Therapeutic Exercise: ROM, PNF, Strength, Balance & Aerobic Training

What is therapeutic exercise?

Systematic performance of planned physical movements, postures, or activities intended to remediate/prevent impairments, enhance function, reduce risk, optimize health, and enhance fitness and well-being.

What are the five characteristics of therapeutic exercise?

Client-centered, goal-oriented, meaningful, purposeful, evidence-based.

When should an OT consider therapeutic exercise?

When decreased ROM, flexibility, strength, or endurance directly impacts function.

Name five examples of therapeutic exercise.

Agility, balance, body mechanics, breathing, coordination, gait, neuromuscular re-education, postural stabilization, ROM/stretching, relaxation, strength/power/endurance.

What is ROM?

Movement performed by the patient with or without external assistance.

What is AROM?

Movement performed through the patient's voluntary effort without external aid.

What is AAROM?

Movement performed by the patient's voluntary effort along with assistance from an external force.

What is PROM?

Movement performed by external efforts only.

Give three examples of external assistance for AAROM.

Another body part, another person, or a device such as a cane or pulley.

What is the purpose of ROM exercise?

To maintain or improve current joint movement.

Name three benefits of ROM exercise.

Maintain joint mobility, provide nutrition to a joint, prevent tissue adhesion and contracture.

Name four benefits of AROM/AAROM.

Increase circulation, prevent clot formation from venous stasis, increase proprioceptive input, maintain contractility, slow atrophy, improve coordination/motor control.

What are indications for stretching?

Limited ROM, risk of bony deformity/decreased ADLs, goals to regain normal ROM, prevent contractures, or increase flexibility.

Name three contraindications to stretching.

Bony block limiting ROM; recent fracture or surgery; acute inflammation or infection; sharp acute pain; hematoma; functional contracture.

What is an important precaution before stretching?

Know the patient's normal ROM.

What may pain/soreness lasting more than 24 hours indicate?

The stretch may have been too aggressive.

Define muscle flexibility.

The ability of a muscle to lengthen.

What are the two methods of stretching?

Manual and mechanical.

What is manual stretching?

Clinician provides external force and controls direction, speed, intensity, and duration.

What is mechanical stretching?

Long-duration stretch (20 minutes or more) applied through patient positioning.

What is static stretching?

Slowly elongating a muscle to tolerance and holding it at the greatest tolerated length.

What should a static stretch feel like?

Comfortable stretch with mild tension; short of pain.

How long is a static stretch held for someone younger than 65?

30 seconds, then rest; repeat 4-5 times daily.

How long is a static stretch held for someone older than 65?

60 seconds, then rest; repeat 4-5 times daily.

What is ballistic stretching?

Repetitive bouncing or jerking movement to stretch a muscle.

Why is ballistic stretching discouraged?

Uncontrolled jerking can increase injury risk.

What is dynamic stretching?

Stretching that uses movement/momentum to encourage full ROM.

Which population is dynamic stretching associated with?

Athletes.

Which populations is static stretching best for?

Geriatric and non-athlete populations.

What does PNF stand for?

Proprioceptive neuromuscular facilitation.

What can PNF be used to improve?

Muscle strength and flexibility.

What characterizes PNF movement patterns?

Spiral and diagonal mass movement patterns resembling ADLs, sports, and work.

Name four ways PNF patterns can be performed.

Passive, active-assisted, active, resisted, functionally, or with multiple muscles at once.

What are the four upper-extremity PNF diagonals?

D1 flexion, D1 extension, D2 flexion, D2 extension.

What is UE D1 flexion?

Flexion, adduction, external rotation.

What is UE D1 extension?

Extension, abduction, internal rotation.

What is UE D2 flexion?

Flexion, abduction, external rotation.

What is UE D2 extension?

Extension, adduction, internal rotation.

What is LE D1 flexion?

Flexion, adduction, external rotation.

What is LE D1 extension?

Extension, abduction, internal rotation.

What is LE D2 flexion?

Flexion, abduction, internal rotation.

What is LE D2 extension?

Extension, adduction, external rotation.

Describe autogenic inhibition (hold-relax).

Passively stretch to end range; patient isometrically contracts target muscle against resistance for 15 sec; relax while clinician moves to new end range and holds 30 sec; repeat 3-5 times.

Autogenic inhibition is associated with relaxation of what?

Golgi tendon organ (GTO) mechanism.

Describe reciprocal inhibition.

Passively stretch target muscle; patient concentrically contracts opposite/agonist muscle; take up slack; relax while clinician holds new ROM 30 sec; repeat 3-5 times.

What muscle contracts during reciprocal inhibition?

The opposite/agonist muscle.

Describe combination PNF stretching.

Passively stretch; target muscle isometrically contracts 10 sec; opposite muscle concentrically contracts while slack is taken up; relax 30 sec; repeat 3-5 times.

Define muscle strength.

Maximum force a muscle or muscle group can exert during a contraction.

Define muscular endurance.

Ability to sustain contractions repeatedly or over a period of time.

What are the six exercise prescription variables?

Dosage, mode, repetitions, sets, duration, frequency.

How can dosage be increased?

Increase intensity, resistance, sets/repetitions, or frequency; decrease rest intervals.

What is mode?

Method of exercise, such as free weights or TheraBand.

What are repetitions?

Number of times an exercise is repeated consistently.

What makes up one set?

A specified number of repetitions.

Define a set.

Consecutive repetitions followed by rest or a different exercise.

How many sets does the lecture generally suggest?

About 2-3 sets of each exercise.

Define duration in an exercise prescription.

Number of sets/reps and rest between sets; overall length of workout.

Define frequency.

How often exercises are performed.

What rest interval range does the lecture give?

1-3 minutes, depending on program purpose and patient need.

What is overload?

Increasing training load enough to challenge current fitness and produce adaptation.

What is an example of adaptation to overload?

Increased muscle strength.

What is overloading?

Training load exceeds the individual's ability to adapt/recover.

What can overloading cause?

Fatigue, inadequate recovery, substitution patterns, injury, and reduced performance.

Define specificity.

Training effect is determined by the nature of the training load; exercise should match the individual's goal/activity.

What is cross-training?

Training in another exercise mode to potentially improve performance in a different mode.

Why is specific training usually more effective than cross-training?

Transfer effects from cross-training are usually not as great as those from specific training.

What is overtraining?

Insufficient recovery time after chronic bouts of training.

What is the Valsalva maneuver?

Holding one's breath during exertion.

What does the lecture recommend regarding Valsalva?

Avoid it; encourage proper breathing during all exercise.

What is DOMS?

Delayed onset muscle soreness.

When does DOMS typically develop?

24-48 hours after exercise.

How is DOMS described?

Dull, diffuse pain, stiffness, tenderness to direct pressure, possible ROM loss and decreased force production.

How long does DOMS usually resolve within, according to the lecture?

Within about a week; most within 72 hours.

What is an isometric contraction?

Muscle creates tension without changing length.

What is a concentric contraction?

Muscle shortens while contracting.

What is an eccentric contraction?

Muscle lengthens while contracting.

What is an isotonic contraction?

Contraction during dynamic change in muscle length.

What is an isokinetic contraction?

Muscle contracts against constant resistance while muscle tension varies through ROM.

When are isometric exercises often used in rehab?

Early stage after acute injury or surgery, often at sub-maximal intensity.

What is an open kinetic chain exercise?

Distal segment is not fixed and can move freely.

What is a closed kinetic chain exercise?

Distal segment is fixed and force is transmitted through the foot or hand.

Give an example of a functional movement combining OKC and CKC.

Walking.

Name two benefits of closed-chain exercise.

Weight-bearing; improved joint proprioception/dynamic stability; muscular co-contraction; may help reduce pain.

Define balance.

Control of the body's center of gravity over the base of support or within limits of stability.

What is static balance?

Maintaining a stable antigravity position while at rest.

What is dynamic balance?

Maintaining a stable antigravity position while moving.

Define base of support (BOS).

Area defined by body parts and assistive devices in contact with the supporting surface.

Define center of gravity (COG).

Point where the mass of an object is equally balanced.

What are limits of stability?

Boundaries within which COG must remain without changing BOS.

What three systems contribute to balance?

Proprioceptive/somatosensory, visual, and vestibular.

Name three balance assessments from the lecture.

Romberg, Berg Balance Scale, Tinetti; also TUG.

What does TUG stand for?

Timed Up & Go.

Describe the TUG test.

Stand, walk 3 meters, turn, return, and sit.

According to the lecture, what TUG time may indicate limited mobility?

Over 10 seconds; over 30 seconds indicates limited mobility and assistance may be required.

What is the ankle strategy used for?

Small disturbances or slow perturbations.

When is the hip strategy used?

When disturbance is too great to be counteracted by ankle strategy.

When is the stepping strategy used?

When a sudden, large force displaces COG beyond limits of stability; stepping enlarges BOS.

Name signs of poor aerobic exercise tolerance.

Chest/arm/jaw/back/neck pain or pressure; severe shortness of breath; abnormal sweating; pallor/cyanosis/cold clammy skin; vertigo/ataxia/gait problems/confusion; leg cramps/claudication; severe fatigue.

What aerobic exercise benefits are listed in the lecture?

Improved work/sport performance, blood lipid profile, immune function, glucose tolerance, body composition, well-being; reduced risk of CAD, HTN, type II diabetes, osteoporosis, anxiety/depression and certain cancers.

What duration does the lecture recommend for aerobic exercise?

20-60 minutes, including at least 5-minute warm-up and cool-down; for OT, less than half in most circumstances.