Prescribing Therapeutic Exercise Notes

Prescribing Therapeutic Exercise

  • This topic was recently added to the course to ensure students have a solid understanding before their wellness and health promotion lab.
  • It also fits well into the human movement curriculum, emphasizing the OT's role in improving functional outcomes for clients.
  • OTs can prescribe exercise, which is essential for improving a client's function.

Key Takeaways

  • The key takeaways presented in the slideshow may not be exhaustive, so it's important to take comprehensive notes.

Simulating Everyday Tasks

  • Simulate stepping over a bathtub with decreased balance and no grab bar to understand the muscles and performance skills involved.
  • Consider the experience of carrying groceries from a car and the muscles it requires.

Activity Analysis

  • OTs possess a unique skill in activity analysis, employing a top-down approach to assess the whole picture, not just the big picture.
  • Clinical judgment is used for compensation, adaptation, promotion, or rehabilitation on a case-by-case basis.
  • Rehabilitating performance deficits, such as range of motion, cardiovascular stamina, balance, and strength, is billable and within the OT scope of practice if it's client-centered and linked to function.

Physical Abilities for Pumping Gas

  • Physical abilities needed to pump gas include standing balance, grip strength, arm strength, trunk stability and strength, quad strength stability, cervical rotation range of motion, and knee extension and flexion.
  • Fine motor skills are required for credit card use, and visual skills are important as well.

Dosing Exercises

  • Exercises should be dosed with a gradual progression, prioritizing safety and functional relevance.
  • The patient's response should be monitored, and dosing adjusted in real-time.
  • Exercise dosing should relate back to occupational goals, such as improving strength, balance, and cardiovascular stamina to support participation in meaningful activities.

Cardiovascular Stamina (Endurance)

  • Cardiovascular stamina is often labeled as endurance, but it's important to note that endurance and fatigue are different. Endurance is physiological, while fatigue is more general, encompassing muscular, cardiovascular, emotional, behavioral, and cognitive factors.
  • Patient populations that may benefit from cardiovascular stamina exercises include cardiac clients, frail elderly, fibromyalgia, rheumatoid arthritis, and multiple sclerosis.
  • OTs need to objectively analyze and document endurance and fatigue, modifying activities based on these factors.

Measuring Cardiovascular Stamina

  • Methods to measure cardiovascular stamina include:
    • Percentage of max heart rate.
    • Blood pressure.
    • O_2 levels.
    • MET levels.
    • RPE (Rate of Perceived Exertion).
  • Functional outcome tests, such as a two-minute step test, can also be used.

Blood Pressure Stages (per American Heart Association)

  • It's crucial to know your client's normal blood pressure range. A client's normal might fall within stage one hypertension, requiring you to work within their baseline.
  • Normal, elevated, high blood pressure stages 1 and 2 are to be considered along with knowing when to seek emergency care

Rate of Perceived Exertion (RPE)

  • RPE is a simple, real-time measure of exertion during activity.
  • The Borg scale (6-20) or Modified Borg scale (0-10) can be used. The modified Borg scale correlates with heart rate.
  • The Borg scale correlated with heart rate
  • The modified board is a rate from 0 to 10
  • The Borg is a rate from 6 to 20

Cardiovascular Stamina Exercises

  • Examples include walking, dancing, and vacuuming, which should be client-centered.
  • Other exercises include swimming, biking, elliptical training, stairs, running, golfing, walking a dog, standing to make a meal. Modify as needed for specific populations.

Balance

  • Balance exercises should challenge the client's stability safely to improve occupation-based performance.
  • Methods to challenge stability include reducing the base of support (BOS) and adding dynamic movement.

Balance Assessments

  • Assessments include:
    • Single leg stance.
    • Timed up and go.

Patient Population

  • Populations that may benefit from balance exercises include:
    • Basic conditioning.
    • Total hip replacement.
    • Total knee replacement.
    • Foot drop.
    • Extremity amputation.

Sample Balance Exercises

  • Repetitive functional transfers, such as in and out of the bathtub.
  • Yoga poses modified for different populations (pediatric, older adult, chair yoga).
  • Dusting at different surface levels to provide a challenge, and walking on uneven surfaces to challenge balance.
  • The balance pad challenges people's balances further.
  • Vision plays a big role in balance.

Strength and Range of Motion (ROM)

Assessments

  • Manual muscle testing (MMT) for strength, goniometry for ROM.
  • Grip dynamometer.
  • Arm curl test.
  • Thirty-second chair stand test.
  • Back scratch test.
  • Chair sit and reach test.
  • Choice of assessment is based on population

Progression

  • ROM exercises should be performed before strength exercises.
  • Progression:
    • Passive ROM.
    • Active assistive ROM.
    • Active ROM.
    • Strengthening.

Exercise Implementation

  • Exercises can involve RM (repetition maximum) and one rep max, lower resistance with higher repetitions (8-12 reps, 2-3 sets, 3-5 times a week).
    • For strength, frequency is important.
  • Frequency and length of time can be beneficial for improvement
  • Resistance, sets, and frequency can be increased as strength improves.

Example

  • Towel slides (active assistive ROM).
  • Weights, bands.
  • Push-ups (wall push-ups, standard push-ups).
  • Putty exercises for hand strength.

Positioning

  • Positioning is important:
    • Sitting or standing for towel slides.
    • Prone or supine for posture exercises, or standing.
    • Static or dynamic for balance exercises.
  • The aim is to provide the just right challenge for the patient

Gradation

  • If exercises are not challenging enough, there will be no physiological effect, leading to frustration and boredom.
  • If exercises are too challenging, it can lead to injury and decreased motivation.

Contraindications and Precautions

  • Cardiovascular contraindications to exercise
    • Discontinue for chest pain, shoulder pain, fatigue.
    • Monitor as well for sweating
  • Hip replacement precautions.
  • Fall risk: Monitor for dizziness and cognition. Always avoid pain.

Therapeutic Exercise Prescription

  • In rehab settings, therapeutic exercise must be connected to functional purposes to increase patient engagement.
  • Walking in home health to the mailbox improves repetitiveness, it can really improve. You just have to be creative with your activities.

Test Tips

  • Isotonic exercises cause the muscle to change length during contraction causing a movement of a joint.
  • Isometric - contraction without movement of a joint.
  • To get arc of ROM you add up all the flexion numbers and subtract for the extension numbers