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