G e n e r a l Therapeutic Exercise

Citation andPrinciples
Reference.

Dr: Mennaallah Youssef Mohamed

Lecturer of Physical Therapy
 Professional physical therapy
knowledge
• A therapist must understand how the many forms basic
of exercise affect tissues of the body and body science
systems and how those exercise-induced effects
have an impact on key aspects of physical
function as they relate to the human movement
system.
critical
thinking and
Professional
behavioral
• A therapist must also integrate and apply problem- physical sciences
solving
knowledge of anatomy, physiology, kinesiology, therapy
and pathology, to develop therapeutic exercise
programs that culminate in positive and
meaningful functional outcomes for patients and
client.
Knowledge
of human
movement
system
 The basic requirements of a movement system
practitioner
1. Knowledge of the movement system and its component elements (anatomical structures
and physiological functions).

2. The ability to evaluate and diagnose movement dysfunction in the clinical setting (using
observation, instruments, or both).

3. The ability to identify physical impairments across various body systems (e.g.,
integumentary, musculoskeletal, cardiorespiratory, neurological, endocrine, genitourinary)
that may be contributing to dysfunctional movement, such as muscle weakness, limited
joint range of motion, limited oxygen impaired motor control e.g:low levels of physical
functioning experienced by patients with chronic kidney disease.

4. The ability to design an intervention program to address underlying impairments as well

as the movement dysfunction itself
 Impairment

Impairments are defined by the loss of integrity of the physiological,

anatomical, and/or psychological functions and structures of the body and
are partial reflection of a person's health status.

Body functions are the physiological functions of systems of the body,

body structures are the anatomical parts of the body including organs, limbs, and their components.
 Therapeutic exercise interventions

• The individualized therapeutic exercise is based on a

therapist's determination of
the underlying risk or cause of impairments in body function
or structure.
Activity limitation or participation restriction. As identified in
patient
 Therapeutic Exercise
• Is the systematic, planned performance of
physical movements, postures, or activities.

Why?
■Remediate or prevent impairments of body
functions and structures.
■Improve, and restore activities and participation.
■Prevent or reduce health-related risk factors.
■Optimize health, fitness, or sense of well-being.

• Therapeutic exercise programs designed by

physical therapists are individualized to the
unique needs of each patient or client.
Components of Physical Function Related to
Human Movement:
 Components of Physical Function Related to
Human Movement:

1- 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 via interaction of the sensory
and motor systems.
 Components of Physical Function Related to
Human Movement:

2-Cardiopulmonary Endurance:
• The ability to perform moderate-
intensity, repetitive, total body
movements (walking, jogging,
cycling, swimming, etc.) over an
extended period of time.
 Components of Physical Function Related to
Human Movement:
3-Flexibility: The ability to move freely, without restriction;
used interchangeably with mobility.

4- 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

non contractile).
• In addition, active mobility requires neuromuscular
activation.
 Components of Physical Function Related to
Human Movement:
5- Muscle performance.
• The capacity of muscle to produce
tension and do physical work.

• Muscle performance encompasses

strength, power, and muscular
endurance.
 Components of Physical Function Related to
Human Movement:
5- Muscle performance
 Components of Physical Function Related to Human Movement:
5- Muscle performance
 Components of Physical Function Related to
Human Movement:
5- Muscle performance

Power= strength* speed

Require fast motion to be effective.
 Components of Physical Function Related to
Human Movement:
6- 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.
 Factors influence a patient’s safety during exercise

 Age
 Medical history: patient's health history and current health status must be explored.
A patient with a known or an undiagnosed health condition may be at risk for adverse
effects from exercise especially if they are unaccustomed to physical exertion.
 Medications: can adversely affect a patient's balance and coordination or
cardiopulmonary response to exercised.
 Factors influence a patient’s safety during exercise

 Environment and spacing: Adequate space and a proper support surface for exercise are necessary.
 proper posture of the body during exercise.

 Fatigue and the time of recovery .

 Physical Stresses (stress = force / area)
 patient must be informed of the signs of fatigue, the relationship of fatigue to the risk of injury, and
the importance of rest for recovery during and after an exercise routine.
 performance of each exercise with the appropriate intensity, speed, and duration.
 Factors influence a patient’s safety during exercise
 Fatigue and the time of recovery.

• Imposed excessive forces and physical stresses can cause acute injuries, such as
sprains and fractures, or chronic conditions, such as repetitive stress disorders.

• The absence of typical forces on the body also can cause degeneration,
degradation, or deformity.

• For example, the absence of normal weight bearing associated with prolonged
bed rest or immobilization weakens muscle and bone.

• Prolonged inactivity also leads to decreased efficiency of the circulatory and

pulmonary systems.
 Patient instruction for exercise safety
• For Accurate t performance of exercise consider: proper posture of
the body, execution of the correct movement patterns, and
performance of each exercise with the appropriate intensity, speed,
and duration.

• Avoid fatigue: patient must be informed of the signs of fatigue, the

relationship of fatigue to the risk of injury, and the importance of
rest for recovery during and after an exercise routine.

• Home program: effective exercise instruction and patient

education.
Range of motion Exercise
Range of motion (ROM) is The full motion possible.

Is a basic technique used for the examination of movement and for

treatment.
Range of motion (ROM) is determined by osteokinematics and arthrokinematics in addition to the functional
excursion of the muscle.

There are two kinds of osteokinematics, active range of motion (AROM) and passive range of motion (PROM).

The movement that occurs between two joint surfaces during AROM is called arthrokinematics (Accessory joint
motion).
 Range of motion (ROM)
Func tiona l Exc ursion of Muscles .
M usc le rang e is rela te d to the func tio na l exc ursio n of
muscles .
Functional excursion is the distance a
muscle is c a p a b l e of shortening after it has
b e e n e l o n g a t e d to its maximum.

In s o m e cases the functional excursion, or

r a n g e of a muscle, is directly influenced b y
the joint it crosses.
 Range of motion (ROM)
Func tiona l Exc ursion of Muscles .

one-joint muscles
 Range of motion (ROM)
Func tiona l Exc ursion of Muscles .

• Active insufficiency, where it is too short to produce much

tension. This is one end of its range
• Passive insufficiency: When it is fully lengthened and limits
motion at one of the joints it crosses.

• Full finger flexion cannot be achieved if wrist flexion occurs

simultaneously.
 ▶Passive ROM.
Types of R O M • ▶Active RO M .
Exercises
• ▶Active-Assistive RO M .
 Types of R O M Exercises
Passive R O M

Passive ROM (PROM) is mo v e m e n t of a

segment within the unrestricted ( available)
R O M that is p r o d u c e d entirely b y a n external
force; there is little to n o voluntary muscle
contraction.

The external force m a y be from gravity, a

machine, another
individual, or another part of the individual’s own body.
P R O M a n d passive stretching are not synonymous.
 Types of R O M Exercises
Active R O M

Ac tive ROM (AROM):

is movement of a
segment within the
unrestricted ROM that is
produced by active
c ontrac tion of the muscles
crossing that join
 Types of R O M Exercises
Active-assistive R O M
Active-assistive ROM
(A-AROM) : is a type of
AROM in which
assistance is provided
m a nua lly or
mechanically by a n
outside force because
the p rim e m over
m usc les need
Assistanc e to
c omplete the motion.
Goals for PROM
The primary goal for P R O M is to decrease the complications that would occur
w ith immobiliza tion ,

c artilage degeneration, adhesion and c ontrac ture

suc h as
formation, and sluggish c irc ulation
Indications for PROM
**** Acute, inflamed tissue (Inflammation after injury or surgery usually lasts
2 to 6 days).
****PROM is indicated after surgical repair of contractile tissue when active
motion would compromise the repaired muscle.
**** Comatose, paralyzed, or on complete bed rest patient, movement is
provided by an external source.
Other Uses for PROM
■When a therapist is examining inert structures,
PROM is used to determine limitations of motion,
joint stability, muscle flexibility and other soft tissue
elasticity.
■When a therapist is teaching an active exercise
program, PROM is used to demonstrate the desired
motion.
■When a therapist is preparing a patient for
stretching, PROM is often used preceding the passive
stretching technique
Limitations of Passive Motion:

True passive, relaxed ROM may be difficult to obtain

when muscle is innervated, and the patient is
conscious.
Passive motion does not:

Prevent muscle atrophy.

■

Increase strength or endurance.

■

Assist circulation to the extent that active, voluntary

■

muscle contraction does.

Indications for aAROM
■When a patient has weak musculature and is
unable to move a joint through the desired range
(usually against gravity),
A-AROM is used to provide enough assistance to
the muscles in a carefully controlled manner so the
muscle can function at its maximum level and be
progressively strengthened.
■
 Goals for AROM

Maintain physiological elasticity and contractility of the

participating muscles.
 Provide sensory feedback from the contracting muscles.
 Provide a stimulus for bone and joint tissue integrity.
 Increase circulation and prevent thrombus formation.
 Develop coordination and motor skills for functional activities.
When a segment of the body is immobilized for a period of
time, AROM is used on the regions above and below the
immobilized segment to maintain the areas in as normal a
condition as possible and to prepare for new activities, such
as walking with crutches.

Once patients gain control of their ROM, they are progressed

to manual or mechanical resistance exercises to improve
muscle performance for a return to functional activities .
Limitations of Active ROM
For strong muscles, active ROM does not maintain or increase strength.

It also does not develop skill or coordination except in the movement patterns
used.
Precautions and Contraindications to ROM Exercises

• When motion to a part is disruptive to the healing process.

• after acute tears, fractures, and surgery;

but b e c a u s e the benefits of controlled motion h a v e
demonstrated decreased pain a n d a n increased rate of
recovery, early controlled motion is used so long as the patient’s
tolerance is monitored.

It is imperative that the therapist recognizes the value as well as potential abuse
of motion and stays within the range, speed, and tolerance of the patient during
the acute recovery stage.
 Precautions and Contraindications to ROM Exercises

 Additional trauma to the part is contraindicated.

 Signs of too much or the wrong motion include increased pain

and increased inflammation (greater swelling, heat, and redness).
 Careful monitoring of symptoms, perceived exertion, and
blood pressure is necessary.

Individualized activities are initiated and progress gradually

Continuous passive motion (CPM):
Refers to passive motion performed by a mechanical device
that moves a joint slowly and continuously through a controlled
ROM.

Continual passive motion has beneficial healing

effects on diseased or injured joint structures and soft
tissues
 Benefits of Continuous passive motion (CPM):

Prevents the degrading effects of immobilization

Prevents development of adhesions and contractures and thus joint stiffness
Increases synovial fluid lubrication of the joint and thus increases the rate of
intra-articular cartilage healing and regeneration
Provides a stimulating effect on the healing of tendons and ligaments and
incisions over the moving join
Provides a quicker return of ROM
Decreases postoperative pain
 General Guidelines for CPM
The device may be applied immediately after surgery while
the patient is still under anesthesia or as soon as possible if
bulky dressings prevent early motion.
• The arc of motion for the joint is determined.
• Often a low arc of 20° to 30° is used initially and progressed 10° to 15° per
day as tolerated.

• The portion of the range used initially is based on the range available and
patient tolerance.

• The rate of motion is determined; usually 1 cycle/45 sec or 2

min is well tolerated.
The amount of time on the CPM machine varies for different
protocols—anywhere from continuous for 24 hours to continuous
for 1 hour three times a day.

The longer periods of time per day reportedly result in a shorter

hospital stay, fewer postoperative complications, and greater ROM
at discharge.
• Physical therapy treatments are usually initiated during periods
when the patient is not on CPM, including active assistive and
muscle-setting exercises.

• The minimum duration for CPM is usually less than 1 week or

when a satisfactory range of motion is reached.

• CPM machines are designed to be adjustable, easily controlled,

versatile, and portable.
Principles and Procedures for Applying ROM Techniques
  Examination, Evaluation, and Treatment Planning.

 Patient Preparation:

a)Communicate with the patient.

b)Free the region from any restrictive
c)Comfortable position with proper body alignment and
stabilization but that also allows you to move the
segment through the available ROM.
d)Position yourself so proper body mechanics can be
used.
 Examination, Evaluation, and Treatment Planning
• 1. Examine and evaluate the patient’s impairments and level of
function, determine any precautions and their prognosis, and plan
the intervention.

• 2. Determine the ability of the patient to participate in the ROM

activity and whether PROM, A-AROM, or AROM can meet the
immediate goals.

• 3. Determine the amount of motion that can be applied safely for

the condition of the tissues and health of the individual.
 Examination, Evaluation, and Treatment Planning

• 4- Monitor the patient’s general condition and responses during

and after the examination and intervention; note any change in
vital signs; in the warmth and color of the segment; and in the
ROM, pain, or quality of movement.

• 5. Document and communicate findings and intervention.

• 6. Re-evaluate and modify the intervention as necessary.

 Application of Techniques
a) Grasp the extremity around the joints. Without causing pain .
b) Support areas of poor structural integrity, such as recent fracture site, or
paralyzed limb segment.
c) Move through the complete pain-free range to the point of tissue resistance.
d) Do not force beyond the available range. To avoid it becomes a stretching
technique.
e) Perform the motions smoothly and rhythmically, with 5 to 10 repetitions.
The number of repetitions depends on the objectives of the program and the
patient’s condition and response to the treatment.
 Application of PROM
a)During PROM the force for movement is external;
it is provided by a therapist or mechanical device.
b)No active resistance or assistance is given by the
patient’s muscles that cross the joint. If the
muscles contract, it becomes an active exercise.
c)The motion is carried out within the free ROM—
that is, the range that is available without forced
motion or pain.
 Application of AROM
a)Demonstrate the motion desired using PROM; then ask
the patient to perform the motion. Have your hands in
position to assist or guide the patient if needed.
b) Provide assistance only as needed for smooth motion.
c)When there is weakness, assistance may be required
only at the beginning or the end of the ROM, or when
the effect of gravity has the greatest moment arm
(torque).
d) The motion is performed within the available ROM.
 Manual
 Wand or T-bar
Finger ladder, wall climbing, ball rolling
 Pulleys
 Functional ROM
Is the range of motion required for
individual to maintain maximal
independency for activity of daily living
 Functional range of motion according to International
Classification of Functioning, Disability and Health

Is the range of motion required

for individual to maintain
maximal independency for
activity of daily living Hand to head Eating

Wallet placement to back pocket Hanging jacket Removing belt

Functional range of motion according to International
Classification of Functioning, Disability and Health
Dominant shoulder:
37.85° extension, 91.18° flexion, 1.25° adduction,
39.45° abduction, 63.6° internal rotation,
21.8° external rotation

Dominant elbow: 124.17° flexion, 40.29° extension,

Water pouring
Brushing teeth Dominant wrist:
23.66° flexion, 18.31° supination, 12.56° pronation,
18.27 ulnar deviation and, 18.36° radial deviation.

Maximum trunk range of motions :

29.75° flexion in C7-T1,
10.74° flexion in T12-L1, and
24.16° flexion in L5-S1.
washing hands and face
1. According to the definition of therapeutic exercise and the impact of exercise on the
disablement process, which of the following is a correct statement about therapeutic
exercise? It can be used to:

A)Remediate physical impairments but has little to no impact on functional limitations

B) Halt or retard the process of disablement but cannot partially or
fully reverse the process of disablement
C)Remediate, decrease, or prevent physical impairments and functional limitations
D)Remediate or decrease physical impairments and functional limitations but cannot
reduce risk factors for pathology
1. When moving a segment through its ROM, all structures in the
region are affected: muscles, joint surfaces, capsules, ligaments,
fasciae, vessels, a n d nerves ( ).
2. Joint range is the distance a muscle is c a p a b l e of shortening
a fter it ha s b e e n elo ng a te d to its ma ximum( ).
3 . R a n g e of motion is a basic technique used for the examination
of movement only. ( ).
4. Ranges of available joint motion are usually measured with a
goniometer a n d recorded in cm( ).