Therapeutic Exercise 1

Foundational Concepts

P ROF. MYRG EN Q. T I N GSON

ST. DOMI N I C COL L EG E OF A S I A - S HS P
Almost everyone, regardless of age, values the ability to function as independently as possible
during activities of everyday life.
Health-care consumers (patients and clients) typically seek out or are referred for physical
therapy services because of physical impairments associated with movement disorders caused
by injury, disease, or health-related conditions that restrict their ability to participate in any
number of activities that are necessary or important to them.
Physical therapy services may also be sought by individuals who have no impairments or
functional deficits but who wish to improve their overall level of fitness and quality of life or
reduce the risk of injury or disease
To develop and implement effective exercise interventions, a therapist must understand how the
many forms of exercise affect tissues of the body and body systems and how those exercise-
induced effects have an impact on key aspects of physical function. A therapist must also
integrate and apply knowledge of anatomy, physiology, kinesiology, pathology, and the
behavioral sciences across the continuum of patient/client management from the initial
examination to discharge planning.
Therapeutic Exercise:
Impact on Physical Function
o 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.
Therapeutic exercise
o Individualized
 patient
 client
Components 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
Interrelated
components of
physical function
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 moderateintensity,repetitive, total body
movements (walking, jogging, cycling, swimming) over an extended period of time.1,105 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. 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).3,161
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 maintenance of proper alignment of bony
partners of a joint by means of passive and dynamic components
Types of Therapeutic Exercise
Interventions
• Aerobic conditioning and reconditioning
• Muscle performance exercises: strength, power, and endurance training
• Stretching techniques including muscle-lengthening procedures and joint
mobilization/manipulation 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
 Risk factors must be identified and weighed carefully before an exercise program is initiated
 Medications can adversely affect a patient’s balance and coordination during exercise or
cardiopulmonary response to exercise.
 Adequate space and a proper support surface for exercise are necessary prerequisites for
patient safety
A patient must be informed of the signs of fatigue
when a patient is carrying out an exercise program independently at home or at a community
fitness facility, patient safety is enhanced and the risk of injury or re-injury is minimized by
effective exercise instruction and patient education
 therapist safety also is a consideration to avoid work-related injury (proper body mechanics
and joint protection into these manual techniques to minimize his or her own risk of injury.)
Classification of Health Status, Functioning,
and Disability—Evolution of Models and
Related Terminology
o Disablement, a term often used in the early health classification models, refers to the impact(s)
and functional consequence(s) 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

EARLY MODEL
o Nagi Model
o International Classification of Impairments, Disabilities, and Handicaps (ICIDH)
Despite the variations in the early models, each taxonomy identified the following key
components:

■ Acute or chronic pathology

■ Impairments
■ Functional limitations
■ Disabilities, handicaps, or societal limitations
The ICF Framework
Definition of Terms
Impairments in body function: Problems associated with of body systems (including
physiological and psychological functions).
Impairments in body structure: Problems with the anatomical features of the body, such as
significant deviation or loss, affecting all body systems.
Activity limitations: Difficulties an individual may have in executing actions, task, activities.
Participation restrictions: Problems an individual may experience in involvement in life
situations, including difficulties participating in self care, responsibilites in the home, workplace,
or the community, and recreational, leisure and social activities
Components of Functioning and Disability
Models and Applications in Physical Therapy
Physical therapy profession has been defined by a body of knowledge and clinical applications
that are directed toward the elimination or remediation of disability
Impairments
impairments are the consequences of pathological conditions and encompass the signs and
symptoms that reflect abnormalities at the body system, organ, or tissue level.
Types of Impairment
Physical therapists typically provide care and services to patients with impairments of body
function and/or body structure that affect the following systems:
■ Musculoskeletal
■ Neuromuscular
■ Cardiovascular/pulmonary
■ Integumentary
Common Physical Impairments Managed
with Therapeutic Exercise
Musculoskeletal
■ Pain
■ Muscle weakness/reduced torque production
■ Decreased muscular endurance
■ Limited range of motion due to:
■ Restriction of the joint capsule
■ Restriction of periarticular connective tissue
■ Decreased muscle length
■ Joint hypermobility
■ Faulty posture
■ Muscle length/strength imbalances
Neuromuscular
■ Pain
■ Impaired balance, postural stability, or control
■ Incoordination, faulty timing
■ Delayed motor development
■ Abnormal tone (hypotonia, hypertonia, dystonia)
■ Ineffective/inefficient functional movement strategies
Cardiovascular/Pulmonary
■ Decreased aerobic capacity (cardiopulmonary endurance)
■ Impaired circulation (lymphatic, venous, arterial)
■ Pain with sustained physical activity (intermittent claudication)

Integumentary
■ Skin hypomobility (e.g., immobile or adherent scarring)
Types of Activity Limitations/Functional
Limitations
Basic activities of daily living (BADL)
o Bathing, dressing, or feeding
Instrumental activities of daily living (IADL)
o Occupational tasks, school-related skills, housekeeping, and recreational activities, or
community mobility (driving, using public transportation)
Common Activity Limitations/ Functional
Limitations Related to Physical Tasks
Difficulties with or limitation of:

■ Reaching and grasping ■ Squatting (crouching) and kneeling

■ Lifting, lowering, and carrying ■ Standing up and sitting down (from
■ Pushing and pulling and to a chair, the floor)
■ Bending, stooping ■ Getting in and out of bed
■ Turning, twisting ■ Moving around (crawling, walking,
■ Throwing, catching running) in various environments
■ Rolling ■ Ascending and descending stairs
■ Sitting or standing tolerance ■ Hopping and jumping
■ Kicking or swinging an object
Participation Restrictions and Disability
defined as problems a person may experience in his or her involvement in life situations as
measured against social standards
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.
Disability used to describe the 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.”
 “An assumption is made that when impairments and activity limitations are so severe or of such
long-duration that they cannot be overcome to a degree acceptable to an individual, a family, or
society, the perception of “being disabled” occurs. The perception of disability is highly
dependent on a person’s or society’s expectations of how or by whom certain roles or tasks
should be performed.”
Contextual factors:
The entire background of an individual’s life and living situation composed of:
■ Environmental factors: Factors associated with the physical, social, and attitudinal
environment in which people conduct their lives; factors may facilitate funcitoning (facilitators)
or hinder functioning and contribure to disability (barriers).
■ Personal factors: Features of the individual that are not part of the health condition or health
state; includes age, gender, race, lifestyle habits, coping skills, character, affect, cultural and
social background, education, etc.
Patient Management and Clinical Decision-
Making: An Interactive Relationship
Prevention of Disability
Categories of prevention:
o Primary prevention: Activities such as health promotion designed to prevent disease in an at-
risk population
o Secondary prevention: Early diagnosis and reduction of the severity or duration of existing
disease and sequelae
o Tertiary prevention: Use of rehabilitation to reduce the degree or limit the progression of
existing disability and improve multiple aspects of function in persons with chronic, irreversible
health conditions