Therapeutic Exercises . Introduction To Therapeutic Exercises Therapeutic exercise is a major & an important part of the practice of physical therapy. One of the most difficult tasks for any physical therapist is to design & apply an exercise program. Exercise presents both benefits & risks. This balance can be easily achieved towards the benefit side of the equation with the optimal ex prescription. 11/27/2018 PHTH201

Definition of Therapeutic Exercises It is a planned body movements that aim to improve & restore physical action. It is the activity that is performed or practiced to develop or improve a specific function or skill for the sake of developing & maintaining physical fitness. 11/27/2018 PHTH201

Goals of Therapeutic Exercises The ultimate goal is the achievement of an optimal level of symptom free movements during physical activities. To improve & restore physical function. To prevent loss of function & to enhance the pt’s functional capabilities. To prevent & ↓impairment & disability. To improve overall health status, fitness & sense of well-being. 11/27/2018 PHTH201

Exercise Program Prerequisites 1. Knowledge of Anatomy, physiology, pathology & kinesiology. 2. Understanding the different forms of exs. & how these exs. affect body systems. 3. The ex. program should be individualized to the special needs of the patient. 11/27/2018 PHTH201

Designing Exercise Program Start with a comprehensive examination of the patient (pt.). Determine the patient’s problems & functional disabilities . Set the aims & objectives of the treatment (ttt) program. Select the proper exercise program that can solve the pt’s problem’s & improve functional capabilities. 11/27/2018 PHTH201

5 . Periodically re-evaluate & examine the pt. 6 . Modify the program according to the re- evaluation to attain the optimal degree of improvement. 7. Clearly identify the purpose & goal of the exercise program to the pt. 11/27/2018 PHTH201

Therapeutic Exercises Active Exercises Passive Exercises Static Exercises Relaxed Passive Movement Active Assisted Exercises Active Free Exercises Forced Passive Movement Active Resisted Exercises 11/27/2018 PHTH201

Definitions Passive Exercises: movement is performed by an external force without any voluntary contraction of the patient. External force may be another person ,machine or the sound limb of the pt. Relaxed Passive Exercises: movement performed by an external force ,within the pain free range, to maintain the ROM. Forced Passive Movements : Movement performed by an external force, within the tolerance of pain to ↑ the limited ROM. 11/27/2018 PHTH201

Active Assisted Exercises : Active Exercises: Exercise in which movement is performed by the voluntary pt. effort ( under pt. control ). Active Assisted Exercises : Exercise in which mov. is performed by voluntary pt. effort & with external assistance to complete the ROM. Active Free Exercises : Exercise in which mov. is performed by voluntary pt. effort, through full ROM without the gravity( gravity eliminated) or against gravity. 11/27/2018 PHTH201

Active Resisted Exercises : Exercises in which the mov. is resisted by an external force. Types of Therapeutic Exercises Classification according to the aim & purpose of exercises into : Range of motion ex. which aim to maintain & ↑ROM ( e.g. passive, active assisted, active ROM exercises ) & other techniques of joint mobilization & soft tissue stretching . 2. Postural ex. to improve posture & correct faulty posture . 11/27/2018 PHTH201

5. Relaxation ex. to induce relaxation . 3. Muscle performance ex. to ↑ m. strength, power & endurance e.g. resisted exs. & endurance exs. 4. Balance & coordination exercises to improve balance & coordination . 5. Relaxation ex. to induce relaxation . 6. Specific area exs. e.g. breathing exs. & many circulatory exs. 11/27/2018 PHTH201

Other Classification : Specific exs.: conducted as local or specific. General exs. : mov. for the whole body. for best results specific & general exs. should be combined. Combined : passive , occupational therapy & various recreational activities ( hydro gymnastics, games, swimming, walking & cycling ). 11/27/2018 PHTH201

Basic Principles of Specific Exs. 1. They must be performed in a smooth & rhythmical manner, so that they don’t subject ms. & js. to sudden unexpected stress & strain 2. They must be based on sound starting positions. 3. They must provide smooth progression from the stage of extreme weakness to full use against the stress of normal working conditions 11/27/2018 PHTH201

4. The ex. must be done with coordinated muscle work. 5. The exs. might provide progression of : strength, mobility, coordination,…etc. 6. All the exs. thay aim to strengthen weak ms. should provide a wide ROM as possible. 11/27/2018 PHTH201

Principle of Rhythm Muscular contraction must be followed by relaxation & the relaxation period must be complete and long enough to allow normal circulatory conditions to be restored. This principle applies particularly to exs. used to re-develop weak ms. after trauma or disease. It is based on the fact that m. efficiency depends largely on the condition of it's local circulation: If the circulation is good  the breakdown products of contractions are carried away quickly. If the circulation is poor  the products tend to accumulate & produce early fatigue. 11/27/2018 PHTH201

Principle of Sound Starting Position The starting positions from which ex. is performed should facilitate the work of the m. & be suitable for the particular phase of recovery reached by the patient 11/27/2018 PHTH201

Principle of Strengthening & Mobilizing To strengthen weak ms. or to mobilize stiff joints, the starting positions of the exs. should be as steady as possible, so as to give the working muscles a firm origin from which to work. The larger the base of support, the steadier will be the position of the body. The nearer the center of gravity to the base of support, the steadier the position. In some instances, additional stability is achieved by arranging for the base to be enlarged in the direction of the movement. 11/27/2018 PHTH201

Principle of Developing Coordination For developing neuromuscular co-ordination, the starting position should be chosen gradually to increase the difficulty in maintaining the balance 11/27/2018 PHTH201

Principle of Progression The methods of progression used depend on whether an ex. is designed . Indicated to re-develop strength, restore mobility, or redevelop neuromuscular co-ordination. One method of progression is the progression in time (performing the ex. for increasing periods of times). 11/27/2018 PHTH201

Principle of Wide Range of Motion Except in early phases of recovery, when the ms. are very weak, all exs. which aim at strengthening ms. should provide a wide range of mov. as possible. In this way, all the fibers of the m. responsible are exercised normally. Exercising a muscle in part of it's range of mov. does not mean that all it's fibers will be brought into action. 11/27/2018 PHTH201

Functional Excursion Functional excursion is defined as the distance that a m. is capable of shortening after it has been elongated to it's maximum. Movement of the body segment occur either by the effect of m. contraction (active) or by an external force (passive), forces which move the bones with respect to each other at the connecting joints. The type of mov. depends on the structure of the joint, integrity and flexibility of the soft tissues. The full motion possible is called range of motion. When moving a segment through it's range of motion ( R.O.M.) all structures in the region are affected ( muscles, joints, surfaces, capsules, ligaments, fasciae, vessels and nerves). 11/27/2018 PHTH201

. is described in terms of joint range ( flexion, extension, abduction, adduction,& rotation) and muscle range (related to functional excursion of ms.) Functional excursion or range of a m. is limited by the range available by the joint it crosses. This is true for one joint m. ( brachialis m.) : ms. with their proximal and distal attachments on the bones on either side of one joint. For two joint or multi-joint ms. ( crosses over two or more joints), their range goes beyond the limits of any one joint they cross ( biceps brachii). 11/27/2018 PHTH201

R.O.M. is described in terms of joint range ( flexion, extension, abduction, adduction,& rotation) and muscle range (related to functional excursion of ms.) 11/27/2018 PHTH201

Definition of Active Insufficiency Active insufficiency is when the ms. can shorten no more. If the ms. contracts and moves the elbow into flexion and the forearm into supination, while simultaneously moving the shoulder into flexion, it will shorten to a point known as active insufficiency. 11/27/2018 PHTH201

Definition of Passive Insufficiency The position known as passive insufficiency is when the ms. is fully elongated. The m. is lengthened full range by extending the elbow, pronating the forearm & simultaneously extending the shoulder. N.B.: To maintain normal R.O.M., the segments must be moved through their available ranges periodically (whether it is a joint range or muscle range). 11/27/2018 PHTH201

Factors lead to decreased ROM Systemic, joint, neurologic or muscular diseases. Surgical or traumatic causes. Inactivity or immobilization for any reason. Therapeutically, range of motion activities are administered to maintain existing joint or soft tissue mobility. This will minimize the effects of the formation of soft tissue adhesions, m. weakness, joint range limitations & finally m. contractures. 11/27/2018 PHTH201

Indications and Goals of Range of Motion When a patient is unable to or unsupposed to actively move a segment or segments of the body e.g. when comatosed, paralyzed or on complete bed rest, or when there is an inflammatory reaction + active ROM is painful, controlled passive ROM is used to decrease the complications of immobilization in order to: Maintain joint & soft tissue integrity( avoid adhesions). Minimize the effect of formation of contractures. Maintain mechanical elasticity of m. Assist in circulation and vascular dynamics. Enhance synovial mov. for cartilage nutrition & diffusion of materials in the joint. Decrease pain Assist the healing process following injury or surgery Help maintain the pt.'s awareness of movement. 11/27/2018 PHTH201

When a therapist is teaching an active ex When a therapist is teaching an active ex. program, passive ROM is used to demonstrate the desired motion to the pt. When a therapist is preparing the pt. for stretching, passive ROM is often used before passive stretching techniques (techniques to increase the ROM, when ROM is restricted). When a therapist is evaluating inert structures, passive ROM is used to determine limitations of motion, to determine joint stability, and to determine m. & other tissue elasticity. 11/27/2018 PHTH201

Indications of Active and Active Assistive ROM When a pt. is able to actively contract the ms. and move a segment either without assistance and there are no contra-indications, active ROM is used to: Accomplish the same goals of passive ROM with the added benefits that results from the m. contraction. Maintain physiologic elasticity & contractility of the participating m. Provide sensory feedback from the contracting m. Provide a stimulus for bone and joint tissue integrity. Increase circulation and prevent thrombus formation. - Develop co-ordination & motor skills for functional activities. 11/27/2018 PHTH201

When a pt. has weak musculature, and scores poor to fair minus m When a pt. has weak musculature, and scores poor to fair minus m. test (grade 2, grade 3 - ), active Assistive ROM is used, to provide enough assistance to the ms. in a controlled manner, so that the m. can function at its maximum level & progressively be strengthened. Active and Active Assistive ROM can be used to improve cardiovascular and respiratory responses, when done with multiple repetitions. 11/27/2018 PHTH201

Special Considerations 1. When a segment of the body is immobilized for a period of time, ROM is used on the regions above and below the immobilized segment to: a) Maintain the areas in as normal condition as possible. b) Prepare for new activities as walking with crutches. 2. When a patient is on bed rest, ROM is used to avoid the complications of decreased circulation, bone demineralization, decreased cardiac & respiratory function. 11/27/2018 PHTH201

Limitations of ROM Limitations for Passive Motion: True passive relaxed range of motion may be difficult to obtain, when the m. Is innervated & the pt. is conscious. Passive motion will not: 1 . Prevent m. atrophy. 2 . Increase strength and endurance. 3 . Assist circulation to the extent that active, voluntary m. contraction does. 11/27/2018 PHTH201

Limitations for Active ROM: For strong ms., it will not maintain or increase strength. Active ROM will not develop skill or co-ordination except in the mov. pattern used. 11/27/2018 PHTH201

Precautions & Contra-indications to ROM: A. Both passive and active ROM are contra-indicated under any circumstance when the motion to a part is disruptive to the healing process. But also, complete immobility leads to adhesion & contracture formation, sluggish circulation & prolonged recovery time. Historically, ROM has been contra-indicated immediately following acute tears, fractures and surgery, but because the benefits of controlled motion have demonstrated decreased pain and increased rate of recovery, early controlled motion is used as long as the pt.'s tolerance is monitored. Additional trauma to the part is contra-indicated. 11/27/2018 PHTH201

Signs of too much or wrong motion include: Increased pain Increased inflammation ( great swelling, heat and tenderness). B. Usually active ROM of the upper extremities and limited walking near the bed are tolerated as early exs. after myocardial infarction. Careful monitoring of symptoms, bl. pressure, perceived exertion are necessary. 11/27/2018 PHTH201

Procedures for Applying ROM Techniques On the basis of evaluation of the pt.'s impairments & level of function, determine whether passive, active assistive or active ROM will meet the goals. Place the pt. in a good aligned, comfortable, relaxed position. Free the region from restrictive clothing, splints & dressing. The therapist (th.) must be positioned so that the proper body mechanics are used. To control mov., grasp the extremity around joints. If the joints are painful, modify the grip to provide support necessary for control 11/27/2018 PHTH201

Full support is given to the areas of poor structural integrity, as hyper mobile joints, recent fractures or paralyzed limb segment. Move the segment through its pain free range. Do not force beyond the available range. If you force motion  stretching technique. Perform the motion smoothly and rhythmically, 5 to 10 repetitions. The no. of repetitions depends on the objectives of the of the program & the pt.'s condition. 11/27/2018 PHTH201

The force for mov. is external  provided by the P.T If the plan includes the use of passive ROM: The force for mov. is external  provided by the P.T or normal body part or mechanical. b) No active assistance or resistance is given by the pt's ms. crossing the pt. If so, it becomes an active exercise. The motion is carried out within the free ROM (available range, without force or pain). 11/27/2018 PHTH201

If the plan is to use active assistance or active ROM; Demonstrate to the patient the desired motion, using passive ROM, then ask the patient to perform the motion. Assistance is given only when needed for smooth motion. When there is weakness, assistance is given only at the beginning or at the end of ROM. The motion is performed within the available RO M 11/27/2018 PHTH201

ROM techniques may be performed in : a) Anatomic planes of ROM ( frontal, sagittal & transverse). b) M. range of elongation (antagonistic to the line of m. pull). c) Combined patterns ( in several planes of motion). d) The motion is performed in functional patterns, used in ADL ( Activities of Daily Living). The pt.'s general conditions should be monitored during and after the procedure. Record observable and measurable reactions to the treatment. Modify or progress the treatment (ttt) as necessary. 11/27/2018 PHTH201