Biomechanics Exam 1
Lecture 1: Introduction
5/4/20
 Biomechanical frame of reference
o Evaluation and intervention focus on ROM, strength, endurance, and preventing contractures and
deformities
o Purpose
 Improve ROM
 Increase strength
 Increase endurance
 Restore function
 Reduce deformity
 3 biomechanical main domains
o ROM
 Ability of a joint to move
 Active range of motion (AROM)
 Active assistive range of motion (AAROM)
 Self-range of motion (SROM)
 Passive range of motion (PROM)
 Factors that affect ROM
 Connective tissues
 Muscles and tendons
 Skin
 Edema
 Bone
 Psych/cognition
 Pain
o Strength
 Ability of muscle to produce tension
 Stability (isometric contraction)
o Doing a plank
 Mobility (isotonic contraction)
o Bicep curls
 Factors that influence strength
 Number and size of muscle fibers
 Joint ROM
 Nervous system
 Pain
 Psych/cognition
 Fatigue
o Endurance
 Ability to sustain muscle activity
 Muscular endurance
o Number of repetitions of a single exercise without needing a rest
o 15 bicep curls in a row
 Cardiopulmonary endurance
o How well heart, lungs and muscles work together to sustain an activity over
time
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Factors that influence endurance
 Work being done
o i.e. running downhill v. uphill
 Oxygen supply
 Medical complications
 Age
 Pain
 Psych/cognition
 Fatigue
Common uses
o Commonly used with evaluation and intervention of:
 Orthopedic disorders
 Lower motor neuron dysfunction
o Used with anyone with limitations in:
 ROM
 Strength
 Endurance
 Primary systems
o Musculoskeletal system
o Nervous system
o Integumentary system
o Cardiopulmonary system
 Uses remediation to improve:
 ROM
 Strength
 Endurance
 Goals of biomechanical intervention
1. Restore function
 Prescribe purposeful activities to increase available ROM, strength and endurance through
remediation
2. Prevent further injury
 Encourage functional activity
 Educate on safety & techniques
3. Compensate for limitations
 Modify the environment, activity or tools
 Overload principle
o Use the overload principle to change a system (ROM, strength, and endurance)
 Stress the system
 Change occurs when the system works above its normal capacity
 Allow the system to adapt
 This takes time
 Permit adequate rest
 This is the period of time needed for the system to adjust to new stress and adapt to
new functional demands
For example, a marathon runner trains for 6 months to build up her endurance to run 26.2 miles. Each week she
runs a certain number of miles during the week and then she runs one long run one day a week. The first long run is
typically around 6 miles. She gradually increases the mileage during the week and then increases the long run by 1
or 2 miles. She stresses her endurance and over time her endurance adapts, but this takes time. She needs to
adequately rest before and after the long run to allow her system to adapt. It takes a novice runner 6 months to
properly train for a marathon.
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7 biomechanical domains
o Structural stability
 Includes the concept of pain
 Needs to be addressed first
 Bone fractures
 Torn muscles
 Burned skin
o Edema
 Limits ROM
 Assessment
 Volumeter
 Figure 8 measurement
 Circumferential
o ROM (PROM & AROM)
o Muscle strength
o Sensation
o Dexterity
o Endurance
 Low-level endurance
 ICU patient
 High-level endurance
 IADLs are more effected
 Rating of perceived exertion (RPE)-BORG Scale
Assessment
o Structural Stability (Pain)-Visual Analog Scale
o ROM (AROM & PROM)-Goniometry
o Strength-Manual Muscle Testing (MMT) & Dynamometry
o Endurance- Vital signs, stress test, timed activity
o Sensation-Semmes Weinstein
o Dexterity- 9-hole Peg Test
o Edema-Volumeter & circumferential measurement
Lecture 2: Range of Motion Assessment (ROM): Goniometry
5/5/20
 AROM
o Active range of motion
 PROM
o Passive range of motion
 Rationale for testing
o Identify and document motion restrictions that may affect functional abilities
 Contraindications
o Dislocation or fracture
o Tendon repair
o Surgery
 Precautions
o Inflammation
o Severe osteoporosis
o Dislocation or subluxation
o Hemophilia
o After prolonged immobilization
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Assessing AROM
o Acronyms
 WNL- within normal limits
 WFL- within functional limits
 BNL- below normal limits
o In general:
 If AROM is WNL/WFL, then PROM will also be WNL/WFL
 If AROM is limited, evaluate PROM to determine the reason for the limitation
 If PROM > AROM, likely due to weakness
 If PROM=AROM, likely due to a structural issue
Basic UE AROM Screen
o Shoulder flexion
 Lift arm up & over head
o Shoulder abduction
 Lift arm out to the side, then over head
o External rotation
 Touch back of head
o Internal rotation
 Touch behind low back
o Elbow flexion
 Touch shoulders
o Supination & pronation
 Turn palms up & down
o Wrist flexion & extension
 Bend wrists up & down
o Digit flexion & extension
 Make a fist & open
o Opposition
 Touch thumb to small finger
Assessing PROM: guidelines
o Respect pain
o Describe procedure to patient
o Position patient
o Support proximal bone
o Move in physiological fashion (anatomic)
o Move slowly
Assessing PROM: End Feel
o The resistance felt at the end of PROM
 Hard: bone-on-bone contact
 Soft: soft tissue restriction (fleshy surfaces contact)
 Firm: capsular/ligamentous- significant contact)
 Firm: capsular/ligamentous- significant resistance but slight give
 Muscular stretch: more give than capsular/ligamentous
 Empty: pain or lack of motivation preventing movement
Goniometry
o Measures arc of motion in degrees
o Used to precisely document range of motion
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Goniometry procedure
o Position client with joint in neutral position
 Stationary arm: parallel to proximal bone
 Axis of goniometer: over the axis of motion
 Moveable arm: parallel to the moving limb
o Not 0 (zero) position
o Patient performs the movement
o Reposition goniometer after movement is completed
o Read scale
 Measure the arc of movement
 Proper scale: starts low and increases
When do I position the moveable arm of the goniometer?
o Two ways to measure range:
 Follow client’s extremity with moveable arm of goniometer
 Keep goniometer in start position until movement is completed, then align moveable arm
with extremity
o Both are correct
 Try both, see which works for you
Rotary movements
o Rotary movements are unique
 Internal/external rotation & pronation/supination: no “proximal bone”
 Instead. Stationary arm is positioned perpendicular to the floor
Goniometry recording
o Record two numbers (range of motion)  the starting (1st) number  the final (2nd) number
 Starting number
 If neutral position: usually 0 degrees
 If client can’t reach neutral (lack ROM); a positive number
 Final number
 Where the motion stopped
Why measure start position?
o Measuring a RANGE of motion, not a single position
o Ensure client can reach neutral position
o Position stable arm for accurate measurement
Documentation: neutral start position
o End position 130 degrees
 ROM: 0-130 degrees
Documentation: impaired start position
o End position: 130 degrees
 ROM: 30-130 degrees
Recording hyperextension
o Most common at elbow and MCP
o American academy of orthopedic surgeons recommends a separate measurement to avoid confusion
o Example: 20 degrees elbow hyperextension
 Record as:
 0-150 degrees flexion and extension
 0-20 degrees hyperextension
Documentation: hyperextension start position
o End position: 130 degrees
 ROM: 1-130 flexion
 0-20 degrees hyperextension
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Fused and contracted joints
o Joint fusion: start & end positions are the same (client has no ROM)
 Record as: fused at x degrees
o Joint contracture: motion limited in one direction
 Example: 15-degree wrist flexion contracture
 Wrist cannot move into extension (can’t even reach neutral or 0 degrees)
 Record wrist extension as: none
 But client is able to flex wrist past contracture into more flexion: record wrist flexion as 15-80
degrees
Goniometry reliability
o Inter-rate reliability should be <5 degrees
o Goniometer size does not affect reliability
o What can affect reliability?
 Tone/spasticity
 Pain
 Client motivation/behavioral issues
Compensation
o Be aware of client’s entire body, not just the joint you are testing
o Watch for any movement out of original positioning- client could be substituting or compensating for
decreased ROM or strength
 Common substitutions:
 Trunk extension to increase shoulder flexion
 Shoulder elevation to increase internal rotation
 Using shoulder rotation for forearm movements
Alternate shoulder IR/ER
o Use if client has shoulder ROM limitations
o Humerus adducted, elbow flexed at 90 degrees
Technique for shoulder extension
o Float the goniometer around ball and socket
Supination & pronation
o Measure proximal to wrist crease
 Why?
o Achieve maximal contact with moveable arm on both radius & ulna
 Why?
Lecture 3: Manual Muscle Testing
5/6/20
 Strength
o Demonstrating a degree of muscle power when movement is resisted, as with objects or gravity
o Why do OTs assess strength?
 Weakness can limit occupational function
o First, measure & document degree of weakness
o Second, determine appropriate treatment plan
 Remediation
 Compensation (modify task or environment)
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Factors that can decrease strength
o CNS disorder
o PNS disorder
o Direct muscle disease
o Trauma/injury
o Disuse
o Pain
o Psychological/cognitive
o Fatigue
Factors influencing strength
o Cross sectional area of the muscle
o Number of motor units activated
o Inhibition of antagonist muscle groups
How to measure strength
o Clinicians use manual muscle testing (MMT) to measure an isolated muscle or muscle group
 see chart Radomski p. 188-90
 MMT is a break test
 Therapist attempts to break a client’s isometric contraction
o Position the “prime mover” at greatest mechanical advantage to achieve best voluntary muscle
tension
 Typically 10% longer than resting muscle length
 This reduces other (synergistic) muscles from contributing to the MMT
Strength testing consideration
o MMT tests to the breaking point
 Resistance should be applied until the patient cannot support the resistance, and the limb
moves
o Limbs are heavy
 Gravity is part of the resistance
 If appropriate, test without gravity (gravity-eliminated plane)
Strength and ROM different
o Can have limited ROM and full strength
o Can have full ROM and limited strength
o MMT always measures within available range
Reliability
o MMT is subjective, but follows standardized format
o Inter-rater reliability within ½ grade
MMT contraindications & precautions
o Contraindications
 Significant inflammation
 Significant pain
 Non-healed structure such as tendon, bone, joint capsule, ligament, etc.
o Precautions
 History of heart disease or vascular disease (instruct not to hold breath)
 Severe debility
 Respiratory distress or disorders
 Avoid fatigue for clients with MS
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MMT terminology
o Available Range
 Assess the patient’s AROM prior to MMT.
 If the patient cannot move through full AROM, then move them through PROM
 Does not have to be full range
o Against Gravity Position
 Client first attempts to move limb against gravity
 Perpendicular to the ground
o Gravity Eliminated Position
 If client can’t move against gravity, position client so that gravity isn’t pushing against limb.
 Parallel to the ground
 May require patient to be supine or prone
 Requires less strength than against gravity
MMT procedures
o Determine if precautions or contraindications are present
o Clearly explain the procedure to the patient
o Position so the motion will be performed against gravity
o Stabilize proximal to the joint that will move to prevent substitutions
o Instruct the patient to move actively to the end position. If the patient CANNOT move actively against
gravity, place the patient in a gravity eliminated plane and ask them to move in this position
o If the patient CAN move actively against gravity, tell the patient to hold the contraction at the end
position.
o Apply resistance
o Record the appropriate grade
MMT procedures
o If client cannot move limb against gravity:
 Position in gravity eliminated plane
 Observe AROM while palpating the muscle
 If appropriate, apply resistance distal to the joint being tested
 Determine the appropriate grade
How to apply resistance
o Resistance is applied at the distal end of the bone that is moving
o Resistance is directed 90 degrees with respect to the bone
o Resistance should be applied in gradual manner
 When the patient starts to break, that is the indication that they have reached maximal
strength
o Match your resistance to the client’s muscle being tested
Muscle testing grading system
o MMT labels strength on a 0 to 5 range
o 5: Moves through full available range against gravity
 Takes maximal resistance (can’t break).
o 4: Moves through full available range against gravity
 Takes moderate resistance.
o 3: Moves through full available range against gravity,
 Can’t take any resistance.
o 2: Moves through full available range in gravity-eliminated plane
 Can’t take any resistance.
o 1: Trace tension (can feel or see muscle twitch) without limb movement
o 0: No tension (can’t feel or see any movement)
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Grading system: now add +/- for more detail
o 5 NORMAL
 Moves through available ROM against gravity, takes maximal resistance without breaking
o 4 GOOD
 Moves through available ROM against gravity, takes moderate resistance, then breaks
o 4- GOOD MINUS
 Moves through available ROM against gravity, takes less than moderate resistance, then
breaks
o 3+ FAIR PLUS
 Moves through available ROM against gravity, takes minimal resistance, then breaks
o 3 FAIR
 Moves through available ROM against gravity, unable to take any resistance
o 3- FAIR MINUS
 Moves through LESS than available ROM against gravity
o 2+ POOR PLUS
 Moves through available ROM in gravity eliminated, takes minimal resistance, then breaks
o 2 POOR
 Moves through available ROM in gravity eliminated, unable to take any resistance
o 2- POOR MINUS
 Moves through less than the available ROM in gravity eliminated
o 1 TRACE
 Muscle tension can be palpated but no motion is occurring
o 0 ZERO
 No muscle tension is palpated, and no motion is occurring
 Gravity is the key to help you decide
o After initial AROM against gravity (you have palpated and observed), make a decision on how to
proceed:
 Full available AROM against gravity  apply resistance
 Grade: at least 3
 Less than full available AROM against gravity  do not apply resistance
 Grade: 3 No AROM against gravity  reposition in gravity eliminated plane
 Grade: 2+ or below
Lecture 4: Measuring cardiopulmonary endurance
5/12/20
 Endurance and OT
o Endurance deficits can limit participation in functional & meaningful occupational tasks
o During OT assessment: determine if endurance is a limiting factor
o Signs & symptoms of decreased endurance?
o Measure and document endurance
o Vital signs, activity tolerance, frequency/length of rest breaks
o Develop treatment plan to improve endurance
o Modify and grade activities to focus on endurance as well as other deficits
 Example: vacuuming
 Muscular endurance: picking up the vacuum on stairs, etc.
 Cardiopulmonary endurance: vacuum for a long period of time, etc.
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Deconditioning
o Cardiovascular
o Pulmonary
o Muscles and bones
o Digestive
o Urinary
o Blood
o Endocrine
o Skin
o Functional
o Psychological
What affects cardio-pulmonary endurance?
o Myocardial Infarction (MI)
o Congestive Heart Failure (CHF)
o Cardiomyopathy
o Hypertension (HTN)
o Angina
o Coronary Artery Bypass Graft (CABG)
o Chronic Obstructive Pulmonary Disease (COPD)
o Asthma
o Extended bedrest or decreased physical activity
Blood Test
o Troponins: protein present s/p heart damage
o CPK: enzyme present s/p MI
Echocardiogram (“Echo”)
o Monitor heart function
Stress Echocardiogram
o Monitor heart function during physical activity / exercise
Ejection Fraction (EF)
o How much blood heart ejects with each beat?
o Normal EF >60%
o Significant impairment & risk of heart damage <40%
Chest X-Ray
o Pneumonia, atelectasis; cardiomegaly
Electrocardiogram (ECG or EKG)
o Electrical activity of heart via electrodes
o Holter monitor: client wears 24 hours – can do at home
Transesophageal Echocardiography (TEE)
o Ultrasound probe
o Visualize the cardiac structures
Coronary Angiography (“angio”)
o To dx CAD
o Catheter into groin – through blood vessels into heart – radioactive dye
o Cardiac catheterization (“cath”)
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Pulse: automatic measurement
o Pulse Oximeter: “Pulse-ox”
o Usually on fingertip
 Alternate: ear lobe, forehead
o Non-invasive
o Infrared light passes through tissues
o Measures heart rate
 Beats Per Minute
o Measures oxygen level
 Hemoglobin saturation in blood
 95 - 100% is ideal, varies based on client
 <90% doctor will usually order oxygen
 (example: “2L NCO2”)
 Some patients chronically in 80’s
Pulse: manual measurement
o Measured in Beats Per Minute (bpm)
o Palpate artery lightly with two fingers
o Common sites: radial artery @ wrist, brachial artery @ elbow, carotid artery @ neck
o Don’t push too hard – will occlude blood flow
o Don’t use your thumb
o Note if pulse is regular or irregular (arrhythmia)
o Monitor during activity
o For compromised patients, safe increase in pulse with activity: <20 bpm
Heart rate: norms
o Per National Institute of Health (NIH):
o Newborns (0 - 3 months old): 100 - 150 beats per minute
o Infants (3 - 6 months old): 90 - 120 beats per minute
o Infants (6 - 12 months old): 80 - 120 beats per minute
o Children 1 - 10 years: 70 - 130 beats per minute
o Children over 10 and adults (including seniors): 60 - 100 beats per minute
o Well-trained athletes: 40 - 60 beats per minute
o Tachycardia: high heart rate
o Bradycardia: low heart rate
Blood pressure
o Pressure on walls of arteries
o Consists of two numbers
 Systolic (SBP): top number. Pressure during heart beat
 Diastolic (DBP): bottom number. Pressure between heart beats
o Measured with a sphygmomanometer & stethoscope
o Recorded in mmHg
o Typically measured in upper extremity
 Contraindication: mastectomy / axillary lymph node removal; PICC or IV
o Can measure in lower extremity (at calf)
 SBP may be higher (5-10 mmHg)
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UE BP: brachial artery + LE BP: tibial artery
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Blood pressure: automatic measurement
o “vitals cart”
o Quick, easy
o Can be unreliable for HTN & HoTN
o Often has pulse-ox as well
o Client must be still
Blood pressure: manual measurement
o Use correct size of BP cuff
o Arm supported at heart level
o Stethoscope at brachial artery
o Inflate sphygmomanometer to 180-200
o Slowly deflate & listen…
 First beat heard: SBP
 Last beat heard: DBP
Orthostatic pressures
o Blood pressure varies based on body position: WHY?
 Supine: higher BP
 Standing: lower BP
o If variance is significant, can signal a medical issue.
o To take “orthostatic pressures”
 Supine
 Sitting
 Standing
Blood pressure: norms
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Management of hypotension
o Compression garments
o TED hose
o Tubigrip
o Abdominal binder
o Recline or supine
o Medication
o Hydration
Metabolic equivalent of task (MET)
o How much oxygen body needs during activity
o One MET = O2 consumption at rest
 3.5 ml of O2/kg body weight/minute
o Studies have been done to determine MET for various activities
 (see chart: Radomski & Latham pg. 1304)
 1 -- 2.5 METS: setting table, pumping gas, walking
 2.6 – 4 METS: bathing, gardening, golf
 4 – 6 METS: painting room, laying tile, dodge ball
 6 – 10 METS: shovel snow, moving furniture, basketball
Modified Canadian home fitness step test (MCAFT)
o Simple endurance test for any setting
 Check pulse at rest
 Step up & down one stair x 3 minutes at certain rhythm
 Check pulse
 Repeat stepping x 3 minutes
 Check pulse again
 Compare to norm data
Breathing techniques
o GOALS:
 Increase SaO2 (oxygen saturation)
 Decrease SOB (shortness of breath)
o TECHNIQUES:
 Pursed Lip Breathing
 Diaphragmatic Breathing
Pursed lip breathing
o Breath in 2 counts
o Breath out 4 counts
Diaphragmatic breathing
o Diaphragmatic breathing is intended to help you use the diaphragm correctly while breathing to:
 Strengthen the diaphragm.
 Decrease the work of breathing by slowing your breathing rate.
 Decrease oxygen demand.
 Use less effort and energy to breathe.
Lecture 5: Biomechanical Theory & Practice
5/13/20
 Biomechanical concerns
o Pain
o Edema
o PROM
o AROM
o Muscle strength
o Sensation
o Dexterity
o Endurance
 OT Clinical Reasoning
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Biomechanical evaluation
o 1) Preliminary narrative hypothesis
 Chart review
 Talk with interprofessional team
 Generate list of limitations and impairments
 Develop a hypothesis
o 2) Cue acquisition
 Complete the evaluation
 Observations
 Screenings
 Assessments
o 3) Cue interpretation
 What did you find?
 What are the biomechanical problems?
 Identify which cues are pertinent
 Interpret results
 Do cues confirm preliminary hypothesis?
 Start to hypothesize the underlying impairments of the problems
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o 4) Occupational diagnosis
 What areas of occupation will be affected by the biomechanical problems?
 Hypothesize occupational performance problems from biomechanical impairments
 Develop occupational profile
o 5) Goal writing
 Write goals to improve occupational performance
 Time frame: In 2 days
 Behavioral statement: Increase
 Condition that is measurable: AROM of her L knee to 90’
 Occupation/functional result: Put on her socks
 In 2 days, Angela will be able to increase the AROM of her L knee to 90’ to put on her socks
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Goals
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Collaborative
Functional
Measurable
Reasonable
 Examples:
 In 2 days, the patient will be able to increase AROM of her L knee to 90’ to
complete LB dressing independently
 In 2 days, the patient will be able to decrease the edema in her L knee to WNL to
transfer on and off of the toilet with stand by assist
 In 2 days, the patient will be able to increase her endurance to WFL to complete a
full body shower with minimal assistance
Interventions for Impairments in ROM
5/18/20
 ROM diagnosis and treatments-guide
ROM
PT HX
PROM=AROM
PROM > AROM
Limited ROM
Abnormal soft end feel
(spongy)
Full PROM
Limited ROM
Firm end feel
Limited Active ROM
Normal end feel
Limited ROM
Spasticity/Rigidity
MMT = F- or P-
Tone preventing
movement
Resistance Training
Neuromuscular
Interventions
No visible issues
Unable to move joint
PROM
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Able to move joint
AROM
Changes in size of limb
(Edema)
Visible skin issues
(scars, burns)
Dx suggests likely to be
Shortening of structures
Edema Control
Scar Massage, Stretching
Stretching
(e.g. muscle, tendon,
ligament, joint capsule)
Range of motion
o Passive
o Active assisted
o Active
 Always choose AROM unless
 Unable to perform active exercise
 Unable to adequately achieve full ROM (either AROM and or PROM)
 Recent, unhealed trauma or surgery
 Cardiopulmonary stress
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PROM
o Maintain joint motion
 If client is unlikely to move body part through full excursion
 Coma
 Paralysis
 Pain
 Age
 Sedentary lifestyle
Stretching
o Increase joint motion
 If client has limitations in motion 2nd to soft tissue contractures/tightness
 Stretching allows you to increase PROM
ROM interventions- PROM
o Benefits
 Minimize contracture and adhesion formation
 Maintain elasticity of muscle
 Promote & maintain local circulation
 Enhance joint & cartilage nutrition
 Inhibit or reduce pain
 Promote sensory awareness
 Evaluate joint integrity, flexibility, tone
 Preparatory to use
o Limitations
 Does not:
 Prevent atrophy
 Reduce adipose tissue
 Maintain or increase muscle tone, strength or contractile endurance
 Improve cardiovascular or muscular endurance
ROM Interventions- AROM
o AROM benefits
 Improve physiological functions of muscles
 Local circulation
 Sensory and joint motion awareness
 Cardiopulmonary function
 May prevent thrombosis formation
 Structural integrity of tendon-bone interface
AROM & PROM- contraindications
o Increase in symptoms
o Limitation is due to a bony block
o Acute inflammation or infection
o Sharp, acute pain with joint motion
o Cardiopulmonary distress
 Breathing changes
 Complaints of dizziness, lightheadedness, vertigo, pain and/or nausea
 Changes in pulse oximetry
 Skin temperature (cold/clammy, warm)
 Sweating out of proportion to movement/temperature
 Pallor
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ROM interventions considerations
o Move through all planes of motion
o Move through full available ROM
o Move muscle groups opposite to direction in which they contract
ROM interventions considerations: multi-joint muscles
o Must range multi-joint muscles to maintain
 Full joint motion (limitation in joint capsule)
 Muscles/tendons released/slack
 Maintains joint capsule and ligament flexibility
 Full tendon length (limitation in tendon/muscle)
 Joints being crossed moved to full range (tension), joint of interest ranged as far as
possible within these extremes
 Maintains tendon length
 Examples: wrist/fingers
o Important to note exception patients with SCI and limited active finger flexion
 Avoid stretching fingers into extension when wrist is extended
 Need to encourage tenodesis action (active wrist extension shortens finger flexors) to
facilitate functional grasp
ROM interventions- Techniques
o Consider body mechanics (you and client)
o Start proximally and move distally
o Stabilize proximal segment before moving distal part
o Smooth, slow motions to end of range
o May need to readjust hand positions to obtain full ROM/stretch
o Respect pain
o Too much  increased pain, more guarding and/or tenderness
ROM interventions- PROM frequency/duration
o Not well established
o Repetitions vary from 3-10
o At least 1x daily, more if patient immobile
o Study by Tseng et al. (2007) self PROM or assisted self PROM significantly improved movement,
function and pain in bedridden older stroke survivors
 Repetitions – 5 times per joint
 Frequency – 2x day
 Duration – 6 days a week for 1 month
ROM interventions- stretching
o Any therapeutic intervention designed to increase mobility by elongating soft tissue structures that
have adaptively shortened and have become hypomobile
o Indications
 Used to elongate pathologically shortened soft tissue structures (muscle, tendons, ligaments,
skin)
o Contraindications
 Bony ankylosis,
 Severe joint destruction or
 Long standing contractures with extensive fibrotic changes
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o Alignment
 Position of area stretched and external forces
 Influences
 Force applied
 Comfort
 Stability
 Depends on joint being stretched
 Direction of stretch
o Stabilization
 Fixate either proximal or distal to joint
o Traction
ROM interventions- stretching considerations
o Velocity
 Speed at which load applied
 Slow speed
 Prevents stretch reflex
 Allow tissue deformation
 Provide patient control
o Intensity
 Amount of load
 Low intensity
 Comfortable
 Prevents guarding
 Optimal rate of improvement
 Reduced risk of tissue damage (overstretch)
o Duration
 Length of time load applied
 10 to 60 seconds
o Frequency
 How many times per session/week?
 No clear guidelines for impaired tissue
o Dependent on type of impairment and size of joint
o 2-3 times per session (no further gains seen)
o At least daily, more frequently for severe tissue shortening
o Balance tissue re-healing after stretch
 Healthy
o 60 secs of total time per session; ≥2 times per week
o PAMS (Physical Agent Modalities)
 Preparatory
 Post intervention
 They include applying heat or ice and can be used as both preparatory and post
intervention
 For example, you may place heat on someone with a contracture prior to providing
passive prolonged stretch. Or you may provide ice after exercise for comfort and to
decrease edema
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o Client input
 Trust
 Watch for
 Sweat
 Stretching skin
 Patient looks away
 Constriction of Pupils
 Client control
ROM interventions- passive stretching manual stretching
o Warm up
o Position client comfortably
o Explain technique; may involve tolerable discomfort
o Allow client to ask questions and express concerns and facilitate trust
o Slow, gentle controlled movement to point of stretch
o Hold for 10-60 seconds
o Slow release; discomfort subsides
o Repeat; attempt to slowly increase motion
ROM interventions- passive stretching overstretching
o DO NOT OVERSTRETCH
 Inflammation
 Sensory loss
 Stop with Resistance
ROM interventions- stretching v. PROM
o Indications for PROM
 Patient already has full ROM to joint or stress on the joint is contraindicated
 Goal – to prevent loss of motion
 Therapist or patient moves patient through full range of motion
o Indications for Stretching
 Patient has decreased ROM
 Goal – to increase motion
 Therapist or patient moves patient through available range and then pushes further
Self ROM
o Self PROM/Stretching
 Client initiates and controls PROM/Stretching
 Mechanisms
 Unaffected upper extremity
 External devices
o Stick or a broom handle
o Tabletop
o Gravity
Functional activities
o Promote active use of increased range
o Beneficial if activities are something client does regularly
o Provide feedback to client re: progress in achieving goals of stretch
o Adapt activity to increase or challenge active motion
o Grade tasks to facilitate greater excursion
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AAROM
o Form of active exercise whereby an external force is used to assist client move through arc of motion
o Indications
 Body segment has partial ROM but needs assist to complete full active range
 Individuals with low level strength P- to FPrimary remediation purpose
o Strengthen joint
3 ways to adapt an activity: change
o Task position
o Resistance
o Size/shape
Adapting an activity- task position
o Incline  height  position  change objects
o Outcomes
 ROM of task
 Strength requirement (gravity vs. gravity eliminated)
 Muscular or cardiovascular endurance
 Dexterity
Adapting an activity- resistance
o Lever arm  weights  springs or rubber bands
o Outcomes
 ROM- passive stretch
 Muscular performance
 Cardiovascular endurance
 Dexterity/coordination
Adapting an activity- size/shape
o Build up objects  change materials  change size or shape
o Outcomes
 Effect ROM of fingers/hand
 Effect strength
Goal:
Characteristic
PROM
Controlled stretch with hold at end range: Ability to increase range as ROM
improves
AROM
Moves through full available range: Ability to increase range as ROM improves
Strength
Resistance or velocity can be incorporated into task: Ability to increase
resistance as strength improves
Muscular Endurance
Repetitious, resistance at less than 50% of 1RM: Ability to increase reps or
resistance
Cardiovascular
Endurance
MET level slightly higher than client MET level: Ability to increase duration,
frequency, or MET level
Edema
Repetitive isotonic contractions, preferably with the extremity elevated
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Primary compensation purpose
o Substitute for absent strength
ROM
o OTR role
 Evaluation
 Determining intervention
 Training
 Reassessing patient status
o COTA/OTA tole
 ROM sessions
 Assess need for changes
o Family role
 ROM sessions (once trained)
 Activity adaptation
o Occupation as an END
o Occupation as a MEANS
o Needs to meet the following characteristics:
 Inherently repetitive
 Can be graded
 Patient can complete the activity with minimal help
 Needs to be meaningful
 Goals  necessary characteristics
 Method
o Identify Biomechanical Goal
o Identify Activity
 Meaningful and feasible
 Complete activity analysis
 Decide how to adapt activity to enhance remediation properties
 Trial with patient
 Does it really obtain the goal you want (be honest)?
 Adjust as needed
 Grade as patient improves
 Keys to a good adaption
o Accomplishes the goal
o Demands the desired response
o Not contrived
o Motivating
 ROM interventions- preparation
o Position client appropriately
o Explain purpose, procedures & obtain consent
o Allow client to ask questions
o Instruct client to maintain a breathing pattern
o Ask for feedback
 During PROM lab
o Practice explaining what you are doing and why in “layman’s” terms
o Complete range of motion on both sides
o Move each joint through 3 repetitions
o When doing PROM on the finger joints, try different fingers
o Practice ROM to encourage tenodesis
Intervention Implementation Muscle Performance
5/19/20
 Muscle performance
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o To carry out physical demands of daily life safely and efficiently, muscle must be able to produce,
sustain and regulate muscle tension to meet these demands
o Key elements: muscle strength and muscle endurance
Muscle strength
o Greatest measurable force that can be exerted by a muscle (or group) to overcome a load (resistance)
during a single, maximal effort
o Conditioning Fast Twitch Fibers (Type II Fibers)
Muscle endurance
o Ability of a muscle to contract repeatedly against a load (resistance), generate and sustain tension,
and resist fatigue over an extended period of time
o Conditioning Slow Twitch Fibers (Type I Fibers)
One-repetition maximum (1RM)
o Maximum amount of weight one can lift in a single repetition for a given exercise (1RM)
o Guide to determine the weight for a strengthening program
o Needs to be re-assessed every few sessions
Estimating your 1RM
o Warm up with a weight that you can easily lift for 8-10 reps.
o Rest 1-2 minutes. Increase weight by 10-20%, then perform another set of 6 reps.
o Rest 1-2 minutes. Increase weight by 10% and perform another set to failure. Note the weight you
lifted and how many reps you successfully performed
o Calculate 1RM
 1RM = (r/30 + 1) x w
 r = repetitions
 w = weight
o Larry a 30 yo male client sustained a rotator cuff injury. He is a stockman in a warehouse. His job is
to fill orders by moving materials weighing from between 10 lbs to 40 lbs from 40” shelves to a pallet
that is 6” high. He fills 8 to 10 pallets a day, with between 30 to 50 items each.
 Goal: increase Larry’s strength
 Larry’s 1RM= 51lbs
General principles of muscle performance remediation
o Torque
o Increasing muscle efficiency
 Overload Principle
 Hypertrophy
 Synchrony
 Motivation
o Specificity of training
o Purpose of training – muscle strength or muscle endurance
Increasing muscle performance
o Overload Principle
 A load that exceeds the metabolic capacity of the muscle must be applied if strength or
endurance is to be increased
 This means
 Muscle must be challenged to perform at a level greater than it is accustomed
 Amount of resistance and/or number of repetitions (time spent contracting) is
incrementally and progressively increased
o In increasing muscle performance combine stress with rest
 Stress the muscle
 Allow the muscle to rest and heal
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Increasing muscle strength
o Hypertrophy
 High resistance activity stresses muscles requiring more motor units to maintain contraction
 Recruits other fibers
 Eventually causes microtrauma to sarcomeres
o Microtrauma causes growth of more sarcomeres = more contractile elements to myofibrils increasing
size of motor units
o Larger motor units allow greater and/or longer recruitment
Increasing muscle endurance
o Aerobic Power
 High repetition over longer time increases oxidative and metabolic capacities of muscle
 Allow better delivery of oxygen and removal of lactic acid
 Reduces local muscle fatigue and allows for faster return
Muscle strength
o Goal:
 Overcome resistance with single maximal effort
o Method:
 High resistance/low rep
Muscle endurance
o Goal:
 Generate and sustain tension and resist fatigue over an extended period of time
o Method:
 Low resistance/high rep
Isometric exercise (same length)
o Indications
 prevent or minimize atrophy when movement is not possible
 healing injuries
 joint pain or inflammation
 external immobilization (cast, splint)
 weakness
o develop postural or joint stability
Isometric strengthening regimens
o Isometric
 Co-contractions
 Muscle Setting
 Contract muscle (or muscle groups)
o maintain tone and contractile awareness
 hold for 5-8 seconds
 Relax for 5-8 seconds
 Position within range
o Isometric resistive
 Co-contractions against external force
 Increase strength through the addition of manual or mechanical resistance

Muscle Setting
 Contract muscle (or muscle groups)
 Apply resistance
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 Hold 5-8 seconds
 Relax 5-8 seconds
 Position within range may be varied
Isotonic exercise (same tension)
o AAROM (active assistive exercise)
o AROM (active exercise)
o Active resistive exercise
Types of isotonic contractions
o Two types
 Concentric
 muscle shortens to move limb in direction of the muscle pull
 Internal force overcomes external resistance
 can lift less weight than eccentric can lower
 Eccentric
 contracted muscle lengthens to act as a brake against an external force to allow for
smooth, controlled movement
 Best method to encourage muscle hypertrophy
Isotonic assistive (AAROM)
o Exercise in which a weak muscle is actively contracted through as much range as client can achieve
o Encourage contraction to the maximal extent
o Therapist, client, external force (gravity) or device provides assistance to complete motion
o Indications
 Individuals with low level strength (less than full ROM in either gravity-eliminated plane or
against gravity)
o Can be done in either gravity-eliminated or gravity planes
o Allow individual to move as much as possible prior to external assistance
o Assistance provided when client has greatest difficulty doing activity
o Eventual goal: progress to active free exercise when able to move through available range w/o assist
or substitute motions
Isotonic active (AROM)
o Movement of a joint or body segment produced by active voluntary muscle contractions
o Used when client is able to voluntarily contract, control and coordinate movements throughout full
available range; no assist needed
o Indications
 When client unable to tolerate resistance
 When goal is to maintain motion
 When goal is functional movement without resistance
o Will not increase muscle strength, but may increase muscle endurance
Isotonic active resistive
o Also known as active resistive or progressive resistive exercise
o Client contracts muscle to move body segment through full available ROM against resistance
o Indications
 When goal is to increase muscle strength and muscle endurance
o Progressive resistive exercises (PRE) – 1 RM method
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Larry uses which sequence of muscle contraction for the biceps:
o lifting a box: isotonic concentric
o carrying it: isometric
o lowering it: isotonic eccentric
Goal- increase muscle performance
Stress & Rest
o Method- PRE
Goal- increase muscle strength
o Pre-high resistance/low repetition
 PRE parameters
Novice - Intermediate
Experienced
Deconditioned/ Older
% 1RM
60 – 70%
≥80%
40 – 50%
Repetitions
8 - 12
8 - 12
10 - 15
Sets
1-4
2-4
1
Rests
2 – 3 mins between each set
Frequency
2-3 days per week (≥ 48 hrs between sessions for a muscle group)
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Strength
Endurance
High
Resistance
Low
Repetition
Low
Resistance
High
Repetition
Progression
o Resistance
 Start at low end of parameters for safety
 If patient unable to complete minimum number of reps, decrease resistance
o Reps
o Rate of increase depends on client and goal
 1 rep increase per session conservative
 2 rep increase per session more aggressive
 Can change increase rate depending upon performance
 If patient can complete maximum reps without fatigue, increase weight and reduce reps
o Sets
 To reduce time in exercises, keep sets to minimum
Resistance
o Resistance is applied distal to joint being moved
 Consider Torque and moment arm
o Direction of resistance
 Concentric contraction – resistance is applied opposite to the direction movement
 Eccentric contraction – resistance is applied in the same direction as the movement
o Free weights, exercise bands, exercise equipment most often used
Larry’s strengthening program
o Larry’s progressive resistive exercise for shoulder flexion
 31lbs
 60% of 51= 31 and he is at the novice level
o How many repetitions?
 8 reps
 Be conservative
Monday
Tuesday
30lb
Thursday
Friday
Saturday
Sunday
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Weight
30lb
off
30lb
Off
30lbs
off
off
Reps
8 reps
Sets
1 set
Rest
None
9 reps
1 set
None
10 reps
1 set
None
Muscle endurance
o Ability to contract repeatedly or generate and sustain tension for prolonged periods of time
o More common component of daily activity than muscle strength
Goal- increase muscle endurance
o PRE-low resistance/high repetition
 PRE parameters
Novice Intermediate
Experienced
Deconditioned/
Older
% 1RM
<50%
<50%
<50%
Repetitions
15 – 20*
Sets
≤2
Rests
< 90 seconds between sets
Frequency
≥48 hours between sets
Larry’s muscle endurance program
Weight
Monday
30lb
Tuesday
off
Wednesday
30lb
Thursday
Off
Friday
30lbs
Saturday
off
Sunday
off
Reps
15 reps
Sets
1 set
Rest
None
15 reps
1 set
None
15 reps
1 set
None
Muscle strength v. muscle endurance
o Need to distinguish whether you are looking at deficits in muscle strength or muscle endurance as
different interventions are needed
o If both are deficient, may need to do both types of strengthening
o Strengthen muscle to build power then increase repetitions
o Match strengthening to needs of task
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Activity-based strengthening
o Incorporating strengthening into everyday activities depends upon the strengthening goals and the
current level of the client.
 Progressive resistive exercises (high resistance/low rep) is the most effective method to
increase muscle strength in clients with moderate strength deficits
 Clients with low strength will gain muscle strength simply by taking part in everyday
activities
 Muscle endurance goals are more easily addressed by everyday activities than muscle
strength goals
 You must analyze the activity carefully to ensure that you are really strengthening the muscles
you think you are
Exercise- When do you stop a strengthening program?
o Pain that occurs during or after
o Abnormal breathing changes
o Undesired cardiopulmonary stress
o Stress to unstable area
o Undesired movement occurs
o Undesired tone occurs
o Undesired adverse response
o Patient condition or ability regresses
o Patient has met his goals
Observe client for:
o Compensation techniques
o Signs of fatigue
 slowed performance
 decreased motion; unable to perform reps
 distraction
 perspiration; increased breathing or SOB
Adapting activities to increase strength
o Increase resistance
 Add weights, springs or bands
 Change orientation of activity (gravity)
 Change materials or texture (friction)
 Increase speed
o Increase repetitions
o Change lever arm
 Change method of doing activity
Improving muscle performance
MMT Grade
Clinical Presentation
Muscle Performance to address
Type of Intervention
ZERO (Flaccid)
0 muscle contraction
ROM
PROM and/or stretching
TRACE (1)
Tension is palpated in muscle or
tendon; no motion occurs
Primary: Muscle strength
Isometric
PROM → AAROM in GE plane
POOR (2)
Able to move limb but not
against gravity
Primary: Muscle strength
Isometric
AAROM in GE plane → AROM in GE plane → add
resistance → AAROM in AG plane
FAIR (3)
Able to move limb against
gravity but not with added
resistance
Primary: Both muscle strength
and endurance
AAROM in AG plane  AROM in GE plane  add
resistance (high wght/low rep; Low wght/high rep)
Isometric
F+ to G
(3+ to 5)
Able to move limb against
gravity w/ resistance
Depends upon patient goals
Isotonic resistive (high wght/ low rep;Low wght/high rep)
Isometric resistive
GOAL: Increase
Muscle
Performance
Increase Muscle
Strength
Unstable Joint
Stable Joint
F- or P-
Isometric or
Isometric Resistive
(reps)
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Increase Muscle
Endurance
AAROM
Moving muscles
Stabilizing muscles
P/P+ or
F or greater
Isotonic Resistive
(Low Rep/High
Wght)
Isometric or
Isometric resistive
(hold)
P- or F-
P or F
AAROM
AROM
P+ or
F+ or greater
Isotonic Resistive
(High Rep/Low
Wght)
COTA roles
o Carry out portions of strength assessment
o Implement strengthening program
 Teach strengthening program
 Increase resistance or reps to meet strengthening goals
 Adapt activities to meet strengthening goals
 Teach home strengthening program
o Monitor progress and report status
Long term strengthening
o Functional Goal
o Maintaining Good Health (US Department of Health and Human Services – Physical Activity
Guidelines 2008)
 “Children and adolescents should include muscle-strengthening physical activity on at least 3
days of the week.”
 “Adults should also do muscle-strengthening activities that are moderate or high intensity and
involve all major muscle groups on 2 or more days a week, as these activities provide
additional health benefits.”
 “Older adults with chronic conditions should understand whether and how their conditions
affect their ability to do regular physical activity safely.”