PROGRESSION OF EXERCISE

PROGRESSION OF EXERCISE

PLANNING YOUR TREATMENT Evaluation guides your treatment How?

IRRITABILITY Pain level Linger Sleep How quickly does the pain come on? Consistency or behavior

STAGE Acute Chemical vs Mechanical Subacute Chronic

NATURE Protocol Source of the symptoms Movement dysfunction

IMPAIRMENTS Ranking your Impairments Contributing factors

Manuals** Progression Work Tasks Recreation/ Sport Functional limitation, balance/ gait dysfunction, Strength, motor control/ endurance Range of Motion Pain, Inflammation, Edema/ Swelling

EXAMPLE: S/P TOTAL KNEE 3 weeks post op, using cane, step to stairs C, V, deep ache, i/m sharp with movement Edema Aggs: movement, amb, sitting sustained, u/a to do household chores Eases: elevation ice, pain meds every 4-6 hours Sleep: disrupted, using pain meds ROM: 8-82 Strength: poor QS, 5 deg Quad lag Circumference: 2cm difference patella Gait: decreased stance time, decreased TKE, decreased knee flexion swing

TREATMENT DAY ONE? Rank the Impairments Pain Edema ROM Strength Quads, LQ Chain Function: amb, transfers, gait, balance deficits

TREATMENT DAY ONE Start with HIGH irritabilty 1. Address the Pain/ Inflammation Kinesiotape for lymphedema Ice/ Game Ready/ Elevation end 2. ROM deficits Education regarding heel prop to gain extension Heel slide (also addresses the edema) 3. QS education 4. Sleep education

ADDRESSING PAIN WHY? Constant symptoms= chemical component Need to treat the chemical component before mechanical treatment will be effective Example: RTC tendonitis with constant symptoms Strengthening the injured weak tendon with increase the pain Tape techniques for repositioning Addressing the scapular mechanics Ice/ IFC Pain inhibition MUSCLES do not function with Pain OR Edema Example: irritation fat pad: will shut off Quad Tape techniques to limit hyperext/ LQ strengthening Patient relationship

If your patient experiences pain for more than 30-45 minutes after your treatment you have over worked the patient.

ROM/ FLEXIBILITY Ability of the neuromuscular system to function properly requires the right ROM, while providing optimum NM control through full ROM.

ROM/ FLEXIBILITY For example: your primary hypothesis for a patient with Low Back Pain is inadequate Glut Max strength. You notice in gait that she has significant loss hip extension and MMT is less than 3+/5 with hyperextension in LB to perform. Why is she hyperextending? Inadequate Hip Extension of Hip flexor length must be addressed FIRST

ADDRESSING ROM/ FLEXIBILITY Loss ROM/ Flexibility may be an issue of Post-surgical Disuse Fibrous Adhesions: a response that occurs due to overuse of the muscle/ scarring Nerve tension

ADDRESSING ROM/ FLEXIBILITY Static Stretching (manual or self) Myofascial Release (manual or self) Neurodynamic Stretching (nerve glides) Active stretching Neuromuscular stretching (CR/ PIR) Dynamic flexibility

STRENGTHENING/ STABILIZATION Strengthening progressions should incorporate 3 components in this order: 1. Stabilization: exercise involves little joint motion; designed to improve intrinsic stabilization and provide optimum NM control (ex: RTC impingement: Supine ER/IR) 2. Strength: isometric stabilizing activities progress to dynamic concentric and eccentric activities through full ROM eccentric and concentric (ex: isometric GH to foam roll outs to FTW flexion to scaption) 3. integrates stabilization and strength into activity specific progressions. Entire muscle action and contraction velocity spectrum used with functional movements. Exercises performed at similar intensity and rate of force production that the individual will be exposed to upon return to their environment. (ex: Bosu, wall push up, walk outs, BB, box lift, lat pull down with lift, functional squat with row)

STRENGTHENING Principle of Overload: provide appropriate training stimulus to elicit optimal physical, physiological and performance adaptations Principle of Variation: enable continuous adaptations; high volume = cellular changes; high intensity = neural changes Specificity Principle: mechanics of training exercise should be similar to individuals sport or job; Transferof-Training Effect Individualization Principle: improved functional ability with movement specific training

CONSIDER THE TYPE OF STRENGTH YOU ARE TRYING TO ACHIEVE Limit Strength/ Maximal Strength : maximal force single contraction Relative Strength: maximal force that an individual can generate per unit of body weight **Optimum Strength: ideal level of strength that individuals need to perform functional activities **Endurance Strength: ability to produce/ maintain force over prolonged periods of time Speed Strength: ability to produce greatest possible force in shortest amount of time **Stabilization Strength: ability of kinetic chain stabilizing muscles to provide optimal dynamic joint stability and maintain postural equilibrium during functional movements **Core Strength: control individuals changing center of gravity; improves segmental stabilization **Functional Strength: ability of NM system to produce dynamic, multiplanar eccentric, isometric stabilization, and concentric contractions quickly and efficiently during functional movements

= 3 X 10? Training Adaptation Sets Reps Intensity Rest Interval Neural 4-8 1-5 85%-100% 3-5 min Strength 3-4 6-8 75%-85% 2-3 min Cellular 3 9-12 70%-75% 45-90 sec Strength/Endurance 2-3 12-25 50%-70% 30-60 sec

CORE STABILIZATION FOUNDATION Lumbo-Pelvic-Hip-Complex: **Inner (local musculature): TA, internal obliques, multifidi, lumbar transversospinalis Outer (global musculature): RA, external obliques, erector spinae, QL, adductor complex, quadriceps, hamstrings, glut max Core stabilizers are primarily type 1, slow twitch fibers

PROGRESSION OF STABILIZATION Slow fast Simple complex Known unknown Low force high force EO EC Static dynamic Quality of movement Proprioceptively challenging

PROGRESSION OF STABILIZATION Balance Modality Body Position Base of Support LE/UE Symmetry External Resistance Floor Supine Tandem 2 legs/arms TBand Dynadisc Prone Narrow Staggered Dumbells Bosu Sidelying Wide 1 leg Medicine Ball

BALANCE/ PROPRIOCEPTION Proprioception: cumulative neural input to CNS from mechanoreceptors that sense position of the limb movement. Kinesthesia: conscious awareness of joint movement and joint position sense that results from proprioceptive input from CNS Postural Control: integrated feedback control circuit between CNS and MS system. Control center of gravity form appropriate muscle activation patterns. Postural Equilibrium: sensory organization, sensorimotor integration, muscle coordination.

BALANCE/ PROPRIOCEPTION Reflex mediated control: regulates antagonistic and syngergistic patterns of muscle contraction; *should dominate neuromuscular training Brainstem mediated control: inhibits antagonistic muscle activity under conditions of rapid lengthening and periarticular distortion; sensory information relayed to brainstem to assist with posture and balance Cognitive mediated control: sensory afferent interact and influence cognitive awareness of body position and joint movement

WORK/ RECREATION Be specific to job duties/ recreational tasks Recreate the environment