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Test Bank for Therapeutic Exercise Foundations and Techniques, 6th Edition : Kisner

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This is completed downloadable Test Bank for Therapeutic Exercise Foundations and Techniques, 6th Edition : Kisner

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ISBN-10 ‏ : ‎ 080362574X
ISBN-13 ‏ : ‎ 978-0803625747
Author: Carolyn Kisner PT MS (Author), Lynn Allen Colby PT MS (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)
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

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