“The investment you make in yourself must
receive ‘Top Priority’. When you GROW your
entire world Expands...when you do not grow
your whole world starts to become ‘Very
Small’...that smallness reflects in all areas of life
including your income."
Bob Proctor
Author and Personal Coach
Therapeutic Exercise
Foundations and
Techniques
Abdel Hamid Nabil
MPT (Paediatric)
Lecturer
Introduction:
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THERAPEUTIC EXERCISE: IMPACT
ON PHYSICAL FUNCTION
Definition of Therapeutic Exercise
Aspects of Physical Function:
Definition of Key terms
Types of Therapeutic Exercise
Intervention
PATIENT MANAGEMENT
AND CLINICAL DECISION
MAKING:
AN INTERACTIVE
RELATIONSHIP
Clinical Decision Making
Evidence-Based Practice
A Patient Management Model
Definition of Therapeutic
Exercise
 Therapeutic exercise2 is the
systematic, planned performance of
bodily movements, postures, or
physical activities intended to provide
a patient/client with the means to
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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
Aspects of Physical Function:
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The ability to function independently at home, in the workplace, within
the community, or during leisure and recreational activities is contingent
upon physical as well as psychological and social function.
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.
Cardiopulmonary fitness.
The ability to perform low intensity,
repetitive, total body movements (walking,
jogging,
cycling, swimming) over an extended period of
time. ,a snonymous term is cardiopulmonary
endurance.
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. It is the basis of smooth, accurate,
efficient movement and occurs at a conscious or automatic
level.
Flexibility. The ability to move freely, without
restriction; used interchangeably with mobility.
Muscle performance. The capacity of muscle to
produce tension and do physical work. Muscle performance
encompasses strength, power, and muscular endurance.
Neuromuscular control. Interaction of the sensory and
motor systems that enables synergists, agonists and
antagonists,
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.
Postural control, postural stability, and equilibrium.
Used interchangeably with static or dynamic balance.
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 maintenence of proper alignment of bony partners of
a joint by means of passive and dynamic components.85
Types of Therapeutic Exercise
Intervention
• Aerobic conditioning and reconditioning
• Muscle performance exercises: strength, power, and
endurance training
• Stretching techniques including muscle-lengthening
procedures and joint mobilization 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
Exercise Safety
safety is a fundamental consideration in every aspect
of the therapeutic program whether the
exercises are performed independently or under a
therapist’s supervision.
Safety of the therapist must also be considered,
particularly when the therapist is directly involved
in the application of an exercise procedure or a
manual therapy technique.
Factors can influence a patient’s safety during
exercise.
patient’s health history
Medications
Environment
Fatigue
The Disablement Process
Definition
Disablement is a term that refers to the impact(s) and functional
consequences of acute or chronic conditions, such as disease,
injury, and congenital or developmental abnormalities, on
specific body systems that compromise basic human
performance and an individual’s ability to meet
Necessary, expected, and desired societal functions
and roles.
Models of Disablement
Nagi model
International
Classification of Impairments, Disabilities, and
Handicaps (ICIDH) model for the World Health Organization
(WHO).
International Classification of
Functioning, Disability, and Health (ICF).
Requirements for Skilled Clinical Decision
Making During Patient Management
Knowledge of pertinent information about the problem(s)
• Prior clinical experience with the same or similar problems
• Ability to recall relevant information
• Cognitive and psychomotor skills to obtain necessary
knowledge of an unfamiliar problem
• Ability to integrate new and prior knowledge
• An efficient information-gathering and information processing
style
• Ability to obtain, analyze, and apply evidence from the
literature
• Ability to critically organize, categorize, prioritize, and
synthesize information
• Ability to recognize clinical patterns
• Ability to form working hypotheses about presenting
problems and how they might be solved
• An understanding of the patient’s values and goals
• Ability to determine options and make strategic plans
• Use of reflective thinking and self-monitoring strategies
to make necessary adjustments
The process of evidence-based practice
1. Identify a patient problem and convert it into a specific
question.
2. Search the literature and collect clinically relevant, scientific
studies that contain evidence related to the question.
3. Critically analyze the pertinent evidence found during
the literature search and make reflective judgments
about the quality of the research and the applicability
of the information to the identified patient problem.
4. Integrate the appraisal of the evidence with clinical
expertise and experience and the patient’s unique circumstances
and values to make decisions.
5. Incorporate the findings and decisions into patient management.
6. Assess the outcomes of interventions and ask another
question if necessary.
The process of patient management has five basic
components.
A comprehensive examination
Evaluation of data collected
Determination of a diagnosis based on impairments, functional
limitations, and disability
Establishment of a prognosis and plan of care based on
patient-oriented goals
Implementation of appropriate interventions
STRATEGIES FOR EFFECTIVE EXERCISE AND TASK-SPECIFIC
INSTRUCTION
Practical Suggestions for Effective
Exercise Instruction
• Select a nondistracting environment for exercise instruction.
• Demonstrate proper performance of an exercise (safe vs.
unsafe movements; correct vs. incorrect movements).
Then have the patient model your movements.
• If appropriate or feasible, initially guide the patient
through the desired movement.
• Use clear and concise verbal and written directions.
• Complement written instructions for a home exercise
program with illustrations (sketches) of the exercise.
• Have the patient demonstrate an exercise to you as you
supervise and provide feedback.
• Provide specific, action-related feedback rather than general,
nondescriptive feedback. For example, explain why
the exercise was performed correctly or incorrectly.
• Teach an entire exercise program in small increments to
allow time for a patient to practice and learn components
of the program over several visits.
Concepts of Motor Learning: A Foundation of Exercise and
Task-Specific Instruction
Motor learning is a complex set of internal processes
that involves the relatively permanent acquisition and
retention of a skilled movement or task through practice.
Performance involves acquisition of a skill,whereas learning involves both
acquisition and retention.
Types of Motor Task
Discrete task. A discrete task involves a movement with a recognizable beginning
and end. Grasping an object, doing a push-up, or locking a wheelchair
Serial task. A serial task is composed of a series of discrete movements that are
combined in a particular sequence. For example, to eat with a fork, a person must
be able to grasp the fork, hold it in the correct position,
Continuous task. A continuous task involves repetitive, uninterrupted
movements that have no distinct beginning
and ending. Examples include walking, ascending and
descending stairs, and cycling.q
Range of Motion
Range of motion is a basic technique used for the examination
of movement and for initiating movement into a program of
therapeutic intervention.
Movement that is necessary to accomplish functional activities
can be viewed, in its simplest form, as muscles or external
forces moving bones in various patterns or ranges of motions.
TYPES OF ROM EXERCISES
Passive ROM. Passive ROM (PROM) is movement of a segment within the
unrestricted ROM that is produced entirely by an external force; there is little to or no
voluntary muscle contraction.
Active ROM. Active ROM (AROM) is movement of a segment within the
unrestricted ROM that is produced by active contraction of the muscles crossing
that joint.
Active-assistive ROM (AAROM) is a type of AROM in which assistance is provided
manually or mechanically by an outside force because the prime mover muscles need
assistance to complete the motion.
INDICATIONS AND GOALS FOR ROM
Passive ROM
Indications for PROM
In the region where there is acute, inflamed tissue, passive motion is beneficial;
When a patient is not able to or not supposed to actively move a segment or
segments of the body,
Goals for PROM
Maintain joint and connective tissue mobility
Minimize the effects of the formation of contractures
Maintain mechanical elasticity of muscle
Assist circulation and vascular dynamics
Enhance synovial movement for cartilage nutrition and
diffusion of materials in the joint
Decrease or inhibit pain
Assist with the healing process after injury or surgery
Help maintain the patient’s awareness of movement
Active and Active-AssistiveROM
Indications for AROM
1-Whenever a patient is able to contract the muscles actively and move a segment
with or without assistance,
2- When a patient has weak musculature and is unable to move a joint through the
desired range (usually against gravity),
3- AROM can be used for aerobic conditioning programs
Goals for AROM
1-Maintain physiological elasticity and contractility of the participating muscles
2-Provide sensory feedback from the contracting muscles
3-Provide a stimulus for bone and joint tissue integrity
4-Increase circulation and prevent thrombus formation
5-Develop coordination and motor skills for functional activities
LIMITATIONS OF ROM
Limitations of Passive Motion
1-Prevent muscle atrophy
2-Increase strength or endurance
3-Assist circulation
Limitations of Active ROM
For strong muscles, active ROM does not maintain or increase strength. It also does
not develop skill or coordination except in the movement patterns used.
PRECAUTIONS AND CONTRAINDICATIONS TO ROM
ROM should not be done when motion is disruptive to the healing process.
• Carefully controlled motion within the limits of pai
• PROM may be carefully initiated to major joints and AROM to ankles and feet to
minimize venous stasis and thrombus formation.
• After myocardial infarction, coronary artery bypass surgery,
AROM of upper extremities and limited walking are usually tolerated under careful
monitoring of symptoms.
Stretching
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Flexibility
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Flexibility is the ability to move a single joint or series of joints smoothly
and easily through an unrestricted, pain-free ROM.
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Dynamic flexibility.
The degree to which an active muscle contraction moves a body segment
through the available ROM of a joint.
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Passive flexibility.
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The degree to which a joint can be passively moved through the available ROM