1. ACTIVE MOVEMENTS Lecture 1
Dr.Tanveer Sikander
lecturer
Indus University
Department of Physical Therapy And Rehabilitation Sciences

2.  ACTIVE MOVEMENT :
Movements performed within the unrestricted ROM controlled by the voluntary contraction of the muscles 

3. Classification of Active Movement
1- Free exercise
2- Assisted exercise
3- Resisted exercise
Classification of Active Movement 1- Free exercise: the working muscles are subjected only to the forces of gravity acting upon the part moved or stabilized.
2- Assisted exercise: the muscle strength is inadequate to perform a movement, an external force ( manually or mechanically) is applied to compensate for the movement.
3- Resisted exercise: the forces of resistance offered to the action of the working muscle are manually or mechanically and systematically increased to develop the strength and endurance of the muscles.

4. Guess the exercise activity type?

5. More examples

10. Active Free Exercise
Free exercises are those which are performed by the patient’s own muscular efforts without the assistance or resistance of any external force other than gravity.

11. Advantages /Disadvantages: Easy practice at home once its mastered!
Cant be taught or mastered to the ones with neuromuscular disorders due to detoriating status, so this may lead to what ????
From book pg 42

12. Free Exercises Classification
GENERAL
Subjective/ Objective
LOCALIZED
Free exercise may be:
localized to produce a local or specific effect i.e. to mobilize a particular joint or strengthen a particular muscle group.
Generalized involving use of more joints and muscle groups.
discuss examples now?
Subjective: anatomical movements in full range ,is focused and accurate
Task oriented e.g reaching a glass of water
Objective: concenterated work e.g throw a ball, more collective level of effort eg take a cup of tea and walk around the room

13. Techniques of free exercises:
The starting position is selected and taught with care to ensure the maximum postural efficiency as a basis for movement.
Instruction is given to gain interest and cooperation of the patient.
The speed at which the exercise is done depends on the effect required.
The duration of the exercise depends very largely on the patient’s capacity.

14. Indications and uses of Active Free Exercise This type of exercise can be used to obtain the following: 1- Relaxation: can be induced by exercises which are rhythmical or pendulum in character. Lets share examples !

17. 2.Joint mobility:
The normal range of joint motion is maintained by exercises performed in full range.
Limited range is increased by rhythmical swinging exercises incorporated and performed with pressure at the limit of free range.

19. 3.Muscle power and tone:
The power and endurance of the working muscles are maintained or increased in response to the tension developed in them.
Tension is greater when the exercise is performed at a speed slower or faster than the natural speed of movement and also greater with the duration of exercise.
During fixation of a joint the power can only be maintained or improved by repeated static contraction.

20. 4.Neuromuscular co-ordination:
Co-ordination is improved by the repetition of an exercise.
As the pattern of movement is established the conduction of the necessary impulses along the neuromuscular pathways is facilitated.

21. 5.Confidence:
Achievements of coordinated and efficient movement assure the patient of his ability to maintain subjective control of his movements, giving him confidence to attempt other and new activities.

22. 6.Circulatory and respiratory improvement:
During vigorous or prolonged exercise, the speed and depth of respiration is increased leading to the production of heat.

23. Active ASSISTED EXERCISE
When the voluntary muscular action is insufficient for the production or control of movement, an external force may be added to augment it.

24. Principles of assistance
This external force must be applied in the direction of the muscle action .
The assistance given must decrease proportionally.

25. Technique of Assisted Exercise The purpose is to ensure that insufficient muscles exert their maximum effort to produce movement under conditions designed to facilitate their action. 1- Starting position: stability of the body is important to ensure that the patient’s attention is concentrated on the pattern of the movement and the effort required performing it.

26. 2.Pattern of movement:
Can be explained to the patient by performing it passively or actively on the sound limb.
3-Fixation:
Fixation of the proximal part of the prime movers improves their efficiency. Avoid trick movements to occur by proper fixation.

27. 4. Support: Support may be provided by a. PT’s hand b
4.Support: Support may be provided by a. PT’s hand b. suspension slings c. buoyancy of water However, manual support is more effective since it can be provided in any plane suitable for the movement and the assistance can be adjusted in each successive part of the range.

28. 5. Antagonistic muscle: a proper starting position should be selected to reduce the tension in the antagonistic muscles, e.g. a position in which the knee flexed is suitable for assisted dorsi-flexion of the foot. 6- Traction: stretching of the weak muscle provides a powerful stimulus to contraction because it elicits the myotatic reflex which helps in the initiation of movement.

29. 8.Assistance force: the force used in assisting the action of the muscle must be applied in the direction of the movement by the PT hands. Patient may assist the movement himself so he can thoroughly understand the procedure. The movement should be possible in full range. Assistance is mostly required at the beginning of the movement to overcome initial inertia and at the end to complete the range.

30. 9.The character of the movement: movement is performed smoothly and its efficiency depends on the patient’s full attention. The speed of contraction depends on the type of muscle whether fusiform or pennated, etc.

31. 10.Repetitions: repetition of the movement depends on the rate of fatigue. Therefore, the condition which caused the weakness must be known and understood. 11-The cooperation of patient: is essential during this type of exercise with the aim to achieve controlled active movement without assistance. The patient should be encouraged to exert maximum effort.

33.  Indications and uses of assisted exercise
1- In the early stages of neuromuscular re-education. Active assistive exercise is used to provide sensory feedback from the contracting muscles.
2- Maintain the physiological properties of the muscle to increase muscle strength and hypertrophy.

34. 3.Coordination training : The memory of the pattern of coordinated movement is stimulated. By frequent repetition of the pattern with decreasing assistance the patient may relearn to control the movement himself as the conduction of impulses is facilitated in the neuromuscular pathways.

35. 4.Confidence in the ability to move is established with the performance of the movement. These exercises are helpful in case with painful joints such as rheumatoid arthritis. 5- Increase and maintain ROM. 6-Provide stimulus for bone integrity(unity).
The feeling of the patient that the limb is supported encourages him to produce a maximum effort.

36. Contraindications 1- Acute tears and fractures.
2- Gross swelling, fever and redness.3- Acute intolerable pain during movement

37. Acute tears, fractures and swelling. Will you go for these exercises
Acute tears, fractures and swelling? Will you go for these exercises? Why not? Discuss!

38. Assisted resisted exercises:
This type of exercises constitutes a combination of:
Assistance
Resistance
In a duration of single movement and as per possibility the preference is to meet the muscular need with maximum accuracy.

39. Resisted Exercise:
Resistance exercise is an essential element of Rehab programs for person with impaired function and for those who wish to promote and maintain health and physical well-being.
Defination:
Any form of active exercise in which a dynamic or static muscle contraction is overloaded (resisted) by an external force (manually or mechanically).
Point to remember :
The resistance must be sufficient to increase the intra-muscular tension to the maximum without interfering with the ability of the muscle to do coordinated movements.

40. Forms of resistance: Free weights Pulley circuit Springs Water
The patient himself
The physiotherapist
Strong elastic bands
(dumbbells, weight machines)

42. Factors That Determine Levels of Strength, Endurance & Power 1.Size
2.Number of Muscle Fibers
3.Age
4.Gender
Hypertrophy Increase in muscle size.
Atrophy Decrease in muscle size
of Muscle Proportional to cross-sectional diameter of muscle fibers Increased cross-sectional area = increased strength and force production.
Neuromuscular EfficiencyStrength is directly related to efficiency of the neuromuscular systemInitial increases in strength during first 8-10 weeks are attributed to neuromuscular efficiency
Men & women increase strength throughout puberty & adolescence Peaks at age 20-25After age 25, max strength declines 1% annuallyDecline is related to physical activityAble to retard decline in performance through activity

43. Technique of Manual resistance exercise
When applying resistance, 4 basic rules should be observed:
1- The resistance must be given smoothly from the beginning to the end of range.
2- The direction of resistance force must be opposite to the direction of the movement.
3- It should be diminish gradually from the beginning to the end of movement.
4- enough period of relaxation to avoid fatigue.
Warmups and cool down period

44. Mechanical Resistance Exercise
Definition:
Any form of exercise in which resistance is applied by the use of mechanical equipment.
They include :
1.Progressive resisted exercise
2.Active resistive training
3.Overload training

45. Advantages:
1- Considered as baseline measurement for muscular performance prior to exercise.
2- Appropriate during the advanced phase of Rehabilitation program.
3- Practical and Useful for improving muscle strength, endurance and power.
4- Appropriate for independent exercise in a home program.
5- Effective source for patient motivation Objective measurement for patient progress.

46. Equipment used for Resistance Exercise are:
Free weights as Dumbbells
Sandbags
Cuff weight
Elastic resistance devices:
Thera-band
Pulley system
Exercise bicycle 

48. Progressive resisted exercise (PRE)
One way to progressively increase muscle performance (strength, power and endurance) is to increase the amount of resistance used in an exercise program. In PRE the contracting muscles are overloaded by a constant mechanical external load that is incrementally progressed.
The basis for determining and resistance progression is the repetition maximum (RM).
RM is the greatest amount of weight a muscle can move through the ROM a specific amount of time.

49. Ways to achieve progressive resistance:
1.Increase the weight being lifted.
2.Increase the number of repetitions, use the same weight for each workout but increase the repetitions each week.
3.Increase the number of sets each time you workout.
4.Shorten the rest time between the sets.
5.Lengthen the time under tension- or how long your muscle fibers are under stress.
6.Use the same weight and repetitions, but slow down the exercise.

50. Effects/uses of resisted exercises
Muscle power
Blood flow
Blood pressure rise
Heat
Pg 58-59
Discuss how?

51. Involuntary movements
An involuntary movement occurs when you move your body in an uncontrollable and unintended way.
These movements can be anything from quick, jerking tics to longer tremors and seizures.
You can experience these movements in almost any part of the body, including: neck. face.

52. REFLEX MOVEMENT: Involuntary Motor response to sensory stimulation
Pg 59

53. A pathway of impulses which gives rise to a reflex activity
REFLEX ARC:
A pathway of impulses which gives rise to a reflex activity
Such activity can be stimulated and used to improve or facilitate movement or the postural maintenance.
Pg 60

55. Stretch Reflex:
A spinal reflex which is activated by a stretch reflex .
pg60

56. Righting reflex:
Series of reflex concerned with maintenance and restoration of equilibrium.
Pg 60

57. an efferent response to an afferent stimulus
Postural reflex:
The erect posture is maintained by complex serial reflexes , and are collectively called as postural reflex.
an efferent response to an afferent stimulus
Pg 246 please read

58. Effect /uses of reflex movement:
Promoting the neuromuscular mechanism.
Muscle extensibility and normal joint movement maintenance
Circulation improvement
Relaxation of spastic toned muscles temporarily