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1. EXERCISE
PRESCRIPTIONS
Caroline Kisner
ACSM 9th edition

2. EXERCISE
1. Flexibility
2. Muscular strength & endurance
3. Aerobic (Cardiovascular Endurance)
4. Neuromotor /Motor Skill/ Functional Fitness Training (Balance,
Coordination, Gait, Agility, Proprioceptive)
5. Others : aquatic, plyometric, challistenic, speed training, relaxation

3. Tips utk mencegah overuse injury & cedera musculoskeletal lainnya :
• Warm-up & cool-down
• Stretching
• Gradual progression of volume & intensity
Tips utk mencegah cardiovascular disease complication :
• Skrining & evaluasi prepartisipasi latihan
• Memulai program latihan baru dengan intensitas ringan-sedang
• Tingkakan secara bertahap kuantitas & kualitas latihan

5. 1. FLEXIBILITY EXERCISE
Terdiri dari :
1. ROM exercise (on available ROM)
a. Passive ROM  MMT 0-1
b. Active-assisted ROM  MMT 2
c. Active ROM  MMT ≥ 3
2. Stretching exercise (beyond the available ROM)

6. Pattern ROM Exercise :
a. Anatomical plane : frontal, sagittal, transverse
b. Muscle range of elongation : antagonistic to the line of pull of the muscle
c. Combine patterns : diagonal & several planes of motion
d. Functional patterns : motions use for ADL
ROM Exercise can be done by:
a. Doctor/therapist/practitioner
b. Manual self assisted
c. Machine : CPM (Continuous Passive
Motion)
Self-Assisted ROM Technique
a. Manual
b. Equipment :
• Wand / T-Bar
• Finger ladder, wall climbing, ball
rolling
• Pulleys
• Skate board/powder board
• Reciprocal exc device (bicycle,
upper body ergometer)
Kisner, C.

7. Manual Self-Assisted ROM
Kisner, C.

8. Kisner, C.

9. CONTINUOUS PASSIVE MOTION (CPM)
• Passive motion performed by mechanical device that
moves a joint slowly and continuously through a
controlled ROM.
• General guideline :
a. May be applied immediately after surgery
b. Initially 20-300 and progressed 10-150 /day as
tolerated
c. Rate of motion : 1 cycle/45 sec or 2 min
d. Amount of time : vary from continuous 1 hour 3x/day
to 24 hours/day (best 4-8 hours/day)
e. Minimum duration : < 1 week or until satisfactory
ROM is reached
Kisner, C.

10. ROM EXC RECOMMENDATION (Kisner C.)
• Tidak ada FITT VPP utk ROM exc
• Rekomendasi :
•Repetisi 5-10 x. Number of repetition depends on objectives
program & px condition
• Move the segmen through its complete pain-free ROM, smoothly
& rhtmically.
• Frequency : ???

11. STRETCHING EXC
• Contracture  adaptive shortening of muscle-tendon unit & other
soft tissues that cross or surround joints that results in significant
resistance to passive/active stretch & limitation of ROM.
• Type of Contracture :
a. Myostatic (myogenic)
b. Pseudomyostatic  hypertonicity (spasticity / rigidity)
c. Arthrogenic and periarticular
d. Fibrotic

14. Stretching
Exercise
(ACSM)

15. 2. MUSCULAR STRENGTH & ENDURANCE EXERCISE

16. ISOMETRIC STRENGTHENING (Kisner C.)
FITT-VP Recommendation
Frequency 2-3 day/week
Intensity 60-80% max isometric contraction
Time 10 seconds (2’ rise time, 6’ hold time, 2’ fall time)
Type Isometric
Volume -
Pattern 20x repetition, exercise at different specific angle
Progression As tolerated

17. Resistance Exercise Recommendations (ACSM)
Frequency • 2-3 day/week
Intensity Strength :
• Begginer : 60-70% 1-RM
• Experienced : ≥ 80% 1-RM
• Older/sedentary : 40-50% 1-RM
Endurance : < 50% 1-RM
Time No specific duration
Type Involved each muscle group.
Use exercise equipment and or body weight.
Repetitions Strength : Adult : 8-12 repetitions ; Older : 10-15 repetitions
Endurance : 15-20 repetitions
Sets Strength : 2-4 set
Endurance : ≤ 2 sets
Pattern Rest interval 2-3 minutes between set; Rest ≥ 48 hours between session
Progression Gradual progression resistance/repetition per set/frequency

18. Progressive Resistive Regimen (Kisner, C.)

19. 3. AEROBIC (CARDIOVASCULAR ENDURANCE) EXERCISE
Measure Exercise Intensity :
a. HRR (Karvonen)
THR = % intensity x (HRmax-HRrest) + HRrest
HRmax according to stress test/age estimated
b. Age adjusted MHR
HRmax = 220-age
THR = % intensity x HRmax

20. Jenis Exercise : Anaerobic dan Aerobic exercises
1. Anaerobic exercises :
• Terjadi pada 1-2 menit pertama dari latihan (fase glikolisis)
• Yaitu pada latihan dengan high resistance dan short duration pada
80% maximum exertion capacity (misal: sprint)
2. Aerobic exercises
• Meliputi latihan penguatan dan endurance kardiopulmoner
• Melibatkan banyak otot untuk meningkatkan konsumsi oksigen secara
bertahap
• Latihan low impact yg dianjurkan : sepeda statik, berenang,
bersepeda, jalan cepat, callisthenic, low impact aerobic, mendayung,
hiking, mendayung

21. Aerobic Exercise Recommendations (FITT-VP) (ACSM)
FITT-VP Recommendation
Frequency • ≥ 5 day/week of moderate intensity
• ≥ 3 day/week of vigorous intensity
Intensity Moderate or vigorous intensity for most adults.
Light to moderate intensity for deconditioned individuals
Time • 30-60 minutes of moderate exercise
• 20-60 minutes of vigorous exercise
• < 20 min can be beneficial, especially in sedentary iNdividual
Type Regular, continuous, rhythmic exc that involve major muscle group
Volume ≥ 500-1000 MET-min /week ; step count ≥ 7000 step/day
Pattern One continuous session or multiple session of ≥ 10 min /day
Progression Gradual adjusting duration, frequency, and intensity

22. 4. NEUROMOTOR EXERCISE (ACSM)

23. 4.1 BALANCE
• Sensorimotor integration
• Anticipatory control
• Reactive control
- Postural alignment - ROM
- Muscle strength - Motor coordination
- Muscle endurance - Pain

24. BALANCE CONTROL
1. Static Balance Control  maintain a stable antigravity position
2. Dynamic Balance Control  stabilize body when support surface is
moving or when body move on a stable surface
3. Automatic Postural Reactions  maintain balance in response to
unexpected perturbation (berdiri di bis & tiba-tiba bis ngebut)
Kisner, C.

25. Motor Strategy for Balance Control (Kisner, C.)
1. Ankle Strategy (Ant Post)
• For small perturbation
• Activation from distal to proximal
• Anterior perturbation  gastroc
• Posterior perturbation  tib ant
4. Hip Strategy
• For rapid/large perturbation
• Activation from proximal to distal
• Rapid hip flx/ext + trunk active
2. Weight-Shift Strategy (Med Lat)
• Hips are key control
• Activation hip abd-add + some
contribution ankle inv-evertor
5. Stepping Strategy
• Forward or backward step to enlarge
base of support
• Active if COM displace beyond limits
of stability
3. Suspension Strategy
• Lower COM by flx knee, causing flx of
hip & ankle
• Combine w/ankle or weight-shift to
enhance balanCe
6. Combines Strategies

27. STATIC BALANCE TRAINING (Kisner, C.)
Progress :
1. Maintain sitting, half-kneeling, tall kneeling, standing on firm surface
2. Tandem, single leg stance, lunge, squat position.
3. Working on soft surface (foam, sand, grass), narrowing base of support, moving
arms, closing eyes.
4. Provide resistance via weight or elastic resistance & add 2nd task (catching a ball)

28. DYNAMIC BALANCE CONTROL (Kisner, C.)
1. Standing on moving surface (sitting on thera ball, standing on wobble board,
bouncing on mini trampoline)
2. Progress the activities by shifting body weight, rotating trunk, moving head/arms,
vary position of arms from outside to above head.
3. Stepping exc (small step  mini lunge  full lunge)
4. Hopping, skipping, rope jumping, hopping down
5. Arm & leg exc while standing, tandem or single leg stance

29. ANTICIPATORY BALANCE CONTROL (Kisner, C.)
1. Reach in all directions, catch a ball, kicking a ball
2. Use different posture (sitting, kneeling, standing) & throwing a ball at
different speed & height
3. Use functional task (open & close door, maneuver through an
obstacle cource

30. REACTIVE BALANCE CONTROL (Kisner, C.)
• Increase sway while standing on a firm stable surface
• To emphasize ankle strategy  standing on 1 leg w/ trunk erect
• To emphasize hip strategy  tandem walking, tandem stance or 1 leg stance w/
trunk bending, stand on minitrampoline, rocker balance, sliding board
• To emphasize stepping strategy  step up onto a stool, stepping w/ leg cross
• Add challenge : lifting weight, throw & catch ball, increase/decrease speed
Balance During Functional Activities (Kisner, C.)

31. Kisner, C.

32. 4.2 LATIHAN KOORDINASI
TIPE LATIHAN KOORDINASI :
1. Frenkel exercise
2. Pendekatan secara tradisional untuk meningkatkan kontrol motorik dan
koordinasi.
 Peripheral neuromuscular fascilitation (PNF)
 Movement therapy (Brunnstrom approach)
 Neurodevelopment technique (NDT) (Bobath approach)
 Sensorimotor approach (Road approach)
3. Pendekatan secara kontemporer untuk meningkatkan kontrol motorik dan
koordinasi.
 Motor relearning program (MRP) untuk pasien stroke (Carr and Shepherd
approach)
 Kontemporer task-oriented approach

33. Prinsip Umum Latihan Koordinasi :
• Repetisi konstan dari beberapa aktivitas motorik.
• Penggunaan sensori (taktil, visual, propriosepsi) untuk membantu
fungsi motorik.
• Meningkatkan kecepatan saat aktivitas.
33
Dibagi dalam 4 divisi :
1. Berbaring
2. Duduk
3. Berdiri
4. Berjalan
Setiap gerakan di ulang pelan-pelan 3-4x, minimal 2x/hari

34. Latihan saat berbaring Latihan saat duduk
34
• Heel sliding (flx-ext ; abd-add)
• Heel to shin
• Flx-ext AGB bersamaan
• Flx 1 AGB, ext 1 AGB
• Angkat tumit-angkat AGB
• Gerakkan kaki ke depan,
belakang, kanan, kiri
• Berdiri – flx trunk –duduk
• Gerakkan kaki mengikuti gambar

35. Latihan dengan Berdiri dan Berjalan
1. Berjalan menyamping
2. Berjalan ke depan pada 2 garis
sejajar, jarak ≤ 15 cm
3. Tandem walking
4. Berputar pada gambar lingkaran
di lantai
5. Naik turun tangga
6. Berjalan di parallel bar dng
bantuan Frenkle’s mat (dari wide
base menjadi narrow base)
7. Pivot turning (AGB yg lemah tetap
pd 1 titik)
Frenkle’s Mat
Pivot Turning

36. 5. AQUATIC EXERCISE (all from Kisner, C.)
Physical Properties of Water
Definition Clinical Significance
1 Buoyancy Upward force that works opposite to
gravity
• Weightlessness & joint
unloading
2 Hydrostatic
pressure
Pressure exerted on immersed
objects
• Reduce effusion, assist
venous return, bradycardia
• When closer to surface, allow
exercise more easily
3 Viscosity Friction occurring between molecules
of liquid resulting in resistance to flow
• Creates resistance
4 Surface
tension
Surface of fluid acts as a membrane
under tension
• Extremity that moves through
surface perform more work
than if kept under water

37. Exercise Water
Temperature
Flexibility, strength, gait,
relaxation
26-330C
Acute painful musculoskeletal
injury
330C
Aerobic 26-280C
Intense aerobic exc > 80% MHR 22-260C

38. INDICATIONS :
a. ROM exc
b. Resistance exc
c. Weight-bearing exc
d. Cardiovascular exc
e. Enhance manual tech
f. Provide 3 dimensional access to the Px
g. Initiate functional activity replication
h. Minimize risk of injury or reinjury
i. Enhance Px relaxation
CONTRAINDICATIONS :
a. Cardiac failure & unstable angina
b. Respiratory dysfunction (VC < 1 lt)
c. Severe PAD
d. Danger of bleeding & hemorrhage
e. Severe kidney dis
f. Open wound, colostomy, skin infection
g. Uncontrolled bowel & bladder
h. Water or airborne infection (flu, thypoid,
gastrointestinal infection, polio)
i. Uncontrolled seizure
PRECAUTIONS :
a. Fear of water
b. Neurologic disorder (ataxia, multiple sclerosis with heat intolerance)
c. Seizure
d. Cardiac dysfunctions (angina, abnormal BP)
e. Small, open wound, tracheostomy, IV line

40. ROM EXC RECOMMENDATION (Kisner C.)
• Tidak ada FITT VPP utk ROM exc
• Rekomendasi :
•Repetisi 5-10 x. Number of repetition depends on objectives
program & px condition
• Move the segmen through its complete pain-free ROM, smoothly
& rhtmically.
• Frequency : ???

41. Stretching
Exercise
(ACSM)

42. ISOMETRIC STRENGTHENING (Kisner C.)
FITT-VP Recommendation
Frequency 2-3 day/week
Intensity 60-80% max isometric contraction
Time 10 seconds (2’ rise time, 6’ hold time, 2’ fall time)
Type Isometric
Volume -
Pattern 20x repetition, exercise at different specific angle
Progression As tolerated

43. Resistance Exercise Recommendations (ACSM)
Frequency • 2-3 day/week
Intensity Strength :
• Begginer : 60-70% 1-RM
• Experienced : ≥ 80% 1-RM
• Older/sedentary : 40-50% 1-RM
Endurance : < 50% 1-RM
Time No specific duration
Type Involved each muscle group.
Use exercise equipment and or body weight.
Repetitions Strength : Adult : 8-12 repetitions ; Older : 10-15 repetitions
Endurance : 15-20 repetitions
Sets Strength : 2-4 set
Endurance : ≤ 2 sets
Pattern Rest interval 2-3 minutes between set; Rest ≥ 48 hours between session
Progression Gradual progression resistance/repetition per set/frequency

44. Aerobic Exercise Recommendations (FITT-VP) (ACSM)
FITT-VP Recommendation
Frequency • ≥ 5 day/week of moderate intensity
• ≥ 3 day/week of vigorous intensity
Intensity Moderate or vigorous intensity for most adults.
Light to moderate intensity for deconditioned individuals
Time • 30-60 minutes of moderate exercise
• 20-60 minutes of vigorous exercise
• < 20 min can be beneficial, especially in sedentary imdividual
Type Regular, continuous, rhythmic exc that involve major muscle group
Volume ≥ 500-1000 MET-min /week ; step count ≥ 7000 step/day
Pattern One continuous session or multiple session of ≥ 10 min /day
Progression Gradual adjusting duration, frequency, and intensity

45. 4. NEUROMOTOR EXERCISE (ACSM)