principles of exercising

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principles of exercising
2011-10-03 13:45:07
principles exercising

principles of exercising
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  1. Types of exercise
    Range of Motion & Flexibility
    • AROM
    • PROM
    • A/AROM
    • Stretching
  2. Reasons for Exercise
    resistive exercise

    progressive resistive exercise
  3. Reasons for exercise
    Cardiovasular endurance Exercise
    breathing exercises

    breathing during exercise

    endurance-tolerance to overall activity
  4. ROM
    • -to assess the available movement at a joint
    • -provides a baseline to determine where to begin with therapeutic exercise program
    • -to maintain joint and soft tissue mobility & minimize the loss of tissue flexibility & contracture formation
  5. Factors that lead to decrease in ROM
    • -systemic disease such as arthritis
    • -joint, muscular or neurologic diseases
    • -joint surgery
    • -burns
    • -inactivity that comes with any immobilization
    • ex: wearing a cast
  6. Effects of Immobilization
    • -shortening of the length of muscle that is immobilized into the shortened position
    • -atrophy
    • -muscle weakness
  7. Specifics on the effects of Immobilization
    When atrophy occurs(decrease in number of myofibrils)
    Degree of atrophy affected by:
    • 1.durration of immobilization
    • longer=worse
    • decrease in cross sectional size of muscle fibers
    • decrease in motor unit recruitment

    • 2.position of immobilization-
    • shortened position=worse
    • sarcomere absorption
    • increased production of connective tissue
    • 3.composition of muscle-
    • slow-twitch atrophy more quickly
  8. When weakness occurs
    • -decrease in the force muscle can produce:
    • less myofibrils=decrease in size

    fewer muscle fibers are recruited

    sarcomeres are all in a shortened position

    sarcomeres are overlapped-less functional
  9. information gained by knowing ROM
    use goniometry to measure the specific point angles for both base line & reassessment

    clues about muscle strength and potential for increasing ROM by comparing AROM and PROM
  10. PROM
    performed entirely with an external force such as a therapist or caregiver moving a joint

    patient usually cannot perform PROM by themselves

    used to determine if additional ROM available past what the patient can do actively
  11. Indications for PROM
    if there's acute inflamed tissue in the region-2-6 days after injury

    if patient is not able or not supposed to actively move a joint

    • if patient is comostose or paralzed
    • following surgery and surgeon's protocol calls for "no active ROM" such as with a rotator cuff repair
  12. Primary goal for PROM=
    decrease complications that would occur with immobilization such as:
    cartilage degeneration

    adhesion within the joint capsule

    contracture formation-joint stuck in a particular position

    poor circulation
  13. Specific Goals for PROM(7)
    1.maintain joint and connective tissue mobility

    2.minimize the formation of contractures

    3.maintain the elasticity of muscles

    4.enhance joint lubrication via stimulating synovial fluid production and application for cartilage nutrition

    5.decrease or inhibit pain maintain the patient's awareness of movement

    7.assist in the healing process following injury or surgery
  14. AROM
    how far a patient can actively move their joint

    sometimes demonstrates the patient's willingness to move

    requires no assistance to complete the range of motion

    performed by active contraction of the muscles crossing that joint
  15. Indications for AROM
    patient is able to actively contract the muscle to move the body part through all or part of the expected ROM

    aerobic conditioning programs for cardiovascular health

    AROM activity used above & below an injured joint to prevent contracture in the available joints

    general assessment of total ROM
  16. A/AROM
    Active assisted range of motion
    assistance from an outside source to assist in holding the weight of the limb while the patient moves the joint through range of motion
  17. Indications for A/AROM
    when a patient has weak muscles, A/AROM can be used to provide the level of assist required to move through the full available range
  18. Goals for AROM/AAROM
    • if no inflammation or contraindications to AROM, goals are the same as PROM
    • maintain elasticity & contractility of muscles

    provide sensory feedback from the contracting muscles

    provides a stimulus for bone joint tissue integrity

    increase circulation & prevent/decrease thrombus formulation

    used in development of coordination & motor skills
  19. Hyper-mobility
    an increase in PROM that exceeds normal values for that joint

    • due to laxity in soft tissue structures that normally prevent excess joint motion
    • ex; gymnist
  20. Hypo-mobility
    • decrease in PROM that is substantially less than normal values for that joint
    • possible causes:
    • 1.inflammation of soft tissue structures

    • 2.abnormalities of joint surfaces
    • changes due to old injuries
  21. Other factors to consider
    • normal range of motion and functional ROM may be 2 different values
    • individuals can be functional even if they do not have "by the book" full ROM

    ex: can still raise arms high enough to do hair but still not FROM. This is functional
  22. Role of Hyper or Hypo
    Mobility in ROM
    need to know if the patient has a history of either hypo or hyper mobility

    if pt is usually hyper-mobile they may feel their joints are stiff even though when measured goniometrically they are within normal limits

    if a patient is typically hypo-mobile, you may not expect them to have full normal range
  23. Limitations of ROM Exercise
    • PROM will not:
    • 1.prevent muscle atrophy
    • 2.increase strength or endurance
    • 3.assist with circulation to the extent that AROM does

    • AROM will not:
    • 1.maintain or increase strength in already strong muscles

    only develops skill or coordination in the movement pattern it is used in
  24. Precautions & Contraindications
    to ROM exercise
    • if motion is distuptive to the healing process.
    • ex: after surgery

    • ROM should not be done when the patient response or the condition is life threatening
    • ex: after an accident, ICU
  25. How ROM activties are described
    • joint range
    • use terms like flexion, abduction, extension, etc
    • measured using goniometry and recorded in the number of degrees of the angle
    • Functional
    • Excursion-distance a muscle is capable of moving from it's most contracted to it's most stretched
  26. Assessment of ROM Beyond Goniometry
    other things to consider:
    • 1.the shape of the bones or joints. end feel comes into play
    • 2.what is the integrity of the joint at the end of the range
    • 3.what muscles may be holding the joint back
    • 4.stretch muscles opposite, prime movers
  27. Osteokinematics
    General joint movement

    Classic movements like:
  28. Arthrokinematics
    joint surface movement

    how one bone moves across or around another within a joint

    • the way adjoining joint surfaces move on each other
    • described as:
    • roll-hindge jt
    • glide-slide
    • spin-rotate
  29. Roll
    new points on each surface come in contact with each other throughout the movement

    • rolling of one joint surface on another
    • like a ball rolling on the ground
  30. Glide:
    one point on one joint surface comes in contact with new points on the other joint surface

    like an ice skater blade moving across the ice
  31. Spin:
    the same points on each bone surface in the joint remain in contact with each other throughout the movement

    ex: humerus spinning in the glenoid cavity during internal and external rotation

    similar to a top spinning on a table
  32. Arthrokinematics are dependent on the shapes of the joints
  33. Joint surface shape
    Convex-rounded outward

    concave-caved in

    most joints have one convex joint end and one concave joint end
  34. Joint surface shape
    ovoid-2 bones forming a convex-concave relationship

    • ex: glenohumeral joint, hip joint, PIP
    • this is the make-up of most synovial joints

    • stellar/saddle shaped
    • each joint surface is convex in one direction and concave in the other

    ex: the CMC(carpo meta) of the thumb
  35. Accessory Motions
    motions that accompany the classical movements

    essential to functional movement

    • essential full ROM
    • Ex:
    • anterior glide of tibia on the femur during knee extension

    upward rotation of the scapula with active shoulder flexion
  36. joint play
    a type of accessory motion

    occurs within the joint

    necessary to joint function

    • can be done passively by applying external force but not actively
    • used in a technique called joint mobilization
    • joint mobilization is used to decrease pain and increase ROM
  37. Accessory motion forces
    assist in that motion
    traction or distraction

    approximation or compression



  38. Traction
    • also called distraction
    • is the separation of the joint surfaces

    an external force acting on the joint

    pulls the joint surfaces apart
  39. approximation
    • also called compression
    • a decrease in the space between the bones in a joint

    • create approximation with:
    • weight bearing
    • muscle contraction

    • used to provide stability
    • ex: bear wt on joint the push joints together. build strength around joint by building muscles
  40. shear
    force that occurs parallel to the joint surfaces resulting in a gliding motion at the joint

    • joints that demonstrate glide
    • shearing forces cause bones to be more vulnerable and can produce fracture
  41. Bend
    conbination of compression on one side of the joint and distraction on the other

    • occurs when other than vertical forces are applied which result in compression on the concave side and distraction on the convex side
    • Ex:
  42. rotary forces
    twisting forces
  43. joint congruency
    how closely or loosely the joint surfaces are approximated (or the quality of how the bones of the joint come together)

    • 2 types of joint congruency:
    • closed packed position
    • open packed position
  44. closed packed position
    • joint surfaces have max contact with each other
    • tightly compressed and difficult to distract or pull apart
    • usually occurs at one extreme of ROM
    • also called congruent
  45. open packed position
    • also called incongruent
    • the point where the joint capsule and ligaments are lax and allow for roll, spin, and glide motions (accessory motions)

    the preferred position for joint mobilization techniques
  46. end feels
    a characteristic feel experienced by the examiner while performing PROM

    the feel is a barrier to further motion

    being able to differentiate between different types of end feels is important when assessing a joint to determine if dysfunction exists
  47. end feels
    it is important to know the structure and shape of the joints
    as you visualize them you can assume the type of end feel you should be getting

    by having an understanding of the joint structure, you have a better idea of what is going on inside
  48. End Feels
    some joints are designed so the capsule limits ROM in a particular direction

    some are structured so that the ligaments limit the end of a particular ROM

    end feels will be different among patients and descriptions may vary with the examiners

    it takes practice & experience to distinguish normal end feels!
  49. end feel terminology
    • boney-hard stop. elbows and knees
    • capsular-
    • empty-you think you can take it further, but the patient doesn't
    • springy block-feels like something isn't right, bounce
    • soft tissue approximation-body builder
    • soft, firm, hard
  50. Bony end feel
    hard abrupt limit to joint motion

    occurs when bone contacts bone at the end of ROM

    ex: end range of elbow extension
  51. capsular end feel
    a hard leather-like(littlegive)

    limitation of motion-has a slight give

    end range of full normal joint ROM of the shoulder

    if a capsular end feel occurs before full normal joint ROM is achieved as compared to the other side, this is abnormal
  52. empty feel
    no mechanical limitation to joint ROM

    motion is likely limited by pain

    could be a complete disruption of soft tissue constraints

    • acute joint inflammation:
    • bursitis
    • abscess
    • fracture
    • psychogenic disorder-all in head
  53. springy block feel
    rebound movement(bounce) found at the end of ROM

    • occurs with mechanical derangement
    • ex: torn cartilage-
  54. soft tissue approximation feel
    when soft tissue like skin and muscle prevent the joint from moving completely

    ex: limited elbow or knee flexion in some who is either obese or a body builder
  55. soft end feel
    • same as soft tissue approximation
    • firm
  56. firm end feel
    • muscular stretch
    • stretch'capsular stretch(extension of MCPs of digits 2-5)
    • ligaments stretch(forearm supination-palmar radioulnar ligament)
  57. Hard end feel
    • bone contacting bone
    • same as boney
  58. Capsular pattern end feel
    • a capsular pattern results from a pathological condition involving the entire joint capsule which causes a particular pattern of restriction involving all or most of the PROM of the joint.
    • Ex: Frozen shoulder. adhesives from surgery
  59. what is stretching
    a general term used to describe any therapeutic maneuver designed to increase mobiity of soft tissues and improve ROM by elongating (lengthening) structures that have adaptively shortened and have become hypo-mobile
  60. why do we stretch
    1.increase mobility (ROM) coordination by allowing for freer and easier movement

    3.prevent injuries due to strain

    4.develop body awareness

    5.reduce muscle tension and make the body feel more relaxed
  61. Mobility
    Functional ROM
    ability of structures or segments of the body to move or be moved to allow the presence of ROM for functional activites
  62. mobility
    functional mobility
    • ability of an individual to initiate, control or sustain active movements of the body to perform simple to complex motor skills
    • ADL's
  63. flexibility
    ability to move a single joint or series of joints smoothly and easily through an unrestricted, pain-free ROM

    • factors that determine flexibility:
    • 1.muscle length
    • 2.joint integrity
    • 3.extrensibility of the musculotendinous units that cross the joints

    ex: the muscle we are stretching is the muscle antagonist to the movement producing
  64. elasticity
    ability of soft tissue to return to its resting length after a passive stretch

    think of a rubber band.

    it is elastic and returns to it's normal shape once you release the stretch
  65. plasticity
    tendency of soft tissue to assume a new and greater length after the stretch force has been removed

    think of stretching a piece of silly putty or theraputty
  66. contracture
    the adaptive shortening of the muscle-tendon unit and other soft tissues that surround the joint

    • significantly restricts passive or active stretch and motion
    • ex: if there is a biceps contracture elbow extension will be limited. arm n cast
  67. contractile(muscle) vs non-contractile tissue
    • contractile-muscle
    • non-contractile-everything else
    • skin
    • fascia
    • ligaments
    • tendons
    • joint capsule
    • connective trissue within the muscle
  68. properties of soft tissue that affect their response to stretch
    • 1.mechanical properties of contractile tissue
    • 2.mechanical properties of non-contractile tissue
    • 3.neurophysiological properties of contractile tissue
  69. mechanical properties of
    contractile tissue
    • contractile tissue vs noncontractile tissue in muscle
    • noncontractile tissue =connective tissue
    • epimysium, perimysiun, endomysium
    • contractile elements of muscle
    • the sarcomere
    • the sliding of the myofilaments, actin and myosin, over one another
  70. the mechanical response of the contractile unit to stretch
    • response to stretch
    • myofilaments slide apart(WHEN STRETCHING)
  71. neurophysiological properties of contractile tissue
    the muscle spindle

    found in the muscle among muscle fibers

    stimulated by changes in the muscle length and speed of that change

    if movement is quick, the response is to reflexively cause the muscle to contract
  72. GTO
    Golgi tendon organ
    • found at the
    • musculo-tendinous junction

    • with slow gentle static stretching, reflexly allows muscle relaxation
    • with too much stretch, initiates muscle contraction to prevent over stretching
    • has the ability to override the muscle spindle
    • internal mechanism to prevent injury
  73. neurophysiologic response of
    muscle to stretch
    • stretching velocity
    • quick stretch
    • monosynaptic stretch reflex
    • a quick stretch to a muscle causes:
    • 1.the spinal cord sends info back to the muscle to contract
    • 2.muscle spindle fires
    • 3.slow stretch
    • 4.GTO fires
    • 5.slow stretch force,
    • 6.GTO fires and inhibits tension in muscle allowing the muscle to relax and lengthen

    do not bounce
  74. autogenic inhibition
    stimulation of a muscle that causes neurologic relaxation
    • ex:
    • put hamstring on stretch
    • ask the patient to provide max isometric contraction
    • GTO kicks in to protect hamstring. when isometric contraction relaxed, hamstring will more fully relax as well
  75. Reciprocal Inhibition
    neurologic mechansim

    the agonist contracts to move a joint

    the antagonist reflexively relaxes to allow the movement

    in other words: when the agonist/ on the antagonist/off
  76. Interventions to increase
    soft tissue mobility
    1.manual or mechanical,passive or assisted stretching-pully


    3.neuromuscular inhibition techniques-contacting opposite muscles

    4.joint mobilization/manipulation-

    • 5.soft tissue mobilization/manipulation-rubbing a muscle can relax it (massage)
    • 6.neural mobilization-
  77. Selective Stretching
    • the overall function of the patient may be improved by applying stretching techniques to some muscles and joints, but allowing other muscles and joints to remain tight
    • EX: tendonesis/spinal cord injured patient
    • needs trunk stability for independent sitting. tight muscle can substitute for support
    • EXAMPLE: with cervical and thorcic injuries the patient loses back extensors, therefore you need to improve and maintain hamstring flexibility and allow some hypo-mobility/tightness to develop in the back extensors for stability.
  78. Elements that determine the effectiveness
    of a stretching program
    • 1.the alignment and stabilization of the body during stretching
    • 2.the intensity, speed, duration, mode and frequency of stretch
    • 3.the integration of neuromuscular inhibition and functional activities into stretching procedures
  79. factors applied together to
    max stretching
    • 1. correct alignment-patient comfort, stability during stretching, actually stretching what you think you are stretching
    • 2. stabilization-fixing either the proximal or distal muscle attachment, use proximal stabilization, hold one end while muscle is being stretched
    • 3. Intensity-use low intensity gentle stretch, keeps patient comfortable, less likely to contract away in pain.
    • 4. Duration-choose safe, effective, and efficient stretch. lower intensity of stretch/longer duration, 30 second stretch to increase ROM
  80. Types of Duration
    • Long duration
    • static-
    • sustained
    • maintained
    • prolonged
    • Short duration
    • cyclic
    • intermitten
    • ballistic-bounce can tear muscle

    slow controlled stretch is 10-30 seconds
  81. Static stretch
    • most common
    • muscles are lengthened to the point of tissue resistance
    • held for 15-30 seconds or longer
  82. static progressive stretch
    • assume a stretching position similar to static
    • as the muscle lengthens, hold the new position until further relaxation is felt
  83. cyclic stretching
    • repeated short duration stretches
    • multiple repetitions, 5-10 second holds
  84. speed of stretch
    always slow to allow for good relaxation

    force used to stretch should be gradually applied and released

    slow stretches are easier to control for both the patient and therapist
  85. frequency of stretching
    • how may repetitions for each stretch and how many days/week or times/day
    • factors that determine frequency:
    • 1.underlying cause of immobility

    2.quality and level of tissue healing

    3.chronicity and severity or contracture

    4.use of corticosteroids(arthritis)

    5.previous response to stretching-they need to trust us
  86. mode of stretching
    manual (by therapist or caregiver)






    neuromuscluar inhibition
  87. manual stretching
    applied external force slightly beyond the point of tissue resistance and available ROM

    performed for the patient by the therapist or caregiver
  88. mechanical
    performed with the use of equipment

    could be as simple as a cuff weight providing traction or a sophisticated device

    • may be some sort of splint or brace
    • devices will come with a protocol for wear and fitted to each patient individually
  89. self stretch
    you stretch yourself

    patient independent in doing the stretch in good form

    know this before you send the patient out to do it on their own

    have them do ALL the repetitions, to be sure right
  90. passive, active, assisted
    • just like it sounds
    • passive is force being applied into the direction of the stretch from outside the muscle

    active is using active movement to produce a gentle stretch

    assisted is using equipment of some sort
  91. neuromuscular inhibition=
    autogenic inhibition
    takes advantage of the effect the nervous system has on muscle function to help relax a muscle prior to stretching

    • also known as Autogenic inhibition
    • 2 types/PNF(proprioceptive neuromuscular facilitation)
    • 1.hold-relax technique
    • 2.contract-relax technique
  92. autogenic inhibition
    • theory:
    • upon contraction of the muscle the GTO(Golgi Tendon Organ) causes a reflexive relaxation of the same muscle to allow for passive elongation
  93. PNF
    proprioceptive neuromuscular facilitation
    PNF-advanced form of stretching that relies on the relax reflex of the muscles

    uses autogenic mechanisms via GTO and Muscle spindle
  94. ****Contract-relax
    technique of inhibition
    1.therapist stretches the muscle to the end of the joint's natural range

    2.patient performs isometric contraction x10sec

    3.patient performs concentric contraction of the antagonist

    4.patient relaxes

    5.therapist once again stretches but this time further

    6.perform 3-5 reps before moving the limb to rest
  95. *****hold-relax
    • similar to contract-relax in that
    • 1.the patient also contracts the muscle being stretched
    • in "hold-relax" the muscle contraction is isometric
    • hold the isometric contraction for 10 seconds
    • may be repeated 3-5 times before moving into resting position
  96. final thoughts on stretching
    use stretching to develop increased ROM and flexibility

    never go for the burn

    always apply pressure slowly and gently

    hold a static stretch approx 15-30 sec

    NEVER do a ballistic stretch-bounce

    5-10 reps is plenty
  97. more thoughts on stretching
    if you use theraband to assist a stretching program...the only thing stretching is the theraband
  98. isometric contractions
    muscle contraction produces increased tension in the muscle but the length does not change

    muscle feels tight but the joint does not move
  99. advantages of isometrics
    good for early stages of strengthening

    can isolate a part of a range to address specific weakness

    called for in early post surgical protocals

    retards atrophy
  100. disadvantages of isometrics
    strengthens only in part of the range

    not good for overall strengthening
  101. isotonic contraction=joint motion
    when the muscle contracts, the muscle length shortens, thus the joint moves

    2 types of isotonic contractions: concentric/eccentric
  102. concentric contraction
    movement produced by the agonist(prime) of that movement

    shortening contraction

    muscle shortens when it contracts

    • insertion moves toward the origin
    • ex: picking up a weight, the biceps contract concentrically
  103. eccentric contraction
    action of the antagonist in any movement

    lengthening contraction

    • allows for slow controlled movements
    • ex: lowering a weight, the biceps contract eccentrically
    • eccentric can produce greater force than concentric
  104. types of isotonic exercise
    • resistive exercise-wt/theraband
    • progressive resistive exercise
    • kinetic chains:
    • open chain-distal moves
    • closed chain-distal fixed(closed)-
    • plyometrics-
  105. resistive exercise
    add resistance to work muscles more against gravity

    weight applied distal to the joint being exercised

    can apply the weight closer to the joint to decrease the moment arm and therefore increase efficiency
  106. progressive resistive exercise
    when patient accommodates to the starting weights, then it's time to increase the weight(resistance) in order to progress the patient to greater strength
  107. kinetic exercise
    describes how forces occur during human motion

    how segments of the body are linked together
  108. open chain exercise
    • distal segment is free to move
    • ex: elbow curl
  109. closed chain exercise
    • distal segment is fixed
    • ex: push-up
  110. plyometrics
    • build power
    • eccentric contractions immediately followed by explosive concentric contraction
    • ex:
    • catching/throwing weighted ball
    • dribbing ball
    • drop push-ups
    • vertical jumps/reaches
    • jumping over objects on the floor
    • hopping
  111. isokinetic contraction
    need special equipment-OT's not likely to use

    muscle move a joint at a constant speed all the way through its range against resistance

    control quality of the contraction by controlling the machine
  112. advantages to isokinetic exercise
    • more for sports medicine
    • control ROM
    • both directions of joint movement
    • isometricly,concentricly,eccentricly
    • feedback from computer
    • assess force output for a single point
  113. disadvantages/isokinetic
    • expensive equipment
    • training to use equipment
  114. endurance exercise
    cardiovacular strength

    allows one to participate in more activity

    5 minutes of sustained movement

    aerobic/increase oxygen
  115. aerobic vs anaerobic
    • aerobic
    • uses oxygen

    • exercise can be carried on for 5 minutes of longer
    • Anaerobic
    • w/o oxygen

    exhaustion ensues w/i 1-2 minutes

    O2 cannot meet muscle demand
  116. breathing exercises
    increases lung capacity

    breath duringmovement

    changes pressure in chest cavity/support lymphatic system produce relaxation,calm,anxiety