Therapeutic Exercise

Foundational Concepts

Lecture - 1
Dr. Momena Shahzad

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THERAPEUTIC EXERCISES & TECHNIQUES I

 CREDIT HOURS 3 (2-1)

Sessional exam 30
Final exam 40
Viva/Assignment 30
Total 100

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  A systematic, planned performance of bodily movements,
postures, or physical activities intended to provide a patient/client
with the means to:
Therapeutic ■ Remediate or prevent impairments.
Exercise ■ Improve, restore, or enhance physical function.
■ Prevent or reduce health-related risk factors.
■ Optimize overall health status, fitness, or sense of well-being.

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 Physical therapists design individualized therapeutic exercise programs according to
the unique needs of each patient or client.
 Patient: an individual diagnosed with impairments and functional deficits by a
physical therapist and is receiving physical therapy care to improve function and
prevent disability.
 Client: an individual without diagnosed dysfunction who engages in physical therapy
services to promote health and wellness and to prevent dysfunction.

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Components  The ability to function independently at home, in the workplace,
of Physical within the community, or during leisure and recreational activities is
contingent upon physical as well as psychological and social function.
Function

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 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; via interaction of the
sensory and motor systems.
 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.
 Cardiopulmonary fitness. The ability to perform moderate intensity, repetitive, total body
movements (walking, jogging, cycling, swimming) over an extended period of time. A
synonymous term is cardiopulmonary endurance.
 Muscle performance. The capacity of muscle to produce tension and do physical work.
Muscle performance encompasses strength, power, and muscular endurance.

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 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
 Flexibility. The ability to move freely, without restriction; used interchangeably with
mobility.
 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 (contractile and
noncontractile) extensibility; in addition, active mobility requires neuromuscular
activation.
 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. Joint stability is the
maintenance of proper alignment of bony partners of a joint by means of passive
and dynamic components.

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 Impairment of any one or more of the body systems and subsequent impairment of
any aspect of physical function, separately or jointly, can limit and restrict an
individual’s ability to carry out or participate in daily activities.
 Therapeutic exercise interventions involve the application of carefully graded physical
stresses and forces that are imposed on impaired body systems, specific tissues, or
individual structures in a controlled, progressive, safely executed manner to reduce
physical impairments and improve function.

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Types of  The techniques selected for an individualized therapeutic exercise
Therapeutic program are based on a therapist’s determination of the
underlying cause or causes of a patient’s impairments, activity
Exercise limitations, or participation restrictions (functional limitations or
disability).
Interventions

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Therapeutic Exercise Interventions

■ Aerobic conditioning and reconditioning

■ Muscle performance exercises: strength, power, and endurance training

■ Stretching techniques including muscle-lengthening procedures and joint

mobilization/manipulation techniques
■ Neuromuscular control, inhibition, and facilitation techniques and posture awareness training

■ Postural control, body mechanics, and stabilization exercises

■ Balance exercises and agility training

■ Relaxation exercises

■ Breathing exercises and ventilatory muscle training

■ Task-specific functional training

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  In a patient’s exercise program, safety is a fundamental consideration in
every aspect of the program.
 Prior to engaging in exercise, a patient’s health history and current
health status must be explored.
 A patient unaccustomed to physical exertion may be at risk for the
occurrence of an adverse effect from exercise associated with a known
or an undiagnosed health condition.
Exercise  Medications can adversely affect a patient’s balance and coordination
during exercise or cardiopulmonary response to exercise. Therefore,
Safety medical clearance from a patient’s physician may be indicated before
beginning an exercise program.
 The environment in which exercises are performed also affects patient
safety. Adequate space and a proper support surface for exercise are
necessary prerequisites for patient safety.
 If exercise equipment is used, equipment must be well maintained and
in good working condition, must fit the patient, and must be applied
and used properly.

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 In each specific exercise, the accuracy with which a patient performs an exercise affects
safety, including proper posture or alignment of the body, execution of the correct
movement patterns, and performance of each exercise with the appropriate intensity,
speed, and duration.
 A patient must be informed of the signs of fatigue, the relationship of fatigue to the risk
of injury, and the importance of rest for recovery during and after an exercise routine.
 In a clinical or home setting while learning an exercise program, the therapist can control
these variables.
 However, when a patient is carrying out an exercise program independently at home or
at a community fitness facility, patient safety is enhanced and the risk of injury or re-
injury is minimized by effective exercise instruction and patient education.
 Therapist safety also is a consideration to avoid work-related injury. For example, when a
therapist is using manual resistance during an exercise designed to improve a patient’s
strength or is applying a stretch force manually to improve a patient’s ROM, the therapist
must incorporate principles of proper body mechanics and joint protection into these
manual techniques to minimize his or her own risk of injury.

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Process and models of disablement

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  Disablement is a term that refers to the impact(s) and functional
The consequences of acute and chronic conditions, such as disease,
Disablement injury and congenital or developmental abnormalities, on specific
body systems that compromise basic human performance and an
process individual’s ability to meet necessary, expected and desired societal
functions and roles.

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• The Disablement Process, a socio-medical model of disability, is the main pathway
leads from pathology to impairments, functional limitations and disability. It is especially
useful for epidemiological and clinical research.
• The Disablement Process:
1) describes how chronic and acute conditions affect functioning in specific body
systems, generic physical and mental actions, and activities of daily life, and
2) describes the personal and environmental factors that speed or slow disablement,
namely, risk factors, interventions, and exacerbators.

• Disability is defined as difficulty doing activities in any domain of life (from hygiene to
hobbies, errands to sleep) due to a health or physical problem.
• Disability is not a personal characteristic, but is instead a gap between personal
capability and environmental demand.

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  Nagi model
Models of  International classification of Impairments, Disabilities and

Disablement Handicaps (ICIDH) for the World Health Organization ( WHO)

 International Classification of Functioning, Disability and Health (ICF)

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  The first two schema developed were the Nagi model and the
International Classification of Impairments, Disabilities, and
Handicaps (ICIDH) model for the World Health Organization
(WHO).
 The National Center for Medical Rehabilitation Research (NCMRR)
Models of integrated components of the Nagi model with the original ICIDH
Functioning model to develop its own model.
 The Nagi Disablement model was adopted early as a means to
and describe how a disease or a pathology results in impairments,
Disability functional limitations, and disability and how this may vary across
individuals. More recently, the Nagi Disablement model has been
replaced with the World Health Organization (WHO) International
Classification of Functioning (ICF) as a means to track how a health
condition affects activity.

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Key components

Active pathology: it is an interruption in normal body processes that leads to a

deviation from the normal state such as infection, trauma, disease processes or
other degenerative conditions.

Disease: a pathological condition of the body or abnormal entity with a

characteristic group of signs and symptoms that affect the body".

Impairment: a loss or abnormality at the tissue, organ and body system level

Functional limitations: refers to the individual’s inability to perform the tasks

and obligations of his/her usual roles and normal daily activities

Disability: a physical and /or mental limitation in performing socially defined

roles and tasks expected of an individual

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Patient Management and Clinical Decision Making:

An Interactive Relationship

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• Provision of quality patient care involves the ability to make sound clinical
judgments, solve problems that are important to a patient, and apply
knowledge of the relationships among a patient’s health condition(s),
impairments, limitations and restrictions in daily activities, and resulting
disability throughout each phase of management.

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  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 patient care.
 In clinical decision-making process, a therapist is involved in the
selection, implementation, and modification of therapeutic
Clinical exercise interventions based on the unique needs of each patient
Decision- or client.
 Clinical prediction rules (CPRs) are the tools, first developed in
Making medicine and now also have been developed for use by the
physical therapists, assist in the decision-making process and
ultimately improve patient care.
 A greater number of CPRs in physical therapy have been
established to predict likely responses of patients to treatment.

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  The process of patient management has five basic components:
 A comprehensive examination

A Patient  Evaluation of data collected

 Determination of a diagnosis based on impairments of body structure
Management and function, functional limitations (activity limitations), and disability
(participation restrictions)
Model  Establishment of a prognosis and plan of care based on patient-
oriented goals
 Implementation of appropriate interventions

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A comprehensive outcomes-oriented model of patient management.
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Examination
• First component of the patient management model.
• A systematic process by which a therapist obtains information about a patient’s problem(s) and his or
her reasons for seeking physical therapy services.
• If treatment of the identified problems does not fall within the scope of physical therapy practice,
referral to another healthcare practitioner or resource is warranted.
• There are three distinct elements of a comprehensive examination.
■ The patient’s health history

■ A relevant systems review

■ Specific tests and measures

1. History
• A mechanism by which a therapist obtains an overview of current and past information (subjective
and objective) about a patient’s present condition(s), general health status (health risk factors and
coexisting health problems).
• Sources of information about the patient’s history include:
■ Self-report
■ Interviews with family, or other significant individuals involved in patient care.
■ Review of medical record.
■ Reports from referral source, consultants, or other health-care team members.

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2. Systems Review
• A brief but relevant screening of the body systems, known as a systems review, is
performed during the patient interview as a part of the examination process after organizing
and prioritizing data obtained from the health history.
• The systems review serves to identify a patient’s symptoms that may have been overlooked
during the investigation of the patient’s chief symptoms.

3. Specific Tests and Measures

• Once it has been decided that a patient’s problems/conditions are most likely amenable to
physical therapy intervention, specific (definitive/diagnostic) tests and measures used by
physical therapists provide in-depth information about impairments, activity limitations,
participation restrictions/disabilities.

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Evaluation
• Evaluation is a process characterized by the interpretation of collected data.
• By pulling together and sorting out subjective and objective data from the examination, a
therapist should be able to determine the following:
■ General health status and its impact on current and potential function
■ Acuity or chronicity and severity of the current condition(s)
■ Extent of structural and functional impairments and impact on functional abilities
■ Impairments are related activity limitations
■ A patient’s current, overall level of physical functioning
■ Impact of physical dysfunction on social/emotional function
■ 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
Diagnosis
• The term diagnosis refers to either a process or a category (label).
•Diagnostic process is a complex sequence of actions and decisions that begins with:
(1) the collection of data (examination);
(2) the analysis and interpretation of all relevant data collected, leading to the generation
of working hypotheses (evaluation); and
(3) organization of data, recognition of clustering of data (a pattern of findings), formation
of diagnostic hypothesis, and subsequent classification of data into categories
(impairment-based diagnoses).
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Prognosis and Plan of Care
• A prognosis is a prediction of a patient’s optimal
level of function expected as the result of a plan for
treatment during an episode of care and the
anticipated length of time needed to reach specified
functional outcomes.
• Plan of care, an integral component of the
prognosis, delineates the following:
■ Anticipated goals.
■ Expected functional outcomes that are
meaningful, sustainable, and measurable.
■ Extent of improvement predicted and length
of time
necessary to reach that level.
■ Specific interventions.
■ Proposed frequency and duration of
interventions.
■ Specific discharge plans.

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Intervention
• Intervention, a component of patient management, refers to any purposeful interaction a therapist has that
directly relates to a patient’s care .
• 3 broad areas of intervention that occur during the course of patient, management.
■ Coordination, communication, and documentation

■ Procedural interventions

■ Patient-related instruction

Outcomes
• Simply stated, outcomes are results.
• Measurement of outcomes is a means by which quality, efficacy, and cost-effectiveness of services can
be assessed.
• Patient-related outcomes are monitored throughout an episode of physical therapy care—that is,
intermittently during treatment and at the conclusion of treatment.
Discharge Planning
• A patient is discharged from physical therapy services when the anticipated goals and expected outcomes
have been attained. The discharge plan often includes some type of home program, appropriate follow
up, possible referral to community resources, or re-initiation of physical therapy services.
• Discontinuation refers to the ending of services prior to the achievement of anticipated goals and
expected outcomes.

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Strategies for Effective Exercise

and

Task Specific Instruction

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• Effective strategies founded on principles of motor
learning that are designed to help patients initially
learn an exercise program under therapist
supervision and then carry it out on an independent
basis over a necessary period of time contribute to
successful outcomes for the patient.

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Concepts of Motor Learning:

A Foundation for Exercise

and Task-Specific Instruction

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• Motor learning is a complex set of internal processes that involves the acquisition and relatively
permanent retention of a skilled movement or task through practice.
• In literature a distinction is made between motor performance and motor learning.
• Performance involves acquisition of the ability to carry out a skill, whereas learning involves both
acquisition and retention.
Types of Motor Tasks
3 basic types of motor tasks: discrete, serial, and continuous.
• Discrete task. An action or movement with a recognizable beginning and end.
E.g. quadriceps setting exercise, grasping an object, doing a push-up, locking a wheelchair,
kicking a ball, lifting and lowering a weight or self-stretching maneuver.
• Serial task. A series of discrete movements that are combined in a particular sequence.
E.g. to eat with a fork, a person must be able to grasp the fork, hold it in the correct position,
pierce or scoop up the food, and lift the fork to the mouth.
Some serial tasks require specific timing between each segment of the task or momentum
during the task. Wheelchair transfers are serial tasks.
• Continuous task. A task involves repetitive, uninterrupted movements that have no distinct
beginning and ending.
E.g. walking, ascending and descending stairs, and cycling.

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