Physical Therapy/Study Notes/Therapeutic Exercises

Therapeutic Exercises

Evidence-based exercise interventions for rehabilitation, including ROM exercises, strengthening techniques, flexibility training, and functional activities.

1. Range of Motion Exercises 2. Strengthening Exercises 3. PRE Techniques 4. Manual Muscle Testing

5. Stretching Techniques 6. PNF Techniques 7. Balance & Coordination 8. Functional Training

1. Range of Motion Exercises

Passive ROM (PROM)

• No patient muscle contraction
• Therapist moves the limb
• Maintains joint mobility
• For paralyzed/comatose patients
• Post-surgical immobilization

Indication: MMT 0-1

Active-Assisted ROM (AAROM)

• Patient initiates movement
• Assistance to complete ROM
• Transition exercise
• For weak muscles
• Builds confidence

Indication: MMT 2-2+

Active ROM (AROM)

• Patient performs alone
• Full muscle contraction
• Maintains strength
• Improves coordination
• Promotes circulation

Indication: MMT 3+

Goals of ROM Exercises

• Maintain joint and connective tissue mobility
• Minimize effects of contracture formation
• Maintain mechanical elasticity of muscle
• Assist circulation and vascular dynamics
• Enhance synovial movement for cartilage nutrition
• Decrease/inhibit pain
• Assist with healing process

Contraindications & Precautions

Contraindications:

• Unstable fractures
• Immediately post-surgery (check protocol)
• Active infection at site
• Acute joint inflammation

Precautions:

• Pain with movement
• Hypermobility
• Recent injury
• Osteoporosis

2. Strengthening Exercises

Types of Resistance Training

Isometric

• No joint movement
• Muscle contracts at set length
• Good for: Acute injury, post-surgical
• Strength gain is angle-specific (±20°)
• Caution: BP increases (Valsalva)

Isotonic (Dynamic)

• Constant load, variable speed
• Concentric and eccentric
• Free weights, machines
• Most functional type
• Builds strength through ROM

Isokinetic

• Constant speed, variable resistance
• Accommodating resistance
• Requires special equipment
• Maximal force throughout ROM
• Good for testing & training

Manual Resistance

• Therapist applies resistance
• Highly adjustable
• Immediate feedback
• Good for weak muscles
• Limited by therapist strength

Training Principles

Overload: Resistance must exceed normal demand
Specificity (SAID): Specific Adaptation to Imposed Demands
Reversibility: "Use it or lose it" - gains reverse with detraining
Progressive Overload: Gradually increase resistance as strength improves
Recovery: Allow adequate rest between sessions (48-72 hours)

3. Progressive Resistance Exercise (PRE) Techniques

Technique	Protocol	Progression
DeLorme	3 sets × 10 reps Set 1: 50% of 10RM Set 2: 75% of 10RM Set 3: 100% of 10RM	Progressive (warm-up to max)
Oxford (Reverse DeLorme)	3 sets × 10 reps Set 1: 100% of 10RM Set 2: 75% of 10RM Set 3: 50% of 10RM	Regressive (max to fatigue)
DAPRE (Knight)	4 sets × variable reps Set 1: 10 reps @ 50% Set 2: 6 reps @ 75% Set 3: Max reps @ 100% Set 4: Max reps @ adjusted	Daily adjustment based on set 3 performance
Brief Isometric (Hettinger-Muller)	1 rep × 6 seconds @ 60-80% MVC	Increase resistance weekly

DAPRE Adjustment Guidelines

Reps in Set 3	Set 4 Adjustment	Next Session
0-2	Decrease 5-10 lbs	Decrease 5-10 lbs
3-4	Decrease 0-5 lbs	Same weight
5-6	Same weight	Increase 5-10 lbs
7-10	Increase 5-10 lbs	Increase 5-15 lbs
11+	Increase 10-15 lbs	Increase 10-20 lbs

4. Manual Muscle Testing (MMT)

Grade	Name	Description	%
5	Normal	Full ROM against gravity + maximum resistance	100%
4	Good	Full ROM against gravity + moderate resistance	75%
3+	Fair+	Full ROM against gravity + minimal resistance	~60%
3	Fair	Full ROM against gravity only	50%
3-	Fair-	Partial ROM against gravity	~40%
2+	Poor+	Full ROM gravity-eliminated + minimal resistance	~30%
2	Poor	Full ROM gravity-eliminated	25%
2-	Poor-	Partial ROM gravity-eliminated	~20%
1	Trace	Palpable contraction, no visible movement	10%
0	Zero	No contraction palpated	0%

Testing Principles

• Stabilize proximal segment
• Position for gravity-eliminated testing if grade appears less than 3
• Apply resistance at distal end of segment
• Apply gradual pressure ("make" test) or sudden ("break" test)
• Compare bilaterally
• Grade at end of available ROM

5. Stretching Techniques

Static Stretching

• Hold position 30-60 seconds
• Low force, long duration
• Safe and effective
• Best after warm-up or exercise
• 2-4 repetitions per stretch

Dynamic Stretching

• Controlled movement through ROM
• Active muscle contractions
• Sport-specific movements
• Best before activity
• Improves functional flexibility

Ballistic Stretching

• Bouncing movements
• Momentum-based
• Higher injury risk
• Not recommended for most patients
• May trigger stretch reflex

Prolonged Mechanical Stretching

• Low load, long duration
• 20-30 minutes or more
• Serial casting, splinting
• For established contractures
• Causes plastic deformation

Stretch Reflex vs. Autogenic Inhibition

Stretch Reflex (Muscle Spindle): Rapid stretch → spindle fires → muscle contracts (protective)
Autogenic Inhibition (GTO): Sustained tension → GTO fires → muscle relaxes (basis for PNF stretching)
Reciprocal Inhibition: Contract agonist → antagonist relaxes (basis for active stretching)

6. PNF Techniques

Proprioceptive Neuromuscular Facilitation

Techniques that use diagonal movement patterns and neuromuscular principles to improve strength, flexibility, and coordination.

PNF Stretching Techniques

Hold-Relax (HR)

Stretch to point of limitation
Isometric contraction of tight muscle (6-10 sec)
Relax
Move into new range

Uses: Autogenic inhibition

Contract-Relax (CR)

Stretch to point of limitation
Isotonic contraction of tight muscle through range
Relax
Move into new range

Uses: Autogenic inhibition + active movement

Hold-Relax-Agonist Contract (HRAC / CRAC)

Stretch to point of limitation
Isometric contraction of tight muscle (6-10 sec)
Relax
Contract opposite muscle (agonist) to pull into new range

Uses: Autogenic inhibition + Reciprocal inhibition (most effective)

PNF Diagonal Patterns

Pattern	Upper Extremity	Lower Extremity
D1 Flexion	Flex, Add, ER (hand to opposite shoulder)	Flex, Add, ER
D1 Extension	Ext, Abd, IR	Ext, Abd, IR
D2 Flexion	Flex, Abd, ER (reaching up and out)	Flex, Abd, IR
D2 Extension	Ext, Add, IR	Ext, Add, ER

PNF Strengthening Techniques

Rhythmic Initiation

PROM → AAROM → AROM (for learning movement)

Repeated Contractions

Repeated isotonic contractions (for weak muscles)

Rhythmic Stabilization

Alternating isometric contractions (for stability)

Slow Reversal

Alternating isotonic contractions (for coordination)

7. Balance & Coordination Training

Balance Components

Visual System

Spatial orientation

Vestibular System

Head position/movement

Somatosensory

Proprioception, touch, pressure

Progression of Balance Training

Wide base of support → Narrow base
Stable surface → Unstable surface (foam, wobble board)
Eyes open → Eyes closed
Static → Dynamic
Bilateral → Unilateral stance
No perturbation → With perturbation
Dual-task activities (cognitive + motor)

8. Functional Training

Transfer Training

Stand-pivot transfer: Weight-bearing on both legs
Squat-pivot transfer: Partial weight-bearing
Sliding board transfer: Non-weight bearing
Dependent lift: Total assistance (2-person)

Gait Training Progression

Pre-gait activities (standing, weight shifting, stepping)
Parallel bars
Walker/Crutches
Cane
Independent ambulation
Outdoor mobility, stairs, ramps

Key Takeaways for the Board Exam

ROM Exercises

• PROM: MMT 0-1
• AAROM: MMT 2-2+
• AROM: MMT 3+

PRE Techniques

• DeLorme: 50-75-100% (progressive)
• Oxford: 100-75-50% (regressive)
• DAPRE: Daily adjustment

PNF Stretching

• HR: Isometric of tight muscle
• CR: Isotonic of tight muscle
• HRAC: Most effective (both inhibitions)

MMT Grades

• 5: Full ROM + max resistance
• 3: Full ROM against gravity only
• 2: Full ROM gravity-eliminated

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