Chapter 13: Therapeutic Exercise Program Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Goal of Therapeutic Exercise Return injured participant to pain-free functional activity Must address Pain modulation ROM & flexibility Strength Cardiovascular fitness
Copyright 2017 Wolters Kluwer All Rights Reserved Developing a Therapeutic Exercise Program Steps Assess the patient Current level of function and dysfunction Subjective and objective components of SOAP Interpret the assessment Identify factors outside normal limits Primary deficits Secondary problems Part of assessment component of SOAP
Copyright 2017 Wolters Kluwer All Rights Reserved Developing a Therapeutic Exercise Program (cont.) Steps (cont.) Establish goals Therapist and patient work together Long term and short term Part of assessment component of SOAP Copyright 2017 Wolters Kluwer All Rights Reserved Developing a Therapeutic Exercise Program (cont.)
Develop and supervise the treatment plan. Incorporate therapeutic exercise, modalities, and medication. Four phases Reassess the progress of the program. Adjust as needed Copyright 2017 Wolters Kluwer All Rights Reserved Phase 1: Controlling Inflammation Goal
Copyright 2017 Wolters Kluwer All Rights Reserved Effects of Immobilization Immobilization Prolongs repair and regeneration of damaged tissues Remobilization Early controlled mobilization speeds healing process
Tissues Muscle Immobilization: initially strength; fatigability, rapid loss; slows after 5 to 7 days; position of immobilization Remobilization: regeneration begins after 3 to 5 days; maximum isometric contraction4 months Copyright 2017 Wolters Kluwer All Rights Reserved Effects of Immobilization on Tissues Articular cartilage Immobilization: constant contact with opposing bone ends pressure necrosis & cartilage cell death;
noncontact growth of connective tissue into the joint Remobilization: tissue changes reversible, immobilization 30 days; may not be if 30 days Ligament Immobilization: weaker, more compliant structure; tensile strength Remobilization: boneligament junction recovers more slowly than midportion of the ligament; recovery depends on the duration of immobilization Copyright 2017 Wolters Kluwer All Rights Reserved Effects of Immobilization on Tissues (cont.)
Bone Immobilization: bone loss as early as 2 weeks after immobilization; as immobilization time , bone resorption brittleness Remobilization: recovery can be several times greater than the period of immobilization; isotonic and isometric exercises during immobilization can some bone loss Copyright 2017 Wolters Kluwer All Rights Reserved Protection Postinjury Depends on
Injury severity, structures damaged Philosophy of supervising health care provider Restricted activity Relative rest Detraining Can occur after only 1 to 2 weeks of inactivity Copyright 2017 Wolters Kluwer All Rights Reserved Criteria for Progression to Phase 2 Control of inflammation with minimal edema, swelling, muscle spasm, and pain ROM, joint flexibility, muscular strength, endurance, and power maintained in general
body Cardiovascular fitness maintained at preinjury level Copyright 2017 Wolters Kluwer All Rights Reserved Phase 2: Restoration of Motion Focus Restoring ROM and flexibility Maintaining general body strength and cardiovascular endurance
Factors that limit joint motion Bony block Joint adhesions Muscle tightness Tight skin or inelastic dense scar tissue Swelling Pain Fat or other soft tissues that block normal motion Copyright 2017 Wolters Kluwer All Rights Reserved Passive Range of Motion (PROM) Types of movement
Physiological motion Angular, measured with goniometer Accessory motion Involuntary spinning, rolling, or gliding of one articular surface relative to another Normal accessory movement must be present to obtain full physiological ROM Copyright 2017 Wolters Kluwer All Rights Reserved Joint Mobilization Oscillating forces applied in open-packed position to free up stiff joints
Benefits Breaking up adhesions and relieving capsular restrictions Distracting impacted tissues Increasing lubrication for normal articular cartilage Reducing pain and muscle tension Restoring full ROM
Contraindications Acute inflammation Advanced osteoarthritis Congenital bone deformities
Fractures Hypermobility Infections Malignancy Neurological signs Osteoporosis Premature stress on surgical sites Rheumatoid arthritis Vascular disease Copyright 2017 Wolters Kluwer All Rights Reserved Joint Mobilization (cont.)
Five grades Performing joint mobilization Open-packed position Direction of forceconcave/convex rule Treatment: 3 to 6 mobilizations up to 30 seconds, with 1 to 3 oscillations per second Copyright 2017 Wolters Kluwer All Rights Reserved Flexibility
Total ROM at a joint that occurs pain free in each of the planes of motion Combination of normal joint mechanics, mobility of soft tissues, and muscle extensibility Mechanoreceptors influence flexibility Muscle spindle Lie parallel with contractile muscle
fibers Send sensory info to CNS Muscle length Velocity of length change Excite/facilitate muscle contraction Copyright 2017 Wolters Kluwer All Rights Reserved Flexibility (cont.) Golgi tendon organs (GTOs) Lie in tendon, mostly at tenomuscular junction Stimulated by stretch Sends sensory info to CNS Muscle load and tension
Inhibit/relax muscle contraction Copyright 2017 Wolters Kluwer All Rights Reserved Stretching Techniques Active stretching Muscle spindle is stretched, but GTO do not fire; muscle resists relaxation Momentum can lead to overstretching, tearing Static GTO override impulses from the muscle spindles Safer, more effective muscle stretch Copyright 2017 Wolters Kluwer All Rights Reserved
Stretching Techniques (cont.) Proprioceptive neuromuscular facilitation (PNF) Involves stimulation of the proprioceptors flexibility in one muscle group (i.e., agonist), and simultaneously strength in another group (i.e., antagonist)
Copyright 2017 Wolters Kluwer All Rights Reserved Stretching Techniques (cont.) Proprioceptive neuromuscular facilitation (cont.) Techniques Active inhibition Reciprocal inhibition Advantages Early use Single plane or diagonal patterns Copyright 2017 Wolters Kluwer All Rights Reserved Active Assisted and Active ROM
AAROM Working the limb through available pain-free motion with assistance will more quickly restore normal active ROM than working within limited voluntary motion AROM Enhances circulation Initiation of strength exercises before full AROM Should be relatively painless Copyright 2017 Wolters Kluwer All Rights Reserved Resisted ROM (RROM) Static or dynamic
Static Measured with an isometric muscle contraction Used during phases 1 and 2 in pain-free arc of motion Isometric training Advantages Disadvantages Technique Copyright 2017 Wolters Kluwer All Rights Reserved Proprioception and Kinesthesia Proprioceptionsensation of joint position Kinesthesiasensation of joint movement
Information is sent from sensory receptors to CNS relative to tissue deformation. Copyright 2017 Wolters Kluwer All Rights Reserved Proprioception and Kinesthesia (cont.) Sensory receptors Visual and vestibular centers provide afferent information Cutaneous, muscle, & joint mechanoreceptors mediate the ability to sense body position Joint mechanoreceptors Ruffini corpuscles Golgi receptors Pacinian corpuscles
Free nerve endings Muscle mechanoreceptors Copyright 2017 Wolters Kluwer All Rights Reserved Regaining Proprioception Injury can interrupt the neuromuscular feedback mechanisms.
Restoration of feedback is necessary to promote dynamic joint and functional stability to prevent reinjury. Exercises Specific to type of activity Progression: slow-speed to high-speed, low-force to highforce, and controlled to uncontrolled activities Copyright 2017 Wolters Kluwer All Rights Reserved Open Versus Closed Kinetic Chain Exercises
Kinematic chain Series of interrelated joints Motion at one joint will produce motion at the other joints in a predictable manner Closed kinetic chain (CKC) Distal segment of the extremity cannot move independently Weight bearing
Open kinetic chain (OKC) Distal segment of the extremity is free to move without causing motion at another joint Nonweight-bearing Copyright 2017 Wolters Kluwer All Rights Reserved Open Versus Closed Kinetic Chain Exercises (cont.) Copyright 2017 Wolters Kluwer All Rights Reserved Advantages of CKC Exercises Provide greater joint compressive forces
Multiple joints are exercised Velocity and torque are more controlled Shear forces are reduced Joint congruity is enhanced Proprioceptors are reeducated Postural and dynamic stabilization mechanics are facilitated Exercises in spiral or diagonal movement patterns Copyright 2017 Wolters Kluwer All Rights Reserved Open Kinetic Chain Exercises Advantages Isolate specific muscle group for intense
strength and endurance Develop strength in very weak muscles that may not function properly in a CKC system Disadvantages Limited to one joint in a single plane (uniplanar) Greater potential for joint shear Limited functional application Limited eccentric and proprioceptive retraining Copyright 2017 Wolters Kluwer All Rights Reserved Criteria for Progression to Phase 3
Inflammation and pain under control ROM within 80% of normal Bilateral joint flexibility restored and proprioception regained Cardiovascular endurance and general body strength maintained at preinjury level Copyright 2017 Wolters Kluwer All Rights Reserved Phase 3: Developing Muscular Strength, Endurance, and Power Muscular strength Ability of a muscle or group of muscles to produce force in one maximal effort
Concentric contraction Shortening; decreases joint angle Work to accelerate a limb Eccentric contraction Lengthening; increases joint angle Work to decelerate a limb and provide shock absorption Copyright 2017 Wolters Kluwer All Rights Reserved Dynamic Strength Isotonic exercise
Variable speed/fixed resistance Advantages Permits exercise of multiple joints simultaneously Allows both eccentric & concentric contractions Permits weight-bearing, CKC exercises Disadvantage When a load is applied, the muscle can only move that load through the ROM with as much force as the muscle provides at its weakest point Copyright 2017 Wolters Kluwer All Rights Reserved Isokinetic Exercise Isokinetic exercise
Fixed speed/variable resistance Advantages 100% loading throughout ROM Pain disengages mechanism Disadvantages As muscle fatigues, resistance decreases Most machines only permit concentric contraction Cost of the machine, computer, and software package ranges from $25,000 to $60,000 Copyright 2017 Wolters Kluwer All Rights Reserved Dynamic Strength (cont.)
Copyright 2017 Wolters Kluwer All Rights Reserved Muscular Endurance and Power Muscular endurance Ability of muscle tissue to exert repetitive tension over an extended period Fatigue is related to endurance Relationship between strength and endurance Lifting low weights/faster velocity/more repetitions Copyright 2017 Wolters Kluwer All Rights Reserved Muscular Endurance and Power (cont.)
Muscular power Ability of muscle to produce force in a given time Started when at least 80% of strength Weight training at higher contractile velocities Use of plyometric exercises Explosive exercise that maximizes the myotatic onstretch reflex Caution: injury potential Copyright 2017 Wolters Kluwer All Rights Reserved Functional Application of Exercise Overload principle Specific adaptations to imposed demands (SAID) principle
Intensity Strength gains depend primarily on intensity of overload, not the specific training method DAPRE Effective but not advised in early phases of rehabilitation Strength: weight/ repetitions endurance: repetitions/ weight Copyright 2017 Wolters Kluwer All Rights Reserved Functional Application of Exercise (cont.) Duration The length of a single exercise session
Minimum: 20 minutes in absence of pain, swelling, or muscle soreness Frequency Number of exercise sessions per day or week Three to four times per week Twice per day may be appropriate Do not work the same muscle groups on successive days Copyright 2017 Wolters Kluwer All Rights Reserved Functional Application of Exercise (cont.) Specificity
Needs Type of exercise Copyright 2017 Wolters Kluwer All Rights Reserved Functional Application of Exercise (cont.) Speed Rate at which the exercise is performed Initially, slow, deliberate movements Eventually, vary speeds Progression Objective improvement should occur each day Orderly progression with ever-increasing
demands as healing process allows Copyright 2017 Wolters Kluwer All Rights Reserved Criteria for Progression to Phase 4 Bilateral ROM and flexibility restored Muscular strength, endurance, and power equal or near equal to those of the unaffected limb Cardiovascular endurance and general body strength at or better than the preinjury level Sport-specific functional patterns completed using mild-to-moderate resistance Individual psychologically ready to return to protected activity
Copyright 2017 Wolters Kluwer All Rights Reserved Phase 4: Return to Sport Activity Focus Correct any biomechanical inefficiencies in motion Restore coordination and muscle strength, endurance, and power in sport-specific skills Copyright 2017 Wolters Kluwer All Rights Reserved Phase 4: Return to Sport Activity (cont.)
Coordination Bodys ability to execute smooth, fluid, accurate, and controlled movements Categories Gross movement Fine movement Direct link with proprioception Improving coordination Copyright 2017 Wolters Kluwer All Rights Reserved Components of Phase 4 Sport/activity-specific skill conditioning
Exercise should progress to the load and speed expected for the individuals sport Exercises must be coupled with functional training Copyright 2017 Wolters Kluwer All Rights Reserved Components of Phase 4 (cont.) Cardiovascular endurance Bodys ability to sustain submaximal exercise over an extended period Detraining occurs within 1 to 2 weeks Cardiovascular level impacts fatigue ACSM recommends Activity 3 to 5 days per week
20 minutes Intensity of 60% to 90% of maximal heart rate (HRmax) Copyright 2017 Wolters Kluwer All Rights Reserved Return to Sport/Activity Criteria Individual can return to their sport activity as soon as muscle strength, endurance, and power are restored Copyright 2017 Wolters Kluwer All Rights Reserved
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