T3 Therapeutic Exercise: Introduction & Terms PDF

LEARNING OBJECTIVES Introduce importance of therapeutic exercise Understand fundamental terminology in relation to exercise, stretching, strengthening, and phys...

LEARNING OBJECTIVES Introduce importance of therapeutic exercise Understand fundamental terminology in relation to exercise, stretching, strengthening, and physiological adaptations Understand precautions and contraindications for resistance exercise Differentiate between the various types of resistance exercise RESOURCES Kisner, C., & Colby, L. (2012). Therapeutic exercise: INTRODUCTION Foundations and techniques (6th ed.). Philadelphia: F.A. Davis. TO EXERCISE T3 THERAPEUTIC EXERCISE  INTRODUCTION TO THERAPEUTIC EXERCISE Chapter 1, p. 1-3 Therapeutic Exercise is a continuum health procedure designed to improve or restore an individual’s function, or to prevent dysfunction. The following are purposes as to why one would incorporate therapeutic exercise into their lifestyle. 1. REMEDIATING or PREVENTING impairments* 2. ENHANCING function* 3. REDUCING risk of injury/re-injury* 4. OPTIMIZING overall health 5. ENHANCING fitness and well-being STRETCHING Chapter 4 Stretching: is the process of elongation of CONTRACTILE and NON-CONTRACTILE tissues. Effects and benefits of stretching include: ▪ Increasing flexibility and ROM ▪ Allowing the body to move more efficiently ▪ Decreasing the chance of injury ▪ Invigorating the respiratory, circulatory and lymphatic systems T3 Therapeutic Exercise: Intro & Terms | Page 1 of 9 Types of Stretching: PASSIVE STRETCHING: A sustained or intermittent external end range stretch force, applied with overpressure by manual contact. Shortened tissue is elongated by moving a restricted joint just past the available ROM, while the patient is as relaxed as possible. SELF-STRETCH: Any stretching exercise that is carried out independently by a patient after instruction and supervision by a therapist DYNAMIC STRETCH: active movements that take joints and muscles through their ROM. Dynamic stretches can be functional and mimic the movements of the activity or sport you are about to perform. For example a swimmer may circle their arms before getting into the water. They can also be a series of movements to get the body ready for a certain exercise: ie, walking lunches leg swings against the wall. Terminology: ELASTIC DEFORMATION: Spring-like response, recoil; the stretched material recovers its pretensile dimensions after the applied load is removed. PLASTIC DEFORMATION: Putty-like response; the linear deformation produced by the tensile stress remains even after the applied load is removed, resulting in permanent deformation. CREEP: When a load is applied for an extended period of time, the tissue elongates, and does not return to its original length. The amount of deformation depends on the amount of force and the rate at which the force is applied. OVERSTRETCH: A stretch well beyond the normal range of motion of a joint and surrounding soft tissue, placing heavy loads on tendons and ligaments (tendons can rupture at 10% increase in length). This causes micro-tearing and inflammation and can lead to hypermobility and degenerative arthritis. CONTRACTURE: Adaptive shortening of a muscle or other soft tissues that cross a joint; which results in limitation of ROM. Conditions that can produce contractures are prolonged immobilization (cast), restricted mobility (sling), disease (MS), tissue pathology due to trauma (skin grafts, scars), congenital and acquired deformities (scoliosis, torticollis) ACTIVE INHIBITION: Inhibition of a muscle by either its own activity, or that of its antagonist T3 Therapeutic Exercise: Intro & Terms | Page 2 of 9  Indications for Stretching Contraindications for Stretching Box 4.1 Box 4.2 ROM is limited because soft tissues have lost Bony block that limits joint motion extensibility (from adhesions, contractures, scar tissue, Recent fracture etc.) Evidence of acute inflammation or infection (heat and Restricted motion may lead to structure deformities swelling), or soft tissue healing that may be preventable Presence of sharp, acute pain with joint movement or Muscle weakness and shortening of opposing tissue muscle elongation have resulted in limited ROM Hematoma or other indication of tissue trauma Prevent/reduce the risk of musculoskeletal injuries Hypermobility already exists May be used prior to and after exercise to reduce post- When shortened tissue provides necessary joint exercise muscle soreness stability When shortened tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills otherwise not possible RESISTANCE EXERCISE Chapter 6 Resistance Exercise: Any form of active exercise in which a dynamic or static muscular contraction is resisted by an outside force. Terminology: REPETITION (REP): A single rendition/occurrence of an exercise (one work interval). ▪ Ex. Pressing two dumbbells straight above your head and then lowering them back down to your shoulders constitutes one complete repetition of the dumbbell shoulder press. SET: A group of consecutive repetitions (a group of work intervals) without resting. ▪ Ex. When 12 repetitions of the dumbbell shoulder press have been performed, one set has been completed. Resting for 1 minute and repeat 12 more repetitions equals 2 sets performed. RECOVERY/REST INTERVAL: The period of time between sets. This period varies based on the type of exercise being performed. Goals Of Resistance Exercise Increased muscular ENDURANCE: p. 159 ▪ Ability of muscle to perform low-intensity, repetitive, or sustained activities over a prolonged period of time. ▪ It is improved by performing exercise against mild resistance for many repetitions (amount of muscular activity that can be performed without fatigue; tolerance towards moderate levels of work performed for extended periods of time). ▪ Postural muscles, repetitive work activities, long shift workers T3 Therapeutic Exercise: Intro & Terms | Page 3 of 9 Increased muscular STRENGTH: p. 158 ▪ Maximum force that a muscle can produce during a single contraction ▪ A procedure of a muscle or muscle group lifting, lowering, or controlling heavy loads for a relatively low number of repetitions over a short time. (Maximal amount of resistance you can overcome) Increased muscular POWER (most likely not included in rehab plan - increased potential for injury): p. 159 ▪ The rate of performing work; power = work/time ▪ A single burst of high-intensity activity: Work (force x distance) produced by a muscle per unit of time (force x distance/time) TYPES OF RESISTANCE EXERCISES Active Resisted (Manual/Mechanical) Resistance Exercise: The application of an external load/resistance to the muscle’s active contraction. The therapist, the patient, an immovable, or a movable object may apply the external resistance. 1. ISOTONIC EXERCISE (DYNAMIC) p. 180-182: A dynamic form of exercise that is carried out against a constant or variable load as a muscle lengthens OR shortens through the available range of motion → Concentric Exercise Overall shortening of the muscle occurs as it generates tension and contracts against resistance. → Eccentric Exercise Overall lengthening of the muscle occurs as it develops tension and contracts to control motion against the resistance of an outside force; negative work is done. *It creates more force than concentric actions. 2. ISOMETRIC EXERCISE p.179-180 A muscle contraction in which there is no lengthening or shortening of the muscle and therefore no movement around the associated joint. ▪ Used in the initial stages of rehab when joint pain or an immobilizing device (cast) restricts or prevents movement, when weakness exists at a specific point in the ROM, or when the individual is in a low state of training. ▪ Provides a base for dynamic (isotonic) exercise ▪ Isometric strength gains ~5% per week every day over a 6-week period T3 Therapeutic Exercise: Intro & Terms | Page 4 of 9 ▪ Can be used to promote static strength or develop sustained muscular control (endurance) – except for muscle setting ▪ Helps to decrease pain and spasm and maintain neuromuscular pathways until progression to active free can be accomplished (nerve injury, new exercises – neuromuscular learning phase and athletic visualization) TYPES OF ISOMETRIC EXERCISE Muscle-setting Stabilization Multiple Angle* ▪ Not considered a resistance ▪ Develops a submaximal but ▪ Resistance is applied exercise – because no appreciable sustained level of contraction manually or mechanically, at resistance is applied to improve postural stability multiple joint positions within ▪ Low intensity isometric or dynamic stability of a joint the available ROM contractions performed against ▪ Uses midrange isometric ▪ Used to improve strength little or no resistance contractions against throughout the ROM when ▪ Used to decrease muscular pain resistance in weight-bearing joint motion is available but and to promote relaxation and postures dynamic resistance exercise is circulation during acute stage of ▪ Focuses on trunk/postural painful or inadvisable healing control ▪ Does not increase strength except ▪ See Chapter 16 for in very weak muscles application of these exercises ▪ Helps negate muscle atrophy during immobilization, to protect healing tissues 3. ISOKINETIC EXERCISE p.184 Form of active-resistive exercise in which the speed of movement of the limb is controlled by a preset rate- limiting device Open Kinematic Chain Exercise (Proximal Attachment Fixed) p. 188 Movement that occurs with the distal segment of a limb moving freely in space. Examples: Closed Kinematic Chain Exercise (Distal Attachment Fixed/Reverse Action Exercise) p. 188 Movement that occurs with the body moving over the fixed distal segment of a limb. “The terminal segment remains fixed, the encountered resistance moves the proximal segments over the stationary distal segments.” –Steindler Examples: T3 Therapeutic Exercise: Intro & Terms | Page 5 of 9 Parameters p. 171-175 Parameters – training zones; can be determined after 1 Repetition Maximum (1RM) is established Used for isotonic and/or isokinetic exercises With the purpose of achieving strength adaptations: Parameter % of Strength Population Low 30 – 40 % Sedentary, untrained individuals Medium 50 – 70 % Healthy, untrained individuals High 70 – 80 % Trained individuals Very High > 80 % Highly trained individuals **At the beginning of a program lower percentage loads and ranges are used to be safe – and to allow focus and learning of correct exercise form and technique – before progression to higher loads With the purpose of training with significant deficits in muscle strength or establishing training for muscular endurance: Low loads 30%-50%, safe, yet challenging **NB: These parameters will be used for all written tests (and should be applied in realistic situations). Whereas other parameters will be given for use in OPs and applied in the OSCEs T3 Therapeutic Exercise: Intro & Terms | Page 6 of 9  PRECAUTIONS FOR RESISTANCE EXERCISE Although the use of resistance exercise is often the basis of a training program designed to improve a patient’s functional capabilities, the therapist must consider a number of precautions and contraindications before implementing and while executing a resistance exercise program. 1. CARDIOVASCULAR PRECAUTIONS ▪ Avoid the VALSALVA maneuver during resistance exercise. The Valsalva maneuver should be avoided during exercise so that abnormal stress on the CV system and the abdominal wall can be avoided o High-risk patients include: ▪ Patients with a history of CV problems (cerebrovascular accident, myocardial infarction (5 weeks post with clearance), hypertension) ▪ Geriatric patients ▪ History abdominal surgery or herniation of the abdominal wall ▪ How do we prevent our patients from performing the Valsalva maneuver during exercise? o Caution the patient about holding their breath o Have the patient EXHALE when performing the targeted motion o Ask the patient to count, talk or breathe rhythmically during exercise 2. FATIGUE: A complex phenomenon that affects functional performance and must be considered in a therapeutic exercise program. ▪ Local Muscle Fatigue: diminished response of a muscle to a repeated stimulus. Characterized by a reduction in the force-producing capacity of the neuromuscular system. ▪ General Muscular (Total-Body) Fatigue: diminished response of a person during prolonged physical activity such as walking or jogging. AKA Cardiopulmonary Fatigue. ▪ FATIGUE Associated With SPECIFIC PATHOLOGY: in some conditions associated with neuromuscular or cardiopulmonary dysfunction, fatigue may occur more rapidly or at predictable intervals. E.g. in MS, the patient usually reaches a peak of fatigue by early afternoon and can become noticeably weaker. This is significant in the design (parameters and timing) of a patient’s exercise program. 3. RECOVERY FROM EXERCISE ▪ Adequate time for recovery from fatiguing exercise must be built into every resistance-training program in order to maximize improvements in long-term physical performance. ▪ Changes that occur in muscle during recovery: o Lactic Acid is removed from skeletal muscle and blood, around 1 hour post exercise o Oxygen stores are replenished in muscles o Glycogen is replaced within several hours to several days (depending on duration, intensity of exercise, and post-exercise nutrition) ▪ Light exercise performed during recovery period will decrease recovery time from exercise T3 Therapeutic Exercise: Intro & Terms | Page 7 of 9 4. OVERWORK/OVERTRAINING ▪ Progress cautiously to avoid exercising until total fatigue or exhaustion. ▪ Overwork/overtraining can cause TEMPORARY or PERMANENT deterioration of strength as a result of exercise and may occur in normal individuals or in patients with certain neuromuscular conditions. ▪ It is NOT always true that MORE is BETTER. Overwork can be avoided if the intensity, duration and progression of exercise are increased and monitored, closely ▪ Some patients will tend to perform more of the exercises you give them while others will do less. Take this into consideration when setting parameters 5. SUBSTITUTE MOTIONS (Alignment & Stabilization) ▪ Can occur if too much resistance is applied to a contracting muscle during exercise or when a new exercise is progressed too rapidly and good form is lost ▪ When muscles are weak because of fatigue, paralysis or pain, a patient will attempt to carry out the movements that those weak muscles normally perform by any means possible ▪ Ensure that the patient performs the exercise correctly and with good form. Demonstrate the exercise and watch the patient perform the motion. 6. OSTEOPOROSIS ▪ Osteoporotic changes within bone tissue make the bone unable to withstand normal stresses and increases the risk of pathological fractures (even as a result of minor stresses especially in the vertebral bodies, hips, wrists and ribs) ▪ Factors that increase the risk for OP: o Post-menopausal women: the loss of estrogen at menopause leads to accelerated bone loss o Nutritional status (relating particularly to intake of CALCIUM) o Lack of weight-bearing (sedentary life-style, prolonged bed-rest, immobilization, wheel-chair) o Certain medications (especially corticosteroids) can increase rate of bone loss ▪ Modifications to exercise programs for patients with osteoporosis will include: o Emphasis placed on endurance exercise, low intensity strength training, core stabilization and balance exercises. Low impact weight bearing activities should be incorporated. o Explosive, twisting movements should be avoided o Intensity of program is increased very gradually 7. EXERCISE-INDUCED MUSCLE SORENESS A. ACUTE MUSCLE SORENESS ▪ Often develops during or directly after strenuous exercise performed to the point of fatigue and is due to ISCHEMIA (lack of adequate oxygen and temporary build-up of metabolic waste products in the exercised muscle). o Sensation: burning, aching ▪ When adequate blood flow and oxygen is restored to the muscle, the muscle pain experienced during the intense exercise subsides rapidly. An appropriate cool-down period of low-intensity exercise can facilitate the process. T3 Therapeutic Exercise: Intro & Terms | Page 8 of 9  B. DELAYED ONSET MUSCLE SORENESS (DOMS; muscular mechanical hyperalgesia) ▪ After vigorous and unaccustomed exercise or any form of muscular overexertion, muscle tenderness and temporary stiffness may begin at approximately 12 – 24 hours after the completion of the exercise. Gradually the DOMS intensifies and usually peaks 24 – 48 hours after the exercise. DOMS can last up to 7 days in the worst cases. Muscle pain is usually felt in the muscle belly and/or at the musculotendinous junction. ▪ The pain is felt when the muscle is stretched, contracted or put under pressure, not at rest ▪ DOMS is reported more frequently and more intensely with ECCENTRIC exercises (lengthening contractions in which muscle fibres are contracting to control an exercise load with local CT absorbing some of the load) o The underlying mechanism of DOMS has not been determined** o Avoiding DOMS is difficult at the onset of a new exercise program after a period of inactivity. To decrease the severity of DOMS you can try: ▪ Gradually increasing the intensity and duration of the exercise program; ▪ Perform low-intensity warm-up and cool-down exercises ▪ Avoid prolonged static stretching post exercise CONTRAINDICATIONS TO RESISTANCE EXERCISE INFLAMMATION: Dynamic resistance exercises are contraindicated when a muscle or joint is inflamed or swollen. The use of resistance can lead to increased swelling and more damage to the muscle or joints. Low- intensity isometric exercises (muscle setting) can be performed in the presence of inflammation if the activity does not increase pain levels PAIN: If the patient experiences severe joint or muscle pain during exercise or for more than 24 hours after exercise, the activity should be ELIMINATED or SUBSTANTIALLY REDUCED. If reducing the resistance does not eliminate the pain the exercise should be stopped. SEVERE CARDIOPULMONARY DISEASE: Severe cardiac or respiratory disorders associated with acute symptoms are contraindicated for resistance training. Patients with severe coronary artery disease, carditis, cardiac myopathy, congestive heart failure (CHF), or UNCONTROLLED hypertension or dysrythmias should not participate in VIGOROUS physical activities. T3 Therapeutic Exercise: Intro & Terms | Page 9 of 9