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Chapter 20 Optimizing Abilities and Capacities: Range of Motion, Strength, and Endurance Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives • State the biomechanical and physiological mechanisms that underlie therapeutic exercise and occupation. • Apply the methods for decreasing edema, minimizing contracture, and mobilization to prevent limitation of range of motion. • Apply biomechanical and physiological principles of the biomechanical approach to the selection of occupations as a means for treating range of motion, strength, and/or endurance problems as needed for occupational performance. • Design treatment goals and therapy for clients who have problems with range of motion, strength, and/or endurance to enhance occupational performance. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Musculoskeletal System: Biomechanical Aspects • Kinematic analysis – Describes the amount and direction of movement, speed, and acceleration of body segments and joint angles • Kinetics – Addresses the forces that cause motion or maintain stability • Torque – Tendency of a force to produce rotation about an axis • Lever systems – Effort is the force that causes movement and resistance is the force that tends to keep the object moving. • First-class lever • Second-class lever • Third-class lever Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Musculoskeletal System: Physiological Aspects • Strength – Muscle hypertrophy • Activity stresses the muscle’s ability to produce tension and force – Result of neural change • Development of more effective neural patterns and neuromotor connections Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Biomechanical Approach to Treatment: Maintaining or Preventing Limitation in Range of Motion • An individual’s actual ROM at any joint is determined by the structures surrounding the segments that are moving. • Functional ROM is the range necessary to perform daily activities. • Occupational therapists are concerned with providing treatment that helps clients maintain functional motion or to help patients gain motion when there are limitations that interfere with occupation. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors That Limit Range of Motion • Systemic, neurological, or muscular diseases impair muscle performance. • Joint diseases such as arthritis that create pain and inflammation decrease motion, and surgical or traumatic insults that produce edema and scarring. • Simple inactivity or immobilization affects ROM. • Changes may occur in the muscles, ligaments, joint capsules, tendons, or joints. • This leads to pain, inflammation, and edema. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods: Decreasing Edema • Used to prevent ROM limitations secondary to edema • Techniques include the following: – Elevation – Cryotherapy – Compression – Massage – Electrical current Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods: Minimizing Contractures • Occupational therapists may use therapeutic positioning and splinting. • Therapeutic positioning is designed to help – With edema resolution when limbs are elevated – Preserve function by holding limbs at a proper muscle length – Patients avoid positions that result in tissue shortening or contracture • Splinting used to hold joints in a position with optimum tissue length Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods: Movement Through Full Range of Motion • Methods for ranging – Teaching the patient to move the joints that are injured, immobilized, or edematous – Passively move the joints if the patient is unable to actively move the joint themselves • Attention must be given to plane of motion, structures involved with the movement of the joint, and joint biomechanics. • AROM or AAROM is preferred to PROM for reduction of edema because the contraction of the muscles helps pump the fluid out of the extremity. • AROM and PROM have no set protocol of frequency. • Occupational therapists often structure activities to promote AROM and PROM to prevent loss of motion. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Increasing Range of Motion • If limitations in ROM impair a patient’s ability to function independently in occupations or are likely to lead to deformity, treatment to increase ROM is indicated. • Problems that can be changed – Contractures of soft tissue • Skin • Muscles • Tendons • Ligaments • Problems that cannot be changed – Ankylosis or arthrodesis – Long-standing contractures – Severe joint destruction Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Increasing Range of Motion: Stretching • Stretch is a process by which the target tissue is lengthened by an external force, usually through manual therapy or through the use of splinting, casting, or external equipment. • Change is only created when tissue is stretched repeatedly or sustained over time. • Factors that determine the effectiveness of stretching are the duration, the intensity, the speed, and the frequency of the stretch being applied. • Gentle, controlled stretching that achieves small increments of gain over time is thought to be more effective than vigorous stretching aimed at large, rapid gains. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods for ROM: Active Stretching • The use of occupation for stretching is empirically based on the idea that a person involved in an interesting and purposeful activity will gain greater range. • Because occupations can be performed using a number of muscle patterns, the therapist must determine how the patient completed the activity prior to injury. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods for ROM: Active Stretching—(cont.) • Occupations used as a means to increase ROM must provide a gentle active stretch by use of slow, repetitive isotonic contractions of the muscle opposite the contracture or by use of a prolonged passive stretched position of the contracted tissue. • Exercises that increase the range of shortened tissue are the proprioceptive neuromuscular facilitation (PNF) techniques called contract relax and agonist contraction. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods for ROM: Passive Stretching • Preparatory method for increasing ROM so patients are able to engage in purposeful activity • Techniques – Manual stretch – Use of orthotic devices • Splints • Casts – Home program on specific joint stretches – Pilates, yoga, or the ROM dance – These tasks can be integrated into a patient’s daily occupations. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Biomechanical Approach to Treatment: Strengthening • If limitations in a patient’s strength prevent participation in occupations or may lead to a deformity, treatment aimed at increasing strength is warranted. • If weakness prohibits patients from moving the limb or maintaining a functional position, their lack of regular active range of motion may lead to contracture. • Occupation or exercise parameters that may be manipulated to increase strength include the following: – Type of contraction and speed – Muscles involved – Intensity of task Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods for Strengthening: Occupations and Exercise • Therapists may find that various occupations provide sufficient opportunities for muscle strengthening and are more effective at maintaining the patient’s interest and motivation than exercise alone. • Exercise may be used as a warm-up to occupation, or occupation may be introduced to enhance carryover of the strength gained by exercise. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Grading Muscle Strength Parameters • When prescribing a strengthening program, therapists can manipulate the exercise or occupational parameters. • Amount of resistance imposed on the contracting muscle or muscle groups during each repetition is increased. – 40%–60% of one-repetition maximum (1 RM) • Training volume: Changing the number of repetitions of an activity, changing the number of sets required of that one activity, or changing the number of activities done during a treatment session. • Rest period between activity should be 3–4 minutes for high loads or repetitions; rest period of 1–2 minutes for low intensity or low repetition activity. • Patients starting a strengthening program should exercise 2–3 days a week, which can then increase to 3–5 days a week as the strength progresses. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Biomechanical Approach to Treatment: Increasing Endurance • Factors that influence muscle endurance – With activities that call for maximum muscle contraction, such as lifting heavy loads, more motor units must contract simultaneously without the opportunity to recover, resulting in quicker fatigue. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Methods: Increasing Endurance • Provide patients with interestsustaining occupations that can be graded along the dimension of time or repetition. • Work with patients to schedule their everyday routines so that they gradually increase the amount of time they engage in occupations throughout the day and/or gradually increase the duration of engagement in one particular occupation. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins