LORMA COLLEGES

COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

THERAPEUTIC EXERCISES
2ND SEMESTER – BSPT II
PREPARED BY: WRC, PTRP

MODULE 2
PRINCIPLES
OF
INTERVENTION
I. Soft Tissue Injury, Repair, and Management

SOFT TISSUE LESION:

Examples:

1.STRAIN

➢ overstretching, overexertion, overuse of soft tissue

➢ less severe than SPRAIN
➢ frequently used to refer specifically to some degree of disruption of the musculotendinous unit

2. SPRAIN

➢ severe stress, stretch or tear of soft tissues, such as joint capsule, ligament, tendon or muscle.
➢ Frequently used to refer specifically to injury of a ligament and is graded as:
o First/mild
o Second/moderate
o Third/severe
3. SUBLUXATION

➢ Incomplete or partial dislocation that often involves secondary trauma to surrounding soft
tissue.
4. DISLOCATION

➢ Displacement of a part, usually the bony partners within a joint. Leading to soft tissue damage,
inflammation, pain and muscle spasm.
5. MUSCLE/TENDON RUPTURE OR TEAR

➢ If a rupture or tear is partial, pain is experienced in the region of the breach when the muscle is
stretched or when it contracts against resistance.
➢ If it is complete, muscle does not pull against the injury so stretching or contraction of the
muscle does not cause pain.
6. TENDINOUS LESION

a. tenosynovitis – inflammation of the synovial membrane covering a tendon

b. tendonitis - inflammation of the tendon, there may be calcium deposits or scarring

c. tenovaginitis – inflammation with thickening of the tendon sheath

d. tendinosis – degeneration of the tendon from repetitive microtrauma

e. synovitis - inflammation of the synovial membrane; an excess of normal synovial fluid within a
tendon sheath/joint from trauma or disease.

f. hemarthrosis – bleeding into a joint, usually from severe trauma

g. ganglion – ballooning of the wall of a joint capsule or tendon sheath

 h. bursitis – inflammation of the bursa

i. contusion – bruising from a direct blow, resulting in capillary rupture, bleeding, edema and
inflammatory response

j. overuse syndromes, cumulative trauma disorders, repetitive strain injury – repeated submaximal
overload and or frictional wear to a muscle or tendon resulting in inflammation and pain.

CLINICAL CONDITIONS RESULTING FROM TRAUMA OR PATHOLOGY

1. DYSFUNCTION – loss of normal function of a tissue or region; may be caused by adaptive

shortening of the soft tissues, adhesions, muscle weakness, or any condition resulting in loss of
normal mobility.
2. JOINT DYSFUNCTION – mechanical loss of normal joint play in synovial joints; commonly causes
loss of function and pain; precipitating factors: trauma, immobilization, disuse, aging or a serious
pathologic condition.
3. CONTRACTURES – adaptive shortening of skin, muscle, fascia, joint capsule
4. ADHESIONS – abnormal adherence of collagen fibers to surrounding structures during
immobilization/trauma
5. REFLEX MUSCLE GUARDING – prolonged contraction of a muscle in response to a painful
stimulus; guarding ceases when painful stimulus is relieved.
6. INTRINSIC MUSCLE SPASM – prolonged muscle contraction in response to the local circulatory
or metabolic changes that occur when a muscle is in a continued of contraction; may also be a
muscle’s response to viral infection, cold, prolonged periods of immobilization, emotional
tension or direct trauma to the muscle.
7. MUSCLE WEAKNESS – decrease in strength of contraction of a muscle

SEVERITY OF SOFT TISSUE INJURY

A. GRADE 1 (FIRST DEGREE)

a. Mild pain at the time of injury or within the first 24 hours
b. Mild swelling
c. Local tenderness
d. Pain occur when tissue is stressed

B. GRADE 2 (SECOND DEGREE)

a. Moderate pain that requires stopping the activity
b. Stress and palpation of the tissue greatly increases the pain
c. Injury to ligaments---torn fibers---increased joint mobility

C. GRADE 3 ( THIRD DEGREE)

a. Near complete/complete tear or avulsion of the tendon or ligament
b. Severe pain
c. Stress to tissue is usually painless
 d. Palpation may reveal the defect
e. Torn ligament results in instability of the joint

STAGES OF INFLAMMATION AND REPAIR ( pls. refer to table 8-1 of Textbook page 287)

1. ACUTE STAGE (Inflammatory reaction)

a. Signs of inflammation present
b. ROM – movement is painful
c. Guarding before completion of the range
d. Causes of pain and LOM
i. Nerve ending irritation
ii. Increased tissue tension from edema or joint effusion
iii. Muscle guarding
e. Usually lasts for 4 to 6 days

2. SUBACUTE STAGE ( Repair and Healing)

a. Progressive decrease of signs of inflammation; eventually absent
b. ROM – pain synchronous with encountering tissue resistance at the end of the available
range
c. Pain only when newly developing tissue is stressed beyond its tolerance or when tight
tissue is stressed
d. MMT --- weak
e. Lasts 10-17 days (14-21 days after onset of injury
f. May last up to 6 weeks in some tissue with limited circulation, such as tendon.

3. CHRONIC STAGE (Maturation and Remodelling)

a. No signs of inflammation
b. Contractures and adhesions present that limits ROM
c. Muscle weakness limiting function
d. Stretch pain may be felt when testing tight structures at the end of their available range
e. Function may be limited by;
i. Muscle weakness
ii. Poor endurance
iii. Poor neuromuscular control
f. Lasts for 6 months to 1 year depending on the tissue involved and amount of tissue
damage
4. CHRONIC INFLAMMATION (Overuse Syndrome)
a. Prolonged inflammation
b. Symptoms
i. increased pain
ii. swelling
iii. muscle guarding that last more than several hours after activity
iv. Increased feelings of stiffness after rest
v. Loss of ROM 24 hours after activity
 vi. Progressively greater stiffness of the tissue as long as the irritation persists.
5. CHRONIC PAIN SYNDROME
a. Persist longer than 6 months
b. Symptoms:
i. Pain that cannot be linked to a source of irritation or inflammation
ii. Functional limitations and disability that include physical, emotional and
psychosocial parameters.

MANAGEMENT:

A. ACUTE STAGE:

1. patient education
a. expected duration of symptoms 946 days)
b. what she can/cannot do during this stage
c. precautions/contraindications
d. what to expect when symptoms lessen
2. protection of the injured tissue – RICE SPAM
 a. rest (cast, tape), ice, compression, elevation, splint, protect, assistive device, medication
b. manual methods --- massage, gentle (grade 1) joint oscillations
3. Prevention of Adverse Effects of Immobility

B. SUBACUTE STAGE

1. Patient education

2. Promote healing of injured tissue

➢ Wound closure in muscle and skin: 5 to 8 days; tendons and ligaments: 3 to 6 weeks
3. Restore soft tissue, muscle and or joint mobility

4. Develop neuromuscular control, muscle endurance, and strength in involved and related muscles

5. Maintain integrity and function of associated areas

C. CHRONIC STAGE

a. patient education
b. increase mobility
c. Increase strength, neuromuscular control, muscle endurance
d. Improve cardiovascular endurance
e. Progress functional activities
D. CUMULATIVE TRAUMA – CHRONIC RECURRING PAIN
Etiology of Chronic inflammation leading to Prolonged or Recurring Pain

1. Overuse cumulative trauma – repetitive microtrauma results in structural weakening or fatigue

breakdown of connective tissue with collagen fiber cross-link breakdown and inflammation.
2. Trauma – if followed by superimposed repetitive rauma results in a condition that never
completely heals; may be caused by too early return to high demand functional activities before
proper healing of the injury has occurred
3. Reinjury of an “old scar” – the region becomes more susceptible to injury with stresses that
normal, healthy tissue could sustain.
Contributing factors:
 1. Imbalances between the length and strength of the muscles around the joint, leading to faulty
mechanics of joint motion or abnormal forces through the muscles.
2. Rapid or excessive repeated eccentric demand placed on muscles not prepared to withstand the
load, leading to tissue failure, particularly at the musculotendinous region.
3. Muscle weakness or inability to respond to excessive strength demands that results in muscle
fatigue with decreased contractility and shock-absorbing capabilities and increased stress to
supporting tissues.
4. Bone malalignment or weak structural support that causes faulty joint mechanics of force
transmission through the joints
5. Change in the usual intensity or demands of an activity such as increase or change in an exercise
or a training routine or change in job demands.

II. Joint, Connective Tissue, and Bone Disorders and Their

Management

Arthritis is inflammation of a joint. Types of arthritis: inflammatory and noninflammatory; that

affect joints and other connective tissues in the body.
o The most common types treated by therapists are rheumatoid arthritis and
osteoarthritis.
Arthrosis is limitation of a joint without inflammation

• Signs and Symptoms of Arthritis

o Impaired Mobility
o Impaired Muscle Performance
o Impaired Balance
o Activity Limitations and Participation Restrictions

Rheumatoid Arthritis vs Osteoarthritis

Rheumatoid Arthritis- an autoimmune, chronic, inflammatory, systemic disease primarily of unknown

etiology affecting the synovial lining of joints as well as other connective tissue. It is characterized by a
fluctuating course, with periods of active disease and remission.

Characteristics of RA

• This disease is characterized by symmetric, erosive synovitis4 with periods of exacerbation

(flare) and remission
• Inflammatory changes also occur in tendon sheaths (tenosynovitis); if subjected to recurring
friction, the tendons may fray or rupture.
 • Extra-articular pathological changes sometimes (rheumatoid nodules, atrophy and fibrosis
of muscles with associated muscular weakness, fatigue, and mild cardiac changes)
• Progressive deterioration and decline in the functional level of the individual attributed to
the muscular changes and progressive muscle weakness leading to major economic loss and
significant impact on families.
• The degree of involvement varies.

Signs and Symptoms of RA

• effusion and swelling of the joints causing aching and limited motion.
• Joint stiffness is prominent in the morning
• pain on motion, and a slight increase in skin temperature can be detected over the joints.
• Pain and stiffness worsen after strenuous activity.
• Onset in the smaller joints of the hands and feet, most commonly in the proximal
interphalangeal joints.
• Bilateral symptoms
• Joints may be deformed and may ankylose or subluxate.
• Pain is felt in adjoining muscles, and eventually muscle atrophy and weakness occur
• Asymmetry in muscle strength and alterations in the line of pull of muscles and tendons add to
the deforming forces.
• nonspecific symptoms such as low-grade
fever, loss of appetite and weight, malaise,
and fatigue.

Criteria for Diagnosis of Rheumatoid Arthritis

Principles of Management: Active Inflammatory

Period

• Patient education. (Box 11.3)

• Joint protection and energy conservation.
• Joint mobility.
• Exercise.
Principles of Management: Subacute and Chronic Stage

• Treatment approach. The treatment approach is the same as with any subacute and chronic
musculoskeletal disorder, except appropriate precautions must be taken because the
pathological changes from the disease process make the tissues more susceptible to damage
• Joint protection and activity modification. Continue to emphasize the importance of protecting
the joints by adapting the environment, and by modifying activity, using orthoses, and assistive
devices.
• Flexibility and strength. To improve function, exercises should be aimed at improving flexibility,
muscle strength, and muscle endurance within the tolerance of the joints.
• Cardiopulmonary endurance. Nonimpact or low-impact conditioning exercises—such as aquatic
exercise, cycling, aerobic dancing, and walking/running—performed within the tolerance of the
individual improve aerobic capacity and physical activity and decrease depression and anxiety.
Group activities, such as water aerobics, also provide social support in conjunction with the
activity.
PRECAUTIONS: Secondary effects of steroidal medications may include osteoporosis and ligamentous
laxity, so use exercises that do not cause excessive stress to bones or joints.

CONTRAINDICATIONS: Do not perform stretching techniques across swollen joints. When there is
effusion, limited motion is the result of excessive fluid in the joint space. Forcing motion on the
distended capsule overstretches it, leading to subsequent hypermobility (or subluxation) when the
swelling abates. It may also increase the irritability of the joint and prolong the joint reaction

Osteoarthritis: Degenerative Joint Disease

Osteoarthritis (OA) is a chronic degenerative disorder primarily affecting the articular cartilage of
synovial joints, with eventual bony remodeling and overgrowth at the margins of the joints (spurs and
lipping)

Etiology:

• Although the etiology of OA is not known, mechanical injury to the joint due to a major stress or
repeated minor stresses and poor movement of synovial fluid when the joint is immobilized are
possible causes.
• OA is also genetically related, especially in the hands and hips and, to some degree, in the knees.
• Other risk factors:
o Obesity
o weakness of the quadriceps muscles
o joint impact
o sports with repetitive impact and twisting (e.g., soccer, baseball pitching, and football),
o occupational activities such as jobs that require kneeling and squatting with heavy lifting

Characteristics of OA

• With degeneration, there may be capsular laxity leading to hypermobility or instability in some
ranges of joint motion.
• With pain and decreased willingness to move, contractures eventually develop in portions of the
capsule and overlying muscle, so as the disease progresses, motion becomes more limited.
 • cartilage splits and thins out, losing its ability to withstand stress causing crepitation or loose
bodies. Eventual, subchondral bone exposure. During the early stages, the joint is usually
asymptomatic but pain becomes constant in later stages.
• Affected joints may become enlarged. Heberden’s nodes (enlargement of the distal

interphalangeal joints of the fingers) and Bouchard’s nodes (enlargement of the proximal
interphalangeal joints) are common.
• Most commonly involved are weight-bearing joints (hips and knees), the cervical and lumbar
spine, and the distal interphalangeal joints of the fingers and carpometacarpal joints of the
thumbs

Principles of Management of OA
 Fibromyalgia and Myofascial Pain
Syndrome
Fibromylagia- a chronic condition characterized by widespread pain that affects multiple body
regions (right or left side, upper or lower half of the person) plus the axial skeleton and that has lasted
for more than 3 months. Additional symptoms include 11 of 18 tender points at specific sites throughout
the body, nonrestorative sleep, and morning stiffness. A final common problem is fatigue with
subsequent diminished exercise tolerance.
Characteristics of FM

• occur at any age but usually appear during early to

middle adulthood.
• symptoms develop after physical trauma such as a
motor vehicle accident or a viral infection
• hallmark complaints: Pain described as muscular
in origin and is predominantly reported in the
scapula, head, neck, chest, and low back.
• significant fluctuation in symptoms. Some days an
individual may be pain free, whereas other days
the pain is markedly increased often the response
to exercise.
• Individuals with FM have a higher incidence of
tendonitis, headaches, irritable bowel, temporal
mandibular joint dysfunction, restless leg
syndrome, mitral valve prolapse, anxiety,
depression, and memory problems

Factors contributing to flare

• Environmental stresses include weather changes, especially significant changes in barometric

pressure, cold, dampness, fog, and rain.
• Physical stresses include repetitive activities, such as typing, playing piano, vacuuming;
prolonged periods of sitting and/or standing; and working rotating shifts.
• Emotional stresses are any normal life stresses

Principles of Management. Learning to pace activities throughout the day so as to not push too hard or
too little is an important component of the intervention plan.

• Exercise. Research supports the use of exercise, particularly aerobic exercise, to reduce the most
common symptoms associated with FM. aerobic fitness and strengthening exercises are
beneficial in the overall management of FM for pain relief, muscle strength, quality of life, self-
efficacy, and decreased depression and that progressive strengthening programs do not cause
an exacerbation of exercise-induced FM symptoms
• Additional interventions
o Prescription medication
o Over-the-counter medication
o Instruction in pacing activities, in an attempt to avoid fluctuations in symptoms
o Cognitive behavior therapy
o Avoidance of stress factors
o Decreasing alcohol and caffeine consumption
o Diet modification
o Manual therapy
Myofascial Pain Syndrome

defined as a chronic, regional pain syndrome.56,141 The hallmark classification of MPS comprises the
myofascial trigger points (MTrPs) in a muscle that have a specific referred pattern of pain (Fig. 11.8),
along with sensory, motor, and autonomic symptoms.

The trigger point is defined as a hyperirritable area in a tight band of muscle.45,48,49,56,74 The pain
from these points is described as dull, aching, and deep.

Possible Causes of Trigger Points. Although the etiology of trigger points is not completely understood,
some potential causes are:

• Chronic overload of the muscle that occurs with repetitive activities or that maintain the muscle
in a shortened position.
• Acute overload of muscle, such as slipping and catching oneself, picking up an object that has an
unexpected weight, or following trauma such as in a motor vehicle accident.
• Poorly conditioned muscles compared to muscles that are exercised on a regular basis.
• Postural stresses such as sitting for prolonged periods of time, especially if the workstation is
not ergonomically correct, and leg length differences.
• Poor body mechanics with lifting and other activities.

Principles of Management for MPS: Treatment consists of three main components:

• Correct chronic overload. Correct contributing factors that cause chronic overload of the
muscle, such as faulty posture, repetitive activity, or poor lifting techniques. The correction is
often done with education including stressing the importance of taking intermittent mini-
breaks. If indicated, an ergonomic assessment of the work environment is performed.
• Eliminate the trigger point. Several techniques are used to eliminate trigger points
o Contract-relax-passive stretch done repeatedly until the muscle lengthens
o Contract-relax-active stretch also done in repetition
o Trigger point release
o Spray and stretch
o Modalities
o Dry needling or injection
• Strengthen muscle. Exercise prescription, using a muscle endurance protocol, is typically
indicated for core and scapular stabilizing muscle groups to improve overall muscle
performance.
OSTEOPOROSIS
-Osteoporosis is a disease of bone that leads to decreased mineral content and weakening of the bone.
This weakening may lead to fractures, especially of the spine, hip, and wrist

-The diagnosis of osteoporosis is determined by the T-score of a bone mineral density (BMD) scan.

Risk Factors

• Primary osteoporosis. Risk factors for developing primary osteoporosis include being
postmenopausal, Caucasian or Asian descent, family history, low body weight, little or no
physical activity, diet low in calcium and vitamin D, and smoking. Additional risk factors include
prolonged bed rest and advanced age.
 • Secondary osteoporosis. Secondary osteoporosis develops owing to other medical conditions
(i.e., gastrointestinal diseases, hyperthyroidism, chronic renal failure, and excessive alcohol
consumption) and the use of certain medications such as glucocorticoids.

Prevention of Osteoporosis

The National Osteoporosis Foundation (NOF) recommends four ways to prevent osteoporosis.

• Eating foods that are good for bone health, such as fruits and vegetables
• Maintaining a balanced diet that is rich in calcium and vitamin D
• Performing regular weight-bearing exercise
• Following a healthy lifestyle with moderate alcohol consumption (limit 2-3 drinks per day) and
no smoking

Physical Activity

Physical activity has been shown to have a positive effect on bone remodeling. In children and
adolescents, this activity may increase the peak bone mass. In adults, it has been shown to maintain or
increase bone density; in the elderly, it has been shown to reduce the effects of age-related or disuse-
related bone loss

Effects of Exercise

Muscle contraction (e.g., strengthening exercises and resistance training) and mechanical loading
(weight bearing) deform bone. This deformation stimulates osteoblastic activity and improves BMD

Recommendations for Exercise

• Weight-bearing exercise, such as walking, jogging, climbing stairs, and jumping

• Nonweight-bearing exercise, such as with a bicycle ergometer
• Resistance (strength) training of 8 to 10 exercises that target major muscle groups
• Mode: Aerobic
o Frequency. Five or more days per week.
o Intensity. Thirty minutes of moderate intensity (fast walking) or 20 minutes of vigorous
intensity (running). Doing three short bouts per day of 10 minutes of activity is
acceptable.
• Mode: Resistance
o Frequency. Two to three days per week with a day of rest in between each bout of
exercise.
o Intensity. Eight to 12 repetitions that lead to muscle fatigue.

Precautions and Contraindications

 • flexion activities and exercise, such as supine curl-ups and sit-ups, as well as the use of sitting
abdominal machines, should be avoided. Stress into spinal flexion increases the risk of a
vertebral compression fracture.
• Avoid combining flexion and rotation of the trunk to reduce stress on the vertebrae and the
intervertebral discs.
• When performing resistance exercise, it is important to increase the intensity progressively but
within the structural capacity of the bone

Fractures and Posttraumatic Immobilization

A fracture is a structural break in the continuity of a bone, an epiphyseal plate, or a cartilaginous joint
surface. When there is a fracture, some degree of injury also occurs to the soft tissues surrounding the
bone.
A fracture is identified by:

• Site: diaphyseal, metaphyseal, epiphyseal, intra-articular

• Extent: complete, incomplete
• Configuration: transverse, oblique or spiral, comminuted (two or more fragments)
• Relationship of the fragments: undisplaced, displaced
• Relationship to the environment: closed (skin intact), open (fracture or object penetrated the
skin)
• Complications: local or systemic; related to the injury or to the treatment

Risk Factors Risk factors for fracture include:

• Sudden impact (e.g., trauma, accidents, abuse, or assault)

• Osteoporosis (women more than men)
• History of falls (especially with increased age, low body mass index, and low levels of physical
activity)
• Repetitive stress (repeated microtrauma)
• Pathology (abnormal fragile bone from neoplastic, poor health, or disease conditions)

Bone Healing Following a Fracture

Fracture healing has

• an inflammatory phasein which there is hematoma formation and cellular proliferation

• a reparative phase in which there is callous formation uniting the breach and ossification,
• a remodeling phase in which there is consolidation and remodeling of the bone
Principles of Management: Period of Immobilization

• Local Tissue Response With immobilization, there is connective tissue weakening, articular
cartilage degeneration, muscle atrophy, and contracture development as well as sluggish
circulation with bleeding and scar formation.
o Early, nondestructive motion within the tolerance of the fracture site
o Keep structures in the related area in a state as near normal as possible by using
appropriate exercises
o alert to complications that can occur following a fracture
• Immobilization in Bed. General exercises for
the uninvolved portions of the body are
initiated to minimize these problems.
• Functional Adaptations If there is a lower
extremity fracture, alternative modes of
ambulation, such as the use of crutches or a
walker, are taught to the patient who is
allowed out of bed.

Postimmobilization Impairments

• Decreased ROM, joint play, and muscle

flexibility.
• Muscle atrophy with weakness and poor muscle endurance.
• Postimmobilization Impairments
• Decreased ROM, joint play, and muscle flexibility.
• Muscle atrophy with weakness and poor muscle endurance.

Management of Post-Immobilization

Consultation with the referring physician is necessary to determine if there is clinical or radiological
healing. Until the fracture site is radiologically healed, care should be used any time stress is placed
across the fracture site, such as when applying resistance or a stretch force or during weight-bearing
activities

• Joint mobilization. Joint mobilization techniques are effective for regaining lost joint play
without traumatizing the articular cartilage or stressing the fracture site
• PNF Stretching. Hold-relax and agonist-contraction techniques are used during the
postimmobilization period because the intensity can be controlled by the patient
• Functional activities. The patient can resume normal activities with caution
• Muscle performance: Strengthening and muscle endurance. Using light isometrics before
progressing to more dynamic PREs
• Scar tissue mobilization. If there is restricting scar tissue, manual techniques to mobilize the
scar are used. The choice of technique depends on the tissue involved