Sem. a week 2 day1


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Sem. a week 2 day1

  1. 1. Connective Tissues <ul><li>Collagen </li></ul><ul><li>- Primary structural component of all connective tissues </li></ul><ul><li> - Forms a matrix to support function </li></ul><ul><ul><ul><ul><li>Sometimes rigid (bone, articular cartilage) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sometimes fluid (blood, adipose tissue) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sometimes something in between (tendons, ligaments) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- Not a cell! Primarily fibrous, less energy need, hence less vascularization. </li></ul></ul></ul></ul>
  2. 2. Connective Tissue cont.. <ul><li>Results in slower growth rates and slower healing process than muscle. </li></ul><ul><li>Injury to this tissue is frequently caused by muscle strength outstripping joint strength – usually found in beginners and with drug induced muscularity. </li></ul><ul><li>This type of injury is particularly gruesome: the tendon may snap (usually at insertion) and the muscle rolls up like a window shade. Requires surgery to fix. </li></ul>
  3. 3. Types of Connective Tissue: <ul><li>Bone </li></ul><ul><li>Blood </li></ul><ul><li>Adipose tissue </li></ul><ul><li>Tendons </li></ul><ul><li>Ligaments </li></ul><ul><li>Fascia </li></ul><ul><li>Cartilage </li></ul><ul><li>- We’ll be dealing primarily with bone, tendons, ligaments, and cartilage in this course. </li></ul>
  4. 4. Bone cont… <ul><li>Two different bone types: </li></ul><ul><li>1.) S pongy ( trabecular ) – Where some blood cells are made and fats are stored. Blood vessels extend from here as a network of horizontal and vertical canals into the cortical bone. </li></ul><ul><li>2.) Compact ( cortical ) bone: the dense, compact outer shell that is bridged by trabecular bone </li></ul>
  5. 5. Connective Tissue cont… <ul><li>Bone </li></ul><ul><ul><li>- Mineralized connective tissue </li></ul></ul><ul><ul><li>- - Prefix &quot;Osteo” means bone </li></ul></ul><ul><ul><ul><li>Osteo blast : bone forming cells (mnemonic – you make things in a “blast furnace” – osteoblasts make bone) </li></ul></ul></ul><ul><ul><ul><li>Osteo genesis : Osteo - bone… “genic” - genesis - beginning of </li></ul></ul></ul><ul><ul><ul><li>Osteo porosis : porous, as in sponge like… </li></ul></ul></ul>
  6. 6. Bone cont.. <ul><ul><li> Locations of “ spongy” bone: </li></ul></ul><ul><ul><ul><li>- Vertebral bone is 70% trabecular (axial bone) </li></ul></ul></ul><ul><ul><ul><li>- In marrow cavities and ends of long bones (appendicular bone). </li></ul></ul></ul><ul><ul><ul><li>Locations of “ compact ” bone – the outer shell of all bones </li></ul></ul></ul>
  7. 7. Process for Strengthening Bone <ul><li>1.) Mechanical forces cause deformation at specific sites (only need about 1/10th of the force it would take to break the bone). </li></ul><ul><li>2.) Osteo blasts migrate to stress site </li></ul><ul><li>3.) Start bone modeling: </li></ul><ul><li>- osteoblasts secrete collagen to build bone matrix. </li></ul><ul><li>- collagen molecules become mineralized in the presence of calcium and phosphate “hence”- bone becomes denser, more rigid. </li></ul>
  8. 8. Bone cont.. <ul><li>Osteoporosis: </li></ul><ul><li>- Bones become porous (weak and prone to fracture) without regular loading. </li></ul><ul><li>- Can be caused by- Inactivity </li></ul><ul><li> (i.e) - lack of vertical loading. </li></ul><ul><li>Example : Astronauts lose 1% of bone mass within the first month of zero gravity.) </li></ul>
  9. 9. Bone cont… <ul><li>Calcium leaching (Remember that Ca++ is essential to a muscle contraction…) </li></ul><ul><li>–The body will leach Ca++ from the bones to support muscle function if necessary). Very common problem in high protein diets. The high intake of protein leaches calcium from the bones, which leads to osteoporosis. </li></ul>
  10. 10. Additional Causes… <ul><ul><li>Genetics </li></ul></ul><ul><ul><li>Hormonal changes </li></ul></ul><ul><ul><li>Thyroid disorders </li></ul></ul><ul><ul><li>Excess Vitamin A </li></ul></ul>
  11. 11. Consider this… <ul><li>“Relying strictly on calcium supplements to fend off osteoporosis is like someone gulping protein shakes and thinking he's going to grow huge muscles without lifting…” </li></ul>
  12. 12. Bones cont.. <ul><li>Remember the operating principles of overload & adaptation. Our muscles grow because we cause them to work harder than they're accustomed to. </li></ul><ul><li>Bones respond in the same fashion. Bones grow strong in response ( adaptation ) to the stresses we put on them ( overload ) -- No overload = No adaptation. </li></ul>
  13. 13. Bones cont… <ul><li>Need “ structural ” or “ weight bearing ” exercises to stimulate adaptation: loaded, multi-joint exercises seem to be best. </li></ul><ul><li>Isolation exercises (especially ones that don’t load the bones vertically, like leg extensions and leg curls) are less effective </li></ul>
  14. 14. “ Window of Opportunity Theory”… <ul><li>– “Bone density is primarily formed young, in teen and adult years. If you fail to optimize bone strength in this time, you may forfeit bone density potential for the rest of your life…” </li></ul>
  15. 15. Tendons, Ligaments, and Fascia <ul><li>Both tendons and ligaments : </li></ul><ul><ul><ul><li>Not very metabolically active </li></ul></ul></ul><ul><ul><ul><li>Have a low requirement for O2 and nutrients </li></ul></ul></ul><ul><ul><ul><li>Do have a limited direct blood supply </li></ul></ul></ul><ul><ul><ul><li>Contain extensible protein “ elastin ” allows some stretch for normal joint motion. </li></ul></ul></ul><ul><ul><ul><li>Attach directly to cartilage or bone </li></ul></ul></ul><ul><ul><ul><li>- Ligaments attach bone to bone </li></ul></ul></ul><ul><ul><ul><li>- Tendons attach muscle to bone </li></ul></ul></ul>
  16. 16. Fascia <ul><li>Fibrous connective tissue that surrounds and separates different organizational levels w/n skeletal muscle. </li></ul><ul><li>Formed primarily in sheets arranged in different planes to provide resistance to forces from several different directions </li></ul>
  17. 17. Fascia <ul><li>All three layers of fascia converge near the end of the muscle to form a tendon that actually attaches to the periosteum, or in some cases, to the bone’s surface. Muscle contraction force is thus transmitted to the bone via fascia to tendon to periosteum to bone . </li></ul>
  18. 18. Cartilage <ul><li>Very dense matrix to handle tremendous forces </li></ul><ul><li>Little to no blood supply </li></ul><ul><li>- Gets O2 and nutrients through diffusion from “ synovial fluid” – so it’s very slow to heal, if at all. </li></ul>
  19. 19. Cartilage cont.. <ul><li>Articular Cartilage - Formed over the ends of bones to allow smooth movement and reduce friction. ( Also called: “hyline ” cartilage..) </li></ul><ul><li>Fibrous Cartilage - Forms the “intervertebral disks” and the “symphysis pubis”, to absorb shock. </li></ul>
  20. 20. Tendonous cartilage <ul><li>Strengthens attachment point of tendon to bone </li></ul>
  22. 22. COMMON INJURIES OF THE SPINE: <ul><li>Cervical, thoracic, lumbar and sacral regions </li></ul><ul><li>The spine is central to all movement of the human body </li></ul><ul><li>Instrumental in posture and alignment </li></ul><ul><li>Structurally designed to carry the weight of the head and provide a stable base for locomotion </li></ul><ul><li>Most common complaint seen in physical therapy and the third most common complaint seen in physician’s offices </li></ul><ul><li>‘ Back pain’ accounts for 175.8 million days of restricted activity per year and costs an estimated $85 billion per year </li></ul>
  23. 24. COMMON INJURIES OF THE SPINE: <ul><li>Intervertebral joint complex comprises: </li></ul><ul><ul><li>Vertebra above </li></ul></ul><ul><ul><li>Vertebra below </li></ul></ul><ul><ul><li>Intervertebral disc </li></ul></ul><ul><ul><li>Facet joints </li></ul></ul>
  24. 25. COMMON INJURIES OF THE SPINE: <ul><li>Nerves exit the spinal column posterior to the disc and vertebral bodies </li></ul><ul><li>Nerves transmit “do” messages from the brain and spinal cord to the muscles and joints of the body (for example: lift your arm so that you can push that door). These messages are carried in motor nerve fibers. </li></ul><ul><li>Nerves also transmit “feeling” messages back from the body to the brain and spinal cord (for example: the surface I am walking on is an incline, so I need to recruit more muscles to stabilize my ankles). These messages are carried in sensory nerve fibers. </li></ul><ul><li>One nerve contains multiple motor and sensory fibers. </li></ul>
  25. 26. COMMON INJURIES OF THE SPINE: <ul><li>Nerves are often affected in spinal injuries and can cause upper extremity pain and/or weakness (cervical spine involvement) or lower extremity pain and/or weakness (lumbar spine involvement) </li></ul><ul><li>Intervertebral discs are responsible for shock absorption throughout the spinal column </li></ul><ul><li>Discs consist of an outer fibrous layer: the annulus fibrosis and an inner gelatinous substance: the nucleus pulposus (like a jelly donut) </li></ul>
  26. 27. COMMON INJURIES OF THE SPINE: <ul><li>Because the discs are positioned between the vertebrae, they are susceptible to changes in pressure as we move through our daily lives </li></ul><ul><li>Age and weight are predisposing factors for disc injury: </li></ul><ul><ul><li>Every 10# of body mass gained increases disc pressure by 40% </li></ul></ul><ul><ul><li>The average person loses ½ to 2” in height by the age of 70. </li></ul></ul><ul><ul><li>After 12 weeks in orbit, astronauts grow 2” </li></ul></ul>
  27. 29. Herniated disc: <ul><li>Commonly called “slipped disc” which is a misnomer </li></ul><ul><li>Intervertebral discs begin to degenerate by the third decade of life </li></ul><ul><ul><li>In younger adults the nucleus pulposis is 70-90% water. Fluid content decreases with age. </li></ul></ul><ul><ul><li>Annulus fibrosis 10-20 concentric collagen layers weaken and loose elasticity with age (just like skin gets wrinkles) </li></ul></ul><ul><li>Prolonged seated postures, poor body mechanics, poor choice of exercise type and poor form during work-outs </li></ul><ul><li>Decreased activity level and subsequent muscle weakness </li></ul><ul><li>Above factors predispose discs to degeneration and herniation </li></ul><ul><li>Most common locations are L4, L5 and S1 in the lumbar region and C5, C6 and C7 in the cervical spine </li></ul>
  28. 31. Herniated disc: <ul><li>Symptoms might include lower back pain and/or stiffness with associated muscle spasm </li></ul><ul><li>Worse after running or prolonged sitting </li></ul>
  29. 32. Herniated disc: <ul><li>Treatment: </li></ul><ul><ul><li>Stop all potential aggravating activities (crunches, high impact exercise) </li></ul></ul><ul><ul><li>Early physical therapy before disc disease progresses (once disc is extruded will probably need surgery) </li></ul></ul><ul><ul><li>Educate patient in body mechanics (bending and lifting techniques) and posture (sitting, standing, walking, lying) </li></ul></ul><ul><ul><li>Ergonomic evaluation and prescription for correct work station set-up </li></ul></ul><ul><ul><li>Modify work-outs to low impact, core stability-based activities with neutral or extended spine </li></ul></ul>
  30. 33. Herniated disc: <ul><ul><li>Avoid flexion-based activities like sit-ups for ‘acute discs’ </li></ul></ul><ul><ul><li>Stretching of hamstrings and hip flexors </li></ul></ul><ul><ul><li>If unresponsive to physical therapy and exercise, might benefit from epidural injections into the nerve (up to 3 /year) </li></ul></ul><ul><ul><li>Minidiscectomy is commonly performed for large herniations, but runs a risk of recurrence where annulus is weakened </li></ul></ul><ul><ul><li>If disc is sequestrated or extruded (part of nucleus pulposus has broken off from disc) might require surgery to remove free segment </li></ul></ul>
  31. 35. Radiculitis/ Radiculopathy: <ul><li>Inflammation or irritation of the nerve </li></ul><ul><li>Often called ‘pinched nerve’ </li></ul><ul><li>Can be at the nerve root (as it emerges from the spinal column) or along the path of the nerve </li></ul><ul><li>Various causes of inflammation including: herniated discs, muscle spasm, scar tissue, osteophyte formation </li></ul><ul><li>Patient will complain of symptoms radiating down the arm or leg </li></ul><ul><li>May not experience ANY back or neck pain </li></ul><ul><li>Can experience pain, weakness, numbness/ tingling along the path of the affected nerve root </li></ul>
  32. 36. Radiculitis/ Radiculopathy: <ul><li>Might affect patients function (for example walking in a lumbar radiculopathy or gripping a pen in the case of a cervical radiculopathy) </li></ul><ul><li>In advanced condition, patient may present with atrophy of muscles along the affected dermatome </li></ul>
  33. 37. Radiculitis/ Radiculopathy: <ul><li>Treatment: Physical therapy: </li></ul><ul><ul><li>Full evaluation including movement testing (what direction of motion reproduces symptoms) </li></ul></ul><ul><ul><li>Identify cause of nerve irritation and treat the cause (muscle spasm, pressure on nerve root from bulging disc, instability of spinal segment) </li></ul></ul><ul><ul><li>If disc related, often respond to extension-based program (Demonstrate REIL and RRIS) </li></ul></ul><ul><ul><li>Eliminate forward bending and axial loading from work-out routine </li></ul></ul><ul><ul><li>Discontinue high impact activities (replace cardio with elliptical trainer in good posture) </li></ul></ul><ul><ul><li>Educate patients in correct posture and body mechanics and re-enforce during all activities of daily living </li></ul></ul><ul><ul><li>Ergonomic evaluation and prescription </li></ul></ul>
  34. 38. Muscular sprain/ strain: <ul><li>Lower back muscles designed for postural support, as opposed to heavy lifting </li></ul><ul><li>Larger, stronger leg muscles can handle heavier loads </li></ul><ul><li>“ Bend with you knees, not with your back” </li></ul><ul><li>When overstrained, back muscles tend to go into painful spasms </li></ul><ul><li>Patient will present with pain on all directions of motion involving affected muscles </li></ul><ul><li>Might have visual ‘hypertrophy’ of paraspinal muscles </li></ul><ul><li>If severe, can cause pelvis to shift/ tilt </li></ul><ul><li>Patient will feel most comfortable lying down (muscles relaxed and supported) </li></ul>
  35. 39. Muscular sprain/ strain: <ul><li>Treatment: </li></ul><ul><ul><li>Manual techniques for muscle relaxation/ lengthening </li></ul></ul><ul><ul><li>Modalities for pain </li></ul></ul><ul><ul><li>Stretches </li></ul></ul><ul><ul><li>Strengthening exercises </li></ul></ul><ul><ul><li>Body mechanics re-education </li></ul></ul><ul><ul><li>If prolonged, could lead to further complications due to compensatory techniques </li></ul></ul><ul><ul><li>Physiatrist/ primary care physician might prescribe muscle relaxants </li></ul></ul>