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Therapeutic Exercise

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OVERVIEW OF REHAB

ReviewTissue Healing Modalities

• Acute Inflammation• Repair or Fibroplasia• Maturation• Wolff’s Law- tissues will

adapt to stresses/tension applied to them

• Pain control• Inflammation control• Facilitate ROM• Can be used during

rehab program

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Goals of Injury Rehabilitation

• Pain Control• Regain/increase ROM and flexibility• Proprioception• Regain/increase strength and power• Regain/increase endurance• Return to functional and sports specific

activity• Maintain conditioning of whole body!

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Your Duties as a Clinician

• Understand injury and subsequent healing phase and design appropriate exercise regimen – Have purpose for exercise choice

• Provide direction and instructions– Correct/modify/adjust program as needed

• Supervision• Professionalism and courtesy• Support and encourage patient

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EARLY THERAPY STAGES

Terminology

• AROM (active range of motion): patient performs motion by his/herself

• PROM (passive range of motion): clinician moves patient through range of motion

• AAROM (active assisted range of motion): combination of passive and active; patient performs what he/she can and clinician assists with rest of movement

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Terminology

• Subjective measurement: an approximation, guess

• Objective measurement: factual, exact measure

• Goniometer: tool used by clinicians to measure a patient’s ROM; similar to a protractor in math

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Pain Control

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• Pain control is usually a component of modality usage

• Psychological Techniques– Relaxation– Meditation– Visualization

• Medications

Active Range of Motion

• May be done in conjunction with modality usage– Alphabet with toes/foot in cold whirlpool

• Initially pain free ROM indicated

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Passive ROM used

• When patient cannot move on his/her own – Maintain flexibility– Increase blood flow

• Adhesions or scar tissue not allowing full ROM• Machine or therapist can provide ROM

– CPM- continuous passive movement used with ACL or knee replacement surgery

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Active Assisted ROM

• Increase flexibility• Assist weak musculature• Perform a specific ROM pattern• Use gravity to increase ROM

– Pendulums– Wall slides– Bicycle – Dowel

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http://calder.med.miami.edu/pointis/upper.html

Measuring ROM

• Determines normal vs. abnormal ROM• Goal setting• Can be completed both subjectively and

objectively

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Goniometer• Maintain consistency!• Note position of patient during testing• Use same landmarks on lateral side of joint

each time tested• Start at 0 degrees (anatomical position) then

move through ROM to gain measurement• Compare bilaterally

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Remember!

If a therapy session results in increased pain or a return of inflammation, the clinician may be progressing too aggressively. Feedback from patient determines speed of progression.

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MUSCLE STRENGTH, ENDURANCE, AND PROPRIOCEPTION: EARLY STAGES

Terminology

• PRE (progressive resistive exercise): exercises that become increasingly more difficult

• RROM (resistive range of motion): some form of resistance is applied to the movement

• Manual resistance: clinician physically resists range of motion

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Terminology

• SLR (straight leg raise): ROM performed at hip if there is a lower extremity injury that prevents knee ROM

• Open kinetic chain exercises: when the foot or hand is mobile or off the ground

• Closed kinetic chain exercises: when the foot or hand is fixed or on the ground

• Neuromuscular control: ability for muscles to respond to environmental changes

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Considerations

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• Protect healing tissue, but must provide some stress for proper healing (Wolff’s law) – PRE

• Safe ROMs and planes of movement• Exercise choice• Maintain rest of body fitness to prevent

atrophy

Strengthening

• Isometric vs. isotonic vs. isokinetic• Easy progression:

– Isometric– Gravity resistance– Light weight or manual resistance

http://www.youtube.com/watch?v=Hhcz0qJvEeI – Tubing/bands

http://www.youtube.com/watch?v=z1zInVH6X28

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Endurance

• Pain-free ROM• No undue stress to healing site• Examples:

– Bike– UBE- upper body

ergometer– Rowing– Swimming– Elliptical– Treadmill

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http://www.abqjournalfit.com/414/blog/2010/09/11/try-your-hand-on-a-ube/

Proprioception

• Static balance exercises- tandem stance or one leg– Flat hard surface– Foam or mat surface– Add weights or movements to each

• Static upper extremity exercises– Mirror movements between limbs– Closed kinetic chain stability on hand-

tandem and single arm

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http://www.reflexportland.com/exercise/at-home-knee-strengthening-exercises/

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MUSCLE STRENGTH, ENDURANCE AND PROPRIOCEPTION: LATER STAGES

Terminology

• Agility: ability to accelerate, decelerate, and change direction while maintaining balance and posture

• Plyometric exercise: movements that involve speed, agility and power

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Considerations

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• Phase of tissue healing• Range of motion and planes of movement

– Should have near-full or full ROM– Advance to multi-planar activity

• Exercise choice– Multi-joint exercises– Specific supplemental exercises for injury site

Strengthening and Endurance

• Increased resistance loads• Moving resistance with multiple joints • Weight room activity• Plyometrics

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http://www.rejectfat.com/kettlebell-exercises-health-fitness-benefits/

http://www.bodyproject.be/?page_id=355

Strengthening and Proprioception

• Plyometrics • Advanced static balance and dynamic balance

exercises– Wobble boards– Adding distractions or other movements

27http://xrlifestyles.com/alternate-exercises/

http://www.thera-band.com/store/products.php?ProductID=17

http://www.exercise-ball-exercises.com/exercises-for-skiing.html

• What muscles is this exercise working?

• When and why would one use this exercise?

• Is this exercise proprioceptive? strengthening? endurance?

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http://www.passbracing.com/misc.html

• What muscles is this exercise working?

• When and why would one use this exercise?

• Is this exercise proprioceptive? strengthening? endurance?

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• What muscles is this exercise working?

• When and why would one use this exercise?

• Is this exercise proprioceptive? strengthening? endurance?

http://athletefit.com/programs/speed_agility/

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FUNCTIONAL TRAINING AND SPORT SPECIFIC REHABILITATION

Terminology

• ADL (activities of daily living): procedures or things that must be accomplished daily in order to properly function

• Functional Training: training the body for activities that must be performed in daily life

• Motor learning: practice and experience increases skilled movements

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Terminology

• Specificity: the theory that training should be relevant to what the desired results should be

• SAID principle: (specific adaptations to imposed demands) body will adapt to demands placed upon it

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ADLs

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• What are some movements that a person must be capable of doing in order to function on his/her own?

Functional Training

• Requires smooth, coordinated movements across multiple planes

• In training, exercises must be able to transfer over to the desired movements at desired speed

• Components of the movement can be isolated, but goal is multi-joint coordination

• Repetition of movement is important for motor learning

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http://www.usmilitary.com/8036/us-marine-corps-combat-

engineer-careers/

http://www.guardian.co.uk/lifeandstyle/wordofmouth/2009/jul/30/restaurants-employment-practices

What types of functional exercises would each of

these professionals have to do to effectively and

safely perform their jobs?

Be prepared to share

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Sports Specific Training

• Factors that must be considered:– Movements required– Endurance, strength and agility needed– Surface, facility or environment – Equipment– Rules of sport

• Gradual progression back to full competition

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THERAPY AND UNIQUE POPULATIONS

Therapy Issues

• Sensory deficits• Verbal communication problems• Attention disorders• Spastic muscles/lack of muscle control• Diminished mental function• Chronic pain

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Therapy Options: Aquatic Therapy

• Increased buoyancy• Resistance and compression

from water• Decreased stress on joints• Variety of exercises without

equipmenthttp://www.youtube.com/watch?v=aY0YBdIIgqk

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http://centralpa.easterseals.com/site/PageServer?pagename=PACN_Warm_Water_Therapy_Pool

Yoga Therapy

• Works strength, endurance and flexibility• Can customize for pain and injury through

sequencing of poses• Can modify routine as pain decreases and

strength increaseshttp://www.youtube.com/watch?v=rz_X5XB0FbU

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Interactive Video Gaming Systems

• Can be done in privacy of home or socially

• Hand-eye coordination• Some balance, agility

and coordination neededhttp://www.youtube.com/watch?v=AjY8g98xVsg

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http://howsyourrobot.com/2013/04/24/let-me-get-this-straight-you-want-me-to-play-video-games/

Equine Therapy

• Animals make good companions– Non-judgmental

• Work on communication skills

• Work on muscle tone, flexibility, and coordination

http://www.youtube.com/watch?v=tGtEjl34hLo

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http://www.ahorseconnection.org/

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FITNESS CONCERNS FOR THE GERIATRIC POPULATIONS

Benefits for Geriatric Populations

• Increase calorie use (decrease weight)• Increase in cardiovascular fitness and

strength• Decrease blood pressure• Decrease chance of stroke, some cancers,

osteoporosis, and cardiovascular disease• Decrease psychological stress• Improve sleep and digestion

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Therapeutic Benefits

• Heart attack patients• Diabetics (improves insulin response)• Decrease back pain by increasing strength• Arthritis patients (strong muscles= less joint

pain)• Depression (improved self confidence)• Improves neurocognitive function• Decreases loss of muscle mass

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Considerations

• Patient beginning health and fitness level– Modify workout based on injury/illness– Balance issues

• Previous exercise experience • Medications

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Clinician can control injury prevention

• Ensure proper warm-up and cool down• Control lifting speed• Monitor for proper technique• Keep workout area uncluttered• Consider balance concerns:

– Machines vs. free weights– Body weight or exercise bands– Seated or lying vs. standing– Stable vs. unstable surfaces

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Geriatric Conditioning Guidelines

• Strength program 2-3 times/week• Controlled speeds of repetitions• Beginners: more reps and less load• Provide clear explanation of lift/move• Demonstrate lift/move• Demonstrate breathing technique• Careful supervision with positive

reinforcement

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How can we modify this exercise for improved geriatric safety?

http://fitnessanddefense.com/category/safety-tips/

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Cardiovascular Training

• 2-5 days/week for 20-60 minutes • Workout intensity: 60-90% max HR

– Medications may affect HR• Talk test- if they can say short-medium

sentences during workout, they are at good pace

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Clinician must enforce participant compliance with:

• Increased fluid intake• Proper nutrition• Adequate rest and sleep• Proper hygiene• Approval of exercise regimen with physician

– Communicate concerns to clinician

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