Therapeutic Exercise
What are the stages of motor learning?
Cognitive, associative, autonomous
During what type of contraction does the force a muscle can generate decrease?
Concentric contraction
What are the three types of motor tasks?
Discrete, serial, continuous
What is closed loop control?
It is utilized for precision movements that require sensory feedback (e.g., maintaining balance while sitting on a ball or standing on a balance beam).
What is the sequence for contract-relax (CR)
PROM to mild discomfort; hold 10 seconds Active contraction through full ROM against resistance PROM to new end range - hold 30 seconds
What is the sequence for hold-relax with agonist contraction (HR-AC)
PROM to mild discomfort; hold 10 seconds Isometric hold "match my resistance" - hold 6 seconds Increase to the new end range by contracting the agonist muscle; i.e., stretch muscle by contracting the opposite muscle - hold 30 seconds
What is the sequence for hold-relax (HR)
PROM to mild discomfort; hold 10 seconds Isometric hold "match my resistance" - hold 6 seconds PROM to new end range - hold 30 seconds
What are ways to progress and regress closed-chain exercises?
PWB - full weight bearing - additional weight Wide stance - narrow stance Bilateral stance - unilateral stance Stable support surface - moving/unstable support surface Low step - high step External support - no support Eyes open - eyes closed Short arc - full arc Step forward - step backwards Slow - fast
What information does the somatosensory system provide?
Position and motion of the body, proprioception, touch
What information does the vestibular system provide?
Position and movement of the head with respect to gravity and inertial forces; postural control
What information does the visual system provide?
Position, orientation, direction, and speed of the head and it's movements
Interventions for anticipatory balance?
Reaching, catching, kicking, lifting objects, obstacle course, open doors, use different postures for variation
What is augmented (extrinsic) feedback?
Sensory cues from an external source that are supplemental to intrinsic feedback and that are not inherent in the execution of the task. May arise from a mechanical source or from another person.
What is intrinsic feedback?
Sensory cues that are inherent in the execution of a motor task. Arises directly from performing or attempting to perform the task. May immediately follow completion of a task or may occur even before a task has been completed. Most often involves proprioceptive, kinesthetic, tactile, visual, or auditory cues.
General balance exercise ideas
Sit to stand, stepping in all directions, reaching limits of stability (grabbing stuff from high up), step up/down, sideways reach, ball games, treasure hunt
What is random-order practice?
Slight variations of the same task are carried out in an unpredictable order; for example, a patient could practice stepping to and from platforms of different heights or practice standing up from chairs of different heights or styles in a random order; therefore, the task changes with each repetition.
Interventions for reactive balance?
Standing sway, ankle strategy, hip strategy, stepping strategy, perturbations, walk on balance beam/straight line, single-leg stance, rocker balance, step ups
Types of stretching examples
Static, cyclic/intermittent, ballistic, PNF, manual, mechanical, self-stretching, passive, active
What is selective stretching?
Stretching specific joints or muscles while shortening others
What is muscular strength and training?
The ability of muscle to exert force i.e., greatest measureable force that can be exerted by a muscle in a single effort Strength training is lifting heaving loads for a relatively low number of repetitions for a short period of time
What is whole practice?
The entire task is performed from beginning to end and is not practiced in separate segments. Acquiring continuous skills like walking, climbing stairs, or discrete tasks where the exercises involves repetitions of a single movement pattern
What is the weight shift strategy?
The movement strategy utilized to control mediolateral perturbations involves shifting the body weight laterally from one leg to the other. The hips are the key control points of the weight shift strategy. Lateral to medial
What happens first for both hold-relax and contract-relax procedures?
The range limiting target muscle (muscle being stretched) is lengthened to the point of tissue resistance and held for ten seconds
What is passive flexibility?
This aspect of flexibility, also referred to as passive mobility or passive ROM, is the degree to which a body segment can be passively moved through the available ROM and is dependent on the extensibility of muscles and connective tissues that cross and surround a joint. Passive flexibility is a prerequisite for—but does not ensure— dynamic flexibility
What is dynamic flexibility?
This form of flexibility, also referred to as active mobility or active ROM, is the degree to which an active muscle contraction moves a body segment through the available ROM of a joint.
Isometric exercise indications
To minimize muscle atrophy when joint movement is not possible To activate muscles (facilitate muscle firing) to begin to re-establish neuromuscular control but protect healing tissues when joint movement is not advisable after soft tissue injury or surgery To develop postural or joint stability To improve muscle strength when use of dynamic resistance exercise could compromise joint integrity or cause joint pain
What is random/blocked-order practice?
Variations of the same task are performed in random order, but each variation of the task is performed more than once; for example, the patient rises from a particular height or style chair, and then repeats the same task a second time before moving on to a different height or style chair.
Interventions for static balance?
Varying postures and support surfaces, external loads
Indications for AROM
When a patient is able to contract the muscles actively and move a segment with or without assistance, AROM is used. When a segment of the body is immobilized for a period of time, AROM is used on the regions above and below the immobilized segment to maintain the areas in as normal a condition as possible and to prepare for new activities, such as walking with crutches.
When would you use near-maximal or maximal loading?
When the goal is to increase muscular strength, advanced phase of rehabilitation program, bodybuilding
What factors may cause hypomobility?
(1) prolonged immobilization of a body segment; (2) sedentary lifestyle (3) postural malalignment and muscle imbalances (4) impaired muscle performance (weakness) (5) tissue trauma resulting in inflammation and pain (6) congenital or acquired deformities
What is blocked-order practice?
. The same task or series of exercises or tasks is performed repeatedly under the same conditions and in a predictable order; for example, the patient may consistently practice walking in the same environment, stepping to and from the same height platform, standing up from the same height chair, or lifting containers or equal size or weight; therefore, the task does not change from one repetition to the next.
What are the four main dimensions of tasks?
1. Environment the task in performed in; open/closed 2. Intertrial variability; change in conditions of task so they are not predictable 3. Stationary or movement during task 4. Manipulation of objects; walking while carrying something versus hands free
General sets and repetitions for muscle endurance
40-50 repetitions 3-5 sets OR 12+ repetitions 2-3 sets
For the average adult, approximately how many repetitions are possible when exercising with a load that is 75% of their 1-RM? 60%?
75% = 10 repetitions 60% = 15 repetitions
General sets and repetitions for muscle strength
8-12 repetitions 2-3 OR 6 sets 60-80% of 1 RM
Contraindications to stretching
A bony block limits joint motion. There was a recent fracture, and bony union is incomplete. There is evidence of an acute inflammatory or infectious process (heat and swelling), or soft tissue healing could be disrupted in the restricted tissues and surrounding region. There is sharp, acute pain with joint movement or muscle elongation. A hematoma or other indication of tissue trauma is observed. Hypermobility already exists. Shortened soft tissues enable a patient with paralysis or severe muscle weakness to perform specific functional skills otherwise not possible.
What is part practice?
A task is broken down into separate dimensions. Individual and usually the more difficult components of the task are practiced. After mastery of the individual segments, they are combined in sequence so the whole task can be practiced. Effective for acquisition of complex serial skills; pt will practice difficult dimensions before practicing the task as a whole
What is muscular endurance and training?
Ability to perform low-intensity, repetitive, or sustained activities over a long period of time; resist fatigue Endurance training includes low-intensity muscle contractions, large number of repetitions or sustaining a muscle contraction over an extended period of time
What are strategies for the associative stage?
Add more variety to tasks, increase complexity, vary in sequence (random order), allow patient to practice independently, delay/fade feedback, increase distraction
What is resistance exercise?
Any form of active exercise in which a static or dynamic muscle contraction is resisted by an outside force manually or mechanically applied
What are the four main conditions of balance control?
Balance during stance, perturbed standing, balance during whole-body lifting, balance during gait
What is balance?
Balance is a complex motor control task involving the detection and integration of sensory information to assess the position and motion of the body in space and the execution of appropriate musculoskeletal responses to control body position within the context of the environment and task. Thus, balance control requires the interaction of the nervous and musculoskeletal systems and contextual effects
What are forms of self assisted ROM?
Ball rolling, T-bar, pulleys, skate board, table slides
What is the PNF theory for agonist contraction?
Classic PNF theory suggests that when the agonist (the muscle opposite the range-limiting muscle) is activated and contracts concentrically, the antagonist (the range-limiting muscle) is reciprocally inhibited, allowing it to relax and lengthen more readily.
What are strategies for the cognitive stage?
Closed environment, demonstrate, assist, break movements into parts, frequent feedback, start with blocked order and progress to random order
Are open or closed-chain exercises better for neurorehabilitation? Why?
Closed-chain Closed-chain training provides greater proprioceptive and kinesthetic feedback Because most closed-chain exercises are performed in weight bearing positions, closed-chain exercises stimulate joint and muscle mechanoreceptors, facilitate co-activation of agonists and antagonists (co-contraction), and consequently promote dynamic stability
Define closed-chain exercises
Closed-chain exercises involve motions in which the body moves on a distal segment that is fixed or stabilized on a support surface.
When would you used submaximal loading?
Early stages of soft tissue healing, after prolonged immobilization, early learning to emphasize form, to improve endurance
What is the hip strategy?
For rapid and/or large external perturbations or for movements executed with the COG near the limits of stability, a hip strategy is employed. The hip strategy uses rapid hip flexion or extension to move the COM within the BOS. Proximal to distal
What are the parameters for ROM and stretching treatment?
Frequency: 2-5x/week Intensity: low; to the point of tightness of slight discomfort Time: 15-30 second increments Type: manual, mechanical, self, passive, active, PNF
Functional activities for ROM
Grasping eating utensil, eating, reaching to shelf heights, brushing hair, phone to ear, talking clothes on/off, supine to sit, putting on socks
What is the stepping strategy?
If a large force displaces the COM beyond the limits of stability, a forward or backward step is used to enlarge the BOS and regain balance control
What is the overload principle?
If muscle performance is to improve, a load that exceeds the metabolic capacity of the muscle must be applied; muscle must be challenged to perform at a level greater than it is accustomed to
What is the ankle strategy?
In quiet stance and during small perturbations (i.e., slow speed perturbations usually occurring on a large, firm surface), movements at the ankle act to restore a person's COM to a stable position Distal to proximal
Indications for PROM
In the region where there is acute, inflamed tissue, passive motion is beneficial; active motion would be detrimental to the healing process. Inflammation after injury or surgery usually lasts 2 to 6 days. When a patient is not able to or not supposed to actively move a segment(s) of the body, as when comatose, paralyzed, or on complete bed rest, movement is provided by an external source.
What is proprioceptive neuromuscular facilitation (PNF) stretching?
Integrating active muscle contractions into stretching maneuvers to inhibit or facilitate muscle activity Increases the likelihood that the muscle being lengthened stays relaxed as it is stretched
What is anticipatory control?
It involves activation of postural muscles in advance of performing skilled movements, such as activation of posterior leg and back extensor muscles prior to a person pulling on a handle when standing or planning how to navigate to avoid obstacles in the environment.
What is feedforward (open loop) control?
It is utilized for movements that occur too fast to rely on sensory feedback (e.g., reactive responses) or for anticipatory aspects of postural control.
What is important about a slowly applied stretch?
Minimizes muscle activation and reduces risk of injury, less likely to increase tensile stress on connective tissues
How long should rest intervals be between sets for the different exercise intensities?
Moderate intensity: 2-3 minutes Low-intensity: less High-intensity: >3 minutes
Define open-chain exercises
Open-chain exercises involve motions in which the distal segment (hand or foot) is free to move in space, without necessarily causing simultaneous motions at adjacent joints Open-chain testing and training identifies strength deficits and improves muscle performance of individual muscles or muscle groups more effectively than closed-chain exercises.
