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Thread: Therapeutic Exercise Techniques

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    Lightbulb Therapeutic Exercise Techniques

    INTRODUCTION



    Exercises performed on a patient to achieve therapeutic benefit are called

    Therapeutic Exercises. These exercises are classified as follows:

    • Coordination exercises

    • Balance training

    • Gait training

    • Strengthening exercises

    • Relaxation exercises

    • Mobilization exercises

    • Endurance exercises

    • Re-education

    • Massage techniques



    COORDINATION EXERCISES



    Definition



    Coordination is needed for performing precise smooth and purposeful movement involving multimuscular activity superimposed on an efficient postural background. It is the process that results in activation of motor units of multiple muscles with simultaneous inhibition of all other muscles in order to carry out a desired activity.



    Components of Coordinated Activity



    • Volition- ability to initiate, maintain or stop an activity.

    • Perception-intact proprioception and subcortical centres to integrate motor impulses and the sensory feedback. When proprioception is affected it is compensated with visual feedback.

    • Engram Formation- an engram represents the neurological

    muscular activity developed in the extrapyramidal system. Research proved that 20,000 to 30,000 repetitions of precise performance must performed in order to develop an engram. This is why, to t such as driving, it is necessary to keep practising it over and over again becomes an engram.



    Indications for Coordination Training



    • Lesions of cerebellum resulting in Cerebellar ataxia.






    /

    - Lesions in the posterior column of the spinal cord resulting in sensory ataxia. Incoordination may also result from lesions affecting the muscle, the

    peripheral nerve or the upper motor neurons.

    In these cases since the incoordination is the result of muscle weakness, hypo- or hypertonicity, it does not fall under the category of primary incoordination, and other measures like muscle strengthening, relaxation are used.



    General Principles of Coordination Training



    • Learning environment, i.e. an environment which provides for attention to tasks, is created.

    • Activities are broken down into components that are simple enough to be performed correctly. If the patient has very poor coordination, it may be necessary to completely desynthesise the multimuscular movement and practice the contraction of an individual prime mover.

    • Assistance is provided whenever necessary, to maintain precision so that the patient concentrates on sensations produced by the activity.

    • Fatigue may occur during attempts for precision and may decrease the concentration of the patient. The patient should therefore have a short rest after two or three repetitions.

    • Repetition-as stated before 20,000 to 30,000 repetitions of precise performance must be performed for the engram to form.

    0 Whenever a new movement is trained, various inputs are given simultaneously, like instruction (auditory), sensory stimulation (with touch), or positions in which the patient can view the movement (visual stimulation). If necessary the therapist may demonstrate with a passive movement on the patient which will provide a kinaesthetic feedback.

    0 The rate of performance should be slowed with each new addition to a pattern.

    • Progression of the technique involves:

    -Increasing the range of movement during the activity.

    - Increasing the complexity- where more muscles get involved. -Increasing the speed.

    - Removing the sensory feedback that is given.



    Frenkel's Exercises



    Dr. HS Frenkel was a physician from Switzerland who aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.







    . Each patient should have individual attention, and should not be left unattended in case he should fall and injure himself.

    • The patient should be adept in each exercise or set of exercises, before he is allowed to proceed to a more difficult one.



    • Strong muscle contractions should not be given since progression is by complexity, not strength.

    • The patient should practise exercises first with his eyes open, and then eyes closed.

    • Movements in complete range are preferred to those in small range,

    beginn g.

    • Such movements should be given rapidly, then more slowly.

    • Exercises are prescribed for the upper and lower extremities in positions-sitting, lying, etc



    Examples



    Sometimes all this is quite boring especially for children. Diversionar such as playing with putty building with toy bricks, or drawing on tailing the donkey lead to more useful movements such as using a knife fork, doing up buttons and doing the hair. Transfer of objects from one to the other, playing cricket or throw ball are examples of play therap3 " coordination.

    BALANCETRAINING

    Almost all our daily activities are performed under the influence of gravity. Most of our time is spent in reacting to the effects of gravity upon the body.

    Protective responses in maintaining balance are considered to have survival value by preventing us from falling as well as enabling us to maintain our sense 0fverticality.

    Posture is the word used to describe any position of the human body. Balance and posture are interrelated. Depending upon the base and the position of the centre and line of gravity a body is either balanced in equilibrium-or not.

    The maintenance of balance is dependent upon the integration of sensory input from exteroceptors, proprioceptors and the special senses - the eyes and the vestibular apparatus, and on an integrated motor system and the basic postural reflexes in the normal individual. Balance is maintained almost completely at a subconscious level. In retraining a patient's balance the patient must be trained to react to stimuli rather than to make a conscious effort to maintain equilibrium.

    Balance, therefore, is the basis of all static or dynamic postures and should be considered when planning any exercise or rehabilitation programme. It should not be confined to patients with neurological conditions.

    There are two approaches to balance, both of which are necessary for normal function-static balance and dynamic balance.



    Static Balance

    This approach is based upon PNF principles and techniques. Static balance is the rigid stability of one part of the body on another and is based upon isometric and cocontraction of muscles.

    As a general principle balance is developed progressively by moving from the most stable to the least stable position, for example from forearm support prone lying to standing without support.

    0 Stability and control of the head should be established first, as it is vital in all

    positions

    = Strong neck and back muscles can then be used to reinforce muscle contraction elsewhere, e.g. fighting reactions, which are involuntary movement responses to stimuli, serving to maintain the alignment of the head and body in normal upright posture in space.



    I)ynamic Balance



    The body, unless it is fully supported and relaxed, is in a constant state of adjustment to maintain its posture and its equilibrium. The body's reactions to maintain its equilibrium will vary in degree.



    Equilibrium Reactions



    It is an involuntary automatic movement response to a disturbance in the base of the body, that serves to maintain or regain balance during posture and movement.


    These balance reactions may occur in two ways:

    An adjustment in tone

    An adjustment in posture



    Method of Stimulation



    For balance to improve in a position, the patient must be assisted to assume that position. Man's body axis is vertical, and it is in the vertical position, that he needs the ability to withstand the effects of gravity.

    Analysis of balance reactions and body alignment in responses to shifts in weight will identify the missing or abnormal components, which require specific stimulation. For example, the regaining of balance in a lateral direction requires movement of the head and trunk laterally, with elevation of the pelvis. Any one or all of the components of balance may be missing and must be stimulated by the therapist.

    Alternate tapping stimulates balance in antigravity positions. Gentle taps are applied alternately to the upper trunk with the body in normal alignment. The effect should be to displace the patient slightly off balance in alternate directions, which will stimulate the necessary adjustments. It must be stressed that the displacement should be small so as to stimulate only fine adjustments.



    Maintenance of Position



    The patient is instructed to maintain the position, for example, prone kneeling, kneeling, sitting or standing against the therapist's tappihg technique to displace him backwards, forwards and laterally.

    The use of a moving support is valuable in some positions. There are three basic types:

    • A balance board,

    • A roll which can be made of a cardboard tube, and

    • Therapeutic ball

    If balance reactions fail, protective extension (saving reactions) of the arms is one of the most important reactions. (Parachute reflex)



    Some General Points of Treatment



    In general, movement is stimulated smoothly and steadily, in a small range initially, gradually increasing the range as the patient gains more control. Any position can be made more stable by using pressure and approximation and by giving the patient more than one fixed point of stability. Too much emphasis on stability would prevent the patient from moving or trying to move. On the other hand, too much stimulation of movement might result in loss of balance and the confidence to regain it. The use of weights worn by the patient is sometimes suggested as a means of improving movement control.



    Balance Boards

    Balance boards are primarily used to re-educate balance and increase the strength of the muscles of the lower leg. They consist of a platform,


    GAIT

    be either rectangular or circular, resting on curved supports. The aim of the .exercise is that the subject should learn to maintain balance while sitting, kneeling or standing on its central portion.



    Gait or human locomotion, may be described as a translatory progression of the body as a whole, produced by co-ordinated movements of body segments. It is the forward progression of the center of gravity of the body, based on the reciprocal movements of the lower extremities. Normal gait is rhythmic and characterized by alternating propulsive and stabilising motions of lower extremities. ,Each person has his own characteristic gait pattern.

    Normal human gait requires the normal functioning of the limbs and spine. Good sensory feedback from the feet and the joints, visual and labyrinthine sensory inputs add to the smoothness, rhythm and elegance of the human gait.

    The centre of gravity of the body is a point in front of the body of 2nd sacral vertebra.



    Gait Cycle



    The gait cycle includes the activities that occur from the point of initial heel contact of one lower extremity to the point at which the heel of the same

    extremity contacts the ground again. Gait is divided into 2 phases: 1. Stance 2. Swing.



    ) percent of the total duration of the Gait Cycle, when the foot is with the ground.



    when the foot is off the ground, forms 40 percent of the cycle. There is a

    .g 11 percent of the cycle when both legs are on the ground. This called Double Stance.

    Energy is used up in walking at the initiation of movement (acceleration), nd when coming to a stop (deceleration). More energy is consumed during



    The path taken by the centre of gravity determines the energy expenditure

    of Gait. Given the situation, the ideal path should be a sinusoidal with minimum displacement.



    $tudying Normal Human Locomotion



    Factors:

    The force of gravity

    • Forces exerted by muscular contraction

    • Effects of inertia

    • Angular relationship between the segments


    Gait Analysis



    • Description of gait pattern and gait variables

    • Description of all gait deviations

    • Anatysis of the deviations

    • Energy expertditue and endurance



    • Capabilities of the patient in functional ambulation

    • Demands of the home and community environment.



    Quafitafive Gait Analysis



    Four different reference systems:

    • Absolute spatial system: The environment is used as a reference.



    • Relative system: The position of one body segment is described in relation another body segment.

    • Absolute reference system: The body segment is described in reference the v#rt'ical or horizontal position.

    • Relative reference system: The excursion of a body segment from one positid to another.



    Observational Gait Analysis



    • Measure the distance that you want the patient to cover

    • Have an unobstructed view of the patient

    • Select the joint or segment to be assessed

    • Select sagittal plane observation or a frontal plane observation

    • Observe during the initial part of the stance phase. Note any deviations froM the normal

    • Repeat the process until completed assessment of all segments in the sagittal1 and frontal planes. Concentrate on one segment at a time in one part'of the! gait cycle. Perform observations on both sides (right and left).



    DETERMINANTS OF GAIT

    The factors modifying the path taken by the centre of gravity, to smoothen out its extreme movements and reduce the amplitude of displacement, sideways and vertically, are called Deteninants of Gait.

    • Pelvic rotation: The pelvis rotates by 4 degree on either side, and elevates the lower end of the center of gravity by 6/16"

    • Pelvic tilt: The pelvis drops on the side of swinging leg (action of abductors of opposite side). This saves vertical excursion by 3/16"

    • Knee flexion: During mid stance, this decreases leg length and height of center of gravity by 7/16". Thus the total saving in the vertical excursion of


    center of gravity 7/16" + 3/16" + 6/16" = 1 inch., the other determinants function to smoothen out the movement of the Center of gravity ' Knee and ankle: Movement smoothens out the vertical excursion to 2"

    amplitude

    , Pelvic sway: This is the sideways sway of pelvis, brings the center of gravity over 1 leg and produces a side to side sinusoidal curve

    • Limb rotation: The leg goes into a total of 25 degree internal rotation on stance and external rotation on swing, smoothening out the sideways curve.

    Stride Length: The distance between heel strike of one leg and heel strike of same leg. This is approximately 156 cm on an average.

    Step Length: The distance between heel strike of one foot to heel strike of the other foot (1/2 of stride length).

    Skide Width: This is the distance between midline of one foot to mid line of the other. It works out to 8 cm -+ 4 cm.

    Toe out angle: The angle made by the midline of foot to direction of propulsion. It varies from 6-7 degrees.

    Cadence: This is the number of steps per minute. It ranges from 80 to 120 steps per minute depending on the speed of the gait. The mean duration of Gait cycle is nearly I sec.



    PATHOLOGICAL GAITS
    gaits may be due to neurological or orthopaedic causes as a result

    of:

    Pain during movement

    ' Loss of muscle power

    ' Increased or fluctuating muscle tone

    , Incoordination of muscles

    * Skeletal deformities

    Pregnancy

    • Brain injury.

    ' Spinal Cord injury

    • Peripheral nerve miuries

    • Fractures of bones

    • Degenerative conditions.

    Some common pathological gaits are:



    Parkinsonian Gait (Festinant Gait)

    Thisgait is characterized by increase in cadence, shortened stride, lack of heel strike and toe off, and diminished arm swinging. The patient walks with flexed posture and short rapid shuffling steps, due to neurologic changes that result in rigidity of muscles and prevent normal reciprocal patterns of movement.



    g Gait is a characteristic gait of a spastic child with marked bilateral adductor spasm at the hips and equinus spasm in the ankle.


    The subject is in permanent forward and lateral inclination which permits him to pass his rear limb forward. He raises the corresponding shoulder and the knee, which comes forward, rubs against the other knee in support. The hip serves as pivot for the pelvis, which transposes one side of the body in an ehtire block without scapular compensation


    • Hip and trunk sway from side to side or a pelvic waddle.

    • Asymmetry of weight bearing and unequal steps

    • Walk on toes

    • Overactive arms to maintain balance.



    Ataxic Gait



    It is present in cerebellar disease, disseminated sclerosis, and cerebellar ataxia. There is increased length of base of support. The child, has to use more visual cues for mobility.

    The patient increases his base of support in an attempt to control eq

    by sight, and walks in a swaying, reeling or staggering manner like a "drunk'i and with a tendency to swing to one or other side.



    Sensory Ataxic Gait (Stamping Gait)



    This type of gait may be noted in Tabes dorsalis, or a cauda equina lesion. The patient walks with the feet wide apart. The affected leg is suddenly raised high,! thrown forward or waved about in an uncertain r heel first, in a noisy stamping manner. His eyes are firmly glued to the ground whilst walking to compensate for the lack of sensory



    Waddling Gait

    This type of gait may be due to congenital dislocation of hip,

    or late pregnancy. In this, the body sways or waddles from side to :

    the feet are plantar flexed and wide apart to increase the base of :which is limited by shortening of the calf muscle. The shoulders are

    and the abdomen pushed forward. This also happens in paralysis i?,luteus medius on both sides.



    Stepping Gait



    gait is present in conditions like lateral popliteal nerve paralysis of

    where the dorsiflexors of the foot are paralyzed. Here the foot ground on heel strike and then drops during the swing phase. To

    the toes against the ground, the patient compensates by lifting knees and hips higher than normal.



    Knee Gait



    type of gait is seen typically inpatient with paralysis of quadriceps due to ; or femoral nerve injury. Normally the knee is actively extended the midstance phase. When the quadriceps is weak or paralyzed, the of knee in this phase is done by passively pushing the knee backward the patient putting his hand over the front of the lower .thigh. This results in [imp and ma, even cause enu recuvtum in course o ime.



    Gluteus Maximus Gait (Lordotic Gait)

    The gait of a person with paralysis of gluteus maximus has a typical backward lurch during every step forward. Normally when the body moves forward in midstance phase the hip is extended by the gluteus maximus acting from its • insertion below and tilting the pelvic posteriorly to retain the centre of gravity over the supporting leg. When the gluteus maximus is paralyzed the stabilising factor is lost and patient leans backward during heel strike to passively extend the hipand keep the centre of gravity over the stance leg. This causes backward lurch of the trunk (Fig. 3.3).





    HIP HIKING GAIT

    CIRCUMDUCTION GAIT

    LORDOTIC GAIT

    Antalgic Gait



    This is the gait of a person with pain in the lower extremities. It is self-protective and is the result of injury to the pelvis, hip, knee, ankle or foot. To minimise the pain, the person shortens the time duration of the stance phase on the painful side and quickly transfers the weight to the painless leg. The swing phase of the uninvolved leg is reduced. The result is shorter step length on the uninvolved side, with reduced cadence.



    Arthrogenic/Hip Hiking Gait



    It results from stiffness, laxity or deformity and it may be painful or pain free. When the hip/knee is ankylozed or the plaster cast has been recently removed from the knee, it is not possible to flex at the hip/knee joint during walking to clear the ground in swing phase. So the patient lifts the entire leg higher than normal to clear the ground. During the gait cycle, the pelvis is elevated by exaggerated plantar flexion of the opposite ankle and circumduction of the stiff leg to provide toe clearance (Fig. 3.3).



    Hemiplegic Gait



    The extensor synergy of the lower limbs interrupts the association between the ankle dorsiflexor and the knee extensor muscles. Due to spasticity of the quadriceps and calf muscles knee flexion is prevented during the late stance phase, with a consequent absence Of push off phase (Fig. 3.3).

    If the spasticity is marked, the patient touches the ground with the toes first with the ankle inverted, the weight is borne on the lateral border of the foot, and the knee goes into full extension. This 'pseudolengthening of the affected limb' is compensated by external rotation and circumduction at affected side or hip hiking on the involved side, so that it clears the ground effectively.



    GAITTRAINING



    Crutch Walking: Patterns of Gait



    There are six different patterns of gait. They are: • Four-point crutch gait • Two-point crutch gait • Three-point crutch gait • Swing to crutch gait

    • Swing through crutch gait

    • Tripod gait.

    The type of crutch gait to be taught to the disabled person will of course, depend on several factors like type, extent degree of disability and residual patterns of weakness. Of course the patient with least amount of disability will find even the so-called difficult gaits easy to perform while the severely disabled will find the simplest gait difficult.

    'To select the pattern of gait to be employed by a particular patient, the f0110wing must be evaluated.

    The ability of the patient to:

    ' Bear weight and to keep his balance on one or both lower limbs. . Push his body off the ground by pressing down on both crutches. ' Step forward with either one or both feet.

    • Generate and sustain the increased expenditure of energy required in all assisted gaits.

    The partial weight-bearing gaits using crutches (either axillary or elbow)

    percent more energy than normal walking, whereas about more energy is required by the three points nonweight bearing and



    Each patient must be encouraged to walk even if he does not use a recognized Any mobility is better than immobility.

    gaits (four points and two points). These are somewhat stable time are both feet or both crutches off the ground at the same time.
    gait is the most stable of all the gait patterns, providing three limb or an assistive device is moving. The person one ambulatory aid, such as a cane or crutch, about 1-1/2 lahead, followed by the opposite foot forward. Next the opposite assistive moved forward, and finally the other foot is brought forward. The is as follows: right crutch, left foot, left crutch, right foot. The feet about six or seven inches behind the crutch. The center of gravity lbetween the four points of support. Four point gait is most easily performed


    using hip hikers in which progression is accomplished by successive forward advance of each point



    Two-point Gait



    The two point gait is a natural progression from the four points gait. It require more balance and stability, but has a natural rhythm and arm motion that resembles normal gait. With a two points gait, the person advances one assistive device and the opposite foot at the same time. At the beginning of the stance phase of one limb, the assistive device on the opposite side makes contact with the floor and provides support.

    Adequate power of hip muscles (flexors, extensors and abductors) is essential. for two point gait. It can be accomplished in two ways, either the crutch and foot on the same side advance together or the crutch on one side advances with the foot on the other side. The latter is more stable as weJ sides.



    Three-point Gait



    The three-point gait is used where a single lower extremity affected. The pattern is either non-weight bearing or partial weight bearing on that assistive devices move forward with the involved limb. As the unaffected begins the swing phase, and is placed on the floor in front of the involved limb, the body weight is shifted to the locomotor aid. So he three be both crutches, normal limb and involved limb.



    Swing to Gait



    To perform the swing to gait pattern, the weight is momentarily lower limbs as the crutches are moved forward simultaneously. As the is shifted to the hands, both legs are brought forward until the feet placed slightly behind, or at the level of the crutches.

    At the end of the step the person should be in normal crutch stance, ready t take the next 'step'



    Swing through Gait



    This is an extension of the swing to gait mentioned earlier. It is

    some amputees and paraplegics on gaining expertise with the swing to gait. provides a much more rapid means of ambulation than the other crutch gaits. is the least stable of the gait patterns, and therefore requires practice and to perform safely. As in the swing to gait, the initial phase req momentarily on both legs as the crutches are moved forward. by shifting the weight to the arms and hands, and forcefully depressing scapula while the legs swing forward through the crutches, landing ahead of them. As a result, the crutches are behind you when the feet ground. Immediately the crutches have to be brought forward before hip trunk lose balance and lead to a fall. The fall can be prevented by hip extension



    Tripod Gaits



    This is used by paraplegics and polio patients. The sequence is R crutch, L crutch and drag the body. This can also be modified as follows: Both crutches at the same time in front of the body then drag the body (Fig. 3.6).

    The feet rarely leave the ground so that a tripod is constantly maintained, which provides an extra-balance and stability. Slightly better balance is needed for this gait to accommodate minor shifting of weight from one side to other. Sometimes gaits are taught within a walking frame to ensure beltest stability
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    RELAXATION EXERCISES AND MANAGEMENT OF SPASTICITY

    Definition: 'Relaxation' is defined as a state in which the muscles of the body are relatively free from tension. This is because living muscles can never be completely free from tension as they retain a certain degree of tension known as muscle tone

    Indications: Acute or chronic pain and muscle spasm associated with spasm.

    Mental stress that is due to any cause, e.g. a systemic disease, stressful lifestyle, certain psychological disorders, etc.

    Hypertonicity- resulting from upper motor neuron lesion.



    General Principles



    • A position that ensures full support to the body (which reduces mechanical tension on muscles or ligaments) should be selected. Conditions of individual patients should be kept in mind, e.g. for aged patients with inspiratory disorders- prone lying may not be ideal

    • Constrictive clothing such as corsets and belts should be removed

    • The treatment room should be as quiet as possible

    • Strong colours and bright lights should be avoided. The room should have low, well-diffused light

    • The mariner of the physiotherapist should be pleasant and understanding and her voice should be low pitched

    • A simple explanation of what is to be done is given to the patient so that any fear is removed

    • Attention to the little things like emptying of bladder before treatment can lead to greater compliance.

    Methods forTraining Relaxation Classification



    A. Methods for general relaxation- which relax the total body.

    B. Methods for local relaxation- which relax a specific part of the body.

    • Meditative: Where the patients thinking is the major component, e.g. Benson's controlled breathing, transcendental meditation.

    • Physicah Where physical activity is the maior component, e.g. acobson's progressive relaxation.



    Techniques for General Relaxation Meditative



    Visual Imagery



    Elton and Stanley described the use of imagery for persons who find creating a blank mind difficult. The images need to:

    ' Be meaningful and relevant to the patient.

    • Be interesting.

    • Have pleasant association.

    ' Contain an element of change to hold the attention until patients learn to progress towards images without change.



    Consciousness of Breathing

    The patient is asked to breathe deeply with a slight pause at the end of expiration. He is asked to concentrate on his own rhythm of breathing. During expiration, he is instructed to feel like 'letting go' of the whole body.



    Physical



    Jacobson's Progressive Relaxation



    This method encourages the patients to tense, then relax sequentially, groups of muscles while attending to the components of tension and relaxation that are being experienced. Jacobsen suggested that by teaching the patient to contract a muscle and develop recognition of the tension signals, reduction of tension in daily life would be possible. The method appears to be of clinical value, particularly in hypertension, epilepsy and respiratory distress.



    Mitchell's Simple Physiological Relaxation

    This is based mainly on the principle that "In the action of group muscles, there is reciprocal innervation of opposing groups, whereby contraction in agonist muscles is accompanied by reflex relaxation of antagonists.

    Respiration control is also encouraged -with instruction directed towards diaphragmatic and lateral costal breathing.
    Muscle groups targeted in this method: Shoulder depressors Elbow extensors Shoulder abductors

    Finger and thumb extensors Hip lateral rotators Ankle dorsiflexors Trunk flexors Neck extensors



    Rhythmical Passive Movement



    Passive movements of the limbs and head may assist in general relaxation in some cases. Group movements of joints are preferable.



    Local Relaxation



    • Rhythmical passive movement to the joint adjacent to the area of pain. If joint is the source of pain - passive movements should be given in the free range.

    • Deep rhythmical massage also help in relaxing the area where it is given.

    • Hold relax and contract relax:

    The muscle under tension in the area of pain or its antagonist is put isometric contraction by applying maximal resistance. This is then followed 1 patient's voluntary relaxation of muscles.



    Progressive Relaxation Training (PRT)



    Trainee is asked to focus attention on a particular group of muscles. A muscles to be tensed at 5 - 7 seconds during which the sensations of muscle contractions. On a predetermined word 'release', 'let the muscle group is relaxed.



    Passive Neuromuscular Relaxation



    Start to repeat the phase, "I am relaxed." Repeat it every time you breath

    Technique consists of one continuous wave of relaxation which begins crown of head and progresses down.



    The Alexander Technique

    A person's posture is the way that individual habitually holds himself the forces of gravity.

    This can become distorted by emotional and physical influences. technique re-educates the body to perform and causerve energy. • Neck free

    • Head forward and up • Back lengthen • Back widen

    • Shoulder release and widen


    Yoga



    The word 'Yoga' itself means to 'unite' - uniting the body with the sprit; uniting the various aspects of life to achieve a harmonious whole. Traditionally the ultimate aim of the yogic life was to realise the self to achieve liberation from the distractions of the mind and suffering caused by the sense of isolation. Patanjali a sage around 300 to 400 BE was the first to clearly write down the basic principles of yogic philosophy. , Asanas - practice of postures • Pranayama - breath control

    , Pratyahara - control of senses

    0 Dhyana - meditation.

    The holistic yogic approach to life includes - proper exercise, proper breathing, proper diet, proper relaxation and meditation.



    Benefits of Yoga



    It is safe

    There is no body strain

    It helps to become relaxed and more focussed.



    SPASTICITY



    Spasticity is one type of hypertonia, i.e. increased resistance to passive movement. Not all increased muscle tone is spasticity - it may have other causes. e.g. rigidity, or myotonia. The term spasticity comes from the Greek word 'Spasticos' which means to tug or pull.



    Definition



    $pasticity is a state of hyperactivity of the stretch reflex mediated by muscle spindle stretch receptors. It is velocity-dependent, i.e. it increases with the speed of joint movement, maximum at the beginning of movement, smoothly sustained and sudden lapse at the end of movement - the 'clasp-knife' type of spasticity. It is seen after lesions in the cerebral cortex, brainstem or spinal cord, e.g. cerebral palsy, hemiplegia, and multiple sclerosis.



    Pathophysiology



    Fundamental to the understanding of spasticity is Sherrington's concept of the 'Final Common Pathway'. The motor neurons in the brainstem and spinal cord are the final common path through which all motor output is conveyed. Each motor neuron receives excitatory and inhibitory signals from 2 maior groups of neurons:

    • The supraspinal, and

    • The reflex spinal

    Summation of inputs from these two major groups causes stimulation of the motor neurons. Spasticity occurs when there is loss of the supraspinal input and consequently overaction of the reflex spinal input.

    In the acute stages of a CNS lesion, there is often a state of spinal or cerebral shock. This is postulated to be due to the loss of facilitation from the supraspirl neurons and thus insufficient excitatory input from spinal reflexes to depolize the motor neurons. Soon after, neuronal mechanisms within the spinal cord compensate for the supraspinal loss and cause an increase in reflex excitability by:

    • Denervation super sensitivity

    • Collateral sprouting

    • Growth of new synaptic connections within the spinal cord.

    These mechanisms develop sequentially and mediate the onset of spasticity and the appearance of hyperreflexia.



    Classification of Spasticity



    Modified Ashworth scale

    0 = Normal tone

    1 = Slight hypertonus, a 'catch and release' or minimal resistance when limbi

    moved.

    1+ = Mild hypertonus, the catch is followed by minimal resistance throughout

    the FROM,

    2 = Moderate hypertonus throughout FROM, affected part moved easily. 3 = Increased hypertonus, passive limb movement is difficult. 4 = Severe hypertonus, limb is rigid in flexion or extension.



    Types of Spasticity



    • Immobilising Type: Spasticity in the absence of attempted movement

    • Mobility Type: Spasticity with attempted movement

    • Spasticity causing inability to relax after a voluntary movement, e. lobe injury



    Effects of Spasticity



    Benefits



    • Helps maintain muscle mass

    • Decreases severity of osteoporosis in the spastic extremity.

    • Reduces risk of deep vein thrombosis

    • Reduces dependent edema

    • In the lower limb, may help in standing and walking, (if not too severe).



    Deleterious Effects



    • Loss of balance

    • Interference with ADL, e.g. driving, sleep, perineal hygiene sexual

    • Contractures

    • Decubitus ulcers

    • Pain

    • Gait abnormalities



    Spasticity is increased by temperature, stress, trauma, pressure sores, urinary infection, faecal impaction, and excessive sensory stimuli. It is reduced by fatigue, drugs, and alcohol.



    Clinical Evaluation



    ' A clinical history followed by a physical examination is mandatory, including the functional impact of spasticity.

    • Severity of the hypertonia is assessed with the Ashworth scale.

    • Tendon reflexes, amplitude, spread to other muscles and presence of clonus should be noted.

    • Flexor spasms, mass reflexes, Babinski sign should be looked for.

    • Voluntary muscle strength and control should be assessed. Power grading in the presence of spasticity is of limited use. FROM and synergy should be noted.

    • Functional impairments should be looked for and identified.



    MANAGEMENT



    The goal is to minimise the adverse effects of hypertonus without compromising function. Stepped care for spasticity begins with conservative methods that carry the fewest side effects and progresses to aggressive treatments with more risks of side effects: Sometimes spasticity need not be aggressively treated where the patient "walks" on his spastic limbs. First any remediable sources of pain should be eliminated. Urinary tract infection, bowel impaction, pressure sore, fracture, infection of nails are all nociceptive sources that may increase spasticity.

    Second, patient education should be done. The benefits and adverse effects of spasticity are identified and he is taught the use of slow movements and daily stretching. Triggering useful extensor or flexor spasms during transfer or bed mobility can be taught. Patients are instructed to use foot protection devices and to remove heel-loop bolts from wheel chair footrests to prevent skin break down. Waist or chest straps may be needed, if spasms are severe. Education allows patient to minimise adverse effects and to function despite spasticity.



    Principles



    o Inhibit excess tone as far as possible. o Give the patient a sensation of normal position. 0 Facilitate normal movement patterns.

    Hypertonus predisposes the patient to fixed muscle shortening and joint capsule tightening. Daily range of movement exercises can reduce stretch reflex hyperactivity and improve motor control.

    Standing is another form of static stretch. It can reverse early contracture and may reduce stretch reflex excitability. In children with cerebral palsy, spinal extensor muscle activity can be altered by adjusting head position and back angles of seating systems.

    Biofeed back using electromyography or joint position sensors and providing auditory or visual feedback reduces spasticity in patients with voluntary motor
    Prolonged static stretching of muscles with splints, and serial castings have also been used. Ankle foot orthoses are used to control spastic equinus deformity at the ankle. Medial or lateral T straps or a plastic brace can be added to help control varus or valgus.

    Muscle cooling reduces phasic stretch, reflex activity and clonus. Spasmoiytic muscle cooling requires prolonged application of ice for 15 minutes or more. The early effect of skin cooling often is to increase hypertonus. Because coolin8 is only transient, the benefit lasting a few hours, it is often not practical for patient use. It can be used with static stretch to overcome hyperactive stretch reflexes predisposing to contractures. Painful spasms may also be controlled.

    Electrical stimulation at nearly all levels of the nervous system relieves spasticity. Peripheral stimulation of muscle or nerve for 15 minutes spasticity and clonus for hours. Transcutaneous electrical nerve decreases spasticity in some patients.

    Deep rhythmical massage with pressure over muscle insertions has proved effective in some cases. Rhythmical, slowly performed passive movemen through normal patterns may also be helpful.

    Movement itself will reduce spasticity if it follows normal patterns. Rotational movements of the trunk and limbs are important and spiral-rolling involving head, shoulder girdle, pelvis and limbs should be encouraged. Those .functions which do not produce pattern abnormalities should be encouraged and progress should be made relative to this.

    Use of reflex inhibiting patterns of movement- may be done actively with or without assistance.

    Compression through joints - this encourages co-contraction and thereby reduces increased tension in any one group of muscles.

    Stretch of trunk muscles - in particular rotational and side flexion encourage righting and this may inhibit the increased tension.

    Vestibular stimulation with rocking in a rocking chair, hammock etc. b reported to be useful in relaxing hypertonic muscles.



    Bobath Neurodevelopmental Treatment



    First developed in the 1940's by Berta Bobath a physical therapist and her husband Dr Karel Bobath, NDT is based on normal development and movemenL The term neurodevelopmental treatment was first coined by the Bobaths from their work with children with cerebral palsy. Also known as Bobath approach, NDT has been used successfully in the treatment of adult hemiplegia.

    During recovery a patient typically overuses the uninvolved side, compensating for the loss of sensory and motor function on the hemiplegic side. In NDT the therapist develops a program to help the patient avoid these abnormal patterns of movement. The foundation is based on relearning normal movements that promotes highest level of functional recovery rather than compensation. The person is encouraged to use both sides of the body. One of the central principles of NDT is that alignment and symmetry of trunk and pelvis are necessary for good positioning of the extremities. Adaptive equipment is used when absolutely necessary for safety, but not as a first resort and certainly

    not as a replacement for treatment. For the neurodevelopmental approach, postures and movements that inhibit tone and abnormal reflexes are as important as those that promote recovery.



    Specifics of NDTTreatment



    ' Weight bearing over affected side

    ' Trunk rotation

    . Scapular protraction

    • Positioning pelvis forward

    • Facilitation of slow, controlled movements

    • Proper positioning of head and trunk.



    PNF--Proprioceptive Neuromuscular Facilitation



    It is based on normal movements and motor development. In normal motor activity the brain registers total movement and not individual muscle action. Encompassed in the PNF approach are mass movement patterns that are spiral and diagonal in nature and resembling movement seen in functional activities. In this multisensory approach, facilitation techniques are superimposed on movement patterns and postures through the therapist's manual contact, verbal commands and visual cues. It is effective in the treatment of numerous conditions including Parkinson disease, spinal cord injury, arthritis, stroke, and hand injury.



    Pharmacology inTreatment of Spasticity



    Commonly used drugs to reduce spasticity are

    ' Baclofen -Central action
    • Diazepam -Central action

    • Dantrolene Sodium - Peripheral action



    Blocks



    Motor Point Blocks



    Motor point blocks are most effective for clonus and phasic stretch reflex, but less effective for tonic stretch reflex, flexor spasms, rigidity and dystonia. This selective action on spasticity with relative sparing of voluntary movement makes this procedure a very useful tool.

    Phenol (2-10%) and ethyl alcohol are commonly used. Botulinum A exotoxin can be used but is prohibitively expensive. The most commonly performed motor point blocks are to triceps surae, tibialis posterior, hamstrings, fingers and wrist flexor muscles.

    Botulinum toxin is a/so used successfully in adductor spasm, writer's cramps and facial spasms. The beneficial effects of the injections last upto 6 months.



    Nerve Blocks



    Epidural or Intrathecal injections of phenol or ethanol for severe spasticity of the lower limbs, have been used. Loss of voluntary movement, bowel and

    bladder control and sexual function have limited the use of this procedure.



    STRENGTHENING EXERCISES

    Strength



    It is referred as the ability of a muscle/muscle group produce a force in maximal effort either dynamically or statically. The strength of a muscle varie relatively upon the demands placed by it. Strengthening exercises are a exercises that are used widely by the physiotherapist in improving the power of the muscle or muscle groups.



    Strength Training

    To strengthen a muscle, its contraction must be loaded or resisted so that increasing levels of tension develops.

    The force output of a muscle is directly proportional

    developing in the muscle.

    The muscle skeletal systems undergo adaptive changes in response strengthening, like:

    In the muscular system there occurs

    • Increase in size of muscle fibres.

    • Increase in the content of actin and myosin filaments.

    • Increase in the amount of enzymes used for metabolism inside the muscle.

    • Increase in the amount of stored nutrients.

    In the nervous system there is

    • Increased activation of central nervous system.

    • Increased synchronization of motor units so maximum number of motor units work to produce maximum tension in the muscle.

    • Stimulation of larger motor units which help in activation of more number of muscle fibres.

    • Enhanced inhibition of central neural inhibitory mechanisms, which will result in increased force output. Other physiological adaptations

    • Bone- Increase in the mineral content.

    • Connective tissue- Increase in strength of tendon and ligament Indications for strengthening:

    • Lesion in anterior horn cells, e.g. poliomyelitis. • Lesion in efferent motor pathways: neuropraxia. • Muscle injuries.

    • Disuse atrophy due to prolonged immobilisation.



    General Principles



    • When designing a resistance training or strengthening program, the therapist


    must always consider the overall level of fitness of the patient, the type of injury or disease, the stage of healing after injury and, most importantly the desired functional outcome.

    Specificity of training-exercises incorporated should mimic the desired function in terms of range, types of contraction, and velocity of contraction of muscle work, e.g. training a person for climbing stairs should include training in ascending steps, one by one.

    If the activity needs endurance also, then the parameters should be geared

    also for endurance.



    /ype of Contraction



    Eccentric Contraction

    Muscles working eccentrically become longer and thinner as they pay out and allow their attachments to be drawn apart by force producing the movement.

    The ability of the muscle to produce more force with less 02 and energy consumption and with minimum motor unit recruitment is evident in eccentric training. Also, the muscle spindle is stretched throughout eccentric movement and provides additional peripheral reflex support for contraction.

    Eccentric training improves only the eccentric strength of the muscle. Control is easily learnt in eccentric activity of muscle.



    Isometric Contraction

    The length of the muscle remains the same throughout the muscle work and no movement results.

    The hold period for this contraction should be at least 6 seconds for maximal recruitment of motor units. It has been suggested that isometric training of a weak muscle would strengthen the muscle only up to 5 weeks, and after this period, it maintains the strength gained during the training.

    Isometric strength gains occur at the specific angle of the joint at which the muscle is strengthened. Therefore, for the muscle to function better throughout the available range, isometric strengthening at 4 or 5 angles throughout the FROM is essential.



    Concentric Muscle Work



    Muscles working concentrically become shorter and thicker as their attachments are drawn closer together anti joint movements

    A patient doing concentric muscle work performs a movement and in so doing overcomes some force which offers resistance such as friction, gravity, manual pressure by the physiotherapist, or some other form of mechanical resistance.

    The physiological cost of this type of work is high, as only about a quarter of the energy liberated during contraction is available as mechanical work. Concentric muscle work is used to build up muscle power, e.g. lifting weights

    Intensity of Training



    The absolute level of overload will vary according to the individual. It has been suggested that a certain threshold point of intensity must be exceeded for strengthening to occur. The threshold for isometric training is 40 percent o,f the maximum load that the patient can lift.



    Velocity of Training



    In the case of concentric contraction as the velocity increases, force output from the muscle decreases. Therefore when a weak muscle is rehabilitated, low velocities are used so that it can generate more force. Velocity is progressively increased since it will be difficult for the muscle to generate more force at higher velocities. In the case of eccentric contraction as the velocity decreases force output from the muscle increases.



    Range of Muscle Work

    The outer range of muscle work is used extensively in muscle re-education and strengthening of a weak muscle, as concentric contraction is initiated more easily from stretched position of a muscle. Middle ranges can be used for training eccentric contractions. Inner range is added to the program as a progression.



    Inner Range



    The muscle work either concentrically from the position, in which it is partially contracted to a position of full contraction or vice versa if it works eccentrically.

    Exercise in the inner range is used to gain or maintain movement of a joint in the direction of the muscle pull and to train some extensor muscles responsible for stabilizing joints.



    Outer Range

    The muscles work concentrically from the position in which they are fully stretched to a position in which they are partially contracted, or vice versa if working eccentrically.

    The outer range of muscle work is used extensively in muscle reeducation as a contraction is initiated more easily from full stretch in most muscles.



    Middle Range



    The muscles are never either fully stretched or fully contracted. Exercises this range maintain muscle tone and power but full joint movement is achieved.

    Central inhibitory mechanisms influence force output, so we can use facilitatory techniques such as tapping, verbal prompts, manual contact and repetitions which inhibit the central mechanism and result in the increased for output of the muscle.
    Recovery from active exercise has been shown to be more rapid with light ex6rcise following strengthening program, than with total rest.

    Appropriate stabilization of proximal segments should be done to avoid substitution.



    Principles of Treatment to Increase Strength and Function

    The affected muscles must be strengthened progressively by resisted exercises, which are specific for the group to which the muscles belong.


    Progresslve Reslsted Exerclse



    For strengthening not only overload is important, but it must be progressively increased as the individual adapts to the training and increases in strength. This approach is known as Progressive resisted exercise. This term was coined by DeLorme. DeLorme and McQueen based their progressive resistance programme on the concept of 10RM, i.e. the maximum load which can be lifted ten times.



    Reslstance



    The resistance is increased by:

    • Increasing the poundage of the resistance

    • Increasing the leverage of the resistance.



    Isotonic Reslstance Equlpment



    • Free weights: These are graduated weights that are hand held c the upper or lower extremity and include: a. Barbells b. Dumbbells c. Sand bags

    • Elastic resistance devices: Elastic resistance materials and such as The.ra-band, Bull worker and exercise tubing grades or thicknesses.

    • Pulley systems: Free standing or wall mounted pulley systems or springs) provide either fixed or variable resistance and upper and lower extremity and trunk strengthening

    • Variable-resistance equipment: Designed to provide variable resistance throughout the range of motion as a muscle contracts concentrically and eccentrically.

    • Exercise bicycle: The stationary exercise bicycle is used to increase lower extremity strength and endurance. Some exercise cycles provide resistance to both the upper and lower extremities.

    0 Other resistance devices • Minels apparatus • Wrist exerciser • FEPS

    • Grip exerciser

    • Stepping machine

    • Sliding seats



    Precautions



    Valsalva Maneuver



    It is the expiratory effort against closed glottis. During this, there occurs increase in intra-abdominal and intrathoracic pressure which leads to decrease in venous flow to the heart which may have an impact on cardiac output, with a temporary drop in blood pressure and increase in heart rate. Valsalva maneuver is commonly seen in isometric and heavy resistance training. Care should be given to negate Valsalva maneuver when framing these training programmes for patients with cardiovascular problems, cerebrovascular accident, myocardial infarction, herniation, unhealed incisional scar, or those who belong to the geriatric age group, and it requires close monitoring.



    Local or Genera/Fatigue



    Persons may have this phenomenon due to decrease in sugar, K÷ long, 02 in blood and advanced age. Persons with multiple sclerosis may function well in the early morning, and their strength deteriorates due to fatigue as the day passes on, in early evening strength improves. Persons with cardiopulmonary disease may fatigue more rapidly and require longer periods for recovery after exercise. So training would require low intensity strengthening with rest intervals to avoid fatiguing the muscles.



    Osteoporosis



    It is common in neuromuscular disease, inflammatory joint diseases, postmenopausal period, and due to sedentary lifestyle. Resistance should be added gradually with care.



    Contraindications



    When a muscle or a joint is acutely inflamed, strengthening is too stressful and contraindicated.

    MOBILIZATION EXERCISES

    Definition



    Mobilization is defined as a passive movement performed in such a manner speed that the patient can stop the movement at his will. It is a manner restoring or maintaining joint movement.



    General Principles



    • The patient should be positioned such that he feels comfortable and

    • Techniques of relaxation can be used if necessary.

    • Warming of the tissues using massage/heating modalities can be done to mobilization.

    • The joint to be mobilized is placed in least painful position.

    • The bone proximal to the joint is fixed manually or mechanically etc.

    • The treatment force should be applied close to the joint.

    • Progression of the technique depends on how the joint reacts

    • Dosage is decided in terms of the grade, speed and duration of treatment.



    Indications



    • Pain and associated muscle spasm: Small ampl!tude oscillatory
    distraction movements used in the pain free range stimulate types I and
    mechanoreceptors located in the joint capsule, ligaments and
    pad. This inhibits pain at the spinal level through the pain gate
    (Ref Chap. 6). The technique can also reduce muscle spasm directly
    stimulating type III joint receptors which can inhibit the activity
    neurons (functioning similar to Golgi tendon organs) of the nearby
    • Restriction of joint FROM: due to capsular tightness, meniscus dis
    ligamentous tightness
    Most of these can result due to prolonged immobilization.
    tissue is immobilized there is reduction in water and glycosamino
    while the total collagen remains the same. This reduces the s
    to formation of cross-inks between collagen fibres, leading to tightness. It
    better to use joint play stretching techniques to mechanically distract
    contracted tissue.


    Contraindications



    1. Hypermobility

    2. Joint effusion

    3. Infection

    4. Recent fracture involving articular surfaces

    5. Neoplasms

    6. Acute inflammatory conditions of the joint 7. Haemarthrosis (Hemophilia)



    Effects of Joint Motion



    1. It stimulates biological activity by increasing circulation of synovial fluid.

    2. It maintains extensibility and tensile strength of the articular and peri-articular tissue.

    3. It provides sensory input on speed, direction, and tone relating to the joint. Other benefits are:

    • Pain relief - through pain gate mechanism

    • Restoring or maintenance of elasticity of the articular structures

    . Improving tissue nutrition by increasing cellular diffusion rates and tissue fluid transport

    • Kick starting the healing process by helping in scar tissue formation and myofibroblast formation

    0 Placebo effect of something being done to the patient

    . Improving quality of life by maintaining/restoring the ADL's as in RA.



    Grade



    Refers to the amplitude of movement and the range in which the movement is performed. Different systems of grading have been devised and used in mobilization. The most common ones in practice are those of Maitland and Cyriax.



    Maitland; Grading



    GradeI: A small amplitude movement performed at the beginning of the range within the resistance free part of the range

    Grade II: A large amplitude movement performed within the resistance free part of the range.

    Grade III: A small amplitude movement performed into resistance or up to the limit of resistance.

    Grade IV: A large amplitude movement performed into resistance or upto the limit of resistance.

    Grade V: A high velocity, short amplitude, thrust often near or at the limit of abnormal movement (at a speed outside patient's control).



    Selection of Dosage



    Dosage depends on the patient's condition.

    • In cases where the pain is experienced before tissue resistance, mobilising the joint can induce pain relief.

    In cases where pain is experienced after tissue limitation, the effect desired is increase in FROM.

    Here the dosage in Grades I/I, IV and V can be given at- 2-3 cycles/sec, for a duration of 2 to 5 minutes. This is different from manipulation, which is a passive movement done with greater force when the patient is under anesthesia.

    Obviously the type of motion occurring between bony partners within a is influenced by the shape of joint circumference, the type of joint, of movement permitted, and accessory movements.



    Techniques



    1. Passive angular stretching

    2. Joint glide stretching

    3. Compression

    4. Traction.



    ENDURANCE EXERCISES

    It is the ability of a muscle or a group of muscles to sustain physical

    without undue fatigue. It depends on: a. Strength of muscles involved b. Localized energy stores c. The capacity of the circulatory system and respiratory system to

    02 to the working muscles and to carry chemical wastes away from When a person contracts a muscle group 15 to 20 percent voluntary contraction, blood flow will decrease causing a shift to metabolism leading to cramps, burning and tremor due to accumulation i acid. Muscular work also increases the oxygen demand due to which he and stroke volume rises. The maximum amount of oxygen that a take in during the exercise is termed Maximal Oxygen Uptake (VO2 ma×)- This a standard measure of cardiovascular fitness and decreases with bed age



    EnduranceTraining



    It is that training which augments energy capacity of the muscle by means off exercise program.

    • Significant changes can be measured in a minimum of 10-12 Adaptations occur centrally (heart) and peripherally (muscle), and thought that these changes are probably due to interaction two systems, rather than due to one or the other.

    • The adaptations represent a variety of changes within the cardic

    and muscular system resulting in their increased efficiency.

    • The degree of adaptation depends on the initial level of fitness of and the training stimulus.

    The changes in response to endurance training are:



    Circulatory



    • Greater ventricular chamber size

    • Thickening of the walls of ventricles


    0 Larger end diastolic volume at rest and during exercise

    ° Increase in stroke volume and increase in cardiac output

    . Enhanced myocardial contractility

    ° Decreased heart rate during submaximal exercise

    ° Increase in plasma volume enhancing circulation, thermodynamics, 02 delivery during exercise

    ° Improve 02 extraction from the blood

    • Decrease in BP especially systolic BP.



    :Pulmonary

    • Increased tidal volume

    • Increased breathing frequency

    . Decreased ventilation - increased ventilatory economy.



    Peripheral Mechanism



    Muscular Level:

    • Increased in number and size of mitochondria

    ° Increased muscle myoglobin

    • Enhanced 02 diffusing capacity

    . Enhanced oxidising capacity of fat and carbohydrates

    ° Improved capillary network in the muscle

    • Extrastorage of muscle glycogen

    • Increase in fat mobilising and metabolising enzymes


    Psychological Benefits



    • Reduced anxiety

    • Decreased levels of depression

    • Improvement in mood, self esteem and self concept

    • Reduction in various indices of stress.



    Indications for Endurance Exercise



    • Patients with coronary artery disease • Pregnant women • Obese patients

    • Patients with depression

    • Patients with prolonged immobilization

    • Muscular dystrophy

    The exercise programme prescribed for a patient is related to the consumption required to complete the set goals and measured by BP, heart rate and respiratory rate.



    Principles



    • This basically involves improving aerobic capacity of an individual

    longer at higher work load with less distress to the system

    • Frequency of training-3 to 5 days/veek

    • Intensity of training- 60 - 90 percent of maximum heart rate

    • Duration of training- 20 - 60 minutes of continuous mode of aerobic Duration is dependent on the intensity of activity, thus lower intensi should be conducted over a longer period of time.

    • Mode of activity: Any activity, which uses larger muscle groups and can be maintained continuously and is rhythmic and aerobic in nature, e.g. walking running, jogging, cycling, rowing, swimming.

    • Resistance training relies on the application of lower levels of resistance over a greater number of repetitions. It has been reported that 30-40 percent maximum resistance applied 25-35 times will produce optimal training effect.

    • The development of muscle endurance is closely linked with devel.

    of strength and power. A stronger muscle can perform a given task at lower resistance for a longer period of time without fatigue.



    Exercise Program



    There are three components of the exercise program:



    Warm up period



    Physiologically a time lag exists between onset of activity and the bodies adjustment to exercise.


    Numerous adjustments must take place before exercise:

    0 Increasing in muscle temperature.

    ' Increases the efficiency of muscular contraction by increasing muscle viscosity and the rate of nerve conduction.

    0 Increasing the need for 02 to meet the energy demands for the muscle.

    Extraction from Hb is greater at higher temperature facilitating the oxidation process.

    , Dilatation of the previously constricted capillaries with increase in circulation, augmenting 02 delivery to active muscles and minimising 02 deficit and formation of lactic acid.

    • Adaptation in sensitivity of neural respiratory centre to various exercise stimulants.

    , An increase in venous return, this occurs as blood flow is shifted centrally from peripherally.

    , Warm up decreases susceptibility to musculoskeletal injuries by increasing flexibility. It should be gradual and sufficient to increase muscle and core temperature without causing fatigue or decreasing energy stores. A 10 minutes period of total body movement would constitute warming.



    Aerobic Exercise Period



    There are four methods of training that will challenge aerobic system: Continuous Activity can be prolonged from 20-60 min without exhausting the 02 transport system. Work rates increase progressively as training improvement occurs. Overload can be accomplished by increasing the exercise duration. In healthy individuals continuous training is most effective

    Interval training: In this type the work or exercise is followed by properly prescribed relief or rest interval. It is less demanding than continuous training.

    The relief interval can be rest relief or work relief and its duration ranges from few seconds to Jew minutes. Work relief involves continuing exercises but at a reduced level from work period. During relief period, muscular stores of ATP and 02 associated with myoglobin are replenished by aerobic system.

    Significant amount of high intensity work can be achieved with interval or intermittent work if there is appropriate spacing of work relief intervals.

    Circuit training: It employs a series of exercise activities. At the end of the last activity the individual starts from the beginning and again moves through the ane series. Several exercise modes involving large, small muscle groups and a mix of static and dynamic effort can be used. Circuit training stresses both aerobic and anaerobic systems

    Circuit interval training: Combining circuit and interval training is effective in ATP production by means of aerobic and anaerobic system.



    Cool Down Period

    Purpose:

    • To prevent pooling of blood in extremities by continuing the use of muscles to aid venous return.



    To prevent pain by increasing return of blood to heart and brain maintaining cardiac output.

    To enhance recovery period with oxidation of metabolic wastes replacement of energy stores.

    This period about 5-8 min and involve the total body.



    Equipment Used for Endurance



    Treadmill, stationary bicycle, stair stepping, swimming pool, jogging multi-exercise pulley unit.





    MASSAGETECHNIQUES



    The massage techniques are:

    • Stroking

    • Effleurage

    • Kneading

    • Hacking

    • Rolling

    • Frictions



    Stroking



    It is usually performed with the fingers or finger tips. The operator hands a relaxed and passed over the patient's skin in a rhythmid mmmer with on the finger tips producing a sedative effect.



    Effleurage



    It is performed by the palmar surface of the hands with moderate pressure speed from distal to proximal in the direction of venous and lymphatic and ending into the major lymphatic glands of the body. It produces an" in venous and lymphatic drainage and also soothing effect, and is used of gross lymphedema.



    Kneading



    Here the fingers are used for moulding the part by alternate compression release in a circular manner, mainly performed for the soft tissues such muscles. Occasionally thumb kneading may also be applied for irre such as eyebrows. It increases blood circulation to the tissues.



    Hacking



    It is performed by the ulnar borders of ring and little fingers with pronation and supination of the relaxed hand and the wrist slightly

    It produces a sensory stimulation to the tissues treated as in muscle re-educa

    Iolling



    Here both the hands are moved alternatively between the thumbs and fingers o lifting and releasing of the part occurs which helps in stretching of soft tissue adhesions and skin.



    These are similar to kneading but are applied to the joints. These are done with the finger tips and thumb and range from superficial to deep frictions. Friction may be performed in circular manner with considerable pressure on the fingers d thumb (for other techniques refer Chapter 25).
    " VALUE HAS A VALUE ONLY IF ITS VALUE IS VALUED "
    Never Let Student Die In Your Heart When It Dies You Want Remain A Doctor But You Will Be A Technician

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