2Objectives 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.
3Somatic DysfunctionImpaired 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.
4Words of WisdomOsteopathy 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 healthWhen 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
5Introduction to Exercise Prescription Historical:Qi Gong and Tai Chi from TCMSeveral studies have reported positive effects of Tai Chi or Qigong for enhancing balance and preventing falls in the elderly 1Yoga asana and pranayama (breathing exercises) from AyurvedaRecent decades in USA have seen significant growth in popularity of these exercise methods that are rooted in the healing arts.
6Exercise Prescription Current: Growth in exercise-based modalities such as physical therapy and personal training.Fitness “craze” in the USAPhysical exercise has profound benefits now supported by research. 2Benefits: Cardiac (HTN, HLD) Mental Health (depression, anxiety) MSK, Pain Medicine, Lymphedema, endocrinology, cancer (PSA), endocrine (DM), etc
7Exercise Prescription 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:Dr. Kappler’s section V Introduction, Foundations for Osteopathic Manipulation, 2nd ed.Dr. Philip Greenman, Principles of Manual Medicine, 3rd ed.D.O. Professor emeritus of Michigan State University
8Why exercise prescription? Interrelationship of OMT and PT for somatic dysfunction and specific exercise prescriptionOMM or PT sets the stage for therapeutic exercise and makes the exercise more effectivePrescribed exercise then reinforces the correction or healing facilitated by OMT or PT
9Why exercise prescription? (con’t) Consider key principles of Osteopathic philosophy1. 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 interrelated4. Rational treatment is based on the understanding of these principles
10Why 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.
11Why exercise prescription? (con’t) Encourages patient to become a consciously active participant in their own healing processBrings healing process more to conscious levelPatient more aware of own agency, own power to further the healing and health maintenance.
12Why exercise prescription? (con’t) Additional important reasons for prescribing exercise:Psychological benefits, i.e. encouragement and optimismNatural biochemical high – diminishing or breaking cycle of chronic painCardio-vascular healthWeight managementFacilitates integration of body-mind-spirit
13Diagnostics: Structural Screening Exam Words of Wisdom: “Is there a significant musculoskeletal component to the patient’s problem?” -- Dr. KapplerThis 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.
14Diagnostics: Structural Screening Exam (con’t) May contain all or some of following components:1. Gait analysis2. Observation of paired anatomical landmarks, antero-posterior and lateral curves3. Active ROM from head to toe.Overall “Gestault”
15Diagnostics: Structural Screening Exam (con’t) 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.
16Diagnostics: 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.paraphrased from Dr. Hugh Ettlinger
17Diagnostics: Somatic Dysfunction (con’t) 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”
18Diagnostics: Muscle Firing Patterns Vladimir Janda, physiatrist from Czech RepublicStudied 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.
19Diagnostics: Muscle Firing Patterns (con’t) Postural/tonic musclesiliopsoasrectus femorispiriformisadductorstensor fascia latalevator scapulaupper trapeziuspectorals>In dysfunction these tend to become hypertonic, facilitated or contracted
20Diagnostics: Muscle Firing Patterns (con’t) Dynamic/phasic musclesgluteus medius and maximussupraspinatusdeltoidsinfraspinatusrhomboidslower trapeziusserratus anterior>In dysfunction these tend to become hypotonic, inhibited, weakened.Janda called this “pseudoparesis”.
21Diagnostics: Muscle Firing Patterns (con’t) Muscle function and dysfunction charactized by sequential neuromuscular firing patternsObserving 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.
22Diagnostics: Muscle Firing Patterns (con’t) Important in exercise prescriptionfor accurate and effective prescriptionto 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.
23Diagnostics: Muscle Firing Patterns (con’t) Prone Hip Extension Muscle Firing PatternNormalMost Common Variation1. hamstrings2. gluteus maximus3. contralat. lower lumbar erector spinae4. ipsilat. lower lumbar erector spinae2. upper lumbar and low thoracic erectors3. inhibited gluteus maximus
27OMTGreenman 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.the patient is then be ready to begin a progression into an exercise program.
28Elements 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.”-- Dr. Robert Kappler
29Elements of Exercise Prescription (con’t) Order of progression for exercise prescriptionStage one: proprioceptive balance trainingStage two: stretch hypertonic musclesStage three: strengthen hypotonic musclesStage four: aerobic training
30The Patient . . . “Doc, my back hurts and I can’t straighten up . . . .”
31Elements of Exercise Prescription (con’t) Diagnostics, OMT or PT, then . . .Stage one: proprioceptive balance trainingProprioceptive 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.
32Greenman suggests the following progression: Elements of Exercise Prescription: Proprioceptive Balance Training (con’t)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 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.
39Elements of Exercise Prescription (con’t) Stage two: Stretching hypertonic musclesstretch 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.
43Stage 2: Stretch Hypertonic Muscles CRAAAAAZYYYY!!!!! Easy does it!!!
44Elements of Exercise Prescription (con’t) Stage three: Strength TrainingWhen 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.
45Elements 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.
46Elements of Exercise Prescription (con’t) Stage four: Aerobic TrainingAdded 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.
47Elements of Exercise Prescription (con’t) Essential principle: BREATHEControlled, conscious breathingOften 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.
48Elements of Exercise Prescription (con’t) Breathe!!!! (con’t)Performance of exercise will improvePerceived benefit will improvePatient awareness of immediate effects of exercise will be heightenedWith controlled breathing the patient becomes more focused and more actively and intentionally participates in own healing
49Elements of Exercise Prescription (con’t) Effective prescriptionGive clear and precise explanations of exercisesHave patient demonstrate to ensure proper technique or formIncorporate breath-workCommunicate goal of the program and each specific exerciseDosage
50Elements of Exercise Prescription (con’t) Dosage:Intensity – how far to go or how hard to push oneself with any given exerciseDuration – how long to hold a position or sustain a prescribed exerciseFrequency – how many repetitions per set and how many sets per session or dayDiscuss warning signs of “overdose”Oral explanation and written prescription
51Exercise 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.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
52References1) Qigong and Tai Chi Detailed Scientific Review, MD Andersen Center- The University of Texas.Kessenich Cathy R. Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing 1998 Jul-1998 Aug;27-9Wolf 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: NoteUniversity 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)