This document discusses principles of therapeutic exercise and its physiological effects. It defines therapeutic exercise as movement prescribed to correct impairments and restore function. It outlines common training principles like overload and specificity. It describes the physiological effects of exercise on the cardiovascular, pulmonary, and musculoskeletal systems. Exercise causes acute effects like increased cardiac output and blood flow to muscles. It causes chronic adaptations like muscle fiber hypertrophy and increased bone mineral density. The document provides an overview of therapeutic exercise interventions and their impact on the disablement process.

1. Principles of Therapeutic
Exercises & it’s Physiological
Effects
Dr. Himani Kaushik (PT)
MPT Neurology

2. Objectives
• Identify the anatomical structures, indications, and contraindications
of therapeutic exercise.
• Describe the equipment, personnel, preparation, and technique in
regards to therapeutic exercise.
• Review the appropriate evaluation of the potential complications and
clinical significance of therapeutic exercise.
• Summarize inter-professional team strategies for improving care
coordination and communication to advance therapeutic exercise and
improve outcomes.

3. Introduction
• In the simplest terms, therapeutic exercise involves movement
prescribed to correct impairments, restore muscular and skeletal
function and/or maintain a state of well-being.
• Though therapeutic exercise involves a cavalcade of benefits for the
restoration of function, quality of life, and overall health.
• A therapeutic exercise programme may include a range of different
types of exercise such as those for improving or preventing
deterioration in aerobic capacity, muscle strength, power and
endurance, flexibility or range of movement, balance, coordination,
and agility.

4. • The body's responses to a single bout of exercise are regulated by the
principle of homeostasis. Homeostasis is defined as the ability of the
body to maintain a stable internal environment for cells by closely
regulating various critical variables such as pH or acid base balance,
oxygen tension, blood glucose concentration and body temperature.
• The overload, specificity, reversibility and individuality principles
influence training adaptations in the body, for health as well as
performance.

5. Common Training Principles
• Overload
• Specificity
• Reversibility
• Individuality
• Motor learning
• Safety

6. Overload
• The overload principle states that habitually overloading a system
causes it to respond and adapt.
• The overload principle can be quantified according to load (intensity
and duration), repetition, rest and frequency.
• Load refers to the intensity of the exercise stressor i.e., in strength
training it can refer to the amount of resistance or in swimming it can
refer to speed.
• The greater the load, the greater the fatigue and recovery time needed.
• Repetition implies the number of times that a load is applied. Rest
refers to the time interval between repetitions and frequency refers to
the number of training sessions per week.

7. • The specificity principle states that only the system or body part
repeatedly stressed will adapt to chronic overload. Therefore the
overload principle will only apply to the system or body part used
while exercising.
• Reversibility states that whereas training may enhance performance,
inactivity will lead to a decrease in performance.
• The individuality principle states that while the physiological
responses to a particular stressor can be mostly predictable, the precise
responses and adaptations will still differ among individuals.

8. Basic Exercise Principles
• Practicing the basic exercise principles is crucial for developing an
effective fitness training program.
• The basic principles of exercise if you use the so-called FITT factors,
whereas, FITT stands for
Frequency (how often),
Intensity (how hard),
Time (how long), and
Type of activity (what kind of exercise).
The principles of exercise apply to everyone at all levels of physical
training.

9. Progression and Regression Design Principles
• When prescribing exercises, it is important to understand how to
progress and regress exercises.
• If patients are improving, exercises can be progressed. However, if
they experience an increase in pain / symptoms, it may be necessary to
alter certain parameters, including:
• Sets
• Repetitions
• Speed
• Resistance

10. • Delorme Method: A systematic method of applying progressive
resistive exercise. (Originally referred to as the Delorme-Watkins
method).
Classified as a light to heavy approach.
Delorme Procedure: Determine the 10 RM for the patient.
Perform 3 sets: 1st set – 10 reps at 50% of the 10 RM
2nd set – 10 reps at 75% of the 10 RM
3rd set – 10 reps at 100% of the 10 RM
When 10 reps are exceeded on the 3rd set, establish a new 10 RM

11. • Oxford Method: Developed in England as an alternative to the
Delorme method.
Involves a heavy to light approach.
Designed to accommodate the cumulative fatigue of each set of
maximal resistance.
Oxford Procedure: Following a brief warm up, determine the 10 RM.
Perform 3 sets: 1st set – 10 reps at 100% of 10 RM
2nd set – 10 reps at 75% of 10 RM
3rd set – 10 reps at 50& of 10 RM
When 10 reps are exceeded on the 1st set, establish a new 10 RM.

12. • Maximal Heart Rate:
Heart rate that is reached at the maximum level of physical
exertion.
The common standard used for setting intensity for aerobic
conditioning.
Exercise prescriptions will range on average from 60% to
90% of max heart rate; percentage used will depend on the
patient’s current health status and conditioning level.
Age Predicted Maximal Heart Rate Method:
Subtract the person’s age from 220.
Assign a % of that number as the target heart rate to maint
-ain during a period of aerobic training.

13. Example: patient age = 60 years
220- 60 = 160
70% of 160 = 112 (112 = the target heart rate to maintain)
• Karvonen Formula – a method of determining the target heart rate
based on a percent of the difference between the individual’s maximal
and resting heart rate or heart rate reserve.
(APMH) Age Predicted Maximum Heart Rate = 220 – age (HRR)
Heart Rate Reserve = APMHR – (RHR) Resting Heart Rate
(THR)
Target Heart Rate = (HRR x Exercise Intensity) + RHR BPM =
Beats Per Minute.

14. • Rate of Perceived Exertion (Borg Scale): A subjective method of
determining exercise intensity in which the patient is taught to
estimate the work intensity level.
Borg Scale – a numerical rank is assigned to various levels of
perceived exertion.
10 – maximal effort
7 – very strong effort
5 – strong effort
3- moderate effort
2- weak effort
0 – no effort

15. Each measure has guidelines for what parameters denote vigorous, moderate, and low
intensity exercise. The following table offers a comparison of intensity across multiple
measurement methods.

16. SAID Principle
• The Specific Adaptation to Imposed Demands (SAID) principle is a
framework on which strength and conditioning programmes can be
designed.
All training is specific to a particular task
Specific skills or training may not be easily generalised or
transferred to distinct activities
The SAID principle is the key factor in determining the response
that will occur as a result of an exercise application.

17. • For e.g., Persons who train primarily by running long distances
become more efficient distance runners, their bodies generally become
leaner, aerobic metabolism is enhanced and slow twitch fibers are
enhanced.
• Persons who train primarily by lifting heavy weights for low
repetitions become stronger, their bodies becomes more muscular, and
fast twitch muscle fibers are enhanced.
• Kinetic Chain Model: Kinetic Chain - A biomechanical principle that
means bones, joints, muscles, and ligaments work together (as in links
in a chain) to accomplish functional movement. Weakness in one link
of the chain can alter the function of the total movement pattern.

18. Warm-Up
• Precaution against unnecessary injuries and muscle soreness.
• May improve certain aspects of performance.
• Prepares body for physiologically for physical work.
• Metabolic process heats up bodies core temperature
an increase of temp in skeletal muscle alters the mechanical
properties of the muscle

19. Cool Down
• Enables body to return to resting state.
• May decrease muscle soreness.
• Helps Clear Lactic Acid and flush unwanted free radicals.

20. Overtraining
• Can cause a negative effect.
• Can result in physiological and psychological breakdown.
• Can cause fatigue, injury, sickness.
• Proper training, eating habits and rest can counter effect overtraining.

21. Components of Physical Function

22. Types of Therapeutic Exercise
Interventions
• Therapeutic exercise procedures embody a wide variety of activities,
actions, and techniques.
• The techniques selected for an individualized therapeutic exercise
program are based on a therapist’s determination of the underlying
cause or causes of a patient’s impairments, activity limitations, or
participation restrictions (functional limitations or disability).

23. • 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

24. Although joint mobilization and manipulation techniques often are
categorized as manual therapy procedures, not therapeutic exercise
Impact of therapeutic exercise on the disablement process

25. 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

26. 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)

27. Precautions of Therapeutic Exercise
• Uncontrolled or poorly controlled asthma
• COPD: Patients are required to be stable before training and oxygen
saturation levels should be above 88-90%.
• Cancer or blood disorders: when treatment or disease cause leukocytes
below 0.5 x109/L, haemoglobin below 60g/L or platelets below 20 x
109/L. If a patient has a platelet count of <20 000 then only AROM
and ADLs are advised due to the increased risk of bleeding, 20 000-30
000: light exercise only.

28. • Diabetes: If blood glucose is >13 mmol or <5.5 mmol/l then it should be
corrected first. Patients with severe diabetic peripheral or autonomic
neuropathy or foot ulcers should be assessed before undertaking exercise.
Cease exercise with diabetes with acute illness or infection.
• Hypertension: resting blood pressures of a systolic >180 or diastolic >100
or higher should receive medication before regular physical activity with
particular restrictions on heavyweights strength conditioning, which can
create particularly high pressures.
• Osteoporosis: avoid activities with a high risk of falling.
• Unexplained dizzy spells.

29. Contraindications and Indications of
Therapeutic Exercise
Unstable Cardiovascular Disease (peripheral and central):
• Acute myocardial infarction or unstable angina until stable for at least 5
days, dyspnoea at rest, pericarditis, myocarditis, endocarditis, symptomatic
aortic stenosis, cardiomyopathy, unstable or acute heart failure, uncontrolled
tachycardia.
• Fever: should be settled to avoid a risk of developing myocarditis.
• Acute pulmonary embolism or pulmonary infarction. Excessive or
unexplained breathlessness on exertion.
• Any acute severe illness
• Serious musculoskeletal injury/problem
• Severely impaired cognitive functioning

30. Physiological Effects of Therapeutic
Exercise
I. Acute Effects:
A Cardiovascular Responses
To accommodate the increased metabolic activity in skeletal muscle,
the circulatory system must properly control the transport of oxygen and
carbon dioxide, as well as help to buffer the pH level of active tissues.
• This is accomplished by increasing cardiac output (increased heart
rate and stroke volume) and modulating microvascular circulation.
• In addition, the action of local vasodilators such as nitric oxide
from endothelial cells helps to ensure adequate blood flow.

31. 1. Cardiac Output (Q)
• The amount of blood pumped by the left ventricle per minute is expressed
as litres/minute.
Q = (HR) X stroke volume (SV).
• With a stepping working rate, the cardiac output increases in a nearly linear
fashion in order to meet the increased oxygen demand.
• Cardiac output is measured by echocardiography.
• VO2 is the consumption of oxygen and can be explained by the Fick
equation.
This equation states that VO2 = [Cardiac Output] x [Difference in arterial
and venous oxygen levels].

32. • VO2max is a measure of aerobic exercise capacity and is defined as
the highest rate of oxygen uptake an individual can maintain during
intense activity.
• At rest, the value is on average about 4-5 mL/100mL of blood and
• can raise progressively during an exercise up to 16 mL/100mL of
blood.
• Blood flow is preferentially shunted away from the gastrointestinal
(GI) and renal systems and toward active muscles through the
selective constriction and dilation of capillary beds with increasing
physical stress,
at maximal rates of work, 80 per cent of the cardiac output goes
to the activated muscles and the skin
in rest, this value is just twenty per cent.

33. 2. Blood Pressure
There is a linear increase in systolic blood pressure to peak values of
200 to 249 mmHg in normotensive individuals, and the diastolic
pressure value remains near rest level.
• Hypertensive individuals reach higher systolic blood pressures at a
given rate of work, and they can also reach higher diastolic values.
• The peripheral resistance of blood flow is related to vessel diameter
and length and blood viscosity in the peripheral vessels.[2]
• Under physical demands the vessels dilate, increasing their diameters.

34. • Hypertension patients have increased peripheral resistance compared
to normal, and this is a major cause of their higher average blood
pressure.
Two to three hours post-exercise blood pressure drops below pre-
exercising values, this is known as "post-exercise hypotension".
3. Coronary Circulation
• Coronary arteries supply the myocardium with blood and nutrients; on
average one capillary supplies one myocardial fibre in
the ventricular walls and papillary muscles.

35. B Pulmonary System Adaptations
• Pulmonary ventilation is initiated via the respiratory centre in
the brainstem with parallel activation through the motor cortical drive that
activates skeletal muscles and afferent Type III-IV muscle afferent fibres.
• The respiratory system works in junction with the cardiovascular system.
The pulmonary circuit receives almost all of the cardiac output. In response
to the increased cardiac output, perfusion increases in the apex of each lung,
increasing the available surface area for gas exchange
(decreased alveolar dead space).
• Maximum exercise training ventilation rates in normal-sized healthy people
may increase by a factor of ten, compared to ventilation rates at rest

36. C Musculoskeletal System
There are 3 types of muscle fibers which have different characteristics.
• Type-I fibres are known as slow-twitch fibres. These fibres have
abundant mitochondria and myoglobin with great vascular supply.
They have: Low myosin ATPase activity, High oxidative, Low
glycolytic capacity
These fibres are predominant in postural muscles as they provide low
force but don’t fatigue as easily as the others.

38. • Type-IIa fibres are known as fast-twitch oxidative fibres.
They have: High myosin ATPase activity, high oxidative, high
glycolytic capacity
Relatively resistant to fatigue
These fibres are recruited for power activities that require sustained
effort such as weight lifting for multiple repetitions.
Type-IIa fibres can be considered as the middle-ground type of fibre,
between the slow but fatigue-resistant type-I fibres and the fast but
fatigue-prone type-IIb fibres.

39. • Type IIb fibres are known as fast-twitch glycolytic fibres.
They have high myosin ATPase activity, low oxidative, high glycolytic
activity.
Rapidly fatigue
These fibres are recruited for high intensity, short-duration exercises
such as full effort sprints.
With the introduction of progressively overloading exercise training, we
can expect skeletal muscle fibres to hypertrophy meaning they increase
in diameter and volume.

40. • Muscle contraction acts upon the skeleton and initiates movement.
When a progressive force is applied to the muscles over time, they will
adapt to the increasing load.
• Satellite cells play a role in this repair and growth process.
• The process of exercise (e.g. long-distance running or powerlifting)
places a burden of stress on muscle fibres and bones which causes
micro-tears and trauma.
• In response to this, satellite cells are activated and mobilized to
regenerate damaged muscle tissue.
• This process is made possible by the donation of daughter nuclei from
the satellite cells after multiplication and fusion.
• The bones will increase their mineral density over time to manage this
increasing load.

41. Resistance Exercise
• Dynamic training and strength training differ primarily in the fact
that resistance training produces a vigorous increase in peripheral
vascular resistance.
• Strength training, high isolated forces generated in the activated
musculature which compresses the small arteries and thus increases
the peripheral vascular resistance.
Skeletal Muscle Fibre Type
• The type of physical exercise being undertaken determines the
predominant muscle fibre type.

42. • Endurance Training ( regular)
• Increases the number of mitochondria and the gas exchange capacity
of the trained myofibrils.
• In marathon runners, slow-twitch fibres dominate the trained leg
muscles (while sprinters possess predominantly fast-twitch fibres).
• has the potential to change the metabolic properties of skeletal muscles
in the direction of an oxidative profile. The question as to how far
muscle fibre types can be reprogrammed remains open.

43. D Hormonal Responses to Exercise
Endocrine System
• Plasma levels of cortisol, epinephrine, norepinephrine,
and dopamine increase with maximal exercise and return to baseline after
rest.
• The increase in levels is consistent with the increase in sympathetic nervous
system activation of the body.
• Growth hormone is released by the pituitary gland to enhance bone and
tissue growth.
• Insulin sensitivity increases after long-term exercise.
• Testosterone levels also increase leading to enhanced growth, libido, and
mood
• Catecholamines are part of cardiovascular and respiratory training
adaptations and in fuel mobilisation and utilisation.

44. E Immunological Adjustments
• Moderate training enhances some components of the immune system
and thereby reduces the susceptibility to infections. In contrast,
reduced functionality of immune cells occurs after overstraining.

45. II. Chronic Effects:
A. Skeletal Muscle Adaptations
1. Endurance Training
• Slow-twitch fibres: The cross-sectional area of slow-twitch (AKA red) fibres
increases slightly in response to aerobic work.
• Fast-twitch fibres: These fibres develop a higher oxygen capacity.
• Capillary bed density: Trained muscles possess a higher density of capillaries
than untrained muscle, which permits a greater blood flow with increased delivery
of nutrients.
2. Resistance/ strength Training
• Resistance training causes increased muscle size (hypertrophy) through an
increase of myofibril size and the number of fast- and slow-twitch fibres.
Moreover, the recruitment pathway of muscle fibres become more effective.
Resistance training thus leads to greater force development of the trained muscles.

46. B. Ligament and Tendon Adaptations
• There is an increase in the cross-sectional area
of ligaments and tendons in response to prolonged training, as the
insertion sites between ligaments and bones and tendons and bones
become stronger.
C. Metabolic Adaptations of Prolonged Exercise
• Endurance training:
• Increases the size and number of mitochondria in the trained muscle
• The myoglobin content may sometimes increase, thus the oxygen
storage capacity increases.
• Trained muscles glycogen storage capacity increases, and the ability to
use fat as an energy source.

47. D. Long Term Cardiac Adaptations
When healthy individuals participate in a long term aerobic exercise programme they undergo
positive cardiac adaptions, both morphologically and physiological.
• Increased early diastolic filling and increased contractile strength.
• Morphological changes appear in both the left ventricle and right ventricle.
• Cardiac adaptations lead to increased cardiac output while exercising, and a higher VO2max
after exercise
• Post-training heart rate is decreased at rest and during sub-maximal exercise.
• Stroke volume increases through long term endurance training.
E. Long Term RespiratoryAdaptations
• The blood flow in the upper regions of the lungs increases after prolonged endurance
training and the respiration rate increases.

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