation and adduction and movements of the pelvis in anterior pelvic tilt can impose friction on the nerve, resutting in in­ flammation of the neural tissue. Strain of the piriformis can ensue as a result of the muscle functioning in a chronically stretched posi tion.

FIGURE 20-38. Anatomy of the lumbosacral plexus.

gluteal nerves . Pain caused by piriformis strain can also be felt deep in the buttock. Posterior thigh pain can be caused by the posterior cutaneous nelve of the thigh, which would explain the absence of distal sciatic neurologic signs in some cases. It is possible that the obturator intemus/gemelli com­ plex is an alternative cause of neural compression. For this reason, "deep gluteal syndrome" may be a more appropri­ ate term for symptoms isolated to the buttOl:k. 159 Symptoms of sciatica related to a stretched, short, or h)1)eltrophied piriformis can be experienced from the posterior buttock extending inferiorly as far as the toes. Symptoms of pain or tingling may appear in the cutaneous areas below the knee supplied by branches of the peroneal or posterior tibial nerve before symptoms of numbness or signs of weakness become apparent. Key tests used in making a differential diagnosis that in­ cludes a stretched piriformis, a shortened piriformis, lum­ bar radiculopathy, or referred pain are summarized in Table 20-7.

Diagnosis

Treatment

Differential diagnosis of buttock and posterior thigh pain can be quite complex. One has to consider the potential causes of symptoms including; piriformis (lengthened, shOltened, strained, or hypertrophied), obturator inter­ nus/gemelli complex, lumbosacral radiculopathy, or re­ ferred pain. Given the anatomic relationship of the piri­ formis to the various nerves in the deep gluteal region, it is possible that the buttock pain represents entrapment of the

For the purposes of this text, this discussion will be isolated to the piriformis syndrome. Therapeutic exercise interven­ tion is baseo on the phYSiologic and morpholOgiC status of the piriformis. Careful differential diagnosis of whether the muscle is strained, lengthened, shortened, or hypertro­ phied is necessary to develop the appropriate therapeutic exercise intervention. For example, a short piriformis must be stretched, whereas this would aggravate a lengthened

480

Therapeutic Exercise: MovingToward Function

Differential Diagnosis of Stretched Piriformis Syndrome KEY TESTS Standing alignment Selective tissue tension tests Range of motion Palpation Positional strength Functional tests Lumbar clearing examination

SIGNS Lordosis and anterior pelvic tilt Hip flexion and medial rotation High iliac crest on involved side <90 degrees of hip flexion, with adduction and medial rotation reproduces symptoms Passive or active lateral rotation and abduction reduces symptoms R('sisted knee fl exion is negative Excessive hip medial rotation relative to lateral rotation \'ithin the involved side Excessi ve medial rotation of the in volved side relative to the uninvoh (·d side Tendemess dicited in r('gion of the sciatic notch Weakness in hip lateral rotators and posteIior gluteus medius TendC'ney to fUlletion in hip medial rotation , hip adduction , and antelior pelvic tilt dllling functional activities Repl'titive mOVf'llle nts ill medial rotation and/or adduction, with the pelvis in anterior tilt, reproduce symptom s Lateral rotation , abduction, and neutral pelvic alignment relieves symptoms Symptoms diminish or disappear when not bearing weight

Muscle Performance

In the case of a strained or lengthened piriformis, grad­ ual progressive strengthening is indicated. Often the mu<;­ cle is quite weak initially due to the strain or shifter. length-tension properties. Caution must be used vvitI dosage parameters so as not to exceed the muscle's phys­ iologic capabilities. Exercise in the short range is indi­ cated for the lengthened piriformis. Strengthening exer­ cises should be avoided for the short or hypertrophied piriformis. Exercises that can target hip lateral rotator strength and length-tension properties include; prone fOO" pushes (Fig. 20-39), prone hip extension with pelvic sta­ bilization (Self-.\1anagement 20-1), sidelying hip abduc­ tion "vith emphasis on lateral rotation (Self-Manage men' 20-4), and prone hip lateral rotation in the short ral1f!t" (Fig. 20-20). Strengthening the abdominal muscles (see Chapter 1 in the short range may be necessary to address an associat anterior pelvic tilt in the strained or lengthened piriformG syndrome. Strengthening the ipSilateral gluteus mediu may be necessary to reduce adduction patterns that will ad further stress to a strained or lengthened piriformis. After the muscle performance of the piriformis has im ­ proved to maintain the femur in neutral while beari ll _ weight, exercises can be progressed to standing. In tb lengthened Or strained piriformis, the focus is to train th femur to function in less medial rotation and adductio

piriformis syndrome. Periodic ROM measures combined with positional strength testing and dynamic functional testing can indicate the status of recovery of the strain and length-tension properties. The follOWing sections provide gUidelines for the therapeutic exercise intervention for all forms of the piriformis syndrome. Pain

Patients should be instructed in positions that relieve nerve pain and which positions to avoid to prevent further nerve initation. Regardless of the length of the piriformis, relief may be achieved by plaCing the involved leg in lat­ eral rotation and abduction in lying and standing posi­ tions. Sitting with the hips in lateral rotation (i.e., legs crossed at the ankles ) can alleviate symptoms while sitting. Posture and Movement

Permune llt dwnges with respect to postural habits are encouruged to help alter the length-tension properties of the mnscle. The patient should be instructed to position the limb to take the muscle off stretch or to stretch a ShOit muscle as dictated by the diagnosis. Limb position should be monitored during ADLs such as transitioning from sit to stand, squatting, and during stance phase of gait.

FIGURE 20-39. Prone foot pushes strengthen the piriformis isometrically in the short range. The patient positions the hip in abduction and lateral ro­ tation. The patient pushes the heels together with a submaximal contra c­ tion . Submaximal contraction is desired over max imal to reduce the amount of accessory muscle recruitment (ie, lateral hamstrings and ad­ ductorsL Duration and repetitions are determined based upon the goal 01 the exercise (i.e., strength versus endurance).

Chapter 20 The Hi p

481

AGURE 20-40. Piriformis stretch. (A) Passive stretch for the pi riformis muscle. With the patient lying supine, -he lower extrem i,ty is grasped at the flexed knee. The latera l' aspect of the il iac crest and the ASIS are stabilized by the cranial hand while the caudal hand flexes the femur to 50 deg uees and guides the femur into adduction. (8) Self-stretch of the piriformis and other deep hip rotators. After 50-degree hip flexion, the piriformis medially rotates the femur. To stretch the right deep hip lateral rotators, the patierlt lies supine and the right femur is flexed and laterally rotated such that the right ankle rests on the posterior aspect of the distal left thigh. From (his position, the left hip is flexed until tension is perceived in the right buttock.

and the pelvis in less antelior tilt, vvithout promoting ex­ cessive hip flexion, In the short or hypertrophied pili­ [ormis syndrome, the focus is to train the femur to func­ tion in less lateral rotation and abduction and encourage the hip to function in more flexion (see Self-Management :20-2; Self-Management 20-3; Self-Management 20-8; and Fig,20-15.) Range of Motion

Stretching the piriformis is contraindicated for the . trained or lengthened piliformis, However, stretching the opposing medial rotators may be necessary if the stiffness or shortness contlibutes to the hip functioning in medial rotation, imposing undue tension on the lengthened pili­ formis. Stretching the medial rotators (e.g" posterolateral ibers of the TFL, gluteus minim us, unterior gluteus medius) can be difficult to perform unassisted. Assisted stretching with the patient in a prone position into lateral rotation, with careful stabilization of the pelvis and the tibia, ensures optimal stretch to the medial rotators (see Fig, 20-29E). The pelvis must be stabilized actively or pas­ Sively to prevent antelior pelvic tilt and lumbar extension while stretching the TFUITB complex, Stretching the piriformis is indicated in the short or hy­ pertrophied piriformis syndrome, Passive stretches for the piliformis are shown in Figure 20-40, Stretching the low back muscles (see Self-Management :20-6) may be necessary to reduce forces contributing to ,mterior pelvic tilt. This same stretch can be used to stretch the piriformis. Caution must be heeded when stretching the low back muscles in the lengthened piriformis syn­ clrome so as not to place further tension on the sciatic nerve while moving into hip flexion, the emphasis should be on achieving a flat low back and not on hip flexion, Stretching the ipsilateral hip adductors (Fig. 20-22) or abductors (Fig. 20-35 and 20-36) may be necessary to im­

prove frontal plane alignment of the hip depending on the initial length of the piriformis, Adjunctive Interventions

Support to a strained piliformis is indicated for rapid re­ covery The lengthened piriformis should also be sup­ ported to relieve tension and allow for length-tension changes to occur. The combination of taping, posture, and exercise provicling this support can be determined on a case by case basis, but it must be addressed in some Llsh­ ion and for a period sufficient to allow recovery, Taping techniques to support the limb in more neutral pOSitions and provide feedback to avoid medial rotation and adduction are indicated for the stretched or struined piriformis. McConnell has developed a taping technique for the buttock that can SIlPPOrt a strained piliformis and assist in unloading neural 'tissues, 160 Taping behind the knee can serve as "biofeedback" to prevent excessive me­ dial rotation tendencies during standing exercises and function (Fig, 20-41).

KEY POINTS • The structure of the hip joint is deSigned for stability and to withstand high kinetic forces, • The angles of inclination and torsion are clitical to ideal functioning of the hip joint. • The ligaments of the hip provide Significant stability to the hip, particularly in hip extension, adduction, and medial rotation, • The tension of the ligaments correspond to positions of stability and instability of the hip. • Hip osteokinematic ROM is closely linked to the lum­ bopelvic region. Limitation in hip mobility may manifest

482

Therapeutic Exercise Moving Toward Function

FIGURE 20-41. Excess ive med ial rotat ion of the femur in standing as shovvn by (A) tape on the hamstring tendons . (8) Corrective tap ingl posterior to t ~ e knee. To encourage hip lateral rotation and tibia medial rotation, the tape is applied from the lateral femur distally to the medi al tibia and from the media l tibia proxi­ mally toward the lateral femu r. NOTE Because thi s taping procedure does not anchor the tape to any bony prominence, its abil ity to prevent unwanted tibiofemoral movement is question­ able. At best it can provi de temporary feedba ck to the patient until the tape has sufficiently stretched.

in compe nsatory lumbopehic mobility and at the knee, ankle, and foot, although to a lesser degree. • Hip arthrokinematic motions follow convex moving on concave rules \,ith rolling and translation (minillwI as it may b e ) moving opposite in direction to the distal end of the fe mur. • It is important to unde rstand the fun ction of the muscles that cross the hip and the relationships they have with the LP region and the knee joint. • In vivo loads acting at the hip joint have demonstrated the average patient loaus the hip joint \vith 238 % body weight when walking at abut 4 kmJ11, while climbing up­ stairs increases jOint contact force to 251 % BW going downstairs to 260% BW. • A thorough hip examination is necessary to understand the an atomic and phYSiologic impairm ents in tl1e hip and those in related regions that affect the pati e nt's func­ tionallimitations and disability. • Impairments in muscle performance, gait and balance, posture anu move ment, and ROM and jOint mobility comm o nly occur together in hip-re late d cond itions . Treatm e nt must fo cus on the impairm e nts most related to the presenting functional limitations and disabi lity. The initial focus should be on rf's torin g functional ca­ pacity of each rel'evant impairment and gradual progres­ sion toward functional activity. • Th e pri mary focus of treatment of hip OA is to improve joi llt loading. Restoring proper joint mobility <[ntl force or torqu e are ofte n prerequisites to res toring endurance and improvi ng posture . Balance skills are the final ele­ me nt to resto ring more optimal movemen t patterns and joint loading. • Num e rous ITS-related syndromes exist. The focus of treatment is to improve the force or torqu e and func­

tional recruitm ent of the underused synergists in m e~ ­ ingful functional movement patterns. • The stre tched piriformis s)i11drome can mimic hllnb..r rauiculopathy. Correct diffe rential diagnosis from lU ll ­ bar radiculopathy, short piriformis syndrome , and ball · strings strain is mandatory for a success ful outcomt" Treatmcn t focuses on improving the movement patte JT and associated physiologic impairme nts that contribu to fem ur medial rotation and adduction and on ante Jic: pelvic tilt, all of which can contribute to stress on the pir­ iformis and the sciatic ne rve. r

CRITICAL THINKING QUESTIONS 1. To which type of knee alignment does coxa vara aT' coxa valga contribute ?

2. vV-hat direction are the femoral condyles ori en teu . femoral aJlteversion and retrove rsion? If a patient \\it fe moral anteversion participates in ballet, what typ e mobility proble m could he or she develop? If a patie with fe moral anteversion partiCipates in soccer, wh type of mobility could he or she develop ? \Vhat are you recomm endations for the alignm ent of the antevert femur during sport activitif's~) 3. \;\That would be the co mpensatory hllllhar lllotions ,1] what phases of the gait cycle>would be involved if rigl hip mobility \v('re restricted in flexion, extension, or me­ elial rotation ~ 4. If the hip were restricteu in flexion, what movem ell patterns would you be conce rned about contributin g t, thi s hip flexjo n restriction? What movement patte would you re train to improve hip flexion mobili ty?\:Vha. mu scle force or torqlle impanrnwnts would you be con­

Chapter 20 The Hip

1. How would you progress a patient with OA in stand­ ing exercises to improve weight acceptance and sin­ gle-limb SUppOlt phases of gait? Would you use any assistive devices'? 2. With respect to Critical Thinking Question 4, de­ velop a program of exercises that improve the mobil­ ity and associated force or torque impairment for each scenario. Teach this program to your partner. Assume that all manual muscle test grades are :3+/5. Progress specific nonfunctional exercises to func­ tional exercises. 3. \Vith respect to Critical Thinking Question 6, how would you begin to improve the force or torque pro­ duction of a gluteus medius underused synergist with a positional strength grade of 3-/5. How would you progress this exercise as the positional strength im­ proved? Teach your partner these exercises. Can you feel the TFL trying to dominate the exercise move­ ment pattern '? What is the associated pattern of movement with TFL dominance'? Progress this exer­ cise to standing functional exercises. How does the foot alignment contribute to the hip position in closed chain positions and movements'?

cerned about that could help perpetuate the hip flexion restriction? Answer these same questions with respect to restrictions in hip extension and medial rotation . What is this pattern of restriction (i.e., restricted hip flexion, medial rotation , extension ) called? 5. Describe the Trendelenburg pattern of gait. Can you describe other hip joint movement patterns that could indicate hip abductor weakness? 6. In TFUITB overuse diagnoses, why is the hip the focus of treatment? What are the common underused syner­ gists that contribute to TFUITB overuse? 7. Ho\v \vQuld you differentially diagnose a stretched piri­

formis syndrome from a short piriformis syndrome, lumbar radiculopathy, or strained hamstrings?

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4. Your partner has been diagnosed with iliotibial band sVlldrome. List svnergists that may be underused ancl therefore, contribute to this diagnosis . Develop an exercise to improve muscle performance for each un­ derused synergist. Consider each underused syner­ gist has a 3+/.5 muscle test grade. 5. Practice the balance progreSSion described in Dis­ play 20-4. What type of balance strategy are you us­ ing? Develop balance drills that stress the frontal plane and crossover stepping strategies. 6. With respect to Critical Thinking Question 7, progress hip lateral rotator exercises from specific, nonfunctional exercises to functional exercises. How would you stress the lateral rotators in a Single-limb balance drill (be creative)? 7. Refer to Case Study #9 in Unit 7. Develop a com­ plete therapeutic exercise intervention plan using the intervention model developed in Chapter 2. 8. Refer to Case Study #10 in Unit 7. Develop a com­ plete therapeutic exercise intervention plan using the intervention model developed in Chapter 2.

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136. ~I(')seley CF. Leg length discrep:1J1 cy and angular deIO. ­ mitv of tlw lower limbs. In: Lovell and Winter's Pediatn Orthopaedics. 4th Ed. PI'l iladelphia, Lippincott-Ran · 1996. 137. Felson DT, Lawrence RC , Hochbe rg tvlC , et a!. 0 ·­ teoarthritis: new insights. Palt 2: treatment approaches. Intern Mad 2000;133:726-737. 138. Goldberg v, Caplan AI. BiolOgical Restoration of Amcul Surfaces . Amelican Academy of Orthopaedic Surgeons 1-­ stru ctional Course Lectures. Rosemont, IL: Ameri Academy of Olthopaedic Surgeons, 1999. 139. Felson DT, Lawrence RC, Dieppe PA, et a!. Osteoarth riti. new inSights. Part 1: th e disease and its risk factors . Ann I tern Med 2000;133:635-646 . 140. van Saase , van Romunde LK, Cats A, et a!. Epidemiology OA: Zoetermeer survey. Comparison of radiological OA ill Dutch population with that in 10 other populations. / Rheum Dis 1989;48:271- 280. l41. Mikkelsen WM, Dodge iTJ, Duff IF. et al. Estimates of preval ence of rh eumatiC' diseasf's in the population Tecumseh, Y1ichigan , 1959-60. .T Chronic Dis 196 7 ; ~ 3.51-369. 142. Cunningham LS , Ke lsey JL. Epidemiology of muse' loskeletal impairm ents and assuciated disability. Am J Pu lie H ealth 1984; 74 :.5 74-:579. 143. f elson DT, Naimark A, Anderson.T, et a!. The prevalence kn ee OA in th e elderly. The Frall1ingliam OA Study. Althrc ti~ Rheum 1987;30:914-918. 144. Dieppe P. What is the relationship hetwecn pain and 0 :\­ Rheurnatol Eur 1998;27:55-.56. 145 . Plice SA, Wilson L M. PathophYSiology: Clinical Concept Disease Processes . 2nd Ed. New York: McGraw-Hill, 195:: 146. Buckwalter JA, Mankin I-IJ. Articular Cartilage Degener.­ tion and OA, Repair, Rege neration and Transplantatio; Ros emont, I L: Am e rican Acade my of OrthopaediC Su. geons , 1998. 147. National Institutes ofl-Iealth. Total IIip Replacement: Kif Consensus Statement. Beth esda , MD US Department Health and Human Services, 1994 . 148 . Mc:Alindon TE , LaValley MP, GuJin JP, et al. Glucosami and chondroitin for treatmen t of OA : a systematic yualih' ii--­ sessment and meta-analysis. JAMA 2000;21)3:1469-1475. 149. Wyatt F B, Milan S, Manske R, et a!. The effects of aqua and traditional exercise programs 011 persons \vith lalee JStrength Cond Res 2001: 15:337- 340. 150. Pare EB, Stern .fT, Schwali z JM. Functional differentiati \\itJilll the tensor fascia latae. J Bone joint Surg Am 19: 63:1457- 1471. 151. O'lson JH, Armour Sports injuries and their treatmen Philadelphia: Lippincott, 1975. 152. Orchard JW, Flicker PA, Abud AT, et al. Biomechanics , iliotibial band friction syndrome in runners. Am J Spon 'vred 1996;24:375-379. 153. Nishimura G, Yamato 1",1, Tamai K, et al. MR findings in ili­ otibial band syndrom e. Skele tal RadioI1997;26:,3 33-537. ]:34. Taunten JE, Clement DB, McKenzie DC, et a!. A retro­ spective case-control analysis of 2002 running injuries. Br SPOItS Med 2002:36:95-10l. 1:35. Nobel CA. The treatment of iliotibial band friction 5\ 1)­ drome. Br J SPOlts Med 1979;13:51 - 54. 156. Winslow J, Yoder E. Patellofemoral pain in female ball dan cers: correlation \vith iliotibial band tightness and tibial exte rnal rotation. J Orthop Sports Phys Ther 1995;2:?' 18-21. 157. Freiburg AH , Vink" TH. Sciatica and sacroiliac jOint. J Bone Joint Surg 1934; Hi :126- 136. 158. Yeoman W. The relatiollship of arthIitis of the sacro-ilia joint to sciatica. Lancet 192&;11 :1119-1122.

"'lj.

Chapter 20: The Hip 159. McCrory P, Simon B. Nerve entrapment syndromes as a causc of pain in the hip, groin, ami buttock. Sports Med 1999;27:261- 274. [60. McConnell J. Recalcitrant chronic low back and leg pain­ a new theory and different approach to management. Man Tlw r 2002;7:183-192. Jeka JJ, Lackner JR. Fingertip contact influ ences human postural control. Exp Brain Res 1994;100:495-502. 162. eumann DA, Cook T,Vl , Sho'lty RL, e t al. An electromyo­ graphic analysis of hip abductor muscle activity when sub­ jects Un' carrying loads in one or both hands. Ph ys Ther 1992;72:207- 217. 163. "'[aitland GD. Peripheral />'![unipulation. 2nd Ed. London: Butterworths, 1977. 164. Felson DT. Preventing kn e(' and hip OA. Bull H.hculTI Dis 1998;471--4. 16·5. Gelber AC, Hochb fa MC, McaJ LA, et al. Body mass in­ dex in young me n an~ the lisk of subsequent knee and hip OA. Am J Med 1999;l0754.2-:54S. 166. Heliovaara M, Makela M, Impivaara 0, et al. Association of overweight, traum a, and workload with coxarthrosis: a health surveyof7217 p rsons. Acta Orthop Scalld 199.3; 64:513--518. 167. Okama-Keulen , Hopman-Rock M. The onset of generalized OA in older women: a qualitative approach. Arthritis Care R s 2001 ;4:5:183- 190. 168. Mllndermann A, :--.r igg BM, Humble R . 1, et al. Foot or­ thotics affect lmver e!l:tre mity kinematics and kinetics during running. Clin Biom ch 2003;1H:2.54-262. 169. Bradley JD , Brandt KD, Katz BP, ct al. Compatison of an anti-inflammatory dos e of ibuprofe n, an analgesic dose of ibuprofen, and acetaminophen in the treatme nt of patients with OA of th e knee. N Engl J .\Jed 1991 :32:5:87- 91. 170. Williams HJ, Ward JR, Egger MJ , et al. Compalison of llapl'OXell and acetaminophell in a two-year study of treatment of OA I'lrtlw knee. Artlllitis Rh e um 199:3;36: 1196-206. L7 1. Towheed TE , Hochbe rg Me. A systematic review of ran­ dI'lmized controlled trials of pharlllacological therapy in pa­ tients with 0.\ of the hip. J Rheulliatol 1997;24:349-357. 172. Eccles M, Freemantle . , Mason J. l\Olih of England evi­ dence basC'd guideline development project: Sllrl1ln,uy gUide­ line for non-steroidal anti-inflammatory drugs versus basic analgC'sia in treating the paill of degen erative artlllitis. The North of EIl<1land Non-Steroidal Anti-Inflammatory Drug Guidelin e D evelopment Group. BMJ J 998 ;317: .'526-530. 173 . The mana a ment of chronic pain ill older pe rsons. AGS Panel on C hronic Pail! in Older Pe rsons. American Ge ri­ atri c's Socie t),. Geriatrics 1998;.'i.'3 (SuppI3):S8-S24.

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174 Ronca F, Palmieri L, Panicucci P, et al. Anti-inflammatory activity of chondroitin sulfate. OA Cartilage 1995;6(Suppl A): 14-21. 175. Deal CL, Schnitzer TJ, Lipstein E, et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther 1991;13:383-395. 176. Ernst E. Acupuncture as a symptom atic treatm e nt of OA. A systematic review. Scand J Rheumatol 1997;26 :444­ 447. 177. Berman BM , Singh BB, Lao L, et a!. A randomized trial of acupuncture as an adjunctive therapy in OA of the knee. Rh cumatology (Oxford) 1999;38:346-354. 178. Ayral X. Injections in the treatment of OA. Best Practices Res Clin Rheumatol 2001;15:609-626. 179. Creamer P. Intra-articular corticosteroid treatment in OA. Curr Opin RheumatoI1999;1l:417--421. 180. McGibbon CA, Krebs DE , Mann RW. In vivo hip pressure's during cane and load-carrying gait. Arthritis Care Res 1997;10:300-307. 181. Ne umann DA. An electrom),ographic study of the hip ab­ ductor muscles as subjects with a hip p rosthesis walked \vith different methods of using a cane and carrying a load. Phys Ther 1999;79:116.3-1173. 182. Lorig KR, Mazonson PD , Holman HR. Evidence suggest­ ing that health education for self-management in patients with chronic arthritis has sustained health benefits while re­ ducing health care costs. Arthritis Rh e um 1993;36:439­ 446. 183 Supelio-Cabuslay E, Ward MM, Lorig KR. Patient educa­ tion interventions in OA and rheumatoid arthritis: a meta­ analytiC comparison \vith nonsteroidal antiinflammatory drug treatment. Arthlitis Care Res 1996;9:292--J0i. 184. Cronan TA, Groessl E, Kaplan RM. The effects of social support and education int rventions on health care costs. Arthritis Care Res 1997;10:89-110. 185. Minor MA, Hewett JE, \""e be l RR, et al. Efficacy of physi­ cal conditioning exe rcise in patients \\1th rheumatoid arthri­ tis or OA. Arthritis Rheum 1989;32:1397-1405. 186. Ettinger WH Jr, Bums R, Messier SP, et a!. A randomized trial comparing aerobic exercise and resistance exercise \vith a health education program in I'llder adults \vith knee OA. The Fitness Arthritis and Seniors Trial (FAST). lAMA . 1997;277::2.5- 31. 187. van Baal' ME , Asse' ndelft \'VJ, Dekker J, et a!. Effectivencss of exercise therapy in patients with OA of the hip or kn ee : a systelllatic revi ew of randomized clinical trials. Arthritis Rheum 1999;42:1361-1369.

chapter 21

The Knee LORI THEIN BRODY AND ROBERT LANDEL

Review of Anatomy and Kinesiology Anatomy Kinematics

Kinetics

Anatomic Impairments Genu Valgum

Genu Varum

REVIEW OF ANATOMY AND KINESIOLOGY A thorough understanding of the anatomy and kinesiolo of the knee joint is necessary to comprehend the impact 0: impairments on function of the kinetic chain. The unique kinematic relationships oflower extremity jOints depend 0 the local anatomic structures.

Examination and Evaluation Patient/Client History

Tests and Measures

Therapeutic Exercise Intervention for Physiologic

Impairments

Mobility Impairment

Impaired Muscle Performance

Therapeutic Exercise Intervention for Common

Diagnoses

Treatment of Ligament Injuries

Fractures

Meniscallnjuries

Degenerative Arthritis Problems Articular Cartilage Lesions

Surgical Procedures

Interventions for Degenerative Arthritis Problems

Tendinopathies Patellar Tendinopathy

Iliotibial Band Syndrome

Patellofemoral Pain Syndrome

The knee is one of the most frequently injured jOints in the body. The quadriceps muscle spans the antelior thigh and crosses the tibi ofemoral joint, producing knee ex­ tension when tensed. The patella enhances muscle per­ formance across the longest lever arm of the body. Im­ pairments at the knee joint can produce significant functional limitations and disability. The closed chain de­ mands of daily activities such as walking, standing, and ris­ ing from a chair require smooth, coordinated action of the lower extremity neuromuscular sys tem. 1- 5 When consid­ ering knee impairments, the impact of these impairments on the related joints in the kinetic chain also must be addressed.

Anatomv Osteology The femoral component of the tibiofemoral joint is com­ posed of two large condyles separated by the intercondylar notch. The asymmetric medial condyle extends farther dis­ tally than the lateral, and the lateral condyle is slightI. wider at the center of the intercondylar notch 6 - 9 View. from the tibial surface, the medial condyle appears to III shOlier, but is on average two thirds of an inch longer to ac­ commodate the medial angulation of the femoral shaft." This medial angulation varies from individual to individu<>.. and contributes to the quadriceps angle and degree 0 varus or valgus alignment. The lateral condyle is more di ­ rectly in line with the femoral shaft. lO The condylar asymmetry contributes to the screw hom mechanism , which occurs during terminal knee extension The screw home mechanism is the femoral internal rota­ tion coupled with tibial external rotation that occurs dUJi n!: the last few degrees of terminal extension (Fig. 21-1 ). .\ small prominence of bone, the adductor tubercle, can hi palpated at the superior aspect of the medial fem or: condyle, and it serves as the attachment for the adductor magnus muscle. This tubercle is an important landmarl used when assessing the patellofemoral joint for malalilln­ ment or instability. Two concave plateaus on the tibia correspond with tb femoral condyles. The medial and lateral tibial plateaus arl separated by the intercondylar tubercles , two bony spin that enter the intercondylar notch when the knee is in ex­ tension. The lateral tibial plateau is smaller, circular, and concave, whereas the medial plateau is more oval and flat. 10 The larger size of the medial plateau and its in­ creased articular caltilage thickness support the larger me­ dial femoral condyle. The patella is the largest ses amoid bone in the body. Its triangular shape is divided into two major concave facet (medial and lateral) that glide on the two convex surfaces of the femur. Each of the medial and lateral facets are divided

488

489

Chapter 21 . The Knee Medial patellar surface

Lateral

Medial femoral condyle A

Lateral femoral condyle

Intercondylar fossa

A

Medial

Lateral

B

FIGURE 21-1. (A) View of the femoral surface from the inferior articulat­ 119 surface. Note the more anterior prominence of the lateral femoral .:::Indyle. (B) The medial femoral condyle is longer than the lateral. and the .ateral femoral condyle lies more directly in line with the shaft than the me­ : al. However. the prominence of the medial femoral condyle results in a ori zontal articulating surface . (Adapted from Norkin CC. Levangie PK . ..oint Structure and Function A Comprehensive Analysis 2nd Ed. Philadel­ : ia. FA Davis. 1992)

. two transverse ridges into superior, middle, and inferior ·cets. A seventh facet, also called the odd facet, lies on the cst medial aspect of the patella, and articulates with the emur only in extreme flexion.

",rthrology e tibiofemoral joint is supported by a fibrous joint cap­ ..ue and lined with synovial membrane. Stability of the knee p ends on the integlity of the capsule and its ligamentous d tendinous supporting structures. Posteriorly, the cap­ e is attached to the femoral and tibial condyles just be­ nd their articular margins and is strengthened by the lique popliteal ligament. Laterally, the capsule extends m the femur distally to the tibia and fibular head and IS para ted from the lateral collateral ligament (LCL) by fat neurovascular tissues. Medially, the capsule extends m the femur to the tibia just beyond their respective ar­ ular margins and is reinforced by the medial collate:allig­ ent (MCL). The medial structures have been dlVlded :0 three layers. The most superficial is in the fascial plane, middle layer consists of the superficial MCL, and the p layer is composed of vertically oriented, thickened ular tissue known as the deep medialligament. 9 _\nteriorly, the capsule blends 'vvith the expansions of the tus lateralis and vastus medialis to attach to the patellar r!!ins and patellar tendon. The expansion continues mev and laterally to the respective collateral ligaments and eI10rly to the tibial condyles. 7 ,10 The medial and lateral --ansions are called the medial and lateral patellar rett­ "U ia, sometimes known as the extensor retinaculum. l l retinacula prOVide the static balance for the ellofemoral jOint, which is influenced by differences ben the medial and lateral retinacula. The medial retinac­ can be stretched or tom with a lateral patellar subllL'<­ or dislocation , and the medial pain is often mistaken .\tICL sprain. Tightness in the lateral retinaculum con­ :.ltes to lateral patellar tracking The structure can be di­ .d into superficial fibers affecting lateral glide and deep

B

c

E

D

FIGURE 21 -2. The multiple soft-tissue layers affect the patellofemoral joint (A) the superficial arciform layers with transverse fibers over patella and patellar tendon; (B) the intermed iate oblique layer with chevron­ oriented fibers from the rectus femoris. vastus lateralis. and vastus medi­ alis; (C) the deep longitudinal layers, which are extremely adherent to the anterior surface of the patel/a; (0) the deep transverse layer blend ing with fibers of the iliotibial band; and (E) the deep capsular layer composed of the medial and lateral patellomeniscal ligaments (Adapted from Dye SF. Patel/ofemoral anatomy. In. Fox JM, Del Pizzo W. eds. The Patellofemoral Joint. New York. McGraw-Hili. 1993.)

fibers contributing to lateral tilt. Some controversy exists about the classification of the anterior layers of the knee . Dye l2 describes five layers which can be seen in Fig. 21-2. The capsule is reinforced anteriorly by the patellar ten­

don. The fibers originate from a broad area on the inferior

pole and from the undersurface of the patella, and the most

superficial fibers are continuous over the patella as the ex­

tension of the quadriceps. The deepest fibers are most af­

fected in individuals with patellar tendinitis. Medially and

laterally, the tendon is continuous 'vvith the medial and lat­

eral patellar retinacula. 10

The infrapatellar fat pad can be a source of anterior and inferior knee pain because of its innervation. "Vhen the in­ frapatellar fat pad becomes enlarged or inflamed, it can cause a Significant amount of pain because of increased pressure from the inferior pole of the patella. Patella infera, caused by shortening of the patellar tendon in response to injUly or surgery, can increase pressure and pain originat­ ing from the fat pad (Fig. 21-3).

\~.;~I-_ _ _ Quadriceps

femoris tendon Posterior part of synovial capsule Medial meniscus ---~ Lateral meniscus

_ _ _ _ Suprapatella bursa Synovial cavity Patellar ligament Fat pad

Fibular (lateral)

collateral

ligament

FIGURE 21-3. Posterolateral view of the knee indicating the extent and subdivisions of the synovial cavity. Note the size and relationship of the fat pad to the anterior structures. (Adapted from Pratt NE. Clinical Muscu­ loskeletal Anatomy Philadelphia. JB Lippincott, 1991)

490

Therapeutic Exercise Moving Toward Fu nction

The synovial me mbranp of the knee is tl1P most exten­ sive and 'compl ex in the hody and generally adheres to the inne r surface of th e capsule. The synov1unl may invagi­ nate between Illuscle and the fem oral condyles on the medial and lateral aspects of the joint, creating medial and lateral glitters . Fibrosis after trauma or smgery to the knee can result in scar tissue accu mulating in tb cs(' gut­ ters and blocking extension motion. Emb l)~()JliC relllTl:mts of th e synovial sep ta may rernain into adulthood, forming synovial plicae. The most common are the infrapatellar plica or fold (i.e ., ligamentum mucosum ), suprapatel lar plica, and mediopatellar p lica 8 . lo These plicae may mimic or contlibute to patellofemoral pain . Several ligaments about th e kn ee p rovide additional sta­ bility. The MCL (tibial) is a broad, Oat stmctme whos~ su­ perfi Cial portion is located in the second layer of th e medial tissues. It contains vertical (anterior) and ohlique (poste­ rior) fibers originating slightly posteriorly from the medial epi c~ndyle, an ~ tb ~ li§ament courses distally to the mewal memscus an d ti blaJ,l Because of Its rn emscal attachment, the medial meniscus is at lisk wh en the MCL is torn. The LCL (fibular) is a more distinct, ropelike structure than the MCL and courses from the lateral epicondyle to the fibular head, blending with tbe inse rtion of the biceps femoris ten­ don. Unlike the MCL, tbe LCL does not attach to its re­ spective meniscus, plaCing it at less lisk with an LCL injUly. Th e cruciate ligam ents can be found within tIle knee jOint, just postelior to the arti cular center. Th ey are named by their relative tibial positions and are intracapsular but xtrasynovi al. The ante rior cruciate ligament (AC L) at­ taches on the an te romcdi al ti bial plateau and courses pos­ terolaterally, twisti ng on itself to attach at the posterome­ dial aspect of the lateral femoral condyle. It is co mposed of fascicl es grouped into anterOine ciial and post e rolateral bundles, named by th eir relative tibial attachm ents. The AC L passes throu gh the intercondylar not ch, pressing agains t its roof in full extension. Previous literature sug­ ested that individuals witb a small notch might be more susceptible to AC L injuries, but this has not been substan­ tiated. 13 .H Howeve r, scar in the notch aft er AC L recon­ struction or poor graft placement can result in roof im­ pinge ment, preventing full knee extension. The posterior cru ciate ligament (PCL) is more vertically oriented near the longitudinal axis of tJ1e knee. I ts tibial origination is from a c1eprPssion on the posterior tibia betw('('J) the two platcans, and it ascends anteromedially, att aching to the latt> ral surface or th e medial femoral condyle . T his origin is important in total kn ep arthroplasty, in which the PC L may be spared because of its attachmen t distal to the joint line. Like the AC L, the PCL is composed of two functional bands, the anterolateral and the posteromedial , which pro­ vide a continuum of stability throughout most of the range of motion (ROM ).15 Th e menisci , or semilun ar cartilages , are t""o crescent­ shaped fib rocartilaginous structures with peripheral bor­ ders that are thick, convex, and triangular in cross-section an d taper to a thin , co ncave mobil e edge centmlly.1O,16 Each covers approxim ately hvo tb irds of the tibial surface. The superior surface of each menisci is concave and artic­ ulates with the femoral con dvles; the inferior surface is flat and rests on the tibial articular surface . The medial menis­

eus has a semilunar shape and is broader posteriorly and narrower anteriorlv and attaches to th e intercondylar area anterior to the AC L. Aro und its periphery, th~ medial meniscus is attached to the capsule and to the tihia through the coronary ligament. It is further stabilized by its attach­ ment to the undersurface of the MeL. Tlw semi membra­ nOSllS muscl e also attach<;:s indirectly to the medial menis­ cus through its capsular arm. I(j The lateral mell iSGllS i nearly circular, constituting approximately four fifths of a ling, and covers a lar~e r portion of the tihial plateau than the medial meniscus. 0 Its pelipheral attachments to a l ~'\: capsule and lack of attachment to the LCL partially ac­ count for the in creased mobility of the lateral meniscLlS This mobilitv con tlibutes to thp'lower incidence of lateral meniscal tea~·s.

Myology The muscles crossing the knep joint consist of one-joint and two-joint muscles acting as agollists, antagonists, and stabi­ li zers. Because the complex interactions of the hip, knee. ankle, and foot are beyond the scope of this chapter, the discussion of muscle function is limited to actions occur­ ring at th e kn ee joint (see Chapters 20 and 22). T he primaly anterior muscles are the quadricep femoris (rectus fe moris, vastus lateralis , vastus inter­ medius, vastus medialis), which act as the principle knee extensors 17 D yll amically, the length of the rectus fem oris an d tb e patellar tendon are critical to allo"v free patellar gliding during flexion and extension. Shortening of the patellar tendon (i.e., patella baja or patella infera) or short­ ening of th e rectus femoris can contribute to increaset. compressive forces and ineqUitable force distribution ove: the patellar facets. The relative differences bet\veen tht:' vastus lateralis and vastus medialis have been implicated · tbe etiology of patellofeJJ1oral pain. Compared with the v::.;,­ tus lateraJis, the vastus mediali s has greater hulk, insert: more distally, has a more oblique ori entation (approxI ­ mately .'55 to 65 degrees ), has a shorter tendon, and has separate nerve supply. l2 T he main posterior muscles are the hamstring mu,, · cles-biceps femoris , semitendinosu s, and semimembr,, · nosus. T hese muscles function primarily as knee flexo whereas the long head of the biceps assists in extension am.. lateral rotation of th E' hip. The se mitendi nosus an semimembranosus also assist in extension and medial rot ..­ tion of the hip]' Aft(' r knee injury or surgely, patients ffL · quently LIse the halilstrings as hip extensors to passively tend the knee rath er than using the quadriceps. Ti, therapist must closely observe muscle firing to en sur proper quadriceps activity. Medially, the graCilis and adductors longus, magnlli and brevis function primarily at the hip but may provid.. dynamiC stability to the knee joint. The lateral 1nllsculatul acts primarily at the hip, with no direct action at the kne The tensor fasciae latae alises from the an terior aspect the iliac crest and the lateral aspect of the anterior superi"F iliac spine. It courses distally behveen and attad1ed to layers of th e iliotibinl tract at the mid-thigh, with the tnK continuing to th e lateral femond condyle, lateral tibi cOlldyle, fihlllar bead and the patella (via horizontal fib en At the knee, th e tensor fnsciae latae produces extension an

Chapter 21 . The Knee lateral rotation through the iliotibial tract, and it assists in flexion, medial rotation, and abduction at the hip. The glu­ teus maxilllus also inserts into the iliotibial tract, emphasiz~ ing the importance of hip musculature to knee function. 1O Through the iliotibial tract, the gluteus maximus indirectly helps to stabilize the knee in extension. In addition to re­ ceiving fibers from the tensor fasciae latae and gluteus maximus , the iliotibial tract has superficial fibers that as­ cend laterally to the iliac crest and Jeeper fibers that blend with the hip joint capsule. lO

Kinematics Tibiofemoral Joint Th knee is considered to be a tricompartmentaljoint, "rith medial, lateral, and anterior (patellofemoral) compart­ ments. The arthrokinernatic and osteokinematic motions at the tibiofemoral joint result in six degrees of freedom , in­ cluding three rotations-flexion and extension, medial and lateral, valgus and varus-and three translations-anterior and ~osterior , medial and lateral, distraction and com pres­ ion. 8 Normal ROM in the sagittal plane from extension to flexion is approximately 0 to 140 degrees , ",rith extension limited by the ACL and PCL, the posterior capsule, and the anterior horns of the menisci. Flexion is limited by the cruciate ligaments and the posterior horns uf the menisci . .\lotion may be limited by quadriceps, hamstrings , and gas­ trocnemius muscle lengths. Normal knee extension is ac­ companied by anterior glide of the tibia on the femur, and posterior tibial glide is associated \\lith knee flexion. The differentiaI size of the femoral condyles and the static soft tissues contribute to the screw home mechanism of termi­ b Tj I knee extension. ,lS.19 Motion in the frontal plane is minimal when the knee is held in full extension. For this reason, any varus or valgus -tress is more likely to damage the collateral or cruciate lig­ aments as the knee approaches full extension. ''''hen the knee is flexed to 30 degrees, the LCL, posterolateral jOint capsule, arcuate complex, and cruciate ligaments provide restraint against varus forces. 19 On the medial side, the .\ICL, the posteromedial capsule, and the cruciate liga­ ments stabilize against valgus forces . Normally, greater varus motion than valgus motion is found because of the !!reater laxity in the lateral structures and the breadth and orientation of the MCL. In the transverse plane, medial rotation is limited by the LCL, menisci , and the posterolateral capsule as well as the :\ CL rotating on the PCL. Lateral rotation is restricted by the MCL, the posteromedial capsule, and menisci. The amount of medial and lateral rotation increases as the angle of knee flexion increases up to about 120 degrees. Minimal rotation can occur as the knee approaches full extension because of the articulation of the femoral condyles \\lith the menisci and tightening of the ligaments. Any excessive ro­ tation near full extension is likely to damage the menisci and ligaments. The instant center of rotation is the axis about which the tibia rotates during flexion and extension at any instant in time. 18 Because of the arthrokinematic motion occurring during flexion and exte nsion, the instant center of rotation changes throughout the ROM. At the initiation of flexion,

491

the femur rolls on the tibia for approximately the first 15 degrees of flexion , after which gliding and spinning occur. If only rolling occurred throughout the range, th . fe mur would roll off the back of the tihia before reaching full fle, ­ ion (Fig. 21-4). Alterations in the instant center of rotation have occurred with knee injuries such as ligam e nt and mcniscal tears . 18 .19 These alterations can produce focal ar­ eas of increased articular cartilage loading

Patellofemoral Joint As the knee flexes from the fully extc nded position, the ill­ ferior pole first contacts the femur at approximately 20 de­ grees. As flexion proceeds to 90 degrees, the contact area includes more of the central portion of the patella, and it is not until 135 degrees that the medial odd face t contacts the medial femoral condyle. zo This hahitual noncontact and secondary cartilage underloading rnay contribute to the de­ generation seen at the odd facet. In ideal static alignment, the patella is situated slightly laterally because of the screw home mechanism that later­ alizes the tibial tubercle. As the knee flexes and the tibia derotates, the patella is drawn into the trochlear groove . The patella remains in the trochlear groove until approxi­ mately 90 degrees of flexion . With continued t1exion, the patella moves laterally and completes a lateral C-shaped curve. This motion occurs p aSS ively as the knee flexes through a ROM. However, this tracking changes during ac­ tive knee extension , and the patella moves superiorly along the line of the femur if the vastus medialis obliquus (VM 0 ) and the vastus lateralis (VL) are in balance.

Kinematics of Gait A ROM of 0 to 60 degrees at the knee is necessary for normal gait. Howeve r, this presumes normal mohility at the pelvis, hip, ankle, and foot. Any limitations at adjacent joints rna)' require additional motion at the knee. When the foot makes initial contact \\lith the ground, the knee is fully extended. The knee then flexes to 1.'5 degre es during the loading response of gait. After this initial flexion, the knee begins to extend until it reaches full extension at midstance. As the body weight passes over the limb , the knee paSSively flexes to 40 degrees. As the knee moves into the initial s"ving phase, the knee further flexes to 60

' a-/

Femur

1",,!~oJ:

I

D-

,,

/

Posterior

( ","~o_g~__,) '

Anterior

_

-

Anterior \ rolling

, \

, Femur ,"-....,-=-....

sliding

Tibia

ABC

FIGURE 21-4. (A) Pure roll ing of the femur on the tibia . The fe mu rwould roll off the tibia if no gl iding occurred. (8) Posterior roll ing and anterior glidi ng occur with flexion. whereas (C) anterior roll ing and posterior glid­ ing occur with extension. (Adapted from Norkin CC, Levangie PK. Joint Structure and Function A Comprehensive Analysis. 2nd Ed. Philade lphia. FA Davis. 1992)

492

Therapeutic Exercise Moving Toward Function

Kinetics and Kinematics of the Gait Cycle at the Knee

PHASE OF THE GAIT CYCLE

RANGE OF MOTION (DEGREES)

MOMENT

MUSCLE ACTIVITY

MUSCLE CONTRACTION TYPE

Initial contact Loading response Midstance

0

Flexion

Quadriceps Hamstrings Quadriceps

At hip, isometJic

Concentric

Tenninal stance Preswing Initial swing

Extends to 0

Midswing Terminal swing

Flexes 0 to 15

Flexion

Extends to 5 flexion

Flexion moving toward extension Extension

Quadriceps

Flexion

Minimal Hamstlings

Flexes to 40 Flexes from 40 to 60 Extends from 60 to 30 Extends from 30 to 0

degrees to assist the foot clearing the floor. The knee then continues to extend through the midswing and terminal swing phases , achieving full extension before initial con­ tact (Table 21-1).

Kinetics Tibiofemoral Joint Ground reaction forces and muscle activation combine to create significant forces about the knee jOint. Malalign­ ment in any plane can result in considerable focal increases in force. Motions occurring in the sagittal plane result pli­ malily in activation of the knee flexors and extensors. Dur­ ing the loading response phase of the gait cycle, a flexion moment requires quadriceps activation isometrically and eccen trically to counteract the moment. As the knee ap­ proaches midstance, the flexion moment is moving toward an extension moment, and the quadriceps muscles are ac­ tive until the knee is fully extended. Subsequently, muscle activHy about the knee is minimal because of the passive nature of the terminal stance and preswing phases despite the respective extension and flexion moments. As the leg enters the swing phase, the hamstrings are active to flex the knee in initial swing and to decelerate the leg in terminal swing, whereas the quadriceps are active only in terminal swing to extend the leg (see Table 21-1). Ground reaction forces, muscular forces , and the nor­ mal lower extremity alignment combine to produce im­ portant loads in the frontal plane. During the stance phase, the varus moment produces a relative compression in the medial compartment and distraction in the lateral compartment of the knee. This puts greater loads on the medial articular structures (e.g., articular cartilage, menis­ cus) and on the lateral stabiliZing structures (e.g., LCL, jOint capsule). Force plate analysis demonstrates that ground reaction vertical force rarely exceeds 115% to 120% of body weight during normal ambulation. How­

Isometric Eccentric

Minimal

Mostly passive with some hamstrings Hamstrings Quadriceps

Concentric Eccentric

Eccentric Concentric

ever, during jogging and running, ground reaction for, approach 275% of body weight. IS

Patellofemoral Joint In addition to ground reaction forces, joint reaction for are created at the patellofemoral joint by tension in th quadriceps and the patellar tendon. As the knee fle xes i a weight-bearing pOSition, greater quadriceps torque is re­ quired, and joint reaction force increases. For exampl the quadriceps torque during level walking is one-half the body weight, stair climbing is three to four times th body weight, and squatting is seven to eight times body weight. 21 These compressive forces can be min'­ mized by a properly aligned patella, which disperses th force over a large surface area. Patellar subchondral bo "vith a strong, well-organized trabecular arrangement minimizes joint reaction forces. Pathology, such as degc. ­ eration of patellar or femoral chondral surfaces, furtb reduces the capability of responding to patellofemon joint reaction forces. The balance between the VMO and VL appears to b critical for maintaining normal patellar tracking. Results 0; surface electromyography (EMG) have suggested an ap­ prOximately 1:1 ratio ofVMO to VL input in normal indi­ viduals and less than 1: 1 in those with patellofemorCll pain. 2:2 ,23 Small amounts of swelling (as little as 20 mL fluid ) may inhibit the VMO.24

ANATOMIC IMPAIRMENTS The primary anatomic impairments at the knee occur in the frontal plane. Alignments of the hip, knee , and ankle combine to form an integrated kinetic chain, which mu be considered in its entirety. The pOSition of the hip affecL the position of the knee, and the position of the knee dic­ tates foot position, The anatomic impairments at the knee

Chapter 21 : The Knee

493

100ving sections discuss key aspects of knee joint examina­ tion (Display 21-1).

Patient/Client History

A

B

AGURE 21·5. (A) Decreased tibiofemoral angle associated with coxa vara results in genu valgum (B) Increased tibiofemoral angle associated with coxa valga results in genu varum. (Adapted from Norkin CC. Levangie 11K. Joint Structure and Function A Comprehensive Analysis. 2nd Ed. :lhi ladelph ia FA Davis. 1992)

must be evaluated in light of the posture of the lum­ bopelvic, hip, ankle, and foot jOints.

The most important data to be gathered first are subjective information, which gUides the objective examination and provides the clinician \vith important information about functional limitations and disability. Key questions focus on which symptoms are most disabling for the patient, who may e;';perience pain, instability, mobility loss , weakness, catch­ ing, or other aggravating symptoms. From this information, the clinician chooses tests to match the patient's symptoms and designs a treatment program to address the functional limitations and disabilities described by the patient. At the knee, symptoms of giving way, catching, or locking may be present in addition to complaints of pain. The examination must clarif)r the source of the symptoms through thorough questioning and appropriate test and measure choices. For example, a history of a deceleration injury along \vith com­ plaints of the knee giving way, would lead the clinician to tests such as a Lachman's to assess the integrity of the ACL.

Tests and Measures Genu Valgum The femur descends obliquely from the hip in a distal and edial direction. This medial angulation with a vertical 'bia results in a valgus angle at the knee, or genu valgum Fi . 21-5A). This medial angle is 5 to 10 degrees. Any ap­ _ areater than this is considered to be excessive genu vaJ­ m. This valgus position places greater load on the lateral

mpartment of the knee and relatively unloads the medial

mpartment. Over time, development of degenerative

int disease in the lateral compartment produces physio­

'c lengthening of the MCL as the lateral compartment

IJ apses and the medial compartment is unloaded. In­

ases in the angulation increase the lateral pull of the

. driceps, placing excessive loads on the patellofemoral

.mt and increasing the risk of patellar dislocation. Genu gus is associated \'lith coxa varum at the hip and exces­ pronation at the subtalar joint.

enu Varum 11 n the angulation of the femur and tibia is vertical (0 :-rees) or laterally Oliented, the condition is referred to as _ u varum (Fig. 21-5B ). Genu varum increases the loads th medial compartment of the knee and relatively un­ s the lateral compartment. Genu varum is associated JJ oxa valgum, and because the heel contact occurs in a . neal varus position, excessive pronation occurs to ori­ the calcaneus vertically.

MINATION AND EVALUATION \ith all the jOints of the lower extremity, a comprehen­ knee examination includes the adjacent joints and the bopelvic region. The choice of specific tests and mea­ for the examination depend on the situation. The fol­

The objective examination should begin \vith observation of posture and the position of the limb. Basic tests for the lumbopelvic and hip regions should be performed. Any of

DISPlAY 21-1

Components of the Knee Assessment I. Pelvis or hip A. Length of 1. Hip rotators 2. Hamstrings 3. Iliotibial band B. Hip alignment C. Strength of 1. Hip rotators 2. Hip abductors 3. Hip extensors D. Hip capsule mobility II. Knee A. Range of motion B. Ligamentous sta bility tests C. Meniscal tests D. Extension overpressure response (infrapatellar fat pad testing) E. Palpation for local tenderness III. Patella A. Patellar orientation B. Relationships of vastus medialis obliquus and vastus lateralis C. Lateral retinacular tightness IV. Tibia A. Tibial torsion B. Tibial varum or valgum C. Tibial rotation V. Foot A. Pronation or supination B. Rearfoot or forefoot alignment

494

Therapeutic Exercise: Moving Toward Function

these areas may refer pain to the thigh, Imee, or calf. Sev­ eral observations are important: • Plumb line landmarks anteriorly, posteriorly, and lat­ erally • Genu recurvatum , flexion , valgum or varum • Hip anteversion or retroversion • Q angle • Position of the patella, including glide , tilt , and ro­ tation • Muscle tone of the lower extremities • Tibial intemal or external torsion • Foot posture, including pronation and supination • Ecchymosis, swelling, or redness • Ability to place weight on the limb

Range of Motion Mobility examination at the knee includes osteokinematic (ROM ) and arthrokinematic (joint integrity and mobility) testing. Examination must include the tibiofemoral and the patellofemoral joints. These two joints work in unison to produce smooth, coordinated movement at the Imee joint. Goniometric measures of the tibiofemoral jOint should be performed, as should a subjective report of the patellar po­ sition during active ROM.

Joint Integrity and Mobility Joint integrity and mobility measures assess the arthrokine­ matic motion of the joint and any specific tests to assess the integrity of various joint structures. At the tibiofemoral joint, anterior and posterior glides along with distraction are the major arthrokinematic motions tested . At the patellofemoral jOint, the amount of glide, tilt, and rotation should be assessed. Specific tests for ligament laxity, ap­ prehension in the case of patellar dislocation , and meniscal tests are a few of the many used. Magee's Orthopedic Phys­ ical Assessment 2 .5 offers a complete description of special tests. Some of the most common special tests are listed in Display 21-2.

Muscle Performance Muscle function at the hip , Imee, foot, and ankle should be tested in a logical order based on the subjective inform a­ tion and clinician's impressions after examination. Th strength of most muscles acting at the knee exceeds the strength of most clinicians' manual muscle test skills. The test results for many patients indicate normal strength al­ though they have deficits. Other testing, such as isokine bc dynamometry or the use of hand-held dynamometers, ma\ be more suitable at the knee. However, the clinician should ensure that the limb is positioned so the muscle is tested at the correct length. These muscles are commonly tested i patients with knee complaints: • Medial and lateral hamstrings • Quadriceps • Glutealmuscles • Iliopsoas • Gastrocsoleus • Hip rotators • Posterior tibialis

Pain The pain examination is pelformed as part of the subjecti\ examination, and results are further clarified dUling the ob­ jective examination. Complaints of warmth, swelling, an local tenderness are symptoms of pain and inflammatio Palpable tenderness and warmth over speCific anatomIc structures are objective tests of pain. This information I correlated with subjective information to guide th e rt' · maining examination and treatment planning.

THERAPEUTIC EXERCISE INTERVENTION FOR PHYSIOLOGIC IMPAIRMENTS After a thorough examination and determination of the di­ agnOSiS and prognosis, the treatment plan is implement Any impairments found must be correlated with a func­ tional limitation or disability, \vith this aspect of th e p;..­ tient's care treated concurrently. However, some impai l ­ ments must be improved before their associated functio limitation or disability can be addressed.

DISPLAY 21-2

Commonly Used Tests of the Knee • • • • • • • • • • • • • •

Vafgus stress at 0 and 30 degrees Varus stress at 0 and 30 degrees Lachman's test Anterior drawer Posterior drawer Pivot shift test Flexion rotation drawer test Posterior sag test External rotation recurvatum test Reverse pivot shift test Patellar apprehension test Fluctuation test McMurray's test Patellar tendon reflex

Mobility Impairment Hypomobility The first step in treating mobility impairment at th e kn determining the cause. Mobility can be decreased becau of any type of connective tissue (i.e. , musculotendino capsular) shortening. Mobility can be diminished by iatro­ genic or pathologic abnormalities such as an incorrectr placed ligament graft or a hypelirophic fat pad. Examinin _ the pattern of limitation and the patient's location of pai can clarifY the cause of mobility impairment. Hypomobili . at the Imee joint results in compensation at adjacent joint::; For example, squatting down with limited knee motion re­ quires additional motion at the hip, ankle, and low back and these jOints are at risk for injury from the excessive de­ mands placed on them.

Chapter 21 •The Knee

Capsular restriction is common after total knee arthro­ plas ties, multiple operations, or immobilization for any rea­ son. Capsular limitations can occur at the tibiofemoral jOint, patellofemoral joint, or 'both, and the source of the limitation must be ascertained. Full knee extension re­ quires superior glide of the patella and anterior glide of the tibia on the femur. Knee flexion requires inferior glide of the patella along with posterior glide of the tibia on the fe­ mur. Capsular restrictions are treated with the respective glides and joint distraction techniques (Fig. 21-6). Quadri­ ceps setting is an excellent exercise to increase and main­ tain superior patellar glide (see Self-Management 21-1). However, if adhesions in the suprapatellar pouch limit the excursion of patellar glide, these exercises may increase patellar pain. Patellar mobilization in the direction of limi­ tation can be performed by the therapist or by the patient in a home program (see Self-Management 21-2 ). Limitations caused by muscle shortening usually are treated with stretching exercises. The quadriceps and hal11­ stling muscles may be lengthened in several positions, but care must be taken to ensure proper positioning of the spine, pelvis, and hip. Incorrect positioning can increase the stress in these areas and decrease the effectiveness of the stretch. The quadriceps may be stretched across the kn ee only or, with the addition of rectus femoris stretching, across the hip (Fig. 21-7). The pelvis must be prevented from tilting anteriorly, increasing lumbar extension during this stretch (see Self-Management 21-3). Stretching the quadriceps at the knee may also be performed in prone with an abdominal support to prevent excessive lumbar ex­ tension (Fig. 21-8). The hamstrings are eaSily stretched in a sitting position with the knee extended and the lumbar spine held in neu -

SELF-MANAGEMENT 21-1 Quadriceps

Setting Exercise

Purpose:

To strengthen quadriceps muscle, mobilize patella superiorly, stretch tight tissues behind the knee, and re-educate the quadriceps how to work

Position:

Sitting with the legs straight out, toes pointed up to the ceiling; a small towel may be placed behind the knee

Movement technique: Levell.

Tighten the quadriceps muscle on top of your thigh. You should see your kneecap move up toward your hip. Your knee may push down toward the floor, and your foot may come up off the flool. You should be unable to manually move your kneecap when doing a quadriceps set correctly. If you are having difficulty, try doing a quadriceps set on the other leg at the same time. Be sure your hip muscles stay relaxed.

Level 2.

Perform the same quadriceps set in a standing position.

Dosage Repetitions: _ _ _ _ _ __ Frequency _ _ _ _ _ __

Relaxed muscle

FIGURE 21-6. Joint distraction and posterior glide of the tibia on the ' emur can be performed simultaneously to increase knee joint flexion obility.

495

Tightened muscle

tral. Avoid posteriorly tilting the pelvis or flexing the lum­ bar spine. This exercise can be performed throughout the day at a variety of workstations (Fig. 21-9). The medial hamstrings may be emphaSized by laterally rotating the leg, and the lateral hamstrings may be emphaSized by medially rotating the leg. HOlizontally adducting the hip with internal rotation of the hip enhances stretching of the iliotibial band and its associated lateral structures (Fig. 21-10 ). In addition to the major muscle groups acting at the knee, th e closed chain nature of the lower extremity neces­ sitates assessment at adjacent joints. For example, shorten­

496

Therapeutic Exercise: Moving Toward Function

Patellar Mobilization Performed by the Patient

SELF-MANAGEMENT 21-2

Purpose:

To increase the mobility of the kne ecap in all directions

Position:

Sitting with the legs straight out, toes pointed up to the ceiling

Movement technique: Using your fingers or the heel of your hand, push your kneecap (A) down toward your foot, (8) toward the outside, (e) toward the inside, and (0) up toward your hip. Hold each position for a count of five. These movements should not be painful.

Dosage Repetitions: _ _ _ _ __ Frequency _ _ _ _ _ __

A

ing of the medial rotators of the hip or the gastroc-soleus can contribute to patellofemoral pain at the knee. These tissues must be examined over all the appropriate jOints.

Hypermobility Hypermobility at the knee joint is associated with patellar instability and possibly increased risk for ACL injUlies. 13 Hypermobility is associated with clinical signs such as knee recurvatum and subtalar joint pronation . This combin ation may predispose individuals to patellofemoral pain at the knee. Treatment of hypermobility at the knee joint requires postural education and retraining. This education is fo­ cused at all lower extremity joints and the lumbopelvic area. Good posture requires an integrated approach throughout the entire kinetic chain. Any further training must be superimposed on correct postural mechanics. Af­ ter this posture is achieved, closed chain activities empha­ sizing cocontraction of lower extremity musculature en­ hance postural stability (Fig. 21-11 ). High-repetition , low-resistance activity is used to enhance stability.

B FIGURE 21-7. Quadriceps stretching while stand ing. (A) Across the kn Es only. (8) Across the hip and knee.

Impaired Muscle Performance Impaired muscle performance about the knee incilld e~ decreases in strength, power, and endurance of major muscle groups such as the quadriceps and hamstring: The quadriceps are essential for controlling the motion

Chapter 21. The Knee

497

Quadriceps Stretching While Avoiding Lumbar Extension

SELF-MANAGEMENT 27 -3

PUlpose:

To increase flexibility of the quadriceps muscles

Position:

This exercise can be performed in several positions. Pick a position that is comfortable or convenient for you, but avoid arching your back when stretching; tighten your abdominal muscles to keep your back steady. 1. In a sidelying position, with abdominal muscles tightened (Al 2. In a standing position, with some support, abdominal muscles tightened, and knees close together (B) 3. On your stomach, with a small pillow or towel under your hips and abdominal muscles tightened (e)

FIGURE 21-8. Prone quadriceps stretching with a pi llow under the ab­ domen. These exercises can be performed with or without weights on the ankle for additional stretch.

Movement technique: Grasp your ankle or a strap attached to your ankle, pulling it toward your buttocks until you feel a gentle stretch in the front of your thigh. Hold each stretch for 15 to 30 seconds.

Dosage Repetitions: _ _ _ _ __ Frequency _ _ _ _ __

A

FIGURE 21-9. Hamstring stretch while seated at a works tation.

498

Therapeutic Exercise Moving Toward Function

persons also need power for performing work or reut)­ ational activities that reqnire generating a great deal of strength in a short period (as in jumping activities or lift­ ing very heavy objects). Chapter 5 desclibes a variety of strength, endurance, and power training activities. Plyo­ metric exercises are commonly used to build power in th e muscles surrounding the knee joint. Be sure that the indi­ vidual is ready for such vigorous, impactfu~ activities, or an overuse injury may occur. Also be sure that activities of this level are necessary for the patient. Not all patients are candidates for pIyometric exercises.

Neurologic Causes

FIGURE 21 -10. Lateral hip and leg stretch. Close observation prevents trunk rotation substituti on for hip adduction.

and Joint reaction forces across the knee jOint, and, as sllch, are critical for maintaining the long-term health of t1w joint surfaces. Th e muscles contro]]ing the knee joint require, at a minimum , both strelwth ,lnd endurance. For mallY individ\lals. power is critical ~s well. Strength is nec­ essary to raise the body up out of a chair or up the stairs. Endurance is necessary f()r walking any distance. Manv

Neurologic disorders can prodm:e impairm ents in muscle performance in muscles surrounding and supporting tllP knee joint. The most common cause is a lumbar spine in­ jury or disease . In addition to directly '-lHecting the quadri­ ceps or h'-ll1lstring musculature, IUl11har spine patholog:, af­ fecting proximal or distal musc\llature necessarily affec: gait and other movelllent patterns. Altered movement pal ­ tern s affect knee jOint mechanics and ultiJnately the joir. itself. An)' complaints of knee joint impajrments shou1 prompt examinations of the spine and proximal and di joints. Other neurolOgiC disorders , such as multiple sclerosis ~ Parkinson's disease, profoundly affect the ability to pr duce torque about the knee. Each of these situations mID be evaluated within the context of the disease process. Be­ cause many muscles and movement patterns are affect a more global examination is necessary to determin e treatment strategy. Some autholities have suggested there is a neurolOf' component to patellofemoral pain. Studies of differe quadriceps activation patterns in response to a patellar te don tap have suggested timing differences in those \vith without patellofemoral pain.2~ .2627 The ke), consideration when designing inte rvention those with neurologically mediated impaired muscle formance is ensuring use of the desired muscle. NeuraL _ weakness produces altemtions in firing patterns to acco plish movement in the most efficient manner pOSSible. . ergists may accommodate for weakness , or biomechan modifkations may enhance the activity of other muscl compensation for the weakness. For example, a fo n' lean during stair ascent allows the hip extensors to pemate for 'lI'eak quadriceps (Fig 21-12). Close moni' ing of exercise quality is necessal)' to ensure t raining ot desired muscle.

Muscular Strain ~

I

'/

'-'

FIGURE 21 ·11. Knee extension exercise using tu bing and with a focus on posture. This is a closed chain exercise on the \Jveight-bearing side, and an open chain exercise on the non-weight-bearing side. It requires consider­ able balance and postural control.

The ability to produce torque at the knee can be affa by muscular strain injuries. The quadriceps and hamstr muscle groups are the most commonly illjured , often result of sudden decelerative forces. The quadriceps d erate the fleXing knee during the loading response of gait cycle, and the ham strings decelerate the fo m swinging shank dUling the terminal swing phase. These centric muscle contractions may produce macrotrauu:, or microtraumatic injury. . The quadriceps rna)' be injured as the result of a co sion. A blow from an object such as a ball or hockey p

Chapter 21. The Knee

A

499

B

FIGURE 21-12.. (A) Ascending sta irs using proper mechan ics. (8) Ascen ding stairs with the hip extensor muscle substituting for a wea k quadriceps muscle.

can produce a deep muscle contusion that rt' clujr s special rehahilitation consideration. Initially bleedin g within the muscle must be controll d, followed by progressive mobil­ ity and strengtbening. When returning the patient to func­ tion, the role of the affected muscle in should be retr::Uned to fit the expected activity. For example. the runner with a hamstring strain injury as a result of the swil.g phase of gait shourd be trained in an open chain, decelerative function. Inertial exercise or other forms of repetitive clecejerative exercise also can be used (Fig. 21-13). F or those returning to sports, plyometric exercises are an excellent choice for retraining the lower extremity muscles.

Disuse and Decanditianing Disuse of the knee musculature occurs primarily in the quadriceps and may occur as a result of an injury at tlw knee or from any other joillt in the kinetic chain, inclucling th e low back An injury at an associated joint can prC'vcnt par­ tiCipation in usual activities, leading to disllse of muscula­ ture throughollt the kinetic chain. D isu ·e of the quadriceps affects the loading and midstallc phases of the gait cycle , during which the CflladricC'ps dec lcrate the flexing kn e . followed by a change ofdir etion and accplpration into hlee extension. This quadriccps action decreases loads on the joint surfaces and is critical in maintaining the health of the knee joint. The quadriceps mllscles work to decelerate the boJy when descending stairs and, akJ11g with th e hip muscula­ ture, to ascend stairs and arise fro m a sittin position. D is­ use can lead to profound changes in how activiti s of daily living (ADLs) are performed. F ailure to p rform these

FIGURE 21·13. Ham stri ng mu scle training with inertial exe rc ise for high­ rep etiti on, low-res istance acceleration and decelerati on training.

500

Therapeutic Exercise Moving Towa rd Function

activities efficiently and continuously places additional loads on adjacent joints, Treatment should focus on the pri­ mary cause of the disuse as well as strengthening activities for the quadriceps muscle ,

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON DIAGNOSES Ligament Injuries Anterior Cruciate Ligament The ACL is one of the most commonly injured ligaments in the knee, The short- and long-term morbidity associated \vith an ACL injury \vith or without reconstructive surgery has made this injury the nemesis of many athletes, Fortu­ nately, the ACL injury has become better understood and better managed, resulting in Significant decreases in mor­ bidity, The ACL tear usually occms as the result of a quick deceleration, hyperextension, or rotational injury and does not involve contact with another indIviduaL Injury to the ACL is frequently associated with injuries to the MCL, t~le medial meniscus, and the lateral meniscus, In the adoles­ cent, the ACL may avulse from the tibial spine rather than tear in the midsubstance, and it should be surgically re­ paired with bone-to-bone fixation, Al~though fundioning independently, the ACL and PCL gUide the instant center of rotation of the knee , thereby con­ trolling the jOint arthrokinematics, Any alteration in normal kinematics can produce focal areas of increased alticular cartilage and other soft-tissue loading, Sequelae such as de­ generative joint disease and tendinitis must be considered when determining prognOSiS and treatment approach, Pa­ tients \vith ACL deficient knees were found to have altered joint arthrokinematics in the transverse plane during walk­ ing,28 The authors suggest that the repeated rotational in­ stability may playa role in the development of meniscus tears or osteoarthritis, Injury to the ACL can result in sig­ nificant functional limitations and potential disability be­ cause of its role as the primary restraint against anterior tib­ ial translation, Rupture of the ACL results in substantially increased anterior translation, \vith the maximum occurring between 15 and 45 degrees of flexion .18 The posterior hom of the medial meniscus prOvides secondary restraint against anterior tibial translation and is at risk for injury after an ACL rupture. The ACL prOvides stability against tibial me­ dial and lateral rotation and against varus and valgus stresses. Because of its role in controlling the instant center of ro­ tation, some individuals e;.:perience episodes of instability after ACL injury and suhsequently fail conservative treat­ ment. They may have surgery using static restraints to re­ construct the ACL. These tissues include the central one third of the patellar tendon or the hamstring tendon. 29 Those involved in high-de mand SpOtts usually have more difficulty returning to activities \vithout symptoms. Prein­ jury hours of sports participation, age, and arthrometer testing were correlated \vith a need for surgery 90 days or more after injury.30 Continued vigorous activity \vith an un­ stable knee can lead to meniscal tears, espeCially at the pos­ telior horn of the medial meniscus.

Clinical examination procedures to detect an ACL tear start with an accurate history, including the mechanism of injury and time of onset of effusion, Acute injuries to the ACL are associated with an immediate, te nse effusion. Lachman's test remains the gold standard for assessing ex­ cessive anterior tibial translation 25 Arthrom e ter testing, such as the KT-2000, is routinely used to com,pare laxity with that of th e contralateral knee and with population norms. Instability testing can be performed by several spe­ cial tests, including the pivot shift, flexion rotation drawe r. and the jerk test. z, Significant impairments, functional limitations , and dis­ abilities occur after ACL tears. The acute ACL rupture i characterized by acute hemarthrosis , pain , and instability. Impairments such as effusion , loss of motion, inability to bear weight, decreased muscle performance, poor balance and coordination , and pain are evident early in the course. Functional limitations include an inabilitv to ambli lat \,v ithout an assistive device, limitations in b;sic and instru­ mental ADLs, and difficulty negotiating stairs. For individ­ uals involved with sport and leisure activities or work that necessitates physical labor, an ACL injury can lead to sig­ nificant disabihty, The inability to lift and cany heavy ob­ jects or to walk moderate distances can lead to the loss of functional and social interactions on many levels. Chronic impairments include instability, effUSion, wealaJess, PO OT balance and coordination, and pain. These impairments can lead to functional limitations such as an inability to am­ bulate moderate distances \vithout a brace or assistive de­ vice, difficulty ascending or descending stairs , or limita­ tions in lifting and carrying objects, Persons may become disabled because these limitations prevent return to work. leisure activities, or basic or instrumental ADLs. Rehabilitation issues of concern when treating the in di­ vidual after ACL injury include the impairments , functional limitations, and disabilities identified during the evaluation and any concomitant injuries. Associated injury to the Mel or meniscus affects the rehabilitation program, T he arthrokinematic changes and potential for secondary inju . guide rehabilitation. Resistive open chain quadriceps exer­ cises between 15 and 45 degrees are often avoided because of the increased anterior tibial translation found \\lith thi type of exercise. This translation is minimized in a closed chain exercise, which is a good choice after ACL injury or reconstruction. Because of the difficulty in returning to de ­ celeration and cutting maneuvers, the rehabilitation pro­ gram should include these types of moveme nts along with resistive, balance, and coordination activities in multiple planes, Exercises may include resisted lateral movements_ resisted rotational movements , and activities on unstable surfaces. Individuals returning to high-demand athletic frequently partiCipate in a plyom etric program as well. Because of the high incidence of ACL injuries in atJl ­ letes, particularly female athletes , clinicians have been searching for factors predispOSing females to these injuries. and for interventions to prevent their occurrence.:TI ­ 33 number of intrinsic and extrinsic factors have been consid­ ered. IntJinsic factors include muscle flexibility, joint hLxity, postural factors such as genu recurvatum and excessive foot pronation, notch \vidth, strength and hormone levels. E x­ trinsic factors include training and conditioning, coaching.

Chapter 21: The Knee

and position. Sorting out the contributions of these factors has been a challenge, particularly because there is overlap among many of the factors. However, several authors have studied the impact of neuromuscular training programs on the biomechanics of jumping, neu rom uscular performance and on the subsequent incidence of ACL injuries. 34 -36 These studies have found that neuromuscular training can improve neuromuscular perform ance as measured by a crossover hop test. 36 Such training improved the biome­ chanics of landing from a jump, decreasing knee adduction moments and peak landing forces ,-35 This program also ulti­ mately decreased the incidence of ACL injuries in high school volleyball players compared \vith a control group. The authors all consider the educational component of the program to be vital. The neuromuscular training included considerable time spent educating the female athletes on the proper mechanics oflanding, jumping, and changing di­ rection . It is difficult to know which component res ulted in the decreased incidence of inju ry: the education, strength increases, neuromuscular coordination improvement, or changes in biomechanics/posture. However, the combina­ tion of these factors in the neuromuscular training program has been effective in decreasing ACL injuries in female ath­ letes (see Display 21-3).

Posterior Cruciate Ligament The PCL injUlies repres_ent an estim ated 1 % to 30% of all knee ligament injUlies. 3 , Most injuries occur as the result of a traum a such as a motor veh icle accide nt, with fewer PCL injuries occurring in sports. 37 The mechanism pro­ ducing a PCL injury is most often a blow to the anterior as­ pect of the tibia, forCing it posteriorly. Less commonly, the PCL is injured as a result of hyperflexion , hyperextension, or a vams or valgus injury. In the case of hyperextension, the ACL is usually injured first. In the varus or valgus in-

DISPLAY 21·3

Neuromuscular Training for Injury Prevention • warm-up: any large muscle group activity jogging bicycling calisthenics • flexibility: stretching hip and leg muscle groups quadriceps and hamstring muscles hip flexors, extensors, rotators, abductors, adductors calf musculature low back • dynamic balance: teaching proper landing techniques weight on ball of foot hop with knees bent land with 'knees in flexion knees under hips avoiding internal rotation and adduction • dynamic balance: impact activities front-back and side-to-side hopping hop and stick the landing cone hopping: with and without turns agility drills including direction changes vertical box hops: single and multiple, with and without turns

501

jury, the respective collateral ligam en t is injured , and in some cases, the ACL is injured before the PCL injury. The PCL is the primary restraint to posterior subluxa­ tion of the tibia on the femur, providing approximately 95% of the resistance against posterotibial translation. 38 A tear of the PCL results in significant increases in posterior tib­ ial translation, with the greatest occurrin g between 70 and 90 degrees. 39 The PCL resists vams or valgus tra~slation and is a secondary restraint to lateral tibial rotation .3 ( Along with the ACL, the PCL helps control the instant center of rotation at th e knee and joint arthrokinematics. The alter­ ation in joint arthrokinematics after PCL rupture can result in significant problems . Articular caltilage contac t pres­ sures in the medial and an terio r compartme nts are in­ creased after PCL mpture , with peak medial pressures at 60 degrees and peak anterior compaltment pressures at 90 degrees of flexion. 37 The individual with a PCL rupture generally complains of pain related to these changes, rather than frank instability. The natu ral history of the PCL-deficient knee is difficult to assess because of the heterogeneity of most populations studied. Many patients remain asymptomatic and are able to return to their preinjury activity levels , but others de­ velop osteoarthritic changes in the medial and anterior compartments 40 The clinician must consider the possibility of these changes and modify the rehabilitation program ap­ propriately. Some persons \-vith multiple ligament o r soft­ tissue injUlies undergo reconstruction of the PCL using static restraints such as the central one third of the patellar tendon, Achilles tendon, or allograft. Clinical examination procedures to assess the PCL in­ jured knee begin with a thorough histo ry. The mechanism of inju ry and the symptoms are different from those of an ACL inju ry and should alert the clinician to a PCL injury The posterior drawer test, performed at 90 degrees of flexion, is the gold standard for detection of PCL rup­ ture. 25 However, the PCL injury is often misdiagnosed as an ACL rupture because of the clinician 's inability to cor­ rectly determine the neutral position of the knee. In th e 90-degree pOSition, the tibia may sag poste riorly from the weight of gravity, and no further posterior translation is fo und , although excessive anterior translation may occur. This is translation from the posteriorly subluxed position to th e neutral position, rather than from neutral to an an­ teriorly displaced position. The clinician should accurately determine the neutral position of the knee before laxi ty testing by assessing the relationship between the tibial plateau and femoral condyles. The posterior sag and ac­ tive quadriceps tests also can assess posterior translation, and the reverse pivot shift and external rotation recurva­ tum procedures test posterolateral instability. Althrome­ ter tes ting using the KT-2000 can provide objective com­ parisons of translation with the contralateral side or with population norms. The extent of impairments, functional limitations, and disabilities after PCL rupture depends on associated in­ juries. Immediately after injury, the individual may present with effUSion , loss of motion, weakness , poor balance and coordination, and an inability to ambulate without an assis­ tive device. Functional limitations may include an inability to ambulate moderate distances, climb stairs, drive , or stand

502

Therapeutic Exercise Moving Toward FunctIOn

for extended periods. The resulting disClbility can affect the person's ability to participate in community, work, and leisure ADLs. When patie nts are seen for chronic func­ ticmallimitations because ofPCL defiCiency, the subjecti ve complaints usually are related to medial and an te rior compartment pain and diffi culty ambulating down a decline or stairs. The issues affecting the rehabilitation approach are re­ lated to the potential medial and anterior compartment changes . Any additional ligament injuries that could fur­ the r alter arthrokinematics or medial meniscal dam age that could modify aJiicular cartilage pressures have the potc;n­ tial to exacerbate compartmental changes. Comorbidities such as underlying osteoarthritic changes, a varus align­ ment, or history of patellofe ll1oral pain negatively alter the prognosis. These issues should be the frumework from which the rehabilitation program is deSigned. As in treating the ACI,-deficient knee, open chain resistive exercise (knee flexion in this case) can increase posterior tibial translation, and closed ch ain activities are an important therapeutic exercise mode.

Medial Collateral Ligament The MCL consists of the tibial collateral ligament and the middle one third of the medial capsule (deep portion ), which is subdivided into a thin anterior third, a stroJl~ middle third, and a moderately strong poste rior thi rd. 4 The incidence of MCL inju ries is Significantly l1ighe r than that of LCL injuries, and the MCL has been reported to be the most frequently injured ligament of the kllee. '12 D amage to the MCL occurs less frequently at the femoral inse liion compared \vith the tibial insertion because of differences in the inse rtion site structures. The MCL is usually torn as a result of a valgus stress by a late ral blow or by forced abduction of the tibia, as occurs when catch­ ing the inside edge of a ski. Associated injuries may in­ clude the ACL and merual meniscus. In the adolescent, injury to the femoral or tibial growth plate often precedes injury to the MCL and should be considered in the dif­ ferential diagnosis. The MCL is the primaly restraint against valgus loads, and it resists tibial medial rotation. Unlike the cruciate lig­ aments, the MCL has the capacity for repair 'vvithout sur­ gical intervention. Most MCL injuries heal well 'vvithout any long-term damage to the knee, despite some residual valgus laxity. 43 .4·1 For this reason, most MCL injuries are usually treated conservatively. In the individual 'vvith a combined MCL and ACL injUly, a shOii period of recov­ ery usually is allowed , followed by reconstruction of the ACL. Injuries to the MCL in the presence of AC L rup­ tures do not heal as well as isolated MCL sprains. 45 Re­ pairing the MCL or ACL risks the loss of extension ROM. The effects of le ngthy immobilization on the hgament substance and insertion sites have been studied.1 '5 In dogs, surgical repair followed by 6 weeks of immobilization of MCLs resulted in inferi or mechanical and structural properties, even at 48 weeks. W00 45 reported that a re­ mobilization period six times longer tllan the time of im­ mobilization might be required for recovery. However, in ­ dividuals vvith surgical stabilization of bony avulsions have an excellent prognosis.

Exam ination of the knee after MCL injUly begins vvith a thorough history, including detemlin ing the mechanism of injury. The inruvidual may present with locahzed swelling over the MCL or \-vith an effusion if concomitant damage to the capsule has occurred . Because tll e MC L is taut in full extension, the knee may be h eld in a position of slight fl exion. Overpressure to full extension reproduces merual kn ee pain. The midrange is the least painful, with pain in­ creasing as the MCL begins to tighte n again at approxi­ mately 70 d egrees of flexion. Point ten derness may be found vertically along the length of the ligam ent , rather than transversely along the joint line (indicative of rncnis­ cal injuly), and greate r tendern ess is generally [ound at the lllidsuhstance and the tibial insertion thall at th e femoral insertion. Valgus stress testing at 30 degrpps o[ flexion as­ scm's the integrity of the MCL, and valgus loading in full e.xtension tests the yI C L, AC L, and PC L . CompaIi son s with the contralate ral side must ahvays be performed be­ cause of individual diffe rences and physiologic laxity The impairm en ts , functional limitations, and disahilities seen after acute MCL sprains arc silllilar to those of cruci­ ate ligame nt sprain s. The progllosis after isolated MC sprain is ge nerally good because of the liWllllellfs ability to heal well. Some individuals may expelience difficulties with lateral and rotational move me nts or \vith activities on un­ even surfaces. Persons returning to physical work or recre­ ation are most at risk for limitations in these areas. Although the clinical examination nwy he benign after 6 to 8 weeks of rehabilitation, th e le ngtllY ligament remodeling process may limit the MCL's tolerance for high-dem and loading. The most significant rehabilitation issues in the iso­ lated MC L inj Uly are the fact that the re modeling proces. lags behind the clinical examination flnrungs and the need for frontal and transverse plane rehabilitation techniques. Traditional clinical examination procedures are not se nsi­ tive enough to determine readiness to re tUll1 to high de­ mand activities. F requently, the individual has full RO Nt symmetric strength, minimal or no valgus laxity, no e lfu­ sion, and no te nde rness to palpation afte r a few weeks of rehabilitation. However, the MCL is not stressed much ill ordin my daily activities or even in sagittal plane activiti e. such as straight-ahead running. The ligame nt must b loaded and trained just like muscle tissue to e nsure ade­ quate rern od eling for high-demand activities. Loading in the frontal and transverse p~alles must oecur to strengtber the ligam e nt and its bony attachJllents and to ensure safe return to physi cal activities (Figs. 21-14 and 21-15).

Lateral Collateral Ligament Injuries to the LCL are much less common than injuries t the MCL, and as with tvl CL injuries, th ey heal well an without signiflcant long-term disability. The LCL is the pri­ mary restraint to varus strcss, and because of its location i the posterior one third, it also resists hY,gereXi ension, espe­ cially in the presellce of a varus stress. 1 Late ral collater; ligament injuries usually result from hyperexte nsion vam ' forces , \·vith or without contact \vith anoth e r individua.. Complete tears occur in the ligament midsuhstance or " the fibular inse rtion. Associated injuries may ocelli" to tL posterolateral structures. inclucling the joint capsult" arcuate ligament, biceps fe moris or popliteus tendons , (

Chapter 21. The Knee

503

Treatment of Ligament Injuries

FIGURE 21 -14. Side-stepping in th e pool is an early lateral movement activity

c ruciate ligaments. In the adolescent, injury to the growth plate usually prececles ligam ent injury and should be con­ sidered in the differential diagnosis. The natural history of the LC L injmy rarely includes ong-term disability because of its healing potential. Surgi­ c: 1repair of the isolatecl LCL is rarely perforllled. Individ­ uals with Significant varus deforrniti · may expe rience in­ tab ility after this injUly and may re quire surgical tabilization. A bony avulsion should be suraicaUy reat­ tached. \lore extensive posterolateral corne r injnries typi­ cally are reconstructed llsing static restraints or b iceps fe moris tenodes is. The subj ective history of an individual with isolated LCL inj ury includes varus, hyperexte nsion, or both forces, with or without a "pop ." As with the M L, the extraarticu­ lar position of the LCL precludes a true jOint effusion un­ less damage to the joint capsule coexists. Localized swelling may occur over the Jigml1ent. Because the LCL is most taut in full extension, the incliviclualmay exp e rience lateral knee pain with overpressure into full extension. The ligalllent is tender to touch, but tl'le joint line should not be tender. h e varus stress test at 30 degrees of flexioll best assesses the integrity of th e LCL. T he functional lim itations and disabiliti es scen after a LC L injury are fewer than those seen with al' M L injury. \I ost individuals are minimally limitecl after this injury, ex­ cept in the case of a thinl-degrec tear or conco mitant liga­ me nt or capsular in)ury. Rehabilitation issues are similar to those for MCL in­ ju ries. The prolonged cours e of ligament remodeling mllSt be considered, along with the importance of retrairillg 1e individual and loading the ligament in the frontal and sagittal planes.

Inte rve ntions shou!d be aimed at achieving speciJic goals related to impairments, func:tional limitations, and dis abi l­ ities. I mpairments shouId be addressed if t.hey are associ­ ated with a functional limitation or clisability or' if continued impairm ent cou ld lead to disability in the future. P ain awl effusion can be managed in the short term with physical ag n ts, mechanical and electroth erapeutic modalities, and g ntle therapeutic exercise. Cold packs, ice massag , co m­ pression therapies, and electrical stimulation a re COlll­ monly used to minimize pain and effusion. TlleFapeuh c ex­ ercise such as active ane! passive ROY! activities within a comfortable range can provide lublication to joi nt surfaces and can assist resorption of excessive joint fluid. The pa­ tient should receive instruction in the application of these proceclures at home and guidance ill modifying activities to mi n.imize pain and effusion. T raditional phYSiolOgiC stretchin g and active and passive ROM activities facilitate restoration of pl-ei njUlY joint mo­ tion. Occasionally, joint mobilization techniques may be nec­ essary, although ligaml'l1tous injury ge nerally results in too much mobility rather than too little. H owever, lengthy im­ mobilization or an inability to fire dIe qlladriceps may result in a loss of knee extension ROM. Neuromuscular re-educa­ tion exercises such as quadticcps setting. hamstting setting, and other muscle activation techniques can restore the abil­ ity to fire muscles, which is a prerequiSite for normalization of movement patterns. The home program should im'lude exercises to facilitate ROM increases and neuromuscular re­ education exercises to advance gains made in the clinic (Fig. 21-16) (see Self-Manaaement 21-4 ancJI 21-5).

FIGURE 21-15. More challenging lateral movements include side­ stepping on a balance beam on foam rollers.

504

Therapeutic Exercise Moving Toward Functi on

FIGURE 21-16, Active range of motion for knee fl exion. (A) Heel slides. (B) Seated knee fl exion on a chair.

SELF-MANAGEMENT 27-4 Performing

SELF-MANAGEMENT 21-5 Prone Hang for

Flexion and Extension Mobility Exercises During the Day

Knee Extension

Purpose: Position:

Purpose:

To increase mobility in knee extension and sttetch tight tissues behind the knee

Position:

On your stomach, with your knee just over the edge of the ta ble; a towel under your thigh may be more comfortable

To increase mobility in the knee Sitting or in another position of comfort

Movement technique: Actively exten d the leg as far as possible and then bend it back as far as possible. You may use your other leg to help lift it the last little bit or to push it back a little farther.

Movement technique:

Dosage Repetitions: ______ Frequency ______

Let your knee straighten by hanging over the table's edge. Your clinician may want you to put weight on your ankle or to use your other leg to increase the stretch. Hold for 1 to 2 minutes.

Dosage Repetitions:

Frequency ______

Chapter 21. The Knee

FIGURE 21-17. Sing le-leg minisquats in the pool are performed to in­

FIGURE 21-18. Single-leg wall slides.

:rease mobility and strength.

The pool is an excellent envirollm ent for performillg mobility, normalizing gait, and initiating balance and gentle trengthening exercis s. The water's buoyancy minimizes weight bearing, whereas the hydrostatic pressure controls ffusion. Walking, physiologic stretching, leg kicks, toe raises, single-leg balance, and squats can be accomplished easily in the pool (Fig. 21-17), As the patient progresses out of th e acute phase, more \igorous exercises may be initiated. Continuation of ambu­ tation training and progression to ambulation without an sistive device are primary considerations for the return to normal activities. Land-based, closed chain exercises such as wall slides, minisquats , step-ups, stair stepping, and leg p resses can facilitate functional activities such as stair climbing, rising from a chair, and getting in and out of a car Fig. 21-18), Balance and coordination exercises such as step-ups , wobble board, Single-leg pulleys, and toe raises without support can retrain balance reactions . Any motion Joss , impaired mtlScle performance. pain, ur effusion that is related to functional limitations should be addressed con­ urrently. Traditional progressive resistive exercises can be incorporated, keeping in !Ililld the arthrokinematic issues. Weight machines, free weights, isokinetic devic s, p ulleys, and body weight are means to accomplish increases ill the ability to produce torque. The clinician must be aware of the loads placed on the knee ligaments with various exer­ cises and use caution to avoid overstressing a healing liga­ ment. For example, resistive hip adduction using a resistive band around the ankle places a Significant load on the MeL, 'which may be fine in the LIte stages but too much in the early stages (Fig 21-19), At home , the use of body

FIGURE 21-19. Resisted hip adduction using a resistive band .

505

506

Therapeutic Exerci se Moving Toward Function

Performing Weight-BeBring Exerci.e. When performing exercises in weight-bearing, the following important points should be reviewed: 1. Place only the amount of weight on your leg as allowed. This may be only part of your body weight. 2. Be sure that your knee is at the correct angle, as directed by your clinician. 3. Avoid hyperextending your knee (bending it

backward).

4. Keep your knee in line with your toes and your hips. Avoid letting your knees uroll in" (i.e., being "knock­ kneed"). 5. Tighten your buttocks muscles together, and use the muscles in the front of your thigh, as directed by your clinician. 6. Hold each exercise for the amount of time specified by your clinician. Be sure to breathe in and out slowly while performing each exercise.

Running, cutting, jumping, and sports skill activities CaI' help el1Sure a safe return to sporting activities (Fig. 21-20 A running program or sport-specific drills may be used te test readiness to return to play. Completion of an appro­ priate functional progression can ensure a safe return tf sports. Although this program does not need to be und the direct supervision of th e physical therapist, it should b constructed with and guided by th e clinician in conjunctio ,-,vith the patient. Any deficits in movement patterns shoul, have been corrected by the clinician in tJ1e earlier therap stages and should not be an issue at the functional proe:re-­ sion stage.

Fractures Knee fractures can involve the patella, distal femur, orpro· ­ imal tibia. These fractures generally occur as a result trauma such as a fall or motor vehide accident but can ah result from osteoporosis. Th e rehabilitation issues associated with knee fractuTt include the effects of the original trauma, surgical proc dures, and immobilization. A trauma Significant enough fracture a bone al.so causes substantial soft-tissue damal!:' which is frequently overlooked. D amage to articular cart lage and fractures extending through the articular cartila:_ to the joint surface have the potential to affect the lon'.. ~ term health of the joint, and these issues should be consi, ­ ered in the rehabilitation program.

Patellar Fractures

Correct

Incorrect

weight as resistance in the form of wall slides, squats, lunges, and step-ups is convenient and cost-effective (see Patient-Related Instruction 21-1). The final phase of rehabilitation helps return the patient to his or her premorbid level of function in ADLs, work, or recreation. Because the activity level and functional goals are different for each patient, the rehabilitation program must be tailored to individual needs. For the individual returning to sedentary work and recreational walking, dis­ charge to an independe nt program may be considered af­ ter motion, strength , endura ncc , and impairments and function al lillJitations have heen llormalized. The patient should de monstrate a thorough understanding of the home manage men t of impairments, includ.ing infJammation, pain, NOM, and strength. F or individuals returning to a higl1Pr level of physical functioning, such as physical labor or sports activities, reconditioning to that level is necessary. T his may require advanced work-related activities such as lifting, pushing, pulling, and carrying objects over uneven surfaces. A functional capacity evaluation may be per­ formed to determine restrictions or precautions affecting a return to work.

Patellar fractures account for approximately 1% of skeletal injuries and occur most fre~uently in persons tween the ages of 40 and 50 years. 4 Falls account for greatest percentage of patellar fractures, followed by 1110 vehicle accidents. Fractures can occur as a result of a fo ful quadriceps contraction. Traumatic fractures us ual produce comminuted fractures , whereas forceful quadr­ ceps contraction cause transverse fractures. However, tl degree of knee flexion , the y atient's age , presence of teoporosis, and the velOCity 0 injury can affect the type location of fracture. 46 Treatment of patellar fractures can be conservative \\­ immobilization and rehabilitation , or surgical, such as op reduction with internal fixation (ORIF) or partial pateU tomy. Because of the morbidity associated with imm lization, ORIF is often the treatment of choice for me. cally sound candidates. A transverse fracture is distract, by quadriceps activation and is best treated by fixatic Tension cerclage wiring is frequently used , paliicularh com minuted and transverse fractures. Because of th e " perficial nature of the patella, the hardware is frequen removed after h ealing is ensured. Oc casionally. a sm fragment or fragm ents are removed rather than fixat (i.e., partial patellectomy). The prognOSis after patel! fracture is good if patellofemoral pain, muscular atropL and loss of motion are add ressed. These impairments oec regardless of treatment method. \"'itb conservative III agem ent , the clinician must also be aware of th e effects immobilization on the soft tissues .

Chapter 21. The Knee

507

FIGURE 21·20. (A) Lateral crossover run ning in the late stage of reh abilitation. (8) slide board la tera l movements.

Jistal Femur Fractures Distal femur fractures are the co nsequence of trauma in ost cases, although spiral fractures may occur in the el­ rly as the result of a twistin injury. Associated frac:tmes Me common and include the patella, tibial plateau, foot, an­ kle, and hip. Distal femur fractures can be classified as pure up racondylar, supracondylar and intercondylar, or Illono­ '(mdylur, each \\ith subclassifications .4G fractures through ~e growth plate occur in children and adolescents amI are ·lassifled as Salter types I through V.47 Treatment of distal femur fractures is categorized as nservative or surgical. ! ondisplaced, minimally dis­ placed, stable, or impacted fractures or frac:tures in indi­ iduals who are not suraical candidat s mav, be treated with n mmobilization. Because of the morbidity
Tibial Plateau Fractures Tibial plateau fractures occur almost l'xcillsively as the re­ sult of trauma such as mutor vehicle accidents, pedestrians hit by cars, accidental falls, or twists or dircc:t blows to the knee . Fractures are produced by a varus , valgus, or com­ pressive force, resulting in lateral plateau, medial plateau , or bIcondylar fractures. Tibial plateau fractmes are classi­ fied morphologically:46 1. Split fracture , in which the margin of the tibial plateau is separated from the rest of the plateau

2. Compression fracture , in which the subchondral bone is crushed but the margins are spared 3. Combination split-compression fradme Compression fractures an' the most difficult to diagnose, because the depressed fragments are often missed on stan­ dard radiographs. These fractures also are the most difficult to treat, because adequate reduction requires the elevation and stabilization of depressed fragments. Compression frac­ tu re are seen most commonly after falls from heights and 111 elderly mdIviduals with osteoporosis. T rea tment of tibi~l plateau fractures depends on the locatIon and type of tractme. Compression hactures \-vith depressed fragments require surgical elevation and stabi­ lization of the fragments. Thes fragments usually are supported WIth bOI1t' grafts, and split fractures are stabi­ lized with screws, wires, or plates and lag screws. Conser­ vative manage ment with or without traction and immobi­ lization. is an option that m ust be consid red in light of the deletel'lolIs effec:ts of immobilization . Postoperative or postllnmohilizahon rehabilitation depends on the numer­ ous factors outlined previously.

Treatment of Fractures Treatment programs for individuals \-vith fractures at the knee may begin early after the fracture or after healing has taken place. Persons with fractures surgically fixated generally begin mobility and strengthening exercises soon after the operation (see Self-Management 21-6). Active and passive ROM for flexion and extension an d functional mobility exercises for the entire kinetic chain are initiated early. Quadriceps setting and hamstring setting exercises are statted early to retrain these muscle groups. When pen11ltted, closed chain weight-bearing exe rcises should be initiated. even if only partially weight bearing (see Pa­ tient-Related Instruction 21-2). This \vill be determined

508

Therapeutic Exerci se: Moving Toward Function

SELF-MANAGEMENT 2'-6 Straight-Leg

Raises

Purpose:

To increase the strength ofthe quadriceps and hip flexor muscles and to improve control of the knee

Position:

lying on your back, with your opposite knee bent and foot flat on the floor; stomach muscles are tightened

Movement

technique: This is a four-step process.

1. Perform a quadriceps set, tightening the quadriceps muscles. 2. Slowly raise the leg until it is even with the opposite thigh . 3. Slowly lower the leg back to the floor. 4. Relax the quadriceps set. Be sure to relax the quadriceps muscle between each repetition.

joint arthrokinematics; the deeper major fiber orientation is circumferential. The menisci receive their blood supply from the medial and lateral superior and inferior geniCU­ late arteries and have variable vascularity. The vascular supply penetrates 10% to 30% of the width of the medial meniscus and 10% to 2.5% of the \vidth of the lateral meniscus. The pelipheral one third is often cal led the red zone, the middle one third is the red-white zone, and the central one third is the white (avascular) zone. The menis­ cus receives its nutIition by diffusion, and it has a low metabolic rate and a low reparative response. Repair of the meniscus considers this low reparative response and often uses the peripheral blood supply to assist the heal­ ing process. The menisci have many functions, UllderscOling the importance of maintaining their structure. In addition to enhancing jOint congruity and stability, the menisci also function to transmit load across the knee jOint, with ap­ proxim ately 40% to .50% of the compressive load tran s­ mitted through the meniscus in full extension and 8.5% at 90 degrees of f1exion 1 6AlJ Partial meniscectomy with a

Dosage Repetitions: Frequency _ _ _ _ __

Walking With Crutches

by the physician based on the fracture site and healing, as \Nell as by the patient's ability to control the knee . Before beginnillg any weight bearing exercise, the patient should demonstrate a good quadriceps set and the ability to dy­ namically control the knee . These activities can enhance articular cartilage nutrition throughout the kinetic chain and prOvide a stimulus for muscle activation. An exercise bicycle with little or no resistance can enhance nutrition and muscle activity in the area while improving mobility. Pool exercise is excellent for the individual with a knee fracture. Weight bearing may be limited while muscle acti­ vation and mobility exercises are performed with assistance from buoyancy. Passive motion assisted by buoyancy or ac­ tive motion can improve ROy! about the knee (Fig. 21-21 ). Gait can be normalized with or 'vvithout railing assistance.

Meniscallnjuries The menisci were Oliginally thought to be useless remains of leg I1lllScles.
When walking with crutches and some of your weight on the involved knee, several guidelines should be followed: 1. Make sure your weight is on your hands, not under

your arms. Your arms should be slightly bent when

your crutches fit properly.

2. When walking. place your crutches out first. followed

by your involved leg and then your uninvolved leg.

3. Place your involved heel down first, let your knee bend

slightly, and allow your foot to roll toward your toes as

you begin to bring your uninvolved leg forward.

4. As you bring your uninvolved foot through, bend your

involved knee, and pick it up behind you. Straighten

the involved knee as you bring it past your crutches to

place it on the floor in front of you. Your knee should

be straight just before your heel contacts the ground.

5. When using a single crutch, be sure to use it on the

side opposite your injured knee.

B. Check with your clinician to ensure that your gait with

crutches is correct.

~

Ij

Chapter 21. The Knee

FIGURE 21·21. Buoyancy-assisted knee flexion using a buoyant strap. The return motion (to extension) is buoyancy resisted, eliciting a concen­ :ric quadriceps muscle contraction.

10% decrease in contact area increases peak local stresses b, 65%, whereas total meniscectomy decreases the con­ tact area by 75% and increases peak local stresses by ~3 5(!r.so Total meniscectomy is no longer routinely per­ rormed because of the Fairbanks changes seen postoper­ . tively. These changes include marginal femoral osteo­ phyte ridging, flattening of the ~lleclial femoral condyle, and narrowing of the joint space:)] The menisci also work as shock absorbers, although the suhchondral bone is the main static shock absorber at the kllee. Some of the most important fUllctions of the menisci are joint lubrication an d articular cartilage nutrition. The biphasic properties of the meniscus assist in providing a lubricant film across the joint surface vvith loading and unloading of the kne 4 8 The meniscus is most often injured traumatically, al­ though degenerative tears are also common. Traumatic tears usually occur in individuals between the ages of 13 and -w who are involved in physical activities or in those who sustain trauma in a fall or motor vehicle accident. Degener­ ative tears occur vvith increasing frequency with advancing age and are often complex tears. A degenerative tear can be precipitated by a specific stress, although it may seem to be minor, such as turning to walk a different direction.

Treatment Degenerative tears associated with articular cartilage le­ sions often require surgery to remove loose fragments and to stimulate a healing response in the articular CaIiilage. Acute traumatic tears may heal vvithout intervention if the tear is longitudinal and periphe~al, Some tears may not heal but remain asymptomatic,::>2 Tears producing me­ chanical symptoms such as catching, locking, and effusion are treated by partial meniscectomy or by meniscal repair, The treatment of choice depends on the type and location

509

of the tear and on the associated injuries. For example, a meniscal repair in the posterior horn of the medial menis­ cus in an ACL-deficient knee does not heal well. How­ ever, if the ACL is reconstructed Simultaneously, the meniscal repair has an opportunity to heal if prOVided a blood supply, Complex degenerative tears are nearly im­ possible to repair and probably will fail in the presence of articular cartilage degeneration. The interventions chosen for patients vvith paliial menis­ cectomy correlate with the changes in load distribution and increases in peak local stresses associated with this proce­ dure. The knee has been distributing and dispersing loads during normal activities based on the patient's anatomy for many years. Suddenly, the load distribution is changed, and other structures must shoulder the burden of the load pre­ viously carried by the intact meniscus. The joint's ability to adapt to this change in loading pattern depends on many factors, including lower extremity alignment, quadriceps function, comorbidities, and the response to the stresses placed on it (i.e., Wolffs law). The body must have time to adapt to the changing loading pattern, and although some individuals adapt quickly, others may develop symptoms of overload such as inflammation, c[fusion, or pain Anyactiv­ ity that produces significant shear forces with compressive loading (e.g., squatting, steps) may overwhelm the load­ bearing capabilities in some knees. Individuals with subop­ timal alignment, degenerative joint discase, poor quach'i­ ceps function or neuromuscular control, or limited ROM probably will have the most difficulty. Issues associated vvith meniscal repair are related to the normal meniscal motion during knee flexion and extension, the shear forces across the repair, and the location and type of tear repaired. The meniscus moves posteriorly up to 12 111m during knee extension to flexion, vvith most motion oc­ currin~ between 0 and 15 degrees and beyond 4,5 de­ grees. ),53 Although motion up to 80 to 90 degrees is per­ mitted in the carly phase actively and passively, weight-bearing activities through a large range should be avoided. Early partial weight bearing or weight bearing as tolerated is often permitted depending on the tear size, type, and location. The knee goes through a limited ROM in a weight-bearing position during normal gait. Repairs in the white zone, repairs vvith additional vascular access, or repairs of complex or radial tears are protected longer, and progression is dictated by the procedure.

DEGENERATIVE ARTHRITIS PROBLEMS Articular Cartilage Lesions Articular cartilage is a unique tissue that has remarkable propeliies, including an ability to be deformed and regain its Oliginal shape, except~onal durability, and an unparal­ leled low-hiction surface ,::>4 These are just a few of the prop­ erties that make articular caliilage so difficult to reproduce. Despite the prevalence of artificial joint replacements, the average life of an artificial joint is much shorter than that of native articular cartilage. This comparison highlights the unique characteristics of this material, which functions op­ timally in the presence of adequate ROM, joint stability, and an equitable load distribution 4 'l

510

Therapeutic Exercise Moving Toward Function

Articular cartilage is compo~e?_primarily of water, type II collagen, and proteoglycans:,4,;),) Water is approximately 60% to 85% of the weight of articular cartilage and is re­ sponsible for its biphasic properties 48 ,51 ,55 The water con­ tent decreases with age, increasing the stiffness and defor­ mation of cartilage and decreasing its biphasic material properties, This decrease contributes to the changes seen in the normal aging process, Every jOint has its own pattern or "footprint" on the surface, reflecting the specific shear forces across that joint.<s The articular cartilage rn adults receives its nutrition by diffusion , and the cartilage in chil­ dren receives ~ome nutrition from the underlying sub­ chondral bone:?5 Articular cartilage responds to loads in a time-depen­ dent manner like any other viscoelastic material; it creeps under a constant applied load and relaxes under a constant deformation, When an external load is applied to the carti­ lage surface, an instantaneous deformation occurs, and ap­ prOximately 70% of the water within the cartilage may be moved until the compressive stress \vithin the articular car­ tilage matches the applied stress, and equilibrium is reached, Stress and relaxation also occur, depending on the length of time the cartilage is loaded, Cartilage also in­ creases the congruity of the surfaces, distributing loads over a greater surface area. 54 The ability to withstand com­ pressive loads (based on these properties) vari_~s from jOint to joint and within the same articular surface,;» From a mechanical perspective, the requirements for a healthy jOint include freedom of motion, stability, and an equitable load distribution. 48 These necessities form the basis for some of the treatments for articular caltiJage le­ sions. Adequate lower extremity strength to absorb loads dUling the loading response of the gait cycle, and normal movement patterns help minimize excessive loads on the articular cartilage. Partial-thich"Tless articular cartilage le­ sions in adults do not heal, but they may not get any worse in a joint with freedom of motion , stability, and an equi­ table load distribution, However, in an ACL-deficient knee or a knee with a significant varus alignment, the lesion may progress to become a full-thickness lesion. When this le­ sion degrades far enough, bleeding occurs , and the healing process begins. This is the rationale for abrasion arthro­ plasty, in which ali alticular cartilage lesion is treated with perforations, drilling, or "punctating" th e underlying bone to stimulate a healing response. However, the replacement tissue is fibrocartilage, which is a lesser quality tissue than the original articular cartilage, The fibrocartilage may be adequate in the presence of adequate motion , jOint stabil­ ity, and equitable load distribution. The rehabilitation program must consider tl1e fundamen­ tal requirements for a healthy jOint when determining the appropriate mode and progression of tl1erapeutic exercise. Activities that minimize shearing forces while increasing sta­ bili!:)! and mobility provide the foundation for the therapeu­ tic exercise program (see Patient-Related Instruction 21-3),

Surgical Procedures Several surgical procedures are used to improve function in patients with articular cartilage lesions, They can be classi­ fied as marrow stimulation techniques, resUlfacing proce-

~e·

rep Tips to Maintain the Long-Term Health of Your Knee The following tips can help you maintain the long-term health of your knee: 1. Maintain the mobility of your knee. With your clinician's help, choose a couple of simple exercises to be done daily to maintain your ability to fully bend and straighten your knee. 2. Keep the muscles around your knee strong, especially the muscles in the front of your thigh and your hip muscles. With your clinician's help, choose a couple of simple exercises to be done daily to maintain the strength of your leg. 3. Maintain a healthy body weight. 4. Wear good supportive shoes that provide some shock absorption. 5. Use a supportive device (e,g., cane, crutch) when walking long distances.

dures, realignment procedures, and arthroplasty. The n row stimulation techniques lise bleeding at tl1e jOint surf in an attempt to initiate a healing response. Abrasion arth plasty, drilling, and microfractures arc all techniques to sti: ulate bleeding and initiate healing. These procedures reI in the deposition of fibrocartilage , which mechanically d: not withstand the test of time. It may prOvide some tel rary relief until the fibrocartilage fails. ResUlfacing prl dures include techniques such as osteoarticular transp and autologous chondrocytes implantation. Discussior. these procedures can be found in Chapter 11.

Osteotomy The high tibial osteotomy or tibial varus osteotomy i formed in cases of unicompartmental osteoarthriti varus alignment; the supracondylar (femoral ) ostcoto used to treat ynicompartmental osteoarthritis and \ _ _ alignm e nt. 56 .51 The rationale behind high tibial osteo for varus alignment is that the alignment excessiveh' 1 the medial t!biofemoral compartment, which promot teoarthritis.;)!i Conversely, the valgus alignment load lateral tibiofemoral compartment, leading to subcho' sclerosis, loss of caliilage space, and osteophyte for m• .which is indicative of osteoarthritis. The tibial osteoto:

t

IiI

Fo

pro

Chapter 21 · The Knee

aenerally performed on patients wishing to delay total joint replacement. Despite the short-term success of tibial os­ teotomy, most results can be expected to deteriorate over ti rne.·~g

The technique of tibial osteotomy includes making a wedge cut in the tibia at least 1.5 crn distal to the joint line. For a varus alignment, the lateral osteotomy is inclined rne­ ially and distally, and the tibia is fixated with hardware. A fi bular osteotomy is performed as well. The results of this procedure depend on proper patie nt selection, accurate measurements, and adel[uate correction. Patients who are poor candidates for this procedure include those with tri­ w mpartmental degeneration, Significant ligamentous lax:­ it)', or markedly restricted motion 60 Correction of varus deformities to at least 5 degrees of valgus produce the best r sultS. 51 - 53 Two-plateau weight bearing is the ultimate goal, and excessive bone loss , inaccurate measurements, or inadequate correction can interfere with achieving this !Toal. Patients with preoperative low adduction moment at the knee maintained better clinical results that those with high adduction moment, suggesting that adaptive gait me­ chanics playa role in outcome 6 4 Complications include in­ fection, nonunion, patella baja, infrapatellar scarring, per­ oneal nerve palsy, and lateral ligament laxity. Rehabilitation after tibial osteotomy is guided by the re­ q uirements for a healthy jOint and the sudden change in loading patterns across the joint. The change in weight­ bearing distribution may overload a previously under­ loaded compaltment. The bony and soft tissues need ade­ quate time to remodel and adapt to the change. How well the tissues adapt vaJies Significantly from individual to in­ dividual , accounting for the variation in intervention choices, treatment frequency, and treatment duration . Restoration of normal ROM is esse ntial to ensure distribu­ tion of loads over as large a range as possible. Normaliza­ tion of movement patterns to minimize impact loads and excessive compartmental loading can prolong the life of the osteotomy. Quadriceps strengthening for shock absorption during the loading response of th e gait cycle can minimize loads on the articular cartilage and subchondral bone.

Total Knee Arthroplasty Individuals with significant bicompartmental (medial and lateral) or tricompartmental (med.ial, lateral, and anterior) osteoarthritis and associated impairments, functionallimi­ tations, and disability are candidates for total knee althro­ plasty (TKA). These individuals may have undergone pre­ vious osteotomies that subsequently deteriorated and may present with impairments such as pain, joint instability, or loss of motion. Pain is one of the chief indications for TKA; stahility, bone integrity, and age are additional considera­ tions . Patients generally seek medical attention when the pain becomes disabling, affecting th eir ability to participate in community, work, leisure, or basic ADLs. The materials and techniques used in TKA have advanced significantly, thereby increasing the patient pool, minimizing complica­ tions, and decreaSing disability. The prostheses used are classified in many ways, includ­ ing the number of compartments replaced (i,e., unicom­ partmental, bicompartmental, or tricompartmental), the degree of constraint (i.e. , unconstrained, partially con-

511

strained, or fully constrained), and the type of fixation (i.e., cemented, cementless, or hybrid). The prosthesis choice depends on the status of the bone and any soft-tissue defor­ mities (e.g. , I1gament laxity, absence of PCL). Most pros­ theses are tricompartmental and partially constrained 'v\lith hybrid fixation. Hybrid fixation usually includes a cemented tibial component and cementless femoral component. The design can presume that the PCL is intact (PCL retention) or absent (PCL substitution/posterior stabilized) . Other prostheses are used in speCial cases, and this information should be obtained before initiating treatment. Each design has its strengths and weaknesses and should be matched to the speCific needs of the patient. Ce­ mented fixation allows for earlier weight-bearing than bio­ logiC ingrowth, but loosening at the bone-cement interface has been a problem. The uncemented femoral component decreases operative time , reduces polyethylene wear from cement debris, and avoids an adverse reaction to the mate­ rials, but is more costly and requires a more precise fit. The tibial component is the most problematic in both cemented and uncemented deSigns, with difficulty achieving fixation resulting in micromotion and failure. SpeCific design fea­ tures are incorporated to assist in balanCing soft tissues in three planes to avoid instability problems . Complications ofTKA include loosening, infection, per­ oneal nerve palsy, patellar instability, fracture, instability, and osteolysis. Bone ingrowth is negatively affected by non­ steroidal anti-inflammatory medication and oophorectomy. Other complications include polyethyle ne wear reactions, 'vvith pain, effusion, and loss of motion developing about 5 years after surgery. Most complications are on the medial side, and the component may sink into the tibia on the me­ dial side. Several factors affect the rehabilitation approach after TKA. The type of prosthesis provides an indication of the underlying stability, bone quality, and ultimately the prog­ nosis. Fixation choice also affects rehabilitation, with non­ cemented components protected longer to allow biolOgiC ingrowth. Patellar instability is a proble m in 5% to 30% of TKAs, and the clinician should be alert to signs of patellar subluxation or dislocation. 65 Ligamentous stability, partic­ ularly varus and valgus stability, should be assessed after TKA. Most prosthetic deSigns ass ume that no ACL exists and that the PCL is variably intact. The medial and lateral ligaments and joint capsule prOvide most of the stability. The overall status of the patient's condition and the lower extremity can affect rehabilitation. Individuals with os­ teoarthritis at the knee may have concurrent changes in other lower extremity joints. Limitations in ROM at the hip and ankle can affect the function and prognOSiS at the knee. It is reasonable to attempt knee flexion ROM from 0 to 120 degrees or more. Patients with less than 120 degrees of flexion after TKA use compensatory movements of the hip, trunk, and ankle during daily activities. 66

Interventions for Degenerative Arthritis Problems Interventions used by physical therapists should address the impairments, functional limitations , and disabilities identified during the initial and subsequent evaluations.

512

Therapeutic Exercise: Moving Toward Function

Impairments should he treated if they are associated with a functional limitation or disability or if continued impair­ ment could lead to disability in the future . For example , limited ROM after abrasion arthroplasty may not be iJlJ­ mediately disahling, but it could lead to future functional limitations or disability by overloading focal areas of ulticu­ lar cartilage or by damaging other joints bt>cause of com­ pensatory movements. Individuals with articular cartilage damage cannot expect to be cured of their problem , but they must learn to manage their symptoms and maintain the long-term health of their joint. Individuals with jOint surface damage must demonstrate all understanding of the home managemcnt of impairments , including inflamma­ tion, pain, and mobility and streugth loss. After surgery, physical the rapy interventions are gener­ ally aimed at the immediate impairme nts of pain, effUSion, and loss of motion and neuromuscular control. Physical ageuts, mechanical and electrotherapeutic modalities, and gentle' mobility can minimize pain and facilitate resorption of an effusion. Therapeutic exercise in the form of active and passive motion, phYSiologic stretching, or jOint mobilization facilitate normal osteokinematics and althrokinematics. Af­ ter the surgical incisions are healed or with the use of a bio­ clusive dreSSing, many of these impairments can be treated in the pool. The hydrostatic pressure of the water minimizes effusion, al1d the water's buoyancy limits weight-bearing to a comfOltahle level. If progressive loading of the joint surface is the goal, gradually de~reasing the water's depth can slowly increase thE' joint load. Isometric setting exercises for the quadliceps, hamsttings , and gluteal muscfes help re-educate these muscles while facibtating circulation. In the subacute phase, rehabilitation continues to focus on residual impairments, functional limitations, and dis­ ahilities identified during reexamination. Ambulation training and progn'ssive weight-bearing advance according to the specific injury and therapeutic procedure. The reha­ bilitation should continue to focus on restoring full mobil­ ity, normalizing gait, and re-establishing full function to the individual. Mobility activities should emphasize activities that enhance alticular cartilage nutrition, such as gen tle ac­ tive and passive ROM or compressive loading and unload­ ing. Combining th ese two modes should be approached with caution to avoid ove rloading developing or remodel­ ing fibrocartilage or articular cartilage. Closed kinetic chain exercises with Significant \vpight-bearing through a ROM should be incorporated judiciously (Fig. 21-22). Strength­ ening exe rcises must respect the changes in loading pat­ te rns afte r some surgical procedures. Eccentric strength­ ening of the quadriceps and gluteals facilitates shock absorption during the loadillg response phase of gait, stair and incline descent, and lowe ring into a chair. Strengthen­ ing can be initiated in an open kinetic chain and progressed to a closed kin e tic chain as the joint allows. Similar exer­ cis es must be performed on a daily basis as palt of the home exe rcise program to continue the advances made in the clinic. The final rehabilitation phase emphasizes return to the previous activity level Or higher. For the individual under­ going a tibial osteoto m~1 the expectation is return to a higher le\'e1 of function because of a decrease in p ai n . Each person should be pro\ided \\ith a functional retraining pro-

FIGURE 21 ·22. Squats are performed in the pool to increase flexion a _ range of motion with minimal weight bearing

gram tailored to the activities to which he or she will be ft"­ turning. Moreover, the importance of continuing an exer­ cise program incorporating activities to maintain the lon _­ term health of the joint must be elllphasiz D emonstration of the ability to home manage an exacerl tion of symptoms is fundamental to safe and cost-effecti long-term management of articular cartilage lesions. P tient education to manage lifestyle factors such as walh. distances, floor surfaces, time spent standing, maintenar of appropriate body weight, shoe wear, and use of assi devices is also a critical intervention.

TENDINOPATHIES Tendinopathies about the knee occur most frequently in t1 patellar tendon but can also be found in the hamstrin g ter ­ dons and pes anserine tendon. Iliotibial band friction S~T­ drome can be considered a type of te ndinopathy. Althou!!. tendinopathies can result from an acute injur)" they usual! are caused by microtrauma or overuse. Repetitive loadin.:. without adequate recoH:ry time prev('nts the normal adap­ tations to occur. Although Single loads do not exceed tl strength of the tendon , the cumulative loads exceed tl reparative capabilities. Intrinsic factors contributing tendinopathies include Illalalignm ent limh le ngth di screp­ ancies. and muscular imbalance or insuffiCiency. Extrin factors include training errors , surfaces, environm ental cor ­ ditions, and foot\.year.6~

Patellar Tendinopathy Patellar tendinopathy occurs at the distal pole of patella, and is distinct fro m Sinding-Lacsen-Johanss disease. which is apophysitis n[ llic: 6::.:J patellar pole

Chapter 21: The Knee

nd from Osgood-Schlatter disease, which is apophysitis at the tibial tubercle. Both of these syndromes occur in adolescents before closure of the growth plates. Patellar tendinopathy has also been called jumper's knee because of its high prevalence in jumping and impact sports. The eccentric nature of jumping places tremendous loads on the patellar tendon, often resulting in overuse. The patel­ lar tendon attaches one of the strongest muscles in the body, the quadriceps femoris, to its insertion using the patella as a "balance." The loads generated by the quadri­ ceps mechanism are transmitted through the tendon to its bony attachments. Areas of increased stress such as tran­ itional zones are susceptible to overuse. In the adult with d osed epiphyses, the transition zone on the undersurface f the patella's distal pole is the most vulnerable area. Tenclinopathies of the patellar tendon can take various fo rms. All tendinopathies tend to demonstrate a normal macroscopic appearance without any gross degeneration of the tendon, but microscopic abnorm<.llities at the bone-ten­ don junction most always exist. 58 Necrosis and fragmented tissues ,vith mucoid degeneration usually involve the deep central fibers at the tendinous inseliion and can be pal­ pated at the undersurface of the patella'S distal pole 69 Individuals with patellar tendinopathies present with \ rious degrees of impairments, functional limitations, and disabilities. The person often reports a history of pain and tiffness in the anterior knee that improves as the knee is warmed, gets sore as the activity continues, and gets stiff and sore after completion of the activity. Point tenderness experienced on the undersurface of the distal pole of the patella and is best palpated by tipping the inferior border anteriorly to allow access to the undersurface. Functional limitations may include abnormal walking or running gait, pain ,\lith jumping or kneeling, or pain when ascending and descending stairs. Disabilities can include an inability to partiCipate in community, work, or leisure activities, de­ pending on t~e individual's lifestyle and functionallimita­ bons. Blazina' U categorized patellar tendinitis in athletes in four stages, based on the pain history (Display 21-4). Poor postural habit, such as standing with the knees hyperex­ tended, can contribute to patellar tendinitis because of a shortening of the quadriceps and patellar tendon.

Treatment Rehabilitation for the individual with patellar tendinopathies focuses on the patellar tendon's role in decelerating knee flexion in gait, jumping, descending stairs, and many other

513

functional activities. The role of tendon length and speed relative to deceleration activities forms the foundation for the rehabilitation program. Stretching exercises to ensure adequate tendol1 length are combined with eccentric quadriceps contractions of progreSSively increasing velOCity up to the speeds used in daily activiUes. Before an individual can perform an eccent,ric muscle contraction, he or she must be able to preset isometric tension in the muscle. The reha­ bilitation program may begin with isometric contractions be­ fore progressing to eccentric contractions. Eccentric con­ tractions can be performed in an open or a closed chain, recognizing that substitution may occur in a closed chain ex­ ercise. Hmvever, this may provide enough assistance to the injured tendon to allow pain-free exercise performance. To create an optimal healing environment, adjuncts to the ther­ apeutic exercise program are used and typically include forms of cryotherapy. Deep·heat modalities should be used judiciously in highly active individuals, because simple ADLs can perpetuate an acute inflammation. Postura! retraining should be incorporated with appropliate patellar mobi1iza­ tion and soft tissue stretching. The 100w-term prognOSiS for this problem in male athletes is only fair. A IS-year prospec­ tive study found that S3% of these athletes had quit sports because of this problem 71

Iliotibial Band Syndrome Iliotibial band syndrome is a common cause of lateral knee pain in individuals who regularly jog, bicycle, or walk for exercise. Postural problems such as anterior pelvic tilt or knee hyperextension along with poor mechanics such as decreased gluteus medius or VMO activity can be pre­ disposing factors. These factors should be identified dur­ ing the examination process to ensure comprehensive treatment. The individual presenting with iliotibial band syndrome often complains of a sharp, stabbing pain at the lateral epi­ condyle that begins with the onset of activity and worsens as the activity progresses. Palpable tenderness over the lat­ eral epicondyle can confirm the diagnosis. Predisposing factors such as poor postural habits or muscle imbalance should be identified during the examination. Hamstring, gluteal, quadriceps, and iliotibial band flexibility should be assessed. Any impairments or functional limitations identi­ fied during the examination should form the basis for the rehabilitation program. In many cases, a combination of predisposing factors, activity choices, and impairments converge to produce iliotibial band syndrome.

DISPLAV 21-4

Treatment

The Blazina Classification for Functional Limitations Associated With Patellar Tendinitis

Rehabilitation focuses on the identification and treatment of predisposing factors, impairments, and functionallimita­ tions. Patient education regarding these factors and consci­ entious participation in self-managing this problem con­ tribute to a successful outcome. Postural education and identification of the underlying impairments (e.g., hip rota­ tor weakness) prOVide the foundation for appropriate stretching or strengthening exercises. Stretching for the hip and knee musculature with emphasis on good posture is the mainstay of treatment. These stretches may be performed on land or in the pool (see Figs. 21-7 through 21-10).

Stage 1: Pain after sports activity Stllge 2: Pain at the beginning of sports activity, disappearing with warm-up and sometimes reappearing with fatigue Stage 3: Pain at rest and during activity; inability to participate in sports Stage 4; Rupture of the patellar tendon Blazina ME, Kerlan RK Jobe FW Jumper's knee. Orthop Clin North Am 1973.4.665-678.

514

Therapeutic Exercise: Moving Toward Function

Iontophoresis and ice may be used to treat pain and inflam­ mation associated with this problem,

PATELLOFEMORAL PAIN SYNDROME The typical patient -vith patellofemoral pain syndrome (PFPS) is a young female v~ho complains of pain iJl the anterior aspect of the knee,12 The pain is aggravated by knee extension activities such as ascending or descending stairs, squatting, rising from a chair, or ju mping. Several intelventiolls for PFPS have gained Widespread accep­ tance in the clinical community, including general and specific hip and knee strengthening using both op,m and closed kinetic chain exercises, prOViding surface EM G biofeedback, stretching, acupullcture, low-level laser, patellar mohilization, corrective foot orthoses, patellar taping, and external patellar bracing,73.7'J Unfortunately, experimental evidence to support the use of many of these approaches is lacking, and clinicians are left with anecdotal information as the basis for treatment. An un­ derstanding of what is known about the efficacy of various interventions , whe re the research lags behind clinical practice, and a thorough understanding of the etiology of the condition should gUide the intelligent choice of man­ agement strategies for the patient vvith PFPS.

Etiology The causes of PFPS can range from suhluxation and dislo­ cation to patellar malalignm ent. Frank dislo cation resulting from a blow to the kn ee is eaSily determined through his­ tOlY. Recurrent subluxation is suggested when the patient reports that his or her knee gives way, usuallywben the knee is partially flexed in weight-bearing. T his shou ld be associ­ ated vvith hypemlObility of the patella, tenderness of both the patellar borders and femoral condyles, and radiographic evidence of a shallow intercondylar groove, Other cauSes of knee buckling (e,g., ligame nt tears ) should be ruled out. Overuse is another causative factor to be considered, Not all pati~~ts ,:vi.th PFP demonstrate lateral subluxation or tracking, This suggests that other reasons must exist , and one should look for an increase in usage patterns asso­ ciated vvith the onset of the anterior knee pain, Again, the patient's history vvill provide the clues, vvith repetitive work or recreational activities that stress th e knee being key fac­ tors, such as an increase in running distance, an increase in workload demands, or a change in shoe wear. It is gen erally accepted that PFPS results from a cascade of events. Poor alignm en t of the patella in the trochlear groove, typically with the patella tracking laterally, results in poor distribu tion of the patellofemoral jOint re~ction forces (PFJRF ) on the posterior aspect of the patella, 16 The patellofemoral joint reaction forc e is the amount of pres­ sure on the joint surfaces of the patellofemoral joint, and is a fun ction of the flexion angle of the kn ee and the amount of te nsion developed by th e quadricep s nl11scle . As the knee flexe s and as the quadriceps become more active, the PFJRF increase, Under normal circumstances the pressure is distributed to both the medial and lateral facets, and with near end-range flexion , to the odd facet. When th e patella tracks poorly, the PFJRF will be cOl1cen trated into a (0

smaller contact area, resulting in increased shear on the ar­ ticular surfaces, le ~9~n g to ti ss ue breakdown, pain, and im­ paired function , {oJ,II ,18 The possible causes of patellar malalignment are gener­ ally separated into two basic eategOlies, The first includes problems ,\ith the static structures sllch as the shape of the osseous surfaces or length of the fascia. The second catego~· of patellar malalignrnent etiology includes issues related to the dynamic stlUctures about the knee, In particular, there has been much discussion about the role of the vastus medi­ alis longus (VML), YMO, and the VL muscles' [unction in the development ofPF PS. The thought is that an imbalance in th e amollnt of pull or the timing of the contraction of the muscles \vill either cause or allow the pateIla to track late r­ ally in the trochlear groove and produce a concentration of force to the retropatellar surface, In addition, poor align­ ment of the knee resulting from hip, foot, or ankle dysfunc­ tion can cause a change in the angle of pull of these muscl and lead to altered patellar tracking, As the discussion that follows suggests, there is a lack of consensus in the research literature with regard to the etiology of PFPS , although re­ search contin ues, In the meantime, clinical experience and outcome studies demonstrate the effectiveness of consen'a­ tive trcat.ment for this disorder, although the relative effec­ tiveness of any individual intervention has yet to be shown,

'T

Static Structures It has been reported that Q-angle appears to discri mi­ nate between runners vvith and Without PFPS 79 The Q-an­ gle is form ed by a line drawn from the anterior superior il­ iac spine to the middle of the patella, and from the middle of the patella to the tibial tuherosity, A greater Q-angle ~ thought to be associated with increased lateral forces on th< patella and therefore associated \vith lateral patellar track­ ing, Increased gen u valgus, internal rotation of the fe mU!' relative to the tibia, and a wide pelviS all increase the Q­ angle. Although the latter cannot be changed, hip rotatio[ and genu valgus can both be influenced by hip, foot, and an­ kle mechanics, This underscores the need for the who. lower kinetic chain to be evaluated in the patientvvith PFP Usin a kinematic magnetic resonance imaging (MRI P owers8rl.'ll found that there was a difference in the dep of the trochl ear groove between young women vvith aD~ v-rithout PFP, Su bjects ,~rith a shallower trochlear groO\' had a laterally tilted patella in terminal extension (30 to degrees ) and a laterally displaced patella in the last 9 de­ grees of extension. The patients with PF PS had a greate degree of lateral patellar tilt than did the asymptomati! control subjects, This suggests that at terminal extensio the osseous structures that prevent lateral tilt and displa ment may be less than adequate, E xcessive pronation at the foot may contribute to PFP'" by negatively affecting th t' Q-angle. Pronation of the foc causes inte rnal rotation of the tibia, which , if carried int, late midstance and termin al stance when the knee is tende d, will cause internal rotation of the hip as well. Thi shifts the patella medially relative to the anterior superi iliac spine (ASIS ) and theoretically increases the later. forc es on the patella, Although one st~dy suggested t} foot motion is not associated ',rith PFPS , 19 there is evidenc that foot orthoses can reduce PFPS symptoms,':' The un­ derlying mechanism of this relief is yet to be determined.

,[

Chapter 21 The Knee

Dynamic Structures

There is a school of thought that suggests that an im­ alance between the VMO-pulling the patella medi­ .ll ~ I-and the VG-pulling the patella laterally-ill terms of timing or magnitude of contraction, was at least partly responsible for the onset of PFPS S 2 Early studies sug­ gested that painful joint distension could inhibit quadri­ .c:eps function in the knee contributing to the symptoms of PF PS.2.4b3 Other studies suggested a dif!erence in reflex response times in patients with PFPS ,2.2,21 but their meth­ oos have been called into question 84 ~Some studies sup­ pOlied a neural explanation for PFPS 8 .:>-8b Other research has found no differences between symptomatic and ymptomatic subjects in either amount of VMO:VL MG activityR990 or the timincr of the onset of the two ~eads o~ the (Iuadriceps26,7-L90oor in the reflex response l une~ of the VMO relative to the VL. 26 'W hether or not there is reduced timing or intensity of the VMO relative o the VL in patien ts with PFPS, it is not known if altered patellofemoral joint mechanics results. Early evidence uggests an increase in VML muscle EMG is associated \Vitll greater lateral patellar displacement and tiltSO,SI Although the controversy rages about VMO:VL ratios and function, what seems to be clear is that improving quadnceps strength and endurance is integral part of any rehabilitation program for PFPS. Poor knee extensor mus­ cle endurance as measured by isokinetic dynamometry dis­ criminates between symptomatic and asymptomatic run­ ners 79

Examination and Evaluation Differential Diagnosis

It is important to differentiate patellofemoral pain from otller disorders of the knee. Generally, PFPS "vill manifest in the anterior aspect of ilie knee as a diffuse ache, vvith the pain aggravated with activity such as ascendin
515

locked with active movement. In any event, this type of complaint warrants further inV(~s tigation dUlillP' the phvs­ 0 / ical examination. History

Questions to the patient should explore whether the etiology appears to be due to trauma, congenital stmc­ tural problems, or overuse, Questions regarding painful patellar movements (s ubluxations), limp , pain, running, cllmbll1g stall'S , and prolonged sitting with th t' knees flexed may help differentiate between asymptomatic incli­ \'lduals , and subjects "vith anterior knee pain, patellar sub­ luxation , and patellar dislocation. 91 Particular attention should be paid to determining what activities reproduce the patient's pain, because these motions can be used to monitor the patient's progress. In addition, these "asterisk signs" can be used to judge the efficacy of an applied in­ tervention. For example, after applying tape in an attempt to reahgn the patella, having the patient perform the symptom provoking manellver (for example, a minisquat or a lateral step-do\\!J1) and determining if there was a change in the amount of pain \vil! help guide the choice of taping technique. Posture

An assessment of the patient's static alicrnll1ent will pro­ vide clues as to the presence of abnormal ~echanical stress being placed on the knee. Problems with alignment of the hip, foot, and ankle may result in increased mechanical stress at the knee. These alignment problems mayin turn be caused by structural deformities (e.g., femoral anteversion causing a toe- in stance ), habitual usage patterns (e.g. , tend­ ing to stand on one leg versus the other), impaired motor control or performance (e.g. , weak hip abductors allowing hlp abduction during stair descent), or range of motion Iim­ it~tions (e.g., lack of hip external rotation). Genu valgum ~ligns the knee medially to the hip, increasing the lateral forces acting on the patella. One shou ld also suspect that the hlp adductors could be shortened and the hip abductors might be lengthened and perhaps weak. An excessively pronat~d foot Will. result in tibial internal rotation, bringing the tIbIal tuberOSIty medially and altering the direction of forces acting on the patella. An in-toe posture could result in illcreas~d lateral pull on the patella. This type of align­ ment, whIch may also manifest as "squinting patellae." could be the result of the hip anteversion , a congenital struc­ tural abnormality. As can be seen from these examples, a good postural assessment willle[\d the astute clinician to de­ velop hypotheses about possible impairments, which in turn lead to specific physical examination maneuvers. Asymmetry or excessive lateral weight shift when as­ suming a Single limb stance posture may Signal weakness of the hip abductors or lack of hip control. This will result in a relative hip adduction on the stance limb, again biasing the knee toward an increase in Q-angle, an increase in the lateral forces acting on th e patella, and lateral patellar tracking. In addition , over time the hip adductors may be­ come shortened. Range of Motion

Active ROM testing in open chain provides informa­ tion on the patient's willingness to move, the amount of motion available, and the severity of pain. Often, open

516

Therapeutic Exercise: Moving Toward Functio n

chain knee extension is not enough to elicit symptoms, and closed chain activities such as sqJlatting, stepping down off a block or step, lising from a chair, or a lunge will reproduce the patient's pain. Analyzing the biome­ chanics of the activity that reproduces the patient's pain wia provide insights into the causative factors; for exam­ ple, poor hip alignment dUling a squat resulting from hip weakness. Typical findings of poor mechanics when doing a squat are hip adduction and internal rotation, resulting in the knee tracking medially over the foot. This vvill re­ sult in an increased Q-angle. Passive ROM measurements of the entire lower kinetic chain are important to determine if postural faults are due to impaired soft-tissue or joint mobility. Differentiation be­ h"'een one- and two-joint muscle length is critical at the hip , knee, and ankle. Key tests include dorsiflexion with the knee extended and fl exed, hip flexion with the knee extended and flexed (straight leg raise), hip extension ill neutral adduc­ tion/abduction with and \vithout knee fle xion (Thomas test), and hip adduction (Ober test). Differentiate between structural abnormaUties and faulty alignment resulting from soft-tissue imbalances. For example, it is important to determine if a patient is stand­ ing in an "in-toe" or "squinting patellae" position from an apparent internal rotation of the hips caused by tight hip in­ ternal rotators or because of a structural problem such as femoral anteversion. The Craig test call be used in the clin­ ical setting to sug.e;est the pres ence of femoral torsions .25 H the normal amount of torsion appears to be present (15 de­ grees) , then treatment can be aimed at stretching short­ ened tissues. Joint Integrity and Mobility Patellar alignment at rest may prOvide clues to poor me­ chanics during knee motion. Measure ments oflateral glide or displacemen t, lateral tilt, lateral rotation , and inferior tilt of the patella have bee n advocated,H2 but the validity and reliability of these measmes have been questioned?VJ3 The presence of patella alta may be significant, defined as the length of the pateLlar tendon being greater than 20% of the le ngth of the patell a. It seems reasonable that the patella in this condition will not engage ill the troch lear groove until later in the range of motion of the knee, re­ sulting in patellar hypermobility. JOint play, particularly patellar mobility in the superior, inferior, medial, and lateral directions, needs to b e as­ sessed. F ull patellar mobility is required for full knee mo­ tion and to e nsure that the P F JRFs are ad equately dis­ persed. In addition, the ahility of th e patella to tilt medially (and thus lift the lateral border away from the kneel is an important assessment of the length of the lateral retinacu­ lum. Tightness of the lateral retinaculum is a common find­ ing in patients with PFPS. Muscle Peliormance As mentioned previously, habitual usage patterns and postural deviations can res ult in changes in the normal length-strcngth relationships of the muscles. It is impOltant to perform a careful assessment of muscle function in the entire lower ext rcmity. Particular attentioll should he paid to the hip, foot , and ankle.

InteIVention An appropriate management plan for PFPS should be based on the evaluation of all the colleeted data , which are distilled into a diagnosiS. Issues related to bony structural abnonnalities are not appropriate for physical therapy in­ tervention . Habitual move ment pattems can be corrected with movement re-education. ROM impairments and mo­ tor deficits can be addressed through stre ngthening, stretching, and manual interventions. After p ain has been reduced and as ROM impairments are being addressed, re­ habilitation of the extensor mechanism and control of prope r lower extremity alignment are the foundation of managing PFPS. There are many studies on the biomechanics of the syn­ drome, suggesting that the underlying assumption drivin intervention choice is that by altering abnormal biome­ chanics one can improve the condition. However, there are relatively few studies of the direct clinical benefit of any par­ ticular management approach.'3.7,j,7S,lH ~ one of the studi are randomized controlled clinical t rials and few investigat the efficacy of any Single conservative intervention, Therapeutic Exercise

Vastus Medialis Oblique Training. Much has been maUF about the imbalance beween the VL and the VMO as causative faetor in PFPS, The VMO was first described as separate fun ctional component of the vastus medialis (V:\1 by Lieb and PerIlS based on the orientation of the muse! fibers at their attachment to the patella, They concluded th... the VMO \NaS plimatily responsible for stabilizing the pate medially. This led to the theory that poor VMO funco would result in lateral tracking of the patella and cau PFPS. R2 It followed that training the VMO and improvin function would be an important component of any inten tion strategy aimed at decreaSing the lateral trackina of patella. Despite multiple investigations 2G ,8:S,86.R8- ijO th does not seem to be consensus about whether there is ducecl VMO activity in patients with PFPS 74 A common mistake made when interpreting EMG cIa that a difference in EM G activity beween wo muscles, when both are normalized, signifies a difference in JJl acti.on on the jOil1t. UnfO!t1ll~atcly, this misconeeption led to the common clinical practice of using surface E. biofeedback to "train" the patient to recmit the VM greater degree that1 the VL. The problem with this apprl is fundamental: there is no way to assess VMO force r duction in vivo, and using EMG activity to reflect pate: stability is fraught with p roblems. EMG is a measure of , electlical activity of the mllScle and not the amount of fc or tension the muscle can produce. Physiolol:,ric and bi chanical factors, such as muscle cross-sectional area and Olientation of the muscle's fibers relative to the jOint moti determine the effect the muscle has on the joint. In additi to compare the activity of wo different muscles, the E M Signals must be normalized, or stated as a perc<"nt of the nal generated by a maximal contraction. Another problem with desigllin g intelvention prograr to improve VM O function is the assumption that traini; _ can improve VMONL timing. III addition, certain ext cises are purported to selectively target and strengthen tI VMO and the reby improve the VMO :VL strength ra

Th trac

:ith

tern

oftt. n

.h

e

1

Chapter 21 . The Knee

These include exercises such as isometric quadriceps con­ tractions, straight leg raises, and short arc quad exercises either alone or combined "vith resisted hip adduction or in­ ternal tibial rotation. As noted previously, surface EMG is often used for biofeedback to assist in the process. The ba­ sis for choosing these exercises is th e thought that the VMO is primarily responsible for terminal knee extension, that the VMO has as part of its origin a slip from the adductor magnus, or that internal tibial rotation improves the Q-an­ gle and therefore the pull of the VMO. Isolated contraction of the VMO separate from the rest of the heads of the quadriceps, however, has never been demonstrated. 74 In the absence of selective recruitment of the VMO, it is un­ likely that the VMO can be strengthened without VL and the rest of the quadriceps also being strengthened. The amount of time, effOlt, and attention paid to training the VMO is made further interesting in light of convincing evidence that general quadriceps strengthening results in positive outcomes, as discussed in the follOwing sections. 94 Mobility Activities. Other than structural deformities , the main impairments associated with poor alignment are limi­ tations in the ROM and motor function, which encom­ passes both strength and control. ROM limitations can be enerally categorized as either being due to joint mobility restrictions or to soft-tissue shortness. Appropriate joint mobilization techniques should be used to improve hip, tibiofemoral, patellofemoral, tibiofibular (both inferior and superior) , talocrural, intercarpal, and metatarsalphalangeal jOint motion, as indicated by examination findings (see Chapter 6). Soft-tissue restrictions can be addressed using oft-tissue mobilization techniques that address specific ar­ eas of hypomobility, or through longitudinal stretching ei­

-

- -

ther done manually by the therapist or done by the patient independently. Hold-relax techniques work well in improv­ ing overall length of muscle. With regard to PFPS, key ar­ eas that need to be addressed include improving hip ad­ duction (indicated by a positive Ober Test), hip extension (Thomas Test), external hip rotation, hee flexion "vith the hip extended (Thomas test), and ankle Jorsillexion (Table 21-2). Poor ankle dorsiflexion can lead to compensatory pronation at the subtalar jOint, which causes internaJi rota­ tion of the tibia. As noted earlier, this may adversely affect patellar alignment. Iliotibial band (ITB ) stretching has been advocated as part of an overall intervention program, with positive outcomes repOlted.96 Based on the structure, tissue makeup, and tensile properties of the ITB , it is un­ likely that a stretching or soft-tissue mobilization program \'lill Significantly lengthen it. It is more probable that length is gained in the proximal attachments of the ITB , likely the tensor fascia lata. A simple active hamstring and gastrocnemius exercise that can be performed in sitting is appropriate and conve­ nient for most patients. In a sitting position, the patient should support the low back \'lith a firm hand support to maintain the lumbar lordosis. He or she slowly extends the lower leg while maintaining this lumbar lordosis. At the end of the comfoltable ROM, the patient dorsiflexes the foot and holds for 15 to 30 seconds. This exercise can be performed frequently throughout the day (see Self­ Management 21-7). General Recommendations

After pain has been addressed, the cornerstone of man­ agement of PFPS is improving strength and control of the

-

__ " ."

Stretching'Exercises tO I A~9(~ss ' Hip Soft Tissue Mobility Impai!~e_n~~ ,__ _ "_ _ =~. ~~

_~~._.J

IMPAIRMENT-LACK OF:

PATIENT POSITION

KEY POINTS

Hip extension

Half-kneel Supine, leg off table

• Stabilize pelvis to isolate femoral-pelvic movement

Hip flexion

Hip adduction

Hip external rotation Knee flexion with hip extended

Ankle dorsiflexion

Sidelying Prone Supine SLR Knee extension with hip maintained in flexion Half-kneel

Half-knee on a c hair Half-kneel Sidelying Prone Standing

517

• Stabilize pelvis to isolate femoral-pelvic movement • Maximize stret<;h to tensor fascia lata, minimi ze lateral trunk stretch. • Stabilize pelvis • Stabi lize pelvis to isolate femoral-pelvic movement

• Prevent foot pronation to isolate ankle dorsiflexion • Address both gastrocnemius and soleus

518

Therapeutic Exercise: Moving Toward Function

Hamstring and Gastrocnemius Stretching While Maintaining a Lumbar Neutral Position

SELF-MANAGEMENT 21-7

Purpose: To in crease the fl exibility of the hamstring and calf muscles

Position: In a sitting position, place one hand behind your back to maintain the proper position of your lower back

Movement technique: Maintaining this position, slowly straighten the knee until you feel a gentle stretch behind your thigh. While holding this position, pull your toes up, flexing your ankle until you feel a gentle stretch behind your calf. Hold for 15to 30 seconds.

Dosage

Repetitions:

Frequency _ _ _ _ __

lower extremity. Interventions aimed at improving limite d ROM can proceed conc urrently. Altl10ugh e mphasi zing VMO recruitment currently has little evidence to support it , even should one choose this form of intervention, the ex­ tellsor mechanism will be positively affected and thus pos­ itive outcomes will be achicved. General guadriceps strengthening exercises are effective in treating the condi­ tion.g'l All resistancc exercises should be pelform ed in the pain-free ROM. It may be that only isornetIic exercise is tole rated in a highly irritated condition . If this is the case, multi-angle isometrics should be empToyed. There is no reason to emphasize ter1llinal kne E' pxtcnsinn over exercise in greate r amounts of flexion. Avoidance of patellofeIlIoral joint cornpression forces can be counterproductive, consid­ ering that cartilage nutrition is dependent ill large part on weight-bearing. The guiding principle should bc dispe rsing the PFJHF by increasing the patellofemoral contact area by improving patellar tracking. Exercises can be chosen that are open or closed kinetic chain. There appears to be only a slight advantage to us­ ing only closed kinetic chain exercises over using only open kinetic chain exercises, but both modes result in im­ proved function and decreased pain up to 3 months after concluding the exercise program. 8i Because all interven­

tion should be directed at improving functional limitations and disabiliti es, closed chain exercises rnay be a better choice for certain patients, given the principle of speci­ fi citv of exercise. Performing all exe rcises with excellent lower extremity and tnmk alignment is essential to addreSSing the dynamic malulignm cnt issues. Exercise diffleulty should he adjusted to allow motion through tlw total target RO\I while the alignment remains good. This will affect the choice of open versus closed chain exercise. For example, step-dowll exer­ cises are impmiant, because stairs are a problem for most individuals with patelJofemoral pain. In performing a step­ down exercise the pati ent should maintain th e knee aligned over the second toe. The hip should remain in the same align ment as during double limb stance, with allowance made for slight weight shift over tl1e weight bearing leg as the non-weight-beming leg is lifted. Excessive lateral shift suggests hip weakness, particularly in the abductors and ex­ te nsors. A drop of the non-weight-bearing pelviS occurring concurrently \vith the weight shift should increase suspi­ cion of abductor weah'Tless. If the knee moves medially over the foot during the step-down, besides hi p abductor and extensor weakness , one can suspect hip external rotation weakness. Suspicion can also be placed on poor muscular control of foot pronation , particularly the posterior tibiali and gastrocnemius/soleus complex. This movement pat­ tel'll ,"viII n~ sult in relative hip adduction and increase the lateral pull on the patella. Whe n this pattcrn of move ment is observed, assessment of muscle strength (manual muscle testing at minimum ) in these musdes is mandatory. The re­ sults of the strength tests \vill guide the choice of exercis es Many indiviouals with PFPS have poor eccentric contr dUJing stair descent and drop off the ste p and catch their body weigh t with the uninvolved leg. Wh en aske d to con­ trol the step-down motion, mallY are unable to do so be­ cause of pain or inadequate muscle control. In this case, tht' step-down exercise is too demanding of the patient and ' not yet indicated, because the patient cannot maiIltain op­ timal alignment. Open chain strengthe ning of the specifi muscles may prove ben e fi Cial at this point , because specifi muscles can be targeted for strengthe ning and the appro­ priede aIllount of resistance applied. For example, sidelyin _ hip ahduction with weight applied to tJ1e knee or ankle ,,·i f sel ectively strengthen the primary movers. Al tern ativeh-. i may be that closed chain exercises can be pe lform ed usin _ appropriate e quipm ent, su ch as a leg press or inclin squ at machine. These machines and others like them all the amount of resistance to be adjusted to proper levels. , opposed to full weight-bealing exercises that dellland con ­ trol of body weig h t. Should open chain exe rcises be us ed first. a progression toward closed chain exercises may im ­ prove the functional outcome. At late r stages, the speed movement and step height should be increased to appro.,.­ mate normal function. Th e individual should move slow enough to be able to stop at any pOint during the motior Close observation can detect poor alignment of the hip knee, and ankte or substitution at the hip . E xe rcises shouk. be progressed to fu nctional activities (Fig. 21-28 ). The foot position can also influence the lower extremi _ alignm ent and should be obs erved during the exe rcise pro­ gram. Foot muscle training requires the individual to im­ prove the align ment of the foot in relation to th e leI! an

Chapter 21. The Knee

519

FIGURE 21-23. (A) Patient perform· ing asquat exercise. (8) Progressing to a lifting exercise.

subtalar joint. This approach includes educating and train­ ing the individual to recognize a position close to the neu­ tral position of the foot for all standing activities. As the in­ dividual lifts the arch, it is important to observe for and discourage anterior tibialis substitution. The tibialis poste­ rior should lift the subtalar joint while the peroneus longus stabilizes the first ray. Pressing down (plantar flexing ) through the first metatarsal head is often a beneficial cue to facilitate correct alignment and appropriate muscle re­ cruitment. Recruitment of the foofs intrinsic muscles to maintain a shortened arch should be encouraged. 'Prescription. Application. and Fabrication of Devices and Equipment It is important to address the symptoms experienced during knee extension. Pain \-vill inhibit muscle recruitment and therefore interfere with any attempt at muscle strengthening. The one intervention that conSistently ap­ pears to be of benefit is the use of patellar taping. Several studies have shown that patellar taping decreases the r ainYO %- IOO Successful application of patellar tape can prOvide immediate relief of symptoms experienced with performing the provocative activity. It is thought that patel­ lar tape improves patella alignment, quadliceps function, and knee function in gait. In general, the tape is applied to the patella in a lateral to medial direction , pulling the patella mediallifg vvith the idea that lateral patellar tracking is diminished . 9 With improved tracking, the PFJRF are more evenly distributed on the posterior surface of the patella. Although the precise mechanism is not well under­ stood, functional measures improve after the application of patellar tape.90,lOl BraCing helped improve alignment of the patella as measured by kinematic MRI while the knee was under load. 102 Unfortunately, no attempt was made to assess the effect of the brace on the subjects' symptoms, so the association between improved patellar alignment and positive outcomes was not clarified by this study. Although there is no evidence that supports the use of knee orthoses in all patients, it may be that a trial use of an orthosis \-vill benefit certain patients.

B A second goal of the rehabilitation process is improving static and dynamiC alignment of the entire lower extremity. The presence of structural deformities may be addressed using compensatory measures. For example, overpronation of the foot may be addressed using foot orthotics. However, the efficacy of this intervention as a 16rimary method of treating PFPS has not yet been shown.

°

Postoperative Rehabilitation The three common types of surgical procedures for the patellofemoral joint are chondroplasties for debridement of patellar or femoral chondral degeneration, lateral reti­ nacular release for the severely restricted lateral retinacu­ lum, and realignment procedures for those with more complicated biomechanical problems. Rehabilitation after any of these procedures should follow the program as pre­ viously outlined. With simple chondroplasties, the program should progress without problems unless Significant pain or swelling exists. If more progreSSive chondral damage has occurred, more caution should be placed on gradual and careful reintroduction of activity and exercise to allow the accommodation of the chondral surfaces. With lateral reti­ nacular releases , care should be taken to ensure the lateral retinaculum does not adhere to surrounding soft tissues. Aggressive releases must be progressed much more slowly than conservative releases, because postoperative pain and large amounts of edema are common. The time for recov­ ery and the length of rehabilitation may also be prolonged as a result of aggressive surgery.

Prognosis Th e prognOSis for PFPS is generally good. 103 A regimented program of quadriceps , hamstrings, and iliotibial stretching; 15 minutes of quadriceps electrical stimulation; isometric quadriceps setting; progreSSive straight leg raises and short arc quad exercises; ice after treatment; and anti-inHamma­ tory medication improved symptoms immediately after the phYSical therapy program in 87% of the patients studied. \04 Two thirds thought their symptoms remained improved an

520

Therapeutic Exercise Moving Toward Function

average of 16 months after completion. The program con­ sisted of treatJnent sessions three times per week for 4 to 6 weeks and progressed to resistance ofO.S to S.O kg, increas­ ing from 0 to 20 repetitions to three sets of 10 repetitions. nfortunately, tl1ere was no control group to compare with the intervention subjects and there is 110 way to tell the effi­ cacy of the individual interventions applied. 'When only closed kinetic chain exercises are employed, the duration of symptoms and the reflex response time of the VMO are the only predictive factors of a positive out­ come. The shorter the duration of symptoms, or the faster the response of the VMO , the better the outcome was. 105

KEY POINTS • The relationships among the lumbopehic, hip, knee, an­ kle, and foot necessitate a thorough examination and an integrated approach to treatment. • Anatomic impairments, including femoral anteversion, coax valgum and varum, genu valgum and genu varum , a shallow trochlear groove, and foot pronation can pre­ dispose the patelloh:!moral joint to poor tracking and therefore to excessive loads. • Physiologic impairments such as mobility or muscle per­ form ance loss at the hip, ankle, or foot can be manifested as symptoms in the an terior knee. • Because of these compensations and the relationships among joints, therapeutic exercises may be performed incorrectly, allowing substitution to occur. • Examination of the patellofemoral joint must in clu de muscle length and joint mobility at the hip, knee , and ankle, and assessment of patellar position and motion relative to medial and lateral glide and patella alta. • Patellofemoral taping is effective in reducing PFPS pain and improves knee function.

LAB ACTIVITIES I. Demonstrate the likely gait pattern if your quadri­ ceps strength was 3/,5. 2. Demonstrate three strengthening exerdses to treat quadriceps strength impairment, given a strength grade of 3/S. 3. Demonstrate two exercises to treat the functional limitations seen in the gait pattern. 4. Is an assistive device necessary? If so, what would you choose for this patient if she had no other im­ pairments? Fit and instruct the patient in use of the device. S. Demonstrate the likely gait pattern if the patient's quadriceps strength was 215. 6. Demonstrate three strengthening exercises to treat the quadriceps strength impairment, given a strength grade of 2IS. 7. Refer to Case Study #2 in Unit 7. Instruct your pa­ tient in the first phase of the exercise program . Have your patient demonstrate all exercises.

• Improvements within the entire lower kinetic chain in impaired joint and soft-tissue mobility, muscle perfor­ mance and motor control, and general quadriceps strengthening result in positive outcomes \\lith PFPS. • The existence of problems with the timing of onset or the magnitude of VMO EMG Signal remains controver­ sial but appears to be nonexistent. No evidence exists to support speCific recruitment of the VMO separate from the rest of the quadliceps. Attempts to do so probably serve to improve overall quadriceps function. • The major anatomic impairments at the knee are genu valgum and gen u varum. These postures predispose the lateral and medial compartments, respectively, to exces­ sive loads. • Physiologi c impairments such as mobility loss at the knee can be compensated by motion at other joints. For example, increased ankle, hip , or lumbar motion can compensate for decreased knee flexion . • Palpation, education, and biofeedback are techniques to ensure proper muscle firing patterns without substitu­ tion dUling rehabilitative exercises. • Loss of the meniscus can lead to degenerative joint dis­ ease. Treatment after meniscectomy should focus on preservation of articular cartilage and joint protection techniques. • The major function of the quadriceps muscle in th long-term health of the knee is its ability to absorb shock eccentricalJy in the loading phase of the gait cycle. A fo­ cus on eccentric, closed chain qu adriceps exercise in the first 0 to IS degrees of flexion is essential to maintain th e health of alticular cartilage. • PatelJar tendinitis results from the tendon's inability to \vithstand eccentric forces dUling impact activities. The rehabilitation program must eventually progress to ec­ centric impact activities if the patient is to return to thi, type of activity.

.,

._';;ps'

8. Create five exercises for a patient with subacute

patellar tendinitis.

9. Determine your patient's 10 repetition maximum

for a straight-leg raise \\·i th the weight.

a. At the ankle b. Above the knee 10. Teach your patient how to check VMO firing dUling the following activities: a, Isometric quadriceps contraction while i. Sitting with the knee at 90 degrees ii. Sitting with the knee at 70 degrees iii. Sitting \vith the knee at 4S degrees iv. Sitting with the knee at 30 degrees vi. Sitting with the knee at 0 degrees b. Wall slide c. Sit to stand d. Lunge e. Gait

" 1

I

Chapter 21 : The Knee

CRITICAL THINKING QUESTIONS ---------' 1. Read Case Study #6 in Unit 7. a. List the patient's impairments and functionallimita­ tions. b. Describe the relationship between this patient's im­ pairments and functional limitations. c. Describe the relationship between this patient's im­ pairments, functional limitations, and any disability. d. Identify and prioritize shOlt- and long-term goals. e. Choose a specific goal, and describe five different ex­ ercises used to achieve that goal. Include posture, mode, and movement. f. This patient is returning to work as a delivery truck driver. Describe three functional exercises that can prepare him for this activity. g. Presume that this same patient is returning to work as a basketball referee. Describe three functional ex­ ercises that can prepare him for this activity. 2. Read Case Study #3 in Unit 7. a. Describe three exercises to address her difficulty with stairs. Include posture, mode , movement, and precautions. b. Given her histOlY, describe three exercises to in­ crease the endurance of her quadriceps muscles. In­ clude posture, mode, movement, and precautions. c. Describe three exercises to increase the endurance of her calf muscles. Include posture, mode, move­ ment, and precautions. d. The patient no longer feels any muscle fatigue when performing the exercises outlined in questions band c. Describe how you would progress each of these exercises. Include dosage parameters.

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51. Fairhank TJ, Knee joint changes after meniscectomy, J Bone joint Surg Br 1948;30:664--670, .52. Fitzgibbons RE , Shelbourne KD, "Aggressive" nontreat­ men t of lateral meniscal tear's seen during anterior crueiate ligament reconstruction, Am J Sports Med 1995;23:1 56-165. 53, DeHaven KE, Arnoczk,), SP, Meniscal repair. In: Finerman GAM, 'Koyps FR , eds , Biology and Biomechanics of the Traumati zed SynOvial Joint: The Kn ce as Model. Ros emont, IL: Am('rican Academy of Orthopaedic Surgeons , 1992. 54 , Buckwalter J, Hunziker E , Rosenberg L, et a'l. Articular car­ tilage: composition and structure, In: Woo SL-Y, Buck-val­ tcr JA, cds, Injury and Repair of the Musculoskeletal Soft Tissues, Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1988, 0 ,) , Mow V, Rosenwasser M, Articular cartilage: biomechanics, In: Woo SL-Y, Buck-valter JA, eds , Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, IL: American Academy of Orthupaedic Surgeons, 1988, 56, Coventry MB . Proximal tibial varus osteotomy for os­ teoarthritis of the lateral compartment of the knee, J Bone Joint Surg Am 1987;69:32-38, 57, Coventry MB, Proximal tibial osteotomy, Orthop Rev 1988; 17:456-458, 58, 0Joyes FR , Barber SD, Simon R. High tibial osteotomy and ligament reconstruction in varus angulated , anterior cruci­ ate ligament-defiCient knees. Am J Sports Med 1993;21: 2-12, 59, Hernigou P, Mede'viell D , Debel)'re J, et al, Proximal tihioJ! osteotolllY for osteoarthritis \,ith varus deformity, J Bone joint Surg Am 1987;69:332-354, 60 , Kettelkamp DB , Leach RE , l\asca R. Pitfalls of proximal tibial osteotomy, Clin Olihop 1975;106:232-241. 61. Kettelkamp DB, \;<" cnger DR, Chao EYS , et al. Results of pruximal tihial osteo to Illy, J Bone Joint Surg Am 1976;58: 9.52-960. 62, Keene JS , Dyreb)' JR. High tibial osteotumy in the treat­ Dlent of osteoarthritis of the knee, J Bone joint Surg Am 1983;65 :36-42. 63, Insall Ji\ , Joseph DM , Msika C. High tibial osteotoIllY for varus gonarthrosis , J Bone Joint Surg Am 1984;66: 1040-1047, 64, Wang JW, Kuo K:\T, Andriaccbi TP, et al. The influence of walking mechanics and time OIl th e results of proximal tibial osteotomy, J Bone JOint Surg Am 1990;72:905- 909, 65, Menkow RL, Soudry M, Insall IN. Patella dislocation fol­ lOWing knee replacement. J Bone Joint Surg Am 1985;67: 1321-1327. 66, Keays S, Mason M, The benefit of increased range of mo­ tion follo\\in g tutal knee replaCell1Cl1t. Platform presen ta­ tion at the 12th International Congress of the \"'orld Con­ fed e ration for Physical Therap) ': June 25-30, 1995. Washingtun , DC. 67, Jarvinen ~l. Epidemiology of tenclon injuries in sports, Cun Sports Med 1992;11:493-504, 68. Puddu G, Cipolla \1 , Cerullo G, et al, :\Ton-osseous lesiOIl$ In: Fox J\1 , Del Pizzo W, eds , The Patellofemoral Joint New York: McGraw-Hill, 1993, 69, Leadbetter WB, Cell-matrix response in tendon injury, Coo Sports Med 1992;11:533-578. 70, Blazina \lIE, Kerlan RK , Jobe F'VV, Jumper's knee, Orthop Clin !\orth Am 1973;4:665-678, 71, Kettunen JA, Kvist M, Alanen E, et al , Long-term progn osis for jumper's knee in male athletes: a prospective follow- up study, Am J Sports Med 2002;30:689-692, 72, Witvrouw E , Sneyers C, Lysens R, et al , Reflex response times of vastus medialis oblique and vastus laterali s in normal subjects and in subjects with patellofemoral pain

Chapter 21. The Knee syndrome [comment], J Orthop Sports Phys Ther 1996; 24,160-165, 73, Crossley K, Bennel K, Green S, et aI. A systematic review of physical interven tions for patellofemoral pain syn drome, Clin J Sports Med200l;l1l03-110, 74, Powers CM, Rehabilitation of pntellofemoral joint disor­ ders: a critical review, J Orthop Sports Phys Ther 1998;28: 34,5-354, 75, Shellock FG, Mink jH , Deutsch AL, et al, Kinematic MR imaging of the pateilofemoral joint: compaJison of passive positioning and active move ment techniques, Radiology 1992;184:574-577. 76, Kramer p, Patellar malignment syndrome: rationale to re­ duce excessive lateral pressure, J Orthop Sports Phys Ther 1986;8:301-309, 77, Fulkerso n JP, Shea KP, Mechanical basis for patellofemoral pain and cartilage breakdown, In: Ewing JW (ed ), Art,i cular Cartilage and Knee Joint Function: Basic Science and Arthroscopy, I\e\\' York: Raven Press, 1990, 78, Papagelopoulos PJ , Sim FH, Patellofemoral pain syndrome: diagnosis and management. Orthopaedics 1997;20:148-157, 79, Messier SP, Davis SE, Curl V/\;Y, et aI. EtiolOgiC factors as­ sOCiated with patellofemoral pain in runners [published er­ ratum appears in Med Sci Sports Exe rc 1991:23:1233] , Med Sci Sports Exerc 1991;23:1008-1015, 80, Powers CM, Patellar kinematics, Part II : the influence of the depth of the trochlear groove in subjects with and with­ out patellofemoral pain, Phys Ther 2000;80:965-973, 81. Powers CM, Patellar kinematics, Part I: the influence of vas­ tus muscle activity in subjects with and without patellofemoral pain , Phys Ther 2000;80:956-964, 82. McConnell J. The management of chondromalacia patella: a long term solution. J Aust Physiother 1986;32:215- 222. 83, de Andrade JR, Grant C , Dixon AS, JOint diste ntion and re­ flex muscle inhibition in the knee, J Bone JOint Surg 1965; 47 A:313-323, 84, Karst GM, Willett GM, Reflex response times of vast us me­ dialis oblique and vas tus lateralis in normal subjects and in subjects with patellofemoral pain [comment ] J Orthop Sports Phys Ther 1997;26:108- 110, 85, Boucher JP , King MA, Lefebvre R, et al. Quadriceps femoris muscle activity in patellofemoral p ain syndrome, Am J Sports Med 1992;20:527-532. 86, Gillcard W, McConnell1J, Parsons D . The effect of patellar taping on the onset of vas tus medialis obliquus and vastus lateralis llluscle activity in persons with patellofe moral pain, Phys Ther 1998;78:25-32, 87, Hanten WP, Schulthies S, Exercise effect on electromyo­ graphiC activity of the vastus medialis oblique and vastus lat­ eralis muscles, Phys Ther 1990;79:561-565, 88, Souza DR, Gross MT. Comparison of vastus medialis obliquus: vastus lateralis muscle integrated electromyo­ graphiC ratios between healthy subjects and patients with patellofemoral pain, Phys Ther 1991;71:310-316, 89, MacIntyre DL, Robertson DG, Quadriceps muscle activity in women runners v,':ith and without patellofemoral pain syn­ drome, Arch Phys Med RehabiI1992;73:1O-14 , 90, Powers CM, Landel RE, Perry J. Timing and intensity of vasti muscle activity during functional activities in subjects with and without patellofemoral pain, Phys Ther 1996; 76:946-955 , 91. Kujala UM , Jaakkola LH, Koskinen SK, et aI. Scoring of patellofemoral disorders , Arthroscopy 1993:9: lo9-163, 92, Powers eM, Mortenson S, Nishimoto D , e t aI. Concurrent critelion-related validity of a clinical measure ment used for

523

determining the medial!lateral component of patellar orien­ tation, J Orthop Sports Ph)'s Ther 1999;29:372-377, 93, Watson CJ, Propps Yl, Galt W, et al. ReliabiLity of ;Vlc Con­ nell's classification of patellar orientation in symptomatiC and asymptomatic subjects, J Orthop Sports Phys T her 1999;29378-385. 94, Arroll B, Ellis-Pegler E, Edwards A, etal, Patellofemoral pain syndrome, A critical review of the clinical trials of nonoperative therapy, Am J Sports Yfed 1997;25: 207-212. 95, Lieb FJ, Perry J, Quadriceps function : an anatomical and mechanical study using amputated limbs. J Bone JOint Surg 1968;50A: 1535-1548, 96, Doucette SA, Goble EM, The effects of exercise on patellar tracking in lateral patellar compression syndrome, J Orthop Sports Phys Ther 1992;20:434-440, 97, Witvrouw E, Lysens R, Bellemans J, et al. Open versus closed kinetic chain exercises for patellofemoral pain, A prospective, randomized study, Am J Sports Med 2000;28: 687-694 . 98, Bockrath K, Wooden C, Worrell T , et a'!. Effects of patella taping on patella position and perceived pain, Med Sci Sports Exerc 1993;25:989-992, 99, Cushnaghan J, McCarthy C, Dieppe p, Taping th e patella medially: a new treatment for osteoarthritis of the knee? BMJ 1994;308:753-755, 100, D'Hondt NE, Struijs PA , Kerkhoffs GM , et al, Orthotic de­ vices for treating patellofemoral pain syndrome, Cochrane Database Syst Rev 2002;2:CD002267, 101. Powers CM, Landel R, Sosnick T, et al. The effects of patel­ lar taping on stride characteristics and joint motion in sub­ jects v,':ith patellofemoral pain, J Orthop Sports Phys Ther 1997;26:286-291. 102. Shellock FG, Mink JH , Deutsch AL, et al. Effect of a patel­ lar realignment bra<:e on patellofemoral relationships: eval­ uation with kinematic MR imaging, j Magn Reson Imaging 1994;4:590--594. 103, Baker MM, Juhn MS, Patellofemoral pain syndrome in the female athlete, Clin Sports Med 2000;19:315-329, 104, Whitelaw GP, Rullo DJ, Marko\vitz HD , et aI. A conserva­ ti ve approach to anterior knee pain, Clin Orthop 1989; 246:234-237, 105, Witvrouw E , Lysens R, Bellemans J, et al. Which factors predict outcome in the treatment program of ante rior knee pain? Scand J Med Sci Sports 2002;12:40-46.

RECOMMENDED READINGS Buchvalter J, Rosenberg L, Coutts R, et al, Articular cartilage: in­ jUlY and repair, In : Woo SL-Y, Buckwalter JA, eds, Inju ry and Repair of the Musculoskeletal Soft Tissues , Park Ridge, IL: American Academy of OrthopaediC Surgeons, 1988. Buchvalter JA, Mechanical injuries of articular cartilage, In: Fin­ erman GAM , Noyes FR, eds, Biology and Biomechanics of the Traumatized Synovial JOint: The Knee as ~10del. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1992, Mosko\vitz RW, Howell DS, Altman RD , et al. Osteoarthritis: Di­ agnOSis and MedicaL/Surgical Management, 3rd Ed, Philadel­ phia: W.B, Saunders, Co., 2001. Mow VC, Ateshian GA, Ratcliffe A, Anatomic form and biome­ chanical properties of articular cartilage of th e knee, In: Fin­ erm
chapter 22

\\

hi pI

The Ankle and Foot

is

JOHN P. MONAHAN, RYAN HARTLEY, CARRIE HALL, AND STAN SMITH

Review of Anatomy and Kinesiology Osteology Arthrology Myology Neurology Foot and Ankle Kinesiology Talocrural Joint Subtalar Joint Midtarsal Joint Gait Kinetics Gait Kinematics Alignment Anatomic Impairments First Ray Hypermobility Subtalar Varus Forefoot Varus Forefoot Valgus Examination and Evaluation Patient/Client History Balance Joint Integrity and Mobility Muscle Performance Pain Posture Range of Motion and Muscle Length Other Examination Procedures Therapeutic Exercise Intervention for Common Physiologic Impairments Balance Impairment Muscle Performance Pain Posture and Movement Impairment Range of Motion. Muscle Length. Joint Integrity. and Mobility Therapeutic Exercise Intervention for Common Ankle and Foot Diagnoses Plantar Fasciitis Posterior Tibial Tendon Dysfunction Achilles Tendinosis Functional Nerve Disorders Ligament Sprains Ankle Fractures

Adjunctive Interventions

Adhesive Strapping

Wedges and Pads

Biomechanical Foot Orthotics

Heel and Full Sole Lifts

The key to developing a successful therapeutic exercise program for the ankle and foot is to understand the inter­ . actions among the lower extremity jOints. Anatomic im­ pairments (e.g., coxa vara, hip anteversion , forefoot varus), physiologic impairments (e.g. , hypomobility, hypermobil­ ity, diminished muscle performance, loss of balance ), or trauma at one joint can lead to dysfunction at other joints in the kinetic chain. For example, excessive pronation, a faulty movement pattern of the foot and ankle, can lead to compression of the medial tibiofemoral compartment and medial knee pain resulting from excessive pronatory forces up the kinetic chain. Treatment of the faulty ankle and foot movement patterns can relieve abnormal forces in the me­ dial knee. Typically, appropriate treatment of the complex interplay of impairments throughout the kinetic chain re­ sults in improved function in the lower extremity. Effective examination, diagnosis , and exercise intervention are es ~ sential for long-term resolution of symptoms, impairments. functional loss , and disability.

REVIEW OF ANATOMY AND

KINESIOLOGY

The foot and ankle are composed of 26 bones that are in­ terconnected by ligaments and muscles. The static and dy­ namic interrelationships of the bony and soft-tissue struc­ tures enable the foot to function as a base of support for the lower extremity, shock absorber, torque converter, and mobile adaptor to ground reaction changes. A thorough knowledge of the anatomy and kineSiology of the foot and ankle is necessary to understand the functional effects of impairments in the foot and ankle both locally and through­ out the kinetic chain.

Osteology The talocrural joint is composed of the distal fibula, tibia. and the talus. The distal fibula, or lateral malleolus, extends farther distally than the medial malleolus , the distal projec­ tion of the tibia. The distal flat end of the tibia articulatin

524

1'1

Chapter 22: The Ankle and Foot

with the talus is wider ant rio rIy, allowing dorsiflexion mo­

bility. The talus articulates with the (us ta! tibia and fibula,

providing th e link b tween th e leg and the foot. The talus

is composed of a head, a neck, and a body (Fig. 22-1). Th e largest of the seven talar bones, the calcan eus. is ir­ r(2 ,."')'\llarly shaped, ..md con tains sev ral muscle attachments and arooves for tendons passing distally. It p lantar surface serves as the attaciullcnt of the plan tar fascia. Toge ther, the talus and th calcaneus comprise the hindfoot 1 The midfoot consists of the navicular, cuboid, and three cuneiform hon es. J T he navicular bone is most medial and articulates bet'vvee n th talar head proximally and the cllneiform bones distally. The naviclllar plays an important mechanical role in mainte nance of th lonaitudina! arch. It contains a tuberosity for di stal attachment of the poste rior tibialis 1l111scle. The cuboid is the most lateral bone in the distal tarsal row and sits b e tw en th e calcane us proximally and the fourth and flfth metatarsals distally. It contains a groove for th e tell don of th e peroneus lonO'u s muscle . The three cuneiform bones are wedge-sbap d and articlllat with the naviclllar proximally and the bases of the first to third metatarsal bODes distally. The fore foot consists of th e five metatarsals and the phalanges. The first metatarsal bOlle is the shortest and th ickes t and has two sesamoid bOll es inr(~riorly at its base . TIl e phalanges are sim ilar to those of the hand; each consi.sts of a shaft, base, and head. 1 An understanding of bony relationships can clarify the terminology used throughout tills chap ter. The talocrural joint is the articldatio]l of the tibia and fib ula with the talus. ~rhc subtalar joint is a composite joint fonn ed by three distillct planar artic ulations betwecn the talus and th e cal­ caneus. The midtarsal joint, or transversc tarsal joiIl t, is a complex articulation formed by the talonaviclllar and calca­ neocuboid join ts.

Arthrology Talocrural Joint The capsule of the ankle joint is f~lirly thin and weak anteri­ orly and post riorly, aIld the stability of the anldc joint depends on an intact Iiga mcntous stnlcture . The two major li gamen ts are the medial collateral ligament and the lateral

525

collateral liO'ame nt. 2 1'1 e medial collateral ligament is com­ monly refe rred to as the deltoid ligament, a fan-shaped lig­ ame nt with supe rfiCial and deep fib r s that are quite strong (Fig. 22-2A). This ligament cOlltrols m elial joint stabilit) and controls extrem s of plantar flexion ;.mel uorsiHexion. The lateral collate ral ligament is far weaker than the me­ di al coll ateral ligament ancl co mpri ses three sep a rate bands: the an t rior and posteJior talofibular and the calca­ neofibular ligame nts (Fig. 22-2B). Th e ante rior talofibular ligament is th e weak t of the lateral collateral ligament co mp lex. T he lateral collateral ligament controls lateral joi1lt stability and checks extremes of range of motion (RO M) Th e ant rior talofibular and the calcaneofibular ligaments aTe the most frequently injur d whe n the ankle is sprained, which usually is an inversion injury whil e the ankle is in its most unstable position of plantar flexion.

Subtalar Joint The subtalar joint is a stable joint that randy dislocates. Its ligamentous support consists of the medial and late ral collat­ e ralligam nts, the interO$S ' ous taJocalcanealligarn n t, and the postelior and late ral talocalcan al ligaments (Fig. 22-3).

Midtarsal Joint T he calcaneocuboid joint has its OVVIl capslIie that is rein­ forced by sevcral major ligcllllE'nts: the lateral hand of the bifurca te ligamen t, the dorsal calcancocuboid, th e p lantar calcaneocuboid (short plantar) , and the long plantar liga­ ment. The long plantar ligament extellds from the calca­ neus and cuboid to th e bases of the seco1ld through fourth metatarsals. It is cO llside red the most importan t of the mid­ tarsalligan lellts, because it contributes Significantly to mid­ tarsal joiut stahility and SUppOlt of the laterallolIgitudinal arch of the foot. I1l1portant support for the miutarsaljoint is also provided by the extrinsic muscle s passiug medially and laterally and th in t'linsic muscles inferiorly. i ,igarnentou!: suppo rt for the talon<.1vi cu lar joint is prmidecl by the Iigam nts supporting the subtalar joint,

A B

Styloid process

Bifurcate ligament

Tibia Fibula Talus

A

Medial plantar tubercle C

Anterior talofibular Calcaneofibular Posterior talofibular ~---"---+--

Lateral plantar tubercle

FIGURE 22-1. Osteology of the foo t and ankle. (A) Superior view. (B)lat­ eral view. (C) Posterior view.

B

Dorsal calcaneocuboid ligament

FIGURE 22-2. Ligaments of the ankle. (A) Medial aspect (B) Lateral as­ pect (From Nankin CC, Leva ngie PK. Joint Structure and Functi on A Com­ prehensive Analys is 2nd Ed. Ph ilade lphia FA Davis, 1992)

526

Therapeutic Exercise Moving Toward Function

Myology

.:..... ••\

Crural tibiofibular interosseous ligament

:: I

;..~ •••!".:~ ••\')(::.~ ,!.... ... ',? . - _~

Deltoid _ _ __ ligament ~

Interosseous talocalcaneal ligament

Calcaneofibular ligament

The musculature of the foot and ankle can be broadly cat­ egOrized into intrinsic and extrinsic muscle groups as listed in Displays 22-1 and 22-2. These displays describe their open chain function ; however, to prescribe exercise with precision, the practitioner should know the unique closed chain function of each muscle as well. The Recommended Reading section proVides sources for more information on muscle function , and closed chain function is described later in the Gait Kinematics section.

Neurology FIGURE 22-3. Cross-sectional posterior view of the ligaments of the sub­ talar joint.

The prim ary motor and sensory nerve supply to the foot are

the tibial and common peroneal nerves.

Motor Innervation

including the spring ligament, the medial band of the bi­ furcate ligament, and the dorsal talonavicular ligam ent. The triangular spring ligament arises from the sus tentac­ ulum talus and inserts on the inferior navicular. The cen­ tral portion supports the talar head. Medially, it is con­ tinuous with the deltoid ligament, and laterally, it joins the medial band of the bifurcate ligament. The spring ligament is the primary support of the medial longitudi­ nal arch. As it spans and supports the talocalcaneon­ avicular joint, it checks joint motion that contributes to flattening of the arch . Additional support is supplied from the ligaments that reinforce the adjacent calca­ neocuboid joint. The plantar aponeurosis, also known as the plantar fas­ cia, spans and SUppOltS the longitudinal arch (see Fig. 22­ 2)3 It begins posteriorly on the calcaneus and continues anteriorly to attach to the proximal phalanx of each toe. Its strong fibrous structure prOvides protection to the under­ lying muscles, vessels, and nerves. The plantar fascia par­ ticipates in longitudinal arch support during the propulSion phase of gait. Dorsiflexion of the toes causes traction on the plantar fascia , which elevates the longitudinal arch through the "vindlass mechanism (Fig. 22-4).

The tibial nelve innervates seven muscles in the posterior

compartment before it divides into medial and late ral plan­

tar nerves. The common peroneal nerve is divided into th

deep and superficial peroneal nerves . The motor innerva­

tion for each of these nerves is listed in Table 22-1.

Sensory Innervation

The sensory supply from the tibial nerve comes from th

medial sural cutaneous. This nerve joins the lateral sural cu­

taneous from the common peroneal to form the sural nerv

which supplies the skin on the dorsolateral surface of the

lower leg and the lateral side of the foot (see Fig. 22-5) . Th

DISPLAY 22-1

Extrinsic Muscles of the Foot and Ankle Anterior Compartment

Open Chain Action

~

• Peroneus tertius

Dorsiflexion (same for all fourl. also inverts the foot Extend the phalanges of the first ray Extend the phalanges of the toes Everts the foot

Anterior tibialis

• Extensor hallucis longus • Extensor digitorum longus

Lateral Compartment

Open Chain Action

• Peroneus longus • Peroneus brevis

Eversion (same for both)

Posterior Compartment

Open chain action

Superficial muscles • Gastrocnemius

Plantar flexion (same for all three)

• Soleus • Plantaris Deep Muscles • Posterior tibialis • Flexor hallucis longus • Flexor digitorum longus

FIGURE 22-4. As the toes are extended, the windlass effect of the plan­ tar fascia assists passive elevation of the heel. (From When the feet hit the ground everything changes. In Program Outline and Prepared Notes-A Basic Manual Toledo, OH APRN, 1984 )

Plantar flexion and inversion First ray flexion Flexion of the phalanges of the toes

(Data from this display are excerpted from Gray's Anatomy, Bounty Books, 1977/

Chapter 22 The Ankle and Foot

527

DISPlAY 22·2

Intrinsic Muscles of the Foot and Ankle Superficial layer

Open chain action

Deepest layer

Open chain action

• Abductor halluc is

Abduction of first ray, flexion of proximal phalanx Flexion of the second phalanges on the first digits Abducts fifth ray, flexion of proximal phalanx

• Seven interossei

The dorsal interossei are abductors from an imaginary line passing through the axis of the second toe, so that the first muscle draws the second inward, toward the first ray; the second muscle draws the same toe outward; the third draws the third toe, and the fourth draws the fourth toe in the same direction. They also flex the proximal phalanges and extend the two terminal phalanges. The plantar interossei adduct the third, fourth,and fifth toes toward the imaginary line passing through the second toe, and by means of their insertion into the aponeurosis of the extensor tendon, they flex the proximal phalanges, and extend the two terminal phalanges.

• Flexor digitorum brevis • Abductor digiti minimi

Second layer • Quadratus plantae

• Four lumbricals

Assists the long flexor of the toes, and conve rts the oblique pull of the tendons of that muscle into a direct backward pull upon the toes. Assists in flexing the proximal phalanx, and by their insertion into the long extensor tendon, aid in straightening the two terminal phalanges

Third layer • Flexor hallucis brevis • Adductor halluc is • Flexor digiti minimi brevis

Flexes the first ray Adducts the first ray Flexes fifth ray and draws its metatarsal bone downward and inward

medial plantar nerve supplies the medial side of the sole of the foot and the medial three and one-half toes, whereas the lateral plantar nerve innervates the lateral side of the sole and the lateral one and one-half toes (see Fig. 22-5). The sensory portion of the common peroneal nerve, the lateral sural cutaneous nerve, joins the medial sural cuta­ neous nerve from the tibial nerve as stated previously. The deep peroneal nerve ends as a cutaneous branch to the ad­ jacent sides of the great and second toes. The superficial peroneal nerve supplies the skin on the front of the lower leg, dorsum of the foot, medial side of the great toe, and ad­ jacent sides of the second to the fifth toes (see Fig. 22-5).

TIBIAL NERVE Gastrocnemius Soleus Plantaris Popliteus Flexor hallucis longus Flexor digitorum longus Tibialis posterior

FOOT AND ANKLE KINESIOLOGY The fundamental functions of the foot and ankle include adapting to uneven terrain, absorbing shock, absorbing lower extremity rotatory forces, and providing a rigid lever for effective propulsion. Three joints in the foot and ankle complex are chiefly responsible for these functions: thr:: talocrural joint, the subtalar joint, and the midtarsal joint. 4 •o Motion at the talocrural, subtalar, and midtarsal joints occur around triplane axes, which run from a posterior iateral plan­ tar position to an anterior medial dorsal position. The result­ ing triplane motions are called pronation and supination

MEDIAL PLANTAR NERVE

LATERAL PLANTAR NERVE

DEEP PERONEAL NERVE

SUPERFICIAL PERONEAL NERVE

Flexor digitorum longus Abductor hallucis Flexor hallucis brevis P'lumbrical

Quadratus plantae Abductor digiti minimi Flexor digiti minimi brevis Adductor hallucis Interossei

Tibialis anterior Extensor haUucis longus Extensor digitorum longus Peroneus tertius Extensor digitorum brevis

Peroneus longus Peroneus brevis

2nd through 4th lumbricals

528

Therapeutic Exercise: Moving Toward Function

(D isplay 22-3). Pronation is movement in the direction of ev­ ersion, ahduction, and dorsiflexion; supination is movement toward inversion, adduction, and p lantar flexion. Saphenous Tibial Sural Saphenous Superficial fibular (peroneal) Lateral plantar

Medial plantar

Deep fibular (p eroneal)

FIGURE 22-5. Cutaneous di stribution of nerves of the distal leg and foot. (Adapted from Moore L. Clinically Oriented Anatomy 3rd Ed. Ba ltimore : Wi lliams & Wilkins, 1985)

Talocrural Joint Th e talocrural joint a-Qs is pitched close to the frontal and transverse plane , with minimal angulation in the sagittal plan e (Fig. 22-6)6 T echnically, th e talocrural joint pronates and supinates. During pronation , dorsiflexi on is the 1110St dominant co mponent motion , wi th minimal components of eversion and abduction. Talocrural joint supination is dominated by plantar flexion , with minimal componen ts of inversioJl and adduction. Cli nically, th e dorsiflexion and p lantar flexion components arc so domi­ nant that pron ation and supination terms are rarely used to describe the move ment. DUling closed kinetic chain talocrural joint fun ction , the foot and talus are stabilized by weight- bealing forces and motion ~s in the form of the ti bia and fihula movin\! over the foot. '

h

Subtalar Joint The subtal arjoint axis is pitched midway between th e sagit­ tal and transve rse plan es , with llliJl or ilngu latioll in the frontal plane (F ig. 22-7 ).8 C loscd chain wCight-bearin g

DlSPLAY22-3

Planar Motion General Principles of Planar Motion • Joint motion occurs perpendicular to an axis. • Joint motion is often described by the cardinal plane in which it occurs. The three cardinal planes are frontal, sagittal, and transverse. • An axis that lies in two planes will give rise to a single plane motion in the third plane. Planar Motion of the Ankle and Foot • In the foot and ankle, an axis that lies in the frontal and transverse plane gives rise to plantar flexion and dorsiflexion in the sagittal plane . • An axis falling in the sagittal and transverse planes gives rise to inversion and eversion in the frontal plane . .. An axis running in the frontal and sagittal planes gives rise to abduction and adduction in the transverse plane. .. An axis that obliquely crosses the three cardinal planes gives rise to motion in all three planes, or triplane motion. General Principles of Triplane Motion Triplane motion is often described by the component motions from each cardinal plane. • The angulation or pitch of an axis determines the amount of each component motion. A triplane axis that is pitched evenly across all three planes gives rise to motion with equal components from each plane. If the axis is pitched closer to one plane, there is a larger or dominant component motion. For example, if a triplane axis lies close to the sagittal plane, the dominant

component motion is inversion or eversion. Abduction or adduction and plantar flexion or dorsiflexion are less significant.

Triplane Motion of the Ankle and Foot • Motion at the talocrural, subtalar, and midtarsal joints occur around triplane axes. • These axes run from a posterior lateral plantar position to an anterior medial dorsal position. • Triplane motion at the foot and ankle that occurs around an axis in the previously described angulation is called pronation and supination. • Pronation is movement in the direction of eversion, abduction, and dorsiflexion . • Supination is movement toward inversion, adduction, and plantar flexion . • The axis of each joint has a different pitch and therefore has different degrees of component motions from the cardinal planes. • Triplane motion at the foot and ankle during open chain motion is readily apparent by observing the plantar surface of the forefoot. • During closed kinetic chain function, weight-bearing forces provide some element of distal fixation, which limits motion distal to the axis and promotes motion above the joint axis. • Triplane motion under load is less apparent because of the motion occurring distal and proximal to the joint axis. • It is important to understand triplane motion in the open and closed kinetic chain to duplicate the ideal biomechanics during range of motion exercise and functional retraining of the ankle and foot complex and its relationships to the talofibular, tibiofemoral, and hip joints.

r; 11 ~ st

Chapter 22: The Ankle and Foot

529

A

FIGURE 22·6. The axis of the talocrural joint is rotated laterally 25 de­ grees in the transverse plane and inclined distolaterally 10 degrees in the frontal plane. (A) Superior view. (8) Lateral view.

forces at the subtalar joint differ from open chain forces; however, the joint still follows triplane motion. During closed chain subtalar joint pronation, the calcaneus everts, but because of weight-bearing forces, the foot does not abduct or dorsiflex. The talus completes the triflane mo­ tion by adducting and plantar flexing (Fig. 22-8). This mo­ tion of the talus results in the lowering of the mediallongi­ tudinal arch and influences internal rotation of the tibia and fibula. During closed kinetic chain subtalar joint supination, the calcaneus inverts, and the talus adducts and dorsiflexes (Fig. 22-9) . Subtalar joint supination elevates the medial longitudinal arch and influences external rota­ tion of the tibia and fibula. s

Midtarsal Joint The midtarsal joint has two independent axes (Fig. 22-1O)Y The longitudinal midtarsal jOint axis falls close to the sagittal plane, and during pronation has a large component of everion and small components of dorsiflexion and abduction.

FIGURE 22·8. Posterior view of the right foot showing subtalar joint

pronation. Pronation is a triplane motion consisting of calcaneal eversion, talar abduction, and dorsiflexion. (From When the feet hit the ground ev­ erything changes. In Program Outline and Prepared Notes-A Basic Man­ ual. Toledo, OH: APRN , 1984)

The oblique midtarsal jOint axis crosses the frontal and trans­ verse plane with minimal angulation toward the sagittal plane. This axis gives rise to large components of dorsiflexion and abduction and a small component of eversion during pronation. Although complex, the biomechanics of the mid­ tarsal jOint can be thought of as depending on subtalar joint biomechanics. In a subtalar joint pronated position, the talar head moves medially and plantarly. In this position, the axes of the midtarsal joint are parallel, which promotes mobility in the midtarsal joint and forefoot. As the subtalar joint supinates toward a neutral and then supinated position, the axes of the midtarsal joint progressively converge. The con­ verging axes promote stability in the midtarsal joint and fore­ foot (Fig. 22-11). Subtalar joint pronation an~ supination is said to "unlock and lock" the midtarsal joint. 4 ,b

Gait Kinetics A thorough understanding of the kineSiology of gait is cru­ cial for developing a therapeutic exercise program promot-

A

L

FIGURE 22·9. Posterior view of right foot showing subtalar joint supina­

FIGURE '12·7. The axis of the subtalar joint is inclined 42 degrees antero­ superiorly from the transverse plane and inclined medially 16 degrees from the sagittal plane. (A) Superior view. (8) Lateral view.

tion. Supination is a triplane motion consisting of calcaneal inversion, ta­ lar adduction, and plantar flexion. (From When the feet hit the ground ev­ erything changes. In Program Outline and Prepared Notes-A Basic Manual. Toledo, OH APRN, 1984)

530

Therapeutic Exercise: Moving Toward Functio n

Stance Phase

extremity moves forward over the foot by way of talocrural joint dorsiflexion. Ideally, the talocrural joint moves to a position of 10 degrees of dorsiflexion before heel rise. Loss of talocrural dorsiflexion is a common phYSiologic impair­ ment, which can lead to further intrinsic and extrinsic phys­ iologic impairments (see Patient-Related Instruction 22- 1). As the lower extremity moves fOJ\vard, the subtalar joint supinates from a pronated position and passes from neutral to slight supination before heel rise. This supination pro­ gressively "locks" the midtarsal joint and promotes stabih h throughout the foot, creating a rigid lever for propulsion_ At th e forefoot, weight is progressed distally to th metatarsal heads. The knee and hip are extending through ­ out midstance, and the tibia and femur are laterally rotat­ ing. This lateral rotation is augmented by talar abduction and dorsiflexion and by subtalar joint supination. As the heel is hfted during terminal stance, the talocru­ ral joint flexes an additional 5 to 1.5 degrees of dorsiflex­ ion. The talocrural joint plantar flexes as the heel is lifted during terminal stance. The subtalar jOint and midtarsal joints remain supinated during these ph ases, maintaining a rigid lever at the foot. A relative pronation twist occu rs . at the forefoot. Moving into the swing phases, the talocru­ ral joint continues to plantar flex , the knee flexes, and tll lower extremity continues to laterally rotate until the toe has left the ground 4 ,.5

At initial contact, the talocrural jOint is in neutral position, and th e subtalar joint is slightly supinated. As the foot passes into loading response, the talocrural joint plantar flexes from 0 to 15 degrees, and the subtalar joint pronates. This pronation "unlocks" the midtarsal joint, creating mo­ bility throughout the foot. Shock absorption results from a com bination of subtalar pronation, calcaneal eversion, talar plantar flexion, knee flexion , and tibial and femoral medial rotation. Biomechanically, the knee requires medial tibial rotation for effective knee flexion. Talar plantar flexion and adduction during subtalar jOint pronation allows the re­ qUired tibial medial rotation. At the midfoot, midtarsal pronation occurs, and the forefoot has a compensatory supination_twist. This twist is relative to the position of the rearfoot. 4 ." As the leg moves into midstance, the lower

Swing phase begins with preswing and ends with initial contact. The s'vving phase of gait is in part responsible for effective propulsion. As the lower extremity moves fOJ\vard during s\.ving, developing momentum provides much of tlle energy for propulsion on the opposite extremity. If the lower extremity biomechanics are sound, ambulation i performed'vvith a low expenditure of energy. During swing phase, the lower extremity prepares itself for upcoming ini­ tial contact. By terminal s\.ving, the femur has medially ro­ tated to near neutral, the knee is near extension, and the ankle is dorsiflexed to the neutral position. The subtalar joint is slightly supinated and prepared for initial contact just lateral to midline of the calcaneus. 9

FIGURE 22·10. Midtarsal joint axes, The t'vvo axes are the (A) longitudi­

na l midtarsal joint axis and (B) oblique midtarsal joint axis, ing functional return, This section describes the phases of gai t, the relationship of gait to ankle and foot biomechan­ ics, the relationship of gait to hip and knee biomechanics (see Chapters 20 and 21), and muscle function during the gait cycle. Kinetics are discussed relative to the gait phase (Table 22_2)H.10

Swing Phase

Gait Kinematics A thorough understanding of muscle function during gait i necessary to prOvide specificity for exercise prescription and functional retraining. To be efficient and effective in exercise prescription, it is important to restore the type 01 muscle contraction and the precise phase of gait in which the muscle functions , In terms of closed kinetic ch ~ ' biomechanics, the muscles of the foot and ankle functioJ" eccentrically to decelerate motion , isometrically to stabiliz, motion, and concentrically to accelerate motion. Muscle often have double functions at hvo or more joints during the different periods of stance.

Stance Phase FIGURE 22·11. Locking and unlocking of the midtarsal joint. (A) Whenthe

axes are divergent, the midtarsal joint is locked producing a rigid foot. (B)The axes in the neutral, resti ng position of the foot. (C) When the axes are parallel, the midtarsal joint is unlocked, producing a flexible foot.

At initial contact, the anterior tibiahs and toe extensors fir to maintain the neutral talocrural position opposing a plan­ tar flexjon moment l l As the foot moves into loading re­ sponse, these same muscles work eccentrically to lower the

Chapter 22 The Ankle and Foot

531

Kinetics and Kinematics of the Foot and Ankle During Gait

PHASE OFTHE GAIT CYCLE

JOINT TALOCRURAL JOI NT SUBTALAR JOI NT TALOCRURAL JOINT SUBTALAR

Initial Contact

Loading response

TALOCRURAL JOI:'H SUBTALAR ~ OI ~T

Terminal stance

TALOCRURAL J OI~T

SUBTALA.R JOI NT TALOCRURAL JOINT SUBTALAR JOINT TALOCRURAL JOL T TALOCRURAL JOINT TALOCRURAL JOINT

Preswing

Initial swing Midswing Terminal swing

odeg dorsi flexion STJ supination Plantar flexes from 0-15 deg PF STJ begins pronating Dorsiflexes to 10 degDF STJ begins resupinating Dorsiflexes to 15 degDF STJ continues supinating Plantar flexes to 20 deerb PF STJ remains supinated Dorsiflexes to 10 degPF Dorsiflexes to 0 deg Stays at 0 deg

JOI ~ T

Midstance

RANGE OF MOTION

MOMENT

MUSCLE ACTIVITY

MUSCLE CONTRACTION TYPE

Plantar flexion

Dorsiflexors

Isometric

Varus

Isometric

Plantar flexion

Evertor muscles Dorsiflexors

Eccentric

Moving to valgus

Invertors

Eccentric

Moving to dorsiflexion Valgus moving to varus Dorsiflexion

Plantar flexors

Eccentric

Invertors

Varus

Evertors

Eccen bic to concentric Eccentric to concentric Isometric

Dorsiflexors

Dorsiflexors

Dorsiflexors

Dorsiflexors

Dorsi flexors

Dorsi flexors

Plantar flexors

Dorsiflexion Varus

deg, degrees of; DF, dorsiflexion; PF, plantar flexion; STJ, subtalarjoint.

Ankle Mobility and Walking Patterns To restore the most ideal walking pattern, you must have adequate ankle mobility. You will be asked to perform a specific exercise or series of exercises frequ ently throughout the day to improve your ankle mobility. The pictures show what your walking pattern should look like. Halfway through the step, you need the most ankle mobility. Be sure that your foot remains pointed forward and does not toe-out (Fig. AI. Be sure that you do not allow your arch to flatten (Fig. B).

A Normal arch

B

-JJ

Slight flattening

foot to the ground in opposition to the plantar flexion mo­ ment. At the subtalar joint, the peroneus longus and brevis fire to evert the calcaneus and initiate pronation. 12 . 13 As the foot moves from loading response to midstance, the tibia advances over the stationary foot, necessitating eccentric gastrocnemius and soleus activity to decelerate the advanc­ ing tibia. At the subtalar joint, the tibialis posterior, fl exor digitorum longus , and flexor hallucis longus also work ec­ centrically to control the pronating foot. This eccentric work is minor during slow walking, but it Significantly in­ creases during fast walking and running. The tibialis posterior functions to accelerate resupina­ tion and provides medial longitudinal arch stability during midstance 14 When moving from midstance through preswing, the gastrocnemius-soleus complex continues fir­ ing eccentrically until preswing, when heel lift is a relatively passive event. The peroneus longus also functions to plan­ tarly stabilize the first cuneiform and first metatarsal during these phases 1213 Plantar stability of the first metatarsal is important for normal push-off and weight distribution across the metatarsal heads during late midstance and preswing phases (see Patient-Related Instruction 22_2) 4.5

Alignment Alignment of the ankle and foot is an important component of function because of the interplay of alignment, move­

532

Therapeutic Exercise: Moving Toward Function

Maintaining the Long Arch in Standing and Walking While walking, attempt to maintain the long arch of your foot during the weight-bearing period of the step. Avoid roiling onto the outside portion of your foot by attempting to keep your big toe firmly against the floor as you keep your long arch elevated. Exercises in sitting or standing positions can help you to feel this action (Fig. A). After you can feel this action during static postures. try to incorporate it into walking (Fig. B).

~

The subtalar joint must be assessed in both the non-weight-bearing and standing positions. The relaxed alignment of the longitudinal and transverse arches, tibia, talus, calcaneus, and toes may change between the weight­ bearing and non-weight-bearing positions, demonstrating compensation (or lack thereof) for an abnormal forefoot to rearfoot relationship. Alignment of the tibia, foot, and an­ kle in a standing position should be as follows:

Sagittal plane • Plumb line alignment is slightly anterior to a midline through the knee and lateral malleolus and through the calcaneocuboid joint. • The navicular tubercle is on a line drawn from the medial malleolus to the point where the metatar­ sophalangeal joint of the great toe rests on the floor.

Frontal plane B

ment and the relationships among kinetic chain compo­ nents. Deviation from optimal alignment occurs in the form of anatomic or physiologic impairments. Alignment of the foot must be assessed from a subtalar neutral position. Subtalar neutral is the position in which the subtalar joint is neither pronated nor supinated. The position of the subtalar joint is assessed in the prone position and is found by palpating congruency of the talon­ avicular joint with one hand and loading the lateral side of the foot with the opposite hand. 15 Rearfoot alignment is the relationship between the bisection of the posterior cal­ caneus and the bisection of the distal tibia and fibula (Fig. 22-12). Forefoot alignment is the relationship between the posterior bisection of the calcaneus and a plane made by the plantar surface of the metatarsal heads. Each relation­ ship may be described as varus or valgus . The rearfoot and forefoot relationships are independent of each other and must be assessed separately.

FIGURE 22-12. Ideal rearfoot alignment. The plumb line bisects the cal­ caneus and talus. (From Gould JA. Orthopaedic and Sports Physical Ther­ apy 2nd Ed. St. Louis CV Mosby, 1990)

f

• The distal one third of the tibia is in the sagittal plane. • The great toe is not deviated toward the midline of the foot (i.e. , hallux valgus). • The toes are not hyperextended. The original classification system and criteria for the concept of subtalar neutral as described previously were developed by Root and coll eagues. 16 Although lower ex­ tremity problems have been treated for many years on the basis of this concept, the scientific and clinical foundations for this concept are questionable. There are several con­ cerns about the Root approach: 15.17 • The reliability of the measurement techniques to as­ sess normal and abnormal foot posture • The criteria for "normal" foot alignment • The proposition that th e subtalar joint reaches neutral between midstance and preswingli' Measurements of weight-bearing and non-weight­ bearing calcaneal and subtalar joint positions have sho\o\fJ1 low interrater reliability.18-21 Tllere is concern that clini­ cal treatm ent, which is based on these measurements. may be Similarly unreliable as a result. Moreover, on the basis of Root's criteria for normal foot alignment, most of the population (68% ± 27.5% based on a normal distIi­ bution ) should have normal feet. Studies of foot align­ ment in normal populations have found Root's norm al alignment in only 15% to 31 % of subjects studied. 19.:21 Another area of dispute is the position of the subtalar jOint during gait. Root and colleagues 16 have asserted that the subtalar joint reaches its neutral position at or Just af­ ter midstance. They based this assertion on the findings 0 Wright and coworkers,22 whose work was based on onl~' two subjects and whose definition of subtalar neutral was Significantly different than the one later used by Root Wright defined subtalar neutral as the resting position of the subtalar joint in relaxed standing. Recent litera­ ture based on videotape analysis of 100 subjects' gait pat­ terns indicates that the rearfoot actually reaches maxi­ mum pronation later in the gait . cycle than originall~' thought, and stays there until the end of the stance phase. returning only to the resting calcaneal position instead of subtalar neutral. 21

I

c

Chapter 22: The Ankle and Foot

The debate between these two schools of thought puts the clinician in a difficult position when evaluating and treating patients. At this time it is best to be aware of the pros and cons of each, and to choose your plan of care based on the best available research at the time, the char­ acteristics of your patient and the goals you and your pa­ tient have set for treatment. Descriptions of optimal alignments of the spine, pelvis, femur, and tibia can be found in Chapters 18 through 22. Alignment of the entire lower extremity must be assessed and treated because of the structural and functional rela­ tionships of the knee, hip, foot, and ankle (see Patient­ Related Instruction 22-3)

ANATOMIC IMPAIRMENTS Anatomic impairments throughout the lower extremity can lead to abnormal alignment and movement patterns of the foot and ankle. Conversely, anatomic impairments of the foot and ankle can lead to abnormal alignment and move­ ment patterns up the kinetic chain at the knee , hip, pelvis, and spine. Abnormal alignment and movement patterns (see Chapter 9) can result in excessive stress and strain on soft tissue and bony structures, leading to cumulative mi­ crotrauma and musculoskeletal pain. If left untreated, mi­ crotrauma can result in pathology of the musculoskeletal system that can affect function and lead to disability. ''''hen optimal alignment is lacking, the clinician must de­ cide whether the alignment fault results from an anatomic impairment or a phYSiologic impairment. An anatomic im­ pairment cannot be altered with manual therapy or exercise

Ideal Alignment of the Lower Extremity You should pra ctice good alignment of your hips, legs, ankles, and feet. Good alignment of your lower extremities helps to achieve normal movement. Your physical therapist wi" instruct you in exercises to help overcome problems that make it difficult for you to achieve normal alignment. The picture below can assist in understanding ideal alignment of the hips, knees, ankles, and feet. Practice this alignment frequently throughout the day. Soon, it wi" feel normal, and your old posture wi" feel abnormal.

533

intervention, because it is a fixed structural abnormality. However, it can be treated with orthotic therapy and exer­ cise to prevent associated phYSiolOgiC impairments from de­ veloping. A phYSiolOgiC impairment can be altered with ap­ propriate intervention, such as joint mobilization , soft-tissue mobilization and stretching, and muscle strengthening. The follOWing impairments are described as if struc­ tural, and they are therefore listed as anatomic impair­ ments. Physiologic impairments are discussed in the con­ text of therapeutic exercise intervention.

First Ray Hypermobility First ray hypermobility is defined as a dorsal translation v.rith a soft endpOint. Structures responSible for first ray sta­ bility are plantar ligaments, extrinsic muscles inserting onto the first ray, and the plantar aponeurosis. Any changes in these structures can lead to abnormal function and pro­ gressive deformity of the first ray. If deformity develo~s in the first ray, functional stability is often compromised.-3

Subtalar Varus Subtalarvarus is gefined as an invt'rted twist within the body of the calcaneus." While the foot is held in the subtalar neu­ tral position, the bisection of the posterior calcaneus is in­ velted relative to the bisection of the distal tibia and fibula (Fig. 22-13). A subtalar varus posture may result in exces­ sive pronation during loading response and midstance. The subtalar joint may resupinate in midstance; however, if the excessive pronation is sicrnificantly large, the subtalar joint may not reach the desired neutral to slightly supinated po­ sition before heel lise. This may result in decreased stabil­ ity at the midtarsal joint during propulSion , thereby in­ creasing the shearing forces in the forefoot and causing potential strain on supportive soft-tissue structures.

Forefoot Varus Forefoot varus is an inversion deviation of the forefoot rel­ ative to the bisection of the posterior calcaneus (Fig. 22­ 14).4 A forefoot varus posture may result in excessive

B

FIGURE 22-13. Posterior view of right foot subtalar varus. (A) Uncom· pensated subtalar varus. (8) Compensation for this impairment is usua lly excessive pronation. (From Gould JA. Orthopaedic and Sports Physical Therapy. 2nd Ed. St. Louis : C.v. Mosby, 1990.)

534

Therapeutic Exercise Moving Toward Function

EXAMINATION AND EVALUATION

A

~= 00

8

FIGURE 22-14. Posterior view of right foot forefoot varus. (A) Uncompen· sated forefoot varus. (B) Compensation for this impairment is usually ex· cessive pronation. (From Gould JA Orthopaedic and Sports Physical Ther­ apy. 2nd Ed. St. Louis CV Mosby, 1990)

pronation during midstance. As with subtalar varus, exces­ sive pronation results in excessive forefoot mobility during push off. Su pporting structures of the foot are strained, and lower extremity medial rotation takes place when lateral ro­ tation should he normally occurring. This rotational fault can contribute to symptoms up the kinetic chain in the knee, hip, pelvis , and lumbar spine.

Forefoot Valgus Forefoot valgus is an eversion deviation of the forefoot relative to the bisection of the posterior calcaneus (Fig. 22-15).4 A forefoot valgus posture may result in early and excessive supination in midstance phase. Functionally, this compensation creates a rigid lever, and adaptation to the terrain and shock absorption may be compro­ mised. There may also be a lateral weight shift, creating greater forces at the fifth metatarsal and potential lateral instability.

Examination and evaluation of the foot and ankle must consider the findings related to the foot and ankle and their relationships to the knee, hip, pelvis, and spine. The tests described in this section are primarily for the ankle and foot and should be considered in any foot and ankle examilla­ tion. However, examination of the knee and hip is essential as well.

R

Patient/Client History The patient's histolY gUides the overall examination and proVides the clinician with important information about functional limitations and disability. In addition to standard history and subjective examination questions, the clinician should inquire about usual footwear and daily activities. Using this information , the clinician chooses tests accord­ ing to the patient's symptoms and deSigns a treatment pro­ gram to address the impairments, functional limitations, and disabilities descrihed by the patient.

Balance Balance is an importallt area to assess when looking at foot and ankle dys function. See Chapter 8 for details.

Joint Integrity and Mobility Several special tests are used to assess the integrity of foot and ankle structures. Many of these tests are used to more closely assess the mechanics of the foot and ankle. Magee 24 provides a complete listing and description of speCial tests. some of the most common include varus and valgus stress testing of the ankle, and the talar tilt test.

Muscle Performance Muscle functioning at the hip, knee, foot , and ankle should be tested in a logical order and based on patient histOlY in­ formation and clinician's impression. Functioning of all an­ kle and foot muscles should be tested. Any proximal mus ­ cles in the back, hip, and knee that may affect the foot and ankle should be tested as well , as thcir weakness can coo­ tribute to mechanical faults distallv.

Examination of the patient's pain and inflammation is per­ formed as part of the subjective examination and is fUIth· . clarified during the objective examination. Complaints warmth , swelling, and local tendemess indicate pdin inflammation. Palpabl e tendemess and warmth ove r spe­ cific anatomic structures are objective indications of p~' or inflammation. This obiective information is correlat with subjective information to gUide the remaining exam,­ nation and treatment planning. 8

pensated forefoot valgus. (B) Compensation for this impairment is usually excessive supination. (From Gould JA. Orthopaedic and Sports Physical Therapy. 2nd Ed. St. Louis CV Mosby, 1990)

Ra

Ii

Pain

FIGURE 22-15. Posterior view of right foot forefoot valgus. (A) Uncom­

a..,

aL_

Posture Observation of posture and position of the lower extremi including the lumbopelvic and hip regions . is an import,

o

Chapter 22 The Ankle and Foot

aspect of the examination. 2426 Detailed foot and ankle alignment was discllssed previously in this chapter.

Range of Motion and Muscle Length ROM and muscle length examination for this region should inclmle both the foot and ankle as well as the knee, hip, and spine. These regions work in unison to produce smooth, coordinated movement throughout the entire limb. The following tests of ROM ana muscle length should be performed: • Hip and knee RO\lI and muscle length • Calcaneal inversion and eversion ROM • Y1idtarsal joint supination and pronation ROM • First rav position and mobilitv • Hallux dorsiflexion ROM ' • First to fifth ray mobility • Ankle dorsiflexion and plantar flexion ROM \.vith the knee fl exed and extended

Other Examination Procedures A variety of additional examination procedures may be used depending on the specific patient situation. For example, patients \v:ith diabetes should have sensory testing and as­ sessment of pulses. Anthropometric measurements such as circumferential measures are important in any patient \'lith swelling of the foot or ankle. Footwear and orthotic assess­ ment is necessary to evaluate proper fit, noting locations of excessive wear and tear. Finally, most patients should have a gait examination to determine the kinetics and kinematics of the foot and ankle during walking.

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON PHYSIOLOGIC IMPAIRMENTS Therapeutic exercise is an invaluable clinical tool for treat­ ment of physiologic impairments of the ankle and foot. This sedion provides examples of therapeutic exercise for the treatment of impairments in balance, muscle performance, pain, posture and movement, ROM, muscle length, joint mobility, and integrity. The clinician may need to make appropriate modifica­ tions based on individual signs and symptoms. Exercise recommendations for specific diagnoses of the ankle and foot are addressed in a later section.

walking to the mailbox compared with playing competi­ tive basketball) should be considered when designing proprioceptive training activities (see Patient-Related Instruction 22-4). An average person recovering from an ankle fracture should be able to balance on one leg for 30 seconds with eyes closed during a mild external perturbation (i.e., \v:ith a balance board, foam, a balance machine, or another person providing an external force). This prepares the person to regain balance encouraging improved neurological input to the ankle and foot musculature. Another patient may need to return to high-level gym­ nastics, and drills deSigned on a low balance beam would be appropliate. Plyol1wtric exercises in the form of progres­ sive height jump-dO\ovn activities prepare the ankle to bal­ ance during high-impact activities. Restoration of balance and coordination requires posi­ tion scnse. or proprioception. \Vith an ankle sprain or mus­ cle strain, these proprioceptive nerve fibers arc often in­ jured. The proprioceptive sense can also become deconditioned after a period of immobilization. The pro­ prioceptors should be retrained in a controlled, progressive manner staliing as soon as pOSSible. Use of a balance board can provide proportionate and progressive stress. The fol­ lo'.v:ing exercise progression can be used at home \ovithout special equipment: • Balancing on one leg \'lith eyes open; progressing to eyes closed standing in a door fame \'lith hands close to the door jam for safety. • Standing on one leg on a pillow or couch cushion \v:ith eyes open; progressing to eyes closed.

Ideal Alignment During Walking You should atta in idea l al ignment during wa lking. The most diffi cult pha se to control is during the weight-bearing period of the step. Place the heel, ball of the foot, and toes down on the floor as three distinct areas. The heel should hit slightly on the outside border without turning the entire foot out. The weight line should progress from the outside of the foot toward the big toe. Attempt to maintain the knee over the toes, with the foot progressing straight ahead and the long arch of the foot held upward. If these alignments are maintained throughout the weight-bearing period, the foot should feel stable for push-off.

Balance Impairment The specific adaptations to imposed demands (SAID) principle states that the involved joint structures must be sufficiently prepared to assume the loads reqUired for the patient's chosen activities. A well-conditioned and neuro­ logically trained ankle is necessary to enable balance and function in a variety of directions as the center of gravity fluctuates. The patient must be able to control the ankle at extremes of motion while performing simultaneous ac­ tivities in other extremities. The level of activity (e.g.,

535

t

536

Therapeutic Exercise: Moving Toward Function

Single-leg balance can also be progressed by swinging the uninvolved lower extremity first in flexion and extension and then in abduction and adduction (see Self-Management 22­ 1: Balance Activities). The faster and greater excursion of the swing, the more the static stance is challenged. Elastic bands can be used for the advanced patient. An elastic band is tied in a circle and looped around a table leg or similar secure structure. Standing toward the table leg, the patient puts the uninvolved ankle inside the cir­ cled elastic band. While balancing on the involved foot , the patient is instructed to extend their hip against the elastic band. The patient performs extension-flexion oscil­ lations before returning to double-limb support. The pa­ tient then turns 90 degrees and performs adduction-ab­ duction oscillations into the band (Fig. 22-16). The rotating continues until the patient returns to the initial starting position. The exe rcise can be progressed by in­ creasing oscillation repetitions , oscillation speed, upgrad­ ing the tension of the elastic band, or adding foam or a balance board with single-limb SUppOlt.

SELF-MANAGEMENT 22· '

Balance

Activities

FIGURE 22·16. Resisted hip adduction retrain s balance and propriocep, tion on the weight-bearing limb. A chair or other stable surface mu st Ir available to ensure patient safety.

Purpose: Increased balance on a single leg

Muscle Performance

Position: Standing on one leg, near a counter or in a

Resisted exercise is used to restore musc:le perform,me because of muscle strain, neurologic deficit, or disuse. A.­ though open chain exercise is useful to improve physiol o!:' strenf-,rth parameters and patient awareness of muscle fun tion (i.e., muscle re-education) , it is critical to progress tl exercise to weight-bearing activities as soon as tolerated. many cases, closed chain activity can be broken into si mp steps and serve as a starting point for exercise prescripb

doorway to provide a surface to stabilize if necessary

Movement technique: Level 7: Practice standing on a single leg with your Level 2: Level 3: Level 4:

eyes open for 30-second periods Eyes closed Standing on a pillow with your eyes open Standing on a pillow with your eyes closed

Dosage Repetitions: _ _ _ _ __ Frequency _ _ _ _ __

Intrinsic Muscles Intrinsic muscle strengthening can be performed in a ting position with the pati ent's feet placed on the end towel lying on the floor. The patient flexes his or her t, attempting to draw the towel under the foot. An altem ' benefit \-vith the same positioning is to make an areh w " the tarsal and metatarsals then relax. Repeat this proc. holding for 6 seconds (see Fig. 22-17). Using the toe pick up marbles and other small objects also exercises' intrinsic musculature. Standing \-vith a resistive band a1 _ the bottom of the foot and pulling the toes into exte can be used to resist toe flexion (see Self-Management 2: Resisted Toe Flexion). These exe rcises are low inten and may require high repetitions to achieve a training fect. Maintenance of the longitudinal and transverse arc... during closed chain exercises such as small knee bends . . walk stance position, stair-stepping, and gait use the in sic musculature in a functional manner. Care must be t to prevent unwanted hammer or claw toe positions dur­ functional training drills.

=­

Extrinsic Muscles Open chain strengthening exercises for extrinsic muse: ture can be performed with elastic bands or tubing.

Chapter 22 The Ankle and Foot

----------------------------------------------------~------

537

the plantar surface of the forefoot. \Nhile holding the op­ posite end of the band, the patient plantar flexes against the resistanee of the band (Fig. 22-18). Slow, eccentric length­ ening to a dorsiflexed position should be emphasized be­ cause of the gastrocnemius muscle's deceleration function dUling gait. A towel roll or small pillow placed under the leg, proximal to the talocrural joint, is helpful in providing heel clearance. Resisted talocrural dorsiflexion and subta­ lar joint pronation and supination can be completed with an elastic band looped around a table leg or similar secure structure. The patient performs the intended movement against the resistance of the band (Fig. 22-19 ). Care must be taken when performing pronation and supination to en­ sure the motion is at the subtalar joint and not at the tibiofemoral or hip jOint. A pulley and weight stack system can also be used for resistance. Slow, eccentric lengthening FIGURE 22-17. Intrinsic muscle strengthening of the foot. should be emphasized because of the deceleration function of these muscles during gait. Closed chain , weight-bearing strengthening exercises must be taken not to overload weak muscle groups , which are a natural progression toward return to functional activ­ Illay cause unwanted substitution patterns and abnormal ity. Talocrural jOint plantar flexors can be strengthened by a performing double-leg toe stands off the end of a stair step. .joint shearin 0 and pain. Muscles need to be recruited in isolation before they can be strengthened in functional ex­ Emphasis is placed on eccentrically controlling a descent to ercises to help eliminate substitution patterns. end-range talocrural dorsiflexion without excessive prona­ Resisted talocrural plantar fl exion can be achieved in a tion or eversion (Fig. 22-20). This is followed by concentric long-s itting position with the elastic band \wapped around lifting to a neutral or slightly plantar-Hexed position with­ out excessive supination or inversion. The exercise is pro­ gressed by shifting weight toward the involved extremity and eventually performing a single-heel lise. Dynamic ankle strengthening and stabilization can be SELF-MANAGEMENT 22-2 Resisted Toe performed in a sitting position "vith the knee at 90 de­ Flexion grees with the foot in contact of a small physioball (see Fig. 22-21). Purpose: Increased strength in toe flexor and intrinsic Subtalar joint supinators can be strengthened by per­ foot muscles forming double-leg arch lifts. In a standing position, the pa­ tient is instructed to lift both arches, thereby rocking out­ Position: Standing with your fo ot along the length of the resisted band and with the band in one hand. ward to the lateral portion of the feet. Care must be taken pull up to pull toes up to maintain the great toe in contact with the floor to involve the peroneals and their role in stabiliZing the first ray. Slow, Movement controlled lowering to a neutral position is emphasized. Ex­ technique: Holding the band in this position. curl your ercise intensity is increased by progressing body weight toes down against the resistance of the band toward the involved extremity.

Dosage

Repetitions: _ _ _ _ __ Frequency _______

Pain The key for an effective exercise prescription for treating pain is in prescribing the appropriate intensity of exercise. Severity, irritability, and nature of pain must be assessed and used in the development and progression of exercise. For example, exercise for the involved joint should be

FIGURE 22-18. Resisted plantar flexion with a resi stive band should em­ phasize plantar flexor--controll ed eccentric dorsiflexion.

538

Therapeutic Exercise Moving Toward Function

I

A Pronation

B Supination

FIGURE 22-19. Resisted supination and pronation with the knee flexed. Flexi ng the knee minimizes hip rota tiorl substitution. (A) Resisted prona­ tion. (8) Resisted supination.

initiated in pain-free range in the acute stage, just up to the painful range in the subacute stage, and slightly into the painful range in the chronic stage. Active assisted exercise may be required if the patient demonstrates poor active control. Exercise for the involved side's hip and knee may be indicated to prevent disuse weakness and can decrease pain. In many situations, stationary biking is tolerated well and can maintain cardiovascular and musculoskeletal health. Soft-tissue mobilization, cryotherapy, electrical stimulation, and a variety of other therapeutic modalities may be beneficial in conjunction with exercise for the con­ trol of pain and swelling. Generally, the ultimate treatment of pain is to deter­ mine the biomechanical cause of pain. This chapter pro­ vides the reader with the theoretical framework and sam­ ple exercise options to diagnose and treat the underlying cause of pain.

FIGURE 22-21. The therapist provides perturbations to the physi o!).; while the patient maintains a neutral position of the knee and foot. Te. ­ crease dilficu lty. start with predicted patterns and move to unp re dic '~ patterns or close the eyes for an additional challenge witll perturbatio" '

Posture and Movement Impairment

FIGURE 22-20. A standing toe raise wi ll strengthen a number of muscles throughout the foot and ankle as media l. lateral. and intrinsic muscles sta­ bilize the foot and ankle whil ethe gastrocnemius and soleus muscles plan­ tar flex the ankle .

Posture and movement impairm ents are often treated multaneously in the foot and ankle. Ideal alignm ent a: movement should be emphaSized, regardless of what i pairment or combination of impairments are heing dressed. The most common faulty movement patterns affec the ankle and foot complex are excessive pronation supination. These abnormal patkrns sliould not be r forced in prescribed exercise. The impairm ents rcspollSi for excessive pronation (e.g. , short gastrocnemiu s, talocrural jOint, forefoot varus , weak posterior tibii1 or supination (e.g., hypomobile first ray, hypomolc supinated talus post immobilization, short posterior tibia. must be treated speCifically and ultimately dealt \-vith d ing a functional achvity. Numerous repetitions of exercise developed from co ponents of gait (e.g., walk stance, Single-limb stance, stt. through) should be employed frequ ently throughout ~ day to alter neuromuscular function and change a habit faulty movem ent pattern. SpeCifiC functional exercise can be preSCribed to fu rtl: reinforce ideal posture and movement habits. The goal functional exercise progression is to control a variety of n tions into and out of the static position at varying spe' The functional exercise program should be consistent \\ the patient's activity level and functional goals. Trun k a.

Chapter 22 The Ankle and Foot

lower extremity alignment, strength, mobility, and move­ ment patterns must be assessed and treated during a func­ tional exercise program . Functional exercise can begin early in the rehabilitation process, depending on the nature of the injury. Because gait is a primary functional goal, the patient is encouraged to use a three-point gait pattern with walker or two axillary crutches in conjunction with controlled partial weight bearing and a near-normal gait pattern (i.e. , heel-to-toe pattern). Amhlllation on a painful foot without an assistive device results in compensations and abnormal gait biome­ chanics. These abnormal biomedHlnics can lead to cumll­ lative stress affecting the involved extremity, trunk, and un­ involved extremity. These co mpensations can develop into habits that are difficult to alter l l Assistive devices are valuable in performing static aVld dynamic weight-shifting drills in preparation for we,ight­ bearing. Static weight-shifting drills are completed by pro­ gressively shifting weight toward the involved foot. A bath­ room scale, indicating the amount of weight-bearing, can be used for ohjectivity, control, and motivation. D)'11amic weight-shifting d!rills are performed with the patient's in­ ,"olved foot stable on the floor and the Ilninvolved extrem­ ity stepping forward and bac""ward. This drill can increas'e weight-bearing tol erance , promote hee l to toe weight transfer, and facilitate talocrural dorsiflexion. Medial-lateral weight shifting can be facilitated through a circular weight-shifting drill. The patient uses an assistive device for balance and stands wi th weight equally dis­ tribllted over both feet. The patient is instructed to shift weight in a slow circular pattern , beginning at the fifth metatarsal head, The patient should then progress posteri­ orly to the lateral heel, medially to the medial heel, and an­ teriorly to the first metatarsal head. The drill can be per­ formed clockv"ise and countercloc](\vise. It may be easier for the patient to perform this drill with both lower ex­ tremities Simultaneously, As weight-bearing tolerance im­ proves , the drill can be progressed by increasing body weight toward a Single-leg stance. Functional drills such as retrowalking, Side-stepping, cross-over stepping, and resisted walking are also benefi­ cial for upgrading the patient's level of function . These drills are progressed by distance, speed, and adding resis­ tance through elastic tubing or a pulley and weight-stack system. Jumping down may be a critical functional de­ mand for athletes and persons retuming to medium and heavy occupations. This task can be initiated bilaterally on a 2- to 4-inch box. Ultimately, exercise must be progressed to higher levels of function (e.g., stair stepping, running, jumping, cutting, Sidestep over cones, slideboard, clock step) that are appro­ priate for each patient's goals (see Self-Management 22-3: Clock Step). Ideal alignment and movement patterns must be reinforced with each repetition Orthotic prescription or counseling about proper footwear may be necessary to promote ideal function (see Patient-Related Instruction 22-5). However, exercise in bare feet may be appropriate in lower to mid-level activities to ensure foot muscle function is providing the ideal align­ ment and move ment pattern instead of the orthotic or footwear providing external support. An exception is a

539

SELF-MANAGEMENT 22-3 Clock Step

Purpose: Improve dynamic stability, control, coordination and proprioception of the lower extremity

Position: Standing on involved lower extremity in the center of a circle with markers at each hour (i.e., like a clock)

Movement Technique: Single-leg squat with involved lower extremity while re aching out in a clock hour type pattern with opposite lower extremity. Toe touch with the out stretched lower extremity. Do this in clockwise and counterclockwise directions.

Dosage Repetitions _times for _seconds Frequency _ _ _ _ _ __

severe anatomic impairment (e.g., Significant forefoot varus), for which the use of a custom orthotic during all ex­ ercise is recommended.

Range of Motion, Muscle Length, Joint Integrity, and Mobility The talocrural, sub talar, and midtarsal joint have triplane axes and therefore demonstrate triplane motion. Passive and active assistive ROM (~xcrcisc for treatment of hypo­ mobility should fonow the triplane concept. Accessory joint mohility shoulu he assessed, and joint mobilization techniques should be initiated if indicated. Open chain active stretch can be progressed to passive stretch and eventually progressed to use of the new mobility during function .

540

Therapeutic Exercise Moving Toward Function

Talocrural Joint Purchasing Footwear Know your foot type. Your shoe size and width give a two­ dimensional picture of your foot, but your foot is a three­ dimensional object. Your foot's arch height affects the fit of your shoe. You can gauge your foot's arch height with a "wet test." Wet the sales of your feet, and then stand on a dry surface, su ch as a piece of cardboard, to leave an imprint of your foot. The imprint shows whether you have a flat (pronatedl, normal, or high-arched (supinatedl foot. Match the bottoms of the shoes you're considering with your foot type.

Normal

Supinated

Certain guidelines should be followed in addressing hy­ permohility impairments: • In the acute phase, the hypermobile segment must be protected from excessive motion by taping, bracing, casting, or more stable footwear. • Adjacent hypo mobile segments should be mobilized with manual therapy or mobility exercise to prevent excessive motion from being imposed on the hyper­ mobile segment. • Dynamic stabilization exercise should be initiated at the hypermobile segment. At the foot and ankle, dynamic stabilization exercise can be in the form of proprioception training (see the Balance Impairment section) and functional retraining (see the Posture and Movement Impairment section).

Talocrural joint dorsiflexion is a common limitation after in­ jury or immobilization of the foot and ankle. This limitation can result from a short or stifT gastrocnemius or soleus mus­ cle, froill talocrural joint hypomQbility, or both. The clini­ cian must rely on the examination to determine the source of hypomohility. Complaints of anterior ankle discomfort during dorsiflexion may suggest talocrural joint h)'T)omobil­ it)', posterior compartment soft-tissue restrictions, and or extensor wea:kness. Gastrocnemius and soleus stretchinL; are depicted in Figure 22-22. Care must be taken to preven't subtalar pronation while dorsiflexing at the talocrural joint If the patient is using the long-sitting position, the clinician must ensure proper patient positioning, avoiding posterior pelviC tilt and lumbar flexion due to short hamstrings. A cushion under the pelvis releases tension in the hamstring' and improves the patient's position (Fig. 22-22B). The supine position is an alternative to the long-sittin;:: position and can accommodate short hamstrings, maintain­ ing better !umbopelvic alignment It has the added benefit of stretching the hamstrings without overstretching the lumbar spine. Talocrural joint dorsiflexion ROM can be performed in a lorrg-sitting position, but a pillow is placed under the knee to minimize the gastrocnemius and hamstring stretch. The soleus is stretched in this position if the talocrllraJ joint ha adequate dorsiflexion mobility (Fig. 22-22C). Lower ex­ tremity biomechanics must be considered when progress­ ing dorsiflexion ROM exercises to a weight-bearing posi­ tion. If the subtalar joint is pronated in stance, talocmraJ joint or gastrocnemius stretching will increase ci1e prona­ tion forces. Stretching should be completed with the sub­ talar joint in a neutral to slightly supinated position. The gastrocnemius can be paSSively stretched with the patien standing arm's length plus apprOximately 6 inches awa~' from the wall. The involved foot is positioned with its lat­ eral border perpendicular or slightly toe-in to the wall. It . important to be in this position, because gastrocnemiu. stretching in a toe-out position causes weight-bearing: forces to cross the medial longitudinal arch and promote increased subtalar joint pronation (Fig. 22-23). The use 0 a small hand towel folded under the medial longitudin a.. arch may help support the subtalar joint and midtarsal joint during stretching. These exercises should be incorporated into a patient" functional activities throughout the day. An active exercise such as small knee bends from a standing position, may re­ inforce functional mobility of talocrural dorsiflexion in­ stead of subtalar pronation. Progressing small knee bends to a walk stance position reinforces gastrocnemius length­ ening as the knee is in extension. Attention must foclls on maintaining a subtalar neutral position and avoiding a toe­ out position (see Patient-Related Instmction 22-1). Thera­ peutic exercise progression must involve functional re­ training of the new mobility during the swing phase of gait and during late midstance, when maximal dorsiflexion is r e­ qUired. During the late midstance phase, care must be taken to ensure a subtalar neutral position is maintained and that the foot is progressed wici10ut toeing-out. TheSE compensations avoid talocrural dorsiflexion and produce subtalar pronation and midtarsal abduction.

541

Chapter 22 The Ankle and Foot

FIGURE 22-22. Increasing dorsifl exion mobility of the ankle. (A) Long-sit­ ti ng gastrocnemius muscle stretch using a towel. (8) A cushi on under the pelvis relieves some ha mstri ng tension, allowing proper lu mbopelvic pos­ ture. (C) Talocrural joint and soleus muscle stretching IS empha sized by p'l acing a pillow under the knees.

B

A FIGURE 22-23. (A) The gastrocnemius muscle can be stretched by lean ing against a wall. Be sure to instruct the patient to keep the foot in the sagittal plane. Any turn-out of the foot will contribute to prona tory forces. (B)The soleus muscle can be stretched with the knee slightly flexed. Again, instruct the pati ent to keep the foot in the sagittal plane.

542

Therapeutic Exercise Moving Toward Function

Subtalar Joint Subtalar joint supination mobility can be addressed with the patient sitting with the involved distal leg placed on th e opposite knee. Fun active supination is performed, fol­ lowed by the patient using his hands to progressively pull the calcaneus and foot into greater supination (Fig. 22­ 25A). If combined with dorsiflexion, this exercise also stretches th e peroneal musculature . Subtalar joint prona­ tion mobility can be completed in a similar position by the patient actively pronating and applying graded oveq)res­ sure (Fig. 22-25B). If comhined with dorsiflexion, this ex­ ercise also stretches the tibialis postelior muscle. Thera­ peutic exercise progressions involve functional retraining of the new pronation and supination mobility during thr appropriate phase of the gait cycle.

Swelling

FIGURE 22·24. A step-down exercise is used to improve functional dorsi­ flexion. The patient must be able to control the promation component of this motion.

Step-down training can be used to facilitate controlled eccen tric lengthening of the calf muscle group and the knee and hip extensors. A patient stands on a 2- or 4-inch box and is instructed to maintain involved side heel contact while lowering the uninvolved heel to the floor (Fig. 22-24). This exercise is progressed by increasing the step height.

Swelling is often the result of impaired joint integrity and can become a chronic problem in the foot and ankle, be­ cause the ankle is the most dependent weight-bearing joint in the body. Early intervention is critical to efficiently treat this impairme nt. Low-level dynamic exercise and compres­ sion in conjunction with frequent elevation can be effectiYt' for control of swelling. Emphasis is placed on high­ repetition, low-inten sity dynamic exercise for adjacen non injured joints. For example, a patient with swelling a the rearfoot and pain on subtalar joint supination may be instructed how to perform elevated active toe flexion and extension and to perform midrange talocrural joint plantar flexion and dorsiflexion (see Self-Management 22-4: Tot' and Ankle Active Range of Motion). High-repetition exer­ cise can be preSCribed as multiple repetitions at one sittin!! but it is probably more effective if prescribed as moderat repetitions completed frequently throughout the da (e.g., every 2 hours) .

FIGURE 22-25. Passive stretching for triplane motion of the foot. (A) Subtalar joint supination. (8) Subtalar joint pronation.

~

Chapter 22: The Ankle and Foot

SELF-MANAGEMENT 22-4 Toe and Ankle

Active Range of Motion Purpose:

Increased mobility in the foot and ankle after an injury

Position;

Lying on your back with your foot elevated above chest level

Movement technique: Repeatedly flex and extend your toes. Move your ankle up and down or write the alphabet with your ankle

Dosage

Repetitions: _ _ _ _ __

Frequency _ _ __ - - ­

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON ANKLE AND FOOT DIAGNOSES Although therapeutic exercise intervention is based on the impairments, functional limitations, and disability of each patient, some generalizations can be made about common medical diagnoses. Celtain impairments are commonly as­ sociated with celtain diagnoses, and though this section is not exhaustive, it addresses the most common conditions encountered. The problems fall into the broad categories of localized inflammation (e.g., heel pain/plantar fasciitis , Achilles tendinosis , postelior tibialis tendinitis/tendinopa­ thy) , functional nerve disorders , connective tissue disor­ ders (ligament sprains ), and fractures.

543

where it arises from the medial calcaneal tuberosity on the anteromedial aspect of the heel. A common symptom is sharp pain at th e medial aspect of the heel. Because of the proximity of the medial calcaneal tuberosity and the origin of the plantar faSCia, it is not possible to clinically differen­ tiate a fascial from a bony source of pain. Dorsiflexion of the toes almost always exacerbates the patient's symptoms because of the windlass mechanism stretching the fascial fibers. Other structures may be painful besides the plantar fascia, and should be considered for differential diagnosis, including abductor hallucis , flexor digitorum brevis, or abductor digiti minimi muscles, the long plantar ligament, the nearby bursae, and the possibility of compression neuropathyJO

Treatment Management of plantar fasciitis is classified into three broad categories: decreas ing pain and inflammation, re­ ducing tissue stress, and restoling muscle strength and flex­ ibility to involved tissues 30 ,31 The cornerstone of conservative treatment for plantar fasciitis is modification of activity. For the running athlete, for example, mileage reduction, alternate activities, footwear evaluation, work reduction , and shortened work­ ou ts should be considered. Low- resistance cycling and swimming pool running are effective alternatives to run­ ning on land. The primary goal of treatment of plantar fasciitis in the acute stage is the control of pain and inflammation. Meth­ ods to control pain and inflammation include the use of nonsteroidal anti-inflammatory meuications,32 steroid in­ jection, iontophoresis, phonophoresis , ultrasound , deep tissue massage, cryotherapy, and hydrotherapy. Reduction in tissue stress is another method of treat­ ment for plantar fasciitis. Taping, foot orthoses, night splints, and modification of footwear are all methods of re­ ducing stress on the plantar fascia. Circumferential or low­ dye taping of the foot is usually beneficial as an initial in­ tervention to unload the plantar fascia and reduce inflammation (see Displays 22-4 and 22-5 for longitudinal arch strapping technique ).

DISPLAY 22-4

Preparing the Foot for Adhesive Strapping

Plantar Fasciitis The plantar fascia provides stability to the foot by increas­ ing the longitudinal arch during the propulsion phase of gait by means of the vvindlass mechanism.l ;).23,27-~9 Injury to the plantar fascia is a result of either intrinsic or extrin­ sic factors. Plantar fasciitis is considered an overuse injury with the most common cause being excessive pronation. Intrinsic factors include reduced plantar flexion strength, torsional malalignment of the lower extremity, obesity, and foot structure. Extrinsic factors include trainini3 errors and surfaces, improper or excessive worn footwear. 0,31 Excessive subtalar pronation, pes cavus, and medially shifted weight-bearing forces fatigue the plantar fascia

1. The foot must be clean and dry. Soap and water or alcohol wipes are used to remove perspiration and skin oils, which decrease the tape adherence to the skin. 2. Hair should be shaved to avoid irritation to hair follicles

and the pain associated with pulling hair out during tape

removal.

3. Skin should be sprayed with a skin preparation or

"toughener" that improves tape adherence.

4. Thin foam prewrap used before taping helps protect the

skin, but when maximal support is necessary, the tape

should be applied directly to the skin. Prewrap has been

used successfully when patients are limited to a medium

or low activity level.

544

Therapeutic Exercise: Moving Toward Function

DISPLAY 22-5

Longitudinal Arch Strapping Tech ni que Tape: 1-inch athletic tape. Taping position: Patient is supine on the treatment table, with his or he r foot over the edg e. Tapmg technique: Place two anchor strips circumferentially just proximal to the metatarsal heads (apply lightly). Begin the first diagonal strip of tape on the medial side of the foot, ju st proximal to the head of the first metatarsal. Ta pe posteriorly and around the heel. Angle the tape under the foot, crossi ng th e plantar surfa ce, and return medially near the origin of thi s strip (A). Place the second diagonal strip of tape on the lateral side of the foot, just proximal to the head of the fifth metatars al. Tape un der the foot, around the hee l, and up th e lateral side towa rd the origin of this strip (B) . Co ntinu e altern ating strips in the same pattern until the "fan" is filled in (e). Tie down the entire procedure by pla cing plantar strips over the previous strips by starting on the dorsolateral aspect of the foot; continue under the arch, and fini sh on the dorsomedial aspect of the foot. Leave a gap on the to p of the foot; bridge this by placing short strips of tape across the gap (0) and (E) . Each strip of tape should overlap the previous strip by approximately 1/4 inch.

In the subacute phase, progressive cross -fricti on mas­ sage and stretchin g of the plantar fascia helps guard against ahllormal scar formation and can improve plantar fascia ex­ tensibility (se(' Self-Managemen t 22-5: Plantar Fascia Step Stretch ). Long-term resolution of sYll1ptoms of plantar fasci itis can only be achieved by addressing the phYSiologiC impair­ men ts directly affecting the biomechanics of the plantar fascia. If pron ation is causing stress to th e plantar fascia, and a stiff talocrural jOint and or short gastrocnemius­ sole us complex are con tribu ting to the pronation, mobiliza­ tion to the talocrural joint or stretching of the gastrocne­ mius-s ulcus complex is indicated. In conjun ction wi th mohilization and stretching, strengthening the tibialis ante­ l;or and extensor digitorum is critical to maintain and use dorsiflexion range dU ling functional activities. If intrinsic muscle weakness is contri bu ting to loss oflongitudinal and transwrsv arch support, strengthening can be initiated to promote dynam iC stabi lity agai nst excessive prona ti on. In addition, lower extremity alignment, muscl e fl eXibi lity. muscle pe rformance, and movement patterns must be as­ sessed for ('xtrins ic pronator), factors. Functional exercis and proplioceptive training should be initiated to redue pronatory forces and improve talocrural dorsiflexion.

SELF-MANAGEMENT 22-5 Plantar Fascia

c 6 f--..---'1

~

3 2

1 D

.,-----,

E

Abnor mal intlinsic rem·foot and fo refoot align ment must be assessed for potential Olthotic therapy. Proper Olthotic p resCliption with approp riate fo refoot and rearfoot posting can SUppOlt the plantar fascia without diJ"ect p ressure on the soft tissue underneath the longitudinal arch. Recent litera­ tUTe supports the use of economi c prefabricated or over-the­ counter orthoses over eX'Pensive custom orthotics. 33 Care must be taken to assess th e need for Olthotics as a long-term solution to the problem. By preventing plantar flexion dmi ng sleep, night splin ts can be another helpful tool in the man agem ent of plantar fasciitis. Low load and long duration are some of the best methods for stretching tissue. Using a ni gh t splint provides a shorter recove ry time versus standing gas trocn e miu s­ soleus complex stretching. 34 Shoe modification, such as a medial heel wedge to limit p ronation. is yet another manageme nt techni que, as is hanging shoes to provide a fi rm heel counter to control rerufoot motion, or laCing shoe!; to provide control uf mid­ [00t. 31

Step Stretch Purpose:

Increased flexibility of the plantar fasc ia

Position:

Standing with the toes extended against the vertical part of a step and the heel on the floor

Movemenr technique: Slowly bend the knee above the toes you

are stretching back. Keep your arch from rolling in.

Dosage Duration Repetitions: _ _ _ _ __ Frequency _ _ _ _ __ _

p

o

\"{

d th

jo m

t:"

R

Chapter 22 The Ankle and Foot

Posterior Tibial Tendon Dysfunction During open chain mechanics, the tibialis posterior in­ verts and plantar flexes the foot, whereas during closed chain mechanics, it decelerates subtalar joint pronation in the loading response phase and supinates the subtalar jOint in the midstance and terminal stance phases. 35 The mechanism of posterior tibial tendon dysfunction is usu­ aIly excessive subtalar joint pronation and results in ac­ quired flatfoot deformity. However, the tendon can be strained because of poor physical condition or by exces­ sive physical activity. This dysfunction is most common in females who are obese and in their fifth and sixth decade of life and live sedentary lifestyles. 36 The least common mechanism of injury is an eversion ankle sprain. Symp­ toms are commonly located at the distal one third of the medial tibia or inferior and posterior to the medial malle­ olus resulting from a zone of hypovascularity that corre­ lates to the region of tendon pathology.3G Typical symp­ toms include tenderness to palpation along the tendon, pain, and or weakness with resisted inversion and plantar flexion, and pain with closed chain pronation. Walking can become painful if accompanied by excessive pronation. Running, cutting, or jumping can become painful because of recruitment of the posterior tibialis during deceleration activities. The patient may note feeling increasingly unsta­ ble at the ankle, indicating altered proprioception, strength, and coordination.36

Treatment As in plantar fas ciitis , a primary goal of treatment in the acute phase is to control inflammation with appropriate medications and therapeutic modalities. Arch strapping is beneficial for controlling end-range pronation , which de­ creases the strain on the tibialis posterior muscle. Pain-free, low-intensity, high-repetition, open chain plantar flexion and inversion exercises should be initiated early in the rehabilita­ tion process to control pain and inflammation . Open and closed chain strengthening exercises are initiated as toler­ ated in the subacute phase. Assess intrinsic and extrinsic pronatory factors and use orthotic therapy and functional ex­ ercise as indicated for long-term resolution of symptoms a7 Non-weight-bearing short leg casting may be necessary for 4 to 6 weeks for patients with evidence of a partial tear signified by delayed heel varus \vith toe raises and weak­ ness. 36 Resolution of posterior tibial tendon dysfunction re­ sistant to conservative treatment often involves surgery be­ cause of the progressive nature of the disorder. 36

Achilles Tendinosis Overuse pathology of the Achilles tendon is one of the more common tendon injuries of the lower extremity.38-44 It is particularly prevalent among persons participating in running and jumping sports. The Achilles tendon functions eccentrically to lower the heel to the floor when landing from a jump. The tendon is also stressed during the late midstance phase of gait, when it elongates to slow the ad­ vancing tibia. This stress is particularly high when walking or running uphill , when the tendon must slow the tibia ec­ centrically but propel the body uphill concentrically.

545

The tendon is parbcularly susceptible to injury approxi­ mately 2 to 6 cm above its insertion into the calcaneus be­ cause of a poor blood supply.45 The blood supply decreases with age, predisposing this area of the tendon to chronic in­ flammation and possible rupture. 46 Recent research into chronic Achilles tendinosis has re­ vealed the findings of high concentrations of an excitatory neurotransmitter, glutamate in the tendon and absence of inflammatory cells. This may explain why treatment strate­ gies aimed solely at reduCing inflammation ~r~ mildly suc­ cessful and why this condition is so painfuI. 4.>4i The Achilles tendon is also susceptible to rupture. The typical patient sustaining a rupture is a middle-age, com­ petitive person involved in intermittent athletic activities. Chronic degeneration is observed in most ruptured ten­ dons , although the majority of ruptures occur 'without any preexisting complaints 48 At the time of rupture, the pa­ tient complains of feeling as ifhe or she had been kicked in the back of the leg, despite the fact that most ruptures are the result noncontact injuries. A defect may be palpated, and the Thompson test result is positive. Treatment of Achilles tendinosis should follow the guidelines in Chapter 11. Stretching is essential to increase the length over which the tendon loads can be dispersed, but only after talocrural mobility is restored; otherwise, excessive tension is placed on the Achilles if not accompanied by talocrural motion. Stretching should be performed with the knee straight, iso­ lating gastrocnemius muscle, and the knee bent isolating soleus muscle, with care taken to maintain a neutral foot position (see Fig. 22-23). Strengthening exercises are an important intervention, but should only be introduced following appropriate recov­ ery of the acute inflammation to avoid exacerbating the pa­ tient's condition. Focus is on progression to eccentric exer­ cise such as controlled lowering from a plantar-flexed to dorsiflexed position. Eccentric calf strengthening in pa­ tients with painful chronic Achilles tendinosis results in sig­ nificantly better results than compared to concentric strengthening. 39 .49 The speed should be gradually in­ creased to progressively challenge this muscle group (see Self-Management 22-6: Hop-Down Drills). Achilles tendon ruptures are treated conservatively with immobilization in a cast or cast boot for as long as 12 weeks, followed by progressive rehabilitation as outlined for Achilles tendinitis. The effects of immobilization and the damage to the Achilles tendon must be considered in plan­ ning activities . Mobility activities to restore the length ofthe gastrocnemius-soleus complex and restore the mobility of the talocrural joint are necessary. Surgical treatment is com­ mon after rupture and is discussed in the Surgical Proce­ dures section.

Functional Nerve Disorders Assessment of impairments associated with nerve dysfunc­ tion affecting muscles of the lower leg, ankle, and foot should always begin with screening of proximal entrapment sites. Paresis or paralysis of muscles innervated by the pos­ terior tibial or common peroneal nerves can be the result of lumbar spine impai rme nt. After the spine has been ex­ cluded as the source of the nerve disorder, other entrap­

546

Therapeutic Exercise: Moving Toward Functior'1

SELF·MANAGEMENT 22·6 Hop-Down Drills

Purpose: Increased balance and coordination during dynamic movement, impact loading, and controlled lengthening of the Achilles

Position: Standing on a small step of about 4 inches

Movement technique: Hop down onto both feet, controllin g Levell: the landing.

Level 2:

Hop down, landing on a single leg.

Dosage

Repetitions _ _ _ _ _ _ __ Frequency ________

ment sites in the bip (e.g. , piriformis syndrome ) should be ruled out. Many nerve disorders are considered to be functional, which means that th e nerve is compressed dmil1g functional activity. l\erves can be compressed by bony impingements, compartm cnt syndromes, or as a result of joint hypcnnobil­ ity or instability. Occasionally, a nerve can be compressed in multiple locations. It is impOliant to understand the anatomy and innervation patterns to di.agnose and treat nerve disor­ ders appropliately (see Review of Neurology). Nerve com­ pression or entrapment may resolve with shoe changes, or­ thotics, or alteration of impairments in alignment, mobility, and movement patterns through the application of thera­ peutic exercise. The followillg sections describe selected sites for injury, compression, or entrapment of the posterior tibial and common peroneal nerves and branches.

Tibial Nerve The tibial nerve is injured less frequently than the common peroneal nerve because of its deep and prote cted position within the popliteal fossa. If a lesion or entrapme nt occurs in th e popliteal fossa , all of the calf muscles and plalltar mus­ cles of the foot are affected. A comprete lesion in the popliteal fossa results in a shuffling gait and difficulty rais­

ing the heel during propulSion because of the loss of ankle plantar flexors. The unopposed action of the muscles inner­ vated by the common peroneal nerve can lead to an in­ creased concavity of the longituninal arch of the foot (i.e, pes c(\\'lls ) and clawing of the toes. Sensory loss occurs on the sole of the foot and the plantar surfaces of the toes. Painful disorders, such as causalgia, are com mon with in­ complete or irritative lesions. If entrapment is suspected, the muscles surrounding the popliteal fossa must be assessed for length. If the popliteus. plantaris, and gastrocnemius are short, the tibial nerve may be co mpressed. Appropriate stretching and changes in alignm ent and movement patterns that perpetuate muscle sh ortening may alleviate the pressure and reduce nerve com pression . A more common disorder affecting the tibial nerve is tarsal tunnel s}'11drome. Signs and symptoms include burn­ ing, tingling, numbness , pain in the medial portion of th ankle and or the plantar aspect of the foot, local tenderness behind the medial malleolus , and a positive Tinel sign , These signs and symptoms should betEresent but often the complete constellation is not found. 5 ,51 The tarsal tunnel is a fibro-osseous tunnel formed by the flexor retinaculum , the medial wall of the calcaneus, the posterior portion of the talus, the distal tibia, and the me­ dial malleolus. The tibial nerve travels through this tunnel and may be compressed behind the medial malleolus un­ der the retinacular ligament. Compression leads to an in­ sidious onset of weakness of toe flexion, abduction, and ad­ duction and sensory impairment of the medial and lateral side of the sole of the foot and toes.-52 ,53 "\lith a hypennobile subtalar joint, the posterior tibial nerve is stretched by a prominence of the posteromedial talus. Intervention for compression or entrapment in tIlis region should include treating the impairments associated with subtalar pronation, This may involve stretching a short gastrocnemiUS , strengthening a weak posterior ti b­ ialis, educating the patient regarding altered postural habits , and instructing the patient in proper foot biome­ chanie's during components of gait. Improved biomechan­ ics durin g gait and other functional activities are the goal. In conjunction with exercise, the lise of appropriate foo twear alone or with orthotics to control excessin " pronation may be necessary for complete resolution of symptoms related to nerve compression .

Peroneal Nerve T he common peroneal is the most commonly injured nen "e in the lower limb , primarily because of its exposed position as it winds around the neck of the fibula. Injury causes pare­ sis or paralysis of all th e muscles supplied by the deep and superfiCial peroneal nerves. The result is a loss of dorsiflex­ ion and eversion of the foot and extension of the toes , pro­ ducing footdrop and a steppage gait. An accompanying 10 of sensation occurs in the front of the lower leg, dorsum 01 the foot , and adjacent sides of all toes. Recurrent an kle sp rains may also result from peroneal "veakness. A thorough knowledge of allatomy, innervation patterns , and fUl1ctiof' of the affected muscles during gait is necessary to develop an appropriate exercise program during the stages of nel'\' recovery. Care must be taken to prevent fatigue of a muscl

TI

Chapter 22: The Ankle and Foot

recoverin a from a nerve injury. An extemal support (i.e., dorsiflexion assist spLint) is usually necessary during the early phases of recovery, when the muscles are weakest. The deep peroneal nerve may become entrapped dis­ tally under the extensor retinaculum, a condition known as anterior tarsal tunnel syndrome. Trauma often plays a role. Recurrent ankle sprain places the deep peroneal nerve on maximal stretch as the foot plantar flexes and supinates. Tight-fitting shoes or ski boots have also been implicated. Compression of the deep peroneal ne rve usually results in pain radiating into the first web space. The extensor diPito­ 54 n Ull brevis may be weak or atrophied. F or patients with antelior tarsal tunnel syndrome, en­ sure that nerve compression is not caused by poorly fitting footwear. If the ankle is hypennobile or unstable, associ­ ated impairments should be treated with appropriate ther­ ape utic exercise, footwear, bracing, taping, or orthotics to reduce excessive stretch of the deep peroneal nerve. One clinical provocative test for tarsal tunnel is maxi­ mally evert and dorsiflex the foot while all of the metatar­ sophalangeal joints are maximally dorsiflexed. This clinical test is help~u1 in increasing the sensitivity of the physical ex8mination. "o Exercise may include strengthening the per­ oneals , combined vvitl1 drills to train ankle proprioceptors and help prevent recurrent ankle sprains.

Ligament Sprains Ligament sprains are the m_os~ common sports-related in­ juries to the foot and ankle:'s-"s Between 70% and 80% of the sprains involve the anterior talofibular ligament ( TFL), calcaneal fibular licra rnent (CFL), or posterior talofibular ligament (PTFL).:t'(;59-GI Ligaments of the mid­ foot, including the dorsal calcaneal cuboid and the bifurcate ligament, may also be involved. The mechanism of injury is usually an inversion and plantar flexion twist. Isolated in­ juries of the ATFL constitute 65% of ankle sprains, and a combination injury involving the ATFL and CFL comprise 10% of the cases. Isolated injury of the CFL or PTFL is rare. Li gam e nt sprains are generally classified as one of three grades : • Grade I represents minor tearing vvith no functional loss of ankle stability. • Grade II represents partial tearing of the ligament with moderate instability. • Grade III describes a complete rupture with signifi­ cant functional instability. Grade III sprains are further classified by degrees of in­ jury. First-degree sprains suggest complete rupture of the TFL. A second~degree sprain is a complete rupture of the T F L and CFL. A third-degree sprain suggests a disloca­ tion in which the ATFL, CFL, and PTFL are ruptured. 62 The patient can usually recall the mechanism of injury, and there is usually a specific site of pain and tendemess. A sprain ultimately has edema of the area. Ecchymosis may occur, indicating injury to blood vessels in the area. Spe­ cific stability testing of the affected ligaments may produce guarding and pain . Syndesmosis sprains are common and often occur in combination with other injuries . A syndesmosis sprain is a

547

disruption of th e distal tibiofemoralligaments, resulting in diastasis, Or vvidening of the mortise at the talocruraljoint. The mechanism for syndesmosis disruption is external ro­ tation on a fixed foot or extreme dorsiflexion. These me ch­ anisms force the talus into the morti.se formed by the tibia and fibula , widening this space and disrupting the distal tibiofibular ligame nts. If missed on initial evaluation, the patient may subsequently complain of postelior ankle p<1in, particularly when trying to push off of the involved ankle . Failure to recognize and treat a significant syndesmOSiS sprain can produce widening of the mortise and seve re de­ ge nerative jOint disease. Weight-bearing radiographs are necessary to assess the integrity of the tibiofibular juint in a suspected syndesmosis sprain. Healing of a ligament sprain, as in most soft-tissue in­ juries, follows a process of inflammation, repair, and re­ modeling. These events are sequential, but each phase of healing overlaps another. Optimal healing occurs when the introduction of exercise and functional activity is appropri­ ate for each phase. Controlled stress promotes healing and results in a stronger repair, but excessive loading can inter­ rupt healing and prolong the inflammatory process. T he time needed for healing depends on the grade of injury, and clinical decisions should be based on signs, symptoms, and functional assessments 62 The initial treatment croals focus on controllin a inflam­ mation and associated pain and swelling. Treatment of grade I and II ankle spraills during the first 1 to 4 days in­ cludes protection, rest, ice, compression , and elevation (PRICE ). Gradual, early weight-beari ng6J is allowed and encouraged, but the injury must be protected with an ex­ ternal support in the form of a semi-rigid ankle support 64 Severe grade I and grade II sprains may need axillary crutches for additional protection during ambulation. Pa­ tients are instructed to elevate the foot higher than the heart in conjunction with ice applications. Compression with an elastic wrap is benefiCial, espeCially when the foot is in a dependent position . Elevated edema massage and vasopneumatic compression are also helpful in controlling pain and swelling. Midrange active dorsiflexion and plantar flexion ROM exercises are initiated early, with care not to elongate the injured ligament. Progress exercise as pain and swelling are con trolled and weight-bearing tolerance increases. Open chain inversion ROM is progressed as tolerated . Dorsiflexion ROM and calf flexibility can be treated more aggreSSively. Weight­ shifting drills performed with full or partial weight bealing and with an extemal support h elp to maintain muscle tone and promote balance reactions (see Self-Management 22­ 7: Dynamic Weight Shifting and Self-M anagement 22-8: Medial!Lateral vVeight Shifting). Proprioception boards are helpful, but exercise must be controlled to prevent in­ terruption of the repair process. Toe raises off of a step help maintain strength and fleXibility of the calf. Trunk, hip , and knee exercises are helpful in preventing the obvi­ ous effects of inactivity. Remodeling of new collagen is under way 3 to 6 weeks after an injury. Restoration of proprioception and muscle performance are key treatment goals to prevent recurrent hypermobility impairments. Reinjury may occur during this phase, because many patients have false confidence in the

548

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 22-7

Dynamic Weight

Shihing

SELF-MANAGEMENT 22-8

Medial/lateral

Weight Shihing

Purpose: Promotes return to weight-bearing and proper

Purpose: Improve control and coordination of standing

heel-toe weight transfer during walking

balance, and prepare for dynamic activities

Position: Standing in a stride position

Position: Standing, using a supportive surface or

Movement Technique: 1. Step forward with _ (uninvolved) leg,

Levell: Level 2: Level 3:

keeping _ (involved) leg stable on the ground 2. Step back again with _ (uninvolved) leg, keeping (involved) stable on the ground

assistive device if necessary Standing on two legs Standing on one leg Remove support/assistive device

Movement Technique: Shift weight in a slow, circular pattern around the perimeter of the foot. Do this in clockwise and counterclockwise directions

Dosage Repetitions: _ _ __ _ _ Frequency _ _ _ _ _ __

Dosage Repetitions _times for _seconds

Frequency _ _ _ _ _ __

t

involved foot kept stable

ankle. Return to a high level of activity should be con­ trolled. Running at slow speeds in straight lines must pre­ cede fast speeds and cutting. Slow nmning in a large fig­ ure-eight pattern can be progressed to faster speeds in a smaller figure-eight pattern. An external suppOli should be used dUling high-level activity for 6 to 8 weeks after injury. Immediate treatment of grade III sprains is some\vhat debated . One school of thought suggests surgical repair fol­ lowed by immobilization and then rehabilitation. Recent comparisons suggest that, in the short term , surgical treat­ ments do not show any advantage over functional treat­ ment for grade III sprains 65 Subotnick60 ,61 thinks that sur­ gical repair is indicated if there has been history of other disabling sprains; othe[\vise, conservative treatment should be attempted. The rehabilitation approach for grade III sprains, whether treated \:vi.th surgical repair or immobi­ lization , is similar to that for grade I and II sprains. A clin­ ician should expect greater deficits in ROM, flexibility, and

muscle strength throughout the lower extremity. Exte supports are important until full strength and proprioc-= tion have been obtained. Chronic recurrent sprain or functional loss is us related to insufficient recovery of proprioception strength, hypomobility related to abnormal scarring. hypennobility resulting from insufficient ligam en t healing. A patient "vith ankle dysfunction related to h~ mobility usually demonstrates limitation and pain witi version and plantar flexion stress testing . Cross-fritt' massage, joint mobilization, and mobility exercises usually beneficial. Recurrent sprains resulting fro m permobility may require long-term use of extern al ~ ports or surgical repair. Progressive proprioception functional strength training is usually needed in cases chronic ankle dysfunction. Ankle braCing has been known to prOvide increased tor neuron excitability v:vi.thin the peroneus lon~us mill thus providing internal stability of the ankle ,66­ Syndesmosis sprains are treated conservatively "­ cast immobilization for 4 to 6 weeks . An unstable vvidened mortise is often treated with surgical fixa Subsequent rehabilitation is similar to that for mediilr lateral anlde sprains.

Chapter 22: The Ankle and Foot

Ankle Fractures Tailocrural fractures aTe the most common fractures in the lower extremity. Excessive talar external rotation. abduc­ [ion, or adduction within the malleoli can result in shearing or avulsion fractures of the ma:lleoli. Ligament sprains are Frequently associated with malleolar fractures. Talocrural joint fractures arc commonly classified by the position ofthe foot (pronated or supinated) and by the direction of force xerted on the malleoli by the talus. Symptoms are similar to those of ankle sprains, although more severe in nature. The following is a description of common talocrural frac­ . t he Lauge- H amen cIassl'f'Ica t'Ion sys t em.' 97011 , hI res usmg

Supination Adduction Injury. Extreme lateral loading of the foot results in excessive supination and poten­ tial avulsion fracture of the distal fibula in addition to lateral collateral ligament strain. If the force contin­ ues, the talus is adducted in the distal tibiofibular joint, which results in a shearing fracture of the distal medial malleolus at the joint line. Supination External Rotation Injury. Forced exter­ nal rotation of the talus with a supinated foot can re­ su lt in tearing of the anterior inferior tibiofibular lig­ ame nt, followed by fracture of the distal fibula. Continued external rotation force may result in a del­ toid ligament rupture or avulsion fracture of the dis­ tal medial malleolus. Because the deltoid ligament is very strong, the avulsion fracture of the medial malle­ olus is more com mon. Michelson et al. found that a lateral (valgus) load pushes the talus laterally against the fibula resulting in_this type of injUly adding to this classification system. 11 Pronated Abduction Injury. Excessive abduction of the talus in the distal tibiofibular joint while the foot is pronated results in avulsion fracture of the medial malleolus. Continued abduction of the talus can rup­ ture the anterior and posterior tibiofibular ligament. Separation of the distal tibiofibular joint is referred to as jOint diastasis. The final stage of this fracture pat­ tern is shearing off of the lateral malleolus at the level of the joint liue. Pronated External Rotation Injury. Forced external rotation of the talus on a pronated foot can result in a avulsion fracture oftlw medial malleolus, followed by tearing of the anterior tibiofibular ligament and frac­ ture of the fibu lao The fibular fracture is usually in the fibular shaft above the talocrural joint. Tibiofibular diastasis may exist. The kev element in the acute treatment of talocrural jOint fractures is the restoration of tibiotalar anatomic alignment. Fractures can be treated with closed reduction or with open reduction and internal fixation (ORIF). Fibular fractures without loss of tibiotalar alignment are usually treated \'lith closed reduction. Fractures of both malleoli or one malleolus and a ligament rupture usually result in malalignment and therefore require ORIF. Pa­ tients are usually immobilized in a plaster cast for 6 to 10 weeks after ORIF. The initial phase of rehabilitation should include in­ struction in elevation and active exercise of the noninjured

549

joints. Edema massage, surgical scar mobilization, and modalities for edema reduction are beneficial. Talocrural accessory joint motion must be assessed and joint mobiliza­ tion techniques initiated as indicated. Active ROM begins in midrange vvith low intensity and high repetition. Con­ trolled, partial-weight-bearing ambulation with an assistive device (i.e., walker or axillary crutches) is often preferred to ambulation with no assistance. Unprotected ambulation may increase pain and swelling at the foot and ankle and re­ sult in undue strain at the lumbopelvic region and opposite lower extremity. Early stationary biking prOvides a gentle exercise for both lower extremities. Patients are initially in­ structed to pedal with the heel and progress to pedaling with the forefoot. As swelling is controlled, treatment emphaSiS swings to­ ward aggressive ROM , strengthening, and functional exer­ cise. Involved knee and hip biomechanics should be as­ sessed and treated. The key structural deficit seen in ankle fractures is usually lack of talocrural joint dorsiflexion . Common gait compensations for limited dorsiflexion in­ clude the follOwing: • Abduction and external rotation of the lower extremity • Genu recurvatum • Excessive subtalar joint pronation Early use of heel lifts can help eliminate these compen ­ sations (see Heel and Full Sole Lifts section). As function normalizes , ROM exercise is generally more tolerable , and progress is usually accelerated. The goal is to remove the heel lifts as soon as ROM is improved. If trauma was ex­ treme and the structural impairment is deemed penna­ nent, heel lifts can be fabricated externally on the shoe for long-term use. Excessive subtalar joint pronation as a compensation for limited talocrural joint dorsiflexion can create midfoot hypermobility and dysfunction. Foot orthotics may be in­ dicated for the current condition and future foot health. Heel lifts in conjunction with foot orthotics are an adjunct to functional strengthening and proprioceptive training. These supportive devices should be considered early in the rehabilitation process and may be needed for long­ term function.

ADJUNCTIVE INTERVENTIONS A therapeutic exercise program for the ankle and foot can be enhanced by the use of supportive devices. Adhesive strapping, wedges and pads, biomechanical foot orthotics, and sole or heel lifts can help control excessive compensa­ tion and promote a faster return to functional activity. The supportive devices are an adjunct to a thorough exercise program and, if used independently, may be less successful. In many situations, the converse is also true.

Adhesive Strapping The use of adhesive strapping is beneficial in controlling the end range of jOint motion. Longitudinal arch strapping is valuable when excessive pronation is deemed a primary stressor. Caution must be taken in supportive strapping if

550

Therapeutic Exercise: Moving Toward Function

the foot is swollen. Strapping should improve the patient's symptoms, and if symptmns increase, the strapping should be removed immediately. The patiellt must be instructed to remove the strapping slowly by pulling the tape back­ ward on itself. Avoid qUick jerking movements and exces­ sive skin distraction when removing the tape, because this could pull superficial skin layers off. The foot must be properly prepared before adhesive strapping is applied to enhance support and decrease the risk of skin irritation. Display 22-4 provides guidelines for preparing the foot for adhesive strapping. The longi.tudinal arch strapping technique presented in Display 22-5 is deSigned to decrease soft-tissue strain caused by excessive subtalar joint pronation. Many additions and variations of supportive foot strapping can be explored.

Wedges and Pads Medial heel wedges, longitudinal arch pads, and metatarsal pads can be placed in a shoe or on a flat insole to decrease soft-tissue strain. Medial heel wedges or varus wedges are thick medially and taper laterally. They are made of firm rubber and used with the philosophy of controlling cal­ caneal eversion and thereby decreaSing the degree of sub­ talar joint pronation. Metatarsal and longitudinal arch pads are made of felt or foam rubber. The metatarsal pad is placed directly proximal to the symptomatic metatarsal head. Medial wedges, longitudinal arch pads, and metatarsal pads are most successful "vhen used in conjunc­ tion with adhesive strapping. Longitudinal arch and metatarsal pads can be taped on top of an arch strapping for precise positioning The medial wedge can be secured in a shoe with the use of double-faced tape. If symptoms are re­ lieved and performance is improved through adhesive strapping and supportive pads, a biomechanical orthotic may be indicated.

Biomechanical Foot Orthotics It is beyond the scope of this text to prOvide a detailed de­ scription of orthotic evaluation and prescription. This sec­ tion describes the purpose of orthotic devices, the general fabrication method , the concept of posting, and therapeu­ tic exercise prescription to augment orthotic prescription. A biomechanical foot orthotic is a device t11at attempts to control dysfunction by controlling the subtalar jOint near its neutral position. Dis~lay 22-6 describes the general pur­ poses of a foot orthosis. 12 A foot orthotic is composed of a shell, which conforms to the contours of the foot, and posting material, which

DISPLAY 22·6

tilts the shell according to the angulation and degree of control desired. The shell is fabricated from an impression of the foot taken while the subtalar joint is held in a neutral position. The shell encompasses the heel, fits closely to the arch, and ends immediately proximal to the metatarsal heads. The shell can be made of a variety of materials , ranging from a flexible foam to a semirigid thermoplastic. Generally, the more rigid shells are indicated for the hypermobile foot re­ quiring motion controL Flexible accommodative shells are used for arthritic conditions, diabetes, and the hypo mobile foot. Body weight is also a deciding factor wben clloosing a shell's rigidity. A heavy individual may require a more rigid shell for more adequate motion controL Orthotic posting is prescribed from the findings of a biomechanical evaluation of the entire lower extremity. Posting material is added to the undersurface of the shell. Rear-foot posting is placed under the heel of the shell, and forefoot posting runs under the metatarsal area to the end of the shell. Medial or varus rearfoot posting is indicated for a subtalar varus or a genu varus abnormality. Varus fore­ foot posting is indicated for a forefoot vams abnormality. Lateral or valgus forefoot posting is indicated for a forefoot valgus abnormality. Posting brings the shell up to the foot and supports the structural abnormality of the foot. The foot orthotic therefore decreases the compensation caused by the structural abnormality. Foot and ankle exercises such as calf stretching, arch lifts, toe clclws, and Single-leg standing balance drills can help prepare the foot before orthotic therapy. Foot or­ thotic therapy requires a break-in period of 1 to 6 weeks During the break-in period, the orthotics are worn inter­ mittently, perhaps as little as 1 to 2 hours per day, with l-hour progression each day. The break-in period can be accelerated based on orthotic tolerance and nature of th injury. Open chain exercises established before orthotk wear should continue. Closed chain exercise in the or­ thotics should be progressed slowly. Initially, patients car be instructed to actively supinate off of the orthotic an slowly lower onto it. Static weight-shifting drills can b progressed to exercise involving higher ground reactiOi forces. Athletic activity should not begin until light acti\ ­ itv is tolerated welL ; Foot Olthotics must be reassessed for wear and brei down . Refurbishment or upgrading may be necessary. D UT ing the orthotic reassessment, the patient's foot and fu nc ­ tion should also be reassessed. Alignment resulting frOl: anatomic impairments does not change, but the patient ability to control his or her compensation may imprO\ (­ Alignment resulting from physiologic impairments ill change. Day-to-day orthotic wear and wear for various at.. ­ tivities may be adjusted The reassessment schedule van \vith each individual, ranging from 1 week to 1 year after break-in period.

Purposes of a Foot Orthosis 1. To even the distribution of weight-bearing forces 2. To reduce stress on proximal joints 3. To control foot motion at the subtalar and mid·tarsal joints, including magnitude, end range, and rate 4. To balance intrinsic foot deformities if necessary

Heel and Full Sole Lifts Heel lifts are commonly used for correction of leg len.., discrepancies . Heel lifts should be isolated for use equinus contractu res and not used for correction of II _ length discrepanCies. Full sole lifts are more approp11

f( h,

Ul

P fi:

h·

Chapter 22 The Ankle and Foot

for the treatment of leg length discrepancies, because the heel is in contact with the ground for only a short peliod in the gait cycle. After the loading response phase is com­ pleted and the foot enters the midstance phase, the fore­ foot is in contact wit11 the ground. If ilie lift is only in the heel, the foot functions as if it is descending a small step after the forefoot contacts the ground. The full sole lift eliminates this problem. However, the disadvantage of the full sole lift is that it can occupy excessive room within the shoe. Typically, if a lift beyond 1/8 inch is recommended, it should be added to the outside of the shoe. The pre­ scription of a sole lift should be considered carefully, be­ cause an apparent leg length discrepancy often is func­ tional and not structural. The reader is referred to Chapter 20 for a detailed description of functional versus structural leg length cliscrepalley. A functional leg length discrepancy often can be treated with the rapeutic exercise intervention, es­ peCially fOCUSing on alignment and movement impairments throughout the kinetic chain. The use of a lift for a functional leg length discrepancy can capture and rein­ force the alignment impairment rather than resolve the impairment. Heel lifts can be helpful in the treatment of foot and an­ kle dysfunctions related to limited motion of the talocrural joint. A lack of 10 degrees of talocrural jOint dorsiflexion can result in compensatory subtalar joint pronation during midstance and propulSion . A heel lift places ilie talocrural jOint in a few degrees of plantar flexion at midstance (Fig. 22-26). This increases the available range of dorsiflexion and decreases the abnormal compensation. Heel lifts can be used in the acute phase to decrease strain on the Achilles tendon, talocrural jOint, and subtalar jOint. Early ambulation with less pain increases indepen­ dent function and enhances the effects of an exercise pro­ gram. The goal is to normalize the impairment and remove the heel lifts. If a heel lift is necessary, the follOWing information can guide the proper amount of lift to prescribe. A patient with 0 degrees dorsiflexion may require a 3/4- to I-mch heel lift. Less severe limitations can be treated with smaller lifts. A 1/4- to 3/8-inch lift can be placed inside

\! )

FIGURE 22·26. A heel lift is used to increase the range of dorsiflexion at midstance.

the shoe. The lift depends on shoe style and fit. Allor some portion of the lift can be added to the sole of ilie shoe by a shoe repair service. A lift of the same height should be added to the uninvolved extremity to avoid cre­ ating a leg length discrepancy. -

KEY POINTS • The three main joints of the ankle and foot are the talocrural, subtalar, and midtarsal, which is further sub­ divided into the calcaneocuboid and talonavicular. • The medial collateral ligament controls medial joint sta­ bility and controls ilie extremes of plantar flexion and dorsiflexion in the ankle and foot. The lateral collat­ eral ligament controls lateral jOint stability and checks extremes of ROM along with the medial collateral ligament. • The extrinsic muscles consist of the anterior, lateral , and posterior groups. The anterior group allows dorsiflexion, the lateral group functions as evertors, and ilie posterior group functions as plantar flexors. The intrinsic muscle group is composed of four layers. • The functions of the foot during gait are shock absorption, load transmission , surface adaptation , and propulSion. • The foot and ankle examination must include a subjec­ tive history and evaluation of the w .i ht-bearing a nd

LAB ACTIVITIES

1. Perform resisted ankle dorsiflexion, plantar flexion, inversion , and eversion using a variety of resistive bands. Perform exercises in long-Sitting and short­ sitting positions and while standing on one leg. What are the most likely substitutions in eaeh position? 2. Instruct a laboratory partner in correct lower ex­ tremity standing posture. 3. Perform the follOWing exercises, maintaining subta­ lar neutral pOSition and exaggerating pronation. Ob­ serve the differences in alignment throughout the lower extremity:

551

a. Wall slide b. Single-leg wall slide c. Step down d. Standing on a minitramp e. Stair stepper, forward and backward 4. Consider the patient in Case Study #1 in Unit 7. De­ sign a rehabilitation program for this athlete in the early, intermediate, and late phases. lnstruet your pa­ tient in the exercise program, and have your patient perform all exerdses.

552

Therapeutic Exe rcise: Moving Toward Function

non-weight-bearing foot. Relationships of the lower ex­ tremity joints must be evaluated . • Co mmon lower ex tremity anatomi c impairments in­ clude subtalar varus, forefoot varus , and forefoot valgus. • The common physiologic impairments at the foo t are mobility loss, loss of force or torque produ ction , im­ paired posture and movement, pain, and impaired bal­ ance and coordination . • The therapeutic exercise program must consider the ki­ netics and kinematics of the foot during gait. • Adjunctive agents may be necessalY to treat the struc­ tural impairment or to prevent secondary problems as­ sociated with phYSiologic impairm ents .

~ ~

CRITICAL THINKING QUESTIONS 1. Consider Case Study #1 in Unit 7. How would the treat­ ment program differ if the patient was a. A competitive runner b. A landscaper walking on uneven surfaces c. An elderly individual who is a community walker d. A recreational golfer 2. Consider Case Study #9 in Unit 7. Theorize about potential relationships between this patient's plan­ tar fasciitis , her thigh pain, and other symptom s Describe a comprehensive treatment program for thj individual.

SELECTED INTERVENTION 22-1

For the lower Ouadrant

See Case Study 1.

DOSAGE

Although this pati ent requires comprehellsive intervention as descJibed ill previolls chapte rs, only one exerc:ise prescribed in the final stage of recovery is desC'libed.

Special Considerations Anatomic: Calcall t'oflhular ligament Physiologic: Late-stage recove ry from grade :2 sprain Learning capability: Good bodv awareness and coordination . should be no trouble

ACTIVITY: Lunging ball drill PURPOSE: Improve balance. proplioceptioll , ancl agility RISK FACTORS: 10 weeks afte r second-tlegree sprain of the right calcaneoflbular ligament ELEMENT OF THE MOVEMENT SYSTEM: Modulator

Repetitions/sets: To t())'Jll fatigue , pain , or :20--:30

repetitions, up to three sets

Frequency: Every other day Sequence: FollOWing warm-up of light acti\.i ty and

stretching

Speed: Functional speed

STAGE OF MOTOR CONTROL: Skill POSTURE: Standing in "ready" position with kn ees flexed

Environment Home with a pmtner Feedback: lnitiallv in clinic with mirror and verbal

feedbac:k , tapered to no mirror in home environment

MOVEMENT: Step forward and lunge as hall is tossed toward you

SPECIAL CONSIDERATIONS: Be sure foot lands in a good position and th at it is in good alignment with respect to the knee, hip, pehis, and spine.

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60. Subotnik SI , ed. Sports Medicine of the Lower Extremity. New York: Churchi'll Lh;ngstone, 1989 . 61. Subotnik S1. Pouiatric Sports Medicine. Mount Kisco, NY: Futura Publishing, 1975. 62. Safran MR, ZachazelVski JE, Benedettie RS , et al. Lateral an­ kle sprains. Palt 2: treatment anu rehabilitation with an em­ phasis on the athlete. Med Sci Sports Exerc 1999;31: S438-S447 . 63. Kelll-Steiner R, Washecheck HS, Kelsey DD . Strategy of ex­ ercise prescription usin g an unloading technique for fun c­ tional re habilitation of an athlete with an inversion ankle sprain . J Orthop Sports Phys Ther 1999;29 :282-287. 64 . Kerkh offs GM, Struijs PA, Marti RK, et al. Different fun ctional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database System Rev 2002;3: CD002938. 65. SpecchiuUi F , Cofano RE. A comparison of surgical and con­ servative treatme nt in ankle ligam ent tears. Orthopedics 2001 ;27:686-688. 66. Nishikawa T, Grabiner ~D. Peroneal motoneuron excitabil­ ity increases illl mediately foll OWing application of a semirigid ankle brace. J Orthop Sports Phys Ther 1999;29: 168-1 76 . 67. 1'\ishikawa T, Ozaki T, Mizuno K, et a!. Increased reflex activa­ tion of the peroneus longus follOWing application of an ankle brace declines over tim e. J Orthop Res 2002;20: 1323--1326. 68. Re fshau ge K'v!, Kilbreath SL, Raymond J. Deficits in detec­ tion of inve rsion and eversion moveme nts among subjects with recurrent ankle sprain s. J Orthop Sports Phys Ther 2003;33:166-1 67. 69. Cordova ML, Inge rsoll CD . Peroneus longus stretch reflex amplitude increases after ankle brace application. Br J Sports

Med 2003;37:2,5 8-262. 70. Lauge-H ans e.n :'-J . Fractures of th e ankle: genetiC roentgeno­ logiC uiagnosis of fra cture of th e ankle . Am J Roentgenol Ra­ clium Ther Nucl ~\'Ied 19.54;71 :456. 71. ~\'lich e lson J, Solocoff D , \Valdman B, et al . Ankle fractures . Clin Orthop Rei Res 1997;.'34.5: 198-205. 72. Cornwall MW. Foot and Ankle Orthoses. La Crosse, \\'l. APTA Inc., 2000.

RECOMMENDED READING D'Ambrosia R, Drez D. Prevention and Treatment of Runnio_ Injuries . Thorofare, NJ: Slack, 1989. Kendall FP, McCreary EK, Provance PC. Muscles Testing am. Function. Baltimore: Williams & Wilkins, 1993. Langer S, Wernick J. A Practical Manual for a Basic App roac' to Biomechanics. Wheeling , IL: Langer Biom ech an ic Croup, 1989. Magee D. Orthopedic Physical Assess me nt. 3rt! Ed . Philadelplu WB Saunders, 1997. McPoil TC , Cornwall MW. The relationship betwee n static 01, ­ surements of the lower extremity and the p"tt crn of rearft motion during walking [abstract ]. Phys Ther 1994;74:5141 McPoiJ TC, Knecht HC, Schuit D. A surve), of foot types benl' the ages of 18 to 30 years J Orthop Sports Phys Ther 19 406-409. Root ML, Orien WP, Weed JH . Neutral Position Casting T niques. Los Angeles , CA: Clinical Biomechani cs Corpo ra 1971.

chapter 23

The Temporomandibular Joint DARLENE HERTLING

Review of Anatomy and Kinesiology Bones

Joints

Muscles

Nerves and Blood Vessels

Kinetics

Examination and Evaluation Subjective Data

Mobility Impairment Examination

Pain Examination

Special Tests and Other Assessments

Therapeutic Exercise Interventions for Common Physiologic Impairment Mobility Impairment

Posture and Movement Impairments

Therapeutic Exercise Interventions for Common Diagnoses Capsulitis and Retrodiskitis Degenerative Joint Disease Derangement of the Disk Surgical Procedures

Adjunctive Therapy

The temporomandibular joint (TMJ ) cannot be viewed in isolation. Its relationships with the cranium, jaw, and cervi­ cal spine are important in function and dysfunction and should be acknowledged in assessment and management strategies. TMJ dysfunction can be the result of a problem anywhere along this kinetic chain . The TMJ is unique be­ ause its function is directly related to dentition and the contacting tooth surfaces. Proble ms with the TMJ can di­ rectly influence occlusion and vice versa. A comprehensive approach to the treatment of th e TMJ addresses the person as a whole by taking into account these relationships, the performance of functional activities, and the influence of physical and emotional stress on this system.

This chapter provides a brief review of TMJ anatomy and kineSiology and supplies guidelines for the basic exam­ ination and evaluation . It cove rs treatment interventions for common phYSiologic impairmen ts and common diag­ noses affecting the TMJ.

REVIEW OF ANATOMY AND KINESIOLOGY In referring to the TMJs , the mas ticatory system, its com­ ponent structures, and all the tissues related to it , the term stomatognathic system is used. This system has seve ral components: • Bones of the skull, mandible , maxilla , hyoid, clavicle, sternum, shoulder girdle , and cervical vertebrae • TMJ and dentoalveolar joints (j.e., joints of the teeth ) • T eeth • Cervical spine • Area vascular, lymphatic, and nervous systems • Muscles and soft tissues of the head and neck and muscles of the cheeks, lips , and tongue Kinematically, the joints and muscles of this system inter­ act to influence the alignment and function of the mandible in the TMJ Functional activities such as talking and eating are affected by the kinematics of this system.

Bones The mandible. the largest and strongest bone of the face , ar­ ticulates \vith the two temporal bones and accommodates the lower teeth. It is composed of a hOlizontal portion , called the body, and two perpendicular portions , called the rami , which unite with the end of the body nearly at right angles. Each ramus has two processes: the coronoid process and the condylar process. The coronoid process serves as an insertion for the temporalis and masseter muscles. The condylar process consists of the neck and the condyle. The condyle, which is convex, articulates with the disk (Fig. 23­ 1). The two condyles form the floor of the TMJ

555

556

Therapeutic Exercise Moving Toward Function

------------

------------------------------------------------------------

il Synovial membrane

(]

Upper Joint

c

~'

disk

II Lower Joint

component

FIGURE 23-1. Articular structures of the temporomandibular joint in the closed position.

The roof of the TMJ consists entirely of the squamous part of the temporal bone, and it is divided into four de­ scriptive parts: 1. Articular tubercle 2. Articular eminence

3. Mandibular fossa 4. Posterior glenoid spine The hyoid bone is a horseshoe-shaped bone at the level of C3 and acts as an attachment for the suprahyoid and in­ frahyoid muscles (Fig. 23-2). The greater wings of the sphenOid bone join into the pterygOid plates that serve as attachment for the medial and lateral pterygoid muscles (Fig. 23-3). Osteokinematically, three basic movements exist within the mandible: depression, protrusion, and lateral excur-

Posterior belly

digastric muscle

Stylohyoid muscle

!

~~'"

:~;~I;O~d

Infrahyoid Omohyoid muscles muscle Sternohyoid muscle

FIGURE 23-2. Hyoid bone and the digastric, stylohyoid, and infrahyoid muscles.

Lateral pterygoid muscle

Upper head L ( owe head

Medial pterygoid muscle

AGURE 23-3. Medial and lateral pterygoid muscles.

sion. These three basic movements can be combined to produce an infinite variety of mandibular motions.

Joints There are two TMJs, one on either side of the jaw, Both joints must be considered together "vith the teeth (Le., the trijoint complex) in an examination. 1 The TMJ is a synovial condyloid joint found between the mandibular fossa of the temporal bone and the condylar process of the mandibular bone (see Fig. 23-1). The two bony surfaces are cover with collagen fibrocartilage rather than the hyaline carti­ lage found in most synOvial joints of the body, The pres­ ence of fibrocartilage is significant because of its ability tl repair and to remodeL2 The articular disk, or meniscus, also consists of pliablt­ collagen fibrocartilage , but it lacks the ability to repair or remodeL This biconcave disk divides each joint into tWI cavities (an upper and a lower jOint cavity) and compen­ sates functionally for the incongruity of the two opposing joint surfaces (see Fig. 23-1 ), During opening and closing:. the convex surface of the condylar head must move acro the convex surface of the articular eminence. Kinematically, the mandible may be considered a fret:­ body that can rotate in angular directions. It has three de­ grees of freedom. The basic accessory movements required for functional motion are rotation, translation, distractior compression, and lateral glide 3 Accessory movemen t: most often restricted because of periarticular tissue tight­ ness and disk displacement are lateral glide, translatio and distraction. According to Kraus,4 of these accessor' movements, translation causes the most limitation of 05 ­ teokinematic movement of the mandible and is more diffi-· cult to restore. Gliding movements occur in the upper ca'­ ity of the joint, whereas rotation or hinge movements occ

Chapter 23: The Temporomandibular Joint

in the lower cavity. Gliding and rotation are essential for opening and closing the mouth. The capsule of the TMJ is thin and loose. The capsule and the disk are attached to one another anteriorly and pos­ teriorly but not attached medially or laterally. Because there are no medial and lateral attachments of the disk and capsule, translation (anteliorly) of the disk can occur within the capsule. The posterior ligament attaches the disk to the posterior aspect of the neck of the mandible, in the bilam­ inar zone, and the posterior portion of the TMJ.1-6 The strongest ligamentous attachments are on the me­ dial side such as the mediodisco ligament (i.e., Tanaka's ligament) . .ci The TMJ has no capsule on the medial half of the anterior aspect, which allows excessive translation of the condyle, leading to joint pathology 7 The TlvIJ can ac­ tively displace antetiorly and slightly displace laterally2 The rest position , or loose packed position, for the TMJ is v"ith the mouth slightly open so the teeth are not in con­ tact. The rest position of the tongue, often referred to as the postural position, is with the first half of the tongue against the hard palate of the mouth S .9 Tongue up , teeth apart, and lips closed (TUTALC) is the functional rest po­ sition that should be taught to the patient. There are two closed packed positions: maximal ante­ rior position of the condyle with maximal opening and maximal retrusion in which the ligaments are taut and the condyle cannot go farther back. The mouth is closed, and the teeth are clenched. In bilateral restriction, the capsu­ lar pattern of restriction produces significant loss oflateral movements and limits opening of the mouth and protru­ sion. In unilateral capsular patterns of restriction, con­ tralateral excursions are most limited. During mouth opening, the mandible deviates toward the restricted side. The normal range of mandibular opening is 40 to 50 mm. The range of motion (ROM) is considered functional for most jaw activities if 40 mm of opening is pOSSible. This motion should be composed of 25 mm of rotation and 15 111m of translation. [0 To achieve the initial 25 mm opening, rotation occurs between the mandibular condyle and the inferior surface of the disk. The last 15 to 25 mm is the re ­ sult of anterior translation between the superior surface of the disk and the temporal bone.

force, such as denching, nail biting, and forced mandiblllar opening on an unstable occlusion. Muscles can be re­ educated by the use of exercise, biofeedback, and func­ tional electrical stimulation.

Main muscles of temporomandibular joint motion Five main muscles contribute to TMJ motion: 1. Temporalis 2. Masseter

3. Medial pterygoid 4. Lateral pterygOid 5. DigastriC These muscles also connect the cranium to the mandible along with the buccinator and superior pharyngeal constrictor. Jj The three major elevator muscles of the mandible are the temporalis , the masseter, and the medial pterygOid. All of the fibers of the te mporalis (Fig. 23-4 and Table 23-1) contribute to elevation for closure, partic~larly for posi­ tioning of the condyle at the end of closure." The masseter (Fig 23-5 and see Table 23-1) is composed of the deep and superfiCial bellies. The superfiCial fibers protract the jaw to some degree , and the deep portion acts as a retractor. The medial pterygOid's function (see Fig. 23-3 and Table 23-1) is similar to the masseter's function , although it is less pow­ erful than the masseter. The primary muscle responSible for mandibular de.p,res­ sion is the digastric (see Fig. 23-2 and Table 23-1).2,1- The lower portion of the lateral pterygOid and the ot11er suprahyoids are active during forced opening of the mandible, when the hyoid bone is fixed by the infrahyoid muscle group.

Muscles Function of all the muscles of the upper quadrant need to be understood because of their impact on TMJ function and dysfunction. The movements of the mandible are the result of the action of the cervical and jaw muscles: • Elevation • Depression • Protraction • Retraction • Lateral gliding All of these movements are used to some extent when cheV\'ing. Because the TMJ is bilateral, the muscles of mas­ tication must activate and relax in a regular pattern and in perfect synchronization with the muscles on the contralat­ eral side. Muscles often need to be re-educated after trauma, surgical procedures, and long-standing parafunc­ tional acti\'ity, including habitual excessive use of biting

557

Temporalis muscle Coronoid process

FIGURE 23-4. Temporalis muscle.

558

Therapeutic Exercise Moving Toward Function

Muscles and Nerves of the Mandible MUSCLE AND NERVE (N)

ORIGIN

INSERTION

FUNCTION

Digastric N: trigeminal and facial

Anterior belly: depression on inner side of infelior border of mandible Posterior belly: mastoid notch of the temporal bone Temporal fossa and deep surface of temporal fascia

Common tendon to the hyoid bone

Mandibular depression and elevation of hyoid (in swallowing)

Medial and anterior coronoid process and anterior ramus of mandible

Elevates mandible to close the mouth and approximates teeth (biting motion); retracts the mandible and palticipates in lateral grinding motions Elevates the mandible; active in up and down biting motions and occlusion of the teeth in mastication Elevates the mandible to close the mouth ; protrudes the mandible (with lateral pterygoid). Unilaterally, the medial and lateral pterygoid rotate the mandible forward and to the opposite side Protracts mandibular condyle and disk of the temporomandibular jOint forward while the mandibular head rotates on disk; aids in opening the mouth. Joint action of the medial and lateral pterygoid rotates the mandible forward and to the opposite side Elevates the hyoid bone and tongue for swallowing; depresses the mandible when fixed Assists in depression of the mandible; elevates and protracts the hyoid bone; moves the tongue fOl'vard Draws the hyoid bone upward and backward in swallo\ving; assists in opening the mouth and pmticipates in mastication

Temporalis N: mandibular division of trigeminal nerve

Masseter N: mandibular division of trigeminal nerve

Superficial: zygomatic arch and maxillary process Deep portion: zygomatic arch Greater wing of sphenoid and pyramidal process of palatine bone

Angle and lower half of lateral ramus Lateral coronoid and supelior ramus Medial ramus and angle of mandibular foramen

Lateral pterygoid N: mandibular division of trigeminal nerve

Superior: inferior crest of greater wing of sphenoid bones Inferior: lateral surface of pterygoid plate

Articular disk, capsule, and condyle Neck of mandible and medial condyle

Mylohyoid N: mylohyoid branch of the trigeminal nerve Geniohyoid N: ventral ramus of Cl through hypoglossal nerve Stylohyoid N: facial

Medial surface of mandible, entire length Mental spine of mandible

Body of the hyoid bone (floor of the mouth )

Styloid process of temporal bone

Body of the hyoid bone

Medial pterygoid N: mandibular division of trigeminal nerve

Body of the hyoid bone

The lateral pterygoid inserts into the mandibular condyle and articular disk and plays a large role in stabilization of the TMJ (Fig. 23-6 ). The inferior fibers are active in conjunc­ tion 'with mandibular depressors during mandibular open­ ing and protraction. The superior fibers (upper head) of the lateral pterygoid (see Fig. 23-3 and Table 23-1 ) act in con­ cert with the elevator muscles during closing. Their role is to decelerate and prevent inv~gination of the joint capsule with closure of the mandible:' Because the attachrnent of the superior and inferior fibers are mostly medial, they pull the condyle and disk in a medial direction.

tant role in tongue mobility, speech, mandibular deprn ­ sion, manipulating boluses of tood, and swallowing. 1 The suprahyoids consist of the mylohyoid, geniohyoid (Fig. :2 7 and see Table 23-1), and the paired digastriC and styloll\ . oid muscles (see Fig. 23-2). The infrahyoid muscles (i.e. , stemohyoid, thyrohyoid sternothyroid, and omohyoid) act together to stabilize th hyoid bone. This provides the suprallyoids with a stabl base from which to contract and move the mandible (s Fig. 23-2).

Suprahyoid and Infrahyoid Muscles

The tongue is composed of various intrinsic and extrin muscles. The genioglossus is the main muscle responsib for positioning of the tongue in the oral cavity.4 It is pn ­ marily responsible for establishing and maintaining the n~'l

Tongue The lingual surface of th~ mandible , anterior to the mus­

cles of mastication, is composed of the suprahyoid muscles.

These muscles influence jaw position and play an impor­

Chapter 23 The Temporomandibul ar Joint

559

Masseter muscle (deep)

Masseter muscle (superficial)

A

B

AGURE 23-5. (A) Superficial and (8) deep layers of masseter muscle.

position of the tongue and is active in protracting and ele­ vating the tongue. The resting position of the tongue provides the foundation for the resting muscle tone of the mandibular elevators (i.e., temporalis, masseter, and me­ dial pterygoid) and establishes resting activitr: of_the tongue musculature itself (i.e., jaw-tongue reflex).4. 3-1/ Tongue thrust and other parafunctional habits are of­ ten accompanied by an abnormal tongue position against the lingual surface of the mandibular incisors rather than the normal palatal tongue posture.1 4 -l 6 Excessive mastica­ tory muscle activity is thought to occur in patents who ac­ quire an altered sequence of swallowing in which tongue

thrust occurs. 4 The most frequently cited signs of tongue thrust activity during swallowing include protraction of the tongue against or between the anterior teeth and ex­ cessive muscle activity. 15 As a result, the masseter muscles contract incompletely, and there is a concomitant variable state of tension of the orbicularis oris and buccinator mus­ cles. 15 Although tongue thrust is more common in chil­ dren, it also occurs in adults and is referred to as an ac­ quired adult tongue thrust 4 It is theorized that tongue movement and positioning in the oral cavity are influ­ enced by dysfunctional mobility and positioning of the cervical spine. ls

External meatus

Upper head 01 the external pterygoid muscle

Interior stratum

Geniohyoid muscle

FIGURE 23·6. Sagittal section of the temporomandibular joint. The lateral pterygoid inserts into the mandibular condyle and the disk. The disk has three parts (1) a thick anterior band (pes meniscus), (2) a thicker posterior band (pars posterior), and (3) a thin intermediate zone (pars gracilis) be­ tween the two bands.

FIGURE 23·1. Mylohyoid and geniohyoid muscles viewed from above and behind the floor of the mouth.

560

Therapeutic Exercise Moving Toward Function

Nerves and Blood Vessels The region is supplied by cranial and cervical nerves. Over­ lapping of the branches from both types of nerves compli­ cates the neurologic analysis of this region and may account for the extensive range of symptoms in head, TMJ, and cer­ vical dysfunction s. The innelvated tissues of the TMJ ate supplied by three nerves that are palt of the mandibular division of cranial nerve V. The posterior deep temporal and masseteric nerves supply the medial and anterior regions of the joint, and the auriculotemporal nerve supplies the posterior and lateral regions of the joint. The auriculotemporal nelve is th e major nerve innervating the capsular blood vessels, the retrodiskal pad, the posterolateral capsule, and the TMJ ligament of the TMJ These tissues have an abundant sup­ ply of type IV receptors (Le ., mticular pain receptors ). Be­ cause branches of the auriculotemporal nerve supply the tragus, external acoustic meatus, and tympanic membrane, temporal mandibular dysfunction is often associated with hearing problems, tinnitus, and vertigo. The external carotid arterial system provides the main vascular supply to the TMJ , masticatory muscles , and asso­ ciated soft tissues. This vessel divides at the level of the neck of the condyle into the superficial temporal and inter­ nal ll1axillary alteries. The internal maxillary altery and its branches supply the maxilla and mandible, the teeth, and the muscles of mastication. The arterial supply and venous and lymphatic drainage can be clinically significant in pa­ tients \.vith head and neck pain. Theses circulatory systems can be compromised by trauma , disease, changes of the head and neck positions, and muscle spasm.

Kinetics An overview of the management of the cervical spine mus­ cle imbalances and the relationship of head posture and the rest position of the mandible are included because of the frequently associated muscle hyperactivity and accompa­ nyi llg symptoms observed in the mandibular and cervical spine areas. Functionally, the TMJ, the celvical spine, and the articulations between the teeth are intimately related (Fig. 23-tl). Muscles attach the mandible to the cranium , the hyoid bone, and clavicl e. The celvical spine is, in essence, interposed betwpen the proximal and distal at­ tachments of some of the muscles controlling the TMJ.2 The balance between th e flexors and extensors of th e head and neck is affected by the muscles of mastication and the suprahYOid and infrahyoid muscles19 Dysfunction in the mllscles of mastication or the cervical musculature can eas­ ilv disturb this balance. The neurollmsculature of the cer­ vical and masticatory regions actively influences the func­ tion of mandibular movement and cervical positioning.2 o- 22 Celvical posture change affects the mandibular path of closure, the mandibular rest position, masticatory muscle activity,20,2J.:2.:J and the occlusal contact patterns. A forward head posture (FHP) is a common postural defect that in­ creases the gravitational forces on the head and often leads to hyperextension of the head (i.e. , posterior cranial rota­ tion [PCR] on the neck) (Fig. 23-9A). When the head is held anteriorly, the line of vision extends downward if the normal angle at which the head and neck meet is main-

Temporalis

// ~Infrahyoids

FIGURE 23-8. A lateral view of the head, neck, and mandible showing the muscula r forces that flex the head. The infrahyoid muscles pul l downward on the hyoid bone. The suprahyoids pull down on the mandible, and thE muscles of mastication stabilize the jaw.

tained. To correct for visual needs , the head tilts backward. the neck flexes over the thorax, and the mandible migrate posteriorly, :14 The posterior cervical muscles are shOltened and forced to contract excessively to maintain the head in this position while the anterior submandibular muscles a stretched, resulting in a retraction force on tJ1e mandibl and an altered occlusal contact pattern. The contracted postelior cervical muscles may ent~ap the greater occipit.· nerve and refer pain to the head.2,) Excessive mandibu lar shuttling (Le. , excursions) between opening and closi ng which are necessalY for functional activiti es such as chew­ ing and eating, may lead to h)1Jermobility of the TMJ frorr overstretching of the capsule .' G In the presence of a FHP vvith no Significant PCR (F i!:!: 23-9B), the suprahyoids shorten , and the infrahyoi d. lengthen , consequently decreasing or eliminating the frec­ way space, a space that exists betvveen the upper and 1m\'{. arch of the teeth when the mandible is in the rest posi­ tion. 27 ,2S The hyoid bone is repositioned superiorly, and thO:" degree of elevation is proportional to the;: decrease in tlk­ cervical lordosis or increase in the FHP.21 ,21'3 Hyperacti\i ~ of the suprahyoids produces a depressive force on th mandible. According to Mannheimer,2!l when combine vvith hyoid anchOring by means of the infrallyoids, the n mandibular repositioning effect is one of retraction and de­ pression with increased contact in the molar region, The tonic neck reflex plays a primary role in an individual's abil­ ity to achieve correct head-neck posture, FHP is often as­ sumed if tonic neck reflexes or cervical proprioceptive

Chapter 23: The Temporomandibular Joint

561

respiration (i.e. , sternocleidomastoids, scaleni, and pec­ torals ).7.16,30 This pattern is perpetuated by decreased ac­ tivity of the diaphragm and hypotonicity of the abdominal musculature.16 Consequently, many abnormal force vec­ tors are created by abnormal swallow.

EXAMINATION AND EVALUATION A thorough evaluation of the TMJ includes all components of the stomatognathic system. This assessment assists the therapist in determining the cause of the dysfunction and the influence of other factors and in designing an effective treatment plan.

Subjective Data A

A comprehenSive history is essential and helps to direct the objective evaluation. The client should prOvide detailed in­ formation about the onset of symptoms, incidence of joint locking, presence of jOint noise, history of surgery and trauma, and medical history. Pain should be descIibed in terms of location, intensity, frequency, time of day, and ac­ tivities that reproduce it. Functional limitations should be addressed along with parafunctional habits. Clients should be asked about their level of psychosocial, environmental, and postural stress, noticing if they sense an increase in clenching or other parafunctional habits when under stress. The type of job a patient has can provide information about posture. Use of a functional outcome questionnaire is help­ ful in evaluating these patients.

Mobility Impairment Examination

B

FIGURE 23-9. Types of forward head (A) increased cervical lordosis with posterior cranial rotation, and (B) total flattening out of the cervicallordo­ sis without posterior cranial rotation.

afferents are injured (e.g., whiplash, direct trauma) or are overused (e.g., sports activities, daily postures). The pro­ pIioceptive afferents may lose their ability to position the head and neck. 7 The FHP is exacerbated by many occupations and ac­ tivities of daily living (Le. , improper home , work, or driving postures) that require the upper extremities and the head to be positioned more anteIior to the hunk than is normal or comfortable. 13 ,27-29 Another contributing factor is the effect of mouth breathing. The dysfunctional patterns of the mouth-breathing syndrome constitute a chain reaction of body adaptation to abnormal breathing patterns. VaIious investigations have shown that ~ost ural relationships change to meet respiratory needs. ,29 Breathing through the mouth facilitates FHP, a low and forward tongue posi­ tion (as a result of this pattern, abnormal swallOWing en­ sues), and increased activity of the accessory muscles of

Structures, which must be examined as a possible cause of symptoms, include the TMJ, upper cervical spine, cervical spine, thoracic spine, soft tissues , muscles, and neural tis­ sue. Mobility testing should look at the quality and symme­ try of the motions performed to determine the type of dys­ function: • Active and passive phYSiolOgiC joint movement of the cervical and thoracic spine • TMJ: vertical opening, lateral excursion, protrusion (active and passive joint movement) • Joint function including TMJ rotation and translation • Joint play • Muscle tests including muscle length, strength, and control • Mobility of the nervous system (if indicated)

Pain Examination Subjective complaints of pain should be evaluated. The client should be asked to pOint to the site of greatest pain while the therapist notices whether the pain is in the joint or muscular region. Tenderness, warmth, and inflamma­ tion should be assessed during palpation and espeCially when examining several areas: • Mandible, hyoid bone, and TMJ (note position and prominence)

562

Therapeutic Exercise: Moving Toward Function

• Relevant joints of the upper quadrant cervical and up­ per thoracic spine • Muscle (masseter, temporalis, medial and lateral pterygoids, splenius capitis, suboccipital, trapezius , sternocleidomastoid, digastric), tendon, tendon sheath, bone, ligament, and nerve • Relevant trigger pOints and tender points of fibrom yalgia

Special Tests and Other Assessments Several tests address the functional component of the TMJ complex: • Segmental stability tests for the atlantoaxial joint • Oral function • Occlusion pattern • Swallowing pattern • Breathing pattern The therapist also should evaluate th e patient's posture and screen for systemic hypermobility.

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENT A treatment plan is implemented after a thorough exami­ nation and determination of the diagnosis, functionallimi­ tations , and prognosis. Therapelltic exercise int~ rventions should address specific impairments and seek to increase functioning of th e Tvq.

Mobility Impairment Hypomobility Etiology

Mandibular hypomobility (j.e., limitation of functional movements) may result from disorders of the mandible or cranial bone, which include aplasia , drsplasia, hypoplasia, hyperplasia, fractures, and neoplasms? Temporomandibu­ lar dysfunctions that can contribute to mandibular hypo­ mobility are ankylosis (fibrous or bony); arthritides, espe­ cially polyarthritides involving the periarticular tissue (capsule) and structural bony changes; disk displacement (i.e. , acute disk displacement that does not reduce); and in­ flammation or jOint effUSion. Also contributing to hypomo­ bility are masticatOlY muscle disorders such as myofascial pain, muscle splinting, myositis , spasm , contracture, and neoplasia 31 Hypomohility may lead to capsular fibrosis (a res ult of th e intermolecular cross-linking adhesions of collagen fibers ). It most commonly accompanies one or some com­ bination of three situations: 1. Resolution of an acute articular inflammatory process 2. A chronic, low-grade articular inflammatory response 3. Immobilization in which the capsule may be partially or totally involved

This condition mayor may not be painful. If painful, the pain is felt over the side of involvement, with possible ref­ erence into areas innervated by cranial nerve V. Pain in­ creases during functional and parafunctional movements of the mandible. If complete capsular shortening exists, the mandibular opening is less than functional, and the patient presents with a capsular pattern of restriction . Lateral movements of the mandible to the opposite side are de­ creased. With bilateral restriction, lateral movements are most restricted; opening of the mouth and protruSion are limited, but closing is free. Treatment

Therapeutic modalities such as ice or heat can help to decrease pain and muscle guarding. Ultrasound in con­ junction with active motion or prolonged static stretch is used to increase extensibility of the capsular tissues?2 JOin t mobilization techniques are used to further enhance cap­ sular extensibility. JOint mobilization procedures for the TVIJ includ,edistraction, medial glide, and translation (Fig. 23_10)4.19,_4)) In each case, the manual hold IS performed over the mandible or over the inner aspect of the lower mo­ lars. Direct joint mobilizations may also be used , "vith con­ tact of the therapist's thumbs over the lateral or posterior surface of the condyle of the mandible,32 Mobilization 0 the involved soft tissues can facilitate stretching techniqu and joint mobilization procedures, making them more tol­ erahle and effective. Most patie nts with hypomobility impairment requir home program of active ROM exercises, self-mobilizatioJ1 and a passive stretching program with tongue depressors 0­ the Th crabite (Therabite Inc. , Brvn Mawr, PA) to maint . and facilitate capsular extensibility along with instructior. on proper posture and avoidance of aggravating factors. As part of their horne program, they are educated a maintaining the normal rest position of the tongue mandible (i.e., TUTALC ). Limited mandibular movement can be corrected b\ number of self-treatment ttechniques. Frequent actr stretch (I.e., active opening and closing of the mandibl ~ during the day should be encouraged. The th erapeut value of this exercise is to develop mandibular movem in a controlled manner. The tongue-up exercise can cont. translation. Active protrusion and lateral excursions (\\ or with out tongue blades positioned between the t can be used to actively mobilize the mandible (Fig. 23­ Passive stretch (i.e., prolonged static stretch) m a~­ used by placing a number of stacked tongue blades h. zontally bel:\veen the upper and lower incisors to incre the mandibular opening. The stretch position is maintai for 5 to 10 minutes or until the muscl es relax. As the R increases, the patient can gradually increase the numoo tongue depressors until he or she can open far enoU' insert the knuckle of her index and middle fin ge rs he\'.\ the anterior teeth. ); orInal translation begins after 11 or about six tongue blades. 13 The Simplest method of self-stretch is to use th e th crossed over the index finger. The index finger is placeC. the lower teeth, as far poste riorly as possible, and thull1b is placed on the upper teeth. The patient ac" opens the jaw and applies gentle press ure in openin

Chapter 23 The Temporomandibular Joint

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563

FIGURE 23-10. (A) Interoral distraction . The clinician's thumb is positioned to apply a distraction force. (B) Lat­ eral glide. The clinician's thumb is positioned to apply a lateral glide force. (e) Intraoral translation (ventral gl ide) The clinician's index and third fingers are positioned to apply translation.

a stretch is felt (Fig. 23-12). This technique should be per­ form ed bilaterally to avoid compression of one joint while trying to stretch the other side. Techniques used for mandibular opening may be help­ ful in joint restrictions caused by anterior disk displace­ ment 'v'lith and 'vvithout reduction. In the case of a nonre­ ducing disk, it is important to limit intracisal opening to approximately 30 mm to protect the retrodiskal tissue from being overstretched. 13 Postisometric relaxation techniques (PIRs ) use active muscle contractions at various intensities from a precisely controlled position in a specific direction against a coun­ terforce to facilitate motion 35 For one PIR technique for mandibular opening, the patient sits at a table, 'vvith one el­ bow on the table and with the hand propping her forehead;

the fi~gers of the other hand are on the mandibular denti­ tion:1.) After opening his or her mouth to take up the slack, the patient breathes out; during inhalation, he or she opens her mouth as wide as possible, as if yawning (Fig 23-13). This is followed by closing the mouth against isometric re­ sistance with minimal force ; the exercise is then repeated. Deviation of the mandible to the side during the relaxation phase may be introduced as a separate exercise. For PIR self-treatment for relief of tension of the lateral pterygoid, the patient assumes a supine position . Using his or her thumbs on the mandible, the patient presses her chin forward against the isometric resistance of the thumbs \'lith minimal force while breathing. The patient next holds his or her breath and then breathes out while relaxing and letting the chin drop back (Fig. 23-14),35 The exercise

FIGURE 23-11. Active exercise to increase mandibular lateral excursions

and protrusion. The patient is given enough tongue blades to place be­

tween the teeth to allow for approx imately 10 to 11 mm of opening. The

patient is then asked to protrude the mandible at this opening to improve translation . The patient may also be instructed to protru de and glide the mandible to one side to improve tran slation of one si de.

FIGURE 23-12. Active-passive mandibular exercise. The patient is in­

structed to actively open the mouth. Then finger pressure is applied to the

maxillary and mandibu lar dentitions with one or both hands.

564

Therapeutic Exercise: Movi ng Toward Function

FIGURE 23·13. Postisometric relaxation self-exercise for ma ndibular

opening (temporal, masseters, and med ial pterygoid muscles). The patient sits at a table, with one elbow on the table and with the hand propping his or her forehead; the fingers of the other hand are on the maxi llary teeth. After taking up the slack of mouth opening, the patient breathes out. Dur­ ing inhalation, he or she opens the mouth as wide as possible The hand on the forehead should prevent flexion, which would interfere with maximum opening.

should be done with minimal effort; the rela.xation phase is most impoltant. Tension of the digastric is best diagnosed by trying to shift the hyoid from side to side. When tightness or tension is marked on one side, deviation of the thyroid cartilage to the ipsilateral side may be evident. For self-treatment using PIR, the thumb of one hand lies lateral to the hyoid on the restricted or tense side. During the resistance phase, the pa­ tient slightly opens his or her mouth and breathes in, holds his or her breath, and then relaxes while breathing out. The patient closes the mouth while his or her thumb moves the hyoid very gently to the opposite side (Fig. 23-15).3.;

FIGURE 23·14. Postisometric relaxation self-exercise of the lateral ptery­ goid. The patient is supine, with the mouth slightly open. He or she places both thumbs on the mandible and is instructed to press the chin forward against his or her thumbs while breathing in. The patient holds his or her breath, then breathes out, letting the chin drop back.

The goal of functional kinetic exercises developed by Klein-Vogelbach:36 ..17 is for the patient to learn to move the TMJs freely and with precision in all directions. In normal TMJ activity, it is the mandible that moves while the head remains stationary. If movemen t at th e TMJ is restricted , it is often helpful to reverse these roles. Normally, jaw eleva­ tion , depression, protraction, retraction , and lateral gliding are initiated at the mandible (i.e., distal lever). To facilitate increased motion and to functionally circumvent and break faulty habit patterns , the levers are reversed; the head (i.e ., proximal lever) initiates the motion. The head moves but not the mandible. These movements are transmitted to the upper cervical spine joints (i.e., atlanto-occipital and at­ lantoa.xial joints). While the patient sits with good vertical alignment, the therapist or patient provides flxation of the mandible; the flngers of both hands should grasp the mandible. Exercises include opening and closing of the mouth, lateral devia­ tions, and protrusion and retrusion (Fig. 23-16). These pre­ cise and unfamiliar movements of the TMJ must be per­ formed at low intensity and slowly, because the body is learning movement that it does not need in normal motor behavior but that can be used effectively to reduce restric­ tion. 37 These exereises are followed with normalmandibu­ lar motions to assess progress and maintain function. A sen­ sory awareness exercise tape, using these same principles of initiating motion of the jaw with the head and other neu­ romuscular learning techniques based on the Feldenkrais Method, has been developed by Wildman 38 for home use. A variation of Klein-Vogelbach's kinetic exercises for opening and closing the jaw freely and "vith precision is an exercise with the head in the inverted position (for patients who can assume the position) (Fig. 23-17). Opening of the mouth in this position must be performed against gravity. providing eccentric isotonic work of the masseter muscle in

FIGURE 23·15. Postisometric relaxat,ion self-exercise for the digastric muscle. While sitting, one hand is placed under the chin, and the other hand contacts the lateral aspect of the hyoid bone (tense side) with the thumb. After the resistance phase, the thumb gently moves the hyoi medially.

Chapter 23 The Temporomandibular Joint

FIGURE 23-16. Functional kinetic exercises using the proximal lever for (A) opening . With the mand ible stabi­ lized; the patient extends the head (the tip of the nose moves cranially and dorsal ly). As the mouth opens. the joints of the upper cervical spine extend, and the TMJs open. (8) Closing. The patient flexes the head (the tip of the nose moves caudally and ventrally) as the mouth closes; the joints of the upper cervical spine flex and the TMJs close. (e) Functional kinetic exercises using the proximal lever for lateral movements to the right. With the mandible stabilized. the right upper teeth slide laterally to the right of the silized mandible and (0) to the left (the opposite applies for movement to the left) The movement is one of rotation of the atlanto­ occipital and atlanto-axial joints of the cervical spine and lateral translation in the TMJ (E) Functiona l kinetic exercises using the proximal lever for protrusion . With the mand ible stabi lized the upper teeth slide dorsally in relati on to the lower teeth. (F) Re trusion. With the upper teeth moving ventrally to the lower. The movement is one of dorsal or ventral glide of the cervical spine and dorsal or ventral translation of the TMJs.

565

566

Therapeutic Exercise Moving Toward Function

closely related to TM J hypermobility, and other investiga­ tions suggest disk displacement and osteoarth rosis. 3't"'4 1 Parafunctional habits that contIibute to hypermobility of the TMJ include prolonged bottle feeding, thumb suck­ ing, and pacifier use in children J6 Many adult patients present with a history of habitually opening their mouths excessively wide when yawning or eating. Both jOints usu­ ally are involved, but unilateral ~l)'pennobility can occur as a compensatory reaction to h)1)omobility of th e contralat­ eral side. Believed to be th e most common mechanical disorder of the T\1J, hypermobility of the TMJ is characterized by early or excessive anterior translation or by early and excessive an­ terior translation of the mandible 42 In cases of hypermobil­ ity, translation occurs within the first 11 mm of opening, rather than the last 15 to 25 mm. Excessive antelior transla­ tion results in laxity of the surrounding capsule and liga­ ments. The breakdown of these structures allows disk de­ rangement in one or both TMJs. Ultimately, impairments such as functional loss and arthlitic changes may occur. Intervention FIGURE 23-17. Opening the mouth exercise with the long axis of the body inverted.

opening and concentric work in closing. The reverse is true of the jaw-opening muscles, the suprahyoids.

Hvpermobility Etiology

The cause of TMJ hypermobility is unknown. Potential predisposing factors range from doint laxity to psychiatric disorders to skeletal disorders. 9 Investigations suggest that syste mic hypermobility (i.e. , ligament laxity) may be

Therapeutic modalities such as heat and ice are benefi­ cial if the condition is painful. An important step is to edu­ cate the patient regarding the functioning of his or her joints, the reason for the symptoms, al1d how to modulate these symptoms. The following sections describe treatment options for hypermobility impairment. Muscle Performance: Temporomandibular Joint Rotation and Translation Control. For the therapist to teach control of

the ja\v muscles, the patient must first recognize the rest­ ing position of the mandible: lips closed, teeth slightly apart, and the tongue on th e hard palate. Th e patient should breathe in and out through the nose and use di­ aphragmatic breathing. The initial exercise limits TM J mechanics to condylar ro­ tation through an active assistive technique lllsing the index finger and thumb to assist the movement. While maintain-

SELF MANAGEMENT 23-1 Concentric and Eccentric Exercises

Purpose:

To restore proper "tracking" to the temporomandibular joint (TMJ), to limit TMJ mechanics to rotation through an active assisted technique (the patient's thumb and finger of one hand are needed to assist the movement!, and to decrease or eliminate clicking, cracking, popping, or excessive movement occurring in the TMJ.

Precautions:

Carefully monitor the axis of rotation of the TMJ joint, eliminating any subsequent translatory motion. Monitor this trial jaw opening in a mirror to ensure a straight opening (i.e., tongue stays on roof of the mouth). Exercise must be done slowly and rhythmically within the pain limits.

Position:

The patient sits on a firm chair, close to the front edge, with feet on the floor about 12 inches apart. Instruct the patient to maintain, neutral pelvis, lumbar thoracic, and cervical spine alignment. Instruct the patient to think of the head leading up and the torso lengthening and widening to achieve full spinal length. The cervical spine should remain in neutral (eyes focused to horizontal). Assistive positioning devices may be used. The patient can sit with the back and cervical spine supported against a wall (towels behind the head to maintain neutral cervical spine if forward head posture is stiff or rigid).

Chapter 23 The Temporomandibular Joint

567

•

~.,~ SELF MANAGEMENT 23-1 Concentric and Eccentric Exercises (Continued)

'V"

Movement technique:

Place one index finger on the TMJ.

Place the opposite thumb and index finger

lightly on the tip of the chin.

Instruct patient to: Keep the tongue on the roof of mouth.

Allow the lower jaw to drop down and back with guidanc e from the thumb and index on the chin. After learning to control movement by proprioceptive feedback, rotation-controlled movement without the tongue on the roof of the mouth may be attempted.

Dosage:

ing the tongue on the roof of the mouth, one index finger is placed on the involved TMJ , and the other index finger is placed on the chin. The lower jaw is allowed to drop down and back with the gUidance of the index finger and thumb (Self-Management 23-1). The use of a mirror to monitor motion is helpful in achieving normal tracking and to ensure that the tongue stays up and the jaw does not deviate. The exercise is progressed by placing both index fingers on the TMJs (Fig. 23-18). Th e lower jaw is allowed to drop down and back, bringing th e chin to the throat, as in the first exercise but without the guidance of the index finger on the mandible. As the patient teams to control movement by proprioceptive feedback, he or she may then attempt rota­ tion on opening ,vithout the tongue on the palate (without condylar translation) , first vvith the guidance of the index

FIGURE 23-18. Neuromuscular re-education for rotation and translation control. The patient starts with the tongue on the roof of the mouth and index fingers on both TMJs. The mandible is allowed to drop down and back; the tongue is dropped from the roof of the mouth and opening is completed. A mirror is used to monitor complete opening and to ensure a straight open ing.

Repeat this exercise 5 times, 5 times per day. The patient is instructed to use this pattern of movement frequently during the day or whenever observing himself or herself in a mirror.

finger and thumb on the mandible, as shown in Self-Man­ agement: Concentric and Eccentric Exercises, and then with both index fingers on the TMJs (see Fig. 23-18). Muscle Performance: Strengthening and Stabilization Exercises. After or concurrently with an exercise program

to develop TMJ rotation and tran slation control, a mandibular stabilization program should be started to strengthen the jaw muscles and balance the strength and function of the right and left TMJs . These strengthening exercises are also used to control excessive translation and establish a normal jaw position at rest and in the open­ mouth position. Isotonic exercises may be used in the man­ agement of painless clicking, after a painful episode is re­ solved, and when the click is not caused by a displaced articular disk n Strengthening exercises are also indicated after TMJ operations and for a variety of other TMJ dys­ functions and disorders. Muscle Performance: Isometric or Static Exercises. Propri­ oceptive neuromuscular techniques (P NF ), such as the contract-relax exercise and rhythmiC stabilization tech­ nique are used. Light pressures are applied to the jaw ,vith the index finer and thumb on either side of the mandible. The patient is asked to place the tip of the tongue up against the palate, vvith the teeth slightly apart. Gentle pressures are applied for a short time. Pressure is applied as the patient attempts to open and close the mandible, glide it to the left or light, and glide it ventrally and dorsally or in diagonal direction back toward or away from either ear (see Patient-Related Instruction 23-1: Mandibular Sta­ bilization Instructions). Motion in each direction is re­ peated several times to exercise various muscles and stim­ ulate neuromuscular awareness. These exercises may then be performed with the jaw in a position ,vith the teeth one knuckle apart and then two knuckles apart (Fig. 23-19), PNF techniques of resisted isometric opening contrac­ tions of the lateral pterygoids and suprahyoids promote re­ laxation of the primary closing muscles of the mandible

568

Therapeutic Exercise Moving Toward Function

FIGURE 23-19. Isometric stabilization exercises (one- and two-knuckle­ width opening). First one and then two knuckles are placed betwee n the up­ per and lower teeth. The knuckle or knuckles are removed, keeping the teeth apart Apply gentle pressure to the lower jaw as in Patient-Re la ted Instruc­ tion 23-1. Mandibular Stabilization Instructions. These exercises build on the exercise shown in the Patient-Related Instruction.The earlier stabiliza­ tion exercise is continued as these exercises are added . r-,Iot all patients are progressed automatically to the two-knuckle-width opening exercise. (i.e. , temporalis and masseter) through reciproc:al inhibi­ tion. This teclmigue can also facilitate maximum interin­ cisal distance 44,4.0 Muscle Performance: Isotonic or Dynamic Exercises. Iso­ tonic exercises are performed against the manual resis­ tance of the patient's or therapist's hand on the mandible. The amount of chin resistance allows controlled jaw movements over a restricted ROM , allOWing full activity of all the muscles operating about the joint. Exercises in­ clude resisted opening and dosing and lateral movem ents (Fig. 23-20). Open-dose movements are limited to about 1,5 mm of opening (ie., width of one knuckle). The pa­ tient should be reminded not to push the jaw fonvard dur­ ing the opening movement and to allow the jaw to open in an arc toward the chest. Resis tance to dosing should be done slowly. Lateral movem en ts are limited to ahout 5 mm. These exercises should never be performed so that pain or dicking sounds occurs. ROM should stop before the onset of pain or clicking.

Posture and Movement Impairments Signs and Symptoms FHP with resultant rounding of the shoulders can produce dysfunction of the craniocervical and temporomandibular system. Symptoms associated with the FHP can be ex­ tremely variable. Patients complain of stiffness, tiredness, tingling, aching, numbness, and vertigo. A patient may also complain of limitation of neck motion and various pain re­ ferrals to the head , anTIS, and upper thoracic spine. To restore balance to the system, patients must address excess tension , head and shoulder girdle alignment, jaw

The objectives are to strengthen the jaw muscles and to es­ tablish a normal jaw position at rest and in the open-mouth position. The following exercises require the application of light pressure to the jaw with your index fingers. The inten­ sity of pressure should be 2 on a sc ale of 1to 10 (10 = high­ est force). The jaw should not move during the application of pressure. Monitor this exercise in front of a mirror. Maintain the following mouth and jaw position: 1. Keep your teeth apart. Let your jaw and mouth drop open slightly and remain in that position. 2. The tip of the tongue remains on the roof of the mouth, just behind the upper two front teeth, Maintain good head, neck, and back posture. It is helpful to imagine two strings. One string pulls straight up from the top and back of the head to the ceiling; the second string pulls up from the breast bone, 1. Place the index fingers and thumbs of your hands on either side of your jaw.

2. Apply gentle pressure (2 on a scale of 1to 1O) in the following directions a. To the left side of the jaw b. To the right side of the jaw c. Up to the ceiling d. In toward the neck e. Diagonally back toward left ear f. Diagonally back toward right ear 3. Hold each pressure for 2 seconds. 4. Repeat each direction _ times, _ times per day.

and tongue position. and breathing. Postural re-education exercises; manual therapy techniques applied to tight mus­ des, soft tissue, and jOints; and neuromuscular relcLxation training may be needed. III general, treatment should be­ gin by developing a hOllle program of relaxation training and postural correction programs monitored jOintly by the patient and therapiSt. Ergonom ic advice and spinal sup­ ports should be provided as needed. Ultimately, manage­ ment should become the patient's responsibility. The ther­ apist assists with reinforcement and periodiC follow-up visits for adapting programs based on the patient's changes and progress.

569

Chapter 23: The Temporoma ndibular Joint

26). Therapists may also use a variety of movement r - du­ cation approaches to attain balanced posture, alignm nt. st~cture, and function. Therapeutic approaches i.?c!~lde a vanety of methods, such as Aston Patternmg, tl , th e Alexan~e~ Technique,"9.6o.,J the Feldenkrais Metl~od, f)3-67 tai chi, 14-16 and Trager Psychophysical Integmtion, 12 which use sensory, kinesthetic , and proprioceptive feedback to the body-mind system. A useful method of achieving good postural alignment in sitting and standing ,is to imagine two "s tlings " attached to the body: one to the sternum and the other to the top of the head posteriorly. As these strings are pulled up to the ceiling, head posture is made more axial, with increased opening of the subOCCipital space. As th e sternum becomes elevated, the shoulder girdle becomes more retracted and depressed. However, fl.attening of the cervical curve should be avoided. According to Rocabado,24 cranial flexion should not exceed 150 degrees. The sternum must be lifted without hype rextension of the thoracic or lumbar spine. The concept of alloWing the neck to release so the head can balance "fonvard and up" should be used to encourage length in the spine .'5H The for­ ward instruction does not mean that the head moves for­ ward of the rest of the body; it is implemented only to undo the backward pull or PCR on the neck. In a patient "vith PCR, the distance between the occiput and atlas is de­ creased, narrowing the subOCCipital region. This pulls the occiput posteriorly and inferiorly, resulting in upward and backward displacement of the mandible in the fossa. The Alexander use of the word up means away from the top of the spine, with the purpose of eliminating any muscle ten­ sion that pulls the head down into the neck. The head for­ ward and up movement is allowed to happen by releaSing tension in the posterior neck muscles (Fig. 23-21)59 1-

FIGURE 23-20. Isotonic strengthen ing exercise. Resistive exercise strengthen sthe leh lateral pterygo ids against a ri ght lateral force provided by the patient's right hand. Resistance is provided by pla cing the palm aga in st the ch in with the arm stabi lized (ie, elbow resting against a firm su rface or with the arm held firmly against the chest)

Intervention Therapeutic Exercise: Neuromuscular Relaxation Training

Effective self-regulatory and neuromuscular relaxation training involves development of more flexible habits of at­ ten tion, which must be fully transferred by the trainee to everyday activities. Various relaxation procedures that em­ ploy physical and mental exercises and exercises called therapeutic awareness have been devised 4 6--48 Rei2 Au~ogenic training e mploys adaptive mental im­ agery.')3,,,4 The verbal content of the standard exercises is focused on the neuromuscular system (e.g., heaviness of the limbs), the vasomotor system (e.g., warmth of the limbs, coolness of the forehead ), and slOwing of the cardio­ vascuTar system and respiratory mechanisms. Yoga, meditational mantra , and diaphragmatic bre_,~tl~~ ing techniques are adapted from Eastern disciplines. oo:>-.:><" Particularly valuable approaches, which focus on inte­ grated functions of the tongue, jaw, and breathing, include the use of sensory awareness techniyues 56 ,59--fi2 and sen­ sory-motor learnillg exercisesas.6:1-6, Therapeutic Exercise: Head, Neck, and Shoulder Postural Exercises

A significant aspect of the therapy for the head, neck, and shoulder isa postural exercise prog:-am. The principl,e~J)fo­ posed by Kendall and coworkers"s and Sahrmann o), are most beneficial for these patients (see Chapters 18,24, and

Therapeutic Exercise: Mandibular and Tongue Postural Exercises

Proper resting position of the tongue, in addition to helping maintain normal posturing of the mandible and ax­ ial spine, enhances normal swallOWing patterns and makes daytime clenching more difficult. 77 The correct resting po­ sition of the tongue (i.e., comfortably resting against the hard palate) should be discussed with the patient and demonstrated 8 The most anterosuperior tip of the tongue should lie in an area against the palate just posterior to the back side of the upper central incisors. Instructing the pa­ tient to maintain TUTALC helps to achieve the resting po­ sition of the jaw and tongue and overcome parafunctional and functional muscle hyperactivity. 16 Tongue push-ups may be used as an initial exercise to strengthen the tip of the tongue and famili~rize the patient with the correct placement of the tongue. I:, The tongue tip is pOinted and pressed against the hard palate (just above the upper teeth ), then released, and the exercise is repeated. One exercise involves instructing the patient to "cluck" the ti~ of the tongue against the hard palate and leave it there. 4 Another requires the patient to practice certain sounds, such as those made bv the letters T, D L, and N, that raise the tip of the tongue' to the incisal papilla. Words such as Ted, dad, love, and nut can be practiced with added force to activate the tongue muscles b Neuromuscular control can be achieved by practicing tongue-up exercises along with opening and closing the

570

Therapeutic Exercise: Moving Towa rd Function

FIGURE 23-21. Head and neck release . (A) I-~ correct head pulled back and down. (8) Cor­ rect head rel easing forward and up

mouth with speed. 4 This exercise involves having the pa­ tient open and close the mouth ,vide 'vvith the tongue in its resting position. The patient should be instructed to stop shOlt of a "click" ,vith no deviations of the mandible or excessive anterior translation. After controlled opening is achieved, the patient increases the speed of movement. Kraus 4 fowld this a useful technique in reducing symp­ toms associated with inflammatory disorders such as syn­ mitis and capsulitis and when inflammation coexists with hypermobility, hypomobility, or excessive parafunctional acti\ities. Therapeutic Exercise: Exercises to Correct

Dysfunctional Swallow Sequence and

Breathing Patterns

A commonly overlooked problem in patients present­ ing with TMJ and craniocervical disorders is an altered swalloWing sequence, which is most often associated 'vvith tongue thrust swallow or abnormal breathing. In abnor­ mal breathing, such as mouth breathing, the tongue is usually depressed, and the upper and lower part of the tee th are apart during swallOWing. Persons who swallow abnormally usually bring their tongues forward to mee t the glass or cup when taking a drink, and excessive lip ac­ tivity may be evide nt. Becaus e of the FHP, the hyoid bone may elevate on swallowing and abnormal contrac­ tion of the subOCCipital musculature may occur. 13 One of the methods, according to Funt and colleagues,l.5 of changing this pattern when drinking from a cup or glass is to instruct the patient to bite the back teeth together, put the tongue to "the spot" on the anterior palate directly be­ hind the upper incisors, Siphon th~ water in between the teeth, and swallow (Fig. 23-22).1 .) As water is siphoned during the initial phase of swallowing, the tip of the tongue should return to its H'sting position without putting pressure on the posterior teeth. When this is ac-

complished, many sips of water are taken and swallo\\ without any movement of the facial muscles. Becaus tongue thrust habit is usually well rooted , this exercb,o should be practiced several times daily. After the patier; can use the new swallOWing pattern for all eating an drinking activities and has learned proper posturing, he 0:­ she must apply (at a subconscious level) what he or s h~ has learned to all swallov.ring activities and become aware­ of th e rest position of the tongue throughout the day. Proper diaphragmati c b reathing is also important t normal TMJ funct\on. 55 ,59,61. i8- 80 The mouth breather patients with allergies , or patients with nasal obstructi often breathe with in creased activity of the accessor muscles of respiration (i.e. , scaleni , sternocleidomastoid and pectoralis minor), leading to the FHP with peR.

FIGURE 23·22. Swallowing exercise. As water is siphoned during the ir; . tial phase of swa'llowing , the tip of the tongue should return to its restir;; position. When thi s is accomplished, many sips of water are taken anr swallowed without any movement of the fa cial muscles.

Chapter 23: The Temporomandibular Joint

571

• Initially. assume a comfortable position on the floor with your hands on your stomach. • Relax your belly as much as possible. • During the first third of inhalation, the belly should expand slightly (on its own) in an outward direction as the diaphragm pushes down on the contents of the abdomen.

• The dimension of breathing often neglected is sideways intercostal breathing. • Exhalation is largely a passive occurrence. The chest muscles and diaphragm relax. the ribs drop back close together. and the lungs recoil as air is quickly expelled.

• Next. the air should move into the middle portion of the lungs. causing the area of the lower and middle ribs to expand. Complete inhalation means filling the lungs forward. sideways. and backward.

The patient should be instructed in nasodiaphragmatic breathing (see Patient-Related Instru ction 23-2). Di­ aphragmatic breathing occurs more eaSily by breathing through the nose and with co rrect positioning of the tongue. A correct rest position of the tongue forces naso­ diaphragmatic breathin g. Diaph ragm atic bre athing is best learned in supine, followed by practice during sitting, standing, and activity. Diaphragmatic breathing controls stress, promotes general relaxation of the body, strength­ ens the diaphragm , improves oxygenation with increased depth of respiration , and decreases the use of the acces­ sory muscle of respiration. This is an important technique taught to patients with d),s fun ctional involvement of other regions , such as the pelViC floor , lumbar spine, thorax, and cervical spine.

Attempts to alter breathing patterns are often difficult. However, a more normal breathing pattern can be facili­ tated by altering the head and neck posture. This may be facilitated by an exercise proposed by Fieiding S2 A soft ball (eg. , old tennis ball) or equivalent is placed behind the pa­ tient's back at the level of the scapula as he or she sits in a strai ght-back chair (Fig. 23-23 ). The mechanism for im­ prove ment is not clear, but observation of the patient re­ veals a slower rate of breathing, improved spinal alignment, mouth closure, and relaxation of the shoulder girdle. The patient should be encouraged to make a conscientious ef­ fort to keep the tongue on the roof of the mouth and to practice diaphragmatic breathing. To fully transfer these ideas to other activities on a sub­ conscious level, it is often helpful for the trainee to prac­

572

Therapeutic Exercise Moving Toward Functi on

------------------------------------------------------

FIGURE 23-23. Posterior co-contraction using a ball behind the back at the level of the scapula to facilitate a more norma l breathing pattern.

tiee awareness exercises directed at restoration of the neutral resting position of the head , neck, jaw, and shoul­ Jer girdle throughout the day. The RTTPB system (relax­ atioll, teeth apart, tongue on the palat~c. posture, and breathing) proposed by EHis and Makofsy" is one way to help the trainee remember and practice frequently. This helpful acronym addresses th e common imbalance seen in the upper quadrant.

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON DIAGNOSES In an average clinical setting, the most common disorder of the TMJ is dysfunction involving the capsule and intra­ articular structures. TMJ dysfunction can occur as a sepa­ rate entity or can be a complication of disease, trauma, or developmental abnormalities. Some of the more common diagnoses of the TMJ are reviewed in the follOWing sections.

Capsulitis and Retrodiskitis Signs and Symptoms Overloading of the joint from bruxism, excessively hard chewing, trauma, strain, or infection may cause an inflam­ matory response in the fibrous capsule, synovial mem­ brane, and retrodiskal tissues. The condition is called cap­ sulitis. Habits such as bru xing , tongue thrusting, gum chewing, and pencil chewing can offset the normal pattern of masticatory behavior and lead to asymmetric muscl'e ac­ tivity and mandibular malalignm ent. Overload problems are often related to emotional stress causing excessive mus­ cular activity.

Retrodiskitis occurs v.ith encroachmellt of the condyle on the articular disk This causes inflammation or exacer­ bation of an existing inflammatory condition. It can occur gradually, as the result of chronic repetitive microtrauma when the condyles are displaced posteriorly because of an­ terior disk displacement, or by acute external trauma to the chin, forCing the condyles posteriorly into the tissues. Persistent, subtle changes in joint kinematics may cause muscular imbalance between the elevators and depressors and produce abnormal stresses sufficient to result in im­ proper loading of the articular cartilage. This pattern can lead to potential fatigue failure and possible arthritic changes in the articular cartil age. Repeated overload leads to microtrauma and an inflammatory reaction in the cap­ sule, the peripheral parts of the disk , and the lateral ptery­ goid insertion. The overfatigued lateral pterygOid's abilit:­ to move the disk harmoniously dUling jaw move ment~ can be upset and result in disk displacement and Jamage. i Signs and symptoms of capsulitis include pain at rest (in­ tensified dUling functional maximum intercuspation of the teeth ) and parafunctional (bruxism) movements of the mandible. Pain occurs on the side of involvement in the area of the TMJ , with possible reference of pain into are~ innervated by cranial nerve V. Impairment resulting fro m capsulitis ranges from minor jOint restriction to total im­ mobilization. Signs and symptoms of retrodiskitis include constant pain and palpable tenderness posterior and lateral to the joint. Pain is usually increased by clenching or by mOvill'l the mandible to the affected side, which permits tbe condyle to press against the inflamed tissue. With swelling the condyle may be forced anteriorly, resulting in acute malocclusion. Because chewing on the contralateral sid, can increase pressure in the inflamed jOint, causing mon. pain, the patient should be advised to chew on the side the involved joint. 1Z H3

Intervention Treatment depends in large part on the cause. If caused a Single traumatic event, a program of limited mandibuL: function , mild analgeSiCS , ice, and moist heat or ultrasoun may be effective. To decrease pain and muscle guardilY... use of phonorrhoresis, ionophoresis, or laser therapy may 1:. indicated 1 3, 6,84 The most commonly used therapeu" modality after trauma or surgical intervention is cryothe.-­ apy.13 Cold is used to reduce inflammation, muscle spas and edema. Cold packs, ice massage, or vapocoolant spr, are used. Massage, biofeedback, relaxation techniques , electrical stimulation of the mandibular elevators can he promote muscle relaxation. If minor tenderness perSists duly, judicious use of ultrasound with exercises to exte translatory movement may be needed. Because hemarthr­ sis may occur in an acutely traumatized joint, meas should be taken to prevent ank),losis. As soon as the oce sion remains stabilized, cautious movement of the jor­ should be encouraged until resolution is complete. . When the inflamm ation is related to chronic mi trauma or disk displacement , more definitive therapy be indicated. Placement of a joint-stabilization splint reduce bruxism and decrease pressure on the joint. b5 face electromyography is often beneficial in the treat r

•

Chapter 23: The Temporomandibular Joint

of diurnal parafunction s6 ,87 When retrodiskitis is caused by disk displacement, anterior repositioning therapy is in­ dicated to reestablish the normal disk-condyle relationship, Maintaining the mandibular rest position by adapting to the normal rest position of the tongue against the palate with normal lip closure also reduces joint pressure, After inflammation, pain and muscle guarding are under control, a program of stretching and muscular re-education should be instituted. The stretching and PIR techniques discussed in the Hypo mobility section help to increase cap­ sular extensibility and restore muscle length. Functional ki­ netic exercises and strengthening and stabilizing exercises can assist in muscular re-education and relaxation.

Degenerative Joint Disease Signs and Symptoms Osteoarthritis, often referred to as degenerative joint dis­ ease,. of the TMJ is considered primarily a disease of mid­ ~le or older age, Osteoarthritis alters the force-bearing sur­ faces of the TMJ, often leading to secondary inflammation of the capsular tissue. The joint space narrows with spur formation and marginal lipping of the jOint. There is often erosion of the condylar head, articular eminence, and fossa.' Advanced joint disease may lead to atrophy of asso­ ciated muscles. Some causes of this degenerative process include internal derangement of the disk, an anterior placed disk, and repetitive overloading. The clinical features of osteoarthritis are similar to those of other forms of joint dysfunction. Typically, pain and crepitation occur during mandibular motions. Usually, crepitation remains after the other symptoms disappear. Most persons experience restriction of the mandible.

Intervention The primary therapy is directed at symptoms and may in­ volve surgery, drug therapy, and phYSical therapy. Active ROM exercises, mobilization techniques, and stretching, as discussed in the Hypomobility section, may be used during the chronic phase. Graded exercises involving a few simple movem e nts performed frequently during the day are often prescribed as a homc tr 'atment. Joint pro­ tection techniques, such as avoidance of excessive open­ ing and parafunctional lwbits, and proper resting position of tongue and mandible shollld be taught. Advanced bony changes within the joint may necessitate aIihroplasty and joint debridement.

573

Among the various theories regarding the came of disk de­ rangement are excessive pressure on the joint from clench­ ing or trauma; incoordinate contraction of the two bodies of the lateral pterygoid so that the disk snaps over the condyle rather than follOwing the movement smoothly and coordi­ nately when the mouth is open; deterioration of the disk and cartilaginous surfaces; and stretching of the joint liga­ ments by frequent subluxation. s.3,9081 Joint sounds such as clicking are considered one of the hallmarks of disk derangement. The frequency and quality of clicking or other sOl'lnds and their association \vith spe­ cific functional movements anJ pain often helps to provide important clues regarding the condition of bony and soft tissues within the joint. Clicking may occur as one or more clicks in one or both joints, and it mayor may not be asso­ ciated with pain. Various types of dicking noises have been observed during sagittal opening, including a opening click, an intermediate click during the opening phase, and an end-range click at full opening. An opening click is believed to be caused by an anterior displacement of the disk, \vith the condyle displaced poste­ riorly and superiorly. As the mandible opens, the condyle must pass over the posterior band of the disk and fall into its normal position in the concave articular surface beneath the disk (Fig. 2.3-24)91 Clicking during various parts of opening is probably caused by ru~tures or rents of the disk or anteroposterior displacement. 2 A dick occurring early in jaw opening indicates a small degree of anterior disk dis­ placement; a click occurring near maximal opening sug­ gests farther anterior displacement. On closing, a soft, closing click may also be detected as the condyle slips behind the posterior edge of the band of the disk, leaving the disk displaced anteriorlv and medially. The opening click occurs as the disk snaps back into its nor­ mal position, and the closing click results in disk displace­ ment. Clicking can worsen with time as the posterior liga­ mentous attachments become further stretched and damaged. In addition to clicks produced dUting mandibu­ lar opening, clicks may be produced by eccentric 111ove­

Derangement of the Disk Two general classifications of this disorder are recognized: the anteriorly displaced disk that reduces during joint translation and the anteriorly dis~laced disk that does not reduce during joint translation,' S These two conditions may exist indefinitely or may be one of the stages in the continuum of a disease process that leads to degenerative joint disease,s9 Malocclusion (i,e" overclosure of the mouth vvith back­ ward displacement of the condyle) or trauma may cause derangement of the disk. Trauma to the disk may cause a partial tearing of the disk from its capsular attachment.

FIGURE 23·24. Mandibular depression with disk displacement. (A) TMJ with the mouth closed. (8) Early in the translatory cycle, the condyle is un­ able to pass under the posterior aspect of the disk. It overrides the poste­ rior disk material and clicks, (e, 0) Normal joint motion allows complete opening

574

Therapeutic Exercise: Moving Toward Function

ments. These clicks may result from structural changes in the disk or incoordinate function of the parts of the jOint.

Associated Impairments The classic signs of the type of anterior disk di slocation with reduction is a distinguished, somewhat loud dick or pop on opening accompanied by a coincident palpable jar­ ring of the joint. This Signifies that the disk 11<15 relocated it­ self with respect to the condyle. The opening click is fol­ lowed by a subtler click, usually occurring dUJing closing and signifying that the disk has displaced anterior to the mandibular condyle. Mandibular ROM is usually normal in disk displacement with reduction, and the amount of verti­ cal opening may be greater than normal .85 The sign of an anterior disk dislocation that does not re­ duce is the absence of joint noises with a series of repro­ ducible restrictions during mandibular movements . These restrictions are caused by th e disk blocking translatory glide. This results in limited condylar translation in the af­ fected jOint, and the disorder is often referred to as a closed lock. 93- 95 A restricted maximum opening of 20 to 25 mm is the most obvious sign of an acute anterior disk displace­ ment without reduction. The mandible is sharply deflected to the affected side at the end of ope ning . Lateral excursion to the contralateral side is limited. Over time , a more nor­ mal range is achieved because of elongation of the poste­ rior attachment and continued stretching and tearing of the diskal attachments. 84 ,90,96 Pain may be felt in the region of the TMJ on the side of involvement, with possible reference of pain into areas in­ nervated by the trigeminal nerve. Pain increases or is al­ tered during functional and parafunctional movements of the mandible. Most patients with chronic anterior disk dis­ placement without reduction report a history of clicking and occasional locking. The most common sound is crepi­ tus, which represents degenerative changes in the articular surfaces. Moffett and coworkers demonstrated that perfo­ ration of the disk is usually followed by osteoarthritic changes on the condylar surface, which is followed by sim­ ilar bony alterations on the opposing surface of the fossa H7

Education and exercises in facilitating relaxation of muscle tone of the jaw and cervical muscles are often beneficial; these exercises were discussed in previous sections.

ape

Temporomandibular Joint Clicking In the absence of obvious malocclusion, simple exer­ cises deSigned to allow controlled joint movement under load with simultaneous activitv of the extensor and flexor muscles operating about the j~int have been found to alle­ viate the annoying problem of TMJ clicking. Gersch­ mann 98 found that simple exercises, such as lower jaw thrust exercises in a forward , backward, or anterior direc­ tion with the teeth disengaged with a pencil and perform­ ing chewing exercises with the pencil, could decrease click­ ing in about 2 weeks (Fig. 23-25). Au and Klineberg,43 in a stud), of young adults, found that clicking was a reversible condition that could b treated successfully with noninvasive isometric exercises (I.e., jaw opening as a hinge movement and lateral devia­ tions ) (see Patient-Related Instruction: Mandibular Stabi­ lization Instructions), which suggests that there is a neuro­ muscular cause for many TMJ clicking problems.

Su

Anteriorly Dislocated Disk Without Reduction JOint mobilization techniques of distraction (i. e., caudal glide) and translation (i. e., protrusion) to the involved sid may be beneficial whe n hindrance in function warranL treatment (see Fig. 23-10). Therapeutic modalities and soft-tissue mobilization techniques, such as myofascial re­ lease and massage, can be used to decrease pain and in­ crease tissue extensibility. If articulation techniques in re­ locating the disk are successful, proceed immediately with the treatment discussed for an anterior disk dislocation that reduces. Management in disk derangements may best be accom­ plished by normalization of muscle tone and function When pain or hindrance of function is Significant and ther-

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Intervention Anteriorly Dislocated Disk With Reduction A common treatment for an anteliorly dislocated disk with reduction is to use an anterior repositioning appliance or a nonrepositioning appliance applied by a dentist spe­ cializing in the treatment ofTMJ. Physical therapy modal­ ities such as heat and ice help to decrease pain and muscle guarding, enhancing the effectiveness of the appliance. In­ stituting a home program to decrease the incidence of parafunctional activity is a first step in managcment. After parafunctional activities such as gum cheWing, nail biting, clenching, excessive opening, and ovefllse are identified, the client is instructed to avoid these habits. With clench­ ing, the client should be instructed in self-cuing techniques to decrease frequency. The client should check the position of the tongue and mandible frequently throughout the day. A visual cue, such as a clock, in the patient's environment should be used as a reminder. V\Then he or she notices clenching, a deep breath is take n, and the tongue and mandible are restored to their normal resting positions.

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FIGURE 23·25. Chewing the pencil exercise. A soft cylindrical rod (1 .5 to 2 mm) is placed horizontally at the back of the mouth so that the object thrusts forward with the mandible. The patient is instructed to bite on the rod with a grinding movement.

Chapter 23 The Temporomandibular Joint

575

apeutic intervention and appliances are unsuccessful, con­ sultation with an oral surgeon is indicated.

Surgical Procedures Postoperative rehabilitation can take 6 months to 1 year. A preoperative physical therapy evaluation should include obtaining a co mplete medical histOlY and conducting a craniomandihular evaluation, which includes assessment of posture, tongue pOSition, and swallovving sequence. Patient education and patient compliam:e are critical to successful postoperative treatment. At the preoperative visit, patients hould be made aware of the surgical procedure and what to expect postoperatively. Patients should be instructed in t chniques of pain control and the reduction of swellincrM ( .g. , cryotherapy, transcu taneous electrical nerve stimula­ tion, diaphragmatic breathing) to be used immediately af­ ter su rgery. Active and passive exercises that may be indi­ cated after surgery should be explained before surgery. Physical therapy procedures after surgery consist of modal­ ities to decrease inflammation, edema, reflex muscle guarding, and pain. The patient's diet is often limited to oft foods for up to 3 months, depending on the extent of ~rgery and possible scar growth. It is important to empha­ lZe that the home program is the most Significant part of the patient's rehabilitation program.

Postoperative Arthroscopic Surgery :\.rthroscopic surgery is indicated for diagnosis and treat­ ment of intracapsular derangement and joint adhesions. 99 Before the advent ofTMJ arthroscopy, physical therapy re­ fe rrals were made usually no earlier than 2 weeks and as late as 6 weeks postoperatively.loo Arthroscopy has changed this course dramatically. Patients are seen in phys­ ical therapy 24 to 48 hours after surgery. The patient should be reevaluated postoperatively. Changes in pain patterns, sensation, occlusion, and active motions should be recorded along with evidence of intra­ capsular or ext racapsular swelling In most postoperative ' procedures, an immediate goal is to maintain the interin­ cisal opening achieved under anesthesia by the surgeon. 1:3 Postoperative adhesions between the articular surfaces and the disk may occur if mobility is not maintained. Intraoral joint mobilization techniques include distraction and lateral (rlides (see Fig. 23-10). Thes e techniques are desicrned to in­ hibit reformation of adhesions, decompress thebTMJ, en­ 11ance synovial lubrication, £romote muscle rela.xatio~, and restore functional ROM 4 . J J Joint mobilization techniques must be performed gent1ly and slowly within the pain-free range and usually to both TMJs to prevent hypomobility from long-standing dysfunction on the non surgical side. One of the most important exercises postoperatively is teaching the patient to open the mouth with the tip of the tongue on the hard palate to inhibit early translation (see Self-Management 23-1). Studies by OsbornelOZ.I03 and Salter !04 have shown that constant mohility after joint trauma or surgery usually lyses blood clots, forestalling or­ ganization into connective tissue. Active isomdric and iso­ tonic exercises are performed as previously described (see Patient-Related Instruction 23-1 and Figs. 23-19 and 23­ 20). Time and effort should be spent on achieving normal

FIGURE 23-26. Self-distraction may be performed by the patient gently squeezing the face and pulling forward and downward on the mandible. The elbows should rest on a firm surface, or the patient should hold the forearm s firmly against the chest. To enhance the mobilization techniques, active participation by the patient is encouraged. The patient actively opens or closes using minimal muscle contraction. and after relaXing, ad­ ditional distractIOn can be applied .

tracking and balancing lateral movements. Self-distraction (Fig. 23-26) and gentle active-passive mandibular opening exercises (see Figs. 23-12 and 23-18 and Self-Management: Concentric and Eccentric Exercises) and lateral deviation of the mandible (see Fig. 23-11 ) should be performed with­ out causing pain. If hypo mobility develops as healing progresses and the problem is attributed to capsular constriction , ultrasound treatment (under the constant force of tongue blades or a Therabite unit) and more vigorous joint mobilization tech­ niques may be considered. Emphasis should be placed on lateral and medial gliding and on protrusive movements. If hypomobility is attributed to fascial restriction or muscle dysfunction , myofascial release techniques, PNF tech­ niques (i.e., contract-relax exercises, rhythmiC stabiliza­ tion ), PIR techniques (see Figs . 23-12 through 23-15), and isotonic exercises may be used increase mandibular motion and promote relaxation. At all times, the therapist must consider the cervical spine and any abnormal forces that the exercise may place on the TMJ s. The therapist mllSt consider the suprahyoid­ lIlfrahYOld length-tenSion relationship and its influence on tongue phYSiology and the resting position of the jaw. I7,lOS Treatment of the cervical spine, based on the evaluation findings, may be directed at postural corrective exercises for the head and neck, releaSing myofascial restrictions, restoring j?int mobility, or providing segmental stabiliza­ tIOn exercises for hypermob ile segments. 106 The typical postarthroscopic surgical patient is followed for 5 to 7 weeks. I :,

Postarthrotomy Surgery The most common indication for postarthrotomy surgery is a deran gement of the disk that has not responded to non­ surgical management. Arthrotomy (i.e., open joint) proce­ dures vary, depending on the existing pathology and the

576

Therapeutic Exercise: Moving Toward Function

FIGURE 23-27. Extraora l articulation techniques are performed with the patient in sidelying on the noninvolved side with the head supported on a pillow. (A) Extraoral medial glide. Gentle oscillatory mobilizations are per­ formed over the lateral pole of the condyle in a medial direction with the thumbs. (8) Extraoral protrusion. Gen­ tle osc illatory mobi lizations are performed over the posterior aspect of the condyle in an anteri or direction.

technique of the maxillofacial or oral surgeon. Surgical op­ tions include disk plication and partial or total diskectomy with grafts or without repletcement. The degree of disk de­ formation and health of the intercapsular disk attachments dictate the feasibility of plication. The patient should be seen within the first 3 to 4 days postoperatively to administer appropriate anti-inflamma­ tory modalities and to begin active or passive ROM 107 Most surgeons request that only active motion without re­ sistance he used during the first 3 postoperative days.13 They believe passive mobilization can disrupt healing and cause surgical failure . Physical th('rapy after a disk plication procedure is based on an understanding of revasculal; zation and healing of the involved tissues. Tlw greatest change in vascularity and healing occurs in the second and third wC'ek after surgery, and complete healing occurs in 6 weeks. l lJ'; If a disk has been reconstructed or retrodiskal tissue repair performed,

Illotion may be quite limited, initially allovving only condy­ letr rotation. Splint therapy is usually an integral part of the patient's overall treatmellt. After the fifth or si.xth week postoperatively, condylar rotation is allowed. Careful early mobilizatioll prevents th potential loss of 1l1andibular movement associated with im­ mobilization. Th e method of choice is extraoral medi8 glides, protrusion (Fig. 23-27), and distraction, which can also be done by the patient (see Fig. 23-26).13 The patient should be instructed in active and passive mandibular ex­ ercises (see Fig. 23-12; Self-Management: Concentric and Eccentric Exercises; and Patient-Related Instruction: Di­ aphragmatic Breathing). Re-education of the masticaton muscles is usually started in the third or fourth week. Rp­ sisted opening (Fig. 23-28) and active lateral glide \-vi tongue blades (see Fig. 23-11) or surgical tubing is first in.i ­ tiated on the contralateral side (Fig. 23-29 ). Lateral glide exe rcises may then be performed with submaximal isom et-

FIGURE 23-28. Resisted concentric opening at the midline is performed by the closing force provided by the therapist's or patient's hand. Empha­ sis is placed on straight, midline mandibu lar depression and protrusion with the tongue on tile hard palate. To avoid provoking pain or clicking, opening should be restricted to less than 20 mm interincisor separat ion.

FIGURE 23-29. Lateral deviation of the mandible. Tubing is mainta ine: with the frontal incisors at an end-to-end position. Active exercises a';; performed by rolling it side to side . A mirror should be used fo r visual feee· back to ensure that no retrusion occurs.

Chapter 23: The Temporomandibular Joint

rics. Lateral deviations are usually limited to 5 mm on the side opposite the surgery. Massage of the temporalis and inferior to the masseter in particular permits a better stretch. 103 Soft-tissue mobi­ lization techniques may include deep pressure-point mas­ sage. lOg friction massage. 110 acupressure. lll strain-coun­ terstrain. 1l2 craniosacral thera?y. ll3-115 and myofascial release or manipulations. 13. 116 .11

ADJUNCTIVE THERAPY Surface electromyography (EMG) of the muscles of masti­ cation is used routinely by some dentists and therapists as part of the diagnosis and treatment ofTMJ disorders . Mus­ cle hyperactivity. spasms. and imbalance have bee n sug­ gested in the literature for many years to be major features ofTMJ disorders. but evidence to support such concepts is lacking. w H2o The use of surface EMG is based on the as­ sumption that various dysfunctional or pathologic condi­ tions can be discerned from records ofEMG activi~ of the masticatory muscles. including muscle imbalances. 8 .121-123 functional hyperactivity and hypoactivity.1Z4-1 28 postural hyperactivitY.tl.) ,126.129-l.31 muscle spasm,J2.5.126.132,l3.3 fa­ tigue,134,135 and abnormal occlusal positions. 12.3,}.1(i- 140 Records of EMG activity before and after therapeutic intervention have been used to document changes in mus­ cle function and have been cited as proof that the treat­ ment was successfuI.121.122.133 Most researchers agree that surface EMG can measure a behavioral event such as brux­ ism or clenching. 138.141 With portable E:vt G devices, relax­ ation of the masticatory muscles may be attained by the pa­ tient through biofeedback at home or work. Nocturnal biofeedback exercise can produce a Significant decrease in the frequ ency and duration of nighttime bruxism142-146 However, the benefits of this treatment did not last long, and a return to pretreatment EMG levels was observed as soon as biofeedback stopped. 143 ,144 A few controlled stud­ ies have shown significant reduction of diurl!al masseter · muscle activity by using diurnal biofeedback.(i·o,R(i

KEY POINTS • The relationships of the stomatognathic system, in terms of structure and function, require a thorough evaluation and integrated treatment approach.

• FHP affects the position if the mandible, tongue, and hyoid, altering mandibular rest pOSition , swallOWing function , breathing pattern, and muscle balance. • Prop er positioning of the tongue on the roof of the mouth helps to maintain normal resting position of the mandible and promotes normal swallowing function. • H ypomobility of the TM J may result from various condi­ tions involving the bones, muscles, joint capsule, retrodiskal tissue, or disk. Treatment seeks to decrease inflammation and pain and increase motion and function . • In the case of a nonreducing disk, it is important to limit interincisal opening to approximately 30 mm to protect the retrodiskal tissue from being overstretched. • Hypermobility of the TMJ is characterized by early and excessive translation of the mandible . Treatment seeks to increase joint proprioception and retrain motion , lim­ iting translation through controlled motions and stabi­ lization exercises. • Hypermobility is usually bilateral; however, it occurs unilaterally when the contralateral joint is hypomobile. • Postoperative rehabilitation can take 6 months to 1 year. Therapeutic intervention should begin as soon as possi­ ble to administer appropriate anti-inflammatory modal­ ities and to begin active or passive ROM . One of the most important exercises postoperatively is teaching the patient to open the mouth with the tip of the tongue on the hard palate to inhibit early translation. • It is important to involve patients actively in their treatment plan and to emphaSize that the home pro­ gram is the most Significant part of their rehabilitation program.

CRITICAL THINKING QUESTIONS 1. Describe the follOwing: a. The rest position of the tongue b. The motions available to the TMJ c. The relationship of the cervical spine and the TMJ d . The muscular control necessary for normal TMJ mo­ tion 2 . Differentiate a. Between the motions available in the upper and lower joint components of the TMJ. b. Between the classic sign of anterior disk location with reduction and an terior disk location that does not reduce.

LAB ACTIVITIES

1. Outline a conceptual model of musculoskeletal TMJ dysfunction and its sequelae. 2. List nine generic treatment goals appropriate for treatment of a patient with musculoskeletal pain and dysfunction of the TMJ. 3. Provide a sequential treatment plan using the goals identiHed in question #2 for the following: a. A soft-tissue lesion \vithout a mechanical deficit

577

h. A soft-tissue restriction without an articular deficit c. An articular deficit with soft-tissue les ions or length and flexibility deficit

578

Therapeutic Exercise. Moving Toward Function

3. H,y;dl dfe i/;e /l11}lOf e/e/.lle/.lls o//.oe elC'/~/Se/lfeSCqilZ./ P e/lj/ C .;)Ieu/i?/JJLlfCl/ler co/7//o/o//JJd/}d/;//~2rH / ./}o.;/Ad.oed'/'f/7,;fva·7./,/-zpa 170/./ aWe/­ 22. H-;r ke .BD. Neuromuscular mec.hanisJ1J~- L a. Postoperative a.rthroscopic surgely. mane/ibular posture: a neurologist's reVIew ofCUlTent (: b. Postarthrotomy surgery

REFERENCES 1. Magee OJ. Temporomandibular joints. In: Magee OJ, ed. Orthopedic Phys ical Assessment. 2nd Ed . Philadelphia: WB Saunders, 1992. 2. l\orkin CC, Levangie PK. The temporomandibularjoint. In : Norkin CC, Levangie PK, eds. joint Stnlcture and Func­ tion: A Comprehensive Analvsis . 2nd Ed. Philadelphia: FA Davis, 1992. 3. Moss YI. The functional matrix concept and its rel ationship to temporomandibular joint dysfunction and treatment. Dent Clin North Am 1983;27:44,3 -455. 4. Kraus S. Physical therapy manage ment of TMD. In: Kraus S, ed. Temporomandibular Disorders . 2nd Ed . New York: Churchill Livingstone, 1994. 5. Eggleton TM, Langton DP. Clinical anatomy of the TM J complex, In: Kraus SL, ed, Temporomandibular Disorders, 2nd Ed, New York: Churchill Livingstone, 1994, 6, Tanaka TT. Advanced Dissection of the Temporomandibu­ lar JOint. Chula Vista, CA: Instructional Video, Clinical Re­ search Foundation, 1988, 7. Hartley A. Temporomandibular assessment. In : HaJiley A, ed, Practical JOint Assessment : Upper Quadrant. 2nd Ed . St. Louis: Mosby, 1995. 8. Fish F. The functional anatomy of the rest position of the mandible. Dent Prad 1961 ;11:178, 9, Sauerland EK , Mitchell SP . Electrom),ographic activity of intrinsic and extrinsic muscles of the human tongue, Tex Rep BioI Med 1975;33:445-455, 10, Pertes RA, Attanrlsio R, CillOtti WR, et al. The te mporo­ mandibular joint in function and dysfunction. Clin Prev Dent 1988;10:23-29. 11. Assael LA . Functional anatomy, In : Kaplan AS, Assel LA, eds, Temporomandibular Disorders: Diagnosis and Treat­ ment. Philadelphia: WB Saunders , 1991. 12, Bell WE. Temporomandibular Disorders : Classification, DiagnOS iS, Management. 3rd Ed , Chicago: Year Book Med­ ical Publishers, 1990, 13, Dunn J. Physical therapy. In : Kaplan AS, Assael LA, eds . Temporomandibular Disorde rs, Philadelphia: WB Saun­ ders, 1991. 14, Fricton JR, Kroening RJ, Hathaway KM. TMJ and Cranio­ facial Pain: Diagnosis and Management. St. Louis: Ishiyzku EuroAmerica, 1988. 15. Funt LA, Stack B, Gelb S. Myofu nctional therapy in the treatment of the craniomandibular syndrome. In : Gelb H, ed . Clinical Management of Head , Neck, and TMJ Pain and Dysfunc tion : A Iv/ulti- Disciplinary Approach to Diagnosis and Treatment. 2nd Ed. Philadelphia: WB Saunders, 1985. 16. Racabado M, Iglarsh ZA. Musculoskele tal Approach to Maxillofacial Pain . Philadelphia: JB Lippincott, 1991. 17. Moumoto T. Km,vamura y, Properties of tongue an d jaw moveme nts elicited by stimulation of th e orbital gyrus of cat. Arcll Oral BioI 197:3;18::361-372. 18. Kraus SL. Influences of the cervical spine on the stomatog­ nathi c svstCI11. In : Donntelli R, Wooden M, eds. Or­ thopaedi~ Physical Therapy. 2nd Ed. New York: Churchill Livings tone, 1993. 19. Racabado M. Advanced Upper Quarter Manual, Tacoma, WA: Rocabado Instit ute, 1981. 20. Halbert R. E lectromyographic study of head position , J Can Dent Assoc 1958;23: 11-23,

cepts. J Dent 1972;2:111-120. 23 . Prieskel HW. Some observations on the postural position 0 the mandible. J Prosthet De nt 1965;15:625-6.33. 24. Racabado M. Diagnosis and treatment of abnormal cran­ iomandibular mechanics. In: Solberg W, Clark G, eels. Ab­ normal Jaw Mechanics: Diagnosis and Treatment. Chi cago: Quintessence Publishing, 1984. 25. Cailliet R. Neck and Arm Pain. 3rd Ed. Philadelphia: F.'\ Davis, 1991. 26, Friedman MH, Weisberg J. Temporomandibular Joint Dis­ orders: Diagnosi S and Treatme nt. Chicago : Quintcssenc(' Publish ing, 1985. 27, Man nheimer JS , Dunn J. Cervical spine. In: Kaplan AS , As­ sael LA, eds . Temporomandibular Disorders . Philadelphia: WB Saunders, 1991. 28. Mannheimer JS, Rosenthal RM . Acute and chronic postural abnomlalities as related to craniofacial pain and temporo­ mandibular disorders. Dent Clin North Am 1991 ;305:185-20&. 29, Darnell YI. A proposed chronology for events for forward head posture, J Craniomandib Pract 1983;1:50-54, 30. Proffit W, Equilibrium theory revisited: factors influenCing position of the teeth . Angle Orthod 1978;48:175-186. 31. M c ~ e ill C, ed . Temporomandibular Disorders : Guidelin e~ for Their Classification and Managem ent. Chicago: Quintessence Publishing, 1993. 32. Mmtland GOP. Periphe ral Ylanipulations . 3rd Ed . Boston: Butterworth , 1991. 33, Hertling OM. The tem poromandibular joint. In : Hertlin OM, Kessler R, eds , Management of Common Mus cu­ loskeletal Disorders . 3rd Ed . Philadelphia: JB Lippincott. 1995. 34. Mannheinwr J. Physical therapy modalities and procedur In: Peltes RA, Gross SG , eds. Clinical Management of Temporomandibular Disorders and Orofacial Pain. Chicago: Quintessence Publishing, 1995. 35. Le\\it K: Therapeutic techniques, In : Lewit K, ed . Manipu­ lative Therapy in Rehnhilitation of the Locomotor System, 2lld Ed. Oxford, UK : ButterwOlih-Heineman n, 1991. 36, Kl ein-Vogelback S. Functional Kineti cs: Observing, Analyz­ ing, and Teaching Human Movement. Berlin: Springer-Ver­ lag, 1990, 37. Klein-Vogelback S. Therapeutic Exercises in Functional Ki­ netics: Analysis and Instruction ofIndividually Adaptive Ex­ ercises . Berlin: Springer-Verlag, 1991. 38. Wi,l dman F. The TMJ Tape for Jaw, Head and Neck Pain. The Intelligent Body Tape Series. Berkeley, CA: Institute OJ Movement Studies, 1993. 39. Keith DA, Surgery of the Temporomandibular JOint. 2n Ed. Boston: Blackwell Scientific Publications, 1992. 40 , Buckingham RB, Braun T, Harinstein DA, et al. Temporcr mandibular joint dysfun ction: a close nssociation with s\; ­ temic joint laxity (the hyp ermobile joint syndrome ). Or... Surg Oral Med Oral PathoI1991 ;72:514-519. 41. Wes tling L, Mattiasson A, General joint hypermobility an temporomandibular joint derangement in adolescents. Am Rheum Dis 1992;051:87-90. 42. Morrone L, Ylakofsky H. TMJ home exercise program. Cli Manag 1991;1 1 :20-23 . 43, Au AR , KLin e berg JJ. Isokinetic exercise management 0 te mporomandibular jOint clicking in young adults. J Pro; ­ th et Dent 1993;70:33-38. 44 . Carstensen B. Indications and contraindications of manu therapy for TMJ. In: Grieve G, ed . Therapy of the Vertebt Column. New York: Churchill Livingstone, 1986.

Chapter 23 The Temporomandibular Joint 45, Plante D, Pos toperative physical therapy, In: Keith DA, ed, Surgery of the Temporomandibular JOint, Chicago: Black­ well Scientific Publishers, 1988, 46, Benson H , Stualt E'vl. The Wellness Book: The Compre­ hensive Guide to Maintaining Health and Treating Stress­ Related Illness , New York: Simon & Schuster, 1992. 47. Cannistraci AJ, Fritz G, Biofeedback-the treatment of stress-induced muscle activity. In : Gelb H, ed . Clinical Management of Head, '\eck and TMJ Pain and Dysfunc­ tion : A Multi-DiscipUnaJY Approach to Diagnosis and Treat­ ment. 2nd Ed. Philadelphia: WB Saunders, 1985. 48. Davis M, Robbins Eshelmann E , McKay M. The Relaxation and Stress Reduction Workbook. 3rd Ed. Oakland, CA: '\ew Harbinger Publishers, 1988. 49. Jacobson E. Progressive Rela'\ation. 4th Ed. Chicago: Uni­ ve rsity of Chicago Press, 1962. 30, .lacobson E. Anxiety and Tension Control. Philadelphia: JB Lippincott, 1964. 51. Carlson CR, CoUin FL, Nitz AJ, et al. Muscle stretching as an alternative rela'\ation training procedure. J Behav Ther Exp Psychiatry 1990;21 :29-83. 52. Carlson CR, VenTrella ~vlA, Sturgia ET. Relaxation training through muscle stretching procedures: a pilot case. J Behav Ther Exp Psychiatry 1987:18:121-123. 53. Luthe W, ed. Autogenic Therapy. Vol. 1-6. New York: Grune & Stratton, 1969-1972, 54. Schultz JH , Luthe W. Autogenic Training: A PsychophYSiO­ logical Approach in Psychotherapy. New York: Grune & Stratton, 1959. 55. Jenks B. Your Body: Biofeedback at Its Best. Chicago: Nel­ son, Hall, 1977. 56. Iyengar BKS. Light on Yoga. New York: Schocken, 1979, 57. Proctor J, Breathing and Meditative Techniques, tape 12, New York: Bio-Monitoring Applications, 1975, 58. Schatz MP, Back Care Basics: A Doctor's Gentle Yoga Pro­ gram for Back and Neck Pain Relief. Berkeley, CA: Rodmell Press , 1992. 59, Caplan D, Back Trouble. Gainesville, FL: Triad Publishing, 1987, 60, Alexander FM, The Use of Self. London: Re-education Publications, 1910, 61. Barlow W, The Alexander Technique, New York: Alfred A Knopf, 1973. 62. Masters R, Houston J, Listening to the Body: The Psy­ chophysical 'Way to Health and Awareness, New York: Delta, 1978. 63, F eldenkrais M. Body and Mature Behavior. New York: In­ ternational University Press, 1949. 64, Feldenkrais M. Awareness Through Movement. \:ew York: Harper & Row, 1972. 65. Feldenkrais M. The Master Moves, Cupertino, CA: Meta Publishers , 1984. 66. Feldenkrais M. The Potent Self. Cambridge: Harper & Row, 1985. 67. Feldenkrais M. Bodily expressions. Somatics 1988;4:52--59. 68. Kendall FP , McCreary, EK, Provance PG. Muscle Testing and Function. 4th Ed. Baltimore: Williams & Wilkins, 1993. 69. Sahrmann S. A program for correction of muscular imbal­ ances and mechanical imbalances . Clin Manag 1983;3:23-28 . 70. Sahrmann S. Adult posturing. In : Kraus S, ed: TMJ Diso r­ ders: Management of the Craniomandibular Complex. New York: Churchill Livingstone, 1988. 71. Low J. The modem body therapies . Part four: Aston pat­ terning. Massage 1988;16:48-52. 72. Ivlill r B. Alternative sOillatic therapy, In: Anderson R, ed. Conservative Care of Low Back Pain, Baltimore: Williams & Wilkins, 1991.

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73. Jones F, Body Awareness, New York: Schocken Books, 1979. 74. Crompton P. The Elements ofTai Chi. Shaftesbury, Dorset: Element, 1990. 75, Crompton P The Art of Tai Chi, Shaftesbury, Dorset: Ele­ ment, 1993. 76. Kotsias T. The Essential Movements of Tai Chi. Brookline, MA Pa~adigm Publishe rs, 1989, 77. Ellis Makofsky HW . BalanCing tbe llpper ql1arter through awareness of RTTPB Clin ~vlanag Hl87;7:20-23. 78. Frownfelter DL. Chest Physical Th erdpy and Pulmonary Rehabilitation, 2nd Ed. Chicago: Year Book 'I1edical Pub­ lishers , 1987. 79. Kisner C, Colby LA . Chest therapy. In : Kisner C, Colby LA, eds. Therapeutic Exercise: Foundation and Techniques, Philadelphia: FA Davis , 1990. 80. Allen RJ, Leischow SJ. The effect of diaphragmatiC and tho­ racic breathing on cardiovascular arousal. In: Proceedings of the VlIth International Respiratory PsychophYSiology Sym­ posium. The Nobel Institute for ~ e urophys iology, Stock­ holm Sweden, 1987. 81. Tallgren A, Solow B. Hyoid bone pOSition, facial morp hol­ ogy and head posture in adults. Ellr J Orthod 1987;9:1-8. 82. Fielding M. Physical therapy in chronic airway limitation. In: Peat M, ed. Current Physical Therapy. Toro nto: BC Decker, 1988, 83. Okeson JP. Management of Ternporomandihular Disorders and Occlusion. 3rd Ed. St Louis: Mosby, 1993. 84, Mannheimer JS. Physical therapy concepts in evaluation and treatment of the upper quarter. In : Kraus SL, ed. Dis­ orders: Management of the Craniomandibular Complex. New York: ChurchiU Livings tone, 1988. 85. Peltes RA, Gross SG. Disorders of the temporomandibular joint. In: Pertes RA, Gross . eds. Clinical Management of Temporomandibular and Orofacial Pain . Chicago: Quintessence Publishing, 1995. 86. Dohrmann RJ, Laskin DM . An evaluation of electromyo­ graphiC biofeedback in the treatment of myofascial pain and dysfunction, J Am Dent Assoc 1978;96:656-662, 87, Gale EN. Biofeedback treatment for TMJ pain, In: Igersoll BD, McCutcheon WR, eds, Clinical Research in Behavioral Dentistry: Proceedings of the Second l\ational Conference on Behavioral Dentistry, 1979; University School of Den­ tistry; Morgantown, VolV, 88. Farrar W, McCarty W Jf. Outline of Temporomandibular JOint Diagnosis and Treatment. 6th Ed. Mon tgomery, AL: Normandy Study Group, 1980, 89. Lawrence ES , Razook SJ, Nonsurgical management of mandibular disorders. In: Kraus S, ed. Temporomandibular Disorders. 2nd Ed . ~e\V York Churchill Livingstone, 1994, 90. Ro ss JB, Diagnostic criteria and nomenclature for TMJ arthrography in sagittal section, Part 1: Derangement. J Craniomand Disord Facial Oral Pain 1987;1:185-201. 91. Shore MA . Temporomandibular JOint Dysfunction and Oc­ clusal Equilibration, Philadelphia: JB Lippincott, 1976. 92. Whinery JG. Examination of patients with facial pain. In: Alling C, Mahan P, eds. Facial Pain, Philadelphia: Lea & Febiger, 1977. 93. Farrar \>\fB , McCarty WL, Normandie Study Group For TMJ D ysfunction. A Clinical Outline of Temporomandibu­ lar Join DiagnOSiS and Treatll1 en t. 7th Ed. Montgomery, AL: Normandie Publications , 1982. 94. Schwartz HC, Ke ndrick RvV. Internal derangement of the te mporomandibular joint: deSCription of clinical syndromes. Oral Surg Or<.ll PathoI1984;58:24-29. 95. \Vestesson PL. Clinical and arthrographic findings in pa­ tients with TMJ disorder. In: Moffett Be, ed. Diagnosis of Internal D e ra ngemen t of the Temporomandibular JOint. Vol. 1. Seattle: University of Washington, 1984.

n,

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Therapeutic Exercise: Moving Toward Function

96, Eriksson L, Westesson. PL. Clinical and radiological study of patients with anterior disc displacement of the temporo­ mandibular jOint. Swed Dent J 1983;7:55-61, 97. Moffett BC, Johnson LC, McCabe JB, et al. Articular re­ modeling in the adult human temporomandibular joint. Am J Anat 1964;11510--130, 98, Gerschmann JA, Tempo romandibular dysfunction, Aust Fam Physician 1988;17:274, 99, Vriell P, Bertolucci L, Swaffer C. Physical therapy in the postoperative manageme nt of temporomandibular joint arthroscopic surgery, J Craniom<1ndib Pract 1989;7:27--32, 100, Mannheimer JS , Postoperative physical therapy, In: Kraus SL, ed, Temporomandiblliar Disorders, l\cw York: Churchill Livingstone, 1994, 101. Racabado M, Physical therapy management for the post sur­ gical patient. J Craniomandib Disord F acial Oral Pain 1989;3:75-82, 102, Osborne II, A physical therapy protocol for orthognathic surgery, J Craniomandib Pract 1989;7:132-136, 103, Osborne II, Postorthognathic surgery, In: Kraus SL. ed, Te mporomandibular Disorders, 2nd Ed, New York: Churchill Livingstone, 1994, 104, Salter RD , Regeneration of articular cartilage through con­ tinuous passive motion: past, present and future, In : Stab R, Wilson PH , eds, Clinical Trends in Orthopedics. New York: Thieme Stratton, 1982, 105, Daly P, Preston CD, Evans WG, Postural response of the head to bite opening in adult males , Am J Orthod 1982; 82:157-160, 106, Blakney M, Hertling D, The cervical spine, In : Hertling D, Kessler R, eds, Management of Common Musculoskeletal Disorde rs, Philadelphia: JB Lippincott, 1995, 107, Keith T, Post
119, Mohl ND, Lund JP, Widmer CG, et al, Devises for the di­ agnosis and treatment of temporomandibular disorders. Part II: electromyography and sonography, J Prosthet Dent 1990;63:332--335, 120, \;Vidmer CG, Evaluation of diagnostiC tests for TMD, In: Kraus SL, ed, Temporomandihular Disorders, 2nd Ed, Ne\1 York: Churchill Livingstone, 1994, 121. Festa F, JOint clistraction and condyle advancement with a modified functional distraction appliance, J Craniomand Pract 1985;3:344-350. 122, Jankelson B, Pulley ML. Electromyography in Clinical D en­ tistry. Seattle: MyoTronic Research, 1984, 123, Moye rs RE. Some phYSiologic considerations of centri c and other jaw relations, I Prosthet Dent 19.'56;6: 11)3-194, 124, Moller E. Muscle li)'lJeractivi ty leads to pain and dysfunc­ tion: position paper. In: Klineberg I, Sessle BJ, eds, Oro-fa­ cial Pain and Neuromuscular Dysfunction, Oxford, UK Pergamon, 1985, . 125, Moller E, Sheikoleslam A, Louis 1. Response of elevator ac­ tivity during mastication to treatment of functional disor­ ders, Scand J Dent Med 1984;92:64-83, 126, Sheikoleslam A, Moller E, Lous 1. Postural and maxi m.... activity in elevators of mandible before and after treatme of functional disorders, Scand J Dent Res 1982;90:37­ 46, 127, Stohler C, Yamada Y, Ash MM . Antagonistic muscle stiff­ ness and associated reflex behavior in the pain-dysfunetil state, Helv Odont Acta 1985;29:13-20, 128, Yemm R. A neurophYSiological approach to the pathol and aetiology of temporomandibular dysfunction, J Oral Rf'­ habiI1985 ;12:343--353, 129, Cooper :BC, Rubuzzi DD, Myofascial pain dysfunction s~ drome: a clinical study of asymptomatic subjects, Laryn scope 1984;94:68-75, 130, Dolan EA, Keefe FJ, Muscle activity in myofascial pain- d~,­ function patients: a structural clinical evaluation, J Cr iomand Disord 1988;2:101- 105, 131. Lous I, Sheikoleslam A, Moller E. Postural activity in jects wi th functional disorders of the che\,\~ng apatus , Sc J Dent Res 1970;78:404-410, 132, Gordon TE. The influence of the herpes Simplex virus jaw muscle function, J Craniomand Pract 198.3;2:31-:3 133, Ramfjord Sp, Bfll xism, a clinieal and electromyogr ap~ study, J Am Dent Assoc 1961;6221-44. 134, Naeije M, H ansson TL. Electromyographic screenin myogenous and arthrogenous Tlv!J dysfunction patie J Oral Rehabil 1986;13433-441. 135, Van Boxtel A, Goudswaard P, Janssen K, Absolute proportion al resting E\1G levels in muscle co ntract and migraine headache patient. Headache 1983 ; 2.3: ~::-~ 228, 136, Frank AST. Masticatory muscle hyperactivity and tempa­ mandibular joint dys function , J Prosthet D e nt 1965: ­ 1122-1121. 137, Funakoshi M, Fujita N, Takehana S, Rela tions between clusal interferent:e and jaw muscle activibes in respon changes in head position, J Dent Res 1976;5.5:6S4- 689. 138. Michler L, Moller E, Bakke lvI, et al. On-line analvsis of ural acti\ity in muscles of mastication, JCranioll1,{nd Di 1988;2:65-1)2. 139, Mongini F , The Stomatognathic System, Chica _ Quintesse nce Publishing, ]9S4, 140. Gelb M, Diagnostic tests, In: Kaplan AS, Assael LA , Temporomandibular Disorders: Diagnosis and Treatm Philadelphia: WB Saunders. 1991, 141 . Rivera-Morales WC, McCall vVD, Reliability of a porn electromyographic unit to measure brwj sm, J Prost De nt 1995;73:184-189 ,

Chapter 23 The Temporomandibular Joint 142. Kardachi BJ, Clarke NG. The use of biofeedback to control bruxism. J PeriodontoI1977;48:639- 642. 143. Pierce CJ, Gale EN. A comparison of diffe re nt treatments for nocturnal bruxism. J Dent Res 1988;67:597-601. 144. Rugh JD , Johnston RW. Temporal analysis of nocturnal bruxism during EMG feedback. J Periodontol 1981;52: 233-235. 145. Rugh JD, Solberg WK. Electromyographic studies of brux­ ist behavior before and during treatme nt. J Calif Dent Assoc 1975;3:56--59. 146. Solberg WK, Rugh JD. The use of biofeedback to control bruxism. J South Calif Dent Assoc 1972;40:852-853.

RECOMMENDED READINGS Bell WE. Temporomandibular Disorders , ClaSSification, Diagno­ sis , Management. 3rd Ed. Chicago: Year Book Medical Pub­ lishers, 1990. Bush FM , Dolvvick MF. The Temporomandibular Joint and Re­ lated Orofacial Disorders . Philadelphia: JB Lippincott, 1994.

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Cohen S. A cephalometriC study of rest pOSition in edentulol!ls persons: inf1uence of variations in head position. J Prosthet Dent 1957;7:467-472. Dutton M. The te mporomandibular joint. In: Dutton M. Manual The rapy of the Spine, An Integrated Approach. 1\ew York: McGraw-Hill , 2002. Kaplan AS , Assel LA. Temporomandibular Disorde rs: Diagnosis and Treatment. Philadelphia: WB Saunders, 1991. Kraus SL ed. Temporomandibular Disorders. :'-l ew York; Churchill Livingstone, 1994. Okeson JP. Bell's Orofacial Pains. 5th Ed. Chicago: QUi ntessence Publishing, 1995. Rocabado M, Iglarsh ZA. Musculoskeletal Approach to Maxillofa­ cial Pain. Philadelphia: JB Lippincott, 1991. Skaggs CD. Diagnosis and treatment of temporomandibular dis­ orders. In: Murphy DR, ed. Cervical Spine Syndromes ~ e\V York: McGraw-Hill, 2000. Vitti M, Basmajian Jv. Integrated actions of masticatUlY muscles: simultaneo us intramuscular electrodes. Anat Rec 1977;187: 173-189.

chapter 24

The Cervical Spine CAROL N. KENNEDY

Review of Anatomy and Kinesi ology Craniovertebral Complex Midcervical Spine Vascular System Nerves Muscles Examination and Evaluati on History and Clearing Tests Posture and Movement Examination Muscle Performance, Neurologic, and Special Tests Therapeutic Exercise Interventions for Common Physio logic Impairments Impaired Muscle Performance Mobility Impairment Posture Impairment Therapeutic Exercise Interventions for Commo n Diagnoses Disk Dysfunction Cervical Sprain and Strain Neural Entrapment Cervicogenic Headache Therapeutic exercise interventions are crucial in the reha­ bilitation of any cervical spine disorder, particularly those of a recurrent or chronic nature. However, exercise pro­ grams deSigned for the treatment of the cervical spine can­ not function in isolation. Because of the close relationship betvveen the neck, thoracic spine, shoulder girdle , and tem­ poromandibular jOint (TMJ), a complete and successful ex­ ercise program must also deal with impairments found in these regions. This chapter reviews cervical spine anatomy and kineSiology and proVides guidelines for examination and evalu abon. Therapeutic exercise intelventions are de­ scribed for common phYSiologiC impairments and common diagnoses affecting the cervical spine.

REVIEW OF ANATOMY AND KINESIOLOGY The cervical spine is composed of two functional units: the craniovertebral (CV) complex and the middle to lower cer­ vical spine. The t""o units are different in structure and biom echanics, but act together to enable the large range of motion (ROM ) available in the cervical spine, while sup­

porting and protecting the vital structures found in this re­ gion. One important function of the cervical spine is to place the head in space for the vital functions of Sight, hear­ ing, and feeding.

Craniovertebral Complex The CV complex includes the atlanto-occipital (AO ) and at­ lantoaxial (AA) jOints. The biomechanics of the CV com­ plex are governed by the articular surfaces, the complex lig­ amentous syste m, and , to a large degree , the intricat speCialized muscular system.

Atlanta-Occipital Joint The AO joint is inherently stable, reinforced by a joint cap­ sule which is thickened anteriorly and laterally (Fig. 24-1 ), Mercer and Bogduk l describe intra-articular inclusions at this joint that contribute to joint stability but, if injured. may be a cause of posttraumatic joint pain. The AO joint is classified as a modified ovoid, bicond\'­ lar joint, "vith two degrees of freedom of motion: flexioD­ extension and combined side flexion-rotation. Because of the convex OCCipital condyles, the occiput glides posteriorl~ during flexion and anteliorly during extension (Fig. 24-2A. B ), High ten sion is developed in the anterior capsule dur­ ing extension and to a lesser degree in the posterior capsule during flexion. 2 During side flexion, the OCCiput glides t the contralateral side, and because of the ioint architecture. side flexion is coupled with a contralate'ral conjunct rota­ tion (see Fig. 24-2C, D).

Atlantoaxial Joint The AA jOint is composed of two lateral joints and a medi ar joint complex (Fig. 24-3 ). With the articular cartilage in­ tact, the surfaces of the lateral joint are biconvex in the an­ teroposterior plane,3 Congruency of the joint surfaces b improved by the presence of fibroadipose meniscoi m which extend well into the joint cavity.l These structure may be implicated in cases of acute restriction of Joint mo­ bility, and bruising of the AA joint meniscus was a comm or. finding in a studl of posttraumatiC cervical spines. Al­ though desclibed as thin and loose, the AA capsule is a ma­ jor restraint to rotation and assists in restricting extensio more than flexion .:2·3.G' The AA 50int has two degrees of motion: flexion­ extension and combined rotation-side flexion. Flexion an extension (Fig. 24-41\ , B) occurs about a transverse axi through the osseo ligamentous ring. At the lateral bicom' joints, the flexion-ex tension movement is prim arily

582

Chapter 24 The Cervical Spine

583

Foramen magnum

A

B

C

0

Superior H---r-""""" articular

surface

FIGURE 24-1. Atlanto-occipital joint architecture. (From White A. Panjabi M. Clinical Biomechanics of the Spine Philadelphia JB Lippincott, 1990)

FIGURE 24-2. Atlanto-occipital joint movement. (A) Flexion. (8) Exten­ sion. (C) Left side flexion. (0) Conjunct right rotation .

Flexion

A Extension

r

Anterior median --~(/( AAjoint Left lateral AAjoint

B A

~

Left rotation

r

rior median joint

Right side flexion

Transverse ligament of atlas

B AGURE 24-3. Atlantoaxial joint architecture. (A) Left lateral joint. (8) Median jOint complex

C

0

FIGURE 24-4. Atlantoaxial joint movement. (A) Flexion. (8) Extension. (C) Left rotation (x marks the axis of rotation) (0) Right side flexion.

584

Therapeutic Exercise 1v10ving Toward Function

Zygapophyseal Joint

Anterior occipital-atlanto membrane Anterior atiantodental ligament

The zygapophyseal joint surfaces are planar, wiili the ori­ entation gradually changing from approximately 60 de­ grees from the vertical in the upper levels to 30 degrees from the vertical in the lower spine. The articular capsule is relatively lax, allowing free mobility, but it is also vely strong, controlling motion at the end range. It is reinforced by the ligamentum flavum and slips of the deep cervical muscles. Fibroadipose meniscoids are commonly found in the cervical zygapophyseal joints. l Injury to this structure resulting in restricted articular glide can cause acute torti­ collis (Le., wry neck).

Atlantal portion of alar ligament

Apical ligament

Posterior occipital-atlanto membrane

~

--- Ligamentum nuchae

Uncovertebral Joints

FIGURE 24·5. Craniovertebralligamentous system. coronal view.

rocking motion. With an intact transverse ligament, there should be minimal anteroposterior glide, with posterior translation occurring during flexion and anterior transla­ tion during extension.7 Rotation (Fig. 24-4C ) is the primary motion of th e AA jOint, and it contrihutes 50% to 70% of the rotational range of the p.ntire ce[\ical spine. At the lateral joints, the ipsilat­ eral atlantal facet gIides posterioriy, and the contralateral facet glides anteliorly. The motion at the median jOint is primarily a spill. Studies have shown side flexion at this joint of up to U degrees (Fig. 24-4D). Several studies''>--lO have shown the coupling of rotation and side flexion to be contralateral at this joint

Ligaments of the Craniovertebral Complex The ligaments of the CV complex are illustrated in Fig. 24­ 5. The transverse ligament is thp major contributor to pos­ teroantPrior plane stability at the AA joint leveL The most common causes of laxity of this ligament are rheumatoid arthritis, ankylosing spondylitis, Dm'.rn syndrome, hyper­ emic softening (i.e., Grisel's syndrome), and trauma. The alar ligarnellt consists of three components: OCCipital, at­ lantal, and anterior atiantodentaL 11 Along "vith the articular capsule, the alar ligament is the primary restraint for rotary stability of the CV complex as a unit. l 2--l4 The tectorial membrane is a continuation of the posterior longitudinal ligament. According to \-Verne,15 the membrane con­ tributes to vertical stability of the CV complex. Studies have found this structure to be more important in stabilizin for flexion , rather than extension, at the AO and AA joints. 3.16 The anterior and posterior AO membranes may be involved in vertical and rotary stability of the CV complex 61b Laxity of the CV ligamentous system results in in­ creased motion of ti1e complex. Signs and symptoms are those related to pressure on the cervical cord, vertebral artery insufficie ncy, or overreactivity of the articular structures themselves.

The UV joints are non synovial clefts between the uncinate processes of adjacent vertebral bodies (F ig. 24-6A ). They are located at the posterolateral corners of the superior as­ pect of ilie C3-C7 vertebrae. The UV joints limit both lat­ eral and postel-ior translation and guide the motion of flex­ ion and extension in the cervical spine. More details about the developm ent and function of iliese joints are prOvided in oti1er sources 17- H1

~

Interbody Joint The vertebral body- disk-vertebral body joint, or interbody joint, is classified as a synchondrosis. The nucleus of the cer­ vical disk is initially vely small and exists as a gel for only the first decade. The UV joint concentrates translational forces onto the posterior disk, resulting in medial extensions of the UV joint cleft, and by ti1e en d of the first decade, horizontal fissuring of the disk is evident. The fissuring often extend through the posterior disk and , by late adult life, Illay com­ pletely divide the posterior two thirds of the disk, leaving thr anterior disk intact 20 Transverse clefting of the posterior disk increases the amount of rotation and side f1exion range available in the cervical spine (Fig. 24-6B). It may also ex­ plain the more common occurrence oflateral translation hy­ permobility found in the cervical region.

r

Motion at the Midcervical Spine Movement of the midcervical spine involves the coordi­ nated motion of each of the three joints described previ­ ously. Each intervertebral segment of the midcervical spine

q

A

~

Midcervical Spine The midcervical spine consists of the region from the C2­ C3 intervertebral segment to the C7-T l segment. Each mobile segment of the midcervicaJ spine consists of several joints, including the paired zygapophyseal and uncoverte­ bral (UV) joints and the interbody (disk) joint

Transverse clefting of interbody joint (disk)

~

~

)

B

FIGURE 24-6. (A) Uncovertebral joint. (B)T ransverse clefting of the in· terbody joint (disk)



Chapter 24 The Cervical Spine

A

B

585

spinous ligaments are only slightly developed in the neck, the supraspinous ligament is absent, and the intertrans­ verse ligament is replaced by the inteltransversarium mus­ cle. 24 The ligamentum nuchae , although not well devel­ oped in humans, decreases the cervical lordosis when tightened during CV flexion 25 It may also have a proprio­ ceptive function for the cervical erector spinae muscles, which are closely related to it. 14

Vascular System

FIGURE 24-7. (A) Midcervical flexion. (B) Midcervical extension. (C) Midcervical rotation left and side flexion.

has two degrees of freedom of motion: flexion-extension and combined rotation-side flexion . Flexion and extension (Fig. 24-7A,B) is a sagittal-plane motion about a transverse axiS. 21 Osteokinematically, flex­ ion consists of an anterior rotation of the ve1tebra with an­ terior translation14 Arthrokinematically, there is an ante­ rior superior glide at the zygapophyseal jOint and an anterior glide at the UV joint during flexion. In extension, the reverse occurs. A paradoxical motion sometimes occurs in patients with hyperlordosed, forward head posture (FHP), where the extension position is associated with anterior, rather than posterior, translation. Rotation and side flexion should be considered as a sin­ gle, combined motion about an oblique axis as described by Penning. 22 Because of the orientation of the zygapophyseal joint surfaces, rotation and side flexion are always coupled ipsilaterally. Arthrokinematically, the ipsilateral zygapophy­ seal joint glides posteriorly, inferiorly, and medially. The ip­ silateral UV joint also glides in a similar direction. The con­ tralateral zygapophyseal joint and UV jOint glides anterior, superior, and slightly medially (Fig. 24-7C). . Panjabi 23 divided the full ROM of an intervertebral seg­ ment into t\vo parts: (Fig. 24-8A ) Neutral zone: portion of the ROM that produces little resistance from the alticular structures. Elastic zone: portion of the ROM from the end of the neutral zone up to the physiologic limit of motion. The entire cervical spine, particularly the CV region, has a large neutral zone of motion. Because of the lack of tension in the capsular or ligamentous system in this middle part of the range, there is less passive control and the muscular sys­ tem must be recruited to actively control the motion in the neutral zone. If there is damage to the ligamentous system, resulting in an increased neutral zone, muscular control be­ comes even more important (Fig. 24-88).

Ligaments of the Midcervical Spine The anterior and posterior longitudinal ligaments bind the anterior and posterior aspects of each veltebral body. The ligamentum flavum connects adjacent laminae and rein­ forces the zygapophyseal joint capsule laterally. The yellow elastic tissue in this ligament helps prevent buckling of the lIgament into the spinal canal on extension. The inter-

An important aspect of cervical spine anatomy is the ver­ tebral alter),. It provides vital blood supply and is close to various structures of the cervical spine that could impede its flow. The vertebral artery supplies the cervical spinal cord, the cervical spinal column, and the posterior cranial fossa. In­ trinsic factors affecting arterial flow are atherosclerosis and thrombus formation. Flow in the artery can also be compro­ mised by various anomalies of the artery itself or the muscles through which it passes. Swelling, degenerative thickening, and osteophytic formation of the UV and zygapophyseal joints can encroach on the artery. These processes should be considered in the patient with a history of degenerative disk disease, cervical osteoarthritis, or trauma. Excessive ROM at the CV joints, as in cases of hypermobility, can kink the artery during rotation. Decreased arterial flow may occur during rotation of the neck, and the addition of extension and traction may further reduce flow. Some of the signs and symptoms of vertebral artery insuffiCiency include dizziness , drop attacks, diplopia, dysarthria, dysphasia, and nystagmus. Vertebral artery tests should be performed for each patient before using these motions dUling treatment.

Nerves The cervical nerve roots exit from the intervertebral fora­ men above the vertebra. The Cl nerve root exits through the osseoligamentous tunnel formed by the posterior AO membrane , which puts it at lisk for impingement. As the cervical nelve roots exit the intervertebral foramen , they are surrounded by several structures: • • • •

Zygapophyseal joint UVjoint Cervical disk Bony pedicle

Degenerative changes affecting any of these structures may diminish the foramen size and alter nerve function.

NZ

EZ

I I I I

r-->

I

I

I

I

NZ EZ

EZ:

\LD Q.

I I I

"-­

V'

~

'--­

EZ

P

I I I

'V"

tROM

ROM

A

I

---

B

FIGURE 24-8. Neutral zone. fA) Normal. (B) Hypermobile. EZ. elastic zone; NZ, neutral zone; ROM, range of motion.

586

Therapeutic Exercise Moving Toward Function ------~-------------------------------------------

Rectus capitis posterior minor

Craniovertebral Region Musculature MUSCLE

ACTION

Superior oblique

Rectus capitis posterior minor Rectus e:apitis posterior major Superior oblique

Atlanto-occipital joint extension

Rectus capitis posterior major

Infelio r oblique Rectus capitis lateralis Rectus capitis antelior

Inferior oblique

Cranioverte bral complex extension and ipsilateral rotation Atlanto-occipital joint ipsilateral side flexion and extension Atlan toaxial join t ipsilateral rotation Atlanto-o(;(:ipital joint ipsilateral side flexion Atlanto-occipital joint flexion

Rectus

laterali~ ~

~.

Rectus capitis anterior minor

Cervical roots 4 through 6 have strong attachments to the transverse processes. The dural sleeve at each level forms a plug that protects the nerve and cord from traction forces . Tension in the neuromeningeal structures may produce a pull on the cervical vertebrae.

B

FIGURE 24·9. Craniovertebral muscles. (A) Posteria l suboccipitals mus­ cles. (8) Short upper cervical flexor muscles.

Muscles

duction of dizziness in patients with dysfunctions of this re­ gion. The upper cervical flexors are crucial in obtaining and maintaining optimal postural balance of the head on the neck. Several long muscles , such as the sternocleidomas­ toid, link the head directly to the trunk. The muscles of the midcervical spine, arranged as else­ where in the spine, consist of slips traversing a variOlL' number of segments. Table 24-2 lists these muscle group, and their actions . In individuals with FHP, the deep ante-

The musculature of the cervical spine is complex, and anatomy texts'Z4 should be consulted for descriptions of ori­ gins and insertions. Table 24-1 lists the muscles of the CV complex and their actions (Fig. 24-9). These muscles enable the specific, fine movements of the head on the neck that are required for sight, hearing, and balance. They are richly supplied with mechanoreceptors, which are integral to the muscles' strong proprioceptive function and implicated in the pro-

Midcervical Musculature ACTION MUSCLE Longus colli Longus capitis Scal enes (elevates first or second rib ) Anterior Medius Posterior Sternocleidomastoid Trapezi'us upper fib ers Levator scapula Splenius, capitis and cervicis Spinalis, capitis and cervici s (inconsistent-blends with semispinalis) Semispin alis, capitis and cervicis Longissimus , capitis and cervi cis Iljocostalis cervicis Inte rspinalis (most distinct in ce rvical spine) M ultificlus Rotatores (inconsistent) Intertransversarii (most distinct in cervical spine) MC , minimal contribution; NA, no action; X, active.

FLEXION

EXTENSION

ROTATION

IPSILATERAL SIDE FLEXION

X

X

NA NA

MC-bilateral Ipsilateral- MC

MC-bilatera. NA

X MC NA X NA NA NA NA

NA NA MC X X X X X

Contralateral-MC NA Ipsilateral-MC Contralateral Contralateral IpSilateral IpSilateral NA

X X X

NA NA NA NA

X

Ipsilateral Ipsilate ral NA NA

NA X X NA

Ipsilate ral-MC IpSilateral !\A

MC MC MC

NA NA NA

X X

X X

X NA

X X X X NA

Chapter 24 The Cervical Spine

rior cervical musculature lengthens and becomes function­ ally weak, and conversely the posterior group tends to shorten.

Deep Cervical Flexors The deep celVical flexors include rectus capitis, anterior minor, longus capitis, and longus colli. Thes e muscles func­ tion as the deep segmental stabilizers of the cervical spine. Contraction of these muscles deceases the cervicallordo­ sis. Longus colli !1as been shown to be active bilaterally as a stabilizer during talking, coughing, swallowing and rota­ tion/side flexion motion of the head and neck. The deep an­ terior segmental muscles have been sho\\1J1 to weaken and lose their endurance capacity in various types of cervical spine dys function , thus producing loss of dynamic stability.

Suprahyoid and Infrahyoid Muscle Groups The suprahyoid and infrahyoid muscle groups are primarily involved with the functions of swallowing, speech, mastica­ tion , and the TMJ. These muscle groups are discussed in Chapter 23. This mllscle group can be used to flex the cer­ vical spine, but are inefficient and produce excessive shear forces at the TMJ. Dysfunction of these muscle groups can have a profound ~ffect on cervical posture, and they should be assessed in persons with chron ic neck conditions.

Scalene Muscle Group Of particular clinical interest is the scalene muscle group (Fig. 24-10). These muscles have a tendency to become dominant neck flexors , and are also often overused during a poor pattern of apical respiration. Because of the angle of pu]}, increased muscle activity creates compressive and lat­ eral forces on the intelVertebral segment. Because of its in­ sertion onto the first and second ribs, the increased activity elevates these ribs. This elevation decreases the space available in the thoracic outlet, which can eventually lead to the symptoms of thoracic outlet syndrome. Adaptive short­ ening of this group also can impinge on the cervical nerve roots as they travel between the scalenes.

Sternocleidomastoid Muscle With FHP, the sternocleidomastoid muscle (SCM) tends to shorten, increasing the compression load on the cervi­ cal spine. It is a prime mover of head on trunk flexion , but

587

the movement pattern it produces causes substantial amounts of anterior translation and a poking chin. When fleXing the head forward on the trunk, it may increase cer­ vical lordosis. A study by deSousa Z4 demonstrated stern­ ocleidomastoid activation in both cervical extension and flexion.

Cervical Extensors The deep segmental stabilizers in the posterior aspect of the spine are the posterior suboccipitals, multifidus , and in­ terspinalis. The middle layer of the erector spinae, specifi­ cally semispinalis cervicus and longissimus cervicus, also have segmental insertions and likely act primarily as stabi­ lizers, as suggested by Conley.26The cervical extensors also playa role in producing and controlling rotation. These muscles have also been sho\\1J1 to weaken in the presence of cervical dysfunction, pOSSibly secondary to shortening with a FHP, or reflex inhibition from underlying joint pathol­ ogy. The more superficial erector spinae muscles tend to extend the head on the trunk.

Levator Scapula and Upper Fibers of Trapezius Several muscles can be classified as cervical or shoulder girdle muscles. The levator scapula and the upper fibers of the trapezius have broad insertions into the cervical spine that originate at the scapula. Alterations in the shoulder girdle resting position change the length of these muscles, affecting the cervical spine as well. For example, a depressed scapular resting position lengthens the upper fibers of the trapeZius muscle and produces a lateral translation and compression force on the cervical spine. Continuous translational forces on the cervical spine can lead to hypermob ility in various planes, depending on the angle of pull.

EXAMINATION AND EVALUATION Examination of the cervical spine should include evaluation of the entire spine, particularly the thoracic region, the TMJ, and shoulder girdle complex. These regions directly influence the posture and mobility of the cervical spine. The clinician must have the knowledge and skills necessary to perform all the appropriate tests to diagnose impairments and functional losses of the cervical spine.

History and Clearing Tests

AnteriOr} Scalene muscles Posterior

' x - - - - - Middle

- - - 7 . L - - - - - - - + First rib

FIGURE 24-10. Scalene muscles.

In addition to the questions included in any musculoskele­ tal subjective examination , some questions specifically ad­ dress the cervical region. These questions ar<:: detailed in Grieve's Common Vertebral JOint Problcl11S. 21 Functional questionnaires prOvide an excellent baseline determination and can be used to monitor the progress of treatment over time. For example, the Neck Disability Index was devel­ oped by Vernon and Mio? to prOvide a reliable and valid measure of cervical spine disability. Shoulder girdle tests should be performed on the pa­ tient if indicated by the subjective history and outcomes of alignment tests.

588

Therapeutic Exercise: Moving Toward Function

Posture and Movement Examination Standing alignment should be assessed in all three planes. The examination includes the spinal curves (i.e., CV region, midcervical region, and cervicothoracic junction), pelvic alignment, and the scapular resting position. Sitting alignment should be evaluated in all three planes. The examiner should look for changes that occur from standing to sitting. Supine alignment also is evaluated. The examiner should assess the resting position of each vertebral segment through palpation. Various motion tests are used to assess the patient's flex­ ibility and ability to move in certain ways: Movement assessments Active ROM Combined movements Assessment of cervical spine passive mobility Passive intelvertebral movements Passive accessory vertebral movements Assessment of myofascial extensibility Muscle lengths Assessment of neuromeningeal extensibility Upper limb tension test Median nerve bias Radial nerve bias Ulnar nerve bias

Muscle Performance, Neurologic, and Special Tests Assess the patient's cervical musculature by performing manual muscle tests for recruitment , strength, and en­ durance. NeurolOgiC tests of sensation , motor activity (i.e., key muscle strength ), and reflexes are performed to detect any nerve root conduction signs in the cervical region. Stability tests , vertebral artery tests, and the foraminal compression test are performed to exclude pathology of the cervical spine.

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENTS Any comprehenSive therapeutic exercise program for the cervical spine must address various phYSiologic impair­ ments. This section describes exercise interventions for im­ pairments of muscle performance (including endurance), mobility (i.e., hypomobility and hypermobility), and pos­ ture. Appropriate modifications may be necessary for some patients, depending on their signs and symptoms.

Impaired Muscle Performance Etiology Janda has suggested that certain muscles in the cervical spine tend to weaken; the most common of these are the deep , anterior cervical flexors. Studies of patients \vith cervicogenic headache symptoms have found decreased maximal isometlic strength and endurance of the short

upper cervical flexor muscles compared with those of nor­ mal subjects. z9 A group of patients with mechanical neck pain also showed Significant weakness of the neck flexor muscles compared with controls 30 A study of patients with osteoarthritis showed more pronounced fatigu e curves for anterior and posterior neck muscles than for the muscles of normal subjects 31 Patients with \Vhiplash Associated Disorder (WAD ), show inability to isolate and tonically hold the deep cervical flexors ,32 without recruit­ ment of the more superficial muscles as compared to con­ trols. Transition of muscle fiber type has been demon­ strated in subjects "vith cervical pain, causing a loss of tonic function, 33 as well as fatty infiltration of the poste­ rior subOCCipital muscles. 34 Many articles in the literature describe cervical strength­ ening grotocols, mainly for the prevention of athletic in­ juries. 5-3B However, few controlled studies have measured the effectiveness of cervical strengthening programs in ob­ taining strength gains for injury prevention or as a compo­ nent of treatment of the painful neck. A program that may be safe for training the healthy neck of an athlete may have little application to the injured neck and particularly to the hypermobile cervical spine. In a study of 90 patients with cervical pain, the subjects participated in an 8-week strengthening program that involved concentric-eccentric and variable resistance cervical extension exercises. As a group, the patients gained strength and range and experi­ enced a reduction in pain. 39 Taimela's40 study of patient with chronic neck pain found that the group that received supervised sessions of specific neck exercises, showed more improvement than the group that received a neck care lec­ ture and two training sessions for a home exercise program. The control group, receiving only the neck care lecture and a recommendation to exercise, improved the least. Exercise dosage should be determined on an individual basis, depending on the variables of strength , endurance. and irritability. A better response seems to occur when loads are initially very low (less than the weight of the head and progressed slowly. An exercise is considered too di ffi­ cult or is stopped when it produces pain, muscle tremor occur because of fatigu e, or the exercise cannot be exe­ cuted correctly. The endurance function of many of thes cervical postural muscles should be emphasized by encour­ aging longer, sustained contractions.

Therapeutic Exercise Intervention Deep Cervical Flexors The most common muscles to become weak with neck dysfunction are the deep, Single segment cervical flexors. It is important to teach the patient to isolate these dynamiC stabilizers without substituting with the more superfiCial muscle groups. The primary exercise to recruit these mus­ cles is the head nod exercise of CV fl exion, continuing seg­ mentally into midcervical flexion. During this exercise it i important to control the tendency to substitute with th overactive superficial flexors that would exceSSively trans­ late anteriorly (see Patient-Related Instruction 24-1). If done initially in the upright position at the wall, the exercise is gravity assisted, but the head must stay back against the wall at all times to prevent any fOIWard movement that would change the exercise into an eccentric contraction of

Chapter 24: The Cervical Spine

589

How to activate your cervical core muscles What are the cervical core muscles?

The cervical core muscles work together to provide deep segmental stability of the cervical spine and maintain optimal posture of the head on the neck with dynamic extremity and trunk movements. They also enable specific, fine movements of the head on the neck. The cervical core consists of the deep cervical flexors and the deep cervical extensors. How do you activate the cervical core muscles?

The cervical core muscles are the most common muscles to become weak for those who suffer from neck dysfunction; therefore, it becomes very important to teach. It is important for you to learn how to isolate the cervical core muscles without substituting larger, superficial muscle groups. Cervical core recruitment must be mastered before using them with more challenging exercises. To contract the deep cervical flexors, gently nod the head so flexion occurs only at the junction between the head and the neck. Head motion should occur about an imaginary axis that runs through your ears. You can progress the movement down toward the middle of your neck. Do not allow superficial muscles such as the sternocleidomastoid and scalene muscles to activate. Your therapist will instruct you in palpating for the superficial muscles. Slowly return to the neutral pOSition. Think about moving one vertebrae at a time. Do not aHow superficial neck extensor muscles such as the erector spinae to activate. Your therapist can teach you how to palpate for activity in these muscles as well if it is a problem for you. Practicing to activate the deep cervical core muscles in many different positions is important before learning to use them with dynamic activities. You:can practice cervical core activation in the followillg positions. __Standing __BackIYlng __Sitting __Stomach lying __Sidelying __Quadruped __Squatting __Walking

the cervical extensors (see Fig. 24-11). The retracted posi­ tion also discourages the use of the SCM muscle. The deep neck flexors are recruited to nod the CV unit, decrease the cervical lordosis, and then overcome the resistance of th e extensors. The patient is taught to palpate at the fron t of the neck for any unwanted contraction of the SCM or sca­ lene muscles and to rest the tongue on the roof of the mouth to inhibit hyoid muscle activity. The patient slowly nods the chin down, sliding the back of the head up the wall. Th e nod is stopped at the point in range that can be achieved with­ out superficial activity, held for 10 seconds to encourage the endurance function, and is repeated 10 times . The assis­ tance of gravity can be decreased by performing the exer­ cise supine on an incli ne board, with difficulty increased by progressively tilting the board backward toward horizontal. When performed while the patient is supine, the deep neck flexors work against th e resistance of gravity, making the exercise more difficult. The head is positioned in neu­ tral, either resting on a pillow, or with a small fo lded towel

FIGURE 24-11 . Wall slide deep neck flexor muscle recru itmen t, palpati ng for unwanted superficial muscle actiVity placed under the occiput as needed to achieve a neutral po­ sition. A small rolled towel is placed under the hollow of the midcervical spine to support the normal ce[\i callordosis. At first, the head nod is pelformed with no lifting of the head off the surface, with the patient again palpating anteriorly to ensure no superficial muscle activity. To progress, the head nod uses the towel roll as a flllcrum , and the back of the head may lift just off the surface during the motion. The patient no longer palpates, because the supelficial muscles must now be active to lift the weight of the head ,-wains t gravity (see Fig. 24-12). The neck should not lose contact 'with the towel , or the chin poke forward, because this is a sign of ex­ cessive anterior translation caused by relative dominance of sternocleidom as toid an d scalenes substituting for the weaker deep neck flexors . The ROM allowed depends on

FIGURE 24-12. Short flexor muscle strengthening over a towel roll with sl ight head lift-off. The patient no longer palpates, because the superfic ial muscles must now be active to lift the weight of the head against gravity The neck should not lose contact with the towel. or the ch in po ke forward , because this is a sign of excessive anterior translation ca used by re la tive domi nance of sternocle idomastoid and scalenes substituting for the weaker deep neck flexors.

590

Therapeutic Exercise Moving Toward Function

the muscle balance and the ability to continue the head nod without excessive anterior translation. A head nod into a flexion quadrant (e.g., flexion , side flexion, rotation to the same side) emphasizes contraction of the fl exors more uni­ laterally and can be used in cases of asymmetric weakness. The exercise can also be performed in a prone position over an exercise ball or in the four-point kneeling (FPK) po­ sition. In this position, gravity draws the head fonvanl into a position of upper cervical extension, which is countereu by the head-nod Illotion into upper cervical flexion. This exer­ cise recruits the upper cervical flexors only; gravity is assist­ ing the lower cervical flexors in this position. If the patient maintains the retracted neutral posture of the spine while nodding, it is very difficult to substitute ,vith SCM because this muscle protrudes the neck, and so this is a useful option for patients \.vith very dominant SCM muscles. A nod lift-off motion can also be perform ed supported on a high incline (Fig. 24-13). The patient is instructed to nod to the point of cervical spine neutral, and then just lift the head off the suppOlting surface to take the weight of the head as resistance. The neutral posture of the neck must be maintained, not allowing dominant superfiCial muscles to cause a chin poke of anterior translation. The patient will progress to holding this sustained neutral posi­ tion for 10 seconds, repeating 10 times. The exercise can be further progressed by gradually bringing the incline closer to the horizontal , as long as the patient can control the pos­ ture of the neck.

FIGURE 24-13. A nod lift-off motion can also be performed supported on a high incl ine. The patient is instructed to nod to the point of cervical spine neutral, and then just lift the head off the supporting surface to take the weight of the head as resistance. The neutral posture of the neck must be maintained, not allowing dominant superficial muscles to cause a chin poke of anterior translation .

In the upright or sitting pOSitions, autoresistance car be applied to the heau-nod motion to increase the loau or: the muscle. Resistance must be applied at such an angl to appropriately resist tlle head-nod motion and not en­ courage a head forward movement. Resistance under th chin rather than at th e forehead can encourage the prop movement. Cervical Extensor Muscles Few studies have investigated the effects of cervic' spine dysfunction on the extensor muscle group. A study patients with cervical osteoarthritis did find more pru­ nounced fatigue curves for the cervical flexors and exten· 3l SOl'S compared with those of controls. Studies on the lurr ­ bar spin e have shown a te ndency for the multifidus t atrophy in cases of spinal dysfunction; a similar process ma occur in the cervical spine 4l The use of electrical muscle stimulation is effective in tl initial stages of retraining, espeCially when the patient has high level of pain that precludes resisted exercise. With tho patient lying supine with the head supported, small elec ­ trodes are placed over the extensor muscles bilaterally at th vertebral level 'vith poor segmental recruitment. It is more difficult to isolate the deep segmental exten ­ sors than the flexors. A study by Mayoux-Benhamou ­ suggested that the motions of return to neutral (RT: ' from the flexed posture, and retrusion, are less likel~' t recruit the superfiCial extensors . If this motion is per ­ formed segment by segment, it is likely that the segmen­ tal extensors will need to be recruited. The patient starts in the forward flexed position and initiates the extensi in the thoracic spine first, incorporating a component retrusion as the movem e nt reaches the lower ceI\iC'<1 spine (Fig. 24-14). Maintaining the CV region in flexio until the end of the motion will tend to inhibit the capito group of the erector spinae muscles. Tactile cues can b given at each level to encourage the segmental nature the motion. The exercise can also be progressed by per­ forming the motion in the FPK position. The patient can be taught to apply autoresistance to th, contraction of a specific muscle determined to be weak 0 assessment. For example, a weak superior oblique muse! can be retrained by applying autoresistance to AO joint sid flexion into extension on the same side (Fig. 24-15). Con­ traction of the multifidus at the C4-C5level can be obtai! by pressure applied to the C4lamina as the patient attemp side flexion and rotation to the same side into extension. Multisegmental extension exercises for more general­ ized weakness can be performed in a supine position wi pillow support. The cervical lordosis should be further supported with a foam roll or rolled towel. While the pa­ tient squeezes tl1e roll by the extension movement, tht:­ therapist must ensure that the motion remains angular and no shearing occurs. The exercise can be made mort" specific in cases of asymmetric weakness by working inte the extension quadrant (i.e., combined extension, side flexion, and rotation to the same side). The roll is thee squeezed between the head and the shoulder on the af­ fected side (Fig. 24-16). In the prone position over an exercise ball, midcervica1 extension exercises can be performed against gravity. The position tends to encourage the poking-chin posture

Chapter 24 The Cervical Spine

FIGURE 24-14. Return to neutral in sitting to recruit the segmental extensors. (A) Start in the fOlWard flexed position . (8) Initiate segmental extension starting at the upper thoracic spine (e) Continue the extension up the cervical spine to the neutral position .

FIGURE 24-15. Retraining a weak right superior oblique muscle by ap· plying autoresistance to atlanto-occipital joint side flexion into extension on the same side.

FIGURE 24-16. Concentric muscle contraction into the right extension quadrant over a foam roll or rolled towel. Palpation will encourage more local recruitment.

591

592

Therapeutic Exercise Moving Toward Function

SELF MANA GEMENT 24- 1

Side Flexor and

Rotator Activation Purpose: 5lBrting Position:

Movement Technique:

To activate and strengthen the neck side flexors and rotators on each side Lie on your back with your head supported on the foam wedge. Knees are bent. Move the wedge so your head is resting off to one side on the slope of the wedge (AI. You will immediately feel that you have to use your neck muscles on the side closest to the peak to hold your head in pia ceo • Perform a slight nod to activate the deep neck muscles. Hold this nod throughout the exercise. • Slowly, in a controlled fashion, lower your head down the slope to the end of range. Stop before there is any pain. Pause at the end of range, then slowly bring the head back up the slope, maintaining the slight nod throughout (8). Go past the center position continuing up the slope of the wedge to the end of range. Again pause at this point. In a controlled fashion, bring your head back to midline. Relax from the nod position. This is 1 repetition. Repeat for the designated number of repetitions, beginning with the preset nod for each. Move the wedge over to have the head resting on the other side of the peak. Repeat the same sequence as above for the designated number of repetitions.

Dosage: Set/repetitions _ _ _ _ __

Right _ _ _ _ __ Left _ _ _ _ __

Frequency _ _ _ _ __

A

With any exercise into cervical extension or an exten­ sion quadrant, it is important to consider the follOWing effects: • Effects on the vertehral artery • Compression loacl on the zygapophyseal joints • Foraminal compression and its effect on the neuro­ logiC structures • Risk of encouraging the cervical lordosis of the FHP Rotation and Side Flexion Component By exercising into a quadrant position, the muscl that are primarily side flexors and rotators are also re­ cruited. A foam weclge can be used to apply resistance to combined flexion, side fl exion , and rotation of the cervi cal spine (see Self-Ylanagement 24-1: Side Flexor and Rotator Activation). In the sidelying position with the head supported on a pillow and a towel roll under the neck, these m uscles can also be trained more speCifi cally and inte nsely. T he muscl opposite to the sicle the patient is lying on can be contracted against gravity as the head is lifted off the pillow. The roll is used as the fulcrum , and the deeper muscles can be e m­ p haSized by ensuring that the neck remains in contact with the roll, decreasing the amount of translation taking pJac (Fig. 24-17). For both of these exercises , the patient is taught to pe r­ form a preset nod to activate the deep stabilizing muscle prior to any motion of the head. Strengthening Functional Movement Patterns Several stre ngth e ning exercises use combined Illo,'e­ ments. Because many of the movement patterns required for functional activity are multiplanar, it is bene ficial to train the muscle group using these movements. The move­ ment patterns chosen for a particular patient depend on the assessment findings (I.e., speCific weakness or repro­ duction of pain ) and on the requirements of work and leisure activities. The patient can be taugh t the correct movement pat­ tern by using a modified m uscle energy technique {or muscle recmitm cnt rather than mobiLization. With the pa­ tient sitting, the th e rapist palpates at the affected level as the patient performs the motion against the resistance oJ

B

CV exte nsion. The patient should be taught to control the upper cervical flexion while working the middle and lower cervi cal spine into extension. The exe rcise can be done into the quadrant position to targe t the muscles unilater­ ally. Th e sam e exercise can be performed in the FPK po­ sition at home .

FIGURE 24-17. Recruiting the side flexors and rotators more specifically. The patient is in the side lying position, with the head supported on a pil­ low with a towel rol l under the neck. The roll is used as the fulcrum, and the deeper muscles can be emphasized by ensuring the neck rema ins in contact with the roll decreasing the amount of translation taking place .

Chapter 24 The Cervica l Spine

593

Mobility Impairment Impairment of mobility can be classified as hypomobil ity (i.e. , reduced motion) or hypermobility (i.e., increased mo­ tion). In the case of hypo mobility, exercises are given to re­ gain and maintain motion. For hypermobility, a stabiliza­ tion exercise program is used to regain control of the excessive motion.

Hyp amability Etiology

Cervical mobility can be reduced for several reasons: • • • • • •

Segmental alticular mobility restriction Capsular thickening and contracture Degenerative bony changes Segmental muscle spasm Myofascial extensibility Adverse neuromeningeal tension

Cervical mobility also can be affected by syndromes in­ volVing the shoulder girdle, and treatment may need to in­ clude interventions for impairments in that region. Therapeutic Exercise Interventions

FIGURE 24-18. Strengthening in functional movement patterns. With the patient sitting, the therapist palpates at the affected level as the patient performs the motion against the resistance of the therapist.

the therapist (Fig. 24-18). The recruitment of the muscles at that segment and any excessive translation can be mon­ itored. Concentric or eccentric muscle contractions can be used. After the patient can perform these movements cor­ rectly (without excessive translation) , autoresistance throughout the range can be applied by the patient. Heavy resistance should be avoided, because it tends to encourage faulty movement patterns, as does static maximal isometric contractions. Concentric contractions can be used first through short-arc movements, progress­ ing to full-arc motion and then to eccentric contractions (Fig. 24-19). Pulley systems can be used to apply graded resistance. Head pieces can apply resistance to the weak cervical muscles as determined at assessment. The pulley height is important in providing the correct angle of pull to en­ courage an optimal movement pattern of the neck. The weights must be kept low enough to allow the patient to perform the motion smoothly and without substitution of unwanted muscle groups. Supervision is important, be­ cause there is a tendency to use a translation motion against the resistance, which often exacerbates the prob­ lem, espeCially in cases of hypermobility Additional resis­ tance beyond the weight of the head is often not neces­ sary, as not many activities involve lifting more than the weight of the head.

Even in the early stages of treatment for an acute neck problem , ROM exercises can be taught for each of the re­ stricted planes of motion. Care must be taken in teaching these exercises to ensure that the normal movement pattern is performed and that this pattern is reinforced with repeti­ tion. With the patient lying supine with the head supported on a pillow, the weight of the head is eliminated, decreasing the compression load. This position can be helpful for pa­ tients with painful neck motion. The use of rhythmiC respi­ ration during the exercise can aid in relaxation of the scalene muscles and create a pumping action to help reduce swelling. This activity can be progressed to rotation exer­ cises with the head positioned on the peak of a foam wedge (Fig. 24-20 ). The amplitude of motion obtained is increased and there is some extension incorporated with the move­ ment on rotation and flexion on return to midline. ROM ex­ ercises can also be performed in the upright position. If a mobility exercise into extension or the extension quadrant is being considered, the effects on vascular and neurologiC tissue should be tested. Keep in mind that a considerable weight-bearing force is sustained by the artic­ ular facet in these positions. Segmental Articular Restrictions

Segmental articular restrictions generally respond well to manual therapy mobilization techniques unless there is excessive degeneration of the bony structures (see Chap­ ter 7). Self-mobilization exercises are a useful adjunct to this treatment. The patient is taught to localize to the in­ volved segment with his fingers or a towel support and perform a specific, sometimes multiplanar motion to mo­ bilize the joint restriction as determined by mobility test­ ing (see Self-Management 24-2: Self-Mobilization for the Cervical Spine). Muscle Extensibility

Assessment of muscle lengths is necessary because of muscle imbalances and postural asymmetries that are unique to each individual. Janda 43 states that certain

594

Therapeutic Exercise: Moving Toward Functio n

~

"'

FIGURE 24·19. Strengthening in functional movement patterns using autoresistance. (A) Concentric contractions into the left flexion quad­ rant. (8) Eccentric contractions back into the right extension quadrant learly in range).

muscle groups in the cervical spine have a greater tendenc) to shorten. This may be related to the effect of the limbic system on these muscles, the large percentage of afferent fibers supplying these muscles, and the more tonic rather than phasic properties of th ese muscles. According to Janda,!:3 the following muscles tend to shorten: ' • • • • • • FIGURE 24-20. Range of motion exerc ises on a foam wedge. Allows non-weight-bearing motion, combining rotation and side flexion with flex­ ion-extension .

Posterior suboccipital muscles Cervical erector spinae muscles Scalenes (anterior, medius, posterior) Sternocleidomastoid Levator scapula Trapezius, upper fibers

A study of cervical musculoskeletal function in postcon­ cussional headache i I showed a higher incidence of moder­ ate muscle tightness compared with controls. This finding of tightness was not isolated to anyone of the muscles tested

Chapter 24 The Cervical Spine

6."" ...

595

SELF MANAGEMENT 24-2 Self-mobilization for the Cervical Spine

Purpose: ADjoint Starting position:

Movement Technique'

To maintain the range gained during treatment at a particular joint.

Sit tall in a chair with back support. Clasp your hands behind your neck with your little fingers just under the base of your skull. Stabilize the neck, but be careful not to drag the neck forward by pulling forward with your hands.

Midcervical Joints Starting position. Find the stiff joint as instructed. It often will fee l tender, or thick under your finger. Hold the bot­ tom bone sta ble by pushing in gently with your fingers. Alternatively, place the salvage edge of a towel along the effected joint to stabilize it.

Movement Technique

Flexion (A) • Nod your head on your neck. The head must tip away from the stiff side, and chin deviate toward the stiff side. In other words, tuck your chin toward your armpit on the side of the stiff joint. Extension (B) • Tip your head back on your neck. Tip the head toward the stiff side and poke the chin away from the stiff side. In other words, poke your chin toward the opposite elbow.

Dosage: Hold _ _ _ _ _ _ count

Repetitions _ _ _ _ __

Frequency _ _ _ _ __

AA Joint Starting Position:

Flexion • Nod your chin forward until you feel a pull at the stiff joint. Tip the head away from the stiff side, and rotate the head away (E). The movement to stretch the joint maximally will be off on the opposite diagonal. • The fixing fingers should hold the bottom bone down toward the floor. • You should feel a strong stretch on the side of the nee k at the stiff joint. Extension • TIp your head back over the stabilizing fingers or towel. The head should also tip and rotate to that same side on a diagonal (F). • You can push in and up slightly with the fixating fingers . • Focus the movement to the level that is stiff. Do not arch your whole neck back over the fingers.

Dosage: Hold _ _ _ _ _ _ count Repetitions _ _ _ _ __ Frequency _ _ _ _ __

Wrap your hands behind your neck with your little fingers resting at the level of the large bump at the top of the neck below the skull. Stabilize the neck, but be careful not to drag the neck forward by pulling forward with your hands.

Movement Technique: • Keep eyes level as you rotate the head in the stiff direction, being sure not to let the rest of the neck move with the head. • If instructed, bias the movement to the joint on one side or the other by: _ tucking the chin into a bit of flexion as you turn, and slightly pull the supporting hand forward on the side you are turning to (e). _ tip the chin slightly up as you turn, and hold back with the supporting hand on the side opposite to the direction you are turning to (D). • Do not let the neck collapse as you turn the head; stay tall.

A

B

E

F

Dosage: Hold Repetitions

Frequency

count

596

Therapeutic Exercise Moving Toward Function

(e.g. , upper fibers of the trapezius , levator scapula, scalenes, upper cervical extensors), but it was most frequently identi­ fied in the ~pper cervical extensors. A study by Edgar and coworkers.j> showed a relationship between decreased neu­ romeningeal extensibility and decreased length of upper fibers of the trapezius, possibly as a protective mechanism. Patients with WAD showed greater electromyelography ac­ tivity of both their ipsilateral and contralateral upper fibers of the trapezius during repetitive upper extremity activity and were less able to relax that muscle follOwing activity as compared with controls. 46 Alterations in resting posture may cause a muscle that is of normal length to be placed on tension because of the in­ creased distance between the origin and insertion caused by the posture. For example, a depressed scapular resting po­ sition puts tension on the levator scapula, potentially reduc­ ing opposite-side flexion and rotation of the cervical spine. The neck motion can be regained immediately on elevating the scapula, confirming that the tension on the levator scapula, resulting from the depressed position of the scapula, was contributing to the loss of neck ROM. Other muscles may adaptively shorten because of long-standing changes in posture. The sternocleidomastoid, for example, tends to adaptively shorten in response to FHP. When the head is brought back into a more normal position, the mus­ cle may appear to be a tight band, inhibiting attempts to re­ train optimal posture. Treatment of both cases consists of postural correction exercises. Chapter 26 illustrates taping techniques to correct scapula position and normalize length-tension propeliies of the cervical m usdes that attach to the scapula (i.e., levator scapula and upper trapezius). The posterior suboccipital muscle group can be length­ ened by using the CV flexion head nod exercise (Fig. 24-21). The stretch can be localized by supporting the rest of the

FIGURE 24-21. Stretching the posterior suboccipital muscles using the craniovertebral flexion head-nod exercise.

FIGURE 24-22. Stretching into the middle to low cervical erector spina:­ at the wall.

neck with clasped hands and further localized by side flex­ ion away and rotation toward the tighter side. Further neck flexion must be incorporated to obtain stretch into the middle to low cervical erector spinae. CY flexion must be maintained throughout the exercise to maintain the stretch on the long superficial extensors. If an~ anterior translation is allowed, cervical lordosis is produced which results in a shortening of these muscles. Performing this stretch with the trunk against the wall helps fixate the cervicothoracic (CT) junction (Fig. 24-22 ). Adding side flexion and rotation to the opposite side biases the stretch to the right or left side. The scalene muscle group also tends to shorten and be­ come overactive because of improper breathing pattern Teaching proper diaphragmatic breathing can decrease re­ cruitment of this group as a secondary muscle of inspiratiorr (see Chapter 23 ). Exercises deSigned to stretch this muscle must allow for adequate fLxation of the first and second rib which can be achieved through manual or belt fixation. The scalene group is lengthened by side flexion away and sligh rotation toward the affected side (Fig. 24-23). Performin pure side flexion at the wall prevents the neck from collaps":: ing into an FHP and \vill allow a more effective stretch. The­ patient must be instructed to stop at the point of tension, be­ cause the muscle pull can produce a lateral translation fo re on the cervical spine. An effective method of regaining normal stemodeido­ mastoid muscle length is to correct the FHP. Retraining the use of the deep cervical flexors for the habitual movement pattem of neck flexion also decreases overuse tightness of the stemocleidomastoid. If the muscle has become short­ ened by posttraumatic adhesions , it may be necessary to stretch the muscle. This can be achieved by extension, side

Chapter 24 The Cervical Spine

597

FIGURE 24-25. Stretching the levator scapula-arm overhead (scapular upward rotation), scapular depression. side flexion away, rota tion away from affected side, and flexion .

FIGURE 24-23. Stretching the scalene muscles-first rib fixed. side flex­ ion away, and slight rotation toward the affected side at the wall.

flexion away from , and rotation toward the side being treated. Lordosis must be controlled, because that position shortens the muscle. This effect can be achieved by blinging the CV flexed head on a straight neck back behind the line of the trunk (Fig. 24-24). When attempting to lengthen the levator scapula mus­ cle, it is important to fix the scapula into depression, up­ ward rotation , or both. Upward rotation of the scapula can be achieved by arm elevation, but this position muy be dif­ ficult for patients with pain on arm elevation. In the sitting position , depression can be maintained by holding the un­ derside of a chair. The muscle is then stretched by cervical side flexion and rotation to the opposite side and cervical flexion (Fig. 24-25). To stretch the upper fibers of the trapezius, the scapula must be fixed into depression, dO\o\lJ1ward rotation , or both.

Scapular depression and downward rotation can be achieved by reaching the arm down allli behind the back The stretch is then performed into neck flexion, "vith side flexion away from and rotation toward the affected side (Fig. 24-26 ). The concern about the latter two stretches is the resul­ tant forces on irritable zygapophyseal jOints from the end­ range combined movements. These two muscles and the scalene muscles, because of their angle of pull, also pro­ duce a lateral translation force on the vertebrae when stretched. An alternative exercise is to have the patient face the wall , with the ulnar border of the hands and forearm ill contact overhead, and perform a wall slide. The arms are slid downward, creating scapular depreSSion. The cervical spine can then be moved into flexion. From this pOSition,

FIGURE 24-26. Stretching the upper fibers of the trapezius-scapular de­ FIGURE 24-24. Sternocleidomastoid stretch-extension, side flexion away from and rotation toward the side being treated.

pression, neck flexion, side flexion away, and rotation toward the affected side.

598

Therapeutic Exercise: Moving Toward Function

FIGURE 24-27. Alternative wall slide exercise. (A) Contralateral rotation lengthens the right levator scapula muscle. (B) Ipsilateral rotation lengthens the upper fibers of the right trapezius muscle.

contralateral rotation lengthens the levator scapula muscle, and ipsilateral rotation lengthens the upper fibers of the trapezius muscle (Fig. 24-27). Adverse Neuromeningeal Tension

Adverse tension in the neuromeningeal structures of the cervical spine can affect the mobility of the neck, thoracic spine, shoulder girdle, and upper extremi ty 47 Signs of de­ creased extensibility of these structures are found on the Upper Limb Tension Tests, with a median , radial, or ulnar nerve hias. \"'hen prescribing an exercise deSigned to im­ prove neuromeningeal extensihility, the effect on the cervi­ cal spine should be considered. Because of direct attach­ ment of dural structures into th e cervical vertebrae, tightness in tl1e neurom eningeal system may cause lateral translation of the verte\'lrae with each attempt to stretch the structures, which can lead to hypermobility of the segment. The affected segment should be manually fi.,xated by the op­

FIGURE 24-28. Dural stretch with manual stabil ization and fixation of lateral shear.

posite hand supporting under the neck so that the fingers wrap around to the affected side and prevent the lateral translation (Fig. 24-28). The stretch can be performed by the patient in supine ly­ ing, with a belt wrapped over the shoulder and around the knee to maintain the scapular depression. Median , radial, and ulnar nerves are biased via various arm, elbow, forearm , and wrist positions as shown in Fig. 24-29. It may be more effective initially to emphaSize mobility of the system, by us­ ing "slider" exercises that add tension in one component of the movement, while removing tension in another compo­ nent. For example tipping the head toward the ann as the elbow is extended. For median nerve bias, the arm , flexed at the elbow, is abducted to the tension point and externally rotated, 'vvith the forearm supinated and the wrist and fingers extended. The elbow is then slowly extended to produce the stretch (Fig. 24-29A).

Chapter 24 The Cervical Spine

599

ing an active preset nod. If recruitment of the deep seg­ mental stabilizers decreases the amount of translation on passive testing, there is a degree of dynamic stability pre­ sent. The neck can also be observed or palpated during bi­ lateral or unilateral elevation of the arm in the relaxed up­ right posture, and then repeated with tht' cervical spine under the dynamic control of a preset nod (Fig. 24-30). Be­ cause of the large netltral zone in the cervical spine, much of the stability in this region is imparted by the dynalllic con­ trol of the active muscular system. In the case of loss of in­ tegrity of the inert stabilizing structures, tnLining of neuro­ muscular control may resu lt in a functionally stable spine. Therapeutic Exercise Intervention

FIGURE 24-29. Dural stretch in supine lying with a belt wrapped over the shoulder and around the knee to maintain scapular depression (A) For me­ dian nerve bias, the arm, flexed at the elbow, is abducted to the tension point and externally rotated, with the forearm supinated and the wrist and fi ngers extended. The elbow is then slowly extended to produce the stretch. (8) For radial nerve bias, the arm, flexed at the elbow, is abducted and internally rotated, the forearm is pronated, with the ,vrist flexed. The stretch is produced by slowly extending the elbow. (e) For ulnar nerve bias, the arm, flexed to a right angle at the elbow, is abducted and externally ro­ tated, the forearm is pronated, with the wrist extended. The stretch is pro­ duced through further flexion of the elbow.

Similar stretches can be perform ed by the patient in standing. The opposite hand is required to maintain de­ pression of the scapula. With each ofthese exercises, a more intense stretch can be obtained by the addition of con­ tralateral side flexion or rotation of the neck.

For the hypermobille cervical spine, care must be taken in prescribing ROM or stretching exercises that may exag­ gerate the excessive translation. The neck must be paSSively fixed at the affected segment during the stretch, or another exercise should be chosen that does not incorporate the un­ wanted motion. For example, a patient may have a tight right levator scapula muscle but also be hypermobile into right lateral translation at the C3-C4 interveltebral seg­ ment. Attempts to stretch the levator scapula muscle by left: side flexion encourage right lateral translation at C3-C4. The patient can control the right lateral translation 'vvith the left hand cupping behind the neck, offering a counteract­ ing left translation at the C4 vertebra (Fig. 24-31). It may be more appropriate in this case to choose the wall slide ex­ ercise described in the Hypomobility section, using con ­ tralateral rotation rather than side flexion. For the patient with lateral translation hypermobility, at­ tempts to incorporate dural stretch exercises cause repeti-

Hypermobility Etiology

Hypermobility is excessive motion of the intervertebral segment. As hypotheSized by Panjabi ,23 spinal stability is obtained through three subsystems: • Passive musculoskeletal subsystem: inert osseoliga­ mentous column, including the vertebra, disk, cap­ sule, and ligament • Active musculoskeletal subsystem: the muscle and tendon units • Control subsystem: the neural and feedback mecha­ nism s The role of the spinal stability system is to provide suffi­ cient stability through aU three subsystems to match the demands made on the spine. Deficiencies in on e subsystem can be compensated for, within certain limits. Gross insta­ bility, as documented by functional radiographs, may re­ quire surgical fixation. Hypermobilities are best addressed by conservative measures , including a progressive exercise program. Exercise programs can be used to enhance the active and control subsystems. Specific passive stability testing is performed to deter­ mine the degree and planes of laxity. Special attention is given to the amount of translation and the end feel. This as­ sessment determines the structural integrity of the passive subsystem of the spine. To determine the dynamic stal>ility of the cervical spine, the passive tests can be repeated dur-

FIGURE 24-30, To determine the stabil ity of the cervical spine during dy­ namic upper extremity movernents, the neck can be observed or palpated during bilateral or un ilateral arm elevation in the relaxed upright posture, and then repeated ,,\lith the cervical spine under the dynamic control of a preset nod. If recruitrnent of the deep seg mental stabilizers decreases the amount of translation, there is a degree of dynamic stabi lity present.

600

Therapeutic Exercise Moving Toward Function

program can be divided into three stages: • Stage 1: Isolated contraction of the deep segmental

flexors and extensors and co-contraction in the cervi­

cal neutral position

• Stage 2: Cervical stability during various upper ex­

tremity movement patterns

• Stage 3: Cervical stability during functional neck

movements

FIGURE 24-31 . Levator scapula stretch: fixing C4 to prevent right lateral translation.

tive lateral translation at the affected joint. A stretch can be performed effectively by first stabiliZing that segm ent for lateral translation (see Fig. 24-28). Postural correction exercises are an integral component in unloading the hypermobile segment in the ce rvical spine. Any deviation from the optimal posture of the cervi­ cal spine increases the translational forces that the spine is subjected to. The resting posture of the shoulder girdle also plays a role in imparting translational forces to the cervical spine. For example, weakness or poor recruitment of the upper fibers of trapezius leads to a depressed and down­ wardly rotated scapula, which places the muscle in a lengthened position. Constant pull on the insertion into the cervical spine may eventually lead to hypermobility into lat­ eral translation. In cases of pre-e;\is ting lateral hyvermobil­ ity, the continuous lateral force exacerbates symptoms aris­ ing from that segment. Exercise should focus on correcting the impairments found on assessment of the shoulder gir­ dle. Taping to reposition the scapula into elevation and up­ ward rotation can reduce this force, allow a more normal movement pattern of the cervical spine, and relieve the in­ creased dural tension caused by the abnormal resting posi­ tion (see Chapter 26). Cervical hwermohiJity can also be addressed through training to facilitate neuromuscular control of the cervical spine with graduated exercise. A series of cervical strengthening exercises can be implemented as deter­ mined by specific muscle testing. These exercises, as de­ scribed in the Impaired Muscle Performance section , enhance the active subsystem of t1~e spinal stahility sys­ tem. Another approach is to determine the direction of the hypermobility and to design exercises that can control those particular motions by recruiting muscles that move the spine out of that direction . For example, for hyper­ mobility into the right extension quadrant, strengthening exercises can be done for left side f1exion and rotation and flexion. Although an isometric contraction produces higher force values , it is easie.st for the patient to control and therefore may he the first exercise taught. Concentric contractions, initially short-arc motion and then progrc5s­ ing to full-arc motion, are taught before eccentric con­ tractions. Simultaneously, a cervical stabilization program can be developed to focus on the control subsystem. A stabilization

Display 2.4-1 proVides examples of exercise tJlat can be prescribed in each stage. Throughout the stabilization program, motion at the hypermobile segment must be controlled, particularly for the excessive translation component. In many cases, the patient can be taught to palpate the translation motion of the vertebra and stop moving when it begins. The patient can also be taught to stabilize the affected level manually or through muscle co-contraction as an exercise is per­ formed. Progressing regardless of translation of the af­ feded level does not succeed in developing stability, and through increased stresses on the capsule and ligaments. it may result in painful exacerbation to the point that the program has to be discontinued. Because of the importance of tJle role of muscles in dy­ namic stahility of the spine, it can be deduced that, despite the presence of hyper mobility, functional stability can be re­ gained through neuromuscular retraining. The key is gradu­ ally challenging the cervical musculature over several months while preventing excessive motion at the involved segment.

Posture Impairment Etiology Although posture is affected by the whole of the axial skele­ ton, the cervical spine plays an important role in the control of posture. The rich supply of mechanoreceptors in the ar­ ticular capsules and muscles of the cervical spine provid proprioceptive input and feed into the vestibular system. 48 Any attempt to alter cervical spine posture must include an evaluation of the thoracic spine, shoulder girdle, and pelviS. Many of the involved muscles are multijoint musc:les , span­ ning the first three of these related regions. Changes in th lengths of muscles such as the levator scapula, trapezius, pectoralis major and minor, or rhomboids have profound ef­ fects on the shoulde r complex and the cervical spine. Changes in tl,e strength of these scapular stabilizers also al­ ter the resting posture of the neck. Alterations of the pelvic base in any plane have effects throughout the spinal column, including the cervical spine. The optimal posture for the cervical spine is the position of axial extension (see Fig. 24-37 A and Patient-Related In­ struction 24-2: Optimal Posture of the Neck). In axial ex­ tension, minima!! muscle work is required to maintain the pOSition, the spine is in an elongated state, and compressive and translatory forces on the spinal stmctures are reduced compared with those in the FHP. The most common pos­ tural impairment of the cervical spine is the FHP. A patient with FHP can presen t vvith several variations. In some individuals, the lower cervical spille flexion juts th whole cervical spine forward above that level, and exten­ SiOll mainly occurs at the CV region ,vith little increase in

as

• il

Chapter 24 The Cervical Spine

601

DISPLAY 24-1

Cervical Spine Stabilization Program Stagel The first goal of the stabilization program is to isolate the deep neck flexors and extensors. The next goal is to perform co-contraction patterns in the cervical neutral position. The following exercises can be used to achieve these goals. The exercises are described in more detail in the Impaired Muscle Performance section. Isolation ofthe deep cervical flexors: • Cervical core activation in variety of positions (PatientRelated Instruction 24-1 and Fig . 24-11) • Autoresistance to the deep flexors Isolation of the rieep cervical extensors: • Electrical muscle stimulation to the cervical extensors in supine • Return to neutral from flexion (fig. 24-14) • Autoresistance to specific multifidus or suboccipital musc les (fig. 24-15) • Concentric extension over a foam roll (fig . 24-16) Rotation and side flexion components: • Supine head roll on a foam wedge, offset (Self­ Management 24-1) Co-contraction of the deep cervical flexors and extensors: • Early co-contraction training can be accomplished in supine lying with the cervical lordosis supported over a towel roll. The extensors are recruited using the electrical muscle stimulator while the patient prevents the extension motion by simultaneously performing the head nod exercise such that the cervical spine remains in neutral. • A more difficult co-contraction exercise positions the patient prone over an exercise ball or in four-point kneeling. These positions encourage craniovertebral extension. The patient should be taught to control the upper cervical flexion while working the middle and lower cervical spine into extension. The head nod motion is performed concurrently with lower cervical extension. If done properly, the cervical lordosis should straighten to a neutral position. Stage II After the patient is able to achieve co-contraction of the anterior and posterior muscles of the cervical spine in resting positions, the next goal is to be able to maintain cervical stabilization during arm motion. The exercises consist of initial co-contraction ofthe cervical musculature (preset nod). which is maintained while the patient performs repetitive motions of the upper extremity in various positions (i.e., supine, four-point kneeling, sitting, standing). The pattern of the arm motion, amplitude, and position of the exercise is based on what combination challenges the patient optimally while maintaining neutral position ofthe affected segmentallevel(s). The goal is to accomplish segmental cervical stability in a variety of positions with an assortment of arm movements and a range of amplitudes. • Because the most stable position is supine, it is used as the initial starting position. • Various movements of the upper extremity (e.g., flexion, ab­ duction, diagonals) are performed while palpating the af­ fected segment for unwanted translation. Only those motions in which the segment remains neutral can be performed.

• Bilateral arm motions below 90 degrees often are the least challenging. Unilateral, overhead movements place higher demands on the stabilization system (however, these effects depend on factors such as the plane or direction of the hypermobility, dural tension, and shoulder or thoracic mobility). • Progression includes adding hand weights, which increases the resistance, or lying on a half roll, which reduces the stability of the base (Fig. 24-32). • These same exercises can be progressed by having the patient perform them in a sitting or standing position (Fig. 24-30). because these positions are more challenging to spinal stability. To make the transition to upright less challenging, the patient can be instructed to sit with the back to the wall to provide feedback of where the head is in space (Fig , 24-33). Upper extremity motion can be altered in direction, amplitude, and pattern. • The therapy ball can be used as another surface to promote cervical spine stability with upper extremity movements. Ball sitting and the use of pulley systems are beneficial at this stage (Fig . 24-34). Prone, progressed to supine on the ball, the patient can be taughtto maintain a controlled cervical spine position while performing simple rocking motions. Increased demands can be made on the cervical spine by adding unilateral or bilateral arm motions, with or without weights. This can be progressed to more complicated arm and leg patterns (Fig. 24-35). • The use of proprioceptive neuromuscular facilitation patterns or sport- and work-specific movements introduce a more functional approach (Fig. 24-36). • Various wobble board systems can be used; the unstable base can further challenge the control of posture as the patient performs various upper or lower extremity movements.

FIGURE 24·32. Maintai ning axial extension on a half roll with unilateral overhead motion. (continued)

602

Therapeutic Exercise Moving Toward Function

DISPLAY 24-'

Cervical Spine Stabilization Program (Continuedl

FIGURE 24-35. Maintaining axial extension in four-point kneeling­ opposite arm and leg pattern.

th ce ce 3.'i

At this stage, heavier loads can also be added to resist cervical musculative • Head nod with lift-off on high incline (Fig. 24-13) and in

supine (Fig. 24-12)

• Sidelying head lift (Fig. 24-17)

Stage III FIGURE 24-33. Wall posture with preset nod and unilateral arm eievation.

This stage challenges the patient to maintain segmental control during various neck motions. A preset nod activates the deep segmental flexor muscles as stabilizers, permitting the more superficial muscles to perform the movement pattern without excessive segmental translation patterns.

de tI1 C3

tn

nc cu

I

tt

n1 0g ~

\\i I

m

FIGURE 24-34. Maintaining sitting axial extension on a ball-arm motion with pulley resistance.

FIGURE 24-36. Maintaining axial extension with proprioceptive neuro­ muscular facilitation pattern against tubing resistance.

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Chapter 24: The Cervical Spine

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DISPLAY 24-1

Cervical Spine Stabilization Program (Continued)

Position is based on the ability to control segmental stability during neck motion with gravity assisted versus resisted . The amplitude of motion is graded based on the range in which the patient can control segmental stability. • Controlled, non-weight-bearing side flexion and rotation can be initiated in supine using a foam wedge, starting at the peak (Fig. 24-20), progressing to the offset position (Self­ Management 24-1). • Pure rotation and side flexion motions can be practiced at the wall in front of a mirror to give feedback and prevent the tendency to collapse into the hypermobile plane of movement.

the midcervicallordosis (Fig. 24-37B) . In others, the lower cervical spine flexion is compensated for by an exaggerated cervical lordosis that may start abruptly, sometimes as low as the C6-C7 segment. In these cases, the midcervical lor­ dosis tends to be accompanied by an excessive anterior translation that is an unphysiologic coupling of motion, be­ cause extension (i.e., lordosis ) should couple with posterior translation (Fig. 24-37C ). Each individual should be as­ sessed to determine the exact components of his or her ab­ normal posture, the levels at which changes in the spinal curves are taking place, and what the emphasis of the pos­ tural correction should be. Table 24-3 summarizes align­ ment findings at various levels of the cervical spine in the optimal position and FHP. Reversal of the normal cervical lordosis is a less common postural impairment. In this situation, the patient presents with a very straight cervical spine or even a kyphOSiS. Treat­ ment focuses on regaining extension in the cervical spine to encourage the normal cervical lordosis. Postural abnormalities may be obselved in the frontal plane with the head and neck tilted to one side. This posture can be caused by factors such as muscle imbalance, articular hypomobilities , habitual work or leisure positions, and hear­ ing or Sight deficits necessitating altered head position. Treat­ ment should be directed at the cause of the asymmetry.

Therapeutic Exercise Interventions

• Cervical segmental flexion and return to neutral from the flexed position are movement patterns that require seg­ mental stabilization during a dynamic movement pattern (Fig. 24-14). • A faulty extension movement pattern using excessive anterior translation can be corrected and practiced in either a sitting or four-point kneeling position. • Manual resistance to a movement pattern can be provided by the therapist (Fig. 24-18). • Autoresistance in functional patterns (Fig. 24-19). • Sidelying head lift (Fig. 24-17). • Nod lift· off (Fig. 24-12 and 24-13).

Muscle Imbalance

The following short muscles should be lengthened; • • • • •

Posterior cervical extensors Scalene muscles Upper fibers of the trapezius Levator scapula Pectoralis major and minor

It is important to practice proper posture of the head and neck. Good posture decreases the stresses on muscles, joints, and ligaments of the cervical spine, which can reduce pain and prevent wear and tear on these structures. Your therapist will instruct you in additional exercises to enable you to achieve and maintain this posture. The upper back should be straightened, the shoulder blades pulled back together, and the chin brought back so that the head is centered over the trunk. A useful guideline is that the ear should be over the midline of the shoulder. Do not overcorrect, because a slight curve in the neck is normal. Proper posture must be practiced frequently throughout the day so that this position becomes habitual. This posture must also be adopted during exercise for the neck and upper extremity.

Treatment for FHP should address muscle imbalance ,

neuromeningeal extensibility, articular hypol110bility, and

proprioception .

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FIGURE 24-37. (A) Axial extension. (B) Forward head position minimal midcervica l lordosis. (C) Forward head position excessive midcervical lordosis.

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604

Therapeutic Exercise Moving Toward Function

Summary of Optimal and Faulty Regional Cervical Spine Positions FORWARD HEAD POSITION-MINIMAL MID CERVICAL LORDOSIS (See Fig. 24-378)

FORWARD HEAD POSITION-EXCESSIVE MIDCERVICAL LORDOSIS (See Fig. 24-37C)

raniovertebral (CV) flexion Midcc l\·i cal spine nClltral (slight cervi cal lordosis)

CV extension

CV extension

Midcervicallordosis

Cervicothoracic extension Upper thoracic extension

Low cervical and upper thoracic flexion Thoracic kyphosis

Excessive midcervical lordosis, C~lJ1 extend as low as C6-C7. Accomp
OPTIMAL CERVICAL SPINE POSTURE (See Fig. 24-37A)

It also is important to strengthen the following weak muscles: • Deep, short cervical flexors (upper and midcervical) • Scapular stabilizers (middle and lower fibers of the trapezius, rhomboids , and serratus an terior) • Upper thoracic erector spinae Neuromeningeal Extensibility

Abnormal cervical postures may be caused by an at­ tempt to decrease stretch on shortened neurom eningeal structures. Side flexion of the cervical spine and elevation of the scapula decrease tension in these structures. Exer­ cises deSigned to alter these postures v\~thout first address­ ing the adverse neural tension can exacerbate the pain and possibly amplify the neurologic symptoms. Articular Hypomobility

Manual therapy techniques may be indicated in con­ junction with mobdity exercises to regain the restricted motions of • Upper cervical flexion • Cervicothoracic junction extension • Upper thoracic extension Postural Correction

To correct the FHP, the head must be brought back over the tmnk. This can often be achieved by directing the patient to "lift the sternum upward, " thus decreasing the upper to midthoracic kyphOSiS. In many patients in whom the thoracic posture is the main component of their faulty posture, this sten1al lift is sufficient to automatically draw the head back in line with the trunk. Another primary exercise for achie~ng many of the goals of postural correction is the head nod exercise. It corrects the upper cervical extension, and because it also tightens ligamentum nuchae, it Simultaneously reduces cervical lor­ dosis. In patients \~th excessive lordosis of the midcervical spine, continuing the head nod into further cervical flexion stretches the posterior structures that have become short­ ened by the lordotic position. The head-nod exercise can be modified to include posterior displacement (retraction ) of

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Thoracic kyphoSis

the head and neck complex to encourage extension at the lower cervical spine and cer~cothoracic junction. One study on the effect of repeated neck retractions in normal subjects found that there was a significant change in resting posture toward a more retracted position after two sets of repeated retractions. 4lJ It is important to control the amount of flexion and retraction motion to prevent over­ compensation into a kyphotic cervical spine position Supine is a good position for the patient learning this exer­ cise, because there is more proprioceptive feedback fro m the contact of the head. Lying length\~se along an Epifoam roll, with the roll directly under the spine, encourages the thoracic extension component of postural correction (Fig 24-38). In this position, the patient controls the lumbar curve \~th a sustained contraction of transversus abdom.iJlli and then performs the head-nod exercise, Sitting and stand­ ing against wall support are natural progressions of the ex­ ercise (see Fig. 24-11). The patient must maintain a neutra. lumbar spine pOSition, and a towel may have to be used be­ hind the head initially to support the forward head or later to maintain a neutral neck position. Exercises must be included to help regain thoracic elt.ien­ sion. Chapter 25 provides deSCriptions of these exercises. Maintaining this axial extension posture while incorpu­ rating upper extremity motion is the next progression; the exercise is done first with wall support (see Fig. 24-33 ) and

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FIGURE 24-38. Lying on an Epifoam roll.

Chapter 24: The Cervical Spine

then in free-standing. Resisted upper extremity exercises can be added through the use of free weights, elastic tub­ ing, or pulley systems (see Fig. 24-34 ). Exercises can be chosen to address strength impairments found on assess­ ment or to simulate work or leisure movement patterns. Various wobble board systems can be used; the unstable base can further challenge the control of posture as the pa­ tient performs various upper or lower extremity move­ ments. Because many daily activities require a bent­ forward position, maintaining proper axial extension while prone over the exercise ball can simulate this position, and upper extremity movements can be incorporated as de­ scribed previously (see Fig. 24-35), " Kinesthetic Awareness Several studies32.50-o2 have shown that subjects with neck pain, cervicogenic dizzi­ ness, and WAD are less accurate in their ability to per­ ceive a neutral resting posture, and return to a cervical neutral posture after motion in either the horizontal or vertical plane. Patients were able to improve their kines­ thetic awareness follOwing manual therapy, vestibular ex­ ercises, or ht practicing return to neutral movements us­ ing a target.'>"'"

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON DIAGNOSES Some of the more common diagnoses of cervical spine disorders are discussed in the follOwing sections. The im­ pairments that occur 'vvith each diagnosis are identified, and examples of exercises for treatment of that condition are given.

Disk Dysfunction Etiology Although disk herniation is less common in the cervical spine than in the lumb ar spine, various dysfunctions of cer­ vical disks do occur. The term disk dysfunction could be used whenever changes in the disk alter its biomechanical properties and prevent normal function. Included in this grouping are degenerative disk disease, excessive disk cleft­ ing, and rim lesions (i.e., separation of the disk from the end plate),s,- ·56 In the acute stages, disk dysfunction can mani­ fest as an irritable condition, with painful limitation of active ROM in all planes, particularly flexion; pain on cough or sneeze; painful cervical muscle contraction resulting from compression loading; and difficulty in maintaining upright postures because of the compression load of the head on the neck. There mayor may not be associated neurologiC signs, depending on the degree of foraminal encroachment by the disk and the condition of other structures surrounding the foram en, such as the zygapophyseal joint capsule, liga­ ments, and bone.

Treatment Treatment initially is aimed at resting the neck, which is achieved through education about proper resting pOSitions to unload the compressive and translatory forces on the cervical spine. Therapeutic modalities may be useful to

605

help alleviate the inflammatory response and decrease as­ sociated muscle spasm. Manual therapy techniqu es can be used to mobilize the involved segment if segmental hypo­ mobility is found during mobility testing , Muscle energy techniques can also be used to mobilize and alter muscle activity at that segment. Manual traction techniques help to decompress the disk and increase intervertebral foramen size. Breathing pattern re-education is a good exercise during the acute stages, be­ cause excessive use of the secondary muscles of inspiration, such as the scalene muscles , can add a compression load to the cervical spine and should be avoided. Instruction in di­ aphragmatic breathing encourages an optimal breathing pattern and unloads the cervical spine. Using postural cor­ rection exercises reduces translational forces. Supine exer­ cises, such as gentle head nod (i.e., CV flexion) may be tol­ erated at this stage. As the condition improves, impairments can be identi­ fied and addressed. After a period of protected function, the patient vvill usually exhibit signs of hypomobility impair­ ment. Degenerative changes at that vertebral segment may also decrease its mobility, Care must be taken in selecting and teaching ROM exercises to minimize compressive or translatory forces. Because muscle extensibility may be decreased as a re­ sult of muscle guarding during the acute phase, stretching exercises should be implemented. Neuromeningeal exten­ sib ility should also be assessed at later stages, particlllarly in cases of neurologiC involvement. Exercises to increase the mobility of these structures should not be stalied when there are still signs of decreased nerve conduction, because the movements can eaSily exacerbate the condition. The disk is an impOJiant structure in the control of mo­ tion of the intervertebral segment, and hypermobility im­ pairment may occur as a result of disk dysfunction. Stability testing at the affected segment may detect increased motion because of the loss of the disk's ability to control transla­ tional forces in the spine. This impairment must be ad­ dressed 'vvith a progreSSion of stabilization exercises. The Hypermobility section describes these exercises. To prevent further disk degeneration and reduce the in­ cidence of recurrence of an acute episode, it is important to correct all postural impairments of the cervical spine, tho­ racic spine, and shoulder girdle. Postural asymmetry of the pelvic girdle also influences the cervical spine, and impair­ ments should be addressed as previously discussed.

Cervical Sprain and Strain Etiology Any traumatic incident can produce a sprain or strain of the cervical spine. The most common incident is the WAD that occurs after a motor vehicle accident. The complex injuries sustained can involve many differ­ ent tissues . The soft-tissue structures involved can include muscle, ligament, capsule, articular cartilage , and the disk (including rim lesions ). Concurrent bony injuries can in­ clude fractures of the aliicular subchondral bone, trans­ verse and spinous pr~cesses , lateral masses of the atlas, and the vertebral body;'" and suspicion of thes e injuries re­ quires referral to the phYSician for management. Patient

606

Therapeutic Exercise: Moving Toward Function

exhibiting signs of instability from traumatic injury should also be referred to the physician for further cliagnostic tests and appropriate me dical interve ntion. The severity of these injuries varies widely, and the irritability of the condition must be assessed individually. Patients with WAD have been shown to have decreased recruitment , strength and endurance of their deep cervical flexors ,'1z a!:ld poor kines­ thetic awareness as compared with controls."'1

permobility section). The carly stage I exercises put very little stress on the cervical spine and can be implemente d early in rehab . Postural impairments continue to be a con­ cern, and treatment interventions should include dynamic exercises that encourage movement patterns that incorpo­ rate optimal posture.

Treatment

Neural Entrapment Etiology

During the acute inflammatory stage , treatment is aimed at reducing pain and inflammation and promoting optimal heabng. Education about proper resting pOSitions, limita­ tions of activity, and the use of ice can assist in readling these goals. If segmental hypermobility is suspected, brac­ ing should be considered to reduce stresses on the healing structures. Exercise at this time involves the use of breath­ ing exercises and ROM exercises within the pain-free range. The supine position is often best tolerated at tbis stage, because it unloads the weight of the head, and the wedge pillow can be used to assist the mobility exercise. Rhythmic neck rotation movements performed in a supine position in conjunction with breathing can increase mobil­ ity and assist vascular flow. Therapeutic modalities such as ice, interferential current, pulsed ultrasound, or transcuta­ neous electrical nerve stimulation may also be indicated at this stage to reduce inflammation, decrease muscle spasm, and assis t in pain control. In the subacute stage, it is important to continue to pro­ tect the injured structures and to introduce stresses that encourage optimal healing. Grade I and II manual therapy mobilization techniques are effective in pain relief, and grade III and IV mobilizations can help resto re motion of the involved segments (see Chapter 7). Impairment of mo­ bility may continue to be the primary dysfunction. Mobility exercises may be progressed into larger arc movements, more specific to the multiplanar articular restrictions found on manual mobility testing. Specific muscle length tests may also indicate that certain muscles are short. However, the effect on the whole spine (e.g., dural stretch, disk com­ pression) must be taken into consideration whcn choosing exercises. It is also prudent to begin postural re-education, progressing through the exercises as tolerated. Overhead arm motions are often too stressful on the celvical spine at this stage because of increased translation and compression forces. During the remodeling phase or as the condi tion be­ co mes more chronic, other impairments can be ad­ dressed. The muscles strained at the time of injury and the segmental muscles related to levels of articular dys­ function often show impairment of force production. A specific strengthening program can be deSigned to im­ prove muscle function. Depending on the degree of liga­ mentous or disk injury, there may be a mobility impair­ ment of hypermobility. As studies have shown decreased dynamic stability in this patient population , stage I and II stabilization exercises (see Display 24-1) should be taught and progressed as tolerated. Development of a stabiliza­ tion program must take into consideration the direction, sevelity, and irritability of the hypenn obility (see the Hy­

The cervical nerve roots can become entrapped at their exit at the intervertebral foramen. The foramen is bounded by the zygapophyseal jOint, th e UV joint, the disk, and thO pedicle. Any pathologic condition increasing the size of these surrounding structures can lead to narrowing or stenosis of the foramen, potentially entrapping the nern ' root. Foramen size is also reduced by the movements of ex­ tension and ipSilate ral side flexion and rotation. Any mus­ cle imbalance producing this resting position of the ceni ­ cal spine would further aggravate the problem. The FHP can place the upper and midcervical spine into a posture 01 increased cervical lordosis, decreasing the intervertebra. foramen size. Any scapular resting positio n that encourage~ this cervical position (e.g., e levated scapula) or stretch e~ the nerve root (e.g. , depressed or protracted scapu la would also aggravate t!Ie condition. Changes in neural con ­ duction depend on the degree of pressure or traction 0 the nerve root. The term double c'rush syndrome or multiple crush sy,, ­ drome has been used to describe the syndrome in which th nerve is affected at multiple sites along its course from t1 cervical spine to the hand.~3 Common sites of entrapmerr are the cenical intervertebral foramen, the thoracic ou rle ' the e lbow, and the carpus. Pressure at anyone of these sit in isolation may be insufficient to produce symptoms , b there can be a summation effect as subsequent sites al their "crush" to the nelve . A common example of crush syndrome is carpal tun s),l1drome. There may be decl'e ased space in the carpal tu nel locally, but it may not be as marked as the symptor suggest. There may be additional proximal symptoms th are unexplained by pressure at the carpal tunnel alon e . the cervical spine, there may be some mild degene ratr changes involving the zygapophyseal joint and un cin. process that decrease the intervertebral foraminal di m€' sions. A superimposed FHP places the upper and midCt:'­ vical spine into a resting pOSition of extension, Furth. compromising intervertehral foramen size. A short scale muscle on the same side, because of a faulty respi ratc.­ pattern or the habitual crooking of a phone bet\vccn h and shoulder, causes a side-fl exed posture of the cen; spine and further decreases the inte rve rteb ral foram space. At the rll0racic outlet, a shortened scalene muse' can also elevate the first rib, decreasing the size of the tho­ racic outlet and creating another potential site of neural en­ trapment. A depressed scapular resting position place traction force on the brachial plexus , which can also de­ crease neural conduction, ,mel increases tension in the neu­ romeningeal systcm in the upper quadrant, which can fU!­ gravate the condition.

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Chapter 24: The Cervica l Spi ne

Treatment Thorough assessment at each of the sites of entrapment can identify the impairments contributing to the condition. Treatment interventions address the impairments found at the cervical spine, tho racic spine, shoulde r girdle, and wrist. If wrist dysfunction is treat ,d in isolation, the symp­ toms tend to recur or change, often working their way prox­ imaIly. Exercise treatm ent interventions for the impair­ ment of posture are particularly useful , as is addressing the findings of neuromenillgeal hypomobility.

Cervicogenic Headache Etiology Ce rvicogenic headache can be caused by two mecha­ nisms. First, the posterior aspect of the skull, as far for­ ward as the vertex, is supplied by the greater occipital nerve (a branch of the C2 and C3 posterior rami). Any structure supplied by the second or third cervical nerve can refer pain into that distribution. Second, the spinal nucleus of the trigem inal nerve descends into the spinal cord to at least the level of C3. Branches of the trigemi­ nal nerve supply the mandibular, m,L'tiILIlY, and frontal ar­ eas of the face. Afferents from the first three or four cer­ vical nerves converge with afferents of the trigeminal nerve. Any structure supplied by these neurologic seg­ ments can refer pain into the head and face, causing headache of cervical origin. 48 A study by Watson and Trott 29 found an increased in­ cidence of FHP and weakness and decreased endurance of upper cervical flexor muscles in subjects with c~r:i=~1 g headaches compared WIth controls. Several studles- ··of ,,9 have found involvement of the upper four cervical zy­ gapophyseal joints in patients presenting with cervico­ genic headache. In another study,44 patients vvith post­ concussional head ache were found to have significant differences from th e control group, including a trend to­ ward a more FHP, symptomatic segmen tal hypomobility of the upper cervical spine, decreased endurance of the upper cervical fl exor muscles , and a highe r incidence of moderate muscle tightness, most c<,?mmon ly of the upper cervical extensor muscles. Jaegert>g found a Significant number of myofascial trigger points on the symptomatic side compared wi th th e asymptomatic side in patients presenting with cervicogenic headache .

Treatment Treatment interventions shou ld mainly target impair­ ments of posture and mobility. Mobility exercises may be performed as generalized ROM exercises or deSigned as specific articular mobilization exercises to address the seg­ mental mobility restrictions found on manual mobility testing, most often of the upper cervical intervertebral levels (see the H ypomobility section). SpeCifiC muscle stretches, particularly for the upper cervical extensor mus­ cles, can address the myofascial tightness and trigger points that may be con tributing to the headache. Exe r­ cises to increase muscle performance and endurance of the deep upper cervical flexor muscles should be included in the exercise program.

607

KEY POINTS • The CV complex includes the AO and AA joints. liga­ ments include the alar, transverse, tectorial memb rane anterior and posterior AO membranes, and posterior AA ligamen t. • The AO joint is a bicon dylar, modified ovoid joint. It has tvv'O degrees of motion: flexion-extension and combined side flexion-rotation. The AA joint is a mu!tijoint com­ plex and has tv-'O degrees of motion: flexion-extension and rotation combined with a small amount of conjunct side flexion. • The jOints of the midcervical spine include the paired zygapophyseal jOints, the UV joints, and the interbody joint. Th e important ligaments of the midcervical spine include the anterior longitudinal ligaments and poste­ rior longitudinal ligaments, the ligamentum flavum , th e int erspinous ligaments, and the ligamentum nuchae. • Coordinated motion occurs among the joints of the mid­ cervical spine. Each segment of the midcervical spine has two degrees of motion: flexion-extension and com ­ bined rotation- side flexion . Each joint partiCipates in any motion. • The cervical spine examination and evaluation consists of a patient report (subjective histOlY) and the physical (objective) examination . The patient report should in­ clude information about the client's job, sitting position, and type of exercise performed. The phYSical examina­ tion includes visual observation; active and passive movem ent tests , including myofacial and neu­ romeningeal extensibility tests; manual muscle testing; neurol ogic tests; various speCial tests; and clearing tests of the thorax, shoulder girdle, and TMJ. • Common phYSiologic impairments affecting the cervical spine includt· muscle performance impairment, posture impairmen t, and mobility impairment (i.e. , hypomobil­ ity and hypermobility). • A therapeutic exercise program is developed to address each impairmen t and improve overall function of the individual. • The follOWing are common diagnoses of th e cervical spine: • Disk dy~function: Impairm ents that are often associ­ ated with this diagnosis include mobility (i.e .. , hypo­ mobility and hypermobility) and posture. • Sprain or strain: Impairments associated vvith this di­ agnOSiS include mobility, posture, and muscle per­ formance. • Neural entrapment: Impairments associated with this diagnosis include mobility and posture . • Cervicogenic headache: Associated impairments in­ clude mobility, posture, and muscle performance pro­ duction , particularly endurance. • For any patient presenting with a particular diagnosis, the associated impairments are iden tified. Th ey mus t then be prioritized according to their relative impor­ tance as those requiling immediate attention and those most likely to be tolerated by the patient.

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Therapeutic Exercise: Moving Toward Function

LAB ACTIVITIES 1. Consider a 3.5-year-old female nurse with FHP and a history of trauma to the cervical spine who presents with signs and symptoms of decreased conduction of the right C5 nerve root, deltoid weakness, decreased biceps reflex, decreased sensation of the radial aspect of forearm, and decreased ROM , most notablv of right rotation and right side flexion and exten;ion. Her right quadrant tested positive for paraesthesia of the base of the thumb. The Upper Limh Tension Test results were positive for decreased motion on right compared with the left (paraesthesia to the base of the thumb ). Traction eases and compression ag­ gravates her symptoms. A slight increase in right lat­ eral translation at the C4-C5 intervertebral level was detected by stahility testing. a. List some of the possible causes of the C5 root palsy. b. Identify the phYSiologiC' impairmen ts that may be contlibuting to this problem . c. Design a th erapeutic exercise program to im­ prove th e hypermohility impairm ent described for this patient. Teach your pmtn er th ese exe r­ cises. d. What are your criteria for discharging this pa­ tient? e. Prescribe a home program for this pati ent. 2. List the posterior suboCcipital muscles and state their actions. Test the strength of these individual muscles

CRITICAL THINKING QUESTIONS

1. Using the intervention model, describe at least two ac­ tivities or techniques that would address the posture im­ pairments contributing to neck pain in Case Study #7 in Unit 7. You may need to include therapeutic exercise for other phYSiologic impairments to resolve posture impairments related to neck pain. 2. Could neck pathology contribute to lateral forearm and interscapular pain in Case Study #8 in Unit 7? a. Desclibe this mechanism. b. If neck pain does contribute to lateral forearm and interscapular pain, would you ell.-pect complete reso­ lution of pain in these regions \vithout resolution of neck dysfunction? c. Using the intervention model described in Chapter 2, develop a comprehenSive therapeuti c exe rcise program for the patient's functional limitations and related impairments caused by neck dysfunction. You may need to include exercise for the shoulder girdle and thoracic spine.

REFERENCES

1. Mercer S, Bogduk N. Intra-articular inclusions of the cervical synOvial jOints. Br J Rheum 1993;32:705-710.

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on your paltner. Be aware of the recruitment of other more dominant muscles during testing. 3. Your partner plays the role of a patient at 1 week af­ ter an acceleration-deceleration injury from a skiing accident. ­ a. Educate this very active patient about appropriate activity. b. Teach' the patient appropriate breathing exercises to retrain an optimal respiratOlY pattern. c. Teach the patient th e initial exercises for im­ provement of a postural impairment. 4. Have your pa.tner hold th e position of right scapular depression , and then test cen1cal rotation and side flexion ROM in each direction . Repeat the same tests with the scapula held in a position of elevation. a. Is there anv difference in ROM between the two scapular p<;sitions? b. 'Vhich Illuscles may be implicated in restriction s of which movements? c. Based on the stalt position of the scapula, can you make a determination on whether the muscle is shOlt and requires stretching, or is overstretched and requires SUppOlt? d. Teach your partn er an exercise to increase the length of each of the muscles you have identifi ed. e. '''hat can you teach your partner to do to support overstretched muscles'? '''hat could you do as an adjunctive intervention (refer to Chapter 26).

2. Goel V, Yall1:mishi TM , Chang H . Development of a com­ puter model to predict strains in the individual fibres of ligament across th e ligamentous occipito-atlanto-axial (CO­ CI-C2) complex. Ann Biomed Eng 1992;20:667-686. 3. Koebke J, Brade H. MorpholOgical and fun ctional studi es the lateral joints of the first and second cervical vertebra " man. Anat EmbryoI1982;164:265-275. 4. Schonstrom N, Twomey L, Taylor J. The lateral atlanto-axi. joints and their synovial folds: an in vitro study of soft tissue injury and fractures. J Trauma 1993;35:886-892. 5. Goel V, Clark C R, Gallaes K, et al. Moment-rotation rel,,­ tionships of the ligamentous occipito-atlanto-axial complex. Biomech 1988;21673-680. 6. Goel V, Winterbottom JM , Schulte KR, et al. Ligamentou. laxity across CO-CJ -C2 complex, axial torque-rotation char­ acteristics until fai lure. Spine 1990;15:990-996. 7. Oda T , Panjabi MM , Crisco JJ 3rd. Three-dimensional traos­ lational move ments of the upper cervical spine. J Spinal Di<­ ord 199.1 ;4:4] 1-419. 8. Penning L, \Vilmink JT. Rotation of the cerVical spi ne . Spin 1986;12732-738. 9. Mimurd :vl , Moriva H , Watanabe T, et al. Three-dim ensional motion analysis of the cervical spine ,vith speCial refe rence to axial rotation. Spine 1989;14:1135-1139. 10. Iai H , Moriya H, Goto S, et al. Three-dimensional motion analysis of the uppe r ce rvical spi ne during axial rotation. Spine 1993;18:2388-2.392. 11. Dvorak J, Panjabi M. Functional anatomy of the alar liga­ ments. Spine 1987;12:183-189. 12. Panjabi M, Dvorak J, Clisco J 3rd, et al. Flexion, extension .

Chapter 24 The Cervical Spine and lateral bending of the upper cervical spine in response to alar ligament transections. J Spinal Disord 1991;4:157-167. 13. Panjabi M, Dvorak J, Crisco J 3rd, et al. Effects of alar liga­ ment transection on upper cervical spine rotation. J Orthop Res 1991;9:584-593. 14. \"'hite A, Panjabi M. Clinical Biomechanics of the Spine. Philadelphia: JB Lippincott, 1990. 15. Werne S. The possibilities of movement in the cranio-verte­ bral joints. Acta Orthop Scand 1957;28:165-173. 16. Harris MB, Duval MJ, Davis JA, et a1. Anatomical and roen­ tenographic features of atlantooccipital instability J Spinal Disord 1993;6:3-10. 17. Hyashi K, Yabuka T. Origin of the uncus and of Luschka's joint of the cervical spine. J Bone joint Surg Am 1985;67: 788-791. 18. Milne :-.J. The role of zygapophyseal joint orientation and un­ cinate processes in controWng motion in the cervical spine. J Anat 1991;178:189-20l. 19. Tondury G. The behaviour of the cervical disc during life . In : Proceedings of the International Symposium on Cervical Pain. Wennergreu Centre, Stockholm , 1971. 20. Twomey L, Taylor J. Functional and applied anatomy of the cervical spine . In: Grant R, ed . Physical Therapy for the Cer­ vical and Thoracic Spine. Melbourne : Churchill Livingstone, 1994. 21. Dvorak J, Panjabi MM, Novotny JE , et al. In vivo fleldon/ex­ tension of the normal cervical spine. J Orthop Res 1991;9: 828-834, 22. Penning L. Normal movements of the cervical spine, Am J RoentgenoI1978;l30:317-326. 23. Panjabi M, The stabiliZing system of the spine, Part 1: Func­ tion, adaptation, and enhancement. Part 2: Neutral zone and instability hypotheSiS. J Spinal Disord 1992;5:383-397. 24. 'Williams P, Warwick R. Gray's Anatomy. 36th Ed. Philadel­ phia: Churchill Livingstone, 1980. 25. Jirout J. The dynamiC dependence of the lower cervical ver­ tebra on the atlanto-occipital joints. Neuroradiology 1974;7: 249-252. 26. Conley MS, Meyer RA, Bloomberg JJ, et a1. Noninvasive analysis of human neck muscle function. Spine 1995;20: 2505-2512. 27. Grieve G. Common Vertebral Joint Problems. Edinburgh: Churchill Livingstone, 1981. 28. Vernon H , Mior S. The neck disability index: a study of reliabil­ ity and validity. JManipulative Physiol Ther 1991;14:409-415. 29. Watson D , Trott P Cervical headache: an investigation of natural head posture and upper cervical flexor muscle per­ formance. Cephalgia 1993;13:272-282. 30. Silve rman J, Rodliquez AA, Agre JC. Quantitative cervical flexor strength in healthy subjects and in subjects with me­ chanical neck pain. Arch Phys Med Rehabil1991;72: 679-681. 31. Gogia P, Sabbahi M. Electromyographic analysis of neck muscle fatigue in patients with osteoarthritis of the cervical spine. Spine 1994;19:502-506. 32. Jull G . Deep neck flexor dysfunction in whiplash . J Muscu­ loskeletal Pain 2000;8:143-154 . 33. Uhlig Y, We ber BR, Grob D , et al. Fibre composition and fi­ bre transformation in neck muscles of patients with dysfunc­ tion of the cervical spine. J Orthop Res 1995;13:240--249. 34. Hallgren RC , Greenman PE, Rechtien JJ. Atrophy of suboc­ Cipital muscles inpatients with chronic pain: a pilot study. JAOA 1994;94:1032-1038. 35. Stump J, Rash G , Semon J, et al. A comparison of two modes of cervical exercise in adolescent male athletes. J Manipula­ tive Physiol Ther 1993;16:l.'53-160. 36. Deange J, Strengthening the neck for football. Athlet J 1984; Sept:46-48.

609

37. Leggett S, Graves JE, Pollock ML, et a!. Quantitative, e ­ ment and training of isometric cervical extension str ngth . Am J Sport Med 1991;19:653-659. 38. Polilock ML, Graves IE, Bammon MM, et al . Freque n yand volume of resistance training: effect on cervical exteIlsion strength. Arch Phys :'ded RehahiI1993;74:10SO--lO 6. 39. Highland T, Dreisinger TE, Vie LL, et al. Changes in iso­ metric strength and range of motion of the isolated cenical spine after eight weeks of clinical rehabilitation. Spine 1992: 17(SuppI6):S77-S82. 40. Taimela S, Tabla EP, Asklof T, et a1. Active treatment of chronic neck pain: a prospective randomized inten'ention. Spine 2000;25:1021-1027. 41. Hides J, Stokes MJ, Saide M, et a1. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19: 165-172. 42. Mayoux-Benhamou MA, Revel ~vl , Vallee C. Selective elec­ tromyography of dorsal neck muscles in humans. Exp Brain Res 1997;113:353-360. 43. Janda V. Muscles and motor control in cervicogenic disor­ ders : assessment and management. In: Grant R, ed. Physical Therapy for the Cervical and Thoracic Spine. Melbourne: Churchill Livingstone, 1994. 44. Treleaven J, Jull G, Atkinson L. Cen1ical musculoskeletal dysfunction in post-concussional headache . Cephalgia 1994; 14:273-279. 45. Edgar D , Jull G, Sutton S. The relationship between upper trapezius muscle length and upper quadrant neural tissue ex­ tensibility. Aust Physiother J 1994;40:99-103. 46. Nederhand MJ, Ijzerman MJ, Hermens HJ, et a1. Cervical muscle dysfunction in the chronic whiplash associated disor­ der grade II (WAD-II) Spine 2000; 25:1938-1943. 47. Butler DS. Mobilization of the ~ervous System. Melbourne: Churchill Livingstone, 1991. 48. Bogduk N. Cervical causes of headache and dizziness. In: Grieves G, ed. Modern Manual Therapy of the Vertebral Col­ umn. Edinburgh: Churchill Livingstone, 1986. 49. Pearson ND , Walmsley RP. Tlial into the effects of repeated neck retractions in norTllal suhjects. Spine 1995;20:124.5­ 1250; discussion 1251. 50. Revel M, Andre-D eshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients \vith cervical pain. Arch Phys Med 1991;72:288- 291. 51. Heikkila H, Astrom PG. Cr rvicocrphalic kinrsthetic sensibil­ ity in patients with whiplash injury. Scand J Rehabil Med 1996;28: 1.'33- 138. 52. Loudon JK, Ruhl M, Field E. Ability to reproduce head posi­ tion after whiplash injury. Spine 1997;22:865--868. 53. Karlberg et al. Postural and symptomatic improvemeut after phys iotherapy in patients with dizziness of suspected cervical OIigin. Arch Phys Med RehabiI1996;77:874-882. 54. Revel M, Minguet M, Grego), P, et al. Changes in cervico­ cephalic kinesthesia after a proprioceptive rehabilitation pro­ gram in patie nts with neck pain. Arch Phys Med Rehabil 1994; 75:895-899 . .55 . Taylor JR , Kakulas BA, Margolius K. Road accidents and neck injUlies. Froc Australas Soc Hum Bioi 1992;5:211-231. 56. Taylor JR , Kakulas BA, Margolius K. Acute injuries to the cervical jOints. Spine 1993;18:1ll:"i-1122. 57. Jull G. Headaches of cervical origin. In : Grant R, ed. Physical Therapy for the Cervical and Thoracic Spine. Melbourne : Churchill Livingstone, 1994. 58. Jull GA. Headaches associated \vith the cervical spine-a clin­ ical review. In: GJieves G, ed. Modern Manual Therapy of the Vertebral Column. Edinburgh: Churchill Livingstone , ] 986. .59. Jaeger B. Are "cervicogenic" headaches due to myobscial pain and cervical spine dysfunction? Cephalgia 1989;9: 137- 163.

chapter 25

The Thoracic Spine ROB LANDEL, CARRIE HALL, MARILYN MOFFAT, AND SANDRA RUSNAK SMITH

Review of Anatomy Osteology/Arthrology/Myology Kinetics Anatomic Impairments Kyphosis Scoliosis Examination and Evaluation History

Systems Review

Tests and Measures

Therapeutic Exercise Interventions for Common Physiologic Impairments Impaired Muscle Performance Impaired Range of Motion, Muscle Length, and Joint Mobility/Integrity Pain Impaired Posture and Motor Function Therapeutic Exercise Interventions for Common Diagnoses Exercise Management of Parkinson's Disease Management of Scoliosis Exercise Management of Kyphosis Thoracic Outlet Syndrome

The thoracic spine is unique in its structure and function from the remainder of the spine because of its articula­ tions with the sternum and ribs and its critical role in ven­ tilation . The thoracic spine's location between the cervi­ cal and lumbar spine allow it to be vulnerable to impairments in the se related regions . Conve rsely, impair­ ments in the thoracic region affect function of the sur­ rounding spinal regions. As a critical link in the kinematic chain, functions of other regions of the body (e.g., shoul­ der girdle, hip, foot, ankle ) affect function of the thoracic spine and vice versa. Unlike the lumbar and even the cervical spine, there is a paucity of literature regarding the manage ment of tho­ racic spine impairments, particularly "vith regard to inter­ ventions for impaired muscle performance. Much of the approach to exercise for the region must be extrapolated from the lumbar and cervical regions , with allowance made for differences because of the thoracic cage. This chapter reviews basic anatomic and biomechanical features and

presents pl;nciples and examples of therapeutic exercise prescription for common impairments and medical diag­ noses affecting the thoracic region.

REVIEW OF ANATOMY

Osteology/Arthrology/Myology A thorough understanding of the unique anatomy of the thorax is required to grasp the biomechanics of the region . Fi~re 25-1 describes a typical thoracic vertebra (Fig. 25­ 1). -5 Of particular importance is the cbnical significance of each feature , as listed in Table 25-1 , which will be useful to keep in mind when designing an exe rcise program. In the thoracic region , 5 of the 12 vertebrae are consid­ ered atypical: Tl and T9 through Tl2. Each of these atyp­ ical veliebra possesses certain characteristics, as listed in Table 25-2. The most apparent difference of the thoraci c region from the remainder of the spine is the group of 1:2 ribs and their articulations (Fig 25-2). The 12 pairs of ribs have several functions: • To protect the heart, lungs, and great vessels against trauma • To prOVide attachment for skeletal and respiratory muscles • To facilitate postural alignment and upper extremity function The typical rib has two costovertebral articulations (the costovertebral and costotransverse joints , both synovial) that join the typical rib with the bodies of the vertebrae above and below by means of demifacet joints (Fig. 25-3 ). The rib is also connected to the intervening annulus of the intelvertebral disk through a strong ligamentous attach­ ment (Fig. 25-4). The costotransverse articulation joins the tubercle of the rib with the transverse process of the nu­ merically corresponding vertebra. For example, rib 3 at­ taches by its • Upper facet to the inferior demifacet (costovertebral joint) ofT2 • Lower facet to the superior demifacet (costovertebral joint) ofT3 • Strong ligamentous attachment to the intervertebral disk between T2 and T3 • Costotransverse articulation to the transverse process ofT3

610

Chapter 25: The Thoracic Spine

Vertebral foramen

-~>-L

Superior costal facet Pedicle

Superior articular

process and facet



Transve r=.se=---_----c process Lamina Superior articular facet Pedicle - - - - - - - .

Spinous process Superior articular process ~---",___

Superior costal facet

+ - - - - - - - Body

611

Numerous ligam ents stabilize the thoracic vert bral segment and rib articulations (s e F ig. 25-4 ). Other sources can provide more information about the function of each ligamentous structure, vvhich are critical in contri buting to stability of the respectiv'e articlllation. 26 .7 .11 !\umerous muscles control movement of the thoracic spine and the process of respiration. The movemellts that they ~roduce or assist with are categorized in Table 2.'5­

36~_l:..

Kinetics 13•14

Facet for tubercle of rib

--=-""'---Inferior costal facet

Range of Motion

Spine - - - - - I

'-----Inferior vertebral arch

The thoracic region is less flexible and more stable than the cervical region because of the limitations imposed by the rib cage, spinous proc esses, zygapophyseal joints, and the dimensions of the vertebral bodies (see Table 25-1). Ribs 1 through 10 articulate postl'J10rly with tht' vertebral column and with the manubriosternum anteriorly, forming a closed kinematic chain . The closed chain relationship means the segments are interdependent, and motion is more restricted. Ribs 11 and 12, lacking anterior articula­ tions , form an open kinematic chain and their mobility is therefore less restricted. Motion in all cardinal planes is possible in the thoracic region , but the magnitude depends on the segmental leve l. The range of motion (ROM ) for the thoracic spine is given in Table 25-414 The following points should be noted:

Inferior articular process

FIGURE 25-1. A Typical Thoracic Vertebra.

The sternum is another unique feature of the thoracic re­ D'ion. It is composed of a manubrium , body, and xiphoid pro­ cess (Fig. 25-2). The anterior articulations of the ribs with the sternum are called the costochondral joints. The costal cartilages, composed of hyaline cartilage, greatly enhance mobility of the ribs 6 . 7 Ribs 1 through 7 are called true ribs because they articulate with the sternum through their costal cartilage. Ribs 8 through 10 are classified as false ribs because they are attached to the sternum through the costal cartilage of the rib immediately above 8 - 10 Ribs 11 and 12 are classified as floating ribs because they do not attach to the sternum or costal cartilages at their anterior ends.

• Flexion and extension are more l,i mited in the upper thoracic region , where the facets lie closer to the frontal plane.

Typical Thoracic Vertebrae ANATOMIC SITE

DESCRIPTION

CLINICAL SIGNIFICANCE

Body and interveliebral joint

The ratio of disk height to vertebral body height is less in the thoracic spine than in the cervical or lumbar regions. The ratio of disk diameter to disk height is two to three times higher in the thoracic spine than in the lumbar spine. There is an acu te angular orientation of the lamellae of th e anulus and a relatively small nucleus pulposus Slope infe riorly and overlap the spinous processes of th e adjace nt inferior vertebrae On the ventral aspect, a facet articulates with the tubercle of the rib to form the costotransverse joint. In the upper and middle thoracic spine (Tl-T6) , this facet is concave, corresponding to a convex tubercl c on the neck of thc rib. In th e lower thoracic region (T7-T10), this facet is planar. Orie ntation of the zygapophyseal facets depends on the region of the thora,'{. Except fo r Tl, Tll, and T12, the posterolateral comers of the superior and inferior aspects of the vertebral body contain an ovoid demifacet.

Creates stiffness and stability

pinous processes Transverse processes

Facets

Limit extension The shape of the upper and middle thoracic costotransverse joints restricts motion of th e rib in rotation ahout an a,'{is parallel to and through the neck of the rib. Tlw sh'lpe of tl\(' lower tllOracic costotransV('rsc joint allows the rib greater flcxihilit, of Illotion duting respiration and Illotion of the thorax. Zygapophyseal facet orientation guides and n~ stric ts mobility. Demifacets articulate with the head of th e rib at th e costovcrtebral joint. Development of the costovertebral joint is delayed until early adolescence. contributing to the flexibility of the young thora,'{.

612

Therapeutic Exercise: Moving Toward Function

Characteristics of the Five Atypical Thoracic Vertebrae VERTEBRAL LEVEL

CHARACTERISTICS

First thoracic vertebra

Superior costal facets are circular to articulate with the entire head of the first rib. Spinous process is horizontal and is as long and prominent as C7. The inferior costal facets are absent, and there is no direct articulation with the 10th ribs. The inferior costal facets are absent, and there is no direct articulation with the 11th ribs. It articu lates only \~ith the heads of the 11th ribs. The transverse processes are small and do not have articular facets for the tubercles of the ribs. It possesses only two costal facets for the 12th ribs . The body, transverse processes, and inferior facets are similar to those of the lumbar vertebrae .

Ninth thoracic vertebra Tenth thoracic vertebra Eleventh thoracic verteb ra

T,velfth thoracic vertebra

• Lateral flexion remains similar throughout but in­ creases in the lower thoracic region. • Rotation is more J:imited in the lower thoracic region, where the facets lie closer to the sagittal plane.

Nonarticu lar part of tubercle .

Manubriosternal Suprasternal notch notch ---'C lavicles Manubrium ~~~~~~~~~~~~ Sternoclavicular Costo, joint chondral Second joint chondrosternal joint Body of Chondrosternal sternum joints Xiphisternal Fifth rib joint Xiphoid process ~ V ~ Eighth rib Costal Tenth rib cartilage

Interch ondral joints

FIGURE 25-2. An anterior view of the articulations of the rib cage. The shaded areas indicate costa l cartilage. The costal cartilages join the ribs at the costochondral joints. Interchondral joints may also exist between the fifth throu gh ninth costal cartilages. (From Norkin CC, Levangie PK. Joint Structure and Function: A Comprehensive Analysis. 2nd Ed . Philadelphia FA Davis, 1992)

F

Head Crest of head of rib

Osteokinematics and Arthrokinematics of Thoracic Motion l3, 14 Flexion occurs in the sagittal plane during forward bending of the tmnk and during the exhalation phase of respiration. The total osteokinematic range of fl exion is 20 to 45 de­ grees, and is limited by th e posterior longitudinal ligament, ligamen tum flavum , interspinous ligament, supraspinous ligament, and the capsular Lgaments 14 D uring flexion , the articular facets of the cranial vertebra glide upward and forward on the caudal partncr,1 5 causing coupled anterior translation. Extension also occurs in the sagittal plane, dur­ ing bachvard bending, elevation of both arms, and the in­ spiration phase of respiration. The ROM of extension in the thoracic spine is 20 to 45 degrees. 14 Extension is coupled with posterior translation. The articular and spinous pro­ cesses limit extension. During extension, the anterior lon-

L.t

Articular facet of tubercle

Articular facet

~

Costal groove

FIGURE 25-3. A typical rib.

Radiate ligament (superior portion)

Intra·articular. ligament Anterior longitudinal ligament Intervertebral disk

Anteri or

IJi \ '

, I

?j ~

Posterior

FIGURE 25-4, A lateral view of the costovertebral joint and

liga m6-~

The three bands of the radiate ligament reinforce the costovertebra l jc--' The superior and inferior portions of the radiate ligament attach to the (C'­ sula r ligament (removedi and to the vertebra l body. The middle portio the ra diate ligament attaches to the intervertebral disk. The middle of :. illustration demonstrates the costovertebral joint with the radiate ligam::: and capsule removed to show the intra-articular ligament. which alta the head of the rib to the annulus.

Chapter 25 The Thoracic Spine

.

613

Myology of the Thoracic Spine

MOVEMENT

MUSCLE

MOVEMENT

MUSCLE

Extension

Spinalis capitis, celvicis , thoracic

Longissimus thoracis (bilateral)

Iliocostalis thoracis (bilateral)

Semispinalis thoracis (bilateral)

Rotatores thoracis (bilateral)

Multifidus (bilateral)

Interspinales

Levatores costarum

Rectus abdominis (bilateral)

Internal obliques (bilateral)

External obliques (bilateral)

Longissimus thoracic (unilateral , ipsilateral)

Iliocostalis thoracis (unilateral, ipsilateral)

Semispinalis thoracis (unilateral,

contralateral ) Multifidus (unilateral, contralateral) Intertransversarii (unilateral, ipsilateral ) Levatores costarum Iliocostalis thomcis (u nilateral, ipsi lateral) Semispinalis thoracis (uni lateral, contralateral) Rotatores thoracis (unilateral, ipsilateral) M ultifidlls (unilateral, contralateral) In tertransversarii (ipsilateral) Internal oblique (unilateral, ipsilateral) xternal oblique (unilateral, contralateral) Levatores costarum Longissimus thoracis (bilateral) Iliocostalis lum borum (bilateral )-lower ribs

Rib elevation

Iliocostalis cervicis (bilateral)-upper ribs Transversus abdominis

Flexion

Lateral flexion

Rotation

Hib depression

~itudinal ligament is taut, and the posterior longitudinal

ligament, ligamentum flavum, and the interspinous liga­ ment are relaxed. Lateral flexion of the thoracic spine occurs in the frontal plane and is approximately 20 to 40 degrees. 14 As the tho­ rax laterally flexes toward the light, the ribs on the light ap­ proximate, and the ribs on the left separate at their lateral margins. Rotation occurs about the transverse plane and is

Viscera compression Respiration

Diaphragm (inspiration) Intercostals (inspiration and e;':piration ) Rectus abdominis (expiration ) Internal/external obliques (expiration) Transversus abdomin is (expiration) Accessory muscles of respiration Inspiration Levatores costarum PectoraLis major Pectoralis minor Rhomboids Anterior, medial, posterior scalenes Serratus anterior Serratus posterior superior Sternocleidomastoid Subclavius Thoracic erector spinae Trapezius Expiration Iliocostalis lumborum Transversus thoracis Inspiration! Latissimus dorsi expiration Quadratus lLllnborum Serratus posterior inferior Maintenance of Intercostals rib cage shape

approximately 35 to 50 degrees in each direction. 14 Al­ though lateral flexion and rotation are coupled motions in the thoracic spine, the coupled motions depend on which motion is introduced first. Lee 2 states that, if lateral flexion is performed about the frontal plane, it is accompanied by contralateral rotation, whereas if rotation is performed about tlle transverse plane, it is accompanied by ipsilateral lateral flexion.

Range of Motion of the Thoracic Spine

INTERSPACE

Tl­ T2

TZ-T3 T3-T4 T4-T5 T5-T6 T6--T7 T7-T8 T8-T9 T9-TlO TlO-Tll Tl1-Tl2 Tl2-Ll

COMBINED FLEXION AND EXTENSION (limits of range in degrees)

UNILATERAL LATERAL FLEXION (limits of range in degrees)

LATERAL AXIAL ROTATION (limits of range in degrees)

3-5 3-5 2----5 2----5 3----5 2-7 3-8 3- 8 3-8 4--14 6--20 6--20

5 5-7 3-7 5-6 5-6 6

14 4- 12 5-11 5-11 5-11 4-11 4--11 6--7

3-8

4-7 4-7

3-----5

3-10

2--3

4-13 5- 10

2-3

2-3

614

Therapeutic Exercise: Moving Toward Functi on

Respiration13,14 The rhythmic movements of res~iration cause changes in the size and shape of the thorax.c;· (i The thoracic cavity ll1ay be increased in its transverse , anteroposterior, and ve rtical dimensions. The an teroposterior diameter of the thoracic cavity is increased by the elevation of the shaft of the lih , the forward and upward thllJst of the lib, and the minimal movement occuning at the sternal angle . The transverse diameter is increased by the rib rotation and the elevation of the ribs posteriorly. Contraction of the diaphragm in­ creases the vertical dimension of the thoracic cavity. During inhalation and exhalation, the primary rib move­ ments have been described as pump handle and bucket handle movements (Fig. 25-5 ). Pump handle movement is the result of the anterior aspect of a rib moving superiorly. Bucket handle movement is the result of the lateral aspect of the rib moving superiorly. During exhalation, the ante­ lior and lateral aspects of the rib l1Iove inferiorly. The in vivo osteokinematics and althrokinematics of th e ribs have not been well studied. Clinical hypotheses about the spe­ cific mechanics of these joints are beyond the scope of this

Common axis for "­ upper ribs

\ JOint \ '-

Vertebral body

.

Anterior

'-.

A Pump handle motion (anterior/superior motion of ribs)

Posterior

/'1

Costotransverse joint / " .......... I .1 -\ Costovertebral . joint \ ,\ \ Anterior

i

Vertebral body

1\

B Bucket handle motion (lateral/superior motion of ribs)

FIGURE 25-5. Pump and bucket handle motions of the ribs during inspira­ tion. (A) The arrow represents the common axis of motion for the upper ribs, which is close to the frontal plane. The upper ribs move upward and forward in a pump handle motion. (B) The axis of the lower ribs lies closer to the sagittal plane. The upward and lateral motion of these ribs is re­ ferred to as bucket handl e motion. (From Norkin CC, Levangie PK. Joint Structure and Function A Comprehensive Analysis. 2nd Ed. Philadelphia FA Davis, 1992.)

6.' u

tc

ANATOMIC IMPAIRMENTS The thoracic spine presents vvith problems distinctive to the region that occur in patients throughout the lifespan. For example, children need to be screened for scoliosis and abnormal kyphOSiS to identify increasing spinal curvatures. Older adults, especially women with osteoporosis, can de­ velop kyphosiS resultinK from painless thoracic vertebral body fractures. Unique functional. limitations and disabili­ ties result from impairments in the thoracic spine because of the effect of the rib cage and sternum on the underlying cardiopulmonary organs. A significant kyphOSiS or scoliosis can impair aerobic capacity and endurance, circulation. balance, and mobility. This section will discuss the struc­ tural changes in the thoracic spine that occur because of anatomic impairm ents. Th e nonstructural impairments are discussed later in this chapter in the section Impaired Pos­ ture and Motor Function.

Kyphosis

Posterior

Costotransverse / ~ joint , \lcostovertebral

text , b~t other sources can provide information on the topic.!

Taber's Cyclopedic Medical Dictionary defines kyphosiS an exagge ration of the normal posterior curve of th spinelS The causes of thoracic kyphOSiS may be either anatomic. th at is, resulting from changes in the stllJcture and shape of the spine itself, or postural. Children may exhibit kyphosis resulting frorn congenital spinal malformation. A kyphotic posture can be acquired from fractures of the anterior as­ pect of the thoracic vertebral bodies. This is one of the manifestations of osteoporosis. Scheuermann's disease is hereditary disorder that results in thoracic kyphOSiS from anterior wedging of the thoracic spine, occurring primaril~ in preteens and adolescen ts. The de finitions, diagnoses, and general treatment rec­ omm endations for these two conditions are disc-u5sed ir this section. Exercise guidelines for th e treatment 0 kyphOSiS are discussed later in the chapter.

Osteoporosis and Vertebral Compression Fractures Osteoporosi~ is a common disabling disease, particularly L older women, characterized by low bone density, skelet:. fragility, and fracture. 19 Because of the Significant morbid­ ity and mortality that results from complications related t osteoporosis, namely fractures of the hip and spine, ost, porosis is recognized as an important public heal problem. 2o Vertebral com pression fractures affect approxim ate 25% of postmenopausal women in the United States. 21 T prevalence of this condition steadily increases with advaru ing age, reaching 40% in women 80 years of age. 22 Wome:­ diagnosed with a compression frac ture of the vertebra ha a 15% higher mortality rate than those who do not exper: ­ ence frac tures 2 :3 Although less common in older me: compression fractures also are a major health concem this group.24-26 Because the age-group of those older t

y

b

aJ

m

b: t(]

Chapter 25 The Thoracic Spine

65 years is n?w .the fastest growing segment of the US pop­ ulatIOn , the ~ncldence of this age-specific fracture is likely to increase. 2 1 Pathophysiology and Risk Factors

Vertebral compression fractures are recognized as the hallmark of osteoporosis,28 and mallY of the risk factors are the same. 29 Risk factors are categorized as those not modifiable and those that are potentially modifiable. Nonmodifiable risk factors include advanced uge , female gender, Ca~casian race, presence of dementia, suscepti­ blhty to fallmg, history of fractures in adulthood, and his­ tory of fractures in a first-degree relative. 27 Potentially modifiable risk factors include bein a in an abusive situa­ tion , alcohol or tobacco use, presen ce of osteoporosis or estrogen deficiency, early menopause or bilate ral ovariec­ tomy, premenopausal amenorrhea for more than 1 year, frallty, ImpaIred eyeSight, insufficient physical activity, low body ~eight, and dietary calcium or vitamin D deficiency.21 Acute fra. ~llres occur when the weight of the upper body exceeds [he ability of the bone within the vertebral body to support the load. Generally, some trauma occurs with each compression fracture. In cases of severe osteo­ porosis, however, the came of trauma may be simple, such as VlgOroUS sneezing, or lifting a light ohject, or the trauma may be caused by muscle contraction:1o Up to 30% of com­ pression fractures occur while the patient is in bed al In cases of moderate osteoporosis, more force or trauma is re­ quired to create.a fracture, such as falling off a chair, trip­ pmg, or attemptmg to lift a heavy object. The applied force usually causes the anterior part of the vertebral body to crush, forming an anterior wedge frac­ ture. The midcUe column remains intact and may act as a hinge. This results in loss of anterior height of the vertehra while the posterior height remains unchanged. As the col­ lapsed antelior vertebrae fuse together, the spine bends forvllard , causing a kyphotic deformity. Becallse the major­ Ity of damage is limited to the anterior vertehral column, the fracture is usuall>:: stable and rarely associated with neu­ rolOgiC compromise. 32 Spinal compression fractures can be insidious and may produce only modest back pain early in the course of pro­ gressIve disease. Over time, multiple fractures may result in Significant loss of height. Progressive loss of stature re­ sults in length-tension changes in paraspinal musculature and prolonged active contraction for maintenance of pos­ ture, resulting in the potential for pain from muscle fatigue. This pain may continue long after the acute fradure has healed. 33 Commensurate with the thoracic kyphOSiS, the lib cage presses down on the pelviS, redUCing thoracic and abdomi­ nal space In severe cases , this results in impaired pul­ monary function, a protuberant abdomen , and, because of c0l11f4ressed abdominal orguns , early satiety and weight loss. ComplicatIOns from compression fractures are sum­ marized in Table 25-5 n Preventi on and Intervention

With respect to vertebral compn:ssion fradures secondary to osteoporosis, the tl1Prapist must be directed by the re­ ferring physician as to whether the fracture is stable or un-

615

Complications from Compression

Fractures of the Spine

Constipation Bowel obstruction Prolonged inactivity Deep venous thrombosis Increased osteoporoSiS Progressive muscle weakness Loss of independence KyphOSiS and loss ofhei).\ht Crowding of internal

RespiratOlY decreaseatelectasis, pneumonia Prolonged pain Low self-esteem f<~motional and social problems Increased nurSing home admissions Mortality

organs

~tabl~. 27 , 1,0 A stable fracture will not be displaced by phys­

IOlogIC forces or movement. Fortunately, compression fractures are normally stable secondary to the impacted nature. Traditional treatment is nonoperative and conser­ vative. Patients ar~ treated witb a short period (no more tha~ a fev" days ) of hed rest. Prolonged inactivity should be aVOIded, espeCially in elderly patients. Treatment of pain control can be in the form of oral or parenteral analgesics , muscle relaxants, external back braces, and physical ther­ apy modalities . Patients who do not respond to conservative treatment or who continue to have severe pain may be candidates for surgical intervention. However, most patients can make a full recovery or at least Significant improVl'ments in 6 to 12 weeks and can return to a normal exercise program after the fracture has fully healed. A well-balanced diet, regular exercise, calcium and vitamin D supplements,:16 smoking cessation, an? medications to treat osteoporosis may help prevent addItIOnal compression fractures. Age should never preclude treatment. There is .now good evidence that diagnosing and treating osteoporosIs ·does mdeed reduce the incidence of com­ pression fractures of the spineY-39 Regular activity and muscle strengthening exercises have been shown to de­ crease vertebral fractures and back pain 40 Inactivity leads to bone loss, but weight-bealing exercise can reduce bone loss and increase bon mass . The optimal type and amount of physical activity that can prevent osteoporosis has not been established , but moderate weight-bearing exercise such as walking is recommended. Resisted upper extremity exercise IS also recommended to induce wei,rht-bearing stress on the spine and wrist. Exercises to rcdu~ the stress of kyphOSiS are discussed in a later section of this chapter (see Therapeutic Exercise Intervention for Common Diag­ nosis: Kyphosis ). vleasures to prevent falls must be initiated by patients and their caregivers , because a fall in this population can lead to morbidity or death from the secondary effects of immobilization and reduced activity. SpeCifiC exercise technillues addreSSing impairm ents related to balance are addressed in Chapters 7 and 20. Table 25-6 lists items that should be assessed when determining what preventive measures should be followed 41

616

Therapeutic Exercise Moving Towa rd Function

Items to Assess in Determining Risk for Falls in the Elderly Avoidance of restraints Neurologic function; cortical, extrapyramidal , and cerebelhlr functions ; lower extremity peripheral nelves; proplioccption ; reflexes Balance assessment

Gait Muscle strength Cardiac function, cardiac rhythm, heart rate, orthostatic pulse, and blood pressure Vision

Scheuermann's Disease Scheuermann's disease, or Scheuermann's kyphosis, is the most frequent cause of hyperkyphos is of the thoracic and thoracolumbar spin e during adolescence 42 Different crite­ ria have bee n suggested for diagnosing classic Scheuer­ mann's dis eas e. S0rensen43 in 1964 defined Scheuer­ l11
Intervention is usually limited to patients with a painful de­ formity, documented progression, and at least 2 years of growth remaining. Younger children wi th a mild deformity can be initially treated with a program of exercise to strengthen spinal extensor muscles (Fig. 25-7) and stretch the hamstring (see Fig. 20-24A), pectoralis major (see Fig. 26-1 ), and superior fibers of the rectus abdominis muscles and an­ terior longitudinal ligament (see Self-Management 18-7: Prone Press-up Progression , level II, in Chapter 18). Though there is a paucity of research on the effect of spinal exercise

FIGURE 25-6. Cobb method for measurement of a scoliosis curve. (FrO fTI Ri cha rdson M. Approaches to Differential Diagnosis in Musculos keleta Imagi ng. 1994.Available: http!lwvvw.radwashington.edu/ Books/NewAr . proach/Scoliosis/CobbAngle7.g il)

on spinal parameters in Scheuermann's disease , one stud> did demonstrate the beneficial effect of regul ar exercise. 5O • In adolescents , Scheuermann's disease is effectiyel managed with braCing until skeletal maturity has bee reached (see Scoliosis section ). Contraindications to brae treatment include curves greater than 70 degrees , seye' apical wedging, and a rigid curve. Surgery (spinal fusion considered as an option for patients with severe deformi and disabling pain and as necessary in cases of neuroloc. compromise. At any stage in life , management of th suiting kyphOSiS can be effective in preventing increas postural kyphoSiS overlaid over the anatomic kyphOSiS < Therapeuti c Exercise Interventions for Common DL_­ noses: KyphoSiS ).

A

B

c

FIGURE 25-7. Activity promoting strength of the thoracic spine e>.~ in the short range in various start positions. In each position, the pc: = instructed to maintai n neutral cervical, thoracic, and lumbar s pir~ tions using co re activation strategies (see Chapters 18 and 24 for ::.; on core activation strategies for the lumbar and cervical regi ons, r=. tively). Supine (A), resisted upper extremity extension from a flexe':' tion using elastic tubing The thoracic extensors stabilize against t~~ ion moment. Sitting (8) and stand in g (e) upper extremity ee" lowering from a flexed position stimulates thorac ic extensor activity ~ bilize aga inst a flexion moment.

Chapter 25 The Thoracic Spine Spinous process deviated to concave side Lamina thinner and vertebral canal narrower on

617

DISPLAY 25·'

Rib pushed posteriorly and thoracic cage narrowed

Rib pushed laterally and anteriorly convex side Concave side FIGURE 25-8. Typical distortion of the vertebra and ribs in thoracic scol­ iosis as seen from below.

Scoliosis Scoliosis is a lateral curvature of the spine, involving lateral flexion and rotation of the vertebrae of the involved region. On the concave side of the curve, the ribs apprOximate, and on the convex side, they are widely separated. As the verte­ bral bodies rotate, the spinous processes deviate toward the concave side, and the tibs follow the rotation of the verte­ brae (Fig. 25-8). The posterior tibs on the convex side are pushed posteriorly, causing the characteristic rib hump seen in thoracic scoliosis. The anterior tibs on the concave side are pushed anteriorly. Scoliosis can also be caused by morphologic changes in the vertebral bodies and interver­ tebral disks (Fig. 25-9) . Scoliosis can be classified into three types (see Display 25-1): non structural, transient structural, and structural. Scoliosis resulting from a postural impairment is nonstruc­ tural; that is, there are no morphologic changes in the bones. It is this type of scoliosis that stands the best chance of a positive outcome through exercise, changes in postural habits, and compensatol)' devices such as shoe lifts. With structural scoliosis, which makes up the majority the cases, . there is little evidence to support the use of exercise inter­ vention. It is therefore imperative to distinguish between the two types, structural and nonstructural, so that the ap­ propriate intervention is chosen. In the absence of radio­ lOgic evidence of structural changes or progressive curves,

Classification of Scoliosis

Nonstructural scoliosis Postural scoliosis Compensatory scoliosis Transient structural scoliosis Sciatic scoliosis Hysterical scoliosis Inflammatory scoliosis Structural scoliosis Idiopathic 170% to 80% of cases) Congenital Neuromuscular Poliomyelitis Cerebral palsy Syringomyelia Muscular dystrophy Amyotonia congenita Friedreich's ataxia Neu rofibromatosis Mesenchymal disorders Marfan's syndrome Morquio's syndrome Rheumatoid arthritis Osteogenesis imperfecta Certain dwarves Trauma Fractures Irradiation Surgery

an exercise approach is warranted. These cases are dis­ cussed later in this chapter. The majority of scoliosis cases have no known cause. Id­ iopathic scoliosis accounts for about 80% of all cases of scol­ iosis and has a strong female predilection (7:1 ).51 It can be subclassified into infantile, juvenile, and adolescent types, depending on the age of onset. The adolescent type is the most common idiopathic scoliosis in the United States. The prevalence in children ages 9 to 15 is 1. 7% . Structural scol­ iosis can also result from congenital vertebral anomalies (Fig. 25-10 ). Discovery of these anomalies should prompt screen-

~ ~ 00 00

JE

FIGURE 25-9. Coronal view of a scol iotic spine. The height of the verte­ brae and intervertebral disks is decreased on the concave side.

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~

~

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9f2P

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~ ~ Partial Complete Unilateral Bilateral unilateral unilateral failure of failure of failure of failure of segmentation segmentation formation formation (congenital (block vertebra) (wedge (hemivertebrae) bar)

vertebrae)

FIGURE 25-10. Congenital vertebral anomalies causing scoliosis.

618

Therapeutic Exercise: Movi ng Toward Function

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8 El

ISfJ r ,,,­ Dr ""'Ir

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Thoracic Thoracolumbar curve curve FIGURE 25-11 . Patterns of scoliosis.

~

D

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~r ~r ,f"" ,f"" ,r

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-..,r

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Double major curve

ing for associated cardiac, genitourinary, or other vertebral anomalies. Other causes of scoliosis include trauma, neurofi­ bromatosis, and other neuromuscular disorders.51 Scoliosis is generally desclibed in terms of the location of the curve or curves (Fig. 25-11). The direction of the curve is named for the convexity of the curve, and each curve of a double curve must be named. The most com­ monly used radiographic assessment of the magnitude of the curves is the Cobb method (Fig. 25-6). 'iVhen report­ ing the angle of the curve, it is important to mention that the Cobb method was used and to list whicll end verte­ brae were chosen; tbis illformation allows the measure­ ment to be consistent with follow-up radiographic studies. Another goal of radiographic examination is to determine the physiologic or skeletal maturity of the patient. This can help determine the chances that the degree of curva­ ture will increase.

!EXAMINATION AND EVALUATION A comprehensive examination, including the history, sys­ tems review, and tests and measures, enables the physical therapist to determine the diagnOSiS (based whenever possi­ ble on impairments, functional limitations, and disabilities), prognosis, and interventions. 2 '11 ;:2 The physical therapist must follow an organized, sequential approach to avoid omit­ ting crucial information that may prevent an accurate inter­ pretation of the findings. In addition, a detailed history must be taken to determine the nature and extent of the dysfunc­ tion. Throughout this process, good listening skills and skill in asking questions to promote open communication in an effective, efficien t Illanner is necessary. Beyond the general data generated from a patienUclient history as defined in Chapter 2, the following information is impOltant to obtain from a patient with impairment, functional limitation, or dis­ ability involVing the thoracic spine.

History Because the thoracic region is a site of many visceral causes and sources of pain (e.g., chest pain from acute myocardial infarction, pain at the costovertebral angle of the lower tho­ racic segments originating in the kidneys ), questions must be asked which will help determine whether or not physi­ cal therapy is the appropriate management option for the

patient. The findings from a thorough history can indicate possible nonmechanical sources of symptoms (see Ap­ pendix 1). If the therapist suspects that the pain is derived from nonmechanical or visceral sources, the patient should be referred to the appropriate medical practitioner.

Systems Review A systems review prOVides a qUick screen of the pertinent systems. If problems are observed during this review, more detailed tests should be done as the next phase of the ex­ amination process. Information about disorders of other systems (e.g., cardiopulmonary, genitourinary, gastroin­ testinal) that may mimic thoracic musculoskeletal disorders should be obtained during the medical histolY portion of the examination and used to guide the subsequent systems review. For example, a systems review of the cardiopul­ monary system includes screens of the lungs (e.g., respira­ tory rate , breath sounds), heart (e.g., heart rate, heart sounds), and blood pressure. A systems review of the skeletal system is also called a .scan examination. The scan examination is a qUick proct;'­ dure that includes tests and measures listed in Display 25­ 2. Because the thoracic spine spans the upper and lower quadrants, screens of both regions are advisable, particu­ larly as they relate to the transitional zones (i.e., C7-Tl an d T12-Ll ). Chapter 24 prOvides a more detailed explanation of the upper quadrant scan examination, and Chapter 1 explains the lower quadrant scan examination. Kyphotic in dividuals, especially elderly women ,vith a history of osteoporosis, should be screened for vertebral body fractures. Individuals with excessive spinal stiffne should be examined radiographically for ankylosing spondylitis. To be considered Significant, radiographiC findings must be correlated with the clinical examination findings. Additional medical screening is highly indicated in in di­ viduals whose symptoms do not appear to be mechanical·

DISPLAY 25·2

Outline of a Scan Examination Observation Range of motion Motor assessment Sensory assessment Vascular status Reflexes Palpation Clearing tests Upper quadrant (see Chapters 24 and 26) Foraminal encroachment Compression or distraction Upper limb tension test (ulnar bias may indicate upper thoracic pathology) Thoracic outlet syndrome tests Lower quadrant (see Chapters 18 and 20) Prone knee bend (may indicate low thoracic pathology) Straight-leg raising Slump test Hip flexion, abduction, external rotation (FABER) Scour test

Chapter 25: The Thoracic Spine

nature, who have a history of cancer, risk fa ctors for vascu­ lar disease, a history of exposure to tuberculosis, or bilateral lower extremity neurologic complaints with or without re­ ports of incontinence (see Appendix I ). In cases such as these where physical thentpy is not indicated, referral to the appropriate health care provider is required. It is im­ portant to understand where the proble m may lie, because the decision to refer on an emergency basis rath r than on a routine follow-up visit with the physician will depend on the system involved, t11e nature and severity of the com ­ plaint, and the clinis:al findings.

Tests and Measures The next step in the examination process is the selection of one or more tests and measures to ascertain the impair­

619

ments , functional limitations, and disabilities of the patient. This determination leads to the development of the final diagnosis and the prognosis , which should gUide the physi­ cal therapist's choice of management optio ns. The selec­ tion of tests and measures, like the choice of questions asked, should be driven by the provisional diagnosis list. Each test or measure should contribute to the process of i­ ther confirming or disconfirming a potential cause of the problem. The choice of performing any tests and measure there­ fore depends on the results of the history and systems re ­ view. T 'sts for regions other than the thoracic spine- for example, the IUl11bopelvic, hip, or cervical areas- may he chosen should the provisional diagllos is list require them . Display 25-3 lists impairments that may require examina­ tion in patients with thoracic complaints. For a detailed

DISPLAY 25-3

Required Tests and Measures for Thoracic Spine Examination Aerobic capacity: Assessment of vital signs may be necessary, particularly when working with patients with a cardiopulmonary disorder or patients at risk for falls. Ergonomics and body mechanics: The ergonomics of the patient's work stationls) can provide vital information regarding the pathomechanics of the condition. Observation of the activities of daily living and the patient's occupational and recreational movement patterns can reveal impairments in movement in the thoracic and related regions. For example, when reaching across the body one might observe excessive thoracic flexion and lateral flexion that may occur as compensatory movements for insufficient hip and thoracic rotation . Gait, locomotion, and balance; Assessment of these skills can determine risk for falls. Joint mobility and integrity: Arthrokinematic testing of the zygapophyseal, costotransverse, sternocostal, and sternochondral joints. Motion findings in these tests should correlate with osteokinematic findings. Specific testing of osteokinematic function of the ribs can be assessed during inhalation and exhalation.1 Motor function: Altering impaired movement patterns and ob­ serving for an associated change in symptoms will assist in determining the pathomechanics of the symptoms. For ex­ ample, in the case of compensatory thoracic flexion and lat­ eral flexion resulting from reduced hip and thoracic rotation, having the patient rotate the hip and thoracic spine to the limit of mobility while thoracic flexion and lateral flexion are restricted should alter the m:lVement. This can be achieved manually by the therapist or actively if the patient is able to make the change from verbal instruction alone. Ifthe symp­ toms are reduced with the new movement pattern, the flex­ ion or lateral flexion movement patterns are assumed to be contributing to the symptoms. Muscle performance: Include muscle performance tests to de­ termine presence of nerve root dysfunction in the cervi­ cothoracic and thoracolumbar regions. Manual muscle testing can identify imbalances in muscle performance be­ tween synergists and agonist-antagonist muscle pairs in the trunk and shoulder girdles (see Chapters 18 and 26). Pain tests and disability measures: The Functional Rating In­ dex90 (measures the magnitude of clinical change in spinal

conditions). Oswestry,91 and Roland-Morris Disability Ques­ tionnaires 92 Idisability scales developed for the cervical and lumbar spines that, although not specific to the thoracic spine, can be used to gain insight into the condition's effect on the patient's life; see Chapters 18 and 24). Posture: Particularly as it relates to the head and neck and lumbar-pelvic-hip complex in standing, sitting, and recumbent positions; signs of asymmetry; and scoliosis. Range of motion and muscle length: Assess the quality and quantity of motion in general as well as intersegmental mobility during active and passive osteokinematic thoracic and upper extremity movements; observe for localized areas of hypermobility with associated areas of hypomobility. Assessment of unilateral upper extremity elevation can assist in the assessment of mobility of the upper thoracic region . For example, upper thoracic extension and rotation to the ipsilateral side should accompany upper extremity arm elevation.2 If articular function in a specific joint is found to be normal, and yet overall mobility is limited,lack of myofascial extensibility can be suspected as a primary cause. For example, a stiff or short right external and left internal oblique can limit right thoracic rotation . If this were the case, accessory joint play assessment would reveal normal joint mobility. Sensory integrity; Function of the intercostal nerves; special tests, such as those for thoracic outlet syndrome and neural tension . Ventilation, respiration, and circulation: Observation of breathing patterns can be very useful in fully understand­ ing underlying contributing factors to numerous diagnoses such as kyphosis related diagnoses and thoracic outlet syndrome. Assess the quality le.g., proper pump and bucket handle motions of the rib cage, looking for move­ ment in all three directions) and quantity Irate, inspirome­ try) of respiration. 2 Other: Radiographs Idiagnosis and curve angle in scoliosis, Scheuermann's disease, and kyphosis related to osteoporosis, signs of ankylosing spondylitis); magnetic resonance imaging Isoft-tissue pathology such as herniated nucleus pulposus); additional medical screening for visceral sources of thoracic pain Isee Appendix 1).

620

Therapeutic Exercise: Moving Toward Function

e»''Planation of each test and measure the reader is referred to Magee 's text on orthopedic physical assessment. 12

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENTS The basic strategy in designing the plan of care for a pa­ tient or client is to identify the impairments that relate to the observed posture or movement pattern, functional limitation and disability, and address each causative im­ pairment as necessary. Therapeutic exercise interventions for the thoracic region include activities and techniques that address impairments that directly and indirectly af­ fect thoracic spine function. Comprehensive treatment of thoracic functional limitations and impairments requires treatment of related areas, including the cervical spine , shoulder girdle, and lumbopelvic region. The ultimate goal of all therapeutic exercise interven­ tions should be to regain maximum pain-free function. This requires addreSSing impairments contributing to the faulty movement that is related to the functional limita­ tion and disability. Analysis of complex movements (e.g., gait, forward bending, reaching, rising from sitting, ascending or descending stairs) requires division of the movement into component parts to analyze the contribu­ tion from each segment or region involved in the movement. The examination and evaluation should reveal specific regional physiologic impairm en ts such as hypo­ mobility in the hips or impaired muscle performance of the shoulder girdle. Combining the information obtained from movement analysis and specific examination of se­ lected regions can determine which impairments need to be addressed to improve the strategy of movement for the given task. For example, a goal of maintaining a neutral spine while walking for an individual with pain related to thoracic kyphosis may require improving anyone or all the impairments listed in Display 25-4. In an appropriate treatment progression, component impairments are first addressed, followed by integrated movements with relatively simple activities or tech­ niques, progressed to more challenging activiti es or techniques, and then progressed to complex, integrated functional movement patterns. Figure 25-12 demon­ strates an integrated movement in sidelying, which is gravity lessened for the hip flexors and gravity assisted for the oblique abdominal muscles and spinal extensors. This movement pattern can be progressed to the upright position of the swing phase of step-up (Fig. 25-13) and eventually into the s'vving phase of gait after the stance phase of gait components have adequately improved through another set of exercises. Because the thoracic spine lies between the shoulder girdle and lumbar-pelvic-hip complex, correction of move­ ment impairments of these regions may be necessary to im­ prove the movement pattern of the thoracic spine. Move­ ment impairments at the foot and ankle also can contribute to impairments in the thoracic spine. The link between the foot and the thoracic spine is reviewed in a subsequent sec­ tion on scoliosis. Chapter 22 details the exercise prescrip­ tions for impai rments in the foot and ankle.

DISPLAY 25-4

Component Impairments Related to Thoracic Kyphosis During Gait Stance Limb • Initial contact: Hip extensor strength is necessary to prevent backward lean by means of lumbar lordosis. Lumbar lordosis can lead to thoracic kyphosis. • Terminal stance: Hip flexor length and hip joint extension mobility are necessary to prevent lumbar lordosis and secondary thoracic kyphosis. Swing Limb • Hip extensor length, hip joint flexion mobility, and hip flexor strength are necessary to perform proper hip flexion during swing and prevent backward lean by means of lumbar lordosis to advance the limb. Lumbar lordosis can lead to

thoracic kyphosis.

f

Trunk Balance between length and performance of oblique

abdominal or spinal extensor muscles is necessary to

prevent thoracic kyphosis.

• Counterrotation between the pelvis and trunk is necessary to promote optimal trunk function during gait to prevent compensatory thoracic flexion.

AGURE 25-12. This exercise promotes simul taneous hip flexion and trunk counterrotation to prepare for the complex movement of the swing phasE' of gait on the left. (A) The start position is supine with hip and knee fl ex­ Ion. (8) The end position is sidelying with hip and knee flexion and left trunk rotation.

F

Chapter 25 The Thoracic Spine

621

A B

FIGURE 25-13. During thes wing phase of the step-up, trunk counterrota­ tion can be emphasized to facilitate the complex movement during the swing phase of gait

Impaired Muscle Performance Patients with impairments, functional limitations, or dis­ abilities related to impaired muscle performance require resistive exercise with dosage parameters targeted toward a goal of increased force or torque production, power, or en­ durance (see Chapter 5). Any of the muscles listed in Table 25-1 could be affected. The cause ofthe altered muscle per­ formance must be determined to ascertain the appropriate intervention to treat the impairment. The intervention plan developed is specific to the source or cause. There are sev­ eral possible sources of reduced force or torque production: • Neurologic impairment or pathology (e.g., peripheral nerve injury, nerve root injury) • Muscle injury or strain • Disuse resulting in atrophy and general deconclition­ ing • Length-associated changes resulting in altered length-tension properties

Neurologic Impairment or Pathology Intervention \iVhen muscle performance is impaired because of neuro­ logic injury or pathology, the neural input must be restored for muscle performance to improve. If the nerve injury or pathology is permanent and paresis or paralysis is the out­ come, the clinician must consider the effect of the resulting muscle weakness and subsequent adaptive shortening or contracture in the opposing muscles. In the case of paresis, the clinician must consider the effect of stretch on the weak muscle because of antagonist action superimposed on the initial weakness caused by the nerve damage. If reinnerva­ tion is latent, these same considerations must be heeded during the recovery process. \iVeak muscles must be pro­ tected from overstretch with proper support and stimulated with appropriate-dosage resistive exercise in the short range. The strong muscles must be stretched to maintain proper extensibility and prevent contracture and deformity. One example of impaired muscle performance related to neurologic injury or pathology is reduced muscle force production in the diaphragm resulting in faulty breathing

AGURE 25-14. (A) Lateral trunk flexion stretch is aSSisted by gravity over a gymnastic ball. (8) Lateral trunk flexion while standing against a wall with arms overhead. The wall guides movement in the frontal plane. The arms-overhead position facilitates stretch to the intercostals. Diaphrag­ matic breathing into the stiff region can augment the stretch.

mechanics. Diaphragmatic breathing exercises cannot be effective until the source of the weakness is appropriately addressed. Because the diaphragm is innervated by the phrenic nerve (C3-C5), treatment of any cervical dysfunc­ tion at these levels may be necessary to improve diaphrag­ matic function. Subsequently, appropriate diaphragmatic breathing must be taught along with stretch of the lateral trunk and intercostal muscles (Fig. 25-14). The lateral trunk and intercostal muscles may become stiff because of the unilateral rib approximation that may result from inad­ equate rib expansion, causing weakness in the diaphragm. In the case of paraplegia with thoracic spine involve­ ment, impaired respiration may result. Full excursion of chest expansion should be encouraged via deep breathing exercises using the diaphragm. Resistance can be applied to the chest walls, diaphragm, and sternum via manual con­ tacts using principles of proprioceptive nemomuscular fa­ cilitation (see Chapter 14) or using equipment. For exam­ ple, inspiration can be facilitated Ilsing elastic bands wrapped around the chest. Resistance can be given to the diaphragm by plaCing weight on the abdomen. The patient should be instructed to take full, deep breaths.

Muscle Strain or Injury Causes

Trauma, such as a blow to the chest or a sudden rotational injury sustained in a motor vehicle accident, can obviously lead to muscle injury or strain. An insidious-onset strain can also occur in muscles surrounding the thoracic region. Possible mechanisms of gradual insidious-onset muscle strain can include overuse or overstretch, One example of overuse in the thoracic region is pro­ vided by the scalene muscle group, particularly the anterior scalene. The actions of the anterior scalene include cervi­ cal flexion, ipSilateral cervical lateral flexion, contralateral cervical rotation, and elevation of the first rib (i,e., acting as an accessory muscle of respiration). Overuse of the anterior scalene can result from underuse or weakness of the deep cervical flexors (i.e., longus colli and capitis and rectus capi­ tis anterior), other contralateral cervical rotators (i.e., deep cervical rotators, semispinalis cervicis, sternocleidomas­

622

Therapeutic Exercise: Moving Toward Function

toid, or upper trapezius), or primary muscles of inspiration (Le. , diaphragm, levator costarum , and intercostals ). Chronic overuse can lead to stiffn ess or adaptive shorten­ ing of the anterior scalene, which can contribute to eleva­ tion of the first rib. Elevation of the first rib can disrupt cer­ vicothoracic joint mechanics and contribute to thoracic outlet syndrom e (see Therapeutic Exercise Interventions for Common Diagnoses: Thoracic Outlet Syndrome later in this chapter). Another example is middle and lower trapezius strain, which refers to the painful upper back condi tion resulting from gradual and con tinuous tension on the middle and lower trapezius muscles. s The strain in these muscles is caused by overstretch resultin g from a habitual position of forw'ard shoulders (see Chapter 26), kyphosis, or a combi­ nation of these two faults. Treatment of the thoracic region must include treatment of the impairments related to the postural fault or the kyphosis to reduce the habitual stretch on the tissues (see Posture and Movement Impairment and Kyphosis sections). Intervention

Treatment of OvellJSe of a particular muscle group must improve muscle peiformance of underused synergists and address the posture and movement patterns contributing to excessive use. In the anterior scalene example described above, instructing the patient in proper diaphragmatic breathing (see Patie nt-Related Instruction 23-2: Diaphrag­ matic Breathing) rathe r than using accessory muscle strate­ gies may be an important intervention to reduce the stress placed on the anterior scalene. The deep neck flexors are of­ ten weak, particularly after a neck injury (such as whiplash), and need to be strengthened in isolation of the overused muscle(s). Chapter 24 provides exercises in the Impaired Muscle Performance section to address ,"veak cervical flex­ ors. Stretch of the anterior scalene should be performed with caution. Stabilization of the first rib is essential so that gen tle active ROM of the cervical spine in ipsilateral rota­ tion can stretch the scalene without rib elevation or cervical anterior shearing (Fig. 25-15 ). The patient should be in­ structed to avoid chronic postures of neck ipsilateral side

FIGURE 25-15. It is important to stabilize the first rib while stretching the anterior scalene . Aher the rib is stabilized. gentle active range of motion into ipsilateral rotation stretches to the same side anterior scalene without undue cervical shear or first rib elevation.

FIGURE 25-16. Resting a telephone on an elevated shoulder wi th the neck in lateral flexion and opposite rotation can cause shortening and overuse of the anterior scalene muscle.

bending and contralateral rotation to avoid overuse of the muscle in the short range (e.g. , talking on the phone for pro­ longed periods without use of a headset) (Fig. 25-16).

Disuse Resulting in Atrophy and General Deconditioning Disuse and deconditioning can be caused by illness, immo­ bilization , sedentary lifestyle, or subtle shifts in muscle bal­ ance from repetitive faulty movement patterns. Progressiv resistive exercises for the upper body can address general disuse and deconditioning. Initially, the weight of the limb alone can provide enough stimulus for strength gains in th severely deconditioned individual. ProgreSSion in small in­ crements is recommended because the upper body muscle are smail compared with those of the lower body, and ex ­ cessive resistance added prematurely may promote muscl imbalance by strengthening the dominant synergists or an­ tagonists (see Chapter 26). Abdominal and back extensor strengthening (see Fig. 25-7) may be indicated to impro\'{' the alignment, movement, and stabilizing function of the thoracic region . Chapter 18 describes proper exercise pre­ scription for the abdominal muscles. Muscle function in response to injury has not been as well studied in the thoracic spine as it has in the lumbar spine. However, one can extrapolate lumbar findings to the thoracic spine in an attempt to make educated decision s re­ garding thoracic spine management. Many authors han: highlighted the importance of the lumbar multifidus mus­ cle in providing dynamic control;'·1-56 and there is cumula­ tive evidence that the cross sectional area of the paraspinal muscles is smaller in patients with chronic51 --60 and postop­ erativeGl,G210w back pain. Furt~ermore , it has been ShO\\11 that recovery of multifidi muscle function in the lumbar spine is not automatic after resolution of the pain.f):J This at­ rophy may permit spinal hypermobility and instability and therefore be an important factor to consider in treatment 0 persons with spine-related pain G 4 There is general consensus in the lite rature supporting the need for active reconditioning exercise in the treatment of spine pain.65 Add to these findings the natural te nden c~ toward kyphOSiS (from the effects of gravity, aging, and ha­ bitual usage patterns ) and it seems clear that thoracic ex­ tension strength should be an emphaSiS in any plan of car, for the region. In addition to strength, because the thoracic extensors are pIimarily postural muscles, any exercise plan

e

Chapter 25 The Thoracic Spine

623

should be dosed so as to improve muscular endurance. Un­ fortunately, there is little agreement on which exercise reg­ imens are most effective. The use of static stabilization training l1as been advocated by Jull and Richardson 66 as an ideal means of improving the recruitment of back muscles capable of enhancing spinal stability, particularly the mul­ tifidus. This text describes a series of specific exercises to promote spine stability in Chapter 18 (see Patient-Related Instruction 18-1 and Self-Management 18-1 and 18-2). The exercises presented in Chapter 18 can be extrapolated to the thoracic spine by adding the focus on thoracic spine alignment and thoracic multifidus activation. Progression of these exercises to use of thoracic multifidus activation during activities of daily living (ADLs ) and occupational and recreationaJ activities are necessary for the best func­ tionaloutcome.

Length-Associated Changes Resulting in Altered Length-Tension Properties Causes

Subtle imbalances in muscle length can lead to length­ associated strength changes and positional weakness of one synergist compared with its counterpart or its antago­ nist muscle group. For example, in the thoracic spine, the erector spinae and upper rectus abdominis are susceptible to length-associated strength changes from chronic kyphotic posture. The thoracic erector spinae are vulner­ able to overstretch, and the upper rectus abdominis is sus­ ceptible to adaptive shortening. Overstretching and short­ ening can lead to conditions "vithin the thoracic region such as joint impairments and respiratory dysfunction. The muscle imbalance can contribute to conditions in the adjacent cervical and lumbopelvic areas, and soft-tissue dysfunction from the kyphOSis-lordosis or swayback pos­ ture (see the Kyphosis section). Intervention

Treatment of muscle length imbalance requires a twofold approach of strengthening the weak and over­ stretched muscle group (for example, the thoracic erector spinae ) in the shortened range (see Fig. 25-7; Fig. 25-17), and stretching adaptively shortened muscle groups (e.g., the upper rectus abdominis ). Supportive taping (see Fig. 25-18 ) can be used as an adjunctive measure to facilitate positive length-associated changes. Patient-related instruc­ tion aimed at correcting posture and movement patterns that perpetuate these length-associated changes is required to prevent recurrence of conditions caused by this muscle performance impairment.

FIGURE 25-17. This exercise stretches superior fibers of the external oblique muscle at the rib angle and the shoulder adductors and it provides resistance to the spine extensors and scapular upward rotators in the short range Standing with the back to the wall in a neutral spine position, the patient raises her arms raised in horizontal abduction. The elbows are for­ ward of the wall to maintain the arms in scapular plane. Deep diaphrag­ matic breathing is performed in this position. The arms can slide up the wall as the length of the pectoralis major allows. The lower abdominals contract to maintain the lumbar spine and pelvis in neutral alignment

each case (joint mobilization versus soft-tissue mobilization, for example). The exercise intervention, on the other hand, \viII typically address both causes. The general plan for ex­ cessive motion (hypermobility) is to stabilize \vith muscle function while addreSSing biomechanical factors , such as adjacent hypomobile areas , that transmit increased forces to and produce excess motion in the problem area. Finally, op­ timal function requires trunk stability during extremity movements. Therefore, appropriate thoracic exercise man­ agement \vill progress from active extremity movement to resisted extremity exercise, while demanding concurrent trunk stability.

Impaired Range of Motion, Muscle Length, and Joint Mobility/lntegrity Optimal function of the thoracic region requires full and symmetrical cardinal plane motion as well as "vith combined motions. In addition, full thoracic spine and rib motion dur­ ing breathing should be the goal. The examination should delineate joint versus soft-tissue movement impairments and the plan of care be designed appropriately. Lack of mo­ tion (hypomobility) can be the result of either joint or soft­ tissue impairments, and manual intervention will differ in

AGURE 25-18. Longitudinal tape spanning the kyphosis. applied in four­ point kneeling to capture neutral spine alignment, can prevent excessive thoracic flexion.

624

Therapeutic Exercise Moving Toward Function

Hypermobility Causes

The rational therapeutic exercise intelvention plan for hypermobility of the thoracic spine must consider the mechanism or cause of the hypermobility. Spinal mobility must be examined both glohally (e.g. , the thoracic spine as a whole ) and locally (e.g. , segmentally). Optimal global spinal movement incorporates motion contributions from each spinal level. Lack of motion in one segment will trans­ fer the mechanical stress to adjacent movement segments. The segments experiencing greater stress over time will be­ come hypermobile. Tissue responses to the increased load may render the region symptomatic. In this case, interven­ tion must address the local impairments. If the underlying cause is impairment in habitual posture or repetitive move­ ment, the clinician must consider the integrated relation­ ship between the foot and ankle, pelviC girdle, trunk, and upper extremity in developing a plan of care. If there is a his­ tory of macrotrauma and the expected healing time has been surpassed, the clinician must consider issues con­ tlibuting to delayed or interrupted healing. Interventions

Regardless of the mechanism or cause of the hypermo­ bility, central to the success of a program to improve stabil­ ity of the thoracic spine is the concept that the trunk mus­ cles must hold the vertebral column stable for independent upper and lower extremity movement to occur. This role must be executed regardless of the speed of movement and any additional load the individual may be carrying. Loads must be transferred from the ground upward in an efficient manner, and this can be done without cumulative micro­ trauma only if the forces are attenuated through an efficient kinematic chain from the foot and ankle upward through to the thoracic spine. Improved Motor Control. Intervention for hypermobility begins at the stability stage of motor control. The patient is instructed to hold the spine in ideal alignment during movements of the upper and lower extremity. The activity or technique chosen depends largely on the level of inten­ sity the patient can sustain while maintaining ideal align­ ment with proper recruitment patterns. The preSCribed di­ rection of force imposed on the spine depends on the direction of the hypermobility. For example, a patient may present with difficulty in stabilizing against flexion forces such that, when the arm is lowered from a flexed position, the thoracic spine flexes insteau of remaining in neutral alignment. A flexion force such as resisted (in some cases, using only the weight of the arm ) or rapid upper extremity extension (from an overhead start position ) can be used to challenge the spinal extensors. The exercises can begin in sitting with the back against the wall or in supine and then progressed to standing. (see Fig. 25-7) The former posi­ tions require stabilization of fewer regions than standing (i.e., sitting eliminates the need to stabilize the foot, ankle, knee, and hips), and the wall or floor prOvides propriocep­ tive feedback to enhance stabilization. Similar principles can be used in creating e.'(ercises to stabilize against rota­ tional or lateral flexion forces. Applying an axial load to the thorax and gauging the re­ sponse can allow the estimation of ideal or optimal align­

ment in sitting or standing. In the optimal position axial loading forces arc distributed equally throughout the verte­ bral body and intelvertebral disk. In symptomatic patients the ideal alignment or "neutral spine" position will often 31­ low asymptomatic axial loading. Additionally, ill patients and clients alike , the therapist can feel the increased stabil­ ity of the spine as the load is applied, because the spine does not give way into either flexion or extension. SpeCific motion segments that demonstrate hypermobility can be identified and e'(ercises promoting stability can be preSCribed. Exer­ cises should target the Single segment muscles, such as the multifidi, because multis egment muscles like the semispinalis or iliocostalis promote multisegmental motion. Because the primary action of the multifidus is rotation, re­ sisted isometric rotation isolated to the hypennobile seg­ ment is a rational starting point. This can be initiated in side­ lying with manual resistance. Home exercises can be performed using a straight-backed chair for stability and elastic band or tubing for resistance. As control of the hypermobile segment(s) improves, sev­ eral variables can be adjusted to progress the difficulty of the exercises and make them more specific to the functional .limitations and disabilities of the patient. Using the inter­ vention model described in Chapter 2 can be helpful in this process. For example, after stability control has been achieved for a given load, adding resistance to the extremi­ ties can increase the intensitv of the demand. As another ex­ ample, the speed of eAirel~ity movement can be altered based on the functional demands of the patient's work or lifestyle. Slow, controlled movements promote stability and endurance, whereas faster mOVf~ ments such as catching a medicine ball promote fast recruitment. Motor control and motor learning theory, based on find­ ings in normal individuals,67 suggests that altering the prac­ tice conditions and the amount, type , and scheduling oi' feedback is essential to optimal acquisition of motor skills. Accordingly, exercises and activities shou ld be sequenced in a random fashion , rather than repeating the same activit;; over and over. Feedback should be prOvided on an inter­ mittent, rather than continuous, basis. Attention to these details will enhance skill acquisition. Gymnastic balls, foam rolls , and balance boards can modify stabilization activities to prOvide a greater challengl by destabilizing the base of support (Fig. 25-19) The the­ Oly behind the use of these pieces of equipment is that the labile base of support stimulates balance anu equilibriull reactions. Continuous postural adjustments are required facilitating smooth coordination of posture and movemen Care must be taken to ensure that the patient emplO\ proper trunk stabilization strategies when using equipmen' that destabilizes the base of support. / Adjacent Areas of Hypomobility. Difficulty stabilizi n _ against flexion forces is a common problem for the tho rae; spine. The therapist must consider that excessive thoraC" flexion may occur because of lack of mobility in rela! regions. For example, in sitting a decrease in hip fl ex:io mobility may be compensated for by thoracic flexion ' \i forward-reaching or forward-bending movements. FOII -· point kneeling with a sit-back movement (Fig. 25-20 ) promote hip flexion mobility and thoracic spine stabilit­ This movement pattern must eventually be transferred

Chapter 25 The Thoracic Spine

625

FIGURE 25·20. In four-point kneeling, the patient is instructed to ma intain neutral spine position while rocking back toward the heels (A, B). At the point of hip flexion stiffness, the tendency is to flex in the lumbar or tho­ racic spine. The patient is instructed to stop at the onset of spine fle xion.

FIGURE 25·19. (A)These exercises use the labile surface of the gymnas­ tic ball to stimu late ba lance and equi librium reactions. The patient is in­ structed to maintain axial extension and neutral thoracic and lumbar spine alignment. Teach the patient cervical and lumbopelvic core activation prior to adding any arm or leg movements (see Chapters 18 and 24 for detai Is on lumbar and cervical core activation st rategies, respectively). (B)The foam rolls further destabilize the base of support.

controlled mobility and skill level activities in sitting and standing positions, such as reaching forward with hip flex­ ion while maintaining neutral spine position (Fig. 25-21). Another common cause of excessive thoracic spine mo­ tion is lack of thoracic and hip rotation combined with ex­ cessive shoulder girdle protraction. For example, in cross­ body reaching tasks , the elbow extends and the shoulder flexes and hOrizontally adc1ucts until the full length of the arm has been reached. If further reach is required, the thoracic spine should rotate, followed by lumbar spine and hip joint flexion and rotation. If standing, a step to­ ward the object can increase the reach span. The ann can effectively reacl1 across the body if the scapula provides a stable base for arm movement and the thorax provides a stable base for the shoulder girdle. This movement re­ quires appropriate recruitment and length-tension prop-

erties of the scapulothoracic, glenohumeral, spinal exten­ sor, and oblique abdominal muscles. There must be am­ ple mobility in the glenohumeral jOint for upper extrem­ ity horizontal adduction and in the thoracic spine and hip joints for rotation. A prevalent faulty movement pattern is to reach instead with scapular abduction and thoracic flex­ ion (Fig. 25-22 ). Impairments in the shoulder girdle, tho­ rax, and hips may need to be addressed separately to im­ prove the movement pattern of cross-body reaching and thereby reduce the tendency toward excessive thoracic flexion . One useful activity to retrain independent motion among the upper extremity, thoracic spine, and hip joints is shown in Self-Management 25-1: Cross-body Reaching. The prerequisites for correct performance of this exercise are proper movement patterns at the scapulothoracic, glenohumeral, and hip joints (see Chapters 20 and 26). External Support. Treatment of hyper mobility in the tho­ racic spine may also include supportive devices such as a posture brace (to prevent thoracic flexion) (Fig. 25-23) and taping. Taping can be used to facilitate and remind against excessive flexion and rotation (see Fig. 25-18) As strength, endurance and control improve the patient can be 'vveaned off the supportive devices.

Hypomobility Causes

Hypomobility can result from pain or altered tone, restric­ tions in neural or dural mobility, trauma indUCing os­ teokinematic restriction, degenerative joint changes, dis­ ease processes, or generalized stiffness in the joints or myofascial tissues from self-induced or externally induced immobility. Self-induced immobilization can result from pain or repetitive altered movement patterns. Repetitive altered movement patterns can produce sites and direc­

626

Therapeutic Exercise: Moving Toward Function

FIGURE 25·22. A prevalent movement pattern is to reach with scapu lar abduction and thoracic flexion.

Intervention

Patients with long-standing joint mobility restrictions are likely to develop myofascial restrictions, requiring con­ current intervention to both. Treatment of joint restric­ tioDS usually requires joint mohilization teduIiques , and treatment of myofasC:ial tissu e requires passive stretching, active ROrv! exercises. or both . Therefore, to maintain mo­ bility gained ,"vith jOint mobili zation techniques, it is im­ port31~t to teach the pati ent a self-management exercise program that includes a passive stretch, active ROM exer­ cise, Of both. Functional move ment patterns should be learned that reinforce th e mobility gained through mobi­ lization and specific exercise. A clinical example may best illustrate this point. A patient presents with left rotation and left lateral flexion restJictions in the thoracic spine at the T7 segmental level. The exami­ nation determines th at this restriction is articular. The ap­ propriate jOint mobilization technique is performed to rf'­

FIGURE 25·21. (A) The standing subject reaches forvvard with excessive thoracic flexion. (8) The movement pattern is altered such that flex ion takes place at the hips, knees, and shoulder; the thoracic spine rem ains in neutral.

tions of relative mobility and concurrent sites and direc­ tions ofhypOlnobility. For example, the movem ent strategy of scapular abduction and thoracic flexion to rcach across the body can lead to hypolllObility in thoracic rotation. One must consid er the effect that postoperatively induced im­ mobility, such as opell heart surgery or mastectomy, has on the mobility of the thoracic cage. Hyp omobility can be caused by limitations in myofascial le ngth or mobility. In the case of myofascial restriction ill the absence of articular hypomobility, correlating articular glides are normal, but osteokinelllatic motion is limiteo in rotation . For example, restri ction in right rotation can indicate short or stiff right cxt:crnal and ldt internal ohlifJue muscles. Hypoil1obilityof the thoracic spine can also be found ill relation to breath­ ing, with reduced movement in pump or bucket handle breathing mechanics.

FIGURE 25-23. A posture brace can be used to contro l excessive thorac l~ flexion.

Chapter 25 The Thoracic Spi ne

• • ~ SELF-MANAGEMENT 25- 1 ~

~".

Cross-body Reaching

Purpose: To promote independent motion of the

Level 2

After you can reach your arm to the midline of your body, rotate your torso as far as you can without moving atthe hips, knees, ankles, or feet. Do not move your shoulder blade from its starting position. Do not let your thoracic spine flex; rotate it.

Leve! 3:

After you have mastered independent rotation of your torso. add hip rotation to the movement. Do not move your feet from the starting position U.e ., do not take a step forward, but allow your ankles and feet to rotate naturally with hip rotation). Do not move YOllr shoulder blades from the original position or allow your thoracic spine to flex forward .

Leve! 4:

After you have performed rotat-ion sequentially at the torso and hips, take a step diagonally forward across midline of your body. Do not let your shoulder blade move from its starting position, but achieve a greater reach by stepping across your body.

shoulder joint from the shoulder blade, torso, and hip. You should not progress to the next level without mastering the previous level. Use the movement pattern acquired in Level 4 when reaching across the body for an object farther away than the span of the arm. Avoid reaching by moving your shoulder blade or flexing in your thoracic spine excessively.

St8rting

position:

Stand with feet about 2 inches away from the

wall and the pelvis and spine in neutral. If your

hip flexors are short or stiff, you may need to

flex your hips and knees to achieve a neutral

spine and pelvis position.

Movement

Technique:

Leve! 1.

Move your arm across your body to the midline

without letting your shoulder blade move from

its starting position. This may require a

submaximal contraction of your interscapular

muscles.

(continued)

627

628

.(9)

Therapeutic Exercise: Moving Toward Function ~

SELF-MANAGEMENT 25-1 Cross-body Reaching (Continued)

Dosage: Repetitions _ _ _ _ _ _ __

Sets Frequency _ _ _ _ _ _ ___ Variations After a wall is no longer required for feedback, a pulley Dr elastic can be used to resist the movement pattern. _ _ _ _ _ _ _ Increase the speed of the

movement.

____________ Add a weight in your hand.

store the arthrokinematic glide. 2 A4 To maintain the mobil­ ity gained, the patient is instructed to perform specific midthoracic lateral flexion, blocking motion at the relatively hypermobile segments below T7, to facilitate motion at the stiff segmental level (Fig. 25-24). Repeated thoracic left ro­ tation can also be instructed (Fig. 25-25). The patient should be instructed to use left rotation of the thoracic spine frequently throughout the clay to further facilitate mainte­ nance of articular mobility. All exercises should be done with a high number of repetitions (up to 20 times) and fre­ quentlythroughout the day (up to 10 times), and in the pain­ free range to prevent a&2;ravation of symptoms. Proper diaphragmatic breathing is essential to the treat­ ment of many impairments in the thoracic spine and related regions (see Chapters 18 and 2.3). The Patient-Related In­ struction 2.3-2: Diaphragmatic Breathing in Chapter 2.3 de­ scribes proper diaphragmatic breathing, with emphasis on pump and bucket handle breathing. After mastering di­ aphragmatic breathing in a supine position, the patient

Block motion belowT7

>. ___

should progress to sitting and standing while apptying tl1e same breathing techniques. In older adults, aerobic conditioning may provide signif­ icant improvements in spinal mobility, physical function. and overall health. 68 The effects of a .3-month supervised program of spinal flexibility and aerobic exercises was com­ pared with one with aerobic exercise alone on axial rotation , mclximal m"'Ygen uptake; functional reach, timed-bed mo­ bility; and the Physical Function Scale (PhysFunction) of the Medical Outcomes Study SF -.36. Both groups improved in all measures although there was no difference between the groups, suggesting that for this population either type of exercise would be beneficial.

Muscle/Mvofascia/ Length Specific myofascial tissue length impairments that promote poor thoracic mobility can be gleaned from analyzing the

--.r.;

~I

Prevent lateral pelvic shift

FIGURE 25-24. Left thoracic spine lateral flexion can be encouraged at T7 by blocking excessive lateral flexion below T7.

FIGURE 25-25. Hold1ing onto a light dowel rod can encourage thoracic ro­ tation by keeping the dowel rod level while rotating the torso. The patiem is instructed to rotate the sternum. Lower segments can be stabilized b\, keeping the lower back flat against the back of the chair.

Chapter 25 The Thoracic Spine

movements created by each muscle as listed in Table 25-3. Common areas of impairment include the pectoralis major and minor, rectus abdominis, and oblique abdominals (ex­ tension); the paraspimlls and the more lateral iliocostalis (flexion); and the intercostals, which can limit motion in all directions. Specific soft-tissue mobilization and longitudi­ nal stretching techniques are often necessary to restore full mobility but must always be followed by exercises aimed at maintaining the new mobility if not gaining more ROM. Restrictions in oblique abdominal muscle length can limit thoracic rotation. In the case of myofascial restric­ tion in the absence of articular hypomobility, correlating articular glides are normal, but osteokinematic motion is limited in rotation. Restriction in right rotation can indi­ cate short or stiff right external and left internal oblique muscles. A passive stretch (Fig. 25-26) can be used in conjunction with diaphragmatic breathing (see Patient­ Related Instruction 23-2: Diaphragmatic Breathing) into the right thoracic rib cage. Lying on a foam roller can in­ crease the stretching force. Postural habits and repetitive movement patterns must be analyzed for potential causes of myofascial restrictions. Comprehensive treatment may include changing the ergonomics of the workstation to re­ duce factors contributing to myofascial restrictions (e.g., rearranging the workstation to reduce sustained and re­ peated left rotation and promote occasional right rota­ tion). The patient's movement patterns and activities may need to be altered to limit repeated left rotation and pro­ mote more activities requiring symmetric rotation. For ex­ ample, the patient should reduce the time spent playing tennis (an asymmetric activity) and begin walking, jog­ ging, biking, or swimming (symmetric activities ). Patients who have undergone surgery such as a coronary artery bypass graft (CABG) or mastectomy will develop tho­ racic spine and rib hypo mobility if not exercised properly. Early exercises should focus on maintaining deep inspira­ tion ROM as tolerated by the patient. Diaphragmatic breathing will also assist in lymphatic drainage after a mas­ tectomy. Gentle stretching of the chest musculature should be undertaken , within the confines of postoperative pre­ cautions. In general, such precautions would include avoid­ ing undue stress to the involved tissues in the early stages of healing. Resisted exercises that stress the involved muscu-

629

lature and their associated joints should be avoided until such time as allowed by postoperative protocols. For exam­ ple, pectoralis major strength e ning after a CABG should not take place until the sternum has healed. As the surgical incisions heal , shoulder ROM exercises should be intro­ duced, gradually progressing to full arcs of motion and adding resistance (see Fig. 25-17).

Pain Pain in the thoracic region has many possible causes or mechanisms. The onset of pain may be the result of joint dysfunction (i.e., thoracic vertebrae or lib articulations), soft-tissue injury or strain, or of nonvisceral (e.g., osteo­ porosis, ankylosing spondylitis, Scheuermann's disease) or visceral diseases (see Appendix 1). Treatment must focus on the cause or mechanism of the pain, not just the source. This chapter should provide you vvith theoretical strategies and clinical examples of exercises used to alleviate impairments that could be contributing to the causes and mechanisms of musculoskeletal origin pain.

Impaired Posture and Motor Function Optimal postural alignment is discussed in detail in Chap­ ter 9. As noted previously, it is important to distinguish be­ tween postural faults that are the result of permanent changes in the structure of the spine and those that are amenable to change. The anatomic impairments cornmon to the thoracic spine were discussed earlier. This section will deal vvith nortstructural impairments of posture. Head posture is contingent on thoracic posture, which in turn is dependent on the lumbar spine, pelvis, and lower ex­ tremities. In addition , as noted earlier, full upper extremity motion requires thoracic mobility. Therefore, all aspects of the kinetic chain must be examined and evaluated.

Kyphosis Causes

Postural kyphOSiS is caused by habitual trunk f1exion, for which there are several reasons. An individual with poor postural habits-for example, a studellt who spends most of his or her time sitting in c:lass in a flexed posture-is likely to develop a kyphOSiS. "Veak trunk extensors can exacerbate already poor posture. A dominant daily activity that encour­ ages thoracic flexion-for example, working daily sitting at a computer writing a book chapter on thoracic spine exer­ cise while using a chair with poor trunk and pelvic sup­ port-will likely encourage a kyphotic spine. Finally, there are diseases that tend to manifest vvith thoracic kyphOSiS as a secondary complication. Parkinson's disease is an example of one such disorder, in which there is a lack of movement into extension , and is discussed later in this chapter. Intervention

FIGURE 25-26. Rotation stretch for short or stiff right external and left in­ ternal oblique muscles .

In patients without a structural kyphosis in whom lack of extension ROM is the ptimary impairment, manual jOint and soft-tissue mobilization is a key palt of successful man­ agement. JOint mobilization techniques are desclibed and discussed in Chapter 7. Often a kyphotic posture is associ­ ated with shortened soft tissues on the anterior aspect of the

630

Therapeutic Exercise: Moving Toward Function

thorax. Soft-tissue mobilization and manual stretching of the pectoralis major and minor is often required, followcd by a home stretching program (see Fig. 25-17). Home exercises that promote extension throughout the thoracic spine often end up exacerbating segments that are already hypermobile, because the hypomohile segments resist being moved and only transfer the motion to the seg­ ments that move easily. It is therefore important to use self­ management exercises that target the stiff segments while protecting the mobile ones. Figure 25-27 illustrates an ef­ fective self-mobilization technique. Another relatively specific extension exercise involves the use of a foam roll. Lying on the foam roll with it posi­ tioned horizontally encourages extension of the thoracic spine but also serves to mobilize the ribs. With the roll po­ sitioned at 45 degrees, mobilization into extension and ro­ tation is pOSSible. As \\lith the use of tennis balls, the key el­ ement in this exercise's potential for success is time. Taping the thoracic spine for proprioceptive feedback and as a reminder to avoid flexion postures is a powerful way to teach patients new habits. The patient is asked to assume a quadruped position with the thoracic spine held flat, not in flexion. The tape is applied along the paraspinal region on each side and spans several segments above and below the hypermobile segment or "hinge point" (see Fig. 25-18).

Each time the patient fl exes from this area, the tape will pro­ vide proplioceptivE' feedback in the form of a pull on the skin, reminding the patient to stay in more extension. This type of feedback is very successful when used during symp­ tomatic activities, aleliing patients to how often and how unaware they are that potentially harmful movements oc­ cur. The use of tape is gradually decreased as patients de­ velop improved awareness. Finally, exercises to address kyphOSiS need to be pre­ sClibed that address muscle performance impairments in the thoracic extensors. This was described previously in the section on Muscle Performance Impairment.

Scoliosis Causes Nonstructural scoliosis may result from highly repetitive , asvmmetric activities related to hand dominance. A com­ m~n pattern of muscle imbalance and alignment changes for right-handed individuals is pictured in Fig. 25-28. The therapist should be aware of the postural habits of a child in the various ,positions of the body, such as sitting, standing. and lying, because habits developed in childhood can per­ sist into adulthood. A right-handed child may sit at his or her desk to write with the upper body laterally flexed to the right. If this posture is also assumed in sidelying to perform

FIGI cres

ada I ada:

cies.

hon hon chil can pe~

1

illg'

ur

q uir

f~lUll

peh­ thor

I~

T

help

chile sis oj

tioni B

CO ITt

ric e'

CO 1151

Tl FIGURE 25-21. A self-management exercise can be used to mobilize stiff segments in the thoracic spine. One way to accomplish this is to have the patient lie supine on two tennis balls that have been taped together into a peanut shape (A) The balls themselves contact tile transverse processes while the spinous processes are spared direct contact by the indentation between the balls. The patient positions the tennis balls first at the thora­ columbar junction (B) and lies on top of them for 1 minute. The patient repositions the tennis balls at 1-minute intervals, progressing superiorly one segment at a time to address each spinal level. The primary forces at work are gravity and time. The balls act as a fulcrum selectively forcing each movement segment into extension. Adding active shoulder abduction, flexion or protraction (e) can increase the amount of force. Because the forces are relatively small, a relatively long time is required The exercise must be done daily at least, and results typically occur over weeks or months.

bar c:

FIGUR

c

floor or side so a postu

Chapter 25 The Thoracic Spine

631

-=.,..,>4--Shoulder low

Pelvis high

FIGURE 25-30. Sitting on one foot (the left in this illustration) causes the pelvis to tilt downward on the left and upward on the right. This places the spine in a left convex cUlVe.

FIGURE 25-28. In a typical dominant right-hand pattern, the right iliac crest is high and the shoulder low. The darkly shaded muscles can develop adaptive shortening, whereas the lightly shaded muscles can develop adaptive lengthening. (From Kendall FP, McCreary EK, Provance PG. Mus­ cles Testing and Function. 4th Ed. Baltimore Williams & Wilkins, 1993)

homework (Fig. 25-29), sitting (Fig. 25-30), and to carry homework in a backpack slung over the right shoulder, the child is prone to develop muscle imbalance problems that can lead to acquired scoliotic deviations of the spine that persist into adulthood. The pronation of one foot, standing on one leg, or stand­ ing with the same knee always bent (these habits often oc­ cur together) can contrihute to the development of ac­ quired scoliosis. The imbalances in hip musculature or faulty foot alignment or knee position that result in lateral pelvic tilt are more closely related to primary lumbar or thoracolumbar curves than to plimary thoracic curves. Intervention

The correction of asymmetrical postural habits may be helpful in preventing the development of scoliosis during childhood. Exercises should be carefully selected on the ba­ sis of thorough examination findings, and adequate instruc­ tion is needed to ensure that the exercises will be performed correctly and with precision. The object is to use asymmet­ ric exercises to promote symmetry. To illustrate this point, consider the follOwing case. The patient is a gymnast with a right thoracic, left lum­ bar curve (Fig. 25-31). Along with otller findings, right il-

FIGURE 25-29. Children sometimes assume a sidelying position on the floor or bed to do their homework. A right-handed person lies on the left side so that the right hand is freeto write or turn the pages in a book. Such a posture places the spine in a left convex cUlVe.

iopsoas and right external oblique weaknesses are diag­ nosed. An example of an asymmetric exercise is resisted ex­ ercise to the right iliopsoas (Fig. 25-32). Because the ilio­ psoas muscle attaches to the lumbar vertebrae, transverse processes, and the intervertebral disks., this muscle can pull directly on the spine. Figure 25-33A demonstrates the ad­ verse effect of resisting the left iliopsoas, and Figure 25-.3:3B illustrates the positive effect of resisting the right iliopsoas. A left upper extremity diagonal reaching movement pattern can facilitate right thoracic lateral flexion. Simultaneous right hip flexion and left upper extremity diagonal reaching should promote lateral deviation, correcting both curves (Fig. 25-34). If performed as a home program, someone should monitor this movement to ensure that the appropri­ ate spine correction occurs. Kendall 8 describes an exercise in supine to address the weakness of the right external oblique. In the supine po­ sition, the subject places the right hand on the right lat­ eral chest wall and the left hand on the left side of the pelviS. Keeping the hands in position , the object of the exen.:ise is to bling the hvo hands closer by contraction of the abdominal muscles without fl exing the trunk. It is as if the upper part of the body shifts toward the left, and the pelvis shifts toward the right . By not allowing trunk flexion and contracting the posterior lateral fibers of the

FIGURE 25-31. This person has a right thoracic and left lumbar cUlVe.

632

Therapeutic Exercise: Moving Toward Function

FIGURE 25-32. Resisted end-range hip flexion can isolate the iliopsoas from the other hip flexors that do not attach directly to the spine. The pa­ tient is instructed to passively lift the thigh to end range and hold the posi­ tion against gravity while maintaining a neutral spine position. The patient is instructed to activate the lumbopelvic core prior to letting go of the leg (see Chapter 18 for core activation strategies). Resistance is applied only af­ ter the patient is able to hold the limb against gravity without resistance.

external oblique, there \vill be a tendency toward some counterclockwise rotation of the thorax in the direction of correcting the thoracic rotation that accompanies a right thoracic curve. There is some evidence in small groups that exercise us­ ing trunk rotation may inhibit the progreSSion of adolescent scoliosis 6 9 However, there was no control group in this trial and there were only 20 subjects. One study has looked at the effect of axial unloading in ch.§lnging the spinal curvature and found som e improvement, 10 but vvithout lasting results. Again , the group was small (six subjects) and there was no control group for comparison. A review of the literature found that physical exercise prevents or reduces disabilities, and facilitates the neutralization of p~stural deficits to pro­ duce a stationary or regreSSive curve. 11

Lordosis Causes

Thoracic lordosis is a loss of the normal posterior CUlve of the thoracic spine, and it can be associated ,vith abnormal posture correction strategies. For example, in an attempt to correct fOlward shoulders, the individual extends the tho­ racic spine, rather than adduct the shoulder girdle on the stable thora.x. If this is done habitually, the thoracic spine becomes a site of relative flexibility. Intervention

FIGURE 25-33. (A)The dotted line shows the adverse effect of resisting the left iliopsoas in a left lumbar curve. (B)The dotted line shows the pos­ itive effect of resisting the right iliopsoas in a left lumbar curve.

Attempts to improve impairments of the shoulder gir­ dle with lower trapeziUS resistive exercises (Fig. 25-35A ) cause thoracic extension instead of scapular adduction. Use of a support under the sternum (Fig. 25-35B ) can somewhat block the undesired thoracic extension to allo\\' resistive exercises to transmit forces to the scapula instead of the thoracic spin e. Applying tape anteriorly as a propri­ oceptive feedback mechanism to prevent excessive tho­ racic extension will facilitate movement in the lumbar spine and pelvis. Patient-related instruction is necessalY to alter the strategy of posture correction performed b~ the patient. Self-mobilization into thoracic flexion can be performed, using the back of a firm chair to stabilize cau­ dal segments while the cranial vertebrae are activeh­ flexed (Fig. 25-36). .

A

B

FIGURE 25-35. (A) In a person with thoracic lordosis, attempts at iE'­ RGURE 25-34. The dotted line shows the effect of reducing the right tho­ racic and left lumbar curve by simultaneously reaching diagonally upward with the left arm and resisting right hip flexion.

forming resisted lower and middle trapezius exercises promote thoracic e tension instead of scapular adduction. (B) Use of a firmly rolled tOI" placed under the sternum can stabilize the thoracic spine in flexion, all ing the force of the middle and lower trapezius to adduct the scapula stead of extending the thora cic spine.

Chapter 25 The Thoracic Spine

633

FIGURE 25·36. Blocking motion of the caudal segme nts by stabilizing against the back of achair, while mobilizing the segments above. (A) Start­ ing position. (8) End position, rotation. Be sure to instruct the patient to ro­ tate the spine versus adduct the scapula. (e) End position, extension. Be sure to instruct the patient to stabilize the thoracolumbar and lumbar re­ gions to prevent extension.

THERAPEUTIC EXERCISE INTERVENTION FOR COMMON DIAGNOSES This s~ction contains selected medical diagnoses that have a beanng on the muscular, skeletal, and nervous systems as they relate to the thoracic region. Although there are nu­ merous musculoskeletal diagnoses associated with the tho­ racic region, only a few are discussed to provide examples of therapeutic exercise prescriptions for the related functional limitations, disabilities, and related impairments.

Exercise Management of Parkinson's Disease Parkinson 's disease is a progressive neurologic disorder that results in the los s of levodopa (L-dopa) in the substantia ni­ gra. The clinical findings of the disease include rigidity, fa­ cIal masking, resting tremor, dyskinesia, bradykinesia, diffi­ culty initiating movement, and a flexed posture.

Intervention Appropriate treatment for Parkinson's disease includes a combination of drug therapy, usually a form of L-dopa

replacement, and exercise. A consideration in designing ex­ erCIse p~ograms m Parkinson's disease is the typical 'waxing and wanmg of the drug effectiveness, often termed the "on" and "off' periOds. The patient may s'wing from a fully func­ tional and mobile individual while "on" to one who is immo­ bilized and "frozen," all in a matter of minutes. As the disease progresses, the "on" periods may become very short despite appropriate medication doses. The patient in this situation may not wish to spend this valuable "on" time exercising, optmg mstead for performing highly valued or necessary tasks. In these cases, the exercise program must be econom­ ical given the time needed to perform it. That is, only the few, most effective, and broadly useful exercises should be chosen. The patient must be made aware of the importance of the exercises to consider them wOlth the time investment. This can ?e accomplished in a powerful way if the patient can expenence the henefit of performing the exercise. For exa~~le, a simple exercise practicing a fOlward weight shift m slttmg usmg an exercise ball or a stick (Fig. 25-37) often will result in dramatic improvement in sit-to-stand ability (from unable to independent). ExperienCing this improve­ ment will make it more likely that the patient will attach im­ portance to it and will therefore increase compliance.

634

Therapeutic Exercise: Moving Toward Function

I\j

tr

! re dl

p

G

bI t re

FIGURE 25·37. Encouraging thoracic exten­

sion coupled with shou lder eleva tion. using a forw ard wei ght shift (A) With the exercise ball resting in the palient" s lap and his arms resting on top of the ba ll. the patient shifts his weight forward, caus ing shou lder elevation and thoracic extension. (8) Assistance wi th the movement can be provided by a fam ily member or friend (C),A stick, dowel, or broom­ stick can be substituted for the ba ll. These ex­ ercises can be especially effective in encour­ aging spinal extension with simultaneous hip fle xion as a pretransfer activity in patients wilth Parkinson's disease. Be sure to instruct the pa­ tient to stabilize against lumbar flexion during this motion by activating lumbar erector spinae The hips must have enough mobi li ty to move into flexion without associated lumbar flexion.

Even so, it may be that th e "on" periods are so sholi as to makE' it unreasonable to ask the patient to spend it doing ex­ ercises. In these cases the help of a family member or care­ giver is crucial, in the form of a program of plimarily ROM exercises. Using inexpensive equipment such as exercise balls and wands or canes, and teaching positioning tech­ ni(}ues that promote spinal extension, can allow even a frail spouse to assist in the exercises (see Fig. 25-37), There is growing evidence that exercise can play an im­ pOliant role in the management of Parkinson's disease. For

d e

example, th e effectiveness of an exercise intervention fe people in early and midsta~e Parkinson's disease (stages :: and 3 of Hoehn and Yahr) in improving spinal flexibilit­ and physical performance in a sample of cornmuni t: ­ dwelling older people was described by Schenkrnan et aI. They compared people with Parkinson's disease who re­ ceived 10 weeks (30 sessions) of exercise instruction with group of patients who received no exercise instruction anc. found improved functional axial rotation, functional read and timed supine to stand. 1-

Chapter 25: The Thoracic Spine

Management of Scoliosis

635

DISPLAY 25-5

Scoliosis is a complicated deformity that is characterized by lateral curvature and vertebral rotation. The classification of scoliosis is given in Display 25_1. 52 Patients with mild scoliotic curves often do not require treatment, as long as the curve does not progress. Periodic observation is required to make sure the degree of curva­ ture is not increasing. After skeletal maturity has been reached~ a curvature (by the Cobb method ) of less than 25 degrees 1'1 to 30 degrees I S typically does not progress. In the patient with an immature spine, if the curve is between 25 degrees and 40 degrees, there is a high risk of further pro­ gression. These patients need to be treated using a brace, which in 70% to 80% of the cases will prevent further pro­ gression. 74 In one study, a 'brace worn 16 or more hours each day was shown to be effective in preventing 90% or more of the curves from getting worse, palticularly mild curves (25 to 35 degrees)76 Most authorities recommend wearing the brace for 23 hours each clay, because using it part-time can create compliance problems about when to take it off and put it on . When it becomes part of a daily routine, it be­ 'omes a standard function. However, the brace cannot cor­ rect a curve. At best, it can prevent it from worsening. In adults , the curve may progress slowly over the years, and braCing may not be a practical solution. In children who are growing, a curve of greater than 40 degrees typicaily requires spinal fusion. 74 Surgery is usually reserved for teens and preteens with curves of40 degrees or more. 74 For adults, the reasons for doing surgery are less well defined but include increasing, disabling pain and a documented increase in a curve. Often adolescents with scoliosis 'vvill have impairments in their overall fitness level. This has to do as much with poor self-image and reluctance to participate in activities while wearing the brace as it has to do "vith impairments in respi­ ratolY function. These children must be encouraged to re­ main as phYSically active as possible, and the parent must take an active role in this process. If the curve is severe enough, aerobic capacity may become impaired and appro­ priate endurance exercises should be prescribed. Although Chapter 6 prOVides an in-depth discussion of intervention for impaired aerobic capacity, it has been shown that 30 minutes of bike ergometry four times a week over 2 months produced a Significant improvement in aerobic capacity in voung girls with scoliosis compared witl~_a control group of <'iris with scoliosis who did not exercise. I As noted earlier, the use of exercise in the management of scoliosis is controversial. Muscle imbalance that exists as a result of postural or other nonstructural scoliosis theoret­ ically can be treated through the use of exercise to prevent Iluther exaggeration of the scoliosis beyond that which the disease has caused. The message that exercise is of little or no value prevails in the literature, leaving individuals with scoliosis the treatment options of doing nothing, bracing, or surgery. In the American Academy of Orthopedic Surgeons 1985 lecture series, this statement appears: "PhYSical therapy cannot prevent a progressive defor­ mity, and there are those who believe specific spinal exer­ cise programs work in a counterproductive fashion by mak­ ing the spine more flexible than it ordinarily would be an_d, by so dOing, making it more susceptible to progression." ,8 I

Tests and Measures Included in a Scoliosis Evaluation Posture alignment • Plumb-line and segmental, in back, front, and side views

Muscle length tests • Hip flexor (differentiating psoas from tensor fascia lata and rectus femoris) • Hamstrings • Forward bend for length of posterior muscles • Tensor fascia lata-iliotibial band • Teres major and latissimus dorsi

Muscle strength tests • Back extensors • Abdominal muscles (differentiating trunk curl from pelvic

stabilization roles)

• Lateral trunk • Oblique abdominals • Hip flexors • Hip extensors • Hip abductors (differentiating posterior gluteus medius) • Middle and lower trapezius

Movement • Forward bending to determine a structural curve and the

location of the curve

Kendall B warns that overemphasis on flexibility is the ex­ ercise approach that leads to the view that exercise is of lit­ tle value or even counterproductive in the treatment of sco­ liosis. She states that adequate musculoskeletal evaluation has been lacking, and, as a result, there has been little sci­ entific basis on which to justify the selection of therapeutic exercises. Kendall's premise for using therapeutic exercise is that scoliosis is a problem of symmetry and that restoring symmetry requires the use of asymmetric exercises along

DISPlAY 25-6

Principles of Exercise Prescription for Scoliosis • Symmetric exercises should not be attempted. • If one group or one muscle within a group is too strong for its antagonist or synergist, that muscle or group should be stretched, and the weaker,longer antagonist or synergist should be strengthened and supported to provide balance to the region. • The lateral and anterior abdominal muscles, pelvic girdle, and leg muscles usually have asymmetric strength, causing the body to deviate about all three planes of motion but primarily in the transverse and frontal planes. Because the posterior spinal muscles are relatively less affected, the program should emphasize promoting strength of the relatively weak muscle or groups of muscles in the anterior thoracolumbar region and the pelvic-hip complex.

636

Therapeutic Exerc ise : Moving Toward Fu nction

with appropriate support. Stretching of stiff or short mus ­ cles is desirable only if it is performed with simultaneous ex­ ercise and appropriate support to shorten and strengthen what is too long and relatively weak. To develop a comprehensive approach to treatm ent, a comprehensive musculoskeletal evaluation mus t be per­ formed. The evaluation should include the tests and mea­ sures described in Display 25-5. Exercises should be care­ fully selected on the basis of the examin.ation fin dings. The general principJ'es of exe rcise prescripti on fo r patients with scoliosis are li sted in Display 25-6. Exercises to be avoided by individuals \vith scoliosis include those listed in Display 25-7. An altemative exercise is shown in Self-Managemen t 25-2: Postural Exercise With Back to Wall. Exercises for muscle imbalances associated \vith acquired scoliosis were described preViously.

SELF-MANAGEMENT 25·2

Purpose:

Starting position:

DISPLAY 25-7

Exercises to Avoid in Treating Scoliosis

• Exercises that promote flexibility of the spine should be avoided without counterbalancing exercises or support promoting opposing shortening and strength to maintain corrections. • A subject who is also developing kyphoscoliosis should avoid back extension exercises performed in prone because it promotes further lumbar extens ion (see Self­ Management 25-2: Wall Sitting Postural Exercise for an alternative exercise). Trunk curl exerc ises or sit-ups should be avoided even if the rectus abdominis and internal oblique muscles are weak, because thorac ic flexion promotes the kyphosis (see Chapter 18 for alternative methods of abdominal strengthening).

Postural Exercise With Back to Wall Caution: Do not let you r chin rise in an attempt to get your head closer to the wall. Place your thumbs on the wall with your elbows pointing slightly forward. If you have an exagg erated curve of your upper or middle back, you may not be able to get your thu mbs to the wall. (AI

To reduce the tendency for excessive midback forward flexion and forwa rd shoulder posture. After this exercise is mastered in sitting, you can progress to performing it while standing. Sit on a stool with the lower back nearly flat against the wall. You should be able to fit your hand behind your lower back if your spine is in optimal position. If you have an exaggerated upper and midback curve, you may have a larger space between the wall and your back. Try to reduce this space as much as possible by contracting your lower abdominal muscles. Caution: Do not let your upper and middle back forward flex more in an attempt to re­ duce the curve of your lower back.

A Press your head back with your chin tucked down. If you have an exaggerated curve of your upper or middle back, you may not be able to get your head to the wall. Place one or two towe l rolls behind your head with your head as close to the wall as possible and with your eyes and nose positioned horizontally.

Movement Technique: Keep your thumbs in contact with the wall, keep your head and low back in the starting position, and slide your arms to a diagonal position overhead. When your head or low back deviate from the start position or your shoulders shrug excessively, stop the movement. (B)

B

Dosage: Repetitions Sets _ _ _ _ _ _ __ Frequency _ _ _ __ __ ­

Chapter 25: The Thoracic Spine

Supports in the form of orthotics, lifts, and braces can be used to assist in the treatment of structural scoliosis. Cor­ rection of lateral pelvic tilt associated with a lumbar curve can be helped by proper lift on the side of the low iliac crest. H owever. no lift can help if the patient continues to stand in an asymJlletric posture, such as with weight predominantly on the legvvith the higher iliac crest and with the knee flexed on the side of the lift. Unilateral pronation can also contribute to the asymme­ try and muscle imbalance found in acquired and structural scoliosis. For example, the combination of left pronation, shortness of the left tensor fascia lata, left glu teus medius and right hip adductors , and weakness of the right gluteus medius, left hip adductors, and left lateral abdominals can be seen in a person with a right thoracic curve and left lum­ bar curve. In cases such as these, along with specific exer­ cises to improve the le ngth of the left tensor fascia lata and strength of the right gluteus medius , left hip adductors, and lateral abdominal muscles (see Chapters 18 and 20), tlle use of an orthotic to support the left foot may be indicated (see Chapter 22). Early detection and intervention are key to the treatment of scoliosis. A few carefully selected exercises that help to maintain muscle balance and a kinesthetic sense of good alignment are recommended over a vigorous, complex pro­ gram. This means providing good patient-related education about how to avoid habitual positions and activities that can increase the curvature. It also means providing incentives that help keep the child, adolescent, or adu lt interested and cooperative in an ongoing program.

637

DISPLAY 25-8

Physiologic Impairments Associated With Kyphosis Alignment Forward head Cervical lordosis Abducted scapulae Kyphosis-lordosis: Lumbar lordosis, anterior pelvic tilt, hip joint flexion, knee joint hyperextension, ankle plantar flexion Swayback: Lumbar flexion, posterior pelvic tilt, hip joint hyperextension, knee joint hyperextension, neutral ankle Kyphosis-Lordosis Short and Strong* Neck extensors Hip flexors Lumbar spinal extensors Shoulder adductors Pectoralis minor Intercostals Elongated and Weak Neck flexors Upper back spinal extensors External oblique Hamstrings Middle and lower trapezius

Swayback Hamstrings Upper fibers of internal oblique Shoulder adductors Pectoralis minor Intercostals Neck flexors Upper back spinal extensors External oblique One-joint hip flexors Middle and lower trapezius

• Findings associated with short muscles must be tested by muscle length and manual muscle tests, because not all muscles held in short positions develop shortness.

Exercise Management of Kyphosis Any plan of care for kyphosis must consider the anatomic impairment and pathology in addition to the related physi­ ologic impairments. Display 25-8 lists potential physiologic impairments associated with kyphosis, and Table 25-7 lists general exercise recommendations to address physiolOgiC impairments associated with kyphosis. Patient-related instruction is indicated to improve pos­ ture alignment and avoid positions that contribute to the kyp hOSiS. Support to the lower back may be indicated to help relax: the musculature holding the spine in lordosis in the lordOSis-kyphosis posture, and a shoulder support may be indicated for the kyphosis to help stretch the pectoralis minor and relieve strain on the middle and lower trapezius and thoracic paraspinal muscle group (see Fig. 25-23). As illustrated in Table 25-7, exercise prescription for the treatment of kyphosis may need to go well beyond stre ngth­ ening the thoracic erector spinae. The thoracic spine must function as part of a kinematic chain , and treatme nt ofphys­ iologic impairments in each region influenCing the kyphosis is indicated . Ultimately, improved physiologiC capabilities in each region can provide a good foundation for enhanced function and quality oflife. Specific exercises must progress to functional movements meaningful to th at patient. For ex­ ample, a patient with Scheuerman n's disease \.vith a desk job needs to maintain his or h 'r best neutral spine when work­ ing. This patient would benefit from leaming to lean for­ ward and bacbvard from the hip joints while maintaining a neutral spine. Thinking about the distance between the

symphysis pubis an d th e base of the stemum and keeping this distance constant during forward and backward move­ ments at the hip joints can be useful in changing movement pattems that promote thoracic flexion. Although diseases such as osteoporoSiS and Scheuer­ mann's cause anatomic changes in the vertebrae that create the kyphosis, postural habits and movement patterns can ex­ aggerate the posture impairment. Although exercise cannot correct the anatomic changes that have occurred in the ver­ tebrae, it can pOSitive ly infl uence phYSiologiC factors that ex­ aggerate the kyphOSiS. Only through a comprehensive pro­ gram of exercise and patient-related instruction can these contributing factors be properly addressed.

Thoracic Outlet Syndrome Thoracic outlet syndrome (TOS ) was first described by Peet et al 79 as a synJrome caused by compression or stretching of the brachial plexus or the subclavian artery and vein as they transverse the thoracic outlet. All the symptoms attributed to TOS imply compression or stretching of th e brachial plexus, subclavian artery and vein, or both areas. Traditionally, the etiology ofTOS has been thought to be due to mechanical , nontraumatic brachial plexus compres­ sion caused by bony, ligamentous , or muscular obstacles

638

Therapeutic Exercise: Moving Toward Function

r;->

.0'

" " ,Therapeutic Exercise Management for Kyphosis STRENGTHEN

STRETCH

Kyphosis

Cervical spine eAiensors (see 24-21, 24-22)

Intercostals (see Figs. 25-14, 25-17)

Lumbar spine extensors (see Fig. 25-20)

Pectoralis minor, shoulder adductors (see Fig. 25-17)

Lordosis

Lumbar spine extensors (see Fig. 25-20)

Swayback

Intercostals (see Figs. 25-14,2.5-17)

Hamstrings (see 20-24A & Self-Management 20-7)

Diagnosis A careful evaluation is necessary to diagnose the subsets of TOS and to differentiate it from a spinal tumor, multiple sclerosis, cervical disk pathology, carpal tunnel syndrome, angina, tendinitis, and other brachial plexus injuries. Pa­ tients with TOS present with the follOwing signs and symp­ toms: (1) persistent diffuse pain or paresthesia involving the neck, shoulder, arm , forearm, or wrist and hand; (2) sensory and motor loss most commonly involves the C8-Tl segmental level (because of the C8-T1 sensory and motor changes, fine coordination may be affected, and patients may complain of symptoms when holding a newspaper, combing hair, or buttoning clothes ); (3) a positive Tinel's sign over the brachial plexus; (4) elicitation of reproducible pain or paresthesia by at least one provocation maneu­ ver83-86 or induction or aggravation of symptoms on pulling downward on the arm and their improvement or elimina­ tion on supporting the arms upward; or (5) exclusion of dis­ eases of the cervical spine and a peIipheral neuropathy.

Middle and lower trapezius (see Self-Management 26-2) External oblique (see SeJf-~[an ageIlle nt 18-1) Hip extensors (see Self-Management 20-1)

Hip flexors (see Self-Management 20-9)

anywhere between the cervical spine and lo\~er border of the axilla. Common sites of compressiol1 include the ante­ rior scalene, between the clavicle and first rib, and I!lnder the pectoralis minor. Several types of anatomic impair­ ments , such as a cervical rib , a J-curve structural variation of the first rib, and a long transverse process of C7, may pre­ dispose the neurovascular bundle to compression. Fibrous bands between the cervical vertebrae and first rib may also be a source of compression. Less commonly, a tumor in the thoracic outlet may compress the neurovascular bundle. Recently, Ide et a180 identified three subsets of patients with TOS; those \vith compression only, those \vith only stretching, and those with combined compression and stretching. Swift and Nichols 81 reported that some patients with TOS had droopy shoulder syndrome suggesting that their symptoms resulted from stretching of the brachial plexus. Nakatsuchi et al 82 proposed that the symptoms of TOS might be related to increased tension of the brachial plexus and surrounding vasculature resulting from muscu­ lar imbalance and the resultant downward traction.

Cervical spine fl exors (see Display 24-1 ) Thoracic spine extensors (see Fig. 25-7)

External oblique (see Self-Management 18-1) Hip fl exors (see Self-M anageme nt 20-5)

Treatment After the patient is diagnosed into the appropriate subset. treatment can be spedfied toward relieVing compression. stretching, or both. Ultimately, the patient must be in­ structed in self-management techniques that treat the sit · and cause (s) ofTOS and prevent recurrences. 1i7

Treatment of Type 3 TOS Characteristically, patients \vith type 3 TOS are youn slender women with drooping shoulders and poor po,,­ ture 80 The distance between the first thoracic spinous pro­ cess and coracoid process indicates the stretch placed 0 the neurovascular bundle. Presumably, the greater the di~ ­ tance, the greater the magnitude of stretch.'~o Therefore treatment aimed at improving the muscle performance an redUCing the elongation of the upper trapezius and middl trapezius would be highly beneficial. Supportive taping the scapula can relieve the stretch on the brachial plex'U~ General shoulder strengthening exercises with taping t prevent traction on the brachial plexus and posture educ:~­ hon is recommended. Conservative treatment is often suc­ cessful \vith this type of TOS. Thoracic outlet decompr' sion surgery may not be effective in patients whose m ~ symptoms are due to stretching of the brachial plexus s ,

General Treatment Concepts for Type 1and 2 TOS • Correct posture and movement impairments rele\'( to neurovascular compression or stretching, such correcting a depressed and anterior tilted scapula. • Taping the scapula into elevation (see Fig. 26-28) c ten reduces compression and alleviates symptoms Ir' ­ til the related impairments are remedied. • Alter sleep habits such as sleeping on the stomach \ \1" the neck extended and rotated, or arms overhead. • Improve diaphragmatic breathing patterns. Ac sory breathing patterns using scalenes and pecto}', minor may elevate the first rib and pull the scap and therefore the clavicle, closer to the first causing compression of the fibers of the anter..

Chapter 25: The Thoracic Spine

scalene, within the costoclavicular space, or under the pectoralis minor. • Correct physiologic impairments linked to posture and movement impairments , such as improving the length of the scalenes and pectoralis minor to in­ crease the space of the thoracic outlet and mobility of the first rib ; force-generating capacity or length-ten­ sion properties of underused synergists or antago­ nists such as the upper trapezius to alleviate a de­ pressed scap ula or lower trapezius to offset a short pectoralis minor. • Alter movement patterns dUling instrumental ADLs . Examples include changing work station ergonomics, body mechanics, or sport-speCific movements. • Appropliately refer for treatment of any patients with cognitive-affective ele ments or exacerbating health habits that may be causing tension in the relevant musculature. For example, anxiety may cause cervical or brachial tensi on, or smoking may cause poor breathing habits.

KEY POINTS • Stiffness and stability of the thoracic spine are facili­ tated by the rib cage, the low ratio of disk height to ver­ tebral body height, the acute angular orientation of the lamellae of the anulus and the relatively small nucleus pulposus, and the orientation of the zygapophysial joints. • 'Many muscles function about the thoracic spine to pro­ duce the prim ary movements of flexion , extension, lat­ e ral flexion , rotation , inspiration, and expiration. Imbal­ ances in muscle length and performance can contribute to impairments in mobility and posture and movement of the thoracic spine. • All motions are possible in the thoracic region , but the range of flexion and extension is limited in the upper thoracic region (TI-T6), \",here the facets lie closer to the frontal plane . In the lower part (T9-TI2), the facets lie more in the sagittal plane, allOWing an increased amount of flexion and extension. Lateral flexion is free in the upper thoracic region and increases in the lower re­ gion. Rotation, which also is free in the upper thoracic region, decreases caudally. • During inhalation and exhalation, the primary move­ ments of the ribs are called pump and bucket handle. To ensure proper breathing mechanics, both of these motion s mu st be occurring during inhalation and exhalation . • A comp rehen sive examination of all patien ts, including the history, systems review, and tests and measures , must be performed to enable the the rapist to deter­ mine the diagnosis (based on impairments, functional limitation s, and disabilities ), prognOSiS, and interven­ tions . • When considering therapeutic exercise interventions for common physiologic impairments of the thoracic region, the therapi st must consider the role of the tho­ racic spine in the kinematic chain and how other

639

segmental levels can affect the phYSiologic function of the thoracic spine . • Although few exercises solely address the thoracic region , those that address respiration, mobility, and performance of the trunk, shoulder girdle, and cer­ vical muscles are important for optimal thoracic function. • Thoracic spine function can be enhanced by treating the cervical and lumbar spine, shoulde r girdle, pelvic-hip complex, and foot and ankle complex. • Therapeutic exercise intervention is thought to affect the course of nonstructural scoliosis if the disorder is treated through asymmetric exercises, patient- related instruction , and movement retraining. • There are many causes of kyphOSiS. If the cause is a disease such as Scheuermann's or osteoporosis, exer­ cise intervention cannot reverse the pathology, but it may be able to retard or prevent further exaggeration of the kyphOSiS. • Exercises may play an important role in the manage­ ment of Parkinson's disease . Exercises should be chosen carefully to maximize their effect without stealing pre­ cious "on" time from the patient. • DiagnosiS and treatment of thoracic outlet syndrome requires extensive knowledge of the anatomy and kine­ siology of the cervical, thoracic, and shoulder girdle regions.

CRITICAL THINKING QUESTIONS 1. Describe how function of the foot and ankle , hip , and shoulder girdle could affect funct ion of the thoracic spine. Provide one example for each region . 2. You have been referred an I8-ye ar-old boy with Scheuermann's disease . a. What two posture types would this patient probably exhibit? b. List the possible shortened and lengthened muscles around the hunk and pelvis for each posture type. 3. You have been referred a I6-year-old female with right thoracic and left lumbar scoliosis. a. What are the possible shortened and lengthened muscles in the anterior and posterior trunk and pelvic girdle? b . What foot and ankle alignment faults could con­ tribute to this scoliosis? 4. Why would trunk curl exercises be contraindicated for someone with Scheuermann's disease or osteoporosis? 5. Why would prone hyperextension exercises be con­ traindicated for someone ,vith Scheuermann's disease or osteoporosis? 6. ''''hat five exercises would you choose to teach to a pa­ tient with Parkinson's disease who complains of an in­ creaSingly flexed posture, if he has only 3 hours each day when he is "on?" 7. List common postural impairments found in someone with TOS. 8. Given the list you created in #7, what muscles would you want to stretch versus strengthen?

640

Therapeutic Exercise: Moving Toward Function

3-l

LAB ACTIVITIES

1. Your patient has trouble stabiliZing against rotational forces in the upper thoracic region. Develop and teach your partner three sequentially more difficult exercises to improve stabilization skills against rota­ tional forces. 2. Refer to the Patient-Related Instruction 23-2: Di­ aphragmatiC Breathing. Assess your paltner's breath­ ing in the supine position. Does your paltner have in­ tegrated pump and bucket handle lib motions? Are they sYlllmetric? Teach your paltner proper breath­ ing mechanics. :3. Play the role of a person with Scheuermann's disease with a desk job at a visual display terminal. Teach your partner proper ergonomics at the workstation. Teach your partner to reach across the desk and into a file cabinet. Avoid exaggerating the kyphosis.

3.5

4. Design an exercise program for a patient with right thoracic and left lumbar scoliosis. Teach each activity to your partner. Can you see or feel the effect O'f asymmetric exercise on the spine? 5. Refening to Critical Thinking Question 4, what al­ ternative exercise would you prescJibe to your pa­ tient with osteoporosis if she had weak abdominal muscles? Teach vour partner this activitv. Which ab­ oominal muscle ~vould you expect to dO~linate in the exercise you instruct for someone with kyphOSiS? 6. Referring to Critical Thinking Question ,5, what al­ ternative exercise would you prescJibe to your pa­ tient with osteoporoSiS if he or she had weak tho­ racic erector spinae? Teach your partner this activity. Be sure to role-plav someone with mooer­ ate to'marked kyl)hosis. '

36

37

39

-:<1

REFERENCES 1. Lee DG. Biomechanics of the thorax: a clinical model of in vivo function. J Man Manipulative Ther J 993;1:13. 2. Lee DG. Manual Therapy for the Thorax-A Biomechanical Approach. Delta, British Columbia, Canada: DOPC , 1994. 3. Lee DG. Biomechanics of the thorax. In: Grant R, ed . Physi­ cal Therapy of the Cervical and Thoracic Spine. New York: Churchill Livingstone, 1994. 4. E dmondston SJ , Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther 1997;2:132-143. 5. Penning L, Wilmink JT. Rotation of the cervical spine-CT study in normal subjects. Spine 1987;12:732-738. 6. Warwick R, Williams P. Gray's Anatomy. 35th Ed. Philadel­ phia: WB Saunders, 1973. 7. Moore K. Clinically Oriented Anatomy. Baltimore: Williams & VVilkins, 1980. 8. Kendall FP, McCreary EK , Provance PG. Muscles Testing and Function. Baltimore: Williams & Wilkins, 1993. 9. Guide to physical therapy practice. Phys Ther 1997;77: l.l63-1650. 10. Maitland GO. Vertebral Manipulation. London: Butter­ worths, 1986. 11 . Norkin C, Levangie P. JOint Structure and Function. Philadelphia FA Davis, 1992. 12. Magee OJ, ed. OrthopediC Physical Assessment. Philadel­ phia: W.B. Saunders Co. , 2002. 13. Kapandji IA. The PhYSiology of JOints The Trunk and the Vertebral Column. Vol. 3. New York: Churchill Livingstone. 1990. 14. White AA, Panjabi MM. Clinical Biomech anics of the Spine. Philadelphia: JB Lippincott, 1990. 15. Panjahi MM, Brand RA, White AA. Mechanical properties of the human thoracic spine. J Bone JOint Surg ,\m 1976;58: 642-652. 16. Grccnman P. PrinCiples of Manual Medicine. 2nd Ed. Balti­ more: Williams & Wilkins, 1996. 17. S(;hafer R. Clinical Biomechanics: Musculoskeletal Actions and Reactions. Baltimore: 'vVilliarns & Wilkins, 1983. 18. Venes 0, ed. Taber's Cyclopedic Medical Dictionary. Philadelphia, PA: FA Davis Co., 2001.

19. Buist OS , LaCroix AZ, Mandredoni a 0, et aJ. Ide ntifying postmenopausal women at high risk of fracture in popula­ tions: a comparison of three strategies. J Am Geriatr Soc 2002;50: 1031-1038 20. Melton LJ III , Th amer M, Ray NT, et a!. Fractures at­ tributable to osteoporosis: report from the National Osteu­ porosiS Foundation. J Bone Miner Res 1997;12:16-23. 21. Melton LJ III. Epidemiology of spinal osteoporosis. Spi ne 1997;22(Suppl) 2S-11S. 22. Melton LJ III , Kan SH, Frye MA, et aJ. Epidemiology of ver­ tebral fractures in women. Am J Epidelniol 1989;129 1000-1011. 23. Cooper C, Atkinson EJ, Jacobsen SJ, et aJ. Population-bas study of survival
..­

>3

55

Chapter 25: The Thoracic Spine .'34. Silverman SL. The clinical consequences of vertebral com­ pression fracture. Bone 1992;13(SuppI2):S27-S31. 35. Ernst E. Exercise for female osteoporosis. A systematic re­ view of randomized clinical trials. Sports Med 1998;25: 359-368. 36. Reid IR. The role of calcium and vitamin D in the prevention of osteoporosis. Endocr Metab Clin North Am 1998;27:3 89-398. 37. Ullom-Minnich P. Prevention of osteoporosis and fractures. Am Fam Physician 1999;60:194-202. 38. YIaricic M, Adachi JD, Sarkar S, et al. Early effects of ralox­ ifene on clinical vertebral fractures at 12 months in post­ menopausal women with osteoporosis. Arch Intern Med 2002;162: 1140-1143. 39. Black DM, Thompson DE, Bauer DC, et al. Fracture risk re­ duction with alendronate in women with osteoporosis: the Fracture Intervention Trial. FIT Research Group. J Clin En­ docrinol Metab 2000:85:411 8-4124. 40. Sinaki M, Hoi E, Wahner HW, et aI. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone 2002;30: 836--841. 41. American Geriatrics SOCiety, British Geriatrics SOCiety, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older per­ sons. J Am Geriatr Soc 2001;49:664-672. 42. Harm C, Ggraat A, Lodewijk W, et al. Classical Scheuermann disease in male monozygotic twins: further support for the genetic etiology hypotheSiS. Spine 2002;27:E485-E487. 43. Sorensen KH. Scheuermann's Juvenile KyphoSiS: Clinical Appearances, Radiography, Aetiology, and Prognosis. Copenhagen: Munksgaard, 1964. 44. Flyon TW. The Thoracic Spine and Rib Cage: M usculoskele­ tal Evaluation and Treatment. Boston: Butterworth-Heine­ mann, 1996. 45. Halal F, Gledhill RB, Fraser Fe. Dominant inheritance of Scheuermann's juvenile kyphOSiS. Am J Dis Chilcl1978;132: 1105--1109. 46. Axenovich TI, Zaidman AM, Zorkoltseva IV, et al. Segrega­ tion analysis of Scheuermann disease in ninety families from Siberia. Am J Med Genet 2001;100:275--279. 47. Aufdermaur M. Juvenile kyphosis (Scheuermann's disease): radiography, histology, and pathogenesis. Clin Orthop 1981; 154:166--174. 48. Lowe TG. Current concepts review Scheuermann's disease. J Bone Joint Surg [Aml1990;72:940-945. 49. Stagnara P, deMauroy JC, Dran G. ReCiprocal angulation of vertebral bodies in the sagittal plane: approach to references for the evaluation of kyphOSiS and lordosis. Spine 1982;7: 3:33-342. 50. Somhegyi A, Ratko I, Gomor B. Effect of spinal exercises on spinal parameters in Scheuermann disease. Orv Hetil 1993; 20:401-403. 51. Richardson ML. Scoliosis. Department of Radiology, Univer­ sity of Washington, Seattle, WA, 1994. 52. Guide to Physical Therapist Practice. 2nd Ed. American Physical Therapy Association, 2001. 53. Panjabi M. The stabiliZing system of the spine. Part I Func­ tion, dysfunction, adaptation, and enhancement. JSpinal Dis­ ord 1992;5:383-389. 54. Daneels LA, Vanderstraeten GG, Cambier DC, et al. A func­ tional subdivision of hip, abdominal and back muscles during asymmetric Lifting Spine 2001;26:El14-E121. 55. Goel V, Kong '<\', Han J, et al. A combined finite element and optimization investigation of lumbar spine mechanics with and without muscles. Spinc 1993;18:1531-1541.

641

56. Wilke H, Wolf S, Claes L, et al. Stability increase of the lum­ bar spine with different muscle groups. A biomechanical in vitro study. Spine 1995;20: 192-198. 57. Daneels L, Vanderstracten G, Cam bier D, et al. SSE Clinical Science Award 2000: computed tomography imaging of trunk muscles in chronic low back pain patients and healthy control subjects. Eur Spine J 2000;9:266--272. 58. Gibbons L, Vidernan T, Bathe M. Isokinetic and psychophys­ icallifting strength, static back muscle endurance, and mag­ netic resonance imaging of the paraspinal muscles as predic­ tors of low back pain in men. Scane! J Rehabil Med 1997;29: 187-191. 59. Kader D, Wardlaw D, Smith F. Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clin RadioI2000;55:145-149. 60. Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multifidus muscle wasting ipSilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19: 165-172. 61. Kawaguchi Y, Matsui H, Tsui H. Back muscle injUry after posterior lumbar surgery. Spine 1994;19:2398-2602. 62. Sihvoncn T, Herno A, Paljarvi L, et al. Local denervation of paraspinal muscles in postoperative failed back syodrome. Spine 1993;18:375--58 l. 63. Hides J, Richardson C, Jull G. Mllltihdus recovery is not au­ tomatic follOWing resolution of acute flrst episode of low back pain. Spine 1996;21:2763-2769. 64. Daneels LA, Vanderstraeten GG, Cambier DC, et al. Effects of three different training modalities on the eross sectional area of the lumbar multiHdus muscle in patients vvith chronic low back pain. Br J Sports Med 2001;33:186-191. 65. Carpenter D, Nelson B. Low back strengthening for the pre­ vention and treatment of low back pain. Med Sci Sports Ex­ erc 1999;31:18-24. 66. Tull G, Richardson e. Rehabilitation of active stabilization of the lumbar spine. In: Twomey LT, Taylor JR, eds. Physical Therapy of the Low Back. 2nd Ed. New York: Churchill-Liv­ ingstone, 1994. 67. Winstein CJ. Knowledge of results and motor learning-Im­ plications for physical therapy. Phys Ther 1991;71:140-149. 68. Morey MC, Schenkman M, Studenski SA, et al. Spinal-flexi­ bility-plus-aerobic versus aerobic-only training: effect of a randomized clinical trial on function in at-risk older adults. J Gerontol A BioI Sci Med Sci 1999;54:M335-M342. 69. Mooney V, Brigham A. The role of measured resistance exer­ cises in adolescent scoliosis. Orthopedics 2003;26:167-171. 70. Hales J, Larson P, laizzo PA. Treatrncnt of adult lumbar sco­ liosis with axial spinal unloading using the LTX3000 Lumbar Rehabilitation System. Spine 2002;27:E71-E79. 71. l\egrini S, Antonini G, Carabalona R, et al. Physical exercise as a treatment for adolescent idiopathic scoliosis. A system­ atic review. Pediatr RehabiI2003;6:227-235. 72. Pellecchia MT, Grasso A, Biancardi LG, et al. Physical ther­ apy in Parkinson's disease: an open long term trial. J Neurol 2004;251 :595-598. 73. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and function for people with Parkin­ son's disease: a randomized, controlled trial. J Am Geriatr Soc 1998;46: 1207-1216. 74. Roach ]VV. Adolescent idiopathic scoliosis. Orthop Clin N Am 1999;30:353-365. 75. Soucacos PN, Zacharis K, Soultanis K, et al. Risk factors for idiopathic scoliosis: review of a 6-year prospective study. Or­ thopedics 2000;23:833-838. 76. Blackman R, O'Neal K, Picetti G, et al. Scoliosis treatment. Oakland: Children's Hospital, Kai. er Permanente Hospital, 1998.

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Therapeutic Exercise Moving Toward Function

77. Athanasopoulos S, Paxinos T, Tsafantakis E, et al. The effect of aerobic training in girls with icliopathic scoliosis. Scand Jo Med Sci Sports 1999;9:36-40. 78. American Academy of Orthopedic Surgeons Staff. In­ structional Course Lectures. St. Louis, MO: CV Mosby, 1985. 79. Peet RM, Henriksen JD, Anderson TP, et al. Thoracic outlet s)'l1drome: evaluation of a therapeutic exercise program. Staff Meetings of Mayo Clinic 1956;31:281-287. 80. Ide J, Kataka Y, Yamaga M, et al. Compression and stretch­ ing of the brachial plexus in thoracic outlet syndrome: corre­ lation between neuroradiographic findings and symptoms and signs produced by provocation manoeuvres. J Hand Surg 2003;3:218-223. 81. Swift TR, Nichols FT. The droopy shoulder s),11drome. Neu­ rology 1984;34:212-215. 82. !'\akatsuchi Y, Saitoh S, Hosaka M, et al. Conservative treat­ ment of thoracic outlet syndrome using an orthosis. J Hand Surg 1995;20B:34-39. 83. Adson AW. Surgical treatment for symptoms produced by cervical ribs and the scalenus anticus muscle. Surg Gynecol Obstet 1947;85:687-700. 84. Eden KC. The vascular complications of cervical libs and first thoracic lib abnormalities. Br J Surg 1939;27:111-139. 85. Roos DB. New concepts of thoracic outlet S)11drome that ex­ plain etiology, symptoms, diagnosis, and treatment. Vase Surg 1979;13:313-320. 86. Wright IS. The neurovascular syndrome produced by hyper­ abduction of the arms. Am Heart J 1945;29:1-19. 87. Edgelow PI. Neurovascular consequel1ces of cummulative trauma disorders affecting thoracic outlet: a patient centered approach. In: Donatelli RA, ed . Physical Therapy of the Shoulder. 3rd ed. New York: Churchill Livingstone; 1997. 88. Ide J, Ide M, Yamaga M. Longterm results of thoracic outlet decompression. Neuro-orthopedics 1994;16:59-68. 89. Tagaki K, Yamaga M, Morisawa K, et al. Management of tho­ racic outlet syndrome. Arch Orthop Trauma Surg 1987;106: 78-81.

90. Feise RJ , Menke JM. Functional rating index-a new valid and reliable instrument to measure the magnitude of c:linical change in spinal conditions. Spine 2001;26:85-86. 91. Fairbank JC, Couper J, Davies JB, et al. The Oswestry low back pain disability questionnaire. Physiotherapy 1988;66: 271-273. 92. Roland M, \1onis R. A study of the natural history of back pain. Part 1: development of a reliable and sensitive measure of disability in low back pain. Spine 1983;8:141-144.

RECOMMENDED READINGS Ascani E, Bartolozzi P. Natural history of untreated idiopathic scoliosis after skeletal maturity. Spine 1986;11 :784-789. Brown C, Deffer P. The natlU'al history of thoracic disc herni a­ tion. Spine 1992;17(SuppI6):S97-Sl02. Cantu R, Grodin A. Myofaseial Manipulation Theory and Clinical Application. Gaithersburg, \lID: Aspen Publishers, 1992. Donatelli R, Wooden M. Orthopaedic Physical Thf'rapy. Ne\\ York: Churchill LilingstollP, 1989. Gould J, Dalies G. Orthopedic and Sports Physical Th erapy. St Louis: CV Moshv, 1985. Gross J, Fetto J, R~sen E. \llusculoskeletal Examination . Cam ­ bridge, MA: Black-well Sci ence, 1996. Irwin S, Tecklin J. Cardiopulmonary Physical Therapy. 3rd Ed St. Louis: Mosby, 1995. Malone T, McPoll T, Nitz A. OrthopediC and Sports PhysiC"d. Therapy 3rd Ed. St. Louis: Mosby-Year Book, 1997. Mitchell FL, Moran PS, Pruzzo NA. An Evaluation and Treat­ ment Manual of OsteopathiC Muscle Energy Procedures . \ '" . ley Park, MO: Mitchell, Moran, and Pruzzo, 1979. Pratt N. Clinical Musculoskeletal Anatomy. Philadelphia: JB Lip­ pincott, 1991. Richardson J, Iglarsh ZA. Clinical Orthopaedic Physical Thera. _ Philadelphia: WB Saunders, 1994. Winkel D. Diagnosis and Treatment of the Spine. GaithersbUl"';! MD: Aspen Publishers, 1996.

chapter 26

The Shoulder Girdle CARRIE HALL

Review of Anatomy and Kinesiology Sternoclavicular Joint

Acromioclavicular Joint

Scapulothoracic Joint

Glenohumeral Joint

Scapulohumeral Rhythm

Myology

Examination and Evaluation Patient/Client History Clearing Examinations Motor Function (Motor Control and Motor Learning) Muscle Performance Pain Peripheral Nerve Integrity Posture Range of Motion, Muscle Length, Joint Mobility, and Joint Integrity Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living)

Therapeutic Exercise Interventions for Common Physiologic Impairments Pain

Range of Motion and Joint Mobility Impairments

Impaired Muscle Performance

Posture and Movement Impairment

Therapeutic Exercise Interventions for Common Diagnoses Rotator Cuff Disorders

Adhesive Capsulitis

levator scapula and upper trapezius). In addition, faulty movement patterns and associated impairnwllts of the spine and pelvis can affect fUIlction of the shoulder girdle. For example, asymmetriC spine and pelvis alignment can contribute to faults in shoulder girdle alignment and sub­ sequent movement patterns. This chapter will first present information related to anatomy, kinesiology, and evaluation ofthe shoulder girdle. This information will set the stage for the sections on ther­ apeutic exercise intervention for common physiologic im­ pairments and diagnoses. As with all other chapters in this book, the goal is not to provide a list of exercises for shoul­ der girdle impairments and conditions, but rather to pro­ vide the necessary information to become a critical thinker and perceptive problem solv r such that you wiU be pre­ pared with the knowledge necessary to develop an efficient and effective exercise prescription for any case involving the shoulder girdle.

REVIEW OF ANATOMY AND KINESIOLOGY The anatomy and kineSiology of the shoulder girdle is one of the most complex regions of the body. The comhined co­ ordinated movements of the four distinct articulations and the involved muscles and periarticular structures allow the arm and hand to be positioned in space for a variety of functions. The result is a range of motion (ROM) tbat ex­ ceeds that of any other joint complex in the body. The shoulder girdle is composed of four distinct articu­ lations: sternoclavicular (SC ), (AC ), scapulothoracic (ST), and glenohumeral (GH ). Each of these joints function in­ terdependently and in synchrony.

Adj unctive Interventions: Taping Scapular Corrections

Prevention of Allergic Reaction

Prevention of Skin Breakdown

The shoulder girdle functions 'Nith the arm , forearm, wlist, and hand in a kinetic chain vvith the trunk and lower ex­ tremity. Therefore, dysfunction of the shoulder girdle can affect function of related regions , and conversely dysfunc­ tion of related regions can affect function of the shoulder girdle. For example, faulty movement patterns and associ­ ated impairments of the shoulder girdle can affect function of the cervical spine because of shared musculature (i.e.,

Sternoclavicular Joint The SC joint is a synovial jOint in which the clavicle articu­ lates with the sternal notch and cartilage of the first rib (Fig. 26-1). An alti cular disk, )oint capsule, and associated ligaments complete the joint. Binding to the clavicle, the disk prevents medial displacement and acts as a l1inge and shock absorber on which the clavicle moves when the shoulder is moved up and down. 2 The movements allowed at the SC joint are summarized in Table 26-1. The major ligaments surrounding the SC joint include the costoclavicular, the anterior and posterior sternoclavic­ ular, and the interclavicular (see Fig. 26-1). The joint cap­ sule is reinforced by these ligaments. 1 Though each of these

643

644

Therapeutic Exercise: Moving Toward Function

Costoclavicular ligament

Posterior

Interclavicular ligament

Acromion process

Sternal end of clavicle Articular disc

Medial rotatior Lateral rotation

----,.L-Carti lage of rib

Anterior sternoclavicular ligament

' - - - - - - - Manubrium

FIGURE 26-1 . Sternoclavicular articulation, anterior view. Coracoid process

A

ligaments provides a specific function, they act together to support the weight of the shoulder and arm. This support is so strong that, even with paralysis of the trapezius, the shoulder girdle remains supported 3 The capsular and liga­ mentous restraints result in a very stable joint that is rarely dislocated; consequently, forces imposed on tlle clavicle frequently result in fracture rather than joint dislocation. 4

Downward rotation

\~

Upward rotation

1

~ 1

Acromioclavicular Joint The AC joint is formed by the articulation of the acromion process of ilie scapula with the acromial end of the clavicle. The miicular facets of the AC joint are small, afford limited motion , and have a \,vide range of individual differences. For these reasons, studies are inconsistent in identifying the movement and axes of motion for this joint. This text presents one theory of the biomechill:!ics of the AC joint de­ scribed by Zuckerman and Matsen. ) The movements are summarized in Table 26-2 and illustrated in Fig. 26-2. The three major ligaments that are important for proper functioning of the AC joint are the superior and inferior AC and coracoclavicular ligaments (Fig. 26-3). The superior and inferior AC ligaments cover the superior and inferior aspects of the AC jOint, offer some protection to the joint, and assist horizontal joint stability. The cora­ coclavicular ligament prOvides much of the AC joint sta­ bility and acts as the binding force between the clavicle and scapula. The most critical role played by this ligament is in producing longitudinal rotation of the clavicle, which is necessary for full ROM of the scapula during elevation of the upper extremity.6

1 -')

I

MOTION

DEGREES

Elevation Depression Protraction or retraction Rotation

4-60 5-15 15 (from resting position) 30-50 (posteriorly about the horizontal axis)

Data from refe rences 7, 223, 224.

1 I

1

! (;

B

\~

C

Sternoclavicular Joint Motions

"

\~ \

~

FIGURE 26-2. Top view of the scapula and clavicle, showing the axes motion at the acromioclavicular joint. (A)Vertical axis (solid dod for scar lar medial rotation ("winging ") and lateral rotation. (B)Transverse axis the sagittal plane (dotted line) for scapular upward and downward rota ti :-­ (e) Transverse (horizontal) axis in the frontal (coronal) plane (dotted Ir -E for scapular anterior and posterior tilting ("tipping"). Adapted from Zucker man JD, Matsen FA III. Biomechanics of the shoulder. In: Nordin M, Fra n r~ VH, eds. Basic Biomechanics of the Musculoskeletal System. 2nd e: Philadelphia: Lea & Febiger, 1989.

Chapter 26 The Shoulder Girdle

645

Acromioclavicular Joint Motions MOTION

AXIS

DESCRIPTION

Rotation

Sagittal axis through acromioclavicular joint Vertical axis through conoid ligament Frontal axis through trapezoid ligament

Scapular rotation cranially or caudally Vertebral border posterior, glenoid fossa an telior Inferior border posterior, superior border anterior

Winging (medial rotation) Tilting (tipping)

The AC joint is prone to degenerative changes,' which is significant for several reasons. Because scapular rotation is necessary for functional shoulder movement, disease or ossification of the AC joint tends to encourage the scapula and clavicle to function as a unit. This pattern of use alters the scapular path of instant center of rotation (PICR). Be­ cause of its intimate association with the rotator cuff and bursa, changes in the PICR of the scapula can lead to mi­ crotrauma or macrotrauma of subacromial structures. Pathology of the subacromial structures can contribute to physiologic impairments, functional limitation, and disabil­ ity. Evaluation of the function of the AC joint is often crit­ ical to understanding causal determinants of several shoul­ der conditions.

Scapulothoracic Joint The ST joint is a functional joint (i.e., not a true joint) of the concave ventral scapula and articulates with the convex rib cage. Surrounding this joint are the coracoacromial and su­ perior transverse ligaments (see Fig. 26-3). The cora­ coacromial ligament forms a roof over the head of the humerus as it runs from the coracoid process to the acromion, helping to prevent upward displacement of the head of the humerus. This ligament provides a protec­ tive mechanism for the underlying bursa and supraspinatus

tendon. It has a sharp lateral edge that may impinge on the underlying structures when the arm is elevated, particu­ larly if the PICR of the GH or ST jOint is faulty or the sub­ acromial tissues are inflamed. The superior transverse ligament bridges the lesser scapular notch to form a foramen for the passage of the suprascapular nerve (see Fig. 26-3). Under ordinary cir­ cumstances the tunnel may offer protection to the nerve, but if there is injury, inflammation, or scarring in the region, the confined area becomes a source of entrapment.·~-l'o ST movement requires motion of the clavicle on the thorax at the SC joint and motion of the scapula relative to the clavicle at the AC jOint. Traditionally, motions of the scapula are known as elevation/depression, abduction/ad­ duction, medial (i.e., winging)/lateral rotation, and up­ ward/downward rotation.

Glenohumeral Joint The GH joint is a synovial join t composed of the head of the humerus articulating with the glenoid fossa of the scapula. With ideal postural alignment, the humeral head is oriented medially, posteriorly, and cranially, and the glenoid faces laterally, anteriorly, and cranially (Fig. 26-4),u However, variations in the alignment of the glenoid fossa occur. For example, an individual with a thoracic kyphOSiS does not

Coracoclavicular

ligament

Conoid ligament Trapezoid -:::::=:~~:JI:Jff:.~~>i: ligament

Superior transverse ligament Scapular foramen Coracoid process

FIGURE 26·3. Acromioclavicular joint glenohumeral joint anterior view.

Coracoacromial ligament Coracohumeral ligament

646

Therapeutic Exercise: Moving Toward Function

FIGURE 26·4. Anterior view of the orientation of the head of the humerus 222

and glenoid fossa The humeral head is oriented medially, posteriorly, andcranially, and the glenoi dfossa faces laterally, anteriorly, and cranially.

have optimal alignment of the scapula. In most subjects, the fossa tilted slightl1 inferiorly, as wOllld be expected with thoracic kyphosis. 2- 17 The glenOid is one half as long and one third as wide as the head of the humerus, but it is deepened somewhat by a fibrocartilage rim called tlJe glenOid labrum 1 8 The labnlm has thTee ke), roles in contributing to stability of the GH jOint. First, it doubles the anteroposterior depth of the glenOid socket from 2.5 to 5 mm and deepens the concav­ ity to 9 mm in the superior-inferior plane. lU Second, the labrum enhances stability of the jOint by increasing the sur­ face area of contact for the hWlleral head. 20 F inally, and perhaps most importantl)" the labrum serves as a fibrocar­ tilaginous ring to which the glenorumeral ligaments attach. 21 Early investigators underappreciated the importance of the GH ligaments. 22 Selective GH lig
Superior glenohumeral ligament

~

Biceps

FIGURE 26-5. Glenohumeral ligaments, posterior view, looking at the un­ derside of the GH ligaments.

and strain gauge analyses led the way to fully appreciating the contribution of the GH ligaments to shoulder stabil­ ity "l-26 The GH ligaments are discrete thickenings in the joint capsule (Fig. 26-5). Superiorly, the capsule is rein­ forced by the coracohumeral ligament, which blends inti­ mately with the rotator cuff tendons and fills in the space between the subscapulalis and supraspinatus tendons (see Fig. 26-3). The superior GH ligament courses from the an­ terosuperior labrum anterior to the biceps tendon and in­ serts superior to the lesser tuberosity near the bicipital groove. Th,,:.!" two structures in concert limit inferior trans­ lation and external rotation of the adducted shoulder and postelior translation of the fle xed, adducted , internally ro­ tated shoulder. 21 The middle GH ligament arises next to the superior GH ligament and extends laterally to attach on the lesser tuberosity in association with tlle subscapularis tendon. This ligament limits antelior translation of the humeral head when the arm is abducted between 60 degrees and 90 de­ grees. 24 .26 The inferior GH ligament is described as the thickest and most consistent structure (see Fig. 26_5).26The inferior GH ligament functions like a hammock in prevent­ ing increased translation of the humeral head on th e glenoid. With abduction, the entire complex moves beneath the humeral head and becomes taut. Conversely, with in­ ternal rotation, the complex moves posteriorly and limits posterior translation. Finally, with external rotation, the complex moves anteriorly and limits anterior translation. 2 !

tI iJ

P u

T ir

13 a ~

n;

b. C1

E'J

tl n

ql to

d, fo

Scapulohumeral Rhythm The intricate interplay of the four articulations of the shoulder complex results in a coordinated movement pat­ tern of ~1l1 elevation referred to as scapulohumeral rhyth m (SHR ).2t T he involved movements at each joint are conti n­ uous, although occurring at various rates and at differen t phases of arm elevation. E levation of the ann involves GH and ST motion; wi.th ST motion the result of motions at the AC and SC jOints. After Codman 27 described scapulo­ humeral rhythm dUlini? abduction in 1934, J1umerous stud ­ ies followed G ,28.1u 1--1 ) 29-:-lS In man et aiR shovved that thl" SHR is fixed and almosi~.O : l during abduction. However tllis belief has not been supported by late r investi\!a­ tions. lJ I :).I()_29. l.~ Bagt8 repOlts that three distinct patterns of SHR exi and that each pattern is more complex than the 2:1 rati proposed by Inman and colleagues. ) The most common 0 ' the three patterns is characte rized by three separatl phases, each havi ng different SHH. ratios. D uring the mid­ dle phase, from approxilllately 80 d~grees to 140 degrees abduction, scapular rotation provides a greater contribu­ tion to ann elevation than GH motioll. A possible explana­ tion of the relative increase in the scapular contributi during the midrange of arm devation is that the mom eO' arms of the scapular rotators are larger during that ~eriO thall those of the deltoid and rotator cuff muscles. 5 .29 J seellls reasollable that the greatest relative amount scaplllm rotation occurs over the most difficult range c arm abduction. l l The existence of three patterns of SH may be explained by variatiolls in anthropometric mea­ sures, postures, and muscle imbalances. It may be possibl,

(

\'

h. Tt

Chapter 26 The Shoulder Girdle

that one of the patterns is ideal and that the other patterns indicate faulty PICR at the ST and GH joints. Faults in the PICR of the ST and GH joints may predispose an individ­ ual to shoulder dysfunction.

Myology The muscles acting on the shoulder complex can be divided into three major groups: scapu lohumeral (SH), axioscapu­ lar (AS), and ax.iohumeral (AH). Table 26-3 prOvides a list of the muscles in each group and their primary functions. The rotator cuff-deltoid force couple and scapular force couples deserve special mention because of the coordi­ nated and integrated function of the muscles within and between each force couple. Optimal function of the rotator cuff-deltoid forc e couple reqUires the coordination of sev­ eral muscles in the SH group, whereas optimal function of the scapular force couple requires coordination of several muscles in the AS group. Dynamic stabilization of the com­ posite movement of the scapular-humeral aliiculation re­ quires coordinated function of both the scapular and del­ toid-rotator cuff force couples. The follOwing sections will detail functions of the deltoid-rotator cuff and scapular force couples.

Shoulder Girdle Categories and

Muscle Function

MUSCLE Scapulohumeral Group Supras pin at us • Infraspinatus Teres minor· Subscapularis " Deltoid Anterior fibers yliddle fibers Posterior fibers Teres major Coracobrachialis Axioscapular Gmup Trapeziusf Upper fibers Middle fibers Lower fibers Serratus an teriort Rhomboid major and minod Levator scapulat Pectoralis minor anterior

AxiohumeraI Group Pectoralis major

Latissimus dorsi

FUNCTION Humeral abduction

Lateral rotation (LR)

LR

Medial rotation (MR)

Flexion and MR

Abduction

Extension and LR

MR

Flexion and MR

Scapular elevation

Scapular adduction

Scapular depression and

adduction Scapular abduction Scapular elevation and adduction Scapular e levation Scapular depression and tilting MR extension and adduction, clavicular fibers flex to 90 degrees MR and extension

• Part of the rotator cuff. t Part of the scapular upward rotator force couple. I Part of the scapular dOl-Vnward rotator force coup le.

647

Rotator Cuff- Deltoid Force Couple Humeral elevation relative to the scapula is chiefly the re­ sult of an appropriate balance behveen forces of the deltoid and rotator cuff. Lack of muscle balance can result in an al­ tered PICR contlibuting to impingemen t, hypermobility, or instability. The deltoid muscle provides the priIl1ary force for arm elevation, yet also produces a superior trans­ lation component:3\J,40 The inferior and medially direct d forces of the rotator cuff offset the superior translation force of the deltoid, speCifically the ,infraspinatus, teres mi­ nor, and subscapularis muscles 41 -44 Optimally, the supe­ rior translation component of the deltoid muscle is offset by the inferior translation component of the rotator cuff, al­ lo\ving the PICR to achieve the kineSiolOgiC standard. In addition to offsetting s\.!perior translatory forces, the cuff muscles also assist in limitin~ ~nterio.r and posterior translatIOns of the humeral head 4 . ConcaVIty compresSIOn refers to the stability afforded a convex object that is pressed into a concave surface. This mechanism is active in all GH positions but is particularly important in the func­ tional midrange in which the capsule and ligaments are slack. 46 The specialized anatomy of the rotator cuff muscles along with the intraaliicuiar long head of the biceps are ideally suited to activery compress the humeral head into the glenOid concavity.4 1 Shoulders with weakened or defi­ cient rotator cuff mechanisms are likely to have compro­ mised stability from concavity compression.20.48.49

Scapular Force Couple Recent three-dimensional research has expanded Inman et aI's original description of "scapulohumeral rhythm" to in­ clude anterior/posterior tipping (about an axis approxi­ mately parallel to the scapular spine) and medial and lateral rotation (about an apprOximate vertical axis) , in addition to the Originally described upwardldownward rotation (about an axis ~e~endicular to the plane of the scapula) (see Fig. 26_2).6.. 0-.0 ' During arm elevation in the scapular plane, scapular upward rotation increases and tipping progresses from anterior to posterior..50-·;257 Scapular medial rotation is more variable, either decreasing, increasing, or staying relatively unch:mged S O-.52,.57 Deviations from the normal pattern have been identified in patients with impingement and will be discussed in detail is a subsequent section. Rotation of the scapula is prOvided by a force couple ac­ tion from the trapezius (upper, middle, and lower fibers) and the serratus anterior. These muscles , working in com­ bination, provide concentric control for upward rotation and eccentric control for the returning motion under slow, unresisted conditions. If working with optimal magnitude, direction, and timing, the PICR of the scapula migrates from the root of the scapula toward the acromioclavicular joint.16.5b.59 Understanding the timing of the onset ofscapu­ lar muscle activity offers insights into the causes of deviation from the ideal PICR of the scapula. This knowledge can help diagnose and manage various shoulder conditions. PartiCipation of the middle trapeZius , lower trapezius , and serratus anterior muscles varies with the plane of mo­ tion in which the arm is moving 6 The middle and lower trapezius muscles are the more active component of the force couple during arm movement in the frontal plane, and the serratus anterior is the more active component of

648

Therapeutic Exercise: Moving Toward Func tion

the force couple during arm movem e nt in the sagittal plane 6 The middle and lower trapezius muscles relax somewhat during movem ent in the sagittal plane, presum­ ably to allow the scapula to abduct around the rib cage. 6 If the onset of action of each scapular muscle in the course of scapular upward rotation in the scapular plane could be obse rved, the most optimal pattem fiO to create the expected PIeR could be determined (Fig. 26-6). In the up­ per trapezius , increased activity occurs as soon as arm ele­ vation begins; plateauing between 15 to 45 degrees and 90 to 120 cJegrees arm elevation. As the arm elevates beyond this point, the activity increases, reaching maximal activity at the termination of arm elevation (see Fig. 26_6A)60 Minimal activity occurs in the lower trapezius until ap­ proximately 90 degrees of arm elevation. Early activity of the lower trapezius may interfere with elevation of the scapula at the sternoclavicular joint. As elevation increases beyond this pOint, activity increases quite rapidly until the termin ation of arm elevation; this pattern probably results from the improved mechanical advantage of the lower

trapezius as the PIeR migrates toward the acromioclavicu­ lar joint (see Fig. 26-6B ). Activity patterns vary markedly in the middle trapezius. There is a slight increase in acth,ity initially, with a plateau phase occuning bet\veen 15 and 105 degrees. Beyond the plateau phase, the activity increases Significantly until the termination of arm elevation. The middle trapezius most likely prevents excessive movement of the scapula into ab­ duction from forces generated by the serratus anterior (see Fig 26-6C ). The lower serratus anterior exhibits a gradual initial in­ crease in activity, "vith a brief plateau phase occurring at approximately 90 degrees that is followed by a rise in activ­ ity until the termination of ann elevation. Relatively con­ stant activity is found in the serratus anterior throughout scapular upward rotation (see Fig. 26-6D). Another study by Wadsworth and Bullock-Saxton used surface electromyography (EMG) to prOVide data regard­ ing specific timing of the onset of musc:le activity in the AS muscles during arm elevation. 51 Surface EMG data for the upper and lower trapezius and serratus anterior indicate

Upper trapezius

Middle trapezius

EMG activity vs. arm angle

100% EMG 935 ~v

100

E ::J

::J

E

E

'x ro

E

'0

~

50

C

50

C

'>

:~

~ ~

75

E

'0

ti ro

U ro

25

~

25

~

w

w I 30

I

I

60 90 120 Arm angle (degrees)

150

30

120 60 90 Arm angle (degrees)

Lower trapezius

::J

::J

E

§

75

E

'0

~

50

~

~ ~

75

E

'0

'> t5ro

=

E

E

~

EMG activity vs. arm angle 100% EMG 1005 ~v

~ 100 ~

=

E

150

Serratus anterior

EMG activity vs. arm angle

100% EMG 612 ~v

100

§

vl

=

E

'xro 75

~

EMG activity vs. arm angle 100% EMG 818 ~v

~ 100 ~

=

50

~

'>

nro

25

~ ~

w

25

w 30

60 90 120 Arm angle (degrees)

150

30

90 120 60 Arm angle (degrees)

FIGURE 26-6. Commonly observed patterns of electrical activity for the trapezius and lower serratus anterior muscles. (Adapted from Bagg SO, Forrest WJ. Electromyographic study of the scapular rotators during arm ab­ duction in the scapular plane. Am J Phys Med 1986;65:3)

150

, I i (

-

<

Chapter 26 The Shoulder Girdle

649

that the upper trapezius is activated 217 milliseconds (ms) before shoulder motion, followed by serratus anterior acti­ vation 53 ms after motion commences. Lower trapezius was not recruited until 349 ms after shoulder motion, when the arm had attained 15 degrees of elevation.

Integrated Rotator Cuff- Deltoid and Scapular Force Couples The integrated functions of the scapular and rotator cuff-deltoid force couples are essential for optimal func­ tion of the GH and ST joints. Scapular rotation during arm elevation adds to the total ROM and enables the humeral head to clear the acromion process during arm elevation. \Vithout adequate scapular rotation, the humerus may im­ pinge against the acromion process (Fig. 26-7). Further importance is attached to scapular rotation when the length-tension relationship of the deltoid muscle is considered. When the arm is at the side, the deltoid mus­ cle is at its resting length and is capable of generating max­ imum tension when contracting. As the arm is elevated, the deltoid contracts and shortens. If the scapula does not ro­ tate sufficiently, the length-tension property of the deltoid is disrupted. Scapular rotation is necessary to keep the acromion moving away from the deltoid insertion to main­ tain the deltoid close to its resting length. If the scapula fails to rotate sufficiently, the deltoid functions in a rela­ tively shortened length, which disrupts the deltoid-rotator cuff force couple, potentially leading to an excessive proxi­ mal force vector from the deltoid. This disruption causes the head of the humerus to translate superiorly, leading to impingement of the subacromial structures. Adequate movement of the scapula is also necessary to assist in stabilization of the GH jOint. Insufficient move­ ment of the scapula may contribute to compensatory ex­ cessive movement of the GH joint to achieve the desired ROM. For example, during horizontal abduction move­ ments, scapular adduction is necessary to move the arm posterior to the frontal plane. Failure of the scapula to adduct suffiCiently may cause the humeral head to translate anteriorly to achieve the desired motion of the arm in a pos­ terior direction. This motion is required in the cocking phase of pitching, the backswing during a tennis ground stroke, or in reaching behind the back (Fig. 26-8).

"Abduction" (frontal plane)

FIGURE 26-8. The scapular plane is approximately 30 to 40 degrees an­ terior to the frontal plane.

EXAMINATION AND EVALUATION More than 50 physical diagnostic tests have been de­ scribed for the shoulder girdle 62-D6 Diagnosis of dysfunc­ tion in the shoulder girdle is challenging because of the complex anatomy and kineSiology and interrelationships of the AV, SC, GH, and ST joints and the cervicothoracic spine. Furthermore, functions of the elbow, forearm, wrist, and hand are related to the function of the shoulder girdle as part of the upper quarter kinetic chain. Dys­ function in one segment of the chain affects the function of other segments. A clinical example of the close relationship between joints in the upper quarter is an individual with reduced forearm pronation ROM. The compensation for this re­ striction during the activities of daily living (ADLs) requir­ ing forearm pronation may be medial rotation and abduc­ tion of the GH joint to orient the palm of the hand downward. If this pattern is performed repetitively, partic­ ularly in elevated arm positions biased toward the frontal plane, impingement of the subacromial structures of the shoulder may develop. The descriptive examination and evaluation information discussed in this section is not intended to be comprehen­ sive or reflect any specific philosophical approach. It is pre­ sented in alphabetical order and should simply serve as a review of pertinent tests performed in shoulder girdle ex­ aminations.

Patient/Client History

FIGURE 26-7. Decreased subacromial space resulting from lack of scapu­ lar rotation during arm elevation. This is a potential extrinsic cause of im­ pingement syndrome.

In addition to the general data collected from a patient! client history as defined in Chapter 2, Display 26-1 illus­ trates a sampler of information that is important to obtain from a patient ,vith impairment, functional limitation, or disability involving the shoulder girdle complex

650

Therapeuti c Exercise Moving Toward Function

DISPLAY 26·'

Functional Index Questionnaire

Functional Index Part 1:

Answer a/l five sections in Part 1. Choose the one answer in each section that best describes your condition. Walking o Pain does not prevent me walking any distance.

:J Pain prevents me walking more than 1mile.

CI Pain prevents me walking more than '/2 mile.

..J Pain prevents me walking more than '/4 mile.

..J I can only walk using a stick or crutches.

':J I am in bed most of the time and have to crawl to the toilet.

Work

(Applies to work in home and outside) ..J I can do as much work as I want to.

o I can only do my usual work, but no more. o I can do most of my usual work, but no more. '.oJ I cannot do my usual work. o I can hardly do any work at all (only light duty). :l I cannot do any work at all. Personal Care

(Washing, dressing, etc.) CI I can manage all personal care without symptoms. ':J I can manage all personal care with some increased symptoms. .J Personal care requires slow, concise movements due to increased symptoms. CJ I need help to manage some personal care . ..J I need help to manage all personal care. :l I cannot manage any personal care. Sleeping

':J I have no trouble sleeping.

o My sleep is mildly disturbed (less than 1 h sleepless).

Q My sleep is mildly disturbed (1-2 h sleepless).

':::l My sleep is moderately disturbed (2-3 h sleepless).

:J My sleep is greatly disturbed (3-5 h sleepless).

o My sleep is completely disturbed (5-7 h sleepless).

Recreation/Sports

(Indicate sport if appropriate _ _ _ _ _ _ _ _ _,

o I am able to engage in all my recreational/sports activities without increased symptoms.

w I am able to engage in all my recreational/sports activities with some increased symptoms.

o I am able to engage in most, but not all of my usual recreational/sports activities because of increased symptoms. ::l I am able to engage in a few of my usual recreational/sports activities because of my increased symptoms.

Clearing Examinations Rou tine cervicoth oracic spine scre ening should be in­ eluded durin g the examination of any patient with shoulder girdle signs and symptoms, Dysfunction of the ce rvico t~o ­ racic region may contribute to shou lder dysfuncti on 6 1­ 69 Additionally, the elbow-wrist-hand complex should be ex-

:l I can hardly do any recreational/sports activities because of increased symptoms. o I cannot do any recreational/sports activities at all. Acuity

(Answer on initial visit.)

o How many days ago did onset/injury occur?

days

Part II:

Choose the one answer that best describes your condition in the sections designated by your therapist. Upper Extremity Carrying o I can carry heavy loads without increased symptoms. o I can carry heavy loads with some increased symptoms. o I cannot carry heavy loads overhead, but I can manage if they are positioned close to my trunk. o I cannot carry heavy loads, but I can manage light to med ium loads if they are positioned close to my trunk. o I can carry very light weights with some increased symptoms. o I cannot lift or carry anything at all.

Dressing

;:J I can put on a shirt or blouse without symptoms.

::1 I can put on a shirt or blouse with some increased symptoms. ..l It is painful to put on a shirt or blouse and I am slow and careful. o I need some help but I manage most of my shirt or blouse dressing. w I need help in most aspects of putting on my shirt or blouse. ...J I cannot put on a shirt or blouse at all. Reaching Q I can reach to a high shelf to place an empty cup without increased symptoms. Q I can reach to a high shelf to place an empty cup with some increased symptoms. I can reach to a high shelf to place an empty cup with a moderate increase in symptoms. :l I cannot reach to a high shelf to place an empty cup, but I can reach up to a lower shelf without increased symptoms. o I cannot reach up to a lower shelf without increased symptoms, but I can reach counter height to place an empty cup . :l I cannot reach my hand above waist level without increased symptoms. Adapted with permission from Therapeutic Associates Outcomes System, Therapeutic Associates, Inc" Sherman Oaks, CA.

eluded as a source of pain , although it rarely refers p::... prOximally to the shoulder. Visceral referral of symptoms should be considered cases refractory to physical therapy intervention. Appen 1 lists speCific visceral pain referral patterns into the sh der girdLe . A thorough health history can assist in iden ing signs that may deSignate visceral sources of sympto

Chapter 26 The Shoulder Girdle

Motor Function (Motor Control and Motor Learning) Visual observation and palpation of the PI '1\ of tilE' ST and GH joints c:an be augmented by surface E MG. The ~se of surface EMG can assist in determining patterns and tlJ1lmg of recrnitment of the trapezius, serratus, deltoid, and in­ fraspinatus muscles; the infraspinatus is the only rotator cuff muscle that c:an be examined with palpation or surfac EMG. Surface EMG can be usefu'l in determining faulty motor control patterns responsible for mallYshoulder diag­ noses. This type of qualitative testing is important, because active ROM may he vvithin normal limits ,vith an abnormal PICR and an abnormal PICR can contribute to shoulder dysfunction.

651

Diagnosis Based on Resistive Tests FIND ING OF RESISTIVE TEST Strong and painless Strong and painful Weak and painful

Weak and painless

LESION Normal Minor muscle lesion Minor t 'ndon lesion Gross lIlacrotra umat ic lesion sllch as fracture Partial rupture of muscle or tendon Muscle or tendon rupture ~eurol o gjc dysfunction

Muscle Performance Impaired muscle performance can resnlt from numerous causes/sources (refer to Chapter 5). Various tests can de­ termine the presence and potentia) cause or source of im­ paired muscle performance. Specific manual muscle testing (lvIMT) prOvides infor­ mation regarding the amount of force or torque that a mus­ culotendinous unit can generate. Display 26-2 prOvides a list of muscles that should be included in YlMT of the s110ulder girdle. MMT is traditionally done, but testing of muscle performance can be performed with a dynamome­ ter, and both types of testing can be performed in conjunc­ tion with,surface EMG when appropriate. T exts 012 f£lanual testing for specific protocols should be consulted. 10. , l. Positional strength testing is a speCialized form of .\tIYIT that tests the muscle at a specific length to obtain informa­ tion regarding the ]ength-tension properties of the muscle (see Chapter 5). Positional strength testing is particularly useful in determininG" whether a muscle is weak because of altered len gth-tensi6n properties. If a muscle is length­ ened, it tests weak in the short range but strong in a slightly more lenothened range. If a muscle is weak bec:ause of oth er cau~es, it tests weak throughout the range. Sarhmann has provided more information on po~~tiona] strength test­ ing of muscles in the shoulder girdle. i_

DISPLAY 26-2

Shoulder Girdle Muscles to Include in Manual Muscle Testing* • Upper, middle, and posterior deltoid • Glenohumeral lateral rotators • Glenohumeral medial rotators (with isolation of subscapularis) • All portions of the trapezius • Serratus anterior • Rhomboids and levator scapula • Pectoralis major • Latissimus dorsi • The reader is referred to the appropriate reference for specific manual muscle testing techniques lD 84

Selective tissue te nsion tests combine active and passi.ve RO M \vith resisted tests of muscles about the shoulde r gir­ dle. 7 The sum total of the results of each test assists the practitioner in determining whic]: !~ssue is the probable source of the shoulder condition. r\ ," .\tIany clinicians use Cyriax's selective tissue tension m9d I for the diagnosis of soft-tissue lesions of the shoulder. ,6 T he Cyria,'{ model has been shown to be a reliable scheme for assessing patients with shoulder pain. 77 If selective tissue tension test res ults are positive for a contractile lesion, the resisted test can fur­ ther diagnose the severity of the lesion. Table 26-4 high ­ lights diagnostic findings of resisted tests.

Pain Evaluation of pain is done throughout the examination pro­ cess. Palpation of suspeded tissues is llsed to evaluate tis­ sue tension, te mperature, swelling, and provocation of pain 7s Cyriax73 and Maitland 79 advocate use of the se­ quence of pain and resistance during passive movement testing to establish the irritability level of a tissue. This in­ formation can gUide the ag:rressiveness ,vith whic:h stretch­ ing and mobilization tpc:hniques are performed. . . Because a subjective report of the pam assoclated Wlth specific activities can help in the assessment, the clinician should question the patien t about which a b,ities are asso­ ciated ,vith pain. Pain often is latent (Le., experienced af­ ter the adivity), which makes it difficult to relate a cause or source. The range of pain, from the least pain to the worst pain ex-perienc:ed, should be examined through some accepted method of pain assessment (e.g., visual analog scale).BO

The clini.cian rn ust attempt to determ ine a medmnical cause of the pain during the cours e of the examination. This is often quite challenging but necessary to ensure full recovery and prevention of recurrences. F or example, al­ though the supraspinatus tendon c:an be diagnosed as the source of pain through selective tissue tensio~ testing and palpation, the c:ause of the pain may be insufficient scapu­ lar upward rotaticlI1. Insufficient upward scapular rota~iun can lead to pain because of mechanical imp ingement of the supraspinatus under the acromion process . Local treat­ ment of the supraspinatus may dec:rease the pain in the short tenn. However, treatment of the faulty postures and

652

Therapeutic Exercise Moving Toward Function

movements and related impairments is essential to rem edy the problem for the long term.

DISPLAY 26-3

Elements to Include in Testing Range of Motion, Muscle Length, Joint Mobility, and Joint Integrity of the Shoulder Girdle

Peripheral Nerve Integrity Thoracic outlet81 and neural tissue provocation testing 82 can be performed in addition to the peripheral nerve in­ tegrity tests included in cervicothoracic screening and re­ sisted tests designed to determine a pattern of muscle weakness due to peripheral nelve injury. Tests of shoul­ der girdle musculature, combined with elbow, forearm, wrist, and hand musculature, can indicate whether a nerve deficit is at the level of the cervical spine (i.e., nerve root) or is a peripheral nerve lesion. The pattern of weak­ ness indicates peripheral or nerve root involvement or possibly forms of myopathy (i.e., fascioscapulohumeral muscular dystrophy).

Posture Atypical positions of the ST and GH joints and cervicotho­ racie spine have?een noted in patients with shoulder gir­ dle dysfunction .6 i ,68,7o.H3.1l1 Although there is inconsistent clinical reliability and va1idity with tests to measure scapula and humerus position,S, there is research supporting the relationship between the incidence of pain in the shoulder girdl e and aberrant scapu la and humerus posture. 67 ,6S Therefore, the clinician should observe and document the following: • Total body alignment-particularly related to sym­ metry in limb lengths • Head, thoraCiC, and lumbar spine alignment • Pelvic position about all three planes • Analysis of alignment of the scapula, clavicle, and humerus about all three planes of motion

Range of Motion, Muscle Length, Joint Mobility, and Joint Integrity

• Active and passive osteokinetic ROM of the scapulothoracic. glenohumeral, and cervicothoracic spine joints • Passive arthrokinematic mobility tests of the sternoclavicular. acromioclavicular, glenohumeral. scapulothoracic joints, and cervicothoracic spine • Capsuloligamentous integrity225-228 • Glenoid labrum integrity tests 22 9-231 • Rotator cuff integrity232,233 • Subacromial impingement tests 234,235 • Muscle length testing for scapulohumeral. axioscapular, and axiohumeral muscle groups. Examples of muscles that fall into each category are summarized in Display 26-4, Sarhmann 72 and KendaWo have described the appropriate muscle length testing procedures, • Functional movements should be examined. including reaching behind the back. touching the back of the head and neck. and reaching across to the opposite shoulder,

DISPLAY 26-4

Shoulder Girdle Muscles Prone to Adaptive Length Changes Adaptive Shortening Rhomboid major and minor Levator scapula Upper trapezius Subscapularis Teres major Latissimus dorsi Pectoralis major and minor Long head of biceps Glenohumeral lateral rotators

Elements to include in testing range of motion, muscle length, joint mobility and joint integrity of the shoulder gir­ dle are listed in Display 26-3.

Adaptive Lengthening Middle trapezius Lower trapezius Upper trapezius Subscapularis Serratus anterior

DISPLAY 26-5

Shoulder Pain and Disability Index .

Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living) Functional testing, whether in the form of performance testing or subjective grading, should be included in the examination. One form of subjective grading that can be time efficient is a health-related quality of life scale. The Shoulder Pain and Disability Index (SPADI)HIi,s7 is a self­ administered questionnaire that consists of two dimen­ sions, oue for pain and the other for functional activities, and requires 5 to 10 minutes for a patient to complete. Dis­ play 26-5 lists the SPADI items . Roach and colleagues 86 and Williams and associates 87 have explained the adminis­ tration of this test.

Pain dimension: How severe is your pain? At its worst?

When lying on the involved side?

Reaching for something on a high shelf?

Touching the back of your neck?

5. Pushing with the involved arm?

1, 2, 3, 4,

Disability dimension: How much difficulty do you have?

1. Washing your hair? 2. Washing your back?

3, Putting on an undershirt or pullover sweater?

4, Putting on a shirt that buttons down the front?

5. Putting on your pants? 6. Placing an object on a high shelf? 7. Carrying a heavy object (e,g,. 10 Ibl? 8. Removing something from your back pocket?

Chapter 26 The Shoulder Girdle

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENTS After a thorough examination and evaluation of the shoul­ der girdle, tlw clinician should have a good understanding of the functional limitations affecting the patient and the related impairments, A diagnosis and prognosis are fornlU­ lated, and an intervention is planned, After it is determined which impairments should be treated to restore function, a plan of care must be developed to treat the appropriate im­ pairments and functional limitations, Therapeutic exercise intervention is vital in the restoration of ~houlder girdle function, primarily because exercise is important in restor­ ing the preCise coordinated muscular force couples acting on the four integrated joints in the shoulder girdle com­ plex. The folloWing sections provide information about therapeutic exercise intelventions for common physiologic impairments, Pain is presented as the first impairment be­ cause of the importance of understanding the underlying impairments contributing to andlor causing the pain,

Pain Differential diagnosis of pain in the upper quarter is diffi­ cult in part because of the interdependence in the anatomy of the shoulder, elbow, wrist, hand, and cervicothoracic spine, Pain stemming from tissues in the shoulder girdle may be experienced locally or referred distally down the arm as far as the ,\lTist and hand ss Confounding the diag­ nosis of the source of shoulder pain is the fact that the shoulder girdle is a common region for referral from other musculoskeletal regions such as the cervicothoracic spine 8890 and non musculoskeletal sources, such as the heart and diaphragm (see AppendiX 1)91 If the source of the pain is determined to be in the shoul­ der girdle, treatment may involve a combination of inter­ ventions, including manual therapy, physical agents or electrotherapeutic modalities, and therapeutic exercise. A clinical example can illustrate the use and interaction of physical therapy interventions. Display 26-6 lists hypothet­ ical examination and evaluation findings of a person diag­ nosed ,\lith rotator cuff impingement. Treatment of the source of the pain may include tl1e follOWing techniques: • Transverse friction massage to the affected rotator cuff tenoperiosteal or musculotendinous junctions to assist in the formation of a strong and mobile scar 73 • Active exercise, electrical stimulation in mid range, or both to broaden the muscle (serving a similar purpose to that of transverse friction massagef3 • Physical agents (e ,g" cryotherapy) or electrothera­ peutic modalities (e,g., phonophoresis, ultrasound)92 used to treat the inflammatory process • Activity modification in the form of changing patterns of posture and movement; or reducing or eliminating the activities thought to cause or perpetuate the con­ dition 93 Treatment isolated to the source of the pain provides tem­ porary relief, particularly if the cause of the pain is repeti­ tive microtrauma from faulty postures or movement pat-

653

terns, The clinician must address the cause of the pain for long-term resolution of the problem. A common cause of rotator cuff impingement is repetitive impingement under the acromion process of the scapula because of faulty movement patterns or postural habits h4 ,:)Ogj Treating the cause of the rotator cuff impingement re­ quires eliminating or modifying th e slIstained postures and repetitive movelnent patterns believed to contribute to or perpetuate the condition, This training is far more speCific than the basic activity modification described under treat­ ment of the source of the pain. Optimal training of sus­ tained postures and repetitive movement patterns usually requires prior therapeutic exercise intervention focused on muscle performance, joint mobility, and muscle extensibil­ ity, Improved physiologic capabilities prOVide a better foundation for precise posture and movement control. For exa mple , lower trapeziu s and serratus anterior muscles \\lith an MMT grade of 3-/5 cannot paJiicipate in a mus­ cular force couple to upwardly rotate the sClpula against gravity, Therapeutic exercise aillied at improving muscle performance of the upward rotators until they achieve a minimal MMT grade of 3 to 3+/5 is a prerequiSite for re­ training the coordinated muscular force couples reqUired for functional movement patterns against gravity. Posture and movement education must be initiated as soon as pos­ sible, but premature introduction of functional activities can perpetuate the faulty postures and movement patterns causing the pain and inflammation, In the case presented in Display 26-6, the follo\\ling im­ pairments must be addressed to promote optimal posture and movement patterns: • Muscle performance of the rotator cuff (see Self­ Management 26-1: Facelying Shoulder Rotation) and scapular upward rotators (see Self-Management 26-2: Facelying Arm Lifts and Self Management 26-3: Ser­ ratus Anterior Progression) • Muscle extensibility of the pectoralis minor (Fig. 26­ 9), rhomboids and levator scapula (Fig 26-10), and GH lateral rotators (see Self-Management 26-4: Lat­ eral Rotator and Posterior Capsule Stretch) • JOint mobility of the AC, SC, ST, and GH joints Because of altered length-tension properties of the scapu­ lar upward rotators, the exercises prescJibed must be initi­ ated at relatively low levels of intensity, For example, the patient should begin ,vith level I of the lower trapezius (see Self-Management 26-2) and serratus anterior progreSSions (see Self-Management 26-3), Even so, improving the mus­ cle performance of the lower trapezius, serratus anterior, and rotator cuff may not translate directly into improved function, Transitional exercises should be prescribed to train the muscle to function with the appropriate magni­ tude and timing during ADLs or instrumental ADLs, Ex­ amples of transitional exercises are shown in Fig, 26-11, Ineffective treatment of pain may result from failing to determine that the source of symptoms is not within the shoulder girdle, Even if the source is determined to come from an associated musculoskeletal region , ineffec­ tive treatment may nonetheless result from failing to recog­ nize that the shoulder girdle may be contributing to the cy­ cle of pain and dysfunction, For example, a patient may be (text continues on page 661)

654

Therapeutic Exercise Moving Toward Function

DISPLAY 26-6

Clinical Case of Rotator Cuff Impingement (Primary Rotator Cuff Disorder) Examination and Evaluation History A 35-year-old, right-handed man complains of right shoulder pain. His occupation requires him to sit at a visual display ter­ minal (VDT) 8 to 10 hours each day, 5 days each week. He also engages in cross-country skiing, climbing, and kayaking . He is unable to sleep on his right shoulder and has pain at night that awakens him briefly two to three times each week. He is unable to participate in any recreational activity using his right arm overhead. Work is not disrupted at this time, al­ though he does experience a fatiguing discomfort between his shoulder blades while working at the computer about two-thirds into his workday. Postunl Aligrment Moderate forward head, moderate abducted, anterior tilted, and downwardly rotated scapulae, with the right scapula slightly depressed, bilateral humerus in moderate abduction (R > L), and moderate thoracic kyphosis Cervical Cleanng Exammation Slight stiffness in cervicall rotation to the right, otherwise neg­ ative for shoulder girdle signs or symptoms Passive Range of Motion Elevation in the plane of the scapula (see Fig . 26_8)236.237_ 150 degrees Lateral rotation at 90 degrees of abduction-90 degrees Medial rotation at 90 degrees of abduction-40 degrees Elbow, forearm, wrist, hand-within normal limits (WNL) Active Range of Motion Active arm elevation in flexion and abduction-WNL Total scapular upward rotation is 45 degrees. Glenohumeral (GH) I'ateral rotation with the arm adducted to the side is 60 degrees, but it improves to 80 degrees when the scapula is positioned in neutral instead of the patient's ab­ ducted rest position. Scapulohumeral Rhythm Faulty scapulohumeral rhythm is present. The scapula is slow to elevate from the initial depressed position and is still de­ pressed relative to the left at 90-degree flexion, but exces­

sively elevates in the last half of flexion . In addition, the scapula fails to fully uRwardly rotate and is only rotated up­

ward to 10 degrees at 90 degrees of flexion. The patient expe­ riences pain from 90 degrees to end range. Pain ;s reduced with assisted elevation and upward rotation of the scapula . Muscle Length Moderate shortness in the GH lateral rotators and rhomboids and lengthened right upper trapezius and middle trapezius. JOint Mobility Hypomobile GH posterior and inferior glide, scapulothoracic (ST) upward rotation, and acromioclavicular (AC) joint antero­ posterior glide Muscle Performance (tests performed on r;ght only) Glenohumeral lateral rotators: 3+/5 (pain) Glenohumeral abductors: 4-/5 (pain) Supraspinatus (full can test)233: 3+/5 (pain) Subscapularis (lift-off positionj14.75: 3+/5 Upper trapezius: 3+/5 Middle trapezius: 3+/5 Lower trapezius: 3+/5 Serratus anterior: 3+/5

Rhomboids/levator scapula : 5/5 Biceps: 4-/5 Triceps: 5/5 Resisted Tests General abduction, outer-range lateral rotation, and supraspinatus are weak and painful. Motor Control Surface EMG analysis demonstrates latent upper trapezius and serratus anterior activity, when compared to the unin­ jured side, during scaption . Pa patlOn Tenderness was elicited over the tenoperiosteal and muscu­ lotendinous junction of the supraspinatus and AC joint. Special Tests Neer impingement sign 133 and Hawkins and Kennedy impingement tests 238 are positive Jobe apprehension test 134 is negative Drop arm tesr39 is negative Sulcus sign 240 is negative Assessment This patient appears to have primary rotator cuff disorder. His impairments include: • Altered mobility in periarticular soft tissues limiting posterior and inferior glide of the GH joint Reduced muscular extensibility in GH lateral rotators, further contributing to limited GH posterior glide • Reduced muscular extensibil ity in scapular downward rotators, limiting scapular upward rotation Lengthened scapular elevator and upward rotator group, affecting length-tension properties of muscles participating in the upward rotator force couple • Decreased muscle performance of the elevator or upward rotator, affecting the muscle's participation in the active force couples • Altered motor control patterns in scapular rotators • Positive signs of injury to subacromial tissue, particularly supraspinatus (i.e., positive impingement sign, weak and painful resisted tests, palpation). Summery of Pathomechanics

This patient is vulnerable to developing impairments that contribute to impingement syndrome. The prolonged faulty posture he sustains during an 8- to 10-hour workday can lead to altered base, modulator, and biomechanical ele­ ments of the movement system . The faulty joint alignment (biomechanical), can contribute to GH impingement because of the altered relationship between the ST and GH joints. Prolonged faulty postures can lead to altered muscle length­ tension properties (base), which can contribute to altered movement and recruitment patterns (biomechanical and modulator). For example, if the scapula is chronically ab­ ducted, downwardly rotated, depressed, and anteriorly tilted at rest, the axioscapular upward rotators could adaptively lengthen and the axioscapular downward rotators and scapulohumeral muscles could adaptively shorten. When he raises the arm overhp.ad, as is required for rock climbing and kayaking, the patient's scapula may not sufficiently up­ wardly rotate and the humeral head may translate exces­ sively superior in the glenoid fossa . This movement pattern results in impingement of subacromial structures against the AC ligament and possibly the acromion process.

~

[

.

Chapter 26 The Shoul der Girdle

r~'

• • • • SELF-MANA GEMENT 26- 1

~

Purpose' St8rling position:

Facelying Shoulder Rotation

.

To strengthen the shoulder rotators and train independent motion between the shoulder blade and the arm Kneel next to a weight bench; if at home, lie on your stomach adjacentto the edge of your bed. Place two or more rolled towels under your shoulder joint. Position your arm out to the side with the elbow bent to 90 degrees. Keep as much of your shoulder supported on the bench or bed as possible. Your arm should hang from your elbow down, not from your shoulder. Properly positioned, your elbow should be slightly lower than your shoulder and the " ball" of the "ball-and-socket" joint should be well supported with towel rolls.

Lateral rotation I I

i

10"'1

(targe mil cle subscapulafls)

Movement technique: Lateral rotation (target muscles: infraspinatus, teres minor) • You may perform this exercise just by rotating your arm or with weight. If you are to perform this with weight, see the amount of weight you have been prescribed under dosage. • Slowly rotate your shoulder so that your forearm moves up toward your head. Stop just short of horizontal. Concentrate on letting your arm move independent from your scapula. Your shoulder should "spin " in the socket. There should be no movement of your scapula . An alternate activity is to place your forearm on the table in the start position, slowly move your wrist off the supporting surface and hold your wrist and forearm isometrically for 5to 10 seconds. Return your hand back to the supporting surface. Repeat for the designated number of repetitions.

Dosage Weight Sets/repetitions Frequency

Dosage Weight Sets/repetitions Frequency

Medial rotation

You may perform this exercise by rotating your arm with or without added weight. If you perform this with weight, see the amount of weight you have been prescribed under dosage. Slowly rotate your shoulder in the opposite direction so that your forearm moves backward. Do not let your shoulder displace into the towel roll. Think of keeping your shoulder "pulled away" from the towel roll, or the "ba1l" in the "socket." Your range of motion is more limited in medial rotation than lateral rotation (possibly only 10 to 20 degrees). Remember, it is quality not quantity that is important.

655

656

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 26-2

Face/ying Arm Lifts

Purpose: To strengthen the middle and lower trapezius Starting position: Lie on your stomach with at least one pillow under your abdomen. Place your hands on the back of you r head. Use this position for levels I through III.

• Relax your elbows to the table. • Stop when your neck muscles become more tense; this is an indication that the middle and lower trapezius are fatiguing and you should stop and rest.

--...

Start position

Movement technique: Levell: Stomach-lying elbow lifts(t8rget muscles: middle and lower trapezius) Barely lift your elbows. Keep your neck muscles (upper trapezius' relaxed, and contract the region between your shoulder blades (lower trapezius'. Keep the contraction just enough to lift the elbows so as not to use rhomboids to adductthe shoulder blades. • Hold the contraction for 5 seconds. • Lower the elbows and repeat. Stop when your neck muscles become more tense; this is an indication that the middle and lower trapezius are fatiguing and that you should stop and rest.

--...

Level I, end position

Dosage Sets/repetitions Frequency

Levell!, mid-position

Dosage Sets/repetitions Frequency Level III: Stomach-lying elbow lift with arm extension overhead (target muscles: middle and lower trapezius) Barely lift your elbows. Keep your neck muscles (upper trapezius' relaxed, and contract the region between your shoulder blades (lower trapezius'. Keep the contraction just enough to lift the elbows so as not to use rhomboids to adduct the shoulder blades. As you extend your elbows while raising your arms overhead, be sure not to tense your neck muscles (upper trapezius) during this level of exercise. If you are unable to keep your neck muscles rel'atively relaxed, you may not be ready for this level of exercise. • Return your hands to your head, lower your elbows, and relax.

Level II: Stomach-lying elbow lift with arms extended (target muscles: middle and lower trapezius)

Barely lift your elbows. Keep your neck muscles (upper trapezius' relaxed, and contract the region between your shoulder blades (lower trapezius',. Keep the contraction just enough to lift the elbows so as not to use rhomboids to adduct the shoulder blades. ~ Slowly extend your elbows so that your arms are straight. Bend your elbows so that the hands retu.rn to the position behind your head.

Level III

Dosage Sets/repetitions Frequency (continued.1

Chapter 26. The Shoulder Girdle

•.....

I.

~~ SELF-MANAGEMENT 26-2

Face/ying Arm Lifts (Continued )

Starting position. Lie on your stomach on a weight bench, piano

Level/VB Stom8ch-IYlng dlagon81 reverse flV (target mL cle: IOLVer frapezfU )

bench, or low bed. Your chest should be sus­ pended off the edge ofthe bench. Bend your knees if they extend too far off the bench. Pull your abdomen up and in. Your head should be in line with your spine with your chin tucked. Hold dumbbells with palms facing forward and thumbs up. Arms should be relaxed at chest level and resting on the floor or against the bench if the bench is tall. Keep elbows slightly bent.

• Raise your elbows in a semicircular motion, diagonally upward toward the head to just below the level of the head. Do not lift the elbows above the level of the head. • Lower to the starting position using the same path. • Exhale up; inhale down. • Repeat in sets of 10 repetitions. Begin using a light weight when you can complete two sets of 10 repetitions maximum with proper techniqu e.

Movement techmque. Level IVA: Stomach lying reverse honzontal ffy (target muscle. middle trapezius) • Raise the dumbbells in a semicircular motion to just below chest height. Do not lift beyond chest level. • Lower to the starting position using the same path. • Exhale up; inhale down.

Level IV B

Dosage Weight Sets/repetitions Frequency

Dosage Weights Sets/Repetitions Frequency

657

658

Thera peu tic Exercise: Moving Toward Functi on

SELF-MANAGEMENT 26·3

Serratus Anterior Progression

Purpose: To progressively strengthen your serratus anterior

Levell: Back/ying isometric with 8rm overhead

Starting position:

Levell!, start position

Movement techmque •

Slide your arm upward toward your head, keeping it in contact with the pillows. • Sl owly lower the arm back down to the starting position. Do not pull the arm back down, but slowly lower it against the resistance of the elastic .

Ue on your back with one to two pillows positioned above (not unded your head.

Movement

technique. •

Raise your arm overhead, close to your ear, until it reaches the pillow. • Gently but consistently push your arm backward into the pillow and hold for 10 seconds.

Levell

Dosage Sets/repetitions Frequency

Leve/I/: Side/ying with dynamic arm slide

Starting position: Lie on your side with two to three pillows in front of your head and shoulders. Bend your hips and knees. Rest your arm on the pillows with your elbow bent. Grasp the prescribed color of elastic band in your hand and attach the other end to your top toot.

Levell!, end position

Dosage Color of elastic Sets/repetitions Frequency

Leve/III: Standing back to the wall and arm lift

Starting position:

Stand with your feet about 2to 3 inches from the wall. Your head should be againstthe wall. If you cannot bring your head against the wall, place one or two small, rolled hand towels behind your head. Pull in your stGmach to rotate your pelvis backward and reduce the arch in your back. You should be able to place one hand between your lower back and the wall. If there is more space between your !back and the wall, bend your hips and knees slightly to reduce the pull from yourhip (continued)

Chapter 26 The Shoulder Girdle

659

SELF-MANAGEMENT 26-3 Serratus Anterior Progression (Continued)

flexors. You should be able to reduce the arch of your back more easily.

• Slowly lower your arms to your side, ensuring your shoulders stay back against the wall and do not roll forward,

Level III, start position

Movement technique: •

Lift your arms in front of your body with your elbows straight. • Try to bring the arms all the way back to the wall, but stop if you feel your back arching or your shoulders shrugging.

Level III, mid position

Dosage Weight Sets/repetitions Frequencv

FIGURE 26-10, Rhomboid and levator stretch. The patient's elbow is rest­ FIGURE 26-9. Manual stretch of the pectoralis minor. The hand applying the stretch force is placed over the coracoid process A sta bi lizing hand can be placed over the rib cage. The fo rce appl ied by the practitioner is in a pos­ terior, superior, and lateral di rection .

ing on the practitioner's abdomen. The practiti oner cups her hands around the scapu la By shifting the body weight from the caudal to the cran ial po­ sitioned foot, a rotationa'i force is transmitted to the scapula. The hands ro­ tate the scapula upwa rd like the scapula r force couple.

660

Therapeutic Exercise: Moving Toward Function -

~o~

SELF· MANAGEMENT 26·4

Purpose: Starting position:

Lateral Rotator and Posterior Capsule Stretch

To stretch the shoulder rotators and train independent movement between the shoulder blade and the arm Slide your arm out to the side, and bend your elbow to 90 degrees. Position your forearm so that the fingers point to the ceiling. Hold your shoulder down with the opposite hand.

Movement technique: •

Relax and let your shoulder joint rotate, allowing your forearm to move toward the floor. • Do not let your shoulder come off the floor and move into your hand as your forearm gets closer to the floor. • You may hold up to a 2-lb weight in your hand to assist in the stretch.

Dosage Hold the stretch for Sets/repetitions _ _ _ _ _ _ __ Frequency _ _ _ _ _ _ __

seconds

AltemBte position:

Movement:

Lie on the side of your affected arm. Be sure to lie directly over your shoulder joint with your arm positioned at perpendicular to your body and your elbow bent to 90 degrees. • Using your free hand, place it on the dorsum ofthe hand ofthe shoulder you are stretching. Gently perform an isometric contraction into your free hand. Hold for 6 seconds. Relax. • On relaxing, move your forearm downward in the direction of your fe et until you feel a mild stretch. Repeat the isometric contraction. Move your hand to the next barrier. Repeat 3to 4times.

Chapter 26: The Sh ou lder Girdle

661

FIGURE 26·11 . Transitional rotator cuff exercises. (A)The patient places the ulnar aspects of the hands on the wall and slides the hands up the wall in the sagittal or scapular plane. depending on whether the focus is on the serratus anterior or lower trapezius. respectively. (8) Medial rotation bias. The patient places the palm of the hand against the door frame and slides the hand upward and downward while mainta ining a mi ld pressure into medial rotation against the door frame. The patient must not push so hard that she recruits the pectora lis ma­ jor, latissimus dorsi, and teres major The goal is to use the subscapularis to encourage an increased rotator cuff force vector during arm elevation by facilitating subscapularis (C) Lateral rotation bias. The patient places the dorsum of the hand aga inst the door frame and slides the hand upward and downward while maintaining a mild pressure into lateral rotation against the door frame.

diagnosed with radicular pain originating from an inflamed C5-C6 nerve root caused by a protruding nucleus pulposus at that level. However, it may be determined that faulty pos­ tures and movements of the shoulder girdle are contribut­ ing to faulty postures and movements of the cervical spine because of the shared musculature and joint articulations H5 An example is a person with a depressed scapula at rest (Fig. 26-12) and insufficient elevation of the scapula during movement. This person may experience excessive tension on the cervical spine because of overstretching of the upper trapezius at rest and levator scapula during upward scapula rotation. This excessive tension may compromise normal movement of the cervical spine and restrict cervical rotation with the arms at the side or simultaneously with movement of the shoulder girdle (e.g. , driving a car and needing to look behind the shoulder). In this case, treating the cervical spine in isolation may not result in full functional recovery. How­ ever, adding treatment of the posture and movement pat­ terns of the shoulder girdle and the related shoulder im­ pairments to the plan of l:<1re may remedy pain originating from the cervical spine. Intervention for this case could in­ clude the following features: • Scapular taping into elevation and upward rotation (see Adjunctive Interventions: Taping later in this chapter) • Upper trapezius strengthening (Fig. 26-13 ) • Education regarding posture habits (e.g., do not allow the shoulder to assu me a depressed position) • Movement retraining (Le., exaggerating scapular ele­ vation initially and retraining normal movement after the upper trapezius participates well in the scapular upward rotation force couple)

Range of Motion and Joint Mobility Impairments This category of impairments covers the scope of 05­ teokinematic and arthrokin ematic mobility from excf'ss ive ROM or joint hypermobility to reduced ROM or joint hy­ pomobility. An example of extreme loss of Illobility is ad­ hesive capsulitis or frozen shoulder, and an example of cx-

FIGURE 26·12. Slightly depressed right scapula .

662

Therapeutic Exercise Moving Toward Function

~~.

•

c

8

FIGURE 26·13. Upper trapezius strengthening into the short range. For patients with 3/5 muscle strength the patient faces the wall and slides the ulnar aspect of the hand up the wall (See Fig . 26-11A). At the end range, scapula elevation is performed through ava ilable ROM (not pictured). For patients with 3+/5 to 5/5 muscle strength: patient performs an overhead press technique (A) At end ra nge, scapula elevation is performed through full available ROM. (8 and C)

treme excessive mobility is GH dislocation. Mobility is a hallmark characteristic of the shoulder girdle. Even a mi­ nor alteration in mobility at any of th e four joints can dis­ rupt the normal mechanics of the shoulder girdle. For the purposes of simplifying terminology in this sec­ tion , we have chosen to use the terms hyponwbility when referring to either loss of range of motion, reduced exten­ sibility in soft tissues, or reduced joint mobility; and hyper­ nwbility when referring to excessive ROM, excessive mus­ cle length, m- excessive joint mobility. H ypomobil.ity usually causes a compensatory increase in motion at m10tler joint in the complex (Le" scapular eleva­ tion as compensation for lack of GH motion or a hypomo­ bile posterior GH capsule causing excessive anterior GH translation and anterior hypermobility)U6.<J7

Hypomobility Hypomobility and hypermobility impairments can coexist in the shoulder girdle complex. For example , if the scapula does not fully upwardly rotate during ann elevation, arm el­ evation can be achieved by moving into excessive scapula elevation; or the humerus may compensate by translating excessively inferiorly.84 When restoring balanced and coor­ dinated 111otion to the shoulder girdle, mobility must be re­ stored in the specific direction of the relatively less mobile jOint. Simultaneously, the relatively more mobile segments must be protected from motion in the offend ing direction

(i.e., external support such as bracing or taping) or retrain­ ing movement pattems ). The method by which mobility is restored must be deter­ mined on a case-by-case basis. To choose the appropriate treatment technique, it must be determined which struc­ tures are responsible for the loss of mobility (i.e., muscle, pe­ riarticular tissue, boney alterations), the direction of the loss of motion, and the severity of res triction, Anyone or a com­ bination of the four jOints may be restricted in one or nu­ merous directions because of articular or peliarticular soft tissue or bony restlictions or loss of extensibility or adaptive shortening of myofascial tissue. If the restrictions are mild and the compensatory movements can be minimized, self­ stretching, self-mobilization, and active exercise may suffice. However, if tlle restrictions are Significant (involVing more than one segment) or affect a specific arthrokinematic mo­ tion, manual joint mobilization, soft-tissue mobilization , or manual stretching may be indicated (see Chapter 7). Stretching

Stretching short or stiff myofascial tissue with a self managemen t program can be challenging because of the complexity of the join t system and the ease of moving in compensatory patterns, espeCially in the shoulder girdle For example, it is dimcult to self-stretch a short rhomboid muscle that is limiting scapular upward rotation , because the compensatory motion may be to elevate t:he scapula. which does not result in a stre tch to the rhomboids. Man­

Chapter 26 The Shoulder Girdle

663

Scap1l1ohumeral Mmcle Stretch; and Fig. 26-1.5, respec­ tively. Stretchin a is ineffective if the improved nexibility does not translate into an improved func tional outcome. Posture education is anoth r important aspect to consider when treating mobility impairments. The patient must be edu­ cated to avoid posturcs that adaptively shorten the target soft tissues and lengthen the opposing ones. In the case of a shOJi pectoralis minor, sittillg or standing in kyphOSiS and forward head posture must be gradl'lal'ly reduced. Scapular taping can assist in improving postural habits (see Adjunc­ tive Intervent,ions: Scapular Taping). Active exe rcise throuah a functional range must be in­ structed and performcd precisely to stretch the short soft tissues and recruit th e len thened and weak muscles with the optimallengtb-tension re lationships. Though originally depicted as an exercise to promote function of the rotator cuff, Fig. 26-11 cun also be llsed to orient the scapu1la into upward rotation, plaCing the rhomboid in an elongated po­ sition. The PICR of the scapula must be close ly obselved,

FIGURE 26-14. Traditional pectoralis major and minor stretch.

ual stretching (see Fig. 26-10) may be necessary to restore normal tissue extensibility to the rhomboids. Concurrent strengthening exercises for the scapular upward rotators (see Self-Management 26-2 and Self-Management 26-3) is encouraged until normal scapular upward rotation mobility is restored during active motion. The same challenge can occur in attempting to stretch a short pectoralis minor that is limiting scapular posterior tilt of the scapula dUling arm elevation. The traditional corner stretch (Fig. 26-14) can be ineffective because the head of the humerus can compensate by moving anteriorly into the weak anterior capsule in stead of stretching a short pectoral muscle. This action reflects a fundamental physical law: ob­ jects tend to move through the path ofleast resistance. The relatively lax anterior capsule is the path of least resistance, and it stretches more readily than a short pectoralis minor. Manual stretching (see Fig. 26-9) may be necessary until normal extensibility of the pectoralis minor is achieved. Stretching should be combined with strengthening of the lower trapezius (see Self-Management 26-2) and serratus anterior (see Self-Management 26-3) until posterior tilt is restored during active motion. In these example s, stretching the short muscle was combined \vith strengthening an antagonist muscle. This principle is important to restore muscle balance. In this case, stretch ing the pectoralis minor, rhomboid, or both muscles can be complemented with active exercise of the middle and lower trapezius and serratus antelior muscles in the shortened range . Other common muscles in the shoulder girdle that re­ quire stretching include the GH lateral rotators and the me­ dial rotator-adductor group. Although these often can be successfully self-stretched, speCial self-stabilization tech­ niques should be employed to ensure compensatory mo­ tions do not occur. These exercises are illllstrated in Self­ Management 26-4; Self-Management 26-5: Latissimus and

Latissimus and Scapulohumeral Muscle Stretch

SELF-MANAGEMENT 26-5

Purpose: Starting position:

To stretch the trunk muscles that attach to your arm and the muscles that originate on the shoulder blade and attach to your arm. • Lie on you r back with your hips and knees bent and feet flat on the flo or. To stretch your scapulohumeral muscles, you need to prevent your sh oulder blade from slidin g out to the sid e. To do this, you need to hold the outside edge of your shoulder blade with the opposite hand.

Movement technique: •

Raise your arm over your head, keeping the arm close to your ear. When you feel your back arch or your shoulder blade slide out to the side, stop the movement. • Rest your arm on the appropriate number of pillows so that your arm may relax in the position previously determined. • Hold the stretch for the prescribed amount of time, and lower your arm back to your side. Keep your shoulder back as you lower your arm, and do not let it roll forward.

Dosage Hold the stretch for Sets/repetitions Frequency

_ _ _ _ _ _ _ _ seconds

664

Therapeutic Exercise: Moving Toward Function

gressive exercise protocols if it is occurring in response to a less mobile segment. For example, the GH joint may be­ come hypermobile in the anterior direction in response to a hypo mobile scapula in the direction of adduction. A func­ tional scenario is reaching behind the back, which requires a combination of GH extension, medial rotation and ad­ duction, and scapular downward rotation and adduction. If the scapula fails to adduct, it becomes a barrier to the head of the humems. If the goal is to reach behind the back, the humerus may compensate by translating into the ante­ rior capsule. This is just one functional example of how the humerus may compensate ,vith excessive anterior translation, but if

AGURE 26-15. Active pectoralis major stretch. (A)The patient rests her

A

abducted and laterally rotated arms on pi llows in the scapu lar plane The pillows should be of sufficient height to prevent glenohumeral anterior translation . (8)The patien t sl ides her arms upwa rd until she feels a stretch across the pectoralis region A static stretch can be maintained at the end position.

and biofeedhack provided to the patient regarding any de­ viation from the optimal PICR to ensure stretch to the rhomboid muscle. Effects of Immobilization

Loss of ROM and muscle extensihility and joint hypo­ mobility can occur as a result of immobilization; self­ immobilization resulting from pain , fear, or a decondi­ tioned state; or imposed immobilization after an injury to allow healing to occur. Immobilization should never be prolonged because of the tendency to develop myofascial shortening, loss of capsular extensibility, muscular atrophy, and disturbed motor control. Immobilization resulting in hypomobility can c:ause functional limitation and profound disability. To prevent immobilization during painful periods or during the "rest" phase of healing, carefully prescribed ROM exercises c:an be initiated. Pain , lack of strength, and poor motor control can lead to further pain and injury dur­ ing elevation against gravity. In the early phases of healing, a traditional gravity-lessened exercise in which GH motion is ac:hieved is the Cod man exercise, also called the pendu­ lum exercise (Fig. 26-16 ). This exercise adds traction to the GH jOint, stretches the capsule, avoids active abduction , and minimizes the commOJ1 faulty movement pattern of scapular elevation during exercise against gravity. The rhythmic pendulum movements can modulate pain.

Hypermobility To effectively treat hypermobility or instability in the ab­ sence of a traumatic: onset, the hypomobile segments must be identified. Hypermobility does not improve despite ag­

B

c FIGURE 26-16. Pendulum exercise. (A)The patient should bend forward G the hips approximately 90 degrees, and his knees should be slightly bent \{ allow greater hip flexion and minimize stress to the low back. The patie r _ should place the hand not being used in the exercise on a firm surface (e.g stool) and place his head on the hand. This permits relaxed movement ar,;: concentration on the indicated movement of the involved shoulder. The ir­ volved arm should dangle free ly, and aweight can be held in the hand. Us;, of an iron as aweight is suggested for home exercise. Aweight adds tractiu;­ to the glenohumeral joint and widens the pendulum arc. The patient shau': maintain the thoracic spine in neutral to prevent excessive scapula abd l.l~­ tion, so as to transmit the forces from the weight to the GH joint rather th
Chapter 26: The Shoulder Girdle

665

this compensation is repeated throughout daily activities, hypermobility results in the CH joint in the anterior direc­ SELF-MANAGEMENT 26-6 Subscapularis tion. Treatment must focus on the cause of the hypermobil­ Isometric Exercise ity by improving mobility of the relatively less mobile seg­ ments and concurrently reducing mobility at the relatively Purpose. To strengthen the subscapularis in the short more mobile segments. Improving the muscl e perfor­ range mance, length-tension propeliies, and motor control of the dynamic stabilizers in the relatively more mobil e direction Starting position: Kneel next to a weight bench; if at home, lie is the recommenued approach to decrease excessive or ab­ on your stomach adjacent to the edge of your normal mobility. SpeCific exercise to remedy impairments bed. Place one or two towels rolled under associated with faulty movement patterns must be included your shoulder. Position your arm out to the in the plan of care. Ultimately, the functional movement side with elbow bent to 90 degrees. Ke ep as patterns causing the hypennobility must be addressed (e.g., much of your shoulder supported on the retraining scapular adduction at the appropriate time in the bench or bed. Your arm should hang from your coordinated hOiizontal arm adduction movement pattern). elbow down, not from your shoulder. Rotate An impairment commonly associatcd with a faulty move­ your arm backward as far as you can before ment pattern that contributes to an anterior GH hypermo­ you feel the "ball" drop out of the socket. bility is impaired muscle performance and altered length­ Position a garbage can or another object sufficient to support your arm. tension properties of the CH medial rotators. However, only one of the GH medial rotators is in an anatomic posi­ Movement tion to prOvide a dynamic anterior restraint to the CH joint: technique: • Raise your hand 1/2 inch off the garbage the subscapularis. To isolate subscapulalis function from can, and hold it for 10 seconds. the other medial rotators (i.e., pectoralis major, latissimus • Be sure the "ball" does not drop out of the dorsi, and teres major), its unique function must be pro­ socket. moted by carefully prescribing the posture and movement Lower your hand back to the garbage can. parameters of the activity chosen. Because ofits anterior in­ Dosage sertion close to the axis of rotation, the subscapulariS theo­ Sets/repetitions retically can prevent anterior translation during functional Frequency activities that require dynamiC restraint against excessive CH anterior translation (i.e., cocking phase of pitching). An exercise to improve the muscle performance and length-tension properties of a lengthened subscapulariS is prone medial rotation (see Self-Management 26-6: Sub­ scapulariS Isometric Exercise ). If the subscapularis can produce enough force or torque to rotate the ann against gravity, prone is the desired position for the patient to per­ form medial rotation S 4 Prone medial rotation poses a greater challenge to the subscapularis to prevent the humerus from translating anteriorly than a supine position, in which gravity assists the humerus posteriorly. Theoreti­ cally, if the other medial rotators dominate the subscapu­ laris during this exercise, anterior translation during medial rotation will occur. The goal in this case is to strengthen the subscapulariS to prevent abnormal or excessive anterior translation of the head of the humerus during CH medial rotation and dur­ ing other functional movement patterns. Resolution of this element defect. A bas e element problem may be caused by impairment does not necessarily translate into a functional insufficient subsc
666

Therapeutic Exercise: Moving Toward Function

Impaired Muscle Performance As discussed in the examination/evalu ation section, im­ paired muscle performance can result from numerous causes. This section discusses therapeutic exercise interven­ tion for each major cause of impaired muscle performance.

Neurologic Pathology Neurologic pathology can lead to sensory or motor changes and occur at the level of the nerve root or in the periphery. Thorough examination and evaluation can determine the anatomic site of the neurologiC deficit. A thorough discus­ sion of thoracic outlet syndrome can be found in Chapter 25, The Thoracic Spine. Alterations in neurologic function at the nerve root level from cervical involvemei1t can be a source of im­ paired muscle performance in the shoulder girdle muscu­ lature. For exam ple, rnechanical dysfunction of the C4 or C5 levels may result in weak abduction, flexion, medial, or lateral rotation9~ Strength-related actiyities will not im­ prove muscle performance in the shouTder until the cause of the l1lechani cal dysfunction of the ce rvical spine is ad­ dressed (see Chapter 24, Cervical Spine, for concepts re­ lated to therapeutic exercise intervention of the cervical spine) . If the underlying cause of impaired muscle per­ formance is cervical mechanical dysfunction, the position of th e cervical spine with respect to the trunk and the shoulders is extremely important when performing shoul­ der exercises. Another common neurologiC deficit involving the shoul­ der girdle is injury of a peripheral nerve resulting from traction , compression, trauma, or surgery. Nerves that are vulnerable to injury are the supraspinatus nerve in the suprascapular notch ,99.100 the axillary nerve between teres major and teres minor, the Tong thoracic nerve along the middle axillary lin e,101 spinal accessory in the jugular fora­ men or posterior triangle 102, 103 and the brachial plexus in the thoracic outlet. 10 1 Nerve injury often results in weak­ ness of the innervated muscles. Injury to the long thoracic nerve is discussed to demonstrate the resulting muscle per­ formance impairments and the related therapeutic exercise intervention. The pathophysiology of long thoracic nerve palsy is de­ termined by three factors: direct pressure on the nerve , stretching of the nelve, and ischemia. Each factor sepa­ rately can cause a nerve lesion. The long thoracic nerve is particul arly susceptible to stretch from postures or move­ ments of depreSSion of the scapula (e.g., carrying a heavy bag with the strap over the shoulder). The stretchinp' ca­ pacity of a peripheral nerve is estimated at SCi( to 15%,flJ5 In research on human cadavers, in which the head was turned to the opposite shoulder while elevating the ipSilateral arm, th e l on~ thoracic nerve could be stretched twi ce its length I G The injury manifests as weakness of the serratus anterior, a critical muscle for normal scapular mechanics. A hallmark sign for long thoracic nerve injury is scapularv.ljng­ ing at rest that is exaggerated during arm elevation, arm lowering, or pushing. The pathomechanics that contributed to the injury must first be resolved before strength-related activities can be effective, In the case of a traction injury to the long tl~omcic nerve, the postures and body mechanics that cause depression of the scapula must be addressed ,

Strength exercises for the scapular elevators (e.g" upper trapezins ) is often necessary. Taping the scapula into eleva­ tion may also be reqUired to relieve the tension on the nerve (see Adjunctive Intelven tions: Scapular Taping). To develop a working prognosis, one must consider the anatomy of the long thoracic nerve. From its origin, the root of C5-C7, and the brachial plexus, the long thoracic nerve runs between the first rib an d the clavicle to the serratus anterior muscle over a distance of approximately 35 cm. Recovery of the nerve is a very slow process: about 1 cm per week. Re c_overy may occur between a few months and 2 years. IOI Initially, neuromuscular electrical stimulation (N MES) can be used to prevent muscle atro­ phy,JOB NMES can be used \vith biphasic pulses in burst mode applied via electrodes over the motor points of the affected serratus anterior 109 Self-Management 26-3: Ser­ ratus Anterior ProgreSSion Level I can be used in con­ junction \vith NMES for prevention of atrophy initially and later to re-educate the serratus anterior as motor function returns, Passive range of motion exercises can be prescribed and manual j.o int mobilization techniques can be applied to the GH and ST joints to prevent loss of mobility in the early stages. As reinnervation of the muscle occurs, a progressive strengthening exercise program must be introduced , Fol­ lowing the prinCiple of specificity of training, when possi­ ble, the exercise should duplicate the function of the serra­ tus anterior. The most critical function of the serratus is to contribute to the scapular upward rotation force couple, particularly in the sagittal plan,lo An activity sim ulating this function must be developed, The posture, mode, move­ ment, and dosage parameters depend on the strength of the muscle at the time of the examination and the expected functional outcome of the patient. A clinical example detailed in Display 26- 7 can provide a platform for describing a therapeutic exercise intelvention. A sample initial strengthening exercise for this patient's serratus anterior is shown in SelPvIanagement 26-3: Ser­ ratus Anterior ProgreSSion, level 1. She is progressed from performing exercise in a gravity-assisted position, to a grav­ ity-lessened position (see Self-Management 26-3: Serratus Anterior ProgreSSion, level II), and then to progressiveh more resisted exercises (see Self-Management 26-3: Serra­ tus Anterior Progression, level III). The hand-knee position is an alternative position to pro­ vide resistance to the serratus antelior. Figure 26-17 illus­ trates an initial progreSSion on hands and knees. The goal

DISPLAY 26,7

Clinical Scenario for Traction Injury to the Long Thoracic Nerve A 39-year-old female homemaker injured her long thoracic nerve from constantly carrying a diaper bag and her 25-lb toddler on her left side. The MMT grade of her serratus anterior at the time of initial examination is 3-/5. Her functional goals are to be able to perform activities of daily living and instrumental activities of daily living of a full-time homemaker. She is not involved in any upper extremity sports or recreational activities.

Chapter 26 The Shoulder Girdle

FIGURE 26-17. Progressive serratus strengthening exercises. (A) The patient assumes a quadruped position, with the hips directly over the knees and the shoulders directly over the hands. The scapula should be flat against the rib cage in neutral position. (8) The patient then lifts the opposite hand slightly off the ground The sup­ porting shoulder girdle should not demonstrate any alteration in scapular position (C) The patient assumes a quadruped pos itio n, with the hips slightly in front of the knees and shoulders directly over the hands. The scapula should be flat against the rib cage in neutral position (D)The patient then lifts the opposite hand slightly off the ground. The supporting shoulder girdle should not demonstrate any alteral'ion in scapular pos ition. (E) "Serratus push-up" The patient assumes the position shown. The hips should be in neutral with respect to the sagittal plane This subject is in more hip flexion than is desirable. The scapu la should be resting against the rib cage in a neutral position. The elbows should be in the sagittal plane with the olecranon process facing posteriorly and the antecubital fossa facing anteriorly. The fingers should be directed forward with the wrist in extension; a small towel roll may be placed under the palm of the hand to reduce the amount of wrist extension if full wrist extension is uncomfortable. (F) The patient slowly lowers his body toward the floor while maintaining neutral pelvis and spine alignment. The elbows should flex in the sagittal plane (sometimes called a triceps push-up) The scapula shou ld abduct and adduct during the movement. Evidence of winging or lack of abduction indicates t~e load is too great or the muscle has fatigued (G) The patient is positioned as in (E) and (F), but the legs are straight. (H)The exercise proceeds as in (E) and (F)

667

668

Therapeutic Exercise Moving Toward Function

with this exen:ise is to support the body weight through the affected upper extremity without scapular adduction or \vinging. Stepping the knees back of the hips increases the weight the arms must support, thus increasing the strength demand on the serratus anterior (see Figs. 26-17C, D ). This exercise can be progressed to a push-up position. The desired position for a "serratus push-up" is modified from the traditional "pectoral push-up" by positioning the ole­ Cranon and antecubital fossa in th e sagittal plane. This modified position is also called a "triceps push-up." To progress the level of difficulty, the exe rcise can be per­ form ed first in th e bent-knee position (see Figs. 26-17E, F) an d then progressed to a straight-body position (see Figs. 26-17G, H) ifhigher levers of pelfonnance using the serra­ tus anterior are reqUired .

Muscle Strain Muscle strain results from an injurious tension. M usele strain can result from a sudden and excessive tension or from a gradual and continuous tension imposed on a mus­ cle. Both types of muscle strain com monly occur in the shoulder girdle. An example of a muscle strain caused by sudden and ex­ cessive tension imposed on a muscle is a sudden fall onto the shoulder or outstretched arm, resulting in a rotator cuff strain or complete tear. The examination may reveal weak­ ness in some or all portions of the rotator cuff. Selective tis­ sue tension tests may also reveal pain with resistive testing and stretch, depending on th e severity of the strain. Treatment should follow the guidelines for tissue healing outlined in Chapter 11. Low-load muscle contraction can be introduced in the repair-regeneration phase to impose a load on the healing tissue along lines of stress. Initially, sub­ maximal isomehic contractions at various positions ",rjthin the pain-free range can be prescribed. Alternatively or in addition, concentric-eccentric dynamiC exercise can be pre­ scribed. Dosage parameters related to the load, starting and ending pOSitions, and RO~ depend on the severity of the strain. y!ore aggreSSive strength regimens can be gradually introduced in the later stages of the repair-regeneration phase to prepare the muscle for the final phase of healing (Fig. 26-18). The type of contraction and specific move­ ment pattern required of the muscle should be trained as early as possible. For example, prevention of excessive humeral head superior translation is a specific and neces­ sary function for the rotator cuff during arm elevation (con­ centric) and the return from arm elevation (eccentric) (see Fig. 26-11). The final phase of healing should include activity-spe­ cific exercises related to the patient's functional goals. Complex functional movement patterns can be trained, and a gradual return to sport-specific activities, such as re­ turning to a pitching program (Display 26-8 ), llO can be ac­ complished. Quality of movement during exercise and functional activities must be emphasized and used as a guide for progreSSion at any stage. Another form of strain common in the shoulder girdle is the type resulting from gradual and continuous tension. For example, strain to the middle and lower trapezius often results from a habitual position of abducted and down­ wardly rotated scapulae found in thoracic kyphOSiS. Sub­

,.,.

/ 1

//

oN

-:/

./ ~ -~

_ d-~

;:~~

c FIGURE 26-18. Higher-level rotator cuff exercise using elastic tubing. The therapist must ensure precise motion at the GH joint and provide biofeed­ back to the patient regarding the PICR of the ST joint during these move· ments. (A) Medial rotation. Caution must be taken to prevent scapula ab­ duction and medial rotation during GH medial rotation . (8) Lateral rotatio/l Caution must be taken to prevent scapula adduction during GH lateral ro­ tation. (C) Extension. Caution must be taken to move the elbow onl slightly posterior to the midaxillary line to prevent excessive anterior dis· placement of the humeral head. (0) Flexion. Caution must be taken to er · sure optimal PICR of the ST joint during arm elevation and control over su­ perior trans lation of the humeral head.

DISPLAY 26-8

Nine-level Rehabilitation Throwing Program* Level One Two Three Four Five Six Seven Eight Nine

Throws{feet

ThrowslFeet

Throws/Feet

25/25 25/25 25/25 25/25 25/25 25/25 25/25 25/25 25/25

25/60 50/60 75/60 50/60 50/60 50/60 50/60 50/60 50/60

25/90 25/120 25/150 25/180 25/210 25/240

• This program is deSigned for athletes to work at their own pace to develop the necessary arm strength to begin throwing from a mound The athlete is to throw 2 days in a row and then rest for 1day. It is not important to progress to the next throwing level with each outing. It is preferred that a number of outings at the same level be completed before progressing. It is important to throw with comfort, which may necessitate moving back a level on occasion. Data from reference 177.

Chapter 26 The Shoulder Girdle

FIGURE 26-19. Posture brace .

jective and objective characteri sti cs of middle/lower trapezius strain include: 84 • Symptoms of "burning" pain along the course of the middle or lower trapezius may be experienced. If the strain is not accompanied by adaptive shortening of the anterior muscles, pain is not constant and can be relieved in the recumbent position. However, change of position does not affect the symptoms of a person with associated adaptive anterior sho rtness. • Heavy breasts that are not adequately supported • Positional weakness in the middle and lower trapezius • Adaptive shortening of the pectorals and other inter­ nal rotators

669

Treatmen t in the early healing phase should include support in the form of taping (see the Adjunctive Interventions: Tap­ ing section ), bracing (Fig. 26-19), or supportive brassiere to relieve the tension on the middle and lower trapeziu . If shortness affects the shoulder medial rotator and adductor group, gradual stretching (see Fig. 26-15 and Self-'\1ana a e­ ment 25-2) is indicated before strengthening the middle and lower trapezius. Stretching allows the middle and lo\\'er trapezius to be strengthened at the appropriate length. Exercises to strengthen the middle and lower trapezius muscles should consider the length at which the muscles are being strengthened. The lengthened range must be avoided to prevent fUIiher strain to the muscle. Lengthened mus­ cles produce less force or torque in the short range ; there­ fore, initial exercises may need to be performed in gravity­ lessened positions The gravity-lessened position decreases the load on the lengthened musc.:!e so it can produce suffi­ cient force or torque in the ShOlt range . Figure 26-20 de­ picts a strengthening exercise for the lower trapezius in a gravity-lessened position. The progressive exercises shown in Self-Management 26-2 should proceed when force or torque capability can be produced in the short range against the higher loads imposed by longer lever arms and the in­ troduction of gravity Figure 26-11 can be tlsed , this ti me \vith the emphaSiS on optimal length-tension properties of the lower trapezius, timing of activation \vith respect to the upper trapeZius and serratus anterior (see Fig. 26-6), opti­ mal ST PIeR, and concentric/eccentric control. One of the ultimate goals is to alter length-tension prop­ erties of both lengthened and shortened muscles. New len gth -tension properties of the affected musculature should be achieved if the follO\ving conditions are met: • Strengthening in the shortened range is combined \.vith proper support for the middle and lower trapezius. • Stretch is applied to the an terior musculature (i .e. , p ctoralis minor, pectoralis major, short head of biceps).

A FIGURE 26·20. Gravity-lessened position to strengthen lower trapezius. (A) Position the patient in side lying with as many pillows as neces sa ry to support the arm in the sagittal or scapular plane. The arm rests on the pil­ low at 90 degrees of elevation with the elbow bent. (8) Slide the arm upward toward full elevation. The scapu­ lothoracic and glenohumeral joint PICR should be monitored for any deviations. Once full available upward ro­ tation is achieved. the patient lifts the arm 1 to 2 inches off the pillow An isometric contraction of the lower trapezius is held for the specified duration. Care must be take n to li ft the entire arm . and not just the elbow. This photo depicts incorrect lifting of the elbow lead ing to GH MR versus the desired minimal abduction movement necessa ry to stimulate lower trapezius recruitment.

670

Therapeutic Exercise Moving Toward Function

• Education is provided regarding improved postures , movement patterns, workstation ergonomics, and body mechanics. Use of these concepts and principles will resuJt in alleviating the precipitating pathomechamcs to allow the strain to heal.

Disuse, Deconditioning, and Reduced Conditioning In some cases, muscles become weak because of disuse or deconditioning or may not be able to produce enough force or torque to enable an individual to achieve higher levels of performance (i.e., reduced conditioning). Impaired muscle performance due to disuse or lack of conditioning can man­ ifest as alterations in performance of ADLs, instrumental ADLs , recreation , leisure activity, or sports. Muscle per­ formance impairments can be caused by many forms of dis­ use or deconditioning: • Gradual development of subtle alterations in ago­ nist-antagonist relationships caused by habitual pos­ tures or repetitive movement patterns, which can cre­ ate problems related to muscle balance (e.g. , insidious onset of shoulder impingement without evi­ dence of anatomic impairments as a precipitating fac­ tor)84 • Generalized weakness from prolonged bed rest or re­ duction in activity because of illness, preventing per­ formance of ADLs and instrumental ADLs (e.g. , dressing, meal preparation, housework) • Decreased power output preve nting maximal perfor­ mance of a high strength-demand sport , such as swimming, tennis , or throvving. The shoulder girdle poses a challenge for the clinician pre­ scribing a general stren~h-condition~ng program because of the potential for creatmg muscle Imbalances. A condi­ tioning program should include exercises for all major muscle groups. The posture and movement of the tech­ nique are critical to a successful program . For example, if a biceps curl is done with poor technique (i.e., anterior scapular hit is increased during the elbow fl exion motion) rather than optimal technique (i.e., scapula re mains neutral with respect to tilt dUling the elbow flexion motion), the patient risks development of impaired muscle length-ten­ sion properties of the scapular stabilizers, which could cause secondary impairments or pathology (e.g., impinge­ ment syndrome from a scapula functioning in excessive an­ terior tilt). This risk increases if the same faulty posture is used during a variety of other exercises. Display 26-9 sum­ marizes exercises that are recommended for inclusion in a general shoulder girdle conditioning program. In the case of a high-level athlete or strenuous industrial worker, general conditioning exercises may not be enough to improve performance of the desired activity. The choice of what type of exercise (e.g. , dynamic, isokinetic, isomet­ ric) is used in training depends on the performance level and the speCific activities to which the individual vvishes to return. The prescription of high-level strength condition­ ing exercises must be specific for mode, contraction type, and velocity whenever possible. For example, when strength training the medial rotators in the pitching athlete ,

the type of contraction should duplicate the eccentric con­ traction lIsed in the cocking phase to decelerate motion and a concentric contraction used in the acceleration phase to create pitching velocity.] II Examples of techniques or ac­ tivities that can provide concentric amI eccentric contrac­ tion training include manual resistance by the phYSical therapist in the clinic, plyometric eqUipment, and a home program using elastics (Fig. 26-21). Prevention of injury is a major concern for the athlete or industrial worker. In designing a training program for these persons, the clinician should prescribe f'xercises to improve the muscle performance of the musdes required for the sport or occupation and prescribe exercises to strengthen opposing muscles to prevent muscle imhalances. For ex­ ample, sports such as baseball may require training for the shoulder meuiul rotators. If strengthening for the opposing lateral rotators and scapular adductor and upward rotators (i.e. , middle and lower trapezius) is not performed, muscle imbalances may develop and lead to phYSiologic impair­ ments and pathology.b4 In addition, the clinician should en­ sure that all the medial rotators are stimulated in a condi­ tioning program and that the larger pectoralis major and latissimus dorsi do not predominate and create an imbal­ ance within the medial rotator group. SpeCific exercise for the subscapu laris as shown in Self-Management 26-6 can be prescribed along with more general medial rotation ex­ ercises to maintain muscle balance. A component of muscle performance includes muscle endurance. Postural faults in the upper quadrant often are attributed to lack of muscle endurance. However, little or no muscle activity has been found in u~per quadrant mus­ cles during relaxed standing posture.] L Postural faul'ts are commonly caused by alterations in muscle length whereby some muscles become adaptively lengthened and others adaptively shortened. The altered lengths of muscles do not provide the optimal support to the shoulder girdle structure. Impairments in muscle endurance have also been impli­ cated in shoulder and neck symptoms. However, despite the methodolo?i~ problems associated with quantifying muscle fatigue , ]" most authorities agree that muscle fa­ tigue is not solely resEonsible for occupational neck and shoulder complaints. l 4 ,1l5 Indeed, it bas been shown that the trapezius, for example" is under constant muscle ten­ sion in myalgic subjects,llb but that a combined program aimed at restoring muscle force , endurance, and cOOl·dina­ tion is more applicable than focusing on muscle endurance alone. 117 Generally, research indicates that prevention and treat­ ment of neck and shoulder symptoms require a multidi­ mensional approach to reduce th e workload on mus­ cle.ll '~ - 12l Suggested interventions include ergonomiC changes in the workstation and appropriate pacing of activ­ ity with rest,J22 combined with measures to reduce stres and anxiety in the work place.l22.l23 In the case of recovel)' from injury, starting a new job vvith greater workload demands, or trying to improve per­ formance levels in an upper extremity for a sport, en­ durance may need to be developed in the upper extremity musculature. Local muscle fatigue has been shown to af­ fect the PIeR of the jOints in the shoulder girdle COlll­

Chapter 26 The Shou lder Girdle

671

DISPLAY 26·9

Shoulder Girdle Conditioning Program Bench press (flat, incline, decline)

Bench press

Prone middle and lower trapezius

Prone midtrap

Prone low trap

• Latissimus pulldown

• Lateral deltoid raise-in frontal plane or scaption (through full range of motion) or

Wall arm lift scapular plane

Lift through full range to wall

(continued)

672

Therapeutic Exercise: Moving Toward Function

DISPLAY 26-9

Shoulder Girdle Conditioning Program (Continued) • Military press

• Biceps curl

" • Front deltoid raise (through full range of motion)

• Triceps extension

Wall arm lift sagittal plane

plex. 124 When the ADLs or instrumental ADLs require more endurance than the muscles possess, endurance must be considered while making decisions about exe rcise dosage. Chapter 5 provides specific dosage recommenda­ tions, but generally, resistance is modified to allow for higher repetitions of a given exe rcise.

Posture and Movement Impairment Restoring optimal posture and movement patterns (motor control) to the shoulder girdle complex and the entire up­ per quadrant (and in many cases, the lower quadrant) should be an integral component of any exercise prescrip­ tion for the shoulder girdle. Attention to posture and move­ ment patterns is a required component of exercise to rem­ edy related impairme nts, The etiology of an overuse injury may be a res ult of poor structure or function in any of the joints included in the shoulder complex. Additionally, func­ tion of prescribed the cervical and thoracic spine is impor­ tant to the maintenance of shoulder girdle complex func­ tion, Attention to the structural and functional details at

each of these joints commonly will lead the clinician to the pathomechanics underlying the overuse injury.

Posture Optimal resting alignment of the shoulder girdle is de­ scribed in Chapter 9. This alignment facilitates ideal joint positions and resting lengths of the axioscapular, scapulo­ humeral, and axiohumeral muscles. The resting length of a muscle <:an ?e a factor in its participation in active forc couples, , 2,120 Head, spinal, and pelvic alignment addition­ ally affect alignment of the shoulder girdle. For example, forward head, kyphosis, lordosis, and anterior pelvic tilt en­ courage abducted and downwardly rotated scapulae. 84 Ha­ bitual faulty alignment such as this places the middle and lower trapezius on stretch. Adaptive lengthening can en­ sue, in turn affecting the length-tension properties of these muscles and ther~by affecting their performance in scapu­ lar force couples.,J4,iZ6 , Optimal alignment of the shoulder girdle complex re­ quires education of habitual cervical, thoracic, and even lumbar and pelvic, postures during standing, sitting, and

Chapter 26: The Shoulder Girdle

A

B

c

D

673

FIGURE 26-21. Plyometric exercise for rotator cuff. fA, B) Starting and ending positions for dynamic plyomet­ ric shoulder external rotation (using Impulse Inertial Exercise System) fe, 0) Starting and ending positions for dynamic plyometric horizontal abduction using elastic tubing. Monitor the patient to prevent excessive anterior translation of the head of the humerus during horizontal abduction.

sleeping. Equally important is the education of preferred postural patterns beginning and ending frequently repeated movements. Optimal ergonomics at the workstation (e.g. , factory assembly line, desk and chair, kitchen counter, car, baby changing table ) are critical to successful postural changes. Support through braCing, taping, and supportive brassieres may be necessary to facilitate the re-education process and reduce strain on lengthened muscles.

Movement Restoration of the optimal PICR during active motion re­ quires knowledge about the kinesiology of the shoulder gir­ dle complex. If the ideal is known, the clinician can devise a program of exe rcises to remedy the impairments and re­ train movements to approach the ideal standard. The goal is to achieve movement as close to the ideal PICR as possi­ hie to enhance the health and longevity of the biomechan­ ical system. The references and reading list at the end of the chapter provide sources for more information about electromyographic or cinematographic analysis of the shoulder girdle during common movement patterns, sport activities, and therapeutic exercises.

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON DIAGNOSES Although comprehe nsive descriptions and intervention plans for all diagnoses affecting the shoulder girdle are beyond the scope of this book, a few diagnoses are dis­ cussed. An overview of the pathogenesis or pathomechan­ ics, examination findings, and proposed treatment plan, with an emphaSiS on exercise, is provided for each se­ lected diagnosis.

Rotator Cuff Disorders For the purposes of this text, the broad categOlY of rotator cuff disorders include such medical diagnoses as impinge­ ment syndrome, rotator cuff/glenoid labral tears, posterior shoulder pain, and GH hypermobility/instability. Although each of these classifications merits a separate detailed review of etiology, diagnOSiS, and treatment concepts, it is beyond the scope of this text to do so. Comprehensive

674

Therapeutic Exercise: Moving Toward Function

understanding of rotator cuff disorders can be established by means of reviewing the literature sited in this section. Rotator cuff disorders can be broadly classified as acute or chronic in origin, though acute, avulsive tears of healthy rotator cuff tendons are considered to be rare. J 27- 12~J Most authors believe that rotator cuff tears that appear to be of sudden onset after trauma are extensions of underlying chronic tears or tears of previously degenerated ten­ dons. J '27- 129 Two common types of cl~ronic rotator cuff disorders have been described in the literature. One type includes those that can be attributed to mechanical compression of the subacromial structures. Medical diagnoses that are in­ cluded in this category are primary impingement syndrome and bursal surface rotator cuff tears. The second type in­ cludes those disorders that can be attributed to tensile overload of the rotator cuff. Tensile disease is a result of repetitive, intrinsic tension overload. The pathologic changes referred to as "angiofibroblastic hyperplasia" by ~irschl130 occur in the early stages of tendon injury and can progress to rotator cuff tears from the continu ed tensile overload. 131 Throwing or racket sport athletes are at high risk for this type of rotator cuff injUly because of the high, repetitive eccentric forces incurred by the posterior rotator cuff musculature during the deceleration and follow­ through phases of overhead sport activities. Medical diag­ noses that are included in this category are secondary im­ pingement syndrome and undersurface rotator cuff tears. Tears can be classified as paltial or incomplete, complete, or massive. 132 Incomplete tears do not extend through the complete thickJ1ess of tlle tendon. Complete tears extend through the complete thickness of the tendon or muscle. A

massive tear indicates more than one rotator cuff tendon or muscle is tom. Numerous classification systems have emerged in an at­ tempt to logically categorize s"ta?ing and mechanistic fac­ tors of rotator cuff disorders.lv3- 37 There is much overlap "vith iliese systems, and their terminology is not synony­ mous ; therefore, these systems cannot be used inter­ changeably to discuss classification of rotator cuff disor­ ders. The literature presents three general categories of rotator cuff disorders: pure impingement in the absence of instability, impingement with instability, and pure instabil­ ity in the absence of impingement. Table 26-5 presents a modified classification of rotator cuff disorders. Primary rotator cuff disorders can be further classified into three progressive stages of pathology) 1H 1. Stage 1: edema and hemorrhage 2. Stage II: fibrosis and tendinitis 3. Stage III: tendon degeneration and tendon rupture

Because primary rotator cuff disorders have three patho­ logic stages and may involve the supraspinatus, biceps ten­ don, subacromial bursa, and acromioclavicular joint, the­ presenting functional limitations and impairments can vary greatly. Table 26-6 describes the pathology, presenting and diagnostic signs, impairments, subjective complaints, and functional limitations based on the stage of the disorder. Stage I can progress to stage II and ultimately to stage­ III disease if the condition is not appropriately treated. 1 the condition progresses to stage III, a minor injury to the sboulder (e.g., overuse of the shoulder in raking leaYl?s loss of balance requiring a sudden upper extremity mO\'e· ment ) may advance a degenerative or partial-thickness

A Modified Classification of Rotator Cuff Disorders LEVEL OF INSTABILITY

CLINICAL FINDINGS

MEDICAL DIAGNOSIS

Primary impingement

No instability

Primary impingement syndrome Rotator cuff tendinitis Subacromial bursitis Bursal surface rotator cuff tear~

Secondary impingement

Minor instability/hyp e nnobility

Older patients (>35 yr) Painful arc + Impingement sign - Apprehension sign +I- pain at rest pain during overhead activity Stiffness and slow warm-up Pain during overhead activity + impingement + apprehenSion +/ - relocation test

Unidirectional instability (antelior/posteJior)

Multidirectional instability (always inferior) Instability

Posttraumatic instability

Pain duling overhead activity Inability to perform +1- sensation of instability + apprehenSion sign + relocation + sulcus

- impinge ment sign

+ appreh €:'IlSion sign

Stable shoulder E arlv undersurface rotator c~ff changes Early labrUl;i changes GH hypermobility Functional instability Labrallesion undersurface rotator cuff tear Primmy instability with secon cl:u;­ impingement Multidirectional instability Undersurface rotato r cuff tear Attenuated but intact labrum Glenoid labral damage (Baricart lesion ) Humeral head defect (Hill Sacks lesion )

Chapter 26 The Shou lder Gird le

675

Diagnosis of Primary Impingement STAGE

II

III

PATHOLOGY

IMPAIRMENTS

FUNCTIONAL LIMITATIONS

Edema, hemorrhage

1. Pain with impinge ment test 2. Minimal to no weakness in biceps or supraspinatus 3. Minimal to no decrease in mobility 4. Altered PICR at GH and ST joints 1. Pain with impingement test

Minimal pain \vith activity

Fibrosis, tendinitis

Tendon degeneration or tendon rupture

2. SupraspinatllS or biceps weak and painful 3. Moderate decrease in mobility at GH joint and probable compensatory motion at ST joint 4. AC joint tenderness 1. Weaknes (depends on pain level and integrity of rotator cuff and biceps) 2. Significant decrease in mobility at GH joint with obvious compensation at ST joint 3. Significant AC joint tenderness

1. Too thache-like pain that disturbs sleep 2. Inability to participate in ovC'rhead activity without pain

1. Proloncred history of shoulder problems 2. Minimal pain (complete rotator cuff tear) or severe pain (partial rotator cuff tear) 3. Signifkant restriction in use of affected upper extremity

acromiocla\~cular ; GI I, glenohllme ral; PICR, path of instant center of rotation: ST, st emothoracic. (Adopted from ~('c r CS, 'NaIsh, RP. The shollldf'r in sports. Orthop Clin ~orth Am 1977;S:583--591)

AC,

tear to a full-thickness tear. If this occurs, the individual experiences sudden weakness with diminished ability to raise the arm. For stage Ill, roentgenograms and arthro­ grams most often have positive findings of subacromial spurring, calcific deposits, and bursal surface rotator cuff tears. Posterior shoulder pain, often excluded from most clas­ sification systems, is found under secondary impingement ,'lith minor instability/hypermobility. The rationale for this placement is that researchers su a gested,I:34, 139 and later confirmed both arthroscopicalV40-H 3 and with magnetic resonance imaging, 144 that some of the rotator cuff injuries result from impingement of the inner fibers of the rotator cuff and the fibers of the posterior superior labllJm be­ tween the greater tuberosity and the posterior superior glenOid. This condition has been termed "inside impinge­ ment.',134 This mechanism of impingement is not easily identified because the shoulder looks relatively stable and therefore can be eaSily mistaken for early primary im­ pingement. However, treatment must take into considera­ tion the faults in the PIeR of the ST and GH joints to ade­ quately treat this condition .

Etiologic Factors of Rotator Cuff Disorders Etiologic factors of rotator cuff disorders are of tvvo basic types; intrinsic or extrinsic. Intrinsic factors are physical characteristics vvi.thin the subacromial space that prediS­ pose an individual to rotator cuff disorders (Table 26-7). Extrinsic factors are conditions or the environment in which an activity takes place that predispose an individual to rotator cuff disorders (Table 26-7). Because the scapula plays a critical role in controlling the position of the glenOid, relatively small changes in the action of the AS muscles can affect the alignment and forces involved in movement around the GH joint. s4 Ath-

letes with shoulder pathology consistently demonstrate ab­ normalities in scapular rotator activity, suggesting that mo­ tor control is an important factor to consider in extrinsic etiology of rotator cuff disorders 51,61,145-l47 Muscle func­ tion has been investigated in healthy shoulders 52,60.148 and in sh~ulders with GH instabilitl 45 ,146 or impinge­ ment.,L147 Most authors suggest that alterations exist in muscle activity of the scapular rotators in persons 'Nith ro­ tator cuff disorders. The findings of the study by Wadsworth and Bullock­ Saxton indicate that a relationship exists between shoul­ der injury and the temporal recruitment patterns of the scapular rotators, such that injury reduces the consis­ tency of muscle recruitment. 61 They further suggest that injured subjects have muscle function deficits on their unaffected side, indicative of the possibility that muscle function deficits may predispose athletes to injury. Hence, promotion of motor control of scapular rotators may be an impOitant factor in prevention of rotator cuff disorders.

Etiologic Factors in Rotator

Cuff Disorders

INTRINSIC FACTORS

EXTRINSIC FACTORS

Acromial type 81 Degenerative changes in the acromioclavicular 81 joint Vascularity of the rotator

Glenohumeral muscle dysfunction Scapulohumeral muscle dysfunction Postural faults Capsular stiffness Activity type Overtraining

CUf(ll

676

Therapeutic Exercise Moving Toward Function

Muscle dysfunction has also been investigated in the In­ tegrated deltoid-rotator cuff mechanism in persons with subacromial impingement. 149 The middle deltoid and rota­ tor cuff muscles were evaluated during isotonic scaption from 30 to 120 degrees. Overall, the impingement group demonstrated decreased mean muscle activity in compari­ son with the group of normal subj ects, particularly in the infraspinatus and subscapularis during the first portion of arm elevation. The inferior force vector is provided by the infraspinatus and subscapularis, thus humeral head de­ pression during t11e critical first portion of elevation may be insufficient in persons with subacromial impingement. This body of res earch suggests that dysfunction in scapular rotator or deltoid-rotator cuff muscle function is present in persons to rotator cuff disorder. Yet, it must be considered that many rotator cuff disorders involve more than one etiologic fac tor. Consequently, it is critical for the

physical therapist to identify all intrinsic and extrinsic fac­ tors to effectively manage rotator cuff disorders.

Therapeutic Exercise Intervention of Rotator Cuff Disorders Treatment principles for nonoperative rotator cuff disor­ ders are based on the underlying pathology, presenting im­ pairments, and functional limitations. Treatment for sec­ ondary rotator cuff disorders should consider impairments related to hypermobility and instability problems in addi­ tion to impingement. A clinical example of rotator cuff dis­ order is provided in Displ ay 26-6 with general treatment guidelines presented in Display 26-10. Given that normal muscle activity of the scapula rotators is es~~ntial_ fo~_ norm al movement of the shoulder gir­ dle.4 " .,,1.6 1,l ,,6,l "1 the ability to effe ctively strengthen the serratus anterior and all portions of th e trapezius is vital for

DISPLAY 26-10

Treatment for Primary Rotator Cuff Disorder First Aid During the early stages, easy self-management measures can assist in decreasing inflammation and pain and promoting early healing. • Medications: Nonsteroidal antiinflammatory medications may be prescribed by the physician to assist in reducing inflammation to the acromial and subacromial tissues. o Rest: The patient avoids postures or movements that trigger pain and inflammation. This may require absolute restriction of overhead activity, reduced activity, or modification of the technique used during overhead activity. • Resting position: This position provides the greatest amount of volume in the shoulder joint. assisting in blood flow and decreasing pain. The patient should use pillows to support the arm in slight elevation, abduction, and neutral rotation while sitting, driving, or sleeping. The patient should avoid sleeping on the involved side. If sleeping on the uninvolved side, pillows should be used to support the shoulder as described. Ice: Ice can reduce inflammation and relieve pain. Choices include cold packs, bags of chipped ice, or ice massage. Ice should be applied directly to the affected tissues. This may require special positioning to expose the affected tissues 73 Supervised Trealment After a thorough examination and evaluation, a plan of care is developed based on the presenting functional limitations and related impairments. Pain and inflammation: In addition to instructing the patient in first aid self-management, the physical therapist can use physical agents such as ultrasound, phonophoresis, or interferential stimulation.7 • Range of motion, muscle length, joint mobility: Exercise and joint mobilization can be prescribed to increase mobility in periarticular tissues and improve muscle extensibility. Education and exercise can be prescribed to normalize length-tension properties of adaptively shortened and lengthened muscles. &

• Muscle performance: Exercise can be prescribed to im­ prove force or torque capability, length-tension properties, and endurance of the rotator cuff and scapular upward ro­ tators. Dosage parameters should be adjusted according to the goal of the exercise as outlined in Chapter 2. • Posture and movement: For the tissue to heal and to prevent recurrence, the mechanical causes of the impingement must be eliminated. During the early phases of intervention, posture and movement must be addressed to the greatest possible extent given the presenting impairments in force or torque, endurance, and mobility. After the physiologic capabilities have improved, long-term management requires specific training in posture and movement habits, and underlying motor control ofthe integrated function of the scapular rotators and deltoid-rotator cuff mechanism, to eliminate the mechanical cause of impingement during function. This should including ergonomic modifications, specific movement retraining during activities of daily living and instrumental activities of daily living, and alterations in athletic training techniques. Surgery If supervised treatment fails, surgery to remove subacromial spurring and increase space for the subacromial tissues may be necessary. Surgery should be considered only when symptoms have persisted despite conservative treatment for more than 1 year. Anterior acromioplasty is the recom­ mended choice for decompression of the rotator cuff in primary impingement. 133 The posterior half of the acromion is not involved in the impingement process and, therefore, lateral or complete acromionectomy is thought to weaken the deltoid unnecessarily.7ln many cases, repair of the rotator cuff is necessary. Prevention Prevention Ilies in early recognition and prompt and comprehensive treatment of the presenting functional limitations and related intrinsic and extrinsic impairments, particularly those related to motor control of the scapula rotators and deltoid-rotator cuff mechanism.

Chapter 26 The Shoulder Girdle

effective management of rotator cuff disorders (see Dis­ play 26-11). EMG ana]ysis of the tmpezius and serratus an­ terior m~scl~s has been performed during therapeutic ex­ ercises.loO-105 Conclusions dmwn about activation levels of scapular rotator muscles during specific exercises should be made with caution because of inherent limitations in study design. The EMG data presented in Display 26-1 2 were derived from studies minimizing common limitations in EMG research . Th e data presented may assist physical therapists in developing exercise programs that will opti­ mally activate the trapezius and serratus an terior mu scles. Because the results of the studies presented were obtained by studying subjects without pathology of the shoulder gir­ dIe rather than patients with rotator cuff disorders, caution is warranted in extrapolating these findings to a patient population. Exercises may need to be modified to accom­ modate a painful shoulder. Display 26-13 s1lmmarizes ad­ ditional exercises for activation of the scapular ro tators that are illustrated in this chapter.

Etiologic Factors Contributing to Hypermobility/lnstability of the Glenohumeral Joint Because it is not v-rithin the scope of this text to discuss di­ agnoses and treatments of the entire spectrum of GH joint hypermobility/instability, the discussion focuses on an terior

DISPLAY 26-11

Specific Therapeutic Exercise Intervention for Rotator Cuff Disorder Pain and inflammation Short-term resolution as described under "First Aid" in Display 26-10. Long-term resolution requires addressing the remaining impairments.

677

DISPLAY 26-12

Activation Exercises for Trapezius and Serratus Anterior Based on EMG Analysis Exercises for Upper Trapezius • Shoulder shrug (Figure 26_22)'53.155 Exercises for Middle Trapezius Prone arm lift with arm overhead (Self-Management 26-2, Level IV B)'48.155 • Prone horizontal extension with lateral rotation (Self­ Management 26-2, Level IV A)148.155 «

Exercises for Lower Trapezius • Prone arm lift with arm overhead (Self-Management 26-2, Level IV B)155 • Prone shoulder lateral rotation at 90-degree abduction (Self-Management 26-1) 154.155 • Prone horizontal extension with lateral rotation (Self­ Management 26-2, Level IV A)153.155 Exercises for Serratus Anterior • NOTE: In general, exercises that create upward rotation of the scapula were found to produce much more EMG activity in the serratus anterior than straight scapular protraction exercises.'50.153.155 • Shoulder abduction in the plane of the scapula (Fig. 26-8) above 120 degrees (Display 26_7)'48.155 • Diagonal exercise with a combination of flexion, horizontal flexion, and external rotation (Table 16-1 )155 Exercises for simultaneous activation of the trapezius and serratus anterior • Prone arm lift with arm overhead (Self-Management 26-2, Level IV B)155 • Shoulder abduction in the plane of the scapula (Fig. 26-8) 155

Muscle length • Passive manual stretch to rhomboids (see Fig. 26-10) • Self-stretch to GH lateral rotators (see Self-Management 26-5) Muscle Performance • Strengthen middle and lower trapezius in a short range (see Self-Management 26-2) • Strengthen serratus anterior in the short range (see SelfManagement 26-3) • Strengthen rotator cuff (see Self-Management 26-1) Posture and movement • Ergonomic modifications at VDT workstation • Transitional exercises to improve PICR of GH and ST joints in elevation (see Fig. 26-11) • Surface EMG training during simple elevation movements to restore temporal relationships in scapular rotators • Functional retraining for ADLs with focus on motor control and integrated scapula and deltoid-rotator cuff function • Functional retraining for instrumental ADLs (sports and recreation) with focus on motor control and integrated scapula-and deltoid-rotator cuff function • Alter sport-specific training as needed to promote optimal motor control and biomechanics

FIGURE 26-22. Shoulder shrug.

GH hypermobility leading to GH subluxation (Le., partial dislocation ). Hypermobility and subluxation are difficult to diagnose and can best be understood if joint stability is con ­ sidered in terms of a continuum of stability (Fig. 26_25) .156 It is thought that habitual postures and faulty repetitive movement patterns result in microtrauma to static and dynamic stabilizers and dysfunction in the relationship be­ tvveen the GH and ST jOints. Attenuation of the static and

678

Therapeutic Exercise Moving Toward Function

DISPLAY 26-13

Additional Exercises Designed for Isolation of Scapular Rotator Muscles Exercises for Upper Trapelius • Upper trapezius strengthening (Fig. 26-13)

• Back-to-wall arm slides in abduction (Fig. 26-23) • Isometric scapula upward rotation (Fig. 26-24)

Exercises for Middle and Lower Trapezius Activation

Exercises for Serratus Anterior • Serratus anterior progression (Self-Management 26-3) • Progressive serratus strengthening exercises (Fig. 26-17)

• Facelying arm lifts (Self-Management 26-2) • Wall slides (Fig. 26-11)

FIGURE 26·23. Back to wall, arm slides in abduction. With the back to the wall, the elbows and humerus should be in the scapular plane. Thumbs can touch the wall to ensure that the humerus remains in the scapular plane. The patient slides the arms up the wall, and stops when the scapula deviates from the PICR (i.e., excessive elevation). The goal is to achieve full scapular plane elevation with the ideal PICR at the glenohumeral and scapulothoracic Joints.

FIGURE 26-24. Alternative isometric scapular upward rotation. The arms can be positioned in as much elevation as is available. The cue should be to "gently squeeze your shoulder blades together." Caution should be taken to prevent excessive rhomboid or latissimus dorsi con­ tribution.

~

Stable

~ Normal Normal congruity and loading

taX/Hypermobile Congruity maintained, but joint is unloaded

Unstable

4.

l

'CJ Slibluxed Partial contact of articular surfaces-congruity lost.

Dislocated No contact of articular surfaces-congruity lost.

FIGURE 26·25, Continuum of shoulder stabil ity (Adapted from Strauss MB, Wrobel LJ, Neff RS, Cady GW The shrugged-off shoulder a comparison of patients with recurrent shoulder subluxations and dislocations. Physi­ cian Sports Med 1983;11 :96)

Chapter 26 The Shoulder Girdle

dynamic stabilizers contributes to mild hypermobility, in­ creasing the demand on the stabil izing function of the ro­ tator cuff. This may lead to a vicious cycle of excessive translation of the humeral head, mechanical im~in§ement, and attenuation of the subacromial structur s. 5(;",: .58 Left unch ecked, mild h)1)ennobility can progress to subluxation and dislocation. Glenohumeral stahility is achieved through a number of different mecl1i:lnisms, involving th e articular geometJ)', the static capsuloligamentous complex, the dyn~mic (mus­ cular) stabiliz rs , and neuromuscular contro!.131 The spe­ cific contributions of the shoulder musculature to joint sta­ . . are I'Isted'iO O' 15D-16S hlhty ' ISP Iay 26 - 1420.45. .

Diagnosis of Hypermobility/lnstability Early diagnosis and treatment of GH hypennobility can prevent serious pathology resulting from di~location or im­ pingement. However, mild GH hypermo~lhty IS dlffJ~ult to diagnose . because it is caused by excessive translatIOn of the humeral head during active movement without the signs or symptoms associated with subluxation or instability (Le., positive apprehension or relocation signs). ExceSSive passive joint mobility in specific directiom combined with displaced PICRs of the GH joint during active arm el.eva­ tion or GH rotation confirm the diagnoSIS ofhype rmoblhty. The most common abnormal GH motions are excessive su­ perior translatiun during arm elevation , excessive anterior translation during lateral rotation and arm hOlizontal ab­ duc:tion (also called hyperangulation ), 163 and abnormal an­ terior translation during medial rotation. Excessive transla­ tion can be confirmed by palpating the humeral head during active motions and comparing the motion to that on the unaffected side. The diagnosis of unilateral inst
DISPLAY 26-14

Contribution of the Shoulder Musculature to Joint Stability • Passive muscle tension from the bulk effect of the rotator cuff muscle • Rotator cuff contra ction causing compression of the articular surfaces • Joint motion that secondarily tightens the passive ligamentous constraints • Barrier or restrain effect of the contracted rotator cuff muscle • Redirection of the joint force to the center of the glenoid surface by coordination of muscle forces from both GH and ST joints • Scapulothoracic muscle balance • Efficient compressive forces on the rotator cuff are partially dependent upon the sta bility of their origins on the scapula 241 • Scapular position affects length-tension properties of the rotator cuff • Scapula upward rotation, posterior tilt, and lateral

rotation is necessary to maximize subacromial

space242~244

679

itation combined \vith gositive apprehension, relocation, and or sulcus signs. 164 ,] "

Treatment for Glenohumeral Hypermobility/ lnstability Treatment of hypermobility and any hypomobility should occur Simultaneously. For example, a common examina­ tion findina' for the anterior hypermobile or subluxating shoulder i;posterior capsular stiffness and an anteriorly displaced humerus at rest. The stiffness of the posteri or capsule can restrain posterior translation, occurring pri­ marily during the osteokinematic motions of medial rota­ tion and flexion and causing an abnormal antelior transla­ tion durin" these osteokinematic motions. The postenor capsular stiffness can also contribute to an anteriorly dis­ placed rest position of the humeral head. With. the hea~ of the humerus in an anteriorly displaced posItion at rest, It IS more vulnerable to moving ,in to an excessive anterior trans­ lation during lateral rotation and abduction. SpeCific joint mobilization of the posterior capsule combined with pas­ sive self-stretching is the best treatment for the hypomo­ bility (see Self-Management 26-4). As passive mobility is restored, the restoration of precise active mobility must closely follow. Th.e GH joint needs to be trained to move in a precise PICR pattern without ab­ normal or excessive anterior tran slations, This often must occur in conjunction with restoring the normal PICR of the ST joint (explained later in this section). The subluxating shoulder may require a period of immobilization to allow stiffening of lax structures. Abduction and lateral rotation positions must be avoided to prevent stretching of the an­ terior capsule. The immobilization period should last. no longer than 3 weeks, and pain-free isometric exercises should begin as soon as tolerated to avoid the disuse or de­ conditioning effects of prolonged immobilization. Active ROM exercises can be initiated against gravity as the patient regains strength and motor contro!' Abnormal movement patterns should be discouraged. Gradually, resistive exercises can be initiated targeting the pectoralis major, latissimus dorsi, teres majo:, and sub­ scapularis to provide dynamic restraint to antenor transla­ tion into the anterior capsule. Howeve r, the main targe t muscle should be the subscapularis because of its insertion antelior to the GH joint and its proximity to the axis of ro­ tation of the GH joint. Careful observation of the PICR during medial rotation is a good indicator of the participa­ tion of the subscapularis in the medial rotation force cou­ ple. Anterior translation of the humerus should not take place during medial rotation because it is a sign of insuffi­ cient subscapulmis participation, Exercises should be pre­ sClibed to isolate subscapularis function as much as possi­ ble (see Self-Management 26-6). Infraspinatus and teres minor strenbJ'thening can also be targeted to prevent excessive anterior translation of the head of the humerus. ln6 For the infraspinatus and teres mmor to provide a stabilizing force on the GH joint, stability of the ST joint is a prerequisite. If the scapula is not stabilized by th.e a'lioscapular muscles , when the infraspinatus and teres mi­ nor contract, instead of providing a postelior force to the GH joint, contraction of the infraspinatus and teres minor can contrib\lte to further antelior displacement. This occurs by

680

Therapeutic Exercise: Moving Toward Function

reverse action on the scapula; instead of compressing the GH jOint into the glenoid fossa, the resultant force pulls the scapula to\vard the humems and forces the head of the humerus anteriorly. During any lateral rotation exercise, care must be taken to ensure that motion is prevented at the ST jOint and that lateral rotation occurs at the GH joint with· out excessive anteJior translation. Isokinetic or plyometric upper extremity exercises (see Fig. 26-21) can be incorporated into the resistive training program of individuals returning to a high level of function. If the PICR is closely monitored, movements into full lateral rotation and abduction should not be contraindi­ cated. If excessive anterior translation occurs because of lack of force-generating capability from the axioscapular or rotator cuff JIluscles and poor motor control, extremes of ROM should be avoided. SpOli-speC:ific exercises can be gradually incorporated into the treatm ent program to prepare the patient for tran­ sition to functional activity (Fig. 26-26). Attention to the P IeR of the CH joint is the guide to progression. Control over the translatory motions of the GH joint should be em­ phaSized over general strength gains. The literature supports the notion that motor control is criti cal in restoring function to the unstable shoul­ der.161-170 Research indicates that peak torque gains occur in persons trained with EMG biofeedback in purely func­ tional patterns with no e mphasiS on "strength exe rcising. " FUlIctional gains and abolition of pain \vas greate r and oc­ curred earlier in the group trained functionally \vith EMG biofeedback than the group trained in more traditional strength regimens.

Treatment Principles for Postoperative Rotator Cuff Disorders !\';lost tears are managed by surgical decompression and repair. Details of tl1e sur ical techniques are well docu­ mented in the literature. 32 The postoperative exercise

9

regimen after anterior acromioplasty and repair of the ro­ tator cuff is determined by the strength of the rotator cuff. Methodical planning and cooperation by the patient, surgeon, and physical therapist are necessary to plan a program \vith a successful outcome. The patient will have greater confidence if clear objectives are developed. Pre­ operatively, the surgeon and phYSical therapist should ex­ plain to the patient that it \-vill take up to 12 months for mature healing of the tendons. However, during this time. activities wijl be progressively advanced, and strict adher­ ence to the physical therapist's instructions will ensure the most successful outcome. Thf' physical therapist must un­ derstand the specific anatomic considerations and limita­ tions to plan a safe and effective postoperative rehabilita­ tion program. Only the surgeon knows the strength and stability of the repair and therefore should work closelY­ with the physical therapist in developing the aftercare program of each patient. The algorithm show11 in Display 26-15 provides guidunc for rehabilitation after a standard rotator cuff repair. !32 Be­ cause of the unique anatomic arrangement and function of the rotator cuff, rehabilitation after surgery is considered to be more difficult tJ1an that of any other joint. In most pa­ tients, the muscles involved in the preCisely integrated force couples used in upper extremity movements have suffered from months of atrophy and disuse. Early in the rehabilita­ tion process, careful exercises may be preSCribed to prevent severe atrophy of the scapular upward rotators (Fig. 26-24 Toward the latter stages of rehabilitation, precise integra­ tion and coordination of motor control must be restored to all the muscles involved in the functional movements used by the individuaL Postoperative care after repair for a ma5­ sive rotator cuff tear is far more conservative, requirin\! longer periods of immobilization and slower return to func­ tion. The overall postoperative prognosis for individual., with massive tears is considered to be satisfactory (i .e. , some weakness, good function, and no pain) compared with the often excellent (i.e., essentially normal shoulder) progno . for the individual with a complete tear.

Adhesive Capsulitis

FIGURE 26·26. Sport-specilic exerc ise for someone with glenohumeral hypermobil ity: ball tossing upward to simulate a set in volleyba lL

Idiopathic adhesive capsulitis is a condition characterize by gradual loss of active and passive shoulder motion. Al· though the etiology of frozen shoulde r remains elusive, th understallding of the pathophYSiology has improved in re ­ cent years. Factors associated with adhesive c:apsulitis in­ clude fel11~le gender,l7l olde r than 40 yeary,l,;2 trauma,L diabe~~s, 1,3 prolonged imm obilizati0I!, 11~1 thyrOid di , . ease/ I'> stroke or myocardial infarction ,! (('. 117 and the pres­ ence of autoimmune diseases 178 The prevalence of adhe­ sive capsulitis in the general population is slightly greater than 2%. l ,') ApproXimately 70% of patients with adhesi\'t­ capsulitis are women, and 20% to 30% of those affecte2 subsequently develop adhesive capsulitis in the oppositt­ shoulder. 1so The diagnosis of adJlesive capsulitis encompasses pli ­ mary adJlesive capsulitis, which is characterized by idio­ pathic, progreSSive, painful loss of active and passive shoul­ der motion; secondary adhesive capsulitis, which has similar histopathologic appearance but results from

Chapter 26: The Shoulder Girdle

681

DISPLAY 26-15

Rehabilitation After Rotator Cuff Repair Protective Phase (1-6 weeks) • Sling protection is used for 2 to 3 days and up to 6 weeks at night. • Pendulum exercises (see Fig. 26-16) are initiated within the first 48 hours. • Self-assisted ROM exercises are initiated at the end ofthe first week (A. B. C).

B F Early Inlennediate Phase (6 weeks-3 months) • Additional self-assisted ROM exercises are prescribed 6 weeks after surgery !D. E. F).

o

• If motion is restricted at this time. gentle passive stretching by the physical therapist is indicated. Late Intermediate Phase (3 months-5 months) • Isometric exercise may be introduced 3 months after surgery IG. H.I.J). • Isometric exercise is progressed to dynamic exercise based on the physician's recommendations (K. L).

G

H

(continued)

682

Therapeutic Exercise : Moving Toward Functi on

DISPLAV 26-15

Rehabilitation After Rotator Cuff ReJ!air (Continued) General Precautions and Contraindications • Flexion should precede abduction when restoring active motion. • The patient should avoid leaning on the arm or carrying more than 51b of weight in the early and intermediate phases of rehabilitation . • Patients with complete tears of the supraspinatus should avoid lifting more than 151b in the first year postoperatively. • Skiing, skating, rolier-blading, and other such activities are forbidden in the first year after surgery to avoid reinjury from a fall.

J

• Active movement of the arm overhead is introduced based on the physician's recommendations. ~ Swimming is allowed at 5 months after surgery. Advanced Rehabilitation Phase (5 months-1 year) • Submaximal sport-specific training is progressed to maximal training by the end of 1 year after surgery.

(A) Assisted lateral rotation in supine. A towel is placed un­ der the elbow to keep the humerus in neutral and prevent excessive anterior displacement. The patient pushes the in­ volved arm into lateral rotation, using the uninvolved arm to supply the power. (8) Assisted extension. The patient pushes backward into extension, using the uninvolved arm to supply the power. Caution should be used to prevent ex­ cessive glenohumeral (G H) extension and anterior displace­ ment of the GH joint. (C) Pulley-assisted elevation. The unin­ volved arm supplies the power to raise the involved arm. Caution should be used to prevent excessive scapular ele­ vation as compensation for lack of GH mobility. The motion should be stopped as soon as a deviation in the path of in­ stant center of rotation of the GH or scapulothoracic joint is noted. This exercise can be progressed to active assisted elevation when directed by the physician. (0) Assisted me­ dial rotation. The patient is instructed to medially rotate the arm by pushing the arm backward, followed by pulling the hand upward toward the scapula. Cautions should be used to prevent excessive scapular anterior tilt and GH anterior displacement. (E) Assisted abduction. The patient is in­ structed to (1) lie on the back, (2) lock the fingers together and stretch the arms overhead (the uninvolved arm powers the involved arm). (3) bring the hands behind the neck, and (4) flatten the elbows (reverse by sliding the hands overhead and down). Caution should be taken while abducting to en­ sure the scapulae are in a neutral position and adduct as the arm abducts. (F) Assisted lateral rotation in a doorway. The patient is instructed to stand in a doorway facing the door frame . The elbow is flexed to 90 degrees. The palm is on wall. The elbow is held in adduction. The body turns gradually until the patient faces into the room. Caution should be taken to ensure proper scapular alignment during the lateral rotation process. (G) Isometric medial and lateral rotation. (H) Isometric extension. (I) Isometric abduction. (J) Isometric flexion. (K) Resistive exercise for shoulder exten­ sors. Caution should be taken to prevent thoracic flexion or scapular anterior tilt. The range should be limited to exten­ sion to the midaxillary line to prevent contractions of the rhomboid in the short range. (L) Resistive exercise for shoul­ der flexion. The motion is upward into flexion as if throwing an "upper cut" punch. Caution should be taken to monitor the ST PI CR.

Chapter 26 The Shoulder Girdle

known intrinsic or extrinsic cause; and secondary shoulder stiffness after a period of imlllobilization. In primary adhesive capsulitis. an insidious onset of pain causes the individual to gradually limit the use of the arm. Inflammation and pain can cause reflex inhibition of the shoulder muscles, similar to inhibition of the quadriceps af­ ter injury to the knee. There is disagreement in the litera­ ture as to whether the unde~rng pathologic process is an inflammatory condition 1 ~ 1 -18 or a fibrosing condition. 184 Significant evidence existslSUSS-187 in support of the hy­ pothesis that the underlying pathologic changes in adhesive capsulitis are synovial inflammation with subsequent reac­ tive capsular fibrosis.

Diagnosis Adhesiv~ c~psulitis has been .staged based u~on c arthro­

SCOpiC fmdmgs as deSCrIbed m Table 26-8. 1 3,189 These stages represent a continuum of the disease rather than dis­ crete well-defined stages. The course associated wit~ ad­ hesive capsulitis typically lasts from 1 to 3 years. l14.190 There is a relationship of the length of each stage to the length of the remaining stages in that the shorter the initial inflammatory component, the shorter the second and third

stages and overall course of the condition. Thus, early in­ tervention can reduce the overall duration of the condition. The role of the physical therapist is to hasten the progres­ sion through the stages and limit the sevelity of the earlier stages so that the patient can move to the final stages as qUickly as possible ,vith the least amount of impairment, functional limitation, and disability.

Treatment Neviaser and NeviaserlSH.1S9 stress the importance of an in­ dividualized treatment plan based upon the stage of the dis­ ease. Patient related instruction is a critical component in educating the patient as to the stage and progression of the condition and the necessary commitment to self manage­ ment for the best outcome. The use of therapeutic exercise has been shown to be a common and effective comgonent of intervention used for adhesive capsulitis 176 ,191- 5 The determination of the type and intensity of exercise depends on the patient's specific strength, ROM, joint mobility, mo­ tor control needs, and level of irritability. If pain is present before resistance or end feel then the patient's symptoms are considered to be irritable and intervention should not be aggressive.

Stages Based on Arthroscopic Findings STAGE

FINDINGS

Stage 1

• Duration of symptoms is 0 to 3 months • Pain with activ and passive range of motion (ROM) • Examination under anesthesia: normal or minimal loss of ROM • Arthroscopy: diffuse glenohumeral synovitis, most pronounced in anterosuperior capsule • Pathologic changes: hypertrophic, hypervascular synOvitis . rare inflammatory cell infiltrates, normal underlying capsule • Duration of symptoms: 3 to 9 months • Patient presents \vith continued pain • Severe loss of ROM in all planes • Examination under anesthesia: ROM same as without anesthesia • Arthroscopy: dense, proliferative, hypervascular SY110vitis. • Pathologic changes: hypertrophic, hypervascular synovitis with perivascular and subsynovial scar, fibroplasias and scar formation in the underlying capsule • Duration of symptoms .5 to 9 months • Continued severe loss of ROM \vith minimal pain • Examination under anesthesia: same as Stage 2 • Arthroscopy: No hypervascularity seCJI, remnants of fibrotic synovium can be seen. The capsule feels thick in insertion of the arthroscope and there is diminished capsule volume • Pathologic chul1g('s: "burned out" synOvitis ,vithout Significant hypelirophy or hypervasculmity. Underlying capsule shows dense scar formation • Duration of symptoms: 1.5 to 24 months • Minimal pain • ProgreSSive improvc-l ment in ROM

Stage 2: "Freezing stage"

Stage 3: "Frozen stage"

Stage 4: "Thawing stage"

683

684

Therapeutic Exercise Moving Toward Function

Physical Therapy Intervention During Stages 1-4 Adhesive Capsulitis STAGE/GOAL

STRETCHING AND ROM

JOINT MOBILIZATION

PRI

MODALITIES

STRENGTHENING

Educate (pathogeneSiS, posture, activity modification

As needed to control pain , inflammation, and promote relaxation

Early closed chain exercises (i. e., wall slides )

Grade I, II AAROM in mobiHzations pain-free ROM , aquatie exercise gentle PROM , pendulum exere.ise

Posture, neceSSity for HEP

As needed to decrease pain and inflammation and improve tissue extenSibility

More advanced scapular training, specific rotator cuff strengthening

AROM,PROM

Grade II , III mobilizations

Posture, neceSSity for HEP

To promote relaxation , tissue extensibility and reduce treatment discomfort

More specific scapular training to rees tablish force couples, continued rotator cuff strengthening

More speCific AROM to reestablish scapular and GH mechanics; more aggreSSive stretching (PNF, STM, low load prolonged stretch)

Grades III, IV

Stage 1 Goal: interrupt pain and inflammation promote relaxation

Stage 2 Goal: minimize pain , inflammation. capsular adhesions, and restriction of ROM

Stage 3 and 4 Goal: Increase ROM

I\AROM, active assisted range of Illation; AROM. active range of Illation ; PRO\I, passi ve range of Illotion: HEP, home exercise program; I'N F. proprioceptive ne uromuscular faCilitation; STM , soft-tissue mobilization .

The best approach to adhesive capsulitis is prevention. Although this syndrome is considered a self-limited pro­ cess, complete recovery with no residual limitation and dis­ ability is neither ensured nor common. Fibrosis, secondary arthritis , myofascial contracture, disuse atrophy, and al­ tered motor control patterns may be permanent. Only ac­ tive use of the arm and full maintenance of GH and ST ac­ tive mobility with precise PICRs at all four shoulder girdle articulations can reverse these changes. Table 26-9 outlines basic interventions for each stage of adhesive capsulitis. Stage 1

Patients who present with painful limitation of motion are recommended to be given oral nonsteroidal anti­ inflammatory medications that are supplemented with other analgeSiCS as necessary.19S-19S An intraarticular injec­ tion of steroid and local analgeSiC can be extremely useful both in the diagnOSiS and treatment of adhesive capsuli­ tiS .199-203 After injection, passive GH ROM is reevaluated. If the patient has Significant decrease in pain and increased ROM, the diagnosis of stage 1 is confirmed. If, however, pain is improved, but ROM has not changed Significantly, the diagnosis of stage 2 is confirmed. Patients should also be started on a supervised physical program to restore function by decreaSing the pain and in­ flammatory response , increasing ROM , improving muscle performance, and reestablishing normal shoulder mechan­ ics. The primary goal of treatm ent of patients with stage 1

adhesive capsulitis is to interrupt the cycle of pain and in­ flammation . Postural training is incorporated to discourage forward head and thoracic kyphOSiS , which places the shoulder girdle in suboptimal postures. Therapeutic modaliti can be used to reduce pain (high-voltage galvaniC sti­ mulation , transcutaneous electrical stimulation,19S ion­ tophoreSiS, cryotherapy), reduce inflammation (iontopho­ resis, phonophoresis, cryothe ra~6,)' and to prom ote relaxation (moist heat, ultrasound). 4 Grade I and II joint mobilizations and physiolOgiC movements (active assisted ROM ) within a pain-free ROM can also be used to de­ crease pain (see Chapter 7).203 Hydrotherapy can also be effectively used to break the cycle of pain (see Chapter 17).206 Closed chain exercises can be performed to pro­ mote the rotator cuff function of GH stabilization (i. e .. wall slides). 207 Scapular stabilization exercises can be modified to allow the patient to activate the scapular mus­ cles in pain-free pOSitions (see Fig. 26-24; Self-Manage­ ment 26-3, levell , can be modified with more pillows to allow the patient to work in less extreme range of upper extremity elevation). This type of exercise should be initi­ ated as early as possible to promote GH stability and op­ timal ST force couple recruitment. Scapula taping (see Adjunctive Interventions: Taping) can be used to help promote scapula stability and GHmobility. The home ex­ ercise program should include passive ROM exercises in pain-free ROM and pendulum exercises to promote cap­ sular stretch (Fig. 26-16 ).

Chapter 26 The Shoulder Gird le

685

Stage 2

The continuum of symptoms presenting in this stage may mclude pain in the paracervical and peliscapular re­ gIOn as a result of compensatory scapula elevation. At this stage, the individual may learn to use scapulothoracic, el­ bow, or trunk motions to substitute for lost glenohumeral motio~s.96 "Hiking" of the shoulder girdle is evident during elevatIOn of the arm as a result of capsular stiffness and ro­ tator cuff weakness disallo\\ing normal GH mechanics 96 Anterior translation of the humeral head may result from a decrease in capsular volumo. 2l1S The limitation of ROM is in a capsular pattern with lateral rotation the most limited, followed by abduction, then medial rotation 209 The goal of the second phase of rehabilitation is to con­ tinue to decrease inflammation and pain , and to minimize cap~ular restriction and secondary weakness of the rotator cuff and scapular upward rotator force couple. Passive jOint mobilizations are used to stretch the capsule to allow nor­ mal GH mechanics. Passive stretching of the postelior cap­ sule can be performed in pain. free ROM to further pro­ mote capsule extensibility (see Self-Management 26-4 ). Because joint mobility is improved , active exercises can be promoted. If strength is fair or above, active exercises against gravity can be introduced in sagittal, frontal, and the plane of the scapula. The therapist must pay careful at­ tention to ensure res tOling motor control patterns to pro­ mote scapula rotation (ve rsus elevation) and control over GH superior glide 9 (j Careful isolated strengthening of the rotator cuff, serratus anterior, middle and lower trapezius is indicated (see Self-Management 26-1 , 26-2, and 26-3 ). Taping t~e ST joint can Significantly help to limit scapu­ lar substItutIon patterns and force greater mobility at the G H joint during functional activity (see Adjunctive Interven­ tions: Taping section).210 Taping the ST joint may transfer l:nprovements made in mobility and force or torque produc­ tton with specific exercise to ADLs and instrumental ADLs, including specific movement patterns necessalY for sport. Stages 3 and 4

. At these stages, pain may resolve spontaneously. 21 1 Phys ­ ICal examination will reveal a stiff shoulder with faulty SH mechanics. 212 The goal of physical therapy is to improve GH mobility and restore SH rhythm. In this phase, aggres ­ sIve stretchmg and joint mobilization are tolerated and should be a focus of treatment. Figure 26-27 prOvides an ex­ ample of a self-mobilization technique. Full active ROM is the goal , because any residual limitation may reinitiate the cycle. Low load , prolonged stretch produces plastic elonga­ tlOn of tIssues as opposed to high tensile resistance seell in high loau , brief stre tch. 2J .'3.214 Heat may be used for relax­ ation, ultrasound may be used to promote tissue extensibil­ ity in the axillary fold, and cryoth e rapy may be used to re­ duce treatment discomfort. Strengthening of the rotator cuff and SH muscles continues in this phase to reestablish coordinated force couples (see Self-\{anage me nt 26-1, 26-2, and 26-3 ), although positions may still require modifi­ cation because of ROM limitations in the GH joint. Operative Treatment

. Cons:rvative treatment will often be successful in pa­ tients WIth stage 2 adhesive capsulitis; however, some pa­ tients in late stage 2 and stage 3 may have a refractOlY 1110­

FIGURE 26·27. Se lf-mob ilization of the glenohumeral joi nt into lateral distraction.

hon loss. In patients "vho continue to have a refractory mo­ tton loss that creates disability, operative treatm e nt may be ne~e5sary. OP.e rative treatment is demandillg, and proper patIent selectt~Jl1 , anesthesia, and postope rative analges ia ar.e cntlcal to Its success. Operative treatment of p atients With adheSIve capsulitis includes closed manipulation and arthroscopiC release. Clos ed manipulation is con traindi­ cated in pahents with significant osteopenia, rece nt surgi­ cal repair of soft tissues about th shoulder, or in the pres­ ence of fractures, neurologic injmy and instability. Historically, arthroscopy has been oflittle dia r;10stic and therape utic value in patie nts with adhesive caps~litis of the . has bee n su(rgestcd that the arthro­ shoulder. 172 H owever, It scope may be helpful for d elineatio~l of disorde rs , docu­ mentation of the result of closed manipulation, and treat­ ment of concomitant intraarticular al1d subacromial ' I tIwrapy treatment dl'sease .18:3,208.215.216Th e goa I 0 fp l l)'slca after surgery is to maintain ROM achieved under anesthe­ sia and to decrease pain and inflammation. In the recovery room , the arm is placed in the quadrant position while the patient is still under scalene block anesthesia. A second sca­ lene block is administered during an 0 e rnight hospital ~ta)' so the patient can tolerate exercise through the RO\il.21 ,,2 1S Continuous passiv·e motion is recommended throuahout the night. zHl After discharge, the pati e nt should receiv~ out­ patie nt physical therapy 5 days per week for the next 2 wee ks , then three tim es per week until treatment is eum­ pleted. Treatment includes aggressive ROM , l110daliti s for pain ~d inflammation, and hydrotherapy. Sh"engthe nillg exercIses are gradually incorporat d into the program, as outlined previously.

ADJUNCTIVE INTERVENTIONS: TAPING Complex muscular relationships exist among the seapula, humerus , cervical, thoracic spine, lumbar spine, and pelvis. Faulty scal;'lUl~r alignment contributes to a vaticty of syn­ dromes affectmg the upper quadrant. Scapular taping cnn Improve the l'('sting align me nt of the scapula on the thorax, thereby improving joint alignment of the related joints and length-tenSion properties of the shared musculature be­ tween the scapula and other regions of the upper quadrant. Scapular taping can be a use fu l adjunctivt' intervention

686

Therapeutic Exercise Moving Toward Functi on

when used with therapeutic exercise for the treatment of many upper quadrant diagnoses.lil,no Patients can perform exercises and ADLs or instrumen­ tal ADLs while taped with the added benefit of improved joint alignment and length-tension properties of the scapu­ lar musculature, The benefit of scapular taping over an off­ the-shelf brace is that taping allows the specific three­ dimensional correction of each patient's unique alignment faults, Short-term taping (2 to 3 weeks) may assist in im ­ proved neuromuscular control of faulty movement pat­ terns, whereas long-term taping (8 to 12 weeks) may affect muscle length-tension properties. Taping the scapulotho­ racic joint has several goals: • To improve initial alignment, which promotes im­ proved movement patterns • To alter length -ten sion properties by stretching tis­ sues that are too short and reducing tension placed on tis sues that are too long • To provide support and reduce stress to myofascial tissues under chronic tension • To provide kinesthetic awareness of scapular position during rest and movement • To gUide the PICR during movement Each piece of tape provides a specific corrective force on the scapula. Anyone piece can be used in conjunction with other directional pieces to provide a multidimensional Cor­ rection of the alignment of the scapula, The goal is to tape the scapula into improved alignment. If, however, the pa­ tient has Significant kyphOSiS, forward-head , or forward­ shoulder posture, 100 % correction should not be at­ tempted. It is instead recommended to moderately correct

the faulty alignment, because too much change in such a short period may not be well tolerated by an individual with a chronic postural problem, The tape product is specialized for taping the oody fo r alignment and movement. It has the best combination of adhesive, extensible, yet stiff properties. The undeltape is called Cover-Roll stretch, a hypoallergenic tape applied to protect the patient's skin from the overtape, called Leuko­ tape (BeirsdorfInc" Norwalk CT). On the shoulder girdle. the Cover-Roll stretch often is adequate alone, particularl~ on a small-framed person with minimal to moderate postu­ ral faults . The description of taping that follows details on method of taping, but other methods of taping can be used on the scapula and the humerus. 231 The goals of improved alignment and function are common to valious techniqu es. Improved alignment and function during ADLs and in­ strumental ADLs and exercise can be achieved with proper taping techniques , and therefore taping can be a useful ad­ junctive intervention to therapeutiC exe rcise and function al retraining.

Scapular Corrections The follOwing illustrations depict corrections of scapula po­ sition, • Correcting Scapular Depression and Improvin!! Scapular Elevation (Fig, 26-28) • Correcting Scapular Downward Rotation and Im­ proving Scapular Upward Rotation (Fig. 26-29) • Correcting Scapular Abduction and Improvi ne: Scapular Adduction (Figs. 26-30 and 31)

B

A

FIGURE 26-28. Correction of scapula depression, (A) Anchor the tape to the lateral edge of the acromion pro·

cess. Passively elevate the scapula, ensuring the acromial end rotates upward Pull the tape medially toward the

cervic al spine along the suprascapular space, following the fiber direction of the upper trapezius. Do not cross

the cervical spine, Apply a piece in asi milar direction on the oppos ite side to prevent lateral shearing across the

cervical spine, (8) Repeat the application until the correc tion is made, Often, if tape is applied to correct addi·

tional alignment faults, this piece needs to be repeated to ensure that other tape applications have not pulled

the scapula into depression

Chapter 26 The Shoulder Girdle

687

FIGURE 26-29. Taping the scapu la into upward rotation. (A) Anchor the tape slightly medial to the root of the scapula. Passively elevate the arm into fu ll flexion. (8) With the scapula in upward rotation, pull the tape medially and caudally toward the lower thoracic spine. (C) This piece provides a center of rotation for scapular upward rotation.

• Correcting Scapular Winging • Tape as for correction of scapular downward rotation (see Fig. 26-29) and abduction (see Fig. 26-30). • Be sure to cover the medial border of the scapula (Fig. 26-32) • Correction of Scapular Antelior Tilt (Fig. 26-33) • Correcting Scapular Elevation (see Fig. 26-33)

Prevention of Allergic Reaction A common side effect of taping is an allergiC reaction to the tape adhesive or skin breakdown. The follOwing are trou ­ bleshooting tips to help prevent adverse reactions to taping:

• Use only Cover-Roll stretch, which is hypoallergenic. The allergic reaction is usually to the adhesive in the Leukotape. • Use a skin preparation solution before application of the tape. A recommended skin preparation solution is Milk of Magnesia. A thin coat applied to th e skin should completely dry before the tape is applied to al ­ low easier tape removal. • Ensure that all tape residue is removed before the next tape application. • Warn patients of potential skin irritation. Instruct pa­ tients to remove the tape immediately if an)' itching or burning sensations develop. (text co ntinu es on page 690)

FIGURE 26-30. Taping the scapula into adduction. Tape as in Fig. 26-29, but add a piece fol lowing the fiber direction of the middle trapezius as shown on the left scapul a of this subject.

AGURE 26-31 . This is an alternative or adjunctive technique for

taping the scapula into adduction. A second piece of tape can be

used to prevent excessive abduction. (A) Anchor the tape proxi­

mally in the axilla and just anterior to the lateral border of the

scapula. (B) Pull the tape posteriorly and caudally while adduct­

ing and upwardly rotating the scapula. (C) Attach the tape to the

medial border of the inferior scapula. As the patient elevates the

arm, a pull is felt in the axilla if the scapula begins to abduct.

Chapter 26 The Shoulder Gird le

FIGURE 26-32. Taping the scapula into a posterior tilt. (A) Anchor the tape to the coracoid process . (8)While tilting the scapula posteriorly, pull the tape posteriorly, caudally, and medially (opposite to the direction of pull of the pectoralis minor). Anchor the tape to the spine of the scapula Place another tape as for correction of downward rotation (see Fig 26·29) and scapular abduction (see Fig 26·30). being sure to cover the inferior pole of the scapula to control tilt.

FIGURE 26-33, Taping the scapula into depression Use this technique to correct scapu lar elevation . (A) An· chor the tape to the anterior border of the upper trapezius. (8) Pull the tape posteriorly and anchor it to the spine of the scapula.

689

690

Therapeutic Exercise: Moving Toward Function

-------------------------------------------------------------------

Prevention of Skin Breakdown Skin breakdown often occurs because of excessive friction between the skin and the tape. Follow these guidelines to minimize skin breakdown: • Do not cross the midline of the spine with the tape. • Do not cross more than one joint at a time. • Tape the scapulae bilaterally, particularly in eleva­ tion. • Use a skin preparation solution before taping. • Remove all tape residue before the next taping. Use Leukotape to dab off most of the residue, and follow up with adhesive tape remover. • If skin breakdown occurs, allow the skin to heal fullv before reapplying the tape. This may take 1 week o'r longer.

If taped properly, patients can often tolerate taping for ,3 to 5 days. Showering with the tape is allowed, but soaking the tape is not recommended. For a person engaged in aggres­ sive activities, the tape is more likely to loosen and not be as effective for as many days as it is for a less active individual. KEY POINTS • Critical to the management of the shoulder girdle com­ plex is a thorough understanding of the anatomy and ki­ nesiology of each of the four articulations comprising the complex. • Precise PICRs at each of the four articulations and the integration of all four articulations with respect to jOint function, force couples, and precise motor control to co­ ordinate motion are required for optimal function of the shoulder complex. • Because the shoulder girdle is one link in a kinetic chain, the function of the shoulder girdle affects and is affected by the function of other regions of the upper and lower quadrants. • Treatment of impairments, although often necessary for improved function, should be complemented by func­ tional retraining modified to the level of ability at a giv€l1 time in the rehabilitation process. • Ideal total body posture is a prerequisite for optimal movement in the shoulder girdle complex. • A thorough understanding of the integrated approach to therapeutic exercise il1 the shoulder girdle is key to suc­ cesshil outcomes of shoulder girdle conditions. • Rotator cuff disorde.rs include such medical diagnoses as impingement syndrome, rotator cuff/glenOid labral tears, posterior shoulder pain, and GH hypermobility and instability. • Most rotator cuff tears are extensions of underlying chronic tears or tears of already degenerated tendons. • Adhesive capsulitis has been staged based upon arthro­ scopic findings as described in Table 26-8. • Treatment of adhesive capsulitis should be indiVidually based on the stage of the disease. • Early intervention is key to successful outcome of adhe­ sive capsulitis. Complete recovery with no residuallimi­ tation or disability is neither ensured nor common.

• Scapular taping can improve resting posture and thereby affect movement of the shoulder girdle complex.

CRITICAL THINKING QUESTIONS l. What GH motion is a prerequiSite to. restoring full up­ per extremity elevation? 2. Why is th e rotator cuff-deltoid function contingent on the scapular upward rotation force couple? 3. \Vhat structures can limit scapular upward rotation mobility? 4. Which muscles must have normal force or torque an d length-tension relationships to achieve full upward scapular rotation RONi? 5. \Vhat is the timing of onset of the scapular muscles during scapular upward rotation to produce the ideal PICR for scapular rotation? 6. What musculature is shared by the shoulder girdle and cervical spine? What joints are linked by the shared musculature? 7. If the upper trapez ius is overstretched, as in a de­ pressed scapula, in what direction is cervical spine ro­ tation limited? What treatment do you propose to cor­ rect this prohlem? 8. If the levator scapula is adaptivdy shortened, as in a downwardly rotated scapula, in what direction is cervi­ cal spine rotation limited? \iVhat treatment do you pro­ pose to correct this problem? 9. How can cervical nerve root involvement affect th e function of the shoulder girdle ? 10. Using the case described in Display 26-6 determine the dosage parameters for in. prming muscular force or torque of th.e rotator cuff (using the exercise de­ scribed in Self~Managel11ent 26-1). 11. Name the bhree-dimensional movement pattern of the scapula during arm elevation. . 12. What is the most critical intervention to promote heal­ ing of a strained muscle caused by adaptive lengthen­ ing from faulty postures? 13. Ho.W can poor technique during a biceps curl con­ tribute to an anterior tilted scapula? 14. Adapt Self-Management 26-1 dosage parameters to focus on endurance. 15. In what alignment does the scapula rest to develop an elongated serratus antelior ? How does this elongation contribute to a faulty PICR of the scapula durin scapular upward rotation? 16. \iVhat intrinsic and extrinsic factors predispose an indi­ vidual to impingement syndrome? 17. Why is restoring the scapular PICR important in the long-term recovery of impingement s)11drome? 18. With reference to Fig. 26-21, describe the beginning and ending positions, movement, and dosage parame­ ters for an individual with anterior GH hypermobility (see Fig. 26-25). Write this as a self-management pro­ gram for a patient. 19. When is active motion overhead introduced for a pa­ tient after rotator cuff repair? As a physical therapiSt. what physiologiC capabilities do you consider to be

Chapter 26 The Shoulder Girdle

691

or' •

LAB ACTIVITIES 1. Actively depress your left scapula. Rotate your head to the left. Release the depression, and rotate your head to the left. Which scapular position allowed you the greatest cervical rotation? Why? (Hint: think about a muscle that attaches from the shoulder girdle to the cervical spine that is put on stretch when you depress your shoulder and rotate your head to the same side.) 2. Sit in thoracic kyphosis, and raise your arm in the sagittal plane. Sit upright, and raise your arm. Which sitting posture allowed you the greatest up­ per extremity motion? 3. Assume a forward shoulder posture with the scapula abducted. With your arm at your side and elbow flexed 90 degrees, laterally rotate your shoul­ der. Assume a posture with scapular adduction , and laterally rotate your shoulder. 'Vhich scapular posi­ tion allowed you the greatest lateral rotation ROM? 4. Abdud your scapula, and hOlizontally abdud your shoulder. Adduct your scapula, and move your shoulder into horizontal abduction. What differ­ ence did your scapular position make on the arthrokinematic motion of your humerus? 5. Practice the manual stretch techniques for the pec­ toralis minor and rhomboid.

minimal expectations for exercise progression to over­ head positions? 20. How can taping the scapula help adhesive capsulitis to recover? What taping techniques would you use? 21. Using Case Study #4 in Unit 7, develop a compre­ hensive exercise program. Describe each exercise ac­ cording to the therapeutic exercise intervention model described in Chapter 2. You can follow the format used in the Selective Intervention at the end of Chapter 27.

REFERENCES 1. Goss C, ed. Gray's Anatomy of the Human Body. 27th Ed. Philadelphia Lea & Fcbigcr, 1959. 2. DePalllla A. Surgical ana tomy of the acromioclavicular and sternoclavicular joints. Surg Clin l\orth Am 1963;43: 1541-1550. 3. Sarrafian SK. Gross and functional anatomy of the shoulder. Clin Orthop 1983;173: 11-18. 4. Quiring , Boroush EL. Functional anatomy of the shoul­ der girdl . Arch Phys Med 1946:27:90-96. 5. Zuckerman JD , Matsen FA III. Biomechan ics of the shoul­ der. In: Nordin M, Frankel VH , eds. Basic Biomechanics of the Musculoskeletal System . 2nd Ed. Philadelphia: Lea & Fehiger, 1989. 6. Inman V, Saunders M, Abbott LC. Observations on the function of the shoulder joint. J Bone joint Surg Am 1944;261-30.

--6. Analyze the PICR of the head of the humerus dur­ ing prone GH medial rotation (see Self-Manage­ ment 26-1). Teach your partner how to prevent an­ terior translation of the head of the humerus during GH medial rotation. 7. During the prone lower trapezius progreSSion (see Self-Management 26-2), why is it important to barely lift the elbows? '''hat happens when your partner maximally lifts the elbows? (Hint: think about what muscle you are trying to isolate and why more scapula adduction reduces the speCificity of the exercise.) Why is this not a de­ sired response? 8. Attempt the hand-knee progression and the push­ up progreSSion (see Fig. 26-17) for serratus anterior strengthening. What signs indicate an individual is ready to progress to the next level? "Vhat signs indi­ cate the individual is working at too high a level or has fatigued at any given level? 9. Teach your partner to move the scapula "vith the correct PICR during standing wall slides (see Fig. 26-11). 10. Why is the standing corner stretch not desired for stretching the pectoraliS major?

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19b9. 222. Kessler Rlvl , Hertling D. rVl anage ment of Common Mus­ culo skeletal Disorders. Philade lphia: Harper & Row, 1983. 223. Norkin C, Levangie P. JOint structure and fun ction: A com­ prehenSive analYSiS, 2nd ed: Philadelphia, FA Davis, 1992. 224. Steindler A. KineSiology of the Human Body. Springfield, IL: Charles C Thomas, 1955. 225. Ellenbecker TS , Mattalino A], Elam E, et al. Quantification of anterior translation of the humeral head in the throwing

shoulder. Manual assessment versus stress radiography. Am J Sports Med 2000;28:161-167. 226. Speer KP, Hannafin JA, Altchek DW, et al. An evaluation of the shoulder relocation test. Am J Sports Med 1994 ;22 : 177-183. 227. Oliashirazi A, Mamat P, Cofield RH , et al. Examination un­ der anesthesia for evaluation of anterior shoulder instability. Am JSports Med 1999;27:464--468. 228. Gross ~iIL, Distefano Me. AnteIior release test: a new test for occult shoulder instability. Clin Orthop Relat Res 1997;339:105-108. 229. O'Brian S1', Pagnani \1J, Fea!y S, et al. The acti\'e compres­ sion test: a new and effective test for diagnOSing labral t('ars and acromioclavicular abnormaJjty. Am J Sports ~1ed 1998; 26:610-613. 230. Mimori K, Muneta T , Nakagawa T , et al. A new pain provo­ cation tt"st for superior labral tears of the shoulder. Am J Sports f...led H199;27:L37- 142. 2.3 ]. Kim SH , Ha KI , Han KY. Biccps 'load test: a clinical test for supetior labrum anterior and posterior lesions in shouldeJ·s with recurrent anterior dislocations. Am J Sports ~vl e d 1999:27:300-:303. 2:32. Hoi E, Tac1ato K. Sano A. f't al. Which is more useful , th c' "full can test" or the "empty can test" in detecting the tom supraspinatous tendon? Am J Sports Med 1999;27:63-6S. 233. vValch G, Boul ahia A, Calderone A, ct al. The "dropping" and "hornblower's" signs in evaluation of rotator cuff tears. JBone Joint Surg 1998;80B:624- 62". 234. Leroux JL, Thomas E, BOImel F , et al. Diagnostic value of cl inical tes ts for shoulder impingement s),1l0rolll c. Re\ Hh ellm 1995; 62:42:]--428. 235. Riand N, Levigne C, Renaud E. et al. R<'sults of derotational humeral osteotomy in post('rosuppl'ior glenOid impinge­ ment. Am JSports Med 1998;2fi: 45:3-4.'59. 236. Johllston TB. The 1ll0l'cmcnts of the shoulder joint. A pl ea for tIl(' usC' of thC' "plam' of th e scapula" as til(' nam C' of ref­ erence for mOVCllll'llts occurrin g at the hurn eroscapular joint. Br J Surg 19.·37;2.S:2.,)2- 2flO. 237. Saha AK. Mcchanism for shoulder mOVel11f'1l ts and a plea for the recogllition of "zero position " of glenohullle ral joint. Inclian JSnrg Hl50;12:1.53-165. 238. Hawkins RJ, Kenn edy Je. Impingement syndrome in atJ1­ letes. Am JSPOlts Med 1980;8:151- 138 . 239. Hoppe nfeld S. P hysical Examination of the Spine and Ex­ tremities. Norvvalk, CT: Appleton-Century-Crofts , 1976. 240. Silliman JF , Hawkins RJ. Class ification and physical diagno­ sis of instability of the shoulder. Clin Olthop 1993;291 :7-19. 241. Kibler WB. Role of th e scapula in the ove rhead throvvin motion . Contemp Orthop 1991;22:52.'5-532. 242. Ludewig PM , Cook T~·l. Translations of the humerus in persons \\ith shoulder impingement symptoms. J OrtJ1op Sports Phys Ther 1996;80:276-291. 243. Fiatow EL, Soslowsky LJ, Ticker JB , et al. Excursion of the rotator cuff under the acromion. Patterns of subacromial contact. Am JSPOliS Mcd 1994;22:779-778. 244. Brossman J, Preidler KW, Pedowitz RA , et al. Shoulde r im­ pingement syndrome : innuence of shoulder positoion on ro­ tator cuff impillgement- an anatomic study. AJR Am J RoentgenoI1996;l67:1511-]315.

RECOMMENDED READINGS DiGiovine N M, Jobe FW, Pink M, et al. An electromyographic analysis of the upper extremity in pitching. J Shoulder Elbow Sun' 1992;1:15-2;'5.

Chapter 26 The Shoulder Girdle D onatelli RA. Physical Therapy of the Shoulder. 3rd Ed . New

York: Churchill Livingstone, 1997.

Glousman R. Electromyographic analysis and its role in the ath­

letic shoulder. Clin Orthop Rei Res 1993;288:27-34.

Glousman R, Jobe FW, Tibone JE , et al. Dynamic electromyo­

graphic analys is of the thro\ving shoulder with glenohumeral in­

stability. J Bone Joint Surg Am 1988;70:220-226.

Perry J, Pink M, Jobe FW, e t aI. The painful shoulder

during the backstroke: an electromyographic and cine­

matographic analysis of 12 muscles. Clin J Sport Med 1992;2:

13- 20.

697

Pink M, Perry J, Browne A, et al . The normal shoulder during freestyle swimming. Am J Sports Med 1991;19:,369--575. Pink M, Jobe FW, Perry J. The normal shoulder during th e butterfly stroke: an electromyographic and cinematographic anal­ ysis of twelve muscles . Clin Orthop ReI Res 1993;288:48- 59. Pink M, Jobe FW, Perry J. The painful shoulder during the but­ terfly stroke: an electromyographic and cinematographic analys is of twelve muscles. Clin Orthop ReI Res 199:3;288:60-72. Scovazzo ML, Browne A, Pink M. The painful shoulder during freestyle swimming: an electro myographic and cinematographic analys is of 12 muscles. Am J Sports Med 1991;19: 577- 582

chapter 21

The Elbow, Forearm, Wrist, and Hand LORI THEIN BRODY

Anatomy Elbow and Forearm Wrist Hand

Regional Neurology Kinesiology Elbow and Forearm Wrist Hand

Examination and Evaluation History

Observation and Clearing Tests

Mobility Examination

Muscle Performance Examination

Pain and Inflammation Examination

Other Tests

Therapeutic Exercise Interventions for Common Physiologic Impairments

Impaired Mobility

Impaired Muscle Performance

Endurance Impairment

Pain and Inflammation Impairment

Posture and Movement Impairment

Therapeutic Exercise Interventions for Common Diagnoses

Cumulative Trauma Disorders

Nerve Injuries

Musculotendinous Disorders

Bone and Joint Injuries

Complex Regional Pain Syndrome

Stiff Hand and Restricted Motion

Therapeutic exercise texts have often minimized or ex­ cluded the elbow, wrist, and hand, deferring evaluation of this regioll to other health C
view of anatomy and kineSiology prOvides the basis for the interventions chosen.

ANATOMY* Althollgh the anatomy of a given joint is closely related to anatomy of adjacent joints, the elbow, wrist, and hand are discussed separately in the follOWing sections.

Elbow and Forearm Osteology The articulation of the humerus with the ulna and the ra­ dius forms the elbow joint. The spool-shaped trochlea 0 the humerus articulates with the trochlear notch of the ulna, and the rounded humeral capitulum (capitellum ) ar­ ticulates with the radial head laterally (Fig. 27-1). Dulin,!!: elbow extension, the trochlear notch contacts the infef()' posterior aspect of the trochlea, and while in flexion, th trochlear notch slides over and articulates with the anteri trochlea. This movement uncovers the trochlea pOStRriOri. making it vulnerable to trauma from falls or blows. Th. nonarticulating portion of the humerus includes the meru.. and lateral epicondyles and the radial , coronoid, and ole ­ cranon fossae. The medial epicondyle is a subcutaneous blunt prOJection that is eaSily palpable during flexion of th Jbow. 2 The ulnar nerve passes along its posterior surfa through a shallow groove. Th e lateral epicondyle forms th distal end of the lateral hum eral border, inferior to the lat­ eral supracondylar ridge. The lateral epicondyle has an im ­ pression on the anterolateral surface for the origin of tI-. forearm extensor muscles. The radius is the shOlier and more lateral of the 1:'. forearm bones. It is narrower prOximally than it is distill: and it contains the radial head , a cylindrical neck, and tL. oval radial tuberoSity. The head 's shape is discoid, and it ar­ ticulates with the capitulum on the humerus and the radi... notch on the ulna, The radial tuberOSity is distal and medi. relative to the neck, and it serves as the distal attachment the biceps brachii. The distal radius is four-sided with a lat­ eral distally projecting styloid. A dorsal tubercle, ca]!ed Li,­ ter's tubercle, is found on the distal dorsum of the radiu

o

Portions of' thi s secti on are li'om Brody LT. AthJetic injuries about tt­ Jbow. In : Wadsworth C. ('d. The EJhow, Forearm. and Wrist rho study course). LaC ross, WI: Orthopedic Section , APT A. ]997. Rep", elut ed \\~ t h permission.

698

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _---=C:.:.:h.:::.'ap::..::t::..:er~27: The Elbow, Forearm, Wrist, and Hand

Lateral supracondyle

ridge

Radial fossa Capitellum Radial head-----I-" Radial neck------\Radial tuberosity---1-Radius

Coronoid fossa

Trochlear groove -----,,------,¥--Trochlea Coronoid process Ulnar tuberosity Ulna

fiGURE 27-1 . Elbow osteology with significant bony landmarks. (From Stroyan, Wilk KE. The functional anatomy of the elbow complex. J Orthop Sports Phys Ther 1993; 17:280)

The ulna is the longer of the two forearm bones and is the major distal component of the elbow jOint proper. The trochlear notch comprises the proximal end of the ulna, and its articular surface is hook shaped with an anterior concavity The trochlear notch forms the major articulation with the humeral trochlea. At the proximal end of the hook, the olecranon articulates with tlw olecranon fossa on the posterior aspect of the humerus when the elbow is ex­ tended. The more proximal and anterior aspect of the hook contains the coronoid process and radial notch. The coro­ noid process forms the inferior aspect of the trochlear notch and articulates with the coronoid fossa in full elbow flexion. On the lateral aspect of the coronoid process, the radial notch provides an articular surface for the radial head. Just distal to the coronoid process is a sliaht depres­ sion that accommodates the radial tuberosity during prona­ tion. Posteriorly, the olecranon is smooth, and \vith the el­ bow in extension, it falls in a line between the medial and lateral epicondyles. During lbow fl xion, the olecranon moves inferiorly, forming a triangle \vith the epicondyles. The shaft of the ulna is triangular throuah most of its length, changing to a cylinder shape in its distal 25%. Dis­ taUy, the ulna is slightly flared and contains a head and a styloid process. The head is prominent on the dorsal aspect of the wrist when the forearm is pronated. The lateral ulna artioulates \vith the radim at the ulnar notch, but the l!Ilna does not directly articulate with the carpal bones. The stv­ loid process is a distal, rounded projection most easily p~­ pated \vith the forearm in supination. 2

699

The ulnar collateral ligament (V CL) is continuolls with the articular capsule on the medial aspeet of the hllmer­ oulnar joint (F ig. 27-2). ProXimally, it attaches to the me­ dial epicondyle of the humerus and descends inferiorly in a triangular, fan-shaped fashion. The anterior portion is a strong cordlike structure that attaches on the coronoid pro­ cess of the ulna 2 This portion serves as the primary stabi­ lizer against valgus forces throuahout most of the elbow's to range of motion (ROM). The posterior portion is tlianuular and attaches to the medial margin of the olecranon. The thick anterior and posterior portions are united by a thin, oblique band spanning the olecranon and coronoid pro­ cesses, The oblique band converts a depreSSion on the me­ dial trochlear notch into a foramen, where the intracapsu­ lar fat pad is continuous with the extracapsular fat found medial to the joint. 2 The ulnar nerve passes posterior to the medial epicondyle in proximity to the UCL. The radial collateral ligament is also a triangular, fan­ shaped band originating proXimally at the lower portion of the lateral epicondyle, olending distally \vith the annular ligament. Its fibers blend with the origins of the extensor carpi radialis brevis (ECRB) and supinator muscles 3 The a}l nular ligament is a stron a band that nearly fully encircles the radial head to attach to the radial notch ante­ riorly and posteriorly. The ligament's fibers blend with the radial collateral ligament and serve as a portion of the supinator muscle attaehn lent. The interosseous membrane is a broad, thin fascial sheath that attaches to the medial alld lateral borders of the ulna and radius, respectively. The fibers of this membrane are oriented distomedially, functioning to connect the two forearm bones and to prOVide attachments for the deep forearm muscles. The distal surfaces of the radius and ulna at the distal radioulnar jOillt are enclosed by joint capsule and connected by the articular disk. This disk plays an im­ portant role at the wrist and is discussed in greater detail in the Wrist section.

Myology Despite only a few muscles having a direct action at the humeroulnar jOint, numerous llluscles attach about the el­ bow and can be a source of pain and disability. Although

Anterior oblique

Arthrology The elbow jOint contains at least two articulations, the humeroulnar and the humeroradial, and the ulna and radius have two articulations, the proximal and distal radioulnar ar­ ticulations, The elbow is a compound synovial joint because of the multiple articulations. The humeroulnar joint is a hinge joint, although the arthrokinematics are more com­ plex than simple gliding, The humeroradial jOint functions as a hinge-type joint during elbow flexion and extension, but it functions as a pivot joint during forearm pronation and supination. The proximal radioulnar jOint operates as a pivot joint, permitting rotation of the radius about the ulna.

---"7'\~_posterior

oblique

Transverse oblique

FIGURE 27-2. Ulnar colla teral ligaments of the elbow. (From Zarin B, An­ drews J, Carson W. Injuries to the Throwing Arm. Philadelphia: WB Saun­ ders, 1985)

700

Therapeutic Exerci se Moving Toward Function

Muscles ·of the Elbow.and Forearm SPINAL LEVEL

PERIPHERAL NERVE

Forearm pronation

C7

Median

Forearm supination Shoulder flt'xion; elbow fl exion Elbow flexion

C6

Radial

C5-C6

M usculocu taneous

C5-C6

Elbow fle xion

C6

Musculocutaneous and radial Radial

Elbow extension

C7-C8

Radial

MUSCLE

ORIGIN

INSERTION

ACTION

Pronator teres

Medial epicondyle and coronoid proccss of ulna Lateral epicondyle

Middle lateral radius Lateral upper 1/3 of radius Radial tuberosity

Supinator Biceps brachii

Brachialis Brachioradialis

Triceps

Coracoid process; scapular supraglenoid tube rcle Distal 112 of anterior humc nIs Proximal 213 of lateral supracondylar lidge of humc nl s Infraglcnoid tuberde of scapula; proximal posterolate ml hum erus; Distal 2/3 or posteromedial hume rus

Coronoid process of ulna Latc>ral radial stylOid Olecranon process

many muscles perform multiple actions, they are classified by the articulation of their primary action. Muscles and their innervation can be found in Table 27-1.4

Wrist The bony structures of the carpal bones indicate their roles. The outer bones generally have half of their surfaces cov­ ered with articular cartilage (inner surfaces), and their outer surfaces are rough, providing attachment for connec­ tive tissues. The inner bones have two thirds of their sur­ faces covered by articular cartilage, and only the palmar and dorsal surfaces are irregular, providing for ligamentous attachments.

Osteology The wrist jOint is a complex area that includes eight carpal bones, the distal radius and ulna, and the bases of the metacarpal bones (Fig. 27-3). PrOximally, the distal radius and radioulnar disk articulate 'vvith the scaphoid, lunate, and triquetrum. Laterally, the scaphOid is the largest bone in the proximal carpal row. The scaphOid spans the inter­ carpal jOint, linking the proximal and distal rows, and this position makes it susceptible to injury. This bone is divided into segments, including the proximal and distal poles and the middle, or waist, area. The proximal surface articulates with the radius, and the distal surface has two facets, Falls on an outstretched hand witll the v.'list extended place the scaphOid at risk for fracture. The scaphOid receives most of its blood supply from a Single vessel, making the proximal pole susceptible to avascular necrosis after a fracture. Ap­ proximately 70% of fractures occur through the middle third , 20% through llie proximal lliird, and 10% through the distal thirdS

The lunate bone articulates between the scaphOid and the triquetrum late rally and medially, respectively. It is quadrangular, although semilunar in the sagittal plane. The proximal lunate articulates with the radius and articular disk and connects with the capitate distally. The lunate is the most frequently dislocated bone in the wrist. Perilunate instability is most common at the scaphOid-lunate joint (i.e. , scapholunate instability), followed in frequency by th triquetrum-lunate joint (i.e ., triquetrolunate instability).6,. The triquetrum articulates laterally 'vvith the lunate. proximally willi the articular disk, and distally and laterall~' with llie hamate. It has a somewhat pyramidal shape and bears an oval, isolated facet for articulation 'vvith the pisi­ form on its palmar surface. 2 The pisiform is a pea-shaped bone that has sesamoid bone attJibutes and several soft­ tissue attachments. Among the attachments are the tendon

~ C'P;"t'

~ Interosseous \ ligaments Hamate

-

~

Triquetrum Pisiform ArticuJar disk Radiocarpal articulation Radius

\

Ulna

FIGURE 27-3. Wrist osteology. Cross section of the wrist and pertinerl: bony and soft tissues.

701

Chapter 27: The Elbow, Forearm, Wrist, and Hand

Radioulnar disk Radius--------1

Ulna

FIGURE 27-4. Wrist complex. The radiocarpal joint is composed of the ra­ dius and the articular disk, with the scaphoid (SCI, lunate (LUI, and tri­ quetrum (TO) bones. The midcarpal Joint is composed of the scaphoid, lu­ nate, and triquetrum with the trapezium (TPI, trapezoid (TZ), the cap itate (CAl, and hamate (HA) bones.

of the flexor carpi ulnaris and abductor digiti minimi, the flexor and extensor retinacula, and stabilizing ligaments. In the distIl carpal row, the trapezium articulates disto­ laterally with the first metacarpal and dis to medially vvith the second metacarpal. This surhlce is saddle shaped to al­ Iowa large arc of motion at the first carpollletacarpal (CMC) joil1t. The trapezium hears a large, concave medial surLtce that articulates with the trapezoid. The palmar sur­ bce contains a groove through which the tendon of the flexor carpi radialis tendon passes The trapezoid is a small, irregularly shdped bone nesting between the trapezium laterally and the capitate medially. It articulates vvith the scaphOid proximally and the second metacarpal distally. Its palmar and dorsetl smfaces are rough, allowing for attachment of COIlllective tiss ues. The capitate is the central and largest of all carpal bones. Its central position allows articulation witl1 seven ot11er bones and it serves as a central site for ligamentous attach­ ment.' It is generally divided into head, ~eck, and body re­ gions. Its large triangular distal body bears a concavoconvex surface to articulate ,vith the third metacarpaJ.2 The waist divides the distal body from the proximal head. The proxi­ mal head articulates with the lunate and scaphOid. Because of its central location, the capitate is the keystone is the prOximal transverse arch, R The hamate is cuneiform, vvith the exception of its prominent hook (i.e" hamulus), from which it derives its name 2 The lateral surface articulates with the capitate, and, medially, the hamate articulates with the triquetrum. Distally, the hamate bears facets that articulate with the fourth and fifth metacarpals. The hook protrudes from its palmar surface and serves as the origin and attachment for several soft-tissue structures, The ulnar nerve also passes beneath ilie hook as it courses distally to ilie hand.

Arthrology The wrist is generally divided into radiocarpal, midcarpal, and intercarpal joints. The radiocarpal joint is biaxial and ellipsoid, and it is formed by ilie aliiculations of the distal radius and the triangular articular disk witl1 the scaphOid,

lunate, and triquetrum bones,2 The articular disk accounts for approximately 11 % of the articular surface, and the ra­ dial facets account for 89% (Fig, 27-4),9 The medial portion of the radiocarpal joint includes a network of structures called the triangular fibrocartilage complex (Fig, 27-5),9 Structures included in tl1e triangular fibrocartilage complex are the articular disk, dorsal and volar radioulnar ligaments, meniscus homolog, ulnar col­ lateral and radioulnar ligaments, and the sheath of the ex­ tensor carpi UIIl!alis (ECU) tendon 9 The articular disk and meniscus homolog continue their attachments distally vvith these ligaments and tendon to attach to the triquetrum, ha­ mate, and base of the fifth metacarpal The radiocarpal joint is surrounded by an articular cap­ sule that is lined vvith a synovial me mbrane and reinforced by several ligaments. These ligaments are true intracapsu­ lar ligaments, and the radiocarpal and ulnocarpal joints are considered to be extrinsic because of attachments outside the wrist. Ligaments at this joint include the palmar radio­ carpal, palmar ulnocarpal, dorsal radiocarpal, and ulnar and radial collateral carpal ligaments (Fig. 27-6),2 The intercarpal joints consist of articulations between in­ dividual bones within the proximal carpal row and the distal carpal row. The midcarpal joint is the articulation between the proximal and distal rows. The ligaments in this area are considered to be intrinsic and are divided into interosseous and midcarpal ligaments. Interosseous ligaments occur within the proximal or distal row, and midcarpal ligaments span the woximal and distal rows on the palmar and dorsal surfaces. 0 The specific: ligaments are listed in Table 27-2. The CMC joints are also enclosed in an articular capsule that is somewhat loose. The first metacarpal and trapezium are connected by this capsule and by the lateral, palmar, and dorsal ligaments The second through fifth CMC joints also contain dorsal and palmar ligaments and the in­ terosseous ligaments. The interosseous ligaments are short, thick fibrous bands connecting the distal margins of the capitate and hamate with the articulating surfaces of the third and fourth metacarpal bones. 2 The second to fifth metacarpal bases are connected by dorsal, palmar, and in­ terosseous ligaments.

Myology: Muscles Acting at the Wrist Joint Several important muscles that function at the wrist have their origin at the elbow. These are the major wrist flexors and extensors. These muscles can be a source of epi-

Meniscus homolog Lateral radial facet

Medial radial facet

Triangular fibrocartilage

FIGURE 27-5. The proximal surface of the radiocarpal joint is formed by the medial and lateral facets of the distal radius and by the triangular fi­ brocartilage or articular disk. The articular disk and meniscus homolog are together part of the triangular fibrocartilage complex.

702

Therapeutic Exerc ise : Moving Toward Function

Radial collateral ligament

Ulnar collateral ligament Pisiform 'J

Pisohamate ligament

Flexor carpi radialis tendon

Pisometacarpal ligament Head of capitate bone

Palmar radiocarpal ligament

Tubercle of trapezium , Deep transverse .... ~ metacarpal ligaments

Radius - - - - +

Dorsal radiocarpal ligament

..".. •

Deep transverse~ metacarpal ligaments

-'--­

Ulna

~ Ulnar

collateral ligament

Pisometacarpal ligament

FIGURE 27·6. (A) Palmar aspect of the ligaments of the left wrist and metacarpal area. (B) Dorsal aspect of the ligaments of the left wrist.

condylitis from overuse activities at the wrist. Interventions should be directed at the muscle function at the wrist. A list of the key muscles can be found in table 27-3.

Hand Osteology Five metacarpals and 14 phalanges compose the bony structure of the hand. Each metacarpal has a distal head, shaft, and base. 2 The medial four metacarpals have

rounded heads articulating witb their respective proximal phalanges. The metacarpal's articular surface is convex forming the rounded "knuckles" on the hand's dorsum. The medial four metacarpals articulate proximally with each other and with the distal row of carpal bones. The first and second metacarpals do not articulate with each other. Of the metacarpal bones , the third has the longest shaft an d the largest base. 2 The first metacarpal is saddle shaped proximally to articulate with the trapezium, and the distal end is pulley shaped, with two small condyles. There are three phalanges in each finger and two in th thumb. Each phalanx has a distal head, shaft, and proximal base. The base of the proximal metacarpals contains con ­ cave facets to articulate with the pulley shaped, conve.x metacarpal heads. Likewise, the bases of the middle pha­ langes have two concave facets separated by a smooth ridge to articulate \'lith the heads of the proximal phalanges. Th e phalanges provide numerous attachments for ligamen t: and muscles. The thumb contains n'lo sesamoid bones a the MCP joint.

Arthrology The MCP and interphalangeal (IP) joints have si milar

arthrologic structures. Each is composed of an articular cap ­

sule and synovial lining. The MCP joints contain volar liga­

ments, which are thick and fibrocartilaginous, loosely at­

tached to the metacarpal, and firmly attached at the

phalangeal bases. 2 Because of the incongruence of the MCP

jOints, the volar ligament (i.e., volar plate) does more than

reinforce joint capsule. Its fibrocartilaginous structure adch

surface area to the base of the proximal phalanx to more

closely approximate the size of the larger metacarpal head

This plate also checks hyperextension. Its flexible attach­

ments permits motion into flexion without restricting mo­

tion or impinging the long flexor tendons 9 The transverse

metaca11)alligament connects the volar ligaments of the sec­

ond through fifth MCP joints. Collateral ligaments are

found on either side of the joint and are strong, rounded

cords 2 The capsular, volar, and collateral ligament arnm&e­

ment at the MCP joints is the same structure found in t he

IP joints (Fig. 27-7).

Myology: Muscles Acting at the Hand

CLASSIFICATION OF INTRINSIC L.;IGAMENTS Interosseous Distal row

Proximal row Midcarpal Dorsal· Palmar"

LIGAMENT NAMES Trapezium-trapezoid Trapezoid-capitate Capitohamate Scapholunate Lunotriquetral Scaphotriquetral Dorsal intercaq)al Scaphotrapeziotrapezoid Scaphocapitate Triquetrocapitate Triquetrohamate

• Midcarpal ligaments span the proxim,tl and distal rows on the palmar or dorsal surfaces. (From Berger RA. The anatol11v and basic biomechanics of the wrist jOillt. JHand Ther 1996;9:84-93.)

The muscular anatomy of the hand can be classified

thumb and finger musculature. Many muscles contributE"

to the fine motor function of the wrist and hand. Althou

a mere listing of the muscles along with their anatomy does

not address the fine motor skill necessalY for hand func­

tion, it is a place to begin considemtion of hand function. :\

listing of muscles as well as flgures of some key muscula­

ture can be found in Tables 27=4 and 27-5 and Figs. 27­ and 27-9.

REGIONAL NEUROLOGY Several important nerves serve the elbow, wrist, and hand These nerves may be injured locally by trauma, stretched during activities, or compressed within a confined spac Understanding the area anatomy aids the clinician in d termining the sou.rce of symptoms.

703

Chapter 27 The Elbow, Forearm, Wrist, and Hand

Other muscles with primary function at the hand also assist function at the Wlist. These will be included in Table 27-4. SPINAL ACTION MUSCLE ORIGIN INSERTION LEVEL

II

Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) Extensor carpi ulnaIis Flexor carpi radialis Flexor carpi ulnaris Pronator quadratus

Distal l/3 of lateral supracondylar ridge

Base of second metacarpal

vVrist extension and abduction

C6-C7

Radial

Common extensor tendon , lateral epicondyle Common extensor tendon Common flexor tendon of medial epicondyle Common flexor tendon; proximal posterior ulna Medial antelior distal ulna

Base of third metacarpal

Wrist extension and abduction

C6-C7

Radial

Base of fifth metacarpal Base of second metacarpal

Wrist extension and adduction Wlist flexion and abduction

C7-C8

Radial

C6-C7

Median

Pisiform bone, hamate, fifth metacarpal Lateral anterior distal radius

Wrist flexion and adduction

C8-Tl

Ulnar

Forearm pronation

C8-Tl

Median

The median nerve originates from I:\.vo roots from the lateral (C5-C7) and medial (CB-Tl) cords. It descends along the brachial artery to enter the distal arm of the cu­ bital fossa. It passes between the brachialis posteriorly and the biCipital aponeurosis anteriorly. At the elbow, the me­ dian nerve passes under the ligament of Struthers and the lacertus fibrosus and then enters the forearm between the heads of the pronator teres. This nerve can be injured or entrapped in any of these areas. It continues distally behind and adhered to the flexor digitorum superficialis (FDS ) and anterior to the flexor digitarum profundus (FDP). As the median nerve passes the distal margin of the pronator teres muscle, it divides into the median nerve and the an­ terior interosseous nerve. 2 The anterior interosseous nerve supplies the first and second FDP, flexor pollicis longus (FPL), and pronator quadratus. Just proximal to the flexor retinaculum , the median nerve becom es superficial and then passes deep to the flexor retinaculum into the palm. It

First phalanx Collateral ligament

cordlike part

Fanlike part -----j,.,...... Volar accessory

ligament - - - /

PERIPHERAL NERVE



Metacarpal bone

FIGURE 27-7. Ligaments of the fingers.

The collateral and volar accessory ligaments in a typical digit

then passes through the carpal tunnel , where it may be­ come compressed. After passing through the tunnel, the median nerve divides into five or six branches, prOviding motor and sensory innervation to the hand. The ulnar nerve arises from the medial cord (CB-Tl) of the brachial plexus, but it may receive fibers from the ven­ tral ramus ofC7. Because of its location and anatomic rela­ tionships, the ulnar nerve is susceptible to compression, traction , and friction. The ulnar nerve courses distally through the axilla along with the axillary artery and vein and the brachial artery. At the middle of the humerus, it moves medially, descending anterior to the medial head of the tri­ ceps. The ulnar nerve can become entrapped here by the arcade of Struthers, approximately B cm proximal to the medial epicondyle.2 At the elbow, the ulnar nerve passes superficially through a groove on the dorsum of the medial epicondyle, entering the forearm in the cubital tunnel be­ tween the two heads of the flexor carpi ulnaris. The ulnar nerve can become entrapped here as well, because the cu­ bital tunnel narrows 55% during elbow flexion,u Traction across an unstable medial elbow joint can also injure the ul­ nar nerve. Through the forearm , the ulnar nerve descends along the medial side of the FDP. Just proximal to the wrist, it sends off a dorsal branch that continues distally across the flexor retinaculum. The ulnar nerve continues distally with the ulnar altery, beneath the most superficial aspect of the flexor retinaculum, and divides into superfi­ cial and deep terminal branches. The ulnar nerve can be compressed as it crosses the distal edge of the pisohamate portion of the retinaculum. The superficial and deep branches provide motor and sensory innervation to the hand. The radial nerve arises from the posterior cord (C5-CB) and is the largest branch of the brachial plexus. It courses distally bel:\.veen the medial and long heads of the triceps

704

Therapeutic Exerc ise: Moving Toward Function

Muscles Functioning Primarily at the Hand SPINAL LEVEL

PERIPHERAL NERVE

Extends MCP joints and
C6-C8

Radial

C7-C8

Radial

C7-C8

Radial

C7-C8

Median

Flf'xes proximal IP joints, assists \1CP joint and wrist flexion Flexes DIP joints; assists flexion of IP and Mep join ts Mep flexion of fifth finger Opposes Ov!C of fifth finger Digit abdllction and assists flexion and ('xtension Adduction of nngers

C7-C8

Median

C8

CInar

C8-Tl

Ulnar

C8- Tl

Ulnar

C8-Tl

Ulnar

MUSCLE

ORIGIN

INSERTION

ACTION

Extensor digitorum Extensor indicis

Common extensor tendon of lateral epicondyle Posterior ulna

Middle and base of distal phalanx of digits 2-,:) Extensor expansion of index finger

Extensor digiti minimi

Common extensor tendon

Extensor expansion of fifth digit

Palmalis longus (PL) Flf'xor digitorum superficialis (FDS)

Common fl(~xor tendon Common fl exor tendon ; coronoid process; radius

Flexor retinat:ulum, palmar aponeurosis Middle phalanges of digits 2-5

Flexor digitoru!l1 profundus (FDP) Flexor digiti minimi

Antermnedial ulna

Bases of distal phalanges digits

Hook of hamate

Opponens digiti minimi Dorsal interossei

Hook of halllate

Proximal phalaTLx of fifth digit Length of fifth MC

Metat:a1val bones

Radial ,Uld ulnar sides of fingers

Palmar interossei

Metacarpal bones

Ulnar and radial sides of fin ge rs

2-5

IP, interphalangeal; MCP, metacarpophalangeal.

Muscles Functioning at the Thumb SPINAL LEVEL

PERIPHERAL NERVE

Adduction of CMCjoint Abducts and extends CMCjoint Abduction of CM C and MC P jOints Opposes CMC of thumb Flexes IF joint

C8-Tl

Ulnar

C7-C8

Radial

C6-C8

Median

C6-C8

Median

C8-Tl

Median

MUSCLE

ORIGIN

INSERTION

ACTION

Adductor pollieis

Capitate; second and third MC Posterior ulna and radius Trap ezium and scaphoid Trapezium

Proximal phalanx of thumb Firs t 1\lIC

Abductor polliciS longus (APL) Abductor poLlicis brevis (APB) Opponens po!Jicis Flexor polLicis longus

Proxilllal phalanx of thumb First MC

Interosseus membranes, medial epicondyle Trapezius, trapezium , and capitate

Distal phalanx of thumb

Proximal phalanx of thumb

Flexes \1CP and CMC joints of thumb

C6-C8, Tl

Nledian and ulnar

ExtC'nsor polliC'is longus

Posterior ulna

Extends IP joint

C7-C8

Radial

Extensor ponicis brevis

Posterior radius

Distal phalanx of thumb Proximal phalanx of thumb

Extends MCP joint

C7-C8

Radial

Flexor pollicis brevis

CMC, carpometacarpal;

~\"'I C ,

metacarpal : \ICP, lllNacarpophalang(,aL

705

Chapter 27 The Elbow, Forearm, Wrist. and Hand Extensor insertion to second phalanx

Dorsal expansion (hood)

Long extensor tendon

Slips of long Metacarpal bone

Lateral bands Interosseous slip to lateral band

Interosseous muscle

Portion of interosseous tendon passing to base of first phalanx and jOint capsule

FIGURE 27-8. Dorsal view of extensor mechanism of the fingers

and then passes obliquely posterior to the humerus and deep to the lateral head of the triceps to the lateral as~ect of the humerus to penetrate the anterior compartment. Its proximity to the humerus makes it susceptible to injury in mid-humeral fractures. As the radial nerve continues dis­ tally, it bifurcates to become the posterior interosseous and superfiCial radial nelves. The supelficial radial nerve has only sensory fibers . The posterior interosseous nerve is analogous to its anterior correlate (i.e. , anterior in­ terosseous nerve) in tl1at is has only motor fibers. The pos­ terior interosseous nerve passes through the supinator muscle, around the proximal radius, and beneath the ex­ tensor muscle mass, and the superfiCial radial nerve passes beneath the brachioradialis muscle and continues distally to the hand. The superfiCial radial nerve continues distally along the anterolateral aspect of the forearm. Proximal to the wrist, it passes deep to curve around the radius and di­ vides into four or five dorsal digital nerves. This nerve in­ nervates the skin of the dorsolateral hand. It is susceptible to injury in the distal forearm and hand, where it lies su­ perfiCially. Compression can by caused by casts, watch­ bands, and similar items. 12

KINESIOLOGY Elbow and Forearm Normal ROM at the elbow jOint is 0 to 1.33 degrees actively and 0 to 150 degrees paSSively. Much of this mobility is necessary for the normal activities of daily living (ADLs). For example, putting on a shirt requires a range of 15 to 140 degrees, and drinking from a cup requires range of 72 to 130 degrees 13 ROM in flexion is limited by anterior muscle bulk, and ROM in extension is limited by the bony articulation of the olecranon in the olecranon fossa. The ex­ tended position of the humeroulnar joint is the close­ packed pOSition; additional inherent stability occurs in ex­ treme flexion. Motion occurs primarily by gliding of the ulna on the trochlea. Pronation and supination technically occur through the forearm at the proximal and distal radioulnar joints. The normal range of pronation and supination is 0 to 80 degrees in each direction. Pronation occurs as the radius crosses

over the ulna at the proximal radioulnar joint. Although most ADLs occur with the forearm in a middle pOSition, some activities, such as receiving change in the palm of the hand, require full supination. Resistance to valgus stress in full extension is limited equally by the UCL, bony congruity, and the anterior cap­ sule.\) As the elbow moves into fleXion , most of the resis­ tance to valgus stress is ~rovided by the anterior band of the UCL. Morrey and AnI found the UCL to contribute ap­ proximately 54% of the resistance to valgus stress in flexion. The joint articulation contributed 33% of the resistance to valgus. Resistance to varus in full extension is prOvided by the bony congruity and by the radial collateral ligament and capsule 9 Resistance to distraction is prOvided by soft­ tissue components, and the anterior portion of tl1e jOint capsule provides the primarily resistance to anterior dis­ placement. A cadaveric study of the flexor pronator group relative to the UCL throughout the ROM has Significant implica­ tions for rehabilitation of individuals with medial elbow in­ juries. At 30 degrees of elbow flexion , the pronator teres and flexor carpi radialis muscles were entirely anterior to

Lateral band

Lateral view, finger extended

Extensor insertion Extensor to second phalanx insertion to distal phalanx Long extensor tendon Lumbrical Interosseous muscle muscle

Collateral Vincula Vincula ligaments breva longa

Profundus Sublimis tendon tendon Interosseous muscle

Lateral view, finger flexed Insertion of deep portion of extensor tendon to first phalanx Attachment of

interosseous m. to base of first phalanx and joint capsule

muscle

Flex. dig. sublimis

tendon (cut off)

ligaments Flex. dig. profundus tendon (cut off) Tendon ends approximated

Correct position for splinting "mallet finger." Note relaxed lateral band.

FIGURE 27-9. Intrinsic muscle anatomy. (A) Extended position. (8) Flexed position

706

Therapeutic Exercise Moving Toward Function

the DCL, and the flexor carI?~ ulnaris muscle was found over or posterior to the DC L. ~ The F DS muscle was over the DCL in most cas es. The findings were similar at 90 de­ grees, excep t the f1 exor carpi ulnaris muscle was com­ pletely over the DCL, and the F D S mu scle was anterior to the UCL in most cases. At 120 degrees, the pronator teres, flexor carpi radialis, and FDS mmclcs were all anterior to the UCL, and only the flexor carpi 1llnaris muscle was over the DCL. This pattern suggests that th e flexor carpi ulnaris muscle is the primary d)'11amic medial elbow stabilizer througbc;>ut the RO M and particul arly at 120 degrees of flexion 1.0

Wrist The normal wrist ROM is from 80 degrees of flexion to 70 degrees of extension. The resting position of the wrist is be­ t\vc"n 20 and 3.5 degrees of extension and 10 to 15 dep,ree of ulnar deviation while in the close-packed position !' The wrist functions primarily through a range of 10 degree.) of flexion to 35 degrees of extension when performing most AD LsY However, some activities, such as rising from a chair, require Significantly more extension. l i M ov~ment at the radiocarpal joint is predominantly a gliding movement of the concave distal radius and articular disk on the convex prox,imal carpal row. T he prOxi mal carpal row is considered to be an intercalated segment, a relatively unattached mid­ dle segment of a three-segment link, because of its position bet\veen the radius and distal carpus 9 Mechanically, the scaphoid plays a critical role in stabi­ lizing this segment by means of its position bridging the proximal and distal carpal rows (i.e., the midcarpal joint). The racliocarpal and midcarpal joints p rovide variable pro­ portions of the motion during wrist extension and fl exion. 'When the proportion contributed by radiocarpal joint ex­ ceeds that of t.he midcarpal jOints in one direction, this pat­ tern reverses in the other clirectionY V/rist extension is ini­ tiated at the distal carpal row, wit.h this row gliding on the relatively stable proximal row. As t.he wrist passes into ex­ tension, these rows begin to move together, with the scaphoid intervening as the bridge to this process 9 Full f'X­ tension is the close-packed position of the wrist. In general, the distal caq)al row function s as a unit be­ cause of th e interlocking of articular surfaces and the liga­ mentous connections betwee n the distal row and the metacarpals distally. J() The distal row tends to move in uni­ son with the second and third metacarpals, palmar flexing when these metacarpals palmar flex and dorsal fl eXing wh en they dorsally fl ex. The proxilllal carpal row differs in its movement pattei'll from the distal row. In general, the bones in the proximal row move together, although greater motioll occurs between the bones in the proximal row than in the distal row. T his is true of the direction and magni­ tude of motion between tbe bones in tb e proximal row. The proximal row tends to move in tb e same direction as the distal row ~JJ!d therefore in th e saIne uirection as the s(~ cond and third metacarpals. lO Be t\vee n-bone motion also oc­ curs, and, during 'wrist extension, t.he scaphoid supinates while the lunate pronat es, fU11 ctionally separating th ese bones. This motion underlies peril un ate instabilities occur­ ring as a result of forceful extension.

F rontal plane motion is I.1Drmally from 15 degrees of ra­ dial deviation to 30 uegrees of ulnar deviation. The ulnar stylOid is shorter than the radial styloid, accoun t.ing for the greater range in ulnar deviation than radial. Greater ulnar and radial deviation is possihle when the wrist is in a neu­ tral fl exion-extension position. Althrokinernatic motion in radial and ulnar deviation is more complex than in flexio n and extension. During radial deviation, the proximal carpal row glides ulnarly and fl exes while the distal row pi'0ots ra­ dially. D uring ulnar deviation, the proximal row glides ra­ dially and moves into extension while tbe distal ro"v move uL1arly. 10 The mobility of the wrist depends on the position of the fingers because of the length of extrinsic tendons crossin the wrist and hand joints. F or example, wrist flexion is de­ creased wh en the fingers are simu ltaneously flexed be­ calise of the length of the extrinsic finger extensor muscles. Likewise, the mobility of the flngers depends on the posi­ tion of the wrist, as evidenced by the in ability to fully fl ex the fingers when the wrist is flexed. Load transmission across the wrist is significant and varies with wrist position. With the wrist and forearm in neutral, approximately 80% of the force is transmitted across the radiocarp al joint and 20'70 across the ulnocalp al joint. 1S F\.llther breakdO\vn of the radiocarpal loads shO\., that approximately 45% of these forces are transmitted across the radioscaphoid joint and 35% across the radiolu­ nate joint. 18 F orearm pronation increases the load trans­ mitted across the ulnocarpal joint to approximately 3 7 ~ _ with a proportional reduction of load at the radiocarpal joint. Radiocarpal forces increase to 87% when the 'wrist is in rauial deviation. lo

Hand Carpometacarpal Joints CMC joints t\vo through five are similar in structure and function, but th e first C MC is different. The second through fourth CM C joints permit one degree of freedom in fl exion and extension, and the fifth CM C allows som abduction and adduction as well. Motion at the C MC joints is limited primarily by the ligamentous stru cture. Motion increases at the CM C joints from the radial to the ulnar side of the hand 9 Alm ost no motion occurs at the second and third CMC joints, the fourth is slightly more mobile, and the fifth moves through a range of nearly 1 to 20 degrees 9 The first CMC jOint is saddle shaped and has !\vo de· grees of freedom and some axial rotation. This mobility al­ lows for opposition, a kcy f ullction of the thumb. Tbe t.humb is involved in nearly all forms of prehension, or han­ dling activiti es, and loss of th e thumb accounts for the greatest portion of disability in th e hand. HI ROM is appro\­ im ately from 20 degrees of fle xion to 45 degrees of exten ­ sion and from 0 degrees of adduction to 40 degrees of ab­ duction. Mobility at the C MC is limited by the ligamentou and interposed soft tissues. p rim ary role of the CMC joints is to contribute to cup­ ping of th e hand, forming palm ar arches. This hollOwing al­ lovvs the hand to conform to the shape of the object being held . Two arches are visible: th e longitudinal arch th at

Chapter 27 The Elbow. Forearm. Wrist. and Hand

spans the lcn~th of the hand and the metacarpal arch that transverses the palm.

Metacarpophalangeal Joint The four medial metacarpophalangeal (MCP ) joints possess two degre s of freedom , flexion and extension, and abduc­ tion and adduction. The mobility at these joints increases from the radial to ulnar sides of the hand, with an active ROM from 90 degrees of flexion to 10 degrees of extension. Passively, variable amounts of extension are available. Functional flexion at the MCP joint is approximately 60 de­ grees. 16 The range in abduction and adduction is approxi­ mately 20 degrees in each direction. The range in the frontal plane is limited by articular surfaGe geometry, and the range in flexion is limited by joint geometry and capsule, and the rang" in extension is limited by the volar plates. The MCP jOint of the thumb also poss sses two degrees of freedom. The ROM is more limited here than in fingers two through five. Almost no hyperextension is available in normal hands, and only approximately 50 degrees of flexion can be obtained. Extension at this joint is further limited by the presence of two sesamoid bones , stabilized by collateral and intersesamoid ligaments. The primary function of MCP mobility of the thumb is providing additional range for opposition and prehension activities.

Interphalangeal Joints The IP joints of the fingers and thumb are similar in func­ tion . Each is ahinge joint with one degree offreedom . ROM at the IP jOints, as with the other jOints in the hand, increases from the radial to the ulnar side of the hand. This is easily observed when making a fist. The ROYI at the proximal in­ terphalangeal (PIP) is from 0 degrees of extension to 100 degrees of flexion at the radial side of the hand and nearly 135 degrees of flexion at the ulnar side. Little hyperexten­ sion is availablE' because of the volar plates. The distal in­ terphalangeal (DIP ) joint demonstrates less ROM , from 10 degrees of extension to 80 degrees of flexion. Functional flexion at the PIP joints is approximately 60 del~ees, and functional flexion at the DIP joints is 40 degrees. (j

Extensor Mechanism The extensor mechanism of the fingers is composed of the extensor hood (i.e., extensor expansion or dorsal aponeuro­ sis) and the extensor digitorum (ED ), palmar interossei, dorsal interossei, and lumbrical muscles. Each finger con­ tains a similar mechanism that is necessary for successful extension of the finger. As the ED courses distally, it Bat­ tens into an aponeurotic hood over the metacarpal, and just distal to the M P jOint, the ED is jOined by tendon fibers from the interossei muscles. The interossei arise from the lateral borders of the metacarpals (see F ig. 27-9). This aponeurosis formed by the ED and interossei continues distally, where, proximal to the PIP, the hood splits into three branches. All three branches receive fibers from the interossei, and the medial branch also receives fibers from the lumbricals. A central tendon continues distally and crosses the PIP to insert at the base of the middle phalanx. Two lateral bands on either side continue distally, cross the PIP joint, and reunite into a Single tendon that terminates at the distal phalanx. Several local ligaments attach to the

101

extensor hood and prevent bowstringing durin g move­ ment. The oblique retinacular ligaments are important in simultaneous PIP and D IP extensi on. A complete description of the mechanics of the exte nsor hood is beyond th scope of th is text, but a few gen raliza­ tions can b made. At th e M P jOint, contraction of the of the ED produces ext nsion whil activation of the lumbri­ caIs and interossei produce flexion. The torqu produced by the ED exceeds th that of other, and extension results. t the PIP jOint, the ED , interossei, and lumbricals to ether produce extension. I olated contraction of the E D causes the finger to claw or to produce Mep hyperextension with IP flexion 9 because of the p,(ssive pull of the long finger flex­ ors at the rr joints. Extension of the PIP jOint also produces DIP extension (and vice versa) , and when the PIP is held in flexion, the DIP is incapable of isolated extcnsion. This mechanism is finely tuned to produce fine movements and strong grip. Any imbalance in the lateral slips disrupts this mechanism and Significantly alters hand function.

Grip The hand is well suited for the major task of gripping. Grip can be divided into power grip and prehension grip , or pinching. The power grip is used for develuping flrrll con­ trol, and the prehenSion grip is used when accuracy and precision are needed. Examples ofpowe r grip include hook, spherical, cylinder, and fist grasps , and examples of prehen­ sion grip include the three-fingered, key, and tip pinches. Grip activity has been broken down into four stages. In the first step, the hand opens by simultaneous action of the long extensor and hand intrinsic muscles. The fingers then close about the object, requiring activity of the intrinsic and extrinsic fl exor and opposition muscles. The third step is an increase in force in these same muscles to a level appropri­ ate for the task. The hand again opens to release the ob­ ject. 16 While the Hexors are grasping the object, the wrist extensor muscles must fire simultaneously to prevent the long flexors from prodUCing wrist flexion. The innervation of the hand is related to the two types of grip. The ulnar nerve controls the motor and sensory distri­ bution of the medial digits , and th ese digits are used more for the power grip. The median nerve controls th e lateral digits, which are used more for the prehensile grip. The thumb musculature, used in both types of grip, is innervated by both nerves. 16 The power grip is used when force generation is the pri­ mary objective (Fig. 27-10A) . arrying a suitcase, climbing on a jungle gym, making a fist, and grasping a baseball to throw are all examples of power grip. In this situation, the ulnar digits stabilize the object, holding it against the palm , with or without the assistance of the thumb. The fingers are fully flexed while the wrist is extended and ulnarly deviated. The prehension grip is used when fine control is nec­ essary. This grip is used when holding a writing imple­ ment, putting a key in the door, or holding a piece of pa­ per between two fingers (F ig. 27-10B ). The prehenSion grip includes primarily th MCP jOints and the radial side of the hand. The index and middle fingers work with the thumb to create a tripod. In contrast with the power grip, the object in a prehenSion grip may never come in contact with the palm.

708

Therapeutic Exercise: Moving Toward Function

components of general observation: • Posture of the head and neck • Muscle tone throughout upper extremity, including thenar and hypothenar eminences • Quality, color, and temperature of the skin • Quality of the nails • Carrying angle of the elbow • Swelling, ecchymosis • Resting position of the elbow, forearm, and wrist • Ability to use limb during examination The resting position of the hand also should be evaluated. including these deformities:

B A FIGURE 27-10. (A) Power grip (8) Prehension grip used while writing.

EXAMINATION AND EVALUATION Examination and evaluation of the elbow, wrist, and hand must include a comprehensive assessment of the upper quarter. The upper extremity relationships between the cervical spine and distal joints requires a full examination to ensure identification of the problem source. Many of the ex­ amination techniques depend on the situation. The pres­ ence of comorbidities such as diabetes or rheumatoid arthritis necessitates different examination techniques from those used for the patient without such additional issues. The following sections address the key aspects of elbow, wrist, and hand examinations.

History The history and subjective information focuses the remain­ der of the examination. In addition to the medical history and evaluation of the current problem, subjective informa­ tion about the signs and symptoms after the injury is valu­ able. Information is gathered about the functionallimita­ tions (e.g., inability to manipulate buttons, zippers and other small objects, inability to carry out hygiene activities, difficulty writing or typing, problems opening jars) and dis­ ability (e.g., unable to work because of inability to type, un­ able to care for child because ofpain and weakness in elbow) associated with the current complaint. This information, along with data gathered during the objective examination, forms the basis for the intelventions chosen. Information to differentiate primary elbow, wrist, and hand problems from those referred from the cervical spine must be ascertained.

Observation and Clearing Tests Observation of posture and position of the limb and clear­ ing tests for the celvical spine and shoulder are essential parts of the examination and evaluation. The follOWing are

• Swan-neck deformity • Boutonniere deformity • Ulnar drift • Clubbing of DIPs • Heberden's or Bouchard's nodes • Claw fingers • Dupuytren's contracture • Mallet or trigger finger

Mobility Examination Mobility examination of the elbow, wrist, and hand in­ cludes osteokinematic and arthrokinematic testing and tests of muscle extensibility. It is particularly importaIilt to find the sources of mobility loss in the hand, because till impairment is associated with significant functional limi­ tations and disability. Examination procedures should dis­ tinguish between contractile and noncontractile tissue~ and between inttinsic and extrinsic muscle limitations. In most cases, the follOWing tests of mobility should be per­ formed.

Elbow and Forearm • Active range of motion (AROM), passive range of mo­ tion (PROM), and overpressure for flexion, extension. pronation, and supination • Distraction and anterior, medial, and lateral glides

Wrist • AROM, PROM, and overpressure for flexion, extel '­ sion, and radial and ulnar deviation • Distraction and anterior, posterior, radial, and ulnar glides • Radiocarpal, midcarpal, intercarpal, and car­ pometacarpal assessment

Hand • AROM, PROM, and overpressure for flexion, exten­ sion, abduction, and adduction (at appropriate join • Distraction and antelior, posterior, radial, and uInar glides (at appropriate joints)

Muscle Extensibility • All muscles crossing the elbow, wrist, and hand • Intrinsic muscles of the hand Muscle length testing is performed for the extrinsic fore­ arm flexors and extensors. Forearm extensor muscle lengtl

Chapter 27 The Elbow, Forearm, Wrist, and Hand is assessed duri r
Muscle Performance Examination Muscles fum:tioning at the elbow, wrist, and hand should be tested in a logical or der on the basis of the subjective in­ formation provided, history, and the results of the exami­ nation. Many of the hand muscl s are quite small, and therapists must consider their relative strength when ap­ plying traditional manual muscle testing criteria. St~lbiliza· tion, particularly when trying to isolate small intrinsic mus·­ cles of the hand, ensures that the muscle of interest is being tested. Kenda1l 4 has described the testing proce­ dures for the relevant mus -le s in the region. Grip and pinch (tip pinch and key pinch) force measurements are commonly used and have high reliability. However, large changes (i.e., improvements) in these measures are neces­ sary before they can be reliably detected with standard measuring devices 20

Pain and Inflammation Examination The initial pain examination is performed as part of the subjective history. The patient is asked about the level of pain and the pattern of that pain over 24 hours. During the objective examination, a visual analog scale or similar tool can provide objective information about pain. Inflam­ mation can be detected by palpation for warmth and spe­ cific tenderness. Swelling can be detected by volumetric measurement.

709

DISPLAY 27·'

Special Tests at the Elbow, Wrist, and Hand Elbow Valgus stress test (0 and 30 degrees) Varus stress test (0 and 30 degrees) Tinel's sign Pinch grip Tennis elbow tests Resisted wrist extension

Passive wrist flexion

Resisted third finger extension

Golfer's elbow Resisted wrist flexion Passive wrist extension Wrist and Hand Carpal tunnel tests Phalen's test Tinel sign Three jaw chuck test Allen's test Finkelstein's test Brunnel-Littler test Retinacular test Froment's sign Ligamentous instability testing for the fingers Thumb ulnar collateral ligament testing Lunatotriquetral ballottement test Scaphoid stress test Hand function tests Grip strength test Reflexes and sensation Upper limb tension tests

Hypomobility

Other Tests Many special tests assess the integrity of tissues throughout the upper quarter. These tests examine ligament stability, soft-tissue mobiHty, neurologiC status, and functional tasks. Magee 16 has provided a complete listing and deSCription of special tests. Some of the more common tests used are listed in D isplay 27-1.

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON PHYSIOLOGIC IMPAIRMENTS Mobility Impairment Impaired mobility in the distal upper extremity can be very disabling. Fine motor skills are necessary for the simplest of daily activities. Mobility activities must restore full ROM throughout the distal segments to maintain independence in many household tasks. Impaired mobility in this region is treated with a combination of therapeutic modalities, ex­ ercise, and splinting.

Hypomobility in this region can occur for a number of rea­ sons. Injuries that necessitate a period of immobilization can produce profound mobility loss. Surgery, neurologiC injuries, burns, and falls can Significantly impair mobility. Because of the mobility required for functional use of the upper limb , loss of m otion in this region can be quite dis­ abling. Intervention for mobility loss requires a thorough eval­ uation to determine the structures responsible for or con­ tributing to the motion loss. The joint capsule, short mus­ culotendinous structures, immobile fascial tissues, or restricted nervous tissues are a few examples of tissues that may be at fault. Evaluation techniques aimed at differenti­ ating contractile from noncontractile tissues, followed by specific tension testing, can pinpoint the source of limita­ tion. Only then can appropriate intervention be initiated. Mobility impairment at the elbow includes loss of flex­ ion and extension. Loss of elbow extension occurs fre­ quently after fractures or dislocations at the elbow. Loss of motion occurs rapidly at the elbow, and therefore immobi­ lization is k pt to the minimum acceptable time. Degener­ ative joint disease has a lower impact on the upper extrem­ ity joints than the lower, and loss of motion because of arthritic changes at the elbow therefore is less common

710

Therapeutic Exercise Moving Toward Function

than at the knee . L oss of motio n at the elbow is often com­ pensated by trunk, shoulder, and \Vlist motion , all of which may place additional loads on these structures. ~Iohility loss at the forearm in cludes loss of p ronation and supination. T he capsuJar patte rn sh ows equal loss of pronation and supination. Loss of motion at tJ1 8 fo rearm is common after immobilization for wrist and hand fract ures. The distal radioulnar jOint is affected in indivi duals \vi th rheumatoid milllitis. D isease rnav cause the ulna to dor­ sally sublm:ate on the ntdius at tlie distal radiou ln ar joint. Loss of pronation and snpillation results in diHlcu lti es Witll turni ng kn obs, ope nillg jars, receivirw change, an d turning a key. Th ese motions are freque ntl y transfe rred to th e shoulde r, with th e person pe rforming ext ernal and internal rotation to compens ate. Restoration of motion is importan t to prevent secondary injury to the shoulder. Loss of lllotion at tb e wrist is com mon after falls or fracture ~ injuri ng the wrist. Rhe um atoid arthritis also a['­ feds the vvrist join t. Th e patien t wi th rh eumatoid artlui­ tis often has a wrist deformity of f1 exion. radial de viation , und volar subluxati on of the ~a rpal bone s. 19 An kylosis may eve nt uall y e ns ue , seve rely res tricting mobility at the wrist. This moh on loss is p arti cul arly disabling for the in­ dividual with rhe umatoi d ar th riti s, b ec ause adjace nt joints are also affected and unable to compe nsate for wrist immobility. Loss of motion in th e hand is fr equently caused by rheumatoid mihritic changes. T his disease p roduces MCP joint ulnar deviation and volar sublw[ation of tlle proxi111a1 plLtalangcs. Swan -neck deformity, or h yp erextension of the PIP and flexion of th e D IP , results from fle xor and exten­ sor imbalance and PIP join t laxity.1.9 Loss of motion in the hand may result from osteoarthri tis, and this process te nds to affect tll e PIP and DIP joints bu t not the MCP joints (see Self- Management 27-1: Prm..imal and D istal Inte rpha­ langeal Joint Flexion). T he th umb CMC is Significantly af­ fected by osteoarthritis and rheumatoid arthriti s. I nj Uli es such as fractures , dislocation s, and bUJ'I1S produce limita­ tions in rnobility after treatment. D up uytre n's contr adion . or coMraction of the palmar fascia, usu ally affects th e fourth or fifth fin gers , where the skin is adhe rent to tbe un­ derlying fascia. Thi s progreSSive fibro sis of the pal mar fas­ cia has no known caus e and affects men older than 40 years of <>ge more than wom en. l 6 These impairments can lead to functi onal limitations (e .g., in ability to grasp a pen) and the refo re disability (e .g., unable to work because of inabil­ ity to grasp obj ects ). Activities to increase mohility begin \\lit.h an adjunctive agent such as heat, followed by joi nt mobilization if capsu­ lar restriction is the cause of im mobility. F or exam p le, lim­ ited motion because of capsular restriction at the elbow may be treated witll humeroulnar distraction techniques and some an teli or and posterior glides (see Chapte r 7) Af­ ter mobilization t:ch niques, p a.ssive p rolonged stretch i11g in the direction or limitation may be perfor med alon g vvith concurre nt application of heat or cold . Active mobility in the new range should follow (Fig. 27-11 ). F or example, ac­ tive pronation alld sup ination m ay be followed by active hand to mouth exercises or active fon",'ard reach ing. \iVhen immobility is caused by a short or stiff muscle, tradi tional

SELF-MANAGEMENT 27-7 Proximal and

Distal Interphalangeal Joint Flexion Purpose: To increase the mobility in the joints and tendons of your fingers

Starting position:

Start with all the joints of your fingers as straight as possible.

Movement technique: Keeping your knuckle joints (MCP) straight, bend the middle and fing ertip joints (PIP and DIP) as far as possible. Return to the starting position .

Dosage Repetitions

Frequency ________

PIP

~

MC..f.-­

{ stretching techniques may be employed. At the same ti me. postural corre ction and stre ngthe ning of tIle antagon ist (which is often weak because of its lengthe ned position must occur. Immobi.le fascial connective tissues are mobi­ lized by manual tech niques such as massage and lIIanual deep pressure appbcation. As with stre tching, this inter­ vention should b e followed with active use of the limb (F ig, 27- 12) (see Self- Manage ment 27-2 : Me tacarpophalangeal and P roximal I nterphalangeal Joint F lexion With D istal I n­ terp halangeal Join t E xtension). T reatm en t for im mo bility of the hand of a patient \\ith rhe umatoid arthri tis depends on th e acutent:ss of the situ­ ation and the degree of deformity. I mmobilization lIIay be th e treatment of choice in some phases of this disease pro­ cess (see th e Stiff Hand and Restricted ~Iotion section ). Neural gl iding techniq ues are employed when neural ten ­ sion test reveal s im mobili ty of neural tissue to be the some of the patient's symp toms .

Hypermobility H ypermobility is an uncom mon problem at tll e elbow and forearm; hypomobilit)' is a m uch rriore common complain t. E lbow hYT)erextension RO M is one criteria for a diagnosi,

Chapter 27 The Elbow, Forearm, Wrist, and Hand

A

711

B

FIGURE 27-11. Active motion of the forearm. (A) Pronation. (8) Supination.

of sys temic hypermobility H owev r, hypermohility at this joint is rarely symptom atic because of the limited weight­ bearing occurring in the upper extremities. Individuals participating in up per extremity weight-bearing spo rts such as gymnastics or wrestling may have difficulty associ­ ated with elbow hyperextension du ring sports. Similarly, hypermobility is uncommon at the wrist and hand. Hypermobility should not be confused with instabil­ ity. Instabilities occur in the wrist and the hamL LUllate dis­ location with perilunate instability and scapholunate disso­ ciation are common , and instability in the fingers is evidellt in the hand of the patient with rheumatoid arthri tis. H ow­ ever, phYSi ologic hyp c nl10bility rarely exists without

FIGURE 27-12. Active pinch exercise .

pathology or injury, and ifh.ype rmobility is present, it rarely produces symptoms.

Impaired Muscle Performance Several injuries or pathologies can impair a patient's ability to produce torque in the distal upper extre mity. Fractures, dislocations, contusions , sprains, tendon lacerations, burns, neIVe entrapments , and crush injuries are some of the con­ ditions that can limit a person's torque- produci 19 ability. An evaluation to determin e the source of impairment and an understanding of the h aling process call guide inter­ vention to improve torque produdion. The nAation ship be­ tween the force or torque impairment and functi ollul lillli­ tations Or dis ability must be es tablished to justify and guide treatment. Although specific muscular strengthening exer­ cises are employed, these activities must be progressed to activities that reproduce the functio n of the upper extrem­ ity. This approach may include self-care activities such as dreSSing, grooming, an d bathing and work activities such as grasping, pinching , typing, and other dexterous move­ ments. Any strengthening exercis es for the elbow, wrist, and hand must cons ider th e kinetic chain relationship across these jOints . The jOints are interconnected and related, and the muscular anatomy often crosses several joints . Strengthe ning exercises for the elbow often load the wris t ,mci finger muscles as the individual holds a weight or other resistive equipment in the hand. The difference between strengtl1ening exercis es requiring a grip aud those using re­ sistance around tlle wrist (e.g., a cuff wei Jht) must be con~ sidered. For example, strengt.hening exercises for lateral epicondylitis focu s on strengthening tile wrist extensor muscles in their roles as active wrist extensors (concentri­ cally and eccentrically) and as stabilizers against finger

712

Therapeutic Exercise Moving Toward Function

SELF-MANAGEMENT 27-2

Metacarpophalangeal and Proximal Interphalangeal Joint Flexion With Distal Interphalangeal Joint Extension Purpose: To increase the mobility of your finger joints and tendons

StBrting position:

Start with all joints of your fingers as straight as possible.

Movent technique: Bend your knuckle (MCP) and middle (PIP) joints while keeping the fingertip joints (DIP) straight. Return to the starting position.

Dosage Repetitions

Frequency _ _ _ _ _ _ __

MCP

Muscular Causes

I

/ )

The ulnar nerve is also subject to traction injuries at th e medial elbow in the thrower. Similarly, the mobility of any nerve witmll its nerve sheath may become restJicted. Injury, compression, traction , or ischemia of th ese nelves, proXimally or distally, results in various symptoms, including loss of th e ability to produce torque in the mu s­ cles served by the dam aged nelve. Treatme nt for a limited ability to produce torque depends on the specific situation. For example, the ind.ividual with distal weakness caused by cervical spine disk herniation may benefIt from traction. postural retraining, and cervical spine exercises, followed bv progressive resistive exercises for dis tal musculature only after the proximal symptoms have resolved. Nelve entrap­ ments at the elbow, wrist, or hand must be treated first by rel ease techniques to mobilize the nerve . In contrast, trac­ tion injuries to the ulnar nelve at the elbow should be iru­ tially treated \Nith stabilization teclln.i ques. Only tb en can strengthening exercises be initiated. These exercises may be performed in pOSitions or postures that minim ize the trac­ tion or compressive forces on the nerve. Progression to more provocative and functional patterns shonkl follow.

DIP

Musde injuri es in this region range from tendinopathies a th e elbow (i.e., medial and lateral epicondylitis) and wrist (Le., de Querv
flexor activity such as gripping or shaking hands. Any wlist extension exercise that concurrently requires glipping may overload these muscles (Fig. 27-13 ). This relationship is one reason wby prescribing shoulder exercises while hold ­ ing a 16-01lnce can in the hand can produce lateral epi­ condylitis in previously asymptomatic individuals .

Neurologic Causes NeurolOgiC p athology or injury is a common source of im­ paired muscle function in the distal upper extremity. Cer­ vical degenerative joint disease, degenerative disk disease, and cervical spine injuries can cause symptoms distally in the respective nerve root distributions. After exiting the celvical spine, the nerves may be entrapped in a number of locations throughout the neck and thorax . Entrapment may produce distal neurovascular symptoms such as thoracic outlet s),11drome. In this situation, the neurovascular bun­ dle is compressed at one or more sites (e.g., cervical rib, scalene muscles) producing a variety of intermittent to con­ stant symptoms. More distally, the radial nerve may be compressed in th e radial tunnel, the ulnar nerve at the medial elbow or at the pisiform, and the median nerve in the carpal tunnel.

FIGURE 27-13. Resisted wrist extension with free wei ghts.

Chapter 27: The Elbow. Forearm. Wris t. and Hand

713

FIGURE 27-15. Grip strengtheni ng using putty.

FIGURE 27-14. Res isted wrist flexion with a resistive band.

After th e appropriate 1 v I of load is determined, pro­ gress ive isometric to dynamic exercises may be initiated for elbow musculature (e.g., extensors, flexors ), forearm mllS culaturc (e.g., pronators, supin ators), and wris t and hand (e .., flexors . xtensors. ulnar and radial deviators). Exercises may be p rfo1111ed ill
Disuse and Deconditioning Proximal muscle deconditioning can lead to distal muscle overuse injuries . his occurs with r petitive work or activ­ ity and reinforces the importance of a thorough upper q uarter examination. ffective repetitive distal activity re­ quires proxim al ·tabilization , maintainiJ1g posture within a neutral range. When the proximal muscles fatib'll , post Ire is compromised, and a greate r load is placed on the distal muscles. For exampl ,as the rotator cuff fa tigues duling a r petitive lifting task, more of the Jirti ng may be performed by the elbow flexors an d ,vrist extensors, predisposing the

individual to lateral epicondylitis. As one group of distal muscles fatigues, the load is shiftcd to alternate rnll ~ cle groups, overworking thest' muscles. ppropriaLe muscle e ndurance for the rClIuired task is necessary througllOut the kinetic chain .

Endurance Impairment Muscular endurance impairment is often seen at the \Vlist and hand in individuals who perform repetitive work ,vith their hands. Imb alance betwee n the endurance of wrist

SELF-MANAGEMENT 27-3

Finger Pinch

With Putty Purpose: Starting position:

Movement technique:

To increase the strength ofthe muscles used to pinch Form the putty into the shape of a ball. Hold it between your fin gertips. Pinch the putty between your fingertips and your thumb until your finge rs press through the putty. Reshape the putty and repeat.

Dosage Repetitions

Frequency ._ _ _ _ _ _ __

714

Therapeutic Exercise Movi ng Towa rd Function

flexors and exte nsors , along with a numbe r of other factors, contribute to forearm, wrist, and hand pain, F orms of epi­ condylitis at the elbow may be considered form s of en­ durance impairm ent as well. Epicondylitis may develop as an acute injury because of a muscular strain, or it may re­ sult from fatigue of the re lative 11lllSCldature. In this sit\l a­ tio n. impaire d llillsc:le endurance is cOlltributing to th e situatioll. Intervention for muscle endurance impairm ent focuses on high-rep etiti on , low-resistance exercises fo r th e in­ volvecllllusclcs, with appropriate rest periods he tween sC'ts and repe titions. Particular attC'ntion should be given to tlw posture assumed during p e rformance of these exercises. \Vrist extensor strengthe ning exe rcises should focus on the position of illte rest; if tlle individual fUllctiolls at work with the wrist in a speCific posture. that postu re should be as­ sessed and corrected if necessary, Subs eque nt exe rcises should focus on strengthening the mu scle at the le ngth it will be durillg functiollal activity In contrast, trainill g the wrist exte nsor muscles in the cas p of lateral epicondylitis will likeiy use a dynamiC range of stn>ngthe nillg, given the wide ROM for most acti vities prodUCing late ral epicoll dyli­ tis (e .g " tennis, painting, h am me ring) (see Self-Manage­ m ent 27-4: Wrist Exte nsion E xe rcise With Grocer), Bag) .

tis at th e wri st result from irnpainnen ts in p osture an d movement. The posture of the wrist and hand influence. symptoms at th e e lbow. Grasping and pinching always causE' a fl exion mom ent at th e wrist that must be offse t b,' t'xte nsol' muscle activity. This places loads on the co rn mo; ('xtensor tc ndon at the elbow , H and grip strength is a func­ tion of tIlE' object's size and the posture of tll e wr ist. F or a given size of obj ect , em op timal wlist p osition for m,l." irn um glip strength exists, 21 In the examination of the individual with a disorder related to work or hobbies, tI le size of the tool and its impact on e lbow, wlist, and posture must be considered. T hese tools (;<1n b e hobby re lated (e.g" golf club, racqu et, garde ning tools, kn itting needles) or work re-

SELF-MANAGEMENT 27-4 Wrist Extension Exercise With Grocery Bag

Purpose: To increase the strength of your forearm, wrist, and hand muscles

Starting position: Find a bag or purse with a comfortable handle. An object with too large or too small a handle can increase your pain. Place objects such as cans or bags of beans in the bag according to the weight recommendations of your clinician. Hold the handle of the ba g over the edge of a table with your palm down.

Pain and Inflammation Impairment Pain and inflammation occur throughout the distal up per extre mity for a variety of reasons. Injury or slll'gery can re ­ sult in pain and inflarnrnation, Central or local nelve COll1­ pression usually produces pain locally amI pain radiating from th e site of co mpression. Inf1::nllll1atory conditions such as rheumatoid arthritis or osteoarthriti s produce pain and inflammation in the affecte d joints, and tClldillopathies also are painful. Inflammation is easily de tecte d in this region because of the superfiCial nature of the structures, The MCr, PIP, and D IP joints in the hand are easily obse rved for swelling and redness and palpated for warmth and tenderness , C repitus in te ndons such as th e abductor pollicis longus (APL) and exte ll SQr pollicis brevis (EPB) tendons in a person \\1th de Quervain's syndrome is readily palpable, as is the local ten­ derness associated ,vith medial and lateral epicondylitis, lnte lvention for inflammation is base d ou the acuteness of the inflam matio n (see Chapter 11). Gentle active, active assisted, or p assive motion to maintain mobility d,ui ng the acute phase may be indjcated. In som e situations, illlmobi­ lization ,vith splints may be necessal)" with occasi on al re­ moval for gen tle mobiu!)' activities . After th e acute phase has passed , m ore aggressive activities may be initiated. Gentle grade I oscillations may b e used to dec rease pain in some situ ations. T hjs approach along with ice and other adjunctive agents can decrease pain enough to allow re­ su mption of a th erapeutic exercise program.

Posture and Movement Impairment The most comm on posture and movement impairments in this region are \vork- and hobby-re lated cumulative in­ ju ries . Lateral and medial epicondyliti s at the elbow and carpal tunn el syndrome (CTS) an d de Que lv ain's tendini­

Movement technique: Levell: Level 2:

Hold the bag for a count of 10. Rest by setting the bag down or by holding it with your other hand, Raise and lower the bag through a comfortable range.

Dosage Repetitions

Frequency _ _ _ _ _ _ __

Chapter 27 The Elbow, Forearm, Wrist. and Hand

The following information can help you to evaluate your computer workstation. If you have specific medical problems, consult your clinician for any special needs you may have.

715

controlling force production , and substitution occurs. Sub­ stitution may occur with a synergistiC muscle or a muscle group more proximal or distal in the kinetic chain. In either case, the primary muscle and the substituting group are vulnerable to overuse injuries. Allowing adequate rest time, using proper tool size, reinforcing good posture, and controlling cycle time, recovery time , and exe rtion fre­ quency can decrease repetitive loads.

Computer Correct keyboard position • Elbows bent at 90 degrees • Wrists straight or slightly bent up • Keyboard downwardly sloped • Try placing the keyboard on a commercially available keyboard tray with a wrist rest. Correct monitor position • About 16 to 22 inches away (about an arm's length) • Top of the screen even with top of forehead • Use a stand or adjustable monitor arm to regulate height. Mouse Correct mouse position • Elbows bent at 90 degrees • Wrist straight or slightly bent up • Shoulders relaxed and arm at your side • Elbow supported on armrest if available Your Work • Your document and screen should be at similar

heights.

• Use a document holder. • Sit directly in front of the keyboard, monitor, and document holder. Sitting posture

THERAPEUTIC EXERCISE INTERVENTIONS FOR COMMON DIAGNOSES Cumulative Trauma Disorders Most musculoskeletal injuries that occur in the workplace are not caused by accidents or acute injuries that sprain lig­ aments; they result from wear and tear stresses on th mus­ culoskeletal system . Wear and tear injuries are frequently referred to as cum ul ative trauma disorders (CTDs). There has been a significant increase ill the number of reported cases ofCTDs in the workplace (Display 27-2). According to the Bureau of Labor Statistic's, 23,800 cases Were re­ ported in 1972, a number that steadily increased to 332,000 in 1994. In 1995, the number of cases decreased by 7% to 308,000 22 The clinician workin rr in an outpatient setting may see many patients with this type of disorder. CTDs are by definition work-related phenomena, al­ though these disorders may also occur ,vith certain hobbies and other nonwork-related activities. The World Health Organization has defined CTDs as being multifactorial in nature, indicating that a number of risk fadors contribute to these disorders, including physi<:al risk bctors , environ­ ment, work organization, and psychosocial, sociocultural, and individual risk factors. Because of the multifactorial na­ ture of CTDs, there is some controversy about tlte role these risk factors play in the developlllent of CTDs. Physical risk factors include repetition , awbvard pos­ tures , prolonged activities , forceful exertions, and fatigue (Display 27_3).23 The magnitude, du ration , and repetition need to be considered for each of these lisk t~\ctors . Envi­ ronmentallisk factors , such as vibration and cold , may also be present, further complicating the picture. The worker exposed to these factors and not given adequate recovery time may develop a CTD. The worker is unable to recover

DISPLAY 27-2

lated (e.g., hammers , screwdrivers, shovels, welding tools, sewing tools). When grip is involved, the posture of the up­ per quarter relative to that tool must be exam ined. Posture during nongrip activities such as keyboard operating also is important. The guidelines for posture wh il e sitting at a computer work terminal can be found in the Patient-Re­ lated Instruction 27-1.: Computer Workstation Posture. Movement factors may contribute to injuries in this re­ gion. Fatigue during repetitive activity produces changes in movement patterns and subsequent overuse injuries. As muscles begin to fatigue, tl1e individual has more difficulty

Factors Contributing to the Increase in Cumulative Trauma Disorders • • • • • • • •

Work pace Same task, little variability Concentrated forces on smaller physiologic elements Decreased time for rest Increase in service and high-tech jobs Aging workforce Reduction in staff turnover Increased awareness of the problem

716

Therape~tic

Exercise Moving Toward Function

DISPLAY 27-3

Common Characteristics Associated With Cumulative Trauma Disorders • Work-related: intensity, duration, repetition or cycle time, posture, vibration, force, contact stress, tool geometry • Mechanical and physiologic processes • Exacerbation of an existing health problem (e.g., rheumatoid arthritis, osteoarthritis) • Recovery requiring weeks, months, or years • Multifactorial: work + recreational activity + hobbies • Fatigue • Symptoms often poorly localized, nonspecific, and episodic

from the microi njUli es or microtrauma that occurs at the tissue level over time. CTDs typically have a slow onset, with only minimal symptoms noticed initially. M any people ignore the early symp toms and do not seek medical atten­ tion until th e symptoms prevent them from participating in work or in recreational or home activities. Work may also aggravate or exacerbate an existing health or musculoskeletal problem. For example, forceful glipping at 'vvork may aggravate a previolls spOit injlHY at the elbow, su ch as lateral epicondylitis. The diagnosis of lateral epicondylitis is frequently used to describe a CTD injury at the elbow involving the lateral extensor mecha­ nism. Actin g alone or in combination, awkward postures, ex­ cessive fo rces, and frequent repetitions may cause me­ chanical and phYSiologic stress on t.he soft tissues . When a person is positioned in an awkward posture, the body is un­ able to function at an optimal revel. F or example, wrist de­ viations may stretch tl1e soft tissue, irritating the tendons and tendon sheaths. When in a lengthened position, the wrist muscles may be unable to exert tl1e recluired force for the task. When the wrist is in a 45-degree flexed pOSition, the grip strength may be reduced by 40%.24 The individual may be functioning at a greater percentage of their maxi­ mum capabilities. F atigue is more likely to occur when functioning at a higher percent.age of the maximum volun­ talY contraction. F atigue, coupled with excessive repetitive motions, may exceed the tendon sheath's capacity to lubli­ cate the tendon, causing increased friction and eventual wear and tear of the tendon . Workplace design and ergonomiCS must be carefully evaluated when a patient is diagnosed with a CTD. E r­ gonomics is the study of fitting the job to the indh,i dual. Celtain occupational risk factors such as repetitive grip­ ping or forceful pushing with the wrist in an ulnar-devi­ ated pOSition may preven t the person from successfully returning to that job without symptoms recurring. A job analys is or ergonomic analysis should be completed to as­ sess the risk fac tors present in the individual's work envi­ ron ment. An example is an individual graspi11g a straight­ handled tool such as a knife. This tool and activity places the wrist in an uln ar-deviated pOSition. By angling the tool handle instead of the \,vrist, the wrist's pOSition is im­ proved. By ensuring appropliate preventive maintenance (e .g. , sharpening t.he Imife on a timely basis), the stress on the tool operator is decreased.

Nerve Injuries A variety of nerve iIIjuries occur throughout the elbow, wrist, and hand because of the anatomic stmctmes in the upper extremity and th e functional demands in the region. A thorou gh knowledge of the local anatomy proVides a foundation for und erstanding the impairmeIIts found with these nerve injuri es.

Carpal Tunnel Syndrome TS at th e wrist is the most common peripheral compres­ sion neuropathy. I8 Th e carp a.! tunnel is a small tW1I1el on the volar aspect of the wrist that is occupied h)' the median nerve and by nine tendons. The base of th e cmpal tunnel i formed by the carpal arch, one of three concave arcl1es on the volar aspect of the wrist and hand. The calpal arch i concave on its palmar surface and is spanned hy the flexo r retinaculum. At this level, the median nerve contains mo­ tor fib ers innervating the abductor pollicis breviS, the su­ perficial head of the Hexor pollicis brevis , the opponeIl' pol1icis, and th e flrst and second lumbrical muscles. Sen­ sory fibers provide innervation to the volar thumb and to the index, middle , and one half of the ring fingers. The average cross-sectional area of the carpal tunnel is 1.7 cm 2 with the Wlist in neutral. Pressure in the calpal tun ­ nel varies with wrist position. Normal tissue fluid pressu re with tl'lc wrist in neutral is 2.5 mm Hg. Passive fl exion and extension of the wrist has been shO\vn to increase c
Chapter 27: The Elbow, Forearm, Wrist, and Hand

FIGURE 27-16. A wrist spli nt is used to rest the forearm and wri st mus­ culature.

(and occasionally day) wlist splints positioned at 0 to 15 de­ arees of extension, patient education regarding body me­ chanics and ergonomics , and the rapeutic exercis (F ig, 27­ 16), Exercise interv ntion for CTS focllses on mobility and str ngthening without pro ducing an exace rbation, Stretch s for the extrinsic and intrinsic muscles are pre­ scrihed for several times each day (Fig. 27-17) , If working, a patiel1t shoulcl perform the m bdor ' work, on breaks, or after work They should be performed slowly and gently; the patient shoulcl feel only a gentle stretchil1g sensation, D iflerential tendon gliding exercises are perfon led to lu­ bricate and increase gliding of the FPL, FDS , and FDP tendons, These are best performed "\lith the hand elevated to concurrently control local edema, Median nerve gliding exercises ancl the upper limb te nsion test with median

A

717

nerve bias can be used as treatment techniques , The upper lim b tension test with median nerve bias requires a position of shoulder girdle depression, shoulder abdu ction to ap­ proximately 110 degrees, forearm supination, wrist and fin­ ger ext nsion , and shoulder lat ral rotation,l After assum­ ing this str tch pOSition while standing, th e patient should perform r petitions of elbow fle;-.:ion and e>..'i:ension or wrist flexion and extension, Strengthening is g ne rally not pre­ scribed for patients with CTS who also have flexor tenosyn­ ovitis, If the precipitating factors have been eliminated and weakness creates a fi.ll1ctionallimitation, resistive exer ises are closely monitored, The focus should be on balanCing mobility and strength about the wrist. Patient d ucation is a key intervention in the treatme nt and prevention of CTS, Patients are instructed to maintain a neutral upper extremity joint position dllli n seated or standing work. This position is a com plished with the wrist in neutral , elbow flexed in the l1'Iiddl range, shoulders re­ laxed in adduction , scapula slightly depr ssed and ad­ ducted, and the cervical spine position d with the earlobe in line with the glenohumeral joint. The patient is also in­ structed to avoid a sustained pinch and gIip. especially with the wrist in flexion , and to avoid repetitive overuse of the wrist and fillgers, Patients should avoid direct pressure over the carpal tunllel by using a wrist rest or padded tahle edge or use a downwardly sloped keyboard This type of keyboard has been shown to decrease the wrist ext ension angle and decrease muscle activitY'i (see Patient- Related Instruction 27-1: Computer \.Vorkstation osture) , E rgonomic interventiOlI includes use of ergonomic tools that are padded with appropriately sized grips and handles, Data processing station revision should allow an adjustable chair height arid keyboard height alld tilt. Antivibration gloves are helpful for preoperative and postoperative

B

FIGURE 27-17. (A) Stre tch ing exercise for wrist extensor muscles. (8) Flexi on at the metacarpal joints with ex­ tension at the interphalangeal joints can ma inta in mobility in the extensor digiiorum tendon and the collateral ligaments .

718

Therapeutic Exerci se Moving Toward Function

FIGURE 27·18. Antivibration gloves.

caJ'pa.1 t unn el re lease to p ad an d ~rotect the carpal tun nel fmd flexor te ndons (Fig 27-18) .2 .28 Modality treatmen t can also control symptoms aJ1d e n­ hance the tl1erapeutic exercise program. Patie nts m ay fi nd a decrease in sym ptoms with use of con trast b atlls once daily at home . P atie nts with acute flexor tenosyn ovitis are seen for seve ral cli nic visits that may include phonophore­ sis of the finger fl exor m uscles before stretch ing exe rcise s. Pati e llts treate d acute ly for CTS re lated to flexor tenOsyllOviti s often respond well to con servative treatme nt vvitlloUt recurrence of symp toms if finger and \Vlist position and activi ties are monitored .26 Conse rvative treatment is recommended for patie nts \V'ith transi ent symptoms and negative nerve study results. P ati ents wh o fail conservative treatment (usually a 3-mon th trial ) ofte n require carp al t un­ nel release surge ry. Studies have sh own that the carpal tunnel increases in size with the re le ase of tb e volar cwp al ligame nt. Sym pto ms ofte n i mprove imme diately after surgery i.n m il d to moderate cases.

Cubital Tunnel Syndrome Cubit al tunnel synd ro me is th e second most common en­ trapment neuropathy in the uppe r extre m ity. z..~ Th.is syn­ drome is characte rizeu by ulnar nerve pathology at the el­ bow in the absence of trauma. The cubital t\llmel is form e d by tJ1e medial epicondyle, olecran on, m edial collateral lig­ ament of the elbow, and a fi brous band called the arcade of Struthers.29 Several muscles in the Wli st and h and are in ­ ne rvated by the ulnw' nerve, and the ulnar nerve p rovides sensation to the d orsal and volar ulnar side of the han d. tlle fifth fin ger, and the ulnar half of the ring fm ger, Uln ar nerve entrapment m ay p roduce ne rve injury tlll'ough ischemia or mechanical deformation of the nerve. These fo rces can occur from trau ma to th e elbow. e:.1e m al compression. repetitive elbow motion, or prolonged elbow flexion. The more superficial positions of the sensory fib ers within tlle uln ar ne rve at the elbow m ake them susceptible to comp ression, "Vitll elbow motion , normal n erve excur­ sion has b een reported to be as great as 10 rnm. Traction on the ne rve may occur with repe titive act.ivities such as thrOWing. The nerve may also undergo increases in traction fo rces when its excursion is limi ted by p osttTaumatic adh e­ sions .28 As tl1e elbow moves from eJ>.i:ension to fl exion , iIl­ tra.neuraJ pressure in the cubi tal tun ne l iJ,1creases from 7 to 24 111 m Hg . Pre ssu r e as high as 209 mm Hg has been

recorded in a patient with cubital tunnel syndrome \'lith el­ bow flexion an d flexor carpi uln,llis contraction. 29 Sym ptoms of cubital tunnel syndrome can include aching in the medial forearm and ulnar side of the hand. The aching can radiate proximally or distally. Paresthesias or anesthesias in tbe ulnar nerve distribution often accom­ pany tlle pain 29 P rolonged or repeated end-range elbow fl exion te nds to exacerbate symptoms. Functional activities eliCiting symptoms include sleeping with tll e elbow flexed at night, combing the hair. driving, or holding the tele ­ phone . Leaning on the medial elbow can directly compress the ulnar nerve. Early in the syndrome, patients S1)ically control the paresthesias by repositioning the elbow in a more exten ded position. As the syndrome progresses, func­ tiOllal limitations cdosed by motor changes cause functional limitations such as difficulty in turning keys. a weak glip and pinch. and dropping objects held in the ulnar side of th e hand. ocu sed p hysical examination techniques include Tinel testing over the ulnar nerve, provocative elbow flexion test­ ing (including direct compression over the cubital tunnel), upper limb tension testing with ulnar l1erve bias, observa­ ti on of muscle bulk and clawing in the fourth and fiftll dig­ its, muscl e testing, F roment's sign. and sensory testing . T he cL fle re ntial diagnoses include C8-T1 nerve root pathology, thoracic outlet syndrome, and compression of the ulnar nerve at Guyon's canal. Cons erv,ltive man~gement of cubital tunnel syndrome consists of eliminating all sources of external and dynamiC ulnar nerve compression at the elbow. antiinflammatOl medication, elbow splinting in 40 to 60 degrees at night. el­ b ow pads. and stretching exercises. Stretching exercises fo­ cu s on extrinsi c flexor and extensor muscles along with ul­ nar nerve- iIlnervated intrinsic muscle stretches. Ne rve gliding techniques may be appropriate for patients with in ­ tennittent symptoms. T he ulnar nerve's nOFmallongitudi­ nal excursion can be limite d by adherence to adjacent structu res. Nerve gliding call he achieved by assuming a modified WJl W' nerve bi as tension test position \'.'hile stan d­ ing. T his position requires shoulde r depression and abduc­ ti on , wrist extension, and forearm supination, followed by elb ow extension . 1 Several repetitions of elbow or wlist flex­ ion and extension can be performed. This intermittent stretch is usually better tolerated than a prolonged stretch (Fig . 27-19). Key adjunctive interventions are focused on patient ed­ ucation. Posture correction and proximal stretching or strengtl1ening to mai ntain posture are indicated when the

FIGURE 27·19. Nerve gl iding stretch with elbow extension. forearm supination, and wrist extension.

Chapter 27 The Elbow, Forearm, Wrist, and Hand

patient has faulty posture. Short pectoralis minor and weak scapular stabilizer muscles are often observed in in­ dividuals working at computers or on assembly lil~es. AI­ thou h ADLs can be modified to allow rest of the in­ volved arm , it is more challenging to modify work conditions , Use of the uninvolved arm is en collraged to wash and comb hair, eat, or perform any activity requiring prolonged or repeated elbow fl exio n. se of a telephone headset is helpful in cases of frequent or prolonged tele ­ phone use. A transcutaneous electric'll nerve stimulation unit may provide some relief. FOlD" el ectrod s can be placed along the ulnar nerve, with two proximal to th cu­ bital tunnel and hvo distal. If conservative treatment of cubital tunnel syndrome does not reduce or resolve symptom in 3 months , surgical treatment may be considered. In the absenc of clinic;Jly identifiable s nsory loss or muscle weakness, conservative treatment may be con tinued indefinitely in the form of a home exercise pro ram . Lnar nerve transposition surgery involves mobili7.i ng the ulnar nerve at the ulnar groove and anteriorly transposing it subcutaneously, intramuscularly, or submuscularly to the fl exor prollator muscle group.

Radial Tunnel Syndrome Radial nerve entrapmC'nt at the elbow, also c,llled radial tunn el syndrome, is en trapll1ent of the posterior in­ terosseous nerve in one of five locations \\-ithin the rauial tunnel: • The entrance to th e tunnel where fibrous bands en­ circle the nerve • The leash of Henry, where the radial recurrent ves­ sels supply the brachiorauialis and the extensor carpi radialis longus (ECRL) muscles • The fascia and medial portion of the extensor carpi ra­ dialis brevis (ECRB ) tendon • The arcade of Frohse • Distally between the tendinous origins of the supina­ tor muscle ll ,29 Radial ne rve entrapment occurs much less frequently than median and ulnar nerve compressions. Radial nerve compression may be caused by direct trauma or anatomic structures compressing the nerve. Ne rve compression commonly results from repetitive pronation and supination or wrist fl exion and extension activities. OccaSionally, a sin­ gle strenuous effort initiates the problem, and subsequent repetitive motion pel1Je tuates it. The patient with rauial tunnel syndrome often has symptoms similar to those produced by luteral epicondyli­ tis. Frequently, these persons have undergone unsuccess­ ful treatment for lateral epicondylitis. Tennis elbow straps may increase symptoms because of additional compres­ sion. The most common sYlllptom is that of aching in the extensor-supinator muscle mass that is distal to the lateral epicondyle . Tenderness is approximately 3 inches distal to the lateral epicondyle, with occasional pain radiating dis­ tally. No overt se nsory de ficits are found, because the pos­ terior interosseolls nerve contains only motor fibers. A brachial plexus or C7 nerve root injury should be excluded in the differential diagnosis. The upper limb tension test 'vvith radial nerve bias may prOvide additional information .

719

Intervention for radial tunnel syndrome is cOllselvative, incl uding r st, lll1tiin flammatory 'medication, therapeulic exercise, and wri t cock-up sphnting for 3 06 months . The goal of stret hin . is to restore full xtrins ic wrist extensor and fl xor mus Ie length and tendo n xcursion . If extensor str tdIes ar painful, initial str tches can be perform ed with th e elbow Hexed and forearm SIIpinated, followed by fi sted wrist £1 xion. Th xercise i.s progressed until full el­ bow extension an I [or arm pronation ar a hieved \vith fisted \.vri~ t flexion. \vithout forCing t~Hougb pain. Radial ne rve ghclin tech mques may b h ~1t fuI to encomage ad ­ quat n rYe gliding from the cervical :pine to the wrist alld hand I vel. Adj un tiv treat m nts incl lde iontophores is or phonophor sis applied over the supinato r muscle or moist heat before stretching. oft-tissue ma~sage to the forearm fle 'ors aJ d extensors may help to relax involved musc:les and improve the extensibili and circulatio in the area. Upper extI' mity a 'tivities shou ld be performed with the forear m in neutral to prevent p rolonged stret 'hing or overuse of tJl supinator muscle. This activity l110difi 'ation is particularly importanl in lifting tasks . Job rotatio n or di­ v .rsi fi cation can p reve nt p rolouged use of the extensor­ supi nator musc:le group . FunctioJl al ou t ollles arter 'ollservative manag 111 nt of radial ru nn I syndrom al' di ffil:ult to determine because of th e chal lenge in ide nti fying th e CO ITect d ia mosis, the relative rarity of the ,),nclrome, an d til fwqu nt surgical intervention in cle arly diagnosed cases . The clinicia.n should be alert to raclial tunnel syndrome as a diffe rential diagnOSiSin cases of recalci trant late ral epiconuylitis. When radial tunnel is prop ' rly diagnosed, surgery i often the treatment of choice. Patients ' mrnonly ar seen postoper­ atively for scar and pain man age m nt, stretching, an d strengthening p roO'rams .

Musculotendinous Disorders Lateral Epicondylitis Lateral epicondylitis is the most ommon problem seen in the lateral elbow. The incid nce of lateral epi­ condylitis in re r ati nal and profesSional tennis play rs is 39% to 50 ~ao Although "tenni elbow" is the common name for thi. problem, lateral epicond litis is seen as fre­ quently in persons who are not tennis players . Any indi­ vidual using hand tools for wo rk or hobbies 'lie suscepti­ ble to d veloping symptoms. The com bina 'on of conti nuous glip along with repeated Wlist and Ibow ac­ tivity preCipitates symptoms. Wrist extension is accomplished by the combin d actions of the ECHL, ECRB, fUtd e.ct:ensor cal1)i ulnad . Th · e muscles all originate on the lateral epicondyle and supra­ co ndylar ridg of the hume rus , The lateral epicondyl is also the origin of the extensor digitorum and extensor digiti min­ irni. Of the extensor muscl s involved in lat ral epicondyli­ tis, the ECRB is generally the greatest contributor to symp­ toms. 1 The ECR B may be involved in 100% of cas s, and th extensor d igitorum is iovolv d in 30% of cases 3 1 The wrist is stabilized by the exte nsors workin in synergy with tbe flexors. Biomechanical mod 15 have shown that grasp­ ing and pin hi ng tasks always produ e a Hexion moment at

720

Therapeutic Exercise: Moving Towa rd Function

FIGURE 27·20. Wrist extension exerc ises. (A) Without grip. (8) With grip.

the wrist th at must be countered by the wrist extensors. Many tasks requiring use of hane! tools or writing instru­ ments reqllire Wlist exte nsor activity. Because optimal hand function occu rs when the hand is in u complete fist and the wrist is extended 15 to 20 degrees, the grip size of the im­ plem ent and th e resting posture of the wrist can have a great impact on producing and alleviating symptoms. These fac­ tors are important aspects of patient education. Individuals with lateral epicondylitis nescribe pain with any activity that requires gripping and lifting. such as shak­ ing hanJs, lifting a carton of milk, or turning doorknobs. Use of hand tools. writing, and lifting b ags ulso produce symptoms. T ende rness to palpation over the lateral epi­ condyle is common. and resisted wrist extension is painful. The treatment approach for lateral epicondylitis is con­ servative, consisting of relative rest. occasional bracing, in­ flammation control, and therapeu tic exercise. E xercise iJ1­ cludes stre tching to restore the normal le ngth of the musculotendinous unit. Stretching th e wrist into flexion and p ronation should reprodu ce a sensation of tightness in the forearm. Reproduction of pain at th e elbow indicates that stretching is too vigorous. Strength ening should be ini­ tiated at a level that keeps loading within the optimal load­ ing zon e (see C hap te r 11 ). Because the wrist extensors wurk during wrist extension and gripping, th e clinician must approach us e of hand-held \veights cautiously. The initial stren gthening p rogram may include gripping and wrist extension as separate exercises, gradually progreSSing to concurrent wrist extensi on and gripping (Fig. 27-20). Depending on th e symptoms, the program may begin with isometric muscle contractions and progress to dynamiC concentric and eccentric exercises. Adjunctive interventions include therapeutic modalities such as ice, phonopboresis or iontophoresis, and as cross­ friction massage and braCing. Bracing may include a coun­ telforce brace such as a ten nis elbow strap or a wrist splint

(Fig . 27-21 ) A count('rfurce brace decreases loads on th e extensor origin by creating a n(''', origin of the muscle th at bypasses the inflamed pOliion of the tendon. Counterforce braCing also limits the maximum contraction of the mu s­ cl es , thereby decreaSing forc es . A wrist sp lint can li mit wrist extensor activity necessary by providing an exte rn al stabilization to the wrist. Patient educcltion regarding home and work ergonomics should be prOVided. Lifting with tlle forearm supinated decreases wrist exte nsor muscle activity. Tasks should be modifi ed to limit repe titive elbow and wrist motion whe n pOSSible. Juelicious use of cortisone in­ jections by tlle physician can decrease innammation. How­ ever, Dot all cases of lateral epicondylitis involve inflamma­ tion; some may be a tend inosis , a tendon degene ration without inJ1am mation . 'When conservative management of lateral epicondyliti fails , surgical maJ1age ment may be considered. NiTSchl 30 observed th at most patie nts h ave inade quate and frag­ me nted conse rvative treatm ent plans. Good docum enta-

FIGURE 27·21. Tenn is elbo'N strap.

Chapter 27 The Elbow. Forearm. Wrist. and Hand

hon and appropriate follow-u p care are necessary to ensure that all conse rvative measures have been appropriately ex­ hausted before surgery is considered.

Medial Epicondylitis Medial epicondylitis is ncountered less frequently than lateral epicondylitis and accounts for 10% to 20% of all pi­ condy-Iitis cases. 2fJ The muscles involved are the flcxor­ pronator group, including the flexor carpi radialis, palmaris longus, pronator teres, and flexor carpi ulnaris. Repetitive wrist flexion in recreational activities such as golf or fly fish­ ing or at work subject the commo n wrist f'xtensors to overuse. Affected persons usually describe pain at the me­ dial epicondyle with resisted wrist fl exio n and forearm pronation. Passive stretch into extension and supination also may reproduce symptoms. Management of medial epicondylitis is conservative, with a focus on controlled activity matched with appropri­ ate rest, stretching and strengthening exercises, and inter­ ventions to reduce pain and inflammation. Therapeutic exercises include stretching for the fle xor and pronator muscles, as long as stretching does not reproduce elbow symptoms (Fig. 27-22). As sym ptoms resolve, a progres­ sive strengthening program with an emphasis on the de­ mands specific to the individual patient is implemented. Therapeutic modalities such as ice, iontophoresis , and phonophoresis and physician-prescribed medications (when indicated) can provide relief from the pain and in ­ flammation. This intervention creates a better ellviron­ ment in which the therapeutic exercise program can be more effective. When conservative management fai ls , sur­ gical resection of the diseased portion of the tendon may be undertaken.

De Quervain's Syndrome De Quervain's syndrome, also called stenosing tenosyn­ ovitis, is an inflammation of the tendons of the first dor­ sal wrist compartment. The muscles in this compartment are the EPB and APL. The most common cause is overuse of the hand and wrist, particularly in movements requiring radial deviation while the thumb is stabilized in a grip.32 'Nomen are affected about 3 to 10 times more often than men. Persons with de Quervain's syndrome notice pain on the radial aspect of the wrist in the region of the radial styloid. Flexing the thumb across the palm is quite painful, and re­ sisted extension and abduction may be painful as well. Pal­ pable tenderness and bogginess may be noticed over the tendons of the first compartment. Radial and ulnar devia­ tion may produce clicking or pain. The Finkelstein test is the most commonly used tes t to diagnose de Quervain';. syndrome. Measurements may reveal that pinch and grip are weak and painful. Therapeutic exercise interve ntion for de Que rvain's syndrome includes stretching for the EPB and APL and the extrinsic wrist flexor and exte nsor mnscles. Strength­ ening should be initiated after full pain-free ROM has been achieved. Strengthening includes the thumb and \vrist musculature and full gripping exercises. To prevent further overuse to these tendons during the initiation of a rehabilitation program, immobilization using a forearm

721

base thumb spica splint may be necessary. Th sp un t should bf' wom during symptomalic times or periods of high activi.ty. The sp lint is removed to pe rform exercises thro ughout the day. Oth r aclj unctive meaSlires indu de cross-friction mas­ sage over the first dorsal compartment and activity modifi­ cation. Work, hobby, or sport modiflcations to decr ase the frequency and forcf~s involved with wrist and th umb mo­ tion may be_necc,ssary to allow the reh abilitation program to succeed. Therapeutic modalities to redu inflammation such as ice and iontophoresis may be helpfu l. The phYSician may place the pati ent on an
Trigger Finger Trigger finger , also known as digital tenovaginitis ste nos ans, is a r suit of tbicke ning of tlle fl exor tendon sheath. T hicke nin a causes catchin g of the tendon as the finger actively flexes. 16 The flexor te ndons of the fi ngers have an intricate anatomy that indud s a synovial sh ath exte nding from the mid-metacarpal area to til DIP jOints. Overlyin rr the sheath is a series f annular and cru cifo rm fi­ brous bands or pulleys. These pulleys hold the fl xor ten­ dons dose to the metacarpals and phalan geal bones, thereby improving the effiCiency of motion. T hicke ning of the sheath at the A-1 pulley (i.e , fibrous band tlmt overlays the synovial sheath at the M P joint level) and enlarge­ ment of the flexor tendons are the basis for the synlptoms found. This thickenillg may be caused by r peti tive traum a or by direct pressme over the MCP joint in tlle palm, as when grasp ing. Impairrnf' nts associated with trigg r finger include pain and tenderness in the finger from the volar MCP to the PIP level and intermittent tri&lSe ring or "snapping" of the fin-

RGURE 27·22.. Wrist flexor stretch .

722

Therapeutic Exercise: Moving Toward Function

ger. The tri~e;pring usually occurs with flexion, and it may require passive assist to hilly extend th e finger. I ntervention for trigger finger is usually conservative and involves active IP fl exion and tendon gliding exercises on an hourly basis. Ultrasound, massage, and icing can be used to relieve symptoms of pain ~lI1d sw~l1~J)g . Sp.linting is common, and the hand-based splInt or digital splll1t holds the MCP joint at full extension while leaVing all other joints free. The splint is worn at all times for 1 to 3 weeks. There­ after, it is worn for periods of high activity. The splint pre­ vents triggering at the A-1 pulley and res't to minimtze in­ flamm ation. T he physician muy inj ect into the synovial sheath at the level of the A-I pulley to decreuse local in­ fla mmation. If conservahve managenwnt is unsuccessful, surgery may be performed to release the A-I pulley. Postoperative therapeutic intervention includes the same active exercise program and potential splinting as conservative manage­ ment. Progressive grip strength ening llIay be required to return the patient to full functional use of the hand for work and ADLs . Education and work modification to avoid or limit repebtive grasping and releasing activities of the hand also are necessary.

Tendon Laceration Tendon lacerations and repair require a complex series of treatm ents that must account for wound h('aling, tendon healing, alln surgical technigllcs. Tendon n~pair treatment is complicated by the need for tendon excursion to prevent adhesions while allO\Yillg stability and protection to the healing tendon. Controlled motion helps prevent tendon adh esion, wh ich limits motion and the refore limits func­ tion. Too much motion may compromise the repair. The clinician must provide a systpm of controlled motion, based on physician preference, surgical technique, mechanism of injury, and patient adherence. The extensor tendons are divided into eight zones that determine treatment protocol used. Because of the exten­ siveness of each protocol, we revi ew only the highlights for each zone (Fig. 27-23A )aJ In zones I and II , laceration causes a mallet finger. A mallet fin ger splint is fitted to the patient's DIP jOint in 0 to 15 degrees of hyperextension from postoperative day 1 through 6 ',\leeks. The PIP joint is left fi'ee to allow movement at the PIP level and proximally. The D IP jOint should not be allowed to flex durin g this time. AROM exercises are initiated at 6 weeks , \\,i th PRO\![ started at 7 to 8 weeks. Strengthening is started after 8 weeks ,,,,jth monitoring for an extensor lag. If a lag is pre­ sent, the patient returns to wearing the splint and AROM. For zones III and IV, a digital gutter splint is fahricated to in clude th e D IP and PIP joints (MCP is left free) at 2 weeks afte r surgery. At 4 weeks , ARo.\,r is begun , and at 6 weeks, PRO M is begu n. Treatment must be modified if an extensor lag develops. Gentle strengthening is bellun after 8 weeks. For zone V (distal to tendonae junctionae) , a hand-based splint is custom Llhrieated at 3 days to 1 week. This hand­ based splint holds the MCP in 70 to 80 degrees of flexion and the digit in fiil! extensioll. This position prevent;; con­ tracture of the lateral bands at the \ilCP, AROM, PROM , and strengthening are continued as for zones III and IV.

A II

Zones of extensor tendon injury: I-

DIP joint and distal phalanx

II -

Middle phalanx

111- PIP joint IV -

Proximal phalanx

V- MP joint VI -

Metacarpal bone

VII-Wrist T I - IP joint and distal phalanx of the thumb Til - Proximal phalanx of the thumb T III ­ Thumb MP joint T IV ­ Metacarpal bone of the thumb Tv-Wrist

B

II III

IV

V

Zones of flexor tendon injury: I - Distal to the FDS insertion 11- Between the Aj pulley and the FDS insertion III - Area between the distal carpal ttJnnel border and the A, pulley IV - Within the carpal tunnel V - Proximal to the carpal tunnel TI - From the thumb IP joirit distally T II - Between the thumb A, pulley and the IP joint T III ­ Area of the first metacarpal bone

AGURE 27·23. (Aj Extensor tendon zones of the hand. (8j Flexor tendon zones of the hand.

Chapter 27 The Elbow, Forearm, Wrist. and Hand

For zones V (p ro;.,; maJ to tendona junctionae ), VI, VII, and VIII , a vohu' forearm 'p lin t i fabricated at 3 to 5 days postoperatively. This splint extends from just p roximal to the PIP joint, crosses th e Me p joint, and continu s two thirds of the way up the forearm, with the wrist positioned in 30 uegrees of extension. This allows controlled move­ ment of the extensor tendons through PIP and DIP joint move men t, \Vhich pr ve nts tendon adh esions. AROM , PRO M, and stren th ening exercises are continlled as for th e more distal zone, . Flexor tendon repairs also rely on zones to dekrmine the app rop riate protocol. T here are five flexor tell don zone' (s ee Fig. 27 -23B ). Current treatment protocols locus on controll d motion to prevent scar adhesion s that limit fun ctional move ment. They also rely on the lise of a dorsal blocki ng splint to prevent disruption of the surgical repair. This dorsal blocking splint is custom fabricated with the wrist in 20 d · crrees of flexion, th Me ps in 50 degrees of flexion, and the PIP and D IPs in full xtension. 33 The procrram for zones I, II, and III consists of passive flexion and extension motion at th e PIP and DIP jOints and composite passive flexion and extension at the Mep , P IP , and DIP jOints within the confines of the splint. This pro­ gram i started on postoperative day 1 or 2 and continued through week 5 .3 .3 AROM is started at 31/2 weeks , PRO M into exten sion is begun at 6 weeks , and strengthenin g is start(!d at 8 weeks . F ull fun ctional use is allowed at 10 to 12 weeks postoperatively. The program for zon s I , n, and III uses the dorsal blockin g splint with rubber-band traction. The addition of a pal mar pulley allows for greater F D P ten­ don excursion, The rubber band traction holds the digit into nea r full composite fle xion , and the patient is in­ structed to extend the fi nger ag,unst the force of the rubber band to the dors al blocking splint. The patient is instruct d to do this 20 to 30 times per hour , This protocol is initiated 2 to 6 days postoperatively. AHO M is started 5 weeks post­ operatively, with PRO M into extension started 7 to 8 weeks postope rative ly. Strengthening is performed after 8 weeks J For zones IV and \T, both protocols are overall as previ­ ousl delineated, but they pro rr S faster. AHO M is initi­ ated at 3 weeks ,vithin the dorsal blocki ng splint. AROM out of the splint occurs at 4 weeks. PRO M into extension and strenathening is in itiated at 6 weeks. four-strand su­ ture te "11l1ique allows con trolled active move m nt begin­ ning on postoperati day 2. A wrist-hinged dorsal blocking splint is us d to allow a tenodesis movement in which the digits are held at the end ran
adult, acute rupture of the Ue L can occur. More often, continued valgus loadin and loss of dynamic muscular support plac s loads on the Ue L, leading to gradual insta­ bility. Progressive instability can lead to ruptur or tension of the ulnar nelve. In the child or adolescent, medial elbow instability is commonly known ~L5 "little I ague elbow." The
Elbow Dislocations Elbow dislocations are second in incidence only to disloca­ tions of the shouluer in the adult population. The elbow is th e most frequently dislocated joint in children younger than 10 years of age 3 4 Elbow dislocations are classified by the direction of movement of the radius and ulna on the hum m s, and most are posteriOr. A faIl on an outstretched hand or hyper :-:tension are the most common mechanisms of injury. D islocation also can injure the UC L, the lateral collateral ligament, the anterior caps ul and co rn mon flt'w r and exte nsor mllscle origin or fract ure th e medial epiconuyle , T he ulnar, median , or raelia.! nerves may be in­ jured. After dislocation , the elbow is reduced (and stabi­ 'Iized if necessary) and immobilized for 1 to 2 weeks.

Bone and Joint Injuries Medial Elbow Instability Medial elbow instability is see n in children and adul ts and is found IlI os t often in individuals involw d in thrOWing. High force s on the medial elbow stru ctures durin g th e cocking and accelerati on phas s can result in attenuation an d rupture of th e static ligamentous structures. In the

123

FIGURE 27-24. Wrist flexor musc le strengthen ing.

724

Therapeutic Exercise: Moving Toward Function

Impairments after dislocation include loss of motion, pain, inability to produce torqu e, and occasionally ne u­ rovascular proble ms. H.cstoratiOl1 of full motion may be clif­ ficult and should be a priOlity in the treatm ent program. Many patients retain a residual loss of extension of 10 to 15 uegrees, and full recovery of motion and strength takes :3 to 6 months for most patiellb. 1 3 I nte rve ntion after dislocation includes AROM and AARO M ini tiated 2. to 7 days after the djslocation and PROM 2 weeks after the dislocation . .\II.oti on should be p e rformed in a variety of shouldf'r p ositions. Dynamic splinting may lll' necessary to restore motion. Prefablicated splints are availabre to restore flexion or exte nsion. A static night splint can maintaill current range if a dynamic splint cannot he tolerated all night. Caution is necessary to avoid overly aggreSSive PROM, because it may contlibute to het­ erotopi c bone formation. Individuals with head injuries or those with a cOll1bined fracture-disl ocatioll with pr.olollgcd imrnobilization LIce the greatest risk of h cterotopic bone formation. IsomrtJic Il1llscl'e contractions are initiated early and pro­ gresseJ to clYllamic contractiolls as tolerated (Fig. 27-2.3). Open and closed chaill exercises and proprioceptive neuro­ muscular facilitation techniques are useful for restoration of fun ction . If iJlStability is present, a hinged elbo'vv SUppOlt with extension blocks may allow fu n<:tional use of the elbow within a limited range. E xercises are pelfo rm ed throughout the day, in or out of the hrarc. If the patient bas hypomobil­ it)', joint Jllobilization techniques Cinl help restore full elbow Jnci forearlll Illobility (see Chap ter 7).

Carpal Instability The bony and ligamento us anatolny of the wrist is intri­ cately balanced to allow flexibili ty and stability. W illiams 2 observed th at the calpal bones are sp ri ug loaded like a jack­ in-the-box and kept under control by ligament restraints. The p almar ligam ents are very substanti al compared with the dorsal wrist ligam ents. An area between the capitate and lunate where no ligamentous SUppOlt is maintained is an area of potential weakness. Many types and descriptions of static and dynalllic cmpal p atte rns exist. Static instability p attems de UlOnstrate radiographic changes such as abnonnal gapping be twee n cal1.Jal bon es. A static instability gene rally inclieates a sig­ nificant injury such as a complete ligament tear. D ynamic instability patte rns are detected during t11e physical exami­ nation or \:vith speCial imaging techniq ues. D ynamic insta­ hihty pattem s generally inclicate in creased laxHy or p artial hgarnent tears . Scapholunate di ssociation is the most com­ mon form of carpal in stability an d occurs when ligam ents from the proximal pole of th e scaphOid are torn. This inju call occur from a fall on an e;\'tended, ulnady deviated wlist; degene ration resulting from rh eum atoid altllri tis; a direct blow to the wlist; or in association with a rustal radi us frac­ ture, carpal fracture, or caJl)al dislocation . I mpairmen ts associated with a scapholun ate dissocia­ tion ll1clude point te nde rness ove r the involved li gament, swelling of th e dorsal \-vrist, p ain or limi ted AROM and PROM of the Wlist , a painful click or d Wlk \:vitll radial de­ viation , grip weakness, an d decreased Wlist an d band func­ tion because of pain. In addition to routine examinab on

procedures slIch as docum e ntation of pain wi.th rest and functional activities , ROM . an d strength of the forearm, wrist, and hand musculature, the clinician should assess grip and pinch strength . Grip strength is performed with a dynamometer at th e standa rd setting, with five settings used to demonstrate a b ell-shap ed curve and rapid alter­ natin g grip strength . L ate ral and three-pOint pin ch stre ngth is also assessed . Seve re instabilities are treated with surgical reduction and ligame nt re <.:onstruction. F usions may also be per­ form ed for a ll umber of carpal instability patt erns. Afte r surge ry or for mUd cases of instability, the patient is re­ ferred for rehabilitative manage me nt. The rape uti c exercises for carpal instability include grip and pin ch strengtlleni ng exercises. P utty exe rcises and iso­ lated muscle strengtheni ng eXf' rcises are in eO!l)orated to restore strengtll and dyn amk' fUllction th roughout the re­ gion. VVith a lun ate dislo cation all d ligam e nt injury. a painful grip may in rueate instability leading to lunat(~ de­ stru ction. In this situation. grip stre ngtll ening should he avoided. Any mobility deficits are tTeated with active, pas­ sive, and active assisted HOM . Iuterve ntion for c(ul)al instability ,Jso includes protec­ tive splin ting of the wrist. Th e tlmrnb MCP is included iH cases of scaphOid involve ment, such as scapholunatc rlisso­ ciat:ioll . If thc ligame nt disruption is on th e ulnar side of the wrist a Wlist cock- up or ulnar gutter spliJ1t suffi ces. Thera­ peutic modali ties may be lIsed for pain and inflamm ation. and patient education is a cri tical component of successful manageme nt.

Gamekeeper's Thumb The MCP joint of the thu mb fllllc tions p rirnarily in flexion and extension because of tlle con dyloi d shape of th e joint surface . Small degrees of abd uction . ad du ction , and rota­ tion also OCCU I'. T au tness in th e VCL limits abducbon anc! extension and adds stability to the joint in a functi onal po-

FIGURE 27-25. Res isted pronation using a band.

Chapter 27: The Elbow, Forea rm, Wrist, and Hand

FIGURE 27-26. Thumb spica splint.

sition. However, this functional position also places the DCL at risk for injury. The most common injuries to the thu mb MCP involve th UC L. Gamekeeper's thumb, or a sprain to th e CL of the MCP joint, is the result of abduction or hyperextension forces . This injury occurs frequ ently in skiing when a fall catches the thumb in the strap of the ski pole, pulling the thumb into abduction. Complete mptures lead to instabil­ ity and significant disability. A thorough examination, with valgus stress performe d in extension (collateral ligament and volar plat ) and flexion (collateral ligament only ), should be done to differentiat partial from complete tears. Impairments assodated with gamekeeper's thumb include tend mess along the ulnar aspect of the MCP joint, local­ ized ed rn a, and instability of the joint. T reatment of partial tears requires imm obilization in a thumb spica cast for 3 weeks, follo\ved by a thumb spica splint (Fig. 27-26}. The splint is removed throughout the day to allow exercise of the wrist and hanel. Acute injuries with gross instability require surgical stabilization. Thera­ peutic exercise after ill1mobilization after surgical and non­ surgical treatment include pain-free thumb MCP flexion and ext ' nsion and gradually adeling pain-free rotation and opposition. After 4 to 6 weeks, grip and pinch stre ngthen­ ing exercises are initiateel with putty or glipper equipment (see Self- Management 27-5: Thumb Press) . Lateral (key) pinch is initiated, but the patient should be instructed to limit or avoid tip pinch stress until 6 to 8 weeks. xercises should be progressed to activities pertin ent to the patient's lifestyle as q Uickly as possible within th e constraints of heali ng.

Olecranon Fractures Olecranon fractures are generally the result of a direct blo"v or a fall. A fall on an outstretched hand with the elbow in fl xion, followed by a strong contraction of the triceps, can cause an olecranon fracture. A non displaced fracture is immobilized in 45 to 90 elegrees of flexion for a shOlt time. A displaced fracture may be treated with open reduction and internal fixation (ORIF) using tension band wiring or plate and scre,v fL\:ation. small comminuted fracture may be excised with reattachment of the triceps tendon. Exci­ sion of loose bodie, is required during surge lY to prevent a loss of Dlobility from these frag ments. The impairments

725

seen after fracture or surgery are pain, limited ROM, and loss of the ability to produce torque. The proximity of the ulnar nerve makes it vulnerable to injury in a olecranon fracture. Close examination is necessalY to assess th tatus of the nerve. Intervention after fractur begins with AROM in a forearm neutral position. AROM and AAROM may be initiated as earlv as 2 davs after fracture . These individu­ als usually are i~mo'bilii'ed, and the immobilization is re­ moved for ROM activities. The length of immohiliz tion is decreased for the elderly, and ROM exercise is initiated sool1er 26 ..36 Active ROM' is progressed to PROM and stretching. The biceps muscle often shortens 'because of the flexed elbow position during immobilization or protection peri­ ods. Suggested forms of exercise to restore muscle length include elbow and shoulder extension, walking with a nor­ mal arm swing, and contract-rela.x stretching. The adaptive shortening may result in weakness , and strength should be addressed concurrently. Sugg sted strengthening exercises include isometric contractions throughout the available range for all major muscle groups resistive band exercises for shoulder musculature, resisted elbow flexion in a variety of forearm positions, resisted el­ bow extension, and resisted wrist and forearm exercises. A stationary bicycle with combined ann movem ents or a

.... ~J...

SELF-MANAGEMENT 27-5 Thumb Press

Purpose: To increase the strength of your thu mb

musc les

Starting

position:

Form the putty into a barrel shape, and place it in the palm of your hand, resting against your thumb.

Movement

technique:

Press your thumb into the putty with as much force as is comfortable until your thumb has pressed through the putty into your hand. Reshape the putty and repeat.

Dosage Repetitions _ _ _ _ _ _ __ Frequency _ _ _ _ _ _ __

726

Therapeutic Exercise Moving Toward Function

FIGURE 27-27. Range of mot i o~ of the forearm us ing a hammer. (A) Pronation. (8) Supination .

cross trainer allowing repetitive elbow nexion and exten­ sion is helpeul to restore motion and stre ngth. If forearm rotation strength is limited , a light hammer can be used to train pronation and supination (Fig. 27-27). Adjunctive interventions inclurle elevation, ice, and ac­ tive shoulder, wlist, and finger exe rcises to control edema. Scar massage should be initiated early after surgical stabi­ lization. Generally, the scar is mature enough to tolerate massage 10 to 14 days postoperatively. The triceps may be­ come adherent to the scar and should be treated with cross­ friction massage and triceps resistive exercises. JOint mobi­ lization with distraction may be initiated in later stages if loss of motion is a problem. The prognosis after an olecra­ non fracture is good , but loss of terminal extension is a ommon residual impairment.

Radial Head Fracture Radial head fractures occur most often as a result of falls on an outstretched hand with the forearm in supination. These fractures al so occur in combination with dislocation. The individual with a radial head fracture has pain over the ra­ dial head in the lateral elbow, and forearm rotation is painful. A non disp laced fracture can be treated with sling immobilization for 1 to 2 days, whereas a displaced fracture may be treated with ORIF. F or severe fractures , t]le radial head may be excised. Any p athology at th e distal radioulnar joint can complicate thjs form of treatment. The patient may be imm obilized with the forearm in neutral but allow­ ing elbow RO M (i. e., sugar tong or :vtuenster splint ) for 2 to 3 weeks. The most common impairment aftcr a radial head frac­ ture is a loss of 10 to 20 degrees of elbow extension. C repi­ tus or clicking at the radial head may occur with supination and pronation. Treatment of a non displaced radial head fracture in­ cludes initiation of elbow and forearm AROM 1 week after injury. Successful treatm ent demands early RO :vt . The progreSSion is similar to that for olecranon fractures. After

ORIF of displaced hactures, motion may begin immedi­ ately postoperatively, barring any secondary inj1uri es. Strengthening an d functional llSC' of tlw limb should b progress ed as for other upper extremity injuries.

Calles Fracture T he distal radi us is fractured more frequently than any ot.he r bone in the bod y19 The Colles fracture is a dorsall,' angulated fracture of the distal radius with or 'without cori­ current ulnar fracture. This fracture occurs most often from falling on an outstretched band . The volarly angulated distal radins fracture is knovvn as a Smith's fracture. The Calles fracture is initiailv treated with closed reduction and cast immobilization in' an above- elbow cast to prevent pronation and supination or WitJ1 O HI F. If healing is p ro­ gressing well , a short forearm cast may be applied after 2 wef'ks. . The major impairments after cast removal' are pain, de­ creased mobility and strength, and swellinp-. Control of ed e ma is critical to prevent a stiff hand . ETevation, ice . edema massage, and compression garments can be used to reduce edem a. Education about controlling edema must be e mphasized to prevent furth e r complications. Restoration of mobility is essential for full functioning of the hand. The priority in the early phase of mobility exer­ cises should be to regain wrist fle xion , eKtension, and supination, because these arc usually the most limited mo­ tions and important for a functional outcome (see Self­ Management 27-6: F inger and \-Vrist Flexor Stretching ). E xercises should include AROM and self-PROM tech­ niqu es using the opposite extremity. If mobility remains limited, joint mobilization may facilitate gains in ROM (see Chapter 7). 'Whe n dealing with complicated Calles frac­ tures, splin ting may be necessary to maintain gains in ROM achieved while at rest or at night or to as~ist in increasing mobility. Static splinting provide.s support and maintains rangE' between exercise sessions. This intervention may be supplied by prefabri cated wrist supports or custom-made

Chapter 27 The Elbow, Forearm, Wrist, and Hand

SELF-MANAGEMENT 27-6 Finger and Wrist

Flexor Stretching Purpose: To increase the mobility of the soft tissues in your wrist and hand

Starting position:

With your palm facing up and wrist at the edge of a table

Movement technique: Using your other hand, gently press your wrist and fingers down toward the floor. Hold 15 to 30 seconds, rela x, and repeat.

Dosage Repetitions ________ Frequency

727

The individual \vith a scaphuid fract1ll'c relates a history of a fall on or other trauma to an extended wrist, wHh sub­ sequent pain anc.lloss of motion. Pain is particularly appar­ ent with any overpr ssure in extension, such as in pushing a heavy dour ope n. Athletes are unable to bench press he­ cause of the p ressure into wrist extension. Palpable tender­ ness over the anatomic snuffbox and painful extensiun war­ rant medical evaluation. Medical intervention for scaphOid fractures is immobi­ lization for 8 to 12 weeks. Because the poor vascular supply predisposes the caphoid to non union, these fractures are treated cons ervatively. If the fracture is seve re or dis­ placed, ORIF with a r:lerbert screw may he used. Because of the impOliance of the scaphoid in providing stability to the wrist, healing of this fracture is important. A bone stim­ ulator may be used to facilitate bone healing. The thumb is immobilized along with the wrist because of its involve­ m nt in thumb mobilitv. The rehabili tation aiter immobilization is similar to th at for a Co lies fracture. Edema control and restoration of mo­ bility, stre ngth, and fundion relative to the individual's neeus arc the primary goals. Self-stretching exercises, mo­ bilization, and strengthening exercises are indicated (F ig. 27-29). SpecifiC thumb ARO M and PROM exercises should also be included. SpeCific grip, pinch, and thumb opposition strengthening exercises also arc important after a scaphOid fractures. Putty or other household products (e.g., racquetball, erfball, clothespin, rubher bands) may be used. Include the patient in discovering objects at home or work that may be used to accomplish the established goals (Fig. 27-30).

Metacarpal Fracture The MCP jOints of fingers two through five are essentially ball and socket joints with a slack joint capsule in extension and taut collateral ligaments in flexion. The dorsal and pal­ mar interossei muscles arise from the metacarpal bones and insert into the extensor mechanism. These muscle groups need special attention during evaluation, because splints. Dynamic splinting may also be of value in cases of limited mobility. These splints include a constant or vari­ able tension across the wrist, forearm, or both areas to fa­ cilitate increasing motion in the direction desired. Many commercial devices are available, or a custom splint may be fabricated. Strengthening exercises may be initiated with isometric contractions, grip strengthening, and resisted elbow exer­ cises. As range improves, dynamic xercises for the wrist may be employed using free weigh ts or resistive bands (Fig. 27-2f1). The clinician must consider the patient's preinjury status to establish relevant goals.

Scaphoid Fracture The scaphoid is often fractured as a result of a fall on an outstretched hand but frequently goes unrecognized. Indi­ viduals often pass these fractures off as sprains because of the lack of obvious deformity. The scaphoid is highly sus­ ceptible to injury because of its shape and its pusition. Its narrow midline makes it more vulnerable to stress, and its position crosses the two rows of carpal bones, predisposing it to more frequent injury.

FIGURE 27-28. Grip strengthening exercises. Resistance is easily altered by increasing or decreasing the number of bands.

728

Therapeutic Exercise Mov ing Toward Function

FIGURE 27-30. Res isted pinching us ing a clothespin FIGURE 27-29. Resisted finger extens ion at the proximal interpha· langeal joint.

their length and strength may be affected after injury or immobilization for metacarpal fractures. :VI etacarpal fractures can occur from a fall onto an out­ stretched hand with initial ground contact along the metacarpals, from industrial accidellts (e.g., punch press machines), or from fist fights. When the fifth metacarpal is the onlv involved bone, it is commonly referred to as a boxer's 'fracture . Metacarpal fractures ac<:ount for approxi­ mately 30% to 35% of all hand fractures .31 Impairments as­ sociated with fracture in the acute stage include pain, swelling, loss of motion and strength, and deformity. Medical intervention depends on the severity of the fracture. If the fracture is nondisplaced, it is usually casted for :2 to 3 weeks. A custom static splint that crosses the wrist and includes only the affected Me p jOints up the PIP level may be worn for 2 to 3 weeks. If the Mep joint is fl exe d d\l ling immobilization. the position can pre­ vent collateral ligament contracture. If the fracture is dis­ p.1aced, surgical fixation with pins, Kirschner wires, or a plate is indicated. The start of rehabilitation depends on tl~e medical in­ tervention. If the fracture is surgically stabilized, treatment begins as early as 1 to 3 days after surgel)'. Early interven­ tion avoids associated impairments of dorsal hand edema, extensor tendon adhesions. Mep collateral ligament adhe­ sions, and intrinsic muscle contractures. Exercises in the first phase emphasize gen tle ARO M of the wrist and all fin­ gers and blocked :VIep flexion and extension exercise (see Self-Managemen t 27-7: Metacarpoph alangeal Joint E xten­ sion With Distal Interphalangeal Joint Flexion ). This spe­ cific exercise prevents coll ateral ligament adhesions and encourages extensor tendon gliding with minim al stress place d on the fracture site. Aggressive interosseous and ll!lmbrical stretching along with thumb-index web space stretching also should ue initiated in this phase. Intrinsic muscle stretching can only be accomplished by maintaining the Mep in neutral or hyperextension while flexing at both IP joints (Fig. 27-31 ).

At 2 weeks, scar mobilization may begin, and at 4 to 6 weeks after surgery, passive Mep flexion may be initiated. At 6 to 8 weeks after surgery, intervention may focus on ag­ greSS ive Mep flexion (i .e. , joint mobilizations) , wrist strengthenin g, and grip and pinch strengthenillg, including the intlinsic muscles (e.g., putty exercises for finger i1bduc­ tion and adduction).

SELF-MANAGEMENT 27-7

Metacarpophalangeal Joint Extension With Proximal and Distal Interphalangeal Joint Flexion Purpose; To increase the mobility in your fi nger extensor tendon

Statting position;

Movement technique:

Keep the middle (PIP) and end (DIP) joints flexed. Keeping those joints flexed, actively extend at your knuckle joints.

Dosage Repetitions

Frequency _______ _

Chapter 27 The Elbow, Forearm, Wrist, and Hand

FIGURE 27-31. Stretching exercises at the proxima l and dista l interpha­

729

Displace d fractures require internal fixation with Kirschner wires or pinning. Extreme care is taken to clvoid rotation, and often a buddy splint or buddy taping tech­ nique is used to h Ip minimize this complication. Intervention after nunsurgical postil1l111ubilization carl' of phalangeal fractures is usually initiated at 3 to 6 weeks af­ ter injury or when immobilization is no longer necessary. Exercises of active and passive motion for all Mel', PIP, and DIP joints should be initiate d along with tendon :rlid­ ing xe rcises. For PIP joint restrictiuns of 20 degrees or more, dynamic PIP extension splinting may Ge required. Seve ral commercial prefabricated splints are available, or custom splints celn Ge fabricatcd. Static progI'essive splint­ ing can be lIscd at night. The Hnger splint is fabricated in full extension, and tenSion-adjustable straps arc used to al­ low gradual finger extension toward the splint. After surgical inte rnal fixation, inte rvention rnay begin as early as 2 days after SllL'aely. Gentle HOM of th Mep , PIP, and DIP jOints, with e mphaSiS on full PIP juint mo­ tion , is initiated. Tendon gliding, scar managelllent, and edema control also 'hould be ncouraged . At 4 to 8 wecks afte r surge l)', d)'l1amic PIP extension splinting may be ini­ tiated, along 'with buddy taping during exercises or AD Ls.

langeal joints

Complex Regional Pain Syndrome The paticllt treated with immobilization may begin after cast removal at 2 to 3 vveeks after the injury. Gentle AROM of the wrist and Me p joints is initiated at this time. PRO M is initiated after 4 to 6 weeks. All other noninvolvecl joints and fingers should be completing ROM exercises from the beginning of immobilization to prevent fllnctionalloss. The program is progressed similar to that for surgical man­ agement. Adjunctive agents include education, elpvation, ice, and compression garments to control de ma. Dynamic splint­ ing may be used to promote passive stretching of the Me p joints for 20-llIinllte sessions performed 6 to 8 times per day. Massage is usco to manage scar formation in the oper­ ative cases.

Phalangeal Fracture Phalangeal fractures usually occur as a result of trauma. ApprOximately 4.5% to 50% of all hand fractures involve the distal phalanx, 15% to 20% !he proximal phalanx, and 8% to 12% the midcll phalanx. 3 i Impairments observed in the acute stage include localized sw \ling, pain, and tenderness ov r the fractures; hypo mobility at IP joints and pOSSibly Mep joint; and abnormal alignment of the IP joint. Associ­ ated impairm ents after immobilization usually include re­ stlicted PIP joint extension (from volar plate contracture) and flexor tendon adhesions. As with metacarpal fractu res, the intervention depends on the severity of the fracture. If nondisplaced, the immo­ bilization is accomplished by a custom splint or foam-cov­ ered metal splint. The period of immobilization varies ac­ cording to the location uf the fracture. If located at proximal or distal ends, only 3 to 4 weeks are requLred be­ cause of th e good vascularity in cancellous bone. Mid-shaft middle phalangeal fractures [" quir 10 to 14 weeks or longer because of the poor blood supply in the bony cortex.

Hefl ex synlpatl1etic dystrophy (RSD) is a term used to de­ scribe a cluster of signs and symptoms, including pain djs­ proportionate to the inJury. vasomotor and trophiC chang s, stiffness , swelling, and decreased function. Other terms for HSD have ,i ncluded sympathetically maintained pain, causalgia, sympathetiC dystrophy without pain, shoul­ der-hand syndrome, and Sudeck's atrophy. The uncertain role of the sympathetiC nervous system in RSD led th In­ ternatiunal Associatiun for the Study of Pain and the Amer­ ican Puin Associution to recommend use of the term com­ plex reg ional pain syndrome (eRPS) to replace the term R · D. 'l~ Several common feature s and two classifications of eRPS have been identified. T he common features are lo­ cal tissue damage or ne rve damage that initiates a reflex re­ sponse in the pelipheral and central nervous syste ms. Sev­ eral disorde rs with th e same abnormal clinical findings shar these criteria 'vvith e RPS. The two types have b e n cl assified by the absence or presence of nerve involvement, th fi rst rese mbling RSD (without nerve involvement) and th e second eqUivalent to causalgia (with nerve involv ­ ment ).3R Seve ral impairments are associat d with e RPS and may include pain and inflammatioll, swellin a , stiffness, vasomotor disturbanc 'S , trophic changes, bune demineral­ ization , ami d\>stonia. 3lJ Initial functional limitations are IlU­ merous and a'w based on pain-limiteu me of the extremity. An ADL checklist is he lpful to monitor even small im­ provements in functional tasks. Pain disproportionate to the inj\lly seveIity is the primary clinical feature of eRPS. In the upper extremity, the pain is found throughout a large part of the ann, from the upper arm distally to and fully including the ham!. The pain is of­ ten described as burning initially and eventually changing to pressure, aching, and binding sensations. Pain is oft n con­ stant, starting locally at the original injury site and spread­

730

Therapeutic Exercise: Moving Toward Function

SELF-MANAGEMENT 27-8

Blocked Finger

Extension

Purpose: To increase the mobility of your finger joints and tendons

Starting position: Levell: Level 2:

Hold the knuckle joint of your finger straight. Hold the knuckle and middle joints of your finger straight.

Movement technique: Level 1: Level 2:

Bend your middle joint, keeping your fingertip joint straight. Bend only your fingertip joint.

Dosage Repetitions Frequency _ _ _ _ __ __

,/ PIP

Levell

Level II

ing throughout the extremity. The pain often leads to disuse and self-immobilization of the extremity, along with the known consequences of this response. In addition to con­ stant pain, hypersensitivity to touch occurs, with extreme sensitivity to any ki nd of tactile stimulation . Occasionally, sympathetic and trophic changes occur with minimal com­ plaints of pain or pain related only to motion of stiff joints. Excessive swelling at the injury site is often the first ob­ jective sign noticed in the early phase. Svveliing can subse­ quently spread throughout the distal upper extremity. Ini­ tially, ]t has a fusiforlll and pitting appearance, but it later takes on a hard and bn.l\vuy dw racter that contributes to joint stiffness. Pelialticular thickening is ohscrved at the IP join ts. Edema is difficult to control even witl! othenvise successful intervention techniques. Joint restriction with eRPS is often more profound than expected for the associated cli
about joints, alld adhesions in ten non sheaths limit th e glid­ ing properties of tl1 e tendon , prodUCing infhunrnation and pain. These changes contribute to the vicious circle of pain and inflammation. Prrlmar fascitis can be seen, and nodules and thickening of the palmar fascia can be palpated. This sti ffness contlibutes to limited Mep and IF extension. Discoloration of various degrees occurs with vasomotor instability. Pallor results {i'om with vasoconstliction oftl.le ar­ telial and venous syste ms. Redness is evident when there is cWation ofhoth sides oftlle vascular tree. Blueness (cyanosis) is usually presen t with vasoconshiction of the venous svs­ ~ / te m." Sudomotor changes occuning include hyperhidroSiS (excessive sweating) early and dryness in later stages. Bone demineralization is a reliable sign of CRPS aod as­ sists in making the diagnOSiS. Although some demineraliza­ tion takes place with immobilization , the bulk of ealcium loss results from increased blood flow in the perialticular bone. 39 Sudeck40 described th e condition as "inflamrnatolY bone atrophy." Unh-eated cases progress from "spotty" os­ teoporoSis to diffuse osteoporosis. Trophic changes in th e skin are initially caused by swelling and later by nutritiona.l changes in the hand. The skin appears glossy or shiny, and evidence of subcut:meou tissue atrophy is present. Excessive and dark hair growth may be pres en t. The nails become coarse, rigid , and curved 39 Intervention for eRPS must be approached practically and cautiously. Traditional exercises for restri cted join are often painful and exacerbate th e pain cycle and vaso­ motor in stability. Pain must be controlled before progress­ ing to other treatment techniques. Modalities such as heat and cold may be helpful in redUCing pain but must not ag­ gravate the vasomotor tone . Elevation and moist heat be­ fore edema massage and exercise can improve tissue ex­ tensibility and tolerance to exercise. Therapeutic exe rcise inte rve ntions include ARO ~1. jOint mobilization techniques, and continuous passive mo­ tion (CP M) devices. Exercise is best tolera ted if initiated at proximal and less painful joints. Supine shoulder fl exion or simple posture correction with tlw pati ellt's back against a wall promotes upper extremi ty blood flow and improved proximal joint alignm ent . Active exercise of the wrist and hand should be performed elevated and directed to indi­ vidual joints and Illotions. Blocked finger fl exioll exerci se encourage more complete joint motion and spC'cific tendon gliding (see Self-Management 27-8: Blocked Finge r Ex­ tension). Holding a towel or soft ball while gripping can im­ prove IllOtor function hy the assistance of pal mar sensO T\ stimulation (Fig. 27-32 ). Patients ure encouraged to kepp the wrist in slight extemion during gripping exercises to en­ sure maximal c!Ticiency of the fl exor tendons . A three-colllpon ent stress-loading program has been a successful technjque for treatm ent of eRPS. The compo­ nents include compressive loading of th e upper extre mi ~ . distraction, and m e of oth er modalities, iJ1cluding sphnt­ ing4 1 The obj ect is to providc! stress to the tissues whil mini.mizing painful jOint motion. Loading activities call in­ clude rocking on hands and knees or standing with weight appli ed through the llpper extremity by lean ing on a table (F ig. 27-33 ). Therapy putty or a foam ball under the palm can be used to allow fee dback on the p ressure be ing

Chapter 27 The Elbow, Forearm, Wrist, and Hand

731

FIGURE 27-33. Lean ing on a table can faci litate weight bearing through the wrist.

FIGURE 27·32. Grasping exercise using a towel.

applied with the weight-b aring activities. Fingers can be Hexed over the edge of the table if cOl11posik finger E":--tC" I1­ sion is painful. Res istive band eX(C'fciscs ( ~an aTso he used to provide stress to upper extremity joints without introduc­ ing painful joint motion. Other interventions may be used to decrease pain and edema and to improve mobility. JOint mobilization tech­ niques specific to pain control, such as joint distraction and volar-dorsal glides, are often tolerated well and promote nor­ mal joint proprioceptive s ~ I1S0ry input (F ig. 27-34 ). E nd­ range techniques may produce pain early vvith increased lo­ cal inflammation and a resulting loss of joint motion. These teclmiques should be introduced graduaDy an d instructed for home use when tolerated. CPM devices can be used pe-

rioclically, alternating with active use and exercises. The de­ vice can be adjusted and controlled by the patient to allow slow and repe titive joint motion in pain-free ranges. The CPM may also contribute to pain relief (i.e .. gate control the­ my ) and improve peliarticular and caltilage nutrition. Splinting can be an effective technique to maintain or J'I'gain joint motion. Tissue responds positively to the ap­ propriate amount of force and negatively to excessive force. Static splinting can be effective in early stages to maintain the joints of the hand in their functional posi­ tions at rest. The functional position is described as the wrist in mid-extension, the thumb abducted, the Mep joints fl exed 60 to 70 dearees, and the IP joints near full ·extension. A resting hand splint for an el~tir(' hand or a joint-specific PIP extension splint can prevent anticipated development of joint motioll n:strictions. Dynamic splint­ ing may be tolerated when edema is;tabilized to allow a slow an d gradual stretch of contracted jOint tissues. Dy-

FIGURE 27-34. Mobi lization at the metacarpophalangeal joint (A) Dorsal glides. (8) Volar glides.

732

Therapeutic Exercise: Moving Toward Function

namic splinting should be done intermittently with gentle tension p rovide d for 20 to 30 minutes , Vasculmity should he monitored close ly, Increases in ede ma or pain indicate thc need to decrease te nsion or wearing time . H yperse nsitivity le ads to disuse and tactile overprotec­ tion , and desensitization programs can be d esigned on tlh.e initial visit. T hese programs allow the patie nt a graded and controlled seJies of activities to improve tactile tole rance and raise the sensory pain threshold, Th e program can in­ clude textures (e,g" denim, teny cloth, corduroy), massage or pe rcus sion (e,g., light progressing to firm) with the op­ pOSite hand, and tapping a sen sitive finge r tip on a tahle (Fig. 27-35) , E ffort should be made to avoid cycliC stimula­ tion to avoid increased pain, Protective padding or splint­ ing may be helpful for temporary and intermittent use to protect a hypersensitive area from repeated painful envi­ ronm ental stimuli. Transcutaneous electrical nerve stimulation has been eHe ctive for pain moduJatioIl , vasodilation, and vasocon­ striction. ReE:lrts describe improve ment in RSD paiJl as high as 90%, '>-J-I E lectrode placement and stimulating pa­ rameters may valy i11 eff~ctiveness. E ffective sites may in­ clude direct placement over the anatomic pain sHe, over peripheral or superficiaJ cutaneous nerves, or proximal to the area of discomfort The initial home prograrn should prom ote pain relief to em'ure adhc H'nce, Elevation to dec rease arteriaJ hydrostatic pressure and assist in lymphatic and venous damage, e levated massage, and compression arc techniqu es used to decrease edema, E levated massage from distal to proximaJ aspects can mo­ bilize edema, assist in pain relief, and improve ROM and desensitization, Main tai ni ng contilluous contact wit'h the ski n can decrease the chance for pain exace rbation duJing massage, Compression can be performe d by intermittent seq ue ntiaJ compression pumps and continuous compres­ sion devices. Acute edema may requ ire only 2 hours of se­ quen tial compression pump use daily to be effective in ed ema re duction , Ch ronic fibrotic edema m ay require more prolonge d use, Acute ede ma may require near con­ tinuous use of extemaJ compression, Compression gloves with e"'Posed finge rtips allow use of tlw hand while con­ trolling edema. A light, self-adhe ring wrap can be used for individua.l finger ede ma reduction,

FIGURE21-35. A variety of textures can be used to desensitize the hand,

Physicial1S often pe Iform stellate ganglion blocks in the treatment 01 CRPS, These procedures block aJl efferent sympathetiC' impulses. After a successfu~ hlock, the patie nt may find Significant relief and be 1110rc successful in exer­ cise atte mp ts, The sympathetic block is therapeutic and helps to confirm the diagnosis, Treatm ent of a paticnt with eRPS mlISt be approached with pati ence, sympathy, and flexihle planning, Improve­ me nt is ofte n slow, and the stiffness and pain may worsen be fore improving, Psychologic help is often necessary to as­ sist with pain manage ment Indiviuuals \vith acute symp­ toms ofte n respond qUickly vvith a decreasE:' in pain and swelling after one treatmen t. Those ill latter stages respond slowly and often unpre dictably Th eir impairments and functional limitations can be overwhelming, Keeping th eir program focused Oil one or two priority acti\ities at [1 time increases adherence and the abilitv to assess the effective­ / ness of each treatm ent.

Stiff Hand and Restricted Motion The diagnOSiS of the "stiff hand" is often used to describe joint limitation from a variety of causes, The plirnary diag­ nosis can include lacerations, bums, fractures, soft-tissue cfllsh injuries , and nerve and vascular trauma, The common cause is tissue trauma resulting in an inflammatory response, The resulting edema, fihrosis , and collagen alteration limit· tissue gliding (i,e" tendons) and extensibility (Le., skin, liga­ ment, and joint capsule), RestIicted motion is categOlized as articular 0: extraarticular by t11e tissue causing the limitation . Joint stiffness that follows simple immobilization is at­ tIibutablc to fixation of the joint ligaments to bone in areas normally meant to be free from such fixation, as well as short­ ening of the ligament by new collagen synthesis, Knowledge of th e normal anatomy and kineSiology of the wrist and hand help to understand, predict, and effec­ tively treat limite d mobility. At the Mep joints, the capsule is ve ry elastic dorsally to aUow for full Mep joint flexio n, The e xte llsor expansion glides ove r the dorsal capsule. With dorsaJ hand swe lling, th e Mep joints often lose jOint flexion, This is initiaJly cause d by limited extensibility of the dorsal skin and progreSSively b y adhesions of the collateral ligam e nts in their position of joint extension, The PIP and DIP joints are similar to the MCP joints with two excep­ tions. First, the collate raJ ligamen ts at the IP joints do not becom e slack in flexion; th ey remain taut throughout joint range, preven ting lateral motion of the IP joints, Secon d. unlike the MCP Joint, the loose -packed position for the lP join ts is flexion, Th e :v.o1ar plate b eco mes slack with IP joint flexio n and taut in extension, preventing hyperextension , as seen at the MCr jOint. After prolonged local swelling, the IP joints tend to lose joint extension, and the volar plate can b ecome adhered in its slack pOSition , preventing the neces­ sary lengtJ)ening for fulllP joint extension, Structure s outside the Joint such as muscle, tendon , or skin adhe sion s can also limit joint motion , After prolonged immobilization in wrist and finger flexion , the flexor mus­ cles become shortened, After te ndon repair or fractures ad­ jacent to tendons, tendon gliding is often limited by scar tis­ sue or fracture calluses, F or complete finger flexion, 7 cm of excursion is needed in the FDP tendons,3 After a dorsal

Chapter 27 The Elbow, Forearm, Wri st and Hand

133

AGURE 27-36. A flexion glove can improve the range of motion into flexion.

hand bu rn, metacarpal frac h lf , or prolonaed dorsal hand edema resulting in decreased skin mobility, adjacen t joint motions may be lost. Approximately 4 cm of dorsal skin lax­ ity is needed for full MC P jOint flexion and comp l te fis ting. Patients \-vith alticular and extraarticular tissue restli c­ tion describe functional limitati ons such as an inability to hold a fork or grip a steeling wh eel and difficulty getting their hands into their pockets. Examin ation must distin­ Q'ui sh ber-veen articular and e)-.iraarticuJar sources of lim­ ited motion. A thorough evaluation, performed with an un­ de rstanding of the local anatomy and kinesiology, can result in ffective intervention. Interv ntions for articular limitations include heat be­ fore joint mobilization, stre ngthe ning, and splinting. Splinting can include dynamic splints (worn for 20 to 30 minutes six to eigl~t times each day or 2 to 3 hours for one or two times each day) or static splints (worn at night). A flexion glove can apply nonspecific tension to the dorsal tis­ sue of the fingers, with an elastic strap used to increase fo rces at the IF joints (Fig. 27-36) E xtra-alticu lar restriction rely heavily on tendon gliding activities such as differe ntial tendon gliding and block d IF flexion. As with articll18r restrictions, stati or dynamic splinting plays a role in improving mobility. When intrinsic muscles are shortened or the tendons adhere to surround­ ing tissues, stretching, gl.iding, and sp linting are the treat­ ments of choice. Along with exercise and splintin g, eel ma can be controlled with compression gloves, compr ssion pumps, elevation, and wraps . Scar massage is important in treating smgic:11 or bum cases.

KEY POINTS

• The ulnar nerve may become entrapped in the cubital tunnel, the median nerve compress ed in the carpal tun­ nel, and the radial nerve entrapped in any of several lo­ cations at the lateral elbow.

• The C L is the primary static stabilizer and the flexor carpi ulnaris muscle the primary dynamic stabilize r of th e medial elbow. • The carpal tunnel is located 011 the volar aspect of the wrist and contains ni ne tendons and the median nerve. • Grip is ge nerally divided in pow r grip, used when force ae neration is the p rim ar obj ctive , and p r hension glip, used when precision is the main 9"0 81. • Activi ti es to increase mobility include traditio nal stretching exerdses, joint mobilization, and tendoll aud nerve gli ding exercises. • CTDs are usually th resu lt of a comhination of factors such as work pace, decreased rest intervals, and little variahilir-! in the task. • Conse rvative management of CT S is often successful if hand and wrist postures and hand activities are moni­ tored. • Radial tunnel syndrome is often misdiagnos ed as Lateral epicondyl.itis " . • Cases of lateral and medial epicondyli tis often res ult from repetitive wrist and haud activities at work, at home, or during recreation. • Medial e lbow instability occurs in ch.ildren and adults who participate in thrOWin g sports. ProgreSSive ins tabil­ ity in the child can lead to osteochondrosis of the capitel­ lum and loose body formation. • Sprain of the thumb's CL (or gamekeeper's thu mb) can res ult in degenerative joint disease of the CMC joint if instabi.lity continues . • The anatomy of the scaphOid predisposes it to nonunion after a fracture. Any individual with \\l1; st pain and wrist extension loss after a fall on an outstretched hand should he evaluat d for fracture of the scaphOid. • Individuals with complex regional pain syndrome have various degrees of pain, trophiC changes , loss of mobil­ ity, and a variety of functional limitations and disability. • Interventions for individuals with a stiff hand include mobility activities. splinting, and strengthening exer­ cises .

734

t:;\

\:!J

Therapeutic Exercise Moving Toward Function SELECTED INTERVENTION 27-1

Upper Ouadrant

See Case Study #8

Although this patient requires comprehensive intervention, one specific exercise addressing motor control is desclibed.

ACTIVITY: Simulated typing with surface electromyography (SEMG)

PURPOSE: Develop motor control strategy to use appropliate levels of wrist extensor activation, wrist flexor relaxation , production of micro rests, and complete baseline recovery between timed bouts of data entry

RISK FACTORS: Watch for cervical posture as part of repetitive strain; injury to extensor group may be secondary to cervical dysfundion.

Repetitions/sets: Five minutes of typing form one repetition. Perform up to five sets. Rest period: Random 5-second rest breaks are called out dming each repetition; 15-second breaks are taken after each 5-minute bout of exercise. Frequency: If SEMG is rented, practice should be twice daily for 2 to 4 weeks. If onlv used in clinic, recommend three times a week for 3 to 6 weeks. For cost-effectiveness, unit rental is preferred. Sequence: Perform after stretching exercises are performed, but not after muscle performance exercises so as not to overly fatigue muscles. Speed: Functional speed

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Modulator STAGE OF MOTOR CONTROL: Skill MODE: Isometric wrist extensor and flexors, concentric and eccenttic finger flexors and extensors POSTURE: Sitting at a simulated workstation in optimal ergonomic posture, with SEMG appropliately placed on tight and left forearm flexor and extensor groups41 MOVEMENT: While simulated typing is performed on a keyboard using a palm and wlist rest and optimal ergonomic posture, SEMG monitors forearm flexor and extensor acthity bilaterally. The tight forearm attempts to follow the template developed by the left forearm. Random stopping is called out to determine the spontaneous speed and level of recovery to baseline. Timed rest breaks are scheduled to determine planned speed and level of recovery to baseline.

SPECIAL CONSIDERATIONS: Closely monitor cervical position and paracervical muscle tension . DOSAGE Special Considerations Anatomic: Lateral epicondyle, musculotendinous and tenopetiosteal junction of Wlist and finger extensor group Physiologic: Subacute strain Leaming capability: May be difficult as patient works up to 60 hours a week at ,·isual display terminal. Probably has strong patterns of overuse of wrist and finger extensors.

Environment: Initially in quiet horne em,i ronment, then progress to work environment Feedback: Initially, continuous audio feedback from the SE~IG unit. Threshold is set so as not to exceed left side wIist and finger extensor acthity. Visual feedback is used to see the speed and level of recovery to baselinE' dUling microrests and rest breaks. The patient is reassessed once each week, and the decision to progressively fade feedback is based on performance. Progressive fading of feedback occurs dming exercise sessions to eliminating either audio or visual feedback every third set, to every other set, and so forth. A second party relaying the results between sets prOVides verbal knowledge of the results. Functional movement pattern to reinforce goal of exercise: In addition to using an improved motor strategy during data entry, the patient is encouraged to use elbow flexors instead of forearm extensors during lifting tasks (e.g., lift in forearm supination versus pronation) to reduce the strain to the wrist/finger extensors. Rationale for exercise choice: This exercise was chosen as a skill-level activity to reduce the overuse of the Wlist and finger extensors 'during a highly repetitive functional acti\ity. Through the use of SE~'IG feedback \\~th a proper faded feedback schedule,42 the patient can develop an intlinsic reference for muscle activation and'error detection to improve motor control strategies to reduce recruitment effort and improve the speed and level of relul(ation to baseline.

Chapter 27: The Elbow, Forearm, Wrist, and Hand

t::\

SELECTED INTERVENTION 27-2

\;!J

Total Body

See Case Study #10 Although this patient requires comprehensive intervention, one specific exercise presclibed in the intermediate stage of recovery is desclibed.

high repetitions and Significant feedback in early stages of learning

RepetitionS/sets: Initially to form fatigue as evidenced by hip hike, shoulder drop, and scapula adduction; work up to .3 sets of 20 to .30 repetitions

ACTIVITY: Step-ups; swing phase, with counterrotation (see Fig. 25-29 in Chapter 25)

Frequency: SLX to seven days each week

PURPOSE.: Incorporate proper total-body movements in a functional context

Duration: Expect at least 2 weeks before e\idence of motor control changes and 6 to 8 weeks before skill level is achieved.

RISK FACTORS: None ELEMENT OF THE MOVEMENT SYSTEM EMPHASIZED: Modulator

Sequence: Perform after specific exercises for psoas muscle performance, thoracic rotation mobility, and abdominal muscle pelformance exercises have been performed. Follow IIith step-up: stance phase. Speed: Slow progressed to functional speed

STAGE OF MOTOR CONTROL: Controlled mobility POSTURE: Standing in front of a 6-inch step in front of a mirror MOVEMENT: Lift the right leg onto the step with

simultaneous light thoracic rotation and left forward arm

swing

SPECIAL CONSIDERATIONS: Be sure the patient does not hike his light hip duling the hip flexion phase and does not drop his light shoulder (right thoracic lateral flexion) or adduct his right scapula instead of light thoracic rotation during the upper body counters\\ing maneuver. DOSAGE

Special considerations Anatomic: Right hamstring and adductor, right

subscapulmis, right glenohumeral joint

Physiologic: Chronic moderate strain and tendinitis,

questionable instability of light glenohumeral joint

Learning capability: Very ingrained movement pattern

from a long history of high-mileage mnning; may require

Environment Home in front of a mirror Feedback: Initially in clinic \lith mirror prO\iding lisual feedhack and clinician providing verbal feedback. Taper to continued use of mirror, but with knowledge of results of verbal feedback after every .3 to 4 repetitions. Withdraw mirror and verbally prO\ide KR every.3 to 4 repetitions. Progress toward skill. FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, gait. RATIONALE FOR EXERCISE CHOICE: The total-bodv movement pattern of right hip hike and right sho~lder drop during s\\ing phase of gait may be perpetuating the upper and lower extremity conditions. Without adequate hip flexion, the gluteus maximus is less efficient at assisting the stance phase of gait or step up; the persistent right shoulder drop and scapula adduction and dO\\11ward rotation can pelpetuate posture and movement impairments consistent ,lith glenohumeral impingement and hypermobility. As a result, this pattern of movement must be altered to fully recover £i'om the upper and lower body conditions.

735

136

Therapeutic Exercise ivioving Toward Function

LAB ACTIVITIES

For each of the following case scenarios, evaluate your patient and design and execute an exercise pro­ gram. Teach your patient a home exercise program. 1. A 56-year-old woman sustained an ulnar shaft frac­ ture ,{,hen she slipped and fell on the ice 6 weeks ago. She was casted for 3 weeks above the elbow and then recasted with a below-elbow cast. Her cast was re­ moved 3 days ago. Evaluation reveals loss of AROM and PRO~I for e lbow extension, pronation , and supination, wrist fl exion and extension, and radial and ulnar deviation. Strength testing was not per­ formed. She had no edema. JOint play assessment was not performed, but atrophy was visible. 2. A 12-year-old boy complains of medial elbow pain. He is active in Little LeaglJe and pitched 14 innings over the weekend. He complains of pain along the medial collate ral ligament pain with passive elbow extension, flexion, pronation, and sllpination (with a guarded end feel). A mild effusion is observed, and there is increased I
CRITICAL THINKING QUESTIONS

------

1. Consider Cas e Study #8 i11 Unit 7. Design a workstation for th is individual given his physical examination and subjective history. How would your treatment differ if the patient's occupation was a. A caJpenter b. A house painter c. A portrait paillter d. A violinist e. A pianist 2. Consider potential reasons why this patiellt's symptoms cL d not resolve after his works tation update several months ago.

Joint play assessment reveals decreased humeroul­ nar joint distraction. oj. A 70-year-old woman fell on the ice and sustained a Colles fracture 8 weeks ago. She underwent a closed reduction and was immobilized in a selies of casts. She also has insulin-dependent diabetes mellitus and has decreased sensation over fClr distal forearm, wrist, and hand. Examination reveals a loss of all active and passive wrist motion, decr~ased joint play in the infe­ lior radioulnar joint, "isihle atrophy, and a loss of strength with resisted movements in neutral. 6. A 32-year-old man sllstained a scaphoid fracture 10 weeks ago when he fell on an outstretched hand while skiillg downhill. He was casted for 8 weeks , and peri­ odic radiographs revealed llollunion of' his scaphoid. He unclerwent slll'gical stabilization of the fracture using a hone graft from his iliac spine. He has been immobilized for 12 weeks since surgel),,- He is re­ ferred to physical therapy to begin ROM out of the splint timr ti mes each day. Examination reveals a loss of all wrist motiolls , decreased thumb Hexion and ex­ tension , and decreased opposition. i. A 40-year-old meat cutter sllstained a lace ration of his fi;lger extensors (proximal to his MCP jOints ) while working. He unclenvent surgical fixation and was allowed to activel".' contract onl".: the finaer Hex­ b ors. He has been removed from his splint and is al­ lowed to begin active finger extension. Examination reveals decrease d active finger extension (at the MC P joints) from weakness but full passive finger ex­ tension. Mobility of the MCP joints is decreased. 8. A 50-year-old man sustained a crush injury to his hand when his shilt sleeve got caught in a printing press and pulled his hand in. He sustained multiple metacarpal and carpel fractures, some of which were surgically stabilized through pinning. He has been casteel. for 8 weeks and presents to phYSical therapy today. Exam­ ination reveals a massive loss of motion of all wrist and fingers joints, atrophy in the thenar and hypothenar e mllwl1cc, and decreased joint mobility in the carpal and MC P joints and all finger joints.

3. Discuss the relationship between this patient's head and neck exam ination and his distal complaill ts .

REFERENCES 1. Butler DS. Mobiljzation of the Nervous System . New York:

Chu rchill LiVingstone, 1991. 2. W illiams PL, Wmwi ck R, Dvson M, Bannbter LH , eds. Gray's Anatomy. 37th E d . Ne\~' York: Church ill Livingstone, 1989. 3. Tubiana R. Architecture and fUllctions of th e hand. In: Th omine JYI, Mackin EJ, eds . Examination of the Hand and Upper Limb. Philadelphia: WB Saunders, 1984. 4. Kendall F P, McCreary E K, Provance PC. Musd es Testing and Function . 4th Ed. Baltimo re : "Williams & Wilkins, 1993.

Chapter 27: The Elbow, Forearm, Wrist. and Hand ,5, Russe 0, Fracture of th e carpal navicular. J Bone Joint Surg Am 1960;42:759- 768, 6, Ambrose L, Posner MA, LUllate-triquetral and midcarpal joint instability, Hand Clin 1992;8:6,53-668, 7, Clllver JE, Instabilities of the wrist. Clin Sports Yl ed 1986;,5: 725- 740, 8 Ch ase RA, Anatomy and kinesiology of the hand in rehabili­ tation of the hand, In: Hunter JM , Mackin EJ, Callahan AD, eds, Rehabilitation of the H and: SurgelY and Therapy. 4th Ed, St. LOllis: CV -"los by, 1995, 9, Norkin ce, Levangie PK. JOint Structure and Function: A Comprehensive Analysis. 2nd Ed. Philadelphia: FA Davis, 1992. 10 Be rg r RA. The anatomy and basic biomechallics of the wrist joint. J Hand Ther 1996:9:84--93. 11, Safrall MR. Elbow injufic's in athletes: a review. C lin Orthop J 995;310:2,57-277. 12, Pratt N E. Clinical Musculoskeletal Anatomy. Philadelphia: JB Lippincott. 1991. 13. Morrey BF, Askew KN, Chao EYS. A biomechanical study of normal functional elbow motion . .J Bone JOint Surg Am 1981: 63:872- 8il7. 14. MOlTey BF, An KN, Articular cUlclligamentous contributions to the stability of the elbow jOint, An1 JSports Med 1983;11: 315-319, 15, Davidson PA, Pink M, Perry J, et al. Functional anatomy of the fl exor pronator muscle group in relation to the medial col­ lateral ligament of the elbow, Am J Sports Med 1995;23: 24,5- 250. 16. Magee D. Orthopedic Physical Assessment, .3rd Ed. Philadel­ phia: \VB Saunders, 1997. 17. f3rumfi eld RH , Champoux JA. A biomeciranical study of nor­ mal functional wrist motion . Clin Orthop 1984;187:2:>-25. 18. Viegas SF, Tencer AF, Cantrell J, et al. Load transfer charac­ teristics of the wrist: part I. The normal jOint. J Halld Surg 1987;12:971-978. 19. vVadsworth C. The wrist and hand, In: Malone TR, McPoil T. Nitz AJ, eds. Orthopedic and Sports Physical Therapy. 3rd Ed , St. Louis: CV Mosby, 1997. 20, Schreuders TAR, Roebroeck ~,tlE, Goumans J, et a!. Mea­ surement ermr in grip and pinch force measurements in pa­ tients with hand injuries, Phys Ther 2003;83:806-815, 21. O'Driscol1 SW, Horii E, Ness R, et al. The relationship be­ tween wrist pOSition, grasp size and grip strength, J Hand SurgAm 1992;17:169-177. 22. National Institute for Occupational Safety and Health. \'lus­ culoskeletal Disorders and Workplace Factors: A Critical Re­ view of Epidemiologic Evidence for Work-Related Muscu­ loskeletal Disorders of the Neck, Upper Extremity, am! Low Back. NIOSH Publication No, 97-141. Cincinnati , OH: NIOSH, 1997, 23. Putz-Anderson V. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs . Bristol, PA: Taylor & Francis, 1992. 24. Eastman Kodak Company. E rgonomic Design for People at Work, Vol 2. New York: Van Nostrand Heinhold, 1986.

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2,5. Rempel D. Musculoskeletal loading and carpal tun ne l pres­ sure , In: Gordon SL, Blair Sf, F ine LJ, eds, Repeti tive Mo­ tion Disorders of th pp "r Ext re mity. Rosemont, IL: Amer­ ican cademy of Orthopa dic urgeons, 1995. 26, Ditmars DM, Hovin HP. Carpal tunne l s),11drome. Hand Clio 1986;2525--532. 27. Simon eau GG, \1 arklin RW, Berm an JE. Efle t of computer keyboard slope on wrist position and fo rearm e lectromyogra­ phy of typists without musculoskeletal disorders. Phys T he r 2003;83:816-830. 28. Idler RS. Anatomy and biomechanics of the digital flexor ten­ dons. Hand Clin ] 985;1:3- 11. 29. Plancher KD , Peterson RK, Steich n .TB. Com pre 'sivc neu­ ropathi es and te ndinopathies in the athle ti c e lbow. CliD Sports Med 1996;1.'5:331-:372. 30. Nir.chl RP, Soft tissue injuries about the elbow. Clin Sports Med1986;,s:6.37-6,s2. 31 Kibler WB. Pathophysiology of overload injuries around the elbow. Clin Sports Med 1995;15:447 57. 32. Kirkpatrick Wfl. De Que rvain 's di sease. In: H unt r JM, Schneider LH, Mackin EF, Callallan AD, eds, Reh abilitation of the Hand. 3rcl Ed. St. Louis: CV Mosby, 1990. 33, Cannon NM, ed, Diagnosis and Treatme nt Manual for Physi­ cians and Therapists. 3rd d. Indianapolis: Hand Rehabilita­ tion Center of Indiana, 1991. 34. Sobel J, N irschl RP . · Ibow injuries. I n: Zachaz wski JE, Magee DJ, Quill n WS, eds. Athl tic Injuries ancl Rehabilita­ tion, Philadelphia: \VB Saunders. 1996. 35 Josefsson PO, Johnell 0 , Ge ntz CF . Long term sequelae of simple dislocation of th e elbow. J Bone JOint Surg Am 19 ; 66:927-930. 36. Rowe C. Th manage ment of fractures in elderly patients is different. J Bone JOin t Surg Am 1965;47:104:>-1059. 37. Meyer FN, Wilson RL. Management of non articular frac­ tures of th hand. In: H unter JM, Schneider LH, Mackin F , Callahan D , eds. Rehabilitation of the Hand. 4th E d. St. Louis: CV Mosby, 1995. 38. Stralka SW, Akin K. Reflex sympathetic dystrophy syndrome. In: Orthopaedic Section I-fome Study Course , LaCrosse, \i\II: Orthopaedic Section, APTA, December 1997, 39. Lankford LL. ReHex sym pathetic dystrophy. In: Hunter JM , Schneider LH, Mackin E F , Callahan AD . eds, Rehabilitation of th e H and. 3rd Ed. St. Louis: CV Mosbv, 1990, 40, Sucleck PMH . Ueber die acut entzundiiche Kllockenatro­ phie . !\.reh Klin C hir 1900:62:14;- 156. 41, Watson HK, Hyu J, Degenerative disorders of th e carpus . Or­ thop Clin North Am 1984;1.5:337-354. 42. Lee VH , Reynolds Cc. Clinical application of transcutaneous electrical n rYe stimulator in patients with upper extr mity pain. In: Hunter J\1, Schneider LH , Machin EF. Callahan AD, eds. Rehabilitation of the Hand. 3rd Ed. St. LouiS; CV Mosby, 1990. 43. Cram JB, Kasmanu GS , Holtz J. Introduction to Surface Electromyography. Rockville , MD : Aspen Publishers, 1998. 44. Kas man GS, Cram J R, vVolfSL, Clinical Appli ations in urface Electromyography. Rochill , MD: Aspen Publishers, 1998.

C

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~J

CASE STUDY #1

Usa is a 17-~· ear-old high school student who t'omplains of light (R ) ,mkle pain and swelling. She desc ribes injuring herself yesterday d uring basketbal l practice. Coming dO\\1l after a rebollnd attempt, she lande d on the foot of another pla.r er, twisting her ankle and fa lli ng to the grollnd.

Imlllt'ciiate ly after the injmy, site was able to move he r ank le walk off th e COl.lli. "io\\' Lisa reports difflcility bea rin g 1'1111 we ight on her n foot and is unable to walk or rlln without a significant limp. Her team is contending for th e state championship in 6 weeks , and Lisa hopes t() play.
EXAMINATION Pain: 4/10 at rest, constant in Ilature in nOIl- we ight-hearing: 6/ 10 \\1th weight-bt'
Active Range of Motion: Plantar flexion/dorsiflexion 20-5 degrees ; foot illversion/e\'ersioll 3- .'5 degrees with pain end range Passive Range of Motion: Plantar tlexion/dorsillexion 40-15 degrees ; foot inve rsion/eversion 3-8 degrees with lIluscle guardi ng Accessory MOlion' Subtalar and talocrural distraction h)1)omobile; subtalar medialllateral glide h)poillobile with Illuscle guarding: talo11<1Vicular, cuboid/navicular and cuneiform/na\'icular all hypomobiJe

Palpation: MOllerate localized swelling in region distal to in same region

n lateral malleolus; marked te nde rn ess and early signs of ecchymos is

Strength Testing: Anterior tibialis 4/5 (pain e licited); postt'rior tibialis 5/5; gastrocnemiLls/soleus 5/.'5: peroneus lon gus 4 - /.'5 (pain clidtcd)

Resisted Testing: Dorsiflexors and e\'eliol's weak and painful Balance: Unable to assess because of patient discomfort in weight bearing

EVA LUAT ION: Acute, traumatic ligamentous injury to the Rankle. Impairment

Functionsl Limitstion

Disability

• Localized pain, and swelling of lateral Rankle • Decreas d active and passi 'e range of motion for Rankle • Midfoot hypomobility • F ulty R fo t align ment in stance into calcaneal eve rsion • D ecreased slatic and dynamiC stand­ ing balance

• \Veakness in ankle evertors and dor­ siflexors • Limited weight bearing and move ­ ment tolerance in standing and walk­ ing, necessitating the use of crutches

• Unable to run or jump on R foot • Unable to play basketball

DI A GNOS IS: Second dt>gre sprain of the R calcaneofibular ligament

PROGNOSIS Short- Term GOBls (7-10 days)

Long-T8rm Gosls (3-4 w8eks)

1. Ambulate ,,,ithout an as·j ti\' device, step-through pattel1l, 15 minutes, no an kle pai n 2. Tolerate low-inten "it)' running and jumping

1.

mbulate unlimited , no ankle pain 2. Returu to full-intensity basketball practi ce

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Therapeutic Exercise: Moving Toward Function

C CASE STUDY #2

~

Sarah is a 6g-year-old, retired college professor with a mecikal diagnosis of osteoartillitis in both knees. She is widowed and Ihing alone in a third-floor apartment with elevator access. Yesterday, Sarah underwcnt elective surgery for bilateral (B) total-knee
includes emphysema, myocardial infard 2 ~Iears ago, moderate obeSity, and hypertension. She lives independently but has a maximum walking tolerance of one-half block when using a cane for suppOli.

EXAMINATION Arousal/Cognition: Alert and oriented; follows complex l'ommanrls; motivated to get out orbed Cardiovascular: Pale with complaints of nausea; short of breath \\~th exertion; diaphoretic in sitting; vital signs: pulse 96 supine,

1O~ sitti ng; blood pressnre 144/66 mm Hg supine, 126/64 mm Hg sitting

Wounds: Dressed \\ith gauze and dear tape, moderately soaked \\;th bloody drainage; pt'liwound regions warm to touch ,

h~'PereI)tht'mic, and swollen

Pain: :3/10 at rest. 8/10 \\~th movement

Active Range of Motion: R knee extension/flexion 20-4i degrees (pain elicited); L knee extension/flexion 1.5-52 degrees (pain

elicited )

Endurance: Maxi mum sitting tolerance 1.5 minutes; maximulIl standing tolerance 20 seconds

Strength Testing: lliopsoas (B ) 2+/5; gluteus maximus (B) 4/.5; gluteus medius (B) 2+/.5; qumliiccps (R) 2/5, (L) .3-/.5;

hamstrings (R) 2+/5, (L) 3-/.5

Resisted Testing: Shoulder girdle extension and depreSSion, elbow extension all strong and pain free

Posture: Seminexed both knees, with L > R valgus knee deformity

Gait Wide base of snpport, stiff knees , flexed tnmk, maximum upper extremity support on walker

EVALUATION: Acute, postoperative pain, inflammation, muscle weakness, and decreased active motion of both knees Impairment

Functional LimitlJtion

Disability

• Bilateral decreased knee active range of motion • Bilateral weak quadJiceps and hamstrings • Postoperative pain and inflammatol)' response • Marked1y limited activity tolerance

• Required moderate assist for bed mobility and basic sit to stand transfer • Unable to sit> 15 minutes • Unable to stand >20 seconds • Ul1ahle to walk

• Unable to resume independent basic and instrumental activities of daily living • Unable to walk household distances • Unable to resume teaching and writing interests • Unable to access family, church , and clubs for social interaction

oI A G NOS IS:

Postoperative day 1 after bilateral total knee arthroplasties

PROGNOSIS Short-Tenn Goals (7-10 days) 1. Independent beel mobility and basic transfi:~r with walker 2. I ndependent um buiation .30 meters with walker 3. Active knee range of Illotion > 10-iO degrees to enable up/dO\\ll stairs 4. Out ofbt,d and up in chair >5 hours per day

Long-Tenn Goals (12 weeks) 1. Ambulation > 100 meters, rest breaks as needed, allOWing for baseline compromised cardiopulmonal)' status

2. Return to indept'ndent driving for community access 3. Return to preoperath'e vocational routine

­

Case Studies

C

.­ CAS EST U D V # 3

_. ii".

Cathy is a 61-year-old journalist \\~th a number of complaints, including trunk weakness, leg weakness, and gene ralized fatigue. She has a history of osteoporosis, osteoarthritis, and a recent 2-week bout with diarrhea caused by her medication . Recently, Cathy has had

difficulty managing a 40- to .'SO-hour work week. She hetS no history of regular exercise nor any home exercise equipment. Her maximum walking tolerance is reportedly one block, limited by shortness of breath, general fatigue , and hip discomfort.

EXAMINATION Posture/Alignment: Long kyphosis with posterior displacement of the upper trunk and a forward head. Lumbar spine is flattened. Posterior pel\'ic tilt. B hips extended and internally rotated. B knees in recllIvatum ; tibial exte rn al rotation; scapulae abducted and e levated Muscle Length: Hamstrings: passive straight-leg raise to .'5 0 degrees (B ) Strength Testing: Trunk eur! :3-/.'5 ; leg lowering 2-/.5; iliopsoas (R) 3/.'5 degrees, (L) :3- /5; glute us medius (R) 3/:3, (L) 2 +/5; glu te us maxim us (B) 3 +/,'5 ; quadriceps (R) 4/.'5, (L) 4-/;3 ; hamstrings (R) 4-/5, (L) :3 +/5 Active and Passive Range of Motion: Thoraeolumbar spine: forward beud thoracic> lumbar Hexion with lumbar spine n>maining in neutral; back bend with excessive extension at thoracolumbarjunction ; Hip: internal rotation (R) 0-20 degrees, (L) O-I.'5 degrees, external rotation (R) 0--3.3 degrees, (L) 0--33 degrees, flexion (bent knee) 0-8,5 degrees, extension 0- 2.'5 degrees Shoulder: fl exioll in scapular plane 0-140 degrees, with early upward rotation of scapulae and lackin g thoraciC' extension component at end range Endurance: Standardized .12-minute walk test completed with subjective complaints of shortness of breath and lower extremity muscle fatigue; distance, gOO meters; standing rest required at 10 minutes, peak heart rate of 1:32, blood pressure of 1.5:3/88 mm Hg

EVA l UAT ION; Generalized deconditioning with gradual onset of faulty alignment because of changes in joint mobility and muscle strength and length , compounded by recent illness Impsinnent • Muscle weak'ness peI~c girdle • Faulty spinal, pelviC and lowe r ex­ tremity alignment • Muscle shortening of hamstrings and rectus abdominis • Decreased cardiovascula.r endurance • D ecreased lowe r extre mity muscle endurance • Restrictions at thoracolumbar spine intervertebral and thoracic spille cos­ tovertebral joints • F aultv sho'ulder <Tirdle move ment / " patte rns • Hip joint restlictions

Functional Limitation • Unable to walk> 10 minutes \\~thout shortness of breath and fatigue • Stairs require rail support • Difficulty getting up from low chairs • Rest breaks required during ,\M and PM self-care routine

Disability • Unable to tolerate exertion of a full workweek • Unable to complete basic and instru­ mental activities of daily living in a timely manner • Avoidance to social actil~tj es because of fatigue

DI AG NOS IS: Generalized deconditioning superimposed on baseline medical diagnoses of osteoporosis and osteoarthritis

PROGNOSIS Short- Term Goals (2 weeks) 1. Demonstration of energy conservation and pacing techniques to maximize acti\~ty tolerance at work and home

Long- renn Goals (4-6 months) l. Increase in musculoskeletal and cardiovascular endurance to allow resumption of full duties at work and home

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Therapeutic Exercise: Moving Toward Function

.'~

CASE STUDY #4

Jack is a 58-year-old retired banker who presented \\'Hh complaints of right (R) shoulder pain that was most noticeable when reaching overhead or behind. His pain occasionally wakes him at night. Jack's medical history is signiflcant for a nonspecific R shoulder injury sustained

playing tennis 2 years ago. This went untreated, and the S;'111ptoms resolved. Jack has been refurbishing his :35-foot wooden sailhoat and noticed the onset of shoulder pain after sanding the deck. He is R-hand dOlllinant.

EXAMINATION Posture/Alignment Forward head with upper cervical extension, cenieal-thoracic junction flexion , and flattened thoracolumbar spine; scapulae elevated, abducted. and dO\\11wardly rotated R > L; R humerus anteIiorly displaced in the glenohumeral jOint Active Range of Motion: R shoulder flexion 0-90 degrees, extension 0-.30 degrees, abduction 0--100 degrees, external rotation 0-25 degrees. intemal rotation 0-50 degrees; pain elicited end range all directions Passive Range of Motion: R shoulder flexion 0-1l0 degrees, extension 0-33 degrees, abduction 0-110 degrees , external rotation 0-25 degrees, internal rotation 0-55 degrees; end-range pain elicited in all directions Accessory Motion Testing: Glenohu meral: diffusely h)pomobile, especially posteIior and infelior glides Scapulothoracic: h)pomohile medial glide and upward rotation; hypermohile lateral/cephalic glides Upper thoracic: h)pomobile segmental antelior/posterior glides T2-TR Strength Testing; Upper trapezius/levator scapula (R ) 5/.5, (L) 5/5; middle trapezius (R) 2/5 , ( I.) :3/5; lower trapezius (R) 1/.5, (L) 3/5; rhomboids (R) 3/5, (L) 4/5; serratus antelior (R) 4/5, (L) .5/5 Resisted Testing (neutral position): Strong and painless R shoulder flexioll , extension, internal rotation, abduction and adduction; weak and painless extern al rotation Quality of Movement Glenohumeral tlexion/abduction achie\'ed through 30 degrees of glenohumeral motion, followed by 1:1 scapulobumeral rhythm to rou,,;hly 90 degrees; remaining motion achieved through shoulder girdle elevation

EVAl UAT ION: Decreased osteokinematic and mthrokinematk motion of R shoulder girdle and cervical­ thoracic spine, resulting in faulty movement pattems and pain with end-range shoulder function Impairment • Decreased phYSiolOgiC and accessory motion • Faulty scapulothoracic. gleno­ humeral , and cenical-thoracic spine alignment • Fault) shoultler girtlle movement pattern • Pain with end-rane;e shoulder girdle motion , espeCially forward flexion

oIAGNOS IS:

Functional Limitation • Unable to reach , lift. or pull overhead • Disturbed sleep

Disability • Dimculty retrieving wallet from back pocket • DifTiculh.' unlocking car passenger door from driver's seat • Unable to complete moderate- or heavy-duty boat refurbishing tasks

Subacute R shoulder adhesive capsulitis

PROGNOSIS Short-Term Goals (3 w8eks) 1. Decrease night pain by 50% 2. Light weight lifting and reaching activities up to shoulder height without pain

Long-Term Goals (3-4 months) 1. No night pain 2. Ability to tolerate resisted motion at end range of shoulder lIIotion; thus able to complete heavy-duty jobs on boat

Case Studies

e

~

rr-

.~

CASE STUDY #5 __

Irene is an 85-year-old woman who fell at home, resulting in acute low back pain and right more than left (R > L) lower extremity radiculopathy and necessitating bed rest for more than 2 weeks. She is weak, deconditioned, unsteady on her feet, and fearful of falling. She now uses a walker for

743

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I.

ambulation. Her back still gives her pain, although she no longer suffers lower extremity symptoms. Irene lives in her own apartment in an assisted-living environment. Before the fall, she independently handled her basic activities of daily living and was socially active with fellow residents.

EXAMINATION Posture: Kyphotic!Iordotic thoracolumbar alignment; antelior pelvic tilt; hips slightly flexed Strength Testing: Leg lowering 21.5; gluteus maximus (R) 2+/5, (L) 3+/5; gluteus medius (R) 215, (L) 3/5; iliopsoas (R) 3/5, (L) 4-/5; quadriceps (R) 4/5, (L) 4+1.5; hamstrings (R) 3-/5, (L) 3+/5 Muscle length: Moderate shortening of quads> iliopsoas, R > L; (B) hamstrings unremarkable Functional Movement Testing: Pain with standing or walking (4/10). Pain relief with sitting or sidelying. Standing forward bend at 20 degrees; standing backward bend trace with reproduction of symptoms

Gait Po 'itive Trendelenburg with stance R > L; wide base of SUppOlt; flexed at hips with forward displaced trunk over pelvis;

markedly diminished lumbopeh,i c rhythm

Balance: Standardized stand reach test of 6 inches; provoked balance response demonstrates delayed step response with hip >

ankle strategies

Reflexes: Knee jerk (B) 2+; ankle jerk (R) 1+, (L) 2+

Sensory: Ught touch intact. mildly decreased proprioceptioll R > L

EVA LUAT ION: Fixed kyphOSiS and lordosis malalignment, with conesponding muscle length and tension changes; painful with active or passive extension, affecting static and dynamiC standing balance, and standing tolerance Impairment

Functionsl Limitation

Disability

• Fixed kyphotic-lordotic alignment of thoracolumbar spine • Muscle weakness. espeCially trunk and proximal lower extremity • hortened iliopsoas and quadliceps, R> L • D cre,lSed static and d}1lamic stand­ ing balance • Fear of falling • Pain with lum bar extension

• Assistance required to get out of bed or up from a chair • Inability to stand >2 minutes • Inability to walk> 10 meters • Mobility avoidance

• Loss of independence performing basic activities of daily living • Loss of independence with ambula­ tion • Unable to walk to dining room • Reluctant to participate in usual so­ cial activities (bIidge, mms , out for dinner with family )

oIAGNOS IS: Lumbar spinal stenosis exacerbated by fall. Now with subacute pain, deconditioning, balance deficits , and increased fear of falling. PROGNOSIS Shott-Term Goals (2 weeks)

1. Independent ambulation with walker, 25 meters 2. Independent transfer out of bed 3. Independent stand for 10 minutes for morning self-care routine

Long-Term Goals (8 weeks) 1. Independe nt ambulation within building complex; no

assistive de\,i ce 2. Resume all previous social activities witil fliends
744

Therapeutic Exercise Moving Toward Function

C

CASE STUDY #6

Scott. a 32-year-old man, presented 1 week after right (R) anterior cruciate ligament autograft reconstruction. He is on medical leave of absence from his position as a full-time

dJiver and delivery man for a shipping company. Scott is an outdoor enthusiast and has hopes of returning to rock climbing, kayaking, and skiing after his rehabilitation.

EXAMINATION Gait: Toe-touch pattern with use of axillary crutches; knee held semiflexed Active Range of Motion: Knee extension/flexion 15-60 degrees with subjecti\'e sensation of'·tightness" at both extre mes Passivo Range of Motion: Knee extension/flexion 12-70 degrees with spasm end feel P8lp8tlon~ Moderate suprapatellar swelling; posterior capsule distention; girth (:3 cm proximal to supeJior patellar pole) H = 44 cm. L = 38 em: moderate jOint line tenderness

Strength Testing: Resisted testing contraindicated; surface electromyographic testing confinns :3.5% decreased vastus medialis oblique recmitment relative to nonsurgical leg

ccessory Motion: Hypomobile patellar glides, all directions

E VA L UA T ION: Postoperative R knee joint effusion, pain, decreased range of motion, and altered muscle recruitmen t patterns Impainnenr • Localized swelling in suprapatellar and posterior capsule rE'gions • Acute surgical pain with end-range knee Illotion • Impaired vastus medialis recruitment • Decreased patellofemoral accessOlY joint mobility • Loss of R lower extremity cOOl'dina­ tion

oI A G NOS IS:

Functional Limitation

Oisability

• Unable to tolerate foot flat stance 011 R with a step through pattem • Crutches reqUired secondary to above gait problems • Unable to tolerate prolonged static extension

• Unable to lift from floor height or dlive; therefore, unable to work • Unable to participate in usual out­ door sports

R knee dysfunction from primary structural injlll)' and corrective surgery

PROGNOSIS Short-Tenn Goals (2-4 weeks)

Long-Term Goals (6-12 months)

1. Ambulate without assistive device

1. Return to preoperative work routine

2. Return to modified work routine

2. Resume low-to-moderate intensity sports

C

CASE STUDY #7

Mary is a 36-year-old wife and mother of two young children. She has a 6-month history of chronic back, hip, neck, and shoulder pain, recently diagnosed as fibromyalgia. She is not working, although she is trained as a research laboratOlY technician . Mary reports she's having a hard time keeping up with her husband and children and increasing difficulty

managing her home. Even minor activities such as lifting or carrying her children can result in profound pain , fatigue , or weakness just a few hours later. She once was very active and now is skeptical but hopeful that she can return to a regular exercise program . Ultimately, she would like to retu111 to part-time work.

Case Studies

745

EXAMINATION Posture and Observation: Tall, slim build; stands in ankle plantar flexion, knee recurvatum , anteJior peh~c sway relative to thorax, posterior pelvic tilt ,,,;th lumbar flexion and thorac:ic kyphoSiS. Ccrvical spine in R sidebend. Resting muscle tension apparent in facial, neck, and shoulder Illuscles. Upper chest breathing pattern; respiratory rate 24 at rest Active Range of Motion: emeal: flexion 0-30 degrees; extension 0-25 degrees; rotation (R) 0-40 degrees, (L) 0-28 degrees; sidebending (E ) 0- :30 degrees, (L) 0- 22 degrees Thoracolumbar: flexion to floor with lumbar> hip motion, pain elicited at initial and end range; extension, rotation , and sidebending all mUdly decreased with guarding Muscle length: Shortened hamstrings; shOltened gastroc!soleus ; shortened two joint hip flexors; shortened pectoralis major and minor; lengthened middle and lower trapezius; shortened latissimus dorsi

Strength Testing: Upper trapezius (B) .5/5; middle trapezius (R) :3-/5, (L) 215; lower trapezius (B) 21,5; sternocleidomastoid (E)

2-/5, (L) 2+/5; trunk curl :3-/5; leg lowering 2/5; gluteus maximus (B) :3+/5; gluteus medius (R) :3-/,5, (L) :3/5; iliopsoas (B)

3+15; quads (R) 4/.5, (L) 4-/5; hamshings (R) 4+/5, (L) 4-/5

Surface Electromyography: Elevated resting muscle tension prevalent (temporalis, upper trapezius, sternocleidomastoid,

lumbar paraspinals); same groups demonstrate erratic and asymmetric recruitment \\~th static and active range of motion

testing

Palpation: Tender to light pressure in subOCcipital region, medial upper trapezius, sternocleidomastoid Oligin and insertion Ii.

> L, interscapular region, ilnterior thigh and postelior iliac crest

E VA L UA T ION: Diffuse soft: tissue and muscle pain , weakness, and fatigue Impairment • Multifocal soft-tissue pain, aggra­ vated with activity • Profound muscle fatigue • Abnoflllal static and d~'1ullnic muscle tension and recruitment patterns, generally elevated • ~Iild diffuse loss of active phYSiolOgiC range of motion, especially spine and hips

Functionsl Limitation

Disability

• • • •

• Unable to play on the noor with children • Unable to toIlerate sexual intercourse • Unable to return to work as labor
Unable to sit > 10 minutes Unable to stand> 1,5 minutes Unable to walk> 1/2 mile Unable to lift > 10 pounds frolll floor height

oI A G NOS IS:

Chronic pain of fibromyalgia with secondary weakness, fatigue, loss of motion , and abnormal motor recruitment

PROGNOSIS

Short-Term Goals (6-8 weeks) l. Ambulate 1.5 minutes twice per day \\;thout residual symptoms 2. Lift 20 pounds from floor height 3. Static lift 20 pounds for 3 minutes

C

Long-Term Goals (1 year)

l. Retum to work part time 2. Continuous ambulation for :30-40 minutes without residual pain or fatigue

. I

CASE STUDY #8

George is a 35-year-old computer data entry specialist with a 9-month history of multiple complaints, including interscapular pain, head and neck pain with associated headaches, and right (R) lateral forearm pain. No specific traumatic event p~eceded these syTnptoms, although they have progressively worsened over the last couple months such that they now interfere with his ability to \\'ork. His

. employer completed a workstation assessment several months ago and proVided stnte-of~the-art ollice equipment, but tllis has provided no Significant relie f of George's symptoms. Typically, he can spend several uninterrupted hours on the computer without awareness of time passed. A typical work week is 60 hours. George is moderately obese and admits to a sedentary lifestyle.

746

Therapeutic Exercise Moving Toward Function

EXAMINATION Posture/Alignment Forward head, elevated shoulders L > R, excessive lumbar lordosis with anterior pelvic tilt. Scapulae excessively abducted and downw'ardly rotated L > R. Cubital fossa Oliented medially bilaterally. Laterally rotated felllllfs with hjpcrextended knees in poshLral knock-knees Active Range 01 Motion: Cervical: flexion 0-25 degrees; extension {}-GO degrees, pain elicited; rotation (R) 0-55 degrees, (L) 0-60 degrees; sidebend (R) 0-35 degrees. (L) 0-15 degrees Shoulder: forward fle"ion (R) 0-120 degrees, (L) 0-140 degrees; extension (R) 0-30 degrees, (Ll 0-45 degrees; external rotation (R) 0-35 degrees, (L) 0-50 degrees Hip: hip external rotation (8) 0-45 degrees. internal rotation (B) 0-10 degrees Muscle Length: Shortened latissimus dorsi; lengthened rhomboids and mid-lower trapezius; shortened pectoralis major Strength Testing: Serratus anterior 3/5; rhomboid major 415; upper trapezius 5/S; middle and lower trapezius 1-215; infraspinatus/teres minor 415; anterior/middle deltoid .5/5; biceps (R) 4-/.5, (L) .j/.5; triceps (B) .j/.j; flexor carpi radialis/ulnmis (R) 415. (L ) 5/5; extensor carpi radialis longus bre\is (R) 3+/5, pain elicited, (L) 5/5; pronator teres/supinator (R) 4-/5, (L) ,j/,j; trunk cur!3/S; leg lowering 2/.5: iliopsoas (R) 3+/.5, (L) 4/5 Accessory Motion Testing: Cervical: L> R hypo mobile posterior/anterior and rotation segmental testing at Cl/2 and C2I3; shoulder girdle: decreased anterior/inferior glenohumeral glides; decreased scapulothoracic inferior glide and downward rotation; excessive scapulothoracic lateral glide and upward rotation Palpation: Suboccipital region moderately tender; diffusely tender interscapular L > R; tende r R lateral epicondyle Deep Tendon Reflexes: Biceps (H) 1+, (Ll 2+; triceps 2+ and symmetric Sensation: Di minished light touclr R lateral forearm and thumb

EVA LU AT ION: Chronic postural malalignment resulting in multifocal postural and movement dysfunction most e\'ident in overstretched and weakened scapular stabilizers and upper cervical segmental h)1Jol11obility; subsequent musculoskeletal pain and headaches; subacute overuse injury to R wlist extensor group

Impairment

Functional Limitation

Oisability

• Uppe r cenical, asymmetric face t joint motion dysfunction • Painful and shortened deep suboccipital extensors • Faulty shoulder girdle alignment • Overstretched and weakened shoul­ der girdle adductors, upward rota­ tors, and depressors • Postural muscle weakness and fa­ tigue • Pain and inflammation R extensor carpi radialis longus

• Unable to sit >:30 minutes • Daily headaches, limiting concentration • Difficulty keying \\'ith light hand be­ cause of forearm pain

• Unable to complete job requirements • Loss of job satisfaction

o

I A G NOS IS: Chronic grade 1 muscle strain of middle and lower tr'lpezius; upper cervical facet joint movement dysfunction and possible fIxed deformity; R extensor carpi radialis longus tendinitis

PROGNOSIS Short-Term Goals (2~ weeKS)

Long-Term Goals (6 months)

1. Reduce headache frequency and intensity by .50% 2. Increase sitting tolerance to 60 minutes, incorporating postural adjustments and short breaks

1. Reduce headache frequency and intensity by 75% to

100% 2. Return to baseline work level

Case Studies

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CAS EST U D Y # 9

.I

Janet is a 47-year-old nurse with primary complaints of posterolateral right (R) thigh pain. The pain is worse with weight bearing first tlting in the morning, gets better with limited activity, but worsens by the end of the day-

747

;._ I

especially if she has been on her feet quite a bit during the day. Secondary complaints include intermittent, dull low back pain and occasional bouts of sharp pain in the arch of her R foot.

EXAMINATION Posture and Alignment: Thoracic k")phosis, lnmbar lordosis, posterior pelvic tilt with anterior displacement of pelvis over base of support; elevated iliac crest R > L; medially rotated femurs R > L; laterally rotated tibias R > L; foot pronation H > L

Active Range of Motion: Hip internal rotation

O~5.5

degrees, external rotation 0-30 degrees; thoracolumbar f1exion full and pain

free with reversal of lumbar lordosis

Muscle length: Shortened tensor fascia lata/iliotibial band (TFLJITB) with end-range stretch pain; shortened hamstrings (medial> lateral); sh rtened gastroc!soleus

Strength Testing: Leg lowering 215; tnlllk curl 4/.5; gluteus medius (R) 2+/5, (L) 3/5; gluteus maximus (R) 3/3, (L) 3+/5; TFL (R) 3+/5 (pain elicited), (L) 4/5; iliopsoas (R) 2+/5, (L) :3/.5; quadliceps (R) 4-/5, (L) 4+/.5; hamstlings (R) 4+/.5, (L) 4 +/3; posterior tibiali (B) 5/5 (R > L muscle fatigue )

Accessory Motion Testing: Hypermobile posterior/anterior glides TlO-L2 with relative hypomobility of lower lumbar segments ; hypo mobile dorsal glide great toe R > L

Movement Testing: Single-leg stance (R ) with pain and excessive medial rotation of ft~mur ; decreased pain when femur helJ in lateral rotation Gait Positive Tr ndelenburg (R), medial rotation of femur midstance (R), excessive foot pronation early and late stance R > L

Palpation: Tender along R ITB; slight tenderness to deep palpation of plantar fascia at calcaneus OIigin

EVAl UAT ION: Acute, eaSily initable pain arising from R ITB resulting from compensatory TFL patterns associated with weakness and length-tension imbalance ofTFL synergists; intermittent bouts of foot pain arising from plantar fascia, excessive pronation, and great toe hypomobility, currently nonsymptomatic Impairment • Po ·tural alignment fault of posterior pelvic tilt, medially rotated femur, and foot pronation • Mu cle weakness of tensor fa~cia lata synergists, including gluteus medius, iliopsoas, and quadriceps • Shortened iliotibial band • Lengthened gluteus medius • Faulty movemen t patterns during

gait

Functionsl Limitstio.'I • Unable to walk 20 minutes without onset of R leg pain

Disability • Unable to pe rform all job requirements for full 8-hour shift • Unable to walk for fitness • Difficulty performing household tasks hecause of leg pain

D I A G NOS IS: ITB fascitis and intermittent plantar fascitis

PROGNOSIS Short- Term Goals (4-6 weeks) 1. Perform light duty work 40 hours per week 2. Walk 1.5 miles per day, paced at 20 minutes per mile, without leg or foot pain 3. Perfonn housework without leg pain if paced at 30- to 40minute work intervals

Long-Term Goals (12-16 weeks) 1. Resume full duty work at 40 hours per week 2. Walk:3 miles per day, paced at 20 minutes per mile, without leg or foot pain :3. Perform all housework without limitations

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Therapeutic Exercise Moving Toward Function

CASE STUDY #10

Pete is a 38-year-old man with complaints of right (R) shoulder and hip pain. He fell onto his R shoulder 6 months ago. He complains of clicking and instability. particularly during movements of hand behind back. He also has impingement pain at the middle to end range of arm elevation . He is an avid nmner (30-40 miles per week) and

has posterior, superior, and medial hip pain after about 2 miles of running. The hip pain resolves about 4.'5-60 minutes after the run. His occupation requires prolonged sitting at a computer, and he has increased hip pain after 45-60 minutes of sitting. His shoulder also begins to ache after approximately the same time period.

EXAMINATION Alignment Slight forward head and head tilt to left (L); R head of humerus slightly anterior displaced; R scapula in moderate depression , tilt, downward rotation, adduction; R iliac crest elevated relative to left; R femur adducted and in slight medial rotation relative to L; R tibia slightly laterally rotated; R foot in slight abduction and pronation. Total body posture is a classic swayback. Sitting alignment is with pelvis in posterior tilt and R trunk sidebending with R scapula depressed, downwardly rotated. and tilted Gait: At loading response, H tnmk is in R sidebending with R scapula depressed, downwardly rotated, and adducted; throughout R stance phase, the pelvis demonstrates a compensated Trendelenburg on the light; throughout swing phase on the L, tlle pehis moves in excessive R forward rotation (clockwise approximately 12 degrees); foot mechanics appear unremarkable \\ith exception of slight excessive supination at terminal stance

lumbar and Cervical Scan Examinations: Negative for reproduction of symptoms or neurologic signs Range of Motion: Right shoulder: flexion 0-1.'50 degrees, scaption 0-1.50 degrees, lateral rotation/medial rotation (with arm abducted 90 deg,ees) 90-40 degrees Right hip: flexion/extension 95-10 degrees, abduction/adduction 30-5 degrees, lateraVmedial rotation (prone) ,'50-20 degrees Thoracic rotation : 25% limitation light rotation Scapulohumeral Rhythm: During ann elevation, scapula is slow to upwardly rotate; most of rotation occurs in last phase of ann elevation; reduced overall scapulothoracic (ST) upward rotation on R relative to L; scapular winging on return from elevation Muscle Length: Moderate shortness in right medial hamstlings, R tensor fascia lata/iliotibial band (TFUITB), excessive length of R iliopsoas. moderate shortness in R rhomboid, Significant shortness in (R) infraspinatus/teres minor, excessive length in R trapezius and serratus anterior Strength Testing (short-range positional strength): Gluteus medius (R) 3+/.'5, (L) 4+/5; gluteus maximus (R) 4-/,'5, (L) 4+,'5; iliopsoas (R) 3/5, (L) 4/,5; medial hamstrings (R) 4-/,'5 (pain elicited), (L) ,'5/5; adductors (H) 4-/,5 (pain elicited), (L) 5/.5; hip lateral rotators (R) 3+/5, (L) 4+/5; subscapulmis (R) .3+/.'5, (L) 4+/5; infraspinatus/teres minor (R)I(L) ,'5/5; upper trapezius (R) 4-15, (L) 5/5; middle trapezius (R) .3+/5, (L) 4/5; lower trapezius (H) 3+/.5, (L) 4/5; serratus anterior (R) 3-/5, (L) 4/5; trunk curl 515; leg lowering 3/5 Joint Mobility: Moderate restJiction in glenohumeral (GH) posterior and infelior glide (capsular end feel, pain after resistance), moderate excessive mobility in GH antelior glide (capsular end feel); moderate restriction in ST upward rotation (muscular end feel), and acromioclavicular joint antelior glide (capsular end feel); moderate restJiction in hip posterior and inferior glide (capsular end feel, pain after resistance) Resisted Tests: 'Veak and painful R medial hamstrings, adductors, and subscapulmis Special Tests: Positive apprehension and relocation signs R shoulder, positive impingement sign for R shoulder, positive slump test R lower extremity (pain reproduced in posterior, superior, and medial hip)

Case Studies

749

Palpation: Tenderness over subscapularis and supraspinatus insertions; tenderness in region of medial ischial tuberosity and

inferior pubic ramus

Functional TeS1s; Pain and apprehension with reaching R hand behind back; painful arc with touching R hand to head; during hand behind back mane uver, R scapula fails to adduct, and humeral head translates excessively anteriorly when compared with L. Step-up illustrate hip hike with hip flexion phase on R and compensated R Trendelenburg with R stance limb; squats reveal asymmetrical hip flexion with R hip hike at end range

EV A l U A T ION: Chronic strain to R hamstring and adductor muscles; chronic strain to R subscapularis; impingement R shoulder; questionable R shoulder instability

Impairment

Functional Limitation

Disability

• Locahed pain R antelior and supe­ rior shoulder and right hip • H~'Permobility/in tability(?) of R shoulder • Cap 'ular restriction R hip • Short ST downward rotators, GH lat­ eral rotators, medial hamstrings , TFUITB, R adductors • Long ST upward rotators, subscapu­ laris, iliopsoas • Thoracit spine, GH, ST, hip joint re­ strictions • Weakness in R houlder upward rota­ tors, subscapularis, gluteus medius, gluteus ma.ximus , iliopsoas, hip lat­ eral rotators

• Unable to reach R hand behind back or overhead without discomfort or unstable feeling • Unable to sit, climb more than .5 flights of stairs, or run 2 miles without light hip discomfort

• Unable to sit at computer for Jllore than 4.5-60 minutes at a time at work • Unable to palticipate in recreational acti\ity of running at desired level

oI A GNOS IS: R shoulder impingement and hypermobility and instability; R subscapularis strain; R medial hamstIings and adductor magnus strain with secondcuy sciatic nerve injury or entrapment. Need to rule out R glenOid labrum tear and long thoracic nerve injmy, which may have occurred during the fall. PROGNOSIS Short- Tenn Goals (2-3 months) 1. Elevate R ann through full range of IlIotion and reach behind back without pain or instability 2. Si t 45 min utes without R hip pain 3. Clim b.5 flights of stairs withont R hip pain 4. Run 15 miles per week "ithollt increased R hip pain

CO

Long-Term Goals (6-8 months) 1. Unlimited use of right arm without pain or instability 2. Sit unlimited periods (in good alignment) without R hip pain 3. Climb up to 10 flights of stairs \\ithout R hip pain 4. Run 30 miles per week \dthout R hip pain

PlETE INTERVENTION

A complete intervention for this case study tallows on the next few pages: Complete Intervention: Lower Quadrant and Complete Intervention: Upper Quadrant.

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Therapeutic Exercise: Moving Toward Function

, t:::\

~

" COMPLETE INTERVENTION-LOWER QUADRANT For Case Study #1 0

Following is a comprehensive exercise program for lower

quadrant intervention for Pete. It is prescribed in the first

week.

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, gait, and running without

AT WEEK 1

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen

ACTIVITY: Hand-knee rocking (see Self-Management 20-6 in Chapter 20).

PURPOSE: To improve the flexibility of the hips, stretch the

posterior hip muscles, and train independent movement

hetween the hips, pehis, and spine.

RISK FACTORS: Watch for symmetry when rod.ing backward. ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base. STAGE OF MOTOR CONTROL: :vIobility. MODE: Passive movement exclusively of the hips. POSTURE: Hands and knees \\·i th hips directly over the knees

and shoulders directly over the hands. Hip joints should be

at a gO-degree angle. Knees and ankles are hip-\\idth apart

with feet pointing straight back. Hands shoulder-\\idth apart

with hands pointing straight forward. Keep a slight extension

curve in the low back.

asymmetric pattern.

to improve hip flexion mobility resulting from reduced extensibility in the capsule, ligament, muscle, or myofascial stiffness. For Pete to have a symmetric walking, stair­ climbing, and running pattern , hip mobility needs to be Wl\L hilaterally. It is assumed that the stiffness in his right hip contributes to the hip hiking pattern and that this pattern contributes to the upper qumter asymmetry as well. To recover from both lower and upper quarter ('onditions, hip mobility impairment should be resolved.

ACTIVITY: Iliopsoas strengthening (see Self-Management 20­ 5, level I, in Chapter 20). PURPOSE: Iliopsoas neuromuscular education to promote recruitment in the shortened range with hip flexion.

RISK FACTORS: Ensure use of iliopsoas and not TFL or RF recruitment. Watch for hip hiking on the right.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base and modulator.

MOVEMENT: First set inner core (see Patient-Related

STAGE OF MOTOR CONTROL: Ylobility.

Instruction 18-1 in Chapter 18 ). The patient is instructed to

rock backward at the hip joint only, stopping hefore onset of

back movement.

MODE: Isometric iliopsoas contraction.

SPECIAL CONSIDERATIONS: Motion at the hips should be independent from the lumbopehic region.

DOSAGE Special Considerations Anatomic: Hip joints, not the lumbopelvic region Physiologic: Asymmetric hip stiffness at end range hip flexion Learning Capability: Ingrained movement pattern of hip hiking \\ith functional acthities; may require high repetitions and Significant feedback in early stages of learning Repetitions/sets: 30 repetitions, 1 set Frequency: 7 days per week Sequence: Begin with this exercise, followed by the open kinetic chain strengthening exercises. Speed; Slowly to monitor accessory lumbopelvic movements Environment At home on a flat, firm surface, initially, in front of a mirror ­ Feedback: Initially in the clinic with clinician proViding tactile and verbal feedback and a mirror providing visual feedback. Begin with knowledge of performance for every repetition then tape r every :3-4 repetitions with knowledge of results.

POSTURE: Seated with unilateral hip flexion and slight hip lateral rotation. MOVEMENT: First set inner core. The patient paSSively flexes the hip into end range flexion with slight lateral rotation. Avoidallce of hip hike or lumbar flexion is critical. The patient simply holds the limb without any resistance provided.

SPECIAL CONSIDERATIONS: Hip medial rotation will recruit the dominant hip flexor muscle, tensor fascia lata, over the iliopsoas contributing to further shortening of the IT ba))(1. Hip hiking will contribute to lateral pelViC tilt versus hip flexion and should be avoided.

DOSAGE Special Considerations Anatomic: Right iliopsoas, right hip joint Physiologic: Length associated changes in strength; stronger in the lengthened range than the shortened range Learning Capability: Very ingrained move ment pattern from a long history of high-mileage running; may require high repetitions and Significant feedback in early stages of learning Repetitions/sets: To form fatigue , pain , or 20-30 repetitions, up to 3 sets Frequency: 6-7 days per week

Case Studies

Sequence: After quadruped rocking

Repetitions/sets: To form fatigue, pain . or 20--.30 repetitions

Speed: Hold for 10 seconds

Frequency: 6--7 days per week

Environment At home on a firm surface

Sequence: After quadruped rocking

Feedback: Initially in dinic with clinician providing tactile

Speed: Slowly

and verbal feedback. Begin with knowledge of performance for every repetition then taper eve I)' 3-4 repetitions with knowledge of results.

Environment At home on a firm surface Feedback: Initially in clinic with clinician providing tactile and verbal feedba<.:k. Begin with knowledge of performance for every repetition then tape r every couple repetitions with knowledge of results.

FUNCTIONAL MOVEMENT PATIERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, gait, and running. RATIONALE FOR EXERCISE CHOICE: This exe rcise was chosen to improve muscle performance amI motor control strategies of hip fl exor muscles. Hip flexion without contributing to IT band shortening or hip hiking patterns depends on proper recruitment of the iliopsoa~ muscle in th e shOliened range. This method of neuromuscular re-education is necessary be fore translating to dynamic activity and fUllction.

ACTIVITY: Stom,lch lying gluteus medius strengthening (see Self-Management 20-4, level I, in Chapter 20).

PURPOSE: Gluteus medius muscle strengthening in the shOliened range. RISK FACTORS: Medial hamstring and adductor magnm strain. ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base .

FUNCTIONAL MOVEMENT PATIERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, gait, and runniug. RATIONALE FOR EXERCISE CHOICE: This exercise was cho­ sen to improve motor control strategies and strength of glu­ teus medius , ancl gluteus maximus muscle~. Lllmbopelvic stability and IT band extensibility depends on proper re­ cruitment of the gluteus lTledius muscle throughout the range. This method of neuromuscular re -education and strengthening is necessary be fore returning to functional activities. AT3WEEKS ACTIVITY: Iliopsoas strengthening (see Self-Management 20­ 5, level 2, in Chapter 20).

PURPOSE: Iliopsoas strengthening to improve muscle balance of hip flexor lTluscles.

STAGE OF MOTOR CONTROL: Mobility. RISK FACTORS: Watch for TFL substitution or lateral pelviC MODE: Concentric and eccentric gluteus medius contractions.

tilt.

POSTURE: Stomach lying \\ith a pillow under the pelViS if indicated by the physical therapist. Legs should be in line with hips and slightly rotated outward.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base.

MOVEMENT: First set inner core. Next pe rform an isometric contraction of the gluteus maximus . Slightly lift the leg into extension and abduction until lateral tilt is seen. Stop just short of lateral tilt of the pelViS. Hold at end range. Ensure the knee remains slightly rotated laterally.

STAGE OF MOTOR CONTHOL: Mobility. MODE: Resistive isome tlic iliopsoas contraction. POSTURE: Sitting \\ith unilate ral hip flexion and slight hip lateral rotation. MOVEMENT: First set inne r core. The patient paSSively flexes

SPECIAL CONSIDERATIONS: Keep th e lumbopelvic region stable using the inner core. Hold slight hip lateral rotation throughout the range to avoid tensor fascia lata muscle recruitment. Recmit the gluteus maximus and rela,x the hamstring muscles.

the hip as far as possible while maintaining neutral lumbopelvic position. Next, the patient holds the position and provides gentle resistance to the hip in the direction of extension and slight lateral rotation. The contraction should be isometric.

DOSAGE

SPECIAL CONSIDERATIONS: Hip medial rotation will recruit

Special Considerations

the dominant hip flexor muscle, tensor fascia lata, over the iliopsoas contlibuting to further shortening of the IT band.

Anatomic: Right gluteus medius, right hip joint Physiologic: Length associated changes in strength; stronger in the lengthened range than the shOliened range

Learning Capability; May be difficult secondaJ)' to capsular restrictions. Ingrained muscle recruitment pattern of the tensor fascia lata muscle and lateral trunk muscles from a long history of high-mileage running; may require high repetitions and Significant feedback in early stages of learning

DOSAGE

Special Considerations Anatomic: Right iliopsoas, light hip joint Physiologic: Length associated changes in strength; stronger in the lengthened range than the shortened range Learning Capability: Very ingrained recruitment pattern from a long history of high-mileage nlllning;

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Therapeutic Exercise Moving Toward Function

may require high repetitions and significant feedback in early stages of leaming

DOSAGE Special Considerations

Repetitions/sets: To form fatigue, pain, or 15 repetitions , up to 3 sets

Anatomic: Right gluteus medius, light hip joint

Frequency: 3-4 days per week

Physiologic: Length associated changes ill strength; stronger in the lengthened range than the shortened I-ange

Sequence: After quadruped rocking Speed: Hold for 10 seconds Environment: At home on a firm surface Feedback: Initially in clinic with clinician providing tactile and verbal feedback. Begin \\~th knowledge of pel{ormance for every repetition then taper evel), 3-4 repetitions with knowledge of results.

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, gait and running. RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve strength of iliopsoas muscle. This is the progression from isometric hold without resistance. Hip flexioll \\~thout contlibuting to IT band shortening df'pends on proper recruitment of the iliopsoas muscle in the shOltened range. Iliopsoas strengthening decreases tellsor fascia lata muscle dominance during dYllalllic activity and function . ACTIVITY: Sidelying glutens medius strengthening (sec Self­ Management 20-4, level 4, in Chapter 20).

PURPOSE: Gluteus medius muscle strengthening in the shortened range.

RISK FACTORS:

~Iedial

hamstring and adductor magnus

strain.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base. STAGE OF MOTOR CONTROL:

~'Iobility/stahility .

MODE: Concentric and eccentric gluteus medius contractions.

POSTURE: Sidel).i ng against a wall with a slllall towel roll behind the superior gluteal. The towel roll ensures the hip slides up the wall in slight extellSion. Superior hip should be slightly laterally rotated. MOVEMENT: First set inner core . Slide the leg up the wall, keeping the heel in contact with the wall to ensure hip extension, to end range. Stop before lateral pelviC tilt. Hold at end range. Be sure the hip stays laterally rotated.

SPECIAL CONSIDERATIONS: Keep the lumbopehic region stable using the inner core to pre\'ent lateral pehic tilt. Hold slight hip lateral rotation and extension throughout the nlllge to avoid tellsor fascia lata muscle recruitment.

Learning CBpBbility: May be difficult seeondary to capsular restlictions. Ingrained muscle recruitment pattern of the tensor fascia lata muscle from a long histOl)' of high-mileage nmning; may require high repetitions and Significant fef'dback in early stages of leallling Repetitions/sets: To form fatigue , pain , or 6-8 repetitions Frequency: 3-4 days per week Sequence: After iliopsoas strengthening Speed: Slowly Environment At home on a firm surface Feedback: Initially in clinic with clinician prodding tactile and verbal feedback. Begin with knowledge of performance for every repetition, thell taper every couple repetitions \\ith knowledge of results.

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, gait, and running. RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve strength of the gluteus medius muscle. Lumbopehic stability and IT band extenSibility depends on proper recruitment of the gluteus medius muscle throughout the range . Open kinetic chain gluteus medius strengthening is necessary before transfening to d)~lamic acthity and function.

ACTIVITY: Squats (see Self-Management 20-8 in Chapter 20). PURPOSE: Strengthen hip girdle Illuseles and train independent movement between hips and spine in a functional contf'xt. RISK FACTORS: Watch for spnmetric loading between extremities.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base and modulator.

STAGE OF MOTOR CONTROL: Controlled mobility. MODE: ConcentIic and eccentJic hip girdle muscle contractions. POSTURE: Standing \\ith weight e(]lIally distlibuted between both feet, and pehis and spine in neutral in front of a full­ length mirror.

Case Studies

MOVEMENT: First set inner core. Slowly bend your hips and knees. Return to the start position by using quadliceps and gluteals.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base and modulator. STAGE OF MOTOR CONTROL: Controlled mobility.

SPECIAL CONSIDERATIONS: Knees should not flex beyond the length of the feet or medial to the second toes. More emphasis should be placed on gluteal muscles versus hamstJing muscles. Keep the lumbopelvic region stable and be nd through the hips with equal loading and avoidance of lateral pelvic tilt. DOSAGE Special Considerations Anatomic: Bilateral hip girdle muscles, bilateral hip joints Physiologic: Length-associated changes in eccenhic and concentlic strength and asymmehic mobility in hips L.eaming Capability: Very ingrained movement pattern frolll a long history of high-mileage running; may require high repetitions and Significant feedback in early stages of learning Repetitions/sets: To form fatigue , pain, or 20-30

repetitions

Frequency: 6-7 days per week Sequence: After gluteus medius strengthening Speed: Slowly Environment: At home ,\ith or without a chair, depending on strength Feedback: Initially in clinic with clinician providing tactile and verbal feedback and mirror providing visual feedback. Taper to continued use of mirror, with knowledge of results of verbal feedback after every 3-4 repetitions. Withdraw mirror and verbally prOVide knowledge of results every 3-4 repetitions.

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, sit to stand, walking, and running. RATIONALE FOR EXERCISE CHOICE: This functional exercise was chosen to improve strength of hip girdle muscles and hip joint mobility. Improved hip joint mobility and force­ generating capability of the gluteus maximus enables increased hip fle>.ion and decreased knee flexion duling squatting activities. Squats with shared forces at the hip and knee decrease excessive forces at the low back and knee. ACTIVITY: Step ups. (see Self-Management 20-3) PURPOSE: Incorporate proper total-bod), movements in a functional context. RISK FACTORS: Avoid hip hike patterns and hamstling dominance.

MODE: Conce ntric and eccentric hip girdle muscle contractions. POSTURE: Standing in front of a 6-inch step in front of a mirror. MOVEMENT: First set inner core. Lift the light leg onto the step. Step up. SPECIAL CONSIDERATIONS: Be sure the patient cloes not hike his light hip during the hip flexion phase or perform a Trendelenburg pattern during hip extension phase. The pehis must remain level and stable throughout the entire exercise to adequately recruit iliopsoas dming hip flexion and prepare to use gluteus ma.,irnus ancl gluteus medius muscles in their proper le ngth-tension propclties duling hip extension. DOSAGE Special Considerations Anatomic: Right hamstIing and adductor Physiologic: Chronic moderate strain Learning Capability: Very ingrained movement pattei'll from a long history of high-mileage running; may require high repetitions and significant feedback in early stages of learning

Repetitions/sets:To form fatigue as evidenced by hip hike. pain, or 20-30 repetitions, up to 3 sets Frequency: 6-7 days per week Sequence: Perform after specific exercises for psoas and gluteus medius muscle performance and squats. Speed: Slow progressed to functional speed Environment: At home in fi'ont of a mirror Feedback: Initially in clinic with clinician proViding tactile and verbal feedback and mirror providing visual feedback. Taper to continued use of mirror, with knowledge of results of verbal feedback after every 3-4 repetitions. Withdraw mirror and verbally provide Imowledge of results every 3-4 repetitions. Progress toward skill.

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Ascending stairs, walking, running. RATIONALE FOR EXERCISE CHOICE: This functional exercise was chosen to replace the faulty movement with one that is correct. Faulty hip hiking does not emphaSize hip flexion and efficient recruitment of the gluteus ma.ximllS and medius muscles. Trendelenburg pattern does not emphaSize lumbopelvic stability. Correct step-up pattern encourages gluteus maximus and quadliceps recruitment over hamstring and gluteus medius recruitment over TFL or adductors.

753

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Therapeutic Exercise: Moving Toward Function

1':::'\

COMPLETE INTERVENTION-UPPER QUADRANT

~

For Case Stu dy #10

Following is a comprehensive exercise program for upper

quadrant intervention for Peter. It is presclibed in week.3

post initial evaluation.

RATIONALE FOR EXERCISE CHOICE: This stretch was chosen

AT WEEK 3

to improve tile length of the shoulder lateral rotators. Sufficient shoulder medial rotation is needed for optimal glenohumeral congruency alId to prevent antelior displacenwnt of the humeral head.

ACTIVITY: Sidelying lateral rotator and postelior capsule

ACTIVITY; Supine glenohumeral lateral and medial rotation.

stretch. (see Self-I'vlanagement 26-4)

PURPOSE: Develop motor control strategy of the rotator cuff PURPOSE: To lengthen lateral rotators of the shoulder.

musc:les for ideal PICR of the glenohumeral joint.

RISK FACTORS: None.

RISK FACTORS: Chronic subscapulalis strain and tendinitis.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Base.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Modulator and biomechanical.

STAGE OF MOTOR CONTROL: Mobilitv. STAGE OF MOTOR CONTROL

~vlobility.

MODE: Contract-rela" of the shoulder lateral rotators. MODE: ConcentIic and eccelltIic rotator cuff contractions. POSTURE: Sidelying with bottom ann elevated to 90 degrees and elbow flexed to 90 degrees.

MOVEMENT: Shoulder joint should rotate allowing your

L)~ng supine \\~th arm abducted to 90 degrees and elbow flexed to 90 degrees on an even, stable surface. Right scapular spine should lie at the level of the second veliebra.

POSTURE:

forearm to move toward your feet and the floor. At that pOint, lightly press up int'o the resistance of the other hand and hold for 6-10 seconds. Relax and gently push the bottom forearm further toward your feet and the floor. Repeat :3-4 times.

MOVEMENT: Slowly rotate arm so that your forearm moves

SPECIAL CONSIDERATIONS; Scapula should be entirely on

SPECIAL CONSIDERATIONS: The arm should move

your back rather than under your bod)' to target the lateral

rotators. If the scapula slips under your body, scapular

adductors will stretch instead.

independently from the scapula spinning in its socket. The scapula should not displace forward or depress nor should the humeral head displace forward from the socket.

DOSAGE

DOSAGE Special Considerations

Special Considerations

back toward your head, then in the opposite direction so the forearm moves forward.

Anatomic: Right shoulder lateral rotators.

Anatomic: Right medial ancllateral rotator cuff

Physiologic: Short shoulder lateral rotators. Length­

ll1usc:les, light glenohumeral joint

associated changes in strength; stronger in the shortened range than the lengthened range.

Physiologic: Chronic moderate strain and tendinitis, questionable instability of the light glenohumeral joint

Learning Capability: Good with specific verbal and

Learning Capability: Very ingrained movement pattern

visual instructions.

from a long history of high-mileage 1111lning; may require high repetitions and significant feedback in early stages of learning

Repetitions/sets: 3-4 repetitions; 2 sets Frequency: 3-5 times per day, 7 days per week

Repetitions/sets: To form fatigue, pain, or 20-30

Sequence: Begin with this stretch followed by the rest of

repetitions, up to 3 sets

the exercises.

Frequency: 6-i days per week

Speed: Hold for 6-10 seconds Environment At home on a firm surface Feedback: Initially in clinic with clinician providing verbal, \~sual , and tactile feedback. Begin \dth knowledge of performance for every repetition, then taper every other repetition \dth knowledge of results.

Sequence: Begin \dth this exercise followed by the wall slide \dth subscapulalis bias and muscle performance exercise of the serratus antelior. Speed: Slowly for good-quality movement. Environment: At home on the floor or firm bed. Feedback: Initially in c:linic \\~th c:linician providing tactile

FUNCTIONAL MOVEMENT PATIERN TO REINFORCE GOAL OF EXERCISE: Reaching overhead \\~thout discomfort or unstable feeling.

and verbal feedback. Begin with knowledge of perfomlance for every repetition then taper every 3-4 repetitions \\~th knowledge of results.

Case Studies

FUNCTIONAL MOVEMENT PAmRN TO REINFORCE GOAL OF EXERCISE: Reaching behind the back without discomfort or

performance for every repe tition then taper every :)-4 repetitions with knowledge of results.

unstable feeling.

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve motor control strategies of sllOulder medial and late ral rotators. Independe nt move ment of the glenohumeral joint with ideal PICR is the goal rather than faulty compensatory scapulothoracic movement.

ACTIVITY: Right ann wall slide with medial rotation bias. (see Fig. 26-11C ) PURPOSE: Develop motor control strategy to encourage rotator cuff activation speCifically the subscapularis as opposed to pectoralis major, latissimus dorsi, and teres major muscles for ideal PICR of the glenohumeral jOint. RISK FACTORS: Chronic subscapulaJis strain. ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Modulator

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Reaching overhead and behind th e back without discomfOlt or unstable feeling.

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve motor control strategies of shoulde r medial rotators. Proper recruitment of the subscapularis muscle over other medial rotators provides dynamic anterior stability of the glenohumeral joint during djllamie actil~ty. It is important that the subscapulalis muscle is trained because of its antelior insertion close to the axis of rotation . ACTIVITY: Supine serratus anterior isometric. (see Self­ Manageme nt 26-3 level I)

PURPOSE: Serratus a!lterior ne uromuscular education to promote recruitment in the shortened range:' with scapular upward rotation.

and biomechanical.

STAGE OF MOTOR CONTROL: Controlled mobility. MODE: Isometric rotator cuff activation with subscapularis

RISK FACTORS: Impingement of rotator cuff tendons . ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Modulator.

bias.

STAGE OF MOTOR CONTROL: Mobility.

POSTURE: Standing with palm of the hand against the door frame . Hight scapular spine should lie at the level of the second ve rte bra.

MODE: Isometri<.: serratus anterior contraction.

MOVEMENT: Slide the hand upward and downward while maintaining mild pressure into medial rotation against the door frame . SPECIAL CONSIDERATIONS: More than mild pressure applied iuto medial rotation against the door fram e will recruit pectoralis major, latissimus dorsi, and teres major muscles instead of subscapulaJis causing anterior translation of th e humeral head. DOSAGE Special Considerations Anatomic: Hight subscapulaIis, right glenohumeral joint Physiologic: Chronic moderate strain and tendinitis, questionable instability of the right glenohumeral joint Learning Capsbility: Vel)' ingrain ed movement pattern from a long histOlY of high-mileage running; may require high repetitions and signifi<.:ant feedback in early stages of learning Repetitions/sets: To form fatigue , pain, or 20-30

repetitions, up to .3 sets

POSTURE: Supine \\~ th arm elevated resting on pillows placed above your head. MOVEMENT: Lightly press thumb into pillows engaging the selTatus anterior muscle. SPECIAL CONSIDERATIONS: ~·Iore than mild pressure applied into th e pillows will recruit muscles of the glenohumeral joint over tIl(-) se rratus anterior causing anterior translation of the hume ral head. DOSAGE Spet..ial Considerations Anatomic: Right serratus anterior, light

scapulothoracic joint

Physiologic: Length associated changes in strength; stronger in the lengthe ned range than the shortened range Le8rning C8pability: May be difficult secondary to painful arc. May require a less than desirable startillg point in the range

Repetitions/sets: To form fatigue, pain, or 20-30

repetitions, up to 3 sets

Frequency: 6-7 days per week

Frequency: 6-7 days pe r wee k

Sequence: After wall slides and glenohumeral rotation

Sequence: After glenohumeral rotation but before muscle pe rformance exercise of the se rratus anterior.

Speed: Hold for 10 seconds

Speed: Slowly for good-quality move ment. Environment: At home in a door fram e. Feedback: Initially in clinic with clinician prOViding tactile and verbal feedback. Begi n with knowledge of

Environment: At home on a firm surface Feedback: Initially in c1illic with clinician proViding tactil e and verbal feedback. Begin Illth knowl edge of pe rformance for eve ry repetition then tape r every .3-4 repetitions with knowledge of results.

155

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Therapeutic Exercise Moving Toward Function

FUNCTIONAL MOVEMENT PATIERN TO REINFORCE GOAl OF EXERCISE: Reaching overhead without discomfort or

performance for eve I)' repetition then taper evelY :3-4 repetitions with kllowledge of results.

unstable feeling.

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve motor control strategies of shoulder elevator muscles. Sufflcient scapular upward rotation depends on proper recruitment of the serratus antelior m1lscle in the shortened range with ann elevation. This method of neuromuscular re-education is neCf'SSal), before translating to dynamic activity and function.

AT3 WEEKS ACTIVITY: Stomach lying middle and lower trapezius

FUNCTIONAL MOVEMENT PATIERN TO REINFORCE GOAL OF EXERCISE: Reaching overhead without discomfort or unstable feeling.

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve motor control strategies of scapular stabiliZing muscles. Scapular upward rotation about a stable PICR depends on recruitment of the middle and lower trapezius muscles with ann elevation. This method of neuromuscular re-education is necessary before translating to d)11amic activity and function.

isometJic.

ACTIVITY: Prone glenohumeral lateral and medial rotation with l-Ib weight. (see Self-Management 26-1)

PURPOSE: Middle and lower trapezius neuromuscular education to hold the scapula in a position (If upward rotation.

PURPOSE: Develop motor control strategy of the rotator cuff

RISK FACTORS: I mpingement of rotator cuff tendons and

muscles and scapulothoracic muscles for ideal PIC R of the glenohumeral joint and scapula.

antelior displacement of the humeral head.

RISK FACTORS: Chronic suhscapulalis strain and tendinitis.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Modulator.

ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: \Iodulator

STAGE OF MOTOR CONTROL: Stability.

and biomechanical.

MODE: IsometJ1c middle and lower trapezius contraction.

STAGE OF MOTOR CONTROL: Controlled mobility.

(see SelPvlanagement 26-2 level I)

POSTURE: Stomach lying with both hands resting on the head. Good cervical and scapular alignment.

MOVEMENT: Barely lift your elbows keeping neck and upper trapezius muscles relaxed. Contract middle and lower trapezius muscles.

SPECIAL CONSIDERATIONS: Lifting elbows excessively will n~cruit postelior muscles of the glenohumeral joint and rhomboids causing anterior translation of the humeral head and scapular adduction, respectively.

POSTURE: Lying prone with arm abducted to 90 degrees and elbow flexed to 90 degrees on an even, stable surface. A towel roll should be placed under the antel10r shoulder joint. MOVEMENT: Slowly rotate ann so that vour forearm moves up toward your head, then in the oppo~ite direction so the forearm moves back toward your feet.

SPECIAL CONSIDERATIONS: The arm should move independent from the scapula spinning in its socket. The scapula should not displace forward nor should the humeral head displace forward from the socket.

DOSAGE Special Considerations Anatomic: Bilaterally middle and muscles, scapulothoracic jOint

MODE: ConcentJic and ecccntJic rotator Cliff contractions. Isometlic contractions of the middle and lower trapezius muscles.

10\\'1'1'

trapezius

Physiologic: Weak middle (}ndlower trapezius muscles, dominant rhomboids. Learning Capability: May he difficult secondalY to painful arc. ' , Repetitions/sets: To form hltigue. pain, or 20-30

repetitious, up to :3 sets

Frequency: 6-7 days per week Sequence: Begin with this exercise followed by stomach lying shoulder rotation and sidel)ing serratus (}ntelior exercises. Speed: Hold for 10 seeonds Environment: At home on a firm surface Feedback: Initially in clinic with clinician providing tadile and verbal feedhack. Begin with knowledge of

DOSAGE Special Considerations Anatomic: Right medial and lateral rotator eufT Illuscles. light glenohullleraljoint, light middle and lower trapeZius muscles, light scapula. Physiologic; Chronic moderate strain and tendinitis, questionable instability of the light glenohumeral joint Learning Capability: Very ingrained movement pattern from a long bistory of high-mileage running; may require high repetitions Repetitions/sets: To form fatigue, pain, or 6-8 repetitions with fatigue Frequency: 3-4 days per week Sequence: Begin with this exercise followed by the wall slide with sllbscapulal1s bias and muscle performance exercise of the serratus anteJior.

Case Studies

Speed: Slowly for good-quality movement. Environmtmt: At home on the 1100r or firm bed. Feedback: Initially in clinic with clinician providing tactile and verbal feedback. Begin with knowledge of performance for every repetition then taper every couple of repetitions with knowledge of results.

FUNcnONAl MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Reaching behind the back without discomfort or unstable feeling.

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve motor control strategies of scapular stabilizers and shoulder medial and lateral rotators. Independent movement of the glenohumeral joint with ideal PICR and a stable scapula are the goals.

lower the arm back down to the starting position against the resistance of the banel.

SPECIAL CONSIDERATIONS: Keep the scapula on your back upwardly rotating about a stable PICR. DOSAGE

Special Considerations Anatomic: Right serratus anterior, light

scapulothoracic joint

Physiologic: Faultv eccentric motor control of serratus anterior muscle. .

Learning Capability: Mav be difficult secondary to painful arc. May require a less than desirable ~tarting point in the range

ACTIVITY: Sidelving serratus anterior dvnamic contractions with resistive b~nd. (see Self-Managen~ent 26-:3 level II)

Repetitions/sets: To form fatigue, pain, or 6-8 repetitions Frequency::3-4 days per week

PURPOSE: Serratus anterior muscle strengthening

Sequence: After wall slides and glenohumeral rotation Speed: Slowly

throughout the range with scapular upward rotation.

RISK fACTORS: Impingement of rotator cuff tendons. ELEMENT OF MOVEMENT SYSTEM EMPHASIZED: Modulator and biomechanical.

Environment At home on a firm surface Feedback: Initially in clinic with clinician providing tactile and verbal feedback. Begin with knowledge of performance for every repetition then taper every couple of repetitions with knowledge of results.

STAGE OF MOTOR CONTROl: Controlled mobilitv. MOOE: Concentric and eccentric serratus anterior

FUNCTIONAL MOVEMENT PATTERN TO REINFORCE GOAL OF EXERCISE: Reaching overhead and behind the back without

contractions.

discomfOli or unstable feeling.

POSTURE: Sidelying with arm rested on pillows placed in front of vour head and shoulders. Resistive band is attached on the upper foot and the other end grasped in the resting hand.

RATIONALE FOR EXERCISE CHOICE: This exercise was chosen to improve motor control strategies and strength of shoulder elevator muscles. Sufficient scapular upward rotation depends on proper recruitment of the serratus antelior muscle throughout the rangc ",ith ann elevation. This method of neuromuscular re-education and strengthening is necessary before retllrning to functional activities.

MOVEMENT: Slide your arm upward toward your head, keeping it in contact with the pillows. On the return, slowly

C

CAS EST U 0 Y # 11

Mr. Lawn , a 67-year-old man, had a right (R) total hip replacement (THR) 4 years ago. He also has left (L) hip degenerative joint disease (DJD). For the last 4 months he has been noticing increasing L hip pain and is beginning to have pain in the R hip as well if he attempts to play more than 9 holes of golf. He states that 18 holes is usual, and he pulls his own cart. Recent muddy conditions seem to have made symptoms worse. His main concern is that R low back

--~- ,;

pain will be triggered by R hip pain, as it has been in the past. During the last episode of low back pain, he had to sleep sitting up in his chair, because it was the only place he could get comfortable. "'fr. Lawn lives with his wife, who is in the early stages of Alzheimer's disease, and his golf games are his main social contact with friends. He is otherwise healthy and does all the driving, shopping, and housework.

EXAMINATION Pain: L hip at rest 2110, after 18 holes of golf 7110; R hip at rest

1110, after golf :3/10; R low back at rest 0/10, after golf 1/10

Posture: In standing: bilateral (B) supinated feet; marked B tibial bOWing; B femoral internal rotation; high L iliac crest; anterior tilted pelViS; mild hip flexion; supine apparent short R leg; R iliac crest and ischial tuberosity high compared with L

757

758

Therapeutic Exercise Moving Toward Function

Gait: Marked B trunk sidebend to side of stance leg, decreased hip and knee flexion; slight circumduction B; decreased pronation B feet; R stance time decreased compared \\ith L Active Range of Motion (open chain): Hhip Extension/flexion Intemal/eAternal rotation Abduction Knee flexion/extension Lumbar flexion Lumbar extension

5-UO degrees 20-25 degrees .30 degrees 2-125 B degrees Hands 4 inches below kTlees 25% normal range (pain)

Lhip 5-11.'5 degrees (pain) 20-15 degrees (pain) 20 degrees

Accessory Motion: L Hip: hypomobile in distal glide, capsular tightness in internal and external passive rotation. Lumbar spine: extension and right sidebend with overpressure restricted and painful compared with L Palpation: B rectus fpmoris, iliopsoas, hip adductors, and R quadratus lumborum dense/tender Strength Testing; Reetus femoris (B) .515; iliopsoas (R) 4-/5, (L) 5/.5; gluteus maxi III us (R) 4-/5, (L) 415; gluteus medius (R) 4-/5, L 3+15; quadriceps (B) .5/5; gastroe!soleus (B) ;5/.5; abdominals 4-/5 by leg loweling test

Balance: R single-leg stance time; .5 seconds; L single-leg stance time: 12 seconds Neurologic Signs: Normal for I.;3-S1Iight touch, deep tendon reflexes, and key muscle strength. Active Movemenl Testing (open chain): Pain is elicited with L hip flexion. Internal rotation and abduetion at end of available range in each motion. Standing lumbar sidebend and R rotation is painful. Single-leg stance (R) causes H hip pain, and closed chain testing was deferred because of initial apprehension and balance deficits.

E VA L U A T ION: DJD-related hip muscle strength and range deficits leading to gait and pelvic asymmetry and hip joint pain and to R LS/SI eompression and initation.

Impairment

Functionsl Limitation

Oissbility

• B hip range of motion restriction • B hip joint muscle weakness • Abdominal muscle overstretch • Frontal plane pelvic: asymmetry • Sagittal plane lumbopelvic asymmetry • Decreased standing balance • Gait abnormality • Unable to maintain neutral pehis

• Pain limits walk endurance

• Unable to play golf • Unable to socialize and restore self mentally and emotionally for wife's care

oI A G NOS IS: Condition after R hip THR; L hip DJD with muscle imbalance leading to probable R L5-S1 facet compression irritation PROGNOSIS Short-Term Goals (14-21 dsys)

Long-Term Goals (4-6 weeks)

1. Regain sagittal and frontal plane alignment in standing and walking 2. Regain at least 41.5 strength in all hip and abdominal muscle groups 3. Equalize L hip range of motion to that of R hip 4. Able to balance 30 seconds in Single-leg stance (B)

1. Am bulate \\ith normal gait pattern 2. Walk 18 holes of golf, pulling cart, without pain in hips or low back

appendix 1

Red Flags: Re cognizing Sig ns and Symptoms DAVID MUSN ICK* AND CARRIE HALL

Because therapists often have consistent daily or weekly contact with patients, they may be the health professionals to recognize serious neurol11uscuJoskelet,Ll patholo or systemic dis ease requiring !l edical refe rral. A thorough history, carefully conducted interview, systems review, and screening examinations must be completed during the ini­ tial evaluation. Any red Hags- si.gns or symp toms that sig­ nal pathologic con ditions- may il1dicat seriolls somatic or visceral disease or disorders that are lJeyond the scope of physical therapy intervention. The information outlined in this appendix delineates signs and symptoms of somatic and visceral origin. Physical therapists often perform int rventions, such as therapeutic exercise, to aHeviate pain. The physical thera­ pist must be sure that the pain is of neuromusculoskeletal origin and is within the scope of physical therapy practice. A patjent with pain that may be caused by serious pathol­ ogy or referred from a visceral sourc should be imnwdi­ ately referred to a medical physician for fUlthcr testing. Visceral structures can be a source of rt'ferred pain to musculoskeletal regions, particularly to the shoulder, back, chest, hip, or groin. The mechanism by which visceral struc­ tures refer pain to musculoskeletal reaions is twofold: 1. Visceral afferents that supply internal organs trans­ mit impulses to the dorsal horn in which somatic and visceral pain fibers share second-order neurons . I m­ pubes from visceral nerve endings arrive at similar interneuron pools as impulst,s from somatic origin. Visceral pain may then be felt in somatic segments and skin areas with which it shares lleurons in the dorsal horn. This pattern is called rderrcd visceral sensation. Broader pain referral from visceral stlUC­ tures can OCCllf with multiple-scgment overlap. Re­ ferred visceral sensation may coexist wi th re nex mu s­ cle spasm and vasomotor change'S. 2. Visceral structures in the thoracic and abdolllillal cavities have free nlCrve endings in loose connective tissue in epithelial and serous linings and in blood vessels. 1\eural affere nt inform ation is translllitted "dong small, unmyelinated, type C nelVe fibers within sympathetic and parasympathetic nerves of the auto­ nomic nervolls systclIl. The pain is usually not well localized by the patient and is usually described as vague, deep, and aching. o

D avid Mu ~ nick, MD, is an il.trnlal nll'dicin dsports IlH'(lidnr phys ician in Seattle and Bellevue. Washington. He te
Signs and symptoms associated with referred visceral pain are the most common red flags signalin~ the need for further evaluation. The cause of this pain is related to the pathologic function of the primary visceral structure in­ volved. Viscera may refer pain caused by tissue ischemia, obstruction, !11 ~chanicul distelltion, or inflammation. Ta­ bles 1 and 2 describe the sources and characteristics of so­ matic and visceral pain. Tabl es 3 and 4 review the signs and symptoms associated with refe rred visceral pain. When­ ever a pati a t reports symptoms described ill Tables 3 and 4, screening for systemic diseaSe' is appropriate. The deci­ sion to screen for systemic disease may be even more criti­ cal if the patient is older than 45 years of age and the symp­ toms have an insidious onset. Table 5 describes systemiC, visceral, or nonmechanica] causes of regional musculoskeletal pain. The physical therapist should be aware of constant, severe pain with incrcasps ill intensity, nonmechanical patterns, or the symptoms or signs desctibed in Table 4 in association with regional musculoskeletal pain. Referral of the patient to a physiCian is indicated when pain in a musculoskeletal re­ gion is accompanied by symptoms and signs indicating systemic or non mechanical disease. Some types of re­ ferred visce ral pain are made worse with mechanical stress. Mechanical exacerbation on examination is not 100% specific ,mel cannot alone be used for diagnOSing mechanical problems. Fe male patie nts , persons older than 50 years of age, and children may prese nt with symptoms about which the prac­ titioner should he aware: • Female patients \vith new-onset thoracolumbar, lum­ bosacral, or sacroiliac pain shou ld be screened through a ren.al allel reproductive history and lumbar scanning exnl!lination. Prompt medical screening is indicated if the person has fever, costovertebral angle tendern ess , minary symptoms, pelvic or suprapubic pain or tenderness , tachycardia, orthostatic changes, or an unclear diagnOSis. Renal and reproductive organ disease can cause Significant morbichty if not treated quickly. . • Malignant diseas e should be suspected in patients older than 50 years of age who have constant back pain that is increased with recumbency, history of primary tumor, pathologic fractures , night pain , or multiple painful areas in the spine. The axial skeleton is involved more commonly than the appendicular skeleton, with the lumbar and thoracic spine affected Similarly (incidence of apprOximately 45% to 50%). Cord compression signs require immediate referral to a physician.

759

760

Therapeutic Exercise Moving Toward Function

Sources and Characteristics of Somatic and Visceral Pain

Somatic Sources Superficial Somatic Cutaneous Pain • Localized but may refer within 6-12 inches • Aching • Burning • Throbbing (e .g., abscesses) • Neck, hip, or elbow pain with reactive lymph nodes • Reactive lymph glands are aggravated by pressure or stretching Deep Somatic Pain luscles • Localized or may be in referred patterns • Increases \\~th direct pressure on a tender area or site of lesion, locally or in a referral pattern 0

Joints • Deep aching that is vague within the area (more common with pe riphe ral joints ) and a referred pattern that is felt l110re distally from tIle area (especially spinal joints) • May de<;rease \\~th rest or when stressful action has stopped • May increase with activity • Increases \vith stress testing or palpation

Ligaments • Deep <1ching in tlle region of the ligament but may also be perceived distally • Increases \vith stress testing or palpation

New'ologic Pain • Characteristic pain referral patterns based on the site of the lesion • May be associated \vith bone pain if the origin of neurologic compression is bone Bone Pain • Perceived close to the bone (see Table 2) • Constant and not relieved by rest • May be worse with wqlking, jumping, or oilier impact • ]f a tumor is growing in a bone the pain \vill be gradually increasing and may be worse at night when the patient is trying to sleep Visceral Sources • Vague pain • Deep pain • Aching pain • Boring pain • Tearing pain • If a hollow organ is involved, pain may be more colicky (i.e. , crescendo and decrescendo ) • May involve visceral symptoms (see Table 4) • May be felt deep or referred superficially to a somatic site (see Table 5)

• Pain may originate in muscles, ligaments, joints, periosteum , vessels, dura, and fascia.

• Back pain is rare in patients younger than 16 years of age , especially in nongymnasts and in patients with­ out trauma. Pediatric patients with low back pain and without history of trauma or overuse should be screened by a medical practitioner. • Pediatric patie nts with hip pathology may complain of knee or hip pain or a vague pain with walking. Any pe-

diatric patient seen for recent onset, undiagnosed limping should be evaluated with a medical history and scan of the lumbar spine, hip, knee, and lower ex­ tremit)! (including temperature), Patients with these complaints should be seen promptly by a medical practitioner and have an x-ray examination to evaluate the hip, if indicated.

Causes of Bone Pain and Associated Signs and Symptoms CAUSES

ASSOCIATED CONDITIONS AND SYMPTOMS

• Stress and compression fractures

• Overuse • Osteoporosis • Evaluate for menstrual and eating disorders in young females • Corticosteroid use • Trauma • Fever or other source of infection • Fatigue • Multiple areas of bone pain, especially in the spine and pelviS • Cranial neuropathies • Leg defornlities • "Varm bones on examination • Scoliosis if in the spine, espeCially in a child • Symptoms of the primary cancer • Fatigue • Pain of bone origin in more than one spine site; a spine site combined with a rib or long bone site may be metastatic cancer and should be referred for evaluation

• Avascular necrosis (wrist, femoral head , shoulders, feet ) • Osteomyelitis • HematolOgiC disorders of the bone marrow

• Paget's disease

• Benign tumor • Cancer (primary or metastatic)

Appendix

761

Characteristics of Systemic Symptoms Data Obtained From the History

Constittltional Symptoms

• Insidious onset or no known cause (or both ) • Pattern of presentation: gradual, progressive, cyclical • Constant • Intense • Bilateral • Unrelieved by rest or change of position • Night pain • History of infection • Migratory arthralgias

• • • • • • • • • •

Fever Chills Malaise Fatigue Night sweats Gastrointestinal symptoms Skin rash Weight loss Dyspnea (i.e., shortness of breath) Diaphoresis at rest or with minimal exertion

Visceral Symptoms and Signs Categorized By Origin Infection

Gastrointe8tinal

• Fever • Chills • Malaise • Fatigue • Night sweats • Red rash • Swelling • Purulence • Constant pain • Painful , enlarged lymph nodes • Superficial palpation or percussion tenderness • Root or cord compression by space-occupying lesion in spine

• Nausea • Vomiting • Bloating • Weight loss • Loss of appetite • Change in stools • Bloody stools • Diarrhea • Absence of bowel movement • Abdominal pain • Yellow eyes or skin • Food may help or aggravate Renal • Costovertebral angle tenderness • Hematuria (i.e., red Uline) • Painful or frequent urination

Pulmonary • Cough • Sputum • Wheezing • Shortness of breath • Chest pain • Pain worsened by deep inspiration • Hemoptysis (i.e., coughing up blood) • Decreased aerobic exercise capacity

Cardiac • Arrhythmia (fast> 120, slow <40) • Pauses • Irregular pulse • Chest, jaw, scapular, or left arm pain • High or low blood pressure (> 180 or <85) • Dizziness • Syncope (i.e., fainting ) • Bilateral leg and foot swelling • Shortness of breath

Va8cular • Low-amplitude pulse • Coldness • Paleness • Swelling • Constant pain • Tearing or boring pain • Color change

Endocrine • Energy or temperature changes • Urinary volume change • Possible bone pain

Neoplastic • Constant or night pain • Age > 45 years • Myelopathy signs (e .g., spinal cord compression ) • Previous primary tumor • Pathologic fracture • Generalized weakness • Pain in multiple bony locations

Gynecologic • Pelvic or low back pain • Menstrual abnormalities • Pelvic mass

Rheumatologic • Peripheral joint swelling • Deformity • Redness or pain • Rash • Proximal weakness

762

Therapeutic Exercise Moving Toward Funct ion

Systemic Disease or Visceral Pain Referred from the Musculoskeletal Region Headache • Intracranial tumor (U) • Meningitis (U) • Subarach noid hemorrhage (U) • Sinus infection • Temporal arteritis; refer patients with visual proble ms immedi ately to preven t blindness (U )

Ceroical Spine Region Pain Visceral Referred Pain Thoracic Origin • Cardiac ischemia or infarction (U) • Pneumom ediastinum (U) • Pericarditis (C ) • Aortic arch dissection (U) • Pancoast tumor • Pleuritis Infectious Origin • Meningitis (U) • Epidural abscess (U ) • Osteomyelitis (U) • Disk space infection (U) • Transverse myelitis (U) • Lyme disease

• Lung • Thyroid • Cervical cord or root compression • Pancoast's tumor • Lung cancer Cardiac Origin (left shoulder) • Angina or myocardial infarction (U) • Pericarditis (U ) • Aortic aneurysm (U)

Pulmonary Origin • Empyema anCl lung abscess • Pulmonary tuberculosis • Spontaneous pneumothorax (U) • Lung cancer Breast Origin • Mastodynia • Primary or secondary cancer Abdominal Origin • Live r disease • Ruptured spleen (U ) • Gallbladder disease • SubphreniC abscess

Systemic Disease

• Me tastatic tumor • Intramedullary or extramedullary tumor • Epidural hematoma (U)

• Collagen vascular disease • Gout • Syphilis , gonorrhea • Sickle cell anemia • Hemophilia • Rheumatic disease

Vascular Origin • Subarachnoid hemorrhage ( • Vertebral aliery dissection (U ) • Carotid artery thrombosis (U)

Thoracic-Scapular Region Pain Visceral Referred Pain Cardiac Origin

Neopltutic

CaU8e8

Other Visceral RefelTed Pain • SphenOid sinusitis • Thyroiditis • Parotitis • Cervical lymphadenitis (from a throat or skin source) • Pharyngeal space infection (P) (U) • Cysts (P) Nonviscerogenic Referred Pain

Rheumatologic Disease • Fibromyalgia • Polymyalgia rheumatica • Rheum atoid arthritis • Ankylosing spondylitis • Gout or other crystal-induced inflamm ation

Shoulder Pain Visceral Referred Pain Neoplastic Cause • Metastatic lesions • Breast • Prostate • Kidn ey

• Myocardial ischemia or infarction (U) • Dissecting aortic aneurysm (U )

Pulmonary Origin • Pneumonia (U) • Pleuritis • Pulmonary embolism (U) • Pneumothorax (U) • Empyema (U) Neoplastic Causes • Mediastinal tumors • Pancreatic carcinoma Neck Origin • Esophagi tis Abdominal Origin • Liver disease (e .g., hepatitis , cirrhosis , metastatic tumors ) • Gallbladder disease

Anterior or Lateral Chest Pain Serious Causes (U ) Pulmonary Origin • Pulmol1aryembolism • Pneumothorax • Pneumomediastinum

• Pneumopericardium • YIediastinal tumor • Asthma • Pneumoni,l (if respiratory rate > 20

and short of breath)

Cardiac Origin • Pe ricarditis • Dissecting corollary artery or aOlia

(e.g., \1 arfan 's syndrome)

• Cardiac hype rtrophy • Primal), pulmonary hypertenSion • MyocarditiS • Tachycardia (heart rate> 140-160 at rest) • Suspected myocardial infarction (may occur in younge r patie nt using cocaine )

Less Serious Causes Infectious Origin • Helpes zoster infection • Pneumonia (if no respiratory compromise) • PleUlisy • Bronchitis Gastrointestinal Oligin • Esophageal tear • Spasm • RefllLX

Tlwracolumbar Spine and Sacroiliac Region Pain Visceral Referred Pain [eoplastic Causes • Malignant tumors of th e spinal cord or meninges (neurologiC defiCit) • Lymphoma (night sweats, weight loss, lymphadenopathy) • Multiple myeloma (>40 years of age, moderately severe bone pain , multiple osteopenic spine lesions, kidney disease, fatigue from excessive calcium ) • Metastatic tumors (e.g., prostate, breast, lung, ladney, thyrOid, colon ) • Pediatric malignanCies (e.g. , Ewing's sarcoma, osteosarcoma, lymphoma, leukemia, skele tal metastasis from \Vilms' tumor, neuroblastoma, rhabdomyosarcoma ) (P)

Abdominal Origin • Abdominal aortic aneurysm (U) • Peptic ulcer • Pancreatic disorders • Pyelonephritis (U) • Nephrolithiasis (renal ston e) (U) • H ydronephrosis • Renal tumor • Renal infarction (U)

(continued)

Appendix

763

Systemic Disease or Visceral Pain Referred from the Musculoskeletal Region (Continued) Pelvic Origin

Thrombosis Syndromes (V )

Systemic di ease

• UrinalY bladder retention • Crohn's disease of the rectum • Chronic prostatitis • Uterine masses • Retroverted or prolapsed uterus • Endometriosis • Pelvic inflammatory disease (fever, nausea, pelvic pain) (U ) • Ectopic pregnancy (missed menstrual cycle, pelvic.: pain) (V) • Benign ovarian tumor • Colon diverticuLitis • Retroperitoneal fibrosis

• Deep venous thrombosis with proximal e>.tension to femoral vein andJor pelvic veins (calf p ain and swelling) • Greater saphenous vein phle bitis (superficial, may progress to deep vein thrombosis )

• Sickle cell anemia, avascular necrosis • H ' mophilia (hemarthrosis, bleeding in iliopsoas) • Tuberculosis

Rheumatologic Causes • Ankylosing spondylitis • Reiter's syndrome • Psoriatic arthritis

Infectious Origin (V ) • Osteomyelitis • Disk space infection • Epidural abscess • Pyogenit: sacroiliitis

Endocrine and Metabolic Causes • Osteoporosis with compression fracture

Hip, Groin, and Thigh Pain Visceral Referred Pain Neoplastic Causes • Bone tumors • Spinal metastasis

Abdominal Oligin • Inguinal or femoral hernia • Appendicitis (U) • Crohn's disease • Ureteral colic

Pelvic Oligin • Pelvic inflammatory disease (P ) P, pediatric; U, urgent.

Arthritis • Osteoarthritis • Gout, pseudogout • Rheumatoid arthritis • Ankylosing spondylitis (degenerative joint disease of hip in a younger male ) • Reiter's syndrome

Pediatric Hip Disease (P) • Legg-Calve-Perthes (proximal femoral epiphyseal blood flow interruption and necrOSis ; collapse of femoral head; hip pain, limp, adductor and iliopsoas spasm, possible Trendelenburg sign; child 4-8 years old ) • Slipped capital fe moral epiphysis (hip, thigh, or knee pain; hip hypo mobility especially in medial rotation; older child or adolescent) • Transient synovitis (hip, thigh , or knee pain; difficulty walking and possible fever, 2-12 years of age with peak incidence at 6-7 years)

Infectious Origin • Lymphadenitis caused by cellulitis distally or abdominal wall, perineum, or genital areas or other infections, including sexually transmitted diseases (U)

• Iliopsoas abscess (retroperitoneal infection or inflammation ) (U)

Lower Leg, Knee, and Ankle Region Pain Visceral Referred Pain Alterial Compromise • Occlusion of the popliteal artery from trauma, thrombOSiS, or knee dislocation (U) • Claudication syndromes (age > 55 , coronalY disease, diabetes, calf pain with walking) • Artelial occlusion (acute leg pain , pulseless , cold extremity) (U )

Venous Syndromes • Venous thrombosis (deep venous thrombosis of the veins in the calf, calf pain, enlarged calf, midline tenderness ) (U) • Thrombophlebitis of the greater saphenous vein (medial leg pain ) (U)

Infectious Syndromes (U) • Cellulitis • ErySipelas • Necrotizing fascitis • Gas gangrene • Other myositis syndromes, including streptococcal

Rheumatologic Causes • Reiter's syndrome • Ankylosing spondylitis (chronic ankle or foot tendinitis, bursitis)

Other Causes • Sarcoidosis (ankle or knee swelling, chest synlptoms)

764

Therapeutic Exercise Moving Toward Function

appendix 2

Red Flags: Potentially Serious Symptoms and Signs in Exercising Patients DAVID MUSNICK AND CARRIE HALL

Certain symptoms occurring during exercise may indicate significant medical problems and may be the reason for re­ ferral. Display 1 lists the symptoms associated with comor­ bidities and the tests that should be performed to exclude a medical emergency. Display 2 lists signs indicating med­ ical problems that necessitate medical referral. During supervised exercise, a patient may develop seri­ ous signs and symptoms. Display 3 describes the signs and symptoms related to exercise and the appropriate course of action with respect to various comorbidities:

• Cardiovascular disorders • Syncope • Hypoglycemia • Allergic reactions • Deep vein thrombosis • Pulmonary embolus • Spinal cord compression from metastatic disease

• Asthma or other pulmonary disease • Cough

DISPLAY 1

Sym)!toms Associated With Medical Conditions Condition Bronchial or lung tissue

Coronary artery, heart valve, cardiac tissue

Cardiac rhythm disturbance

Cardiac or pulmonary condition

Chronic fatigue or fibromyalgia Cervical or intracerebral pathologies Neurogenic, vascular claudication, or deep venous thrombosis

Symptoms • Wheezing • Pleuritic pain (chest pain increased by a deep breath) • Cough • Significant shortness of breath • Tightness or pain in the left chest, jaw, scapula, or left arm • Lightheadedness • Nausea • Lightheadedness • Fainting • Bradycardia (heart rate less than 50) • Pauses between beats, especially if associated with lightheadedness • Severe intolerance to aerobic or strength training • Flare-up of fatigue after exercise • Intolerance to aerobic or strength training • Exercise-induced headaches • Calf pain with exercise

Tests • Pulse • Respiratory rate • Blood pressure • Peak flow • Pulse • Blood pressure in both arms to determine differential • Postural pulse • Blood pressure • Neurologic screen

• Pulse • Respiratory rate • Blood pressure • Screen for tender points • Complete neurologic and cervical screen • Peripheral pulses • Straight-leg raise • Neurologic screen • Homans'test • Calf circumference

Appendix

765

DISPLAY 2

Signs Associated With Medical Conditions Signs

Condition

Heart Rate Less than 50 beats per minute (unless very aerobically fit individual) Pauses greater than 3 seconds between beats (especially if associated with lightheadedness) Moderately elevated heart rates during and after cessation of exercise Elevated heart rate before exercise

Heart rate elevation greater than 120 beats per minute 5 minutes after exercise; if heart rate is greater than 140 beats per minute and accompanied by chest pain, considered a medical emergency

Blood Pressure Systolic blood pressure less than 85 mm Hg (exercise is contraindicated) Systolic blood pressure greater than 140 (exercise not contraindicated until systolic reaches 170; isometric exercise contraindicated) Respiratory Rate Greater than 20 (exercise contraindicated unless there is a known chronic lung condition)

• Bradycardia • Diseased sinus node • Serious bradycardia • Chronic pulmonary or cardiac disease • Arrhythmia • Fever • Pulmonary compromise • Hyperthyroidism • Volume depletion (from bleeding or other fluid loss) • Possible myocardial infarction • Fever • Hyperthyroidism • Arrhythmia (tachycardia) • Volume depletion • Hypotension • Hypertension

• Asthma • Pulmonary infections • Chronic lung conditions • Acute pain • Fever

DISPLAY 3

Common Medical Conditions That May Produce Serious Signs and Symptoms During Exercise Asthma. Pulmonary Diseases, and Shortness of Breath If a patient has a history of asthma, chronic pulmonary disease, or recent upper respiratory tract infection with any of the symptoms listed below during or after exercise, he or she may have an asthma flare, temporary bronchospasm, or another pulmonary problem (e.g., bronchitis, pneumonia). Any patient with active asthma should be managed by a physician and encouraged to bring his or her asthma inhaler and peak flow meter to the therapy department. Symptoms and Signs • Coughing • Wheezing • Substernal chest tightness * Mild shortness of breath at rest or precipitated by exercise or cold weather • Use of accessory muscles of respiration (e .g., scalenes, pectoralis minor, intercostals) Elevated respiratory rate (> 18 breaths per minute) 5 minutes after cessation of exercise ~ Low peak flow level for age, sex, and height Clinical Actions • Administer the patient's bronchospasm inhaler. A second inhalation should be administered after 1to 2 minutes. Recheck signs and symptoms within 5 to 10 minutes.

• Peak flow of less than 80% of predicted indicates asthma or chronic obstructive pulmonary disease (CO PO)' indicating referral for a medical evaluation. • Peak flow of less than 250 indicates severe airway obstruction and is reason for referral to the emergency room. • Respiratory rate greater than 24, resting heart rate greater than 100, and a peak flow of less than 200 to 250 are signs of pulmonary compromise or a severe exacerbation and poor clinical response to the medication. If the patient is not improved significantly after the inhalation of medication, the patient's physician should be called immediately. If the patient appears to be in respiratory distress, he or she should be transferred to an emergency room. • Exercise can be continued if the patient responds well to the medication. The physician should be called regarding management of the medications to prevent future exacerbations. Cough Associated Conditions • Pulmonary infection (accompanied by colored sputum, fever, chills) • Medication side effect (continued)

766

Therapeutic Exercise Moving Toward Function

DISPlAY 3

Common Medical Conditions That May Produce Serious Signs and Symptoms During Exercise (Continuedl • Serious lung disorder • Asthma • Reactive airway disease • Congestive heart failure • Mild respiratory tract infection Increased intraabdominal and intrathoracic pressure induced by coughing can greatly exacerbate spine pain conditions of a mechanical nature. Patients with spinal disorders should be advised to suppress cough with over-the-counter medications and consult their physician to determine the cause and receive definitive treatment. Patients with a persistent cough should be referred to a physician. Cardiovascular Disorders Symptoms • Chest, substernal, left arm, anterior neck, jaw, and periscapular pain • Headache, blurred vision, exacerbation of neck pain (symptoms of severe hypertension) • Uncontrolled hypertension that exacerbates headache and neck pain • Chest pain, lightheadedness, fainting, and perceptions of strong beats or irregularity (symptoms of heart rhythm abnorm aIiti es) Clinical Actions • If heart rate is less than 45 or greater than 150 beats per minute after cessation of exercise for more than 5 minutes, refer the patient immediately or call 911. • If the patient has a heart rate greater than 150 and is younger than 50 years old, an attempt to decrease the heart rate by putting slight pressure on the carotid body can be made by massaging the carotid pulse just inferior to the angle of the jaw. The radial pulse can be monitored with another hand, and if it begins to slow, pressure can be taken off the carotid body. If there is no effect within 10 to 15 seconds, this procedure should be stopped. • If the patient has angina symptoms (i.e., severe, constricting chest pain) with known coronary disease, administer his or her own nitroglycerin while sitting or lying down. You may repeat this after 5 minutes. If no relief occurs after a total of three doses in 15 minutes, call 91'1. • If systolic blood pressure is greater than 180 or diastolic pressure is greater than 110, the therapy appointment should be terminated and the patient referred to his physician. • If the systolic blood pressure is greater than 220 and the diastolic pressure is greater than 130, the patient should go to the emergency room, and the referring physician should be called. • High blood pressure, midline thoracic pain, and between­ arm blood pressure differences of 10 mm Hg should be referred immediately. • A patient with a history of coronary disease should be referred immediately if he or she is experiencing arrhythmia and has chest pain. • If the patient is unconscious, call 911 and begin cardiopulmonary resuscitation. Syncope Syncope is defined as a sudden and reversible loss of consciousness and decrease or loss of postural muscle tone.

It can be caused by transient cerebral ischemia (a total loss of cerebral flow for 10 seconds leads to a blood pressure <70) or altered chemical composition of blood flow to the brain (brain cells depend on a constant level of glucose for energy). Symptoms • Changes in vision • Nausea • Sweating • Feeling of dizziness • Feeling of leg or trunk postural weakness • Palpitations or chest pain if tachycardia • Calf or chest pain if pulmonary embolism To determine if the syncope is caused by postural changes, the blood pressure and heart rate are taken in three positions: supine, sitting, and standing. The blood pressure is assessed in each position. If the systolic pressure lowers by more than 20 points or the heart rate elevates by more than 20 points with each positional change, the patient can be determined to have posturally related syncope. Clinical Actions The patient should be positioned in supine with legs elevated for at least 3 minutes to increase venous return of blood. • A patient with posturally related syncope and a history of vomiting or diarrhea is usually dehydrated and requires significant rehydration with more than 2 L of fluid. The patient should have arrangements made for transportation to a physician's office or a medical facility. It may be possible for the patient to take in enough fluid orally. Rehydration may be started in the therapy department, but it should not be completed in the therapy department. - Syncope that occurs more than one time requires termination of the therapy appointment and transportation to the emergency room (unless it is clearly a vasovagal faint). A vasovagal faint is one in which there is no ongoing pathology and the blood pressure and pulse become normal after 3-5 minutes in all positions. Patients who faint more than one time should not be allowed to transport themselves to a medical facility. HVpoglycemic Episodes Hypoglycemic episodes most commonly occur in patients with diabetes. The causes vary, including improper timing of meals or snacks, excessive insulin or improper dosing or timing of insulin, and excessive or unplanned exercise coupled with inadequate food intake. Symptoms and Signs • Shakiness • Weakness • Sweaty • Blurred vision • Excessive anxiety • Irritability • Lightheadedness • Confusion • Decreased cognitive abilities • Unconsciousness • Blood sugar levels less than 50 to 60 (continued)

DISPLAY 3

Common Medical Conditions That May Produce Serious Signs and Symptoms During Exercise ~Conti n ue d ) All diabetes patients should be asked to bring their meters with strips to every therapy visit in case of a hypoglycemic episode. Any of the above symptoms should prompt blood sugar assessment. Climcal Actions • If the glucose level is less than 60, and the patient is awake, give a carbohydrate snack of three glucose tablets, a tube of Insta-Glucose gel, or 1/2 to 1 cup of juice. Ask the patient to take a snack including carbohydrate and protein or fat. • Do not begin any aerobic exercise. • Recheck the serum glucose level in 30 minutes. If the patient feels significantly better, he or she can resume exercise. • If the patient is unconscious, administer glucagon immediatel,y. Mix the liquid in the syringe with the powder in the bottle, and then inject the whole clear solution that is in the syringe into the deltoid muscle or the quadriceps muscle. Place the patient in a sidelying position to protect the airway. When the patient awakens and is fully conscious, give a glucose snack and protein, refer the patient to the emergency room, and call the primary physician. Instructions for Diabetic Patients Before Exercise If the glucose level is 100 to 180, administer 15 g of carbohydrate . • If the glucose level is 180 to 250, it is not necessary to increase food intake. • If the glucose level is more than 250, do not start aerobic exercise.

~

Allergic Reactions Patients may develop allergic reactions to exercise that can occur for the first time in the therapy department: Exercise-related hives (i.e., itchy, raised skin areas filled with fluid) Angioedema (i.e., swelling in the subcutaneous tissues around the eyes, lips, hands, and feet, and possibly in the tongue and posterior pharynx and airway) • Anaphylactic shock (i.e., associated with decreased blood pressure, increased pulse, sweatiness, pallor, angioedema, and asthma symptoms) Anaphylactic shock may occur as a reaction to a medication such as antibiotics, angiotensin-converting enzyme inhibitors, aspirin, or nonsteroidal anti-inflammatory drugs. Exercise­ induced anaphylaxis may occur with vigorous aerobic exer­ cise as the only precipitating factor. Any patient with a history of exercise-induced shock should always exercise with an­ other person and should always carry an epinephrine kit. A patient may also develop any of these reactions in response to latex gloves or another allergen that he or she is severely allergic to that may be used in the therapy department. A patient may also react to medications. Clinical Actions • Hives usually do not cause emergent problems unless this condition progresses to other, more serious problems. Stop exercise, and consider having the patient take an antihistamine such as Benadryl. Call the patient's primary physician. • Angioedema is an emergency if it involves swelling of the tongue and airway. If the patient displays difficulty controlling saliva or breathing, the treatment of choice is to administer one dose of epinephrine (0.3 mL of 1:1000

solution) in the deltoid area. If a qualified person is not on the premises to administer this treatment, ca1l911. Anaphylactic shock is a severe, life-threatening emergency. Blood pressure and pulse should be taken, although blood pressure may be difficult to detect. The patient should lie down with legs elevated. A dose of epinephrine should be administered immediately and 911 called. Deep Venous Thrombosis Individuals at risk for deep vein thrombosis (DVT) include those who have sustained local trauma to a vessel, have a hypercoagulable disorder, or have been immobilized by bed rest or casts. The most common locations of DVT include the calf, thigh, arms, and pelvis. Symptoms and Signs • Pain in the calf or thigh • Swelling of the calf (circumferential tape measurements are indicated to verify swelling) Pain in the calf with walking • Tenderness with palpation of the deep calf along the midline Positive Homans' sign (i.e., pain on dorsiflexion of the ankle) Any patient complaining of calf pain or swelling should be evaluated for DVT. Clinical Actions Suspicion of DVT warrants referral to a physician or emergency room within the next few hours. The patient should walk minimally, because there is a danger of the clot breaking off from the vessel. Pulmonary Embolus Pulmonary embolus (PE) is an urgent condition in which an area of lung is infarcted as a result of a thrombus occluding a pulmonary artery. The thrombus usually originates in a deep vein of the leg and travels through the venous return circulation into the right side of the heart and out through the pulmonary circulation to occlude a pulmonary artery. Small thrombi may progress to the periphery of the lung and infarct the peripheral lung tissue, with resultant inflammation and pleuritic pain. Large thrombi may occlude the pulmonary circulation and lead to severe cardiac compromise. Symptoms and Signs • Pleuritic pain with referred areas of pain • Shortness of breath • Fast respiratory rate • Coughing up blood Rapid pulse rate Suspicion of PE requires immediate referral to the emergency room. If not on the hospital premises, ca1l911 . Spinal Cord Compression and Metastatic Disease Patients with metastatic spine lesions can develop cord compression that is manifested by sensory, motor, or bladder symptoms. For a patient with multisite bone pain and new­ onset neurologic symptoms, a complete neurologic examination is indicated. If you suspect a cord compression syndrome, check for upper motor neuron (UMN) signs on examination (e.g., clonus, Babinski, hypertonicity). If UMN signs and motor, sensory, or bladder symptoms are present, refer the patient immediately.

768

Therapeutic Exercise Moving Toward Function

appendix 3

Source: Physical Activity Readiness Questionnaire (PAR-Q). © 2002. Reprinted with pe rmission from the Canadian Society for Exercise Physiology. http:!www.csep.calforms. asp.

PA'R -Q 6 YOU

"""""~­

Ques_• . PARoll (r"",,,2002)

(A Q•••tlonnal,. fo, Peop'. Ag.d 15 to 69)

Regular physical activity is fun and healthy, and (OO'easingiy more people are starting to become more active every day. Being more active is very s.fe for most people. However, some people should check with their doctor before they start becoming much more physicaly active. If you are planning to become much mo,e physically active than you are now, start by answering the seven questions In the box befow. )f you are betwffil the ages 01 15 and 69, the PAR·Q will tell you ff yOu should'check with your doctor belore you start. If you are over 69 years of age, and you are not used to being very active. check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO. YES

NO

0

0

1. Ho. JOD' dodo, onr .old Ihot NcolIlI••nd.d .., • dodor?

0 0 0 0

0 0 0 0

Z. Do JOu 1001 poln I. JOU' c~ ••1.h.n

0

0

..

0

0

7. Do ,0..... of

'OU

3. I. Ih. po.t monlh, ..... JO' bod

hon 'OU

0 ~ . . rt

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do ph,.kol odlvlty?

c~ ..1 poln .~an

JOu _,. not dol.,

p~,.lcol

activity?

4. Do po. 10•• JOur bll••e. 1Iteca... of clluIMl" or do , . .M' 10M cOMeloua..... ? 5.

Do JO....... 0 _ . 0' Joint p......... (lor ......p.., bock, .... 0' cho... I. JOur p~,.I ..1 octlvlty?

~Ip)

thol coold ....... _ ... .., 0

I. JO.' docto, ••rr.ntIy pr...rlbl.. dr... (for ...mpl., .ot., pili.) 10, JO.' blood p....... or IIoort co.' dltloa?

'Ii olho, ' " " .

wII, roo .~0.1d .ot do p.h,.kol activity?

YES to one or more questions

If you answered

T.~ with your doctor by phone or in person BEFORE you start becorrjr9 much more physically a
• F"d out which oommly p
Hyou atlSWefe
""Ye -

1m part in a fitness appraisal - this is an ~nI witf to deitrmine )'Our ,basic fitness so

that you can plan the best way for you to nve iKIivety It is also high~ recommended that you have YO"( blood pressure evaluated. If )'Our reading is ower 144/94, talk with )'Our doctor before you start becoming much more p~ aC!Ne. Ir!grmed~ of

I

PI.!AS! NOTE: II yourhealth changes SO that YOJ then ""wer YES to any of the abovt qumons. tell year fitlless Of heaJth pro!ess~onat ASk whotlrer you should change your phys:calactiyity pl.n

1hcf'AR.Q The Canadian SoOety for Emdst:~. HealthCaMda., and lheiragmts a.ss~no ilblrybrperson$. unde!'taj(e ~ a6rity.and ~;' doubt aftercornpleti\g

this q~aite , consult )O.lr doctor prior to physical actMly.

No .lIang•• p.,.ltlod. Tou a,••••ouragod to pholocop, tho PAR,Q but onl, If JOtI ... tho .ntlr. lor•. NOTE' II Ike Pfl.R-Q is betIg giYtn to a ~son beb'e he Ot she participates :n a phy9uI ~ progr.Yr! or a !Mess appraisal. tI;'s sec:ion 1t.8)' bt used tor legal cr ad~is!rajve putposes.

'I have read. understood and completed this questionnaire.

Ivrt questions Ihad were answered to my full satislaction.'

~

S

~---------------------------------------­ ______________________________________________

~~~~ ~· --~-~~-¥--d~~~·-.~I---------------------------­

~~~------------------------------­ ","" ss _____________________________

....: nli ph,IIUlI KtlyltJ clearanCII il nlkl for a lIIulm.m of 1Z .-cHIt'" from the date It II completed and . . . . . . Innlld If your condttlon thin... &0 that JOu would an,w., YES to an, of the ,even qu..tl•••.

1tn

© Caoa
SLWOtled by:

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Health Canada

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Canada

continued on other side ...

Appendix

PAR-Q & YOU

.. ,con!iooed from other side

•

Ph slcal ActIvIt

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'"

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ttl,.. ......,

PhysiGIII
i'Med20021 Get Active Your Way, Every Oay-For life! ~Py ~lIOlIIInI-.of~KIMIr WW!l'V d'1.ac.y ~'ly 0t1mpr_}VWr.aIB!. AI 'fO'JIj ~ lO modIIrMll.aiYlllM~ ClIn~Ul do*n lO

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---

. : : : - . . . . . . . . . . . 100

< - ........

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...

Source: Canada's Physical Activity Guide to Healthy Active Uving, HeaitJ1 Canada, 1998 httpBwww.h<:-sc.gc.caibppb/paguideJpdf/guideEng.pdf

© Reproduced wilh permission from lbe Minister 01 Public Works and Government Service,; Canada, 2002. RTliESS AND HEALTH PROFBSIOIlA15 MAY BE INTERESTED IN THE INFORMATION BELOW: The following companio:1 forms are available for doctors' use by contacting the Cara1ian Society for Exercise Physiology (address below): The PhysIc.1 Ac1.lYity Readl.,.. M.llie.1 ba.lnalion (PARIII.II-X) - to be used by doctors with people who answer YES to one or more questlO!1S on the PAR-Q..

The P~ysl",1 Actlottr .....i.... Modical e.o..l..tlonl... Pre,.o"J (PARMod.A 101' ....,... CJ) - to be used by doctors witJ1 pregnant patients wno y,ish to become more active. References: Arraix, GA, W~~, 0.1., M.o, ¥ (1992)_ Risk Assessment of Ph),ical ActMty and Physical fil' ess 'n t'e Canada Health So/'ley fo::OIO-Up Study I. CII., Eplde..lol. 45:4 41'>-428. Motto!a, M., Wcife, LA. (1994). ActNe tJv\Ag and Pregna~ In: A. Quinne'j: L. Gauvin, T. Wall (OOs.). Toward Adl.. U.1nl: Proceeding, ••• 1IIt Inl.rnatlonal C._.co o. Physical Actlylty, Fltnou o.d Heall'" Cham paign, Il Human KineOO;. I'l\R-Q Validabon Repo
The otigiI1aI PAR-Q was dmlopeO by the British Columbia Milistry 01 HeaJlh. It has been revised by an E>.pert AiMs<;ty Commtt.. 01 the Canadian SoOety for E>.e,Ose ~ y c~.aired by Dr. N. Gledhii (2002).

Canadian Society for Exen:ise ~y

202· t85 Somerset St,eet West

[MpoollIt en fra.n\ais sous Ie titre .Questionnaire sur I' aptitude aI'activite physique • ~ (revise 2(02)•.

Ottawa, ON K2P Oll Tel. 1-877·651·3755' F.IX (6t3) 234-3565

Onl ine: www.csep.ca

~~

~"'l © Canadian 5OO"Y1o, _

Pl¥iology

~by

.+.

He.nh Canada

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Canada



769

Index

Page numbers followed by b inchcate box; those followed by t indiwte table:. 1'm>;(' nllmhers in italics indit'a t(' f'igllfe .

A Abdominal exe rci ses (See also Sit-ups)

during pregnancy. 267-268. 268b

Abdominal muscle (See also Innpr core

muscles )

impairment of, 412

pehie Hoor dysfunction and. 412. 41 --419

stretchi.1lg of oblique. 629. 629 .

Abrasion chondroplasty. 224-225.225

Achilles tendinu.si.s , 545. 546

Acromiocla\~<.:ular joint. 644, 644-b45. 645.

645t

Actin-myosin relationship. 60. 60

Active assisted ROM exercises. 122-124. 123b.

124b. 139

Active ROM excrcises.124. 124-125. 125. 139

Acti~ties of daily li~ng (ADLs) (See also

Functionallilllitations) pel~c floor dysfunction and. 418

Acute injUly. management of. 211b

Adenosine triphosphate (ATP). 88

Adherence

defined. 36

in fibromyalgia and chronic fatigue

syndrome. 252

in health beha~or models. 36--38

motivation and, 36--38

Adhesive capsill itis. 680, 683--685

diagnos is of. 683

home exercise program for. 38

opprative treatment of. 6H5

stage 1, 684. 684t

stage 2, 684t, 685

stage 3 and 4, 684t. 685

treatmcnt of. 683-6tl5

Adjunctive intenentions. 30, 30-32. 31b

for ankl/' ancl foot injuries. 549-551

for arthritis. 2:14

for chronic fatigue synd romc. 253-254

cl('ctroth rapeutic modalities. 31--32

lor Ilbromyalgia S),11drome. 253-254

heating techniques. 30. 143--144

for hip. 475.478.481-482.482

for low back pain, 393--394

for lum bope l~c region. 393--394

mechanical modalities, 30-.31

mobility exe rcises and , 143--144

for pain . 202- 205

for pel~l' floor dysfunction . 4:28--432

physical agents, 30

for posture nnd movement impairments.

11l2-183

for pregnant patients. 266

for temporomandibular joint dysfunction ,

577

Adolesce nce

canli ovas~ lIlar pnourallcr training during .

108-109

muscle pC'rformanee during, 66

Adulthood, muscle perform ance during . 66

Advanced athle tes

dr f'ined , 73

dosage of resistive exercisc for . 81 ·2.8lt

Aerobic capac ity (See also Cardiovascular end urance )

case study for impn)\,ing, 110-111

caust'.s of impaired, 94-95

defined.HIl

c\"nlu ution of, 9&-100

anthropometric, 100

circulation , 100

history t'1king. 96

maximal graded exercise te ts. 97

screenin rr , 96, 97

systc ms review, 96

impaired

associated with arth ritis. 237-239

aSSOCia ted with low back pain ..165

associated with prcgnallcy. 276. 276b

phYSiology of, 87-9-1 therapeutiC exercise intervention for . 100-105 (See also Aerobic exe rcise; Cardiovascular encluranee training) Aerobic exercise (Sec also Cardiovasclilar cndu ranee h'ai ning)

abnormal responses to, 92. 92b

dose-r(,spons e relationship in. 94

in fibromyalgia and (:hronic fatigue

syndrom e, 249--250

fuel somccs for. 88

health-rclated be ne fits of, 94. 94b

metabolic pathways in. 88. 90, 92

normal responses to . 90. 92

physiologic adaptation lo, 93-94 . 93b

psycholOgiC benefits of, 94, 94b

in treatment of pain. 198, 200b

Affective paramete rs. modification of. 29d Aging balance and, 1.'53 canl im'a5eular endurance tmining and, 108-109

!:tlls and. 153, 467,615

f"' ln()ral changcs and . 4:3'i'

ililpaired aerobi<.: capac ity and. 95

joint mobility and. 143

Illuscle pcrli11'1nan e and. 66

pain and , 759

postur • and movem ent impairmcnts and, 178

.\ goni st contraction (AC ) scquence, for s tr('tehin~ , 121l

Alcohol, effects on musc\(> performance. 67

Alcoholic myopathy, 67. 'l2

Align me nt (See also Balancc: Postme)

ankle and foot in, 531-533, 532, 533IJ

of lowe r extre mity, 533h

optill1al shoulde r. fi72 - fi7:3

while sitting. .569

while stand.ing. 56'!

while walk in g, 535[,

All 'rgic reactions

exercise and. 767t

to taping, 687

Alplia StiIlJ.l.34

America n Physical TllPrapy .'\ ssociation

(APTA ), physical therapy (lcfinition, 1

Anaerobic glycolysis, RB. 89. 92

AmJ sphincter. 403, 404, 405

AnatoIlJic impairme nt . 5-6. 5b

of hip , 441-44:1. 442

AIl ~ "lii.l

phYSiologiC dilutionai, 260

during pregnancy, 260- 261

Ankl(·

Achilles te ndinosis of. 545, 546

adjunctiv , inten'entions for . 549--551

'Ioot orthotics . ,5'50, .550b

heel lifts. 550-551

tapping, 549~5.50

wedges and pads, -50

anatoillical eonsiderations, 524-.527

arthrology of, 525, 525-526. 526

Illyology of. 5:26. 526b, 52ib

l1!' lIrology of, 526-527. 527t

osteology of, 524-525, 525

balanc'(' impairm ent of, exe rcises for , 535-536,535b,536.536b

in body alignme nt, 531-533, 532, 533b

(,xu mination ano evaluation of, 534-535

fl!' t ray hype nnobility. 533

frac ture of. 549

functional nerve disorders, 545-547

gai t kin e tics and, 529-531• .53lt

inflam mation in . 542

jOint mohilization exercises for . 133b, 136

kin eS iology of, 527-5:33

ligamen t sprains of. 547-548. .548b, 739

in IlIob llity and walki ng, 530. 531b

!1lobility impairm ent of

evaluation of. 534

exe rcises for, 539--542. 541 . 542, 543b

ranae of moti on ex reises for . 123, .540,

541 . .'542, .54.3b muscle pe rformance impairment of

eval uation of. 534

exe rcises for, 536-538, 537, 53Th. 538

pain in, 753t

evaluation of, 534

xercises for. 537-538

plantar faSCitis of, .543--544

posterior tihial te ndon dysfuncti on , 54·5

posture impainnL'nt of

evaluation of, 5:34- 535

exercises for, 538-.539 . .539b

therape utiC exe rcisl' int(~ I"e ntion for .

535-542, 536-538. 536b, 3.3ib, 539b.

541-542

Ankl () eve rsion , isometric. 214b

Ankle strategy. for balance, 151, 1,51-152

Annular ligame nt, 699

Annulus f'ibrosus , 3.50--351

Antagonists , in proprioceptive neuromuscular

facilitation

dvnamic rewrsals of, 321 - :322. 322h-.323h

r~\'crsals of. 321

Antrrior eruciate liga ment. 490

injun' to, 500-501

AntllropoI1le tric characteristics

assessme nt of. 100

in low back pain, 359

711

772

Index

Anthropometric characteristics (cont'd)

in posture and movement impairments, 176,

177

Antivibration gloves, 718

Aquatic therapy, 330-346

for arthritis, 237

balance exerci ses in, 157-158, 163b

for balance impairment, 340, 341b, 342, 342b

bicycling, 201

buoyancy-assisted exercises, 331, 331-J32

buoyancy in , 330-332

buoyant equipment, 332, 333, 340

for cardiovascular endu rance training, 340

for chronic pain, 199, 199b, 201 , 201b, 202b,

203, 203b

coordinating land and water activities,

,344-345

deep water march with barbell, 202b

defined,330

elbow flexion extension exercise, 202b

eX
for fibromyalgia and chronic fatigue

syndrom e, 250

fun ctionallill1itations and , 344

heart rate and, 104

hip external rotation stretch, 5lt, 201b, 517

hydrostatic pressure in, 332, 335-336

jumping jack 200b

for lmee injury, 503, 505, 505

lever arm length in, 332, 332

mobility exer~ises

lower extremities, 339b

range of motion exercises, 337-338

upper extremities, 339b

for muscle performance impairmen t, 338,

338, 339b, 340,340b

patient-related in struction about, 345

physiolOgical resJlonse to immersion,

334-336,336b

physiological responses to exercise and

immersion, 336--337

precautions and con train dications for,

345-346

resistive ('xercises, 337- 338, 338, 339b, 340,

340b

running in water, 336-337

shoulder strengthening exercises, 163b

side-stepping, 503

supin e kicking, 199b

visC'osity in , 332-334 , 334, 334t, 335

wand elevation exercise, 126b

water depth in, 331-332

water temperature and, 336

water walking, 203b

Arch pads , 550

Armlifts, facelyu]g, 656b-657b

Arterial-venous ox,),gen difference

defined, 90

Tl~sponse to aerobic exercise, 90

Arthritis (See also Osteoarthritis)

qerobic capacity impairment in , 237-239

anatomical considerations in, 229-230, 230

ofhip, 461,47Z-475, 472b, 473,474

diagnOSiS, 472, 472b

hypennobility in, 461

treatm ent, 472-475, 757b-758b

of the knee , 509-512

articular cartilage lesions, 509-510

osteotomy for, 510-511

rehabilitation following, 512

total knee aJthroplast:y, 511 , 740

ligament or joint laxity in , 239-240

mobility impai rment in , 234-235

muscle perform ance impairment in, 235--237

osteoarthritis

clinical manifestations of, 231 , 231

effeds of, 230t

etiology of, 230-231

pain associated with , 234 , 241

pathology of, 230-233

patient-related instruction for, 241

pattern s of joint restriction in, 239, 240t

prevention of, 233

restoring muscle balance in , 240

rheumatoid arthritis

clinical manifestations of, 231-232,232

effects of; 230t

etiology of, 231

therapeutic exercise intervention for,

233-239

exercise modifications, 239-241

Arthrokinematic motion

biomechanics of, 129-130

defined , 113

eval uation of, 119

stretching and, 125-126

types of, 129

Arthroplasty

joint, 226

for temporomandibular joint dysfunction ,

575

total lmee, 511 , 740

Arthrotomy, for temporomandibular joint

dysfunction , 575-577, 576

Articular cartilage, 208

arthritis effects on , 230t

effects of remobilization on, 118

effects on immobilization on, 116

function of, 230t

injury to, 219

lesions of the lmee, 509-510

Asthma, 765b

Astran-Ryhming test, 98, 99, 99t

Asymptomatic, defined, 97b

Atlanto-oc'Cipital joint, 582, 583

Atlantoaxial joint, 582, 583, 584

ATP-PCr system, 88, 92

Atrophy

from arthritiS , 240

neuromuscular electrical sti mulation for, 31 ,

31t

steroid-induced,67

Autologous chondrocyte implantation, 225

B

Back pain (See Low back pain (LB P))

Balance (See also Alignm ent)

aging and, 153

closed kinetic chain (CKC) training and, 286

defined, 149,286

effects of training on , 153-154

evaluation of, 446

motor learning and, 152

phYSiology of. 149-152

sensory systems and, 150, 150-151

strategies to maintain, 151 , 151-152,152

Balance beam, balance exercises with, 159

Balance impairment

of ankle and foot , exercises for, 535-536,

535b,536,536b

aquatic therapy for, 340, 341b, 342, 342b

causes of, 152-153

evaluation of, 1,54-155, 360, 446

exercises for, 155--163

dosage of, 158, 162-163

effects of, 153-1.54

modes of, 155-156, 156

patient-related instruction, 163, 386, 386b,

387b

precautions and contraindications for, 163

of hip

evalu ation of, 446

exercises for , 467-468

with osteoarth11hs, 474

oflumbopelv1c region

evaluation of, 360

exercises for, 365, 365-366, 366

movement and , 1.56--158

posture and, 156

Ball

catching, for balance exercise, 157, 161

rehabilitation

balance exercises with , 158, 158b, 365,

365,372

postural reeducation with, 138, 139, 198,

200

for spine mobility, 624, 625

Ballistic exercise, 141-142, 142

Ballistic stretching, 128

Base of support (BOS ), defined, 149

"Baseline" symptoms, 44

Bed, getting up from, 386b

Bed rest

effects of, 273

during pregnancy, 272-273

therapeutic exercise for, 273-274, 274b

Bending forward , 387b, 392, 392b, 464, 467,

468b

Berg Balance Test, 155

Bicep curls, standing, 76b

Bicycle ergometer tests , 98, 99, 99t

Bicycling

for arthritis, 237-238

in fibroll1yalgia and chronic fatigu e

syndrome, 249

guidelines for , 105b

types of, 101, 104

in water, 201

B'iofeedback, for pelvic floor dysfunction ,

428-429,429

Biomechanical parameters, modification of, 28b

Birth injury, of pelViC floor, 407

Bladder dial')', 429, 429t, 430

Bladder training, 429, 429t, 430

Blood flow, response to aerobic exercise, 90

Blood pressure

effects of resistive training on, 72

response to aerobic exercise, 90

Body composition testing, 100

Body mechanics, low back pain and, 359-360

Body positioning, in proprioeeptive

neuromuscular facilitation, 317, 318

Bone denSity, effects of resistive training on, 71,

7lt

Bone pain, 760t

Bone(s)

of ankle and foot, .524-525, 525

arthritis effects on, 230t

components of, 208

effects of remobilizabon on, 118-119

effects on immobilization on , 116-117

of forearm and elbow, 698-699, 699

of band, 702

of hip, 436-437,437

of knee, 488-489,489

ofshoulder,643-646,644-646,644t

of temporomandibular joint, .555-556, 556

of wrist, 700, 700-701, 701

Bow legs, 170,170-171

Bracing

for low back pain, 393-394

Index for thoracic hypennobility, 625, 626

Breath, shortness of, 765b

Breathing, diaphragmatic, for

temporomandibular joint dysfunction, 570-571, 571b . Breathing exercises , for temporomandibular joint dysfunction, 570-572, 571b Brief isotnetric exercise (BRIME), for arthritis , 235, 236

Bruxism , capsulitis due to, 572

Buoyancy, in aquatic therapy, 330-332

Buoyancy-aSSisted exercises, 331, 331-332

Buoyant equipment, 332, 333, 340

C

Calf strengthening, closed kinetic chain (CKC)

training for , 296b, 300b

Capitate, 700, 701

Capsular pattern, of hip, 447-448, 447b

Capsulitis .

of shoulder, 742 (See also Adhesive

capsulitis)

of temporomandibular jOint, 572--573

Carbohydrates, 88, 90

Cardiac output

defined, 90

response to aerobic exercise, 90

Cardiorespiratory endurance, defined, 87

Cardiovascular dtsease

aerobic exercise and, 105-107, 106b

evaluation in, 100

impaired aerobic capacity and, 95

risk factors for, 105

symptoms during exercise, 766t

symptoms of various conditions, 764t

Cardiovascular endurance (See also Aerobic capacity)

defined, 87

phYSiology of, 87-94

Cardiovascular endurance training (See also Aerobic exercise)

aquatic therapy for , 340

for arthritis, 237-239

dosage of, 101-105

life span issues in, 108

modes of, 100-101

patient-related instruction, 107-108

precautions and contraindications, 105-107

strategies to enhance compliance, 107, 107b

training index for, 238-239, 238b

Cardiovascular system

aerobic exercise effect on, 93

evaluation of, 100

during pregnancy, 260-261

resi stive training effect on, 72, 72b

Carpal tunnel syndrome, 716--718,717, 718

during pregnancy, 277

Carpometacarpal joints

anatomy of, 701

kineSiology of, 706--707

Cartilage, 208

arthritis effects on, 230t

effects of remobilization on , 118

effects on immobilization on, 116

function of, 230t

injury to, 219

lesions of the knee, 509--510

Case study

ankle sprain, 522, 739

anterior cruciate ligament surgery, 744

fibromyalgia syndrome, 744-745

hip arthritis, 757-758

knee arthroplasty, 740

lumbar spine stenosis, 743

osteoarthritis, 741

plantar fascitis , 110-111, 747

shoulder capsulitis, 740

shoulder impingement, 735, 748-757

upper quadrant, 734, 745--746

Cauda equina syndrome, 359b, 390

Center of gravity (COG)

concepts of, 149--150, 150

defined, 149

Center of mass, in closed kinetic chain (CKC ) training, 289, 289

Centralization , 363, 384

Cervical extensors muscles, 587

exercises for, 590, 591, 592

Cervical spine

anatomical considerations, 582--587

craniovertebral complex, 582, 583, 584

midcenicalspine,584,584-585,585

muscles of, 586, 586---587, 586t, 587

nerves of, 585-586

vascular system , 585

cervicogenic headache , 607

disk dysfunction in, 605

examination and evaluation of, 587-588

hypermobility of, 599, 599--600, 600,

601lr-603b

mobility impairment exercises, 593--599

adverse neuromeningeal tension, 598,

598-599,599

jOint mobilization, 133b, 136

muscle length, 593-594, 596--598

range of motion exercise, 593, 594

segmental articular restrictions, 593, 595b

muscle performance impairment exercises, 588-592,589-592, 589b,592b

cervical extensors muscles, 590, 591, 592

deep cervical nexor muscles , 588-590, 589,

589b,590

functional movement patterns, 592,

592-593,594

rotation and side nexion, 592, 592

muscle strain of, 605--606

nerve entrapment syndromes of, 606--607

optimal posture for, 600, 603, 603b

pain in, 762t

posture impairments of, 600, 603, 603--605,

604, 604t

segmental articular restrictions of, 593, 595b

self-mobilization for , 595b

sprain and strain of, 605-606

strengthening exercise for, 74b

Cenical spine stabilization program, 600,

601b-603b

Cervicogenic headache, 607

Cesarean section , recovery from, 275--276

Change models , for health behavior, 36--38, 107

Chest pain, 762t

Children

cardiovascular endurance training in, 108

joint mobilization in, 143

muscle performance in, 65-66

pain in, 760

posture and movement impairments in,

177-178, 177b

Chondroplasty, abrasion, 224-225, 225

Chronic fatigue syndrome, 246--247

adjunctive interventions for , 253--254

aerobic capacity impairment in, 249-250

defined, 246, 24Th

emotional stress and, 251-252

etiology of, 247

muscle performance impairment in , 248-249

773

neuromuscular relaxation for, 254, 254b, 255b

pain and, 252

patie nt-related instruction, 254, :r54b

postu ral impairment in, 250-251

prevention and, 247

ps)'chnlogic aspects and, 25 I-254

range nf motion impainll t'nt in, 250

signs and symptoms of, 247

therapeuti c exercise intervention for,

247-252, 248t

Circuit training, 100, 105b

for low back pain , 389

Circulation

eval uatinn of, 100

response to aerobic exercise, 90

Circulation exercises, dUling bed rest, 274

CKC training (See Closed kinetic chain (CKC)

training)

Client, defined, 2

Client history (See also History taking)

components of, 11, lIb Clinical classification, 15 (See also Diagnosis) Clinical decision making difficulties of, 20

for intervention, 17-18

movement system and, 23b

related to dosage, 27b

tips for, 20b

Clinical teaching, 35~3 6 (See also Patientrelated instruction)

Clinician-patient communication, 38-39, 39

Clock step, 539, 539b

Closed-chain exercise, 140-141

Closed kinetic chain (CKC), defined, 283, 284b

Closed kinetic chain (CKC) trairting, 287-292,

292b-305b,306

acti\ity or technique in, 290

biomechanical factors in , 284-286

dosage, 290-291

examination and evaluation in, 287

follo\\ing knee ligament surgery, 283

lower extremity exercise, 291-292

movement system and , 288-289, 289

muscular factors Ln , 284

neutophys iologic factors in , 286--287

precautions and contraindications for, 306

uppe r extremity exercise, 292, 306

WoW' s law and, 286

Coccygeus muscle, 403, 406, 406t, 407

Coccygodynia, 427

Cognitive param eters, modification of, 29b

Cold techniques, in pain treatment, 204

Collateral ligament, of knee , 489-490

Colles fracture , 726--727, 727, 7Z7b

Communication

clinician-patient, 38-39, 39

in patient-related instruction, 40

Complex regional pain syndrome, 729-732,

730b, 731, 732

Compliance, 36 (See also Adherence)

cardiovascular endurance training and , 107,

10Th

Computer workstation posture , 715b

Concentric contraction, 58

Connective tissue

effects of resistive training on, 71, 7lt

elastic properties of, 30

healing of, 209-211, 210

microstructure of. 207-208

optimal loading of, 211-212,21 2

overloading of, 212, 212b

response to loading of, 208-209, 208-210

774

Index

Conn ective tissue (collt'd)

specific awptations to imposed demands

(SAID ), 2 12

\riscous propcrties of, 30

Connective tissue injUly

associatf' d with fractures , 220, 220-221

associated "ith joint replacement surge ry,

226

associated with local inOammation, 219-220

associated with sw'gical procedures, 221-226

cartilage injuri(;!s , 219

co mplicati ons of, 212

in pchi(; fl oor dysfunction , 417-418

principles of treatmen t, 211- 212

sprain, 2]:3, 213, 213t

strain , 213-215 , 214, 215

tendon injuries, 215- 218

Continuous'traini ng, J01-102

Coulract-rehLx-agollist contraction :C RAC)

seque nce, for strf' tching, 12,';

Contract-relax (CR) sequr ncc , (or strc'lc hing,

128

Contrad-relax te chni(juc', in proprioceptive

neuromuscular jilcilitation, 325-326,

,326b

Contractures , de Ified, 11:1

Controlled mobilitv, 24, 24h

COlltl lsions, manageme nt of, 219-220

Convex-concave rul e, 130

COOpf'r 12-lllinutp Irs t, 99

Coordination, defIned, 149

Coordination impairm en t

of IUlllbopchic region

evaluation of, 360

<,x(;'rciscs for, 36-5, 36,'>-366,366

in pcl\ic floor dysfunction, 418-419, 419t

Core strength (See also Inner core muscles)

balance and , 155

Coronary heart disf'a,;c

aerobic p.xu rcise and, l06-107

impaire d aerobic capaci ty and , 95

ri sk factors for, 95b

,

Coronoid process, 555-556, 556 Corticostproids, effect on mu scl e prrt'orJ!laJ1CC,

67

Cos tochondral joints, 611 , 612

C ough, 765h-76nt

CranioVl'rtdJral compl ex , 582, 583, 5S4

ligame nts of, 584, 58-1

n~uscles of, 586

C ross -body rc '
Cross -co untry ski machinf', tOlb

C ross-training, 101

C rush s)mdronl cs, 606

rutches, walki ng \\ith , :50ilG

CTS (See Carpal 'tunn d s}mdn) I,' e)

C uGitaJ tunn el syndrome, 718, 718- 719

Cueing, iu proprioceptive nelll'oll1nscn iar

facilitation , :319

C ultural barri< 'rs, in pallent-rt' lated instructi on,

39-40

C UIllUlatiV<' trauma di sorde rs , 715--715 , 7.1 ,3b,

716b

Cumill and Stan ish Classificati()n, 43, 44t

CyC']ooxY!!('llase (COX)-selectivl' drtl g~;. 204

CyrhLx's sdective tCJl>ion tpst of shouldlT, fi.3 1,

6,) lt

o D(' Querv'llll's syndro lll<' , 714, 721

Debride me nt. reliahilitation h)ll()win~ , 223-:2:2,)

Decision maki ng (Sr" C liniml decision making)

DecOlllp n :osion' >urgcry, rehabilitati on

following , 223- 224

Deconditioning (See also Disuse and decondi tioning)

impai red aerobic capacity and, 95

muscle, 70

Deep ce rvical fl exor muscles. 587

exc; rci ses for, 588--590, 589, 589b, 590

D eep venous throm bosis, 764t, 767b

D egenerative joint disease (See Osteoarthritis)

D eltoid muscle, rotator cuff- de ltoid force

coupl e. 647, 649, 649

Diabetes me llitus, gestational, 260

D iagnosis, 15--16

components of, 15

defln ed,15

medi cal t;s. phvsical th erapy, 15-16

Diagonals of moveme nt, in p roprioceptive

neuromuscular facili tati on , 3 10,

3 1Ol-3131. 314

Diaph ragmatic breath ing

lor temporoma ndibular joint dys functi on,

570-571 , 571b

for thoracic slJi ne d),sfllnction, 62 1, fi'28

Diastasis recti , during pl'egnancv, 268-269 , 269,

270b, 275

Disability

cleflned , 3

eval uation of, 14-15

in Nagi c1isable nle nt wodel , 4

social aspects of, 4, 14

Disablemen t

defi ned, 2

models of, 3, 3--4

process of, 2-4

Disableme nt models . 3, 3-4

Intern ational Cl assification of I mpairme nts, Disabili ties, and Handicaps (lC IDH ), 3, 3--4 modified, 4-8, 5

impairments. 5-6

intelYentions, 7

path ology/pathophysiology, 4-5

p rcvention , 7

risk factors, 7

Nagi Model, 3, 3

Disease, in disab le ment mode ls, 3

Disk, anatomy of, 350, 584, 584

Disk di splacem ent. of temporomanclibLdar

jOill!', 573- 0574, 573-575

Disk dys i'uJl ction

in cervical spine , 605

defi ned, 60S

he rniate d nucleus pulposu s (Hl'\ P ), 389-391

Disk hern iati on , lu mbar , 389-391

acute treatment. 390-,391

c1lronic treatme nt , 391

degenerative process in , 389

exam ination and evalual'ion in . 389-390

patient-related instmction , 391

Disloeation, of elbow, 723- 724, 724

DislJ se and decondiboning

alt hri tis and, 240

of han d , eIGo"', or wri st, 713

of hip m u scle~ , 452, 458-459, 458-459

of kll ee, 499-500

of IUlll bopelvic region, 375-378

muscl e, 70

of shoulder, 670, 671b-672b, 672, 6 7~l L

of thoracic spine region, 622-623

D osage

of balance exercises , 158, 162-163

of cardiovascular e ndurance training,

101- 105

of closed kinetic chain (CKC) train ing,

290-291

of enr!nrance trainin g, Sl

of mobility exe rcises, 1:37-139

in pain treatment, 199,201

of pehi c Hoor exercises, 4 12

of posture anclmovement impairm e nt

treat lllents, J80-J 82

of powe r training, 81

of resi stive exercise, 78, 78--82, 79t

h)r advance d or eli te athlete, 81-82, 8 1t

d uration and volume, 80

frequency, 80

in te nsity, 79-80

sequence, 80

of stabilizati on exercises , 142

of strength training, 80-81

of th e rape utic exe rcise intelYention, 21,

26-27. 27b Dose-response relationship, in ae robic r. x<': rcise, 94

D oubl e <;[ush syndrom es, 600

Dupuytren's co'ntraction, 71 0

D uration

of cardim'uscular ('ndmunce trai,ning, 104-105, 10Sb

of mobi lity exercises , 137-13B

of res istive e., e reise, 80

D'11umic ('<)n traction, 5R D~'lamic exe rcise, 74--77 'for arthritis, :237 in fi b ro01),a1gia and chronic Idtigu e s)01dro me , 249

free-weight, 75-76

plyom ebic, 76-77, 77, 77b

weigh t machi nes, 74-75

Dynamic reversals of antagonists, in p roplioce ptive neuromuscular facili tation, ,321- 322, ,322h-323b Dyn amic strengtll , 73

Dvnamome te rs . isokin etic

'mu scle perfo~m ance evaluation "ith, 73

use in r esistive exercise, 77-78

Dyspareunia, 428

E Ecce ntri c con traction, 58

Ecce ntJi c loadi ng, 68

E ducation (See Pal'ient-re lated instruction)

E lastic modulus. 209

E lastic poten tial, defm ed, 59

Elastic properties , con nective ti ssu e, 3D

E lhow

antl tom ical conside rations , 698-700,699, 700t

cubital tlln nel syn drome, 718, 71"1- 71 9

di slocation of, 723--724, 724

epi condyliti s, 714, 714b

lateral , 7J 9-721, 720

1l1edial, 7'21

exam in ation ,llld evaluation of, 70S-709,

709b

hype rmobJity of, 710-711

joint mobilization exerciSes for, 131b, 134

ki neSiol ogy of, 705-706

medial instability of, 723

mobi li ty impain;le nl of

evalu ation of. 708

exercisE' S for, 709-710

mllSd e pe rformance impairm ent of

evaluation of, 709

e xerci ses fo r, 711

radial tunn e l s)1Jdrom e, 719

range of motion of, 705

te ndin itis of, 712

te nnis, 719-721, 720

Elbow fl exion extension, in pool, 202h

or

175

Index Elderly (See Aging)

Electrotherapeutic modaliti<=s, 31-32

Elite athletes

defined, 73

dosage of resistive exe rcise for, 81--S2, 8It

Elongated muscle , defined, 178

Endocrine syste m, during pregnancy, 259-260

Endometriosis, pelvic floor dysfunction and,

417

Endurance

cardiovascular (See Cardiovascular

endurance )

defined, 58

Endurance training (See also Cardiovascular

e ndurance training)

muscular, 72

dosage of, 81

phYSiologic adaptation to, 72

Entrapment syndromes, nerve

of ('('l-vical spine 606-607

of llip, 45 1, 478--482, 478b, 479 .

of wrist , elbow, or h,mcl, 451

carpal tunnel syndrome, 716--718,717, 718

cllhital tunnel sYlHlrome, 718, 718-719

radial tunnel syndrome , 719

El1\~ronl1Jent

for balance E'xercises, 158

for home exerdse prop;ram, 41--42

Epicondylitis, 714, 7l4b

lat<=rul, 719-721, 720

medial, 72 1

Epimysium, 59

EpiSiotomy, pelvic floor dysfunction from, 417

EqUipment

buoyant, 332,333, 340

for home exercise progmm, 41-42

purch aSi ng for resistive exercise, 74b

Erector spinae

deep , 355, 355

superfiCial, 355, 355

Ergometer, upper body, 100, 102

Er
carpal tunnel syndro me and, 717-718

computer workstation posture and, 715b

cumulative traum a disorders and, 716

loll' back pain and, 359-360

thoracic spine dysfuncti on and, 619b

Evaluation, 12-15

defined, 12

of disability, 14-1.5

of functionalliOlitations, 14

of impairments, 13, 13--14

pathology and, 12

self-report in , 14-15

Evidence-based patient management, 16

Examination, 11-12

components of, 12

defi ned, 11

Excursion test, 287

Exercise

defined, 87

determining level of, 43-44, 44t

health-related benefits of, 94, 94b

Exercise classes, prenatal, 266

Extensor digitorum longus (EDL), 68-69

Extensor mechanism, of fingers, 707

Extensor retinacu lum, 489

F Falls aging and, 153, 467, 615

compression fractures and , 614-61.5

evaluation of' tisk for, 446

hip fracture in , 447--468

prevention of, 615, 616b Family support, home exercise programs and, 41-42

Fasciculi, .59

FaSCitis, plantar, 543-544

Fast-twitch fib ers, 61

Fat pad, of knee, 489, 489

Fats, 88

Fear offalling, 153

Feedback, in balance exercises, 163

Femur

anatomy of, 436-437, 437

angle of inclin ation, 436-437, 437

angle of torsion, 436-437, 437

condyles of, 488, 489

distal fract ure of, 507

Fibromyalgia syndrome

adjunctive interventions for, 253--254

aerobic capacity impairment in, 249-250

case study, 744-74.5

central nervous system origin of, 24.5

classification of, 246b

18 tender points in, 246

emotional stress and , 251-252

etiology of, 245-246

functional limitations in, 246

muscle performance impairment in, 248-249

neuromuscular relaxation for , 2.54, 2.54b,

2.5.5b

patient-related instruction for, 254, 254b

peripheral origin of, 24.5

postural impairment in, 2.50-251

preven tion and, 247

psycholOgiC aspects and , 251-2.54

range of motion impairment in, 2.50

signs and symptoms of, 24.5-246, 246, 246b,

764 t

therapeutic exercise intervention for,

247-252, 248t

adherence, 252

pacing, 252-253

precautions and contraindications, 252

treatment of, 197b

Field tests, for aerobic capacity, 99-100

Finger flexion glove, 733, 733

Fingers

cOIllplex regional pain syndrom e of, 729-732,

730b, 731, 732

extensor mechanism of, 707

joints of, 706- 707

metacarpal fracture of, 727-729, 728b, 729

mobility exercises for, 710, 71Ob , 727, 728,

728b, 729

phalangeal fracture of, 729

pinch with clothes pins exercise, 728

pinch ,,~th putty exercise, 713b

range of Illotion of, 706--707

trigger, 721-722

First ray hypermobility, 533

Flexibility dfc'fined,114 relative, 114,379 Foam rollers

balance exercises with, 1.56b, 159b, 365-366,

366, 372

Side-stepping on balan ce beam, 503

Foot/feet

Achilles tendinosis of, 545, 546

anatomical considerations, .524-527,525,

526, 527b,528

balance impairment of, exercises for,

535-536,535b, 536, 536b

in body alignment, 531-533, 532, .533b

examination and evaluation of, .534-.53.5

first ray hypermobility. 533

forefoot valgus, 534, 534

forefoot varus, .533-534, 534

functional nerve disorders, 54.5-547

gait kinetics and, 529-531, .53It

inflammation in, 542

joint mobilization exercises for, 133b, 136

kineSiology of, 527-533

ligament sprains of, .547-548, 548b, 739

mobility impairment of

evaluation of, 534

exercises for, 539-542, 541, 542, 543b

muscle performance impairment of

evaluation of, 534

exercises for, .536--.538, 537, 537b, 538

pain in

evaluation of, 534

exercises for, 537-538

plantar fascitis, 543--544

posterior tibial tendon dysfunction, 545

posture impairment of

eval uation of. .534-535

exercises for, 538-.539, 539b

subtalar varus, 533, 533

therapeutic exercise intervention for,

535-542,536-538, 536b, 537b,539b,

541-542

Foot muscle strength, closed kinetic chain

(CKC) training for , 293b, 301b, 302b

Foot orthotiCS, 550, .550b

Footwear, purchaSing, .540b

Force, defined, 58

Force closure, 353

Force couple, defined , 172

Force graduation, 61-62

Force-platform biofeedback systems, 468

Force-velOCity relationship, muscle

performance and, 62, 62-63

Forearm

anatomical considerations, 698-700, 700t

fracture of, 725-726

mobility impai rment of, 710, 711

range of motion of, 726, 726

Forefoot valgus, .534. 534

Forefoot varus, 533--534, 534

Form closure, 353

Form fatigu e, 64-6.5

Forward bending, 387b, 392, 392b, 464, 467,

468b

Forward head postu re, 560-561, 561, 600,603,

603,604t

exercises for, 603-605, 604

Fractures, 220, 220-221

ankle, 549

classification of, 220

Colles, 726--727, 727, 727b

immobilized, 221

ofknee,.506--508

metacarpal, 727-729, 728b, 729

olecranon, 72.5-726

phalangeal, 729

radial head, 725-726

scaphoid, 727, 728

stress, 221

surgically stabilized, 221

treatment prinCiples, 220-221

types of, 220,220

Free-weight exercise, 75-76

Frequency

of cardiovascular endurance training, 103,

105b

of mobility exercises, 137-138

of resistive exercise, 80

Fuel sources

for aerobic exercise, 88

selection of, 90

\

776

Index

Functional ('apacity evaillations (FeE ). 3:;Q- .360 Functional incontinence, 424t, 425, 42Sb Functionnllirnilations

",[uatic tberapy for. 344

as sociatedlVilh hip , 441), ·149

associated \\~th shoulder, 652, 6.32h

defined. 3

in disablem ent models. 4

eval uation of, 14

in fibromyulgia syndrome, 246

pelvic floor cksfunction and , 418

Functional outconH'S, for low back pain rehabilitation , 374

Functional Reach Test, 155

Functional spine positions, 372t

Fusion surgery, rehabilitation following ,

225-226

physical thc,rapy defi)1ition , 1

on scope' 01' prach t"' , 47

on screening tools, 50

on tests ancllll easure Jl1C'nts , 72

H

Hamate, 700 , 701

Hamstling llillscl es, 490

musde strain of. 45 l ~452, 452b

st rengthening exercisc:s for , 499, 499

stretching of. 463, 464

passi\"~ sUl~ine, ,380, 381

sc:aled, 495, 491b, 517, S18b

Hand

anatomical considerations, 702, 703, 704t

complex regional pain s)~1drome of, 729- 732,

730b, 731, 7.32

examination and evahJ
709b

joint mobilization exercises for, 132b,

G 134-1.35

Gait

biom echanics of, 357, 358

joints of, 706-707

kineSiology of, 706-707

evaluation of, 360,446

kinetics and kinematics of

mobility impairment of

ankle and foot, .529-531. 53lt

evaluation of. 708

exe rcises for, 710, 711

hip , 441, 442t

kn ee, 491-492, 492t

muscle performance impairment of

kyphosis effects on , 620b evaluation of, 709

exercises for, 7J.l-713, 71.3, 713b

during pregnancy, 270

Gamekeeper's thumb, 724-725,725

range of motion of, 706-707

stiff, 732-733, 733

Gamma system, in regulation of movement, 150

Gastrocnemius muscle , stretching of, 517,

tendon laceration, 72, 722-723

Hand gdp , 707, 708

5l8b,541

power, 707, 708

Gate control theory of pain, 187, 187-188

Genu recurvatum , 171, 171

prehension, 707, 708

Genu valgum, 170, 170, 493,493

strength,714

Genu varum, 170, 170-171,493,493

exercises for, 713, 727, 727, 730, 731

Gestational diahetes mellitus, 260

Hand-knee rocking, 463, 463b, 750b

Glenohumeral joint, 645, 645-646, 646

Handicap, in disablement models, 4

closed kinetic chain (GKG) training for , 303b, Harris Hip Function Scale, 44S, 449

Head nod exercise, S96, 596, 604, 604

304b,305b

exercises for , 754b-756b

Head posture , forward, 560-561 , 561, 600,603,

instability of

603, 604t exercises for, 603-B05, 604

diagnosis of, 679, 679b

etiology of, 677, 678, 679

Hl'adache, celvicogenic, 607

Healing

exercises for, 679-680, 680

GlidC' , in joint rnobiJization C'x('reises, 129

of connective tiss ue , 209-211, 210

Gluteus maxi 111 US muscle, ex{'rcises for , 450,

stages of 42, 209-211 , 210

458-4.59

Health bC'havior models, 36-,38

Health Belid model, 36

Glutcus medins muscle

exercise Jor, 453b-454b, 457b-45Hb, 751b,

Health education, 48, 4S

752b

Health promotion, 48, 48

muscle strain of, 452

wdlness-based practices and, 50, 52-53

taping of, 452, 456

Health protection, 48, 48-49

GlycolYSiS, anaerobic , 88, 89, 92

Health-related benefits, of exercisc, 94, 94b

GlycolytiC system. St>, 89, 92

Health-related quality of life (HRQL)

Goal-oriented treatment, defined , 2

components of, 6-7

Goals, in plan of care, 16

conceptual model of, 50, 51

Golgi t",ndon org~n (GTO), 126-127

Health-related quality of life scales, in pain

Goniometric measurements, 119

evaluation, 190

Graded exercise tests (GXT)

Healthy People 2010, 87

contraindications for, 106b

Heart disease (See also Gardiovascular disease)

maximal,97

impaired aerobic capacity and, 9,5

submaximal, 97-100, 98, 98b

Heart rate

supenision guidelines for, 106, 106b

aerobic exercise effect on , 93

response to aerobic exercise, 90

Grip , 707, 708

power, 707, 708

using to presclibe exercise, 103

Heating techniques, 30, 143-144

prel~ension, 707, 708

deep, 144

Grip strength, 714

exercises for, 71.3, 727, 727, 730, 7.31

in pain treatm ent , 203-204

Guide to Physical Therapist Practice stretching "'ith, 30

on balance assessments, 154

superficial, 143-144

on joint mobilization, 129

Hecllifts, 5.50-551

on 'perceptual asseSSll1c:nt tools , 50

Heel wedges, 550

Herniated l'Jllcleus pulposus (H"iP), ,389-,391 (See also Disk dysfullcti on; Disk hemiation) , Hip abduction ~,\('1'ciscs, 517, 517t

prone, 1T5b-176b

resisted , 505, .50.5

siddying, 26, 26-27, 27b

Hip adduetors

rC'sisted exercises for, .536

strctt:iJing, 461, 461

trigge r points of, 415, 416, 417

Hip arthroplasty, hip hypennohility and, 459-462, 462b Hip extension, exercises for, .517, 517t Hip external rotation stretch, in pool , 51t, 201b, 517

Hip flexors exercise for short, 378, 378b exereises for, 37S, ,378b, 463, 463b, 46Sb, 467, 467b,517, 517t, 620, 620,624-625 , 625

faulty,458

range of motion exercises for, 124, 124, 381b

in sit-ups, 366, 366

Hip joint capsule, 437

Hip lateral rotators, exercises for, 459, 460, 461,

462h

Hip strategy, for balance, 151-152, 152

Hip(s)

anatomical eonsiclerations

arthrology of, 437, 4.37

blood supply to, 438

muscles of, 438, 438t

nerves of, 438

osteology of, 436-437, 437

anatomical impairments of, 441-444

angle of inclination, 441-443, 442

angle of torsion, 441-443, 44.3

angle of Wiberg, 443, 44.3

kg 'length discrepancy, 443-444, 444t

balance impairment of

evaluation of, 446

exercises for, 467-468

examination and evaluation of, 444-450

histol)' taking, 444

lumbar spine d earing examination , 444

functional limitations assQciated \vith , 448,

449

gait ancl, 446

iliotibial banel-related diagnosis, 475,

47S-478,475b , 476b

inflammation in, 447, 472-473, 477

kinematics of, 43~-440, 439t, 440, 441

kinetics of, 440-441 , 441

leg length discrepancy and, 471

mobility impairment of, 473, 473, 477,

477-478,481 closed kinetic chain (eKG) training for, 293b

evaluation of, 446, 446t

exercises for , 446, 446t, 459-467, 461 ,

462b, 463b

joint mobilization, 132b, 1.35

muscle performance impairment of

evaluation of, 446-447

therapeutiC exercise for, 450-452,

452b-45Sb,458-459

muscles of

closed kinetic chain (GKG) training for,

294b, 295b, 298b,299b,302b

disuse and deconditioning of, 452,

458-459, 458-459

pelvic floor dysfunction and , 412

spasms of, 415

strain of, 451-452

Index stretching exc-rcises for, lateraL 495--496,

498

nerve entrapment S}11ciromes, 451, 47B--482,

478b,479

neurologic pathology of, 451, 451b

osteoatthritis of, 461, 472-475, 472b, 473,

474

diagnosis, 472, 472b

hy}lf'nnobility in , 461

treatment, 472-475, 757b--758b

pain in, 447, 468-469, 472--47:3, 477, 763t

in children, 760

exercises for, 469--470, 470b

postural impairment of

evaluation of, 448

exercises for, 470-471

range of motion for, 439, 473

self-traction of, 474

stretching for, 137, 138b

Hist0l)' taking

in aerobk capadty evaluation, 96

in ankle and foot dvsfunction, 534

in cervical spine d}:sfllnction , 587-588

components of, 11, 11b

in elhow, wri st, or band dysfunction, 708

in hip dysfunction , 444

in knee dysfunction , 49.3

in lumhopelvic region dysfunction, 357-358,

359b

in shoulder dysfunction, 649, 650b

in thoracic spine dysfunction , 618

Hold-relax technique, in propriocE'ptive neurom uscular facilitation, 325, 325b HomE' exercise program, 39-42

deterlllining exercise levels, 43--44 , 44t

issues in, 39-42

cultural barriers, 39-40

environment, 41-42

equipment, 41--42

execution, 40-41

instruction clarity, 40

modification of, 44 ' prescription for , 42-45

patient \\~llingn ess , 43

stag s of healing, 42

timing of, 4,3

tissue irritability, 42-43, 42b

printed material for, 40

for program pe"~c floor excrcises , 414, 415b

"Hop and stop" exercise, 157,162

Hop-down drills, 545, 546

Humerus, 698, 699

Hydrostatic pressure, in aquatic therapy, 332,

335-336

Hyoid bone, 556, 556

Hypermobility, jOint, 139--144

causes of, 139

of cervical spin e, 599, 599-600, 600,

60 1b-60Jb

defined , 113, 139

effects of, 139-140

of elbow, wrist, or hand , 710-711

of hip, 459-462, 462b

joint instability tiS., 139

of knee, 496

of lumbopelvic region, 378-380

during pregnanc)" 268

of shollider; 664-665, 665b, 748-749

of temporomandibular joint, 566-568,

566b-567b therapellt.ic exercise intervent.ion for,

140- 143 (See also Stabilization

exen;ises)

of thoracic spine, 624-625,625, 626,

627b-628b

Hype rtonia, 421-422, 422b

chronic pelvic pain, 426

common impairments, 421

eti ology of, 421

function al limitations, 421-422

pain as.'ociated with, 414-413

HypoglycemiC epis()(lPs, 766t-767t

lliococcygeos muscl e, 403--404, 406t

Iliopsoas muscle, 404

strengthening ex~rci se ror, 458, 459b,

750b- 751b

lliosacral rotation, 354

Iliotibial band fascitis

case study, 110-111. 747

hip , 475-476, 475b, 476b

Wotibial band friction syndrome, hip, 475b, 476

Iliotibial band-related diagnosis, 475, 475--478,

475b, 476b Iliotibial band syndrome, 458, 513--514 Immobilization effccts of, 114-115,115, 117

exercises for (See Mobility exercises) Impact activity, 101 , 103b Impairments anatomic, 5-6, 5b

chOOS ing right intervention fOL 17-18

defined, ·3, .5-6

in disable ment models , 3-4

evaluation of, 13, 13-14

movement sys te m in, 23, 23b

physiologic,S, 5b

primary, 6

psychologiC, 5b, 6

secondalY, 6

Impingement, rotator cuff, 649

case study, 654b, 735, 74 15-749

causes of, 653

exercises for, 653, 655b-660b

treatment of, 653

Incontinence

de fin ed,423

evaluation of, 410-411 , 411b

functional , 424t, 425 , 425b

mixed, 424t, 425

overflow, 424t, 425

stress, 424, 424, 424t

snpportive dysfunction and, 420-421

t.herapeutic exercise for, 423-426

urge, 424-425, 424t

Inf1ammation

of ankle or foot, 542

of elbow, \Vl,ist, or hand , 709, 714

of hip, 447, 470b, 472-473, 477

local, management of, 219-220

low back pain and, 385

pain and , 186

Inflammatory response

in healing, 210

in rheumatoid arthritis, 232, 232

Infrahyoid muscles, 558, 559,560,587 Inner core muscles activation of, 368b defined,366 exercises for bent-h."1lee fallout, 370, 372, 372b

Inner Core Series, 370, 371b

manually assisted, 369

supine inner core progression, 369--370,

370

patient-related instruction for, 367, 36ilb

therapeutiC exe rcise for, 366-368,

369b-370b, 370. 371b,372-374

777

Inner core syne rgy 368b Insertion sites

eHects of remobilizat.ion on, 118

effects on immobilization on, 116

Intensity of cardiovascular endurance training, 103-104, 105b

of mobility csereises, 137- 1.315

of resistive exercise, 79~~0

Interbody jOint, 584, 584

Intercarpal joint, 701, 702 , 703

Intercostal neuralgia, dming pregnanc)"

276- 277

Intennediate athletes, defined, 7.3

International Classification of Impairments,

Disabilities, and Handicaps ([CIDf!), 3, 3-4

Interosseous ligament, 702t

Interosseous membrane, 699

Interphalangeal joint, 707

exercises for, 710, 71Ob, 712b, 728b, 729

Interval training, 100

Intelvention, 17-19 (See also Therapeutic

exercise intervention )

clinical decision making for, 17- 18

defined, 17 '

modification of, 19

patient-related instruction ror, 18--19

selection of, 17-IS

types of, 17-18, 17b

Intervertebral disks (IDs) , 350 (See aL,o Disk; Disk d)" sfunction ) Irradiation, in proprioceptive neuromuscular facilitation, 319-320

Isokinetic contraction, 59

Isokinetic d}Tlamometers

mu scle performance evaluation ,,~tb, 73

m e in resistive exercise, 77-78

Isokinetic exercises, 77-78

Isometlic ankle eversion, 214b

Isometric contraction, .58

Isometric exercise, 73--74

ankle ever 'ion, 214b

for arthritis, 235-236, 236, 236b

resisth'c, 73--74

for subscapulariS mu scle , 66.5, 665

Isotoni<.: conh'action, 58

Isotonics, in proprioceptive neuromuscular

facilitation, 325-326, 326b

J Joint capsule

of hip, 437

of knee, 489-490

sprain of, 213, 213, 213t

of temporomalldibular joi.nt, 557

Joint clicking, in te mporomandibular joint dysfunction, .573--574 Joint instability

de fined,113

evaluation of, 119

hypermobility US., 139

JOint mobility (See Mobility)

Joint mobilization, 129-131, 131b-133b,

134-136

of ankle, 133b, 136

biomechanics of, 129-130

defined, 129

of elbow, 131b, 134

of foot , 133b. 136

general procedures for , 130-131

grades for, 129, ]29--130

of hand, 1:32b, 134-135, 731,731

of hip, 132b, 135

778

Index

Joint mobilization (cont'd)

of knee, 133b, 135

of shoulder. 131b, 134

of spine, 133b,136

of temporomandibular jOint. 562, 563

of wrist, 132b, 134- 135

Joint range of motion , 114

evaluation of, H9

joint replacement surgery, 226

JOint surface geometry. 284-286,285

Joint(s)

. of ankl e, 525, 525-526, 526

of cervical spine. 582. 583, 584

elbow (See Elbow)

of hand, 706-707

hip (See Hip)

knee (See Knee)

ofshoulder,643-646, 644-646,644t

strain of. 213-215, 214. 215

synovial, 229-230. 230

temporomandibular (See

Temporomandibular joint)

of wrist, 701. 702. 703

Jumpingjacks to eva luate pelvic: fl oor muscles. 411b in water, 200b

K Kallenborn 's grades for mobilization, 129,

129-130

Kegel exercises, 402

Kinesiologic purpose of exercise, 137

Killesiopathology, defined, 172

Kinesthesia, defined. 150

Kinetics, defined, 58

Klein-Vogclbach kinetic exercises, for

temporomandibular joint dysfunction. 564,564-566,566 Knee anatomical C'on$ iderations. 448-492, 489

arthrology of, 489-490

muscles of, 490--491

osteology, 488-489, 489

arthritis of. 509-512

articular cartilage lesions in , 509-510

osteotomy for, 510--511

rehabilitation follOWing, 512

total knee arthroplasty. 511 , 740

disuse and deconditioning of, 499-500

examination and evalu ation of, 493-494.

493b, 494b

fractures of. 506-508

genu valgum , 493. 493

genu varu m, 493, 493

hyperextension of, 171 . 171 , 470, 470

kinematics of, 491-492, 492t

ligament injuries of, .500--506

anterior cruciate, 500-501 , 744

lateral collateral , 502-503

medial collateral . 502

postelior cruciate, 501-502

training for prevention . 501b

treatment of. 503. 504. 504b, 505, 505-506

meniscal injuries of. 508-509

meniscal repair of, 224

mobility impainnent of

evaluation of, 494

exercises for. 494-496. 496. 496b, 497.

503. 504, 504b. 50S, 505-.506 jOint mobilization for, 133b, 13.5, 1..37,137 muscle performance impairment of

evaluation of, 494

exerciSllS for, 464, 466b, 496-500, 498, 499

muscle strain of, 498-499

neurolOgiC pathology of. 498

normal , 172

pain in . 494 . 763t

path of instantaneous cen ter of rotation for.

172

tendinopathies , 512--520

iliotibial band syndrome, 513-514

patellar, 512-513. 513b

patellofemoral pain syndron1P. 514-520

valgus ar.gle of, 170

Knee bend. prone. 378. 378b

Knee dysfunction. related to hip mobility

impairments, 464.465 Knee extension, exercises for, 498, 504b prone.504b seated. 465b Knee flexion, range of motion exercises for, 125b,495,504, 504b Knee ligament injuri es, 500~506

anterior cmciate, 500--501, 744

lateral collateral, 502-503

medial collateral, 502

posterior cmciate, 501 ~502

training for prevention, .501 b

treatm ent of. 503, 504, 504b, 505, 505-506

Knee ligament surgery, 222, 223b closed kin etic chain (eKe) training follOWing, 283

Knee-to-chest stretching, 123b

Knock kn ees, 170, 170

Krebs cycle, 88, 90. 91, 92

KyphOSiS, 169-170, 170, 176,269,614-616,

629-630 , 630

causes of, 629-630, 630

deflned,614

effects on gait, 620b

exercises for. 629-630, 630, 637, 638t

phYSiolOgiC impairment associated with, 637b

Scheu ermann's disease , 616, 616

taping for, 623, 623, 625 . 630

vertebral compression fractures in , 614-615

L Labrum, repair of, 224

Lateral collateral ligament

of ankle, 525, 525

of knee, 489-490

injury to, 502--503 Lateral femoral cutaneOlls nelve entrapm ent, during pregnam,y, 277

Lateral kicks, standing, 69b

Lateral pterygOid mllscl,,, 558, 558t

Latissimus muscle. stretching of, 663b

Learning (See Patient-related instlllction )

Learning capability. 27

Leg length dis<:repancy, 443-444. 444t.

448-449

functional , 471

hip and . 471

struct ural , 471

Length-tenSion relationship

in movement impairments, 174

muscle performance and. 63, 63, 70

Levator ani muscle. 403-404, 406t

Levator ani syndrome. 426-427

Levator scapula muscle, 587

mobility exercises for, 597, 597,598 stretching of. 659

Lever ann length , in aquatic therapy, 332, 332

Lifes tvle

defin ed,50

sede nta,}, 95

wellness and, 49-50

Ligament injuries, knee, 500-506

anterior cruciate. 500--501. 744

lateral collateral ..502--503

medial collateral. 502

post prior cruciate. 501-502

training for pre\·ention . 501b

treatment of. 503. 504. 504b. 505, 505-506

Ligament reconstruction surgery

closed kinetic chain (eKe) training

following. 283

rehabilitation following. 222. 223b

Ligaments. Z08

of ankle and foot. 525. 525-526. 526

arthritis pffects on. 230t

of craniovertebral complex. 584. 584

effects of remobilization on. 118

effects on immobilization on. 116

of forearm and elbow, 699. 699

function of. 230t

of hand. 702. 703

of hip. 437. 437

of knee. 489. 489-490

of lumbar spine, 350. 3.50-351

of midcervical spine. 585

of shoulder

acromioclavicular joint. 644. 645

glenohumeral jOint. 645. 646, 646

sternoclavicular joint, 643- 644. 644, 644t

sprain of, 213. 213. 213t ankle and foot. 547-548. 548b

of thoracic spine. 611. 612

of wrist. 701. 702t

Limits of stability. deflned. 149

Lister's tubercle , 698

Loads, on spine, 352-353. 353

Long thoracic nerve injury, 666, 666b

Lordosis, 169.170. 269.632,632.633

Low Back Outcome Score (LBOS )' 364. 364.

365t Low back pain (LBP ). 383--386 (See also Lumbopelvic region) aerobic capacity impairment associated with. 365

anatomical considerations, 350-357

anthropometric characteristics in. 359

associated ,vith pregnancy. 270--272, 275

body mechanics and , 359-360

examination aJld evaluation of. 357--364

pathomechanic approach, 357

patient history, 357-358. :359b

scree ning, :358, :359b

tests and measures. 359--364

hip function and. 438

mechanical causes of, 383

mobility exercises for, 380--:382. 381b

muscle strain in. 374

Oswestry Low Back Disability Questionnaire

for. 190, 195-196

positional traction for. 38.5, 385

therapeutic exercise for. 364--389

treatment of. 349

Lower extre mi ties alignment of. 533b closed kinetic chain (eKe ) training for, 291-292

diagonals of movement for. 313t

mobility exercises in pool , .339b

Lower Extremity Functional Profile. Gray and

Team Reaction. 287

Lumbar disk herniation, 389--391

acute treatment, 390--391

chronic treatment. 391

degenerative process in, 389

examination and evaluation in, 389-390

patient-related instruction, 391

Lumbar multifidus muscle, 350, 367, 368b

Index Lumbar pain, during pregnancy. 271

Lumbar spine

arthrology of, 3.50,330- 3,51

innervation of, 352

joint mobilization exercises for, 133b, 136

kinetics of, 352-333

range of motion of, 351-352

stenosis of. 743

vertebrae of, 350, 350

Lumbar spine dearing examination, 444

Lumbar spine strengthening, closed kinetic

chain (CKC) training for, 291>b Lumbar spine vertebrae, 3.50,350 Lumbopelvic region adjunctive interventions for, 393--394

aerobic capacity im pairment associated vlith,

365

anatomical considerations, 350-357

arthrology of, 350, 350-351

muscles of, 354-357, 355, 356

nerves of, 352

balance and coordination impairment of

evaluation of, 360

exercises for, 365, 365-366,366

disuse and deconditioning of, 375-378

examination and evaluation of, 357-364

neurologic testing, 360-366, 362t

pathomechanic approach, 357

patient histo ry, 357-358, 359b

screening, 358, 359b

tests and measures , 359-364

ga it and

biomechanics of, 357, 358

evaluation of, 360

lumbar disk herniation , 389-391

lumbar spine , 350,350-353

mobility impairment of

evaluation of, 362-364

exercises for, 378-383

pelvic floor dysfunction and, 416-417

muscle performance imp airment of

evaluation of, 360

exercises for, 366-375 ,367, 368b,

369b-370b, 371b, 372b, 372t, 373t

muscle strain in, 374

muscles and corresponding nerve root, 36lt

muscles of. :3.54-337, 355, 356, 36lt

neurologic impairment and, 374

pain in (Set? also Low back pain (LBP ))

evaluation of, 361-362, 36lt th erapeu tic exercise for, 383--386

pelvic girdl e, 353--354, 3,S4t

posture impairment of

evaluation of, 362

exercises for, 386-389

spinal stenosis, 391-392

spondylolySis and spon dylolisthes is, 392-393

Lunate bone , 700

M Macrotrauma, defined, 185-186

Maitland's grades for mobilization, 129,

129- 1,'30

Mandible , 555-556, 556

Manipulation , 129-],'31, 131b--133b, 134-136

(See IIlso Joint mobilization)

Manual contacts, in proprioceptive

neuromuscular facilitation , 317-319, 319

Manual muscle test, 72--73

for hip musdes, 446-447

for sh ou.lder muscles, 651

for trapezius muscles, 173-174 , 174

Masseter muscle, 557, 558t, 559, 560

Maximal oxygen uptake, deflned, 88

McGill Pain Questionnaire, 189, 1 9

McKenzie method, 363, 383-384, 390

Medial collateral ligament, of knee, 489-490

effects on immobilization on, 116

injury to, ,502 Medial pterygoid muscle, 557, 558t Median nerve anatomy of, 703

nerve entrapment syndrome of, 716--718,

717,718

Medical conditions

associated ,vith symptoms during exercise,

76,5t

signs associated \vith, 765t

symptoms associated \\~th, 764t

Medical diagnosis, 15-16

Medical Outcomes Study 36-Item Short-Form

Health SUlvey (SF-36), 15

Medi cations

for fibromyalgia and chronic fatigue

syndrome, 253--2S4

pain, 204-205

Meniscal injuries, of knee, 508-509

repair of, 224, S09

Meniscus

of knee , 489

of temporomandibular jOint, 556, 556-557

Metabolic equivalents (VIETS ), 103

Metabolic pathways

ATP-PCr syste m, 88, 92

fuel source selection and , 90

glycolytic system, 88, 89, 92

oxidative system , 88, 90, 91, 92

Metacarpal fracture, 727-729, 728b, 729

Metacarpals, 702, 703

Metacarpophalangeal joint

exercises for, 712b, 728b, 729

kinesiology of, 707

METS (metabolic eqUivale nts), 103

using to prescribe exercise, 103

Mi crotrau rna, defined, 185-186

Micturition, phYSiology of, 405, 408b

Midcarpal ligament, 702t

Midcervical spine, 584, 584-585

ligam ents of, 383

motion at, 584-585, 585

Midtarsal jOint

anatomy of, 325-526, 526

kineSiology of, 529, 530

Million visual analog scale (VAS ), 188,188, 365t Minitralllpoline, balance exerciscs 'vith, 157b Mobility controlled, 24. 24b

defined, 24,24b

effects uf remobilization on, 117-119

evaluation of, 119, 119-120,120

hypermobility (See Hypermobility)

neuromeningeal hypomobility, 382, 382b

phYSiology of normal , 114

posture and movement impairments and, 173

Mobility exercises, 113, 120-139

adjunctive agents for, 143-144

defined, 121

dosage of, 137-139

jOint mobilization, 120, 129-131 , 131b-133b ,

134-136 (See aha Joint mobilization )

lifespan issues associated with, 143

for low back pain (LBP), 380-382, 381b

precautions and contraindications for,

138-139

range of motion exercises, 120-125 (See also

Range of motion exercises)

stretching, 125-129 (See also Stretching)

Mobility impairment

adjunctive agents for, 143--144

779

of ankle and foot

evaluation of, 334

exercises for, 539-542, 541, 542, .543 b

in arthritis, 234-235

causes of, 114

of cervical spine, 593-599, 594, 595b, 598,

599

effects of, 114-117, 115, 11 7

of elbow, wrist, or hand, 708-710

evaluation of, 119, 119-120, 120

exercises for (See Vlobility exercises)

of hip, 462-467, 473,473, 477,477-478,481

closed kinetic chain (C KC) training for, 293b

evaluation of, 446, 446t

exercises for , 446t, 459-467, 461, 462b,

463b,463b,446

iliotibial band-related diagnOSiS, 478

osteoarthritis, 473, 473

of knee

evaluation of, 494

exercises for, 494-496, 496, 496b, 497,

503 , 504,504b,505, 505-506

oflumbopelvic region, 380-382, 381b, 463

evaluation of, 362-364

exercises for, 378-383

in patellofemoral pain syndrome, 515-516

in pelvic floo r dysfunction, 415-418

of shoulder

evaluation of. 652, 652b

exercises for, 661-664 , 663, 663b, 664

of temporomandibula r joint

evaluation of, 361

exercises for, 562-566, 563~566

of thoracic spine , 623

evaluation of, 619b

exercises for, 625-629, 628, 629

Mode, in therapeutiC exercise, 26

Modification

of exercise in arthritis treatment, 239-241

of home exercise program , 44

of intervention, 19

of therapeutic exercise, 27, 28b--29b , 30

Motivation

adherence and, 36-38, 43

in pe h~c floor dysfunction , 408

Motor deve lopment, in proprioceptive ncuromuscular facilitation , 314, 315b tv[ otor function

shoulder, ev,uuation of, 651

thoracic spine

evaluation of. 619b exercises for , 624, 625, 629-632

Motor learning, balance and, 132

Motor output, generating, 151- 152

Motor unit, 61

Movement, 171-172

balance exercises and, 156--158

defined, 171

eva'luation of, 179, 179-180, 178b, 180b

in th prapeutic exe rcise, 26

Movem ent analysis, 179, 179-180, 178b , 180b

Movem ent ann , de fined, 58

Movement control, stages of, 24-26, 24b, 25

Movement impairment

adjunctive interventions for, 182-183

anthropometric characteristics and, 176, 177

causes of, 112- 174, 176--178

in children, 177-178, l i7b

dosage of, 180-182

evaluation of,179, 179-180, 179b, 180b

factors affecting, 168b

of foot and ankle , 538-539, 539b

of hip, 470-471

intervention for, 180- 183

780

Index

Movcment impairment (cont'd)

jOint mobility and, 173

lifespan cominl"rations in , 177-178, 177b

of IUlllbopelvic region, 386-389

musc!p lpngth in, 173

Illllsclc per:!onn
pain in, 174, 176

patient-related instruction in, 182

psychologic impai.rments and , 176-177

range of motion und , 173

ors'houlder, 661 - 664, 663, 663h, 664,

672-673

of temporomandihular jOint, 568-572

Movement system, 21, 21-26, 23b

dosed kinetic chain (eKe ) training and,

28S--289,28U

in lllohiLity C'xercises, 120

in posture and movement impairments,

lS0-181 , ISOb

in stabilization exercises, 140

Multiple cnrsh syndromes, 606

Muscle amnesia , 2,4

Muscl e arch itecture, 64

Muscle eont radions

concentJic, 58

dynalllic,5S

eccentlic, 58

force granuation in , 61-62

isokinetic,59

isometric, .58

isotonic, 58

motor IInit in, 61

sequence of ovcn ts for, 60-61, 61

Muscle dorninancc, defined, 172

Mmclc fatiglle, 64- 6.5

defined, 54

form, 64-6,3

Muscle fiber

3uatomy of, 59, 59-60

diameter of, 62

effect on rflllsde performance, 62

types of, 61, 62

Mmcl e length

in cezvical spi ne dysfunction, 593-594,

596- 598

diastasis recti dUling pregnancy, 268-269,

269,270b

in lumhopelvic dysfunction, 36z-364

in pelvic floor d),sfunction, 415-411)

posture and mOl'ement impairments and, 173

tests of. 179b

in thoracic spine dysfunction, 619b, 623,

623-629

Muscl e performance

during adulthood, 66

alcohol cffeds on, 67

in ch ildren, 65-66

cognitive aspects of, 66-67

corticos teroid's effect on, 67

evalu ation of, 72-73

factors affecting, 62-67

force-velocity relationship and, 62, 62-63

length-tcnsion rclationship and, 63, 63

muscle fatigu e and , 64-65

muscle fibers and, 62

neuroloi(ic adap tation and, 64

in older adults , 66

overvievl, 57--59

phYSiologic adaptation to training, 70-72, 71t

posture and movement impairments and,

173-174,174

dllling puberty, 66

therapeu tiC exercise intezvention for, 73-82

(See also Resistive exercise)

dosage , 78, 78-82,79t

precautions and contraindication" 82

training specificity and, 64

Muscle performance impairmen t

of ankle and foot

eval uation of, 534

exercises for, 536-538, 537, 537b, 538

in arthritis, 235-237

during bed rest, 273-274

causes of, 67-70

disuse and deconditioning, 70

length-associated changes, 70

muscle strain, 68-70

neurologk pathology, 67-68

of cervical spine, 588-592,589-592, 589b,

592b

of elbow, wrist, or hand , 709, 711-71,3

in fihrorn)algia and chronic fatign e

syndrome, 248-249

of hip

evaluatio n of, 446-447

iliotibial band-related diagnosis , 478

ostmarthritis, 473--474, 474

piriform syn drome, 480

therapeutic exercise for, 450-452,

452h-458b,458-459

of knee

evaluation of, 494

exercises for, 464, 466b, 496-500, 498, 499

of lumbopelvic region

eva luation of, 360

exe rcises for, ,366-375, 367, 368b,

369b- 37Gb, ,37J b, 372h, 372t, 373t

during pregnancy, 257-268, 274-276

of shoulder

eval1wtion of, 651, 651b, 551t

exercises for, 666-672, 667-66,9,

671h- 672b

of temporomandibular joint, exercises fo r,

566-568,566b-567b , 56~568

of thoracic spine

ev,iluati on of, 619b

exercises for, 621, 621-623, 622, 623

;\,I( uscle range of motion , 114, 120

Muscle s tr~;1gth, defined, 58

Muscle(s)

of ankle and foot, 526, 526b, 527b

arthritis effects on, 230t

of cervical spine, 586, 586-587, 586t, 587

elongated, 171)

of forearm and elbow, 699-700, 700t

function of, 230t

of hand, 702, 704t, 705

immobilization effects on, 115,115

of lumbopelvic region, 354-357, 355, 356

pelvic diaphragm, 403, 406, 406t

of pelViC floor, 403--404, 404, 405, 406t, 407

remobilization effects on, 117, 117

resistive training effects on, 70-71, 711

short, 178

of shouJder, 647-649, 647 t, 648

skeletal

actions of, 58-59 (Sec also Muscle

contractions)

gross stnrcture of, 59, 59-60

types of muscle fibers, 61

ultrastmcture of, 60, 60

strain of, 213-215,214,215

of temporomandibular joint, 557-559,

557-559

of thoracic spine, 611, 613t

of mist, 701-702, 703t

Muscular endurance, 72

Musculoskeletal pain s)11dromes (MPS ),

regional, posture and movement

impairments in, 167

Musculoskeletal system , during pregnancy,

262-263

Myopathy, alcoholic, 67, 82

N Nagi Y1odel, for disablement, 3, 3--4

1\:erve compression syndromes, during

pregnancy, 276-277 (See also l\elVe

entrapment syndromes )

Nerve t'Jl trapment syndromes

of cervical spine, 606-607

of hip, 451, 478--4S2, 478b, 479

of wlist, elhow, or hand, 451

carpal tunnel SY11drollle, 716-7J8, 717, 718

cubital tunnel syndrome, 718, 718-719

radial tunnel s),11drome, 719

Nerve root pathology

in lu mbopelvic region, 374

muscle performance and, 67-68

Nerves

of ankle and foot, ,526-527, 527t

of cen ical spin e, 585-586

of elbow, wrist , and hand, 702-703, 705

of hip, 438

of temporomandibular joint, 560

Neuroconductive testing, of lumbopelvi c

region, ,360

Neurod)1Iamie testing, oflumbopelvie region,

.360

Neurologi C: adaptation

closc;d kinetic chain (eKe) training and, 286

muscle performance and, 64

Neurologic pathology

in ankle and foot dysfunction, 545-547

in elbow, hand, or wrist dysfunction, 712

in hip dysfunction, 451, 451b

in knee dysfunction, 498

in lumbopelvic dysfunction, 374

muscle performance and, 67-68

in pelvic floor dysfunction , 407

in shoulder dvsfunction, 652, 666, 667, 668

in thoracic spi11e dysfunction, 621

Neurologic testing, oflumbopelvic region,

360-361, .3611

Neuromeningeal hypomobility

exercise for, 3S2b

types of, 382

Neurom eningea1 tension, 598,598~599 , 599

Neuromuscular disease, muscle performance

and, 67- 68, 82

Neuromuscular electrical stimulation (NMES),

31,311

combining \vith SEMG, 32

for long thoracic nezve injury, 666

Neuromuscular parameters, modification of,

28b-29b

Neuromuscular relaxation

in flbromyalgia and chronic fatigue

s)~1drome , 254, 254b, 255b

of lib joints, 256b

of SUhOl'Cipitallllllscles, 254b, 255b

in te rnporojmUldibular joint dysfuncti on, 567,

567,569

Non-nociceptive pain (NNP), 186, 186b

Non-weight bearing exercise, 101, 106

Nonrelaxing puborectalis syndrome, 428

Nons teroidal anti-inflammatory dnrgs

(NSA IDs ), 185,204

Novice clients, deflned, 73

Nucleus pulposus, 350-351

e

o

O bliqu ahdominal Illusd e, stre tchi ng of. 629,

62

Obste trics (Sep Pregnancy)

Obturator illtPrtlUS Illuscle, 404

Olecranon fracture, 72.5-72(;

l-II,iir walk test. 99-100

OpC'n-c!win ewrl'is('. 141

Opcn kinetic chain (OKC)

ddinrd , 21n. 2S4b

t('st for hip, 448

Open reduction and intemal rL~ation (ORIF),

221, 225

for ankle fracture, 549

Opioids, 204-205

Organ prolapse, in pelViC floor dysfunction, 426

OsteoarthJitis , 472 (See also Arthlitis )

aerobic capacity impairm ent in, 237-239

case study, 741

clinical manifestations of, 231, 231

effe<;ts of, 230t

etiology of, 230-231

of hip , 461, 472-475, 472b, 473. 474

diagnosis, 472, 4721>

hypemlobility in , 461

treatment, 472-475

mobility impairm(-' nt in. 234-233

muscle performance impairnlf'nt in , 235--237

pain associated wit h, 234, 241

prevention of, 233

of temporomandibular joint, 373

therapeuti<; exercise intervention for,

233-239

exercise modifications, 239-241

Osteochondral autograft tra nsplantation

(OATs),225

Osteokinel11Gtics

defined, 113

stretching and, 125-126

Osteoporosis

case study, 741

transient, 272

ve rtebral co mpression fractures in, 614-615

Osteoto my, 226

for arth,i tis of the knee, 510--512

OSWE'stry Low Back Disability Qllestionnain',

190,195-196, 363t

Outcomcs of int(av(-'ntion, 19- 20

Overtraining, 82

in aquatic therapy, .346

Overuse injuries, 6~9

in thoracic Spill(' r(,gion , 621-622

Ovoid joint, ddlned, 130

Oxidative syst, 'm, ti8, 90, 91, 92

p

Pain (See also Low back pain (LBP ))

acute'

defincd,185

patient-related in struction , 19Th

sources of, 185-186

therap e utic exercise intervl'IItion for, 190

adjunctive inte rven tions for, 202- 205

cold techniques, 204

heat techlli(jues, 203-204

medication, 204-205

transcutan eous electJical nerve stimulation

(TENS),202-203

in an kle and foot

evaluation of, 534, 763t

exercises for, 537-538

arthriti s and. 234. 241

associat(·d with pregnancy, 270-272 , 276

ho ne, , (iOt

in ce r,il'al spin e' region . 762t

chest. 752t

in chiklrC'n, 760

chronic

defined , 1 5

patie'nt-n'!atcd instruction, 19Th, 204b

sou rccs 0 f, 186

therapeutit! xerc ise inte rve ntion for, 190,

194, 107

in co mplex regional pain syndm me, 729-730

defin ed, 185

in elbow, wrist, or hand, 709, 714

in elderly. 759

evaluation of, 188-190

disE'ase specific tools, 190, 195- 196

he alth-re lated quality of life scales, 190

McGill Pain Questionnaire. J1:i9, 189

visual analog scale (Y.\S ), 18ti, 188

in female patien ts, 759

in fihrom yalgia and chronic fatigllf'

s)'11dronw, 252

in hip . 447 , 461l-469, 763t

exercises for , 469-470, 470b

iliotihial ban(l-r(' lated diagnosi s. 477

osteoarthritis , 470b , 472-473

piri fo rm synorom c, 480

in kn ee, 494, 763t

in leg, 763t

non-nociceptive, 186, 186b

in peh'ic floor dysfunc:tion , 414-415,

421-422,426

phYS iology of, 185-188

in posture and movement impairments, 174,

176

referred

causes of, 186

defined , 1H.5

regionalmuscnlos keletal pain syndromes

(MPS ), 167

in shoulder, 650, 762t

evaluation of, 651-652

exercises for, 653, 654b-660b, 661, 661

somatic sources of, 760t

systemi e s>~nptoms of, 761t

in te mporomalldilJUlar jOint, 561-562

th ('fapellt ic eXC'rcise inte[\''C'nti on for , 190,

1')4, 197- 202

dosage of, 199, 201

modes of, 197- 199

in thoracic spine region, 619b, 629,

762t-763t

visceral source's of. 760t

vi scc ral structures and, 759

visceral symptoms of. 7611-763t

Pain pnth" 'ays , 186-187

Pain t.heory, 187, 187-188

Palmar fascia , 710

Paratenonitis, 216, 217t

Parkimon's disease, 633-634, 634

Passive ROM pxerci ses, 121-122,122, 123b,

118-139

Plltella, 41l8-489

Patellar fractures, 506

Patellar glide, 495. 496b

Patellar mobili zation, 495 , 496b

Pat(-'lIar tendinopathi es, 512-513, 513b

Patellofemoral dysfunction , durin pregnanc)"

277

Patellofemoral joint

kinematics of. 491-492

kinetics of, 492

Patello femoral pain syndrome, 514-520

dyn
781

<'tinlo!..,,' o f', 5 1-1

('xumt',;ution anu e\'.lluation in. - 1.- - 16

pns tope'rativc r habilitation for. 519

progllosis of. 519-520

static structure;'!> in. 514

thc rap(' nti c exercise;' for, 51 6-519, 5 7t. 51 b.

.519

Pat h of in st,llltan eous center 0 rotation

(PIC R), 24, 171 , 1 i:..

for knee, 172

filr shollld('r, 647-648

Pathokin e,jo logv, defin ed, 1,2

Pathology ,.

defln('d, 4-5

in disab le nwnt models, 5

e\'1rluation of, 12

Pathophysiology (See also Patholo ,)

defin ed, 4-5

Patient

cl in iC ian co mmunication \vith, :1H-39, 39

defined, 2

Patient controlled analgesia (PCA), :205

Patil" nt manage ment, 10-32, 20b

evidence-ha,ed, 16

ru odel for, 10, 10- 20

Pati " "t manageme nt mode l, 10, 10--20

clini caJ decision making, 20, 20b

dia\!;nosis, 15-16

,,\·,;Inat ion, 12-15

examin ation, 11-12

int rve ntion , 17- 19 (See also Therapeutic

exercise intervention )

ou tcOI11 S, 19-20

plan of care, 16

prognosis, 16

Patie nt-related instruction, 18-19, 39-45

about ae robic ew rcise, 107-108

abou t aquatic the rap, , 345

about balance impairment, 163,386, 386b,

387h

auo ut cardio\'a eular endurance training,

107-10

about inner core muscles, 367, 368b

abo "t peHc fl oor exercises. 41.1-414, 4J.4b

abou t posture llnd movement impairmC'nts,

182

about proprioceptive neurom uscular

facilitation. 326-327

for aCllte pain. 197b

adhercllce and moti, tion in, 36-38

for arthriti s, 241

b(-,lw lhs of. .1t' 19

for carpa.! tu nne l syndrome, 717

for chronic fatig;I' S)l1drom . 25-1, 254b

for c hro nic pain, 197b. :!04b

in cl inie. 33-36

clinician-patient communication in , -39,

39

components of. 18

cultural barriers in , 39--lO

defined, 18

for fibroul\'ulgia S\l1drome 25-1. 254h

home ex('(cis~ program and. 39-42 (See also

Hom e exe rcise program

for lumbar disk herniation. 391

safety and, 33-36

sel f-lllanagen1ent and, 36

fo r sp inal stenosis, 392, 39'2b

Pectoralis muscle, stretchim!; of. 659, 663, 663,

664 ­ Pelvic diaph ragm Il1 US . 406, -!05t

Pelvic floor, 402-432

anatomy of, 403, -l03-W­ defill ec1.402

782

Index

Pelvic floor dysfunction

adjunctive interventions for, 428-432

biofeedback, 428-429, 429

bladder training, 429, 429t, 430

palpating pelvic floor inuscles, 431-432,

432

scar mobilization, 429, 431, 431 ,

43 It

from birth injury, 407

chronic pelvic pain in, 426

coccygodynia in, 427

coordination impairment in, 418-419, 419t,

422

dyspareunia in, 428

examination and evaluation in, 408-411 ,

409b, 41Ob, 411b

internal examination , 409-410, 410b

screening, 409, 410b

self-assessment tests, 410-411 , 411b, 414,

415b

hype rtonia, 421-422, 422b

common impairments, 421

etiology of, 421

functional limitations, 421-422

pain associated \vith, 414--415, 426

incontinence and, 423-426 (See also

Incontinence)

levator ani syndrome in, 426-427

mobility impairment in, 415-418

muscle performance impairment in,

411-412

neurologic pathology, 407

nonrelaxing puborectalis syndrome

in , 428

organ prolapse in, 426

pain in, 414--415

posture impairment and, 418, 418b

psychologic impairments in, 408

risk factors for, 409, 409b

sexual abuse and, 408, 408b, 409b

supportive, 419-421

common impairments, 420, 421b

etiology of, 419-420

functional limitations, 420-421

organ prolapse, 426

therapeutic exercise intervention for ,

411-419

vagin ismus in , 428

visceral dvsfunction in , 422-423

vulvodynia in , 427-428, 42Th

Peh~c floor exercises, 402, 412-414

Pelvic floor exercises, 41Th

Pelvic floor exercises

dosage, 412

fol.lovving pregnancy, 275

home exercise program for, 414, 415b

Kegel exercises, 402

patient-related instruction, 413-414,

414b

during pregnancy, 267-269

self-assessment test for , 414, 415b

Pelvic fl oor muscles, 403--404, 404, 405, 406t,

407

contraction of, 368b

exercises for, 402, 412-414, 41Th

follo\ving pregnancy, 275

Kegel, 402

during pregnancy, 267-269

impaired, 411-412 (See also Pelvic fl oor

dysfunction)

pain associated with, 414--415

palpating, 431-432, 432

role in micturition, 405, 408b

sexual function of, 405

spasms of, 414-415, 421

sphincteric function of, 405

supportive function of, 404--405

Pelvic girdle, 353-354, 354t

Pelvic pain, during pregnancy, 271-272

Pelvic tilt, 169, 169

anterior, 169, 170

posterior, 169, 170

sitting, 393

Pendulum exercise, for shoulder, 664

Perceptual measurement tools, 50, 5It, 52, 53t

Perimysium, 59

Perineal muscles, supe rficial, 403, 404, 405

Periodization, defined, 79

Peripheral neIVe pathology, muscle

performance and, 67-68

Peripheral \'aseular disease , impaired aerobic

capacity and , 95

Peripheraliz.ation, 363, 384

Peroneal nerve

c'Ompression during pregnancy, 277

injllry, .546--.547

Phalangeal fracture , 729

Phalanges, 702, 703

Physical activity, defined, 87

Physical Acth~ty Readiness Questionnaire

(PAR-Q), for aerobic capacity, 96, 97

Physical fitness, defined, 87

Physical therapy

adjunctive inteIVentions, 30, 30-32, :31b

classification svstem for, 16

components of, 1

defined, 1-2

prevention in, 47

types of inteIVention , 17-18, ITh (See also

InteIVention; Therapeutic exercise

inteIVention )

PhysiologiC impairment, 5, 5b

Physiologic parameters, modification of, 28b

Physiologic purpose of exercise, 137

Piriform syndrome, 478b, 479, 479-482

Piriformis muscle, 404, 407t

stretching of, 481

Pisiform, 700, 700

Pitchillg program, rehabilitation , 668, 668b

Plan of care, 16

Planar motion , of ankle and foot , 528b

PhUltar fascia, 526, 526

stretching of, 544b

Plantar fascitis, 543-,544

case study, 110-111,747

Plantar flexion, resisted, 537, 537

Plumb line test , 178, 178t

Plyometric exercise, 76-77, 77, 77b

Polymodal receptors , defined, 186

Positional strength, 63, 174

tests for, 179b

hip, 447

shoulder, 651

Positional traction , for low back pai n, 385, 385

Positional weJlness, 70

Posterior cruciate ligament, 490

injury to, 501-502

Posterior pelvic pain, during pregnancy,

271-272

Posterior tibial tendon dysfunction, 545

Postisometric relaxation techniques (PIRs), in

temporomandibular joint dysfunction,

563--564,564

Postpartum depression, 276

Postpartum exercise, 274--276, 276b

Postural Dyscontrol Test, 154, 155

Postural exercises , 138

pregnancy and , 266-267, 267

in temporomandibular joint dysfunction , 570

Postural stability, defined, 149

Posture

balance exercises and, 156

computer workstation, 715b

defined , 168

developmental deviations in, 17Th

deviations in, 169-171

evaluation of, 178-179

optimal for cervical spine, 600, 603, 603b

pelvis position and, 169, 170

during pregnancy, 266-267,267, 269-270,

270, 271 , 271b

standard, 168-169,169, 169b, 169t

anatomical structures, 169b

side view, 168, 169t

upper extremity, 169b

in therapeutic exercise, 26

Posture impairment

adjunctive inteIVentions for, 182-183

of ankle and foot

evaluation of, 534-535

exercises for, 5.38--539, 539b

anthropometric characteristics and, 176, 177

causes of, 17:2-174, 176-178

of cervical spine, 600, 603, 603-605, 604,

604t

of elbow, wrist, or hand, 714--715, 715b

evaluation of, 178-179, 362

factors effect ing, 168b

in fibromyalgia and chronic fatigue

syndrome, 250-251

of hip

evaluation of, 448

exercises for, 470-471

osteoarthritis, 474--475

joint mobility and, 173

oflumbopelvic region

eval uation of, 362

exercises for, 386-389

muscle length and, 173

muscle performance and, 173--174, 174

pain in , 174, 176

in patellofemoral pain syndrome, 515

patient-related instruction in , 182

pelvic fl oor dysfunction and , 418, 418b

psychologic impairments and , 176-177

range of Illotion and, 173

of shoulder

equuation of, 652

exercisE's for, 672-1373

temporomandibular joint dysfunction and,

568-572

therapeutic exercise inteIVention for, 1.38,

139, 180-183

dosage, 180-182

for lumbopelvic region, 387-389

pregnan cy and, 266-267, 267, 269-270,

270,271, 271b, 276

in temporomandibular joint dysfunction ,

569-570,570 of thoracic spine

evaluation of, 619b

exercises for, 629-632, 630, 632, 633

types of, 169-171

Posture spl'cificity, 64

Power, defined , 58

Power grip, 707, 708

Power training (See also Resistive exercise)

dosage of, 81

Pregnancy

anemia during, 260-261

bed rest during, 272-273

birth injury and, 407

cardiovascular s~'stem during, 260-261

cesarean section recove r"\', 275-276

diastasis recti during, 268-269, 269, 270b

Index endocrine syste m during, 2,59- 260 gestational diabetes mellitus, 2fiO in later life, :272 muscle performance impairment during, 267-268

musculoskeletal system during, :262-263

nerve compression syndromes dUling,

276--277

pain associated with , 270-272, 276

postpartum depression follOWing, 276

respiratory syste m during, 262

supine hypotensive syndrome, 261-262, 26lt

therapeutic exercise intervention during

adjunctive interventions, 266

exercise classes, 266

guidelines for, 263-265, 265b

higll-risk antepartum, 272- 274, 273b

intensity of, 266

normal ,mtepartum women, 266--272

postpartum, 274-276, 276b

precautions and contraindications, 263,

264b

risks about, 263, 263t

fOf wellness, 263--266

Prehension grip, 707, 708

Prescription, for home exercise program, 42--45

Prevention

of arthritis, 233

chronic fatigue syndrome and, 247

continuum of, 48

of falls , 615, 616b

fibromyalgia and chronic fatigue syndrome

and, 247

in modified disablement model, 7

of muscle strain, 69b

of osteoarthritis, 233

in physical therapy, 47

primary, 48, 48

secondary, 48, 48

tertiary, 48, 48

types of, 7

of vertebral compression fractures , 615, 616b

Preventive health se[\~ces, 48, 49

Primary impairment, 6

Prima ry prevention, 7, 48, 48

PrognOSiS , 16

Prone press-up progression, 384b

Proprioception, defined , 150

Proprioceptive neuromuscular facilitation

(P'\F),309-327

for balance, 157, 160, 161

contract-relax technique in, 325-326, 326b

de fined , 309

diagonals of mO'l'ment in , 310, 31Ot, 313t,

314

dynamiC reve rsals of antagoni sts in, 321-322,

322b-323b

examination and evaluation in , 314, 316

histOlY of, 309

hold-rehx technique in, 325, 325b

motor development in , 314, 315b

muscular activity in, 309

patient-related instruction , 326--327

patterns of facilitation, 316- 317, 317-318

principles of, 315b-316b

procedures for , 317-320, 318, 319

repeated contractions in, 320-321 , 321b

rc~ ve rsals of antagonists in, 321

rhythmiC inibation in, 320, 322b

rhythmiC stabilization in, 323, 324b

stable reversals in, 323, 323b

stretching, 128

techniques of facilitation, 320--326

for temporomandibular joint dysfunction ,

567~S68 , 56~ 568b

in treatmC'nt of pain, 198, 199b Protein, sa ProWedgelt,287 Psoas muscles , 404

Psychologic aspects , 5b, 6

of fibromyalgia and chronic fatigue

syndro me, 251-254

in pelvic floor dysfunction , 408

in posture and movement impairments,

176--177 Puberty (See Adolesct' nce ) Pubococcygeus muscle, 404, 406t Pulmonal)' embolus, 76Th Pulmonary ventilation, response to aerobic exercise, 90

Pyramid training, RI , 8lt

a Q-an gle, 514

Quadricep muscles, 490

strengthening ext'rcises for

closed kinetic chain (CKC) training for,

295b, 296b, 29Th, 30,3b

setting exercise, 495b

stretching e\ ercises for, 495, 497b

prone, 495, 497

standing, 495, 495b, 496

Quality of life, health-related

components of, 6-7

conceptual model of, 50, 51

Quality of life scales, health-related, 190

Queens College Step Test, 99

QUick tests, for hip, 448

R

Radial collateral ligament , 699

Radial head fracture, 725-726

Radial nerve

anatomy of, 703, 705

nerve entrapment syndrome of, 451, 719

Radiocarpal joint, 701, 702, 703

Radius , 698, 699

Range of motion (See also Mobility; Mobility

impairment )

of ankle and foot, 535

decreased

in arthritis, 234-235

in fibromyalgia and chronic fatigue

syndrome , 250

in lurnbopdvic region, 362-364

in pelvic floor dysfunction, 415~18

of elbow, 705

evaluation of. 119, 119-120,120, 362--364

of fingers , 706--707

of hip, 439

osteoarthritis, 470b, 472--473

jOint, 114, 119

of knee, 494

muscle , 114, 120

posturf' and movement impairments and, 173

of thoradc spine, 611-612, 6Ut

of wrist, 706

Range of motion exercises, 64, 120-125

active, 124, 124-125, 125, 1,39

,lctive assisted , 122--124, 123b, 124]" 139

for ankle, 123, 540, 541

for cervical spine, 593, 594

considerations for, 123b

dosage of, 137

for fibrom yalgia and chronic fatiguc

syndrome, 250

for hip flexors , 124,124, 381b

for knee flexion , l25b, 495, 504, 504b

783

passive, 121-122, 122, .123b, 138-139

in pool, 337-338

precautions and contraindications for,

138-139

for shoulder flexion, 121, 122, 124, 125b

for subt alar joint, 542, 542

for talocrunil joint, 540, 541

for toes, 542, 54:3b

in water, 337-338

Range of motion specificity, 64

Range of motion testing, 119, 119-120, 120

hip , 363

lumbopelvic region , 362-364

thoraCic , 363

Rating of perceived exeltion (RPE), 100

Reaching

cross-body, 62Th-628b

functional movement for, 625, 626

Rectus diastasis, 268-269, 269, 270b, 275

Reflex sympathctic dystrophy (RSD) , 729

Rehabilitation ball

balance exercises with , 158, 158b, 365, 365,

372

postural reeducation with , 138, 139, 198,200

for spine mobility, 624,625

Relaxation exercises (See also Neuromuscular relaxation )

during bed rest, 274

postisometric relaxation techniques (PIRs),

563-564,564

Remobilization, effects of, 117-119

Repeated contractions, in proprioceptive

neuromuscular facilit ation, 320--321,

321b

Repeated stretch, in proprioceptive

neuromus<;ular facilitation, 321

Repetition maximum (RM) method , for ll1usde

testing, 73

Resilience , defined , 209

Resisted test , of hip, 447

Resistive exerdse

aquatic therapy and, 336-338, 338, 339b,

340, 340b

free-weights, 75-76

isokinetic, 77-78

isometric, 73-74

for low back pain , 373, 373

physiologic adaptation to, 70-72, 7lt

plyomctric, 76-77, 77, 77b

purchaSing equipment for , 74b

weight machin es , 74-75

Respiration, 614, 614

impaired, 621

in thoracic spine evaluation, 619b

Respiratory rate

aerobic exercise effect on, 93

response to aerobic exercise, 90

Respiratory syste m

aerobic exercis<; effect on, 93--95

during pregllancy, 262

Retrodiskitis, of temporomandibular jOint,

572--573

Reversals of antagonists, in proprioceptive

neuromus<;ular facilit ation, 321

Rheumatoid arthritis

aerobic capacity impairment in , 237-239

classification of, 232--233, 232b, 233b

clinical manifestations of, 231- 232 , 232

effects of, 230t

etiology of, 231

inflam matory respon se in, 232, 232

mobility impairment in, 234-235

muscle performance impai1l11ent in , 235-237

pain associated with, 234, 241

prevention of, 233

784

Index

Rheumatoid arthlitis (c01lt'd)

therapeutic exercise interventi on for,

233-239

C'xcrcise modifications, 239- 241 Rhomboid nllisclc, stretching of, 65,9, 662-663 Rhythmic initiation, in proprioceptive neuromuscular facilitation, 320, 321b Rhythmic stabilizatioll, in propriocc=p tive neuromuscular facilitatioll, 323, 324b RiDS anatomi cal considerations, fil0, 612 false, 610 true, 610 Risk factors in modified disablement model, 7 types of. 7 Roll , in joint mobilization exercises, 129 HOM (See Range of 1lI0tion; Range of motion exe rcises) Rotator cuff exercises for , 653 , 655b-6(jOb , 661, 668, 7Mb-756b plyoll1e tric exercises for, fi70, 673 Rotato r enff-deltoid force cou[Jle, 647, 649, 649 Rotator cufT disorders, 673-fiSO classification of, 674, 674t

etiolo?;), of. 67,s-fi76, 675t

exercises fC)r, 676--677, fi7Th, 678b

rehabilitation fol1o"~ng repair, 680,

fi81b-fiS2b

stages of patlJOlng)', fi74--fi75, 675t

treatment for, fi7fib

Rotator cuff impingement, 649 ease study, fi54b, 748-749 causes of, 653 exercises for, 653, 655b-660b treat ment of, 653 Rotator cufT repair, rehabilitation following , fi80,681h-G82h Ruffini endings, defined, 150 Running, in wate r, 336-3,'37

S Sacroiliac joint (SIJ), :3,53~'354, 354t, 357 Sacroiliac region, pain in, 7G:2t-763t Safety, patient-related instruction and, 35--36 Salutogcnic, defined, 49 Sarcolemma, 59 SarcomE'rr', 60, 60 Sarcoplasmic retiClllum, 60, 61 Scalene rnuself's , 587, 587 mobiJity exprciscs for, ,~96 , 597 Scali examination, 6lli, 618b ScaphOid fradure , 727, 728 Scapula abducted, 171, 171,181, 18 1-182

ant(~rior tilt of. 171, 171

dc-pressed , 661, 661

dcpression of, 171,171

duwnward rotation of, 171 ,171,181,

HH-lli2

elevation of, 171,171

lateral rotatioll of 171,171

posterior tilt of, 171, 171

taping of, 68"5-fiS7, 68fi--68.9

upward rotation of, 171,171,172

wingiFlg of, 171,171

Scapular forct' couple, fi47-649, 648, fi,'J9 capulohumenl muscl e , stretching of, 663h Scap ulolJllOlCraJ rhythm, 646--fi47 Scapulothoracic joint, 645 Scar mohihzation, in pehic floor dysfunction, 429, 431,4.31, 43lt Scheuermann's disease, 176, 616, 616

Scoliosis, 178, fi17-618, 617b, 618b, 630-632 evaluation of for, 635b exercises for, 630--632, 631,635---637, 635b, 6:3fib Screening for aerobic capacity function, 96, 97 for pelvic floor dys function, 409, 410b perceptual, 50, ,5 lt, 53t in shoulder dvsfunetion, 650 Secondary conditions, 6 Secondary impairment, 6 Secondary prevention , 7, 48, 48 Sedentary lifpstyle, impaired aerobic capacity and, 95 Selective tension test of hip , 447 of shoulder, fi51, 65lt Self-management, 36 adhercnce and motivation in, 36--38 clinician-patient interaction allll, 3S-39, .39 equ ipment and el1\~ronmc'nt for, 41--42 ('xercise levels ill, 4.3--44, 44t health behavior moder, and, 33-3fi prC'scription for, 42-4,:; program fon!1lrlation for, 44-4,5 proper exercise execution, 40--41 safety and, 35--36 understanding instructions in, 39--40 Self-report, in evaluation, 14--15 Sclf~tral'tion, of hip, 474 Sellar joint, defined, 130 Sensory systems balance ,md, 150, 150--151 , 154

processing of information by, 151

Sccj1Jf'ncE' ofhalancc cxen,isl's, lfl2--163 of curdiovascnlar endurance training, 102- 103

of mobility ('xneises, 137

of resistive ncrcise, SO

SC'riC's elastic componC'n ts (SEC), 218 Serratus anterior muscle ("(~rcises for, fi77b, 678b progressive strengthening exercises, 65Sb- fi,59b, 666, 667, 668 Sexual abuse guideLines for therapy ,vith survivors , 40911 pelVic floor dysfunction and, 408 sylllptoms of, 40Sb SF-36, in pain evaluation , 190, 191-194 Short muscle, defined, 178 Shoulder ac\JlesivC' l'apwliti s, 680, 6S:1-6t;5, 742

diagnOSiS , fi83

operative treatment, fi85

stage 1, fi84 , fig4t

stage 2, 684t, 685

stage 3 and 4, 6Mt , 685

tre atlllcnt, 61l.3--685

anatomical considerations , 643- 649 acromioclavicular joint, 644, 644--645,645, 645t glenohumeral joint, 645, 645--646,646 muscles of. 647-649, 647t, 648 scapulolilllllnal rhythm, fi46-647 scapu lothoracic joint, 64,s sternoclavicular joint, fi4:3--fi44 , 644, 644t c1osl'd kinetic, clmin (CKC) training for, 303b, 304b,305b '

conditioning program for, 671b-fi72b

disuse and J,:conditioning of, 670,

671b-672b, 672, 673b

examination and evaluation of, 649--652

fun<:tionallimitations, evaluation of, 652,

652b

glenohumeral joint instahility

diagnosis of, fl79 , 67gb

etiology of, fi77, 678, 679

fl79--6S0, 680

exercises hypprmohility of. fi64--665, fi65b impingement of, 64!.J

casC' studv, 6,'>4h, 735, 748-749

ca uses of 653

exercises for , 65:3, 6,S,Sb-DfiOb

t reatlllent of, 653

joint mobilization exercises for, 131b, 134 I~hral rep~ir of, 224 mohil.ily impairmcnt of evaluation of, 652, 652b exe rcises for, 661-664, 663, 663b, 664 motor function of, evaluation of, 651 movelllcnt impairnrent of, exercises for , 6fil-6fi4,663,6fi3h,661 mll sclc per{onllanel' impairment of

evaluation of, 6,s1, fi51b, 65lt

exercisC's for, 66G-672, 661--669,

671b--672b mLlscle strain of, 668, 66S-fl70, fifi8t nC"nrologic pathology of, 652, 666, 667, 6fi8 optima l alignmcnt of, fi72-673 pain in el'alu
eva lu at ion of, 6,52

exercises for, 672--673

roWor cuff disorders, 673--680

classification of, 674, fi74t

etiology of. 675-67fi, fi75t

c-xC'rci scs for, 676-D77, 677b, 678b

rehahi litation follOWing repair, 680,

681b-6.'l2b st
taping for, 6%-687, fi90

Shoulder flexion aquatic therapy exc;rcise for, 340b range of Illotion exercises for, 121,122, 124, 125b supine" 75b Shoulder rotation, exercises for, 65,5b, 660b, 601,7,S4h Side-stepping nquatic the mpy, 503 on baianct' beam , 503 Signs (Sec also S)Ol1ptOI11S ) assnciatC'd wi th llJC'dical condit ions, 76.3t Sit-ups, 3fi6--.378 bC'nt-knee,3fifi-:377 c()ntraindic~tions fOT, 379t hip flexion in, 3fi6, 366 holding !<'c t down, 65, 6.5 illlportall C'l' of technique in, 65, 6.5 proper execution of, 3fi6 straight-leg, 377--378, 37Th trunk curls, 37.'\, 379t trunk flexion in, 36fi, 366 Sitting backrest for. ,,),52, 353 loads on spine while, 352, 3.5.3 propccr posture , 4JSb , ,56,) 6-minutc walk t('st , lOS Skill, defined, 24--2,s, 24b Skin brea kdown , from taping, 690 Slide, in jOint ll1obilization exercises, 129 Slide board, balance exercises \vith, 161, 162 Sliding filarnent theory, 60--61, 61 S i ow-ts\~teh fibers, 61 SLR test. 389

ror,

Index Social aspeds , of disahility, 4, 14

Social support, 110me exercise programs and,

41-42

Soft-tissue (See Cunnec tive tissue; Con nective

tissue injury)

Soft-tissue stabilization surgery, rehabilitation

follo\\ing, 224

Soleus muscle, stretching of. 517, 518b, 541

Somatic pain, 760t

Somatosensory system , neurophysiology of,

150-151

Specific adaptations to imposed demands

(SAID), 212, 286--287

ankle muscles , 535

inner core muscles, 367

Specifici ty

muscle performance and , 64

p osture, 64

range of motion, 64

Spin, in jOint mohilization exercises, 129

Spinal cord compJ'l~ssion, 76Th (See also

Vertebral comp ress ion fractures)

Spinal stenosis, 391-392

C"x3m in ation and evaluation in , 391

lumbar, 743

patient-related instruction, 392, 392b

treatment , 391- ,392

Spine (See also Cervical spine; Lumbar spine; Lnmbopelvic region; Thoracic spine)

joint mobilization exe rcises for, 133b, 136

'positiuns of

functional, 372t neutral, 372t stabilization exercises for, 140-141,141 Splinting, for complex regional pain syn drome, 731-732

Split routine training, 81-82, 82t

Spondylolisthesis, 392-393

SpondylolysiS, 392-393

Sprain, 213, 213, 21 3t

of ankle and foot , 547--548, 548b, 739

of cervical spine, 605-606

Squats, 752b-753b

progressive, 464, 466b, 518, 519

Stability, de fln cd, 24, 24b

Stabildatioo exercises, 140-143

ba llistic exercise, 141-142, 142

closed-chain exercise, 140- 141

dosage of, 142

ope~-chaill ('x(;' rcise, 141

preca utions and contraindications for,

142-143

for spine, 140-141,141

Stable reversals, in proprioceptive

neuromuscular faCilita tion , 323, 323b

Stairs, aseending properly, 498, 499

Standing

loa(ls on spin e while, 352, 353

neutral pOSi tion for, 462b

proper posture for, 569

Static stretching, 127

Stenosis, spinal, 391- 392

exam ination and evaluation in , 391

lumbar, 743

patient-rdated instruction, 392, 392b

treatment, 391-392

Step-down, 542

Step tests, 98-99

Step-up, step-down, 454b-4.55b, 456, 474 , 474

Step ups, 753b

Stepping exercises, for balance, 157,160

Stepping strategy, for balance, 152

Sternoclavicular joint, 64.3-044, 644, 644t

Sternocleidomastoid muscle, 587

mobility exercises for, 596--597, 597

Sternum, 611, 612

Stiff hand, - 32- 733. 733

Stiffness, defi ned, 179

Stomach-lying hip extension , 452b

Straight-leg raises, 508b

Strain, 213-215, 214, 215

causes of, 68-69

of cervical spine, 605-606

evaluation of, 213

of hip , 451-252

ofknee, 498-499

in lumbopelvic region, 374-375

prevention of, 69b

of shoulder, 668, 668-670, 668t

in th oracic spine re?;ion, 621-622, 622

treatment principles for, 214-215

Strapping (See also Taping)

in ankle and foot injuries, 549-550

Strength .

definetl,58

d>'lalllic, 73

Strength training (See also Resistive exercise)

aquatic tl1('nlpy for , 338, 338, 339b, 340,

340b

dosage of, 80-81

in fibromyalgia and chro nic fatigue

syndro me, 248-249, 249t

Stress, associated with pregnancy, 276

Stress fractures, 221

Stress in con tinence, 424, 424, 424t

Stress managem ent, in fibromyalgia and

chronic fatigue syndrome, 251

Stress-strain curve , 208-209, 208-210

Stretch, in prop rioceptive neuromuscular

facilitation, 320

Stretch-shortening cycle (SSC), 284

defined , 59

Stretch weakness, 173

Stretching, 125-129 (See also Range of motion

exercises)

ballistic, 128

dos age of, 137

effects of, 128-129

with heat applkation, 30

of hip , 12Th, 137, 138b

of kn ee, 127

knee-to-chcs t, 123b

lifespan issues in, 143

of lumbopelvic region, 380

ne urophysio logy of, 126--127

proprioceptive neuromuscular facilitation

(PNF ), 128

of shoulder, 662-664, 663, 663b, 664, 664b

static, 127

of temporom andib ula.r joint, .562-563, 563

Stroke volume

aero bic exercise effect on, 93

response to aerobic exerc ise, 90

SubOCCipital muscles

mobility exercises for , 596, 596

neuromuscular rehxati on of, 254b, 255b

Subscapularis muscle, isometric exercises for, 665,665 Subtalar joint

anatomy of, 525, 526

kineS iology of, 527-528, 528

range of motion exercises for, 542, 542

Subtalar jOint pronation, closed kinetic chain (C KC) training for, 302b

Subtalar varus, 533, 533

SupiJ1C hypotensive syndro1l1c , during

pregnancy, 261- 262, 26lt

Supine shoulde r flexi on, 75 b

Suprallyoid muscles, 558, 559, 587

785

Surface elE'ctromyography (SE'vIG ), 3 1-32

combining with !\MES, 32

in temporomandibular joint dysfunction , 577

use in movement analys is, 179

Surgical rehahilitation, 221-226

abrasion chondroplasty, 224-225, 225

autologous chondrocyte implan tation, 225

de bridement, 223-225

decompress ion, 223-224

fUSion, 225-226

joint replacemen t surgery, 226

labral repair, 224

ligament r construction , 222, 223 b, 283

meniscal repair, 224

open reduction and internal fixation (ORIF),

221 , 225

osteochond ral autograft transp lantation

(OATs), 225

osteotomv, 226

soft-tissue stab ilizati on, 224

synovectomy, 223

tt'ndon su rgery, 222- 223

Swallo,,\~ng exe rcises, for temporo1l1andibular joint dysfunction, 570, 570

Sway, postural, defin ed. 149

Sway envelope, 149. ]')U

S"vimming, 100-101

Symptom stabilitv, aSSl'S~I11('nt of, 42-43, 42.b

Symptoms

associated "vith mcd ical conditions, 764t

"baseline," 44

exacerbation of, 4:3-44

pain , by origin, 76 lt-76.'jt

produced by exercise, i 65t-767t

SyncopE', 766t

SyndesmOSiS sprain, 547

Synovectomy, rehabilitation fo Uo\ving, 2.23

SynOvial joint, anatomy of, 229--230, 230

Synovium, 230t

Systems review, ll-12, 12b

in aerobic capacity evaluation , 96

in thoracic spine dys function , 618-619, 6i8b

T T -tubule system, 60, 61

Tai Chi, for balance, 154 ,156,251,468

Talocrura l joint

anatomy' 01', 525, 525

kineSiology of, 527, S28

range of motion E'xcrcis('s for. 540 . .'541

Taping, 31

allergiC reaction to, 687

in ankle and foot injuries. 5.49--550

of gluteus mediu s muscle, 4.5L 456

for kyphOSiS, 623, 623, 625, 6:30

for plantar fascitis, 543, 543b, 544h

scapular, 685-687, 686-689,690

slkin breakdown from, 690

Tarsal tunnel syndrome, during pregnancy, 277

Tautness, defined, 178

Teaching (See Patient-r · latcd in struction )

Te mporal is musde, ,- 57. 557t, 558t, 560

Temporomamlibnlar joint dysfunction

adjllncti\'f' interventions for, 577

anatomical eonsiderations. 555- 560

bones of, 555~556 . 556

joints of, 556, .556- .557

kineti(;s of, ,560--561

muscles of. 55/--559.557--559

nerves of, 560

capsulitis ,572-573

disk displacement, 573--.574, 573~575

examination and ('valuation in, 561--562

joint clicking in , 573-574

786

Index

Temporomandibular joint dysfunction (cont'd) mobility impairment of

evaluation of. 561

exercises for, 562-566, 563-566

mllscl e performance impairment of. 566-568, 5661h567b, 567, .5(i8

neuromuscular relaxation in, 567, 567, 569

osteoarthli tis in, 573

pain in, 561-562

postisometric relaxation techniques in,

563-564, 564

posture impairment nnd, 568-572

during pregnancy, 277

retrodiskitis, 572-573

surgical procedures for, 573-574

arthroplasty, 575

arthrotomy, ,575-577, 576

therape utic exercise intervention for,

562-572, 563-570, .566b, 567b, 568b

Tendinitis, 215-218, 217t

of elbow, 712

TenrunopatJlies, of knee, 512-520

Tendinosis, 216, 217t

AchiJJes , 54.'5. 546

Tendon dysfunction , posterior tibial , 545

Tendon injuries, 215-218

classification of, 216, 217t

evalnation of, 216-217

strains, 213-215, 214, 215

treatment plinciples, 217-218

Tendon lacel'ation , oflland, 72, 722-723

Tendon surgelY, rebabilitation follOwing,

222-223

Tendons, 208

effects of immobilization on , 115-116

effects of remobilization on, 117-118

Tennis elbow, 719-721, 720

Tennis elbow strap, 217, 720, 720

Tension test, ofhip, 447

Tertiary prevention, 7, 48, 48

Therapeutic ball (See Rehabilitation balJ)

Therapeutic exercise intervention, 20-30

adjunctive interventions in , 30, 30-32, 31b

components of, 24

defined,2

model for, 21, 21-27

activity or technique in , 24-2.5

dosage in, 21, 26-27, 27b

modr, posture and movement in, 26

movement c:ontrol in , 24

movement svstem in, 21 , 21-26

modification of, 27, 28b-29b, 30

variables in , 21

Thoracic outlet syndrome

diagnosis of, 638

etiology of, 637-638

during pregnancy, 277

type 3, 638

type 1 and 2, 638-639

Thoracic spine anatomical considerations, 61~11 , 611 , 61lt, 612, 612t, 613t

closed kinetic chain (eKe) training for , 305b

ergonomics and, 619b

examination and evaluation of, 618-620,

618b, 619b

hypenllobility of. 624-625,625, 626,

627b-628b

joint mobilization exercises for, 133b, 136

kinetics of, 611-614, 613t, 614

kyphOSiS, 614-616, 629-630

exercises for, 629-630, 630, 637

phYSiologiC impairment associated with ,

637b .

lateral flexion exercise, 628

ligaments of, 611, 612

lordosis, 632, 6.32, 6.3.3

mobility irnpainnent of, 623

evaluation of, 619b

exerCises for, 62.5-629, 628, 629

motor fum:tion and

evaluation of, 619b

exercises for, 624, 625, 629-632

muscle lengtJl, evaluation of, 619b muscle performance impairment of

evaluation of, 619b

exercises for, 621, 621-623, 622, 623

muscle strain of, 621-622, 622

neurologic pathology of, 621

pain in, 619b, 629, 762t-763t

Parkinson's disease and, 633-634, 634

posture impairment of

evaluation of, 619b

exercises for , 629-632

range of motion for, 611-612, 611t

evaluation of, 619b

respiration and , 614, 614, 619b

rotation exerdse for, 628

sc.'Oliosis, 617-618, 617b, 618b, 630-632

eqlluation of for, 635b exercises for, 63~32 , 631, 635--tJ37, 635b,636b, 638t thoraciC outlet syndrome. 637-639

Thoracic spine extensors, exercises for, 616, 616

Thoracic spine veliebrae, 610, 610, 61lt, 612t

Thoracolumbar fascia, 355

Thumb

gamekeeper's, 724-725, 725

strengthening exercises for, 725b

Thumb spica splint, 725, 725

Tibial nerve injury, 546

Tibial plateau fractures, 507

Tibial tendon dysfunc:tion, posterior, 545

Tibiofemoral joint

kinematics of, 491-492

kinetics of, 492

Tight, defined, 178

Timed Up and Go Test, 155

Timing, in proprioceptive neuromuscular

facilitation, 320

Tissu ," irritability, assessment of, 42-43, 42b

Toe, active range of motion C'xercise, 542, 54:3b

Toe flexion, resisted , 536, 537b

Toe raises , standing, 537, 538

Tongue

anatomy of, 558-559

exercises for, 569-570

in temporomandibular joint dysfunction, 569

Tongue til rust, 559

Torque,defined, 58

Total knee arthroplasty, 511-512, 740

Toughness, defined, 209

Trabeculae svstem

lateral , 438, 4.57

medial, 438, 457

Traction

for low back pain, 393-394

positional, 385, 385

treatment parameters. 394t

in proprioc:cptivt' neuromuscular faCilitation,

319-320

Training index, for cardiovascular endurance

training, 238-239, 238b, 253

Training spec:ificity

closed kinetic: chain (eKe) training and,

286-287

inner core muscles, 367

muscle performance and, 64

Transcutaneous electrical nelve stimulation (TE~S )

for arthritis, 234

for cOlllplex regional pain syndrome, 732

in pain treatment, 202-203

dmiug pregnanc)" 266

Transth eoretical model, for health behavior model,36-38

Transversus abdominis muscle, 356, 368b

Trapez.ius muscle, 587

manual muscle test for, 173-174,174

strain of, 181, 18i-182, 622, 668-669, 669

strengthening exercises for, 632, 6.32, 633,

656b-65Th, 662, 669, 677b, 67%

stretching exercises for, 597, 597, 598

TrapeZOid, 700, 701

Treadmill tests, 98

Trendelenburg test, 441 , 448

Trigger finger, 721-722

Trigger points , of hip adductors , 415, 416, 417

Triplane motion, of ankle and foot , 528b, 542

Triquctrum , 700 , 700

Troc:hantelic bursitis, 475b

Trochanteric Prominence Angle Test, 450, 450

Trochlea, 698, 699

Trochlear notch , 698, 699

TropomYOSin, 60, 60

Troponin, 60, 60

Trunk counter rotation exercise, 221 , 620, 620

Tubing, for muscle strengthening, :373, 373

U In a, 698-699, 699

Ulnar collateralligument, 699, 699

Ulnar nerve

anatomy of, 703

nerve entrapment syndrome of, 451, 718,

718-719

Ultrasound, for deep heat, 144

Uncovertebral joints, 584, 584

Unweighting equipment, in fibromyalgia and

chronic fatigue syndrome, 250

Upper extremities

closed kinetic chain (eKe) training for, 292,

306

diagonal s of movement for , 312t

mobility exercises in pool, 339b

Urge defe rm ent , 429, 431b

Urination , phYSiology of, 405, 408b

Urogenital diaphragm , 403, 404, 405

V

Vaginal self-examination, 410-411, 411b

Vaginismus, 428

Valgus angle of knee, 170

Valsalva maneuver, 72, 82

Valvular heart disease , impaired aerohic

capacity and, 95

Varicosis, during pregnancy, 277, 278

Vastus medialis oblique muscle, exercises for,

516-519,517t,518b,519

Verbal cueing, in proprioceptive neuromuscular

facilitation, 319

Vertebrae

of iumbar spine, 350, 350

of thoracic spine, 610, 610, 611t, 612t

Vertebral artery, 585

Vertebral compression fractures

complications of, 615t

osteoporosiS and, 614-615

prevention, 615, 616b

risk factors for, 615

Index treatmE'nt. 615

Vestibular system. in role balance. 151

Visceral pain. 760t

symptoms of, 76lt-763t

systemic symptoms, 76lt

Visceral st.ructures, pain and, 759

Viscosity, in aquatic therapy. 332-334. 334.

334t.335

Viscous properties, 30

Visual analog scale lV.'\S). 188, 188. 365t

Visual system. in role balance, 151

V0 2 max

aerobic exe rcise effect on, 93-94

defined, 88

evaluation of. 97-100

using to prescribe exe rcise. 103

Volume. of resistive exercise. 80

Vulvodynia. 427--428. 427b

W Waddell Disability I ndex. 361-362, 36lt. 365t

Walk stance progression, 453b--454b

Walking

alignment during. 535b

anklE- mobility and, 530, 531b

with crutche; , SOSb

in fibromyalgia and chronic fatigue

syndrome, 249

with knees over toes, 461, 462b, 467

maintaining long arch while . 532b

in pool, 203b

Walking program, for arthritis, 238

Wall slides, 23. 23, 505

arm, 7.55b

deep ne ck fl exo r muscle, 589, 589

Water (See also Aquatic therapy)

buoyancy of, 330-332

depth of, 331-332

hydrostatic pressure of, 332, 335-336

physical properties of, 330--334

physiological response to immersion in,

334-336,336b

physiolOgical respon ses to exercise and

immersion , 336-337

temperature of, 3,'36

viscosity of, 332-334, 334, 334t, 335

Weight-bearing activity, 101 , 103b

proper form for, 506b

Weight gain , during pregnancy, 262, 278

Weight machine exerCise, to increase musclE'

performance, 74-75

Weight shifting

dynamic , .548b

medial/lateral, 548b

Wellness

definpd,49

dimensions of, 49, 49~50, 49t

exercise dUling pregnancy and. 263-266

flbromyalgia and chronic fatigu E' syndrome

and,247

lifestyle and , 49-50

measures of, 50, 51 t

Wellness-based practice, 50, 5~3

screening in, 52. 53t

starting, 5N3

types of, 52

Wiberg, ang! p of, 443, 443

Wide dynamiC range neuron (WDR), 186

Wolffs law, 114, 286

787

Work. defined, 58

Wrist

anatomical considerations. 700-702, 701 ,

702, 702t, 703t

carpal instability of, 724

carpal tunnel syndrome. 716-718, 717, 718

De Quervain's syndrome, 714 , 721

endu rance impairment of, 713-714. 714b

exam in ation and evaluation of, 708-709,

709b

hypermobility of, 711

kineS iology of, 706

mobility impairment of, 710

evaluation of, 708

joint mobilization, 132b, 134-1 35

muscle performance impairment of

evaluation of, 709

exercises for, 711-712,712

range of motion for, 706

resisted fl exion, 713

stretch for ex tensor muscles, 717

Vhist extensors , exercises for , 713, 717, 720

Wrist flexor;, exercises for, 713, 721, 721, 723,

723, 727

Wrist splint, 716-717, 717

y YMCA protocol, for bicycle ergometer test, 98,

99t

Yoga, in pain treatment, 201b

Z

Zygapophyseal joillt. 350- 351, 584

nerve entrapment at, 606- 607

I SBN 0-7817-4135-1