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Chapter 5 ­ Therapeutic Exercise

1 Therapeutic Exercise

Date Revised 10/8/03

Therapeutic Exercise

GENERAL EFFECTS OF THERAPEUTIC EXERCISE

1. Restoration of muscular strength 2. Restoration of muscular coordination 3. Restoration of flexibility 4. Restoration of cardiovascular endurance 5. Improvement of agility 6. Re-education of skill patterns (coordination)

7. Improvement in speed 8. Impact on psychological aspects 9. Maintenance of general body conditioning 10. Pain reduction 11. Improvement in muscle endurance 12. Improvement in muscular power

INDICATIONS FOR USE Therapeutic exercise is specifically concerned with maximizing body function after an injury. In contrast, conditioning is geared toward improving normal function and maintenance of well being, and is global and more general in nature than therapeutic exercise. Some specific indications for the use of therapeutic exercise include: 1. Pain 2. Decreased range of motion 3. Decreased / lack of strength 4. Decreased / lack of muscular endurance 5. Substandard coordination 6. Loss of musculoskeletal functional integrity

CONTRAINDICATIONS 1. Joint effusion 2. When motion is disruptive to healing process (acute tears, fractures, surgery, dislocations) 3. Muscular inflammation 4. Fever / active infection (systemic or local)

PRECAUTIONS 1. Post-myocardial infarction or cardiac surgery 2. Local muscle fatigue 3. Total body fatigue 4. 5. 6. 7. Osteoporosis Exercising into pain Diagnosis prohibiting exercise Uncontrolled hypertension

Educational and Patient Care Protocols Chapter 5 - 1

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GENERAL COMMENTS Basic components of therapeutic exercise (in order of proper therapeutic sequence) include flexibility and range of motion, strength and muscular endurance and proprioception and coordination. It is necessary to establish a workable range of motion prior to introducing strengthening components. Generally, it is best to improve strength through the existing range of motion, however small, while still focusing on increasing the range. Range of motion is the most limiting factor and the restoration of normal range should continue to be a primary goal throughout the rehabilitation process. Therapeutic exercise is applied a minimum of 3 to 5 times a week depending upon desired therapeutic outcome.

STAGES OF REHABILITATIVE EXERCISE Stage 1: Acute to Subacute Inflammatory response 24 to 72 hours up to 6 days post injury 1. Passive Range of Motion a. Address all ranges of motion. b. Avoid painful motion. c. Move slowly and pause when pain and/or muscle guarding limits range. d. Use manipulation, adjustments, manual therapy, and physical modalities as indicated to facilitate restoration and maintenance of range of motion. 2. Isometric Exercise a. Perform isometric contractions at 20-degree intervals through the pain-free range. b. Contract against resistance and hold for 10 seconds before relaxing. c. Repeat at next 20-degree interval. d. Exercise through full available range 3 to 5 times per day. 3. Active Range of Motion a. Patient moves through full pain-free range. b. Movement must be slow, steady, with good technique. c. 10 repetitions of movement at each range of motion involved in joint movement.

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Subacute · Passive congestion, repair. · 2 to 4 days up to 14 to 21 days post injury. 1. Passive Range of Motion as indicated. 2. Active Range of Motion as indicated. 3. Manual Resistance Exercise. a. Clinicians may provide resistance manually while the patient actively moves through a pain-free range of motion. b. Resistance should not cause joint or muscle pain. c. Patient performs 5 to 10 repetitions of the exercise at every motion involved in joint movement.

Educational and Patient Care Protocols Chapter 5 - 1

Stage 2:

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Stage 3:

Chronic Repair and regeneration. 14 to 21 days to 12 weeks. 1. Externally resisted active exercise: increased emphasis on balance, coordination, proprioception, and kinesthetic awareness. 2. Resistance is provided by dumbbells, elastic tubing, exercise equipment, or even patient's own body weight or the weight of a limb. 3. Exercise is performed through a pain-free range of motion. 4. Patient must be able to perform 8 to 10 repetitions of the exercise with no assistance and using the lightest available resistance (this is for patient safety, and to avoid soreness and difficulty). 5. Patient performs one set of the exercise and gradually works up to approximately three sets of 8 to 15 repetitions for each exercise. 6. When patient can successfully complete 3 sets of the exercise with proper technique, and no pain then resistance can be increased. 7. Progress toward more functional activities and closed kinetic chain activities and plyometrics if indicated.

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Stage 4: Release to Home Program 1. A clear, written program is given to the patient to do at home or at another site outside the clinic (gym, health club). 2. The patient should continue normal medical/ chiropractic care per clinician's orders. 3. Patient should not be released from the supervised exercise program without approval of the treating clinician. 4. Follow up assessments should be performed periodically on all patients discharged to ensure compliance and continued documentation of progress to maximal patient improvement. Depending on the nature of the case, assessments should be performed every two to six weeks with subsequent changes and progressions in plan of care until maximal improvement is reached.

GUIDELINES FOR STAGE UPGRADE Reassessment During re-evaluation or reassessment, quantitative measures should be retaken in accordance with those measures taken during the initial evaluation; manual muscle testing, range of motion measures, girth measures, etc. Criteria for Upgrade from Stage 1 to 2 1. Pain-free range of motion is at least 75% of normal arc. 2. Computerized functional capacity outcome measures (if applicable and available) are within 30% deficit of expected isometric strength. 3. Patient can perform 5 repetitions of isometric exercises through a pain-free range with minimal decrease in strength over the 5 repetitions. 4. Patient has been through at least 5 sessions of exercise in Stage 1. 5. When patient moves to Stage 2, the Stage 1 exercises are continued at the ends of the range of motion as the range progressively improves.

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Criteria for Upgrade from Stage 2 to 3 1. Patient must be able to perform 10 repetitions of manual resistance exercise through a range of motion with no pain and no appreciable decrease in strength over the 10 repetitions. 2. Computerized functional capacity testing (if applicable and available) shows a deficit of 20% or less of expected strength. 3. Patient has shown progressive improvement in range of motion, with a 10% or less deficit of normal range of motion. 4. Patient has performed Stage 2 exercises for at least 5 exercise sessions. 5. When moving to Stage 3 exercises, choose resistance exercises according to the nature of the case, patient tolerance, and patient ability. 6. Emphasis remains on regaining full range of motion as strength increases- patient may still be performing exercises from Stage 1. Criteria for Release to Home Program 1. Patient should have full, expected and pain-free range of motion. 2. Computerized functional capacity testing (if applicable and available) shows less than a 10% deficit from expected strength. 3. Functional capacity for activities of daily living, work related activities, and/ or sport-specific activities is managed or restored. 4. It may be possible to initiate a home program while still in Stage 3. However, the home program must be integrated and progress as the need for supervised exercise declines. 5. Re-assessment of home programs can be accomplished during regular office visits. This is a good time to suggest everyday flexibility, strength training, aerobic conditioning, and nutrition on a whole body scale if it hasn't been addressed earlier in the patient management process. Measurement of Recovery 1. Strength near equal to uninvolved limb or pre-injured state. 2. Range of motion near equal to uninvolved limb or pre-injured state. 3. Functional power and endurance is normal. 4. Restoration of functional balance and proprioceptive sense. 5. Symmetrical girth measurements. 6. Ability to perform sport/job specific skills. 7. Reassessment shows at least a 90% return to normal capacity of all functions necessary for daily activities.

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References Consulted

Houglum, Peggy A., Therapeutic Exercise for Athletic Injuries, Athletic Training Education Series, Human Kinetics. 2001. Kisner, Carolyn; Colby, Lynn Allen, Therapeutic Exercise, Foundations and Techniques, F.A. Davis. 1996.

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