Download Exercise Prescription

Exercise Prescription
John M Lavelle, DO
Objectives
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Objectives:
1. Describe the benefits of employing exercise prescription as an
adjunct to treatment.
2. Describe the purpose and elements of a structural screening
exam.
3. Describe the significance of accurate diagnosis of somatic
dysfunction in exercise prescription.
4. Describe normal and common variants of hip extension and
shoulder abduction muscle firing patterns and discuss their
significance for exercise prescription.
5. Describe the key elements of exercise prescription.
Somatic Dysfunction
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Impaired function of bodily structures (most
often of the MSK, nervous or lymphatic system)
treated by OMT.
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Imparied or altered function of related
components of the somatic (body framework)
system: skeletal, arthrodial and myofascial
structures and their related vascular, lymphatic
and nervous elements.
Words of Wisdom
Osteopathy is based on the perfection of Nature’s work.
When all parts of the human body are in line we have
health. When they are not the affect is disease. When
the parts are readjusted disease gives place to health. . . .
When complete, [the person] is a self-acting, individualized,
separate personage, endowed with the power to move, the
mind to direct in locomotion . . . .
-- A.T. Still
Introduction to Exercise Prescription
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Historical:
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Yoga asana and
pranayama (breathing
exercises) from Ayurveda
Recent decades in USA have
seen significant growth in
popularity of these exercise
methods that are rooted in
the healing arts.
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Qi Gong and Tai Chi from
TCM
 Several studies have
reported positive effects of
Tai Chi or Qigong for
enhancing balance and
preventing falls in the
elderly 1
Exercise Prescription
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Current: Growth in exercise-based modalities
such as physical therapy and personal training.
Fitness “craze” in the USA
Physical exercise has profound benefits now
supported by research. 2
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Benefits: Cardiac (HTN, HLD) Mental Health
(depression, anxiety) MSK, Pain Medicine,
Lymphedema, endocrinology, cancer (PSA),
endocrine (DM), etc
Exercise Prescription
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Physicians frequently encourage exercise to promote
fitness and well-being . . . Often as general
recommendation . . .
We should consider specific exercise prescription as
adjunct to treatment.
References:
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Dr. Kappler’s section V Introduction, Foundations for
Osteopathic Manipulation, 2nd ed.
Dr. Philip Greenman, Principles of Manual Medicine, 3rd ed.
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D.O. Professor emeritus of Michigan State University
Why exercise prescription?
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Interrelationship of OMT and PT for somatic
dysfunction and specific exercise prescription
OMM or PT sets the stage for therapeutic exercise
and makes the exercise more effective
 Prescribed exercise then reinforces the correction or
healing facilitated by OMT or PT
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Why exercise prescription? (con’t)
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Consider key principles of Osteopathic
philosophy
1. Body is a unit; the person is comprised of body,
mind, spirit.
 2. Person is capable of self-healing, self-regulation,
self-maintenance.
 3. Structure and function are interrelated
 4. Rational treatment is based on the understanding
of these principles
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Why exercise prescription? (con’t)
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. . . Therefore, we as physicians are not healing the
patient, per se, but rather facilitating the healing
process inherent to the patient.
Why exercise prescription? (con’t)
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Encourages patient to become a consciously
active participant in their own healing process
Brings healing process more to conscious level
 Patient more aware of own agency, own power to
further the healing and health maintenance.
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Why exercise prescription? (con’t)
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Additional important reasons for prescribing
exercise:
Psychological benefits, i.e. encouragement and
optimism
 Natural biochemical high – diminishing or breaking
cycle of chronic pain
 Cardio-vascular health
 Weight management
 Facilitates integration of body-mind-spirit
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Diagnostics: Structural Screening Exam
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Words of Wisdom: “Is there a significant musculoskeletal
component to the patient’s problem?” -- Dr. Kappler
This ought to be our guiding question as we approach
diagnosis.
Structural screening exam/standing and seated
structural exam is a good starting place.
Efficient overview, broad in scope, yet thorough
enough to reveal postural and functional imbalance.
Diagnostics: Structural Screening Exam (con’t)
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May contain all or some of following
components:
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1. Gait analysis
2. Observation of paired anatomical landmarks,
antero-posterior and lateral curves
3. Active ROM from head to toe.
Overall “Gestault”
Diagnostics: Structural Screening Exam (con’t)
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Allow findings of structural screening exam to
lead you to a more detailed, focused exam and
diagnosis.
Consider how your findings may play into
presenting complaint or problem under scrutiny.
Diagnostics: Somatic Dysfunction
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Words of wisdom: We must be able to move beyond
the mindset of “fixing isolated booboos” to an awareness
of treating a human system, even when our immediate
focus is on a particular dysfunction. If we allow our
structural screening exam to lead us into our regional or
segmental diagnosis, we will be more apt to see a
particular somatic dysfunction in relation to the whole,
integrated body system.
paraphrased from Dr. Hugh Ettlinger
Diagnostics: Somatic Dysfunction (con’t)
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Identify problem.
Try to identify source of problem.
Devise therapeutic plan to address source of
somatic dysfunction as best as possible or to
prevent reoccurrence of the injury or
dysfunction.
i.e. “Shoulder bone connected to the foot
bone”
Diagnostics: Muscle Firing Patterns
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Vladimir Janda, physiatrist from Czech Republic
Studied muscle function and found characteristic
“normal” patterns of neuromuscular activation and
common patterns of dysfunction/abnormal
activation.
 Evaluated muscle function based on tone, sequence
or patterns of muscle activation, and bilateral
symmetry/asymmetry of muscle activation.
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Diagnostics: Muscle Firing Patterns (con’t)
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Postural/tonic muscles
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iliopsoas
rectus femoris
piriformis
adductors
tensor fascia lata
levator scapula
upper trapezius
pectorals
>In dysfunction these tend
to become hypertonic,
facilitated or contracted
Diagnostics: Muscle Firing Patterns (con’t)
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Dynamic/phasic muscles
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gluteus medius and
maximus
supraspinatus
deltoids
infraspinatus
rhomboids
lower trapezius
serratus anterior
>In dysfunction these tend
to become hypotonic,
inhibited, weakened.
Janda called this
“pseudoparesis”.
Diagnostics: Muscle Firing Patterns (con’t)
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Muscle function and dysfunction charactized by
sequential neuromuscular firing patterns
Observing firing patterns offers additional perspective
with which to evaluate somatic dysfunction and
postural balance/imbalance.
Assessed by physician palpating focus muscle groups
while patient actively moves a joint through specific
range of motion, i.e. hip extension or shoulder
abduction.
Physician then compares by evaluating contralateral
firing pattern, evaluating then for symmetry of
neuromuscular activation.
Diagnostics: Muscle Firing Patterns (con’t)
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Important in exercise prescription
for accurate and effective prescription
 to prevent injury . . .
 If a patient has significant imbalance in firing
patterns, continued activity, or increased focal
activity may serve to exacerbate the problem and
dysfunction.
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Diagnostics: Muscle Firing Patterns (con’t)
Prone Hip Extension Muscle Firing Pattern
Normal
1. hamstrings
2. gluteus maximus
3. contralat. lower
lumbar erector spinae
4. ipsilat. lower lumbar
erector spinae
Most Common Variation
1. hamstrings
2. upper lumbar and low
thoracic erectors
3. inhibited gluteus
maximus
Prone Hip Extension Firing Patterns
Diagnostics: Muscle Firing Patterns (con’t)
Seated Shoulder Abduction
Normal
1. supraspinatus
2. deltoid
3. infraspinatus
4. mid and lower
trapezius
5. contralat.
quadratus
lumborum
Most Common
Variation
1. levator scapulae
2. upper trapezius
3. early firing of
quadratus
lumborum
Shoulder Abduction Firing Patterns
OMT
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Greenman writes in his chapter on Exercise Principles,
“the goal for an exercise program is to maintain
the enhanced functional capacity of the
musculoskeletal system that has been achieved by
appropriate manual medicine intervention”
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(Greenman, 498).
Once the structural screening, somatic dysfunction
diagnosis, and asymmetries of muscle firing have been
assessed, manipulative treatment begins restoring
balance to the system.
the patient is then be ready to begin a progression
into an exercise program.
Elements of Exercise Prescription
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Words of wisdom: “The body is no stronger than its weakest
link. Many well-conditioned patients have a back or
musculoskeletal problem that severely limits their function. The
physician should direct treatment to strengthen the weak link.”
-- Dr. Robert Kappler
Elements of Exercise Prescription (con’t)
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Order of progression for exercise prescription
Stage one: proprioceptive balance training
 Stage two: stretch hypertonic muscles
 Stage three: strengthen hypotonic muscles
 Stage four: aerobic training
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The Patient . . .
“Doc, my back hurts and I can’t straighten up . . . .”
Elements of Exercise Prescription (con’t)
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Diagnostics, OMT or PT, then . . .
Stage one: proprioceptive balance training
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Proprioceptive balance training is the first stage of addressing
that “weak link” and restoring symmetry to muscle firing
patterns and motor function control.
Improved neuromuscular firing through balance training
prepares the way for stretching facilitated muscles and
strengthening inhibited muscles.
If during your initial screening the patient has trouble
balancing on one leg (i.e. during stork test), this should
prompt you to make further assessments.
Elements of Exercise Prescription: Proprioceptive
Balance Training (con’t)
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Greenman suggests the following progression:
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Level 1: Patient stands, with bare feet, first on one leg then
the other. Compare steadiness of balance on right and left
legs.
Level 2: Patient stands on one leg with arms crossed.
Compare right and left.
Level 3: Patient stands on one leg with arms crossed and
eyes closed.
The goal is be able to stand in level three for 30
seconds. A more important and immediate goal is to
restore symmetry of balance.
Proprioceptive Balance, level 1
Proprioceptive Balance, level 2
Proprioceptive Balance, level 3
Proprioceptive Balance, level 1
Proprioceptive Balance, level 2
Proprioceptive Balance, level 3
Elements of Exercise Prescription (con’t)
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Stage two: Stretching hypertonic muscles
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stretch the tight muscles identified during initial assessment
or during the course of treatment.
If the physician employs muscle energy techniques, the initial
steps of patient education can readily be addressed in the
course of manipulation.
identify the key muscles to be stretched -- this may change as
the patient progresses with exercises and treatment.
Teach the patient how to isolate the specific muscles or
muscle group to be stretched.
Stage 2: Stretch Hypertonic Muscles
Stage 2: Stretch Hypertonic Muscles
Stage 2: Stretch Hypertonic Muscles
CAREFUL!!!!!
Stage 2: Stretch Hypertonic Muscles
CRAAAAAZYYYY!!!!! Easy does it!!!
Elements of Exercise Prescription (con’t)
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Stage three: Strength Training
 When symmetry has been restored or improved,
inhibition of the antagonist muscles will decrease.
This will allow the focused strength training to be
more effective.
 Danger: patients often try to do more than they are
truly prepared to do. The patient may not feel tired
or winded from the exercises at the early stages of
training, and therefore lose sight of the goal: to
restore balance to the system.
Elements of Exercise Prescription (con’t)
Stage three: Strength training (con’t)
 As the patient pushes beyond their
preparation, the first aspect to be lost will
often be precision and structural/postural
integrity while performing a given exercise.
 Alignment and correct performance of any
exercise prescribed must be taught and
emphasized in order to maximize the benefits
and to prevent further injury.
Elements of Exercise Prescription (con’t)
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Stage four: Aerobic Training
 Added to the regimen only after the goals of the previous
stages have been met.
 It is often the case that patients will come with exercise
programs already in place. In these cases, unless the injury or
dysfunction is preventing participation in the exercise of
choice, the previous stages of proprioceptive balance training,
stretching, strengthening, and integration/combination
exercise will be progressively incorporated into the patient’s
established routine.
Elements of Exercise Prescription (con’t)
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Essential principle: BREATHE
Controlled, conscious breathing
 Often when learning new exercise patients will focus
on details of posture or movement and develop
counterproductive tension.
 To prevent problem, after presenting exercise, and
while patient is demonstrating proper technique,
instruct patient in breath control.
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Elements of Exercise Prescription (con’t)
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Breathe!!!! (con’t)
 Performance of exercise will improve
 Perceived benefit will improve
 Patient awareness of immediate effects of exercise will be
heightened
 With controlled breathing the patient becomes more focused
and more actively and intentionally participates in own
healing
Elements of Exercise Prescription (con’t)
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Effective prescription
Give clear and precise explanations of exercises
 Have patient demonstrate to ensure proper
technique or form
 Incorporate breath-work
 Communicate goal of the program and each specific
exercise
 Dosage
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Elements of Exercise Prescription (con’t)
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Dosage:
Intensity – how far to go or how hard to push
oneself with any given exercise
 Duration – how long to hold a position or sustain a
prescribed exercise
 Frequency – how many repetitions per set and how
many sets per session or day
 Discuss warning signs of “overdose”
 Oral explanation and written prescription
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Exercise Prescription
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Through careful diagnosis, focused manipulative
treatment, and exercise prescription we can reinforce
and augment the effects of rehab treatment. In doing
so, we demonstrate the profound importance of
patients’ active participation in their own healing and
maintenance of health.
Words of Wisdom: “Despite the altered anatomy and
pathology present, it is surprising and satisfying to both the
practitioner and the patient to see the amount of functional
capacity that can be restored and maintained by an appropriate
exercise program.”
-- Dr. Philip Greenman
References
1) Qigong and Tai Chi Detailed Scientific Review, MD Andersen Center- The University
of Texas. http://www.mdanderson.org/education-and-research/resources-forprofessionals/clinical-tools-and-resources/cimer/therapies/alternative-medicalsystems/qigong-tai-chi-scientific.html
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2)
3)
Kessenich Cathy R. Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing 1998 Jul1998 Aug;27-9
Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of Tai Chi quan and computerized balance
training on postural stability in older subjects. Physical Therapy 1997 Apr;77(4):371-84.
Wolfe SL, Coogler C, Xu T. Exploring the basis for Tai Chi chuan as a therapeutic exercise approach.
Arch Phys Med Rehabil 1997 Aug;78:886-92. Note
University of Illinois: Kinesiology Department:
ttp://kch.illinois.edu/Research/Labs/ECRL/
Greenman, Philip. Principles of Manual Medicine. Lippincott Williams & Wilkins;
Third edition (October 17, 2003)
Thank You
Questions?