Principles of Therapeutic Exercise

1. Principles of Therapeutic Exercise Exercise Prescription Week 4 Jane Simmonds

2. Format • Exercise in the context of the physiotherapy profession and practice • Review the principles of training • Review the different types of exercise • Explore the concept of exercise prescription for the prevention and management of diseases and disorders • Review muscle physiology

3. Learning Outcomes • By the end of the session and independent study you should; • Understand the cope of exercise used in physiotherapy practice • Understand the principles of training • Understand the concept of training variables

4. Core Skills - Physiotherapy • Movement analysis • Manual therapy • Electrotherapy • Exercise therapy – exercise prescription (ACPET)

5. Exercise for the prevention of disease • Relationship between a sedentary lifestyle and chronic degenerative disorders • More than 20 disorders related to inactivity • 50 years of research • Seminal research bus conductors • Parffenbarger’s research • Physiotherapists have a role to play in health promotion Morris & Crawford 1958

6. Therapeutic Exercise • Prevent or rehabilitate disabilities • Improve or restore physical function so that ADL’s are no longer a challenge • Improve overall health and fitness • Reduce risk factors Rehabilitation Cycle Functional fitness and rehabilitation Early to middle management

7. Which patients groups benefit from therapeutic exercise? • Cardiac patients • Orthopaedic patients • Amputees • General surgical • Neurological • Elderly • Learning disabilities • Psychiatric • Palliative care • Respiratory • Paediatric • Rheumatology • Musculo-skeletal • Occupational • Spinal injuries • Obstetrics • Gynacological • Burns and plastics

8. Aims of Therapeutic Exercise • Enable ambulation • Release contracted soft tissues • Mobilise joints • Improve circulation • Improve respiratory capacity • Decrease stiffness

9. Aims of Therapeutic Exercise • Improve muscle strength • Improve endurance • Improve co-ordination • Promote confidence and wellbeing • Improve balance • Promote relaxation

10. Overarching Goal • To try whenever possible to restore fullfunction and achieve an optimal level of physical fitness. • Achieve this by setting shared realistic goals and identifying how fit the client needs to be. • Motivation • Adherence, compliance and concordance

11. Designing Exercise Programmes • When designing an exercise programme consider; • Pathology • Person (age, personality – psychology) • Needs - aspirations • Environment • Physiological processes • Principles of training

12. Types of Exercises • Stretching • Range of movement exercises • Strengthening exercises • Endurance exercises • Proprioceptive or balance training • Cardio-vasacular training

13. Principles of Training • Readiness • Overload • Specificity • Motivation • Learning • Reversibility • Diminishing returns

14. Prescription Variables • 5 key components • Frequency • Duration • Intensity • Type of exercise • Progression

15. Stretching • Passive or active • Stretching to retain range e.g. joint pathology • Stretching to increase normal range e.g. sport and dance • Stretching to lengthen contracted, fibrosed, shortened tissue e.g. congenital conditions, post-surgery/immobilisation/injury • How long should we stretch for?

16. Mobility Exercises • Active assisted • Usually used as interim measure moving from passive to active, also when joint pain limits free active movement • Free active • Knowledge of aging and pathologies required to prevent undesirable movements e.g. trunk flexion exercises in osteoporosis

17. Cardio-respiratory Exercise • Aerobic exercise positive influence on risk factors in CVD, diabetes, weight control and cancer. • Rehabilitation programmes for cardiac and pulmonary patients • Incremental monitored progression of exercise • Early on: exercise not more than 20bpm above resting level and not more than 11-12 on RPE (40% Vo2 max) • 40-80% MHR depending on fitness (MHR =220-age) • Isometric exercises for vulnerable patients advise isometric contraction ≤ 6 secs each

18. Monitoring • Why is monitoring important? • Heart rate • Pulse monitor, ECG, chest strap • Blood pressure • Systolic/diastolic • Subjective measure • Rating of perceived exertion (RPE)

19. Borg Scale

20. Proprioception • Essential post-injury especially lower limb • Retraining for amputees and neuro patients • Elderly rehab, altered joint biomechanics in OA. ? May prevent falls

21. Muscle Contractions and Resistance Exercises • Consider why we might choose these different types of exercises? • Are there any risks? • Isometric • Concentric • Eccentric • Isokinetic • Closed and open chain exercises

22. Strength, Power and Endurance • What is the difference? • Load (resistance) • Repetitions • Sets • Frequency • Consider muscle fibre type

23. Muscle Fibre Types • Skeletal muscle fibers are classified into two major categories; slow-twitch (Type 1) and fast-twitch fibers (Type II). • The difference between the two fibers can be distinguished by; • metabolism • contractile velocity • neuromuscular differences • glycogen stores • capillary density of the muscle • and the actual response to hypertrophy

24. Fibre Type • Slow twitch – type 1 • Rich in haemaglobin • Mitochondria • Rich in blood vessels • Red • Common postural muscles. • Slow twitch – type II • Type II a - fast oxidative - fatigue resistant – fast oxidative fibres • Type II (b)x - fast glycolytic fibres - split ATP at a fast rate and have a fast contraction velocity.

25. Progressing Exercise • Overload principle • Motivation principle • Strength? • Endurance? • Power? • Complexity of task • Functional

26. Exercise Prescription • Exercise prescription is based on physiological principles and laws of training and modified by clinical findings. • Pain • Underlying medical conditions – diabetes, cardiovascular disease, diabetes, psychological factors etc. • Safety

27. Exercise prescription requires a detailed knowledge of; • Motor learning • Anatomy • Biomechanics/pathomechanics • Kinesiology • Pathology • Exercise physiology

28. Exercise Psychology • Adherence, compliance and concordance • Goals • Patient factors: age, sex, socio-economics, fear, self-efficacy, support • Programme factors: personnel, education, attention, group dynamics, logistics

29. Summary • Exercise prescription is a core skill for physiotherapists • Underpinned by physiological and patho-physiological processes • Requires a good understanding of exercise physiology and the principles of training • Motivational psychology - stages of change • Imagination

30. References • Hanandez Kravitz (2006) http://www.unm.edu/~lkravitz/Article%20folder/hypertrophy.html • Robergs, R. A. and S. O. Roberts(1997) Exercise Physiology: Exercise, Performance, and Clinical Applications. Boston, WCB McGraw-Hill • National Institute on Aging (2005) www.niapublications.org/exercisebook/chapter4.htm . • Skinner JS (2005) Exercise Testing and Exercise Prescription for Special Cases. Philadelphia, Lippincott, Williams & Wilkins • Woolf-May K (2006) Exercise Prescription – physiological foundations. Churchill Livingstone