This is completed downloadable Test Bank for Therapeutic Exercise Foundations and Techniques, 6th Edition : Kisner
Product Details:
- ISBN-10 : 080362574X
- ISBN-13 : 978-0803625747
- Author:
Thoroughly revised and updated throughout, Kisner & Colby’s 6th Edition offers the most up-to-date exercise guidelines for individualizing interventions for those with movement disorders. Now with contributions from the leading experts in the field, it encompasses all of the principles of therapeutic exercise and manual therapy, including spinal surgery and spinal manipulation. This renowned manual remains the authoritative source for exercise instruction for the therapist and for patient self-management. Plus, you’ll have access to Kisner and Colby’s Therapeutic Exercise Video Library online at DavisPlus, featuring over 30 NEW full-color video clips―94 in all―demonstrating basic therapeutic exercises and techniques.
Table of Content:
- CHAPTER 1 Therapeutic Exercise: Foundational Concepts
- Therapeutic Exercise: Impact on Physical Function
- Definition of Therapeutic Exercise
- Components of Physical Function: Definition of Key Terms
- Balance.
- Cardiopulmonary fitness.
- FIGURE 1.1 Interrelated components of physical function.
- Coordination.
- Flexibility.
- Mobility.
- Muscle performance.
- Neuromuscular control.
- Postural control, postural stability, and equilibrium.
- Stability.
- Types of Therapeutic Exercise Interventions
- Exercise Safety
- BOX 1.1 Therapeutic Exercise Interventions
- Classification of Health Status, Functioning, and Disability—Evolution of Models and Related Terminology
- Background and Rationale for Classification Systems
- Models of Functioning and Disability—Past and Present
- Early Models
- Need for a New Framework for Functioning and Disability
- TABLE 1.1 Comparison of Terminology of Two Disablement Models
- FIGURE 1.2 The ICF Framework.
- The ICF—An Overview of the Model
- Components of Functioning and Disability Models and Applications in Physical Therapy
- Background
- TABLE 1.2 An Overview of the International Classification of Functioning, Disability and Health (ICF)*
- BOX 1.2 Definition of Key Terms in the ICF
- Health Conditions (Pathological/ Pathophysiological Conditions)
- Impairments
- Types of Impairment
- Impairments of body function and body structure.
- Primary and secondary impairments.
- BOX 1.3 Common Physical Impairments Managed with Therapeutic Exercise
- FIGURE 1.3 (A) Impingement syndrome of the shoulder and associated tendonitis of the rotator cuff (health condition/pathology) leading to (B) limited range of shoulder elevation (impairment of body function) are identified during the examination.
- Composite impairments.
- Activity Limitations/Functional Limitations
- FIGURE 1.4 Limited ability to reach overhead (activity limitation/ functional limitation) as the result of impaired shoulder mobility may lead to loss of independence in self care and difficulty performing household tasks independently (participation restriction/disability).
- Types of Activity Limitations/Functional Limitations
- BOX 1.4 Common Activity Limitations/ Functional Limitations Related to Physical Tasks
- Participation Restrictions and Disability
- Prevention of Disability
- BOX 1.5 Areas of Functioning Associated with Participation Restrictions and Disability
- Categories of prevention.
- Risk Factors
- BOX 1.6 Risk Factors for Disability
- Summary
- Patient Management and Clinical Decision-Making: An Interactive Relationship
- Clinical Decision-Making
- BOX 1.7 Requirements for Skilled Clinical Decision-Making During Patient Management
- Evidence-Based Practice
- Definition and Description of the Process
- FOCUS ON EVIDENCE
- Accessing Evidence
- FIGURE 1.5 A comprehensive outcomes-oriented model of patient management.
- A Patient Management Model
- Examination
- History
- BOX 1.8 Key Questions to Consider During the Initial Examination
- BOX 1.9 Information Generated from the Initial History
- Systems Review
- TABLE 1.3 Areas of Screening for the Systems Review
- Specific Tests and Measures
- BOX 1.10 Guidelines for Selection of Specific Tests and Measures
- Evaluation
- FOCUS ON EVIDENCE
- BOX 1.11 Key Questions to Consider During the Evaluation and Diagnostic Processes
- Diagnosis
- Diagnostic Process
- Diagnostic Category
- BOX 1.12 Diagnostic Classifications for the Musculoskeletal System
- Prognosis and Plan of Care
- BOX 1.13 Factors That Influence a Patient’s Prognosis/Expected Outcomes
- Plan of Care
- Setting Goals and Outcomes in the Plan of Care
- BOX 1.14 Key Questions to Establish and Prioitize Patient-Centered Goals and Outcomes in the Plan of Care
- Intervention
- Coordination, Communication, and Documentation
- Procedural Interventions
- FIGURE 1.6 Manual resistance exercise, a procedural intervention, is a form of therapeutic exercise used during the early stage of rehabilitation if muscle strength or endurance is impaired.
- FIGURE 1.7 Task-specific strengthening exercises are carried out by lifting and lowering a weighted crate in preparation for functional tasks at home or work.
- FOCUS ON EVIDENCE
- Patient-Related Instruction
- FOCUS ON EVIDENCE
- Outcomes
- Functional Outcomes
- BOX 1.15 Areas of Outcomes Assessed by Physical Therapists
- Measuring Outcomes
- Impact of interventions on patient-related, functional outcomes.
- Patient satisfaction.
- FOCUS ON EVIDENCE
- BOX 1.16 Examples of Determinants of Patient Satisfaction*
- Discharge Planning
- Strategies for Effective Exercise and Task-Specific Instruction
- Preparation for Exercise Instruction
- BOX 1.17 Practical Suggestions for Effective Exercise Instruction
- Concepts of Motor Learning: A Foundation for Exercise and Task-Specific Instruction
- Types of Motor Tasks
- Discrete task.
- Serial task.
- Continuous task.
- FIGURE 1.8 Taxonomy of motor tasks: dimensions of task difficulty.
- Conditions and Progression of Motor Tasks
- Closed or open environment.
- FIGURE 1.9 Activities of daily living in the context of the taxonomy of motor tasks.
- Inter-trial variability in the environment: absent or present.
- FIGURE 1.10 Learning to maintain standing balance on an unstable surface is an example of a motor skill that is performed in an open (moving) environment.
- Body stable or body transport.
- Manipulation of objects—absent or present.
- Stages of Motor Learning
- Cognitive Stage
- Associative Stage
- Autonomous Stage
- Variables That Influence Motor Learning—Considerations for Exercise Instruction and Functional Training
- Pre-Practice Considerations
- Practice
- Part versus whole practice.
- Practice order—blocked, random, and random/blocked.
- BOX 1.18 Types of Practice for Motor Learning
- Physical versus mental practice.
- Feedback
- Intrinsic feedback.
- BOX 1.19 Types of Feedback for Motor Learning
- BOX 1.20 Feedback Schedules
- Augmented feedback.
- Knowledge of performance versus knowledge of results.
- The feedback schedule—timing and frequency of augmented feedback.
- FIGURE 1.11 (A, B) Use of rehabilitative ultrasound imaging provides augmented (visual) feedback on the screen during exercise instruction to help the patient learn how to activate the transversus abdominis and internal oblique muscles.
- FOCUS ON EVIDENCE
- Application of Motor-Learning Principles for Exercise Instruction Summarized
- BOX 1.21 Characteristics of the Learner and Instructional Strategies for the Three Stages of Motor Learning37,118
- COGNITIVE STAGE
- ASSOCIATIVE STAGE
- AUTONOMOUS STAGE
- Adherence to Exercise
- Factors that Influence Adherence to an Exercise Program
- Patient-Related Factors
- Factors Related to the Health Condition or Impairments
- Program-Related Variables
- Strategies to Foster Adherence
- BOX 1.22 Strategies to Foster Adherence to an Exercise Program
- Independent Learning Activities
- Critical Thinking and Discussion
- REFERENCES
- CHAPTER 2 Prevention, Health, and Wellness
- Key Terms and Concepts
- Health.
- Wellness.
- Health promotion.
- Health-Related Quality of Life (HRQOL).
- Fitness and Physical Activity.
- Role of Physical Therapy in Healthy People 2020
- TABLE 2.1 Examples of Healthy People 202025 Goals
- TABLE 2.2 Prevention Activities
- FOCUS ON EVIDENCE
- Identifying Risk Factors
- Pre-Participation Screening
- Risk Assessment
- BOX 2.1 Activity Prescreening Questions
- Determining Readiness to Change
- BOX 2.2 Risk Factors for Coronary Artery Disease and Osteoporosis
- Behavioral Change Theories
- Social cognitive theory.
- Health belief model.
- Transtheoretical model.
- FOCUS ON EVIDENCE
- Additional Factors Affecting the Ability to Change
- Motivation.
- Self-efficacy.
- Developing and Implementing a Program
- BOX 2.3 Steps to Develop and Implement Prevention, Health, Wellness, and Fitness Programs
- Case Example: Exercise and Osteoporosis
- Step 1: Assessing the Need
- Step 2: Set Goals and Objectives
- Goal
- Objectives
- Step 3: Develop the Intervention
- TABLE 2.3 Sample: Level 1 Exercise and Educational Class Content for Osteoporosis
- Step 4: Implement the Program
- Step 5: Evaluate the Program
- Additional Considerations for Developing Prevention, Health, and Wellness Programs
- TABLE 2.4 Issues Affecting Exercise Adherence
- Independent Learning Activities
- Critical Thinking and Discussion
- REFERENCES
- II Applied Science of Exercise and Techniques
- CHAPTER 3 Range of Motion
- Types of ROM Exercises
- Indications, Goals, and Limitations of ROM VIDEO 3.1
- Passive ROM
- Indications for PROM
- Goals for PROM
- Other Uses for PROM
- Limitations of Passive Motion
- Active and Active-Assistive ROM
- Indications for AROM
- Goals for AROM
- Limitations of Active ROM
- Precautions and Contraindications to ROM Exercises
- BOX 3.1 Summary of Precautions and Contraindications to Range of Motion Exercises
- Principles and Procedures for Applying ROM Techniques
- Examination, Evaluation, and Treatment Planning
- Patient Preparation
- Application of Techniques
- Application of PROM
- Application of AROM
- ROM Techniques
- CLINICAL TIP
- Upper Extremity
- Shoulder: Flexion and Extension (Fig. 3.1) VIDEO 3.2
- Hand Placement and Procedure
- FIGURE 3.1 Hand placement and positions for (A) initiating and (B) completing shoulder flexion.
- Shoulder: Extension (Hyperextension) (Fig. 3.2)
- FIGURE 3.2 Hyperextension of the shoulder (A) with the patient at the edge of the bed and (B) with the patient side-lying.
- Shoulder: Abduction and Adduction (Fig. 3.3)
- Hand Placement and Procedure
- FIGURE 3.3 Abduction of the shoulder with the elbow flexed.
- Shoulder: Internal (Medial) and External (Lateral) Rotation (Fig. 3.4)
- Hand Placement and Procedure
- FIGURE 3.4 The 90/90 position for initiating (A) internal and (B) external rotation of the shoulder.
- Shoulder: Horizontal Abduction (Extension) and Adduction (Flexion) (Fig. 3.5)
- FIGURE 3.5 Horizontal (A) abduction and (B) adduction of the shoulder.
- Hand Placement and Procedure
- Scapula: Elevation/Depression, Protraction/ Retraction, and Upward/Downward Rotation (Fig. 3.6)
- FIGURE 3.6 ROM of the scapula with the patient (A) prone and with the patient (B) side-lying.
- Hand Placement and Procedure
- Elbow: Flexion and Extension (Fig. 3.7) VIDEO 3.3
- Hand Placement and Procedure
- FIGURE 3.7 Elbow (A) flexion and (B) extension with the forearm supinated.
- Elongation of Two-Joint Biceps Brachii Muscle
- Hand Placement and Procedure
- Elongation of Two-Joint Long Head of the Triceps Brachii Muscle (Fig. 3.8)
- Hand Placement and Procedure
- FIGURE 3.8 End ROM for the long head of the triceps brachii muscle.
- Forearm: Pronation and Supination (Fig. 3.9)
- Hand Placement and Procedure
- Alternate Hand Placement
- FIGURE 3.9 Pronation of the forearm.
- Wrist: Flexion (Palmar Flexion) and Extension (Dorsiflexion); Radial (Abduction) and Ulnar (Adduction) Deviation (Fig. 3.10) VIDEO 3.4
- Hand Placement and Procedure
- FIGURE 3.10 ROM at the wrist. Shown is wrist flexion; note that the fingers are free to move in response to passive tension in the extrinsic tendons.
- Hand: Cupping and Flattening the Arch of the Hand at the Carpometacarpal and Intermetacarpal Joints (Fig. 3.11)
- Hand Placement and Procedure
- Alternate Hand Placement
- FIGURE 3.11 ROM to the arch of the hand.
- Joints of the Thumb and Fingers: Flexion and Extension and Abduction and Adduction (Fig. 3.12) VIDEO 3.5
- FIGURE 3.12 ROM to the metacarpophalangeal joint of the thumb.
- Hand Placement and Procedure
- Alternate Procedure
- Elongation of Extrinsic Muscles of the Wrist and Hand: Flexor and Extensor Digitorum Muscles (Fig. 3.13)
- General Technique Hand Placement and Procedure
- FIGURE 3.13 End of range for the extrinsic finger (A) flexors and
- (B) extensors.
- Lower Extremity
- Combined Hip and Knee: Flexion and Extension (Fig. 3.14) VIDEO 3.6
- Hand Placement and Procedure
- FIGURE 3.14 (A) Initiating and
- (B) completing combined hip and knee flexion.
- Hip: Extension (Hyperextension) (Fig. 3.15)
- Hand Placement and Procedure
- FIGURE 3.15 Hip extension with the patient side-lying.
- Elongation of the Two-Joint Hamstring Muscle Group (Fig. 3.16)
- Hand Placement and Procedure
- FIGURE 3.16 ROM to the hamstring muscle group.
- Elongation of the Two-Joint Rectus Femoris Muscle
- Hand Placement and Procedure
- Hip: Abduction and Adduction (Fig. 3.17)
- Hand Placement and Procedure
- FIGURE 3.17 Abduction of the hip, maintaining the hip in extension and neutral to rotation.
- Hip: Internal (Medial) and External (Lateral) Rotation
- Hand Placement and Procedure with the Hip and Knee Extended
- Hand Placement and Procedure for Rotation with the Hip and Knee Flexed (Fig. 3.18)
- FIGURE 3.18 Rotation of the hip with the hip positioned in 90° of flexion.
- Ankle: Dorsiflexion (Fig. 3.19) VIDEO 3.7
- Hand Placement and Procedure)
- FIGURE 3.19 Dorsiflexion of the ankle.
- Ankle: Plantarflexion
- Hand Placement and Procedure
- Subtalar (Lower Ankle) Joint: Inversion and Eversion (Fig. 3.20)
- Hand Placement and Procedure
- FIGURE 3.20 Inversion of the subtalar joint.
- Transverse Tarsal Joint
- Hand Placement and Procedure
- Joints of the Toes: Flexion and Extension and Abduction and Adduction (Metatarsophalangeal and Interphalangeal Joints) (Fig. 3.21)
- Hand Placement and Procedure
- FIGURE 3.21 Extension of the metatarsophalangeal joint of the large toe.
- Cervical Spine VIDEO 3.8
- Flexion (Forward Bending) (Fig. 3.22A)
- Procedure
- FIGURE 3.22 Cervical (A) flexion and
- Extension (Backward Bending or Hyperextension)
- Procedure
- Lateral Flexion (Side Bending) and Rotation (Fig. 3.22B)
- Procedure
- (B) rotation.
- Lumbar Spine VIDEO 3.9
- Flexion (Fig. 3.23)
- Hand Placement and Procedure
- FIGURE 3.23 Lumbar flexion is achieved by bringing the patient’s hips into flexion until the pelvis rotates posteriorly.
- Extension
- Hand Placement and Procedure
- Rotation (Fig. 3.24)
- Hand Placement and Procedure
- FIGURE 3.24 Rotation of the lumbar spine results when the thorax is stabilized and the pelvis lifts off the table as far as allowed.
- CLINICAL TIP
- Self-Assisted ROM
- Self-Assistance
- BOX 3.2 Self-Assisted Range of Motion Techniques
- Arm and Forearm
- FIGURE 3.25 Patient giving self-assisted ROM to shoulder flexion and extension. Horizontal abduction and adduction can be applied with the same hand placement.
- FIGURE 3.26 Arm position of patient for giving self-assisted ROM to internal and external rotation of shoulder.
- Wrist and Hand
- FIGURE 3.27 Patient applying self-assisted wrist flexion and extension with no pressure against the fingers.
- FIGURE 3.28 Patient applying self-assisted finger flexion and extension.
- FIGURE 3.29 Patient applying self-assisted thumb extension.
- Hip and Knee
- FIGURE 3.30 Self-assisted flexion of the hip.
- FIGURE 3.31 Self-assisted hip abduction and external rotation.
- Ankle and Toes
- Wand (T-Bar) Exercises
- FIGURE 3.32 Position of patient and hand placement for self-assisted ankle and toe motions; shown is inversion and eversion.
- FIGURE 3.33 Patient using a wand for self-assisted shoulder (A) flexion, (B) horizontal abduction/adduction, and (C) rotation.
- Wall Climbing
- FIGURE 3.34 Wall climbing for shoulder elevation.
- Overhead Pulleys
- Shoulder ROM (Fig. 3.35)
- FIGURE 3.35 Use of overhead pulleys to assist shoulder elevation.
- Elbow Flexion
- Skate Board/Powder Board
- Reciprocal Exercise Unit
- FIGURE 3.36 Continuous Motion Devices for (A) the shoulder and (B) the knee.
- Continuous Passive Motion
- Benefits of CPM
- FOCUS ON EVIDENCE
- General Guidelines for CPM
- ROM Through Functional Patterns
- BOX 3.3 Functional Range of Motion Activities
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- REFERENCES
- CHAPTER 4 Stretching for Impaired Mobility
- Definition of Terms Associated with Mobility and Stretching
- Flexibility
- Dynamic and Passive Flexibility
- Dynamic flexibility.
- Passive flexibility.
- Hypomobility
- Contracture
- TABLE 4.1 Comparison of Terminology of Two Disablement Models
- Designation of Contractures by Location
- Contracture Versus Contraction
- Types of Contracture
- Myostatic contracture.
- Pseudomyostatic contracture.
- Arthrogenic and periarticular contracture.
- Fibrotic contracture and irreversible contracture.
- Selective Stretching
- Overstretching and Hypermobility
- Overview of Interventions to Increase Mobility of Soft Tissues
- Stretching: Manual or Mechanical/Passive or Assisted
- Self-Stretching
- Neuromuscular Facilitation and Inhibition Techniques
- Muscle Energy Techniques
- Joint Mobilization/Manipulation
- Soft Tissue Mobilization/Manipulation
- Neural Tissue Mobilization (Neuromeningeal Mobilization)
- Indications, Contraindications, and Potential Outcomes of Stretching Exercises
- Indications and Contraindications for Stretching
- BOX 4.1 Indications for Use of Stretching
- BOX 4.2 Contraindications to Stretching
- Potential Benefits and Outcomes of Stretching
- Increased Flexibility and ROM
- General Fitness
- Other Potential Benefits
- Injury prevention and reduced postexercise muscle soreness.
- Enhanced performance.
- Properties of Soft Tissue: Response to Immobilization and Stretch
- Mechanical Properties of Contractile Tissue
- FIGURE 4.1 Structure of skeletal muscle.
- FIGURE 4.2 Muscular connective tissue. Cross-sectional view of the connective tissue in a muscle shows how the perimysium is continuous with the outer layer of epimysium.
- Contractile Elements of Muscle
- FIGURE 4.3 A model of myofilament sliding. Elongation and shortening of the sarcomere, the contractile unit of muscle.
- Mechanical Response of the Contractile Unit to Stretch and Immobilization
- Response to Stretch
- Response to Immobilization and Remobilization
- Morphological changes.
- Immobilization in a shortened position.
- Immobilization in a lengthened position.
- Neurophysiological Properties of Contractile Tissue
- Muscle Spindle
- FIGURE 4.4 Muscle spindle. Diagram shows intrafusal and extrafusal muscle fibers. The muscle spindle acts as a stretch receptor.
- Golgi Tendon Organ
- Neurophysiological Response of Muscle to Stretch
- Mechanical Properties of Noncontractile Soft Tissue
- Composition of Connective Tissue
- Collagen fibers.
- FIGURE 4.5 Composition of collagen fibers showing the aggregation of tropocollagen crystals as the building blocks of collagen. Organization of the fibers in connective tissue is related to the function of the tissue. Tissues with parallel fiber orientation, such as tendons, are able to withstand greater tensile loads than tissue, such as skin, in which the fiber orientation appears more random.
- Elastin fibers.
- Reticulin fibers.
- Ground substance.
- Mechanical Behavior of Noncontractile Tissue
- Interpreting Mechanical Behavior of Connective Tissue: The Stress-Strain Curve
- FIGURE 4.6 Stress-strain curve. When stressed, initially the wavy collagen fibers straighten (toe region). With additional stress, recoverable deformation occurs in the elastic range. Once the elastic limit is reached, sequential failure of the collagen fibers and tissue occurs in the plastic range, resulting in release of heat (hysteresis) and new length when the stress is released. The length from the stress point (X) results in a new length when released (X′); the heat released is represented by the area under the curve between these two points (hysteresis loop). (Y to Y′ represents additional length from additional stress with more heat released.) Necking is the region in which there is considerable weakening of the tissue, and less force is needed for deformation. Total failure quickly follows even under small loads.
- Types of Stress
- Regions of the Stress-Strain Curve
- Toe region.
- Elastic range/linear phase.
- Elastic limit.
- Plastic range.
- Ultimate strength.
- Failure.
- Structural stiffness.
- CLINICAL TIP
- Time and Rate Influences on Tissue Deformation
- Creep.
- Stress-relaxation.
- FIGURE 4.7 Tissue response to prolonged stretch forces as a result of viscoelastic properties. (A) Effects of creep. A constant load, applied over time, results in increased tissue length until equilibrium is reached. (B) Effects of stress-relaxation. A load applied with the tissue kept at a constant length results in decreased internal tension in the tissue until equilibrium is reached.
- Cyclic loading and connective tissue fatigue.
- Summary of Mechanical Principles for Stretching Connective Tissue
- Changes in Collagen Affecting Stress-Strain Response
- Effects of Immobilization
- Effects of Inactivity (Decrease of Normal Activity)
- Effects of Age
- Effects of Corticosteroids
- Effects of Injury
- Other Conditions Affecting Collagen
- Determinants and Types of Stretching Exercises
- BOX 4.3 Determinants of Stretching Interventions
- Alignment and Stabilization
- BOX 4.4 Types of Stretching
- Alignment
- FIGURE 4.8 (A) Correct alignment when stretching the rectus femoris: The lumbar spine, pelvis, and hip are held in a neutral position as the knee is flexed. (B) Incorrect position of the hip in flexion. In addition, avoid anterior pelvic tilt, hyperextension of the lumbar spine, and abduction of the hip.
- FIGURE 4.9 (A) Correct alignment when stretching to increase shoulder flexion: Note that the cervical and thoracic spine is erect. (B) Incorrect alignment: Note the forward head and rounded spine.
- Stabilization
- Intensity of Stretch
- FIGURE 4.10 (A) The proximal attachment (femur and pelvis) of the muscle being stretched (the quadriceps) is stabilized as the distal segment is moved to increase knee flexion. (B) During this self-stretch of the quadriceps, the distal segment (tibia) is stabilized through the foot as the patient moves the proximal segment (femur) by lunging forward.
- Duration of Stretch
- FOCUS ON EVIDENCE
- Static Stretching
- BOX 4.5 Intensity, Duration, Frequency, and Mode of Stretch—Evidence-Based Interrelationships and Impact on Stretching Outcomes
- FOCUS ON EVIDENCE
- Static Progressive Stretching
- Cyclic (Intermittent) Stretching
- FOCUS ON EVIDENCE
- Speed of Stretch
- Importance of a Slowly Applied Stretch
- Ballistic Stretching
- High-Velocity Stretching in Conditioning Programs and Advanced-Phase Rehabilitation
- Frequency of Stretch
- Mode of Stretch
- Manual Stretching
- Characteristics.
- BOX 4.6 Considerations for Selecting Methods of Stretching
- CLINICAL TIP
- Effectiveness.
- Application.
- Self-Stretching
- Characteristics.
- Effectiveness.
- Application.
- FIGURE 4.11 (A) When manually self-stretching the adductors and internal rotators of the hip, the patient moves the distal segment (femur) while stabilizing the proximal segment (pelvis) with body weight.
- (B) When self-stretching the hamstrings, the distal segment (tibia) is stabilized through the foot on the surface of a chair as the patient bends forward and moves the proximal segment. The weight of the upper body is the source of the stretch force.
- Mechanical Stretching
- Characteristics.
- Effectiveness.
- Application.
- FIGURE 4.12 Low-load mechanical stretch with a cuff weight and self-stabilization of the proximal humerus to stretch the elbow flexors and increase end-range elbow extension.
- Duration of Mechanical Stretch
- FIGURE 4.13 JAS orthosis is a patient-directed device that applies a static progressive stretch.
- FOCUS ON EVIDENCE
- Proprioceptive Neuromuscular Facilitation Stretching Techniques
- Types of PNF Stretching VIDEO 4.1
- CLINICAL TIP
- Hold-Relax and Contract-Relax
- FIGURE 4.14 Hold-relax (HR) procedure to stretch the pectoralis major muscles bilaterally. (A) The therapist horizontally abducts the shoulders bilaterally to a comfortable position. The patient isometrically contracts the pectoralis major muscles against the therapist’s resistance for about 5 to 10 seconds. (B) The patient relaxes voluntarily, and the therapist passively lengthens the pectoralis major muscles by horizontally abducting the shoulders into the newly gained range. After a 10-second rest with the muscles maintained in a comfortably lengthened position, the entire sequence is repeated several times.
- Agonist Contraction
- FOCUS ON EVIDENCE
- Hold-Relax with Agonist Contraction
- FOCUS ON EVIDENCE
- Integration of Function into Stretching
- Importance of Strength and Muscle Endurance
- Use of Increased Mobility for Functional Activities
- FIGURE 4.15 (A, B) Stretching-induced gains in ROM are used during daily activities.
- Procedural Guidelines for Application of Stretching Interventions
- Examination and Evaluation of the Patient
- BOX 4.7 Special Considerations for Teaching Self-Stretching Exercises
- BOX 4.8 Special Considerations for Use of Mechanical Stretching Devices
- Preparation for Stretching
- Application of Manual Stretching Procedures
- CLINICAL TIP
- After Stretching
- Precautions for Stretching
- General Precautions
- FOCUS ON EVIDENCE
- Special Precautions for Mass-Market Flexibility Programs
- Common Errors and Potential Problems
- Nonselective or poorly balanced stretching activities.
- Insufficient warm-up.
- Ineffective stabilization.
- Use of ballistic stretching.
- Excessive intensity.
- Abnormal biomechanics.
- Insufficient information about age-related differences.
- Strategies for Risk Reduction
- Adjuncts to Stretching Interventions
- Complementary Exercise Approaches
- Relaxation Training
- BOX 4.9 Indicators of Relaxation
- Common Elements of Relaxation Training
- Examples of Approaches to Relaxation Training
- Autogenic training.
- Progressive relaxation.
- Awareness through movement.
- Sequence for Progressive Relaxation Techniques
- Pilates
- Heat
- CLINICAL TIP
- Methods of Warm-Up
- Effectiveness of Warm-up Methods
- Cold
- CLINICAL TIP
- Massage
- Massage for Relaxation
- Soft Tissue Mobilization/Manipulation Techniques
- Biofeedback
- Joint Traction or Oscillation
- Manual Stretching Techniques in Anatomical Planes of Motion
- Upper Extremity Stretching
- The Shoulder: Special Considerations
- Shoulder Flexion VIDEO 4.2
- Hand Placement and Procedure
- FIGURE 4.16 (A) Hand placement and stabilization of the scapula to stretch the teres major and increase shoulder flexion.
- (B) Hand placement and stabilization of the pelvis to stretch the latissimus dorsi and increase shoulder flexion.
- Shoulder Hyperextension VIDEO 4.3
- Patient Position
- FIGURE 4.17 Hand placement and stabilization of the scapula to increase extension of the shoulder beyond neutral.
- Hand Placement and Procedure
- Shoulder Abduction
- FIGURE 4.18 Hand placement and stabilization of the scapula for the stretching procedure to increase shoulder abduction.
- Hand Placement and Procedure
- Shoulder Adduction
- Shoulder External Rotation VIDEO 4.4
- FIGURE 4.19 Shoulder position (slightly abducted and flexed) and hand placement at the mid to proximal forearm to increase external rotation of the shoulder. A folded towel is placed under the distal humerus to maintain the shoulder in slight flexion. The table stabilizes the scapula.
- Hand Placement and Procedure
- Shoulder Internal Rotation
- FIGURE 4.20 Hand placement and stabilization of the shoulder to increase internal rotation of the shoulder.
- Hand Placement and Procedure
- Shoulder Horizontal Abduction
- FIGURE 4.21 Hand placement and stabilization of the anterior aspect of the shoulder and chest to increase horizontal abduction of the shoulder past neutral (to stretch the pectoralis major).
- Patient Position
- Hand Placement and Procedure
- Scapular Mobility
- The Elbow and Forearm: Special Considerations
- Elbow Flexion
- Hand Placement and Procedure
- FIGURE 4.22 Hand placement and stabilization to increase elbow flexion with shoulder flexion (to stretch the long head of the triceps brachii).
- Patient Position, Hand Placement, and Procedure
- Elbow Extension VIDEO 4.5
- FIGURE 4.23 Hand placement and stabilization of the scapula and proximal humerus for stretching procedures to increase elbow extension.
- Hand Placement and Procedure
- Patient Position, Hand Placement, and Procedure
- Forearm Supination or Pronation
- Hand Placement and Procedure
- The Wrist and Hand: Special Considerations VIDEO 4.6
- Patient Position
- Wrist Flexion
- Hand Placement and Procedure
- Wrist Extension
- Hand Placement and Procedure
- FIGURE 4.24 Hand placement and stabilization of the forearm for stretching procedure to increase extension of the wrist.
- Radial Deviation
- Hand Placement and Procedure
- Ulnar Deviation
- Hand Placement and Procedure
- The Digits: Special Considerations VIDEO 4.7
- CMC Joint of the Thumb
- Hand Placement and Procedure
- MCP Joints of the Digits
- Hand Placement and Procedure
- PIP and DIP Joints
- Hand Placement and Procedure
- Stretching Specific Extrinsic and Intrinsic Muscles of the Fingers
- Lower Extremity Stretching
- The Hip: Special Considerations VIDEO 4.8
- Hip Flexion
- Hand Placement and Procedure
- Hip Flexion with Knee Extension
- Hand Placement and Procedure
- FIGURE 4.25 Hand placement and stabilization of the opposite femur to stabilize the pelvis and low back for stretching procedures to increase hip flexion with knee extension (stretch the hamstrings) with the therapist (A) standing by the side of the table or (B) kneeling on the table.
- Alternative Therapist Position
- Hip Extension VIDEO 4.9
- FIGURE 4.26 Hand placement and stabilization of the pelvis to increase extension of the hip (stretch the iliopsoas) with the patient lying supine. Flexing the knee when in this position also elongates the rectus femoris.
- Patient Position
- Hand Placement and Procedure
- Alternate Position
- Hand Placement and Procedure
- FIGURE 4.27 Hand placement and stabilization to increase hyperextension of the hip with the patient lying prone.
- Hip Extension with Knee Flexion
- Patient Position
- Hand Placement and Procedure
- Hip Abduction VIDEO 4.10
- FIGURE 4.28 Hand placement and stabilization of the opposite extremity (or pelvis) for the stretching procedure to increase abduction of the hip.
- Hand Placement and Procedure
- Hip Adduction VIDEO 4.11
- FIGURE 4.29 Patient positioned side-lying. Hand placement and procedure to stretch the tensor fasciae latae and IT band.
- Patient Position
- Hand Placement and Procedure
- Hip External Rotation
- Patient Position
- FIGURE 4.30 (A) Hand placement and stabilization of the pelvis to increase external rotation of the hip.
- Hand Placement and Procedure
- Alternate Position and Procedure
- Hip Internal Rotation
- Patient Position and Stabilization
- Hand Placement and Procedure
- (B) Hand placement and stabilization of the pelvis to increase internal rotation of the hip with the patient prone.
- The Knee: Special Considerations VIDEO 4.12
- Knee Flexion
- Patient Position
- FIGURE 4.31 Hand placement and stabilization to increase knee flexion (stretch the rectus femoris and quadriceps) with the patient lying prone.
- Hand Placement and Procedure
- Alternate Position and Procedure
- Knee Extension
- FIGURE 4.32 Hand placement and stabilization to increase midrange knee extension with the patient lying prone.
- Patient Position
- Hand Placement and Procedure
- End-Range Knee Extension VIDEO 4.13
- FIGURE 4.33 Hand placement and stabilization to increase terminal knee extension.
- Patient Position
- Hand Placement and Procedure
- The Ankle and Foot: Special Considerations VIDEO 4.14
- Ankle Dorsiflexion
- FIGURE 4.34 Hand placement and procedure to increase dorsiflexion of the ankle with the knee extended (stretching the gastrocnemius).
- Hand Placement and Procedure
- Ankle Plantarflexion
- Hand Placement and Procedure
- Ankle Inversion and Eversion
- Hand Placement and Procedure
- Stretching Specific Muscles of the Ankle and Foot
- Hand Placement and Procedure
- Toe Flexion and Extension
- Neck and Trunk
- Self-Stretching Techniques
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- REFERENCES
- CHAPTER 5 Peripheral Joint Mobilization/Manipulation
- Principles of Joint Mobilization/Manipulation
- Definitions of Terms
- Mobilization/Manipulation
- Thrust manipulation/high-velocity thrust (HVT).
- Self-Mobilization (Auto-Mobilization)
- Mobilization with Movement
- Physiological Movements
- Accessory Movements
- Component motions.
- Joint play.
- Manipulation Under Anesthesia
- Muscle Energy
- Basic Concepts of Joint Motion: Arthrokinematics
- Joint Shapes
- FIGURE 5.1 (A) With ovoid joints, one surface is convex, and the other is concave. (B) With saddle (sellar) joints, one surface is concave in one direction and convex in the other, with the opposing surface convex and concave, respectively.
- Types of Motion
- Roll
- FIGURE 5.2 Representation of one surface rolling on another. New points on one surface meet new points on the opposing surface.
- FIGURE 5.3 Rolling is always in the same direction as bone motion, whether the moving bone is (A) convex or (B) concave.
- Slide/Translation
- FIGURE 5.4 Representation of one surface sliding on another, whether (A) flat or (B) curved. The same point on one surface comes into contact with new points on the opposing surface.
- FIGURE 5.5 Representation of the concave-convex rule. (A) If the surface of the moving bone is convex, sliding is in the direction opposite to that of the angular movement of the bone. (B) If the surface of the moving bone is concave, sliding is in the same direction as the angular movement of the bone.
- FOCUS ON EVIDENCE
- Combined Roll-Sliding in a Joint
- CLINICAL TIP
- Spin
- FIGURE 5.6 Representation of spinning. There is rotation of a segment about a stationary mechanical axis.
- Passive-Angular Stretching Versus Joint-Glide Stretching
- FIGURE 5.7 Examples of joint spin locations in the body. (A) Humerus with flexion/extension. (B) Femur with flexion/extension. (C) Head of the radius with pronation/supination.
- Other Accessory Motions that Affect the Joint
- Compression
- Traction/Distraction VIDEO 5.1
- FIGURE 5.8 (A) Traction applied to the shaft of the humerus results in caudal gliding of the joint surface. (B) Distraction of the glenohumeral joint requires separation at right angles to the glenoid fossa.
- CLINICAL TIP
- Effects of Joint Motion
- Indications and Limitations for Use of Joint Mobilization/ Manipulation
- Pain, Muscle Guarding, and Spasm
- Neurophysiological Effects
- Mechanical Effects
- Reversible Joint Hypomobility
- Positional Faults/Subluxations
- Progressive Limitation
- Functional Immobility
- FOCUS ON EVIDENCE
- Limitations of Joint Mobilization/ Manipulation Techniques
- Contraindications and Precautions
- Hypermobility
- Joint Effusion
- Inflammation
- Conditions Requiring Special Precautions for Stretching
- Procedures for Applying Passive Joint Techniques
- Examination and Evaluation
- Quality of pain
- Capsular Restriction
- Subluxation or Dislocation
- Documentation
- Grades or Dosages of Movement for Non-Thrust and Thrust Techniques
- BOX 5.1 Characteristics to Describe Mobilization and Manipulation Techniques22
- Non-Thrust Oscillation Techniques (Fig. 5.9)
- FIGURE 5.9 Representation of oscillation techniques.
- Dosage and Rate of Application
- Grade I.
- Grade II.
- Grade III.
- Grade IV.
- Indications
- Non-Thrust Sustained Joint-Play Techniques (Fig. 5.10)
- FIGURE 5.10 Representation of sustained joint-play techniques.
- Dosages and Rate of Application
- Grade I (loosen).
- Grade II (tighten).
- Grade III (stretch).
- Indications
- Comparison of Oscillation and Sustained Techniques
- Thrust Manipulation/High Velocity Thrust (HVT)
- Application
- Indications
- Positioning and Stabilization
- Direction and Target of Treatment Force
- FIGURE 5.11 Treatment plane (T.P.) is at right angles to a line drawn from the axis of rotation to the center of the concave articulating surface and lies in the concave surface. Joint traction (distraction) is applied perpendicular to and glides parallel to the T.P.
- FIGURE 5.12 Initiation and progression of treatment.
- Initiation and Progression of Treatment (Fig. 5.12)
- CLINICAL TIP
- Patient Response
- Total Program
- BOX 5.2 Suggested Sequence of Treatment to Gain and Reinforce Functional Mobility
- Mobilization with Movement: Principles of Application
- Principles and Application of MWM in Clinical Practice
- Comparable sign.
- Passive techniques.
- Accessory glide with active comparable sign.
- No pain.
- Repetitions.
- Description of techniques.
- Patient Response and Progression
- Pain as a guide.
- Self treatment.
- Total program.
- Theoretical Framework
- FOCUS ON EVIDENCE
- Peripheral Joint Mobilization Techniques
- Shoulder Girdle Complex
- FIGURE 5.13 Bones and joints of the shoulder girdle complex.
- Glenohumeral Joint
- Resting position.
- Treatment plane.
- Stabilization.
- Glenohumeral Distraction (Fig. 5.14) VIDEO 5.1
- Indications
- FIGURE 5.14 Glenohumeral joint: distraction in resting position. Note that the force is perpendicular to the T.P. in the glenoid fossa.
- Patient Position
- Hand Placement
- Mobilizing Force
- Glenohumeral Caudal Glide in Resting Position (Fig. 5.15) VIDEO 5.2
- Indications
- FIGURE 5.15 Glenohumeral joint: caudal glide in the resting position. Note that the distraction force is applied by the hand in the axilla, and the caudal glide force is from the hand superior to the humeral head.
- Patient Position
- Hand Placement
- Mobilizing Force
- Glenohumeral Caudal Glide (Long Axis Traction)
- Hand Placement
- Mobilizing Force
- Glenohumeral Caudal Glide Progression (Fig. 5.16)
- Indication
- FIGURE 5.16 Glenohumeral joint: caudal glide with the shoulder near 90°.
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Glenohumeral Elevation Progression (Fig. 5.17)
- Indication
- FIGURE 5.17 Glenohumeral joint: elevation progression in the sitting position. This is used when the range is greater than 90°. Note the externally rotated position of the humerus; pressure against the head of the humerus is toward the axilla.
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Glenohumeral Posterior Glide, Resting Position (Fig. 5.18) VIDEO 5.3
- Indications
- FIGURE 5.18 Glenohumeral joint: posterior glide in the resting position.
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Glenohumeral Posterior Glide Progression (Fig. 5.19)
- Indications
- Patient Position
- Hand Placement
- FIGURE 5.19 Glenohumeral joint: posterior glide progression. (A) One hand or (B) a belt is used to exert a grade I distraction force.
- Mobilizing Force
- Glenohumeral Anterior Glide, Resting Position (Fig. 5.20) VIDEO 5.4
- Indications
- Patient Position
- FIGURE 5.20 Glenohumeral joint: anterior glide in the resting position.
- Therapist Position and Hand Placement
- Mobilizing Force
- Glenohumeral External Rotation Progressions (Fig. 5.21) VIDEO 5.5
- Indication
- Techniques
- FIGURE 5.21 Glenohumeral joint: distraction for external rotation progression. Note that the humerus is positioned in the resting position with maximum external rotation prior to the application of distraction stretch force.
- Acromioclavicular Joint
- Indication.
- Stabilization.
- Anterior Glide of Clavicle on Acromion (Fig. 5.22)
- Patient Position
- Hand Placement
- Mobilizing Force
- Sternoclavicular Joint
- Joint surfaces.
- FIGURE 5.22 Acromioclavicular joint: anterior glide.
- Treatment plane.
- Patient position and stabilization.
- Sternoclavicular Posterior Glide and Superior Glide (Fig. 5.23)
- Indications
- Hand Placement
- FIGURE 5.23 Sternoclavicular joint: posterior and superior glides. (A) Press down with the thumb for posterior glide. (B) Press upward with the index finger for superior glide.
- Mobilizing Force
- Sternoclavicular Anterior Glide and Caudal (Inferior) Glide (Fig. 5.24)
- Indications
- FIGURE 5.24 Sternoclavicular joint: anterior and inferior glides. (A) Pull the clavicle upward for an anterior glide. (B) Press caudalward with the curled fingers for an inferior glide.
- Hand Placement
- Mobilizing Force
- Scapulothoracic Soft-Tissue Mobilization (Fig. 5.25) VIDEO 5.6
- Patient position.
- FIGURE 5.25 Scapulothoracic articulation: elevation, depression, protraction, retraction, upward and downward rotations, and winging.
- Hand placement.
- Mobilizing force.
- Elbow and Forearm Complex
- Humeroulnar Articulation
- Resting position.
- Treatment plane.
- Stabilization.
- FIGURE 5.26 Bones and joints of the elbow complex.
- FIGURE 5.27 Lateral view of the humeroulnar joint, depicting the T.P.
- Humeroulnar Distraction and Progression (Fig. 5.28A) VIDEO 5.7
- Indications
- Patient Position
- FIGURE 5.28 Humeroulnar joint: (A) distraction and
- Hand Placement
- Mobilizing Force
- Humeroulnar Distal Glide (Fig. 5.28B)
- Indication
- (B) distraction with distal glide (scoop motion).
- Patient Position and Hand Placement
- Mobilizing Force
- Humeroulnar Radial Glide
- Indication
- Patient Position
- Hand Placement
- Mobilizing Force
- Humeroulnar Ulnar Glide
- Indication
- Patient Position
- Mobilizing Force
- Humeroradial Articulation VIDEO 5.8
- Resting position.
- Treatment plane.
- Stabilization.
- Humeroradial Distraction (Fig. 5.29)
- Indications
- FIGURE 5.29 Humeroradial joint: distraction.
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Humeroradial Dorsal/Volar Glides (Fig. 5.30)
- Indications
- Patient Position
- Hand Placement
- Mobilizing Force
- FIGURE 5.30 Humeroradial joint: dorsal and volar glides. This may also be done sitting, as in Figure 5.32, with the elbow positioned in extension and the humerus stabilized by the proximal hand (rather than the ulna).
- Humeroradial Compression (Fig. 5.31)
- Indication
- Patient Position
- FIGURE 5.31 Humeroradial joint: compression mobilization. This is a quick thrust with simultaneous supination and compression of the radius.
- Hand Placement
- Mobilizing Force
- Proximal Radioulnar Joint
- Resting position.
- Treatment plane.
- Stabilization.
- Proximal Radioulnar Dorsal/Volar Glides (Fig. 5.32) VIDEO 5.8
- Indications
- FIGURE 5.32 Proximal radioulnar joint: dorsal and volar glides.
- Patient Position
- Hand Placement
- Mobilizing Force
- Distal Radioulnar Joint
- Resting position.
- Treatment plane.
- Stabilization.
- Distal Radioulnar Dorsal/Volar Glides (Fig. 5.33)
- Indications
- FIGURE 5.33 Distal radioulnar joint: dorsal and volar glides.
- Patient Position
- Hand Placement
- Mobilizing Force
- Wrist and Hand Complex
- FIGURE 5.34 Bones and joints of the wrist and hand.
- Radiocarpal Joint
- Resting position.
- Treatment plane.
- Stabilization.
- Radiocarpal Distraction (Fig. 5.35)
- Indications
- FIGURE 5.35 Wrist joint: general distraction.
- Patient Position
- Hand Placement
- Mobilizing Force
- Radiocarpal Joint: General Glides and Progression
- Indications
- Patient Position and Hand Placement
- Mobilizing Force
- FIGURE 5.36 Wrist joint: general mobilization. (A) Dorsal glide. (B) Volar glide.
- FIGURE 5.37 Wrist joint: general mobilization—ulnar glide.
- Specific Carpal Mobilizations (Figs. 5.38 and 5.39)
- Patient and Therapist Positions
- Hand Placement and Indications
- To increase extension.
- FIGURE 5.38 Specific carpal mobilizations: stabilization of the distal bone and volar glide of the proximal bone. Shown is stabilization of the scaphoid and lunate with the index fingers and a volar glide to the radius with the thumbs to increase wrist flexion: (A) drawing of the side view with arrow depicting placement of thumbs on the radius and ‘x’ depicting placement of stabilizing index fingers; (B) illustrates superior view of overlapping thumbs on the radius.
- FIGURE 5.39 Specific carpal mobilizations: stabilization of the proximal bone and volar guide of the distal bone. Shown is stabilization of the lunate with the index fingers and volar glide to the capitate with the thumbs to increase extension: (A) drawing of the side view with arrow depicting placement of thumbs on the capitate and ‘x’ depicting placement of stabilizing index fingers; (B) illustrates superior view of overlapping thumbs on the capitate.
- To increase flexion.
- Mobilizing Force
- Ulnar-Meniscal-Triquetral Articulation
- Carpometacarpal and Intermetacarpal Joints of Digits II–V
- Carpometacarpal Distraction (Fig. 5.40)
- Stabilization and Hand Placement
- FIGURE 5.40 Carpometacarpal joint: Distraction.
- Mobilizing Force
- Carpometacarpal and Intermetacarpal: Volar Glide
- Indication
- Stabilization and Hand Placement
- Mobilizing Force
- Carpometacarpal Joint of the Thumb
- Resting position.
- Stabilization.
- Treatment plane.
- Carpometacarpal Distraction (Thumb)
- Indications
- Patient Position
- FIGURE 5.41 Carpometacarpal joint of the thumb. (A) Ulnar glide to increase flexion. (B) Radial glide to increase extension. (C) Dorsal glide to increase abduction. (D) Volar glide to increase adduction. Note that the thumb of the therapist is placed in the web space between the index and thumb of the patient’s hand to apply a volar glide.
- Hand Placement
- Mobilizing Force
- Carpometacarpal Glides (Thumb) (Fig. 5.41)
- Indications
- Patient Position and Hand Placement
- Mobilizing Force
- Metacarpophalangeal and Interphalangeal Joints of the Fingers
- Resting position.
- Treatment plane.
- Stabilization.
- Metacarpophalangeal and Interphalangeal Distraction (Fig. 5.42)
- Indications
- FIGURE 5.42 Metacarpophalangeal joint: distraction.
- Hand Placement
- Mobilizing Force
- Metacarpophalangeal and Interphalangeal Glides and Progression
- Indications
- FIGURE 5.43 Metacarpophalangeal joint: volar glide.
- Mobilizing Force
- Hip Joint
- FIGURE 5.44 Bones and joints of the pelvis and hip.
- Resting position.
- Stabilization.
- Treatment plane.
- Hip Distraction of the Weight-Bearing Surface, Caudal Glide (Fig. 5.45)
- FIGURE 5.45 Hip joint: pistraction of the weight-bearing surface.
- Indications
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Alternate Position and Technique for Hip Caudal Glide
- Hip Posterior Glide (Fig. 5.46) VIDEO 5.9
- Indications
- Patient Position
- FIGURE 5.46 Hip joint: posterior glide.
- Therapist Position and Hand Placement
- Mobilizing Force
- Hip Anterior Glide (Fig. 5.47) VIDEO 5.10
- Indications
- Patient Position
- Therapist Position and Hand Placement
- FIGURE 5.47 Hip joint: anterior glide. (A) prone and
- Mobilizing Force
- Alternate Position
- (B) side-lying.
- Knee Joint Complex
- FIGURE 5.48 Bones and joints of the knee and leg.
- Tibiofemoral Articulations
- Resting position.
- Treatment plane.
- Stabilization.
- Tibiofemoral Distraction: Long-Axis Traction (Fig. 5.49)
- Indications
- Patient Position
- FIGURE 5.49 Tibiofemoral joint: distraction. (A) sitting (B) supine (C) prone
- Hand Placement
- Mobilizing Force
- Tibiofemoral Posterior Glide (Fig. 5.50)
- Indications
- FIGURE 5.50 Tibiofemoral joint: posterior glide (drawer).
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Tibiofemoral Posterior Glide: Alternate Positions and Progression (Fig. 5.51)
- Patient Position
- FIGURE 5.51 Tibiofemoral joint: posterior glide, sitting.
- Therapist Position and Hand Placement
- Mobilizing Force
- Tibiofemoral Anterior Glide (Fig. 5.52) VIDEO 5.11
- Indication
- Patient Positions
- FIGURE 5.52 Tibiofemoral joint: anterior glide.
- Hand Placement
- Mobilizing Force
- Alternate Position and Technique
- Patellofemoral Joint
- Patellofemoral Joint, Distal Glide (Fig. 5.53)
- Patient Position
- Hand Placement
- Mobilizing Force
- FIGURE 5.53 Patellofemoral joint: distal glide.
- Patellofemoral Medial or Lateral Glide (Fig. 5.54)
- Indication
- FIGURE 5.54 Patellofemoral joint: lateral glide.
- Patient Position
- Hand Placement
- Mobilizing Force
- Leg and Ankle Joints
- Tibiofibular Joints
- Proximal Tibiofibular Articulation: Anterior (Ventral) Glide (Fig. 5.55)
- Indications
- FIGURE 5.55 Proximal tibiofibular joint: anterior glide.
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Distal Tibiofibular Articulation: Anterior (Ventral) or Posterior (Dorsal) Glide (Fig. 5.56)
- Indication
- FIGURE 5.56 Distal tibiofibular articulation: posterior glide.
- Patient Position
- Hand Placement
- Mobilizing Force
- Talocrural Joint (Upper Ankle Joint) (Fig. 5.57)
- Resting position.
- FIGURE 5.57 (A) Anterior view of the bones and joints of the lower leg and ankle. (B) Medial view. (C) Lateral view of the bones and joint relationships of the ankle and foot.
- Treatment plane.
- Stabilization.
- Talocrural Distraction (Fig. 5.58) VIDEO 5.12
- Indications
- Patient Position
- FIGURE 5.58 Talocrural joint: distraction.
- Therapist Position and Hand Placement
- Mobilizing Force
- Talocrural Dorsal (Posterior) Glide (Fig. 5.59)
- Indication
- FIGURE 5.59 Talocrural joint: posterior glide.
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Talocrural Ventral (Anterior) Glide (Fig. 5.60)
- Indication
- Patient Position
- FIGURE 5.60 Talocrural joint: anterior glide.
- Therapist Position and Hand Placement
- Mobilizing Force
- Alternate Position
- Subtalar Joint (Talocalcaneal), Posterior Compartment
- Resting position.
- Treatment plane.
- Stabilization.
- Subtalar Distraction (Fig. 5.61) VIDEO 5.13
- Indications
- FIGURE 5.61 Subtalar (talocalcaneal) joint: distraction.
- Patient and Therapist Positions and Hand Placement
- Mobilizing Force
- FIGURE 5.62 ubtalar joint: lateral glide. (A) prone. (B) side-lying.
- Subtalar Medial Glide or Lateral Glide (Fig. 5.62)
- Indications
- Patient Position
- Therapist Position and Hand Placement
- Mobilizing Force
- Alternate Position
- Intertarsal and Tarsometatarsal Joints
- Intertarsal and Tarsometatarsal Plantar Glide (Fig. 5.63)
- Indication
- Patient Position
- FIGURE 5.63 Plantar glide of a distal tarsal bone on a stabilized proximal bone. Shown is the cuneiform bone on the navicular.
- Stabilization and Hand Placement
- Mobilizing Force
- Intertarsal and Tarsometatarsal Dorsal Glide (Fig. 5.64)
- Indication
- FIGURE 5.64 Dorsal gliding of a distal tarsal on a proximal tarsal. Shown is the cuboid bone on the calcaneus.
- Patient Position
- Stabilization and Hand Placement
- Mobilizing Force
- Alternate Technique
- Intermetatarsal, Metatarsophalangeal, and Interphalangeal Joints
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- REFERENCES
- CHAPTER 6 Resistance Exercise for Impaired Muscle Performance
- Muscle Performance and Resistance Exercise: Definitions and Guiding Principles
- Strength, Power, and Endurance
- Strength
- Strength training.
- BOX 6.1 Potential Benefits of Resistance Exercise
- Power
- Power training.
- Endurance
- Endurance training.
- Overload Principle
- Description
- Application of the Overload Principle
- SAID Principle
- Specificity of Training
- Transfer of Training
- Reversibility Principle
- Skeletal Muscle Function and Adaptation to Resistance Exercise
- Factors that Influence Tension Generation in Normal Skeletal Muscle
- TABLE 6.1 Determinants and Correlates that Affect Tension Generation of Skeletal Muscle
- Energy Stores and Blood Supply
- Fatigue
- Muscle (local) fatigue.
- TABLE 6.2 Muscle Fiber Types and Resistance to Fatigue
- Cardiopulmonary (general) fatigue.
- BOX 6.2 Signs and Symptoms of Muscle Fatigue
- Threshold for fatigue.
- Factors that influence fatigue.
- Recovery from Exercise
- FOCUS ON EVIDENCE
- CLINICAL TIP
- Age
- Early Childhood and Preadolescence
- BOX 6.3 Summary of Age-Related Changes in Muscle and Muscle Performance Through the Life Span
- FIGURE 6.1 Resistance training, if initiated during the preadolescent years, should be performed using body weight or light weights and carefully supervised.
- FOCUS ON EVIDENCE
- Adolescence
- Young and Middle Adulthood
- Late Adulthood
- FIGURE 6.2 Conditioning and fitness programs for active young and middle-aged adults include resistance training with a balance of (A) upper extremity and (B) lower extremity strengthening exercises.
- FOCUS ON EVIDENCE
- FIGURE 6.3 Incorporating resistance training into a fitness program has many benefits for older adults.
- Psychological and Cognitive Factors
- Attention
- Motivation and Feedback
- Physiological Adaptations to Resistance Exercise
- TABLE 6.3 Physiological Adaptations to Resistance Exercise
- Neural Adaptations
- Skeletal Muscle Adaptations
- Hypertrophy
- Hyperplasia
- Muscle Fiber Type Adaptation
- Vascular and Metabolic Adaptations
- Adaptations of Connective Tissues
- Tendons, Ligaments, and Connective Tissue in Muscle
- Bone
- FOCUS ON EVIDENCE
- Determinants of Resistance Exercise
- BOX 6.4 Determinants of a Resistance Exercise Program
- Alignment and Stabilization
- Alignment
- Alignment and muscle action.
- Alignment and gravity.
- Stabilization
- Intensity
- Submaximal Versus Maximal Exercise Loads
- TABLE 6.4 Indications for Low-Intensity Versus High-Intensity Exercise
- Initial Exercise Load (Amount of Resistance) and Documentation of Training Effects
- Repetition Maximum
- Use of a repetition maximum.
- CLINICAL TIP
- Alternative Methods of Determining Baseline Strength or an Initial Exercise Load
- Training Zone
- BOX 6.5 Percentage of Body Weight as an Initial Exercise Load for Selected Exercises
- Volume
- Repetitions.
- Sets.
- Training to Improve Strength or Endurance: Impact of Exercise Load and Repetitions
- To Improve Muscle Strength
- To Improve Muscle Endurance
- CLINICAL TIP
- Exercise Order
- Frequency
- Duration
- Rest Interval (Recovery Period)
- Purpose of rest intervals.
- Integration of rest into exercise.
- Mode of Exercise
- Type of Muscle Contraction
- FIGURE 6.4 Types of muscle contractions: their relationships to muscle performance and their tension-generating capacities.
- Position for Exercise: Weight-Bearing or Nonweight-Bearing
- Forms of Resistance
- FIGURE 6.5 Body weight serves as the source of resistance during a push-up.
- Energy Systems
- Range of Movement: Short-Arc or Full-Arc Exercise
- Mode of Exercise and Application to Function
- Velocity of Exercise
- Force-Velocity Relationship
- Concentric Muscle Contraction
- Eccentric Muscle Contraction
- FIGURE 6.6 Force-velocity curve for concentric and eccentric exercise.
- Application to Resistance Training
- Periodization and Variation of Training
- Integration of Function
- Balance of Stability and Active Mobility
- TABLE 6.5 Characteristics of Periodized Training
- Balance of Strength, Power, and Endurance
- Task-Specific Movement Patterns with Resistance Exercise
- Types of Resistance Exercise
- BOX 6.6 Selecting Types of Resistance Exercise: Questions to Consider
- TABLE 6.6 Progression of a Resistance Training Program: Factors for Consideration
- Manual and Mechanical Resistance Exercise
- Manual Resistance Exercise
- Mechanical Resistance Exercise
- Isometric Exercise (Static Exercise)
- Rationale for Use of Isometric Exercise
- Types of Isometric Exercise
- Muscle-setting exercises.
- BOX 6.7 Isometric Exercise: Summary of Rationale and Indications
- Stabilization exercises.
- Multiple-angle isometrics.
- Characteristics and Effects of Isometric Training
- Intensity of muscle contraction.
- CLINICAL TIP
- Duration of muscle activation.
- Repetitive contractions.
- Joint angle and mode specificity.
- Sources of resistance.
- Dynamic Exercise: Concentric and Eccentric
- FIGURE 6.7 (A) Concentric and (B) eccentric strengthening of the elbow flexors occurs as a weight is lifted and lowered.
- Rationale for Use of Concentric and Eccentric Exercise
- Special Considerations for Eccentric Training
- FOCUS ON EVIDENCE
- Characteristics and Effects of Concentric and Eccentric Exercise
- Exercise load and strength gains.
- BOX 6.8 Eccentric Versus Concentric Exercise: Summary of Characteristics
- CLINICAL TIP
- Velocity of exercise.
- CLINICAL TIP
- Energy expenditure.
- Specificity of training.
- Cross-training effect.
- Exercise-induced muscle soreness.
- Dynamic Exercise: Constant and Variable Resistance
- Dynamic Exercise: Constant External Resistance
- FIGURE 6.8 (A) N-K Exercise Unit with torque arm and interchangeable weights provides constant external resistance.
- Variable Resistance Exercise
- (B) Cybex/Eagle Fitness Systems shoulder press provides variable resistance throughout the range of motion.
- Special Considerations for DCER and Variable Resistance Exercise
- Excursion of limb movement.
- Velocity of exercise.
- CLINICAL TIP
- Isokinetic Exercise
- FIGURE 6.9 Biodex isokinetic dynamometer is used for testing and training.
- Characteristics of Isokinetic Training
- Constant velocity.
- Range and selection of training velocities.
- TABLE 6.7 Classification of Velocity of Training in Concentric Isokinetic Exercises*
- Reciprocal versus isolated muscle training.
- Specificity of training.
- Compressive forces on joints.
- Accommodation to fatigue.
- Accommodation to a painful arc.
- Training Effects and Carryover to Function
- Limitations in carryover.
- Special Considerations for Isokinetic Training
- Availability of Equipment
- Appropriate Setup
- Initiation and Progression of Isokinetic Training During Rehabilitation
- Open-Chain and Closed-Chain Exercise
- Background
- BOX 6.9 Progression of Isokinetic Training for Rehabilitation
- Controversy and Inconsistency in Use of Open-Chain and Closed-Chain Terminology
- Alternatives to Open-Chain and Closed-Chain Terminology
- Characteristics of Open-Chain and Closed-Chain Exercises
- Open-Chain Exercises
- TABLE 6.8 Characteristics of Open-Chain and Closed-Chain Exercises
- FIGURE 6.10 Open-chain resisted knee flexion.
- Closed-Chain Exercises
- FIGURE 6.11 Bilateral closed-chain resisted hip and knee flexion/extension.
- Rationale for Use of Open-Chain and Closed-Chain Exercises
- FOCUS ON EVIDENCE
- Isolation of Muscle Groups
- FOCUS ON EVIDENCE
- Control of Movements
- Joint Approximation
- Co-activation and Dynamic Stabilization
- Proprioception, Kinesthesia, Neuromuscular Control, and Balance
- FOCUS ON EVIDENCE
- Carryover to Function and Injury Prevention
- FOCUS ON EVIDENCE
- Implementation and Progression of Open-Chain and Closed-Chain Exercises
- Introduction of Open-Chain Training
- Closed-Chain Exercises and Weight-Bearing Restrictions: Use of Unloading
- TABLE 6.9 Parameters and Progression of Closed-Chain Exercises
- Progression of Closed-Chain Exercises
- General Principles of Resistance Training
- Examination and Evaluation
- Preparation for Resistance Exercises
- BOX 6.10 Is Resistance Training Appropriate? Questions to Consider
- Implementation of Resistance Exercises
- Warm-Up
- Placement of Resistance
- FIGURE 6.12 Resistance (R) is applied to the distal end of the segment being strengthened. Resistance is applied in the direction opposite to that of limb movement to resist a concentric muscle contraction and in the same direction as limb movement to resist an eccentric contraction.
- Direction of Resistance
- Stabilization
- FIGURE 6.13 Stabilization is applied at the proximal attachment of the muscle being strengthened. In this figure, the proximal humerus and scapula are stabilized as elbow flexion is resisted.
- Intensity of Exercise/Amount of Resistance
- Number of Repetitions, Sets, and Rest Intervals
- Verbal or Written Instructions
- Monitoring the Patient
- Cool-Down
- Precautions for Resistance Exercise
- BOX 6.11 General Precautions During Resistance Training
- Valsalva Maneuver
- At-Risk Patients
- CLINICAL TIP
- Prevention During Resistance Exercise
- Substitute Motions
- Overtraining and Overwork
- Overtraining
- Overwork
- Exercise-Induced Muscle Soreness
- Acute Muscle Soreness
- Delayed-Onset Muscle Soreness
- Etiology of DOMS.
- BOX 6.12 Delayed-Onset Muscle Soreness: Clinical Signs and Symptoms
- Prevention and treatment of DOMS.
- FOCUS ON EVIDENCE
- Pathological Fracture
- Prevention of Pathological Fracture
- BOX 6.13 Resistance Training Guidelines and Precautions to Reduce the Risk of Pathological Fracture
- Contraindications to Resistance Exercise
- Pain
- Inflammation
- Severe Cardiopulmonary Disease
- Manual Resistance Exercise
- Definition and Use
- Guidelines and Special Considerations
- BOX 6.14 Manual Resistance Exercise: Advantages and Disadvantages
- Body Mechanics of the Therapist
- Application of Manual Resistance and Stabilization
- CLINICAL TIP
- Verbal Commands
- Number of Repetitions and Sets/Rest Intervals
- Techniques: General Background
- Upper Extremity
- Shoulder Flexion VIDEO 6.1
- Hand Placement and Procedure
- FIGURE 6.14 Resisted shoulder flexion.
- Shoulder Extension
- Hand Placement and Procedure
- Shoulder Hyperextension
- Hand Placement and Procedure
- Shoulder Abduction and Adduction
- Hand Placement and Procedure
- FIGURE 6.15 Resisted shoulder abduction.
- Elevation of the Arm in the Plane of the Scapula (“Scaption”)
- Hand Placement and Procedure
- CLINICAL TIP
- Shoulder Internal and External Rotation
- Hand Placement and Procedure
- Alternate Procedure
- FIGURE 6.16 (A) Resisted external rotation of the shoulder with the shoulder positioned in flexion and abduction (approaching the plane of the scapula).
- (B) Resisted internal rotation of the shoulder with the shoulder in 90° of abduction.
- Shoulder Horizontal Abduction and Adduction
- Hand Placement and Procedure
- Elevation and Depression of the Scapula VIDEO 6.2
- Hand Placement and Procedure
- Alternate Procedures: Scapular Depression
- FIGURE 6.17 Elevation of the shoulders (scapulae), resisted bilaterally.
- Protraction and Retraction of the Scapula
- Hand Placement and Procedure
- Elbow Flexion and Extension VIDEO 6.3
- Hand Placement and Procedure
- FIGURE 6.18 Resisted elbow flexion with proximal stabilization.
- FIGURE 6.19 Resisted elbow extension.
- Forearm Pronation and Supination VIDEO 6.4
- Hand Placement and Procedure
- FIGURE 6.20 Resisted pronation of the forearm.
- Wrist Flexion and Extension VIDEO 6.5
- Hand Placement and Procedure
- FIGURE 6.21 Resisted wrist flexion and stabilization of the forearm.
- Wrist Radial and Ulnar Deviation
- Hand Placement and Procedure
- Motions of the Fingers and Thumb VIDEO 6.6
- Hand Placement and Procedure
- FIGURE 6.22 Resisted flexion of the proximal interphalangeal (PIP) joint of the index finger with stabilization of the metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints.
- FIGURE 6.23 Resisted opposition of the thumb.
- Lower Extremity
- Hip Flexion with Knee Flexion VIDEO 6.7
- Hand Placement and Procedure
- FIGURE 6.24 Resisted flexion of the hip with the knee flexed.
- Hip Extension
- Hand Placement and Procedure
- FIGURE 6.25 Resisted hip and knee extension with the hand placed at the popliteal space to prevent hyperextension of the knee.
- Hip Hyperextension
- Hand Placement and Procedure
- FIGURE 6.26 Resisted end-range hip extension with stabilization of the pelvis.
- Hip Abduction and Adduction
- Hand Placement and Procedure
- FIGURE 6.27 Resisted hip abduction.
- Hip Internal and External Rotation
- Hand Placement and Procedure
- FIGURE 6.28 Resisted external rotation of the hip with the patient lying supine.
- Hand Placement and Procedure
- Hand Placement and Procedure
- FIGURE 6.29 Resisted internal rotation of the hip with the patient lying prone.
- Knee Flexion VIDEO 6.8
- Hand Placement and Procedure
- FIGURE 6.30 Resisted knee flexion with stabilization of the hip.
- Knee Extension
- Alternate Patient Positions
- Hand Placement and Procedure
- FIGURE 6.31 Resisted knee extension with the patient sitting and stabilizing the trunk with the upper extremities and the therapist stabilizing the thigh.
- Ankle Dorsiflexion and Plantarflexion VIDEO 6.9
- Hand Placement and Procedure
- FIGURE 6.32 (A) Resisted dorsiflexion. (B) Resisted plantarflexion of the ankle.
- Ankle Inversion and Eversion
- Hand Placement and Procedure
- Flexion and Extension of the Toes
- Hand Placement and Procedure
- Proprioceptive Neuromuscular Facilitation: Principles and Techniques
- Diagonal Patterns
- TABLE 6.10 Component Motions of PNF Patterns: Upper and Lower Extremities
- Basic Procedures with PNF Patterns
- Manual Contacts
- Maximal Resistance
- Position and Movement of the Therapist
- Stretch
- Stretch stimulus.
- Stretch reflex.
- Normal Timing
- Traction
- Approximation
- Verbal Commands
- Visual Cues
- Upper Extremity Diagonal Patterns
- D1Flexion VIDEO 6.10
- Starting Position (Fig. 6.33A)
- FIGURE 6.33 (A) Starting position and
- Hand Placement
- Verbal Commands
- Ending Position (Fig. 6.33B)
- (B) ending position for D1 flexion of the upper extremity.
- D1Extension
- Starting Position (Fig. 6.34A)
- FIGURE 6.34 (A) Starting position and
- Hand Placements
- Verbal Commands
- Ending Position (Fig. 6.34B)
- (B) ending position for D1 extension of the upper extremity.
- D2Flexion VIDEO 6.11
- Starting Position (Fig. 6.35A)
- FIGURE 6.35 (A) Starting position and
- Hand Placement
- Verbal Commands
- Ending Position (Fig. 6.35B)
- (B) ending position for D2 flexion of the upper extremity.
- D2Extension
- Starting Position (Fig. 6.36A)
- Hand Placement
- Verbal Commands
- FIGURE 6.36 (A) Starting position and
- Ending Position (Fig. 6.36B)
- (B) ending position for D2 extension of the upper extremity.
- Lower Extremity Diagonal Patterns
- D1Flexion VIDEO 6.12
- Starting Position (Fig. 6.37A)
- FIGURE 6.37 (A) Starting position and
- Hand Placement
- Verbal Commands
- Ending Position (Fig. 6.37B)
- (B) ending position for D1 flexion of the lower extremity.
- D1Extension
- Starting Position (Fig. 6.38A)
- Hand Placement
- Verbal Commands
- Ending Position (Fig. 6.38B)
- FIGURE 6.38 (A) Starting position and (B) ending position for D1 extension of the lower extremity.
- D2Flexion VIDEO 6.13
- Starting Position (Fig. 6.39A)
- Hand Placement
- Verbal Commands
- FIGURE 6.39 (A) Starting position and
- Ending Position (Fig. 6.39B)
- (B) ending position for D2 flexion of the lower extremity.
- D2Extension
- Starting Position (Fig. 6.40A)
- Hand Placement
- FIGURE 6.40 (A) Starting position and
- Verbal Commands
- Ending Position (Fig. 6.40B)
- (B) ending position for D2 extension of the lower extremity.
- Specific Techniques with PNF
- Rhythmic Initiation
- Repeated Contractions
- Reversal of Antagonists
- Slow reversal.
- Slow reversal hold.
- Alternating Isometrics VIDEO 6.14
- FIGURE 6.41 (A) Use of alternating isometrics to improve static strength of the proximal musculature by alternately placing both hands and applying resistance to the anterior aspect of the body and then to the posterior aspect of the body. (B) Use of alternating isometrics in the upper extremities.
- Rhythmic Stabilization
- FIGURE 6.42 Use of rhythmic stabilization to improve stability of the trunk by simultaneously applying resistance in opposite directions to the anterior and posterior surfaces of the trunk, emphasizing isometric contractions of the trunk rotators.
- Mechanical Resistance Exercise
- Application in Rehabilitation Programs
- BOX 6.15 Mechanical Resistance Exercise: Advantages and Disadvantages
- Application in Fitness and Conditioning Programs
- BOX 6.16 Summary of Guidelines for Resistance Training in Conditioning Programs for Healthy Adults (<50–60 years old)
- Special Considerations for Children and Older Adults
- Children and Resistance Training
- FIGURE 6.43 Youth resistance training on Kids-N-Motion® equipment (Triceps-Dip), specifically designed and sized for a child’s use.
- FOCUS ON EVIDENCE
- Older Adults and Resistance Training
- BOX 6.17 Resistance Training for Children: Guidelines and Special Considerations
- BOX 6.18 Resistance Training for Older Adults (>60–65 Years): Guidelines and Special Considerations
- Selected Resistance Training Regimens
- Progressive Resistance Exercise
- FOCUS ON EVIDENCE
- Delorme and Oxford Regimens
- FOCUS ON EVIDENCE
- TABLE 6.11 Comparison of Two PRE Regimens
- DAPRE Regimen
- Circuit Weight Training
- TABLE 6.12 DAPRE Technique
- TABLE 6.13 Calculation of the Adjusted Working Weight for the DAPRE Regimen
- BOX 6.19 Example of a Resistance Training Circuit
- Isokinetic Regimens
- Velocity Spectrum Rehabilitation
- Selection of training velocities.
- Repetitions, sets, and rest.
- Intensity.
- Eccentric Isokinetic Training: Special Considerations
- BOX 6.20 Key Differences in Eccentric Versus Concentric Isokinetic Training
- Equipment for Resistance Training
- Free Weights and Simple Weight-Pulley Systems
- Types of Free Weights
- BOX 6.21 General Principles for the Selection and Use of Equipment
- FIGURE 6.44 (A & B) Holding a weighted ball while performing combined patterns of movement provides resistance to upper extremity and trunk muscles and augments the resistance of body weight to lower extremity muscle groups during weight-bearing activities.
- Simple Weight-Pulley Systems
- FIGURE 6.45 Multi-Exercise Pulley Unit can be used to strengthen a variety of muscle groups.
- Characteristics of Free Weights and Simple Weight-Pulley Systems
- FIGURE 6.46 When the patient is standing and lifting a weight: (A) Zero torque is produced in the shoulder flexors when the shoulder is at 0° of flexion. (B) Maximum torque is produced when the shoulder is at 90° of flexion. (C) Torque again decreases as the arm moves from 90° to 180° of shoulder flexion.
- FIGURE 6.47 When the patient is supine and lifting a weight: (A) Maximum torque is produced at 0° of shoulder flexion. (B) Zero torque is produced at 90° of shoulder flexion. (C) The shoulder extensors are active and contract eccentrically against resistance from 90° to 180° of shoulder flexion.
- Advantages and Disadvantages of Free Weights and Simple Weight-Pulley Systems
- Variable Resistance Units
- Variable Resistance Weight-Cable Systems
- FIGURE 6.48 Variable resistance by means of a cam mechanism in the weight-pulley system is applied to concentric and eccentric contractions of the hamstrings as the knees flex and extend.
- Hydraulic and Pneumatic Resistance Devices
- Advantages and Disadvantages of Variable Resistance Machines
- Elastic Resistance Devices
- Types of Elastic Resistance
- Properties of Elastic Resistance: Implications for Exercise
- Effect of elongation of elastic material.
- Determination and quantification of resistance.
- Fatigue characteristics.
- Application of Elastic Resistance
- Selecting the appropriate grade of material.
- FOCUS ON EVIDENCE
- Selecting the appropriate length.
- Securing bands or tubing.
- FIGURE 6.49 Use of elastic resistance to strengthen (A) upper or (B) lower extremity or (C) trunk musculature.
- Setting up an exercise.
- Progressing exercises.
- Advantages and Disadvantages of Exercise with Elastic Resistance
- Advantages
- Disadvantages
- Equipment for Dynamic Stabilization Training
- BodyBlade®
- FIGURE 6.50 Dynamic stabilization exercises of the upper extremity and trunk using the BodyBlade®.
- FOCUS ON EVIDENCE
- Swiss Balls (Stability Balls)
- Equipment for Closed-Chain Training
- Body Weight Resistance: Multipurpose Exercise Systems
- FIGURE 6.51 Closed-chain training: (A) in the semi-reclining position and (B) standing position using the Total Gym® system.
- CLINICAL TIP
- Slide Boards
- FIGURE 6.52 Pro Fitter provides closed-chain resistance to lower extremity musculature in preparation for functional activities.
- Balance Equipment
- Mini-Trampolines (Rebounders)
- Reciprocal Exercise Equipment
- Stationary Exercise Cycles
- Portable Resistive Reciprocal Exercise Units
- FIGURE 6.53 Resisted reciprocal exercise using the Chattanooga Exerciser.®
- Stair-Stepping Machines
- FIGURE 6.54 A stepping machine provides resistance during alternating lower extremity-pushing movements that simulate stair-climbing.
- Elliptical Trainers and Cross-Country Ski Machines
- Upper Extremity Ergometers
- FIGURE 6.55 An upper extremity ergometer is used for upper body strength and endurance training and cardiopulmonary fitness.
- Isokinetic Testing and Training Equipment
- Features of Isokinetic Dynamometers
- Advantages and Disadvantages of Isokinetic Equipment
- Advantages
- Disadvantages
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- REFERENCES
- CHAPTER 7 Principles of Aerobic Exercise
- Key Terms and Concepts
- Physical Activity
- Exercise
- Physical Fitness
- Maximum Oxygen Consumption
- Endurance
- Aerobic Exercise Training (Conditioning)
- Adaptation
- Myocardial Oxygen Consumption
- BOX 7.1 Clinical Relevance—Exertional Angina
- Deconditioning
- BOX 7.2 Deconditioning Effects Associated with Bed Rest3
- Energy Systems, Energy Expenditure, and Efficiency
- Energy Systems
- Phosphagen, or ATP-PC, System
- Anaerobic Glycolytic System
- Aerobic System
- Recruitment of Motor Units
- Functional Implications
- Energy Expenditure
- Quantification of Energy Expenditure
- Classification of Activities
- BOX 7.3 Daily Energy Expenditure
- Efficiency
- BOX 7.4 Efficiency Expressed as a Percentage
- Physiological Response to Aerobic Exercise
- Cardiovascular Response to Exercise
- Exercise Pressor Response
- Cardiac Effects
- BOX 7.5 Factors Affecting the Response to Acute Exercise
- Peripheral Effects
- Net reduction in total peripheral resistance.
- Increased cardiac output.
- Increase in systolic blood pressure.
- Respiratory Response to Exercise
- Responses Providing Additional Oxygen to Muscle
- Increased Blood Flow
- Increased Oxygen Extraction
- Oxygen Consumption
- Testing as a Basis for Exercise Programs
- Fitness Testing of Healthy Subjects
- Stress Testing for Convalescing Individuals and Individuals at Risk
- FIGURE 7.1 Cycle ergometer stress test with electrocardiogram monitoring.
- Principles of Stress Testing
- Purpose of Stress Testing
- Preparation for Stress Testing
- Termination of Stress Testing
- BOX 7.6 Precautions for Stress Testing and Exercise Program
- Multistage Testing
- Determinants of an Exercise Program
- Frequency
- Intensity
- Overload Principle
- BOX 7.7 Case Example of an Exercise Stress Test
- Conclusion
- BOX 7.8 Methods to Determine Maximum Heart Rate and Exercise Heart Rate
- Individuals at Risk
- Variables
- Specificity Principle
- Time (Duration)
- Type (Mode)
- Reversibility Principle
- CLINICAL TIP
- Exercise Program
- Warm-Up Period
- Physiological Responses
- Purposes
- Guidelines
- Aerobic Exercise Period
- Continuous Training
- Interval Training
- Circuit Training
- Circuit-Interval Training
- Cool-Down Period
- Application
- Physiological Changes that Occur with Training
- Cardiovascular Changes
- Changes at Rest
- BOX 7.9 General Guidelines for an Aerobic Training Program
- Changes During Exercise
- Respiratory Changes
- Changes at Rest
- Changes During Exercise
- Metabolic Changes
- Changes at Rest
- Changes During Exercise
- Other System Changes
- FOCUS ON EVIDENCE
- Application of Principles of an Aerobic Conditioning Program for the Patient with Coronary Disease
- Inpatient Phase (Phase I)
- Purpose
- Outpatient Phase (Phase II)
- Purpose
- Guidelines
- Frequency.
- Intensity.
- BOX 7.10 Case Example of a Cardiac Rehabilitation Referral
- Time.
- Type.
- Method.
- Weight training.
- Progression.
- Outpatient Program (Phase III)
- Purpose
- Guidelines
- Recreational activities.
- Activities at 8 METs
- Special Considerations
- Adaptive Changes
- CLINICAL TIP
- Applications of Aerobic Training for the Deconditioned Individual and the Patient with Chronic Illness
- Deconditioning
- Reversal of Deconditioning
- Adaptations for Participation Restrictions (Disabilities), Activity Restrictions (Functional Limitations), and Deconditioning
- Impairments, Goals, and Plan of Care
- Common Impairments
- Goals
- Outcomes
- Guidelines
- Age Differences
- BOX 7.11 Guidelines for Initiating an Aerobic Exercise Program for the Deconditioned Individual and the Patient with Chronic Illness
- BOX 7.12 Guidelines for Progression of an Aerobic Training Program
- Children
- Heart rate.
- Stroke volume.
- Cardiac output.
- Arteriovenous oxygen difference.
- Maximum oxygen uptake.
- Blood pressure.
- Respiration.
- Muscle mass and strength.
- Anaerobic ability.
- Young Adults
- Heart rate.
- Stroke volume.
- Cardiac output for the sedentary young man at rest.
- Arteriovenous oxygen difference.
- Maximum oxygen uptake.
- Blood pressure.
- Respiration.
- Muscle mass and strength.
- Anaerobic ability.
- Older Adults
- Heart rate.
- Stroke volume.
- Cardiac output.
- Arteriovenous difference.
- Maximum oxygen uptake.
- Blood pressure.
- Respiration.
- Muscle mass and strength.
- Independent Learning Activities
- Critical Thinking and Discussion
- REFERENCES
- CHAPTER 8 Exercise for Impaired Balance
- Background and Concepts
- Balance: Key Terms and Definitions
- Center of mass.
- Center of gravity.
- Momentum.
- Base of support.
- Limits of stability.
- FIGURE 8.1 Boundaries of the limits of stability while standing, walking, and sitting.
- Ground reaction force and center of pressure.
- Balance Control
- Sensory Systems and Balance Control
- FIGURE 8.2 Interactions of the musculoskeletal and nervous systems and contextual effects for balance control.
- Visual System
- Somatosensory System
- Vestibular System
- Sensory Organization for Balance Control
- Types of Balance Control
- FIGURE 8.3 Ankle, hip, and stepping strategies used by adults to control body sway.
- Motor Strategies for Balance Control
- BOX 8.1 Factors Influencing Selection of Balance Strategies
- TABLE 8.1 Characteristics of the Three Movement Systems for Balance Control Following Perturbations
- Ankle Strategy (Anteroposterior Plane)
- Weight-Shift Strategy (Lateral Plane)
- Suspension Strategy
- Hip Strategy
- Stepping Strategy
- Combined Strategies
- Balance Control Under Varying Conditions
- Balance During Stance
- Balance with Perturbed Standing
- Balance During Whole-Body Lifting
- COM shift.
- FIGURE 8.4 Balance during forward lifting with knees flexed.
- Anticipated weight and momentum.
- Loss of balance.
- Lifting style.
- Lifting instructions.
- FIGURE 8.5 Postural adjustments for lifting a heavy versus a light load. When subjects approach a load (indicated by the vertical bar at time 0), early in the lift subtle differences in the anticipatory postural adjustments are evident. When a heavy load is expected (dark circles) there is greater flexion of the trunk, hips, and knees compared to when a light load is expected (light circles).
- FIGURE 8.6 Balance during forward lifting with knees extended.
- FIGURE 8.7 Squat lift with trunk erect and object placed between the feet.
- FIGURE 8.8 Straddle lift with trunk erect and object placed between the feet.
- Lifting styles.
- CLINICAL TIP
- FIGURE 8.9 Side lift with the right trunk in lateral flexion and rotation results in high loads on the lumbar spine and should be avoided.
- Balance in Unperturbed Human Gait
- Impaired Balance
- Sensory Input Impairments
- Sensorimotor Integration Impairments
- Biomechanical and Motor Output Impairments
- Deficits with Aging
- BOX 8.2 Most Common Risk Factors for Falls Among the Elderly
- CLINICAL TIP
- TABLE 8.2 Outcome Measures for Fall Risk Assessment
- Deficits from Medications
- Management of Impaired Balance
- Examination and Evaluation of Impaired Balance
- Static Balance Tests
- TABLE 8.3 Balance Assessments and Interventions
- Dynamic Balance Tests
- Anticipatory Postural Control Tests
- Reactive Postural Control Tests
- Sensory Organization Tests
- Functional Tests
- Balance Training
- CLINICAL TIP
- BOX 8.3 Safety During Balance Training
- Static Balance Control
- FIGURE 8.10 Balance during single leg stance.
- FIGURE 8.11 Balance while standing with resistance provided to the arms via elastic resistance.
- FIGURE 8.12 Balance while standing with arm abducting and holding a weight.
- FIGURE 8.13 Balance while standing and catching a ball.
- Dynamic Balance Control
- FIGURE 8.14 Balance while standing on wobble boards.
- FIGURE 8.15 Balance while standing on wobble boards with arm movements.
- FIGURE 8.16 Balance while standing on wobble boards with arms above the head.
- FIGURE 8.17 One-legged stance with resisted shoulder extension using elastic resistance.
- Anticipatory Balance Control
- FIGURE 8.18 Balance when standing while reaching and catching the ball overhead.
- Reactive Balance Control
- Sensory Organization
- Balance During Functional Activities
- FIGURE 8.19 Functional balance during a golf swing.
- Safety During Gait, Locomotion, or Balance
- CLINICAL TIP
- Health and Environmental Factors
- Low Vision
- Sensory Loss
- Medications
- Evidence-Based Balance Exercise Programs for Fall Prevention in the Elderly
- CLINICAL TIP
- Home Exercise Program for Reducing Risk of Falls for People at High Risk
- Otego Home Exercise Program
- FIGURE 8.20 Rising up on toes to strengthen plantarflexors.
- FIGURE 8.21 Rocking back onto the heels while raising the toes to strengthen dorsiflexors.
- FIGURE 8.22 Practicing the sit-to-stand transfer is an important functional activity to strengthen the legs and improve dynamic balance.
- FIGURE 8.23 Tandem walking (A) performed with light touch on a firm surface for support; and (B) performed without external support. Note that the therapist closely guards the patient for safety.
- BOX 8.4 The Otego Home Exercise Program44
- Supervised Group Program Incorporating Strengthening, Walking, and Functional Activities
- FOCUS ON EVIDENCE
- Multisystem Group Exercise Program Incorporating a Circuit of Activities to Address Balance Impairments and Function
- BOX 8.5 Balance Exercise Program Incorporating Strengthening, Walking, and Functional Activities96
- Tai Chi for Balance Training
- TABLE 8.4 Circuit Training Program to Address Balance Impairments and Function112
- FOCUS ON EVIDENCE
- Evidence-Based Balance Exercise Programs for Specific Musculoskeletal Conditions
- FIGURE 8.24 In this Tai Chi form, the participant shifts the bodyweight toward one leg while moving the arms.
- Ankle Sprains
- FOCUS ON EVIDENCE
- FIGURE 8.25 Balance program for reducing the incidence of ankle sprains in athletes using a wobble board: (A) single-leg squat (knee bent 30º to 45º), (B) single-leg stance while rotating the board; and (C) single-leg stance while performing functional activities (i.e., catching a ball).
- Anterior Cruciate Ligament Injuries
- Low Back Pain
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 9 Aquatic Exercise
- Background and Principles for Aquatic Exercise
- Definition of Aquatic Exercise
- Goals and Indications for Aquatic Exercise
- Precautions and Contraindications to Aquatic Exercise
- Precautions
- Fear of Water
- Neurological Disorders
- Respiratory Disorders
- FOCUS ON EVIDENCE
- Cardiac Dysfunction
- FOCUS ON EVIDENCE
- Small, Open Wounds and Lines
- Contraindications
- Properties of Water
- Physical Properties of Water
- Buoyancy (Fig. 9.1)
- Definition.
- FIGURE 9.1 Percentage of weight bearing at various immersion depths.
- Properties.
- Clinical significance.
- CLINICAL TIP
- Hydrostatic Pressure
- Definition.
- Properties.
- Clinical significance.
- CLINICAL TIP
- Viscosity
- Definition.
- Properties.
- Clinical significance.
- CLINICAL TIP
- Surface Tension
- Definition.
- Properties.
- Clinical significance.
- Hydromechanics
- Definition.
- Components of flow motion.
- Clinical significance of drag.
- CLINICAL TIP
- Thermodynamics
- Specific Heat
- Definition.
- Properties.
- Clinical significance.
- Temperature Transfer
- Center of Buoyancy (Fig. 9.2)
- Definition.
- Properties.
- Clinical significance.
- FIGURE 9.2 Center of buoyancy.
- Aquatic Temperature and Therapeutic Exercise
- Temperature Regulation
- Mobility and Functional Control Exercise
- Aerobic Conditioning
- CLINICAL TIP
- Pools for Aquatic Exercise
- Traditional Therapeutic Pools (Fig. 9.3)
- FIGURE 9.3 Traditional therapeutic pool.
- Individual Patient Pools (Fig. 9.4)
- FIGURE 9.4 Hydro Track©, self-contained underwater treadmill system.
- Special Equipment for Aquatic Exercise
- Collars, Rings, Belts, and Vests
- FIGURE 9.5 Cervical collar.
- FIGURE 9.6 Flotation rings.
- FIGURE 9.7 Buoyancy belts.
- Swim Bars
- FIGURE 9.8 Swim bars.
- Gloves, Hand Paddles, and Hydro-tone® Balls
- FIGURE 9.9 Hand paddles.
- Fins and Hydro-tone® Boots
- Kickboards
- FIGURE 9.10 Hydro-tone® boots and bells.
- FIGURE 9.11 Kickboards.
- Pool Care and Safety
- CLINICAL TIP
- Exercise Interventions Using an Aquatic Environment
- Stretching Exercises
- Manual Stretching Techniques
- Spine Stretching Techniques
- Cervical Spine: Flexion
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Cervical Spine: Lateral Flexion (Fig. 9.12)
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- FIGURE 9.12 Hand placement and stabilization for stretching to increase cervical lateral flexion.
- Thoracic and Lumbar Spine: Lateral Flexion/Side Bending (Fig. 9.13)
- Practitioner Position
- FIGURE 9.13 Hand placement and stabilization for stretching to increase lateral trunk flexion.
- Patient Position
- Hand Placement
- Direction of Movement
- Shoulder Stretching Techniques
- Shoulder Flexion (Fig. 9.14)
- Practitioner Position
- Patient Position
- FIGURE 9.14 Hand placement and stabilization for stretching to increase shoulder flexion.
- Hand Placement
- Direction of Movement
- Shoulder Abduction
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Shoulder External Rotation
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Shoulder Internal Rotation
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Hip Stretching Techniques
- Hip Extension
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Hip External Rotation
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Hip Internal Rotation
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Knee Stretching Techniques
- Knee Extension with Patient on Steps
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Knee Flexion with Patient on Steps
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Knee Flexion with Patient Supine (Fig. 9.15)
- Practitioner Position
- Patient Position
- FIGURE 9.15 Hand placement and stabilization for stretching to increase knee flexion.
- Hand Placement
- Direction of Movement
- Hamstrings Stretch
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Self-Stretching with Aquatic Equipment
- Shoulder Flexion and Abduction
- Patient Position
- Equipment
- Direction of Movement
- Hip Flexion (Fig. 9.16)
- Patient Position
- Equipment
- FIGURE 9.16 Self-stretching technique to increase hip flexion (stretch the hamstrings) using aquatic equipment.
- Direction of Movement
- Knee Extension
- Patient Position
- Equipment
- Direction of Movement
- Knee Flexion
- Patient Position
- Equipment
- Direction of Movement
- Strengthening Exercises
- Manual Resistance Exercises
- Upper Extremity Manual Resistance Techniques
- Shoulder Flexion/Extension (Fig. 9.17A & B)
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- FIGURE 9.17 Manual resistance exercise for strengthening shoulder flexion. (A) start position and (B) end position.
- Shoulder Abduction
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Shoulder Internal/External Rotation (Fig. 9.18A & B)
- Practitioner Position
- FIGURE 9.18 Manual resistance exercise for strengthening shoulder external rotation. (A) start position and (B) end position.
- Patient Position
- Hand Placement
- Direction of Movement
- Unilateral Diagonal Pattern: D1Flexion/ Extension of the Upper Extremity
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Unilateral Diagonal Pattern: D2Flexion/ Extension of the Upper Extremity (Fig. 9.19A & B)
- Practitioner Position
- Patient Position
- FIGURE 9.19 Manual resistance exercise for upper extremity unilateral diagonal D2 flexion pattern. (A) start position and (B) end position.
- Hand Placement
- Direction of Movement
- Bilateral Diagonal Pattern: D2Flexion/ Extension of the Upper Extremities (Fig. 9.20A & B)
- Practitioner Position
- FIGURE 9.20 Manual resistance exercise for upper extremity bilateral diagonal D2 pattern. (A) start position and (B) end position.
- Patient Position
- Hand Placement
- Direction of Motion
- Lower Extremity Manual Resistance Techniques
- Hip Adduction
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Hip Abduction (Fig. 9.21)
- Practitioner Position
- FIGURE 9.21 Manual resistance exercise for strengthening hip abduction with resistance applied to lateral aspect of the leg.
- Patient Position
- Hand Placement
- Direction of Movement
- Hip Flexion with Knee Flexion (Fig. 9.22)
- Practitioner Position
- Patient Position
- FIGURE 9.22 Manual resistance exercise for strengthening hip and knee flexion.
- Hand Placement
- Direction of Movement
- Hip Internal/External Rotation
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Knee Extension
- Practitioner Position
- Patient Position
- Hand Placement
- Direction of Movement
- Ankle Motions
- Practitioner Position
- Patient Position
- Hand Placement
- Ankle Dorsiflexion and Plantarflexion
- Hand Placement
- Direction of Movement
- Ankle Inversion and Eversion
- Hand Placement
- Direction of Movement
- Dynamic Trunk Stabilization
- Dynamic Trunk Stabilization: Frontal Plane (Fig. 9.23)
- Practitioner Position
- FIGURE 9.23 Isometric trunk stabilization exercise using side-to-side motions of the trunk.
- Patient Position
- Execution
- Intensity
- Dynamic Trunk Stabilization: Multidirectional
- Practitioner Position
- Patient Position
- Execution
- Intensity
- Independent Strengthening Exercises
- Extremity Strengthening Exercises (Fig. 9.24A, B, C, D, and E)
- FIGURE 9.24 Mechanical resistance for strengthening (A) shoulder internal and external rotation, (B) elbow flexion and extension, (C) hip flexion and extension, (D) functional squatting, and (E) ankle plantarflexion.
- Lumbar Spine Strengthening
- Trunk-Strengthening Exercises: Standing
- TABLE 9.1 Summary of Motions Used for Upper and Lower Strengthening Exercises
- Trunk-Strengthening Exercises: Semi-Reclined
- Trunk-Strengthening Exercises: Supine
- Trunk-Strengthening Exercises: Prone
- Trunk-Strengthening Exercises in Deep Water
- TABLE 9.2 Summary of Lumbar Spine-Strengthening Exercises
- Aerobic Conditioning
- Treatment Interventions
- Deep-water walking/running (Fig. 9.25).
- FIGURE 9.25 Deep water walking/jogging.
- Mid-water jogging/running (immersed treadmill running).
- Immersed equipment.
- Swimming strokes.
- Physiological Response to Deep-Water Walking/Running
- Cardiovascular response.
- Training effect.
- Proper Form for Deep-Water Running
- Instruction for beginners.
- Accommodating specific patient populations.
- Exercise Monitoring
- Monitoring intensity of exercise.
- Monitoring beginners.
- Equipment Selection
- Deep water equipment.
- Midwater equipment.
- Independent Learning Activities
- Case Studies
- Postoperative Arthroscopic Knee Meniscectomy
- Calf Tear
- Chronic Low Back Pain
- REFERENCES
- III Principles of Intervention
- CHAPTER 10 Soft Tissue Injury, Repair, and Management
- Soft Tissue Lesions
- Examples of Soft Tissue Lesions: Musculoskeletal Disorders
- Clinical Conditions Resulting from Trauma or Pathology
- FIGURE 10.1 Self-perpetuating cycle of muscle spasm.
- Severity of Tissue Injury
- Irritability of Tissue: Stages of Inflammation and Repair
- Acute Stage (Inflammatory Reaction)
- FIGURE 10.2 Pain experienced with ROM when involved tissue is in the (A) acute stage, (B) early subacute stage, and (C) late subacute or chronic stage.
- TABLE 10.1 Stages of Tissue Healing: Characteristics, Clinical Signs, and Interventions
- Subacute Stage (Proliferation, Repair, and Healing)
- Chronic Stage (Maturation and Remodeling)
- Chronic Inflammation
- Chronic Pain Syndrome
- Management During the Acute Stage
- Tissue Response: Inflammation
- Management Guidelines: Protection Phase
- Patient Education
- Protection of the Injured Tissue
- Prevention of Adverse Effects of Immobility
- Tissue-specific movement.
- Intensity of movement.
- BOX 10.1 MANAGEMENT GUIDELINES—Acute Stage/Protection Phase
- General movement.
- Specific Interventions and Dosages
- Passive range of motion.
- Low-dosage joint mobilization/manipulation techniques.
- Muscle setting.
- Massage.
- Interventions for Associated Areas
- Range of motion.
- Resistance exercise.
- Functional activities.
- CLINICAL TIP
- Management During the Subacute Stage
- Tissue Response: Proliferation, Repair, and Healing
- Management Guidelines: Controlled Motion Phase
- Patient Education
- Management of Pain and Inflammation
- BOX 10.2 MANAGEMENT GUIDELINES—Subacute Stage/Controlled Motion Phase
- CLINICAL TIP
- Initiation of Active Exercises
- Multiple-angle, submaximal isometric exercises.
- Active range of motion exercises.
- BOX 10.3 Signs of Excessive Stress with Exercise or Activities
- Muscular endurance exercises.
- Protected weight-bearing exercises.
- Initiation and Progression of Stretching
- Warm the tissues.
- Muscle relaxation techniques.
- Joint mobilization/manipulation.
- Stretching techniques.
- Massage.
- Use of the new range.
- Correction of Contributing Factors
- Management During the Chronic Stage
- Tissue Response: Maturation and Remodeling
- Maturation of Tissue
- Remodeling of Tissue
- Management Guidelines: Return to Function Phase
- BOX 10.4 MANAGEMENT GUIDELINES—Chronic Stage/Return to Function Phase
- Patient Education
- Considerations for Progression of Exercises
- Progression of Stretching
- Progression of Exercises for Muscle Performance: Developing Neuromuscular Control, Strength, and Endurance
- Return to High-Demand Activities
- Cumulative Trauma: Chronic Recurring Pain
- Tissue Response: Chronic Inflammation
- Causes of Chronic Inflammation
- Overuse, cumulative trauma, repetitive strain.
- Trauma.
- Reinjury of an “old scar.”
- Contractures or poor mobility.
- Contributing Factors
- Management Guidelines: Chronic Inflammation
- Chronic Inflammation: Acute Stage
- BOX 10.5 MANAGEMENT GUIDELINES—Chronic Inflammation/Cumulative Trauma Syndromes
- CLINICAL TIP
- Subacute and Chronic Stages of Healing Following Chronic Inflammation
- Independent Learning Activities
- Critical Thinking and Discussion
- REFERENCES
- CHAPTER 11 Joint, Connective Tissue, and Bone Disorders and Management
- Arthritis: Arthrosis
- Clinical Signs and Symptoms
- Impaired Mobility
- Impaired Muscle Performance
- Impaired Balance
- TABLE 11.1 Comparison of Osteoarthritis and Rheumatoid Arthritis5,18,44,84,91,92
- Activity Limitations and Participation Restrictions
- Rheumatoid Arthritis
- Characteristics of RA
- BOX 11.1 Criteria for Diagnosis of Rheumatoid Arthritis6
- FIGURE 11.1 (A) Radiographic hallmarks and typical joint deformities with rheumatoid arthritis in small joints of the wrist and hand. (B) Radiographic hallmarks of rheumatoid arthritis in large joints.
- FIGURE 11.2 Advanced rheumatoid arthritis of the hip joints. Note that the destruction caused by rheumatoid arthritis involves the entire joint space and the boney regions on either side of the joint space.
- FIGURE 11.3 Rheumatoid arthritis of the foot. First metatarsophalangeal joint shows severe erosion of the joint surface with subluxation of the metatarsal (arrow).
- Signs and Symptoms: Periods of Active Disease
- Principles of Management: Active Inflammatory Period of RA
- BOX 11.2 MANAGEMENT GUIDELINES—Rheumatoid Arthritis/Active Disease Period
- BOX 11.3 Principles of Joint Protection and Energy Conservation53,73
- CLINICAL TIP
- Principles of Management: Subacute and Chronic Stages of RA
- FOCUS ON EVIDENCE
- Osteoarthritis: Degenerative Joint Disease
- FIGURE 11.4 Radiographic hallmarks of osteoarthritis.
- Characteristics of OA
- FIGURE 11.5 Osteoarthritis of the knees in a 66-year-old woman. This film was taken under weight-bearing conditions. At the patient’s right knee, osteoarthritis is evidenced by narrowed joint space (white arrows), osteophyte formation at the joint margins (large white arrowhead), and sclerotic subchondral bone (small black arrowheads) of both the medial and lateral tibial plateaus. At the patient’s left knee, it is interesting to note that in the area of minimal weight-bearing stress the subchondral bone has lost density, and rarefaction is present on the medial aspect of the joint.
- FIGURE 11.6 Severe osteoarthritis of the hip with pseudocysts. The radiolucent cyst-like areas (arrows) are caused by intrusion of synovial fluid into areas of subchondral bone that have become weakened by microfractures.
- Principles of Management: Osteoarthritis
- BOX 11.4 MANAGEMENT GUIDELINES—Osteoarthritis
- FOCUS ON EVIDENCE
- FOCUS ON EVIDENCE
- Fibromyalgia and Myofascial Pain Syndrome
- TABLE 11.2 Similarities and Differences Between Fibromyalgia and Myofascial Pain Syndrome
- Fibromyalgia
- FIGURE 11.7 Fibromyalgia tender points.
- FOCUS ON EVIDENCE
- Prevalence of FM
- Characteristics of FM
- Factors Contributing to a Flare
- Management: Fibromyalgia
- FOCUS ON EVIDENCE
- CLINICAL TIP
- Myofascial Pain Syndrome
- FIGURE 11.8 Composite pattern of pain (dark red) referred from trigger points (TrPs) (Xs) in the right piriformis muscle (medium red). The lateral X (TrP1) indicates the most common TrP location. The red stippling locates the spillover part of the pattern that may be felt as less intense pain than that of the essential pattern (solid red). The spillover pain may be absent.
- Possible Causes of Trigger Points
- FOCUS ON EVIDENCE
- Management: Myofascial Pain Syndrome
- CLINICAL TIP
- Osteoporosis
- Risk Factors
- Primary osteoporosis.
- Secondary osteoporosis.
- FIGURE 11.9 Osteoporosis of the spine with multiple compression fractures. The arrow points to the T8-T9 disc space, which is deformed by the collapse of these two vertebrae from multiple compression fractures. This 94-year-old woman has severe kyphosis of the thoracic spine (also known as a gibbous deformity) accentuated by vertebral collapse at multiple levels.
- FIGURE 11.10 Osteoporosis is evident in this knee by the accentuation of the remaining trabeculae. The trabeculae have diminished in number and thickness, and the remaining vertically oriented trabeculae stand out as thin, delicate line images.
- Prevention of Osteoporosis
- Physical Activity
- Effects of Exercise
- FOCUS ON EVIDENCE
- Recommendations for Exercise
- Mode: Aerobic
- Frequency.
- Intensity.
- Mode: Resistance
- Frequency.
- Intensity.
- CLINICAL TIP
- Precautions and Contraindications
- CLINICAL TIP
- Fractures and Posttraumatic Immobilization
- TABLE 11.3 Causes and Types of Fractures79
- FIGURE 11.11 (A–F) The position of fracture fragments may be described by how the distal fragment displaces in relationship to the proximal fragment.
- FIGURE 11.12 (A–D) Directions of fracture lines are described in reference to the longitudinal axis of the bone.
- FIGURE 11.13 Comminuted fractures are fractures with more than two fragments. Some frequently occurring comminuted fracture patterns are (A) the wedge-shaped or butterfly pattern and (B) a two- or three-segmented level fracture. (C) Other fractures with multiple fragments, be it several or several hundred, are still described as comminuted.
- BOX 11.5 Symptoms and Signs of a Possible Fracture
- Risk Factors
- Bone Healing Following a Fracture
- Cortical Bone Healing
- Inflammatory Phase
- Reparative Phase
- Remodeling Phase
- Rigid Internal Fixation
- Healing Time
- Cancellous Bone Healing
- Epiphyseal Plate Healing
- Principles of Management: Period of Immobilization
- Local Tissue Response
- BOX 11.6 Types of Abnormal Healing of Fractures
- Immobilization in Bed
- Functional Adaptations
- Postimmobilization
- Impairments
- BOX 11.7 Complications of Fractures10
- BOX 11.8 MANAGEMENT GUIDELINES—Postfracture/Period of Immobilization
- Management: Postimmobilization
- BOX 11.9 MANAGEMENT GUIDELINES—Postfracture/Postimmobilization
- Independent Learning Activities
- Critical Thinking and Discussion
- REFERENCES
- CHAPTER 12 Surgical Interventions and Postoperative Management
- Indications for Surgical Intervention
- BOX 12.1 Indications for Surgery for Musculoskeletal Disorders of the Extremities and Spine
- Guidelines for Preoperative and Postoperative Management
- Considerations for Preoperative Management
- Preoperative Examination and Evaluation
- BOX 12.2 Benefits of Preoperative Contact with a Patient
- Preoperative Patient Education: Methods and Rationale
- Components of Preoperative Patient Education
- An Extended Preoperative Exercise Program
- FOCUS ON EVIDENCE
- Considerations for Postoperative Management
- Postoperative Examination and Evaluation
- Phases of Postoperative Rehabilitation
- BOX 12.3 Factors That Influence the Components, Progression, and Outcomes of a Postoperative Rehabilitation Program
- BOX 12.4 Inspection of the Surgical Incision
- BOX 12.5 MANAGEMENT GUIDELINES—Postoperative Rehabilitation
- Time-Based and Criterion-Based Progression
- Putting Postoperative Rehabilitation into Perspective
- Potential Postoperative Complications and Risk Reduction
- Pulmonary Complications
- Deep Vein Thrombosis and Pulmonary Embolism
- BOX 12.6 Potential Postoperative Complications
- Subluxation or Dislocation after Joint Surgery
- Restricted Motion from Adhesions and Scar Tissue Formation
- Failure, Displacement, or Loosening of Internal Fixation Device
- Deep Vein Thrombosis and Pulmonary Embolism: A Closer Look
- FIGURE 12.1 Veins of the lower extremity.
- Risk Factors for DVT
- Deep Vein Thrombosis: Signs and Symptoms
- Pulmonary Embolism: Signs and Symptoms
- BOX 12.7 Risk Factors for Deep Vein Thrombosis and Thrombophlebitis
- Reducing the Risk of Deep Vein Thrombosis
- CLINICAL TIP
- Management of Deep Vein Thrombosis
- Acute care management.
- BOX 12.8 MANAGEMENT GUIDELINES—Deep Vein Thrombosis and Thrombophlebitis
- FOCUS ON EVIDENCE
- Posthospitalization precautions.
- Overview of Common Orthopedic Surgeries and Postoperative Management
- TABLE 12.1 General Methods and Examples of Musculoskeletal Surgeries
- Surgical Approaches: Open, Arthroscopic, and Arthroscopically Assisted Procedures
- Open Procedure
- Arthroscopic Procedure
- Arthroscopically Assisted Procedure
- Use of Tissue Grafts
- Types of Grafts
- Autograft.
- Allograft.
- Synthetic grafts.
- Repair, Reattachment, Reconstruction, Stabilization, or Transfer of Soft Tissues
- BOX 12.9 Risks with Use of Autografts and Allografts
- Muscle Repair
- Procedure
- Postoperative Management
- Tendon Repair
- Procedure
- Postoperative Management
- Ligament Repair or Reconstruction
- Procedures
- Postoperative Management
- Capsule Stabilization and Reconstruction
- Procedures
- Capsulorrhaphy (capsular shift).
- Capsulolabral reconstruction.
- Electrothermally assisted capsulorrhaphy.
- Postoperative Management
- Tendon Transfer or Realignment
- Procedures
- Postoperative Management
- Release, Lengthening, or Decompression of Soft Tissues
- Procedures
- Postoperative Management
- Joint Procedures
- Arthroscopic Débridement and Lavage
- Synovectomy
- Procedure
- Postoperative Management
- Articular Cartilage Procedures
- Procedures
- Abrasion arthroplasty, subchondral drilling, and microfracture.
- Chondrocyte transplantation.
- Osteochondral autografts and allografts.
- Postoperative Management
- Arthroplasty
- Procedures
- Excision arthroplasty.
- Excision arthroplasty with implant.
- Interposition arthroplasty.
- Joint replacement arthroplasty.
- FIGURE 12.2 Total hip replacement arthroplasty. Both the acetabular and femoral portions of the joint have been replaced with prosthetic components.
- BOX 12.10 Materials, Designs, and Methods of Fixation for Joint Replacement Arthroplasty
- BOX 12.11 Contraindications to Total Joint Arthroplasty
- Postoperative Management
- Arthrodesis
- FIGURE 12.3 Arthrodesis (surgical fusion with internal fixation of the ankle).
- TABLE 12.2 Optimal Positions for Arthrodesis
- Procedure
- Postoperative Management
- Extra-articular Boney Procedures
- Open Reduction and Internal Fixation of Fractures
- Procedures
- Postoperative Management
- FIGURE 12.4 Intertrochanteric fracture of the left femur, fixed with compression plate and screws.
- Osteotomy
- Procedures
- Postoperative Management
- Independent Learning Activities
- Critical Thinking and Discussion
- REFERENCES
- CHAPTER 13 Peripheral Nerve Disorders and Management
- Review of Peripheral Nerve Structure
- Nerve Structure
- Mobility Characteristics of the Nervous System
- FIGURE 13.1 Peripheral nerve and its connective tissue coverings.
- BOX 13.1 Content of Peripheral Nerves
- Common Sites of Injury to Peripheral Nerves
- Nerve Roots
- Brachial Plexus
- FIGURE 13.2 Dermatomes—anterior and posterior views.
- BOX 13.2 Key Muscles for Testing Upper and Lower Quarter Myotomes45
- Peripheral Nerves in the Upper Quarter
- Axillary Nerve: C5, 6
- FIGURE 13.3 Brachial plexus.
- TABLE 13.1 Patterns of Muscle Weakness and Functional Loss with Peripheral Nerve Injuries in the Upper Extremity
- Musculocutaneous Nerve: C5, 6
- Median Nerve: C6–8
- FIGURE 13.4 Sensory and motor innervations of the axillary (C5, 6) and musculocutaneous (C5, 6) nerves.
- Ulnar Nerve: C8, T1
- Radial Nerve: C6–8, T1
- FIGURE 13.5 Sensory and motor innervations of the median nerve (C6–8, T1).
- FIGURE 13.6 Sensory and motor innervations of the ulnar nerve (C8, T1).
- FIGURE 13.7 Sensory and motor innervations of the radial nerve (C6–8, T1).
- Lumbosacral Plexus
- Peripheral Nerves in the Lower Quarter
- FIGURE 13.8 (A) Lumbar plexus and (B) sacral plexus.
- Femoral Nerve: L2–4
- Obturator Nerve: L2–4
- Sciatic Nerve: L4, 5; S1–3
- Tibial/Posterior Tibial Nerve: L4, 5; S1–3
- TABLE 13.2 Patterns of Muscle Weakness and Functional Loss with Peripheral Nerve Injuries in the Lower Extremity
- FIGURE 13.9 Sensory and motor innervations of the femoral (L2–4) and obturator (L2–4) nerves.
- Plantar and calcaneal nerves.
- Common Peroneal Nerve: L4, 5; S1, 2
- FIGURE 13.10 Sensory and motor innervations of the sciatic nerve (L4, 5, S1–3) and tibial nerve (L4, 5, S1–3).
- Superficial peroneal nerve.
- Deep peroneal nerve.
- Impaired Nerve Function
- Nerve Injury and Recovery
- FIGURE 13.11 Sensory and motor innervations of the peroneal nerve (L4, 5, S1, 2).
- Mechanisms of Nerve Injury
- Classification of Nerve Injuries
- Recovery from Nerve Injuries
- BOX 13.3 Seddon’s Classification and Characteristics of Nerve Injury62,63,65
- FIGURE 13.12 Comparison of Sunderland’s and Seddon’s classifications of nerve injuries. (1) First degree injury (neuropraxia): minimal structural disruption—complete recovery; (2) second degree (axonotmesis): complete axonal disruption with wallerian degeneration—usually complete recovery; (3) third degree (may be either axonotmesis or neurotmesis): disruption of axon and endoneurium—poor prognosis without surgery; (4) fourth degree (neurotmesis): disruption of axon, endoneurium, and perineurium—poor prognosis without surgery; (5) fifth degree (neurotmesis): complete structural disruption—poor prognosis without microsurgery.62,65
- Outcomes of Nerve Regeneration
- Management Guidelines: Recovery from Nerve Injury
- Acute Phase
- BOX 13.4 MANAGEMENT GUIDELINES—Recovery from Peripheral Nerve Injury
- Recovery Phase
- Chronic Phase
- BOX 13.5 Desensitization and Sensory Re-education Techniques
- BOX 13.6 Patient Instructions for Preventive Care After Nerve Injury
- Neural Tension Disorders
- Symptoms and Signs of Impaired Nerve Mobility
- History
- Tests of Provocation
- General testing procedure:
- Causes of Symptoms
- FOCUS ON EVIDENCE
- Principles of Management
- CLINICAL TIP
- Precautions and Contraindications to Neural Tension Testing and Treatment
- PRECAUTIONS:
- CONTRAINDICATIONS:
- Neural Testing and Mobilization Techniques for the Upper Quadrant
- Median Nerve (Fig. 13.13)
- Patient position and procedure:
- FIGURE 13.13 Position of maximum stretch on the median nerve includes shoulder girdle depression; shoulder abduction; elbow extension; shoulder external rotation and supination of the forearm; wrist, finger, and thumb extension; and finally contralateral cervical side flexion.
- FOCUS ON EVIDENCE
- Radial Nerve (Fig. 13.14)
- FIGURE 13.14 Position of maximum stretch on the radial nerve includes shoulder girdle depression; shoulder abduction; elbow extension; shoulder medial rotation and forearm pronation; wrist, finger, and thumb flexion; wrist ulnar deviation; and finally contralateral cervical side flexion.
- Patient position and procedure:
- Ulnar Nerve (Fig. 13.15)
- FIGURE 13.15 Position of maximum stretch on the ulnar nerve includes shoulder girdle depression; shoulder external rotation and abduction; elbow flexion; forearm supination and wrist extension; and finally contralateral cervical side flexion.
- Patient position and procedure:
- Neural Testing and Mobilization Techniques for the Lower Quadrant
- Sciatic Nerve: Straight-Leg Raising with Ankle Dorsiflexion (Fig. 13.16)
- Patient position and procedure:
- FIGURE 13.16 Position of stretch on the sciatic nerve includes straight-leg raising with adduction and internal rotation of the hip and dorsiflexion of the ankle.
- Slump-Sitting (Fig. 13.17)
- Patient position and procedure:
- FIGURE 13.17 Slump-sitting with neck, thorax, and low back flexed, knee extended, and ankle dorsiflexed just to the point of tissue resistance and symptom reproduction.
- Femoral Nerve: Prone Knee Bend (Fig. 13.18)
- Patient position and procedure:
- FIGURE 13.18 Position of stretch on the femoral nerve; prone lying with the spine neutral, hip extended to zero degrees, and knee flexed. It is important to maintain the spine in neutral and not allow it to extend.
- Alternate position and procedure:
- Musculoskeletal Diagnoses Involving Impaired Nerve Function
- Thoracic Outlet Syndrome
- Related Diagnoses
- FIGURE 13.19 Region of the thoracic outlet bordered medially by the scalene muscle and first rib; posteriorly by the upper trapezius and scapula; anteriorly by the clavicle, coracoid, pectoralis minor, and deltopectoral fascia; and laterally by the axilla.
- Etiology of Symptoms
- FOCUS ON EVIDENCE
- BOX 13.7 Summary of Contributing Factors to Thoracic Outlet Syndrome
- Sites of Compression or Entrapment
- Common Structural and Functional Impairments in TOS
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Nonoperative Management of TOS
- BOX 13.8 Summary of Guidelines for Management of Thoracic Outlet Syndrome
- Carpal Tunnel Syndrome
- Etiology of Symptoms
- Examination
- History.
- Positive clinical findings.
- FIGURE 13.20 Boundaries of the carpal tunnel.
- Associated areas to clear.
- Double crush injury.
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Nonoperative Management of CTS
- BOX 13.9 Summary of Guidelines for Nonoperative Management of Carpal Tunnel Syndrome
- FIGURE 13.21 Positions for median nerve glides and mobilization in the hand: (A) wrist neutral with fingers and thumb flexed; (B) wrist neutral with fingers and thumb extended; (C) wrist and fingers extended, thumb neutral; (D) wrist, fingers, and thumb extended; (E) wrist, fingers, and thumb extended and forearm supinated; (F) wrist, fingers, and thumb extended, forearm supinated, and thumb stretched into extension.
- FOCUS ON EVIDENCE
- FOCUS ON EVIDENCE
- Surgical and Postoperative Management for CTS
- FOCUS ON EVIDENCE
- Maximum Protection Phase
- Moderate and Minimum Protection Phases
- FOCUS ON EVIDENCE
- Ulnar Nerve Compression in Tunnel of Guyon
- Etiology of Symptoms
- Examination
- History.
- Positive clinical findings.
- Associated areas to clear.
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Nonoperative Management
- Surgical Release and Postoperative Management
- Complex Regional Pain Syndrome: Reflex Sympathetic Dystrophy and Causalgia
- Related Diagnoses and Symptoms
- Etiology of Symptoms
- BOX 13.10 Classification and Clinical Features of Complex Regional Pain Syndromes64
- Clinical Course
- CLINICAL TIP
- Common Structural and Functional Impairments
- FIGURE 13.22 (A) In the early stages of reflex sympathetic dystrophy, generalized edema is present. This edema is often localized over the dorsum of the hand in the metacarpal and proximal interphalangeal joint areas. (B) The edema is usually of a pitting nature, as indicated by the indentation that remains once the pressure is removed.
- Management
- Intervention: Stage I (Box 13.10)
- BOX 13.11 Summary of Guidelines for Management of Complex Regional Pain Syndrome Type I (RSD)
- CLINICAL TIP
- Intervention: Stages II and III
- CLINICAL TIP
- FOCUS ON EVIDENCE
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- REFERENCES
- IV Exercise Interventions by Body Region
- CHAPTER 14 The Spine: Structure, Function, and Posture
- Structure and Function of the Spine
- Structure
- Functional Components of the Spine
- FIGURE 14.1 (A) Lateral and (B) posterior views showing the five regions of the spinal column.
- FIGURE 14.2 Spinal segment showing (A) the anterior weight-bearing, shock-absorbing portion, and (B) the posterior gliding mechanism and lever system for muscle attachments.
- Motions of the Spinal Column
- FIGURE 14.3 Motions of the spinal column. (A) Flexion/extension (forward/backward bending). (B) Lateral flexion (side bending). (C) Rotation. (D) Anterior/posterior shear. (E) Lateral shear. (F) Distraction/compression.
- The Six Degrees of Motion
- Flexion/Extension.
- Side bending.
- Rotation.
- Anterior/posterior shear.
- Lateral shear.
- Compression/distraction.
- Arthrokinematics of the Zygapophyseal (Facet) Joints
- Cervical spine.
- Thoracic spine.
- TABLE 14.1 Arthrokinematics of the Spine
- Lumbar spine.
- Structure and Function of Intervertebral Discs
- Annulus fibrosus.
- FIGURE 14.4 Nodding motions of the atlanto-occipital joints. (A) Flexion. (B) Extension.
- FIGURE 14.5 Rotation of the atlas-axis joints (view from the side). (A) Right rotation showing backward movement of the right articulating surface of C1 on C2. (B) Left rotation showing forward movement of the right articulating surface of C1 on C2.
- Nucleus pulposus.
- FIGURE 14.6 Intervertebral disc. (A) The annular rings enclose the nucleus pulposus, providing a mechanism for dissipating compressive forces. (B) Orientation of the layers of the annulus provides tensile strength to the disc with motions in various directions.
- Cartilaginous end-plates.
- Intervertebral Foramina
- Biomechanical Influences on Postural Alignment
- Curves of the Spine
- Gravity
- Ankle.
- Knee.
- FIGURE 14.7 Lateral view of standard postural alignment. A plumb line is typically used for reference and represents the relationship of the body parts with the line of gravity. Surface landmarks are slightly anterior to the lateral malleolus, slightly anterior to the axis of the knee joint, through the greater trochanter (slightly posterior to the axis of the hip joint), through the bodies of the lumbar and cervical vertebrae, through the shoulder joint, and through the lobe of the ear.
- Hip.
- Trunk.
- Head.
- Stability
- Postural Stability in the Spine
- Inert Structures: Influence on Stability
- TABLE 14.2 Stabilizing Features of Inert Tissues in the Spine
- Muscles: Influence on Stability
- Role of Global and Segmental Muscle Activity
- Global muscle function.
- FIGURE 14.8 (A) Guy wire function of global trunk muscles provides overall stability against perturbations. (B) Instability in the multisegmental spine cannot be controlled by the global trunk muscle guy wires. Compressive loading from the long guy wires leads to stress on the inert tissues at the end-ranges of the unstable segment.
- Deep/segmental muscle function.
- FIGURE 14.9 Deep muscles attached to each spinal segment provide segmental stability.
- TABLE 14.3 Stabilizing Features of Muscles Controlling the Spine
- Muscle Control in the Lumbar Spine
- TABLE 14.4 Muscles of the Spine and Their Stabilizing Function
- Abdominal muscles (Fig. 14.10).
- Transversus abdominis stabilization activity.
- FIGURE 14.10 Abdominal muscles.
- FIGURE 14.11 Transverse section in the lumbar region shows the relationships of the three layers of the thoracolumbar fascia to the muscles in the region and their attachments to the spine. (ES, erector spinae; Mf, multifidus; TA, transversus abdominis; IO, internal obliques; EO, external obliques; LD, latissimus dorsi; PM, psoas major; QL, quadratus lumborum muscles.)
- FIGURE 14.12 Orientation and attachments of the posterior layer of the thoracolumbar fascia. From the lateral raphe, (A) the fibers of the superficial lamina are angled inferiorly and medially and (B) the fibers of the deep lamina are angled superiorly and medially. (C) Tension in the angled fibers of the posterior layer of the fascia is transmitted to the spinous processes in opposing directions, resisting separation of the spinous processes. (D) Diagrammatic representation of a lateral pull at the lateral raphe, resulting in tension between the lumbar spinous processes that oppose separation, thus providing stability to the spine.
- FOCUS ON EVIDENCE
- Erector spinae muscles (Fig. 14.13).
- Multifidus stabilization activity.
- FIGURE 14.13 Muscles of the back.
- Thoracolumbar (lumbodorsal) fascia.
- Muscle Control in the Cervical Spine
- Mandibular elevator group.
- FIGURE 14.14 Head balance on the cervical spine. The posterior cervical muscles (trapezius and semispinalis capitis) counter the weight of the head. The mandibular elevating muscles (masseter, temporalis, medial pterygoid) maintain jaw elevation opposing the mandibular depression force of gravity and tension in the anterior throat muscles (suprahyoid and infrahyoid groups). The scalene and levator muscles stabilize against the posterior and anterior translatory forces on the cervical vertebrae. (Tr, trapezius; SC, semispinalis capitis; M, masseter; T, temporalis; MT, medial pterygoid; SH, suprahyoid; IH, infrahyoid; S, scalene; LS, levator scapulae; G, center of gravity; ▴ axis of motion.)
- Suprahyoid and infrahyoid group.
- Rectus capitis anterior and lateralis, longus colli, and longus capitis (Fig. 14.15).
- FIGURE 14.15 Deep segmental musculature in the cervical spine: rectus capitis anterior and lateralis, longus colli, longus capitis, and scalene muscles.
- Multifidus.
- Role of Muscle Endurance
- FOCUS ON EVIDENCE
- Neurological Control: Influence on Stability
- Feedforward control and spinal stability.
- FOCUS ON EVIDENCE
- Effects of Limb Function on Spinal Stability
- CLINICAL TIP
- Localized muscle fatigue.
- Muscle imbalances.
- Effects of Breathing on Posture and Stability
- Effects of Intra-abdominal Pressure and the Valsalva Maneuver on Stability
- FIGURE 14.16 Coordinated contraction of the transversus abdominis, diaphragm, and pelvic floor musculature increases intra-abdominal pressure, which unloads the spine and provides stability.
- FIGURE 14.17 (A) Increased intra-abdominal pressure (IAP) pushes outward against the transversus abdominis and internal obliques, creating increased tension on the thoracolumbar fascia, resulting in improved spinal stability. (B) Reduced pressure decreases the stabilizing effect.
- Impaired Posture
- Etiology of Pain
- Effect of Mechanical Stress
- Effect of Impaired Postural Support from Trunk Muscles
- Effect of Impaired Muscle Endurance
- Pain Syndromes Related to Impaired Posture
- Postural fault.
- Postural pain syndrome.
- Postural dysfunction.
- FIGURE 14.18 (A) Lordotic posture characterized by an increase in the lumbosacral angle, increased lumbar lordosis, increased anterior tilting of the pelvis, and hip flexion. (B) Relaxed or slouched posture characterized by excessive shifting of the pelvic segment anteriorly, resulting in hip extension, and shifting of the thoracic segment posteriorly, resulting in flexion of the thorax on the upper lumbar spine. A compensatory increased thoracic kyphosis and forward head placement are also seen. (C) Flat low-back posture characterized by a decreased lumbosacral angle, decreased lumbar lordosis, and posterior tilting of the pelvis. (D) Flat upper back and cervical spine characterized by a decrease in the thoracic curve, depressed scapulae, depressed clavicle, and an exaggeration of axial extension (flexion of the occiput on the atlas and flattening of the cervical lordosis).
- Postural habits.
- Common Faulty Postures: Characteristics and Impairments
- Pelvic and Lumbar Region
- Lordotic Posture
- Potential Muscle Impairments
- Potential Sources of Symptoms
- Common Causes
- Relaxed or Slouched Posture
- Potential Muscle Impairments
- Potential Sources of Symptoms
- Common Causes
- Flat Low-Back Posture
- Potential Muscle Impairments
- Potential Sources of Symptoms
- Common Causes
- Cervical and Thoracic Region
- Round Back (Increased Kyphosis) with Forward Head
- Potential Muscle Impairments
- Potential Sources of Symptoms
- Common Causes
- Flat Upper Back and Neck Posture
- Potential Muscle Impairments
- Potential Sources of Symptoms
- Common Cause
- Frontal Plane Deviations: Scoliosis and Lower Extremity Asymmetries
- Scoliosis
- Structural scoliosis.
- Nonstructural scoliosis.
- FIGURE 14.19 (A) Mild right thoracic left lumbar structural scoliosis with prominence of the right scapula. (B) Forward bending produces a slight posterior rib hump, indicating fixed rotation of the vertebrae and rib cage.
- Potential Impairments
- Potential Sources of Symptoms
- Common Causes: Structural Scoliosis
- Common Causes: Nonstructural Scoliosis
- Frontal Plane Deviations from Lower Extremity Asymmetries
- Characteristic Deviations (Fig. 14.20)
- FIGURE 14.20 Frontal plane asymmetries. Pictured is an individual with a long leg and elevated ilium on the right side. Typically, hip adduction, vertical sacroiliac (SI) joint, side bending toward and rotation opposite that of the lumbar spine, and compensations in thoracic and cervical spine are seen on the long-leg side.
- Potential Muscle Impairments
- Potential Sources of Symptoms
- Common Causes
- Management of Impaired Posture
- General Management Guidelines
- Awareness and Control of Spinal Posture
- Posture Training Techniques
- Axial Extension (Cervical Retraction) to Decrease a Forward Head Posture
- BOX 14.1 MANAGEMENT GUIDELINES—Impaired Posture
- Scapular Retraction
- Pelvic Tilt and Neutral Spine
- FIGURE 14.21 Training the patient to correct (A) forward-head posture and (B) protracted scapulae.
- Thoracic Spine
- Total Spinal Movement and Control
- Reinforcement.
- Postural support.
- Posture, Movement, and Functional Relationships
- Relationship of impaired posture and pain.
- Relationship of impaired posture and extremity function.
- Joint, Muscle, and Connective Tissue Mobility Impairments
- BOX 14.2 Stretching Techniques for Common Mobility Impairments
- Impaired Muscle Performance
- BOX 14.3 Training and Strengthening Techniques for Common Muscle Impairments
- Body Mechanics
- Ergonomics: Relief and Prevention
- BOX 14.4 Functional Exercises in Preparation for Safe Body Mechanics
- FOCUS ON EVIDENCE
- Stress Management/Relaxation
- Muscle Relaxation Techniques
- Cervical and Upper Thoracic Region
- Lower Thoracic and Lumbar Region
- Conscious Relaxation Training for the Cervical Region
- Modalities and Massage
- Healthy Exercise Habits
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- Case 1
- Case 2
- REFERENCES
- CHAPTER 15 The Spine: Management Guidelines
- Spinal Pathologies and Impaired Spinal Function
- TABLE 15.1 Spinal Pathologies/Surgical Procedures Related to Preferred Practice Patterns*
- Pathology of the Intervertebral Disc
- Injury and Degeneration of the Disc
- FIGURE 15.1 Disc breakdown, showing (A) breakdown and compression of fibrous layers of the annulus and displacement of disc material; (B) radial fissures/tears with nuclear material bulging against the outer annulus; (C) extrusion of nuclear material through the outer annulus but still in contact with the disc; (D) sequestration of nuclear material beyond the annulus; and (E) magnetic resonance imaging (MRI) scan of a 61-year-old patient with low back pain and symptoms radiating into the leg. The scan demonstrates moderate multilevel degenerative disc disease of T12–L1 through L4–5 with mild retrolisthesis of L2 on L3 and L3 on L4. At the L4–5 level, note a small diffuse disc bulge with large paracentral disc extrusion dissecting cranially.
- Fatigue Breakdown and Traumatic Rupture
- Fatigue breakdown.
- Traumatic rupture.
- Axial Overload
- Age
- Degenerative Changes
- Effect on Spinal Mechanics
- Disc Pathologies and Related Conditions
- Tissue Fluid Stasis
- Signs and Symptoms of Disc Lesions and Fluid Stasis
- Etiology of Symptoms
- Pain.
- Neurological signs and symptoms.
- Variability of symptoms.
- Shifting symptoms.
- Inflammation.
- Onset and Behavior of Symptoms from Disc Lesions
- Onset.
- Pain behavior.
- Acute pain.
- Objective Clinical Findings in the Lumbar Spine
- BOX 15.1 Summary of Common Impairments Related to Disc Protrusions in the Lumbar Spine
- FIGURE 15.2 Examples of peripheralization and centralization of lower-quarter symptoms. Viewing the images left to right illustrates peripheralization of symptoms; from right to left illustrates centralization.
- Objective Clinical Findings in the Cervical Spine
- Pathomechanical Relationships of the Intervertebral (IV) Disc and Facet Joints
- Disc Degeneration
- Initial Changes
- Altered Muscle Control
- Progressive Boney Changes
- Related Pathologies
- Segmental (Clinical) Instability
- Stenosis
- Neurological Symptoms: Radiculopathy
- Dysfunction
- Pathology of the Zygapophyseal (Facet) Joints
- Common Diagnoses and Impairments from Facet Joint Pathologies
- Facet Sprain/Joint Capsule Injury
- BOX 15.2 Summary of Common Impairments and Activity Limitations (Functional Limitations) Related to Facet Joint Pathology
- Spondylosis, Osteoarthritis, and Degenerative Joint Disease
- Rheumatoid Arthritis
- Ankylosing Spondylitis (AS)
- Facet Joint Impingement (Blocking, Fixation, Extrapment)
- Pathology of the Vertebrae
- Compression Fracture Secondary to Osteoporosis
- Scheuermann’s Disease
- Pathology of Muscle and Soft Tissue Injuries: Strains, Tears, and Contusions
- BOX 15.3 Summary of Common Impairments and Activity Limitations (Functional Limitations) Associated with Muscle and Soft Tissue Injuries
- General Symptoms from Trauma
- Common Sites of Lumbar Strain
- Common Sites of Cervical Strain
- Extension injuries.
- Flexion injuries.
- Postural Strain
- Emotional Stress
- Activity Limitations and Participation Restrictions
- Pathomechanics of Spinal Instability
- Neutral Zone
- Neutral spine.
- FIGURE 15.3 Neutral zone of a spinal segment depicted as a bowl, with the sides of the bowl representing the osteoligamentous tissues and the moving ball representing the segmental mobility. (A) In a deep bowl, when perturbations disturb the ball, there is little motion as the ball rolls back and forth and settles in the center of the bowl—representing stability. (B) In a shallow bowl, there is greater motion—representing greater segmental mobility or instability. (C) Viewing the bowl from above, bungee cords attached to the ball and the sides of the bowl represent the dynamic function of segmental muscles. Appropriately graded tension in the bungee cords stabilizes the ball when perturbations disturb the unit.
- Instability
- FOCUS ON EVIDENCE
- Management Guidelines Based on Stages of Recovery and Diagnostic Categories
- Principles of Management for the Spine
- Examination and Evaluation
- History, systems review, and testing.
- Stage of recovery.
- Diagnosis, prognosis, and plan of care.
- FOCUS ON EVIDENCE
- General Guidelines for Managing Acute Spinal Impairments: Protection Phase
- BOX 15.4 Impairment-Based Diagnostic Categories That Direct Intervention33,48,101,138
- Patient Education
- Symptom Relief or Comfort
- BOX 15.5 MANAGEMENT GUIDELINES—Acute Spinal Impairments/Protection Phase
- Extension bias-extension syndrome.
- Flexion bias-flexion syndrome.
- Nonweight-bearing bias-traction syndrome.
- Kinesthetic Awareness of Safe Postures and Effects of Movement
- BOX 15.6 Examples of Passive Positioning of the Spine
- Muscle Performance: Deep Segmental Muscle Activation and Basic Stabilization
- Lumbar Region: Deep Segmental Muscle Activation
- Cervical Region: Deep Segmental Muscle Activation
- Basic Stabilization
- Basic Functional Movements
- General Guidelines for Managing Subacute Spinal Impairments: Controlled Motion Phase
- Pain Modulation
- BOX 15.7 MANAGEMENT GUIDELINES—Subacute Spinal Problems/Controlled Motion Phase
- Kinesthetic Training
- Stretching/Manipulation
- Muscle Performance
- Cardiopulmonary Conditioning
- Postural Stress Management and Relaxation Exercises
- Functional Activities
- General Guidelines for Managing Chronic Spinal Impairments: Return to Function Phase
- Management Guidelines: Nonweight-Bearing Bias
- Management of Acute Symptoms
- Traction
- BOX 15.8 MANAGEMENT GUIDELINES—Chronic Spinal Problems/Return to Function Phase
- Harness
- Pool
- Progression
- Management Guidelines: Extension Bias
- Principles of Management
- Effects of Postural Changes on Intervertebral Disc Pressure
- Effects of Bed Rest on the Intervertebral Disc
- Effects of Traction on the Intervertebral Disc
- Effects of Flexion and Extension on the Intervertebral Disc and Fluid Stasis
- FOCUS ON EVIDENCE
- Effects of Isometric and Dynamic Exercise
- Effects of Muscle Guarding
- Indications, Precautions, and Contraindications for Interventions: Extension Approach
- Indications.
- Interventions Using an Extension Approach in the Lumbar Spine
- Management of Acute Symptoms
- Extension
- BOX 15.9 Contraindications to Specific Spinal Movements
- Lateral Shift Correction
- FIGURE 15.4 Lumbar extension is accomplished (A) by having the patient prop up on the elbows and (B) by propping on hands and allowing the pelvis to sag.
- FIGURE 15.5 Patient with lateral shift of the thoracic cage toward the right. The pelvis is shifted toward the left.
- FIGURE 15.6 A lateral gliding technique used to correct a lateral shift of the thorax is applied against the patient’s elbow and thoracic cage as the pelvis is pulled in the opposite direction.
- FIGURE 15.7 Standing back bend.
- Patient Education
- FIGURE 15.8 Self-correction of a lateral shift.
- Lumbar Traction
- Joint Manipulation
- Kinesthetic Training, Stabilization, and Basic Functional Activities
- Management When Acute Symptoms Have Stabilized
- Signs of Improvement
- Intervention
- Interventions to Manage a Disc Lesion in the Cervical Spine
- Acute Phase
- Passive Axial Extension (Cervical Retraction)
- Patient Education
- Traction
- Kinesthetic Training for Posture Correction
- Progression as Symptoms Stabilize
- FOCUS ON EVIDENCE
- Disc Lesions: Surgery and Postoperative Management
- Indications for Surgery
- Common Surgeries
- Laminectomy.
- Fusions.
- Procedures
- Anterior cervical disc fusion.
- Outcomes
- Transforaminal lumbar interbody fusion.
- Outcomes
- Laminectomy.
- Postoperative Management
- Maximum Protection Phase
- Moderate and Minimum Protection Phases
- FOCUS ON EVIDENCE
- Management Guidelines: Flexion Bias
- Principles of Management
- Effect of position.
- Effect of traction.
- Effect of trauma and repetitive irritation.
- Effect of meniscoid tissue.
- Indications and Contraindications for Intervention: Flexion Approach
- Indications.
- Techniques Utilizing a Flexion Approach
- Management of Acute Symptoms
- Rest and Support
- Functional Position for Comfort
- Cervical Traction
- Correction of Lateral Shift
- Correction of Meniscoid Impingements
- FIGURE 15.9 Self-correction of a lateral shift when there is deviation of the trunk as it flexes.
- Management When Acute Symptoms Have Stabilized
- BOX 15.10 Muscle Imbalances Common with Flexion Bias (Syndrome)
- FOCUS ON EVIDENCE
- Management Guidelines: Stabilization
- Identification of Clinical Instability
- Principles of Management
- Passive Support
- Deep Segmental Muscle Activation
- Lumbar Region
- FOCUS ON EVIDENCE
- Cervical Region
- Progression of Stabilization Exercises
- Management Guidelines: Mobilization/Manipulation
- Management: Lumbar Spine
- FOCUS ON EVIDENCE
- Management: Cervical Spine
- FOCUS ON EVIDENCE
- Management Guidelines: Soft Tissue Injuries
- Management During the Acute Stage: Protection Phase
- Pain and Inflammation Control
- Cervical Region
- Lumbar Region
- Muscle Function
- Cervical Region
- Lumbar Region
- Traction
- Environmental Adaptation
- Management in the Subacute and Chronic Stages of Healing: Controlled Motion and Return to Function Phases
- Management of Regional Diagnoses
- TABLE 15.2 Summary of Interventions for Spinal and Related Pathologies
- Lower Thoracic and Lumbopelvic Region
- Compression Fracture Secondary to Osteoporosis
- Interventions
- Spondylolisthesis
- BOX 15.11 Preventative Measures for Patients with Osteoporosis
- Physical Therapy Interventions
- Ankylosing Spondylitis
- Interventions
- Scheuermann’s Disease
- Interventions
- Rib Subluxation
- Interventions VIDEO 15.1
- FIGURE 15.10 ME technique to correct a posterior rib.
- FIGURE 15.11 ME technique to correct an anterior rib.
- Sacroiliac Joint Dysfunction
- FIGURE 15.12 (A) Normal relationship of the sacrum and innominate, (B) anterior rotated innominate showing the ASIS inferior and PSIS superior, (C) posterior rotated innominate showing the ASIS superior and PSIS inferior, (D) upslipped innominate showing ASIS and PSIS superior on the right compared to contralateral side.
- Identification of SI Joint Impairments
- Interventions VIDEO 15.2
- “Shot-gun” technique.
- FIGURE 15.13 “Shot gun” ME technique.
- Muscle energy techniques to correct an anterior rotated innominate.
- Muscle energy technique to correct a posterior rotated innominate.
- FIGURE 15.14 ME technique of the gluteus maximus to correct an anteriorly rotated innominate bone.
- FIGURE 15.15 ME technique of the rectus femoris to correct a posteriorly rotated innominate bone.
- HVT to treat an upslipped innominate.
- FIGURE 15.16 HVT to correct an upslip of the innominate bone.
- Cervical and Upper Thoracic Region
- Tension Headache/Cervical Headache
- Etiology
- Presenting Signs and Symptoms
- BOX 15.12 History and Symptoms of Cervical Headaches
- Musculoskeletal Impairments
- General Management Guidelines
- Pain Management
- Mobility Impairments and Impaired Muscle Performance
- Mobility and flexibility.
- Cervical stabilization.
- Scapular stabilization and posture.
- Stress Management
- FOCUS ON EVIDENCE
- Prevention.
- Cervical Myelopathy
- Neck Pain
- Temporomandibular Joint Dysfunction
- Structure and Function
- FIGURE 15.17 Structure of the TMJ.
- Motions of the TMJs.
- Signs and Symptoms
- FIGURE 15.18 Mandibular depression: (A) relationship of the condyle, TM disc and glenoid fossa with jaw closed; (B) as the jaw opens the condyle rolls on the TM disc, then (C) the disc and condyle slid anterior on the articular eminence.
- Etiology of Symptoms
- Possible Causes of TMJ Pain
- Relationship to Neck Pain
- Mechanical Imbalances
- Principles of Management and Interventions
- Reduction of Pain and Muscle Guarding
- Soft Tissue Techniques
- Fascial Muscle Relaxation and Tongue Proprioception and Control
- Control of Jaw Muscles and Joint Proprioception
- Stretching Techniques
- Passive Stretching
- Joint Manipulation Techniques VIDEO 15.4
- FIGURE 15.19 Unilateral mobilization of the temporomandibular joint. (A) Distraction is in a caudal direction. (B) Arrow indicates distraction with glide in a caudal, then anterior direction.
- FIGURE 15.20 Bilateral distraction of the temporomandibular joint with the patient supine.
- Reduction of Upper Quarter Muscle Imbalances
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- Case 1
- Case 2
- Case 3
- Case 4
- Case 5
- Case 6
- REFERENCES
- CHAPTER 16 The Spine: Exercise and Manipulation Interventions
- Basic Concepts of Spinal Management with Exercise
- Fundamental Interventions
- BOX 16.1 Fundamental Exercise Interventions for Spinal Rehabilitation
- Patient Education
- General Exercise Guidelines
- TABLE 16.1 Spinal Rehabilitation
- Kinesthetic Awareness
- TABLE 16.2 Intervention for Each Phase of Rehabilitation
- Mobility/Flexibility
- Muscle Performance
- Cardiopulmonary Endurance
- Functional Activities
- Kinesthetic Awareness
- Goal.
- Elements of Functional Training: Fundamental Techniques
- Position of Symptom Relief
- Cervical Spine
- Lumbar Spine
- Effects of Movement on the Spine
- Blending of Kinesthetic Training, Stabilization Exercises, and Fundamental Body Mechanics
- Progression to Active and Habitual Control of Posture
- Mobility/Flexibility
- Goal.
- CLINICAL TIP
- Cervical and Upper Thoracic Region: Stretching Techniques
- Techniques to Increase Thoracic Extension
- Self-Stretching
- FIGURE 16.1 Foam roll stretch to increase flexibility of anterior thorax. (A) In the “touchdown” position, the shoulder extensors are also stretched. (B) With the shoulders abducted and laterally rotated, the pectoralis major and other internal rotators are also stretched. For a less intensive stretch, use a rolled towel placed longitudinally under the spine.
- FIGURE 16.2 (A) Increase flexibility of anterior thorax and pectoralis muscles by adducting the scapula and extending the thoracic spine against the back of the chair. Inspiration increases the stretch; (B) facilitate expiration by bringing the elbows together and flexing the spine.
- Techniques to Increase Axial Extension (Cervical Retraction): Scalene Muscle Stretch
- CLINICAL TIP
- Manual Stretching
- FIGURE 16.3 Unilateral active stretching of the scalenus muscles (manual stretch). The patient first performs axial extension, then side-bends the neck opposite and rotates it toward the tight muscles. The therapist stabilizes the head and upper thorax as the patient breathes in, contracting the muscle against the therapist’s resistance. As the patient relaxes, the rib cage lowers and stretches the muscle.
- Self-Stretching
- Techniques to Increase Upper Cervical Flexion: Short Suboccipital Muscle Stretch
- Manual Stretching
- FIGURE 16.4 Stretching the short suboccipital muscles. The therapist stabilizes the second cervical vertebra as the patient slowly nods the head.
- Self-Stretching
- CLINICAL TIP
- Traction as a Stretching Technique
- Manual Traction: Cervical Spine
- FIGURE 16.5 Manual cervical traction: (A) with the fingers of both hands under the occiput; (B) with one hand over the frontal region and the other hand under the occiput; and (C) using a belt to reinforce the hands for the traction force.
- CLINICAL TIP
- Self-Traction: Cervical Spine
- Cervical Joint Manipulation Techniques
- CLINICAL TIP
- Manipulation to Increase Cervical Flexion (Fig. 16.6)
- FIGURE 16.6 Cervical Flexion Manipulation—prone
- Manipulation to Increase Cervical Extension (Fig. 16.7)
- FIGURE 16.7 Cervical Extension Manipulation—prone
- Manipulation to Increase Cervical Rotation (Fig. 16.8)
- FIGURE 16.8 Cervical Rotation Manipulation—prone
- Manipulation to Increase Cervical Rotation and Side Bending (Fig. 16.9) VIDEO 16.1
- FIGURE 16.9 Cervical Rotation and Side-bending Upglide Manipulation—supine
- Manipulation to Increase Cervical Rotation and Side Bending: Alternate Technique (Fig. 16.10) VIDEO 16.1
- FIGURE 16.10 Cervical Rotation and Side-bending Downglide Manipulation—supine
- Muscle Energy Techniques to Increase Craniocervical Mobility
- To Increase Craniocervical Flexion (Fig. 16.11) VIDEO 16.2
- FIGURE 16.11 Muscle Energy: Craniocervical Flexion
- To Increase Craniocervical Rotation (Fig. 16.12) VIDEO 16.2
- FIGURE 16.12 Muscle Energy: Craniocervical Rotation
- Mid and Lower Thoracic and Lumbar Regions: Stretching Techniques
- Techniques to Increase Lumbar Flexion
- Self-Stretching
- FIGURE 16.13 Self-stretching the lumbar erector spinae muscles and tissues posterior to the spine. The patient grasps around the thighs to avoid compression of the knee joints.
- FIGURE 16.14 Stretching of the lumbar spine. (A) The patient performs a posterior pelvic tilt without rounding the thorax. (B) The patient moves the buttocks back over the feet for a greater stretch.
- Techniques to Increase Lumbar Extension
- Self-Stretching
- Techniques to Increase Lateral Flexibility of the Spine
- FIGURE 16.15 Self-stretching of the soft tissues anterior to the lumbar spine and hip joints with the patient (A) prone (using a press-up) and (B) standing.
- FIGURE 16.16 Stretching hypomobile structures on the concave side of the thoracic curve. Illustrated is a patient with a right thoracic left lumbar curve. The therapist stabilizes the pelvis and lumbar spine while the patient actively stretches the thoracic curve by reaching upward on side of concavity and downward on side of convexity.
- FIGURE 16.17 Stretching hypomobile structures on the concave side of a left lumbar curve. The patient stabilizes the upper trunk and thoracic curve as the therapist passively stretches the lumbar curve.
- FIGURE 16.18 (A) Heel-sitting to stabilize the lumbar spine. (B) Hypomobile structures on the concave side of a right thoracic curve are stretched by having the patient reach the arms overhead and then walk the hands toward the convex side.
- FIGURE 16.19 Stretching tight structures on the concave side of a right thoracic curve. The patient is positioned side-lying with a rolled towel at the apex of the convexity. The lumbar spine is stabilized by the therapist.
- FIGURE 16.20 Side-lying over the edge of a mat table to stretch hypomobile structures of a right thoracic scoliosis. The therapist stabilizes the pelvis.
- Techniques to Increase Hip Muscle Flexibility
- Traction as a Stretching Technique
- Manual Traction: Lumbar Spine
- Positional Traction: Lumbar Spine
- FIGURE 16.21 Positional traction for the lumbar spine. (A) Side bending over a 6- to 8-inch roll causes longitudinal traction to the segments on the upward side. (B) Side-bending with rotation adds a distraction force to the facets on the upward side.
- CLINICAL TIP
- Thoracic and Lumbar Joint Manipulation and HVT Techniques
- CLINICAL TIP
- Manipulation Technique to Increase Thoracic Spine Extension (Fig. 16.22) VIDEO 16.3
- FIGURE 16.22 Thoracic Spine Extension Manipulation or HVT—prone: (A) “V-spread” finger placement on transverse processes and (B) force application with hypothenar eminence.
- Manipulation Technique to Increase Thoracic Spine Flexion
- FIGURE 16.23 Thoracic Spine Left Rotation Manipulation or HVT—prone.
- Manipulation to Increase Thoracic Spine Rotation (Fig. 16.23) VIDEO 16.3
- CLINICAL TIP
- Pistol Thrust to Increase Thoracic Spine Mobility (Fig. 16.24) VIDEO 16.4
- FIGURE 16.24 Thoracic spine manipulation: (A) hand placement on thoracic spine using a “pistol grip” and (B) manipulation force against patient’s crossed arms. (C) Pistol grip on a spinal model, showing carpometacarpal joint of thumb on one transverse process and flexed middle phalanx on opposite transverse process.
- Cross-Arm Thrust to Increase Thoracic Spine Mobility (Fig. 16.25)
- FIGURE 16.25 Thoracic spine manipulation using cross-arm thrust
- Fall Thrust to Increase Thoracic Spine Mobility (Fig. 16.26) VIDEO 16.5
- FIGURE 16.26 Thoracic spine manipulation using a fall thrust
- Rib Manipulation for Expiratory Restriction (Fig. 16.27) VIDEO 16.6
- FIGURE 16.27 Expiratory restriction rib manipulation
- Rib Manipulation for Inspiratory Restriction (Fig. 16.28)
- FIGURE 16.28 Inspiratory restriction rib manipulation
- Elevated First Rib Manipulation (Fig. 16.29) VIDEO 16.7
- FIGURE 16.29 Elevated first rib manipulation
- Manipulation Techniques to Increase Lumbar Spine Extension (Fig. 16.30) VIDEO 16.8
- FIGURE 16.30 Lumbar spine extension manipulation/HVT—prone
- Manipulation to Increase Lumbar Spine Rotation (Fig. 16.31) VIDEO 16.8
- FIGURE 16.31 Lumbar spine left rotation manipulation/HVT—prone
- Manipulation to Increase Lumbar Intervertebral Side Bending (Fig. 16.32) VIDEO 16.9
- FIGURE 16.32 Lumbar spine side-bending manipulation—sidelying
- HVT Lumbar Roll to Increase Lumbar Rotation (Fig. 16.33) VIDEO 16.10
- FIGURE 16.33 Lumbar roll HVT: (A) monitor motion at the spine as the hip is flexed then stabilized by the therapist’s trunk; (B) rotate the patient’s trunk backward to take up the slack, and apply a rotational force through the lower spine by moving the innominate forward; (C) rotational forces applied to the segment above and below, including the innominate, demonstrated on a spine model.
- SI Joint Manipulation Technique to Increase Sacral Nutation (Flexion) (Fig. 16.34) VIDEO 16.11
- FIGURE 16.34 SI Nutation (Flexion) Manipulation.
- SI Joint Manipulation Technique to Increase Sacral Counternutation (Extension) (Fig. 16.35) VIDEO 16.11
- FIGURE 16.35 SI Counternutation (Extension) Manipulation
- Posterior Rotation Manipulation to Innominate (Fig. 16.36) VIDEO 16.11
- FIGURE 16.36 Posterior Rotation Innominate Manipulation
- Muscle Performance: Stabilization, Muscle Endurance, and Strength Training
- Goals.
- Stabilization Training: Fundamental Techniques and Progressions
- FIGURE 16.37 Exercises to improve muscle performance, cardiopulmonary endurance, and functional activities are integrated over a background of activating the deep segmental and global multi-segmental spinal stabilizing musculature.
- CLINICAL TIP
- Guidelines for Stabilization Training
- BOX 16.2 Guidelines for Stabilization Training: Principles and Progression
- Deep Segmental Muscle Activation and Training
- FOCUS ON EVIDENCE
- Cervical Musculature
- FIGURE 16.38 Axial extension (cervical retraction) involves the motion of capital flexion and movement of the lower cervical and upper thoracic spine toward extension, resulting in slight flattening of the cervical lordosis and “lifting” of the head.
- Deep Neck Flexors: Activation and Training VIDEO 16.12
- FIGURE 16.39 (A) The StabilizerTM pressure biofeedback unit (© 2006 Encore Medical, L.P.) is used to provide visual feedback to the patient while training for spinal stabilization. (B) Stabilizer folded into thirds under the cervical spine to test and train capital flexion with neutral spine axial extension.
- BOX 16.3 Testing and Training Deep Segmental Muscle Activation in the Cervical Spine
- FOCUS ON EVIDENCE
- Lower Cervical and Upper Thoracic Extensor Activation and Training
- Progression
- FIGURE 16.40 Axial extension (cervical retraction) exercises.
- Lumbar Musculature
- FIGURE 16.41 Three methods to activate the stabilizing musculature in the lumbar spine. (A) Drawing-in maneuver in which the patient hollows the abdominal region (“draws” the belly button toward the spine). (B) Abdominal bracing in which setting the abdominal muscles results in flaring laterally around the waist. (C) Posterior pelvic tilt in which the pelvis is actively tilted posteriorly and the lumbar spine flattens.
- Drawing-In Maneuver (Abdominal Hollowing Exercise) for Transverse Abdominis Activation VIDEO 16.13
- FIGURE 16.42 Palpation of the transversus abdominis (TA) muscle just distal to the ASIS and lateral to the rectus abdominis muscle. The TA feels like a tense sheet (a bulge is the internal oblique) when performing a gentle drawing-in maneuver.
- Abdominal Bracing
- Posterior Pelvic Tilt
- Multifidus Activation and Training VIDEO 16.14
- BOX 16.4 Testing and Training Deep Segmental Muscle Activation (Transversus Abdominis) in the Lumbar Spine
- FIGURE 16.43 Palpation of the multifidus muscle lateral to the spinous processes in the lumbar spine, (A) bilaterally in the supine position and (B) unilaterally in the side-lying position.
- Progression
- Global Muscle Stabilization Exercises
- Stabilization Exercises for the Cervical Region
- Stabilization with Progressive Limb Loading
- Variations and Progressions in the Stabilization Program
- TABLE 16.3 Cervical Stabilization with Progressive Limb Loading—Emphasis on Cervical Flexors VIDEO 16.15
- FIGURE 16.44 Limb loading for basic stabilization progression of cervical musculature in the supine position. Maximum protection phase: (A) shoulder flexion to 90°; (B) shoulder abduction to 90°; (C) shoulder external rotation arms at the side. Moderate protection phase: (D) shoulder flexion and abduction to end-range; (E) diagonal patterns.
- Integration of Stabilization Exercises and Posture Training
- Progression of Isometric and Dynamic Strengthening in Conjunction with Functional Activities
- TABLE 16.4 Cervical Stabilization with Progressive Limb Loading—Emphasis on Cervical and Thoracic Extensors VIDEO 16.16
- FIGURE 16.45 Limb loading for basic stabilization progression of cervical musculature in prone position. Maximum protection phase: (A) arms at side, shoulder lateral rotation, and scapular adduction; (B) arms at 90/90, horizontal abduction, and scapular adduction. Moderate protection phase: (C) shoulder elevation full range, (D) shoulders 90° with lateral rotation and elbow extended, horizontal abduction, and scapular adduction.
- FIGURE 16.46 Unstable surfaces provide increased challenges to the cervical stabilizing musculature, requiring greater control. Examples include performing upper extremity motions, such as diagonal patterns (A) while sitting on a gym ball, (B) while quadruped over a gym ball, and (C) while pressing a ball against the wall. Use of external resistance is also illustrated.
- Stabilization Exercises for the Lumbar Region
- Stabilization with Progressive Limb Loading
- TABLE 16.5 Basic Lumbar Stabilization with Progressive Limb Loading—Emphasis on Abdominals
- FIGURE 16.47 Bent-leg fall out. Level 2 limb loading for basic stabilization of the abdominal muscles in the supine position. This requires control to prevent pelvic rotation; stability is assisted by the opposite lower extremity while hook-lying. VIDEO 16.17
- BOX 16.5 Instructions for use of StabilizerTM for Stabilization Training with Leg Loading
- FIGURE 16.48 Limb loading for basic stabilization progression of the abdominal muscles in the supine position, levels 3 to 6. Level 3, stability assisted by opposite extremity in hook-lying position; level 4, stability assisted by patient holding opposite leg at 90°; level 5, stability challenged by patient actively holding opposite leg at 90°; level 6, stability challenged with both lower extremities moving. (A) Bent leg lift to 90°. (B) Heel slide to extend knee. (C) Straight-leg lift to 45°. VIDEO 16.18
- TABLE 16.6 Basic Lumbar Stabilization with Progressive Limb Loading: Emphasis on Trunk Extensors
- FIGURE 16.49 Limb loading for basic stabilization progression of the lumbar extensors. Begin in the quadruped position and progress the intensity by (A) flexing one UE; (B) extending one LE with a leg slide; (C) extending one LE by lifting it off the mat; (D) flexing one UE while extending contralateral LE and then alternate to opposite extremities. Progress to prone: (E) extending one LE; (F) extending both LE; and (G) lifting head, arms, and trunk. VIDEO 16.19
- CLINICAL TIP
- Variations and Progressions in the Stabilization Exercise Program
- FIGURE 16.50 Balancing a rod on the back while doing quadruped exercises provides reinforcement that the trunk is not twisting. (A) Single leg slides. (B) Lifting the opposite arm and leg simultaneously, then alternating extremities.
- FIGURE 16.51 (A) Alternating LE motions with the “modified bicycle” or (B) reciprocal and alternating patterns using the UE and LE simultaneously require a strong controlling action in the abdominals.
- Quadratus Lumborum: Stabilization Exercises VIDEO 16.22
- FIGURE 16.52 Developing the stabilizing action of the abdominal muscles by using pull-down activities against a resistive force from pulleys or elastic bands. This exercise can also be done sitting or standing to increase the challenge to the muscles in less stable positions.
- FIGURE 16.53 Using elastic resistance to train and strengthen the abdominal muscles in the upright position. The drawing-in maneuver to set the deep segmental stabilizing muscles precedes the movement of the arms forward against the resistance.
- FIGURE 16.54 Using elastic resistance to train and strengthen the back extensor muscles to stabilize in the upright position (A) diagonal patterns while sitting on an unstable surface and (B) while standing.
- FIGURE 16.55 Strength, balance, and coordination are required to maintain spinal stabilization while sitting on a gym ball and moving the extremities. This activity is progressed by adding weights to the extremities.
- FIGURE 16.56 Activation of the stabilizing trunk muscles occurs to maintain balance on a foam roll while the extremities move in various planes: (A) shoulder horizontal abduction/adduction and (B) ipsilateral hip and shoulder flexion/extension are shown. Weights are added to increase the challenge.
- FIGURE 16.57 Quadratus lumborum stabilization training using side-propping (side plank) (A) on the elbow and knee and (B) on the hand and foot.
- FOCUS ON EVIDENCE
- Progression to Dynamic Exercises
- Isometric and Dynamic Exercises
- Exercises for the Cervical Region
- Isometric Exercises: Self-Resistance
- FIGURE 16.58 Self-resistance for isometric (A) cervical flexion and (B) axial extension.
- Isometric Resistance Activities
- Dynamic Cervical Flexion
- CLINICAL TIP
- FIGURE 16.59 Training the short cervical flexors while de-emphasizing the sternocleidomastoid for cervical flexion to regain a balance in strength for anterior cervical stabilization.
- Manual Resistance: Cervical Muscles
- Intermediate and Advanced Training
- Transitional Stabilization for the Cervical and Upper Thoracic Regions
- Functional Exercises
- FIGURE 16.60 Advanced exercises for strengthening the cervical and upper thoracic flexors and extensors as stabilizers. Begin by (A) sitting on a large gym ball, then (B) walking forward while rolling the ball up the back. With the ball behind the mid-thoracic area, the cervical flexors must stabilize. Continue walking forward until the ball is (C) under the head; the cervical extensors now must stabilize. Walk back and forth between the two positions (B and C) to alternate control between the flexors and extensors. Progress by adding arm motions or arm motions with weights to increase resistance.
- Exercises for the Thoracic and Lumbar Regions
- Alternating Isometric Contractions and Rhythmic Stabilization VIDEO 16.23
- FIGURE 16.61 Alternating isometric resistance applied in the sagittal, frontal, and horizontal planes with the patient supine to stimulate the stabilizing function of the trunk musculature.
- Dynamic Strengthening: Abdominal Muscles
- FOCUS ON EVIDENCE
- Trunk Flexion (Abdominals): Supine
- Curl-ups.
- FIGURE 16.62 The curl-up exercise to strengthen the abdominal muscles. The thorax is flexed on the lumbar spine. The arms are shown in the position of least resistance. Progress by crossing the arms across the chest and then behind the head.
- Curl-downs.
- Diagonal curl-ups.
- Curl-ups on an unstable surface.
- FIGURE 16.63 Curl-ups on an unstable surface. The unstable surface increases activity in the oblique and rectus abdominis muscles.
- FOCUS ON EVIDENCE
- Double knee-to-chest.
- Pelvic lifts.
- FIGURE 16.64 Strengthening the abdominal muscles by flexing the hip and pelvis on the lumbar spine. The legs are shown in the position for least resistance. Progress by decreasing the angle of hip flexion until the legs can be lifted with the knees extended, as in the pelvic lift.
- FIGURE 16.65 Pelvic lifts. Elevating the legs upward toward the ceiling by raising the buttocks off the floor emphasizes strengthening the lower abdominal muscles.
- Bilateral straight-leg raising.
- Bilateral straight-leg lowering.
- Trunk Flexion (Abdominals): Sitting or Standing
- FIGURE 16.66 Standing trunk flexion against elastic material to strengthen the abdominal muscles. The patient performs a posterior pelvic tilt and then approximates the ribs toward the pubis.
- Dynamic Strengthening: Erector Spinae and Multifidus Muscles
- FOCUS ON EVIDENCE
- Extension Exercises in Prone or Quadruped Position
- Thoracic elevation.
- Leg lifts.
- FIGURE 16.67 Strengthening the back extensors with the arms in position to provide maximal resistance. Additional resistance can be provided by holding weights in the hands.
- “Superman.”
- FIGURE 16.68 Strengthen the trunk and hip extensors by lifting the trunk and legs off the mat simultaneously. Greater resistance can be provided by abducting the shoulders to 90° or by elevating them to 180° (“Superman”).
- Variations.
- Extension Exercises Sitting or Standing
- Elastic resistance or weighted pulleys.
- FIGURE 16.69 Using elastic resistance for concentric eccentric back extension.
- FIGURE 16.70 Rotation with extension strengthens the back extensors in functional patterns.
- Trunk Side Bending (Lateral Abdominals, Erector Spinae, Quadratus Lumborum)
- FOCUS ON EVIDENCE
- FIGURE 16.71 Antigravity strengthening of the lateral trunk musculature. (A) There is less resistance if the top arm is at the side and the bottom arm is folded across the chest. (B) Increase resistance by positioning the arms behind the head.
- Cardiopulmonary Endurance
- Goal.
- BOX 16.6 Summary of Aerobic Conditioning Principles
- Common Aerobic Exercises and Effects on the Spine
- Cycling
- Walking and Running
- Stair Climbing
- Cross-Country Skiing and Ski Machines
- Swimming
- Breast stroke.
- Freestyle.
- Backstroke.
- Butterfly stroke.
- Upper Body Ergometers
- Step Aerobics and Aerobic Dancing
- “Latest Popular Craze”
- Functional Activities
- Goal.
- Early Functional Training: Fundamental Techniques
- Rolling.
- Supine to sit/sit to lying down.
- Sit to stand/stand to sit.
- In and out of a car.
- Walking.
- Preparation for Functional Activities: Basic Exercise Techniques
- Weight-Bearing Exercises
- Modified Bridging Exercises
- Push-Ups with Trunk Stabilization
- FIGURE 16.72 Holding a bridge to develop trunk control and gluteus maximus strength while superimposing extremity motions by (A) marching in place and (B) extending the extremities. Adding weights to the arms or legs requires greater strength and control.
- FIGURE 16.73 Push-up activities with the lower extremities balanced on a gym ball for strengthening the arms and developing trunk control.
- Wall Slides
- Partial Lunges, Partial Squats, and Steps
- Walking Against Resistance
- Transitional Stabilization Exercises
- FIGURE 16.74 Wall slides/partial squats to develop LE strength and coordinate with trunk stability in preparation for training body mechanics. (A) The back sliding down a wall, with bilateral arm motion for added resistance. (B) Rolling a gym ball down the wall, with antagonistic arm motion to develop coordination.
- Quadruped Forward/Backward Shifting
- Squatting and Reaching
- Shifting Weight and Turning
- Body Mechanics and Environmental Adaptations
- Principles of Body Mechanics: Instruction and Training
- Lumbar Spine Position
- Spinal flexion.
- Spinal extension.
- Load Position
- Environmental Adaptations
- Home, Work, and Driving Considerations
- Sleeping Environment
- Intermediate to Advanced Exercise Techniques for Functional Training
- Repetitive Lifting
- Repetitive Reaching
- Repetitive Pushing and Pulling
- Rotation or Turning
- Transitional Movements
- Transfer of Training
- Patient Education for Prevention
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 17 The Shoulder and Shoulder Girdle
- Structure and Function of the Shoulder Girdle
- FIGURE 17.1 Bones and joints of the shoulder girdle complex.
- Joints of the Shoulder Girdle Complex
- Synovial Joints
- Glenohumeral Joint
- FIGURE 17.2 Ligaments of the glenohumeral (GH) and acromioclavicular (AC) joints.
- Arthrokinematics
- FOCUS ON EVIDENCE
- BOX 17.1 Summary of Joint Arthrokinematics of the GH Joint
- Stability
- TABLE 17.1 Static and Dynamic Stabilizers of the Scapula and Glenohumeral Joint
- FIGURE 17.3 Lateral aspect of the glenoid fossa (interior view), showing attachments of the glenoid labrum, capsule, and ligaments as well as their relationship to the rotator cuff and long head of the biceps brachii musculature.
- Acromioclavicular Joint
- Arthrokinematics
- Stability
- Sternoclavicular Joint
- FIGURE 17.4 Ligaments of the sternoclavicular (SC) joint.
- Arthrokinematics
- Stability
- Functional Articulations
- Scapulothoracic Articulation
- Motions of the Scapula
- BOX 17.2 Summary of Arthrokinematics of the SC Joint
- FIGURE 17.5 Scapular motions. (A) Elevation occurs with clavicular elevation at the SC joint when shrugging. (B) Protraction (abduction) occurs with clavicular abduction at the SC joint when reaching forward. (C) Upward rotation occurs with clavicular rotation at the SC and AC joints when flexing and abducting the shoulder. (D) Forward tilting (along with downward rotation) occurs at the AC joint when extending and internally rotating the shoulder.
- Scapular Stability
- Postural relationship.
- Active arm motions.
- Faulty posture.
- FIGURE 17.6 Faulty forward head, thoracic kyphosis, and shoulder girdle posture result in a forward tilt and downward rotation of the scapula with relative abduction and internal rotation of the humerus when the arm is in a dependent position.
- FOCUS ON EVIDENCE
- Suprahumeral (Subacromial) Space
- FIGURE 17.7 The supraspinatus and subacromial/subdeltoid bursa lie in the suprahumeral space.
- Shoulder Girdle Function
- Scapulohumeral Rhythm
- Clavicular Elevation and Rotation with Humeral Motion
- FOCUS ON EVIDENCE
- External Rotation of the Humerus with Elevation
- FOCUS ON EVIDENCE
- Deltoid–Short Rotator Cuff and Supraspinatus Mechanisms
- Referred Pain and Nerve Injury
- Common Sources of Referred Pain in the Shoulder Region
- Cervical Spine
- Referred Pain from Related Tissues
- Nerve Disorders in the Shoulder Girdle Region
- Brachial plexus in the thoracic outlet.
- Suprascapular nerve in the suprascapular notch.
- Radial nerve in the axilla.
- Management of Shoulder Disorders and Surgeries
- Joint Hypomobility: Nonoperative Management
- Glenohumeral Joint
- TABLE 17.2 Shoulder Pathologies/Surgical Procedures and Preferred Practice Patterns
- Related Pathologies and Etiology of Symptoms
- Rheumatoid arthritis and osteoarthritis.
- Traumatic arthritis.
- Postimmobilization arthritis or stiff shoulder.
- Idiopathic frozen shoulder.
- Clinical Signs and Symptoms
- Glenohumeral joint arthritis.
- Idiopathic frozen shoulder.
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations and Disabilities)
- Glenohumeral Joint Hypomobility: Management—Protection Phase
- Control Pain, Edema, and Muscle Guarding
- Maintain Soft Tissue and Joint Integrity and Mobility
- CLINICAL TIP
- Maintain Integrity and Function of Associated Regions
- CLINICAL TIP
- GH Joint Hypomobility: Management—Controlled Motion Phase
- Control Pain, Edema, and Joint Effusion
- Progressively Increase Joint and Soft Tissue Mobility
- FOCUS ON EVIDENCE
- FIGURE 17.8 Self-mobilization. Caudal glide of the humerus occurs as the person leans away from the fixed arm.
- FIGURE 17.9 Self-mobilization. Anterior glide of the humerus occurs as the person leans between the fixed arms.
- FIGURE 17.10 Self-mobilization. Posterior glide of the humerus occurs as the person shifts his weight downward between the fixed arms.
- Inhibit Muscle Spasm and Correct Faulty Mechanics
- FIGURE 17.11 Poor mechanics with the patient hiking the shoulder while trying to abduct it, thus failing to upwardly rotate the scapula and elevating rather than depressing the humeral head.
- Improve Joint Tracking
- FIGURE 17.12 Mobilization with movement (MWM) to improve external rotation. A posterolateral glide is applied to the humeral head while the patient pushes the arm into the end-range of external rotation with a cane.
- FIGURE 17.13 MWM to improve internal rotation. An inferior glide is applied to the humerus while the patient pulls the hand up the back with a towel.
- Improve Muscle Performance
- GH Joint Hypomobility: Management—Return to Function Phase
- Progressively Increase Flexibility and Strength
- Prepare for Functional Demands
- GH Joint Management: Postmanipulation Under Anesthesia
- Acromioclavicular and Sternoclavicular Joints
- Related Pathologies and Etiology of Symptoms
- Overuse syndromes.
- Subluxation or dislocation.
- Hypomobility.
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Nonoperative Management of AC or SC Joint Strain or Hypermobility
- Nonoperative Management of AC or SC Joint Hypomobility
- Glenohumeral Joint Surgery and Postoperative Management
- Glenohumeral Arthroplasty
- FIGURE 17.14 Postoperative anterior-posterior view of the shoulder showing a Neer II type of cemented humeral prosthesis and a nonmetal backed polyethylene glenoid.
- Indications for Surgery
- Procedures
- Background
- Implant design, materials, and fixation.
- Selection of procedure.
- BOX 17.3 Designs of Prosthetic Implants for Total Shoulder Arthroplasty
- Operative Procedures
- Complications
- Postoperative Management
- Special Considerations
- Integrity of the rotator cuff.
- BOX 17.4 Complications Specific to Glenohumeral Arthroplasty
- Intraoperative ROM.
- Posture.
- Immobilization and Postoperative Positioning
- Exercise Progression
- BOX 17.5 Positioning After Shoulder Arthroplasty: Early Postoperative (Maximum Protection) Phase
- TABLE 17.3 Comparison of Exercise Guidelines and Precautions Following Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty
- CLINICAL TIP
- Exercise: Maximum Protection Phase
- Goals and interventions.
- BOX 17.6 Precautions for the Maximum Protection Phase of Rehabilitation Following Shoulder Arthroplasty
- Criteria to progress.
- Exercise: Moderate Protection/Controlled Motion Phase
- Goals and interventions.
- Criteria to progress.
- Exercise: Minimum Protection/Return to Function Phase
- Goals and interventions.
- Outcomes
- Pain relief.
- ROM and functional use of the upper extremity.
- Painful Shoulder Syndromes (Rotator Cuff Disease and Impingement Syndromes): Nonoperative Management
- Related Pathologies and Etiology of Symptoms
- Intrinsic Impingement: Rotator Cuff Disease
- BOX 17.7 Categories of Painful Shoulder Syndromes
- Extrinsic Impingement: Mechanical Compression of Tissues
- FIGURE 17.15 Decrease in the suprahumeral space during repetitive elevation activities leads to symptoms of impingement.
- Primary extrinsic impingement.
- Secondary extrinsic impingement.
- FIGURE 17.16 Classifications of the acromion by shape: (A) type I (flat); (B) type II (curved); (C) type III (hooked).
- Internal extrinsic impingement.
- Tendonitis/Bursitis
- Supraspinatus tendonitis.
- Infraspinatus tendonitis.
- Bicipital tendonitis.
- Bursitis (subdeltoid or subacromial).
- Other Impaired Musculotendinous Tissues
- Insidious (Atraumatic) Onset
- Common Structural and Functional Impairments
- Impaired Posture and Muscle Imbalances
- BOX 17.8 Summary of Common Impairments with Rotator Cuff Disease and Impingement Syndromes
- FOCUS ON EVIDENCE
- Decreased Thoracic ROM
- CLINICAL TIP
- Rotator Cuff Overuse and Fatigue
- Muscle Weakness Secondary to Neuropathy
- Hypomobile Posterior GH Joint Capsule
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Management: Painful Shoulder Syndromes
- Management: Protection Phase
- Control Inflammation and Promote Healing
- Patient Education
- Maintain Integrity and Mobility of the Soft Tissues
- Control Pain and Maintain Joint Integrity
- Develop Support in Related Regions
- FOCUS ON EVIDENCE
- Management: Controlled Motion Phase
- Patient Education
- Develop Strong, Mobile Tissues
- Modify Joint Tracking and Mobility
- FIGURE 17.17 MWM to modify joint tracking and improve active elevation. A posterolateral glide is applied to the humeral head (A) manually or (B) with a belt for self-treatment, while the patient actively elevates the humerus. A weight is used to strengthen the muscles through the pain-free range.
- Develop Balance in Length and Strength of Shoulder Girdle Muscles
- Develop Muscular Stabilization and Endurance
- Progress Shoulder Function
- Management: Return to Function Phase
- Increase Muscular Endurance
- Develop Quick Motor Responses to Imposed Stresses
- BOX 17.9 Patient Instructions to Prevent Recurrences of Shoulder Pain
- Progress Functional Training
- Painful Shoulder Syndromes: Surgery and Postoperative Management
- Subacromial Decompression and Postoperative Management
- Indications for Surgery
- Procedures
- Surgical approach.
- Component procedures.
- FIGURE 17.18 Arthroscopic acromioplasty showing the line of resection of the anterior acromion.
- Postoperative Management
- Immobilization
- Exercise Progression
- Exercise: Maximum Protection Phase
- Goals and interventions.
- Criteria to progress.
- Exercise: Moderate Protection Phase
- Goals and interventions.
- CLINICAL TIP
- Criteria to progress.
- Exercise: Minimum Protection/Return to Function Phase
- Goals and interventions.
- Outcomes
- Rotator Cuff Repair and Postoperative Management
- Indications for Surgery
- Procedures
- Type of Repair
- Components of a Rotator Cuff Repair
- Selection of Surgical Procedures
- Postoperative Management
- TABLE 17.4 Factors That Influence Progression of Rehabilitation After Repair of the Rotator Cuff
- Immobilization
- Exercise Progression
- FOCUS ON EVIDENCE
- TABLE 17.5 Relationships of Type and Duration of Immobilization after Arthroscopic and Mini-Open Repair* to the Size of the Rotator Cuff Tear
- BOX 17.10 General Exercise Guidelines and Precautions Following Repair of a Full-Thickness Rotator Cuff Tear
- Exercise: Maximum Protection Phase
- Goals and interventions.
- Criteria to progress.
- Exercise: Moderate Protection Phase
- FOCUS ON EVIDENCE
- Goals and interventions.
- CLINICAL TIP
- Criteria to progress.
- Exercise: Minimum Protection/Return to Function Phase
- Goals and interventions.
- Outcomes
- Pain relief.
- Shoulder ROM.
- Strength.
- Functional abilities.
- Shoulder Instabilities: Nonoperative Management
- Related Pathologies and Mechanisms of Injury
- Atraumatic Hypermobility
- Unidirectional instability.
- Multidirectional instability.
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Traumatic Hypermobility
- Traumatic anterior shoulder dislocation.
- FIGURE 17.19 Lesions associated with traumatic anterior dislocation of the GH joint. A Bankart lesion is a fracture of the anterior rim of the glenoid with the attached labrum. The labrum is pulled away from the anterior glenoid along with a small piece of glenoid. A Hill-Sachs lesion, a compression fracture of the posterolateral humeral head, also may occur.
- Traumatic posterior shoulder dislocation.
- Recurrent Dislocations
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Closed Reduction of Anterior Dislocation
- Management: Protection Phase
- Protect the Healing Tissue
- FOCUS ON EVIDENCE
- Promote Tissue Health
- Management: Controlled Motion Phase
- Provide Protection
- Increase Shoulder Mobility
- FIGURE 17.20 Mobilizing to increase external rotation when an anterior glide is contraindicated. Place the shoulder in resting position, externally rotate it, then apply a grade III distraction force.
- Increase Stability and Strength of Rotator Cuff and Scapular Muscles
- Management: Return to Function Phase
- Restore Functional Control
- Return to Full Activity
- Closed Reduction of Posterior Dislocation
- CLINICAL TIP
- Shoulder Instabilities: Surgery and Postoperative Management
- Glenohumeral Joint Stabilization Procedures and Postoperative Management
- FOCUS ON EVIDENCE
- Indications for Surgery
- Procedures
- Bankart repair.
- Capsulorrhaphy (capsular shift).
- Electrothermally assisted capsulorrhaphy.
- Posterior capsulorrhaphy (posterior or posteroinferior capsular shift).
- Repair of a SLAP lesion.
- Postoperative Management
- General Considerations
- TABLE 17.6 Factors that Influence the Rehabilitation Program After Surgery for Recurrent Instability of the GH Joint
- Immobilization
- Position.
- Duration.
- Exercise Progression
- CLINICAL TIP
- FOCUS ON EVIDENCE
- Exercise: Maximum Protection Phase
- Goals and interventions.
- BOX 17.11 Precautions After Anterior Glenohumeral Stabilization and/or Bankart Repair*
- BOX 17.12 Precautions After Selected Glenohumeral Stabilization Procedures
- Criteria to progress.
- Exercise: Moderate Protection Phase
- Goals and interventions.
- Criteria to progress.
- Exercise: Minimum Protection/Return to Function Phase
- Outcomes
- Recurrence of instability.
- Shoulder ROM.
- Acromioclavicular and Sternoclavicular Joint Stabilization Procedures and Postoperative Management
- Acromioclavicular Joint Stabilization
- Sternoclavicular Joint Stabilization
- Postoperative Management
- Exercise Interventions for the Shoulder Girdle
- Exercise Techniques During Acute and Early Subacute Stages of Tissue Healing
- Early Motion of the Glenohumeral Joint
- Wand Exercises
- FIGURE 17.21 Self-assisted shoulder rotation using a cane (A) with the arm at the side and (B) in scaption. To relieve stress on the anterior capsule, elevate the distal humerus with a folded towel.
- Ball Rolling or Table Top Dusting
- Wall (Window) Washing
- Pendulum (Codman’s) Exercises
- FIGURE 17.22 Pendulum exercises. For gentle distraction, no weight is used. Use of a weight causes a grade III (stretching) distraction force.
- FOCUS ON EVIDENCE
- “Gear Shift” Exercises
- FIGURE 17.23 Gear shift exercise. Self-assisted shoulder rotation using a cane. Flexion/extension and diagonal patterns also can be done.
- Early Motion of the Scapula
- Early Neuromuscular Control
- Multiple-Angle Muscle Setting
- Protected Weight Bearing
- Exercise Techniques to Increase Flexibility and Range of Motion
- FOCUS ON EVIDENCE
- Self-Stretching Techniques to Increase Shoulder ROM
- To Increase Flexion and Horizontal Adduction: Cross-Chest Stretch
- FIGURE 17.24 Self-stretching to increase horizontal adduction.
- To Increase Flexion and Elevation of the Arm
- FIGURE 17.25 (A) Beginning and (B) end positions for self-stretching to increase shoulder flexion with elevation.
- To Increase External (Lateral) Rotation
- FIGURE 17.26 Self-stretching to increase external rotation of the shoulder (A) with the arm at the side using a doorframe and (B) with the arm in the plane of the scapular using a table to stabilize the forearm.
- To Increase Internal Rotation
- FIGURE 17.27 Self-stretching in the “sleeper position” to increase internal rotation of the shoulder using a table to stabilize the humerus.
- FOCUS ON EVIDENCE
- To Increase Abduction and Elevation of the Arm
- FIGURE 17.28 (A) Beginning and (B) end positions for self-stretching to increase shoulder abduction with elevation.
- To Increase Extension of the Arm
- FIGURE 17.29 (A) Beginning and (B) end positions for self-stretching to increase shoulder extension.
- To Increase Internal Rotation, Extension, and Scapular Tilting
- Manual and Self-Stretching Exercises for Specific Muscles
- To Stretch the Latissimus Dorsi Muscle
- Manual Stretch
- Self-Stretch
- To Stretch the Pectoralis Major Muscles
- Manual Stretch
- FIGURE 17.30 Active stretching of the pectoralis major muscle. The therapist gently pulls the elbows posteriorly while the patient breathes in and then holds the elbows at the end-point as the patient breathes out.
- Self-Stretch
- FIGURE 17.31 Self-stretching the pectoralis major muscle with the arms in a reverse-T position to stretch (A) the clavicular portion and in a V-position to stretch (B) the sternal portion.
- FIGURE 17.32 Wand exercises to stretch the pectoralis major muscle.
- FIGURE 17.33 Active stretching of the pectoralis minor muscle. The therapist holds the scapular and coracoid process at the end-point as the patient breathes out.
- To Stretch the Pectoralis Minor Muscle
- Manual Stretch VIDEO 17.1.
- Self-Stretch
- To Stretch the Levator Scapulae Muscle
- Manual Stretch VIDEO 17.1.
- FIGURE 17.34 Stretching of the levator scapulae muscle. The therapist stabilizes the head and scapula as the patient breathes in, contracting the muscle against the resistance. As the patient relaxes, the rib cage and scapula depress, which stretches the muscle.
- Self-Stretch
- FIGURE 17.35 Self-stretching of the levator scapulae muscle (A) using upward rotation of the scapula and (B) using depression of the scapula.
- To Stretch the Upper Trapezius Muscle
- Manual Stretch
- Self-Stretch
- FIGURE 17.36 Self-stretching of the upper trapezius muscle.
- Exercises to Develop and Improve Muscle Performance and Functional Control
- Isometric Exercises
- BOX 17.13 Summary of Exercise Progressions for Shoulder Function
- Scapular Muscles
- Depression (lower trapezius).
- Protraction (serratus anterior).
- Retraction (rhomboids and trapezius).
- FIGURE 17.37 Isometric or dynamic manual resistance to scapular muscles. (A) Resistance to elevation/depression. (B) Resistance to protraction/retraction. Direct the patient to reach across the therapist’s shoulder to protract the scapula while the therapist resists against the coracoid and acromion process. The therapist’s other hand is placed behind the scapula to resist retraction.
- FIGURE 17.38 Isometric or dynamic resistance to shoulder rotation. (A) External rotation with the shoulder in the plane of the scapula. (B) Internal rotation with the shoulder at 90° abduction.
- Multiple-Angle Isometrics: GH Muscles
- External and internal rotation.
- Abduction.
- Scapular plane elevation.
- FIGURE 17.39 Isometric resistance in scapular plane elevation. The shoulder is positioned between 30° and 60° degrees of elevation, and controlled manual resistance is applied against the humerus.
- Extension.
- Adduction.
- Elbow flexion with forearm supination.
- Self-Applied Multiple-Angle Isometrics
- Stabilization Exercises
- FIGURE 17.40 Self-resistance for isometric shoulder (A) flexion, (B) abduction, and (C) rotation.
- FIGURE 17.41 Using a wall to provide resistance for isometric shoulder (A) flexion, (B) abduction, and (C) rotation.
- Open-Chain Stabilization Exercises for the Scapular Muscles VIDEO 17.2.
- Scapular elevation/depression.
- Scapular protraction/depression.
- Scapular upward and downward rotation.
- Open-Chain Stabilization Exercises for the Shoulder Girdle
- FIGURE 17.42 Stabilization exercises. The patient stabilizes with the shoulder girdle musculature (isometrically) against the resistance imposed by the therapist. Resistance to flexion/extension, abduction/ adduction, and rotation is applied in a rhythmic sequence.
- CLINICAL TIP
- Static Closed-Chain (Weight-Bearing) Stabilization Exercises
- FOCUS ON EVIDENCE
- FIGURE 17.43 Closed-chain scapular and glenohumeral stabilization exercises. (A) Bilateral support in a minimal weight-bearing position with both hands against a wall. (B) Unilateral support on a less stable surface (ball). The therapist applies alternating resistance while the patient stabilizes against the resistance, or the therapist applies resistance as the patient moves from side-to-side.
- Dynamic Closed-Chain Stabilization Exercises
- Dynamic Strengthening Exercises: Scapular Muscles
- FOCUS ON EVIDENCE
- Scapular Retraction (Rhomboids and Middle Trapezius)
- FIGURE 17.44 Scapular retraction against handheld resistance in the prone position.
- Scapular Retraction Combined with Shoulder Horizontal Abduction/Extension (Rhomboids, Middle Trapezius, Posterior Deltoid)
- FIGURE 17.45 Horizontal abduction and scapular retraction exercises, with the arms positioned for maximal resistance from gravity. External rotation of the shoulders (thumbs pointing upward) emphasizes the middle and lower trapezius. To progress the exercise further, weights can be placed in the patient’s hands.
- FIGURE 17.46 Corner press-out to strengthen scapular retraction and shoulder horizontal abduction (view from above).
- Scapular Retraction and Shoulder Horizontal Abduction Combined with External Rotation (Rhomboids, Trapezius, Posterior Deltoid, Infraspinatus, Teres Minor)
- FIGURE 17.47 Combined scapular retraction with shoulder horizontal abduction and external rotation against resistance.
- Scapular Protraction (Serratus Anterior)
- CLINICAL TIP
- FIGURE 17.48 Scapular protraction; pushing against elastic resistance.
- FIGURE 17.49 Push-ups with a “plus” to strengthen scapular protraction.
- CLINICAL TIP
- Scapular Depression (Lower Trapezius, Lower Serratus Anterior)
- FIGURE 17.50 Exercises that emphasize the lower trapezius. (A) Shoulder girdle depression against manual resistance. (B) Closed-chain shoulder girdle depression using body weight for resistance.
- Scapular Upward Rotation with Depression (Lower Trapezius, Serratus Anterior)
- FIGURE 17.51 Scapular depression with upward rotation of the scapula against elastic resistance (also activates the upper and middle trapezius and serratus anterior).
- Dynamic Strengthening Exercises: Glenohumeral Muscles
- FOCUS ON EVIDENCE
- Shoulder External Rotation (Infraspinatus, Teres Minor) VIDEO 17.6.
- FIGURE 17.52 Resisted external rotation with (A) the arm at the side using elastic resistance (B) the arm at 90° using a free weight and the patient lying prone, and
- (C) with the shoulder in scapular plane elevation using a free weight and the patient sitting.
- Shoulder Internal Rotation (Subscapularis)
- FIGURE 17.53 Resisted internal rotation of the shoulder using a handheld weight. To resist external rotation, place the weight in the patient’s upper hand.
- Shoulder Abduction and Elevation of the Arm in Scapular Plane (Deltoid and Supraspinatus)
- FIGURE 17.54 Abduction in the plane of the scapula. This is called the “full can” exercise because the shoulder is held in external rotation as if lifting a full can. (A) Front view. (B) Top view. If the shoulder is held in internal rotation, the exercise is called an “empty can” exercise.
- FOCUS ON EVIDENCE
- Shoulder Flexion (Anterior Deltoid, Rotator Cuff, Serratus Anterior)
- FIGURE 17.55 Military press-up. Beginning with the arm at the side in neutral to slight external rotation with elbow flexed and forearm in mid-position (thumb pointing posteriorly), the weight is lifted overhead.
- Shoulder Adduction (Pectoralis Major, Teres Major, Latissimus Dorsi)
- Shoulder Horizontal Adduction (Anterior Deltoid, Coracobrachialis, Pectoralis Major)
- Shoulder Extension (Posterior Deltoid, Latissimus Dorsi, Rhomboids)
- Elbow Flexion (Biceps Brachii)
- Exercises Using Diagonal (PNF) Movement Patterns VIDEO 17.4.
- Functional Progression for the Shoulder Girdle
- FIGURE 17.56 PNF pattern (D2 flexion), emphasizing shoulder flexion, abduction, and external rotation against elastic resistance.
- Exercises Using Combined Movement Patterns with Functional Activities
- FIGURE 17.57 Simulated rowing motion against elastic resistance.
- FIGURE 17.58 Pushing a weighted cart to simulate a functional activity and incorporate proper body mechanics.
- Equipment
- TABLE 17.7 Exercise Devices and Potential Uses for Shoulder Girdle Rehabilitation
- Integration of Functional Activities
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 18 The Elbow and Forearm Complex
- Structure and Function of the Elbow and Forearm
- Joints of the Elbow and Forearm
- Elbow Joint Characteristics and Arthrokinematics
- FIGURE 18.1 Bones and joints of the elbow and forearm.
- Humeroulnar Articulation
- Characteristics.
- Arthrokinematics.
- BOX 18.1 Summary of Joint Arthrokinematics of the Elbow and Forearm Joints
- Humeroradial Articulation
- Characteristics.
- Arthrokinematics.
- Ligaments of the Elbow
- Medial (ulnar) collateral ligament.
- FIGURE 18.2 (A) The three parts of the medial (ulnar) collateral ligament are shown on the medial aspect of the right elbow. The musculature and joint capsule have been removed to show the ligament’s attachments. (B) The lateral collateral ligament complex includes the lateral (radial) collateral ligament, lateral ulnar collateral ligament, and annular ligament. The musculature and joint capsule have been removed to show the ligaments’ attachments.
- Lateral (radial) collateral ligament.
- Forearm Joint Characteristics and Arthrokinematics
- Proximal (Superior) Radioulnar Articulation
- Characteristics.
- Arthrokinematics.
- Distal (Inferior) Radioulnar Articulation
- Characteristics.
- Arthrokinematics.
- Muscle Function at the Elbow and Forearm
- Primary Actions at the Elbow and Forearm
- Elbow Flexion
- Brachialis.
- Biceps brachii.
- Brachioradialis.
- Elbow Extension
- Triceps brachii.
- Anconeus.
- Forearm Supination
- Supinator.
- Biceps brachii.
- Brachioradialis.
- Forearm Pronation
- Pronator teres.
- Pronator quadratus.
- Relationship of Wrist and Hand Muscles to the Elbow
- Wrist flexor muscles.
- Wrist extensor muscles.
- Referred Pain and Nerve Injury in the Elbow Region
- Common Sources of Referred Pain into the Elbow Region
- Nerve Disorders in the Elbow Region
- Ulnar nerve.
- Radial nerve.
- Median nerve.
- Management of Elbow and Forearm Disorders and Surgeries
- Joint Hypomobility: Nonoperative Management
- Related Pathologies and Etiology of Symptoms
- TABLE 18.1 Elbow and Forearm Pathologies/Surgical Procedures, and Preferred Practice Patterns
- Common Structural and Functional Impairments
- Acute stage.
- Subacute and chronic stages.
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Joint Hypomobility: Management—Protection Phase
- Educate the Patient
- Reduce Effects of Inflammation or Synovial Effusion and Protect the Area
- CLINICAL TIP
- Maintain Soft Tissue and Joint Mobility
- Maintain Integrity and Function of Related Areas
- Joint Hypomobility: Management—Controlled Motion Phase
- Increase Soft Tissue and Joint Mobility
- BOX 18.2 Precautions Following Traumatic Injury to the Elbow
- CLINICAL TIP
- CLINICAL TIP
- CLINICAL TIP
- Improve Joint Tracking of the Elbow
- FIGURE 18.3 Mobilization with movement (MWM) to improve elbow flexion. A lateral glide is applied to the proximal ulna while the patient actively flexes, followed by a passive end-range stretch.
- Improve Muscle Performance and Functional Abilities
- Joint Hypomobility: Management—Return to Function Phase
- Improve Muscle Performance
- Restore Functional Mobility of Joints and Soft Tissues
- Promote Joint Protection
- Joint Surgery and Postoperative Management
- BOX 18.3 Surgical Options for Displaced Fractures of the Radial Head
- Radial Head Excision or Arthroplasty
- Indications for Surgery
- Procedure
- Background
- Selection of procedure.
- Implant designs, materials, and fixation.
- TABLE 18.2 Severity of Elbow Joint Disease and Selection of Surgical Procedure
- Overview of Operative Procedure
- Complications
- Intraoperative complications.
- Postoperative complications.
- Postoperative Management
- Immobilization
- Exercise: Maximum Protection Phase
- Goals and interventions.
- CLINICAL TIP
- Exercise: Moderate and Minimum Protection Phases
- Goals and interventions.
- Resumption of recreational and work-related activities.
- Outcomes
- Total Elbow Arthroplasty
- Indications for Surgery
- Procedure
- Background
- Implant design and selection considerations.
- BOX 18.4 Contraindications to Total Elbow Arthroplasty
- FIGURE 18.4 (A) Anteroposterior and (B) lateral radiographs following placement of a Conrad-Morrey (linked/semiconstrained) total elbow arthroplasty.
- FIGURE 18.5 A linked, semiconstrained design is characterized by varus-valgus and axial rotation tolerances of several degrees at the articulation.
- Materials and fixation.
- Operative Overview
- Complications
- FOCUS ON EVIDENCE
- Intraoperative complications.
- Postoperative complications.
- BOX 18.5 Analysis of Three Potential Complications after Total Elbow Arthroplasty
- Postoperative Management
- Immobilization
- Position.
- Duration.
- Exercise Progression
- TABLE 18.3 Factors That Influence the Progression of Exercise After Total Elbow Arthroplasty
- Exercise: Maximum Protection Phase
- CLINICAL TIP
- Goals and interventions.
- BOX 18.6 Specific Precautions After Total Elbow Arthroplasty
- Exercise: Moderate and Minimum Protection Phases
- Goals and interventions.
- Outcomes
- Pain relief and patient satisfaction.
- ROM and functional use of the upper extremity.
- TEA survival rates.
- Myositis Ossificans
- Etiology of Symptoms
- Management
- Overuse Syndromes: Repetitive Trauma Syndromes
- Related Pathologies
- Lateral Elbow Tendinopathy (Tennis Elbow)
- Medial Elbow Tendinopathy (Golfer’s Elbow)
- Etiology of Symptoms
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Nonoperative Management of Overuse Syndromes: Protection Phase
- Decrease Pain, Inflammation, Edema, or Spasm
- Develop Soft Tissue and Joint Mobility
- Maintain Upper Extremity Function
- Nonoperative Management: Controlled Motion and Return to Function Phases
- Increase Muscle Flexibility and Scar Mobility
- Restore Joint Tracking at the RU Joint
- FIGURE 18.6 MWM for lateral epicondylitis. Lateral glide is applied to the proximal forearm (A) with resistance added to wrist extension, (B) with patient squeezing a ball to bring in the wrist extensors, and (C) with self-treatment.
- Improve Muscle Performance and Function
- FOCUS ON EVIDENCE
- Patient Education
- FOCUS ON EVIDENCE
- Exercise Interventions for the Elbow and Forearm
- Exercise Techniques to Increase Flexibility and Range of Motion
- Manual, Mechanical, and Self-Stretching Techniques
- To Increase Elbow Extension
- CLINICAL TIP
- Mechanical Stretch: Mild Flexion Contracture
- Self-Stretch: Mild Flexion Contracture
- Mechanical Stretch: Dynamic Splinting
- FOCUS ON EVIDENCE
- Manual Stretch: Biceps Brachii
- Mechanical Stretch: Biceps Brachii
- Self-Stretch: Biceps Brachii
- FIGURE 18.7 Self-stretching the biceps brachii musculotendinous unit includes stretching the long head across the shoulder joint (A) supine and (B) standing.
- To Increase Elbow Flexion
- Self-Stretch: Mild Extension Contracture
- Self-Stretch: Long Head of Triceps
- FIGURE 18.8 Self-stretching the triceps brachii musculotendinous unit includes stretching the long head across the shoulder joint.
- To Increase Forearm Pronation and Supination
- Self-Stretch to Increase Pronation
- Self-Stretch to Increase Supination
- FIGURE 18.9 Self-stretching the forearm into supination. It is important that the stretch force is against the radius, not the hand.
- Self-Stretching Techniques: Muscles of the Medial and Lateral Epicondyles
- To Stretch the Wrist Extensor Muscles (From the Lateral Epicondyle)
- FIGURE 18.10 Self-stretching of the muscles of the lateral epicondyle.
- To Stretch the Wrist Flexor Muscles (from the Medial Epicondyle)
- Exercises to Develop and Improve Muscle Performance and Functional Control
- Isometric Exercises
- Multiple-Angle Isometric Exercises
- Angle-Specific Training
- Alternating Isometrics and Rhythmic Stabilization
- Open-Chain Exercises
- Closed-Chain Exercises
- Dynamic Strengthening and Endurance Exercises
- Elbow Flexion
- FIGURE 18.11 Resisting elbow flexion with emphasis on the biceps brachii. The shoulder extends as the elbow flexes with the forearm in supination. This combined action lengthens the proximal portion of the musculotendinous unit across the shoulder while it contracts to move the elbow, thus maintaining a more optimal length-tension relationship through a greater ROM.
- Elbow Extension
- Long Head of Triceps with Elbow Extension
- FIGURE 18.12 Resisting elbow extension, beginning with the long head of the triceps brachii on a stretch.
- Pronation and Supination
- FIGURE 18.13 Mechanical resistance exercise using a small bar with an asymmetrically placed weight for strengthening (A) forearm pronators and (B) supinators. The bar also can be rotated through a downward arc to affect the other half of the range for each muscle by placing the weight on the ulnar side of the hand.
- Wrist Flexion and Extension
- FIGURE 18.14 Resisted wrist extension to strengthen muscles of the lateral epicondyle without the use of grasp.
- FIGURE 18.15 Strengthening the muscles of the lateral epicondyle (wrist extensors) while grasping a handheld weight for resistance.
- FIGURE 18.16 Wrist roller exercise to strengthen grip and develop muscles of the lateral epicondyle. This exercise requires stabilization in the shoulder girdle and elbow muscles. The elbows may be flexed or the forearms supinated to emphasize the elbow flexors or muscles of the medial epicondyle, respectively.
- Functional Progression for the Elbow and Forearm
- Diagonal Patterns
- PNF patterns against manual or mechanical resistance.
- Combined Pulling Motions
- FIGURE 18.17 Bilateral pull-up against elastic resistance.
- FIGURE 18.18 Closed-chain, modified chin-up using top half of body weight for resistance to strengthen the elbow flexors. This exercise may be performed in a bed with an overhead trapeze.
- FIGURE 18.19 Simulation of a “lawn mower pull” for functional strengthening of the upper extremity.
- Combined Pushing Motions
- FIGURE 18.20 Closed-chain strengthening of the triceps. (A) Modified push-up. (B) Seated push-up.
- FIGURE 18.21 Strengthening the triceps with pushing activities. (A) Pushing weighted objects across a table. (B) Depressing a door handle and pushing open a door.
- Plyometric Training (Stretch-Shortening Drills)
- Simulated Functional Tasks and Activities
- FIGURE 18.22 Mechanical resistance exercise using wall pulleys to simulate tennis swings. (A) Backhand stroke. (B) Forehand stroke. (C) Serve.
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 19 The Wrist and Hand
- Structure and Function of the Wrist and Hand
- FIGURE 19.1 Bones of the wrist and hand complex.
- Joints of the Wrist and Hand
- Wrist Joint: Characteristics and Arthrokinematics
- Radiocarpal Joint
- Characteristics.
- Arthrokinematics.
- Midcarpal Joint
- Characteristics.
- Arthrokinematics.
- Hand Joints: Characteristics and Arthrokinematics
- Carpometacarpal Joints of Digits 2 through 5
- Characteristics.
- Arthrokinematics.
- BOX 19.1 Arthrokinematics of the Wrist and Hand Joints
- Carpometacarpal Joint of the Thumb (Digit 1)
- Characteristics.
- Arthrokinematics.
- Metacarpophalangeal Joints of Digits 2–5
- Characteristics.
- Arthrokinematics.
- Interphalangeal Joints and MCP Joint of the Thumb
- Characteristics.
- Arthrokinematics.
- Hand Function
- Muscles of the Wrist and Hand
- TABLE 19.1 Muscles of the Wrist and Hand
- FIGURE 19.2 The extrinsic and intrinsic muscles of the wrist and hand create a balance of forces that affect hand function.
- Length-Tension Relationships
- Extensor Mechanism
- FIGURE 19.3 Anatomical structures of the extensor mechanism: (A) lateral view and (B) dorsal view. See text for description of functional relationships.
- Control of the Unloaded (Free) Hand
- Grips and Prehension Patterns
- Power Grips
- Description.
- Muscle control.
- Precision Patterns
- Description.
- Muscle control.
- Combined Grips
- Description.
- Pinch.
- Major Nerves Subject to Pressure and Trauma at the Wrist and Hand
- Nerve Disorders in the Wrist
- Median nerve.
- Ulnar nerve.
- Referred Pain and Sensory Patterns
- Management of Wrist and Hand Disorders and Surgeries
- Joint Hypomobility: Nonoperative Management
- Common Joint Pathologies and Associated Impairments
- Rheumatoid Arthritis
- Acute stage.
- TABLE 19.2 Wrist and Hand Pathologies/Surgical Procedures and Preferred Practice Patterns
- Advanced stages.
- FIGURE 19.4 Joint deformities seen in the hand of a patient with rheumatoid arthritis. Note the hypertrophy of the IP joints, rheumatoid nodules, and volar subluxation of the triquetrum. This patient had fusion of the wrist joints due to pain and complete destruction of the joints, which has helped prevent the deforming, bowstringing effect of the extrinsic tendons on the MCP joints.
- FIGURE 19.5 (A) Swan-neck and (B) Boutonnière deformities. See text for description of the pathomechanics.
- Degenerative Joint Disease/Osteoarthritis and Posttraumatic Arthrosis
- FIGURE 19.6 Advanced-stage osteoarthritis of the hands of an 86-year-old pianist. Note the carpometacarpal (CMC) joint subluxation at the base of each thumb. Atrophy of the first dorsal interossei, nodules, and joint enlargements are apparent, but the individual is still functional.
- Postimmobilization Hypomobility
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Joint Hypomobility: Management—Protection Phase
- Control Pain and Protect Joints
- Patient education.
- Pain management.
- Splinting.
- Activity modification.
- Maintain Joint and Tendon Mobility and Muscle Integrity
- Passive, assistive, or active ROM.
- Tendon-gliding exercises.
- Multiple-angle muscle setting exercises.
- Joint Hypomobility: Management—Controlled Motion and Return to Function Phases
- BOX 19.2 Joint Protection in the Wrist and Hand
- Increase Joint Play and Accessory Motions
- Joint mobilization techniques.
- Unlock a subluxated ulnomeniscal-triquetral joint.
- FIGURE 19.7 Self-mobilization of the ulnomeniscal-triquetral (UMI) joint.
- Improve Joint Tracking and Pain-Free Motion
- MWM of the wrist.
- FIGURE 19.8 Mobilization with movement (MWM) to increase wrist flexion or extension. Apply a lateral glide while the patient actively flexes or extends the wrist and then applies a passive stretch force with his other hand at the end of the range.
- MWM of the MCP and IP joints of the digits.
- Improve Mobility, Strength, and Function
- CLINICAL TIP
- Neuromuscular control and strength.
- Functional activities.
- Conditioning exercises.
- Joint protection.
- FOCUS ON EVIDENCE
- Joint Surgery and Postoperative Management
- BOX 19.3 Surgical Intervention for RA or DJD of the Wrist and Hand
- General goals.
- Wrist Arthroplasty
- Indications for Surgery
- Procedures
- Implant Design, Materials, and Fixation
- BOX 19.4 Contraindications to Arthroplasty of the Wrist or Digits
- FIGURE 19.9 Total wrist arthroplasty.
- Operative Overview
- Postoperative Management
- Immobilization
- Exercise Progression
- CLINICAL TIP
- Exercise: Maximum and Moderate Protection Phases
- Goals and interventions.
- BOX 19.5 Precautions After Wrist Arthroplasty
- Exercise: Minimum Protection/Return to Function Phase
- Goals and interventions.
- Outcomes
- Pain relief.
- Wrist and forearm ROM, strength, and function.
- Complications.
- Metacarpophalangeal Implant Arthroplasty
- Indications for Surgery
- Procedures
- Implant Design, Materials, and Fixation
- FIGURE 19.10 Lateral view of the three most common silicone-based implants: Neuflex (top), Avanta (middle), Swanson (bottom). Note that the Avanta and Swanson implants are of a 0° bend type.
- Operative Overview
- Postoperative Management
- Immobilization
- Dynamic splinting.
- FIGURE 19.11 A dynamic extension splint with rubber bands attached to a dorsal outrigger used after MCP arthroplasty, permits active MCP flexion, and at rest, maintains the MCP joints in extension and sometimes slight radial deviation.
- Static splinting.
- FOCUS ON EVIDENCE
- Exercise Progression
- CLINICAL TIP
- Exercise: Maximum Protection Phase
- CLINICAL TIP
- Goals and interventions.
- Exercise: Moderate and Minimum Protection Phases
- Goals and interventions.
- Outcomes
- Pain relief and patient satisfaction.
- ROM and hand function.
- Complications.
- Proximal Interphalangeal Implant Arthroplasty
- Indications for Surgery
- Procedure
- Implant Design, Materials, and Fixation
- Operative Overview
- CLINICAL TIP
- TABLE 19.3 Comparison of Surgical Approaches for PIP Joint Arthroplasty
- Postoperative Management
- Immobilization
- Exercise Progression
- TABLE 19.4 Position of Immobilization After PIP Arthroplasty
- Exercise: Maximum and Moderate Protection Phases
- CLINICAL TIP
- Goals and interventions.
- BOX 19.6 Postoperative Guidelines and Precautions after Correction of a Boutonnière Deformity
- BOX 19.7 Postoperative Guidelines and Precautions after Correction of a Swan-Neck Deformity
- Exercise: Minimum Protection/Return to Function Phase
- Outcomes
- Complications.
- Carpometacarpal Arthroplasty of the Thumb
- Indications for Surgery
- Procedures
- Background and Surgical Options
- Operative Overview
- Tendon interposition arthroplasty.
- Surface replacement arthroplasty.
- Postoperative Management
- Immobilization
- Exercise Progression
- Exercise: Maximum Protection Phase
- Goals and interventions.
- BOX 19.8 Precautions after CMC Arthroplasty of the Thumb
- Exercise: Moderate and Minimum Protection Phases
- Goals and interventions.
- Outcomes
- Pain relief and patient satisfaction.
- ROM and hand function.
- Complications.
- Tendon Rupture Associated with RA: Surgical and Postoperative Management
- Background and Indications for Surgery
- Procedures
- Postoperative Management
- Immobilization
- CLINICAL TIP
- Exercise Progression
- Exercise: Maximum Protection Phase
- BOX 19.9 Precautions after Extensor Tendon Transfers or Reconstruction in the Rheumatoid Hand
- Goals and interventions.
- CLINICAL TIP
- Exercise: Moderate and Minimum Protection Phases
- Goals and interventions.
- Outcomes
- Repetitive Trauma Syndromes/Overuse Syndromes
- Tendinopathy
- Etiology of Symptoms
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Management: Protection Phase
- Management: Controlled Motion and Return to Function Phases
- FOCUS ON EVIDENCE
- Traumatic Lesions of the Wrist and Hand
- Simple Sprain: Nonoperative Management
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Management
- Lacerated Flexor Tendons of the Hand: Surgical and Postoperative Management
- Background and Indications for Surgery
- FIGURE 19.12 Flexor tendon zones; volar aspect of the hand and wrist.
- BOX 19.10 Flexor Tendon Zones: Anatomical Landmarks
- Procedures
- Types and Timing of Operative Procedures
- Types of repair or reconstruction.
- BOX 19.11 Consequences of Injury to the Volar Surface of the Hand, Wrist, and Forearm
- Timing of a repair.
- Operative Overview
- Surgical approach.
- Suturing technique.
- CLINICAL TIP
- Closure.
- Postoperative Management
- General considerations.
- BOX 19.12 Factors that Contribute to Adhesion Formation After Tendon Injury and Repair
- Approaches to postoperative management.
- FOCUS ON EVIDENCE
- BOX 19.13 Rationale for Early Controlled Motion After Tendon Repair
- BOX 19.14 Indications for Use of Prolonged Immobilization and Delayed Motion After Flexor Tendon Repair
- Immobilization
- Duration of immobilization.
- Type or method of immobilization.
- Position of immobilization.
- FIGURE 19.13 A dorsal-blocking splint with dynamic traction for early controlled motion after flexor tendon repair.
- Exercise: Early Controlled Motion Approaches
- BOX 19.15 Static and Dynamic Dorsal Blocking Splints: Position and Use
- Early controlled passive motion.
- Early controlled active motion.
- FOCUS ON EVIDENCE
- BOX 19.16 A Sequence of Exercises for Early Active Motion with Progressive Tendon Loading after Flexor Tendon Repair57
- Exercise: Maximum Protection Phase
- FIGURE 19.14 Splinting and exercise for early active motion post-flexor tendon repair. (A) Following removal of the surgical compression dressing and fabrication of a static dorsal-blocking splint, a tenodesis splint with a wrist hinge is fabricated. (B) The tenodesis splint allows full wrist flexion but limits wrist extension to 30°. During early movement of the fingers, the MCP joints are maintained in at least 60° of flexion, as the IP joints are passively moved and placed in composite flexion. (C) Then the patient actively extends the wrist while maintaining the flexed finger position with a static muscle contraction and the least amount of tension possible in the finger flexors.
- FOCUS ON EVIDENCE
- Exercise: Moderate Protection Phase
- Exercise: Minimum Protection/Return to Function Phase
- Exercise: Delayed Motion Approach
- Outcomes
- Functional outcomes.
- Complications.
- Lacerated Extensor Tendons of the Hand: Surgical and Postoperative Management
- Background and Indications for Surgery
- FIGURE 19.15 Extensor tendon zones; dorsal aspect of the hand and wrist.
- BOX 19.17 Extensor Tendon Zones: Anatomic Landmarks
- Procedures
- Types of Repairs and Reconstruction
- Operative Overview
- BOX 19.18 Consequences of Injury to the Dorsal Structures of the Hand and Wrist
- Zone III/IV primary repair.
- Postoperative Management
- General considerations.
- Approaches to postoperative management.
- Immobilization
- Duration of immobilization.
- Types of immobilization.
- Exercise: Early Controlled Active Motion Approach
- CLINICAL TIP
- FOCUS ON EVIDENCE
- Use of customized static volar splints.
- FIGURE 19.16 One of two static volar template splints used during early short-arc exercises of the PIP and DIP joints after repair of the extensor mechanism in zones III/IV. During exercise, the patient actively holds the wrist in approximately 30° of flexion and manually holds the MCP joint in neutral to slight flexion. (A) Using minimal active tension during combined active PIP and DIP flexion, the splint initially limits PIP and DIP flexion to 30° and 20° to 25°, respectively, to prevent excessive stretch of the repair site. (B) The patient actively and slowly extends the PIP and DIP joints to full extension and briefly holds the extended position.
- Exercise progression.
- Exercise: Delayed Mobilization Approach
- BOX 19.19 Special Considerations for Exercise After Extensor Tendon Repair and Extended Immobilization
- Outcomes
- Exercise Interventions for the Wrist and Hand
- Techniques for Musculotendinous Mobility
- Tendon-Gliding and Tendon-Blocking Exercises
- Place-and-Hold Exercises
- Flexor Tendon-Gliding Exercises
- FIGURE 19.17 The five finger positions used for flexor tendon-gliding exercises: (A) straight hand, (B) hook fist (claw fist), (C) full fist, (D) table top (intrinsic plus), and (E) straight fist.
- Hook (Claw) Fist Position
- Full Fist
- Straight Fist (Sublimis Fist)
- Thumb Flexion
- Flexor Tendon-Blocking Exercises
- Isolated MCP Flexion (Lumbricals and Palmar Interossei)
- PIP Flexion (Flexor Digitorum Superficialis)
- DIP Flexion (Flexor Digitorum Profundus)
- Full Fist
- FIGURE 19.18 Flexor tendon blocking exercises: (A) isolated MCP flexion of one digit, (B) isolated PIP flexion (flexor digitorum superficialis) of one digit, and (C) isolated DIP flexion (flexor digitorum profundus) of one digit.
- Exercises to Reduce an Extensor Lag
- Isolated MCP Extension
- Isolated PIP and DIP Extension
- Terminal-Range Extension of IP Joints
- FIGURE 19.19 Terminal extension of the PIP joint. The MCP joint is stabilized in extension, and the patient lifts the middle and distal phalanges off the table.
- Extensor Tendon-Gliding Exercises
- FIGURE 19.20 Differential gliding of the extensor digitorum tendons. Move each digit into flexion while stabilizing the other digits in extension.
- Scar Tissue Mobilization for Tendon Adhesions
- To Mobilize the Long Finger Flexor Tendons
- To Mobilize the Extensor Tendons and the Extensor Mechanism
- Exercise Techniques to Increase Flexibility and Range of Motion
- General Stretching Techniques
- To Increase Wrist Extension
- To Increase Wrist Flexion
- To Increase Flexion or Extension of Individual Joints of the Fingers or Thumb
- Stretching Techniques for the Intrinsic and Multijoint Muscles
- Self-Stretching the Lumbricals and Interossei Muscles
- FIGURE 19.21 Self-stretching (A) the lumbricals with MCP extension and IP flexion and (B) the adductor pollicis with CMC abduction of the thumb. To increase thumb abduction, it is critical the stretch force is applied against the metacarpal head, not the proximal or distal phalanges.
- Self-Stretching the Interossei Muscles
- Self-Stretching the Adductor Pollicis
- Manual Stretching of the Extrinsic Muscles
- Self-Stretching the Flexor Digitorum Profundus and Superficialis
- FIGURE 19.22 Self-stretching of the extrinsic finger flexor muscles, showing stabilization of the small distal joints. To isolate stretch to the wrist flexors, allow the fingers to flex over the edge of the table.
- Self-Stretching the Extensor Digitorum Communis
- Exercises to Develop and Improve Muscle Performance, Neuromuscular Control, and Coordinated Movement
- Techniques to Strengthen Muscles of the Wrist and Hand
- To Strengthen Wrist Musculature
- Wrist Flexion (Flexor Carpi Ulnaris and Radialis) and Extension (Extensor Carpi Radialis Longus and Brevis and Extensor Carpi Ulnaris)
- FIGURE 19.23 Mechanical resistance to strengthen wrist extension. Note that the forearm is pronated. To resist wrist flexion, the forearm is supinated.
- Wrist Radial Deviation (Flexor and Extensor Carpi Radialis Muscles and Abductor Pollicis Longus) and Ulnar Deviation (Flexor and Extensor Carpi Ulnaris Muscles)
- FIGURE 19.24 Mechanical resistance to strengthen (A) radial deviation and (B) ulnar deviation of the wrist using a weighted bar.
- Functional Progression for the Wrist
- CLINICAL TIP
- To Strengthen Weak Intrinsic Musculature
- MCP Joint Flexion with IP Joint Extension (Lumbricals)
- FIGURE 19.25 To strengthen intrinsic muscle function for combined MCP flexion and IP extension, the patient begins with (A) MCP extension and IP flexion and (B) pushes his fingertips outward. The same motion is resisted by (C) pushing the fingertips against the palm of the other hand.
- Isolated or Combined Abduction/Adduction of Each Finger (Dorsal and Volar Interossei)
- Abduction of the Thumb (Abductor Pollicis Brevis and Longus)
- Opposition of the Thumb (Opponens Pollicis)
- To Strengthen Weak Extrinsic Muscles of the Fingers
- Metacarpophalangeal Extension (Extensor Digitorum Communis, Indicis, and Digiti Minimi)
- Interphalangeal Flexion (Flexor Digitorum Profundus and Superficialis)
- FIGURE 19.26 Self-resistance to strengthen extrinsic finger flexor muscles.
- Mechanical Resistance Techniques for Combined Intrinsic and Extrinsic Muscle Function
- Towel or Newspaper Crumple
- Disk Weight Resistance
- Other Resistance Aids
- Dexterity and Functional Activities
- Fine-Finger Dexterity
- Functional Activities
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 20 The Hip
- Structure and Function of the Hip
- FIGURE 20.1 Bones and joints of the pelvis and hip.
- Anatomical Characteristics of the Hip Region
- Boney Structures
- The Pelvis
- The Femur
- Hip Joint Characteristics and Arthrokinematics
- Characteristics
- Articular Surfaces
- Ligaments
- FIGURE 20.2 Ligaments supporting the hip joint. (A) Anterior view. (B) Posterior view.
- Arthrokinematics of the Hip Joint
- Motions of the femur.
- BOX 20.1 Summary of Arthrokinematics of the Femoral Head in the Hip Joint
- Motions of the pelvis.
- Influence of the Hip Joint on Balance and Posture Control
- Functional Relationships in the Hip Region
- Motions of the Femur and Muscle Function
- Motions of the Pelvis and Muscle Function
- TABLE 20.1 Muscles of the Hip: Open-Chain (Nonweight-Bearing) Function
- FIGURE 20.3 (A) Neutral position of the pelvis. (B) Anterior pelvic tilt. (C) Posterior pelvic tilt. With anterior pelvic tilt, the decreased angle between the pelvis and femur results in hip flexion, and with posterior pelvic tilt, the increased angle results in hip extension.
- Anterior Pelvic Tilt
- Posterior Pelvic Tilt
- Pelvic Shifting
- Lateral Pelvic Tilt
- Pelvic Rotation
- FIGURE 20.4 (A) Lateral pelvic tilt. Elevation of the iliac crest (hip liking) causes relative adduction of the hip on the elevated side, and lowering of the iliac crest (hip drop) causes relative abduction of the hip on the lower side. (B) Pelvic rotation. Forward motion (forward rotation) of the pelvis causes relative external rotation of the hip; and backward motion (posterior rotation) of the pelvis causes relative internal rotation of the hip.
- Pelvifemoral Motion
- Hip, Knee, and Ankle Functional Relationships in Weight Bearing
- Hip flexion/extension.
- Hip abduction/adduction.
- Hip rotation.
- Pathomechanics in the Hip Region
- Decreased Flexibility
- Muscle Weakness
- Patellofemoral impairment.
- Anterior cruciate ligament strain.
- Piriformis syndrome.
- Hip Muscle Imbalances and Their Effects
- BOX 20.2 Hip Muscle Imbalances Related to Postural Impairments
- Shortened tensor fasciae latae (TFL) and/or gluteus maximus.
- Dominance of the TFL over the gluteus medius.
- Dominance of the two-joint hip flexor muscles over the iliopsoas.
- Dominance of hamstring muscles over the gluteus maximus.
- Use of lateral trunk muscles for hip abductors.
- Asymmetrical Leg Length
- Unilateral short leg.
- Coxa valga and coxa vara.
- Anteversion and retroversion.
- The Hip and Gait
- Hip Muscle Function and Gait
- Hip Flexors
- Hip Extensors
- Hip Abductors
- Effect of Musculoskeletal Impairments on Gait
- Referred Pain and Nerve Injury
- Major Nerves Subject to Injury or Entrapment
- Sciatic nerve.
- Obturator nerve.
- Femoral nerve.
- Common Sources of Referred Pain in the Hip and Buttocks Region
- Management of Hip Disorders and Surgeries
- Joint Hypomobility: Nonoperative Management
- Related Pathologies and Etiology of Symptoms
- TABLE 20.2 Hip Pathologies and Related Preferred Practice Patterns
- Osteoarthritis (Degenerative Joint Disease)
- Postimmobilization Hypomobility
- Common Structural and Functional Impairments
- FOCUS ON EVIDENCE
- BOX 20.3 Clinical Prediction Rule for the Diagnosis of Osteoarthritis of the Hip139
- Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
- Early stages.
- Progressive degeneration.
- CLINICAL TIP
- Management: Protection Phase
- Provide Patient Education
- Decrease Pain at Rest
- Decrease Pain During Weight-Bearing Activities
- Decrease Effects of Stiffness and Maintain Available Motion
- Management: Controlled Motion and Return to Function Phases
- Progressively Increase Joint Play and Soft Tissue Mobility
- Joint mobilization techniques.31
- Stretching techniques.
- Improve Joint Tracking and Pain-Free Motion
- Increase Internal Rotation
- Increase Flexion
- FIGURE 20.5 Mobilization with movement using an inferolateral glide increasing (A) pain-free internal rotation, (B) pain-free flexion, (C) pain-free extension, and (D) extension during weight bearing.
- Increase Extension
- Increase Extension During Weight Bearing
- Improve Muscle Performance in Supporting Muscles, Balance, and Aerobic Capacity
- Provide Patient Education
- FOCUS ON EVIDENCE
- Joint Surgery and Postoperative Management
- Total Hip Arthroplasty
- FIGURE 20.6 Total hip arthroplasty. (A) The preoperative film of a severely degenerative hip joint demonstrates the classic signs of degenerative joint disease. A, N; B arrowed, joint space with superior migration of the femoral head; B, osteophyte formation at the joint margins of both the acetabulum and femoral head; C, sclerosis of subchondral bone on both sides of the joint surface; D, acetabular protrusion (a boney outpouching of the acetabular cup in response to the progressive superior and medial migration of the femoral head). (B) Postoperative film shows a total hip arthroplasty. Both the acetabular and femoral portions of the joint have been resected and replaced with prosthetic components.
- Indications for Surgery
- BOX 20.4 Contraindications to Total Hip Arthroplasty
- Preoperative Management
- FOCUS ON EVIDENCE
- BOX 20.5 Components of Therapy-Related Preoperative Management: Preparation for Total Hip Arthroplasty
- Procedures
- Background
- Prosthetic designs and materials.
- Cemented versus cementless fixation.
- Operative Overview
- Traditional surgical approaches.
- TABLE 20.3 Features of Traditional (Conventional) Surgical Approaches for THA and Potential Impact on Postoperative Function
- BOX 20.6 Features of Minimally Invasive Total Hip Arthroplasty
- Minimally invasive approaches.
- Implantation of components and closure.
- CLINICAL TIP
- Complications
- Intraoperative complications.
- Early postoperative complications.
- Late complications.
- Dislocation: a closer look.
- Leg length inequality: a closer look.
- Postoperative Management
- Immobilization
- Weight-Bearing Considerations
- TABLE 20.4 Risk Factors Contributing to Joint Dislocation after Total Hip Arthroplasty
- BOX 20.7 Early Postoperative Weight-Bearing Restrictions After Total Hip Arthroplasty
- FOCUS ON EVIDENCE
- Exercise Progression and Functional Training
- FOCUS ON EVIDENCE
- Accelerated Rehabilitation
- Exercise: Maximum Protection Phase After Traditional THA
- Goals and interventions.
- CLINICAL TIP
- BOX 20.8 Early Postoperative Motion Precautions After Total Hip Arthroplasty*
- Criteria to progress.
- Exercise: Moderate Protection Phase After Traditional THA
- Goals and interventions.
- FOCUS ON EVIDENCE
- Criteria to progress.
- Exercise: Minimum Protection Phase and Resumption of Full Activity
- Extended rehabilitation and modification of activities.
- CLINICAL TIP
- Return to sport activities.
- Outcomes
- Pain relief, patient satisfaction, and quality of life.
- Physical functioning.
- TABLE 20.5 Guidelines for Participation in Sport, Recreational, and Fitness Activities Following THA69
- Implant design, fixation, and surgical approach.
- Impact of rehabilitation.
- Hemiarthroplasty of the Hip
- Indications for Surgery
- Procedures
- Background.
- Operative procedure.
- Postoperative Management
- Outcomes
- Hip Fractures: Surgical and Postoperative Management
- Hip Fracture: Incidence, Risk Factors, and Impact on Function
- Sites and Types of Hip Fracture
- FIGURE 20.7 Fractures of the proximal femur are broadly divided into intracapsular and extracapsular sites.
- BOX 20.9 Common Sites and Types of Hip Fracture
- Open Reduction and Internal Fixation of Hip Fracture
- Indications for Surgery
- FIGURE 20.8 Reduction and internal fixation of a complete fracture of the femoral neck. Restoration of alignment and good compression is obtained via fixation with three compression screws. The black arrows mark the extent of the fracture line.
- FIGURE 20.9 Intertrochanteric fracture of the hip. This postoperative image shows fracture fixation via a side plate and screw combination device. The fracture line is evident, extending through the intertrochanteric region to the proximal femoral shaft. Some comminution is evident, and a large fragment on the medial shaft is noted. The imposed added densities of soft tissue are seen.
- Procedures
- Types of fixation and surgical approach.
- Postoperative Management
- Weight-Bearing Considerations
- FOCUS ON EVIDENCE
- Exercise and Functional Training
- BOX 20.10 Signs and Symptoms of Possible Failure of the Internal Fixation Mechanism
- BOX 20.11 Special Considerations for Exercise and Gait After Internal Fixation of Fractures of the Proximal Femur
- Exercise: Maximum Protection Phase
- FOCUS ON EVIDENCE
- Goals and interventions.
- Exercise: Moderate and Minimum Protection Phases
- Extended exercise programs after surgery for hip fracture.
- CLINICAL TIP
- Goals and interventions.
- TABLE 20.6 Summary of Studies of Extended Exercise Programs Following Surgery for Hip Fracture
- Outcomes
- General outcomes.
- Impact of rehabilitation.
- Painful Hip Syndromes: Nonoperative Management
- Related Pathologies and Etiology of Symptoms
- Musculotendinous Factors
- Tendinopathies and muscle strains.
- Repetitive trauma.
- Bursitis
- Trochanteric bursitis.
- Psoas bursitis.
- Ischiogluteal bursitis (Tailor’s or Weaver’s Bottom).
- Femoroacetabular Impingement (FAI)
- CLINICAL TIP
- Common Structural and Functional Impairments
- Pain.
- Gait deviations.
- Imbalance in muscle flexibility and neuromuscular control.
- Decreased muscular endurance.
- Management: Protection Phase
- Control Inflammation and Promote Healing
- Develop Support in Related Areas
- Management: Controlled Motion Phase
- Develop a Strong Mobile Scar and Regain Flexibility
- Develop a Balance in Length and Strength of the Hip Muscles
- CLINICAL TIP
- Develop Muscle and Cardiopulmonary Endurance
- Patient Education
- Management: Return to Function Phase
- Exercise Interventions for the Hip Region
- Exercise Techniques to Increase Flexibility and Range of Motion
- Techniques to Stretch Range-Limiting Hip Structures
- To Increase Hip Extension
- Prone Press-Up
- “Thomas Test” Stretch
- FIGURE 20.10 Self-stretching to increase hip extension. The pelvis is stabilized by holding the opposite hip in flexion. The weight of the thigh provides a stretch force as the patient relaxes. Allowing the knee to extend emphasizes the one-joint hip flexors (iliopsoas), whereas maintaining the knee in flexion and hip neutral to rotation as the thigh is lowered emphasizes the two joint rectus femoris and tensor fasciae latae muscles.
- Modified Fencer Stretch
- Kneeling Fencer Stretch
- FIGURE 20.11 Self-stretching of the hip flexor muscles and soft tissue anterior to the hip using a modified fencer’s squat posture.
- To Increase Hip Flexion
- Bilateral Knee to Chest Stretch
- Unilateral Knee to Chest Stretch
- Quadruped (All Fours) Stretch
- Short-Sitting Stretch
- FIGURE 20.12 Gluteus maximus self-stretch with lumbar spine stabilization. (A) The patient on all fours rocks into an anterior pelvic tilt, causing lumbar extension. (B) While maintaining lumbar extension, the patient shifts the buttocks back, attempting to sit on the heels. When lordosis can no longer be maintained, the end-range of hip flexion is reached; this position is held for the stretch.
- To Increase Hip Abduction
- FIGURE 20.13 Self-stretching of the adductor muscles with the hips at 90° of flexion.
- To Increase Hip Abduction and External Rotation Simultaneously
- FIGURE 20.14 Self-stretching to increase hip abduction and external rotation using the figure-4 position.
- To Increase Hip Internal Rotation
- FIGURE 20.15 Self-stretching to increase internal rotation of the hip.
- Techniques to Stretch Range-Limiting, Two-Joint Muscles
- Rectus Femoris Stretches
- “Thomas Test” Stretch
- Prone Stretch
- Standing Stretch
- FIGURE 20.16 Self-stretching of the rectus femoris while standing. The femur is kept in line with the trunk. Care must be taken to maintain a posterior PT and not arch or twist the back.
- Hamstrings Stretches
- Straight Leg Raising
- Hamstrings Stretch in Doorway
- FIGURE 20.17 Self-stretching of the hamstring muscles. Additional stretch can occur if the person either (A) moves the buttock closer to the door frame or (B) lifts the leg away from the doorframe.
- Hamstrings Stretch on Chair or Table
- Bilateral Toe Touching
- FIGURE 20.18 Self-stretching the hamstring muscles by leaning the trunk toward the extended knee, flexing at the hips.
- Tensor Fasciae Latae and Iliotibial Band Stretches
- Supine Stretch
- FIGURE 20.19 Self-stretching of the tensor fascia latae: supine. Pillows support the spine and pelvis, allowing the hips to extend. The crossed-over foot stabilizes the femur in adduction and external rotation.
- Side-Lying Stretch
- FIGURE 20.20 Self-stretching of the tensor fascia latae: side-lying. (A) The thigh is abducted in the plane of the body; then it is extended and externally rotated, then slowly lowered. Additional stretch occurs by flexing the knee. (B) Progress the intensity of a sustained stretch by pulling the hip into extension with a strap and adding a weight.
- Standing Stretch
- FIGURE 20.21 Self-stretching of the tensor fasciae latae: standing. The pelvis shifts toward the tight side with a slight side bend of the trunk away from the tight side. Increased stretch occurs when the extremity is positioned in external rotation prior to the stretch.
- Exercises to Develop and Improve Muscle Performance and Functional Control
- Open-Chain (Nonweight-Bearing) Exercises
- To Develop Control and Strength of Hip Abduction (Gluteus Medius, Gluteus Minimus, and Tensor Fasciae Latae)
- Supine Abduction
- Side-Lying Abduction
- Standing Abduction
- To Develop Control and Strength of Hip Extension (Gluteus Maximus)
- Gluteal Muscle Setting
- Standing Leg Lifts with Trunk Support
- CLINICAL TIP
- Quadruped Leg Lifts
- FIGURE 20.22 Isolated training and strengthening of the gluteus maximus. Starting in the quadruped position, extend the hip while keeping the knee flexed to rule out use of the hamstring muscles. Do not to extend the hip beyond the available ROM to avoid causing stress to the sacroiliac or lumbar spinal joints.
- CLINICAL TIP
- Standing Extension
- To Develop Control and Strength of Hip External Rotation
- Prone External Rotation: Isometric
- Side-Lying External Rotation: Clam Exercise
- FIG. 20.23 Clam exercises to develop control and initiate antigravity strengthening of the external rotators. Wrap an exercise band around the thighs or add a weight to top leg to increase resistance.
- Side-Lying External Rotation: Progression
- Sitting: External Rotation
- FIGURE 20.24 Strengthening the external rotators in a sitting position with elastic resistance.
- To Develop Control and Strength of Hip Flexion (Iliopsoas and Rectus Femoris)
- Supine Heel Slides
- Standing: Hip and Knee Flexion
- Standing: Straight-Leg Hip Flexion
- To Develop Control and Strength of Hip Adduction
- Side-Lying Adduction
- Standing Adduction
- Closed-Chain (Weight-Bearing) Exercises
- FIGURE 20.25 Training and strengthening the hip adductors. (A) The top leg is stabilized by flexing the hip and resting the foot on the mat while the bottom leg is adducted against gravity. (B) The top leg is isometrically held in abduction while the bottom leg is adducted against gravity.
- Closed-Chain Isometric Exercises
- Alternating Isometrics and Rhythmic Stabilization
- BOX 20.12 EMG Analysis of Selected Weight-Bearing Exercises used to Strengthen Lower Extremity Musculature*
- Stabilization in Single-Leg Stance
- FIGURE 20.26 Closed-chain stabilization and strengthening exercises with elastic resistance around the opposite leg. (A) Resisting extension on the right requires stabilization of the anterior muscles of the left side. (B) Resisting abduction on the right requires stabilization by the left frontal plane muscles. To increase difficulty, the resistance is moved distally onto the leg.
- Closed-Chain Dynamic Exercises
- Hip Hiking/Pelvic Drop
- FOCUS ON EVIDENCE
- FIGURE 20.27 Training the hip abductor and hiker muscles for frontal plane strengthening and stability.
- Bridging
- FIGURE 20.28 Training and strengthening the hip extensor muscles using bridging exercises. Resistance can be added against the pelvis.
- Wall Slides
- FIGURE 20.29 Wall slides/partial squats to develop eccentric control of body weight. (A) The back sliding down a wall, superimposing bilateral arm motion for added resistance. (B) The back rolling a gym ball down the wall, superimposing antagonistic arm motion to develop coordination.
- Partial Squats/Mini-Squats VIDEO 20.1
- FIGURE 20.30 Elastic resistance around thighs is used to activate the hip external rotators and abductors while performing partial squats to develop strength of the hip and knee extensors.
- Single-Limb Deadlift VIDEO 20.1
- FIGURE 20.31 Single-limb deadlift to strengthen the hip extensors and develop control in the knee.
- Step-Ups and Step-Downs
- Partial and Full Lunges
- FIGURE 20.32 Partial lunge with cane assistance to develop balance and control for lowering body weight.
- Functional Progression for the Hip
- BOX 20.13 Summary of Functional Progressions for the Hip
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 21 The Knee
- Structure and Function of the Knee
- FIGURE 21.1 Bones and joints of the knee and leg.
- Joints of the Knee Complex
- Tibiofemoral Joint
- Characteristics.
- FIGURE 21.2 The medial meniscus is attached to the medial collateral, anterior cruciate, and posterior cruciate ligaments. The lateral meniscus is also attached to the posterior cruciate ligament (the joint capsule has been removed for visualization).
- Arthrokinematics.
- Screw-home mechanism.
- BOX 21.1 Summary of Arthrokinematics of the Knee Joint
- Patellofemoral Joint
- Characteristics.
- Mechanics.
- Patellar Function
- Patellar Alignment
- Forces Maintaining Alignment
- Patellar Malalignment and Tracking Problems
- FIGURE 21.3 The Q-angle is the angle formed by the intersection of a line drawn from the center of the patella to the anterosuperior iliac spine and a line drawn from the center of the patella to the tibial tuberosity. These two lines represent the bowstring effect on the patella from the pull of the quadriceps femoris muscle and the patellar tendon. An increased Q-angle is a factor contributing to excessive lateral tracking of the patella.
- Increased Q-angle.
- FOCUS ON EVIDENCE
- Muscle and fascial tightness.
- Hip muscle weakness.
- Lax medial capsular retinaculum or an insufficient VMO muscle.
- Patellar Compression
- Patellar contact.
- Compression forces.
- FIGURE 21.4 The extensor retinaculum is reinforced medially by the transversely oriented medial patellofemoral ligament and the longitudinally oriented medial patellotibial ligament. The lateral patellofemoral ligament and lateral patellotibial ligament help resist an excessive medial glide of the patella.
- Muscle Function
- Knee Extensor Muscle Function
- Closed-chain function.
- Patella.
- Torque.
- Knee Flexor Muscle Function
- Dynamic Stability of the Knee
- The Knee and Gait
- Muscle Control of the Knee During Gait
- Quadriceps.
- Hamstrings.
- Soleus.
- Gastrocnemius.
- Hip and Ankle Impairments
- Hip flexion contractures.
- Length/strength imbalances.
- Foot impairments.
- Referred Pain and Nerve Injuries
- Major Nerves Subject to Injury at the Knee
- Common Sources of Referred Pain
- Management of Knee Disorders and Surgeries
- Joint Hypomobility: Nonoperative Management
- Common Joint Pathologies and Associated Impairments
- Osteoarthritis (Degenerative Joint Disease)
- TABLE 21.1 Knee Pathologies/Surgical Procedures and Preferred Practice Patterns
- FIGURE 21.5 Advanced bilateral, medial compartment degenerative joint disease in the knees of a 52-year-old computer programmer/ analyst who subsequently underwent right total knee arthroplasty.
- FOCUS ON EVIDENCE
- Rheumatoid Arthritis
- Postimmobilization Hypomobility
- Common Structural and Functional Impairments
- Common Activity Limitations and Participation Restrictions (Functional Limitations and Disabilities)
- Joint Hypomobility: Management—Protection Phase
- Control Pain and Protect the Joint
- Patient education.
- Functional adaptations.
- Maintain Soft Tissue and Joint Mobility
- Passive, active-assistive, or active ROM.
- Grade I or II joint distraction and anterior/posterior glides.
- Maintain Muscle Function and Prevent Patellar Adhesions
- Setting exercises.
- Joint Hypomobility: Management—Controlled Motion and Return to Function Phases
- Educate the Patient
- FOCUS ON EVIDENCE
- Decrease Pain from Mechanical Stress
- Increase Joint Play and Range of Motion
- Joint mobilization.
- Stretching techniques.
- Mobilization with movement.
- MWM: Lateral or Medial Glides
- MWM: Internal Tibial Rotation for Flexion—Manual Technique
- FIGURE 21.6 MWM with internal tibial rotation to increase knee flexion.
- MWM: Internal Rotation for Flexion—Self-Treatment
- FIGURE 21.7 Self-treatment using MWM with internal tibial rotation to increase knee flexion.
- Improve Muscle Performance in Supporting Muscles
- Progressive strengthening.
- Muscular endurance training.
- Functional training.
- Improve Cardiopulmonary Endurance
- Outcomes
- Joint Surgery and Postoperative Management
- Repair of Articular Cartilage Defects
- Indications for Surgery
- CLINICAL TIP
- Procedures
- Microfracture.
- Osteochondral autograft transplantation/mosaicplasty.
- Autologous chondrocyte implantation.
- Osteochondral allograft transplantation.
- Other procedures.
- BOX 21.2 Special Considerations and Precautions for Rehabilitation after Articular Cartilage Repair*
- Postoperative Management
- Total Knee Arthroplasty
- Indications for Surgery
- Procedure
- Background
- Types of knee arthroplasty.
- BOX 21.3 Total Knee Arthroplasty: Design, Surgical Approach, Fixation
- FIGURE 21.8 Posterior cruciate-retaining total knee arthroplasty of the right knee with cemented fixation. (A) Anteroposterior view. (B) Lateral view. Preoperative ROM is 0° to 125°; ROM 1 month after surgery is 0° to 120°.
- Surgical approach.
- Fixation.
- Operative Overview
- TABLE 21.2 Features of Standard and Minimally Invasive Surgical Approaches for Total Knee Arthroplasty
- Complications
- Postoperative Management
- TABLE 21.3 Total Knee Arthroplasty: Interventions for Each Phase of Rehabilitation
- Immobilization and Early Motion
- FOCUS ON EVIDENCE
- Weight-Bearing Considerations
- Exercise Progression
- BOX 21.4 Exercise Precautions Following TKA
- Exercise: Maximum Protection Phase
- FOCUS ON EVIDENCE
- Goals and interventions.
- Criteria to progress.
- Exercise: Moderate Protection/Controlled Motion Phase
- Goals and interventions.
- FOCUS ON EVIDENCE
- Criteria to progress.
- Exercise: Minimum Protection/Return to Function Phase
- FOCUS ON EVIDENCE
- Outcomes
- Pain relief.
- ROM.
- Strength and endurance.
- Physical function and activity level.
- BOX 21.5 Recommendations for Participation in Physical Activities Following TKA
- Patellofemoral Dysfunction: Nonoperative Management
- Related Patellofemoral Pathologies
- PF Instability
- PF Pain with Malalignment or Biomechanical Dysfunction
- CLINICAL TIP
- PF Pain Without Malalignment
- Soft tissue lesions.
- Tight medial and lateral retinacula or patellar pressure syndrome.
- Osteochondritis dissecans of the patella or femoral trochlea.
- Traumatic patellar chondromalacia.
- PF osteoarthritis.
- Apophysitis.
- Symptomatic bipartite patella.
- Trauma.
- Etiology of Symptoms
- Consensus on Factors Leading to PF Symptoms
- Local factors.
- Distal factors.
- Proximal factors.
- Common Impairments, Activity Limitations, and Participation Restrictions
- Structural and functional impairments.
- FOCUS ON EVIDENCE
- FIGURE 21.9 Excessive hip adduction and internal rotation (valgus collapse at the knee) during descent from a step.
- Activity limitations and participation restrictions.
- Patellofemoral Symptoms: Management—Protection Phase
- Patellofemoral Symptoms: Management—Controlled Motion and Return to Function Phases
- Patient Education
- Instructions.
- Home exercise program.
- Increase Flexibility of Restricting Tissues
- Patellar mobilization: medial glide.
- Medial tipping of the patella.
- FIGURE 21.10 Medial glide of the patella.
- FIGURE 21.11 Medial tipping of the patella with friction massage along the lateral border.
- Patellar taping.
- FOCUS ON EVIDENCE
- Improve Muscle Performance and Neuromuscular Control
- VMO Emphasis: A Closer Look
- Nonweight-Bearing (Open-Chain) Exercises
- Quadriceps setting (quad sets) in pain-free positions.
- Quad sets with straight-leg raise.
- Progression of resisted isometrics.
- FOCUS ON EVIDENCE
- Short-arc terminal extension.
- Weight-Bearing (Closed-Chain) Exercises
- CLINICAL TIP
- CLINICAL TIP
- Functional Activities
- Modify Biomechanical Stresses
- Outcomes
- Patellar Instability: Surgical and Postoperative Management
- Overview of Surgical Options
- BOX 21.6 Surgical Options for Management of Lateral Patellar Instability and Associated Structural Impairments
- FOCUS ON EVIDENCE
- Proximal Extensor Mechanism Realignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures
- Indications for Surgery
- Procedures
- Background and Operative Overview
- MPFL repair or tightening.
- MPFL reconstruction.
- VMO imbrication (advancement).
- Lateral retinacular release and other concomitant procedures.
- Complications
- Following proximal realignment.
- Following LRR.
- Postoperative Management
- TABLE 21.4 MPFL Repair or Reconstruction: Intervention for Each Phase of Postoperative Rehabilitation
- Immobilization and Weight-Bearing Considerations
- Exercise Progression
- BOX 21.7 Exercise Precautions After Proximal or Distal Realignment of the Extensor Mechanism
- Exercise: Maximum Protection Phase
- Goals and interventions.
- Criteria to progress.
- Exercise: Moderate Protection/Controlled Motion Phase
- Goals and interventions.
- Criteria to progress.
- Exercise: Minimum Protection/Return to Function Phase
- Goals and interventions.
- Outcomes
- Distal Realignment Procedures: Patellar Tendon with Tibial Tubercle Transfer and Related Procedures
- Indications for Surgery
- Procedures
- Background and Operative Overview
- Tibial tubercle transfer (Elmslie-Trillat procedure).
- Anteriorization (elevation) of the tibial tubercle.
- Distal medialization of the patellar tendon.
- Complications
- Postoperative Management
- Immobilization and Weight-bearing Considerations
- Exercise Progression
- Outcomes
- Ligament Injuries: Nonoperative Management
- Mechanisms of Injury
- Anterior Cruciate Ligament
- FIGURE 21.12 Sagittal MRI demonstrating a complete midstructure tear of the anterior cruciate ligament (outlined).
- FIGURE 21.13 The “terrible triad,” a combination of injuries to the medial meniscus (MM), medial collateral ligament (MCL), and anterior cruciate ligament (ACL). (A) Intact ligaments stretched by valgus force. (B) Rupture of the MCL, ACL, and MM.
- Posterior Cruciate Ligament
- FIGURE 21.14 Sagittal MRI demonstrating a rupture of the posterior cruciate ligament seen as an interruption in the cordlike structure (outlined).
- Medial Collateral Ligament
- Lateral Collateral Ligament
- Ligament Injuries in the Female Athlete
- Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)
- Ligament Injuries: Nonoperative Management
- FOCUS ON EVIDENCE
- Nonoperative Management: Maximum Protection Phase
- TABLE 21.5 Nonoperative Management of MCL Injuries: Intervention for Each Phase of Rehabilitation*
- Nonoperative Management: Moderate Protection (Controlled Motion) Through Return to Activity Phases
- Improve Joint Mobility and Protection
- Joint mobility.
- Protective bracing.
- Improve Muscle Performance
- Strength and endurance.
- FOCUS ON EVIDENCE
- Neuromuscular control.
- FOCUS ON EVIDENCE
- Improve Cardiopulmonary Conditioning
- Progress to Functional Training
- Ligament Injuries: Surgical and Postoperative Management
- Background
- General considerations and indications for ligament surgery.
- Types of ligament surgery.
- Grafts: Types, healing characteristics, and fixation.
- FIGURE 21.15 Lateral view of the knee depicting graft placement for ACL reconstruction.
- CLINICAL TIP
- General considerations for rehabilitation.
- CLINICAL TIP
- Anterior Cruciate Ligament Reconstruction
- Indications for Surgery
- BOX 21.8 Relative Contraindications to ACL Reconstruction
- Procedures
- Operative Overview
- Surgical approach, graft selection, and harvesting.
- Graft placement and fixation.
- BOX 21.9 Advantages and Disadvantages/ Complications of the Bone-Patellar Tendon-Bone Autograft
- BOX 21.10 Advantages and Disadvantages/ Complications of the Semitendinosus-Gracilis Autograft
- Complications
- FOCUS ON EVIDENCE
- Postoperative Management
- TABLE 21.6 ACL Reconstruction: Interventions for Accelerated Postoperative Rehabilitation
- Immobilization and Bracing
- Types of postoperative bracing.
- Brace use and initiation and progression of knee ROM.
- CLINICAL TIP
- FOCUS ON EVIDENCE
- Weight-Bearing Considerations
- FOCUS ON EVIDENCE
- Exercise Progression
- Preoperative exercise.
- Postoperative exercise progression.
- BOX 21.11 Exercise Precautions After ACL Reconstruction
- CLINICAL TIP
- Exercise: Maximum Protection Phase
- Goals.
- Interventions.
- CLINICAL TIP
- Criteria to progress to next phase.
- Exercise: Moderate Protection/Controlled Motion Phase
- CLINICAL TIP
- Goals.
- Interventions.
- FOCUS ON EVIDENCE
- Criteria to progress to next phase.
- Exercise: Minimum Protection/Return to Function Phase
- Goals.
- Interventions.
- Return to activity.
- Outcomes
- Graft selection and outcomes.
- Approaches to rehabilitation.
- Functional bracing.
- BOX 21.12 Criteria to Return to High-Demand Activities After ACL Reconstruction
- Posterior Cruciate Ligament Reconstruction
- Indications for Surgery
- Procedures
- Operative Overview
- Complications
- Postoperative Management
- Immobilization, Protective Bracing, and Weight Bearing
- FOCUS ON EVIDENCE
- Exercise Progression
- Exercise: Maximum Protection Phase
- BOX 21.13 Suggested Criteria for Ambulation Without Crutches After PCL Reconstruction
- BOX 21.14 Exercise Precautions After PCL Reconstruction
- Goals.
- Interventions.
- Criteria to progress to next phase.
- Exercise: Moderate and Minimum Protection Phases
- Goals and interventions.
- Meniscus Tears: Nonoperative Management
- Mechanisms of Injury
- Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)
- Management
- FIGURE 21.16 Manipulative reduction of a medial meniscus. Internally and externally rotate the tibia as you flex the hip and knee (not shown); then laterally rotate the tibia and apply a valgus stress at the knee as you extend it. The meniscus may click into place.
- Meniscus Tears: Surgical and Postoperative Management
- FIGURE 21.17 Vascularity of the medial and lateral menisci. The peripheral zone (outer one-third) is highly vascular; the central one-third is relatively avascular; and the inner one-third is avascular.
- Meniscus Repair
- Indications for Surgery
- Procedure
- Operative Overview
- Complications
- Postoperative Management
- BOX 21.15 Factors Influencing the Progression of Rehabilitation After Meniscus Repair
- Immobilization, Protective Bracing, and Weight Bearing
- Immobilization and protective bracing.
- Weight bearing.
- BOX 21.16 Exercise Precautions After Meniscus Repair*
- FOCUS ON EVIDENCE
- Exercise: Maximum Protection Phase
- Goals.
- Interventions.
- Criteria to progress to next phase.
- Exercise: Moderate Protection/Controlled Motion Phase
- Goals.
- Interventions.
- Criteria to progress to next phase.
- Exercise: Minimum Protection/Return to Function Phase
- Goals.
- Interventions.
- Outcomes
- Partial Meniscectomy
- Indications for Surgery
- Procedure
- Postoperative Management
- Immobilization and Weight Bearing
- Exercise: Maximum and Moderate Protection Phases
- Goals.
- Interventions.
- Exercise: Minimum Protection/Return to Function Phase
- Exercise Interventions for the Knee
- Exercise Techniques to Increase Flexibility and Range of Motion
- To Increase Knee Extension
- PNF Stretching Techniques
- Gravity-Assisted Passive Stretching Techniques
- Prone Hang
- Supine Heel Prop
- FIGURE 21.18 Heel prop in supine to increase knee extension. A cuff weight or sandbag placed across the distal femur increases the stretch force.
- Self-Stretching Technique
- To Increase Knee Flexion
- PNF Stretching Techniques
- Gravity-Assisted Passive Stretching Technique
- Self-Stretching Techniques
- Gravity-Assisted Supine Wall Slides
- FIGURE 21.19 Gravity-assisted supine wall slide. The patient flexes the knee to the limit of its range and holds it there for a sustained stretch to the quadriceps femoris muscle.
- Self-Stretch with Uninvolved Leg
- Rocking Forward on a Step
- FIGURE 21.20 Self-stretching on a step to increase knee flexion. The patient places the foot of the involved side on a step, then rocks forward over the stabilized foot to the limit of knee flexion to stretch the quadriceps femoris muscle. A higher step is used for greater flexion.
- Sitting
- FIGURE 21.21 Self-stretching in a chair to increase knee flexion. The patient fixates the foot of the involved leg on the floor and then moves forward in the chair over the stabilized foot to place a sustained stretch on the quadriceps femoris muscle and increase knee flexion.
- To Increase Mobility of the IT Band at the Knee
- Foam Roller Fascial Release
- FIGURE 21.22 Foam roller fascial release for a tight IT band.
- Exercises to Develop and Improve Muscle Performance and Functional Control
- TABLE 21.7 Comparison of Forces and Muscle Action at the Knee During Dynamic Open-Chain and Closed-Chain Exercises 67,299
- Open-Chain (Nonweight-Bearing) Exercises
- To Develop Control and Strength of Knee Extension (Quadriceps Femoris)
- Quadriceps Setting (Quad Sets)
- CLINICAL TIP
- Straight-Leg Raise
- CLINICAL TIP
- FOCUS ON EVIDENCE
- Straight-Leg Lowering
- Multiple-Angle Isometric Exercises
- Short-Arc Terminal Knee Extension
- CLINICAL TIP
- FIGURE 21.23 Short-arc terminal extension exercise to strengthen the quadriceps femoris muscle. When tolerated, resistance is added proximal to the ankle.
- Full-Arc Extension
- CLINICAL TIP
- To Develop Control and Strength of Knee Flexion (Hamstrings)
- Hamstring Setting (Hamstring Sets)
- Multiple-Angle Isometric Exercises
- Hamstring Curls
- FIGURE 21.24 Hamstring curls; resistance exercises to the knee flexors with the patient standing. Maximal resistance occurs when the knee is at 90°.
- Closed-Chain (Weight-Bearing) Exercises
- Initiation of closed-chain exercises.
- Partial weight-bearing and support techniques.
- CLINICAL TIP
- Closed-Chain Isometric Exercises
- Setting Exercises for Co-Contraction
- Alternating Isometrics and Rhythmic Stabilization
- Closed-Chain Isometrics Against Elastic Resistance
- Closed-Chain Dynamic Exercises
- Scooting on a Wheeled Stool
- FIGURE 21.25 Forward scooting on a wheeled stool to strengthen knee flexors and backward scooting to strengthen knee extensors.
- Unilateral Closed-Chain Terminal Knee Extension
- FIGURE 21.26 Unilateral closed-chain terminal knee extension.
- Partial Squats, Minisquats, and Short-Arc Training
- FIGURE 21.27 Resisted minisquats using elastic resistance; closed-chain short-arc training in (A) bilateral stance and (B) unilateral stance.
- Standing Wall Slides
- Forward, Backward, and Lateral Step-Ups and Step-Downs VIDEO 21.1
- Partial and Full Lunges
- FIGURE 21.28 (A) A forward step-up with manual pressure applied to the lateral thigh to reinforce proper lower extremity alignment and stimulate the gluteus medius. (B) Resisted step-ups against elastic resistance or a pulley to strengthen knee extensors.
- Functional Progression for the Knee
- Strength and Muscle Endurance Training
- Cardiopulmonary Endurance Training
- Balance and Proprioceptive Activities (Perturbation Training)
- Plyometric Training and Agility Drills
- Simulated Work-Related Activities and Sport-Specific Drills
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 22 The Ankle and Foot
- Structure and Function of the Ankle and Foot
- FIGURE 22.1 Bones of the ankle and foot. (A) Anterior view of the lower leg and ankle, (B) medial view, and (C) lateral view of the ankle and foot.
- Structural Relationships and Motions
- Anatomical Characteristics
- Leg
- Foot
- Hindfoot.
- Midfoot.
- Forefoot.
- Motions of the Foot and Ankle Defined
- Primary Plane Motions
- Sagittal plane motion around a frontal (coronal axis).
- Frontal plane motion around a sagittal (anteroposterior) axis.
- Transverse plane motion around a vertical axis.
- Triplanar Motion
- Pronation.
- Supination.
- Joint Characteristics and Arthrokinematics: Leg, Ankle, and Foot
- Tibiofibular Joints
- Superior tibiofibular joint characteristics.
- Inferior tibiofibular joint characteristics.
- Accessory motions.
- Ankle (Talocrural) Joint
- Characteristics.
- CLINICAL TIP
- Arthrokinematics.
- FIGURE 22.2 Ligaments of the ankle and foot. (A) Medial view, (B) lateral view, and (C) posterior (cross-sectional) view.
- BOX 22.1 Arthrokinematics of the Ankle and Foot Joints
- Subtalar (Talocalcaneal) Joint
- Characteristics.
- Arthrokinematics.
- Talonavicular Joint
- Characteristics.
- Arthrokinematics.
- Transverse Tarsal Joint
- Characteristics.
- Arthrokinematics.
- Remaining Intertarsal and Tarsometatarsal Joints
- Metatarsophalangeal and Interphalangeal Joints of the Toes
- Function of the Ankle and Foot
- Structural Relationships
- Interdependence of leg and foot motions.
- Arches.
- Effect on posture.
- Abnormal foot postures.
- Muscle Function in the Ankle and Foot
- Plantarflexors.
- Secondary plantarflexors.
- Dorsiflexors.
- Intrinsic muscles.
- Stability in standing.
- The Ankle/Foot Complex and Gait
- Function of the Ankle and Foot Joints During Gait
- Muscle Control of the Ankle and Foot During Gait
- Ankle dorsiflexors.
- Ankle plantarflexors.
- Ankle evertors.
- Ankle inverters.
- Intrinsic muscles.
- Referred Pain and Nerve Injury
- Major Nerves Subject to Pressure and Trauma
- Common fibular (perineal) nerve.
- Posterior tibial nerve.
- Plantar and calcaneal nerves.
- Common Sources of Segmental Sensory Reference in the Foot
- Management of Foot and Ankle Disorders and Surgeries
- Joint Hypomobility: Nonoperative Management
- Common Joint Pathologies and Etiology of Symptoms
- TABLE 22.1 Foot and Ankle Pathologies/Surgical Procedures and Preferred Practice Patterns
- RA.
- DJD and joint trauma.
- Postimmobilization stiffness.
- Gout.
- Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)
- BOX 22.2 Common Arthritis-Related Forefoot Deformities
- Joint Hypomobility: Management—Protection Phase
- Educate the Patient and Provide Joint Protection
- Decrease Pain
- FOCUS ON EVIDENCE
- Maintain Joint and Soft Tissue Mobility and Muscle Integrity
- Joint Hypomobility: Management—Controlled Motion and Return to Function Phases
- Increase Joint Play and Accessory Motions
- Joint mobilization techniques.
- CLINICAL TIP
- Improve Joint Tracking of the Talocrural Joint
- MWM: Plantarflexion
- FIGURE 22.3 Mobilization with movement (MWM) to increase ankle plantarflexion. Maintain a posterior glide of the tibia while moving the talus into plantarflexion. This should not cause pain.
- MWM: Dorsiflexion
- FIGURE 22.4 MWM to increase ankle dorsiflexion. Maintain an anterior glide of the tibia with the mobilization belt while the patient lunges forward to move the ankle into dorsiflexion. This should not cause pain.
- Increase Mobility of Soft Tissues and Muscles
- Regain Balance in Muscle Strength and Prepare for Functional Activities
- CLINICAL TIP
- Improve Balance and Proprioception
- Develop Cardiopulmonary Fitness
- Joint Surgery and Postoperative Management
- FIGURE 22.5 Late-stage arthritis of the ankle. (A) Mortise view of the ankle shows severe loss of the normal joint space and partial erosion of the lateral tibia. (B) Lateral view shows tibial erosion with mild joint space loss in the subtalar region and significant osteophyte formation in the anterior ankle.
- BOX 22.3 Surgical Interventions for Early- and Late-Stage Ankle or Foot Arthritis and Joint Deformity
- Total Ankle Arthroplasty
- Indications for Surgery
- Contraindications
- Procedure
- Implant Design, Materials, and Fixation
- FIGURE 22.6 Total ankle arthroplasty. Lateral view of a total ankle replacement in a 78-year-old woman, one year after surgery for post-traumatic arthritis.
- Operative Overview
- Complications
- BOX 22.4 Complications of Total Ankle Arthroplasty
- Postoperative Management
- Immobilization and Weight-Bearing Considerations
- Immobilization.
- Weight-bearing considerations.
- Exercise: Maximum Protection Phase
- Goal and interventions.
- Exercise: Moderate and Minimum Protection Phases
- CLINICAL TIP
- Goals and interventions.
- CLINICAL TIP
- Return to fitness and sports activities.
- Outcomes
- Pain relief, functional improvement, and patient satisfaction in different populations.
- Participation in physical activities.
- Arthrodesis of the Ankle and Foot
- Indications for Surgery
- Procedures
- Common Types of Arthrodesis
- Arthrodesis of the ankle.
- FOCUS ON EVIDENCE
- Arthrodesis of the hindfoot.
- Arthrodesis of the first toe.
- Arthrodesis of the IP joints of the toes.
- Complications
- Postoperative Management
- Immobilization.
- Weight-bearing considerations.
- FOCUS ON EVIDENCE
- Postoperative exercises.
- Return to physical activities.
- Outcomes
- Long-term outcomes.
- Leg, Heel, and Foot Pain: Nonoperative Management
- Related Pathologies and Etiology of Symptoms
- Heel Pain
- Plantar fasciitis.
- Achilles tendinopathy (Achilles tendinitis/Achilles bursitis).
- Tendinosis, Tendonitis, and Tenosynovitis
- Shin Splints
- Anterior shin splints.
- Posterior shin splints.
- Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)
- Leg, Heel, Foot Pain: Management—Protection Phase
- Leg, Heel, Foot Pain: Management—Controlled Motion and Return to Function Phases
- FOCUS ON EVIDENCE
- Educate the Patient and Provide Home Exercises
- Stretch Range-Limiting Structures
- CLINICAL TIP
- Improve Muscle Performance
- Ligamentous Injuries: Nonoperative Management
- Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)
- FOCUS ON EVIDENCE
- Acute Ankle Sprain: Management—Protection Phase
- FOCUS ON EVIDENCE
- Ankle Sprain: Management—Controlled Motion Phase
- Ankle Sprain: Management—Return to Function Phase
- FOCUS ON EVIDENCE
- Traumatic Soft Tissue Injuries: Surgical and Postoperative Management
- Repair of Complete Lateral Ankle Ligament Tears
- FIGURE 22.7 A complete tear of the lateral collateral ligament complex as the result of a severe (grade 3) inversion injury of the ankle.
- Indications for Surgery
- Procedures
- Types of Stabilization Procedures
- FIGURE 22.8 Lateral view of the ankle depicting reconstruction of torn ATF and CF ligaments using a tendon graft to augment stability. Proximal advancement and suturing of the extensor retinaculum (not shown) over the reconstructed ligaments to the distal fibula provide additional stability.
- Direct repair.
- Reconstruction with augmentation.
- Arthroscopic thermally assisted capsular shift.
- Operative Overview
- Postoperative Management
- Immobilization and Weight-Bearing Considerations
- Immobilization.
- Weight-bearing considerations.
- Exercise: Maximum Protection Phase
- Goals and interventions.
- Exercise: Moderate and Minimum Protection Phases
- CLINICAL TIP
- Goals and interventions.
- CLINICAL TIP
- FOCUS ON EVIDENCE
- Outcomes
- BOX 22.5 Activity-Related Precautions to Reduce the Risk of Re-injury After Lateral Ligament Reconstruction of the Ankle
- Repair of a Ruptured Achilles Tendon
- Indications for Surgery
- Procedures
- Primary versus Delayed Repair
- Operative Overview
- Primary repair.
- Delayed repair/reconstruction.
- Complications
- BOX 22.6 Complications Following Primary Repair of a Ruptured Achilles Tendon
- Postoperative Management
- TABLE 22.2 Conventional Postoperative Management After Achilles Tendon Repair or Reconstruction with Graft*
- Immobilization and Weight-Bearing Considerations: Conventional versus Early Remobilization Approaches
- Conventional approach.
- Early remobilization and weight-bearing approach.
- BOX 22.7 Features of Early Weight-bearing and Remobilization Programs After Repair of Acute Achilles Tendon Rupture*
- FOCUS ON EVIDENCE
- Exercise Progression
- Exercise: Maximum Protection Phase
- Goals and interventions.
- Exercise: Moderate Protection Phase
- Goals and interventions.
- BOX 22.8 Precautions and Guidelines for Exercise and Functional Activities Following Achilles Tendon Repair*
- CLINICAL TIP
- Exercise: Minimum Protection/Return to Function Phase
- Outcomes
- Nonoperative versus operative management.
- Open versus percutaneous repair.
- Traditional versus accelerated rehabilitation.
- Exercise Interventions for the Ankle and Foot
- Exercise Techniques to Increase Flexibility and Range of Motion
- Flexibility Exercises for the Ankle Region
- Increase Dorsiflexion of the Ankle
- FOCUS ON EVIDENCE
- FIGURE 22.9 Self-stretching the ankle to increase dorsiflexion (stretching the gastrocnemius muscle).
- Increase Inversion
- FIGURE 22.10 Self-stretching the foot into inversion by pulling on the towel on the medial side of the foot.
- Increase Ankle Plantarflexion and Eversion
- Increase Eversion and Ankle Dorsiflexion
- Flexibility Exercises for Limited Mobility of the Toes
- Passive MTP Flexion
- Passive IP Extension
- Active MTP Flexion
- Great Toe Extension
- Stretching the Plantar Fascia of the Foot
- Exercises to Develop and Improve Muscle Performance and Functional Control
- Exercises to Develop Dynamic Neuromuscular Control
- FIGURE 22.11 Using a rocker board to develop control of ankle motions with the patient sitting. When both feet are on the board, the normal foot can assist the involved side. With only the involved foot on the board, the activity is more difficult.
- Open-Chain (Nonweight-Bearing) Strengthening Exercises
- Plantarflexion
- FIGURE 22.12 Resisting the ankle plantarflexor muscles with an elasticized material.
- Isometric Eversion and Inversion
- Eversion and Inversion with Elastic Resistance
- FIGURE 22.13 Resisting the evertor muscles of the foot with an elasticized material.
- Adduction with Inversion and Abduction with Eversion Using Weights
- FIGURE 22.14 Resisting adduction and inversion with a weight on the end of the towel. The heel is kept stationary while a windshield wiper motion of the foot is used to pull the towel along the floor. Abduction with eversion is resisted by placing the weight on the towel on the medial side of the foot.
- Dorsiflexion
- FIGURE 22.15 Resisting the ankle dorsiflexor muscles with an elasticized material.
- All Ankle Motions
- Closed-Chain (Weight-Bearing) Exercises
- Stabilization Exercises
- FIGURE 22.16 Stabilization exercises with the patient standing and maintaining balance against the alternating resistance forces from the therapist. The therapist applies force through the rod in backward/ forward, side-to-side, and rotational directions.
- Dynamic Strength Training
- BOX 22.9 A Progression of Heel-Raising/ Lowering Exercises for Calf Muscle Strengthening
- FIGURE 22.17 Eccentric loading of the gastrocnemius-soleus muscle group by performing heel lowering of the affected ankle.
- CLINICAL TIP
- Resisted Walking
- FIGURE 22.18 (A) Starting position for activation of the ankle dorsiflexors of the weight-bearing limb by moving opposite limb forward against resistance of an elastic band; (B) ending position.
- Functional Progression for the Ankle and Foot
- FIGURE 22.19 (A) Starting position for activation of the ankle plantarflexors of the weight-bearing limb by moving opposite limb backward against resistance of an elastic band; (B) ending position.
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- REFERENCES
- CHAPTER 23 Advanced Functional Training
- CLINICAL TIP
- Exercises for Stability and Balance
- Guidelines Revisited
- Joint stability.
- Postural stability and balance.
- CLINICAL TIP
- Advanced Stabilization and Balance Exercises
- Sitting
- TABLE 23.1 Parameters for Progressing Balance Exercises
- Sitting and Reaching
- Sitting with External Perturbations
- FIGURE 23.1 Resisted reaching movements while maintaining sitting balance on an unstable surface.
- FIGURE 23.2 Maintaining sitting balance while catching and returning a ball.
- Kneeling
- Kneeling on a Stable Surface
- FIGURE 23.3 Balancing in half-kneeling position (A) while performing diagonal patterns against elastic resistance; and (B) while moving a weighted object from a chair to the floor.
- Kneeling on an Unstable Surface
- FIGURE 23.4 Balancing in high-kneeling position on a BOSU® while catching and tossing a ball.
- Bilateral Stance
- Bilateral Stance on a Stable Surface VIDEO 23.1
- FIGURE 23.5 Balancing in tandem stance on a balance beam with quick alternating resistance applied against the pelvis.
- Bilateral Stance on an Unstable Surface VIDEO 23.2
- FIGURE 23.6 Balancing in bilateral stance on a balance board while performing arm movements.
- FIGURE 23.7 Balancing in bilateral stance on a BOSU® while catching and tossing a ball.
- FIGURE 23.8 Balancing on an unstable surface while performing partial squats.
- Unilateral Stance
- Unilateral Stance on a Stable Surface VIDEO 23.3
- FIGURE 23.9 Balancing in unilateral stance while performing upper extremity diagonal patterns against elastic resistance: (A) unilaterally; and (B) bilaterally.
- FIGURE 23.10 Maintaining balance while touching one foot on each of the lines of a star pattern on the floor and returning to the center; (A) diagonally backward and (B) crossed behind stationary leg.
- FIGURE 23.11 Balancing in unilateral stance while performing a diagonal pattern with one lower extremity. Upper extremity motions add additional challenges to balance.
- FIGURE 23.12 Partial squatting in unilateral stance, leaning to one side and picking up an object.
- FIGURE 23.13 Maintaining balance in unilateral stance: (A) while bending forward at the hips and reaching out with both arms; and (B) while performing a windmill motion using handheld weights.
- Unilateral Stance on an Unstable Surface
- FIGURE 23.14 Perturbations in unilateral stance using elastic resistance while on a balance disc.
- Moving and Planting Activities VIDEO 23.4
- Jump and “Freeze”
- Side Shuffle and “Freeze”
- Run and “Freeze”
- FIGURE 23.15 Jump and freeze sequence and progression: (A) jumping down from a step and holding the end position and (B) hopping up onto a step and holding the end position.
- Exercises for Strength and Power
- FIGURE 23.16 Side shuffle and freeze.
- CLINICAL TIP
- Advanced Strengthening Exercises
- Advanced Strengthening: Upper Extremities
- Exercises with a BodyBlade®
- Upper Extremity Weight-Bearing Exercises Using Selected Equipment
- FIGURE 23.17 Exercises with a BodyBlade®: (A) bilateral isometric strengthening of shoulder rotators with additional activation of trunk stabilizers; and (B) unilateral isometric strengthening of elbow flexors/extensors.
- Pushing/Pulling and Lifting/Lowering Exercises
- FIGURE 23.18 Strengthening shoulder and elbow musculature by pulling (sliding) a heavy object from one position to another.
- FIGURE 23.19 Strengthening shoulder and elbow musculature by lifting or lowering a heavy object to and from a high surface.
- Seated Push-Ups on Unstable Surfaces VIDEO 23.5
- Prone Push-Ups in a Head-Down Position
- FIGURE 23.20 Seated push-ups in a long-sitting position (A) with lower legs on an unstable (soft) surface; and (B) with hands on an unstable surface.
- FIGURE 23.21 Prone push-ups in a head-down position.
- Upper Extremity Step-Ups Combined with Prone Push-Ups VIDEO 23.5
- FIGURE 23.22 Upper extremity step-up with the right upper extremity following a prone push-up.
- Prone Push-ups on Unstable Surfaces
- FIGURE 23.23 Prone push-ups on unstable surfaces: (A) with hands on the floor and knees on a foam roller; (B) with hands on a small ball and feet on the floor; and (C) with hands on a BOSU® and knees on a foam roller.
- Ball “Walk-Out” VIDEO 23.5
- Plantar-Grade “Walking”
- FIGURE 23.24 Ball “walk-out” on hands with lower extremities rolling on a large therapy ball.
- Advanced Strengthening: Lower Extremities VIDEO 23.6
- Unilateral Supine Pelvic Bridges
- Supine Pelvic Bridges on an Elevated Surface
- Supine Hamstring Curls on a Ball VIDEO 23.6
- FIGURE 23.25 Unilateral supine pelvic bridge on an unstable surface while holding a weighted ball in both hands for additional resistance.
- FIGURE 23.26 Supine pelvic bridge with the lower extremities elevated on a platform or chair and hands on the floor.
- FIGURE 23.27 Supine hamstring curls on a ball.
- Hamstrings or Quadriceps Strengthening: Kneeling
- Unilateral Wall Slides: Standing
- FIGURE 23.28 (A) Strengthening the hamstrings against the resistance of body weight by leaning forward from a high-kneeling position; (B) strengthening the quadriceps by leaning backward from the high-kneeling position while holding a weighted for additional resistance.
- FIGURE 23.29 Unilateral wallslides in standing with a midrange hold.
- Deep Squats
- Variations of Lunges VIDEO 23.6
- FIGURE 23.30 Deep squats with an end-range hold, while trying to keep the knees posterior to the toes.
- FOCUS ON EVIDENCE
- FIGURE 23.31 (A) Deep forward lunge while lightly touching a stable surface for balance; (B) multidirectional lunges on a star pattern on the floor; and (C) deep lateral lunge against elastic resistance.
- Sitting Down and Standing Up from a Chair Against Elastic Resistance
- Bilateral or Unilateral Heel-Lowering Over a Step
- Band Walking
- FIGURE 23.32 (A) Sitting down; and (B) standing up against elastic resistance.
- FIGURE 23.33 Heel-lowering over a step while holding weights for additional resistance.
- FIGURE 23.34 Band walking: (A) in a forward direction; and (B) in a sideward direction against elastic resistance looped around the pelvis.
- FIGURE 23.35 Band walking in a forward direction against elastic resistance looped around the thighs for closed-chain strengthening of the hip external rotators.
- Pulling or Pushing a Heavy Object
- FIGURE 23.36 Pulling increasingly heavy objects across the floor.
- Resisted Running Start and Resisted Running
- FIGURE 23.37 Resisted running start.
- Plyometric Training: Stretch-Shortening Drills
- Definitions and Characteristics
- FIGURE 23.38 Plyometric lower extremity sequence against the resistance of body weight: (A) patient stands on a low platform; (B) jumps off the platform to the floor, controlling the impact with a loaded, lengthening contraction of the hip and knee extensors and plantar flexors—the stretch phase; and (C) then without delay jumps forward onto the next platform using a concentric contraction of the same muscle groups—the shortening phase.
- BOX 23.1 Plyometric Activities for the Upper and Lower Extremities
- Neurological and Biomechanical Influences
- Effects of Plyometric Training
- FOCUS ON EVIDENCE
- Application and Progression of Plyometric Exercises
- Preparation for plyometrics.
- Specificity of training.
- Progression and parameters.
- BOX 23.2 Sample Plyometric Sequence for the Upper Extremities
- Precautions.
- Plyometric Exercises: Upper Extremities
- BOX 23.3 Precautions for Plyometric Training
- Bilateral Diagonal Upper Extremity Movements
- Bilateral Chest Press and Throw: Supine
- Bilateral Chest Press and Throw: Standing
- Bilateral Overhead Catch and Throw
- FIGURE 23.39 Bilateral chest press and throw—supine.
- FIGURE 23.40 Bilateral chest press and throw—standing.
- FIGURE 23.41 Bilateral overhead catch and throw.
- Bilateral Horizontal Side Throw and Catch VIDEO 23.7
- Hand-to-Hand Overhead Catch and Throw
- Unilateral Plyometric Shoulder Exercises Using Elastic Resistance
- FIGURE 23.42 Bilateral side throw and catch using horizontal abduction and adduction of the shoulders and trunk rotation.
- FIGURE 23.43 Hand-to-hand overhead catch and throw.
- FIGURE 23.44 Unilateral plyometric exercise for the shoulder external rotators using elastic resistance.
- Bounce a Weighted Ball: Prone-Lying
- Unilateral Side Catch and Throw
- FIGURE 23.45 Unilateral plyometric exercise for the shoulder internal rotators—bounce a weighted ball in the prone-lying position.
- FIGURE 23.46 Unilateral plyometric exercise for the shoulder internal rotators: (A) side catch and throw; and (B) a simulated baseball throw with the shoulder abducted to 90° and elbow flexed.
- Unilateral Reverse Catch and Throw
- Throw and Catch with Elbow Action
- FIGURE 23.47 Unilateral plyometric exercise for the shoulder external rotators—reverse catch and throw: The patient: (A) catches a soft, lightweight object with the shoulder abducted and externally rotated and the elbow flexed; (B) allows the shoulder to internally rotate with control; and (C) externally rotates the shoulder to throw the object back to the therapist.
- Unilateral Throw and Catch with Wrist Action
- FIGURE 23.48 Unilateral plyometric exercise targeting the elbow flexors.
- FIGURE 23.49 Unilateral plyometric exercise targeting the wrist flexors.
- Simulated Sport Activities
- FIGURE 23.50 Dribble a ball against the wall to target the wrist flexors.
- Upper Extremity Weight-Bearing Movements on a Slide Board
- FIGURE 23.51 Using a short-handled racquet, bounce a ball into the air with the forearm pronated to target the wrist extensors.
- FIGURE 23.52 Practice a golf swing using a weighted club.
- FIGURE 23.53 Bilateral plyometric exercise while bearing weight through the upper extremities—side-to-side movements with quick changes of direction on a ProFitter®.
- Push-Offs from a Wall
- FIGURE 23.54 Repeated push-offs from a wall: (A) falling directly forward toward the wall and catching self with both hands; and (B) pushing away from the wall to the upright position.
- Side-to-Side Push-Offs from a Waist-Level Surface VIDEO 23.8
- Variations of Prone Push-Ups VIDEO 23.8
- FIGURE 23.55 Alternating side-to-side push-offs to and from a stable, waist-high surface.
- FIGURE 23.56 Drop push-ups in the prone position: (A) Starting position; (B) prone push-up; and (C) drop hands to floor, allowing elbows to flex. Push up from the floor and quickly return hands to platforms as in (A).
- Plyometric Exercises: Lower Extremities
- CLINICAL TIP
- Kicking a Ball
- Sit-to-Stand from a Ball
- FIGURE 23.57 Moving from sit-to-stand by bouncing on a ball.
- Bilateral Heel Raises on a Mini-Trampoline
- FIGURE 23.58 Side-to-side movements on a Pro-Fitter®.
- FIGURE 23.59 Squat jumps: (A) from a squat position, perform a (B) vertical jump.
- FIGURE 23.60 Bounding: a series of forward jumps across a floor.
- Side-to-Side Shuffle
- Side-to-Side Movements on a Slide Board
- Squat Jumps VIDEO 23.9
- FIGURE 23.61 Four-quadrant jumping or hopping.
- Bounding
- Four-Quadrant Jumps or Hops VIDEO 23.9
- Tuck Jumps
- FIGURE 23.62 Tuck jump.
- FIGURE 23.63 (A), (B), and (C) Lunge-jumps: alternately landing with right, then left lower extremity forward.
- Lunge Jumps VIDEO 23.9
- Zigzag Forward Jumping or Hopping
- Hopping Over Objects VIDEO 23.9
- Single Platform Jumping or Hopping
- Multiple Platform Jumping or Hopping
- FIGURE 23.64 Zigzag forward hopping.
- FIGURE 23.65 Lateral hopping over objects of varying sizes set up in an obstacle course on the floor.
- FIGURE 23.66 Hopping onto and off of a single platform using proper landing technique.
- Independent Learning Activities
- Critical Thinking Questions
- Laboratory Activities
- Case Studies
- Case Study #1
- Case Study #2
- Additional Case Studies
- REFERENCES
- V Special Areas of Therapeutic Exercise
- CHAPTER 24 Women’s Health: Obstetrics and Pelvic Floor
- Overview of Pregnancy, Labor, and Related Conditions
- Characteristics of Pregnancy and Labor
- Pregnancy
- First Trimester Changes
- Second Trimester Changes
- Third Trimester Changes
- Labor
- FIGURE 24.1 Effacement and dilation of the cervix.
- Labor: Stage 1
- Cervical dilation phase.
- Middle phase.
- Transition phase.
- Labor: Stage 2
- FIGURE 24.2 Principal movements in the mechanism of labor and delivery, left occiput anterior position.
- Fetal descent.
- Expulsion.
- Labor: Stage 3
- Placental stage (expulsion of the placenta).
- Uterine involution.
- Anatomical and Physiological Changes of Pregnancy
- Weight Gain During Pregnancy
- BOX 24.1 Total Weight Gain (Ranges) for Single Fetus
- Changes in Organ Systems
- Uterus and Related Connective Tissue
- Uterus.
- Connective tissues.
- Urinary System
- Kidneys.
- Ureters.
- Pulmonary System
- Hormonal influences.
- Respiration.
- Cardiovascular System
- Blood volume and pressure.
- Heart.
- Musculoskeletal System
- Abdominal muscles.
- Pelvic floor muscles.
- Connective tissues and joints.
- Thermoregulatory System
- Metabolic rate.
- Changes in Posture and Balance
- Center of Gravity
- Balance
- Overview of Pelvic Floor Anatomy, Function, and Dysfunction
- FIGURE 24.3 Pelvic floor muscles. (A) Sagittal section—note sling/hammock orientation; (B) viewed from below—note figure-eight orientation of the muscles around the orifice of the urethra/ vagina and the anal sphincter; and (C) posterior view—note the funnel shape of the pelvic muscles.
- Pelvic Floor Musculature
- Female Pelvic Floor
- Innervation
- TABLE 24.1 Pelvic Floor Anatomy: From Superficial to Deep
- Function
- Effect of Childbirth on the Pelvic Floor
- Neurological Compromise
- Muscular Impairment
- Episiotomy
- FOCUS ON EVIDENCE
- Classification of Pelvic Floor Dysfunction
- Prolapse
- FIGURE 24.4 (A) Good pelvic floor support with a firm base, organs in normal position. (B) Inadequate support, pelvic organs descend.
- Urinary or Fecal Incontinence
- FOCUS ON EVIDENCE
- Pain and Hypertonus
- Risk Factors for Dysfunction
- Childbirth
- Other Causes
- Interventions for Pelvic Floor Impairments
- Patient Education
- Teach the patient about pelvic floor anatomy and function.
- Provide individual instruction in exercise performance.
- Neuromuscular Reeducation
- Facilitate pelvic floor muscular activation.
- Biofeedback
- Use biofeedback with instrumentation.
- Combine biofeedback with exercises.
- Manual Treatment and Modalities
- Pregnancy-Induced Pathology
- Diastasis Recti
- FIGURE 24.5 Diagrammatic representations of diastasis recti.
- Incidence
- Significance
- Activity limitations.
- Decreased fetal protection.
- Potential for herniation.
- Examination for Diastasis Recti
- FIGURE 24.6 Diastasis recti test.
- Intervention for Diastasis Recti
- Posture-Related Back Pain
- Incidence
- Characteristics
- Interventions
- FOCUS ON EVIDENCE
- Sacroiliac/Pelvic Girdle Pain
- Characteristics
- Interventions
- Activity modification.
- Exercise modification.
- FOCUS ON EVIDENCE
- External stabilization.
- FOCUS ON EVIDENCE
- Varicose Veins
- Characteristics
- Interventions
- Exercise modification.
- External support.
- Joint Laxity
- Significance
- Interventions
- Exercise modification.
- Aerobic exercise.
- Nerve Compression Syndromes
- Causes
- Interventions
- Exercise Interventions for Pregnancy, Labor, and Related Conditions
- Physiological Effects of Aerobic Exercise During Pregnancy
- Maternal Response to Aerobic Exercise
- Blood Flow
- Respiratory Rate
- Hematocrit Level
- Inferior Vena Cava Compression
- Energy Needs
- Core Temperature
- Uterine Contractions
- Responses of Healthy Women
- Fetal Response to Maternal Aerobic Exercise
- Blood Flow
- Fetal Heart Rate
- Heat Dissipation
- Newborn Status
- Exercise for the Uncomplicated Pregnancy and Postpartum
- BOX 24.2 MANAGEMENT GUIDELINES—Pregnancy and Postpartum
- BOX 24.3 Suggested Sequence for Exercises Classes
- Guidelines for Managing the Pregnant Woman
- Examination.
- Education.
- FIGURE 24.7 To prevent inferior vena cava compression when the patient is lying supine, a folded towel can be placed under the right side of the pelvis so the patient is tipped slightly to the left.
- Stretching/flexibility.
- CLINICAL TIP
- Muscle performance and aerobic fitness.
- CLINICAL TIP
- Recommendations for Fitness Exercise
- BOX 24.4 Borg Rating Scale for Perceived Exertion (RPE)15
- Precautions and Contraindications to Exercise
- Absolute Contraindications
- Precautions to Exercise
- Critical Areas of Emphasis and Selected Exercise Techniques
- Posture Exercises
- Corrective Exercises for Diastasis Recti
- Head Lift
- BOX 24.5 Selected Stretching and Resistance Exercises During Pregnancy
- FIGURE 24.8 Corrective exercise for diastasis recti. The patient gently approximates the rectus muscle toward the midline by pulling with the crossed arms.
- Head Lift with Pelvic Tilt
- Stabilization Exercises
- Dynamic Trunk Exercises
- Pelvic Motion Training
- Pelvic tilt exercises.
- Pelvic clock.
- Pelvic clock progressions.
- Trunk Curls
- Modified Upper and Lower Extremity Strengthening
- Standing Push-Ups
- Supine Bridging
- Quadruped Leg Raising
- Modified Squatting
- FIGURE 24.9 All-fours leg-raising. (A) Patient assumes quadruped position with posterior pelvic tilt. (B) Leg is raised only until it is in line with the trunk.
- Scapular Retraction
- Perineum and Adductor Flexibility
- Self-Stretching
- Pelvic Floor Awareness, Training, and Strengthening
- FOCUS ON EVIDENCE
- Contract-Relax
- Quick Contractions
- “Elevator” Exercise
- Pelvic Floor Relaxation
- Relaxation and Breathing Exercises for Use During Labor
- Visual Imagery
- Muscle Setting
- Selective Tension
- CLINICAL TIP
- Breathing
- Relaxation and Breathing During Labor
- First Stage
- Second Stage
- FIGURE 24.10 The use of a stability ball in labor can provide relief of back pain and the comfort of rhythmical, relaxing movements. The labor coach can massage the back and/or hip muscles and apply heat or ice if desired.
- Unsafe Postures and Exercises During Pregnancy
- Bilateral straight-leg raising.
- “Fire hydrant” exercise.
- All-fours (quadruped) hip extension.
- Unilateral weight-bearing activities.
- Exercise Critical to the Postpartum Period
- Pelvic floor strengthening.
- Diastasis recti correction.
- Aerobic and strengthening exercises.
- Cesarean Childbirth
- Significance to Physical Therapists
- Surgical Risks
- Interventions
- Pelvic floor rehabilitation.
- Postsurgical rehabilitation.
- BOX 24.6 MANAGEMENT GUIDELINES—Postcesarean Section
- Emotional support.
- Suggested Activities for the Patient Following a Cesarean Section
- Exercises
- Coughing or Huffing
- Interventions to Relieve Intestinal Gas Pains
- Abdominal massage or kneading.
- Pelvic tilting and/or bridging.
- Bridge and twist.
- Scar Mobilization
- High-Risk Pregnancy
- High-Risk Conditions
- Premature onset of labor.
- Preterm rupture of membranes.
- Incompetent cervix.
- Placenta previa.
- Pregnancy-related hypertension or preeclampsia.
- Multiple gestation.
- Diabetes.
- FOCUS ON EVIDENCE
- Management Guidelines and Precautions for High-Risk Pregnancies
- BOX 24.7 MANAGEMENT GUIDELINES—High-Risk Pregnancy
- Exercise Suggestions with High-Risk Pregnancies
- BOX 24.8 Bed Exercises for High-Risk Pregnancy
- Positioning
- Range of Motion (ROM)
- Ambulation/Standing
- Relaxation Techniques, Bed Mobility, and Transfer Activities
- Preparation for Labor
- Postpartum Exercise Instruction
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- Clinical Findings
- Clinical Findings
- WEB RESOURCES
- REFERENCES
- CHAPTER 25 Management of Lymphatic Disorders
- Disorders of the Lymphatic System
- Structure and Function of the Lymphatic System
- FIGURE 25.1 Major vessels of the lymphatic system.
- Anatomy of the Lymphatic System
- FIGURE 25.2 Lymph capillary and larger lymph vessel.
- Physiology of the Lymphatic System
- Types of Lymphedema
- Primary Lymphedema
- Secondary Lymphedema
- Surgical Dissection of Lymph Nodes
- Infection and Inflammation
- Obstruction or Fibrosis
- Combined Venous-Lymphatic Dysfunction
- Clinical Manifestations of Lymphatic Disorders
- Lymphedema
- Location.
- Severity.
- CLINICAL TIP
- BOX 25.1 Severity of Lymphedema
- Increased Size of the Limb
- Sensory Disturbances
- Stiffness and Limited Range of Motion
- BOX 25.2 Stages of Lymphedema
- Decreased Resistance to Infection
- Examination and Evaluation of Lymphatic Function
- History and Systems Review
- Examination of Skin Integrity
- CLINICAL TIP
- FIGURE 25.3 Stemmer sign: Objective test for lymphedema in the extremities.
- Girth Measurements
- Volumetric Measurements
- Bioimpedance Measurements
- Lymphedema Risk Reduction
- Management of Lymphedema
- Background and Rationale
- BOX 25.3 Precautions, Risk Reduction, and Self-Management of Lymphedema
- Comprehensive Regimens and Components
- Manual lymphatic drainage.
- BOX 25.4 Components of a Decongestive Lymphatic Therapy Program
- Exercise.
- Compression therapy.
- FIGURE 25.4 Upper extremity multilayer bandaging with padding from the upper arm to the hand.
- FOCUS ON EVIDENCE
- TABLE 25.1 Garment Compression Classification
- Skin care and hygiene.
- Use of Community Resources
- Breast Cancer-Related Lymphatic Dysfunction
- Background
- Surgical Procedures
- Mastectomy
- Breast-Conserving Surgery
- Evaluation of Lymph Node Involvement
- Radiation Therapy
- Impairments and Complications Related to Breast Cancer Treatment
- Postoperative Pain
- Incisional pain.
- Posterior cervical and shoulder girdle pain.
- Postoperative Vascular and Pulmonary Complications
- Lymphedema
- Chest Wall Adhesions
- Decreased Shoulder Mobility
- BOX 25.5 Factors Contributing to Impaired Shoulder Mobility After Breast Cancer Surgery
- FIGURE 25.5 Axillary Web Syndrome.
- Weakness of the Involved Upper Extremity
- Shoulder weakness.
- Decreased grip strength.
- Postural Malalignment
- Fatigue and Decreased Endurance
- Psychological Considerations
- Guidelines for Management Following Breast Cancer Surgery
- BOX 25.6 MANAGEMENT GUIDELINES—After Surgery for Breast Cancer
- Special Considerations
- Patient education.
- Exercise.
- CLINICAL TIP
- BOX 25.7 Exercise Precautions During Treatment of Breast Cancer
- Community resources.
- Exercises for the Management of Lymphedema
- Background and Rationale
- BOX 25.8 Exercises for Lymphatic Drainage: Principles and Rationale
- Components of Exercise Regimens for Management of Lymphedema
- Deep Breathing and Relaxation Exercises
- Flexibility Exercises
- Strengthening and Muscular Endurance Exercises
- Cardiovascular Conditioning Exercises
- FOCUS ON EVIDENCE
- Lymphatic Drainage Exercises
- Guidelines for Lymphatic Drainage Exercises
- Preparation for Lymphatic Drainage Exercises
- During Lymphatic Drainage Exercises
- After Lymphatic Drainage Exercises
- Selected Exercises for Lymphatic Drainage: Upper and Lower Extremity Sequences
- BOX 25.9 Sequence of Selected Exercises for Management of Upper or Lower Extremity Lymphedema
- Sequence of Exercises
- Exercises Common to Upper and Lower Extremity Sequences
- CLINICAL TIP
- Exercises Specifically for Upper Extremity Lymphedema Clearance
- CLINICAL TIP
- FIGURE 25.6 Active circumduction of the edematous extremity.
- FIGURE 25.7 Active shoulder exercises while lying on a firm, foam roll.
- FIGURE 25.8 Overhead wall press.
- Exercises Specifically for Lower Extremity Lymphedema Clearance
- FIGURE 25.9 Repeated outward rotation of the hips with legs elevated and resting on a wall.
- FIGURE 25.10 Sliding feet up and down a wall with hips externally rotated.
- FIGURE 25.11 Repetitive walking movements.
- FIGURE 25.12 Hip adduction across the midline to clear inguinal nodes.
- Independent Learning Activities
- Critical Thinking and Discussion
- Laboratory Practice
- Case Studies
- Case 1
- Case 2
- REFERENCES
- Back Matter
- Glossary
- A
- B
- C
- D
- E
- F
- G
- H
- I
- J
- K
- L
- M
- N
- O
- P
- Q
- R
- S
- T
- V
- Index