Therapeutic Exercise Foundations and Techniques F O U R T H E D I T I O N Carolyn Kisner, MS, PT Associate Professor Physical Therapy Program College of Mount St. Joseph Cincinnati, Ohio Assistant Professor Emeritus The Ohio State University School of Allied Medical Professions Physical Therapy Division Columbus, Ohio Lynn Allen Colby, MS, PT Assistant Professor Emeritus The Ohio State University School of Allied Medical Professions Physical Therapy Division Columbus, Ohio Illustrations by Jerry L. Kisner, MS F.A. Davis Company • Philadelphia 9865.chfm 2/15/02 9:10 AM Page i F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2002 by F. A. Davis Company Copyright © 1996, 1990, 1985 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permis- sion from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher: Margaret Biblis Developmental Editor: Peg Waltner Cover Designer: Louis J. Forgione As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in ac- cordance with professional standards of care used in regard to the unique circumstances that may ap- ply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Kisner, Carolyn. Therapeutic exercise: foundations and techniques / Carolyn Kisner, Lynn Allen Colby; illustrations by Jerry L. Kisner.—4th ed. p. cm. Includes bibliographical references and index. ISBN 0-8036-0968-X 1. Exercise therapy—Handbooks, manuals, etc. I. Colby, Lynn Allen. II. Title. RM725.K53 2002 615.8�2—dc21 2002017442 Authorization to photocopy items for internal or personal use, or the internal or personal use of spe- cific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Cen- ter (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-0968/0 � $.10. 9865.chfm 2/15/02 9:10 AM Page ii To Jerry and our growing family—as always, your love and support has sustained me through this project —CK To Rick and my extended family—a source of constant support and joy —LC To our parents—who have been supportive throughout our lives To our students—who have taught us so much To our colleagues—who have been helpful and stimulating in our professional growth —LC and CK 9865.chfm 2/15/02 9:10 AM Page iii Contributors Terri M. Glenn, PhD, PT Director, Physical Therapy Program College of Mount St. Joseph Cincinnati, Ohio Barbara Settles Huge, PT Women’s Health Specialist/Consultant Adjunct Faculty, Indiana University Physical Therapy Program Fishers, Indiana Janet A. Mulcare, PhD, FASCM Professor, Physical Therapy Program Andrews University Dayton, Ohio Robert Schrepfer, MS, PT Former Clinical Director, The Center for Aquatic Rehabilitation MBA Candidate 2003 Duke University, The Fuqua School of Business Durham, North Carolina iv 9865.chfm 2/15/02 9:10 AM Page iv Preface progression of comprehensive therapeutic exercise interventions. What will be most obvious to those who are fa- miliar with previous editions of this text are the changes in format and design of this edition. The double-column format and the use of color were se- lected to help the reader to locate information more easily and to enhance organization of the material. We have kept the succinct language and straightfor- ward presentation of the content that has been well received in the previous editions; in addition we have expanded the discussion of concepts and techniques to provide the reader with a more comprehensive analysis of the material. Major changes we have made in this Fourth Edition include the following: Complete rewriting of Chapter 1 incorporating in- formation on the disablement process and the po- tential impact of therapeutic exercise on that process, as well as the components of a compre- hensive, systematic approach to patient manage- ment consistent with the guidelines proposed in the Guide to Physical Therapist Practice. A revised outline of a systematic and detailed muscu- loskeletal examination that used to be in Chapter 1 is now in Appendix A. Extensive reorganization of Chapter 3, Resistance Exercise, to include the multi-faceted aspects of muscle performance. In addition, principles and techniques of proprioceptive neuromuscular facil- itation for applications of the extremity patterns have been added. Addition of material on mobilization with move- ment (MWM), based on the work of Brian Mulli- gan, by contributor Jack Miller, an accredited Mulligan concept teacher. The concepts and prin- ciples of MWM are presented in Chapter 6, with specific techniques described in each of the re- spective regional chapters on the extremities (Chapters 9–14). E ach revision of this textbook is a challenging, demanding, sometimes daunting, and in the final analysis, satisfying task. We believe this edition, as with past editions, is inclusive and up-to- date in light of current research and trends in prac- tice. It continually amazes us how quickly the knowledge base and creative interpretations of basic and applied research including outcome studies in- fluence the delivery of healthcare. Since publication of the Third Edition of Therapeutic Exercise in 1996, the American Physical Therapy Association has pub- lished and revised the Guide to Physical Therapist Practice, many new studies on patient outcomes have been published, technology for communication has expanded, and the healthcare environment has demanded continued high-quality care but more ef- ficient delivery of services. Each of these major fac- tors has influenced the way we think and practice and thus has influenced the presentation of material in this text. Our original intent when developing the first edi- tion of this textbook over 16 years ago was to pro- vide a foundation of concepts and techniques upon which an individualized program of therapeutic ex- ercise could be built. With each revision we have expanded the content to include new methods of exercise intervention that have been shown to be beneficial in remediating a patient’s physical im- pairments and functional limitations. The founda- tional material remains an important component of this text. Yet, functional exercise progressions that are built on basic exercise techniques and that pre- pare patients or clients to return to optimal levels of independence are also integral components of this text. In addition to principles of exercise, back- ground information on various pathologies and musculoskeletal surgeries, descriptions of exercise techniques, and management guidelines are in- cluded to assist the reader in the development and v 9865.chfm 2/15/02 9:10 AM Page v Addition of a new chapter on aquatic exercise (Chapter 7) by contributor Robert Schrepfer, MS, PT. Research supporting the use of the aquatic en- vironment in the rehabilitation process of muscu- loskeletal impairments is integrated with various techniques of exercise interventions. Addition of a section at the completion of each chapter entitled Independent Learning Activities. This section has several types of activities for stu- dents using this text. The subsection called Criti- cal Thinking and Discussion has discussion points or a series of questions to stimulate active learning and problem solving or to direct the stu- dent to further inquiry. The subsection called Laboratory Practice directs the learner toward ac- tivities that can be practiced in order to develop specific skills related to the application of thera- peutic exercise interventions. The subsection called Case Studies presents several case scenar- ios and questions that reflect the content of the chapter to help the learner integrate the informa- tion presented and apply it to real-life situations. Reorganization of the spine chapters with the ad- dition of material that reflects current thinking on ways to categorize patient conditions and ap- proaches to intervention (Chapter 15), and the presentation of exercise interventions with empha- sis on activation of core stabilizers and stabiliza- tion techniques integrated into a comprehensive approach to management of spinal impairments and functional limitations (Chapter 16). Those readers familiar with previous editions will notice that the chapter on spinal traction is not in this edi- tion. Nevertheless we still believe that spinal trac- tion is a useful tool for intervention in the treatment of spinal disorders. Because it can be used to stretch joints and tissues in the spinal region, content spe- cific to this purpose is integrated into the stretching section of the treatment chapter (Chapter 16). The chapter on Principles of Exercise for the Ob- stetric Patient (Chapter 17) has been revised and expanded by contributor Barb Settles Huge, PT, to include basic information and interventions for the management of urinary incontinence. A thorough revision of Chapter 18, Management of Vascular Disorders of the Extremities, now includes descriptions and illustrations of exercises for the comprehensive management of lymphedema. In previous editions there were two chapters on interventions for and management of pulmonary conditions. The content of those chapters has been reorganized and merged into one chapter (Chapter 19). The chapter on Critical Analysis of Exercise Pro- grams, which had been in previous editions, has been deleted from this edition. The idea of using knowledge and skills of kinesiology, examination, and safe application of exercise interventions based on an examination and evaluation of each patient or client is fundamental to all we do as therapists. Therefore it was determined that a separate chapter was no longer needed and the concepts from this chapter were integrated throughout the text. Appendices have been added to this edition that include a summary of a systematic musculoskele- tal examination and a reprinting of management guideline boxes from multiple chapters for quick reference and for comparison and contrast in Ap- pendix A and B respectively. As we put the final touches on this revision, we are once again pleased to present our efforts to stu- dents and professionals within the healthcare com- munity. It is always our hope that our efforts will contribute to the effective care and services provided to patients and clients. And finally to our families, colleagues and friends who provided encourage- ment and supported us without hesitation, we ex- tend a resounding THANK YOU!! Carolyn Kisner Lynn Allen Colby vi Preface 9865.chfm 2/15/02 9:10 AM Page vi Acknowledgments I n addition to all those who helped with the pre- vious editions, we wish to thank and acknowl- edge the following people for their expertise and contributions to this revision. Terri Glenn, PhD, PT, and Janet Mulcare, PhD, FASCM—for their revision of Chapter 4, Principles of Aerobic Exercise. Robert Schrepfer, MS, PT—for writing Chapter 7, Aquatic Exercise. Barbara Settles Huge, PT—for her revision of Chapter 17, Principles of Exercise for the Obstetric Patient, and inclusion of material on treatment of the client with incontinence. Jack Miller, BSc(PT), Dip, ManipTher (NZ), FCAMT, Accredited Mulligan Concept Teacher—for writing material on the Mulligan concept of Mobi- lization with Movement in Chapter 6 and describing techniques for inclusion in each of the extremity chapters. Marsha Eifert-Mangine, MEd, PT, ATC—for re- viewing and contributing material on knee surgeries and rehabilitation and developing tables of interven- tion for the stages of rehabilitation following various surgical procedures on the knee. The students and colleagues at the College of Mount St. Joseph in Cincinnati and The Ohio State University in Columbus—who modeled the various exercises and shared ideas in the development of some of the content for this edition. Peg Waltner, Developmental Editor—who pro- vided insight and direction in the design and devel- opment of this edition. The staff at F.A. Davis—Jean-Francois Vilain, Margaret M. Biblis, Susan Rhyner, Bob Butler, Louis Forgione, Sam Rondinelli, Jack Brandt, and Laura Horowitz. vii 9865.chfm 2/15/02 9:10 AM Page vii Contents ix PART I General Concepts and Techniques 1 Chapter 1 Therapeutic Exercise: Foundational Concepts 3 Therapeutic Exercise: Impact on Physical Function 3 Definition 4 Aspects of Physical Function: Definition of Key Terms 4 Types of Therapeutic Exercise Interventions 5 Process and Models of Disablement 5 The Disablement Process 5 Models of Disablement 6 Patient Management and Clinical Decision Making: An Interactive Relationship 11 Clinical Decision Making 12 A Patient Management Model 12 Strategies for Effective Exercise Instruction 24 Preparation for Exercise Instruction 24 Concepts of Motor Learning: A Foundation of Exercise Instruction 24 Adherence 29 Independent Learning Activities 30 Critical Thinking and Discussion 30 Chapter 2 Range of Motion 34 Types of Range of Motion (ROM) Exercises 35 Indications and Goals for Range of Motion 35 Passive Range of Motion 35 Active and Active-Assistive ROM 35 Limitations of Range of Motion Exercises 36 Limitations of Passive Motion 36 Limitations of Active ROM 36 Precautions and Contraindications to Range of Motion 36 Principles and Procedures for Applying Range of Motion Techniques 37 Examination, Evaluation, and Treatment Planning 37 Prepare the Patient 37 Application of Techniques 37 To Apply PROM 37 To Apply AROM 37 Techniques for Joint and Muscle Range of Motion 38 Upper Extremity 38 Lower Extremity 43 Cervical Spine 47 Lumbar Spine 48 Combined Patterns of Motion 48 Self-Assisted ROM (S-AROM) 49 Self-Assistance 49 Wand (T-bar) Exercises 51 Finger Ladder/Wall Climbing 53 Overhead Pulleys 53 Skate Board/Powder Board 54 Reciprocal Exercise Unit 54 Continuous Passive Motion 54 Benefits of CPM 55 General Guidelines 55 Range of Motion Through Functional Patterns 56 Independent Learning Activities 56 Critical Thinking and Discussion 56 Laboratory Practice 57 Chapter 3 Resistance Exercise 58 Muscle Performance and Resistance Exercise—Definitions and Guiding Principles 59 Strength 59 Power 60 Endurance 60 Overload Principle 61 SAID Principle 61 Reversibility Principle 62 Skeletal Muscle Function and Adaptation to Resistance Exercise 62 Factors that Influence Tension Generation in Normal Skeletal Muscle 62 Physiologic Adaptations Associated with Resistance Exercise 68 Determinants of Resistance Exercise 70 Alignment and Stabilization 71 9865.chfm 2/15/02 9:10 AM Page ix Intensity 72 Volume 74 Frequency 75 Duration 75 Rest Interval (Recovery Period) 75 Mode 76 Speed of Exercise 77 Periodization 78 Integration of Function into a Resistance Exercise Program 79 Types of Resistance Exercise 79 Manual and Mechanical Resistance Exercise 80 Isometric Exercise (Static Exercise) 80 Dynamic Exercise: Concentric and Eccentric 83 Dynamic Exercise: Constant Versus Variable Resistance 85 Isokinetic Exercise 86 Open-Chain and Closed-Chain Exercise 89 Resistance Exercise: Principles, Precautions and Contraindications 95 General Principles of Resistance Training 95 Precautions During Resistance Training 98 Contraindications to Resistance Training 103 Manual Resistance Exercise 103 Definition and Use in Rehabilitation 103 Guidelines and Special Considerations for Manual Resistance Exercise 103 Techniques of Manual Resistance Exercise for the Extremities: General Background 105 The Upper Extremity 105 The Lower Extremity 109 Proprioceptive Neuromuscular Facilitation: Principles and Techniques 113 The Diagonal Patterns 113 Basic Procedures and Principles Used with PNF Patterns 113 Upper Extremity Patterns 115 Lower Extremity Patterns 117 Specific Techniques Associated with PNF 120 Mechanical Resistance Exercise 122 Definition and Use 122 Special Considerations for Children and Older Adults 123 Specific Exercise Regimens 124 Use of Equipment with Resistance Exercise 130 Free Weights and Simple Weight-Pulley Systems 130 Variable Resistance Machines 133 Elastic Resistance 134 Equipment for Closed-Chain Training 136 Reciprocal Exercise Equipment 137 Equipment for Dynamic Stabilization Training 138 Isokinetic Testing and Training Equipment 139 Independent Learning Activities 141 Critical Thinking and Discussion 141 Laboratory Practice 141 Chapter 4 Principles of Aerobic Exercise 149 Terri M. Glenn, PhD, PT, and Janet A. Mulcare, PhD, FASCM Key Terms 150 Fitness 150 Maximum Oxygen Consumption 150 Endurance 150 Aerobic Exercise Training (Conditioning) 150 Adaptation 151 Myocardial Oxygen Consumption 151 Deconditioning 152 Energy Systems, Energy Expenditure, and Efficiency 152 Functional Implications 153 Energy Expenditure 153 Efficiency 154 Physiologic Response to Aerobic Exercise 154 Cardiovascular Response to Exercise 154 Respiratory Response to Exercise 155 Responses Providing Additional Oxygen to Muscle 155 Testing as a Basis for Exercise Programs 155 Fitness Testing of Healthy Subjects 156 Stress Testing for Convalescing Individuals and Individuals at Risk 156 Multistage Testing 157 Determinants of an Exercise Program 157 Intensity 157 Duration 159 Frequency 159 Mode 159 The Reversibility Principle 159 The Exercise Program 160 The Warm-Up Period 160 The Aerobic Exercise Period 160 The Cool-Down Period 161 Application 161 Physiologic Changes that Occur with Training 162 Cardiovascular Changes 162 Respiratory Changes 162 Metabolic Changes 162 Other System Changes 163 Application of Principles of an Aerobic Conditioning Program for the Patient with Coronary Disease 163 In-Patient Phase (Phase I) 163 Out-Patient Phase (Phase II) 163 Out-Patient Program (Phase III) 164 Special Considerations 165 Adaptive Changes 165 Applications of Aerobic Training for the Deconditioned Individual and the Patient with Chronic Illness 165 Adaptations for Disabilities, Functional Limitations, and Deconditioning 166 Impairments, Goals, and Plan of Care 166 x Contents 9865.chfm 2/15/02 9:10 AM Page x Age Differences 167 Children 167 Young Adult 168 Older Adult 169 Independent Learning Activities 169 Critical Thinking and Discussion 169 Chapter 5 Stretching 171 Definition of Terms Related to Mobility and Stretching 172 Flexibility 172 Hypomobility 172 Contracture 172 Types of Contractures 173 Interventions to Increase Mobility of Soft Tissues 174 Selective Stretching 175 Overstretching and Hypermobility 175 Properties of Soft Tissue that Affect Response to Immobilization and Elongation 175 Mechanical Properties of Contractile Tissue 176 Neurophysiologic Properties of Contractile Tissue 178 Mechanical Characteristics of Noncontractile Soft Tissue 179 Determinents of Stretching Exercises 183 Alignment and Stabilization 183 Intensity of Stretch 184 Duration of Stretch 184 Speed of Stretch 186 Frequency of Stretch 186 Mode of Stretch 187 Neuromuscular Inhibition and Muscle Elongation 189 Integration of Function into a Stretching Program 191 Guidelines for Applications of Stretching Procedures 192 Examination and Evaluation of the Patient Prior to Stretching 192 Prior to the Initiation of Stretching 193 When Applying Manual Stretching Procedures 193 Special Considerations for Teaching Self-Stretching Exercises 194 Special Considerations for Use of Mechanical Stretching Devices 194 After Stretching 194 Application of Inhibition and Relaxation Procedures 195 Neuromuscular Inhibition Techniques: Procedures for Application 195 General Relaxation Training 196 Additional Adjuncts to Stretching Interventions for Local Relaxation 197 Precautions 198 General Precautions 198 Special Precautions for Mass-Market Flexibility Programs 199 Manual Stretching Techniques Using Anatomic Planes of Motion 200 The Upper Extremity 200 The Lower Extremity 205 The Neck and Trunk 211 Self-Stretching Techniques 211 Independent Learning Activities 211 Critical Thinking and Discussion 211 Laboratory Practice 211 Chapter 6 Peripheral Joint Mobilization 216 Definitions of Terms 216 Mobilization/Manipulation 216 Self-Mobilization (Automobilization) 216 Mobilization with Movement (MWM) 217 Physiologic Movements 217 Accessory Movements 217 Thrust 217 Manipulation Under Anesthesia 217 Muscle Energy 217 Basic Concepts of Joint Motion: Arthrokinematics 217 Joint Shapes 217 Types of Motion 217 Passive-Angular Stretching Versus Joint-Glide Stretching 219 Other Accessory Motions that Affect the Joint 220 Effects of Joint Motion 220 Indications for Joint Mobilization 221 Pain, Muscle Guarding, and Spasm 221 Reversible Joint Hypomobility 221 Positional Faults/Subluxations 221 Progressive Limitation 222 Functional Immobility 222 Limitations of Joint Mobilization Techniques 222 Contraindications and Precautions 222 Hypomobility 222 Joint Effusion 222 Inflammation 222 Conditions Requiring Special Precautions for Stretching 222 Procedures for Applying Passive Joint Mobilization Techniques 223 Examination and Evaluation 223 Grades or Dosages of Movement 223 Positioning and Stabilization 225 Treatment Force and Direction of Movement 225 Initiation and Progression of Treatment 226 Speed, Rhythm, and Duration of Movements 226 Patient Response 227 Total Program 227 Mobilization with Movement, Principles and Procedures 228 Principles of MWM in Clinical Practice 228 Pain Is Always the Guide 228 Contents xi 9865.chfm 2/15/02 9:10 AM Page xi Theoretical Framework 228 Techniques 229 Peripheral Joint Mobilization Techniques 229 Shoulder Girdle Complex 229 The Elbow and Forearm Complex 235 The Wrist Complex 239 The Hand and Finger Joints 242 The Hip Joint 244 The Knee and Leg 246 Ankle and Tarsal Joints 251 Independent Learning Activities 255 Critical Thinking and Discussion 255 Laboratory Practice 256 Chapter 7 Aquatic Exercise 257 Robert Schrepfer, MS, PT Definition of Aquatic Exercise 257 Goals and Indications for Aquatic Exercise 257 Precautions and Contraindications to Aquatic Exercise 258 Precautions 258 Contraindications 258 Properties of Water 258 Physical Properties of Water 258 Hydromechanics 259 Thermodynamics 259 Center of Buoyancy 260 Aquatic Temperature and Therapeutic Exercise 260 Temperature Regulation 260 Mobility and Functional Control Exercise 261 Aerobic Conditioning 261 Special Equipment for Aquatic Exercise 261 Collars, Rings, Belts, and Vests 261 Swim Bars 262 Gloves, Hand Paddles, and Hydro-tone® Bells 262 Fins and Hydro-tone® Boots 262 Kickboards 263 Stretching Exercises 263 Manual Stretching Techniques 263 Self-Stretching with Aquatic Equipment 267 Strengthening Exercises 268 Manual Resistance Exercises 268 Independent Strengthening Exercises 274 Aerobic Conditioning 277 Treatment Interventions 277 Physiologic Response to Deep Water Walking/Running 277 Proper Form for Deep Water Running 278 Exercise Monitoring 278 Equipment Selection 278 Independent Learning Activities 278 Case Studies 278 PART II Application of Therapeutic Exercise Techniques to Regions of the Body 283 Chapter 8 Principles of Treating Soft Tissue, Bony, and Postsurgical Conditions 285 Soft Tissue Lesions 285 Examples of Soft Tissue Lesions 285 Clinical Conditions Resulting from Trauma or Pathology 286 Severity of Tissue Injury 286 Irritability of Tissue: Stages of Inflammation and Repair 287 Management During the Acute Stage 288 Tissue Response—Inflammation 288 Management Guidelines—The Protection Phase 288 Management During the Subacute Stage 290 Tissue Response—Repair and Healing 290 Management Guidelines—The Controlled Motion Phase 291 Management During the Chronic Stage 293 Tissue Response—Maturation and Remodeling 293 Management Guidelines—Return to Function Phase 294 Cumulative Trauma—Chronic Recurring Pain 296 Tissue Response—Chronic Inflammation 296 Etiology of Chronic Inflammation Leading to Prolonged or Recurring Pain 296 Contributing Factors 297 Management Guidelines—Chronic Inflammation 297 Arthritis—Arthrosis 299 Clinical Signs and Symptoms 299 Rheumatoid Arthritis (RA) 300 Osteoarthritis (OA) 302 Fractures—Post-Traumatic Immobilization 304 Tissue Response and Management Guidelines—Period of Immobilization 304 The Postimmobilization Period 305 Surgery 306 Guidelines for Preoperative Management 307 Guidelines for Postoperative Management 307 Overview of Common Orthopedic Surgical Procedures and Guidelines for Postoperative Management 308 Independent Learning Activities 316 Critical Thinking and Discussion 316 Chapter 9 The Shoulder and Shoulder Girdle 319 Review of the Structure and Function of the Shoulder and Shoulder Girdle 319 Bony Parts: Proximal Humerus, Scapula, and Clavicle 319 Synovial Joints 319 Functional Articulations 321 Shoulder Girdle Function 322 xii Contents 9865.chfm 2/15/02 9:10 AM Page xii Referred Pain: Common Sources of Pain in the Shoulder Region 323 Nerve Injury: Common Sites in the Shoulder Girdle 324 Joint Hypomobility: Nonoperative Management 324 Glenohumeral (GH) Joint 324 Joint Lesions: Acromioclavicular (AC) and Sternoclavicular (SC) Joints 329 Glenohumeral Joint Surgery and Postoperative Management 330 Glenohumeral Arthroplasty 331 Arthrodesis of the Shoulder 335 Painful Shoulder Syndromes: Rotator Cuff Disease, Impingement Syndromes, and Shoulder Instabilities 335 Related Diagnoses and Etiology of Symptoms 336 Common Impairments 338 Common Functional Limitations/Disabilities 339 Nonoperative Management: Painful Shoulder Syndromes (Without Dislocation) 340 Impingement Syndromes: Surgical and Postoperative Management 342 Rotator Cuff Tears: Surgical and Postoperative Management 345 Shoulder Dislocations 350 Related Diagnoses and Mechanisms of Injury 350 Common Impairments 351 Common Functional Limitations/Disabilities 351 Nonoperative Management: Dislocations 351 Glenohumeral Joint Instabilities: Surgical and Postoperative Management 353 Thoracic Outlet Syndrome 359 Related Diagnoses 359 Etiology of Symptoms 359 Location of Compression or Entrapment and Tests of Provocation 360 Restricted Nerve Mobility 360 Summary of Contributing Factors 360 Common Impairments 361 Common Functional Limitations/Disabilities 361 Nonoperative Management 361 Reflex Sympathetic Dystrophy 361 Related Diagnoses and Symptoms 361 Etiology and Symptoms 362 Common Impairments 362 Management 362 Exercise Techniques for Management During Acute and Early Subacute Stages of Tissue Healing (Protection and Early Controlled Motion Phases of Intervention) 363 Early Motion of the Glenohumeral Joint 363 Early Motion of the Scapula 364 Early Neuromuscular Control 365 Exercise Techniques to Increase Flexibility and Range of Motion 365 Self-Stretching Techniques 365 Manual and Self-Stretching Exercises for Specific Muscles 367 Exercises to Develop and Improve Muscle Performance and Functional Control 370 Isometric Exercises 371 Stabilization Exercises 373 Dynamic Strengthening—Open- and Closed-Chain 375 Functional Activities 384 Independent Learning Activities 385 Critical Thinking and Discussion 385 Laboratory Practice 386 Case Studies 386 Chapter 10 The Elbow and Forearm Complex 392 Review of the Structure and Function of the Elbow and Forearm 392 Bony Parts: Distal Humerus, Radius, and Ulna 392 Elbow Joint Characteristics and Arthrokinematics 392 Forearm Joint Characteristics and Arthrokinematics 392 Muscle Function at the Elbow and Forearm 394 Wrist and Hand Muscles 394 Major Nerves Subject to Pressure and Trauma Around the Elbow 395 Joint Hypomobility: Nonoperative Management 395 Related Diagnoses and Etiology of Symptoms 395 Common Impairments 395 Common Functional Limitations/Disabilities 396 Joint Management: Protection Phase 396 Joint Management: Controlled Motion Phase 396 Joint Management: Return to Function Phase 398 Joint Surgery and Postoperative Management 398 Excision of the Radial Head 399 Total Elbow Arthroplasty 400 Myositis Ossificans 403 Etiology of Symptoms 403 Management 404 Overuse Syndromes: Repetitive Trauma Syndromes 404 Related Diagnoses 404 Etiology of Symptoms 404 Common Impairments 405 Common Functional Limitations/Disabilities 405 Nonoperative Management of Overuse Syndromes: Protection Phase 405 Nonoperative Management: Controlled Motion and Return to Function Phases 406 Exercises Techniques to Increase Flexibility and Range of Motion 407 Manual, Mechanical, and Self-Stretching Techniques 408 Contents xiii 9865.chfm 2/15/02 9:10 AM Page xiii Self-Stretching Techniques: Muscles of the Medial and Lateral Epicondyles 409 Exercises to Develop and Improve Muscle Performance and Functional Control 410 Isometric Exercises 410 Dynamic Strengthening and Endurance 410 Functional Patterns—Open- and Closed-Chain Strengthening Exercises 412 Independent Learning Activities 416 Critical Thinking and Discussion 416 Laboratory Practice 416 Case Studies 416 Chapter 11 The Wrist and Hand 419 Review of the Structure and Function of the Wrist and Hand 419 Bony Parts 419 Joints of the Wrist Complex and Their Movements 419 Joints of the Hand Complex and Their Movements 421 Hand Function 421 Hand Control 421 Major Nerves Subject to Pressure and Trauma at the Wrist and Hand 423 Referred Pain and Sensory Patterns 423 Joint Hypomobility: Nonoperative Management 424 Related Diagnoses and Etiology of Symptoms 424 Common Diagnoses and Impairments 424 Common Functional Limitations/Disabilities 425 Joint Management: Protection Phase 425 Joint Management: Controlled Motion and Return to Function Phases 425 Joint Surgery and Postoperative Management 427 Radiocarpal Implant Arthroplasty and Total Wrist Replacement 428 Metacarpophalangeal (MCP) Implant Arthroplasty 431 Proximal Interphalangeal (PIP) Implant Arthroplasty 434 Carpometacarpal (CMC) Arthroplasty of the Thumb 436 Tendon Rupture Associated with RA: Surgical and Postoperative Management 438 Repetitive Trauma Syndromes/Overuse Syndromes 440 Carpal Tunnel Syndrome 441 Compression in Tunnel of Guyon 443 Tenosynovitis, Tendinitis 444 Traumatic Lesions in the Hand 444 Simple Sprain: Nonoperative Management 444 Lacerated Flexor Tendons of the Hand: Surgical and Postoperative Management 445 Lacerated Extensor Tendons of the Hand: Surgical and Postoperative Management 452 Techniques for Tendon and Muscular Mobility 456 Flexor Tendon-Gliding Exercises 456 Flexor Tendon-Blocking Exercises 457 Extensor Exercises to Reduce Extensor Lag 458 Extensor Tendon-Gliding Exercises 458 Exercise Techniques to Increase Flexibility and Range of Motion 459 General Stretching Techniques 459 Stretching Techniques of the Intrinsic and Multijoint Muscles 460 Techniques to Mobilize Scar Tissue (Adhesions) that Restrict Gliding of Long Finger Flexor Tendons 461 Techniques to Mobilize Scar Tissue (Adhesions) that Restrict Gliding of Extensor Tendons and Extensor Mechanism 461 Exercises to Develop and Improve Muscle Performance, Neuromuscular Control, and Coordinated Movement 462 Techniques to Strengthen Muscles of the Wrist and Hand 462 Functional Activities 464 Independent Learning Activities 464 Critical Thinking and Discussion 464 Laboratory Practice 465 Case Studies 465 Chapter 12 The Hip 469 Review of the Structure and Function of the Hip 469 Bony Parts: Proximal Femur and the Pelvis 469 Hip Joint 469 Functional Relationships of the Hips and Pelvis in the Kinematic Chain 470 Balance and Posture Control 473 Nerves in the Hip and Buttock Region 473 Referred Pain Into the Hip and Buttock Region 473 Joint Hypomobility: Nonoperative Management 473 Related Diagnoses and Etiology of Symptoms 473 Common Impairments 474 Common Functional Limitations/Disabilities 474 Management: Protection Phase 474 Management: Controlled Motion and Return to Function Phases 474 Joint Surgery and Postoperative Management 476 Total Hip Arthroplasty 476 Hemiarthroplasty of the Hip 483 Fractures of the Proximal Femur and Postoperative Management 484 Background 484 Open Reduction and Internal Fixation of Hip Fracture 485 Painful Hip Syndromes/Overuse Syndromes: Nonoperative Management 489 Related Diagnoses and Etiology of Symptoms 489 Common Impairments 489 Common Functional Limitations/Disabilities 489 Management: Protection Phase 489 Management: Controlled Motion Phase 490 Management: Return to Function Phase 490 xiv Contents 9865.chfm 2/15/02 9:10 AM Page xiv Exercise Techniques to Increase Flexibility and Range of Motion 491 Techniques to Stretch Range-Limiting Hip Structures 491 Techniques to Stretch Range-Limiting Two-Joint Muscles 492 Exercises to Develop and Improve Muscle Performance and Functional Control 495 Nonweight-Bearing Exercises 495 Closed-Chain Weight-Bearing Exercises 497 Independent Learning Activities 502 Critical Thinking and Discussion 502 Laboratory Practice 502 Case Studies 502 Chapter 13 The Knee 506 Review of the Structure and Function of the Knee 506 Bony Parts 506 Knee Joint Complex 506 Knee and Patellar Function 507 Referred Pain and Nerve Injuries 509 Joint Hypomobility: Nonoperative Management 510 Related Diagnoses and Etiology of Symptoms 510 Common Impairments 510 Common Functional Limitations/Disabilities 510 Joint Management: Protection Phase 511 Joint Management: Controlled Motion and Return to Function Phases 511 Joint Surgery and Postoperative Management 514 Synovectomy 514 Total Knee Arthroplasty 517 Patellofemoral Dysfunction: Nonoperative Management 522 Related Diagnoses 522 Etiology of Symptoms 523 Common Impairments 523 Common Functional Limitations/Disabilities 523 Nonoperative Management of Patellofemoral Symptoms: Protection Phase 523 Nonoperative Management of Patellofemoral Symptoms: Controlled Motion and Return to Function 524 Patellofemoral and Extensor Mechanism Surgery and Postoperative Management 526 Lateral Retinacular Release 526 Proximal Realignment of the Extensor Mechanism 529 Distal Realignment of the Extensor Mechanism 531 Ligamentous Injuries 532 Related Diagnoses and Mechanisms of Injury 532 Common Impairments 533 Common Functional Limitations/Disabilities 533 Nonoperative Management: Ligamentous Injuries 533 Reconstruction of Ligamentous Lesions 535 Intra-Articular Anterior Cruciate Ligament Reconstruction 536 Posterior Cruciate Ligament Reconstruction 541 Meniscal Tears 543 Related Diagnoses and Mechanisms of Injury 543 Common Impairments 543 Common Functional Limitations/Disabilities 543 Nonoperative Management 543 Surgical Management of Meniscal Tears 543 Arthroscopic Repair of the Meniscus and Postoperative Management 544 Arthroscopic Partial Meniscectomy and Postoperative Management 545 Exercise Techniques to Increase Flexibility and Range of Motion 546 To Increase Knee Extension 547 To Increase Knee Flexion 547 Exercises to Develop and Improve Muscle Performance and Functional Control 549 Nonweight-Bearing Exercises 550 Weight-Bearing Exercises 553 Techniques to Stimulate Functional Activities, Develop Endurance, Balance, and Progress to Specificity of Training 556 Independent Learning Activities 557 Critical Thinking and Discussion 557 Laboratory Practice 557 Case Studies 557 Chapter 14 The Ankle and Foot 563 Review of the Structure and Function of the Ankle and Foot 563 Bony Parts 563 Motions of the Foot and Ankle 563 Joints and Their Characteristics 564 Functional Relationships of the Ankle and Foot 566 Muscle Function in the Ankle and Foot 566 Major Nerves Subject to Pressure and Trauma 567 Joint Hypomobility: Nonoperative Management 568 Related Diagnoses 568 Common Impairments 568 Common Functional Limitations/Disabilities 569 Management of Joint Hypomobility: Protection Phase 569 Joint Management: Controlled Motion and Return to Function Phases 570 Joint Surgery and Postoperative Management 571 Total Ankle Replacement Arthroplasty 572 Arthrodesis at the Ankle and Foot 573 Overuse Syndromes/Repetitive Trauma Syndromes 574 Related Diagnoses and Etiology of Symptoms 574 Common Impairments 575 Common Functional Limitations/Disabilities 575 Management of Overuse/Repetitive Trauma Syndromes: Protection Phase 575 Contents xv 9865.chfm 2/15/02 9:10 AM Page xv Management: Controlled Motion and Return to Function Phases 575 Traumatic Soft Tissue Injuries 576 Sprains and Minor Tears of Ligaments 576 Complete Ligament Tears: Surgical Repair and Postoperative Management 577 Rupture of the Achilles Tendon: Surgical Repair and Postoperative Management 579 Exercise Techniques to Increase Flexibility and Range of Motion 581 Increase Dorsiflexion of the Ankle 581 Increase Inversion 582 Increase Ankle Plantarflexion and Eversion 583 Increase MTP Flexion and IP Extension 583 Stretch the Plantar Fascia of the Foot 583 Exercises to Develop and Improve Muscle Performance and Functional Control 583 Activities for Active Mobility and to Develop Neuromuscular Control 583 Open-Chain Strengthening Exercises 584 Weight-Bearing Exercises for Strength, Balance, and Function 586 Independent Learning Activities 587 Critical Thinking and Discussion 587 Laboratory Practice 587 Case Studies 588 Chapter 15 The Spine and Posture: Structure, Function, and Management Guidelines 591 Review of the Structure and Function of the Spine 592 Physiologic Curves 592 Functional Components 592 Motions of the Spinal Column 592 Structure and Function of the Intervertebral Disks 593 Inert Structures: Influence on Movement and Stability 593 Neuromuscular Function: Dynamic Stabilization 595 Posture 598 Posture Defined 598 The Equilibrium of Posture 598 Etiology of Pain in Postural Impairments 599 Pain Syndromes Related to Impaired Posture 599 Common Faulty Postures: Characteristics and Impairments 600 Pelvic and Lumbar Region 600 Thoracic Region 602 Cervical Region 603 Frontal Plane Deviations from Lower Extremity Asymmetries 604 Pathology of the Intervertebral Disk 605 Injury and Degeneration of the Disk 605 Disk Pathologies and Related Conditions 606 Signs and Symptoms of Disk Lesions and Fluid Stasis 606 Pathomechanical Relationships of the Intervertebral Disk and Facet Joints 608 The Three-Joint Complex 608 Related Pathologies 609 Pathology of the Zygapophyseal (Facet) Joints 609 Facet Joint Characteristics 609 Common Diagnoses and Impairments from Facet Joint Pathologies 609 Pathology of Muscle and Soft Tissue Injuries: Strains, Tears, and Contusions 610 General Symptoms from Trauma 610 Common Sites of Lumbar Strain 611 Common Sites of Cervical Strain 611 Postural Strain 611 Emotional Stress 611 Functional Limitations/Disabilities 611 Principles of Management for the Spine and Posture 611 Examination and Evaluation 612 General Guidelines for Managing Acute Spinal Problems: The Protection Phase 613 General Guidelines for Managing Subacute Spinal Problems: The Controlled Motion Phase 615 General Guidelines for Managing Chronic Spinal Problems: The Return to Function Phase 616 Guidelines for Management of Impairments with an Extension Bias: Intervertebral Disk Lesions, Flexion Injuries, Flexed Postural Dysfunctions, Fluid Stasis 617 Principles of Management 617 Indications, Precautions, and Contraindications for Interventions Utilizing Extension 618 Techniques of Intervention Using an Extension Approach in the Lumbar Spine 618 Techniques to Manage a Disk Lesion in the Cervical Spine 621 Guidelines for Management of Impairments with a Flexion Bias: Spondylosis, Stenosis, Extension Load Injuries, Swollen Facet Joints 622 Principles of Management 622 Indications and Contraindications for Intervention Using a Flexion Approach 622 Techniques of Intervention Utilizing a Flexion Approach 622 Guidelines for Management of Muscle and Soft Tissue Lesions: Strains, Tears, Overuse, and Contusions 624 Management During the Acute Stage: Protection Phase 624 Management in the Subacute and Chronic Stages of Healing: Controlled Motion and Return to Function Phases 625 Guidelines for Management of Impairments with a Nonweight- Bearing Bias 625 Management of Acute Symptoms 625 Progression 626 Management of Selected Conditions 626 Torticollis (Wryneck, Cervical Scoliosis) 626 Tension Headache/Cervical Headache 626 xvi Contents 9865.chfm 2/15/02 9:10 AM Page xvi