Habitual physical activity provides numerous health benefits including improved cardiovascular function, reduced risk of heart disease and stroke, enhanced muscle function, increased bone density, weight management, and protection against diabetes. Therapeutic exercises include range of motion, resistance training, aerobic exercise, flexibility exercises, and techniques like proprioceptive neuromuscular facilitation to address specific medical conditions and injuries. Contraindications for exercise include certain cardiovascular conditions and acute illnesses.

1. Therapeutic Exercises Margarita Correa MD Physical Medicine Institute @ Orlando & Clermont, FL

2. Effects of Habitual Physical Activity Increase in maximal oxygen uptake and cardiac output and stroke volume Reduced heart rate at given oxygen uptake Reduced systolic and diastolic blood pressure Improved efficiency of heart muscle Decreased myocardial electrical irritability

3. Effects of Habitual Physical Activity Reduce mortality (26%) and morbidity (non-fatal MI’s, CABG & PTCA) Increased capillary density in skeletal muscle Increased activity of aerobic enzymes in skeletal muscle Reduced lactate production at given % of maximal oxygen uptake (VO2 max)

4. Effects of Habitual Physical Activity Enhanced ability to utilize free fatty acid as substrate during exercise-glycogen saving Improved endurance Increased metabolism Increased in the HDL/LDL ratio Improved structure and function of ligaments, tendons and joints

5. Effects of Habitual Physical Activity Increased muscular strength Reduced rate of perceived exertion (RPE) at given work rate Increased release of endorphins Provides a sense of well-being Enhanced tolerance to hot environment – increased rate of sweating

6. Effects of Habitual Physical Activity Reduced platelet aggregation Counteracts osteoporosis Can normalize glucose tolerance Improves endogenous and exogenous insulin sensitivity Decreased percent of body fat Increased lean body mass

7. Contraindications for Exercise Unstable angina pectoris Uncontrolled BP Orthostatic BP drop >20 mmHg with symptoms Critical aortic stenosis Acute systemic illness or fever Uncontrolled atrial or ventricular arrhythmias

8. Contraindications for Exercise Uncontrolled sinus tachycardia (>120 b/m) Uncompensated congestive heart failure 3 rd degree AV block w/o pacemaker Active pericarditis or myocarditis Recent pulmonary embolism

9. Passive Exercise Passive ROM (PROM) exercises are done for a person by a helper. The helper does the ROM exercises because the person cannot do them by himself.

10. Passive Exercise Passive range of motion (PROM) exercise consists of stretching immobile muscles and joint capsules to prevent joint stiffness and muscle contracture.

11. Active Assistive Exercises Active-assisted ROM (AAROM) exercises are done by the person and a helper. Active assistive range of motion (AAROM) exercises are used when the patient has very weak muscles or when joint pain limits movement. During AAROM exercises, it is important to avoid forcing the joint and/or soft tissue beyond the point of pain.

12. Active Exercises Active ROM (AROM) exercises are done by a person who can do the exercises all by himself.

13. Resistive Exercises Resistive exercises are done by a person using several modalities such as weights, against gravity, elastic bands to increase muscle strength.

14. Isometric – static exercises Isometric exercise is a form of exercise involving the static contraction of a muscle without any visible movement in the angle of the joint. This is reflected in the name; the term "isometric" combines the prefix "iso" (same) with "metric" (distance), meaning that in these exercises the length of the muscle does not change.

15. Isometric – static exercises Resistance to isometric contractions can involve maximal contractions of the muscle against the body's own muscle (i.e. pressing the palms together in front of the body) or structural items (e.g. pushing against a door frame), but can also involve holding a joint position against a sub-maximal contraction (e.g. holding a resistance band in a fixed position).

16. Isometric – static exercises Requires great caution because it causes a rise in heart rate (due to decreased vagal tone and increased discharge of cardiac sympathetic nerves). Within a few seconds of the start of isometric exercise, both the systolic and diastolic blood pressures rise.

17. Isometric – static exercises Since this form of training requires great caution, it may be prudent, especially in patients with cardiovascular diseases, not to extend the duration of an isometric contraction beyond 6 seconds.

18. Isotonic Exercises - dynamic Isotonic contractions in which the contraction strength does not change but the joint angle does, i.e.. swinging a bat. Can be either eccentric or concentric and is not speed limited.

19. Concentric Exercise A concentric contraction is a type of muscle contraction in which the muscles shorten while generating force. During a concentric contraction, a muscle is stimulated to contract according to the sliding filament mechanism . This occurs throughout the length of the muscle, generating force at the musculo-tendinous junction , causing the muscle to shorten and changing the angle of the joint. For example, a concentric contraction of the biceps would cause the arm to bend at the elbow (a biceps curl ).

20. Eccentric Exercises During an eccentric contraction , the force opposing the contraction of the muscle is greater than the force produced by the muscle. Rather than working to pull a joint in the direction of the muscle contraction, the muscle acts 'brakes' or slows the movement of a joint, and lengthens while generating force.

21. Eccentric exercises Exercise featuring a heavy eccentric load can actually support a greater weight (muscles are approximately 10% stronger during eccentric contractions than during concentric contractions) and also results in greater muscular damage and delayed onset muscle soreness one to two days after training.

22. Flexibility Exercise Improves mobility of the joints and soft tissue. Joint flexibility is achieved by means of steady and slow manual stretching of large muscle groups and joint capsules or with the help of mechanical devices.

23. Endurance Exercises Aerobic exercises improves cardiovascular tolerance such as swimming, walking, cycling, jogging, running….

24. Physical Fitness Strength Flexibility Aerobic capacity

25. Factors Affecting Training Initial level of fitness Intensity Duration Frequency

26. Exercise Session Warm-up period (5 – 10 mins) - Calisthenics & Stretching exercises Aerobic phase (20 – 45 mins) - Intensity: 60 – 80% of HRmax (220 – age), 50- 85% of maximum O2 uptake ( VO2 max)* - Duration: 20 – 60 mins - Frequency: 3 -5/week Resistive exercises Cool-down period (5 – 10 mins) *VO2 max is the maximum capacity to transport and utilize oxygen during incremental exercise. (The derivation is V̇ - volume per time , O2 - oxygen , max - maximum).

27. Aerobic capacity 'Aerobic capacity' describes the functional status of the cardiorespiratory system, (the heart, lungs and blood vessels). Aerobic capacity is defined as the maximum volume of oxygen that can be consumed by one's muscles during exercise. It is a function both of one's cardiorespiratory performance and of the ability of the muscles to extract the oxygen and fuel delivered to them.

28. Therapeutic Exercise - Endocrine Obesity Diabetes Graded physical training Daily activity level is adjusted to the daily insulin dose.

29. Therapeutic Exercise - Pulmonary Pneumonia Chronic bronchitis Bronchiectasis Asthma Emphysema Respiratory insufficiency Restrictive lung disease Postural drainage exercises Breathing techniques Relaxation techniques Stretching exercises to mobilize respiratory muscles Note: The level of physical effort should be limited because exercise may provoke bronchospasm.

30. Therapeutic Exercises-Gynecology and obstetrics Pregnancy and post-delivery Surgical patients After mastectomy Urinary incontinence Prenatal and postnatal exercises Relaxation techniques Preoperative and postoperative exercises Training to reduce lymphatic edema Isometric exercises to pelvic muscles (KEGEL)

31. Therapeutic Exercises - Neurology Cerebrovascular accident (CVA) Multiple sclerosis PNF (propioceptive neuromuscular facilitation) Bobath - Neuro-Developmental Treatment Training of muscle strength Training of balance and coordination Later training and maintenance of general physical fitness PNF and physical fitness training

32. Propioceptive Neuromuscular Facilitation - PNF Technique of combining Passive Stretching and Isometric Stretching in order to achieve maximum static flexibility. PNF was initially developed as a method of rehabilitating stroke victims. PNF refers to any of several post-isometric relaxation stretching techniques in which a muscle group is passively stretched, then contracts isometrically against resistance while in the stretched position, and then is passively stretched again through the resulting increased range of motion.

33. PNF – stretching First, the relaxed muscle is stretched by an external force, such as an exercise partner, or by ones own body weight against the floor, a wall, or similar resistance. At the point, where no further stretching seems possible, the stretch is held for up to 30 seconds . However, during this period, the muscle should be contracted as much as possible. (In the drawing on the right, this is done by trying to press the feet into the floor.) Finally, when the muscle gets relaxed again, it should be immediately stretched farther, which is then easily possible again.

34. Therapeutic Exercises - Neurology Parkinson disease Myopathies Increasing and maintaining flexibility Training of physical fitness Isometric and isotonic training

35. Therapeutic Exercise - Rheumatology Rheumatoid arthritis Osteoarthritis Flexibility training Gentle fitness training Same as above + aquatic therapy, strengthening

36. Therapeutic Exercises - Spine Cervical, dorsal, and lumbar problems Isometric and PNF training of muscle strength in muscles that have become weakened and in the back extensors and abdominal muscles -core muscles strengthening & trunk stabilization Treatment of muscle contractures Myofascial release Flexibility training (stretching) to mobilize joints Graded fitness training

37. Osteoporosis Benefits of exercise Reduction of bone loss Conservation of remaining bone tissue Improved physical fitness Improved muscle strength Improved reaction time Increased mobility Better sense of balance and coordination Reduced risk of falls Reduced risk of bone fractures caused by falls Reduced pain

38. Osteoporosis Walking Dancing Tai Chi Low impact aerobics Weight training using free weights such as dumbbells and barbells Resistance training using rubber tubes Exercises to improve posture, balance and body strength

39. Peripheral neuropathy Exercise therapy to improve strength, stamina, balance, coordination and propioception are key factors to prevent falls, specially in the geriatric population.

40. Therapeutic Exercises