INTRODUCTION TO EXERCISE

Avanianban Chakkarapani

Therapeutic Exercise The exercise, which is needed for the treatment purpose,

is called as therapeutic exercise. Which are performed to come out from ones ailment or

disease. The main goal of the therapeutic exercise is preparing or

making the patient independent or symptom-free movements.

TYPES OF MOVEMENTS

1. Active movementi. Assistedii. Freeiii. Assisted and resistediv. Resisted.

TYPES OF MOVEMENTS

2. Passive movementi. Relaxed passive movementii. Passive manual mobilization techniquesiii. Mobilizationiv. Manipulationv. Stretching.

INDICATIONS AND GOALS FOR ROM

Passive ROM

Indications for PROMIn the region where there is acute, inflamed

tissue, passive motion is beneficial.Inflammation after injury or surgery usually lasts

2 to 6 days.When a patient is not able to or not supposed to

actively move a segment or segments of the body, as when comatose, paralyzed, or on complete bed rest, movement is provided by an external source.

Passive ROMGoals for PROMMaintain joint and connective tissue mobilityMinimize the effects of the formation of

contracturesMaintain mechanical elasticity of muscleAssist circulation and vascular dynamicsEnhance synovial movement for cartilage

nutrition and diffusion of materials in the jointDecrease or inhibit painAssist with the healing process after injury or

surgeryTo maintain the patient’s awareness of

movement

Other Uses for PROMWhen a therapist is examining inert structures,

PROM is used to determine limitations of motion, to determine joint stability, and to determine muscle and other soft tissue elasticity.

When a therapist is teaching an active exercise program, PROM is used to demonstrate the desired motion.

When a therapist is preparing a patient for stretching, PROM is often used preceding the passive stretching techniques.

Active ROMIndications for AROMIf a patient is able to contract the muscles actively

and move a segment with or without assistance, AROM is used.

If a patient has weak musculature and is unable to move a joint through the desired range (usually against gravity), A-AROM is used.

AROM can be used for aerobic conditioning programsDuring immobilization, AROM is used on the regions

above and below the immobilized segment to maintain the areas in as normal a condition as possible and to prepare for new activities, such as walking with crutches.

Active ROMGoals for AROMMaintain physiological elasticity and

contractility of the participating muscles

Provide sensory feedback from the contracting muscles

Provide a stimulus for bone and joint tissue integrity

Increase circulation and prevent thrombus formation

Develop coordination and motor skills for functional activities

LIMITATIONS OF ROM EXERCISES

Limitations of Passive MotionTrue passive, relaxed ROM may be difficult to

obtain when muscle is innervated and the patient is conscious.

Passive motion does not:Prevent muscle atrophyIncrease strength or enduranceAssist circulation to the extent that active, voluntary

muscle contractiondoes

Limitations of Active ROMFor strong muscles, active ROM does not maintain

or increase strength.It also does not develop skill or coordination

except in the movementpatterns used.

PRINCIPLES AND PROCEDURES

FOR APPLYING ROM TECHNIQUES

Examination, Evaluation, and

Treatment Planning1. Examine and evaluate the patient’s impairments and level of function, determine any precautions and prognosis, and plan the intervention.

2. Determine the ability of the patient to participate in the ROM activity and whether PROM, A-AROM, or AROM can meet the immediate goals.

3. Determine the amount of motion that can be safely applied forthe condition of the tissues and health of the individual.

4. Decide what patterns can best meet the goals. ROM techniques may be performed in thea. Anatomic planes of motion: frontal, sagittal,

transverseb.Muscle range of elongation: antagonistic to the

line of pull of the musclec. Combined patterns: diagonal motions or

movements that incorporate several planes of motiond.Functional patterns: motions used in activities of

daily living (ADL)5. Monitor the patient’s general condition and responses

during and after the examination and intervention; note any change in vital signs, any change in the warmth and color of the segment, and any change in the ROM, pain, or quality of movement.

6. Document and communicate findings and intervention.

7. Re-evaluate and modify the intervention as necessary.

Patient Preparation1. Communicate with the patient. Describe the

plan and method of intervention to meet the goals.

2. Free the region from restrictive clothing, linen, splints, and dressings.Drape the patient as necessary.

3. Position the patient in a comfortable position with proper body alignment and stabilization but that also allows you to move the segment through the available ROM.

4. Position yourself so proper body mechanics can be used.

Application of Techniques1.To control movement, grasp the extremity around

the joints. If the joints are painful, modify the grip, still providing support necessary for control.

2.Support areas of poor structural integrity, such as a hypermobile joint,recent fracture site, or paralyzed limb segment.

3.Move the segment through its complete pain-free range to the point of tissue resistance. Do not force beyond the available range. If you force motion, it becomes a stretching technique.

4.Perform the motions smoothly and rhythmically, with 5 to 10 repetitions.The number of repetitions depends on the objectives of the program and the patient’s condition and response to the treatment.

1. During PROM the force for movement is external, being provided by a therapist or mechanical device.When appropriate, a patient may provide the force and be taught to move the part with a normal extremity.2. No active resistance or assistance is given by the patient’s muscles thatcross the joint. If the muscles contract, it becomes an active exercise.

3. The motion is carried out within the free ROM, that is, the range that is available without forced motion or pain.

Application of PROM

Application of AROM1. Demonstrate the motion desired using PROM;

then ask the patient to perform the motion. Have your hands in position to assist or guide the patient if needed.

2. Provide assistance only as needed for smooth motion.When there is weakness, assistance may be required only at the beginning or the end of the ROM, or when the effect of gravity has the greatest moment arm (torque).

3. The motion is performed within the available ROM.

ACTIVE MOVEMENTS(ACTIVE—BY HIS /HER OWN)

Assisted Exercise:• If the strength or the coordination of the muscle is

insufficient to perform an activity, the external force is utilized to compensate the lack.

• The muscle has the strength or endurance but is not sufficient to perform an activity or control an action.

Types of Assisted Exercises

Active assistance

• The patient himself can assist with his opposite extremity to perform the assisted exercise.

For example,a. The opposite leg is used by the patient to increase the flexion movement of the knee in high sitting.• The main advantage is the patient, he himself only knows the

pain limit and availability of range of movement. • So, that he can perform the exercise conveniently within the

pain limit.

Passive assistance

It is classified into:1. Manual assisted exercise2. Mechanical assisted exercise.

Principles of Assisted Exercise

• Range• Command• Concentration• Speed• Repetition

Uses• Increase the ROM of the joint.• Increase the strength, power and the endurance of the muscles.• It breaks the adhesion formation around the joint.• It reduces the spasm of the muscles.• It stretches the tightened soft tissue.• It reminds the coordinated movement of the joint or a muscle.• Increase the blood circulation and venous return to the joint and

muscle.

Free Exercise• There are two types of free exercises.

1. Localized2. General body.

Characteristics of the Free Exercises

• Subjective• Objective• Example: Bending and touching the great toe with the

middle finger. Here the goal is set to touch the toe.

Uses• Increases the joint range.• Increases the muscle strength, power and endurance.• Increases the neuromuscular coordination.• Increases the circulation and venous drainage.• Increases the relaxation of the muscle by the swinging movements and the pendular

movements.• Repeated active movement breaks the adhesion formation and elongates the shortened

soft tissues.• Regulating the cardiorespiratory function, and the active exercise increases the

respiratory and venous return so that the O2 supply to muscles and blood circulation to the muscle increases.

Resisted Exercises• Performed by opposing the mechanical or manual

resistance is called as resisted exercises.• Types of Resisted Exercises

1. Manual2. Mechanical

Manual Resisted

• These exercises can be operated by: 1. The therapist 2. Patient himself3. Relatives and friends

Mechanical Resisted

• Mechanical resisted exercises can be performed by : 1. Weights 2. Springs 3. Pulleys 4. Water

Mechanical Resisted

• These resisted exercises can be stated when the muscle power is 2., i.e. from gravity eliminated position.

• We can increase the resistance;• By altering the leverage • By increasing the weight • By altering the speed • By changing the duration.

Uses of Resisted Exercises • Resisted exercises increase the strength of the muscle earlier.• The weak muscle can be strengthened much earlier than the any other

exercise regimen.• Can be started from the muscle power 2 onwards. • Strength of the muscle is directly proportional to the tension created

inside the muscle. • The resisted exercise can create the more amount of intramuscular

tension. Strength α Tension

Uses of Resisted Exercises

• Increases the endurance of the muscle. • Powerful muscle contraction increases the blood flow of

the muscle fiber and it gets nutrition and the O2. • Resisted exercise increases the muscular power. • Power is related to the strength of the muscle and the

speed. Power = Force × Distance / Time

Progressive Resisted Exercise

• Repetition Maximum :The maximum amount of the weight a person can lift throughout the range of motion exactly 10 times.

3 types of progressive resisted exercise regimens are available. 1. DeLorme and Watkins 2. MacQueen 3. Zinovieff (Oxford technique).

De Lorme and Watkins

• 10 times with 1/2 10 RM. • 10 times with 3/4 10 RM. • 10 times with 10 RM. Progression i. 30 times weekly 4 sessions ii. Every week 10 RM progression.

De Lorme and Watkins

• a. For example:Consider 10RM—1 kg First week. 1/2 of 10 RM—1/2 kg.3/4 of 10 RM—3/4 kg Full of 10 RM—1 kg Exercise regimen is 10 times with 1/2 kg, 10 times with 3/4 kg, 10

times with 1 kg

De Lorme and Watkins• Second week Progression 10 RM = 10 RM + 10 RM = 1 kg +1 kg= 2 kg Exercise Regimen is 10 times with 1 kg 10 times with 11/2 kg 10 times with 2 kg

De Lorme and Watkins

• In this exercise regimen, the weight is increased, i.e. first with 1/2 kg followed by 3/4 kg and 1 kg.

• Each and every session the patient has to lift the above said three types of weights 10 times each.

• So, that daily 30 times lifting been done.

De Lorme and Watkins• In each and every session 30 times the exercise should be done

with 2 breaks by the patient. i.e. 10 times 1/2 10 RM (1/2 kg) → Break → 10 times with 3/4 10 RM (3/4 kg) → Break→ 10 times 10 RM (1 kg)

• Weekly 4 sessions the exercise has to be practiced. For example:Monday, Wednesday, Friday, Sunday (i.e. every alternative day’s)

exercise has to be practiced and remaining days, i.e. Tuesday, Thursday, Saturday given rest.

Thank you