Some form of therapeutic exercise is indicated in almost every physical therapy case. Physical therapists may assist clients in designing therapeutic exercise programs
Therapeutic exercise includes a broad spectrum of activities, from passive range of motion and breathing exercises to high-speed agility drills. Precautions, therefore, are specific to each individual depending upon his or her condition. The physical therapist must use his or her specialized knowledge to determine exercises that are appropriate for a patient or client's level of ability, age, endurance, severity of injury and/or stage of recovery. Outlined below, however, are a few examples of situations in which general precautions should be observed.
A progression of therapeutic exercise is usually more gradual in a patient recovering from surgery than in one who did not require surgery, especially in order to allow inflamed tissues to heal. In general, specific joint motions and weightbearing are often restricted. High-intensity stretching and resistance exercise is usually limited for at least six weeks to allow adequate healing time for muscles or tendons that have been repaired.
In osteoporosis, bone resorption has taken place at a much higher rate than bone formation, resulting in weakened osseous structures. The risk for pathologic fracture resulting from very minor stress is high. In patients with osteoporosis, low-impact weight-bearing and endurance exercise should be introduced. Caution should be taken when adding resistive exercises, and explosive or twisting movements should be avoided altogether.
There are several high-risk conditions that are contraindications to exercise. These include: incompetent cervix, vaginal bleeding, placenta previa, preterm rupture of membranes, premature labor, and maternal heart disease, diabetes, or hypertension. Precautions need to be taken when women present with the following: multiple gestation, anemia, systemic infection, extreme fatigue, musculoskeletal pain, overheating, phlebitis, diastisis recti, or uterine contractions which last several hours after exercise. In these cases, women who participate in exercise should be monitored closely by both physician and therapist.
Resistance exercise is often a key part of a therapeutic exercise program; however, considerations must be made regarding risk factors. Resistive exercise should not be performed when there is muscle or joint inflammation, or when severe pain is present during or after exercise. Precautions should be taken with high-risk cardiovascular patients. All patients should be taught to avoid the Valsalva maneuver, excessive fatigue and over-work.
Joint mobilization techniques are often used to increase range of motion by passively distracting or gliding the joint surfaces. Gentle, small grade oscillatory movements may be used to inhibit pain and relax the patient; however, larger movements are contraindicated in the cases of hypermobility, joint effusion and inflammation. In addition, precautions should be taken when any of the following exist: malignancy, unhealed fracture, connective tissue or bone disease, total joint replacements, or weakened connective tissue (due to recent trauma, surgery, disuse, or medication).
Therapeutic exercise can be an intervention used in a physical therapy plan of care or as part of a recommendation in client consultation. The physical therapist uses a thorough examination including subjective and objective data to assess each patient's specific needs. It is clear that an 80-year-old woman with osteoporosis with a history of fractures is going to require a much different program from a 20-year-old athlete who wants to return to sports following a knee injury.
The main goal of therapeutic exercise is to improve or maintain functional ability, including daily living skills, through the application of careful and gradual forces to the body. Often, this overall goal is achieved through the objectives of developing, improving, restoring or maintaining one or more of the following: strength, endurance, flexibility, stability, coordination and/or balance.
Strength in muscular tissue is improved through graded and deliberate overloading of the targeted muscle(s). When the main focus is strength, exercise is usually performed against heavy loads with relatively few
Endurance affords individuals the ability to perform activities over a relatively prolonged period. When muscular endurance is developed, a muscle can generate and sustain a larger number of contractions over a period of time. With total body endurance, an individual develops the ability to participate in a period of low-intensity conditioning such as walking, jogging and other aerobic activity. Cardiovascular and pulmonary fitness are increased through this means. In a program directed at improving endurance, large muscle groups are recruited for prolonged periods of time (at least 15 minutes).
Contractile and noncontractile tissues both are susceptible to tightening when injured or exposed to a neurological disease process that causes weakening and/or spasticity. Prevention, through careful and regular movement and stretching, is key to maintaining flexibility. Consideration, however, must be taken regarding restrictions to mobility in post-operative or post-traumatic healing. Muscular flexibility may be increased or maintained through active or passive stretching, while connective tissue mobility requires passive procedures.
Stability is required in order to provide a stable base for functioning. Usually, stability concerns are focused on proximal musculature in the trunk, shoulders, and hips to allow for movement of the extremities.
Coordination and balance
The ability to execute complex patterns of movement with the right timing and sequencing is essential to motor function, as is the ability to maintain one's center of gravity over the available base of support. Coordination and balance are usually trained using motor learning principles, and are important components of a therapeutic exercise program designed to increase function.
Along with training in the above areas, therapeutic exercise may include education about body mechanics, gait and locomotion training, neuromuscular re-education, developmental activities and relaxation strategies. It is important to note also that, although trunk and extremity musculature may be the first to come to mind when discussing strength and endurance, physical therapists may also address ventilatory and pelvic-floor issues with therapeutic exercise.
Because the ultimate goal is function, any discussion about therapeutic exercise has to include the topic of closed-chain exercise, which is the movement of the body over a fixed distal segment such as the hand or foot. Open-chain exercise, in which the distal segment moves freely in space, is the traditional form seen in weight rooms; however, it does not train the patient to perform functional weight-bearing activities such as walking, stair climbing or jumping. If there is a restriction on weight bearing, closed-chain exercises should be delayed or modified to comply with restrictions. Modifications may include performing the exercise in a pool or while sitting instead of standing.
Depending on the individual, the anticipated outcomes may include:
- increase in physical function following a trauma or surgery
- maintenance of, or minimizing loss of, function with respect to a disease process
- prevention of complications post-operatively or after an injury
- prevention of future or further limitations or disability
These outcomes may be reached through increases in strength, endurance, flexibility, mobility, stability, coordination and/or balance. Numerous tests and measures are available to assist in assessing desired outcomes. Strength may be measured using electromyography, dynamometry, and/or manual muscle testing. Muscular endurance may be assessed with physical capacity tests, timed activity tests, and/or functional muscle tests. Aerobic endurance is often measured using cardiovascular and pulmonary signs and symptoms, ergometry, step tests, and timed walk/run, treadmill, or wheelchair tests. Flexibility can be measured by observation of functional range of motion, goniometry, inclinometry, and joint play movements. In addition, many motor control and function tests assess stability, coordination and balance.
Health care team roles
The physical therapist is responsible for evaluating the patient or client and developing a plan of care that includes appropriate therapeutic exercise intervention. The physical therapist also must teach, assist and monitor the patient with the exercise program. Modifications must be made as the patient shows signs of distress, inap-propriate
fatigue, or progress. The physical therapist assistant, under the supervision of a physical therapist, may participate in all aspects of care except for initialevaluation, modifications outside of the plan of care, orinterventions requiring the specific expertise of the physical therapist.
Motor learning—A set of processes related to practice or experience that results in relatively permanent changes in the ability to produce a skilled action.
Neuromuscular re-education—The training of an individual to recover or develop effective sensory and motor strategies for task demands.
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American Physical Therapy Association, 1111 North Fairfax St., Alexandria, VA 22314-1488. (703) 684-2782.<http://www.apta.org>.
Peggy Campbell Torpey, MPT