Therapeutic Exercise Exam 1

Lectures 0-5 (not updated for exam)

3 components of PT interventions

coordination, communication, documentation'; patient/client instruction; procedural intervention

procedural interventions

therapeutic exercise (preferred more/first) and functional training

therapeutic exercise

systematic performance or execution of planned physical movements, postures, or activities intended to enable the patient to": remediate/prevent impairments, reduce risk, optimize overall health, enhance fitness and well-being

goal of therapeutic exercise

achieve optimal level of sx-free movement during basic to complex physical activities

purpose of exercise

mobility, stability, skill

FITT

frequency, intensity, time, type

clinical decision-making is based on:

sound knowledge, critical thinking, and self reflection

what to consider when prescribing exercises

pt’s functional goals, results of exam, EBP, safety, progression of ex program

ther ex must match what?

tissue capabilities (place desirable stresses on tissues, be aggressive without doing harm, want optimal loading)

selection of intervention/progression is dependent on:

tissue involved, stage of healing, response to exercise, criterion-based vs time-based protocols

criterion-based protocols

if pt can do “x” exercise/activity, they can move onto the next activity

SAID principle

Specific Adaptations to Imposed Demands (tissues need “stress” or “load” as healing in order to be prepared for future function)

Wolff’s law

osseous tissue (bone) will adapt to the loads under which it is placed

Davis’s law

soft tissues (tendons, ligaments, fascia) will heal/adapt according to the manner in which they’re mechanically stressed

length of tendon healing: tendonitis

between 3-7 weeks

length of tendon healing: laceration

between 5wks-6 months

length of muscle healing: exercise induced

0-3 days

length of muscle healing: grade I strain

0-14 day

length of muscle healing: grade II strain

4 days-3 months

length of muscle healing: grade III strain

3weeks-6 months

length of ligament healing: grade I sprain

0-3 days

length of ligament healing: grade II sprain

3weeks-6 months

length of ligament healing: grade III sprain

5 weeks-12 months

length of ligament graft healing

2-24 months

length of bone healing

5 weeks-3 months

length of articular cartilage healing

2-24 months

stages of healing

acute, subacute, chronic

acute stage

inflammatory reaction

subacute stage

repair and healing

chronic stage

maturation and remodeling

clinical signs of acute stage

inflammation; pain before tissue resistance

clinical signs of subacute stage

decreasing inflammation; pain at end range

clinical signs of chronic stage

absence of inflammation; pain after tissue resistance

PT phase acute stage

protection

PT phase subacute stage

controlled-motion

PT phase chronic stage

return to function

signs of overload

pain that does not resolve within 12 hours; pain that’s increased from previous session; increased signs of inflammation; decreased functional ability

if no pain/swelling from previous day’s exercise:

modify 1 variable (amount of weight, # of reps)

if some pain/swelling present but recedes with warm-up:

stay at same level

if pain/swelling present and does not recede with warm-up

decrease exercise level

contracture

fixed high-resistance to passive stretch

adaptive shortening

tissue shortening relative to normal resting length

cycle of adaptive shortening

adaptive shortening → decrease ROM → decrease function → pain and weakness → disuse

causes of decreased ROM

trauma/injury (surgery, mm strain, SCI); pain/edema'; disease (RA, OA, scleroderma); overuse (RC tendinosis, lat epicondylosis); aging; immobilization

CV effects of immobilization

sluggish circulation (DVTs); decreased CO and SV; orthostatic hypotension

integumentary effects of immobilization

pressure ulcer; scars/adhesions

MSK effects of immobilization

atrophy/weakness (within 1 week); more weakness than measured by circumference

more muscle atrophy if:

immobilized in the shortened position

tendon effects of immobilization

decreased load tolerance (disorganization of collagen → decreased tensile strength and elasticity); decreased water content

ligament effects of immobilization

decreased strength/stiffness

cartilage effects of immobilization

decreased loading → softening/degeneration of joint surfaces; changes in synovial fluid

bone effects of immobilization

decreased BMD (especially in the first 6 weeks); increase loss in WB bones; more significant in children and older adults

interventions for impaired mobility

ROM exercises, joint mobs (restores accessory motion), stretching (restores muscle extensibility)

ROM exercises

early in rehab

early controlled motion can:

reduce pain and increase healing time

indications for PROM

paralysis/weakness; healing requirements (when active movement may disrupt the healing process); inability to follow directions; pain; used to demonstrate desired AROM activity

goals of PROM exercises

prevent sequelae of immobilization (maintain/restore joint motion; minimize joint contractures, ST stiffness, and adaptive shortening; maintain mechanical elasticity of ST; enhance vascular dynamics; enhance synovial diffusion); decrease or inhibit pain; maintain proprioception and kinesthesia

limitations of PROM

will NOT: prevent muscle atrophy, increase muscle strength, improve circulation as much as active contractions will

continuous passive motion (CPM)

mechanical device that provides PROM; sometimes used post-op or with disease to minimize effects of immobilization

active assisted ROM (A-AROM)

requires some assistance, pt begins motion and then uses assistance when necessary

indications for A-AROM

weakness (injury, neuromuscular disease); pain; injuries where AROM in the early phase of healing is limited; ensure proper exercise performance

goals of A-AROM

same as PROM and stimulate bone activity/mineralization, enhance circulation, increase motor skills/coordination

AROM exercises

AG or GM (depending on strength); same goals at A-AROM and some increase in strength (if <3 strength)

procedure for ROM

perform examination/evaluation; establish POC for ROM; instruct pt in purpose/technique; position pt properly; move segment through pain-free range TO point of restriction (not beyond)

ROM exercise prescription

frequency: 2-3 times/day

intensity: how far into range

time: 10-20 reps

type: PROM/AROM/A-AROM

position: supine, seated, prone, standing

ROM progression

PROM → A-AROM →AROM; progress from GM to AG; progress from cardinal planes to multi-planar movements/functional movements

precautions/contraindications to ROM exercises

when movement would interfere with healing process (fx, tendon repair); when a medical condition is present that movement would be life-threatening

muscle performance

capacity of muscle to do work (work=force x distance)

power

ability to move weight quickly (has to do with rate)

3 elements of muscle performance

strength, power, and endurance

strength

contractile tissue generates enough force to meet the physical and functional demands placed on the system (ability of contractile tissue to produce tension)

functional strength

the result of the neuromuscular system producing the appropriate amount of force, during functional activities in a smooth and coordinated manner

common adaptation to strength training

an increase in maximum force producing capacity of muscle → result of: neural adaptations and increased muscle fiber size

power

requires strength and speed of movement (work produced/unit of time)

how can power be gained?

by either: increasing the work a muscle must perform during a specified amount of time OR reducing the amount of time required to perform the work (wouldn’t do both at once)

the greater the intensity (force and/or distance) of the exercise and the shorter the time period to generate the force…

the greater the muscle power

muscular endurance

(local endurance) ability of muscle to contract repeatedly against load and resist fatigue over time

cardiopulmonary endurance (total body endurance)

associated with repetitive, dynamic motor activities (such as walking, cycling, swimming that involve large muscle groups)

endurance training

muscles adapt to endurance training by increasing in their oxidative and metabolic capacities (allows a better delivery and use of oxygen)

3 guiding principles

overload, SAID, reversibility

overload principle

load must exceed the metabolic capacity of the muscle to increase muscle strength

clinical implications of overload principle

load must be greater than what muscle is accustomed to; load must change as muscle adapts (increase resistance of strength training, increase time/# of reps of endurance training, decrease time of power training)

clinical implications of SAID principle

consider functional needs/goals; ex should mimic functional activity

reversibility principle

“use it or lose it”; detraining occurs after 1 week

clinical implications of reversibility principle

pt education (early rehab and close to discharge), maintenance programs/lifelong fitness

causes of impairments in muscle performance

injury, disease, immobilization (disuse, inactivity)

resistance exercise (resistance training)

improve strength, power, and muscle endurance; reduce risk of injury; enhance physical performance

benefits of resistance training

increased muscle performance, strength of other STs, bone mineral density (BMD); improved CV status (decreased HTN, hyperlipidemia); weight management; metabolic balance; reduce falls; psychological well-being and improved QOL

resistance training precautions

avoid valsalva (temporarily increases BP and intra-abdominal pressure); watch for substitute motions; exercise-induced muscle soreness (acute, DOMS)

delayed onset muscle soreness (DOMS)

develops 12-24 hours post exercise due to high intensity eccentric contractions (result of muscle trauma)

overtraining

occurs in health individuals

overwork

occurs in pts (post-polio, GB)

overtraining/overworking

deterioration in muscle performance from: progressing weight too quickly, inadequate rest

pathological fx

fx to bone already weakened by disease (osteoporosis)

complete contraindications to resistance training

acute inflammation, pain, inflammatory neuromuscular disease; severe CP disease

risk prevention during resistance exercises

caution pt about breath-holding; ask pt to breath rhythmically, count or talk during exercise; have pt exhale when lifting and inhale when lowering an exercise load; restrict high-risk pts from doing high-intensity resistance ex

contractile (active) components

actin and myosin

elastic (passive) components

in series and parallel

length of both active and passive components:

affect muscle performance

at mid-range

there is the greatest force