Quiz 3: Therapeutic Exercise to Enable Function

Occupations

• Broad and specific daily life events that are personalized and meaningful to the

• To support or address client-identified goals

Activities

• Components of occupations that are objective and separate from the client’s engagement or contexts

• Activities designed to enhance occupational engagement through the development of performance skills and performance patterns

Interventions to Support Occupation

• Methods and tasks to prepare the client for occupational performance

• Used as part of a treatment session in preparation for or concurrently with occupations

• Physical Agent Modalities

• Therapeutic Exercise

• Orthotics, Prosthetics

• Assistive Technology & Environmental modifications

Therapeutic Exercises

Augments purposeful activity. Remediates sensory-motor dysfunction. Interventions include:

• Exercise

• ROM

• Endurance

• Flexibility

EX: using weights to do sets of exercise, going against gravity with finger flexion/squeeze nothing

Therapeutic Activities

Augments occupation. Remediates sensory-motor dysfunction. Interventions include:

• Simulated activities

• Fine motor practice

• Components of activities

EX: reaching up to shelf

Both Therapeutic Exercise & Therapeutic Activity…

1. Develop/restore movement patterns

2. Improve voluntary motor responses

3. Improve coordination

4. Increase muscle power

5. Increase endurance

6. Remediate ROM deficits

7. Increase work tolerance

8. Prevent/eliminate contractures

Therapeutic Exercise is a systematic, planned performance of…?

Physical movements, postures, activities 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

Client Factors (Body Functions): Neuromuscular & Movement-related Functions

Functions of bones & joints = joint mobility & stability

Client Factors (Body Functions): Muscle functions

• Muscle power (strength)

• Tone (flaccidity, spasticity)

• Endurance

Client Factors (Body Functions): Movement functions

• Motor reflexes

• Involuntary movement reactions

• Control of voluntary movement (coordination)

To increase strength, practice exercises that:

• Use activity that makes muscles work harder than usual

• Increase muscle strength, size, power, endurance

• Can involve using body weight or work against resistance

To increase flexibility, practice exercises that:

• Improve ability of joint to maintain movement necessary for carrying out daily tasks & physical activity

• Stretching, yoga, etc.

What are the 3 types of muscle activation?

Concentric (Isotonic) Eccentric | Isometric

Muscle activation: Concentric

• Muscle fibers generate force

• Shortening muscles & creating joint motion

Isotonic means that…

Muscle fibers generate a force & change!

Muscle activation: Eccentric

• Muscle fibers gen. force that changes joint angle

• Muscle’s elongating, lengthening contraction

Muscle activation: Isometric

• Muscle fibers contract, but NO joint motion occurs

• Muscle length remains same

• Easiest to do, least amount of effort

EX: holding a bag down at your waist

Eccentric vs Concentric: Which to Use? = Either!

• Eccentric exercise appears to be superior in helping increase muscle strength & mass

  • may also place muscle at greater risk for injury

• Energy cost of eccentric exercise is less than concentric exercise.

Contraindications of Therapeutic Exercise (but sometimes can do isometric exercise)

• Unstable medical state

• Recent joint surgery

• Tendon or nerve repair

• Inflamed joints

• Some cardiopulmonary diagnoses and/or surgical interventions

How can you incorporate isometric exercise into ADL?

• Weightbearing in any activity

• Holding self steady while dressing, holding leg up to put pants in

• Toileting when squatting

• Raising arm when showering

• Holding bowl in 1 hand while eating, or a cup while drinking from straw

How can you incorporate concentric exercise into ADL?

• Brushing hair and teeth (grooming/hygiene)

• Bring utensils to mouth when eating

• Bathing, showering

How can you incorporate eccentric exercise into ADL?

• Putting brush down after brushing hair

• Serving plate by putting down on counter

Can you use combinations of exercises?

YES, you combine all movements (ex: going upstairs, getting up/sitting down on chair)

Open Chain Exercises

• Distal segment moves in space

• Independent joint movement

• Non-weight bearing position

• Resistance applied to the moving distal segment

• Better at isolating a specific muscle

EX: Biceps curl, raising arm overhead, jumping jacks

Closed Chain Exercises

• Distal surface fixed on stationary support

• Interdependent joint movement

• Movement of body segment distal and/or proximal to the moving joint

• Muscle activation of multiple joint muscles

EX: lunges, squats, pull-up, push up

Manual Resistance Exercise (by therapist)

• Can’t be measured quantitatively

• BUT may be useful in early training

• Resistance limited by therapist strength

Mechanical Resistance

• Use of machines, like in gym

• Can be measured quantitatively & increased progressively

Progressive Resistance Exercise is a dynamic exercise in which…

constant external load is applied to a contracting muscle & incrementally increased

Progressive Resistance Exercises are graded by increasing the…?

Max amount of resistance as strength improves

• repetitions remain same: weight/resistance increases

• high load, low reps

In contrast, training for endurance: low-load, high reps

Progressive Resistance Exercises - Both Effective

1. Oxford Method: progressively lighter (100% max → 75% max → 50% max)

2. DeLorme Method: progressively higher (50% max → 75% max → 100% max)

Daily Adjustable Progressive Resistance Exercise (DAPRE): Set 1

• Reps: 10

• Amount of resistance: 50% 6RM

What does 6RM (repetition maximum) mean?

the heaviest weight lifted 6 times with good form

DAPRE: Set 2

• Reps: 6-8

• Amount of resistance: 75% 6RM

DAPRE: Set 3

• Reps: Max possible

• Amount of resistance: 100% 6RM

DAPRE: Set 4

• Reps: 10

• Amount of resistance: 100% of adjusted working weight

How do you decide a person’s “maximum” weight?

• 6 reps in good form

• If the form breaks down and patient compensates = not good

Types of Therapeutic Exercise

1. Passive

2. Passive stretch

3. Active-assisted

4. Active

5. Active stretch

6. Resistive

7. Progressive Resistive Exercise (PRE)

8. Isometric

MMT Muscle Grade & Type of Exercise: 1/T

E-stim, biofeedback

MMT Muscle Grade & Type of Exercise: 2-/P-

Gravity neutral, active assisted

MMT Muscle Grade & Type of Exercise: 2/P

Gravity neutral, active

MMT Muscle Grade & Type of Exercise: 2+/P+

Gravity neutral, resistive (very minimal)

MMT Muscle Grade & Type of Exercise: 3-/F-

AROM, isometric, active-assisted, vs. gravity

MMT Muscle Grade & Type of Exercise: 3/F

AROM vs. gravity

MMT Muscle Grade & Type of Exercise: 4/G

Against gravity w/ resistance (home program)

MMT Muscle Grade & Type of Exercise: 5/N

You shouldn’t be seeing the patient for strengthening!

Passive ROM

Joint(s) to be exercised are moved through their normal ROM manually by the therapist, the client, or external device

• Muscle grade: Zero (0), Trace (1), Poor (2-)

• Purpose: Maintain ROM, Preventing contracture, adhesion,

  deformity

MMT Muscle Grade & Type of Exercise: 3+/F+

Against gravity w/ resistance

Sometimes, isometric exercises are indicated for…?

Pain, fractures, tendon repair, joint inflammation

Passive Stretch Exercise

Therapist moves joint through the available ROM & holds 30 sec - 1 min, applying gentle but firm force or stretch at the end of range, repeated 2-4x

• Muscle Grade: Zero (0) to Trace (1) or any muscle grade below Normal (5) will benefit, client can be taught passive self-ROM

• Purpose: increase ROM

Active Assisted Exercise (AAROM)

Client moves joint through partial ROM (as far as they are capable), and the therapist or mechanical device completes the rest of the ROM

• Muscle Grade: Trace (1), Poor minus (2-) in gravity minimized, Fair minus (3-) against gravity

• Purpose: Maintain ROM, increase strength

Active Stretch Exercise

Client uses the force of the agonist muscle to increase the length of the antagonist (contracting the agonist and stretching the antagonist to increase flexibility of antagonist)

• Muscle Grade: Good (4) to Normal (5)

• Purpose: increase ROM (same as passive stretch)

Active Exercise (AROM)

Client independently moves the joint through its available ROM against NO outside resistance; with gravity minimized or against gravity (depending on muscle grade).

• Muscle Grade: Poor (2) to Fair (3) or higher muscle grade

• To increase strength, maintain ROM

Resistive Exercise

Client uses concentric and/or eccentric muscle contraction against specific amount of weight to move load through a certain ROM (e.g. holding a weight).

• Muscle Grade: 3+, 4, 5 vs. gravity OR 2+ gravity minimized

• Purpose: Increase strength; can also maintain ROM if client moves thru full avail. range

Isometric Exercise: A muscle or group of muscles is actively contracted and relaxed without producing motion of the joint that is ordinarily moved

2 types

1. Isometric exercise without resistance

2. Isometric exercise w/ resistance

Purpose: increase/maintain strength when joint movement’s contraindicated

What grade muscle would need active assisted (A-A) exercise?

• How would you grade the exercise to make it easier?

• How would you grade the exercise to make it harder?

• Grade: 3- (no resistance, just actively assisting)

• Easier: Decrease full ROM so pt. can do it more on their own

• Harder: Add more ROM, slightly reduce resistance

Passive Exercise Purpose

Maintain ROM, prevent contracture, adhesion, deformity

Passive Stretch + Active Stretch Exercise Purpose

Increase ROM

Active-Assisted Exercise Purpose

Maintain ROM, increase strength

Active (AROM) Exercise Purpose

Increase strength, maintain ROM

Resistive Exercise Purpose

Increase strength, can also maintain ROM

Isometric Exercise Purpose

Increase strength

OTs should NOT alter an occupation so much that it’s not…

being performed typically (ex: choose an occupation that’s inherently repetitive)

How would you teach exercises for the following condition:

Wrist extension strength 3+, pain in joint from arthritis. Goal is to increase strength.

Isometric against slight resistance

Which would be the BEST choice for exercises for the following condition: Wrist extension strength 3+, goal is to increase strength.

Eccentric, against gravity, max weight, 10 rep, through full range (might see some compensation)

How would you teach exercises for the following condition:

Elbow flexion strength is 2, goal is to increase strength

Concentric, active, gravity minimized

How would you teach exercises for the following condition: Triceps strength 3+, goal is to increase strength

Concentric and eccentric, against gravity, progressive resistive exercises with weights

The client has C7 quadriplegia; triceps strength 3+; goal is to increase strength. Select the positions that are appropriate for this goal:

B & C