Therapeutic Exercise

Overview of rehab

Review Acute Inflammation Repair or Fibroplasia Maturation Tissue Healing Modalities Acute Inflammation Repair or Fibroplasia Maturation Wolff’s Law- tissues will adapt to stresses/tension applied to them Pain control Inflammation control Facilitate ROM Can be used during rehab program

Goals of Injury Rehabilitation Pain Control Regain/increase ROM and flexibility Proprioception Regain/increase strength and power Regain/increase endurance Return to functional and sports specific activity Maintain conditioning of whole body!

Your Duties as a Clinician Understand injury and subsequent healing phase and design appropriate exercise regimen Have purpose for exercise choice Provide direction and instructions Correct/modify/adjust program as needed Supervision Professionalism and courtesy Support and encourage patient

Early Therapy Stages

Terminology AROM (active range of motion): patient performs motion by his/herself PROM (passive range of motion): clinician moves patient through range of motion AAROM (active assisted range of motion): combination of passive and active; patient performs what he/she can and clinician assists with rest of movement

Terminology Subjective measurement: an approximation, guess Objective measurement: factual, exact measure Goniometer: tool used by clinicians to measure a patient’s ROM; similar to a protractor in math

Pain Control Pain control is usually a component of modality usage Psychological Techniques Relaxation Meditation Visualization Medications

Active Range of Motion May be done in conjunction with modality usage Alphabet with toes/foot in cold whirlpool Initially pain free ROM indicated

Passive ROM used When patient cannot move on his/her own Maintain flexibility Increase blood flow Adhesions or scar tissue not allowing full ROM Machine or therapist can provide ROM CPM- continuous passive movement used with ACL or knee replacement surgery

Active Assisted ROM Increase flexibility Assist weak musculature Perform a specific ROM pattern Use gravity to increase ROM Pendulums Wall slides Bicycle Dowel http://calder.med.miami.edu/pointis/upper.html

Measuring ROM Determines normal vs. abnormal ROM Goal setting Can be completed both subjectively and objectively

Goniometer Maintain consistency! Note position of patient during testing Use same landmarks on lateral side of joint each time tested Start at 0 degrees (anatomical position) then move through ROM to gain measurement Compare bilaterally

Remember! If a therapy session results in increased pain or a return of inflammation, the clinician may be progressing too aggressively. Feedback from patient determines speed of progression.

Muscle strength, endurance, and proprioception: Early stages

Terminology PRE (progressive resistive exercise): exercises that become increasingly more difficult RROM (resistive range of motion): some form of resistance is applied to the movement Manual resistance: clinician physically resists range of motion

Terminology SLR (straight leg raise): ROM performed at hip if there is a lower extremity injury that prevents knee ROM Open kinetic chain exercises: when the foot or hand is mobile or off the ground Closed kinetic chain exercises: when the foot or hand is fixed or on the ground Neuromuscular control: ability for muscles to respond to environmental changes

Considerations Protect healing tissue, but must provide some stress for proper healing (Wolff’s law) PRE Safe ROMs and planes of movement Exercise choice Maintain rest of body fitness to prevent atrophy

Strengthening Isometric vs. isotonic vs. isokinetic Easy progression: Gravity resistance Light weight or manual resistance http://www.youtube.com/watch?v=Hhcz0qJvEeI Tubing/bands http://www.youtube.com/watch?v=z1zInVH6X28

Endurance Pain-free ROM No undue stress to healing site Examples: Bike UBE- upper body ergometer Rowing Swimming Elliptical Treadmill http://www.abqjournalfit.com/414/blog/2010/09/11/try-your-hand-on-a-ube/

Proprioception Static balance exercises- tandem stance or one leg Flat hard surface Foam or mat surface Add weights or movements to each Static upper extremity exercises Mirror movements between limbs Closed kinetic chain stability on hand- tandem and single arm http://www.reflexportland.com/exercise/at-home-knee-strengthening-exercises/

Muscle strength, endurance and proprioception: later stages

Terminology Agility: ability to accelerate, decelerate, and change direction while maintaining balance and posture Plyometric exercise: movements that involve speed, agility and power

Considerations Phase of tissue healing Range of motion and planes of movement Should have near-full or full ROM Advance to multi-planar activity Exercise choice Multi-joint exercises Specific supplemental exercises for injury site

Strengthening and Endurance Increased resistance loads Moving resistance with multiple joints Weight room activity Plyometrics http://www.bodyproject.be/?page_id=355 http://www.rejectfat.com/kettlebell-exercises-health-fitness-benefits/

Strengthening and Proprioception Plyometrics Advanced static balance and dynamic balance exercises Wobble boards Adding distractions or other movements http://www.thera-band.com/store/products.php?ProductID=17 http://xrlifestyles.com/alternate-exercises/

What muscles is this exercise working? http://www.exercise-ball-exercises.com/exercises-for-skiing.html What muscles is this exercise working? When and why would one use this exercise? Is this exercise proprioceptive? strengthening? endurance?

What muscles is this exercise working? When and why would one use this exercise? Is this exercise proprioceptive? strengthening? endurance? http://www.passbracing.com/misc.html

What muscles is this exercise working? When and why would one use this exercise? Is this exercise proprioceptive? strengthening? endurance? http://athletefit.com/programs/speed_agility/

Functional Training and Sport Specific rehabilitation

Terminology ADL (activities of daily living): procedures or things that must be accomplished daily in order to properly function Functional Training: training the body for activities that must be performed in daily life Motor learning: practice and experience increases skilled movements

Terminology Specificity: the theory that training should be relevant to what the desired results should be SAID principle: (specific adaptations to imposed demands) body will adapt to demands placed upon it

ADLs What are some movements that a person must be capable of doing in order to function on his/her own?

Functional Training Requires smooth, coordinated movements across multiple planes In training, exercises must be able to transfer over to the desired movements at desired speed Components of the movement can be isolated, but goal is multi-joint coordination Repetition of movement is important for motor learning

http://www. guardian. co http://www.guardian.co.uk/lifeandstyle/wordofmouth/2009/jul/30/restaurants-employment-practices http://www.usmilitary.com/8036/us-marine-corps-combat-engineer-careers/ What types of functional exercises would each of these professionals have to do to effectively and safely perform their jobs? Be prepared to share

Sports Specific Training Factors that must be considered: Movements required Endurance, strength and agility needed Surface, facility or environment Equipment Rules of sport Gradual progression back to full competition

Therapy and Unique Populations

Therapy Issues Sensory deficits Verbal communication problems Attention disorders Spastic muscles/lack of muscle control Diminished mental function Chronic pain

Therapy Options: Aquatic Therapy Increased buoyancy Resistance and compression from water Decreased stress on joints Variety of exercises without equipment http://www.youtube.com/watch?v=aY0YBdIIgqk http://centralpa.easterseals.com/site/PageServer?pagename=PACN_Warm_Water_Therapy_Pool

Yoga Therapy Works strength, endurance and flexibility Can customize for pain and injury through sequencing of poses Can modify routine as pain decreases and strength increases http://www.youtube.com/watch?v=rz_X5XB0FbU

Interactive Video Gaming Systems Can be done in privacy of home or socially Hand-eye coordination Some balance, agility and coordination needed http://www.youtube.com/watch?v=AjY8g98xVsg http://howsyourrobot.com/2013/04/24/let-me-get-this-straight-you-want-me-to-play-video-games/

Equine Therapy Animals make good companions Non-judgmental Work on communication skills Work on muscle tone, flexibility, and coordination http://www.youtube.com/watch?v=tGtEjl34hLo http://www.ahorseconnection.org/

Fitness concerns for the geriatric populations

Benefits for Geriatric Populations Increase calorie use (decrease weight) Increase in cardiovascular fitness and strength Decrease blood pressure Decrease chance of stroke, some cancers, osteoporosis, and cardiovascular disease Decrease psychological stress Improve sleep and digestion

Therapeutic Benefits Heart attack patients Diabetics (improves insulin response) Decrease back pain by increasing strength Arthritis patients (strong muscles= less joint pain) Depression (improved self confidence) Improves neurocognitive function Decreases loss of muscle mass

Considerations Patient beginning health and fitness level Modify workout based on injury/illness Balance issues Previous exercise experience Medications

Clinician can control injury prevention Ensure proper warm-up and cool down Control lifting speed Monitor for proper technique Keep workout area uncluttered Consider balance concerns: Machines vs. free weights Body weight or exercise bands Seated or lying vs. standing Stable vs. unstable surfaces

Geriatric Conditioning Guidelines Strength program 2-3 times/week Controlled speeds of repetitions Beginners: more reps and less load Provide clear explanation of lift/move Demonstrate lift/move Demonstrate breathing technique Careful supervision with positive reinforcement

How can we modify this exercise for improved geriatric safety? http://fitnessanddefense.com/category/safety-tips/

Cardiovascular Training 2-5 days/week for 20-60 minutes Workout intensity: 60-90% max HR Medications may affect HR Talk test- if they can say short-medium sentences during workout, they are at good pace

Clinician must enforce participant compliance with: Increased fluid intake Proper nutrition Adequate rest and sleep Proper hygiene Approval of exercise regimen with physician Communicate concerns to clinician