Lecture 6 - Exercise Prescription Flashcards
Definition of Therapeutic Exercise
(SPI) S: Systematic P. Planned performance: - physical movements - postures - activities I. Individualisation - meeting the unique needs of patient
Purpose of Therapeutic Exercise
- Remediate/ prevent impairments (body functions + structures)
- Improve and restore activities and participation
- Prevent/ reduce health-related risks
- Optimize overall health and fitness
Therapeutic Exercises Interventions
- Muscle performance (power + endurance)
- Cardiopulmonary endurance (aerobic + breathing ex.)
- Mobility / Flexibility (stretching techniques + joint mobilization)
- Neuromuscular control / coordination
- Stability
- Balance / postural equilibrium (ex. for balance and agility training)
4 body function impairments managed with Therapeutic ex.
- Musculoskeletal (pain, muscle weakness, decrease muscular endurance, limited ROM, faulty posture, muscle length imbalance)
- Neuromuscular (pain, impaired balance, postural stability or control, incoordination, delayed motor development, ineffective functional movement strategies)
- Cardiovascular/ Pulmonary (pain with sustained PA, decrease aerobic capacity, impaired circulation)
- Integumentary: skin hypomobility (immobile)
Common tasks related to Activity Limitations
- Reaching and grasping
- Bending and stooping
- Stand to sit (from and to chair/ floor)
- Moving around (crawling, walking, running) in various environments
How does body function affect participation?
Participation restrictions
- Self-care
- Mobility in the community –> socializing with friends and family
- Occupational tasks
- Home management (indoor and outdoor)
What makes a good patient management process?
Clinical decision making based on
- patient’s needs (selection, implementation, modification of ex. intervention)
- clinical reasoning and knowledge of PT practice
- evidence-based practice (use of current best evidence)
Clinical reasoning
What are the differences between PRIMARY and SECONDARY impairments?
Primary: directly from the health condition
Secondary: results of pre existing impairments
EX: Shoulder impingement syndrome
- Primary: structural issues
- Secondary: pre existing postural impairment (led to the use of upper extremity –> impingement from faulty mechanics)
Examples on task-specific functional training
Improve stair climbing ability of ambulatory older women
- climbing ups and downs stairs while wearing a weighted backpack
What are the benefits of task-specific functional training?
- improve muscle performance (strength and endurance)
- directly enhanced the subject’s efficiency in stair climbing during daily activities
Active ROM
Purpose of assessment and treatment
Assessment:
- AROM
- Muscle strength
- Ability to perform ADL (activities of daily living)
Treatment: Maintain/increase: 1. Joint ROM 2. Muscle strength 3. Ability to perform ADL (activities of daily living)
Exercise:
- Active ROM (Grade 2-3)
- Active assisted ROM (Grade 1-3)
Passive ROM
Purpose of assessment and treatment
Purpose:
- PROM
- End feel
Treatment:
maintain/increase
1. Joint ROM
Exercise: passive movement (Grade 0-1)
Muscle length
Purpose of assessment and treatment
Purpose:
- muscle length
Treatment:
maintain/increase
- muscle length
Exercise: stretching
Muscle strength
Purpose of assessment and treatment
Purpose:
- muscle strength
Treatment:
maintain/increase
- muscle strength
Exercise: resisted exercise (> Grade 3)
Universal Exercise prescription guide (5 points)
- Preparation (environment, equipment, explanation, patient position and exposure)
- Prescription procedure (provide correct exercise, instruction and demonstration)
- Therapist position (guide, support, protect, stabilise, observe)
- Exercise Intensity (FITT principle)
- Providing feedbacks (trick movement, unnecessary stress on other body parts)
4 Factors affect exercise safety
- medical history and current health status
- Medications
- Environment (inadequate space and support surface)
- Exercise equipment (not fit for the patient; not working)
How to improve exercise safety?
- Ensure accuracy of the performing exercise
- proper posture/ alignment of the body
- correct movement patterns
- appropriate intensity, speed, and duration
- Inform the patient (signs of fatigue; risk of injury due to fatigue; importance of rest after ex.)
How can a therapist minimise the risk of work-related injury?
- use proper body mechanics
2. Joint protection when applying resistance or a stretch force to improve patient/s strength or ROM
Practical suggestions for effective Exercise Instruction (give at least 3 suggestions)
- non-distracting environment
- Clear and concise verbal and written cues
- Demonstrate first
- Guide the patient through the desired movement
- Allow the patient demonstrate the exercise to you
- Provide specific feedback
- Home exercise with illustrations of the exercise
- Progress gradually
Factors that influence adherence to exercise program
- Patient related factors: age, sex, exercise habit, interest, motivation
- Health condition/impairment related (pain; the presence of comorbidities)
- Program-related: complexity and duration of the exercise program; interest of the patients
* Therefore, it is important to prescribe an exercise program that a patient and carer will follow
Strategies to foster patient adherence to exercise
(DEEP)
- Appreciate patient’s belief –> exercise to “get better”
- Help patient to identify personal benefits
- Design exercises that meet specific patient centered goals/functional outcomes
- Explain the rationale and importance of each exercise
- Engage patient in the exercise program design process
- Practical and functionally oriented ways –> patient can do it in daily life
- Keep an exercise log
- Follow-up visits (review/modify exercises)
- Point out the progress
- Identify barriers and offer suggestions (time? discomfort? no equipment?)
Clinical factors leads to decrease ROM
- Systemic, joint, neurological, muscular diseases
- Surgical or traumatic insuits
- Inactivity or immobilization
Aim of doing ROM activities
Maintain + Minimize
- Maintain joint and soft tissue mobility
- Minimize loss of tissue flexibility and contracture formation
Precautions and contraindications to ROM exercises
- Patient response or the condition is life-threatening
- During early phases of healing, motion should be within the limits of pain-free
- PROM for major joints; AROM for ankles and feet to minimize venous stasis and thrombus formation (**NOT after thrombosis is formed)
- Careful monitoring for patients with heart diseases
- Patients on mechanically ventilated: AROM and progression to sitting, standing and walking may initiate early
7 procedures for applying ROM
- Evaluate patient’s conditions
- Determine patient’s ability (PROM, A-AROM, or AROM)
- What movement patterns can best meet the goals
- The amount of motion
- Patient’s responses (vital signs, pain)
- Documentation of findings and intervention
- Re-evaluate and modify the intervention
How to apply ROM techniques?
- Control movement - grab the extremity (be careful of patient’s comfort)
- Support areas of poor structural integrity (EX. recent fracture site)
- Move the segment through its pain-free range
- Perform the motions smoothly
Definition of PROM exercise
- Movement of a segment within the unrestricted ROM produced entirely by an external force
- little to no voluntary muscle contraction
Main goal of PROM exercise
reduce complications due to immobilization
Sub goal of PROM exercise
MADE
- Maintain joint and connective tissues mobility; maintain patient’s awareness of movement
- Assist circulation and vascular dynamics
- Decrease pain
- Enhance synovial movement for cartilage nutrition
Indications for PROM exercise?
A patient cannot actively move a segment(s) of the body:
- Inflammation after injury/ surgery (usually lasts for 2 to 6 days)
- when active motion would compromise the repaired muscle
- complete bed rest
Limitations of Passive motion
- True PROM is difficult to obtain when muscle is innervated and the patient is conscious
- Passive motion does not:
- prevent muscle atrophy
- increase strength/endurance
- assist circulation (unlike AROM)
How do you perform shoulder flexion PROM exercise on patient?
- grasp the patient’s arm under the elbow with your lower hand
- With the top hand, cross over and grasp the wrist and palm of the patient’s hand
- Lift the arm through the available range and return
How do you perform Hip and Knee PROM exercise on patient?
Flexion and Extension
- Support and lift the patient’s leg with the palm and fingers of the top hand under
the patient’s knee and the lower hand under the heel - As the knee flexes full range, swing the fingers to the side of the thigh
Definition of Continuous Passive Motion (CPM)?
- Passive motion by mechanical device
2. Moves a joint slowly and continuously through a controlled ROM
Definition of A-AROM and AROM exercises
- movement of a segment within the unrestricted ROM produced by active contraction of the muscles crossing the joint
Main goal of A-AROM and AROM exercises (same as PROM plus + ?)
reduce complications due to immobilization
plus:
- Stimulate bone and joint tissue integrity
- Increase circulation and prevent thrombus formation
- Develop skills for functional activities (coordination and motor)
Indications for A-AROM and AROM
- person can contract the muscles and move a segment with/without assistance
- A-AROM: provide sufficient assistance to the muscles which allows it to function at its maximum level and be progressively strengthened
Limitations of AROM
- Does not maintain or increase strength for the muscle
- Does not develop skill/coordination (except for the movement patterns used)
Transition from PROM to AROM (Cautions)
- Gravity
- when the segment moves up against gravity –> provide assistance
- when moving parallel to the ground (gravity eliminated) –> ONLY support the muscles take part through the range
- When the segment moves downward (gravity “assisted”) –> muscle antagonist becomes active –> needs to support the muscle - Be aware of the above effects and modify the patient’s position to meet the goals for A-AROM and AROM
What are Self-assisted ROM techniques?
ROM exercises that patients can perform themselves
What are important when therapist prescript self-assisted ROM techniques to patients?
- Educate patients on the value of the motion
- Teach patients on correct body alignment and stabilization
- Observe patient performance and correct any substitute or unsafe motions
- Make sure all hazards are eliminated (if equipment is used)
- Provide drawings and clear guidelines for exercise dosage
- Modify or progress the exercise program
2 types of Self-assisted ROM techniques
- Manual
- Equipment
– Wand
– Wall climbing
– Pulleys
– Skate board /powder board
– Reciprocal exercise devices
Purpose of Wand (T-bar) Exercises
Patient usually has voluntary muscle control but needs guidance or motivation to complete the ROM
Actions:
- shoulder flexion
- horizontal abduction/adduction
- rotation
Purpose of Wall Climbing Exercise?
- provide the patient with objective reinforcement and motivation for
performing the task - visual feedback for the height reached
- Steps closer to the wall as the arm is elevated
Purpose of Overhead Pulleys Exercise
- used when extremity is involved to perform ROM exercise
- utilise more muscle activity than therapist-assisted ROM
- Used only when muscle activity is desired
Purpose of Skateboard/ powder board
- Slide along the smooth surface of the board
- Friction-free surface encourage movement without gravity resistance/friction
Purpose of Reciprocal Exercise Unit (bicycle, ergometer)
- provide some flexion and extension to the involved limb while using the strength of the normal limb
What is stretching exercise?
What is the 3-S Principle?
- force the motion passively beyond its available range
- Lengthens the targeted tissue beyond the point of tissue resistance
3=S Principle:
Slow
Sustained (>15 sec)
Stretch by therapist/ self stretching
