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Therapeutic Exercise
The systematic application of exercise and movement
What does therapeutic exercise develop or restore?
Muscular strength, endurance, and flexibility
What does therapeutic exercise improve?
Neuromuscular coordination
What types of therapeutic exercises are used to improve neuromuscular coordination?
Gross and fine motor exercises
What does therapeutic exercise increase?
Cardiovascular efficiency
What type of therapeutic exercise is used to increase cardiovascular efficiency?
Aerobic exercise
What does therapeutic exercise target?
Health and performance factors
2 Goals of Therapeutic Exercise
1. Rehabilitation
2. Habilitation
Is rehabilitation or habilitation, the restoration of function lost due to injury, disease, or behavioral traits?
Rehabilitation
Is rehabilitation or habilitation, the acquisition of age-appropriate skills and functions?
Habilitation
Is habilitation generally used for children or adults?
Children
Rationale for Therapeutic Exercise
Movement is needed
Trauma causes scars that can bind structures together
Inflammation, edema, and immobilization can lead to problems
Why is movement needed?
To maintain joint mobility and tendon gliding
What does immobilization lead to?
Joint stiffness
Restricted tendon gliding
Muscle atrophy
What does trauma cause?
Scars
What can scars bind?
Gliding structures together
What can inflammation and edema lead to?
Fibrosis
Decreased tissue gliding
What does the "stress" of movement enhance?
Normal orientation of collagen fibers to lay in a linear fashion, preventing cross links
What does the "stress" of movement increase?
Tendon and ligament strength
What can the "stress" of movement influence?
Collagen formation to maintain or restore tissue gliding
What can the "stress" of movement restore?
Motion through collagen remodeling
What type of information should clinicians incorporate in their evaluation, subjective or objective?
Objective information
What information needs to be obtained from the evaluation?
Structures that need to be immobilized
Structures that can be moved without restriction
Structures that can be moved only under certain conditions
How soon can a clinician move an affected body part that underwent surgery?
Immediately
How soon can a clinician move an affected body part that was set in a cast via closed reduction?
As soon as the affected body part starts healing (callus)
3 Purposes of Therapeutic Exercise
1. Restore function
2. Maintain mobility
3. Restore motion
What should the clinician anticipate during the evaluation?
What limits may occur
What should the clinician determine during the evaluation?
Reason for limitation and an exercise program to stress the correct structures
When does the clinician determine the correct structures to stress, evaluation or assessment?
Assessment
What can limitation occur as result of?
Pain
Edema
Atrophy
Denervation
Secondary changes in joints and soft tissues
3 Components of Therapeutic Exercise Dosage
1. Intensity/force (active contraction vs. passive stretch)
2. Duration (how long a force should be sustained)
3. Frequency (repetitions per day/sessions per day)
What is therapeutic exercise dosage based on?
What the client can do
What type of motion will the clinician recommend for someone who can move their affected body part halfway, passive, active assisted, or active?
Active assisted motion
What type of motion will the clinician recommend for someone who can not move their affected body part at all, passive, active assisted, or active?
Passive motion
What is a sign to the clinician that they are stretching their client to much?
Blanching (white)
Typically how long should a stretch be held for?
30 seconds
What 2 factors is therapeutic exercise dosage based on?
1. Purpose of exercise
2. Stage of wound healing
What is the course of action during the inflammatory stage of wound healing?
Rest and immobilization
What position can the client rest in during the inflammatory stage of wound healing?
In a balanced position or above the heart
Why is it important to rest an affected body part above the heart?
To minimize swelling and edema
What is the course of action during the fibroplasia stage of wound healing?
Stress to influence collagen
Should a low and gentle or high and hard amount of force be applied to a client in the fibroplasia stage of wound healing?
Low and gentle force
Should a client in the fibroplasia stage of wound healing be given a few repetitions or a lot of repetitions of exercise?
Few
How much pain should be felt during the performance of therapeutic exercises in the fibroplasia stage of wound healing?
None (perform in a pain-free range)
When should the dosage of therapeutic exercise increase in the fibroplasia stage of wound healing?
As tensile strength increases
What can occur during the maturation stage of wound healing?
Stiffness and decreased tendon excursion
Why should therapeutic exercise be used in the maturation stage of wound healing?
To create changes
How can collagen be influenced by therapeutic exercise in the maturation stage of wound healing?
By applying mild or low loads for a long duration, prolonged at the end range of joint motion
What is the purpose of therapeutic exercises in the maturation stage of wound healing?
Stretch tissues
What type of motion should clinicians try and get their clients back to as soon as possible?
Active (or active-assisted)
What can be used in conjunction with therapeutic exercises in the maturation stage of wound healing?
Orthoses
What is a general consideration of therapeutic exercise in the hand?
Restore the muscle balance between the wrist extensors and finger flexors
Treatment Goals of Therapeutic Exercise
Manage pain
Improve posture
Increase motion, endurance, and strength
Restore function
Passive Motion Exercise
Motion produced by an external force such as a therapist or machine
Benefits of Passive Motion Exercise
Maintains joint/soft tissue mobility
Edema control (with elevation and muscle pumping)
Increases circulation and synovial fluid
Pain management (make sure client tells you when it hurts)
Indications of Passive Motion Exercise
Pain with active movement
Weakness
Need to maximize range of motion
Joint replacement
Contracture management
Paralysis
Spasticity
What does passive motion exercise not promote?
Muscle maintenance (passive motion does not prevent atrophy)
What is the only type of exercise someone with a joint replacement can do?
Passive motion exercise
What does pain with passive motion exercises indicate?
Soft tissue injury
Precautions with Passive Motion Exercise (Stretching)
Mobilizing unprotected joints
Stretching wrong joint
Causing additional trauma
Osteoporosis (pressing to hard can cause a fracture)
Edematous tissues (orthosis in a balanced position)
What are edematous tissues more susceptible to?
Injury
Where should the client stabilize when stretching a finger?
Proximal and distal to target a specific joint
Where should the clinician provide a passive stretch, beginning range, mid-range, or end range of motion?
End range of motion to lengthen shortened soft tissues
What type of force should be applied when providing a passive stretch?
A slow, gentle, and sustained force
2 Types of Muscle Fibers
1. Contractile muscle fibers
2. Non-contractile connective tissues
What muscles fibers can a passive stretch elongate?
1. Contractile muscle fibers
2. Non-contractile connective tissues
What do joint contractures require before a passive stretch?
Joint mobilization
What should the clinician determine about the joint contracture before providing a passive stretch?
End feel
What does joint distraction avoid?
Compression during stretch
Should joint compression or distraction be used for someone who experiences pain in the joint due to a soft tissue injury?
Joint distraction
Should joint compression or distraction be used for someone who is hypermobile?
Joint compression
When providing a passive stretch to a finger joint, what should be isolated?
Each individual joint
In what position should the wrist be in when providing a passive stretch to a finger joint?
Neutral
How can a clinician instruct their client to stretch their fingers into abduction?
Slowly lace their fingers together
What should the clinician keep in mind when passively stretching finger joints?
MCP hyperextension (return client back to THEIR normal)
Intrinsic and Extrinsic Tightness Test
Clinician will passively flex the clients PIP joint with the corresponding MCP joint in extension and again with the MCP joint in flexion
Positive Intrinsic Tightness Test
When the PIP joint can not be flexed when the MCP joint is extended
Positive Extrinsic Tightness Test
When the PIP joint can not be flexed when the MCP joint is flexed
Carpometacarpal Joint
Articulation between the distal row of carpals and the base of the 2nd - 5th metacarpals
What 2 CMC joints are immobile?
1. 2nd CMC joint
2. 3rd CMC joint
What does the immobility of the 2nd and 3rd CMC joints allow people to do?
Cup their hand
What 2 CMC joints are mobile?
1. 4th CMC joint
2. 5th CMC joint
How many degrees of flexion are available at the 4th and 5th CMC joints?
10-20°
3 Palmar Arches of the Hand
1. Proximal transverse arch
2. Distal transverse arch
3. Longitudinal arch
What 2 joints form the functional palmar arches in the hand?
1. Carpometacarpal joint
2. Metacarpophalangeal joint
How can a clinician increase their clients palmar arches?
By placing their thumb in the clients palm and fingers on dorsum of hand to roll the metacarpals of the clients hand around the clinicians thumb
What position can a clients hand end up in if the palmar arches are not supported?
Intrinsic minus
What motion does the forearm allow?
Pronation and supination
Passive Stretching of Forearm
Stabilize humerus (avoid internal and external rotation)
Apply force to distal forearm (not wrist or hand)
Stretch with elbow flexed and progress to elbow extended
What may a limit in pronation be caused by?
Biceps brachii tightness
What relaxes muscles to be elongated before stretching?
Active inhibition
Example of Active Inhibition
Contract-relax
Contract-Relax
An isometric contraction of a tight muscle before passive lengthening
Passive Stretching of Intrinsic Muscles of the Hand
Put PIP and DIP joints into flexion
Gently stretch MCP joint into extension
Passive Stretching of Extrinsic Wrist Extensors
Palm down
Flex DIP, PIP, and MCP (fist)
Then slowly flex wrist (felt on dorsal forearm)
Stretch with elbow flexed and progress to elbow extended
What are the extrinsic wrist extensor muscles?
Extensor digitorum
Passive Stretching of Extrinsic Wrist Flexors
Palm up
Extend DIP, PIP, and MCP
Then slowly extend wrist (felt in volar forearm)
Stretch with elbow flexed and progress to elbow extended
What are the extrinsic wrist flexor muscles?
Flexor digitorum superficialis
Flexor digitorum profundus
Active Motion Exercise
Active contraction of muscles
Indications of Active Motion Exercise
Maintain joint mobility
Increase synovial fluid
Pain management
Produce tendon glide
Maintain elasticity/contractility of muscles
Stimulus for bone integrity (weight bearing exercises)
Edema control