Principles of Therapeutic Exercise Prescription Week 4 Jane

Principles of Therapeutic Exercise Prescription Week 4 Jane Simmonds

Format • Exercise in the context of the physiotherapy profession and practice • Review the principles of training • Review the different types of exercise • Explore the concept of exercise prescription for the prevention and management of diseases and disorders • Review muscle physiology

Learning Outcomes • By the end of the session and independent study you should; – Understand the cope of exercise used in physiotherapy practice – Understand the principles of training – Understand the concept of training variables

Core Skills - Physiotherapy • • Movement analysis Manual therapy Electrotherapy Exercise therapy – exercise prescription (ACPET)

Exercise for the prevention of disease • Relationship between a sedentary lifestyle and chronic degenerative disorders • More than 20 disorders related to inactivity • 50 years of research – Seminal research bus conductors – Parffenbarger’s research • Physiotherapists have a role to play in health promotion Morris & Crawford 1958

Therapeutic Exercise • Prevent or rehabilitate disabilities • Improve or restore physical function so that ADL’s are no longer a challenge • Improve overall health and fitness • Reduce risk factors Rehabilitation Cycle Functional fitness and rehabilitation Early to middle management

Which patients groups benefit from therapeutic exercise? • • • Cardiac patients Orthopaedic patients Amputees General surgical Neurological Elderly Learning disabilities Psychiatric Palliative care • • • Respiratory Paediatric Rheumatology Musculo-skeletal Occupational Spinal injuries Obstetrics Gynacological Burns and plastics

Aims of Therapeutic Exercise • • • Enable ambulation Release contracted soft tissues Mobilise joints Improve circulation Improve respiratory capacity Decrease stiffness

Aims of Therapeutic Exercise • • • Improve muscle strength Improve endurance Improve co-ordination Promote confidence and wellbeing Improve balance Promote relaxation

Overarching Goal • To try whenever possible to restore full function and achieve an optimal level of physical fitness. • Achieve this by setting shared realistic goals and identifying how fit the client needs to be. • Motivation • Adherence, compliance and concordance

Designing Exercise Programmes • When designing an exercise programme consider; • Pathology • Person (age, personality – psychology) • Needs - aspirations • Environment • Physiological processes • Principles of training

Types of Exercises • Stretching • Range of movement exercises • Strengthening exercises • Endurance exercises • Proprioceptive or balance training • Cardio-vasacular training

Principles of Training • • Readiness Overload Specificity Motivation Learning Reversibility Diminishing returns

Prescription Variables • • • 5 key components Frequency Duration Intensity Type of exercise Progression

Stretching • Passive or active • Stretching to retain range e. g. joint pathology • Stretching to increase normal range e. g. sport and dance • Stretching to lengthen contracted, fibrosed, shortened tissue e. g. congenital conditions, postsurgery/immobilisation/inju ry • How long should we stretch for?

Mobility Exercises • Active assisted Ø Usually used as interim measure moving from passive to active, also when joint pain limits free active movement • Free active • Knowledge of aging and pathologies required to prevent undesirable movements e. g. trunk flexion exercises in osteoporosis

Cardio-respiratory Exercise • Aerobic exercise positive influence on risk factors in CVD, diabetes, weight control and cancer. • Rehabilitation programmes for cardiac and pulmonary patients • Incremental monitored progression of exercise • Early on: exercise not more than 20 bpm above resting level and not more than 11 -12 on RPE (40% Vo 2 max) • 40 -80% MHR depending on fitness (MHR =220 -age) • Isometric exercises for vulnerable patients advise isometric contraction ≤ 6 secs each

Monitoring • Why is monitoring important? • Heart rate ØPulse monitor, ECG, chest strap • Blood pressure ØSystolic/diastolic • Subjective measure ØRating of perceived exertion (RPE)

Borg Scale

Proprioception • Essential post-injury especially lower limb • Retraining for amputees and neuro patients • Elderly rehab, altered joint biomechanics in OA. ? May prevent falls

Muscle Contractions and Resistance Exercises • Consider why we might choose these different types of exercises? • Are there any risks? • Isometric • Concentric • Eccentric • Isokinetic • Closed and open chain exercises

Strength, Power and Endurance • • • What is the difference? Load (resistance) Repetitions Sets Frequency Consider muscle fibre type

Muscle Fibre Types • Skeletal muscle fibers are classified into two major categories; slow-twitch (Type 1) and fast-twitch fibers (Type II). • The difference between the two fibers can be distinguished by; – metabolism – contractile velocity – neuromuscular differences – glycogen stores – capillary density of the muscle – and the actual response to hypertrophy

Fibre Type • Slow twitch – type 1 – – – Rich in haemaglobin Mitochondria Rich in blood vessels Red Common postural muscles. • Slow twitch – type II • Type II a - fast oxidative fatigue resistant – fast oxidative fibres • Type II (b)x - fast glycolytic fibres - split ATP at a fast rate and have a fast contraction velocity.

Progressing Exercise • • Overload principle Motivation principle Strength? Endurance? Power? Complexity of task Functional

Exercise Prescription • Exercise prescription is based on physiological principles and laws of training and modified by clinical findings. – Pain – Underlying medical conditions – diabetes, cardiovascular disease, diabetes, psychological factors etc. – Safety

Exercise prescription requires a detailed knowledge of; • • • Motor learning Anatomy Biomechanics/pathomechanics Kinesiology Pathology Exercise physiology

Exercise Psychology • Adherence, compliance and concordance • Goals • Patient factors: age, sex, socio-economics, fear, self-efficacy, support • Programme factors: personnel, education, attention, group dynamics, logistics

Summary • Exercise prescription is a core skill for physiotherapists • Underpinned by physiological and patho-physiological processes • Requires a good understanding of exercise physiology and the principles of training • Motivational psychology - stages of change • Imagination

References • Hanandez Kravitz (2006) http: //www. unm. edu/~lkravitz/Article%20 folder/hypertrophy. html • Robergs, R. A. and S. O. Roberts(1997) Exercise Physiology: Exercise, Performance, and Clinical Applications. Boston, WCB Mc. Graw-Hill • National Institute on Aging (2005) www. niapublications. org/exercisebook/chapter 4. htm. • Skinner JS (2005) Exercise Testing and Exercise Prescription for Special Cases. Philadelphia, Lippincott, Williams & Wilkins • Woolf-May K (2006) Exercise Prescription – physiological foundations. Churchill Livingstone