Therapeutic Exercises - 2
Description Of Module

Module Title: Therapeutic Exercises - 2

Module ID: PHT 352

Level: 5
‫ المستوى الخامس‬:‫مستوى المقرر‬

Credit Hours: 3(1+2+0)
3(1+2+0) :‫الساعات المعتمدة‬
٢ ‫ تمرينات عالجية‬:‫اسم المقرر‬
PHT 352 :‫رقم المقرر‬
Module Description
 This
course introduces the therapeutic
exercises which provide the student with
an understanding of the use of various
exercise
in
the
prevention
and
rehabilitation of injury and basic skills
involved in relaxation.
Module Aims
1. Basic principles, indications, contraindications, physiological &
therapeutic effects, precautions & dangers to be considered while
performing different types of exercises.
2. Able to express in writing and demonstration of different exercises
to be used in the postural rehabilitation, traction (Manual &
Mechanical), suspension therapy, relaxation exercises, group
exercises & Balance & coordination exercises including the patient
and therapist starting positions
Objectives of the lecture topic
Definition of good posture,
various muscles responsible
various different abnormal postures,
Active and passive and surgical Correction of abnormal posture,
General assessment of posture ,different braces used to correct and maintain
posture
Posture definition
* Posture is a “position or attitude of the body, the relative arrangement of body
parts for a specific activity, or a characteristic manner of bearing one’s body.
* It is alignment of the body parts whether upright, sitting, or recumbent.
* It is described by the positions of the joints and body segments and also in terms
of the balance between the muscles crossing the joints.
* Impairments in the joints, muscles, or connective tissues may lead to faulty
postures;
* faulty postures may lead to impairments in the joints, muscles, and connective
tissues as well as symptoms of discomfort and pain.
* Many musculoskeletal complaints can be attributed to stresses that occur from
repetitive or sustained activities when in a habitually faulty postural alignment.
Lateral view of standard
postural alignment
* A plumb line is typically used for
reference and represents the
relationship of the body parts with
the line of gravity.
Surface landmarks are slightly
anterior to the lateral malleolus,
slightly anterior to the axis of the
knee joint, through the greater
trochanter (slightly posterior to the
axis of the hip joint), through the
bodies of the lumbar and cervical
vertebrae, through the shoulder
joint and through the lobe of the
ear.
*
Curves of the Spine
The adult spine is divided into four
curves: two primary, or posterior,
curves, so named because they are
present in the infant and the
convexity is posterior;
and two compensatory, or anterior,
curves, so named because they
develop as the infant learns to lift the
head and eventually stand, and the
convexity is anterior.
Factors That Influence Posture

Aging- your body gradually loses its capacity to absorb and transfer forces

Inactivity/sedentary living/reluctance to exercise -leads to loss of natural
movement flow,

Poor postural habits -eventually becomes your structure,

Biomechanical compensation → muscle imbalance, adaptive shortening,

Body composition – increases load, stresses on spinal structure, leads to spinal

Workspace –ergonomics,

Poor movement technique/execution/training ,

Injury -leads to reduced loading capacity or elasticity,

Others:

*Posture is the single most common cause of painful soft tissue syndromes
affecting the body!
however its not aging that influences posture as does:
muscle weakness & instability within the “core”,
deviation,
Lordosis and Kyphosis

Anterior curves are in the cervical and lumbar regions.

Lordosis is a term also used to denote an anterior curve, although some
sources reserve the term lordosis to denote abnormal conditions such as
those that occur with a sway back.

Posterior curves are in the thoracic and sacral regions.
Kyphosis is a term used to denote a posterior curve.

Kyphotic posture refers to an excessive posterior curvature of the thoracic
spine.

The curves and flexibility in the spinal column are important for withstanding the
effects of gravity and other external forces. The structure of the bones, joints,
muscles, and inert tissues of the lower extremities are designed for weight bearing;
they support and balance the trunk in the upright posture.
Postural Stability In The Spine

1.
Spinal stability is described in terms of three subsystems:
passive (inert structures/bones and ligaments),
2.
active (muscles),
3.
and neural control.

The three subsystems are interrelated and can be thought of as a three-legged stool;
if any one of the legs is not providing support, it affects the stability of the whole.

Instability of a spinal segment is often a combination of tissue damage, insufficient
muscular strength or endurance, and poor neuromuscular control.
Muscles responsible for good posture



Abdominal muscles Rectus abdominis, Internal obliques (IO) and external
obliques (EO), Transversus abdominis (TrA),
Quadratus lumborum , Multifidus,
Intersegmental rotators and intertransversarii

Superficial erector spinae (ES) muscles (iliocostalis, longissimus, spinalis)

Iliopsoas (iliacus and psoas major)
Muscles responsible for good posture

Sternocleidomastoid and scalene group

Upper trapezius and cervical erector spinae.

Levator scapulae

Longus colli; rectus capitis anterior and lateralis
Stabilizing Features of Muscles Controlling the Spine
Global muscles

Characteristics
Core muscles
1.
Deep: closer to axis of motion
1- Superficial: farther from axis of motion.
2.
2- Cross multiple vertebral segments.
3.
Control segmental motion; segmental
guy wire function
4.
Greater percentage of type I muscle
fibers for muscular endurance

• Transversus abdominis, • Multifidus, •
Quadratus lumborum (deep portion), •
Deep rotators

• Rectus capitis anterior and lateralis, •
Longus colli
3- Produce motion and provide large guy wire
function.
4- Compressive loading with strong contractions.

Lumbar region: • Rectus abdominis, • External
and internal obliques, • Quadratus lumborum
(lateral portion), • Erector spinae, • Iliopsoas

Cervical region: • Sternocleidomastoid, •
Scalene, • Levator scapulae, • Upper
trapezius, • Erector spinae
Attach to each vertebral segment
Focus on Evidence

In a study that looked at 17 mechanical factors

and the occurrence of low back pain in 600
subjects (ages 20 through 65),

poor muscular endurance in the back extensors
muscles had the greatest association with low
back pain.
Muscle Control in the Lumbar Spine

The role of the transversus abdominis (TrA) and multifidus
muscles and their function as core stabilizers.

These deep muscles have segmental attachments in the
lumbar spine and are therefore able to provide
segmental control and stiffness.

Studies have shown that the deep fibers of the multifidi
and TrA are the first muscles to become active when
there is postural disturbance from rapid extremity
movements.
Abdominal muscles
The rectus abdominals ,
external oblique ,
and internal oblique
muscles are large, multi
segmental global
muscles and are
important guy wires for
stabilizing the spine
against postural
perturbations.
Muscles of the back
Deep core
muscles in
cervical
IMPAIRED POSTURE

Postural Habits

Good postural habits in the adult are necessary to avoid postural pain
syndromes and postural dysfunction. Also,

careful follow-up in terms of flexibility and posture training exercises is
important after trauma or surgery to prevent impairments from
contractures and adhesions.

In the child, good postural habits are important to avoid abnormal stresses
on growing bones and adaptive changes in muscle and soft tissue.
COMMON FAULTY POSTURES:
CHARACTERISTICS AND IMPAIRMENTS
1. Pelvic and Lumbar Region .
2. Cervical and Thoracic Region.
3. Frontal Plane Deviations from Lower Extremity Asymmetries
1-Pelvic and Lumbar Region
* Lordotic Posture

Lordotic posture is characterized by an increase in the lumbosacral angle
(the angle that the superior border of the first sacral vertebral body makes
with the horizontal, which optimally is 30 degree.

An increase in lumbar lordosis, and an increase in the anterior pelvic tilt
and hip flexion.

It is often seen with increased thoracic kyphosis and forward head and is
called kypholordotic posture.
Common Causes




Sustained faulty posture,
pregnancy,
obesity,
weak abdominal muscles .
Scoliosis

Scoliosis usually involves the thoracic and lumbar regions.

Typically, in right-handed individuals, there is a mild right thoracic, left lumbar Scurve, or a mild left thoracolumbar C-curve.

There may be asymmetry in the hips, pelvis, and lower extremities.

Structural scoliosis involves an irreversible lateral curvature with fixed rotation of
the vertebrae .



Rotation of the vertebral bodies is toward the convexity of the curve.
In the thoracic spine, the ribs rotate with the vertebrae so there is prominence
of the ribs posteriorly on the side of the spinal convexity and prominence
anteriorly on the side of the concavity.
A posterior rib hump is detected on forward bending in structural scoliosis .
SCOLIOSIS
Postural scoliosis.

Nonstructural scoliosis is reversible and can be
changed with forward or side bending and with
positional changes such as lying supine,
realignment of the pelvis by correction of a leglength discrepancy, or with muscle
contractions.

It is also called functional or postural scoliosis.
Potential Muscle Impairments

Mobility impairment in structures on the concave side of the curves.

Impaired muscle performance due to stretch and weakness in the
musculature on the convex side of the curves.

If one hip is adducted, the adductor muscles on that side have
decreased flexibility and the abductor muscles are stretched and
weak. The opposite occurs on the contralateral extremity.

With advanced structural scoliosis, cardiopulmonary impairment
may restrict function (RESTRICTIVE LUNG DISEASE).
Potential Sources of Symptoms

Stress to the anterior longitudinal ligament Narrowing of the posterior disk
space and narrowing of the intervertebral foramen.

This may compress the dura and blood vessels of the related nerve root or
the nerve root itself, especially if there are degenerative changes in the
vertebra or disk.

Approximation of the articular facets. The facets may become weight
bearing, which may cause synovial irritation and joint inflammation.
2- Cervical and Thoracic Region

Round Back (Increased Kyphosis) with Forward Head

The round back with forward head posture is characterized by an
increased thoracic curve, protracted scapulae (round shoulders), and
forward (protracted) head.

A forward head involves increased flexion of the lower cervical and the
upper thoracic regions, increase border of the first sacral vertebral body
makes with the horizontal, which optimally is 30 degree, an increase in
lumbar lordosis, and an increase in the anterior pelvic tilt and hip flexion.

It is often seen with increased thoracic kyphosis

and forward head and is called kypholordotic posture.
Common Causes

The effects of gravity, slouching, and poor ergonomic alignment in
the work or home environment.

Occupational or functional postures requiring leaning forward or
tipping the head backward for extended periods,

faulty sitting postures such as working at an improperly placed
computer keyboard or screen, relaxed postures, or the end result of
a faulty pelvic and lumbar spine posture are common causes of
forward head posture. Causes are similar to the relaxed lumbar
posture or the flat low-back posture, where there is continued
slouching, and overemphasis on flexion exercises in general
exercise programs.
3- Frontal Plane Deviations from Lower Extremity Asymmetries

Any lower extremity inequality has an effect on the pelvis that, in turn,
affects the spinal column and structures supporting it.

When dealing with spinal posture, it is imperative to assess lower extremity
alignment, symmetry, foot posture, ROM, muscle flexibility, and strength.

Frontal plane deviations may also be seen with faulty postural habits such
as perpetually standing with a pelvic drop on one side as frequently seen
with slouched postures.

This may result in muscle imbalances in the hip and spine and an apparent
leg-length discrepancy.
Common Causes

Asymmetry in the lower extremities may result from:

structural or functional deviations at the hip, knee, ankle, or foot.

Common functional problems include unilateral flat foot and imbalances
in the flexibility of muscles.

The resulting asymmetrical ground reaction forces transmitted to the pelvis
and back may lead to tissue breakdown and overuse, particularly as a
person ages, becomes overweight,

or is generally deconditioned from inactivity
Lordotic increase
lumbosacral
angle
slouched
Flat low
back
Flat upper
back and
cevicale
MANAGEMENT OF IMPAIRED POSTURE

Faulty posture underlies many spinal and extremity disorders.

Often by simply correcting the underlying postural stresses the primary
symptoms can be minimized or even alleviated.

Because of this the following guidelines may become a part of many of
the interventions.

Headaches are often a symptom of faulty posture.
GENERAL MANAGEMENT GUIDELINES
Before developing a plan of care and selecting interventions for
management, evaluate the findings from the examination of the patient,
including :
the history, review of systems, and specific tests and measures, and
document the findings.

Postural alignment (sitting and standing),

balance, and gait

ROM, joint mobility, and flexibility Muscular strength and endurance for
repetitions and Holding Ergonomic assessment if indicated Body
mechanics Cardiopulmonary endurance/aerobic capacity, breathing
Pattern Common impairments and a summary of the information that
follows on management of patients with impaired posture .
Postural Analysis and Assessment
 Static
Postural Assessment
 Dynamic
 Gait
Postural Assessment
analysis
 Flexibility
 Muscle
assessment
testing
Static Postural Assessment

Standing on both feet: front, side and rear views

Standing on one leg

Sitting supported and unsupported

Kneeling

Supine

Sleeping
Dynamic Postural Assessment

Performing:

A push- up

A squat- with arms in front, lifting overhead

A lunge

Walking

Lifting
Postural Alignment

Proprioception and Control Initially, good alignment may be prevented
because of

restricted mobility of muscle or connective tissue or malalignment of a
vertebral segment,

but developing patient awareness of balanced posture and its effects
should begin as soon as possible in the treatment program in conjunction
with stretching and muscle-training maneuvers.
MANAGEMENT GUIDELINES—Impaired Posture

• Pain (including headaches) from mechanical stress to sensitive structures and
from muscle tension

• Mobility impairment from muscle, joint, or fascial restrictions

• Impaired muscle performance associated with an imbalance in muscle
length and strength between antagonistic muscle

groups

• Impaired muscle performance associated with poor muscular endurance

• Insufficient postural control of stabilizing muscles

• Decreased cardiopulmonary endurance

• Altered kinesthetic sense of posture associated with poor neuromuscular
control and prolonged faulty postural habits

• Lack of knowledge of healthy spinal control and mechanics
MANAGEMENT GUIDELINES
******
Plan of Care Intervention

1. Teach procedures to develop active control of spinal and

1. Develop awareness and control of spinal alignment

extremity movement

in a variety of positions

2. Demonstrate relationship of symptoms with sustained or

2. Learn awareness between posture and pain

repetitive postures

3. Increase mobility in restricting muscles, joints, fascia


4. Develop neuromuscular control, strength, and
3. Manual stretching and joint mobilization; teach selfstretching

endurance in postural and extremity muscles

4. Stabilization exercises; progress repetitions and challenge;

5. Learn safe body mechanics

progress to dynamic strengthening exercises

6. Learn to correct stress provoking postures/activities

5. Functional exercises to prepare for safe mechanics

7. Learn stress management/relaxation

6. Adapt work, home, recreational environment

8. Improve aerobic capacity

7. Relaxation exercises and postural stress relief

9. Develop healthy exercise habits for self-maintenance

8. Implement and progress an aerobic exercise program

9. Integration of a fitness program, regular exercise and safe
body mechanics into daily
Visual reinforcement and Tactile reinforcement

Use mirrors so the patient can see how he or she looks, what it takes to assume
correct alignment, and then how it feels when properly aligned. Verbally reinforce
what the patient sees.

Tactile reinforcement.

Help the patient position the

head and trunk in correct alignment and touch the

muscles that need to contract to move and hold the

parts in place.
Cervical Retraction

Axial Extension (Cervical Retraction)

to Decrease a Forward Head Posture:

Patient position and procedure: Sitting or standing, with arms relaxed at the
side.

Lightly touch above the lip under the nose and ask the patient to lift the head
up and away.

Verbally reinforce the correct movement of tucking the chin in and
straightening the spine, and draw attention to the way it feels.

Have the patient move to the extreme of the correct posture and then return
to midline.
Scapular Retraction

Patient position and procedure: Sitting or standing. For

tactile and proprioceptive cues, gently resist movement of

the inferior angle of the scapulae and ask the patient to

pinch them together (retraction).

Suggest that the patient imagine “holding a quarter between the
shoulder blades.”

The patient should not extend the shoulders or elevate the scapula
Stretching Techniques for Common Mobility Impairments
•

Suboccipital region: self-stretch with capital nodding .
• Levator scapulae: self-stretch with scapular depression and cervical flexion and rotation to the
opposite side

• Scalenes: self-stretch with axial extension, side bend neck opposite and then rotate neck
toward side of restriction (see position.

• Pectoralis major and anterior thorax: self-stretch with corner stretches or lying supine on a
foam roll placed longitudinally under the spine

• Latissimus dorsi: self-stretch lying supine on a foam roll, reach arms overhead

• Lumbar and hip extensors: self-stretch lying supine, bring knees to chest; or quadruped
position, move buttocks back over the feet.

• Lumbar and hip flexors: self-stretch with prone press-ups or standing back bends .

• Tensor fascia lata: self-stretch either side-lying or standing Extend, laterally rotate, then
adduct the hip


• Hamstring: self-stretch with a straight-leg maneuver either lying supine or long-sitting
• Gastrocsoleus (heel cords): self-stretch in a forward stride position with the heel of the back
leg maintained on the floor, or stand on an incline board or edge of a step.
Streatching of
pectoralis
major
SCALENUS
MUSCLES
Anterior thorax
(a)
(B)
PECTORALIS MAJOR
OTHER INTERNAL ROTATOR
References

Therapeutic Exercise: Foundations and Techniques,
Carolyn Kisner, Lynn Allen Colby, F. A. Davis Company;
2012.

Therapeutic Exercise: From Theory to Practice, Michael
Higgins, F. A. Davis Company; 2011.

Therapeutic Exercise: Moving Toward Function, Lori Thein
Brody and Carrie M. Hall, Lippincot Williams & Wiking, 2010.