definition patients vs client

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THERAPEUTIC EXERCISES

DR. FARJAD AFZAL ADJUNCT FACULTY UHS LECTURER SMC, UOS LECTURER UHS PEDIATRIC PHYSIOTHERAPIST COMPASS PEDIATRIC PHYSIOTHERAPIST MBARAK HOSPITAL

DEFINITION

• Therapeutic exercise is the systematic, planned performance of bodily movements, postures, or physical activities intended to provide a patient/client with the means to 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

PATIENTS VS CLIENT

• A patient is an individual with impairments and functional limitations diagnosed by a physical therapist who is receiving physical therapy care to improve function and prevent disability.

• A client is an individual without diagnosed dysfunction who engages in physical therapy services to promote health and wellness and to prevent dysfunction.

Aspects of Physical Function

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.

DEFINITION

• 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 synonymous 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.

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• Flexibility. The ability to move freely, without restriction; used interchangeably with mobility.

• 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.

• 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, as well as stabilizers and neutralizers to anticipate or respond to proprioceptive and kinesthetic information and, subsequently, to work in correct sequence to create coordinated movement.

• 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

Theraputic exercises interventions

• 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

• Patient safety

• Physiotherapist safety

Disablement process

• 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, customary, expected, and desired societal functions and roles.

• Social, emotional, and cognitive disablement can affect physical function and vice versa

• importance

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Models of Disablement

• Nagi model

• International Classification of Impairments, Disabilities, and Handicaps (ICIDH) model for the World Health Organization

• The NCMRR model(The National Center for Medical Rehabilitation Research (NCMRR))

• Although each of these models uses slightly different terminology, each reflects a spectrum of disablement.

• each reflects a spectrum of disablement. • each MODEL reflects the complex

interrelationships among the following. • Acute or chronicpathology • Impairments • Functional limitations • Disabilities, handicaps, or societal limitations

The ICF model consists of the following components of health and health-related influences •Impairment of body structure (anatomical) and function (physiological) •Activity limitation •Participation restriction •Impact of contextual factors (environmental and personal) on functioning, disability, and health

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Pathology/Pathophysiology

Refers to disruptions of the body’s homeostasis as the result of acute or chronic diseases, disorders, or conditions characterized by a set of abnormal findings (clusters of signs and symptoms) that are indicative of alterations or interruptions of structure or function of the body primarily identified at the cellular level.

Impairments

• Impairments are the consequences of pathological conditions; that is, they are the signs and symptoms that reflect abnormalities at the body system, organ, or tissue level.

• In health, any loss or abnormality of physiological, psychological, or anatomical structure or function, whether permanent or temporary. Identifying impairments that contribute to disability,

• a functional problem for a patient, is a key factor for a health professional to determine appropriate treatment.

Types of Impairment

• Musculoskeletal

• Neuromuscular

• Cardiovascular/pulmonary

• Integumentary

direct/primary impairments

• A patient, for example, who has been referred to physical therapy with a medical diagnosis of impingement syndrome or tendinitis of the rotator cuff (pathology) may exhibit primary impairments, such as pain, limited ROM of the shoulder, and weakness of specific shoulder girdle and glenohumeral musculature during the physical therapy examination

Secondary/ indirect impairment

The patient may subsequently develop secondary postural asymmetry because of altered use of the upper extremity.

http://en.wikipedia.org/wiki/Disability

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Composite impairments

• When an impairment is the result of multiple underlying causes and arises from a combination of primary or secondary impairments

• For example, a patient who sustained a severe inversion sprain of the ankle resulting in a tear of the talofibular ligament and whose ankle was immobilized for several weeks is likely to exhibit a balance impairment of the involved lower extremity after the immobilization order is removed. This composite impairment could be the result of chronic ligamentous laxity and impaired ankle proprioception from the injury or muscle weakness due to immobilization and disuse

Thank you Question????

DR. FARJAD AFZAL BSPT (KEMU) DPT(UHS) M.PHILL (UOS*)

Therapeutic exercise

• Therapeutic exercise is the systematic, planned performance of bodily movements, postures, or physical activities intended to provide a patient/client with the means to:

■ 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

PATIENT VRS CLIENT

• A patient is an individual with impairments and functional deficits diagnosed by a physical therapist and is receiving physical therapy care to improve function and pre-vent disability.

• A client is an individual without diagnosed dysfunction who engages in physical therapy services to promote health and wellness and to prevent dysfunction

Components of Physical Function

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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 moderate-intensity, repetitive, total body movements (walking, jogging, cycling, swimming) over an extended period of time

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.

• Coordination 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

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

• Active mobility requires neuromuscular activation.

Muscle performance

The capacity of muscle to produce tension and do physical work. Muscle performance encom-passes strength, power, and muscular endurance

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Neuromuscular control

• Interaction of the sensory and motor systems that enables synergists, agonists and antagonists, as well as stabilizers and neutralizers to anticipate or respond to proprioceptive and kinesthetic information and, subsequently, to work in correct sequence to create coordinated movement.

• 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.

Types of Therapeutic Exercise Interventions

Types of Therapeutic Exercise Interventions

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Exercise Safety

• Specific

• Detail history and examination

• Indication and contra indiacation

• Environment and space

Exercise safety

• Patient safety

• Physiotherapist safety

Disablement process

Disablement process

• 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, customary, expected, and desired societal functions and roles.

• Social, emotional, and cognitive disablement can affect physical function and vice versa

• importance

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Models of Disablement

• Nagi model

• International Classification of Impairments, Disabilities, and Handicaps (ICIDH) model for the World Health Organization

• The NCMRR model(The National Center for Medical Rehabilitation Research (NCMRR))

• Although each of these models uses slightly different terminology, each reflects a spectrum of disablement.

• Each MODEL reflects the complex interrelationships among the following.

• Acute or chronic pathology

• Impairments

• Functional limitations

• Disabilities, handicaps, or societal limitations

The ICF model consists of the following components of health and health-related influences •Impairment of body structure (anatomical) and function (physiological) •Activity limitation •Participation restriction •Impact of contextual factors (environmental and personal) on functioning, disability, and health

Pathology/Pathophysiology

Refers to disruptions of the body’s homeostasis as the result of acute or chronic diseases, disorders, or conditions characterized by a set of abnormal findings (clusters of signs and symptoms) that are indicative of alterations or interruptions of structure or function of the body primarily identified at the cellular level.

First component of disablement process

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Impairments

• Impairments are the consequences of pathological conditions; that is, they are the signs and symptoms that reflect abnormalities at the body system, organ, or tissue level.

• In health, any loss or abnormality of physiological, psychological, or anatomical structure or function, whether permanent or temporary. Identifying impairments that contribute to disability,

• a functional problem for a patient, is a key factor for a health professional to determine appropriate treatment.

Types of Impairment

• Musculoskeletal

• Neuromuscular

• Cardiovascular/pulmonary

• Integumentary

direct/primary impairments

• A patient, for example, who has been referred to physical therapy with a medical diagnosis of impingement syndrome or tendinitis of the rotator cuff (pathology) may exhibit primary impairments, such as pain, limited ROM of the shoulder, and weakness of specific shoulder girdle and glenohumeral musculature during the physical therapy examination

Secondary/ indirect impairment

The patient may subsequently develop secondary postural asymmetry because of altered use of the upper extremity.

Composite impairments

• When an impairment is the result of multiple underlying causes and arises from a combination of primary or secondary impairments

• For example, a patient who sustained a severe inversion sprain of the ankle resulting in a tear of the talofibular ligament and whose ankle was immobilized for several weeks is likely to exhibit a balance impairment of the involved lower extremity after the immobilization order is removed. This composite impairment could be the result of chronic ligamentous laxity and impaired ankle proprioception from the injury or muscle weakness due to immobilization and disuse

http://en.wikipedia.org/wiki/Disability

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FUNCTIONAL LIMITATIONS

• Activity limitations occur when a person has difficulty executing or is unable to perform tasks or actions of daily life

• Result of impairments associated with active pathology and are characterized by the reduced ability of a person to perform actions or components of motor tasks in an efficient or typically expected manner

• For example, restricted range of motion (impairment) of the shoulder as the result of adhesive capsulitis (health disorder/ pathological condition) can limit a person’s ability to reach overhead (activity limitation/functional limitation) while performing personal grooming or household tasks.

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• Limitations in a person’s functioning may be physical, social, or psychological in nature

• Physical therapy interventions are to be effective, the focus of treatment must be directed toward remediating impairments and activity limitations that have the greatest adverse effects on a patient’s functioning during daily activities

• When impairments and activity limitations restrict participation, a patient’s health-related quality of life may begin to deteriorate.

Types of Activity Limitations/Functional Limitations

• Basic activities of daily living (BADL), such as bathing, dressing, or feeding

• Instrumental activities of daily living (IADL), such as occupational tasks, school-related skills, housekeeping, and recreational activities, or community mobility (driving, using public transportation), just to

• An essential element of a physical therapy examination and evaluation is the analysis of motor tasks to identify the component motions that are difficult for a patient to perform.

Participation Restrictions and Disability

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• Participation restrictions encompass problems that deal with fulfilling personal or social responsibilities and obligations in relation to societal expectations in the context of a person’s attitudes and environment

• inability to participate in activities or tasks related to one’s self, the home, work, recreation, or the community in a manner or to the extent that the individual or the community as a whole (e.g., family, friends, coworkers) perceive as “normal.

Evidence-Based Practice

• Available research & clinical studies (best clinical research)

• Experiences of expert therapists (expertise)

• Patient preferences

GOOD PRACTICE In evidence-based practice we need to ‘integrate the best external evidence with

individual clinical expertise and patients’ choice,

EBP

CLINICAL DECISION MAKING & EBP 5-STEPS IN EBP

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Patient examination

THANK YOU CLASS QUESTIONS ARE

WELCONE MOTOR LEARNING

Motor learning • Motor learning is a complex set of internal

processes that involves the acquisition and relatively permanent retention of a skilled movement or task through practice.

• An exercise is simply a motor task (a psychomotor skill) that a therapist teaches and a patient is expected to learn

MOTOR LEARNING INSTRUCTIONS

MOTOR TASK

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MOTOR PERFORMANCE AND MOTOR LEARNING

• Performance involves acquisition of the ability to carry out a skill, whereas learning involves both acquisition and retention

• Motor learning probably modifies the way sensory information in the central nervous system is organized and processed and affects how motor actions are produced

Types of Motor Tasks

There are three basic types of motor tasks:

• Discrete,

• Serial

• ContinuouS

DISCRETE TASK

• A discrete task involves an action or movement with a recognizable beginning and end.

• Isolating and contracting a specific muscle group (as in a quadriceps setting exercise), grasping an object, doing a push-up, locking a wheelchair, and kicking a ball are examples of discrete motor tasks.

• Almost all exercises, such as lifting and lowering a weight or performing a self-stretching maneuver, can be categorized as discrete motor tasks.

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, pierce or scoop up the food, and lift the fork to the mouth.

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.

IMPORTANCE OF RECOGNIZING THE TYPE OF TASK

• To self stretch the hamstrings, a patient must learn how to position and align his or her body and how much stretch force to apply to perform the stretching maneuver correctly.

• As flexibility improves, the patient must then learn how to safely control active movements in the newly gained portion of the range during functional activities.

• This requires muscles to contract with correct intensity at an unaccustomed length

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Conditions and Progression of Motor Tasks

Progression of Motor Tasks

There are four main task dimensions

• (1) the environment in which the task is performed

• (2) the intertrial variability of the environment that is imposed on a task

• (3) the need for a person’s body to remain stationary or to move during the task; and

• (4) the presence or absence of manipulation of objects during the task.

Conditions and Progression of Motor Tasks

END

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STAGES OF MOTOR LEARNING

Cognitive Stage

Associative Stage

Autonomous Stage

COGNITIVE STAGE

COGNITIVE STAGE

• When learning a skilled movement, a patient first must figure out what to do—that is, the patient must learn the goal or purpose and the requirements of the exercise or functional task

• Then the patient must learn how to do the motor task safely and correctly. At this stage, the patient needs to think about each component or the sequencing of the skilled movement.

• The patient often focuses on how his or her body is aligned and how far and with what intensity or speed to move. In other words, the patient tries to get the “feel” of the exercise

• patient’s attention

• distractions in the environment

• errors in performance are common, but with practice that includes error correction

• frequent feedback from a therapist

• Self evaluations

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Cognitive stage

what to do how to do

Associative Stage

• The patient makes infrequent errors and concentrates on fine-tuning the motor task during the associative stage of learning

• Learning focuses on producing the most consistent and efficient movements.

• The timing of the movements and the distances moved also may be refined

• inter-trial variability • The patient also uses problem-solving to self-correct

errors when they do occur • At this stage, the patient requires infrequent feedback

from the therapist

Autonomous Stage

• Movements are automatic in this final stage of learning.

• The patient does not have to pay attention to the movements in the task, thus making it possible to do other tasks simultaneously. Also, the patient easily adapts to variations in task demands and environmental conditions.

• Little, if any, instruction goes on in this phase of learning unless the patient encounters a recurrence of symptoms or other problems.

• In fact, most patients are discharged before reaching this stage of learning.

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Variables That Influence Motor Learning—Considerations for Exercise

Instruction and Functional Training

Variables That Influence Motor Learning

Pre-Practice Considerations

Practice Feedback


• A patient’s UNDERSTANDING

• ATTENTION to the task

• INSTRUCTIONS given to a patient

• DEMONSTRATION of a task prior to commencing practice

• PRE-PRACTICE VERBAL INSTRUCTIONS

PRACTICE

STAGES OF MOTOR LEARNING

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Cognitive Stage

Associative Stage

Autonomous Stage

COGNITIVE STAGE

COGNITIVE STAGE

• When learning a skilled movement, a patient first must figure out what to do—that is, the patient must learn the goal or purpose and the requirements of the exercise or functional task

• Then the patient must learn how to do the motor task safely and correctly. At this stage, the patient needs to think about each component or the sequencing of the skilled movement.

• The patient often focuses on how his or her body is aligned and how far and with what intensity or speed to move. In other words, the patient tries to get the “feel” of the exercise

• Patient’s attention

• Distractions in the environment

• Errors in performance are common, but with Practice that includes error correction

• Frequent feedback from a therapist

• Self evaluations

Cognitive stage

what to do? how to do ?

Associative Stage

• The patient makes infrequent errors and concentrates on fine-tuning the motor task during the associative stage of learning

• Learning focuses on producing the most consistent and efficient movements.

• The timing of the movements and the distances moved also may be refined

• inter-trial variability • The patient also uses problem-solving to self-correct

errors when they do occur • At this stage, the patient requires infrequent feedback

from the therapist

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Autonomous Stage

• Movements are automatic in this final stage of learning.

• The patient does not have to pay attention to the movements in the task, thus making it possible to do other tasks simultaneously. Also, the patient easily adapts to variations in task demands and environmental conditions.

• Little, if any, instruction goes on in this phase of learning unless the patient encounters a recurrence of symptoms or other problems.

• In fact, most patients are discharged before reaching this stage of learning.

Variables That Influence Motor Learning—Considerations for Exercise

Instruction and Functional Training

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Variables That Influence Motor Learning


Practice Feedback


• A patient’s UNDERSTANDING

• ATTENTION to the task

• INSTRUCTIONS given to a patient

• DEMONSTRATION of a task prior to commencing practice

• PRE-PRACTICE VERBAL INSTRUCTIONS

PRACTICE

• The amount, type, and variability of practice directly affect the extent of skill acquisition and retention

• More a patient practices a motor task, the more readily it is learned

• Part versus whole practice

COMMON TYPES OF PRACTICE

PART PRACTICE

• Part practice has been shown to be most effective in the early stage of learning for acquisition of complex serial skills that have simple and difficult components.

• Depending on the patient’s cognitive status, it is usually necessary to practice only the difficult dimensions of a task before practicing the task as a whole

WHOLE PRACTICE

• Whole practice is more effective than part practice for acquiring continuous skills, such as walking and climbing stairs, or serial tasks in which momentum or timing of the components is the central focus of the learning process.

• Whole practice is also used for acquisition of discrete tasks, such as an exercise that involves repetitions of a single movement pattern

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• The type of skill to be learned (discrete, serial, or continuous) and the patient’s cognitive status and stage of motor learning determine which practice strategies are more appropriate than others.

WHICH PRACTICE IS BEST FOR A PARTICULAR PATIENTS?

COMMON TYPES OF PRACTICE

PRACTICE ORDER

• blocked, random, and random/blocked

BLOCKED PRACTICE

• During the initial phase of rehabilitation, practice usually is directed toward learning just a few exercises or functional motor tasks.

• During the initial (cognitive) stage of learning in which a new motor skill is acquired, blocked-order practice is the appropriate choice because it rapidly improves performance of skilled movements

• A transition to random-order or random/blocked-order practice should be made as soon as possible to introduce variability into the learning process.

• Variability of practice refers to making slight adjustments (variations) in the conditions of a task

• for example, by varying the support surface or the surroundings where a task is performed.

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PHYSICAL VERSUS MENTAL PRACTICE

BASIC CONCEPTS OF PREVENTION Part 1

Health.

General physical, mental, or spiritual condition of the body

Wellness

A state of good health often achieved through healthy lifestyle

six dimensions of wellness described by the National Wellness Institute Social: Interacting and contributing to one’s community or environment. Occupational: “Personal satisfaction and enrichment in one’s life through work.” Spiritual: Finding and living a life that has meaning and purpose. Physical: Making appropriate nutritional choices and participating in regular physical activity. Intellectual: Actively using your mind to develop new skills and learn new information. Emotional: Accepting and managing our feelings in all personal interactions.

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Health promotion

Contributing to the growth and development of health

Health-Related Quality of Life (HRQOL)

• The total effect of individual and environmental factors on function and health status, including physical, psychological, and social components.

• Physical therapists have a unique role in providing prevention, health, wellness, and fitness activities needed to address these concerns, and these activities may take many forms.

SCREENING PHYSICAL THERAPIST AS A EDUCATOR

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INTERVENTION AND TREATMENT

Strength training

Stretching Mobilization Aerobics

Types of preventions

Prevention activities IDENTIFYING RISK FACTORS

• Preparticipation screenings

• Risk assessments

PREPARTICIPATION SCREENINGS RISK ASSESSMENTS

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Determining Readiness to Change

• Once the pre-participation screenings and risk assessments are completed and specific programs for an individual are developed, it is important to know whether the person is ready to change.

Behavioral Change Theories

• Social cognitive theory

• Health belief model

• Transtheoretical model

Social cognitive theory

• The social cognitive theory (SCT) looks at the belief systems of individuals.

• An individual must believe that he or she can change a particular behavior and that changing that behavior will lead to the desired outcome

Social cognitive theory

• For example, a patient may want to lose weight. In addition to the desire to change the behavior causing the increased weight, the patient needs to believe that he or she is capable of succeeding (self-efficacy) and that the out-come will improve his or her health.

The health belief model (HBM)

• The health belief model (HBM) is based on several factors

• First, an individual must have sufficient concern about developing an illness (perceived threat).

• Next, the individual needs to believe that by following the health recommendations it is possible to achieve the desired outcome (perceived benefits) at an acceptable cost (perceived barriers).

Transtheoretical model

• The transtheoretical model (TTM) looks at the stages required to make changes.

• There are five stages of change: 1. Precontemplation—no intention of making any changes

within the next 6 months 2. Contemplation—intends to make changes within the next 6

months 3. Preparation—has begun to take steps toward making the

desired change in behavior and plans to make the changes within the next 30 days

4. Action—has changed the behavior for less than 6 months 5. Maintenance—has changed the behavior for more than 6

month

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Additional Factors Affecting the Ability to Change

• Motivation.

• Self-efficacy

DEVELOPING AND IMPLEMENTING A PROGRAM

Part 2

Developing and Implementing a Program

Step 1: Identify a Need

Step 2: Set Goals and Objectives

Step 3: Develop the Intervention

Step 4: Implement the Intervention

Step 5: Evaluate the Results

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Additional Considerations for Developing Prevention, Health, and Wellness Programs

• specific to the goals of the individual…... Specific principles and procedures for resistance training and aerobic exercise training.

• For children, …..For older adults……..

• If screenings are conducted, handouts with the results and with follow-up recommendations should be given to the participants.

• Hand outs for children & older adults.

• Limit terminologies…. pictures of exercises

• Consider the time commitment for you and the participants and the cost involved.

Lists issues related to exercise adherence.

Poor good

Poor or limited leadership Inconvenient time of class or program Injury Boredom with exercise Poor individual commitment Unaware of any progress being made Poor family support— disapproval

Effective leadership Positive reinforcement Part of regular routine No injury Enjoyment—fun—variety Social support from group Regular updates on progress Family approval

THANKS

O S T E O P R O S I S

Developing and Implementing a Program

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• Assignment • You are a physical therapist and you have recently

graduated your studies. You have knowledge that strength training and weight bearing exercises increase bone density and prevent from osteoporosis and fracture from falling.

• Pakistan osteoporosis association consult to you to develop and implement a program for osteoporosis (strength training and exercise plane) for local women.

• How you will start and implement step by step?

• How to submit assignment • Type form • Font 12, times new Romans • Mail to [email protected] • Last date for submission is 01-03-2016,

Wednesday • After due date no submission will be accepted • Assignment carry weight age in internal

assessment • 01_ppt_2015_name

RANGE OF MOTION EXERCISES

FARJAD AFZAL

MOBILIZATION/MANIPULATIONS

DR. FARJAD

university of sargodha, department of physical therapy, sargodha medical college, [email protected]

DEFINITIONS

• are passive, skilled manual therapy techniques

• applied to joints and related soft tissues

• at varying speeds and amplitudes

• using physiological or accessory motions for therapeutic purposes.

• The varying speeds and amplitudes can range from a small-amplitude force applied at fast velocity to a large-amplitude force applied at slow velocity



mailto:[email protected]

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Thrust manipulation/high-velocity thrust (HVT)

• Thrust refers to high-velocity, short-amplitude techniques.

• The thrust is performed at the end of the pathological limit of the joint and is intended to alter positional relationships, snap adhesions, or stimulate joint receptors.

• Pathological limit means the end of the available ROM when there is restriction.


Self-Mobilization (Auto-Mobilization)

• Self-mobilization refers to self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule.

Mobilization with Movement

• Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end-range applied by the patient.

• Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier.

• The techniques are always applied in a pain-free direction


Physiological Movements

• Physiological movements are movements the patient can do voluntarily (e.g., the classic or traditional movements, such as flexion, abduction, and rotation).

• The term osteokinematics is used when these motions of the bones are described


Accessory Movements

• Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient.

• Terms that relate to accessory movements are component motions and joint play.


component motions

• These are motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement

• example, motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, and rotation of the fibula, which occurs with ankle motions, are component motions


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Joint play

• Joint play describes the motions that occur between the joint surfaces and also the distensibility or “give” in the joint capsule, which allows the bones to move. The movements are necessary for normal joint functioning through the ROM and can be demonstrated passively, but they cannot be performed actively by the patient.

• The movements include distraction, sliding, compression rolling, and spinning of the joint surfaces.

• The term arthrokinematics is used when these motions of the bone surfaces within the joint are described.


Manipulation Under Anesthesia

• Manipulation under anesthesia is a procedure used to restore full ROM by breaking adhesions around a joint while the patient is anesthetized.

• The technique may be a rapid thrust or a passive stretch using physiological or accessory movementS


Muscle Energy

• Muscle energy techniques use active contraction of deep muscles that attach near the joint and whose line of pull can cause the desired accessory motion.

• The technique requires the therapist to provide stabilization to the segment on which the distal aspect of the muscle attaches.

• A command for an isometric contraction of the muscle is given that causes accessory movement of the joint


university of sargodha, department of physical therapy, sargodha medical college,

[email protected]

Best of luck

university of sargodha, department of physical therapy, sargodha medical college,

[email protected]

ENOUGH FOR TODAY THANK YOU CLASS

ANY QUESTION????

• The full motion possible is called the range of motion (ROM). When moving a segment through its ROM, all structures in the region are affected: muscles, joint surfaces, capsules, ligaments, fasciae, vessels, and nerves.

• ROM activities are most easily described in terms of joint range and muscle range.

• To describe joint range, terms such as flexion, extension, abduction, adduction, and rotation are used. Ranges of available joint motion are usually measured with a goniometer and recorded in degrees

• Muscle range is related to the functional excursion of muscles.

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Functional excursion

• Functional excursion is the distance a muscle is capable of shortening after it has been elongated to its maximum.

• In some cases the functional excursion, or range of a muscle, is directly influenced by the joint it crosses.

Active insufficiency

• Maximum shortening of the muscle

passive insufficiency

• Maximum lengthening of the muscles. • To maintain normal ROM, the segments must be moved through their available ranges periodically,

• many factors, such as systemic, joint, neurological, or muscular diseases; surgical or traumatic insults; or simply inactivity or immobilization for any reason, can lead to de-creased ROM

Types of ROM Exercises

• Passive ROM

• Active ROM

• Active-Assistive ROM

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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 no voluntary muscle contraction.

• The external force may be from gravity, a machine, another individual, or another part of the individual’s own body.

• PROM and passive stretching are not synonymous.

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

• Active-assistive ROM (A-AROM) is a type of AROM in which assistance is provided manually or mechanically by an outside force because the prim mover muscles need assistance to complete the motion.

Indications, Goals, and Limitations of ROM

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• Although both PROM and AROM are contraindicated under any circumstance when motion to a part is disruptive to the healing process

• complete immobility leads to adhesion and contracture formation, sluggish circulation, and a prolonged recovery time.

• ROM has been contraindicated immediately after acute tears, fractures, and surgery; but because the benefits of controlled motion have demonstrated decreased pain and an increased rate of recovery,

Thank you Arthrokinematics

Joint Shapes

• ovoid or sellar • In ovoid joints one surface is

convex, and the other is concave

• In sellar (saddle) joints, one surface is concave in one direction and convex in the other, with the opposing surface convex and concave, respectively—similar to a horseback rider being in complementary opposition to the shape of a saddle

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Types of Motion

• bony lever moves about an axis of motion

• bone surface

• The movement of the bony lever is called swing and is classically described as flexion, extension, abduction, adduction, and rotation. The amount of movement can be measured in degrees with a goniometer and is called ROM.

• Motion of the bone surfaces in the joint is a variable combination of rolling and sliding, or spinning.

• For the rolling, sliding, or spinning to occur, there must be adequate capsule laxity or joint play.

Roll

• The surfaces are incongruent.

• New points on one surface meet new points on the opposing surface.

• Rolling results in angular motion of the bone (swing).

• Rolling is always in the same direction as the swinging bone motion whether the surface is convex

• Rolling, if it occurs alone, causes compression of the surfaces on the side to which the bone is swinging and separation on the other side. Passive stretching using bone angulation alone may cause stressful compressive forces to portions of the joint surface, potentially leading to joint damage.

• In normally functioning joints, pure rolling does not occur alone but in combination with joint sliding and spinning.

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slide

• The same point on one surface comes into contact with the new points on the opposing surface.

• Pure sliding does not occur in joints, because the surfaces are not completely congruent.

• The direction in which sliding occurs depends on whether the moving surface is concave or convex.

• Sliding is in the opposite direction of the angular movement of the bone if the moving joint surface is convex .

• Sliding is in the same direction as the angular movement of the bone if the moving surface is concave

Combined Roll-Sliding in a Joint

• The more congruent the joint surfaces are, the more sliding there is of one bony partner on the other with movement.

• The more incongruent the joint surfaces are, the more rolling there is of one bony partner on the other with movement.

• When muscles actively contract to move a bone, some of the muscles may cause or control the sliding movement of the joint surfaces.

• For example, the caudal sliding motion of the humeral head during shoulder abduction is caused by the rotator cuff muscles,

• and the posterior sliding of the tibia during knee flexion is caused by the hamstring muscles.

• If this function is lost, the resulting abnormal joint mechanics may cause microtrauma and joint dysfunction.

• The joint mobilization techniques described in this chapter use the sliding component of joint motion to restore joint play and reverse joint hypomobility.

• Rolling (passive angular stretching) is not used to stretch tight joint capsules, because it causes joint compression.

• When the therapist passively moves the articulating surface using the slide component of joint motion, the technique is called translatoric glide, translation, or simply glide.

• It is used to control pain when applied gently or to stretch the capsule when applied with a stretch force.

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Spin

• There is rotation of a segment about a stationary mechanical axis

• The same point on the moving surface creates an arc of a circle as the bone spins.

• Spinning rarely occurs alone in joints but in combination with rolling and sliding.

• Three examples of spin occurring in joints of the body are the shoulder with flexion/extension, the hip with flexion/ extension, and the radiohumeral joint with pronation/ supination

Thanks

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Effects of Joint Motion/mobilizations

Farjad afzal

Nutrition of articular cartilage

• Joint motion stimulates biological activity by moving synovial fluid, which brings nutrients to the avascular articular cartilage of the joint surfaces and intra-articular fibrocartilage of the menisci

Immobilizations

Decreased flow of nutrition to joints cartilage

Atrophy of articular cartilage

Joint extensibility

• Extensibility and tensile strength of the articular and periarticular tissues are maintained with joint motion

• With immobilization there is fibrofatty proliferation, which causes intra-articular adhesions as well as biochemical changes in tendon, ligament, and joint capsule tissue, which in turn causes joint contractures and ligamentous weakening

Properioception

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Properioception and awarness

• Afferent nerve impulses from joint receptors transmit information to the central nervous system and, therefore, provide awareness of position and motion.

• With injury or joint degeneration, there is a potential decrease in an important source of proprioceptive feedback that may affect an individual’s balance response

• Static position and sense of speed of movement (type I receptors found in the superficial joint capsule).

• Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads)

• Sense of direction of movement (type I and III receptors; type III found in joint ligaments).

• Regulation of muscle tone (type I, II, and III receptors).

• Nociceptive stimuli (type IV receptors found in the fibrous capsule, ligaments, articular fat pads, periosteum, and walls of blood vessels)

Indications of joint mobilization

• Gentle mobilizations may be used to treat pain and muscle guarding,

• whereas stretching techniques are used to treat restricted movement.

Pain, Muscle Guarding, and Spasm

• Painful joints, reflex muscle guarding, and muscle spasm can be treated with gentle joint-play techniques to stimulate neurophysiological and mechanical effects

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Neurophysiological Effects

• Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.

Mechanical Effects

• Small-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage when present).

• Gentle joint-play techniques help maintain nutrient exchange and, thus, prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM.

• When applied to treat pain, muscle guarding, or muscle spasm, these techniques should not place stretch on the reactive tissues

Reversible Joint Hypomobility

• Reversible joint hypomobility can be treated with progressively vigorous joint-play stretching techniques to elongate hypomobile capsular and ligamentous connective tissue. Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically.

Positional Faults/Subluxations

• A faulty position of one bony partner with respect to its opposing surface may result in limited motion or pain. This can occur with a traumatic injury, after periods of immobility, or with muscle imbalances

Progressive Limitation

• Diseases that progressively limit movement can be treated with joint-play techniques to maintain available motion or retard progressive mechanical restrictions. The dosage of distraction or glide is dictated by the patient’s response to treatment and the state of the disease.

Functional Immobility

• When a patient cannot functionally move a joint for a period of time, the joint can be treated with nonstretch gliding or distraction techniques to maintain available joint play and prevent the degenerating and restricting effects of immobility.

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Limitations of Joint Mobilization/ Manipulation Techniques

• Joint techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory process of injury.

• In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitations

• The skill of the therapist affects the outcome.

• if these techniques are used indiscriminately on patients not properly examined and screened for such maneuvers or if they are applied too vigorously for the condition, joint trauma or hypermobility may result

Contraindications and Precautions

Hypermobility

• The joints of patients with potential necrosis of the

ligaments or capsule should not be mobilized with stretching techniques.

• Patients with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of motion. Stretching is not done.

Joint Effusion

• There may be joint swelling (effusion) due to trauma or disease.

• Rapid swelling of a joint usually indicates bleeding in the joint and may occur with trauma or diseases such as hemophilia.

• Medical intervention is required for aspiration of the blood to minimize its necrotizing effect on the articular cartilage.

• Slow swelling (more than 4 hours) usually indicates serous effusion (a buildup of excess synovial fluid) or edema in the joint due to mild trauma, irritation, or a disease such as arthritis

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Inflammation

• Whenever inflammation is present, stretching increases pain and muscle guarding and results in greater tissue damage.

• Gentle oscillating or distraction motions may temporarily inhibit the pain response.

Conditions Requiring Special Precautions for Stretching

mobilizations may be used with extreme care in the following conditions if the signs and the patient’s response are favorable

• Malignancy. • Bone disease detectable on radiographs. • Unhealed fracture. (The site of the fracture and

the stabilization provided will dictate whether or not manipulative techniques can be safely applied.)

• Excessive pain. (Determine the cause of pain and modify treatment accordingly.)

• Hypermobility in associated joints. (Associated joints must be properly stabilized so the mobilization force is not transmitted to them.)

• Total joint replacements. (The mechanism of the replacement is self-limiting, and, therefore, the mobilization techniques may be inappropriate.)

• Newly formed or weakened connective tissue such as immediately after injury, surgery, or disuse or when the patient is taking certain medications such as corticosteroids. (Gentle progressive techniques within the tolerance of the tissue help align the developing fibrils, but forceful techniques are destructive.)

• Systemic connective tissue diseases such as rheumatoid arthritis, in which the disease weakens the connective tissue. (Gentle techniques may benefit restricted tissue, but forceful techniques may rupture tissue and result in instabilities.)

• Elderly individuals with weakened connective tissue and diminished circulation. (Gentle techniques within the tolerance of the tissue may be beneficial to increase mobility.

Thanks

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Grades and dosages

• Two systems of grading dosages (or rate of application) and their application in the range of available motion have been popularized.

• Non-Thrust Oscillation Techniques

• The oscillations may be performed using physiological (osteokinematic) motions or joint-play (arthrokinematic) techniques.

Dosage and Rate of Application

• Grade I. Small-amplitude rhythmic oscillations are performed at the

beginning of the range. They are usually rapid oscillations, like manual vibrations.

• Grade II. Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit. They are usually performed at 2 or 3 per second for 1 to 2 minutes.

• Grade III. Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance. They are usually performed at 2 or 3 per second for 1 to 2 minutes.

• Grade IV. Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance. They are usually rapid oscillations, like manual vibrations.

• Indications • Grades I and II are primarily used for treating joints limited by pain

or muscle guarding. The oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem levels.

• These nonstretch motions help move synovial fluid to improve nutrition to the cartilage.

• Grades III and IV are primarily used as stretching maneuvers. • Vary the speed of oscillations for different effects, such as low

amplitude and high speed, to inhibit pain or slow speed to relax muscle guarding.

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Non-Thrust Sustained Joint-Play Techniques

• This grading system describes only joint-play techniques that separate (distract) or glide/translate (slide) the joint surfaces.

• Dosages and Rate of Application • As indicated by the name, rate of application is slow and sustained

for several seconds followed by partial relaxation and then repeated depending on the indications.

• Grade I (loosen). Small-amplitude distraction is applied when no stress is placed on the capsule. It equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint.

• Grade II (tighten). Enough distraction or glide is applied to tighten the tissues around the joint. Kaltenborn called this “taking up the slack.”

• Grade III (stretch). A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures.

• Indications • Grade I distraction is used with all gliding motions and may be used for

relief of pain. Apply intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several cycles. Note the response and either repeat or discontinue.

• Grade II distraction is used for the initial treatment to determine the sensitivity of the joint. Once the joint reaction is known, the treatment dosage is increased or decreased accordingly.

• Gentle grade II distraction applied intermittently may be used to inhibit pain. Grade II glides may be used to maintain joint play when ROM is not allowed.

• Grade III distractions or glides are used to stretch the joint structures and thus increase joint play. For restricted joints, apply a minimum of a 6-second stretch force followed by partial release (to grade I or II), then repeat with slow, intermittent stretches at 3- to 4-second intervals.

Tractions vs. Distraction

Tractions vs. Distraction

Traction

• pulling something along a surface

Distarction

• separation of joint surfaces

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• For distraction to occur within the joint, the surfaces must be pulled apart. The movement is not always the same as pulling on the long axis of one of the bony partners.

• For example, if traction is applied to the shaft of the humerus, it will result in a glide of the joint surface. Distraction of the glenohumeraljoint requires a pull at right angles to the glenoidfossa.

• For clarity, whenever there is pulling on the long axis of a bone, the term long-axis traction will be used. Whenever the surfaces are to be pulled apart at right angles, the terms distraction, joint traction, or joint separation will be used.

• words Traction and distraction are used synonym in many books

• Traction and distraction both are used for joint separations (one of joint play movements)

• Distraction is a separating force at right angle to treatment plane in keltenborn, he also used the term traction for same force

• Traction is applied at long axis to bone and there is some degree of glide also present.

Distraction

Keltenborn also used term the traction for same movements

Traction

Distraction Tractions vs. Distraction

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Separation of joints distraction

Separation with glide(inferior) traction

GLIDE VS DISTRACTION

Both are joint play

Glide

• a joint play movement parallel to the treatment plane.

Distraction

• a joint play movement right angle/vertical/perpendicul-ar to the treatment plane

GLIDE VS TRACTION

Glide Traction

• a joint play movement parallel to the treatment plane.

Separation with

glide(inferior)

traction

STILL CONFUSED? YES……

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THANK YOU

BEST OF LUCK

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

MI or CABG

AEROBIC CONDITIONING

During the past 20 to 25 years, there have been major changes in the medical management of these patients. The changes have included shortened hospital stays, more aggressive progression of activity for the patient following MI or cardiac surgery, and earlier initiation of an exercise program based on a low-level stress test prior to discharge from the hospital. An aerobic conditioning program, in addition to risk factor modification, is a dominant part of cardiac rehabilitation.

AEROBIC CONDITIONING PLANE

Inpatient Phase (Phase I)

Outpatient Phase (Phase II)

Outpatient Program (Phase III)


• The inpatient phase of the program occurs in the hospital following stabilization of the patient’s cardiovascular status after MI or coronary bypass surgery, and generally lasts 3 to 5 days.

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• Initiate risk factor education and address future modification of certain behaviors, such as eating habits and smoking.

• Initiate self-care activities and progress from sitting to standing to minimize deconditioning (1 to 3 days postevent).

• Provide an orthostatic challenge to the cardiovascular system (3 to 5 days postevent). This is usually accomplished by supervised ambulation. Ambulation is usually monitored electrocardiographically, as well as manually monitoring the heart rate, ventilation rate, and blood pressure.

• Prepare patients and family for continued rehabilitation and for life at home after a cardiac event.

PURPOSE


• The outpatient phase of the program is initiated either upon discharge from the hospital or, depending on the severity of the diagnosis, 6 to 8 weeks later.

• This delay allows time for the myocardium to heal as well as time to monitor the patient’s response to a new medical regimen.

• Participants are monitored via telemetry to determine heart rate and rhythm responses; blood pressure is recorded at rest and during exercise; and ventilation responses are noted.

• These programs usually last 6 to 8 weeks




PURPOSE

• Increase the person’s exercise capacity in a safe, progressive manner, so adaptive cardiovascular and muscular changes occur. The early part of the program is referred to by some as “low-level” exercise training.

• Enhance cardiac functions and reduce the cardiac cost of work. This may help eliminate or delay symptoms such as angina and ST-segment changes in the patient with coronary heart disease.

• Produce favorable metabolic changes. • Determine the effect of medications on

increasing levels of activity. • Relieve anxiety and depression. • Progress the patient to an independent

exercise program.




PURPOSE

GUIDLINES

A symptom-limited exercise stress test is performed 6 to 12 weeks after hospital discharge (or as early as 2 to 4 weeks following discharge). The exercise program is predominantly aerobic. Generally, for patients with functional capacities greater than 5 METs, the exercise prescription is based on the results of the symptomlimited test.




PURPOSE

GUIDLINES

Intensity. The initial level of activity or training intensity may be as low as 40% to 60% of the maximum heart rate or 40% to 70% of the functional capacity defined in METs. The starting intensity is dictated by the severity of the diagnosis in concert with the individual’s age and prior fitness level. intensity is progressed as the individual responds to the training program.

Frequency. Participants often attend sessions offered three times per week

Time. The duration of the exercise session may be limited to 10 to 15 minutes at the start, progressing to 30 to 60 minutes as the patient’s status improves. Each session usually includes 8- to 10-minute warm-up and cool-down periods. Type. The mode of exercise is usually continuous, using large muscle groups, such as stationary biking or walking. These activities allow ECG monitoring via telemetry.

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• Method. Circuit-interval exercise is a common method used with the patient during phase II. The patient can exercise on each modality at a defined workload, compared with exercising continuously on a bicycle or treadmill. As a result, the patient can:

• Perform more physical work. • Exercise at a higher intensity—fitness may improve within a shorter

period of time. • Maintain lactic acid and the oxygen deficit at minimum levels. • Exercise at a lower rate of perceived exertion. • Weight training. Low-level weight training may be initiated during

the outpatient program, provided the individual has undergone a symptom-limited stress test. Resistive exercises should not produce ischemic symptoms associated with an increase in heart rate and systolic blood pressure. Therefore, heart rate and blood pressure should be monitored periodically throughout the exercise session. Starting weight may be calculated using 40% of a one repetition maximum (1-RM) effort.

• Progression. Progression of the workload occurs when there have been three consecutive sessions (every-other-day sessions) during which the peak heart rate is below the target heart rate.





Next time





The outpatient phase of cardiac rehabilitation includes a supervised exercise conditioning program, which is often continued in a hospital or community setting.

Heart rate and rhythm are no longer monitored via telemetry.

Participants are reminded to monitor their own pulse rate, and a supervisory

person is available to monitor blood pressure.





Purpose The purpose of the program is to continue to improve or maintain fitness levels achieved during the phase II program.





Guidelines Recreational activities. Activities to maintain levels gained during phase II may include: ■ Swimming, which incorporates both arms and legs. However, there is a decreased awareness of ischemic symptoms while swimming, especially when the skill level is poor. ■ Outdoor hiking, which is excellent if on level terrain.

Activities at 8 METs ■ Jogging approximately 5 miles per hour ■ Cycling approximately 12 miles per hour ■ Vigorous downhill skiing

Special Considerations

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Special Considerations • There are special considerations related to types of exercise and

patient needs that must be recognized when developing conditioning programs for patients with coronary disease.

• Arm exercises elicit different responses than leg exercises. • ■ Mechanical efficiency based on the ratio between output of

external work and caloric expenditure is lower than with leg exercises.

• ■ Oxygen uptake at a given external workload is significantly higher for arm exercises than for leg exercises.

• ■ Myocardial efficiency is lower with leg exercises than with • arm exercises. • ■ Myocardial oxygen consumption (heart rate × systolic • blood pressure) is higher with arm exercises than with leg • exercises. • PRECAUTION: Patients with coronary disease complete 35% less

work with arm exercises than with leg exercises before symptoms occur.

Adaptive Changes

• Adaptive changes following training of individuals with cardiac disease include:

• ■ Increased myocardial aerobic work capacity. • ■ Increased maximum aerobic or functional capacity by predominantly

widening the a-vO2 difference. • ■ Increased stroke volume following high-intensity training 6 to 12 months

into the training program. • ■ Decreased myocardial demand for oxygen. • ■ Increased myocardial supply by the decreased heart rate • and prolongation of diastole. • ■ Increased tolerance to a given physical workload before angina occurs. • ■ Significantly lower heart rate at each submaximum workload and,

therefore, a greater heart rate reserve. When muscles are used that are not directly involved in the activity, the reduction in heart rate is not as great.

• ■ Improved psychological

Physiological Response to Aerobic Exercise

• The rapid increase in energy requirements during exercise requires equally rapid circulatory adjustments to meet the increased need for oxygen and nutrients to remove the end-products of metabolism, such as carbon dioxide and lactic acid, and to dissipate excess heat.

• The shift in body metabolism occurs through a coordinated activity of all the systems of the body: neuromuscular, respiratory, cardiovascular, metabolic, and hormonal

• Oxygen transport and its utilization by the mitochondria of the contracting muscle are dependent on adequate blood flow in conjunction with cellular respiration.

Cardiovascular Response to Exercise

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Cardiovascular Response to Exercise

Exercise Pressor Response • Stimulation of small myelinated and unmyelinated

fibers in skeletal muscle involves a sympathetic nervous system (SNS) response

• The SNS response includes generalized peripheral vasoconstriction in nonexercising muscles and increased myocardial contractility, an increased heart rate, and an increased systolic blood pressure. This results in a marked increase and redistribution of the cardiac output.

• The degree of the response equals the muscle mass involved and the intensity of the exercise.

Cardiac Effects

• The frequency of sinoatrial node depolarization increases, as does the heart rate.

• There is a decrease in vagal stimuli as well as an increase in SNS stimulation.

• There is an increase in the force development of the cardiac myofibers. A direct inotropic response of the SNS increases myocardial contractility.

Peripheral Effects

• Net reduction in total peripheral resistance.

• Generalized vasoconstriction occurs that allows blood to be shunted from the nonworking muscles, kidneys, liver, spleen, and splanchnic area to the working muscles.

• A locally mediated reduction in resistance in the working muscle arterial vascular bed, independent of the autonomic nervous system, is produced by metabolites such as Mg2+, Ca2+, ADP, and PCO 2

• .The veins of the working and nonworking muscles remain constricted.

Increased cardiac output

• The cardiac output increases because of the increase in myocardial contractility, with a resultant increase in stroke volume, heart rate, blood flow through the working muscle,

• and an increase in the constriction of the capacitance vessels on the venous side of the circulation in both the working and nonworking muscles, raising the peripheral venous pressure.

• Increase in systolic blood pressure. The increase in systolic blood pressure is the result of the augmented cardiac output

Respiratory Response to Exercise

• Respiratory changes occur rapidly, even before the initiation of exercise.

• Gas exchange (O2, CO2) increases across the alveolar-capillary membrane by the first or second breath.

• Increased muscle metabolism during exercise results in more O2 extracted from arterial blood, an increase in body temperature, increased epinephrine, and increased stimulation of receptors of the joints and muscles.

• Any of these factors alone or in combination may stimulate the respiratory system.

• Baroreceptor reflexes, protective reflexes, pain, emotion, and voluntary control of respiration may also contribute to the increase in respiration.

• Minute ventilation increases as respiratory frequency and tidal volume increase.

• Alveolar ventilation, occurring with the diffusion of gases across the capillary-alveolar membrane, increases 10- to 20-fold during heavy exercise to supply the additional oxygen needed and excrete the excess CO2 produced.

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QUESTIONS Determinants of an Exercise

Program

FITT- PRINCIPLE

• FITT method: Frequency, Intensity, Time (duration), and Type of exercise

Frequency • There is no clear-cut information provided on the most

effective frequency of exercise for adaptation to occur.

• Frequency may be a less important factor than intensity or duration in exercise training.

• Frequency varies, dependent on the health and age of the individual.

• Optimal frequency of training is generally three to four times a week. If training is at a low-intensity, greater frequency may be beneficial.

• A frequency of two times a week does not generally evoke cardiovascular changes, although older individuals and convalescing patients may benefit from a program of that frequency.

Intensity

• based on the overload principle and the specificity principle

Overload Principle

• Overload is stress on an organism that is greater than that regularly encountered during everyday life

• To improve cardiovascular and muscular endurance, an overload must be applied to these systems

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• The exercise load (overload) must be above the training stimulus threshold (the stimulus that elicits a training or conditioning response) for adaptation to occur.

• once adaptation to a given load has taken place, the training intensity (exercise load) must be increased for the individual to achieve further improvement.

• Training stimulus thresholds are variable, depending on the individual’s level of health, level of activity, age, and gender.

• The higher the initial level of fitness, the greater the intensity of exercise needed to elicit a change

• A conditioning response occurs generally at 60% to 90% maximum heart rate (50% to 85% VO MAX

• depending on the individual and the initial level of fitness.

• Seventy percent maximum heart rate is a minimal-level stimulus for eliciting a conditioning response in healthy young individuals

• Sedentary or “deconditioned” individuals respond to a low exercise intensity, 40% to 50% of VO2 max

• The exercise does not have to be exhaustive to achieve a training response.

• Determining the maximum heart rate and the exercise heart rate for training programs provides the basis for the initial intensity of the exercise

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• When the individual is young and healthy, the maximum heart rate can be determined directly from a maximum performance multistage test, extrapolated from a heart rate achieved on a predetermined submaximum test or, less accurately, calculated as 220 minus age.

Thank you

Time (Duration)

• The optimal duration of exercise for cardiovascular conditioning is dependent on the total work performed, exercise intensity and frequency, and fitness level.

• Generally speaking, the greater the intensity of the exercise, the shorter the duration needed for adaptation; and the lower the intensity of exercise, the longer the duration needed

• A 20- to 30-minute session is generally optimal at 60% to 70% maximum heart rate.

• When the intensity is below the heart rate threshold, a 45-minute continuous exercise period may provide the appropriate overload.

• With high-intensity exercise, 10- to 15-minute exercise periods are adequate

TYPE

• specific aerobic activities, such as cycling and running, the overload must use the muscles required by the activity and stress the cardiorespiratory system (specificity principle)

• If endurance of the upper extremities is needed to perform activities on the job, the upper extremity muscles must be targeted in the exercise program.

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Reversibility Principle

• The beneficial effects of exercise training are transient and reversible.

• Detraining occurs rapidly when a person stops exercising.

• After only 2 weeks of detraining, significant reductions in work capacity can be measured, and improvements can be lost within several months.

• A similar phenomenon occurs with individuals who are confined to bed with illness or disability: the individual becomes severely deconditioned, with loss of the ability to carry out normal daily activities as a result of inactivity.

• The frequency or duration of physical activity required to maintain a certain level of aerobic fitness is less than that required to improve it

GENERAL RECOMMENDATIONS FOR AEROBIC PHYSICAL ACTIVITY:

• Children age 6 to 17: 60 minutes of moderate to vigorous aerobic physical activity per day.

• Adults age 18 to 65: 30 minutes of moderate intensity activity (3–6 MET level) 5 days/week or 20 minutes of vigorous intensity activity (>6 METs) 3 days/week, or a combination of moderate and vigorous intensity. The 30-minute total of moderate intensity can be accumulated in small bouts of continuous activity of at least 10 minutes.

• Older adults age 65 or older (or adults 50 to 65 with chronic health conditions): 30 minutes of moderate intensity activity 5 days/week or 20 minutes of vigorous intensity activity 3 days/week, or a combination of moderate and vigorous intensity. The 30-minute total of moderate intensity can be accumulated in small bouts of continuous activity of at least 10 minute

Exercise Program

a warm-up period

the aerobic exercise period

a cool-down period.

Warm-Up Period

• Physiological Responses • During this period there is: • An increase in muscle temperature. The higher temperature

increases the efficiency of muscular contraction by reducing muscle viscosity and increasing the rate of nerve conduction.

• An increased need for oxygen to meet the energy demands for the muscle. Extraction from hemoglobin is greater at higher muscle temperatures, facilitating the oxidative processes at work.

• Dilatation of the previously constricted capillaries with increases in the circulation, augmenting oxygen delivery to the active muscles and minimizing the oxygen deficit and the formation of lactic acid.

• Adaptation in sensitivity of the neural respiratory center to various exercise stimulants.

• An increase in venous return. This occurs as blood flow is shifted centrally from the periphery.

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Purposes

• In addition to the physiological responses, the warm-up also prevents or decreases the susceptibility of the musculoskeletal system to injury and the occurrence of ischemic electrocardiographic (ECG) changes and arrhythmias.

Guidelines

• The warm-up should be gradual and sufficient to increase muscle and core temperature without causing fatigue or reducing energy stores. Characteristics of the period include:

• A 10-minute period of total body movement exercises, such as walking slowly.

Aerobic Exercise Period

• four methods of training that challenge the aerobic system:

• continuous,

• interval (work relief),

• circuit,

• and circuit interval

Continuous Training

• A submaximum energy requirement, sustained throughout the training period, is imposed.

• Once the steady state is achieved, the muscle obtains energy by means of aerobic metabolism. Stress is placed primarily on the slow-twitch fibers.

• The activity can be prolonged for 20 to 60 minutes without exhausting the oxygen transport system.

• The work rate is increased progressively as training improvements are achieved. Overload can be accomplished by increasing the exercise duration.

• In the healthy individual, continuous training is the most effective way to improve endurance.

Interval Training

• With this type of training, the work or exercise is followed by a properly prescribed relief or rest interval. Interval training is perceived to be less demanding than continuous training. In the healthy individual, interval training tends to improve strength and power more than endurance.

• The relief interval is either a rest relief (passive recovery) or a work relief (active recovery), and its duration ranges from a few seconds to several minutes. Work recovery involves continuing the exercise but at a reduced level from the work period. During the relief period, a portion of the muscular stores of ATP and the oxygen associated with myoglobin that were depleted during the work period are replenished by the aerobic system; an increase in VO2 max occurs.

• The longer the work interval, the more the aerobic system is stressed. With a short work interval, the duration of the rest interval is critical if the aerobic system is to be stressed (a work/recovery ratio of 1:1 to 1:5 is appropriate). A rest interval equal to one and a half times the work interval allows the succeeding exercise interval to begin before recovery is complete and stresses the aerobic system. With a longer work interval, the duration of the rest is not as important.

• A significant amount of high-intensity work can be achieved with interval or intermittent work if there is appropriate spacing of the work-relief intervals. The total amount of work that can be completed with intermittent work is greater than the amount of work that can be completed with continuous training.

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Circuit Training

• Circuit training employs a series of exercise activities. At the end of the last activity, the individual starts from the beginning and again moves through the series. The series of activities is repeated several times.

• Several exercise modes can be used involving large and small muscle groups and a mix of static or dynamic effort.

• Use of circuit training can improve strength and endurance by stressing both the aerobic and anaerobic systems.

Circuit-Interval Training

• Combining circuit and interval training is effective because of the interaction of aerobic and anaerobic production of ATP.

• In addition to the aerobic and anaerobic systems being stressed by the various activities, with the relief interval, there is a delay in the need for glycolysis and the production of lactic acid prior to the availability of oxygen supplying the ATP.

Cool-Down Period

• The cool-down period is similar to the warm-up period in that it should last 5 to 10 minutes and consist of total-body movements and static stretching.

• The purpose of the cool-down period is to: • Prevent pooling of the blood in the extremities by

continuing to use the muscles to maintain venous return. • Prevent fainting by increasing the return of blood to the

heart and brain as cardiac output and venous return decreases.

• Enhance the recovery period with the oxidation of metabolic waste and replacement of the energy stores.

• Prevent myocardial ischemia, arrhythmias, or other cardiovascular complications.

Thank you

Testing as a Basis for Exercise Programs

For healthy clints

&

For patients

• Testing for physical fitness of healthy individuals should be distinct from graded exercise testing of convalescing patients, individuals with symptoms of coronary heart disease, or individuals who are 35 years or older but asymptomatic.

• Regardless of the type of testing, the level of

performance is based on the submaximum or maximum oxygen uptake (VO) or the symptom-limited oxygen uptake.

• The capacity of the individual to transport and utilize oxygen is reflected in the oxygen uptake.

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Fitness Testing of Healthy Subjects

• Field tests for determining cardiovascular fitness include the time to run 1.5 miles or the distance run in 12 minutes. These measures correlate well with VO2 max, but their use is limited to young persons or middle-aged individuals who have been carefully screened and have been jogging or running for some time.

• Other field tests include the 1-mile walk test, 6-minute walk test, and step tests. These tests are more suitable for individuals who are not as physically active.

Multistage testing

• Multistage testing can provide a direct measurement of VO2 max by analyzing samples of expired air.

• Testing is usually completed in four to six treadmill stages, which progressively increase in speed and or grade.

• Each stage is 3 to 6 minutes long. • Electrocardiographic (ECG)

monitoring is performed during the testing.

• Maximum oxygen uptake can be determined when the oxygen utilization plateaus despite an increase in workload

Stress Testing for Convalescing Individuals and Individuals at Risk

• Individuals undergoing stress testing should have a

• physical examination,

• be monitored by the ECG,

• and be closely observed at rest, during exercise, and during recovery

Principles of Stress Testing

• The principles of stress testing include the following. • Changing the workload by increasing the speed and/or

grade of the treadmill or the resistance on the bicycle ergometer

• An initial workload that is low in terms of the individual’s anticipated aerobic threshold

• Maintaining each workload for 1 minute or longer • Terminating the test at the onset of symptoms or a

definable abnormality of the ECG • When available, measuring the individual’s maximum

oxygen consumption

Purpose of Stress Testing

• In addition to serving as a basis for determining exercise levels or the exercise prescription, the stress test:

• Helps establish a diagnosis of overt or latent heart disease. • Evaluates cardiovascular functional capacity as a means of clearing

individuals for strenuous work or exercise programs. • Determines the physical work capacity in kilogram-meters per minute (kg-

m/min) or the functional capacity in METs. • Evaluates responses to exercise training and/or preventive programs. • Assists in the selection and evaluation of appropriate modes of treatment

for heart disease. • Increases individual motivation for entering and adhering to exercise

programs. • Is used clinically to evaluate patients with chest sensations or a history of

chest pain to establish the probability that such patients have coronary disease. It can also evaluate the functional capacity of patients with chronic disease.

Preparation for Stress Testing

All individuals who are taking a stress test should:

• Have had a physical examination.

• Be monitored by ECG and closely observed at rest, during exercise, and during recovery.

• Sign a consent form.

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Precautions during stress test Termination of Stress Testing

Endpoints requiring termination of the test period are

• Progressive angina.

• A significant drop in systolic pressure in response to an increasing workload.

• Lightheadedness, confusion, pallor, cyanosis, nausea, or peripheral circulatory insufficiency.

• Abnormal ECG responses including ST segment depression greater than 4 mm.

• Excessive rise in blood pressure.

• Subject wishes to stop.

Example PRE-STRESS-PHYSICAL EXAMINATIONS

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Exercise for Impaired Balance

Key Terms and Definitions

Balance

• Balance, or postural stability, is a generic term used to describe the dynamic process by which the body’s position is maintained in equilibrium.

• Equilibrium means that the body is either at rest (static equilibrium) or in steady-state motion (dynamic equilibrium).

• Balance is greatest when the body’s center of mass (COM) or center of gravity (COG) is maintained over its base of support (BOS).

Center of mass

• The COM is a point that corresponds to the

• center of the total body mass and is the point at which the body is in perfect equilibrium.

• It is determined by finding the weighted average of the COM of each body segment

Center of gravity

• The COG refers to the vertical projection of the center of mass to the ground.

• In the anatomical position, the COG of most adult humans is located slightly anterior

• to the second sacral vertebra or approximately 55% of a person’s height.

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Momentum

• Momentum is the product of mass times velocity.

• Linear momentum relates to the velocity of the body along a straight path, for example, in the sagittal or transverse planes.

• Angular momentum relates to the rotational velocity of the body.

Base of support

• The BOS is defined as the perimeter of the contact area between the body and its support surface; foot placement alters the BOS and changes a person’s postural stability.

• A wide stance, such as is seen with many elderly individuals, increases stability, whereas a narrow BOS, such as tandem stance or walking, reduces it.

• So long as a person maintains the COG within the limits of the BOS, referred to as the limits of stability, he or she does not fall.

Limits of stability

• “Limits of stability” refers to the sway boundaries in which an individual can maintain equilibrium without changing his or her BOS

• These boundaries are constantly changing depending on the task, the individual’s biomechanics, and aspects of the environment.

Ground reaction force and center of pressure

• In accordance with Newton’s law of reaction, the contact between our bodies and the ground due to gravity (action forces) is always accompanied by a reaction from it, the so-called ground reaction force

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• The center of pressure (COP) is the location of the vertical projection of the ground reaction force.

• It is equal and opposite to the weighted average of all the downward forces acting on the area in contact with the ground.

• If one foot is on the ground, the net COP lies within that foot. • When both feet are on the ground, the net COP lies somewhere • between the two feet, depending on how much weight is taken by each

foot. When both feet are in contact, the COP under each foot can be measured separately.

• To maintain stability, a person produces muscular forces to continually control the position of the COG, which in turn changes the location of the COP. Thus, the COP is a reflection of the body’s neuromuscular responses to imbalances of the COG.

• A force plate is traditionally used to measure ground reaction forces (in Newtons [N]) and COP movements

• (in meters [m]).

Balance Control

• Balance is a complex motor control task involving the detection and integration of sensory information to assess the position and motion of the body in space and the execution of appropriate musculoskeletal responses to control body position within the context of the environment and task.

• Thus, balance control requires the interaction of the nervous and musculoskeletal systems and contextual effects

Nervous system

• The nervous system provides the (1) sensory processing for perception of body orientation in space provided mainly by the visual, vestibular, and somatosensory systems; (2) sensoriomotor integration essential for linking sensation to motor responses and for adaptive and anticipatory (i.e., centrally programmed postural adjustments that precede voluntary movements) aspects of postural control; and (3) motor strategies for planning, programming, and executing balance responses.

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Musculoskeletal system

• Musculoskeletal contributions include postural alignment, musculoskeletal flexibility such as joint range of motion (ROM), joint integrity, muscle performance (i.e., muscle strength, power, and endurance), and sensation (touch, pressure, vibration, proprioception, and kinesthesia).

Environmental system

• Contextual effects that interact with the two systems (sensory and motor) are the environment whether it is closed (predictable with no distractions) or open (unpredictable and with distractions), the support surface (i.e., firm versus slippery, stable versus unstable, type of shoes), the amount of lighting, effects of gravity and inertial forces on the body, and task characteristics (i.e., well-learned versus new, predictable versus unpredictable, single versus multiple tasks).

Motor Strategies for Balance Control

Management of Impaired Balance

Examination and Evaluation of Impaired Balance

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Balance Training

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Thank you FUNCTIONAL LIMITATIONS

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• Activity limitations occur when a person has difficulty executing or is unable to perform tasks or actions of daily life

• Result of impairments associated with active pathology and are characterized by the reduced ability of a person to perform actions or components of motor tasks in an efficient or typically expected manner

• For example, restricted range of motion (impairment) of the shoulder as the result of adhesive capsulitis (health disorder/ pathological condition) can limit a person’s ability to reach overhead (activity limitation/functional limitation) while performing personal grooming or household tasks.

• Limitations in a person’s functioning may be physical, social, or psychological in nature

• Physical therapy interventions are to be effective, the focus of treatment must be directed toward remediating impairments and activity limitations that have the greatest adverse effects on a patient’s functioning during daily activities

• When impairments and activity limitations restrict participation, a patient’s health-related quality of life may begin to deteriorate.

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Types of Activity Limitations/Functional Limitations

• Basic activities of daily living (BADL), such as bathing, dressing, or feeding

• Instrumental activities of daily living (IADL), such as occupational tasks, school-related skills, housekeeping, and recreational activities, or community mobility (driving, using public transportation), just to

• An essential element of a physical therapy examination and evaluation is the analysis of motor tasks to identify the component motions that are difficult for a patient to perform.


• Participation restrictions encompass problems that deal with fulfilling personal or social responsibilities and obligations in relation to societal expectations in the context of a person’s attitudes and environment

• inability to participate in activities or tasks related to one’s self, the home, work, recreation, or the community in a manner or to the extent that the individual or the community as a whole (e.g., family, friends, coworkers) perceive as “normal.

Evidence-Based Practice

• Available research & clinical studies (best clinical research)

• Experiences of expert therapists (expertise)

• Patient preferences

GOOD PRACTICE In evidence-based practice we need to ‘integrate the best external evidence with

individual clinical expertise and patients’ choice,

EBP

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CLINICAL DECISION MAKING & EBP 5-STEPS IN EBP

THANK YOU CLASS QUESTIONS ARE

WELCONE

definition patients vs client

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