Movements By: Dr. M. Abbas

ACTIVE MOVEMENT Movement performed within the unrestricted ROM controlled by the voluntary contraction of the muscle.

Classification of Active Movement: Active free exercise: In which the voluntary contraction of the muscle can perform full ROM against gravity. Active assisted exercise: In which assistance is provided by an outside force, either manual or mechanical when muscle strength is inadequate to complete the motion.

Assisted-Resisted: Muscles may be strong enough to work against resistance in part of the range and external forces applied are adapted in every part of the range to the abilities of the muscles. Active resisted exercise: In which the voluntary contraction of the muscle is resisted by an outside force.

Active Free Exercise: Free exercises are those which are performed by the patient’s own muscular efforts without the assistance or resistance of any external force other than gravity.

Classification: Localized: Localized exercises are designed to produce some specific effect. Examples: To mobilize a particular joint To strengthen particular muscle group

General Exercises: Example: General exercises uses many joints and muscles all over the body. Example: Running

Technique of active free exercise: Starting Position: The starting position is selected and taught with care to ensure the maximum postural efficiency as a basis for movement. Instruction: is given to gain interest and cooperation of the patient.

Speed: The speed at which the exercise is done depends on the effect required. Duration: The duration of the exercise depends very largely on the patient’s capacity without reaching fatigue.

Uses of Active Free Exercise This type of exercise can be used to obtain the following: Relaxation: can be induced by exercises which are rhythmical or pendulum( swinging) in character.

Uses of Active Free Exercise: Joint mobility: the normal range of joint motion is maintained by exercises performed in full range. Muscle power and tone: the power and endurance of the working muscles are maintained or increased in response to the tension developed in them. Tension is greater when the exercise is performed at a speed slower and long duration of exercise

co-ordination: Confidence: is improved by the repetition of exercise. the achievements of coordinated and efficient movement assure the patient of his ability to maintain and control of his movements, and new activities.

Circulatory and respiratory cooperation: during prolonged exercise, the depth of respiration is increased leading to the production of heat and increasing circulation.

Examples of Active Free Exercises:

Active-Assisted Exercise: In which assistance is provided by an outside force, either manual or mechanical when muscle strength is inadequate to complete the motion.

Principles of Assistance: When the voluntary contraction of the muscle is insufficient to produce movement , an external force may be added to complete range. This external force must be applied in the direction of the muscle action.

The magnitude of this assisting force must be sufficient only to augment the muscular action but not allowed to act as a substitute for it. As the muscular power is increasing, the assistance given must be decreased proportionally.

Technique of Assisted Exercise: Starting position: Stability of the body is important to ensure that the patient’s attention is concentrated on the pattern of the movement and the effort required to perform it. Pattern of movement: this can be explained to the patient by performing it passively or actively on the sound limb.

Fixation: fixation of the proximal part of the prime movers improves their efficiency. Avoid trick movements to occur by proper fixation.

Support: the moved part should be supported to reduce the load on the muscle. Manual support is more effective since it can be provided in any plane suitable for the movement and adjusted in each successive part of the range.

Traction: preliminary stretching of the weak muscle provides a powerful stimulus to contraction because it stimulate the muscle spindle( Myotatic reflex) which helps in the initiation of movement.

The antagonistic muscle: a proper starting position should be selected to reduce the tension in the antagonistic muscles. e.g. a position in which the knee flexed is suitable for assisted dorsiflexion of the foot

The assistance force: the force used in assisting the action of the muscle must be applied in the direction of the movement by the PT hands. The character of the movement: movement is performed smoothly and its efficiency depends on the speed of contraction.

The cooperation of patient: Repetitions: repetition of the movement depends on the condition of the patient. The cooperation of patient: this is essential during this type of exercise. The patient should be encouraged to exert maximum effort.

Effects and uses of assisted exercise: When the patient has weak musculature( poor to fair muscle test grade). Active assisted exercises is used to provide enough assistance to strength the weak muscle. Maintain physiologic elasticity and contractility of the muscles which will gain strength.

provide sensory feedback from the contracting muscle to be used in early stages of neuromuscular re- education. provide stimulus for bone integrity, so the range of effective joint movement may be increased.

The repetitive assisted exercises on the correct pattern learn the patient to control the movement by himself, so helping in training co-ordination. Confidence of the patient in his ability to move and helping to co-operate

Contra-indications of assisted exercise: Acute tears and fracture Greater swelling ,fever and redness Immediately followed myocardial infarction If active assisted exercises induced pain during movement

Active Resisted Exercise

Active-Resisted Exercise: Resistance exercise is active exercise in which muscle contraction is resisted by an outside force. This outside force may be manual or mechanical.

Goals and indications of resistive exercises: Muscle strength:

Strength: The greatest measurable muscle tension exerted by a muscle or muscle group to overcome resistance during a single, maximum effort. In order to increase the strength of a muscle, muscle contraction should be loaded for a relatively low number of repetition or over a short period of time.

Muscular endurance: The ability to perform low-intensity, repetitive, or sustained activities over an extended period of time without fatigue. Unlike strength, endurance develops by increasing the oxidative and metabolic capacities due to low-intensity muscle contractions, high repetitions, and a prolonged time.

Power Power is defined as work per unit of time (Force x distance/time). Power can be improved by either increasing the work that a muscle must perform in a specified period of time.

Physiological Adaptations to Resistive Exercise: Regular resistive exercise is associated with several positive adaptations which is dosage dependant. These changes include:

Muscle: Increase of the cross sectional area of the muscle due to increase myofibril per muscle fiber fibers splitting increase number of muscle fiber

Connective tissue: Resistive exercise may alter tendon and ligament structure make them larger, stronger and more resistance to injury.

Bone: Improve and maintain bone density. Cardiovascular system: Increase cardiac output Increase stroke volume Increase maximal oxygen consumption

Mode of Resistance Application (manual-mechanical): Manual Resisted Exercise: Manual resistance exercise is active resisted exercise in which the resistance force is applied by the therapist to either a dynamic or isometric contraction.

Advantage: Disadvantage: The resistance can be varied with changes in strength production throughout the range. Specific or individual muscle could be strengthened. Disadvantage: The amount of resistance depend on the therapist condition. Effort and time consuming as the therapist can treat only one patient at a time.

Mechanical Resistance Exercise: Mechanical resisted exercise is active resisted exercise in which the resistance provided by equipments to either a isotonic or isometric muscle contraction.

A variety of mechanical equipment are available ranging from simple to complex, small to large, and expensive to inexpensive. The choice between them depend on the patients need and ability, goal of the exercise and availability of the apparatus. Free weights Weight machine Exercise bicycle Pulley system

Advantage: Disadvantage: The level of resistance not limited by the therapist strength. Add a variety to the exercise. Safe time and effort of the therapist. Disadvantage: The resistance can not be varied throughout the range of motion. Amount of resistance is fixed all over the range. Need space and may be expensive.

The exercise dosage can be increased by: Changing the relationship to gravity Increase lever arm (hand placement) Increase repetition of exercise Increase duration of exercise Increase amount of resistance (mild- moderate- maximum) Speed

Technique: STARTING POSITION Instruction to patient-----this will help to gain the interest and cooperation of the patient Speed of exercises ----- it depend upon the effect required. Usually it is slow in the period of learning later on it is according to patients natural rhythm Duration--- it depend on patients capacity. Usually three bouts with rest interval so as to avoid fatigue.

Resisting Force: The resistance must be given smoothly from the beginning to the end of range. The direction of resistance force must be opposite to the direction of the movement.

It should be diminish gradually from the beginning to the end of movement. Don’t forget to give enough period of relaxation to avoid fatigue.

Effect and uses of resisted exercise: Strengthening the muscles due to increase tension through gradual overload of resistance of a muscle or muscle group. Increase muscle endurance through low intensity repetitive exercise over a prolonged period of time without fatigue. Increase coordination. Increase muscle cross section (hypertrophy). Increase blood flow of the working muscle. Increase the power.

Contraindication of Resisted Exercise: Acute inflammation of the musculoskeletal system Pain Infection. Recent fracture or non-united fracture

Progressive resistance Exercises

DeLorme technique: De Lorme technique is a method of exercise with weights for the purpose of strengthening muscles in which sets of repetitions are repeated with rests between sets. The technique involves isotonic exercise and determination of the maximum level of resistance.

Delorme Technique History: Right after World War-II  Dr. Thomas Delorme of Harvard Medical School developed a technique that he called Progressive resistance exercise(PRE) to strengthen muscles.

10 Repetition maximum: In PRE, the subject is first tested to determine the max weight that he/she can lift 10 times, this is known as 10 Repitition max or 10 RM.

Delorme then would ask subject to lift various percentages of 10RM starting at 10%, 20%, 30%,etc, upto 100% Subject exercises daily and then retests to determine a new 10RM each week. The progress of the subject is determined by increase in 10RM from week to week and not from 50%,75%, or 100% of 10RM.  

OXFORDS TECHNIQUE

HISTORY Zinovieff, a physician who worked at England United Oxford Hospitals, published a revision of DeLormes program that he named Oxford technique(1951) Zinovieff found that in the DeLormes technique the patient were too fatigued to complete the final set of 10RM exercise. He suggested reversing the system, starting with 10RM on the first set of 10 rep and progressively reducing to 75% and then to 50% on each successive set of rep.

DeLormes Technique@10 rep 1st set of 50% of 10RM 2nd set of 75% of 10RM 3rd set of 100% of 10RM

Oxford technique@10 rep 1st set of 100% of 10RM 2nd set of 75% of 1oRM 3rd set of 50% of 10RM

MacQueen: MacQueen distinguished between exercise regimens for producing muscle hypertrophy and those for producing muscle power. He concluded that the number of repetitions for each set of exercise determines the different characteristics of the various training procedures.