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Biomechanical approach

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Structural Stability: balance, joint stability, ligaments Tissue Integrity- Tissue healing, Edema ROM Strength Coordination Endurance

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occupational limitations

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Remediate impairments from acute injuries Maintenance for chronic disability Prevention of injury or deformity Cumulative stress disorder Back injuries Resting hand splint

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Remediation

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"An intervention approach designed to change client variables to a skill that has not yet been developed or to restore a skill or ability that has been impaired."

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Biomechanical approach explains

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function utilizing anatomical and physiological concepts with exercise physiology, kinetics, anatomy, and kinematics as the foundation.

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biomechanical approach is the study of.....

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the relationship between musculoskeletal function and how the body is designed for and used for performance of daily occupations.

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biomechanical approach Activities can be _____________________

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graded progressively

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biomechanical approach Client must have __________________

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voluntary muscle control

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biomechanical approach Client must be motivated to perform the activity ___________ that are biomechanically advantageous Environment can be adapted to _____________________

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Assume / maintain positions facilitate recovery

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Intervention is aimed at improving:

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Strength ROM Endurance Coordination

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Keep in mind that _____________________

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all systems of the body effect one another

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Primary focus is on the ____________________________________

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musculoskeletal system and physical fitness and health

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Indications

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Orthopedic disorders, lower motor neuron disorders, hand injuries, burns, cardiopulmonary disorders, amputations, generalized debility

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Contraindications

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Impairments with central nervous systems--Spasticity and lack of voluntary control of isolated motion Inflamed joints, recent surgeries--Follow doctor's orders

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The functioning person is able to _______________

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assume and maintain positions that are biomechanically advantageous and promote efficiency of motion.

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Performance depends on __________

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simultaneous actions of muscles across joints to produce the movement and stability that is required of the task

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Dysfunction is the _______________

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inability to demonstrate adequate ROM, strength and endurance for physical subskills and independent life skills of role relevant behaviors.

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biomechanical assessment

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ROM Strength Endurance Activity Analysis Interview Pain Edema

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Intervention

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Graded exercises Graded activities Physical agent modalities Manual techniques You have to address performance in occupation within the intervention plan

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Rarely is the biomechanical approach used in ________ . It is most effective with _______________

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isolation a combination of other approaches

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Structural stability is necessary to

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to regain prior to implementation of other intervention goals. Static vs dynamic Ligament, joint stability

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questions to ask yourself in relation to structural stability

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Is the patient medically stable with cardiovascular and respiratory function? Is a splint or device needed to immobilize a part to promote healing. Rest can help healing Is a splint or device needed to prevent further disability

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Tissue Integrity

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Tissue/Wound Healing Inflammation Phase (1-14 days) Pain reduction, immobilization Fibroplasia Phase (2- 4 weeks) Active ROM Remodeling Phase ( 3 weeks to 2 years) Scar managment

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Scar management intervention

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Scar massage Orthotics Silicone Tendon gliding exercises Slow stretching

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Edema

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ROM is limited--Can be permanent if edema becomes fibrotic Decreased coordination Increased Pain Decreased sensation--Nerve compression

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Edema intervention

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Compression Retrograde massage and/or self-massage Muscle Contraction Positioning Joint in space, orthotics, CPM machines

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Edema modalities

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Ice massage, Ice baths, contrast baths, Ultrasound, Heat

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Immobilized joints =

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Loss of muscle fiber Changes in the number and length of sarcomeres Changes in connective tissue (ligament weakness, elastic stiffness resulting in shortening of the muscle) Disruption of articular cartilage Tendons and ligaments lose strength in the absence of motion and stress

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Immobilization of joints...muscle filaments

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lose their ability to slide

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edema can increase

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the circumference of a joint and limit ROM

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prolonged swelling leads to

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fibrotic changes and adhesions which result in contractures

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When an agonist is weaker than its antagonist,

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the uneven tension can cause a contracture

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Stretching =?

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Tissue is lengthened by outside force

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Stretching eliminates

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tightness that could cause a contracture

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Stretching should be completed to the point of

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maximal stretch Force, speed, direction and extent of stretch must be controlled

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what should you do prior to stretching to increase results?

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relaxation and massage of muscles Superficial and deep heat Low intensity exercises

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Stretching Force:

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must be high enough to put tension on the tissue but not so high to rupture the muscle

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Stetching speed

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slow to allow joint to adjust gradually

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Stretching direction

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Exact opposite to the tightness

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maximal stretch

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few degrees beyond the point of discomfort and held 15 - 30 seconds

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Gentle stretch

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Achieves small increments of gain over time More effective than vigorous stretching Allows connective tissue to adapt to new requirements and adjust to its length over time

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Aggressive stretch

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Connective tissue resists quick, vigorous stretching Aggressive stretch can be ineffective or cause injury Pain can indicate that the stretch was too forceful and caused tearing of soft tissues or blood vessels

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Active Stretching, Involvement in an interesting / purposeful activity -->

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Client is more relaxed Client is not anticipating pain Client is motivated to complete the task

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Active Inhibition Techniques

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Contract / relax PNF patterns

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Passive stretch--Manual stretch

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Relaxing environment Stabilize bone proximal and distal to the joint to be moved Encourage the client to assist with movement Hold position for 15 - 30 seconds Complete movement slowly If patient has sensory loss, they may not feel pain Pay attention to nonverbal signs of discomfort Not the same as PROM

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passive stretching--overstretching can cause

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heterotopic ossification

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Prolonged Mechanical Stretch

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Orthotics / casts

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passive stretching--Joint Mobilizations

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Involves passively rocking, and oscillatory movements aimed at increasing joint play. Used with joint stiffness, pain or reversible joint hypomobility

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Myofascial Release

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Stretching and breaking up of adhesions of the fascia

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Joint Manipulation

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Done to break up massive adhesions and usually done under anesthesia

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ROM impacted by

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occupations

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Functional ROM is the

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range necessary to perform daily occupations Baseball player Professional musician 80 year old homemaker Occupational Therapy's goal is to prevent ROM limitations that interfere with daily occupations

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Types of ROM

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Self-ROM AROM AAROM PROM--Gentle movement, Pay attention to joint biomechanics, Scapulo-humeral rhythm

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Contractures of soft tissue that can be changed:

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Skin Muscles Tendons Ligaments

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Contractures that ____________ be changed

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can't Bony changes / ankylosis Longstanding contractures Severe joint destruction

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Contraindications of ROM

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Motion of the part may interfere with healing (i.e. new pacemaker, surgical repairs, etc.) Unhealed fracture / unstable joint Unhealed suture (i.e. CABG) Blood clot Unstable medical condition Medical lines

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Strengthening

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Stress joint to the extent where additional motor units are recruited Muscle hypertrophies Must be stressed to the point of fatigue

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Muscle strengthening used when

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muscle weakness interferes with occupational performance in work, play and self-care

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Muscle weakness is potentially deforming due to

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muscle imbalances and strengthening weak muscles will balance the forces of agonists and antagonists

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Muscle strengthening duration

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The length or total time the client participates in the activity or exercise

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High intensity, low duration=

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increased strength

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Low intensity, high duration =

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increased endurance

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muscle strengthening rate or velocity

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Speed of the activity or exercise Slower speeds increases muscle strength Eliminates momentum Type of muscle contraction is linked to velocity

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Isometric:

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External and internal forces are equal; length of the contracted muscle remains the same.

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concentric

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muscle shortens to move a body part in the direction of the pull of the muscle. The internal force of the muscle overcomes the external resistance

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Eccentric

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Contracted muscle lengthens to act as a brake against an external force to allow for a smooth controlled movement

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Muscle strengthening frequency

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The number of times per day or number of days per week the activity or exercise is done

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frequency depends upon

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The types of fibers being strengthened The clients' endurance and general health status The type of activity for which the intervention is directed Muscle grades, joint mobility, diagnosis, intervention goals, position of the client, and desirable plane of motion Level of fatigue

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Muscle strengthening Intensity

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Level of exertion or energy expenditure Can be gauged by client's heart rate, perceived exertion, and ability to speak normally

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Increase strength

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Try to reach 50% to 67% of the maximum that the client can lift (one rep maximum) 1-3 sets of 8-10 reps

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Increase endurance

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Try to reach 30% - 50% of one rep maximum 1-3 sets of 15-20 reps

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Optimal intensity

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The last 3 reps of a set begin to get difficult No substitution Quality over quantity

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Muscle strengthening Intensity Can be Changed / Graded

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By the type of exercise or activity that is performed By the amount of resistance By changing the length of the lever arm By changing the point where the load is applied By changing the plane of movement

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Signs of fatigue

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Slower performance Perspiration Increased rate of respiration Decreased ROM Decreased time of contraction Tremors with contraction General sense of fatigue Substitution of movements Increase heart rate

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Acute Pain

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Experienced immediately following a physical injury and is proportional to the physical findings

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Chronic Pain

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Lasts months or years and can change the client's personality, cause disassociation from physical problems, and can develop into different clinical syndromes

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Pain Management

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Modalities, Behavioral techniques, stretching, mobilizations, at times strengthening (if done correctly)

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Isotonic Active Assistive

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Appropriate for clients with trace (1), poor minus (2-) or fair minus (3-) muscle grades The client actively contracts the muscle and then the therapist moves the muscle through the available ROM Poor minus / fair minus muscles (gravity eliminated for 2-, against gravity for 3-) Bilateral activities are useful if only one extremity is involved

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Active Exercises and Activities

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The client moves through the available ROM without resistance Poor (2) or fair muscle (3) (gravity eliminated plane for poor, against gravity for fair) Repeats motion for up to 3 sets of ten with rest break between sets The goal is to progress to a point where some resistance other than gravity can be applied

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Resistive Activities and Exercises

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Completed when an outside resistance is required to apply maximal stress to the muscle in order to promote adaptation (external force greater than gravity) May be applied manually, by equipment, tools, or activities Needed to increase muscle grades to normal Educate client's to avoid holding their breath Talk, count, sing

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Isometric activities and exercises

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Characterized by no visible joint movement nor appreciable change in muscle length but increased muscle tension

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Isometric activities and exercises indications

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Rheumatoid arthritis Pain or inflammation Clients with trace muscle strength Easy to perform, no special "tools", minimal time Gains in strength do not necessarily translate to dynamic activities No effect on coordination and does not cause hypertrophy Causes an increase in blood pressure Contraindicated for patients with cardiovascular disease

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Delayed Onset Muscle Soreness (DOMS)

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Occurs usually 24 to 48 hours after exercise May be more severe and frequent with eccentric than concentric exercise against gravity Minimized or prevented with proper warm up and cool down Gradually increasing resistance also decreased DOMS

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Endurance

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The ability to sustain cardiac, pulmonary, and musculoskeletal exertion over time" Clients with deficits in local muscle metabolism, cardiovascular systems, respiratory system, or on total bed rest 6+ days Influenced by muscle function, oxygen supply, and their combined efforts

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Increasing endurance

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Less than maximal resistance Fatigue occurs more slower with light resistive movements because muscle fibers can rest / recover while other muscle fibers are activated Moderately fatiguing activity for increasingly longer periods of time Intervals of rest to allow metabolic recovery 40 - 60% of RM Increase number of repetitions or lengthening the time a contraction is held

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Assessment of cardiorespiratory function

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Pulse Blood pressure Respiration Vital capacity Oxygen level (oxygen saturation) Cardiac output RPE: rate of perceived exertion Target heart rate range: max HR - resting HR = target heart rate

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benefits of increased endurance

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Decreased heart rate at rest Increased ability to perform repeated motor tasks and carry on sustained activity Decreased exercise recovery time Increased coronary blood flow Increased cardiac output

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Endurance exercise programs

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Low load with high duration Target slow twitch/Type 1 fibers There has to be some resistance for adaptation to occur Work on the larger muscle groups Activities that involve excessive use of the arms overhead or isometric contractions increase blood pressure without aerobic benefits Tolerance is often used in relation to endurance

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Occupational therapy

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OT's compare the abilities of an individual and the physical demands of an activity through biomechanical analysis of activity performance. To use occupations, or purposeful activity, for treatment, you need a full understanding of the individual's abilities and limitations.

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The Biomechanical Analysis of Function . . .THE BASICS

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Perform joint by joint analysis of the activity's demands on the body Integrate all information together Prescribe activity Adapt or modify activity Adapt or modify environment

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Define motion

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Direction - plane and axis Type - linear or rotary Muscles involved - agonist, antagonist, synergist

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quantity

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Velocity - speed, force generated Resistance - friction, gravity, load Range of Motion required for the activity Repetitive, Static or Dynamic

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quality

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Joint movements Muscle contractions

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analysis of components

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motion quantity quality

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