A Framework for Exercise Prescription Flashcards
5 levels of exercise prescription
- tissue healing
- mobility
- performance initiation, stabilization, & motor control
- performance improvement
- advanced skill, agility, & coordination
Tissue healing interventions
- acute/post operative stage (inflammation)
- proliferative/repair stage (tissue integrity is stored but tissue strength is poor)
- remodeling stage (tissue returns to normal or near normal strength)
- main types of exercises that address tissue healing phase: ROM exercises, isometric exercises/quick flickering contractions to create blood flow, & unweighted concentric muscular contractions (AROM, AAROM)
Describe what we do during the inflammation phase
- pain before tissue resistance (open end feel) during a ROM exam
- it is necessary to promote healing
- must be managed/controlled with graded exercise interventions
- most protective phase of rehabilitation
- inflammation must be resolved to progress to proliferation phase but can progress exercises based on “trend”
Clinical signs of proliferation phase
- decreasing inflammation
- pain matches tissue resistance (typically at end range)
Clinical signs of remodeling phase
- no inflammation
- pain only after tissue resistance/stretch
- time line depends on tissue type
Exercise selection for muscle injury
- can control inflammation through light muscle contractions & pain-free ROM
- exercises can be active, passive, or active-assisted dependent on pain
- pain during exercise during inflammation phase = continued damage to injured tissues
- gradual increase in stress & strain (load) in a controlled manner assists int issue development
Exercise selection for bone injury
- heals via regeneration/remodeling w/o permanent scarring
- fracture site must be protected during first 2 weeks to build the initial callus
- after 2 weeks, controlled stress (Wolf’s law) for the next 4 weeks is advised
- evidence of a hard callus (usually X-ray) will indicate return to full activity
- bone healing can take place over 5 years
- LIFTMOR study = 5x5, >85% 1-RM, 2x/week for 8 months
Exercise selection for tendon/ligament injury
- heals by tenoblast proliferation at the cut ends of the structures
- typically immobilized for 2 weeks (short isometric exercises to increase blood flow, movement of injury tissue is ok for ligament but not for tendon)
- gradually increase loads from 2-12 weeks post injury
- avoid intensive exercise throughout remodeling phase (about 1 year)
Exercise selection for cartilage injury
- difficult to heal due to avascularity with limited vascular response/inflammation
- best healing is in the periphery or deep injury close to vascular supplies
- motion is critical to stimulate synovial fluid which contains cells needed for healing
- unloaded motion is optimal in initial stages to stimulate fluid w/o cartilage damage
Healing times based on tissue type and injury
- Exercise muscle soreness: 0-3 days
- Grade 1 muscle strain: 0-2 weeks
- Grade 2 muscle strain: 4 days to 3 months
- Grade 3 muscle strain: 3 weeks to 6 months
- Grade 1 ligament sprain: 0-3 days
- Grade 2 ligament sprain: 3 weeks to 6 months
- Grade 3 ligament sprain: 5 weeks to 1 year
- Ligament graft: 2 months to 2 years
- Tendinitis: 3-7 weeks
- Tendinosis: 3-6 months
- Tendon laceration: 5 weeks to 6 months
- Bone: 5 weeks to 3 months
- Articular cartilage repair: 2 months to 2 years
Application of ROM exercises for tissue healing
- high frequency short duration exercise bouts to promote circulation & laying down collagen in a functional manner
- several bouts each day as often as each hour with 10-30 reps
- incorporate into daily life (ex commercial break when watching TV)
- intensity should be very low at an RPE of 3 or less
- use pain as your guide and work in your pain free ROM
Application of isometric exercises for tissue healing
- high frequency of 20-30 reps every waking hour or as appropriate
- low intensity (25% or less of maximum voluntary isometric contraction (MVIC)
- perform a flicker, 1-2 sec holds for circulation; longer holds (10 secs) are used to progress or strengthen
- goal is not strengthening but to pump/increase circulation to the healing area
Describe the different types of ROM
- ROM: motion gained is due to decreased pain, swelling, or guarding)
- PROM: only used when patient is unable to actively contract muscle or there is a contraindication (tendon or ligament injuries), does not improve local circulation, prevent atrophy, increase strength or endurance
- AAROM: used when patient is unable to complete the full arc of motion, therapist can assist to ensure full ROM as indicated, sensory feedback is provided, good muscle pump, & stimulation to bone/joint
- AROM: preferred motion of choice, muscle contraction must be permitted & must be able to go through ROM without assistance
Contraindications and precautions during tissue healing
- Contraindications: stretching & resistance exercises should not be performed at the site of the inflamed or swollen tissue (can & should apply to joints above & below injury)
- Precautions: ensure proper dosage of rest & movement
- Signs of too much movement: movement increases pain or inflammation, too great of a dosage or it should not be done, monitor tolerance through verbal & non-verbal methods, and reassess at the conclusion of the session to ensure no damage has occurred
Impairments at body structure & function to be expected during tissue healing phase of exercise program
- inflammation, pain, edema, or muscle spasm
- impaired movement
- joint effusion
- restricted use of associated areas
Indications for exercises to address mobility impairments
- used for patients post acute injury or surgery
- commonly used after tissue healing exercises
- all signs of inflammation are absent or tending towards low levels
- pain should not increase during activities, want to avoid repetitive motions
- soft tissue restrictions such as capsular tightness, scarring, ligamentous tightness, & single joint muscle shortening may be addressed with mobility exercise
Exercises to address mobility impairments
- PROM, AAROM, & AROM
- stretching: manual, self, passive, active, or proprioceptive neuromuscular facilitation (PNF)
- joint & soft tissue mobilization
General precautions for mobility exercises
- no mobility exercise directly over a fracture site as part of HEP (or open wound)
- pain should not persist past 24 hours post exercise
- avoid overstretching: gaining mobility without motor control can lead to injury
Precautions/Contraindications for mobility exercises
- ROM should not be done when motion is disruptive to the healing process
- pain is your guide
- PROM is beneficial to the major joints
- AROM is used to minimize venous stasis/thrombus formation (ankle pumps)
- after MI, CABG, angioplasty AROM of the UE & limited walking are usually tolerated with careful monitoring
- sedation interruption followed by AROM with progression to sitting, standing, & walking may be initiated early on mechanically ventilated patients
Contraindications for stretching
- a bony block that limits joint motion
- recent fracture with incomplete bony union
- evidence of acute inflammatory or infectious process
- sharp/acute pain with joint movement/muscle elongation
- hematoma/other trauma
- joint hypermobility already exists (in some patient populations shortened tissues enable necessary joint stability)
Describe what should be performed during the performance initiation, stability, & motor control phase
- Indications: completed tissue healing & mobility phase, patient must have some pain free mobility to work with, & most signs of inflammation should be absent
- high reps & low intensity/load (<50% of 1RM)
- muscle contraction provides functional direction to lay down collagen
- repetitive contractions increase endurance
- foundation is established for proper recruitment of muscles including synergists & stabilizers to begin to develop motor control
Exercises for performance initiation, stability, & motor control phase
- Contractions used: isometric, isotonic/dynamic, eccentric, concentric, open chain, & closed chain
- Isometric contractions: progression from a flicker to longer sustained holds (6-10 secs)
- Isotonic/dynamic resistance exercise: low load resistance training is dictated by the specificity of training concept (need to stabilize = isometric or it’s an eccentric based movement = eccentric)
- perform daily at lower (25-50% of 1RM) intensities which can be determined by the modified sphygmomanometer test or equations/tables
- Motor control exercises: coordination around a joint/body part which involves motor & sensory components
- Stability exercises: the use od prolonged holds specific to the body structure/function or activity needing performance improvement
Difference between isotonic and isokinetic
- Isotonic: occurs when the force or tension in the muscle remains constant while the length of the muscle changes
- Isokinetic: occurs when the velocity of the muscle contraction remains constant while the length of the muscle changes
Difference between open chain and closed chain
- Open: distal body segment is free & not fixed to an object
- Closed: distal body segment is fixed
Examples of foundational motor control & stability exercises
- Rhythmic initiation: show the movement pattern, stretch, & then let the patient contract
- Dynamic alternating isometrics: holding the same position while being pushed in different directions
- Rhythmic stabilization: remove vision input & repeat dynamic alternating isometrics
- Resistance training throughout the functional ROM
Exercises for performance improvement
- the manipulation of load, intensity, speed, volume, & rest is paramount for accurate exercise prescription for muscle performance improvement
- guided by the specificity principle & the patient goals
- 4 domains: strength, hypertrophy, power, & endurance
Parameters for strength
- concentric and eccentric
- 60-80% of 1RM
- 7-12 reps for 1-4 sets
- multi-joint & single joint motions
- large before small, multi-joint before single, & higher intensity before lower
- 2-3 min. rest for multi-joint heavy loads & 1-2 min. rest for assistance exercises
- slow to moderate speeds
- 2-3x per week
parameters for hypertrophy
- concentric and eccentric
- 70-85% of 1RM
- 6-10 reps for 1-3 sets
- multi-joint & single joint motions
- large, multi-joint, higher intensity before small, single joint, & lower intensity
-1-2 min. rest - slow to moderate speed
- 2-3x per week
Parameters for power
- concentric and eccentric
- 30-80% of 1RM
- 7-30 reps for 1-3 sets
- multi-joint motions
- large, multi-joint, higher intensity before small, single joint, & lower intensity
- 2-3 min. rest multi-joint heavy loads & 1-2 min. rest for assistance exercises
- fast speed
- 2-3x per week
Parameters for endurance
- concentric and eccentric
- 30-60% of 1RM
- 12-30 reps for 4-7 sets
- multi-joint & single joint motions
- various sequencing
- <1 min. rest
- intentionally slow speed
- 2-3x per week
Exercises for advanced coordination, agility, & skill
- used when patients approach near normal strength, power, & endurance
- near normal ROM & have foundational motor control skills
- goal is to master a skill
- components of previous phases are combined
- agility training = speed + coordination
- Plyometric training
Describe plyometric training
- muscle as a spring = eccentric contraction to load then concentric to release
- amortization phase = transition (time) from eccentric to concentric contraction
- volume parameter is critical to understand, plyometrics are counted as contacts
Describe aerobic training
- Cardiopulmonary system: ensure the heart is out of the tissue healing phase
- Pulmonary system: ensure adequate mobility of the ribs
- aerobic exercise fits in the performance initiation, stability, & motor control phase
Describe balance training
- fits with the performance initiation, stability, & motor control phase & the advanced coordination, agility, & skill phase
Non-surgical patients rehab considerations
- patients will report some type of overuse or overload injury & major pathology or surgical intervention has been ruled out
- we use PEACE & LOVE for these patients
PEACE and LOVE for non-surgical patients
- Protection
- Elevation
- Avoid anti-inflammatories
- Compression
- Education
& - Load
- Optimism
- Vascularisation
- Exercise
Operative versus non-operative patient management principles
- Operative: protocol driven, emphasis on tissue healing timelines, & more disruptive to patient’s life
- Non-operative: emphasis on patient goals, evidence based practice (EBP), education, assistive device, bracing, manual therapy, physical agents, gradual improvement/decline in function during therapy, & surgical intervention may be indicated if the program fails
Indications for surgery for musculoskeletal disorders
- incapacitating pain at rest or with functional activities
- marked limitation of active or passive motion
- gross instability of a joint or body segment
- joint deformity or abnormal joint alignment
- significant structural degeneration
- chronic joint swelling
- failed conservative (non-surgical) or prior surgical management
- significant loss of function leading to disability as the result of any of the preceding factors
Preoperative management/intervention considerations
- assess preoperative status & review the plan of care
- discuss goals & expectations after surgery
- establish rapport
- education related to post surgery rehabilitation
- answer patient questions/concerns
- instruction for post operative care & preoperative exercise program
Factors that influence the components, progression, & outcomes of a postoperative rehab program
- size or severity of the lesion
- type & unique characteristics of the surgical procedure
- stage of healing
- characteristics of types of tissues involved
- response to immobilization & remobilization
- integrity of structures adjacent to involved structures
- age
- extent of impairments & functional limitations prior to surgery
- healthy history
- needs/support
- goals/expectations
- level of motivation & ability to adhere to an exercise program
- philosophy of the surgeon
Plan of care and intervention options for the maximum protection phase after surgery
Plan of care:
- education
- decrease pain, guarding, & spasm
- prevent infection
- minimize swelling
- prevent DVT/PE/pneumonia
- protect joint & minimize atrophy
- maintain mobility
Intervention options:
- review postoperative precautions/contraindications
- biophysical agents
- wound care education
- PEACE & LOVE
- massage
- early ROM as tolerated & AROM
- pulmonary care
- muscle setting execises
- active & resistive exercises to non-operative areas
- adaptive equipment & devices
Plan of care and intervention options for the moderate protection/controlled motion phase after surgery
Plan of care:
- education
- restore soft tissue & joint mobility
- establish mobile scar
- strengthen involved muscles & improve joint stability
Intervention options:
- teach to monitor effects of the program & adjust
- AAROM & AROM within pain limits
- joint mobilization
- scar massage
- progressive resistance program in open/closed chain positions
- light functional exercises with operated limb
Plan of care and intervention options for the minimum protection/return to function phase after surgery
Plan of care:
- education
- prevent re-injury/complications
- restore full joint/tissue ROM
- maximize muscle performance, stability, & motor control
- restore balance & coordinated movement
- relearn specific motor skills
Intervention options:
- emphasize gradual progression of muscle performance, mobility, & balance
- review signs & symptoms of excessive training
- self stretching techniques
- progressive strengthening program
- progressive balance/coordination training
- apply principles of motor learning (practice & feedback schedules)
