Therapeutic exercises

What are the normal limitations to ROM?

• Articular surface contact

• Limit of ligament extensibility

• Limit of tendon and muscle extensibility- Muscle will adapt to ‘normal’ or frequent positions (desk job, HGV drivers)

• Opposition of soft tissue

• Central nervous system/ability to tolerate range/doesn’t feel safe?

What can cause abnormal limitations to ROM?

• Damage to the Articular surface- Trauma/OA

• Presence of intra articular foreign body

• Displacement of intra capsular structures

• Adhesions/Scar tissue

• Muscle Atrophy

• Muscle disruption (tear) or denervation

• Pain

• Oedema

• Neurological Impairment

• Psychological factors

How does movement help to maintain function?

• Maintain range of movement

• Prevent contractures

• Maintain integrity of soft tissue and muscle elasticity

• Increase venous circulation

• Enhance cartilage nutrition through movement of synovial fluid

• Increase kinaesthetic awareness

• Maintain functional patterns 

• Reduce Pain

• Assist healing process

• Active – will aid in strengthening (grade 2 or above)

What are Passive Movements?

Performed within the unrestricted ROM using external force involving no muscle works

What are the 3 types of Passive movements? and describe them.

• Manual - performed by another person

• Auto-relaxed - performed by the patient

• Mechanical relaxed - performed by a machine in an unrestricted range

When would a Physio use Passive movements?

For both Assessment and Treatment

Why do Physios use passive movemnts in assessment?

To assess the ‘non-contractile structures’

What are Physios looking for during a passive movement assessment?

ROM, Pain, End feel

When do physios use passive movement during treatment?

Used when patient is unable to perform full ROM?

What do physios need to remember when taking a patient through passive movement

• Relaxed starting position – patient should be comfortable with no strain on structures supporting joint.

• Patient comfortable and confident in the therapist – eye contact and communication.

• Therapist position should be comfortable and able to completely support the joint and control the movement.

• Therapist hand position should be able to feel the joint, soft tissue and response to movements performed

• No effort/ voluntary contraction required from the patient – muscles are relaxed.

• Movement within maximum available range without causing stretch or pain.

• Perform smoothly, ensuring full support of the joint being moved.

What are the contraindications to Passive Movements?

• Very early fractures where movement could cause  disruption at fracture site.

• Where pain may be beyond a patient’s tolerance

• Muscle/ligament/soft tissue tears where further damage may occur

What is an Active movement?

The movement of a joint within the unrestricted range produced by the muscles that pass over the joint, no assitance or resistance involved

What are physios looking for during an active movement in assessment?

• ROM, pain, quality, willingness

• Quality –  control, muscle action, smoothness

• Willingness – freedom, anxiety, fear

What are physios assing during active movement?

Assess the contractile structures

What is Active-assisted Movement?

Movement is performed by muscles until they reach their limit then assistance from an external force completes the ROM

What is stretching used for?

Stretching can be used to increase flexibility and therefore joint ROM?

What are the 4 recognised types of stretching

• Static – self/therapist

• Dynamic

• Ballistic

• PNF

What is Static stretching?

• Controlled, slow movement

• Maintaining a position for a sustained period

• Widely accepted at least 30 seconds hold to be effective – muscle spindle adapts to new length and increase in length of visco-elastic structures.

• Target muscle needs to be properly isolated

What is Dynamic Stretching?

• Active movement

• Progressively increasing range until the end of range is reached.

• Can be highly effective to mobilise soft tissue and enhance motor control.

What is Ballistic stretching?

• Quick, repetitive, bouncing movements – momentum to gain range.

• Further Injury risk – caution – no longer recommended

• Rehab of high demand activities

• Precede with warm-up and static stretching

What is PNF stretching?

• Proprioceptive- information regarding movement and position of the body

• Neuromuscular- Utilises nerves and muscles

• Facilitation- to make easier

• A stretching technique that has been shown to be effective in increasing ROM and flexibility.

What do muscle spindles detect?

Sensitive to change in muscle length

What do Golgi tendon organs detect?

Sensitive to tension by stretching or muscle contraction. Can inhibit Muscle spindles

What is a stretch reflex?

When a muscle is stretched quickly the muscle spindle fires and causes a reflexive contraction within that muscle that is undergoing the stretch. The greater the speed of stretch, the stronger the reflex contraction in the muscle being stretched.

What is reciprocal Inhibition

Inhibition of the antagonist muscle group is mediated by the muscle spindle. If the agonist muscle contracts, then the spindle fires, sending messages to the spinal cord causing the antagonist muscle to relax.

What is autogenic inhibition?

The GTO fires when tension increases within the tendon. This tension can be due to stretch or contracting muscle. When the GTO fires, a signal is sent to the spinal cord causing the agonist muscle to relax.

Describe the contract-relax method of PNF.

1. Muscle placed in maximally stretched position for 20-30 seconds

2. The resistance is applied to an isotonic muscle contraction of the muscle thats just been stretched or the antagonist (reciprocal relaxation)

3. Following the contraction relax the limb then stretch again

Describe the Hold relax method of PNF

1. Limb is placed in a maximal stretch for 20-30 seconds

2. the stretched muscle should then produce an isometric contraction for 6-10 seconds

3. Let the limb relax then strect it into its new ROM

What can cause reduced strength?

• Trauma

• Disease

• Degeneration

• Disuse – immobilisation, pain inhibition, atrophy

• Ageing

• Disruption to nerve supply

What are the strength training principles?

• Speceficity

• Individualisation

• Progressive overload

• Variation

• Reversibility

What do Physios need to consider when prescribing strengthening exercises?

• Motivation

• Diminishing returns

• Safety

• Equipment

What are the methods of Overload?

• Gravity

• Resistance-clinician/Patient/body weight/equipment/hydrotherapy

• Leverage

• Speed and duration

• Starting lengths/type of muscle work

• Rest periods

• Intensity

List the types of exercise that can be prescribed.

• Active movement

• Isometric

• Isotonic

• Concentric

• Eccentric

• Resisted

• Body-weight

• OKC / CKC

Name some outcome measures that can be used to measure strength.

• Oxford scale

• Functional scales

• VAS

• Subjective tests

• Dynamometers

• Isokinetic - Biodex