Therapeutic Exercise Lec 1 Chapter 1 Introduction PDF

# Therapeutic exercise (1) course ## Course Details | Credit Hours | Time of final exam | |---|---| | 3hr. 2 hr. Theoretical 1hr. Practical | 2 hr. | ## Total Grades of the Course | Grades | | |---|---| | 10 | Grades ----Course Work | | 10 | Grades ----Midterm | | 30 | Grades ----Final Practical...

# Therapeutic exercise (1) course ## Course Details | Credit Hours | Time of final exam | |---|---| | 3hr. 2 hr. Theoretical 1hr. Practical | 2 hr. | ## Total Grades of the Course | Grades | | |---|---| | 10 | Grades ----Course Work | | 10 | Grades ----Midterm | | 30 | Grades ----Final Practical Exam | | 50 | Grades ----Final Theoretical Exam | ## The table of content of the Note Book | Titles | Page | |---|---| | 1 Introduction of Therapeutic Exercise | 3 | | 2 Range of Motion Exercise: | 22 | | 3 Stretching Exercise: | 49 | | 4 Resistance Exercise for Impaired Muscle Performance | 87 | | 5 Joint Mobilization/Manipulation | 125 | # Lecture (1) - Chapter (1-1) # Introduction of Therapeutic Exercise ## By Dr. Naglaa Gadallah Mohammed Gadallah Lecturer and Consultant of Physical Therapy and Nutrition Faculty of Physical Therapy. Horus University in Egypt ## Objectives - Definition of Therapeutic Exercise - Components of Physical Function Related to Human Movement - Types of Therapeutic Exercise Interventions - Exercise Safety - Types of Impairments - Common Impairments Managed with Therapeutic Exercise - Activity Limitation and Participation Restriction - Risk Factors for Disability - Almost everyone, regardless of age, values the ability to function as independently as possible during activities of everyday life. - Health-care consumers (patients and clients) typically seek out or are referred for physical therapy services because of physical impairments associated with disorders of the movement system caused by injury, disease, or health-related conditions that restrict their ability to participate in any in any number of activities that are necessary or important to them. - Physical therapy services may also be sought by individuals who have no impairments or functional deficits but who wish to improve their overall level of fitness and quality of life or reduce the risk of injury or disease. - An individually designed therapeutic exercise program is almost always a fundamental component of the physical therapy services provided to develop and implement effective exercise interventions. - A therapist must understand how the many forms of exercise affect tissues of the body and body systems and how those exercise-induced effects have an impact on key aspects of physical function as they relate to the human movement system. - A therapist must also integrate and apply knowledge of anatomy, physiology, kinesiology, and pathology, to develop therapeutic exercise programs that culminate in positive and meaningful functional outcomes for patients and clients. ## Definition of Therapeutic Exercise Therapeutic exercise is the systematic, planned performance of physical movements, postures, or activities intended to provide a patient/client with the means to: - Remediate or prevent impairments of body functions and structures. - Improve, restore, or enhance activities and participation. - Prevent or reduce health-related risk factors. - Optimize overall health, fitness, or sense of well-being. Therapeutic exercise programs designed by physical therapists are individualized to the unique needs of each patient or client. - A patient is an individual with impairments and functional deficits diagnosed by a physical therapist and is receiving physical therapy care to improve function and prevent disability. - A client is an individual without diagnosed movement dysfunction who engages in physical therapy services to promote health and wellness and to prevent dysfunction - all individuals receiving physical therapy services must be active participants rather than passive recipients in the rehabilitation process to learn how to self-manage their health needs. ## Components of Physical Function Related to Human Movement: - The ability of the subject to function depends on some elements - These elements of function are characterized by the following definitions **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. **Cardiopulmonary Endurance:** The ability to perform moderate-intensity, repetitive, total body movements (walking, jogging, cycling, swimming, etc.) over an extended period of time. - A synonymous term is Cardiopulmonary Fitness. **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. **Flexibility:** The ability to move freely, without restriction; - used interchangeably with mobility. **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 noncontractile) extensibility; - in addition, **active mobility** requires neuromuscular activation **Muscle performance:** The capacity of muscle to produce tension and do physical work. - Muscle performance encompasses strength, power, and muscular endurance. **Neuromuscular control:** Interaction of the sensory and motor systems that enables synergists, agonists, and antagonists, as well as stabilizers and neutralizers, to anticipate or respond to proprioceptive and kinesthetic information - and, subsequently, to work in correct sequence to create coordinated movement. **Postural control, postural stability, and equilibrium:** Used interchangeably with static or dynamic balance. - **Stability** is the ability of the neuromuscular system through synergistic muscle actions to hold a proximal or distal body segment in a stationary position or to control a stable base during superimposed movement. - **Joint stability** is the maintenance of proper alignment of bony partners of a joint by means of passive and dynamic components. **Physical Stresses (stress = force / area)** - **Gravity**, is a constant force that affects the musculoskeletal, neuromuscular, and circulatory systems. - **Additional forces**, incurred during routine physical activities, help the body maintain a functional level of strength, cardiopulmonary fitness, and mobility. - Imposed forces and physical stresses that are excessive can cause acute injuries, such as sprains and fractures, or chronic conditions, such as repetitive stress disorders. - The absence of typical forces on the body also can cause degeneration, degradation, or deformity. - For example, the absence of normal weight bearing associated with prolonged bed rest or immobilization weakens muscle and bone. - Prolonged inactivity also leads to decreased efficiency of the circulatory and pulmonary systems. - Therapeutic exercise interventions involve the application of carefully graded physical stresses and forces that are imposed on the human movement system, specific tissues, or individual structures in a controlled, progressive, safely executed manner to enhance movement and improve the human experience. ## Therapeutic Exercise Interventions - Therapeutic exercise embodies a wide variety of activities, movements, and techniques. - The individualized therapeutic exercise program is based on a therapist's determination of: - the underlying risk or cause of impairments in body function or structure, - activity limitations, - or participation restrictions as identified in the patient examination. ## Types of Therapeutic Exercise Interventions 1. Aerobic exercises 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, body mechanics, and stabilization exercises 6. Balance exercises and agility training 7. Relaxation exercises 8. Breathing exercises and ventilatory muscle training 9. Task-specific functional training ## Exercise Safety Regardless of the type of therapeutic exercise intervention, safety is a fundamental consideration whether the exercises are performed independently or under a therapist's direct supervision and the safety of the therapist also must be considered. - Many factors can influence a patient's safety during exercise. - Prior to engaging in exercise, a patient's health history and current health status must be explored. - Medications can adversely affect a patient's balance and coordination during exercise or cardiopulmonary response to exercise. - Therefore, risk factors must be identified and weighed carefully before an exercise program is initiated. - Medical clearance from a patient's physician may be indicated before beginning an exercise program. - The environment in which exercises are performed also affects patient safety. - Adequate space and a proper support surface for exercise are necessary prerequisites for patient safety. - If exercise equipment is used in the clinical setting or at home, to ensure patient safety the equipment must be well maintained and in good working condition, must fit the patient, and must be applied and used properly. - Specific to each exercise in a program, the accuracy with which a patient performs an exercise affects safety, including proper posture or alignment of the body, execution of the correct movement patterns, and performance of each exercise with the appropriate intensity, speed, and duration. - A patient must be informed of the signs of fatigue, the relationship of fatigue to the risk of injury, and the importance of rest for recovery during and after an exercise routine. ## Health Conditions, Body Functions and Body Structures - **Health conditions** are: - acute or chronic diseases, disorders, or injuries - or circumstances such as aging, pregnancy, - or stress that have an impact on a person's level of function and it is the basis of a medical diagnosis - **Body functions** are the physiological functions of the body. - **Body structures** describe the anatomical parts of the body. - These domains of classification occur at the cellular, tissue, or body system level. ## Types of Impairments - **Definition of impairment** : Impairments are defined by the loss of integrity of the physiological, anatomical, and/or psychological functions and structures of the body and are a partial reflection of a person's health status. - Some impairments of body structure are readily apparent during a physical therapy examination through : - visual inspection. Such impairments include joint swelling, scarring, presence of an open wound, lymphedema or amputation of a limb, - or through palpation, such as adhesions, muscle spasm, and joint crepitus. - Other structural impairments must be identified by a variety of imaging techniques, such as radiographic imaging to identify joint space narrowing associated with arthritis or magnetic resonance imaging (MRI) to identify a torn muscle or ligament. - **Impairments of body function** such as pain, reduced sensation, decreased ROM, deficits in muscle performance (strength, power, and endurance), impaired balance or coordination, abnormal reflexes, and reduced ventilation are those most commonly identified by physical therapists and managed with therapeutic exercise interventions. ## Common Body Function Impairments Managed with Therapeutic Exercise ### Musculoskeletal Impairments 1. Pain 2. Muscle weakness/reduced torque production 3. Decreased muscular endurance 4. Limited range of motion due to: - Restriction of the joint capsule - Restriction of periarticular connective tissue - Decreased muscle length - Joint hypermobility 5. Faulty posture 6. Muscle length/strength imbalances ### Neuromuscular Impairments 1. Pain 2. Impaired balance, postural stability, or control 3. Incoordination, faulty timing 4. Delayed motor development 5. Abnormal tone (hypotonia, hypertonia, and dystonia) 6. Ineffective / inefficient functional movement strategies ### Cardiovascular / Pulmonary Impairments 1. Decreased aerobic capacity (cardiopulmonary endurance) 2. Impaired circulation (lymphatic, venous, and arterial) 3. Pain with sustained physical activity (intermittent claudication) ### Integumentary Impairments 1. Skin hypomobility (e.g., immobile or adherent scarring) ## Activity Limitation and Participation Restriction **Common Tasks Related to Activity Limitations Difficulties with or limitation of:** 1. Reaching and grasping 2. Lifting, lowering, and carrying 3. Pushing and pulling 4. Bending and stooping 5. Turning and twisting 6. Throwing and catching 7. Rolling 8. Sitting or standing tolerance 9. Squatting (crouching) and kneeling 10. Standing up and sitting down (from and to a chair, the floor) 11. Getting in and out of bed 12. Moving around (crawling, walking, and running) in various environments 13. Ascending and descending stairs 14. Hopping and jumping 15. Kicking or swinging an object This analysis helps the therapist determine why a patient is unable to perform specific daily living tasks ## Categories of prevention: Prevention falls into three categories. 1. **Primary prevention:** Activities such as health promotion designed to prevent disease in an at-risk population. 2. **Secondary prevention:** **Early diagnosis** and reduction of the severity or duration of existing disease and sequelae. 3. **Tertiary prevention:** Use of rehabilitation to reduce the degree or limit the progression of existing disability and improve multiple aspects of function in persons with chronic, irreversible health conditions. - Therapeutic exercise, the most frequently implemented physical therapy intervention, has value at all three levels of prevention. - The use of resistance exercises and aerobic conditioning exercises in weight-bearing postures is often advocated for the primary and secondary prevention of age-related osteoporosis. - In addition, therapists who work with patients with chronic musculoskeletal or neuromuscular diseases or disorders routinely are involved with tertiary prevention of disability. ## Risk Factors - Risk factors are influences or characteristics that predispose a person to impaired functioning and potential disability. - Modifying risk factors through an intervention, such as therapeutic exercise, is an important tool for preventing or reducing the impact of health conditions and subsequent impairments, activity limitations, and participation restrictions associated with disability. - A sedentary lifestyle, obesity, and smoking, has been widely disseminated by the public health initiatives. - Although the benefits of a healthy lifestyle, which includes regular exercise and physical activity, are well founded and widely documented ## Risk Factors for Disability ### Biological Factors 1. Age, sex, and race 2. Height/weight relationship 3. Congenital abnormalities or disorders (e.g., skeletal deformities, neuromuscular disorders, cardiopulmonary diseases, or anomalies) 4. Family history of disease; genetic predisposition ### Behavioral/ Psychological/ Lifestyle Factors 1. Sedentary lifestyle 2. Cultural biases 3. Use of tobacco, alcohol, and/or other drugs 4. Poor nutrition 5. Low level of motivation 6. Inadequate coping skills 7. Difficulty dealing with change or stress 8. Negative affect ### Socioeconomic Factors 1. Low economic status 2. Low level of education 3. Inadequate access to health care 4. Limited family or social support This knowledge establishes a foundation for sound clinical decision-making and effective communication and sets the stage for delivery of effective, efficient, meaningful physical therapy care and services for patients ## A Patient Management Model - The physical therapy profession has developed a comprehensive approach to patient management designed to guide a practitioner through a systematic series of steps and decisions for the purpose of helping a patient achieve the highest level of functioning possible. - This model is illustrated in next Figure. As described in the Guide to Physical Therapist Practice ## The process of patient management has the following elements: 1. **Examination:** A comprehensive examination including successive re-examination as indicated. 2. **Evaluation:** Evaluation of data collected. 3. **Diagnosis:** Determination of a diagnosis based on impairments of body structure and function, activity limitations, and participation restrictions that result in movement dysfunction and/or are amenable to physical therapy intervention. 4. **Prognosis and Plan of Care:** Establishment of a prognosis and plan of care based on patient-oriented goals. 5. **Intervention:** Implementation of appropriate intervention. 6. **Outcomes:** Analysis and communication of outcomes resulting from interventions. - The ability to make timely decisions and appropriate judgments and to develop or adjust an ongoing series of working hypotheses makes transition from one phase of patient management to the next occur in an effective and efficient manner. ## 1-Examination - the first component of the patient management model is a comprehensive examination of the patient. - Examination is the systematic process by which a therapist obtains information about a patient's problem(s) and his or her reasons for seeking physical therapy services. - The examination process involves both comprehensive screening and specific diagnostic testing. to determine whether patient problems can be appropriately treated by physical therapy interventions. - If treatment of the identified problems does not fall within the scope of physical therapy practice, referral to another health-care practitioner or resource is warranted. ## Comprehensive examination includes: 1- The patient's health (medical) history 2- Physical examination: - observation, - Specific tests and measures. ## Health History: The Health history defined as a structured assessment conducted to generate a comprehensive picture of a patient's health and health problems. ## Sources of information about the patient's history include: A. Self-report health history questionnaires filled out prior to or during the initial visit. B. Interviews with the patient, family, or other significant individuals involved in patient care. C. Review of the medical record. A. Reports from the referral source, consultants, or other health-care team members. ## 1- Information Generated from the Initial History ### 1- Demographic Data - Age, sex, race, and ethnicity - Primary language - Education ### 2- Occupation/Leisure - Current and previous employment - Job/school-related activities - Recreational and community activities/tasks ### 3- Growth and Development - Developmental history - Hand and foot dominance ### 4 Living Environment - Current living environment - Expected destination after discharge ### 5- General Health Status and Lifestyle Habits and Behaviors: Past/Present (Based on Self or Family Report) - Perception of health/disability - Lifestyle health risks (smoking and/or substance abuse) - Diet, exercise, and sleep habits ### 6- Medical/Surgical / Psychological History - Previous inpatient or outpatient services ### 7- Medications - Over-the-counter and prescription Medications - Frequency and dosage of Medications ### 8- Family History: Current and Past - Health risk factors - Family illnesses ### 9- Cognitive / Social / Emotional Status - Orientation and 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 and goals - History, onset (date and course), mechanism of injury, and pattern and behavior of symptoms - Current or past therapeutic interventions ### 11- Functional Status and Activity Level - Current/prior functional status: basic activity of daily living (ADL) and instrumental activity of daily living (IADL) related to self-care and home - Current/prior functional status in work, school, and community-related IADL ## 2- Specific Tests and Measures - Once it has been decided that a patient's problems/conditions are most likely amenable to physical therapy intervention, the next determination a therapist must make during the examination process is to decide which aspects of physical function require further investigation through the use of specific tests and measures. - Specific tests and measures used by physical therapists provide in-depth information about body function and structure impairments, activity limitations, and participation restrictions. - These tests also give the therapist a clearer picture of a patient's current condition(s) and may reveal information about the patient not previously identified during the history ## Some examples of specific tests and measures that identify musculoskeletal and neuromuscular impairments include: 1. Observation (Postural evaluations). 2. Palpation of the soft tissues. 3. Assessment of pain 4. Vascular assessment. 5. Goniometry (range of motion assessment) and flexibility testing 6. Joint mobility, stability, and integrity tests (including ligamentous testing) 7. Tests of muscle performance (manual muscle testing, Functional Muscle group test and Special tests) 8. Assessment of balance, proprioception, and neuromuscular control 9. Gait analysis 10. Assessment of assistive, adaptive, or orthotic devices ## 2-Evaluation - Evaluation is a process characterized by the interpretation of collected data. - The process involves analysis and integration of information to establish the diagnosis, prognosis, and plan of care using a series of sound clinical decisions ## By pulling together and sorting out subjective and objective data from the examination, a therapist should be able to determine the following: - A patient's general health status and its impact on current and potential function. - The acuity or chronicity and severity of the current condition(s). - The extent of structural and functional impairments of body systems and impact on functional abilities. - Which impairments are related to which activity limitations. - A patient's current, overall level of physical functioning (limitations and abilities) compared with the functional abilities needed, expected, or desired by the patient. - The impact of physical dysfunction on social/emotional function. - The impact of the physical environment on a patient's function. - A patient's social support systems and their impact on current, desired, and potential function. ## 3-Diagnosis - Determination of impairments of body structure and function, activity limitations, and participation restrictions that result in movement dysfunction and/or are amenable to physical therapy intervention. ## 4-Prognosis and Plan of Care - After the initial examination has been completed, data have been evaluated, and a diagnosis has been established, a prognosis including a plan of care, 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 ## Plan of Care should include the following components: A. Patient goals that are functionally driven and time limited. B. Expected functional outcomes that are meaningful, sustainable, and measurable. C. Extent of improvement predicted and length of time necessary to reach that level from Specific interventions. D. Proposed frequency and duration of interventions. E. Specific discharge plans. ## 5-Intervention - Intervention is purposeful interaction of the therapist with the patient - The therapist selects, prescribes, and implements interventions based on the examination, evaluation, diagnosis, prognosis, and goals established for the patient. - Interventions are updated, progressed, or discontinued based on patient response, achievement of goals, or results of outcomes. ## 6- Outcomes - Collection and analysis of outcome data related to health-care services are necessary, not optional - 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 are producing the intended results ## - Summary - Definition of Therapeutic Exercise - Components of Physical Function Related to Human Movement - Types of Therapeutic Exercise Interventions - Exercise Safety - Types of Impairments - Common Impairments Managed with Therapeutic Exercise - Activity Limitation and Participation Restriction - Risk Factors for Disability