Therapeutic exercises are planned physical movements intended to remediate or prevent impairments, enhance function, reduce risk, and optimize health and well-being. They involve movement prescribed to correct impairments and restore function. The most common therapeutic exercises fall into four groups: strengthening exercises, endurance exercises, flexibility exercises, and balance/coordination exercises. Therapeutic exercise is a core skill of physiotherapy and includes aerobic conditioning, agility training, coordination exercises, range of motion exercises, and more. Factors like a patient's health status, goals, motivation, and support system influence the expected outcomes of therapeutic exercise.

1. PART 2.
General
Rehabilitation

2. Therapeutic Exercises

3. Definition
• The systematic performance or execution
of planned physical movements, postures,
or activities intended to enable the
patient/client to:
 Remediate or prevent impairments
 Enhance function
 Reduce risk
 Optimize overall health
 Enhance fitness and well-being

4. • 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
• Therapeutic exercise is one of the core
skills upon which the profession of
physiotherapy is based.

6. Exercise has been shown to:
• Benefit cardiovascular and respiratory function
• Reduce cardiovascular and respiratory function
• Decrease morbidity and mortality
• Decrease anxiety and depression
• Reduce pain
• Improve cognitive function
• Enhance physical function and independent living in older individuals
• Enhance feelings of well-being
• Reduce risk of falls in older individuals
• Prevent or mitigate functional limitations in older adults
• Enhance performance of work, recreational, and sport activities

8. What is the difference between
physical activity and exercise?
• Physical activity refers to the contraction
of skeletal muscle that produces bodily
movement and requires energy. Exercise
is physical activity that is planned and is
performed with the goal of attaining or
maintaining physical fitness. Physical
fitness is a set of traits that allows an
individual to perform physical activity

9. The U.S. Department of Health and Human
Services published Physical Activity Guidelines in
1996 and more recently in 2018.
• Recommendations for adults include at least 150
minutes a week of moderate-intensity aerobic activity, or
75 minutes a week of vigorous-intensity aerobic activity,
or an equivalent combination of the two. ACSM defines
moderate intensity is defined as 3 to 5.9 metabolic
equivalents (METs), 45-63% VO2 max, or 64-91% of
maximum heart rate. They define vigorous intensity is
defined as greater than 6.0 METs, 64-91% VO2 max, or
77-93% of maximum heart rate (please also refer to
Table 1). Children and adolescents are encouraged to
perform 60 minutes or more of physical activity daily,
including aerobic, muscle-strengthening and bone-
strengthening activities.

13. • There are several methodologies to exercise
prescription. One of the easier methods is the
Frequency, Intensity, Time, and Type (FITT). The ACSM
also recommends FITT-VP (Frequency, Intensity, Time,
Type, Volume, and Progression). Utilizing these
methodologies parallels writing a traditional medication
prescription. Each component of the prescription
provides a patient with specific information to
incorporate aerobic, resistance, flexibility, and
neuromotor exercise training into a fitness program.

14. Exercise
Prescription
Basics

15. Bottom Line Up Front (BLUF)
• Exercise is the best “medicine” around
• Assess physical activity in ALL patients
• Only RARE patients needs GXT before exercise
• GXT pts with symptomatic CV/pulm dz
• The Prescription is: Be “FITT”
– Frequency: 5 days a week (or more)
– Intensity: moderate intensity, 5-6 on 10 scale
– Time: 30 minutes aerobics (10-min chunks OK)
– Type:
• Aerobic activity
• Muscular strengthening activity
• Flexibility activity (in elderly/sick)
• Balance training (if fall risky)

16. Physicians and their Patients
• 47% of primary care physicians include
an exercise history as part of their initial
examination (self report)
• Only 13% of patients report physicians
giving advice about exercise
• Physically active physicians are more
likely to discuss exercise with their
patients

17. ACSM & AHA 2007, HHS 2008
Physical Activity Recommendations
Healthy Adults age 18-64
• Aerobic Physical Activity
– Moderate intensity: 150 minutes/wk, OR
Vigorous intensity: 75 minutes/wk (or a
combo)
– 10 min at least, preferably spread throughout
week
• Muscle Strengthening Activity
– 2 or more days/wk
– 8-10 exercises
– 8-12 reps (one set)

18. • Indications & benefits
• Contraindication
• Side-effects
• Drug interactions
• Cost
• Dose, frequency, duration

19. Indications for Exercise
• Longevity
• Quality of Life
• Socialization
• Weight control
• Disease prevention
• Disease management
• ….(I could go on)

20. Longevity
The more you exercise, the lower your risk of
death
0
0.2
0.4
0.6
0.8
1
1.2
0 90 180 330 420
Relative
Rick
of
Death
Minutes per Week of Moderate- or Vigorous-Intensity Exercise
Risk of Death

21. Dose-response Curve for Exercise

22. Death Prevention:
Attributable Deaths (%) from various
health conditions
Aerobics Center Longitudinal Study (ACLS), Cooper Institute
•40,842 men; 12,943 women

23. Strong Evidence of Benefit
from Physical Activity for…
• Lower risk of:
– Early death
– Heart disease
– Stroke
– Type 2 diabetes
– High blood pressure
– Dyslipidemia
– Metabolic syndrome
– Colon and breast Ca
• Prevention of wt gain
• Wt loss w/dieting
• Improved C-R &
muscular fitness
• Prevention of falls
• Reduced depression
• Better cognitive fxn
(older adults)

24. Moderate evidence for…
• Wt maintenance after loss
• Lower risk of hip fx
• Increased bone density
• Improved sleep quality
• Lower risk lung and endometrial Ca

25. Contraindications for Exercise
• Acute cardiac event happening now
• Uncontrolled arrhythmia causing sxs
• Severe aortic stenosis
• Uncontrolled heart failure
• Acute pulmonary embolism
• Acute myocarditis
• Dissecting aneurysm

26. Side effects of exercise
• Slight risk of Musculoskeletal injury
– Increases with duration & intensity
• RARE cardiac events
– FAR outweighed by benefits to heart!
– 25-50% decrease in CVD in exercisers

27. •If we had a pill that conferred
all the benefits of exercise,
physicians would prescribe it to
every patient. Our health care
system would find a way to
make sure that every patient
had access to this “wonder
drug.”

28. Use the
Sports and Exercise Medicine
approach to patients
• Every patient is a potential “athlete” who
needs exercise for HEALTH, not
competition
• Physical activity is a VITAL SIGN--a
STRONG PREDICTOR OF HEALTH
• Every exam is a pre-participation eval
• Conclude exams with activity clearance
and Exercise Rx

29. How to Write an
Exercise Prescription

30. Rx: Be “FITT”
•Frequency
•Intensity
•Time (duration)
•Type

31. Frequency
• 5 days a week
• Even more is even
better!
–Dose-response curve!

32. Intensity
• Moderate Exercise
– Equivalent of
BRISK WALK
– Noticeably
accelerates RH
– Able to talk
• “talk test”
– RPE 5-6 out of 10

33. Exercise Intensity:
Relative Perceived Exertion
Use 1-10 Scale

34. Examples of Moderate Intensity
• Brisk walking
• Household cleaning: vacuum, mop, wipe
• Mowing lawn
• Shooting hoops
• Recreational badminton
• Ballroom dance
• Golf & pulling clubs
• Leisurely sports
• Leisurely biking, swimming

35. Intensity
• Vigorous Exercise
– Equivalent of
jogging
– Fail “talk test”
– RPE 7-10 out of 10

36. Examples of Vigorous Intensity
• Jogging, running
• Shoveling
• Heavy farming
• Competitive sports
• Cross country skiing
• Intense biking, swimming

37. Time (Duration)
• Accumulate 30
minutes a day
– 10 minute chunks OK
• More is better!

38. Type
• Aerobic Activity AND
• Muscle Strengthening

39. Muscular Strengthening
• Exercise large muscle groups
• 8-12 reps; should fatigue by last rep
• Rest 2-3 minutes between exercises
• 1 set good, 2 sets better
• Rest day in between

40. What about Older Adults >65,
or those with chronic
diseases?
• Aerobic exercise: same
• Strength exercise: same, except 10-15
reps
– Slightly lighter weights
• Flexibility activity 2 days/wk, 10 min
• Balance exercise if at risk for falls,
3x/wk
Nelson ME et al. Physical activity and public health in older adults:
Recommendation from the ACSM and the AHA.
Med Sci Sports Exer 2007;39(8):1435.

41. What about
Children/Adolescents?
• Do 60 minutes or more of physical activity
every day
– Mostly moderate or vigorous
– Vigorous activity at least 3 days/wk
• Strength exercise 3 days/wk
HHS guidelines October 2008

42. Take Home Pearls
• Exercise is the best “medicine” around
• Assess physical activity in ALL patients
• Only RARE patients needs GXT before exercise
• GXT pts with symptomatic CV/pulm dz
• The Prescription is: Be “FITT”
– Frequency: 5 days a week (or more)
– Intensity: moderate intensity, 3-6 on 10 scale
– Time: 30 minutes aerobics (10-min chunks OK)
– Type:
• Aerobic activity
• Muscular strengthening activity
• Flexibility activity (in elderly/sick)
• Balance training (if fall risky)

43. Therapeutic exercise may
include:
• aerobic and endurance conditioning and reconditioning;
• agility training;
• body mechanics training;
• breathing exercises
• coordination exercises;
• developmental activities training;
• movement pattern training;
• neuromotor development activities training;
• neuromuscular education or reeducation;
• perceptual training;
• range of motion exercises and soft tissue stretching;
• relaxation exercises;
• strength, power, and endurance exercises.

44. The most commonly included
exercises fall into 4 groups
• Strengthening exercises, usually performed with heavy resistance
and fewer repetitions.
• Endurance exercises that engage large muscle groups over a longer
period of time, in the area of 50 to 60% VO2Max to achieve greater
cardiovascular endurance.
• Flexibility exercises achieved through stretching and movement.
• Balance and coordination exercises that focus on maintaining an
individual's centre of gravity.

46. strength, power exercises.

47. endurance exercises

48. agility training

49. body mechanics training

50. breathing exercises

51. coordination exercises

52. developmental activities training

53. movement pattern training

54. neuromotor development
activities training

55. neuromuscular education or
reeducation

56. perceptual training

57. range of motion exercises

58. soft tissue stretching

59. Relaxating exercises

64. the prosess of evidence based
practice

66. a comprehensive outcomes oriented model on patient management (2013)

67. Diagnostic classification for the
musculoskeletal system
• Primary prevention/risk for skeletal demineralization
• Impaired posture
• Impaired muscle performance
• Impaired joint mobility,motor function,muscle performance,ROM associated with
connective tissue disfunction
• Impaired joint mobility,motor function,muscle performance,ROM associated with
inflamation
• Impaired joint mobility,motor function,muscle performance,ROM associated with
spinal disorders
• Impaired joint mobility,motor function,muscle performance,ROM associated with
fracture
• Impaired joint mobility,motor function,muscle performance,ROM associated with joint
arthroplasty
• Impaired joint mobility,motor function,muscle performance,ROM associated with
bony and soft tissue surgery
• Impaired joint mobility,motor function,muscle performance,RMO,gait,locomotion and
balance associated with amputation

68. Factors that influence a patients
prognosis/expected outcomes
• Complexity, severity, acuity of the patient’s health condition
• Patient’s general health status and presence of comorbidities and
risk factors
• The patient’s previous level of functioning or disability
• The patient’s living environment
• Patient’s and/or family goals
• Patient’s motivation and adherence and responses to prtvious
interventions
• Safety issuts and concerns
• Extent of support (physical,emothional, social)

70. Independent learning activity
• Critically analyze you own exercise history. Then identify how a
regular regimen of exercise can improve your quality of life.
• Research four health conditions(diseases, injuries or disorder s) that
result in primary impairments of 1) musculoskeletal, 2)
neuromuscular,3) cardiovascular or pulmonary,4) integumentary
systems. Identify characteristic impairments (sight and systems)
associated with each health condition and hypothesize what
activity/functional limitations and participation restrictions are most
likely to develop.
• Using your current knowledge of examination procedures develop a
list of specific tests and measures you would most likely choose to
use when examining the patient whose primary impairments affect
1) musculoskeletal, 2) neuromuscular,3) cardiovascular or
pulmonary,4) integumentary systems.