Lecture 1 Therapeutic Exercise 1 PDF

Introduction Almost everyone, regardless of age, values the ability to function as independently as possible during everyday life. Health-care consumers (patients and clients) typically seek out or are referred for physical therapy services because of physical impairments associated with movemen...

Introduction Almost everyone, regardless of age, values the ability to function as independently as possible during everyday life. Health-care consumers (patients and clients) typically seek out or are referred for physical therapy services because of physical impairments associated with movement disorders caused by injury, disease, or health-related conditions that interfere with their ability to perform or pursue any number of activities that are necessary or important to them. An individually designed therapeutic exercise program is almost always a fundamental component of the physical therapy services provided. This stands to reason because the ultimate goal of a therapeutic exercise program is the achievement of an optimal level of symptom-free movement during basic to complex physical activities. 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. A therapist must also integrate and apply knowledge of anatomy, physiology, kinesiology, pathology, and the behavioral sciences across the continuum of patient/client management from the initial examination to discharge planning. To develop therapeutic exercise programs that culminate in positive and meaningful functional outcomes for patients, a therapist must understand the relationship between physical function and disability and appreciate how the application of the process of disablement to patient management facilitates the provision of effective and efficient health-care services. Of the many procedures used by physical therapists in the continuum of care of patients and clients, therapeutic exercise takes its place as one of the key elements that lies at the center of programs designed to improve or restore an individual’s function or to prevent dysfunction. Definition of Therapeutic Exercise Therapeutic exercise is the systematic, planned performance of bodily movements, postures, or physical activities intended to provide a patient/client with the means to: Remediate or prevent impairments Improve, restore, or enhance physical function  Prevent or reduce health-related risk factors Optimize overall health status, fitness, or sense of well-being Aspects of Physical Function: The ability to function independently at home, in the workplace, within the community, or during leisure and recreational activities is contingent upon physical as well as psychological and social function. The multidimensional aspects of physical function encompass the diverse yet interrelated areas of performance. 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 fitness. The ability to perform low intensity, repetitive, total body movements (walking, jogging, cycling, swimming) over an extended period of time; a synonymous term is cardiopulmonary endurance. 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. It 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.2 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. 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.  Types of Therapeutic Exercise Intervention 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, functional limitations, or disability. The types of Therapeutic Exercise Interventions: Aerobic conditioning and reconditioning Muscle performance exercises: strength, power, and endurance training Stretching techniques including muscle-lengthening procedures and joint mobilization techniques Neuromuscular control, inhibition, and facilitation techniques and posture awareness training Postural control, body mechanics, and stabilization exercises Balance exercises and agility training Relaxation exercises Breathing exercises and ventilatory muscle training Task-specific functional training Exercise Safety Regardless of the type of therapeutic exercise interventions in a patient’s exercise program, safety is a fundamental consideration in every aspect of the program whether the exercises are performed independently or under a therapist’s supervision. Patient safety, of course, is paramount; nonetheless, the safety of the therapist must also be considered, particularly when the therapist is directly involved in the application of an exercise procedure or a manual therapy technique. DISABLEMENT It has been said that the physical therapy profession is defined by a body of knowledge and clinical applications that are directed toward the elimination or resolution of disability. Understanding the disabling consequences of disease, injury, and abnormalities of development and how the risk of potential disability can be reduced, therefore, must be fundamental to the provision of effective care and services, which are geared to the restoration of meaningful function for patients and their families, significant others, and caregivers.  The Disablement Process Disablement is a term that refers to the impact(s) and functional consequences of acute or chronic conditions, such as disease, injury, and congenital or developmental abnormalities, on specific body systems that compromise basic human performance and an individual’s ability to meet necessary, customary, expected, and desired societal functions and roles. Physical therapists most commonly provide care and services to people with physical disability. Social, emotional, and cognitive disablement can affect physical function and vice versa and, therefore, should not be disregarded or dismissed. The process of disablement can be described through several models that reflects the complex interrelationships among the following. Acute or chronic pathology Impairments Functional limitations Disabilities, handicaps, or societal limitations 1. Pathology/Pathophysiology This first major component of the disablement model refers to disruptions of the body’s homeostasis as the result of acute or chronic diseases, disorders, or conditions characterized by a set of abnormal findings (clusters of signs and symptoms) that are indicative of alterations or interruptions of structure or function of the body primarily identified at the cellular level. Identification and classification of these abnormalities of anatomical, physiological, or psychological structure or process generally trigger medical intervention based on a medical diagnosis. 2. Impairments Impairments are the consequences of pathological conditions; that is, they are the signs and symptoms that reflect abnormalities at the body system, organ, or tissue level. Types of Impairment: Impairments can be categorized as arising from anatomical, physiological, or psychological alterations as well as losses or abnormalities of structure or function of a body system. Physical therapists typically provide care and services to patients with impairments that affect the following systems.  Musculoskeletal Neuromuscular Cardiovascular/pulmonary Integumentary Common Physical Impairments Managed with Therapeutic Exercise Musculoskeletal Pain Muscle weakness/reduced torque production Decreased muscular endurance Limited range of motion due to Restriction of the joint capsule Restriction of periarticular connective tissue Decreased muscle length Joint hypermobility Faulty posture Muscle length/strength imbalances Neuromuscular Pain Impaired balance, postural stability, or control Incoordination, faulty timing Delayed motor development Abnormal tone (hypotonia, hypertonia, dystonia) Ineffective/inefficient functional movement strategies Cardiovascular/Pulmonary Decreased aerobic capacity (cardiopulmonary endurance) Impaired circulation (lymphatic, venous, arterial) Pain with sustained physical activity (intermittent claudication) Integumentary Skin hypomobility (e.g., immobile or adherent scarring)  3. Functional Limitations Functional limitations, the third component of the disablement model, occur at the level of the whole person. They are the result of impairments and are characterized by the reduced ability of a person to perform actions or components of motor skills in an efficient or typically expected manner. For example, restricted range of motion (impairment) of the shoulder as the result of shoulder pain can limit a person’s ability to reach overhead (functional limitation) while performing, for example, personal grooming or household tasks. Types of Functional Limitations Functional limitations in the physical domain deal with the performance of sensorimotor tasks, that is, total body actions that are typically components or elements of functional activities. These activities include basic activities of daily living (ADL), such as bathing, dressing, or feeding, and the more complex tasks known as instrumental activities of daily living (IADL), such as occupational tasks, school-related skills, housekeeping, and recreational activities, or community mobility (driving, using public transportation), just to name a few. Common Functional Limitations Related to Physical Tasks Limitation of: Reaching and grasping Lifting and carrying Pushing and pulling  Bending and stooping Turning and twisting Throwing and catching Rolling Standing Squatting and kneeling Standing up and sitting down Getting in and out of bed Crawling, walking, running Ascending and descending stairs Hopping and jumping Kicking 4. Disability The final category of the disablement continuum is disability. There is a growing body of knowledge suggesting that physical impairments and functional limitations directly contribute to disability. Consequently, an approach to patient management that focuses on restoring or improving function may prevent or reduce disability and may have a positive impact on quality of life. A disability is the inability to perform or participate in activities or tasks related to one’s self, the home, work, recreation, or the community in a manner or to the extent that the individual or the community as a whole (e.g., family, friends, coworkers) perceive as “normal.” This is a broad definition of disability and encompasses individual functioning in the context of the environment that includes basic ADL and more complex daily living skills as well as societal functioning. General Categories of Activities Relevant to Disability Self-care Mobility in the community Occupational tasks School-related tasks Home management (indoor and outdoor) Caring for dependents Recreational and leisure activities Community responsibilities and service PATIENT MANAGEMENT AND CLINICAL DECISION MAKING: An understanding of the disablement process as well as knowledge of the process of making informed clinical decisions based on evidence from the scientific literature are necessary foundations of comprehensive management of patients seeking and receiving physical therapy services. Clinical Decision Making Clinical decision making refers to a dynamic, complex process of reasoning and analytical (critical) thinking that involves making judgments and determinations in the context of patient care. One of the many areas of clinical decision making in which a therapist is involved is the selection, implementation, and modification of therapeutic exercise interventions based on the unique needs of each patient. Evidence-Based Practice Physical therapists who wish to provide high-quality patient care must make informed clinical decisions based on sound clinical reasoning and knowledge of the practice of physical therapy. An understanding and application of the principles of evidence-based practice can guide a clinician through the decision-making process during the course of patient care. Evidence-based practice is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of an individual patient. Evidence-based practice also must involve combining knowledge of evidence from well-designed research studies with the expertise of the clinician and the values, goals, and circumstances of the patient. The process of evidence-based practice involves the following steps: 1. Identify a patient problem and convert it into a specific question. 2. Search the literature and collect clinically relevant, scientific studies that contain evidence related to the question. 3. Critically analyze the pertinent evidence found during the literature search and make reflective judgments about the quality of the research and the applicability of the information to the identified patient problem. 4. Integrate the appraisal of the evidence with clinical expertise and experience and the patient’s unique circumstances and values to make decisions. 5. Incorporate the findings and decisions into patient management. 6. Assess the outcomes of interventions and ask another question if necessary.  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 function 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, functional limitations, and disability 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. As the model indicates, the re-examination and re-evaluation process occurs not only at the conclusion of treatment but throughout each phase of patient management. 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 management to the next occur in an effective, 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. There are three distinct elements of a comprehensive examination. The patient’s health history A relevant systems review Specific tests and measures a. History The history is the mechanism by which a therapist obtains an overview of current and past information (both subjective and objective) about a patient’s present condition(s), general health status (health risk factors and coexisting health problems), and why the patient has sought physical therapy services. b. Systems Review A brief but relevant screening of the body systems, known as a systemic review, is performed during the patient interview as a part of the examination process after organizing and prioritizing data obtained from the health history. The greater the number of health-related risk factors identified during the history, the greater is the importance of the review of systems. The systems typically screened by therapists are the cardiovascular and pulmonary, integumentary, musculoskeletal, and neuromuscular systems, although problems in the gastrointestinal and genitourinary systems may also be relevant. This screening process gives a general overview of a patient’s cognition, communication, and social/emotional responses. c. Specific Tests and Measures Once it is decided that a patient’s problems/conditions are most likely responsive 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 (definitive/diagnostic) tests and measures used by physical therapists provide in- depth information about impairments, functional limitations, and disabilities. Tests are selected and administered to target specific impairments of structures within body systems. Typically, testing involves multiple body systems to identify the scope of a patient’s impairments. Some examples of specific tests and measures that identify musculoskeletal impairments are noted here. They include but are not limited to: Assessment of pain Goniometry Joint mobility, stability, and integrity tests (including ligamentous testing) Tests of muscle performance (manual muscle testing, dynamometry) Posture analysis Gait analysis 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 form opinions by means of a series of sound clinical decisions. Although evaluation is depicted as a distinct entity or phase of the patient management model, some degree of evaluation goes on at every phase of patient management, from examination through outcome. Interpretation of relevant data, one of the more challenging aspects of patient management, is fundamental to the determination of a diagnosis of dysfunction and prognosis of functional outcomes. 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 impairments of body systems and impact on functional abilities A patient’s current, overall level of physical function (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 The decisions made during the evaluation process may also suggest that additional testing by the therapist or another practitioner is necessary before the therapist can determine a patient’s diagnosis and prognosis for positive outcomes from physical therapy interventions. 3. Diagnosis The term diagnosis can be used in two ways; it refers to either a process or a category (label) within a classification system. Both usages of the word are relevant to physical therapy practice. The diagnosis is an essential element of patient management because it directs the physical therapy prognosis (including the plan of care) and interventions. 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, and subsequent classification of data into categories (impairment-based diagnoses). This process is 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 desired level of function and his or her capacity to achieve that level of function are identified. 4. 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, 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 course of treatment and the anticipated length of time needed to reach specified functional outcomes. Some factors that influence a patient’s prognosis and functional outcomes. The plan of care, an integral component of the prognosis, delineates the following. Anticipated goals Expected functional outcomes that are meaningful, utilitarian, sustainable, and measurable Extent of improvement predicted and length of time necessary to reach that level Specific interventions Proposed frequency and duration of interventions Specific discharge plans 5. 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. Coordination, communication, and documentation Procedural interventions Patient-related instruction a. Coordination, Communication, and Documentation The physical therapist is the coordinator of physical therapy care and services and must continually communicate verbally and through written documentation with all individuals involved in the care of a patient. 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 third- party payers, other health care practitioners, or community-based resources, and participating in team conferences. b. Procedural Interventions Procedural intervention pertains to the specific procedures used during treatment, such as therapeutic exercise, functional training, or adjunctive modalities (physical agents and electrotherapy). Procedural interventions are identified in the plan of care. Most procedural interventions used by physical therapists, including the many types of therapeutic exercise, are designed to reduce or correct impairments. Although the intended outcome of therapeutic exercise programs has always been to enhance a patient’s functional capabilities or prevent loss of function, until the past two decades the focus of exercise programs was on the resolution of impairments. Success was measured primarily by the reduction of the identified impairments or improvements in various aspects of physical performance, such as strength, mobility, or balance. It was assumed that if impairments were resolved, improvements in functional abilities would subsequently follow. Physical therapists now recognize that this assumption is not valid. To reduce functional limitations and improve a patient’s health related quality of life, not only should therapeutic exercise interventions be implemented that correct functionally limiting impairments, but whenever possible exercises should be task-specific; that is, they should be performed using movement patterns that closely match a patient’s intended or desired functional activities.  c. Patient-Related Instruction There is no question that physical therapists perceive themselves as patient educators, facilitators of change, and motivators. Patient education spans all three domains of learning: cognitive, affective, and psychomotor domains. Education ideally begins during a patient’s initial contact with a therapist and involves the therapist explaining information, asking pertinent questions, and listening to the patient or a family member. Patient-related instruction, the third aspect of intervention during the patient management process, is the means by which a therapist helps a patient learn how to get better by becoming an active participant in the rehabilitation process. A therapist must use multiple methods to convey information to a patient or family member, such as one-to-one, therapist-directed instruction, videotaped instruction, or written materials. Outcomes Simply stated, outcomes are results. Collection and analysis of outcome data related to health-care services is a necessity, not an option. Measurement of out- comes is a means by which quality, efficacy, and cost-effectiveness of services can be assessed. 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 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, outcomes, and interventions in the patient’s plan of care. There are several broad areas of outcomes commonly assessed by physical therapists during the continuum of patient care: Discharge Planning Planning for discharge begins early in the rehabilitation process. As previously noted, criteria for discharge are identified in a patient’s plan of care. Ongoing assessment of outcomes is the mechanism by which a therapist determines when discharge from care is warranted. A patient is discharged from physical therapy services when the anticipated goals and expected outcomes have been attained. The discharge plan often includes some type of home program, appropriate follow-up, possible referral to community resources, or reinitiation of physical therapy services (an additional episode of care) if the patient’s needs change over time and if additional services are approved. Concepts of Motor Learning: A Foundation of Exercise and Task-Specific Instruction Integration of motor learning principles into exercise instruction optimizes learning an exercise or functional task. An exercise is simply a motor task (a psychomotor skill) that a therapist teaches and a patient is expected to learn. Motor learning is a complex set of internal processes that involves the relatively permanent acquisition and retention of a skilled movement or task through practice. In the motor learning literature a differentiation is made between motor performance and motor learning. Performance involves acquisition of a skill, whereas learning involves both acquisition and retention. It is thought that motor learning probably modifies the way sensory information in the central nervous system is organized and processed and affects how motor actions are produced. Motor learning is not directly observable; therefore, it must be measured by observation and analysis of how an individual performs a skill. Types of Motor Task There are three basic types of motor tasks: discrete, serial, and continuous. a. Discrete task. A discrete task involves a movement with a recognizable beginning and end. Grasping an object, doing a push-up, or locking a wheelchair are examples of discrete motor tasks. Almost all exercises, such as lifting and lowering a weight or performing a self-stretching maneuver, can be categorized as discrete motor tasks. b. Serial task. A serial task is composed of a series of discrete movements that are combined in a particular sequence. For example, to eat with a fork, a person must be able to grasp the fork, hold it in the correct position, pierce or scoop up the food, and lift the fork to the mouth. c. Continuous task. A continuous task involves repetitive, uninterrupted movements that have no distinct beginning and ending. Examples include walking, ascending and descending stairs, and cycling. Variables That Influence Motor Learning During Exercise Instruction and Functional Training Motor learning is influenced by many variables, some of which can be manipulated by a therapist during exercise instruction or functional training to facilitate learning. Some of these variables include pre-practice considerations, practice, and feedback. An understanding of these variables and their impact on motor learning is necessary to develop strategies for successful exercise instruction and functional training. Pre-Practice Considerations A patient’s understanding of the purpose of an exercise or task, as well as interest in the task, affect skill acquisition and retention. The more meaningful a task is to a patient, the more likely it is that learning will occur. Including tasks the patient identified as important during the initial examination promotes a patient’s interest. Attention to the task at hand also affects learning. The ability to focus on the skill to be learned without distracting influences in the environment promotes learning. Demonstration of a task prior to commencing practice also enhances learning. It is often helpful for a patient to observe another person, usually the therapist or possibly another patient, correctly perform the exercise or functional task and then model those actions. Practice Motor learning occurs as the direct result of practice—that is, repeatedly performing a movement or series of movements in a task. Practice is probably the single most important variable in learning a motor skill. The amount, type, and variability of practice directly affect the extent of skill acquisition and retention. In general, the more a patient practices a motor task, the more readily it is learned. In today’s health-care environment, most practice of exercises or functional tasks occurs at home, independent of therapist supervision. A therapist often sets the practice conditions for a home program prior to a patient’s discharge by providing guidelines on how to increase the difficulty of the newly acquired skills during the later stages of learning. Feedback Second only to practice, feedback is considered the next most important variable that influences learning. Feedback is sensory information that is received and processed by the learner during or after performance of a movement or task. There are a number of descriptive terms used to differentiate one type of feedback from another. The terms used to describe feedback are based on the source of feedback (intrinsic or augmented), the timing or frequency of feedback, and the focus of feed- back (knowledge of performance or knowledge of results).