Anatomical terminology and exercise training principles
Anatomical position
Specifications
- The body is upright and facing forward.
- Feet are flat and parallel, with toes pointing straight ahead.
- Arms are extended at the sides, with palms facing forward.
- Head is held erect, with eyes looking straight ahead.
Basics of strength training
Muscle fiber types
Slow twitch (Type I)
- Slow contraction speed
- Low force production
- Highly resistant to fatigue
- Example: Postural muscles
Fast twitch (Type IIA)
- Fast contraction speed
- Fatigue resistant
- Can be influenced by training
- Examples: Muscles used for strength and movement
Fast twitch (Type IIB)
- Fast contraction speed
- High force production
- Susceptible to quick fatigue
- Examples: Muscles for quick movements and eye muscles
Guidelines for strength training
Foundational principles
Contraindications to strength training
Types of exercise for strength training
Isometric
- Muscle contraction without change in muscle length
- Example: Quad sets
- Typically used during the acute phase of healing or when learning muscle control
Isotonic
- The muscle changes length while moving a constant external load (e.g., a free weight), allowing movement at a joint. Despite the name (“same tension”), muscle tension varies through the range as the muscle’s length and leverage change; only isokinetic exercise loads the muscle maximally throughout the range.
- Example: Bicep curls with a 20-pound weight
- Used during sub-acute and chronic phases of healing when pain and inflammation are reduced. Requires that adequate motor planning and movement control have already been established.
- Concentric: The muscle shortens, for example, standing from a seated position with shortening of the hip and knee extensors.
- Eccentric: The muscle lengthens while holding tension, for example, controlled sitting from a standing position, controlled with lengthening of the knee and hip extensors.
- In squats and lunges the gluteus maximus works hardest concentrically to extend the hip on the way up, while the quadriceps work eccentrically to control the way down.
Isokinetic
- Muscle changes length (shortening or lengthening) while moving at a constant, controlled velocity.
- Example: Isokinetic machines using electric or hydraulic dynamometers
- Provides accommodating resistance that matches the force the muscle generates, it loads the muscle maximally throughout the entire range of motion
- Used from the sub-acute phase onward to protect healing muscle from re-injury: the machine controls the speed, and the resistance adjusts to the force the patient produces
Plyometric
- Plyometric exercise uses a rapid eccentric pre-stretch followed immediately by a concentric contraction (the stretch-shortening cycle) to build power, as in jumping; it is explosive, unlike isotonic exercise, which moves a constant load.
Endurance training
Effects of endurance training
- Capillary growth: More capillaries in muscles improve blood flow and oxygen delivery.
- Cardiac adaptations: Stronger heart muscle, increased stroke volume, and improved cardiac output.
- Metabolic benefits: Enhanced ability to utilize fat as fuel during exercise.
- Improved VO2 max: The maximum amount of oxygen your body can use during exercise increases significantly with endurance training
Guidelines for endurance training
Contraindications to endurance training
Endurance training is not started, and the PT is told, when the patient has unstable disease:
- Unstable angina
- Decompensated heart failure
- Uncontrolled arrhythmias
- Uncontrolled hypertension at rest (systolic 200 mmHg or more, or diastolic 110 mmHg or more)
- Acute illness or fever
Stable angina, controlled diabetes and well-controlled hypertension are not contraindications; they call for monitoring during exercise.
Signs to stop endurance training
Coordination and balance training
Effects of coordination and balance training
- Reduced fall risk
- Improving ability to react quickly and maintain stability, overall reducing fall risk
- Improved coordination
- Allows for smoother movements, better agility, and quicker reaction times
- Improved proprioception:
- Balance exercises stimulate the nervous system to better sense your body’s position in space, enhancing proprioception.
- Better posture:
- Regular balance training can help maintain proper alignment and posture by strengthening the muscles that support the axial skeleton
- Muscle strength and endurance:
- Improved muscle activation, leading to increased muscle strength and endurance throughout the body
Guidelines for coordination and balance training
Interventions that can be used are as follows
- Therapeutic exercises
- Postural training
- Weight shifting activities
- Sit-to-stands
- Gait training
- Dual tasking
- Changing surfaces
- Sensory training
- Tai chi, which may be beneficial in improving balance and preventing falls in older adults
Contraindications for coordination and balance training
- Acute injuries
- Unstable joints
- Cardiovascular instability
- Uncontrolled medical conditions
Precautions for coordination and balance training
- Severe pain
- Recent surgery (follow the surgeon’s protocol and weight-bearing status)
- Dizziness or vertigo
- Poor vision
Neurological conditions (such as stroke, Parkinson disease, or vestibular disorders) are not contraindications: balance training is a core intervention for these patients, carried out with close guarding and a gait belt.
Aquatic therapy
Related physics
- Buoyancy: Force of water on immersed body segment, decreasing body weight and joint off-loading
- Viscosity (drag): Friction between water molecules resists movement through the water; resistance increases with the speed of movement and the surface area moving through the water
- Hydrostatic pressure: Increases in proportion to water depth; assists venous return and reduces edema
- The deeper the individual is submerged, the greater the hydrostatic pressure and the more body weight is offloaded by buoyancy
Water temperatures
- Cooler water: Used for moderate to vigorous exercise, because the body sheds heat more easily
- 83 - 86°F (28 - 30°C) is a common range for general fitness
- Multiple sclerosis: 80 - 84°F (27 - 29°C), and no warmer than 84°F, because heat can temporarily worsen MS symptoms such as fatigue and weakness
- Warmer water: Used to improve mobility and flexibility while decreasing pain - common rehab population
- 88 - 92°F (31 - 33°C) is a common range for osteoarthritis
Precautions for aquatic therapy
- Fear of water
- Patients with heat intolerance
- Seizure disorder controlled with medication (close one-on-one supervision)
Contraindications for aquatic therapy
- Bowel/bladder incontinence
- Severe kidney disease
- Uncontrolled seizures
- Uncontrolled cardiac or respiratory disorders
- Peripheral vascular disease (PVD)
- Open wounds
- Active bleeding
- Active infections
Ways to progress therapeutic activities
Progressions examples
Musculoskeletal complications of interventions for other systems
- Hemiplegic shoulder: after a stroke the flaccid shoulder is easily injured. Pulling on the affected arm during transfers, bed mobility, or dressing puts traction on the glenohumeral joint and contributes to subluxation and shoulder pain - support the arm and never pull on it.
- Fragile bone: bone below a spinal cord injury loses density quickly, and fractures have occurred during transfers and while being turned in bed. Use safe transfer technique and gentle limb handling; take the same care with anyone who has osteoporosis.
- Heterotopic ossification: forced passive movement of a joint after a period of immobilization (for example, after spinal cord or brain injury) can injure the muscle and raise the risk of heterotopic ossification. Keep range of motion gentle and within the PT’s limits.
- Contracture: prolonged bed rest, immobilization, or a position of comfort (for example, flexion after a burn) lets soft tissue shorten. Follow the positioning, splinting, and range-of-motion schedule in the plan of care.