✳Therapeutic exercise✳

Definition 😊
Therapeutic exercise-->
it is the systematic, planned performance of bodily movements, postures, or
physical activities intended to provide a patient/client with the means to:
■ Remediate or prevent impairments.
■ Improve, restore, or enhance physical function.
■ Prevent or reduce health-related risk factors.
■ Optimize overall health status, fitness, or sense of
well-being.
 Therapeutic exercise programs designed by physical therapists are
individualized to the unique needs of each patient or client.
 A patient is an individual with impairments and functional deficits diagnosed by
a physical therapist and is receiving physical therapy care to improve function
and prevent disability.

Components of Physical Function: there are following

components related to therapeutic exercise.

1.Balance.--> The ability to align body segments against gravity to maintain or move
the body (center of mass) within the available base of support without falling the
ability to move the body in equilibrium with gravity via interaction of the sensory and
motor systems.

2.Cardiopulmonary fitness-->. The ability to perform moderate intensity, repetitive,

total body movements (walking, jogging, cycling, swimming) over an extended
period of time synonymous term is cardiopulmonary endurance.

3.Coordination. The correct timing and sequencing of muscle firing combined with
the appropriate intensity of muscular contraction leading to the effective
initiation,guiding, and grading of movement. Coordination is the basis of smooth,
accurate, efficient movement and occurs at a conscious or automatic level.

4.Flexibility. The ability to move freely, without restriction; used interchangeably with
mobility.

5. Mobility--> The ability of structures or segments of the body to move or be moved

in order to allow the occurrence of range of motion (ROM) for functional activities
(functional ROM).
Passive mobility is dependent on soft tissue (concontractile and non contractile)
extensibility;

6.Muscle performance--> The capacity of muscle to produce tension and do physical

work.
 Muscle performance encompasses strength, power, and muscular endurance.

7.Neuromuscular control. Interaction of the sensory and motor systems that

enables synergists, agonists and antagonists, as well as stabilizers and neutralizers
to anticipate or respond to proprioceptive and kinesthetic information and,
subsequently, to work in correct sequence to create coordinated movement.

8.Postural control, postural stability, and equilibrium.-->Used interchangeably with

static or dynamic balance.

9.Stability-->. The ability of the neuromuscular system through synergistic muscle

actions to hold a proximal or distal body segment in a stationary position or to
control a stable base
during superimposed movement.

Types of Therapeutic Exercise Interventions 😊

 The techniques selected for an individualized therapeutic exercise program are
based on a therapist’s determination of the underlying cause or causes of a
patient’s impairments, activity limitations, or participation restrictions
(functional limitations or disability).

Principal➡
 Benefit cardiovascular and respiratory function.
 Reduce cardiovascular and respiratory disease progression.
 Decrease morbidity and mortality.
 Decrease anxiety and depression.
 Reduce pain.
 Improve cognitive function.
 Enhance physical function and independent living in older individuals.
 Enhance feelings of well-being.
 Reduce risk of falls in older individuals.
 Prevent or mitigate functional limitations in older adults.
 Enhance performance of work, recreational, and sport activities.

Aims of Therapeutic Exercise

I. The main aim of a therapeutic exercise plan is to achieve an optimal level of
pain free movement during normal to complex physical activities.

II. To enhance and restore physical function.To prevent loss of function.

III. To enhance a patient’s functional capabilities.

IV. To prevent and decrease impairment and disability.
V. To improve and maintain overall physical fitness & sense of well-being.

(I)Classification of Therapeutic Exercise on the

basis of force required to produce movement…

1. ROM (Range of motion) Exercise➡

I. Passive Exercise: this exercise is perform with the help of therapist.
a. Manual
b. Mechanical
II. Active Exercise: this exercise is perform by patient without help of
therapist.
a. Static Exercise
b. Assisted Exercise
c. Free Exercise
2. Resisted Exercise➡ Resistance Exercise is defined as movement using body weight
or external resistance that improves muscular strength, power, endurance
A. Isotonic
B. Isometric
C. Isokinetic
(II) Classification of therapeutic exercise
according to objective On the basis of aims and objectives therapeutic
exercise can be broadly categorized as
1. Strength exercise
2. Mobility/ flexibility exercise
3. Balance exercise
4. Breathing exercise
5. Endurance or cardiopulmonary exercise
6. Skill improvement exercise

Techniques-->
1. Demand as much activity as possible: It obtain when all the motor units are
activated at a same time. Contracting maximum.

2. Pattern of movement which are same as those used by the patient for his normal
functional activities: pattern of mass movement is used for most functional
activities.

3. When activity is impossible or contra-indicated than passive movement is used

the extensibility of the muscle and free range of motion.

RANGE OF MOTION (ROM) 😊

 Movement of the joint can be performed by the internal or external force. The
internal force can be produced by the muscles and the external force may be
produced by manually or mechanically.

 The movement of a joint results in angulations of that particular joint. The

angulation of the movements are referred as the range of motion. The ROM will
be perfect in one joint if the soft tissues are intact. If any change occurs in any
soft tissues results in disturbance or alteration of the range of motion.
Generally, in the hypomobile joint the ROM will be less than the normal
prescribed ROM of that particular joint. In hypermobile joint it is vise versa. This
ROM can be measured with the help of goniometer.

 There are two types of ROM

 (i) Active, and
 (ii) Passive

1. Active ROM: The ROM, which is achieved without any external force, i.e. by
the effort of his own called as active ROM. Generally, the Active ROM, will be less in
the hypomobile joint.

1. Passive ROM: The ROM which is achieved with the help of the external
force is called as Passive ROM. Normally, by the Passive ROM we can achieve
greater ROM than Active ROM. In hypomobile joint, the Passive ROM will be more
than the Active ROM because the tightened structures will be stretched by the
passive force but it can not achieve active.

Muscle Action 😊
In normal action a single muscle cannot
produce the effective movement. Depends on
the function of the muscles they are named as:

(i) agonists, (ii) antagonists,

(iii) synergists (iv) fixators.

Agonists:
These are chief muscles, which produce the effective movement. These groups of
muscles are called as prime movers.

Example: For elbow flexion biceps and brachialis are helpful, but the brachialis has
its major part in the contraction or movement. So, brachialis is called as the prime
mover or agonists.

Antagonists:
These are the muscles, which is acting against the agonists.

Example: Triceps act as the antagonists to the brachialis while flexing the elbow. If
the agonists contracts, the antagonist goes for relaxation by the neurological reflex.
Same
mechanism is used in the PNF techniques to reduce the spasm or the spasticity of
the muscle group.

Synergists:
The name itself explains us the muscle acting with the other muscle. The
synergists are acting with the agonists and making stronger the action of agonists.

Example: Biceps acts as synergists to brachialis for the elbow flexion.

Fixators:
Fixators are the muscle, which fixes the attachments of the agonists, antagonists
and synergists.

Example: The muscles attached with the shoulder girdle to the trunk acts as the
fixator for the deltoid action. Fixators are not only fixing the bonycomponent while
movement of agonists, antagonists or synergists and also have the dynamic
properties. It is not only having the isometric contraction but also has isotonic in
altering the pattern of movement.

KINEMATIC CHAIN
Two types of kinematic chains are present.
1. Closed kinematic chains
2. Open kinematic chains.
Closed Kinematic Chain➡
💠occurs
In human body the joints are having interlink with each other, so the motion
in one particular joint causes motion over the other joints in predictable
manner. In the closed kinematic chain the proximal and distal joint will be moving
to produce the movement over one particular joint. Example:
(1) Performing the sit-ups and
(2) performing the push-ups.

 In the first example the hip joint flexion and the ankle joint dorsiflexion occurs
to produce the flexion over the knee to go for the sitting posture.

🔶jointTheis proximal joint (hip) is moving towards the distal (ankle) joint but the distal
fixed without any movement. In the second example the shoulder extension
and wrist extension produce theelbow flexion to perform the push-ups. The
shoulder joint moves towards the fixed wrist.

💠
Open Kinematic Chain➡
The movement occurring independently and not in predictable manner. The
distal joint moving and the proximal joint will be fixed without any motion.

Example➡
a. In shoulder 90° flexion, performing the elbow flexion and extension movement.

b. In standing posture, the leg is lifted from the ground and performing the knee
flexion and extension movement.
 💠ICF💠
The International Classification of Functioning, Disability and Health (ICF) is a
framework for describing and organising information on functioning and disability.

Health Conditions (Pathological/ Pathophysiological Conditions)

Health conditions, based on the terminology of the ICF framework, are acute or
chronic diseases, disorders, or injuries that have an impact on a person’s level of
activity
Types of physical conditions: several physical conditions can be seen
and observe under human population such as…
1. Impairment: the state of having a physical or mental condition which
means that part of your body or brain does not work properly; a particular condition
of this sort.

Types of Impairment
In the ICF model, impairments are subdivided into impairments of body
function and body structure. Physical therapists typically provide care and
services to patients with impairments of body function and/or body
structure that
affect the following systems:
■ Musculoskeletal
■ Neuromuscular
■ Cardiovascular/pulmonary
■ Integumentary
2. Deformity: A deformity is a part of someone's body which is not the normal
shape because of injury or illness, or because they were born this way.

Categories of prevention. Prevention falls into three categories.

■ Primary prevention: Activities such as health promotion designed to
prevent disease in an at-risk population

■Secondary prevention: Early diagnosis and reduction of the severity or

duration of existing disease and sequelae

■ Tertiary prevention: Use of rehabilitation to reduce the degree or limit the

progression of existing disability and improve multiple aspects of function in
persons with chronic, irreversible health conditions
3. Disorder: An illness that disrupts normal physical or mental functions.
Types of disorder: Following are the common disorders
mood disorders (such as depression or bipolar disorder) anxiety disorders. personality
disorders. psychotic disorders (such as schizophrenia)

4. Disease: any harmful deviation from the normal structural or functional state
of an organism, generally associated with certain signs and symptoms.

Clinical Decision-Making:
 Clinical decision-making refers to a dynamic, complex process of
reasoning and analytical (critical) thinking that involves making
judgments and determinations in the context of ptient care

 One of the many areas of clinical decision-making in which a therapist

is involved is the selection, implementation, and modification of
therapeutic exercise interventions based on the unique needs of each
patient or client. To make effective decisions, merging clarification and
understanding with critical and creative thinking is necessary
A Patient Management Model:
The physical therapy profession has developed a comprehensive approach to patient
management designed to guide a practitioner through a systematic series of steps and
decisions for the purpose of helping a patient achieve the highest level
of functioning possible.

 Physical Therapist Practice, the process of patient management has five basic
components.
1. A comprehensive examination
2. Evaluation of data collected
3. Determination of a diagnosis based on impairments of body structure and function,
functional limitations (activity limitations), and disability (participation restrictions)
4. Establishment of a prognosis and plan of care based on patient-oriented goals
5. Implementation of appropriate interventions
Information Generated from the Initial History
Demographic Data
■ Age, sex, race, ethnicity
■ Primary language
■ Education
Social History
■ Family and caregiver resources
■ Cultural background
■ Social interactions/support systems
Occupation/Leisure
■ Current and previous employment
■ Job/school-related activities
■ Recreational, community activities/tasks
Growth and Development
■ Developmental history
■ Hand and foot dominance
Living Environment
■ Current living environment
■ Expected destination after discharge
■ Community accessibility
General Health Status and Lifestyle Habits and Behaviors: Past/Present
(Based on Self or Family Report)
■ Perception of health/disability
■ Lifestyle health risks (smoking, substance abuse)
■ Diet, exercise, sleep habits
Medical/Surgical/Psychological History
■ Previous inpatient or outpatient services
Medications: Current and Past
Family History
■ Health risk factors
■ Family illnesses
Cognitive/Social/Emotional Status
■ Orientation, memory
■ Communication
■ Social/emotional interactions
Current Conditions/Chief Complaints or Concerns
■ Conditions/reasons physical therapy services sought
■ Patient’s perceived level of daily functioning and disability
■ Patient’s needs, goals
■ History, onset (date and course), mechanism of injury,
pattern and behavior of symptoms
■ Family or caregiver needs, goals, perception of patient’s
problems
■ Current or past therapeutic interventions
■ Previous outcome of chief complaint(s)
Functional Status and Activity Level
■ Current/prior functional status: basic ADL and IADL related to self-care and
home
■ Current/prior functional status in work, school, communityrelated IADL
Other Laboratory and Diagnostic Tests

Specific Tests and Measures✳

Once it has been decided that a patient’s problems/conditions are most
likely amenable to physical therapy intervention, the next determination a
therapist must make during the examination process is to decide which
aspects of physical function
require further investigation through the use of specific tests and measures

They include but are not limited to:

■ Assessment of pain
■ Goniometry and flexibility testing
■ Joint mobility, stability, and integrity tests (including ligamentous testing)
■ Tests of muscle performance (manual muscle testing, dynamometry)
■ Posture analysis
■ Assessment of balance, proprioception, neuromuscular control
■ Gait analysis
■ Assessment of assistive, adaptive, or orthotic devices

Evaluation
Evaluation is a process characterized by the interpretation of collected data.
The process involves analysis and integration of information to form
opinions by means of a series of

clinical decisions.:
■ A patient’s general health status and its impact on current and potential
function
■ The acuity or chronicity and severity of the current condition
■ The extent of structural and functional impairments of body systems and
impact on functional abilities
■ Which impairments are related to which activity limitations
■ A patient’s current, overall level of physical functioning (limitations and
abilities) compared with the functional abilities needed, expected, or desired
by the patient
■ The impact of physical dysfunction on social/emotional function
■ The impact of the physical environment on a patient’s function
■ A patient’s social support systems and their impact on current, desired,
and potential function

PHYSIOLOGICAL CHANGES DURING EXERCISES (EXERCISE

PHYSIOLOGY)
Increasing muscular activity needs the more O2 and RBC supply to
the acting muscles. This can be done by:
• By increasing HR
• By increasing BP
• By increasing cardiac output
• By increasing venous return
• By reducing blood flow to the inactive muscles and non-vital
organs
• By redistributing the blood from the nonvital organ to vital organ.

1. Changes in Cardiovascular System

A. Effect on Heart: A prolonged exercise causes the enlargement

of heart. Generally, hypertrophy of the heart in athletes caused by
the strenuous exercises.
This type of hypertrophic and enlarged heart is totally different
from the diseased enlarged heart, i.e. cardiomegaly.
Effect on Heart Rate: The enormous increasing of the heart rate
observed at the beginning stage of the exercise and after some
time the raising ratio of heart rate comes down.
 During the early stage of the exercise the raising of the heart
rate due to
the cerebral activation on the medullary cardiac center.
 This heart rate raising differs from an individual to individual.

Effect on Cardiac Output :The cardiac output tremendously

increases with the strenuous exercise.

Effect on Venous Return

During the muscular exercise the venous return increase.

Effect on BP
The muscular exercise increases the systemic BP.

Effect on Circulation: During exercise blood supply to the active

muscles and vital organ increases,

2. Changes in Respiration

Pulmonary Ventilation
Pulmonary ventilation is so stable up to the severe exercise is
done. The pulmonary ventilation is not increasing with the
increasing of consumption of the O2 by the muscle tissue or the
O2 lack. This pulmonary ventilation
increases with the severe increasing of the workload.

Respiratory Rate
The O2 demand during the strenuous exercise increases the
respiratory rate of an individual.

Changes in Blood Cell

During the strenuous exercise the fluid enters into the tissue from
the blood. So, the hemoconcentration occurs but the prolonged
exercise may reduce the hemoconcentration by sending back the
fluid into the blood. Sometimes during the strenuous exercise the
hemolysis may also occur. The WBC count increases in any sort
of exercise.
 Changes in Blood Temperature: Muscular activity produces the
heat, if the heat
loss is less the body temperature goes up.
 Normally, during exercise the body temperature goes up due
to the temporary failure of the temperature regulation center
activation.

Effect on Kidney Functions: During the exercise the blood flow

to the non
vital and the inactive muscles decreases. Due to the decreased
blood flow to the kidney, there will be lacking of the urine
formation and the increased secretion of the ADH, this ADH
increases the fluid reabsorption.

Digestive System:The mild exercise, like walking, increases

the gastric juice secretion and the motility of stomach.

Therapeutic effect:Improved strength and endurance

 Improved range of motion (ROM)
 Decreased pain
 Improved functional abilities
 Improved quality of life overall

Indications
 Enable ambulation.
 Release contracted muscles, tendons, and fascia.
 Mobilize joints.
 Improve circulation.
 Improve respiratory capacity.
 Improve coordination.
 Reduce rigidity.
 Improve balance.

Contraindications
 Unstable angina.
 Systolic blood pressure higher than 180, and/or diastolic blood
pressure over 100mmHg.
 Blood pressure drops below 20mmHg during ETT.
 Resting heart rate above 100bpm.
 Uncontrolled arrhythmias.
 Heart failure.
 Unstable diabetes.
 Illnesses accompanied by fever.
Thank you

Dr. Kavita Meena

Department of Physiotherapy