Therapeutic Exercise for Physical Therapy Assistants

Techniques for Intervention 3rd Edition

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Library of Congress Cataloging-in-Publication Data

Therapeutic exercise for physical therapist assistants : techniques for
intervention / [edited by] William D. Bandy, Barbara Sanders;
photography by Michael A. Morris.—3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60831-420-1 (alk. paper)
I. Bandy, William D. II. Sanders, Barbara.
[DNLM: 1. Exercise Therapy—methods. WB 541]

616.7’062—dc23
2012016636

DISCLAIMER

Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices.
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tion of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness,
or accuracy of the contents of the publication. Application of this information in a particular situation remains the profes-
sional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute
and universal recommendations.
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this text are in accordance with the current recommendations and practice at the time of publication. However, in view of
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LWBK1056-FM.indd 2 04/07/12 6:28 PM

 To Beth, Melissa, and Jamie for providing constant love,
patience, and inspiration.
WDB

To Mike and Whitney, whose love and support allow me

to do the things I enjoy.
BS

LWBK1056-FM.indd 3 04/07/12 6:28 PM

 C O N T R I B U T O R S

William D. Bandy, PT, PhD, SCS, ATC Barbara Hoogenboom, PT, EdD, SCS, ATC
Professor Associate Professor
Department of Physical Therapy School of Health Professions
University of Central Arkansas Grand Valley State University
Conway, Arkansas Allendale, Michigan

Janet Bezner, PT, PhD Jean M. Irion, PT, EdD, SCS, ATC
Deputy Executive Director Associate Professor
American Physical Therapy Association Department of Physical Therapy
Alexandria, Virginia University of South Alabama
Mobile, Alabama
Marty Biondi, PT
Therapeutic & Wellness Specialists Ginny Keely, PT, MS, OCS, FAAOMPT
Highland Park, Illinois Ronning Physical Therapy
Santa Cruz, California
Mark DeCarlo, PT, DPT, MHA, SCS, ATC
Vice President of Clinical Services Beth McKitrick-Bandy, PT, PCS, MBA
Methodist Sports Medicine/The Orthopedic Specialists Director of Rehabilitation Services
Indianapolis, Indiana Arkansas Children’s Hospital
Little Rock, Arkansas
James P. Fletcher, PT, PhD, ATC
Associate Professor Dennis O’Connell, PT, PhD, FACSM
Department of Physical Therapy Professor
University of Central Arkansas Department of Physical Therapy
Conway, Arkansas Hardin-Simmons University
Abilene, Texas
Gail “Cookie” Freidhoff-Bohman, PT, MAT,
SCS, ATC-L Erin O’Kelley, MSPT, ATC
Bauman Physical Therapy Lecturer (retired)
Lexington, Kentucky Department of Physical Therapy
Texas State University—San Marcos
Denise Gobert, PT, PhD, NCS San Marcos, Texas
Assistant Professor
Department of Physical Therapy Michael M. Reinold, PT, DPT, ATC
Texas State University—San Marcos Facility Director & Coordinator of Rehabilitative
San Marcos, Texas Research
Champion Sports Medicine
Clayton F. Holmes, PT, EdD, MS, ATC American Sports Medicine Institute
Professor and Chair Birmingham, Alabama
Department of Physical Therapy
University of North Texas Health Science Center
Fort Worth, Texas

iv

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 Contributors v

Eric Robertson, PT, DPT, OCS, FAAOMPT Steven R. Tippett, PT, PhD, SCS, ATC
Assistant Professor Professor and Chair
Department of Physical Therapy Department of Physical Therapy and Health Science
Texas State University-San Marcos Bradley University
San Marcos, Texas Peoria, Illinois

Chris Russian, RRT, MEd Timothy F. Tyler, PT, MS, ATC

Associate Professor Clinical Research Associate
Department of Respiratory Care NISMAT at Lenox Hill Hospital
Texas State University—San Marcos New York, New York
San Marcos, Texas
Michael L. Voight, PT, DHSc, OCS, SCS, ATC
Barbara Sanders, PT, PhD, SCS, FAPTA Professor
Professor and Chair Department of Physical Therapy
Department of Physical Therapy Belmont University
Associate Dean Nashville, Tennessee
College of Health Professions
Texas State University—San Marcos Michele Voight, PTA, MPA
San Marcos, Texas Director of Clinical Education
Houston Community College
Michael Sanders, EdD Houston, Texas
Lecturer
Kinesiology and Health Sciences Bridgett Wallace, PT
University of Texas Balance Therapy of Texas
Austin, Texas Austin, Texas

Marcia H. Stalvey, PT, MS, NCS Kevin E. Wilk, PT, DPT

Clinical Manager, Inpatient Rehabilitation Clinical Director
Edwin Shaw Rehabilitation Institute Champion Sports Medicine
Cuyahoga Falls, Ohio American Sports Medicine Institute
Birmingham, Alabama
Russell Stowers, PTA, EdD
Clinical Manager Rehabilitation Reta J. Zabel, PT, PhD, GCS
CHRISTUS St. Vincent Regional Medical Center Physical Therapist
455 St. Michaels Dr. Hot Springs, Arkansas
Santa Fe, New Mexico

J. David Taylor, PT, PhD

Associate Professor
Department of Physical Therapy
University of Central Arkansas
Conway, Arkansas

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 R E V I E W E R S

Lynette Allison Nancy Greenawald

Winnipeg Technical College Montgomery College
Winnipeg, Manitoba, Canada Takoma Park, Maryland

Alina C. Adams Julianne Martin

Wallace State Community College Broome Community College
Hanceville, Alabama Binghamton, New York

Kathleen Tomczyk Born Christie Simon

Milwaukee Area Technical College Kankakee Community College
Milwaukee, Wisconsin Kankakee, Illinois

Linda Farrell Krista Wolfe

Lake Superior College Central Penn College
Duluth, Minnesota Summerdale, Pennsylvania

Jodi Gootkin
Broward College
Naples, Florida

vi

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 P R E F A C E T O T H I R D E D I T I O N

The first two physical therapist assistant (PTA) education using therapeutic exercise techniques that the PTA will
programs, at Miami Dade Community College in Florida provide under the direction and supervision of the PT.
and St Mary’s Campus of the College of St. Catherine in
Minnesota, opened their doors in 1967. In 1969 the first
15 PTAs graduated from these two schools. Since that ●● ORGANIZATION
time the number of these very important technical assist-
ants to the physical therapist (PT) has grown to include A look at the Table of Contents shows that the book is
an estimated 50,000 PTAs currently licensed in the United divided into seven parts. Part I lays the foundation for
States. To date a plethora of textbooks exist defining ther- the next six parts of the book. A history of therapeutic
apeutic exercises and describing the role of therapeutic exercise is provided and an understanding of where ther-
exercise in the treatment of patients and clients. But no apeutic exercise fits into the realm of all interventions is
textbook exists on the topic of therapeutic exercise written explained. Using current policies held by the American
specifically for the PTA. The purpose of Therapeutic Exercise Physical Therapy Association, important terms related
for the Physical Therapist Assistant is to provide descriptions to the management of the patient are defined and the
and rationale for the use of a variety of therapeutic exer- role of the PTA within the healthcare team is clarified.
cise techniques that are frequently delegated to the PTA by Additional information presented in to these first two
the PT for the rehabilitation of an individual with impair- chapters includes the reaction of the various tissues
ment or for the prevention of potential problems. to exercise, the use of complementary modalities, and
We are excited to write the first textbook devoted totally effective use of communication with patients. In addi-
to the use of therapeutic exercise for the PTA. Instead of tion, the Nagi classification model of the disablement
using a therapeutic exercise book written for the PT and process is defined and a newer model that has been pro-
making changes to make the content appropriate to the moted as a successor to the Nagi model by the World
PTA, it is our goal that Therapeutic Exercise for the Physical Health Organization called the International Classifi-
Therapist Assistant will meet the needs of educators who are cation of Functioning, Disability, and Health (known
training the future PTAs. more commonly as ICF) is discussed.
The primary audience for this textbook is individuals Part II presents information for increasing mobility by
in a PTA curriculum. Although written primarily for PTA performing range of motion techniques (passive, active-
students, this textbook can also provide experienced clini- assistive, and active) and stretching activities. Information
cians with background and illustrations of specific exer- on increasing strength and power, ranging from fre-
cise techniques, allowing even the experienced clinician to quently used therapeutic exercise techniques (open-chain
add to their repertoire of therapeutic exercises used. and closed-chain exercises) to more sophisticated and
As indicated in the Guide to Physical Therapist Practice aggressive exercises (PNF and plyometrics), is presented in
(published by the American Physical Therapy Associa- Part III.
tion), therapeutic exercise is the most important pro- Important information needed for understanding the
cedural intervention provided in the field of physical concept of balance and providing therapeutic exercise
therapy. We believe that this textbook is an excellent techniques for treatment of balance dysfunction is pre-
choice for teaching this important topic to the PTA in a sented in Part IV. A unique concept, reactive neuromuscu-
therapeutic exercise course in the curriculum or as unit lar training, is presented in Part IV as well. Part V addresses
in a musculoskeletal course. The basic assumption of the practice area of cardiopulmonary, with informa-
this textbook is that the patient has been examined by tion presented on aerobic conditioning for the unfit but
the PT, the impairment has been identified, and the plan healthy individual, cardiac rehabilitation for the patient
of care has been established by the PT. This textbook after a cardiac accident, and enhancement of breathing for
focuses on the implementation of the treatment plan the person with respiratory dysfunction.

vii

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 viii Preface to Third Edition

Part VI integrates information from the previous five ●● THE THIRD EDITION
parts in order to treat patients with dysfunction of the
upper and lower extremities and the spine. Finally, the Feedback from reviewers of the first two editions was very
unique applications of aquatic therapy and a relatively new complimentary of the use of case studies in each chapter. An
concept, contextual fitness for the elderly, are presented in important part of practicing efficiently, ethically, and legally
Part VII. In addition, Part VII also contains the addition is that the PTA provides therapeutic exercise within the plan
of a new chapter added to the Third Edition on the use of of care developed by the PT. To illustrate the appropriate
therapeutic exercise in the preparation of a patient prior relationship between the PT and the PTA, the Third Edition
to giat activities. continues to include case studies that describe appropriate
(and sometimes inappropriate) interventions performed by
the PTA and the interaction between the PT and the PTA.
●● CHAPTER STRUCTURE In addition, at the end of each case study, a “Summary—An
Effective PT–PTA Team” section is included, which provides
Each chapter in Parts II to VII is set up using a consistent feedback as to whether the interaction between the PTA and
format (excluding Chapter 6). We believe that this con- the PT was appropriate.
sistent format allows a nice flow to the book from one In an effort to write a book that is based on the cur-
chapter to the next and adds to the ease of reading and rent evidence available, the Third Edition has been, again,
clarity. The standard headings are presented in the fol- updated with the most current research available on the
lowing order: techniques presented in each chapter. Each chapter also
contains sample questions and answers to prepare the stu-
Objectives have been added to the beginning of each dent for tests. In addition to updating all chapters for the
chapter to clarify the content that will be presented. student, ancillary materials for each chapter contained
Scientific Basis includes background information and in the Third Edition to assist the PTA educator include:
a brief discussion of the benefits of the intervention PowerPoint presentations, and an image bank containing
being presented—supported by evidence, when avail- all figures in the text, as well as extra figures not presented
able. in the text. The intent of these ancillary materials is to
allow the instructor to individualize their course to meet
Clinical Guidelines provide information such as how, the specific needs of their coursework. All ancillary mate-
why, and when to use the techniques. rial is available online (http://thepoint.lww.com).
Techniques provide illustrations of frequently used
therapeutic exercise techniques.
●● SUMMARY
Case Studies not only provide examples as to how to
use the therapeutic exercise techniques on patients,
Therapeutic exercise can be considered a craft. As such, thera-
but demonstrate how the treatment is advanced as the
peutic exercise must be learned by doing, not by reading. This
patient progresses.
textbook provides ideas and techniques; however, to fully
Summary contains a bulleted list of key concepts. learn therapeutic exercise, the PTA student must practice the
techniques under the supervision of an experienced educator.
References contain the most current evidence avail-
To gain this practical experience, the student should begin
able.
by practicing on an individual who is free from dysfunction
Geriatric and Pediatric Perspectives offer infor- before trying the techniques on patients with impairments;
mation specific to the pediatric and geriatric patient the student should always practice in a supervised environ-
(using “boxes”) that is important for understanding ment. It is our hope that you find Therapeutic Exercise for the
the appropriate use of therapeutic exercise across the Physical Therapist Assistant a valuable asset to the initial and
lifespan. ongoing education of the PTA.

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 A C K N O W L E D G M E N T S

In writing each revision, we continued to be reminded A special thank you needs to go out to Russell Stowers
that the challenges in writing a textbook tend to be and Michele Voight, two very hard-working PTAs who cre-
more than expected. The support that our family, ated the case studies. Their work at giving the case studies
friends, students, and colleagues provided in allowing a PTA focus is appreciated—and we think these case stud-
us to pursue each new edition was outstanding and ies are a strength of the book.
greatly appreciated. The writing of this revision was made easier due to
Michael Morris, FBCA, our photographer, has taken the support of graduate assistants from the University of
every picture for each of the three editions. He remains Central Arkansas and their work with Medline searches,
a joy to work with and we continue to appreciate his tal- editing, writing objectives, organizing the glossary, and
ent. Related to the photographs, we would also like to constant word processing. Our thanks go to Kelly Free,
thank all the models for this book: Michael Adkins, Melissa Leah Lowe, Emily Devan, Marie Charton, Mieke Corbitt,
Bandy, Laura Cabrera, Rachel Cloud, Emily Devan, Carmen Carrie Blankenship, Kristen Hook, and Stacie Morgan.
Lawson, Nancy Bond, Ashlee McBride, Amber Montgom- We would be remiss if we did not acknowledge two out-
ery, Dot East, Neil Hattlestad, Renatto Hess, Jean Irion, standing physical therapy faculties: Departments of Physi-
Verdarhea Langrell, Nancy Reese, and Trigg Ross. A very cal Therapy at the Texas State University—San Marcos and
special thank you goes to Ben Downs from the Respira- the University of Central Arkansas. We really appreciate
tory Therapy Department at Arkansas Children’s Hospi- such a supportive group of colleagues, a group that makes
tal for his assistance for the pictures in Chapter 14. it fun to come in to work every day.
New contributors were added with the Third Edition. Finally, writing a textbook takes time from our families.
We are appreciative of Denise Gobert for the new chapter on We again wish to thank our families—our spouses (Beth
exercises for the preparation of gait activities (Chapter 18), and Mike) and our girls (Jamie, Melissa, and Whitney)—for
as well as the contributions of new units by Eric Robert- their love, patience, and support.
son (Chapter 15) and Marty Biondi (Chapter 17).

ix

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 C O N T E N T S

Contributors iv
Reviewers vi
Preface to Third Edition vii
Acknowledgments ix

PART I ● FOUNDATIONS OF ­THERAPEUTIC EXERCISE 1

1. Introduction to Therapeutic Exercise 2

William D. Bandy, PT, PhD, SCS, ATC • Barbara Sanders, PT, PhD, SCS, FAPTA
Erin O’Kelley, MSPT, ATC • J. David Taylor, PT, PhD

2. The Role of the Physical Therapist Assistant 15

William D. Bandy, PT, PhD, SCS, ATC • Beth McKitrick-Bandy, PT, PCS, MBA
Barbara Sanders, PT, PhD, SCS, FAPTA

PART II ● MOBILITY 29

3. Range of Motion 30
James P. Fletcher, PT, PhD, ATC

4. Joint Mobilization 62
Clayton F. Holmes, PT, EdD, ATC • William D. Bandy, PT, PhD, SCS, ATC

5. Stretching Activities for Increasing Muscle Flexibility 87

William D. Bandy, PT, PhD, SCS, ATC

PART III ● STRENGTH AND POWER 117

6. Principles of Resistance Training 118

Michael Sanders, EdD • Barbara Sanders, PT, PhD, SCS, FAPTA

7. Open-Chain–Resistance Training 138

William D. Bandy, PT, PhD, SCS, ATC
x

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 Contents xi

8. Proprioceptive Neuromuscular Facilitation 173

Marcia H. Stalvey, PT, MS, NCS

9. Closed-Kinetic–Chain Exercise 208

Kevin E. Wilk, PT, DPT • Michael M. Reinold, PT, MS, DPT, ATC

10. Plyometrics 227

Kevin E. Wilk, PT, DPT • Michael M. Reinold, PT, MS, DPT, ATC

PART IV ● BALANCE 251

11. Balance Training 252

Bridgett Wallace, PT, DPT

12. Reactive Neuromuscular Training 281

Michael L. Voight, PT, DHSc, OCS, SCS, ATC • William D. Bandy, PT, PhD, SCS, ATC

PART V ● CARDIOPULMONARY APPLICATIONS 299

13. Principles of Aerobic Conditioning and Cardiac Rehabilitation 300

Dennis O’Connell, PT, PhD, FACSM • Janet Bezner, PT, PhD

14. Enhancement of Breathing and Pulmonary Function 340

Chris Russian, RRT-NPS, MEd • Barbara Sanders, PT, PhD, SCS, FAPTA

PART VI ● FUNCTIONAL ­PROGRESSION IN ­THERAPEUTIC ­EXERCISE 365

15. Functional Progression for the Spine 366

Ginny Keely, PT, MS, OCS, FAAOMPT • Eric K. Robertson, PT, DPT, OCS, FAAOMPT

16. Functional Progression for the Extremities 408

Steven R. Tippett, PT, PhD, SCS, ATC • Michael L. Voight, PT, DHSc, OCS, SCS, ATC
Kevin E. Wilk, PT, DPT

PART VII ● UNIQUE APPLICATIONS OF THERAPEUTIC EXERCISE 431

17. Aquatic Therapy 432

Jean M. Irion, PT, EdD, SCS, ATC • Marti Biondi, PT

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 xii Contents

18. Therapeutic Exercise for the ­Preparation of Gait Activities 471

Denise Gobert , PT, PhD, NCS

19. Principles of Contextual Fitness and Function for Older Adults 488
Reta J. Zabel, PT, PhD, GCS

20. Application of Therapeutic ­Exercise using Sample Protocols 509

Mark DeCarlo, PT, DPT, MHA, SCS, ATC • Gail C. Freidoff, PT, MAT, SCS, ATC
Timothy F. Tyler, PT, MS, ATC • William D. Bandy, PT, PhD, SCS, ATC
Barbara Sanders, PT, PhD, SCS, FAPTA

Geriatric Perspectives written by Reta Zabel, PT, PhD, GCS

Pediatric Perspectives written by Barbara Hoogenboom, PT, EdD, SCS, ATC

Glossary 521
Index 527

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 Foundations of
I
P A R T

­Therapeutic Exercise

1 Introduction to Therapeutic Exercise

2 The Role of the Physical Therapist Assistant

LWBK1056-CH01_p01-14.indd 1 03/07/12 4:55 PM

 1
C H A P T E R

Introduction to
Therapeutic Exercise
William D. Bandy, PT, PhD, SCS, ATC
Barbara Sanders, PT, PhD, SCS, FAPTA
Erin O’Kelley, MSPT, ATC
J. David Taylor, PT, PhD

Obj e c t i ve s
Upon successful completion of this chapter, the reader will be able to:

• Define therapeutic exercise.

• Discuss the role of therapeutic exercise as an intervention in patient care.
• Identify the effect of therapeutic exercise on specific soft tissue.
• Identify physical agent and electrotherapeutic interventions that would be
appropriate in support of therapeutic exercise.

Therapeutic exercise consists of a broad category of a brief discussion of the historical development of the
activities intended to improve a patient’s function and field is presented.
health status. In health care environment of today, passive
modalities are no longer thought of as the core element in
a rehabilitation program. The future of health care arena Historical Perspective
will rely more and more on therapeutic exercise for the The following review of the significant highlights in the
rehabilitation of individuals with impairment. history of therapeutic exercise provides the reader with a
perspective of the progression of the use of therapeutic
exercise by clinicians. For an extensive history of the field,
● D
 EFINITION OF THERAPEUTIC see Licht,2 who defined therapeutic exercise as “motions
EXERCISE of the body or its parts to relieve symptoms or to improve
function.”
In a 1967 survey of more than 100 clinicians and faculty The use of therapeutic exercise (then referred to as
who were using or teaching therapeutic exercise, Bou- medical gymnastics) was recorded as early as 800 BC
man1 collected 53 definitions of therapeutic exercise. in the Atharva-Veda, a medical manuscript from India.
Bouman1 concluded, “I think we all know what thera- According to the manuscript, exercise and massage were
peutic exercise is. It is just difficult to define.” Before pro- recommended for chronic rheumatism. However, most
viding an operational definition of therapeutic exercise, historians in the field believe that therapeutic exercise

LWBK1056-CH01_p01-14.indd 2 03/07/12 4:55 PM

 CHAPTER 1 • Introduction to Therapeutic Exercise 3

first gained popularity and widespread use in ancient Kabat8 took therapeutic exercise out of the cardinal
Greece. Herodicus is believed to be the first physician to plane by introducing diagonal movement and the use of
write on the subject (ca. 480 b.c.e.) and is considered the a variety of reflexes to facilitate muscle contraction. His
Father of Therapeutic Exercise. Herodicus claimed to have work was further developed by Knott and Voss,9 who pub-
used exercise to cure himself of an “incurable” disease and lished the textbook Proprioceptive Neuromuscular Facilitation
developed an elaborate system of exercises for athletes. in 1956.
Hippocrates, the most famous of Herodicus’ students, Using the principles of vector analysis on the flexor and
wrote of the beneficial effects of exercise and its value in extensor muscles that control the spine, Williams10 devel-
strengthening muscle, improving mental attitude, and oped a series of postural exercises and strengthening activ-
decreasing obesity. ities to alleviate back pain and emphasize flexion. In 1971,
Galen, considered by some as the greatest physician in McKenzie11 introduced a program to treat patients with
ancient Rome, wrote of exercise in the 2nd century c.e. He back pain that focused on extension to facilitate anterior
was appointed the physician for the gladiators and clas- movement of the disks.
sified exercise according to intensity, duration, and fre- Hislop and Perrine12 introduced the concept of iso-
quency. In the 5th century c.e., another Roman physician, kinetic exercise in 1967, which was quite popular in the
Aurelianus, recommended exercise during convalescence 1970s and 1980s. Finally, the work of Maitland,13 Men-
from surgery and advocated the use of weights and pul- nell,14 and Kaltenborn15—who introduced the basic con-
leys. In 1553, in Spain, Mendez wrote Libro Del Exercicio, cepts of arthrokinematics and the use of mobilization and
the first book on exercise. The book emphasized exercises manipulation to decrease pain and capsular stiffness—
to improve hygiene. cannot be overlooked as an important contribution in the
Therapeutic exercise in modern times appears to have 20th century.
originated in Sweden in the 19th century with a fencing It is impossible to name all the accomplishments
instructor named Pehr Henri Ling. Ling believed that a related to the area of therapeutic exercise, but some of
good fencer should also be a good athlete, and he devel- the more important events and concepts were high-
oped and taught a system of specific movements. His lighted. This textbook was written by current experts in
system of therapeutic exercise included dosage, count- the field of therapeutic exercise. Each chapter focuses on
ing, and detailed instruction for each exercise. He demon- a specialized field of therapeutic exercise and includes
strated that precise movements, if scientifically applied, background information and references to the major
could serve to remedy disease and dysfunction of the researchers and scholars in that area. In addition, all
body.3 In 1932, McMillan4 wrote, “It is Peter Henry Ling the authors are clinicians and, therefore, have firsthand
and the Swedish systematical order that we owe much knowledge and understanding of the exercise techniques
today in the field of medical gymnastics and therapeutic presented. When Licht’s2 history of therapeutic exercise
exercise.” is revised, it may well refer to the authors of the chapters
About the same time that Ling developed his system, of this textbook.
Swiss physician Frenkel5 wrote a controversial paper
(1889). Frenkel proposed an exercise program for ataxia
that incorporated repetitive activities to improve damaged Physical Therapy Perspective: Guide to
nerve cells. No weights or strengthening activities were
Physical Therapist Practice
used, and the program became very popular. Although
Frenkel’s program is not as popular as it once was, his In November 1997, the APTA first published the Guide to
greatest contribution to the development of therapeutic Physical Therapist Practice.16 The Guide provides an outline
exercise is the insistence on repetition. of the body of knowledge for physical therapists (PT)
Several individuals made major contributions to the and delineates preferred practice patterns. In addition,
development of therapeutic exercise in the 20th century. the Guide describes boundaries within which the PT may
In 1934, Codman6 developed a series of exercises to allevi- select appropriate care. It represents the best efforts of
ate pain in the shoulder; these exercises are now referred the physical therapy profession to define itself. The docu-
to as Codman’s, or pendulum, exercises. One of the most ment was developed over 3 years and involved the expert
important advances was the adaptation of progressive consensus of more than 1,000 members of the physical
resistance exercises (PRE) by Delorme7 in 1945. This exer- therapy community.
cise program was developed in a military hospital in an The Guide defines intervention as “the purposeful and
effort to rehabilitate patients after knee surgery. Accord- skilled interaction of the PT with the patient/client.”
ing to Licht,2 PRE was adapted more widely and rapidly According to the Guide, physical therapy intervention has
than any other concept of therapeutic exercise in the cen- the following three components, listed in order of impor-
tury, except for early ambulation. tance:

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 4 PART I • Foundations of ­Therapeutic Exercise

Coordination, communication, and documentation health of the tissue. The chemical mediators relaying the
message of pain are often dissipated long before the tis-
Patient/client-related instruction
sue is healthy enough to respond to the forces such as
Procedural interventions those that led to the initial injury.
Therapeutic exercise
Phases of Healing
Functional training in self-care and home manage-
ment (activities of daily living, instrumental activi- Although three phases of the healing process exist, in reality,
ties of daily living) healing is an ongoing process until resolution with no clear
delineation of one phase from the other. Phase I is the inflam-
Functional training in work (job, school, play) com- matory response phase. An injury occurs and the body tries
munity and leisure integration or reintegration to respond by stabilizing the injured site; the inflammation
Manual therapy begins and lasts 24 to 48 h and even up to 7 to 10 days. The
acute inflammatory reaction begins with vasoconstriction
Prescription, application, fabrication of devices and of small vessels. As the acute phase resolves, vasodilatation
equipment of the vessels occurs, which increases the blood and plasma
Airway clearance techniques flow to the area of injury. This vasodilatation is followed by
increased permeability that leads to edema. These changes
Integumentary repair and protective techniques allow the increase of white blood cells (WBC) to combat
Electrotherapeutic modalities foreign bodies and instigate the process of debris removal.
The inflammatory process is a time of many complex events
Physical agents and mechanical modalities that manifest themselves with the signs of inflammation
including redness, swelling, pain, increased temperature,
Note that therapeutic exercise is considered the most and loss of normal function.
important procedural intervention. Table 1-1 presents a Phase II is considered the repair sequence, or the prolif-
definition of therapeutic exercise and a detailed account of eration phase, and begins after Phase I, anytime from 48 h
the types of therapeutic exercises used in the practice of to 6 weeks after injury. Tissue regeneration occurs with
physical therapy. The operational definition of therapeutic vascularization and cell growth to fill any tissue voids. The
exercise used in this textbook is the one given in Table 1-1. fibroblastic activity provides proliferation of the repara-
tive cells for wound closure and regeneration of any small
vessels. These events are complex and interactive among
● E
 FFECT OF THERAPEUTIC cells and chemicals in the area. The collagen that is pro-
EXERCISE ON SPECIFIC duced during this phase is type III collagen and is weak
SOFT TISSUE and thin but lays down the foundation for further colla-
gen replacement with type I collagen.
Before providing information on the role of the physical Phase III is the stage of connective tissue formation and
therapist assistant (PTA) and the description of the wide remodeling and begins from 3 weeks to 12 months fol-
variety of therapeutic exercises that the PTA can use in the lowing injury. During this phase, a balance between pro-
treatment of their patients and clients, an understand- teolytic degradation of excess collagen and deposition,
ing of injuries, the healing process, and how therapeutic organization, and modification of the collagen exists in
exercise relates to specific soft tissue of the body is needed. preparation for the maturation process. Type III collagen
This section will provide information that is important to is converted to type I collagen that strengthens and pro-
understand how therapeutic exercise is integrated into the vides much more cross-linkage to develop tensile strength.
total treatment plan and the management of the patient. Remodeling is the process by which the architecture of tis-
sue alters in response to stress.
Tissue repair is an adaptive intrinsic and extrinsic pro-
Injury Classification
cess. Physical therapy cannot accelerate the healing but
Tissue is either injured with a single injurious force can support and not delay or disrupt the process. A bal-
referred to as macro-trauma or by a series of small forces ance needs to exist between protection and application of
referred to as micro-trauma. With a macro-trauma injury, controlled functional stresses.
the pain and tissue destruction occur simultaneously. As more specific makeup of the various tissues in the
However, with micro-trauma, the tissue incurs several body is described, it is important not only to gauge the
small injuries prior to the patient experiencing pain. In stage of healing but to also understand that tissues have
both instances, pain is not an accurate indicator of the different rates of healing. Tissues must receive nutrients

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 CHAPTER 1 • Introduction to Therapeutic Exercise 5

TABLE 1-1 Procedural Interventions

Therapeutic Exercise
Therapeutic exercise is the systematic performance or execution of planned physical movements, postures, or activities
intended to enable the patient/client to (1) remediate or prevent impairments, (2) enhance function, (3) reduce risk, (4)
optimize overall health, and (5) enhance fitness and well-being. Therapeutic exercise may include aerobic and endurance
conditioning and reconditioning; agility training; balance training, both static and dynamic; body mechanics training; breath-
ing exercises; coordination exercises; developmental activities training; gait and locomotion training; motor training; muscle
lengthening; movement pattern training; neuromotor development activities training; neuromuscular education or reeduca-
tion; perceptual training; postural stabilization and training; range-of-motion exercises and soft tissue stretching; relaxation
exercises; and strength, power, and endurance exercises.
Physical therapists select, prescribe, and implement exercise activities when the examination findings, diagnosis, and
prognosis indicate the use of therapeutic exercise to enhance bone density; enhance breathing; enhance or maintain physi-
cal performance; enhance performance in activities of daily living (ADL) and instrumental activities of daily living (IADL);
improve safety; increase aerobic capacity/endurance; increase muscle strength, power, and endurance; enhance postural
control and relaxation; increase sensory awareness; increase tolerance to activity; prevent or remediate impairments, func-
tional limitations, or disabilities to improve physical function; enhance health, wellness, and fitness; reduce complications,
pain, restriction, and swelling; or reduce risk and increase safety during activity performance.

Clinical Considerations
Examination findings that may direct the type and specificity of the procedural intervention may include:
• Pathology/pathophysiology (disease, disorder, or condi- — reflex integrity (e.g., poor balance in standing)
tion), history (including risk factors) of medical/surgical — sensory integrity (e.g., lack of position sense)
conditions, or signs and symptoms (e.g., pain, shortness — ventilation and respiration/gas exchange (e.g.,
of breath, stress) in the following systems: abnormal breathing patterns)
— cardiovascular • Functional limitations in the ability to perform actions,
— endocrine/metabolic tasks, and activities in the following categories:
— genitourinary — self-care (e.g., difficult with dressing, bathing)
— integumentary — home management (e.g., difficulty with raking,
— multiple systems shoveling, making bed)
— musculoskeletal — work (job/school/play) (e.g., difficulty with keyboard-
— neuromuscular ing, pushing, or pulling, difficulty with play activities)
— pulmonary — community/leisure (e.g., inability to negotiate steps
• Impairments in the following categories: and curbs)
— aerobic capacity/endurance (e.g., decreased walk • Disability—that is, the inability or restricted ability to per-
distance) form actions, tasks, or activities of required roles within
— anthropometric characteristics (e.g., increased body the individual’s sociocultural context—in the following
mass index) categories:
— arousal, attention, and cognition (e.g., decreased moti- — work (e.g., inability to assume parenting role, inability
vation to participate in fitness activities) to care for elderly relatives, inability to return to work
— circulation (e.g., abnormal elevation in heart rate with as a police officer)
activity) — community/leisure (e.g., difficulty with jogging or
— cranial and peripheral nerve integrity (e.g., difficulty playing golf, inability to attend religious services)
with swallowing, risk of aspiration, positive neural
provocation response) • Risk reduction/prevention in the following areas:
— ergonomics and body mechanics (e.g., inability to — risk factors (e.g., need to decrease body fat composition)
squat because of weakness in gluteus maximus and — recurrence of condition (e.g., need to increase mobility
quadriceps femoris muscles) and postural control for work [job/school/play]
— gait, locomotion, and balance (e.g., inability to perform actions, tasks and activities)
ankle dorsiflexion) — secondary impairments (e.g., need to improve strength
— integumentary integrity (e.g., limited finger flexion as and balance for fall risk reduction)
a result of dorsal burn scar) • Health, wellness, and fitness needs:
— joint integrity and mobility (e.g., limited range of — fitness, including physical performance (e.g., need to
motion in the shoulder) improve golf-swing timing, need to maximize gymnas-
— motor function (e.g., uncoordinated limb movements) tic performance, need to maximize pelvic-floor muscle
— muscle performance (e.g., weakness of lumbar stabilizers) function)
— neuromotor development and sensory integration — health and wellness (e.g., need to improve balance for
(e.g., delayed development) recreation, need to increase muscle strength to help
— posture (e.g., forward head, kyphosis) maintain bone density)
— range of motion (e.g., increased laxity in patellofemo-
ral joint)

(continued)

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