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Therapeutic Exercise and other alternatife techniques in treatment

Exercise performed on a patient to achieve theraupetic benefit are called therapeutic exercise.
These exercise are classified as follows :

Coordinating exercise

Balance training

Gait training

Relaxation exercise

Strengthening exercise

Mobilization exercise

Endurance exercise

Postural correction

Ergonomic exercise

Hydrotheraphy

Suspension theraphy

Apart from these exercise, there are some skills imparted to the exercise therapist, like
manipulation, taping massage and other alternative healing techniques

Coordination exercise

Coordination is needed for performing purposeful movement that is bot smooth and precise
involving simultaneous activity of many muscles superimposed on a background of good
posture. Motor units of multiple muscle are activated with simultaneous inhibition off all other
muscles in order to carry out a desired activity

Components of coordinated activity

Volition, the patient must have the voluntary control to perform the activity, the ability to initiate,
maintain or stop it.

Perception- to be effective, propioception that is, the peripheral sensation of the joints must be
intact to integrate the motor impulses and sensory feedback with the sub cortical centers. When
propiodception is affected it is compensated with visual feedback. This is the basis for rombergs
phenomenon, when the person starts swaying when he stands and close his eyes.
Engram formation, an engram represents the neurogical organization of muscular activity
developed in the extra pyramidal system. Most of the activities we do involve many muscle
groups, and the brain perceives the final movement objective rather than individual muscles
performance. Research has proved that 20000 to 30000 repetitions of precise performance must
be performed in order to develop an engram. This is why, to perfect an activity such as driving, it
is necessary to keep practicing it over an over again till it becomes an engram. Once perfected,
the brain goes almost into autopilot and can concentrate on more demanding situations while still
continuing the engram pattern, this is how one can talk while driving or read the paper while
eating breakfast.

Indication for coordination training

Lesions of cerebellum resulting in cerebellar ataxia form motor component of ataxia on the other
hand lesions in the posterior column of the spinal cord result in sensory ataxia. Incoordiantion
may also result from lesion affecting the musle, the peripheral nerve or the upper motor
neurons. In these cases since the incoodination is the result of mucle weakness, hypotonicity or
hypertonicity, it is not primary incoodination, and the predisposing factors are treated, instead of
labeling it as incoordination

General principles of coordination training

A suitabl learning environment i.e an environment which provides for attention to tasks is
created, a list of activities is prepared. The activities are broken down into components that are
simple enough to be performed correctly. If the patient has very poor coordination, it may be
necessary to completely break down the multi muscular movement and practice the contraction
of a individual prime mover. The patient is given instruction to perform these simple components
which are then welded together to form the final job performance.

Whenever a new movement is trained, various inputs are given simultaneously, like oral
instruction (auditory), with touch (sensory stimulation), or positions in which the patient can vie
the movement (visual stimulation). If necessary the therapist may demonstrate with a passive
movement on the patient which will provide a kinesthetic feedback. The physiotherapist assist in
the movement where ever necessary for precise function so that the patient concentrates on
sensations produced by the activity. As state before, several repetitions of precise performance
must be performed for the engram to form

The technique progresses in complexity by

Increasing the speed of contraction

Increasing the complexity where more muscles get invoved

Increasing the range of movement during the activity


The rate of performance should be slowed with each new addition to a pattern. Fatigue may
occur during attempts for precision and may decrese the concentration of thee patient. The
patient shoul therefore have a short rest after two or three repetitions

Frenkels execise

Dr hs frenkel was a phycisian from Switzerland who propagated th concept of using sensations
of sight, sound and touch to establish control of voluntary of movement. This is by compensation
for the kinesthetic sensory loss.

Principle

Each patient should have individual attention, and should not be left unattended in case he should
fall amd injure himself

The patient should be adept in each exercise or set of exercise, before he is allowed to proceed to
a more difficult one.

Strong muscle contractions should not be given since progresiion is by complexity, not strength.

The patient should practice exercises first with his eyes open, and then with eyes closed

In the beginning movements in full range are referred to those in small range

Such movements should be given rapidly, then more slowly

Exercises are prescribed fot the upper and lower extremities in various positions-sitting , lying
and so on.

Sometimes all this is quite boring especially for children. Diversionary activities such as playing
with putty, building with toy bricks, or drawing on a blackboard, tailing the donkey lead to more
useful movements such as using knife and fork, doing up buttons and doing up buttons and doing
the hair. Transfers of objects from one container to the other, playing criket or throw ball are
examples of play theraphy improving coordination

Balance training

Almost all our daily activities are performed under the influence of gravity. Most of our effort
and time is spent in reacting to the effects of gravity upon the body. Protective responses in
maintaining balance are considered to have survival value by preventing us from failing as well
as enabling us to maintain our sense of verticality.

Posture is the term used to describe a position of the human body. The human body is capable of
several postures like lying, sitting, crowling and standing. In all these postures the body needs to
be stable in order to do its activities. Stability depends on whether the base and the position of
the centre and line of gravity are either balanced in equilibrium or not. Balance and posture are
interrelated.

Balance is maintained at a subconscious level, by integrating sensory imputs fro the eyes, the
vestibulat apparatus, and the propioceptors and super imposing them on a basic amalgam of
posture and postural reflexes in the normal individual. While retraining a patients balance he is
given stimuli to which he must react. He is moe important than his making a conscious effort to
maintain equilibrium

There are two types of balance-static balance and dynamic balance. Both of these are needed for
normal activities. It need not thought that balance training need be done only for neurogical
deficit. On the contrary balance retraining is an integral part of all gait training exercises or
rehabilitation programs

Static balance

Static balance is the rigid stability of one part of the body on another. Even a person standing
immobile is contracting his muscles in an isomeric fashion. There is also contraction of muscles
equality. As a general principle balance is developed progressively by moving from the more
stable to the lesser stable position, for example from forearm support prone lying to sitting
without support

In the development of a child head control is the first develop. This reinforces the fact tht
stability and control of the head should be given priority as it is needed in all positions. Later, the
extensors of the neck and back and also spinal stabilizers can be stimulated to reinforce muscle
contraction elsewhere, e.g. righting reactions, which are involuntary movement responses to
stimuli, serving to maintain the alignment of the head and body in its normal upright posture.

Dynamic balance

The body, unless it is fully supported and relaxed, like lying down, is in a constant state of
adjustment to maintain its posture and its equilibrium. The force of gravity acts on it threatening
to destabilize it. Maintaining balance means having the centre of gravity of the body within the
base of support, i.e with the trunk aligned over the feet. A soldier at attention might appear
completely still, but he continuosly transfers his wight and oscillates trying to maintain his center
of gravity within his base. He is able to do this because of his sense of propioception which
provides feedback on the status of the body internally whether the body is moving and if so how,
and whether the various parts of the body ar located properly in relation to each other

Equilibrium reactions
These are involuntary automatic responses to a disturbance or destabilization in the structure of
the body that serves to a disturbance or destabilization in the structure of the body that serves to
maintain or regain balnce during posture and movement. These balance reactions may occur by
an adjustment in tone or an adjustment in posture

Method of stimulation

For balance to improve in a position, the patient must be assisted to assume that position. Mans
body axix is vertical, and it is in the vertical position, thet he needs the ability to withstand the
effect of gravity. Analysis of balance reactions and body alignment in responses to shifts in
weight will identify the deficient areas, which require specific stimulation. For example, if a
person is pushed to his right, he moves his head and trunk in the opposite direction with
corresponding ccompensatory reaction of the pelvis and lower limbs to bring his center of
gravity within his base support. Any one or all of the components of balance may be missing and
must be stimulated by the therapist.

Alternate tapping stimulate balance in antigravity positions. Gentle taps are applied alternately to
th upper trunk with the body in normal aligment. The effect should be to displase the patient
slightly off balance in alternate directions, which will stimulate the necessary adjustments. It
must be stressed that the displacement shoud be small so as to stimulate only fine adjustment.

Maintenance of position

Th patient is instructed to maintain the position, for example, prone kneeling, sitting or standing
against the therapists tapping technique to displace him backwards, forward and laterally.

The use of a moving support is valuable in some positions. Objects used include balance boards,
rolls which are made of a cardboard tube, and therapeutic balls. If balance reactions fail,
protective extension (parachute reflex) of the arms in one of the most important reactions.

In general, movement for balance is stimulated smoothly and steadily, in a small range initially,
gradually increasing the range as the patient gains more control. Any position can be made more
stable by using pressure and approximation and by providing the patient a wider base by giving
more than ine fixed point of stability, too much emphasis on stability would prevent the patient
from moving or trying to move. On the other hand too much stimulation of movement might
result in loss of balance and the confidence to regain it, the use of weights worn by the patient on
the trunk or lower limbs is sometimes suggested as a means of improving movement control.

Balance boards consist of a platform, which may be either rectangular or circular, resting on a
hemispherical base. The re-educate balance and increase strength f the muscle of the leg. The
patient is given various position on the balance board and he should learn to maintain his balance
while sitting, kneeling or standing on it, while it is displaced in different direction. The bobath
ball is very useful in this training.
Gait

Gain or human locomotion, may be descrived as traslatory progression of the body as a whole,
produced by coordinated movements of body segments, it is the forward progression of the
center of gravity (a point in front of the 2 nd sacral vertebral body) of the body, based on the
reciprocal movements of the lower extremities. Man is the only animal among vertebrates,
possibly other than some primates who walks on two limbs. Each person has his own
characteristic gait pattern

Normal human gait needs good muscke in the lower limbs, truncal stability, good propioception,
good balance and vision. The movement is rhythmic and smoothened out in to an elegant and
sinous pattern

Gait cycle

The gait cycle is a series of documented movements during walking which by convention is
measured from the point of initial heel contact of one lower extremities to the same point when it
occur again, that is the point at which heel of the same extremity contacts the ground again. It is
divided into 2 phases stance and swing.

When movement is initiated it is called acceleration and when stopping it is called deceleration.
Energy is consumed in both phases but more during deceleration. The path taken by the centre of
gravity determines the energy expenditure and efficiency of gait. Given the situation, the ideal
path should be a sinusoidal curve with minimum displacement. Stance, when the foot is off the
ground, forms the rest 40 percent of the cycle. There is a period called double stance covering 11
percent of the cycle when both legs are on the ground.

Studying normal human locomotion

In the analysis of the walking pattern of a person the external effects like the force of gravity, or
inertia and internal effects like forces exerted by muscular contraction or angular relationship
between the segments, are studied

Kinematics is the division of mechanics, shich deals with the motion of bodies it does not study
the forces acting to produce the motion. Kinetics is the division of mechanics that deals with
forces acting on bodies

Gait analysis

Gait analysis commonly involves the measurement of the subjects given above, like the
movement of the body in space (kinematics) and the forces involved in producing these
movements (kinetics). It is done in a gait lab. Earlier, the analysis used to be done (and still is
done in some places) by photograohy. Strobe lighting at predetermined frequency was used in
the past to aid the analysis of gait on single photographic images.