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Chapter 10
Intervention Principles
An intervention is “the purposeful and
skilled interaction of the physical therapist
and the patient/client and, when
appropriate, with other individuals involved
in the patient/client care, using various
physical therapy procedures and techniques
to produce changes in the condition
consistent with the diagnosis and prognosis”
An intervention is most effectively
addressed from a problem-oriented
Based on the patient’s functional needs, and
on mutually agreed-upon goals
Decisions about the intervention are made
in order to improve the patient’s ability to
perform basic tasks, and to restore the
functional homeostasis
The most successful intervention
programs are those that are custom
designed from a blend of clinical
experience and scientific data, with
the level of improvement achieved
related to goal setting and the
attainment of those goals
Control Pain and
The goals during the initial phase of
intervention for an acute lesion,
therefore, are to decrease pain,
control the inflammation and edema,
and protect the damaged structures
from further damage, while attempting
to increase range of motion and
Control Pain and
During the acute stage of healing the
principles of PRICEMEM are recommended
Manual therapy
Early motion
Promote and Progress
The rehabilitation procedures used to
assist with the repair process differ
depending on the type of tissue
involved, the extent of the damage,
and the stage of healing
Inflammatory phase
Clinical findings during the inflammatory
phase include swelling, redness, heat, and
impairment or loss of function
Usually there is pain at rest or with active
motion, or when specific stress is applied to
the injured structure
The pain, if severe enough, can result in
muscle guarding.
With passive joint mobility testing, pain is
reported before tissue resistance is felt by
the clinician.
Inflammatory phase
Electrotherapeutic and physical
modalities can be used during this
phase to help control the pain,
swelling, and muscle guarding.
Heat, ultrasound and phonophoresis
are introduced once the acute stage is
Inflammatory phase
The intervention aims of this phase
are to:
– Avoid painful positions
– Improve of range of motion
– Reduce muscle atrophy through gentle
isometric muscle setting
– To maintain aerobic fitness
Proliferative phase
Clinically, this phase is characterized
by a decrease in pain and swelling,
and an increase in pain-free active and
passive ROM
During passive ROM, pain is felt to
occur synchronous with tissue
Proliferative phase
The intervention goals during this
phase are:
– To protect the forming collagen, and
direct its orientation to be parallel to the
lines of force it must withstand
– To prevent cross linking and scar
Remodeling phase
Clinical findings during this phase are
pain that is typically felt at the end of
range with passive ROM, after the
tissue resistance has been
Remodeling phase
During this phase, the only
intervention that consistently appears
beneficial across a wide spectrum of
spinal and non-spinal musculoskeletal
problems is the continued application
of controlled stresses
SAID principles
Rehabilitation Modalities
Physical agents and mechanical
– Cryotherapy
– Thermotherapy
– Ultrasound
– Phonophoresis
– Hydrotherapy
Rehabilitation Modalities
Electrotherapeutic modalities
– Electrical stimulation
– Transdermal iontophoresis
– Extracorporal shock-wave therapy
– Transcutaneous Electrical Nerve
Stimulation (TENS)
Opioid analgesics
Non-opioid analgesics
Muscle relaxants
Increasing Strength
The dosage of an exercise refers to
each particular patient’s exercise
capability, and is determined by a
number of variables
For these variables to be effective, the
patient must be compliant and be able
to train without exacerbating the
Exercise Hierarchy
A hierarchy exists for ROM and
resistive exercises during the subacute
(neovascularization) stage of healing,
to ensure that any progression is done
in a safe and controlled fashion
Optimum length-tension relationships
and optimum force couple
relationships ensure maintenance of
normal joint kinematics
Exercise Hierarchy
The hierarchy for the ROM exercises
– Passive ROM
– Active assisted ROM
– Active ROM
Exercise Hierarchy
The hierarchy for the progression of
resistive exercises is:
– Single angle submaximal isometrics performed in
the neutral position
– Multiple angle submaximal isometrics performed
at various angles of the range
– Multiple angle maximal isometrics
– Small arc submaximal isotonics
– Full ROM submaximal isotonics
– Functional ROM submaximal isotonics
Posture and movement
impairment syndromes
The intervention of any muscle
imbalance is divided into three stages:
– Restoration of normal length of the
– Strengthening of the muscles that have
become inhibited and weak
– Establishing optimal motor patterns to
secure the best possible protection to the
joints and the surrounding soft tissues
Integration of Kinetic
Closed kinetic chain
– Fixation of the distal segment so that
joint motion takes place in multiple
planes, and the limb is supporting weight
Open kinetic chain
– Activities that involve the end segment of
an extremity moving freely through
space, resulting in isolated movement of
a joint
Neuromuscular reeducation (NMR)
A method of training the enhancement
of unconscious motor responses by
stimulating both afferent signals and
central mechanisms responsible for
dynamic joint control
Neuromuscular control
Neuromuscular control is governed by
the central nervous system via the
integration of information from the
following systems:
– Vestibular
– Vision
– Proprioceptive
Proprioceptive Retraining
The neuromuscular mechanism that
contributes to joint stability is mediated by
the articular mechanoreceptors. These
receptors provide information about joint
position sense and kinesthesia
Proprioceptive re-training activities should
involve sudden alterations in joint
positioning that necessitate reflex muscular
stabilization coupled with an axial load
Balance Re-training
Balance retraining focuses on the ability to
maintain a position through both conscious
and subconscious motor control
Motor control of the extremities is
dependent upon afferent sensory and
proprioceptive mechanoreceptors, such as
Golgi tendon units, muscle spindles, and
joint receptors
Motor control is also dependent upon
efferent reflexive and voluntary muscular
Balance Re-training
The usual progression employed
involves a narrowing of the base of
support while increasing the
perturbation, and changing the
weight-bearing surface from hard to
soft, or from flat to uneven
Improve Functional
The ultimate goal of functional training
is the restoration of the patient’s
confidence, which implies a return to
normal of the neurovascular,
neurosensory, and kinesthetic systems
of the body, so that the reflex
performance of a movement is not
deliberate, hesitant, or dyskinetic
Improve Functional
Functional progression training, as with
exercise progressions, must be designed in
a sequential, step-by-step manner,
beginning with simple tasks and progress to
highly coordinated tasks, with each step in
the process requiring greater skill than the
The overriding principle of functional
rehabilitation is to return patients to the
functional goal to which they desire, or at
which they were previously functioning
Maintain or Improve
Overall Fitness
It is important that the rehabilitation
program includes exercises that
maintain, or improve the patient’s
cardiovascular endurance
Physical fitness is "a set of attributes
that people have or achieve that
relates to the ability to perform
physical activity"
Maintain or Improve
Overall Fitness
People who maintain or improve their
strength and flexibility may be better able to
perform daily activities, and may be better
able to avoid disability, especially as they
advance into older age
Regular physical activity may also contribute
to better balance, coordination, and agility,
which in turn may help prevent falls in the
It is imperative that the clinician
spends time educating patients as to
their condition, so that they can fully
understand the importance of their
role in the rehabilitation process, and
become educated consumers.
A detailed explanation should be given to
the patient in a language that they can
understand. This explanation should
– The name of the structure(s) involved, the cause
of the problem, and the effect of the
biomechanics on the area
– Information about tests, diagnosis, and
interventions planned
– The prognosis of the problem and a discussion
as to the patient’s functional goals
– What the patient can do to help themselves
Home exercise program
Each home exercise program needs to
be individualized to meet the patient’s
specific needs
– The level of tolerance and motivation for
– The diagnosis
– The stage of healing