Orthopaedic and Rheumatology skill for Physiotherapy Students THERAPEUTIC EXERCISESDone by :Assist Prof.Mosab Amoudi 2011
Definition:• Therapeutic Exercises is defined as science used ultimately to restore the body function (ADL) as normal as possible. This could be obtained through development , improvement, restoration, or maintenance of:- Strength - Endurance - Relaxation- Mobility & flexibility - Coordination- Skills
Definitions of range of motion exercisesA- passive movement within the unrestricted ROM for a segment which is produced entirely by an external force ; there is no voluntary muscle contraction.B- Active within the unrestricted ROM for a segment which is produced by an active contraction of the muscles crossing that joint.C- Passive – Assistive. A type of active ROM in which assistance is provided by an outside force , either manually or mechanically, because the prime mover muscles need assistance to complete the motion.
Goals of Therapeutic Exercises• Improves range of motion• Reduce Pain• Restore joint flexibility• Improve muscle mass, strength & endurance• Reduction of limb edema• Increase body function• Improves balance control• Increases cardiovascular strength and endurance• Helps preventing further injury• Gain self confidence.
RequirementsIn order to effectively administer therapeutic exercise to a patient & to ultimately achieve its target goal, the therapist must know:1. Basic principles & effects of treatment2. The interrelationships of anatomy & kinesiology of the body part.3. The state of disability & potential rate of recovery, complications, precautions & contraindications4. The pathology of orthopedic, neurological, cardiopulmonary & the other medical conditions.
5. The accurate functional evaluation of the patient, that identifies the patient’s of problems, the goals treatment, the plan of treatment & the home care program.6. The basic evaluation procedures, including posture evaluation, goniometric measurements, manual muscle testing, orthopedic evaluation….. Etc.7. The factors that affects the neuro muscular, musculoskeletal & circulatory systems particularly those lead to deformity and injury ( for example absence of gravity and weight bearing)
Range of motion Introduction : principles- Movement of a body segment takes place as muscles or external forces move bones. Bones move with respect to each other of the connecting joint.- The structure of the joints affects the amount of motion that can occur between any tow bones. Also the integrity and flexibility of the soft tissues plays on important role in determining the amount of motion.
- When moving a segment through its range of motion, all structures in the region are affected: muscle, joint surfaces, capsules, ligaments, vessels, and nerves.- To describe joint range, terms such as flexion, extension, abduction, adduction, & rotation are used.- ROM activities are most easily described in terms of joint range & muscle range, Muscle range is related to the functional excursion of muscles.- Functional excursion: is the distance a muscle is capable of shortening after it has been elongated to its maximum
- In order to maintain normal range of motion, the segments must be moved through their available ranges periodically, whether it be the available joint range or muscle range- It is recognized that many factors can lead to decreased ROM , such as systemic joint, neurologic, or muscular diseases, surgical or traumatic insult , or simply inactivity or immobilization for any reason.
- Therapeutically, range of motion activities are administered to maintain existing joint & soft tissue mobility, which will minimize the effects of contracture formation.
Types of ROM Exercises• Passive• Active• Active Assisted_________________________________• Manual• Self‐Exercise• Mechanical (CPM machine)• Assistive tools (pulley, wand)
TYPES OF ROM EXERCISES• Passive range-of-motion exercises – PROM• Active range-of-motion exercises – AROM• Active-Assistive range-of-motion exercises – AAROM
PASSIVE ROM EXERCISES Movement produced by an external force within the unrestricted range of motion of a segment Little to or no muscle contraction elicited
Passive ROM exercises are characterized by:• No muscular activation by the patient• Performed within the available ROM• Applied by some external force• No pain
Importance of Passive ROM Exercises• Passive ROM exercises are very important if you have to stay in bed or in a wheelchair.• ROM exercises help keep joints and muscles as healthy as possible. Without these exercises, blood flow and flexibility (moving and bending) of the joints can decrease.• Passive ROM exercises help keep joint areas flexible.
Indications & goals for ROM• Passive ROM2. When the patient is not able to or not to actively move a segment or segment of the body, such as comatose paralyzed, or on complete bed rest2. When there is an inflammatory reaction and active ROM is painful or sever inflamed injury3. For assessment purposes4.When teaching a patient movement5. To prepare a patient for stretching
Goal for PROM• To maintain joint & connective tissue mobility• To minimize effects of the formation of contractures• To maintain elasticity of muscle.• To assist circulation• improve synovial movement / nutrition of cartilage• decrease pain• maintain patient awareness• Assist with healing process after injury or surgery
Other uses for PROM- When the therapist is examination PROM / is used• to determine limitation of motion• to determine joint stability• to determine muscle & other soft tissue elasticity- When the therapist is teaching an active exercise program PROM is used to demonstrate the desired motion- When the therapist is preparation a patient for stretching, PROM is often used preceding the passive stretching techniques
ACTIVE ROM EXERCISES Movement produced on a segment upon active contraction of the muscles crossing the joint within the unrestricted range of motion.ACTIVE-ASSISTIVE ROMEXERCISES Assistance is provided by an outside force (manual or mechanical), as the prime mover muscles is unable to complete the motion.
Goal for AROMThe same goals of PROM can be met with AROM. Specific goals are:• Maintain elasticity and contractility of 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
IN Indications AROMD When a patient is able to actively contractI the muscles and move the segment withC or without assistanceA Muscle weakness and inability to moveT segment completely against gravityI Aerobic conditioning programsO During periods of immobilization,N AROM is used in joints above and belowS the immobilized segment
L Limitations of ROM ExercisesI • Limitations of passive & active motionM Passive ROM exercise WILL NOT:I - prevent atrophyT - Increase strength or enduranceA - Assist circulation to the extent that active, voluntaryT muscle contraction improvement in circulation willI Active ROM exercise WILL NOT:O – for strong muscles, it will not maintain or increaseN strengthS - it will not develop coordination extent in the movement pattern used
Contraindications of ROM exercise A- Both active & passive ROM are contraindicated under any circumstance where motion to a part will be disruptive to the healing process, such as:- Immediately following a tear to ligaments, tendons, or muscle- In the region of unhealed fracture.- Immediately following surgical procedures to tendons, ligament, muscle, capsule, or skinB- Active ROM is contraindicated when the cardiovascular dysfunction of a patient is unstable & active exercise affect the patient’s life. Such as immediately following a myocardial infarctionC- Should not be done if response will be life-threatening to the patientE- Severe soft tissue trauma.
Active Assisted Range of Motion Exercises• Exercise in which movement is performed by the voluntary effort of the patient with assistance of external force to complete the range of motion.• Patient can voluntary activate the muscle and produce muscle contraction.• Patient is unable to fully activate the muscle and complete the range of motion.
• Assistance may be provided throughout the range or mostly just at ends, depending upon the patient.• Motion can be performed against gravity or in a gravity-minimized situation (omitting gravity or gravity eliminated).
Indications of AAROM Exercises• Patient is unable to complete ROM actively because of weakness due to – trauma – muscular or neuromuscular disease – pain• Pt is not allowed to fully activate muscle following surgery
PRINCIPLES OF ROM TECHNIQUES• Examination, evaluation, and treatment planning2. Level of function , determine any precaution, & prognosis, plan the intervention3. Determine the ability of the patient to participate in the ROM activity & whether PROM, A-AROM or AROM4. determine the amount of motion that can be safely5. decide what patterns can best meet the goals, ROM techniques may be performed in the: a. Anatomic planes of motion(transveres, frontal, sagittal)
b. Muscle range of elongation: antagonistic to the line of pull of musclec. Combined patterns: diagonal motion or movements that incorporate several planes of motiond. Functional pattern: motion used in activities of daily living5. Monitor the patient’s general condition & responses during & after the examination & intervention6. Document & communicate findings & intervention7. Re-evaluate & modify the intervention as necessary
Patient Preparation• Communicate with patient. Describe the plan & method of intervention• Remove all restrictive clothing, linen, splint, and dressings; drape appropriately• Place the patient in a comfortable position which allow you to move the segment through the available ROM• Position yourself so that proper body mechanics can be used
Application of Techniques• Grasp the extremity around the joints providing support needed for control• Support areas of poor structural integrity such as hyper mobile joint or a recent fracture site or where there is paralysis• Do the motion smoothly and rhythmically, with 5 to 10 repetitions. The number of repetition depends on the objectives of the program & the patient’s conduction & response to treatment.• Move the segment throughout its pain-free range to point of tissue resistance
Application of PROM• Movement is being provided by an external force or mechanical device.• No active resistance or assistance is given by the muscles that cross the joint.• Motion is performed within the available or free ROM. that is, the range that is available without forced motion or pain
Application of AROM• In active –Assistive or active ROM, Demonstrate to the patient the motion desired motion using passive ROM, then ask the patient perform the movement. Have your hands in position to assist or guide the patient if needed.• Provide assistance only as needed for smooth . Perform the motion within the available range
Upper Extremity ROM Techniques• Shoulder: flexion andextension– Hand placement andprocedure
Mobility• It is often defined as the abilityof structures or segments of the body to move or be moved to allow the presence of range of motion for functional activities (functional ROM).• It can also be defined as:the ability of an individual to initiate, control, or sustain active movements of the body to perform simple to complex motor skills (functional mobility).
• Mobility, as it relates to functional ROM, is associated with joint integrity as well as the flexibility (i.e., extensibility of soft tissues that cross or surround joints—muscles, tendons, fascia, joint capsules, ligaments, nerves, blood vessels, skin), which are necessary for unrestricted, pain-free movements of the body during functional tasks of daily living.
FlexibilityFlexibility is the ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain- free ROM. M. length in conjunction with joint integrity and extensibility of periarticular soft tissue determine flexibility.Flexibility related to the extensibility of musculotendinous units that cross a joint• What is Flexibility?Flexibility is the amount of movement available at a joint. For example, the amount of movement available at the hip joint is determined by how far the leg can be moved in each of the permitted motions (e.g. flexion - raising the leg up in front).
Dynamic and Passive Flexibility• Dynamic flexibility. This form of flexibility, also referred to as active mobility or active ROM, is the degree to which an active muscle contraction moves a body segment through the available ROM of a joint.• It is dependenton the degree to which a joint can be moved by a muscle contraction and the amount of tissue resistance met during the active movement
Passive flexibility• This aspect of flexibility, also referredto as passive mobility or passive ROM, is the degree to which a joint can be passively moved through the available ROM and is dependent on:• the extensibility of muscles• and connective tissues that cross and surround a joint.
Hypomobility• Hypomobility refers to decreased mobility or restricted motion. A wide range of pathological processes can restrict movement and impair mobility. There are many factors that may contribute to hypomobility and stiffness of soft tissues, the potential loss of ROM, and the development of contractures.
Factors That Contribute to Restricted Motion• Prolonged immobilization Skin disorders Bony blockCasts and splints Vascular disorders or asymmetrical posturesSkeletal traction Paralysis, tonal abnormalities, and muscle imbalances• Pain• Joint inflammation an effusion• Muscle, tendon, or fascial disorders
Contracture• Restricted motion can range from mild muscle shorteningContracture is defined as the adaptive shortening of the muscle-tendon unit and other soft tissues that cross or surround a joint that results in significant resistance to passive or active stretch and limitation of ROM, and it may compromise functional abilities.
Types of Contracture• Myostatic ContractureIn a myostatic (myogenic) contracture, although the musculotendinous unit .there is no specific muscle pathologyPseudomyostatic ContractureImpaired mobility and limited ROM may also be the result of hypertonicity (i.e., spasticity or rigidity) associated with a central nervous system lesion such as a CVA, spinal cord injury, or traumatic brain injury.
• Arthrogenic and Periarticular ContracturesAn arthrogenic contracture is the result of intra-articular pathology. These changes may include adhesions, synovial proliferation, joint effusion, irregularities in articular cartilage, or osteophyte formation.• Fibrotic Contracture and Irreversible ContractureFibrous changes in the connective tissue of muscle and periarticular structures can cause adherence of these tissues and subsequent development of a fibrotic contracture.(UNKOWN CASE)
Indications for Use of Stretching• ROM is limited because soft tissues have lost their extensibility as the result of adhesions, contractures, and scar tissue formation, causing functional limitations or disabilities.• Restricted motion may lead to structural deformities• There is muscle weakness• May be used as part of a total fitness program designed to prevent musculoskeletal injuries.• May be used prior to and after vigorous exercise potentially to minimize postexercise muscle soreness.
Contraindications to Stretching• A bony block limits joint motion.• There was a recent fracture, and bony union is incomplete.• acute inflammatory or infectious process (heat and swelling) or soft tissue healing• acute pain, A hematoma ,trauma , Hypermobility• Shortened soft tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills
Changes in Collagen Affecting Stress– Strain Response• Effects of Immobilization• There is weakening of the tissue because of collagen turnover and weak bonding between the new, nonstressed fibers. There is also adhesion formation because of greater cross-linking between disorganized collagen fibers and because of decreased effectiveness of the ground substance maintaining space and lubrication between the fibers. The rate of return to normal tensile strength is slow.
Effects of Inactivity (Decrease of Normal Activity)• There is a decrease in the size and amount of collagen fibers, resulting in weakening of the tissue. There is a proportional increase in the predominance of elastin fibers, resulting in increased compliance. Recovery takes about 5 months of regular cyclic loading. Physical activity has a beneficial effect on the strength of connective tissue.
Effects of Age• There is a decrease in the maximum tensile strength and the elastic modulus, and the rate of adaptation t stress is slower. There is an increased tendency for overuse syndromes, fatigue failures, and tears with stretching.
Effects of Corticosteroids• There is a long-lasting deleterious effect on the mechanical properties of collagen with a decrease in tensile strength. There is fibrocyte death next to the injection site with delay in reappearance up to 15 weeks.
Effects of Injury• Excessive tensile loading can lead to rupture of ligaments and tendons at musculotendinous junctions. Healing follows a predictable pattern with bridging of the rupture site with newly synthesized type III collagen.
Determinants of Stretching Interventions• Alignment: positioning a limb or the body such thatthe stretch force is directed to the appropriate muscle group• Stabilization: fixation of one site of attachment of the muscle as the stretch force is applied to the other bony attachment• Intensity of stretch: magnitude of the stretch force applied• Duration of stretch: length of time the stretch force is applied during a stretch cycle
• Speed of stretch: speed of initial application of the stretch force(should be slow & should be applied and released gradually)• Frequency of stretch: number of stretching sessions per day or per week• Mode of stretch: form or manner in which the stretch force is applied (static, ballistic, cyclic); degree of patient participation (passive, assisted, active); or the source of the stretch force (manual, mechanical, self)
Types of Stretching• Static stretching (5 seconds to 5 minutes) per repetition • Manual stretching• Cyclic/intermittent stretching • Mechanical stretching• Ballistic stretching • Self-stretching• Proprioceptive neuromuscular • Passive stretchingfacilitation stretching procedures • Active stretching(PNF stretching)
• 1- static stretching: When we extend the work of a particular muscle, until they reach the maximum muscle length was then steadfast in that situation For ten seconds if we want to calm or stability on a prolongation for 30 seconds if we want to develop and increase the dynamic range.• 2- dynamic stretching: Are the types of prolongation which is positive about the performance of the prolongation of the movement such as walking, for example, dynamic, prolongation does not help much in the development of flexible joints and muscles.
• 3- proprioceptive neuromuscular facilitation (PNF)PNF, or proprioceptive neuromuscular facilitation, is a type of stretching used to increase flexibility quickly.The PNF technique allows for greater muscle relaxation following each contraction and increases the soldiers ability to stretch through a greater range of motion.4- Ballistic stretching: involves movements such as bouncing or bobbing to attain a greater range of motion and stretch.
• techniques. It was originally reserved for therapeutic use in stroke patients, but has in recent years gained popularity with athletes.• Common PNF varieties include:1- Hold-Relax The hold-relax is the most common type of PNF stretch. The muscle is held in a passive stretch for about 20 seconds. Then that same muscle is contracted.
The muscle is contracted in a stationary position and is not moved. This contraction is held for 10 to 15 seconds before the muscle is relaxed for no longer than 3 seconds. After this, the passive stretch is done again for 20 seconds. The contraction allows the muscle to be stretched further than before.
• 2- Contract-RelaxThe contract-relax technique is very similar to the hold- relax technique. A passive stretch is held for 20 seconds. The muscle is then contracted. The difference between the contract-relax and and the hold-relax is that in the contract-relax technique, the muscle is contracted concentrically. This means the muscle is moved so it temporarily shortened. The contraction is released for a couple of seconds and then the passive stretch is repeated for another 20 seconds.
• Contract-Relax with Antagonist Contract• The contract-relax with antagonist contract method appears to be the most effective type of PNF stretch. In this stretch, the muscle is stretched for 20 seconds. It is then contracted concentrically, such as in the contract-relax. After holding the contraction for 10 seconds, the muscle opposite to the contracted muscle is contracted statically for 10 seconds as well. After a quick three second relax, the passive stretch is repeated.
Benefits of stretching There are many benefits to be gained from a regular stretching programme:• Increased flexibility and range of motion• Injury prevention• Preventing DOMS (Delayed Onset Muscle Soreness)• Improved posture• Improvements in sports performance• Stress relief
1- What are type of stretching? (3)1) Clinician Guided2) Joint Mobilization3) Auto Stretching2- What is mobility related to?joint integrity and flexibility3- What is hypomobility?Adaptive Shortening of soft tissue
4-What are factors leading to hypomobility?1) Prolonged immobilization2) Sedentary Lifestyle3) Postural Mal alignment4) Muscle Imbalance5) Impaired Muscle Performance6) Tissue Trauma7) Congenital deformities5- What is dynamic flexibility?Amount of motion you have control over
6- Passive FlexibityStatic, End Range type of motion7- What is passive flexibility dependent on?the extensibility of the muscle and connective tissue that croos or surround the joint8- What is dynamic flexibility dependent on?the muscle contraction and the amount of tissue resistance met.
9- What is a contracture?Adaptive shortening of the muscle tendon unit and other soft tissues that surround a joint10- What does a contracture lead to?Significant resistance to stretching and limited ROM11- What are the 4 types of contractures?1) Myostatic2) Pseudomyostatic3) Arthrogenic and Periarticular4) Fibrotic and irreversable
12- What is a myostatic contracture?Musculotendinous unit adaptively shortened13- What is a common problem with Myostatic Contracture?Significant loss of ROM14-Myostatic Contracture is a result of a reduced number of ?Sarcomere units15- How can Myostatic Contracture be healed?With stretching exercises in a short amount of time
16-What is Pseudomyostatic Contractures a result of?1) hypertonicity or spasticity2) CNS Lesions17-Who usually suffers from Pseudomyostatic Contractures? Neuro Pt18-Why do pseudomyostatic Contractures give resistance to passive stretch?Muscle appears to be in a constant state of contraction
19- How do you treat a pseudomyostatic contracture?inhibition procedures20- What is an Arthrogenic and Periarticular Contracture a result of? (2)1) intra-articualr pathology2) connective tissues that cross a joint capsule becomes stiff21-What do Arthogenic Contractures inhibit?Normal arthrokinematic Motion
22- How are fibrotic Contractures caused?Fibrous changes in connective tissue23- What are the treatments for Fibrotic Contractures?1) Stretching 2) surgical intervention24- What are interventions for soft tissue mobility? (5)1) Manual or mechanical stretching2) Self Stretching3) Neuromuscular Inhibition4) Joint Mobilization5) Neural Tissue Glide
25- What is over stretching?stretch well beyond the normal length of muscle ROM26-What can over stretching result in?stretch well beyond the normal length of muscle ROM27- What can over stretching result in? (3)1) Hypermobility2) joint instability3) strength of the muscle are insufficient
28- What are the responses to Soft tissue to immobilization and stretch? (3)1) Elastic Change2) viscoelastic Change3) Plastic Change29- What are the types of muscular connective tissue? (3)1) Endomysium2) Perimysium3) Epimysium30- What type of forces occur during a passive stretch? Longitudinal and lateral
31- What are connective tissue composed of?1) collagen fibers2) Elastin Fibers3) Reticulin Fibers4) Ground Substance32-What are collagen fibers responsible for?1) strength2) Stiffness3) Resisting tensile deformation33- What do elastin fiber provide? extensibility
34- What type of intensity should be applied to a stretch? Low35- What is a static progressive stretch?a stretch that is held in a comfortably lengthened position until relaxed and then progressively lengthened further36- What is a cyclic stretch?- Short duration-repeatedly but gradually applied-released then reapplied
37- What are the 3 way to inhibit the nueromuscular system1) Hold-Relax and Contract-relax2) Agonist Contraction3) Hold relax with agonist contraction38- what are the steps to Hold-Relax and Contract-Relax Stretching?1) Muscle is lengthened to point of limitation2) Pt. Performs a pre-stretch, end range and isometric contration fro 5-10 sec3) voluntary relaxation of tight muscle4) limb passively moved into new range
39- What are the steps to an agonist contraction?1) Concentrically contract the muscle opposite the limited muscle2) Hold the end range position for several sec40-What are the steps for hold-relax with agonis contraction?1) Move the limb to the point of resistance2) Pt perform a resisted, pre-stretch isometric contraction of the range limited muscle3) relaxation of that muscle4) immediate concentric contraction of the oppoiste muscle