Therapetic Exercise in Adult neurological populations

Resistance exercise - Muscle performance

-strength, power, and endurance

Resistance exercise - Determinants of resistance

-alignment, stabilization, load (submaximal vs. maximal), volume, periodization, and variation of training, integration of function

Resistance of exercise - mode of exercise

-type of contraction: isometric, concentric, eccentric

-Open chain and closed chain

-Isokinetic

-Manual and mechanical resistance

-constant and variable

Resistance exercise - precaurtions

-avoid valsalva, substitutions, overtraining and overwork, monitor exercise-induced muscle soreness (acute, DOMS), review medical hx

“Beginners” Chart

Individual	Reps	Sets	Load	Effort	Frequency
Beginner (no previous training)	8-12 reps	2-3 sets	65-75% of 1RM	7-8 RPE	1-2x/week (per muscle group)
Intermediate (> 3 months of training)	5-8 reps	3-4 sets	75-85% of 1 RM	8-9 RPE	2-3x/week (per muscle group)
Advanced (>12 months of training)	1-5 reps	4-5 sets	85-100% of 1 RM	9-10 RPE	2-3x/week (per muscle group)

Aerobic exercise includes what?

-Physical activity - bodily movement produced by a skeletal muscle that results in an increase over resting energy expenditure (exercise, physical fitness)

-Endurance (muscular, cardiovascular)

-Training - dependent on exercise of sufficient frequency, intensity and time; produced adaptation (~10-12 wks) based on specificity

FITT acronym

-Frequency

-Intensity

-Time

-Type

Frequency

-No clear cut agreement for optimal frequency; depends on age and health of person

-Generally 3-4x per week (2x per week does not create cardiovascular changes - depending on age or complexity)

-Lower intensity may require greater frequency

Intensity

-Most important component for successful change in aerobic fitness

-Overload principle- the exercise load must be above the regularly encountered stresses to elicit a change. That progression needs to continue as adaptation occurs

How to determine initial intensity

-HRmax and exercise HR

→HRmax- by multistage testing or 220-age (less accurate) (should not be done with pts at risk or with CAD, elderly, this on cardiac meds, or deconditioned)

→Exercise HR - percent of HRmax or Karvonen’s formula (HRreserve/HRR)

→→HR rest + 60-70%(HRmax-HRrest)

→→Borg scale

Intensity parameters for conditioning response

-Generally occurs at 60-90% max HR (50-85% VO2 max)

-70% max HR is min level for healthy person

-40-50% for deconditioned individual

-Individuals at risk - should be determined using stress testing

-Variables - high intensity, short duration appears to lead to greates increase in VO2max (but may lead to increased risk)

ANPT HIGT recommendation

-Recommended target HR range is 70-85% of HR max (HRmax=208-0.7 * age)

Moderate intensity absolute scale and relative scale

-absolute: 3.0-5.9 METs

-Relative: 5 or 6 on a scale of 0-10

Vigorous intensity absolute scale and relative scale

-Absolute: 6.0 or more METs

-Relative: begins at a 7 or 8 on a scale of 0-10

Time (duration)

-Optimal duration is dependent unpon the total work done, intensity, frequency, and fitness level

→generally, the greater the intensity, the shorter the duration needed for adaptation; lower intensity requires longer duration

→20-30 min exercise at 60-70% HRmax

→Lower HRmax needs +45 min exercise

→Higher intensity exercise for 10-15 min

-Three 5-minute periods may be effective for deconditioned patients

Type (mode)

-Involve large muscle groups in rhythmic, aerobic nature

→Must overload the targeted muscles

→Specific to the activity you are working toward

Volume

-Product of frequency, intensity, and time; should be > 500-1000 MET-min/week or 1000kcal per weelP

Progression

-Dependent on individual’s overall health

(think time first→ frequency→intensity)

Reversibility principle

-decreased work capacity can be seen in 2 weeks of not training; improvements can be lost in several months

→ Frequency and duration of activity required to maintain a certain level of aerobic fitness is less than that required to improve it

-Warm up period

-allows time for physiological responses to catch up to activity onset

-Prevents or decreases susceptibility for mask injury or arrhythmias

-begin gradually to increase muscle/core temperature without fatigue

-5-10 min with total body movements such as slow gait, stretching, calisthenics, biking

-HR should be within 20 beats of the target HR

Aerobic exercise period (4 types)

-Continuous training- sub-max throughout

→best for endurance (20-60)

-Interval training - work/recovery ratio ranging from 1:1 to 1:5

→rest relief (passive recovery) - stop moving

→work relief (active recovery)- continued exercise at a reduced level from work period

-Circuit training

→can involve bith large and small muscle groups and a mix of static and dynamic

→Improves strength and endurance (stresses anaerobic and aerobic systems)

-Circuit-interval training - combo of both

Cool down period

-(similar to warm up) 5-10 minutes of total-body movements and static stretching

-Prevents pooling of blood in extremities

-Prevents fainting - increases venous return to the heart

-Enhances recovery periods

-Prevents cardiovascular complications

Key guidelines for adults with chronic health conditions and adults with disability WHO ARE ABLE

-Should do at least 150 minutes (2hr and 30 min) to 300 min (5 hr) a week of moderate intensity, or 75 minutes (1hr 15min) to 150 min (2 hr 30 min) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity

-Should do muscle-strengthening activities of moderate or greater intensity that involve all major muscle groups on 2 or more days a week

Key guidelines for adults with chronic health conditions and adults with disability WHO ARE NOT ABLE

-Should engage in regular physical activity according to their abilities and should avoid inactivity

-Should be under the care of a healthcare provider to knows about the types and amounts of activity appropriate for their abilities and chronic conditions

Move more and sit less, sedentary behavior increases risk of:

-all-cause mortality

-cardiovascular disease mortality

-cardiovascular disease

-Type 2 diabetes

-Colon, endometrial, and lung cancersA

Any activity counts

-No lower threshold for benefits from physical activity

-Most benefits are attained with at least 150-300 minutes of moderate physical activity per week

-Some health benefits are immediate 

Physical Activity and Exercise in people with neurological conditions “Bridging the Gap” objective # 1

-Understand the duration and scope of physical therapy for maximizing recovery and planning for lifelong physical activity and exercise

Objective 1 cont. - During PT episode of care, people with a neurological condition may undergo tx to address the following areas:

-Maximizing recovery of motor function

-Improve ability and independence with functional activities and walking

-Return to previous home and community roles, as well as, return to leisure physical activity participation

-Minimizing risk of future injury/medical problems

-Maximizing health, wellness, and adjustment to changes in abilities

Objective 1 cont. - continuum of PT for pts with neuro conditions

-Prior to discontinuing an episode of PT care, planning fore lifelong physical activity and exercise is needed.

-Planning should start in the initial setting and ensure completion prior to discharge and transition to community fitness and wellness

-During the planning process, it is important to discuss the role of a  long-term relationship with PT

Physical Activity and Exercise in people with neurological conditions “Bridging the Gap” objective # 2

Outline recommendations for a long-term relationship with PT, including reassessments and reasons to reinitiate care

Objective 2 cont. - PT after the initial episode of care is completed:

-It is appropriate for the people with neuro conditions to maintain long-term, intermittent relationships and communication with PTs including:

→1. addtional bouts of care after PT d/c

→2. annual or semi-annual reassessments, and/or

→3. consultation for a 2nd PT opinion

Objective 2 cont. -additional bouts of care after initial PT d/c:

-Based on changes in the person’s abilities in order to:

→address specific problems that arise (pain, shoulder injury), or

→upgrade the person’s functional activities and/or exercise programs

-Discuss a plan for future interactions and follow ups prior to d/c from the initial episode of care, including potential indications or benchmarks for additional bouts of care or reassessments in the future.

Objective 2 cont. - reassessments

-Annual, semi-annual,or as frequently as deemed appropriate or necessary

-People with neuro conditions may follow-up with rehabilitation professionals for reassessment related to their condition. A reassessment with a PT should be indivudalized to each persons needs and may include

→Reassessment to determine progression or decline

→Reassessments to determine need for further PT care

→Modification to functional mobility strategies 

→Equipment assessment and modification

→Review/modification to physical activity and exersie programs

Objective 2 cont. - consultation

-For a second (PT) opinion

-Regarding rehab POC at a facility that specializes in rehab for their neuro condition

-Areas that could be addressed in such a consultation include, but not limited to:

→Appropriateness of current rehab POC in therms of content, duration, and frequency

→Any additional interventions that may be beneficial

→Equipment recommendation

→Prognosis for further recover

→Recommendations related to return to daily life functions such as driving, school, work, family responsibilities, and/or household management

Physical Activity and Exercise in people with neurological conditions “Bridging the Gap” objective # 3

-Describe the reasons for lifelong PT and exercise after PT; this includes continued recovery of physical function as well as maintenance of physical function.

-PTs can help with transition to community-based fitness and wellness programs by helping clients understand the reasons and set goals

→Promote functional independence through continued practice of compensatory and restorative-based interventions

→Promote recovery of function and neurological status

Objective 3 cont. - how to optimize physical and mental heal and wellness throughout the lifespan

-Maintain ROM and strength while considering secondary conditions

-Decrease cardiovascular risk factors. Help improve cholesterol levels, exercise capacity, BP control, and prevent obesity

-Slow decline in bone density. Many neuro pts see BMD decrease, leading to inc risk of fx and osteoperosis

-Promote adequate insuling uptake and release to decrease risk and consequences of DM

-Prevent secondary injury

Objective 3 cont - helping pts social factor

-develop and maintain social support through building community with peers and professionals.

-Improves ones QOL and reduce the reliance or level of physical assistance needed from others

-Maintain mental health and /or reduce the risk of of anxiety and depression

Physical Activity and Exercise in people with neurological conditions “Bridging the Gap” objective # 4

-Provide recommendations for setting and achieving goals, including providing criteria and considerations for evaluating resources and modifying physical plans

Obective 4 cont. - recommendations for setting and achieving “After Initial PT” Goals:

-When setting goals and physical activity plans, it is important for the PT to determine any medical guidelines or limits, including:

→Vital sign targets and limits

→WB precautions

→Appropriate or inappropriate types of exercise

→Responses to medical emergencies such as extreme HTN (autonomic dysreflexia)

-Recommendations related to specific parameters for exercise for persons with various neurological conditions are available

Objective 4 cont. - to optimize goal setting and goal achievement and ultimately establish an action plan for lifelong physical activity and exercise, PTs treating pts with neuro conditions should:

-Know values

-Set SMART goals

-Make an action plan

Objective 4 cont. - Know values

-Clarify what matters most to the individual

-When values and goals match, action and success follow. Ensure that goals match values

Objective 4 cont. - Set SMART goals

-When establishing specific behavioral goals, ensure they align with client values, support their general reasons for being physical active and exercising, and make them SMART

-Specific, Measurable, Achievable, Realistic, and Time-based

Objective 4 cont. Make an action plan; The action plan should match SMART goals and include:

-What the client will do. Be specific

→Address FITT

-When they will do it (time of day, day of week)

-Where they will do it (location)

-How they will monitor what they do, overcome obstacles, and celebrate

Objective 4 cont. - Action Plan example

•Practice walking 5 days per week at home for 5 minutes at a moderate effort, 3 –5/10 on the rate of perceived exertion 0 – 10 scale. 

•Ride an arm  bike  for  aerobic  exercise 3  days  per  week  at  the  gym  for 45 minutes at a moderate to  heavy  effort,  5-8/10  on  the  rate  of perceived exertion 0–10 scale. 

•Log walking and biking in a fitness App or paper calendar or log book 

•Go to PT for a check-up in 6 months to test aerobic exercise capacity, heart rate, blood pressure, and a 6-minute walk test.

Explore what resources are available to the client, revise and finalize the plan considering potential challenges, ways to overcome, and rewards. These considerations may include:

-Using other aerobic training equipment (arm bike, recumbent cross trainer, etc)

-Addressing motivation and engagement (people thrive in different environments and situations)

-Assessing the resources available, including people, facilities, and services. Consider local gyms, YMCA, community programs, etc