Introduction to Theraputic Exercises PDF

Introduction to theraputic exercises By Dr. Marwa Mostafa Definition Therapeutic exercise is the systematic, planned performance of bodily movements, postures, or physical activities intended to provide a patient with the means to: 1- Prevent impairments. 2- Improve, restore, or e...

Introduction to theraputic exercises By Dr. Marwa Mostafa Definition Therapeutic exercise is the systematic, planned performance of bodily movements, postures, or physical activities intended to provide a patient with the means to: 1- Prevent impairments. 2- Improve, restore, or enhance physical function. 3- Prevent or reduce health-related risk factors. 4- Optimize overall health status, fitness, or sense of wellbeing. Therapeutic exercise programs designed by physical therapists are individualized to the unique needs of each patient. Components of Physical Function The ability to function independently at home, work place, within the community, or during recreational activities is contingent upon physical as well as psychological and social function. 1. Balance The ability to align body segments against gravity to maintain or move the body (center of mass) within the available base of support without falling; the ability to move the body in equilibrium with gravity via interaction of the sensory and motor systems. 2. Cardiopulmonary fitness. The ability to perform moderate intensity, repetitive, total body movements (walking, cycling, swimming) over an extended period of time. A synonymous term is cardiopulmonary endurance 3. Coordination The correct timing and sequencing of muscle firing combined with the appropriate intensity of muscular contraction leading to the effective initiation, guiding, and grading of movement. Coordination is the basis of smooth, accurate, efficient movement and occurs at a conscious or automatic level. 4. Flexibility The ability to move freely, without restriction; used interchangeably with mobility. 5. Mobility The ability of structures or segments of the body to move or be moved in order to allow the occurrence of range of motion (ROM) for functional activities (functional ROM). Passive mobility is dependent on soft tissue (contractile and non contractile) extensibility; in addition, active mobility requires neuromuscular activation 6. Muscle performance The capacity of muscle to produce tension and do physical work. Muscle performance encompasses strength, power, and muscular endurance. 7. Neuromuscular control Interaction of the sensory and motor systems that enables synergists, agonists and antagonists, as well as stabilizers and neutralizers to respond to proprioceptive and kinesthetic information and, subsequently, to work in correct sequence to create coordinated movement Impairment of any one or more of the body systems and subsequent impairment of any aspect of physical function, separately or jointly, can limit and restrict an individual’s ability to carry out or participate in daily activities Types of Therapeutic Exercise Interventions Therapeutic exercise procedures embody a wide variety of activities, actions, and techniques. The techniques selected for an individualized therapeutic exercise program are based on a therapist’s determination of the underlying cause or causes of a patient’s impairments, activity limitations, or participation restrictions (functional limitations or disability). The types of therapeutic exercise interventions include: 1. Aerobic conditioning and reconditioning. 2. Muscle performance exercises: strength, power, and endurance training. 3.Stretching techniques including muscle-lengthening procedures and joint mobilization/manipulation techniques. 4. Neuromuscular control, inhibition, and facilitation techniques and posture awareness training. 5. Postural control and stabilization exercises. 6. Balance exercises. 7. Relaxation exercises. 8. Breathing exercises and ventilatory muscle training. 9. Task-specific functional training. Impairments Impairments of the physiological, anatomical, and psychological functions and structures of the body reflects a person’s health status. Typically, impairments are the consequences of pathological conditions and encompass the signs and symptoms that reflect abnormalities at the body system, organ, or tissue level. Common Physical Impairments Managed with Therapeutic Exercise Physical therapists typically provide care and services to patients with impairments of body function and/or body structure that affects the following systems: A) Musculoskeletal 1. Pain 2. Muscle weakness 3. Decreased muscular endurance 4. Limited range of motion due to: a. Restriction of the joint capsule b. Restriction of peri-articular connective tissue c. Decreased muscle length 5. Joint hypermobility 6. Faulty posture 7. Muscle length/strength imbalances B) Neuromuscular 1. Pain 2. Impaired balance, postural stability 3. Incoordination, faulty timing 4. Delayed motor development 5. Abnormal tone (hypotonia, hypertonia, dystonia) 6. Ineffective/inefficient functional movement strategies C) Cardiovascular/pulmonary 1. Decreased aerobic capacity (cardiopulmonary endurance) 2. Impaired circulation (lymphatic, venous, arterial) 3. Pain with sustained physical activity (intermittent claudication) D) Integumentary Skin hypomobility (e.g., immobile or adherent scarring) Primary and secondary impairments Impairments may arise directly from the health condition (direct/primary impairments) or may be the result of preexisting impairments(indirect/secondary impairments). A patient, for example, who has been referred to physical therapy with a medical diagnosis of impingement syndrome or tendonitis of the rotator cuff (pathological condition) may exhibit primary impairments of body function, such as pain, limited ROM of the shoulder, and weakness of specific shoulder girdle and glenohumeral musculature during the physical therapy examination. The patient may have developed the shoulder pathology from a preexisting postural impairment (secondary impairment), which led to altered use of the upper extremity and impingement from faulty mechanics Management The physical therapy profession has developed a comprehensive approach to patient management designed for the purpose of helping a patient achieve the highest level of functioning possible. The process of patient management has five basic components: 1. A comprehensive examination. 2. Evaluation of data collected. 3. Determination of a diagnosis based on impairments of body structure and function, functional limitations (activity limitations), and disability (participation restrictions). 4. Establishment of a prognosis and plan of care based on patient-oriented goals. 5. Implementation of appropriate interventions The patient management process culminates in the attainment of meaningful functional outcomes by the patient, which then must be re-examined and re-evaluated before a patient’s discharge from care. The re-examination and re-evaluation process occurs not only at the conclusion of treatment but throughout each phase of patient management  I. Examination The first component of the patient management model is a comprehensive examination of the patient. There are three distinct elements of a comprehensive examination. A. The patient’s health history 1. Demographic Data Age, sex, race, ethnicity 2. Social History Family and caregiver resources Cultural background Social interactions/support systems 3. Occupation/Leisure Current and previous employment Job/school-related activities Recreational, community activities/tasks 4. Growth and Development Developmental history Hand and foot dominance 5. Living Environment Current living environment 6. General Health Status and Lifestyle Habits and Behaviors: Past/Present (Based on Self or Family Report) Perception of health/disability Lifestyle health risks (smoking, substance abuse) Diet, exercise, sleep habits 7. Medical/Surgical/Psychological History Previous inpatient or outpatient services 8. Medications: Current and Past and Family History Health risk factors Family illnesses 9. Cognitive/Social/Emotional Status Orientation, memory Communication Social/emotional interactions 10- Current Conditions/Chief Complaints or Concerns _ Conditions/reasons physical therapy services sought _ Patient’s perceived level of daily functioning and disability Patient’s needs, goals _ History, onset (date and course), mechanism of injury, pattern and behavior of symptoms _ Family or caregiver needs, goals, perception of patient’s problems _ Current or past therapeutic interventions _ Previous outcome of chief complaint(s) 11. Functional Status and Activity Level _ Current/prior functional status: basic ADL related to self-care and home _ Current/prior functional status in work, school, community related 12. Other Laboratory and Diagnostic Tests B. A relevant systems review The systems typically screened by therapists are the cardiovascular and pulmonary, integumentary, musculoskeletal, and neuromuscular systems, although problems in the gastrointestinal and genitourinary systems also may be relevant. 1. Cardiovascular/pulmonary: Heart rate and rhythm, respiratory rate, and blood pressure; pain or heaviness in the chest or pulsating pain; lightheadedness; peripheral edema 2. Integumentary: Skin temperature, color, texture, integrity; scars. 3. Musculoskeletal: Height, weight, symmetry, gross ROM, and strength. 4. Neuromuscular: General aspects of motor control (balance, locomotion, coordination); sensation, changes in hearing or vision; severe headaches. 5. Gastrointestinal and genitourinary: Heartburn, diarrhea, constipation, vomiting, severe abdominal pain, problems swallowing, problems with bladder function, unusual menstrual cycles, pregnancy. 6. Cognitive and social/emotional: Communication abilities (expressive and receptive), cognition, affect, level of arousal, orientation, attentiveness/distractibility, ability to follow directions or learn, behavioral/ emotional stressors and responses 7. General/miscellaneous: Persistent fatigue, malaise, unexplained weight gain or loss, fever, chills, sweats C- Specific tests and measures Specific tests and measures used by physical therapists provide in-depth information about impairments, activity limitations, participation restrictions/ disabilities. They include but are not limited to: 1. Assessment of pain 2. Goniometry and flexibility testing 3. Joint mobility, stability, and integrity tests (including ligamentous testing) 4. Tests of muscle performance (manual muscle testing, dynamometry) 5. Posture analysis 6. Assessment of balance, proprioception, neuromuscular control 7. Gait analysis 8. Assessment of assistive, adaptive, or orthotic devices.  II. Evaluation Evaluation is a process characterized by the interpretation of collected data. The process involves analysis and integration of information to form opinions by means of a series of sound clinical decisions. Addressing the certain questions during the evaluation of data derived from the examination enables at therapist to make pertinent clinical decisions that lead to the determination of a diagnosis and prognosis and the selection of potential intervention strategies for the plan of care. 1- What is the extent, degree, or severity of structural and functional impairments, activity/functional limitations, or participation restrictions/disability? 2- What is the stability or progression of dysfunction? 3- To what extent are any identified personal and environmental barriers to functioning modifiable? 4- Is the current health condition(s) acute or chronic? 5- What actions/events change (relieve or worsen) the patient’s signs and symptoms? 6- How does the information from the patient’s medical/ surgical history and tests and measures done by other health-care practitioners relate to the findings of the physical therapy examination? 7- Have identifiable clusters of findings (i.e., patterns) emerged relevant to the patient’s dysfunction? 8- Is there an understandable relationship between the patient’s extent of impairments and the degree of activity/functional limitation or participation restriction/ disability? 9- What are the causal factors that seem to be contributing to the patient’s impairments, activity/functional limitations, or participation  III. Diagnostic Process The diagnostic process is a complex sequence of actions and decisions that begins with: (1) the collection of data (examination);(2) the analysis and interpretation of all relevant data collected, leading to the generation of working hypotheses(evaluation); and (3) organization of data, recognition of clustering of data (a pattern of findings), formation of a diagnostic hypothesis. The diagnostic process is also necessary to develop a prognosis (including a plan of care) and is a prerequisite for treatment. Through the diagnostic process a physical therapist classifies dysfunction (most often, movement dysfunction), whereas a physician identifies disease. For the physical therapist, the diagnostic process focuses on the consequences of a disease or health disorder and is a mechanism by which discrepancies and consistencies between a patient’s current level of performance and desired level of function and his or her capacity to achieve that level of function are identified.  IV. Prognosis and Plan of Care After the initial examination has been completed, data have been evaluated, and an impairment-based diagnosis has been established, a prognosis must be determined before initiating any interventions. A prognosis is a prediction of a patient’s optimal level of function expected as the result of a plan for treatment during an episode of care and the anticipated length of time needed to reach specified functional outcomes. Factors that influence a patient’s prognosis and functional outcomes may include: 1 Complexity, severity, acuity, or chronicity and expected course of the patient’s health condition(s) (pathology), impairments, and activity/functional limitations 2. Patient’s general health status and presence of co morbidities (e.g., hypertension, diabetes, obesity) and risk factors 3. The patient’s previous level of functioning or disability 4. The patient’s living environment 5. Patient’s and/or family’s goals 6. Patient’s motivation and adherence and responses to previous interventions 7. Safety issues and concerns 8. Extent of support (physical, emotional, social) Plan of Care: It is an integral component of the prognosis, and delineates the following: 1. Anticipated goals; Setting up short-term and long-term goals, particularly for patients with severe or complex problems, is also a way to help a patient recognize incremental improvement and progress during treatment. 2. Expected functional outcomes that are meaningful, useful, sustainable, and measurable. 3. Extent of improvement predicted and length of time necessary to reach that level. 4. Specific interventions. 5. Proposed frequency and duration of interventions. 6. Specific discharge plan  V. Intervention Intervention, a component of patient management, refers to any purposeful interaction a therapist has that directly relates to a patient’s care. There are three broad areas of intervention that occur during the course of patient management. 1. Coordination, communication, and documentation: This aspect of intervention encompasses many patient related administrative tasks and professional responsibilities, such as writing reports (evaluations, plans of care, discharge summaries); designing home exercise programs; keeping records; contacting other health-care practitioners. 2. Procedural interventions: it pertains to the specific procedures used during treatment, such as therapeutic exercise, functional training, or adjunctive modalities (physical agents and electrotherapy)to reduce or correct impairments. 3. Patient-related instruction: it is the means by which a therapist helps a patient learn how to reduce his or her impairments and functional deficits to get better by becoming an active participant in the rehabilitation process. Patient- related instruction first may focus on providing a patient with background information, such as the interrelationships among the primary health condition (pathology)and the resulting impairments and limitations in activity or explaining the purpose of specific interventions in the plan of care.  VI. Outcomes Simply stated, outcomes are results. Patient-related outcomes are monitored throughout an episode of physical therapy care—that is, intermittently during treatment and at the conclusion of treatment. Evaluation of information generated from periodic re-examination and re-evaluation of a patient’s response to treatment enables a therapist to ascertain if the anticipated goals and expected outcomes in the plan of care are being met and if the interventions that have been implemented are producing the intended results. It may well be that the goals and expected outcomes must be adjusted based on the extent of change or lack of change in a patient’s function as determined by the level of the interim outcomes. This information also helps the therapist decide if, when, and to what extent to modify the goals, expected outcomes, and interventions in the patient’s plan of care.