I BOT_FOT I_Therapeutic Exercises_Dr. Punita V. Solanki_May 2024.pdf

First (I) Year BOT. Subject/Course: Fundamentals of Occupational Therapy I
S. No. 4: Principles of Therapeutic Exercises
Lecture Notes by Dr. Punita V. Solanki. Professor & Incharge. May 2024
DYPU School of Occupational Therapy Nerul, Navi Mumbai. Dr. Punita V. Solanki Page 1 of 25
Course Syllabus: D Y Patil Deemed to be University School of Occupational Therapy
Bachelors of Occupational Therapy (BOT) Program 2021-2022
Year: First (I) Year BOT
Subject/Course: Fundamentals of Occupational Therapy I
Section (S. No.) 4: Principles of Therapeutic Exercises
Contents (Level 1)
1. Generalized & Specific Principles.
2. Types of Movements, Muscle Contraction Used in Exercise.
3. Exercise Classification & Application to Activity.
4. Objective To Develop I) Strength/Power II) Endurance III) Coordination IV) ROM.
5. Progressive Resistive Exercise (PRE), Regressive Resistive Exercise (RRE), Brief
Repetitive Isometric Exercise (BRIME).
References
1. Therapeutic Exercise: Foundations and Techniques by Carolyn Kisner, Lynn Allen Colby.
4th
Edition 1996, 5th
Edition 2002 and 6th
Edition 2012.
2. Occupational Therapy for Physical Dysfunction. Catherine A. Trombly, Mary Vining
Radomski. 4th
Edition 1997, 5th
Edition 2002. 7th
Edition 2014. Section V. Intervention for
Occupational Function. Chapter 20. Optimizing Abilities and Capacities: Range of Motion,
Strength, and Endurance. Page. 589.
3. Occupational Therapy: Practice Skills for Physical Dysfunction. Lorraine Williams
Pedretti, Mary Beth Early. 2nd
Edition 1985, 3rd
Edition 1990, 4th
Edition 1996, 5th
Edition
2001 & 7th
Edition 2013 & 8th
Edition 2018.
4. Therapeutic Exercise by John V. Basmajian. 5th
Edition 1990
I. Definition of Therapeutic Exercise
Therapeutic exercise is the systematic, planned performance of bodily movements, postures,
or physical activities intended to provide a patient/client with the means to
1. Remediate or prevent impairments
2. Improve, restore, or enhance physical function
3. Prevent or reduce health-related risk factors
4. Optimize overall health status, fitness, or sense of well-being.

II. Generalized & Specific Principles
Generalized Principles of Therapeutic Exercises
1. Principle of Overloading: An exercise to be effective in augmenting conditioning must be
at a work level greater than that at which the individual usually performs. This can be
accomplished by manipulating the intensity, duration and frequency of the exercise with
intensity as the most important component.
2. Principle of Specificity: Each type of exercise brings about a specific metabolic and
physiologic adaptation resulting in a specific training effect. Power training using isometrics
results in an increase in strength but may not increase endurance. Aerobic training is the type
of exercise that leads to improvement in endurance, which includes exercise of large muscle
masses; it can improve cardiovascular functional capacity. All these types of training are
important in rehabilitation to improve basic activities of daily living (BADL) and Job-related
performances.
The SAID principle (specific adaptation to imposed demands) suggests that a framework of
specificity is a necessary foundation on which exercise programs should be built. This
principle applies to all body systems and is an extension of Wolff’s law (body systems adapt
over time to the stresses placed on them). The SAID principle helps therapists determine the
exercise prescription and which parameters of exercise should be selected to create specific
training effects that best meet specific functional needs and goals.
3. Principle of Individual Variation: Training should be individualized according to
person’s capacities and needs. Although some cardiac patients can run marathons for
example, the functional capacities of most cardiac patients will not permit this to be
accomplished regardless of the amount of training that the cardiac patient is willing to
perform.
4. Principle of Reversibility: The beneficial effects of training are not permanent. The
improvements attained begin to disappear only 2 weeks after cessation of exercise and half of
the gains may be lost in only 5 weeks. When a patient on an exercise program goes on
vacation, that patient should continue to exercise in a format similar to the exercise program
or should plan other similar activities to be continued during the vacation.

Specific Principles of Therapeutic Exercises
1. A therapist’s determination of the underlying cause or causes of a patient’s impairments,
functional limitations, or disability via evaluations and assessments must precede an
individualized therapeutic exercise program.
2. Patient safety, of course, is paramount; nonetheless, the safety of the therapist must also be
considered, particularly when the therapist is directly involved in the application of an
exercise procedure or a manual therapy technique.
3. Adequate space and a proper support surface for exercise are necessary prerequisites
for patient safety. If exercise equipment is used in the clinical setting or at home, to ensure
patient safety the equipment must be well maintained and in good working condition, must fit
the patient, and must be applied and used properly.
4. The accuracy with which a patient performs an exercise, including proper posture or
alignment of the body, execution of the correct movement patterns, and performing each
exercise with the appropriate intensity, speed, and duration, must be ascertained prior to
initiating a therapeutic exercise program.
5. A patient must be informed of the signs of fatigue, the relationship of fatigue to the risk of
injury, and the importance of rest for recovery during and after an exercise routine.
Signs of fatigue are: slowed performance, distraction, perspiration (sweating), increase in
rate of respiration, performance of exercise through a decreased ROM, inability to complete
the prescribed number of repetitions, tremulousness in the contracting muscle, active
movements become jerky and are not smooth, an uncomfortable sensation in the muscle,
even pain and cramping and decline in peak torque during isokinetic testing.
6. Therapeutic exercises must be selected, programmed and performed as per the
individualized dose and prescription and must be reviewed by the therapist at regular
intervals for the change in the dose and prescription depending upon the response of the
patient.
S. No Exercise Prescription
1. Type of Exercise
2. Exercise Intensity
3. Duration for Each Session
4. Frequency
Table 1: Exercise Prescription

III. Types of Movements, Muscle Contraction Used in Exercise
Types of Muscle Contractions
1. Isotonic: Concentric versus Eccentric
a. Concentric: Muscle shortens to move a limb section in the direction of the muscle pull. In
a concentric contraction, the internal force of the muscle overcomes the external resistance.
Example: Raising a flag on a flagpole requires concentric muscle contractions. Keeping the
filled 10-pound cookie jar to top of the refrigerator.
b. Eccentric: Contracted muscle lengthens to act as a brake against an external force to allow
for a smooth controlled movement.
Example: Lowering a flag on a flagpole requires eccentric muscle contractions. Lowering a
filled 10-pound cookie jar from the top of refrigerator.
2. Isometric: External and internal forces are in equilibrium, and the length of a contracted
muscle remains the same.
Example: Securing a flag on a flagpole requires isometric muscle contractions. Holding the
cookie jar
3. Isokinetic: When the velocity of muscle contraction is held consistent or is under control
by a rate-controlling device. The muscle contraction may be concentric or eccentric under
controlled velocity.
Example: Performing exercise in Baltimore Therapeutic Equipment machine at a set speed
of movement.
IV. Purpose of Therapeutic Exercises
The purposes of therapeutic exercises are as follows:
1. To develop awareness of normal movement patterns and improve voluntary, automatic
movement responses.
2. To improve flexibility and mobility and range of motion of the joints of the body.
3. To develop strength and endurance in patterns of movement that are acceptable, necessary
and do not produce deformity.
4. To improve power of specific isolated muscle or muscle groups.
5. To increase strength of muscles that will power hand splints, mobile arm support and other
devices.
6. To improve coordination.

7. To increase work tolerance and physical endurance through increased strength and
exercising for a specific duration.
8. To prevent or eliminate contractures developing as a result of imbalanced muscle strength
by maintaining range of motion and by strengthening the antagonistic muscles.
V. Prerequisites for Use of the Therapeutic Exercises
For therapeutic exercise to be effective, the candidate must meet certain criteria. The
candidate for therapeutic exercise must:
1. Be medically able to participate in the exercise regimen.
2. Be able to understand the directions for the exercise and its purpose.
3. Be interested and motivated to perform the exercise.
4. Have available motor pathways and the potential for recovery or improvement of strength,
range of motion, coordination and movement patterns as applicable.
5. Have some sensory feedback i.e., the sensation must be at least partially intact so the
patient can perceive motion and position of the exercised part and sense superficial and deep
pain.
6. Have intact muscles and tendons, stable and free to move.
7. Be relatively free of pain during motion and should be able to perform isolated coordinated
movement.
8. Be able to control dyskinetic movement if present, so the exercise procedure can be
performed as prescribed.
VI. Precautions During Therapeutic Exercises
1. Joints must be worked through pain free range of motion only.
2. Weak muscles must not be overstretched in the exercise procedure. Weak muscles that are
overstretched will function less efficiently.
3. Excess fatigue of muscles should be avoided.
4. Muscles around sites of recent surgery such as tendon transplants, tendon grafts, skin
grafts, joint and bone reconstruction, must not be exercised until medical clearance has been
obtained.
5. Unless directed by the physician, the therapist must not exercise inflammed joints with
active or resistive exercises.

VII. Indications of Therapeutic Exercises
Therapeutic exercises are most effective in the treatment of orthopaedic disorders such as
fractures (after initial orthopaedic management), arthritis (after initial medical management),
lower motor neuron disorders that produce weakness and flaccidity e.g., peripheral nerve
injuries and diseases, poliomyelitis, Guillain Barre Syndrome, infectious neuronitis, spinal
cord injuries and diseases etc.
VIII. Contraindications of Therapeutic Exercises
Therapeutic Exercises are contraindicated for:
1. Patients who have poor general health, inflammed joints or who have had recent injury or
surgery.
2. Severely limited joint range of motion as a result of well-established permanent
contractures wherein initially orthopaedic intervention would be indicated.
3. Patients with spasticity and lack of voluntary control of isolated motion or those with
dyskinetic movement. The upper motor neuron disorders are more amenable to sensorimotor
approaches to treatment.
IX. Exercise Classification & Application to Activity
Figure 1: Exercise Classification Flow Chart
Therapeutic Exercises
Exercises to
Improve Range of
Motion & Prevent
or Correct
Contracture
Exercises to
Improve Muscle
Strength & Power
Exercises to
Improve Muscle
Endurance &
General Endurance
Exercises to
Improve
Coordination
Application to
Therapeutic Activities

Types of Therapeutic Exercises
I. Exercises to Improve Range of Motion (Mobility and Flexibility Exercises) and to
Prevent and Correct Contractures
1. Stretching Exercises
a. Active Stretching Exercises
b. Passive Stretching Exercises
c. Manual Stretching Techniques: Muscle-Lengthening Procedures and Joint Mobilization
Techniques
d. Self-Stretching Exercises
2. Passive Range of Motion (PROM) Exercises
II. Exercises to Improve Muscle Strength and Power (Muscle Performance Exercises)
1. Isometric Exercises without Resistance
2. Isometric Exercises with Resistance
3. Active Assistive Exercises (Dynamic Active Assistive Range of Motion Exercises)
(AAROM)
4. Active Exercises (Dynamic Active Range of Motion Exercises) (AROM)
5. Active Resistive Exercises (Dynamic Active Resistive Range of Motion Exercises)
III. Exercises to Improve Muscle Endurance and General Endurance (Aerobic
Conditioning and Reconditioning Exercises)
IV. Exercises to Improve Coordination
V. Exercises to Improve Neuromuscular Control
VI. Exercises to Improve Posture, Postural Control, Body Mechanics and Stabilization
VII. Exercises to Improve Balance and Equilibrium
VIII. Agility Training
IX. Relaxation Exercises
I. Exercises to Improve Range of Motion (Mobility and Flexibility Exercises) and to
Prevent and Correct Contractures
1. Stretching Exercises
Stretching is a process by which the target tissue is lengthened by an external force, usually
through manual therapy or through the use of splinting, casting, or external equipment.

Stretching is used to eliminate tightness that has the potential to cause contracture, even in
periods of brief inactivity. Stretching Exercises are of following types:
a. Active Stretching Exercises
In active stretching, contraction of muscles opposite to the direction of limitation is the
source of the force. e.g. forceful contraction of the triceps to stretch the biceps muscle in
order to improve elbow extension range of motion. Supervision and frequent evaluation of its
effectiveness is necessary.
Indication: To increase joint range of motion and to correct tightness or contracture of
muscles.
Application to Activity: Wood sawing requires forceful contraction of triceps with a
concomitant stretch of the biceps.
b. Passive Stretching Exercises
In passive stretching, an external force is applied. In passive stretching the therapist moves
the joint through the available range of motion and holds momentarily, applying a gentle but
firm force or stretch at the end of the range of motion. Passive stretching is often done by an
occupational therapist as a preparatory method for increasing ROM so patients are able to
engage in purposeful activity. Techniques for passive stretching may include manual stretch
and the use of orthotic devices, such as splints or casts, to provide controlled passive
stretching. There should not be any residual pain when the stretching is discontinued.
Gentle firm stretch held for a few seconds is more effective and less hazardous than quick
short stretch.
Safety Precautions Related to Passive Stretching
● Inflammation weakens the structure of collagen tissues. Therefore, inflammed tissues must
be stretched cautiously with slow, gentle motions.
● Sensory loss prevents the patient from monitoring pain; thus, the therapist must pay
particular attention to the tension of the tissues being stretched.
● Overstretching or incorrect stretching must be avoided because it may increase pain and
inflammation and cause internal bleeding and subsequent scar formation. It may also lead to
heterotopic ossification.

● Resistance can be provided by weights either held in the patient’s hand or strapped around
the moving part. Resistance can also be provided by tools and materials of the activity. The
greater the resistance that is provided, the more aggressive the stretch will be, so the therapist
must take care that the stretch is slow and gentle.
Indications: To increase joint range of motion in cases of joint stiffness following
immobilization, surgery or muscle tightness or contracture etc.
Application to Activity: Passive stretching may be incorporated into an activity if an
unaffected part guides the movement of the affected part or joint and forces it slightly beyond
the available range of motion. e.g., passive stretch of wrist flexors during a block printing
activity if the block is pressed down with the open hand while the patient is standing.
c. Manual Stretching Techniques: Muscle-Lengthening Procedures and Joint
Mobilization Techniques
● Provide a relaxing environment for the patient.
● Describe manual stretching, noting that it involves tolerable pain.
● Use motions identical to motions used in ROM evaluation.
● Stabilize the bone proximal and distal to the joint that is to be moved to avoid any
compensatory movement.
● Move the bone smoothly, slowly, and gently to the point of maximal stretch (mild
discomfort indicated verbally or facially by the patient).
● Make sure the movement is in the line of pull of the muscle.
● Encourage the patient to assist in moving the limb if possible.
● Hold the limb at the point of maximal stretch for 15-60 seconds.
● Relief of discomfort should immediately follow the release of stretch.
● If the patient complains of residual pain, future stretches should be performed more slowly
and with less force.
d. Self-Stretching Exercises
There are many ways patients can perform stretching of soft tissue contractures themselves.
Patients can be given a home program on specific joint stretches, or they can participate in
activities such as Pilates, yoga, or the ROM dance, which includes some passive stretching
and can be integrated into their daily occupations. Occupational therapists can help a patient

modify these activities to provide the necessary active and passive stretches to meet the ROM
needs.
2. Passive Range of Motion (PROM) Exercises
In passive range of motion exercise there is no muscle contraction and no external stretch
applied. During the exercise procedure the joint or joints to be exercised are moved through
their normal ranges manually by the therapist or the patient himself/herself or mechanically
by an external device such as a pulley or counter balance sling. The joint proximal to the joint
being exercised must be stabilized during the exercise procedure.
Passive exercise is NOT used for increasing strength or increasing range of motion (because
no force is applied to the joint).
Indications: To maintain range of motion thereby preventing contractures and adhesions and
deformity. To achieve this goal, the exercise must be performed for at least 3 repetitions
twice daily. This exercise is performed when absent or minimal muscle strength (grade 0 or
trace) precludes the active motion or when active exercise is contraindicated because of
patient’s physical condition.
Application to Activity: 1. Bilateral activity when the contralateral extremity is unaffected.
e.g., overhead pulley and sling exercise.
2. Continuous Passive Motion (CPM) machines can be used for passive exercises.
II. Exercises to Improve Muscle Strength and Power (Muscle Performance Exercises)
1. Isometric Exercises without Resistance
In isometric exercises of a specific joint a muscle or a group of muscles is actively contracted
and relaxed without producing movement of the joint that it ordinarily mobilizes.
The patient is taught to set or contract the muscles voluntarily and to hold the contractions for
5 to 6 seconds. The therapist’s fingers may be placed distal to the joint on which the muscle
acts, without offering resistance, the therapists fingers provide a Kinesthetic image of
resistance and help the patient learn to set the muscle.
Indications: To maintain muscle strength when active motion is not possible or
contraindicated. It may be used with any muscle grade above trace. It is useful for patients in
casts, after surgery and with arthritis or burns.

Contraindications: Isometric exercise cause a rapid and sudden increase in blood pressure;
therefore, it should be used with caution in patients with cardiovascular diseases. Maximal
isometric contraction is contraindicated for patients with cardiac disease.
Application to Activity: At knee joint, vastus medialis oblique (VMO) isometric
strengthening on bed by pressing the ball or pillow under the thigh and in-between the thighs.
Figure 2: Isometric Exercise
2. Isometric Exercises with Resistance
In isometric exercise with resistance, the patient sets the muscle or muscle group while
resistance is applied and holds the contraction for 5 or 6 seconds. Isometric exercises should
be performed for one exercise session per day, 5 days a week.
Besides manual resistance, the patient may hold a weight or resist against the solid surface
depending upon the muscle group being exercised e.g., a small weight held in the hand while
the wrist is stabilized at neutral, requires isometric contractions of wrist flexors and
extensors. Exercise is graded by increasing the amount of outside resistance.
Indications: 1. To increase muscle strength and endurance of muscles graded fair+ or 3+ to
normal or 5.
2. In arthritis, when joint motion may be contraindicated but muscle strength must be
increased or maintained.
Contraindications: Maximal isometric contraction is contraindicated for patients with
cardiac disease.
Application to Activity: Any activity that requires holding or static posture incorporates
isometric exercise. Holding tool handles or holding the arm in elevation while painting etc.

Figure 3: Isometric Exercise with Resistance
3. Active Assistive Exercises (Dynamic Active Assistive Range of Motion Exercises)
(AAROM)
Exercise in which a weak muscle is concentrically or eccentrically contracted through as
much ROM as patient can achieve; therapist and/or external device provides assistance to
complete motion, are known as Active Assistive Exercises (Dynamic Active Assistive Range
of Motion Exercises) (AAROM).
Indications: 1. To increase muscle strength of muscles graded Poor minus (2-) or Fair minus
(3-) The muscle can move only through partial available range in either a gravity eliminated
or against-gravity plane.
2. These exercises also help in maintaining joint range of motion.
Application to Activity: 1. Bilateral Horizontal or Inclined Sanding
2. Bilateral Sponge Wiping.
3. Bilateral Use of Sweeper
4. Bilateral Limb Use whilst Sawing a Wood
5. Bilateral Overhead Pulley Exerciser
6. Bed or Seated Arm or Leg Cycling on Pedal Exerciser
In bilateral activities the unaffected arm or leg can perform the major share of the work and
the affected arm or leg can assist to the extent possible.

Figure 4: Active Assistive Exercises (Dynamic Active Assistive Range of Motion
Exercises) (AAROM): Sanding, Sponge Wiping, Wood Sawing, Overhead Pulley, Cycling
4. Active Exercises (Dynamic Active Range of Motion Exercises) (AROM)
When patient contracts muscle to move the joint or part of the body through full ROM in
gravity eliminated or against gravity planes, it is known as Active Exercises (Dynamic Active
Range of Motion Exercises) (AROM).
Indications: 1. To increase muscle strength of muscles graded Poor (2) or Fair (3). Muscle
can move through full available range in either gravity eliminated or against-gravity plane.

2. These exercises also help in maintaining joint range of motion.
Application to Activity:
1. A needle work activity performed in the gravity decreased plane can provide active
exercises to the wrist extensors or elbow extensors
2. When a grade of fair (3) is reached, the wrist can be moved against gravity in an activity
such as picking up and placing tiles for a mosaic tile project or peg board activity in against
gravity planes.
Figure 5: Active Exercises (Dynamic Active Range of Motion Exercises) (AROM):
Needle Work such as Embroidery, Peg Board Activity
5. Active Resistive Exercises (Dynamic Active Resistive Range of Motion Exercises)
When a patient contracts muscle to move joint or part through full available ROM in
gravity eliminated or against gravity, against resistance, it is known as Active Resistive
Exercises (Dynamic Active Resistive Range of Motion Exercises). (High Load Low
Repetition Exercises)
Indications: 1. To improve muscle strength of muscles graded Poor plus (2+), Fair (3), Fair
plus (3+), Good (4) and Good plus (4+).
2. Producing relaxation of the antagonists to the contracting muscles. This can be useful if
increased range is desired for stretching or relaxing hypertonic antagonists.
Examples of Standardized Active Resistive Exercises are:
1. DeLorme Method of Progressive Resistive Exercise (PRE)
2. Oxford Technique of Regressive Resistive Exercise (RRE)

Application to Activity: 1. Purposeful activities such as leather lacing, sanding, sawing and
hammering etc.
2. Instrumental activities of daily living such as kneading dough, rolling pizza base etc.
3. Enabling or simulated activities such as forming clay objects that offer resistance to
muscles of the hand.
4. Resistive exercises on standardized equipment or machines such as Baltimore Therapeutic
Equipment
Figure 6a: Active Resistive Exercises (Dynamic Active Resistive Range of Motion
Exercises): Unilateral Wood Sawing, Hammering, Kneading Dough, Clay Modelling, Dough
Rolling

Figure 6b: Active Resistive Exercises (Dynamic Active Resistive Range of Motion
Exercises): Exercises on Baltimore Therapeutic Equipment Machine
III. Exercises to Improve Muscle Endurance and General Endurance (Aerobic
Conditioning and Reconditioning Exercises)
Muscle Endurance refers to the ability of a muscle to maintain performance over a sustained
period of time.
Factors that influence muscle endurance include
1. Activation and recruitment of motor unit.
2. Predominant type of fiber that is contracting during the activity (type I slow twitch fibers
fatigue slower than type II fast twitch fibers)
3. Energy and oxygen storage within the muscle.
4. External factors such as room temperature, altitude, and amount of allowed recovery time
during an activity.
Endurance training are low-intensity muscle contractions, a large number of repetitions,
and a prolonged time period of training to the point of muscle overload. The American
College of Sports Medicine advocates for light to moderate loads (40%-60% of 1 RM) for
high repetitions (>15) using short rest periods (<90 seconds) for endurance training. (Low
Load High Repetition Exercises)
Indications: To improve muscle endurance or work of muscles.
Application to Activity: Muscle endurance can be improved through weight training, but
occupational therapists prefer to use purposeful activity to provide the same benefits. For
example, for patients who are interested in computer games or sports that can be replicated on

a Wii™, the therapist may increase the number of games they play or the length of time they
play to get to muscle fatigue. Occupational therapists can also work with patients to schedule
their everyday routines so that they gradually increase the amount of time they engage in
occupations throughout the day and/or gradually increase the duration of engagement in one
particular occupation. For example, increasing the time working in the garden or the amount
of muscular effort put forth through repetition (picking tomatoes versus pulling weeds) is an
effective way to increase muscular endurance.
General Endurance (Aerobic Conditioning and Reconditioning Exercises) or
Cardiopulmonary Fitness or Cardiopulmonary Endurance
The ability to perform low intensity, repetitive, total body movements (walking, jogging,
cycling, swimming) over an extended period of time; a synonymous term is cardiopulmonary
endurance.
Aerobic exercise is associated with low-intensity, repetitive exercise of large muscle groups
performed over an extended period of time. This mode of exercise primarily increases
muscular and cardiopulmonary endurance.
Type I (tonic, slow-twitch) muscle fibers generate a low level of muscle tension but can
sustain the contraction for a long time. These fibers are geared toward aerobic metabolism, as
are type IIA fibers. However, type I fibers are more resistant to fatigue than type IIA.
Indications: To improve general body fitness and endurance.
Application to Activity: spot march, walking, running, jogging, cycling, swimming etc.

Figure 7: General Endurance (Aerobic Conditioning and Reconditioning Exercises) or
Cardiopulmonary Fitness or Cardiopulmonary Endurance: Spot Marching, Walking,
Cycling, Running, Swimming
IV. Exercises to Improve Coordination
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. It is the basis of smooth, accurate, efficient movement and occurs at a
conscious or automatic level.
Indications: To improve the ability to perform multi-muscular motor patterns that are faster,
more precise and stronger than those performed when only control of individual muscles is
used. Coordination depends on repetition. Initially the movements must be simple and slow
so that patient can be consciously aware of the movements during the activity and its
components.
Coordination exercises are divided into components that the patient can perform correctly.
Kottke calls this approach desynthesis. It is important to keep the effort low by reducing the
speed and resistance, this prevents the spread of excitation to muscles that are not part of the
desired movement pattern. As the patient masters the components of the pattern and performs
them independently, the exercise sequence is graded to subtasks or several components and
practised repetitively. As the subtasks are perfected, they are chained progressively until the
movement pattern can be performed effectively.
The coordination exercises are graded for speed, force or complexity. Increased effort by the
patient should be avoided, which may result in incoordinated movement.

Factors Causing Increase in Incoordination: fear, poor balance, too much resistance, pain,
fatigue, strong emotions and prolonged inactivity due to illness or diseases.
Examples of Exercises & Application to Activity to Improve Coordination
1. Reciprocal leg movements (10 repetitions, eyes closed)
2. Bridging (10 repetitions)
3. Sitting/standing (5 repetitions)
4. Braiding exercises (2 repetitions)
5. Reciprocal ankle motion (10 repetitions)
6. Rung ladder: forward stepping (2 repetitions)
7. Placing small blocks, marbles, cones, paper cups or pegs on the board
8. Leather lacing, mosaic tile work, needle crafts
9. Repetitive household tasks such as wiping, sweeping, dusting etc.
X. Objective to Develop I) Strength & Power II) Endurance III) Coordination IV) ROM
Assessment
The first step in designing the therapeutic exercises for the patient is to assess the patient’s
abilities, inabilities and needs. The examination and assessment provide the foundation for
establishing a baseline from which outcomes of therapeutic exercises can be measured and
designed for further improvement.
1. Muscle Strength: is evaluated or assessed by manual muscle testing procedures by the
therapist and graded on 0–5-point scale (Modified Research Council Oxford’s Manual
Muscle Strength Grading System). It can also be measured objectively through use of
Dynamometers, Pinch Guage, Vigorometer etc.
2. Muscle Power: is evaluated as muscle strength with respect to time (Strength/Time).
3. Endurance: of a specific muscle or a muscle group can be assessed by the ability of the
patient to perform an activity for specific duration or number of repetitions.
4. Coordination: of a movement pattern is assessed by smoothness of the activity performed
by the patient by clinical tests e.g., Heel Knee Test, Finger Nose Test etc. and rated on time
(speed), space and rhythm or objectively through standardized coordination/dexterity hand
function tests.
5. Range of Motion: is measured by use of various types of goniometers.

Objectives to Develop Muscle Strength and Power
Strength: is the ability of a muscle or muscle groups to produce tension and a resulting force
during a maximal effort, either dynamically or statically, in relation to the demands placed
upon it.
Factors that Influence the Strength of Normal Muscles
1. Cross-sectional size of the muscle: the larger the diameter, the greater the strength.
2. Length-tension relationship of a muscle at the time of contraction: a muscle produces the
greatest tension when it is slightly lengthened at the time of contraction.
3. Recruitment of motor units: the greater the number of motor units firing, the greater the
force output.
4. Type of muscle contraction: a muscle produces the most force output when contracting
eccentrically against the resistance. The muscle produces slightly less force when contracting
isometrically (holding) and the least force when contracting concentrically against a load.
5. Fibre type distribution: Type II a and IIb (fast twitch) fibers generate greater amount of
tension but fatigue very quickly and Type I (slow twitch) fibers develop less tension but are
more resistant to fatigue.
6. Energy stores and blood supply: A muscle needs adequate sources of energy to contract,
generate tension and resist fatigue.
7. Speed of contraction: greater torques are produced at lower speeds.
8. Motivation of the patient: to generate maximum strength motivation plays a great role.
Changes in Neuromuscular System that Lead to Increased Strength
1. Hypertrophy: with exercise specifically designed to develop strength, the size of the
individual skeletal muscle fiber can be increased and is called hypertrophy.
2. Hyperplasia: the strength of muscle may also be increased with exercise that causes
hyperplasia i.e., an increase in the number of muscle fibers.
3. Recruitment: muscle strength increases with recruitment of increased numbers of motor
units during exercise.
Indications: Exercises to increase muscle strength and power are indicated after partial or
complete denervation of muscle, during inactivity or disuse where muscle strength decreases.
Types of Exercises and Activities: to increase muscle strength and power are:
1. Isotonic Active Assistive
2. Isotonic Active

3. Isotonic Active Resistive
4. Isometric With and Without Resistance
A muscle must contract at or near its maximal capacity and for enough repetitions and time to
increase strength and power.
Muscle strengthening exercises generally are based on having the muscle contract against a
large resistance for a few repetitions. (Low Load High Repetition)
Substitutions and compensatory movements and fatigue should be prevented from the
beginning of the therapeutic exercises. The muscle must be exercised to the point of fatigue
and not beyond it for adaptive increases in strength to occur and to prevent delayed onset
muscular soreness (DOMS).
Objectives to Develop Muscular Endurance and Cardiovascular Fitness
Endurance: is the ability of the muscle to work for prolonged periods and resist fatigue.
Types of Endurance
1. Muscular Endurance: The ability of a muscle to contract repeatedly or generate tension,
sustain that tension and resist fatigue over a prolonged period of time.
2. General Body Endurance (Cardiovascular Fitness): The ability of and individual to
sustain low intensity exercise, such as spot march, walking, jogging, running, climbing stairs,
running, swimming etc. over an extended period.
Guidelines for Developing Endurance
1. Muscular Endurance: A low load and high repetition exercise program is more effective
for building endurance. Having determined the patient’s maximum capacity for a
strengthening program, the therapist can reduce the maximum resistance load and increase
the number of repetitions to adopt the strengthening program to build endurance. This
approach is used to build endurance in specific muscle or muscle groups.
2. General Body Endurance (Cardiovascular Fitness or Physical Conditioning): Exercise
to improve general physical endurance uses large muscle groups in sustained, rhythmic
aerobic exercise or activity e.g., spot march, walking, jogging, running, climbing stairs,
running, swimming, bicycling, games and sports. This type of exercise is used in cardiac
rehabilitation programs in which the parameters of the patients physical capacities and
tolerance for exercises should be well defined and medically supervised.

To improve cardiovascular fitness exercises should be done 3-5 days per week at 60% to 90%
of maximum heart rate or 50% to 85% of maximum oxygen uptake. Fifteen to sixty minutes
of exercises of rhythmic activities using large muscle groups is desirable.
Objectives to Develop Joint Flexibility and Improve Range of Motion
When an individual with normal neuromuscular control carries out activities of daily living,
soft tissues and joints continually elongate and/or shorten and their appropriate mobility or
flexibility is maintained. Diseases or trauma to soft tissue and joints, which can cause pain,
weakness or inflammation can impair mobility.
If tightness or restricted mobility occur, mobility exercises may be used to restore the
involved structures to their appropriate length.
Guidelines to Maintain Joint Range of Motion or Flexibility: Active and Passive ROM
exercises are used to maintain joint motion and flexibility. Active exercise is done by
performer and passive exercise is done by the therapist or a device such as continuous passive
motion machine. (a mechanical device that can be preset to provide continuous passive
motion throughout the joint range or the set joint range)
Guidelines to Increase Joint Range of Motion or Flexibility: 1. Stretching or Forced
exercises is necessary to increase joint range of motion. Active or passive stretch is applied to
the part when the soft tissue (muscles, tendons or ligaments) is at or near its available length.
The use of a low resistance stretch of sustained duration is preferred to high resistance and
repetitive quick bouncing movements. The use of thermal agents or neuromuscular
facilitation techniques may enhance static stretching.
2. Self-stretching exercises and therapist driven manual mobilization techniques may also be
used for improving joint range of motion.
3. Active resistive exercises also put stretch force on the contracting muscle or group of
muscles whilst releasing the hold or contraction in a slow sustained manner.

XI. Progressive Resistive Exercise (PRE), Regressive Resistive Exercise (RRE), Brief
Repetitive Isometric Exercise (BRIME)
Progressive Resistive Exercise (PRE)
DeLorme (1945) and DeLorme and Watkins (1948) developed a progressive resistive
exercise program based on the use of a repetition maximum (RM). It was originally called as
the heavy resistance training and later load-resisting exercise to describe a new system of
strength training.
A repetition maximum (RM) is defined as the greatest amount of weight (load) a muscle can
move through the available range of motion (ROM) a specific number of times for e.g., 5
times, 10 times or just one time. Once the RM is established, then the intensity of training can
be set up based on a percentage of this maximum.
Patients at the beginning of training or rehabilitation should use a lower percentage (40%-
60% of 1 RM) versus those who have progressed or are well trained, where 80% of 1 RM is
recommended. The DeLorme technique builds a warm-up period into the protocol.
Regressive Resistive Exercise (RRE)
The Oxford technique of regressive resistive exercise (RRE) diminishes the resistance as the
muscle fatigues. In Oxford technique as well, A repetition maximum (RM) is defined as the
greatest amount of weight (load) a muscle can move through the available range of motion
(ROM) a specific number of times for e.g., 5 times, 10 times or just one time. Once the RM is
established, then the intensity of training can be set down, based on a percentage of this
maximum, starting first with the maximum load.
PRE Versus RRE: Both regimens viz. PRE and RRE incorporate a rest interval between
sets; both incrementally increase the highest resistance load over time; and both have been
shown to result in training-induced strength gains over time. Since the DeLorme and Oxford
systems of training were first introduced, numerous variations of PRE and RRE protocols
have been proposed and studied to determine an optimal intensity of resistance training,
optimal number of repetitions and sets, optimal frequency, and optimal progression of
loading.

Table 2: Comparison of DeLorme’s PRE and Oxford’s RRE Regimen
Brief Repetitive Isometric Exercise (BRIME)
Gerber and Hicks described a program of brief repetitive isometric exercises (BRIME) of one
to six isometric contractions, held for 3 to 6 seconds with 20 seconds of rest in between the
contractions and rhythmic breathing during the contractions is recommended to prevent
increase in blood pressure.
Hetlinger and Muller in 1950s advocated that isometric exercises can be prescribed as an
alternative method of muscle strengthening, that was preferable to PRE or RRE.
Indications: To maintain and improve muscle strength of muscles that are immobilized
during recovery period in the acute phase of intervention e.g. after immobilization following
fracture or surgery following fracture, arthritis etc.
Application to Activity: Grasping handles of tools or equipment, stabilization of materials
being used say whilst stitching in tailoring machine, by positioning projects so that the limbs
must maintain antigravity positions during any activity.

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