Monday Memo 8/7/17

The Monday Memo

August 7, 2017                                                                           PITT DPT STUDENTS

 

WHAT IS MOBILITY?

Charles R. Badawy SPT, CSCS, USAW

 

 

MOBILITY

This term is thrown around constantly, but do we really know what it means? Some see it as a measure of the amount of range-of-motion (ROM) available at a joint, others imply a stability component. This indecision is an issue and the term must be clearly defined if it’s to be used properly.

 

To start, we need to address a few things. You see, there are principles at play concerning how “Mobility” is typically used. I think it’s important to bring them to attention in order to enhance our understanding of the term.

 

I think we can clearly understand that the term mobility at a basic level has to do with joint function. I like to believe people are well intentioned and genuinely use this term to help patients. They’re using it as an attribute. As a way to describe joint movement. Are there other well defined terms that would help us?

 

  • Range of Motion: Refers to the distance and direction a joint can move, measured in degrees in the field of physical therapy. There are two types to concern us with, although a third exists
    • Passive ROM (PROM)
    • Active ROM (AROM)

 

  • Flexibility: Refers to the ability to move a joint or series of joints through a full, non-restricted, injury, and pain-free ROM.

Flexibility helps us further break down PROM. Flexibility applies to any human joint, where PROM can refer to any mechanical system. Flexibility depends on the following factors: Joint ROM, Muscle Extensibility, & Neuromuscular control.

 

JOINT ROM, MUSCLE EXTENSIBILITY (ME) & NEUROMUSCULAR (NM) CONTROL

 

  • Joint ROM: In essence, PROM describes Joint ROM, the degrees of rotation allowed by the bony articulations, so what do the other two terms mean?

 

  • ME: A measure of the effect of muscles that cross the joint on the ROM available at the bony articulations. Is it highly extensible, giving it the ability to lengthen and allow for great joint movement? Or not? This applies a muscular layer to our current description of PROM or Joint ROM.

    Muscle extensibility has a passive effect, which is where the nervous system comes into play.

 

  • NM Control: The nervous system gives us our greatest gift, the ability to move. The nervous system has an affect on the muscular components of a joint, and applies an active component to the bony articulations. It is a measure of our AROM.

The nervous system processes information taken in through various receptors throughout the body and provides instructions to the muscles to contract a certain way. The end goal being: stability. A system can be referred to as being inherently stable when homeostasis, or the ability to maintain neutral position, is adequate to restore previous function. This poses the question, “What is stable?”
 

“WHAT IS STABLE?”

 

When it comes strictly to bony articulations, stable is a position where the bony structures are balanced against the effects of gravity. As the bones change positions and the forces applied to them change, our bodies depend on two factors to help us maintain stability, or this position of balance.

  • Active Restraints: Structures that produce and apply force to a joint.
  • Passive Restraints: Structures that don’t inherently produce force, but limit joint ROM due to their structure. Things like ligaments, bony architecture, etc.

 

You see, neuromuscular control affects these active restraints. When we run, forces are applied to the system that must be counteracted. The active restraints perform the bulk of the work here and the nervous system must be effective enough to accomplish a given task

 

The term neuromuscular control has huge implications on our understanding of mobility, in that it demands further information from those who utter it. Are we talking about the active mobility or passive mobility of a joint?

  • If we’re discussing the passive mobility of a joint, we’ve truly only discussing the extensibility of the soft tissue and bony architecture. We’re discussing the passive restraints.
  • If we’re talking about the active mobility of a joint, we are discussing nervous system function. How effective it is in processing information and modulating muscular force application. We’re discussing neuromuscular control.

 

SO WHAT’S OUR TAKEAWAY HERE?
Does the term even have a purpose? I’d argue that we already have defined attributes of joint function. If the definitions laid out in this article are to be accepted, the following statements can be made:

  1. Active mobility and neuromuscular control are synonymous.

  2. Passive mobility is simply a measure of tissue extensibility and bony architecture.

 

I’ve thrown around the term “mobility” countless times, but I’m trying to be more judicious in the way I communicate. These reflections show me that there may be more appropriate ways to describe joint function when talking to clients/patients.

 

At the end of the day, when attempting to create a therapeutic effect or change in performance, it’s important to understand the limiting factor: Should we be focusing on improving neuromuscular control, tissue extensibility, or bony architecture? The answer should greatly influence our method of intervention.

 

 

August 7, 2017 |

Monday Memo 7/17/17

The Monday Memo

July 17, 2017                                                                           PITT DPT STUDENTS

Concentric & Eccentric Contractions

As therapists, we understand so much about the human body and how it functions. It’s important to realize, however, that in many ways the ultimate goal is to educate the patient who’s coming to us for help.

 

We understand that our muscles act in many ways: statically or dynamically, quickly or slowly, voluntarily or involuntarily. One concept I continually stress to my patients is that of eccentric and concentric contractions. It’s a topic that most of us probably take for granted, but an effective explanation can make all the difference when it comes to patient buy in.

 

Let’s begin with defining three terms:

🔹Isometric Contractions: When a muscle produces force without changing length.

🔸Concentric Contractions: When a muscle produces force and shortens.

🔹Eccentric Contractions: When a muscle produces force and lengthens.

 

These are the classic definitions, and many of us explain this to our patients, but a simple tweak may enhance their understanding.

 

In reality, we can think of the eccentric contraction in an exercise as the deceleration phase and the concentric contraction as the acceleration phase. This adjustment in terminology can allow us to simplify things for our athletes and improve communication over our course of care.

 

Remember, the more effectively you can communicate with your clientele, the more effective of an educator your will be. It’s these little things that can make a huge difference in your success as a clinician.

Charles Badawy, SPT, CSCS, USAW,

Pitt DPT Class of 2019

July 17, 2017 |

Monday Memo 6/19/2017

The Monday Memo

June 19, 2017                                                                           PITT DPT STUDENTS

Personal Training & Physical Therapy

 

The two years I took between my undergraduate education and beginning physical therapy school at Pitt was perhaps the best decision I’ve ever made. I didn’t realize it at the time, but the experience that I received over those 26 months allowed me to develop skills that will be valuable during my career as a therapist. The mentors I cultivated over that time, both in person and online, helped me to recognize that the two professions don’t have to work in isolation. Rather, I think it’s incredibly important to blend the two. Whether you approach it from a patient education standpoint or integrate strength and conditioning protocols into the therapeutic plan, there is an immense amount of value in successfully integrating both aspects into patient care.

At the end of the day, professionals in both fields have very similar goals: To improve the function and performance of the person standing in front of them. Therapists typically work with a population in pain, with the ultimate goal of moving them out of the symptom modulation phase, improving upon the impairments found in the physical exam, and returning the patient to their desired level of participation. The trainer works on the other end of the spectrum to help improve their client’s body composition, performance goals, and overall resilience. At the end of the day, both are attempting to make significant changes in their client’s level of function.

We know that Americans don’t exercise enough. We know that sedentary lifestyles only accelerate our body’s natural degenerative process. We know that a lack of physical activity and progressive overload results in a gradual weakening and deterioration of your body’s tissues, eventually leading to injury/pathology. We know this because as therapists and trainers, we are exercise professionals. We live and breathe this culture of physical activity, but, unfortunately, the majority of our patients do not. It’s important to educate your clients: Inform them of the benefits of physical activity and impress upon them the vast effect it will have on their personal lives.

In addition, encourage active modalities over passive methods during your therapeutic plan. There is always a reason to default to moist heat to warm up body tissue and prepare it for work, but an active warm-up can accomplish this same goal while also increasing calorie burn, circulation, muscular function, and more. If your client is seeing you for a lower extremity injury, show them how to train their upper body and trunk in a safe and effective manner. An injury doesn’t always mean you should stop training and there is plenty of research that shows benefits to the involved limb when you continue to train the uninvolved side.

At the end of the day, physical therapists are experts in the human movement system. We understand the human body, biomechanics, and the effect of physical activity (or lack thereof) on your body. If we want to elevate our profession, our outcomes, and our patients, we need to do a better job of educating them on all things health and fitness. We also need to embody this belief ourselves. Be an example for your patients and practice what you preach. How often are you strength training? Performing some sort of cardiovascular exercise? As cliche as it sounds: Be the change you want to see in the world.

Charles Badawy, SPT, CSCS, USAW,

Pitt DPT Class of 2019

June 19, 2017 |

Monday Memo 6/12/2017

The Monday Memo

June 12, 2017                                                                           PITT DPT STUDENTS

Patient Adherence

 

As is typical with most physical therapy students, I had a very active and healthy lifestyle growing up. I was a competitive swimmer in high school and spent nearly 20 hours a week in the pool training. I got into triathlon, weightlifting, and played intramurals throughout my academic career at Virginia Tech. My personal interests always revolved around physical activity and training, so naturally pursuing a career in health care made sense.

Like many, I figured I would apply to medical school upon graduating, but I slowly started to realize that physical therapy was much better suited for me. This profession gives you the opportunity to analyze a patient’s movement system, determine the best course of treatment, and help initiate their path to recovery. This path may include some passive methods, such as employing the RICE method or prescribing orthotics, but these typically lead us to the more effective and vitally important method that we utilize: active therapeutic exercise.

Your TherEx protocol is the “meat and potatoes” of your therapeutic protocol. This is what will provide true adaptation to your patient’s issue. At least for me, it’s also the aspect of PT that as a clinician you are most excited about. You’re creating an exercise regimen that will help the patient grow stronger, safer, and more resilient, and all they have to do is follow your instructions! What could go wrong?

The answer: A lot.
For instance, the patient may not do it. Unless you have the opportunity to work with the elite athletic population whose paychecks are on the line, you’ll be fighting the constant battle of patient adherence. Your patients are busy. They have jobs. They had kids. They have other interests and other priorities, and completing your 3×10 sit-to-stand protocol is likely very low on the totem pole.

We know how important exercise is. We understand the consequences of working a desk job 50-60 hours a week and coming home to eat a microwaveable meal and sit on the couch for the remainder of the evening. It is up to us to create patient buy-in; and to educate the public on the importance of regular physical activity and adherence to our therapeutic protocols.

This concept applies to all therapeutic settings: in-patient neuro, outpatient ortho, pediatrics, etc. We must work everyday to connect with our patients and show them how improving their functional deficiencies will lead to improved participation in the activities that they truly care about. Our goals and protocols must be patient-centered. They must be dedicated to helping the patient get back to the activities of their choice. This will not only enhance patient adherence, but also result in improved outcomes and reduced healthcare costs further down the road.

 

  • Charles Badawy, SPT, CSCS, USAW,

            Pitt DPT Class of 2019

June 12, 2017 |

Monday Memo 5/22/17

The Monday Memo

May 22, 2017                                                                           PITT DPT STUDENTS

Below is a hypothetical case study: The patient is representative of an impairment/functional deficit that is common in an outpatient physical therapy clinic. Leave a comment with the next steps that you would take if you were the primary clinician: Would you continue with the physical exam? Redirect your focus? Do you feel comfortable prescribing treatment from the given information? What other questions might you ask this patient? Is this a situation where referral may be needed? Why or why not?

 

Patient: 26 y.o Female Graduate Student

Chief Complaint:

  • Right shoulder pain with elevation affecting the ability to perform overhead activities and reach across to grab her seatbelt.

Onset:

  • Over 1 month ago — Occurred while performing dumbbell presses in a strength training group class. Immediate limitations included putting on a shirt and reaching across her body. Pain at the AC joint area.
  • Seemed to get better on its own over the next week or two… Then got worse after a poor night’s sleep. This worsening presented as more of a “constant” pain and stiffness with the patient feeling as though she needed to pop it back into place. Reports “cracking” with movement.
  • Seemed to get better again with time, but 2 days ago the patient was leaning on her elbows and pain flared back up after standing back up and unweighting the shoulder. New onset of pain is in a different place: More lateral to the AC Joint. Pain has decreased over the past 48 hours.
  • Worst: 5-7/10 , Best: 1/10

PMHx:

  • No prior history of shoulder injuries besides bilateral broken clavicles at a young age.
  • Pt has been dealing with headaches since teenage years. Two main types: First is typical with a cervicogenic left-sided “Ram’s Horn” presentation and also has referral to the supraorbital area over the R. eye. She also complains of tension-type headaches that she correlates with dehydration, stress, and posture. Reports that the tension-type headaches are helped with postural exercises (chin tucks).

Exam:

  • Patient appears to be in good health. Slender frame with average or slightly below average muscle mass. Slight forward head posture. Depressed R shoulder relative to L.
  • Full ROM with slight pain at end-range FLEX/ABD; 4/5 on MMT with most movements, but painful with resisted FLEX/ABD/ER.
  • Abnormal scapular mechanics noted with ABD. R side seems to get hung up, especially on descent. Flexion mechanics appear normal, but a “click” or “pop” is felt and heard with both movements on elevation and descent.
  • Special Tests:
    • No signs of instability or apprehension with testing.
    • Clicking felt with Load and Shift to assess anterior capsule/labrum
    • (+) Neers, (+) Jerk for anterior pain, (+) Crank w/ clicking, (+) Hawkins Kennedy
    • (-) RTC cluster, (-) Sulcus Sign, (-) Biceps load test

May 22, 2017 |