xi

Contributors

John D. Borstad, PT, PhDAssociate ProfessorDivision of Physical TherapyThe Ohio State UniversityColumbus, Ohio

Elaine L. Bukowski, PT, DPT, MS, (D)ABDAEmeritusProfessor and DirectorPhysical Therapy ProgramThe Richard Stockton College of New JerseyGalloway, New Jersey

John DeWitt, PT, DPT, SCS, ATCAssistant Clinical ProfessorDivision of Physical TherapyThe Ohio State UniversityTeam Leader—RehabilitationOSU Sports Medicine CenterColumbus, Ohio

Deborah L. Givens, PT, PhD, DPTProfessor and ChairDepartment of Physical TherapyCreighton UniversityOmaha, Nebraska

Karen L. Hock, PT, MS, CLT-LANAPhysical TherapistThe Ohio State University Comprehensive Cancer CenterArthur G. James Cancer Hospital and Richard J. Solove

Research InstituteThe Stefanie Spielman Comprehensive Breast CenterColumbus, Ohio

Karen Holtgrefe, PT, DHS, OCSAssociate Professor and ChairPhysical Therapy DepartmentCollege of Mount St. JosephCincinnati, Ohio

Barbara Settles Huge, PTWomen’s Health Specialist/ConsultantBSH WellnessAdjunct FacultyIndiana University Physical Therapy ProgramFishers, Indiana

Anne D. Kloos, PT, PhD, NCSAssociate Professor of Clinical Allied MedicineThe Ohio State UniversityColumbus, Ohio

Jacob N. Thorp, PT, DHS, MTCAssistant ProfessorEast Carolina UniversityGreenville, North Carolina

2574_FM_i-xxxii 25/08/12 7:26 PM Page xi

xv

Contents

Part I: General Concepts 1

Chapter 1: Therapeutic Exercise: FoundationalConcepts 1

Therapeutic Exercise: Impact on Physical Function 1

Definition of Therapeutic Exercise 2

Components of Physical Function: Definition of Key Terms 2

Types of Therapeutic Exercise Intervention 3

Exercise Safety 3

Classification of Health Status, Functioning, and Disability—Evolution of Models and Related Terminology 4

Background and Rationale for Classification Systems 4

Models of Functioning and Disability—Past and Present 4

Components of Functioning and Disability Models and Applications in Physical Therapy 5

Patient Management and Clinical Decision-Making: An Interactive Relationship 12

Clinical Decision-Making 12

Evidence-Based Practice 13

A Patient Management Model 15

Strategies for Effective Exercise and Task-Specific Instruction 27

Preparation for Exercise Instruction 27

Concepts of Motor Learning: A Foundation for Exercise and Task-Specific Instruction 27

Adherence to Exercise 36

Independent Learning Activities 37

Chapter 2: Prevention, Health, and Wellness 43Karen Holtgrefe, PT, DHS, OCSKey Terms and Concepts 43

Role of Physical Therapy in Healthy People 2020 43

Identifying Risk Factors 45

Determining Readiness to Change 45

Additional Factors Affecting the Ability to Change 46

Developing and Implementing a Program 46

Case Example: Exercise and Osteoporosis 47

Additional Considerations for Developing Prevention, Health, and Wellness Programs 48

Independent Learning Activities 49

2574_FM_i-xxxii 25/08/12 7:26 PM Page xv

Part II: Applied Science of Exerciseand Techniques 51

Chapter 3: Range of Motion 51

Types of ROM Exercises 52

Indications, Goals, and Limitations of ROM 52

Passive ROM 52

Active and Active-Assistive ROM 52

Precautions and Contraindications to ROM Exercises 53

Principles and Procedures for ApplyingROM Techniques 53

Examination, Evaluation, and Treatment Planning 53

Patient Preparation 54

Application of Techniques 54

Application of PROM 54

Application of AROM 54

ROM Techniques 54

Upper Extremity 54

Lower Extremity 59

Cervical Spine 62

Lumbar Spine 63

Self-Assisted ROM 63

Self-Assistance 63

Wand (T-Bar) Exercises 66

Wall Climbing 67

Overhead Pulleys 67

Skate Board/Powder Board 68

Reciprocal Exercise Unit 68

Continuous Passive Motion 68

Benefits of CPM 69

General Guidelines for CPM 69

ROM Through Functional Patterns 70

Independent Learning Activities 70

Chapter 4: Stretching for Impaired Mobility 72

Definition of Terms Associated with Mobility and Stretching 73

Flexibility 73

Hypomobility 73

Contracture 73

Selective Stretching 75

Overstretching and Hypermobility 75

Overview of Interventions to Increase Mobility of Soft Tissues 75

Indications, Contraindications, and Potential Outcomes of Stretching Exercises 76

Indications and Contraindications for Stretching 76

Potential Benefits and Outcomes of Stretching 76

Properties of Soft Tissue: Response to Immobilization and Stretch 77

Mechanical Properties of Contractile Tissue 78

Neurophysiological Properties of Contractile Tissue 80

Mechanical Properties of Noncontractile Soft Tissue 81

Determinants and Types of Stretching Exercises 85

Alignment and Stabilization 85

Intensity of Stretch 86

Duration of Stretch 87

Speed of Stretch 89

Frequency of Stretch 90

Mode of Stretch 90

Proprioceptive Neuromuscular FacilitationStretching Techniques 93

Integration of Function into Stretching 96

Procedural Guidelines for Application of Stretching Interventions 97

Examination and Evaluation of the Patient 97

Preparation for Stretching 98

Application of Manual Stretching Procedures 98

After Stretching 99

Precautions for Stretching 99

General Precautions 99

Special Precautions for Mass-Market Flexibility Programs 99

Adjuncts to Stretching Interventions 100

Complementary Exercise Approaches 100

Heat 101

Cold 102

Massage 102

Biofeedback 102

Joint Traction or Oscillation 102

xvi Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xvi

Manual Stretching Techniques in Anatomical Planes of Motion 103

Upper Extremity Stretching 103

Lower Extremity Stretching 108

Neck and Trunk 113

Self-Stretching Techniques 113

Independent Learning Activities 113

Chapter 5: Peripheral Joint Mobilization/Manipulation 119

Principles of Joint Mobilization/Manipulation 120

Definitions of Terms 120

Mobilization/Manipulation 120

Self-Mobilization (Auto-Mobilization) 120

Mobilization with Movement 120

Physiological Movements 120

Accessory Movements 120

Manipulation Under Anesthesia 121

Muscle Energy 121

Basic Concepts of Joint Motion: Arthrokinematics 121

Joint Shapes 121

Types of Motion 121

Passive-Angular Stretching Versus Joint-Glide Stretching 123

Other Accessory Motions that Affect the Joint 123

Effects of Joint Motion 124

Indications and Limitations for Useof Joint Mobilization/Manipulation 124

Pain, Muscle Guarding, and Spasm 124

Reversible Joint Hypomobility 124

Positional Faults/Subluxations 124

Progressive Limitation 125

Functional Immobility 125

Limitations of Joint Mobilization/Manipulation Techniques 125

Contraindications and Precautions 125

Hypermobility 125

Joint Effusion 125

Inflammation 125

Conditions Requiring Special Precautions for Stretching 125

Procedures for Applying Passive Joint Techniques 126

Examination and Evaluation 126

Documentation 126

Grades or Dosages of Movement for Non-Thrust and Thrust Techniques 126

Positioning and Stabilization 128

Direction and Target of Treatment Force 128

Initiation and Progression of Treatment 129

Patient Response 130

Total Program 130

Mobilization with Movement: Principles of Application 130

Principles and Application of MWM in Clinical Practice 130

Patient Response and Progression 131

Theoretical Framework 131

Peripheral Joint Mobilization Techniques 131

Shoulder Girdle Complex 131

Glenohumeral Joint 132

Acromioclavicular Joint 135

Sternoclavicular Joint 135

Scapulothoracic Soft-Tissue Mobilization 136

Elbow and Forearm Complex 137

Humeroulnar Articulation 137

Humeroradial Articulation 138

Proximal Radioulnar Joint 140

Distal Radioulnar Joint 140

Wrist and Hand Complex 141

Radiocarpal Joint 141

Carpometacarpal and Intermetacarpal Joints of Digits II–V 143

Carpometacarpal Joint of the Thumb 144

Metacarpophalangeal and Interphalangeal Joints of the Fingers 145

Hip Joint 145

Knee Joint Complex 147

Tibiofemoral Articulations 147

Patellofemoral Joint 149

Leg and Ankle Joints 150

Tibiofibular Joints 150

Talocrural Joint (Upper Ankle Joint) 151

Subtalar Joint (Talocalcaneal), Posterior Compartment 152

Intertarsal and Tarsometatarsal Joints 153

Intermetatarsal, Metatarsophalangeal, and Interphalangeal Joints 154

Independent Learning Activities 155

Contents xvii

2574_FM_i-xxxii 25/08/12 7:26 PM Page xvii

Chapter 6: Resistance Exercise for Impaired Muscle Performance 157

Muscle Performance and Resistance Exercise: Definitions and Guiding Principles 158

Strength, Power, and Endurance 158

Overload Principle 160

SAID Principle 160

Reversibility Principle 160

Skeletal Muscle Function and Adaptation to Resistance Exercise 161

Factors that Influence Tension Generation in Normal Skeletal Muscle 161

Physiological Adaptations to Resistance Exercise 167

Determinants of Resistance Exercise 170

Alignment and Stabilization 170

Intensity 171

Volume 173

Exercise Order 174

Frequency 174

Duration 174

Rest Interval (Recovery Period) 174

Mode of Exercise 175

Velocity of Exercise 176

Periodization and Variation of Training 177

Integration of Function 177

Types of Resistance Exercise 177

Manual and Mechanical Resistance Exercise 178

Isometric Exercise (Static Exercise) 179

Dynamic Exercise: Concentric and Eccentric 180

Dynamic Exercise: Constant and Variable Resistance 183

Isokinetic Exercise 184

Open-Chain and Closed-Chain Exercise 186

General Principles of Resistance Training 192

Examination and Evaluation 192

Preparation for Resistance Exercises 192

Implementation of Resistance Exercises 192

Precautions for Resistance Exercise 194

Valsalva Maneuver 194

Substitute Motions 195

Overtraining and Overwork 195

Exercise-Induced Muscle Soreness 196

Pathological Fracture 197

Contraindications to Resistance Exercise 198

Pain 198

Inflammation 198

Severe Cardiopulmonary Disease 198

Manual Resistance Exercise 198

Definition and Use 198

Guidelines and Special Considerations 199

Techniques: General Background 200

Upper Extremity 200

Lower Extremity 204

Proprioceptive Neuromuscular Facilitation: Principles and Techniques 207

Diagonal Patterns 208

Basic Procedures with PNF Patterns 208

Upper Extremity Diagonal Patterns 209

Lower Extremity Diagonal Patterns 212

Specific Techniques with PNF 214

Mechanical Resistance Exercise 215

Application in Rehabilitation Programs 216

Application in Fitness and Conditioning Programs 216

Special Considerations for Children and Older Adults 217

Selected Resistance Training Regimens 219

Progressive Resistance Exercise 219

Circuit Weight Training 220

Isokinetic Regimens 220

Equipment for Resistance Training 222

Free Weights and Simple Weight-Pulley Systems 222

Variable Resistance Units 225

Elastic Resistance Devices 225

Equipment for Dynamic Stabilization Training 228

Equipment for Closed-Chain Training 229

Reciprocal Exercise Equipment 230

Isokinetic Testing and Training Equipment 231

Independent Learning Activities 232

xviii Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xviii

Chapter 7: Principles of Aerobic Exercise 241Karen Holtgrefe, PT, DHS, OCSKey Terms and Concepts 241

Physical Activity 241

Exercise 242

Physical Fitness 242

Maximum Oxygen Consumption 242

Endurance 242

Aerobic Exercise Training (Conditioning) 242

Adaptation 242

Myocardial Oxygen Consumption 242

Deconditioning 243

Energy Systems, Energy Expenditure, and Efficiency 243

Energy Systems 243

Energy Expenditure 244

Efficiency 244

Physiological Response to Aerobic Exercise 245

Cardiovascular Response to Exercise 245

Respiratory Response to Exercise 245

Responses Providing Additional Oxygen to Muscle 245

Testing as a Basis for Exercise Programs 246

Fitness Testing of Healthy Subjects 246

Stress Testing for Convalescing Individuals and Individuals at Risk 246

Multistage Testing 247

Determinants of an Exercise Program 247

Frequency 247

Intensity 247

Exercise Program 250

Warm-Up Period 250

Aerobic Exercise Period 250

Cool-Down Period 251

Application 251

Physiological Changes that Occur With Training 251

Cardiovascular Changes 251

Respiratory Changes 252

Metabolic Changes 252

Other System Changes 253

Application of Principles of an Aerobic Conditioning Program for the Patient with Coronary Disease 253

Inpatient Phase (Phase I) 253

Outpatient Phase (Phase II) 253

Outpatient Program (Phase III) 254

Special Considerations 255

Adaptive Changes 255

Applications of Aerobic Training for the Deconditioned Individual and the Patient with Chronic Illness 255

Deconditioning 255

Reversal of Deconditioning 255

Adaptations for Participation Restrictions (Disabilities), Activity Restrictions (Functional Limitations), and Deconditioning 256

Impairments, Goals, and Plan of Care 256

Age Differences 256

Children 257

Young Adults 257

Older Adults 258

Independent Learning Activities 259

Chapter 8: Exercises for Impaired Balance 260Anne D. Kloos, PT, PhD, NCSDeborah L. Givens, PT, PhD, DPTBackground and Concepts 260

Balance: Key Terms and Definitions 260

Balance Control 261

Sensory Systems and Balance Control 261

Motor Strategies for Balance Control 263

Balance Control Under Varying Conditions 265

Impaired Balance 268

Sensory Input Impairments 268

Sensorimotor Integration Impairments 268

Biomechanical and Motor Output Impairments 269

Deficits with Aging 269

Deficits from Medications 270

Management of Impaired Balance 270

Examination and Evaluation of Impaired Balance 270

Balance Training 272

Health and Environmental Factors 276

Evidence-Based Balance Exercise Programs for Fall Prevention in the Elderly 277

Evidence-Based Balance Exercise Programs for Specific Musculoskeletal Conditions 282

Independent Learning Activities 284

Contents xix

2574_FM_i-xxxii 25/08/12 7:26 PM Page xix

Chapter 9: Aquatic Exercise 290Elaine L. Bukowski, PT, DPT, MS, (D)ABDAEmeritus

Background and Principles for Aquatic Exercise 290

Definition of Aquatic Exercise 290

Goals and Indications for Aquatic Exercise 291

Precautions and Contraindications toAquatic Exercise 291

Precautions 291

Contraindications 292

Properties of Water 292

Physical Properties of Water 292

Hydromechanics 293

Thermodynamics 294

Center of Buoyancy 294

Aquatic Temperature and Therapeutic Exercise 294

Temperature Regulation 294

Mobility and Functional Control Exercise 295

Aerobic Conditioning 295

Pools for Aquatic Exercise 295

Traditional Therapeutic Pools 295

Individual Patient Pools 295

Special Equipment for Aquatic Exercise 296

Collars, Rings, Belts, and Vests 296

Swim Bars 297

Gloves, Hand Paddles, and Hydro-tone®

Balls 297

Fins and Hydro-tone® Boots 297

Kickboards 297

Pool Care and Safety 298

Exercise Interventions Using an AquaticEnvironment 298

Stretching Exercises 298

Manual Stretching Techniques 298

Spine Stretching Techniques 299

Shoulder Stretching Techniques 300

Hip Stretching Techniques 300

Knee Stretching Techniques 301

Self-Stretching with Aquatic Equipment 301

Strengthening Exercises 302

Manual Resistance Exercises 302

Upper Extremity Manual Resistance Techniques 303

Lower Extremity Manual Resistance Techniques 305

Direction of Movement 306

Dynamic Trunk Stabilization 306

Independent Strengthening Exercises 307

Aerobic Conditioning 309

Treatment Interventions 310

Physiological Response to Deep-Water Walking/Running 310

Proper Form for Deep-Water Running 310

Exercise Monitoring 311

Equipment Selection 311

Independent Learning Activities 311

Part III: Principles of Intervention 315

Chapter 10: Soft Tissue Injury, Repair, and Management 315

Soft Tissue Lesions 315

Examples of Soft Tissue Lesions: Musculoskeletal Disorders 315

Clinical Conditions Resulting from Trauma or Pathology 316

Severity of Tissue Injury 316

Irritability of Tissue: Stages of Inflammation and Repair 317

Management During the Acute Stage 318

Tissue Response: Inflammation 318

Management Guidelines: Protection Phase 318

Management During the Subacute Stage 320

Tissue Response: Proliferation, Repair, and Healing 320

Management Guidelines: Controlled Motion Phase 320

Management During the Chronic Stage 323

Tissue Response: Maturation and Remodeling 323

Management Guidelines: Return to Function Phase 323

Cumulative Trauma: Chronic Recurring Pain 325

Tissue Response: Chronic Inflammation 325

Causes of Chronic Inflammation 326

Contributing Factors 326

Management Guidelines: Chronic Inflammation 326

Independent Learning Activities 328

xx Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xx

Chapter 11: Joint, Connective Tissue, and Bone Disorders and Management 330Carolyn Kisner, PT, MSKaren Holtgrefe, PT, DHS, OCSArthritis: Arthrosis 330

Clinical Signs and Symptoms 330

Rheumatoid Arthritis 331

Osteoarthritis: Degenerative Joint Disease 335

Fibromyalgia and Myofascial Pain Syndrome 338

Fibromyalgia 338

Myofascial Pain Syndrome 339

Osteoporosis 340

Risk Factors 341

Prevention of Osteoporosis 341

Recommendations for Exercise 342

Precautions and Contraindications 342

Fractures and Posttraumatic Immobilization 342

Risk Factors 344

Bone Healing Following a Fracture 344

Principles of Management: Period of Immobilization 345

Postimmobilization 345

Independent Learning Activities 347

Chapter 12: Surgical Interventions and Postoperative Management 351

Indications for Surgical Intervention 351

Guidelines for Preoperative and Postoperative Management 352

Considerations for Preoperative Management 352

Considerations for Postoperative Management 353

Potential Postoperative Complications and Risk Reduction 357

Deep Vein Thrombosis and Pulmonary Embolism: A Closer Look 358

Overview of Common Orthopedic Surgeries and Postoperative Management 360

Surgical Approaches: Open, Arthroscopic, and Arthroscopically Assisted Procedures 361

Use of Tissue Grafts 361

Repair, Reattachment, Reconstruction, Stabilization, or Transfer of Soft Tissues 362

Release, Lengthening, or Decompression of Soft Tissues 364

Joint Procedures 365

Extra-articular Boney Procedures 369

Independent Learning Activities 371

Chapter 13: Peripheral Nerve Disorders and Management 374

Review of Peripheral Nerve Structure 375

Nerve Structure 375

Mobility Characteristics of the Nervous System 375

Common Sites of Injury to Peripheral Nerves 376

Impaired Nerve Function 386

Nerve injury and Recovery 386

Mechanisms of Nerve Injury 387

Classification of Nerve Injuries 387

Recovery from Nerve Injuries 387

Management Guidelines: Recovery from Nerve Injury 389

Neural Tension Disorders 390

Symptoms and Signs of Impaired Nerve Mobility 391

Causes of Symptoms 391

Principles of Management 391

Precautions and Contraindications to Neural Tension Testing and Treatment 392

Neural Testing and Mobilization Techniques for the Upper Quadrant 392

Neural Testing and Mobilization Techniques for the Lower Quadrant 393

Musculoskeletal Diagnoses Involving ImpairedNerve Function 395

Thoracic Outlet Syndrome 395

Related Diagnoses 395

Etiology of Symptoms 396

Sites of Compression or Entrapment 397

Common Structural and Functional Impairments in TOS 397

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 397

Nonoperative Management of TOS 397

Carpal Tunnel Syndrome 398

Etiology of Symptoms 398

Examination 398

Contents xxi

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxi

Common Structural and Functional Impairments 399

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 399

Nonoperative Management of CTS 400

Surgical and Postoperative Management for CTS 401

Ulnar Nerve Compression in Tunnel of Guyon 402

Etiology of Symptoms 402

Examination 402

Common Structural and Functional Impairments 403

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 403

Nonoperative Management 403

Surgical Release and Postoperative Management 403

Complex Regional Pain Syndrome: Reflex Sympathetic Dystrophy andCausalgia 403

Related Diagnoses and Symptoms 403

Etiology and Symptoms 403

Clinical Course 404

Common Structural and Functional Impairments 404

Management 405

Independent Learning Activities 406

Part IV: Exercise Interventions by Body Region 409

Chapter 14: The Spine: Structure, Function, and Posture 409

Structure and Function of the Spine 409

Structure 409

Functional Components of the Spine 409

Motions of the Spinal Column 410

Arthrokinematics of the Zygapophyseal (Facet) Joints 411

Structure and Function of Intervertebral Discs 412

Intervertebral Foramina 414

Biomechanical Influences on Postural Alignment 414

Curves of the Spine 414

Gravity 414

Stability 415

Postural Stability in the Spine 415

Inert Structures: Influence on Stability 415

Muscles: Influence on Stability 417

Neurological Control: Influence on Stability 422

Effects of Limb Function on Spinal Stability 423

Effects of Breathing on Posture and Stability 423

Effects of Intra-abdominal Pressure and the Valsalva Maneuver on Stability 423

Impaired Posture 424

Etiology of Pain 424

Effect of Mechanical Stress 424

Effect of Impaired Postural Support from Trunk Muscles 424

Effect of Impaired Muscle Endurance 424

Pain Syndromes Related to Impaired Posture 425

Common Faulty Postures: Characteristics and Impairments 425

Pelvic and Lumbar Region 425

Cervical and Thoracic Region 426

Frontal Plane Deviations: Scoliosis and Lower Extremity Asymmetries 427

Management of Impaired Posture 429

General Management Guidelines 429

Awareness and Control of Spinal Posture 429

Posture, Movement, and Functional Relationships 431

Joint, Muscle, and Connective Tissue Mobility Impairments 431

Impaired Muscle Performance 432

Body Mechanics 432

Ergonomics: Relief and Prevention 432

Stress Management/Relaxation 433

Healthy Exercise Habits 434

Independent Learning Activities 434

Chapter 15: The Spine: Management Guidelines 438Carolyn Kisner, PT, MS Jacob N. Thorp, PT, DHS, MTC

Spinal Pathologies and Impaired Spinal Function 439

Pathology of the Intervertebral Disc 440

Injury and Degeneration of the Disc 440

Disc Pathologies and Related Conditions 441

Signs and Symptoms of Disc Lesions and Fluid Stasis 442

xxii Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxii

Pathomechanical Relationships of the Intervertebral (IV) Disc and Facet Joints 444

Disc Degeneration 444

Related Pathologies 444

Pathology of the Zygapophyseal (Facet) Joints 445

Common Diagnoses and Impairments from Facet Joint Pathologies 445

Pathology of the Vertebrae 446

Compression Fracture Secondary to Osteoporosis 446

Scheuermann’s Disease 446

Pathology of Muscle and Soft Tissue Injuries: Strains, Tears, and Contusions 446

General Symptoms from Trauma 447

Common Sites of Lumbar Strain 447

Common Sites of Cervical Strain 447

Postural Strain 447

Emotional Stress 447

Activity Limitations and Participation Restrictions 447

Pathomechanics of Spinal Instability 448

Neutral Zone 448

Instability 448

Management Guidelines Based on Stages of Recovery and Diagnostic Categories 449

Principles of Management for the Spine 449

Examination and Evaluation 449

General Guidelines for Managing Acute Spinal Impairments: Protection Phase 450

General Guidelines for Managing SubacuteSpinal Impairments: Controlled Motion Phase 452

General Guidelines for Managing Chronic Spinal Impairments: Return to Function Phase 454

Management Guidelines: Nonweight-Bearing Bias 454

Management of Acute Symptoms 454

Progression 455

Management Guidelines: Extension Bias 455

Principles of Management 456

Indications, Precautions, and Contraindications for Interventions: Extension Approach 456

Interventions Using an Extension Approach in the Lumbar Spine 457

Interventions to Manage a Disc Lesion in the Cervical Spine 460

Disc Lesions: Surgery and Postoperative Management 460

Indications for Surgery 460

Common Surgeries 460

Procedures 461

Postoperative Management 461

Management Guidelines: Flexion Bias 462

Principles of Management 462

Indications and Contraindications for Intervention: Flexion Approach 462

Techniques Utilizing a Flexion Approach 462

Management Guidelines: Stabilization 464

Identification of Clinical Instability 464

Principles of Management 464

Management Guidelines: Mobilization/Manipulation 465

Management: Lumbar Spine 465

Management: Cervical Spine 465

Management Guidelines: Soft Tissue Injuries 466

Management During the Acute Stage: Protection Phase 466

Management in the Subacute and ChronicStages of Healing: Controlled Motion and Return to Function Phases 467

Management of Regional Diagnoses 467

Lower Thoracic and Lumbopelvic Region 469

Compression Fracture Secondary to Osteoporosis 469

Spondylolisthesis 469

Ankylosing Spondylitis 470

Scheuermann’s Disease 470

Rib Subluxation 470

Sacroiliac Joint Dysfunction 471

Cervical and Upper Thoracic Region 473

Tension Headache/Cervical Headache 473

Cervical Myelopathy 475

Neck Pain 475

Temporomandibular Joint Dysfunction 475

Structure and Function 475

Signs and Symptoms 475

Contents xxiii

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxiii

Etiology of Symptoms 476

Principles of Management and Interventions 477

Independent Learning Activities 478

Chapter 16: The Spine: Exercise and Manipulation Interventions 485Carolyn Kisner, PT, MS Jacob N. Thorp, PT, DHS, MTC

Basic Concepts of Spinal Management with Exercise 486

Fundamental Interventions 486

Patient Education 487

General Exercise Guidelines 487

Kinesthetic Awareness 487

Mobility/Flexibility 489

Muscle Performance 489

Cardiopulmonary Endurance 489

Functional Activities 489

Kinesthetic Awareness 489

Elements of Functional Training: Fundamental Techniques 489

Position of Symptom Relief 489

Effects of Movement on the Spine 490

Blending of Kinesthetic Training, Stabilization Exercises, and Fundamental Body Mechanics 490

Progression to Active and Habitual Control of Posture 490

Mobility/Flexibility 490

Cervical and Upper Thoracic Region:Stretching Techniques 491

Techniques to Increase Thoracic Extension 491

Techniques to Increase Axial Extension (Cervical Retraction): Scalene Muscle Stretch 492

Techniques to Increase Upper Cervical Flexion: Short Suboccipital Muscle Stretch 492

Traction as a Stretching Technique 493

Cervical Joint Manipulation Techniques 493

Manipulation to Increase Cervical Flexion 494

Manipulation to Increase Cervical Extension 494

Manipulation to Increase Cervical Rotation 495

Manipulation to Increase Cervical Rotation and Side Bending 495

Manipulation to Increase Cervical Rotation and Side Bending: Alternate Technique 495

Muscle Energy Techniques to IncreaseCraniocervical Mobility 496

To Increase Craniocervical Flexion 496

To Increase Craniocervical Rotation 496

Mid and Lower Thoracic and Lumbar Regions: Stretching Techniques 497

Techniques to Increase Lumbar Flexion 497

Techniques to Increase Lumbar Extension 497

Techniques to Increase Lateral Flexibility of the Spine 497

Techniques to Increase Hip Muscle Flexibility 499

Traction as a Stretching Technique 499

Thoracic and Lumbar Joint Manipulation and HVT Techniques 500

Manipulation Techniques to Increase Thoracic Spine Extension 500

Manipulation Techniques to Increase Thoracic Spine Flexion 501

Manipulation to Increase Thoracic Spine Rotation 501

Pistol Thrust to Increase Thoracic Spine Mobility 502

Cross-Arm Thrust to Increase Thoracic Spine Mobility 502

Fall Thrust to Increase Thoracic Spine Mobility 503

Rib Manipulation for Expiratory Restriction 503

Rib Manipulation for Inspiratory Restriction 503

Elevated First Rib Manipulation 504

Manipulation Techniques to Increase Lumbar Spine Extension 504

Manipulation Techniques to Increase Lumbar Spine Rotation 504

Manipulation to Increase Lumbar Intervertebral Side Bending 505

HVT Lumbar Roll to Increase Lumbar Rotation 505

SI Joint Manipulation Technique to Increase Sacral Nutation (Flexion) 506

SI Joint Manipulation Technique to IncreaseSacral Counternutation (Extension) 506

Posterior Rotation Manipulation to Innominate 506

Muscle Performance: Stabilization, MuscleEndurance, and Strength Training 507

Stabilization Training: Fundamental Techniques and Progressions 507

xxiv Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxiv

Guidelines for Stabilization Training 508

Deep Segmental Muscle Activation and Training 509

Global Muscle Stabilization Exercises 513

Isometric and Dynamic Exercises 521

Exercises for the Cervical Region 522

Exercises for the Thoracic and Lumbar Regions 523

Cardiopulmonary Endurance 528

Common Aerobic Exercises and Effects on the Spine 529

Cycling 529

Walking and Running 529

Stair Climbing 529

Cross-Country Skiing and Ski Machines 529

Swimming 529

Upper Body Ergometers 529

Step Aerobics and Aerobic Dancing 529

“Latest Popular Craze” 529

Functional Activities 530

Early Functional Training: Fundamental Techniques 530

Preparation for Functional Activities: Basic Exercise Techniques 530

Weight-Bearing Exercises 531

Transitional Stabilization Exercises 532

Body Mechanics and Environmental Adaptations 533

Principles of Body Mechanics: Instruction and Training 533

Environmental Adaptations 534

Intermediate to Advanced Exercise Techniques for Functional Training 534

Repetitive Lifting 534

Repetitive Reaching 534

Repetitive Pushing and Pulling 535

Rotation or Turning 535

Transitional Movements 535

Transfer of Training 535

Patient Education for Prevention 535

Independent Learning Activities 535

Chapter 17: The Shoulder and Shoulder Girdle 539Carolyn Kisner, PT, MSLynn Allen Colby, PT, MSJohn D. Borstad, PT, PhD

Structure and Function of the Shoulder Girdle 540

Joints of the Shoulder Girdle Complex 540

Synovial Joints 540

Functional Articulations 542

Scapular Stability 543

Shoulder Girdle Function 544

Scapulohumeral Rhythm 544

Clavicular Elevation and Rotation with Humeral Motion 544

External Rotation of the Humerus with Full Elevation 545

Deltoid–Short Rotator Cuff and Supraspinatus Mechanisms 545

Referred Pain and Nerve Injury 545

Common Sources of Referred Pain in the Shoulder Region 545

Nerve Disorders in the Shoulder Girdle Region 545

Management of Shoulder Disorders and Surgeries 545

Joint Hypomobility: Nonoperative Management 545

Glenohumeral Joint 545

Acromioclavicular and Sternoclavicular Joints 552

Glenohumeral Joint Surgery and Postoperative Management 552

Glenohumeral Arthroplasty 553

Painful Shoulder Syndromes (Rotator Cuff Disease and Impingement Syndromes): Nonoperative Management 561

Related Pathologies and Etiology of Symptoms 561

Common Structural and Functional Impairments 564

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 565

Management: Painful Shoulder Syndromes 565

Painful Shoulder Syndromes: Surgery and Postoperative Management 567

Subacromial Decompression and Postoperative Management 567

Rotator Cuff Repair and Postoperative Management 570

Shoulder Instabilities: Nonoperative Management 577

Related Pathologies and Mechanisms of Injury 577

Contents xxv

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxv

Closed Reduction of Anterior Dislocation 579

Closed Reduction Posterior Dislocation 580

Shoulder Instabilities: Surgery and Postoperative Management 581

Glenohumeral Joint Stabilization Procedures and Postoperative Management 581

Acromioclavicular and Sternoclavicular Joint Stabilization Procedures and Postoperative Management 588

Exercise Interventions for the Shoulder Girdle 588

Exercise Techniques During Acute and Early Subacute Stages of Tissue Healing 588

Early Motion of the Glenohumeral Joint 589

Early Motion of the Scapula 590

Early Neuromuscular Control 590

Exercise Techniques to Increase Flexibility and Range of Motion 590

Self-Stretching Techniques to Increase Shoulder ROM 591

Manual and Self-Stretching Exercises for Specific Muscles 593

Exercises to Develop and Improve Muscle Performance and Functional Control 596

Isometric Exercises 596

Stabilization Exercises 598

Dynamic Strengthening Exercises: Scapular Muscles 601

Dynamic Strengthening Exercises: Glenohumeral Muscles 605

Functional Progression for the Shoulder Girdle 608

Independent Learning Activities 610

Chapter 18: The Elbow and Forearm Complex 618

Structure and Function of the Elbow and Forearm 619

Joints of the Elbow and Forearm 619

Elbow Joint Characteristics and Arthrokinematics 619

Forearm Joint Characteristics and Arthrokinematics 620

Muscle Function at the Elbow and Forearm 620

Primary Actions at the Elbow and Forearm 621

Relationship of Wrist and Hand Muscles to the Elbow 621

Referred Pain and Nerve Injury in the Elbow Region 621

Common Sources of Referred Pain into the Elbow Region 621

Nerve Disorders in the Elbow Region 621

Management of Elbow and Forearm Disorders and Surgeries 622

Joint Hypomobility: Nonoperative Management 622

Related Pathologies and Etiology of Symptoms 622

Common Structural and Functional Impairments 623

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 623

Joint Hypomobility: Management—Protection Phase 623

Joint Hypomobility: Management—Controlled Motion Phase 623

Joint Hypomobility: Management—Return to Function Phase 625

Joint Surgery and Postoperative Management 625

Radial Head Excision or Arthroplasty 626

Total Elbow Arthroplasty 628

Myositis Ossificans 635

Etiology of Symptoms 636

Overuse Syndromes: Repetitive Trauma Syndromes 636

Related Pathologies 636

Etiology of Symptoms 637

Common Structural and Functional Impairments 637

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 637

Nonoperative Management of Overuse Syndromes: Protection Phase 637

Nonoperative Management: Controlled Motion and Return to Function Phases 638

Exercise Interventions for the Elbow and Forearm 640

Exercise Techniques to Increase Flexibility and Range of Motion 640

Manual, Mechanical, and Self-Stretching Techniques 640

xxvi Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxvi

Self-Stretching Techniques: Muscles of the Medial and Lateral Epicondyles 642

Exercises to Develop and Improve Muscle Performance and Functional Control 642

Isometric Exercises 642

Dynamic Strengthening and Endurance Exercises 643

Functional Progression for the Elbow and Forearm 645

Independent Learning Activities 648

Chapter 19: The Wrist and Hand 651

Structure and Function of the Wrist and Hand 651

Joints of the Wrist and Hand 652

Wrist Joint: Characteristics and Arthrokinematics 652

Hand Joints: Characteristics and Arthrokinematics 652

Hand Function 654

Muscles of the Wrist and Hand 654

Grips and Prehension Patterns 656

Major Nerves Subject to Pressure and Trauma at the Wrist and Hand 657

Nerve Disorders in the Wrist 657

Referred Pain and Sensory Patterns 657

Management of Wrist and Hand Disorders and Surgeries 657

Joint Hypomobility: Nonoperative Management 657

Common Joint Pathologies and Associated Impairments 657

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 659

Joint Hypomobility: Management—Protection Phase 660

Joint Hypomobility: Management—Controlled Motion and Return to Function Phases 660

Joint Surgery and Postoperative Management 662

Wrist Arthroplasty 663

Metacarpophalangeal Implant Arthroplasty 666

Proximal Interphalangeal Implant Arthroplasty 671

Carpometacarpal Arthroplasty of the Thumb 675

Tendon Rupture Associated with RA: Surgical and Postoperative Management 678

Repetitive Trauma Syndromes/Overuse Syndromes 680

Tendinopathy 680

Traumatic Lesions of the Wrist and Hand 681

Simple Sprain: Nonoperative Management 681

Lacerated Flexor Tendons of the Hand: Surgical and Postoperative Management 681

Lacerated Extensor Tendons of the Hand: Surgical and Postoperative Management 690

Exercise Interventions for the Wrist and Hand 696

Techniques for Musculotendinous Mobility 696

Tendon-Gliding and Tendon-Blocking Exercises 697

Scar Tissue Mobilization for Tendon Adhesions 699

Exercise Techniques to Increase Flexibility and Range of Motion 700

General Stretching Techniques 700

Stretching Techniques of the Intrinsic and Multijoint Muscles 701

Exercises to Develop and Improve Muscle Performance, NeuromuscularControl, and Coordinated Movement 702

Techniques to Strengthen Muscles of the Wrist and Hand 702

Dexterity and Functional Activities 704

Independent Learning Activities 704

Chapter 20: The Hip 709

Structure and Function of the Hip 710

Anatomical Characteristics of the Hip Region 710

Boney Structures 710

Hip Joint Characteristics and Arthrokinematics 710

Influence of the Hip Joint on Balance and Posture Control 711

Functional Relationships in the Hip Region 711

Motions of the Femur and Muscle Function 711

Motions of the Pelvis and Muscle Function 711

Hip, Knee, and Ankle Functional Relationships in Weight Bearing 714

Pathomechanics in the Hip Region 714

Contents xxvii

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxvii

The Hip and Gait 716

Hip Muscle Function and Gait 716

Effect of Musculoskeletal Impairments on Gait 716

Referred Pain and Nerve Injury 716

Major Nerves Subject to Injury or Entrapment 717

Common Sources of Referred Pain in the Hip and Buttock Region 717

Management of Hip Disorders and Surgeries 717

Joint Hypomobility: Nonoperative Management 717

Related Pathologies and Etiology of Symptoms 717

Common Structural and Functional Impairments 718

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) 718

Management: Protection Phase 719

Management: Controlled Motion and Return to Function Phases 719

Joint Surgery and Postoperative Management 721

Total Hip Arthroplasty 721

Hemiarthroplasty of the Hip 735

Hip Fractures: Surgical and Postoperative Management 736

Hip Fracture: Incidence, Risk Factors, and Impact on Function 736

Sites and Types of Hip Fracture 736

Open Reduction and Internal Fixation of Hip Fracture 737

Painful Hip Syndromes: Nonoperative Management 743

Related Pathologies and Etiology of Symptoms 743

Common Structural and Functional Impairments 744

Management: Protection Phase 744

Management: Controlled Motion Phase 744

Management: Return to Function Phase 745

Exercise Interventions for the Hip Region 745

Exercise Techniques to Increase Flexibility and Range of Motion 746

Techniques to Stretch Range-Limiting Hip Structures 746

Techniques to Stretch Range-Limiting, Two-Joint Muscles 748

Exercises to Develop and Improve Muscle Performance and Functional Control 751

Open-Chain (Nonweight-Bearing) Exercises 751

Closed-Chain (Weight-Bearing) Exercises 753

Functional Progression for the Hip 757

Independent Learning Activities 758

Chapter 21: The Knee 764Lynn Allen Colby, PT, MSCarolyn Kisner, PT, MSJohn DeWitt, PT, DPT, SCS, ATC

Structure and Function of the Knee 765

Joints of the Knee Complex 765

Tibiofemoral Joint 765

Patellofemoral Joint 766

Patellar Function 766

Patellar Alignment 766

Patellar Compression 767

Muscle Function 768

Knee Extensor Muscle Function 768

Knee Flexor Muscle Function 769

Dynamic Stability of the Knee 769

The Knee and Gait 769

Muscle Control of the Knee During Gait 769

Hip and Ankle Impairments 770

Referred Pain and Nerve Injuries 770

Major Nerves Subject to Injury at the Knee 770

Common Sources of Referred Pain 770

Management of Knee Disorders and Surgeries 770

Joint Hypomobility: Nonoperative Management 770

Common Joint Pathologies and Associated Impairments 770

Joint Hypomobility: Management—Protection Phase 772

Joint Hypomobility: Management—Controlled Motion and Return to Function Phases 772

Outcomes 775

Joint Surgery and Postoperative Management 775

Repair of Articular Cartilage Defects 776

Total Knee Arthroplasty 778

Patellofemoral Dysfunction: Nonoperative Management 788

xxviii Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxviii

Related Patellofemoral Pathologies 788

Etiology of Symptoms 789

Common Impairments, Activity Limitations, and Participation Restrictions 790

Patellofemoral Symptoms: Management—Protection Phase 791

Patellofemoral Symptoms: Management—Controlled Motion and Return to Function Phases 791

Outcomes 794

Patellar Instability: Surgical and Postoperative Management 795

Overview of Surgical Options 795

Proximal Extensor Mechanism Realignment: Medial Patellofemoral Ligament Repair or Reconstruction and Related Procedures 796

Distal Realignment Procedures: Patellar Tendon with Tibial Tubercle Transfer and Related Procedures 801

Ligament Injuries: Nonoperative Management 802

Mechanisms of Injury 802

Ligament Injuries in the Female Athlete 804

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities) 804

Ligament Injuries: Nonoperative Management 804

Ligament Injuries: Surgical and Postoperative Management 807

Background 807

Anterior Cruciate Ligament Reconstruction 809

Posterior Cruciate Ligament Reconstruction 820

Meniscus Tears: Nonoperative Management 822

Mechanisms of Injury 822

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities) 822

Management 823

Meniscus Tears: Surgical and Postoperative Management 823

Meniscus Repair 824

Partial Meniscectomy 827

Exercise Interventions for the Knee 828

Exercise Techniques to Increase Flexibility and Range of Motion 828

To Increase Knee Extension 828

To Increase Knee Flexion 829

To Increase Mobility of the IT Band at the Knee 830

Exercises to Develop and Improve Muscle Performance and Functional Control 830

Open-Chain (Nonweight-Bearing) Exercises 831

Closed-Chain (Weight-Bearing) Exercises 834

Functional Progression for the Knee 837

Independent Learning Activities 838

Chapter 22: The Ankle and Foot 849

Structure and Function of the Ankle and Foot 850

Structural Relationships and Motions 850

Anatomical Characteristics 850

Motions of the Foot and Ankle Defined 850

Joint Characteristics and Arthrokinematics: Leg, Ankle, and Foot 851

Function of the Ankle and Foot 853

Structural Relationships 853

Muscle Function in the Ankle and Foot 853

The Ankle/Foot Complex and Gait 854

Function of the Ankle and Foot Joints During Gait 854

Muscle Control of the Ankle and Foot During Gait 854

Referred Pain and Nerve Injury 854

Major Nerves Subject to Pressure and Trauma 855

Common Sources of Segmental Sensory Reference in the Foot 855

Management of Foot and Ankle Disorders and Surgeries 855

Joint Hypomobility: Nonoperative Management 855

Common Joint Pathologies and Etiology of Symptoms 855

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities) 856

Joint Hypomobility: Management—Protection Phase 857

Joint Hypomobility: Management—Controlled Motion and Return to Function Phases 858

Contents xxix

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxix

Joint Surgery and Postoperative Management 859

Total Ankle Arthroplasty 860

Arthrodesis of the Ankle and Foot 865

Leg, Heel, and Foot Pain: NonoperativeManagement 867

Related Pathologies and Etiology of Symptoms 868

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities) 868

Leg, Heel, Foot Pain: Management—Protection Phase 869

Leg, Heel, Foot Pain: Management—Controlled Motion and Return to Function Phases 869

Ligamentous Injuries: Nonoperative Management 869

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities) 870

Acute Ankle Sprain: Management—Protection Phase 870

Ankle Sprain: Management—Controlled Motion Phase 870

Ankle Sprain: Management—Return to Function Phase 871

Traumatic Soft Tissue Injuries: Surgical and Postoperative Management 871

Repair of Complete Lateral Ankle Ligament Tears 871

Repair of a Ruptured Achilles Tendon 876

Exercise Interventions for the Ankle and Foot 883

Exercise Techniques to Increase Flexibility and Range of Motion 883

Flexibility Exercises for the Ankle Region 883

Flexibility Exercises for Limited Mobility of the Toes 884

Stretching the Plantar Fascia of the Foot 885

Exercises to Develop and Improve Muscle Performance and Functional Control 885

Exercises to Develop Dynamic Neuromuscular Control 885

Open-Chain (Nonweight-Bearing) Strengthening Exercises 886

Closed-Chain (Weight-Bearing) Exercises 887

Functional Progression for the Ankle and Foot 888

Independent Learning Activities 889

Chapter 23: Advanced Functional Training 895

Exercises for Stability and Balance 896

Guidelines Revisited 896

Advanced Stabilization and Balance Exercises 896

Exercises for Strength and Power 902

Advanced Strengthening Exercises 903

Plyometric Training: Stretch-Shortening Drills 911

Independent Learning Activities 925

Part V: Special Areas of Therapeutic Exercise 929

Chapter 24: Women’s Health: Obstetrics and Pelvic Floor 929Barbara Settles Huge, PTCarolyn Kisner, PT, MS

Overview of Pregnancy, Labor, and RelatedConditions 930

Characteristics of Pregnancy and Labor 930

Pregnancy 930

Labor 930

Anatomical and Physiological Changes of Pregnancy 932

Weight Gain During Pregnancy 932

Changes in Organ Systems 932

Changes in Posture and Balance 933

Overview of Pelvic Floor Anatomy, Function, and Dysfunction 934

Pelvic Floor Musculature 934

Effect of Childbirth on the Pelvic Floor 935

Classification of Pelvic Floor Dysfunction 936

Risk Factors for Dysfunction 937

Interventions for Pelvic Floor Impairments 937

Pregnancy-Induced Pathology 938

Diastasis Recti 938

Posture-Related Back Pain 939

Sacroiliac/Pelvic Girdle Pain 940

Varicose Veins 940

Joint Laxity 941

Nerve Compression Syndromes 941

xxx Contents

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxx

Exercise Interventions for Pregnancy, Labor, and Related Conditions 941

Physiological Effects of Aerobic Exercise During Pregnancy 941

Maternal Response to Aerobic Exercise 941

Fetal Response to Maternal Aerobic Exercise 942

Exercise for the Uncomplicated Pregnancy and Postpartum 942

Guidelines for Managing the Pregnant Woman 944

Recommendations for Fitness Exercise 945

Precautions and Contraindications to Exercise 946

Critical Areas of Emphasis and Selected Exercise Techniques 946

Pelvic Floor Awareness, Training, and Strengthening 949

Relaxation and Breathing Exercises for Use During Labor 950

Unsafe Postures and Exercises During Pregnancy 951

Exercise Critical to the Postpartum Period 951

Cesarean Childbirth 952

Significance to Physical Therapists 952

Suggested Activities for the Patient Following a Cesarean Section 953

High-Risk Pregnancy 954

High-Risk Conditions 954

Management Guidelines and Precautions for High-Risk Pregnancies 955

Independent Learning Activities 957

Chapter 25: Management of Lymphatic Disorders 961Karen L. Hock, PT, MS, CLT-LANALynn Allen Colby, PT, MSDisorders of the Lymphatic System 961

Structure and Function of the Lymphatic System 961

Types of Lymphedema 962

Clinical Manifestations of Lymphatic Disorders 963

Examination and Evaluation of Lymphatic Function 964

Lymphedema Risk Reduction 965

Management of Lymphedema 965

Breast Cancer-Related Lymphatic Dysfunction 968

Background 968

Surgical Procedures 968

Radiation Therapy 969

Impairments and Complications Related to Breast Cancer Treatment 969

Guidelines for Management Following Breast Cancer Surgery 971

Exercises for the Management of Lymphedema 973

Background and Rationale 973

Components of Exercise Regimens for Management of Lymphedema 974

Guidelines for Lymphatic Drainage Exercises 975

Selected Exercises for Lymphatic Drainage:Upper and Lower Extremity Sequences 975

Independent Learning Activities 979

Glossary 983

Index 991

Contents xxxi

2574_FM_i-xxxii 25/08/12 7:26 PM Page xxxi