Therapeutic Exercise

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Definition

Therapeutic exercises are activities that are prescribed by the physician and are performed with the assistance and guidance of a physical therapist or a nurse. The ultimate goal of therapeutic exercises is to help and aid the patient or injured individual gain independence in functional activities and make the activity as much as possible comfortable and pain-free.

Goals:

• Enable ambulation
• Release contracted muscles, tendons, and fascia
• Mobilize joints
• Improve circulation
• Improve respiratory capacity
• Improve coordination
• Reduce rigidity
• Improve balance
• Promote relaxation
• Improve muscle strength and, if possible, achieve and maintain maximal voluntary contractile force (MVC)
• Improve exercise performance and functional capacity (endurance)

Physiological Aspects of Physically Fit Person

• Higher oxygen consumption (mL/min)
• Greater cardiac output per minute
• Higher stroke volume and total blood volume
• Greater oxygen extraction by the tissues
• Greater cardiac volume
• Lower resting pulse rate
• Greater muscle strength
• Lower pulse rate on exercise
• Lower blood pressure on exercise
• Better adaptation of circulation and respiration to effort

Benefits of Therapeutic Exercises

When correctly performed, therapeutic exercises will have the following outcomes:

1. Improve or maintain muscle strength. It is only through the execution of these exercises that muscle strength is built and reinforced.
2. Enhancing joint function.
3. Helps in preventing deformities.
4. Assists in stimulating blood circulation.
5. Developing a person’s endurance.
6. Promoting relaxation.
7. Helping to restore motivation and well-being of the patient

Approach Considerations
Therapeutic exercises aimed at achieving and maintaining physical fitness fall into the following major categories, each of which has a specific purpose:

• Endurance training
• Resistance training
• Flexibility training

Endurance Training
An endurance training program has 3 variables: frequency, intensity, and duration. The American College of Sports Medicine (ACSM) recommendations are as follows:

• Frequency - Aerobic exercise 3-5 days a week
• Intensity of training - 64/70-94% of maximum heart rate (HR max), or 40/50-85% of maximum oxygen uptake reserve (VO2 R) or heart rate reserve (HRR)
• Duration of training - Continuous or intermittent aerobic activity for 20-60 minutes (minimum of 10-min bouts accumulated throughout the day). Duration is dependent on the intensity of the activity; thus, lower-intensity activity should be conducted over a longer period of time (≥30 min), and, conversely, individuals training at higher levels of intensity should train at least 20 minutes or longer. Moderate-intensity activity of longer duration is recommended for adults not training for athletic competition, because total fitness is more readily attained with exercise sessions of longer duration and because potential hazards and adherence problems are associated with high-intensity activity.

Application to healthy individuals
Exercises that use large muscle groups that can be maintained continuously and are aerobic in nature are recommended. These exercises include walking, running, jogging, dancing, stair climbing, cycling, swimming, rowing, skating, aerobic dance/exercise classes, jumping rope, and cross-country skiing.

The HR max can be determined by the following: HR max = 220 – Ag

The exercise session should consist of the following:

• A warm-up period of approximately 10 minutes: This should combine calisthenic-type stretching exercises and progressive aerobic activity that should increase the heart rate close to the prescribed heart rate for the session.
• Endurance training (20-60 min)
• A cool-down period of 5-10 minutes

Application to patients
For at-risk patients, especially those with cardiac or respiratory disease, a less intense training regimen must be used, with the training heart rate not exceeding that attained at 50-60% of maximum O2 uptake (VO2 max).

In the absence of data regarding maximum attained heart rate measurements, it is prudent not to allow a patient to exceed a heart rate of 130 beats per minute (bpm). In elderly patients and patients at risk, the intensity, frequency, and duration of therapeutic exercise should be established for each patient individually through prior medical evaluation (see Medical evaluation).
Using the following equation, the HRR method, otherwise known as the Karvonen method, should be employed to determine the target heart rate for the ill or elderly patient: Target HR = (220 - age - resting heart rate × % intensity selected) + resting heart rate

Progression

Progression must be a part of an exercise program to ensure continued results. With endurance training, progression can occur by increasing the duration or the intensity. Several factors contribute to the optimal rate of progression; current activity levels, exercise goals, age, and physiologic limitations should be considered. Most importantly, a rate of progression should be used that results in long-term participation. Being too aggressive with progression can lead to increased dropout rates as a result of injuries and/or perceived excessive discomfort.


Resistance Training

Resistance training increases strength, walking speed, stair-climbing power, balance, and lean body mass and decreases regional and total fat mass. This form of exercise has been shown to bring about favorable changes in risk factors for coronary artery disease, osteoporosis, diabetes mellitus, and cancer. For example, resistance training has been proven to lower systolic blood pressure, increase bone mineral density, increase mechanisms involved with blood glucose metabolism (glucose tolerance and insulin resistance), and increase bowel transit time, which decreases the risk of colon cancer in healthy men and women who are middle-aged or older. Back pain and work-related back injuries also have been shown to decrease with resistance training.


Factors Affecting the Adherence to Therapeutic Program

A therapeutic exercise program is beneficial to the patient. However, some individuals do not adhere to the program. The following are some of the identified factors that affect the performance of therapeutic exercise:

• Lack of knowledge about the exercise program
• Lack of Skill. Explaining and demonstrating the methods or techniques of exercise execution may be helpful in assuring adherence to the exercise program. Though the patient may indicate familiarity with the exercise, the technique execution might be wrong. An exercise is ineffective if done incorrectly. Thus, it is ideal to demonstrate the techniques and skill to the patient beforehand and let the patient perform the complete set of exercise while watching to correct improper technique execution. Correcting errors can be easily provided by positive reinforcement and suggestions.
• Lack of Risk Taking Ability. An individual’s fear of feeling increased pain, discomfort or possible reinjury sometimes limits the individual’s motivation to exert full effort and thus it prevents the patient from sticking to the therapeutic exercise program. Emotions are one factor that may motivate or block the individual to deal successfully with the challenges of the exercise program. Nurses should provide constant positive feedback to deal with this.
• Lack of Social support. When an individual feels alone or isolated, he or she might lose the motivation to meet the challenges of the exercise program. Assuring and acknowledging that value of a patient in an activity and encouraging socialization are the key steps in handling this problem.
• Confidence. One of the most essential factors that affect the completion of the exercise program is the confidence of the person.  Timely recovery will be delayed when a person has low confidence because focus is interfered with negative thoughts.
• Motivation. The greatest influence in the completion of the exercise program is based on how motivated an individual is. Low motivation results to the following:

1. Low effort and intensity
2. Poor attention
3. Lack of attentiveness to instructions
4. Undefined goals
5. Insupportable excuses to avoid the exercise program

IELTS Writing

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Grading System for Essays

• Task Response
• Coherence and Cohesion
• Lexical Resource
• Grammatical Range and Accuracy

“Task Response”
Means that your essay shows that you understood and covered the topic from all its sides, aspects, etc. Let’s take this topic for example – “Internet: connecting or isolating people?”. Those who chose to write about how Internet connects people – loose marks, those who chose to write about how Internet isolates people – loose marks, those who compare and contrast both sides of the Internet and give arguments for and against – gain marks.

“Coherence and Cohesion”
Means how well you connected the paragraphs and sentences inside each paragraph. You see, all of your paragraphs need to be logically connected. For example, if paragraph 1 explains the advantages of the Internet, and paragraph 2 explains its disadvantages, then paragraph 1 should have last sentence saying something like this: “In spite of Internet being such a help in communication, its drawbacks can not be overlooked”. This sentence creates the connection between 1st and 2nd paragraphs. If it wasn’t there, examiner could think that you jumped from advantages to disadvantages without a reason. The same rule applies to sentences inside the paragraph. Every sentence should lead to the next one.

“Lexical Resource”
Means vocabulary and different types of sentences, simple and complex. You should be able to use words and their synonyms.

“Grammatical Range and Accuracy”
Means spelling and grammar of sentences. You should be able to spell the words correctly, do not forget articles “a” and “the”, punctuations is also important, etc.

WRITING

W – Work with a coach.

Practice is one way to enhance your writing skills. However, it would be ideal if you practice with a teacher or IELTS coach that will correct your output. You can never be prepared to combat the IELTS writing tasks without receiving feedbacks on your writing errors. For those who are in a tight budget and cannot afford to hire an IELTS coach, you can work on your own but be sure to have a good IELTS preparatory manual that will serve as your guide in honing of that writing ability.

R – Read through the instructions and questions carefully.

Aside from the main question, the point of issue often will ask you to address three or four things. Make sure to get these queries and discuss them in your answer.

I – Inspect your watch!

Keep track of your time! Monitor your own progress! Remember you only have one hour to finish both writing tasks. For those who have difficulty hitting the 60-minute mark for tasks 1 and 2, speed is developed by practicing constantly.

T – Think and write it out.

While rehearsing your writing ability, sit and write out tasks 1 and 2. Some people are not actually writing the brilliant ideas they were thinking while reading the question. Thus, a structured format approach should be utilized in this case. Repetitive writing can also be avoided if you practice, practice and practice.

I – Inscribe those words legibly!

Messy writing is not a criterion in marking your written output. However, if the examiner cannot read what you have written, then, you are not getting any mark either. Before taking the examination, my coach kept on reminding me about my writing because the words are too small and she had difficulty reading them. Keep in mind than an unreadable output means no mark at all!

N – No reason to start writing immediately for task 1.

Yes, I told you to keep track of your time. But don’t start writing immediately after looking at the graph or table and understanding what is asked and given. Before writing, make sure that you know what each axis represents and the units that are used. Even if you finished writing task 1 for 10 minutes but the data written is incorrect you will never hit your target mark.

G – Go for task 2 first!

Task 2 in the IELTS writing section is easier to compose and is worth more mark than task 1. I am not saying that you should ignore the other component in this section, but making sure you completed the part which weighs more points to your mark is a wise choice.

Phlebotomy

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Phlebotomy is a procedure that consists of venipuncture and withdrawal of blood. It is a safe outpatient method where blood is extracted from the vein through a cut or puncture. This procedure is performed by a nurse or technician called phlebotomist.

Purpose

Phlebotomy is performed for many reasons which include the following:

1. To obtain sample for analysis and diagnosis.
2. To treat polycythemia. Polycythemia is a condition where elevation or red blood cell volume is noted. Part of the treatment of this disorder is carrying out therapeutic phlebotomy.
3. To decrease the total blood volume of patients with pulmonary edema.
4. To remove blood from the body during blood donation.
5. To analyze blood substances contained in blood before clearing a person for blood donation.

Safety Guidelines

• Universal precautions are used with this procedure. Gloves should be worn when performing this procedure.
• Prior to blood collection it is important that the one performing the procedure is properly trained and identified as licensed phlebotomist.
• Properly identify your patient. Check the name tag and verify with the patient or nurse on duty.
• Supplies should be checked for their integrity.
• Label vials and tubes properly. Indicate date and time of extraction with the name of the patient clearly indicated.
• Needles should be immediately disposed in an approved sharps container. They never be recapped and should only be used once.
• Assess the patient for complications associated with the phlebotomy procedure.

Venipuncture Site Selection:

Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications.

Certain areas are to be avoided when choosing a site:

• Extensive scars from burns and surgery - it is difficult to puncture the scar tissue and obtain a specimen.
• The upper extremity on the side of a previous mastectomy - test results may be affected because of lymphedema.
• Hematoma - may cause erroneous test results. If another site is not available, collect the specimen distal to the hematoma.
• Intravenous therapy (IV) / blood transfusions - fluid may dilute the specimen, so collect from the opposite arm if possible. Otherwise, satisfactory samples may be drawn below the IV by following these procedures:
  
  • Turn off the IV for at least 2 minutes before venipuncture.
  • Apply the tourniquet below the IV site. Select a vein other than the one with the IV.
  • Perform the venipuncture. Draw 5 ml of blood and discard before drawing the specimen tubes for testing.
• Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. The line must be flushed first. When using a syringe inserted into the line, blood must be withdrawn slowly to avoid hemolysis.
• Cannula/fistula/heparin lock - hospitals have special policies regarding these devices. In general, blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician.
• Edematous extremities - tissue fluid accumulation alters test results.

Description of Procedure

In this procedure, blood is extracted from a vein on the back of the hand or over the antecubital fossa. However, some tests require blood to be taken from an artery. In blood transfusion, donors are placed in a semirecumbent position and the skin over the antecubital fossa is carefully cleansed with an iodine preparation or antiseptic solution. A tourniquet or elastic band is applied around the arm to retain blood in the area and make the veins visible. After the phlebotomist selects an appropriate vein for blood extraction, venipucture is performed. – A needle is inserted into the vein and the tourniquet is released.

The appropriate amount of blood to be withdrawn widely varies. Blood donation and therapeutic phlebotomy require larger amount of blood than blood analysis. Blood donors usually give about 450 to 500 ml of blood per session. For laboratory analysis, the volume of blood needed depends on the type of test performed. Approximately, one or more 5 to 10 ml tubes of blood are withdrawn.

Withdrawal of 450 ml of blood takes less than 15 minutes. After the needle is removed, the donor is asked to hold the involved arm straight up and apply firm pressure on the site with sterile gauze for about 2 to 3 minutes or until the bleeding stops. The phlebotomy technician then places a bandage on the site.

Instructions After the Procedure

• Within 1 to 2 minutes the donor is asked to remain in the position until they feel able to sit up. If weakness or faintness is experienced, the donor should rest for a longer time.
• Foods and fluids are given when the donor sits up and is asked to remain for another 15 minutes.
• Heavy lifting should be avoided for several hours.
• Smoking should be avoided for an hour.
• Alcoholic beverages should be avoided for 3 hours.
• For 2 days, fluid intake should be increased and balanced diet should be practiced for 2 weeks.

NOTE: Always observe aseptic technique to protect your patient and yourself.