Physical Therapy; Function & Dysfunction

1. Physical Therapy
Function & Dysfunction

3. Sometimes only small amount of mechanical change can
have great outcomes

4. The physiology is subservient to the mechanics
Mechanics have driven the physiology

5. When we are able to make changes in the sagittal curve,
we change the coupling action relationship, and reduces
the lordotic spine.

6. A structural defect causes adaptation in connective tissue
and structure

7. A negative change allows the condition to progress,
leading to an excessive curve in the thoracic, what causes
an increase in compressive stresses on the anterior region

8. Causal philosophy of the link system theory and the
capacity to change

9. It’s biological, so it’s changeable (Wolff’s law), The principle
that changes in the form and function of a bone are
followed by changes in its internal structure

10. Movement in the body is produced by a system of levers.
These series of levers work together to produce
coordinated action, some by actual movement (dynamic)
and others by stabilization (static)

11. Functionality should be maintained
If you don’t know what to maintain, how do you know
what to do?

12. Your greatest stability is in your mobility

13. The problem is we don’t move well,we are jamming up
We are not moving enough and changing it’s function

14. The Axial and Appendicular system is made up of
biological material After a submaximal load there is a time
bridge between it takes to change the structure to its
original state after the load is taking off

15. When leaving the load on the structure it will elongate
further causing Creep

16. Ligamentous hysteresis is defined as the energy lost (as
heat) within the tissue between loading and unloading.
When the ligament is stimulated repetitively with constant
peak load, hysteresis develops and the ligament length
limits increase with each cycle.

17. The repetitive use of the same force produces greater and
greater ligamentous deformation (creep). This is why
postural/structural corrective exercises work and should
always be done first, before the patient is adjusted or has
any traction performed

18. Ligament creep is defined as the time dependent
elongation of a ligament when subjected to a constant
stress. Ligament creep is not linear in nature.

19. Most of the ligament elongation occurs during the first 15-
20 minutes of a traction load.
This is why at least 10-20 minutes of structural corrective
traction is usual recommended

20. But, how long does is take the ligament to recover from
the elongating force and return to its original length?

21. Both creep and tension-relaxation induced in 20-50
minutes of loading or stretching a ligament, respectively,
demonstrated 40-60% recovery in the first hour of rest,
whereas full recovery is a very slow process which may
require 24-48 hours

22. Performing corrective procedures on patients three times
per week with 48 hours or more between sessions will not
be very successful if the patient is not also performing
some type of ligamentous rehabilitation at home on a
daily basis.

23. Having them re-stretch the soft tissues in-between the in-
office therapy sessions with postural/structural corrective
exercise.

24. Ligament behavior is also dependent on the frequency of
load application and unloading or strain rate.

25. Cyclic loading of a ligament with the same peak load, but
at a higher frequency, results in larger creep development
and longer time for the full recovery of the creep to occur.

26. Having the patient perform their corrective exercises in a
slightly faster, but still controlled manner is better than a
slow methodical fashion.

27. Ligament length-tension (strain-stress) behavior is also
temperature-dependent, exhibiting reduced capability and
therefore increased deformation at higher temperatures.

28. The main point to understand is to not perform corrective
procedures in a cold room or with a cold patient.

29. It re-iterates the importance of heating-up the tissues with
exercise before other corrective procedures are
performed.

30. The exercises “heat-up” the ligaments, increase their
length and reduce their internal tension. This “sets-up” the
spine to better receive any corrective spinal manipulation
or traction.

31. How do you get the ligaments to stay elongated if they
recover so quickly? This is accomplished by getting the
ligament stretched out to a length that moves it out of its
elastic capability and into its plastic (viscous) range.

32. Plastic deformation of a ligament can occur all at once,
such as in athletic injuries where an extremely large force
is applied, or through what is called “repetitive
overwhelm”.

33. Repetitive overwhelm is when a sub-maximal physical
stress is applied so often, that it causes a micro-failure of
the ligamentous cross-links, resulting in permanent
deformation of the ligament.

34. The main factors that affect plastic deformation are the
amount, duration and frequency of the applied force.

35. If you can increase the peak load during the patient’s
corrective exercise session you will increase tissue
hysteresis.

36. Creep is a concentrated load causing adaptation fibers of
connective tissue to change

37. Creep can end up negative if you’re not be able to utilize
it well

38. Ligamentous material elongates in length by Manipulation
of ligaments and connective tissue.What increase mobility
and function

39. By changing posture in the sagittal plane, you will be able
to change every interrelated joint(s) as well. Creep
because the load has changed and new adaptations set in
progress

40. Establish Creep and Hysteresis by overcoming Negative
Blocks Change the Nature of Pliability, Change the Nature
of ElasticityEncouraging a Positive Plasticity, Encouraging
Freedom of Movement

41. Establish Creep and Hysteresis by overcoming Negative
BlocksChange the Nature of Function-Change the Nature
of StructureChange the Nature of Position- Change the
Nature of Extensibility

42. Establish Creep and Hysteresis by overcoming Negative
Blocks The link-system interrelationship in structure
will be affected.

43. When ligaments are exposed to loading over an extended
period of time, they increase in mass, stiffness, and load to
failure

44. When a ligament is overloaded, or exposed to tensions
greater than the structure can sustain, the tissue fails,
resulting in partial or complete ligament discontinuities,
more commonly known as disruptions or tears.

45. Ligament injuries create disruptions in the balance
between joint mobility and joint stability, causing abnormal
force transmission throughout the joint which results in
damage to other structures in and around the joint

46. Osteoarthritis is the long-term consequence of non-
healed ligament injuries

47. The biomechanical function of each pair of facet joints is
to guide and limit movement of the spinal motion
segment and contribute to stability of each motion
segment

48. Creep in a vertebral disc causes water lose over time, what
causes: Change of structure to a more fibrosis nature

49. Degeneration: the deterioration of the cartilage tissues
that support the weight-bearing joints in the body.

50. Deal with adaptation, even a small space around the
zygapophyseal joints can have a positive effect in
restoring better function

51. The biomechanical function of each pair of facet joints is
to guide and limit movement of the spinal motion
segment and contribute to stability of each motion
segment

52. Once the cartilage is thinned or lost, the constant grinding
of bones against each other causes pain and stiffness
around the joint.

53. Creep in a vertebral disc causes water lose over time, what
causes:Dysfunction: Joint dysfunction is the gross
anatomical deformity, i.e., subluxation, contracture, or
bony or fibrous ankylosis, and chronic pain and stiffness of
any joint, with limitation of motion, instability, or abnormal
motion of the affected joint(s)

54. Functional loss is defined as the inability to ambulate
effectively on a sustained basis for any reason, including
pain associated with the underlying musculoskeletal
impairment.

55. Functional Loss -The inability to perform fine and gross
movements effectively on a sustained basis for any reason,
including pain associated with the underlying
musculoskeletal impairment.

56. Loss of function may be due to bone or joint deformity or
destruction from any cause; miscellaneous disorders of the
spine with or without radiculopathy

57. Loss of function may be due to bone or joint deformity or
destruction from any cause; neurological deficits;
amputation; or fractures or soft tissue injuries, including
burns, requiring prolonged periods of immobility or
convalescence

58. Functional loss is defined as the inability to ambulate
effectively on a sustained basis for any reason, including
pain associated with the underlying musculoskeletal
impairment

59. Functional loss ;the inability to perform fine and gross
movements effectively on a sustained basis for any reason,
including pain associated with the underlying
musculoskeletal impairment.

60. Functional loss ; The inability to ambulate effectively or the
inability to perform fine and gross movements effectively
must have lasted, or be expected to last, for at least 12
months

61. Inability to ambulate effectively means an extreme
limitation of the ability to walk; i.e., an impairment(s) that
interferes very seriously with the individual's ability to
independently initiate, sustain, or complete activities.

62. Ineffective ambulation is defined generally as having
insufficient lower extremity functioning to permit
independent ambulation without the use of a hand-held
assistive device(s) that limits the functioning of both upper
extremities

63. To ambulate effectively, individuals must be capable of
sustaining a reasonable walking pace over a sufficient
distance to be able to carry out activities of daily living.

64. To ambulate effectively, they must have the ability to travel
without companion assistance to and from a place of
employment or school.

65. Ineffective ambulation include, but are not limited to, the
inability to walk without the use of a walker, two crutches
or two canes, the inability to walk a block at a reasonable
pace on rough or uneven surfaces

66. Ineffective ambulation include, the inability to use
standard public transportation, the inability to carry out
routine ambulatory activities, such as shopping and
banking, and the inability to climb a few steps at a
reasonable pace with the use of a single hand rail.

67. The ability to walk independently about one's home
without the use of assistive devices does not, in and of
itself, constitute effective ambulation.

68. Inability to perform fine and gross movements effectively
means an extreme loss of function of both upper
extremities; i.e., an impairment(s) that interferes very
seriously with the individual's ability to independently
initiate, sustain, or complete activities.

69. To use their upper extremities effectively, individuals must
be capable of sustaining such functions as reaching,
pushing, pulling, grasping, and fingering to be able to
carry out activities of daily living

70. Inability to perform fine and gross movements effectively
include, but are not limited to, the inability to prepare a
simple meal and feed oneself, the inability to take care of
personal hygiene.

71. Inability to perform fine and gross movements effectively
include, but are not limited to, the inability to sort and
handle papers or files, and the inability to place files in a
file cabinet at or above waist level.

72. Pain or other symptoms may be an important factor
contributing to functional loss. In order for pain or other
symptoms to be found to affect an individual's ability to
perform basic work activities

73. Medical signs or laboratory findings must show the
existence of a medically determinable impairment(s) that
could reasonably be expected to produce the pain or
other symptoms.

74. The musculoskeletal listings that include pain or other
symptoms among their criteria also include criteria for
limitations in functioning as a result of the listed
impairment, including limitations caused by pain

75. It is important to evaluate the intensity and persistence of
such pain or other symptoms carefully in order to
determine their impact on the individual's functioning
under these listings.

76. Diagnosis and evaluation of musculoskeletal impairments
should be supported, as applicable, by detailed
descriptions of the joints.

77. Diagnosis and evaluation of musculoskeletal; ranges of
motion, condition of the musculature (e.g., weakness, atrophy),
sensory or reflex changes, circulatory deficits, and laboratory findings,
including findings on x-ray or other appropriate medically acceptable
imaging.

78. Medically acceptable imaging includes, but is not limited
to, x-ray imaging, computerized axial tomography (CAT scan) or
magnetic resonance imaging (MRI), with or without contrast material,
myelography, and radio nuclear bone scans.

79. "Appropriate" means that the technique used is the proper
one to support the evaluation and diagnosis of the
impairment.

80. The physical examination must include a detailed
description of the rheumatological, orthopedic,
neurological, and other findings appropriate to the
specific impairment being evaluated.
.

81. Alternative testing methods should be used to verify the
abnormal findings; e.g., a seated straight-leg raising test in
addition to a supine straight-leg raising test.

82. Abnormal physical findings may be intermittent, their
presence over a period of time must be established by a
record of ongoing management and evaluation.

83. Care must be taken to ascertain that the reported
examination findings are consistent with the individual's
daily activities.

84. Examination of the spine should include a detailed
description of gait, range of motion of the spine given
quantitatively in degrees from the vertical position (zero
degrees)

85. Examination of the spine should include ; For straight-leg
raising from the sitting and supine position (zero degrees),
any other appropriate tension signs, motor and sensory
abnormalities, muscle spasm, when present, and deep
tendon reflexes.

86. Observations of the individual during the examination
should be reported; e.g., how he or she gets on and off
the examination table.

87. Inability to walk on the heels or toes, to squat, or to arise
from a squatting position, when appropriate, may be
considered evidence of significant motor loss

88. A report of atrophy is not acceptable as evidence of
significant motor loss without circumferential
measurements of both thighs and lower legs, or both
upper and lower arms, as appropriate, at a stated point
above and below the knee or elbow given in inches or
centimeters.

89. A report of atrophy should be accompanied by
measurement of the strength of the muscle(s) in question
generally based on a grading system of 0 to 5 , with 0
being complete loss of strength and 5 being maximum
strength.

90. A specific description of atrophy of hand muscles is
acceptable without measurements of atrophy but should
include measurements of grip and pinch strength.

91. When neurological abnormalities persist. Neurological
abnormalities may not completely subside after treatment
or with the passage of time.

92. Residual neurological abnormalities that persist after it has
been determined clinically or by direct surgical or other
observation that the ongoing or progressive condition is
no longer present will not satisfy the required findings

93. Major joints refer to the major peripheral joints, which are
the hip, knee, shoulder, elbow, wrist-hand, and ankle-foot,
as opposed to other peripheral joints (e.g., the joints of
the hand or forefoot) or axial joints (i.e., the joints of the
spine.)

94. The wrist and hand are considered together as one major
joint, as are the ankle and foot.

95. Since only the ankle joint, which consists of the juncture of
the bones of the lower leg (tibia and fibula) with the
hindfoot (tarsal bones), but not the forefoot, is crucial to
weight bearing, the ankle and foot are considered
separately in evaluating weight bearing

96. Musculoskeletal impairments frequently improve with time
or respond to treatment. Therefore, a longitudinal clinical
record is generally important for the assessment of
severity and expected duration of an impairment unless
the claim can be decided favorably on the basis of the
current evidence.

97. Documentation of medically prescribed treatment and
response. Many individuals, especially those who have
listing-level impairments, will have received the benefit of
medically prescribed treatment. Whenever evidence of
such treatment is available it must be considered

98. When there is no record of ongoing treatment. Some
individuals will not have received ongoing treatment or
have an ongoing relationship with the medical community
despite the existence of a severe impairment(s).

99. When there is no record of ongoing treatment, evaluation
will be made on the basis of the current objective medical
evidence and other available evidence, taking into
consideration the individual's medical history, symptoms,
and medical source opinions.

100. An individual who does not receive treatment may not be
able to show an impairment that meets the criteria of one
of the musculoskeletal listings

101. The individual may have an impairment(s) equivalent in
severity to one of the listed impairments or be disabled
based on consideration of his or her residual functional
capacity (RFC) and age, education and work experience.

102. Evaluation when the criteria of a musculoskeletal listing
are not met. These listings are only examples of common
musculoskeletal disorders that are severe enough to
prevent a person from engaging in gainful activity.

103. In any case in which an individual has a medically
determinable impairment that is not listed, an impairment
that does not meet the requirements of a listing, or a
combination of impairments no one of which meets the
requirements of a listing, will be considered medical
equivalence.

104. Individuals who have an impairment(s) with a level of
severity that does not meet or equal the criteria of the
musculoskeletal listings may or may not have the RFC that
would enable them to engage in substantial gainful
activity.

105. Evaluation of the impairment(s) of these individuals should
proceed through the final steps of the sequential
evaluation process

106. Asymmetry
What is happening here?, One side isn’t working as well as
the other side, What is the good side?,What is the bad
side?

107. Changes and adaptations of structure effects the
functionality of rotation to the right.Caused by:
Adaptations in functionality, exhausting the movementLeft
rotation adaptation of cumulative repetitive to exhaustion
of movement

108. Where is the lack of optimal movement happening?
How can we maintain function in this area?
How can you create optimal function?

109. Asymmetry is always there- Left and ride side are loaded
differently, as well function differently

110. Asymmetry is always there- Left rotation is different from
right rotation -Different pulling on structures- Different
stresses on structures

111. When you start to change your mechanics, you become
more vulnerable to trauma
If you got it wrong, same orientation, what overtime
breaks the camel’s back

112. Physical fatigue put a strain on the focus in maintaining
proper use of mechanics, mechanics become more
labored with a high energy cost

113. Incorrect loading of a structure increases the risk of
fatigue. Fatigue doesn’t cause the injury, changes in
mechanics does

114. Repeatedly badly loading of the system, causes the body
to be unable to adapt. Don’t load it badly, stop when
you’re not able to continue with correct Mechanics

115. Use training resistance according to your training level. If
you don’t lift it properly, the weight is too much, the
mechanics are out of whack

116. A negative mechanical shift has Negative repercussions
A positive mechanical shift has positive repercussions

117. Skeletal muscles contract to produce the force necessary
in everyday life, but cannot contract continuously without
impairment in performance, i.e. they fatigue

118. The extent of neuromuscular fatigue is classically
quantified by the decrease in the maximal voluntary
contraction (MVC) force.

119. Single muscle fiber changes in Ca2+ handling and
myofibrillar function can explain the impaired contractile
function in fatigue

120. Intramuscular processes limit the duration of prolonged
isometric contractions performed at relatively high
intensity

121. Central factors contribute to the failure of maintaining
continuous contractions at lower intensities (∼30% MVC
or less)

122. Muscle cells are important contributors to the fatigue
induced changes in muscular function in humans.

123. The decrease in MVC induced by a prolonged isometric
contraction can be mainly attributed to impairment within
the muscle fibers, and particularly to changes in Ca2+
handling