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Therapeutic Exercise. Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation. Clinical Decision Making. Examination Evaluation Diagnosis Prognosis Set up Interventions. Clinical Decision Making. - PowerPoint PPT Presentation
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Natalia Fernandez, PT, MS, MSc, CCSUniversity of Michigan Health Care System
Department of Physical Medicine and Rehabilitation.
Clinical Decision MakingExaminationEvaluationDiagnosisPrognosis
Set up Interventions
Clinical Decision MakingMed Dx: CAD Med Dx: COPD
Use of Hypothesis Testing and AlgorithmsMed Dx and History of Cardiopulmonary
DiseaseLab and Diagnostic Test ResultsPT DxType of activity, specifics of activity, timeResponse to exercise/mobility/ADL
Vital signs – rest, activity, recovery EKG changes Need and time to stop, rest Observed signs – color changes
Subjective responses Concerns – Fatigue, SOB Rate of Perceived Exertion
DeTurk & Cahalin - pg 368-369, Fig 12-4 & pg 370, Fig 12-5
Musculoskeletal, Integument, & Neuromuscular Considerations
Musculoskeletal Osteoporosis & Spinal Deformities Ankylosing Spondylitis Idiopathic Scoliosis Pectus Deformities Shoulder Hypomobility
Integument Sarcoidosis Systemic Lupus Erythematosus Scleroderma Sjogren Syndrome
Neuromuscular Stroke Traumatic Brain Injury Spinal Cord Injury Multiple Sclerosis Parkinsons Guillain-Barre Syndrome Post Polio Syndrome
Nagi (Disablement) ModelDisability Inability to shop for family
Functional limitation Limited walking distance Impairment Impaired aerobic capacity
Pathology Myocardial Infarction
APTA, Guide PT Practice, 1st ed.1997.
Therapeutic Exercise for Cardiopulmonary Practice Patterns
Aerobic capacity/endurance conditioning or reconditioning
Balance, coordination, and agility trainingBody mechanics and postural stabilizationFlexibility exercisesGait and locomotion trainingRelaxationStrength, power, and endurance training
for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles
Pattern A: Prevention and RiskInclusion Criteria
Risk Factors or Consequences of Pathology DiabetesFamily history of heart diseaseHypercholesterolemia or hyperlipidemiaHypertensionObesitySedentary lifestyleSmoking
Impairments, Functional Limitations, or Disabilities
Decreased functional work capacityDecreased maximum aerobic capacityDyspnea on exertionSedentary job role
Pattern A: Prevention and RiskTher Ex
Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices
Aquatic programsGait and locomotion training - Walking and
wheelchair propulsion programs
Increased workload over timeTask-specific performance training
Flexibility exercises Muscle lengtheningRange of motionStretching
Body mechanic and ergonomics trainingBreathing exercisesPosture awareness training
Pattern A: Prevention and RiskTher Ex
Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic,
complementary exercise approachesStrength, power, and endurance training
Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices)
Aquatic programs Standardized, programmatic,
complementary exercise approaches Task-specific performance training
Pattern A: Prevention and Risk Patient Education
DiseaseAtherosclerosisHyperlipedemiaHypertensionDiabetes
DietExerciseSmokingHealth & WellnessFitness
Pattern B: DeconditioningInclusion Criteria
Risk Factors or Consequences of Pathology Acquired immune deficiency syndromeCancerCardiovascular disordersChronic system failureInactivity Multisystem impairmentsMusculoskeletal disordersNeuromuscular disordersPulmonary disorders
Impairments, Functional Limitations, or DisabilitiesDecreased enduranceIncreased cardiovascular response to low level work
loadsIncreased perceived exertion with functional activitiesIncreased pulmonary response to low level work loadsInability to perform routine work tasks due to
shortness of breath
Pattern B: DeconditioningTher Ex
Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices
Aquatic programsGait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time
Balance, coordination, and agility training Developmental activities trainingNeuromuscular education or reeducationStandardized, programmatic, complementary exercise approaches
Breathing exercisesBody mechanics, ergonomics, and postural stabilization
Body mechanics training Postural control and awareness training
Flexibility exercises Muscle lengthening Range of motion Stretching
Pattern B: DeconditioningTher Ex
Gait and locomotion trainingDevelopmental activities trainingGait trainingImplement and device trainingStandardized, programmatic, complementary exercise
approachesWheelchair training
Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise
approaches Strength, power, and endurance training for head and neck, limb,
pelvic-floor, trunk, and ventilatory musclesActive assistive, active, and resistive exercises (including
concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics)
Aquatic programsConditioning and reconditioning - Strengthening or ResistiveStandardized, programmatic, complementary exercise
approaches
Pattern C: Airway ClearanceInclusion Criteria
Risk Factors or Consequences of Pathology Acute lung disordersAcute or chronic oxygen dependencyBone marrow/stem cell transplantsCardiothoracic surgeryChange in baseline breath soundsChange in baseline chest radiographChronic obstructive pulmonary disease (COPD)Frequent or recurring pulmonary infectionSolid-organ transplants (eg, heart, lung, kidney)Tracheostomy or microtracheostomy
Impairments, Functional Limitations, or DisabilitiesDyspnea at rest or with exertionImpaired airway clearanceImpaired coughImpaired gas exchangeImpaired ventilatory forces and flowImpaired ventilatory volumesInability to perform self-care due to dyspneaInability to perform work tasks due to dyspnea
Pattern C: Airway ClearanceTher Ex
Aerobic capacity/endurance conditioning or reconditioning activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices
Aquatic programsGait and locomotion training - Walking and wheelchair
propulsion programs Increased workload over time
Body mechanics, ergonomics, and postural stabilizationPosture awareness training Postural control training
Flexibility exercises Muscle lengtheningRange of motionStretching
Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise
approaches
Pattern C: Airway ClearanceTher Ex
Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles
Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric,and plyometric – using manual
resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices)
Aquatic programsStandardized, programmatic, complementary exercise approachesTask-specific performance training
Balance and coordination trainingDevelopmental activitiesNeuromuscular relaxation, inhibition, and facilitation
Pattern D: CV Pump DysfunctionInclusion Criteria
Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)
AngioplastyAtrioventricular blockCardiomyopathyCardiothoracic surgeryComplex ventricular arrhythmiasComplicated MI (failure); uncomplicated MI (dysfunction)Coronary artery diseaseDecrease in ejection fraction (EF) on exercise testing (EF of 30-
50% with dysfunction; < 30% with failure) DiabetesHypertensive heart diseaseValvular heart disease
Impairments, Functional Limitations, or DisabilitiesAbnormal heart rate response to increased oxygen demandAbnormal pulmonary response to increased oxygen demandDecreased ability or the inability to perform activities of daily
living (ADL) because of symptomsChange in baseline breath sounds with activityFlat or falling blood pressure response to increased oxygen
demand (failure)
Pattern D: CV Pump DysfunctionTher Ex
Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics
Aquatic programsGait and locomotion training - Walking and wheelchair
propulsion programs Increased workload over time
Balance, coordination, and agility training Developmental activities trainingMotor function (motor control and motor learning) training or
retrainingNeuromuscular education or reeducationStandardized, programmatic, complementary exercise
approachesTask-specific performance training
Breathing exercises Body mechanics, ergonomics, and postural stabilization
Body mechanics training Postural awareness training
Flexibility exercises Muscle lengthening Range of motion Stretching
Pattern D: CV Pump DysfunctionTher Ex
Gait and locomotion trainingDevelopmental activities trainingGait trainingImplement and device trainingStandardized, programmatic, complementary exercise
approachesWheelchair training
Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise
approaches Strength, power, and endurance training
Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices )
Standardized, programmatic, complementary exercise approaches
Task-specific performance training
Pattern E: Resp Pump DysfunctionInclusion Criteria
Risk Factors or Consequences of Pathology Elevated diaphragm and volume loss on chest radiographNeuromuscular disordersPartial or complete diaphragmatic paralysisPoliomyelitisPulmonary fibrosisRestrictive lung diseaseSevere kyphoscoliosisSpinal cord injury
Impairments, Functional Limitations, or DisabilitiesAbnormal or adventitious breath soundsAbnormal increased respiratory rate and decreased tidal
volume at restAirway clearance dysfunction secondary to ventilatory
pump impairmentDecreased to severely impaired strength and endurance of
ventilatory musclesDyspnea with self-careDyspnea with work tasksDys-synchronous or paradoxical breathing at rest or with
activity
Pattern E: Resp Pump DysfunctionTher Ex
Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics,
Aquatic programsGait and locomotion training - Walking and wheelchair propulsion
programs Movement efficiency and energy conservation trainingIncreased workload over time
Balance, coordination, and agility training Developmental activities trainingMotor function (motor control and motor learning) training or
retrainingNeuromuscular education or reeducationStandardized, programmatic, complementary exercise approachesTask-specific performance training
Breathing exercises Body mechanics, ergonomics, and postural stabilization
Body mechanics trainingPostural control trainingPostural stabilization activitiesPostural awareness training
Flexibility exercises Muscle lengthening Range of motion Stretching
Pattern E: Resp Pump DysfunctionTher Ex
Gait and locomotion trainingDevelopmental activities trainingGait trainingImplement and device trainingPerceptual trainingStandardized, programmatic, complementary exercise
approachesWheelchair training
Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise
approaches Strength, power, and endurance training for head and neck, limb,
pelvic-floor, trunk, and ventilatory musclesActive assistive, active, and resistive exercises (including
concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics
Standardized, programmatic, complementary exercise approaches
Task-specific performance training
Pattern F: Respiratory FailureInclusion Criteria
Risk Factors or Consequences of PathologyAdult respiratory distress syndromeAbnormal alveolar to arterial oxygen tension differencesCardiothoracic surgeryChronic obstructive pulmonary disease (COPD)Multisystem failurePneumoniaPre- and post-lung transplant or rejectionRapid rise in arterial carbon dioxide at rest or with activitySepsisThoracic or multisystem trauma
Impairments, Functional Limitations, or DisabilitiesAbnormal or adventitious breath soundsAbnormal vital capacity Airway clearance dysfunctionDyspnea at rest Dyssynchronous or paradoxical breathing patternImpaired gas exchange
Pattern F: Respiratory FailureTher Ex
Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics
Aquatic programsGait and locomotion training - Walking and wheelchair
propulsion programs Movement efficiency and energy conservation trainingIncreased workload over time
Balance, coordination, and agility training Neuromuscular education or reeducationPosture awareness training
Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control training Postural awareness training
Flexibility exercises Muscle lengthening Range of motion Stretching
Pattern F: Respiratory FailureTher Ex
Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary
exercise approachesStrength, power, and endurance training for head and
neck, limb, pelvic-floor, trunk, and ventilatory musclesActive assistive, active, and resistive exercises
(including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights,
hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices )
Task-specific performance training
Therapeutic ExerciseAerobic capacity/endurance conditioning
or reconditioningAquatic programs Gait and locomotion training – Walk or W/CIncreased workload over timeMovement efficiency and energy conservation
training
Aerobic Capacity/Endurance Conditioning or Reconditioning
Activity, specific set up, time Improve oxygen demandUse of large muscle groups in a rhythmic fashion, over time
ModeMarching, Walking, Bike, Gardening
IntensityMax HR and take age adjusted50-70% depending on exercise test, age
Frequency4-5 days per week
Duration5-10 min bouts 3x/dayWork up to 30-40 min in one session
For Progression, see DeTurk & Cahalin, pg 447 & 448, Figs 15-7 & 15-8
Aerobic Capacity/Endurance -EvidencePatient Education on Risk or Disease
Exercise, DietDeconditioning
Rate of VO2 max decreases greatest the first week of bedrest1
Longer the bedrest the more diminished the VO2 max1
Use of HR, RPE, and METs
1 Convertinao VA, Med Sci Sports Exer, 1997:29:191
Aerobic Capacity/Endurance -EvidenceGroup-based (8-12 patients) simple aerobic dance
movements (with music)2 days a week for 4 monthsEach session lasted 50 minutes (including warm-up
and cool-down), followed by 15-30 minutes of counseling
The exercise program included three intervals of high intensity, during which patients were encouraged to reach 15-18 on the Borg scale for 5-10 minutes.
6 min walk, resistance on bike, bike time, MN Living with Heart Failure QOL all increased with significance as compared to the control group for 4 and 12 mn.
Nilsson et al, Long-term effects of a group based high intensity aerobic interval training program in patients with chronic heart failure, Am J Cardiol 2008; 102(9):1220-1224
Therapeutic ExerciseBalance, coordination, and agility training
Developmental activities trainingPosture awareness trainingStandardized, programmatic, complementary
exercise approachesTask-specific performance training
Balance, Coordination, and Agility TrainingMode
Massery TechniqueIntensityDurationFrequency
No set parameters
Balance - Evidence
Sensory-specific balance classes were held 3 times per week, for 1 hour each session, over 8-week
Tasks included standing or walking on various support surfaces, such as a rocker
board, foam, or narrow beam Standing in a tandem position, a semitandem position, on one leg, or in
a feet together Progressions to these tasks included simultaneous alterations of
visual and vestibular inputs Instructed to close their eyes, to engage vision with a reading or
tracking secondary task Perform balance tasks with a distracting background Instructed to tilt their head backward or to quickly move their head
side to side and up and down. Results
Less destabilization within the first 5 seconds following vibration with or without a secondary task than there was at baseline or in the falls prevention education group
Training effects were not maintained at the 8-week follow-up.
Westlake & Culham. Sensory-Specific Balance Training in Older Adults: Effect on Proprioceptive Reintegration and Cognitive Demands Physical Therapy. Oct 2007. Vol. 87, Iss. 10; p. 1274
Therapeutic ExerciseBody mechanics and postural stabilization
Body mechanics trainingPostural control trainingPostural stabilization activitiesPosture awareness training
Body Mechanics and Postural StabilizationModeIntensityDurationFrequency
No set parameters
Body Mechanics -EvidencePerfusion study in prone and supinePts were under conditions of
Normal breathing of room airUnassisted breathing of 45% O2Assisted PEEP
Ventral, Middle, Dorsal measurements with ventral more perfuse in prone and dorsal more perfuse in supine
Suki et al, Perfusion, Science Letter. Atlanta: Mar 25, 2008. pg. 2580
Body Mechanics -EvidencePt with ischemia of stable and unstable
anginaValsalva and measured QT of EKGWith valsalsa showed significant difference of
EKG changes of QT segmentAuthors related to carrying or lifting
restrictions of heavy objects with CAD
Balbay et al, Effects of valsalva maneuver on QT dispersion in patients with ischemic heart...Angiology; Nov 2001; 52, 11
Therapeutic ExerciseFlexibility exercises
Improve motion of the chest wall, lengthen anterior chest wall, improve hip and knee flexor shortening
Muscle lengtheningRange of motionStretching
Flexibility ExercisesMode
Isolate muscle or limited jointIntensity
After warmupDuration
Hold with no pain for 30 secFrequency
3-5 days/week
Flexibility - EvidencePt with ankylosing spondylosis3x/wk for 3 months18 stretching exercises of entire spine and
extremities along with aerobic and chest expansion exercises
Significant improvement in cervical and thoracic spine movement AND chest expansion
Ince et al , Effects of a Multimodal Exercise Program for People With Ankylosing Spondylitis, Physical Therapy; Jul 2006; 86, 7
Therapeutic ExerciseGait and locomotion training
Developmental activities trainingGait trainingImplement and device trainingStandardized, programmatic, complementary exercise
approaches
Gait and Locomotion TrainingModeIntensityDurationFrequency
No set parameters
Gait and Locomotion - EvidenceSee aerobic exerciseMassery Pairing
Massery et al, Coordinating transitional movements and breathing in patients with neuromotor dysfunction, NDTA Network, Nov/Dec 1996
Gait and Locomotion - EvidenceCase Report of pt with C6 tetraplegiaTaught breathing strategy and reducing
valsalva with tasks with w/cLean forwardPut foot on footplatePosterior lean for pressure relief
Able to perform tasks with new breathing strategies
Henderson, Application of Ventilatory Strategies to Enhance Functional Activities for an...Journal of Neurologic Physical Therapy; Jun 2005; 29, 2
Therapeutic ExerciseRelaxation
Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise
approaches
Relaxation
ModeIntensityDurationFrequency
No set parameters
Relaxation -Evidence
Five 60 minute individual treatments with the Papworth method from a respiratory physiotherapist
No significant differences were found between the groups at baseline
SGRQ Symptom mean scores were lower in the Papworth method group than in the control group after treatment and at 12 months
The Nijmegen and HADS scores were also significantly lower in the intervention group than in the control group
Objective respiratory measures did not differ significantly across the groups, apart from breathing rate.
Holloway and West, Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial , Thorax 2007; 62(12): 1039-1042
Therapeutic ExerciseStrength, power, and endurance training for
head, neck, limb, pelvic-floor, trunk, and ventilatory musclesMore efficient motion
Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)
Aquatic programsStandardized, programmatic, complementary exercise
approachesTask-specific performance training
Strength, Power, and Endurance Training for Trunk, Extremities and Ventilatory Muscles
Mode AAROM, AROM Resistance
Manual Weights
Intensity Incorporate breathing with resistance Resistance may start light and work up
8-12 reps, 1-3 sets Resistance of 1 rep max and then calculate
8-10 reps at 70% of max, 6 reps at 80% of max, 4 reps at 90% of max, 2 reps at 95% max and finally 1 rep at max
High weight, low reps for strength Low weight, high reps for endurance
Duration
Frequency Every other day or rotate muscle groups
Strength - Evidence Systematic review to determine the effect of inspiratory muscle training
(IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis.
Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (413 years
of age) (2) an IMT group was compared to a sham IMT, no intervention or other
intervention group (3) the study used a randomized controlled trial or cross-over design (4) it was published
Results: The search strategy yielded 36 articles Meta-analyses were limited to forced expiratory volume in 1 second (FEV1)
and forced vital capacity (FVC) No difference in effect between the IMT group and the sham and/or
control group. Individual study results were inconclusive for improvement in inspiratory
muscle strength One study demonstrated improvement in inspiratory muscle endurance.
Conclusion: The benefit of IMT in adolescents and adults with cystic fibrosis for
outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear
Reid et al, Effects of inspiratory muscle training in cystic fibrosis: a systematic review, Clinical Rehabilitation. London: Oct 2008. Vol. 22, Iss. 10-11
Goals and Outcomes Impact on Pathology
Atelectasis Joint swelling, inflammation, restrictionNutrient delivery Osteogenic effects of exercise Pain Physiological responseSoft tissue swelling, inflammation,
restrictionIncreased oxygen demand symptomsTissue perfusion and oxygenation
Goals and Outcomes Impact on Impairments
Aerobic capacity is increased.Airway clearance is improved.Balance is improved.Endurance is increased.Energy expenditure per unit of work is decreased. Gait, locomotion, and balance are improved.Integumentary integrity is improved.Joint integrity and mobility are improved.Motor function (motor control and motor learning) is improved.Muscle performance (strength, power, and endurance) is increased.Postural control is improved. Quality and quantity of movement between and across body
segments are improved.Range of motion is improved.Relaxation is increased.Sensory awareness is increased.Ventilation and respiration/gas exchange are improved. Weight-bearing status is improved.Work of breathing is decreased
Goals and Outcomes Impact on Functional Limitations and DisabilitiesFunctional Limitations
Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.Performance of and independence in ADL and IADL with or without devices and equipment are increased.Tolerance of positions and activities is increased.
Impact on disabilitiesAbility to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.
Goals and Outcomes Risk Reduction/Prevention Health, Wellness, and Fitness
Risk Reduction/PreventionPreoperative and postoperative complications are
reduced. Risk factors are reduced.Risk of recurrence of condition is reduced.Risk of secondary impairment is reduced.Safety is improved.Self-management of symptoms is improved.
Impact on Health, Wellness, and FitnessFitness is improved.Health status is improved.Physical capacity is increased.Physical function is improved.
Goals and Outcomes Impact on Societal Resources& Patient Satisfaction
Societal ResourcesUtilization of physical therapy services is optimized.Utilization of physical therapy services results in efficient use of health care dollars.
Patient/client SatisfactionAccess, availability, and services provided are acceptable to
patient/client.Administrative management of practice is acceptable to
patient/client.Clinical proficiency of physical therapist is acceptable to
patient/client.Coordination of care is acceptable to patient/client.Cost of health care services is decreased.Intensity of care is decreased.Interpersonal skills of physical therapist are acceptable to
patient/client, family, and significant others.Sense of well-being is improved.Stressors are decreased.