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Therapeutic Exercise Notes PDF
Therapeutic Exercise Notes PDF
TherTherapeutic ExerThecise
Notes
Based on Kiner & Colby 5th Edition
Dpt. Aamir Raoof Memon
2012-14
https://www.facebook.com/groups/653602987987375/
Therapeutic Exercise
Patient → Individual with impairments & functional limitations (diagnosed by a PT), who is receiving
Physical therapy care to improve function & prevent disability.
Client → Individual without diagnosed dysfunction, who engages in Physical therapy services to
promote health & wellness, & to prevent dysfunction.
1. Balance → Ability to align body segments against gravity, to maintain or move the body
segments within the available BOS without falling.
OR
Ability to move the body in equilibrium with gravity, via the interaction of sensory &
motor systems.
Conscious, explicit, & judicious use of current best evidence in making decisions about the care
of an individual patient.
Steps:-
Pathology/Pathophysiology
Disruption of the body’s homeostasis as a result of acute or chronic diseses,disorders, or conditions
characterized by set of abnormal findings-signs & symptoms- that indicate alterations/interruptions
of body structures/function primarily identified at the cellular level.
Impairments
Consequences of pathological conditions that reflect abnormalities of the body systems, organs, or
tissue level.
Categories of Impairments
1. Musculoskeletal
Pain,muscle weakness, ↓endurance, joint hypomobility
Muscle length & strength imbalances
Limited ROM → Restriction of joint capsule & periarticular connective tissue, ↓
muscle length
2. Neuromuscular
Pain, abnormal tone (hyper- or hypo- or dystonia)
Delayed motor development, Inco-ordination & faulty timing
Impaired balance, postural stability or control
Ineffective/inefficient functional movement strategies
3. Cardiopulmonary
↓aerobic capacity→ cardiopulmonary endurance
Impaired circulation → Lymphatic,Venous, Arterial
Pain with sustained physical activity → intermittent claudication
4. Integumentary
Skin hypomobility → Immobile/Adherent scaring
Functional Limitations
Disability
1. Biological factors
Age, Sex, Race
Height/Weight relationship
Congenital abnormalities & disorders
Family history of a disease → Genetic predisposition
2. Behavioral/Psychological/Lifestyle factors
Sendentary lifestyle
Use of tobacco,alcohol, other drugs
Poor nutrition
Low level of motivation
Difficulty dealing with change
Negative effect
3. Physical Environment Characteristics
Architecture barriers in home, community, workplace
Engonomic characteristics of home, work, school environment
4. Socioeconomic factors
Low economic status
Low level of education
Inadequate access to health care
Limited family/social support
Dynamic complex process of reasoning & analytical i.e. critical thinking that involves making
judgements & determinants in context to the patient care.
Prognosis
Prediction of patient’s optimal level of function expected as a result of a course of treatment &
anticipated length of time needed to reach a specified functional outcome.
Chapter 2
Health
Wellness
Health promotion
Prevention
3. Tertiary → decreasing degree of disability & promoting rehabilitation for individuals with
chronic/irreversible disease
1. Passive ROM
“Movement of a body segment within the unrestricted ROM that is produced entirely by an external
force”.
“Movement of a body segment within the unrestricted ROM that is produced by active contraction
of muscles crossing that joint”.
3. Active-Assisted ROM
“Type of A-ROM involving manual/mechanical assistance provided by an outside force because the
prime mover muscles need assistance to complete the motion”.
1. Passive ROM
Acute inflamed tissue → 2-6 days
Comatose/Paralyzed/Completely bed-ridden patient
2. Active & Active-Assisted ROM
Active muscle contraction → Active ROM
Aerobic conditioning program → Active ROM
Region above & below the immobilized segment → Active ROM
Weak musculature → Active- Assisted ROM
Control gained → Manual/Mechanical Resistance Exercise →
Improve muscle performance
Passive ROM
Primary Goal
Specific Goals
Other uses
Determine limitations of motion, to determine joint stability, and to determine muscle and
other soft tissue elasticity.
Demonstrate the desired motion for an active exercise program.
Used preceding the passive stretching techniques.
Active & Active-assisted ROM
Primary Goal
Specific Goals
Passive ROM
Precautions
Used to protect healing tissue when more intensive muscle contraction is contraindicated i.e. Post-
surgical or Post-trauma
Forms of S-AROM
Manual
Equipment
Wand or T-bar
Finger ladder,Wall climbing, Ball rolling
Pulleys
Skate or Powder board (Hip abd: & adduction, Shoulder Horizontal flexion &
extension)
Reciprocal Exercise devices → Bicycle, Upper/Lower body ergometer etc
“Passive motion performed by a mechanical device that moves the joint slowly & continuously
through a controlled ROM”.
Benefits
Demonstration by Salter
Mobility
“Ability of structures/body segments to move/be moved to allow the presence of functional ROM”.
OR
“Ability of an individual to initiate, control, or sustain active movements of body to perform simple
to complex motor skills is called Functional Mobility”.
Hypomobility
Prolonged immobilization
o Extrinsic
(Casts & Splints, Skeletal traction)
Fractures, Osteotomy, Soft tissue trauma & repair
o Intrinsic
Pain
Microtrauma or macrotrauma; degenerative diseases
Joint inflammation & effusion
Joint diseases or trauma
Muscle, tendon, facial disorders
Myositis, tendonitis, fasciitis
Skin disorders
Burns, skin grafts, scleroderma
Bony block
Osteophytes, ankylosis, surgical fusion
Vascular disorders
Peripheral lymphedema
Flaxiblity
OR
“Ability to move a single joint/series of joints smoothly & easily through unrestricted, pain-free
ROM”.
OR
“Degree to which an active muscle contraction moves a body segment through the available ROM”.
“Ability due to which a joint can passively be moved through the available ROM”.
“Degree to which an active muscle contraction move a body segment through the available ROM”.
Muscle tightness
Tightness
Contraction
“Adaptive shortening of muscle-tendon unit & other soft tissues crossing/surrounding a joint
resulting in significant resistance to active/passive stretch & ROM limitation”.
Designation of Contractures:-
Types of Contractures
1. Myostatic/Myogenic Contracture
“Adaptive shortening of musculotendinous unit & loss of ROM without specific muscle pathology”.
“Impaired mobility & limited ROM due to hypotonicity (spasticity/rigidity),muscle spasm/guarding, &
pain”.
Periarticular→ result of decreased /loss of connective tissue mobility that cross/attach to joint/joint
capsule.
Fibrotic→ result of fibrous changes in connective tissue of muscles & periarticular cartilage causing
adhesions & contracture development
Contraindications to Stretching
A bony block limits joint motion.
Recent fracture and incomplete bony union.
Acute inflammatory or infectious process (heat and swelling) or soft tissue healing could be disrupted in
the tight tissues and surrounding region.
Sharp, acute pain with joint movement or muscle elongation.
Hematoma or other indication of tissue trauma.
Hypermobility already exists.
Shortened soft tissues
o Provide necessary joint stability in lieu of normal structural stability or neuromuscular control.
o Enable a patient with paralysis or severe muscle weakness to perform specific functional skills
otherwise not possible.
Interventions to increase Soft tissue mobility
Stretching & Mobilization → therapeutic maneuver to increase extensibility of restricted soft tissues.
“Stretching exercise carried out independently by a patient after the instructions & supervision by a
therapist”.
“Purported to relax tension in shortened muscle reflexively prior to/during muscle elongation”.
Uses voluntary muscle contraction in a precisely controlled direction & intensity against a
counterforce by the therapist.
Evolved from Osteopathic medicine.
5. Joint mobilization & manipulation
“Manual therapy techniques applied to joint structures & used to stretch capsular restrictions or
reposition a subluxed/dislocated joint”.
“Techniques to improve muscle extensibility & involve the application of specific & progressive
forces to effect the changes in the myofascial structures that can bind soft tissues & improve
mobility”.
“Techniques to prevent post-traumatic & post-surgical adhesions or scar tissue formation around
the meninges & nerve roots or at the site of injury at plexus on peripheral nerves”.
Selective Stretching
“Process whereby the overall function of a patient may be improved by applying stretching
techniques selectively to some muscles & joints but allowing limitation of motion to develop in other
muscles & joints”.
Decision for selective stretching of musculotendinous units & joints is made in patients with
permanent paralysis.
Overstretching→ stretch beyond the normal muscle length & the joint ROM & the surrounding soft
tissues.
1. Alignment
2. Stabilization
3. Intensity of Stretch/Magnitude of force
4. Duration of Stretch
5. Speed of Stretch
6. Frequency of Stretch
7. Mode of Stretch
Properties of Soft tissue response to Immobilization
1. Elasticity →Ability of soft tissue to gain its prestretch resting length directly after the
removal of short duration stretch force.
2. Viscoelasticity→ Time-dependent property of soft tissue that initially resists the deformation
of tissue when a stretch force is first applied.
Possesed by connective tissue only(not the contractile element).
3. Plasticity→ Tendency of soft tissue to adopt a new & greater length after the removal of
stretch force.
Response to Stretch
Morphological Changes
Note: - Adoptation of sarcomeres to prolonged positioning is transient, lasting only 3-5 weeks if
muscle resumes its preimmobilization use & degree of lengthening for functional activities.
Mechanoreceptors that convey information to CNS about the changes in muscle tendon unit (length
& tension) & affect muscle response to stretch.
Receive & convey information about the changes in length & velocity of length changes
Composed of:-
Intrafusal fibers lie b/w & parallel to Extrafusal fibers ―muscle body
Small diameter motor neurons k/n “ɣ-motor neurons” innervate Polar Regions of intrafusal fibers.
Large diameter motor neurons k/n “ɑ-motor neurons” innervate extrafusal fibers.
Sensory organ located near the musculotendinous junction of the extrafusal muscle fibers.
Quick/Slow stretch force to muscle-tendon unit→Primary & Secondary Intrafusal afferents sense
length changes→Extrafusal fiberactivation via ɑ-motor neurons in spinal cord results in:-
GTOs impact in prolonged stretch force→ inhibitory on the level of muscle tension in muscle-tendon
unit is k/n Autogenic Inhibition→ contributes to Reflexive muscle relaxation in stretching & enables
muscle to elongate against less muscular tension.
Low-intensity, prolonged stretch preferred → inhibit muscle tension & allow sarcomeres to remain
relaxed & lengthen.
Topocollagen→myofibril→subfibril→fibril→fascicle(tendon,ligament,skin)
2. Elastin Fibers
Provide extensibility
Elastin ɑ Flexibility
3. Reticulin Fibers
4. Ground Substance
Proteoglycans
Stress-Strain Curve
“Principle used for stretching by applying repetitive (cyclic) loading at a submaximal level on
successive days”.
Repetitive tissue loading→ increase heat production→ resulting in failure below yield point
Endurance limit→ below minimum load, apparently infinite number of cycles doesn’t cause failure
Connective tissue fatigue from cyclic loading results in Stress Fractures & Overuse Syndrome
Time is allowed b/w bouts of cyclic loading to allow for Remodeling & Healing in new range.
Toe-Region → Area where there is considerable deformation without the use of much force
Elastic Range/Linear Phase→ Stress is directly proportional to tissue’s ability to resist force
Elastic Limit→ Point beyond which the tissue doesn’t return to its original shape & size
Plastic range→ Range beyond the elastic limit extending to the point of rupture
Region of Necking→ region where there is considerable tissue weakening & if the stress is
maintained results in complete tissue tearing
Structural Stiffness
Increased stiffness
Increased degree of bonding b/w collagen fibers & surrounding matrix
Creep→ occurs when load is applied for an extended time period, the tissue elongates & results in
permanent deformation
Low magnitude loads applied in Elastic range for long periods→result in increase in connective tissue
deformation & ultimately allow gradual remodelling of collagen fibers & Redistribution of water to
surrounding tissue
Stress Relaxation
“Principle used in prolonged stretching procedures where the stretch position is maintained for
several hours or days”.
Occurs when load is applied o stretch a tissue while the length is kept constant
Effects of Immobilization
Tissue weakening due to collagen turnover & weak bonding b/w new fibers
Adhesion formation due to increased cross-linkage b/w disorganized collagen fibers
Decreased effectiveness of ground substance maintaining space & lubrication b/w fibers
Rate of return to normal tensile strength is slow
Effects of Age
Effects of Corticosteroids
Effects of Injury
Excessive tensile loading→ ligament & tendon rupture at the musculotendinous junction
Healing→ newly synthesized type-III collagen
Remodeling→ collagen type-I
o Begins 3 weeks after injury till months-years
General Precautions
Do not passively force a joint beyond its normal ROM; be aware of age & sex related changes
in flexibility.
Use extra caution in patients with known or suspected osteoporosis due to disease,
prolonged bed rest, age, or prolonged use of steroids
Protect newly united fractures
Avoid vigorous stretching of muscles and connective tissues that have been immobilized for
an extended period of time→ loss of tensile strength in tendons, ligaments
o High-intensity short-duration stretch→ more trauma→ soft tissues weakness.
Progress the dosage (intensity, duration, and frequency) gradually to minimize soft tissue
trauma and post-exercise muscle soreness
Avoid stretching edematous tissue→ increased pain and edema
Avoid overstretching weak postural muscles
General flexibility programs include: - stretching the body regions that are
mobile/hypermobile but may neglect the regions that are tight due to faulty
posture/inactivity.
Faulty postures may worsen rather than the improvement
Insufficient warm-up
Ineffective stabilization
Exercise may fail to stretch the intended tight structure & transfer the force to the structures
that are already mobile/hypermobile.
Uncontrolled stretching→ increase post-exercise muscle soreness & soft tissue injury
Excessive Intensity
Effective flexibility routine should be progressed gradually & not cause pain or excessive
tissue stress.
Abnormal Biomechanics
Result of normal aging process→ decreased connective tissue mobility→ decreased activity
level
Adjuncts to Stretching
Relaxation Training
“Methods of general relaxation/total body relaxation that help the patient learn to relieve/decrease
pain, muscle tension, anxiety/stress & associated physical impairments (tension headache, increased
BP & RR)”.
Common element is to involve→ decrease in muscle tension in entire body/region that is
painful/restricted by conscious effort & thought.
Examples include:-
“Invade conscious relaxation via autosuggestion & progression of exercises & medications”.
2. Progressive Relaxation―Jacobson
“Use systematic, distal to proximal, progression of voluntary muscle contraction & relaxation”.
“Combines sensory awareness, movements of limbs & trunk, deep breathing, conscious relaxation,&
self-massage to alter muscle imbalances & abnormal postural alignment to remediate muscle
tension & pain”.
Indicators
HEAT:
↑ in Sensitivity of GTO’s
Thermal agents → used to heat small areas prior to or during stretching (individual joints,
muscle groups, tendons)
→Superficial heating agents → Hot packs, paraffin.
Effectiveness of warm-up:
Heat combined with stretching procedures → Produce great Long-term gain in tissue length.
Pre-stretching cryotherapy → ↓ muscle tone & sensitivity during stretch ( healthy &
spasticity secondary to UMNL)
→ Immediately after soft tissue injury → ↓ pain & muscle spasm.
→ 24-48 hrs Post-soft tissue injury → ↓ swelling, pain & muscle spasm.
Joint mobilizations:
Terms:
Joint Play: Motion b/w joint surfaces & Dispensibility or “give” in the joint
capsule which allows the bone to move.
Types of motion
Hip → flexion/extension
Combined Roll-Slide
(Tendon, ligament,
Capsule)
restriction
Limitations
1. Hypermobility
Potential necrosis of ligament and capsule
Painful hypermobile joints→ Gentle joint-play techniques
within limits of motion.
2. Inflammation
Stretching → ↑ pain & muscle guarding→ ↑ed tissue
damage.
Gentle oscillatory or distraction motions → Temporarily
inhibits pain.
3. Joint effusion — Traumatic or Pathological
Rapid swelling — Indicate bleeding in joint → Hemephilia or
trauma.
→ Medical intervention (aspiration) required:
Malignancy
Bone disease detectable on radiograph
Unhealed fracture — Depends upon: Site & Stabilization.
Excessive pain — determine the cause & Modify Rx
Hypermobility in associated joints — proper stabilization of them.
Total joint replacement
Systemic connective tissue disease — rheumatoid arthritis – weaken
C.T.
Newly formed or weakened connective tissue → Post-trauma, surgery,
disease & corticosteroid use.
TECHNIQUES:
Sensitivity.
b) Mechanical effects
Small-amplitude distraction or gliding movements
Cause --Synovial fluid motion
Bring nutrients to Avascular portion of Articular cartilage (Intra-articular and Fibrocartilage)
Gentle joint-play techniques
Help maintain nutrient exchange
Prevent painful and degenerative effects of stasis in pain and Inflammation
1. Static Stretching.
2. Cyclic Stretching.
3. Ballistic Stretching.
4. PNF Stretching.
5. Manual Stretching.
6. Mechanical Stretching.
7. Active Stretching.
8. Passive Stretching
Elongation of soft tissues just past the point of tissue resistance & then held in elongated
position with a sustained stretch force over a period of time.
Shortened soft tissues held in comfortably lengthened position until a degree of relaxation is
felt & are the incrementally lengthened even further & held in a new End range position for
additional duration of time.
Relative Short-duration stretching force thet is repeatidly but gradually applied, released &
then applied.
OR.
End range stretch force with ↓ed Velocity & intensity & in a controlled manner.
MODES OF STRETCHING:
Manual Stretching:
Therapists or other person applies external force to move the involved body segment slightly
beyond the point of tissue resistance & the available ROM.
Mechanical Stretching:
Stretching via using → Cuff weight or weight-pulley system, orthosis or automated
stretching machines.
Apply very low-intensity stretch force → Low loads over a prolong time provide to create
permanent (maintained) soft tissue lengthening. Due to → Plastic deformation.
o Effective to → ↓ Long-standing contractures
o Long duration of stretch needed for patients with chronic contractures due to
Neurological or Musculoskeletal disorders
o Duration → substantially longer overall duration of stretch.
→15-30 mins → as long as 8-10 hrs. at a time → continuous throughout the day.
Requires normal innervations & voluntary control of either shortened muscles or muscles on
opposite side of the joint.
Effective in Neurorehabilitation & rehabilitation of MSK conditions.
USE: → Develop muscle strength & endurance & facilitate mobility & stability.
→ Develop neuromuscular control & coordinated movements.
→ Restoration of function.
Can’t be used effectively in patients with Paralysis or spasticity resulting neuromuscular disease
and injury.
Procedures designed to affect contractile elements of muscle & non contractile connective
tissue → more appreciated when muscle spasm limits motion & less appropriate for Fibrotic
contractures.
Performed with combined muscle groups acting in a diagonal patterns → ↑ flexibility & ROM.
Strong muscle groups of a diagonal pattern facilitate responsiveness of weaker muscle groups.
Important for → strength, Endurance, Dynamic stability development.
Useful throughout the rehabilitation :
→early phase of tissue healing →isometric techniques used.
Resistance
1. range limiting muscle is 1st lengthened to point of limitation or the comfortable extent.
2. patient performs pre-stretch, end-range, isometric contractions for the 5-10 sec.
followed by Voluntary relaxation of tight muscles.
3. Limb passively moved into new range → Range-limiting muscle elongated.
HR technique → limb rotators are allowed to contact concentrically whereas all other
muscle groups contract Isometrically during the prestretch contraction of resisting muscle.
CR & HR technique → Make passive elongation of muscle more comfortable for the patient
than manual passive stretching.
Due to
AUTOGENIC INHIBITON.
Multiple repetitions of Maximal Presretch Isometric Contraction.
Effective when significant muscle guarding restricts muscle lengthening & joint movement.
Less effective to ↓ choronic contractures.
Useful when patient cannot generate → Strong, pain-free contraction of the Range-limiting
muscle→ HR-PROCEDURE.
Useful to initiate Neuromuscular control in new range → DYNAMIC FLEXIBILITY.
Less effective in Close to Normal flexibility
PRECAUTION: Avoid full range, ballistic movements when performing concentric contraction of
Agonist muscle group.
1. Move the limb to the point where tissue resistance is felt in the Tight muscle (Range-
limiting muscle).
2. Patient performs → resisted, prestretch isometric contraction of the range-limiting muscle.
3. Relaxation of the muscle & Immediate concentric contraction of the muscle opposite to the
tight muscle.
Diagonal patterns
→Asymmetrically
→Reciprocally
Basic procedures of PNF patterns:
Diagonal patterns used with → various forms of Mechanical resistance.(free weights, simple weight-
pulley system, Elastic resistance , Isokinetic units)
Manual Contacts
“How & where the therapist’s hands are placed on the patient”.
Maximal Resistance
Therapist position → Shoulders & Trunk facing in the direction of moving limb.
Therapist movement → move pivot over wide BOS to allow rotation.
Traction
Approximation
Normal timing
→ Reflex
“Placing the body segments in the position that lengthen agonist muscle”
Facilitated by a rapid stretch (overstretch) just past the point of tension to already
elongated agonist muscle.
Quick stretch followed by sustained resistance to agonists.
→ Keep contracting the muscle under tension.
Directed to a distal musce group → Elicit a Phasic muscle contraction → Initiate PNF
patterns.
Prior to Resisted Isometric contraction during early stages of soft tissue healing.
→ Post-trauma or post surgical.
Verbal commands:
Visual Cues:
Rhythmic Initiation
Voluntary relaxation→ Passive motion throughout the available Rom – several times →
Patient familiar with Sequence of movements in pattern.
Repeated Contractions
Pattern
Reversal of Antagonists
Releasing objects.
Slow Reversal:
↓Quickly followed by
Isometric contraction of Agonist muscle group.
ALTERNATING ISOMETRICS:
Promote stability via Coordination of proximal stabilizing musculature of the Trunk, Shoulder
and Pelvic gridle.
Multiple muscle groups around the joint must contract → Rotators mostly.
Procedure
UPPER LIMB:
SHOULDER:
SCAPULA:
D2 – Flexion →
D2 – Extension →
ELBOW:
FOREARM
D1 – Flexion → Supination
D1 – Extension → Pronation
D2 – Flexion →
D2 – Extension →
WRIST
LOWER LIMB:
HIP
KNEE
ANKLE
D1 – Flexion →Extension
D1 – Extension → Flexion
D2 – Flexion → Extension
D2 – Extension → Flexion
MUSCLE PERFORMANCE
Active exercise in which dynamic or stable muscle contraction is resisted by an outside force
applied manually or mechanically.
Strength:
Ability of a contractile tissue to produce tension & a resultant force based on the demands placed
on the muscle.
OR
Greatest measurable force exerted by muscle or group of muscle to overcome the resistance
during a single maximum effort.
Functional strength:
Systematic procedure of a muscle or muscle group Lifting, Lowering or controlling heavy loads
(resistance) for a relatively low number of repetitions or a short period of time.
OR
Power training:
Endurance
Ability of a muscle to perform low- intensity, repetitive, sustained activities aver a prolonged
period of time
Repetitive, dynamic motor activities which involve the use of large body muscle.
Ability of muscle to contract repeatedly against a load, generate & sustain tension & resist
fatigue over an extended time period.
Key Elements→ Low intensity muscle contraction, Prolonged time period, Large number of
repetitions.
Adaptability: ↑ Oxidative & metabolic capacities →Better O2 delivery & use.
Minimize adverse forces on joints.
Produce less irritation to soft tissue & Comfortable.
Overload principle:
To improve muscle performance, a load exeding the metabolic capacity of the muscle must be
applied.
Application
Reversibility Principle:
Adaptive changes in a body systems in response to resistance exercise program → are transient
unless training-induced improvements are regularly used for functional activities.
Detraining
↓ in muscle performance begins within 1-2 weeks after the cessation of resistance exercises
& continues until the training effects are lost
Adaptive effects of training ( ↑ in strength, power, endurance) are highly specific to the training
method employed.
Relative to:
o Mode and velocity of exercise.
o Limb position ----- Joint angle
o Movement pattern during exercise
Basis related to:
o Morphological and metabolic changes
o Neural adaptations to the stimulus associated with motor learning.
Desired functional outcome → Ascend or Descend stairs:
o Eccentric and concentric exercise in a weight-bearing pattern.
Occurs to a very limited basis w.r.t velocity training & mode of exercise
Effects can occur from exercised limb to nonexercised contralateral limb in a resistance
training program.
Determinants and correlates that affect tension generation in a skeletal muscle:
Factors → Cross-section & size of muscle → Muscle fiber number and size.
Influence → Short fiber with Pinnate and multipinnate design → High force producing
Sartorius, lumbricals.
Development.
Contribute to:
→ Magnitude, Duration, Speed of force production.
2. Fatigue:
Complex phenomenon affecting muscle performance.
Caused by:
Multiple sclerosis
→ Awaken rested & function well – Early morning
→ Glycogen replaced from skeletal muscle & Blood within → 1 hour (Post-exercise)
Intermediate
High
Aerobic.
Intermediate
Fast
Fast
Type II B → Phasic, Fast-twitch – Gastrocnemius, bicep brachii → lift entire body
Low
Low
Anaerobic
Large
Fast
Fast
Hyperplasia
Strength and Endurance training → Motor unit recruitment → ↑ motor unit firing
Synchronization of firing → ↑
3. Metabolic system:
Myoglobin storage → ↑
Known → Strength
4. Enzymes:
Myokinase → ↑
5. Body composition:
6. Connective tissue:
Volume & frequency → Additional ↓ in repetitions, sets, number of exercise & frequency
Muscle performance
Puberty
Rate of muscle strength decline – accelerate to 15-20% per decade – 6-7th decade
→ ↑ t 30% per decade after 6-7th decade
Loss f muscle mass - ↓ed by 50% of peak muscle mass(young adulthood) – 8th decade
↓ in muscle fiber size & number & in ∞ - motor neuron number
→ Atrophy of type-II muscle fibers
Ability to develop or sustain sufficient muscle tension for execution or acquisition of functional
motor tasks – Adversely affected by:
“Ability to process relevant data while screening out irrelevant information from environment & to
respond to internal cues from the body”
→ Dynamic → at rest
“Point corresponding to center of total body mass & point where body is in perfect
equilibrium”.
Momentum
“Sway boundaries in which person can maintain equilibrium without changing BOS”
Quick stance — Area encompassed by outer edges of feet in contact with ground.
Normal adult — Anterioposterior sway limit — 12° from most posterior to most
anterior
Adult with 4 inches B/W feet — standing — 16° lateral sway limit
Sitting without trunk support — ↑ed limits of stability then …….
→ Height of COM above BOS is less & BOs is larger( buttocks in contact with surface)
Ground reaction force → “Reaction from ground due to contact b/w our bodies & ground
due
Equal and opposite to — weighted average of downward forces acting on the area in
Balance Control
“Complex motor control task involving detection & integration of sensory information to
assess the position & motion of the body in space & the execution of appropriate
Musculoskeletal responses to control body postion within the context of Environment and
Task.
2. Musculoskeletal contributions
Includes:
Postural alignment, Musculoskeletal flexibility (ROM), Joint integrity, Muscle
performance(strength, endurance, power), Sensation (touch, pressure, vibration,
proprioception, Kinesthesia)
3. Contextual effects — Environmental Interaction
Open environment → Unpredictable & with distractions
Closed environment → Predictable with no distractions
Support surface → Firm v/s slippery
Amount of lightening, effects of gravity, internal forces on body.
Tasks characteristics:
o Well learned v/s new
o Predictable v/s unpredictable
o Single v/s Multiple
→ somatosensory
→ Vestibular system
1. Visual system
Provide information about:
Position of head relative to environment
Orientation of head to maintain level gaze
Direction & speed of head movements → surrounding objects move in opposite
Direction
Used to improve → stability when → Proprioceptive or vestibular inputs are
unreliable by fixating the gaze.
Some provide inaccurate information balance → illusion of movement.
2. Somatosensory system
Provide information about:
Position and motion of body, body parts w.r.t each other, support surface.
o Proprioceptors → sensitive to → muscle length and tension
o Joint receptors → sensitive to → joint position, movement, stress
o Mechanoreceptors → sensitive to → vibration, light touch, deep pressure,
stretch
Inappropriate inputs about body position due to
o Surface is moving → on a boat
o Non horizontal surface
Local anesthetization of joint tissue & total joint replacement
o Donnot impair joint position awareness
3. Vestibular system
Provide information about → position and movement of head w.r.t Gravity and
Inertia.
Semicircular canal(SSC) receptors → detect angular acceleration of head
→sensitive to → Fast head movements → walking or during episodes of imbalances
(slips, trips, stumbles)
Otoliths (uterlie, saccule) receptors → detect linear acceleration, head position.
→ Respond to → Heaad movements → postural sway
1. REFLEX
2. AUTONOMIC
Mediating pathway → Brainstem/Subcortical
Mode of activation → external stimuli
Latency of Response → Intermediate
Response → Co-ordinate among leg & trunk muscles, stereotypical but adaptable
Role in balance → Resist disturbances
Response modifying factors → Musculoskeletal or Neurological abnormalities,
Configuration of support, prior experience
3. VOLUNTARY:
Mediating pathway → Cortical
Mode of activation → External or Internal stimulation
Latency of Response → Slowest
Response → co-ordinated, highly variable
Role in balance → Generate purposeful movements
Response modifying factors → Musculoskeletal or Neurological abnormalities,
Conscious effort, prior experience, task
complexity
Balance assessment & interventions:
1. Static balance
external loads.
2. Dynamic balance
CLINICAL TESTS → Observation of patient catching ball, Opening door, Lifting objects
4. Reactive —Feedback
CLINICAL TESTS → Observations of patient responses to pushes → small v/s large,
slow
v/s rapid, Anticipated v/s Unanticipated
Pull, Backward release, Postural stress test
5. Sensory organization
CLINICAL TESTS → Physical performance test, Barthel ADL index, Katz ADL Index,
STRAIN: Overstretching, Over exertions & Over use of soft tissues caused by
slight trauma or unaccustomed repeated trauma of a minor degree.
Referred superficially to distribution of “Musclotendinous Unit”.
Clinical Signs:
o Absence of inflammation.
o Pain after tissue resistance.
Plan of Care:
o Educate the patient.
o Control pain, edema, and spasm.
o Maintain soft tissue &joint integrity & mobility.
o Reduce joint swelling if symptoms are present.
o Maintain integrity & function of associated areas.
Interventions:
o Inform the patient of anticipated recovery time & how to protect the part
while maintaining appropriate functional activities.
o Cold, compression, elevation, massage (48 Hrs);
o Immobilize the part (Rest, splint, tape, cast);
o Avoid position of stress to the part;
o Avoid position of stress to the part;
o Gentle (Grade – 1) joint oscillations in pain free position.
o Appropriate dosage of passive movements within the limits of pain,
specific to the structures involved;
o Appropriate dosage of intermittent muscle setting or electrical
stimulation;
o May require medical intervention if swelling is rapid (Blood);
o Provide protection (Splint, Casts).
o Active – Assisted, resistive, modified Aerobic Exercises;
o Depends on
Proximity of associated areas.
Effects on primary lesion.
o Adaptive or Assistive devices
Protect the part during functional activities.
Precautions:
o Proper dosage of rest & movement during inflammatory stage.
o Signs too much movement (increased pain & Inflammation)
Contraindications:
o Stretching with resistance exercises.
(Should not be performed at the site of inflamed tissue)
SUBACUTE STAGE OR CONTROLLED MOTION PHASE.
Plan of Care:
o Educate the patient.
o Promote healing of injured tissue.
o Restore soft tissue, muscle, joint mobility.
o Develop N.M. Control, Muscle endurance & strength in the involved &
related muscle.
o Maintain integrity & function of associated areas.
Interventions:
o Inform the patient of anticipated healing time & importance of the
following guidelines;
(Teach home exercises & encourage functional activities)
(Modify & Monitor as the patient progresses).
o Monitor the tissue response to exercise program;
(Decrease in the intensity if inflammation increases)
o Protect healing tissue with assistive devices (Splints, tape, Wrap);
o Progressively increase the amount of time, the joint is free to move each
day;
o Decrease use of assistive devices as strength in supporting muscle
increases
o Progress from PROM to AAROM to AROM within pain limits;
o Gradually increase the mobility of scars (specific to involved structures);
o Progressively increase the mobility of related tight structures (Specific to
tight structures)
o Initially, progress multiple angle isometric exercises within the patient.
o Tolerance (begin with mild resistance with caution).
o Initiate AROM + protected weight bearing + stabilization exercises.
o ROM + joint play + Healing improves progress isotonic exercise with
increased repetition;
o Emphasize control & proper mechanics.
o Progress resistance later in this stage.
o Apply progressive strengthening & stabilizing exercises;
(Monitor effect on primary lesion)
o Resume low intensity functional activities involving the healing tissue
that don’t exacerbate the symptoms.
Precautions:
o Signs of inflammation or joint swelling decrease early in this stage.
o Discomfort with progression in activity level (not more than few hours)
o Signs of too much motion or activity are:
Resting Pain, Fatigue, Increase weakness, Spasm.
CHRONIC STAGE OR RETURN TO FUNCTION PHASE.
Plan of Care:
o Educate the patient.
o Increase soft tissue, muscle & joint mobility.
o Improve N.M control, strength & muscle endurance.
o Improve cardiovascular endurance.
o Progress Functional activities.
Interventions:
o Instruct the patient in safe progression of exercises & stretching.
Monitor understanding & complains.
Teach ways to avoid re – injury & safe body mechanics.
Provide ergonomics counseling.
o Stretching techniques specific to tight structures are:
Joint & selected ligaments (Joint mobilization).
Ligaments, tendons, soft tissue adhesions (Cross fiber massage).
Muscle NM inhibition, passive stretch, Massage, Flexibility
Exercise.
o Progress Exercise:
Submaximal to maximal resistance.
Specificity of exercise using resisted concentric & eccentric,
weight bearing & non – weight bearing.
Single plane to multi – plane motions.
Single to complex motions emphasizing movements that stimulate
functional activities.
Controlled proximal stability, super – imposed distal motion &
safe biomechanics.
Increase time of slow speed, progress complexity & time, progress
speed & time.
o Progress aerobic exercises using safe activities.
o Continue using supportive & assistive devices until the ROM &
functional joint play & muscle strength is adequate.
o Progress functional training stimulated activities from protected &
controlled to unprotected & variable.
o Continue progressive strengthening exercises & advance training
activities
Muscle capable to respond to the required functional demands.
Precautions:
o No signs of inflammation.
o Discomfort with progression in activity level.
o Signs that activities are progressing too quickly are:
Joints swelling.
Pain (for more than 4 Hours)
Decreased strength.
Fatiguing more easily.
Need medications.
ARTHRITIS – ARTHROSIS
Arthritis
o Inflammation of a joint.
Inflammatory & non – inflammatory.
Arthrosis:
o Joint limitation without inflammation.
Traumatic Arthritis:
o Bloody effusion
Aspiration.
Impaired Mobility:
o Signs of inflammation & joint involvement.
Characteristic pattern of limitation (CAPSULAR PATTERN)
Firm End – Feel.
Guarded end –feel in acute cases.
o Decreased & painful joint play.
o Joint swelling (Effusion).
Arthrosis in
o Recovery from a fracture.
o Problems requiring immobilization.
Impaired Balance
o Altered or decreased sensory input (Mechanoreceptors & muscle
spindle).
Develop balance deficit.
Problem with weight – bearing joints.
Functional Limitations
o Minimal or significant restriction of home, community, work related
social activities.
o Adaptive or Assistive devices Improve function or prevent deforming
forces.
RHEUMATOID ARTHRITIS
Characteristics:
o Periods of exacerbation (active disease) & remission (fluctuating course).
o Early inflammatory changes in:
Synovial membrane.
Peripheral portion of articular cartilage.
Subchondral narrow spaces.
o Granulation tissue (PANNUS) forms, covers, erodes
Articular cartilage, bone, ligaments in the joint capsule.
o Adhesion formation (Restricted joint mobility)
o Cancellous bone exposed with disease progression.
o Deformity & disability caused by:
Fibrosis, Ossific ankylosis, Subluxation.
o Inflammatory changes in tendon sheath (TENOSYNOVITIS).
Recurring friction Tendon fray or rupture.
o Extra – articular changes are:
Rheumatoid nodules.
Atrophy & fibrosismuscle weakness associated.
Fatigue.
Mild cardiac changes.
o Progressive deterioration & decreased functional level progressive
muscle weakness.
o Irreversible loss of function of joint.
Characteristics:
o Degeneration bone remodeling & capsular distention capsular
laxity
(Hypermobility /
Instibility)
o Pain & decreased willingness to move
Contractures in the portions of capsule & overlying muscle.
Unknown Etiology:
o Mechanical injury to the joint
Major stress.
Repeated minor stress.
o Poor movement of synovial fluid immobilized joint.
Rapid destruction of articular cartilage with immobilization.
(Deprivation of nutritional supply)
o Genetics Hands, Hips, knees.
Other Risks factors are:
o Obesity.
o Weakness of Quadriceps.
o Joint impact.
o Sports with repetitive impact & twisting soccer, baseball, football.
o Occupational activities.
o Jobs requiring
Kneeling.
Squatting with heavy lifting.
o Cartilage splits & Thins out:
Crepitations & loose bodies (joints) Subchondral bone exposed.
o Increased bone density in joint line:
Cystic bone & osteopenia in adjacent metaphysis.
Enlarged Joints:
o Heberden’s nodes Finger DIP enlargement.
o Bouchard’s nodes PIP enlargement.
Most Commonly Involved joints:
o Weight bearing joints.
o Cervical & lumbar spine.
o Finger DIPs & Thumb CMC joints.
Symptoms:
o 11 out of 18 tender pints at specific bony sited.
o Non – restorative sleep.
o Morning stiffness.
o Fatigue with diminished exercise tolerance.
Characteristics:
o Symptoms usually appear in early – middle adulthood.
o Symptoms after physical trauma:
Motor vehicle accident, viral infection 30% Dx.
Hallmark Complaints:
o Pain (Muscular origin) scapula, head, neck, chest & low back.
o Fluctuating symptoms is common.
Pain – free to marked increase in pain.
Higher Incidence of:
o Tendonitis.
o Headaches.
o Irritable bowel.
o Temporomendibular joint dysfunction.
o Restless leg syndrome.
o Mitral valve prolapsed.
o Anxiety, depression, memory problems.
Contributing Factors:
o Environmental, physical, emotional stress aggravates F.M.
Environmental Stress:
o Weather changes baroreceptor pressure changes, cold, dampness, fog
rain, fluorescent lights.
Physical stress:
o Repetitive activities Typing, playing piano, vacuuming.
o Prolonged periods of standing or sitting.
o Working rotating shifts.
Emotional stress:
o Life stresses.
Hallmark Classification:
o Myofascial trigger points in a muscle with referred pattern of pain.
Trigger Points:
o Hyperirritable area in tight band of muscle.
o Pain is dull, aching, deep.
Types:
o Active produce classic pain pattern.
o Passive or latent asymptomatic unless palpated.
Impairments:
o Decreased ROM with stretching a muscle.
o Decreased muscle strength.
o Decreased pain with stretching a muscle.
Possible Causes (of Trigger points):
o Chronic Overload of Muscle with:
Repetitive activities.
Maintained shortened position.
o Acute Overload of Muscle:
Slipping & catching one self.
Following a trauma Motor vehicle accident.
Picking up object with unexpected weight.
o Postural Stresses:
Prolonged time sitting.
Leg – length differences.
o Poorly conditioned muscles.
o Poor body mechanics.
OSTEOPROSIS
T – Score:
o Number of standard deviations (SD) above or below a reference value.
Normal: -1 or Higher.
Osteopenia: -1.1 to -2.4
Osteoporosis: -2.5 or less
Risk factors:
o Primary osteoporosis:
Post menopause.
Low body weight.
Family History.
Little or no physical activity.
Smoking
Caucasian or Asian descend.
Prolonged bed rest.
Advanced age.
o Secondary Osteoporosis:
Medical Conditions:
G.I – Disease.
Hyperthyroidism.
Chronic renal failure.
Excessive alcohol consumption.
Medical Use:
Glucocorticoids.
o Radiograph Defects:
Cortical Thinning.
Osteopenia Increased bone radiolucency.
Trbecular changes.
Fractures.
Prevention:
o Diet rich in Ca++ & Vitamin – D.
o Weight bearing exercises.
o Healthy life style Moderate alcohol consumption.
o No Smoking.
o Testing Bone density & medications (if needed)
Upper Quarter:
o C1 – 2 cervical flexion
o C3 cervical side flexion
o C4 scapular elevation
o C5 shoulder abduction
o C6 Elbow flexion & wrist extension
o C7 Elbow extension & wrist flexion
o C8 Thumb extension.
o T1 Finger abduction.
Lower Quarter:
o L1 – 2 Hip flexion
o L3 knee extension
o L4 Ankle dorsi flexion
o L5 Big toe extension
o S1 Ankle eversion, plantar flexion, hip extension
o S2 Knee flexion.
o S3 No specific test action – intrinsic foot muscles (except, Abd.
Hallucis)
BRACHIAL PLEXUS
Vasomotor fibers from sympathetic trunk join anterior primary rami.
o Course within brachial plexus & peripheral nerves to extremities.
Formed by Anterior primary division of C5 – T1 nerve roots.
Function as distribution center for organizing the contents of each peripheral
nerve.
Course through thoracic outlet (Vascular & neurological symptoms TOS)
o 3 primary sites for compression or entrapment of neuromuscular
structures.
1. Interscalene bordered by scalenus anterior, medius & 1st rib
2. Costoclavicular space between clavicle(superiorly) & 1st rib (inferiorly)
3. Axillary interval between deltopectoral fascia, pectoralis minor, coracoids
process.
Structural anomalies (cervical rib or Malunion of clavicular fracture)
o Compress or entrap a portion of plexus.
Upper plexus injuries (C5 – 6):
o Most common injury compression or tearing of upper trunk
o Mechanism Shoulder depression & neck contra lateral flexion
o Result loss of shoulder abduction & lateral rotation
Weakness in Elbow flexion
Weakness in forearm supination
Erb’s Palsy or Waiter’s Tip Deformity:
o Occur with birth injuries shoulder stretched downward.
o Maternal & infant factors described by Benjamin
Stinger land on upper torso & shoulders with head & neck contra lateral
lateral flexion (playing football)
Radial Nerve C6 – T1
o Emerge directly from posterior cord at the lower border of Pectoralis
mior.
o Descends in arm, wound around humerus posteriorly in musculospinal
groove.
Continue to radial aspect of elbow.
o Innervate Triceps, Anconeus, upper portion of forearm extensors &
supinators.
o Injury with shoulder dislocation & mild humeral fractures.
o Crutch Palsy:
Condition of nerve compression due to leaning on Axillary
crutches.
o Saturday night Palsy:
Occurs when sleeping with person’s head on arm, slung over the
back of a chair or open car window.
Triceps involve if compression or injury occurs close to the axilla.
o Pierce lateral muscular septum, anterior to lateral epicondyle.
o Pass under the origin of extensor carpi radialis brevis.
Divide intosuperficial & deep branches.
o Deep BranchEntrapped under the edge of ECR brevis & fibrous slit in
the supinator.
Progressive weakness in wrist & finger extensor & supinator
muscles.
(Except ECR longusinnervated proximal to the bifurcation)
Impingement erroneously k/n Tennis elbow or lateral epicondylitis.
Pass around the neck of radiusinjury with radial head fractures.
o Superficial Branchundergoes direct traumasensory changes.
Enter the hand on dorsal surfacesensory only.
o Injury proximal to elbowResults in wrist drop & inability to actively
extend the wrist & fingers.
o Length – tension relationship of extrinsic finger flexors affected.
o Result in ineffective gripwrist splinted in partial extension.
o Injury to mid – forearmsupinator, extrinsic abductor & extensor
pollicis muscle affected.
Lumbosacral Plexus:
o Lumbarformed by anterior primary divisions of nerve rootsL1,3 & 4.
o SacralFormed fromL4-5, S1, S2, S3(part).
o Anterior primary rami receive postganglionic sympathetic nerve fibers
from sympathetic chain.
Innervate sweat glands, blood vessels, piloerrector muscle.
o Isolated injuries are uncommon.
o Symptoms commonly arise from:
Disc lesions.
Spomdylitic deformities affecting greater than or equal to 1 nerve
roots.
Tension or compression of specific peripheral nerves.
Femoral Nerve L2 – 4
o Arise from 3 posterior divisions of lumbar plexus.
o Emerge from lateral border of Psoas major (superior to inguinal ligament)
o Descent under Inguinal ligament to femoral triangle (lateral to femoral
artery)
o Innervate the Sartorius & Quadriceps.
o Iliopsoassupplied superior to inguinal ligament.
o Injuries occur:
With traumafracture of upper femur & pelvis.
During reduction of CDH (Congenital dislocation of hip)
From pressure during a forceps labor & delivery.
o Weakness of hip flexion, loss of knee extension.
o Symptoms from neuritis in D.M.
Obturator Nerve L2 – 4
o Arise from three anterior divisions of Lumbar plexus.
o Descend to medial side of thigh via Obturator canal in the medial
Obturator foramen.
o Innervate Abductor muscle group & Obturator externus.
o Injury via hernia pressure & damage during labor.
o Adduction & external rotation (thigh) impaired difficulty in crossing
legs.
Sciatic Nerve L4 – S3
o Emerge from sacral plexus as largest body nerve.
o Component parts Tibial & common peroneal nervedifferentiated in
common sheath.
o Small nerves from sacral plexus (proximal to sciatic nerve formation)
innervate buttock muscles external rotators & gluteal muscles.
o Exit pelvis via greater sciatic foramen & course below via piriformis
muscle.
Piriformis Syndrome:
Occurs from shortened musclecompression & irritation of
nerve.
o Course between Ischial tuberosity & greater trochanter
Protected under gluteus maximus.
Injury with hip dislocation or reduction.
o Tibial portion Innervateshamstrings & Adductor magnus (portion)
o Common peroneal protion innervatesshort head of biceps femoris.
o Terminate into tibial & common peroneal nervesproximal to popliteal
fossa.
Seddon’s Classification
o Three levels of pathology.
Sunderland’s Classification
o Five levels of injury & potential for recovery.
Acute phase
Early after injury or surgery
Emphasis on healing & complication prevention.
Recovery phase
Reinnervation occurs
Emphasis on retraining & re – innervations
Chronic phase
Potential for re – innervations has peaked & significant residual deficits
are present
Emphasis on training compensatory function
Acute Phase
After injury or surgery (decompression & release or lacerated nerve)
Immobilization (brief period)
Protect the nerve.
Minimize inflammation.
Minimize tension at injured or repeated site.
Movement (ROM)
Minimizing joint & connection.
Splinting or Bracing:
Prevent deformities due to strength imbalances
Radial nerve splint Prevent Wrist drop
Median nerve splint position the thumb in opposition
Plantar flexion splint Prevent foot drop
Prevent undue stress on healing nerve
Patient Education:
Prevent extremity to avoid injury due to sensation loss.
Chronic Phase
Re – innervations peaked & minimal or no sign of re – innervations
Train for compensatory function
Continue wearing supportive splint or brace
Preventive care continues (to avoid injury)
Recovery Phase
Begins with the signs of reinnervation
(Volutional muscle contraction & hypersensitivity)
Motor retraining
Signs of volutional muscle contractionmuscle positioned shortened
Electrical stimulationused to re – enforce active effort
Control gainedBegin gravity eliminated AA – ROM
Weak musclesprotected with splint or a brace.
Desensitization
Regenerationhypersensitivity in the area
Graded series of modalities & proceduresdecreased irritability &
increased awareness
Multiple texture & contactssensory stimulation
Pattern of recovery after nerve injury:
Pain (Hypersensitivity)
Perception of slow vibration (30cps), moving touch, constant touch
Perception of rapid vibration (256cps), awareness from proximal to
distal
Discriminative sensory re – education
“Process of retraining the brain to recognize a stimulus once the
hypersensitivity diminishes”
Begins with moving touch stimulus & stroke over the area
Open eyed followed by closed eye
Constant touch localizedprogress to identify various sizes, shapes,
textures
Hand keys, eating utensils, blocks, tooth brush, safety pins
Feet Grass, sand, wood, pebbles, uneven surfaces
Patient education
Resume the use of the extremity
Monitor pain, swelling, discoloration
Modify or temporarily avoid aggravating factors
Preventive care to avoid injury.
History
Vascular & mechanical factors nerve pathology
Pain most common symptom
Sensory response stretch pain or paresthesia with neural stretch
position
Tests of provocation
Neurodynamics tests detect tension signs in neural tissue
Upper limb tension test ULTT
Upper limb Neurodynamics test ULNT
Straight leg raise SLR
Slump test
Additional testsNerve palpation, sensory testing, muscle testing
Test positions & maneuvers same as those of Rx
Tension signsStretch pain or paresthesia
Neurological system stretched across multiple joints
Caused bystress on nerve proximal or distal to the compression
site
Principles of Management
Nerve irritability increased with intensity of the maneuver
Tension or primary restriction
“stretch force applied into the tissue resistance & held for 15 – 20
sec, released & then repeated”
Stretched released neurological symptoms (tingling, increased
numbness) vanish
Position the patient at the point of tension (Beginning of symptoms)
Actively or passively move the joint stretch & release the
tension
Teach self stretching.
Neural Tension Disorder
Nerves vulnerable to increased pressure or tension with
Excessive or repetitive stress or strains imposed
Nerve compressed passing near a bony structure or a confined
space
Adhesive scar tissue or swelling restrict the mobility
Tests of provocation performed
NEURAL TESTING & MOBILIZATION TECHNIQUES
Median nerve
Position supine
Application
Shoulder depression
abduction (slight)
Elbow extension
Arm lateral rotation
Fore arm supination
Wrist extension
Fingers extension
Thumb extension
Neck contra lateral side flexion
Examine & Rx problems with:
Shoulder girdle depression (Thoracic Outlet Syndrome)
Carpal tunnel syndrome
Radial Nerve
Position supine
Application
Shoulder depression
abduction
Elbow extension
Arm medial rotation
Fore arm pronation
Wrist ulnar deviation
flexion
Fingers flexion
Thumb flexion
Neck contra lateral side flexion
Examine & Rx symptoms related to:
Shoulder girdle depression
Tennis elbow & de Quevaion’s syndrome
Ulnar nerve
Position supine
Application
Shoulder depression
abduction
external rotation
Elbow flexion
Fore arm supination
Wrist extension
Neck contra lateral side flexion
Important in symptoms related to
C8 – T1 nerve roots, lower brachial plexus, ulnar nerve
Medial epicondylitis
Femoral Nerve
Position neutral (not extended) & hip extended to 0 o
Apply knee flexion.
LBP or sensation changes in anterior of thigh
Upper lumbar nerve root tension
Femoral nerve tension
Spine Hyper – extension
Decreased foraminal space nerve root pressure
Spinal movement facet pain
Thigh pain
Rectus femoris tightness
Alternate positions & procedures
Position side lying with involved leg upper most
Application
Pelvis Stabilization
Hip Extension
Knees flexion
Sciatic Nerve (SLR with ankle dorsiflexion)
Position supine
Apply SLR with ankle dorsiflexion
Variations :
Hip adduction
medial rotation
Ankle Dorsiflexion
plantar flexion
Inversion
Neck flexion (passive)
Variations are used to differentiate
Tight or strained hamstrings
Nerve mobility in Lumbosacral plexus & sciatic nerve