Exercise Therapy Carolin Kisner

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Therapeutic Exercise

Foundations and Techniques

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Therapeutic Exercise

Foundations and Techniques

F I F T H E D I T I O N

CAROLYN KISNER,

PT, MS

Assistant Professor Emeritus

The Ohio State University

School of Allied Medical Professions Physical Therapy Division

Columbus, Ohio

LYNN ALLEN COLBY,

PT, MS

Assistant Professor Emeritus

The Ohio State University

School of Allied Medical Professions Physical Therapy Division

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2002, 1996, 1990, 1985 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmit-ted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher: Margaret Biblis

Manager, Content Development: Deborah J. Thorp Developmental Editor: Jennifer A. Pine

Art and Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Kisner, Carolyn.

Therapeutic exercise : foundations and techniques / Carolyn Kisner, Lynn Allen Colby. — 5th ed. p. ; cm.

Includes bibliographical references and index. ISBN-13: 978-0-8036-1584-7

ISBN-10: 0-8036-1584-1

1. Exercise therapy—Handbooks, manuals, etc. I. Colby, Lynn Allen. II. Title. [DNLM: 1. Exercise Therapy—methods. WB 541 K61t 2007]

RM725.K53 2007

615.8′2—dc22 2007007512

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v

Dedication

To Jerry and our growing family—as always, your love and support has sustained me through this project. —CK To Rick and my extended family—a source of constant support and joy —LC In memory of our parents—who were supportive throughout our lives To our students—who have taught us so much To our colleagues—who have been helpful and stimulating in our professional growth —LC and CK

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vii

Preface

Y

ou will notice a new “face” with the fifth edition of

Therapeutic Exercise—Foundations and Techniques. The

soft cover, a feature of the first four editions, has been replaced with a hard cover. Each edition of this text has grown in scope and depth to reflect the expanding body of knowledge related to therapeutic exercise. The fifth edition is no exception.

There are many exciting trends in physical therapy which have influenced therapeutic exercise, and thus the content of this edition. These trends include entry-level physical therapist education rapidly progressing toward the Doctor of Physical Therapy degree, basic and clinical research lending evidence for critical analysis and support for therapeutic exercise interventions, and the practice of physical therapy moving toward direct access and autono-my enabling physical therapists with the assistance of physical therapist assistants to provide services to individu-als with movement disorders that impair function.

Although there are a number of new features in this edition directed toward the changes in education, clinical practice, and the healthcare environment, this text contin-ues to provide a foundation of concepts, principles, and techniques on which an individualized program of thera-peutic exercise can be built. This foundation remains an important component of the text. In addition to principles of exercise and background information on various pathologies and musculoskeletal surgeries, descriptions of exercise interventions and management guidelines are included to assist the reader in the development and pro-gression of individualized and comprehensive therapeutic exercise programs.

Major changes we have made in this fifth edition include:

A new feature called “Focus on Evidence” appears throughout the text to underscore the importance of evi-dence-based practice. The reader will find brief descrip-tions of research that highlight evidence related to various concepts and therapeutic exercise interventions. This feature is in addition to summaries of “outcomes” on selected topics that were added as a feature of the fourth edition and were extensively updated for this edi-tion.

The content of the text has been expanded to include several new areas and has also been completely

reorgan-ized. There are now five major sections. Highlights of each of the sections are as follows.

• Part I, General Concepts. We have added a new chapter, “Prevention, Health, and Wellness,” by Karen Holtgrefe, DHS, PT, OCS. She has done considerable graduate work and teaches in this area. The content of the chapter describes the importance of these topics in physical therapy practice.

• Part II, Applied Science of Exercise and

Tech-niques, covers the basic concepts and principles of

therapeutic exercise and foundational techniques. We have added a new chapter, “Exercise for Impaired Balance.” This chapter reflects the combined expert-ise of Anne D. Kloos, PT, PhD, NCS whose doctoral studies, teaching, and research have focused on neu-ral plasticity and neurological physical therapy, and Deborah Givens Heiss, PT, PhD, DPT, OCS whose doctoral studies, teaching, and research have inte-grated the areas of orthopedic physical therapy and motor control. Their chapter has a rich blend of neu-rological and orthopedic perspectives to the manage-ment of impaired balance.

• Part III, Principles of Intervention, was one chapter in previous editions, but to accommodate expanding science and evidence, we divided the content and developed three new chapters. In addition to “Soft Tissue Injury, Repair, and Management” and “Surgi-cal Interventions and Postoperative Management,” we added chapters on “Joint, Connective Tissue, and Bone Disorders and Management” (with new infor-mation of myofascial pain syndrome and fibromyal-gia and expanded information on fracture healing and management) and “Peripheral Nerve Disorders and Management.” These chapters provide background information for the practitioner to make sound clini-cal judgments when developing, implementing, and progressing programs that utilize therapeutic exercise.

• The chapters in Part IV, Exercise Interventions by

Body Region, have been extensively revised,

updat-ed, and expanded. In each of these chapters we fea-ture a table that links physical therapist preferred practice patterns to each of the pathologies and sur-geries presented. In addition, the chapters on posture and spinal impairments have been placed before

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the extremity chapters to emphasize the importance of posture on movement and control of the extremi-ties.

• Lastly, Part V, Special Areas of Therapeutic

Exer-cise, contains chapters that expand on areas of

prac-tice utilizing therapeutic exercise as a significant component of management, yet have distinct con-cerns that need to be emphasized. With the important emphasize on women’s health, Chapter 23 “Women’s Health: Obstetrics and Pelvic Floor” has been expanded by Barbara Settles Huge, BS, PT, Women’s

Health Specialist, to provide a background and basic skills for managing women with pelvic floor impair-ment.

As with previous editions, we hope that our efforts in planning and developing this edition will provide a useful resource for the continued professional growth of students and health practitioners who utilize therapeutic exercise.

Carolyn Kisner Lynn Allen Colby

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ix

Acknowledgments

In addition to all of our colleagues who were integral to the development of previous editions, we wish to acknowl-edge and express our gratitude to the following people for their expertise and contributions to this edition.

Barbara Settles Huge, BS, PT – for her revision of Chapter 23, “Women’s Health: Obstetrics and Pelvic Floor.” Karen Holtgrefe, DHS, PT, OCS, for writing the new chap-ter, “Prevention, Health, and Wellness,” for revising the chapter, “Principles of Aerobic Exercise,” and for con-tributing material on fibromyalgia, myofascial pain syn-drome, and osteoporosis to Chapter 11.

Anne D. Kloos, PT, PhD, NCS and Deborah Givens Heiss, PT, PhD, DPT, OCS for developing and writing the new chapter, “Exercise for Impaired Balance.”

Angie Dolder, PT, MS and the students at The Ohio State University who modeled for the pictures.

A special thank you goes to Berta Steiner of Bermedica Production Ltd, who spearheaded the copyediting and pro-duction process.

Once again F.A. Davis has brought their energy and resources to the development of yet another edition of this textbook. We are so grateful for their continued support for more than two decades. As with the fourth edition, Mar-garet Biblis, Publisher, has brought her vision, keen insight and style to the fifth edition. We also thank Jennifer Pine, our Development Editor, for always moving the project along and keeping us focused, as well as Deborah Thorp, Manager of Content Development for her help and input during our planning stages.

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xi

Contributors

Terri M. Glenn,

PhD, PT Adjunct Faculty

Doctor of Physical Therapy Program University of Dayton

Dayton, Ohio

Deborah Givens Heiss,

PT, PhD, DPT, OCS Associate Professor

Division of Physical Therapy The Ohio State University Columbus, Ohio

Karen Holtgrefe,

DHS, PT, OCS Assistant Professor

College of Mount St. Joseph Cincinnati, Ohio

Barbara Settles Huge,

BS, PT Women’s Health Specialist/Consultant

BSH Wellness Adjunct Faculty

Indiana University Physical Therapy Program Fishers, Indiana

Anne D. Kloos,

PT, PhD, NCS Assistant Professor of Clinical Medicine

Division of Physical Therapy The Ohio State University Columbus, Ohio

Robert Schrepfer,

MS, PT, MBA Former Clinical Director

The Center for Aquatic Rehabilitation Associate Director

Bear Stearns Health Care Value Partners New York, New York

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xiii

Brief Contents

P A R T I :

General Concepts

₁

C H A P T E R 1

Therapeutic Exercise:

Foundational Concepts

1

C H A P T E R 2

Prevention, Health, and

Wellness

37

Karen Holtgrefe, DHS, PT, OCS

P A R T I I :

Applied Science of

Exercise and

Techniques

43

C H A P T E R 3

Range of Motion

43 C H A P T E R 4

Stretching for Impaired

Mobility

65

C H A P T E R 5

Peripheral Joint

Mobilization

109

C H A P T E R 6

Resistance Exercise for

Impaired Muscle

Performance

147

C H A P T E R 7

Principles of Aerobic Exercise

231

Karen Holtgrefe, DHS, PT, OCS Terri M. Glenn, PhD, PT

C H A P T E R 8

Exercise for Impaired

Balance

251

Anne D. Kloos, PT, PhD, NCS Deborah Givens Heiss, PT, PhD, DPT, OCS

C H A P T E R 9

Aquatic Exercise

273

Robert Schrepfer, MS, PT

P A R T I I I :

Principles of

Intervention

295

C H A P T E R 1 0

Soft Tissue Injury, Repair, and

Management

295

C H A P T E R 11

Joint, Connective Tissue, and

Bone Disorders and

Management

309

C H A P T E R 1 2

Surgical Interventions and

Postoperative Management

329

C H A P T E R 1 3

Peripheral Nerve Disorders and

Management

349

P A R T I V :

Exercise Interventions

by Body Region

383

C H A P T E R 1 4

The Spine and Posture:

Structure, Function, Postural

Impairments, and Management

Guidelines

383

C H A P T E R 1 5

The Spine: Impairments,

Diagnoses, and Management

Guidelines

407

C H A P T E R 1 6

The Spine: Exercise

Interventions

439

C H A P T E R 1 7

The Shoulder and Shoulder

Girdle

481

C H A P T E R 1 8

The Elbow and Forearm

Complex

557

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xiv BRIEF CONTENTS C H A P T E R 2 5

Management of Pulmonary

Conditions

851 A P P E N D I X

Systematic Musculoskeletal

Examination Guidelines

883

Glossary

889

Index

897 C H A P T E R 2 0

The Hip

643 C H A P T E R 2 1

The Knee

687

C H A P T E R 2 2

The Ankle and Foot

759

P A R T V :

Special Areas of

Therapeutic Exercise

797

C H A P T E R 2 3

Women’s Health: Obstetrics

and Pelvic Floor

797

Barbara Settles Huge, BS, PT

C H A P T E R 2 4

Management of Vascular

Disorders of the

Extremities

825

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xv

General Concepts

₁

C H A P T E R 1

Therapeutic Exercise:

Foundational Concepts

1

THERAPEUTICEXERCISE: IMPACT ONPHYSICALFUNCTION 2 Definition of Therapeutic Exercise 2

Aspects of Physical Function: Definition of Key Terms 2 Types of Therapeutic Exercise Intervention 3

Exercise Safety 3

PROCESS ANDMODELS OFDISABLEMENT 4 The Disablement Process 4

Models of Disablement 4

Use of Disablement Models and Classifications in Physical Therapy 5

PATIENTMANAGEMENT ANDCLINICALDECISIONMAKING: AN

INTERACTIVERELATIONSHIP 11 Clinical Decision Making 11 Evidence-Based Practice 11 A Patient Management Model 12

STRATEGIES FOREFFECTIVEEXERCISE ANDTASK-SPECIFIC

INSTRUCTION 24

Preparation for Exercise Instruction 24

Concepts of Motor Learning: A Foundation of Exercise and Task-Specific Instruction 24

Adherence to Exercise 31

INDEPENDENTLEARNINGACTIVITIES 33

C H A P T E R 2

Prevention, Health, and

Wellness

37

Karen Holtgrefe, DHS, PT, OCS

ROLE OFPHYSICALTHERAPY INHEALTHYPEOPLE2010 37 Identifying Risk Factors 38

Determining Readiness to Change 38 Developing and Implementing a Program 40 Case Example: Exercise and Osteoporosis 40 Additional Considerations for Developing Prevention,

Health, and Wellness Programs 41

P A R T I I :

Applied Science of

Exercise and

Techniques

43

C H A P T E R 3

Range of Motion

43

TYPES OFROM EXERCISES 44

INDICATIONS ANDGOALS FORROM 44 Passive ROM 44

Active and Active-Assistive ROM 44

LIMITATIONS OFROM EXERCISES 45 Limitations of Passive Motion 45 Limitations of Active ROM 45

PRECAUTIONS ANDCONTRAINDICATIONS TOROM EXERCISES 45

PRINCIPLES ANDPROCEDURES FORAPPLYINGROM TECHNIQUES 45

Examination, Evaluation, and Treatment Planning 45 Patient Preparation 46 Application of Techniques 46 Application of PROM 46 Application of AROM 46 ROM TECHNIQUES 46 Upper Extremity 47 Lower Extremity 52 Cervical Spine 55 Lumbar Spine 55

Combined Patterns of Motion 56

SELF-ASSISTEDROM 56 Self-Assistance 57 Wand (T-Bar) Exercises 59 Wall Climbing 60 Overhead Pulleys 60

Skate Board/Powder Board 61 Reciprocal Exercise Unit 61

CONTINUOUSPASSIVEMOTION 61 Benefits of CPM 61

General Guidelines for CPM 62

ROM THROUGHFUNCTIONALPATTERNS 62

C H A P T E R 4 :

Stretching for Impaired

Mobility

65

DEFINITIONS OFTERMSRELATED TOMOBILITY AND

STRETCHING 66 Flexibility 66 Hypomobility 66 Contracture 66 Types of Contracture 67

Interventions to Increase Mobility of Soft Tissues 68 Selective Stretching 69

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PROPERTIES OFSOFTTISSUE–RESPONSE TOIMMOBILIZATION ANDSTRETCH 69

Mechanical Properties of Contractile Tissue 70 Neurophysiological Properties of Contractile Tissue 72 Mechanical Properties of Noncontractile Soft Tissue 73

DETERMINANTS, TYPES,ANDEFFECTS OFSTRETCHING

INTERVENTIONS 77

Alignment and Stabilization 77 Intensity of Stretch 79 Duration of Stretch 79 Speed of Stretch 81 Frequency of Stretch 81 Mode of Stretch 82

Proprioceptive Neuromuscular Facilitation Stretching Techniques 85

Integration of Function into Stretching 87

PROCEDURALGUIDELINES FORAPPLICATION OFSTRETCHING

INTERVENTIONS 88

Examination and Evaluation of the Patient 88 Preparation for Stretching 89

Application of Manual Stretching Procedures 89 After Stretching 90

PRECAUTIONS FORSTRETCHING 90 General Precautions 90

Special Precautions for Mass-Market Flexibility Programs 91

ADJUNCTS TOSTRETCHINGINTERVENTIONS 92 Relaxation Training 92

Heat 92 Massage 93 Biofeedback 93

Joint Traction or Oscillation 93

MANUALSTRETCHINGTECHNIQUES INANATOMICALPLANES OF

MOTION 94

Upper Extremity Stretching 94 Lower Extremity Stretching 99

C H A P T E R 5 :

Peripheral Joint

Mobilization

109

DEFINITIONS OFTERMS 110 Mobilization/Manipulation 110

Self-Mobilization (Auto-mobilization) 110 Mobilization with Movement 110 Physiological Movements 110 Accessory Movements 110 Thrust 110

Manipulation Under Anesthesia 110 Muscle Energy 110

BASICCONCEPTS OF JOINTMOTION: ARTHROKINEMATICS 110 Joint Shapes 110

Types of Motion 111

Passive-Angular Stretching Versus Joint-Glide Stretching 113

Other Accessory Motions That Affect the Joint 113 Effects of Joint Motion 114

INDICATIONS FORJOINTMOBILIZATION 114 Pain, Muscle Guarding, and Spasm 114 Reversible Joint Hypomobility 114 Positional Faults/Subluxations 114 Progressive Limitation 114 Functional Immobility 114

LIMITATIONS OFJOINTMOBILIZATIONTECHNIQUES 115

CONTRAINDICATIONS ANDPRECAUTIONS 115 Hypermobility 115

Joint Effusion 115 Inflammation 115

Conditions Requiring Special Precautions for Stretching 115

PROCEDURES FORAPPLYINGPASSIVEJOINTMOBILIZATION

TECHNIQUES 116

Examination and Evaluation 116 Grades or Dosages of Movement 116 Positioning and Stabilization 117

Treatment Force and Direction of Movement 118 Initiation and Progression of Treatment 118 Speed, Rhythm, and Duration of Movements 119 Patient Response 119

Total Program 119

MOBILIZATION WITH MOVEMENT: PRINCIPLES OF

APPLICATION 120

Principles of MWM in Clinical Practice 120 Pain as the Guide 120

Techniques 120

Theoretical Framework 121

PERIPHERALJOINTMOBILIZATIONTECHNIQUES 121 Shoulder Girdle Complex 121

Elbow and Forearm Complex 127 Wrist Complex 131

Hand and Finger Joints 133 Hip Joint 135

Knee and Leg 137 Ankle and Foot Joints 141

C H A P T E R 6 :

Resistance Exercise for Impaired

Muscle Performance

147

MUSCLE PERFORMANCE ANDRESISTANCEEXERCISE–DEFINITIONS ANDGUIDINGPRINCIPLES 148

Strength 149 Power 149 Endurance 149 Overload Principle 150 SAID Principle 150 Reversibility Principle 150

SKELETALMUSCLEFUNCTION ANDADAPTATION TORESISTANCE

EXERCISE 151 xvi CONTENTS

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Circuit Weight Training 207

Plyometric Training–Stretch-Shortening Drills 208 Isokinetic Regimens 210

EQUIPMENT FORRESISTANCETRAINING 212

Free Weights and Simple Weight-Pulley Systems 213 Variable Resistance Machines 215

Elastic Resistance Bands and Tubing 216 Equipment for Closed-Chain Training 219 Reciprocal Exercise Equipment 220

Equipment for Dynamic Stabilization Training 221 Isokinetic Testing and Training Equipment 222

C H A P T E R 7

Principles of Aerobic

Exercise

231

Karen Holtgrefe, DHS, PT, OCS Terri M. Glenn, PhD, PT

KEYTERMS ANDCONCEPTS 232 Fitness 232

Maximum Oxygen Consumption 232 Endurance 232

Aerobic Exercise Training (Conditioning) 232 Adaptation 232

Myocardial Oxygen Consumption 232 Deconditioning 233

Energy Systems, Energy Expenditure, and Efficiency 233 Functional Implications 234

Energy Expenditure 234 Efficiency 234

PHYSIOLOGICALRESPONSE TOAEROBICEXERCISE 235 Cardiovascular Response to Exercise 235

Respiratory Response to Exercise 235

Responses Providing Additional Oxygen to Muscle 236

TESTING AS ABASIS FOREXERCISEPROGRAMS 236 Fitness Testing of Healthy Subjects 236 Stress Testing for Convalescing Individuals and

Individuals at Risk 236 Multistage Testing 237

DETERMINANTS OF ANEXERCISEPROGRAM 237 Intensity 237 Duration 239 Frequency 239 Mode 239 Reversibility Principle 240 EXERCISEPROGRAM 240 Warm-Up Period 240 Aerobic Exercise Period 240 Cool-Down Period 241 Application 241

PHYSIOLOGICALCHANGES THATOCCUR WITHTRAINING 241 Cardiovascular Changes 241

Respiratory Changes 242 Metabolic Changes 242 Other System Changes 243 Factors that Influence Tension Generation in Normal

Skeletal Muscle 151

Physiological Adaptations to Resistance Exercise 157

DETERMINANTS OFRESISTANCEEXERCISE 159 Alignment and Stabilization 160

Intensity 161 Volume 162 Exercise Order 163 Frequency 163 Duration 163

Rest Interval (Recovery Period) 164 Mode of Exercise 164

Velocity of Exercise 165 Periodization 166

Integration of Function 166

TYPES OFRESISTANCEEXERCISE 167

Manual and Mechanical Resistance Exercise 167 Isometric Exercise (Static Exercise) 168 Dynamic Exercise–Concentric and Eccentric 170 Dynamic Exercise–Constant and Variable Resistance 172 Isokinetic Exercise 172

Open-Chain and Closed-Chain Exercise 174

GENERALPRINCIPLES OF RESISTANCETRAINING 180 Examination and Evaluation 180

Preparation for Resistance Exercises 181 Application of Resistance Exercises 181

PRECAUTIONS FORRESISTANCEEXERCISE 182 Valsalva Maneuver 182

Substitute Motions 183 Overtraining and Overwork 183 Exercise-Induced Muscle Soreness 184 Pathological Fracture 185

CONTRAINDICATIONS TORESISTANCEEXERCISE 185 Pain 186

Inflammation 186

Severe Cardiopulmonary Disease 186

MANUALRESISTANCEEXERCISE 186 Definition and Use 186

Guidelines and Special Considerations 187 Techniques–General Background 188 Upper Extremity 188

Lower Extremity 192

PROPRIOCEPTIVENEUROMUSCULAR FACILITATION–PRINCIPLES AND

TECHNIQUES 195 Diagonal Patterns 196

Basic Procedures with PNF Patterns 196 Upper Extremity Diagonal Patterns 197 Lower Extremity Diagonal Patterns 200 Specific Techniques with PNF 202

MECHANICALRESISTANCEEXERCISE 203 Use in Rehabilitation 204

Use in Conditioning Programs 204

Special Considerations for Children and Older Adults 204

SELECTEDRESISTANCETRAINING REGIMENS 206 Progressive Resistance Exercise 206

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APPLICATION OFPRINCIPLES OF ANAEROBIC

CONDITIONINGPROGRAM FOR THEPATIENT WITH

CORONARYDISEASE 243 Inpatient Phase (Phase I) 243 Outpatient Phase (Phase II) 243 Outpatient Program (Phase III) 244 Special Considerations 244 Adaptive Changes 244

APPLICATIONS OFAEROBICTRAINING FOR THE

DECONDITIONEDINDIVIDUAL AND THEPATIENT WITH

CHRONICILLNESS 245

Adaptations for Disabilities, Functional Limitations, and Deconditioning 245

Impairments, Goals, and Plan of Care 245

AGE DIFFERENCES 246 Children 246 Young Adults 247 Older Adults 248

C H A P T E R 8

Exercise for Impaired

Balance

251

Anne D. Kloos, PT, PhD, NCS

Deborah Givens Heiss, PT, PhD, DPT, OCS

BACKGROUND ANDCONCEPTS 251 Balance: Key Terms and Definitions 251 Balance Control 252

Sensory Systems and Balance Control 253 Motor Strategies for Balance Control 254 Balance Control Under Varying Conditions 256

IMPAIREDBALANCE 258 Sensory Input Impairments 258 Sensorimotor Integration 259

Biomechanical and Motor Output Deficits 259 Deficits with Aging 259

Deficits from Medications 260

MANAGEMENT OFIMPAIREDBALANCE 260

Examination and Evaluation of Impaired Balance 260 Balance Training 261

Health and Environmental Factors 265 Evidence-Based Balance Exercise Programs 265 Tai Chi for Balance Training 266

C H A P T E R 9

Aquatic Exercise

273

Robert Schrepfer, MS, PT

BACKGROUND AND PRINCIPLES FOR AQUATIC

EXERCISE 273

DEFINITION OFAQUATICEXERCISE 273

GOALS ANDINDICATIONS FORAQUATICEXERCISE 274

PRECAUTIONS ANDCONTRAINDICATIONS TOAQUATIC

EXERCISE 274 xviii CONTENTS

Precautions 274 Contraindications 274

PROPERTIES OFWATER 274 Physical Properties of Water 274 Hydromechanics 275

Thermodynamics 275 Center of Buoyancy 276

AQUATICTEMPERATURE ANDTHERAPEUTICEXERCISE 276 Temperature Regulation 276

Mobility and Functional Control Exercise 276 Aerobic Conditioning 277

SPECIALEQUIPMENT FORAQUATICEXERCISE 277 Collars, Rings, Belts, and Vests 277

Swim Bars 278

Gloves, Hand Paddles, and Hydro-tone® Balls 278 Fins and Hydro-tone® Boots 278

Kickboards 278

EXERCISE INTERVENTIONS USING AN AQUATIC

ENVIRONMENT 279

STRETCHINGEXERCISES 279 Manual Stretching Techniques 279

Self-Stretching with Aquatic Equipment 282

STRENGTHENINGEXERCISES 283 Manual Resistance Exercises 283 Independent Strengthening Exercises 287

AEROBICCONDITIONING 290 Treatment Interventions 290 Physiological Response to Deep-Water

Walking/Running 290

Proper Form for Deep-Water Running 290 Exercise Monitoring 291

Equipment Selection 291

INDEPENDENTLEARNINGACTIVITIES 291 P A R T I I I :

Principles of

Intervention

295

C H A P T E R 1 0

Soft Tissue Injury, Repair, and

Management

295

SOFTTISSUELESIONS 295

Examples of Soft Tissue Lesions–Musculoskeletal Disorders 295

Clinical Conditions Resulting from Trauma or Pathology 296

Severity of Tissue Injury 297

Irritability of Tissue: Stages of Inflammation and Repair 297

MANAGEMENTDURING THEACUTESTAGE 298 Tissue Response–Inflammation 298

Management Guidelines–Protection Phase 298

MANAGEMENTDURING THESUBACUTESTAGE 300 Tissue Response–Repair and Healing 300

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Joint Procedures 339

Extra-articular Bony Procedures 343

C H P A T E R 1 3

Peripheral Nerve Disorders

and Management

349

REVIEW OFPERIPHERALNERVESTRUCTURE 350 Nerve Structure 350

Nervous System Mobility Characteristics 350 Common Sites of Injury to Peripheral Nerves 351

IMPAIRED NERVE FUNCTION 363

NERVEINJURY ANDRECOVERY 363 Mechanisms of Nerve Injury 363 Classification of Nerve Injuries 364 Recovery of Nerve Injuries 365

Management Guidelines–Recovery from Nerve Injury 365

NEURAL TENSIONDISORDERS 366

Symptoms and Signs of Nerve Mobility Impairment 367 Causes of Symptoms 367

Principles of Management 367

Neural Testing and Mobilization Techniques for the Upper Quadrant 367

Neural Testing and Mobilization Techniques for the Lower Quadrant 368

Prevention 370

MUSCULOSKELETAL DIAGNOSES INVOLVING IMPAIRED

NERVE FUNCTION 370

THORACICOUTLETSYNDROME 370 Related Diagnoses 370

Etiology of Symptoms 371

Location of Compression or Entrapment and Tests of Provocation 371

Common Impairments in TOS 372

Common Functional Limitations/Disabilities 372 Nonoperative Management of TOS 373

CARPALTUNNELSYNDROME 373 Etiology of Symptoms 374 Tests of Provocation 374 Common Impairments 374

Common Functional Limitations/Disabilities 375 Nonoperative Management of CTS 375

Surgical Intervention and Postoperative Management 376

COMPRESSION INTUNNEL OF GUYON 377 Etiology of Symptoms 377

Tests of Provocation 377 Common Impairments 377

Common Functional Limitations/Disabilities 377 Nonoperative Management 378

Surgical Release and Postoperative Management 378

COMPLEXREGIONALPAINSYNDROME: REFLEXSYMPATHETIC

DYSTROPHY ANDCAUSALGIA 378 Related Diagnoses and Symptoms 378 Etiology and Symptoms 378

Management Guidelines–Controlled Motion Phase 300

MANAGEMENTDURING THECHRONICSTAGE 302 Tissue Response–Maturation and Remodeling 302 Management Guidelines–Return to Function Phase 303

CUMULATIVETRAUMA–CHRONICRECURRINGPAIN 305 Tissue Response–Chronic Inflammation 305 Etiology of Chronic Inflammation Leading to

Prolonged or Recurring Pain 305 Contributing Factors 305

Management Guidelines–Chronic Inflammation 306

C H A P T E R 11

Joint, Connective Tissue, and

Bone Disorders and

Management

309

ARTHRITIS–ARTHROSIS 309 Clinical Signs and Symptoms 309 Rheumatoid Arthritis 310

Osteoarthritis–Degenerative Joint Disease 314

FIBROMYALGIA ANDMYOFASCIALPAINSYNDROME 316 Fibromyalgia 316

Myofascial Pain Syndrome 318

OSTEOPOROSIS 318 Risk Factors 318

Prevention of Osteoporosis 319 Recommendations for Exercise 320

Exercise Precautions and Contraindications 320

FRACTURES–POST-TRAUMATICIMMOBILIZATION 320 Risk Factors 322

Bone Healing Following a Fracture 322

Principles of Management–Period of Immobilization 323 Postimmobilization Period 323

C H A P T E R 1 2

Surgical Interventions

and Postoperative

Management

329

INDICATIONS FORSURGICALINTERVENTION 329

GUIDELINES FORPREOPERATIVE AND

POSTOPERATIVEMANAGEMENT 329

Considerations for Preoperative Management 330 Considerations for Postoperative Management 331 Potential Postoperative Complications 334

OVERVIEW OFCOMMONORTHOPEDICSURGERIES AND

Surgical Approaches–Open, Arthroscopic, and Arthroscopically Assisted Procedures 335 Use of Tissue Grafts 336

Repair, Reattachment, Reconstruction, Stabilization, or Transfer of Soft Tissues 336

Release, Lengthening, or Decompression of Soft Tissues 339

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C H A P T E R 1 5

The Spine: Impairments,

Diagnoses, and Management

Guidelines

407

REVIEW OF THESTRUCTURE ANDFUNCTION OF THE SPINE 408 Functional Components of the Spine 408

Motions of the Spinal Column 408

Structure and Function of Intervertebral Disks 409 Intervertebral Foramina 409

Inert Structures: Influence on Movement and Stability 410 Neuromuscular Function: Dynamic Stabilization 410

SPINAL PATHOLOGIES AND IMPAIRED SPINAL

FUNCTION 410

PATHOLOGY OF THE INTERVERTEBRAL DISK 410 Injury and Degeneration of the Disk 410 Disk Pathologies and Related Conditions 412

Signs and Symptoms of Disk Lesions and Fluid Stasis 412

PATHOMECHANICALRELATIONSHIPS OF THEINTERVERTEBRAL

DISK ANDFACETJOINTS 414 Three-Joint Complex 414 Related Pathologies 414

PATHOLOGY OF THE ZYGAPOPHYSEAL(FACET) JOINTS 415 Facet Joint Characteristics 415

Common Diagnoses and Impairments from Facet Joint Pathologies 415

PATHOLOGY OFMUSCLE ANDSOFTTISSUEINJURIES: STRAINS, TEARS,ANDCONTUSIONS 416

General Symptoms from Trauma 416 Common Sites of Lumbar Strain 416 Common Sites of Cervical Strain 416 Postural Strain 416

Emotional Stress 417

Functional Limitations/Disabilities 417

PATHOMECHANICS OFSPINALINSTABILITY 417 Neutral Zone 417

Instability 417

MANAGEMENT GUIDELINES BASED ON

IMPAIRMENTS 418

PRINCIPLES OFMANAGEMENT FOR THESPINE 418 Examination and Evaluation 418

General Guidelines for Managing Acute Spinal Problems: Protection Phase 420

General Guidelines for Managing Subacute Spinal Problems: Controlled Motion Phase 421

General Guidelines for Managing Chronic Spinal Problems: Return to Function Phase 423

MANAGEMENTGUIDELINES–NON-WEIGHT-BEARINGBIAS 424 Management of Acute Symptoms 424

Progression 424

MANAGEMENTGUIDELINES–EXTENSIONBIAS 424 Principles of Management 424

Indications, Precautions, and Contraindications for Interventions–Extension Approach 425 xx CONTENTS

Three Stages of CRPS Type I (RSD) 378 Common Impairments 379

Management 379

P A R T I V :

Exercise Interventions

by Body Region

383

C H A P T E R 1 4

The Spine and Posture:

Structure, Function, Postural

Impairments, and Management

Guidelines

383

POSTURE AND BIOMECHANICAL INFLUENCES 384

ALIGNMENT 384 Curves of the Spine 384 Postural Alignment 384

STABILITY 385

Postural Stability in the Spine 385

Effects of Limb Motion on Spinal Stability 392 Effects of Breathing on Posture and Stability 392

IMPAIRED POSTURE 393

ETIOLOGY OFPAIN 393

Effect of Mechanical Stress 393

Effect of Impaired Postural Support from Trunk Muscles 393

Effect of Impaired Muscle Endurance 394 Pain Syndromes Related to Impaired Posture 394

COMMONFAULTYPOSTURES: CHARACTERISTICS AND

IMPAIRMENTS 394

Pelvic and Lumbar Region 394 Cervical and Thoracic Region 395

Frontal Plane Deviations from Lower Extremity Asymmetries 397

MANAGEMENT OF IMPAIRED POSTURE 398

GENERALMANAGEMENTGUIDELINES 398

Postural Alignment: Proprioception and Control 398 Relationship of Impaired Posture and Pain 400 Joint, Muscle, and Connective Tissue Mobility

Impairments 400

Impaired Muscle Performance 401 Body Mechanics 401

Stress Provoking Postures and Activities: Relief and Prevention 401

Stress Management/Relaxation 401 Healthy Exercise Habits 402

TENSIONHEADACHE/CERVICALHEADACHE 403 Causes 403

Presenting Signs and Symptoms 403 General Management Guidelines 403

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Techniques to Increase Thoracic Extension 444 Techniques to Increase Axial Extension (Cervical

Retraction)–Scalene Muscle Stretch 445 Techniques to Increase Upper Cervical Flexion–Short

Suboccipital Muscle Stretch 445

Techniques to Increase Scapular and Humeral Muscle Flexibility 446

Traction as a Stretching Technique 446 Other Techniques for Increasing Mobility 447

MID ANDLOWERTHORACIC ANDLUMBAR

REGIONS–STRETCHINGTECHNIQUES 447 Techniques to Increase Lumbar Flexion 447 Techniques to Increase Lumbar Extension 448

Techniques to Increase Lateral Flexibility in the Spine 448 Techniques to Increase Hip Muscle Flexibility 450 Traction as a Stretching Technique 450

MUSCLE PERFORMANCE: STABILIZATION, MUSCLE

ENDURANCE, AND STRENGTH TRAINING 451

STABILIZATIONTRAINING–FUNDAMENTALTECHNIQUES AND

PROGRESSIONS 451

Guidelines for Stabilization Training 451

Deep Stabilizing (Core) Muscle Activation and Training 452 Global Muscle Stabilization Exercises 456

ISOMETRIC AND DYNAMICEXERCISES 465 Exercises for the Cervical Region 466

Exercises for the Thoracic and Lumbar Regions 467

CARDIOPULMONARY ENDURANCE 472

COMMONAEROBICEXERCISES ANDEFFECTS ON THESPINE 472 Cycling 472

Walking and Running 473 Stair Climbing 473

Cross-Country Skiing and Ski Machines 473 Swimming 473

Upper Body Ergometry Machines 473 Step Aerobics and Aerobic Dancing 473 “Latest Popular Craze” 473

FUNCTIONAL ACTIVITIES 473

EARLYFUNCTIONALTRAINING–FUNDAMENTALTECHNIQUES 474

PREPARATION FORFUNCTIONALACTIVITIES–BASICEXERCISE

TECHNIQUES 474

Weight-Bearing Exercises 474 Transitional Stabilization Exercises 476

BODYMECHANICS ANDENVIRONMENTALADAPTATIONS 476 Principles of Body Mechanics–Instruction and

Training 476

Environmental Adaptations 477

INTERMEDIATE TOADVANCEDEXERCISETECHNIQUES FOR

FUNCTIONAL TRAINING 477 Repetitive Lifting 477 Repetitive Reaching 478

Repetitive Pushing and Pulling 478 Rotation or Turning 478

Transitional Movements 478 Transfer of Training 478 Techniques Using an Extension Approach in the Lumbar

Spine 425

Techniques to Manage a Disk Lesion in the Cervical Spine 428

MANAGEMENTGUIDELINES–FLEXIONBIAS 429 Principles of Management 429

Indications and Contraindications for Intervention–Flexion Approach 429

Techniques Utilizing a Flexion Approach 429

MANAGEMENTGUIDELINES–STABILIZATION 430 Identification of Clinical Instability 430 Principles of Management 431

MANAGEMENTGUIDELINES–MOBILIZATION 431 Management–Lumbar Spine 431

Management–Cervical Spine 432

MANAGEMENTGUIDELINES–SOFTTISSUEINJURIES 432 Management During the Acute Stage: Protection

Phase 432

Management in the Subacute and Chronic Stages of Healing: Controlled Motion and Return to Function Phases 433

MANAGEMENTGUIDELINES–TEMPOROMANDIBULARJOINT

DYSFUNCTION 433 Signs and Symptoms 433 Etiology of Symptoms 433 Principles of Management 434

C H A P T E R 1 6

The Spine: Exercise

Interventions

439

BASIC CONCEPTS OF SPINAL MANAGEMENT

WITH EXERCISE 440

FUNDAMENTALINTERVENTIONS 440

PATIENTEDUCATION 440

GENERALEXERCISEGUIDELINES 441 Kinesthetic Awareness 441 Mobility/Flexibility 441 Muscle Performance 441 Cardiopulmonary Endurance 441 Functional Activities 442 KINESTHETIC AWARENESS 443

ELEMENTS OFKINESTHETICTRAINING–FUNDAMENTAL

TECHNIQUES 443

Position of Symptom Relief 443 Effects of Movement on the Spine 443

Integration of Kinesthetic Training With Stabilization Exercises and Fundamental Body Mechanics 443

PROGRESSION TOACTIVE ANDHABITUALCONTROL OF

POSTURE 443

MOBILITY/FLEXIBILITY 444

CERVICAL ANDUPPERTHORACIC

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EDUCATION FORPREVENTION 478

C H A P T E R 1 7

The Shoulder and Shoulder

Girdle

481

STRUCTURE AND FUNCTION OF THE SHOULDER

GIRDLE 482

JOINTS OF THESHOULDERGIRDLECOMPLEX 482 Synovial Joints 482

Functional Articulations 484

SHOULDERGIRDLEFUNCTION 486 Scapulohumeral Rhythm 486

Clavicular Elevation and Rotation With Humeral Motion 486

External Rotation of the Humerus With Full Elevation 487 Internal Rotation of the Humerus With Full Elevation 487 Elevation of the Humerus Through the Plane of the

Scapula–Scaption 487

Deltoid-Short Rotator Cuff and Supraspinatus Mechanisms 487

REFERREDPAIN ANDNERVEINJURY 487

Common Sources of Referred Pain in the Shoulder Region 487

Nerve Disorders in the Shoulder Girdle Region 487

MANAGEMENT OF SHOULDER DISORDERS AND

SURGERIES 488

JOINTHYPOMOBILITY: NONOPERATIVE MANAGEMENT 488 Glenohumeral Joint 488

Acromioclavicular and Sternoclavicular Joints 493

GLENOHUMERALJOINT SURGERY ANDPOSTOPERATIVE

MANAGEMENT 494

Glenohumeral Arthroplasty 494 Arthrodesis of the Shoulder 501

PAINFULSHOULDERSYNDROMES(ROTATORCUFFDISEASE, IMPINGEMENTSYNDROMES, SHOULDER INSTABILITIES): NONOPERATIVEMANAGEMENT 502

Related Pathologies and Etiology of Symptoms 502 Common Impairments 505

Common Functional Limitations/Disabilities 506 Management: Painful Shoulder Syndromes (Without

Dislocation) 506

PAINFULSHOULDERSYNDROMES: SURGERY ANDPOSTOPERATIVE

MANAGEMENT 508

Subacromial Decompression and Postoperative Management 508

Rotator Cuff Repair and Postoperative Management 511

SHOULDERDISLOCATIONS: NONOPERATIVEMANAGEMENT 518 Related Pathologies and Mechanisms of Injury 518 Common Impairments 519

Common Functional Limitations/Disabilities 519 Closed Reduction of Anterior Dislocation 519 Closed Reduction Posterior Dislocation 521

SHOULDERINSTABILITIES: SURGERY ANDPOSTOPERATIVE

MANAGEMENT 521

Glenohumeral Joint Stabilization Procedures and Postoperative Management 521

Acromioclavicular and Sternoclavicular Joint Stabilization Procedures and Postoperative Management 529

EXERCISE INTERVENTIONS FOR THE SHOULDER

GIRDLE 529

EXERCISETECHNIQUESDURINGACUTE ANDEARLYSUBACUTE

STAGES OFTISSUEHEALING 529

Early Motion of the Glenohumeral Joint 529 Early Motion of the Scapula 531

Early Neuromuscular Control 531

EXERCISETECHNIQUES TOINCREASEFLEXIBILITY ANDRANGE OF

MOTION 531

Self-Stretching Techniques 531

Manual and Self-Stretching Exercises for Specific Muscles 533

EXERCISES TODEVELOP ANDIMPROVEMUSCLEPERFORMANCE ANDFUNCTIONALCONTROL 536

Isometric Exercises 536 Stabilization Exercises 539

Dynamic Strengthening Exercises–Scapular Muscles 541 Dynamic Strengthening Exercises–Glenohumeral

Muscles 545

Functional Activities 549

C H A P T E R 1 8

The Elbow and Forearm

Complex

557

STRUCTURE AND FUNCTION OF THE ELBOW AND

FOREARM 558

JOINTS OF THEELBOW ANDFOREARM 558

Elbow Joint Characteristics and Arthrokinematics 558 Forearm Joint Characteristics and Arthrokinematics 559

MUSCLE FUNCTION AT THEELBOW ANDFOREARM 560 Primary Actions at the Elbow and Forearm 560

Relationship of Wrist and Hand Muscles to the Elbow 560

REFERREDPAIN ANDNERVEINJURY IN THEELBOW

REGION 560

Common Sources of Referred Pain into the Elbow Region 561

Nerve Disorders in the Elbow Region 561

MANAGEMENT OF ELBOW AND FOREARM DISORDERS

AND SURGERIES 561

JOINTHYPOMOBILITY: NONOPERATIVE MANAGEMENT 562 Related Pathologies and Etiology of Symptoms 562 Common Impairments 562

Common Functional Limitations/Disabilities 562 Joint Hypomobility: Management–Protection Phase 562 Joint Hypomobility: Management–Controlled Motion

Phase 562 xxii CONTENTS

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Joint Hypomobility: Management–Controlled Motion and Return to Function Phases 597

JOINTSURGERY ANDPOSTOPERATIVEMANAGEMENT 599 Wrist Arthroplasty 600

Metacarpophalangeal Implant Arthroplasty 603 Proximal Interphalangeal Implant Arthroplasty 608 Carpometacarpal Arthroplasty of the Thumb 610 Tendon Rupture Associated with RA: Surgical and

Postoperative Management 613

REPETITIVETRAUMASYNDROMES/OVERUSESYNDROMES 615 Tenosynovitis, Tendinitis 615

TRAUMATICLESIONS IN THEWRIST ANDHAND 616 Simple Sprain: Nonoperative Management 616 Lacerated Flexor Tendons of the Hand: Surgical and

Postoperative Management 616

Lacerated Extensor Tendons of the Hand: Surgical and Postoperative Management 625

EXERCISE INTERVENTIONS FOR THE WRIST AND

HAND 631

TECHNIQUES FORMUSCULOTENDINOUSMOBILITY 631 Tendon-Gliding and Tendon-Blocking Exercises 631 Scar Tissue Mobilization for Tendon Adhesions 633

EXERCISETECHNIQUES TOINCREASEFLEXIBILITY ANDRANGE OF MOTION 634

General Stretching Techniques 634

Stretching Techniques for the Intrinsic and Multijoint Muscles 635

EXERCISES TODEVELOP ANDIMPROVEMUSCLE

PERFORMANCE, NEUROMUSCULARCONTROL,ANDCOORDINATED

MOVEMENT 636

Techniques to Strengthen Muscles of the Wrist and Hand 636

Functional Activities 638

C H A P T E R 2 0

The Hip

643

STRUCTURE AND FUNCTION OF THE HIP 644

ANATOMICALCHARACTERISTICS OF THEHIPREGION 644 Bony Structures 644

Hip Joint Characteristics and Arthrokinematics 644 Influence of the Hip Joint on Balance and Posture

Control 645

FUNCTIONAL RELATIONSHIPS OF THEHIPS ANDPELVIS 645 Pelvic Motions and Muscle Function 645

Pathomechanics in the Hip Region 647

THEHIP ANDGAIT 648

Hip Muscle Function During Gait 648

Effect of Musculoskeletal Impairments on Gait 648

Major Nerves Subject to Injury or Entrapment 648 Common Sources of Referred Pain in the Hip and Buttock

Region 648 Joint Hypomobility: Management–Return to

Function Phase 564

JOINTSURGERY ANDPOSTOPERATIVEMANAGEMENT 564 Excision of the Radial Head 565

Total Elbow Arthroplasty 567

MYOSITISOSSIFICANS 574 Etiology of Symptoms 574 Management 574

OVERUSESYNDROMES: REPETITIVETRAUMASYNDROMES 575 Related Pathologies 575

Etiology of Symptoms 575 Common Impairments 575

Common Functional Limitations/Disabilities 575 Nonoperative Management of Overuse Syndromes:

Protection Phase 575

Nonoperative Management: Controlled Motion and Return to Function Phases 576

EXERCISE INTERVENTIONS FOR THE ELBOW AND

FOREARM 578

MOTION 578

Manual, Mechanical, and Self-Stretching Techniques 578 Self-Stretching Techniques–Muscles of the Medial and

Lateral Epicondyles 579

Isometric Exercises 580

Dynamic Strengthening and Endurance Exercises 580 Functional Exercises 583

C H A P T E R 1 9

The Wrist and Hand

589

STRUCTURE AND FUNCTION OF THE WRIST AND

HAND 590

JOINTS OF THEWRIST ANDHAND 590

Wrist Joint–Characteristics and Arthrokinematics 590 Hand Joints–Characteristics and Arthrokinematics 590

HANDFUNCTION 592

Muscles of the Wrist and Hand 592 Grips and Prehension Patterns 593

MAJORNERVESSUBJECT TO PRESSURE ANDTRAUMA AT THE

WRIST ANDHAND 594

Nerve Disorders in the Wrist 594 Referred Pain and Sensory Patterns 594

MANAGEMENT OF WRIST AND HAND DISORDERS

AND SURGERIES 594

JOINTHYPOMOBILITY: NONOPERATIVEMANAGEMENT 594 Common Joint Pathologies and Associated

Impairments 594

Common Functional Limitations/Disabilities with Joint Pathologies 596

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MANAGEMENT OF HIP DISORDERS AND SURGERIES 649

JOINTHYPOMOBILITY: NONOPERATIVE MANAGEMENT 649 Related Pathologies and Etiology of Symptoms 649 Common Impairments 650

Common Functional Limitations/Disabilities 650 Management: Protection Phase 650

Management: Controlled Motion and Return to Function Phases 650

JOINTSURGERY ANDPOSTOPERATIVEMANAGEMENT 652 Total Hip Arthroplasty 652

Hemiarthroplasty of the Hip 663

FRACTURES OF THEHIP–SURGICAL ANDPOSTOPERATIVE

MANAGEMENT 664

Hip Fracture–Incidence and Risk Factors 664 Sites and Types of Hip Fracture 664

Open Reduction and Internal Fixation of Hip Fracture 665

PAINFULHIPSYNDROMES/OVERUSESYNDROMES: NONOPERATIVE

MANAGEMENT 671

Related Pathologies and Etiology of Symptoms 671 Common Impairments and Functional

Limitations/Disabilities 671 Management: Protection Phase 671 Management: Controlled Motion Phase 671 Management: Return to Function Phase 672

EXERCISE INTERVENTIONS FOR THE HIP REGION 672

EXERCISETECHNIQUES TOINCREASEFLEXIBILITY ANDRANGE OFMOTION 672

Techniques to Stretch Range-Limiting Hip Structures 672 Techniques to Stretch Range-Limiting Two-Joint

Muscles 674

Non-Weight-Bearing Exercises 676 Closed-Chain Weight-Bearing Exercises 678 Functional Training 681

C H A P T E R 2 1

The Knee 687

STRUCTURE AND FUNCTION OF THE KNEE 688 JOINTS OF THEKNEECOMPLEX 688

Tibiofemoral Joint 688 Patellofemoral Joint 689 PATELLARFUNCTION 689 Patellar Alignment 689 Patellar Compression 691 MUSCLE FUNCTION 691

Knee Extensor Muscle Function 691 Knee Flexor Muscle Function 692 Dynamic Stability of the Knee 692

THEKNEE ANDGAIT 692

Muscle Control of the Knee During Gait 692 Hip and Ankle Impairments 692

REFERREDPAIN ANDNERVEINJURIES 693 Major Nerves Subject to Injury at the Knee 693 Common Sources of Referred Pain 693

MANAGEMENT OF KNEE DISORDERS AND

SURGERIES 693

JOINTHYPOMOBILITY: NONOPERATIVE MANAGEMENT 693 Common Joint Pathologies and Associated

Impairments 693

Common Functional Limitations/Disabilities 695 Joint Hypomobility: Management–Protection Phase 695 Joint Hypomobility: Management–Controlled Motion and

Return to Function Phases 695

JOINTSURGERY ANDPOSTOPERATIVEMANAGEMENT 698 Repair of Articular Cartilage Defects 698

Synovectomy 699

Total Knee Arthroplasty 702

PATELLOFEMORALDYSFUNCTION: NONOPERATIVE

MANAGEMENT 711

Related Patellofemoral Pathologies 711 Etiology of Symptoms 712

Common Impairments and Functional Limitations/Disabilities 712

Patellofemoral Symptoms: Management–Protection Phase 712

Patellofemoral Symptoms: Management–Controlled Motion and Return to Function Phases 712

PATELLOFEMORAL ANDEXTENSORMECHANISMDYSFUNCTION: SURGICAL ANDPOSTOPERATIVEMANAGEMENT 715 Lateral Retinacular Release 716

Proximal Realignment of the Extensor Mechanism 718 Distal Realignment of the Extensor Mechanism 721

LIGAMENTINJURIES: NONOPERATIVEMANAGEMENT 722 Mechanisms of Injury 722

Ligament Injuries in the Female Athlete 722 Common Impairments and Functional

Limitations/Disabilities 723

Ligament Injuries: Nonoperative Management 723

LIGAMENTINJURIES: SURGICAL ANDPOSTOPERATIVE

MANAGEMENT 725 Background 725

Anterior Cruciate Ligament Reconstruction 726 Posterior Cruciate Ligament Reconstruction 735

MENISCAL TEARS: NONOPERATIVEMANAGEMENT 737 Mechanisms of Injury 737

Common Impairments and Functional Limitations/Disabilities 737 Management 738

MENISCAL TEARS: SURGICAL AND POSTOPERATIVE

MANAGEMENT 738 Meniscus Repair 738 Partial Meniscectomy 742

EXERCISE INTERVENTIONS FOR THE KNEE 742

MOTION 743 xxiv CONTENTS

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To Increase Knee Extension 743 To Increase Knee Flexion 743

Nonweight-Bearing Exercises 745 Closed-Chain Exercises 748

Techniques to Simulate Functional Activities 750

C H A P T E R 2 2

The Ankle and Foot 759

STRUCTURE AND FUNCTION OF THE ANKLE AND

FOOT 760

STRUCTURALRELATIONSHIPS ANDMOTIONS 760 Anatomical Characteristics 760

Motions of the Foot and Ankle Defined 760 Leg, Ankle, and Foot Joint Characteristics and

Arthrokinematics 761

FUNCTION OF THE ANKLE ANDFOOT 763 Structural Relationships 763

Muscle Function in the Ankle and Foot 763

THEANKLE/FOOTCOMPLEX ANDGAIT 764

Function of the Ankle and Foot Joints During Gait 764 Muscle Control of the Ankle and Foot During Gait 764

Major Nerves Subject to Pressure and Trauma 764 Common Sources of Segmental Sensory Reference in the

Foot 765

MANAGEMENT OF FOOT AND ANKLE DISORDERS AND

SURGERIES 765

JOINTHYPOMOBILITY: NONOPERATIVEMANAGEMENT 766 Common Joint Pathologies and Etiology of Symptoms 766 Common Impairments and Functional

Joint Hypomobility: Management–Protection Phase 767 Joint Hypomobility: Management–Controlled Motion and

JOINTSURGERY ANDPOSTOPERATIVEMANAGEMENT 769 Total Ankle Arthroplasty 770

Arthrodesis at the Ankle and Foot 773

OVERUSE(REPETITIVETRAUMA) SYNDROMES: NONOPERATIVE

MANAGEMENT 776

Related Pathologies and Etiology of Symptoms 776 Common Impairments and Functional

Overuse Syndromes: Management–Protection Phase 777 Overuse Syndromes: Management–Controlled Motion and

LIGAMENTOUSINJURIES: NONOPERATIVEMANAGEMENT 777 Common Impairments and Functional

Limitations/Disabilities 777 Management: Protection Phase 778 Management: Controlled Motion Phase 778 Management: Return to Function Phase 778

TRAUMATICSOFTTISSUEINJURIES: SURGICAL AND

Repair of Complete Lateral Ligament Tears 779 Repair of a Ruptured Achilles Tendon 782

EXERCISE INTERVENTIONS FOR THE ANKLE AND

FOOT 786

MOTION 786

Flexibility Exercises for the Ankle Region 786

Flexibility Exercises for Limited Mobility of the Toes 788 Stretching the Plantar Fascia of the Foot 788

Activities to Develop Dynamic Neuromuscular Control 788 Open-Chain Strengthening Exercises 789

Weight-Bearing Exercises for Strength, Balance, and Function 790

INDEPENDENTLEARNINGACTIVITIES 792 P A R T V :

Special Areas of

Therapeutic

Exercise

797

C H A P T E R 2 3

Women’s Health: Obstetrics

and Pelvic Floor

797

Barbara Settles Huge, BS, PT

OVERVIEW OF PREGNANCY, LABOR, AND RELATED

CONDITIONS 798

CHARACTERISTICS OFPREGNANCY ANDLABOR 798 Pregnancy 798

Labor 798

ANATOMICAL ANDPHYSIOLOGICALCHANGES OF

PREGNANCY 800

Weight Gain During Pregnancy 800 Changes in Organ Systems 800 Changes in Posture and Balance 801

OVERVIEW OFPELVICFLOOR ANATOMY, FUNCTION AND

DYSFUNCTION 801

Pelvic Floor Musculature 801

Effect of Childbirth on the Pelvic Floor 802 Classification of Pelvic Floor Dysfunction 803 Risk Factors for Dysfunction 803

Interventions for Pelvic Floor Impairments 804

PREGNANCY-INDUCEDPATHOLOGY 804 Diastasis Recti 804

Postural Back Pain 805 Sacroiliac/Pelvic Girdle Pain 806 Varicose Veins 806

Joint Laxity 807

Nerve Compression Syndromes 807

EXERCISE INTERVENTIONS FOR PREGNANCY, LABOR, AND

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PHYSIOLOGICALEFFECTS OFAEROBICEXERCISE

DURINGPREGNANCY 807

Maternal Response to Aerobic Exercise 807 Fetal Response to Maternal Aerobic Exercise 808

EXERCISE FOR THEUNCOMPLICATED PREGNANCY AND

POSTPARTUM 808

Guidelines for Managing the Pregnant Woman 810 Recommendations for Fitness Exercise 811 Precautions and Contraindications to Exercise 811 Critical Areas of Emphasis and Selected Exercise

Techniques 812

Pelvic Floor Awareness, Training and Strengthening 814 Relaxation and Breathing Exercises for Use During

Labor 815

Unsafe Postures and Exercises During Pregnancy 816 Exercise Critical to the Postpartum Period 817

CESAREANCHILDBIRTH 817

Significance to Physical Therapists 817

Suggested Activities for the Patient Following a Cesarean Section 818

HIGH-RISKPREGNANCY 819 High-Risk Conditions 819

Management Guidelines and Precautions for High-Risk Pregnancies 820

C H A P T E R 2 4

Management of Vascular

Disorders of the Extremities

825

DISORDERS OF THEARTERIAL SYSTEM 825 Types of Arterial Disorders 825

Clinical Manifestations of Peripheral Arterial Disorders 826 Examination and Evaluation of Arterial Sufficiency 827 Management of Acute Arterial Occlusion 828

Management of Chronic Arterial Insufficiency 829 Special Considerations in a Graded Exercise Program for

Patients with Chronic Arterial Insufficiency 830

DISORDERS OF THEVENOUS SYSTEM 831 Types of Venous Disorders 831

Clinical Manifestations of Venous Disorders 831 Examination and Evaluation of Venous Sufficiency 832 Prevention of Deep Vein Thrombosis and

Thrombophlebitis 833

Management of Deep Vein Thrombosis and Thrombophlebitis 833

Management of Chronic Venous Insufficiency and Varicose Veins 833

DISORDERS OF THELYMPHATICSYSTEM 834

Conditions Leading to Insufficiency of the Lymphatic System 835

Clinical Manifestations of Lymphatic Disorders 835 Examination and Evaluation of Lymphatic Function 836 Prevention of Lymphedema 836

Management of Lymphedema 836

BREASTCANCER-RELATEDLYMPHATICDYSFUNCTION 838 Background 838

Surgical Procedures 838

Impairments and Complications Related to Breast Cancer Treatment 839

Guidelines for Management After Breast Cancer Surgery 840

EXERCISES FOR THEMANAGEMENT OFLYMPHEDEMA 842 Background and Rationale 842

Components of Exercise Regimens for Management of Lymphedema 842

Guidelines for Lymphatic Drainage Exercises 843

Selected Exercises for Lymphatic Drainage: Upper and Lower Extremity Sequences 843

C H A P T E R 2 5

Management of Pulmonary

Conditions

851

REVIEW OFRESPIRATORYSTRUCTURE ANDFUNCTION 852 Thorax and Chest Wall: Structure and Function 852 Muscles of Ventilation 852

Mechanics of Ventilation 853

Anatomy and Function of the Respiratory Tracts 854 The Lungs and Pleurae 855

Lung Volumes and Capacities 856

EXAMINATION 856

Components of the Examination 857

BREATHINGEXERCISES ANDVENTILATORYTRAINING 861 Guidelines for Teaching Breathing Exercises 861 Diaphragmatic Breathing 862

Segmental Breathing 863 Pursed-Lip Breathing 864

Preventing and Relieving Episodes of Dyspnea 865 Positive Expiratory Pressure Breathing 865 Respiratory Resistance Training 866 Glossopharyngeal Breathing 866

EXERCISES TOMOBILIZE THECHEST 867 Specific Techniques 867

COUGHING 868

The Normal Cough Pump 868

Factors that Decrease the Effectiveness of the Cough Mechanism and Cough Pump 868

Teaching an Effective Cough 868

Additional Techniques to Facilitate a Cough and Improve Airway Clearance 869

Suctioning: Alternative to Coughing 870

POSTURALDRAINAGE 870

Manual Techniques Used with Postural Drainage Therapy 870

Postural Drainage Positions 872

Guidelines for Implementing Postural Drainage 874 Modified Postural Drainage 874

Home Program of Postural Drainage 875 xxvi CONTENTS

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A P P E N D I X

Systematic Musculoskeletal

Examination Guidelines

883

Glossary

889

Index

897

MANAGEMENT OFPATIENTS WITHCHRONICOBSTRUCTIVE

PULMONARYDISEASE 875

Types of Obstructive Pulmonary Disorders 875 Pathological Changes in the Pulmonary System 875 Impairments and Impact on Function 875

Management Guidelines: COPD 876

MANAGEMENT OFPATIENTS WITHRESTRICTIVEPULMONARY

DISORDERS 876

Acute and Chronic Causes of Restrictive Pulmonary Disorders 876

Pathological Changes in the Pulmonary System 876 Management Guidelines: Post-Thoracic Surgery 876

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1

I

P A R T

General Concepts

Therapeutic Exercise:

Foundational Concepts

C H A P T E R

1

THERAPEUTICEXERCISE: IMPACT ON

PHYSICALFUNCTION 2

Definition of Therapeutic Exercise 2 Aspects of Physical Function: Definition

of Key Terms 2

Types of Therapeutic Exercise Intervention 3 Exercise Safety 3

PROCESS ANDMODELS OFDISABLEMENT 4 The Disablement Process 4

Models of Disablement 4

Use of Disablement Models and Classifications in Physical Therapy 5

PATIENT MANAGEMENT ANDCLINICALDECISION

MAKING: ANINTERACTIVERELATIONSHIP 11 Clinical Decision Making 11

Evidence-Based Practice 11 A Patient Management Model 12

STRATEGIES FOREFFECTIVEEXERCISE AND

TASK-SPECIFICINSTRUCTION 24

Preparation for Exercise Instruction 24 Concepts of Motor Learning: A Foundation

of Exercise and Task-Specific Instruction 24 Adherence to Exercise 31

A

lmost everyone, regardless of age, values the ability to function as independently as possible during everyday life. Health-care consumers (patients and clients) typically seek out or are referred for physical therapy services because of physical impairments associated with movement disorders caused by injury, disease, or health-related conditions that interfere with their ability to perform or pursue any num-ber of activities that are necessary or important to them. Physical therapy services may also be sought by individu-als who have no impairment but who wish to improve their overall level of fitness or reduce the risk of injury or dis-ease. An individually designed therapeutic exercise pro-gram is almost always a fundamental component of the physical therapy services provided. This stands to reason because the ultimate goal of a therapeutic exercise program is the achievement of an optimal level of symptom-free movement during basic to complex physical activities.

To develop and implement effective exercise interven-tions, a therapist must understand how the many forms of

exercise affect tissues of the body and body systems and how those exercise-induced effects have an impact on key aspects of physical function. A therapist must also integrate and apply knowledge of anatomy, physiology, kinesiology, pathology, and the behavioral sciences across the continu-um of patient/client management from the initial examina-tion to discharge planning. To develop therapeutic exercise programs that culminate in positive and meaningful func-tional outcomes for patients and clients, a therapist must understand the relationship between physical function and disability and appreciate how the application of the process of disablement to patient/client management facilitates the provision of effective and efficient health-care services. Finally, a therapist, as a patient/client educator, must know and apply principles of motor learning and motor skill acquisition to exercise instruction and functional training. Therefore, the purpose of this chapter is to present an overview of the scope of therapeutic exercise interven-tions used by physical therapists. We discuss models of