Therapeutic exercise:

foundational concepts
Chapter 1
THERAPEUTIC EXERCISE: IMPACT
ON PHYSICAL FUNCTION
Therapeutic Exercise
• Is the systematic, planned performance of bodily
movements, postures, or physical activities intended
to provide a patient/client with the means to:
• Remediate or prevent impairments
• Improve, restore physical function
• Prevent health-related risk factors
• Optimize overall health status
Contd…
• Patient is an individual with impairments and functional
limitations diagnosed by a physical therapist who is
receiving physical therapy care to improve function and
prevent disability.

• Client is an individual without diagnosed dysfunction

who engages in physical therapy services to promote
health and wellness and to prevent dysfunction.
ASPECTS OF PHYSICAL FUNCTION
• The ability to function independently at home, in the
workplace, within the community, or during leisure and
recreational activities is contingent upon physical as well
as psychological and social function.
• The multidimensional aspects of physical function
encompass the diverse yet interrelated areas of
performance.
• These aspects of function are characterized by the
following definitions.
Balance
• The ability to align body segments against gravity to
maintain or move the body (center of mass) within the
available base of support without falling; the ability to
move the body in equilibrium with gravity via interaction
of the sensory and motor systems.
Cardiopulmonary fitness
• The ability to perform low intensity, repetitive, total body
movements (walking, jogging, cycling, swimming) over
an extended period of time, a synonymous term is
cardiopulmonary endurance.
Coordination
• The correct timing and sequencing of muscle firing
combined with the appropriate intensity of muscular
contraction leading to the effective initiation, guiding,
and grading of movement. It is the basis of smooth,
accurate, efficient movement and occurs at a conscious
or automatic level.
Flexibility
• The ability to move freely, without restriction; used
interchangeably with mobility.
Mobility
• The ability of structures or segments of the body to
move or be moved in order to allow the occurrence of
range of motion (ROM) for functional activities
(functional ROM). Passive mobility is dependent on soft
tissue (contractile and noncontractile) extensibility; in
addition, active mobility requires neuromuscular
activation.
Muscle performance
• The capacity of muscle to produce tension and do
physical work. Muscle performance encompasses
strength, power, and muscular endurance.
Neuromuscular control
• Interaction of the sensory and motor systems that enables
synergists, agonists and antagonists, as well as stabilizers and
neutralizers to anticipate or respond to proprioceptive and
kinesthetic information and, subsequently, to work in correct
sequence to create coordinated movement.
Stability
• The ability of the neuromuscular system through synergistic
muscle actions to hold a proximal or distal body segment in a
stationary position or to control a stable base during
superimposed movement. Joint stability is the maintenance
of proper alignment of bony partners of a joint by means of
passive and dynamic components.
• The systems of the body that control each of these
aspects of physical function react, adapt, and develop in
response to forces and physical stresses (stress force/
area) placed upon tissues that make up body systems.
• Gravity, for example, is a constant force that affects the
musculoskeletal, neuromuscular, and circulatory systems.
• Additional forces, incurred during routine physical
activities, help the body maintain a functional level of
strength, cardiopulmonary fitness, and mobility.
• Imposed forces and physical stresses that are excessive
can cause acute injuries, such as sprains and fractures, or
chronic conditions, such as repetitive stress disorders.
• The absence of typical forces on the body can also cause
degeneration, degradation, or deformity.
• For example, the absence of normal weight bearing
associated with prolonged bed rest or immobilization
weakens muscle and bone.
• Prolonged inactivity also leads to decreased efficiency of
the circulatory and pulmonary systems.
• Impairment of any one or more of the body systems and
subsequent impairment of any aspect of physical
function, separately or jointly, can result in functional
limitation and disability.
• Therapeutic exercise interventions involve the
application of carefully graded physical stresses and
forces that are imposed on impaired body systems,
specific tissues, or individual structures in a controlled,
progressive, safely executed manner to reduce physical
impairments and improve function.
THERAPEUTIC EXERCISE
INTERVENTIONS
• Aerobic conditioning and reconditioning
• Muscle performance exercises: strength, power, and
endurance training
• Stretching techniques including muscle-lengthening
procedures and joint mobilization techniques
• Neuromuscular control, inhibition, and facilitation
techniques and posture awareness training
• Postural control, body mechanics, and stabilization
exercises
• Balance exercises and agility training
• Relaxation exercises
• Breathing exercises and ventilatory muscle training
• Task-specific functional training
Exercise Safety
• Safety is a fundamental consideration in every aspect of
the program.
• Prior to engaging in exercise, a patient’s health history
and current health status must be explored.
• Risk factors must be identified.
• Environment also affects patient safety
• Adequate space and a proper support surface for exercise
are necessary prerequisites.
Contd…
• The accuracy with which a patient performs an exercise
affects safety including
• proper posture or alignment of the body
• execution of the correct movement patterns,
• performing each exercise with the appropriate intensity, speed,
and duration.
• The risk of injury or re-injury is minimized by effective
exercise instruction and patient education.
• The therapist must incorporate principles of proper body
mechanics and joint protection into these manual
techniques to minimize his or her own risk of injury.
Process & models of disablement

• Physical therapy profession is defined by a body of

knowledge and clinical applications that are directed
toward the elimination of disability.
• Disablement is a term that refers to the impact(s) and
functional consequences of acute or chronic conditions,
such as disease, injury and congenital or developmental
abnormalities on specific body systems that compromise
basic human performance.
Contd…
• The process is not unidirectional; that is, it is not
necessarily unpreventable or irreversible.
• Disablement process shifts the focus of patient
management from strict treatment of a disease or injury
to treatment of the impact that a disease or injury has on a
patient’s function.
Models of disablement
• Several models that depict the process of disablement
have been proposed over the past 40 years.
• First two schema:
• Nagi model
• International Classification of Impairments, Disabilities,
and Handicaps (ICIDH).
• The National Center for Medical Rehabilitation Research
(NCMRR) integrated components of the Nagi model with
the original ICIDH model to develop its own model.
• The NCMRR model added interactions of individual risk
factors, including physical and social factors, to the
disablement process.
Contd…
• Each taxonomy reflects the complex interrelationships
among the following.
• Acute or chronic pathology
• Impairments
• Functional limitations
• Disabilities, handicaps, or societal limitations

• CRITICS
• It focus on disease and a medical-biological view of
disability as well as their lack of attention to the person
with a disability
Contd…
• Through a comprehensive consensus process WHO
developed the International Classification of Functioning,
Disability, and Health (ICF).
• This model is characterized as a bio-psycho-social model
of disablement consists of the following components:
• Impairment of body structure (anatomical) and function
(physiological)
• Activity limitation
• Participation restriction
• Impact of contextual factors
Components of
disablement process
• Pathology
• Impairments
• Functional limitations
• Disability
Pathology
• It refers to disruptions of the body’s homeostasis as the
result of acute or chronic diseases, disorders, or
conditions characterized by a set of abnormal findings
that are indicative of alterations or interruptions of
structure or function of the body primarily identified at
the cellular level.
• Identification and classification of these abnormalities of
anatomical, physiological, or psychological structure or
process generally trigger medical intervention based on a
medical diagnosis.
• Despite an accurate medical diagnosis and a therapist’s
thorough knowledge of specific pathologies, the
experienced therapist knows full well that two patients
with the same medical diagnosis, such as rheumatoid
arthritis, and the same extent of joint destruction
(confirmed radiologically) may have very different
severities of impairment and functional limitation and,
consequently, very different degrees of disability
• There is need for physical therapists to always pay
close attention to the impact(s) of a particular pathology
on function when designing meaningful management
strategies to improve functional abilities.
Impairments
• Impairments are the consequences of pathological
conditions; that is, they are the signs and symptoms that
reflect abnormalities at the body system, organ, or tissue
level.
• Common physical impairments
• Musculoskeletal
• Neuromuscular
• Cardiovascular/pulmonary
• Integumentary
Contd…
• TYPES OF IMPAIRMENTS:
• Direct/ primary:
• Primary Impairments may arise directly from the
pathology.

• Indirect/secondary:
• Due to the result of preexisting impairments
• A patient, for example, who has been referred to physical
therapy with a medical diagnosis of impingement syndrome
or tendinitis of the rotator cuff (pathology) may exhibit
primary impairments, such as pain, limited ROM of the
shoulder, and weakness of specific shoulder girdle and
glenohumeral musculature during the physical therapy
examination. The patient may subsequently develop
secondary postural asymmetry because of altered use of the
upper extremity.
• Composite impairment:
• The result of multiple underlying causes and arises from
a combination of primary or secondary impairments.
• For example, a patient who sustained a severe inversion
sprain of the ankle resulting in a tear of the talofibular
ligament and whose ankle was immobilized for several
weeks is likely to exhibit a balance impairment of the
involved lower extremity after the immobilization order
is removed. This composite impairment could be the
result of chronic ligamentous laxity and impaired ankle
proprioception from the injury or muscle weakness due to
immobilization and disuse.
Contd…
• An important key to effective management of a
patient’s problems is to recognize functionally
relevant impairments
• The focus of treatment must still be on
restoration of function and prevention of
dysfunction.
Functional limitation

• They are the result of impairments and are characterized

by the reduced ability of a person to perform actions or
components of motor skills in an efficient or typically
expected manner.
• WHO to denote functional limitation is “ability
limitation,” as defined in the ICF model of functioning
and disability.
• Functional limitations may be physical, social, or
psychological in nature.
Contd…
• Types of Functional Limitations
• Functional limitations in the physical domain deal with
the performance of sensorimotor tasks, that is, total body
actions that are typically components or elements of
functional activities.
• These activities include
• Basic activities of daily living (ADL)
• Instrumental activities of daily living (IADL)
Disability
• A disability is the inability to perform or participate in
activities or tasks related to one’s self, the home, work,
recreation, or the community in a manner or to the extent
that the individual or the community as a whole perceive
as “normal
• It encompasses individual functioning in:
• ADLs
• Complex daily living
• Societal functioning
Prevention
• The perception of disability can be minimized if the
patient’s functional ROM and strength can be improved
with an exercise program and the increased ROM and
strength are incorporated into progressively more
challenging functional activities with the use of adaptive
equipment and assistive devices.
• Adjusting expected roles or tasks within the family may
also have a positive impact on the prevention or reduction
of disability.
Contd…
• Prevention falls into three categories.
2

• Primary prevention: Activities such as health promotion

designed to prevent disease in an at-risk population
• Secondary prevention: Early diagnosis and reduction of
the severity or duration of existing disease and sequelae
• Tertiary prevention: Use of rehabilitation to reduce the
degree or limit the progression of existing disability and
improve multiple aspects of function in persons with
chronic, irreversible disease
Risk factors
• Risk factors related to disablement are influences or
characteristics that predispose a person to the process of
disablement
• Intervention for reducing or preventing the major
components of the disablement process
• Factors increase risk factor:
• Biological characteristics,
• Lifestyle behaviors,
• Psychological characteristics,
• Impact of physical and social environments.
Contd…
• BUFFERS:
• When active pathology exists, the reduction of risk
factors by means of buffers (interventions) is appropriate
• EXAMPLES:
• Regular exercise program
• Increasing level of physical activity
• Removing architectural barriers
• Use of assistive devices
PATIENT MANAGEMENT AND
CLINICAL DECISION MAKING
• Clinical Decision Making
• It refers to a dynamic, complex process of reasoning and
analytical (critical) thinking that involves making
judgments and determinations in the context of patient
care.
• Areas of clinical decision making in which a therapist
involved is:
• Selection
• Implementation
• modification of therapeutic exercise interventions
Evidence-Based Practice

• It involves
• Combining knowledge of evidence from well
designed research studies
• Expertise of the clinician
• Values, goals, and circumstances of the patient.
Contd…
• It involves the following steps:
• Identify a patient problem and convert it into specific
question
• Search literature and collect clinically relevant, scientific
studies
• Critically analyze the evidence and make reflective
judgments
• Integrate the appraisal of the evidence with clinical
expertise and experience and the patient’s unique
circumstances and values to make decisions.
• Incorporate the findings into patient management.
• Assess the outcomes of interventions
Patient Management Model

• The patient management process culminates

in the attainment of meaningful, functional
outcomes by the patient, which then must be
re-examined and re-evaluated before a
patient’s discharge.
Examination
• It is the systematic process by which a therapist obtains
information about a patient’s problem(s) and his or her
reasons for seeking physical therapy services.
• The examination process involves both comprehensive
screening and specific diagnostic testing
• Elements of a comprehensive examination:
• The patient’s health history
• A relevant systems review
• Specific tests and measures
History
• The history is the mechanism by which a therapist obtains
an overview of current and past information (both
subjective and objective) about:
• patient’s present condition(s),
• general health status
• why patient sought physical therapy services.
• Sources of information about the patient’s history include:
• Self-report health history questionnaires filled
• Interviews with the patient, family
• Review of medical record
• Reports from the referral source
Systems Review
• A brief but relevant screening of the body systems,
known as a systemic review
• It is performed during the patient interview as a part of
the examination process after organizing and prioritizing
data obtained from the health history.
• The greater the number of health-related risk factors
identified, the greater is the importance of the review of
systems.
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Specific Tests and Measures
• Specific (definitive/diagnostic) tests and measures used
by physical therapists provide in-depth information about
impairments, functional limitations, and disabilities
• These specific tests and measures establish objective
baselines from which changes in a patient’s physical
status as the result of interventions are measured.
• EXAMPLE:
• Specific tests and measures that identify musculoskeletal
impairments are:
Contd…
• Assessment of pain
• Goniometry
• Joint mobility, stability, and integrity tests (including
ligamentous testing)
• Tests of muscle performance (manual muscle testing,
dynamometry)
• Posture analysis
• Gait analysis
• Assessment of assistive, adaptive, or orthotic devices
Contd…
• An in-depth examination of impairments by means of
diagnostic tests provides valuable information about
the extent and nature of the impairments and is the
foundation of the diagnosis made by a physical
therapist.
• Examination should also include use of instruments
that specifically measure functional limitations and
disability, often referred to as functional outcome
measures.
Evaluation
• Evaluation is a process characterized by the
interpretation of collected data.
• The process involves analysis and integration of
information to form opinions by means of a series of
sound clinical decisions.
• During the evaluation it is particularly useful to ascertain
if and to what extent relationships exist among
measurements of impairments, functional limitations, and
the patient’s perceived level of disability.
Diagnosis
• The diagnosis is an essential element of patient
management because it directs the physical
therapy prognosis (including the plan of care)
and interventions
• The term diagnosis can be used in two ways:
• Diagnostic Process
• Diagnostic Category
Diagnostic Process

• The diagnostic process is a complex sequence of

actions and decisions that begins with:
• collection of data(examination)
• analysis and interpretation of all relevant data
• organization of data, formation of a diagnostic
hypothesis, and subsequent classification of data
into categories
• This process is necessary prerequisite for treatment
Contd…
• Diagnostic Category
• A diagnostic category (classification) is a grouping that
identifies and describes patterns or clusters of physical
findings (signs and symptoms of impairment, functional
limitation, and disability).
• Preferred practice patterns
• Are identified by the diagnostic categories, represent
consensus-based opinions that outline broad patient
management guidelines and strategies used by physical
therapists for each diagnostic category
Prognosis and Plan of Care
• A prognosis is a prediction of a patient’s optimal level of
function expected as the result of a course of treatment and
the anticipated length of time needed to reach specified
functional outcomes.
• The accuracy of the prognosis is based on the following:
1.Familiarity with the patient’s condition including the
pathology and the surgical interventions
2.Thorough knowledge of the process and time frames of tissue
healing
3.Experience managing patients with similar pathologies,
impairments, and functional limitations
4.Knowledge of the efficacy of tests and measures and physical
therapy interventions
Contd…
• The plan of care, an integral component of the prognosis,
delineates the following.
• Anticipated goals
• Expected functional outcomes
• Extent of improvement predicted and length of time
necessary to reach that level
• Specific interventions
• Proposed frequency and duration of interventions
• Specific discharge plans
Intervention
• Intervention, a component of patient management, refers
to any purposeful interaction a therapist has that directly
relates to a patient’s care
• Areas of intervention are:
• Coordination, communication, and documentation
• Procedural interventions
• Patient-related instruction
Contd…
• Coordination, Communication, and Documentation
• This aspect of intervention encompasses:
Patient- related administrative tasks.
Professional responsibilities, such as writing reports
(evaluations, plans of care, discharge summaries),
Designing home exercise programs.
Contacting other health care practitioners
Contd…
• Procedural Interventions
• Procedural intervention pertains to the specific
procedures used during treatment, such as therapeutic
exercise, functional training, or adjunctive modalities
(physical agents and electrotherapy).
• The effectiveness of procedural interventions should be
supported by sound evidence.
• To reduce functional limitations not only therapeutic
exercise but exercises should be task-specific.
Contd…
• Effective use of any procedural intervention must
include determining the:
• Appropriate intensity,
• Frequency,
• Duration of each intervention
• Periodic reexamination of a patient’s responses to
the interventions
Outcomes
• Outcomes are results
• Measurement of out-comes is a means by which quality,
efficacy, and cost-effectiveness of services can be
assessed.
• Outcomes are monitored throughout an episode of
physical therapy care, that is, intermittently during
treatment and at the conclusion of treatment
• Functional Outcomes
• Functional outcomes must be meaningful, practical, and
sustainable.
Discharge Planning
• A patient is discharged from physical therapy services
when the anticipated goals and expected outcomes have
been attained
• The discharge plan often includes:
 Home program
Appropriate follow-up
Possible referral to community resources
Reinitiation of physical therapy services
Discontinuation refers to the ending of services prior
to the achievement of anticipated goals and expected
outcomes