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Exercise Prescription John M Lavelle, DO. Objectives Objectives: Objectives: 1. Describe the benefits of employing exercise prescription as an adjunct.

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Presentation on theme: "Exercise Prescription John M Lavelle, DO. Objectives Objectives: Objectives: 1. Describe the benefits of employing exercise prescription as an adjunct."— Presentation transcript:

1 Exercise Prescription John M Lavelle, DO

2 Objectives Objectives: Objectives: 1. Describe the benefits of employing exercise prescription as an adjunct to treatment. 1. Describe the benefits of employing exercise prescription as an adjunct to treatment. 2. Describe the purpose and elements of a structural screening exam. 2. Describe the purpose and elements of a structural screening exam. 3. Describe the significance of accurate diagnosis of somatic dysfunction in exercise prescription. 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. 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. 5. Describe the key elements of exercise prescription.

3 Somatic Dysfunction Impaired function of bodily structures (most often of the MSK, nervous or lymphatic system) treated by OMT. Impaired function of bodily structures (most often of the MSK, nervous or lymphatic system) treated by OMT. 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. 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.

4 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

5 Introduction to Exercise Prescription Historical: Historical: Qi Gong and Tai Chi from TCM 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 Several studies have reported positive effects of Tai Chi or Qigong for enhancing balance and preventing falls in the elderly 1 Yoga asana and pranayama (breathing exercises) from Ayurveda 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. Recent decades in USA have seen significant growth in popularity of these exercise methods that are rooted in the healing arts.

6 Exercise Prescription Current: Growth in exercise-based modalities such as physical therapy and personal training. Current: Growth in exercise-based modalities such as physical therapy and personal training. Fitness “craze” in the USA Fitness “craze” in the USA Physical exercise has profound benefits now supported by research. 2 Physical exercise has profound benefits now supported by research. 2 Benefits: Cardiac (HTN, HLD) Mental Health (depression, anxiety) MSK, Pain Medicine, Lymphedema, endocrinology, cancer (PSA), endocrine (DM), etc Benefits: Cardiac (HTN, HLD) Mental Health (depression, anxiety) MSK, Pain Medicine, Lymphedema, endocrinology, cancer (PSA), endocrine (DM), etc

7 Exercise Prescription Physicians frequently encourage exercise to promote fitness and well-being... Often as general recommendation... Physicians frequently encourage exercise to promote fitness and well-being... Often as general recommendation... We should consider specific exercise prescription as adjunct to treatment. We should consider specific exercise prescription as adjunct to treatment. References: References: Dr. Kappler’s section V Introduction, Foundations for Osteopathic Manipulation, 2 nd ed. Dr. Kappler’s section V Introduction, Foundations for Osteopathic Manipulation, 2 nd ed. Dr. Philip Greenman, Principles of Manual Medicine, 3 rd ed. Dr. Philip Greenman, Principles of Manual Medicine, 3 rd ed. D.O. Professor emeritus of Michigan State University D.O. Professor emeritus of Michigan State University

8 Why exercise prescription? Interrelationship of OMT and PT for somatic dysfunction and specific exercise prescription 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 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 Prescribed exercise then reinforces the correction or healing facilitated by OMT or PT

9 Why exercise prescription? (con’t) Consider key principles of Osteopathic philosophy Consider key principles of Osteopathic philosophy 1. Body is a unit; the person is comprised of body, mind, spirit. 1. Body is a unit; the person is comprised of body, mind, spirit. 2. Person is capable of self-healing, self-regulation, self-maintenance. 2. Person is capable of self-healing, self-regulation, self-maintenance. 3. Structure and function are interrelated 3. Structure and function are interrelated 4. Rational treatment is based on the understanding of these principles 4. Rational treatment is based on the understanding of these principles

10 Why exercise prescription? (con’t)... Therefore, we as physicians are not healing the patient, per se, but rather facilitating the healing process inherent to the patient.... Therefore, we as physicians are not healing the patient, per se, but rather facilitating the healing process inherent to the patient.

11 Why exercise prescription? (con’t) Encourages patient to become a consciously active participant in their own healing process Encourages patient to become a consciously active participant in their own healing process Brings healing process more to conscious level Brings healing process more to conscious level Patient more aware of own agency, own power to further the healing and health maintenance. Patient more aware of own agency, own power to further the healing and health maintenance.

12 Why exercise prescription? (con’t) Additional important reasons for prescribing exercise: Additional important reasons for prescribing exercise: Psychological benefits, i.e. encouragement and optimism Psychological benefits, i.e. encouragement and optimism Natural biochemical high – diminishing or breaking cycle of chronic pain Natural biochemical high – diminishing or breaking cycle of chronic pain Cardio-vascular health Cardio-vascular health Weight management Weight management Facilitates integration of body-mind-spirit Facilitates integration of body-mind-spirit

13 Diagnostics: Structural Screening Exam Words of Wisdom: “Is there a significant musculoskeletal component to the patient’s problem?” -- Dr. Kappler 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. This ought to be our guiding question as we approach diagnosis. Structural screening exam/standing and seated structural exam is a good starting place. 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. Efficient overview, broad in scope, yet thorough enough to reveal postural and functional imbalance.

14 Diagnostics: Structural Screening Exam (con’t) May contain all or some of following components: May contain all or some of following components: 1. Gait analysis 1. Gait analysis 2. Observation of paired anatomical landmarks, antero-posterior and lateral curves 2. Observation of paired anatomical landmarks, antero-posterior and lateral curves 3. Active ROM from head to toe. 3. Active ROM from head to toe. Overall “Gestault” Overall “Gestault”

15 Diagnostics: Structural Screening Exam (con’t) Allow findings of structural screening exam to lead you to a more detailed, focused exam and diagnosis. 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. Consider how your findings may play into presenting complaint or problem under scrutiny.

16 Diagnostics: Somatic Dysfunction 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. 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

17 Diagnostics: Somatic Dysfunction (con’t) Identify problem. Identify problem. Try to identify source of 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. 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” i.e. “Shoulder bone connected to the foot bone”

18 Diagnostics: Muscle Firing Patterns Vladimir Janda, physiatrist from Czech Republic Vladimir Janda, physiatrist from Czech Republic Studied muscle function and found characteristic “normal” patterns of neuromuscular activation and common patterns of dysfunction/abnormal activation. 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. Evaluated muscle function based on tone, sequence or patterns of muscle activation, and bilateral symmetry/asymmetry of muscle activation.

19 Diagnostics: Muscle Firing Patterns (con’t) Postural/tonic muscles Postural/tonic muscles iliopsoas iliopsoas rectus femoris rectus femoris piriformis piriformis adductors adductors tensor fascia lata tensor fascia lata levator scapula levator scapula upper trapezius upper trapezius pectorals pectorals >In dysfunction these tend to become hypertonic, facilitated or contracted

20 Diagnostics: Muscle Firing Patterns (con’t) Dynamic/phasic muscles Dynamic/phasic muscles gluteus medius and maximus gluteus medius and maximus supraspinatus supraspinatus deltoids deltoids infraspinatus infraspinatus rhomboids rhomboids lower trapezius lower trapezius serratus anterior serratus anterior >In dysfunction these tend to become hypotonic, inhibited, weakened. Janda called this “pseudoparesis”.

21 Diagnostics: Muscle Firing Patterns (con’t) Muscle function and dysfunction charactized by sequential neuromuscular firing patterns 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. 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. 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. Physician then compares by evaluating contralateral firing pattern, evaluating then for symmetry of neuromuscular activation.

22 Diagnostics: Muscle Firing Patterns (con’t) Important in exercise prescription Important in exercise prescription for accurate and effective prescription for accurate and effective prescription to prevent injury... 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. If a patient has significant imbalance in firing patterns, continued activity, or increased focal activity may serve to exacerbate the problem and dysfunction.

23 Diagnostics: Muscle Firing Patterns (con’t) Prone Hip Extension Muscle Firing Pattern NormalMost Common Variation 1. hamstrings 2. gluteus maximus 3. contralat. lower lumbar erector spinae 4. ipsilat. lower lumbar erector spinae 1. hamstrings 2. upper lumbar and low thoracic erectors 3. inhibited gluteus maximus

24 Prone Hip Extension Firing Patterns

25 Diagnostics: Muscle Firing Patterns (con’t) Seated Shoulder Abduction NormalMost Common Variation 1. supraspinatus 2. deltoid 3. infraspinatus 4. mid and lower trapezius 5. contralat. quadratus lumborum 1. levator scapulae 2. upper trapezius 3. early firing of quadratus lumborum

26 Shoulder Abduction Firing Patterns

27 OMT 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” (Greenman, 498). 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” (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. 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. the patient is then be ready to begin a progression into an exercise program.

28 Elements of Exercise Prescription 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.” 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

29 Elements of Exercise Prescription (con’t) Order of progression for exercise prescription Order of progression for exercise prescription Stage one: proprioceptive balance training Stage one: proprioceptive balance training Stage two: stretch hypertonic muscles Stage two: stretch hypertonic muscles Stage three: strengthen hypotonic muscles Stage three: strengthen hypotonic muscles Stage four: aerobic training Stage four: aerobic training

30 The Patient... “Doc, my back hurts and I can’t straighten up....”

31 Elements of Exercise Prescription (con’t) Diagnostics, OMT or PT, then... Diagnostics, OMT or PT, then... Stage one: proprioceptive balance training Stage one: proprioceptive balance training Proprioceptive balance training is the first stage of addressing that “weak link” and restoring symmetry to muscle firing patterns and motor function control. 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. 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. 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.

32 Elements of Exercise Prescription: Proprioceptive Balance Training (con’t) Greenman suggests the following progression: Greenman suggests the following progression: Level 1: Patient stands, with bare feet, first on one leg then the other. Compare steadiness of balance on right and left legs. 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 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. 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. 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.

33 Proprioceptive Balance, level 1

34 Proprioceptive Balance, level 2

35 Proprioceptive Balance, level 3

36 Proprioceptive Balance, level 1

37 Proprioceptive Balance, level 2

38 Proprioceptive Balance, level 3

39 Elements of Exercise Prescription (con’t) Stage two: Stretching hypertonic muscles Stage two: Stretching hypertonic muscles stretch the tight muscles identified during initial assessment or during the course of treatment. 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. 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. 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. Teach the patient how to isolate the specific muscles or muscle group to be stretched.

40 Stage 2: Stretch Hypertonic Muscles

41

42 Stage 2: Stretch Hypertonic Muscles CAREFUL!!!!!

43 Stage 2: Stretch Hypertonic Muscles CRAAAAAZYYYY !!!!! Easy does it!!!

44 Elements of Exercise Prescription (con’t) Stage three: Strength Training 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. 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. 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.

45 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. 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. Alignment and correct performance of any exercise prescribed must be taught and emphasized in order to maximize the benefits and to prevent further injury.

46 Elements of Exercise Prescription (con’t) Stage four: Aerobic Training Stage four: Aerobic Training Added to the regimen only after the goals of the previous stages have been met. 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. 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.

47 Elements of Exercise Prescription (con’t) Essential principle: BREATHE Essential principle: BREATHE Controlled, conscious breathing Controlled, conscious breathing Often when learning new exercise patients will focus on details of posture or movement and develop counterproductive tension. 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. To prevent problem, after presenting exercise, and while patient is demonstrating proper technique, instruct patient in breath control.

48 Elements of Exercise Prescription (con’t) Breathe!!!! (con’t) Breathe!!!! (con’t) Performance of exercise will improve Performance of exercise will improve Perceived benefit will improve Perceived benefit will improve Patient awareness of immediate effects of exercise will be heightened 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 With controlled breathing the patient becomes more focused and more actively and intentionally participates in own healing

49 Elements of Exercise Prescription (con’t) Effective prescription Effective prescription Give clear and precise explanations of exercises Give clear and precise explanations of exercises Have patient demonstrate to ensure proper technique or form Have patient demonstrate to ensure proper technique or form Incorporate breath-work Incorporate breath-work Communicate goal of the program and each specific exercise Communicate goal of the program and each specific exercise Dosage Dosage

50 Elements of Exercise Prescription (con’t) Dosage: Dosage: Intensity – how far to go or how hard to push oneself with any given exercise 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 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 Frequency – how many repetitions per set and how many sets per session or day Discuss warning signs of “overdose” Discuss warning signs of “overdose” Oral explanation and written prescription Oral explanation and written prescription

51 Exercise Prescription 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. 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.” 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

52 References 1) Qigong and Tai Chi Detailed Scientific Review, MD Andersen Center- The University of Texas. professionals/clinical-tools-and-resources/cimer/therapies/alternative-medical- systems/qigong-tai-chi-scientific.html Kessenich Cathy R. Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing 1998 Jul Aug;27-9 Kessenich Cathy R. Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing 1998 Jul 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): 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): 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: Note 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: Note 2) 2) University of Illinois: Kinesiology Department: ttp://kch.illinois.edu/Research/Labs/ECRL/ 3) 3) Greenman, Philip. Principles of Manual Medicine. Lippincott Williams & Wilkins; Third edition (October 17, 2003)

53 Thank You Questions?


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