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To comply with professional boards/associations standards:• I declare that I (or my family) do have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 405: Active Care: Mobility Techniques & Tools to Clinically Progress Patient Outcomes
John Hisamoto, PT, ATC & Shawn Burger, PT, DPT
Leading the Way in Continuing Education and Professional Development. www.Vyne.com
John Hisamoto PT, ATC
Owner, Pro‐Active Physical Therapy
Shawn Burger, PT, DPT
Owner, PearFIT Physical Therapy
Before we get started…
• Phones
• Names on workbooks
• Bathrooms
• Waiver
• Pre‐test
• Latex Allergies?
• Anything else…
Today’s Schedule
• Evidence for Home Exercise
• Science Behind Elastic Resistance
• Evidence‐based Mobility Tools & Techniques
Associations Between Treatment Processes, Patient Characteristics, and Outcomes in Outpatient Physical Therapy Practice
Prospective, 2.5 years, 54 clinics, >22,000 musculoskeletal patients
Deutscher D et al. 2009. Arch Phys Med Rehabil. 90:1349-63.
1. HEP & visit compliance associated with better outcomes
● Poor home exercise program compliance had poor outcomes
2. Patient education is needed to improve compliance
● Need to “sell” patient that what they are doing will work
3. Modalities associated with worse outcomes
● Shoulder ultrasound particularly worse
To improve cost‐effectiveness, improve outcomes first!
How do you improve compliance?
1. An Individualized exercise program is the key.
2. Identify patient’s goals and barriers to exercise• Barriers (more than motivators) predict adherence in home exercise
programs
(Forkan et al. 2006)
3. Both the therapist and patient are responsible for patient compliance (Sluijs et al. 1993)4. “Educate and Demonstrate”
Delivering Home Programs
• Verbal explanation & demonstration
(Chase et al. 1993)
• Handouts effective but not alone (Friedrich et al. 1996, Reo and Mercer 2004, Udermann et al. 2004)
• Correlation between performing exercises correctly and reducing pain (Friedrich et al. 1996)
Therapeutic Exercise ProgressionFramework for
Clinical Decision Making
Anyone can follow a protocol…
How do you treat dysfunction?
Dysfunction
Is it a Stability or Mobility Problem?
Stability
Emphasize strength, stability, motor control
Mobility
Emphasize joint and soft tissue
mobility
www.RehabEducation.com/SFMA
Assessment is Critical
Tools & Techniques
MobilityStability Movement
Emphasize joint and soft tissue
mobility
Emphasize strength, stability, motor control
Mobility Tools & Techniques
Force Elongation Characteristics of TheraBand CLX
• Tested 3 different lots of each color CLX
• 4 different lengths (number of loops)
• Validated published force values (within 0.2 pounds)
• No significant difference between number of loops used (ie, length of band)
Same force at same elongation regardless of # of loops
Progression
40% in color
25% in color
TheraBandColor
~125% stretch(pounds)
Yellow 3.0
Red 3.7
Green 4.6
Blue 5.8
Black 7.3
Silver 10.2
Gold 14.2
33
44
66
55
88
1212
15.515.5
TheraBand CLX resistance provides a strength curve
equivalent to ~125% elongation
TheraBand CLX equivalence to weights
(in pounds)
Yellow = 3.42 lbs
Red = 4.20 lbs
Green = 4.93 lbs
Blue = 6.23 lbs
Black = 8.00 lbsbs
Silver = 11.99 lbs
Gold 15.56 lbs ~125%
Regression equation predicts torque
ISOTONICELASTIC
Force AngleFA = Angle created by force and lever arm
2 5 0
resistance-arm angle
0
20
40
60
80
100
120
140
160
180
200
0 11 22 33 45 57 69 83 98 115 135 156 180
joint angle
resi
sta
nce
-arm
an
gle
angle
As joint angle increases, force angle decreases
Force Angle
Join
t Ang
le
Warning: RED Isn’t Always RED
Ensure your patients are using the appropriate resistance at home!
Equivalent to TheraBand
Silver
Equivalent to TheraBand
Black
Equivalent to TheraBand
Blue
Authentic TheraBand
Red
Other retail products on the market
TheraBand CLX Features
• Increase or decrease resistance by changing loops
• Easy connection to lower body
• Quick transition between exercises
• Create multiple resistance vectors
• Connect upper and lower chains
• Loop‐through
• Create spiral transverse plane
CLX Wall Station
• Wall Station– TheraBand CLX – Wall unit– Three Wall Anchors– Accessory Rack– Full color poster
• Clinic Focal Point– Change setups quickly for
maximum use– Small footprint – Transition from Clinic to HEP
consistently and efficiently
Wall Unit Features
• Unique secure connect system• Adjusts height quickly• Can be mounted to be utilized with Silver and Gold CLX• Prescription markers designed to help track and measure individual
progress
Mobility Tools & Techniques
Assisted Range of Motion
Mobility
Elbow Flexion AAROM
1. Securely anchor CLX2. Create vector of assistance3. Assist motion with CLX
To assist joint motion when strength or pain limit ROM
Low Load Prolonged Stretch
Mobility
Anterior Capsule Stretch
1. Securely anchor CLX2. Create vector of resistance3. Position at end ROM
Apply constant low load resistance to joint capsule
1. Open Hands2. Extend Fingers3. Extend Thumbs4. Extend Wrist5. Supinate6. Externally Rotate7. Extend Elbows8. Extend Arms9. Retract Scapula
Slowly return
Postural Chain ResetPostural Chain Reset
Mobility
Facilitate phasic chain to reset posture by balancing postural muscles
Bruegger Upper Body
Post‐Isometric Relaxation
Mobility
1. Stabilize one end of CLX in line with target muscle
2. Shorten target muscle against light resistance
3. Hold for 3 seconds4. Exhale as you relax into
stretched position
Upper Trapezius P.I.R.
Light muscle contraction followed by relaxation to reduce muscular trigger points
Eccentric Stretch
Mobility
Achilles Eccentric Stretch
1. Secure CLX2. Shorten muscle to be
stretched WITHOUT resistance
3. Load muscle in shortened position by stretching CLX
4. Slowly lengthen muscle against CLX
5. Hold stretch at end
Eccentric contraction to facilitate collagen realignment
Contract Relax
Hamstring Contract‐Relax
1. Secure CLX2. Grasp other end of CLX
to stretch muscle3. Contract target muscle
against resistance
Mobility
Pre‐stretch contraction improves passive motion after stretch
AdditionalMobility Tools & Techniques
Standard versus feedback‐augmented shoulder pulley exercises
• Shoulder patients were randomly given either TheraBand or white shoulder pulley for home exercise
• TheraBand shoulder pulley group had significantly more shoulder range of motion after therapy
Marks help withinstruction and feedback for patient.
A comparison of assisted and unassisted PNF techniques and static stretching
• TheraBand Stretch Strap provides flexibility gains similar to partner‐assisted PNF stretching
• “competitive athletes should use these techniques to improve flexibility in a separate stretching routine, and not immediately before training and competition”
Maddigan et al. 2012. J Strength Condition Res. 26(5):1238‐44.
Foam Rolling for DOMS and Recovery of Dynamic Performance Measures
• 20 minutes of foam rolling massage on quadriceps immediately after inducing DOMS. Repeated 24 & 48 hours post.
• Significantly reduced pain and increased performance compared to control condition
• Conclusion:– Short‐term increases in ROM without affecting muscle performance
• Dosage:– Foam Roller: 30‐60 sec (2 to 5 times)– Roller Massager: 5‐120 sec (2 to 5 times)
May benefit pre‐exercise warm‐up & cool down
Cheatham SW et al. 2015. IJSPT. 10(6):827‐838
• Theoretical mechanisms of myofascial rolling– Change viscoelastic and thixotrophic properties of soft tissue
– Increased blood flow and tissue temperature– Changes muscle spindle length or stretch perception– Mechanical mobilization of fascia and scar tissue
Higher density tools may have stronger effects than softer density
Gentle tissue work (3 point support, yellow)
Aggressive tissue work (1 point support, blue)
Depth of tissue releasing is controlled through:
• Body Weight & positioning
• Stroke length & fluidity
• Progressive wrap densities and heights (colors)
TheraBand Foam Rollers and Roller Wraps
TheraBand Roller Massager
Unique ridged design and latex‐free
material Retractable handles
Standard Portable
Neutral Calf
Depth of tissue releasing is controlled through:
• Pressure applied
• Body part positioning
• Stroke length and fluidity
Elongated Calf TrP ReleaseShortened Calf
• Elongated muscle position + longer strokes for superficial tissue layers
• Shorter muscle position + shorter strokes for deeper knots and tightness
• Deep dig with handles for trigger point / tension point (“knots”) release
TheraBand Foot Roller
• Ridged design– Increases pressure points to deliver enhance mobilization
• Hollow core helps shape to foot• Can be chilled or frozen
IASTM and STM Techniques
Mechanical:‐Recreation or Stimulation of the Inflammatory cascade
Fascial:‐Superficial (skin), Middle and Deep (muscle + ligament)
Neurological: ‐Afferent Stimulation
‐Pain control, gait control theory‐Facilitation, motor control pathway
Fluid Dynamics:‐Improve edema, fluid mobility, tissue health
• Improved biomechanical function in treated tendons
• Increased cross‐sectional area in treated tendons.
Untreated Achilles Tendon
IASTM Techniques
*This study was performed in animal models
Bon Vital & Prossage
Prossage Salve & Balm (Menthol) For IASTM and Scar massage
Prossage Cream & Oil (Menthol)Bon Vital Muscle Therapy Massage Cream
For Soft Tissue Mobilization
Janda’s Upper Crossed Syndrome
Neck Pain
Stability Mobility
Lateral Epicondylitis
Stability Mobility
Shoulder Impingement
Stability Mobility
Janda’s Lower Crossed Syndrome
Lower Back Pain
Stability Mobility
Anterior Knee Pain
Stability Mobility
Performance Health Academyhttp://www.performancehealthacademy.com
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Techniques• CE Courses