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Therapeutic Exercise

Therapeutic Exercise. Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation. Clinical Decision Making. Examination Evaluation Diagnosis Prognosis Set up Interventions. Clinical Decision Making.

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Therapeutic Exercise

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  1. Therapeutic Exercise Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation.

  2. Clinical Decision Making • Examination • Evaluation • Diagnosis • Prognosis • Set up Interventions

  3. Clinical Decision Making • Med Dx: CAD Med Dx: COPD • Use of Hypothesis Testing and Algorithms • Med Dx and History of Cardiopulmonary Disease • Lab and Diagnostic Test Results • PT Dx • Type of activity, specifics of activity, time • Response to exercise/mobility/ADL • Vital signs – rest, activity, recovery • EKG changes • Need and time to stop, rest • Observed signs – color changes • Subjective responses • Concerns – Fatigue, SOB • Rate of Perceived Exertion DeTurk & Cahalin - pg 368-369, Fig 12-4 & pg 370, Fig 12-5

  4. Musculoskeletal, Integument, & Neuromuscular Considerations • Musculoskeletal • Osteoporosis & Spinal Deformities • Ankylosing Spondylitis • Idiopathic Scoliosis • Pectus Deformities • Shoulder Hypomobility • Integument • Sarcoidosis • Systemic Lupus Erythematosus • Scleroderma • Sjogren Syndrome • Neuromuscular • Stroke • Traumatic Brain Injury • Spinal Cord Injury • Multiple Sclerosis • Parkinsons • Guillain-Barre Syndrome • Post Polio Syndrome

  5. Nagi (Disablement) Model Disability Inability to shop for family Functional limitation Limited walking distance Impairment Impaired aerobic capacity Pathology Myocardial Infarction

  6. APTA, Guide PT Practice, 1st ed.1997.

  7. Therapeutic Exercise for Cardiopulmonary Practice Patterns • Aerobic capacity/endurance conditioning or reconditioning • Balance, coordination, and agility training • Body mechanics and postural stabilization • Flexibility exercises • Gait and locomotion training • Relaxation • Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

  8. Pattern A: Prevention and RiskInclusion Criteria • Risk Factors or Consequences of Pathology Diabetes Family history of heart disease Hypercholesterolemia or hyperlipidemia Hypertension Obesity Sedentary lifestyle Smoking • Impairments, Functional Limitations, or Disabilities Decreased functional work capacity Decreased maximum aerobic capacity Dyspnea on exertion Sedentary job role

  9. Pattern A: Prevention and RiskTher Ex • Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time Task-specific performance training • Flexibility exercises Muscle lengthening Range of motion Stretching • Body mechanic and ergonomics training • Breathing exercises • Posture awareness training

  10. Pattern A: Prevention and RiskTher Ex • Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches • Strength, power, and endurance training Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices) Aquatic programs Standardized, programmatic, complementary exercise approaches Task-specific performance training

  11. Pattern A: Prevention and Risk Patient Education • Disease • Atherosclerosis • Hyperlipedemia • Hypertension • Diabetes • Diet • Exercise • Smoking • Health & Wellness • Fitness

  12. Pattern B: DeconditioningInclusion Criteria • Risk Factors or Consequences of Pathology Acquired immune deficiency syndrome Cancer Cardiovascular disorders Chronic system failure Inactivity Multisystem impairments Musculoskeletal disorders Neuromuscular disorders Pulmonary disorders • Impairments, Functional Limitations, or Disabilities Decreased endurance Increased cardiovascular response to low level work loads Increased perceived exertion with functional activities Increased pulmonary response to low level work loads Inability to perform routine work tasks due to shortness of breath

  13. Pattern B: DeconditioningTher Ex • Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time • Balance, coordination, and agility training Developmental activities training Neuromuscular education or reeducation Standardized, programmatic, complementary exercise approaches • Breathing exercises • Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control and awareness training • Flexibility exercises Muscle lengthening Range of motion Stretching

  14. Pattern B: DeconditioningTher Ex • Gait and locomotion training Developmental activities training Gait training Implement and device training Standardized, programmatic, complementary exercise approaches Wheelchair training • Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches • Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics) Aquatic programs Conditioning and reconditioning - Strengthening or Resistive Standardized, programmatic, complementary exercise approaches

  15. Pattern C: Airway ClearanceInclusion Criteria • Risk Factors or Consequences of Pathology Acute lung disorders Acute or chronic oxygen dependency Bone marrow/stem cell transplants Cardiothoracic surgery Change in baseline breath sounds Change in baseline chest radiograph Chronic obstructive pulmonary disease (COPD) Frequent or recurring pulmonary infection Solid-organ transplants (eg, heart, lung, kidney) Tracheostomy or microtracheostomy • Impairments, Functional Limitations, or Disabilities Dyspnea at rest or with exertion Impaired airway clearance Impaired cough Impaired gas exchange Impaired ventilatory forces and flow Impaired ventilatory volumes Inability to perform self-care due to dyspnea Inability to perform work tasks due to dyspnea

  16. Pattern C: Airway ClearanceTher Ex • Aerobic capacity/endurance conditioning or reconditioning activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time • Body mechanics, ergonomics, and postural stabilization Posture awareness training Postural control training • Flexibility exercises Muscle lengthening Range of motion Stretching • Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches

  17. Pattern C: Airway ClearanceTher Ex • Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric,and plyometric – using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices) Aquatic programs Standardized, programmatic, complementary exercise approaches Task-specific performance training • Balance and coordination training • Developmental activities • Neuromuscular relaxation, inhibition, and facilitation

  18. Pattern D: CV Pump DysfunctionInclusion Criteria • Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition) Angioplasty Atrioventricular block Cardiomyopathy Cardiothoracic surgery Complex ventricular arrhythmias Complicated MI (failure); uncomplicated MI (dysfunction) Coronary artery disease Decrease in ejection fraction (EF) on exercise testing (EF of 30-50% with dysfunction; < 30% with failure) Diabetes Hypertensive heart disease Valvular heart disease • Impairments, Functional Limitations, or Disabilities Abnormal heart rate response to increased oxygen demand Abnormal pulmonary response to increased oxygen demand Decreased ability or the inability to perform activities of daily living (ADL) because of symptoms Change in baseline breath sounds with activity Flat or falling blood pressure response to increased oxygen demand (failure)

  19. Pattern D: CV Pump DysfunctionTher Ex • Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time • Balance, coordination, and agility training Developmental activities training Motor function (motor control and motor learning) training or retraining Neuromuscular education or reeducation Standardized, programmatic, complementary exercise approaches Task-specific performance training • Breathing exercises • Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural awareness training • Flexibility exercises Muscle lengthening Range of motion Stretching

  20. Pattern D: CV Pump DysfunctionTher Ex • Gait and locomotion training Developmental activities training Gait training Implement and device training Standardized, programmatic, complementary exercise approaches Wheelchair training • Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches • Strength, power, and endurance training Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices ) Standardized, programmatic, complementary exercise approaches Task-specific performance training

  21. Pattern E: Resp Pump DysfunctionInclusion Criteria • Risk Factors or Consequences of Pathology Elevated diaphragm and volume loss on chest radiograph Neuromuscular disorders Partial or complete diaphragmatic paralysis Poliomyelitis Pulmonary fibrosis Restrictive lung disease Severe kyphoscoliosis Spinal cord injury • Impairments, Functional Limitations, or Disabilities Abnormal or adventitious breath sounds Abnormal increased respiratory rate and decreased tidal volume at rest Airway clearance dysfunction secondary to ventilatory pump impairment Decreased to severely impaired strength and endurance of ventilatory muscles Dyspnea with self-care Dyspnea with work tasks Dys-synchronous or paradoxical breathing at rest or with activity

  22. Pattern E: Resp Pump DysfunctionTher Ex • Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Movement efficiency and energy conservation training Increased workload over time • Balance, coordination, and agility training Developmental activities training Motor function (motor control and motor learning) training or retraining Neuromuscular education or reeducation Standardized, programmatic, complementary exercise approaches Task-specific performance training • Breathing exercises • Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control training Postural stabilization activities Postural awareness training • Flexibility exercises Muscle lengthening Range of motion Stretching

  23. Pattern E: Resp Pump DysfunctionTher Ex • Gait and locomotion training Developmental activities training Gait training Implement and device training Perceptual training Standardized, programmatic, complementary exercise approaches Wheelchair training • Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches • Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics Standardized, programmatic, complementary exercise approaches Task-specific performance training

  24. Pattern F: Respiratory FailureInclusion Criteria • Risk Factors or Consequences of Pathology Adult respiratory distress syndrome Abnormal alveolar to arterial oxygen tension differences Cardiothoracic surgery Chronic obstructive pulmonary disease (COPD) Multisystem failure Pneumonia Pre- and post-lung transplant or rejection Rapid rise in arterial carbon dioxide at rest or with activity Sepsis Thoracic or multisystem trauma • Impairments, Functional Limitations, or Disabilities Abnormal or adventitious breath sounds Abnormal vital capacity Airway clearance dysfunction Dyspnea at rest Dyssynchronous or paradoxical breathing pattern Impaired gas exchange

  25. Pattern F: Respiratory FailureTher Ex • Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Movement efficiency and energy conservation training Increased workload over time • Balance, coordination, and agility training Neuromuscular education or reeducation Posture awareness training • Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control training Postural awareness training • Flexibility exercises Muscle lengthening Range of motion Stretching

  26. Pattern F: Respiratory FailureTher Ex • Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches • Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices ) Task-specific performance training

  27. Therapeutic Exercise • Aerobic capacity/endurance conditioning or reconditioning • Aquatic programs • Gait and locomotion training – Walk or W/C • Increased workload over time • Movement efficiency and energy conservation training

  28. Aerobic Capacity/Endurance Conditioning or Reconditioning • Activity, specific set up, time • Improve oxygen demand • Use of large muscle groups in a rhythmic fashion, over time • Mode • Marching, Walking, Bike, Gardening • Intensity • Max HR and take age adjusted • 50-70% depending on exercise test, age • Frequency • 4-5 days per week • Duration • 5-10 min bouts 3x/day • Work up to 30-40 min in one session For Progression, see DeTurk & Cahalin, pg 447 & 448, Figs 15-7 & 15-8

  29. Aerobic Capacity/Endurance -Evidence • Patient Education on Risk or Disease • Exercise, Diet • Deconditioning • Rate of VO2 max decreases greatest the first week of bedrest1 • Longer the bedrest the more diminished the VO2 max1 • Use of HR, RPE, and METs 1 Convertinao VA, Med Sci Sports Exer, 1997:29:191

  30. Aerobic Capacity/Endurance -Evidence • Group-based (8-12 patients) simple aerobic dance movements (with music) • 2 days a week for 4 months • Each session lasted 50 minutes (including warm-up and cool-down), followed by 15-30 minutes of counseling • The exercise program included three intervals of high intensity, during which patients were encouraged to reach 15-18 on the Borg scale for 5-10 minutes. • 6 min walk, resistance on bike, bike time, MN Living with Heart Failure QOL all increased with significance as compared to the control group for 4 and 12 mn. Nilsson et al, Long-term effects of a group based high intensity aerobic interval training program in patients with chronic heart failure, Am J Cardiol 2008; 102(9):1220-1224

  31. Therapeutic Exercise • Balance, coordination, and agility training • Developmental activities training • Posture awareness training • Standardized, programmatic, complementary exercise approaches • Task-specific performance training

  32. Balance, Coordination, and Agility Training • Mode • Massery Technique • Intensity • Duration • Frequency • No set parameters

  33. Balance - Evidence • Sensory-specific balance classes were held 3 times per week, for 1 hour each session, over 8-week • Tasks included • standing or walking on various support surfaces, such as a rocker board, foam, or narrow beam • Standing in a tandem position, a semitandem position, on one leg, or in a feet together • Progressions to these tasks included simultaneous alterations of visual and vestibular inputs • Instructed to close their eyes, to engage vision with a reading or tracking secondary task • Perform balance tasks with a distracting background • Instructed to tilt their head backward or to quickly move their head side to side and up and down. • Results • Less destabilization within the first 5 seconds following vibration with or without a secondary task than there was at baseline or in the falls prevention education group • Training effects were not maintained at the 8-week follow-up. Westlake & Culham.Sensory-Specific Balance Training in Older Adults: Effect on Proprioceptive Reintegration and Cognitive DemandsPhysical Therapy. Oct 2007. Vol. 87, Iss. 10; p. 1274

  34. Therapeutic Exercise • Body mechanics and postural stabilization • Body mechanics training • Postural control training • Postural stabilization activities • Posture awareness training

  35. Body Mechanics and Postural Stabilization • Mode • Intensity • Duration • Frequency • No set parameters

  36. Body Mechanics -Evidence • Perfusion study in prone and supine • Pts were under conditions of • Normal breathing of room air • Unassisted breathing of 45% O2 • Assisted PEEP • Ventral, Middle, Dorsal measurements with ventral more perfuse in prone and dorsal more perfuse in supine Suki et al, Perfusion, Science Letter. Atlanta: Mar 25, 2008. pg. 2580

  37. Body Mechanics -Evidence • Pt with ischemia of stable and unstable angina • Valsalva and measured QT of EKG • With valsalsa showed significant difference of EKG changes of QT segment • Authors related to carrying or lifting restrictions of heavy objects with CAD Balbay et al, Effects of valsalva maneuver on QT dispersion in patients with ischemic heart...Angiology; Nov 2001; 52, 11

  38. Therapeutic Exercise • Flexibility exercises • Improve motion of the chest wall, lengthen anterior chest wall, improve hip and knee flexor shortening • Muscle lengthening • Range of motion • Stretching

  39. Flexibility Exercises • Mode • Isolate muscle or limited joint • Intensity • After warmup • Duration • Hold with no pain for 30 sec • Frequency • 3-5 days/week

  40. Flexibility - Evidence • Pt with ankylosing spondylosis • 3x/wk for 3 months • 18 stretching exercises of entire spine and extremities along with aerobic and chest expansion exercises • Significant improvement in cervical and thoracic spine movement AND chest expansion Ince et al , Effects of a Multimodal Exercise Program for People With Ankylosing Spondylitis, Physical Therapy; Jul 2006; 86, 7

  41. Therapeutic Exercise • Gait and locomotion training • Developmental activities training • Gait training • Implement and device training • Standardized, programmatic, complementary exercise approaches

  42. Gait and Locomotion Training • Mode • Intensity • Duration • Frequency • No set parameters

  43. Gait and Locomotion - Evidence • See aerobic exercise • Massery Pairing Massery et al, Coordinating transitional movements and breathing in patients with neuromotor dysfunction, NDTA Network, Nov/Dec 1996

  44. Gait and Locomotion - Evidence • Case Report of pt with C6 tetraplegia • Taught breathing strategy and reducing valsalva with tasks with w/c • Lean forward • Put foot on footplate • Posterior lean for pressure relief • Able to perform tasks with new breathing strategies Henderson, Application of Ventilatory Strategies to Enhance Functional Activities for an...Journal of Neurologic Physical Therapy; Jun 2005; 29, 2

  45. Therapeutic Exercise • Relaxation • Breathing strategies • Movement strategies • Relaxation techniques • Standardized, programmatic, complementary exercise approaches

  46. Relaxation • Mode • Intensity • Duration • Frequency • No set parameters

  47. Relaxation -Evidence • Five 60 minute individual treatments with the Papworth method from a respiratory physiotherapist • No significant differences were found between the groups at baseline • SGRQ Symptom mean scores were lower in the Papworth method group than in the control group after treatment and at 12 months • The Nijmegen and HADS scores were also significantly lower in the intervention group than in the control group • Objective respiratory measures did not differ significantly across the groups, apart from breathing rate. Holloway and West, Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial , Thorax 2007; 62(12): 1039-1042

  48. Therapeutic Exercise • Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles • More efficient motion • Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) • Aquatic programs • Standardized, programmatic, complementary exercise approaches • Task-specific performance training

  49. Strength, Power, and Endurance Training for Trunk, Extremities and Ventilatory Muscles • Mode • AAROM, AROM • Resistance • Manual • Weights • Intensity • Incorporate breathing with resistance • Resistance may start light and work up • 8-12 reps, 1-3 sets • Resistance of 1 rep max and then calculate • 8-10 reps at 70% of max, 6 reps at 80% of max, 4 reps at 90% of max, 2 reps at 95% max and finally 1 rep at max • High weight, low reps for strength • Low weight, high reps for endurance • Duration • Frequency • Every other day or rotate muscle groups

  50. Strength - Evidence • Systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis. • Articles were included if: • (1) participants were adolescents or adults with cystic fibrosis (413 years of age) • (2) an IMT group was compared to a sham IMT, no intervention or other intervention group • (3) the study used a randomized controlled trial or cross-over design • (4) it was published • Results: The search strategy yielded 36 articles • Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) • No difference in effect between the IMT group and the sham and/or control group. • Individual study results were inconclusive for improvement in inspiratory muscle strength • One study demonstrated improvement in inspiratory muscle endurance. • Conclusion: • The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. • Its impact on exercise capacity, dyspnoea and quality of life is not clear Reid et al, Effects of inspiratory muscle training in cystic fibrosis: a systematic review, Clinical Rehabilitation. London: Oct 2008. Vol. 22, Iss. 10-11

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