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Moving Toward Function

Second Edition

Carrie M. Hall, PT, MHS

Physical Therapist
Owner, Movement Systems Physical Therapy
Clinical Faculty
University of Washington
Seattle, Washington

Lori Thein Brody, PT, MS, SCS, ATC

Senior Clinical Specialist, Sports and Spine Physical Therapy
University of Wisconsin Hospital
Research Park Clinic
Madison, Wisconsin

Graduate Program Director

Orthopaedic and Spo-rts Physical Therapy
Rocky Mountain University of Health Professions
Provo, Utah

with contributors


• A Wolters Kluwer Company
Philadelphia • Baltimore • New York • London
Buenos Aires • Hong Kong • Sydney • Tokyo
Preface to the Second Edition

In the years since the first edition of Therapeutic Exercise: related conditions, knowledge of human behavior derived
Jlodng Toward Function, much has happened in the field from the social and behavioral sciences, and specialized
of physical therapy. In this past year, the Medicare Pre­ clinical skills in the prescription of therapeutic exercise dis­
cription Drug, Improvement, and Modernization Act was tinguishes us among other exercise providers.
passed, including several provisions that positively affect Organized into seven distinctive units, Therapeutic Ex­
our ability to provide crucial rehabilitation services to ercise: Moving Toward Function provides a conceptual
\I edicare beneficiaries. We continue to achieve direct ac­ framework for making clinical decisions regarding the pre­
cess in more states across the country. Over 1,000 entries scription of therapeutic exercise and restoring function.
,lie available through Hooked on Evidence, APTA's online
database , to enhance clinical deCiSion-making and practice.
_•ew strategies are being developed to combat the reemer­ NEW CONTENT
.!ence of physician-owned physical therapy services
PO PTS). The PT Evaluation Tool (PTET) was launched, Although the general organization of units has not changed
-hich makes DPT programs much more accessible. from the first edition, a review of the table of contents will
Through APT A efforts, consumers ,vere educated about reveal the addition of Chapter 4: Prevention, and the Pro­
hildhood obesity via an online chat through washington­ motion of Health, Wellness, and Fitness, and the addition
st. c:om. of Impaired Aerobic Capacity to the chapter on Impaired
It surely is an exciting time for physical therapy, Ac­ Endurance (Chapter 6). The inclusion of this new matelial
rding to the APTA [HOD 06-00-24-35]' by the year underscores the importance of the role of physical therapy
- 20, physical therapy will be provided by physical thera­ in the promotion of health and wellness as a means of im­
t who are doctors of physical therapy and who may proving the quality of life of our patients and clients.
board-certified specialists. Consumers will have direct As members of a health profession, physical therapists
'Cess to physical therapists in all environments for pa­ have a responsibility to promote wellness in its entirety.
ent/client management, prevention, and wellness ser­ While physical therapists are uniquely qualified to develop
ces. Physical therapists will be practitioners of choice for and prescribe exercise programs that help prevent injury,
dividuals with conditions that affect movement, function, promote fitness, and enhance athletic performance, we
d health and wellness, and will hold all privileges of au­ also recognize the importance of integrating the psychoso­
• omous practice. Physical therapists may be assisted by cial, emotional, spiritual, and intellectual dimensions of the
~ ical therapy assistants who are educated and licensed individual in promoting health and wellness.
provide physical therapist directed and supervised com­ Additionally, substantial new coverage of jOint mobiliza­
ents of interventions. tion was added to Chapter 7: Impaired Range of Motion
It was within this context that we developed the second and JOint Mobility in response to student and faculty re­
'tion of Therapeutic Exerc-ise: MO-ving Toward Function. quests . JOint mobilization is introduced in Chapter 7 and
- owing terminology used in the APTA's Guide to Phys­ expanded upon ,vith detailed techniques in Units 5 and 6.
T herapy Practice, this text was written for physical
rapy students entering DPT programs and practicing
nici ns as the primary audience. Howe\er, other health PEDAGOGICAL FEATURES
fessionals will certainly gain valuable inSight from this
as well. Educational features such as illustrations, tables, displays,
The importance of therapeutic exercise as a fundamen­ key pOints, critical thinking questions, lab activities, and
rvice provided by physical therapists will only selected interventions remain consistent with the first edi­
ren hen as our profession moves toward autonomous tion but have been improved and revised in the second
·ce. Although physical therapists provide a variety of edition. Additional and revised illustrated self-manage­
- n' ntions , therapeutic exercise is the most widely used ment boxes provide step-by-step exercises written directly
"en'ention by physical therapists . The premise of this text for the client, demonstrating to the reader how to write
, t therapeutic exercise, with an emphasis on functional clear instructions. Patient-related instruction boxes ad­
~rom es, is a fundamental intervention necessary to re­ dress patient education issues, with tips on enhancing
'ate movement dysfunction, and that the prescription communication and compliance. Case studies are linked
therapeutic exercise requires expeltise found uniquely to lab activities and critical thinking questions to foster
• e profession of physical therapy. Our inimitable knowl­ clinical deCiSion-making. To encourage a thorough under­
_ in basic biomedical and physical sciences, applied and standing of the importance of encompaSSing the total
'cal research evidence regarding specific movement- body when prescribing therapeutic exercise, we have pro­

xiv Preface to the Second Edition

vided a sample com plete intervention for a case with We have worked diligently to incorporate feedback
interconnected upper and lower quarter impairments from cliniCians, students, faculty, and reviewers into th e
to complement selected interventions found in tbe first second edition of Th era.peutic Exercise: lHovin g Toward
edition. Function. Although we believe we have accomplished this
To remain consistent with APT A's "grassroots" effort to task, we are already preparing for the third edition with the
develop a database containing current research and to pro­ goal of accommodating the needs of our changing profes­
vide learning tools to foster evidence-based practice in sion. We welcome feedback from the health care commu­
physical th erapy, we have updated the literature revi ew nity at large to assist us in this endeavor.
and evidence-based data in all chapters. It is our hope that
with these changes, \Ve are providing a text consistent with Carrie Hall, PT MHS,
a DPT curriculum . Lori Thein Brody, PT , MS, SCS, ATe
Brief Contents

• UNIT 3

Foundations of Therapeutic Exercise 1

Special Physiologic Considerations in

Therapeutic Exercise 207

Introduction to Therapeutic Exercise and the
Expanded Disablement Model 1
Soft Tissue Injury and Postoperative Treatment 207

atient Management 10
Therapeutic Exercise for Arthritis 229

"nciples of Self-Management and
Therapeutic Exercise for Fibromyalgia Syndrome and

ercise Instruction 35
Chronic Fatigue Syndrome 244

evention and the Promotion of Health, Wellness,
Therapeutic Exercise in Obstetrics 259

d Fitness 47

Sample Specialties of Therapeutic

siologic Impairments and

Exercise Intervention 283

erapeutic Exercise 51

Closed Kinetic Chain Training 283

aired Muscle Performance 57

-6 Proprioceptive Neuromuscular Facilitation 309

j red Aerobic Capacity/Endurance 87

7 Aquatic Physical Therapy 330

. ed Range of Motion and Joint Mobility 113

Functional Approach to Therapeutic Exercise

149 of the lower Extremities 349

. ed Posture 167
The Lumbopelvic Region 349

The Pelvic Floor 402

xviii Brief Contents


The Hip 436

The Thoracic Spine 610


The Knee 488

The Shoulder Girdle 643



The Elbow, Forearm, Wrist, and Hand 698

The Ankle/Foot 524

• UN IT 7

• UNIT 6
Case Studies 739

Functional Approach to Therapeutic Exercise

for the Upper Extremities 555


Red Flags: Recognizing Signs and Symptoms 759


The Temporomandibular Joint 555

Red Flags: Potentially Serious Symptoms and Signs in

Exercising Patients 764


The Cervical Spine 582

IND EX 771


Issues in Home Exercise Program Prescription 39

Understanding Instructions 39

Proper Exercise Execution 40

Foundations of Therapeutic Exercise 1

Equipment and Environment 41

Home Exercise Prescription 42

Considerations in Exercise Prescription 42

Determining Exercise Levels 43

Introduction to Therapeutic Exercise and the

Formulating the Program 44

Expanded Disablement Model 1


Definition of Physical Therapy 1

Therapeutic Exercise Intervention 2
Prevention and the Promotion of Health, Wellness,

The Disablement Process 2

and Fitness 47

Purpose of Defining the Disablement Process 2


Evolution ofthe Disablement Model 3

The Context for Primary Prevention 47

Modified Disablement Model 4

Definitions 47

Measurement of Wellness 50

Health Promotion and Wellness-Based Practices 50

uHAPTER 2 From Illness to Wellness 52

The Use of Screening as an Examination Tool within a

Patient Management 10

Wellness-Based Practice 52


Starting a Wellness-Based Practice 52

Introduction 10

Patient Management Model 10

Examination 10

Diagnosis 15
Prognosis and Plan of Care 16

Intervention 17
Physiologic Impairments and

Outcome 19
Therapeutic Exercise 57

Clinical Decision Making 20

Therapeutic Exercise Intervention 20

Therapeutic Exercise Intervention Model 21

Exercise Modification 27
Impaired Muscle Performance 57

Adjunctive Interventions 30

Physical Agents 30

Definitions 58

Mechanical Modalities 30

Strength 58

Electrotherapeutic Modalities 31

Power 58

Endurance 58

Muscle Actions 58

CHAPTER 3 Morphology and Physiology of Muscle Performance 59

Principles of Self Management and

Gross Structure of Skeletal Muscle 59

Exercise Instruction 35
Ultrastructure of Skeletal Muscle 60

Chemical and Mechanical Events During Contraction


and Relaxation 60

Teaching in the Clinic 35

Muscle Fiber Type 61

Safety 35
Motor Unit 61

Self-Management 36
Force Gradation 61

Adherence and Motivation 36

Factors Affecting Muscle Performance 62

Health Behavior Models 36

Fiber Type 62

Applications 36
Fiber Diameter 62

Clinician-Patient Communication 38
Muscle Size 62

xx Contents
- - ---.
Muscle Architecture 64
Lifespan Issues 108

Force-Velocity Relationship 62
Guidelines for Cardiovascular Endurance Training in the

Length-Tension Relationship 63
Young 108

Training Specificity 64
Guidelines for Cardiovascular Endurance Training

Neurologic Adaptation 64
in the Elderly 108

Muscle Fatigue 64

Lifespan Considerations 65

Cognitive Aspects of Performance 66


Effects of Alcohol 67

Impaired Range of Motion and Joint Mobility 113

Effects of Corticosteroids 67


Causes of Decreased Muscle Performance 67

Neurologic Pathology 67
Morphology and Physiology of Normal Mobility 114

Muscle Strain 68
Causes and Effects of Decreased Mobility 114

Disuse and Deconditioning 70

Effects on Muscle 115

Length Associated Changes 70

Effects on Tendon 115

Physiologic Adaptations to Training 70

Effects on Ligaments and Insertion Sites 116

Strength and Power 70

Effects on Articular Cartilage 116

Endurance 72
Effects on Bone 116

Examination/Evaluation of Muscle Performance 72

Effects of Remobilization 117

EffectsonMuscle 117

Therapeutic Exercise Intervention for Impaired

Effects on Tendon 117

Muscle Performance 73

Effects on Ligaments and Insertion Sites 118

Activities 73

Effects on Articular Cartilage 118

Dosage 78

Effects on Bone 118

Dosage for Strength Training 80

Dosage for Power Training 81

Mobility Examination and Evaluation 119

Dosage for Endurance Training 81

Therapeutic Exercise Intervention for Decreased Mobility 120

Dosage for Training the Advanced or Elite Athlete 81

Elements of the Movement System 120

Precautions and Contraindications 82

Activities to Increase Mobility 120

Exercise Dosage 137

Precautions and Contraindications 138

Causes and Effects of Hypermobility 139

Therapeutic Exercise Intervention for Hypermobility 140

Impaired Aerobic Capacity/Endurance 87

Elements of the Movement System 140

Stabilization Exercises 140

Physiology of Aerobic Capacity and Endurance 87

Precautions and Contra indications 142

Definitions 87
Lifespan Issues 143

Energy Sources Used During Aerobic Exercise 88

Adjunctive Agents 143

Normal and Abnormal Responses to Acute

Superficial Heat 143

Aerobic Exercise 90
Deep Heat 144

Physiologic and Psychological Adaptations to

Cardiorespiratory Endurance Training 93

Causes of Impaired Aerobic Capacity/Rehabilitation


Indications 94

Impaired Balance 149

Examination/Evaluation of Aerobic Capacity 96


Patient/Client History 96

Systems Review 96
Definitions 149

Screening Examination 96
Physiology of Balance 149

Tests and Measures 97

Contributions of sensory systems 150

Therapeutic Exercise Intervention 100

Processing Sensory Information 151

Mode 100
Generating Motor Output 151

Dosage 101
Motor Learning 152

Precautions and Contra indications 105

Causes of balance impairment 152

Graded Exercise Testing Contra indications and

Effects of training on balance 153

Supervision Guidelines 106

Examination and evaluation of impaired balance 154

Supervision During Exercise 106

Therapeutic exercise intervention for impaired balance 155

Patient-related Instruction/Education and Adjunctive

Mode 155

Interventions 107
Posture 156

Contents xxi

Movement 156

Dosage 158
. UN IT 3

Precautions and Contra indications 163

Special Physiologic Considerations in

Therapeutic Exercise 207


Impaired Posture 167


Soft Tissue Injury and Postoperative Treatment 207

Introduction 167
Definitions 168
Physiology of Connective Tissue Repair 207

Posture 168
Microstructure of Connective Tissues 207

Sta nda rd Posture 168

Response to Loading 208

Deviations in Posture 169

Phases of Healing 209

Movement 171
Principles of Treating Connective Tissue Injuries 211

Causes of Impaired Posture and Movement 172

Restoration of Normal Tissue Relationships 211

Range of Motion 173

Optimal Loading 211

Muscle length 173

Spec ific Adaptations to Imposed Demands 212

Joint Mobility 173

Prevention of Complications 212

Muscle Performance 173

Management of impairments associated with connective

Pain 174
tissue dysfunction 212

Anatomic Impairments and Anthropometric

Sprain: Injury to Ligament and Capsule 213

Characteristics 176
Stra in: Musculotendinous Injury 213

Psychological Impairments 176

Tendinitis and Tendon Injuries 215

Lifespan considerations 177

Cartilage Injury 219

Environmentallnfluences 178

Management of impairments associated with localized

Examination and Evaluation 178

inflammation 219

Posture 178
Contusion 219

Movement 179

Management of impairments associated with fractures 220

Intervention 180
Classification of Fractures 220

Elements of the Movement System 180

Application of Treatment Principles 220

Activity and Dosa ge 181

Management of impairments associated with bony and soft

Patient-Related Instruction and Adjunctive

tissue surgical procedures 221

Interventions 182
Soft Tissue Procedures 222

Bony Proced ures 224

Management of impairments associated with joint

~ APTER 10
arthroplasty 226

Pain 185

Defin itions 185

Therapeutic Exercise for Arthritis 229

Physiology of Pain 185

Pain Pathways 186

Review of Pertinent Anatomy and Kinesiology 229

Pain Theory 187

Pathology 230

Examination and Evaluation 188

Osteoarthritis 230

Pa in Scales 188

Rheumato id Arthritis 231

McGill Pain Questionnaire 189

Disability and Health-Related Quality of Life Scales 190

Exerc ise Recommendations for Prevention and Wellness 233

Therapeutic exercise intervention for pain 190

Therapeutic Exercise Intervention for Common

Acute Pa in 190
Impairments 233

Chronic Pain 190

Pain 234

Impaired Mobility and Range of Motion 234

Adjunctive Agents 202

Impaired Muscle Performance 235

Transcutaneous electrical nerve stimulation 202

Impaired Aerobic Capacity 237

Heat 203
Special Considerations in Exercise Prescription and

Cold 204
Modification 239

~edication 204
Ligament or joint capsul e laxity precautions 239

xxii Contents

Restoring muscle balance 240

Normalizing specific joint movement patterns 241

. UN IT 4

Exercise modifications in response to pain or

fatigue 241

Sample Specialties of Therapeutic Exercise

Pacing treatment 241

Intervention 283

Patient Education 241


Closed Kinetic Chain Training 283


Therapeutic Exercise for Fibromyalgia Syndrome

Physiologic Principles of Closed Kinetic Chain Training 284

and Chronic Fatigue Syndrome 244

Muscular Factors 284

Biomechanical Factors 284

Pathology 244
Neurophysiologic Factors 286

Fibromyalgia syndrome 244

Examination and Evaluation 287

Chronic fatigue syndrome 246

Standardization Tools 287

Therapeutic exercise intervention for prevention and

Therapeutic Exercise Intervention 287

wellness 247
Elements of the Movement System 288

Therapeutic exercise intervention for common

Activity or Technique 290

impairments 247
Dosage 290

Impaired muscle performance 248

Application of Closed Kinetic Chain Exercises 291

Impaired aerobic capacity 249

Lower Extremity Examples & Progression 291

Impaired range of motion 250

Upper Extremity Examples & Progression 292

Impaired posture 250

Precautions and Contraindications 306

Impaired response to emotional stress 251

Pain 252

Precautions/contraindications 252

Adjunctive interventions and patient-related

Proprioceptive Neuromuscular Facilitation 309

instruction 253


Definitions and Goals 309

Basic Neurophysiologic Principles of proprioceptive

neuromuscular facilitation 309

Therapeutic Exercise in Obstetrics 259

Muscular Activity 309

Diagonals of Movement 310

Motor Development 314

Physiologic Changes Related to Pregnancy - Support

Element 259
Examination and Evaluation 314

Endocrine System 259

Impaired range of motion and muscle length 314

Cardiovascular System 260

Impaired muscle performance (power) 314

Respiratory System 262

Impaired muscle performance (endurance) 314

Impaired balance 314

Physiologic Changes Related to Pregnancy-Base

Impaired posture 314

Element 262

Impaired motor control 314

Musculoskeletal System 262

Pain 314

Therapeutic Exercise Intervention for Wellness 263

Treatment Implementation 316

Precautions and Contraindications 263

Patterns of Facilitation 316

Exercise Guidelines 263

Procedures 317

Exercise Intensity 266

Techniques of Facilitation 320

Exercise Classes 266

Patient-related instruction 326

Therapeutic Exercise Intervention For Common

Impairments 266

Adjunctive Interventions 266


Normal Antepartum Women 266

High Risk Antepartum 272

Aquatic Physical Therapy 330

Postpartum 274

Therapeutic Exercise Intervention For Common

Physical Properties of Water 330

Impairments 276
Buoyancy 330

Nerve Compression Syndromes 276

Hydrostatic Pressure 330

Other Impairments 277

Viscosity 330

Contents xxiii

Physiologic Responses to Immersion 334

Effects of Water Temperature 336


Physiologic Responses to Exercise and Immersion 336

The Pelvic Floor 402

Examination and Evaluation for Aquatic Rehabilitation 337

Therapeutic Exercise Intervention 337
Review of Anatomy and Kinesiology 403

Mobility Impairment 337

Skeletal Muscles 403

Balance Impairment 340

Pelvic Diaphragm Muscles 403

Related Muscles 404

Aquatic Rehabilitation to Treat Functional Limitations 343

Pelvic Floor Function 404

Coordinating Land and Water Activities 343

Physiology of Micturition 405

Patient-Related Education 344

Anatomic Impairments 405

Precautions/contraindications 344
Birth Injury 407

Neurologic Dysfunction 407

Psychological Impairments 408

Motivation 408

Sexual Abuse 408

Examination/Eva Iuati on 408

Functional Approach to Therapeutic

Risk Factors 409

Screening Ouestionnaires 409

Exercise of the Lower Extremities 349

Results of the Internal Examination 409

Patient Self-Assessment Tests 410

Therapeutic Exercise Interventions for Common

:::HAPTER 18
Physiologic Impairments 411

Impaired Muscle Performance 411

The lumbopelvic Region 349

Active Pelvic Floor Exercises 412


Pain 414

Review of Anatomy and Kinesiology 350

Joint Mobility and Range of Motion (including muscle

Lumbar Spine 350

length) Impairments 415

Pelvic Girdle 353

Posture Impairment 418

Myology 354
Coordination Impairment 418

Gait 357
Clinical Classifications of Pelvic Floor Muscle

Examination and Evaluation 357

Dysfunction 419

Patient History 357

Supportive Dysfunction 419

Screening Examination 358

Common Impairments 420

Tests and Measures 359

Hypertonia Dysfunction 421

Therapeutic Exercise Intervention for Common

Incoordination Dysfunction 422

Physiologic Impairments 364

Visceral Dysfunction 422

Aerobic Capacity Impairment 365

Therapeutic Exercise Intervention for Common Diagnoses 423

Balance and Coordination Impairment 365

Incontinence 423

Muscle Performance Impairment 366

Organ Prolapse 426

General Disuse and Deconditioning 375

Chronic Pelvic Pain 426

Range of Motion, Muscle Length, and Joint Mobility 378

Levator Ani Syndrome 426

Pain 383
Coccygodynia 427

Posture and Movement Impairment 386

Vulvodynia 427

Vaginismus 428

Therapeutic Exercise Intervention for Common

Nonrelaxing puborectalis syndrome 428

Diagnoses 389

Dyspareunia 428

lumbar Disk Herniation 389

Adjunctive Interventions 428

Examination and Evaluation Findings 389

Biofeedback 428

Treatment 390
Basic Bladder Training 429

Spinal Stenosis 391

Scar Mobilization 429

Examination and Evaluation Findings 391

Externally Palpating the Pelvic Floor Muscles 431

Treatment 391

Spondylolysis and Spondylolisthesis 392


Examination and Evaluation Findings 393

Treatment 393
The Hip 436

Adjunctive Interventions 393


Bracing 393
Anatomy And Kinesiology 436

Traction 394
Osteology and Arthrology 436

xxiv Contents

Muscles 438

Nerves and Blood Supply 438


Kinematics 438
The Ankle/Foot 524

Kinetics 440

Kinetics and Kinematics of Gait 441

Review of Anatomy and Kinesiology 524

Anatomic Impairments 441

Osteology 524

Angles of Inclination and Torsion 441

Arthrology 525

Leg Length Discrepancy 443

Myology 526

Examination and Evaluation 444

Neurology 526

History 444
Foot and Ankle Kinesiology 527

Lumbar Spine Clearing Examination 444

Gait Kinetics 529

Other Clearing Tests 444

Gait Kinematics 530

Gait and Balance 446

Anatomic Impairments 533

Joint Mobility and Integrity 446

Subtalar varus 533

Muscle Performance 446

Forefoot Varus 533

Pain and Inflammation 447

Forefoot Valgus 534

Range of motion and Muscle Length 448

Examination and Evaluation 534

Work, Community, and Leisure Integration or

Patient/Client History 534

Reintegration 448
Joint Integrity and Mobility Examination 534

Special Tests 448

Muscle Performance 534

Therapeutic Exercise Interventions For Common

Pain 534

Physiologic Impairments 450

Posture 534

Impaired Muscle Performance 450

Range of Motion 535

Range of Motion, Muscle Length, Joint Mobility, and

Other Examination Procedures 535

Integrity Impairments 459

Therapeutic Exercise Intervention for Common Physiologic

Balance 467
Impairments 535

Pain 468
Balance and Coordination Impairment 535

Leg Length Discrepancy 470

Muscle Performance 536

Therapeutic Exercise Interventions For Common

Pain and Swelling 537

Diagnoses 471
Posture and Movement Impairment 538

Osteoarthritis 471
Range of Motion and Joint Integrity Impairment 539

Iliotibial Band-Related Diagnoses 474

Therapeutic Exercise Intervention for Common Ankle and

Nerve Entrapment Syndromes 478

Foot Diagnoses 543

Plantar Fascitis 543

Posterior Tibial Tendon Dysfunction 545

Achilles Tendinosis 545

The Knee 488

Functional Nerve Disorders 545


Ligament Sprains 547

Review of Anatomy and Kinesiology 488

Ankle Fractures 549

Anatomy 488
Adjunctive Interventions 549

Kinematics 491
Adhesive Strapping 549

Kinetics 492
Wedges and Pads 550

Anatomic Impairments 492

Biomechanical Foot Orthotics 550

Genu Valgum 493

Heel and Full Sole Lifts 550

Genu Varum 493

Examination and Evaluation 493

Patient/client History 493


Tests and Measures 493

Functional Approach to Therapeutic

Therapeutic Exercise Intervention for Physiologic

Exercise for the Upper Extremities 555

Impairments 494

Mobility Impairment 494


Impaired Muscle Performance 496

Therapeutic Exercise Intervention for Common

The Temporomandibular Joint 555

Diagnoses 500

Ligament Injuries 500

Review of Anatomy and Kinesiology 555

Fractures 506
Bones 555

Meniscallnjuries 508
Joints 556

Degenerative Arthritis Problems 509

Muscles 557

Tendinoplasties 512
Nerves and Blood Vessels 560

Patellofemoral Pain 514

Kinetics 560

Contents xxv

Examination and Evaluation 561

Therapeutic Exercise Interventions for Common Physiologic
Subjective Data 561
Impairments 620

Mobility ImpairmeRt Examination 561

Impaired Muscle Performance 621

Pain Examination 561

Impaired Range of Motion and Muscle Length 623

Special Tests and Other Assessments 562

Impaired Posture and Motor Function 629

Therapeutic Exercise Interventions for Common Physiologic Therapeutic Exercise Interventions for Common
Impairment 562
Diagnoses 633

Mobility Impairment 562

Parkinson's Disease 633

Posture and Movement Impairments 568

Scoliosis 635

TheraP!lutic Exercise Interventions for Common

Kyphosis 637

Diagnoses 572
Thoracic Outlet Syn.drome 637

Capsulitis and Retrodiskitis 572

Degenerative Joint Disease 573

Derangement of the Disk 573


Surgical Procedures 575

The Shoulder Girdle 643

Adjunctive Therapy 575


Review of Anatomy and Kinesiology 643

~,",APTER 24
Sternoclavicular Joint 643

Acromioclavicular Joint 644

The Cervical Spine 582

Scapulothoracic Joint 645

Glenohumeral Joint 645

Review Of Anatomy And Kinesiology 582

Scapulohumeral Rhythm 646

Craniovertebral Complex 582

Myology 647

Midcervical Spine 584

Examination and Evaluation 649

Vascular System 585

Patient/Client History 649

Nerves 585
Clearing Examination 650

Muscles 586
Motor Function (Motor Control and Motor Learning) 651

Examination and Evaluation 587

Muscle Performance 651

History and Clearing Tests 587

Pain 651

Posture and Movement Examination 588

Peripheral Nerve Integrity 652

Muscle Performance, Neurologic, and Special

Posture 652

Tests 588
Range of Motion, Muscle Length, Joint Mobility, and Joint

Therapeutic Exercise Interventions For Common Physiologic

Integrity 652

Impairments 588
Work (Job/School/Play). Community, and Leisure

Impaired Muscle Performance 588

Integration or Reintegration (Including Instrumental

Mobility Impairment 593

Activities of Daily Living) 653

Posture Impairment 600

Therapeutic Exercise Interventions For Common Physiologic

Therapeutic Exercise Interventions For Common

Impairments 653

Diagnoses 605
Pain 653

Disk Dysfunction 605

Range of Motion and Joint Mobility Impairments 661

Cervical Sprain and Strain 605

Impaired Muscle Performance 666

Neural Entrapment 606

Posture and Movement Impairment 672

Cervicogenic Headache 607

Therapeutic Exercise Interventions For Common

Diagnoses 673

PlER 25
Rotator Cuff Disorders 673

Adhesive Capsulitis 680

The Thoracic Spine 610

Adjunctive Interventions: Taping 685


Scapular Corrections 686

Prevention of Allergic Reaction 687

Review of Anatomy 610

Prevention of Skin Breakdown 690

Osteology/Arthrology/Myology 610

Kinetics 611

Anatomic Impairments 614


Kyphosis 614
The Elbow. Forearm. Wrist. and Hand 698

Scoliosis 617

Examination and Evaluation 618

Anatomy 698

History 618
Elbow and Forearm 698

Systems Review 618

Wrist 700

Tests and Measures 619

Hand 702

xxvi Contents

Regional Neurology 702

Musculotendinous Disorders 719

Kinesiology 705
Bone and Joint Injuries 723

Elbow and Forearm 705

Complex Regional Pain Syndrome 729

Wrist 706
Stiff Hand and Restricted Motion 732

Hand 706

Examination and Evaluation 708

History 708

Observation and Clearing Tests 708


Mobility Examination 708

Case Studies 739

Muscle Performance Examination 709

Pain and Inflammation Examination 709

Other Tests 709


Therapeutic Exercise Interventions for Common Physiologic

Red Flags: Recognizing Signs and Symptoms 759

Impairments 709

Impaired Mobility 709

Impaired Muscle Performance 711


Impaired Endurance 713

Pain and Inflammation 714

Red Flags: Potentially Serious Symptoms and

Posture and Movement Impairment 714

Signs in Exercising Patients 764

Therapeutic Exercise Interventions for Common Diagnoses 715

Cumulative Trauma Disorders 715


Nerve Injuries 716

chapter 1

Introduction to Therapeutic Exercise and

the Modified Disablement Model

and revised in March 1995. The author has further revised

Definition of Physical Therapy
the language used in this definition to remain current.
Therapeutic Exercise Intervention Physical therapy, which is the care and senices pro­
The Disablement Process vided by or under the direction and superdsion of a physi­
cal therapist, includes
Purpose of Defining the Disablement Process

Evolution of the Disablement Model

1. Examining patients with impairments, functi onal
limitations, and disahility or other health-related
Modified Disablement Model
conditions to determin e a diagnosis, prognOSiS, and
Pathology/pathophysiology intervention. Examinations within the scope of phys­
Impairments ical therapy practice include, but are not limited to,
Functional Limitations, Disability, and Quality of Life tests and measures of four categories of conditions ;
Risk Factors and Interventions musculoskeletal (e.g., range of motion , muscle per­
Prevention and the Promotion of Health, Wellness, and form ance, joint mobility, posture) , neuromu scular
Fitness (e.g., reflex integrity, cranial nerve integrity, neuro­
Summary motor development, sensory integration ), cardiovas­
cular/pulmonary (e.g. , aerobic capacity/endurance,
ventilation and respiration , circulation), and integu­
.-\mong the many interventions available to physical thera­ mentary (e.g., integumentary integrity).
pists, therapeutic exercise has been shown to ,!>e funda­ 2. Alleviating impa irments and functi onal limitations
mental to imp roving function and disability.l- I It is the by designing, implementing, and nwdifying thera­
premise of this text that , through carefully prescribed ther­ peutic interventions. Interventions include, but are
apeutic exercise intervention, an individual can make sig­ not limited to, procedural interventions such as ther­
niJicant changes in functional performance and disability, apeutic exercise; manual therapy techniq ues; pre­
and that physical therapists have the unique educational scription , fabrication, and application of' assistive,
training to be the preferred clinician for prescribing thera­ adaptive, supportive, and protective devices and
peutic exercise. equipment; airway clearance techniques; physical
agents and mechanical and electrotherapeutic
modalities; and functional training in self-care, home
DEFINITION OF PHYSICAL THERAPY management, work (job/school/play), community,
and leisure activities.
The Guide to Physical Therapist Practices has defined 3. Preventing injury, impairments, fun ctional limita­
physical therapy as follows: tions, and disability , including the promotion and
maintenance offitness, health, and quality of life in
Physical therapy includes diagnosis and management of move­
ment dysfunction and enhancement of physical and functional
all age populatiOns
abilities; restoration, maintenance, and pronwtion of optimal 4. Engaging in consultation, education, and research.
physical function, optimal fitn ess and wellness, and optimal It is evident from these two definitions that phYSical
quality of life as it relates to movement and health; and pre­ therapists examine, evaluate, diagnose , and intervene at
vention of the onset, sympt()ms, and progression of impair­
the level of impairment, functional limitation, and disabil­
ments, functional limitations, and disabilities that may re.sult
from diseases, disorders, conditions, or injuries. ity in the disablement process. The most critical message
promoted by these definitions is that physical therapists are
The Model Definition of Physical Therapy for State primarily concerned with using knowledge and clinical
Practice Acts 9 was adopted by the American Phys ical Ther­ skills to prevent, reduce, or eliminate impairment, func­
apy Association (APTA ) Board of Directors in March 1993 tionallimitation, and disability and enable individuals seek­
2 Therapeutic Exercise: Moving Toward Function

ing their services to achieve the most optimal quality of life Decisions regarding therapeutic exercise intervention
possible. should be based on individual goals that provide patients or
In the past, the focus on measuring and altering impair­ clients .vith the ability to achieve optimal functioning in
ments superseded the goals of improving function and dis­ home, work (job/school/play), and communitylleisure ac­
ability. This text focuses on altering those impairments re­ tivities. To implement goal-oriented treatment, the physi­
lated to improving function and disability through the use cal therapist must
of therapeutic exercise. Instead of considering "which ex­
• Provide comprehenSive and personalized patient
ercise can be prescribed to improve impairment," the ther­
apist should consider "what impairments are related to re­
• Rely on clinical deciSion-making skills
duced function and disability for this patient and which
• Implement a variety of therapeutiC interventions that
exercises can improve functional perfonnance and disabil­
are complementary (e.g. , heat application before joint
ity by addressing the appropriate impairments ." mobilization and passive stretch, followed by active
To understand the relationships among disease, pathol­
exercise to use new mobility in a functional manner)
ogy, impairment, functional limitation , and disability, and
• Promote patient independence whenever possible
to avoid confusion caused by misunderstood terminology, a
through the use of home treatm ent (e.g., home spine
detailed description of the disablement process is neces­
traction , home heat or cold therapy) , self-manage­
sary and is provided later in this chapter. The model pro­
ment exercise programs (e.g., in the home, fitness
posed is based on two conceptual models and their modifi­
club, community-sponsored group classes, school­
cations. The reader is encouraged to use this model to think
sponsored or community-sponsored athletics ), and
about the complex process of disablement and how the dis­
patient-related instruction.
ablement process relates to decisions regarding therapeu­
tic exercise intervention. Care must be taken to prOvide intervention sufficient to
meet functional goals, avoid providing extraneous inter­
ventions , promote patient independence, and promote
health care cost containment. In some cases, patient inde­
THERAPEUTIC EXERCISE INTERVENTION pendence is not possible, but therapeutic exercise inter­
vention is necessary to improve or maintain health status or
Therapeutic exercise intervention is a health service pro­ prevent complications. In these situations, training and ed­
vided by physical therapists to patients and clients. Pa­ ucating family, friends , significant others, or caregivers to
tients are persons with diagnosed impairments or func­
deliver appropriate therapeutic exercise intervention in the
tional limitations. Clients are persons who are not
home can greatly reduce health care costs by limiting in­
necessarily diagnosed ,vith impairments or functionallimi­
house physical therapy intervention .
tations but who are seeking physical therapy services for
prevention or promotion of health, wellness, and fitness .
Interventions for clients of physical therapy can include ed­ THE DISABLEMENT PROCESS
ucation regarding body mechanics provided to a group of
persons involved in strenuous occupational activity, early PhYSical therapists intervene at the level of impairment,
education and exercise prescription geared toward preven­ functional limitation, and disability of the disablement pro­
tion for persons diagnosed with a musculoskeletal disease cess. The concept of disablement refers to the "various im­
such as rheumatoid arthritis , or exercise recommended for pact(s) of chronic and acute conditions on the functioning
a group of high-level athletes to prevent injury or enhance of specific body systems, on basic human performance, and
performance. on people's functioning in necessary, usual, expected, and
Therapeutic exercise is considered a core element in personally desired roles in society."lO,ll A practitioner's un­
most physical therapy plans of care. It is the systematic per­ derstanding of the process of disablement and the factors
formance or execution of planned physical movements , that affect its development is fundamental to achieving the
postures, or activities intended to enable the patient/client goal of restoring or improving function and redUcing dis­
to (1 ) remediate or prevent impairments, (2) enhance func­ ability in the individual seeking physical therapy services.
tion, (3) reduce risk, (4) optimize overall health, and (5) en­ This ,viII become evident as the disablement process is de­
hance fitness and well-beingS fined and described. The speCific relation to therapeutic
Therapeutic exercise may include aerobic and en­ exercise intervention is discussed throughout the explana­
durance conditioning and reconditioning; balance, coordi­ tion of the disablement process.
nation , and agility training; body mechanics and posture
awareness training; muscle lengthening; range of motion Purpose of Defining the
techniques; gait and locomotion training; movement pat­ Disablement Process
tern training; or strength, power, and endurance training.
Although therapeutic exercise can benefit numerous The purpose of defining the disablement process in a text
systems of the body, this text focuses primarily on treat­ on therapeutic exercise is to provide the reader with an un­
ment of the musculoskeletal system. Concepts of thera­ derstanding of the complex relationships of pathology and
peutic exercise intervention specifically for the cardiovas­ disease, impairments, functional limitation, and disability
cular/pulmonary, neurologic, and integumentary systems and to prOvide the conceptual basis for organizing elements
are not covered in this text, except as they relate to impair­ of patient/client management that are provided by physical
ments of the musculoskeletal svstem.
therapists. This text will use an expanded disablement
Chapter 1: Introduction to Therapeutic Exercise and the Modified Disablement Model 3

model that provides both the theoretical framework fO.r .un­ INTERNATIONAL CLASSIFICATION OF
derstanding physical therapist practice and the classIfIca­ IMPAIRMENTS, DISABILITIES, AND
tion scheme by which physical therapists make diagnoses.
Tl'te accepted definitions of imp<tirment, functionallimita­
tion , and disability according to the APT AU are as follows:
• Impairment is a loss or abnormality of anatomic,
physiologic, or pSYl:hologic structure or function. Sec­
ondary imp<tirment is an impairn1l'nt that ongmates NAGISCHEME
from other, preexisting imp<tirments.
• Functional limitation is a restriction of the ability to

perform, at the level of the whole person , a physical PATHOLOGY - IMPAIRMENT - LIMITATION DISABILITY

action , activity, or task in an efficient, typically ex­

pected, or competent manner. FIGURE 1-1 . Two conceptual models fo r the disablement process_
• Disability is defined as tl1e inability to perform or a
limitation in the performance of actions, tasks, and ac­ the continuum of disability are quite complex. The disable­
tivities usually expected in specific social roles that are ment process can be better understood by examining the
customary for the individual or expected for the per­ evolution of the disablement model.
son's status or role in a specific sociocultural context The most frequently presented models of the disable­
and physical environment. ment process are the World Health Organization's (vVHO )
Therapeutic exercise intervention must not focus ~olely International Classification of Impairments, Disabilities,
n pathology, disease, or imp<tirments; it should addltlon­ and Handicaps (ICIDH) 10 and a model developed by soci­
.ill\- consider the functional loss and disability of the patient ologist Saad Nagill in the 1960s (Fig. 1-1). In both disable­
eking physical therapy services. Although a specific tl:er­ ment models, the central theme is the description of a pro­
peutic exercise intervention may be selecte~ to remedlate cess from disease or active pathology toward functional
_IT prevent imp<tirment, it must be selected m V1ew of Im­ limitations and the factors limiting a person's ability to in­
. rO\ ' ng a functional outcome and the person 's role in a spe­ teract as a normally functioning person in society .
fi c sociocultural context and physical environment.
Active Pathology Dr Disease
One example is the scenario of a patient with low back
There is general agreement between the l'\agi and ICIDH
·n. Examination reveals that this patient has impairments
models in the definition of the first two concepts of dis­
- ociated with excessive mobility of the lumbar spine in

ablement (see Fig. 1-1 ). For Nagi, active pathology in­

:. e direction of flexion and low back p<tin after prolonged

volves the interruption of normal cellular processes and the

;"'exion postures and movement patterns associated with

efforts of the affected systems to regain homeostasis. Active

~petitive flexion. A passive or active stretch technique may

pathology can result from infection, trauma, metabolic im~

chosen to apply to the hamstrings. .

balance, degenerative disease process, or another cause. I~

tretching the hamstrings is an intervention at the Im­
ICIDH uses the term disease to refer to the biomechanical,
-.wrment level of the disablement process. Improving the
phYSiol0f,iC, and anatomic abnormalities of the human or­
D!rth of the hamstrings can increase hip range of motion
ganism. ,10,13 Examples of actIve pathology and drsease
d consequently improve mobility to bend forward at the
common to both models are the altered cellular processes
before streSSing the low back in a flexion movement
found in osteoarthritis, cardiomyopathy, or ankylosing
ttern. ChOOSing to treat this imp<tirment directly influ­
function by improving the mobility of a forward bend
'ement (i.e., a functional movement pattern) and re­ Impairment
eing p<tin during an activity of daily living (ADL) (e.g., Both models refer to the next stage in the continuum as im­
nding forward to wash one's face , make the bed, set the p<tirment. Imp<tirment refers to a loss or abnormality at the
Ie, reach into the refrigerator). Although weak abdoml­ tissue, organ, or body system level. The effects of disease or
muscles constitute a common imp<tirment of patients pathology are found in impairments of the body systems in
rh low back p<tin, treating weak abdominal muscles with which the pathologiC state is manifest. The clinical example
"lartial curl-up exercise, for example, may not be appro­ of a person diagnosed with rheumatoid arthritis may help
te for that patient. The flexion force on the low back to clarify the difference between pathology and impair­
y xacerbate symptoms, and the partial curl-up may not ments. Rheumatoid arthritis represents the pathology or
to a meaningful functional movement pattern for the disease diagnosis. The primary phYSiologic impairments
"en t. Understanding the disablement process for each (defined later in this chapter) associated with rheumatoid
tient enables the therapist to make sound decisions arthritis are found chiefly in the alteration of norm al struc­
u t therapeutic exercise intervention. ture and function of bones, joints, and soft tissues of the
musculoskeletal system . The phYSiologic imp<tirments re­
sulting from this disease process relevant to the mu~cu­
E olution of the Disablement Model loskeletal system may include imp<tired range of motton,
t: previous example is ~n oversimplifi~~tion of the use of joint mobility and integrity, or muscle performance. Physi­
disablement process m making deCISIOns about thera­ ologiC impairments of the neuromuscular system (e.g.,
. tic exercise. The relationships of the components along poor balance) or cardiovascular/pulmonary system (e.g.,
4 Therapeutic Exercise: Moving Toward Function

decreased endurance) can also be detected , usually as se­ previous example demonstrated, persons with similar attri­
quelae of the musculoskeletal system impairments (i.e., bution profiles (e.g., pathology, impairments , functional
secondary impairments, which are explained later in this limitations) can present "vith different disability profiles.
chapter). Factors such as age, general health status, personal goals,
motivation, social support, and physical environment influ­
Functional Limitation, Disability, and Handicap ence the level of disability the person experiences.
The I\ agi and ICIDH models diverge at the next two levels
International Classification of Impairments.
of the disablement model (see Fig. 1-1).
Disabilities. and Handicaps Model
Nagi Model The ICIDH model (see Fig. 1-1) does not discriminate
The next level in the disablement model is functional betvv'een fun ctional limitation and disability. According to
limitation. For Nagi, this term represents a limitation in ICIDH, the term disability describes any restriction or lack
peJiormance at the level of the whole organism or person. of ability to perform a task or an activit)' in the manner con­
It appears he is referring to components of more complex sidered normal for a person, such as a disturbance in gait,
tasks of basic activities of daily living (BADL) (e.g., per­ BADLs, or IADLs. Handicap is the term used to describe
sonal hygiene, feeding, dreSSing) and instrumental activi­ the final element of the ICIDH model. It is a disadvantage
ties of daily living (IADL) (e.g., preparing meals, house­ resulting from an impairment or disability that limits or
work, grocery shopping). Examples of functional prevents fulfillment of an individual's normal role . The
limitations for Nagi might include gait abnormalities, re­ WHO stipulates that a handicap is not a classification of in­
duced tolerance to sitting or standing, difficulty climbing dividuals but is a classification of circumstances that place
the stairs, or inability to reach overhead. such individuals at a disadvantage relative to peers when
Disability is the final element in Nagi's model. Nagi de­ judged by the norms of society. The handicap represents
scribes disability as any restriction or inability to peJiorm the social and environmental consequences for the individ­
socially defined roles and tasks expected of an individual ual stemming from the presence of impairments and dis­
within a sociocultural and physical environment. Activities abilities. 10
and social roles associated with the term disability in­ A criticism of the ICIDH model is that it does not dif­
c1ude 13 ferentiate between limitations in performing societal roles
and the cause of these limitations . The cause of societal
• BADLs and IADLs limitations is clear in Nagi's model in that it is broken down
• Social roles, including those associated with an occu­
into functional limitations (i.e., attributes relating to the in­
pation or the ability to perform duties as a parent or
dividual) and disability (i.e. , relational characteristics to so­
ciety). In understanding the disablement process, it is im ­
• Social activities, including attending church and other
portant to identify the extent to which disability results
group activities, and socializing with fri ends and rela­
from the social and physical environment or from factors
vvithin the individual. It is believed that the Nagi model
• Leisure activities, including sports and physical recre­
does this more SUCCinctly than does the ICIDH model.
ation, reading, and travel
Nagi reserves the term disability for social rather than
individual functioning. In considering Nagi's definition of MODIFIED DISABLEMENT MODEL
disability, not all impairments or functional limitations re­
sult in dis ability. For example, two person s diagnosed with The previous two disablement models de monstrate that
the same di sease with similar levels of impairment and much of the discrepancy between the Nagi and ICIDH
functional limitation may have two different levels of dis­ models is semantic and that neither model completely ful­
ability. On e person may remain very active in all aspects of fills the deSCription of the complexity of the disablement
life (i.e., personal care and social roles ), have support from process. Several modifications of the two basic models of
family members in the home , and seek adaptive methods of Nagi and ICIDH have been proposed and each has impor­
continuing vvith his or her occupational tasks, whereas the tant contributions8.13-16 The model described and used in
other individual may choose to limit social contact, depend this text combines elements from each basic model and
on others for personal care and household responsibilities, their modifications to prOVide a model for physical therapy
and have a job where it is not possible to use adaptive meth­ practitioners (Fig. 1-2).
ods to partiCipate in work tasks.
Nagi describes the distinction between functionallimi­ Pathology/pathophysiology
tation and disability as the difference between attributes
and relational concepts . Attributes are defined by Nagi as The first element of the modified model remains the same
phenomena that pertain to characteristics or properties of as in the N agi model, vvith a revision to the definition.
the individual. A functional limitation is primarily a reflec­ Pathology/pathophysiology (disease, disorder, or condi­
tion of the characteristi cs of the individual person. It is tion) refers to an ongOing pathologic/pathophysiologic stat
therefore unnecessary to go beyond the individual to mea­ that is (1) characterized by a particular cluster of signs and
sure a functional limitation. Disability, however, has a rela­ symptoms and (2) recognized by the patient or the practi­
tional characteristic in that it describes the inwvidual's lim­ tioner as "abnormal." Pathology/pathophysiology is primal'­
itation in relation to society and th e environment. As the ily identified at the cellular, tissue, and organ levels and i
Chapter 1. Introduction to Therapeutic Exercise and the Modified Disablement Model 5

risk factors

~ secondary conditions

GURE 1-2. Modified disablement model. Prevention and promotion of heath, weliness, and fitness

• n the physician's medical diagnosis. It is, however, Impairments

-thin the scope of physical therapy practice to diagnose
thology at the tissue level using clinical tests and mea­ Similar to the Nagi and ICIDH models , impairments are
ciT • such a~ those outlined by Cyria'\ (e.g., supraspinatus defined as losses or abnormalities of physiologic, psycho­
donitis),u FUlthermore, the complexity of the in terre­ logiC, or anatomic structure or function. Active pathology
io nships among the components of the disablement results in impairment, but not all impairments originate
del is indicative of the knowledge of pathology and from pathology (e.g. , congenital anatomic deformity or
th ophysiology necessary to perform optimal patient loss, immobilization , faulty movement patterns). Through­
agement. For example, in the case of a patient referred out this text, phYSiologic, anatomic, and psychologic im­
a physical therapist with shoulde r pain , the physical ther- pairments are differentiated (Display 1-1).
A j t performs an examination/evaluation to diagnose the
ndition. It is imperative for the physical therapist to be Physiologic Impairment
owledgeable in the numerous possible causes of the pa­ Physiologic impairment can be defined as an alteration
nt's pain. The physical therapist's knowledge that differ­ in any phYSiologic function such as aerobic capacity, mus­
t cluste rs of si.gns and symptoms are consistent with cle performance (strength, power, endurance), joint mobil­
thology at the tissue (e.g. , tendonitis) , organ (e.g., my­ ity (i.e., hypomobility/hypermobility), balance, posture, or
lrdial infarction), or cellular (e .g., lung cancer) level is motor function (Fig. 1-3). Physical therapy interventions
'!itical for the diagnosis and management of the patient's can most Significantly modify phYSiologic impairments.
, ndition. If the clinical findings on examination suggest a Unit 2 of this text provides a more thorough discussion of
thologic or pathophysiologic condition that is not within each of these phYSiologic impairments and examples of
- e scope of physical therapy practice (e.g., myocardial in­ therapeutic exercise interventions to remediate or prevent
Mction, lung cancer) that has not been addressed by the these impairments.
p ropriate practitioner, an immediate referral is neces­
SdI)' (see Appendix l). In many instances, the pathology Anatomic Impairment

can not be dj~gnosed and the physical therapist must rely Anatomic impairment is an abnormality or loss of struc­

n clusters of impairments to formulate a diagnosis and in­ ture, such as hip anteversion, structural subtalar varus,

~rve ntion. A pathology-based diagnosis does not, by itself, structural genu varum, or congenital or traumatic loss of a

elineate the impairments, functional limitations, or dis­

bility that will guide the physical the rapy intelvention (see
Chapter 2, Patient Management). Therefore, the therapist DISPLAY 1-1
must acknowledge the compTex multidirectional and cyclii­ Impairments
al nature of the disablement model and the fact that in­
Physiologic impairment: an alteration in any physiologic
'e rvention can be introduced at any component of the function
model (e.g., pathology, impairment, functional 1mitation, Anatomic impairment: an abnormality or loss of structure
lisability) , but that the more data collected regarding indi­ Psychologic impairment: any abnormality related to the
i dual components, the more accurate the patient manage­ psychologic system
men t will be.
6 Therapeutic Exercise: Moving Toward Function

ment process is not a unidirectional process, but one that is

much more complex, interrelated, and cyclical.
The term applied to this concept and used in the modi­
fied dis::lhlement model is secondary conditions (see Fig. 1­
2).13 Secondal), conditions occur as a result of a prim ar;
disabling condition. A secondary condition may be a type of
pathology or impairment, as exemplified earlier, and it can
deSignate additional functional limitations and disability.
By definition , seconda,), conditions only occur in the pres­
ence of a plimal)' condition. Other commonly encountered
secondal), conditions include pressure sores, contractures.
urinary tract infection, cardiovascular deconditioning, and
depreSS ion. Each of these secondary conditions can lead to
additional functional limitations and disability.

Functional Limitations, Disability, and

Quality of Life
The final two elements of the main pathway, function
limitation and disability, remain unchanged from the defi­
FIGURE 1·3. The patient exhibits a loss of medial rotation at the gleno­ nitions proVided in the description of?\agi's model (Fig. 1­
humeral joint, a physiologic impairment in range of motion and joint 4). Beyond the main pathway of pathology toward disabJ
mobility ment, a final outcome-health-related quality of Ii
(HRQL)-has been added. HRQL has been defined
limb. Anatomic impairments cannot be remedied with generally corresponding to total well-being, encompassi 7
physical therapy intervention, but modifications can be three major components: 18 ,19
made to function in light of anatomic impairments. The • Physical function component, which includes BADu
physical therapist should be aware of the presence of and IADLs
anatomic impairments to be able to prOvide an appropliate f) Psychologic component, which includes th e '\'an
prognosis and determine the best plan of care. Therapeu­ cognitive , perceptual, and personality traits of a
tic exercise intervention in the presence of anatomic im­ son"; and
pairments will be discussed in selected chapters in Units 5 • Social components, which involves the interaeti,
and 6. the person "within a larger social contE'xt or
ture. "
Psychologic Impairment
Psychologic impairment is any abnormality related to
the psychologic system. Although most persons with any
degree of disability are affected to some extent psycholog­
ically, it is beyond the scope of physical therapy practice to
treat psychologic impairm ents directly. It is the responsi­
bility of the physical therapist to recognize when a psycho­
logic impairment is reducing the effectiveness of a physical
therapy intervention and therefore requires referral to an
appropriate health care practitioner. Because physical
therapy intervention can greatly affect psychologic impair­
nwuts , it is important that the physical therapist under­
stand basic psychologic paradigms. However, it is not
within the scope of this text to proVide the details war­
ranted for a thorough understanding of the topic. Proper
screening for psychologic impairments is the responsibility
of the physical therapist, as is working vvith other members
of the health care team to provide a consistent philosophic
approach to the person's psychologic impairment and

Primary and Secondary Impairments

Primal), impairments can result from active pathology or
disease. A secondary impairment results from plimary FIGURE 1-4. The functional limitation related to impa.rE'::~" - ­
impairments and pathology. Primary impairments can cre­ and joint mobility is the patient's limited ability to rea~- ,:,,­
ate secondary impairments, and primal)' impairments can The patient's disability is the inability to periorm \\":i:E­
lead to secondary pathology (see Fig. 1-2). The disable­ safely.
Chapter 1. Introduction to Therapeutic Exercise and the Modified Disablement Model 7

Assessments of quality of life attempt to capture how racie kyphOSiS and must return to a data entry job (which he
limitations in function affect physical, psychol09,ic, and so­ dislikes ) at a poorly deSigned workstation. The other indi­
cial roles as well as perceptions of health status.-O- 22 A per- vidual is an active and otherwise healthy, 32-year-old man
on may argue that issues related to quality of life are not who enjoys his job as a salesman and is engaged in activities
di tinct from disability, but quality of life is considered such as sitting, standing, and walking throughout the day.
broader than disability, encompassing more than well be­ The disablement profiles of these two individuals are quite
ing related to health such as education and employment. different, and the prognoses, therapeutic exercise inter­
Other "non-health" -related factors contribute to an indi­ ventions, and functional outcomes differ accordingly.
i dual's sense of well being and overall quality of life. Such In addition to the risk factors present before disability,
actors include economic status, individual expectations interventions (see Fig. 1-2) can alter the disablement pro­
.md achievements, personal satisfaction with choices in life, cess at each juncture. Interventions may include extra-in­
d sense of personal safety as depicted in the model (see dividual factors (i.e., outside of the individual) such as med­
Fig. 1-2). The model (see Fig. 1-2) displays HRQL as a ications, surgery, rehabilitation, suppOltive equipment, and
·mall palt of quality of life and that general quality of life environmental modifications or intra-individual factors
·erlaps with components of the main pathway. (i.e., self-induced) such as changes in health habits, coping
mechanisms, and activity modifications. The expected out­
come is that interventions modify the disablement process
isk Factors and Interventions in a positive manner. However, interventions occaSionally
The main pathway from pathology to disability, including serve as exacerbators to the disablement process. Exacer­
uality of life, can be modified by a host of factors such as bators may occur in the folloWing ways:
~e. gender, education, income, comorbidities, health • Interventions may go awry.
bits, motivation, social support, and physical environ­ • Persons may develop negative behaviors or attitudes.
ent. Proper medical care and timely rehabilitation also • Society may place environmental or attitudinal barri­
.m eliminate or reduce the impact of each component's af­ ers in the path of the individual.
ts on one another. Conversely, improper medical care or
"E'habilitation along with other aforementioned factors can
nify the impact of each component in relation to the Prevention and the Promotion of Health,
).-t or accelerate the disablement process. Education, age, Wellness, and Fitness
_ender, disease severity, duration of illness and treatment,
d comorbidity modify the disablement grocess in per­ Physical therapists may prevent impairment, functional
diagnosed with rheumatoid arthritis,2 24 and anxiety, limitation, and disability by identifYing risk factors during
pression, and coping style have been related to func­ the diagnostic process. Three major types of prevention in­
nal limitations in individuals with hip or knee os­ clude: 8
hritis.25 The model exhibits these components as risk • Primary preIJention, which is the prevention of dis­
tors and interventions (see Fig. 1-2). ease in a susceptible or potentially susceptible popu­
Risk factors are predispOSing in that they exist before lation through specific measures such as general
onset of the disablement process. There are several health promotion efforts,
s of risk factors: • Secondary prevention, which includes efforts to de­
• DemographiC, social, lifestyle, behavioral, psycho­ crease duration of illness, severity of disease, and se­
logiC, and environmental factors quelae through early diagnosis and prompt interven­
• Comorbidities (e.g. , coexisting conditions ) tion,and
• Physiologic impairments (e.g. , short hamstrings, weak • Tertiary prevention, whieh includes efforts to de­
abdominal muscles, lengthened lower trapezius ) crease the degree of disability and promote rehabili­
• Anatomic impairments (e.g. , congenital scoliosis , tation and restoration of function inpatients with
shallow glenoid fossa, hip anteversion ) chronic and irreversible diseases.
• Functional performance factors (e.g. , less than opti­ Therapeutic exercise as an intervention intends to pro­
mal work station ergonomics resulting in poor posture mote primary, secondary, and tertiary prevention as well as
at the work station, faulty gait kinetics or kinematics, health , wellness, and fitness. Prevention, health, weIlness,
inappropriate lifting mechanics ) and fitness must be considered critical foundational con­
The physical therapist must be aware of these factors for cepts of therapeutiC exercise intervention (see Chapter 4).
h individual, because they can greatly alter the individ­
. disablement profile. With respect to therapeutic exer­
intervention, many of these factors can directly influ­
e the choice of activities or techniques, dosage , and The modified disablement model (see Fig. 1-2) exhibits the
cted functional outcome. An example is the scenario of complexity of the relationships among pathology, impair­
individuals involved in a motor vehicle accident and di­ ments, functional limitations, disability, risk factors, inter­
o ed vvith an acceleration injury to the cervical spine ventions, quality of life, and prevention , wellness, and fit­
th resultant sprain or strain to the cervical soft tissues. ness. A practitioner's understanding of this model is critical
"'Ie individual is a sedentary, 54-year-old male smoker to developing a therapeutic exercise program that is effec­
th diabetes who has a significant forward head and tho­ tive , efficient, and meaningful for the individual seeking
8 Therapeutic Exercis e: Moving Toward Function

physical the rapy services. Th e amount of data that can be • Disahility

collected during an initial examination or evaluation of an • Secondarv conditions
individual can be irnmense and often overwhelming. This • Previous 'inte rve ntions (intra-individuaL
model (see F ig. 1-2) allows the physical therapist to orga­ ual , and exace rbators)
nize data pertainin g to the patie nt's impairments, func­ How would these elements ch ange if the pati
tionallimitations, and disability. It also allows the physical ferent age, had a different lifestyle, or a difTe­
therapist to categorize pertinent aspects of the patient's tion';:>
IlistOlY, the effect of prior treatm ent, and the presence of
risk factors. Most important, the clinical presentation can
be classified in a way tbat identifies the impairments im­ REFERENCES
peding tile performance of certain functional tasks and ac­ 1. Sayers SP, Bean J. Cuoco A, et al. Change..; •

tiviti es, thereby focusing the treatment on only those im­ disability aftC' r resistance training: does velO('
painn e nts directly related to functional li mitation and lot stucly. Am J Phys YIed Rehabil 2003:S':!:6f~-
disability. It aho enables the practitioner to clarify risk fac­ 2. Morey MC, Shu CWo ImprovC'd fitness DafT

tors and interventions that may serve as impediments to tom-reporting gap hetween older men and,

improved functional performance, reduced disability, and ens Health 200.'3 ;12:3g1-390.

3. Topp R, Mikesky A, Wigglesworth J. et aI. n

improved quality of life, thereby serving the role of pre­

week dynamiC resistance strength training r. __

vention, and promoting health, wellness, and fitness. With velocity and balance of older adults. Ceron

this analysis, the practitioner can develop goals that are rel­ 501-506.

evant to the individual's daily life and promote health, well­ 4. Rejeski WJ, Ettinger WH Jr, \'1 artin K, et ..

ness, and fitness at any level of ability. ability in knee osteoarthritis with exercise tb---­

role for self-efficacy and pain. Arthri


KEY POINTS 5. Teixeira-Salmela LF, Olney SJ, :\adeau

strengthening and physical conditioning to

ment and disability in chronic stroke SUI"\7'

• Physical therapists examine patients with impairments,

YIed 1999;80:121-128.

functional limitations, and disabilities or other health-re­ 6. Weiss A, Suzuki T , Bean J. High intensity

lated conditions to determine a diagnosiS, prognOSiS, and improves strength and functio nal perfo

interve ntion. Arch Phys Med RehabiI1999 ;79:36~i6

• Physical therapists are involved in alleviating and pre­ 7. Hiroyuki S, Uchiyama Y, Kakurai S. Spec

venting impairments, functional limitations, and disabil­ ance and gait exercises on physical function

ity by deSigning, implementing, and modifying thera­ elderlv. Clin Rehuhil 2003;17:472--li9.

peutic interventions. 8. Guicl~ to Physical Therapist Practice. Ph~

• Therapeutic exercise intervention engages the individ­ 9. American Physical Tlwrapy Association. A _

ual to become an active participant in the treatment therapist practice, I: a des cliption of

Phvs Ther 1995;75:709-764.

10. Internati onal Classification of Imp ainnen
• Therapeutic eXf~ rcise should be a core intervention in Handicaps. (;e neva, Switzerland: " 'orld H
most physical therapy treatment plans. ti on, 1980.
• As the health care industry continues to change , the 11. Nagi SZ. Disability and Rehnbilitation.
practitioner must recognize that the third-party reilll­ State Uni versitv Press, 1969.
burser for medical care is seeking health care services 12. VerbruggE' L, J~;tt l' A. The disablement p
that are efficient and cost-effective. Prudent us e of ther­ 1994;38:1- 14.
apeutic exercise can reduce health care costs by pro­ 13. POpE' A, Tarlov A, eds. Disability in :\ mer-""lc
moting patient independence and self-responsibility. tion al Agencla for Prevention. \ \'ashin'!:
• A thorough understanding of the disablement process Academy Press, 1991.
14 . National Advisory Board on \Iew
can assist the practitioner in developing an effective, ef­
Research, Draft V: Report Plan for \Ie.!·
ficient , and cost-contained therapeutic exercise inter­ Research. Bethesda, MD: National 1­
vention, meaningful to the person seeking physical ther­ 1992.
apy services. 15. Cuccionn E' .I\.A. Arthritis and th e prOl. ..., "
Ph)s Ther 1994;74:408-414.
16. Guccionne AA. Physical tlwrap\' diagn .
CRITICAL THINKING ship betwcpn impairm ents and r
1991 ;71499-504.
Develop a case defining each feature of the modified dis­ 17. Cyriax J. Textbook of Orthopedic \ Iedid
tissue lesions. 8th E d. London: Bailliere TI
ablement model. Given a patient with low back pain, pro­
18. Jette AM. Using health-related qualih
vide a probable history of the condition. Include a brief de­ physical th erapy outcomes
scription of each of the follOwing features: 1993;73:528-537.
• Risk factors 19. Jette AM. Physical disablement concept< for~~
• Pathology research and practice . Phys Ther 199-1:- ~.'.)St'-
• Impairments (anatomic, psycholOgiC, physiologic) 20. DeHaan R, Aaronson ~, Limburt >1 , et cl. Mea:::::::::::
• Functionallimitations of life in stroke. Stroke 1993;24:320-321.
Chapter 1: Introduction to Therapeutic Exercise and the Modified Disablement Model 9

IIollbrook M, Skillbeck CE. An activities index for use ""ith 24. Mitchell JM , Burhouser RV, Pincus T . The importance of

stroke patients . Age Ageing 1983;12:166-170. age, education , and comorbidity in the substantial earnings

\litchell DM , Spitz PW, Young DY, et al. SUlvival, prognosis and losses of individuals \\~th symmetlic: polyarthlitis. Arthri­

and cause of death in rh eumatoid althritis. Arthritis Rheum tis Hheum 1988;3 1:348-357.

1986;29:706-714. 25. Summers M~, Haley WE , H.eville JD , et al. Rauiographic as­

_) Sherrer YS, Bloch DA, Mitchell, et al. Disability in rheum a­ sessment and psycholo~c variables as predictors of pain emu
toid arthritis: comparison of prognostic factors across three functional impairment in osteoarthritis of the knee or hip.
populations. J RheumatoI1987;l4:705-709. Arthritis Rheum 1988;31 :348-357.



chapter 2

Patient Management

ing even for the experienced clinician. This chapter pre­

Introduction sents two additional models to assist in organizing the data
Patient Management Model and making the clinical decisions that are necessary to de­
Examination velop an effective and efficient therapeutic exercise inter­
Evaluation vention: the patient management model proposed by the
Diagnosis American Physical Therapy Association 1 and a therapeutic
Prognosis and Plan of Care exercise intervention model.
Clinical Decision Making
Therapeutic Exercise Intervention The physical therapist's approach to patient management is
Therapeutic Exercise Intervention Model described as the patient management model in Fig. 2-l.
The physical therapist integrates these five elements of
Exercise Modification
care in a manner designed to maximize the patient's out­
Adjunctive Interventions come, which may be conceptualized as patient-related
Physical Agents
(e.g. , satisfaction with care) or associated with service de­
Mechanical Modalities
livery (e .g., efficacy and effiCie ncy) The current model of
Electrotherapeutic Modalities
patient management intends to involve the patient in deci­
sion making, which should in turn result in higher satisfac­
tion with care. In addition, in a responsibility-focused
health care system, the clinicians are called to identify and
justify the hypotheSiS that underlie interventions, which
INTRODUCTION should in turn result in improved efficiency of care and
prOvide payers with better justification for interven tion.
An understanding of the disablement process presented in
Chapter 1 enables the clinician to provide optimal patient
management by understanding the relationships among
pathology, impairments, functional limitations, disabilities, Examination
yuality of life, risk factors, and the effects of intra-individ­
ual and extra-individual interventions. Knowledge of the
disablement process enables the clinician to t
• Develop comprehensive yet efficient examinations Evaluation
and evaluations of impairments and functionallimita­
tions relatiJlg to the patient's unique disability profile.
• Reach an accurate diagnosis based on logical classifi­
cation of pathology, impairments, and functional lim­


• Develop a prognosis based on the evaluation and the

patient's goals.
• Create and implement effective and efficient inter­
ventions. Prognosis
• Reach a desirable functional outcome for the patient
as quickly as pOSSible.
Each patient presents with unique anatomic, physio­
logic, kineSiologic, psychologic, and environmental charac­ Intervention ( outcome )
teristics. Consideration of all these variables is necessary to
develop an effective plan of care , but it can be overwhelm­ FIGURE 2·1. Patient management model.
Chapter 2 Patient Management 11

Examination information about the bodily systems involved in the pa­

tient's current disability profile. Data generated hom the
Examination is required before the initial intervention and systems review may affect tests performed during subse­
is performed for all patients/clients. Examination is de­ quent examinations and choices regarding interventions.
Sned as the process of obtaining a history, performing a rel­ The systems review also assists the physical therapist in
evant systems revie'vv, and selecting and adm inistering spe­ identifying possible problems that require consu ltation
cific tests and measures to obtain data. 1 The history is with or referral to another provider. Several major systems
e),.p ected to provide the physical therapist with peltinent should be screened for involvement: cardiovascular/pul­
in formation about the patient: monary, integumentalY, musculoskeletal, and neuromus­
• Demographic profile and social history cular. In addition, comm unication abi lity, affect, cognition,
language, and learning style of the patient shou ld be as­
• Occupation
• Living and working environm ents sessed. Display 2-2 summarizes the data generated from a
• General health history systems review.
• Past and current history of the physical condition Depending on the data gathered from the history and
• Past and current functional status systems review, the therapist may use one or more exami­
• Extra-individual and intra-individu al interventions nations in whole or in part. The examination may be as
brief or as lengthy as necessary to generate a diagnosis. For
These data can be obtained from the patient, family, sig­ exarnple, after taking the history and concluding a systems
nificant others , caregivers, and other interested persons review, the physical therapist may determine that further
through interview or self-report forms , by consulting with examination is not appropriate and that the patient should
th r members of the health care team , and by reviewing be referred to another health care practitioner. Conversely,
e medical record. Display 2-1 summarizes the data gen­ the physical therapist may determine that a detailed exam­
n ted from the history. ination of several bodily systems is required to develop a
The syste ms review is a screening process that provides thorough diagnosis The specific tests and measures

Data Generated From Client History1

nlual Demographics • Patient's, family's, or caregiver's expectations and goals for

Age the therapeutic intervention
Sex Functional Status and Level of Activity
Race • Prior functional status, and self-care and home management
Primary language (i.e., activities of daily living and instrumental activities of daily
ocial History living)
Cultural beliefs and behaviors • Behavioral health risks
Family and caregiver resources Sleep patterns and positions
Social interactions, social activities, and support systems Medications
• Medications for present condition
• Medications for other conditions
Current or prior work (e.g., job, school, play) or community
activities Other Tests and Measures
• Review of available records
owth and Development • Laboratory and diagnostic tests
Hand and foot dominance

Developmental history
History of Present Condition
• Prior therapeutic interventions
living Environment • Prior medications
Living environment and community characteristics
Medical or Surgical History
Projected discharge destination(s)

• Endocrine/metabolic
Liistory of Present Condition • Gastrointestinal
Concerns that led the individual to seek the services of a • Genitourinary
physical therapist • Pregnancy, delivery, and postpartum
Concerns or needs of the individual requiring the services of a • Prior hospitalizations, surgeries, and preexisting medical and
physical therapist other health-related conditions
Onset and pattern of symptoms Family History
Mechanism(s) of injury or disease, including date of onset and • Familiar health risks
course of events
Patient's, family's, or caregiver's perceptions of the patient's Social Habits (past and present)
emotional response to the present clinical situation • Level of physical fitness (self-care, home management,
• Current thera peutic interventions community, work [e.g ., job, school, play) and leisure activities)

12 Therapeutic Exercise: Moving Toward Functi on

intervention. Based on re-examination findings (e.g., new

clinical symptoms or failure to respond in the expected
Systems Review Data 1 manlier to the intervention), the intervention may be ter­
The systems review includes the following: minated or modified. Exercise modification is discussed
• Cardiopulmonary: assessment of heart rate, respiratory later in this chapter.
rate, blood pressure, and edema
~ Musculoskeletal: gross symmetry, gross range of motion,
gross strength, height, weight Evaluation
• Neuromuscular: gross coordinated movement (e.g.,
balance,locomotion, transfers, transitions) Evaluation is the dYllamic process in which the physical
~ Integumentary: skin integrity, skin color, presence of scar
therapist makes judgments based on data gathered dUJing
formation the examination. To make appropriate clinical decisiops re­
• Communication ability, affect, cognition,language and garding the evaluation, the physical therapist must
learning style: includes the assessment of the ability to
make needs known, consciousness, orientation (person, • Determine the priority of problems to be assessed
place, and time), expected emotional/behavioral responses, based on the medical history (and any other pertinent
and learning preferences (e.g., learning barriers, data collected through medical records or interac­
educational needs) tions with other health care providers ) and systems
• Implement the examination.
• Interpret the data.
included in each examination generate data about the pa­
tient's impairments and functional limitations. Implemen­ Interpretation of the data constitutes the evaluation. In­
tation of the examination is based on a prioritized order of . terpretation of the examination findings is one of the most
tests and measures that depend on medical safety, patient critical stages in clinical decision making. In interpreting
comfort, and medical treatment priorities; the patient's the data to understand the sources or causes of the patient's
physiologic, emotional, functional, social, and vocational impairments, fundionallimitations , and disabilities, all as­
needs; and financial resources. The most relevant examina­ pects of the eX{lmination must be considered and analyzed
tions to this text tllat are performed by a physical therapist to determine the follmving:
• P rogreSSion and stage of the signs and symptoms
• Aerobic capacity/endurance • Stability of tll e condition
• Anthropometric characteristics • Presence of preexisting conditions (j.e., comorbidJties)
• Assistive and adaptive devices • Relationships among involved systems and sites
• Circulation (arterial, venous , lymphatic)
To remain consistent with the language of the disable­
• Cranial and pelipheral nelve integrity
ment process and to link the patient management model
• Environmental, home, work (job/school/play) barriers
with the disablement model, tlle following sections provide
• ErgonomiCS and body mechanics the reader witll examples of examinations and evaluations
• Gait, locomotion , balance
for each element of tlle disablement model.
• Integumentary integrity
• JOint integrity and mobility
• Motor function (motor control and motor learning) Pathology
• Muscle performance (strength, power, endurance) Laboratory tests, radiologiC studies, and neurologiC exam­
• Orthotic, protective, and supportive devices inations are used to assess the presence and extent of the
• Pain pailiologic process at the organ, tissue, or cellular level.
• Posture Because some biochemical and physiologic abnormalities
• Range of motion (including muscle length ) may be beyond the scope of medical testing, detection of­
• Reflex integlity ten relies on the examination/evaluation of impairments.
• Sensory integrity One of the frustrations for physical therapists follOWing
• Ventilation and respimtion/gas exchange the disablement model is that underlying pathology asso­
• Work (job/school, play), commullity, and leisure inte­ ciated with the impairments, functional limitations, and
gration or reintegration resulting disabilities often cannot be identified. Radio­
lOgi C, neurologic, or laboratory study results commonly
Other information may be required to complete the ex­ are negative despite tlle presence of clinical signs and
amination process; symptoms. H owever, the lack of an identifiable pathology
• Clinical findings of other health care professionals should not lead the physical therapist to believe that an
• Results of diagnostic imaging, clinical laboratory, and organic reason for the individual's impairments , func­
electrophysiologic studies tional limitation, or disability is not present. Even with a
• Information from the patient's place of work regard­ diagnOSiS of pathology, the physical therapist should con­
ing ergonomic, posture, and movement requirements. centrate on examination and evaluation of impairments,
functionallirnitations , and disabilities, because the pathol­
The examination is an ongoin g process throughout the ogy diagnosis may not provide much gUidance for physical
patient's treatment to determine th e patient's response to therapy intervention.
Chapter 2 Patient Management 13

Impairments (i.e., primary pathology ). Los s of mobility of th e

Medical procedures to evaluate impainllents include clini­ shoulder is a secondalY impairment, and retlnced USt'
cal examinations, laboratory tests, neurologic tes ts , illlaging of the upper ('xtr >mity during ADLs is a secondary
procedures, and the patient's medical histOlY and symptom func tional limitation, both of which dewloped be­
re ports. Physical therapy procedures to examine and eval­ cause of pain in the shoulder originating from the pri­
uate impairmen ts should be based on bodily systems most mary conwtion of celvical degenerative disk disease.
treated by physical therapists including the musculoskele­ • Can the impairment be related to future functional
tal, neuromuscular, cardiovascular, pulmonary, and integu­ limitation? Studies have shown that a relationship can
mentary systems (F ig. 2-2A ). Many bodily systems are not exist betwee n current impairment findings and future
within the scope of thorough and de finitive examination by functional limitations. 2.3 F or example , 10 " of shoul­
a physical therapist (e.g. , metabolic, renal , circulatory). der range of motion (RO M ) in the absence of fllIlC­
However, if peliinent to the physical therapy intervention , tionallimitation [)lay lead to functional limitation in
this information should he gathe red from the patit~ llt , other the future from exaggeration of the impairment or the
medical and llC'ulth caw profc>ssionals, or medical r('cords. existing impairment leading to other impairm ents.
Specific tests (e.g. , pulse. hlood pressme ) inclicating system • Is the impairm e nt unrelated to the fu nctionallimita­
impairments that are \;vitltin the scope of therapists should tion and disability and tlw r(O fore should not be as ­
be performed (Fig 2-2B). sessed or treated? F or example, a patient complains
Examinations ma)' reveal a list of impairments that may of shoulder pain (i.E> ., impairment) and reduced use of
or may not be amenahle to physical therapy treatment. It is the shoulder girdle during ADLs. Hypomobility of
tempting to evaluate and treat lists of impairments, but this the shoulder girdle may be an obvious impairment,
type of practice may not be the most effective or efficient but it may not be related to the functional limitation
use of health care dollars. It is therefore prudent to make or disability. T h patient's pain may occur in the
simultaneous decisions about whether testing or measuring midrange and be a result of impaired scapulohumeral
anyone impairment is pertinent to determining the cause rhythm, not hypomobility.
of the functional limitation and disability. T o facilitate this
In summar)" not all impairments result in functional
decision-making process, ask the follOwing questions:
limitations , and not all functional limitations resnlt in dis­
• Is the impairment related directly to a functional lim­ ability. For the clinician to provide effective care that will
itation? For example, reduced shoulder girdle mobil­ ultimately affect function and reduce the potential for dis­
ity (i.e., impairment ) can be directly related to an in­ ability, therapeutic interventions should, in theory, target
ability to reach upward (i. ., functional limitation). only those impairments that are related to the functional
• Is the impairm ent a secondary condition of the pri­ limitations. Indeecl, it has been suggested that through the
maty pathology or impairment? For example, a pa­ examination process, the clinician determines the interre­
tient has complaints of shoulder p ain and loss of mo­ latiollships among impairments, functional limitations, and
bility (i.e. , impai rments) resulting in reduced fun ction disability for a patient with a given diagnosis and that this
of the upper extremity (i.e., fundionallimitation ) for information then guides treatme nt. 4 Examples of cervical
the activities of daily living ( D Ls). However, the spine impairments include reduced range of cervical spine
source of the shoulder pain is cervical disk disease motion and deep cervical muscle performance, whereas a

FIGURE 2-2. (A) Measurement of range of motion

and muscle length impa irment. The patient shows
signs of limited hamstring extensibility. (8) Measure­
me nt of aerobic capacity impa irment. The clinician
takes the patient's blood pressure. B
14 Therapeutic Exercise Moving Toward Function

functional limitation might be a driver's inability to rotate ing tasks (e.g. , no difficulty, some difficulty, much dif­
the head and neck to be able to see behind when driving an ficulty, inability)19,2o
automobile in reverse. If an individual is then unable to • Observation of performance of functional tasks, rat­
work because his or her occupation requires automobile ing the level of difficulty (e.g. , fully able, partially
use, that person could be considered to have a disability. able , unable ), such as measuring distances, weight
lifted, number of repetitions, or quality of motion
Functional Limitations based on kineSiologic standards 21
Rarely does the patient seen in the physical therapy de­ • Clinical tests of physical mobility (e.g., Six-Minute
partment, clinic, or office describe specific complaints of Walk Test, Berg Balance Scale, Timed
gait speeds, Timed Movement Battery)2 - 24
Ur& Go Test,
weakness , loss of muscle length, or loss of jOint mobility
(i.e., impairments). For example, the patient is probably • E1uipment-based evaluation of performance (e.g.,
more concemed about his or her ability to climb a flight of usc of a hand dynamometer to examine grip strength, '
stairs (j.e., functional outcome ) than the adequate knee computer-assisted assessment of balance, use of spe­
ROM and quadriceps force or torque production needed cialized grids to measure performance of closed chain
to climb the stairs (i.e. , impairments ). Improved knee activities)25-29
ROM and quadriceps force production may not result in
the ability to climb a flight of stairs. The inability to climb Disability
stairs may be related to other impairments, such as weak Improvement in functional outcome may not be the only or
gluteal musculature, lack of ankle mobility, or psychologic most important measure of the positive effects of physical
impairments (e.g. , fear). therapy intervention . Disability, as defined in the disable­
One question must be addressed in daily practice and in ment model introduced in Chapter 1 (see Fig. 1-2), entails
physical therapy research: \Vhich and to what degree are the social context of functional loss. Social function encom­
impairments linked to functional limitations? More studies passes three domains: social interaction, social activity, and
are attempting to establish the relationships among pathol­ social role. 30 Each of these domains requires a certain de­
ogy, impairments, and functional limitations because this gree of physical ability. For example, functional limitation
question is clinically impOltant to physical therapists. For in going up and down stairs may limit
example, the information gained from a deSCriptive study
of individuals ,vith arthritis indicates correlations among 1. A person's social interaction because of the inability
pathology (i.e. , arthritis ), impairments (i.e. , knee ROM , to go outside the home to visit friends.
pain and joint stiffness, reduced muscle performance ), and 2. A person's social activity because of the inability to go
functional limitations (j.e., performing ADLs including to church ,vith stairs to the front door.
getting down to and up from the floor and ascending/de­ 3. A person's social role because of the inability to go to
scending stairs ) 5 This study indicates that quadriceps mus­ work and perform tasks that require going up and
cle performance, joint pain dUling the activity, perceptions down stairs.
of functional ability, and body weight combined can predict
Successful performance of complex instrumental ADLs
betvveen 39% and 56% of the variance in time to perform
such as personal hygiene, housekeeping, and dreSSing re­
four fun ctional tasks in adults with osteoarthritis of the
quire integration of physical, cognitive, and affective abili­
knee. These findings appear to indicate that interventions
ties. As a result, measurement of disability requires tests
that improve quadriceps muscle performance, reduce joint
that consider the complexity of variables that affect the per­
pain and body weight, and facilitate perceptions of func­
son's ability to interact in society. The standard and most
tional ability may have a positive impact on the ability to get
economic procedure for measuring disability is self-repOlts
down to and up from tbe floor and ascend/descend stairs in
or proxy reports, which include simple ordinal or interval
adults with osteoarthritis of the kn ee.
scoring of the degree ofdifficulty in performing roles within
Improving the impairments related to the functional out­
the person's milieu. Questions regarding functionallimita­
come is necessary, but the measure of success is in the abil­
tions, disability, and quality oflife are included in many self­
ity to achieve a functional outcome such as climbing the reports used by phYSical therapistsy ·l 1 , 15 ,26,27 ,.1 1 ~3') Similar
stairs. To determin e success in achieving functional out­
to tests and measures of functional limitation , no one self­
come, valid, reliable, and sensitive tests must be used to
repOlt can encompass all aspects of disahility from a physi­
measure functional performance . \Vith standardized tests,
cal therapist's perspective, and it is important to be aware of
no single assessment instrument can measure the full range
numerous reports pertin ent to specific areas of practice.
of potential impairments, functional limitations, and dis­
The appropriate self-report can offer comprehensive, con­
abilities. Adequate evaluation usually must rely on a battery
cise information peltaining to functional limitations, dis­
of appropriate instruments. It is beyond the scope of this
ability, and quality of life, which can guide the physical ther­
text to discuss the various stanJardized tests, but a literature
apist's evaluation and intervention.
search on the speCific population you are testing can offer
Results of a disability measure often reveal aspects of
explicit tests and measures for your Jesired purpose. 6-- 11;
the disability that are beyond physical impairments and
Tests and measures of physical functional limitations
functional limitations. Refer the patient to the appropriate
have various formats:
health care profeSSional if aspects of his disability are be­
• Self-reports or proxy reports (e.g. , spouse, parent, yond your knowledge , expertise, or experience. Decide
personal physician ) of the level of difficulty perform­ whether further physical therapy intervention is appropri­
Chapter 2: Patient Management 15

ate or physical therapy should be deferred until other as­

pects of disability are adequately dealt with. For example,
a patient with low back pain may have a high level of anxi­ Definitions of Terms
ety or depression associated with the loss of function and Cluster: A set of observations or data that frequently occur as
the disability. Physical therapy may not be effective until a group for a single patient.
the patient is treated for the anxiety or depression, or phys­ Syndrome: An aggregate of signs and symptoms that
ical therapy concurrent with counseling may be deter­ characterize a given disease or condition.
mined to be most effective. Diagnosis: A label encompassing a cluster of signs and
The time it takes to complete and interpret the self­ symptoms commonly associated with a disorder,
report forms has been described as a methodologic and syndrome, or category of impairment, functional limitation,
practical barrier to using self-reports. However, self-reports or disability.
assist in determining whether functional limitations and dis­ Adapted from American Physical Therapy Association. A guide to physical
ability exist beyond the scope of physical therapy practice therapist practice. I: a description of patient management. Phys Ther
and result in a referral to health care providers educated to 1995.75.'749-756.
evaluate and treat components outside the physical thera­
pist's domain. This information may save financial resources
and time spent attempting to treat physical impairments or
functional limitations that cannot be resolved without more in the examination and evaluation and organizing it into
comprehensive intervention involVing other health care clusters, syndromes, or categories (see Display 2-3 for def­
practitioners, family members, or significant others. The inition of terms) to help determine the most appropriate
tim e and cost savings to the patient and the health care sys­ intervention strategy for each patient The diagnostic pro­
tem justifies the time spent completing and interpreting the cess includes the folloV\ring components;l
for m. It is beyond the scope of this text to discuss all of the
andardized tests of disability. The Medical Outcomes • Obtaining a relevant history (i.e., examination)
rudy 36-Item Short-Form Health Survey (SF-36)36 is a • Performing a systems review (i.e., examination)
m ultidimensional generic measure designed to assess both • Selecting and administering speCific tests and mea­
physical and mental health status. The SF-36 is a good sures (i.e., examination)
choice for a baseline and can be complemented by a more • Interpreting all data (i.e., evaluation)
patient population speCific disability questionnaire ~uch_ as • Organizing all data into a cluster, syndrome, or cate­
ill e prov1'de d'lI1 t h e assocla
. t e d relerence
[' I'IS.t 1819.2S.3L31.38
. . gory (i.e., diagnosis)
nderstanding the relationships among physical impair­ The end result of the diagnostic process is establishing a
ments, functional limitations, and disabilities is relevant to diagnosis. To reach an appropriate diagnosis, additional in­
me evaluation and treatment of a person seeking phYSical formation may need to be obtained from other health care
therapy services. In 2003, Rothstein and Echtemach pub­ professionals. In the event that the diagnostic process does
.li.shed a revised algOrithm designed to meet the needs of not )rield an identifiable cluster, syndrome, or category, in­
contemporary practice. 39 They present a patient manage­ tervention may be gUided by the alleviation of impairments
ment system that involves the patient in decision making and and functionai limitations. Caution should be taken in ran­
can be used to provide payers with better justification for in­ domly treating impairments not associated with functional
en-entions. Compatible with the Guide to Physical Thera­ outcome. The purpose of a diagnosis made by a physical
ist Practice'sl patient management model and terms of the
therapist is not to identify all of the patient's impairments,
- blement model presented by Nagi,40 this algorithm calls but to focus on which impairments are related to the pa­
the clinician to identifY the impairments, when appropri­ tient's functional limitations and therefore should be ad­
; to examine how these impairments relate to functional dressed by the physical therapist To ensure optimal pa­
ficits; and to examine whether interventions designed to tient care, the physical therapist may need to share the
4IJleliorate or reduce impairments can result in changes in diagnosis determined from the physical therapy examina­
-unction and levels of disability. In addition, the revised ver­ tion and evaluation process with other profeSSionals on the
non calls on the clinician to identify hypotheses that under· health care team. If the diagnostiC process reveals that the
. interventions used for prevention. The reader is strongly condition is outside of the therapist's knowledge, experi­
ed to review this article in that it is believed that by ap­ ence, or expertise, the patient should be referred to the ap­
_ing the hypothesis-oriented algorithm for clinicians II on propriate practitioner.
individual patient basis, therapists will be ideally posi­ Diagnosis in the physical therapy patient management
ned to apply evidence to patient care and to defend their model is synonymous with the term clinical classification
terventions to colleagues and to third-party payers?9 and is not to be ~onfused with the term medical diagnosis. 41
Medical diagnosis is the identification of a patient's pathol­
ogy or disease by its signs, symptoms, and data coll~cted
Diagnosis from tests ordered by the physician. Diagnosis establIshed
ia211 0sis is the next element in the patient management by a physical therapist is related to the primary dysfunction
el. Diagnosis is the process and end result of inform a­ toward which the physical therapist directs treatment 41 --43
n obtained in the examination and evaluation. The diag­ The ability to diagnose clusters, syndromes, or categories
tic process includes analyzing the information obtained can foster the development of efficient treatment interven­
16 Therapeutic Exercise Moving Toward Function

bons and facilitate reliable outcomes research to present to the ability to walk 300 feet with paltial weight bearing, us­
the pubHc. medical community, and third-party payers. For ing a walker, in 3 days; an expected long-term outcome may
example, a common medical diagnosis of patients referred be the abi lity to walk independently without a gait devia­
to outpatient physical therapy practices is low back pain, tion in 12 to 16 weeks.
which is nothing more than a location of pain. If an out­ The plan of care consists of statements that specify the
comes study Was performed that included all patients with interventions to be used and the proposed duration and
the diagnosis oflow back pain in a given practice, the results frequency of the interventions that are required to reach
would not shed ligl1t on the best approach for treating low the anticipated goals and expected outcomes 1 The plan of
back pain because of the diverse causes, stages and severity care is the culmination of the examination, diagnostic, and
of the condition, and comorbidities involved. Subclassifica­ prognostic processes.
tion of patients based on diagnostic classification paradigms The prognosis and plan of care should be based on the
is necessary to provide more efficient patient management follm;ving factors:
strategies aml more meaningful outcome data .
• The patient's health stat us, lisk factors , and response
Technologic advances (e .g., diagnos tic imaging) for
to previous interventions
identifying pathology have not necessaJily decreasecI the
• The patient's safety, needs, and goals
peliod in which symptoms resolve nor do they always guide
• The natural history and th e expected clinical course of
physical therapy treatment. Medical diagnosis (e.g., hemi­
ated nucleus pu lpos\ls, spondylolisthesis) has not been the patholos,ry, impairment, or diagnosis
shown to be helpful in direCtin~ successful rehabilitation of • The results of the exam in ation , evaluation, and diag­
nostic processes
patients 'vvith low back pain. 4 . Identifying the patholosry
should not be the goal of diagnosis made by a physical ther­ To ensure the prognosiS and pian of care are based on
apist. The medical diagnOSiS , in most cases, does not pro­ the patient's safety, needs, and goals, the physical therapist
vide the physical therapist with enough information to pro­ should confer v'Vith the patient and establish patient goals ..'52
ceed ,;vith intervention. The physical th erapist's diagnosis is DUling this discussion , th e patient must be informed of th e
reached only after performing a thorough examination and diagnosis or prioritized impairment list if a diagnosis can­
evaluation combinecL jf Jlecessarv, v'Vith th e results of tests not be developed. The patient should also be proVided v'Vith
and measures ordered and pe/fornwd by professionals an explanation of tlle relationship between the diagnos is or
from· other disciplines and with the medical diagnosis. impairments and the function al limitations and dis ability.
Physical therapy is in the early stages of developing im­ This information can assist the patient in developing realis­
pairm ent-based, functional li mitation-based, ancI treat­ tic goals and understanding the purpose of th e selected in­
ment-basecI cIiagnostic classiflcations. After classifications terven tions. Agreement between the patient and therapist
are developed, much work regarding validity, reliability, on the long-term and short-term goals is imperative for
and sensitivity of diagnostic classifications needs to be successful treatment outcom es . When the physical thera­
done. Formulation and develogment of a useful classifica­ pist determines that physical therapy intervention is un­
tion design require the use of: likely to be beneficial, the reasons should be discussed with
the patient and other individuals concerned and docu­
• Measure ment theory and advanced stati~tical tech­ mented in the medical record .
niques (i.e., facto r and cluster analyses) to validate To ensure the prognosiS and plan of care are based on
clinical observations and systematize the compleXities the natural history and the expected clinical courses of the
of clinical findings. pathology, impairment, or diagnosis, the physical therapist
• Advanced technology that enables simultaneous col­ must rely on textbooks, lectures from instructors, literature
lection, storage, and repeated acqUisition of data that reviews, research articles, evidence-based clinical practice
characterize multiple eleme nts of movement. gUidelines, and clinical experience. 53 Straus SUCCinctly out­
lined the steps necessary to pract~ce evidence based patient
Many leaders in the physical therapy community hope in
management in her 1998 article:""
the future to correlate effective and efficient treatment v'Vith
the cunica] diagnosis made by physical therapists to estab­ • Convert the need for information into clinically rele­
lish more efficient ancI cost-effective outcomes 4 J .43,46-51 vant, answerable questions
Only then can physical the rapists promote the efficacy of • Find, in tbe most efficient way, the best evidence with
the profeSSion in today's responSibility-focused health care which to answer these questions (whether this evi­
environmen t. dence comes from clinical examination, published re­
search, medical tests , or oth er sources)
Prognosis and Plan of Care • CliticaUy apprais e the evidence for its validity (close­
ness to the tlllth) and usefulness (clinical appkabil­
After a diagnosis has been es tablish ed, th e physica] thera­ ity)
pist determ ines the prognosis and develops the plan of • Integrate the appraisal v'Vith clinical expertise and ap­
care. Prognosis is the process of determining the level of ply the results to clinical practice
optimal improvement that may be obtained from interven­ • Evaluate your performance.
tion , and the amount of time reqUired to reach that level. l
For example, an expected short-term outcome for an oth­ FollOWing th ese steps can assist the clinician in develop­
erwise healthy 65-year-old person after a hip fracture ing a sound prognosis and plan of ca re based on finding the
treated with open reduction and intemal fLxation may be best evidence available in a practical time frame.
Chapter 2: Patient Management 17

Intervention identified functional limitation or disability. In this in­

stanc , an impairment may not correlate with a functional
Intervention is defined as the purposeful and skilled in­ limitation or disahility, but if le ft: untreated. it may lead to
teraction of the physical therapist with the patient using future func tional lim itation. In this instance, the physical
various methods and techniques to prod lice changes in the therapist may treat the impairment as a preventive mea­
patient's condition consistent with th e evaluation, diagno­ sure. For example, a patient has been preSCribed a prone
sis, and prognosis 1 Ongoing decisions regarding interven­ hip extension exercise to improve gluteal strellgth for treat­
tion are contingent on the timely monitoring of the pa­ ment of hip pain. However, wh ile the patient is extending
tient's r sponse and the progress made toward achieving the hip , his or her lumbar spine is moving into excessive ex­
outcomes. The three major types of intervention are listed tension . If the faulty movement pattern is [eft: untreated,
in Display 2-4. This text focuses on one aspect of direct in­ low back pain may develop. E xe rcises need to be pre­
te rvention (i.e., therapeutic exercise) and patient-related scribed to improve the stahility of the low back to prevent
instruction as it relates to therapeutiC' xercise. the possibility of future episodes of low back pain.
The key to a successful intervention and patient out­ If an impairment seems to be linked to a functional lim­
co me is to do the right thin gs well ..5.5 To determine the right itation or disability, the therapist mllst question whether
t11ings, the physical therapist must have a thorough under­ the impairment is amenable to physical therapy interven­
tanding of the patient's disahlement process and sound tion. To help determine the answer, the physical therapist
clinical deCision-making skills. should ask several questions:
Clinical Decision Making for Intervention • \Vil! the pati ent henefit from the intervention (i.e.,
T he physical therapist is educated and trained to effectively can treatment improve functioning or prevent func ­
and effiCiently treat phYSiologiC and certain anatomic im­ tionalloss)?
pairments related to functional limitations and to arrive at • Are there any possible negative effects of the treat­
desirable functional outcomes for the patient. In designing ment (contraindications )?
the plan of care, the physical therapist analyzes and inte­ • What is the cost-benefit ratio?
grates the clinical implications of the severity, complexity,
If the treatment cannot be justified, the physical thera­
and acuity of pathology/pathophysiology, the impairments,
pist should consider other options such as the fo llOWing:
the functional limitations, and disabilities. Recall that the
ulti mate functional goal of physical therapy is the achieve­ • D iscussing the decision to decline intelvention with
ment of optimal movement and functioning. Physical ther­ the patient to ensure patient agreement and under­
apists generally develop treatment interventions with the standing of the decision
in tention of restoring function and reducing disability. • Referring the patient to an appropriate practitioner or
However, strictly impairment-based interventions often do resource
"lot achieve functional goals because the focus may not be • Assisting in modifying the environment in which the
n the right impairment. individual lives, goes to school, or works to ensure
maximal performance despite the impairment, func­
Treating the "Right" Impairments tionallimitation, or disability
An important clinical decision in the patient management • Teaching the individual to appropriately compensate
process is to determine the impairment that most closely re­ for the impairment, functional limitation, or disability
tes to a functional limitation or disability. Physical thera­
p' ts are often tempted to include impairments that do not If the impairment is amenab le to treatment, decide
_ rrelate in their intervention plan because they assume that whether to treat the impairment, functional limitation , or
:.he reduction of any or _all impairments leads directly to im- both . For example, a 72-year-old man , after total knee re ­
Tovement in function. 56 In reality, the treatment of impair­ placement, may present with weakness of the quadJiceps
ents can only lead to improvement in function if the im­ and reduced mobility of the knee. The therapi st may
'1airrnents contribute to a functional hmitabon. choose to treat the impairments with speCific exe rci se in­
- There is one instance, however, in which physical ther­ struction to increase quadJiceps muscle performance and
ists must treat impairments that do not contribute to an tibiofemoral joint mobility or to teach the patient the func­
tional task of sit to stand that can resolve the impairments
and restore function to the patient's satisfaction. The added
DISPLAY 2.-4 benefit of chOOSing to focus on function rather than on spe­
Types of Physical Therapy Interventions cific exercise is that patient compliance may improve, be­
cause incorporating function al exercise into daily life is eas ­
Direct intervention (e.g., therapeutic exercise, manual ier than finding time for speCific exercise. However, the
therapy techniques, debridement. wound care) impairments may be too profound to allow adequate per­
Patient-related instruction (e.g., education provided to the form ance duJing a functional activity. For example, if the
patient and other caregivers involved regarding the quadJiceps strength in the previous example is less than
patient's condition, treatment plan, information and training
fair, specific quadriceps strengthening may be necessary to
in maintenance and prevention activities)
Coordination, communication, and documentation (e.g., achieve enough force or torque production to participate in
patient care conferences, record reviews, discharge a functional activity without compromising tl1e quality of
planning) movement. Caution must be applied in prescribing func­
tional activities prematurely to improve impairments.
18 Therapeutic Exercise Moving Toward Function

Selecting and Justifying Treatment Interventions person, even when educating the patient is possible, can
After a decision has been made to treat a specific im­ promote compliance by teaching the support person to in­
pairment or functional limitation, the next step is to select tervene in an appropriate manner and encouraging the dis­
an appropriate treatment approach or combination of com­ play of appropriate attitudes toward the patient's functional
plementary approaches (e.g., moist heat before joint mobi­ limitations and disabilities.
lization, which is followed by stretching and ends with a Patient-related instruction is critical to enhance com ­
functional task that employs the new mobility). The clini­ pliance in follOwing through with interventions and pre­
cian must select and justifY the chosen intervention. venting future disability. Imparting your knowledge of
Physical therapists may select an intervention from the patient's disablement process enables the patient to gain
among the following possibilities: 1 confidence in your skills, which fUliher enhances compli­
• Therapeutic exercise (including aerobic condi tioning) ance. Patient-related instruction may include the follOWing:
• Functional training in self-care and home manage­ • Education pertaining to the
ment (including basic ADLs and instrumental ADLs ) • pathologic process and impairments contributing to
• Functional training in community or work reintegra­ functional limitation and disability;
tion (including instrumental ADLs, work hardening, • the prognosiS;
and work conditioning) • and the purposes and potential compli cation s of the
• Manual therapy techniques (including mobilization intervf'ntion
and manipulation ) • Instruction and assistance in making appropriate de­
• Prescription, fabrication , and application of assistive, cisions about management of the condition during
adaptive, supportive, and protective devices and the ADLs (e.g., work station ergonomiC modifica­
equipment tions, altered movement patterns and body mechan­
• Airway clearance techniques ics, altered sleep postures)
• Integumentary repair and protection techniques • Imtruction and assistance in implementing interven­
• Physical agpnts and mechanical modalities tions under the direction of the physical therapist
• Electrotherapeutic modalities (e.g., training a support person in techniques of ther­
Numerous patient factors must be taken into considera­ apeutic exercise in the event that cognitive, phYSical,
tion to determine which of the described interventions are or resource status of the patient requires assis tance to
correct. This information is obtained from the history and perform a home management program)
systems review (see Displays 2-1 and 2-2). An awareness of Patient-related instruction confers several benefits:
the physical environment for living, working, or participat­
ing in recreational activities to which the patient wishes to • Increased patient, Significant other, family, and care­
return is important in developing functional activities and giver knowledge about the patient's condition, prog­
achieving functional outcomes. For example, a successful nosis, and management
outcome may not be reflected in increased strength in the
physical therapy office by a hand-held dynamometer, but
may be observed in the use of that strength in a functional
manner in the patient's environment, such as walking up a
flight of stairs with 20 pounds of groceries
The process of selecting and justifying treatment inter­
vention must include knowledge of research literature and
the ability to interpret the literature as reliable and valid.
The most credible source of justification is based on rele­
vant research literature. Use caution when making deci­
sions based on theory of pathophysiologic mechanisms and
expert opinion not substantiated by credible clinical evi­
dence. Knowledge of the literature combined with an ac­
cumulation of clinical experience facilitates the most in­
formed choice.

Patient-Related Instruction
Patient-related instruction is the process of impaliing
information and developing skills to promote indepen­
denc(' and to allow care to continue after discharge 1 It
must be an integral part of any physical therapy interven­
tion (Fig. 2-3 ) and will be featured in this text to enhance
FIGURE 2-3. Patient-related instruction is an integral part of physical
the t)wrapeutic exercise intervention. therapy intervention. By helping the patient understand his impairment and
When patient education is not possible (e.g., the patient functional limitations. the clinician promotes patient compl iance with the
is an infant, comatose, or has a head injury), educating fam­ therape utic intervention program. In addition. patient satisfaction is pro­
ily members, Significant others, friends, or other caregivers moted by taking the time to educate the patient regardi ng the cause(s) of
is essential. Patient-related instruction offered to a support his cond ition, self-management techniques. and prevention
Chapter 2: Patient Management 19

• Acquisition of behaviors that foster healthy habits, be measured through outcome analysis. This is a systematic
wellness, and prevention examination of patient outcomes in relation to selected pa­
• Improved levels of performance in employment, tient variables (e.g., age, sex, diagnosis, interventions, pa­
recreational, and sports activities tient satisfaction). It can be part of a quality assurance pro­
• Improved physical function , health status, and sense gram, used for economic analysis of a practice, or used to
of well-being demonstrate efficacy of intervention.
• Improved safety for the patient, sign ificant others, Although positive outcomes are not synonymous with
family, and caregivers improved impairment measures , rneasurement of impair­
• Reduced disability, secondary conditions , and ments and functional status should be performed to deter­
recurrence mine the efficacy of the intervention plan. By measuring
• Enhanced decision making about the use of health both variables , the therapist can determine whether
care resources by the patient, significant others, fam­ changes in the im,gairment are associated with changes in
ily, or caregivers functlonal status,'>J If functlOnal status has not changed,
• Decreased service use and improved cost containment consider modifying the intervention plan. Modification of
intervention is based on the status relative to the expected
Patient-related instruction represents the first and most
outcome and the rate of progress. Modification of an inter­
important step toward directing responsibility for treat­
vention is also based on the follOwing considerations :
ment outcome from the phYSical therapist to the patient. A
thorough understanding of the individual's disablement • Medical safety
process and the factors that may impede improved func­ • Patient comfort
tional outcome are necessary to proviJe comprehensive • Pati e nt's level of independence with the interven ­
and personalized patient-related instruction . The success­ tion (especially related to therapeutic exercise inter­
ful practitioner is one who is skillful in the delivery of an ac­ vention)
tive treatment approach based on treatment speCific to the • Effect of the intervention on the impairments and
individual's disablement profile and on eJ ucation that functional outcome
places the patient (or caregiver) in the position of taking re­ • New or altered symptoms due to interve ntion by
sponsibility for the outcome. other health care providers
• Patient finances, environment, and schedule con­
As the patient/client reaches the termination of physical The intervention may be modified by one of the follow­
therapy services and the end of the episode of care, the ing actions:
physical therapist measures the global outcomes of the
• Increasing or decreaSing the dosage of the interven­
physical therapy services by characterizing or quantifying
tion, espeCially in the case of therapeutic exercise in­
the impact of the physical therapy interventions on the fol­
tervention (see the section on exercise modification in
lOWing domains: l
this chapter)
• Pathology/pathophysiology • Treating different impairments
• Impairments • Changing the focus to functional limitations
• Functional limitations • Consulting or referring to a more e>"'Perienced physi­
• Disabilities cal therapist
• Risk reduction/prevention • Referring the patient to a more appropriate health
• Health, wellness, and fitness care prOvider
• Societal resources • Improving physical therapy techniques , verbal cues,
• Patient/client satisfaction and teaching skills
An outcome is considered successful when the follOWing Prudent clinical reasoning assists the clinician in deter­
conditions are met: mining the need for modification and the best adjustments
to implement. In determining and implementing revised
• Physical function is improved or maintained when­
goals and interventions, the clinician uses the additional
ever pOSSible.
data gathered from the re-evaluation. This re-evaluation
• Functional decline is minimized or slowed when the
and modification process continues until the decision to
status quo cannot be maintained.
stop treatment is reached.
• The patient is satisfied.
Physical therapists have a responsibility to demonstrate
At each step of the patient management process, the to patients and third-party payers that physical therapy is
physical therapist considers the possible patient outcomes. efficient , cost effective, and prOvides patient satisfaction.
This ongoing measurement of patient outcomes is based on In daily practice, physical therapists should adhere to the
the examination and evaluation of impairments , functional same principles of measurement used in research .
status, and level of disability. To evaluate the effectiveness Changes should be carefully documented in an effOlt to
of the intervention, the physical therapist must select crite­ demonstrate that physical therapy intervention is related
lia to be tested (e.g. , impairments , functional limitations) to successful outcomes in an efficient and cost-effective
and interpret the results of the examination. Outcomes can manner.
20 Therapeutic Exercise Moving Toward Function


Patient Management Conceots Clinical Decision-Making Tips for Patient
• Develop an examination or evaluation schema pertinent to
the patient. Examination: Prioritize the problems to be assessed and the
Diagnose the patient's impairments, functional limitations, tests and measures to be implemented.
and disabilities. Evaluation: Consider and analyze all examination findings for
Develop a prognosis based on the patient's individual relationships, including the progression and stages of the
disablement process. symptoms, diagnostic findings by other health care
Develop a plan of care designed to improve function (i.e., professionals, comorbidities, medical history, and
the right things). treatment or medications received.
Apply appropriate judgment and motor skills to provide the Diagnosis: Segregate findings into clusters of symptoms and
appropriate intervention. signs by common causes, mechanisms, and effects.
Continually use clinical reasoning to modify the intervention Prognosis and Plan of Care: Develop long-term and short­
as needed for a positive outcome. term goals based on patient safety, needs, and goals and
on information regarding the natural history and expected
clinical courses ofthe pathology, impairment, or diagnosis.
InterventIOn: Determine whether impairments correlate with
In the current health care environment, physical thera­
a functional limitation or disability and are amenable to
pists are faced with the challenge of practicing in an in­ physical therapy treatment. Select and justify a method of
creasingly competitive marketplace. As marketplace com­ intervention. The most credible source of justification is
petition continues to grow, patient satisfaction with based on relevant research literature.
physical therapy is emerging as an outcome variable of crit­ Outcome: Measure the success ofthe intervention plan
ical importance. The results of one study show that patient according to functional gain and make appropriate
satisfaction with care is most strongly correlate_~ with the modifications when necessary.
quality of patient-care provider interactions."1 This in­
cludes the care provider spending adequate time \\lith the
patient, demonstrating strong listening and communica­
tion skills, and offering a clear explanation of treatment and functional limitations; and disciplined, systematic thought
prevention strategies. processes. Common to those who strive to excel in clinical
Successful patient management entails many aspects of decision making are the following characteristics:
clinician and patienUclient interaction. Display 2-5 sum­ • Wide range of knowledge
marizes patient management concepts. • Ongoing acquisition of knowledge
• Need for order or a plan of action
CLINICAL DECISION MAKING • Questioning unproven conventional solutions
• Self-discipline and persistence in work
At each juncture in the patient management model, clini­ Information regarding clinical decision making and the
cal decisions are made. Appropriate decisions are crucial process involved warrant their own text. However, this text
for a successful outcome. However, the clinical reasoning strives to include theoretic information and pertinent is­
process involved in patient management presents the sues related to clinical decision making. This information
greatest challenge to the physical therapiSt. The following empowers the physical therapist with some of the neces­
aspects are found to be most difficult in the clinical deci­ sary tools to make appropriate clinical decisions regarding
sion making process: the design and application of treatment plans.
• Organization of evaluation findings into a diagnosis
• Development of a prognOSiS based on the patient's
functional limitations and disabilities
• Development of realistic patient-based goals
Of the three components of physical therapy intervention
• Development and implemelltation of an intervention
(see Display 2-4), this text presents information regarding
that is effective and efficient
the direct inte rvention of therapeutic exercise and patient­
Display 2-6 summarizes clinical deCiSion-making tips in related instruction associated with therapeutic exercise in­
relation to patient management to help the physical thera­ tervention.
pist address some of these challenges. The effectiveness of After a thorough examination and evaluation has been
clinical decision making is based on obtaining pertinent performed; a diagnosis and prognOSiS have been devel­
data. The physical therapist must possess oped; and the clinician understands the relationships be­
tween the pathology, impairments, functional limitations,
• Knowledge about what is pertinent
and disability, a plan of care is determined through the clin­
• The skill to obtain the data
ical deCiSion-making process. Therapeutic exercise may be
• The ability to store, record, evaluate, relate, and in­
the basis of the intervention or may be one component of
terpret the data.
the intervention, but it should be included to some extent
These actions require knowledge of the disablement in all patient care plans. Therapeutic exercise includes ac­
process; clinical experience in treating impairments and tivities and techniques to improve physical function and
Chapter 2: Patient Management 21

health status resulting from impa.irments by identifying DOSAGE

specific performance goals that allow a patient to achieve a
higher functional level in the home , school, workplace, or Type of contraction
community. It also incorporates activities to allow well Intensity
clients to improve or maintain their health or performance Speed
status for work, recreation, or sports and prevent or mini­ Duration
mize future potential functional loss or health problems. Frequency
To develop an efficient, effective therapeutic exercise
intervention, consider these variables:
• Which elements of the movement system (defined Feedback
subsequently) need to be addressed to restore func­
• Which activities or techniques are chosen to achieve Posture
a functional outcome, including the sequence within
a given exercise session and the sequence of gradation
in the total plan of care?
• \Vhat is the purpose of each specific activity or tech­
nique chosen? Mode
• What are the posture, mode, and movement for each
activity or technique?
• What are the dosage parameters for each activity or
The follOwing section presents a therapeutic exercise in­
tervention model to assist in organizing all the details neces­
sary to prescribe an effective, efficie nt exercise prescription.

Therapeutic Exercise Intervention Model

A three-dimensional model has been developed to assist
the clinician in the clinical decision-making process re­
garding exercise prescription (Fig. 2-4). Three axes are ACTIVITY
used to visualize three components of exercise prescription FIGURE 2-4. Therapeutic exercise intervention model. Note the three­
and their relationships: dimensional model indicating the relationship between elements of the
movement system, activity, and dosage.
1. Elements of the movement system as they relate to
the purpose of each activity or technique
2. The specific activity or technique chosen
3. The specific dosage
metabolic support required to maintain the viability
of the other systems. Examples of components in­
Elements of the Movement System cluded in this element would be cardiovascular status,
To prescribe the appropriate exercise, factors regarding
breathing patterns, and hormonal factors .
the patient's disability profile must be considered. The
• Base eleme nt: the functional status of the muscular
most critical factor is the patient's functional status. Each
and skeletal systems. This element provides the basis
exercise prescription has one common goal: to restore
for movement, including components such as range
functional movement as best as possible and prevent or
of motion, extensibility/stiffness properties of muscle,
minimize functional loss in the future.
fascia, and periarticular tissues; joint mobility and in­
Sahrmann describes movement as a system that is made
tegrity, muscle performance, and muscle length-ten­
up of several elements, each of which has a unique basic
sion properties.
function necessary for the production and regulation of
movement. 5S The optimal actions and interactions of the
• Modulator element. the phYSiologic status of the neu­
romuscular system. This element is particularly re­
multiple anatomic , phYSiologic, and psychologic systems
lated to motor fUIlction, including components such
involved in movement must be considered. Ideal move­
as patterns and timing of muscle recruitment and
ment can be thought of as the result of a complex interac­
feed-forward and feedback systems .
tion of several elements of the movement system as defined
• Bio1Tlechanical element: the functional status of static
by Sahnnann 58 and modified for the purposes of this
and dynam iC kinetics and kinematics. The biome­
chanical element is an interface between motor con­
• S-upport element: the functional status of the cardiac, trol and musculoskeletal function , the reby affecting
pulmonary, and metabolic syste ms. These systems the pattern of muscle use and the shape of bones and
play an indirect role in that they do not produce mo­ jOints. Components of the biornechanical ele ment in­
tion of the segments, but provide substrates and clude static forces affecting alignment and muscle re­
22 Therapeutic Exercise Moving Toward Function

cruitment, and dynamic forces affecting arthrokinet­

ics, osteokinetics, and kinematics.
• Cognitive or affective element: the functional status of
the psychologic system as it is related to movement.
Components of this element include learning ability,
compliance, motivation, and emotional status.

(Note: The cognitive element is not an original element

of the movement system as defined by Sahrmann. 58 )
The elements of the movement system are along the hor­
izontal axis of the therapeutic exercise intervention model
(see Fig. 2-4). The diagnostic process can determine the im­
pairments that are related to the patient's functionallimita­
tions and disability. To begin the therapeutic exer­
cise intervention, the impairments should first be related to
the elements of the movement system. This process not only
illustrates the complex interaction of the elements of the
movement system, but also guides the clinician toward the
most appropriate activities ot techniques, the sequence of ex­
ercise, and the specific dosage to treat the impairments re­
lated to the functional limitations and disability. For example,
a person with knee pain with a posture impairment of genu
valgus will require orthotic intervention to correct the biome­
chanical element before muscle performance (base element)
or motor control (modulator element) training. Changing the
FIGURE 2-5. Thoracic kyphosis with excessive scapular anterior tilt.
alignment at the knee is prerequisite to effective base or mod­
ulator element training. It may then be decided that muscle
performance training is prerequisite to motor control train­ fails to posterior tilt during upper extremity flexion (Fig. 2­
ing due to the fact that the patient's strength, power, or en­ 6). As a result, the glenohumeral joint mechanically im­
durance are below functional levels. Muscle performance pinges under the acromion process, and tissues in the sub­
dosage parameters are different from motor control dosage acromial space (e.g., bursa, biceps tendon , rotator cuff
parameters (See Dosage in a subsequent section of this chap­ tendons ) undergo microtrauma resulting in pain (Le. , im­
ter). Understanding the sequence of intervention based on a pairment), inflammation (i.e., pathology), and the inability
prioritization of the elements of the movement system, and
that dosage parameters are different for the different ele­
ments of the movement system, can assist in organizing the
complex data collected during the examination.
After evaluating a patient, it may be apparent that one,
a few, or all elements of the movement system are involved.
Most often, the interaction of the elements is critical, but
one or two elements usually are pivotal to effect change.
First, determine which element(s ) is/are involved to
choose the appropriate activity or technique, the proper
dosage related to the element for which the exercise is pre­
scribed, and in what order the exercises should be pre­
scribed to be most efficient at restoring normal movement.
The follOwing simplified case is prOVided for a detailed ex­
ample of this clinical deciSion-making sequence:

A 42-year-old female graphiC deSigner presents with a
diagnosis of impingement syndrome of the shoulder. She
spends a large part of her day at a monitor creating design '­ /
documents. She has two children ages 1 and 3. She likes to
garden and cook. A functional limitation is an inability to
raise the arm to groom her hair or lift her small children
without pain.

A pivotal impairment is determined to be a thoracic
kyphosis that results in the scapula resting in an excessive FIGURE 2-6. Lack of scapular posterior tilt leads to glenohumeral im­
anterior tilt (Fig. 2-.5). The scapula, resting in anterior tilt, pingement.
Chapter 2: Patient Management 23

to raise the arm 'without pain (i.e., fUIlctionallimitation). If

left untreated, loss of mobility of the upper extremity may
ensue, further affecting function and potentially leading to
disability (e.g., inability to pick up children, inability to per­
form work-related duties , inability to participate in desired
recreational activities ).
Impairments can be listed and categorized by the ele­
ments of the movement system, as exhibited in Display 2-7.
As can be seen from this example, different impainnents
are correlated with each element of the movement system.
A specific exercise can be prescribed to address each im­
pairment associated with an element of the movement sys­
tem (e.g. , stretching the pectoralis minor to address the
base element). Most often, the interaction of elements is
critical; therefore, one exercise may address numerous ele­
ments of the movement system. For example, wall slides
(Fig. 2-7) can improve several features:
• Extensibility of the pectoralis minor (i.e., base
• Muscle performance (i.e., base element) and recruit­
ment (i.e., modulator element) of lower trapezius
• Thoracic extension mobility to reduce th e thoracic
kyphoSiS (i.e., biomechanical element )
When instructing a patient in the performance of this
exercise, provide verbal , visual, or tactile feedback to focus
on the correlating ele ment of the movement system, or FIGURE 2-7. This exercise illustrates a patient performing a wall slide.
prOvide instruction to the patient regarding the interaction The patient moves from the position shown here to the end position of the
of elements. For example, tactile feedback into the lower shoulders in full elevation. Note the arms are positioned in the scapular
trapezius during a speCific exercise (See Self-Management plane, slightly fONvard of the wall.
26-2: Facelying Arm Lifts in Chapter 26 ) can assist in re­
cruitment (modulator element). The sequence in which Attempts should be made to prescribe exercise that will
each exercise is presclibed is based on prioritizing which address the complex interaction of the elements of the
elements are pivotal to restoring function and which ele­ movement system. For example, to restore normal shoul­
ments must be improved for other elements to follow. For der girdle movement, diaphragmatic breathing (i.e. , sup­
example, it may be decided that the patient needs to take port element) may be pivotal to reduce the activity of the
measures to improve her emotional status (i.e., pectoralis minor (modulator element), improve thoracic
cognitive/affective element) to assist in addressing the spine alignment (biomechanical element), and increase
slumped posture that correlates with sadness, and combine thoracic spine mobility (base element). Another example is
this vvith exercise to improve postural habits (i.e. , biome­ to design an exercise that will concurrently stretch the pec­
ch anical element), before any other intervention. toralis minor and strengthen (in the shortened range ) the
lower trapezius (j.e., base element) (Fig. 2-7). Optimizing
the recruitment strategy (i.e., modulator element) during
speCific exercise and during functional movement is always
Elements of the Movement System Related necessary to achieve the best functional outcome.
to Impairments Display 2-8 summarizes the factors to consider before
a Support element impairment: Using accessory muscles of determining the relevant and prioritized list of the ele­
respiration versus diaphragm for breathing pattern, ments of the movement system.
potentially leading to overuse and shortening of pectoralis
• Base element impairment: Short pectora lis minor and short DISPLAY 2·8
head of biceps pulling coracoid process anterior and
inferior, lengthened and weak lower trapezius not providing Considerations in Clinical Decision
sufficient counterforce Making Relevant to the Elements of the
• Modulator element impairment: Reduced recruitment of Movement System
lower trapezius and serratus anterior
• Biomechanical element impairment: Thoracic kyphosis • Identify the functional limitations and related impairments
contributing to the anterior tilt of scapula to be treated .
Cognitive and affective element impairment: Patient is • Relate functional limitations and impairments to be treated
clinically depressed, and the physical manifestation is a with the appropriate elements of the movement system.
slumped posture contributing to the thoracic kyphosis. • Prioritize elements of the movement system.
24 Therapeutic Exercise Moving Toward Function

Activity or Technique
Along the vertical axis is the activity or technique chosen to DISPLAV2-9
ultimately achieve the functional goal. Therapeutic exer­ Stages of Movement Control
cise activities and techniques include the following: Mobility: A functional range through which to move and the
• Stretching (passive and active) ability to sustain active movementthrough the range
• ROM exercises (e.g. , active assisted ROM , active Stability: The ability to provide a stable foundation from
which to move
Controlled mobility: The ability to move within joints and
• Strengthening (e.g. , active assistive, active, and resis­ between limbs following the optimal path of instant center
tive exercise using manual resistan ce; pulleys, of rotation (PICR)
weights, hydraulics , elastics, robotics; mechanical or Skill: The ability to maintain consistency in performing
electromechanical devices) functional tasks with economy of effort
• NeuromusculaF re-education
• Developmental activities
• Breathing exercises
• Aerobic or muscular enduran ce activities using cy­ through the range .50 A person with musculoskeletal dys­
clf's , treadmills , steppers, pools, manual resistance:' , func tion may exhibit impairments in either or both parame­
pull eys, wei'ghts, hydraulics, elastics, robotics , and ters of mobility. For example, after total knee arthroplasty, a
mecbanical or electromechanical de\,1ces person may e>:perience passive mobility restrictions caused
• Ar]uatic exercise by pain , swelling, and soft-tissue stiffiless or shOliness and
• Gait training have decreased ability to initiate knee motion as a result of
• Balance and coordination training reduced muscle force or torque production or reduced re­
• Posture awareness training cmitment capability. The cause of the mobility restriction
• Body mechanics and ergonomics training must be determined on a case-hy-case basis to determine the
• Movement training most appropliate exercise intervention (see Chapter 7).
Stability in the construct of stages of movement control
To be successful in chOOSing the proper activity or tech­ is defined as the ability to prOvide a stable foundation from
nique , first determine the elpment of the lIlovcment sys­ which to move 60 A precursor to achieving the stability nec­
tem associated vvith the impairment or fum:tional limita­ essary for lll ove ment, or dynamiC stability, is optimal pos­
tion. Each element is associated with spcciflc therapeutic ture. The inruvidualmust be able to maintain optimal pos­
exercise interventions. For example, the biomechanical el­ ture without a load before optimal posture can be
ement is associated with posture awareness training, the maintain ed during movement of a limb. Mobility and sta­
modulator element is associated with speCific neurOITHlSCU­ bilityare not mutually exclusive. Achieving mobility before
lar re-education, the support element is associated vvith addreSSing stability is unnecessary; the two stages of move­
breathing exercises and aerobic endurance activities , and ment control can occur concurrently. For example, as mo­
the base element is associated with stretching and bility after total knee arthroplasty is achieved paSSively, ac­
strengthening activi ties. tive motion must be prescribed. For optimal active motion,
After identifYing the elements of the movement system , the knee requires a stable proximal base from which to
the physiolOgiC status of the impairments or functional lim ­ move (i.e ., pelvis and trunk) and distal base for weight
itations must be considered. This information assists in de­ bearing (i.e. , foot and ankle). Stability must be achieved at
termining the activity or technique, posture, movement, these regions for optimal active motion to take place.
and mode parameters. For example, if muscle performance Controlled mobility is defined as the ability to move
(i.e. , base element ) is pivotal to a successful functional out­ within joints and between limbs, follOwing the optimal path
come, the chosen activity or technique may depend on the of instant center of rotation (PICR) (See Chapter 9 for clar­
force or torque capahility of the affected muscles. If the ity on the definition of the PICR. ) This requires proper re­
force or torque capability is)ess than fair in muscle strength, cruitment of synergists that perform movement (i.e., sta­
as determined by Kendall,,,g a gravity-lessened position ac­ bility within a segment during movement ) and proper
tive ROM activity or an against-gravity active assisted tech­ length and recruitment, if necessary, of muscles providing
nique may be chosen. Another example may be related to a stable foundation for movement. The previous example
reduced muscle recru itment from prolonged immobiliza­ would progress from exercises improving knee mobility, as
tion (i.e., modubtor element) or muscle amnesia. If the abil­ well as pelvic-trunk and foot-ankle stability, to functional
ity to recruit is poor, a graVity-lessened active ROM activity movement patterns. To walk, th e knee must flex and ex­
may be chosen with tactil e feedback or against-gravity ac­ tend at proper stages in the gait cycle. The trunk, pelVis,
tive HO M with neuromuscular electrical stimulation as an ankle, and foot must move into proper position at each
adjunctive intervention (discussed later in this chapter), stage of the gait cycle and provide proximal and distal sta­
both of which are chosen to augment muscle re-education. bility for optimal knee function. The activity may involve
the swing phase of gait, which requires a stable pelvis from
Stage of Movement Control which to swing the lower limb (Fig. 2-8A ), or the stance
Another factor to consider in chOOSing an activity is the phase of gait (Fig. 2-8B) , which requires a stable foot for
stage of movement control (Display 2-9). Mobility is defined optima! knee loading.
as the presence of a functional range through which to move The final progression in the stages of movement con­
and the ability to initiate and sustain active movement trol is skill. Skill implies consistency in performing func­
Chapter 2: Patient Management 25

FIGURE 2-8. (A) Swing phase of gait requires a stable pelvis. (B) Stance
phase of gait requires a stable foot.

tional tasks with economy of effort 61 Skill in the upper

extremities most often requires freedom of movement in
space in a coordinated manner within and between the FIGURE 2-10. A gymnast performing on the balance beam represents an
upper extremity closed chain movement.
hand, wrist, forearm, elbow, shoulder girdle, trunk, and
pelvis (e.g., grasping a cabinet door) (Fig. 2-9). Occasion­
ally, closed chain (weight-bearing) movements are re­ functional movement control. Conversely, patients may be
quired in the upper extremity (e.g. , gymnast performing a prescribed exercises developing the other stages of move­
handstand on the balance beam) (Fig. 2-10). Skill in the ment control without finalizing the intervention with skill­
lower extremities requires coordination of open chain level activities during functional movements. Skill is a nec­
(non-weight-bearing) movements (e.g., svving leg in kick­ essary stage of movement control despite the prognosis of
ing a soccer ball) (Fig. 2-11) and closed chain movements the patient (e.g" walk 10 feet vvith a walker versus run a
(e.g., stance leg in kicking a soccer ball) within and be­ marathon ), which must be worked toward by achieving op­
tween the foot, ankle , tibia, femur, pelvis, and trunk for timal function at each prior stage of movement control.
movement on varied surfaces. For total body movement In summary, an activity can be as simple as performing
to be optimal, coordinated movement must occur vvithin a dynamlc knee extension movement in supine (i.e" mobil-
and between each segment involved in the movement
(e.g., the tennis serve) (Fig. 2-12).
Commonly, patients are asked to perform skill-level ac­
tivities without first developing proper foundations for

URE 2-9. Grasping a cabinet door requires freedom of movement in FIGURE 2-11. Skill in lower extremities requires coordination of open and
_ in a coordinated manner within and between the joints of the upper closed chain movement. The swing leg performs an open chain movement
-"mity. trunk, and pelvis. as the stance leg performs a closed chain movement.
26 Therapeutic Exercise: Moving Toward Function

narrow base of support) need to be determined. Included in

this information is proper hand placement and angle of ap­
plication of the force if the activity is performed manually.
When using elastics, pulleys, mechanical, or electrome­
chanical devices , proper equipment placement and angle of
application of force must be determined. These descrip­
tions must be included in the heginning and ending posture
information. The movement needs to be specifically defined
(e.g. , paltial squat through a 30-degree arc, unilateral arm
raise through full-range , proprioceptive ne uromuscular fa­
cilitation diagonal of th e upper extremity to chest height).
The quality of performance of the exercise is critical to
the outcome (i.e. , modulator element of the movement sys­
tem ) In relation to base or modulator elements , an obvious
but often neglected concept is that a mllsde cannot be
strengthened if it is not recruited. Even if the correct ac­
tivity is ch osen , and the mode, posture, and movement are
carefully selected, proper execution of the exercise is nec­
essary to ensure a successful outcome. For example, hip
abduction while sidelying can be performed ,vith at least
five different recruitment patterns (Fig. 2-13 and Display
2_11 )sa Attention to preciSion of movement and recmit­
ment patterns is vital and always must be promoted to the
best of the illdivi dual's capabi lity. Modify the exercise to
achieve the best performance pOSSible.
FIGURE 2-12. A tennis serve represents a total body movement, whi ch is Dosage
coordinated within and between each segment involved in the movement The third axis is related to dosage parameters (see Fig. 2­
4). When determining dosage, anatomic sites, and the
ity) or as difficult as an integrated movement pattern such physiologic status of the affected elements of the move­
as walking on an uneven surface (i.e., skill). An under­ ment system , the patient's learning capability must be con­
standing of th e level of involvement of the support, base, sidered. The anatom ic site comprises the speCific tissues
modulator, and cognitive/affective elements of the move­ involved (e.g., ligament, musdc , capsule, faSCia). The phys­
ment system help to determine the complexity or the task iologiC status of the affected elements of the movement
and the stage of movement control in which to intervene. system includes the severity of the tissue damage (e.g., par­
Display 2-10 summ arizes the factors to consider before de­ tial versus complete tear) , the irritability of the condition
termining the activity or technique. (e.g., easily provoked and difficult to resolve versus difficult
to provoke and easy to resolve), the nature of the condition
Mode, Posture, and Movement
(e.g., chemical versus mechanical mediated pain), and the
After choosing the activity or technique , further break­ stage of the condition (e.g. , acute, subacute, chronic). For
down of the activity is necessalY for precise prescription. pati ents recovering from an injury, the dosage parameters
The mode, which is the method of performing the activity are modified aceording to the tissues involved and the prin­
or technique, must be chosen. For example, if aerobic exer­ ciples of tissue healing. In the early stages of healing, tis-
cise is chosen, the mode can be cycling, swimming, walking,
or a similar activity. If strengthelling is chosen, the mode
can be weights, manual resistance, or active assisted exer­
cise. If ba1an ce and coordination training is chosen, the
mode can be a balance board, balance beam, or computer­
ized balance device. The initial and ending postures (e.g. ,
standing, sitting, supine, prone, wide base of support,

Considerations Involved in Clinical
Decision Making Related to Choice of
Activity or Techniaue
• Determine the element of the movement system related to
the impairment or functional limitation to be treated. FIGURE 2-13. Hip abduction in the sidelying position. Optimal execution
• Consider the physiologic status of the movement system. is with the pelvis and femur in the frontal plane and the movement of hip
Determine the stage of movement control. abduction occurring in the fro nta l pla ne. This requ ires recruitment of al l of
the hip abductors in synergy.
Chapter 2: Patient Management 27

• Sequencing of the exercise prescription (i.e., stretch

before strengthen, low intensity warm-up before
Variations in Performing Side lying Hip moderate or intense aerobic activity, or Single jOint
Abduction uniplanar movement before multijoint mu ltiplanar
1. Sidelying with pelvis in frontal plane and abducting the hip
• Environment in which the exercise is performed (i.e.,
with all of hip abductors in synergy (see Fig. 2-13)
2. Sidelying with pelvis rotated backward and femur rotated
quiet, controlled environment of a private room in a
laterally, causing the movement to move toward the physical therapy clinic versus a loud, chaotic, uncon­
sagittal plane and resulting in recruitment of hip flexors trolled, outside environment )
3. Sidelying with pelvis in frontal plane with femur rotated
• Amount of feedback necessary for optim al perfor­
medially and flexed, resulting in recruitment of tensor
mance of the activity
fascia lata

4. Sidelying with pelvis in frontal plane, but movement is at

the pelvis (hip hike). resulting in recruitment of lateral Summary
trunk muscles
In sum mary. numerouS variables in this model must be
5. Sidelying with pelvis in frontal plane, but movement is

abduction of opposite hip, resulting in recruitment of

considered in prescribing an exercise, and variables often
opposite hip abductors
overlap (e.g. , learning capabilities under dosage is similar
to stages of movement control under activity, vvhich is sim­
ilar to modulator and cognitive/affective elements for the
movement sys tem ). The task of organizing this data can be
sues tolerate low-intensity passive or active activities, but in overwhelming. The three-dimensional model may help to
the later stages, tissues tolerate more aggressive resistive visualize the relationships among the components of exer­
activities (see Chapter 10). cise prescription. It is the goal of this text that this model
The patient's ability to learn , or learning capability, in­ assists in organizing the data necessary to develop an effec­
fluences the schedule and the amount of reinforcement , tive, efficient therapeutic exercise intervention.
feedback, or sensory input needed to perform the activity
successfully. If a patient has difficulty learning a motor
task, the dosage may be altered according to the principles Exercise Modification
of learning (see Chapter 3). For example, various forms of When the desired patient outcome is not met in a reason­
feedback (e.g., verbal, visual, tactile) combined with nu­ able time frame , modification is based on evaluating how
merous , lOW-intensity repetitions may be required initially the following possibilities affeCt the lack of progress
for optimal performance of an activity. As skill is acquired, achieved vlith the therapeutic exercise intervention:
feedback and repetitions may be reduced and a more com ­
plex activity eventually may be prescribed. • The physical therapist may choose the wrong activity,
After the anatomic and phYSiologic elements and the dosage of exercise, or both.
learning capabilities are understood, specific dosage pa­ • The physical therapist may not be able to effectively
rameters can be determined. Display 2-1 2 summarizes the implement or teach the exercise.
factors to consider before determining dosage parameters. • The patient may not be able to learn the exercise well
Parameters related to dosage include enough or misunderstand or forget the instructions or
• Type of contraction (i.e. , eccentric , concentric, iso­ • The patient may not follow through with the pre­
metric, dynamic, or isokinetic) sCliption.
• Intensity (i.e., amount of assistance or resistance re­
quired ) To be most effective and efficient with exercise pre­
• Speed of the activity or technique scription, constant re-exam ination and evaluation of
• Duration tolerated (i.e ., number of repetitions or changes in impairments and function are required. The ex­
number of sets, particularly related to endurance and ercises must be continually modified to increase or de­
stretching activities) crease the difficulty to ensure continual progress is being
• Frequency of exercise (i.e., number of exercise ses­ made 'Nith minimal setbacks. Numerous parameters can be
sions in a given period) modified to render an exercise more or less difficult. Four
general parameters can be varied in an exercise prescrip­
tion: biomechanical, phYSiologic, neuromuscular, and cog­
nitive or affective. Display 2-13 outlines parameters that
can be varied and provides examples for various types of ex­
Considerations Involved in Clinical ercise. Th e reader is strongly encouraged to review Display
Decision Making Related to Choice of 2-13 before continuing further in the text.
Dosage Parameters If you've paid careful attention to these basic methods
Determine the anatomic sites involved in the current
and principles, but the patient is not responding to the in­
tervention, you must realize that all has been done within
Determine the physiologic status of the tissue(s) involved.
the scope of your therapeutic knowledge, expertise, and ex­
Consider the patient's learning capability.
perience and that the patient should be discharged if you
feel maximum improvement has been attained. If not, the
28 Therapeutic Exercise Moving Toward Fu nction

Exercise Modification Parameters
Biomechanical hamstrings is reduced if hip extension is done with the knee
flexed compared with the knee extended.
• Size of base of su pport Passive TensIOn ofTwo· Jomt Muscles
Example : It is more difficult to balance with feet close The hip can be flexed to only 70 to 90 degrees with the knee
together or in tandem than feet wide apart, and in sidelying extended but considerably more if the hip and knee are flexed.
rather than supine. Similarly, the ankle can dorsiflex more when the knee is flexed
Height of center of mass than when the knee is extended. These considerations are
Example: Sit-ups may be done first with hands at the particularly important in planning effective stretching activi­
sides, progressed to forearms folded across the chest, ties and in analyzing stabilization of body segments in all types
progressed to hands clasped behind the neck. This upward of exercise. Altering joint positions or the use of external sup­
shift of arm weight moves the center of mass toward the ports such as pillows can reduce or increase the tension of
head by stages, progressively increasing the difficulty of two-joint muscles based on the goal of the exercise.
the exercise.
Open Vp,rsus Cosed Kinetic Cham
• Support surface The kinetic chain is related mostly to specificity of exercise. If
Example: The stability of the support surface can be
the desired activity is in the closed kinetic chain, this position
progressed from a static or stable surface to a mobile
should be used for training whenever possible. However, the
base, such as foam, a balance board, or a trampoline.
closed kinetic chain often cannot isolate muscle function as
8 .ternal Load well as a specific open kinetic chain exercise.
• Magnitude
Stabilization (External or Within)
Example: Increased magnitude of resistance alters the
• If stability is required for a movement, use of external straps
weight of the segment and thereby increases the difficulty
or pre positioning a limb may assist stabilization if the patient
of movement; however, it may also increase feedback from
is unable to stabilize with proper patterns internally. For ex­
muscle and joint receptors and enhance the response.
ample, in supine, the trunk can stabilize with greater ease if
Gravitational forces
the hip and knee are flexed and held in place by the hands
Example: The force of gravity on a segment is maximal
when the part is horizontal and diminishes as it moves while the other limb slides down and back during an abdomi­
nal strengthening exercise (Fig. 2-14). This is an example of
toward the vertical. Knee flexion in prone is more difficult
pre positioning to offer external stability.
at the beginning of the movement and becomes easier as
the motion progresses. Hip abduction is gravity reduced in Physiologic
prone or standing and against gravity in sidelying. Durat~on
Speed (see Chapter 5) • Duration of activity in seconds, minutes, or hours
Example: A medium rate is usually easier than very
• Number of repetitions or sets performed
rapid or very slow.

• Length of lever arm Frequency

Example: In prone exercises for scapular adductors • Number of exercise sessions in a given time period
(middle and lower trapezius)' raising the arms with the Speed
elbows flexed gives less resistance than if the arms are • Slower is not necessarily easier (see earlier)
nearly or completely straight. Intensi'.y of ContractIOn or ExtLrnal Load
Point and ang le of application of manual or mechanical • Percentage of maximum voluntary contraction
Example: A muscle pulling at or near a right angle to the Type of Musc e Contract.on
long axis of the segment exerts its force more effectively • Eccentric, isometric, concentric
than when its angle of pull is very small. Seouence o' Exercise
• May require beginning with less complex tasks or less strenu­
Number of Segments Involved
ous activity in early stages of learning or healing and pro­
• Fewer segments may not always be easier than more
segments, especially as in fine motor control. gressing to less need for "warm-up" activities as skill is
achieved and tissues are in more advanced stages of healing
Length of Muscle Rest Between RepetitIOns and Sets
A muscle is better able to exert active tension when it is in a • As strength or endu rance improves, less rest is necessary
lengthened state than after it has undergone considerable between repetitions and sets. Be cautious of overtraining,
shortening. When it is desirable to limit the participation of a espec ially in presence of neuromuscular disease or injury.
given muscle in a movement, it is placed in a shortened
position, or · put on slack." The active tension exerted by a Neuromuscula
muscle spanning more than one joint at a given joint depends Sensory mput
on the position of the second joint over which it passes, Visual, proprioceptive, and tactile inputs can be manipulated.
because this determines the length of the muscle. For If the eyes are closed, visual input is eliminated, leaving the
instance, the hamstrings are more effective as knee flexors vestibular, proprioceptive, and tactile receptors to detect any
when the hip is flexed and less effective when the hip is disturbance. The tactile input can be varied by standing on
extended. Similarly, if the goal is to isolate the gluteus soft foam. The proprioceptive input can be varied with head
maximus during hip extension, the participation of the movement.
Chapter Z: Patient Management 29


Exercise Modification Parameters (Continued)

FIGURE 2·14. Leg slide movement for strengthening deep abdomi­

nal muscles. The hip and knee are flexed and held closer to the chest
as the other limb slides down and back. (A) Starting position is actu­
ally with both knees fully bent and both feet positioned off the floor.
This photograph illustrates the mid position of the exercise. (A) End­
ing position.The patient should end with the extremity as close to full
extension as the length of the hip flexors wil l allow.

Sensory Facilitation or Inhibition Cognitive or Affective

• Techniques such as cutaneous and pressure input,
approximation, and traction can alter muscle responses. Frequency and Duration of the Activity
Prolonged pressure on the long tendons such as the quadriceps, • Increased frequency and duration of the activity increases
biceps, hamstrings, or finger flexors seems to inhibit responses. the practice schedule to enhance learning .
The placement of manual contacts is critical to facilitate the Initial Information ProVided
desired response. Contacts are placed in the direction toward Care should be taken to provide enough information to
which the segment is to move. Approximation or compression perform the activity with the correct strategy, but not to give
into or through a joint stimulates the joint receptors and may too much information, which may overwhelm the learner.
facilitate extensor muscles and stability around a joint. Traction
separates the joint surface and is incorporated if increasing Accuracy Provided
range of motion around a joint is desired. As skilll is acquired, increased accuracy of cues is provided to
"fine tune" a movement.
Number of Segments Involved
• In weight-bearing postures, joint involvement usually refers to Variability of Environmental Conditions
the weight-bearing segments; for example, prone on elbows • Initially reduced number of external distractions is provided
does not require participation of the forearm and hand or the with increasing external distractions toward a functional
lower body compared with quadruped. The placement of manual environment as skill is acquired.
contacts or other external forces also influences the number of
segments involved. For example, contacts placed on the scapula Complexity of Activity
and pelvis in sidelying involve the entire trunk, whereas contacts • Number of steps involved; as in breaking down components of
positioned on the lumbar spine and pelvis result in more isolated gait into single tasks and then uniting them into the integrated
activity of the lower trunk. complex motor task of gait with numerous steps
Stage of Movement Control Anxiety Level
• Mobility, stability, controlled mobility, skill (see Display 2-9 for • Initially, greater focus on the activity is combined with the
the definitions of stages of Movement Control) least emotional distractions to enhance early learning.
30 Therapeutic Exercise : Moving Toward Function

patient should be referred to another practitioner for fur­

ther treatment.

To complete this chapter on patient management, adjunc­
tive interventions were chosen to be included in this sec­
tion to provide insight into the complementary role they
play in therapeutic exercise prescription. The interventions
presented in this section are considered adjunctive to ther­
apeutic exercise in that they are not regarded as essential to
achieving a functional outcome.
When choosing to use an adjunctive intervention , a de­
cision must be made regarding the benefit of its use in con­
junction v.rith therapeutic exercise. The clinician should be
reasonably sure that combining the adjunctive intervention
FIGURE 2-15. The clinician ices the patient's knee as an ad junct to ther­
with the therapeutic exercise would produce more rapid or apeutic exercise.
optimal functional recovery. Make it clear to the patient
that the adjunctive intervention is being used to augment
the exercise and that the exercise and modified posture and Theoretically, stretchi ng protocols produce deformational
movement habits v.rill ultimately change the impairments changes that lengthen the connective tissue and increase
and functional limitations for long-term improvement. . joint ROM. Thermal agents also playa role in determining
There are conditions for which physical agents, mechanical the amount of elongation obtained from a static stretch. EI­
and electrotherapeutic modalities, and orthotics are imper­ <,vating the temperature of conn ective tissue has been
ative to achieve improved physical function and health sta­ sho,vn to increase its extensibility; when combined ,vith
tus, in which case these intelventiollS are not considered stretching procedures, it can produce permanent elonga­
adjunctive (e.g., significant soft-tissue inflammation, severe tion. The combined application of heat and stretching was
pain disorders, skin conditions, nerve injUl)', impaired mo­ found to be more effective in prodUCing permanent in­
tor function, structural abnormalities). crease in length than heat or stretching alone 65 When mo­
Physical agents, mechanical modalities, and electrother­ tion is limited by connective tissue crossing the joint, the
apeutic modalities are presented in this section because of combined application ofheat and stretch may be a useful in­
their effective adjunctive role in therapeutiC exercise. Ad­ tervention if the follOWing considerations are observed: 66
ditional adjunctive interventions such as taping and or­
thotic presCliption are presented in Units 5 and 6. • Stretch should be combined with the highest tolera­
ble therapeutic temperature that can be achieved in
the area to be treated.
Physical Agents • The application of stretch should be at least 30
Physical agents use ice, heat, sound, or light energy to in­ • Moderated forces should be used to take advantage of
crease connective tissue extensibility, modulate pain, or re­ the viscous nature of the tissue.
duce or eliminate soft-tissue inflammation and swelling • The tissue temperature should be elevated before ap­
caused by musculoskeletal injUl)' or Circulatory dysfunc­ plying stretch to reduce tissue damage .
tion. In addition, physical agents increase the healing rat • The tissue elongation achieved should be maintained
of open wounds and soft tissue, remodel scar tissue, or treat while the tissue is allowed to cool. This takes approx­
skin conditions. Examples of physical agents include ultra­ imately 7 minutes.
sound, moist heat, paraffin baths, cryotherapy (Fig. 2-15),
and hydrotherapy. Infrared radiation , electromagnetic radiation, and ultra­
Heat com bined with stretch is an example of using phys­ sound are three sources of energy used for therapeutic
ical agents as an adjunct to therapeutiC exercise. Because heating. The choice of energy source depends on the treat­
connective tissue is a major factor in joint contracture, a ment objective, because each of the three sources produces
method for elongating or stretching this tissue is important a different heating pattern in tissue. Please refer to the ap­
in changing a jOint mobility impairment. Connective tissue propriate reference for further information regarding the
is a viscoelastic structure capable of plastiC and elastic choice of physical age nt. 67
changes. The viscous properties of connective tissue allow
it to go through a permanent change in structure 62 .63 Elas­
tic properties refer to the connective tissue's ability to re­
Mechanical Modalities
gain its original length. When an applied stretch to a con­ Mechanical modalities i.nclude a broad group of proce­
nective tissue is removed, the elastic components recover dures (e.g., traction, continuollS passive motion , tilt table,
their orikrinallength and the viscous components remain de­ vasopn eumatic compression devices, compression, taping)
formed. )2 The amount of elastic and viscous deformation to modulate pain, stabilize an area that requires tempo­
can vary conSiderably, depending on the amount of applied rary support, increase RO M. , or apply distraction, approx­
force, duration of appli ed force , and tissue temperatmc 64 imation , or compression. C andidates for mechanical
Chapter 2 Patient Management 31

modalities include patients with pain disorders , disk dis­ 2-1 illustrates suggested parameters for initiating a NMES
orders, nerve compression or entrapm e nt, sprains or program for patie nts with various degrees of atroph y 74
strains, hypomobility or hypermobility, and hemodynamiC: Wheneve r possible, involve the patient in active exercise
impairments. combined with NMES . For example, a patient with mod­
Although many mechanical modalities can assist thera­ erate disuse atrophy of th e vastus medialis oblique (VMO)
peutic exercise in achieving functional outcome, taping is with patellofemoral pain may use NMES in conjunction
discussed in more detail because of its potential direct ef­ with a closed chain isometric exercise for the VMO. The
fect on enhancing the outcome of therape\ltic exercise. The decision to discontinue a NMES program for disuse atro­
clinical indications for taping have expanded bcyond the phy should be based on the patient's recovery of fun ction.
traditional taping to imm obilize and protect a sprained or When the patient is able to voluntarily exercise effectively
strained tissue. There are several indications for taping: against res istance, NMES may be discontinued.
Patients who are weak or experience pain and joint
• Improvement of contact areas for weight-bearing car­
swelling have difficulty moving a joint through its available
ROM. In the absence of a fracture involving the joint itself,
• Improvement of initial alignm ent. thereby assisting in
early motion is desirable to accelerate rehabilitation and
restoration of normal movement patterns
prevent loss of motion. NMES may be used for p atients
• Alteration of length-tension prope rties of muscle tis­
with orthopediC or .neUl:ol~~c dysfunction to promote full
sue; progreSSive stretching of shortened tissue and return of Jomt moblhty. 15- 1
shortening of lengthened tissue
Most patients who have difficulty regaining or maintain­
• Unloading of inflamed or injured tissue
ing ROM have been immobilized or have Significant weak­
Specific techniques for taping are included in the r levant ness and disuse atrophy, and similar guidelines with regard
regional chapters. The techniques illustrated include hip to disuse atrophy may be followed for frequency and duty
jOint taping (see Chapter 20 ), patellofemoral joint taping cycle selection. NMES is ideally suited as an adjunct to ac­
(see Chapter 21 ), plantar fascia taping (see Chapter 22) , tive ROM exercises because of its cyclic, repetitive nature.
and scapulothoracic taping (see Chapter 26). NME S is not intended to replace passive stretching, active,
or active assistive ROM exercises or functional retraining of
ne"" ROM gained.
Electrotherapeutic Modal ities NMES can be used for muscle re-education and facili­
Electrotherapeutic modalities include a broad group of tation to re-establish voluntary control of body pOSitions
physical agents that use electricity to modulate pain, reduce and movements after injury or disease h as affected the mo­
or eliminate soft-tissue inflammation, decrease muscle tor control mechanism or when less than optimal move­
spasm, and assist in muscle re-education. Electrotherapeu­ ment patterns have been learned because of repetition of
tic modalities include alternating direct and pulsed current , faulty movement patterns dUling ADLs, sport, recreation,
neuromuscular electrical stimulation (NME S), transcuta­ or work. Improvemen t in motor control has been docu­
neous electrical nerve stimulation, and surface electromyo­ mented afte r ~MES was used at a current intensity suffi­
graphy (S E M G ). Although many el ctrotherapeutic modal­ cient to evoke a muscle contraction (i.e., motor thresh­
ities deal with the treatment of pain, inflammation , and old) .' 0 When using NMES for muscle re-education and
soft-tissue healing, this discussion focuses on the use of facilitation, the patient should attempt to perform a desired
NMES and SEMG for treatment of muscle re-education. movement or contraction along with the stimulation. That
way, NMES is used to augment the voluntary movement,
not replace it. Use of N MES for muscle re-education and
Neuromuscular Electrical Stimulation
facilitation is limited only by the therapist's creativity.
NMES is a versatile modality that can be integrated into
treatme nt plans for a variety of patient proble ms. MES
can be a safe and effective adjunct to treahnent of disuse Surface Electromyography
atrophy, ROM deficits , and muscle re-education. M S SEMG is increaSingly recognized by physical therapists as
has even been sho\\'l1 to improve muscle performance in a tool to augment evaluation and treatment of a variety of
basketball playe rs' jumping ability.58 NMES can be deliv­ musculoskeletal and neuromuscular conditions 81 - S::; Appli­
ered via commercial house power-driven or portable elec­
tJical stimulators. Wavdorm ruther than the source of the
stimulator appl'ars to be more important in g@e rating
strong muscle contractions with the least fati gue 6 \J It ~ggested Treatment Parameters for
should be possible to establish hom e treatment protocols Patients Wltti Disuse Atrophy
\'lith battery-operated stimulators providing monophasic or
biphasic waveforms, which could be just as e ffective as the SEVERE MODERATE MINIMAL

more expensive treatment with a clinical stimulator 70 ATROPHY ATROPHY ATROPHY

Although studies have not shown ME S to be effective

in preventing disuse atrophy, there is some evidence that it
Frequency (pps) 3-10 10-30 30-50
On time (s) 5 5-10 10-15
can retard the effects of immobilization and disuse and in­ Off time (s) 25-50 20-30 10-30
crease muscle force. 71 - 73 Treatment protocols reported to Session length (min) .5-10 15 15
decrease the effects of disuse atrophy vary conSiderably. Se sions per day 3---4 3---4 1-2
The patient's diagnosis and pre-injury condition influence
.I the initial parameter settings and rate of progression . Table pps, pllises per second; s, seconds
32 Therapeutic Exercise Moving Toward Function

cations have heen proposed for numerous comjjtions in patient satisfaction and in delivering tl1e most effective
which inapproplinte patterns of muscle activity are thought and efficient sClvices pOSSible.
to be contributory. SEMG can be used as a form of • The clinician's knowledge, expertise, experience, and
biofeedhack to augment relaxation-based training, tension ongOing acquisition of knowledge and e.\'Perience are
recognition trailling, postural training, body mechanics in­ the determinants for successful patient management.
struction, tllerapeutic exercise, and functional activity or • Critical clinical decisions are those involveu in deter­
work station modification. It can serve as an online biofeed­ mining which impairments from the list generated
back technique to ensure the desired response is elicited at from the examination are most closely related to func­
the df:sired time. For example, it can Hllgment a stretching tional limitation and disability anu thcrefore warran t
technique hy placing th e electrodes on the muscle to be intervention.
stretched and Illaintaining low or no activity during the • Patient-related instruction must be an integral part of
stretch. It CJn be used uuring a specific exercise to ensure any physical ilierapy intelvention.
isolated recmitmel1t of a muscle. For exalliple, one elec­ • The three-dimensional therapeutic l'wrcise interven­
trode can be.: pi8ccd over the tensor fascia lata and one over tion model is deSigned to help organize the data neces­
the glutellS ll1C'dius during prone hip abduction. If the de­ sary to make clinical decisions regarding therapeutic ex­
sired mlIscle for recruitme nt is the gluteus medius, activity ercise intervention.
in the gluteus medius is expected wiili relative quiescence • Exercises must be continually monitored to determine
in the tensor fascia lata. SFMG also can be used to ensure the need for modification to increase or decrease diffi­
the desired synergy and timing of muscles acting in a force culty to ensure continual progress is being made with
cO\lple during a functional movement pattern. For exam­ minimal setbacks. To be most effective with exercise
ple, one electrode is placed over the upper trapezius, one modification, the clinician must possess thorough un­
over the lower trapezius, and one over the serratus anterior derstanding of the parameters that can be modified.
during upper extremity flexjon. The proper recruitment • Therapeutic exercise can be complemented wiili adjunc­
pattern and timing of the muscles can be correlated with tive interventions if ilie additional intervention can lead
the path of motion at the scapula. If the scapula appears to to a higher level of functional outcome in a shorter
be elevating, more activity is required under the lower period.
trapezius and serratus anterior; likewise , if the scapula is
not elevating enough , more activity is needed under ilie
upper trapezius and serratus anteJior.
_ _ _ _ _- - 1
Appropriate use of SEMG requires a thorough knowl­
edge of instrumentation, set-up, and interpretation of data.
1. Read Case Study #2 in Unit 7.
Please refer to recommended reading on the topic. 86-88
a. List the phYSiologic, anatomic, and psychol ogic im­
Surface Electromyography-Triggered b. List the functional limitations.
Neuromuscular Electrical Stimulation c. Correlate the impairments to the functional lirnitil­
Combining SEM G with N MES can more;owerfully facil­ tions.
itate muscle than eitller modality alone In SEMG-tlig­ d. Choose ilie impillrments and functional limitations
gered NMES , NM E S is delivered to a target musclc after you feel warrant treatment.
a prescribed electromyography threshold is exceeded. The e. Correlate ilie impillrments and functional limitations
benefit of com hilling the two mocialities is th8t the patient you have chosen to treat vvith the elements of the
must actimte the llluscle to a predetermined threshold, movement system.
the re by serving as an active partiCipant in the process, f. Prioritize the elements of the move ment system.
which may not happen during traditional 1\.\1ES. This 2. Still using Case Study #2, you have decided to prescribe
modality is particularly useful for muscles in which voli­ exercises to improve knee mobility, because you know
tional control is difficult (e.g., gluteus medius, VMO, serra­ the patient requires 70 degrees of knee flexion to per­
tus antelior, lovver tr<lpezius). For example, during a step fonn simple ADLs. You would like to use a sit to stand
activity, the VMO is set up for electromyography-triggered movement to work on knee mobility. Recall that she re­
NMES . After ilie VM O has reached a predetermined level quires moderate assistance with sit to stand transfers.
of activity as sensed by SEMG, ili e NMES is triggered to a. Describe the posture, mode, and movement of the
contract the muscle beyond its volitional capability. This activity.
approach can assist in tre<lting disuse atrophy, muscle re­ b. Describe all pertinent parameters of dos<lge.
eciucatioll, alld s}11chroniz<ltion of muscle activity. :3. The patient has progressed to 70 degrees of flexion and
no longer requires assistance witll sit to stand transfers.
How would you modif)' the mobility exercises to make
KEY POINTS them more difficult? l,'sc the principles of exercise
modification listed in Display 2-12 .
• The physical therapist integrates five elements of care­ 4. The patient is having difficulty with recruitment of her
examination , evaluation, diagnosis, prognosis , and inter­ quadriceps.
vention-in a manner deSigned to maximize the pa­ a. What adjunctive intelvention would you use?
tient's outcome. b. Describe the posture, mode, and movement of the
• An understanding of each component of the patient activity.
management model assists tlle clinician in maximizing c. Describe all pertinent parameters of dosage.
Chapter 2: Patient Management 33

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electromy stimulation training and basketball practice on 89. Fields RW. Electromyographically triggered electric muscle
muscle strength and jumping ability , Int J Sports Med stimulation for chronic hemiplegia, Arch Phys Med 1987:68:
2000;21:437-4A3 . 407-414 .
chapter 3

Principles of Self-Management and

Exercise Instruction

and willingness to adhere are often based on the fulfillment

Teaching in the Clinic
of their expectations. The more time spent educating the
patient on prognosis and expectations from the rehabilita­
tion program, the more likely the patient is to adhere to and
Adherence and Motivation
be satisfied "vith the tre atment program. Gahimer and
Health Behavior Models
Domholdt 3 found that therapists educated their patients
primarily in the areas of information about illness, home
exercises, and advice and information. Moreover, the pa­
Clinician-Patient Communication tients reported attitudinal or beha\lo ral changes ranging
Issues in Home Exercise Program Prescription
from 83.8% to 86.5% as a result of this education. Health
Understanding Instructions
education and stress counseling were addressed less fre­
quently during the treatment session.
Proper Exercise Execution

Equipment and Environment

Home Exercise Prescription

Considerations in Exercise Prescription

Determining Exercise Levels

Teaching in the clinic is a constant and ongOing process. As
Formulating the Program
changes in health care occur, many clinicians are finding
that their role has changed from full-time, hands-on
prOviders of rehabilitation services to part-time educators,
Patient education has become a more critical component of administrators , and c1inicians. 3 Clinical teaching, parti cu­
patient care in the last decade. Changes in the structure of larly in the area of the home exercise program, is espeCially
the medical system, reimbursement issues, and an increase important, because in-house supervised physical therapy is
in the prevalence of chronic problems require more patient often inadequate to achieve the patient's goals. For exam­
education about their condition and self-management ple, performing stretching exercises three times per week
trategies. Patient-related or client-related instruction is for 30 minutes under the clinician 's supervision probably
de fined as the "process of informing, educating, or training will be insufficient to produce a change. The development
patients/clients, families, significant others, and caregivers of a thorough, complementary home exercise program is
\\i th the intent to promote and optimize physical therapy essential. Exercise prescription for the bome, workplace, or
,ervices."l Instruction , education, and training of the pa­ school can prove to be an interesting challenge for the clin­
tient or client includes information on their current condi­ ician and patient. H e lping the patient establish a daily
'on, the diagnosis, prognosis and plan of care, health and exercise program as a routine can be a positive lifelong
vellness issues , and risk factors for pathol ogy, impair­ influence.
ents, functional limitations, and disability.
Teaching in th e clinic can take many form s. Serving as a
.jnjcal mentor for a physical therapy intern or teaching
ents how to assist their child in stretching exercises are Depending on the speCific circumstances, provision of re­
\lOUS examples of teaching in the clinic. Clinicians also habilitation services may be limited to a few visits. In this
h patients during the evaluation and treatment ses­ situation, the patient may be carrying out the rehabilitation
ns . A study of the perceptions of physical therapists re­ program at home or at a local health club with intermittent
• their involvement in patient education showed that rechecks for status and progreSSion of the program. To en­
rapists educate 80% to 100% of their patients. 2 These sure safety during exercise and improvement in the pa­
rapists primarily recognized teaching range of motion tient's symptoms, the exercise program must be executed
~l) techniques, home exercise programs, and treat­ properly. Frequently, the patient appears to understand
t rationales. Clinicians recognize but may underesti­ proper performance of the exercises, but he or she subse­
the importance of educating their patients on impor­ quently forgets the instructions, resulting in improp er
. sues such as the relationship between symptoms and techniqu e. This p ro blem can result in a lack of improve­
r patients' daily routines and the e>"'Pected response to ment and potentially in exacerbation , or worsening, of the
..;ercise program. Patients' satisfaction with treatment symptoms. The patient should understand which signs and
36 Therapeutic Exercise Moving Toward Function

symptoms predict an exacerbation so he or she can modify schedules).·5-7 A number of behavior change models have
the exercise program appropriately. This education can been put forth. For example, the Health Belief Model
prevent an exacerbation and potential reinjury. stresses a reduction of environmental barriers to healthy
behaviors includin~ ~erceived barriers, benefits , self-effi­
Self-Management cacy, and severity. ' Other models include the Healili
Locus of Control, Self-Efficacy and Transtheoretical, or
In addition to increasing the safety of the exercise pro­ stages of change model./i· 10 Of these models, ilie Trans­
gram, educating the patient about the effects of the exer­ theoretical model has been applied to many aspects of ex­
cise program on specific symptoms can empower him or ercise behaviors.
her to self-manage the situation. The more clearly pa­ The Transtheoretical model emphaSizes the temporal
tients understand the relationships among various activi­ aspect of a behavior change, underscoring the ability to
ti es (including the exercise program) and their symptoms, change a behavior over a valiable length of time. lndividu­
the better able they ,,,,,ill be to regulate their activity lev­ als may spend varying lengths of time in the different stages
els. This makes the patient a partner in the rehabilitation as they slowly make changes, or they may get stuck in one
program. The patient still looks to the clinician for gUid­ stage. Additionally, the patient may move through some of
ance' and education regarding the physical problem, but the stages several times before completing the behavior
tlIP clinician give.~ the patient some responsibility in the change.!O The stages identified in iliis model include: pre­
deci~ion-making process. This approach gently gUides tlw contemplation, contemplation, preparation, action, and
patie nt in the se lf-managt~ lllent process. Holmes et at! maintenance.
successfully used a self-manage ment approach in the In the precontemplation stage, the individual has no in­
treatment of a woman with impingement syndrome and tention of changing or does not see any need for change.
adhesive capsulibs. She was seen for six visits over 10 Prochaska II quantifies this stage by a person stating he or
weeks and followed for 1 year. The authors felt that the she did not intend to change \vithin the next 6 months. A
intensive patient education allowed the patient to develop person in this stage will be reluctant to begin any rehabili­
an internal sense of control and prevented the develop­ tation program and generally does not see the need or ben­
ment of an external focus in which the patient depends on efit of it. The individual may feel forced to corne for reha­
the therapist for management of the condition. Motiva­ bilitation by some outside party (physician, family member,
tion exhibited hy patients may be a manifestation of their employer), and no amount of explanation or information
locus of control beliefs.s 'vvill improve adherence.
Individuals in the contemplation phase are seriously
considering change but have not yet initiated it. Individu­
ADHERENCE AND MOTIVATION als in this stage state that they are planning to make a
change witllin tlle next 6 months. Those in the preparation
Patient compliance 'vvith a treatment regimen is the subject stage indicate that they are planning to change in the next
of a great deal of research. The terms compliance, adher­ month or had made some changes, but had not fully
ence, and therapeutic alliance are often used to discuss the achieved the change . Individuals in the action stage have
extent to which a patient's behavior coincides with medical reached some criterion level of change (such as quitting
advice." Some feel that the term compliance is too dictato­ smoking or exercising three times per week) within the past
rial on the part of the caregiver, and seems to neglect the 6 montl1s. Those in the maintenance stage had reached the
philosophy of "patient as partner" ill determining the plan criterion level of behavioral change more tllan 6 months
of care. The term adherence will be used throughout this earlier.ll
chapter. The best-designed rehabilitation program
achieves little if the patient is not compelled to participate.
A study by Sluijs et aL 6 demonstrated a complete adher­
ence rate of only 35%, with 76% of the patients "partly" The patient will be more willing to adhere to a rehabilita­
compliant "vith their rehabilitation program. The factors tion program if attention is ~ven to the stage of readiness
related to nonadherence were barriers that patients to begin such a program.7,lo. 2 The first step is truly listen­
perceived, lack of positive feedback, and the degree of ing to the patient to identify clues as to their state of readi­
helplessness. ness for change. This can be done by using open-ended
questions to explore issues related to adherence and to fa­
cilitate the patient's personal involvement. Help the pa­
Health Behavior Models tient identify potential barriers to participation and request
Clinicians spend a great deal of time designing what they input as to how these barriers can be removed or mini­
believe to be tlle best plan of care for their patients. How­ mized. Patients need to believe that ilie pros of participa­
ever, even t1w best intclvention plans will fail in ilie ab­ tion outweigh the cons, and that they are capable of achiev­
sence of patient participation. The factors associated with ing ilie e>"'Pected outcomes if they participate. ll ,13.14 Help
compliance with medical professional recommendations the patient in the precontemplation phase to identify per­
have been well-studied. Some studies focus on eliminat­ sonal goals that might be achieved by participation in the
ing unhealthy behaviors (smoking, excessive alcohol use), rehabilitation program. Build rappOlt through regular ap­
whereas others focus on initiating healthy behaviors (good pointments and reflective conversation. 14 For the patient
eating habits , exercise, compliance with medication in the contemplation phase, build motivation through en­
Chapter 3: Principles of Self-Management and Exercise Instruction 37

courageJllent and the provision of information. Review the

pros and cons of participation, reflecting the patient's own
personal goals. Enhance adherence by educating the pa­
tient regarcling the relationships among the injury or
pathology, the exercise program, and the expected out­
come. The c1iniciall may purposefully link the exercise to
the patient's speciflc problem or goals, but the patient may
not understand this relationship. He or she should under­
stand this relationship to ensure active partiCipation in the
treatme nt program. Brus et a1. 15 found that compliaBce
with physical exercise, en ers'Y conservation, and joint pro­
tection was increased by patient education in a group of pa­
tients with rheumatoid alihritis. For those in the action
phase, actively engage the patient in plan of care formula­
tion and provide support for the plan. H elp identify barri­
ers to implementation and address these in the treatment
plan . Patients in the action and maintenance phases need
positive reinforcement to continne partiCipation and pre­
vent relapses.
Motivation is a key factor in exercise adherence. Every
person experiences various influences on motivation.
What motivates one person is unlikely to motivate an­
other. The clinician should attempt to determine which
factors motivate the patient to adhere with the exercise FIGURE 3-1. Choose home exercises reflective of the patient's usual
program and use these as the "carrot" or reward. These activities.
factors vary tremendously and may include return to ac­
tivities the patient enjoys (e.g., gardening, sports, leisure,
recreational activities), return to work, return home (e.g., type of activity has the added ben efit of requiring distal
from hospital or intermediary care facility), ability to shop muscle function that more closely replicates the actual
or carry out instrumental activities of daily liVing, or the important activity than lifting a weight or using resistive
ability to care for a child. After the motivators are identi­ tubing. \i\ie ights and tubing are useful adjuncts to the re­
fied, 'the exercise program should be tailored to those ac­ habilitation progranl and , wh en possibl e, should be used
tivities. Inability to participate in these activities is often in a way that duplicates the functional activity. Rather
one of the primary reasons the patient sought medical at­ than performing a series of cardinal plane shoulder exer­
tention initially. cises, miIIlicking activities such as a tennis svving, raking,
When designing the rehabilitation program with moti­ sawing, or throwing a ball can increase stre ngth and rein­
vation and adhe rence in mind, use caution when using "ex­ force important motor programs .
e rcise files." If' the exercise program seems nonspecifIc or An exercise pro gram requiring the fewest lifestyle
unrelated to the patient's functional needs , adherence changes increases the patient's adherence to it. Rather than
could become a problem. In the early rehabilitation phases, trying to add more activities to the pati ent's day (o~ten ask­
some exe rcises may not seem particularly "functional" to ing that exercise be performed several times per day),
the patient, but they are important aspects of the treatment choose exercises that can be incorporated into her day. If
program. Explaining the importance of the exercis e edu­ an exercise program requires a 15- or 30-minute time block
cates the patient about the condition, asslires the patient of carved out of a person's busy day once or twice daily, ad­
the clinician's understanding of the problem and the po­ herence is difficult despite the patient's desire to partici­
tential solution, and treats the patient as an educated par­ pate. If the exercises can be blended into activities that the
ticipant in the rehabilitation process. Further explanation patient already does during the day, adherence becomes
of how the exercises will progress to more functional activ­ much easier. A study by Fields et a1. I6 examined the rela­
ities or how a specific exercise is related to the motivatin a tionships among self-motivation or apathy, perceived exer­
activity validates the importance of that activity and verifies tion, social support, scheduling concerns, clinical environ­
that this is important to the patient. ment, and pain tolerance to adherence to sport injury
As the exercise program progresses, it should reflect rehabilitation in college-age recreational athletes. Of the
more and more close ly the activity to which the patient variables under consideration, significant differences were
will be returning. The same physical th erapy goals can be seen between adherers and nonadherers in self-motivation ,
achieved while increasing motivation and function by us­ scheduling concems, and pain tolerance; of these factors,
ing functional activities as the exercise program. For ex­ scheduling concerns contributed most to the overall group
ample , for the individual recovering from shoulder difference. In another study, Slu,ijs et a1. 6 found that the
surgery who is unable to unload the dishwasher, transfer­ strongest factor in nonadherence was the barriers patients

ring dishes of increasing weight from the counter to shelf perceived. The most frequent complaint was that the exer­
t for progressively longer periods is more motivating and cise program required too much time and that the exercises
1- interesting than lifting a 1-pound weight (Fig. 3-1) This did not fit into the patient's daily routine. An example of an
38 Therapeutic Exercise: Moving Toward Function

exercise program for a patient with adhesive capsulitis can

DlSPLAV 3-1 be found in Display 3-l.
Home Exercise Program for Office Worker Fitting exercise into the patient's daily routine estab­
with Adhesive Capsulitis lishes a conditioned response that may cany over after
therapy is concluded. For example, if a patient needs to in­
Impairments crease the length of the gastrocnemius-soleus complex by
1. Decreased range of motion in all directions in a capsular stretching several times each day, instructing that person to
pattern stretch for 20 to 30 seconds each time he or she ascends the
2. Decreased strength tested by manual muscle tests in all stairs is less burdensome than doing this as part of an exer­
major shoulder muscle groups cise routine at the day's end. For the individual needing to
3. Resting pain at 4 on 0-10 (0 = least; 10 = most pain);
increase shoulder flexion ROM , leaning al1ead with his or
activity pain at Band 0-10.
her arm forward and flexed on the desk or kitchen counter
Functional Limjtations before making a phone call is a productive use of time. This
1. Unable to use arm for activities of daily living may beco me a conditioned response, and whenever the
2. Unable to lift weight with arm held away from the body phone rings, the individual associates that activity with
3. Unable to get arm over head for work and daily activities stretching his or her shoulder, or when ever the patient
climbs the stairs, he or she thinks of calf stretching. This
technique works particularly well with postural re-educa­
1. Unable to fulfill all roles at work because of limitations tion exercises (Fig. 3-2).
2. Unable to participate in leisure activities
Home Exercises
1. Stretching for shoulder elevation while in warm shower CLINICIAN-PATIENT COMMUNICATION
2. Active use of arm for personal hygiene, including

showering, combing hair, dressing, eating, pendulum

Individual differences Sign ificantly affect the patient-clini­
exercises during dressing
cian relationship. Fundamental personality differences,
3. Scapular retraction exercise with abduction in front of values , and teaching and learning styles influence com mu­
mirror during grooming three times per day, looking in the nication and may ultimately affect adherence and outcome.
mirror each time Possessing important skills to assess the patient's willing­
4. Shoulder flexion or abduction stretch on desk when
ness and style of communication and learning can enhance
talking on the phone
the rehabilitation program. These skills include the ability
5.. Passive shoulder external rotation stretch at file cabinet
to actively listen and reflect t~e patient's re~orts and to
every time
6. Isometric exercise while reading morning mail provide appropJiate feedbackY.l S Sluijs et al. found lack
7. Walk with large arm swings during lunch hour of positive feedback to be one of the primary factors related
B. Supine overhead stretches on couch during the evening to lack of adherence ,vith a rehabilitation exercise program,
news Cameron 5 suggests improving the quality of the interaction
9. Use arm as much as possible for cooking, dishwashing, by showing sensitivity to the patient's verbal and nonverbal
housework, and yardwork communications , and understanding of and empathy with
10. Resistive tubing exercises sometime during the day; the> patient's feelings.
patient's choice. Patient education implies a willingness to partiCipate by
the patient and the clinician. The patient's readiness to

FIGURE 3-2. The clinician should prescribe exercises that can be

performed during other home or work activities.
Chapter 3 Principles of Self-Management and Exercise Instruction 39

learn depends on many factors, including the relationship education about reasonable goals. The ability to perform
\-vith the health care provider. The clinician must be able to the same level of exereise or acthrity at a lower level of pain
assess the patient's readiness and willingness to learn. The is a reasonable short-term goal. The patient may only see
relationship is based on how the patient is coring with the that he or she is performing at the same level and perceive
particular situation. Schwenk and Whitman l described a this as a lack of progress. ClaJification on how progress is
control scale in which the control level of the patient and defined and reasonable expectations regarding progress
clinician were inversely related. As the clinician uses less can improve patient adherence and satisfaction. Some ad­
controlling or assertive behaviors, the patient's control of vocate a contract approach in which the specific obligations
the situation increases. The converse is also true; the active of each party in the attainment of the therapy goals are set
and assertive clinician is likely to push the patient into a forth and a timeline determined. 5
more passive role. If the patient is unwilling to be in such a
role, conflict "rill ensue, or the clinician will become more
passive, relinquishing some control to the patient. ISSUES IN HOME EXERCISE PROGRAM
The clinician's attention to the patient's needs can guide PRESCRIPTION
the appropriate communication style. In the initial visits, a
more passive listener role gives the patient an opportunity The home exercise program is an increasing component of
to explain his or her needs. This gives the clinician an op­ the overall treatment program for most patients. In some
portunity to hear the patient's concerns, expectations, and cases, the patient performs the exercises independently,
goals. Fundamental skills necessary for active listening in­ whereas, in other cases, a family mem ber or other health
clude close observation of the patient's words, intonation, care provider assists in the exercise program. In either sit­
and body language. Eye contact, along "rith affirmation and uation, clarity in goals and exercise procedures is essential
reflection of the patient report, can clarify what the clini­ to ensure an optimal outcome.
cian heard and validate the patient report (Fig. 3-3). This
gives the clinician an opportunity to discuss the recovery
prognosis given adherence to the treatment program, Understanding Instructions
which, along "vith discussion of the clinician's expectations
One of the fundamental steps in ensuring a positive out­
of the patient, can enhance communication and the reha­
come after initiation of a rehabilitation program is the pa­
bilitation process. Several studies have shown the
tient's ability to understand the therapist's instructions.
"Pygmalion effect" in a variety of settings in which the
Many variables affect this aspect of patient care, including
instructors' eXf-ectations were matched by students'
language or cultural barriers, reading or comprehenSion
achievements. 1 -22
levels , hearing impairment, and clarity of instructions.
Although communicating the expectations of all in­
The best-deSigned rehabilitation program may fail be­
volved participants is important, it is equally important to
cause it has not been carried out well. Do everything pos­
prOvide realistic expectations in the form of short-term and
sible to ensure that your instructions are clear and easy to
long-term goals. Setting reasonable and achievable goals
can provide one form of positive feedback for the patient.
Occasionally, the patient's motivation can be improved by
Cultural Barriers
Identify any cultural barriers to understanding early in the
rehabilitation course. Language differences may hinder the
use of even the Simplest terminology. Although an indhrid­
ual may appear to understand many words in English,
communicatin,~ thoughts about medically related issues is
likely to be dillicult. Use of an interpreter, whether a pro­
fessional or a family member, can minimize communica­
tion difficulties in this area.
Other cultural barriers to adherence may exist and
should be identified to the best of your ability. Religious or
other cultural customs may prevent individuals from exer­
Cising on certain days or from wearing clothing that allows
a body part to be visualized or palpated during exercise. In
major metropolitan areas, a multitude of cultures exist. It is
difficult to know all the intIicacies of many cultures and
customs. Do your best to know the times and meanings of
your patient's ethnic or religiOUS holidays. Seek informa­
tion on cultural or religiOUS customs related to eye and
phYSical contact, including the appropriate type of greet­
ing. This includes not only appropriate eye contact (avoid­
ing eye contact is a sign of respect in some cultures), but
how the patient is addressed, and if any physical contact
FIGURE 3-3. In appropriate cultural situations. eye contact can enhance (i.e., handshake) is appropriate. 23 Although these speCific
communication. instances are difficult to know ahead of time , be alert to
40 Therapeutic Exercise Moving Toward Function

signs during the appointm ent that the patient is unwilling Communication with the patient regarding the exercise
or hesitant to participate. Ask for permission to perform ex­ program should be written and verbal. Simply handing a pa­
amination procedures in advance, or explain what needs to tient the exercise program without having the patient per­
be done and determine what the patient needs to feel com­ form each of the exercises increases the likelihood of non­
fortable in the situation. In many cases, the patient feels adherence and incorrect pelformance. A study by Friedrich
most comfortab le being examined by a therapist of the et al. 24 found that patie nts who received a brochure of ex­
same sex. To the best of your ability, these issues should be ercises rather than supervised instruction had a lower rating
addressed when scheduling the patient. of "correctness" of exercise performance. A strong correla­
tion between the quality of exercise performance and a de­
Clarity of Instruction crease in pain was found. 24 Although patients may say they
can remember their exercises, it is best to document the ex­
Simple aspects of the exercise program such as clear de­
ercises with a written description that is reinforced \¥ith ver­
scriptions and legible writing are also important for adher­
bal cueing as the exercises are performed.
ence. Although written programs may provide a
Organize the exercises to follow a lOgical sequence. An
personalized touch to the program, it may prove detrimen­
exercise program requiring frequent position changes is
tal if the patient is unable to read your writing. Busy sched­
time-consuming and burdensome for the patient. Cluster
ules and too little time contribute to hastily written patient
exe rcises of a similar nature for ease of understanding and
instructions. The specific exercise descriptions may make
ease of performance. For example, cluster all exerci ses per­
perfec t sense to the clinician but confuse the patient. Base­
formed in a supine position to minimize position changes
line knowledge assumed by the therapist may be too much
and group together shoulder rotation exercises because of
for th e patient and may result ill incorrect exercise perfor­
their similar nature . Be sure to organize the exercises to
mance. Although the patient may be extremely bright and
simplify th eir performance and minimize the impact on the
appears to grasp many aspects of medical care, clarity about
patient's lifestyle.
which direction is "forward" or "up" is still necessalY- Di­
rections should be lengthy enough to be comprehenSive
vvithout overburdening the patient with details, Full sen­
Proper Exercise Execution
tences are unnecessary, but key phrases or bulle ted points
can improve clarity. Although the patient may appear to follow the exercise in­
Pictures of the exercises should be included and ideally structions, he or she may still perform the exercise incor­
demonstrate the exercise in the start and finish pOSitions. rectly. The patient may understan d Ule instructions, but the
Communicating a three-dimensional movem en t on a Single instructions may be incomplete, the patient may read things
sheet of pape r at a stationary point in time is difficult. into the instructions, or the patient may simply be unaware
Showing starting and eflding positions or shO\lVing pictures that he or she is not doing what the instructions call for. For
from different angles helps clarify the three-dimensional example, the patient may think he or she is performing a
nature of the movemen t. Arro'vvs shOWing the direction of trunk curl but raUler is doing a full sit-up, or pelforming a
movement with marks clearly indicating the start and end straight leg raise without the necessary quadriceps set first.
positions are helpful. Often, exercise pictures show posi­ Ensure proper performance by having the patient per­
tions midway through the exercise and the patient is un­ form each of the exercises under your direction and guid­
clear as to the full excursion of the movement. Throughout an ce, with verbal and tactile cueing for proper perfor­
this book, Self-Managcmcnt boxes present examples of ex­ mance. Encourage the patient to take notes during these
ercise instructions. sessions to enhance participation , responsibility; and un­
Many clinics provide picture files or computer­ derstanding of the exercise program. Although written and
generated exercises with pictures, descriptions, and exer­ verbal instructions help ensure proper performance, more
cise prescriptions included. These are helpful for tJle clini­ instruction is occasionally necessary. Other options include
cian , but lise caution with these for the foll OWing reasons . haVing a famil y member observe the clinician instructing
First, the therapist frequently needs to modi~' the exercise the pati ent, so that this individual may gUide the patient's
in some way to adapt it to the speCific patient needs. These home exercise performance. Videotaping the exercise ses­
modifi cations should be made on the patient's exercise sion allows the patient to see himself or herself performing
record, not just verbalized. Do not assume that because an the exercise, along with hearing the clinician's verbal cues
exercise is prOvided in one of th ese formats, that it is Ule and observing tactile cues for proper performance . The pa­
bes t or only way to perform the exercise. Second, the exer­ tient can replay this tape at home if a question regarding
cise prescription should be individualized based on the pa­ the exercise program exis ts.
tient's needs and ability to self-manage the problem, not When the patient returns for follow-up, ask him or her to
necessarily prescribed as a certain number of sets and rep­ demonstrate the home exercise program. If the patjent has
etitions per day. This type of prescliption may confBct \vith been performing th e exercises on a daily basis, the exercises
the goal of teaching the patient self-management skills. Ex­ should nearlv be committed to memo!'v. The ability of the
erc.ises that appear to be "canned" or Ulf' standard sheet of patient to qu'ickly recall the exercises with or without the as­
exerci sE'S that is given to every patient with a certain diag­ sistance of the handout may provide a due about adherence.
nosis minimizes the individuality of the exercise program. Moreover, this shows preCisely how the patient has been ex­
Lack of individualization minimizes the skills of the thera­ ecuting the exercise. Frequently the exercise has been
pist and may affect adherence if the patient feels his or her changed somewhat from the clinician's original intended
needs are not being met. performance, and this may affect the patient's progress since
Chapter 3 Principles of Self-Management and Exercise Instruction 41

FIGURE 3-4. The exercise program must be reviewed at fol low-up visits to ensure correct performance. (A) Incorrect position-substituting scapular
movement for glenohumeral movement and incorrect degree of rotation . (8) Correct position-clinician corrects exercise performance.

the last visit. Occasionally, the incorrect exercise perfor­ environment. The patient must be able to comfOltably tran­
mance can have negative consequences, such as increasing sition positions to and [rom that surface. If the only available
the patient's symptoms or hindering progress (Fig. 3-4). firm surface to carry out the exercise program is the floor,
r the patient must be able to easily get up and down from the
a floor. If not, the exercise program should be modified to in­
a Equipment and Environment crease the ease of participation in the program.
t. Along with determining what motivates the patient, deter­ A final aspect of the environment that the clinician has
mine the motivation derived from use of exercise equip­ little control over but should consider is the presence of a
ment. Performing exercises using body weight, objects at
the home or office, or work tools may be more functional;
however, the patient may feel like this is not really exercise
if it does not involve weights or resistive bands. Patient ed­
ucation is necessary to ensure the patient of the impOltance
of these activities. However, preconceived ideas about ex­
ercise are frequently difficult to overcome, and adherence
may be improved by use of some equipment. The financial
cost of purchasing some equipment for home use may in­
crease or decrease adherence. If money mllst be spent to
carry out the exercise program, the patient may decline
participation. However, some patients feel obligated to use
equipment that they have purchased. Assess the patient's
position on this issue before issuing or recommending pur­
chase of equipment.
to When designing an exercise program "vith some specific
equipment, ensure that the patient has a place to use the
res equipment (Fig. 3-5). Depending on the region of the coun­
ne trY, homes mayor may not have stairs. Other accommoda­
tions may be necessary if exercises require the use of a step.
\\ l1en prescribing exercises to be performed in a supine or
ro ne position, a surface of the appropriate height and firm­
n ness must be available. Exercises often are easy to perform
ed n the plinth in the clinic, but the quality or the ability to per­ FIGURE 3·5. The clinician should choose equipment that can be easi ly
orm the exercise is negated at home because of the patient's used by the patient at home.
42 Therapeutic Exerci se: Moving Toward Functi on

supportive family. Social support is an importan t factor in scheduled supervised visits. In the early phase, appoint­
patient adherence to a treatment regimen. Social support ments may be more frequent because of the rapidity ,'lith
includes both the medical community and the patient's which the patient's symptoms, impairments, and function
family and immediate community. Social isolation has been are changing. The exercise program changes more fre­
determined to be a major factor in nonadherence to a med­ quently as goals are met and new goals established. In the
ication regimen. Lack of social support has contributed to early stage, the symptoms may be new to the patient, mak­
dropping out of treatment in a number of studies. 25 Social ing determination of the appropriate exercise level diffi­
support is particularly important when managing chronic cult. Close follow-up of response to treatment is necessary
disease, due to the ongoing nature of the problem . to ensure forward progress. Conversely, in the intermedi­
Be sure to evaluate the role of the family and other sup­ ate to later stages, changes in the patient's symptoms and
port systems in the patient's immediate community. The function occur more slowly, and the exercise program may
family or work co mmunity can provide support, or poten­ be more extensive. The patient is often instructed in self­
tially have a negative effect. A supportive family can maxi­ progression of activities.
mize the patient's opportunity to participate in medical
care by being physically and emotionally supportive. Fam­ Tissue Irritability and Symptom Stability
ily members who take over duties normally carried out by Tissue irritability has a significant effect on the rehabilita­
the patient and advocate participation in the exercise pro­ tion program choices. This factor is somewhat subjective
gram can enh ance the patient's opportunity for improve­ and is determined through a complete subjective examina­
ment. A nonsupportive family who criticizes the patient for tion. Questions regarding the patient's symptoms prOvide
being injured or unable to carry out expected roles can cre­ the clinician \'lith the best information on this issue (Dis­
ate barriers to improvement. play 3-2).
If possihle, involve the family in the patient's care to en­ Before deCiding on tlle choice or intensity of the exer­
sure an understanding of the plan of care and prognosis. cises, understand what kinds of activities or pOSitions
This vvill help them understand realistic goals and the plan worsen the patient's symptoms. These activities or posi­
to achieve them. If family members are nonsupportive, do tions mayor may not need to be avoided. If the patient can
your best to minimize their negative impact by providing tolerate the activity or position for some time, is able to de­
additional support to your patient. Always be alert to signs tect the prodromal signs that the symptoms are going to
of this situation and make referrals as necessary to ensure worsen , and understands that stopping the activity or
optimal participation in the rehahilitation program. changing position can alleviate the symptoms, use these ac­
tivities or positions therapeutically. For example, if a pa­
tient with carpal tunnel syndrome enjoys knitting and this
HOME EXERCISE PRESCRIPTION is one of the patient's functional goals , knitting may be used
as part of the rehabilitation program. The patient must be
Prescribing exercises for a home program is challenging.
able to recognize the onset of synlptoms and be able to al­
These exercises are performed vvi thout supervision , and
leviate them by taking a rest period or discontinuing the
patient edu cation is critical to a successful home exercise
knitting. Similarly, if a patient \vith back pain enjoys and is
program. Frequently, limited patient visit time further
able to tolerate some walking, this activity can be a compo­
challenges the clinician to teach the patient all the neces­
nent of the exercise program. The patient must be able to
sary components of the self-management program. Provid­
detect the onset of symptoms and be able to relieve them
ing a short, safe home exercise program is better than be­
by discontinuation, stretching, icing, or some other self­
ing too broad and overwhelming the patient vvith
management intervention. Conversely, if the patient re­
information on the first visit.
ports an unmanageable, inevitable worsening of symptoms
once irritated, the exercise program should expressly avoid
Considerations in Exercise Prescription any position or activit)' that may exacerbate symptoms.
Exercise prescription can be difficult for several reasons. Be sure to consider the stability of the patient's symp­
Determining the number of exercises and the quantity of tom s as a component of tissue irritability. Individuals may
repetitions, sets, bouts, and intensity is challenging. Too lit­
tle exercise may not produce the desired result, but too
much exercise may overwork the patient, resulting in a de­ DISPLAVJ·2
cline in progress. Many factors influence choices regarding Questions Assessing Tissue Irritability
the exercise prescription:
1. What activities or positions increase your symptoms?
• Stage of healing 2. How much time can you spend in that activity or position

• Tissue irritahility and symptom stability before your symptoms begin?

• Patient's time and willingness to participate 3. When you start feeling these symptoms, will they continue
• Time between physical therapy visits to progress despite discontinuing the activity or changing
positions? Will changing the activity or position alleviate
Stages of Healing the symptoms?
The acuity or chronicity of the injury affects the exercise 4. After you begin experiencing your symptoms, how long do
prescription , including the regularity of supervised physical they last? How long until you return to "baseline"?
therapy and the time between visits. In the early stages , 5. Is there anything you can do to relieve your symptoms?
give the patient a few things to do at home bet\.veen closely
Chapter 3 Principles of Self-Management and Exercise Instruction 43

have significant unpredictable Huctuations in their symp­ program, educate the patient about the importance of the
toms over the course of the day or week. If symptom program, but make conscious choices about priority exer­
changes cannot be associated with the time of day, position, cises. Make an effort to select exercises considered to be the
or any specific activity, th e exercise prescription can be dif­ most important for the exercise program. More is not always
ficult. If the patient is unable to determine what kinds of better, and giving thoughtful consideration to the core exer­
things make him or her better or worse, assessing the effects cises is beneficial for the clinician and the patient. Choosing
of the exercise program becomes yet another variable in the exercises that have the greatest impact for the least time
symptomatology. Deciding whether a specific exercise pre­ commitment can minimize the time requirement and maxi­
scription is beneficial or deleterious is challenging if the pa­ mize the benefits. The patient will probably appreciate your
tient's symptoms fluctuate randomly. When possible, it is concern and attention to his or her needs. Couple this ap­
best to proceed with fevver exercise interventions until a sta­ proach with education regarding the importance of the
ble baseline of symptoms is achieved. This baseline then home exercise program to achieve the determined goals in as
serves as a gauge of the effect of the exercise program. expedient and efficient a time frame as possible. Emphasize
Th e patient's other daily activities affect the exercise pre­ the patient's responsibility in achieving those goals.
scription. Understanding the behavior of a patient's symp­
toms over a 24-hour period and how his or her normal daily
routine affects the symptoms helps the clinician to gauge Determining Exercise Levels
appropriate exercise levels . Frequently, the patient is un­ Determining the appropriate level of exercise can be diffi­
aware of the im pact of certain routine activities on his or her cult, particularly when the patient has had little or no ex­
problem, or the patient must perform some activities that perience vvith the specific problem previously or little pre­
worsen his or her symptoms (such as sitting or walking). For vious experience with exercise. Although many individuals
example, the individual with patellofemoral pain should be exercise regularly, many others have little experience with
counseled about the importance of good shoes , particularly exercise. Knowing how to respond to different sensations
if standing for a large portion of the day. Despite the fact felt during the rehabilitation exercises can prove frustrating
that standing behind a cash register for 8 hours may exacer­ to the patient. Many patients ask whether to continue ex­
bate the patient's symptoms, this work may be necessary to erciSing if the exercise produces pain. Despite the fact that
provide financial support for the family. The individual with pain is a subjective symptom, acknowledge this sensation.
back pain may need to lift a child out of a crib several times Consider pain in the context of change from the patient's
each day, despite the fact that this activity is painful. The baseline symptom level and how the symptoms behave
clinician must educate the patient about the impact of these over the subsequent 24-hour period.
activities on symptoms and provide suggestions to minimize Curwin and Stanish 26 provide guidelines originally de­
their negative effects. Moreover, the clinician must educate signed to help determine readiness to return to a sport.
the patient regarding modification of the exercise program However, these same gUidelines are nicely adapted to eval­
based on the symptoms related to participation in these ac­ uation of the patient's exercise program (Table 3-1). The
tivities. On days when the patient's symptoms may be in­ column in Table 3-1 entitled "DeSCription of Pain" refers to
creased because of excessive standing, working, or lifting, the level of pain during rehabilitation exercise perfor­
he or she may need to decrease the rehabilitation exercise mance, and the categOlY "Level of Sports Performance"
level. Failure to recognize the impact of daily activities on could be retitled "Level of Exercise Program Perfor­
symptoms may cause the clinician to erroneously assume mance. " Activity levels that keep the patient 'v\Jjthin his or
that a change in the patient's symptoms was caused by the her optimal loading zone are generally levels 1 through 3.
exercise program alone. Occasionally, some patients may be able to tolerate exer­
cise at level 4 vvithout any residual effects. In these cases,
Time Between Physical Therapy Visits progress may need to be reassessed on a weekly basis
The time between follow-up visits affects the exercise pre­ rather than on an exercise session to exercise session or a
scription. For the patient attending supervised physical daily basis. Patients with adhesive capsulitis often experi­
therapy one or more times per week, the clinician may be ence pain at level 4, but this level of pain does not interfere
more willing to give the patient more challenging exercises with their overall function or progress. Th ese gUidelines
for the home program, knOwing that the patient will be prOvide the patient and the clinician com mon criteria " Jjth
monitored more closely in the clinic. For those patients which the exercise program prescription is evaluated.
who live some distance away or who have longer intervals Despite the clinician's best efforts, some patients expe­
between supervised visits for other reasons , the clinician rience an exacerbation of their symptoms, which mayor
should provide exercises less likely to overwork the pa­ may not be related to the exercise program. Although the
tients. This program is supplemented with instructions on first response of the clinician and the patient may be some
how to progress exercises jf they become too easy (e.g., in­ level of distress, an exacerbation is not always a negative
rease time, repetitions, intensity) or an intermediate expe rience. Valuable lessons can be learned from an exac­
phone follow-up can take place. erbation. At some pOint, whether days , weeks, months, or
years later, most patients experience some type of symp­
Patient's Time and Willingness toms related to the current problem. The patient with
The amount of time the patient has available to exercise is an patellofemoral pain may experience a milder level of pain
important factor affecting exercise prescliption. If the pa­ after a hiking vacation , or the individual 'v\Jjth low back pain
tient claims to have little time available for the home exercise may notice some back discomfort after a long plane flight.
44 Therapeutic Exercise: Moving Toward Function

Curwin and Stanish Classification for Determining the Appropriate

Level of Discomfort Associated with.HomeExercise Prescription

1 [\0 pain N ormal

2 Pain only with extreme exertion Norma]
3 Pain with extreme exertion
and 1-2 hours afterward Norma] or slightly decreased
4 Pain during and after any
vigorous ac:ti\ities Somewhat decreased
5 Pain during activity and
fordng termination Markedly decreased
6 Pain during daily activities Unable to perform

F rolll Curwin S, Stallish WD: Tendinitis: Its Etioi o,)..,'Y and Treatment. Lexington, MA: DC Heath und Co.,

Some patients expelience a complete exacerbation of their minable cause make assessing the effects of intervention
symptoms at some future pOint. Patients must learn how to difficult. Ask the patif~ nt to articulate his or her "normal"
manage the exacerbation. level of symptoms to assist in determining the stability of
Frequently, seve ral weeks have pas.~ed by the tilllc the symptoms. If patients have difficulty determining the sta­
patient seeks medical attention and gets an appointment bility of their symptoms, slow progression is necessary.
with the physician and a subsequent appointment v.rith the 'When the patient is able to perform the sallle exercise pro­
therapist. The optimal time for intervention has passed, gram for tl1fee consecutive sessions without an increase in
and the patient may be struggling v.rith secondary problems symptoms, progression is appropriate.
resuJting from compensation, or movement changes made If intervention needs to be implemented before the es­
because of pain or other impairments. One of the best ser­ tablishment of a stable baseline, give the patient as few ex­
vices the clinician can offer the patient is instruction on ercises as pOSSible. This minimizes the impact of the exer­
how to manage a return of symptoms. Instruction may in­ cise program, thereby lowering the possibility of
clude the use of modalities such as ice, appropriate activity exacerbating the symptoms. If the patient's symptoms do
modifications or rest, changes in the maintenance exercise worsen, you'll have an easier time determining ilie cause,
program, or education regarding when to seek medical at­ and changes can be made more appropriately. As symp­
tention. toms resolve and the baseline stabilizes, increase activities
In addition to possibly preventing reentry to the medical systematically and gradually. Do this by increasing the time
system tl1rough immediate, appropliate symptom manage­ and repeti tions or by adding new exercises slowly.
ment, self-management has the added benefit of enhancing Dow the exercise program is progressed depends on each
patient<;' confidence in their ability to resolve tllC symptoms person 's stage of injury, speCific goals, and stability of symp­
The exacerbation experience coupled with instruction in ap­ toms. F or the individual who is in the intermediate to late
propriate management under tlle clinician 's guidance can healing stages and has demonstrated stable symptoms, sev­
greatly decrease the patient's anxiety. Patients are often fear­ eral exercises can be progressed Simultaneously. For those
ful about palticipating in activities tl1at may provoke their with unstable symptoms and frequent exacerbations, only
symptoms, afraid that they v.rill be "back where they started" one change in the rehabilitation program should be made at
in the early stages of their injury. Learning that an exacerba­ a time. In this way, any positive or negative response to the
tion does not necessarily send them back to the initial phase change can be more easily identified and remedied.
and tllat they can successfully manage the problem empow­ Teach patients how to modify their exercise program
ers patients to make appropriate activity choices. Eventually, based on their activity level on any given day. Put exercises
patients may choose to participate in activities they enjoy at in the context of their daily routine. On days when the pa­
the expense of getting a little sore, knov.ring that they can tient is more active (e.g., working overtime, child care,
successfully manage the symptoms independently. shopping, yard work), modify the home exercise program
to prevent overload . On days when the patient is more
sedentary (e.g., bad weather, day off from work), increase
Formulating the Program the exercise program. In this way, the patient begins to un­
When pOSSible, forrnu]ate the exercise program after the derstand the impact of his or her overall acthrity level on his
paticnt's baseline level of symptoms has stabilized and the or her symptoms. This assists the patient in the self-man­
preViously mentioned factors (e.g., tissue initability) have agement of symptoms in the future.
been determined. EnsUling the patient's understanding of ChOOSing exercises that can be incorporated into activi­
what the "baseline" feels like aJJows better communication ti es already performed durin g the clay should be a funda­
between the clinician and patient regarding the behavior of mental aspect of tl1e exercise program. This type of exer­
their symptoms and the effects of the exercise program. cise prescription results in short bouts of exercise
Symptoms that are unstable or fluctuating \\rithout deter­ performed several times throughout the day, thus improv­
Chapter 3: Principles of Self-Management and Exercise Instruction 45

ing motivation and adherence. In this case, the patient is • Wlitten and verbal instructions should be included in a
unlikely to overwork in any single session, resulting in a home exercise program. Written exercises should include
lower chance of an exacerbation of symptoms. Moreover, beginning and ending positions and any precautions.
the likelihood of exacerbation is decreased despite a • On subsequent visits, the patient should demonstrate
greater volume of exercise than can be performed in any the home exercise program to ensure correct perfor­
single session. For example, the individual with Achilles mance of all exercises.
tendinitis may tolerate only two repetitions of 30 seconds of • Home exercise choices are affected by the acuity of the
calf stretching at a time. If that individual performs those injury, tissue irritability, stability of symptoms, time
two repetitions six times spread out over the course of her available for exercise, and factors affecting the length of
day, the stretch has been performed 12 times. In contrast, follow-up.
if the patient tried to carry out the home exercise program • A symptom exacerbation can be a learning experience
in the evening after work and dinner, chances are only two for the patient if educated properly about the experi­
repetitions would be performed that day. ence.
Finally, teach the patient that some exercise is better • Patients must be taught how to modify their home exer­
than none, and if time limitations exist, a couple of key ex­ cise program based on other activities and symptoms.
ercises should be performed. Occasionally, other life • Understanding the typical behavior of their symptoms
events prevent completion of the full home exercise pro­ allows patients to more easily recognize an exacerbation
gram despite the patient's willingness to adhere. Prioritize and be able to guide activity choice and intensity.
the exercises, highlighting those that are most important to • Any cultural, language, education, visual, or hearing bar­
complete if time does not permit completion of the entire riers should be identified early and appropriate accom­
program. Emphasize the importance of finishing all of the modations made.
exercises when time permits, while suggesting that some • Prioritize exercises so that the patient may perform at
exercise is better than none. least some of her exercises on busy days .


• Changes in health care delivery systems require more 1. How would your home exercise instruction differ for
patient education and self-management. patients who were
• Patient safety is the primary issue when designing a a. Visual learners
home exercise prescription. b. Auditory learners
• The best-designed treatment program is of little value if c. Kinesthetic learners
the patient does not adhere to the clinician's recom­ 2 . Consider the patient in Lab Activities question 1. How
mendations. would you prOvide this patient with a home exercise
• The clinician must determine the patient motivators to program if he or she were blind?
enhance likelihood of adherence. 3. A patient returns to see you and reports that the home
• Exercises requiring the fewest lifestyle changes and im­ exercise was not done because of a lack of time. How do
posing changes that mimic the patient's usual activities you respond? What is your strategy and rationale?
can increase adherence. 4 . A patient returns to see you and reports that the home
• Patient-clinician communication is enhanced by deter­ exercise program was not done because the exercises
mining the patient's willingness to learn and listening ac­ hurt. How do you respond? What is your strategy and
tively to the patient's needs. rationale'?

l...­_ _ _ _


1. Refer to Case Study 6 in Unit 7. Design a home pro­ 3. Using the exercises developed for the first question,
gram for this patient. Include written instructions plioritize the exercises for the patient, and explain
and diagrams for all exercises. Teach your patient this your rationale for the priOlitization to the patient.
home program while relaying the follOWing emo­ Use language the patient can understand.
tions: 4. Your patient desires to return to several sporting ac­
a. Empathy tivities. Choose two of the exercises you have given
b. Disinterest the patient, ancll11odif)' them to mimic a spolting ac­
c. Hurry tivity to which the patient woulcllike to return.
11­ d. Insecurity S. Teach someone else in the class who does not know
2. Using the exercises developed for the first question, how to tie a necktie how to do this without looking at
modify each exercise to be performed throughout each other and without using the words yes or 110.
the da)" incorporating the exercises into the patient's
c1ailv routine.
46 Therapeutic Exercise: Moving Toward Function

REFERENCES 13. Bandura A, Adams ~E, Beyer J. Cognitive processes mediat­

ing behavioral change. J Personality Social Psychol 1977;35:
1. Cuide to physical therapist practice. 2nd ed. Phys Ther 2001; 14. Nolan RP. How can we help patie nts initiate change? Can J
81(1):Sl-S738. CardioI1995;1l(Suppl A):16A-19A.
2. Chase L, Elkins JA, Readinger J, et al. Perceptions of physi­ 15. Brus HL, van de Laar MA, Taai E, et. al. Effects of patient ed­
cal therapists toward patient education. Phys Ther 1993;73: ucation on compliance with basic treatment regimens and
787-796. health in rece nt onset active rheumatoid arthritis. Ann Rheum
3. Calumer JE , Domholdt E. Amount of patient education in Dis 1998;57:146-151.
physical therapy practice and perceived effects. Phys Ther 16. Fields J, Murphey M, Horodyski MB , et al. Factors associated
1996; 76: 1089-1096. with adherence to spo rt injury rehabilitation in college-age
4. Holmes CF, Fletcher JP, Blaschak MJ , et al. Management of recreational athletes. J Sport Rehab 1995;9: 172-180.
shoulder dysfunc tion. J Orthop Sports Phys Ther 1997;26: 17. Gieck J. PsycholOgical considerations for rehabilitation. In:
347- 354. Prentice W, ed. Rehabilitation Techniques in Sports
5. Cameron C. Patifmt compli ance: recognition of factors in­ Medici ne. 2nd Ed. St. Louis: Mosby-Year Book, 1994.
volved and suggestions for promoting compliance with thera­ 18. Schwenk TL, Whitman N. The Physician as Teacher. Balti­
peutic regim e ns. J Adv Nurs 1996;24:244-250. more: Williams & Wilkins, 1987.
6. Sluijs EM , Kok GJ, van der Zee J. Correlates of exercise com­ 19. Brophy J. Research on the self-fulfilling prophecy and teacher
pliance in physical therapy. Phys Ther 1993;73:771-787. expectations JEd PsychoI1983;75:631-661.
7. Marcus BH, Simkin LR. The stages of exercise behavior. J 20. Fisher A. Adherence to sports injury rehabilitation pro­
Sports Med Phys Fitness 1993;33:83-88. grammes. Sports Med 1990;9: 151-158.
8. Chen CY, Neufeld PS, Feely CA, et al. Factors influencing 21. Hom T. Expectancy effects in the interscholastic athletic set­
compliance with home exercise programs among patients ting: methodolOgical concerns. J Sport PsychoI1984;6:60-76.
\vith upper-extremity impairme nt. Am J Occup Ther 1999; 22. Wilder KC. Clinician's expectations and their impact on an
.53:171-180. athlete's compliance in rehabilitation. J Sport Rehab 1994;3:
9. Elder JP, Ayala GX, Harris S. Theories and intervention ap­ 168--175.
proaches to health-behavior change in primary care. Am J 23. Spector RE. Cultural Diversity in Health and Illness. Upper
Preven ivied 1999;17:275-284. Saddle River, NJ: Pren tice-Hall , Inc. , 2000.
10. Marcus BH, Simkin LR. The transtheoretical model: applica­ 24. Friedrich M, Cermak T , \1aderbacher P. The effec t of
tions to exercise behavior. Med Sci Sports Exerc 1994;26: brochure use versus therapist teaching on patients perrorm­
1400-1404. ing th erapeutic exercise and on changes in impairme nt status.
11. Prochaska JO. Strong and weak prinCiples for progressing Phys Ther 1996;76:1082-1088.
from precontemplation to action on the basis of tvvelve prob­ 25. Becker MH, Green LW. A family approach to compliance
lem behaviors. Health PsychoI1994;13:47-51. \,vith medical treatment: a selective re\1eW of the literature. Int
12. Peterson TR, Aldana SG. Improving exercise behavior: an ap­ J Health Educ 1975;18:173-182.
plication of the stages of change model in a worksite setting. 26. Curwin S, Stanish WO. Tendinitis: Its Etiology and Treat­
Am J Health Promotion 1999;13:229-232. ment. Lexington , MA: DC Heath , 1984.
chapter 4

Prevention and the Promotion of Health,

Wellness, and Fitness

Physical therapist efforts in health and wellness promo­

The Context for Primary Prevention tion require an expanded view of health beyond the
biomedical or disablement models. Additionally, it is im­
Measurement of Wellness
portant to recognize that clients may not be motivated to
Health Promotion and Wellness-Based Practices participate in health-causing behaviors until they become
From Illness to Wellness symptomatic or ilL The purpose of this chapter is to explore
The Use of Screening as an Examination Tool Within a Well­ the concepts of prevention, health promotion, and wellness.
Because the remainder of this book discusses interventions
ness-Based Practice
aimed at injured or ill patients, this chapter will focus on pri­
Starting a Wellness-Based Practice
Tnan} prevention and the services that physical therapists
can provide to clients before they become patients.

The function of protecting and developing health must rank THE CONTEXT FOR PRIMARY
even above that of restoring it when it is impaired.-­
Hippocrates PREVENTION
Numerous physical therapy profeSSional references sup­
Interventions aimed at preventing injury and illness are port a role in health promotion and wellness. The Guide to
among the many tools physical therapists use on a daily ba­ Physical Therapist Practice, which defines the physical
sis to address the health needs of the patients we serve. In­ therapy scope of practice, discusses the physical therapist's
deed, prevention, health promotion, and wellness efforts role in prevention and the promotion of health, wellness,
have recently garnered increased attention as the nation and fitness. 4 The American Physical Therapy Association's
struggles to control escalating health care costs and to stop vision statement, goals, and objectives and several policy
the progression of chronic diseases that have reached epi­ statements reference the role of the physical therapist in
demic proportions. 1,2 It has been estimated that 50% of the provision of health and wellness services. 5 Numerous
premature deaths in the United States are related to mod­ state licensing acts include within the definition of physical
ifiable lifestyle factors,3 so there is clearly a need for effec­ therapy a reference to promoting and maintaining fitness,
tive prevention programs and efforts aimed at reducing risk health, or wellness in all age groupS.6 The accreditation cri­
factors and improving health and wellness. teria for physical therapy educational programs state that
Traditionally the physical therapist's role in prevention graduates of accredited programs are prepared to identify
and wellness has been narrowly focused on preventing a re­ and assess health needs and provide approflriate preven­
currence of the injury or illness a patient already has experi­ tion and well ness information and programs. 7
enced, or identifYing risk factors and preventing escalation Thus the expectation that physical therapists participate
into disease. For example, when treating a patient recover­ actively in health and wellness practice exists in many pro­
ing from an ankle sprain, some rehabilitation activities are di­ fessional documents. To provide such services, the physical
rected toward preventing a recurrence of that injury. The therapist must first understand and differentiate the many
approach may include direct interventions such as balance terms used to describe these concepts.
exercises or indirect interventions such as patient education.
ome physical therapists perform biomechanical analyses
such as running gait analysis or ergonomiC workstation anal­
ysis to identify risk factors predisposing clients to injury. Al­ Prevention, Health Promotion, and Health
though appropriate and worthwhile, these efforts do not Education
produce the signuicant outcomes that primary prevention There are many terms used ""fjthin the context of "preven­
programs might, because they are applied after the onset of tion" within the US health care system. Differentiating
li sk, illness, or injury. Contemporary physical therapist prac­ these terms proVides a valuable perspective for the delivery
tice includes a role for the physical therapist in primary pre­ of appropriate sef\fjces by physical therapists. Figure 4-1 il­
\'ention-that is, interacting with clients to promote health lustrates the prevention to intervention continuum, rang­
and improve wellness before they become patients. ing from health promotion services to rehabilitation. The

48 Therapeutic Exercise Moving Toward Function

Prepathogenesls Period Period of Pathogenesis

Health Health Preventive Early Disability Rehabilitation

Promotion Protection Health Diagnosis Limitation
Services and

Primary Prevention Secondary Prevention Tertiary FIGURE 4·1. Differentiation of primary, sec­
ondary, and tertiary prevention.

associated pathologic state of the patienUclient at each nutrition and hormone status are addressed , 'vvhich will re­
stage of prevention is shown across the top of the diagram . inforce the need to partake in physical activity, as well as
Prevention is divided into primary and secondary preven­ provide valuable information about other useful interven­
tion services. Also referred to as public health, primary tions. The word combination also suggests that interven­
prevention includes health promotion, health protection, tions should be matched to specific behaviors. In the case
and preventive health services . Primary prevention takes of the osteoporosis program , interventions should be
place in the "prepathogenesis" period before the onset of planned to increase the quantity of weight bearing activity
disease. Secondary prevention services take place after the participants experience.
the onset of illness or injury, in the presence of pathology, Education within the definition of health promotion
and include screening for the purpose of early diagnosis refers to health education, which is "any combination of
and treatment of disease , as well as disability limitation. learning experiences designed _to facilitate voluntary ac­
Secondary prevention includes efforts to ide~tify disease tions conducive to health. " 9 (p l /) Health education activi­
early hy recognizing either the physiologic changes that ties are planned out, rather than incidental experiences
precede illness or signs of subclinical illness. Examples in­ (e.g., designed) and facilitate behavior change without co­
clude breast and prostate cancer screening, osteoporosis ercion (e.g., voluntmy). Examples of health education ini­
screening, medical preplacement evaluations, and accident tiatives include counseling a patient on the risks of smok­
reportingt-l Also included within secondalY prevention are ing, providing an osteoporosis prevention class for a
efforts to limit disability for those with chronic diseases corporate wellness program, and teaching children how to
such as diabetes (i.e ., a foot care educational program) or carry and load their backpacks safely.
spinal cord injury (i.e., a program to prevent skin break­ The word "environmental" in the definition is meant to
down ). Tertiary care, or rehabilitation , is the category encompass the myriad of social forces th at influence
that encompasses most of traditional physical therapist ser­ health, including social, political , economic, organizational,
vices. Although the physical therapist may use health edu­ policy, and regulatory issues 9 It is critical to recognize that
cation methods to provide information in the case of a sec­ health promotion is broad and includes both individual and
ondary prevention effort, the health status of the social/regulatory activities. For example, a physical thera­
patienUclient dete rmines whether this information falls pist working for a large manufacturing company may want
under primary, secondary, or teliiary care. For example, to begin a smoking cessation program to improve overall
providing information about how to be physically active for worker health. However, if the employer does not have a
a client without injury or illness might be classified as pri­ nonsmoking policy, efforts to stop smoking at the individ­
mary prevention, whereas providing the same information uallevel will most likely be ineffective. Other illustrations
to a client with diabetes would be considered secondary of the broad net of health promotion include programs to
prevention , and including physical activity in an interven­ increase the activity levels of youths or the elderly, corpo­
tion plan for a diabetic client who is receiving rehabilitation rate policies that provide release time to exercise , and
for an amputation would be considered tertiary care. funding to support or build public parks and trails.
In terms of primary prevention, health promotion is the Based on these definitions , it is apparent that the term
most significant component for the physical therapist to health education falls under the umbrella of health promo­
understand. Health promotion can been defined as a tion, and often the activities that would define each are
combination of educational and environmental programs overlapping 9 More recently, it has been suggC'sted that the
or actions that are conducive to health. 9(p. 17)Three terms in terms health prol1wtion and health education are not sig­
this definition are worth exploring to understand the con­ nificantly different, and , in fact , are often used inter­
cept. They are: combination, educational, and endronmen­ changeably.9 The bottom line is that both health promotion
tal. The term "combination" suggests that a variety ofleam­ and health education refer to the "broad and varied set of
ing experiences are necessary to influence behavior strategies to influence both individuals and their social en­
change. It is rare that a Single intervention can make a pro­ vironments, to improve health behavior, and to enhance
found change. For example, in instituting an osteoporosis health and quality of life." IO(plO)
prevention program, it would be appropriate for the physi­ The terms health promotion or health education are the
cal therapist to consider factors beyond the exercise pro­ most relevant aspects of primary prevention for the physi­
gram. Other health care providers on the program team cal therapist. Health protection refers to strategies deal­
might be enlisted to ensure that important factors such as ing with engineering the physical environment such as wa­
Chapter 4 Prevention and the Promotion of Health, Wellness, and Fitness 49

te r fluoridation, whereas preventive health services

refers to traditional medical system efforts to prevent in­
jury and illness-for example, immunizations.

WeI/ness and Lifestyle

Wellness is defined in the Guide to Physical Therapist
Practice, 2nd edition, as "concepts that embrace positive
health behaviors and promote a state of physical and men­
tal balance and fitness."4 Since H.L. Dunn conceptualized
wellness in 1961 and offered the first formal definition of
the term ("an integrated method of functioning which is
riented toward maximizing the potential of w\~ich the in­
dividual is capable."ll(p.j)), wellness has been explained by
n l.rious models and approaches l2 - W Although the litera­
tu re is full of definitions of, references to, and information
about wellness, a universally accepted definition has failed
to emerge. Several conclusions can be drawn, however,
from the abundance of literature about wellness.
For many people, including the public, health and well­
ness are synonymous with physical health or well-being, and
commonly consists of physical activity, efforts to eat nutri­
tiously, and adequate sleep, Research has indicated that FIGURE 4-2. The Wellness Model.
when the publlic is asked to rate their general health, they
nan owly focus on their physical health status, and do not The second characteristic of wellness is that it has a salu­
consider their emotional, social, or spiritual health. 20 R'fer­ togenic fo cus in contrast to a pathogeniC focus in an illness
ring back to the definitions introduced earlier, it is obvious mode1. 24 E mphasizing that which causes health is consis­
that wellness includes more than just physical parameters. tent with Dunn's original dellnition.! l It suggests that well­
The common themes that emerge from the various ness involves maximizing an individual's potential, not just
models and definitions of wellness suggest that wellness is preventing an injury or maintaining the status quo. Well­
multidimensional, 1113- 19,21 .22 salutogenic or health caus­
ness involves choices and behaviors that emphaSize optimal
ina 11,13,16,17,19,23,24 and consistent with a systems view of
health and well-being beyond the status quo.
peb;sons and their environments. 11,25-27 Each of these char­ Third, wellness approaches me a systems perspective, In
acteristics will be explored, systems theory each element of a system is independent and
First, as a multidimensional concept, wellness is more contains its own subelements, in addition to being a subele­
than simply physical health . Among the dimensions in­ ment of a larger system. 21,25,2(; Further, the elements in a s,Ys­
cluded in wellness are physical, spiritual, intellectual, psy­ tem are reciprocally interrelated, indicating that a disruptlOn
cholOgiC. social, emotional, occupational, and community ofhomeostasis at any level of the system affects the entire sys­
or environmental, 2.'} Adams et al, 28 proposed six dimensions tem and all of its subelements. 2.S,2fi Therefore, overall well­
of wellness based on the strength and quality of the theo­ ness is a reflection of the state ofbeing within each dimension
retical support in the literature, The six dimensions and and a result of the interaction among and between the di­
their corresponding definitions are shown in Table 4-1. mensions of welJness. Figure 4-2 illustrates a model of well­
ness reflecting this concept. Vertical movement in the model
-~-I --. -
Definitions of,the Dimensions ' occurs between the wellness and mness poles as the magni­
tude of wellness in each dimension changes (see blaek arrow
~ of ;yv~~ness .. _ __ __ _ ____ above), The top of the model represents wellness because it
Phvsica] Positive perceptions and expectancies of
is expanded maXimally, whereas the bottom ofthe model rep­
physical health resents illness.
PsycholOgiC A general perception that one will expelience The size of each dimension (a subelement in systems
positive OutCOlllPS to the events and theory) represents how much wellness an individual pos­
circull1stances of 'life sesses in that dimension. As wellness fluctuates in each di­
ociai The perception that family or friends are mension an erred is aenerated on all of the other dimen­
available in times of need, and the sions (r~ciprocal interrelation), see red arrow above,
perception that one is a valued suppOli According to systems theory, movement in every dimen­
I provider sion influences and is influenced by movement in the other
f E motional The possession of a secure sense of self-identity dimensions. 28 As an example, an individual who experi­
and a positive sense of self-regard
ences a knee injury and undergoes surgery to repair the an­
piritual A positive sense of meaning and purpose in life
Intellectual The perception that one is internally terior cruciate ligament will probably e)<,.-perience at least
energized by the appropliate amount of short-term decreased physical wellness (the size of the
intellectually stimulating activity physical dimension on the diagram will decrease), Applying
systems theory and according to the model, this individual
\ dam s et al., 1997) may also experience a decrease in other dimensions, such

50 Therapeutic Exercise Moving Toward Function
as emotional or social wellness, in the postoperative period comes.28.30.33-35 Perceptual measures can complement the
resulting from the connectedness or interrelatedness of all information prOvided by body-centered measures. 32
of the dime nsions. The overall effect of the changes in Although some perceptual measures assess only Single
these dimensions will be a decrease in overull wellness, system status (e.g., psychologiC well-being, mental well-be­
which anecdotally we know occurs when patients e>..'peri­ ing), numerous multidimensional perceptual measures ex­
ence a physical illness or injury. In other words , they also ist and can serve as wellness measures. Perceptual con­
experience a change in their emotional or social states. Fur­ structs that have been used as wellness measures include
ther applying the model in terms of an intervention plan, general health status,31 subjective well_being,36.37 general
focus on a nonphysical state, such as the emotional or social well_being,38,39 morale,40.4'1 happiness ,42.4:t' life satisfac­
dimension , can positively affect the physical dimension and tion ,44-46 hardiness , 47.4'1 and perceived wellness. 2s , ~9.,)U Ex­
result in improvf'd wdlness during recovery from an injury ample questions from a few of these perceptual tools are
or illness. listed in Table 4-2.
The word lifestyle differs from wellness and thus is also The influence of perceptions on health and well ness has
important to consider, because many Significant causes of been demonstrated repeatedly in a variety of patient/client
disease , such as obeSity and diabetes, involve lifestyle populations and a variety of settings. Mossey and Shapir0 30
choices. 29 The Simplest definition of lifestyle is perhaps demonstrated more than 20 years ago that self-rated health
"the consciously chosen, rersonal behavior of individuals as was the second strongest predictor of mortality in the el­
it may relate to health.,,9(p3) A more complex notion of derly, with age being the strongest predictor. Numerous
lifestyle recognizes that personal behaviors are Significantly other researchers have replicated these findings in other
influ enced by social and cultural circumstances, indicating populations, lending support to the value of perceptions in
that behavioral choices may not be entirely under volitional understanding health and wellness and indicating that how
control. For example, there is a great deal of controversy well you think you are may be more important than how
over tobacco advertising and its influence on celtain popu­ well you actually are. Patient's perceptions are critical in
lations. Consideration, therefore, of an individual's behav­ understanding and explaining quality of life.:32 Health per­
iors related to health and wellness , is most appropriately ceptions prOvide an important link betvveen the biomedical
done \,vithin the context of social and cultural influences , model with its focus on "e tiological agents, pathological
and, more importantly, interventions deSigned to change processes, and biological, phYSiological, and clinical out­
behaviors should recognize the important influence of so­ comes" and the quality of life model, with its focus 011 "di­
ciety and culture. This understanding of lifestyle is congru­ mensions of functioning and overall well-being. ',;)2;p59)
ent "vith defiinitions of wellness, because it acknowledges (Fig. 4-3). Health perceptions "are among the best prediC­
that there are multiple influences on behavior. tors of general medical and mental health services as well
as strong predictors of mortality, even after controlling for
clinical factors. "30..31:p62)
Measurement of Wellness
Physical therapists assess perceptions as a part of the pa­
As a result of the varied way that wellness has been defined tient/client history, as recommended in the Guide to Phys­
and unde rstood, a variety of wellness measures exist. A ical Therapist Practice. 4 Some of the kinds of perceptions
good well ness measure should reflect the multidimension­ that can be assessed include perceptions of general health
edity and systems orientation of the concept and have a status, social support systems, role and social functioning,
salutogenic focus. In the literature and in daily practice, and functional status in self-care and home management
clinical, phYSiologiC, behavioral, and perceptual indicators activities, and work, community, and leisure activities. Al­
are all touted as wellness measures. Clinical measures in­ though a few of these categories are included in overall
clude blood lipid levels and blood pressure; physiologic in­ wellness, such as general health status and social and role
dicators include skin fold measurements and maximum oxy­ functioning, measuring wellness perceptions speCifically
gen uptake; behavioral measures include smoking status can proVide additional and more complete information
and physical activity frequency; perceptual measures in­ about the patient that the physical therapist can use to for­
clude patient/client self-assessment tools such as global in­ mulate a plan and that can be insightful to the
dicators of health status ("Compared to other people your patient/client. Therefore, perceptual tools should be in­
age, would you say your health is excellellt, good, fair, or cluded when measuring weliness for primary prevention
poor,?,,)30 and the SF-.36 Health Status Questionnaire. 31 and when examining patients/clients for secondary or ter­
Although clinical, phYSiologiC, and behavioral variables tiary prevention.
are useful indicators of bodily wellness and are commonly
used to plan individual and commuHity interventiOns, they
are incomplete measures of wellness.:1':2 Clinical and physi­
ologiC measures assess the status of a single system, most HEALTH PROMOTION AND WELLNESS­
commonly within the physical domain of wellness. Overall, BASED PRACTICES
behavioral measures are a better reflection of multiple sys­
tems due to the influence of motivation and self-efficacy on Establishing a wellness-based practice or offering health
th e adoption of behaviors, but they do not describe the promotion and wellness services requires that the physical
wellness of the mind. On the other hand, perceptual mea­ therapist or prOvider modify the traditional approach used
sures are capable of assessing all systems and have been to treat patients. Creating a successful weliness-based prac­
shown to predict effectively a variety of health out­ tice involves changing the focus from illness to weliness ,
Chapter 4 Prevention and the Promotion of Health, Wellness , and Fitness 51

Sample Items from Perceptual Measurement Tools


SF_363 l General health perceptions "In general , would you say your health is:" (excellent, very
good , good, fair, or poor)
"Compared to one year ago, how would you rate your health in
general now?" (much better than one year ago, somewhat
better, about the same, somewhat worse, much 1I"0rse)
Satisfaction with Life Scale 44 Life satisfaction "In most ways my life is close to my ideal"
"I am satisfied \\lth my Life" (7-point Likert scale from stroll gly
disagree [lJ to strongly agree [7])
Perceived Well ness Surver8 Perceived well ness "I am always optimistic about my future"
"I avoid activities that require me to cuncentrate"
(6-point Likert scale from very strongly disagree [1] to vely
strongly agree [6])
NCHS General Well-Being General well-being "How have you been feeling in genera r~" (In excellent spirits ,
Schedule39 In very good spirits , In good spirits rnostly, I have been up
and down in spirits a lot , In low spirits mostly, In ve ry
low spirits )
"H as your daily life been full of things that were interesting to
you?" (All the time, Most of the time, A good bit of the time,
Some of the time, A little of the time, None of the time )
Philadelphia Geriatric Center Morale "Things keep getting worse as I get older"
Morale Scale 40 "I am as happy now as \vhen I was younger"
(yes, no)
Memorial University of Happiness "In the past months have you been feeling on top of the
Newfoundland Scale world?"
of Happiness 43 "As I look back on my life, I am fairly well satisfied" (yes, no,
don't know)

Characteristics of the
Individual ~
Symptom L-- - - -- - - - - - - ' \ Values
1 /
AmPlif/ication Personality p\references ~

Biological and
Symptom Functional
\' Physiologic
- - Health
- Quality of
Status Status
n Variables
Perceptions Life

e \ t !/

Social and
Supports p ppo,,
Social and

Characteristics of Nonmedical
the Environment Factors
FIGURE 4·3. Health-related Quality of Life Conceptual Model.


52 Therapeutic Exercise Moving Toward Function

being a role model of well'ness, incorporating wellness which the client feels empo\Vered to take control. Rath er
measures into th e examination , considering the client than "making" the client well , the provider can view the
within his or her system, and offering services beyond the client as a whole person within a biopsychosocial context
traditional patient-pro\iiuer relationship. and consider teaching the client how to achieve wellness.
Being a role model and fulfilling the role of facilitator will
establish a relationship and environment in which clients
From Illness to Wellness can attain greater wellness.
The types of services provided in a physical therapist well­
ness-based practice can be varied and are influenced by The Use of Screening as an Examination
the population served, the skills and eJ..'Pertise of the phys­ Tool within a Wellness-Based Practice
ical therapist, and the setting in which the services are
provided. Based on the definition and characteristics of The Guide to Physical Therapist Practice defines screening
wellness provided earlier in this chapter, wellness services as determining the need for further examination or consul­
can be provided in any setting and to any population-it tation by a ph:sical therapist or for referral to another health
just requires changing the approach to consider patients profeSSional. Screening is important and applicable in a
as clients who have the potential and opportunity to be health promotion context because it enables identification
more well. of the health status, personal goals, and available resources
The most common weJJness-based practices are inte­ of the client. Within a physical therapist's scope of practice
grated within a tradition al physical tl1erapy setting in which and a health promotion/wellness context, clients can be
patients convert to "members" after uischarge from physi­ screened in numerous ways. Wellness programs routinely
cal therapy services for a specific diagnosis. These pa­ screen for osteoporosis, physical activity level, balance/risk
tients/clients use the clinic or fitness faCility to continue for fall s, muscle strength and endurance, flexibility, per­
their exercise program. In this case, the client would have ceived wellness and quality of life, and motivation to change
access to the faCility to perform an individually or group health-related behaviors or adopt new behaviors. A number
prescribed exercise program and to the physical therapist of tools have been developed and are available in the litera­
who would be available to answer questions and progress ture for use in scree ning clients. Example perceptual
the client's program. Additionally, to truly address "weJJ­ screening tools that can be used in a wellness or primary
ness ," the prOvider must consider offering services beyond prevention context and tlleir uses are listed in Table 4-3.
only the physical domain. Screening tools can be used to identify whether or not a
Establishing a well ness-based practice within an exist­ client has risks that should be investigated before partici­
ing physical therapy setting requires several features. p ating in an intervention program. The physical therapist
The facilitv should be available and staffed at convenie1lt can also use the screening information to identify who
hours for '~lie nts and the staff should have expertise in should perform further examination and intervention, and
exercise prescription as well as awareness and knowl­ the conditions under which the intervention should be per­
dge of wellness. For exa mple, opportunities can be cre­ form ed (e.g., with or without supervision, the need for a
ated to acknowledge the influence of social connections medical diagnostic test). Screening tools can also identify a
on wellness by offering group classes and group interac­ baseline from which progress can be assessed and docu­
tion among clients. The intenectual aspect of wellness mented. Depending on specific state law, screens may be
can be tapped by providing educational resources and performed on existing clients or can be used to identify
challenges for clients. For example, offering an educa­ those who would benefit from services.
tional class on topics such as progressing an exercise pro­
gwm or nutrition, then testing understanding of an ex­ Starting a Wellness-Based Practice
ercise prescription or the content of a class are activities
that would use and challenge the intellectual dimension. The mechanics of starting a specific wellness-based prac­
Additional staff with expertise in mental and spiritual tice do not differ from starting or e}..'Panding any type of
health can be retained as consultants to provide services practice. The first step should include verifying that "well­
in th ese uilllensions when indicated or requested by ness" or "health promotion " is included within the defini­
clients. Some facilities provide an integrated experience, tion and description of pbysical therapy in the state prac­
vvith mental and spiritual health as a component of the tice act. Second, the liability pohcy should be checked to
wellness program. ensure coverage for wellness type activities. As with any
E stablishing a well ness-based practice also requires new endeavor, physical th erapists should spend time iden­
that the prOVi de r assume the role of a facilitator or part­ tifyi ng and understanding the potential risks involved in the
ner rather than that of an authority figure. 51 'When a pa­ provision of wellness services.
tient is ill it is often appropriate for the health care Although great strides have been made in the area of in­
prOvider to act as the exp ert because the patient has lim­ surance coverage for health promotion and wellness ser­
ited ability to prOVide self-care and is relying on the vices, most in surers do not reimburse health care providers
provider for information and sblls to recover and im­ for these services. However, the public understands the
prove. In a wellness setting the best approach ]S to believe value of these services and is becoming more and more
that the client knows best i.n terms of maximizing his or willing to pay directly for them. 52 In the case of populatiOns
her potential; therefore, assuming a partner or facilitator that are unable to afford these types of services, consider
role is more appropriate and will create a relationship in prOViding more affordable group and community pro­
Chapter 4: Prevention and the Promotion of Health, Wellness, and Fitness 53

~ _ Perc,eptual Screening Tools


Physical Activity Readiness General activity screen Canadian Society for Indicates whether or not an individual
Questionnaire for ages 15-69 Exercise Physiology should seek further medical consultation
(PAR-Q) before beginning an aerobic exercise
Self-efficacy for Assesses the beliefs Marcus, Selby, Niaura, Provides the physical therapist ~tith
Exercise one has regarding et al. (1992) 53 information about perceptions of success
Questionnaire success with with physical acti\tity, which can be a
phySical activity barlier to adopting an activity habit if
not addressed.
Physical Activity Assesses how Kendzierski , Provides information about how enjoyable a
Enjoyment Scale enjoyable a client DeCarlo (199 1) 54 cl.ient finds exercise, Researchers have
(PACES ) finds exercise found that enjoyment is related to
adherence to physical activity, so when
enjoyment is low it should be addresse d in
the exercise prescription.
Motivational Readiness Assesses a client's Marcus , Simkim Provides information from which the physical
for Change Scale readiness to (1993)55; Prochaska, therapist can tailor the intervention for a
(Trans theoretical change for any DiClemente (19S3) 56 speCific behavior. For example, if a client is
Model) behavior (exercise, not ready to change, the intervention ,viII
smoking, etc.) be very different compared to a client who
is ready to make a change.
Short Form 36 (SF -36) General perceptual Medical Outcomes Trust Provides information about perceptions
health status and in e ight health concepts, including physical
outcomes functioning, role limitations resulting from
q uestionnai re physical health problems , bodily pain,
social functioning, g('neraimentalll('al th,
role limitations resulting from emotional
problelll s, vitality (c nC'f)"''Y/fatigue), and
generall1('alth perc('ptions . Can be used to
determine the relative burden of an injury
or illness and to document the relative
benefits/outcomes of an intervention or
interven tions.
Perceived'Vellness General perceptual Adams, Bezner, Provid('s information about general well ness
Survey (P'VS) well ness survey Steinhardt (1997) 28 perceptions ill six diml'nsions , including
phYSical, emotional, social , psycholOgiC,
spilitual , and intellectual. Can be used to
determine the relative burden of all injury
or illness and to docume nt the effect of an
intervention on overal l we llness.
Risk for falls Assesses a client's Balance Self-Test Indicates an individual's lisk for falling and
risk for falling www.balanceandmobility. thus the need for further examination
com/patienUnfo/ and intervention.
Computer Workstation Identi fies clients at Ww\v.os LTC/etools/ Identifies speCific areas "'tithin a computer
Checklist risk for injury as com pu terworksta tions/ works tati on wlwre problems may exist that
a result of checklist .htm l wou ld benefit the worker to be addn:ssed.
computer use Includes the areas of posture. seating,
keyboarcl!input devi(;(" mon itor, work area,
accessories, and general issues.

!rrams, applying for state and federal grants to support pro­ stalting a speCific wellness-based practice or program or
grams, or providing pro bono services that offer recognition are adopting a wellness approach within an existing health
through positive public relations. care setting, shifting from a medical to a biopsychosocial fo­
Other activities that should be well thought out and cus, recognizing that, as impOltant as they may be, there is
planned include marketing and advertising the program more to wellness than physical parameters, and adding the
and evaluating program success. Although speCifics of assessment of perceptions to your examination toolbox are
rhese activities are outside the scope of this chapter, they both approaches that will provide a strong basis for a well­
Me key to overall program effectiveness. Whether you are ness program.
54 Therapeutic Exercise: Moving Toward Function

rated health status. Am T Health Promotion 1998;12:

KEY POINTS 275--282. .
21. Nicholas DR, Gobble DC, Crose RG, et al. A systems view of
• Prevention is classified as primary, secondary, or tertiary health, wellness and gender: implications for mental health
• Health promotion and wellness fall into the realm of pri­ counseling. J Ment Health Counsel 1992;l4:8- 19.
malY prevention, whereas most rehabilitation is sec­ 22. Whitmer JM , Sweeney TJ. A holistic model for wellness pre­
ondary or tertiary prevention vention over the life span. J Counsel Develop 1992;71:
• The terms health promotion and health education are 140-148.
often used interchangeably 23. World Health Organi za tion. Basic Documents. 15th Ed.
• Well ness is multidimensional, salutogenic, and requires Geneva, Switzerland: WHO , 1964.
a systems perspective 24. Antonovsky A. Unraveling the Mystery of Health: How Peo­
ple Manage Stress and Stay Well. San Francisco: Jossey-Bass,
• \Vellness extends beyond only the physical domain to in­
clude many other dimensions such as spiritual, intellec­ 25. Jasnoski ML, Schwartz GE. A s)~lchronous systems model for
tual, psychosocial, and emotional health. Am Behav Scientist 1985;28:468-485.
• Perceptual measures are often better predictors of gen­ 26. Seeman J. Toward a model of positive health. Am Psychol
eral well-being than physiolOgiC measures 1989;44:1099-1109.
• Wellness requires a vision beyond just the physical do­ 27. Crose R, Nicholas DR , Gobble DC, et al. Gender and well­
main and the biomedical model ness: a multidimensional systems model for counseling. J
Counsel Develop 1992;71:149-156.
28. Adams T, Bezner J, Steinhardt M. The conceptualization and
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20. Ratner PA , Johnson, JL, Jeffery B. Examining emotional, 44. Diener E , Emmons R, Larsen R, et al. The satisfaction with
physical, social, and spiritual health as determinants of self- life scale. JPers Assess 1984:49:71-75.
Chapter 4 Prevent'ion and the Promotion of Health, Wellness, and Fitness 55

4.5. Neugarten B, Ha\ighurst R, Tobin S. The measurement of 51. Ferguson T. "Vorking \\ith your doctor. In: Coleman D,
life satisfaction. J CerontoI1961;16:134--143. Curin J, eds. Mind Body Medicine. New York: Consumer
46. "Tood V, Wylie M, Sheafor B. An analysis of a short self-re­ Reports Books, 1993.
port measure of life satisfaction: correlation with rater judg­ 52. Eisenberg DM, Da\is RB, Ettner SL, et al. Trends in alter­
ments. J CerontoI1969;24:465-469. native medicine use in the United States, 1990-1997. JAMA
47. Kobasa S. Stressfuil life events, personality, and health: an in­ 1998;280:1.569-157.5.
quiry into hardiness. J Pers Soc 1'sychoI1979;.'37:1-11. 53. Marcus BH, Selby VC, Niaura RS, et al. Self-efficacy and the
48. Williams P, Wiebe D, Smith T. Coping processes as media­ stages of exercise behavior change. Res Q Exerc Sport
tors of the relationship benveen hardiness and health. J Be­ 1992;63:60-66.
hav .\ied 1992;15:237-255. 54. Kendzierski D, DeCarlo KJ. Physical activity enjoyment
49. Adams TB, Bezner JR, Drabbs ME, et a1. Conceptualization scale: two validation studies. J Sport Exerc Psychol 1991;
and measurement of the spiritual and psychological dimen­ 13:50-64.
sions of wellness in a college population. J Am Coli Health 55. Marcus BH, Simkim LR. The stages of exercise behavior. J
2000;48:165-173. Sports Med Physical Fitness 1993;33:83-88.
50. Bezner JR, Hunter DL. Wellness perceptions in persons \\ith 56. Prochaska JO, DiClemente CC. The stages and processes of
traumatic brain injury and its relation to functional indepen­ self-change in smoking: towards an integrative model of
dence. Arch Phys Med RehabiI2001;82:787-792. change. J Consult Clin PsychoI1983;5l:390-395.

un it 2
_ _ _ _ _ _ _ _ _ _ _ _ _ _~~~~~~~----~~
- , - _ ._I

FunctionaIApproach \~t() ']h.e~ape, utic{ Exercise.fcfr,,: ~ :' (

Physiologic Impai~ments ~ I'i>-t
-' .-~~'

chapter 5

Impairment in Muscle Performance


Definitions Examination and Evaluation of Muscle Performance

Therapeutic Exercise Intervention for Impaired Muscle
Power and Work
Activities to Increase Muscle Performance
Muscle Actions
Morphology and Physiology of Muscle Performance Dosage for Strength Training
Gross Structure of Skeletal Muscle Dosage for Power Training
Ultrastructure of Skeletal Muscle Dosage for Endurance Training
Chemical and Mechanical Events During Contraction and Re­ Dosage for Training the Advanced or Elite Athlete
laxation Precautions and Contraindications
Muscle Fiber Type
Motor Unit
Force Gradation Physiologic, anatomic, psychologic, and biomechanical
Factors Affecting Muscle Performance factors affect muscle performance. Pathology/pathophysi­
Fiber Type
ology and disease affecting the cardiovascular, en­
docrine/metabolic, integumentary, musculoskeletal, neu­
Fiber Diameter

romuscular, or pulmonalY systems can also affect muscle

Muscle Size

performance. Muscle performance impairment can be fur­

Force-velocity Relationship
ther classified by impairments in strength, power, or en­
Length-tension Relationship
durance. These impairments must be related to a func­
Muscle Architecture
tional limitation or disability, or promote prevention,
Training Specificity
health, wellness, and fitness , to justify therapeutic exercise
Neurologic Adaptation
intervention. For example, an individual lacking the muscle
Muscle Fatigue
performance to carry a bag of groceries into the house re­
Lifespan Considerations
quires intervention to achieve this instrumental activity of
Cognitive Aspects of Performance
daily living. A worker lacking the muscle performance to
Effects of Alcohol
maintain efficient posture and safe movem ent patterns
throughout the workday requires intervention to prevent
Effects of Corticosteroids

work disability.
Causes of Decreased Muscle Performance Although not all scientific and clinical information on
Neurologic Pathology
streIlgth, power, and endurance production can be cov­
Muscle Strain
ered in this text, this chapter provides a strong foundation
Disuse and Deconditioning
for this element of therapeutic exercise intervention. Fun­
Length-associated Changes
damental terms and concepts are defined, the essential
morphology and physiology of skeletal muscle relative to
Physiologic Adaptations to Training muscle performance are reviewed, and clinical applica­
Strength and Power
tions are presented.


58 Therapeutic Exercise: Moving Toward Function

DEFINITIONS Power and Work

Power is the rate of performing work. Work is the magni­
Strength tude of a force acting on an object multiplied by the dis­
Impaired muscle performance is commonly treated by tance through which the force acts. The unit used to de­
clinicians and is usually described as a strength deficit. scribe work is the joule, which is equivalent to 1
However, strength is only one of three components of newton-meter (the foot-pound unit is used in the British
muscle performance (i.e., strength , power, and en­ system ). Work is algebraically expressed in this equation:
durance ). Strength is defined as the maximum force that a work = force x distance
muscle can develop during a Single contraction, and is the
result of complex interactions of neurologic , muscular, The unit of power in the metric system is the watt, which
biomechanical, and cognitive syste ms. Strength can be as­ is equal to 1 joule/second (foot-pound/second in the British
sessed in terms of force , torque , work, and power. If ap­ system ). Power can be determined for a Single body move­
propriate decisions are to be made regarding these impair­ ment, a series of movements , or for a large number of
ments , operational definitions are necessary. repetitive movements, as in the case of aerobic exercise.
Force is an agent that produces or tends to produce a Power is algebraically expressed as:
change in the state of rest or motion of an object. I For ex­
ample, a ball sitting stationary on a playing field remains in power = ,,,ork / time
that position unless it is acted on by a force . Force, de­ For the simple movement of lifting or lowering a weight,
scribed in metric units of newtons or British units of the muscle must overcome the weight of the limb and the
pounds, is displayed algebraically in the follOwing equation: weight (force ), acting some distance from the axis of rota­
force = mass x acceleration tion (torque) through a range of motion (work) during a
speCific time frame (power). This example summarizes the
Kinetics is the study of forces applied to the body. practical aspects of force, torque, work, and power in resis­
Some of the factors influencing muscular force production tance training.
include the neural input, mechanical arrangement of the
muscle , cross-sectional area, fiber-type composition, age,
and gender. I Endurance
All human motion involves rotation of body segments Endurance is the ability of muscle to sustain forces re­
about their joint axes. These actions are produced by the peatedly or to generate forces over a certain period. It is of­
interaction of forces from external loads and muscle activ­ ten measured as the ratio of the peak force that can be gen­
ity. The ability of a force to produce rotation is torque. erated by a muscle at a given point in time, relative to the
Torque represents the rotational effect of a force with re­ peak force that was possible during a Single maximum con­
spect to an axis: traction. Muscle endurance can be examined by isometric
contractions, repeated dynamiC contractions, or repeated
torque = force x moment arm contractions on an isokinetic dynamometer.
The moment arm is the perpendicular distance from
the line of action of the force to the axis of rotation. The Muscle Actions
metric unit of torque is the newton-meter; the foot-pound
is used in the older British system of units. Poorly defined muscle actions can be a source of confusion
Clinically, the word strength is often used synonymously and inaccuracy. Resistive exercise uses various types of
with torque. Large amounts of torque are produced by the muscle contraction to improve impaired muscle perfor­
musculoskeletal system during everyday functional activi­ mance. Muscle actions can be divided into two general cat­
ties such as walking, lifting, and getting out of bed. It is in­ egories: static and dynamic. A static muscle action, tradi­
correct to conclude that a person is "strong" only because tionally referred to as isometric, is a contraction in which
his muscles generate large forces. It would be just as erro­ force is developed without any motion about an axis , so no
neous to conclude that a person is strong only because he work is performed.
has large moment arms. All other muscle actions involve move ment and are
Torque can be altered in biomechanics through three called dynamiC or isotonic. An isotonic contraction is a
strategies: uniform force throughout a dynamiC muscle action. No dy­
namic muscle action uses constant force because of
• Changing the force magnitude changes in mechanical advantage and muscle length. Iso­
• Changing the moment arm length tonic is therefore an inappropriate term to describe human
• Changing the angle between the direction of force exercise performance, and the term dynamic is preferred.
and momentum Dynamic muscle action is further described as concen­
In the human musculoskel e tal system , changing the tric or eccentric action . The term concentric describes a
force magnitude (i.e. , tension -producing capability of mus­ shortening muscle contraction, and the term eccentric de­
cle) can be altered by training, the moment arm can be de­ scribes a lengthening muscle contraction. Eccentric con­
creased by positioning a load closer to the body, and the an­ tractions differ from concentric and isometric contractions
gle between the force and moment arm may be changed by in several important ways. Per contractile unit, more ten­
altering joint alignment through postural education. sion can be generated eccentrically than concentrically and
Chapter 5: Impairment in Muscle Performance 59

at a lower metabolic cost (j.e. , less use of ATP-derived en­ Muscle

ergy).2 Eccentric contractions are an important component
of a functional movement pattern (e.g., required to decel­ A.
erate limbs during movement), are the most energy-enl­
cient form, and can develop the greatest tension of the var­
ious types of muscle actions.
The term isokinetic refers to a concentric or eccentric
muscle contraction in which a constant velocity is main­
tained throughout the muscle action. A person can exert a
continuous force by using an isokinetic device, which pro­
vides a resistive surface that restricts movement to a set, Myofibril
constant velocity Some acceleration and deceleration oc­
curs as the individual accelerates the limb from a resting po­ C.
z = zline
sition to the preset velocity and decelerates the limb to A = A-band
change directions. By constraining the speed of the isoki­ Z I = I-band
netic device, the limb moves at a constant velocity. Because Sarcomere
the device cannot be accelerated beyond the preset speed,
any unbalanced force exelted against it is resisted by an D.
equal and opposite force. This mu scular force may be mea­
sured, displayed, recorded , or used as concurrent visual
feedback. Although the isokinetic device may be moving at
a constant velocity, it does not guarantee that the user's E.
muscle activation is at a constant velocity. Despite this inac­ Thick filament: myosin Thin filament: actin
curacy, the terms isokinetic and isotonic to describe muscle
action are likely to be employed for pragmatic reasons.
Myosin filament ~ ~ ••• ~ Actin filament
During functional movement patterns, combinations of
static and dynamiC contractions occur. Tnmk muscles con­ "e • . • •
tract isometrically to stabilize the spine and pelvis during F .:~:~:~:.
movements of the extremities such as reaching or walking. • ••••••
Lower extremity muscles are subjected to impact forces
requiring combinations of concentric and eccentric con­
• • •
Cross section at level of A-band
tractions, sometimes within the same muscle acting at two FIGURE 5-1. Schematic drawing of the structura lorganization of skeletal
different joints. Muscles commonly perform eccentric con­ muscle. (AI A fibrous connective tissue, epimysium surrounds the muscle,
tractions against gravity, as in slowly lowering the arm from which is composed of manyfascicles. The fa scicles are encased in a dense
an overhead position. connective sheath, the perimysium. (8) The fascicles are composed of
Muscles often act eccentrically and then contract con­ muscle fibers surrounded by capillaries and covered by a loose connective
centrically. The combination of eccentric and concentlic tissue called the endomysium. Each muscle fiber is composed of numerous
actions forms a natural type of mu scle action called a myofibrils (C) Myofibrils consist of sma ller filaments that form a repeat­
stretch-shortening cycle (SSC).3,4 The SSC results in a ing banding pattern along the length of the myofibril One un it of this seri­
final action (i.e., concentric phase) that is more powerful ally repeating pattern is called a sarcomere . (O-FJ The banding pattern of
than a concentJic action alone. This phenomenon is called the sarcomere is formed by the organization of thick and thin filaments,
actin and myosin
elastic potentiation.4 The SSC is discussed in more detail
later in this chapter.
multinucleated muscle fibers lie parallel to one another
and are separated by the innermost layer of connective tis­
MORPHOLOGY AND PHYSIOLOGY OF sue, called the endomysium. As many as 150 fibers are ar­
MUSCLE PERFORMANCE ranged into bundles called fasciculi. Fasciculi are sur­
rounded by perimysium, the next layer of connective
a Improving muscle performance often translates into im­ tissue. The entire muscle is encased by the outermost layer
provements in functioning by the patient. A thorough un­ of connective tissue, the epimYSium. This connective tissue
~f derstanding of muscle morphology and phYSiology is re­ sheath tapers at the ends as it blends into and joins the in­
1­ quired to prescribe an appropriate exercise program that tramuscular tissue sheaths forming the tendons. The ten­
!Il proceeds to the ultimate goal of a functional outcome for dons connect to the outermost covering of the bone, the
~ each patient. periosteum. The force of muscle contraction is transmitted
directly from the muscle's connective tissue to the point of
a Gross Structure of Skeletal Muscle attachment on the bone.
e­ Beneath the endomysium and surrounding each muscle
fl­ Each of more than 430 voluntary muscles in the body con­ fiber is a thin , elastic membrane, called the sarcolemma,
ns sists of various layers of connective tissue. Figure 5-1 illus­ enclOSing the fiber's cellular contents. The aqueous proto­
fl ­ trates a cross-section of a muscle consisting of thousands of plasm or sarcoplasm contains the contractile proteins, en­
~d muscle cells called muscle fibers (Fig. 5-lA-B). These zymes, fat and glycogen particles, the nuclei , and various
60 Therapeutic Exercise: Moving Toward Function

specialized cellular orga ne lles . E mbedded in the sar­ Sarcomere relaxed

coplasm is an extensive network of interconnecting tubular
channels kllown as the sarcoplasmic reticulum. This highly
specialized syste m provides the cell with structurall in­
tegrity and also serves important functions in muscular
Thin filament Thick filament
Ultrastructure of Skeletal Muscle
(actin) J
The ultrastructure of skeletal muscle consists of different
levels of subcellular organization (see F ig. 5-1). Each mus­
cle fiber consists of smail fibers called myofibrils (see Fig. J
5-1C). Myofibrils are composed of even smaller threads Sarcomere contracted
caJled myofilaments (see Fig. 5-1D-F). Th e myofilaments
are composed pri marily of two proteins, actin and myosin.
Six other proteins have been identified that have a struc­
tural or physiologic purpose. The contractile unit of the en­
tire myofibril is known as the sarcomere. FIGURE 5-2. Actin-m yosin relationsh ips in relaxed and contracted position.

The Sarcomere
The sarcomere is the functional unit of the contractile sys­ contraction. Tropomyosin is a long polypeptide chain that
tem in mu scle, and the events that take place in one sar­ lies in the grooves behveen the helices of actin. Troponin is
comere are duplicated in the others. Various sarcomere a globular molecule attached at regular intervals to the
build a myofibril, myofibrils build the muscle fiher, and tropomyosin (Fig. 5-3).
muscle fibers build a muscle. Th e sarcomere is composed
of thin filaments (approximately 5 nm in diameter) formu­ Intracellular Tubule System
lated from the protcin actin and the thick filaments (ap­ The sarcoplasmic reticulum and transverse tu bu le (T ­
proximately 15 11111 in diameter) formulated from the pro­ tubule) system within the muscle fiber can be seen in Fig.
tein myosin. 5-4. The sarcoplasmic reticulum lies parallel to the myofib­
Figure 5-1C illustrates the structural pattern of myofila­ rils , whereas the T-tubule system runs perpendicular to the
mcnts witHn a sarcomere. The lighter area is referred to as myofibril. The lateral end of the sarcoplasmic reticulum
the I band and contain s the portion of the thin filaments terminates in a saclike vesicle that stores calcium . The T­
that do not overlap with the thick filam ents. The darker tubule system appears to function as a micro transportation
zone is known as the A band and is the region where actin network for spreading the action potential (i.e., wave of de­
and myosin overlap . T he Z line bisects the I band and pol arization ) from the fiber's outer membrane inward to
adheres to the sarcolemma to give the entire structure sta­ the deep regions of the cell.
bility. The repeating unit between two Z lines represents
the sarcomere. The actin and myosin filaments within the Chemical and Mechanical Events During
sarcomere arc primarily ]nvoh-ed in the mechanical process
of muscular contraction and therefore in force develop­ Contraction and Relaxation
ment. E ach myosin cross-bridge is an independent force The most widely held theory of muscle contraction is the
gent'rator. sliding filament theory. According to this theory, active
shortening of the sarcomere, and hence of muscle, results
Actin-Myosin Orientation from the relative movement of tlle actin and myosin fila­
Figu re 5-2 illustrates the actin-myosin orientation within a ments past one another whiJe retaining its onginallength .
sarcomere at res ting and contracted lengths. Actin , the Excitation-contraction is th e phYSiologic mechanism
chief component of the th in filament. has the shape of a whereby an electric discharge at the muscle initiates the
double helix and app ears as two strands of beads spiraling chemical events that lead to contraction. Wh en a muscle
around each other. Two additional proteins, troponin and fiber is stimulated to contract there is an immediate in­
tropomyosin, are important ('onstituents of the actin helix crease in tile intracell!ular calcium concentration . Arrival
becaus e they appear to regulate th e making and breaking of tbe action potential at the T-tubules causes calcium to
of contacts between the actin and myosin filaments dUling be released from the lateral sacs of the sarcoplasmic retic-

FIGURE 5·3. The re lationship of actin, troponin, and tropomyos in. Tropomyosin
Chapter 5: Impairment in Muscle Performance 61

Sequence of Events in Muscular Contraction
The following is a list of the main events in muscular
Sarcolemma contra ction and relaxation. The sequence begins with the
initiation of an action potential by the motor nerve. This
impulse is propagated over the entire surface of the muscle
.:...o!It=;r--~_ Sarcoplasmic
fiber as the cell membrane becomes depolarized.
1. Depolarization of the T-tubules causes release of calcium
"-;r,pf---f'+-+ T-tubule from the lateral sacs of the sarcoplasmic reticulum.
2. Calcium binds to the troponin-tropomyosin complex in the
actin filaments, releasing the inhibition that prevented
actin from combining with myosin.
3. Actin combines with myosin-activated myosin ATPase,
which splits ATP. The energy that is created produces
movement ofthe cross-bridge, and tension is created.
4. ATP binds to the myosin cross-bridge, breaking the actin­
myosin bond and allowing the cross-bridge to dissociate
FIGURE 5-4. Relationships of the sarcoplasm ic reticulum, T-tubule sys­ from actin.
tem, and myofibrils. 5. Cross-bridge activation continues as long as the
concentration of calcium remains high enough to inhibit
the action of the troponin-tropomyosin system.
ulum. The inhibitory action of troponin (i.e., preventing 6. When stimulation ceases, calcium moves back into the
actin-myosin interaction) ceases when calcium ions bind lateral sacs of the sarcoplasmic reticulum.
rapidly with troponin in the actin filaments. The globular 7. Removal of calcium restores the inhibitory action of
head of the myosin cross-bridge provides the mechanical troponin-tropomyosin . In the presence of ATP, actin and
myosin remain in the dissociated, relaxed state.
means for the actin and myosin filaments to slide past
each other. During contraction, each cross-bridge under­
goes many repeated but independent cycles of movement.
Thus at any given moment on ly approximately half of the Motor Unit
cross-bridges actively generate force and displacement,
and when these detach, others take up the task so that The motor unit consists of the motor neuron . its axon, and
shortening is maintained. Display 5-1 summarizes the the muscle fibers supplied by the motor neuron . The num­
vents during excitation, contraction, and rela;i:ation of the ber of muscle fibers belonging to a Single motor unit can
muscle. vary from ,5 to 10 to more than 100. As a general rule, small
muscles responsible for precision tasks (e.g., intrinsic hand
Muscle Fiber Type muscles) are composed of motor units supplying few mus­
cle fibers, whereas trunk and proximal limb muscles con­
Skeletal muscle is not a simple homogenous group of fibers tain motor units supplying a large number of muscle fibers.
\vith similar metabolic and functional properties. Distinct . Human motor units with the following characteristics
fiber types have been identified and classified by their con­ tend to be classified as tonic motor units: long contraction
tractile and metabolic characteristics. Slow-twitch fibers, or times , low-twitch tension, high resistance to fatigue, small­
type I fibers, are characterized by slow speed of contraction, amplitude action potentials, and slow conduction velocities.
low activity of myosin ATPase, and glycolytic capacity that Conversely, phasic motor units tend to be recruited at high
is less well developed than that of their fast-twitch counter­ levels of voluntalY contraction, display short contraction
parts. Slow-twitch fibers are well suited for prolonged aer­ times and high-tvvitch tensions, are not fatigue-resistant,
obic exercise. and show large-amplitude action potentials and fast con­
Fast-twitch fibers are divided into fast oxidative­ duction velocities.
glycolytiC. or type IIA, and fast-glycolytic. or type IIB ,
fibers. Generally, fast-twitch fibers have a high activity level
of myosin ATPase associated with their ability to generate Force Gradation
energy rapidly for quick. forceful contractions. Fast oxida­
tive-glycolytic fibers are a hybrid between slow-twitch and Motor units are activated to increase force production or
fas t-glycolytic fibers. These fibers combine the ability to deactivated to decrease force produ ction. Force gradation
produce quick, forceful contractions and sustain them for can be likened to a rheostat, through which more motor
longer than fast -glycolytic fibers (though not as long as slow­ units are brought on line as the need for force increases
twitch fibers ). Compared vvith fast oxidative-glycolytic or taken off line as the need for force decreases. Force
fibers, the fast-glycolytic fibers possess a greater anaerobic increases can occur by increasing the rate of discharge
potential. A third fast-nvitch fiber, type IIC, has been iden­ (j.e., rate coding) or by graded recruitment of higher
tified. The type IIC fiber is normally a rare and undifferen­ threshold motor units (i.e ., size principle)6 Rate coding
tiated fiber that may be involved in reinnervation or motor implies high-frequency discharge when high forces are
W1it transformation. s needed, and low-freq,uency pulses are delivered when low
forces are necessary. I The size prinCiple states that, dur­
62 Therapeutic Exercise Moving Toward Function

ing activation of motor neurons , those with the smallest fibers tend to have smaller diameters than type II (fast)
axons have the lowest thresholds and are reclllited first, fibers, a high percentage of type I fibers is believed to be
followed by larger cells with higher thresholds. associated ,vith a smaller muscle diameter and therefore
In most voluntary everyday contractions, slow (type I) lower force development capabilities. J3
motor units are the first to be reclllited. \"lith increasing
power output, more fast (type II) units are activated.
Trained persons can activate all the motor units in a large
Muscle Size
limb muscle during a static, maximal , voluntary contrac­ When adult muscles are trained at intensities that exceed
tion, whereas this is not possible for untrained persons . The 60% to 70% of their maximum force-generating capacity,
fastest (type lIB ) motor units are preferentially activated in the muscle increases in cross-sectional area and force pro­
fast corrective movements and reflexes. Explosive maximal duction capability. The increase in muscle size may result
contractions are thought to activate fast and slow motor from increases in fiber size (i.e. , hypertrophy), fiber num­
units Simultaneously. ber (i.e., hyperplaSia), interstitial connective tissue, or
Violations of the size prinCiple do occur. Two departures some combination of these factors. 14 . 15
occur through neural adaptations related to the specificity Although the major mechanism for increased muscle
of velocity and movement pattern in strength training. size in adults is hypertrophy, ongoing controversy sur­
High-threshold, fast-twitch motor units are preferentially rounds evidence of hyperplaSia. Mammalian skeletal mus­
activated during brief, r~id concentric actions in which the cle does possess a population of reserve or satellite cells
intent is to relax qUickly. It has also been demonstrated that that, when activated, can replace damaged fibers with new
fast-twitch motor units are preferentially reclllited in ec­ fibers .16 .17 A mechanism exists for the generation of new
centric actions performed at moderate to high velocities. 9 fibers in the adult animal. Scientific models of exercise and
stretch overload have shown Significant increases in fiber
number. 14 The mechanisms for fiber hyperplasia probably
FACTORS AFFECTING MUSCLE are the result of satellite cell proliferation and longitudinal
PERFORMANCE fiber splitting. 14
Despite few investigations of the effect of strength train­
The total force a muscle can produce is influenced by nu­ ing on interstitial connective tissue, it appears that, because
merous factors. When prescribing therapeutic exercise in­ interstitial connective tissue occupies a relatively small pro­
tervention for muscle pelformance, knowledge of princi­ portion of the total muscle volume, its potential to con­
ples regarding muscle morphology, phYSiology, and tribute substantial changes in muscle size is limited 1 8
biomechanics are critical. The follOwing text discusses the
primary factors influencing force production and, hen ce,
muscle performance. Force-Velocity Relationship
Muscle can adjust its active force to preCisely match the ap­
Fiber Type plied load. This property is based on the fact that active
force continuously adjusts to the speed at which the con­
Sedentary men and women and young children possess tractile system moves. When the load is small, the active
45 % to 55% slow-twitch fibers .10 Persons who achieve high force can be made cOlTespondingly small by increasing the
levels of sport profiCiency have the fiber predominance and speed of shortening appropriately. When the load is high,
distributions characteristic of their sport. For example, the muscle increases its active force to the same level by
those who train for endurance sports have a higher distri­ slowing the speed of shortening (Fig. 5-5) .19
bution of slow-twitch fibers in the Significant muscles, and
sprint athletes have a predominance of fast-twitch fibers.
Other studies show that men and women who perform in
middle-distance events have an approximately equal per­
centage of the tvvo types of muscle fibers l l Any resistive
rehabilitation program should be based on the probable 300
distribution of fiber type of the individual. E
Clear-cut distinctions between fiber type composition t 200
and athletic performance are tllle for elite athletes. A per­ III
son's fiber composition is not the sale determinant of per­
formance. Performance capacity is the end result of many ~
100 -, MV
phYSiolOgiC, biochemical, and neurologic components, not
simply the result of a Single factor such as muscle fiber
type. 12 0+1-.-------,----~4-~----,_----_._,
360° 180° 60° 0° 60° 180° 360°
Eccentric Concentric
Fiber Diameter
FIGURE 5-5. Relationship between the force and velocity of eccentric
Although the different fiber types show clear differences in muscle contractions. (Adapted from Herzog W. Ait-Haddou R. Mechanical
contraction speed, the force developed in a maximal static muscle models and their application for force and power production. In:
action is independe nt of the fiber type but is related to the Komi PV, ed. Strength and Power in Sport, 2nd ed. Malden, MA: Blackwell
fiber's cross-sectional diameter. Because type I (slow ) Sc ientific Publications, 2003. p. 176).
Chapter 5: Impairment in Muscle Performance 63

Slowing the speed of contraction allows a patient time to 3000

develop more tension during concentric contractions. Lengthened position
1I.mvever, during eccentric contractions, increased speed Casts removed "' ... /
of lengthening produces more tension. This appears to pro­ Adult muscles immobilized I , . . ...
vide a safety mechanism for limhs excessively loaded. In­
creasing the speed of a concentric contraction significantly (/)

lowers the amount of concentric torque developed. In con­ Q;

E Casts - ,, \ '
trast, increasing the speed of an eccentric contraction in­ o
~ removed
creases the amount of torque developed until a plateau co Shortened
speed is reached. position

Length-Tension Relationship
A muscle's capacity to produce force depends on the length
at which the muscle is held with maximum force delivered
near the muscle's normal resting length (Fig. 5-6). The re­
lationship between strength and length is called the Time (weeks)
length-tension property of muscle. The number of sar­
FIGURE 5·7. Changes in the number of sarcomeres in various conditions.
comeres in series determines the distance through which
the muscle can shorten and the length at which it produces
maximum force. Sarcomere number is not fixed and in cause the manual muscle test position is a shortened po­
adult muscle, this number can increase or decrease' (Fig. 5­ sition. zs Conversely, the lengthened muscle (e.g., gluteus
7 ).20 Re?;Ulation of sarcomere number is an adaptation to medius on the high iliac crest side) tests weak, because
changes in the functional length of a muscle. the manual muscle test occurs at a relatively shortened
Length-associated changes can be induced by postural range, which is an insufficient position . Accordin a to ani­
malalignment or immobilization. 21 ,22 In muscles chronically rnaI studies, 26hh
t e s ort muscles should develop bthe least
maintained in a shortened range because of faulty posture or peak tension , followed by the normal-length muscle and
immobilization, sarcomeres are lost, and the remaining sar­ the lengthened muscle, which develops the greatest peak
comeres adapt to a length that restores homeostasis; the new tension (Fig. 5-8). This finding reflects the number of sar­
length enables maximum tension development at the new comeres in series. The lengthened muscle may be inter­
immobilized, shortened posibon. 23 In muscles immobilized preted as weak although it is capable of producing sub­
or posturally held in a lengthened position, sarcomeres are stantial tension at the appropriate point in the range. This
added, and maximum tension is developed at the new in­ phenomena is called positional strength. A muscle should
creased length. When a cast is removed or posture restored, be tested at multiple points in the range to determine

the sarcomere number returns to normal. The stimulus for whether the muscle is positionally weak or weak through­
e out the range.

sarcomere length changes may be the amount of tension
along the myofibril or the myotendon junction, with high The emphaSiS of therapeutic exercise intervention
-e should be on restoJing normal length and tension develop­
e tension leading to an addition of sarcomeres and low tension
to a subtraction of sarcomeres. 24 .
ment capability at the appropriate point in the range,
The clinical implication of the length-tension relation­ rather than just strengthening the muscle. The positionally
ship is that the evaluation of muscle "strength" must be
reconsidered. Muscles that tend to be shortened (e.g., hip
weak muscle should be strengthened in the shortened
range, and the weak muscle should be strengthened dy­
flexors ) may test as strong as normal-length muscles, be­ namically throughout the range.

, -----,

~ SO - Control

~ 2
- - . Lengthened
......... Shortened

C OL...L---'---'----'----'----'---~'--
% Muscle belly length of control

.ri c 1.0 1.S 2.0 2.S 3.0 3.S

cal FIGURE 5-8. Changes in the length·tension relationship caused by length
Sarcomere length (~m)
. In: changes associated with immobilization. (Modified from Gossman,
, ell FIGURE 5-6. The length·tension curve depicts the relationship between Sahrmann SA. Rose SJ Review of length·associated changes in muscle.
muscle length and force development. Experimental evidence and clinical implications. Phys Ther 1982;62:1799.)
64 Therapeutic Exercise: Moving Toward Function

Muscle Architecture the neurologic system. The muscles responsible for pro­
ducing the large force in the intended direction, called ag­
The arrangement of the contractile components affects the onists, must be fully activated. Muscles that assist in coor­
contractile properties of the muscle dramatically. The dinating the movement, called synergists , must be
more sarcomere lie in series, the longer the muscle will be, appropriately activated to ensure precision of rotating
the more sarcomere lie in parallel, the larger the cross­ parts. Muscles prodUCing force in the opposite direction
sectional area of the muscle will be. These two basic archi­ of the agonists, called antagonists, must be appropriately
tectural patterns affect the contractile properties of the activated or relaxed. For example, during a squat or step­
muscles in the folloWing ways: up, the jOint alignment and muscular recruitment patterns
• The force the muscle can produce is directly propor­ at the trunk, pelvis, hips, knees, ankles, and feet can alter
tional to the cross-sectional area. which muscles are trained. The nervous system control
for resistive exercises such as the squat is complex. When
• The velocity and working excursion of the muscle are
proportional to the length of the muscle . an unfamiliar exercise is introduced into the resistive ex­
ercise program , the early increase in strength partially re­
Generally, muscles with shorter fibers and a larger sults from adaptive changes in the nervous system control.
cross-sectional area are designed to produce force, whereas The clinician must ensure appropriate nervous system
muscles with Ismg fibers are designed to produce excursion control over the movement pattern for the desired out­
and velocity.21 For example. the quadriceps muscle con­ come. Inappropriate instruction or failure to monitor the
tains shorter myofibrils and appears to be specialized for exercise can render it ineffective or detrimental to th e ex­
force production , whereas the sartorius muscle has longer pected outcome.
fibers and a smaller cross-sectional area and is better suited DeLorme and Watkins 3.5 hypotheSize that the initial in­
for high excursion. crease in strength after progressive resistance exercise oc­
curs at a rate greater than can be accounted for by muscle
morphologic changes. The initial rapid increases in
Training Specificity strength probably result from motor learn ing. When a new
Training specificity suggests that "you get what you train exercise is introduced, lleural adaptation predominates in
fOL" This spe~ifi~i~ i~ particularly si~n.ifican t in terms ~f the first several weeks of training as the individual masters
trammg veloclty._8,_9 1 he greatest tramlIlg effects are eVI­ the coordination necessary to perform the exercise effi­
dent when the same exercise type is used for testing and Ciently. Subsequently, hypertrophic factors gradually dom­
training, although this principle varies by muscle contrac­ inate over neural fa ctors in the gain in muscle perfor­
tion types. A study of concentric and eccentric quadriceps mance. 36 Although neurologic auaptations were once
training found that specificity was rel ated to eccentric thought to dominate i£l the first few weeks of training,
training but not concentric training ao Concentlic training Staron and colleagues 3( found that morphologic changes
showed increases only in concentric an d isometric begin to occur in the second week of training.
strength a1 Studies have shown bilateral transfer; training Other adaptations, such as the ability to fire motor units
one limb resulted in strength gains in the contralateral at very high rates to develop power, may require a longer
limb a2 Further studies of bilateral versus unilateral train­ period of training to attain and be lost more rapidly during
ing have shown improved bilateral scores when training bi­ detraining. 38 In the long term , further improvement in per­
laterally and improved unilateral scores when training uni­ formance Critically depends on the way the muscles are ac­
laterally. These findings were consistent for upper tivated by the nervous system dUling training. 39
extremity and lower extremity training.·1:,
ROM specificity also exists ; stren~h improvements are
greatest at the joint angles exercised.- h A study of eccentric Muscle Fatigue
training showed isometiic strength gains that were joint an­ Muscle fatigue may be defined as a reversible decl'E:'C1se in
gle-specific; a similar study of COIH:entric training showed contractile strength that occurs after long-lasting or re­
improvements throughout the range .32 peated muscular activity.4o Human fatigue is a complex
The effects of posture on the specificity of training was phenomenon that includes failure at more than one site
assessed using squat and bench press lifts as the training along the chain of events that leads to muscle fiber stim u­
tool. A variety of tests followed an 8-week training session lation. Fatigue involves a central component, which puts an
that included skills such as veliical jump, 40-meter sprint, upper limit to the numberof command Signals that are sent
isokinetic tests, and a 6-second bout on a power bicycle. to the muscles , and a peripheral component. Peripheral
The authors found results to support the concept of pos­ changes in cross-bridge function associated with fatigue in­
ture specificity, because the exercise postures similar to the clude a slight decrease in number of interacting cross­
training postures enabled the greatest improvements. 34 bridges , reduced force output of the individu al cross­
bridge, and reduced speed of cycling of the bridges dUling
Neurologic Adaptation muscle shortening.
When the patient is performing resistive training, be
Muscle performance is determined by the type and size of alert for signs of fatigue. Fatigue can lead to substitution or
the involved muscles and by the ability of the nervous sys­ injury. The dosage for resistive exercise is often limited to
tem to appropriately activate muscles. Activities requiring form fatigue, th e point at which the individual must dis­
high force development require coordinated input from continue the exercise or sacrifice technique.
Chapter 5: Impairment in Musc le Performance 65

FIGURE 5-9. Two phases of a sit-up (A) Trunk curl phase, (B) Hip flexion phase, NOTE Refer to chapter 18 for
IndlcatlOns/contralndlcallOns for bent-knee versus straight-leg sit-up

Quality of motion usually is the most important factor in Lifespan Considerations

prescribing any exercise, Although this seems quite obvi­
OlIs , it is a concept that is often neglected, With resistive ex­ Prepuberty
ercise, the patient cannot expect gains in force or torque Only about 20 % of a newborn child's body mass is l1111sl'k
production unless the muscle is recruited during the move­ tissll~, The infant is weak, and muscular strengthening in
ment pattern, Because synergists can readily dominate a the first months takes place by spontaneous movem nts .
movement pattern, take care to ensure precision of motion These movements should not be limited by tight clothes or
during all exercise prescription, After the form is compro­ constant bundling of the newborn, However, the infant and
mised (i.e" form fatigue), stop the exercise. Continuing to toddler should not be burdened with sys tematic resistive
i­ training; normal developmental progression provides an
,­ exercise with poor technique compromises the outcome
appropriate stimulus for the development of an optimal
r­ and may be detrimental,
An example of the importance of technique is the tradi­ amount of muscular strength
'e In the prepubertal phase, muscle mass increases paral­
tional sit-up and the effect of holding the feet dO'wn while
the trunk raises forward. Kendall 25 prOvides a detailed anal­ lel to body mass. Children are able to make strength gains
ysis of muscle function during the Sit-up. For the curled­ above and beyond growth and maturation, Benefits of ex­
tllJnk sit-up to be used as a technique or test of abdominal ercise in this age group include improved muscle perfor­
strength , the ability to flex the trunk must be differentiated mance, increased motor performance, improved body
from the ability to flex the hips, The trunk flexion phase composition, an enhanced sense of well-being, and a posi­
g tive attitude toward fitness. 10d!2rate stretlgth training is

must precede the hip flexion phase in the trunk raising
movement (Fig, 5-9), When the feet are not held down, the acceptable , but heavy resistan ee should be avoided be ­
e- cause of the sensitivity of joint structures , especially at the
abdominal muscles tilt the pelviS posteriorly as the head and '
shoulders are raised, With the feet held do\:vJ1, the hip flex­ epiphyses of bones. R sistive training at th is age should
ors are given distal fixation , and the trunk raising may be­ focus on technique and the neurologiC asp cts of training.
come a hip flexor activity (Fig, 5-10), The trunk flexion Maximum lifts are contraindicated, and submaximal resis­
phase is bypassed, and the motion is primarily hip flexion,
in Recruitment of the abdominal muscles is minimized, and
re ­ recruitment of the hip flexors is maximized, When per­
lex forming abdominal curls, the individual may exhibit proper
lit technique for a few repetitions but then slip into faulty tech­
u­ nique, or form fatigue, as the abdominal muscles fatigue,
an With the feet free, abdominal muscle fatigue results in an
en t inability to complete the trunk curl. The feet raise in an at­
~fal tempt to use the hip flexors, but \Nithout distal fLxation, they
in­ are rendered insufficient and unable to lift the trunk up­
) ­ ward, To ensure testing or training of the abdominal mus­
~s s- cles, do not hold the feet dUling the trunk flexion phase,
ng As in the previous example, the proper exercise may be
prescribed but performed incorrectly, therefore not
be achieving the desired result of increased abdominal
Of strength, It is not good enough to perform the exercise; it
d to must be performed correctly and with the appropriate re­ FIGURE 5-10. Improperly performed sit-up, with only a hip flexion phase.
dis- cruitment pattern, A person cannot strengthen a muscle NOTE Refer to chapter 18 for indications/contraindications for bent-knee
that is not being recmited. versus straight-leg sit-up
66 Therapeutic Exercise: Moving Toward Function

tive training focused on form is preferred (8 to 12 repeti­ the onset of training in many elderly individuais. A study of
tions per set or more) . During prepuberty, there are no dif­ older men (mean age, 70 years) de monstrated that the
ferences between girls and boys ,vith respect to trainability training-induced strength gains resulted from neural fac­
for strength. Boys have a small genetic advantage, which is tors , as indicated by the increases in maximal integrated
completely compensated by the developmental advantage electromyography in the absence ofhypertrophy.45 Neural
of girlS. 41 There is no biologic basis for a sex-dependent dif­ factors are a significalQt mechanism by which older subjects
fere nce in strength performance. Any difference in the increase strength in the absence of any signjficant evidence
strength between girls and boys, particularly in the shoul­ of hypertrophy. In general, fatigability increases \vith ad­
ders and arm s, appears to result from social expectations vancing age, and older muscles require a longer period of
and gender roles in SOCiety. Muscle perform an ce training recovery after strenuous exeltion. There is also a significant
should always be superVised by knowledgeable staff to increase in the collagen content of muscle with advanc:ing
avoid risk of injury. age . This is associated ,vith thickening of the connective tis­
sue and increased muscle stiffness.
Puberty The decrease in muscle performan ce with advancing
The ability to improve strength increases rapidly dUling age affects men and women differently. The absolute de­
puberty, particularly in boys. The increase in male sexual cline in strength is less steep in women than in men. Palts
hormones is Significant because of their anabolic (i.e., pro­ of the body are also affected differently. The arms are more
tein-incorporating) com ponent. During maturation, the affected than the trunk and legs, probably because of less
propOltion of musc:le in boys increases from 27% to 40% of use of the upper extremities in strength-related activities.
body mass .41 With the onset of puberty, the strengths of Active elderly women surpass inactive men with respect to
girls and boys diverge markedly. On average, the strength trunk muscle strength.
of girls is 90% that of boys at 11 to 12 years of age, 85% at Adequate muscle strength helps to preven t or moderate
13 to 14 years , and 75% at 15 to 16 years 4 1 Although this the symptoms of degenerative changes of the joints. Resis­
gender difference has a biologiC basis, it does not com ­ tive exercise by the elderly should be directed toward the
pletely account for the differences seen, suggesting contin­ muscles susceptible to atrophiC changes. 46 Priority should
ued societal influences. be given to the deep neck flexors , scapular stabilizers, ab­
General strength training is recommended during this dominal muscles, gluteal muscles, and quadriceps. Unjus­
phase. Optimal strength and muscular balance is critical tifiably, little attention is paid to strength of the ventilatory
for the quickly growing skeleton. Some precautions dur­ muscles (i.e. , diaphragm ) and pelvic floor muscles. Train­
ing strength exercise are still warranted. The epiphyses ing should include both multiple joint and Single joint ex­
remain sensitive and liable to injUlY. Avoid heavy loads, ercises, performed at moderate loads for 1 to .3 sets of 8 to
unilateral burdens, or faulty techniques to prevent epi­ 12 repetitions.
physeal damage. Additionally, the elderly should consider training for
power, not just strength. Leg power has been shoWQl to sig­
Early Adulthood nificantly influence the;,hysical performance of mobility­
Stren~h potential is at its highest in the 18- to 30-year pe­ limited elderly people. 4 Fielding et al 48 found high veloc­
liod. 4 The competent biologiC structures show a state of ity resistance traini ng to increase muscle power more
good adaptability, the jOints tolerate high loads , and the so­ effectively than low velOCity training in older wom en.
cial situation makes specific use of strength necessary. Power training in this group should include light to moder­
Most individuals are actively involved in physical activity ate loads performed for 6 to 10 repetitions with high veloc­
without the responsibility of working long hours. During ity. See Chapters 18 through 27 for resistive exercises for
this period, emphaSiS should be placed on a balanced fit­ the spine, shoulder, arm , hip, knee , and pelViC floor.
ness program for cardiopulmonalY fitness , muscle perfor­ With advanCing age, the social needs and individual mo­
mance , and flexibility. tivation fo r the use of strength lessen ; the atrophy reflects
Middle Age the effects of disuse , not mere age-related changes. The
The decrement of strength during this phase oHife must be voluntary and deliberate use of the motor system in daily
differentiated according to training activities, gender, and life activities and intentional resistive training are able to
body area. Trainjng for as little as 2 hours or more each counteract the loss of muscle mass with increasing age . The
week is sufficient to pOSitively influence strength. A small vigorous use of muscles, particularly among old persons,
amount of training increases the difference between active improves their health and sense of well-being.
an d inactive persons with increasing age. Persons from
white-collar profeSSions have the same or even more
strength than persons from blue-collar profeSSions; leisure
Cognitive Aspects of Performance
time activities account more for existin g strength than pro­ The cognitive or mental aspects of strength and perfor­
fessional demands 43 mance are most easilv seen in elite athletes. The use of
mental imagery techniques such as visualization and posi­
Advanced Age tive self-talk has been suppOlted by sport psycholOgists and
The body can adapt to strengthening exercise throughout athletes alike. Positive cognitive strategies can enhan ce
th e lifespan. It is possible to reverse existing muscular strength and performance, an d negative strategies may
weakness in old age. 44 Strength increases result from rela­ have a negative or negl igible impact. A study of different
tively low stimuli because of the marked atrophy present at mental preparation techniques (i.e., arousal, attention, im­
Chapter 5 Impairment in Muscle Performance 67

gery, self-efficacy, and control-read conditions) showed sition, deranged elements of the sarcoplasmic reticulum,
that preparatory arousal and self-efficacy techniques pro­ and abnormal mitochondria. Type II fiber atrophy has also
nced greater ~osttest strength performance than in the been attributed to chronic alcohol abuse. 50 Type II atrophy
control group. 9 A similar study showed no difference suggests that alcoholic patients may exhibit speCific deficits
IDl ong the mental preparation conditions, but all per­ in muscle performance, such as an inability to generate ten­
onned significantly better than a control group.50 sion rapidly and to produce power. For many patients, ab­
Some types of mental preparation can have a negligible stinence leads to full recovery of muscle function, but for
o · negative impact on strength performance. A study of others, the injury may be more severe and resistant to treat­
relaxation-visualization training by non-strength-trained ment, and this must be considered as a comorbidity when
men showed poorer knee extensor measures for them projecting the prognOSiS .
than a control group. The investigators suggested that this
training dive~ted their full concentration away from the
exercise task.") A mental task requiring subjects to imag­
Effects of Corticosteroids
ine situations making them angry or fearful produced The \videspread use of oral corticosteroid agents as anti­
increased levels of arousal but no change in strength per­ inflammatory and immunosuppressant agents has led to
£ rmance. 52 cases of steroid atrophy.61 The primary biopsy finding in
A study of the impact of imagery, preparatory arousal, patients treated with prednisonelike steroids (e.g., pred­
and counting backward on hand grip strength found im­ nisone, prednisolone, methylprednisolone) is type II fiber
ery to enhance grip strength in older and younger sub­ atrophy61 This reduction is thought to be most pro­
jects. 53 Gould and coworkers 54 found that imagery and nounced in type lIB fibers 52 and is believed to occur more
preparatory arousal improved strength pelformance. Dif­ often in women than men 63 Corticosteroids are a potent
ferent kinds of imagery and their impacts on power and en­ catabolic stimuli, and the atrophy caused by prolonged cor­
durance activities (i.e., seated shot-put and push-ups to ex­ ticosteroid use occurs as protein degradation exceeds pro­
haustion) have been studied. Results show that all imagelY tein syntheSiS. Goldberg 5 believes that the constant use of
techniques have a positive impact and that using the type I fibers during normal voluntary movement pro­
metaphors is particularly effective in improving power and vides these fibers with a protective or sparing influence
endurance measures.s5 from the catabolic effects of steroids. Exercises recruiting
The knowledge of results of isokinetic peak torque out­ type II muscle fibers may protect them from steroid­
put (i.e., visual feedback) provides an important error-cor­ induced atrophy. Normal function can be expected to re­
rection function. This type of training may help patients de­ turn \vithin 1 year or, more often, \vithin several months af­
velop cognitive strategies that can be used to guide ter steroid use has stopped. 53
performance in clinical and nonclinical settings. 56 Studies
u a est that mental preparation and the current mental
tate can affect strength performance. Consider this when CAUSES OF DECREASED MUSCLE
performing and interpreting the results of resistive tests. PERFORMANCE
Muscle performance can be impaired for a variety of rea­
Effects of Alcohol sons. Central or peripheral neurologic pathology decreases
The deleterious effects of alcohol abuse on muscle have an individual's ability to effectively recruit and functionally
been well documented. 57 The myopathic changes seen in use his muscles. Injury to the muscle from a strain or con­
the alcoholic patient have at times been attributed to mal­ tusion decreases performance, as does disuse or decondi­
nutrition or disuse. Experiments have demonstrated that, tioning for any reason. The goal of examination/evaluation
even \vith nutritional support and prophylactic exercise, of muscle performance is to determine the cause of the im­
normal subjects can develop alcoholic myopathy if they in­ pairment to develop the most efficient and comprehensive
gest large amounts of ethanol. 58 intervention plan. The follOWing section discusses the po­
Alcoholic myopathy has two clinical phases: an acutely tential factors that can cause impaired muscle perfor­
painful presentation that follows "binges" and a chronic mance, examination/evaluation results of each potential
phase that consists of morphologic and functional alter­ cause, and general intervention concepts for each speCific
ations in muscle. 59 Acute alcoholic myopathy has morpho­ cause.
logic features, such as fiber necrosis , intracellular edema,
hemorrhage, and inflammatory changes, that can be seen
under light microscope . Binges by chronic alcoholics can
Neurologic Pathology
'esult in an acute myopathy characterized by muscle NeurologiC pathology can affect the contractile capacity of
cramps, muscle weakness, tenderness, myoglobinuria, re­ muscle as a result of pathology in the central or peripheral
If d uced muscle phosphorylase activity, and decreased lactate nervous system. The peripheral nervous system can be af­
response to ischemic exercise. Exercise is contraindicated fected at the nerve root or peripheral nerve level.
for persons with acute myopathy and those with myo­ Individuals \vith nerve root pathology may present \-vith
O'lobinuria, because it may stress an already compromised muscle performance impairments in the nerve root distri­
'stem. bution. Examination will discover muscle performance
Changes seen in chronic alcoholic myopathy include in­ impairment associated with a specific nerve root distribu­
tracellular edema, lipid droplets, excessive glycogen depo­ tion. For example, nerve root compression at the LA-L5
68 Therapeutic Exercise: Moving Toward Function

spinal level can produce quadriceps femoris weakness, and dent (CVA ). Resistive exercise programs must consider the
nerve root compression at the C5-C6 spinal level can result prognosis and tailor the exercises appropriately. In situa­
in deltoid and biceps weakness. Sensory changes usually tions such as Guillain-Barre syndrome, certain cases of
precede muscle performance changes , but individuals with spinal cord injury and e VA, and progreSSive stages of mul­
more severe patholob'Y may have se nsory and motor tiple sclerosis, some recovery is expected. Examination re­
changes. Therapeutic exercise intervention depends on the sults will distinguish more global patterns of weakness or
prognosis for the nerve root involvement. If the changes tone changes. E xercise programs focus on maintaining
are relatively recent and resolution of the nerve root com­ strength in intact m usculature and gently strengthening
pression is expected through conservative or surgical man­ weakened muscles as recoveIJI and remission advances.
agement, preventive and protective measures are taken. Take care to avoid fatiguing these weakened muscles dur­
The goal of therapeutic exercise intervention is not only to ing strengthening exercises. D osage pararneters generally
promote optimal muscle performance of the muscles in­ include several short exercise sessions of a few repetitions
nervated by the affected spinal segment (pending progno­ interspersed throughout the day. Duling quiescent periods
sis) but also promote spine stability and optimal movement of diseases such as multiple sclerosis, a general condition­
patterns to alleviate any mechanical cause of nerve root ing program of balanced strengthening and mobility exer­
pathology incurred by the spinal segment(s) (see chapters cises is appropriate. When recovery is not expected, resis­
18 and 24). Peripherally, resistive exercise can be used to tive exercise programs emphaSize functional strength of
maintain/improve current strength levels, whereas training remaining musculature. This includes strength for func­
inner lumbar or cervical core and girdle muscles provide tional activities such as self-care, transfers, and mobility.
proximal stability. CentraDy, use resistive exercise to train Take care to avoid overworking these muscles. Unlike per­
inner core muscles (i.e. , longus coli , transversus abdominis, sons with full innervation who use their muscles efficiently,
lumbar multifidus, pelvic floor; see Chapters 18, 19, and 24 the individual with paralysis uses th e few innprvated mus­
for detailed muscle performance training) to effectively cles they have for nearly all their activities. The potential
stabilize the spine and relieve mechanical nerve root irri­ for overuse injuries is very high.
tants. After the mechanical or chemical cause of nerve root
injury is remediated, speCific, localized resistive exercise of
the involved musculature is often indicated to restore pre­
Muscle Strain
cise recruitment patterns. Muscle strain occurs along a continuum from acute macro­
NeurologiC weakness may also result from a peripheral traumatic injury to chronic microtraumatic overuse injuries
nerve injmy. Compromise of the median nerve at the (see Chapter 11). Examination results will distinguish this
carpal tunnel, the radial nerve at the cubital tunnel , or the form of \Veakness by pain with resistance, typically in the
common peroneal nerve at tIle fibular head are examples of lengthened ranges of the muscle where the cross-bridges
such injmy. The pattern of sensory loss and wcakness de­ are most separated. Resistive exercise in the treatment of
pends on which nerve and where along the nerve's course muscle strain injuries depends on where along this contin­
the damage occurs. Some peripheral nerve entrapments uum the injury occurs. Resistive exercise that neither over­
have only a motor component, others have only a sensory loads nor underloads the tissue is optimal. Determining
component, and some are mixed. Examination results will this resistance dosage is the challenge.
demonstrate sensOlY changes and weakness consistent with Acute traumatic injulies occur when a muscle is rapidly
the peripheral nerve innervation pattern. As in nerve root overloaded or overstretched and the tension generated ex:
involvement, attention should be focused on remediating ceeds the tensile capability of the musculotendinous unit. 60
the mechanical cause of the peripheral nerve injury. For These injuries occur near the musculotendinous junction
example, a depressed shoulder girdle may contribute to and at random areas within the muscle belly. The ham­
traction on the long thoracic nerve, causing motor changes string muscle is a common site of muscle strain injury. A
in the serratus antelior. Exercise and posture education to combination of insufficient strength, reduced extenSibility,
elevate the shoulder girdles may alleviate the traction on inadequate wann-uf' and fatigue has been implicated in
the long thoracic nerve and ultimately restore normal in­ hamstring injuries 6 (see Patient-Related Instruction 5-1:
nervation to the serratus anterior. Resistive exercise should Preventing Musc:le Strain ). Strength, extenSibility, and fa­
also focus on maintaining and increasing the strength of the tigue resistance protect a muscle from strain injUly.
unaffected motor units in the involved musculature, and Eccentric loading is a common mechanism of muscle
progreSSively strengthening motor units on reinnervation. strain injury, and a muscle prepared for eccentric loading is
Caw must be taken to not focus too much on strengthen­ less likely to sustain an injury. E ccentric loading should be
ing muscles that are intact for fear of creating Significant an integral part of any resistance training program (see
muscle imbalance. Exercise should try to maintain muscle Selected Intervention 5-1: Lateral Kicks for an example of
balance and efficient movement patterns \:vi.thout develop­ eccentric loading). A program to prevent muscle strain in­
ing a dominant muscle group that overrides other muscle juries should include dynamiC resistive exercises \ a
action. Splinting, braCing, taping, or other supportive mea­ strong eccentric component, flexibility exercises, an appro­
sures may be necessary to maintain balance. priate \Varm-up before activity, and attention to fatigue lev­
Other neurolOgiC conditions include neuromuscular dis­ els. The rehabilitation program after injury should also fo­
ease such as multiple sclerosis, postpolio syndrome, and ellS on these factors.
Guillain-Barre syndrome, and muscular paralYSis or paresis ~v[uscles may also be strained from chronic overuse. For
resulting from spinal cord injuIJ' or cerebral vascular acci­ example, extensor digitorum longus (EDL) strain is com­
Chapter 5: Impairment in Muscle Performance 69

flexion) can alleviate the overuse strain to the EDL. A

thorough evaluation can determine the cause of the
overuse problem. Ergonomic assessment and appropriate
Preventing Muscle Strain
Although some muscle strains are not preventable, work site modification is also necessary to prevent a recur­
prec autions can reduce your risk of inju ry. rence of the strain if ergonomics are at the root of undesir­
able posture or movement patterns. If left untreated, this
1. Warm-up before a vigorous activity; 5 to 7 minutes of a
large muscle group activity such as walking, jogging, impairment can quickly lead to disability.
or cycling should suffice. This should be enough Strain resulting from muscle dominance overuse is man­
activity to break a sweat. aged by reducing the loads imposed on the strained mus­
2. Stretch stiff and short muscles after your general cle. When the tensor fascia latae dominates over the ilio­
warm-up. Stretch each muscle for 15 to 30 seconds for psoas during hip flexion and gluteus medius during
four repetitions. abduction, the tensor fascia latae is at risk for an overuse
3. Balance your sports or other leisure activities with strain. Improving the strength and recruitment patterns of
strengthening exercises. Your clinician can help you the iliopsoas and gluteus medius can reduce the load on the
focus on muscles susceptible to injury. tensor fascia latae and allow it to recover. Postural habits
4. Avoid fatigue during the activity. Fatigue can increase
(e.g. , standing in medial rotation ) and movement patterns
your risk of injury.
5. Strengthen underused muscles to prevent overuse to (e.g. , hip flexion or abduction with medial rotation) must
susceptible muscles. Your clinician can help you al so be modified to improve recruitment of the underused
determine which muscles these are and what specific synergists.
exercises you need to perform to maintain muscle A potential risk factor of muscle strain is gradual, contin­
balance. uous overstretching, which occurs when a muscle is contin­
uously placed in a relatively lengthened, tension -producing
pOSition. For example, the lower trapezius in a person with
forward shoulders is subjected to continuous tension and
mon in workers performing continuous repetitive elbow, has adapted to a lengthened state. It may not take much
wrist, and hand activities as a result of using the EDL for force to produce a strain injury in a muscle that is already
wrist extension and elbow flexion. Training the individual overstretched. This type of strain puts the muscle at risk for
to use the biceps for elbow flexion whenever possible (i.e. , two fo rms of muscle weakness , one from length-tension
keep the hand supinated versus pronated during elbow changes and the other from overstretch strain.


f ~ Lateral Kicks

See Case Study #1 DOSAGE: Two to three sets per day to form fatigue . If patient
g does not fatigue by 20 repetitions, increase the resistance of
Although this patient requires comprehensive intervention as
the bane!.
described in other chapters, only one exercise related to
resistive training is described . This exercise would be used in
the late phase of this patient's rehabilitation.
increases muscle performance in tile hip abductors ,lIlel ankle
evertors in a synergistic fashion. Abductors are strengthe ned
ACTIVITY: Resisted hip abduction and ankle eversion
in both concentric and eccentric modes. It may be
progressed to a higher speed to challenge stability.
PURPOSE: To increase the muscle performance of the ankle
eve rtor and hip abdu ctor muscles.

STAGE OF MOTOR CONTROL: Controlled mobility

MODE: Resistive band

POSTURE: Standing with one foot on the resistive band and

th e band around the other foot. A SUppOlt should be readily
available for balance as needed.

of MOVEMENT: Standing on the uninjured leg, abduct the hip in

ll ­ the frontal plane, and eve It (pronate ) the ankle. ~'Iaintain
a good spinal posture throughout the exercise. Do not hike
'0 ­ pelviS . Move only at the hip joint. Avoid moving out of the
frontul plane. Moving toward flexion results in th e motion
fo- performed by the flexor abductor group. Return to the start
70 Therapeutic Exercise: Moving Toward Function

Patient education is a key component of the rehabili ta­ are preferentially activated in forearm supination. The re­
tion program in the case of muscle strain associated with cruitment thresholds of motor units in a muscle are also in­
continuous overstretch. In the lower trapezius example, fluenced by the type of mu scle actions associated \\lith a
educate the patient about optimal postural habits to re­ movement. In elbow flexion, biceps motor units have a
duce tension on the lower trapezius. Improving postural lower threshold in slow concentric and eccentric actions
habits and reducing tension on the lower trapezius with than isometric actions; the reverse is true for the
bracing or taping (see Chapter 26 ) will allow the muscle brachialis 68 The recruitment thresholds of motor units of a
to heal more rapidly. In addition, it ,vill promote adaptive muscle active in a movement may also be affected by
shortening and therefore ultimately achieve a more opti­ changes in jOint angle. 69 Some muscles or portions of a
mal length-tension relationship and reduce the risk for muscle may be overused while other muscles or portions
future reinjury. are disused, and the resistive rehabilitation program must
acknowledge this imbalance. In the previous example, in­
struction in general resisted elbow flexion may exacerbate
Disuse and Deconditioning the imbalance whereas speCific training of the vveaker re­
cruitment pattern can restore muscle balance.
Muscle performance may be impaired because of disuse or
deconditioning for a variety of reasons. Illness , surgery,
specific physical conditions (e .g., pregnancy ,vith twins), or Length-Associated Changes
injury may necessitate a period of decreased activity. Sub­
tle muscle imbalances can lead to overuse of one muscle The principle of the length-tension curve affects muscle
and to disuse and deconditioning of another. performance when a muscle is adaptively lengthened from
Illness and injury are common causes of deconditioning. prolonged posture and repetitive movement patterns of the
For example, illness such as pneumonia or an injury such as muscle in the lengthened state. Examination of postural
a herniated disk can result in a period of decreased activity . alignment controlled by the muscle suggests that the mus­
and subsequent deconditioning. In these situations, total­ cle is longer than ideal as in depressed shoulders or hip ad­
body deconditioning occurs, and general conditioning is duction and medial rotation. Muscles ,viJi test weak in the
necessaly. However, specific exercises also may be neces­ short range when compared ,vith synergists, paired muscle
sary to improve muscle performance and prevent sec­ of the other extremity, or other half of the axial skeleton
ondary impairments. For example, an elderly individual (i.e., posterior gluteus and tensor fasciae latae, right and
may have relatively asymptomatic osteoarthritis until a left posterior gluteus medius, or right and left external
bout with pneu monia produces general deconditioning. oblique muscles, respectively). As previously mentioned,
Subsequently, knee osteoarthritis becomes symptomatic this is referred to as positional weakness. Intervention
because of impaired muscle performance in the lower ex­ should focus on strengthening the muscle in the shortened
tremity muscles involved in gait and other functional activ­ range, optimizing posture to reduce lengthening tension 011
ities. Specific resistive exercises to recondition those mus­ the muscle , and altering movement patterns to recruit the
cles are necessary to restore proper biomechanics and muscle in the shortened range.
prevent further disability.
Reduced activity levels can impair muscle performance
in a similar manner. Multiparous pregnancies, exacerbation PHYSIOLOGIC ADAPTATIONS
of a musculoskeletal injury, an episode of colitis, or social TO TRAINING
factors such as major life changes (e.g., job, school , divorce,
family illness, death ) can reduce activity levels and result in Strength and Power
impaired muscle performance. For example, regular exer­
cise may keep a woman's patellofemoral malalignment from The benefits of resistive exercise extend beyond the obvi­
becoming symptomatic. When her activity level decreases ous improvements in muscle performance to include posi­
in the late stages of pregnancy, the combination of de­ tive effects on the cardiovascular system, connective tissue,
creased activity, weight gain, and hormonal changes pro­ and bone. Moreover, these effects translate into fun<:tion.
duces symptoms at the patellofemoral joint. Selective resis­ Individuals perform their daily activities \\lith more ease
tive exercises combined with patient education can prevent because they are functioning at a lower percentage of tbeir
this exacerbation. Resistive exercises in the case of overall maximum capacity. Improved functioning also enhances
decreased activity must consider the muscles most likely to the patient's sense of well-being and independence.
be affected , the patient's desired activity level and prefer­
ence, and any underlying or residual medical conditions. Muscle
An overlooked source of deconditioning or disuse is a The most obvious benefits of resistive training are for th
subtle muscle imbalance. vVh en activating muscles for a muscular system. Regular resistive exercise is associated
functional movement, the body chooses the most efficient with several positive adaptabons, most ofwhich are dosagp.­
muscular and motor unit activation pattern. Certain motor dependen t (Tahle 5-1). The cross-sectional area of th
units in a muscle may be preferentially recruited when a muscle increases as a result of an increase in th e rnyofiblil
muscle is engaged in a particular task()f For example, mo­ volume of individual muscle fibers, fiber splitting, and po­
tor units in the lateral portion of the long head of the biceps tentially an increase in the number of muscle fibers. This
are preferentially activated when this muscle is engaged in cross-sectional area increase primarily results from prefer­
elbow flexion, whereas motor units in the medial portion ential hypertrophy of type II fibers. Changes in the muscle
Chapter 5: Impairment in Muscle Performance 71

~ . Physiologic.Adaptations to Resistance Although protein volume and cross-sectional area increase

in response to resistive training, some of the cellular or sys­
Training ~_. _ _ '
temic factors may remain unchanged, giving the percep­
RESULT AFTER tion of a decrease, although the decrease is only relative.
VARIABLE RESISTANCE TRAINING Energy sources necessary to fuel muscle contraction in­
crease after resistive training. In general, levels of creatine
Performance phosphate, ATP , myokinase, and phosphofructoJ.<:in~se in­
Muscle strength Increases crease in response to a resistive exercise ~rogram.ll- 14 Lac­
Muscle endurance Increases for high power output tate dehydrogenase is variably changed. Z
.'\erobic capacity No change or increases slightly Neural adaptations occur with resistive training. Studies
Ylaximal rate of force Increases have shown increases in the muscle's ability to produce
production torque and increased neural activation, as measured by
Vertical jump Increases electromyography (EMG)38 Increases in muscle activity
Anaerobic power Increases
were also seen after resistive training that consisted of ex­
Sprint speed
plOSive jumping. Increased EMG values associated "vith
Muscle Fibers
greater power and maximal contraction were attributed to
Fiber size Increases
No change or decreases
a combination of increased motor unit recruitment and in­
Capillary density
Mitochondrial density Decreases creased firing rate of each unit. 75
Enzyme Activity
Creatine phosphokinase Increases Connective Tissue
Y1yokinase Increases Although disuse and inactivity cause atrophy and weaken­
Phosphofructokinase Increases ing of connective tissues such as tendon and ligament,
Lactate dehydrogenase No change or vmiable physical training can increase the maximum tensile
Metabolic Energy Stores stre'2r,!l and the amount of energy absorbed before fail­
Stored ATP Increases ure. I Physical activity returns damaged tendons and liga­
tored creatine phosphate Increases ments to n~~mal tensile strength values faster than com­
Stored glycogen Increases plete rest. I I Physical training, particularly resistive
Stored triglycerides May increase exercise, may alter tendon and ligament structures to make
Connective Tissue them larger, stronger, and more resistant to injury.
Liaament strength May increase
T ndon strength May increase
Collagen content May increase
Bone density Increase Weightlessness 78 and immobilization 79 can cause profound
loss of bone denSity and mass. Weight-bearing activities
Body Composition
that recruit antigravity muscles can maintain or enhance
Percentage of body fat
Fat-free mass Increases bone denSity and mass. 80 Weight training, paliicularly with
a weight-bearing component, can substantially alter bone
-\dapted from Falkel JE, Cipriani DJ. Physiological principles of mineral denSity. Individuals in sports requiring repeated
. tance training and rehabi.litation. In: Zachazcwski JE , \,1agee DJ, high-force movements such as weight lifting and thrO\ving
-Quille n WS. eds. Athletic Injuries and Rehahilitation. Philadelphia: WB. events have higher bone densities than distance runners
:runders, HJ96. and soccer players or swimmers. sl Those who play tennis
regularly have higher bone denSity in their dominant fore­
arms, and professional pitchers have greater bone denSity

L pend on fiber type and the stimulus. Hypertrophy of in the dominant humerus 8z A 5-month study of weight
..tSt-twitch fibers occurs when all or most of the fibers are training compared with jogging found that weight training
in recruited and is considered an adaptation for in­ produced Significantly better increases in lumbar bone
a~ed power output. Slow-twitch fibers hypertrophy in denSity than the aerobic exercise 83
ponse to frequent recruitment. In repetitive, low-inten­ These studies suggest that regular exercise, speCifically
.' activity, fast-twitch fjbers are rarely recruited, and exercise such as resistive training, can maintain or improve
e fibers may atrophy while the slow-twitch fibers hy­ bone density. Resistive training to improve bone denSity is
rtrophy. A study by Staron and colleagues 37 examined important for women of all ages. A study of adolescent fe­
differences in the proportion of muscle fiber types in male athletes found runners to have higher total body and
tance runners, weight lifters, and sedentary controls. site-specific bone mineral denSity than swimmers or cy­
e investigators found the weight lifters had a greater clists, and that knee extension strength was an independent
,d portion of type IIA fibers and had a greater ~e IIA predictor of bone mineral denSity in this population. 84 Fi­
e- r area than the controls or distance runners 7 Spec i­ nally, a study of bone mass and exercise dosage found that
e ty of resistive training exists and must be considered daily loading regimens broken down into four sessions with
ril n designing a training program. recovery time in between improved bone mass Significantly
Other changes occur on cellular and systemic levels. over a loading schedule that gerformed the training in a
capillary denSity is unchanged or decreases, and the Single, uninterrupted session. Thus smaller exercise ses­
:ochondrial denSity decreases. Some of these changes sions separated by recovery periods may be a better pre­
.tit from their number relative to total muscle volume. scription when increased bone mass is the goal.
72 Therapeutic Exercise Moving Toward Function

Cardiovascular System Endurance

Resistive training benefits the cardiovascular system. The
idea that strength training causes hypertension is erro­ The muscle's response to endurance training is different
neous. Most reports show that highly strength-trained atll­ from its response to strength or power training. This re­
!etes have average or lower tilan average systolic and dias­ sponse is expected because of the differences in training
tolic blood pressures .86 When performed properly and dosage. Muscular endurance depends on oxidative capac­
heeding the proper precautions, strength training can have ity, and training increases the muscle's metabolic capacity.
a positive effect on the cardiovascular system. Muscular endurance is often limited by a local accumula­
Increased intrathoracic or intra-abdominal pressures tion of lactate, \Vitll glycolysis inhibition and a failure to re­
may affect cardiac output and blood pressure during resis­ generate ATP in tile working muscle.~~ During prolonged
tive exercise. In the classic model, increased intratiloracic activities, depletion of intramuscular glycogen reserves
pressures are thought to decrease venous return to the may contribute to impaired muscular endurance.
heart and decn~ase cardiac output. Intrathoracic pressure Muscles trained for endurance demonstrate cells with
is inversely related to cardiac output and stroke volume and increased mitochondrial size , number, and enzymatic ac­
directly related to systolic and diastolic blood pressure our­ tivity, as well as increased penusion 9o Increased enzymatic
ing resistive exercise. Increased intrathoracic pressmes activity allows the muscle to better use the oxygen deliv­
may limit venous return and decrease cardiac output while ered, encouraging use of fats as a fuel and sparing glycogen.
causing an accumulation of blood in the systemic circula­ Muscles that are stronger use a smaller portion of the max­
tion that may increase blood pressure. Performing resistive imum voluntary contraction force with activity, thereby de­
exercises with a Valsalva maneuver, which elevates in­ laying the onset of muscular fatigue.
trathoracic pressure, leads to a greater blood pressure re­ Muscles trained for endurance also demonstrate in­
sponse than yenormance of the exercise without a Valsalva creased local fuel storage. Glycogen stores may be in­
maneuver 8 1 Instructing the patient to breathe properly creased twofold, and when endurance training is combined
during exercise may reduce the increase in blood pressure with appropriate carbohydrate intake, stores may increase
sometimes seen during exercise. as much as threefold 90 In addition to increasing fuel stores,
Increased intramuscular pressure during resistive exer­ the endurance-trained muscle also increases fatty acid use
cise may result in increased total peripheral resistance and and decreases tlle use of glycogen as a fuel. This alteration
increased blood pressure . Mechanically induced increases allows more exercise before fatigue. Endurance muscle
in peripheral resistance probably are the cause of higher training improves the m.ygen delivery system by increasing
blood pressures during isometric and concentric exercise the local capillary network, producing more capiUaJies per
compared with pressures during eccentric exercise S8 Iso­ muscle fiber. 90 Increased perfUSion slows the accumulation
metric or concentric exercise combined witil a Valsalva ma­ of lactate in the working muscles.
neuver can produce the greatest increase in blood pres­
sure. This combination should be avoided, espeCially by
individuals at risk for elevated blood pressure (see the Pre­ EXAMINATION AND EVALUATION OF
cautions and Contraindications section).
Resistive exercise does result in a pressor response that
affects the cardiovascular system by causing hypertension
Decreases in muscle performance may occur for a num­
through exciting the vasoconstrictor center, which leaos to
ber of reasons. A thorough examination is necessal)' to de­
increased pelipheral resistance. If precautions are taken to
termine the cause of impaircd muscle performance and
ensure proper breathing and avoid isometric contractions
the link betv.reen impaired muscle performance and func­
in persons at risk for a pressor response, resistive exercise's
tional limitations or disabilities. After that relationship is
benefits outweigh the risks. Long-term performance of
established, the intervention must be matched to the
resistive exercise can result in positive adaptations of the
cause of impaired muscl e pelformance. The muscle test is
cardiovascular system at rest and during work. Cardiovas­
only one small part of the examination process and must
cular adaptations to resistive training are su lllmarized in
be used "vith additional information (e.g. , range of mo­
Display 5-2.
tion, joint mobility, balance, sensory and reflex integrity)
to determine the speCific cause of impaired muscle
The tests and measures recommended by the Guide to
PhljsiC(J/ TheTapist Practice9 J ensure comprehensive as­
Benefits of Strength Training on the
sessment of the patient's impairments, functional limita­
Cardiovascular System tions, and disability. Within the examination is a subset of
• Decreased heart rate measures speCific to the penormance of the muscle, These
• Decreased or unchanged systolic blood pressure tests include an analysis of functional muscle strength,
• Decreased or unchanged diastolic blood pressure power, or endurance; manual muscle tests; dynamometry;
• Increased or unchanged cardiac output and electrophysiologic testing.
• Increased or unchanged stroke volume Manual muscle testing is the most fundamental of all
• Increased or unchanged maximal oxygen consumption strength tests. Length-tenSion relationships, muscle imbal­
• Decreased or unchanged total cholesterol ance, and positional weakness must be considered when
choosing manual muscle test positiOns. Close attention to
Chapter 5 Impairment in Muscle Performance 73

substitution patterns and testing in a variety of positions The American College of Sports Medicine (AC M ) de­
minimizes the chance of erroneous results. ""hen used re­ fines a no-dee as someone vvith no training experience , in­
liably, hand-h eld dynamomete rs can provide muscle per­ termediate as someone vvith 6 months of consistent resis­
formance information that is more reliable than that of tance training expelience, and advanced as someone vvith
tests using the traditional clite ria of 0 through 5. years of resisti ve training experience,al Elite individuals
Isokinetic dynamometers are commonly used to assess are highly competitive athletes, Strength gains vary con­
muscle performance, Computerized systems provide siderably among these training groups . You can e;..-pect
trem e ndous data reduction capabilities, Tests can be pe r­ muscle strength gains of approximately 40% in untrained
formed at a variety of speeds and comparisons made with individuals, 16% to 20% gains in intermediate , 10% in ad­
antagonists, the contralateral limb, normative standards , or vanced, and 2% in elite athletes. 94 These gains can be x­
previous test results. These tools provide reliable data that pected over the course of 4 weeks to 2 years, with the ma­
can be used to assess progress , as a motivator, or as criteria jority of gains (espeCially in the untrained) occurring in
for progression to more advanced rehabilitation phases. the first 4 to 8 wee ks, For untrained individuals, thc' re­
A variety of mus cle actions can be ass essed using this sponses to just about any training program will be pro­
equipment. found , whereas making gains in intermediate, advanced,
Dynamic strength can also be de termined using the rep­ or elite athletes is much more difficult. E xercise prescrip­
e tition maximum (RM ) mctll od, For example, a 10 RM is tion will ne d to be mOre creative and variable in these
the maximum amount of we ight that can be lifted 10 times , individ uals,
and a 1 RM is the maximum amount of weight that can be
lifted once. The amount of weight that can be lifted for a
given number of repetitions can be determined and com­ Activities to Increase Muscle
pared vvith that for the antagonist, the opposite limb , or to Performance
a previous test result. The specific activities and dosage chosen to improve mus­
e The magnitude of measured increases in force or torque cle performance d pend on many factors, including the in­
depends on how similar the test is to the training exercise,92 dividual's age and medical condition, muscles involved, ac­
e For example, if athletes train their legs by doing the squat tivity level, current level of training, goals (i.e ., str ngth,
n exercise, the increase in strength measured as maximal power, and endurance), and cause of decreased muscle
s(luatting is much greater than the strength increase mea­ perform ance. The folloV\ing sections describe the activities
sured in isometric leg press or knee extension tests. Tbis used to increase muscle performance and their relative
specificity of movement pattern in strength training ~roba­ risks and benefits, Be sure to match the appropriate train­
bIy reflects the role of learning and coordination. 3 Im­ ing mode to the patient's goals,
proved coordination takes the form of the most efficient ac­
tivation of all of the involved muscles and the most efficient
Isometric Exercise
activation of motor units within each muscle in volved,
Isometric exercise is commonly used to increase muscle
Testing force production in the manner in which the mus­
performance. Although no joint movement occurs, isomet­
cle has been trained reflects the morphologic and neuro­
lic exercise is considered functional because it provides a
lOgiC adaptations,
strength base for dynamiC exercise and because many pos­
tural muscles work primarily in an isometric fashion (see
THERAPEUTIC EXERCISE INTERVENTION Self-Manage ment 5-1: Cl~ rvical Spine Extension for an ex­
FOR IMPAIRED MUSCLE PERFORMANCE ample of isometric exercise for postural muscles ). Isomet­
ric exercise is a valuable rehabilitation tool when joint mo­
Therapeutic activities to enhance muscle performance are tion is uncomfortable or contraindicated, du ri ng
at the core of the intervention program for man)' patients. immobilization, or when weakness exists at a specific point
is The dinician is faced vvith a multitude of variables to con­ in the ROM. Isom etric exercise is used as a special tech­
t ider when designing this program. These variables are nique in proprioceptive neuromus cular facilitation to en­
found in the intervention model in Chapter 2, Prioritizing hance stability and strengthen muscles in a weak portion of
t\.) and balancing all these variables to achieve the best patient the range, This resistive mode is easy to understand and
.i outcome requires both knowledge and experience. The fol­ perform correctly, requires no equipment, and can be per­
10vving sections vvill highlight the key variables to consider formed in almost any setting, Isometric exercise is most ef­
to when designing a resistive exercise program. fective when individuals are in a low state of training, be­
. s­ Be sure to consider another impOltant variable: the ini­ cause the benefits of isometric exercise decrease as the
a­ tial training status of the patient. Realize that recomm en­ state of training increases. Most gains_are made within the
of d tions about the intervention model variables vvill change first 5 weeks of the onset of training D ,
with the training status of the individual patient. Two p a­ Some factors are important in chOOSing isom etric exer­
b, tients vvith identical impairments may present vvith an in­ cise for rehabilitation , Isom etric strength is specific to the
T\ ' flammatory shoulder condition , one who is a regular exer­ joint angle. Studies have demonstrated isometric joint an­
ciser, lifting we ights 5 days per week and working gle specificity, noting that strength gained at one joint an­
all construction, whereas the other is a sedentary individual, gle did not predictably carry over to other joint angles%
al­ "'orking at a desk job , The initial exercis e prescription and Keuromuscular changes accoun ted for the joint-angIe-de­
,en progression plan will differ based on the diffe rence in their pendent effects, and obtaining generalized strength gain~
~ to mitial training status, required multiple-angle training programs. Whitlel '
74 Therapeutic Exercise: Moving Toward Function

patient for more advanced dynamic activities. Quadriceps

SELF-MANAGEMENT 5-1 Cervical Spine and gluteal sets are also used to enh ance circulation
throughout the lowe r extremity during periods of bed rest.
Extension Use caution wh en prescribing isometric exercise for pa­
tients with hypertension or known cardiac disease. Isomet­
Purpose: To strengthen cervical extensors. ric exercise can produce a pressor response , increasing
Position: Lying on your stomach with fists positioned blood pressure. Perform isometric exercise without breath
under your forehead and a pillow under
holding or a Valsalva maneuver. Individuals with hyperten­
your trunk; a small towel roll under your
chin may be necessary to keep your head sion may benefit from simple, repeated contractions held
in neutral. only 1 to 2 seconds.

Movement Dynamic Exercise

technique: Remove your hands from your forehead
Dynamic resistive exercise can be performed in a variety of
and hold your head in a proper neutral
position. modes, postures, and dosages , as well as with a variety of
contraction types (i. e., concentric, eccentric). Body weight,
Hold for 10 seconds.
resistive bands, free weights, pulleys, and weight machines
Dosage are a few modes of dynamic resistive exercise (see Patient­
Repetitions: ___ per set sets Related Instruction 5-2: PurchaSing Resistive Equipment).
Manual resistance applied by the cliniCian, the patient, or a
Frequency __ sessions per day, __ sessions per
family member is another form of dynamic resistive exer­
cise. Concentric and eccentric contractions can be used in
different combinations depending on the mode of exercise
chosen (i.e., free weights uses concentric and eccentric
contraction of the same muscle groups whereas manual re­
sisted exercise can use concentric contractions of opposing
muscle groups). As with isometric exerCise, each type of dy­
namic exercis e has risks and bene fits, and the training
mode must be matched to the speCific needs of the indi­
vidual . The ACSM reco mm ends that for novice and inter­
mediate training, both free weights and machines be used,
whereas the advanced and elite athletes' emphaSis should
found significantly increased strength at all joint angles af­ be primarily with free weights94
ter 10 weeks of training at specific jOint angles. Others have
found this gen eral transfer, although only after training was Weight Machine Exercise
well advanced. 96 In the beginning training phase , the "Weight machines are commonly found in rehabilitation
strength gains were transferred only when the muscle ,vas clinics and health clubs. Most of these machines work in a
at shorter than resting length. similar fashion, although some differences exist. Histori­
Beeause of the angle specificity, mu ltiple-angle isomet­ cally, most weight machines were deSigned to isolate a spe­
ric training is recommended whenever possible. Sample cific muscle group such as the quadriceps femoris or biceps
dosage parameters for isometric exercise prescription are brachii. Some equipm ent trains multiple muscle groups in
as follows: combination patterns such as a leg press or pull-up machine.

• Perform isometric contractions every 15 to 20 de­

grees thro ughout the ROM .
Patient-Related Instruction 5-2
• Hold each contraction approximately 6 seconds (the
first few seconds of the first maximum contraction ap­ Purchasing Resistive Equipment
pears to trigger the major training effect-after the Before purchasing resistive equipment for home use, the
first few seconds, the ability to maintain a maximal following information should be considered:
contraction drops off dramatically). 1. Is the equipment safe? Is it approved by a reputable
• Hold the contraction long enough to fully activate all organization?
motor units, and repeat it frequen tly throughout the 2. How easy is the equipment to use? How long will it
day. take to learn how to use it?
• Isometric contractions have their greatest effect near 3. Is the equipment versatile? Can it be used to train a
number of different muscle groups?
maximal contraction, although this may not be possi­
4. Will the equipment suit your needs as your training
ble in many clinical situations. progresses?
Isometric exercise is used for purposes other than mus­ Before purchasing equipment, consider joining a health
cle strength training. One of the benefits of isometric club for a month or two to see:
exercise is the ability to perform repetitive submaximal con­ 1. Which equipment you tend to use regularly
tractions as "reminder" or reeducation exercises. Quadri­ 2. What features you like about some equipment
ceps sets are used after injUly or surgelY to reeducate the 3. What features you dislike or seem to be lacking
person on how to activate the quadriceps. This prepares the
Chapter 5: Impairment in Muscle Performance 75

These machines usually have stacks of plates weighing 5 to

20 pounds each. The weight stack configuration varies vvith
the specific muscle action trained. A pin placed in the SELF-MANAGEMENT 5-2 Supine Shoulder
weight stack selects the amount of weight to be lifted. Flexion
An important weight machine valiable is the pulley or
cam system used. A simple pulley system provides relatively Purpose: To increase the strength of the shoulder
constant resistance through the ROM. Other machines con­ muscles, especially serratus anterior.
tain an elliptical cam that varies the resistance through the Position: lying on your back with the band tied
ROM. The cam is an attempt to account for changes caused around your foot. Hold the band in the
by varying length-tension relationships, and the machine is ipsilateral hand with the arm next to your
called a variable resistance machine. Less resistance is pro­ side and elbow bent to 90 deg rees.
vided at the beginning and end of the ROM. Movement
Weight machines also differ in their adjustability. Lever technique:
arms and seat positions should be adjustable for a variety of Level 7: Keeping your elbow bent, punch your hand
body sizes. This ensures the ability to align the joint axis towa rd the ceiling until your elbow is
with the axis of the machine and prevent injury from poor straight, then move your straight arm
posture or exercise mechanics. Stops and range-limiting upward toward your head. Press backward
devices should be available and easily adjustable. into the surface you are lying on or
An advantage of weight machines over free weights is pillow(s) as needed to support you at the
safety. Patients are stabilized effectively by the equipment, end of your range of motion. Push back
with an isometric contraction for 10
and the risk of falls or injury resulting from instability is
seconds. Return arm in reverse movement
minimized. It takes less time to learn weight machine exer­ pattern. Repeat as prescribed.
cises. After the adjustments are learned, the equipment is Level 2: Perform level one with a straight arm.
relatively easy to use, and novice weight lifters are less in­
timidated by the equipment. vVeight machines are also rel­ Dosage
atively time efficient because the machines are already set Repetitions: _ _ per set, _ _ sets
up. Only a few simple adjustments are necessary, and the Frequency __ sessions per day, __ sessions per week
patient is ready to begin.
One of the disadvantages of weight machines is their ex­
pense. An expensive machine may train only biceps,
whereas this could be done inexpensively vvith a couple of
free weights and a bar, With the weight machines , the in­
creases in weight are restricted to fLxed increments (Le.,
weight plates), Smaller changes of 1 or 2 pounds are not
n possible on most machines. Despite the many size adjust­
a ments on weight machines, they still do not fit everyone.
\lost also have a fixed , two-dimensional movement pat­ 10"£
tern. Because the machine gUides the patient through the
ROM, little proprioception , balance, or coordination is .
m learned from the experience. Most machines are deSigned
to perform bilateral exercise. In some cases, performing Free-weight training allows more discrete increases in
un ilateral exercise is difficult, if not impOSSible. resistance, and resistance can differ from one side to the
Free-Weight Exercise other (see Self-Management 5-3: Standing Biceps Curls).
Free-weight training is the resistive exercise technique For example, reCiprocal biceps curls can be performed
of choice for body builders and power lifters. Free-weight 'vvith 10 pounds on the injured side and 15 pounds on the
Lraining usually is done with a bar and weight plates , al­ uninjured side. Incremental increases of 1 to 2 pounds or
though smaller hand-held weights are available. ReSistive less are available , allOwing a more gradual overload. The
b nds , tubing, and pulleys are used in a similar fashion to free-weight equipment is affordable, and a multitude of ex­
•ree weights. One benefit of bands and pulleys over free ercises can be pe rformed vvith the same free weights .
\'eights is the ability to position the patient vvithout regard These exercises c:an include simple strengthening and en­
-0 gravity (see Self-Management 5-2: Supine Shoulder durance activities or power training techniques.
Flexion). Free weights, resistive bands, and pulleys have One of the biggest advantages of free-weight training is
dle advantage of movement in a variety of three­ the neural component of balance. Compared with the ex­
Jimensional patterns without fixed movement patterns. ternal stabilization prOvided by a weight machine, the free
This allows highly specific training that matches individual weight usually has little external stabilization. These exer­
eeds . For example, resisted lunging patterns forward, cises require postural muscle stabilization beyond the
ackward, laterally, or diagonally can be performed with work required to move the weight. The individual lifting
resistive bands, pulleys, or free weights. These movement vvith free weights must understand proper posture and
patterns can be performed in whatever range is necessary spinal stabilization to prevent injmy to the back. If bal­
or the individual, rather than in ranges dictated by a
ance is a rehabilitation goal , free weight exercise may be
-eight machine.
76 Therapeutic Exercise Moving Toward Function

The neural demands of free-weight exercise are a disad­

vantage for some. It takes longer to learn free-weight exe r­
SELF-MANAGEMENT 5-3 Standing Biceps cise, because the free-weight tasks usually are more com­
Curls plex than those with weight machines. Novice lifters may
be at greater risk for injury because of poor technique
Purpose: To strengthen the biceps muscles (Fig. 5-11 ). Spotters are necessary for many of the free­
Position' Standing position, with shoulder girdles, weight lifts, increasing the personnel demands of this resis­
spine, and pelvis in neutral. Hold a weight tive technique. Because of the time required to load and
in each hand, palms facing sideway toward unload bars, free-weight training is less time efficient.
your thighs. Safety tips for individuals training with free weights in­
Movement clude working with a knowledgeable partner who can spot
technique: safely. Collars should always be used to lock the weights on
Levell: Alternately bend your elbows, tu rning your the bar and prevent movement of the plates on the bar.
palms upward as the weights clear your Proper form and technique should be acquired before lift­
hips; and straighten your elbows, turning ing with any weight.
your palms sideways again as yo u move
Plyometric Exercise
toward your hips. Do not alter your neutral
shoulder, spine, or pelvic position as you Functional activity seldom involves pure forms of iso­
lift and lower the weight. lated isometric, concentric, or eccentric actions , because
Level 2: Bend and straighten your elbows the body is subjected to impact forces (Fig. 5-12) , as in run­
simultaneously. ning or jumping, or because some external force , such as
Hold __ pounds in each hand gravity, lengthens the muscle. In these move ment patterns,
the muscles are acting eccentrically and then concentrically.
Dosage By definition of eccentric action , the muscle must be active
Repetitions: ___ per set. ___ sets during the lengthening phase. The SSC is the combination
Frequency __ sessions per day. __ sessions per week of an eccentric action followed by a concentric action.
Training techniques that employ the SSC are called plyo­
metrics. Examples of plyometric exercises include hopping,
skipping, bounding and jumping drills for the lower ex­
tremity, and plyometric ball or elastic resistive exercises for
the upper extremity. However, not all jumping or resistive
band exercises are plyometric Plyometrics are done \vith a
specific goal in mind: to increase power and speed.
Plyometrics are qUick, powerful movements that are
used to increase the reactivity of the nervous system. Plyo­
metJics enhance work performance by storing elastic en­
ergy in the muscle during the stretch phase and reusing it
as mechanical work during the concentric phase. Bosco
and colleagues98 found that the amoun t of elastic energy
stored in a muscle during eccen tric work determines the
recoil of elastic energy during positive work. Part of the de­
veloped tension during the stretching phase is taken up by
Level 2 the elastic elements arranged in series with sarcomeres
(i.e., series elastic component or tendon). This mechanical
work is stored in the sarcomere cross-bridges and can be

FIGURE 5-11. (A) Front arm raise performed with poor technique with exce ss ive scapula elevation and (B) front
arm raise performed with improved scapula stability.
Chapter 5: Impairment in Muscle Performance 77

Sample Plyometric Activities
• Ankle bounces in place
Ankle bounces side to side
• Ankle bounces with SO-degree turn
• Ankle bounces in stride
• Single leg push ofts from box
• Lateral hopping over cones
• Forward hopping over cones
• Jump ups on box
• Side jumps on to box
GURE 5-12. The stretch-shortening cycle in dally activities. At contact • Tuckjump
muscle is stretched and contracts in a lengthening action [eccentric) • Multiple jumps forward
AI- The stretch phase is followed by a shortening [concentric) action [B) • Multiple jumps sideways
- e figure demonstrates the SSC. which is the natural form of the muscle • Split squat jump
-.nction. • Cone hops with turn
Cone hops with land and sprint
""eused during the folloV\rjng pos itive work if the muscle is Advanced
-ontracted immediately after the st retch. The muscle's • Multiple box jumps with single leg land
.iliility to use th e stored energy is determined by the timing • Squat jumps to multiple boxes
f the eccentric and concentric con tractions and by the ve­ • Depth jumps with ball catch
ocity and magnitude of stretch. A quick transition from ec­ • Standing long jump with SO-degree turn and sprint
:entric to concentric (Le., undamped landings) along V\rith • Depth jump with SO-degree turn and sprint
• Single leg bounding
high-velocity stretch of high magnitude produces the • Bounding and vertical jump combination
-rreatest benefits. The transition time between the eccen­
r tric and concentric contractions is called the amortization
phase, and the distinction between plyometrics and other
mpact activities is the goal of decreasing this phase as patient's limb for him or her. These dynamometers provide
much as possible. reCiprocal concentlic resistance at fixed speeds, and they
Plyometrics are high- level activitie s. Because of the provide multi-angle isometric resistance, fixed resistance
tored energy in the series elastic component, the tendon is concentric and eccentric con tractions, passive motion, and
usceptible to overuse injury when performing plyometrk fL'{ed speed concentlic and eccentric contractions. The re­
exercises. The individual should be in an advanced training mainder of this discussion focuses on th e isokinetic capa­
tage before these techniques are employed . In an ad­ bilities of th ese devices.
\-anced exercise program, these techniques develop power The major advantage of isokine tic resistive training is its
and speed, the key muscle performance elements of ath­ ability to fully activate more muscle fibers for longer peri­
I tics. Jumping from or to different heights, bounding (i.e. , ods. Because the machine matches the torque provided by
jumping for distance), progressive thro\\rjng programs, and the patient, it "accommodates" th e patient's changing abil­
throV\rjng for speed or distance are methods of using sse ities throughout the ROM . In contras t, free weights (i.e.,
for e nhancing speed or power performance. Before per­ fLxed resistance training) overload only the weakest portion
forming lower extremity plyometrics, the individual must of the range , but the stronger portion (usually the middle
be able to squat hi s or her body weight , perform a standing third ) is not overloaded.
long jump equal to his or her height, and balance on a sin­ Isokinetic devices allow training at a variety of speeds.
erIe leg \'1rjth eyes closed. Programs should be well-planned The positive effect of fast-speed training on performance is
and progressed slowly and appropriately for the individual highlighted \vith isokinetic training. Training at faster speeds
and the goals. An example of a plyometric program can be can assist the return to functional activities that require less
fo und in Display 5-3. See Additional Reading for more ply­ muscle torque devclopment but faster speeds of contraction .
ometric materials. Speeds that more closely match the patient's function can be
chosen to match functional velocities. Higher speeds can de­
Isokinetic Exercise crease joint compression forces in areas such as the
Isokinetic dynamom eters provide maximum resistance patellofemoml joint, decreasing the pain and discomfort of­
through the entire ROM. The first isokinetic dynamome­ ten seen with heavy resistance exercis es. Although less
ters performed resisted concentlic contractions at speeds torque is generated at high speeds, the decrease in pain and
fixed by the clinician. The dynamometer was passive in that more functional speeds may produce better results.
the machine was unable to move independently; the pa­ Studies assessing the speed variable favor slow-speed
tient was required to move the dynamometer ann. The isokinetic trainin~ over fast-speed training for the develop­
new isokinetic devices are active compu terized training ment of strength. 9 High muscular tension is necessary for
and testing devices that are capable of actively moving tlle generating strength gains and is achieved when the isoki­
78 Therapeutic Exercise: Moving Toward Function

loading through the ROM. Newer isokinetic devices have

some closed-chain components, which have the advantage
Dosage Variables for Individuals with Muscles of testing a functional movement pattem but the disadvan­
of Various Stren.!l!h Grades tage of being unable to tell where the muscle performance
impairment lies.
Muscles Fair or Below Progressing to Muscles Above Fair
1. Gravity lessened or against gravity
2. Active assistive, active, or resisted Dosage
3. Range of motion
4. lever arm length (bent elbow to straight arm) The exercise dosage can be altered in a variety of ways. In­
creasing the intensity or amount of weight is the most ob­
Muscles Above Fair Strength Grade vious means; changing the relationship to gravity, increas­
1. Type of contraction (e.g., isometric, concentric, eccentric, ing the lever arm length, increasing sets and repetitions ,
isokinetic, plyometric) decreasing the rest interval, and increasing the frequency
2. Weight or resistance are others. The dosage parameters of intensity, duration ,
3. Sets or repetitions and frequency are related and considered as training
4. Frequency of training sessions (be cautious of volume, and all must be considered when designing a
overtraining) resistive exercise program. The resistive exercise must be
5. Speed of movement (slower speed increases amount of
progressed to a functional activity to transition intervention
force or torque generated during concentric exercise)
6. Distance (E.g., running, jumping, throwing)
at the impairment level to a functional situation (Fig. 5-13).
7. Rest interval between sets Choose appropriate dosage parameters based on the needs
of the patient (Display 5-4). Determine whether the goal is
to develop muscuLr strength, power, endurance or some
combination of these muscle performance parameters.
netic speed is slow enough to allow full recruitment and Patients 'vvith low levels of function often require resis­
generation of a high resisting force. tive exercise prescriptions. Examination of many patients
Isokinetic resistive training also has disadvantages. presenting with functional limitations reveals a less than
These devices are expensive to purchase and maintain. fair grade of muscle strength. Patients ,vith fair or lower
They require trained personnel for setting up patient train­ muscle grades are unable to initiate resistive exercise
ing programs, testing, and data interpretation. From a against gravity with proper recruitment and movement pat­
biomechanical perspective, most training is done in a single terns. When resistive exercise is prescribed against gravity,
plane, with a fixed axis at a constant velocity in an open ki­ the patient is forced to train a faulty movement pattern .
netic chain. Testing and training in a Single plane improve For example, a patient may be unable to lift his or her arm
test reproducibility but do not necessarily carry over to overhead without pain. The patient is evaluated and is
function. We rarely move at a constant velocity in func­ found to have a physiologic impairment of a muscle
tional activities, although this feature prOvides for maximal strength grade of fair for the lower trapezius and serratus

FIGURE 5-13. Progression of exercise. (A) Squat progressed to (B) squat with a bag of groceries
Chapter 5 Impairment in Muscle Performance 79

anterior. The exercise prescription then is to dynamically above a grade of fair, initiate active exercise against gravity
lift a free weight in the sagittal plane through a full arc of (e.g., bent arm progressed to straight arm ) and progress to
motion. Because of the lack of strength of the lower trapez­ resistive exercise against gravity.
ius and serratus anterior, the patient lifts the arm with ex­ Dosage parameters can be manipulated for maximum
cessive scapular elevation, recruiting the upper trapezius gains in strength , power, and endurance through a system
instead of the preferred scapular upward rotation force of training called periodization. Periodization systemati­
couple of the upper, middle, lower trapezius, and serratus cally varies the training dosage to prevent "plateaus" in
anterior. This faulty pattern strengthens the upper trapez­ training gains , to maintain interest, and to provide a well­
ius and reinforces the faulty osteokinematic motion at the balanced program. Varying the training program is essential
scapulothoracic joint. The patient's functional limitation to making long-term gains in training. Periodization breaks
does not change (i.e., still has pain with overhead lifting) the training program down into cycles of a specific length
even though the straight arm lift gets "stronger" over time. and goals (i.e., hypertrophy, basic strength, power, and en­
To resolve the functional limitation of pain with overhead durance ). The cycles can vary from "minicycles" of 1 week
lifting, the impairment of the specific strengths of the lower to mesocycles of several months. Often a training program
trapezius and serratus anterior must be addressed. Because comprises a variety of cycles ofvariable lengths. Further dis­
these were tested at grades of fair or lower, resistive exer­ cussion of periodization is presented later in this chapter in
cise against gravity is an in appropriate initial exercise pre­ relation to training the advanced or elite athlete.
sCription. Give this patient an initial exercise program in a
gravity-lessened plane for the lower trapezius and serratus
anterior (see Self-Management: Serratus Anterior Progres­ Intensity
sion in Chapter 26). Lever arm length and ROM can be al­ Extensive strength training research has been performed
tered as needed pending the muscle test results. To ensure on individuals without injury. Dosage parameters to
concentric contraction during elevation and eccentric con­ increase strength began ,vith DeLorme's classic paper in
traction during lowering in a gravity lessened position, use 1945. 100 He proposed a 10 RM, 10-set regimen. Later, De­
resistive bands at the appropriate resistance. To ensure that Lorme and Watkins 35 modified this regimen to a 10 RM ,
an eccentric contraction of the upward rotators occurs dur­ three-set regimen with loads increasing progress ively for
ing the lowering phase, take care to ensure adequate resis­ each set from one half to three fourths to a full 10 RM set.
tance throughout the entire lowering phase; if resistance is DeLorme called this regimen progressive resistance exer­
e lost, the contraction becomes concentric movement of the cise, a term still used today (Table 5-2). DeLorme's three­
scapular downward rotators. After the muscle strength is set progreSSive resistance program has served as a control



DeLorme 10 1. 50lk of 10 RM 10
2. 75 % of 10 RM 10
3. 100% of 10 RM 10
Oxford 10 1. 100% of 10 RM 10
2. 7Y 7c of 10 RM 10
3. 50% of 10 RM 10
DAPRE 6 1. 50% of6 RM 10
2. 75% of6 RM 6
3. 100lk of6 RM As many as possible
4. Adjusted weight As many as possible,
based on number this number of reps
of reps performed is used to determine
in set 3" the working weight for
the next day"


Pe Iformed in Set 3° Weight for set 4° Weight for next day"

0-2 D ecrease 5-10 lb Decrease 5-10 lb
3-4 Decrease 0-5 lb Same weight
5-6 Keep weight the same Increase 5-10 lb
7-10 Increase 5- 191b Increase 5-15 lb
11 Increase 10-15lb Increase 10-20 lb

• djustments for the Daily Adjustable Progressive Res istive Exercise (DAPRE) program.
80 Therapeutic Exercise: Moving Toward Function

condition by which the effectiveness of other methods has heavy dynamiC exerc ise may be performed every other day.
been judged. F requency of one exercise is related to the exercise goal, in­
In 1951, an alternative to the DeLorme regimen was tensity, duration, and other exercises in the patient's reha­
proposed by Zinoviefflo l at Oxford. He suggested adjusting bilitation program. Individuals training for power lifting or
the intensity of the load to allow for progressive fatigue. body bUilding lift daily or twice daily, whereas individuals
This was achieved by selecting an initial load that was just in rehabilitation programs may perform resistive exercise 3
enough to permit each set to be completed. This regimen days per week and cardiovascular exercise on alternate
was called th e Oxford ted1l1 ique. McMorris and Eikins l02 days. Be sure to allow adequate time for recovery bet""'een
compared the DeLorme and Oxford techniques and found training sessions. Shortening the recovery period between
the Oxford technique to be slightly better, but the differ­ training sessions can produce perSistent fatigue. 106
ences were not statistically significant. Studies prOVide a variety of frequency recommenda­
The daily adjustable progressive resistive exercise tions, and these need to be balanced with intensity, dura­
(DAPRE ) technique has been proposed as a more adapt­ tion , initial training status, and the goals of the training.
able progressive exercise program than the Oxford or De­ Progressive resistive exercise training one time weekly with
Lorme approaches (see Table 5_2).103 This program elimi­ 1 RM for one set increases strength Significantly after the
nates arbitrary decisions about the frequency and amount first week of training and each week up to at least the sixth
of weight increase. The DAPRE program can be used "vith week los Significant increases have occurred for beginners
free weights or with weight machines. A 6 RM is used to es­ training 1 to 5 days per week
tablish the initial working weight. Thereafter, weight in­
creases are based on the performance during the previous Sequence
training session. The sequence of training muscles can affect the develop­
These gUidelines have been based on studies of unin­ ment of strength. In general, multijoint exercises are advo­
jured subjects. When treating a patient with s~ecific im­ cated for strength and power gains. However, speCific iso­
pairments, the resistive exercise dosage varies. I 4 Exercise lated muscle training is often necessary when rehabilitating
should be performed to substitution or form fatigue , the individuals with impaired muscle performance. These ex­
point at which substitution or alterations in form occur. ercises should be performed first before the patient gets fa­
tigued. Follow these exercises with multijoint functional
Duration and Volume movement patterns. For training novice, intermediate, and
Duration of resistive training can be considered the num­ advanced individuals wanting to increase strenph, the
ber of sets or repetitions of a specific exercise session and ACSM prOvides the following recommendations: 9
the amount of rest in between sets. Intensity and duration • exercise large muscle groups before small and per­
are inversely related. The greater the intensity, the fewer form multijoint before single-joint activities
repetitions are performed. • when training all major muscle groups in one training
Volume is the total number of repetitions performed session, rotate upper body and lower body activities
during a training session multiplied by the resistance used. • when training upper body and lower body muscles on
When training at a low RM (near the 1 RM or maximum different days, alternate agonist and antagonist
amount of weight that can be lifted), very few repetitions exercises
are performed, and strength gains are the chief goal. When • when training individual muscle groups, perform
training at 10 RM or higher, many repetitions are per­ higher intensity exercises before lower intensity
formed , and the goals are endurance and other aspects of exercises
muscle perFormance.
Very little stimulus is necessary to make strength gains
in the beginner. In untrained individuals, one set of 10 RM , Dosage for Strength Training
two to four times per week, may be adequate. In advanced For strength development, the ACSM recommends that
or elite athletes , multiple set routines , three times per novice and intermediate lifters train at an intenSity of 60%
week, will be necessary to achieve strength and power to 70% of 1 RM for 8 to 12 repetitions. 94 Novices should
gains. For this group, performing one set of an exercise is train the entire body 2 to 3 days per week whereas inter­
less effective for increasing strength than performing two mediate lifters should train similarly, unless desiring to
or three sets, and there is evidence that three sets are more progress to split workouts (upper body one day and lower
effective than two sets.l05 However, multiple sets pose another). In this case, the frequency should be 3 to 4 days
higher risk for injury; the refore, careful technique must be per week, allOWing training of each muscle group 1 to 2
employed to avoid injUl)'­ days/week The volume prescription should include either
The rest interval between sets is another important vari­ Single or multiple sets initially (such as the DeLorme or
able. Rest intervals will vary from less than 1 minute to 2 to DAPRE ) and progressed to periodized training using mul­
3 minutes depending on the intenSity of the lift and the tiple sets . Advanced lifters should train at 80% to 100% of
purpose of the training. Muscles can be overloaded by de­ 1 RM in a periodized plan. 94 Apply an approximately 2% to
creasing the rest interval between sets. 10% increase in load based on the muscle group and activ­
ity to progress training.
Frequency For general training purposes, it is important to train
Training frequency depends on the rehabilitation goals. both concentric and eccentric muscle actions unless one
Isometric exercise is performed several times per day, and type of action is preferred based on the pathology, impair­
Chapter 5: Impairment in Muscle Performance 81

ments, or functional limitations. For example, patients who quency is the same as for strength training, and the training
have difficulty descending stairs because of poor quadri­ velOcity should be slow 'vvhen doing a moderate (10 to 15)
ceps contro l, but no trouble ascending stairs, should em­ number of repetitions , and moderate or fast velocities when
phaSize eccentric muscle actions. performing higher numbers of repetitions (15 to 25 or more).
Slow to moderate velocities are recommended for
novice trainers unless the patient has difficulty generating Dosage for the Advanced or Elite Athlete
torque or controlling movement at a speCific functional
speed. The ACSM recommends moderate velocities for in­ The follo'vving techniques are used by those who train com­
te rmediate training, and a spectrum of velocities from un­ petitive athletes. These techniques can be used to provide
intentionally slow to fast to maximize training gains in the variety, increase resistance, or maximize the workout time
advanced and elite ath lete. 94 in daily workouts. These speciflc: techniques are not well­
For novice, intermediate, or advanced training, the studied, but do provide the recommended variability nec­
.·\CSM recommends rest intervals of 2 to 3 minutes for essary for training the advanced or elite athlete. They are
multijoint exercises using heavy loads 94 For other exer­ introduced to familiarize the therapist with the terminol­
cises (including weight machines) they recommend a ogy used in training these ath letes. Use good judgment
horter rest interval of 1 to 2 minutes. This recommenda­ based on scientific prinCiples when using these techniques.
tion is the same for developing both strength and power. A superset consists of two sets of exercise involving op­
posing muscles that are performed in sequence without a
rest between sets (e.g. , a biceps curl followed by a triceps
Dosage for Power Training extension , without rest, proceeding to the re maining sets).
Power requires a combination of strength, speed, and skill Supersets can reduce workout time or allow more exercise
and the training program should reflect these variables. Ef­ to be performed during the same period.
fI ctive use of power requires baseline strength at both fast A triset is a group of three f'xercises, each done after the
and slow speeds, the ability to generate force quickly, effi­ other with little rest between muscle groups. Trisets can be
cient use of the SSC, and good neuromuscular coordination. used to exercise three different muscle groups or three an­
For power development, one to three sets of30% to 60% gles of a complex muscle (e.g. , flat , incline, decline bench
f IRM for three to six repetitions should be incorporated press for the different fiber directions of the pectoraliS
'n to the intermediate training program 94 ProgreSSion major).
hould use various loads planned in a periodized fashion. Pyramid training is a modification of the DeLorme train­
\d anced training should include a 3 to 6 set (1-6 repeti­ ing program. The regimen stalis with a high number of rep­
tions/set) power program incorporated into the strength etitions and low weight (to warm-up), but instead of main­
program. ProgreSSion ofpower training requires both heavy taining the repetitions constant and increasing the weight,
ding (85% to 100% of 1 RM) for force development, and the repetitions are reduced and weight is increased. After
"g;ht to moderate loading (30% to 60% of 1 RM) performed the series is completed, the individual works backward, tak­
'high velOCity for increasing fast force production. 94 Focus ing off weight and adding repetitions. The number of repe­
oly on heavy loading may actually decrease power output titions and sets is arbitrarily established as long as the high­
not accompanied by quick, explosive-type exercises such repetition, low-weiaht progreSSion to a heaVier-weight,
the loaded jump squat. 94 Rest period recommendations low-repetition regimen is followed (Table 5-3).
the same as for strength training. A typical split routine consists of a series of exercises
that usually emphaSize two or three major muscle groups
or body parts. This allows the individual to train on 2 con­
osage for Endurance Training secutive days \vithout overtraining muscle groups, because
one muscle group is resting while the other is exerCising.
I 'cle endurance is necessary for a valiety of activities and
Body builders often follow a double-split routine, in which
uscle groups. For example , postural muscles must pro­
two sessions ar~ performed on each day (Table 5-4).
. e sustained or repetitive contractions for long periods,
MatveyevlO I described the basic ideas of periodized
1 h as during prolonged standing, walking, or work activ­
training programs for these athletes . A program is peri­
. Many lower extremity muscles need endurance for
odized when it is divided into phases, each of which has pri­
[) Jiletic endeavors such as distance running, tennis, or
T er sports and leisure activities . Repetitive work activities
eb as carpentry, factory work, or other manual labor re­
') e local muscle endurance to fulfill job requirements SalT!ple Pyramid Training for a Squat
'r _.mng 8- to 12-hou r work shifts, Exercise for a H!ghly Trained Individual
If For development of muscular endurance in novice and
!­ .:ennediate training, the ACSM recommends relatively SETS REPETITIONS WEIGHT
If loads with moderate to high volume (10 to 15 repeti­
1 12 100
o ). For advanced training, various loading strategies 1 8 135
d be used for multiple sets per exercise (10 to 25 rep­ 1 6 185
. ns) using a periodization scheme,94 1 4 225
n L shorter rest periods such as 1 to 2 minutes for high 1 2 250
Ie tition (15 to 20 repetitions) and less than 1 minute for 1 1 275
r- erate (10 to 15 repetitions) sets 94 The training fre­
82 Therapeutic Exercise Moving Toward Function

Example of a Split Routine for Total­

patients with cardiopulmonary disease or after recent ab­
Body Resistive Training
dominal, interveliebral disk, or eye surgery. Educate pa­
tients to breathe properly during exercise, typically exhal­
SIX-DAY, TWO SESSIONS ing on exertion. Use isometric exercise with caution by
FOUR-DAY PROGRAM* PER DAY PROGRAM* persons at risk for pressor response effects (e.g., high blood
pressure after an aneurysm).
Monday: upper body Monday AM: chest During resistive training, especially in an untrained
Tuesday: lower body Monday P~I: back state, minor lesions of the muscle structure and inflamma­
Wednesday: rest Tuesday AM: shoulders tion resulting in muscle soreness are common. Soreness
Thursday: upper body Tuesday PM: upper legs
Friday: lower body Wednesday AM: triceps
may be caused by myofibrillar damage localized to the Z
Saturday: rest Wednesday PM: biceps band, membrane damage, or inflammatory processes. The
Sunday: repeat sequence Thursday AM: chest serum or plasma level of creatine kinase is elevated and is
Thursday P~I: back an indicator of muscle damage, because the enzyme is
found almost exclusively in muscle tissue. Delayed sore­
•Abdominal and calf muscles are exercised each day. ness, clearly linked to eccentric activity, usually peaks
about 2 days after exertion. Muscle function deteriorates,
and muscle strength may be reduced for a week or more af­
mary and secondary goals. The program is based on the ter intensive eccentric exercise. However, an adaptive pro­
premise that maximum stl"ength gains are not made by con­ cess reduces the soreness after repeated training ses­
stant heavy training but are made possible by different sions. lOD Even during the soreness period, moderate
training cycles or periods. These cycles allow the athlete to activity is advised, because the adaptation response occurs
reach maximum performance level at a predesignated before full recovery and restoration of muscle function. Pa­
time, usually the day of competition. tients should be cautioned that eccentric training may lead
In his original model, Matveyev l07 suggested the initial to muscle soreness 24 to 48 hours after exercise, but that
phase of a strength-power program should contain a high moderate exercise should continue during the recovery pe­
volume (Le., many repetitions) with lower intensity (i.e., low riod. A somewhat different type of soreness and reduced
average weight lifted relative to maximum possible in each muscle function may occur during very long and intense ex­
movement). Typical high-volume phases for weight lifters ercise bouts. It is probably related to the total metabolic
contain more training sessions per week (6 to 15), more ex­ load, not muscle tension development. lOg
ercises per session (3 to 6), more sets per exercise (4 to 8), Overwork phenomena may exist even at moderate train­
and more repetitions per set (4 to 6). As weeks pass, the vol­ ing regimens over an extended period. Overtraining may
ume decreases and intensity increases. The resulting higher lead to mood disturbances and reduce the effect of training
intensity and lower volume represent the characteristics of by a decrease in performance. Avoid fatigue and overtrain­
a basic strength phase of training. Typical high-intensity ing by patients 'vvith metabolic diseases (e.g., diabetes, al­
phases for weight lifters contain fewer training sessions per coholism), neurologiC diseases, or severe degenerative joint
week (5 to 12), fewer exercises per workout session (l to 4), diseases because of the risk of further jOint damage. Over­
fewer sets per exercise (3 to 5), and fewer repetitions per set training may be the reason for a lack of progress, decreased
(1 to 3). A third, optional phase may include low volume performance, or development of joint pain and swelling.
(low repetitions) with high intensity (heavyweights) to work Care should be taken when developing resistive exercise
on power. The final phase is considered an active rest phase programs for prepubertal and pubertal children and ado­
'vvith very low volume and very low intensity. lescents. Minimize stress to epiphyseal sites and develop
Each phase may be several weeks to several months long. balanced exercise programs to avoid muscle imbalances.
Two or more complete cycles may fit into a training year. An absolute contraindication to resistive exercise is
Stone and colleagues l08 proposed and successfully acute or chronic myopathy, as occurs in some forms of
tested a periodized model of strength-power training with neuromuscular disease or in acute alcohol myopathy. Re­
sequential phases that change rather drastically. An exam­ sistive exercise in the presence of myopathy may stress and
ple is a phase to increase muscle size (five sets of 10 RM in permanently damage an already compromised muscular
core exercises), a phase to improve specific strength (three system.
to five sets of 3 RM), and a phase to "peak" for competition Scientific knowledge and common sense should be ap­
(one to three sets of one to three repetitions). The use of 10 plied in prescribing resistive exercise. Caution should be
RM is higher than typically recommended in the early taken with exercise in the presence of pain, inflammation,
preparation phase but has proved to be successful in a and infection. Although resistive exercise may be indicated.
number of studies. 108 the mode and dosage should be carefully chosen.


• The term muscle pe1formance includes strength, power,
Be sure to consider certain precautions and contraindica­ and endurance.
tions when prescribing resistive exercise. Avoid using the • The term strength should be clarified in terms of force,
Valsalva maneuver during resistive training, especially by torque, and work.
Chapter 5 Impairment in Muscle Performance 83

• Muscle actions are static and dynamic. Static muscle ac­ • Impaired muscle performance can result from neuro­
tions are called isometric. logiC pathology, muscle strain, muscle disuse, or length
• A thorough knowledge of muscle morphology is neces­ associated changes.
sary for effective/efficient therapeutic exercise prescrip­ • Adaptations to resistive training extend beyond the mus­
tion to improve muscle performance. cle to include connective tissues , the cardiovascular sys­
• Dynamic action is the preferred term over isotonic. Dy­ tem , and bone.
namic actions can be further divided into concentric and • Activities to improve muscle performance include iso­
eccentric actions. metric, dynamiC, plyometric, and isokinetic exercise.
• The sliding filament theory describes the events that oc­ • Dynamic exercise can be performed with a variety of
cur during muscle contraction. modes , including free weight, resistive bands, pulleys,
• Basic muscle fiber types are slow oxidative, fast gly­ weight machines, or body weight; including various
colytic, and fast oxidative glycolytic. com binations of concentric and eccentric contractions.
• Force gradation occurs by rate coding and the size prin­ • Plyometric activities use the stretch-shortening cycle
Ciple. to enhance muscle performance.
• Overload training produces changes in the size of the • The dosage of exercise to improve muscle performance
musde primarily through hypertrophy but also through depends on the goal (i.e., strength , power, and en­
hyperplasia. durance) as well as the initial fitness level of the individ­
• :\1uscle strength must be evaluated relative to the mus­ ual (i.e., novice, intermediate, advanced, and elite ).
cle's length because of length-tension relationships. • Precautions and contraindications to resistive exercise
• :\1uscle architecture can Significantly affect muscle force must be known to ensure safety to the patient/client.
• Specificity of training exists, especially relative to train­
• Adaptations to resistive training are partially neurologic -----
ill that changes in performance often precede morpho­ 1. Consider each of the questions in the Lab Activities in
logiC changes. the next section. How would your dosage differ if you
• Form fatigu e is the point at which the individual must were training for
discontinue the exercise or sacrifice technique. a. strength
• . lthough dosage and goals differ, resistive training is b. power
beneficial from late childhood through old age. c. muscle endurance


1. A series of musculoskeletal conditions is listed from i Musculoskeletal and neuromuscular conditions

to viii. For each condition, perform the following:
i. Achilles tendinitis
a. Determine which muscles are involved. In­ ii. Iliotibial band fascitis
clude possible underused synergists that may iii. Patellar tendinitis
lead to overuse of the muscle involved. List iv. Hamstring strain
each muscle and describe its specific: action. v. Peroneal nerve palsy (i.e. , common peroneal
r b. Design and perform one exercise for each mus­ nerve) (list muscles innervated)
cle (group) given the manual muscle test grade vi. Supraspinatus tendinitis
of fair minus (3-/5). Include complete dosage vii. Middle trapezius strain resulting from over­
parameters. stretch
c. Design and perform two exercises for each viii. Lateral epicondylitis
musde (group) given the manual muscle test
grade of good (4/5). Use an elastic band for one 2. Using free weights or a weight machine, determine
and a free weight for the other, and include the 1 Ri\lI , 6 RM , and 10 RM for a bench press and
complete dosage parameters. leg extension . Determine the dosage for Oxford. De­
d. Progress the exercises in question lc to two Lorme, and DAPRE programs.
functional activities. 3. Pick three muscle groups throughout your body (one
upper quarter, one lower quarter, and one trunk).
Design two different resistive exercises for each mus­
I cle group using a variety of equipment, including
elastic bands, free weights, and pulleys and weight
machines if available. Determine the dosage for a
.. DeLorme program .
84 Therapeutic Exercise: Moving Toward Function

2. Design a muscle performance program for a woman 17. Schultz E, Jarysza k DL, Gibson MC, et al. Absence of
confined to bed rcst for 3 weeks after an acute lumbar exogenous satellite cell contlibution to regeneration of frozen
fracture without neurologic involvement. Include skeletal muscle. J Musclc Res Cel! MotiI1986;7: 361-367.
dosage parameters for strength and endurance. 18. MacDougall JD , et al. Muscle fiber number in biceps
3. Consider Case Study #5 in Unit 7. List muscles with brachii in body builders and control subjects. J Appl Physiol
1984;57: 1399-1403 .
impaired muscle performance. Determine whether 19. Herzog W, Ait-Haddou R. Mechanical muscle models and
the muscle requires strength, endurance, or power their application for force and power production. In: Komi
training. Decide on one activity for each muscle and PV, ed. Strength and Power in Sport, 2nd ed. Malden, ~"lA:
determine the dosage relative to the goal (i.e., Black-veil Scientific Publications, 2003.
strength, power, and endurance) and initial fitness 20. TabaI)' JC, Tabary C, Tardieu C, et al. PhYSiolOgical and
level for this patient. Develop the sequence of exercise structural changes in the eat's soleus muscle due to immobi­
for each session and include the frequency in the lization at different lengths by plaster cast. J Physiol 1972;
dosage parameters. 224:231-244.
21. Oude t CL, Petrovic AG. Regulation of the anatomical
length of th e lateral pterygoid muscle in the growing rat.
Adv Physiol Sci 1981;24:115-121.
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Testing and Prescription. 2nd ed. Philadelphia: Lea & quency on the dynamiCS of performance response to a Single
Febiger, 1993. training bout. J Appl Physiol 2002;92:572~80.
91. Interactive Guide to Physical Therapist Practice, vol 1.0. 107. Matveyev LP. Periodisienang das Sportlichen Training.
Alexandria, VA: American Physical Therapy Association, Berlin: Beles Wernitz, 1972.
2002. 108. Stone MH , O'Bryant H, Garhammer J. A hypothetical
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review for the coach and athlete. Can J Appl Sports Sci 1981;21:342-351.
1981;6:87-92. 109. Friden J, Seger J, Sjostrom M, et al. Adaptive response in
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94. Kraemer vVJ, Adams K, Cararelli E, et al. Amel1can College
of Sports Medicine position stand. ProgreSSion models in re­
sistance training for healthy adults. Med Sci Sports Exerc ADDITIONAL READING
2002;34:364-380. Chu DA. Jumping into Plyometrics. Champaign, IL: Human Ki­
95. Atha J. Strengthening muscle. Exerc Sport Sci Rev 1981; netics Publishers, 1992.
9:1-73. Gans C, Bock WJ. The functional Significance of muscle architec­
96. Muller EA. Influence of training and of inactivity on muscle ture-a theoretical analysis. Ergeb Anat Entwickel Gesch
strength. Arch Phys Med Rehabil1970;51:449--462. 1965;38:115--142.
Chapter 6

Im paired Aerobic Capacity/Endurance


nary healt disease, and is associated with lower mortality

Physiology of Aerobic Capacity and Endurance rates in both older and younger adults. l-3 Despite this evi­
Definitions dence, recent surveys of exercise trends among inhabitants
Energy Sources Used During Aerobic Exercise of the United States (U.S.) illustrates that apprOXimately
Normal and Abnormal Responses to Acute Aerobic Exercise 15% of U.S. adults perform vigorous physical activity (3
Physiologic and Psychologic Adaptations to Cardiorespira­ times per week for at least 20 minutes) during leisure time,
tory Endurance Training approximately 22% partake in sustained physical activity (5
times per week for at least 30 minutes) of any intensity dur­
Causes of Impaired Aerobic Capacity/Rehabilitation
ing leisure time, and about 25% of adults perform no phys­
Indications ical activity in leisure time. l Adolescents and young adults
Examination/Evaluation of Aerobic Capacity (ages 12 to 21) are similarly inactive and approximately
Patient/Client History
50% regularly participate in vigorous physical activity.l
Systems Review
Because of the widespread prevalence of physical inac­
Screening Examination
tivity among the U.S . population, the U.S . Public Health
Tests and Measures
Service has created goals for exercise participation in the
LI Healthy People 2000 and the Healthy People 2010 docu­
Therapeutic Exercise Intervention ments, aimed at im~~oving the quality and increasing the
years of healthy life. ' ·J In addition , the U.S. Department of
n Dosage
Health and Human Services, the Centers for Disease Con­
c trol and Prevention, the National Center for Chronic Dis­
Precautions and Contra indications
ease Prevention and Health Promotion, the President's
Graded Exercise Testing Contraindications and Supervision
Council on PhYSical Fitness and Sports, and the American
Guidelines College of Sports Medicine (ACSM ) recommend that all
Supervision During Exercise adults should accumulate 30 minutes or more of moderate­
i- Patient-related Instruction/Education and Adjunctive intensity physical activity on most, and preferably all, days
Interventions of the week. I .6 Tovvard this end, health care profeSSionals
have an opportunity to contlibute to the overall well-being
h Lifespan Issues of the patients and clients we serve by prescribing mean­
Guidelines for Cardiovascular Endurance Training in the ingful exercise programs based on the most contemporary
Young sci en tific evidence. In this chapter, the scientific basis of
Guidelines for Cardiovascular Endurance Training in the aerobic training \vill be presented along with guidelines for
Elderly prescribing and supervising aerobic exercise.

Cardiovascular endurance is the ability of the cardiovascu­ PHYSIOLOGY OF AEROBIC CAPACITY

lar system (i.e., heart, lungs, and vascular system) to take in, AND ENDURANCE
l'xtract, deliver, and use m.:ygen and to remove was te prod­
ucts. Cardiovascular endurance, or aerobic capacity, sup­ Definitions
ports the performance of repetitive activities using large
muscle groups for extended peliods. Clients and patients There are many terms used in relationship to aerobic ca­
who work at home or on the job, participate in athletic pacity and exercise that require clarification. Physical ac­
endeavors of all levels, skill, and type, and who perform tivity has been defined as any bodily movement produce~
physical activity for fun or leisure, require adequate aero­ by skeletal muscles that results in energy expenditure. (
bic capacity. Concurrently, these activities also improve Similarly, exercise is a type of physical activity that is
impairments in a robic capacity, and are thus useful thera­ planned, structured, repetitive, and is purposely aimed at
peutically in a rehabilitation setting. improving physical fitness. 7 Physical fitness is a set of at­
The literature contains convincing evidence that the tributes that people have or achieve and includes compo­
regular performance of cardiorespiratory endurance activ­ nents of health-related (cardiorespiratOlY endurance, body
ities reduces the risk of developing disease, such as coro­ composition, muscular endurance, muscular strength ,

88 Therapeutic Exercise: Moving Toward Function

flexibility) and athletic-related skills.' Being physically fit Protein is us ed as an energy source in cases of starvation
thereby enables an individual to perform claily tasks vvith­ or extreme energy depletion and it provides approxi mately
out undue fatigue and with suffici ent en ergy to enjoy 5% to 10% of th e total energy needed to perform en­
leisure-tim e activities and to respond in an emergency sit­ durance exercise. Protein yields approximately 4 kcal of en­
uation , if one arises. ergy per gralll and is not a preferred energy source under
Cardiorespiratory endurance training, or repetitive normal conditions 8
movements of large muscle groups fueled by an adequ ate>
response from the Circulatory and respiratory systems to Metabolic Pathways
sustain physical activity and eliminate fatigue, is designed ATP-PCr System
to achieve physical fitness.! Said another way, cardiorespi­ The first pathway is anaerobic, meaning th at it does not
ratOlY endurance is the ability of the whole body to sustain require m.ygen to function, although it also can occur in
prolonged exercise." Another term for cardiorespiratOlY the presence of oxygen. This pathway is called the ATP­
endurance training is aerobic training, indicating the role PCr system, where PCr stands for phosphocreatine Or cre­
of oxygen in the performance of this type of exercise . atine phosphate. s As vvith ATP , PCr is a high-energy com­
Anaerobic training, on the other hand, involves exercise pound found in skeletal muscle cells that functions to
performed in short bursts that does not require an ongOing replenish ATP in a working muscle, extending the time to
supply of oxygen, such as strength training. s fatigue by 10 to 20 seconds. 9 Thus energy released as a re­
The highest rate of m:ygen that the body can consume sult of the breakdown of PCr is not used for cellular
during maximal exercise is termed aerobic capacity , maxi­ metabolism , but rather to prevent ATP levels from falling.
mal oxygen uptake, or V0 2 max 8 V0 2 max is considered One molecule of ATP is produced per molecule of PCr.
the gold standard measurement of cardiorespiratory This simple energy system can produce 3 to 15 seconds of
endurance and aerobic fitness and can be measured in maximal muscular work8 and requires an adequate recov­
absolute (liters/minute) or relative (milliliterslkilograms/ . ery time, genera]]y three times longer than the duration of
minute) terms. s the activity.
Glycolytic System
Energy Sources Used During The production of ATP during longer bouts of activity,
Aerobic Exercise such as that required to address an aerobic capacity im­
pairment, requires the breakdown of food energy
To base exercise prescription on sound scientific princi­ sources.'s In the glycolytic system, or during anaerobic gly­
ples, it is important to understand and differentiate the fuel colysiS, ATP is produced through the breakdovm of glu­
sources and the metabolic pathways used during the per­ cose, obtained from the ingestion of carbohydrates or
formance of aerobic exercise. The performance of aerobic from the breakdovm of stored liver glycogen. Anaerobic
exercise requires readily available energy sources at the glycolysis also occurs ,vithout the presence of oxygen, but
cellular level. Ingested food, comprised of carbohydrate, is much more complex than the ATP-PCr pathway, re­
fat , and protein, is converted to and stored in the cell as quiring numerous enzymatic reactions to break dovm glu­
adenosine triphosphate (ATP) , the body's basic energy cose and produce energy (Fig. 6-1). The end product of
source for cellular metabolism and the performance of glycolysis is pyruvic add , or pyruvate which is converted
muscular activity. Each food source has a unique route to lactic acid in the absence of oxygen, and the net energy
whereby it is converted to ATP. There are three methods, production from each molecule of glucose used is two
or metabolic pathways, by which ATP is produced. s molecules of ATP, or three molecules of ATP from each
molecule of glycogen . Although the energy yield from the
Fuel Sources glycolytic system is small, the combined energy produc­
Carbohydrate, including sugars, starches, and fibers, is the tion of the ATP-PCr and glycolytic pathways enables mus­
preferred energy source for the body, is the only fuel capa­ cles to contract ,vithout a continuous ~».ygen supply, and
ble of being used by the central nervous system, and is the thus provides an energy source in the first part of a high­
only fuel that can be used during anaerobic metabolism. intensity exercise until the respiratOlY and Circulatory sys­
Carbohydrates are converted to glucose and stored in mus­ tems catch up to the sudden increased demand placed on
cle cells and the liver as glycogen, ,"lith approximately 1,200 them. FUliher, the glycolytic system can only prOvide en­
to 2,000 kcal of energy stored in the form of carbohydrate. ergy for a limited tim e because the end product of the
Each gram of carbohydrate ingested produces approxi­ pathway, lactic acid , accllll1ulates in the muscles and in­
mately 4 kcal of energy8 hibits further glycogen breakdown and eventually im­
Fat can also be used as an energy SOurce and is the pedes muscle contraction. 8
body's largest store of potential energy, about 70,000 kcal
in a lean adult. s However, the basic storage form of fat use­ Oxidative System
ful as an energy source, triglyceride, must be broken down The production of ATP from the breakdown of fuel
into free fatty acids (FFA) and glycerol before FFAs can be sources in the presence of oqgen is termed aerobic oxida­
used to form ATP by aerobic oxidation. The process of tion or cellular respirationS ATP is produced in the mito­
triglyceride reduction, termed lipolYSiS, requires Significant chondria, cellular organelles conveniently located next to
amounts of oxygen, thus carbohydrate fuel sources are myofibrils, the contractile elements of individual muscle
more efficient than fat fuel sources 9 and are thus preferred fibers. The oxidative production of ATP involves several
during high-intensity exercise. From each gram of fat 9 kcal complex processes, including aerobic g~colySiS, the Krebs
of energy is produced. cycle, and the electron transport chain. (Fig. 6-2)


@~ • hexokinase

glucose 6-~lhosp~latEl .._ _ _ _ _~,lIjill





I f) phosphofructo­

fructose 1, 6-diphosphate
e H21_;:/Q~H2 •

• Aldolase HO H

¢;::=====:I dihydroxyacetone
9 trlosephosphate phosphate
Isomerase ..J.
3-phosphoglyceraldehyde 3-phosphoglyceraldehyde

., 7°

+-1. - - J lglyceraldehyfJ! 3-phosphate 't-- (~,
,~., + fDl

1, 3-diphosphoglycerate 1, 3-diphosphoglycerate

To electron
phoS_/~m"~ ....

chain 3-phosphoglycerate 3-phosphoglycerate

11 phoSPhogrtm~. ,

" ::{IIy'~I' enolse "'''"'j O'' ' ' '

phosphoenolpyruvate phosphoenolpyruvate

pyruvate kinase

Lactate 1Q • Lactate
lactate lactate
dehydrogenase dehydrogenase

FIGURE 6-1. The derivation of energy (ATP) via glycolysis An overview of the breakdown of glucose (a six-car­
bon molecule) and glyco gen (a chain of glucose molecules) to two three-carbon molecules of pyruvic acid. Note
that there are ro ughly 10 separate steps in thi s anaerobic process. (From McArdle W, Katch F, Katch V. Exercise
Phys iology: Energy, Nutrition, and Human Performance, 5th ed . Baltimore Lippincott Williams & Wilkins, 2001)
90 Therapeutic Exercise: Moving Toward Function

Carbohydrate or glycogen is broken down in aerobic Normal and Abnormal Responses to

glycolysis, Similarly to the breakdown of carbohydrate in
anaerobic glycolysis, but in the presence of oxygen pyru­
Acute Aerobic Exercise
vic acid is converted to acetyl coenzyme A (acetyl CoA).s Normal Responses to Acute Aerobic Exercise
Acetyl CoA undergoes a number of complex chemical re­ To assess an individual's response to exercise, it is impor­
actions in the Krebs (citric acid ) cycle, producing two tant to understand the normal phYSiologic changes that oc­
molecules of ATP (Fig. 6-2). The end result of the Krebs cur as a result of the performance of physical activity. The
cycle is the production of carbon dioxide and hydrogen ability to sustain aerobic exercise depends on numerous
ions , which enter the electron transport chain, undergo a cardiovascular and respiratory mechanisms aimed at deliv­
series of reactions, and produce ATP and water. Thirty­ ering oxygen to the tissues. The follOwing changes would
nine molecules of ATP are produced from one molecule be eA'Pected during aerobic exercise and would be consid­
of glycogen or .38 molecules of ATP from one molecule of ered normal responses.8-12
glucose (one ATP is used in the conversion of glucose to
glycogen )8 The presence of oxygen thus enables signifi­ Heart Rate
cantly more energy to be produced and results in the abil­ There is a linear relationship between heart rate (HR),
ity to perform longer periods of work without the measured in beats/min, and intensity of exercise, indicating
impedance of muscle contraction created by the build up that as workload or intenSity increases, HR increases pro­
of lactic acid. Figure 6-3 summarizes and compares the portionally. The magnitude of increase in HR is influenced
energy production capabilities of the three metabolic by many factors, including age , fitness level, type of activity
pathways. being performed, presence of disease, medications , blood
volume, and environmental factors such as temperature and
Metabolic Pathway and Fuel Source Selection
During Exercise Stroke Volume
High-intensity, brief-duration exercise (efforts of less than The volume or amount of blood ejected from the left
15 seconds ) is accomplished using stored ATP in the muscle ventricle per heart beat is termed the stroke volume (SV),
for energy created via the ATP-PCr pathway. High-in tensity, measured in mLibeat. As workload increases, SV increases
short-duration exercise (efforts of 1 to 2 minutes' duration ) linearly up to approximately 50% of aerobic capacity, after
relies on the anaerobic pathways, including the ATP-PCr which it increases only slightly. Factors that influence the
and glycolysis systems for the provision of ATP. High­ magnitude of change in SV include ventricular function,
intensity, brief-duration and high-intensity, short-duration body pOSition, and exercise intensity.
exercise thus use carbohydrate or glucose as the fuel sources
Submaximal exercise efforts use carbohydrate, fat, and Cardiac Output
protein for energy. Low-intensity (less than 50% of maxi­ The product of HR and SV is cardiac output (Q ), or the
mal oA),gen consumption) exercise performed for long du­ amount of blood ejected from the left ventricle per minute
ration uses both FFA and carbohydrate fuel sources "vithin (Llmin ) (Q = HR X SV). Cardiac output increases linearly
the aerobic oxidative pathway to produce ATP. 9 As exercise with workload because of the increases in HR and SV in re­
duration increases or intenSity decreases, and in the pres­ sponse to increasing exercise intenSity. Changes in Q de­
ence of an abundant supply of oxygen, the body will use a pend on age, posture, body size, presence of disease, and
higher level of FFA oxidation compared with carbohydrate level of physical conditioning.
fuel sources for ATP production . During work loads of
moderate to heavy intensity (greater than 50% of maximal Arterial-Venous Oxygen Difference
oxygen consumption), the proportion of carbohydrate used The amount of oxygen extracted by the tissues from
for ATP production increases and the proportion of FFA the blood represents the difference between arterial
used decreases. This same relative proportion of carbohy­ blood oxygen content and venous blood oxygen content
drate and FFA use continues as workload approaches max­ and is referred to as the arterial-venous oxygen differ­
imal exercise capaCity. Above maxim al levels, exercise is ence (a-v02 diff) , measured in mLidL. As exercise in­
anaerobic and thus can only be performed for a short tirrie. 9 tenSity increases, a-v02 diff increases linearly, indicating
As noted earlier, protein partiCipates as an energy source that the tissues are extracting more oA),gen from the
only in eAiremely deficient situations (e.g. , starvation) and blood, decreaSing venous oxygen content as exercise
minimally during endurance exercise. progresses.
To summarize, carbohydrate is the preferred fuel
source for the production of ATP to supply the body with Blood Flow
energy during exercise. Exercise can occur anaerobically, The distribution of blood flow (mL) to the body changes
via the ATP-PCr or anaerobic glycolYSiS pathways, or aero­ dramatically during acute exercise. Whereas at rest, ap­
bically, via the aerobic oxidative pathway. The oxidative proximately 15% to 20% of the cardiac output goes to mus­
pathway has the greatest ATP yield and enables exercise to cle, during exercise approximately 80% to 85% is dis­
continue for prolonged periods without the fatigue caused tributed to working muscle and shunted away from the
by lactic acid buildup. To support the aerobic needs of pro­ viscera. During heavy exercise, or when the body starts to
longed exercise, numerous changes occur in the cardiovas­ overheat, increased blood flow is delivered to the skin to
cular and respiratory systems, which "vill be discussed in conduct heat away from the body's core, leaving less blood
the follOwing section. for working muscles.
Chapter 6: Chapter Impaired Aerobic Capacity/ Endurance 91



FIGURE 6-2. After glucose and glycogen have been reduced to pyruvate, IPhase I) pyruvate is catalyzed to
acetyl CoA, which can enter the Krebs cycle or citric acid cycle, where oxidative phosphorylation occurs. Hydro­
~e gen released during the Krebs cycle then combines with two coenzymes that carry the hydrogen atoms to the
to electron transport chain IPhase 11). IFrom McArdle W, Katch F, Katch V. Exercise Physiology Energy, Nutrition,
to and Human Performance, 5th ed . Baltimore Lippincott Williams &Wilkins, 2001)
92 Therapeutic Exercise Moving Toward Function

ATP-P~~ • • Oxidative

..... ...... ..
~ 100

J........ .

~ 80 .............

FIGURE 6·3. Energy producti on capabilities of the three metabolic ~ ..:....:: ..

pathways. This figure depicts the actions and interactions of the ATP­ ~ 60 ...... .'
.. .. ..
phosphocreatine, glycolytic, and oxidative metabolic pathways. High-in­
'0 II
.. ..
tensity, brief duration exercise is fueled by the ATP-phosphocreatine ~ 40 .................

pathway, whereas high-inten sity, short-duration exercise relies on the

glycolytic pathway, both of which are anaerobic . The aerobic oxidative
pathway provides energy for muscular contraction during prolonged ex­
() 2° 11 ., ......
ercise of low to mode rate intensity. (From Bezner J Principles of aero­
'#­ ... -......
bic conditioning. In: Bandy WD, Sanders B, eds. Therapeutic Exercise.
40 80 120 180
Techniques for Intervention. Baltimore Lippincott Williams & Wilkins,
2001) Work time (sec)

Bl ood Pressure prescription and as an indication that further djagnostic

The two components of blood pressure (BP), systolic testing may be indicated.
(SBP) and diastolic (DBP) pressure, respond differently In general, responses that are inconsistent ,vith the nor­
during acute bouts of exercise. To facilitate blood and oxy­ mal response gUidelines described previously are consid­
gen delivelY to the tissu es, SBP increases linc<.lrlywith work­ ered abnormal responses. Of the parameters described, HR
load. Because DBP represents the pressure in the arteries and BP are most commonly assessed dUling exercise. The
when the heali is at rest, it changes little during aerobic ex­ failure of HR to lise in propOliion to exercise intensity, a
ercise, regardless of intensity. A change in D BP ofless than failure of SBP to rise or a decrease in SBP 2: 20 mm Hg dur­
15 mm Hg from the resting value is considered a normal re­ ing exercise, and an increase in DBP 2: 15 mm Hg would all
sponse. Both SBP and DBP are higher during upper ex­ be examples of abnormal responses to aerobic exercise l l
tremity aerohic activi.ty, compared to lower extremity aero­ Signs and symptoms of exercise intolerance should also
bic activi.ty. This increase is thought to be due to increased be recognized und include those usted in Display 6-1. Ab­
resistance to blood How and a resulting increase in blood normal exercise responses, such as failure of HR to rise, of­
pressure to overcome the increased resistance as a result of ten occur with exercise intolerance, defined as patient­
the smaller !l1usde mass and vasculature of the upper ex­ related signs and symptoms; however, they can occur
tremities compared to the lower extremities s independently so the clinician should be familiar "vith both.
Knowledge of the normal and abnormal phYSiologic and
Pulmonary Ventilation symptom responses to exercise will enable the clinician to
The respiratory system responds during exercise by in­ prescribe and monitor exercise safely and confidently and to
creasing th e rate and depth of breathing in order to in­ minimize the occurrence of untoward events during exer­
crease the amount of air exchanged per minute (Umin ). An cise. Regular exposure to aerobic exercise results in changes
immediate increase in rate and depth occurs in response to to the cardiovascular and respiratOlY systems that can also be
exercise and is thought to be facilitated by the nervous sys­ assessed by monitoring basic phYSiolOgiC variables durin&
tem, initiated by th e movement of the body. A second, rest and exercise. These adaptations will be discussed next. L
more gradual, increase occurs in response to body temper­
ature and blood chemical changes as a result of the in­
creased oxygen use by the tissues. Thus both tidal volume,
or the amount of air moved into and out of the lungs dur­
ing regular breathing, and respiratory rate (RR) increase in
proportion to the intensity of exercise. Angina, typically manifested as chest, left arm, jaw, back or
lower neck pain or pressure
Abnormal Responses to Aerobic Exercise • Unusual or severe shortness of breath
Individuals with suspected cardiovascular disease or any • Abnormal diaphoresis
other type of disease that may produce an abnormal re­ • Pallor, cyanosis, cold and clammy skin
• Central nervous system symptoms such as vertigo, ataxia,
sponse to exercise should be appropriately screened and
gait problems, or confusion
tested before th e initiation of an exercise program. This • Leg cramps or intermittent claudication
topic will be discussed in greater Q(;taillater in this chapter. Physical or verbal manifestations of severe fatigue or
However, abnormal responses may occur in individuals shortness of breath
without known or docllmented disease and thus routine ACSM Resource manual for Guidelines for Exercise Testing
monitoring of exercise response is important and can and Prescription, :rd Edition
be used to evaluate the appropriateness of the exercise
Chapter 6 Chapter Impaired Aerobic Capacity/ Endurance 93

Physiologic and Psychologic HR and SV (Q = HR X SV), it does not change much at rest
Adaptations to Cardiorespiratory or during submaximal exercise because HR decreases and
SV increases. However, because of the increase in maximal
Endurance Training SV, maximal Q increases considerably.811 .12
In healthy individuals, cardiovascular training produces Adaptations also occur in the vascular system and inc.:!ude
profound changes throughout the cardiorespiratory and blood volume, blood pressure, and blood flow changes. Aer­
vascular systems. The documented benefits of aerobic ex­ obic training increases overall blood volume, pIimaIily be­
ercise are a result of the adaptations the oxygen delivery cause of an increase in plasma volume . The increase in hlood
system undergoes secondary to the performance of regular plasma results from an increased release of hormones (an­
activity. These adaptations, considered chronic changes, tidiuretic and aldosterone) that promote water retention by
enable more efficient performance of exercise and thus af­ the kidney and an increase in the amount ofplasma proteins,
fect cardiorespiratory endurance and fitness level. These namely albumin. A small increase in the number of red blood
chronic adaptations occur in the cardiovascular and respi­ cells may also contribute to the increase in blood volume.
ratory systems and affect the values of both V0 2 max and The net effect of greater blood volume is the delivery of
body composition (see Display 6-2). more oxygen to the tissues. Resting blood pressure changes
with training are most noteworthy in hypertensive or bor­
Cardiovascular Adaptations derline hypertensive individuals, in whom aerobic training
Factors involving the heart that adapt in response to a reg­ can decrease both SBP and DBP up to 10 mm Hg . During
ular exercise stimulus include heart size, HR, SV, and CO. the performance of submaximal and maximal exercise, there
The weight and volume of the heart and the thickness and is little change, if any, in blood pressure as a result of train­
chamber size of the left ventIicle increase in trained indi­ ing. Several adaptations are responsible for the increase in
\riduals. As a result, the heart pumps more blood out per blood flow to muscle in a trained individual , including
beat (SV) and the force of each contraction is stronger. SV greater capillarization in the trained muscle (s), greater
is thus increased at rest, as well as duIing sub maximal and opening of existing capillaIies in trained m uscle(s), and more
maximal exercise, because of more complete filling of the efficient distIibution of blood flow to active muscles 8 ,11,l2
left ventricle duIing diastole compared with an untrained
heart and an increase in plasma blood volume, discussed in Respiratory Adaptations
the follov\ring section. Changes to HR include a decreased The capacity of the respiratory system to deliver oxygen to
tl resting HR and a decreased HR at sub maximal exercise lev­ the body typically surpasses the ability of the body to use
els, indicating that the indhridual can peIform the same oxygen, thus the respiratory component of performance is
o amount of work v\rith less effort after training. Maximal HR not a limiting factor in the development of cardiorespiratory
I­ typically does not change as a result of training. The amount endurance. Nevertheless, adaptations in the respiratory sys­
of time it takes for HR to return to resting after exercise de­ tem do occur in response to aerobic training. The amount of
t­ creases as a result of training and is a useful indicator of air in the lungs, represented by lung volume measures, is
Ir progress towards better fitness. Because Qis the product of unchanged at rest and during submaximal exercise in
n. trained individuals. However, tidal volume, the amount of
d air breathed in and out dUling normal respiration , increases
a DISPLAY 6-2 during ma'<.imal exercise. Respiratory rate (RR) is lower at
~o Physiologic Adaptations to Cardiorespiratory rest and duIing submaximal exercise and increases at maxi­
Endurance Training mal levels of exercise. The combined increases in tidal vol­
[ ume and RR during maximal exercise of trained indhriduals
k • Increased heart weight and volume
• Increased left ventricle size
produce a substantial increase in pulmonary ventilation, or
the process of movement of air into and out of the lungs.
l~ • Increased stroke volume Pulmonary ventilation at rest is either unchanged or slightly
Increased plasma blood volume
reduced and during submaximal exercise is slightly reduced
• Decreased resting and submaximal heart rates
• Decreased time required for heart rate to return to resting follOwing training. The process of gas exchange in the alve­
after exercise oli, or pulmonary diffusion, is unchanged at rest and at sub­
• Increased maximum cardiac output maximal exercise levels, but increases duIing maximal exer­
• Increased total hemoglobin cise because of the increased blood flow to the lungs and the
• Decreased systolic and diastolic blood pressure in increased ventilation as discussed previously. These two
hypertensive clients factors create a situation that enables more alveoli to par­
Increased peripheral capillary formation ticipate in gas exchange, and thus the perfusion of oxygen
• More efficient blood distribution to active muscles into the arteIial system is enhanced dUling ma'<.imal exer­
• Increased tidal volume during maximal exercise cise. Finally, a-v02 diff increases at maximal exercise in re­
• Decrease resting and submaximal respiratory rates
sponse to training as a result of increased oxygen distraction
• Increased respiratory rate during maximal exercise
• Increased pulmonary ventilation during maximal exercise by the tissues and greater blood flow to the tissues because
• Increased pulmonary diffusion during maximal exercise of more effective blood distIibution. 8 ,ll,12
• Increased a-v02 difference during maximal exercise One net effect of these cardiovascular and respiratory
• Increase in V0 2 max adaptations on aerobic capacity is an increased V0 2 max af­
• Decreased body fat ter endurance training. A typical training program consist­
ing of three times per week, 30 minutes per session exer­
94 Therapeutic Exercise Moving Toward Function

cise at 75% of VO z max, as discussed in a later section of performance of vigorous physical activity compared with
this chapter, over the course of 6 months can improve VOz moderate intenSity activity, such as the current guidelines
max 5% to 30% in a previously sedentary individual. Rest­ to accumulate 30 minutes of moderate intenSity activity
ing V0 2 max is either unchanged or slightly increased fol­ daily,2/j- 3o Until additional research is performed clarifying
lOwing training, and submaximal VO z is either unchanged this association, it appears that an exercise prescription
or slightly reduced, representing greater efficiency 8 The based on an individual client's motivations and desires is
second net effect relates to body composition changes that the best approach to follow, with the aim of performing
have been documented as a result of aerobic exercise train­ consistent with current recommendations to accumulate
ing. Whether caloric intake stays the same during training 30 minutes or more of moderate-intenSity phisical activity
or is decreased, individuals lose fat mass as a result of train­ on most, and preferably ail, days of the week. ,6
ing. Several mechanisms have been postulated to produce The dose-response relationship relative to improve­
a loss of body fat secondary to training, including appetite ments in quality of life has also been examined, The ob­
suppression, an increase in the resting metabolic rate, and served improvement in quality of life in individuals who
increase in lipid mobilization from adipose tissue and thus participate in regular exercise is achieved from quantities
the burning of fat for energy.8 of exercise considered to produce health-related (versus
fitness-related ) benefits. Fitness-related benefits include
Psychologic Benefits of Training those resulting in Significant changes in physical fitness
In addition to the myriad of cardiovascular, respiratory, and level, as measured by cardiorespiratory endurance and
metabolic improvements that occur after aerobic training, body composition changes, SpeCific recommendations for
psychologiC benefits have also been documented, although fitness-related changes usually include vigorous, continu­
are less weil understood. An overall assessment of the litera­ ous activities vvith a focus on the specific parameters of ex­
ture in this area indicates tllat depreSSion, mood, anxiety, ercise (intenSity, mode, duration, frequency). Health­
psychologic well-being, and perceptions of physical function related benefits can be achieved through the performance
and well-being imgrove in response to the performance of of moderate intensity, intermittent activity wherein the fo­
physical activity. 1, ' The finding that exercise can decrease cus is on the accumulated amount of activity performed. 6
symptoms of depreSSion and anxiety is consistent witll the The documented health-related benefits from the perfor­
fact that individuals who are inactive are more likely to have mance of regular exercise are shown in Display 6-3.
depreSSive symptoms compared to active persons, Improve­ Although improvement in fitness level is a worthwhile
ments in depreSSion and mood have been found in popula­ goal and also results in the health-related benefits listed
tions with and witllOut clinically diagnosed psychologic im­ previously, exercise to achieve health-related benefits ap­
pairment, as well as in those with good psychologic health, pears to be easier for most people to incorporate into their
although the literature is less conclusive in this specific area, lifestyle and thus prOvides a valuable exercise option .3l<>3
A number of factors have been postulated to explain the The specific parameters necessary to achieve both fitness­
beneficial effects of aerobic training on psycholOgiC func­ related and health-related benefits of aerobic exercise are
tion , including changes in neurotransmitter concentrations, presented later in this chapter.
body temperature, hormones, cardiorespiratory function ,
and metabolic processes, as well as improvements in psy­
chosocial factors such as social support, self-efficacy, and CAUSES OF IMPAIRED AEROBIC
stress relief. Further research is needed to verify the pote n­
tial contribution of changes in these factors resulting from
aerobic training to improvement in psychologiC function. 1 INDICATIONS
Despite the inability to explain why psycholOgiC param­
eters improve in response 1:..0 training, the effect on overull The ability of the body to use oA)'gen can be limited by dis­
quality of life is positive. J4.\.o Improvement in quality oflife ease and is affected by aging and inactivity, A systems re­
as a result of physical activity has been demonstrated in in­
dividuals without 1&-19 and v\lith disease, including coronary
heart disease patients who are obese,20 coronary heart dis­ DISPLAYS·3
ease patients who are elderly,Zl patients with chronic heart Health-Related Benefits from the Performance
failure,z2 patients after coronary bypass graft surgery,23 and of Regular Exercise
patients with multiple sclerosis24 and cancer. 25
• Decreased fatigue
Dose-Response Relationship • Improved performance in work- and sports-related

The amount of physical activity associated vvith decreased activities

risk for cardiovascular disease and death has been the topiC • Improved blood lipid profile
of numerous studies recently.2&-30 Authors agree that an in­ • Enhanced immune function
verse linear dose response exists between the amount of • Improved glucose tolerance and insulin sensitivity
physical activity performed and all-cause mortality.2&-28 Al­ • Improved body composition
• Enhanced sense of well-being
though the minimal effective dose of physical activity is un­ • Decreased risk of coronary artery disease, cancer of the

clear, expenditure of 1,000 kcalJweek is associated vvith a colon and breast, hypertension, noninsulin-dependent

Significant reduction in all-cause mortality.26,28 It is less diabetes mellitus, osteoporosis, anxiety, and depression

clear whether additional benefits are achieved from the

Chapter 6 Chapter Impaired Aerobic Capacity/Endurance 95

view, conducted as a part of the examination, discussed in traumatic brain injury, spinal cord injury, osteoporosis,
the next section, can identify the presence of or risk for arthritis , and AIDS either directly or indirectly impair aer­
pathology/pathophysiology, impairments, functional limi­ obic capacity and thus limit cardiovascular endurance.
tations, or disabilities that impact aerobic capacity.34 Al­ Any medical condition necessitating hospitalization or
though injury to or diseases of the heart, lungs, and vascu­ bed rest can result in deconditioning of the cardiovascular
lar system-the primary tissues involved in cardiovascular system. Surgical procedures for the gallbladder, appendix,
endurance-are the most obvious causes of impairment or uterus, or other internal organs require a period of de­
functional limitation, diseases and conditions of other body creased activity. Accidents resulting in multiple system in­
systems also affect aerobic capacity. juries can limit activity for long periods of time , resulting in
There are three categories of diseases that directly affect deconditioning.
the heart, including conditions of the heart muscle, diseases The effects of aging on the cardiovascular and respira­
affecting the heart valves, and cardiac nervous system condi­ tory systems are numerous, resulting in an overall decrease
tions.:)'3 Heart muscle conditions include coronary artery dis­ in aerobic capacity. Some of the factors that have been at­
ease (CAD), myocardial infarction , pericarditis, congestive tributed to the decline in aerobic capacity documented
heart failure, and aneurysms. 35 The pathologic processes in­ "vith age include decrements in central and peripheral cir­
volved in the impairment of aerobic capacity in these heart culation including a decrease in maximal HR , SV, and a­
muscle conditions involve obstruction or restriction of blood V02 difference; increases in body fat and decreases in lean
flow, inflammation, or dilation or distension of one or more body mass; and lung function decline including a d crease
heart chambers?5 Aerobic capacity is impaired because the in vital capacity and forced expiratory volume, an increase
heart is weakened as a result of the disease or condition or in residual volume, and a loss of elasticity in the lung tissue
blood flow is impaired, resulting in ischemia and necrosis of and chest walL 8 Because the elderly respond to cardiovas­
heart muscle and an inability to pump enough blood in re­ cular training with impressive improvements in aerobic ca­
'ponse to increased demand from activity. pacity, it is difficult to differentiate between biolOgiC aging
The heart valves can become diseased by rheumatic fever, and phYSical inactivity as the primary cause of the decline
ndocarditis, mitral valve prol&pse, and various congenital in aerobic capacity that occurs with age.
deformities. Valve defects increase the workload of the heart, A sedentary lifestyle, or physical inactivity, impairs aer­
as the heart must work harder to pump blood through a mal­ obic capacity and is considered a modifiable risk factor for
fu nctioning valve, resulting in impaired aerobic capacity.35 cardiovascular disease (Display 6-4). ConSidering that ap­
The nervous system that controls cardiac muscle contraction, proximately 40% of the U.S. adult population is sedentary,

when diseased, produces arrhythmias such as tachycardia physical inactivity is more prevalent than the diseases dis­
.r nd bradycardia. Arrhythmias impair aerobic capacity by cussed previously that cause impairment in aerobic capac­
causing changes in circulatory dynamics becat,:?e the heart is ity, and thus is a major public health concern. s On the pos­
beating too slow or too fast, or skipping beats. x' itive side, as a modifiable risk factor, physical inactivity is
There are numerous types of peripheral vascular disease , mutable and can and should be addressed when identified
including arterial, venous, and lymphatic disorders, such as during the examination of a patient.
atherosclerosis, embolism, Buerger's disease, Raynaud's dis­
ease, deep venous thrombosis, venous stasis, and lymph­
edema?5 Because aerobic capacity is determined by the DISPLAY 6-4
condition and capacity of both the heart and the peripheral . Risk Factors for Corona Heart Disease
circulation, these conditions also produce impairments. The
" ascular system is used to transport oxygen to exercising Major Risk Factors-Nonmodifiable
muscles so that diseases of the peripheral vascular system Increasing age
disrupt circulation to peripheral muscles , prodUCing a loss of Male gender
nction at rest and during exercise, impairing aerobic ca­ Heredity (including race)
pacity. The most common disease of the vascular system is Ma,or Risk Factors-Modifiable
h)pertension, considered a major risk factor for myocardial
Tobacco smoke
in farction, stroke, and cardiovascular death. High blood cholesterol levels
Conditions affecting the pulmonary system influence High blood pressure
the ability of the lungs to bring in and absorb oxygen and Physical inactivity
expel carbon dioxide from cells in the body. These pro­ Obesity and overweight
'esses are of primary importance to cardiorespiratory en­ Diabetes mellitus
urance; therefore, diseases affecting ventilation and respi­ Contributing Factors
ration impact aerobic capacity. Diseases affecting the lungs Individual response to stress
. c1ude lung tumors , chronic obstructive pulmonary dis­ Peripheral vascular disease
ase (including bronchitis, bronchiectasis, emphysema), Personality
thma, pneu monia, tuberculosis, cystic fibrosis , and vari­ Hormonal status
us occupational lung diseases (pneumoconiosis ).35 Alcohol consumption
Disease of the neurologiC, musculoskeletal, en­
Goodman and Snyder. p. 96;
. Dcrine/ metabolic, and integumentary systems may also http.!/ 235, accessed
egatively affect aerobic capacity. Conditions such as November 27, 2002
ancer, neuromuscular disease, cerebrovascular attacks ,
96 Therapeutic Exercise: Moving Toward Function

EXAMINATION/EVALUATION OF Specific questions that should be posed during the pa­

tienUclient history to identify the presence of cardiovascu­
AEROBIC CAPACITY lar and pulmonary disease and the relevant aspects of the
client's overall status that may affect aerobic capacity as dis­
With the exception of clients with cardiovascular and pul­
cussed above can be found in Goodman and Snyder's text 35
monary diseases, most clients who are referred to physical
on differential diagnOSiS.
therapy do not have as their primary diagnosis impaired
aerobic capacity. Because aerobic capacity influences any
exercise a client may perform as a part of an intervention, Systems Review
and thus the outcomes that client will achieve, it is impor­
tant that examination and evaluation of the cardiovascular After, and based on, the patienUclient history, a systems re­
and respiratOlY systems be included as a part of the exam­ view is conducted as a brief or limited examination of the
ination and evaluation of all clients. The tests and mea­ status of the other major body systems (integumentary,
sures described in this section are aimed at identifying the musculoskeletal, neuromuscular) , and the communication
presence of disease, describing baseline aerobic capacity, ability, affect, cognition, language, and learning style of the
and measuring change in aerobic capacity as a result of in­ patient. 34 The systems review helps to identify impair­
tervention(s). The clinician is assumed to have the knowl­ ments in other areas that may affect the performance of an
edge and skill to perform the basic tests necessary to diag­ activity or task within the plan of care. FUlther, the systems
nose impairments and functional limitations in aerobic review may identify potential problems that require refer­
capacity; however, detailed information will be provided ral to another provider.
for the more advanced tests of aerobic capacity because Because the primary intervention used to address aero­
many clinicians may not have experience performing these bic capacity impairments, therapeutiC exercise, requires
tests on a regular basis. Additional information may be . adequate musculoskeletal, neuromuscular, and integu­
obtained from the ACSM texe 6 on exercise testing and mentary function, it is espeCially impOltant to perform a
prescliption. tl10rough systems review in clients with cardiovascular and
pulmonary impairments. Failure to do so could result in
prescribing an intervention that the patient either cannot
Patient/Client History perform or that compromises the safety of the patient. At a
Specific portions of the general data generated from a pa­ minimum, skin integrity, muscle strength, joint range of
tienUclient history as defined in Chapter 2 are important to motion, balance, gait function , and assessment of the abil­
note when attempting to identify the presence of an im­ ity to make needs known should be assessed.
pairment in aerobic capacity that either should be directly
addressed in the intervention or that may influence the
clinician's ability to set and achieve goals related to other
Screening Examination
impairments. Knowledge of the risk factors for coronary Before the initiation of an exercise program, individuals
heart disease provides a basis for collecting the most rele­ should be assessed to ensure safety and minimize risksl l
vant information regarding impaired aerobic capacity. As The ACSM 36 has created guidelines delineating who
shown in Display 6-4, general demographic information should be medically evaluated before participation in vig­
such as age, gender, and ethnicity is very important to con­ orous exercise (defined as in tensi ty > 60% VOz max ).
sider. Social/health habits such as smoking and physical ac­ Those who do not require medical evaluation includ
tivity are important behaviors to inquire about during the asymptomatic (Display 6-5) apparently healthy women
histOlY. Assessm ent of general health status in terms of younger than age 50 and men younger than age 40 wbo
phYSical, role, and social functioning as well as functional have fewer than two CAD risk factors (family history of
status and activity level can provide additional indication of CAD, Cigarette smoker, hypertenSion, hypercholes­
limitations in cardiovascular endurance. Clinical tests of terolemia, diabetes mellitus, sedentary lifestyle) .;)G
blood cholesterol are useful to identify clients at risk for In addition, asymptomatic apparently healthy men and
coronalY heart disease. Other factors that should be noted women , regardless of age or CAD risk factor status, who
from the history include personalitylbehavior, pregnancy, wish to begin a moderate exercise training program (de­
and breast-feeding status, factors that also may modify the fined as intenSity between 40% and 60% VO z max) do not
exercise prescIiption .lI need medical evaluation. For individuals who do not re­
\1edication histOlY is of primary importance to review, quire medical evaluation , preparticipation screening can
espeCially for clients with documented cardiovascular and be performed using a self-report questionnaire, such as the
pulmonary disease, but also for those ,vith risk factors for Physical Activity Readiness Questionnaire or PAR-QI J,:1R.37
disease. \1a1lY cardiac and pulmonalY system drugs affect (see Appendix 3). Based on the answers to the seven ques­
aerobic capacity, and thus clients using these drugs should tions on the PAR-Q, individuals between the ages of 15 and
be carefully monitored during any intervention that affects 69 can either appropriately partiCipate in exercise or be re­
the cardiovascular and pulmonalY syste ms , including ferred to a physician for further evaluation before begin­
therapeutic exercise, functional training, airway clearance ning an exercise program. All individuals who fall outside of
techniques, integumentary repair techniques, electrother­ the boundaries described should be referred to a physician
apeutic modalities, and physical agents and mechanical for medical evaluation before participating in exercise
modalities. training.
Chapter 6: Chapter Impaired Aerobic Capacity/Endurance 97

Thus submaximal testing is most commonly us ed, espe­

DISPLAY 6-5 cially \vith low-risk, apparently healthy individuals, and "viII
Asymptomatic is Defined as Without: be further described in this section. Individuals who wish
to conduct maximal graded exercise testing are referred to
• pain in the chest, neck, jaws, or other areas suggestive of the ACSM Guidelines for Exercise Testing 36 or th ACSM
ischemia Resource Manual l l for more detailed information.
• shortness of breath at rest or with mild exertion
• dizziness or syncope Submaximal Graded Exercise Tests
• orthopnea (difficulty breathing in any position other than
Submaximal exercise tests can be used to estimate V0 2
sitting upright)
max because of the linear relationship bet\veen HR and
• ankle edema V0 2 , and HR and workloadY That is, as workload or V0 2
• palpitations or tachycardia
increases, HR increases in a linear, predictable fashion.
• intermittent claudication
• known heart murmur Therefore, the clinician can estimate max V0 2 by plotting
• unusual fatigue or shortness of breath with usual activities HR against workload for at least t\vo exercise workloads
and extrapolating to age-predicted maximal heart rate (220
ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed. - age) to estimate V0 2 max (Fig. 6_4 ). 36 Submaximal exer­
cise testing is based on several assumptions , as shown in
Display 6-6. Failure to meet these assumptions fully, which
is usually the case, results in errors in the prediction ofV0 2
Tests and Measures max. Therefore, submaximal testing typically results in less
The examination categories directly relevant for the accurate V0 2 max estimations. Submaximal tests are ap­
client "vith aerobic capacity impairment include tests and propriately used to document change over time in response
measures of aerobic capacity/endurance, anthropometriC to aerobic training and, given the time and money saved,
characteristiCS, and circulation. There are numerous tests are very useful clinically.
d ACSM 36 provides recommendations for physician super­
. nd measures in each of these categories and often the
most difficult task for the clinician is selecting the most vision during graded exercise testing. For women younger
rt than age 50 and men younger than age 40 who are without
appropriate test. Tests and measures should be selected
based on data collected from the history, systems review, Iisk factors or symptoms (Display 6-5), physician supervi­
and screening, the means the client has available for fol­ sion is not deemed necessary duling maximal or submaxi­
J­ mal testing. Individuals in these age ranges who have t\vo or
lOwing through with a program of aerobic exercise, client
goals , and the equipment and monitoring equipment more Iisk factors but no symptoms or disease can unde rgo
available. submaximal testing 'Arithout phYSician supervision. Physi­
cian supervision during submaximal and maximal testing is
Aerobic Capacity/Endurance recommended for any individual with CAD or with symp­
The development of an appropriate and useful exercise toms of CAD. Last, during maximal testing for men older
prescription for cardiorespiratory endurance depends on than age 40 and women older than age 50 "vith t\.vo or more
o an accurate assessment of V0 2 max, which is most com­ risk factors but no symptoms, physiCian supervision is rec­
ommended a6 Therefore, submaximal testing can be per-.
~~~ monly achieved through the performance of a graded exer­
cise test (GXT). Exercise tests can be maximal, in which an. formed safely by physical therapists 'Arith any age individual
I:le individual performs to his or her phYSiologic or symptom who is symptom or disease free , as defined by ACSM. 36
n limit, or submaximal, in which an arbitrary stopping or lim­ Numerous testing protocols have been gubJished and are
10 iting criterion is used. available for submaximal exercise testing. 6 Because of the
of requirement of reproducible workloads, treadmills, bicycle
~ ­ Maximal Graded Exercise Tests ergometers, and stepping protocols are most commonly
The most important characteristics of a maximal GXT used. Test selection should be based on safety concerns, fa­
!Dd are that it has a variable or graded workload that increases miliarity \vith and knowledge of the testing protocol, equip­
ho gradually and that the total test time equal approximately 8 ment aVailability, and clienUpatient goals, abilities, and con­
e­ to 12 minutes a6 In addition, individuals undergoing maxi­ ditions (e.g. , the presence of orthopediC limitations).
ot mal GXT testing are usually electrocardiogram (ECG) Bicycle Ergometer Tests
re­ monitored. The direct measurement of V0 2 max requires The t\vo most common bicycle ergometer tests are the
the analysis of expired gases, which requires speCial equip­ YMCA protocol and the Astrand-Ryhming test. 36 In the
ment and personnel and is thus costly and time-consum­ YMCA protocol, the client performs two to four, 3-minute
ing. 36 V0 2 max can be estimated from prediction equations stages of continuous cycling, deSigned to elevate the HR to
after the individual exercises to the point of volitional fa­ bet\veen 110 and 150 beats/ min dming t\vo consecutive
tigue , or it can be estimated from submaximal tests. For stages. The client begins cycling at 50 revolutions/min at a
most clinicians, maximal exercise testing is not feasible be­ resistance of 150 kgm/min or 0.5 kg and progresses to
cause of the special equipment required and the ECG greater resistance in subsequent stages based on HR
monitoring, although it is the most accurate test of aerobic recorded during the last minute of the first stage according
tial capacity. Additionally, it is recommended that maximal to Table 6-1. For example, if HR = 85 at the end of the first
cise graded exercise testing be reserved for research purposes, stage, the second stage workload wOlllJ be 600 kgm/ min and
testing of diseased individuals, and athletic populations. II the third stage workload would be 750 kgm/ min.
98 Therapeutic Exercise: Moving Toward Function

180 ---, estimated - - extrapolated ~ /

Individuals pedal at SO revolutions/min and HR is measured
maximal HR to max HR //
during the fifth and sixth minutes. The two HR measures

must be within 5 beats of one another and the HR between
160 { // 130 and 170 beats/min for the test to be completed. If the HR
E •
cr; 140


80 ---i :estimated
I V0 2max
50 100 150 200

Exercise Intensity (watts)

900 1500 2100 2700
Estimated \/0 2 (ml/min)
FIGURE 64 Heart rate (HR) obtained from at least two (more are prefer­
able) submaximal exercise intensities may be extrapolated to the age­
predicted maximal HR. A vertical line to the intensity scale estimates max- .
imal exercise intensity from which an estimated V0 2 max can be
calculated. (From Kenney WL ACSM's Guidelines for Exercise Testing and
Prescription. 5th Ed . Baltimore Williams & Wilkins, 1995)

The test is terminated \vhen two consecutive stages yield

a HR reading between llO and 150 beats/min. The two HR
measures and corresponding workloads are plotted on a
graph and the line generated from the plotted points is ex­
tended to the age-predicted maximal HR and an estimation
ofYO z max is obtained. 36
The Astrand-Ryhming test involves a single 6-minute
stage, with workload based on sex and activity status:
• unconditioned females, 300 or 450 kgm/min (SO or 75
• conditioned females , 450 or 600 kgmlmin (75 or 100
• unconditioned males , 300 or 600 kgm/min (50 or 100
• conditioned males, 600 or 900 kgrnlmin (100 or 150

Assumptions for Submaximal Exercise Testing
• The workloads used are reproducible.
• Heart rate is allowed to reach steady-state at each stage of 3.4
the test. 3.5
• The age-predicted maximal HR is uniform (220 - age) with
L..-_--'-, 1.500
a prediction error of 10% to 15%.

• A linear relationship exists between HR and oxygen uptake, AGURE 6-5. The Astrand-Rhyming nomogram. A nomogram used to calcu­
late aerobic capacity (V0 2 max) from pulse rate during submaximal work. ThE
• Mechanical efficiency is the same for everyone (e.g., V0 2

at a given work rate),

clinician must know the pulse rate, sex, and work load from the bicycle er­
gometer test performed on the client to determine absolute V0 2 max. Va:
ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed; American
max values obtained from the nomogram should be adjusted for age by a cor­
College of Sports Medicine Resource Manual for Guidelines for Exercise
rection factor (Table 6-2), (Reprinted with permission from Astrand PO, Ry~ ·
Testing and Prescription 3rd Ed. Baltimore: Williams & Wilkins, 1998.
ming LA nomogram for calculation of aerobic capacity [physical fitness] fro
pulse rate during submaximal work. J Appl Physiol1 954;721 8-221)
Chapter 6 Chapter Impaired Aerobic Capacity/Endurance 99

~ ~iEycle Ergometer Test Protocol-Workload Settings
HR < 80 HR 8!H19 HR 90-100 HR > 100

Second Stage 750 kgmlmin 600 kgmlmin 450 kgmlmin 300 brm/min
(2.5 kg ) (2.0 kg) (1.5 kg) (l.0 kg)
(125 watts) (100 watts) (75 watts) (50 watts )
Third Stage 900 kgmlmin 750 kgmlmin 600 kgmlmin 450 kgm/min
(3.0 kg) (2.5 kg) (2.0 kg) (1.5 kg)
(150 watts ) (125 watts) (100 watts) (75 watts)
Fourth Stage 1050 kgmlmin 900 kgmlmin 750 kgmlmin 600 kgm/min
(3.5 kg) (3.0 kg) (2.5 kg) (2.0 kg)
(175 watts) (150 watts) (125 watts ) (100 watts)

Resistance settings shown apply to ergo meters \\~th a 6 meter/revolution flywheel. )

. less than 130 beats/min , the resistance should be increased mode of submaximal exercise testing. Several protocols
b SO to 100 watts and the test continued for another 6 min­ have been developed,39 but only one \-vill be presented. The
utes. The test may be terminated when the HR in the fifth Queens College Step Test requires a 16.2S-inch step (simi­
and sixth minute differs by no more than S beats and is be­ lar to the height of a bleacher).:39.4o Individuals step up and
tween 130 and 170 beats/min. An average of the HRs is cal­ down to a 4-count rhythm (on Count 1 subject places one
culated and a nomogram is used to estimate VO z max (Fig. 6­ foot on step, on Count 2 subject places the other foot on the
5).36 The value determined from the nomogram is corrected step, on Count 3 the first foot is brought back to the ground,
or age by multiplication of a correction factor (Table 6-2). on Count 4 the second foot is brought down). A metronome
Treadmill Tests is useful to maintain the prescribed stepping beat. Females
ubmaximal treadmill tests are also used to estimate VO z step for 3 minutes at a rate of 22 steps/min, whereas males
max. A single-stage submaximal treadmill test has been de­ step at a rate of 24 steps/min. At the end of the 3 minutes, a
"eloped for assessing VO z max in low-risk individuals. 38 It recovery IS-second pulse is measured, starting at S seconds
involves beginning with a comfortable walking pace be­ into recovery while the individual remains standing. The
,\'een 2.0 and 4.S mph at 0% grade for a 2- to 4-minute pulse rate is attained and is converted to beats/min by mul­
warm-up, designed to increase HR to within 50% to 7S% of tiplying by 4. This value is termed the recovery HR. The fol­
ae-predicted (220 - age) maximum HR, followed by 4 lOwing equations are used to estimate VOz max.
minutes at S% grade at the same self-selected walking
Females: V0 2 max (mUkglmin) = 6S.81 - [0.1847 X
;peed. HR is measured at the end of the 4-minute stage
recovery HR (beats/min)]
.md VO z max is estimated using the following equation:
Males : V0 2 max (mUkglmin) = 111.33 - [0.42 X
V0 2 max (mUkglmin) = lS.l + 21.8 X speed (mph) recovery HR (beats/min)]
- 0.327 X HR (bpm ) - 0.263 X speed X age (years) Field Tests
+ 0.00S04 X HR X age + S.98 X sex (0 = F , 1 = M) Field tests refer to exercise testing protocols derived from
Step Tests events performed outside, or in the "field ." They are also
tep tests were developed based on a need to test large submaximal tests and, as with the step test, are more prac­
umbers of individuals expeditiously and represent another tical for testing large groups of people, appropriate when
time or equipment is limited, and when assessing individu­
als older than age 40 a9 A variety offield tests exist,39 but
only the Cooper 12-minute test and the I-mile walk test
. Correction Factor.foi'J\ge for Astrand­ will be discussed. In the Cooper 12-minute test, individu­
R.l1yming Nomogr~I11 , als are instructed to cover the most distance possible in 12
-- -- - - -
minutes , preferably by running, although walking is ac­
AGE CORRECTION FACTOR ceptable. The distance covered in the 12 minutes is
recorded and VO z max estimated according to the follow­
15 1.10
25 1.00 ing equation?9
35 0.87 V0 2 max (mUkglmin) = 3S.97 (miles ) - 11.29
40 0.83
45 0.78 A I-mile walk test is another option in the field test cate­
50 0.75 gory41 Individuals walk 1 mile as fast as possible without
e 55 0.71 running and the average HR for the last two complete min­
er­ 60 0.68 utes of the walk is recorded . A HR monitor is necessary to
~2 65 0.65
tor­ record and average the HR over the last 2 minutes. If a HR
monitor is not available, a IS-second pulse can be mea­
m ill p . 223 Bandy and Sanders, which was reprinted from American
rom .ollege of Sports Yiedicin c. Guidelines for Exercise Testing and sured immediately on test completion. VO z max is esti­
re- cription. 5th Ed. Media, FA: vViili ams & Wilkins , 1995. mated from the follOwing equation: 41
100 Therapeutic Exercise Moving Toward Function

V0 2 ma;\ (mLlkglmin ) = 132.85 - 0.077 X body weight position is an important examination tool in the presence of
(pounds ) - 0.39 X age (years) + 6.32 X sex (0 = F, 1 = obesity and is considered superior to simple measures of
M) - 3.26 X elapsed time (min) - 0.16 X HR height and weight. The gold standard measure of body
(beats/min) composition is hydrostatic or unde[\l1/ater weighing that re­
quires speCialized equipment and the patient to tolerate to­
All clients should be closely monitored during exercise test tal body immersion. Because of these limitations, several
performance. Vital signs should be assessed before, during reliable measures of body composition estimation have
each stage or workload of the test, and after the test for 4 to been developed and are used widely, including body mass
8 minutes of recovery. 11 In addition, the rating of perceived index, bioelectric impedance, near-infrared interactance;
exertion (RPE) is commonly used to monitor exercise tol­ skinfold measurements, and waist to hip ratio. Bioelectric
erance 42 RPE refers to the "degree of heaviness and strain impedance, near-infrared interactance, and skinfolds re­
experienced in physical work as estimated according to a quire speCialized equipment and, in the case of skinfolds,
specific rating method,,42.p9 and is an indicator of overall specialized training; whereas the body mass index and
perceived exertion. The Borg RPE scale and instructions waist-to-hip ratio can be measured using height, weight,
for use are shown in Fig. 6-6. and circumferential measurements. The clinician is re­
ferred to ACSM 's Guidelines for Exercise Testing and Pre­
Anthropometric Characteristics scription 36 for additional information about performing
Body composition is important to assess in individuals par­ these tests.
taking in an aerobic exercise program because of the
changes e>"'Perienced in fat mass as a result of chronic train­
ing discussed earlier in this chapter. In addition, body com-
Assessment of blood pressure; heart rate, rhythm , and
sounds; and respiratory rate , rhythm, and pattern is impor­
tant to establish a baseline and to determine impairments.
In addition, these measures can be assessed over time
RATING DESCRIPTION to determine the effect of aerobic training on the cardio­
vascular and pulmonary systems and ' to document
6 None at all


Impaired aerobic capacity/endurance involves the support
9 Light element of the movement system , and as such is the under­
lying impairment for num erous functional limitations and
10 disabilities and is thus a priority to address with the inter­
vention plan. A wide variety of aerobic endurance activities
11 Light exist and are the most efficient techniques to achieve the
goal of improved aerobic capacity. The modes and dosage
12 specifics used when establishing an aerobic endurance ex­
ercise prescription will be presented. A primary objective of
13 Somewhat hard the exercise prescription is to assist in the adoption of regu­
lar physical activity as a lifestyle habit and thus should take
into consideration the behavioral characteristics, personal
15 Hard (heavy) goals, and exercise preferences of the individuaP6

17 Very hard Several modes of cardiovascular endurance training are
available. Any activity that uses large muscle groups and is
18 repetitive is capable of prodUCing the desired changes.
Extremely hard
Such activities include walking, jogging, cross-country ski­
ing, bicycling, rope jumping, rowing, swimming, or aerobic
20 Maximal dance (see Selected Intervention 6-1 ). Although lap swim­
ming is the most common aquatic cardiovascular exercise,
water jogging, cross-country skiing, and water aerobics are
FIGURE 6-6. The rating of perceived exertion scale. (From Bezner J. Prin­ also effective aquatic training methods. An upper body er­
ciples of aerobic conditioning. In: Bandy WD, Sanders B, eds. Therapeutic
gometer is a good cardiovascular training tool and is espe­
Exercise. Techniques for Intervention. Baltimore: Lippincott Williams &
Wilkins, 2001. Data from American College of Sports Medicine. The rec­ Cially well suited for individuals unable to use their legs
ommended quantity and quality of exercise for developing and maintaining (see Fig. 6-7).
cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports The choice of exercise mode depends on the patient's
Exerc 1990;22:265-274.) goals and speCific physical condition . Performing an activ­
Chapter 6 Chapter Impaired Aerobic Capacity/Endurance 101


\::.J Cross-Country Ski Machine

Refer to Case Study #10 DOSAGE: Ten minutes, adding 5 minutes every three ses­
Although this patient requires comprehensive intervention,
only one exercise is described:
ment is included, cross-country skiing is a total body exer­
ACTIVITY: Cross-country ski machine
cise. Aerobic conditioning can be achieved, along \\~th
shoulder, trunk, hip, and leg extensor muscle endurance
PURPOSE: To increase cardiovascular endurance and
musculoskeletal muscle endurance of quachiceps, gluteals ,
and spine and arm extensors
EXERCISE GRADATION: This exercise can be progressed by
increasing the frequency, intenSity, or duration of acti\~ty.


POSTURE: Standing posture, maintaining proper pelvic and

spine posture. Arms are resting on the machine for balance
or can paliicipate by performing altemate ann extensions
with attached pulleys (with or without resistance)

MOVEMENT: Alternate hip flexion and extension in a walking

pattern \\~th minimal knee motion is pelformed. The

patient/client must be sure to transfer weight completely
li'om leg to leg during the activit\', rather than shuffling or
sliding the feet while bearing weight bilaterally. The arms
can move in an alternate fashion \\~th the legs. Bange of
motion may be limited by individual needs.

SPECIAL CONSIDERATIONS: (1 ) All precautions to

cardiovascular endurance exercise must be considered. (2)
rt Individuals with balance and coordination difficulty should Used with the permission of Kordie Track, Inc. , Chaska. MN.
r­ he assessed for ability to perform the activity safely.

ity that is convenient, comfortable, and enjoyable increase s '<\' ithin one mode of exercise, several postures or equip­
the likclihood of adherence. The amount of impact is also ment types are available. For example , during bicycling,
an important consideration when choosing the exercise the trunk postllfe selected depends on the goals. Bicycling
mode. For the individual ~th lower extremity degenera­ may be performed on a recumbent bike (Fig. 6-8A), ~th
tive jOint disease or the overwe ight indi~dual , impact ac­ the hips flexed 90 degrees or more and the low back sup­
ti~ties should be avoided. The pool is a better choice for ported , or it may be performed in a upright position with
those who need to minimize weight bearing or impact. the anTIS moving (Fig. 6-8C ), or in a fOlward leaning posi­
Weight bearing can be completely negated by exercising in tion (Fig. 6-8B ). The optimal posture for maximal exercise
the deep end of the pool. For those desiring to return to benefit should be emphaSized (see Patient-Related In­
lfe impact acti~ties, gradual impact progression can prepare struction 6-2).
lis the body for the demands of this type of lo ading (see
e. Patient-Related Instruction 6- 1).
ki­ Variety and cross-training in the cardiovascular en­
bic durance program are imperative. Alternating moell's of aC­ Type
Pl­ ti~ty can allc~ate boredom and prevent overuse injuries The training session itself may be performed using a variety
e. resulting from repetitive activity. Many individuals have of training techniques, from continuous activity to interval
~e such low muscular endurance th at they are incapable of training. Continuous training relies on the aerobic energy
er­ performing the sa me repetitive ac tivity for more than a few system to supply energy for the exercise session and can be
pe­ minutes. The acti~ty mode can be alternated within the carried out for prolonged periods. The individual exercises
eos training session and among sess ions. Although one individ­ continuously, without rest, at a steady exercise rate. Al­
ual may bicycle 2 days per week, swim 2 days, and walk 2 though continuous in nature , several different activities can
·t's days, another may bike , walk, and stair step for 10 minutes be combined ~thin the same session, such as tread mill and
ti\,­ each daily. bicycle or s\:vi.mming and deep-water running.
102 Therapeutic Exercise: Moving Toward Function

FIGURE 6-7. Upper body ergometer. An upper

body ergometer is an exercise mode that provides
an aerobic exercise alternative for those with sig­
nificant lower extremity impairments or to provide
variety in an exercise prescripti on. Because the C\lBE)(
smaller upper extremity muscles perform the exer­
cise, lower heart rates are experienced. In addi­
tion, it is difficult to monitor vital signs during ac­
tivity. The seat on the device should be adjusted to
allow slight elbow flexion in the outstretched po­
sition of the arm while the back maintains contact
with the seat. and the seat height position should
ensure that the shoulder is even with the axis of
the crank arm. (From Bezner J Principles of aero­
bic conditioning. In Bandy WD, Sanders B, eds.
Therapeutic Exercise. Techniques for Intervention.
Baltimore: Lippincott Williams & Wilkins, 2001.
Courtesy of Henley Healthcare, Sugar Land)

Interval training incorporates rest sessions between cise, concomitantly, relying on the aerobic oxidative path­
bouts of exercise. This technique is useful for clients who way, can be performed adequately from an energy avail­
are unable to maintain continuous exercise for the optimal ability standpoint for longer periods of time with shorter
length of time (e.g., 30 minutes) and for those recuperating rest intervals that may consist of complete-rest or work-re­
from an orthopedic injury or who are deconditioned. When lief intervals.
presclibing interval training, the ratio of the rest period to Circuit training can be continuous or interval. Circuit
the training period determines the activity intensity and the training is a training technique in which the individual ro­
energy system used. The aerobic energy syste m is used to a tates through a series of exercise stations. A variety of up­
greater extent vvith longer training intervals and shorter per extremity, lower extremity, core, and cardiovascular
rest periods. For example, performance of three bouts (in­ training exercises tYl)ically are included. The individual
tervals) of activity at an inten sity of 50% of V02. max or performs the activity at each station for a specified time
greater for 10 minutes with a 2-minute rest period in be­ (i.e., 30 seconds ) ann then moves on to the next station .
tween each bout would use the aerobic energy' system. The activity choices, activity intensity, and rest between
The rest periods can be true rest (i.e., no activity) or a stations determine the energy system used and whether the
work-relief interval , during which light activity such as . activity is interval or continuous. This type of training pro­
walkjng may be performed. High-intensity activity usually vides the opportunity for a well-balanced exercise program
is combined vvith longer complete-rest intervals, and low with valiety. Multiple individuals can be trained simultane­
to medium intensities are combined with shorter rest in­ ously if there are adequate stations (see Patient-Related In­
tervals or work-relief intervals. F or example, a training struction 6-3).
session might inc:lude a set of 10 100-meter sprints, in
which each sprint may only take 10 to 20 seconds to com­ Sequence
plete, with a 10-minute complete rest inteJ-val between Cardiovascular endurance training may be performed as
each sprint. Because high-intensity exercise of short dura­ pali of a comprehellsive relwhilitation program that in­
tion uses the ATP-PCr and glycolysis systems for the pro­ cludes mobility. stretching, and strength ening activities.
vision of ATP , a longer rest period is required to allow Gen(.;' ral warlll-up activities should he performed initially,
musc:le energy stores to be replenished. Less intense exer­ followed by stretching ann the cardiovascular training ses­
Chapter 6: Chapter Impaired Aerobic Capacity/Endurance 103

three to flve times per week,s.:l(; with those initiating a pro­

gram beginnina at three to four times per week and pro­
Return to Impact Activity gressing to fiv . The ov rload principle in tCrIllS of the in­
Any return to impact activities such as jogging, impact teraction alDong inte nsity, duratio n, and frequency is
aerobics, or sports requiring running or jumping should be importan t to consider when prescribing exercise. Individu­
preceded by impact progression. This approach ensures als with very low functional capacities can perform daily or
readiness to return to the activity and decreases the twice daill)' exercise because the total amount of exercise ,
likelihood of setback. Prerequisites for impact progression considering intenSity, duration , and frequency , is so 10\v.36
include the following:
In a highly trained individual, exercise at a greater fre­
1. Adequate muscle strength and endurance quency may be necessary to produce overload, depending
2. Full range of motion in the joints on the exercise intenSity.
3. No swelling
A suggested progression is as follows:
1. Two-footed hopping As with frequency and duration, setting the intensity of
2. Alternate-footed hopping
exercise shollid be bas d on the overload plinciple and
3. Single-footed hopping (optional)
consideration should be given to the fun ctional limita­
4. Skill drills (optional)
tions , goals, and fitness level of the individual. Exercise in­
This progression should be implemented as follows:
tensity indicates how much exercise should be performed
1. Begin on a low-impact surface (e.g., pool, minitramp, or how hard one must ex rcise and is typically presclibed
shock-absorptive floor). on the basis of H R max, H R reserve, VO z m ax, RPE, or
2. Subsequently progress to the terrain you will be using.
METS (metabolic equivalents) . Prescribing exercise in­
3. Begin with 5 minutes, and increase by 2- to 5-minute
tensity using HR is considered the preferred method be­
increments when you are able to complete three
consecutive sessions without pain, swelling, or cause of the correlation between HR and the stress on the
technique compromise. heart and because it is readily accessible for monitoring
4. Return to your full activity is determined 'by the criteria during exerciseS Several methods involving HR can be
set by your clinician. used.
vVhen prescribing exe rcise as a percentage of maximum
HR , either directly measured or on the basis of age-pre­
dicted maximum HR, the training range sho uld be be­
sion. The warm-up period should last 5 to 10 minutes to tween 55% and 65% to 90% of HR max 36 A second
prepare the body for exercise. Large muscle group activ­ method involves the use of the HR reserve or Karvonen
ity such as walking, calisthenics, or bicycling should be formula:
performed with gradually increasing intensity. T he warm­
Target HR range = [(HR max - HRrest) X 0.60 and
up session may be a lower-intensity version of the cardio­
0.80] + HRrest 36
vascular training activity. Walking at a slower speed for 5
minutes may be used as a warm-up activity for fast rvvalk­ If exercise is prescribed using VO z max, 5.5 clc to 7.5% is also
ing or jogging. The warm-lip activities incr ase muscle used as a training range and V0 2 max should be stated in
blood flow, muscle temperature, and neural conduction. relative terms (mUkg/ min), which accounts for the indi­
These changes , along with mental preparedness, can vidual's body weight. The HPE can also be used to pre­
decrease the risk of muscle injury during exercise. After scribe exercise intensity, \vithin the range of 12 to 16 on the
uit the warm-up, stretching exe rcises are performed, fol­ RPE scale shown in Fig. 6-7. RPE is espeCially useful for
ro­ lowed by the more vigorous cardiovascular endurance ses­ prescribing intensity for individuals who are un able to pal­
sion . The cardiovascular training session should be pate pulse or when HR is altered because of the influence
concluded with cool-down activities, which often consist of medication and should be considered an adjunct to mon­
of lower-intensity versions of the training sessio n and itoring HR in all other individuals. 36
stretching exercises. M E TS may also be used to prescribe activity intensity.
The exercise session should be concluded with a cool­ METS are used to estimate the metabolic cost of physical
down period of 5 to 10 minutes to allow redistribution of activity relative to the resting state. One MET is equal to
blood flow that has chang d with exercise, including pre­ 3.5 mL of oxygen consumed per kilogram of body weight
vention of lower extremity pooling of blood by enhanCing per minute (mUkglmin).36 Therefore, when V0 2 is known,
venous return to the heart. Activ mllscle contraction by the intensity can be prescribed in METS by dividi ng rela­
continued walking, cycling, or low-level calisthenics assists tive VO z by 3.5 mL/kg/min. In general, walking at 2
with blood flow redistribution. Stretching should conclude mileslhr is the equivalent of approximately 2.0 METS , and
the session to ensure maintenance of the working muscle's walking at 4 miles/hr is the equivalent of apprOximately 4.6
optimal length. METS.
Selection of an appropriate training range versus a spe­
Frequency cific training value has been recommended to prOVide
The frequency of cardiovascular training should be deter­ greater flexibility in the exercise prescription, yet ensure
mined through consideration of the patient's goals, the in­ that a training respon se will be achieved. For example, an
tensity and duration of exercise, and the patient's base line individual who is starting an exercise program might be
fitness level. The optimal frequency for most individuals is given a target HR range between 60% an d 70% of HR max
104 Therapeutic Exercise: Moving Toward Function

FIGURE 6-8. (A) Exercise on a semirecumbent

bike positions the individual differently from ex­
ercise on a traditional bike, (B) Bicycling in a tra­
ditional position places more weight on the up­
per extremities, challenging the postural muscles
more than in a recumbent position, (C) Exercise
on an upright bike with moving arms places dif­
ferent loads on the patient.

instead of being told to keep target HR at a value equiva­ rotator cuff tendinitis limiting the use of upper extremi­
lent to 60% of HR max. ties). The intensity necessalY to achieve a workload in the
Intensities between 70% and 85% HR max or 60% and target training zone varies among individuals and usually
80% HR reserve are recommended for most people to ex­ correlates with the previously determined conditioning
perience improvements in cardiorespiratOlY endurance. 36 level.
Health-related benefits can be realized at lower intensities,
and thus lower intensities may be appropriate if the goal of Duration
exercise is to improve health rather than fitness. 43 Exercise duration can be manipulated to produce overload
In the pool, the heart rate is decreased when exercising and a resultant cardiovascular training effect. Duration de­
while immersed to the neck because of the Starling reflex pends on the frequency, intensity, and the conditioning
and is therefore a poor gauge of workload. The heart rate level of the patient. In general, exercise of greater intensity
of deep-water exercise is 17 to 20 beats/ min less than that is performed for a shorter duration and exercise of lower
of the comparable land-based activity 44 intensity can be performed for a longer duration. Manipu­
Increase exercise intensity by adding resistance, in­ lation of these variables is goal-dependent. If the patient is
creasing speed, changing terrain (e.g" up hills ), removing required to perform an activity for a long duration (i.e"
stabilization , or adding upper extremity activity. The continuous walking as part of a job or recreation), progres­
method for increasing intensity is goal-specific and may sion of the rehabilitation program should focus more on in­
be limited by other medical or physical conditions (e.g. , creasing the duration and less on increasing the intensity.
Bicycling Guidelines Setting Up a Circuit
The following guidelines will keep your bicycling Your regular exercise routine can be enhanced and
experience healthy and safe: made more enjoyable by breaking up a continuous activity
1. Seat height The seat should be set so that your knee with stations of alternative activities. A circuit can be
is slightly bent in the down-most position. If you place created outside along a normal walking or running route, or
your heel on the pedal in the down position, your knee at your indoor exercise location. For example, a walking or
should be perfectly straight. When you place the ball jogging program through the neighborhood or on the
of your foot on the pedal, your knee should be bent at treadmill can be broken up with the following activities
the correct angle (15 to 20 degrees of knee flexion performed at certain intervals throughout the session:
with the ankle in 90 degrees of dorsiflexion). 1. Toe raises
2. Cadence: Your pedal cadence should be high, at least 2. Abdominal curls
60 rpm or more. Your clinician may have other 3. Push-ups
recommendations, depending on your specific 4. Squats
situation. 5. Dips
3. Resistance: The resistance should be low enough to 6. Lunge walks
allow a higher cadence. Resistance too high can 7. Quadriceps, hamstring, and calf stretches
place extra stress on the knee. Keeping the resistance
low and the cadence high produces the desired
benefits without hurting your knees.
4. Safety: If riding outside, always wear a helmet, and High-risk patients also show disregard for appropriate
obey your local bicycle laws. warm-up and cool-down , consistently exceed prescribed
training heart rate , are more likely to be male , and to smoke
cigarettes. Although this profile is helpful, it is important to
note that a Significant number of patients with one or more
The optimal duration recommended for aerobic train­ of these characteristics will never experience an exe rcise­
ing is between 20 and 30 minutes per session of exer­ related cardiovascular complication , and others without
cis e .8 ,36 For individuals who are unable to perform 20 any of these characteristics ma)' experience a complication
minutes of continuous exercise , discontinuous exercise Therefore, the wise clinician will follow the recomnlt'nua­
can be prescribed. That is , several 10-minute bouts can tions in Display 6-7 when prescribing and monitoring aer­
be performed, for example, until eventually exercise can obic exercise to reduce the incidence and severity of com­
be tolerated for 20 to 30 minutes continually. Duration plicatiolls during exercise.
can be progressed up to 60 min utes of continual activ­ Endurance exercise places a significant load on the car­
ity.36 The same activity or different activities may be per­ diovascular and musculoskeletal systems. Consideration
formed in each of these sessions (see Patient-Related should be given to any injury or disease affecting either of
Instruction 6-4). these sys tems. Individuals with degenerative joint disease
should be encouraged to partiCipate in non-weight-bearing

Frequency, Intensity, and Duration
In addition to the signs and symptoms of exercise intoler­
ance described in the physiology of aerobic capacity and
e ndurance section an d Display 6-1 , clinicians should be
Determining how often (frequency), how hard (intensity),
and how long (duration) to exercise can be difficult. These
parameters are related and must be balanced to find the
Ih­ aware of the risks associated "vith exercise, as well as mon­ right quantity of exercise for you. The following broad
rn itoring and supervision gUidelines. The incidence of car­ guidelines can be refined by your clinician:
diovascu lar complications during exercise has been docu­ 1. Frequency: Generally, if you exercise more frequently
mented to be extremely low for individuals without (more times per day or days per week), the intensity
Significant cardiac disease':16 For persons with cardiovascu­ and duration of those sessions should be lower. This
bd lar disease, the incidence of cardiovascular complications recommendation allows adequate recovery before the
de­ during exercise is conSiderably greater; however, the over­ next session. If the intensity and duration are high, you
~g all absolute risk of cardiovascular complications during ex­ may not be fully recovered before the next session.
I it)"
2. Intensity: The more intense the exercise, the shorter is
ercise is low when considered in light of the health benefits
I \'er
the duration. Intense exercise cannot be sustained
associated with chronic exercise. very long by most people.
ipu­ A profile has developed of individuals at gr atest risk for 3. Duration: Exercise that is lower in intensity can be
at is cardiovascular complications du ring exercis ,36 The prom sustained for longer periods . For example, sprinting
i.e ., includes those with a history of multiple myocanlial infarc­ can be sustained for seconds, but jogging can be
[res­ tions, impaired left ventricular function with an ejection sustained for up to several hours. The intensity and
in­ fraction of less than 30%, rest or unstable angina pectoris, duration are inversely related; as one increases, the
ih·. se riou s arrhythmias at rest, significant multivessel other must decr ease .
atherosclerosis on angiography, and 10\.\/ serum potassium .
106 Therapeutic Exercise Moving Toward Function


Recommendations to Reduce the Incidence Contraindications to Exercise Testing
and Severity of Complications During Exercise
• Ensure medical clearance and follow-up A recent significant change in the resting ECG suggesting
• Provide on-site medical supervision, if necessary significant ischemia, recent myocardial infarction (within 2
• Establish an emergency plan days) or other acute cardiac event
• Promote participant education Unstable angina
• Initially encourage mild-to-moderate exercise intensity Uncontrolled cardiac arrhythmias causing symptoms or
• Use continuous or instantaneous ECG monitoring for hemodynamic compromise
selected participants Severe symptomatic aortic stenosis
• Emphasize appropriate warm-up and cool-down Uncontrolled symptomatic heart failure
procedures before and after vigorous exercise, including Acute pulmonary embolus or pulmonary infarction
stretching Acute myocarditis or pericarditis
• Modify recreational game rules and minimize competition Suspected or known dissecting aneurysm
• Maintain supervision during the recovery period Acute infections
• Take precautions in the cold
• Consider added cardiac demands in the heat Relative
Left main coronary stenosis
ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed. Moderate stenotic valvular heart disease
Electrolyte abnormalities (e.g., hypokalemia,
hypomagnesemia I
Severe arterial hypertension (i.e., systolic BP > 200 mm Hg
exercises such as bicycling and water ~xcrcise, and those and/or a diastolic BP > 110 mm Hgl at rest
\-vith low buck pain should participate in activities that sup­ Tachyarrhythmias or bradyarrhythmias
port or safely strengthen the back (e.g. , semireclllllbent Hypertrophic cardiomyopathy and other forms of outflow
biking, water activities ). Individuals with osteoporosis tract obstruction
Neuromuscular, musculoskeletal, or rheumatoid disorders
should be encouraged to participate in weight-bearing ac­ that are exacerbated by exercise
tivities. Positions and postures should be chosen that mini­ High-degree atrioventricular block
mize the risk of fracture. Ventricular aneurysm
Uncontrolled metabolic disease (e.g., diabetes)
Chronic infectious disease (e,g" mononucleosis, hepatitis,
Graded Exercise Testing AIDS)
Contraindications and Supervision ACSM's Guidelines for Exercise Testing and Prescription, 6th Ed.
There are numerous contraindications to exercise testing,
and guidelines for supervision of graded exercise tests. Dis­
play 6-8 lists the absolute and relative contraindications to age 55 in fath er or male first-degree relative or before age
exercise testing. The relative contraindications should be 65 in mother or female first-degree relative), or who have
considered in light of the potential bene fits of exercise and documented CAD should be supervised during exercise.,16
a less vigorous prescription created for individuals in this Additionally, individuals mth the follOWing signs or symp­
category. toms should be supervi sed during exercise: pain or dis-
All clients should be closely monitored during exercise
test performance. Vital signs should be assess ed before,
during each stage or workload of the test, and after the
test for 4 to 8 minutes of recovery.lI In addition, the DISPLAY 6-9
RPE is commonly used to monitor exercise tolerance Guidelines for Cessation of Graded Exercise
(Fig. 6-7 )Y' Finally, individuals should be monitored for Testing
signs and symptoms of exercise intolerance, The guide­
lines for stopping an exercise test are presented in Dis­ • Onset of angina or anginalike symptoms
play 6-9. • A significant drop (20 mm Hg) in SBP or a failure ofthe SBP
to rise with an increase in exercise intensity
• Excessive rise in SBP > 260 mm Hg or DBP > 115 mm Hg
Supervision During Exercise • Signs of poor perfusion (lightheadedness, confusion,
ataxia, pallor, cyanosis, nausea, cold or clammy skin)
A thorough screening or medical evaluation is critical for • Failure of HR to increase with increased exercise intensity
determining which individuals may require supervision • Noticeable change in heart rhythm
durin g exercise ,36 Apparently healthy individuals do not • Client requests to stop
require supervision during the performance of aerobic ex­ • Physical or verbal manifestations of severe fatigue
ercise , Those individuals "vith two or more risk factors for • Failure of the testing equipment
CAD (Display 6-4, plus family history of myocardial in­ ACSM's Guidelines for Exercise Testing and Prescription, 5th Ed.
farction/coronary revascularizationlsudden death before
Chapter 6 Chapter Impaired Aerobic Capacity/Endurance 107

comfort secondary to ischemia, shortness of breath at rest a lifelong habit. 46 Factors that have been found to be most
or with mild exertion, dizziness or syncope, orthopnea or predictive of exercise dropout or noncompliance include
paroxysmal nocturnal dyspnea, ankle edema, palpitations personal, program, and other characteristics. Personal
or tachycardia , intermittent claudication , known heart characteristics that predict dropout include being a
murmur, or unusual fatigue or shortness of breath with smoker, being sedentary during leisure tim , having a
usual activities. sedentary occupation, possessing a Type A personality, be­
ing employed in a blue-collar occupation, being overweight
or overfat, possessing a poor self-image, b~ ing depressed or
PATIENT-RELATED anxious , and having a poor credit rating 4 , Program factors
INSTRUCTION/EDUCATION AND predicting dropout include inconvenient time or location ,
excessive costs, the prescription of high-intenSity exercise,
ADJUNCTIVE INTERVENTIONS lack of exercise variety, exercising alone, lack of positive
feedback, inflexible exercise goals, and poor exercise lead­
Patient education regarding cardiovascular endurance ership.47 Additional factors that have bee n identified to
training is a critical component of the program. Endurance
predict dropout are lack of spouse support , inclement
training should be canied out daily or several times per
weather, excessive job travel, injury, medical problems, and
week, and some of the program may be carried out without
job change or move 4 7 These factors in sum indicate that
the clinician's supervision. Clinicians should recall the re­
programs and individuals prescribing exercise can and
cent recommendation of the U.S . Department of Health
should adopt speCific strategies to enhance comphance
and Human Services, the Centers for Disease Control and
with exercise prescription. Examples of these strategies are
Prevention, the !\ational Center for Chronic Disease Pre­
shown in Display 6-10.
vention and Health Promotion, the President's Council on
The use of behavior change theOlies to enhance the
Physical Fitness and Sports, and the Amelican College of
adoption of exercise has received increased attention re­
Sports Medicine that all adults accumulate 30 minutes or
cently in the literature, specifically the application of the
more of moderate-intensity physical activity on most, and
stages of change model, as discussed in Chapter 3. After
preferably all , days of the week l ,6
identifying the stage the patient is currently in , the ll1ter­
Patient education should include the "why" and the "how
vention can be tailored to enhance compliance and
to" of the warm-up, training session, and cool-down phases. movement towards a lifelong habit. For example, an in­
The patient should be alerted to signs or symptoms neces­ dividual in contemplation is not quite ready for an exer­
sitating early cessation of the activity (including those in
cise prescription. Efforts in this stage should focus on the
Display 6-1) These symptoms may be musculoskeletal
provision of information about the costs and benefits of
(e.g., joint pain, muscle pain, cramps ) or cardiovascular
exercise, strategies to increase activity within the present
(e.g., shortness of breath, chest pain, lightheadedness), or lifestyle, and the social benefits of activity, for example 48
they may be specific to the patient's particular problem (.i.e., Those in the preparation stage would benefit most from
reprodUCing the patient's original symptoms ). The patJ~nt a thorough examination and exercise prescription.
should be counseled regarding modifications in the exercIse
Whereas , those in the action or maintenance stage would
program based on fatigue level and other activities that day. benefit from learning about strategies to prevent relapse,
As the patient is prepared for discharge, education re­
making exercise enjoyable, and diverSifying the exercise
garding a maintenance program is critical to continued ad- .
here nce with the exercise program. ProgreSSion through a
P"lP­ conditioning program should be individualized and is de­
dis­ pendent on the client's functional capacity, pre morbid state, DISPLAY 6·10
health status, age, and individual preferences, goals, and tol­ Strategies to Enhance Compliance With
erance of the training. 36 The client's objective and subjective Cardiovascular Endurance Training Programs
training res~onses should most heavily influence t.raining
progreSSion. 1 Signs and syn1ptoms of overtrammg mclude • Minimize musculoskeletal injuries by adhering to the
exercise and nonexercise fatigue, reduction in maximum principles of exercise prescription
performance, decreased interest in training compared with Encourage group participation or exercising with a partner
• Emphasize mode variety and enjoyment in the program
nonnal decreased HR and RPE values at the same work­ • Iincorporate behavioral techniques and base prescription
load, ~d increased complaints of aches and pains. 45 on theories of behavior change
Emphasizing the importance of continued exercise in • Use periodic testing to document progress
lona-term health maintenance can assist the patient in • Give immediate feedback to reinforce behavior change
making exercise a lifelong commitment. Information about • Recognize accomplishments
safe progression, exercise dosage , and signs and symptoms • Invite spouse or significant other involvement and support
of overload can assist the patient in making appropriate ex­ of the training program
ercise choices. Ensure that the exercise leaders are qualified and
The documented success of programs deSigned to en­ enthusiastic
courage the adoption of a regular exercise habit is similar to Reprinted, by permission, from B.A. Franklin, 1988, "Program factors that
the success of changing other health-related behaviors influence exercise adherence" in Exercise adherence, edited by R. K.
such as smoking and weight reduction, in that approxi­ Dishman (Champaign, IL Human Kinelil;sl, 242-249.
Inately 50% of those who initiate the behavior will develop
108 Therapeutic Exercise Moving Toward Function

prescription to include more variety. Given the difficulty likely to partiCipate in activities that are fun versus highly
most peoplp encounter when changing health-related be­ structured. As children age, they can progress to league
haviors, it seems prudent to use documented hehavior and team sports. Adolescents can benefit from league
change theori es when possible, such as the stages of sports as well as cardiovascular exercise such as s\vim­
change model. ming, bicycling, and jogging. If desired, prescribing exer­
cise using the parameters recommended for adults is safe