Principles of Therapeutic
Exercise
Exercise Prescription
Week 4
Jane Simmonds
Format
• Exercise in the context of the physiotherapy
profession and practice
• Review the principles of training
• Review the different types of exercise
• Explore the concept of exercise prescription
for the prevention and management of
diseases and disorders
• Review muscle physiology
Learning Outcomes
• By the end of the session and independent
study you should;
– Understand the cope of exercise used in
physiotherapy practice
– Understand the principles of training
– Understand the concept of training variables
Core Skills - Physiotherapy
•
•
•
•
Movement analysis
Manual therapy
Electrotherapy
Exercise therapy – exercise prescription (ACPET)
Exercise for the prevention of
disease
• Relationship between a
sedentary lifestyle and
chronic degenerative
disorders
• More than 20 disorders
related to inactivity
• 50 years of research
– Seminal research bus
conductors
– Parffenbarger’s research
• Physiotherapists have a
role to play in health
promotion
Morris & Crawford 1958
Therapeutic Exercise
• Prevent or rehabilitate
disabilities
• Improve or restore
physical function so
that ADL’s are no longer
a challenge
• Improve overall health
and fitness
• Reduce risk factors
Rehabilitation Cycle
Functional fitness
and rehabilitation
Early to middle
management
Which patients groups benefit
from therapeutic exercise?
•
•
•
•
•
•
•
•
•
Cardiac patients
Orthopaedic patients
Amputees
General surgical
Neurological
Elderly
Learning disabilities
Psychiatric
Palliative care
•
•
•
•
•
•
•
•
•
Respiratory
Paediatric
Rheumatology
Musculo-skeletal
Occupational
Spinal injuries
Obstetrics
Gynacological
Burns and plastics
Aims of Therapeutic
Exercise
•
•
•
•
•
•
Enable ambulation
Release contracted
soft tissues
Mobilise joints
Improve circulation
Improve respiratory
capacity
Decrease stiffness
Aims of Therapeutic
Exercise
•
•
•
•
•
•
Improve muscle
strength
Improve endurance
Improve co-ordination
Promote confidence
and wellbeing
Improve balance
Promote relaxation
Overarching Goal
• To try whenever
possible to restore full
function and achieve an
optimal level of physical
fitness.
• Achieve this by setting
shared realistic goals
and identifying how fit
the client needs to be.
• Motivation
• Adherence, compliance
and concordance
Designing Exercise
Programmes
• When designing an
exercise programme
consider;
• Pathology
• Person (age, personality
– psychology)
• Needs - aspirations
• Environment
• Physiological processes
• Principles of training
Types of Exercises
• Stretching
• Range of movement
exercises
• Strengthening exercises
• Endurance exercises
• Proprioceptive or
balance training
• Cardio-vasacular
training
Principles of Training
•
•
•
•
•
•
•
Readiness
Overload
Specificity
Motivation
Learning
Reversibility
Diminishing returns
Prescription Variables
•
•
•
•
•
•
5 key components
Frequency
Duration
Intensity
Type of exercise
Progression
Stretching
• Passive or active
• Stretching to retain range
e.g. joint pathology
• Stretching to increase
normal range e.g. sport and
dance
• Stretching to lengthen
contracted, fibrosed,
shortened tissue e.g.
congenital conditions, postsurgery/immobilisation/inju
ry
• How long should we stretch
for?
Mobility Exercises
• Active assisted
 Usually used as interim
measure moving from
passive to active, also when
joint pain limits free active
movement
• Free active
• Knowledge of aging and
pathologies required to
prevent undesirable
movements e.g. trunk
flexion exercises in
osteoporosis
Cardio-respiratory Exercise
• Aerobic exercise positive influence on risk factors in
CVD, diabetes, weight control and cancer.
• Rehabilitation programmes for cardiac and
pulmonary patients
• Incremental monitored progression of exercise
• Early on: exercise not more than 20bpm above
resting level and not more than 11-12 on RPE (40%
Vo2 max)
• 40-80% MHR depending on fitness (MHR =220-age)
• Isometric exercises for vulnerable patients advise
isometric contraction ≤ 6 secs each
Monitoring
• Why is monitoring important?
• Heart rate
Pulse monitor, ECG, chest strap
• Blood pressure
Systolic/diastolic
• Subjective measure
Rating of perceived exertion (RPE)
Borg Scale
Proprioception
• Essential post-injury
especially lower limb
• Retraining for amputees
and neuro patients
• Elderly rehab, altered
joint biomechanics in
OA. ? May prevent falls
Muscle Contractions and
Resistance Exercises
• Consider why we might
choose these different
types of exercises?
• Are there any risks?
• Isometric
• Concentric
• Eccentric
• Isokinetic
• Closed and open chain
exercises
Strength, Power and Endurance
•
•
•
•
•
•
What is the difference?
Load (resistance)
Repetitions
Sets
Frequency
Consider muscle fibre
type
Muscle Fibre Types
• Skeletal muscle fibers are classified into two major categories;
slow-twitch (Type 1) and fast-twitch fibers (Type II).
• The difference between the two fibers can be distinguished
by;
– metabolism
– contractile velocity
– neuromuscular differences
– glycogen stores
– capillary density of the muscle
– and the actual response to hypertrophy
Fibre Type
• Slow twitch – type 1
–
–
–
–
–
Rich in haemaglobin
Mitochondria
Rich in blood vessels
Red
Common postural muscles.
• Slow twitch – type II
• Type II a - fast oxidative fatigue resistant – fast
oxidative fibres
• Type II (b)x - fast glycolytic
fibres - split ATP at a fast
rate and have a fast
contraction velocity.
Progressing Exercise
•
•
•
•
•
•
•
Overload principle
Motivation principle
Strength?
Endurance?
Power?
Complexity of task
Functional
Exercise Prescription
• Exercise prescription is based on physiological
principles and laws of training and modified
by clinical findings.
– Pain
– Underlying medical conditions – diabetes,
cardiovascular disease, diabetes, psychological
factors etc.
– Safety
Exercise prescription requires a
detailed knowledge of;
•
•
•
•
•
•
Motor learning
Anatomy
Biomechanics/pathomechanics
Kinesiology
Pathology
Exercise physiology
Exercise Psychology
• Adherence, compliance and concordance
• Goals
• Patient factors: age, sex, socio-economics,
fear, self-efficacy, support
• Programme factors: personnel, education,
attention, group dynamics, logistics
Summary
• Exercise prescription is a core skill
for physiotherapists
• Underpinned by physiological and
patho-physiological processes
• Requires a good understanding of
exercise physiology and the
principles of training
• Motivational psychology - stages
of change
• Imagination
References
• Hanandez Kravitz (2006)
http://www.unm.edu/~lkravitz/Article%20folder/hypertrophy.
html
• Robergs, R. A. and S. O. Roberts(1997) Exercise Physiology:
Exercise, Performance, and Clinical Applications. Boston,
WCB McGraw-Hill
• National Institute on Aging (2005)
www.niapublications.org/exercisebook/chapter4.htm .
• Skinner JS (2005) Exercise Testing and Exercise Prescription for
Special Cases. Philadelphia, Lippincott, Williams & Wilkins
• Woolf-May K (2006) Exercise Prescription – physiological
foundations. Churchill Livingstone