MSK 3 Compiled Notes Weeks 1-6 PDF

6.1 pelvic thigh pathology hip area pain osteitis pubis classification based tx mechanism of injury overuse stress injury 2ndary to excessive sup/inf shear forces at the pubic symphysis (rectus above & ADD below)-vertical direction -most common in soccer players and race walkers pelvic area injuries...

6.1 pelvic thigh pathology hip area pain osteitis pubis classification based tx mechanism of injury overuse stress injury 2ndary to excessive sup/inf shear forces at the pubic symphysis (rectus above & ADD below)-vertical direction -most common in soccer players and race walkers pelvic area injuries 1. osteitis pubis 2. meralgia parenthetical 3. hip pointer/contusion 4. piriformis syndrome osteitis pubis contmanagement: – rest, NSAIDs, normalize SIJ osteitis pubis continued signs and symptoms: -palpation tenderness over pubic symphysis -symptoms often exacerbated by passive ABD (faber position), resisted ADD or abdominal contractions -can be done simultaneously -can aggregate by springing one of the pubic rami to look for discomfort w increased shear forces mechanics – when acute symptoms subside begin adductor stretching, balance abductor- adductor strength, and core stabilization training -groins can be stretched meralgia paresthetica dysfxn of sensory lat femoral cutaneous n of the thigh as it passes thru or over the inguinal ligament as it courses down the anterolateral thigh meralgia paresthetica predisposing factors obesity pregnancy - transient tight pants signs/symptoms pain & parades this over upper anterolateral high may be able to reproduce w sidelying femoral n tension test w hip ADD no muscle weakness meralgia paresthetica: tx 1.avoidance of irritating activities and selective rest 2. NSAIDs 3.SIJ screen/tx 4.wt loss 5.ADL modifications -clothing, tool belts, seat belts piriformis syndrome deep aching in the sciatic notch of the buttock (intersection of sciatic nerve and piriformis) − referred posterior thigh pain usually not beyond the knee pain often aggravated by sitting, squatting or walking more common in females and often associated with SIJ dysfxn ex: biomechanics limited and painful passive IR or adduction and resisted ER or horizontal abduction of the hip (good SN/SP) (~80%) seated SLR with adduction and IR (high SP) *could be used to rule out (last 2) piriformis syndrome tx ultrasound (deep heat) hp manual therapy & soft tissue mobilization ex: hard ball or PT address faulty pelvis (SIJ), hip or foot mechanics address postural or work related contributing factors gentle piriformis stretching best piriformis stretch IMO piriformis is an IR above 90 degrees and an ER below 70 -key is to keep thigh in sag plane (or medial to it) other piriformis exercise ideas iliac crest contusion all figure 4 related hip pointer mechanism of sitting position injury pigeon position -direct blow to can be supine or sitting iliac crest make sure to keep pelvis -cranial nerves from post rot can become sensitive to this hip pointer sign/symptoms area if ICC exquisite tenderness in soft tissues around the iliac crest pain with trunk rotation or hip motion * most likely will see ecchymosis bc area is heavily vascualrized quadriceps contusion mechanism of injury direct blow to ant thigh signs/symptoms point tenderness hematoma formation come quickly bc its heavily vascularized present hip pointer managemnt ice elastic bandage compression gentle, pain free trunk & hip ROM needs time to heal upon return to activity of risk ensure properly fitting hip pads &/or hard shell orthoplastic protection of the area quadriceps contusion severity of injury grade 1- 90 degrees knee flex grade 2- 45-90 knee flex grade 3: - hours, but used if myositis develops later regain motion and prevent bc can cause more bleeding which is what we DONT want complications myositis ossificans complication hematoma can cause calcifications significant injury that limits physical fxn morel-lavallee lesions (another type of thigh contusion) definition: closed soft tissue degloving injury in which the subcutaneous fat layer is separated from the underlying muscular fascia and disrupts the rich perforating vessels void is created and filled with blood, lymph, and necrotic fat deforming force is usually shear (80%) instead of blunt trauma impact perpendicular to the thigh (20%) Tejwani, et al, Am J Sport Med, 2007 morel-lavallee lesion differential: – 60% will have full ROM at initial eval and relatively painless and full muscle strength of anterior thigh muscles (even in acute phase) – feel tightness in the anterior thigh – quad contusions tend to be "tense" while MLL is fluctuant (can almost mobilize fluid thats collecting) Tejwani, et al, Am J Sport Med, 2007 morel lavallee lesion: tx -ice and compression wrap -game ready (pneumatic intermittent compression concurrent w cold therapy) -immediate AROM for hip and knee and/or CPM at a pain free level extra-articular hip injuries 6.2 contractile injuries strains 1.groin (ADD) 2.hamstrings 3.iliac apophysitis 4.iliopsoas GTPS 1.tendinopathies 2.snapping hips 3.”trochanteric bursitis” groin pain differential contractile strain tx considerations acute phase – ice, compression wraps, rest, modalities or medication to control inflammation, pain-free hip AROM; lumbopelvic core stability training; and reduced stride direction gait training subacute phase – contrast thermotherapy, soft tissue myofascial techniques, dynamic stretching, balance drills, low-level agility, and progressive, eccentric training in protected arcs (no passive insufficiency) terminal phase – fxnal rehab progressing toward plyometric mvmnt and correction of soft tissue and structural dysfxns and predisposing factors core muscle injury- sports hernia athletic pubalgia w/o a true herniation weakening of the abdominal wall in the area of the inguinal canal possible entrapment of the genitofemoral nerve pain with twisting/turning in single limb stance; resisted adduction; sit-ups + Rocker Test valsalva type maneuver may be provocative forcible exhalation against a closed airway rest or surgical repair with emphasis on restoration of abdominal strength, adductor flexibility, and a gradual resumption of activity valsalva: holding breath goal: optimal tissue loading to enhance tensile capacity core muscle injury proposed tx algorithm prox HS injury most common: prox attachment injuries -tearing at ischial tuberosity identification symptomatic complaint tolerate activities that dont involve stored energy (eccentrics) or compression such as level surface walking, standing, or supine lying aggravated by activities that require deeper hip flexion – squatting, lunging, prolonged sitting on firm surfaces; mild AM stiffness differentiate from sciatica by slump test symptom management refrain/rest from activities that increase symptoms reduce ambulation stride length adopt cross training (alternate activities) — Flutter Kicking, Pool or Alter-G Ambulation Consider exercise position rehab focuses on progressive hamstring loading isometric holds isotonics in hip / isotonics in hip flex energy storing eccentrics (plyometrics) -optimal tissue loading to enhance/restore tensile capacity phase load progression active lengthening protocol dont start in passively insufficie nt position dynamic eccentric hamstring training progressions -lower to higher tension -slower to faster speed -limited to full arc -load addition plyometric drills for return to activity proposed grading scheme to determine severity and predict return to play time older pts w larger, distal and retracted tears have slowest recovery summary of recommendations 6.3 Greater Trochanteric Pain Snapping Hips AKA coxa saltans Can hear an audible snap from an external or internal source confused with dislocation at times. EXTERNAL- IT band crosses over greater trocanter INTERNAL- illipsoas tendon crossing iliopectineal eminence when UNCROSSING legs from FABER position Ludloff Sign - active SLR from sitting in chair where RF is actively insufficient Dr Alison Grimaldi- great hip source. talks about extra articular injuries , snapping of ilipsoas and IT Band OBJECTIVE FINDINDGS External- seen MUCH more dramatic SNAP Look for TIGHT ABDUCTORS EXT * Internal- felt or heard. Subtle , deep snap with tenderness to palpation in the femoral triangle Look for tight HIP FLEXORS int TREATMENT - for snapping hip address identified impairments Correct limb length discrepancy Strengthen Weak glutes Train core trunk stability Hip mobilization Stretch tight muscles Glute MAX (external) Iliopsoas (internal) Greater Trochanteric Pain Syndrome Likely a tendinous of some kind Prolonged intermittent peritrochanteric pain Accompanied by tenderness to palpate Lateral aspect of the hip USED to be called bursitis Indicated but NOT responsible fort he symptoms thats why there normally isn’t any cardinal symptoms (edema, erythema, rubor) MRI - only 8% patients indenfied as having GTPS actually had bursitis where 100% actually had GLUTE MED tendon abnormalities 80% with GT did not have bursitis but 50% had tendinosis GTPS Prevalance USUALLY females 2-5 times more likely 10-25% in between 4th-6th decades of life. 2.5% of hip injuries in a sporting population GTPS RISK FACTORS History of Low back pain 20-62% of the time From a cross sec, multi center observational study ITB tenderness and knee osteoarthritis are positively related BUT……..can’t find a positive relationship with over 30BMI or limited hip mobilitity UNPROVEN but reasonable risk factors Extrinsic factors assymetrical shoe wear RUnning on cambered or crowned surface unreasonably fast progression in the intensity duration or frequency of training Intrinsic factors NOT enough core stability Glute weakness Functional limb length discrepancies Alterations int he pronation supination sequence 3 [ Clinical Criteria for the diagnosis of TROCHANTERIC BURSITIS - GTPS Aching of lateral hip DIstinct tenderness around the greater trochanter ↳ HAVE TO HAVE BOTH -Pain at end range Abd/Add or IR/ER or +FABER -Pain on resisted hip ABD (SLS test) -Pseudoradiculopathy (pain extending down lateral thigh) Media e - __ - 7 max + IN ENSITY [MANAGEMENT↳ Keep IT band out of stretched and compressed position NO ITB stretching or foam rollers Massage rollers distal to GT may be tolerated ADL recommendations Don’t cross leg sit, Don’t stand on one leg Sleep with pillow between thighs SLAM - Sit like a man, man spread Core Stability training Hip mobility enhancement Address posteroINF capsular restrictions Manual therapy- lateral distraction and posterior glides ONE OF DEEZ REHAB Ice Low Level Laser Therapy Unload tissue with reduced weight bearing Soft tissue massage and suction decompressive unloading Outer range hip abduction training No CLAM Shells Training DEEP gluteals bridging side lying isometric holds weight bearing slides in out range Progress towards eccentric and functional training COrticosteroid injections have shown to have short term impact but no long term value as opposed to exercise intervention and shockwave therapy 6.4 Pediatric Injury - HI Intra-Articular Hip Injuries - Pediatric - LCP, SCFE, Apophysitis - Traumatic - Fractures, Dislocations - Impingement - FAI: Pincer/Cam - Hypermobility - Focal (DDH) vs. Global Laxity (Instability) - Hypomobility - DJD/OA - Pediatric Apophysitis - Mechanism of Injury - Gradual onset of growth plate inflammation at its ossification center secondary to repetitive contractions by oblique abs, glute med, TFL, or hammys - Musculocutendinous units cause tractional bony change on developing insertional areas - Common in adolescent runners, soccer players, jumpers - Signs/Symptoms - Pain over growth plate at muscular insertions - Increased pain w/ resisted contractions - Management - 4-6 weeks of rest w/ gradual resumption of training activities - Work on running & jumping mechanics - Complications - Avulsion fractures E Apophyseal Injury - Therapy - Typically starts after 2-4 weeks of rest - Flexibility (Pain free range) - Strengthening - Progression from concentric to eccentric - Slow, careful progression to prevent avulsion Legg Calves Perthes - Avascular necrosis - Results in flattening of femoral head (Coxa Plana) - Disease Process - Avascular Phase - Blood supply stops - Collapse (Fragmentation) Phase - Acetabulum Collapses - Revascular Phase - Blood Supply restored - Healing (Reossification) Phase - Flattened femur replaced with new bone - Healed Phase - Formation fo femur completed (18-24 months) - Shape may continue to round until end of skeletal maturity - Prevalence - 1:1200 kids (boys>girls) - Self limiting disease w/ spontaneous healing as necrotic bone is replaced by new bone formation (1-4 yrs) - Can have residual effects from incongruency & persistent hip ABD weakness - Signs & Symptoms - Gradual onset in boys (4:1) b/w age 4-8 - More typical in small, hyperactive kids - Mild limp (Trendelenburg) following activity w/ vague hip & groin pain - Symptoms resolved by rest - Limitation in ABD & IR - Management - Rest, crutches, maintain ROM, NSAIDs - Surgery indicated if patient over 8 (pelvic/femoral osteotomy) Slipped Capital Femoral Epiphysis (SCFE) - Femoral head slips in posteromedial direction on femoral neck - Onset - Acute - Sudden onset of pain/disability w/ specific trauma - Results in restricted hip ABD/IR - Acute on Chronic - Aching pain in thigh/hip/knee for weeks or months as a result of chronic slip - Followed by trauma causing acute symptoms - Chronic - > 3 weeks of pain & disability w/ history of limp & progressive loss of hip ABD/IR ROM - Signs & Symptoms - Obese males b/w 9-15 yrs - BEWARE of lateral knee pain - Limited & painful hip IR w/ hip often held in FLEX - Secondary to Psoas Spasm - Leg Length discrepancy, involved limb shortens - Post-Op Management - 4-6 weeks of NWB - Gradual resumption of WB & ADL activities Differentiation of SCFE & LCP - SCFE has more limitation in FLEX - SCFE symptoms are more severe - Evidence of slippage evident on radiograph - Clinical Evidence of Slippage - Stable - Vague knee/hip pain - Antalgic limp w/ toe out gait - Unstable - Hip FLEX accompanied by ER - Unable to walk w/o crutches 6.5 fracture instability femoral stress fractures -most prevalent in runners and military personnel in basic training most common in femoral neck and shaft “fatigue” injury as a result of excessive training, predisposing bone pathology, and/or poor nutrition{in females} (REDs) symptoms deep aching in hip; pain often referred into groin and knee morning stiffness does not ease symptoms increase with activity femoral stress fracture clinical signs + fulcrum or percussion test gold standard for dx is MRI — SN – 100%; SP – 76-100% pain at extreme of hip motions antalgic gait pain/weakness to resisted hip flexion may have + FABER with anterior hip pain and muscle spasm femoral neck stress fracture management management dependent upon compression (inferior-approximates fracture) tension (superior-separates fractor) or location ORIF if tension or > 50% compression femoral stress fracture management NWB for 2-3 weeks and progressive return to FWB over 4-6 weeks using absence of pain as guide initial strength/mobility emphasis is in a nonWBing position nutritional counseling — adequate calcium and vitamin D intake education on appropriate training (IDF) macro and microtraumatic hip instability traumatic hip dislocation: mechanism typically, high-velocity collision resulting in posterior dislocation ex; car accident or motorcycle accident traumatic hip dislocation management pts feel really good once the bone is put back in place after a dislocation slow, cautious rehab secondary to high risk for avascular necrosis NWB for 2-6 weeks careful of: — flex — ADD — IR in initial rehab Ju especially mvmnts that are all together most common effectiveness of nonoperative management of hip micro instability 70% (2/3) of pt were able to avoid surgery with a non-op PT program of hip (flexors, abductors, and ERs) and core strengthening – mHHS improved from 67 to 85 after 6 weeks ↓ modified harris hip scale 6.6 FAI & HI 2 varieties pincer/cam both FAI: abnormal, pathological femoral acetabular contact/shearing that happens in normal ROM secondary to bony deformities or spatial malorientation eventually symptomatic DX of FAI s/s clinical exam imaging cam = bump on femoral neck pincer= over coverage of acetabulum Bony Cam Impingement Femoroplasty surgeon removes piece of femoral head for more ROM in elevation = review video! E FAI is an intra-articular, non-arthritic hip pathology 1. possible anatomical variants that may predispose to injury - femoral neck anomalies (like cam) - structural instability - femoral or acetabular torsion/version 2. resultant symptomatic pathologies - acetabular labral tears - osteochondral lesions - loose bodies - ligamentum teres tears VARIANTS AND PATHOLOGIES ARE NOT MUTUALLY EXCLUSIVE name * can have abnormal anatomy but doesn’t mean you’ll be symptomatic b/c high activity FAI Symtpoms deep ant groin pain exacerbated by - prolonged sitting, squatting, car transfers, dressing, & hip flex/rot activities (twisting/pivoting) - C sign putting thumb in front of groin area, sometimes hurt in back limited painful hip flexion & internal rotation (FADIR sign) limited & painful squat CPG : covers all hip pathology thats not arthritic FAI Hip dysplasia Chondral Injuries Loose bodies only F =. expert opinion “whatever works” in your experience/pt response 2023 update of hip pain & mvmt dysfxn CPG for non arthritic “suggested” = C Therapeutic ex pt education & counseling mvmt. pattern retraining B - highest! if you choose multiple approaches Non operative management case series case series demonstrating conservative success in four subject what limits the pain phase 1: modalities, core stab phase 2: manual therapy, hip strengthening, restoring capsular mob phase 3: unstable surface dynamic, activity specific training systematic study 60% (3/5) experimental studies reported favorable outcomes for non op tx 65% (31/48) found non op tx appropriate w/ activity modification and various forms of exercise therapy - increased strength, motor control, mobility, & flex of hip & trunk muscles - avoid motion extremes & teach activity & technique modifications Non-operative management RCT HEP vs PT pilot only difference w/ manual = more rom no real difference of pain Non -op approach should be first (a study) non op approach successful 80% time in adolescents stretching avoidance and activity modification seemed most important another study,,, - favors PT in decreasing pain and increasing fxn - = another one! - 2 PT BETTER YALL - - - Add in trunk stabilization… 2 L don’t forget to work proximal to injury! - - - managing hip pain grade 1/11 mobs - transient value for pain mod elctro therapeutic modalities, LLL therapy & dry needling - no evidence psychosocial influence - powerful outcome predictor activity modification activity modifications caution/avoidance w/ cross leg sitting (most important) resisted hip flex (iliopsoas inflammation) - symptomatic SLR or sitting knee lifts end range activities (IR, FLEX, ABD, AND EXT) lunges WB rotations prolonged sitting/standing bent knee sit ups (unless do pelvic tilt) cycling (low seat) he cut out so idk avoid PPT, do APT = reduce hip forces on ant jt can try to see if this relieves the pain - - - Long axis distraction or true lateral distraction helpful!! - - Mully experiences 1. post glides in positions of tolerance - important that pt feels stretch in post lat hip and not report ant pinching (contraindication!) 2. quadruped rocks and lung steps w/ lat distraction 3. passive hip flexion tolerated better than active hip flexion secondary to potential iliopsoas irritation 6.7 Manual Therapy and Exercise - HI good for FAI stretching more comfy here HEP good for FAI restricted flexion/IR not good for FAI but good for other things that he didn’t go into… in lab we’ll focus on iliopsoas & piriformis med and deep to sartorius to get to iliopsoas to relieve spasm Mully not convinced… might just be eliciting femoral n. only cure to hip problems is getting thick supervise PT 1. exercise based tx recommended for hip pain - mod evidence of effectiveness - hip, trunk, and fxnal strengthening - fxnal and movement retraining - ROM exercises - most effective type, dose, & progression of exercise unknown - exercise based tx should be at least 3 months duration Exercise therapy works but we dont know what type, progression, surface NWM -> WB Lower -> high EMG B -> Uni Single plane -> multiplanar Stable -> labile surfaces Glute med exercise non WB exercises but for people who can WB Glute Max Exercises 6.8 Hip Intervention Post OP Prognosis - Failed conservative intervention over 6-12 weeks is probably a good indicator that arthroscopic hip surgery should be considered When Conservative Interventions Fail - Pic to the right > General Post-Op Rehab Considerations - PWB for first 2-4 weeks dependent on resection vs. repair - Careful EROM during first couple weeks - Labral Repair - Limit ER to < 20 for first 2-4 weeks - Capsular Closure/Plication - Limit EXT and ER for 4-6 weeks - Surgeon may recommend bracing - Expect full PROM in 2-6 weeks - Isometrics begin 2nd post op day - AROM in most planes at about 2 weeks - WB PREs can begin as tolerated when non-antalgic FWB gait Recommendations Least time to greatest time to WB “Excise” Protocol “Repair” or “Plication” Protocol excision repair glute med tendon repair micrfracture pao Precautions & Progression Criteria Periacetabular Osteotomy (PAO) - Surgical Intervention for symptomatic dysplasia in pre-arthritic adult - Reorientation of acetabulum when pelvis is completely detached & then repositioned to orientate acetabulum to capture more of femoral head - Takes a lot of expertise of the hip surgeon Returning to Sport after PAO Hip Arthroscopy Surgery Success - 86-93% of athletes return to sport following surgery - 1 in 4 do not return to previous level of performance - 57% return to pre injury sport at pre injury level - 17% achieve “optimal” sports performance Key Points - Contractile injuries require progressive, optimal load strategies to recover - Lateral hip pain is rarely bursitis - GTPS management values postural recommendations to control symptoms - Pediatric hip pathology usually a gradual onset, almost always requires some element of “rest” in recovery - Exercise Therapy, patience, & Educational interventions are vital - FAI should be addressed first for 6-12 weeks before considering surgical interventions - Post-operative management is dependent on nature of surgery & type of tissue involved 6.9 Physical Therapy Protocols Physical Therapy Rehab Protocol - Document outlining general rehab procedures specific to pathological diagnosis to provide clinician info to guide care & standardize practice What it’s NOT - Formula - Use your brain - Commandment, Recipe, Instructional Manual - Its a guide that should have context - “One size fits all” document - Customize/individualize to circumstance - Absolute or Concrete Rule - 30/35/35 rule - typical, slow, fast Helpful - Novice practitioner - Infrequent case - Benchmark for “typical” progression - Most Helpful - Ensures all key treatment ingredients are present & considered - Reminds practitioner of best evidence interventions that create intended outcome - Place emphasis on active intervention & therapeutic Alliance - Informs patient of expectations & natural history of problem Hurtful - Most Hurtful - Replacement of licensure or expertise - Assumption that protocol is all encompassing - Assumption that protocol is “proven” - Completely ignores patient values or provider experience What Protocol can help with - Define goals - Identify precautions/contraindications - Reminder for common complications - Provide rationale/circumstances for progressions - Prompt for points to emphasize - Suggest alternate perspectives or treatment ideas - Decrease unwarranted variations in practice - Outline of tissue healing time frames Cant modify - Tissue Healing time frames - Increased by vascularity, age, medical health, nutritional status - Bone - Muscle - Ligament - Tendon - Articulalr Cartilage General Healing Times - Healing times may be influenced by new technology - Internal Brace - Healing times may be influenced by vascularity - Retrograde perfusion from nutrient arteries Phases/Stages - Inflammatory Phase (1) - Convalescence; protect tissue, facilitate healing, reduce pain & inflammation - Minimize muscular atrophy - Proliferation (2) - Restore impairments (ROM, flexibility, strength, proprioception, stability/control - Remodeling (3) - Functional restraining, activity stimulation, tissue adaptations, recurrence prevention - Re-Establishment (4) - Return to sport, work progressions Needs to know for writing protocol - Type/Severity of Injury - Surgical Technique - Description/Lay explanation - Indications - Contraindications - Surgeon Expectations - Terminal Prospects - Functional Testing - Success Rates - RTS/RTW - Return to ADLs - Made by referral source & provider 6.10 Protocol Ingredients What should be included in a rehab protocol surgical incision wound management WB status & Progression (circumstance/time interval) home management - symptom control - posture/position awareness - medication instructions - ADL self care immobilization: type/length/method/progression bracing/external support devices precautions/restricitons - ROM limitations - muscle protection - avoid contracting - activity limitation phase progression: time and or measurable criteria based on pt status - some people feel better before healing time or other way PT visit frequency recommendations need to design our way - like pizza age/sex BMI DNA Medical history cook vs chef cook - find protocol and make yummy food chef - find protocol and build off of it through appropriate modification/innovation recipe doesn’t work pt knows how to refine APTA protocol variability findings for achilles tendon study 22 protocols from 155 ortho academic programs 78% immediate post op splinting 96% immediate NWB w/ progression to PWB at 3 wks & FWB at 7 wks didn’t agree on inclusion and timing of common rehab activities Non-op vs Post-op protocols - Examples - surgeon variables Graft tensile strength preferences single vs double protocols bundle timing of surgery auto vs allograft - learn how to consider these as PT pt goals/expectations surgical considerations rare to have an surgical approach graft placement/isometricity comorbidities present intraoperative graft tension other ligament involvement method of fixation menoscaba health ligament augmentation OA PRP osteochondral bruising physeal status DEVELOP RELATIONSHIP W/ REFERALS!!! recommendations for protocol content brief description of pathology & surgical procedure & any other gen info immob protocol/ROM limitations WB status/progression wound management Phase 1 (early protection) - Phase 11 (impairment restoration) - Phase 111 (PLOF) - timeline/progression criteria - precautions/considerations - pt edu - exercise therapy activities - self admin physical agents/modalities - ADL limits/ recommendations - visit frequency recommendation DX info isolated injury* - 6.11 Exercise Prescription Exercise therapy WISH for abs The most POTENT and underutilized free antidepressant Winston Churchill quote “EXERCISE” This guy lived to 94, ALSO he smoked a FUCK TON of cigars. Which is why a certain size of cigar is even named after him. The Churchill size cigars. Davidoff Cigars even has a Winston Churchill line of cigars. INCREDIBLY expensive. Never had one. Ok back to notes…. * Exercise should be as precise as medicine for its optimal benefit why? Most COMMON intervention we will provide as a PT CONSIDERATIONS for exercise prescriptions What is the goal ? What stage of healing is the patient in ? trying to improve mobility? stabilize joint? improve under dynamic control? work on skill? Amount ,Plane ,and Speed of motion Posture and Position Determinants? Biomechanical correctness is important do exercises with good form 3 PERCEIVED CONTRO EFFICACY EMPOWERMENT IMPORTANT Who is yo patient? Why pick that exercise? Consider their genetics, age, size, sex, and attitude, and current activity levels Fun but not silly exercises Work related functional training? 6.12 Exercise DOSING UNDERSTAND B/W INVERSE RELATIONSHIP - WEGHT/LOAD : REPS Gauging difficulty and intensity. Sensation? DId you flare up? Did it last 24h? If yes to both- decrease load If not to either, then go to reps! HOW MANY REPS? If you do more than 20, you can do more If you did 15-20, you’re int he right range If you did less than 15, its probably too heavy for you. Know OMNI RPE scales. 1-10 , 10 being extremely tough Word Specificity inflamed or irritated? Torn? Or deteriorate/frayed Impinged? Or contacting and touching? Exercise Prescription sample Endurance 3 sets of 15-25 1min rest at 40-50% 1repmax POWER 3 sets of 8 at 70% 3 sets of 6 at 80% 3 sets of 4 at 90% General Exercise progression Correct any deviations and decrease pain ROM Flexibility Strength and Proprioception Agility Performance ↓ MOBILITY STABILITY CONTROLLED SKILL MOBILITY