PT 113: INTRO TO THERAPEUTIC EXERCISE

Chapter 1: Foundational Concepts

Trisha Sandico, PT, PTRP, DPT – Faculty of Physical Therapy
1st Semester | Comprehensive Exam Notes | A.Y 2022 – 2023

IMPACT ON PHYSICAL FUNCTION

TYPES OF THERAPEUTIC EXERCISE INTERVENTIONS

DEFINITION OF THERAPEUTIC EXERCISE
1. Aerobic conditioning and reconditioning
 Systematic, planned performance of physical movements 2. Muscle performance exercises
intended to: 3. Stretching techniques
o Prevent impairments of body functions and structures 4. Neuromuscular control, inhibition, and facilitation
o Improve, restore, or enhance activities and 5. Postural control, body mechanics, and stabilization exercises
participation 6. Balance exercises and agility training
o Prevent or reduce health-related risk factors 7. Relaxation exercises
o Optimize overall health, fitness, or sense of well- 8. Breathing exercises and ventilatory muscle training
being 9. Task-specific functional training
 Individualized to the needs of patient
EXERCISES SAFETY
 Patient – with impairments + PT to improve function and
prevent disability  Fundamental consideration; paramount
 Client – w/o impairment + PT to promote health and wellness
and prevent dysfunction Factors that influence exercise safety

DEFINITON OF KEY TERMS a. Patient’s health history and current health status
b. Medications
c. Medical clearance
 Align body segments against gravity and
BALANCE d. Environment
maintain w/o falling
e. Exercises equipment
f. Effective exercise instructions and patient education (for
 Ability to perform moderate- independent exercises at home)
CARDIOPULMONARY intensity, repetitive, total body g. Proper body mechanics (for PT)
ENDURANCE movements over an extended
EVOLUTION OF MODELS AND RELATED TECHNOLOGY
period of time

BG AND RATIONALE FOR CLASSIFICATION SYSTEMS

 Correct timing and sequencing of Disablement – impact and functional consequence of acute or chronic
COORDINATION muscle firing + appropriate intensity conditions
of muscular contraction
 Disabling process – depends on:
o Access to quality care
FLEXIBILITY  Move freely w/o restriction o Severity and duration of the condition
o Motivation and attitude of the patient
 Ability of structures to move or be moved to o Support from the family and society
allow ROM
MODELS OF FUNCTIONING AND DISABILITY
 Passive mobility – dependent on soft tissue Early Models - criticized due to perceived focus on pathology,
MOBILITY
extensibility unidirectional path
 Active mobility – requires neuromuscular
activation  Nagi model
 International Classification of Impairments, Disabilities, and
Handicaps (ICIDH)
MUSCLE  Capacity of muscle to do physical work
PERFORMANCE (strength, power, endurance)

International Classification of Functioning, Disability, and Health

NEUROMUSCULAR  Interaction of sensory and motor (ICF)
CONTROL systems to work in correct sequence
 Biopsychosocial model

POSTURAL CONTROL,  Static or dynamic

POSTURAL STABILITY, & balance
EQUILIBRIUM

 Hold a proximal or distal body segment in a

stationary position
STABILITY
 Joint stability – proper alignment of bony
partners of a joint

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  torn muscle or ligament (MRI)
 Pain, reduced sensation, decreased
IMPAIRMENTS ROM, deficits in muscle
IN BODY performance, impaired balance,
FUNCTION abnormal reflexes, reduced
ventilation
 Primary/direct – directly from the
PRIMARY AND
health condition
SECONDARY
 Secondary/indirect – result of
IMPAIRMENTS
preexisting impairments
 impairment is the result of multiple
COMPOSITE underlying causes and arises from a
IMPAIRMENTS combination of primary or secondary
impairments
FUNCTIONALLY  directly contribute to current or
 Part 1: Functioning and Disability RELEVANT future activity limitations and
o Functioning – positive interactions; ability perform IMPAIRMENTS participation restriction
activities and participate in life situations
o Disability – negative interactions; impairments in Activities and Participation
body functions and structures, activity limitations,
participation restriction  Activity – execution of a task or action
 Part 2: Contextual Factors – complete bg of an individual’s life  Participation – involvement in a life situation
and living situation  Activity Limitation – difficulty executing tasks or actions of
daily life
COMPONENTS OF ICF AND APPLICATIONS IN PT o Unable to reach overhead
Definition of Key Terms in the ICF
o Pushing and pulling
 Impairments in body function – problems associated with the o Rolling
physiology of the body systems o Bending and stooping
 Impairments in body structure – problems with the anatomical o Sitting or standing tolerance
structures of the body  Participation Restriction – problems in his or her involvement
 Activity Limitations – difficulties an individual may have in in life situations as measured against social standards
executing actions, tasks, and activities o Self-care
 Participation restrictions – problems with involvement in life o Mobility in the community
situations o Occupational tasks
 Contextual factors – entire bg of an individual’s life and living o School-related tasks
situation o Home management
o Environmental factors – physical, social, and
attitudinal environment; may facilitate or hinder Contextual Factors
functioning
o Personal factors – not part of the health condition or  Environmental factors – outside of the individual
health state  Personal factors – unique to the individual
 Age, gender, race, lifestyle habits, coping Role of Prevention
mechanism, character, etc.
 Primary prevention – health promotion; to prevent disease in an
Health Conditions
at-risk population
 Acute or chronic diseases that have an impact on a person’s  Secondary prevention – early diagnosis and reduction of the
level of function severity or duration of disease
 Basis of medical diagnosis using ICD  Tertiary prevention – use of rehab to reduce the degree of limit
the progression of existing disability
Body functions and Body structures
Risk factors – Influences that predispose a person to impaired
 Body functions – physiological functions of the body functioning and potential disability
 Body structures – anatomical parts of the body
PRINCIPLES OF COMPREHENSIVE PATIENT MNGMT

CLINICAL DECISION-MAKING

 Dynamic, complex process of reasoning and analytical thinking

that involves judgements and determinations in the context of
TYPES OF IMPAIRMENTS
patient care
IMPAIRMENTS  joint swelling, scarring, open wound,
IN BODY amputation (through visual COORDINATE, COMMUNICATE, AND DOCUMENTATION
STRUCTURES inspection)
 adhesions, muscle spasm, joint  Communicate verbally and through written documentation w/
crepitus (through palpation) all individuals involved in the care of patient
 joint space narrowing associated with  Circumstances where it is appropriate to communicate with
arthritis (imaging techniques) another provider:
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 o Co-management – sharing responsibility Diagnostic Process
o Consultation – seeking professional expertise
1. Examination
o Supervision – delegation of some portion of
2. Evaluation
treatment while remaining responsible for the care
3. Organization of data, recognition of clustering data, formation
provided
of a diagnostic hypothesis
o Referral – referring to another provider and receiving
 PT - Identifies impairments of body structure and function that
referrals from another
affect human movement system
EVIDENCE-BASED PRACTICE  Doctor/physician – identifies diseases

Diagnostic Category – identifies and describes patterns or clusters of

 Conscientious, explicit, and judicious use of current best
findings from examination
evidence in making decisions about the care of an individual
patient Prognosis and Plan of Care
Accessing Evidence  Prognosis – prediction of a patient’s optimal level of function
expected as the result of a plan for treatment during an episode
 Read one’s professional journals on a regular basis
of care and the anticipated length of time needed to reach
 Seek out relevant evidence from high-quality studies
specified functional outcomes
A PATIENT MANAGEMENT MODEL  Plan of Care
o Patient goals
 Guide a practitioner through a systematic series of steps and o Expected functional outcomes
decisions for helping a patient achieve highest level of o Extent of improvement predicted and length of time
functioning possible necessary to reach that level
Examination o Specific interventions
o Proposed frequency and duration of interventions
 PT obtains information about patient’s problems/reason for PT o Specific discharge plans
 Setting Goals and Outcomes in the POC
3 Distinct Elements of a Comprehensive Examination
o Goals – intended impact of functioning established
 Health History – overview of current and past info about with specific time limits
present conditions, general health status, and chief complaint o Outcomes – actual results of the episode of care
o Sources of info about Pt history  Functional outcomes – have an impact on
 Self-report health history questionnaire pt’s ability to function at work, home or
 Interviews community that are important to the patient
 Review of medical record o Results – reduction on impairments, activity
 Reports from referral sources limitations, and participation restrictions
 Systems Review – brief but relevant screening of body systems
Intervention
o Cardiovascular and pulmonary, integumentary,
musculoskeletal, and neuromuscular systems  Purposeful interaction of the therapist with patient and other
o General overview of a patient’s cognition, family members
communication, and learning preferences
 Specific Test and Measures – provide in-depth info about body Patient or Client Instructions – used throughout the entire episode of care
function and structure impairments, activity limitations, and
Discharge Planning – patient is discharged = anticipated goals and
participation restriction
expected outcomes have been attained
o Examples that identify musculoskeletal and
neuromuscular impairments Discontinuation – ending of services prior to the achievement of
 Assessment of pain anticipated goals and expected outcomes
 Goniometry and flexibility testing
 Joint mobility, stability, and integrity tests  Decision by a patient to stop
 Test of muscle performance  Change in Pt’s medical status (progress is no longer possible)
 Posture analysis  Need for further services cannot be justified to the payer

Evaluation STRATEGIES FOR EFFECTICE EXERCISE AND TASK

SPEFICIC INSTRUCTION
 Interpretation of data
 Determine the ff:
HEALTH LITERACY
o Pt’s general health status and its impact on current
and potential function  Degree to which individuals have the capacity to obtain,
o Acuity or chronicity of current conditions process, and understand basic health information and services
o Extent of structural and functional impairments needed to make appropriate health decisions
o Which impairments are related to which activity
limitations PREPARATION OF EXERCISE INTERACTION
o Pt’s current, overall level of physical functioning
 Plan that will facilitate learning prior to and during exercise
Diagnosis interventions

 Process or a category (label) within a classification system CONCEPTS OF MOTOR LEARNING: A FOUNDATION FOR
 Differential diagnosis – identify an appropriate diagnostic EXERCISE AND TASK-SPECIFIC INSTRUCTION
Motor learning
category amenable to PT intervention
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  Acquisition and relatively permanent retention of a skilled 4. Manipulation of objects – absent or present
movement through practice o No manipulation of objects = less complex
 Performance – ability to carry out a skill
 Learning – acquisition and retention

Types of Motor Tasks

Stages of Motor Learning
1. Discrete Task – movement with a recognizable beginning and
end 1. Cognitive Stage – figure out what to do and how to do it
o Grasping an object o Pt must learn the goal/purpose and requirements of
o Doing a push-up exercise of functional task
o Locking a wheel chair o Errors are common
o Kicking a ball 2. Associative Stage – Pt makes infrequent errors and
o Lifting and lowering weight concentrates on fine-tuning the motor task
2. Serial Task – series of discrete movements that are combined o slight variations and modifications of movements
in a particular sequence 3. Autonomous Stage – movements are automatic; final stage
o To eat with a fork, a person must be able to grasp the
fork, hold it in the correct position, pierce or scoop Variables that Influence Motor Learning
up the food, and lift fork to the mouth
Pre-Practice Consideration
o Wheelchair transfers
3. Continuous task – repetitive, uninterrupted movements, that  A patient’s understanding of the purpose of an exercise or task
have no distinct beginning and ending affects acquisition and retention
o Walking  Attention – ability to focus on the skill to be learned w/o
o Ascending and descending stairs distraction
o Cycling  Demonstration of a task prior to commencing practice
 Pre-practice verbal instruction that describe the task but should
Conditions and Progression of Motor Tasks be succinct

 To improve a patient’s function = include performing and Practice – repeatedly performing a movement or series of movements in
learning a variety of tasks a task
1. Closed or open environment
a. Closed environment – objects around the patient and  Part vs whole practice
the surface on which the tasks is performed do not o Part practice – task is broken down into separate
move dimensions
i. Drinking while sitting in a chair and o Whole practice – entire task is performed from
maintaining an erect trunk beginning to end and is not practiced in separate
ii. Standing at a sink and washing your hands segments
iii. Walking in an empty hallway where  Blocked, Random, and Random/Blocked Practice Orders
furniture placement is consistent o Blocked-order practice – same task or series of
b. Open environment – objects or other people are in exercises is performed repeatedly under the same
motion or the support surface is unstable during the conditions and in a predictable order
taks  Practice walking in the same environment
i. Maintaining sitting or standing balance on  standing up from the same height chair
a movable surface o Random-order practice – slight variations of the same
ii. Standing on a moving train or bus task are carried out in unpredictable order
iii. Ascending or descending stairs in a  Stepping to and from platforms of different
crowded stairwell heights or practice standing up from chairs
2. Intertrial variability in the environment – absent or present of different heights
a. Intertrial variability is absent = when the o Random/blocked-order practice – variations of the
environment in which a task occurs is constant from same task are performed in random order, but each
one performance of a task to the next variation of the task is performed more than once
i. Practicing safe lifting techniques using a  Patient rises from a particular height or
box of the same dimensions and weight style chair and the repeats the same task a
b. Intertrial variability is present = demands change second time before moving on to a
from one attempt or repetition of a task to the next different style or height
i. Lifting and carrying objects of different
sizes and weight
3. Body stable or Body transport – tasks are analyzed from the
perspective of the person doing the tasks
a. Body stable – maintaining the body in a stable o Physical vs Mental Practice
position  Physical Practice – movements of an
i. Maintaining an upright posture exercise or functional task are actually
b. Body transport – task requirements involved the performed
patient moving from one place to another  Mental Practice – cognitive rehearsal of
i. Performing a transfer how a motor task is to be performed occurs
ii. Walking prior to actually executing the terms
iii. Jumping
 Visualization and motor imagery
iv. Climbing
practice
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Feedback – sensory information that is received and processed by the
learner during or after performing or attempting to perform a motor skill

 Types of Feedback for Motor Learning

o Knowledge of Performance – either intrinsic
feedback sensed during a task or immediate, post-
task, augmented feedback about the nature or quality
of the performance
o Knowledge of Results – immediate, post-task,
augmented feedback about the outcome of a motor
task
o Intrinsic Feedback – sensory cues that are inherent in
the execution of a motor task
 arises directly from performing or
attempting to perform the task
o Augmented Feedback – sensory cues from an
external source that are supplemental to intrinsic
feedback and that are not inherent in the execution of
the task
 Arise from a mechanical source or from
another person
 Feedback Schedules
o Concurrent – during task/performance; real-time
o Post-response – after completing or attempting to
complete a motor skill
o Immediate – info that is given directly after a task is
completed
o Delayed – info that is given after a short interval of
time has elapse, allowing time for the learning to
reflect on how well or poorly a task was executed
o Summary – info that is given about the average
performance of several reps of a motor skill
o Variable – occurs irregularly. Randomly during
practice of a motor task
o Constant – occurs on a regularly, recurring,
continuous basis during practice of a motor task

Adherence to Exercise

Factors that Influence Adherence to an Exercise Program

1. Patient-Related Factors
2. Factors Related to the Health Condition or Impairments
3. Program-Related Variables

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 PT 113: INTRO TO THERAPEUTIC EXERCISE
Chapter 2: Prevention, Health, and Wellness
Trisha Sandico, PT, PTRP, DPT – Faculty of Physical Therapy
1st Semester | Comprehensive Exam Notes | A.Y 2022 – 2023

KEY TERMS AND CONCEPTS  Attain hq, longer lives free of preventable disease
 Achieve health equity, eliminate disparities, improve health of
all groups
 A state of complete physical, mental, and
 Create social and physical environments that promote health
HEALTH social well-being and not merely the absence
for all
of disease or infirmity
 Promote quality of life, healthy development, and healthy
behaviors across all life stages
 A state of being that incorporates all facets
WELLNESS ROLE OF PT IN HEALTH PROMOTION AND WELLNESS
and dimensions of human existence

FACILITATING TRANSFORMATION
 Degree to which individuals have the capacity
HEALTH to obtain, process, and understand basic health  Through typical practice of working with patients in rehab after
LITERACY info and services needed to make appropriate onset of injury or illness or after surgery
health decisions  By patient education to enhance health and wellness
 identifying community resources available to the client to
support a healthy lifestyle
 Any effort taken to achieve awareness of
HEALTH  influencing public policy at the local, state, and national levels
and empowerment to prevention and
PROMOTION
wellness Promoting Health and Behavioral Change

 PT are uniquely qualified to lead the assault on lifestyle

 Practice of preventing disease and promoting conditions
PUBLIC good health by providing the resources and  Promote health and influence behavior change so that the
HEALTH creating environments that help people stay outcome is improved individual health and function and
health improved health of the community

Assess State of Wellness

 A broad multidimensional concept
HEALTH-RELATED that includes self-reported  PT should assess patient/client current state of wellness using
QUALITY OF LIFE measures of physical and mental an assessment tool such as the Perceived Wellness Survey or
health the Model for Health Living Assessment Wheel

Function of the Physical Therapist

WELL-  A positive outcome that is meaningful for
1. Identifying risk factors and interventions to reduce risk in
BEING people
individuals and community
2. Preventing or slowing progression of functional decline and
CHRONIC DISEASE, PREVENTION, AND HEALTH CARE disability and enhancing activity in those with a diagnosed
condition
3. Reducing disability by restoring skills and independence in
CHRONIC CONDITIONS RELATED TO BEHAVIORS those with chronic conditions
4. Screening – identifying individuals or groups who would
 Chronic conditions are often attributable to behaviors
benefit from education, intervention, or referral to an
 Examples that lead to health problems
appropriate healthcare provider
o Tobacco use and second-hand smoke exposure
5. Consultation – Providing expertise and knowledge
o Physical inactivity and lack of regular exercise
6. Education – providing information on prevention, health,
o Poor diet and nutrition wellness, and fitness topics
o Excessive alcohol use 7. Critical Inquiry – obtaining, synthesizing, and utilizing current
research
HEALTH-CARE COSTS DUE TO RISKY BEHAVIORS
8. Administration – planning, developing, and managing all
 Risky lifestyle behaviors result in increased cost for healthcare aspects of a prevention or wellness project

INVESTMENT IN PREVENTION Prevention Activities

 Primary Prevention – developing fitness programs for children

 To facilitate change and improve health behaviors, and thereby
to prevent obesity or a back injury prevention program for
reduce healthcare costs and spending, investment in prevention
warehouse workers
is critical
 Secondary Prevention – developing resistance programs for
HEALTHY PEOPLE 2020 individuals with osteoporosis
 Tertiary Prevention – developing programs for individuals with
 Vision: A society in which all people live long, healthy lives SCI

4 overarching goals of this agenda are the following: IDENTIFYING RISK FACTORS
Preparticipation Screening
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  Individual should be asked several questions; yes to 1 or more  Moderate intensity – min. 150 minutes / week
= evaluated further and may require consultation w/ their  Vigorous intensity – 75 minutes / week
physician  Include balance exercises to reduce risk of falls
 Episodes of at least 10 mins count toward daily total
Risk Assessment  Muscle strengthening activities should be included at least 2
 Participant should be assessed for risk factors associated with days per week
specific conditions (eg. CAD) Adults with Disabilities
DETERMINING READINESS TO CHANGE  Engage in regular physical activity according to their ability
and should avoid inactivity
 Know where person in terms of readiness for changed behavior
 Consult with their healthcare provider for an individualized
Behavioral Change Theories program that is appropriate for their abilities

 Social Cognitive Theory – learning occurs within a social CONSIDERATINOS FOR PEOPLE WITH DISABILITIES
context with a dynamic and reciprocal interaction between
cognitive processes, environment, and behavior HEALTH DISPARTIES AND RISKS
o Believe that she can change a particular behavior and
that changing that behavior will lead to positive  Individuals with disability experience greater health disparities
outcomes that outweigh possible negative outcomes than those without disability
 Health Belief Model – explain the failure of people to  Adults with disabilities and chronic conditions generally
participate in programs to prevent or to detect disease receiver fewer preventive services and poorer health status than
 Transtheoretical Model – aka stages of change model; those w/o disabilities with the same condition
integrative framework for understanding how individuals and
populations progress toward adopting and maintaining health ACHIEVING HEALTH EQUITY FOR PPL W/ DISABILITIES
Objectives in Healthy People 2020 for those with disabilities
behavior change for optimal health
o 5 stages of change: 1. Inclusion in public health activities
 Precontemplation – no intention of making 2. Receiving well-timed intervention and services
any changes within next 6 months 3. Interaction with their environment w/o barriers
 Contemplation – intend to make changes 4. Participation in everyday life activities
within the next 6 mos
 Preparation – begun to take steps and plans Role of PTs
to make changes within 30 days
 Consult with individuals with disability and help them develop
 Action – change the behavior for less than
fitness programs to facilitate wellness
6 months
 Maintenance – has changed the behavior Exercise Adherence
for more than 6 mos
 Some suggestions:
Motivation Affecting the Ability to Change o Using a buddy system to be physically active with a
friend or care giver
 Motivation – how we move ourselves or others to act
o Keep an exercise log
o Intrinsic motivation – goal or expectation to do one’s
o Using a reward system (not food)
personal best
o Performance motivation – positive and negative MINDFULNESS: IMPLICATIONS 4 HEALTH & WELLNESS
reinforcement or rewards can improve performance,
as can success or failure
o Task motivation – knowledge and feedback on the MINDFULNESS DEFINED
performance and should include info on how to
 Paying attention in a particular way: on purpose, in the present
improve
moment, and non-judgmentally
PHYSICAL ACTIVITY GUILDINES
Qualities of Mindful Awareness

1. Present moment – invited one to be in the moment and

PHYSICAL ACTIVITY RECOMMENDATION
Children and Adolescents (6 years and older) experience peace
2. Fundamental Kindness – meeting oneself with kindness
 60 mins of moderate to vigorous physical activity daily 3. Nonjudging – be an impartial witness w/o those automatic
 At least 3 days a week (vigorous) behaviors
 Both bone and muscle strengthening activities should be 4. Acceptance - accepting one’s thoughts, feelings, and actions
included in daily activity at least 3 days per week just as they are
 Should be age appropriate and fun 5. Non-striving – being fully aware of one’s experience just as it
is
Adults
6. Not Knowing – allows temporary suspension of preconceived
 Moderate intensity – min. 150 minutes / week ideas, concepts, and expectations so that new learning can
 Vigorous intensity – 75 minutes / week occur
 Episodes of at least 10 mins count toward daily total 7. Letting go – let go and be open to those changes
 Muscle strengthening activities should be included at least 2
MINDFULNESS MEDITATION
days per week

Older Adults (65 years and older)

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  The deliberate training of the mind in present moment
awareness

MINDFUL BREATHING

 Observing the breath and breathing deeply during distress and

it can be taught as part of mindfulness meditation (15-60
minutes) or as brief (5 minute) practices

MINDFUL EATING

 Practice with a raisin

o When one finds the mind wandering from the task at
hand, gently return attention to raisin and what is
being done with it

DEVELOPING AND IMPLEMENTING A WELLNESS PROGRAM

Step 1: Identify a need

 Identify the intended audience

Step 2: Set Goals and Objectives

 Identify the purpose of the program

 Identify the goals to achieved
 Identify the objectives

Step 3: Develop the Intervention

 Screenings – identify valid and reliable right tools to use for the
screening
 Education – develop the program including handouts for
participants
 Exercise – develop the plan for each class
 Logistics – secure a location for the program

Step 4: Implement the Intervention

 Be adaptable and to be prepared for the unexpected

Step 5: Evaluate the Results

 For educational: ask the participants to evaluate the program

 For exercise: record baseline data and assess progress during
the program and at the end
 Ask participants to evaluate the exercise program
 Ask for feedback on what could be done to improve the
program

ADDITIONAL CONSIDERATION FOR DEVELOPING

PREVENTION, HEALTH, AND WELLNESS PROGRAMS

 Exercise or activity has to be specific to the goals

 What would motivate individuals to participate and then
incorporate some of their suggestions
 For children: fun and less structured
 For adults: start slowly to allow the participants to experience
success

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 PT 113: INTRO TO THERAPEUTIC EXERCISE
Chapter 3: Range of Motion
Trisha Sandico, PT, PTRP, DPT – Faculty of Physical Therapy
1st Semester | Comprehensive Exam Notes | A.Y 2022 – 2023

Range of Motion - Technique to examine movement and initiating Indications for AROM
movement into intervention
 Pt able to contract the muscles actively with or w/o assistance
 Full motion possible  Pt has weak musculature and unable to move a joint through
desired range
Joint Range - Flexion, extension, abduction, adduction, etc.  Segment is immobilized for a period of time, AROM is used
Muscle Range - Related to functional excursion of muscles regions above and below the immobilized segment
 For aerobic conditioning program & relieve stress from
Functional Excursion – distance that a muscle is capable of shortening sustained postures
after it has been elongated to its maximum
Goals for AROM
Active Insufficiency – muscle is too short to produce much tension
 No inflammation or contraindication to active motion = same
Passive Insufficiency – muscle is fully lengthened and limits motion at goals for PROM
one of the joints it crosses (Ex. Knee is extended and full range of hip
flexion is limited) Physiological Benefits & Motor Learning

Factors Decreasing ROM 1. Maintain physiological elasticity and contractility of

participating muscles
1. Systemic, joint, neurological, or muscular disease 2. Provide sensory feedback from the contracting muscles
2. Surgical or traumatic insults 3. Provide a stimulus for bone and joint tissue integrity
3. Inactivity or immobilization 4. Increase circulation and prevent thrombus formation
5. Develop coordination and motor skills for functional activities
TYPES OF ROM EXERCISES
Passive ROM (no active muscle contraction) Limitations

 Movement is produced entirely by an external force such as  Does not maintain or increase strength
gravity, machine, another person, or another part of  Does not develop skill or coordination
individual’s body

Active ROM - Movement is produced by active muscle contraction

Active-Assistive ROM - Assistance is provided manually or

mechanically by an outside force

INDICATIONS, GOALS, AND LIMITATIONS OF ROM

PASSIVE ROM
Indications of PROM

 Region where there is acute, inflamed tissue

 Not able or not supposed to actively move a segment
o Paralyzed, bed rest, or comatose
 After surgical repair of contractile tissue

Goals for PROM

 Primary Goal: Decrease complications that occur w/

immobilization
1. Maintain joint and connective tissue mobility
2. Minimize the effects of the formation of contractures PRECAUITIONS AND CONTRAINDICATIONS TO ROM
3. Maintain mechanical elasticity of muscle
4. Assist circulation and vascular dynamics  Contraindicated under any circumstance where motion is
5. Enhance synovial movement for cartilage nutrition and disruptive to the healing process
diffusion of materials in the joint
6. Decrease or inhibit pain
7. Assist w/healing process after injury or surgery
8. Maintain the patient’s awareness of movement

Other Uses for PROM

 Determine LOM, joint stability, muscle flexibility, other soft

tissue elasticity
 Demonstrate the desired motion
 Preparing a patient for stretching

ACTIVE AND ACTIVE-ASSISTIVE ROM

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 1. Grasp the extremity around the joints for stabilization; modify
grip if joints are painful
2. Support areas of poor structural integrity
3. Move segment through its complete pain-free range to point of
tissue resistance
4. Perform smoothly and rhythmically with 5-10 reps

APPLICATION OF PROM

1. Pt may provide force and taught to move the part w/ a normal

extremity
2. No active resistance or assistance
3. Carried within free ROM (no forced motion or pain)

APPLICATION OF AROM

1. Demonstrate using PROM

2. Provide assistance only as needed for smooth motion
3. Carried within available ROM

PRINCIPLES AND PROCEDURES FOR APPLYING ROM

EXAMINATIONS, EVALUATION, AND TREATMENT PLAN

1. examine, evaluate, determine prognosis, plan the intervention

2. Determine the ability of the Pt to participate in ROM
3. Determine the amount of motion that can be applied safely
4. Decide what patterns can best meet the goals
a. Anatomic planes of motion: frontal, sagittal,
transverse
b. Muscle range of elongation: antagonistic to the line
of pull of the muscle
c. Combined patterns: diagonal motions that
incorporate planes of motion
d. Functional patterns: motions used in ADLs
5. Monitor general condition and responses
6. Document and communicate findings & intervention
7. Re-evaluate and modify as necessary

PATIENT PREPARATION

1. Communicate with patient

2. Free the region from restrictive clothing
3. Position patient comfortably
4. Position yourself for proper body mechanics

APPLICATION OF TECHNIQUES

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 PT 113: INTRO TO THERAPEUTIC EXERCISE
Chapter 4: Stretching For Improved Mobility
Trisha Sandico, PT, PTRP, DPT – Faculty of Physical Therapy
1st Semester | Comprehensive Exam Notes | A.Y 2022 – 2023

Mobility – ability of the body to do tasks; associated with joint integrity Pseudomyostatic Contracture (apparent contracture)
and soft tissue flexibility
 Result of tonicity (i.e, spasticity or rigidity) associated with
Functional Mobility – sustain active movements of the body to perform CNS lesion
motor tasks  Muscle spasm or guarding may cause pseudomyostaic
contracture
Hypomobility – reduced functional motion  Muscles appear to be in a constant state of contraction
Potential Factors Arthrogenic and Periarticular Contracture
1. Prolonged immobilization  Arthrogenic Contracture - Result of intra-articular pathology
2. Sedentary lifestyle
o May include: adhesions, synovial proliferation, joint
3. Postural malalignment with muscle length alterations
effusion, irregularities in articular cartilage, or
4. Impaired muscle performance
osteophyte formation
5. Tissue trauma = inflammation and pain
 Periarticular Contracture – CT that cross a joint lose mobility,
6. Congenital or acquired deformities
restricting normal arthrokinematics motion
Stretching – increase soft tissue extensibility to improve flexibility and
Fibrotic Contracture and Irreversible Contracture
ROM by elongating structures that have adaptively shorten and become
hypomobile  Fibrotic Contracture – fibrous changes in the CT of muscle and
periarticular structures
DEFINITION OF TERMS W/ MOBILITY AND STRETCHING
 Irreversible Contracture – prolonged fibrotic contracture or
more extensive the tissue replacement = more difficult to
FLEXIBILITY regain optimal mobility = irreversible contracture

 Ability to move joint easily SELECTIVE STRETCHING

 Muscle length, joint integrity, periarticular soft tissue
extensibility  Applying stretching techniques to some muscles and joints
while allowing motion limitations to develop in other muscles
Dynamic Flexibility (active mobility or AROM) or joints

 Movement through available ROM via active muscle OVERSTRETCHING AND HYPERMOBILITY
contraction Overstretching – stretch well beyond the normal length of muscle and
ROM
Passive Flexibility (passive mobility or PROM)
Hypermobility – excessive mobility; overstretching results in
 Joint passively rotated through its available ROM hypermobility
 Prerequisite, but does not ensure, dynamic flexibility
INTERVENTIONS TO INC. MOBILITY OF SOFT TISSUES
HYPOMOBILITY Stretching and mobilization/manipulation – any therapeutic maneuver
that increases the extensibility of restricted soft tissues
 Decreased motion
Stretching: Manual or Mechanical/Passive or Assisted
CONTRACTURE
Passive Stretching – patient is relaxed during the stretch
 Adaptive shortening of muscle-tendon unit and other soft
tissues Assisted Stretching – patient assists in moving the joint through greater
 Almost complete loss of motion range

Shortness – partial loss of motion Self-Stretching – stretch is carried out independently by Pt

Tightness – restricted motion due to adaptive shortening of soft tissue Neuromuscular Facilitation and Inhibition Techniques – reflexively
decreasing tension in shortened muscles prior to or during the stretch
Muscle Tightness - adaptive shortening of contractile and noncontractile
elements of muscle Muscle Energy Techniques – voluntary muscle contractions by the Pt in
precisely controlled direction and intensity against a counterforce applied
DESIGNATION OF CONTRACTURES BY LOCATION by the practitioner

 The side of the joint that has the tissue tightness Joint Mobilization/Manipulation – specifically applied to joints to
 Ex. If tightness is on the flexion side of the flexion/extension modulate pain and treat joints that limit ROM
joint axis, it is called flexion contraction
Soft Tissue Mobilization/Manipulation – improve the extensibility of
TYPES OF CONTRACTURES any soft tissue that limits mobility
Myostatic Contracture
Neural Tissue Mobilization (Neuromeningeal Mobilization)
 No specific muscle pathology present
 No decrease in individual sarcomere length  Improve or restore nerve tissue mobility

INDICAITIONS, CONTRAINDICATINS, OUTCOMES

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 INDICATIONS FOR STRETCHING

1. Limited ROM d/t soft tissues losing their extensibility

2. Restricted motion may lead to structural deformities that are
preventable
3. Muscle weakness and shortening of opposing tissue
4. Component of a total fitness or sport specific conditioning
program
5. Prior to and after vigorous exercise

CONTRAINDICATIONS TO STRETCHING

1. Any bony block limits joint motion

2. Recent fracture & bony union is incomplete
3. Acute inflammatory or infectious process
4. Sharp, acute pain
5. Hematoma
6. Hypermobility already exists
7. Shortened soft tissue provide necessary joint stability
8. Shortened soft tissue enable a patient with paralysis

POTENTIAL BENEFIST AND OUTCOMES

Increased Flexibility and ROM – restore or increase muscle-tendon
unit extensibility to regain or achieve flexibility and ROM

General Fitness – warm up prior to or cool down following physical

activity

Other Potential Benefits

1. Injury prevention and reduced post-exercise muscle soreness

2. Enhanced performance

PROPERTIES OF SOFT TISSUE: RESPONSE TO

IMMOBILIZATION AND STRETCH

 Ability of the body to move w/o restriction depends on active

neuromuscular control and passive extensibility of soft
tissue
 Decreased extensibility of soft tissue – primary cause of
restricted mobility
 Soft tissue stretched = elastic, viscoelastic or plastic changes
occur
o Contractile and noncontractile tissues have elastic &
plastic qualities
o Only noncontractile tissues have viscoelastic
properties

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