Exercise therapy

Systemic, planned performance of body movement and posture intended to:

• Remediate or prevent impairments.
• Restore physical function.
• Prevent or reduce health related risk factors.
• Optimize over all heath status, fitness or sense of well being .
✓ Types of exercise therapy :
1 .land based exercise .
2 .under water exercise .
✓ Types of land-based exercise :
1. ROM exercise
2. Conditioning
3. Stretching
1) ROM exercises:
N.B:For burned patient: ROM exercises are used mainly for controlling edema and
to assist movement .
✓ TYPES OF ROM EXERCISE :

A.PROM exercises:
❑ Indication
• Inability to perform movement actively (comatose patient –paralysis –
complete bed rest).
• Area of acute inflammation or burn.
• Examination of patient.
• Education of p.t the active movement program.
• When there is need for saving energy (In burned patient to avoid hyper
metabolic response).
B. AROM exercises:
➢ AROM is used during any period of immobilization to:
• maintain normal structure & ROM
• prevent edema
• improve contractility
• improve circulation

C. AAROM exercises:
➢ Movement is provided by assistance which may be manual or mechanical.
➢ It is indicated when there is:
• Muscle weakness.
• Sever pain.
• Muscle shortening

❖ Precaution:
1. Early phases of skin graft.
2. Joint laxity and hyper mobility.
3. comatose patient ECG and monitor

2) Conditioning exercises:
1. Strength.
2. Endurance.

❖ Deconditioning:
✓ The end result of prolonged bed rest due to extended acute illness or prolonged
chronic condition leading to decreased:
o Maximum oxygen consumption.
o Cardiac output.
o Muscle mass.
o Muscle strength.
o Total blood volume
1. Strengthening exercise:

❖ Types of strengthening exercises:

A.Isometric contraction:
• Type of strength training in which joint angle and muscle length don't change
during contraction (in demand to resistance).
• It occurs in a static position. It increases strength only at specific joint angle so
it should be done at multiple joint angles to involve all joint and muscle range.
• Resistances in Isometrics include:
▪ Body's own structure and ground.
▪ Against structure items.
▪ Free weight
B.Isotonic contraction:
• Dynamic process in which tension of muscle remains unchanged and
length changes as lifting an object at constant speed
• Types:
 A-Eccentric action: (lengthening action)
Muscle lengthening due to tension produced by load with force greater than the
muscle produces rather than working to pull muscle to direction of muscle
contraction so muscle acts to decelerate joint at the end of movement , It occurs
involuntarily (movement is away from the center).
B-Concentric contraction: (Shortening action)
Muscle shortens while generating force as the tension produce by muscle exceeds
external load. (Movement is toward the center)
C-Isokinetic training :( constant velocity)
It is a form of a dynamic exercise in which the velocity of muscle shortening or
lengthening and the angular limb velocity is predetermined and held constant by
a rate limiting device known as isokinetic dynamometer

• (A-concentric contraction - B-eccentric contraction - C-isometric contraction)

2. Endurance Exercise:
✓ Endurance means the ability to perform low intensity, repetitive or sustained
activities for a prolonged period of time.
Endurance Training:
✓ Having the muscle to lift or lower light object for repetitive times or for
prolonged period of time so muscle increase their oxidative and metabolic
capacities so better delivery and use of oxygen.
❖ Endurance may be:
• General endurance: cardiopulmonary endurance and maintaining body
balance and alignment by postural muscle endurance.
• Specific or local: applied for specific muscular group and classified to (repeated
isotonic, repeated isometric, sustained isometric.)
o Repeated isometric endurance: determined by isometric contractions of
short duration at a given frequency.
 o Repeated isotonic endurance: determined by isotonic contractions of
short duration at given frequency.
o Sustained isometric contraction: determined by length of time an
isometric contraction is maintained
3) Stretching exercises:
➢ Contracture:
• is defined as the adaptive shortening of the muscle-tendon unit and other soft
tissues that cross or surround a joint that results in significant resistance to:
1) Passive stretch
2) Active stretch
3) Limitation of ROM
4) It may compromise functional abilities

TYPES OF STRETCHING EXERCISE:

1) Passive Stretching:
1. Manual Passive Stretching.
2. Mechanical Passive Stretching.
3. Cyclic Mechanical Stretch.

2) Active Inhibition Techs:

1. Hold - Relax.
2. Hold - Relax - Contract.
3. Agonist Contraction.

3) Other Types:
1. Selective Stretching.
2. Self-Stretching.
3. Over Stretching.
4. Ballistic stretch (bouncy)

A- PASSIVE STRETCHING:
 While the patient is relaxed, an external force applied either manually or
mechanically, lengthens the shortened tissues.
1-Manual passive stretching:
▪ External force: Applied by the therapist.
▪ Speed: Slow.
▪ Duration: Applied for at least 15-30 or 30-45 sec.
▪ The intensity and the duration: of the stretch are dependent on the patient's
tolerance and the therapist's strength and endurance.
▪ The gains achieved: in ROM are transient and are attributed to temporary
sarcomere give (elastic changes) (work on contractile element).so it is less
effective.
2-Mechanical passive stretching:
▪ External force: Applied by cast, splint or pully system.
▪ Duration: 20-30 min. or as long as several hours or days except the hour of
hygiene or exercise.
▪ The gains achieved in ROM :are permanent in contractile and non contractile
tissues (plastic changes) (work on both contractile and non contractile
elements).so it is more effective.
▪ There are many ways to use equipment: the equipment can be as simple as a
cuff weight or weight-pulley system or as some adjustable orthoses.
▪ N.B: Mechanical stretching devices apply a very low intensity stretch force
(low load) over a prolonged period of time to create relatively permanent
lengthening of soft tissues, presumably due to plastic deformation.

3- Cyclic mechanical stretch:

▪ Passive stretching : using mechanical device such as the autorange can be done
in a cyclic mode.
▪ The intensity, duration and the mode: of each stretch cycle and the number
of stretch cycle per minutes can be adjusted on the mechanical stretching unit.
parameter adjusted for each patient.

B- ACTIVE INHIBITION TECHNIQUES:

❖ The patient reflexively relaxes the muscle to be elongated prior to the
stretching maneuver. This type of stretching is only possible if the muscle to
be elongated is normally innervated and under voluntary control. It
depends on Neurophysiologic basis.
1-Hold–Relax (Contract–Relax):
 1) With the hold–relax (HR) procedure, the range limiting muscle is first
lengthened to the point of limitation or to the extent that is comfortable
for the patient.
2) The patient contract the shortened muscle against resistance & then
relax.
3) Then the therapist applies passive stretch of the MS.
4) Depend on that, isometric contraction of MS.(for 5 to 10 seconds)
stimulate (Golgi tendon organ) to send impulses to spinal cord to inhibit
alpha motor neuron & so MS. Relax ( autogenic inhibition).
5) Advantages: when the therapist stretches MS. He stretches fibers which
are already relaxed, so gain more benefit.

2-Contract–Relax– contract (Hold–Relax– contract):

▪ To perform this procedure:
1)move the limb to the point that tissue resistance is felt in the tight
(range-limiting) muscle;
2)then have the patient perform a resisted, pre-stretch isometric contraction
of the range-limiting muscle followed by relaxation of that muscle and then
3)an immediate concentric contraction of the muscle opposite the tight
muscle (antagonist).to stretch the affected muscle.
➢ This technique combines (autogenic inhibition and reciprocal inhibition) to
lengthen the tight muscle.so more relaxation.

3-Agonist Contraction:
▪ The “agonist” refers to the muscle opposite to the range-limiting muscle.
“Antagonist” therefore, refers to the range-limiting muscle (tight muscle).
▪ To perform the AC procedure the patient concentrically contracts the
antagonist MS. Against maximum resistance , so inhibition of the affected
muscle.
▪ Depends on reciprocal inhibition.
▪ This techniques needs normally innervated muscle .
▪ It has been suggested that when the agonist is activated and contracts
concentrically, the antagonist (the range - limiting muscle) is reciprocally
inhibited by inhibitory interneuron, allowing it to relax and lengthen more
easily.
C- OTHER TYPES OF STRETCHING EXERCISES:
 1-Selective Stretching:
▪ is a process occurs when the overall function of a patient may be improved by
applying stretching techniques selectively to some muscles and joints but
allowing limitation of motion to develop in other muscles or joints. When
determining which muscles to stretch and which to allow to become slightly
shortened, the therapist must always keep in mind the functional needs of the
patient and the importance of maintaining a balance between mobility and
stability for maximum functional performance.
▪ The decision to allow restrictions to develop in selected musculotendon units
and joints is usually made in patients with permanent paralysis (spinal cord
injuries) as this tightness of the muscles (like Back muscles) provides more
stability.
2-Self-Stretching:
 Self-stretching (or active stretching) a patient carries out independently. Uses
his body parts & weight to apply the stretching force.
1) Self-stretching enables a patient to maintain or increase the ROM gained as
the result of direct intervention by a therapist.
2) This form of stretching is often a home exercise program and is necessary for
long-term self-management of many musculoskeletal and neuromuscular
disorders.

3-Overstretching:
 Is a stretch well beyond the normal length of muscle and ROM of a joint and
the surrounding soft tissues,
 Resulting in hypermobility (excessive mobility).Creating selective
hypermobility by overstretching may be necessary for certain healthy
individuals with normal strength and stability participating in sports that require
extensive flexibility.
1. BALLISTIC STRETCHING:(BOUNCY)
➢ Usually associated with bouncing during the stretch. In ballistic stretching,
ROM is increased by using the momentum of repeated bouncing up and down.
An example of ballistic stretching would be swinging your arms out to the side
so that the momentum is responsible for the increased flexibility.

 N.B:
1) Ballistic stretching has a high risk of injury and is not recommended for
patients.
 2) It is recommended for athletes.
3) It improves the dynamic stability.
4) It is characterized by high intensity, very short duration and facilitates the
stretch reflex.

Indications of stretching:
1. Contractures.
2. Adhesions.
3. Scar tissue formation.
4. Anticipated deformities.
Contraindication of stretching:
1. Bony block.
2. Recent factures.
3. Sharp pain.
4. Recent skin graft.
5. Exposed tendon.
6. D.V.T.
7. Compartment syndrome.

✓ Remember to:
➢ Warm-up your muscles first before stretching.
➢ Stretch until you feel mild discomfort, not pain.
➢ Never bounce or force a stretch.
➢ Hold the stretch for 10-30 seconds and then relax.
➢ Do not hold your breath when stretching.
➢ Do stretching exercises at least 2-3 times a week.
 Stretching exercise examples
❖ Neck muscles:
A) trapezius:
✓ Action:
Bilateral: extension
Unilateral: side bending to the same, slight extension.
✓ Stretch:
Bilateral: flexion (hand at chin & hand at occiput
Unilateral: side bending to opposite & slight flexion.
B) Sternocleidomastoid muscles:
✓ Action:
Bilateral: flexion
unilateral: side bending to same & rotation to the opposite .
✓ Stretch:
Bilateral: extension.
Unilateral: side bending to opposite & rotation to the same.
C) Scalene:
✓ Action: slight flexion & side bending to the same
✓ Stretch : chin in & side bending to opposite.

Self stretch of upper trapezius Self-stretching the pectoralis

major muscle with arms in a
reverse (T )to stretch the
clavicular portion (A),
and in a (V )to stretch the
sternal portion (B).

PASSIVE STRETCHING OF PECTORALIS MAJOR MUSCLE.

Exercise Therapy For Burned Patient
❖ Rehabilitation of burned patient is an essential and integral part of treatment
formed of continuum of active therapy.
❖ Main parts of treatment are:
1. splinting,
2. positioning,
3. exercise,
4. pressure techniques,
5. Activities of daily living and ambulation.
Specific goals for burned patients:
➢ Short term goals :
1. Reduction of edema and promoting good circulation.
2. Preventing contracture development and deformity.
3. Preserving muscle strength and joint mobility.

➢ Long term goals:

• Therapeutic exercise aims to enable patient to be independent as possible and
able to be functional so the program should be individualized and progressed
to meet unique need of each patient.

❖ To reach with patient to be functional you should deal with all aspects of
physical function:
1. Balance and posture equilibrium.
2. Cardiopulmonary fitness or endurance.
3. Stability.
4. Mobility.
5. Muscle performance.
6. Neuromuscular control and coordination.
❖ This task requires the integration of skills of all members of the burn team.

FACTORS AFFECTING MOVEMENT:

❖ In acute stage:
1- Time prior to wound closure and time of immobilization:
 • As the time allowed for healing increase (above 2 weeks) the risk of scar
formation thus increasing risk of movement restriction.
• Also increased period of immobilization and delayed initiation of physical
therapy often have adverse effects.
2- Extent, depth and location of burn:
• The percent of patients with limitations in ROM is increased with larger TBSA
burns.
• The depth of burn is (one factor that affect degree of joint limitation).
• Those patients with full thickness burns sustained greater loss of joint range of
motion than those of partial thickness burn.
nd
• Prior to wound closure 2 degree burn tissue maintain its elastic properties and
rd
is soft in texture while 3 degree burn tissue is leathery like and inelastic prior
to wound closure so more resistant to movement.
• The location and configuration of a burn in relation to the underlying joint axis
and the adjacent body parts will affect the patient ability to move in particular
direction. Generally those movements that stretch the involved tissue are the
most difficult to perform.
3) Edema formation:
➢ Accumulation of edema restricts the joint movement particularly in the digits of
the hand and large areas of deep circumferential burn where there is limited
space to allow for edema.
➢ Prolonged edema contribute to lying down of fibrin which coupled with
immobilization contribute to formation of adhesions disrupting normal gliding
and sliding between the underlying structure.
4) age:
➢ The amount of tissue limitation is adversely affected by increasing age and
period of immobilization.
Patient immobilizes the involved part in a comfortable fetal position which is
maintained by muscle contraction or self-splinting
5) Psychological and physiological stress:
➢ Both would affect motor control.
➢ The main psychological complication in first 2 or 3 weeks is delirium (major
impairment in thinking, memory and perception).
➢ Also physiological factors such as infection, hypoxia, metabolic imbalance and
cardiovascular insufficiency are most important.
➢ So both would affect patient ability to perform voluntary or directed movement.
 6) Prolonged period of immobilization or delayed onset of an exercise:
• they may contribute to musculoskeletal and cardiovascular alterations as:
1. Bone structures that are not stressed with activity soon become demineralized
and osteoporotic.
2. Muscle atrophy or weakness results from disuse due to break down of protein
structure within the tissue.
3. Alteration of efficiency of the cardiovascular system for stroke volume,
oxygen uptake, cardiac output and heart rate following prolonged period of
bed rest.
❖ In chronic stage:
1) Existing soft tissue contractures.
2) Maturity of hypertrophic scar.

❖ General guidelines for post-operative exercise :

1. The patient will feel some tightness in the chest and armpit after the
operation .this is normal and the tightness will decrease as one continuous
exercise program.
2. Many women have a burning, tingling, numbness, or soreness on the back
of the arm and/or chest wall. this is because the surgery has irritated some
of the nerve ends .although the sensation many increase a few weeks ,
patient should continue to do the exercises unless on notices unusual
swelling or tenderness in the arm , shoulder girdle , upper back , chest and
neck . Such incidence must be informed to the surgeon immediately.
sometimes rubbing the area with hand or a soft cloth can help desensitize
the area
3. It may be helpful to do exercises after a warm shower when muscles are
warm and relaxed.
4. The patient should wear comfortable, loose clothing when doing the
exercises. Do the specified movement until a slow stretch is felt. Hold
each stretch at the end of the motion for a count of 5. It’s normal to feel
some pulling as one stretches the skin and the muscles that have been
shortened .one shouldn’t do bouncing or jerky movement when doing any
of the exercise. One should also not feel pain as she does the exercises,
only gentle stretching. Do 5 to 7 repetitions of each exercise.
5. To do each exercise correctly one needs to do the same under the vision of
a PT.
 6. Exercises should be done twice a day until the patient regains normal
flexibility and strength.
7. Patient must be reminded to take deep breathes while performing each
exercise

GENERAL CONTRAINDICATIONS OF EXERCISE:

1. Completely exposed tendons.

2. Deep venous thrombosis or thrombophlebitis.
3. Immediately after skin grafting (not before 10 to12 day).
4. Compartment syndrome (paresthesia, numbness, poor capillary refill, decreased
peripheral pulsation, pain).
General precautions to exercise:
1. Incomplete healing process
2. Avoid intensive program
3. Aged patient
4. Intravenous lines and ventilator support.
5. Frostbite burn
6. Exposed tendon

THANK YOU!