THERAPEUTIC EXERCISE

Presented by : Myra Leslie S. Viloria

SPT IV
Therapeutic Exercise
Enables the patient to :
Remediate or reduce impairements
Enhance function
Optimize overall function
Enhance fitness and well-being
Coordination of the muscular system.
For motion to take place the muscles producing movement must have
a sable base which to work. Muscles perform a variety of roles
depending o nthe required movement. These roles include :

Prime movers/agonist : muscles that are directly responsible for
producing movement

Synergist : muscles perform a cooperative function in relation nto the
agonist.
Stabilizers : muscles that contract statistically to steady or support
some part of the body against pull of the contracting muscles against
the pull of gravity

Neutralizers : muscles or muslces groups that act to preent an
undesired action of one of the movers .
Atagonist : muscles or muscle groups that have an effect opposite to
that of the agonist.
Types of muscles contraction
Contraction : used to describe the generation of tension within
muscle fibers conjures up an image of a shortening of a muscle fibers.

Isometric contraction : occurs when there is a tension produced in the
muscle without any appreciable change in muscle length or joint
movement


Concentric contraction : produces a shortening of the muscle.

Eccentric contraction : occurs when a muscle slowly lengthens as it
gives it to an external force that is greater than the contractile force it
is exerting.

Isotonic contraction : contraction in which the tension within the
muscle remains constant as the muscle shortens or lengthens.
Isokenitic contraction : occurs when a muscle is maximally contracting
at the same speed throught the whole range of its related lever.

According to Cyriax, pain with contraction generally indicated an
injury to them uscle or capsular structure.
Factors affecting muscle performance
Extensibility : the ability to be stretched or to increase in length

Elasticity : the ability to return to nornmal restign length following a
strectch.

Irritability : ability to respond to a stimulus. With reference to skeletal
muscle., this stimulus is provided electrochemically


Factors affecting muscle performance
Muscle Fiber type

Muscle fiber size

Force-length relationships
Fatigue

Age

Level of cognition
Force-Length Relationship
If the muscle is in a shortened position, the overlap of actin and
myosin reduces the number of sites available for cross-bridge
formation

Active insfuffiency : occurs when the muscle is incapable of
shortening to the extent required to produced full range of motions
at all joints crossed simultaneously.
For ex: the finger flexor cannot produced a tight fist when the wrist is
fully flexed as when it is in neutral


If the muscle is in a lengthened position compared to the resting
length, the actin filaments are pulled away from the myosin heads
such that they cannot create cross-bridges.

Passive insufficiency : occurs when 2 joint muscle cannot stretch to
the extent required for full range of motion in the opposite direction
at all joints crossed.

For ex : a larger range of hyperextension is possible at the wrist when
the fingers are not fully extended.
skeletal muscle blood flow increases 20-fold during muscle
contraction. The muscle blood flow generaly increases in proportion
to the mebaolic demands of the tissue , a relationship reflected by
positive correlations bet. Muscle blood flow and exercise.


Fatigue :

Can compromise exercise tolerance and work productivity while
retarding rehabilitationof diseased or damaged muscle. The
development of fatigue probably involves several factors that
influence force production in a manner dependent on muscle fiber
type and activation pattern.
Characteristic of muscle fatigue :
reduction in muscle force production capability and shortening
velocity,
a reduction in the release and uptake of intracellular calcium by the
sarcoplasmic reticulum
Prolonged relaxation of motor units between recruitment.
Muscle Performance
Strength : the maximum force that a muscle can develop during a
single contraction. Muscular strength is derived both from the
amount of tension a muscle can generate and from the moment arms
of contributing muscles with respect to the joint center.

Muscle strength can be measured using a number of methods :
MMT
Using a dynamometer
Isokinetic machine
Endurance : the ability of a muscle to sustain or perform repetitive
muscular contractions for an extended period. The ability to perform
endurance activities is based on the patients aerobic capacity

Power : the rate of performing work . Work is the magnitude of force
acting on an object multiplied by the distance through wich the force
acts .
Improving muscle performance
The promotion nad progresson of tissue-repair while exercising
involves a delicate balance bet. Protection and the application of
controlled functional stresses to the damaged structure.
The goal of the functional exercise: is to identify the motion or
motions that the patient is able to exercise into without eliciting
symptoms other than post op exercise soreness.


A number of principles can be used to guide the clinician in the
progression of therapeutic exercise:

Exercise prescription will vary according to the stage of healing and
degree of irritability .Degree of irritability of each condition can often
indicate the stage of healing to the clinician
The patient is typically taught to exercise in cardinal planes before
progressing as quickly as allowed to exercising in the functional
planes.

The exercise protocol should intiate wih exercises that utilize a short
lever arm. These exercises serve to decrease the amount of torque at
the joint. Extremity exercises can be adapted to include short levers
by flexing the extremity or by exercising with the extremity closer to
the body.
The goals should be to achieve the closed-pack position at the earliest
opportunity. The closed pack position of a joint is this position of
maximum stability

The prescribed exercises should repdocued the forces and laodign
rates will approach the patient;s functional demands as rehabilitation
progress.
Variation. Variation to the exercises van be provided by altering
a. the plane of motion
B. ROM
Body position
Exercise duration
Exercise frequency
A safe progression. A safe progression is ensured if the exercises are
progressed from :
Slow to fast
Simple to complex
Stable to unstable
Low force to high force
Improving strength
To increase strength, the load or resistance must be gradually
increased during the muscle contraction . Strengthening of a muscle
occurs when the muscle is forced to work at a higher level than to
which it is accustomed.

To most effectively increase muscle strength a muscle must work with
increasing effort against progressively increasing resistance.
Adapative changes in improving strength :

Hypertrophy
Increase in the efficiency of the neuromuscular system . This
increased efficiency results in :
a. Icnrease in the number of motor units recruited
b. Increased in the firing rate of each motor unit
c. Increase in the synchronization of motor unit firing.
Improved endurance
Stimulation of slow-twitch ( type I ) fibers ( when performing
workloads of low intensity ) and stimulation of fast-twitch ( type II)
fibers ( when performing workloads of high intensity and short
duration )

Rhythmic activities increase blood flow to exercising muscles via
contraction and relaxation
Muscle power improves
Improve bone mass ( Wolfes law)
Increased in metabolism /calorie burning/ weight control /
Cardoivascular benefits when using large muscle groups.
Muscle can beomce weak or atrophied through :
Disease
Neurologic compromise
Immobilization
Disuse
Types of Exercise
Isometric exercise :
Provides a static contraction with a variable and accommodating
without producing a change in muscle length.
It has an obious role where joint movement is restricted either by
pain or by bracing
Primary role : to prevent atrophy and prevent decrease of ligament,
bone and muscle strength.
Disadvatages of isomettic exercises :
Strength gains are developed at a specific point in the ROM and not
throughout the range
Not all of a muscles fibers are activated there is predominantly an
activation of slow-twitch
There are no flexibility or cardiovascular fitness benefits
Peak effort can be injurious to the tissues due to vasoconstriction and
joint compression forces

There is limited functional carryover
Considerable internal pressure can be generated esp. if the breath is
held during contraction which can result in :
Further injury to patients w/ a weakness in the abdominal wall
Cardiovascular impairement ( increased bp through the valsavla
maneuver even if the exercise is correctly performed )
Concentric/Isotonic Exercise :

Are commonly used in the rehabilitation process and occur frequently
in acitivties of daily living the biceps curl and lifting of a cup to the
mouth are examples.




Eccentric Exercises

Is important functional activities and can provide a source of shock
absorption during closed-chain functional acitvities.

Functional Execises :

Functional strength is the ability of the neuromuscular system to
perform the various types of contraction involved with mutijoint
functional activities in an efficient manner and in a multiplanar
environment.
Uses combinations of concentric and eccentric contraction in the
performance of activities that relate to a patients needs and
requirements.
Isokinetic Exercise :
Requires the use of special equipment that produces an
accommodating and variable resistance. The main pricinple behind
isokinetic exercise is that peak torque ( the maximum force
generated through the ROM ) is inversely r/t to angular velocity ( the
speed that a body segment moves through its ROM )
Types of Resistance
Resistance can be applied to a muscle by any external force or mass

Gravity :
Can supply sufficient resistnace w/ weakned muscle. W/ respect to
gravity , muscle actions may occur in :
The same direction of gravity ( downward )
In the opposite direction to gravity ( upward )
In a direction perpendicular to gravity ( horizontal )
In the same or opposite direction to gravity, but at an angel
Body weight :
No equipment
Relying on the patients body weight

Small weight :
Cuff weights and dumbbells are economical ways of applying
resistance.
Small weights are typically used to strengthen the smaller muscles or
to increase the endurance of larger muscles by increasing the number
of reps.
Surgical Tubing/Theraband :
The amount of variable resistnace offered by elastic bands or tubing is
a factor of the internal tension producedby the material

Exercise Machines :
This can be used when larger muscle groups require strengthening a
multitude of specific indoor exercise machines can be used.
Manual Resistance :
Type of active exercise in which another person provides resistance
manually.

Advantages :
Re-education of the muscle or extremity
Critical sensory input to the patient through tactile stimulation and
appropriate facilitation techniques
Ability to limit the range
Disadvantages :
Amount of resistance applied cannot be measured quantitatively
Amount of resistance is limited by the strength of the clinician /family
member
Difficulty with consistency of the applied forced throguhtou the
range and with each repitition
Type of Exercise:

Intensity : how much the effort is required to perfrom the exercise
It isn ow recognized that an individual perception of effort ( relative
perceivd exertion or RPE ) is closely r/t to the level of physiologic
patients response to exercise
Duration :
Refers to the length of the exercise session. In most functional
exerxcise, fatigue must be considered when doing exercises so that
the patients tolerance is not exceeded.

Frequency :
How often is the exercise is performed
DOMS :
is a type of soreness that is r/t to eccentric exercise
Occurs bet. 48-72 hours.
Intervention :


Conditioning, Total Body
Endurance Exercises, or
Cardiopulmonary Endurance
Exercises

These exercises use large muscle groups, and are continuous and
rhythmic, providing low intensityand high repetition, to improve
overall cardiopulmonary fitness.
They can be divided into aerobic and anaerobic endurance exercises.
Cardiovascular effects of
conditioning exercises


Decreased resting heart rate and submaximal effort
Increased peak BP during maximal exercise, decreased BP at rest and
submaximal effort.
Muscle shortening. Tension develops to overcome resistance.
Increase in stroke volume during maximal exercise
Reduced myocardial oxygen consumption at rest and submaximal
activities
Thick and thin filaments are linked to one another via cross bridges
that arise from the myosin molecule. During muscle contraction,
increasing amount of myosin overlap is observed, and muscle
shortening occurs. Contraction results in the Z lines approaching
each other, shrinking of the H zone and I band.
Aerobic endurance exercises
Combination of cardiopulmonary endurance exercise with strengthening
Should consist of a warm-up period, a training period and a cool-down
period:
Warm-up 5 to 10 minutes
Training period20 to 30 minutes at 40%60% (low intensity), 60%70%
(moderate intensity),
or 70%85% (heavy intensity) of their VO
max
Cool-down period 5 to 10 minutes
2
Guidelines for the quantity and quality of aerobic exercise programs for
healthy adults as proposed by
the American College of Sports Medicine
Modeany exercise that uses large muscle groups, continuous and
rhythmic in natur
Examples: running, swimming, walking, stair climbing.
Frequency35 days/week
Duration2060 minutes
Intensity60%90% HR max
50%85% of VO
max or 50%85% of HR reserve max



Anaerobic exercises

High-resistance, short-duration exercises at 80% of maximum exertion
capacity.
Deplete the glycolytic system, which functions during the first two
minutes of exercise.
Mobility exercises: exercises to improve flexibility
Flexibility is defined as the ability to move body joints through their
entire range of motion
(ROM)
Each joint of the body has a specific ROM
Flexibility exercises maintain mobility within the available ROM
Flexibility exercises should be done at least three times a week,
should consist of three to
five repetitions once or twice a day
TECHNIQUES TO IMPROVE FLEXIBILITY
Can be done through anatomic planes of motion, combined planes
of motion (similar to
peripheral neuro-facilitation patterns), or through functional teaching
activities
Stretching Exercises

Increase ROM by lengthening tendon and muscle beyond the
available range
Include static stretching, static stretching with contraction of the
antagonist muscle (reciprocal inhibition), static stretching with
contraction of the agonist muscle, and ballistic stretching
Ballistic stretchingutilizes repetitive bouncing movements with a
rapid stretch. More
tension is developed, and more energy is absorbed into the muscle
and tendon, which can
lead to bone avulsion or muscletendon tears. High risk of injury
Static stretchThe joint is moved to the end of the ROM where the
position is slowly held
for 5 to 60 seconds. Can be done actively or passively. Safe technique
Reciprocal inhibitionThe joint is also moved to the end of ROM, and
this is followed by
a symmetric contraction of the antagonist muscle group for 5 to 30 seconds
Static stretching with contraction of the agonistThe joint is moved to
the end of ROM
and followed by an isometric contraction of the agonist muscle for 5 to 30
seconds
EFFECTS OF EXTENDED
BEDRESTIMMOBILIZATION
AND INACTIVITY
MUSCLE
Strengthimmobilization decreases strength by 1.0%1.5% per day.
Strength can decrease as much as 20%30 % during only a week to
nine days of bedrest.
Five weeks of total inactivity costs 50% of the previous muscle
strength.
A plateau is reached
25%40% of original strength. One contraction a day at 50% of
maximal strength is
enough to prevent this decreas
Strength is lost especially in the quadriceps and extensors
A decrease in fiber diameter is found affecting type I fibers (slow
twitch) during early
immobilization. A decrease of percentage of type I fibers is noted. A
decrease in oxidative
enzymes is also noted
Restricted activities affect muscle strength and recruitment patterns
of muscles distant
from specific sites of injury.
BONE AND JOINTS

Lack of gravitational force and muscle pull on bone cause osteopenia.
As a result of
osteopenia, hypercalcemia develops. Calcium is excreted in the urine
and feces
starting at 23 days after immobilization, and peaking at 37 weeks.
After activity is
resumed, calcium levels remain high for 3 weeks, reaching normal
values at 56 weeks
When comparing calcium to nitrogen and protein changes in the
urine, it is noted
that calcium improves last. Nitrogen loss is 2g N/day. Loss begins at
56 days after
immobilization, peaks in the second week. After activity is resumed,
loss continues for
1 week, normalizes during the second week, below normal values are
obtained at 4
weeks, and returns to normal values in 6 weeks
Calcium excretion in addition to phosphorus loss causes atrophy and
a reduction in
fracture threshold of bone
Joints show a decrease in periarticular connective tissue extensibility
after inactivity.
Articular cartilage begins to deteriorate due to lack of nutritional
support. The hyaline
cartilage in synovial joints is not supplied by vascular blood flow. It
depends on nutrition
from
the synovial fluid through
loading and unloading of pressure
Ligaments undergo biochemical changes noted as early as two weeks
after immobilization.
In the case of surgically repaired ligaments, improvement in strength
is affected by
immobilization.
Immobilization causes ligament strength
to decrease, compliance to increase, and collagen degradation to
increase.
GASTROINTESTINAL (GI)Decreased GI motility leads to constipation
and loss of appetite.
GENITOURINARYUrinary stasis, leading to an increased risk of
urolithiasis and urinary
tract infections.
PULMONARYDiminished diaphragmatic movement and chest
expansion, due to loss of
strength of diaphragm and intercostal muscles, leading to impaired
secretion clearance.
Reduced cough and bronchial ciliary activity. Patients can develop
hypostatic pneumonia.
Reduction in pulmonary function with decreased tidal and minute
volumes, decreased
vital capacity.
A-V shunting and regional changes in ventilation-perfusion occur.
CARDIAC
Reduction in blood and plasma volumes.
Redistribution of body fluids leads to postural hypotension. Venous blood
pooling
occurs in the legs. In addition, -adrenergic sympathetic activity is increased.
Cardiovascular efficiency is decreased, increased HR, decreased stroke
volume.
Heart rate increases approximately 0.5 beats/minutes/day, leading to
immobilization
tachycardia and abnormal HR with minimal or submaximal workloads.
Thromboembolism secondary to a decrease in blood volume and
increased coagulability.

TEGUMENTARYskin atrophy and pressure sores develop.
EVALUATION OF FUNCTIONAL
INDEPENDENCE
Difference between impairment, disability, and handicap:
Impairmentphysical or psychological abnormality, usually the
manifestation of a
disease or injury. Example Cerebral Vascular Accident (CVA)
Disabilityloss of ability to perform a particular activity or function,
such as walking
Handicapinability to fulfill a usual role or life activity as a result of
the impairment
and disability. Example: inability to perform a certain job due to
inability to ambulate

The evaluation of functional independence is important in the
process of assessing a safe
return home after a patient has been hospitalized
One of the measurement scales used for this assessment is the FIM
score (Functional
Independence Measure) (Figure 8-4). It documents the severity of
disability as well as the
outcomes of rehabilitation treatment as part of a uniform data
system.

Consists of 18 items organized under 6 categories:
Self care (eating, grooming, bathing, upper body dressing, lower
body dressing, and
toileting)
Sphincter control(bowel and bladder function)
Mobility (bed, chair, wheelchair, tub or shower, and toilet transfers)
Locomotion (ambulation, wheelchair mobility, and stair
management)
Communication (comprehension and expression)
Social cognition (interaction, problem solving, memory)
Patients obtain points on each category on a scale of 1 (total
assistance required) to 7
(complete independence)

PHYSIOLOGIC EFFECTS OF AGING

CARDIAC
Progressive decline in maximal heart rate, possibly related to
decreased chronotropic
response to adrenergic stimuli. Max HR = 220 age
ncreased left ventricle end systolic volume and decreased ejection
fraction with exer-
cise. When this is added to a decreased HR response, cardiac output
during exercise is
more dependent on an increased stroke volume
rate of diastolic early filling is decreased;

Maximal oxygen consumption (VO max) decreases regardless of the
level of activitybut more physically active patients have smaller
decreases compared to sedentary
patients

PULMONARY

Decreased vital capacity
Decreased PO

No change in total lung capacity
High incidence of pneumon
INTEGUMENTARYDecreased elasticity of connective tissue leads to
increased risk for
pressure ulcers and skin breakdown. Decreased moisture, decreased
skin sensation
MUSCULOSKELETALOverall muscle mass decreases, including number of
myofibrils,
and concentration of mitochondrial enzymes
Decreased number of motor units
Increased fat15% increase at age 30, 30% increase at age 80. Patients
retain more fat-
soluble medications and have increased side effects
Muscle endurance increases or remains stable due to muscle fiber type
regrouping,
increasing type II fibers with age

THERMOREGULATORY
Impaired temperature regulation with decreased autonomic vasomotor
control and
impaired sensitivity to changes in temperature
Patients are vulnerable to hypothermia and hyperthermia. Hypothermia
is affected by
impaired sweating and aggravated by medical conditions, such as
malnutrition, hypoglycemia,
and hypothyroidism;
or medications such as narcotics,
ethanol, and benzodiazepines
NEUROLOGIC

Decreased short-term memory and incidental learning
Slowing in the rate of central information processing tasks requiring new
information
processing tend to decline progressively after 20 years of age
Increase in choice reaction time is noted. The more complex the task, the
greater the age
effect
Older adults are capable of learning but at a slower rate
Decrease in proprioception and gait, leading to problems with coordination and
balance. There is associated decrease in nigrostriatal neurons with age
Loss of speed of motor activities
GENITOURINARY
Reduction in bladder capacity
Decreased urethral and bladder compliance
Reduced urinary flow rate

RENAL
Atrophy of the glomeruli and decrease in renal tubular cell mass,
leading to decreased
glomerular filtration rate and decreased tubular function

GASTROINTESTINAL
Impaired esophageal functiondecreased amplitude of peristaltic
contractions
Delayed esophageal emptying, and incomplete sphincter relaxation
are associated with
disease
Colondecreased force of muscle contraction with impaired rectal
perception of feces.
It is important to explore contributing factors for development of
constipation:

GASTROINTESTINAL
Impaired esophageal functiondecreased amplitude of peristaltic
contractions
Delayed esophageal emptying, and incomplete sphincter relaxation
are associated with
disease
Colondecreased force of muscle contraction with impaired rectal
perception of feces.
It is important to explore contributing factors for development of
constipation:

EFFECTS OF ACUTE
HOSPITALIZATION AND
DECONDITIONING IN THE ELDERL
Disorientation
Insomnia
Emotional sequelaeAnxiety and confusion are common in relation
to illness, prognosis, and hospitalization. Patients tend to develop
depression.
Many times patients are dependent
for functional activities
Deconditioning effects include:
Decreased VO
max
Shortened time to fatigue during submaximal work
Decreased muscle strength
Decreased reaction time/balance/flexibility
2
Joint Mobilization
\ 86
Outlines
What is Joint Mobilization?
Terminology
Relationship Between Physiological & Accessory
Motion
Basic concepts of joint motion : Arthrokinematics
Effects of Joint Mobilization
Contraindications for Mobilization
Precautions
Techniques of joint mobilization
14/10/1435 RHS 322 87
What is Joint Mobilization?
Joint Mobs

Manual therapy technique
Used to modulate pain
Used to increase ROM
Used to treat joint dysfunctions that limit ROM by
specifically addressing altered joint mechanics

Factors that may alter joint mechanics:
Pain & Muscle guarding
Joint hypomobility
Joint effusion
Contractures or adhesions in the joint capsules or
supporting ligaments
Malalignment or subluxation of bony surfaces
Pondering Thoughts
Would you perform joint mobilizations on someone who has a
hypermobile joint?
14/10/1435 89 RHS 322
Terminology
Mobilization passive joint movement for increasing
ROM or decreasing pain
Applied to joints & related soft tissues at varying speeds &
amplitudes using physiologic or accessory motions
Force is light enough that patients can stop the movement

Manipulation passive joint movement for increasing
joint mobility
Incorporates a sudden, forceful thrust that is beyond the
patients control
Terminology
Self-Mobilization (Auto-mobilization) self-
stretching techniques that specifically use joint
traction or glides that direct the stretch force to
the joint capsule

Mobilization with Movement (MWM) concurrent
application of a sustained accessory mobilization
applied by a therapist & an active physiologic
movement to end range applied by the patient
Applied in a pain-free direction
Terminology
Physiologic Movements
Osteokinematics motions of the bones
movements done voluntarily
traditional movements such as flexion, extension, abduction,
rotation
Accessory Movements movements within the joint & surrounding
tissues that are necessary for normal ROM, but can not be actively
performed by the patient
Component motions motions that accompany active motion,
but are not under voluntary control
Ex: Upward rotation of scapula & rotation of clavicle that occur with
shoulder flexion
Joint play motions that occur within the joint
Determined by joint capsules laxity
Can be demonstrated passively, but not performed actively
92
Terminology
Arthrokinematics motions of bone surfaces within the joint
5 motions - Roll, Slide, Spin, Compression, Distraction

Muscle energy use an active contraction of deep muscles
that attach near the joint & whose line of pull can cause the
desired accessory motion
Therapist stabilizes segment on which the distal aspect of the muscle
attaches; command for an isometric contraction of the muscle is given,
which causes the accessory movement of the joint

Thrust high-velocity, short-amplitude motion that the patient
can not prevent
Performed at end of pathologic limit of the joint (snap adhesions,
stimulate joint receptors)
93
Terminology
Concave hollowed or rounded inward

Convex curved or rounded outward
94
Relationship Between Physiological &
Accessory Motion
Biomechanics of joint motion
Physiological motion
Result of concentric or eccentric active muscle contractions
Bones moving about an axis or through flexion, extension, abduction,
adduction or rotation

Accessory Motion
Motion of articular surfaces relative to one another
Generally associated with physiological movement
Necessary for full range of physiological motion to occur
Ligament & joint capsule involvement in motion
95
Basic concepts of joint motion :
Arthrokinematics
1. Joint Shapes
Type of motion is influenced by the
shapes of the joint surfaces
Ovoid one surface is convex,
other surface is concave

Sellar (saddle) one surface is
concave in one direction & convex
in the other, with the opposing
surface convex & concave
96
Basic concepts of joint motion :
Arthrokinematics
2. Types of joint motion
5 types of joint arthrokinematics
Roll
Slide
Spin
Compression
Distraction

3 components of joint mobilization
Roll, Spin, Slide
Joint motion usually often involves a combination of rolling, sliding
& spinning

97
Roll
A series of points on one articulating surface
come into contact with a series of points on
another surface
Ball rolling on ground
Example: Femoral condyles rolling on tibial plateau
Roll occurs in direction of movement
Occurs on incongruent (unequal) surfaces
Usually occurs in combination with sliding or
spinning

98
Spin
Occurs when one bone rotates around a
stationary longitudinal mechanical axis
Same point on the moving surface creates
an arc of a circle as the bone spins
Example: Radial head at the humeroradial
joint during pronation/supination;
shoulder flexion/extension; hip
flexion/extension
Spin does not occur by itself during normal joint
motion

14/10/1435 99 RHS 322
Slide
Specific point on one surface comes
into contact with a series of points on
another surface

Surfaces are congruent
When a passive mobilization technique
is applied to produce a slide in the joint
referred to as a GLIDE.
Combined rolling-sliding in a joint
The more congruent the surfaces are, the
more sliding there is
The more incongruent the joint surfaces
are, the more rolling there is
100
Compression
Decrease in space between two joint surfaces
Adds stability to a joint
Normal reaction of a joint to muscle contraction

Distraction -
Two surfaces are pulled apart
Often used in combination with joint mobilizations to
increase stretch of capsule.
101
Convex-Concave & Concave-Convex Rule
Basic application of correct mobilization
techniques - **need to understand this!
Relationship of articulating surfaces associated with
sliding/gliding

One joint surface is MOBILE & one is STABLE

Concave-convex rule: concave joint surfaces slide
in the SAME direction as the bone movement
(convex is STABLE)
If concave joint is moving on stationary convex surface
glide occurs in same direction as roll
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Convex-concave rule: convex joint
surfaces slide in the OPPOSITE
direction of the bone movement
(concave is STABLE)
If convex surface in moving on
stationary concave surface
gliding occurs in opposite
direction to roll
103
RULE OF CONCAVE-
CONVEX

104 RHS 322
Effects of Joint Mobilization
Neurophysiological effects
Stimulates mechanoreceptors to pain
Affect muscle spasm & muscle guarding nociceptive stimulation
Increase in awareness of position & motion because of afferent nerve
impulses

Nutritional effects
Distraction or small gliding movements cause synovial fluid movement
Movement can improve nutrient exchange due to joint swelling &
immobilization

Mechanical effects
Improve mobility of hypomobile joints (adhesions & thickened CT from
immobilization loosens)
Maintains extensibility & tensile strength of articular tissues

Cracking noise may sometimes occur
105
Contraindications for Mobilization
Should not be used haphazardly

Avoid the following:
Inflammatory arthritis
Malignancy
Tuberculosis
Osteoporosis
Ligamentous rupture
Herniated disks with nerve
compression
Bone disease
Neurological involvement
Bone fracture
Congenital bone deformities
Vascular disorders
Joint effusion
May use I & II
mobilizations to relieve
pain

106
Precautions
Osteoarthritis
Pregnancy
Flu
Total joint replacement
Severe scoliosis
Poor general health
Patients inability to relax
107
108
14/10/1435 109 RHS 322
Maitland Joint Mobilization Grading
Scale
Grading based on amplitude of movement & where
within available ROM the force is applied.

Grade I
Small amplitude rhythmic oscillating movement at the
beginning of range of movement
Manage pain and spasm
Grade II
Large amplitude rhythmic oscillating movement within
midrange of movement
Manage pain and spasm

Grades I & II often used before & after treatment with
grades III & IV
110
Grade III
Large amplitude rhythmic oscillating movement up to point
of limitation (PL) in range of movement
Used to gain motion within the joint
Stretches capsule & CT structures
Grade IV
Small amplitude rhythmic oscillating movement at very end
range of movement
Used to gain motion within the joint
Used when resistance limits movement in absence of pain

Grade V (thrust technique) - Manipulation
Small amplitude, quick thrust at end of range
Accompanied by popping sound (manipulation)
Velocity vs. force
Requires training
111
Indications for Mobilization
Grades I and II - primarily used for pain
Pain must be treated prior to stiffness
Painful conditions can be treated daily
Small amplitude oscillations stimulate mechanoreceptors -
limit pain perception
Grades III and IV - primarily used to increase motion
Stiff or hypomobile joints should be treated 3-4 times per
week alternate with active motion exercises
112
ALWAYS Examine PRIOR
to Treatment
If limited or painful ROM,
examine & decide which
tissues are limiting
function

Determine whether
treatment will be directed
primarily toward relieving
pain or stretching a joint
or soft tissue limitation
Quality of pain when
testing ROM helps
determine stage of
recovery & dosage of
techniques
1) If pain is experienced BEFORE tissue
limitation, gentle pain-inhibiting joint
techniques may be used
Stretching under these circumstances
is contraindicated

2) If pain is experienced CONCURRENTLY
with tissue limitation (e.g. pain &
limitation that occur when damaged
tissue begins to heal) the limitation is
treated cautiously gentle stretching
techniques used

3) If pain is experienced AFTER tissue
limitation is met because of stretching
of tight capsular tissue, the joint can
be stretched aggressively

14/10/1435 113 RHS 322
Joint Positions
Resting position
Maximum joint play - position in which joint capsule and ligaments are
most relaxed
Evaluation and treatment position utilized with hypomobile joints

Loose-packed position
Articulating surfaces are maximally separated
Joint will exhibit greatest amount of joint play
Position used for both traction and joint mobilization

Close-packed position
Joint surfaces are in maximal contact to each other

General rule: Extremes of joint motion are close-packed, &
midrange positions are loose-packed.
114
Joint Mobilization Application
All joint mobilizations follow the convex-concave rule
Patient should be relaxed
Explain purpose of treatment & sensations to expect to
patient
Evaluate BEFORE & AFTER treatment
Stop the treatment if it is too painful for the patient
Use proper body mechanics
Use gravity to assist the mobilization technique if
possible
Begin & end treatments with Grade I or II oscillations
115
Positioning & Stabilization
Patient & extremity should be positioned so that the
patient can RELAX

Initial mobilization is performed in a loose-packed
position
In some cases, the position to use is the one in which the
joint is least painful

Firmly & comfortably stabilize one joint segment,
usually the proximal bone
Hand, belt, assistant
Prevents unwanted stress & makes the stretch force more
specific & effective
116
Treatment Force & Direction of
Movement
Treatment force is applied as close to the opposing
joint surface as possible
The larger the contact surface is, the more comfortable the
procedure will be (use flat surface of hand vs. thumb)

Direction of movement during treatment is either
PARALLEL or PERENDICULAR to the treatment plane
117

Treatment plane lies on the
concave articulating surface,
perpendicular to a line from the
center of the convex articulating
surface (Kisner & Colby, p. 226 Fig. 6-11)

Joint traction techniques are
applied perpendicular to the
treatment plane
Entire bone is moved so that the
joint surfaces are separated
Treatment Direction
14/10/1435 118 RHS 322
Gliding techniques are applied parallel to the treatment
plane
Glide in the direction in which the slide would normally occur for the
desired motion
Direction of sliding is easily determined by using the convex-concave
rule
The entire bone is moved so that there is gliding of one joint surface
on the other
When using grade III gliding techniques, a grade I distraction should be
used
If gliding in the restricted direction is too painful, begin gliding
mobilizations in the painless direction then progress to gliding in
restricted direction when not as painful

Reevaluate the joint response the next day or have the
patient report at the next visit
If increased pain, reduce amplitude of oscillations
If joint is the same or better, perform either of the following:
Repeat the same maneuver if goal is to maintain joint play
Progress to sustained grade III traction or glides if the goal is to increase joint
play
119
Speed, Rhythm, & Duration of
Movements
Joint mobilization sessions
usually involve:
3-6 sets of oscillations
Perform 2-3 oscillations per
second
Lasting 20-60 seconds for
tightness
Lasting 1-2 minutes for pain
2-3 oscillations per second
Apply smooth, regular
oscillations
Vary speed of oscillations for
different effects
For painful joints, apply
intermittent distraction for 7-
10 seconds with a few
seconds of rest in between
for several cycles
For restricted joints, apply a
minimum of a 6-second
stretch force, followed by
partial release then repeat
with slow, intermittent
stretches at 3-4 second
intervals
120
Patient Response
May cause soreness
Perform joint mobilizations on alternate days to allow soreness to
decrease & tissue healing to occur
Patient should perform ROM techniques
Patients joint & ROM should be reassessed after treatment, & again
before the next treatment
Pain is always the guide
121
Joint Traction Techniques
Technique involving pulling one articulating surface
away from another creating separation
Performed perpendicular to treatment plane
Used to decrease pain or reduce joint hypomobility
Kaltenborn classification system
Combines traction and mobilization
Joint looseness = slack

122
AQUATIC THERAPY


Intro to Aquatic Therapy
Aquatic therapy
is a therapeutic modality that involves the patient to do an exercise
program in water
Aquatic therapy uses the physical properties of water to assist in patient
healing and exercise performance.
Buoyancy (up to 90% of our body weight is removed)

Who Benefits from Aquatic therapy
Patients with:
Arthritis
Healing fractured bones
Stress fractures
Who have pain only in WB activities
who are overweight
Post surgery
The Benefits of Aqua Therapy
Pain Control
Water against the skin causes a sensory response which blocks pain receptors and therefore
inhibits the sensation of pain from getting to the brain.
Increase in Self-Esteem
People who have suffered a devastating injury and need to slowly regain the movements of
daily living. Once they have achieved this goal, and are not so dependent on others, they
may get a psychosocial boost.
Decrease Impact
Exercises in the water decreases the impact created within the joints as compared to
completing exercises on land

Other Benefits
Great for patients with:
Swelling
Decreased ROM
Decreased strength
Decreased balance, coordination,
proprio
Weight bearing restrictions
Cardio deconditioning
Gait deviations


Difficulty with land intervention
Arthritis
Healing fractured bones
Stress fractures
Who have pain only in WB
activities
who are overweight
Post surgery

Disadvantages
Access to a pool
Not every clinic will be near or have a pool suitable for aquatic therapy
Qualified pool attendants
Qualified ATs
Precautions and contraindications
Open wounds
Respiratory dysfunction
Seizure disorders, controlled by meds
Fear of water
chlorine allergy
altered peripheral sensation
untreated infectious disease
serious cardiac conditions
Upper limb
Can be used for treatment of
The shoulder complex
Elbow
Wrist
Hand


Exercises for
Shoulder Complex Injuries
Initial Level
Start with patient in shoulder deep water
walking forwards and backwards trying to keep a normal arm swing
GH movements can be done with patient back against the wall to stabilize the
scapula
The movements can be done supine or prone depending on the patients level
of comfort in the water




Exercises for
Shoulder Complex Injuries
Intermediate Level
At this stage you can use equipment to increase the resistance to build on
strength
Keeping with in a pain free zone
Scapular stabilization can be progressed from the standing position to a
supine position
Over head movements can be incorporated in the program by positioning the
patient in a supine or prone position
(
Exercises for
Shoulder Complex Injuries
Final Level
The goal for this level is to incorporate sport specific movements, and to make
it more challenging
By bringing in sport equipment into the pool the patient can do sport specific
movements



Lower Limb
Can be used for treatment of
Hip
Knee
Ankle

Exercises for
Lower Limb Injuries
Initial Level
Goals
Increase normal movements
Increase strength of unaffected muscles
Increase ROM
Walking forward, backwards and sideways help maintain a normal gait
Deep water activities help maintain cardio for patients who cant WB due to
stress fractures or other injuries that require NWB activities
Exercises for Lower Limb
Intermediate Level
Goals
Increase ROM
Increase Strength
Increase Flexibility
Aqua belts can be used to allow for deep water running
Can do eccentric activities in shallow water by standing on a flutter board or a
noodle

Exercises for Lower Limb
Final Level
Best used as a compliment to on land training
Can have the athlete do deep water activities without a flotation belt
Can do squats on noodles, dumbbells, or flutter boards
Pool running


Things you can use for
Aquatic Therapy
Thera-band
to tether them to the wall for pool running
For added resistance
Tennis balls on a rope
a rope with knots
Milk jugs for weights
Hockey sticks, old golf clubs, old tennis racquets,
clothing