DEEPIKA DANGI

EXERCISE THERAPY

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AEROBIC EXERCISE
 Aerobic exercise is defined as any activity that uses large muscle groups, can
be maintained continuously and is rhythmic in nature .
 It is a type of exercise that overloads the heart and lungs and causes them to
work harder than at rest .
 Some examples: walking , jogging , running , dancing , swimming etc
 Aerobic Exercise refers to a structured physical activity that requires the
body’s metabolic system to use oxygen to produce energy .
 Aerobic workout can be done in 3-4 times a week .

Key Terms——————————
1. Physical activity
is “any bodily movement produced by the contraction of skeletal muscles that
result in a substantial increase over resting energy
expenditure”.
Or

any movement of the body that requires energy expenditure.

2. Physical Fitness

Fitness is a general term used to describe the ability to perform physical work.
Optimum body composition is also included when describing fitness. Physical
fitness is your ability to carry out tasks without undue fatigue. To become
physically fit, individuals must participate regularly in some form of physical
activity that uses large muscle groups

3. Maximum Oxygen Consumption (VO2 max)

VO2 max) is a measure of the body’s capacity to use oxygen. It is usually

measured when performing an exercise that uses many large
muscle groups such as swimming, walking, and running. It is the maximum
amount of oxygen consumed per minute when the individual has reached
maximum effort.

Average consumption is 40-50 mL/kg/min.

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4. Endurance
is the ability to work for prolonged periods of time and the ability to resist
fatigue
or
The capacity to last or to withstand wear and tear

5. Adaptation
 The cardiovascular system and the muscles used adapt to the training
stimulus over time. Significant changes can be measured in as little as 10 to
12 weeks.
 Adaptation represents a variety of neurological, physical, and biochemical
changes in the cardiovascular and muscular systems.
 Adaptation is dependent on the ability of the organism to change and the
training stimulus threshold (the stimulus that elicits a training response).
 The person with a low level of fitness has more potential to improve than the
one who has a high level of fitness.
 The higher the initial level of fitness, the greater the intensity of exercise
needed to elicit a significant change
.
6. Myocardial oxygen consumption

 Is a measure of the oxygen consumed by myocardial muscle .

 The need or demand for oxygen is determined by the heart rate (HR),
systemic blood pressure, myocardial contractility, and after-load.
 After-load is determined by the left ventricular wall tension and central
aortic pressure.
 In a healthy individual, a balance between myocardial oxygen supply and
demand is maintained during maximum exercise. When the demand for
oxygen is greater than the supply, myocardial ischemia results.

7. De conditioning
De conditioning occurs with prolonged bed rest, and its effects are frequently
seen in the patient who has had an extended, acute illness or long-term chronic
condition. Decreases in VO2 max, cardiac output (stroke volume), and muscular
strength occur rapidly.
EFFECTS OF De conditioning ASSOCIATED WITH BED REST
↓ Muscle mass. ↓ Strength. ↓ Cardiovascular function
↓ Total blood volume. ↓ Plasma volume. ↓ Heart volume
↓ Orthostatic tolerance. ↓ Exercise tolerance. ↓ Bone mineral density

Energy Systems ————————-

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 Energy systems are metabolic systems involving a series of bio- chemical

reactions resulting in the formation of adenosine triphosphate (ATP), carbon
dioxide, and water
 The cell uses the energy produced from the conversion of ATP to adenosine
diphosphate (ADP) and phosphate (P) to perform metabolic activities.
 Muscle cells use this energy for actin-myosin cross- bridge formation when
contracting.
 There are 3 major energy systems
1. Phosphagen or ATP-PC system Is the body’s fastest way to produce
energy by utilising stored adenosine triphosphate and carotene
phosphate in muscle cells, providing a immediate energy for short and
high intensity activity
2. Anaerobic Glycolytic System is a metabolic pathway that produces
energy when there is limited oxygen. It is also known as fast
glycolysis.
3. Aerobic System a process that uses oxygen to create energy for
sustained activities like walking and running. The body breaks down
carbohydrates ,fats and proteins..
 Bursts of intense activity lasting only seconds develop muscle strength and
stronger tendons and ligaments. ATP is supplied by the phosphagen system.
 Intense activity lasting 1 to 2 minutes repeated after 4 minutes of rest or mild
exercise enhances anaerobic power. ATP is supplied by the phosphagen and
anaerobic glycolytic system.
 Activity with large muscles, which is less than maximum intensity for 3 to 5
minutes repeated after rest or mild exercise of similar duration, may develop
aerobic power and endurance capabilities. ATP is supplied by the
phosphagen, anaerobic glycolytic, and aerobic systems.
 Activity of sub maximum intensity lasting 20 to 30 minutes or more taxes a
high percentage of the aerobic system and develops endurance.
 Energy expenditure- Energy expended is computed from the amount of
oxygen consumed. Units used to quantify energy expenditure are METs and
kilocalories.
MET | Type of Physical Activity
1.0–2.9 | Sitting, standing, , walking-less .
. than 2.5 mph
3.0–5.9 | Walking downstairs, playing golf
6.0–8.8 Walking faster , swimming laps, .
……. | jogging, running

Physiological Response to Aerobic Exercise. —————-

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The rapid increase in energy requirements during exercise requires equally rapid
circulatory adjustments to meet the increased need for oxygen and nutrients to
remove the end products of metabolism, such as carbon dioxide, water, and
lactic acid, and to dissipate excess heat.

1. Cardiovascular Response

 The stimulation Sympathetic Nervous System response includes generalised

peripheral vasoconstriction in non-exercising muscles
 increased myocardial contractility
 an increased Heart Rate
 an increased systolic blood pressure
 increase and redistribution of the cardiac output.
 increase in the force development of the cardiac myofibers
 Increases in the peripheral venous pressure
 Increase in systolic blood pressure.
 Increase VO2 max
 Increased extraction of oxygen by the working muscle
 Decreased myocardial consumption

2. Respiratory Response

 Gas exchange (O2, CO2) increases across the alveolar-capillary membrane

by the first or second breath.
 Increased muscle metabolism during exercise results in more O2 extracted
from arterial
 increase in venous PCO2 and H+
 an increase in body temperature
 increased stimulation of receptors of the joints and muscles.
 Minute ventilation increases as respiratory frequency and tidal volume
increase.
 Alveolar ventilation occurring with the diffusion of gases across the
capillary-alveolar membrane
 increases 10- to 20-fold during heavy exercise to supply the additional
oxygen needed and excrete the excess CO2 produced.
 Ventilatory efficiency is increased.
 Larger diffusion capacities
 The maximal minute ventilation is increased

3. Metabolic response

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 Muscle hypertrophy
 increase in number and size of mitochondria
 Increased capillary density
 increased oxygen transport
 lower blood lactate level at sub-maximal work

4. Other system changes

 Decrease in body fat

 Decrease in blood cholesterol and triglyceride level
 Increased heat acclimatisation
 Increase in breaking strength of bones and ligaments
 Tensile strength of tendon

Testing as a basis of Exercise programs ——————

Testing for physical fitness of healthy individuals should be distinct from
graded exercise testing of convalescing patients, individuals with symptoms of
coronary heart disease, or individuals who are 35 years or older but
asymptomatic.

1. Fitness testing

o Tests for determining cardiovascular fitness include the time to run 1.5 miles
or the distance run in 12 minutes.
o These measures correlate well with VO2 max, but their use is limited to
young persons or middle-aged individuals who have been carefully screened
and have been jogging or running for some time.
o Other field tests include the 1-mile walk test, 6-minute walk test, and step
tests.
o It is suitable for individual’s who are not as physically active
o Multistage testing can provide a direct measurement of VO2 max by
analysing samples of expired air
o Testing is usually completed in 4 to 6 treadmill stages, which progressively
increase in speed and grade. Each stage is 3 to 6 min long.
o Electrocardiographic (ECG) monitoring is performed during the testing.
o Maximum oxygen uptake can be determined when the oxygen utilization
plateaus despite an increase in workload.

2. Stress testing

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o Individuals undergoing stress testing should have a physical examination; be

monitored by the ECG; and be closely observed at rest, during exercise, and
during recovery
o The principles of stress testing include:
1. Changing the workload by increasing the speed and/or grade of the
treadmill or the resistance on the bicycle ergometer
2. An initial workload that is low in terms of the individual anticipated
aerobic threshold Maintaining each workload for 1 minute or longer

o The purpose of stress testing :

1. Helps establish a diagnosis of overt or latent heart disease.
2. Evaluates cardiovascular functional capacity as a means of clearing
individuals for strenuous work or exercise programs.
3. Evaluates responses to exercise training and/or preventive programs.
4. Assists in the selection and evaluation of appropriate modes of treatment
for heart disease.
o Is used clinically to evaluate patients with chest sensation or a history of
chest pain to establish the probability that such patients have coronary
disease.

o The preparation of stress test :

1. Have had a physical examination
2. Be monitored by ECG and closely observed at rest, during exercise, and
during recovery
3. Sign a consent form

o The termination of stress testing :

1. Terminating the test at the onset of symptoms or a definable abnormality
of the ECG
2. Onset and/or progressive angina
3. A drop in systolic pressure in response to an increasing workload
4. Lightheadedness, confusion, pallor, cyanosis, nausea, peripheral
circulatory insufficiency, shortness of breath, wheezing,or leg cramps
5. Excessive rise in blood pressure
6. No increase in HR with an increase in exercise intensity
7. Onset or change in heart rhythm
8. Subject wishes to stop
9. Observed or reported symptoms of severe fatigue

3.Multistage Testing

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o Each of the four to six stages lasts approximately 1 to 6 minutes

o Differences in protocols involve the number of stages, magnitude of the
exercise (intensity), equipment used , duration of stages, endpoints, position
of body, muscle groups exercised, and types of effort
o The most popular treadmill protocol is the Bruce protocol. Treadmill speed
and grade are changed every 3 minutes. Speed increases from 1.7 mph up to
5 mph, and the initial grade of 10% increases up to 18% during the five
stages

 Precautions for stress Testing and Exercise program

1. Heart rate increases with exercise approximately 8–12 beats per min per
MET of physical activity.
2. Monitor for abnormal increases in heart rate.
3. Blood pressure increases with exercise approximately 8 to12 millimetres
(mm) of mercury (Hg) per MET of physical activity.
4. Systolic pressure should not exceed 250 mm Hg.
5. Diastolic pressure should not exceed 115 mm Hg.
6. Rate and depth of respiration increase with exercise.
7. Respiration should not be laboured.
8. The individual should have no perception of shortness of breath
9. The increase in blood flow while exercising, which regulates core
temperature and meets the demands of the working muscles, results in
changes in the skin of the cheeks, nose, and earlobes. They become pink,
moist, and warm to the touch.

Determinants of an Exercise Program. ————————

1. FREQUENCY – ( how often you exercise)

 optimal frequency of training is generally three to four times a week.
 Frequency varies, dependent on the health and age of the individual, and
may be a less important factor than intensity duration in exercise training
 If training is at a low intensity, greater frequency may be beneficial.
 Frequency is especially important when it comes to weight loss. The more
you exercise, the more calories you will burn.
 Aim for a minimum of 3 days per week with no more than 2 days between
sessions.
 Gradually work your way up to 5 or 6 days per week.

2. INTENSITY- ( how hard you exercise )

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Determination of the appropriate intensity of exercise to use is based on the

overload principle and the specificity principle
 Overload principle
 Overload is stress on an organism that is greater than that regularly
encountered during everyday life.
 To improve cardiovascular and muscular endurance, an overload must be
applied to these systems
 The exercise load must be above the training stimulus threshold for
adaptation to occur.
 Once adaptation to a given load has taken place, the training Intensity
must be increased for the individual to achieve further improvement.
 Training stimulus thresholds are variable, depending on the individual’s
level of health, level of activity, age, and gender.
 The higher the initial level of fitness, the greater the intensity of exercise
needed to elicit a change.
 70% HRmax is a minimal-level stimulus for eliciting a conditioning
response in healthy young individuals
 Deconditioned individuals respond to a low exercise intensity
 Determining the HRmax and the exercise HR for training programs
provides the basis for the initial intensity of the exercise
 Methods to Determine Maximum Heart Rate and Exercise Heart Rate
(1) Determine Maximum Heart Rate (HR)
From multistage test (for young and healthy)
HR achieved in predetermined sub-maximum test
220 — age (less accurate)
(2) Determine Exercise HR
Percentage of maximum HR (dependent on level of fitness
Karvonen’s formula (HRR)
Exercise HR = HRrest+ 60%–70% (HRmax - HRrest)

 Exercising at a high-intensity for a shorter period of time appears to elicit

a greater improvement in VO2 max than exercising at a moderate
intensity for a longer period of time.
 as exercise approaches the maximum limit, there is an increase in the
relative risk of cardiovascular complications and the risk of
musculoskeletal injury.
 The higher the intensity and the longer the exercise intervals, the faster
the training effect.
 VO2 max is the best measure of exercise intensity.
 Specificity principle
o refers to adaptations in metabolic and physiological systems depending
on the demand imposed

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o There is no overlap when training for strength-power activities and

training for endurance activities.
o Muscle strength without a significant increase in total oxygen
consumption.
o Aerobic or endurance training without training the anaerobic systems
Anaerobic training without training the aerobic systems.
 Aerobic training specific to the type of activity. When training for
swimming events, the individual may not demonstrate an improvement in
VO2 max when running.

3. TIME ( Duration ) – how long you exercise for

 The optimal duration of exercise for cardiovascular conditioning is dependent
on the total work performed, exercise intensity and frequency, and fitness level.
 the greater the intensity of the exercise, the shorter the duration needed for
adaptation, and the lower the intensity of exercise, the longer the duration
needed.
 A 20- to 30-minute session is generally optimal at 70% HRmax.
 When the intensity is below the HR threshold, a 45-minute continuous exercise
period may provide the appropriate overload.
 With high-intensity exercise, 10- to 15-minute exercise periods are adequate;
three 5-minute daily periods are effective in some deconditioned patients.

4. TYPE (Mode) – what kind of exercise you do

 The important factor is that the exercise involves large muscle groups that are
activated in a rhythmic, aerobic nature.
 For specific aerobic activities, such as cycling and running, the overload must
use the muscles required by the activity and stress the cardiorespiratory system.
 If endurance of the upper extremities is needed to perform activities on the job,
the upper extremity muscles must be targeted in the exercise program.
 The muscles trained develop a greater oxidative capacity with an increase in
blood flow to the area.
 Training benefits are optimised when programs are planned to meet the
individual needs and capacities of the participants
 . The skill of the individual, variations among individuals in competitiveness
and aggressiveness, and variation in environmental conditions must be
considered

5. VOLUME

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 The volume or quantity of exercise completed weekly is the product of

frequency, intensity, and time
 The recommended volume of moderate intensity exercise needed for
reaching health and fitness goals and to decrease the risk of cardiovascular
disease for adults is ≥ 500 to 1,000 MET-min per week.

6. PROGRESSION

 How to progress the aerobic exercise prescription is dependent on an

individual’s overall health at the start of the program and what their fitness
and health goals are.
 the time should be increased first, and then the frequency, with the intensity
increased last.

o Reversibility Principle - The beneficial effects of exercise training are

transient and reversible. Detraining occurs rapidly when a person stops
exercising.

 The frequency or duration of physical activity required to maintain a certain

level of aerobic fitness is less than that required to improve it

 The following are the general recommendations:

1. Children age 6 to 17: 60 minutes of moderate to vigorous aerobic

physical activity per day.

2. Adults age 18 to 65: 30 minutes of moderate intensity activity

5days/week or 20 minutes of vigorous intensity activity or a combination
of moderate and vigorous intensity.

3. Older adults age 65 or older (or adults 50 to 65 with chronic

health conditions): 30 minutes of moderate intensity activity
5 days/week or 20 minutes of vigorous intensity activity
3 days/week, or a combination of moderate and vigorous intensity.

The adult criteria are based on MET level. The older adult criteria for
moderate or vigorous intensity are based on a 10- point scale, where 0 is sitting
and 10 is working as hard as you can. Moderate intensity activity would be a 5
to 6 and vigorous activity would be 7 to 8.

Exercise program. ——————————

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There are three components of the exercise program:

(1) a warm-up period;
(2) the aerobic exercise period
(3) a cool-down period

1. WARM UP PERIOD –

Physiologically, a time lag exists between the onset of activity and the bodily
adjustments needed to meet the physical requirements of the body. The purpose
of the warm-up period is to enhance the numerous adjustments that must take
place before physical activity.
 Physiological Responses—-
During this period there is:
1. An increase in muscle temperature. The higher temperature increases
the efficiency of muscular contraction by reducing muscle viscosity
and increasing the rate of nerve conduction.
2. An increased need for oxygen to meet the energy demands for the
muscle.
3. Dilatation of the previously constricted capillaries with increases in
the circulation, augmenting oxygen delivery to the active muscles
4. An increase in venous return.
 Purpose—-
the warm-up also prevents or decreases the susceptibility of the
musculoskeletal system to injury and the occurrence of ischemic ECG
changes and arrhythmias.
 Guidelines—-
The warm-up should be gradual and sufficient to increase muscle and
core temperature without causing fatigue or reducing energy stores.
Characteristics of the period include:
1. A 10-minute period of total body movement exercises
2. Attaining a HR that is within 20 beats/min of the target HR

2.AEROBIC EXERCISE PROGRAM –

 The aerobic exercise period is the training part of the exercise program
 The main consideration when choosing a specific method of training is that
the intensity be great enough to stimulate an increase in stroke volume and
cardiac output and to enhance local circulation and aerobic metabolism in
the appropriate muscle groups.

 The exercise period must be within the person’s tolerance, above the
threshold level for adaptation to occur, and below the level of exercise that
evokes clinical symptoms.

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 In aerobic exercise, sub-maximal, rhythmic, repetitive,dynamic exercise of

large muscle groups is emphasised.
 There are four methods of training that challenge the aerobic system:
continuous, interval (work relief), circuit, and circuit interval.

1. Continuous Training
 A sub-maximum energy requirement, sustained throughout
the training period, is imposed
 Once the steady state is achieved, the muscle obtains energy by
means of aerobic metabolism.
 Stress is placed primarily on the slow-twitch fibers
 The activity can be prolonged for 20 to 60 minutes without
exhausting the oxygen transport system
 Overload can be accomplished by increasing the exercise duration.
 Most effective way to improve endurance in healthy individual .

2. Interval Training
 With this type of training, the work or exercise is followed by
properly prescribed relief or rest interval
 The relief interval is either a rest relief (passive recovery) or a
work relief (active recovery), and its duration ranges from a few
seconds to several minutes.
 Work recovery involves continuing the exercise but at a reduced
level from the work period. During the relief period, a portion of
the muscular stores of ATP and an increase in VO2 max occurs
 The longer the work interval, the more the aerobic system is
stressed.
 A rest interval equal to one and a half times the work interval
allows the succeeding exercise interval to begin before recovery is
complete and stresses the aerobic system.
 A significant amount of high-intensity work can be achieved with
interval or intermittent work if there is appropriate spacing of the
work-relief intervals.
 The total amount of work that can be completed with intermittent
work is greater than the amount of work that can be completed
with continuous training.
 It is either passive recovery or active recovery ( active recovery is
greater than passive recovery) .
 Tends to improve strength and power in healthy individuals

3. Circuit Training
 Circuit training employs a series of exercise activities.

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 At the end of the last activity, the individual starts from the
beginning and again moves through the series. The series of
activities is repeated several times.
 Several exercise modes can be used involving large and small
muscle groups and a mix of static or dynamic effort.
 Use of circuit training can improve strength and endurance by
stressing both the aerobic and anaerobic systems.
4. Circuit-Interval Training
 Combining circuit and interval training is effective be cause of the
interaction of aerobic and anaerobic production of ATP.

3.COOL DOWN PERIOD –

 The cool-down period is similar to the warm-up period in that it should

last 5 to 10 minutes and consist of total-body movements and static
stretching.
 The purpose of the cool-down period is to:
1. Prevent pooling of the blood in the extremities by continuing to use the
muscles to maintain venous return
2. Prevent fainting by increasing the return of blood to the heart and brain as
cardiac output and venous return decreases
3. Enhance the recovery period with the oxidation of metabolic waste and
replacement of the energy store
4. Prevent myocardial ischemia, arrhythmias, or other cardiovascular
complications and prevent fainting

4.GENERAL GUIDELINES FOR AN AEROBIC TRAINING PROGRAM

1. Establish the target heart rate and maximum heart rate.

2. Warm-up gradually for 5 to 10 minutes. Include stretching and repetitive
motions at slow speeds, gradually increasing the effort.
3. Increase the pace of the activity so the target heart rate can be maintained
for 20 to 30 minutes.
4. Cool-down for 5 to 10 minutes with slow, total body repetitive motions
and stretching activities
5. The aerobic activity should be undertaken three to five times per week.
6. To avoid injuries from stress, use appropriate equipment, such as correct
footwear, for proper biomechanical support.
7. To avoid overuse syndromes in structures of the musculoskeletal system,
proper warm-up and stretching of muscles to be used should be
performed.

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8. During recovery following an injury or surgery, choose an exercise that

does not stress the vulnerable tissue. Begin at a safe level for the
individual and progress as the individual meets the desired goals

Principles of Aerobic Exercise.—————————-.

1. Overload principle
2. Specificity principle
3. Reversibility principle

TERMINATION

1. Progressive angina
2. Significant drop in systolic pressure
3. Lightheadedness , confusion , pallor , cyanosis , nausea
4. Abnormal ECG response
5. Excessive rise in bp
6. Subject wishes to stop

Therapeutic uses or benefits. ———————————-

1. In rehabilitation
2. Chronic diseases management
3. Functional Independence
4. Improves circulation
5. Helps reduce the risk of developing heart disease
6. Helps to reduce fat
7. Helps to reduce stress , tension, anxiety , depression
8. Improves sleep
9. Increase endurance
10.Increase energy
11.Reduce the risk of developing diabetes
12.Helps to reach and maintain a healthy weight

COORDINATED EXERCISES
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SYLLABUS- Definition of coordinated movements, incoordinated movements,

. Factors for coordinated movements , technique of coordination
. . exercises.

PYQS-
 detail about exercises to improve coordination of upper extremity.
 Coordinated movements, factors affecting the coordinated
movements. Explain Freckle’s exercise in supine, sitting, standing
and add a note on test for incoordination
 co-ordination? Describe in detail Freckle’s coordination exercise
 neuromuscular coordination Explain its principles and Freckle’s
exercise .
 Explain factors responsible for in-coordination.
 Freckle exercises for upper-limb , lower-limb all parts of body

 Co-ORDINATED movement, which is smooth, accurate and purposeful, is

brought about by the integrated action of many muscles, superimposed upon
a'basis of efficient postural activity.
 The muscles concerned are grouped together as prime movers, antagonists,
synergists and fixators, according to the particular function they are called
upon ,to perform.
 It is the ability to perform smooth, Acura and controlled movements.
 Coordination is the ability to select the right muscle at the right time with
proper intensity achieve proper action.
 Motor coordination is the combination of body movements created with the
kinematic and kinetic parameter result in intended actions.
 This involves the integration of proprioceptive information detailing the
position and movement of the musculoskeletal system with the neural
process in the brain and spinal cord which control, plan, and relay motor
commands.
 The cerebellum plays a critical role in this neural control of movement
*
 Coordinated movements are characterized by:
1. Appropriate speed, distance, direction, rhythm, and muscle tension.
2. Appropriate synergist influences.
3. Easy reversal between opposing muscle groups.
4. Proximal fixation to allow distal motion or maintenance of a posture.
 This concept involves the integration of multiple body systems, such as the
nervous, muscular, and skeletal systems, to produce movements that are
well-organized and controlled.

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 These movements are essential for everyday activities, from walking and
running to more complex tasks like playing sports or dancing.
 Coordinated exercises are physical activities specifically designed to
improve and enhance an individual's coordination, which involves the ability
to control and synchronise multiple muscles or body parts in a smooth,
efficient, and purposeful manner.
 Coordinated exercises can range from simple movements to more complex
activities, depending on the individual’s fitness level and the specific
coordination skills they are trying to improve

Group Action of Muscles. ————————

 The contraction of the prime movers results in the movement of a joint,
while the reciprocal relaxation of the opposing group, the antagonists,
controls their action without impeding it
 Other muscles may work as synergists, either to alter the direction of the
pull of the prime movers, or, where the latter pass across more than one
joint, to stabilise the joint in which movement is not required.
 Efficiency is still further ensured by muscular fixation of the bone, or
bones, from which the prime movers take origin.
 when strong resistance is offered, muscles all over the body are
frequently involved.

Nervous Control. —————————-

1. MOTOR PATHWAY - The action of each muscle group is determined

by the afferent impulses which reach it by the motor pathways
.
2. THE CEREBRAL CORTEX- Voluntary movement is usually initiated in
response to some sensory stimulus. an initiation centre exists in the brain
stem which alerts the cerebral cortex, which then is responsible for
planning the pattern of movement. This plan is based on memories of
patterns used on previous occasions.

3. THE CEREBELLUM- It is the primary center in the brain for

coordination of movements . The cerebellum is a receiving station of
information which reaches it by the afferent pathways conveying
impulses of kinaesthetic sensation from the periphery and from other
parts of the brain including the cerebral cortex and the vestibular nucleus.
In the light of this information the delicate adjustments, which ensure
harmonious inter-action of the various groups of muscles concerned in
the pattern of movement, are made and conveyed to the anterior horn

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cells by either the extra-pyramidal tracts or other descending pathways of

the spinal cord

4. KINAESTHETIC SENSATION- . The afferent impulses of kinaesthetic

sensation arise from proprioceptors situated in muscles, tendons and
joints and they record contraction or stretching of muscle and the
knowledge of movement and position of the limbs.

Key components of coordinated exercises ——————

 Proprioception: The body’s ability to sense its position in space plays a
significant role in coordinated exercises. Many coordinated exercises
incorporate exercises that enhance proprioception by challenging your
awareness of body position during movement.

 Neuromuscular Control: Coordinated exercises enhance neuromuscular

control by improving the brain’s ability to send signals to muscles in a
coordinated and controlled manner.

Rhythm and Timing: Exercises that require timing, rhythm, and sequence
are excellent for improving overall coordination. These exercises often
involve movements that need to be performed in a particular order or at a
specific pace

 Bilateral Coordination: This refers to the ability to use both sides of the
body together in a controlled, synchronised manner.

 Volition: is the ability to initiate, maintain or stop an activity or motion.

 Engram: A postulated physical or a biochemical change in neural tissue that

represents a memory

Changes in coordinated movement with age

1. Decreased strength.
2. Slowed reaction time.
3. Loss of flexibility.
4. Faulty posture.
5. Impaired balance.
Principle of coordinated exercises. ————————
General Principles of Coordination Exercises Involve
1. Constant repetition of a few motor activities

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2. Use of sensory cues (tactile, visual, proprioceptive) to enhance motor

performance
3. Increase of speed of the activity over time
4. Activities are broken down into components that are simple enough to be
performed correctly.
5. Assistance is provided when ever necessary
6. The patient therefore should have a short rest after two or three
repetitions, to
avoid fatigue.
7. High repetition of precise performance must be performed for the engram
to form.
8. When ever a new movement is trained, various inputs are given, like
instruction(auditory), sensory
stimulation(touch) , or positions in which the patient can view the
movement (visual stimulation) to enhance motor performance.

1. Repetition
 Repeat a few motor activities multiple times

2. Sensory cues
 Use visual, tactile, or proprioceptive cues to improve performance

3. Increase speed:
 Gradually increase the speed of the activity over time

4. Break down activities:

 Break activities into simple components that can be performed
correctly

5. Provide assistance:
 Provide assistance when needed

6. Rest :
 Take a short rest after a few repetitions to avoid fatigue

7. Multi-system Engagement
 Coordinated exercises engage multiple systems of the body
musculoskeletal , nervous, and sensory systems to work together
during physical activity. it allows for smooth and efficient
movement.
 For example, exercises like squats or lunges not only activate the
muscles of the legs but also engage the core and balance systems,

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while requiring input from the proprioceptive system to maintain

proper posture and form.

8. Neuromuscular Integration
 The principle of coordinated exercises emphasizes the integration
of the nervous and muscular systems.
 The brain coordinates muscle movements through motor
pathways, ensuring that the correct muscles fire at the appropriate
time, in the right sequence, with the proper force.
 such as jumping, throwing, or dancing.

9. Balance and Proprioception

 Coordinated exercises often involve movements that challenge
balance and proprioception. These types of exercises improve the
body's ability to adjust posture, maintain stability, and prevent
falls or injuries.
 Exercises like balance drills, stability ball work, or yoga poses
emphasise coordination between the body and the sensory
feedback it receives, refining the brain’s ability to control
movement patterns.

10.Timing and Rhythm

 Coordinated exercises require the body to execute movements in a
precise order and timing to achieve optimal results. This can
involve the synchronous contraction and relaxation of opposing
muscles (agonist and antagonist), as well as a continuous flow
between movements.
 sports like tennis or swimming, timing and rhythm are crucial for
effective performance. exercises like burpees or kettlebell swings
require synchronised body movements for efficiency.

11.Agility and Speed

 Agility, or the ability to quickly change direction while
maintaining control, is a key element of coordinated exercise. It
requires precise control over the body's movements and the ability
to shift between various movement patterns rapidly.
 ladder drills or cone drills

12. Cross-Lateral and Bilateral Coordination

 Bilateral Coordination: Involves the simultaneous use of both
sides of the body. For example, cycling, swimming, or performing
exercises like push-ups or squats involve the coordinated work of
both the upper and lower body.

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 Cross-Lateral Coordination: This involves the coordination of the

body’s opposite sides, such as when one arm and the opposite leg
are moving together, like in a crawling motion or running. Cross-
lateral movements improve brain function, enhance motor control,
and refine the body’s ability to move efficiently.

13.Muscle Synergy and Functional Movements

 Coordinated exercises rely on muscle synergy, where different
muscle groups work together to produce smooth and efficient
movement patterns. For example, the gluteal, hamstrings, and
quadriceps work synergistically during a squat to control
movement and maintain balance.
 Functional movements, such as lifting, bending, or twisting, often
involve coordinated use of various muscle groups and joints.
Training with functional exercises helps improve the body's
efficiency in performing everyday tasks and activities.

14.Progression and Adaptation

 Coordinated exercises promote gradual progression by building
the complexity and difficulty of movements over time. As
coordination improves, individuals can increase the intensity,
speed, and complexity of their exercises to challenge their
neuromuscular systems further.
 For example, starting with simple exercises like walking lunges or
step-ups and progressing to more complex movements like jump
lunges or box jumps.

15.Mental Focus and Mind-Body Connection

 Coordinated exercises often require concentration, mental focus,
and a strong mind-body connection. Being aware of the body’s
movements, controlling posture, and ensuring proper alignment is
key to executing the exercises correctly and avoiding injury.

16. Joint Stability and Mobility

 Coordinated exercises help promote both joint stability and
mobility. Exercises that challenge joint stability (like planks or
single-leg stands) can improve overall balance and coordination,
while dynamic stretching and mobility work enhance the range of
motion.

17.Variety of Movement Patterns

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 Coordinated exercises typically incorporate a variety of movement

patterns to engage different muscles and systems in the body. This
variety can include bending, twisting, jumping, reaching, lifting,

Factors affecting coordinated movements ———————

 Nervous system health (particularly the cerebellum)

 muscle strength and flexibility
 joint mobility
 age
 overall health
 sensory input (vision, proprioception)
 environmental conditions
 fatigue
 stress
 any neurological conditions that might affect motor control

essentially, any factor that impacts the complex interplay between the brain,
muscles, and sensory systems involved in movement coordination.

1. Cerebellum function: The cerebellum is the primary brain region

responsible for coordinating movement, so any damage or dysfunction in
this area can significantly affect coordination.

2. Sensory input: Proper sensory feedback from the eyes, muscles, and
joints is crucial for precise movement control.

3. Muscle strength and flexibility: Weak or tight muscles can limit the
range of motion and impair coordination.

4. Joint mobility: Restricted joint movement can hinder the ability to

perform coordinated actions.

5. Age : Coordination tends to decline with age due to natural changes in

the nervous system and muscle function

6. Neurological conditions: Stroke, multiple sclerosis, Parkinson's disease,

and other neurological conditions can significantly impact coordination.

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7. Psychological factors: Stress and anxiety can negatively affect motor

control and coordination.

8. Environmental factors: Slippery surfaces, uneven terrain, and poor

lighting can pose challenges for coordinated movements.

Types of coordinated exercise —————————-

1. Gross Motor Coordination skills :

These exercises involve large muscle groups and complex body
movements.like trunk and extremities
They help improve the ability to use multiple muscles together in
dynamic activities.
Example:walking , running , lifting
 Lunges - This combines lower body strength with upper body
rotation, engaging multiple muscle groups and improving
coordination between the limbs and torso.
 Jumping Jacks: This basic exercise helps with coordination
between the arms and leg they move together in a synchronised
manner
 Running Drills: Drills that involve high knees, butt kicks, or
Carioca (grapevine) movements help with footwork, rhythm, and
leg coordination.

2. Fine Motor Coordination skills :

These exercises target smaller, more precise movements that
require intricate control over smaller muscle groups.
Example:writing , drawing
 Piano Finger Exercises: Playing the piano or other musical
instruments requires intricate hand and finger coordination.

3. Hand- eye skills :

The ability of visual system to coordinate visual information.
Received and then control or direct the hands in the
accomplishment of a task
Example : catching a ball , sewing ,computer mouse use

Benefits of Coordinated Exercises ——————-

o Improved Motor Skills: Enhances both fine and gross motor skills.

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o Better Reaction Time: Trains the brain and body to react more quickly
and efficiently to different stimuli.
o Increased Agility: Many coordinated exercises improve agility, making it
easier to change direction quickly and efficiently.
o Enhanced Cognitive Function: Since coordination often involves
complex tasks that require mental focus, these exercises can also improve
cognitive functions such as memory,
concentration, and decision-making.
o Functional Fitness: Better coordination enhances your ability to perform
day-to-day activities more efficiently and safely.

INCOORDINATION

 Interference with the function of any one of the factors which contribute
to the production of a co-ordinated movement said to be incoordinated
movements . ,
 Lack of coordination is said to be incoordination or asynergia.
 Incoordination is the jerky, inaccurate non-purposeful movement done by
the group of muscles.
 Incoordination (coordination deficit):
"abnormal motor function characterise by awkward, extraneous, uneven,
or inaccurate movements."
 Coordination deficits are often related to, and indicative of, CNS
involvement including cerebellum, basal ganglia, and dorsal columns.
 Examples of diagnoses that typically demonstrate coordination deficits:
Multiple sclerosis , Cerebral palsy, Cerebellar tumours , Parkinsonism
Huntington's disease , Sydenham's chorea:

Causation ———————-

 Inco-ordination associated with weakness or flaccidity of a particular muscle

group.
In this case, either some lesion of the lower motor neurones prevents the
appropriate impulses from reaching the muscles, or the condition of the
muscles modifies their normal reaction to these impulses.(atonic muscle)

 Inco-ordination associated with spasticity of the muscles.

Lesions affecting the motor area of the cerebral cortex, or the upper
motor neurones, result in spasticity of the muscles, therefore, even when

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some appropriate impulses are able to reach them, the condition of the
muscles is such that their response to them is abnormal.
It never occur in one group of muscles , it always part of total flexors or
total extensors .

 Inco-ordination resulting from cerebellar lesions.

This is generally known as cerebellar 'ataxia', the prefix 'a' meaning
'without' and the Greek word 'taxis' meaning 'order'. marked hypotonicity
of the muscles, which tire easily, and inadequate fixator action, not only
of the muscles directly concerned with the group action, but of the body
generally. Movement is irregular and swaying, with a marked intention
tremor.

 Inco-ordination resulting from loss of kinaesthetic sensation.

Sensory ataxia', or in the case of tabes dorsalis, 'tabetic ataxia', leprosy ,
diabetes mellitus Without using his eyes to gain the information, the
patient with this condition is completely unaware of the position of the
body in space, or of the position of the joints.
The muscles are hypotonic and tire easily, but they are unaware of this as
the sensation of fatigue is not recorded.

Cerebellum: —
o Primary functions:
1. Coordination of motor activity.
2. Equilibrium.
3. Muscle tone.

o Lesions produce:
1. Incoordination.
2. Impaired balance.
3. Decreased muscle tone.

o Clinical features of cerebellar dysfunction:

1. Hypotonia and hyporeflexia.
2. Dysmetria: Disturbance in the ability to judge the distance or range of a
movement
o Hypometria = underestimation.
o Hypermetria = overestimation.
3. Dysdiadochokinesia: Impaired ability to perform rapid alternating
movements.
4. Tremor: Involuntary oscillatory movement resulting from alternate
contractions of opposing muscle groups

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5. Movement decomposition: Movement performed in a sequence ur component

parts rather than as a single, smooth activity.
6. Disorders of gait:
o Broad base support.
o Unsteady, irregular, staggering, and deviated gait pattern.
o Slow initiation of forward progression of lower extremity.
o Difficulty in slowing down the forward progression of the lower extremity
once initiated.
7. Ataxia: uncoordinated movement that results from the combined influence
of cerebellar dysfunction (especially dysmetria and decomposition of
movement) on gait, posture, and patterns of movement.
8. . Dysarthria (scanning speech): Disorder of the motor component of speech
articulation."
o Speech pattern is slow, slurred, hesitant, with prolonged syllables and
inappropriate pauses.
o Word selection and grammar remain intact.
9. Nystagmus.
10.Rebound phenomenon: Absence of a check reflex; when resistance to an
isometric contraction is suddenly removed, the body segment moves forcibly
in the direction in which effort was focused.
11.Asthenia: Generalised muscle weakness associated with cerebellar lesions.
12.Difficulty in initiating, stopping, or changing the direction, speed, or force of
voluntary movements.

Basal ganglia: —

• Components:
1. Putamen.
2. Caudate nucleus.
3. Globus pallidus.
4. Substantia nigra.
5. Sub thalamic nucleus.

• Primary functions:
o Initiation and regulation of gross intentional movements.
o Ability to accomplish automatic movements and postural
adjustments.
o Inhibitory effect on motor cortex and posterior fossa brainstem
to maintain normal background muscle tone Cognitive and
perceptual functions.

• Lesions produce:

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1. Slowness of movement.
2. Involuntary movement.
3. Disturbance of muscle tone.
4. Diminished postural reactions.

• Clinical features of basal ganglia dysfunction:

1.Bradykinesia:Abnormally slow movements.
o Decreased arm swing; slow, shuffling gait; difficulty initiating or
changing direction of movement; lack of facial expression; or difficulty
stopping a movement once begun.
2.Rigidity.
3.Dystonia.
4.Resting tremor.
5. Akinesia:Inability to initiate movement; seen in the late stages parkinsonism.
o Associated with fixed postures.
o Tremendous amount of mental concentration and effort is required to
perform even the simplest motor activity.
6. Chorea (choreiform movements): Involuntary, rapid, irregular, jerky
movements; clinical feature of Huntington's disease.
7. Athetosis (athetoid movements): Slow, involuntary, writhing, twisting,
"wormlike" movements; clinical feature of cerebral palsy.
8. Choreoathetosis: Chorea + athetosis.
9. Hemiballismus: Sudden, jerky, forceful, wild, flailing, motions of one side of
the body.
o Results from a lesion of the contralateral sub thalamic nucleus.

Dorsal columns:—

 Primary function: Mediate proprioceptive input from joint and muscle

receptors.

 Lesions produce:
Coordination and balance deficits that are less characteristic than those
produced by other CNS lesions due to compensation from visual
feedback. Thus, these deficits are exaggerated in dark or with closed eyes.

 Clinical features of dorsal columns dysfunction:

1. Dysmetria: visual feedback reduces the manifestations of dysmetria.
2. Slowed movements: because visually guided movements are more accurate
when the speed is reduced.
3. Disorders of gait:
o Wide base.

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o Sway.
o Uneven step length.
o Excessive lateral displacement.
o Watching feet during ambulation.
o Advancing leg may be lifted too high and then dropped abruptly with an
audible impact.

Factors responsible for in-coordinated movements ———-

Several factors can contribute to incoordinated movement, and they generally
affect the central nervous system (CNS) or its communication with muscles.

1. Neurological Factors

 Cerebellar Dysfunction: The cerebellum, located at the back of the

brain, is responsible for coordinating voluntary movements, balance, and
motor control.
o Cerebellar atrophy: Degeneration of cerebellar neurons, often seen
in conditions like spinocerebellar ataxia (SCA) and multiple
system atrophy (MSA).
o Stroke: A stroke affecting the cerebellum can result in sudden
ataxia.
o Tumours or lesions: Growths or lesions in the cerebellum or its
connecting pathways can disrupt coordination.
o Genetic disorders: Inherited conditions such as Frederick’s ataxia
or ataxia-telangiectasia can cause progressive cerebellar
degeneration.
 Basal Ganglia Dysfunction: The basal ganglia are a group of nuclei in
the brain that help regulate movement.
o Parkinson’s disease: Degeneration of dopamine-producing neurons
in the basal ganglia leads to tremors, rigidity, and bradykinesia.
o Huntington’s disease: A genetic disorder that causes the
degeneration of neurons in the basal ganglia, leading to involuntary
movements and coordination issues.
 Peripheral Nervous System Issues: The nerves outside the brain and
spinal cord are responsible for transmitting motor commands from the
brain to muscles.
o Diabetic neuropathy: High blood sugar can cause nerve damage,
affecting coordination and balance.
o Alcoholic neuropathy: Chronic alcohol use can damage peripheral
nerves, leading to coordination problems.
o Vitamin deficiencies: Deficiencies in vitamins such as B12 can lead
to nerve damage and ataxia.

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2. Metabolic and Systemic Factors

 Hypoglycemia (Low Blood Sugar): When blood sugar levels drop

significantly, it can lead to confusion, tremors, and a lack of coordination.
 Electrolyte Imbalances: Imbalances in essential electrolytes like sodium,
potassium, calcium, and magnesium can impair nervous system function
and lead to muscle weakness and incoordination.
 Thyroid Disorders: Both hyperthyroidism and hypothyroidism can
contribute to coordination issues. Hypothyroidism, in particular, can lead
to a slowing of motor functions.
 Liver and Kidney Dysfunction: Diseases affecting liver or kidney function
(e.g., cirrhosis, uremia) which affects the nervous system
 Vitamin Deficiencies: Deficiency in certain vitamins, particularly Vitamin
B12 and Vitamin E, can lead to neurological symptoms, including ataxia.

3. Toxins and Drugs

 Alcohol: Chronic alcohol consumption can damage the cerebellum and

lead to ataxia, sometimes called "alcoholic cerebellar degeneration."
 Medications: Some medications, especially sedatives, anti-seizure drugs,
and certain chemotherapies, can impair coordination as a side effect.
 Heavy Metals: Exposure to heavy metals like lead or mercury can lead to
nerve damage, affecting coordination and motor control.

4. Infections and Inflammatory Conditions

 Multiple Sclerosis (MS): MS is an autoimmune disease that damages the

protective sheath (myelin) covering nerve fibers in the brain and spinal
cord, impairing motor coordination and leading to ataxia.
 Encephalitis: Inflammation of the brain due to infection (e.g., viral
infections) can disrupt motor coordination.
 Guillain-Barré Syndrome: This autoimmune disorder causes rapid-onset
muscle weakness and sometimes ataxia, starting from the legs and
spreading upwards.

5. Structural Abnormalities and Trauma

 Traumatic Brain Injury (TBI): Head injuries, particularly those affecting

the cerebellum or brainstem,
 Spinal Cord Injury:

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6. Psychological Factors

 Psychosomatic Disorders: In some cases, psychological factors can

contribute to a lack of coordination, such as in conversion disorder, where
neurological symptoms like incoordination occur without a clear
physiological cause.

7. Other Genetic and Rare Disorders

 Ataxia-Telangiectasia: A rare genetic disorder that leads to progressive

loss of coordination and other neurological issues.
 Friedreich’s Ataxia: An inherited disease that causes progressive damage
to the nervous system, leading to ataxia.

Some other causes are :-

 head trauma
 alcohol use disorder
 infection
 multiple sclerosis
 stroke
 cerebral palsy
 brain tumours
 paraneoplastic syndromes
 nerve disease or injury (neuropathy)
 spinal injuries
 Huntington’s disease
 multi system atrophy
 anti-seizure medications
 chemotherapy drugs
 lithium
 cocaine and heroin
 sedatives
 mercury, lead, and other heavy metals
 toluene and other types of solvents
 stroke
 multiple sclerosis

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Assessment of coordination
o Assessment must be done bilaterally in unilateral lesion
o Assessment must be done in quiet place to avoid distraction
o Age and psychological state must be considered
Assessment of coordination contain:
 Motor assessment including muscle tone and muscle test
 Sensory assessment including superficial and deep sensation
 ROM
 Orofacial function assessment including facial expression, lip &jaw
closure
 Sensitivity of face
 Coordination of respiration with swallowing and speech
 Coordination assessment including non equilibrium and equilibrium
subtypes
 Non equilibrium coordination tests
 Finger to nose
 Finger to finger
 Finger to doctor's finger
 Adiadokokinesia
 Rebound phenomenon
 Buttoning and unbuttoning
 Heal to knee
 Walking along a straight line

Test of incoordinated :—

Upper Limb
o Finger nose test
o Finger to finger test
o Rapid alternating movement

Lower Limb
o Finger Toe Test
o Heel-Shin Test
o Romberg's Test

Coordination tests —————

• Preliminary considerations:
 Initial observation of functional activities guides the therapist in test
selection.

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 Initial assessment of motor and sensory functions improves validity.

 Apprehension, fear, and fatigue.
 Lack of reliability.
 Safety.

 Classifications of coordination tests:

1. Gross vs. fine motor activities.
2. Non-equilibrium vs. equilibrium tests.

• Coordination tests focus on assessment of movement in four areas:

1. Alternate or reciprocal motion, which tests the ability to reverse
movement between opposing muscle groups.
2. Movement composition, or synergy, which involves movement control
achieved by muscle groups acting together.
3. Movement accuracy, which assessment the ability to gauge or to judge
distance and speed of voluntary movement.
4. Fixation or limb holding, which tests the ability to hold the position of an
individual limb or limb segment.

 Recording test results

o Arbitrary scale.
o Timed tests.
o Videotape recording.

 Coordination Requires integration of:

o Motor system
o Cerebellar system
o Vestibular system
o Sensory system

 Assessed by:
o Rapid alternating movements
o Finger-to-Nose / Heel-to-Knee Test
o Romberg's Test
o Gait

1. Finger-to-Nose Test
o Finger-to-nose with moving target
o Stationary finger-to-nose with eyes closed
o In cerebellar disease, the patient touches the nose with wavy and
oscillatory motion.

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o In posterior column disease, the patient can touch the nose accurately
with eye opening but he cannot with closed eyes.

2. Finger-to-finger Test
o Both shoulders are abducted to bring both the elbow extended , the
patient is asked to bring both the hand towards the midline and
approximate the index finger from opposing hand.
3. . Rapid Alternating Movement
o The patient asked to do rapidly alternate movement e.g. forearm
supination and pronation, hand tapping.
o Diadochokinesia = ability to perform RAM
o Dysdiadochokinesis = slow, irregular, clumsy movements

4. Romberg's Test
o Patient is made to stand straight with the eyes opened.
o Then the patient is instructed to shut the eyes
o Patient may begin to sway and may even fall if he is not supported, it
occurs the patient with posterior column disease.

5. Rebound phenomena
o The patient with his elbow fixed, flex it against resistance.
o When the resistance is suddenly released the patient's forearm flies
upward and may hit his face or shoulder.

6. Finger Toe Test

o The therapist's finger is pointed two feet above the patient's great toe and
instructs him to touch with the great toe.

7. Heel-shin Test
o Patient's is asked to touch the knee with opposite side heel and is sliding
on the shin towards the great toe.
o Same test is asked to the patient to perform without rubbing on the skin.

Standardised instruments for coordination assessment.

1. Jebsen-Taylor Hand Function Test:Measures hand function using seven

functional activities: writing; stacking; card turning; simulated feeding;
picking up small objects; picking up large, lightweight objects; and
picking up large, heavy objects.

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2. Minnesota Rate of Manipulation Test :Assesses hand dexterity in five

operations: placing, turning, displacing, one-hand turning and placing,
and two-hand turning and placing.

3. Purdue Peg board Test:Assesses hand dexterity using a test board, pins,
washers, and collars. Subtests include prehension and assembly using
right, left, and both hands.
4. Crawford Small Parts Dexterity Test: Assesses hand dexterity using a test
board, screwdriver, tweezers, pins, screws, and collars.

Treatment Methods of treatment:

1. PNF technique
2. Rhythmic stabilisation to improve proximal stability
3. Reversal tech. to improve ability to alternate movement from agonist and
antagonist
4. Approximation to improve proximal fixation
5. Tapping and weight bearing increasing stability
6. Using ankle and wrist weight to decree tremor
7. Balance can improved in antigravity position in normal base of support
8. Postural stability is improved by using antigravity position in the
developmental sequence
9. Frenkel's exercises improve co ordination

RE-EDUCATION

 It is therefore of major importance to interest and encourage patients

suffering from inco-ordination to persevere in making effort to overcome it

 The Use of Alternative Nervous Pathways It is rare that all the available
nervous pathways, by which the impulses essential for co-ordinated
movement travel, are blocked, and the purpose of re-education is to
encourage the use of those which remain, or to develop alternative routes.
If, however, the pathway is blocked, an alternative route can be used, but the
going will be difficult at first though it will become progressively easier each
time it is used, provided the same alternative route is used on each occasion.
In this way a new pathway is eventually established.

 The Condition of the Muscles As a preliminary to re-educating the

movement, the condition of the muscles requires attention as they are the
effector organs concerned. They must be prepared to receive the
coordinating impulses so that their reaction to them is as normal as possible,

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by an attempt to relax those which are spastic or tense, and to strengthen

those which are weak.

Principle of re-education

1. Weakness or Flaccidity of a Particular Muscle Group.

Treatment is designed to correct imbalances by emphasis on the activity of
weak or ineffective muscles and to restore the normal integrated action of
muscles in the performance of patterns of functional movement. The latter is
achieved most successfully by slow reversals techniques with normal timing

2. Spasticity of Muscles.
The spasticity of the muscles modifies their reaction to the stimuli they receive
as they cannot, or can only with difficulty, relax and so allow movement to
occur. Treatment is designed to promote relaxation, to stimulate effort, to give
confidence in the ability to move and to train rhythm. Active exercises based
on everyday movements help to make the patient as independent as possible and
give him confidence. Those which involve the use of the more proximal joints
and are large and basic in character are used first. All exercises are performed
rhythmically to aid relaxation and reduce fatigue, assistance being given when
necessary but only after, and as long as, the effort is made to do them
independently.
Rhythmic counting, music, or the rhythm of a bouncing ball are used to regulate
the speed of the movement

3. Cerebellar Ataxia.
Loss of the function of the cerebellum, which is a co-ordinating centre, results
in loss of the co-ordinating impulses which are normally discharged from it.
The muscles become hypotonic and postural fixation is disturbed, consequently
balance is difficult and movements are irregular, swaying and inaccurate.
The aim of treatment is to restore stability of the trunk and proximal joints to
provide a stable background for movement. When muscular weakness is severe,
strengthening methods must be used first but the main emphasis in treatment is
given to holdings (isometric contraction) which are done in any and every part
of the range. Holdings are maintained as long as possible and their strength and
endurance is increased by resistance to increase the demand on the
Neuromuscular Mechanism and help to develop new nervous pathways for the
impulses required.

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4.Loss of the Kinaesthetic Sense.

Lesions causing loss of this information result in hypotonicity of the muscles
and inco-ordinated movement. Substitution of the sense of sight to compensate
for the loss of the kin-aesthetic sense forms the basis of re-education, and by
maintaining relatively normal body movements it may be possible to bring into
use some undamaged but hitherto redundant nervous pathways capable of
conveying the impulses of kinaesthetic sensation.
Exercises based on Frenkel's principles are used to train smooth movement and
precision, with emphasis on the ultimate aim of helping the patient to carry out
the normal activities of everyday life.

FRENKEL’S. EXERCISE

 a series of gradual progressive exercises designed to increase coordination

 This is the specialized exercise regimen for the sensory ataxia patient
 .It was presented by Dr HS Frenkle who was the Medical Superintendent of
the sanatorium, Freihof in Switzerland in the end of the last century. He
made the special study on the Tabes dorsalis patients and derived the
procedure for treating the sensory ataxia.
 These sensory ataxia patients are having chief complaints of loss of
impulses, lack of voluntary control of movements. These two problems are
compensated by the sensory mechanism, which is intact, i.e. vision, hearing,
and touch.
 AIM : Establishing control of movement by use of any part of sensory
mechanism which remain intact as sight & hearing to compensate for the
loss of kinaesthetic sensation
 Each movement will be performed unilaterally fast then slow then
interrupted by hold, bilateral performance simultaneously then alternatively

 RULES OF GIVING FRENKLE’s Ex

1. Commands should be given in an even, monotonous and the exercise
should be done by counting.
2. Patient should be able to do all exercise accurately and smoothly.
3. Exercise involving strong muscles work should not be given
4. Progression is by complexity, not strength.
5. No movement should be taken beyond its normal built because the
hypotonia of the muscle and laxity of ligaments render the patient
vulnerable to dislocation or the onset of Charcot's joints.
6. The patient should practice movements first with his eyes open and then
with close.
7. Rest must be given between the exercise; after so many minutes work, an
equal number of minutes rest should be taken.

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8. It is necessary, when planning the treatment scheme take into

consideration, the patient's general healing and mental attitude, the state
of his muscles and and complications
9. In the paralytic stage, only very simple movements can be given, but
breathing exercise are important.
Principles ————
1. Concentration
2. Precision
3. Speed and range
4. Command
5. Repetition
6. Complication.

1. Concentration
The patient has to be positioned to watch the every movement, which he
performs. Normally, half-lying position is adopted during the treatment session.
The patient must give full attention on the movement, which he performs. This
attention of the movement may create the proprioceptor activities over the joint.
The visual watching the movements are recorded in the brain and it may
improve the kinaesthetic sense. Regular movements of the joint also may induce
the proprioceptor activity.

2. Precision
The movements should be accurate and rhythmical. There should not be any
jerky, arrhythmic, and inaccurate movements. Because the movement which the
patient performs will be recorded in his brain through the visual pathway. The
alternative sensory pathway will set depends on the movements which the
patient performs.

3. Speed and Range

Quick movement needs less control than the slow movements. So, normally
slow movements are recommended to perform by the patient. The speed should
maintain slow and in even tempo throughout the exercise regimen. Larger joints
are concentrated more than the smaller joints; and also big movements are
concentrated than the small movements. Selected attain range should be reached
during each and every movement accurately and slowly. The therapist directs
speed by using the command, using hand, counting number or by using music.
Range will be selected depends on the functional useful range, i.e. normal day-
to-day activity. The range need not to be in fullest range, selected range
movements indicated by marking the spot over the couch or by the therapist
placing the finger in the air.

4. Command

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Audition is another source of the sensory mechanism to compensate the

proprioceptive activities and involuntary movements. Commanding is the very
much necessary source to perform and progress the activity. With the command
we can alter the speed, range of the movement, which the patient perform. All
the instructions are mostly given by the form command in this exercise regimen
.
5. Complexity
Complexity introducing in the exercise regimen improves the coordination as
well as proprioceptive activities. It may increase the concentration power and
memorising capacity of the brain on particular movement pattern. Complexity
made by commanding the patient to touch the specific numbered mark
alternatively.

6. Repetition
The movements are repeated until the accurate movement performed by the
patient. The repetition of the accurate movement improves the kinaesthetic
sense and the coordination. The exercise will be discarded whenever the patient
feels tired. Frequent rest period must be allowed, repeating the movements are
helpful for the cerebrum to record and memorise one particular movement
perfectly.

Technique ————

 Patient is positioned in convenient posture normally half-lying posture by

which the patient can watch the movement performed by him.
 Selected range is decided and the distances between two points are marked
in the couch by the chalk according the agreed count. Normally, 4 counts are
made, if the patient attains the range, the additional count will be added.
 Untreated parts should be covered by the blanket to protect privacy of the
patient.
 Proper demonstration about the exercise program to the patient. The patient
must know the correct picture about the exercise
 INDICATION- cerebellar ataxia, sensory ataxia , stroke, cerebral palsy ,
multiple sclerosis, Wilson’s disease, Parkinson’s , neurological disease

Progression in Exercise Program ———

1. A polished re-education board or non-slippery surface is used for the
exercise programme.
2. Dragging the limb on the board and touching the marked spot with the
voluntary halt.

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3. Dragging the limb on the board and touching the marked spot with the halt
on command.
4. Limb unsupported movements.
5. Unsupported movements touching the marked spot with voluntary halt.
6. Limb unsupported touching the marked spot with the halt on command.
7. Limb supported touching the opposite side body specific points with the heel
or finger by voluntary halt.
8. Limb unsupported touching the opposite side body specific points with the
heel or finger by halt on command.
9. Touching the finger, which is placed in the air by the therapist.
10.Therapist placing finger in the air and moving here and there, the patient
reaches the point.

EXERCISE

1. Lying
Upper limb
• Half-lying—Abduction and adduction of
shoulder.
• Half-lying—Wrist flexion, extension, ulnar
and radial deviation.
• Side lying—Flexion and extension of elbow.
• Side lying—Flexion and extension of
shoulder.

Lower limb
• Half-lying—Abduction and adduction of hip.
• Side lying—Flexion and extension of hip.
• Side lying—Flexion and extension of knee.
• Half-lying—Flexion and extension of hip and
knee.

2. Sitting
Lower limb

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• Sitting—Knee flexion and extension.

• Sitting—Hip abduction and adduction.
• Sitting—Dragging the foot and placing over the marked point or numbered
board half and halt on command
 Sitting—Foot unsupported and placing over the marks.
• Sitting—Unsupported foot and touching the therapist’s finger, which is placed
in air.
• Sitting—Standing and sitting down.
• Sitting—From long sitting toilet training.
• Sitting—Hitching, hiking movements.
• Sitting—Walking on the buttocks.
• Sitting—Beginning stage sit with the upper limit support later without the
upper limb support.

Upper limb
• Sitting—Alternating the movements like supination and pronation, flexion and
extension, closing and opening the fist, touching the finger tips with the thumb.
• Sitting—Reaching the therapist’s finger which is placing in the air.
• Sitting—Pegboard exercises.
• Sitting—Separating the same coloured blocks from the box.
• Sitting—Constructing some objects with help of the blocks.
• Sitting—Transferring the ball from one hand to another hand.
• Sitting—Pushing and punching movements.
• Sitting—Elbow flexing and touching the shoulder with the palm.
• Sitting—Combing, drawing, tying the shoelace and normal household
activities

3.Standing

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• Standing with the support is practiced first.

• Walking training with help of the parallel bars.
• First train the walking with wider base later changed into narrow base.
• Frenkle’s mat is used to improve the walking skill.
1. Walking on the both side footprints by leaving the middle
footprint with the “swing to” gait, i.e. right foot forwards and
left foot up to it.
2. As said above with the “swing through” gait, i.e. right foot forwards
and left foot through and forwards. This type of walking increases the
base.
3. Walking on the middle and one-side footsteps to reduce the base with
the ‘swing to’ gait, same like ‘swing through’ gait. Sideways walking can
also be practiced.
4. Turning can be practiced with pivoting and lifting and placing on the
footmarks.

4.Pivoting
The turning is done towards the weak side. The weak side will be stable in one
point and rotating with the fixed axis and another leg is lifted and kept on the
marked place, e.g. right side. Right foot is rotated or turned 90° and the left foot
is raised and placed parallel to the right foot.

5.Lifting and Turning

This is the progression from the pivoting, e.g. right side. Right side is lifted and
turned 90° and placed on the floor and the left leg also lifted and placed parallel
to it.

EXERCISES TO PROMOTE MOVEMENTS AND RHYTHM

1. All exercises are repeated to rhythmic count.

2. a)Sitting; one Hip flexion & adduction.
3. b)Half lying; one Leg abduction to bring knee to side of plinth, followed by one Knee
bending to put Foot on floor, the movement is then reversed & repeated.
4. c)Sitting; lean forward and take weight on Feet(as if to stand), then sit down again.

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5. d)Standing; Arms swing forwards & backwards(with partner holding two sticks).
6. e)Standing or walking; bounce & catch, or throw & catch a ball.

PROGRESSION OF FRENKLE’s EXERCISE

o Made alteration in speed, range & complete

o Quick movements, less control
o Stow movement, high control
o Simple movements build up to form complex movements e.g walking
o According to disability re-education starts from lying to standing.

BENEFITS OF FRENKEL'S EXERCISE

o Improve co-ordination.
o Improve balance.
o Improve body awareness.
o Improve postural awareness.
o Improve selective movements.
o Improve proprioception.

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PNF
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION

 Proprioceptive, means receiving stimulation within the tissues of the body.

Neuromuscular, means pertaining to the nerves and muscles.
Facilitation, means the effect produced in nerve tissue by the passage of an
impulse.

 defined as " Methods of promoting or hastening the response of the

neuromuscular mechanism through stimulation of the proprioceptors".

 THe techniques of Proprioceptive Neuromuscular Facilitation rely mainly on

stimulation of the proprioceptors for increasing the demand made on the
neuromuscular mechanism to obtain and facilitate its response.

 This method of rehabilitation was developed by Doctor Herman Kabat,

M.D., Pd.D., and Miss Margaret Knott, B.S., at the Kabat-Kaiser Institute
between 1946 and 1951, and the philosophy of treatment and the techniques
used are described in a book entitled 'PROPRIOCEPTIVE
NEUROMUSCULAR FACILITATION. Patterns and Techniques, by
Margaret Knott, B.S., and Dorothy E. Voss, B.Ed.

 These techniques and the method of treatment in which they are used aim to
obtain the maximum quantity of activity which can be achieved at each
voluntary effort and the maximum possible number of repetitions of this
activity to facilitate the response.

 Treatment by these techniques aims to summate the effects of facilitation to

increase the response of the neuromuscular mechanism. Resistance and
stretch are applied manually to muscles working to perform patterns of mass
movement, and dynamic commands give verbal stimulation to the patient's
voluntary effort.

 PNF is a therapeutic technique used primarily in physical therapy to enhance

the strength and flexibility of muscles.

 PNF techniques are commonly used for rehabilitation and improving

mobility, often following injuries or surgeries.The method utilises specific
patterns of movement that are designed to activate muscle groups across
multiple joints.

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Principles. ———————-
1. PATTERN OF FACILITATION
o Mass movement patterns are used as the basis upon which all the techniques
of Proprioceptive Neuromuscular
o Facilitation are superimposed because mass movement is characteristic of all
motor activity.
o The patterns of movement used are spiral and diagonal and they are closely
allied to those of normal functional movement; they may be observed in
everyday use, e.g. in taking the hand to the mouth, and in work or sports
o There are two pathways of movement for each major part of the body, and as
movement can take place in either direction, each pathway provides two
antagonistic patterns.
o Components of movements-
 Each pattern of movement has three components, the pathway is
specific and in the line of action of the main muscle components
responsible for the movement.
 Two components of the movement are angular and the third is
rotatory, the latter being of major importance because it gives
direction to the movement as a whole. .
 Each pattern is named according to movements which take
place at the proximal joint or joints of the part moved, e.g.
Flexion-adduction with lateral rotation of the Leg
 Movement in distal joints follows the direction of that in the
proximal joints but intermediate joints may move in either
direction, e.g. in Flexion-adduction with lateral rotation of the
Leg the Foot dorsieflexes
o Movement in pattern- The pattern of movement starts with the major muscle
components at the limit of their extended range and is completed when they
are as shortened as possible. The range of the rotatory component is only
partial but essential, rotation starts the movement and gives it direction.

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o Effects and uses- these patterns of movement are specific and closely allied
to those of functional movements they can be repeated to facilitate
movements which the patient requires most urgently

2. MANUAL CONTACT

o Pressure of the physiotherapist's manual contact with the patient provides a

means of facilitation and is the only satisfactory way of applying maximal
resistance to movement in patterns of facilitation.
o The Application of Manual Contacts-
 Touch contributes to facilitation by stimulating the
exteroceptors.
 Manual contacts must be (i) purposeful, (is) directional, (iii)
comfort-able
 (1) Purposeful. Pressure must be firm, and applied directly to
the patient's skin whenever possible. Pressure is given with the
palm of the hand to ensure even contact with a wide area of
skin, preferably over muscles and tendons taking part in the
movement.
 (2) Directional. Manual pressure is applied only in the direction
of the movement to resist the action of the muscles taking part
and to give direction to the patient's effort.
 (3) Comfortable. Manual contacts which are uncomfortable or
which produce painful stimuli must be avoided as they inhibit
contraction and may lead to the initiation of unwanted
movements.
o for contact lumbrical muscles is better to grip .

3. THE STRETCH STIMULUS AND STRETCH REFLEX

o Proprioceptors situated in the muscles (muscle spindles) are stimulated

by stretching, which increases the intramuscular tension.
o The Application of the Stretch Stimulus- The muscles to be worked are put
on full stretch, all components of the pattern being considered, so that
tension is felt in all muscle groups.
o The Application of the Stretch Reflex- A sharp but controlled stretch of the
muscles at the limit of their extended range is given and synchronised with a
dynamic command for the patient's maximum voluntary effort to perform the
movement.Use of this technique in patterns of facilitation makes it possible
to stretch the muscles effectively in all their , components of action

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o Effects and Uses Stretch is a valuable means of initiating contraction and,

when applied to weak muscles, increases their response and so accelerates
the strengthening process.

Stretching – Isotonic ex.

Strengthening- Isometric ex.

4. TRACTION AND APPROXIMATION

o Traction
 Manual contacts make it possible to maintain traction
throughout the range of movement It is most effective when
used in flexion movements probably because any weight lifted
would normally exert traction in proportion to its weight.
 The elongation or stretching of a limb or trunk by the therapist
performed throughout the movement, except when reaching the
end of the pattern

o Approximation
 Compression of joint surfaces against each other simulates the
normal circumstances which arise during weight-bearing or
pushing, it is therefore more effective for facilitating extension
movements
 It promotes stabilisation, facilitates weight bearing and
facilitates upright reactions.

5. COMMANDS TO PATIENTS

o The physiotherapist's voice is used as a verbal stimulus to demand the

patient's maximum voluntary effort.
o Brief, simple, accurate and well-timed instructions suitable for his age,
character and ability to co-operate demand the patient's attention and effort
at the right time and indicate the type of reaction required from him, even if
he does not understand the language
o Accuracy in commanding is essential:

HOLD. For isometric contraction

PULL or PUSH. Isotonic contraction

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RELAX relaxation

o The physiotherapist must make sure that her commands are carried out to the
maximum of the patient's ability.
6. TIMING

o Timing is defined as the sequence of muscle contraction occurring in motor

activity, and the production of co-ordinated movement presupposes the
ability to, achieve normal timing.
o In functional movements timing usually proceeds from distal to proximal
o Proximal control develops first, then, during the process of learning co-
ordination and purposeful movement, distal control is established.
o As movement is completed in each joint the muscles which have produced it
(by their isotonic contraction) continue to contract isometrically until the
movement as a whole is completed.
o Normal timing may be defeated by the application of too much resistance to
a particular component of the movement with the result that its efficiency is
decreased.

7. MAXIMAL RESISTANCE

o Maximal resistance is defined as the greatest amount or degree of resistance

which can be given to muscular contraction.
o Maximal resistance to an isometric contraction is the greatest amount of
resistance which can be applied without breaking the hold.
o Maximal resistance to an isotonic contraction is the greatest amount of
resistance against which the patient can perform a smooth co-ordinated
movement through full range.
o The Application of Maximal Resistance-
 In facilitation techniques maximal resistance is applied
manually to movements and holdings in patterns of
facilitation.
 All three components of the movement are resisted
maximally at every stage of the movement.
o Effects and Uses-
 Stimulation of the muscle spindles and a maximal increase
in intramuscular tension leads to a spread of excitation to
adjacent muscle groups by means of irradiation.
 The demands of the resistance determines the extent of this
spread of excitation and the pattern of movement the
particular muscles affected by it.

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 Maximal resistance is used in all techniques of

Proprioceptive Neuromuscular Facilitation to increase
excitation, to strengthen muscles, to build up endurance, to
demand relaxation and to improve co-ordination, increase
motor control , increases ability of muscle to contract , help
the patient gain an awareness of motion and its direction.
8. REINFORCEMENT ( making something stronger)

o Innumerable combinations of movements are required and utilised in

everyday life and when great effort is required movement of one part of the
body is associated and reinforced by those of other parts.
o Muscle components of a pattern of movement re-enforce each other
automatically according to the demands of the resistance and when this is
maximal re-enforcement extends beyond the muscle components of the
pattern to other segments of the body
o The proprioceptive stimulation which results from tension in strongly
contracting muscles leads to a spread or overflow of excitation in the C.N.S.
by the process of irradiation, the purpose of which is to recruit the cope-
ration of allied muscles which, by contracting as synergists, increase the
efficiency of the movement.
o The Use of Reinforcement-
 The maximal contraction of strong muscles is used to reinforce
the action of weaker allied muscles
 . Re-enforcement always takes place from strength, therefore
strong muscle components of a pattern are used to reinforce
weaker components of the same pattern and strong patterns
reinforce weaker patterns provided they are related.
 enforcement is used with timing for emphasis as a means of
obtaining or emphasising the contraction of ineffective or weak
muscles to correct imbalances.

9. BODY POSITION AND MECHANICS

o The therapist body should be in line of motion.

o Shoulder and pelvic face direction of motion.
o The resistance comes from the therapist’s body , While the hands and arms
stay comparatively relaxed .

10. VISION

o The feedback from the visual sensory system can promote a more powerful
contraction.

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o It helps the patient to correct position and motion.

o It provides another avenue of communication and helps to ensure co
operative interaction.

Pattern ———————-
o The patterns of movement associated with PNF are composed of multi-joint,
multi-planar, diagonal and rotational movements of extremities, trunk and
neck.
o There are two pairs of diagonal patterns for upper and lower extremities.
1. Diagonal 1
2. Diagonal 2

o Basic Principles of PNF Patterns:

1. Diagonal and spiral movements
2. Involvement of Multiple muscle group
3. Resistance and facilitation
4. Rotational component

o The four main PNF patterns :

1.UPPER LIMB PATTERN

These patterns describe movements of the shoulder, elbow, wrist, and hand,
and are typically named as D1 and D2 for both flexion and extension
directions.

D1 Pattern (Flexion and Extension):


o D1 Flexion (Flexion, Adduction, External Rotation)

o The pattern begins with the arm in a position where the shoulder is
in extension, abduction, and internal rotation (for example, arm
positioned behind the body).
o The movement follows a diagonal upward motion, combining
flexion, adduction, and external rotation of the shoulder.
o The hand starts in a closed fist or neutral position and moves into a
grasping position (flexion of the wrist).
o Example: The motion resembles the action of a person reaching for
a seatbelt across their body and then pulling it.

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 D1 Extension (Extension, Abduction, Internal Rotation)

o Starting from the D1 flexion position, the movement moves

downward and outward in the opposite direction: shoulder
extension, abduction, and internal rotation.
o The hand and wrist also follow the movement from a flexed
position to neutral, followed by wrist extension.

 D2 Pattern (Flexion and Extension):

 D2 Flexion (Flexion, Abduction, External Rotation)

o The pattern starts with the arm in a position of extension,

adduction, and internal rotation (like the arm behind the body).
o The movement involves bringing the arm across the body in a
diagonal fashion, moving into flexion, abduction, and external
rotation at the shoulder.
o The wrist and hand also follow this motion, where the wrist moves
into extension, and the fingers are in an open position.
o Example: The motion resembles pulling a sword out of a sheath, or
reaching up and out as if to grab an object from an overhead shelf.

 D2 Extension (Extension, Adduction, Internal Rotation)

o This pattern starts from the D2 flexion position and reverses the
motion: extension, adduction, and internal rotation at the shoulder.
o The wrist and hand return from a position of extension to a more
neutral position.

2.LOWER LIMB PATTERN :

 D1 Pattern (Flexion and Extension):

 D1 Flexion (Flexion, Adduction, External Rotation)

o Starting with the leg extended and slightly abducted in a neutral

position, the movement follows a diagonal motion, bringing the hip
into flexion, adduction, and external rotation.
o The foot moves from plantar flexion to dorsiflexion, and the toes
follow the diagonal movement.
o Example: This movement is similar to stepping forward and across
the body to take a step in a forward and outward direction.

 D1 Extension (Extension, Abduction, Internal Rotation)

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o Starting from the D1 flexion position, the leg moves downward and
outward into extension, abduction, and internal rotation at the hip.
o The foot moves back from dorsiflexion into plantar flexion.
o Example: This resembles stepping backward and outward to return
to a neutral stance.

D2 Pattern (Flexion and Extension):


 D2 Flexion (Flexion, Abduction, Internal Rotation)

o From a position of hip extension, adduction, and internal rotation,

the leg is moved into a diagonal motion that results in hip flexion,
abduction, and internal rotation.
o The foot moves from plantar flexion to dorsiflexion, and the toes
follow the motion in a similar diagonal direction.
o Example: This resembles stepping forward and out to the side in a
high-knee, outward direction.

 D2 Extension (Extension, Adduction, External Rotation)

o Starting from the D2 flexion position, the movement involves

extending the leg back into a position of adduction and external
rotation at the hip.
o The foot moves from dorsiflexion back into plantar flexion.
o Example: This is similar to a returning motion when stepping back
in a reverse outward direction.

Summary of Upper and Lower Limb PNF Patterns:

 Upper Limb D1 patterns: Flexion is characterized by a diagonal, upward

and inward movement; extension is downward and outward.
 Upper Limb D2 patterns: Flexion moves upward and outward; extension
moves downward and inward.
 Lower Limb D1 patterns: Flexion involves stepping forward and inward
across the body; extension is a return step outward and backward.

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 Lower Limb D2 patterns: Flexion involves stepping forward and

outward; extension is a return to a neutral stance with a slight outward
step.

TECHNIQUES OF PNF ———————-

Techniques of emphasis use the means of facilitation to correct muscle

imbalances and restore the patient's ability to perform effective co-ordinated
movement.

1. REPEATED CONTRACTIONS

 Repetition of activity against resistance is essential for the development of

muscle strength and endurance.
 The contraction of specific weak muscles or weaker components of a pattern
is repeated in this technique while they are being reinforced by maximal
isotonic or isometric contraction of stronger allied muscles.

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 Patient move isotonically against maximum resistance repeatedly until

fatigue is evidence , When fatigue is evident then a stretch at that point in the
range should facilitate the weaker muscles and results in coordinated
movement.

 Application of Repeated Contractions

a. Normal Timing-isotonic muscle work: A maximal isotonic
contraction is obtained in the desired pattern and when the patient
can go no further the stretch reflex is repeated in order to facilitate
contraction of the weaker muscle groups.
 This enables the patient to move through range.
 Two or three repetitions of the stretch reflex may be used:

PULL UP!-NOW (stretch) PULL UP!-NOW (stretch) PULL

UP!

b. Normal Timing-isotonic and isometric muscle work: A maximal

isotonic contraction is obtained in the desired pattern and the
muscles are then held in an isometric contraction
 This contraction is held against maximal resistance to obtain a
build-up of excitation (by a gradual increase in resistance
without breaking the hold).
 Then, without relaxing, the resistance is reduced slightly, the
patient is instructed to move and the stretch reflex is repeatedly
applied to facilitate movement throughout the remainder of the
range
 The stretch reflex must be short and sharp, and contraction of
the reinforcing muscles must be maintained throughout.

PULL UP!-HOLD! ... PULL UP!-NOW (stretch) PULL UP!- NOW (stretch)
PULL UP

c. Timing for Emphasis isotonic and isometric muscle work: the

performance of movement is adjusted to provide the means of
reinforcing the action of weaker components of a pattern or of a
weaker pattern.
 The maximal contraction of strong muscle groups for use in
reinforcement is obtained first, then movement is pivoted to the
joint or joints over which the weaker muscles in question are
effective.

 Effects and Uses

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o Repeated contractions build up strength and endurance of weaker

components of a pattern
o Co-ordinate weaker muscle’s activity with those of stronger
components of the same pattern.
o They are used to correct imbalances of muscle strength
o To demand relaxation of antagonistic muscles
o To gain range of movement in the treatment of stiff joints.

2. SLOW REVERSALS

 Immediately after the flexor reflex is elicited the excitability of the extensor
reflex is increased.
 This principle is applicable to voluntary movement and to the interaction of
antagonistic groups in the performance of movement.
 The contraction of strong agonistic muscles or patterns is used as a source of
proprioceptive stimulation for weaker antagonistic muscles or patterns.
 Involves isotonic contraction of the agonist followed immediately by an
isotonic contract of the antagonist.
 Application of Slow Reversals
o Movement in a strong agonistic pattern against maximal resistance is
followed immediately and without relaxation by a reversal of the
movement into the antagonistic pattern, with maximal resistance.
o A sequence of slow reversals follows; movement always beginning in
the stronger pattern and ending in the weaker.

 Effects and Uses

o The contraction of muscles of the weaker antagonistic pattern is
facilitated by that of the stronger muscles of the agonistic pattern
working against maximal resistance.
o The technique is used to strengthen and build up endurance of weaker
muscles or of two antagonistic patterns
o develop coordination
o establish the normal reversal of antagonistic muscles in the
performance of movement.
o For development of active ROM

3. RHYTHMIC STABILISATION

 Isometric contraction of antagonistic muscles is used in this technique to

stabilise joints. Stability is maintained against resistance by a co-contraction
of antagonistic muscles.
 Application of Rhythmic Stabilisation

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o The patient is instructed to 'HOLD!' while the physiotherapist applies

maximal resistance alternating rhythmically from one direction to the
other. The rotatory component of the pattern is particularly important
for "locking in' the joint, and is therefore given special attention and
the direction of the resistance must be changed smoothly to hold in the
simultaneous contraction (or co-contraction) of all the muscles.
o The patient is commanded to-'HOLD' (against resistance in any
direction) for if his effort is directional an isometric reversal of
antagonists takes place and not a co-contraction.

 Effects and Uses

o Maintenance of a co-contraction of antagonistic muscles against
maximal resistance builds up excitation
o strength increased
o Circulation is improved Rhythmic Stabilisation is followed by an
attempt to increase the free range.
o All parts of the range are used successively when postural inco-
ordination is present and the technique is repeated at each point to
improve stability.

4. HOLD-RELAX

 This is a relaxation technique designed to obtain a lengthening reaction of

muscles whose action is antagonistic to the movement limited in range.
 It is effective, simple and pain-free.
 Application of Hold-Relax-
a.Isometric contraction of the hypertonic muscles: either passively or
actively.
 When movement is active it is resisted maximally with normal timing
it continues to the point at which it is limited either by tension or pain.
 Having made sure that the position is pain- free, the physiotherapist
changes the position of her hands and commands the patient to
'HOLD!' while she applies maximal resistance to the hypertonic
muscles.
 This isometric contraction is held to obtain a build-up of excitation
and then followed by the patient's voluntary relaxation of all the
muscles, 'Let go' or 'Relax'.
 Time is allowed for relaxation to take place, then an attempt is made
to move in the direction of limitation to gain an increase in range.
 Special attention is given to the rotatory component of both the
holding and the movement.

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 The technique is repeated as often as required and is usually followed

by Repeated Contractions to consolidate any increase in range.

b. Isometric contraction of the reciprocal muscles: The technique is

applied in a similar way to but the muscles working antagonistically to
the hypertonic group are made to contract isometrically, in order to gain
reciprocal relaxation of the hypertonic group.

 Effects and Use-

o Immediately following the isometric contraction of the hypertonic
muscles the activity of their antagonists is facilitated (successive
induction).
o When the antagonists are facilitated, the lengthening. reaction of the
hypertonic muscles is increased (reciprocal innervation).
o Hold-relax is used as a means of increasing the range of movement in
joints or of obtaining pain-free movement when pain is a limiting
factor.

5. RHYTHMIC INITIATION
 This is a relaxation technique for specific application to the rigidity of
Parkinson's Disease.

 Application of Rhythmic Initiation-

o The limb is taken passively and rhythmically through the range of a
pattern and when some relaxation has occurred the patient is
instructed to assist in the movement.
o Several repetitions of active-assisted movement are carried out and
progression is made to resisted movement. Finally the therapist's
hands are removed and the patient is encouraged to maintain a free
active movement.
o The rhythm must not be lost during the changes from passive to
active-assisted to resisted and finally free active movement.

 Effects and Use

o The rhythmical movement of this technique produces relaxation and
thus helps the Parkinson patients to improve their ability to initiate
movement.

6. SLOW- REVERSAL HOLD

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 Slow reversal hold is similar to slow reversal but includes an isometric hold
at the end of each movement.
 Involves isotonic contraction if the agonist followed immediately by
isometric contraction, with a hold command given at the end of each active
movement.
 It is used in developing strength at a specific point in the range of motion

7. CONTRACT RELAX

 Moves the body part passively into the agonist pattern

 Patient is instructed to push by contracting the antagonist isotonically against
the resistance.

 Effects
o Improves range of motion
o Strengthens muscles
o Improves flexibility
o Helps regain range of motion after injury and surgery

Uses of PNF —————-

 PNF treatment has been used to increase strength, flexibility,

coordination and functional mobility.
 The main goal of treatment is to facilitate the patient in achieving a
movement or posture.
 Stretches as well as diagonals and rational exercise patterns are used to
improve ADL's functional mobility and athletic performance
 It is mainly used in orthopaedic rehabilitation for musculoskeletal injuries
neurological rehab.
 PNF can be used for any condition, however the patient condition level
may require modifications
 PNF is used to supplement daily stretching and is employed to make
quick gains in range of motion to help athletes improve performance.
 Good range of motion makes better biomechanics, reduces fatigue and
helps prevent overuse injuries.
 PNF techniques are most frequently applied during rehabilitation of the
knee, shoulder, and hip, ankle rehabilitation has increased.
 The most frequently used techniques were contract-relax and hold-relax
 The use of PNF techniques in the muscle reeducation phase of
rehabilitation
 Facilitating motion initiation

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oRhythmic initiation
o Repeated stretch from the beginning of the range.
 Learning a motion
o Rhythmic initiation
o Combination of isotonic
o Repeated contractions
o Replication
 Increasing strength
o Combination of isotonic
o Reversals
o Rhythmic stabilisation
o Repeated contractions
 Increasing stability
o Combination of isotonic
o Reversals
o Rhythmic stabilisation
 Increase endurance
o Reversals
o Rhythmic stabilisation
o Repeated contractions
 Increase coordination and control
o Combination of isotonic
o Rhythmic initiation
o Reversals
o Rhythmic stabilisation
o Repeated contractions
o Replication
 Increase ROM
o Reversals
o Rhythmic stabilisation
o Repeated contractions
o Contract-relax
o Hold-relax
 Relaxation
o Rhythmic initiation
o Rhythmic stabilisation
o Hold-relax
 Decrease pain
o Rhythmic stabilisation
o Reversals
o Hold-relax

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RE-education in PNF ————————-

 Functional re-education using (PNF) focuses on restoring or improving
the patient's ability to perform functional movements and tasks
 The primary goal is to retrain the body's neuromuscular system to restore
the coordination, strength, and flexibility
 PNF techniques are designed to incorporate functional, multi-joint
movement patterns, mimicking the natural movements required for daily
activities, sport, and work.

1. Understanding Functional Re-Education in PNF

o Functional re-education in PNF involves training the body to perform
specific tasks or movements with efficiency, coordination, and strength.
o In functional re-education, the following principles are emphasised:
a. Multi-Joint Patterns: Functional tasks require movements the involve
several joints PNF patterns are designed to mimic these multi-joint
movements.
b. Neuromuscular Facilitation: PNF helps facilitate neural pathways and
motor control, enhancing the brain's ability to send efficient signals to
muscles, thus improving muscle coordination and function.
c. Postural Control and Stability: Many functional tasks require a high level
of postural control and stability. PNF techniques focus on engaging
stabilising muscles to improve balance and sterility during movement.

2.PNF pattern in functional reeducation – describe pattern

3.Specific techniques in functional re-education using PNF –

slow reversal,
slow reversal hold
rhythmic stabilisation

4.Incorporating functional

The goal of PNF in functional re-education is not just to improve muscle

strength but to allow the patient to execute functional movements with proper
coordination, timing, and stability. These movements are essential for everyday
activities, such as:
Reaching and Grasping: Upper body PNF patterns, like D1 and D2
flexion/extension, simulate reaching across the body, lifting objects from the
ground, or putting something overhead.

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• Walking and Running: Lower body PNF patterns address walking mechanics
by improving flexibility, coordination, and strength in the hip, knee, and ankle
joints.
• Lifting: Functional lifting involves patterns of flexion and extension,
incorporating trunk rotation and postural control. PNF techniques can facilitate
proper lifting mechanics to reduce the risk of injury.
• Squatting and Bending: PNF patterns can help a person perform deep squats,
bend forward from the waist, or pick up objects from the ground.
• Rehabilitation for Specific Functional Tasks: After surgery or injury, PNF can
be tailored to assist with functional re-education for activities like climbing
stairs, getting in and out of chairs, or performing activities of daily

GAIT
 It is the forward propulsion of the body by the lower extremity with the
coordinated rotated movements of the body segment
 The lower extremity support and carries the head, trunk and arm
 Rhythmic, cyclic movement of the limbs relation to the trunk resulting in
forward propulsion of the body.
 Gait is the style, manner, or a pattern of walking.
 The head, neck, upper limb and trunk contributes of 75 percent of body
weight, among this head and upper limb contributes 25 percent of the total
body weight, neck and trunk contributes 50 percent of the body weight, and
lower extremity contributes 25 percent of the body weight.
 Gait requires more coordination, balance, kinaesthetic sense, proper muscle
strength.
 The walking pattern or style may differ from individual to individual.
 It depends on the age, sex, mood, of an individual and may be due to some
diseases.

 Normal gait require:

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o It is characterised by symmetry, regularity and smoothness.

o Main characteristics of a normal gait cycle is
 a heel- to- toe progression
 foot clearance during swing phase , with no dragging of
foot
 Smooth transition between phases , with a natural flow
 Symmetric step length and cadence
 A natural arm swing accompanies the opposite leg’s
motion to maintain balance and forward propulsion
o Normal functioning of musculoskeletal system of lower limbs &
spine.
o Good sensory feedback from proprioceptive sensation from feet and
the joints
o Visual ,labyrinthine, sensory inputs & co ordination add smoothness,
rhythm & elegance to the human gait.
o Equilibrium
o Locomotion- the ability to initiate and maintain rhythmic stepping.

 Base of support:
o Distance between a person's feet while standing or during ambulation.
o Provides balance & stability to maintain erect posture.
o Normally 2-4 inches from heel to heel.

Gait cycle ————————-

 It is the activity, which occurs between the points of the initial contact of the
same extremity two times.
 When the one lower extremity begins its stance phase, another extremity
ends in the stance phase
 Normal gait is a series of rhythmic, alternating movements of the trunk and
limbs resulting in the forward progression of the center of gravity
 A person’s gait can provide valuable insights into their overall health and
can be used to diagnose or monitor certain conditions.

 Gait cycle consists of two phases.

1. Stance phase: The activity, which occurs during the foot having the
contact with the ground. the stance phase contributes 60 percent of the
gait cycle ( weight acceptance, pull up , forward continuance)

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2. Swing phase: The activity, which occurs during the foot when is not
having the contact with the ground. the swing phase 40 percent.( foot
clearance , foot placement )

 Activities occur in stance phase :

o Heel strike- (first phase)

1. Beginning of stance phase when the heel contacts the
ground.
2. Begins with initial contact & ends with foot flat
3. Muscle work
 HIP-The gluteus maxim-us stabilize the pelvis and
prevent excessive forward tilting. The hip flexors
(iliopsoas) are also slightly active to prepare for the
subsequent stance phase.
 KNEE- The quadriceps vastus lateralis are active to
prevent knee collapse and help stabilize the knee at the
moment of contact.
 ANKLE- The tibialis anterior is actively dorsiflexing the
ankle to prevent the foot from dropping and to place the
heel on the ground.
 FOOT- The intrinsic foot muscles help with balance and
shock absorption.

o Foot Flat-
1. It occurs immediately following heel strike
2. It is the point at which the foot fully contacts the floor.
3. Muscle work
 HIP- gluteus maxim-us and hamstrings stabilise the
hip and control movement and prevent tiling.
 KNEE- quadriceps are engaged to control knee
flexion as the body’s weight shifts to stance leg.
Hamstrings also assist in stabilising knee
 ANKLE- Tibialis anterior stabilises ankle, while
gastrocnemius and soleus are also engaged to prevent
excess movement
 FOOT- muscle of arches of foot act as shock absorber

o Mid Stance-
1. It is the point at which the body passes directly over the
supporting extremity.

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2. Muscle work
 HIP- gluteus medius stabilises the hip and prevent
drop on opposite limb and illiopsoas prevent hip
flexion
 KNEE- quadriceps maintain knee stability
 ANKLE- gastrocnemius and soleus work
eccentrically to control the-forward motion of tibia ,
providing stability to ankle joint
 FOOT- intrinsic muscles maintain arch and stability

o Heel off-
1. The point following mid-stance the heel of the reference
extremity leaves the ground.
2. Muscle work
 HIP- gluteus maximus is actively involved in
extending the hip , helping propel body forward
 KNEE- no activity as knee is extended and moving in
pre-swing
 ANKLE- gastrocnemius and soleus are highly active
and generate plantar flexion to propel the body
forward and assist in toes off
 FOOT- intrinsic muscles provide support to the arch
and assist with the toes off.

o Toes off-
1. the stage at which the toe of the reference lower extremity
leaves the ground
2. Muscle work
 HIP- hip flexors, particularly illiopsoas , are highly
active to flex and prepare for swing phase
 KNEE- Hamstring are active to help flex and prepare
for the leg to swing forward
 ANKLE- gastrocnemius and soleus are active to assist
in push off . The Tibialis anterior begins to prepare for
dorsiflexion
 FOOT- intrinsic muscles are highly active to stabilise
the foot as it prepares to leaves the ground.

 Activities occur in swing phase

o Acceleration-

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1. It begins once the toe leaves the ground & continues until
mid-swing, or the point at which the swinging extremity is
directly under the body.
2. Muscle work
 HIP- hip flexors, ( rectus femoris , illiopsoas )
continue to work to flex the hip and initiate forward
motion of leg
 KNEE- Hamstring are active to help in flexion to
clear the foot from ground
 ANKLE- Tibialis anterior is highly active to dorsiflex
the ankle and ensure that foot clear during the swing
 FOOT- intrinsic muscles help stabilise the foot for
upcoming landing.

o Mid swing -
1. It occurs approximately when the reference extremity passes
directly under the body
2. It extends from end of acceleration to the beginning of
deceleration
3. Muscle work
 HIP- hip flexors continue to work to flex the hip and
propel the leg forward
 KNEE- Hamstring are active to help in flexion to
maintain during swing
 ANKLE- Tibialis anterior is highly active to dorsiflex
the ankle and ensure that foot clear during the swing
 FOOT- intrinsic muscles help stabilise the foot as it
moves forward

o Deceleration-
1. It occurs after mid-swing when the reference extremity is
decelerating in preparation for heel strike.
2. Muscle work
 HIP- Gluteus maximus is active at the end of swing to
decelerate the leg and initiate contact. The hip flexor
are still active to maintain the leg’s forward motion.
 KNEE- Quadriceps engage at end of the swing to
extend the knee and prepare for initial contact.
Hamstring act to decelerate the leg and control knee
extension
 ANKLE- Tibialis anterior is active to dorsiflex the
ankle and prepare for heel strike

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 FOOT- intrinsic muscles help stabilise the foot for

upcoming heel strike

 Double limb support - This is the period at which both the lower extremities
having contact with the ground. The double limb support is possible between
heel-off or toe-off of the one extremity and the heel strike or foot flat of
another extremity. In fast walking or running the double support time
reduces and in the slow walking, double support time increases.
 Single limb support- It is the period at which single limb contacts the
ground. The single limb support has seen during the reference extremities in
the mid-stance phase.

 TERMS
1. Step Length- This is the distance between the heel strike of one lower
extremity to the heel strike of another extremity.
2. Stride length- This is the distance between the heel strike of one lower
extremity to the heel strike of the same lower extremity once again to
the ground.
3. Step duration - It is the time taken for completion of one step.

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4. Stride duration - It is the time taken for completion of heel strike of

one extremity to the heel strike of the same extremity again. The stride
duration and the gait cycle duration are same.
5. Cadence –
o It is the number of steps taken per minute
o Cadence = no. of steps / minute
o Larger the step length results in reduction in cadence,
and the shorter the step length vice versa.
o In females the cadence is more due to their shorter
step length . In normal walking the cadence in female
is 116 and in male is 110.
o The cadence may depends on the speed of walking. In
normal walking the cadence is between 80-120.

 Degree of toe out or foot angle- It represents the angle of foot placement.
The lines intersecting the center of heel and the second toe is called as foot
angle. In normal walking the foot angle is 7° it may decrease in fast walking.

Determination of gait ———————

 There is the coordinated movement of the trunk, upper limb, head to render
the good gait pattern.
 The components are:
1. Lateral pelvic tilt.
2. Knee flexion.
3. Knee, ankle , foot interaction
4. Pelvic forward and backward rotation
5. Physiological valgus of knee
 These determinants are much more helpful to keep the COG in the minimal
level to produce the efficient gait.
 In normal walking pattern vertical displacement of the COG produces the
sinusoidal curve. This is drawn by marking the COG level in each phase and
the line connecting all the points gives a wavy curve called as sinusoidal
curve. Disturbance in this curve results due to some diseased pathology.

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1. Lateral Pelvic Tilt

During the mid-stance period the COG reaches the peak level and the total body
is supported by one lower extremity. To reduce the COG level, opposite side,
i.e. swing phase pelvis tilts laterally. So that the COG comes little down,
meanwhile the stance phase hip abductors helps to prevent the swing phase side
pelvis drop.
Result: Lateral pelvic tilt helps to reduce the COG level during the mid-stance
period.

2. Knee Flexion
helps to reduce the COG level during the mid-stance period. If the swinging
lower extremity knee remains in extended position, the COG still more
increases in the mid-stance phase.
Result: Knee flexion helps to reduce the COG level during the mid-stance
period.
3. Knee, Ankle-foot Interaction
prevent the abrupt hike of the upward displacement of the COG when the foot
passes from the heel strike to foot flat. Normally, after the heel strike huge
upward displacement of COG occurs. To reduce that, there is some interaction
between the knee, ankle, foot takes place (Knee flexion, ankle plantar flexion,
foot pronation) and also the same interaction takes place during the mid-stance
to heel off. After the mid-stance there is sudden dropping of COG. To maintain
the sudden drop of COG there is some changes happening in the knee, ankle
and foot (ankle plantar flexion, knee extension, foot supination)

4. Forward and Backward Rotation of Pelvis

It occurs in the transverse plane. The forward rotation starts during the
acceleration and ends in decele-ration. During the mid-swing the pelvis comes
to the neutral position, meanwhile opposite pelvis goes for backward rotation.
After the mid-stance there will be sudden dropping of the COG level. The
forward and backward rotations help to prevent further reduction of the COG
level. The same time lengthening of both the lower extremities prevent the
further reduction of the COG. The lengthening of the legs is possible due to the
forward and backward rotation of the pelvis.
Result: Forward and backward rotations help to minimise the hyper-reduction of
the COG.

5. Physiological Valgus
It is a structural feature of the human knee joint that limits lateral movement in
the body’s center of gravity during the gait cycle.
Generally, during walking forward placing leg will have mild-knee valgus is
called as physiological valgus, but the vertical alignment of the limb (Vertical
alignment of the tibia and fibula) provides more BOS than the normally placed

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limb. To overcome from the reduced BOS by the physiological valgus, i.e.
normally placed limb, the lateral shifting of the body occurs to shift the COG
from one lower extremity to another.

DETERMINANTS OF GAIT

 Displacement of center of gravity

 Factors responsible for minimising displacement of center of gravity
o Major determinants: Pelvic Rotation (transverse plane) , Pelvic
Lateral Tilt (Obliquity) , Knee Flexion During Stance , Ankle
Mechanism (Dorsiflexion) , Ankle Mechanism (Plantarflexion),
Step Width
o Minor determinants:. Neck movement , Swinging of arms.

Causes for Gait Impairment. ——————-

 Age ~ During the crawling stage of the child the base of support is more and
COG is in lower level and the position is called quadruped position. After
some days the child adopts toddler walking with wider base to avoid falling.
After five years there will be increased cadence, increases velocity, reduced
step length, more arm swing and less pelvic tilt can be noticed. In adults age
group people normal gait is achieved because in this age the person has
well-developed muscles, skeletal system, proprioceptive response, power
and strength. The old age group will be having reduced velocity, reduced
cadence, decreased step length due to their weakness of the musculoskeletal
and nervous system.
 Sex ~ decreased step length, increased steps, decreased stride length can be
seen in the female. The cadence is more in female than in the male and also
due to wider pelvis there will be some difference in arm swinging in the
female. There will be more pelvic rotation noticed in female
 Occupation ~ Continuous adaptation of one position may cause some
changes in the muscles and soft tissues, which leads to some difference in
the gait pattern. Due to the changes in the muscle property the person is
forced to adopt the same variety of gait pattern during the normal activities
also. Some other examples are soldiers with raised chest, Washerman with
kyphosis, rickshaw pullers with kyphosis, bangle sellers with lordosis.
 Clothing ~ The tight clothing may cause some deviations in the gait pattern
 Assistive Devices ~ patients who uses the assistive devices relatively shows
different gait pattern from the normal person. Calliper, prosthesis, walkers,
crutches gives its own characteristics of walking,

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 Body Structure ~ slim person walks with increased step length, decreased
steps, increased arm swing, decreased pelvic rotation and the obese
individual walks with decreased step length, increased steps, decreased arm
swing, increased pelvic rotation
 Footwear ~ The person who wears the shoes from birth may have the
proper, straight and non-deviated hip, knee and ankle interaction gait. But
person who uses slippers for longer period and shows the slight hip rotation
and some other deviation in the ankle and knee.
 Psychological State of Individual ~ The person with depressed mood may
have the decreased step length, decreased stride length, reduced steps, and
decreased velocity, less upper limb swinging, less pelvic rotation and more
neck flexion. This may be reversed in the joyful mood.
 Diseased State ~ Some pathological changes may cause the improper gait
pattern and abnormality in the gait.
i. Neurological gait ii. Muscular weakness gait iii.Joint or muscular
limitation gait iv.Leg length discrepancy gait v. Painful gait.
Pathological Gait —————-
Pathological gaits refer to abnormal patterns of walking or movement that are
typically caused by underlying neurological, musculoskeletal, or systemic
disorders.

TYPES

 Due to pain –
o Antalgic or limping gait - (Psoatic Gait)

 Due to neurological disturbance

o Muscular paralysis –
 Spastic (Circumducutory Gait, Scissoring Gait, Dragging or
Paralytic Gait, Robotic Gait [Quadriplegic]) and
 Flaccid (Lurching Gait, Waddling Gait, Gluteus Maximus Gait,
Quadriceps Gait, Foot Drop or Stapping Gait,)
o Cerebellar dysfunction (Ataxic Gait)
o Loss of kinaesthetic sensation (Stamping Gait)
o Basal ganglia dysfunction (Festinant Gait)

 Due to abnormal deformities –

o Equinus gait
o Equinovarous gait
o Calcaneal gait
o Knock & bow knee gait

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o Genurecurvatum gait

 Due to Leg Length Discrepancy (LLD) –

o Equinus gait

 Some other cause

o Scissoring gait
o In toeing gait, Out toeing gait
o High stepping gait
o Short limb gait
o Quadricep gait
o Gluteal medius gait
o Gluteal maximus gait
o Stiff hip gait

1. Hemiplegic Gait (Common in Stroke or Hemiparesis) / Circumduction Gait

 Characteristics: The individual walks with one leg that appears to be

dragged or swung around. The arm on the same side is often held in a
flexed position.
 Cause: Typically caused by a stroke or damage to one side of the brain,
leading to weakness or paralysis on the opposite side of the body.
 Features:
o The affected leg is stiff and extended, with limited ankle and knee
movement.
o The person often has a circumduction (circular motion) of the
affected leg, which compensates for weakness.
o The non-affected leg compensates by taking more steps to maintain
balance.
o The patient rotates the hip sideways during the swing phase due to
the hip flexor tightness and places the foot in flattened manner or
toe first before heel strike.There is absence of heel strike due to the
plantar flexor contracture. Upper limb is flexed in the affected side.
The steps are lengthened towards the affected side comparatively
with the unaffected side.

2. Parkinson’s Gait/ Shuffling Gait / Festinant Gait / shuffling gait

 Characteristics: Characterized by small, shuffling steps with reduced

arm swing.

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 Cause: This gait results from the degeneration of dopamine-producing

neurons in the brain, leading to motor symptoms in Parkinson’s disease.
 Features:
o Shuffling steps and a stooped posture.
o Decreased arm swing and a reduced stride length.
o "Freezing" episodes where the person feels as if their feet are glued
to the ground, often triggered by stress or narrow spaces.
o Difficulty initiating movement or turning.
o The patient adopts the flexed posture of neck, trunk, hip and knee
due to the rigidity of the muscles. Because of the flexed posture,
the COG falls anteriorly.
o In this gait heel strike is absent, so toe strikes first hence called as
Toe-heel gait. This type of gait may be seen in Parkinson's disease,
Wilson's disease, cerebral atherosclerosis.
o The person tends to lean forward and their walking speed increases
involuntarily, the person struggling to stop ( festinating gait )

3. Ataxic Gait (Common in Cerebellar Disorders) / DRUNKEN GAIT

 Characteristics: A wide-based, unsteady gait with a staggering quality.

 Cause: Caused by damage to the cerebellum (the part of the brain that
controls coordination and balance), often seen in conditions like multiple
sclerosis, alcohol intoxication, or cerebellar strokes.
 Features:
o Wide base of support, often with feet placed apart.
o Difficulty in maintaining balance and often staggering or swaying
when walking.
o Cerebellar ataxia: Hypotonia and the ataxic gait are the main
features of the cerebellar lesion. There will be lacking of the
coordinated movements. The gait pattern resembles like 'drunker
gait'. The patient sway here and there without stability and balance.
This gait is otherwise called as 'reeling gait'. If the patient is having
one side cerebellar lesion shows the lesion side swaying and
normal walking pattern in the normal side.
o Sensory ataxia: It can be seen in tabes dorsalis, diabetes mellitus,
leprosy and syringomyelia. The patient raises the foot in the air,
through forward in uncertain manner and stamp on the floor slowly
due to the lack of kinaesthetic sensation. The gait pattern looks like
'space walk'.

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4. Spastic Gait (Common in Cerebral Palsy or Spinal Cord Lesions) /

Scissor gait / crossed- leg gait

 Characteristics: The gait is characterized by stiffness and dragging of

the legs, with the person walking with a stiff, robotic motion.
 Cause: Often due to spasticity, which is increased muscle tone resulting
from neurological damage, such as cerebral palsy, spinal cord injuries, or
upper motor neuron lesions.
 Features:
o The legs are held in a straightened, rigid posture, making it difficult
for the person to bend the knees or walk with a normal rhythm.
o The feet may drag or scuff the ground.
o The gait is often slow, and the person may need to swing the entire
body to move forward.
o The legs are crossing each other while walking due to the adductor
tightness. The knee might may be flexed in the spastic diplegia is
called as 'couch gait'. During the swing phase of one lower
extremity cross the stance leg.

5. Antalgic Gait (Pain-Related Gait)/ LIMPING gait

 Characteristics: A limp or altered gait that is a direct response to pain,

often from conditions like arthritis, fractures, or sprains.
 Cause: The person favors one leg to minimise weight-bearing on an
injured or painful area.
 Features:
o Shortened stance phase on the affected leg.
o The person may take smaller steps or avoid full weight-bearing on
the painful leg, leading to a lopsided or limp-like walk.
o The gait is typically associated with discomfort or pain, which is
why the person avoids using the affected leg fully.
o Can be seen in osteoarthritis, Fractures , tendinitis

6. Trendelenburg Gait (Common in Hip Weakness or Hip Joint Issues)/

Gluteus medius lurch

 Characteristics: A lurching gait caused by weakness of the hip abductors

(particularly the gluteus medius).
 Cause: Usually caused by weakness in the muscles that stabilize the
pelvis, such as in hip joint arthritis, post-surgical recovery, or nerve
injury, hip muscle weakness
 Features:

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o The person tilts their pelvis downward toward the unaffected leg
when standing or walking.
o This compensatory motion is to keep the pelvis level while
walking, creating a side-to-side swaying motion.
o Often accompanied by a limp
o Pelvic drop , unilateral weakness if bilateral it is waddling gait

7. Steppage Gait/ High stepping gait / foot drop gait / (Common in Foot
Drop)

 Characteristics: High-stepping gait, often with the person lifting their

knee unusually high to compensate for an inability to dorsiflex the foot.
 Cause: Common in foot drop, where the individual has difficulty lifting
the foot due to nerve injury or weakness, often from conditions like
peripheral neuropathy or stroke.
 Features:
o The person lifts their leg higher than normal to clear the foot off
the ground.
o The foot often slaps the ground during the swing phase of walking,
due to lack of control in the ankle.
o During the heel strike the ankle goes for dorsiflexion. If the
dorsiflexors are paralysed, the plantar flexors overacts. During heel
strike due to foot drop the toes goes and contact the ground first, to
avoid this the patient flexes his hip and raises the foot and slap on
the floor forcibly.
o It is seen in some neurological conditions like poly-neuritis,
muscular dystrophies and peroneal muscle atrophy.
o In some cases it is also called as dragging gait

8.Waddling Gait (Common in Muscular or Neurological Disorders) /

Myopathic gait /Duck walking gait

 Characteristics: A gait where the person walks with a side-to-side

motion of the trunk, often due to weakness in the hip muscles.
 Cause: Often seen in conditions like muscular dystrophy or congenital
myopathies.
 Features:
o A pronounced swaying or rocking motion of the body while
walking.
o Waddling is most noticeable when walking, and it results from the
person’s inability to maintain a stable pelvic position.

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o When both the abductors of the hip paralysed the patient bends his
trunk laterally towards the stance phase. Lower extremity,
whenever the same side lower extremity goes for swing phase.
o To prevent the over dropping of the pelvis and to clear the foot
from the ground, this adjustment made by the patient.

9.Gluteus medius gait

One side gluteus medius paralysis results in Trendelenburg gait, both the side
paralysis results in duck walking.

10.Gluteus maximus gait / rocking horse gait

 The gluteus maximus causes posterior pelvic tilting gait and shifting the
COG towards the stance hip.
 While the body propels forward during the mid-stance phase if the
gluteus maximus paralysed the trunk is lurched posteriorly to cause the
posterior tilting and shifting the COG towards to stance hip.
 It is seen in poliomyelitis and above knee amputation with prothesis
 Gluteus maximus gait is a compensatory walking pattern caused by
weakness or dysfunction of the gluteus maximus muscle.

11.Quadriceps (hand to knee gait)

 This type of gait is possible typically in the patients with quadriceps

paralysis.
 During the mid-stance, to transmit the weight on the stance lower leg
extremity, the knee should be locked. This locking is not possible if the
quadriceps is paralysed so that the patient himself-is locking the knee by
placing his hands above the knee joint.

12.Genu Recurvatum gait

 If the hamstring muscles paralyses, the knee goes for hyperextension in

the mid-stance while transmitting weight through the stance leg, the knee
goes for hyperextension due to the lack of counteraction of the hamstring.
 And also during the late stage of swing phase slowering of the swing due
to the hamstring paralysis and the knee will snap into extension.
 It is commonly seen in polio.

Joint of Muscular Limitation Gait

13.Toe tip gait:

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 Foot remains in plantar flexion due to the contracture of the plantar

flexor or may be due to paralysis of dorsiflexors so that the patient walks
on the toe tip and the ball of the metatarsals
 . This type of gait can be seen in some neurological conditions like DMD
and spastic diplegia.

14.Calcaneal gait:

 Contracture of dorsiflexor or paralysis of plantar flexor may cause the

stable dorsiflexed foot. So, while walking there is absence of foot flat,
mid-stance, toe-off stages.
 Instead of that the patient walks with heel or the calcaneum. This type of
gait is said to be calcaneal gait.

15.Hip flexor contracture gait:

 The hip flexor plays main role to propel the swinging extremity forwards.
If it is contracted or hip joint is ankylosed the flexion movement will be
restricted. To compensate that the patient hikes his pelvis and laterally
half-circumducts his hip and propels forwards as well as due to hip flexor
contracture, hip extension is also restricted to compensate that the patients
do more anterior pelvic tilt and lordosis to swing the extremity forwards.
16.Stiff knee gait:

 Normally, during the early stage of swing phase the knee should go for
flexion to clear the foot from the ground.
 If the knee is stiff the patient hikes his hip and clears the foot from the
floor and swing sideways with hip circumduction of abduction to propel
the limb forward to reach the heel strike. This type of gait is called as hip
abductor gait.

17.Leg Length Discrepancy Gait / EQUINES GAIT

 When the leg length difference is half-inch it can be negligible and it may
be compensated by pelvic tilt while walking.
 if the shortening is more than two-inch leads to marked pelvic tilt and
equines deformity at the foot.

Gait Analysis ————————-

 A broad spectrum of potential assessment strategies used to evaluate normal
and abnormal gait. It is used for clinical and laboratory identification of gait .

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 KINEMATIC GAIT ANALYSIS

Describe the movement pattern without regard for the force involvement in
producing movement
1) Distance and time variable
2) Measurement of joint angles of lower-limb and upper-limb
3) Determinants of gait
o Qualitative analysis- stride length, cadence , speed , arm swing
posture , step width , 6 in , 1 min walking test, 10 meter walking test
o Quantitate analysis- in some cases objective data is gathered using
tools like pressure-sensitive walking , motion capture system or
wearable sensors , electrogoniometer

 KINETIC GAIT ANALYSIS

Determine the force involved in gait pattern without regard for the are involved
in the gait. force involved in producing the movement
 Prerequisites of normal gait
1. Maintenance of upright position of the HAT against gravity (H= head,
A= arms, T= trunk).
2. Maintenance of body stability & balance.
3. Good foot control, to ensure safe foot clearance and gentle heel
contact during gait.
 Observation method – naked eye examination
Photographic method – video
 The gait parameter measurement are made by timing process over a 16m
walkway & identifying events by means of foot switch system .
 Ambulatory phase- supported by orthotic and prothesis
 ASSESSMENT OF GAIT –
o Observation of gait pattern
o Qualitative analysis
o Quantitative analysis
o Assessing for specific gait disorder
o Functional gait test
 Time- up and Time-go test
 6-minute walk test
 Gait speed test
o Assessment of balance and coordination

 GAIT EXAMINATION-
 Take history
 Couch examination- Observe deformities & lesions , Check
ROM's , Check muscle , tightness/strength , Neurological &
vascular assessment

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 Static examination- Feet non-weight bearing (hanging) with

weight bearing, Standing from front ( Shoulders, hips, knees,
feet , From behind, Shoulders, hips, calcaneus)
 Allow patient to relax
 Reasonable length walkway – gait pattern changes before &
after turn

 General points to remember during gait analysis- Is the gait fast or slow? Is it
smooth? Does the patient appear relaxed & comfortable or pained? Is it
noisy?

MOBILITY AIDS
 The appliances or devices, which are useful for the mobility as well as
stability purpose of an individual who cannot walk independently without
any support, called as mobility or walking aids.
 It is the forward propulsion of the body via coordinated and integrated action
of neuromuscular system. It is the highest level of motor control skill.
 Walking is a complex activity which requires the co operation and control of
the whole body.
 These devices are mostly prescribed for cases of :
 Pain
 Muscle weakness
 Problem in balancing
 Fractures
 Joint diseases
 Injured or inflamed limb
 Lack of proprioception.

 Mobility aids useful for muscle skeletal and neuromuscular problems

 These mobility aids reduce the weight-bearing from the lower limb.

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 Ambulation: To walk from place to place or move about. It is a technique of

post operative care in which a patient gets out of bed and engages in light
activity (as sitting, standing, or walking) as soon as possible after an
operation.Some time this term is also use in the place of walking
 Purpose of walking aids
 Increase area of support or base of support
 Maintain center of gravity over supported area
 Redistribute weight-bearing area by decreasing force on injured
or inflamed part or limb
 Can be compensate for weak muscles
 Decrease pain
 Improve balance
 Improves proprioception

 There are six (6) major varieties of mobility aids:

1. Crutches
2. Canes
3. Walkers
4. Wheelchairs
5. Braces and splints (orthosis)
6. Prothesis

Crutches —————-
 Crutches are used mostly to relieve the weight-bearing in the one or both the
lower extremities and provide additional support where the balance is
impaired for the patients.
 At present three types of crutches are available:
1. Axillary crutch
2. Elbow crutch
3. Gutter crutch.

1. AXILLARY CRUTCH

 Axillary crutch provides the maximum stability and support to the patient
than any other crutches.
 It gives more than 80 percent of stability. So that it can be recommended for
the patient having marked instability in walking.
 It is made of aluminium, steel materials, and sometime by the wood.

 Parts of Axillary Crutch

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 Axillary pad: Axillary pad situated at the top portion of the

crutch. It should be placed 5 cm below the axilla.Normally, this
axillary pad is made-up of metal and is covered by the cushion
materials to avoid the damage to the lateral aspect of the chest
wall. The axillary pad placed in the lateral wall of the chest to
provide the improved lateral stability.
 Handgrip: It is made-up of plastic material, and sometimes
covered by the cushion material.Handgrip normally comes
around the greater trochanter area of the person using it. It has
the adjustable clips or screws to adjust the height and push
button handgrips also available.
 Rubber ferrule: It is situated in the lower end of the crutch.
This rubber tip provides more grip for the patient while walking
in the normal/ slippery surface.

 Axillary Crutch Measurement

Before giving the crutch to the patient, it should be measured perfectly because
lengthier crutch may cause the compression over the axilla, which leads to
neuropraxia. Sometimes if it is small, the patient's gait pattern may change or it
may cause some other complication like back-ache.
Measurement
1. Shoes off – Lying , standing
2. Shoes on – Lying , standing

1. Shoes off
Supine lying: to be taken the measurement from the apex of the axilla to-the
medial malleolus. It is the accurate method to measure the crutch length.
Standing: 2 inches below the axilla to the 2 inches lateral and the 6 inches
anterior to the foot when the patient is standing.

2. Shoes on
Supine lying: measurement taken from the 5 cm below the apex axilla to the 20
cm lateral to the heel of the shoe. It is not accurate method
Standing Same like the shoes off

 Handgrip Measurement

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The measurement taken from the 5 cm below the apex of the axilla to the ulnar
styloid process in the elbow in 20°-30° flexed position.

 Weight transmission
Elbow is extended and weight is transmitted to the hand piece , so that
pressure over axilla is reduced.

2.ELBOW CRUTCH

 It gives less stability than the axillary crutch.

 It renders 60 percent of stability to the patient using it. So, elbow crutches
recommended for the patient having the minimal in stability in walking.
 It is made up of aluminium or plastic sometime stainless steel metals.

 Parts of Elbow Crutch

 Forearm cuff: made by metals and is coated by the plastic or
cushion materials & placed just below the elbow joint.
 Single upright: It has the proximal adjustable press clips and
the distal adjustable press clips. The proximal press chips adjust

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the height of the forearm cuff and the digital press clip helps to
adjust the height of the crutches.
 Hand-piece: Hand-piece placed junction between the proximal
and digital adjustable press clips and the hand-piece comes
around the greater trochanter region of the person using it.
 Rubber ferrule: It affords more grip even while walking in the
slippery surface too.

 Weight Transmission
the weight is transmitted to the hand-piece when the elbow is extended.

 Elbow Crutch Measurement

The measurement taken from the ulna styloid process with the elbow in 20°-30°
flexion to the 20 cm lateral to the heel or the heel of the shoes.

3. GUTTER CRUTCH

 This is also made up of metal and it contains the forearm pad with the
supporting strap, adjustable hand-piece and rubber ferrule.
 These types of crutches are mainly used for the rheumatoid hand and those
who cannot weight bear through the wrist and hand for example, fracture
wrist or dislocation.
 The length of the crutch and hand-piece position can be adjustable.

 Measurement
o In standing: The measurement is taken from the elbow to the floor.
o In lying: The measurement taken from the point of the flexed elbow to 20
cm lateral to the heel (shoes on).

 Pre crutch training

o Before making the patient walk with the crutches , the therapist has to
assess the patient whether is capable of using the crutch by his own
o Psychological state:
 The mental acceptance is the very important factor to
make the patient practice the crutch walking.
 First of all patient has to cooperate with the therapist to
learn the gait pattern with the help of his mental stability
and support.

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 Mainly the therapist has to gain the confident of the

patient to make him practice the crutch walking.
 Making the mental acceptance of the patient plays the
main role in the gait-training program.

o Crutch muscles-
 Patient needs the good strength or power in some group
of muscles. So, the therapist should assess the crutch
muscles whether it has normal power or not.
 They are:
 Shoulder: Depressors, extensors, adductors
 Elbow: Extensors
 Wrist: Extensors
 Finger: Flexors
 Hip: Extensors, adductors
 Knee: Extensors
 Ankle: Plant flexors
 Toe: Flexors.

o Balancing:
 Balancing is the important criteria to be assessed, bed
lack of balance leads to falling while walking which
causes some other complication like injury or re-fracture.
 If the patient lacks balance in sitting or standing, it has to
be treated first before going for crutch walking.

o Gait pattern
 The therapist teaches the needed gait pattern depends on
the condition of the patient that is non-partial, full
weight-bearing walking. All the instructions like do's and
don't in the crutch walking and about the progression
techniques and changing of the pattern has to be taught.

o Pattern of Crutch Walking

 The therapist or the assistant has to hold or support the patient while he
walks for the first time. The therapist has to give the instruction when the
patient does any mistake.
o Non-weight-bearing gait-Good first (Crutch or limb)
o Partial weight-bearing gait-Bad first (Crutch or limb)
o Full weight-bearing gait-Bad first (Crutch or limb)
 Floor walking rules:
1. Non-weight-bearing-Good first (Crutch or limb)

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2. Partial weight-bearing-Bad first (Crutch or limb)

3. Full weight-bearing-Bad first (Crutch or limb)

1. Non-Weight-Bearing Gait
o Patient stands with the triangular base.
o The affected side leg never carries the weight is non weight- bearing gait.
o The patient with the brace, long cast, POP, fracture limb. Early stage of joint
replacement surgery open reduction internal fixation needs this type of non-
weight bearing gait.
o Non-Weight-Bearing Gait
i. 3-point gait
ii. 2-point gait
iii. Shadow walking (4-point gait).

3-point gait
1. Unaffected side crutch
2. Affected side crutch
3. Unaffected leg.
In the early stage the patient has to keep his unaffected leg behind the crutch
line is called as 'swing-to' gait. Once the patient mastered it can keep the leg
beyond the crutch line is called as 'swing-through' gait.

2-point gait
It is the progression from the 3-point gait
1. Unaffected side crutch and effected side crutch.
2. Unaffected side leg.
Progression Early stage-Swing-to gait , Later-Swing-through gait.

Shadow Walking
This is the progression from the 2-point gait. In this the affected leg contacting
the ground but not carrying the weight on it.
1. Affected and unaffected side crutch.
2. Unaffected leg.
3. Affected leg without weight-bearing.
2. Partial Weight-Bearing Gait

 This is the progression from the shadow walking.

 The weight added gradually and the amount of the bearing the weight can be
measured by the weighing machine.
 Patients who are recovered from fractures, internal fixation, joint
replacement surgery and early stage from removal of POP are eligible to
recommend for the partial weight-bearing walking.

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i. Four-point gait
ii. Three-point gait
iii. Two-point gait.

Four-point gait
1. Affected side crutch
2. Unaffected side crutch
3. Affected leg
4. Unaffected leg.
Progression. Early stage-swing-to , Later-swing-through.

Three-point gait
1. Both the crutches
2. Affected leg
3. Unaffected leg.
Progression Early stage-swing-to , Later-swing-through.

Two-point gait
In this two-point gait, two methods are used.
Method I
o Affected and unaffected crutch with affected leg.
o Unaffected leg.

Method II
i. Unaffected crutch with affected leg.
ii. Affected crutch with unaffected leg.

3.Full weight bearing

o This is the progression from partial weight bearing. The walking pattern is
same like the partial weight-bearing walking.
o The patient who can able to transfer more weight to the affected side after
immobilisation are eligible for this type of weight-bearing walking.

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Stair climbing
Rules: Good to heaven bad to hell.
Leg placed first while climbing up.
Crutch placed first while coming down.

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Climbing-up
 Non-weight-bearing
 Partial weight-bearing
 Full weight-bearing
Non-weight-bearing.
1) Three-point
 Unaffected leg
 Affected crutch
 Unaffected crutch

2) Two-point
 Unaffected leg
 Affected and unaffected crutch

Partial weight-bearing
1) Four-point gait
 Unaffected leg
 Affected leg
 Affected crutch
 Unaffected crutch.

2) Three-point gait
 Unaffected leg
 Affected leg
 Affected and unaffected crutches.
Full weight-bearing is like partial weight-bearing gait

Climb Down
 Non-weight-bearing
 Partial weight-bearing
 Full weight-bearing
Non-weight-bearing
1. Three-point
 Unaffected side crutch
 Affected side crutch
 Unaffected leg

2. Two-point
 Unaffected and affected crutches
 Unaffected leg.

Partial weight-bearing

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1) Four-point
 Affected crutch
 Unaffected crutch
 Unaffected leg.

2) Three-point
 Affected and unaffected crutch
 Affected leg
 Unaffected leg.

Canes ————————
 Canes are not normally recommended for the non-weight-bearing and partial
weight-bearing cases. Transmit 20%-25% body weight.
 It is useful for increasing the base of support and to improve the balance.
 Canes are preferred to provide opposite to the affected side.
 During the normal gait, the stance hip abductors counterbalance the
swinging hip and prevent it from titling. Providing the canes in the stance
side upper-limb reduces the force and straining in the stance side hip .
 Types of Canes
I. Standard canes
II. Standard adjustable canes
III. Standard adjustable offset canes
IV. Tripod canes
V. Quadruped canes

1. Standard canes
o They are made up of plastic, wood, aluminium
o It has curved or half circle hand piece
o It is not height adjustable. It has to be made depends on the height of the
patient. It is inexpensive and can be carried anywhere.
o Normally recommended for elderly people

2. Standard adjustable canes

o Made up of aluminium and may have plastic covering
o It also has curved or half circle piece
o It is having the height adjustable press clips. Easy to carry anywhere

3. Adjustable aluminium offset canes

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o Upper half of the cane is offset anteriorly so that the LOG falls on the
cane and it gives more stability It too has the adjustable screws or press
clips.
o Commonly all the sticks are having the hand-piece and the rubber ferrule
except the wooden made standard canes.The hand-piece comes up to the
greater trochanter level for the person using it.

4. Quadruped or tripod canes

o It has 4 or 3 legs with rubber tip and gives broader base. As a result the
BOS in this varieties of canes are huge.
o It gives more stability then any other varieties.
o It is more useful in neurological patients like hemiplegia and in elderly
patient who had the injury of the lower limb.
o Difficult to carry in staircase if the BOS is broader
o Height adjustable clips or screws are available.

 Gait Patterns
o The patient's muscle power, stability, and the psychological state should
be assessed as said in crutch training.
o Normally, while using the canes, the patient must have the maximum
weight bearing capacity. The canes are used in the unaffected side and it
is placed close to the body-line, otherwise the dynamic stability may be
decreased. There are two types of gait patterns.
1. Three-point gait
2. Two-point gait.
Three-point gait
o Cane
o Affected leg
o Unaffected leg
Progression - Early stage-swing-to , Later—swing-through

Two-point gait
o Canes and affected side leg
o Unaffected side leg

Stair climbing technique

Three-point gait
Ascending
o Unaffected leg
o Affected leg
o Cane

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Descending
o Affected leg
o Cane
o Unaffected leg

Two-point gait
Ascending
o Unaffected leg
o Affected leg and cane

Descending
o Affected leg and cane
o Unaffected leg.

Walkers and Walking Frames. ——————

 It may be useful for the non-weight-bearing, partial weight-bearing, and the

full weight bearing gait pattern.
 It gives more stability as it has the broader base. Since the COG falls within
the base of support, it gives anterior as well as lateral stability.
 The walker is having two anterior and two lateral bars, the horizontal bar
connects all the vertical bars in three sides, and one side is kept opened.
 Normally, the therapist and the doctor avoid prescribing walker the patients
because if the patient practice with the frame never walk proper gait
pattern, while progressed to the cane, crutches, sticks.

1. Rigid walking frame

2. Foldable walker
3. Gutter walker
4. Rollator
5. Reciprocal walker.

1. Rigid Walker
o This is the standard type with above said features it has the handgrip and
rubber ferrule.
o The patient has to lift and place it front and walk. It is difficult to carry easily
in and out of the house.

2. Foldable Walker
o It has all the features of rigid walker except the folding nature. It is easily
foldable and kept in a store place.

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o It is also easy to carry while traveling.

3. Gutter Walker
o It is also having the entire feature like rigid walker and additionally it has
the forearm platform instead of the handgrip.
o It is more helpful for the patient who has the problem over the wrist
(Rheumatoid arthritis , wrist bone fracture, wrist or hand injuries).

4. Reciprocal walker
o This is designed to allow unilateral forward movement of one side of the
walker. These types of walkers are useful for the patients who cannot lift
and walk with the walker.
o There will be swivel joints present between vertical and horizontal bars.
o One side of the walker moved forward with the opposite side leg
followed by it, and the other side of walker with the another leg.
o So alternatively, each side of the walker moves forward.

5. Rollator
o The anterior vertical bars having the caster and lateral bar remains same
as said in rigid walker.
o While walking the patient has to lift the rear bars off the ground and the
wheels moved forward and ends with the rear bar placing on the ground.
o Rollator is helpful for the patients who cannot lift the walker or needs
more stability. It may not be recommended to the elderly patients because
it may move fast if the patient looses his stability.
Commonly, it is recommended for the children.

 Modifications in the Walker

Baskets
o Baskets can be attached to the anterior portion of the walker to carry
some of their personal items.
o Sometimes instead of baskets plastics or nylon bags may be used

Seating Surface
o It can be attached in the inner portion of the walker. Generally, it is
foldable inside. It is needed for the patient who has the less endurance,
e.g. post-polio syndrome.

Glides
o The plastic attachment made instead of the rubber ferrule. With the help
of the plastic attachment, the patient can drag or slide the walker forward
in smooth surface.

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o It is useful for the patient who is unable to lift the walker.

Wheelchair ————————
 The patient who has both lower limbs non-functioning or partial functioning
has to be recommended for the wheelchair. It may be modified depends on
the condition of the patient.
 It gives 100 percent stability to the patient.
 Normally, wheelchairs are recommended for paraplegic, quadriplegic,
muscular dystrophy, spinal cord injuries, and fracture conditions. It provides
physical as well as mental support to the patient.
 Types of Wheelchairs
1. Rigid- The rigid wheelchairs are having the solid frame and also it
is lighter. It is mainly used for the sports. It
2. Foldable- Foldable wheelchair contains foldable frames and it is
very much heavier. It occupies less space, so it is very much easy
to carry while traveling also.
3. One arm driven wheelchair- used for the patient those who are not
able to use their one side upper limb mainly in hemiplegia. This
wheelchair is activated and steered by one upper limb. The
wheelchair contains two hand rims in one side. One controls (outer
ring) the same side wheel; another (inner ring) controls the
opposite side wheel. If both the rings are simultaneously used the
wheelchair propels in straight line.
4. Powered wheelchair.- Powered wheelchairs are the sophisticated
one. It can be steered, propelled, adjust the seat hand rest, back rest
by the power control.
 Parts
I. Wheels
There are two types of wheelchairs: (1) Solid metal wheel, (2) metal wheel with
spokes. In solid metal wheel is totally moulded by the metal with some gaps or
hole in the flat surface. It never looses its shape due to its solid moulding. In
metal wheel with spoke instead of moulded flat surface. It is very much easier
to propel forward with this wheelchair. The spokes may break easily with the
minimal forced violence. The rim of the wheel may loose its shape if the spokes
are broken. The wheel size may change depends on the weight of the patient.
The smaller size wheelchair may require more energy to propel forward than the
larger variety.

II. Tyres
Hard polyurethane tyres or pneumatic tyres are used in wheelchairs. Hard
polyurethane with smooth thread are designed for the indoor use or smooth
surface and does not provide the shock absorption. The pneumatic are air-filled

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tyres are generally used for the outdoor uneven surface. It gives more shock
absorption and smooth mobility. It needs more energy to propel.
III. Wheel Locks
Wheel locks or brakes can be helpful for slowering or stopping the movement
of the wheelchair. Normally, high or low mounted brakes can be used in the
wheelchair. High mounted brakes are mainly provided for the limited upper
limb activation person.

IV. Casters
These are the small wheels, which are two in numbers and allowing all
directional move-ment. The caster wheel also may contain the polyurethane,
pneumatic or semi-pneumatic tyres.

V. Hand rim
There are three types of hand rims, (1) standard metal rim, (2) friction rim, (3)
projection rim. Standard rims can be used when the patient has no problem of
grip. Friction rims are nothing but the standard rim with the surgical-plaster
tubing added for the additional grip. Projection rim can be used for the patient
with the problem of gripping. It has the number of projection knobs; these
knobs are perpendicular to the rim.

VI. Footrest
It may be fixed or movable. It keeps the foot in neutral position. The footrest
with heel loop is leg strap can be added for maintaining the foot in neutral
position. It may increase the length of the wheelchair

VII. Tilt Bar

It is the projection from the frame, which presents in the back portion of the
wheelchair. It is used by the person who pushes the wheelchair. By pushing
down the tilt bar with the leg, the wheelchair can be tilted backwards by lifting
the caster up.

VIII. Seat and Backrest

The seating and the backrest normally are made-up of cushionThe cushion is
used for the comfortability and to prevent the pressure sore and these cushions
may be air filled or contour foamed. The height of the backrest can be increased
for the quadriplegic and high level spinal cord lesion patients.

 INDICATION
1. Quadriplegia , Hemiplegia , Paraplegia
2. Spinal cord injury
3. Muscular dystrophy
4. Amputation

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5. Lower-limb fracture

INDIVIDUAL EXERCISES
 It is a one-to-one therapy .
 As each patient's problem differs in some respects from that of others
individual treatment is essential to obtain and accelerate his rehabilitation by
correcting specific imbalances of muscle strength, limitation of joint range
and establishing co-ordination.
 As too much individual attention leads to the patient relying on the presence
of the physiotherapist as a stimulus to activity, he must be encouraged and
given the opportunity to practise on his own.
 These exercises are prescribed when the patient is in acute phase of disease /
condition
 Individual exercises are specifically designed for a single person based on
their unique physical condition, health goals, and needs.
 These exercises are often personalized to target specific impairments,
weaknesses, or imbalances that an individual may be experiencing.

 Personalized Program:
o Assessment: It is done before the treatment This includes evaluating the
patient's medical history, current symptoms, physical limitations,
mobility, strength, range of motion, posture, and any other
o Goal Setting: The physiotherapist works with the patient to set realistic,
measurable goals. These could be long-term or short-term, such as
regaining full range of motion after an injury, improving strength,
reducing pain, or enhancing functional mobility.
o Customisation: Based on the assessment and goals, the physiotherapist
designs a program that targets the patient's specific needs, such as
strengthening weak muscles, improving flexibility, correcting posture, or
enhancing balance and coordination.

 Progression and Adaptation: One of the key aspects of individual exercises

is the ability to progress and adapt the exercises as the patient improves.This
may involve:
o Increasing Resistance: Using heavier weights, resistance bands with more
tension, or adding additional reps or sets.
o Advancing the Complexity: Adding more challenging variations of an
exercise, such as transitioning from seated exercises to standing or
incorporating unstable surfaces (e.g., balance pads, BOSU balls).

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o Varying the Type of Exercise: As patients progress, the physiotherapist

may introduce new exercises to challenge different muscle groups or
functional movements.
 Monitoring and Education: In individual physiotherapy, the therapist
closely monitors the patient's form and technique during exercises to ensure
they are performed correctly. Proper technique is crucial to prevent injury
and ensure that the exercises are effective. Physiotherapists educate patients
about the importance of the exercises, their purpose, and how they contribute
to the overall rehabilitation process.
 Home exercise programs: These programs are typically designed to be
done outside of the therapy sessions and may include instructions ,
demonstrations, and a set routine that the patient follows at home. Home
exercises help reinforce the progress made during therapy and encourage
patient and speed up recovery
 Frequency and Duration : depends upon nature and severity of the
condition.
 Benefits of individual exercises
o Targeted treatment
o Increase motivation
o Faster recovery
o Preventing further injury
o Special care
o Proper attention
o Patient is comfortable to open up

GROUP EXERCISES
 Group exercises involve a small group of individuals who are working
together under the guidance of an instructor or therapist.
 These exercises may be designed for people with similar conditions or
rehabilitation needs, although they are often less personalized than individual
therapy.
 Working with other patients stimulates his effort and helps to give him
confidence in his own abilities while his performance is guided and
controlled by the physiotherapist.
 A small number of patients, preferably never exceeding six or eight-are
grouped together because they have some common disability which will
benefit from exercises which are similar in character.
 Because of the common ground, the pattern of each exercise can be taught to
the whole group simultaneously; time is then allowed for free practice of the
whole of part of the exercise, during which each patient performs the

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movement according to his own capacity and in his own rhythm, being
helped, resisted, encouraged and corrected by the physiotherapist according
to his individual need.
 The Value of Group Exercise
1) The patient learns to take a measure of responsibility for his own
exercise, and so is helped towards adequate home practice.
2) In a group, the amount of attention given to the individual patient
decreases in proportion to the number in the group, and yet a measure
of help, supervision and encouragement is available when required
3) The patient learns to work with others and no longer considers himself
set apart from his fellow-men because of his disability.
4) The patient is given confidence in the treatment and is therefore
stimulated to further effort
5) The patient is given confidence in his ability to hold his own with
others when the group performs some exercises in unison.
6) Effort is stimulated by some activities which call for a mild form of
competition.
7) Patients are helped to forget their disability temporarily by Objective
and Game-like Activities, which are only possible in Group
Treatment. This helps to promote natural movement, general activity
and a cheerful outlook.

 The Disadvantages of Group Treatment

Faulty selection of patients, inadequate explanation to the patient, lack of, or
inefficient, grading of groups, overcrowding of groups, and poor technique of
instruction on the part of the physiotherapist, are the most common causes of
failure to benefit the patient.

 The Organisation of Group Exercise

 Selection of Patients. Any patient who is capable of, and is expected
to do, home exercise can be drafted into a suitable group once the
basic instruction has been given and is understood.
 Grading of Groups. The patient must only be drafted to a group in
which the exercises performed are suitable to his capacity, and he
must be progressed from that group to another as his capacity
increases.Groups are formed according to the location and nature of
the dis-ability, the age group and sex of the patients, and are graded
according to the nature and strength of the exercises performed. For
example, a convenient method of grading Leg Exercises for
Men is as follows—
(i) Leg C.(Traumatic Injuries; for non-weight-bearing exercise.)
(it) Leg B. (Traumatic Injuries; for partial weight-bearing exercise.)
(iii) Leg A. (T. I, for full weight-bearing ex. and activities leading rehabilitation

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(iv) Leg X. (Non-traumatic Conditions, for non-weight-bearing The majority of

members of this group would in all probability be elderly and would therefore
require exercise at a slower rhythm.)

(v) Weight Lifting and Pulleys. Patients needing repetitive resisted exercise for
various parts of the body can work simultaneously under the direction of one
physiotherapist who checks the magnitude of the weight and its application for
each in turn.

 Explanation to the Patient

Before joining a group the patient must be given preliminary instruction of the
exercises and an explanation of their purpose with regard to his disability.

 The Number of Patients in a Group

The number of patients who can be successfully treated in a group depends to
some extent on the nature of their disability and how much help or resistance
each will re-quire, and also on the ability of the physiotherapist to see and give
this attention when it is needed. Overcrowding results in a form of mass
exercise as the number of patients in the group makes it impossible for the
physiotherapist to give adequate individual attention.

 The Technique of Instruction.

The ability to see where help and encouragement are required in the case of
several people is merely an extension of the ability required to give it to one,
and it comes with practice and experience.

 Sessions
Group exercise sessions are usually conducted in a group setting, such as a gym,
rehabilitation clinic, or community center, and may last anywhere from 30
minutes to 1 hour, depending on the program and intensity

 Frequency and duration

Group physiotherapy sessions usually occur on a regular basis, such as once or
twice a week, depending on the treatment goals and the patient's needs. The
duration of each session is typically around 30-60 minutes.

 Progression
As the group becomes more comfortable with the exercises, the physiotherapist
may gradually increase the intensity, duration, or complexity of the exercises to
ensure continued progress and challenge.

 Modifications

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For individuals with injuries or specific needs, the physiotherapist may suggest
alternative exercises or provide assistance to ensure that all participants can take
part safely.

MASS EXERCISES
 Mass exercises refer to large-scale exercise sessions, often involving a large
number of individuals.
 These exercises are typically less personalized as they are aimed at a broad
population or large community.
 Mass exercises are often used in public health initiatives, wellness programs,
or as part of a therapeutic intervention in large settings, such as hospitals or
rehabilitation centers.
 This method is only suitable for giving general exercise.
 Because of the large number who take part, it is impossible to give much
more than general encouragement and correction during the presentation of
the exercises.
 The exercises are done in unison to a formal command or a rhythm dictated
by the instructor, in which case the identity of the individual is submerged to
produce a uniform pattern of movement, as for example in army drill or
exercises arranged for demonstration purposes.
 Introduced at the right time and used in conjunction with individual or group
treatment this method of giving exercise often plays a part in the whole
scheme of rehabilitation, as the circulation and general exercise tolerance are
improved, and the discipline of working with others is stimulating.

 Characteristics
o Large participation
o Standrarslized program
o Public health initiatives
o Minimal individual focus
o Mass aerobic
o Fitness classes
o Accessible for all
o Improving physical fitness

 Challenges in mass exercises

o Lack of individual attention
o Risk of injury
o Motivation and adherence

 Examples

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o World health events

o Flash mobs or outdoor fitness events
o Charity walks or run

Aspect Individual Exercises Group Exercises Mass Exercises

Exercises conducted by a
Exercises done by a
Exercises performed large group, often
Definition small group of people
by a single person. involving many people
together.
simultaneously.
Number of 2-10 or more depending Dozens to hundreds, or
1
Participants on the setting. even thousands of people.
Highly personalized Some level of Little to no
based on individual personalisation, but personalisation; generally
Personalisation
fitness levels and exercises are done in a for the masses, focused on
goals. group setting. general fitness.
Focused on personal Encourages teamwork
Typically aimed at general
progress, specific and camaraderie, but
Focus fitness, participation, or a
goals (strength, individual goals may
unifying event.
flexibility, etc.). still exist.
Limited interaction,
Minimal to no
Interaction and support mainly focused on
Interaction interaction (usually
among participants. participation rather than
done alone).
engagement.
Motivation through
Self-motivation is Motivation from the crowd
Motivation group energy and shared
key. or event atmosphere.
experience.
Usually moderate or low
Can be adjusted to the Varies depending on the
intensity, though can be
Intensity individual’s level, group’s pace, but often
high in specific events
from low to high. set at a moderate level.
(e.g., marathons).
Often structured with Often structured as a mass
Highly structured,
some freedom, allowing event, such as a public
Structure with a clear focus on
interaction and workout or a fitness
individual progress.
adjustment. challenge.
Can be aerobic, Can include circuit Can include mass aerobics
Type of Exercise strength, flexibility, training, group fitness classes, charity runs, or
or sport-specific. classes, or team sports. group yoga sessions.
Performed in gyms, at Often in group fitness Typically outdoor events,
Environment home, or personal centers, parks, or team- fitness expos, or large
workout spaces. specific settings. public venues.
Running on a
Group cycling classes, Marathon, charity walk, or
Example treadmill,
team sports like large public Zumba
Activities weightlifting, yoga at
basketball or soccer. session.
home.
Builds social Promotes general fitness,
Focused on personal
interaction, community engagement,
Benefits health, fitness, and
accountability, and and public health
progression.
teamwork. awareness.

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MAINTENANCE EXERCISES
 Maintenance exercises are those physical activities specifically tailored to
maintain or sustain an individual's physical condition and functional
capabilities after completing a rehabilitative phase of therapy.
 maintenance exercises concentrate on long-term fitness and health, ensuring
that the progress gained during rehabilitation is preserved and enhanced.
 Once recovery is achieved or significantly improved, the next stage is to
shift focus towards maintaining those gains through a structured, long-term
exercise routine.
 This phase is vital in preventing future injuries, reducing the risk of relapse,
and enhancing overall health.

 Key Objectives of Maintenance Exercises:

1. Preventing Function Decline: After rehabilitation, the primary objective

of maintenance exercises is to avoid the loss of strength, mobility, or
function.
2. Enhancing Long-Term Health: Regular maintenance exercises help
improve cardiovascular health, muscle strength, and overall fitness,
which contribute to long-term health.
3. Injury Prevention: One of the most crucial aspects of exercise therapy is
to ensure that the body stays strong and flexible, helping to prevent re-
injury or the occurrence of new injuries.
4. Improving Physical and Mental Health: Regular physical activity
promotes the release of endorphins, helping to reduce feelings of anxiety,
depression, stress, improve sleep, cognitive function, and well-being.
5. Maintaining Mobility and Functional Independence: Maintenance
exercises focus on strengthening muscles and improving joint flexibility
to help maintain balance, mobility, and functional independence.

 Types of Maintenance Exercises in Exercise Therapy

Maintenance exercises are highly varied, depending on an individual’s specific

needs, goals, and health conditions.

1. Strengthening Exercises

Strengthening exercises are fundamental to maintaining muscle mass and

preventing muscle atrophy, particularly after prolonged periods of inactivity.

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These exercises help build strength in both large muscle groups and smaller
stabilising muscles. Strength training improves muscle endurance and bone
density, reduces the risk of injury, and enhances overall body mechanics.

Examples Bodyweight exercises , Resistance training , Functional movements

2. Flexibility and Stretching Exercises

Maintaining flexibility is crucial for preventing stiffness, improving range of

motion, and reducing the risk of injury. Flexibility exercises help to elongate
muscles and joints, improving mobility and posture. They are especially
important for individuals recovering from joint surgeries or those with
conditions like arthritis, where stiffness and limited mobility can be common.

Examples Dynamic stretching, Static stretching, Yoga or Pilates

3. Cardiovascular or Aerobic Exercises

Cardiovascular exercises are essential for maintaining heart health and

improving overall stamina. These exercises involve activities that increase the
heart rate and improve aerobic capacity. For individuals with chronic health
conditions such as heart disease, diabetes, or hypertension, maintaining
cardiovascular fitness is critical for managing these conditions and preventing
further health issues.

Examples Walking or hiking, Cycling , Swimming or water aerobics , Elliptical

machines or treadmills

4. Balance and Stability Exercises

Balance training strengthens the muscles involved in maintaining posture and

coordination, thus reducing the risk of falls and improving overall movement
efficiency.

Examples Standing on one leg,Heel-to-toe walking,Yoga, Stability ball exercises

5. Posture Correction Exercises

particularly for individuals with back or neck pain. Posture correction exercises
strengthen the muscles that support the spine, correct imbalances, and promote
better body alignment.

Examples Chin tucks, Scapular squeezes, Back extensions

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6. Joint Mobility and Stability Exercises

are designed to preserve or enhance the range of motion in joints, particularly

those that may be affected by conditions like arthritis, joint replacement, or
injuries. These exercises ensure that joints remain supple, stable, and functional.

Examples Ankle pumps, Shoulder circles ,Hip openersWrist and hand stretches

 Implementation of Maintenance Exercises in Exercise Therapy

Once a person has gone through an initial rehabilitation phase, the next step
is to incorporate a maintenance exercise program. To achieve the desired
benefits, maintenance exercises need to be designed thoughtfully and
implemented progressively
 Frequency and Duration
exercise 2-3 times a week, although some conditions may require more
frequent sessions. The duration of each session usually ranges from 20-60
minutes, depending on the intensity of the exercises and the individual’s
fitness level.
 Progression
While maintenance exercises aim to preserve current fitness levels, gradual
progression is important to avoid stagnation. Over time, exercise intensity or
volume may need to be increased to ensure continued improvement.
 Customisation:
Maintenance exercises should be personalized to an individual's unique
needs and goals. Factors such as age, injury history, health status, and
current fitness level must be considered when designing an exercise
program. For example, older adults with osteoarthritis may require lower-
impact activities compared to younger individuals recovering from a knee
injury.
 Monitoring and Adaptation
Periodic evaluations can help to determine whether the current routine is still
meeting the individual's goals or if adjustments need to be made. Physical
therapists or trainers should regularly check for any signs of discomfort or
injury to ensure that the exercises remain safe and beneficial.
 Motivation and Adherence
Adherence to a maintenance exercise program is crucial for its success. To
maintain motivation, individuals should set achievable goals, track progress,
and find exercises they enjoy. Social support, whether through a training
partner or group class, can also help individuals stay engaged with their
program over the long term.

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PLAN OF EXERCISE THERAPY TABLE

 A plan of exercise therapy table is a detailed, structured document or chart
used in physical therapy, rehabilitation, or fitness settings to guide
individuals through exercises aimed at treating or preventing specific
injuries, improving physical function, enhancing strength, or promoting
overall health.
 The goal of such a table is to provide a comprehensive framework for
rehabilitation, recovery, and fitness that ensures proper progression and
safety.
 This document is tailored to the individual’s unique needs, health conditions,
and rehabilitation goals
 Key Components of an Exercise Therapy Table

A plan of exercise therapy table typically includes several important

components that contribute to its effectiveness. These components are essential
in guiding a person through their rehabilitation or fitness program. The
components generally consist of:

1. Days of the Week (or Frequency)

One of the first considerations when designing an exercise therapy plan is the
frequency of exercise. The days of the week on which exercises are performed
play a crucial role in ensuring recovery and avoiding overtraining. The
frequency of the exercises depends on the rehabilitation goals, the nature of the
condition, and the patient’s ability to recover.Common frequency schedules are:

 3-4 days per week for strength training, rehabilitation, or moderate

recovery programs.
 5-6 days per week for high-intensity athletic training or advanced
rehabilitation programs.
 Every day or daily exercises for mobility or flexibility training programs.

2. Exercise Descriptions

Each exercise included in an exercise therapy table must be described in detail

to ensure correct execution and maximum benefit. These descriptions include:

 Name of the Exercise: For easy identification.

 Starting Position: The initial posture or body position from which the
exercise begins (for example, standing, seated, lying down).

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 Movement Pattern: Clear instructions on how to perform the exercise,

describing the actions the individual should take, including how to
breathe, maintain posture, and engage muscles.
 Muscles Targeted: Describing which muscle groups are engaged and
strengthened by the exercise (e.g., quadriceps, hamstrings, core, etc.).
 Repetitions and Sets: Explaining how many repetitions and sets of the
exercise should be completed to achieve therapeutic results.
 Precautions and Modifications: Information about potential risks,
common mistakes, or suggestions for modifications
 Progressions/Variations: Guidelines for advancing the exercise over time
to make it more challenging or add variety

3. Repetitions (Reps)

Repetitions (or "reps") are the number of times a specific movement or exercise
is performed in a row without rest. Reps are a critical aspect of any exercise
therapy plan, as they determine the intensity and focus of the exercise. The
number of reps prescribed can vary depending on the goal of the therapy. Reps
are often adjusted based on how the individual feels.

 Strength: Fewer reps (e.g., 5-8 reps) with higher resistance (e.g., heavy
weights) are used to build strength and power.
 Endurance: More reps (e.g., 12-20 reps) with lighter resistance are
focused on improving endurance and muscular stamina.
 Rehabilitation/Recovery: Reps may be set at a moderate range (e.g., 10-
12 reps) to rebuild strength while minimising risk of injury..

4. Sets

A set refers to the number of cycles in which an individual performs a series of

repetitions. For example, performing 12 squats is one set, and doing that 3 times
in total means three sets.

The number of sets typically correlates with the goal of the exercise therapy.
For rehabilitation, fewer sets may be performed, often starting with 1-2 sets and
progressing as the patient becomes more capable of completing them with
proper form.

 Strength and Power: 3-5 sets of 4-8 reps are typical.

 Hypertrophy (muscle growth): 3-4 sets of 8-12 reps are common.
 Endurance: 3-5 sets of 15-20 reps are prescribed.

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5. Rest Time

Rest periods are the breaks taken between sets or exercises, allowing the
muscles to recover. Rest times vary depending on the training goal and the
intensity of the exercise.

 Strength Training: Rest times are longer (2-5 minutes) to allow the body
to recover fully between sets of heavy lifting.
 Endurance Training: Shorter rest times (30-90 seconds) are typical to
keep the heart rate elevated and improve cardiovascular endurance.
 Rehabilitation: Moderate rest periods (1-2 minutes) are used to ensure
that the muscles recover without causing fatigue.

6. Intensity/Progression

Intensity refers to how hard an individual works during exercise.The intensity

can be modified through:

 Resistance: Increasing the weight or resistance used in exercises.

 Volume: Increasing the total number of reps and sets performed.
 Speed and Tempo: Altering how quickly the exercise is performed can
make an exercise harder or easier.

Progression refers to the gradual increase in the intensity or difficulty of an

exercise over time. Progression is important because it ensures continued
improvement while preventing stagnation and overuse injuries. For example:

 Increase Weight or Resistance: As strength improves.

 Increase Reps or Sets: to build endurance.
 Change Exercise Variations: Switching to more difficult exercises.

7. Purpose/Target Area

Each exercise included in the therapy plan is chosen based on the specific
muscles or systems it targets. The purpose of the exercise could range from
improving flexibility, building strength, enhancing joint mobility, or recovering
from an injury. Examples Core Strengthening Exercises, Joint Mobility
Exercises, Flexibility Training

 Designing the Plan: Key Considerations

When designing an exercise therapy table, several factors must be taken into
account to ensure it is effective, safe, and aligned with the individual’s needs:

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o Individual Goals and Needs- A well-designed exercise therapy plan

must consider the individual’s rehabilitation goals, physical condition,
and limitations. Goals might include: Post-surgery rehabilitation ,
Sports injury recovery , Chronic condition management, Posture
improvement or injury prevention.
o Progression and Adaptation Progression is essential to avoid
plateauing and to continuously challenge the individual as they gain
strength and recover from injury. An effective therapy plan should
build incrementally over time, ensuring that exercises become
progressively more challenging as strength, endurance, and mobility
improve.
o Monitoring and Feedback Monitoring progress is essential for
ensuring that exercises are being performed correctly and are
effective. Feedback from the patient or client on their pain levels,
fatigue, or discomfort helps adapt the program to better meet their
needs.
o Safety and Precautions A thorough assessment of the individual’s
health history, current injuries, and physical limitations is essential
before prescribing exercises. If exercises cause discomfort or worsen
an injury, modifications or alternatives should be provided.

 Benefits of Using an Exercise Therapy Table

1. Clear Structure and Focus: A therapy table provides a structured, easy-to-

follow guide that ensures the correct number of reps, sets, and exercises
are followed consistently.
2. Customised Plans: The therapy plan can be tailored to suit the specific
needs, limitations, and rehabilitation goals of the individual.
3. Progress Tracking: A well-documented plan allows for tracking progress
over time and adjusting exercises as needed for continuous improvement.
4. Injury Prevention: By prescribing exercises that focus on strength,
mobility, and stability, a therapy table helps to prevent future injuries and
promotes long-term recovery.
5. Motivation and Accountability: Having a visual reference for the
exercises helps patients stay motivated, stay on track, and hold
themselves accountable.

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Rest
Day Exercise Reps Sets Target Area Purpose
Time
Increase heart rate and
Day Warm-Up: Light 5-10 Cardiovascular blood flow to muscles,
- -
1 Jogging/Walking minutes system reduce the risk of injury
during exercise.
Improve lower body
Lower body strength, functional
Squats 12-15 3 30 sec
(quads, glutes) movement, and
mobility.
Strengthen core
20-30 Core (abs,
Plank 3 30 sec stability, improve
sec obliques)
posture and balance.
Upper body Increase shoulder
Shoulder Press 10-12 3 30 sec
(shoulders, arms) strength and stability.
Improve flexibility,
Cool Down: Stretching
5-10 enhance recovery, and
(Hamstrings, Quads, - - Full body
minutes reduce muscle
Shoulders)
tightness.
Increase heart rate,
Day Warm-Up: Cycling 5-10 Cardiovascular engage lower body, and
- -
2 (Stationary) minutes system warm up muscles for
more intense activity.
Lower body
Enhance leg strength,
(quads,
Lunges 10-12 3 30 sec improve balance and
hamstrings,
coordination.
glutes)
Build upper body
Chest Press
Upper body strength, focusing on
(Dumbbells or 8-12 3 30 sec
(chest, triceps) the chest, shoulders,
Machine)
and triceps.
Strengthen lower back
Lower back,
Superman Exercise 15-20 3 30 sec muscles and improve
glutes
posture.
Improve flexibility and
Cool Down: Stretching 5-10 Lower body and recovery of the muscles
- -
(Lower back, Quads) minutes back used during the
workout.
Mobilize the shoulder
Day Warm-Up: Arm 5 Shoulders and joints, activate the
- -
3 Circles, Shoulder Rolls minutes arms upper body muscles
before the workout.
Strengthen lower
Leg Raises (Supine) 10-15 3 30 sec Core (lower abs) abdominal muscles,
improve core stability.
Strengthen upper back,
Rows (Resistance Upper back,
10-12 3 30 sec improve posture and
Band or Machine) biceps
shoulder health.

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Rest
Day Exercise Reps Sets Target Area Purpose
Time
Improve glute and
Glute Bridge 12-15 3 30 sec Glutes, lower back hamstring strength,
promote hip mobility.
Improve flexibility and
Cool Down: Stretching 5-10
- - Lower body promote muscle
(Hip flexors, Glutes) minutes
relaxation.
Warm up muscles
Warm-Up: Gentle
Day 10 Full body (low gently and safely,
Swimming/Water - -
4 minutes impact) especially if there is a
Aerobics
history of joint issues.
Improve leg strength,
Lower body
Step-Ups 10-12 3 30 sec balance, and
(quads, glutes)
coordination.
Strengthen the upper
Seated Rows Upper back, back, improve posture,
10-12 3 30 sec
(Machine or Band) shoulders and promote shoulder
health.
Improve hip stability,
Hip abductors,
Side Leg Raises 12-15 3 30 sec strengthen outer thighs
glutes
and glutes.
Cool Down: Stretching Improve flexibility and
5-10
(Hip abductors, Upper - - Full body promote muscle
minutes
back) recovery.
Elevate heart rate,
Day Warm-Up: Walking 5-10 Cardiovascular
- - prepare body for more
5 or Cycling minutes system
intense exercise.
Strengthen posterior
Deadlifts (with light Hamstrings,
8-10 3 30 sec chain (hamstrings,
weights) glutes, lower back
glutes, lower back).
Improve upper body
Chest, triceps, strength and endurance,
Push-Ups 8-12 3 30 sec
shoulders enhance functional
pushing movements.
Improve core stability,
Bird-Dog 12-15 3 30 sec Core, glutes, back balance, and
coordination.
Cool Down: Stretching Promote muscle
5-10
(Lower back, - - Full body flexibility and
minutes
Shoulders) recovery.

SCHEMES OF EXERCISE
Key components of a well-designed exercise therapy scheme include:

 Assessment of the individual’s condition and goals

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 Selection of appropriate exercises

 Frequency, intensity, and duration of exercises
 Progression to ensure continued improvement
 Rest and recovery strategies
 Monitoring and adjustment of the plan based on progress

 Following the assessment of patients, the aims are determined for the
individual or group. The therapist then plans a set of exercises designed for
the initial airs. These can be progressed or altered depending on their effect
on the patient or group. The exercises may be either general or specific
according to the nature of the patient's condition and the aims of treatment.

GENERAL EXERCISES

 These provide activity for the whole body, although they can be adapted to
lay emphasis on exercise for a particular area if this is required
 They are used in the treatment of general conditions, e.g. debility,
rheumatoid arthritis, or as an adjunct to treatment given for a specific area
whenever the nature of a localised lesion tends to reduce the normal
efficiency of body movement generally.
 Exercises which are easy and involve no great muscular effort come first to
warm and prepare the body for the peak of effort which comes rather more
than half-way through the set of exercises when the large muscles of the
trunk work to move the heaviest parts of the body.
 The treatment session is completed by the inclusion of exercises which
require no great muscular effort but considerable control and concentration
 Basic Plan for a Set of Exercises
1) Respiratory Exercise.
2) Extremity Exercises- These are easy and often well-known exercises
to prepare the body for more strenuous activity.
3) Head and Neck Exercise. These are generally used to improve the
posture of the head
4) Trunk Exercises.
5) Extremity Exercises.The Arm and Leg Exercises included at this stage
differ from those at the beginning in that they require more control
and concentration, possibly because of the difficulty of the starting
position or of keeping the body in a state of equilibrium. A Balance
Exercise is usually included in all tables designed for patients with
poor posture or gait.
6) Respiratory Exercise. This is designed to have a quietening effect and
is frequently followed or accompanied by correction of posture.

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 Posture is checked or corrected before, during and after every exercise to

ensure a satisfactory basis on which the movements made during the
exercises are superimposed.
 When rest periods between exercises are necessary or desirable, these may
take the form of relaxation in a suitable posture.
 A 'break' is some form of easy activity in which there is usually an element
of competition and which is much enjoyed.
 Changing scheme
o The physiotherapist must be ready to change exercises as the need
o The patient may have achieved the aim of a particular exercise and it
can be progressed or exchanged for a more difficult exercise..
o Too frequent changes often reduce the benefit to be gained exercises
.
SPECIFIC EXERCISES

 These are used in the treatment of local conditions when exercise for a
specific area of the body is required, e.g. Coles fracture ( radius fracture) .
 When the local condition is such that it impedes the normal activities of the
body as a whole, and when time permits, both specific and general exercises
may be included in a treatment.
 The arrangement of the exercises within a specific scheme can only be
planned in broad outline, those which are strengthening and mobilising in
effect being placed at the beginning, and those which train co-ordination and
the functional use of the part predominating towards the end.
 An effort must be made to avoid using the same muscles strongly in
consecutive exercises to avoid undue fatigue.
 A satisfactory plan of the type of exercise and the timing of a half- hour
period of treatment by group exercises is as follows:
(i) Assemble group, take register and assess condition of individual members of
the group…….. 5 min
(ii) Subjective exercises which are strengthening or mobilising.in effect during
which the patient concentrates on precision of movement…… 10 min
(iii Objective exercises and activities by means of which the functional use of
the area being treated is tested and developed…… 10 min
(iv) Suggestion and practice of exercises suitable for home practice…5 min

PLANNING OF EXERCISES

Before choosing suitable exercises, the physiotherapist must know certain

relevant facts about the patient or group of patients for whom it is to be
designed.
From the doctor or the doctor's notes the following information about each
patient is acquired:

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1) Name
2) Age
3) Sex
4) Occupation
5) History
6) Present condition
7) Diagnosis
8) Treatment ordered , including physical treatment
9) Date of review by doctor

From her own examination of the patient she observes and assesses

10) The patient’s capacity for exercise and his attitude to treatment
11) The number of treatment periods to be arranged each week
12) The duration of each treatment period

 When the exercises have been chosen, a careful check must be made to see
that the aims of treatment have been fulfilled, that the effort required is well
balanced and that the continuity and variety of the exercises is satisfactory.
 A record of the exercises, dated and written in correct terminology, is kept
for use at subsequent treatments and for reference, together with notes
indicating the patient's reaction and progress.

TREATMENT SESSION

 The aims may require the inclusion of other techniques or skills such as
electrotherapy, massage or passive manual mobilisation.
 The exercises must be related to the whole plan of treatment.
 Patients may also be receiving treatment from other therapists, for
example occupational therapists or speech therapists.
 In this case the physiotherapist should consider the total management of
the patient and the place of physiotherapy treatment within this.

INSTRUCTING THE PATIENT

 The instruction which is given to a patient with regard to exercises must be
presented to him in a manner which will gain his co-operation and ensure
that he has a thorough understanding of what is required of him

 THE CO-OPERATION OF THE PATIENT

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o A brief explanation of the purpose of the exercises, given in simple terms

which can be understood
o The calm and cheerful atmosphere created, maximal voluntary relaxation,
and ensures the co-operation of the patient.
o The co-operation of the patient is required for the performance of both
passive movement and active exercise.
o Voluntary effort on the part of the patient and an understanding of what is
required of him are essential for the performance of active exercise and
he must be stimulated and given every encouragement to make this effort.
o The design of the exercises and the manner-in which they are presented
are of the greatest importance in eliciting maximum effort.

 THE TREATMENT ROOM

o An atmosphere of efficiency is created by order and cleanliness in the
treatment room, which should be light and well ventilated. In winter some
form of heating is essential while in summer some additional out-door
space is an advantage for use in fine weather.
o When artificial lighting is required it should be adequate and well
diffused, electric bulbs and shades being protected wherever activities
involving the use of balls, beanbags or sticks are to be carried on.
o A clean floor with a non-slippery surface, such as close-grained
unpolished wood
o Sufficient space should be available to allow each patient to move freely
without fear of collision with other patients or apparatus.
o All portable apparatus, which will be required for the exercises, must be
collected before they are begun
o Fittings such as wall-bars, horizontal bars and the like must be in good
condition and inspection of these at frequent intervals by a competent
authority is essential to ensure safety.
o When not in use movable apparatus such as plinths, forms, stools and
mattresses should be stacked neatly to make the most of the free space.
o An adequate supply of small portable apparatus makes it possible for
each patient to practise individually, and suitable containers for balls,
bands, quoits, ropes, etc., should be provided
o A selection of brightly coloured beanbags, balls and bands are much
appreciated by both children and adults, and when in use they give a
colourful and cheerful appearance to the room.
o Tidiness and an intelligent use of both space and apparatus do much to
obtain the maximum value from the available facilities and to relieve
apparent overcrowding.

 CLOTHING

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o For the Patient. All garments which restrict movement or make it

impossible should be removed.
o The posture and movements of the physiotherapist do much to
demonstrate her attitude towards both the patients and the treatment.
o Good posture, alert but well-controlled movements when these are
required, and an absence of mannerisms give an impression of interest •
and efficiency.
o It is advisable to sit or stand still when actually giving verbal instructions
unless these are accompanied by a demonstration of the exercise.
o Restless or purposeless movements distract attention

 METHOD OF INSTRUCTION
o For teaching purposes it is usually advisable to analyse the exercise and
allow the patient to practise each of these simple movements before
attempting to build them up into the sequence which constitutes the
exercise as a whole.
o Verbal instructions Instruction may be given verbally, by demonstration,
or by the use of passive movement.
o Formal Commands. These are now rarely used, but they are a convenient
method of starting an exercise which is well known. They specify the
point in time at which the exercise is to begin, so that many patients can
perform it in unison, or to a definite beat dictated by a musical
accompaniment.
o A formal command is essential to achieve a fair start for most competitive
games and activities. Each command consists of three parts, (i)
Preparatory or Descriptive (it) Pause, iii) Executive word; eg
o Instruction by Demonstration Any demonstration given by the physio
must be as perfect and as accurate as possible, so that the patient gets the
correct mental picture of the exercise.
o It is often preferable for the physiotherapist to do the exercise with the
patients in response to her own instructions, except when a rest period
will be beneficial to them. It is interesting and very salutary to estimate,
with the help of a stop-watch, the proportion of the treatment time during
which exercise is actually performed by the patient in relation to that used
exclusively by the physiotherapist in talking and demonstrating.
o Instruction by Passive Movement for patients who are blind or deaf, or for
those who have sustained long periods of inactivity during which the
pattern of the movement, as recorded by the kinaesthetic sensation, has
been forgotten.

 CORRECTIONS

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o Verbal corrections should invariably be constructive in character and

they may be given while the exercise is in progress or during rest
periods between bouts of activity.
o patient's reaction to correction must be observed and suitable praise or
encouragement given whenever a real effort is made to improve,
o General Corrections. given when several members of the group will
benefit from them or to give a nervous or inattentive patient a chance
to improve his performance without drawing the attention of the group
to his mistake.
o Individual Corrections. The patient is addressed by name before a
verbal correction of this kind is given, or the physiotherapist can give
manual help and guidance by standing beside a shy or nervous patient.
Patients often show a keen interest in observing, correcting and
encouraging each other, and this is to be encouraged on suitable
occasions, provided their efforts are carefully supervised

 THE VOICE OF PHYSIOTHERAPIST

o The physiotherapist's voice is of major importance in interpreting the
nature, speed, rhythm and intensity of the exercises.
o Diction must be good so that every word can be heard clearly without
strain, and a voice which is relatively low-pitched is an advantage as it is
easily produced and pleasant to listen to.
o The volume should always be suited to the room and to the size of the
audience and any tendency to shout, especially in group work, must be
resisted.
o Variation in pitch and volume, in the duration of words and the timing of
sentences, makes it possible to interpret the precise nature of an infinite
variety of activities and ensure emphasis where it is required.
o A voice which is flexible and varied commands attention from the
listeners, and is never dull.
o Every patient who has received instruction in active exercise should feel
that he has benefited by, and enjoyed, the treatment.
o In addition, he should clearly understand that having gained a knowledge
and experience of suitable exercises he is expected to co-operate in
accelerating his own recovery by practice at home.

THERAPEUTIC EXERCISE IMPACT ON

PHYSICAL FUNCTION

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Therapeutic exercise is the systematic, planned performance of physical

movements, postures, or activities intended to provide a patient/client with the
means to:
o Remediate or prevent impairments of body functions and structures.
o Improve, restore, or enhance activities and participation.
o Prevent or reduce health-related risk factors.
o Optimise overall health, fitness, or sense of well-being.:

1. Improved Strength

 Muscular Strength: Therapeutic exercises, such as resistance training,

work to rebuild and enhance muscle strength. important after injury,
surgery, or prolonged immobility. Stronger muscles support joints,
protect bones, and contribute to better overall movement.
 Functional Strength: By improving the strength of muscles that are
crucial for day-to-day tasks, therapeutic exercises help individuals
perform routine activities more efficiently, such as lifting, standing up, or
walking. For example, exercises that target the core muscles can reduce
the strain on the back when bending or lifting.

2. Enhanced Flexibility and Range of Motion (ROM)

 Joint Mobility: Therapeutic exercise often includes stretching, which

helps to maintain or increase the flexibility of muscles and the range of
motion in joints. This is vital for preventing stiffness and restoring
normal movement, especially after injury or surgery.
 Pain Reduction: Regularly stretching and improving flexibility can help
reduce muscular tightness and joint pain. For instance, stretching
exercises can alleviate pain caused by conditions like arthritis by reducing
inflammation and improving joint function.

3. Postural Control and Balance

 Improved Balance: Many therapeutic exercises target balance,

particularly in patients with neurological conditions (e.g., stroke,
Parkinson's disease) or elderly individuals prone to falls. Exercises that
challenge stability—such as standing on one leg or using balance boards
—help train the neuromuscular system, which improves the body’s ability
to maintain equilibrium.
 Postural Alignment: Therapeutic exercises often focus on strengthening
muscles involved in maintaining posture, such as the back, neck, and core
muscles. Proper alignment can prevent or correct issues like slouching,

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rounded shoulders, or forward head posture, leading to improved body

mechanics.

4. Endurance and Cardiovascular Health

 Cardiovascular Endurance: Aerobic exercises like walking, cycling, or

swimming are often incorporated into therapeutic regimens, boosting
cardiovascular health. These exercises enhance blood flow, improve lung
capacity, and increase overall endurance, making it easier for individuals
to engage in physical activity without fatigue.
 Energy Levels: By improving cardiovascular fitness, therapeutic exercise
helps increase energy levels and stamina, which can reduce feelings of
fatigue during daily activities.

5. Neuromuscular Re-education

 Coordination: Therapeutic exercises also focus on the coordination

between the brain and muscles, helping individuals with neurological
conditions retrain their movement patterns. For example, proprioceptive
exercises help patients restore their sense of body position in space,
which is essential for coordinated movement.
 Motor Control: For those with conditions such as stroke or brain injury,
exercises that target motor control can help re-establish more precise and
efficient movements, allowing for a smoother and more purposeful
execution of tasks.

6. Pain Management and Reduction

 Alleviating Chronic Pain: Therapeutic exercise has been shown to be

effective in reducing chronic pain from conditions such as osteoarthritis,
fibromyalgia, and lower back pain. Regular movement promotes blood
flow to tissues, helping reduce inflammation and muscle tension, which
in turn can reduce pain.
 Endorphin Release: Exercise also stimulates the release of endorphins—
natural painkillers produced by the body—which can further help in
reducing the perception of pain.

7. Preventing Future Injuries

 Injury Prevention: Strengthening muscles, improving flexibility, and

promoting proper movement patterns are all ways therapeutic exercises
help reduce the risk of future injuries. For instance, strengthening the
muscles around a joint can provide better support and stability, reducing
the chances of sprains or strains.

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 Rehabilitation: In post-injury or post-surgical scenarios, therapeutic

exercise helps individuals regain strength and function while reducing the
likelihood of re-injury by promoting proper healing and gradually
restoring movement.

8. Psychological and Emotional Benefits

 Mental Health: Therapeutic exercise can also have positive effects on

mental health by reducing stress, anxiety, and depression. Physical
activity stimulates the release of neurotransmitters like serotonin and
dopamine, which help improve mood and overall well-being.
 Self-Esteem: As patients progress through their therapeutic exercise
regimens and notice physical improvements, it often leads to an increase
in self-confidence and a sense of achievement. This can be motivating
and help individuals stay committed to their rehabilitation goals.

9. Restoration of Functional Independence

 Functional Mobility: Therapeutic exercises are often tailored to help

individuals recover the ability to perform basic functional tasks, such as
walking, getting in and out of bed, or sitting down and standing up from a
chair. This can be especially important for individuals recovering from
surgeries, strokes, or orthopaedic injuries.
 Quality of Life: By improving strength, endurance, balance, and
flexibility, therapeutic exercise enhances overall mobility, contributing to
a better quality of life. Individuals who are able to move more freely and
without pain are more likely to engage in social activities, hobbies, and
work, thus leading to greater independence.

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INDEPENDENT LEARNING ACTIVITIES

 Independent learning is a process, a method and a philosophy of education
whereby a learner-acquires knowledge by its own efforts and develops the
ability for enquiry and critical evaluation.
 Continuing professional development (CPD) is "the maintenance,
enhancement and extension of the knowledge, expertise and competence of
health professionals throughout their careers"
 self-directed practices and techniques that individuals can engage in outside
a structured classroom or clinical setting to enhance their understanding and
application of therapeutic exercises.
 These activities are designed to improve knowledge, develop skills, and
promote self-efficacy in managing one's health through exercise, particularly
in rehabilitating injuries, managing chronic conditions, or improving
physical function.
 Below are detailed explanations of various independent learning activities in
exercise therapy:

1. Self-Assessment and Monitoring:

 Purpose: This activity allows individuals to assess their progress,

symptoms, and overall health without direct supervision. It helps in
fostering self-awareness and recognizing changes in their condition.
 Examples:
o Range of Motion (ROM) Tracking
o Pain or Symptom Logs
o Progressive Exercise Logs
 How it supports exercise therapy: Self-assessment empowers
individuals to modify their exercise programs based on their current state,
increasing the likelihood of improvement without exacerbating the
condition.

2. Instructional Videos or Digital Platforms:

 Purpose: Online resources or apps that guide individuals through

exercises, provide demonstrations, and educate about the principles of
exercise therapy.
 Examples:
o YouTube tutorials or online courses
o Exercise apps
 How it supports exercise therapy: These platforms provide visual aids
and professional guidance, which helps ensure that exercises are done
correctly, reducing the risk of injury and improving outcomes.

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3. Written Education and Exercise Plans:

 Purpose: Individuals can learn through detailed written materials or

printed guidelines that outline specific exercises and their benefits.
 Examples:
o Printed exercise programs that include sets, reps, frequency, and
technique tips for specific conditions.
o Pamphlets or ebooks
 How it supports exercise therapy: Written plans offer structured
guidance, providing a clear roadmap for exercise progression and offering
flexibility in practicing therapy at their own pace.

4. Mindfulness and Relaxation Techniques:

 Purpose: These activities help to reduce stress, pain, and tension,

complementing physical therapy exercises.
 Examples:
o Breathing exercises
o Guided imagery or meditation
 How it supports exercise therapy: Mental relaxation can enhance the
healing process, decrease stress-related pain, and improve an individual’s
adherence to an exercise regimen.

5. Goal Setting and Reflection:

 Purpose: Setting specific, measurable, achievable, relevant, and time-

bound (SMART) goals helps individuals stay focused on their
rehabilitation journey.
 Examples:
o Short-term goals such as increasing strength in a specific muscle
group by 10% within a month.
o Long-term goals like returning to a sport or resuming normal daily
activities.
o Daily or weekly reflections on the challenges and successes
experienced during exercises.
 How it supports exercise therapy: Goal setting provides motivation and
a clear direction, while reflection helps individuals stay engaged and
adjust their strategies as needed.

6. Community Engagement or Peer Support:

 Purpose: Interacting with others who are going through similar

rehabilitation processes can provide encouragement, shared experiences,
and additional learning.

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 Examples:
o Online forums or social media groups .
o Peer support groups
 How it supports exercise therapy: Social support can improve
motivation, offer accountability, and provide alternative perspectives on
managing exercise therapy.

7. Virtual or Remote Monitoring:

 Purpose: Some exercise therapy programs incorporate technology to

remotely monitor a patient’s progress and adherence.
 Examples:
o Wearable devices
o Telehealth consultations
 How it supports exercise therapy: Remote monitoring provides ongoing
feedback and allows for early intervention if issues arise

8. Reflection on Body Mechanics and Posture:

 Purpose: Being mindful of posture and body mechanics during everyday

activities can aid in faster recovery and prevent re-injury.
 Examples:
o Watching for correct posture while sitting, standing, or lifting
during daily routines.
o Self-correcting body alignment during functional tasks like
walking or bending.
 How it supports exercise therapy: Correcting body mechanics supports
the healing process by preventing strain on vulnerable areas and
promoting long-term musculoskeletal health.

9. Journaling or Logging:

 Purpose: Keeping a written log of exercises and symptoms helps

individuals track their own progress and notice any trends or patterns in
how they feel during or after therapy.
 Examples:
o A fitness journal
o Symptom diaries
 How it supports exercise therapy: Logging progress helps individuals
and therapists make informed decisions about adjusting exercises and
optimising outcomes.

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STRETCHING
 It is the elongation of the pathologically shortened or tightened soft tissues
with the help of some therapeutic techniques.
 Stretching is a general term used to describe any therapeutic manoeuvre
designed to increase the extensibility of soft tissues, thereby improving
flexibility by elongating (lengthening) structures that have adaptively
shortened and have become hypo-mobile over time.

Terms associated with stretching ————————-

 FLEXIBILITY
o Refers to ability of the muscles to relax and yield to a stretch force
o Flexibility is the movement through an unrestricted, pain-free ROM.
o Muscle length, joint integrity, and periarticular soft tissue extensibility
all interact to determine flexibility.
o Flexibility is maximised when the muscle-tendon units that cross a
joint have adequate extensibility to deform and yield-to a stretch force.
o Dynamic flexibility. active mobility or active ROM, is the extent to
which an active muscle contraction can rotate a joint through its
available ROM. Dynamic flexibility depends on the ability of a
muscle to contract through the ROM and on the degree and quality of
tissue extensibility
o Passive flexibility. as passive mobility or passive ROM, is the extent
to which a joint can be passively rotated through its available ROM
and depends on the extensibility of soft tissues that cross and surround
a joint.

 HYPO-MOBILITY
o decreased mobility or restricted motion at a single joint or series of
joints.
o Prolonged immobilisation of a body segment

 CONTRACTURE
o A contracture is a permanent tightness or shortening of muscles ,
tendons, skin or nearby tissue, leading to stiffness and a reduced range
of motion in a joint or body part.
o Contracture is defined as the adaptive shortening of the muscle-tendon
unit and other soft tissues that cross or surround a joint, resulting in
significant resistance to passive or active stretch and limited ROM.

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o Contractures are described as the side of the joint that has the tissue
tightness. If the tightness is on the flexion side of the flexion/extension
joint axis, it is called a flexion contracture.

 SELECTIVE STRETCHING
o Selective stretching is a process whereby the overall function of a
patient may be improved by applying stretching techniques to some
muscles and joints while allowing motion limitations to develop in
other muscles or joints.

 OVERSTRETCHING AND HYPER-MOBILITY

o Overstretching is a stretch well beyond the normal length of muscle
and ROM of a joint and the surrounding soft tissues resulting in
hyper-mobility (excessive mobility).
o Hyper-mobility can create detrimental joint instability if the static
supporting structures and/or the dynamic muscular control of the joint
are unable to maintain the joint in a stable, functional position during
activities. Instability of a joint often causes pain and may predispose a
person to musculoskeletal injury.

Stretch reflex ————————-

 The proper muscle function is decided by the afferent and efferent impulses
from the nervous-system. The efferent system contains two varieties of
neurons, they are: i. a motor neuron ii. y motor neuron.
 Alpha motor neurons are the neurons, which supply large muscle fibers and
excite too many skeletal muscles, which are collectively called as motor
units. The afferent system, which contains the (1) muscle spindle, (2) Golgi
tendon organ like receptors to send the impulses to the afferent neurons

 Muscle Spindle
o The muscle spindle is the major sensory organ of muscle and is
sensitive to quick and sustained (tonic) stretch
o The main function of muscle spindles is to detect and convey
information about muscle length changes and the velocity of those
changes.
o Muscle spindles are small, encapsulated receptors composed of
afferent sensory fiber endings, efferent motor fiber endings, and
specialized muscle fibers called intrafusal fibers.
o Intrafusal muscle fibers are bundled together and lie between and
parallel to the extrafusal muscle fibers that make up the main body of
a skeletal muscle.

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o There are two general types of intrafusal muscle fibers: nuclear bag
fibers and nuclear chain fibers, named based on the arrangement of
their nuclei in the equatorial region. Primary (type la) afferent
endings, which arise from nuclear bag fibers, sense and cause muscle
to respond to both quick and sustained stretch. However, secondary
(type II) afferents from the nuclear chain fibers are sensitive only to
sustained stretch.

 Static Response
o When the muscle spindle is stretched, the receptors which is present in
that spindle is activated and it sends impulses to the nervous system
through the group I and group II fibers.
o Whenever the muscle spindle is stretched slowly, the proportion of the
impulse transmit impulses many more minutes is called as static
response of the spindle.
o It occurs due to the stretching of the nuclear chain fibers because it
supplied by both the group la (primary afferent) and group II
(secondary afferent) nerve fibers.

 Dynamic Response
o If the muscle spindle structures stretched suddenly the nerve ending is
stimulated powerfully and it is called dynamic response of the spindle.
It occurs when the nuclear bag fibers stretched

 Stretch Reflex
o The stretch reflex is a rapid , involuntary muscle contraction that
occurs in response-to a muscle’s passive stretching , helping to
maintain muscle length and prevent injury
o Whenever the sudden stretching of the muscle spindle, the dynamic
stretch impulses carried out through the type Ia (primary afferent)
nerve fibers to the spinal cord, from there strong contraction reflex
comes to the muscle.
o After the dynamic reflex is over the muscle is kept in new stretched
position, so the slow and continuous stretch reflex goes via the group
Ia and group II afferent fibers to the spinal cord, and the continuous
contraction response originates from the spinal cord.

 Negative Stretch Reflex

o Whenever the muscle is shortened, the opposite effect occurs. If the
muscle shortens, will elicit both the static and dynamic reflexes.

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 Golgi Tendon Organ( autogenic inhibition)/ active inhibition technique

o The GTO is a sensory organ located near the musculotendi-nous junctions
of extrafusal muscle fibers which monitor changes in tension of muscle-
tendon unit.
o These sensory organs are sensitive to even slight changes of tension on a
muscle-tendon unit brought on by passive stretch or active muscle
contractions during normal movement.
o When muscle tension develops, GTO activation signals to the spinal cord
inhibit alpha motoneuron activity and decrease tension in the muscle-
tendon unit. Muscle spindle reflex changes the length of the muscle and
the GTO reflex changes the tension in the muscle.

Determinants / Protocols of stretching —————

1. Alignment
o Proper alignment or positioning of the patient,the specific muscles and joints
to be stretched is necessary for patient comfort and stability during
stretching.
o In addition to the alignment of the muscles and joint to be stretched, the
alignment of the trunk and adjacent joints must also be considered.
o effective stretching requires maximising the distance between origin and
insertion, alignment that compromises this requirement

2. Stabilisation
o To achieve an effective stretch of a specific muscle or muscle group and
associated periarticular structures, it is imperative to stabilize (fixate) either
the proximal or distal attachment site of the muscle-tendon unit being
o for manual stretching, it is common for a therapist to stabilize the proximal
attachment and move the distal segment
o During self-stretching, it is often the distal attachment that is stabilised as the
proximal segment moves
o Stabilisation helps maintain the proper alignment necessary for an effective
stretch. Sources of stabilisation include manual contacts; straps or belts;
body weight; or a firm surface, such as a table, wall, or floor.

3. Intensity of Stretch
o The intensity of a stretch is determined by the tensile load placed on soft
tissue to elongate it. stretching should be applied at a low intensity by means
of a low load.

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o Low-intensity stretching is more comfortable for the patient and minimises

voluntary or involuntary muscle guarding, enabling the patient to remain
relaxed or assist with the stretching manoeuvre.it shows improvement in
ROM without exposing tissues, possibly weakened by immobilisation

4. Duration of Stretch
o The duration of stretch refers to the period of time a stretch force is applied
and tissues are held in a lengthened position. Or how long a single cycle of
stretch is applied.
o In general, the shorter the duration of a single stretch cycle, the greater the
number of repetitions needed during a stretching session.
o The duration of stretch must be applied in context with the other stretching
parameters of intensity, frequency, and mode.

5. Speed of Stretch
o To minimise muscle activation during stretching and reduce the risk of
injury to tissues and post-stretch muscle soreness, a stretch force should be
applied and released at a slow rate.
o A slowly applied stretch is less likely to increase tensile stresses on
connective tissues or to activate the stretch reflex.
o a stretch force applied at a low velocity is easier for the therapist or patient to
control making it safer than a high-velocity stretch.

6. Frequency of Stretch
o Frequency of stretching refers to the number of individual sessions per day
or per week that a patient carries out the planned intervention.
o The optimal frequency of stretching is based on factors such as the
underlying cause of impaired mobility, the quality and level of tissue
healing, and the chronicity and severity of a contracture, as well as a
patient's age, use of corticosteroids, and previous response to stretching.
o Frequency typically ranges from two to five sessions per week with time
between sessions as needed for tissue healing and to minimise post-exercise
soreness.
o With excessive loading frequency, tissue breakdown may exceed repair and
tissue macro-failure becomes possible.
o if there is progressive loss of ROM over time rather than a gain in range,
continued low-grade inflammation from repetitive stress may be causing
excessive collagen formation and hypertrophic scarring.

7. Mode of Stretch
o refers to how the stretch force is applied and who is actively participating in
the process.

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o To facilitate this, stretching should be preceded by either low-intensity active

exercise or therapeutic heat to warm the tissues that are to be lengthened.

Types of stretching ———————

i. Passive stretching
ii. PNF
iii. Self-stretching.

I. PASSIVE STRETCHING
1) Manual
2) Mechanical.
Manual Stretching
o It is done by the therapist or by the physician.
o The stretching may be given for 15-30 seconds, sometimes it may be
extended up to 60 seconds.
o It is of two types : i. Static stretching ii. Ballistic stretching.
o Static stretching: slow and prolonged stretch is applied to avoid the
reflex contraction-from the muscle spindle and Golgi tendon organ.
o In this stretch, the muscle is elongated gently and maintained for long
period without pain.
o Ballistic stretching: It is the bouncing or jerky type of stretching. It is a
high velocity and short duration stretching. It can be done actively.it may
cause injury because the movements may exceed the limits of
extensibility and it has poor control over the movements. the ballistic
stretch causes the micro-trauma in the muscle and connective tissues,
apart from increasing their flexibility
Zachazawski derived one stretching program for the athletes that is called as
"Progressive Velocity Flexibility Program". This stretching program is mainly
based on the velocity (slow, fast] ROM

Mechanical Stretching
o Long duration mechanical stretching: The low intensity and long duration
stretch gives more flexibility in the muscle and connective tissue is given
from 20 minutes to several hours, gives good effect than the stretch
applied for less than 20 minutes. The serial cast, pulleys, dynamic splints,
tilting table, traction are some of the mechanical devices made for
prolonged mechanical stretching. The stretch is given by external force in
low intensity for longer duration with the help of mechanical instrument.
o Cyclic mechanical stretching: The stretching program can be given in
cyclic manner with the help of mechanical devices. The intensity of
stretch, duration of stretch and number of stretch cycle per minute can be
set in the mechanical device itself. Thus, manual and mechanical

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stretching have different effect. The mechanical stretching (long duration,

cyclic) gives more flexibility in a short period than the manual method of
applying stretching.

II. PNF
o According to Knott and Ross, facilitation the proprioceptor with help of
neuromuscular activities can be used to stretch a particular muscle
o some main PNF techniques are used for the stretching, they are:
1. Hold and relax
2. Contract relax
3. Slow reversal.

III. SELF-STRETCHING
o The patient himself does this stretching program.
o This type of exercise showing early improvement in performing stretching
with the guideline of the therapist improves the neuromuscular facilitation
and relaxes the muscle.
o All the procedures are same as in passive stretching.

IV. EFFECTIVE STRETCHING

o Some of the physical modalities are helpful to increase the effect of

stretching
o . The assistive modality that increases the quality of stretch can be given
before the stretching regime.
o Some of them are:
1. Heat
2. Massage
3. Oscillation
4. Joint mobilization
5. Active exercise.

V. SKIN STRETCHING

o It is also like the joint stretching, the stretching has to be performed in the
side of the movement lacking.
o This type of stretching mainly performed for the burns contracture,
prolonged immobilisation contracture and traumatic contracture.
o For example, if the skin is tight in the necks that restrict the extension
movement has to undergo for the extension stretching. The same procedure
as said in the joint stretching has to be followed.

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TYPES OF STRETCHING
1. Muscle stretching
2. Joint stretching
3. Skin stretching
Manual stretching techniques or muscular stretching
techniques ——————-
 To stretch one particular muscle, the opposite action of that muscle should
be performed.

Tendo-Achilles Stretching
Action-Flexion of knee, plantar flexion of ankle.
Passive Stretching
Position of Patient: Supine lying.
Position of therapist: Standing beside the patient.
Procedure:
o The therapist holds the lower thigh region with his left hand
and flexing the knee.
o The therapist's right hand holds the heel in neutral position.
o Slowly extending the knee with the left hand and dorsiflexes
the heel with the right hand.
Self-stretching
o Standing on slopping surface and falling forwards
o Standing on the steps with the ball of the toes
Note: For soleus stretching knee extension should be avoided. Gastrocnemius
flexes the knee and plantar flexes the ankle but soleus is purely for plantar
flexion.

Dorsiflexors of Ankle
Passive Stretching
Position of patient: Supine lying.
Position of therapist: Standing beside the patient.
Procedure:
o Therapist's left hand holds the lower leg region and right
hand holds the foot, plantar flexing (pulling downwards).
Self-stretching
o Sitting on the stool by leg hanging, right foot is placed on the
left foot and stretching the dorsiflexors.

Quadriceps Stretching

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Action: Hip flexion and knee extension (Rectus femoris— hip flexion and knee
extension, vastus medialis, vastus lateralis, vastus intermedils knee extension).
Passive Stretching
Method-I
Position of the patient: Prone lying.
Position of the therapist: Standing beside the pt. and looking the
stretched part.
Procedure:
o Patient's knee is flexed and the therapist's left hand holds
the anterior portion of the knee, right hand holds the
ankle of the patient while forearm and elbow stabilising
the patient's pelvic.
o Lifting the thigh up with the left hand of the therapist
extends patient's hip.
Method - II
Position of the patient: Supine lying with the lower part kept
hanging at the end of the couch (from the hip region).
Position of the therapist: Standing beside the leg region of the
patient, which is hanging.
Procedure:
o Left leg of the patient is kept flexed and hold by the patient
himself.
o Therapist's right hand holding the lower leg and pushing
towards inside, i.e. flexing the knee.
o Left hand applies force on the lower part of the thigh and
pushes downwards, i.e. hip flexion.
Method-III
Position of the patient: Side lying.
Position of the therapist: Standing back to the patient and seeing
the limb.
Procedure:
o Left hand of the therapist stabilises the pelvic and restrict the
movement.
o Right hand of the therapist holds the right knee flexed
position and forearm supporting the leg.
After maximum flexion of the knee, hip extension is made by
pulling the leg backwards.
Self-stretching
Patient standing with one-foot support and the other foot, ankle
grasped by the respective side hand by knee flexion then the hip is
extended.

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Hamstring Stretching
Action: Flexion of the knee, extension of the hip.
Passive Stretching
Position of the patient: Supine lying.
Position of the therapist: Therapist is kneeling near the leg region
of the patient and the patient leg is kept over his shoulder.
Procedure: With the knee extension therapist flexes hip of the pt.
Self stretching
o Patient standing on one leg and other over an elevated
position and stretching the hamstrings by bending the hip
and trunk
o Long sitting on the floor-grasping the toes by the
corresponding hand and bending the trunk forwards.

Iliacus and Psoas Major Stretching

Passive Stretching
Method - I
Action: Hip flexion.
Position of the patient: Supine lying with the lower part of the
body hanging at the end of the couch.
Position of the therapist: Therapist is standing near to the leg
region of the patient.
Procedure:
o Normal side leg is kept flexed and holding by the patient
himself.
o Therapist is grasping the other leg and performing the hip
extension by pushing the leg down.
Method - II
Position of patient: Side lying.
Position of therapist:Standing back to the patient.
Procedure:
o Therapist's left hand stabilises the pelvis and right hand
grapes the lower thigh and knee, with forearm supporting the
leg region of the patient.
o The leg is pulled back with the help of right hand.
Self-stretching
o Fall out standing posture stretches the illiopsoas
o Stretched side hip and knee are extended and kept
backwards, the opposite side hip and knee are medium
flexed and kept forwards and stretches the iliopsoas.

Gluteus Maximus

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Action: Hip extension.

Passive Stretching
Position of patient: Patient is lying supine.
Position of therapist: Therapist is standing beside the pt. and facing
the limb.
Procedure:
o Therapist's right hand grasping the ankle while his left hand
holds the knee posteriorly.
o The leg is lifted with hip and knee flexed, towards the
cranial side of the patient.
Self-stretching
o Kneel sitting is one way of stretching the gluteus maximum.
o Patient flexing the hip and knee himself, in supine with his
hand maintains a good stretch.

Hip Adductor
Passive Stretching
Position of patient: Crook lying.
Position of therapist: Standing or sitting beside the patient facing
the limb.
Procedure: Both the heels are kept together and then drawn apart.
Self-stretching
o Knee bending to placing the sole of the foot together.
o Pressure applied on the knee to touch
o Carrying the child in the hip (Indian style of carrying the
child).

Iliotibial Tract
Passive Stretching
Action: Flexion, abduction, exte. rotation of hip, flexion of knee.
Position of patient: Side lying.
Position of therapist: Standing back to the pt. and facing the limb.
Procedure:
o Therapist's left hand stabilises the pelvic and right hand
grasps the patient knee with the leg placed over the forearm.
o Hip is extended, adducted and medially rotated, finally knee
extended to stretch the illioitibial tract.
Self-stretching
o Patient is standing and feet away from the wall and leaning
forward with one leg placed front and the other internally
rotated, 1 foot back to the front leg (Fig. 11.18).

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o In side lying the patient top leg foot is hooked over the bed
end, the hip is internally rotated, adducted and knee is
extended with support of the bed end.

Pectoralis Major
Passive Stretching
Action: Flexion, adduction, and medial rotation of the shoulder.
Position of patient: Supine lying with the upper limb kept at the
end of the couch.
Position of therapist: Therapist is standing beside the patient and
facing the respective upper limb.
Procedure:
o Therapist's left hand grasps the wrist and hand of the
patient while the right hand stabilises the shoulder then
the left hand performs the reverse action of pectoralis
major, i.e. lateral rotation abduction, extension of
shoulder.
Self-stretching
o Both the hands grasped behind the head and the patient is asked
to relax and drop down to touch the support surface (Fig.
11.20).
o The relative hand is placed over the wall by standing 3-4 feet
away from the wall and back facing the wall with the shoulder
externally rotated, abducted and extended.

Biceps Stretching
Action: Flexion of shoulder and elbow, supination of forearm.
Passive Stretching
Position of patient: Side lying.
Position of therapist: Therapist is standing back to the patient and
facing the limb to be stretched.
Procedure:
o Therapist's left hand grasps the wrist and hand of the
patient while right hand stabilises the shoulder.
o Left hand performs the shoulder extension, elbow
extension and forearm pronation.
Self-stretching

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o In high sitting, the patient place the hand back to body on the
surface and stretches the biceps.
o In standing—holding the rod back side and stretching

Triceps
Action: Shoulder extension and elbow extension.
Passive Stretching
Position of patient: Supine lying or sitting.
Position of therapist: Therapist is standing beside the patient.
Procedure:
o Left hand of the therapist holding the patient hand and
flexing the elbow after the hand reaches the shoulder.
Therapist's left hand stabilises the shoulder also.
o Therapist's right hand grasping the elbow lifts up to gain
shoulder flexion.
Self-stretching
o In sitting or standing with the opposite side hand elbow and
shoulder extension is performed to stretch the triceps.

Flexor Compartment Muscles of Forearm

Action: Wrist flexion, elbow flexion, finger flexion ( MCP, PIP, DIP).
Passive Stretching
Position of the patient: Sitting or supine lying, side lying.
Position of the therapist: Standing beside the patient.
Procedure:
o Therapist's left hand grasping the lower arm and
preventing the shoulder movement.
o Therapist's right hand grasps the hand and the fingers.
o Therapist extending the fingers and wrist after the elbow
extension. Here the whole flexor compartment muscles
undergo stretching.
Self-stretching
o Place the hand on the couch with wrist, fingers and elbow
extended and stretching the flexor compartment of the forearm.

Sternomastoid Stretching
Action: Same side flexion and opposite side rotation of the neck and also
forward flexion of the neck.
Position of the patient: Sitting or supine lying with the neck placed
at the end of the couch.
Position of the therapist: Therapist is standing behind the pt. head.

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Procedure: The therapist holds the patient head with both the hand
(one below the occipital other below the chin) and performs the
opposite action of the sternomastoid, i.e. opposite side flexion and
same side rotation and extension of the neck.

Soleus stretching

Key Parameters for Soleus Stretching

1. Duration:
o Hold each stretch for 20–60 seconds
o Repeat 2–4 times per session
o
2. Frequency:
o Daily or at least 3–5 times per week, depending on the goal (rehabilitation vs.
maintenance)
3. Intensity:
o Stretch should be gentle to moderate (mild discomfort but no pain)
o Avoid bouncing (ballistic stretching) to prevent muscle strain
4. Positioning:
o Knee must be bent to effectively target the soleus (as opposed to the
gastrocnemius, which is stretched with a straight knee)

Techniques for Stretching the Soleus

1. Standing Soleus Stretch (Wall or Lunge Method)

 How to do it:
1. Stand facing a wall, place both hands on it for support.
2. Step one foot back and bend both knees (keeping heels on the ground).
3. Lean slightly forward until you feel a stretch in the lower calf (Achilles area).
4. Hold and switch legs.

2. Seated Soleus Stretch

 How to do it:
1. Sit on the floor with legs extended.
2. Use a towel or resistance band around the ball of your foot.
3. Pull the foot towards you while keeping the knee slightly bent.

3. Heel Drop Stretch (Stair Stretch)

 How to do it:
1. Stand on a step with heels hanging off the edge.
2. Slightly bend the knees and drop the heels down.
3. Feel the stretch in the lower calf and hold.

4. Soleus Foam Rolling (Myofascial Release)

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 How to do it:
1. Sit on the floor and place a foam roller under the lower calf.
2. Cross the other leg on top for added pressure.
3. Roll back and forth slowly to release tightness

Joint stretching ————————-

 Joint stretching means the stretching of the soft tissue around the joint
including the muscles.
 we need to stretch the ligaments, bursae, capsule, cartilage and other soft
tissues of the joint-which may get tight and make the joint stiff. To prevent
the stiffness and to improve the ROM of the joint, this joint stretching will
be helpful. To stretch one joint we have to analyse which action or
movement has been restricted and same action or movement has to be
performed to stretch the structures, which is stiff.

Shoulder Joint
For Restricted Flexion Movement
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the limb.
Procedure
o Therapist's left hand grasps the lower arm region and the
patient's forearm resting over the therapist's forearm.
o Therapist's right hand apply opposite force on the scapular
region to prevent scapular movement
o Stretch force is given towards the flexion of the shoulder
with the therapist's left hand.
Stretched parts: Capsule, articular cartilages, glenoidal labrum,
extensor muscles and synovial membrane of the shoulder joint.

For Restricted Extension Movement

Position of patient : Prone lying
Position of the therapist : Therapist is standing beside the pt and
facing the limb
Procedure:
o Therapist's left hand grasps the lower arm region and the
patient's forearm resting over the therapist's forearm.
o Therapist's right hand apply opposite force on the scapular
region to prevent scapular movement
o Stretch force is given towards the extension of the shoulder
with the therapist's left hand.

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Stretched parts : Capsule, articular cartilages, glenoidal labrum,

flexor muscles, glenohumeral ligament and synovial membrane of
the shoulder joint.

Restricted Abduction Movement

Position of the patient: Supine lying.
Position of the therapist: Standing beside the patient and facing the
limb.
Procedure:
o Therapist's left hand grasps the lower arm region and the
patient's forearm resting over the therapist's forearm.
o Therapist's right hand applies opposite force on the scapular
region to prevent scapular movement.
o Stretch force is given towards the abduction of the shoulder
with the therapist's left hand.
Stretched parts: Capsule, articular cartilages, glenoidal labrum,
adductor muscles and synovial membrane of the shoulder joint.

For Restricted Medial Rotation

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the pt. and
facing the limb
Procedure:
o Therapist's left hand grasping the lower arm of the patient
while his right hand grasping the wrist and applying the
stretch force towards the medial rotation.
Stretched parts: Capsule, articular cartilages, glenoidal labrum,
lateral rotator muscles and synovial membrane of the shoulder

For Restricted Lateral Rotation

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the limb.
Procedure:
o Therapist's left hand grasping the lower arm of the patient
while his right hand grasping the wrist of the patient and
applying the stretch force towards the lateral rotation.
Stretched parts: Capsule, articular cartilages, glenoidal labrum,
medial rotator muscles and synovial membrane of the shoulder

Elbow Joint
For Restricted Flexion Movement

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Position of the patient: Supine lying.

Position of the therapist: Therapist is standing beside the patient
and facing the limb.
Procedure:
o Therapist's left hand grasping the lower arm of the patient
and stabilising the proximal joint.
o Therapist's right hand grasping the wrist of the patient.
o Stretch force is applied with the right hand of the therapist
towards the flexion of the elbow.
Stretched parts: Capsule, articular cartilages, elbow extensor
muscles, radial and ulnar collateral ligament.

For restricted extension movement

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the limb.
Procedure:
o Therapist's left hand grasping the lower arm of the patient
and stabilising the proximal joint.
o Therapist's right hand grasping the wrist of the patient.
o Stretch force is applied with the right hand of the therapist
towards the extension of the elbow.
Stretched parts: Capsule, articular cartilages, elbow flexors
muscles, radial and ulnar collateral ligament.

Forearm
For Restricted Supination and Pronation Movement
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the limb.
Procedure:
o Therapist's left hand stabilising the anterior aspect of
proximal humerus of the patient.
o Therapist's right hand grasping the lower forearm, wrist and
hand of the patient and elbow is in 90° flexed position.
o Therapist's right hand supinates and pronates the forearm
and stretches the structures
Stretched parts

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o While performing supination: Annular of the therapist

towards the extension of ligament, ulnar collateral ligament,
capsule, articular cartilages and pronator muscles.
o While performing pronation: Annular ligament, radial
collateral ligament, capsule, articular cartilages and
supinator muscles.

Wrist joint
Restricted Flexion Movement
Position of the patient: Patient is sitting on the stool or supine lying
Position of the therapist: Therapist is standing beside the pt. and
facing the wrist .
Procedure:
o Therapist's left hand grasping the lower forearm of the pat
while his right hand grasp the palm and fingers.
o The therapist flexes the wrist of the pat. with his right hand.
Stretched parts: Articular disc, capsule, extensor muscles of the
wrist, ulnar and radial ligament, extensor retinaculum

Restricted Extension Movement

Position of the patient: Patient is sitting on the stool or supine lying

Position of the therapist: Therapist is standing beside the pt. and
facing the wrist .
Procedure:
o Therapist's left hand grasping the lower forearm of the pat
while his right hand grasp the palm and fingers.
o The therapist extends the wrist of the pt. with his right hand.
Stretched parts: Articular disc, capsule, extensor muscles of the
wrist, ulnar and radial ligament, flexor retinaculum

Restricted Ulnar deviation

Position of the patient: Patient is sitting on the stool or supine lying

Position of the therapist: Therapist is standing beside the pt. and
facing the wrist
Procedure:
o Therapist's left hand grasping the lower forearm of the
patient while his right hand grasp the palm and fingers.
o The therapist performs the ulnar deviation of the wrist of the
patient with his right hand.

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Stretched parts : Articular disc, capsule, radial deviation muscles

of the wrist, radial ligament, radial part of extensor and flexor
retinaculum

Restricted radial deviation

Position of the patient: Patient is sitting on the stool or supine lying

Position of the therapist: Therapist is standing beside the pt. and
facing the wrist
Procedure:
o Therapist's left hand grasping the lower forearm of the
patient while his right hand grasp the palm and fingers.
o The therapist performs the radial deviation of the wrist of
the patient with his right hand.
Stretched parts : Articular disc, capsule, ulnar deviation muscles of
the wrist, ulnar ligament, ulna part of extensor and flexor
retinaculum

Hip joint
Restricted Flexion Movement
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the hip joint.
Procedure:
o Right hand of the therapist is grasping the lower leg region
of the patient while left hand grasping the patient’s knee.
o Therapist both hand flexes hip and knee of the patient
Stretched parts : Capsule , articular cartilage, ischiofemoral
ligament , extensors of hip

Restricted Extension movement

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the hip joint.
Procedure:
o Therapist's left hand stabilising the patient pelvis, while his
right hand grasping the upper thigh and the leg is resting on
the forearm of the therapist.
o Patient's thigh is lifted by the therapist's right hand and
performing the extension movement of the hip.
Stretched parts: Capsule, iliofemoral ligament, pubofemoral
ligament and flexors of hip.

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Restricted Abduction Movement

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the hip joint.
Procedure:
o Therapist's left hand stabilizes the opposite leg while his
right hand grasping the lower thigh and the leg is placed on
the therapist's forearm.
o Leg is pulled apart by the therapist's right hand.
Stretched parts: Capsule, transverse ligaments, articular cartilage,
adductor muscles.

Restricted Adduction Movement

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the pt. and
facing the hip
Procedure:
o Therapist's left hand stabilizing the opposite leg of the
patient, while his right hand grasping the lower thigh.
o Therapist's right hand pushes the leg inside.
Stretched parts: Capsule, abductors of the hip, articular cartilages.

Restricted Medial and Lateral Rotation Movement

Position of the patient: Supine lying
Position of the therapist: Therapist is standing beside the patient
and facing the hip joint.
Procedure:
o Therapist's left hand stabilising the thigh of the patient, while
his right hand grasping the lower leg
o Hip and knee are kept in flexed position of 90°.
o Therapist performing stretching both in medial and lateral
rotation directions.
Stretched parts:
o During medial rotation-Capsule, ischia-femoral ligament,
articular cartilage, lateral rotators.
o During lateral rotation-Capsule, pubs-femoral ligament,
iliofemoral ligament, transverse ligament, round ligament,
articular cartilages, medial rotators.

Knee Joint
Restricted Flexion Movement

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Position of the patient: Prone lying.

Position of the therapist: Therapist is standing beside the patient
and facing the knee joint.
Procedure:
o Therapist's left hand stabilising the pelvis of the patient
while his right hand grasping the lower leg region.
o Therapist's right hand flexes the knee and stretches the
tightened structures.
Stretched parts: Ligaments, medial and lateral meniscus, capsule,
bursae and extensor muscles.

Restricted Extension Movement

Position of the patient: Prone lying.
Position of the therapist: Therapist is standing beside the patient
and facing the knee joint.
Procedure:
o Therapist's left hand stabilising the pelvis of the patient
while his right hand grasping the lower leg region.
o Therapist's right hand extends the knee and stretches the
tightened structures.
Stretched parts: Ligaments, medial and lateral meniscus, capsule,
bursae and flexor muscles.

Ankle Joint
Restricted Plantar Flexion Movement
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the ankle joint.
Procedure:
o Therapist's left hand grasping the lower leg region and his
right hand palm holding the heel of the patient.
o Therapist's right hand plantar flexes the ankle and stretches
the tightened structures.
Stretched parts: Ligaments, capsule and dorsi-flexors.

Restricted Dorsiflexion Movement

Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the ankle joint.
Procedure:
o Therapist's left hand grasping the lower leg region and his
right hand palm holding the heel of the patient.

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o Therapist's right hand dorsiflexes the ankle and stretches the

tightened structures.
Stretched parts: Ligaments, capsule and plantar flexors
.
Subtalar Joints
Restricted Inversion Eversion Movement
Position of the patient: Supine lying.
Position of the therapist: Therapist is standing beside the patient
and facing the ankle joint.
Procedure:
o Therapist's left hand grasping the ankle joint of the patient
while his right hand grasping the foot region.
o Therapist's right hand is applying stretch force towards the
inversion and eversion movement and stretches the tightened
structures.
Stretched structures
o During inversion-Ligaments, capsules, articular cartilages
and evertors.During eversion-Ligaments, capsules, articular
cartilages and invertors.
Stress strain curve —————————-
 The role of the extensibility of the soft tissue, the stress-strain curve gives
the perfect knowledge about the load deformation of the soft tissue.
 Whenever the external force is applied to a soft tissue, it goes for more
stress and strain.
 The first phase is "elastic phase", the stretched tissue will go for normal
position after removing the external force.
 The second is "plastic phase", the stretched tissue may be remain in the
elongated state when the external force is removed.
 Third phase is "failure point", the stretched tissue may be teared or
separated.
 Normally, stretch techniques are done up to the limit of the plastic range
and sometimes about to reaching the breaking point but without causing
any tissue damage.
 While stretching the tightened joint or muscle the therapist may feel the
restriction by the surrounding structures
 Limitations may be due to capsule, ligaments, muscle, skin, fascia,
cartilages tightness or adhesions.
 The limitations or restrictions to stretch is felt by the therapist s called as
first tissue stop.
 Normally, the passive movement can cross the first tissue stop.
 If the therapists add more force after the fist tissue stop, he may feel again
the restriction to stretch by some structures is called as second tissue stop.

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If we apply force more than the first tissue stop the tissue will be attaining
the plastic range. But if the therapist crosses the second tissue stop, the
tissue may be separated or teared. So, the stretching technique should be
performed within the second tissue stop.

INDICATIONS ————————
o Post-traumatic stiffness
o Post-immobilisation stiffness
o Restrictive mobility
o Congenital or acquired bony deformity
o Joint pathology resulting in soft tissue stiffness
o Soft tissue pathology leading to relative soft tissue stiffness
o Healed burn scars
o Fear of pain spasm
o Adhesion formation over soft tissue
o Contracture of the joint and soft tissue
o Any type of muscular spasm
o Spasticity (UMS cause).
o ROM is limited because soft tissues have lost their extensibility as the
result of adhesions, contractures, and scar tissue formation, causing
activity limitations or participation restrictions.
o Muscle weakness and shortening of opposing tissue have
o May be a component of a total fitness or sport-
o to prevent or reduce the risk of musculoskeletal injuries.
o May be used prior to and after vigorous exercise.

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CONTRAINDICATIONS ————————-
o Synovial effusion
o Recent fracture
o Sharp pain while doing stretch
o Inflammation in the tight tissue
o Infection over tight tissue
o Immediately after dislocation
o Oedema
o Osteoporosis
o Haemophilic joint
o Hemarthrosis
o Malignant tumours
o Flail joint
o After joint arthroplasty
o Neuropathic joint
o Unhealed scars
o Unhealed burns
o Chronic rheumatoid arthritis.
Benefits of stretching ———————
 Improved Flexibility: Stretching enhances the flexibility of muscles and
joints, allowing for a greater range of motion. This can help individuals
regain or improve mobility, especially after injury or surgery.
 Injury Prevention: Regular stretching prepares muscles for physical activity
by enhancing flexibility and reducing the likelihood of strains and sprains.
Stretching before exercise ensures that muscles are warm and less prone to
injury.
 Reduced Muscle Tension: Stretching helps relieve tightness in muscles
caused by overuse, stress, or poor posture. This can reduce discomfort,
enhance muscle function, and improve overall movement.
 Pain Relief: Stretching can alleviate chronic muscle pain and discomfort,
particularly in conditions like back pain, muscle stiffness, or repetitive strain
injuries. It helps release endorphins, which are the body's natural painkillers.
 Enhanced Blood Circulation: Stretching increases blood flow to muscles,
improving oxygen and nutrient delivery while aiding in the removal of
metabolic waste products. This can speed up recovery and reduce post-
exercise soreness.
 Posture Improvement: Stretching can address muscle imbalances,
especially tight muscles, and improve posture. Proper alignment is important

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in preventing musculoskeletal problems and improving daily functional

activities.
 Reduced Stress and Anxiety: Stretching promotes relaxation by activating
the parasympathetic nervous system. It can reduce stress, lower anxiety
levels, and create a sense of well-being, which is helpful in both physical
rehabilitation and overall mental health.
 Enhanced Performance: Stretching regularly can improve overall athletic
performance by optimising muscle elasticity and joint mobility. This enables
better technique and efficiency during physical activities, enhancing overall
outcomes in exercise therapy.
 Improved Balance and Coordination: By increasing flexibility and range
of motion, stretching contributes to better balance and coordination. This is
especially beneficial for individuals recovering from injuries or those with
neurological conditions affecting motor control.
 Recovery and Rehabilitation: Stretching exercises are often prescribed in
rehabilitation programs to help recover from muscle injuries, improve joint
mobility, and reduce scar tissue formation. Stretching can also speed up the
healing process by improving circulation to the affected area.
 Improved Joint Health: Stretching helps maintain or improve the health of
joints by promoting proper movement and preventing stiffness. This is
particularly beneficial for individuals with arthritis or those experiencing
joint pain.
 Better Mental Focus and Mind-Body Connection: Stretching encourages
mindfulness and body awareness, improving the mind-body connection. This
is valuable for individuals in exercise therapy as it allows them to focus on
their movements, aiding in more effective rehabilitation and reducing the
risk of further injury.

Precautions —————-
1. Proper Assessment of the Individual:Ensure a thorough assessment of the
individual’s current physical condition, including any medical conditions,
injuries, or limitations. If the person has a history of injury (e.g., muscle
strains, ligament tears, joint issues) or chronic conditions (e.g., arthritis,
osteoporosis), consult with a healthcare professional before proceeding with
stretching.
2. Warm-Up Before Stretching:Stretching cold muscles can lead to injury.
Always recommend a gentle warm-up (such as light aerobic activity) before
performing any stretching exercises to increase muscle temperature and
elasticity.A warm-up helps prepare the body for deeper stretches and reduces
the risk of muscle strains or ligament sprains.
3. Gradual Progression:Begin with less intense stretches and gradually
progress to more challenging stretches as the individual becomes more

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flexible. This avoids overstretching and reduces the risk of injury.Increase

the intensity and duration of stretches slowly over time, allowing the body to
adapt to the increased range of motion.
4. Avoid Bouncing or Jerking Movements:Static stretches (holding a stretch)
should be preferred over ballistic stretches (bouncing or jerking). Bouncing
while stretching can lead to muscle strains or tears.A controlled, steady
approach to stretching is more effective and safer.
5. Maintain Proper Technique:Ensure the individual uses proper technique
during stretching exercises. Incorrect posture or form can lead to muscle
imbalances and potential injuries.Instruct the person to align their body
correctly and focus on stretching the target muscle group without forcing the
stretch.
6. Limit Overstretching:Stretching should never cause pain. If an individual
feels pain during a stretch, they are likely pushing beyond their range of
motion. This can lead to injury.Stretch only to the point of mild tension, not
discomfort or pain. It’s important to respect the body’s limits to prevent
overstretching.
7. Avoid Stretching During Acute Injuries:If an individual is experiencing
acute muscle strains, sprains, or other injuries, avoid stretching the injured
area until healing has begun. Stretching on an acute injury can exacerbate the
problem.Stretching should only be introduced in the recovery phase after the
acute pain subsides, and in consultation with a healthcare provider.
8. Consider Medical Conditions:For individuals with medical conditions like
osteoporosis, herniated discs, or hyper-mobility, stretching may need to be
modified or avoided entirely.In such cases, exercises should be prescribed by
a physical therapist or healthcare professional, who can tailor the program to
the individual’s condition.
9. Age-Related Considerations:The flexibility of older adults tends to
decrease with age, so stretching exercises should be gentle and focus on
maintaining mobility rather than increasing flexibility.Ensure that stretches
are performed in a safe manner, with adequate support and gradual
progression.
10.Breathing During Stretching:Encourage deep, slow breathing during
stretching exercises. Holding the breath can cause tension and discomfort in
the body, which can limit the effectiveness of the stretch.Inhale to prepare
for the stretch and exhale as the stretch is held, promoting relaxation and
better results.
11.Hydration and Nutrition:Ensure the individual is adequately hydrated
before performing stretching exercises. Dehydration can lead to muscle
cramps and reduce flexibility.Proper nutrition is also important for muscle
function and repair, so a balanced diet with sufficient protein and electrolytes
is essential.

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12.Monitor for Discomfort:Continually assess how the individual is

responding to the stretches. If they report pain, dizziness, or any unusual
discomfort, stop the stretch immediately.Modify the stretch or choose a
different exercise to ensure the safety-and comfort of the individual.

Principles of stretching ——————

1. Warm-Up First:
o Always perform a gentle warm-up before stretching. This increases
blood flow to muscles, raises body temperature, and prepares tissues
for stretching. A warm-up could include light aerobic activity (e.g.,
walking, cycling, or jogging) for 5-10 minutes.
2. Stretching to the Point of Mild Tension, Not Pain:
o Stretch to the point where you feel mild tension in the muscle, not
pain. Stretching should feel like a gentle pull, not a painful sensation.
Pain during stretching can indicate overstretching or injury.
3. Hold, Don’t Bounce (No Ballistic Stretching):
o Use slow, controlled, static stretching techniques where you hold the
stretch for 15-30 seconds. Avoid bouncing or jerking movements
(ballistic stretching), as this can increase the risk of muscle strains
o
4. Progress Gradually:
o Increase the intensity and duration of your stretches gradually. Over
time, as flexibility improves, you can extend the stretch and hold it
longer. Sudden or rapid increases in stretch intensity can cause injury.
5. Breathe Normally:
o Maintain a relaxed and steady breathing pattern during stretching.
Avoid holding your breath, as this can create tension in the body and
hinder the stretch. Inhale before stretching and exhale while deepening
the stretch.
6. Stretch Both Sides Equally:
o Always stretch both sides of the body equally. Many people have
imbalances in flexibility between their left and right sides, so it's
important to ensure that both sides are stretched in order to promote
balanced flexibility and avoid injuries.
7. Stretch Regularly:
o To improve flexibility and mobility, incorporate stretching into your
routine consistently. Stretching should be performed several times a
week for best results, particularly after workouts, during warm-ups, or
as part of a rehabilitation program.
8. Avoid Overstretching:

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o Avoid stretching beyond your body’s limits. Overstretching can lead

to muscle strains, ligament injuries, and long-term damage. It's
important to listen to your body and avoid pushing too far too quickly.
9. Focus on Proper Alignment and Posture:
o Maintain proper posture and body alignment during stretching.
Incorrect positioning can place unnecessary strain on joints and
muscles, leading to injury. Be mindful of body posture and alignment
to get the most benefit from each stretch.
10.Incorporate Stretching into a Balanced Program:Stretching should be
part of a comprehensive exercise program that includes strength training,
aerobic exercise, and flexibility work. A balanced approach ensures overall
physical health, strength, and flexibility.

11.Individualisation: Tailor stretching exercises to individual needs, goals, and

physical conditions. Factors such as age, injury history, and specific goals
should guide the type, intensity, and duration of the stretches.

12.Static vs. Dynamic Stretching: Static stretching (holding a stretch for a set
time) is beneficial for improving flexibility and should be done after a warm-
up or workout. Dynamic stretching (controlled leg swings, arm circles) is
ideal before exercise to prepare muscles for movement and increase range of
motion.

PERIPHERAL JOINT
MOBILISATION
o Joint mobilization, also known as manipulation refers to manual therapy
techniques that are used to modulate pain and treat joint impairments that
limit range of motion (ROM) by specifically addressing the altered
mechanics of the joint.
o The altered joint mechanics may be due to pain and muscle guarding, joint
effusion, contractures or adhesions in the joint capsules or supporting
ligaments, or aberrant joint motion.
o High-velocity thrust techniques, typically called manipulation.
o The terms "mobilization" and "manipulation" will be used interchangeably,
with the distinction made between non-thrust and thrust technique.
“ It is a slow, repetitive, rhythmical, oscillatory arthrokinematic and
osteokinematics movement done by a therapist within the available range and
using various grading under the patient's control.”

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KINEMATICS ————
Kinematics is the descriptions of motion and includes the time, space and mass
aspects of a moving object. It is of two types:
1. Arthrokinematics
2. Osteokinematics.

Arthrokinematics
Arthro— Joint, Kinematics-motion. The movement, which occurs in the joint
surface, is called as an "arthrokinematics".
 The articular surface undergoes for movement and the other remains stable.
These arthrokinematic movements are called as "joint play movements".
 Types of Arthrokinematics Movements
1.Rolling
2.Sliding (Gliding)
3. Spinning
4.Traction
5.Compression.
 JOINT SHAPE
 The type of motion occurring between bony partners in a synovial
joint is influenced by the shape of joint surface .
 For example in ovoid joint , one surface is convex and other is
concave
ROLLING (diagram all types)
One bone rolling on other
o Rolling occurs when the new equidistant point of moving surface
comes into contact with the new equidistant points on the stable
surface
o It occurs between the flat and curved surface. For example, ball rolling
on the floor
o Convex surface moves on concave surface moving object or vice
versa.Joint surfaces are incongruent.
o Rolling results in angular motion.
o If pure rolling occurs in any physiological it results in compression of
the joint capsule towards the bony movement.
o Rolling combines with the gliding, spinning during the physiological
movement.
o Direction of the rolling will be towards the physiological movement.

GLIDING ( SLIDING)
Characteristics of one bone sliding (translating) across an-other include the
following:

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o For a pure slide, the surfaces must be congruent, either flat or curved
o The same point on one surface comes into contact with the new points
on the opposing surface.
o Pure sliding does not occur in joints because the surfaces are not
completely congruent.
o The direction in which sliding occurs depends on whether the moving
surface is concave or convex.
o Sliding is in the opposite direction of the angular movement of the
bone if the moving joint surface is convex
o Sliding is in the same direction as the angular movement of the bone if
the moving surface is concave

Combined Roll-Sliding in a Joint

The more congruent the joint surfaces are, the more sliding there is of one bony
partner on the other with movement.
The more incongruent the joint surfaces are, the more rolling there is of one
bony partner on the other with movement.
o When muscles actively contract to move a bone, some of the muscles
may cause or control the sliding movement of the joint surfaces.
o For example, the caudal sliding motion of the humeral head during
shoulder abduction is caused by the rotator cuff muscles, and the
posterior sliding of the tibia during knee flexion is caused by the
hamstring muscles. If this function is lost, the resulting abnormal joint
mechanics may cause micro-trauma and joint dysfunction.
o The joint mobilization techniques described in this chapter use the sliding
component of joint motion to restore joint play and reverse joint hypo-
mobility.
o Rolling (passive angular stretching) is not used to stretch tight joint
capsules because it causes joint compression.

SPINNING
Characteristics of one bone spinning on another
o There is rotation of a segment about a stationary mechanical axis
o The same point on the moving surface creates an arc of a circle as the
bone spins.
o Spinning rarely occurs alone in joints but in combination with rolling and
sliding.
o Three examples of spin occurring in joints of the body are the shoulder
with flexion/extension, the hip with flexion/ extension, and the
radiohumeral joint with pronation/supination

COMPRESSION

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Compression is the decrease in the joint space between bony partners

o Compression normally occurs in the extremity and spinal joints when
weight bearing. Some compression occurs as muscles contract, which
provides stability to the joints.
o As one bone rolls on the other some compression also occurs on the side
to which the bone is angulating.
o Normal intermittent compressive loads help move synovial fluid and
thus help maintain cartilage health.
o Abnormally high compression loads may lead to articular cartilage
changes and deterioration.

TRACTION
Traction and distraction are not synonymous.
Traction is a longitudinal pull. Distraction is a separation, or pulling apart.
o Separation of the joint surfaces (distraction) does not always occur when
a traction force is applied to the long axis of a bone.
o For example, if traction is applied to the shaft of the humerus when the
arm is at the side, it results in a glide of the joint surface
o Distraction of the gleno-humeral joint requires a force to be applied at
right angles to the glenoid fossa

CONVEX- CONCAVE RULE

More the congruent surface, more the sliding occurs and more the incongruent
surface, more the rolling occurs.

Osteokinematics / physiological movements

Osteo—Bone, Kinematics-Movement/motion.
 The movement occurs in the bone rather than the joints surface is called as
"physiological movement".
 The physiological movement may differ from one joint to another due to the
structure of the bony alignment and the structure of the soft tissues around
the joint.
 Some joint has uniaxial movement, some has biaxial and some has triaxial.
 Mobilization techniques are totally contraindicated for hyper-mobile joint(
due to the laxity of the ligaments, reduced tension in the joint capsule and
the soft tissues around the joint)
 Mobilisation techniques are indicated for hypo-mobile joint ( due to spasm
of the ligaments, muscles, capsule or any other soft tissues around the joint
and sometime may be due to adhesion formation.
 If the joints are hyper-mobile or hypo-mobile there shall be some change of
normal joint ROM.

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 These osteokinematics movements are the visible movements and are

determined by the invisible arthrokinematics movements.
 It is believed that the arthrokinematic movements are very much needed for
the effective osteokinematic movements.
 Manual Grading of Movement
The joint movement can be graded by below mentioned scale. Amount of
the motion from the resting position can be measured by the goniometer
Grade -0 - No movement (stiff joint) [ HYPOMOBILE]
Grade -1 - Considerable limited movement[“]
Grade -2 - Slightly limited movement[“]
Grade -3 - Normal
Grade -4 - Slightly increased movement [ HYPERMOBILE]
Grade -5 - Considerable increased movement[“]
Grade -6 - Unstable (or) flail joint. [“]

 Osteokinematic movements are:

o Flexion
o Extension
o Abduction
o Adduction
o Medial rotation
o Lateral rotation
o Circumduction
o Supination
o Pronation
o Opposition
o Inversion
o Eversion
o Plantar flexion
o Dorsiflexion
o Forward bending
o Backward bending
o Lateral bending, etc.

 These osteokinematic movements are classified into two motions.

1. Rotatory motion / angular motion.
o Movement of an object around a fixed axis . Each segment moves
through the same angle, same time at a constant distance.
2. Translatory motion
o Each segment or object moves in straight line. Each segment moves
through same distance at the same time in parallel path.

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o If the movement occurs in straight line is called as "linear motion".

o If it occurs in curved pathway is called "curvilinear motion"

 To perform osteokinematic movement there should be an axis and a plane.

Plane and Axis ———

Planes are the space or surface where the movements take place.

Axis is the point by which the movements take place.

 The anatomical position is the correct position to discuss about the planes
and axes.
 The imaginary planes are made to each other perpendicular in the human
body. These are called as "Cardinal planes".
 They are:
1. Frontal plane (Coronal plane)
2. Sagittal plane (A-P plane)
3. Transverse plane (Horizontal plane).

1. Frontal plane
o The plane, which divides the body into equal front and back parts.
o This plane passes through the coronal suture of the skull.
o Movement occurs in X-Y plane.
o Movement occurs in sagittal axis or A-P axis.
o Movements possible are abduction and adduction.

2. Sagittal plane
o The plane, which divides the body into equal right and left parts.
o Movement occurs in Y-Z plane.
o This plane passes through the sagittal suture of the skull.
o Movements possible are flexion and extension.
o Movement occurs in frontal axis or coronal axis.

3. Transverse plane
o The plane, which divides the body into equal upper and lower parts.
o Movement occurs in X-Z plane.
o Movements possible are medial and lateral rotation.
o Movement occurs in vertical axis.

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Position of joint —————-

 It deals about the position of the articular surfaces of the joint and its merits
and demerits.The particular position of the joint has its own characteristics,
values and properties. The therapist uses some position for examination,
some for relaxation, and some for treatment purposes.
 They are:
1. Loose packed position
2. Zero position
3. Actual resting position
4. Tightly packed position (close packed).

Resting Position (Loosed packed position)

o Joint structures are most relaxed in this position.
o Contacts between the joint surfaces are lesser, so more space is
available for the accommodation of the synovial fluid and more
joint play movement also easily felt.
o For example, the shoulder joint is totally relaxed and more joint
play is felt in 30°-40° abducted position

Zero Position (Starting position)

o This is the starting position of the joint. While measuring the ROM
by the goniometer, the zero position is taken as starting point of
measurement.
o For example, to measure shoulder joint movements like flexion,
extension, adduction, abduction with goniometer, the zero position
we adopt is the arm kept by the side of the chest wall, and for the
medial and lateral rotations the adopted position is the shoulder in
90° abduction with elbow in 90° flexion.
Actual Resting Position
o An alternative resting position is adopted, since the resting position
may not be obtained effectively in some pathological and painful
conditions of the joint.
o For example, in post-traumatic stiffness, it is impossible to place the
joint in resting position. So that alternative position is adopted to
reduce the torque of the joint. This position is meant as actual resting
position.
o These actual resting positions are useful for testing and treating the
pathological joint conditions. While, choosing the actual resting
position, an attempt should be made to find out the loosest position of
the joint.

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Close Packed Position (Tightly packed position)

o The joint structures are maximum taut in this position.
o The articular surfaces are having maximum congruency between each
other and also the joint play movement will be very much difficult in
this position.
o The close packed position is usually at the extreme end of the ROM,
during this position the synovial fluid moves to the other side as the
synovial membrane gets compressed.
o This movement of the synovial fluid helps the capsule in getting extra
nourishment. It is essential for the therapist, to have a sound
knowledge about the close packed position of all the joint to avoid any
of the mobilization techniques in this position

Treatment plane ————

 It lies over the concave surface of the articular surface.
 The treatment plane moves with the movement of the concave surface. It
will be constant or stable while the convex surface moves.
 The treatment plane is perpendicular to the axis of the rotation. The joint
traction also will be given perpendicular to the treatment plane .
 While assessing a joint movement or joint play, the parallel or perpendicular
to the treatment plane should be performed.
 The gliding or rolling tests are done parallel to the treatment plane. Traction
and distraction can be performed perpendicular to the treatment plane. This
joint play movement decides the grade of the joint movement.

Accessory movenents-
are movements in the joint and surrounding tissues that are necessary for
normal ROM but that cannot be actively performed by the patient

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Mobilisation with movement-

also known as the mulligan techniques, a manual therapy approach that
combines a therapist's sustained accessory mobilization with the patient's active
physiological movement to address joint restrictions and improve mobility

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Physiology of joint ——————

a) Nutrition
 Joint articular surfaces are avascular and it receives the nutrition from
synovial fluid.
 The synovial fluid circulates inside the capsule to supply the nutrition to the
articular surfaces.
 The synovial fluid movement occurs by the compression of the articular
cartilage and capsule.
 The joint mobilization techniques also doing the same as said above
mechanism. So that the articular surface will be getting good nutrition
supply.

 Immobilisation of the joint may result in atrophy of the articular cartilage,

synovial membrane, and formation of adhesion. This can be cured by the
mobilization techniques.

b) Extensibility
 Joint mobility maintains the extensibility and tensile strength of the articular
tissues.
 If the joint is immobilised, the ligaments, tendons and cartilages loose its
extensibility property, which leads to joint stiffness and hypomobile.
 Normal joint movement prevents the contracture, shortening, and thickening
of the tissues.
 The mobilization techniques are also helpful to prevent the contracture and
thickening of the soft tissues and improve the extensibility property of the
soft tissues.

c) Joint Receptors
 Joint receptors transmit the impulses to the afferent nervous system from the
joint.
 The joint receptors give the awareness of the position and movement of the
joints.
 Injury, disease or immobilisation of the joint may cause the lack of
functioning of the joint receptors.
 There are four types of joint receptors
i. TYPE I ( postural )
ii. TYPE II ( dynamic)
iii. TYPE III ( inhibitive)
iv. TYPE IV ( nociceptive)

Stress – strain curve ——————

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Effect of pathological changes of the joint ————

 Each and every structure of the joint is much more important for the total
functioning of the joint. Defect in any of the structure leads to improper
functioning of the joint.
 Disease
o Joint diseases cause some deformation of the some joint structures
results in the improper, imperfect movement of the joint.
o For example, in RA the synovial membrane gets affected, so that there
is alteration in the synovial fluid secretion. Lack of nutrition may
cause deformation of the joint structures.
o In osteoarthritis erosion or degeneration of the cartilages occurs. So,
there will be restricted movement and painful movement.
o If the disease progresses results in contracture of the muscles,
weakness of the muscles, ligaments tightness, osteophytic formation
over the articular surfaces, osteoporotic changes in the articular
surface, makes the joints immovable.

 Injury
o Injury of the joint structure causes the improper movement and
improper gait pattern.
o If the synovial membrane injured, it secretes more synovium.
o Lacking of the stability comes due to the ligament injury.
o Injury of capsules and cartilages results in lacking of loading and
unloading.
o Any tendon injury may cause the lack of movement over the joint.
.
 Immobilisation
o Immobilisation may be imposed by the plaster cast, bedrest, and fear
of pain.
o Due to the non-mobility of the joint causes many changes over the
joint structures.
o Normally, after immobilisation, contracture develops in the
surrounding soft tissues, so that after the immobilisation of joint, it is
impossible to attain normal range of motion .
o ( table ) These are the changes occur in the surrounding tissues of the
joint. It may result in reduced ROM.
o Sometimes muscles may go for weakness or contracture due to the
immobilisation. So that the joint cannot function normally.

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Structure Changes
Bone Osteoporosis
LigamentsOsteoclastic activity leads to weakness of the ligaments. Decreased matrix
compound, degenerative changes in the ligaments lead to deterioration of
biomechanical activities
Cartilage Decreased
Proteoglycans , decreased water content, decreased thickness, increased stiffness.
Capsule Decreased proteoglycans, increased water content, atrophy of the
capsule
Tendon Decreased collagen content, atrophy, dec. size of the collagen fiber.
Synovium Proliferation of fibro-fatty connective tissue and formation of adhesion.

 Overuse
o Prolonged standing, sitting or attaining one particular posture or
attaining one particular movement may create some strain and stress
of the surrounding structures of the joint.
o Continuous loading of a joint tissue that is deformed earlier may not
get the time to recover.
o So that the tissue may be more prone to get overuse injury or
syndrome
o Normally, the cartilages, which is the most important connective
tissue for loading of a joint. If the deformation and degeneration
changes occur in the cartilage, the permeability of the cartilage will
get decreased.

Principles ————
Relaxation
 Patient should be in relaxed position before starting treatment
procedure.
 During the relaxed state there will not be any muscle work.
 the position of the patient is strictly noticed before giving the
treatment and also the position should not be altered during a
treatment process.
 The therapist's position also plays an important role to treat the
patient. The therapist has to adopt the walk standing position while
treating the patient.

Fixation
 The joint, which is proximal to the mobilising joint, should be fixed
and avoid trick/vicarious movement. So, that the accessory movement
may not occur in that joint which may reduce the ROM of the

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mobilising joint and also the movement can be localized to one

particular Joint.
Support or Stabilisation
 The distal part of the joint being moved should be supported or
comfortably stabilised for the relaxation and avoid the inconvenience.
 The therapist should grasp firmly which may stimulate the nerve
endings and improves the condition as well as the psychological
support of the patient.

Treatment Direction
 The treatment direction may be parallel or perpendicular to the treatment
plane.
 Distraction may be applied perpendicular to the treatment plane.
 The oscillatory technique may be performed parallel to the treatment
plane.
 Gliding is applied parallel to the treatment plane.

Treatment Force and Range

 The treatment force will be depended on the grade of the movement of
the joint; it may be gentle or forcible.
 Range of the movement may differ depends on the stiffness of the joint.
 The treatment force is given within the second tissue stop or within the
plastic range or sometime about to reach the breaking point of the tissue.

Treatment techniques ——————

 Treatment is graded according to the amount of the motion and the joint play
movement of the joint.
 There are two systems of grading of the mobilization.
1. Traction technique
2. Oscillatory technique.

 Traction Technique

Grade I: Slow, small amplitude perpendicular movement (distraction) to the

concave joint surface performed within first tissue stop. Used for reducing pain
Grade II: Slow, large amplitude perpendicular movement (distraction) to the
concave joint surface done up to the first tissue stop. Used for pain reduction
and increases the periarticular extensibility.
Grade III: Slow, large amplitude perpendicular movement (distraction) to the
concave joint surface performed up to the level of crossing the first tissue stop,

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but without reaching the second tissue stop. Used for periarticular extensibility,
to correct the positional fault and reduces the spinal disc herniation

Oscillatory Technique

Grade I: Slow, small amplitude oscillatory movement parallel to the concave

joint surface performed within the beginning range. Used for pain reduction
Grade II: Slow, large amplitude oscillatory movement parallel to the concave
joint surface performed within the first tissue stop. Used for pain reduction
Grade III: Slow, large amplitude oscillatory movement parallel to the concave
joint surface performed up to reaching the first tissue stop. Reduces the pain,
increases the periarticular extensibility, correct the postural faults, breaking
the adhesion.
Grade IV: Slow, small amplitude oscillatory movement parallel to the concave
joint surface performed slightly through the first tissue stop. Reduces the pain,
increases the periarticular extensibility, correct the postural faults, breaking
the adhesion.
Grade V: Slow, small amplitude, large velocity, thrust movement parallel to the
concave joint surface performed to snap the adhesion and up to about to reach
the second tissue stop. Reduces the spinal disc herniation and breaking the
adhesion.

 Traction is given for 10 seconds followed by rest period of several seconds.

 Oscillation is given for 2 or 3 per second for about 1 minute.
 Normally, the mobilization can be performed combined with the other
modalities like wax bath, hot water fomentation, massage, IFT, ultrasound,
etc.

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INDICATIONS ————
 Post-traumatic stiffness of the joint
 Postoperative stiffness of the joint
 Postimmobilization stiffness of the joint.
 Adhesion formation around the joint.
 Atrophy of the capsule.
 Atrophy of the synovial membrane.
 Painful joint.
 Disuse atrophy of the joint structures.
 Hypomobilty
 Spasm

CONTRAINDICATION ————
 Synovial effusion.
 Hemarthrosis.
 Recent fractures around the joint.
 Dislocation.
 Recent injuries around the joints.
 Acute RA.
 Flail joint.
 Malignant tumours..
 Immediately after surgery around the joint.
 Total joint replacements.
 Scoliotic spine.
 Spondylolisthesis.
 Hyper-mobility
 Inflammatory disease
 Bone disease
 Excessive pain
 Systemic connective tissue diseases such as rheumatoid arthritis, in which
the disease weakens the connective tissue (Gentle techniques may benefit
restricted tissue, but forceful techniques may rupture tissue and result in
instabilities.)
 Elderly individuals with weakened connective tissue and diminished
circulation (Gentle techniques within the tolerance of the tissue may be
beneficial to increase mobility.)
 High pyrexia
 Epilepsy
Procedure to apply Peripheral Joint Mobilisation ———

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1. Patient Assessment and Preparation:

 Patient History: Obtain a detailed history of the patient's condition, including pain
levels, previous injuries, and any contraindications to manual therapy
 Assessment: Perform a physical assessment of the joint’s range of motion, muscle
strength, and joint mobility. Assess any pain levels and identify areas of stiffness or
mechanical restriction.
 Informed Consent: Ensure the patient understands the procedure and has given
consent, explaining any potential discomfort
 Positioning: Position the patient comfortably. the joint being mobilised should be
positioned so that the therapist can apply a force while maintaining proper leverage
 Relaxation: Encourage the patient to relax to prevent muscle guarding during
mobilization.

2. Choosing the Appropriate Mobilization Grade:

Based on the assessment, choose the appropriate grade of mobilization (I, II, III, IV, or
MWM):

 Grade I or II for pain relief or improving tissue mobility in mild to moderate

conditions.
 Grade III or IV for restoring joint range of motion in stiff joints or chronic
conditions.
 MWM (Mobilization with Movement) can be used if there is a mechanical block or
specific movement dysfunction.

3. Technique for Performing the Mobilization:

a. Grade I or II (Pain Relief and Mobility):

 Hand Placement: Place one hand on the distal aspect of the joint to stabilize it. The
other hand will apply a mobilising force in the direction that aids in joint movement.
 Movement: Apply small to moderate oscillatory movements at a slow and controlled
speed, focusing on improving joint movement and relieving pain..
 Duration: Perform oscillations for 1–2 minutes or until the patient reports pain relief
or a reduction in muscle tension.

b. Grade III or IV (Joint Mobilization for Stiffness):

 Hand Placement:place one hand above the joint surface, applying pressure to stretch
the joint capsule. The other hand stabilises the joint, ensuring that the correct
mobilising force is applied.
 Movement: Grade III , Grade IV
 Duration: For Grade III or IV mobilisations, perform the oscillations for 30-60
seconds, repeating the mobilization 2–4 times as needed. Always monitor for patient
discomfort or pain beyond a mild level.

c. Sustained (Non-Oscillatory) Mobilization:

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 Hand Placement: As with oscillatory techniques, place one hand above the joint
surface, applying a steady force, and stabilize the joint with the other hand.
 Movement: Apply a sustained, continuous stretch to the joint capsule at a specific
point within the joint’s range of motion. This is typically done at the end range of
motion where there is resistance.
 Duration: Hold the sustained stretch for 20-30 seconds, then release. Repeat 3-5 times,
allowing the joint to relax between each stretch.

d. Traction Mobilization (Distraction):

 Hand Placement: One hand stabilises the joint while the other applies a gentle, longitudinal
traction force to create space between the joint surfaces.
 Movement: Gradually apply a controlled traction force, allowing space to increase between
the joint surfaces. This can be done in the direction of the joint's natural alignment (e.g.,
downward for the shoulder, forward for the hip).
 Duration: Apply traction for 20-30 seconds, repeating the procedure multiple times (2-3
repetitions) or longer depending on the patient’s response.

e. Mobilization with Movement (MWM):

 Hand Placement: The therapist stabilises one part of the joint (e.g., proximal tibia or humeral
head) while the patient actively moves the joint through a specific movement
 Movement: While the patient moves actively, the therapist provides a mobilising force in the
direction that supports the movement. The mobilising force should be applied in conjunction
with the active movement.
 Duration: Perform 10-15 repetitions, depending on the patient’s response, and reassess after
each set.

4. Reassessment and Adjustments:

 Recheck Range of Motion: Determine if the mobilization has improved the joint’s range of
motion.
 Patient Feedback: Ask the patient about their pain level and any discomfort experienced
during the procedure. The goal is to improve mobility while managing discomfort.
 Adjust Mobilization: If the patient feels too much discomfort or if the desired range of motion
hasn’t been achieved, adjust the technique (e.g., change the grade of mobilization, decrease
amplitude, or focus on a different direction).

5. Post-Treatment Care:

 Patient Instructions: Educate the patient on post-mobilization care. This may include gentle
movement exercises or stretches to maintain the joint’s range of motion.
 Monitoring: Instruct the patient to monitor any changes in symptoms (e.g., soreness, pain,
swelling) and to report any adverse effects.
 Follow-Up: Schedule follow-up sessions based on the patient’s condition and progress,
adjusting the mobilization techniques as needed.

Mobilisation techniques for individuals joints ————

[ From book Laxmi narayan ]
Maitland grades of mobilisation————-

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The Maitland Concept of joint mobilization is widely used in manual therapy to treat joint stiffness,
pain, and restricted movement. It consists of five grades (I–V), each differing in amplitude and depth
of movement.

▶ Grade I (Pain Relief & Relaxation) used for pain relief before reaching resistance

 Small-amplitude movement.
 Performed at the beginning of the joint’s range (before resistance is felt).
 Used to reduce pain and muscle guarding.

▶ Grade II (Pain Reduction & Maintaining Mobility) used for pain relief before reaching resistance

 Large-amplitude movement.
 Performed within the joint’s available range, but not reaching tissue resistance.
 Helps in pain relief and maintaining joint motion.

▶ Grade III (Increasing Joint Mobility) used for stiffness and mobility improvement

 Large-amplitude movement.
 Performed up to the limit of available motion (into tissue resistance).
 Used to improve joint range of motion and reduce stiffness.

▶ Grade IV (Stretching Joint Capsule & Tissues) used for stiffness and mobility improvement

Small-amplitude movement.

 Performed at the end range of motion, within tissue resistance.

 Helps in gaining flexibility and breaking adhesions.

▶ Grade V (Joint Manipulation) used for high velocity manipulations

 High-velocity, low-amplitude (HVLA) thrust beyond the joint’s normal range.

 Produces a "click" or cavitation sound (common in spinal manipulations).
 Used for rapid pain relief and improving joint motion but requires advanced training.

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AQUATIC EXERCISES
 Aquatic exercise refers to the use of water (in multi-depth immersion pools
or tanks) that facilitates the application of established therapeutic
interventions, including stretching, strengthening, joint mobilization, balance
and gait training, and endurance training.

Goals and Indications for Aquatic Exercise ———-

o The specific purpose of aquatic exercise is to facilitate functional
recovery by providing an environment that augments a patient's and/or
practitioner's ability to perform various therapeutic interventions.
o Facilitate range of motion (ROM) exercise
o Initiate resistance training
o Facilitate weight-bearing activities
o Enhance delivery of manual techniques
o Provide three-dimensional access to the patient
o Facilitate cardiovascular exercise
o Initiate functional activity replication
o Minimise risk of injury or re-injury during rehabilitation
o Enhance patient relaxation

Precautions and Contraindications to Aquatic Exercise

——
Precautions
 Fear of Water
Fear of water can limit the effectiveness of any immersed activity. Fearful
patients often experience increased symptoms during and after immersion
because of muscle guarding, stress response, and improper form with exercise.

 Neurological Disorders
Ataxic patients may experience increased difficulty controlling purposeful
movements. Patients with heat-intolerant multiple sclerosis may fatigue with
immersion in temperatures greater than 33°C. Patients with controlled epilepsy
require close monitoring during immersed treatment

 Respiratory Disorders
Water immersion may adversely affect the breathing of the patient with a
respiratory disorder. Lung expansion tends to be inhibited due to hydrostatic

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pressure against the chest wall.increased circulation in the chest cavity may
further inhibit lung expansion due to increased circulation to-the body.
 Cardiac Dysfunction
Patients with angina, abnormal blood pressure, heart disease, or compromised
pump mechanisms also require close monitoring.

 Small, Open Wounds and Lines

Small, open wounds and tracheotomies may be covered by waterproof
dressings. Patients with open lines require proper clamping and fixation.
Precautions should also be exercised with patients having G-tubes and
suprapubic appliances.

Contraindications
o Incipient cardiac failure and unstable angina
o Respiratory dysfunction, vital capacity of less than 1 liter
o Severe peripheral vascular disease
o Danger of bleeding or haemorrhage
o Severe kidney disease
o Open wounds without occlusive dressings, colostomy, and skin
infections, such as tinea pedis and ringworm
o Uncontrolled bowel or bladder
o Menstruation without internal protection
o Water and airborne infections or diseases
o Uncontrolled seizures during the last year

Properties of water ————-

Physical Properties of Water/ principles of aquatic exercise
 Buoyancy
 Buoyancy is the upward force that works opposite to gravity.
 Archimedes' principle states that an immersed body experiences
upward thrust equal to the volume of liquid displaced.
 Buoyancy provides the patient with relative weightlessness and joint
unloading by reducing the force of gravity on the body. In turn, this
allows the patient to perform active motion with increased ease.
 Buoyancy provides resistance to movement when an extremity is
moved against the force of buoyancy. This technique can be used to
strengthen muscles
 Buoyancy allows the practitioner three-dimensional access to the
patient.

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 Hydrostatic Pressure
 Hydrostatic pressure is the pressure exerted by the water on immersed
objects.
 Pascal's law states that the pressure exerted by fluid on an immersed
object is equal on all surfaces of the object. As the density of water
and depth of immersion increase, so does hydrostatic pressure.
 Increased pressure reduces or limits effusion, assists venous return,
induces bradycardia, and centralises peripheral blood flow.
 The proportionality of depth and pressure allows patients to perform
exercise more easily when closer to the surface.

 Viscosity
 Viscosity is friction occurring between molecules of liquid resulting in
resistance to flow.
 Resistance from viscosity is proportional to the velocity of movement
through liquid.
 Water's viscosity creates resistance with all active movements.
 Increasing the velocity of movement increases the resistance.
 Increasing the surface area moving through water increases resistance
.
 Surface Tension
 The surface of a fluid acts as a membrane under tension. Surface
tension is measured as force per unit length.
 The attraction of surface molecules is parallel to the surface. The
resistive force of surface tension changes proportionally to the size of
the object moving through the fluid surface.
 An extremity that moves through the surface performs more work than
if kept under water.
 Using equipment at the surface of the water increases the resistance.

Hydromechanics
 Hydromechanics comprise the physical properties and characteristics of fluid
in motion.
 Components of flow motion. Three factors affect flow; they are laminar
flow, turbulent flow, and drag.
 Moving water past the patient requires the patient to work harder to maintain
his or her position in pool.
 Application of equipment (glove/paddle/boot) increases drag and resistance
as the patient moves the extremity through water device to increase the drag
force on the leg/foot.
 Barbosa and associates' measured hydrodynamic drag in barefoot and
hydro-boot conditions to determine the coefficients of drag on a human
leg/foot model during simulated knee extension-flexion exercise.

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 The influence of water resistance created higher drag force when using the
hydro-boot during the early part of extension.
Thermodynamics
 Water temperature has an effect on the body and therefore on performance in
an aquatic environment.
 Specific Heat
o Specific heat is the amount of heat (calories) required to raise the
temperature of 1 gram of substance by
o The rate of temperature change is dependent on the mass and the
specific heat of the object.
o Water retains heat 1,000 times more than air
 Temperature Transfer
o Water conducts temperature 25 times faster than air.
o Heat transfer increases with velocity. A patient moving through the
water loses body temperature faster than an immersed patient at rest.

Center of Buoyancy
 Center of buoyancy affects the body in an aquatic environment.
 The center of buoyancy is the reference point of an immersed object on
which buoyant (vertical) forces of fluid predictably act.
 Vertical forces that do not intersect the COB create rotational motion.
 In the vertical position, the human center is located at the sternum.
 In the vertical position, posteriorly placed buoyancy devices cause the
patient to lean forward; anterior buoyancy causes the patient to lean back.
 During unilateral manual resistance exercises, the patient revolves around
the practitioner in a circular motion.
 A patient with a unilateral lower extremity amputation leans toward the
residual limb side when in a vertical position.
 Patients bearing weight on the floor of the pool (i.e., sitting, kneeling, or
standing) experience aspects of both the COB and COG.

Mobility and Functional Control Exercise ——-

Aquatic exercises, including flexibility, strengthening, gait training, and relaxation,
may be performed in temperatures between 26°C and 35°C. Therapeutic exercise
performed in warm water (33°C) may be beneficial for patients with acute painful
musculoskeletal injuries because of the effects of relaxation, elevated pain threshold,
and decreased muscle spasm.

Aerobic Conditioning ——
Cardiovascular training and aerobic exercise should be performed in water
temperatures between 26°C and 28°C. This range maximises exercise efficiency,
increases stroke volume, and does not elevate the heart rate to the extent that warmer
water does. Intense aerobic training performed above 80% of a patient's maximum

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heart rate should take place in temperatures between 22°C and 26°C to minimise the
risk of heat illness.
Pools for Aquatic Exercise ——-
 Pools used for aquatic therapy vary in shape and size. The rooms in which
pools are housed need to be adequately ventilated to avoid the accumulation
of condensation on walls, windows, and floors.
 A dressing room should be provided for changing clothes and showering.
 Traditional Therapeutic Pools
o Traditional therapeutic pools measure at least 100 feet in length and
25 feet in width. Depth usually begins at 3 to 4 feet with a sloping
bottom, progressing to 9 or 10 feet.
o This larger type pool may be used for groups of patients and the
therapists conducting the session while in the pool.
o These pools have built-in chlorination and filtration systems.
 Individual Patient Pools
o Pools designed for individual patient use are usually smaller, self-
contained units.
o The therapist provides instructions or cueing from outside the unit.
o In addition to built-in filtration systems, these units may include
treadmills, adjustable currents, and varying water depths.

Special Equipment for Aquatic Exercise ————-

Aquatic equipment is used to provide buoyant support to the body or an
extremity, challenge or assist balance, and generate resistance to movement.
By adding or removing equipment, the practitioner can progress exercise
intensity.
Type of equipment used is determined by the current functional level of the
patient and the specific goals for the therapy session.

 Collars, Rings, Belts, and Vests

o Equipment designed to assist with patient positioning by providing
buoyancy assistance can be applied to the neck, extremities, or trunk.
o Inflatable cervical collars are used for the supine patient to support the
neck and maintain the head out of the water
o Flotation rings are used to support extremities in any immersed position.
o Often the rings are used at the wrists and ankles during manual
techniques to assist with patient positioning and relaxation.
o Belts and vests are used to position patients supine, prone, or vertically
for shallow and deep water activities.

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o Belts and vests are used to assist with buoyancy of an extremity or the
entire body

 Swim Bars
o Buoyant dumbbells (swim bars) are available in short and long lengths.
o They are useful for supporting the upper body or trunk in upright
positions and the lower extremities in the supine or prone positions
o Patients can balance (seated or standing) on long swim bars in deep water
to challenge balance, proprioception, and trunk strength.

 Gloves, Hand Paddles, and Hydro-tone Bells

o Resistance to upper extremity movements is achieved by applying
webbed gloves or progressively larger paddles to the hands .
o these only resist motion in the direction of movement.
o Hydro-tone bells are large, slotted plastic devices that increase drag
during upper extremity motions.
o bells generate substantially more resistance than gloves or hand paddles

 Fins and Hydro-tone® Boots

o The application of fins or boots to the feet during lower extremity
motions generates resistance by increasing the surface area moving
through the water.
o Fins are especially useful for challenging hip, knee, and ankle strength.
o Hydro-tone* boots are most effective during deep water walking and
running

 Kick-boards
o The shapes and styles of kick-boards vary extensively among
manufacturers.
o Kick-boards may be used to provide buoyancy in the prone or supine
positions; to create resistance to walking patterns in shallow water when
held vertically; or to challenge seated, kneeling, or standing balance in
the deep water.

Pool Care and Safety ———

o Therapeutic pools require regular care and cleaning to avoid an infection
o Cleaning should occur at least twice weekly, and chlorine and pH level
tests should be done twice daily.
o All walking surfaces near and around the pool should be slip-resistant and
free of barriers.

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o Water splashes should be dried immediately to prevent slips and falls.

o Safety rules and regulations are a must, as are emergency procedures, and
should be posted and observed by all involved in therapeutic pool use.
o Life preservers should be readily available, and at least one staff member
who is CPR certified should be present at all times.

EXERCISE INTERVENTION USING AQUATIC ENVIRONMENT

Stretching exercise ———-

 Patients may tolerate immersed stretching exercises better than land
stretching because of the effects of relaxation, soft tissue warming, and ease
of positioning

 Manual Stretching Techniques

Manual stretching is typically performed with the patient supine in waist depth
water with buoyancy devices at the neck, waist, and feet. the patient may be
seated on steps. The buoyancy-supported supine position improves both access
to patient and control by practitioner, as well as the position of the patient.

Spine Stretching Techniques

 Cervical Spine: Flexion
Th. Position - Stand at the patient's head facing caudally.
Patient Position- BS supine without cervical collar.
Hand Placement- Cup the patient's head with your hands, the
forearms supinated and thumbs placed laterally. Alternatively,
place your hands in a pronated position with the thumbs at the
occiput. This results in a more neutral wrist position at end-range
stretch.
Direction of Movement- As you flex the cervical spine, the patient
has a tendency to drift away from you if care is not taken to
perform the motion slowly.

 Cervical Spine: Lateral Flexion

Th. Position- Stand at the side facing the patient.
Patient Position- BS supine without a cervical collar.
Hand Placement- Reach fixed hand dorsally under patient and
grasp contralateral arm; support the head with the movement hand.
Direction of Movement- Move the patient into lateral flexion and
apply stretch force at desired intensity. This position prevents
patient drift as fixed hand stabilizes patient against the practitioner

 Thoracic and Lumbar Spine: Lateral Flexion/Side Bending

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Th. Position- Stand on the side opposite that to be stretched, facing

cep-haled with ipsilateral hips in contact (e.g., if stretching the left
side of the trunk, therapist's right hip is against patient's right hip).
Patient Position- BS supine, if tolerated. The patient's stretch side
arm is abducted to end-range to facilitate stretch.

Hand Placement- Grasp the patient's abducted arm with the fixed
hand; alternately, grasp at deltoid if patient's arm is not abducted.
The movement hand is at the lateral aspect of the lower extremity
of the side to be stretched (more distal placement improves
leverage with stretch).
Direction of Movement- With the patient stabilised by your hip,
pull the patient into lateral flexion. This technique allows
variability in positioning and hand placement to isolate distinct
segments of the spine.

Shoulder Stretching Techniques

 Shoulder Flexion
Th. Position- Stand on the side to be stretched facing cephalwd .
Pt.Position - BS supine with affected shoulder positioned in slight
abduction.
Hand Placement- Grasp the buoyancy belt with the fixed hand; the
movement hand is at the elbow of the affected extremity.
Direction of Movement- After positioning the arm in the desired
degree of abduction, direct the arm into flexion and apply the
stretch force with the movement hand.

 Shoulder Abduction
Th. Position- Stand on the affected side facing cep-haled with
your hip in contact with the patient's hip.
Patient Position- BS supine.
Hand Placement - Stabilize the scapula with the fixed hand; the
movement hand grasps medially on the affected elbow joint.
Direction of Movement Guide the arm into abduction and apply the
stretch force. The hip contact provides additional stabilisation as
the stretch force is applied.

 Shoulder External Rotation

Th. Position Stand lateral to affected extremity facing cep haled .
Pt. Position- BS supine; position arm in desired degree of
abduction with elbow flexed to 90°.

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Hand Placement- Grasp the medial side of the patient's elbow with
the palmar aspect of the fixed hand while fingers hold laterally;
grasp the mid-forearm with the movement hand.
Direction of Movement - Movement hand guides forearm dorsally
to externally rotate the shoulder and apply stretch force.

 Shoulder Internal Rotation

Th. Position- Stand lateral to patient's affected extremity facing
caudally.
Patient Position- BS supine; position arm in desired degree of
abduction with elbow flexed to 90°.
Hand Placement- Stabilize scapula with dorsal aspect of fixed
hand entering from axilla; movement hand is at the distal forearm.
Direction of Movement- Direct the forearm palmarward and apply
the stretch force.
Use care to observe the glenohumeral joint to avoid a forward
thrust and substitution.

Hip Stretching Techniques

 Hip Extension
Practitioner Position- Kneel on one knee at patient's affected side.
Pt. Position-BS supine with hip extended and knee slightly flexed.
Hand Placement-Stabilize the patient's affected extremity by
hooking the top of the foot with your ipsilateral thigh. Grasp the
buoyancy belt with the movement hand and guide the motion with
the fixed hand on the knee.
Direction of Movement-Direct the patient caudally with the
movement hand. To increase the stretch on the rectus femoris,
lower the patient's knee in the water. Motion is performed slowly
to limit spinal and pelvic substitution.

 Hip External Rotation

Practitioner Position- Face the lateral aspect of the patient's thigh
with your ipsilateral arm under the patient's flexed knee.
Patient Position- BS supine; hip flexed 70° and knee flexed 90°.
Hand Placement- Grasp the buoyancy belt with contralateral
(fixed) hand while ipsilateral (movement) hand grasps the thigh.
Direction of Movement- Externally rotate hip with the movement
hand as patient's body lags through water to create stretch force.

 Hip Internal Rotation

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Practitioner Position- Face the lateral aspect of the involved thigh

with the ipsilateral arm under the flexed knee.
Patient Position- BS supine, hip flexed 70° and knee flexed 90°.
Hand Placement- Stabilize buoyancy belt with contralateral (fixed)
hand while grasping thigh with the ipsilateral (movement) hand.
Direction of Movement- Internally rotate the hip as the patient's
body lags through water to create the stretch force.

Knee Stretching Techniques

 Knee Extension With Patient on Steps
Practitioner Position -Half-kneel lateral to the affected knee with
the ankle of the affected extremity resting on your thigh.
Patient Position- Semi-reclined on pool steps.
Hand Placement- Place one hand just proximal and one just distal
to the knee joint.
Direction of Movement- Extend the patient's knee.

 Knee Flexion With Patient on Steps

Practitioner Position- Half-kneel lateral to the affected knee.
Patient Position- Semi-reclined on pool steps.
Hand Placement- Grasp the distal tibia with the ipsilateral hand;
the contralateral hand stabilizes the lateral aspect of affected knee.
Direction of Movement- The stretch force into flexion.

 Knee Flexion With Patient Supine (Fig. 9.15)

Practitioner Position- Half-kneel lateral to the affected knee with
the dorsal aspect of patient's foot hooked under ipsilateral thigh.
Patient Position- BS supine, affected knee flexed.
Hand Placement- Place the ipsilateral (fixed) hand on distal tibia
and the contralateral (movement) hand on buoyancy belt to pull the
body over the fixed foot.
Direction of Movement- Pull the patient's body over the fixed foot,
creating the stretch to increase knee flexion. Lower the patient's
knee into the water to extend the hip and increase the stretch on the
rectus femoris. Perform the motion slowly to limit spinal and
pelvic substitution.

 Hamstrings Stretch
Practitioner Position- Face the patient and rest the patient's
affected extremity on your ipsilateral shoulder.
Patient Position- BS supine, knee extended.
Hand Placement- Place both hands at distal thigh.

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Direction of Movement- Start in the squatting position and

gradually stand to flex the hip and apply the stretch force. Maintain
knee extension by pulling patient closer and increasing the stretch.

Self-Stretching With Aquatic Equipment

Self-stretching can be performed in either waist-deep or deep water. The patient
frequently utilises the edge of the pool for stabilisation in both waist-deep and
deep water. Applying buoyancy devices may assist with stretching and increase
the intensity of the aquatic stretch.
The following terms are used to describe the self-stretching
techniques:
o Patient position. Includes BA (seated/upright), BS (supine), or vertical.
o Buoyancy-assisted. Using the natural buoyancy of water to "float" the
extremity toward the surface.
o Equipment-assisted. Includes use of buoyancy devices attached or held
distally on an extremity.

 Shoulder Flexion and Abduction

Patient Position- Upright, neck level immersion.
Equipment- Small or large buoyant dumbbell or wrist strap.
Direction of Movement- Grasping the buoyant device with affected
extremity allows extremity to float to surface-as buoyancy device
provides gentle stretch.

 Hip Flexion
Patient Position-Upright, immersed to waist, or seated at edge of
pool/on steps with hips immersed.
Equipment- Small buoyant dumbbell or ankle strap. For hip flexion
with knee flexion, place strap/dumbbell proximal to the knee. For
hip flexion with knee extension (to stretch the hamstrings), place
strap/dumbbell at the ankle.
Direction of Movement- Allow buoyancy device to float hip into
flexion, applying stretch to hip extensors or hamstrings.

 Knee Extension
Patient Position- Seated on steps/edge of pool with knee in a
position of comfort.
Equipment- Small dumbbell or ankle strap.
Direction of Movement- Allow buoyancy device to extend knee
toward the surface applying stretch to increase knee extension.

 Knee Flexion

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Patient Position- Stand immersed to waist with hip and knee in

neutral position; increasing the amount of hip extension increases
the stretch on the two joint knee extensors.
Equipment- Small dumbbell or ankle strap.
Direction of Movement- Allow buoyancy device to flex the knee
toward the surface, applying stretch to knee extensors.

Strengthening exercises
 By reducing joint compression, providing three-dimensional resistance, and
dampening perceived pain, immersed strengthening exercises may be safely
initiated earlier in the rehabilitation program than traditional land
strengthening exercises
 Both manual and mechanical immersed strengthening exercises typically are
done in waist-deep water.

 Manual Resistance Exercises

Manual aquatic resistance exercises are designed to fixate the distal segment of
the extremity as the patient contracts the designated muscle group .
The patient's movement through the viscous water generates resistance, and the
patient's body produces the drag forces.
Stabilisation of the distal extremity segment is essential for maintaining proper
form and isolating desired muscles.

Upper Extremity Manual Resistance Techniques

 Shoulder Flexion/Extension
Th. Position- Face caudal, lateral to patient's affected shoulder.
Patient Position- BS supine; affected extremity flexed to 30°.
Hand Placement- Place the palmar aspect of the guide hand at the
patient's acromioclavicular joint. The resistance hand grasps the
distal forearm. An alternative placement for the resistance hand
may be the distal humerus; this placement alters muscle
recruitment.
Direction of Movement- Active shoulder flexion against the
resistance hand causes the body to move away from the
practitioner. Active shoulder extension from a flexed position
causes the body to glide toward the practitioner.
NOTE: The patient must be able to actively flex through 120°
for proper resistance to be provided.

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 Shoulder Abduction
Th. Position- Face medially, lateral to patient's affected extremity.
Patient Position- BS supine; affected extremity in neutral.
Hand Placement- Place the palmar aspect of guide hand at the proximal
humerus as the thumb wraps anteriorly and the fingers wrap posteriorly.
Place the resistance hand at the lateral aspect of distal humerus.
Direction of Movement - The practitioner determines the amount of
external rotation and elbow flexion. Active abduction against the
resistance hand causes the body to glide away from the affected
extremity and the practitioner.
 Shoulder Internal/External Rotation
Th. Position- Face medially on lateral side of pt affected extremity.
Patient Position- BS supine; affected extremity's elbow flexed to 90°
with shoulder in desired amount of abduction and initial Rotation .
Hand Placement- Place the palmar aspect of the guide hand at the
lateral aspect of the elbow. The resistance hand grasps the palmar
aspect of the distal forearm. An alternative method requires the
practitioner to "switch" hands. The practitioner's ipsilateral hand
becomes the guide hand and grasps the buoyancy belt laterally. The
practitioner's contralateral hand becomes the resistance hand. This
approach allows improved stabilisation; however, the practitioner
loses contact with the patient's elbow and must cue the patient to
maintain the desired degree of shoulder abduction during the
exercise.
Direction of Movement- Active internal rotation by the patient
against the resistance hand causes the body to glide toward the
affected extremity; active external rotation causes the body to glide
away from the affected extremity.

 Unilateral Diagonal Pattern: D, Flexion/ Extension of the Upper

Extremity
Practitioner Position- Stand lateral to the patient's unaffected
extremity and face medially and caudally.
Patient Position- BS supine; affected extremity internally rotated
and pronated with slight forward flexion.
Hand Placement- Secure the medial and lateral epicondyles of the
distal humerus with the guide hand. Place the resistance hand on
the dorsal surface of the distal forearm.
Direction of Movement- execute the specific joint motions
expected in diagonal patterns. Active contraction through D,flexion
pattern causes body to glide awayfrom practitioner. At end position
of D,secure medial and lateral epicondyles of distal humerus with
the guide hand. The resistance hand will be on the palmar aspect of

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the distal forearm. From the flexed position, the practitioner cues
the patient to contract through the D, extension pattern.

 Unilateral Diagonal Pattern: D,Flexion/ Extension of the Upper

Extremity
Practitioner Position- Stand lateral to the patient's affected
shoulder; face medially and caudally.
Patient Position- BS supine; affected extremity adducted and
internally rotated.
Hand Placement- Secure the medial and lateral epicondyles of the
distal humerus with the guide hand. Wrap the palmar aspect of the
resistance hand on the dorsal wrist medial to the palmar surface.
Direction of Movement- Active movement through the D,flexion
pattern causes body to glide away from the practitioner. From the
fully flexed position, cue patient to then move into the D,extension
pattern. This causes the body to glide toward the practitioner.

 Bilateral Diagonal Pattern: D,Flexion/Extension of the Upper

Extremities
Practitioner Position- Stand cephalaed towards the head to
patient, facing caudally.
Patient Position- BS supine; upper extremities adducted and
internally rotated.
Hand Placement- Use both hands to provide resistance. Grasp the
dorsal aspect of each of the patient's wrists, wrapping medially to
the palmar surface.
Direction of Motion- Active contraction through the D,flexion
pattern causes the body to glide away from the practitioner. From
the fully flexed position, cue the patient to contract through D,
extension, causing the patient to move toward the practitioner.

Lower Extremity Manual Resistance Techniques

 Hip Adduction
Practitioner Position- Stand lateral to the patient's affected
extremity and face medially.
Patient Position- BS supine; hip abducted.
Hand Placement- Place the guide hand on the buoyancy belt and
the resistance hand on the patient's medial thigh.
Direction of Movement- Active contraction of the hip adductors
causes the affected leg to adduct as the contralateral leg and body
glides toward the affected leg and the practitioner.

 Hip Abduction

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Practitioner Position- Stand lateral to patient's affected extremity,

facing medially.
P.P.- BS supine; hip adducted.
Hand Placement- Place the guide hand on the buoyancy belt or
lateral thigh and the thumb and base of the resistance hand on the
patient's lateral leg.
Direction of Movement- Active contraction of the hip abductors
causes the affected leg to abduct as the contralateral leg and body
glide away from the affected leg and the practitioner.
 Hip Flexion With Knee Flexion
Practitioner Position- Stand at the side of the patient's affected
extremity, facing cephalad.
Patient Position- BS supine.
Hand Placement- Place the guide hand on the buoyancy belt or
lateral hip. The resistance hand grasps proximal to the distal
tibiofibular joint.
Direction of Movement- Active contraction of the hip and knee
flexors causes the patient's body to glide toward the practitioner
and fixed distal extremity.

 Hip Internal/External Rotation

Practitioner Position- Stand lateral to the patient's affected
extremity, facing medially.
Patient Position- BS supine; hip in neutral at 0° extension with
knee flexed to 90°.
Hand Placement- Contact distal thigh medially with guide hand
for resisted internal rotation&laterally for resisted external rotation.
Place the resistance hand at the distal leg.
Direction of Movement- Active contraction of hip rotators
(alternating between internal and external rotation) causes the
patient's body to glide away from the distal fixed segment.
PRECAUTION: Avoid this exercise for patients with possible
medial or lateral knee joint instability.

 Knee Extension
Practitioner Position- Stand at the patient's feet, facing cephalad.
Patient Position- BS supine.
Hand Placement- Place the guide hand at patient's lateral thigh and
the resistance hand on the dorsal aspect of distal tibiofibular joint.
Direction of Movement- Active contraction of the quadriceps
against the practitioner's resistance hand directs the body away
from the practitioner as the knee extends.

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 Ankle Motions
Practitioner Position- Stand lateral to affected leg, facing caudally.
Patient Position- BS supine.
Hand Placement- The hand placement creates a short lever arm at
the patient's ankle. As the patient moves through the resisted ankle
motions, patient's entire body moves through the water, producing
a significant amount of drag and demand on the ankle complex.
PRECAUTION: For patients with ligamentous laxity and unstable ankles or compromised ankle
musculature, the practitioner should cue the patient to avoid maximum effort during contraction to avoid
potential injury.
 Ankle Dorsiflexion and Plantarflexion
Hand Placement- Place the guide hand on the lateral aspect of the
leg and the resistance hand over the dorsal aspect of the foot to
resist dorsiflexion and on the plantar aspect to resist plantarflexion.
Direction of Movement- body moves toward the practitioner during
dorsiflexion and away from practitioner during plantarflexion.

 Ankle Inversion and Eversion

Hand Placement- Place the guide hand on the lateral aspect of the
lower leg during inversion and on the medial aspect of tibia during
ever-sion. To resist inversion, grasp the dorsal medial aspect of the
foot and to resist eversion grasp the lateral foot.
Direction of Movement- During inversion, body glides toward
practitioner,during eversion, body glides away from practitioner .

Dynamic Trunk Stabilisation

 Dynamic Trunk Stabilisation: Frontal Plane
Practitioner Position- Hold the patient at the shoulders or feet.
Patient Position- Typically, the patient is placed in a supine
position with buoyancy devices at the neck, waist, and legs.
Execution- Have patient identify his or her neutral spine position,
perform a "drawing-in maneuver" and maintain spinal position
(isometric abdominal contrac-tion). Move patient from side to side
through the water; monitor and cue patient to avoid lateral trunk
flexion, an indication that patient is no longer stabilising the spine.
Intensity- Moving patient through water faster increases drag &
exercise intensity. Holding patient more distally increases exercise
intensity.

 Dynamic Trunk Stabilisation: Multidirectional

Practitioner Position-Stand at the shoulders or feet of patient and grasp
patient's extremity to provide fixation as patient contracts.
Patient Position- Typically, the patient is placed in a supine position with
buoyancy devices at the neck, waist, and legs.

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Execution- Instruct the patient to assume a neutral spine, perform the drawing-
in maneuver, and "hold" the spine stable. Instruct the patient to perform either
unilateral or bilateral resisted extremity patterns while maintaining a neutral
spine and abdominal control. Monitor and cue the patient to avoid motion at
the trunk, an indication that the patient is no longer stabilising with the deep
abdominal and global muscles. Upper extremity motions include shoulder
flexion, abduction, and diagonal pat-terns. Lower extremity motions include
hip and knee flexion and hip abduction and adduction.
Intensity- Unilateral patterns are more demanding than bilateral patterns.
Increasing speed or duration increases exercise intensity

Independent Strengthening Exercises

 Often patients perform immersed strengthening exercises in-dependently.
Because the resistance created during movement through water is speed
dependent, patients are able to control the amount of work performed and the
demands imposed on contractile elements.
 The following terms are used for equipment-assisted exercise.
o Buoyancy-assisted: Vertical movement directed parallel to vertical forces
of buoyancy that assist motion
o Buoyancy-supported: Horizontal movement with vertical forces of
buoyancy eliminating or minimising the need to support an extremity
against gravity
o Buoyancy-resisted: Movement directed against or perpendicular to
vertical forces of buoyancy, creating drag (performed without
equipment).
o Buoyancy-super-resisted: Use of equipment generates resistance by
increasing the total surface area moving through water by creating greater
drag. Increasing the speed of motion through water generates further
drag.

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Aerobic conditioning ———————

 Aquatic exercise that emphasizes aerobic/cardiovascular conditioning can be
an integral component of many rehabilitation programs,
 Aerobic/cardiovascular exercise typically takes place with the patient
suspended vertically in deep water pools without the feet touching the pool
bottom.
 Treatment Interventions
Deep-water walking/running are the most common vertical deep-water
cardiovascular endurance exercises. Deep-water cardiovascular training,
which may be used as a precursor to midwater or land-based
cardiovascular training, eliminates the effects of impact on the lower
extremities and spine.
The patient can be tethered to the edge of the pool to perform deep-water
running in those pools with limited space.
Mid-water jogging/running (immersed treadmill run-ning).which may be
used as a precursor to land training, lessens the effects of impact on the
spine and lower extremities. As a patient's tolerance to impact improves,
midwater jogging may be performed in progressively shallower depths to
provide increased weight bearing and functional replication. In pools
limited space, tethering with resistive tubing can provide resistance.
Immersed equipment. Immersed equipment includes an immersed cycle,
treadmill, or upper body ergometer.
Swimming strokes. For patients able to tolerate the positions necessary to
perform various swim strokes (neck and shoulder ROM and prone,
supine, or side-lying positions), swimming can be an excellent tool to
train and improve cardiovascular fitness.
PRECAUTION: Recommending swimming for poorly skilled swimmers
with cardiac compromise may adversely challenge the patient's
cardiovascular system.

 Physiological Response to Deep-Water Walking/Running

Cardiovascular response. Patients without cardiovascular compromise
may experience dampened elevation of heart rate, ventilation, and
VOmax compared to similar land-based exercise. During low-intensity
exercise, cardiac patients may experience lower cardiovascular stresses.
As exercise intensity increases, cardiovascular stresses approach those of
related exercise on land.
Training effect. Patients experience carryover gains in VOmax from
aquatic to land conditions Additionally, aquatic cardiovascular training
maintains leg strength and maximum oxygen consumption in healthy
runners
 Exercise Monitoring

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Monitoring intensity of exercise.

o Rate of perceived exertion. at both sub-maximal and maximal
levels of exertion, subjective numerical rating of effort appears to
correlate adequately with the heart rate during immersed exercise.
o Heart rate. Because of the physiological changes that occur with
neck level immersion, decreases range from 7 to 20 beats per
minute. The immersed heart rate can be reliably monitored
manually or with water-resistant electronic monitoring devices.
Monitoring beginners.
o Care should be taken to monitor regularly the cardiovascular
response of novice deep-water runners or patients with known
cardiac, pulmonary, or peripheral vascular disease.
o Novice deep-water runners may experience higher levels of
perceived exertion and VOmax than they would during similar land
exercise.

 Equipment Selection
Deep water equipment. Selection of buoyancy devices should reflect the
desired patient posture, comfort, and projected intensity level. The most
common buoyant device for deep-water running is the flotation belt
positioned posteriorly . Patients presenting with injuries or sensitivity of
the trunk may require an alternative buoyant device, such as vests,
flotation dumbbells, or noodles. Providing the patient with smaller
buoyant equipment (i.e., smaller belts, fewer noodles) requires the patient
to work harder to maintain adequate buoyancy, thereby increasing the
intensity of the activity. Fins and specially designed boots can be applied
to the legs and feet to add resistance.Also, bells or buoyant dumbbells can
be held in the hands to increase resistance (see Fig. 9.10).
Midwater equipment. Specially designed socks can help eliminate the
potential problem of skin breakdown on the feet during impact activities,
such as running. Patients can run against a forced current or tethered with
elastic tubing for resistance. Using noodles around the waist or running
while holding a kick-board increases the amount of drag and resistance
against which the patient must move.

Physiological effect ——————-

1. Buoyancy and Reduced Weight-Bearing
o Water reduces the effect of gravity, decreasing stress on joints and bones.
o It allows for pain-free movement in individuals with musculoskeletal
conditions.
o
2. Hydrostatic Pressure

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o Improves venous return and circulation, reducing swelling and oedema.

o Aids in stabilising the body, enhancing proprioception and balance.
3. Cardiovascular Effects
o Increases cardiac output due to improved venous return.
o Reduces heart rate compared to land-based exercise, making it ideal for
cardiac rehabilitation.
4. Respiratory Benefits
o The pressure of water on the thorax increases respiratory effort, strengthening
respiratory muscles.
o Beneficial for individuals with COPD or asthma.
5. Muscle Activation and Strengthening
o Water resistance enhances muscle engagement without high-impact stress.
o Facilitates gentle strengthening in post-surgical and arthritic patients.
6. Thermal Effects
o Warm water (around 32–34°C) promotes muscle relaxation, reduces pain, and
enhances flexibility.
o Cold water therapy can help with inflammation reduction.

Therapeutic Effects of Aquatic Exercise in Exercise Therapy ——-

1. Pain Reduction
o Warm water and buoyancy reduce joint compression and pain, benefiting
arthritis and fibromyalgia patients.
2. Improved Range of Motion & Flexibility
o Water’s resistance and reduced gravitational pull help increase joint mobility.
3. Rehabilitation & Injury Recovery
o Used in post-surgical and orthopaedic rehabilitation for gradual weight-
bearing progression.
4. Improved Balance & Coordination
o Hydrostatic pressure and water turbulence challenge stability, enhancing
balance in neurological conditions (e.g., stroke, Parkinson’s).
5. Enhanced Cardiovascular Fitness
o Beneficial for individuals with limited weight-bearing capacity, such as obese
or elderly populations.
6. Psychological Benefits
o Reduces stress, anxiety, and depression.
o Promotes relaxation and a sense of well-being.

Role of Aquatic exercise ————-

Aquatic exercises play a significant role in fitness, rehabilitation, and overall well-being.
Here are some key benefits and roles of aquatic exercises:

1. Rehabilitation & Physical Therapy

 Water provides buoyancy, reducing stress on joints and allowing people with injuries,
arthritis, or mobility issues to exercise safely.

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 It supports post-surgery recovery, particularly for knee and hip replacements.

2. Low-Impact Fitness

 The buoyancy of water minimises the impact on bones and joints, making it ideal for
people with joint pain, seniors, or those recovering from injuries.
 It helps improve cardiovascular health without straining the body.

3. Strength & Endurance Training

 Water resistance helps build muscle strength and endurance.

 Exercises like water aerobics, resistance training with pool weights, or swimming
target multiple muscle groups effectively.

4. Flexibility & Range of Motion

 The reduced gravity environment allows for greater movement, improving flexibility
and joint mobility.

5. Weight Management & Cardiovascular Health

 Activities like swimming and aqua jogging provide effective calorie-burning

workouts.
 Helps in managing weight while being gentle on the body.

6. Mental Health & Relaxation

 Water exercises can be therapeutic, reducing stress and anxiety.

 Warm water, in particular, promotes muscle relaxation and reduces tension.

7. Improves Balance & Coordination

 The water environment provides resistance and challenges stability, enhancing

balance and core strength.
 Beneficial for seniors to reduce fall risks.

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PULMONARY EXERCISE
AND POSTURAL DRAINAGE
 Chest physiotherapy (CPT) is a technique used to mobilise or loosen
secretions in the lungs and respiratory tract.This is especially helpful for
patients with large amount of secretions or ineffective cough.
 Chest physiotherapy consists of exhale mechanical manoeuvres; such as
chest percussion, postural drainage, vibration to augment mobilization and
clearance of airway secretions, diaphragmatic breathing with pursed-lips,
coughing and controlled coughing
 Chest physiotherapy consists of three techniques:
1. Percussion/Clapping/Cupping
2. Vibration
3. Postural drainage

PERCUSSION
o Chest percussion involves striking the chest wall or the area being
drained.
o Percussing lung areas involves the use of cupped palm to loosen
pulmonary secretions so that hey can be expectorated with ease.
o Percussing with the hand held in a rigid dome-shaped position, the area
over the lung lobes to be drained in struck in rhythmic pattern.
o Usually the patient will be positioned in supine or prone and should not
experience any pain.
o Cupping is never done on bare skin or performed or surgical incisions,
below the ribs, or over the spine breasts because of the danger of tissue
damage.
o Typically, each area is percussed for 30 to 60 seconds several times a
day.
o If the patient has tenacious secretions, the area must be percussed for 3-5
minutes several times per day.

VIBRATION
o In vibration, the nurse uses rhythmic contractions and relaxations of her
arm and shoulder muscles while holding the palm flat on the patient's
chest as the patient exhales.The purpose is to help loosen respiratory
secretions so that they can be expectorated with ease.

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o To avoid patient's discomfort, vibration is never done over the patient's

breasts, spine, sternum, and rib cage.

Procedure for percussion & vibration..

o Instruct the patient use diaphragmatic breathing.
o Position the patient in prescribed postural drainage positions.
o Spine should be straight to promote rib cage expansion.
o Percuss with cupped hands on chest wall for 5 minutes over each segment
(5 minutes for cystic fibrosis and 1-2 minutes for other conditions).
o Instruct the patient to inhale slowly and deeply.
o Vibrate the chest wall as patient exhales slowly through the pursed lips.
o Place one hand on top of the other over affected area or place one hand
on each side of the rib cage
o Tense the muscles of the hands while applying moderate pressure
downward and vibrate arms and hands.
o Relieve pressure on the thorax as the patient inhales.
o Encourage pt. to cough, using abdominal muscles, after 3&4 vibrations.
o Allow the patient rest several times.
o Listen with stethoscope for changes in breath sounds.
o Repeat the percussion and vibration cycle according to the patient's
tolerance and clinical response: usually 15-30 minutes.

POSTURAL DRAINAGE
 Postural drainage (bronchial drainage), is an intervention for airway
clearance by mobilising secretions in one or more lung segments to the
central airway by placing the patient in various positions so gravity assists in
the drainage process.
 Postural drainage is the positioning techniques that drain secretions from
specific segments of the lungs and bronchi into the trachea.
 In postural drainage, the person is tilted L propped at an angle to help drain
secretions from the lungs.
 Also, the chest or back may be clapped with a cupped hand to help loosen
secretions- the technique called chest percussion.
 In normal healthy state, mucociliary mechanism clears off the bronchial
secretions. In diseased state they get compromised and secretions get
accumulated especially in smaller airways that cannot be emptied without
gravity assistance which can further lead to inflammation and scarring.
 The exercises are performed two to three times a day, before meals and
bedtime. Each position is done for 3-15 minutes.

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 Scheduling of treatment
o The treatment protocol should be in the early morning because secretion
builds up during the night. treatment can be done at night to minimalize
coughing during sleep. you have to start treatment at least 1-2 hours after
eating. This minimises nausea and vomiting. don't do CPT before meals
because it will cause tiredness and appetite loss.

 Goals of postural drainage

The primary goals of postural drainage include:

1. Clear Airway Secretions – Facilitate the removal of mucus from the

lungs, reducing airway obstruction.
2. Improve Breathing Efficiency – Enhance lung function by allowing better
airflow and gas exchange.
3. Prevent Lung Infections – Reduce the risk of infections such as
pneumonia by preventing mucus buildup.
4. Enhance Oxygenation – Improve oxygen delivery to the body by clearing
blocked airways.
5. Reduce Work of Breathing – Decrease respiratory effort by making it
easier to breathe.
6. Support Recovery from Respiratory Conditions – Aid in managing
conditions like cystic fibrosis, bronchiectasis, chronic bronchitis, and
pneumonia.
7. Remove accumulated fluid from lungs

 Principles
1. Gravity-Assisted Drainage- Body positioning allows gravity to move secretions from
smaller airways to larger airways for easier expulsion.The affected lung segment is
positioned higher than the main airways (trachea and bronchi).

2. Segmental Lung Drainage - Specific patient positions target different lung segments,
ensuring mucus is drained effectively from all lung areas.

3. Deep Breathing and Effective Coughing- Encouraging deep breathing expands the
lungs, mobilising secretions. Coughing is essential to expel loosened mucus.

4. Combination with Chest Physiotherapy- Percussion (clapping on the chest) helps

loosen mucus.Vibration (gentle shaking on exhalation) moves secretions toward the airway.

5. Patient Comfort and Safety- Proper support (pillows, positioning aids) ensures
comfort.Monitor for signs of distress (dizziness, shortness of breath, low oxygen levels) and
adjust therapy as needed.

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6. Hydration for Mucus Clearance- Adequate fluid intake keeps secretions thin and
easier to drain. Nebulisation or humidified air may enhance effectiveness.

7. Avoiding Contraindications- Certain conditions (severe hemoptysis, pneumothorax,

recent surgery, unstable cardiovascular status, or GERD) require modified or avoided
positions.

8. Frequency and Duration- PDT is performed 2–4 times per day, depending on mucus
production.Each position is maintained for 3–5 minutes, and full sessions last 15–40 minutes.

9. Individualised and Adaptive Therapy- Positions and techniques should be tailored to

the patient’s condition, tolerance, and response. Adjustments are made for elderly, post-
surgical, or weak patients.

10. Integration with Other Airway Clearance Techniques- PDT is often combined
with bronchodilator therapy, suctioning, and breathing exercises for better secretion
clearance.

INDICATIONS

 Cystic Fibrosis
 Bronchiectasis
 Chronic Obstructive Pulmonary Disease (COPD)
 Atelectasis
 Lung Abscesses.
 Pneumonia
 Postoperative Pulmonary Complications
 Neuromuscular Disorders:muscular dystrophy or spinal injuries
that impair ability to cough& clear secretions effectively.
 Artificial Airways: Individuals with tracheostomies or
endotracheal tubes who have difficulty clearing secretions.
 Foreign Body Aspiration
 Recovery from thoracic or abdominal injury
 Spinal cord injury
 Poor oxygenation in certain body parts
 Asthma with mucus plugging

 CONTRAINDICATIONS
 Severe hemoptysis
 Pulmonary embolism
 Untreated pneumothorax
 Severe pulmonary oedema
 Unstable cardiovascular status
 Recent myocardial infarction
 Increased intracranial pressure

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 Recent head trauma or neurosurgery

 Rib fractures with flail chest
 Severe osteoporosis
 Acute spinal cord injury
 Uncontrolled hypertension
 Recent oesophageal surgery
 Gastric reflux with risk of aspiration
 Large pleural effusion
 Cardiac arrhythmia
 Patient who are unable to tolerate the position required
 Patient who are taking anticoagulation drugs,
 Patient who have recently vomited up blood,

 Procedure
o The patient is tilted or propped at an angle required and chest
percussion is performed to loosen the secretions. Frames, tilt tables,
and pillows may be used to support patients in these positions. There
are postural beds that have a hinge in the middle.
o In general, the upper lobe segments have the advantage of gravity
drainage both in erect as well as in semi recumbent position, so
postural drainage can be facilitated in sitting or lying posture. The
middle and lower lobes do not have the advantage of gravity drainage
in erect, semi-recumbent or recumbent postures.
o A foot end elevation of 14-18 inches is requires for the drainage of
middle and lower lobes.
o Each position consists of placing the target lung segments superior to
the carina. Positions should generally be held for 3 to 15 minutes
o Standard positions are modified as the patient's condition and
tolerance warrant.
o In critical care patients, including those on mechanical ventilation,
Postural Drainage should be performed from every 4 to every 6 hours
as indicated. PDT ( postural drainage therapy ) order should be re-
evaluated at least every 48 hours based on assessments from
individual treatments. Domiciliary patients should be reevaluated
every 3 months and with change of status.
o In the actively cooperating pt. postural drainage can be complemented
by thoracic expansion exercises and by breathing control.
o chest or back may be clapped with a cupped hand to help loosen
secretions- the technique called chest percussion.
o Before postural drainage , the client may be given a bronchodilator
medication or nebulisation therapy to loosen secretion.

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o PDT are scheduled 2 or 3 times daily , depending on the degree of

lung congestion.
 Position of patient
Upper Lobe
APICAL SEGMENTS -The patient should sit upright, with slight
variations according to the position of the lesion which may necessitate
leaning slightly j backward, forward or sideways. The position is usually
only necessary for infants or patients being nursed in a recumbent j
position, but occasionally may be required if there is an abscess or
stenosis of a bronchus in the apical region.

ANTERIOR SEGMENTS - The patient should lie flat on his back with his
arms relaxed to his side; the knees should be slightly flexed over a pillow

POSTERIOR SEGMENT
o Right - The patient should lie on his left side and then turn 450 on
to his face, resting against a pillow with another supporting his
head. He r should place his left arm comfortably behind his back
with his right arm resting on the supporting pillow; the right knee
should be flexed.
o Left - The patient should lie on his right side turned 450 on to his
face with three pillows arranged to raise the shoulder 30cm (izin)
from the bed. He should place his right arm behind his back with
his left arm resting on the supporting pillows; both the knees
should be slightly bent.

Middle Lobe
LATERAL SEGMENT: MEDIAL SEGMENT The patient should lie on his
back with his body quarter turned to the left maintained by a pillow under
the right side from shoulder to hip and the arms relaxed by his side; the
foot of the bed should be raised 35cm (14in) from the ground. The chest
is tilted to an angle of 15°.
Lingual
SUPERIOR SEGMENT: INFERIOR SEGMENT - The patient should lie
on his back with his body quarter turned to the right maintained by a
pillow under the left side from shoulder to hip and the arms relaxed by his
side; the foot of the bed should be raised 35cm (14m) from the ground.
The chest is tilted to an angle of 15°.

Lower Lobe

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APICAL SEGMENTS - The patient should lie prone with the head turned
to one side, his arms relaxed in a comfortable position by the side of the
head and a pillow under his hips.

ANTERIOR BASAL SEGMENTS - The patient should lie flat on his back
with the buttocks resting on a pillow and the knees bent; the foot of the
bed should be raised 46cm (i8in) from the ground. The chest is tilted to
an angle of 20°

POSTERIOR BASAL SEGMENTS - The patient should lie prone with his
head turned to one side, his arms in a comfortable position by the side of
the head and a pillow under his hips.
The foot of the bed should be raised 46cm (i8in) from the ground. The
chest is tilted to an angle of 20°.

MEDIAL BASAL (CARDIAC) SEGMENT - The patient should lie on his

right side with a pillow under the hips and the foot of the bed should be
raised 46cm from the ground. The chest is tilted to an angle of 20°.

LATERAL BASAL SEGMENT - The patient should lie on the opposite

side with a pillow under the hips and the foot of the bed should be raised
46cm (i8in) from the ground. The chest is tilted to an angle of 20°.

 Assessment for postural drainage

1. Medical History & Diagnosis

 Check for respiratory conditions (e.g., pneumonia, bronchiectasis,

COPD).
 Identify recent surgeries, trauma, or contraindications (e.g.,
pneumothorax, unstable cardiovascular status).

2. Respiratory Assessment

 Breath Sounds: Auscultate for crackles, wheezing, or diminished sounds.

 Cough Effectiveness: Assess the strength and frequency of the cough.
 Sputum Characteristics: Note color, consistency, and volume.

3. Oxygenation & Vital Signs

 SpO2 (Oxygen Saturation): Ensure levels are stable (>90%).

 Heart Rate & Blood Pressure: Monitor for stability.
 Respiratory Rate: Check for distress or abnormal breathing patterns.

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4. Lung Segments Involved

 Use clinical examination and imaging (X-ray, CT scan) to identify mucus

accumulation.

5. Contraindications Check

 Severe hemoptysis, pulmonary embolism, untreated pneumothorax,

recent head/spinal surgery, severe osteoporosis, or uncontrolled
hypertension.

6. Functional & Physical Tolerance

 Assess the patient’s ability to tolerate different postural positions.

 Ensure comfort and minimise risks of dizziness, aspiration, or discomfort.

7. Monitoring & Documentation

 Track response to treatment regularly (improved breath sounds, mucus

clearance).
 Adjust therapy based on effectiveness and patient tolerance.

 Guidelines to perform PDT

1. Patient Preparation

 Assess the patient’s condition (vital signs, lung sounds, oxygen levels, and
contraindications).
 Explain the procedure to the patient to ensure cooperation and relaxation. Encourage
comfortable, loose clothing for ease of movement. Ensure the patient is well-
hydrated to help thin secretions for easier drainage.

2. Positioning for Effective Drainage

 Select appropriate drainage positions based on the affected lung segment.

 Each position should be maintained for 3–5 minutes (or longer if tolerated).
 Use pillows and supports for patient comfort and stability.

3. Use of Chest Physiotherapy Techniques

 Percussion (clapping): Performed over the affected lung area to loosen secretions.
 Vibration: Gentle shaking motion during exhalation to move mucus upward.
 Deep breathing & effective coughing: Encouraged throughout the session to expel
loosened secretions.

4. Treatment Frequency

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 Postural drainage is typically performed 2–4 times per day based on the severity of
mucus buildup.
 Sessions usually last 15–40 minutes depending on patient tolerance.

 Precautions
1. Avoid Treatment in Certain Conditions

 Severe cardiovascular instability (e.g., recent heart attack, uncontrolled hypertension),

Untreated pneumothorax (collapsed lung) , Severe hemoptysis (coughing up blood) ,
Recent head injury or increased intracranial pressure. Gastroesophageal reflux disease
(GERD) or recent abdominal surgery (risk of aspiration).

2. Monitor Patient Throughout the Procedure

 Watch for signs of distress (shortness of breath, dizziness, low oxygen levels).
 Adjust or stop treatment if the patient experiences nausea, discomfort, or cyanosis
(bluish skin color due to low oxygen levels).

3. Proper Handling During Percussion and Vibration

 Do not perform over bony areas (spine, sternum, ribs) to avoid injury.Avoid excessive
force to prevent bruising or discomfort, especially in elderly or frail patients.

4. Ensure Safe Head-Down Positions

 Head-down (Trendelenburg) positions should be avoided in patients with:

 Hypertension or heart disease (can increase blood pressure).
 GERD or risk of aspiration (can cause reflux and choking).

5. Adjust for Special Populations

 Elderly patients: Use gentler techniques and shorter session durations.

 Post-surgical patients: Modify positions to avoid stress on surgical sites.
 Neurological or weak patients: Support positioning to prevent falls or discomfort.

6. Post-Treatment Care

 Allow the patient to rest and recover in a comfortable position.

 Encourage hydration to continue mucus clearance.
 Document treatment response (amount and type of mucus cleared, breath sounds,
patient tolerance).

 For positions diagram refers googleeeeee

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YOGA
 Yoga is an ancient practice that originated in India and combines physical
postures, breathing exercises, meditation, and ethical principles to promote
overall well-being.
 It is both a physical and spiritual discipline, aiming to harmonise the body,
mind, and spirit.
 yoga is a therapeutic movement practice that combines physical postures ,
breathing techniques, and mindfulness to promote healing and rehabilitation.
 It is widely used in physical therapy, rehabilitation programs, and holistic
wellness due to its gentle yet effective approach to improving strength,
flexibility, balance, and mental well-being.
 Benefits of Yoga as Exercise Therapy:
o Improves Mobility & Flexibility
o Strengthens Muscles
o Enhances Posture & Alignment
o Reduces Pain & Inflammation
o Boosts Circulation & Healing
o Regulates Nervous System

 Yoga in Specific Rehabilitation Cases:

o Orthopaedic Rehabilitation
o Neurological Disorders
o Cardiac & Pulmonary Rehab
o Mental Health Therapy

Principles of yoga —————

1. Individualisation & Adaptation

Yoga therapy is personalized based on the individual’s physical condition, needs, and
limitations. Adaptations are made using modifications, props (blocks, straps, chairs),
or alternative postures to ensure safety. Progressive overloading is applied in a gentle,
gradual manner, respecting the body’s pace of healing.

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2. Breath Awareness & Control (Pranayama)

Breath is a fundamental component of movement and healing. Diaphragmatic and

deep breathing techniques improve oxygenation, reduce stress, and promote
relaxation, help manage pain, lower blood pressure, and regulate the nervous system.
Synchronisation of breath with movement enhances efficiency, stability, and control
in therapeutic exercises.

3. Postural Alignment & Stability

Proper body alignment prevents strain and enhances functional movement. Ensuring
correct posture minimizes unnecessary stress on joints, muscles, and the spine. Core
engagement is emphasised to improve stability, balance, and injury prevention.
Therapists use gentle adjustments to guide patients into proper form without causing
discomfort.

4. Mind-Body Connection & Awareness

Yoga enhances body awareness, which is crucial for recovery and movement
efficiency. Encourages individuals to listen to their bodies, preventing overuse or
injury. Improves neuromuscular coordination, making movements more intentional
and controlled. Reduces fear-avoidance behaviors in patients with chronic pain,
fostering confidence in movement.

5. Balance Between Strength & Flexibility

Yoga maintains an optimal balance between muscle strength and flexibility. Strength-
based postures (e.g., Warrior poses, Planks) help stabilize joints and enhance
endurance. Stretching postures (e.g., Seated Forward Bend, Hip Openers) promote
flexibility, reducing stiffness. Dynamic and static stretching are used strategically to
improve mobility without causing hyper-mobility issues.

6. Gradual Progression & Sustainability

Therapeutic yoga follows a step-by-step approach to ensure long-term recovery.

Movements begin with gentle, low-impact exercises and gradually progress to more
dynamic flows. avoiding sudden increases in intensity. Consistency is prioritised over
intensity, ensuring sustainable benefits over time.

7. Stress Reduction & Relaxation

Yoga therapy focuses on activating the body's natural relaxation response. Restorative
yoga, meditation, and guided relaxation techniques reduce stress and tension.
Encourages parasympathetic nervous system activation, helping with conditions like
anxiety, PTSD, and chronic pain. Reduces cortisol levels, promoting overall emotional
and physiological balance.

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8. Holistic Healing Approach

Yoga integrates physical, mental, and emotional healing for comprehensive well-
being. Unlike conventional exercise, yoga therapy considers mental health, emotional
stability, and lifestyle factors. Encourages mindfulness in daily life, supporting
recovery beyond the mat. Patients are guided toward sustainable self-care practices,
improving long-term health.

Physiological and therapeutic effects —————

1. Musculoskeletal System

Physiological Effects:

 Improves muscle flexibility, reducing stiffness and preventing injuries.

Enhances muscle strength and endurance, especially in weight-bearing
postures. Promotes joint stability and mobility, reducing strain on ligaments
and tendons. Aids in correcting postural imbalances, reducing musculoskeletal
pain.

Therapeutic Benefits:

 Helps in managing chronic pain conditions like arthritis, fibromyalgia, and

back pain.Supports rehabilitation post-injury or surgery by improving range of
motion. Reduces risk of falls and fractures in older adults by improving balance
and coordination.Eases muscle tension in conditions like cervical spondylosis
and frozen shoulder.

2. Nervous System (Brain & Nerve Function)

Physiological Effects:

 Activates the parasympathetic nervous system, inducing relaxation and

reducing stress. Enhances neuroplasticity, improving brain function, memory,
and cognitive ability. Lowers cortisol (stress hormone) levels, reducing anxiety
and depression. Improves vagal tone, aiding in emotional stability and
autonomic nervous system regulation.

Therapeutic Benefits:

 Effective for managing neurological disorders like Parkinson’s disease,

multiple sclerosis, and stroke rehabilitation. Helps with stress-related
disorders such as PTSD, anxiety, and insomnia.Reduces migraine frequency
and severity by relieving nervous system tension. Enhances focus and mental
clarity, beneficial for ADHD and cognitive disorders

3. Cardiovascular System

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Physiological Effects:

 Lowers blood pressure and improves vascular flexibility. Enhances circulation

and oxygen delivery to tissues. Regulates heart rate variability (HRV),
improving heart health. Reduces cholesterol and triglyceride levels, supporting
cardiovascular function.

Therapeutic Benefits:

 Beneficial for patients with hypertension, heart disease, and post-cardiac

rehabilitation. Aids in preventing atherosclerosis and stroke by improving
blood flow. Enhances recovery after heart surgery through gentle, controlled
movements. Supports lung function, making it useful for asthma and COPD
management.

4. Respiratory System

Physiological Effects:

 Increases lung capacity and efficiency through diaphragmatic breathing.

Improves oxygen exchange and CO₂ elimination, enhancing respiratory health.
Strengthens respiratory muscles, improving breath control.

Therapeutic Benefits:

 Helps manage asthma, bronchitis, and chronic obstructive pulmonary disease

(COPD). Reduces breathlessness in patients recovering from respiratory
infections. Enhances pulmonary rehabilitation post-COVID or pneumonia.
Supports pranayama to improve endurance in athletes.

5. Endocrine System (Hormonal Balance)

Physiological Effects:

 Regulates hormonal secretion, stabilising metabolism and mood.

Lowers cortisol (stress hormone) levels, reducing chronic stress effects
Enhances insulin sensitivity, supporting blood sugar regulation.
Balances thyroid function, affecting metabolism and energy levels.

Therapeutic Benefits:

 Beneficial for diabetes management, improving glucose utilization. Helps

with hypothyroidism and hyperthyroidism by regulating endocrine function.
Reduces symptoms of PCOS and menstrual irregularities. Aids in menopause
symptom relief, reducing hot flashes and mood swings.

6. Digestive System

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Physiological Effects:

 Stimulates gut motility, aiding digestion and nutrient absorption.

Enhances blood flow to abdominal organs, improving liver and kidney
function. Regulates the gut-brain axis, reducing stress-induced digestive issues.

Therapeutic Benefits:

 Helps in managing irritable bowel syndrome (IBS) and acid reflux.

Reduces bloating and constipation by improving peristalsis. Aids in
detoxification by promoting liver and kidney health. Enhances gut microbiome
balance, improving overall digestion.

7. Immune System

Physiological Effects:

 Increases white blood cell count, enhancing immune defense.

Reduces inflammatory markers, lowering chronic disease risk
Improves lymphatic circulation, aiding in toxin elimination.

Therapeutic Benefits:

 Helps in managing autoimmune diseases like rheumatoid arthritis and lupus.

Supports post-illness recovery, enhancing immunity. Reduces systemic
inflammation, beneficial for chronic inflammatory conditions.

8. Psychological & Emotional Well-Being

Physiological Effects:

 Increases production of serotonin and dopamine, improving mood.

Reduces amygdala activity, lowering fear and stress responses.
Enhances prefrontal cortex function, improving decision-making and emotional
regulation.

Therapeutic Benefits:

 Effective for depression, anxiety, and PTSD management. Reduces symptoms

of OCD and panic disorders. Enhances self-awareness and emotional
resilience. Supports grief recovery and trauma healing.

Common Yoga Asanas and Their Benefits

1. Tadasana (Mountain Pose)

 Benefits: Improves posture, strengthens legs, enhances body awareness.

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 Therapeutic Use: Helps with spinal alignment and balance training.

2. Vrikshasana (Tree Pose)

 Benefits: Improves balance, strengthens legs and core, enhances focus.

 Therapeutic Use: Useful for neuromuscular coordination and postural stability.

3. Adho Mukha Svanasana (Downward-Facing Dog)

 Benefits: Stretches the spine, hamstrings, and shoulders; strengthens arms and legs.
 Therapeutic Use: Reduces back pain, improves circulation, and relieves stress.

4. Bhujangasana (Cobra Pose)

 Benefits: Strengthens the spine, opens the chest, improves lung capacity.
 Therapeutic Use: Helps with lower back pain and respiratory health.

5. Paschimottanasana (Seated Forward Bend)

 Benefits: Stretches the spine, hamstrings, and lower back; promotes relaxation.
 Therapeutic Use: Relieves stress, improves digestion, and enhances flexibility.

6. Setu Bandhasana (Bridge Pose)

 Benefits: Strengthens back muscles, improves spinal flexibility, enhances blood

circulation.
 Therapeutic Use: Beneficial for lower back pain, posture correction, and stress relief.

7. Balasana (Child’s Pose)

 Benefits: Relaxes the body, stretches the lower back, reduces fatigue.
 Therapeutic Use: Helps in stress management, lower back pain, and relaxation.

8. Shavasana (Corpse Pose)

 Benefits: Promotes deep relaxation, reduces stress, calms the nervous system.
 Therapeutic Use: Effective for anxiety, depression, and sleep disorders.

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RANGE OF MOTION
 Range of motion is a basic technique used for the examination of movement
and for initiating movement into a program of therapeutic intervention.
 When a person moves, the intricate control of the muscle activity that causes
or controls the motion comes from the central nervous system. Bones move
with respect to each other at the connecting joints. The structure of the joints,
as well as the integrity and flexibility of the soft tissues that pass over the
joints, affects the amount of motion that can occur between any two bones.
The full motion possible is called the range of motion (ROM).
 When moving a segment through its ROM, all structures in the region are
affected: muscles, joint surfaces, synovial fluid, joint capsules, ligaments,
fasciae, vessels, and nerves.
 Functional excursion is the distance that a muscle is capable of shortening
after it has been elongated to its maxi-mum. In some cases the functional
excursion, or range of a muscle, is directly influenced by the joint it crosses.
For example, the range for the brachialis muscle is limited by the range
available at the elbow joint. An example of a two-joint muscle functioning
at the hip and knee is the hamstring muscle group.
 To maintain normal ROM, the segments must be moved through their
available ranges periodically, whether it is the available joint range or
muscle range.
 ROM activities are administered to maintain joint and soft tissue mobility to
minimise loss of tissue flexibility and contracture formation. Extensive
research by Robert Salter has provided evidence of the benefits of movement
on the healing of tissues in various pathological conditions in both the
laboratory and clinical settings.

Types of ROM ————-

 Passive ROM is movement of a segment within the unrestricted ROM that is
produced entirely by an external force; there is little to no voluntary muscle
contrac-tion. The external force may be from gravity, a machine, another
individual.

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 Active ROM is movement of a segment within the unrestricted ROM that is

produced by active contraction of the muscles crossing that joint.

 Active-assistive ROM is a type of AROM in which assistance is provided

manually or mechanically by an outside force because the prime mover
muscles need assistance to complete the motion.
Indications , goals , and limitations of ROM ————
PASSIVE ROM
Indications for PROM
o acute, inflamed tissue, passive motion is beneficial; active motion
would be detrimental to the healing process. Inflammation after injury or
surgery usually lasts 2 to 6 days.
o When a patient is not able to or not supposed to actively move a
segment(s) of the body, as when comatose, paralysed, or on complete
bed rest, movement is provided by an external source.
o surgical repair of contractile tissue

Goals for PROM

The primary goal for PROM is to decrease the complications that would occur
with immobilisation, such as cartilage de-generation, adhesion and contracture
formation, and sluggish circulation. 9,27,33 Specifically, the goals are to:
o Adhesion decreases
o Maintain joint and connective tissue mobility.
o Minimise the effects of the formation of contractures.
o Maintain mechanical elasticity of muscle.
o Assist circulation and vascular dynamics.
o Enhance synovial movement for cartilage nutrition and diffusion of
materials in the joint.
o Decrease or inhibit pain.
o Assist with the healing process after injury or surgery.
o Help maintain the patient's awareness of movement.
o joint stability, muscle flexibility, and other soft tissue elasticity.
o When a therapist is teaching an active exercise program,
PROM is used to demonstrate the desired motion.
o When a therapist is preparing a patient for stretching, PROM is often
used preceding the passive stretching techniques.

Limitations of Passive Motion

o Prevent muscle atrophy
o Increase strength or endurance
o Assist circulation to the extent that active, voluntary muscle contraction
does

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ACTIVE AND ACTIVE- ASSISTED ROM

Indications for AROM
o When a patient is able to contract the muscles actively and move a
segment with or without assistance, AROM is used.
o When a patient has weak musculature and is unable to move a joint
through the desired range (usually against gravity), A-AROM is used to
provide enough assistance to muscles in a carefully controlled manner
so the muscle can function at its maximum level and be progressively
strengthened. Once patients gain control of ROM, they are progressed to
resistance exercises to improve muscle performance for a return to
functional activities
o When a segment of the body is immobilised for a period of time, AROM
is used on the regions above and below the immobilised segment to
maintain the areas in as normal a condition as possible and to prepare for
new activities such as walking with crutches.
o AROM can be used for aerobic conditioning programs and is used to
relieve stress from sustained postures.

Goals for AROM

If there is no inflammation or contraindication to active motion, the same goals
of PROM can be met with AROM. In addition, there are physiological benefits
that result from active muscle contraction and motor learning from voluntary
muscle control. Specific goals are to:
o Maintain physiological elasticity and contractility of the participating
muscles.
o Provide sensory feedback from the contracting muscles.
o Provide a stimulus for bone and joint tissue integrity.
o Increase circulation and prevent thrombus formation.
o Develop coordination and motor skills for functional activities.

Limitations of Active ROM

o For strong muscles, AROM does not maintain or increase strength. It
also does not develop skill or coordination except in the movement
patterns used.

Precautions and contraindications ————-

 ROM should not be done when motion is disruptive to the healing
process
 Signs of too much or the wrong motion include increased pain and
inflammation.
 ROM should not be done when patient response or the condition is
life-threatening.

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 PROM may be carefully initiated to major joints and AROM to ankles

and feet to minimise venous stasis and thrombus formation. Alter MI,
coronary artery bypass surgery. or percutaneous transluminal coronary
angioplasty
 AROM of upper extremities and limited walking are usually tolerated
under careful monitoring of symptoms.
 Sedative interruption followed by AROM with progression to sitting,
standing, and walking may be initiated early on mechanically
ventilated patients

Principles ——-
 Active ROM (AROM): The person moves the joint without assistance,
strengthening muscles and maintaining mobility.
 Passive ROM (PROM): A therapist or external force moves the joint, used
when a person is unable to move independently.
 Active-Assisted ROM (AAROM): The person moves the joint with some
assistance to improve strength and mobility.

Procedure for applying ROM technique———-—

Preparation

 Assess the patient’s condition: Determine their mobility level, pain tolerance,
and any restrictions.
 Explain the procedure: Inform the person about what will be done and its
benefits.
 Ensure a comfortable position: Position the person properly, ensuring joint
support and safety.
 Use proper body mechanics: Both the patient and therapist should maintain
good posture to prevent strain.

Performing the ROM Exercises

A. Passive Range of Motion (PROM)

 Support the joint above and below to prevent unnecessary strain.

 Move the joint gently and smoothly through its full range.
 Perform movements slowly, avoiding any jerky motions.
 Stop immediately if the person experiences pain or resistance.
 Repeat each motion 5-10 times, as tolerated.

B. Active-Assisted Range of Motion (AAROM)

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 The person attempts to move the joint, while the therapist or an external aid
provides slight assistance.
 Encourage gradual participation, allowing the patient to build strength.
 Adjust support based on the person’s ability.

C. Active Range of Motion (AROM)

 The person performs movements independently without external aid.

 Encourage slow, controlled movements to maximise flexibility and strength.
 Ensure proper breathing and posture during exercises.

3. Specific Joint Movements

Each joint should be moved through its normal planes of motion, which may include:

 Neck: Flexion, extension, lateral flexion, rotation.

 Shoulder: Flexion, extension, abduction, adduction, internal/external rotation.
 Elbow: Flexion, extension, pronation, supination.
 Wrist: Flexion, extension, radial/ulnar deviation.
 Fingers: Flexion, extension, abduction, adduction.
 Hip: Flexion, extension, abduction, adduction, internal/external rotation.
 Knee: Flexion, extension.
 Ankle: Dorsiflexion, plantarflexion, inversion, eversion.
 Toes: Flexion, extension.

4. Monitoring and Safety

 Observe for signs of discomfort, pain, or fatigue.

 Modify or stop the exercise if pain, swelling, or resistance occurs.
 Ensure the person is comfortable and properly supported throughout.

5. Aftercare

 Document the ROM achieved, patient’s response, and any limitations.

 Provide rest and support to the joint after exercises.
 Encourage regular ROM exercises to maintain or improve mobility.

ROM Techniques —————-

UPPER EXTREMITY

Shoulder: Flexion and Extension

o Grasp the patient's arm under the elbow with your lower hand
o With top hand, cross over and grasp wrist and palm of pt. hand.
o Lift the arm through the available range and return.

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Shoulder: Extension (Hyperextension)

o To obtain extension past zero, position patient's shoulder at edge of
bed when supine or position the patient side-lying, prone, or sitting.

Shoulder: Abduction and Adduction

o Use same hand placement as with flexion, but move the arm out to
side. elbow may be flexed for ease in completing arc of motion.

Shoulder: Internal (Medial) and External (Lateral) Rotation

If possible, the arm is abducted to 90°, the elbow is flexed to 90°, and the
forearm is held in neutral position. Rotation may also be performed with the
patient's arm at the side of the thorax, but full internal rotation is not
possible in this position.
o Grasp the hand and the wrist with your index finger between the patient's
thumb and index finger.
o Place your thumb and rest of your fingers on either side of Pt wrist, thereby
stabilising the wrist. With other hand, stabilize the elbow.
o Rotate the humerus by moving the forearm like a spoke on a wheel.

Shoulder: Horizontal Abduction (Extension) and Adduction (Flexion)

o To reach full horizontal abduction, position patient's shoulder at the edge of
table. Begin with the arm either adducted or abducted 90°.
o Hand placement is the same as with flexion, but turn your body and face the
patient's head as you move the patient's arm out to the side and then across
the body.

Scapula: Elevation/Depression, Protraction/ Retraction, and Upward/Downward

Rotation
Position patient prone with his or her arm at the side or side-lying facing
toward you with patient's arm draped over your bottom arm
o Cup the top hand over the acromion process and place the other hand
around the inferior angle of the scapula.
o For elevation, depression, protraction, and retraction, clavicle also moves as
scapular motions are directed at the acromion process.
o For rotation, direct the scapular motions at the inferior angle of the scapula
while simultaneously pushing the acromion in the opposite direction to
create a force couple turning effect.

Elbow: Flexion and Extension

o Grasp distal forearm and support wrist with one hand. This hand also
controls forearm supination and pronation. With other hand, support elbow.
Flex and extend the elbow with the forearm supinated and also with the
forearm pronated.

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o NOTE: The scapula should not tip forward when the elbow ex-tends, as it
disguises the true range.

Elongation of Two-Joint Biceps Brachii Muscle

To extend the shoulder beyond zero, position the patient's shoulder at the
edge of the table when supine or position the patient prone lying, sitting, or
standing.
o First, pronate the patient's forearm by grasping the wrist and extend the
elbow while supporting it. Then, extend (hyperextend) the shoulder to the
point of tissue resistance in the anterior arm region. At this point, full
available lengthening of the two-joint muscle is reached.
Elongation of Two-Joint Long Head of the Triceps Brachii Muscle
When the near-normal range of the triceps brachii muscle is available, the
patient must be sitting or standing to reach the full ROM. With marked
limitation in muscle range, ROM can be performed in the supine position.
o First, fully flex patient's elbow with one hand on the distal forearm.
Then, flex shoulder by lifting up on humerus with other hand under elbow.
o Full available range is reached when discomfort is experienced in the
posterior arm region.

Forearm: Pronation and Supination

Hand Placement and Procedure
o Perform pronation& supination with elbow flexed as well as extended.
When elbow is extended, prevent shoulder from rotating by stabilising
elbow. Grasp pt wrist, supporting hand with index finger and placing thumb
and the rest of the fingers on either side of the distal forearm.
o Stabilize the elbow with the other hand. The motion is a rolling of the
radius around the ulna at the distal radius.
Alternate Hand Placement
o Sandwich patient's distal forearm between the palms of both hands.
o PRECAUTION: Do not stress the wrist by twisting the hand; control
pronation and supination motion by moving radius around ulna.

Wrist: Flexion (Palmar Flexion) and Extension (Dorsiflexion); Radial

(Abduction) and Ulnar (Adduction) Deviation
o For all wrist motions, grasp the patient's hand just distal to the joint with
one hand and stabilize the forearm with your other hand.
o NOTE: The range of extrinsic muscles to fingers affects range at wrist if
tension is placed on tendons as they cross into fingers. To obtain full range
of wrist joint, allow fingers to move freely as you move wrist.

Hand: Cupping and Flattening the Arch of the Hand at the Carpometacarpal
and Inter-metacarpal Joints
Hand Placement and Procedure

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DEEPIKA DANGI

o Face patient's hand; place fingers of both of your hands in palms of the
patient's hand and your thenar eminences on the posterior aspect. Roll
metacarpals palmarward to increase arch and dorsal-ward to flatten it.
Alternate Hand Placement
o One hand is placed on the posterior aspect of the patient's hand with
the fingers and thumb cupping the metacarpals.
NOTE: Extension and abduction of the thumb at the car-pometacarpal
joint are important for maintaining the web space for functional
movement of the hand. Isolated flexion-extension and abduction-
adduction ROM of this joint should be performed by moving the first
metacarpal while stabilizing the trapezium.
Joints of the Thumb and Fingers: Flexion and Extension and Abduction and
Adduction
The joints include the metacarpo-phalangeal and interphalangeal joints.
Hand Placement and Procedure
o Depending on position of pt, stabilize the forearm and hand on bed or table
or against your body. Move each joint of pt hand individually by stabilizing
proximal bone with index finger and thumb of one hand and moving distal
bone with index finger and thumb of the other hand.
Alternate Procedure
o Several joints can be moved simultaneously if proper stabilisation is
provided. Example: To move all metacarpopha-langeal joints of digits 2
through 5, stabilize metacarpals with one hand and move all the proximal
phalanges with the other hand.
NOTE: To accomplish full joint ROM, do not place tension on the extrinsic
muscles going to the fingers. Tension on the muscles can be relieved by
altering the wrist position as the fingers
are moved.

Elongation of Extrinsic Muscles of the Wrist and Hand: Flexor and Extensor
Digitorum Muscles
o First, move distal interphalangeal joint and stabilize it; then move proximal
interphalangeal joint. Hold both these joints at end of their range; then
move metacarpophalangeal joint to end of available range.
o Stabilize all the finger joints and begin to extend the wrist When patient
feels discomfort in the forearm, muscles are fully elongated.
NOTE: Motion is initiated in the distal-most joint of each digit to minimise
compression of the small joints. Full joint ROM will not be possible when
the extrinsic muscles are elongated.

LOWER EXTREMITY

Combined Hip and Knee: Flexion and Extension

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To reach full range of hip flexion, the knee must also be flexed to release
tension on the hamstring muscle group. To reach full range of knee flexion, hip
must be flexed to release tension on rectus femoris muscle.
Hand Placement and Procedure
o Support and lift the patient's leg with the palm and fingers of the top hand
under the patient's knee and the lower hand under the heel.
o As the knee flexes full range, swing the fingers to the side of the thigh.

Hip: Extension (Hyperextension)

o Prone or side-lying must be used if pt has near-normal or normal motion. If pt is
prone, lift thigh with bottom hand under pt knee; stabilize pelvis with top hand or
arm.If pt is side-lying, bring bottom hand under thigh and place hand on anterior
surface; stabilize pelvis with top hand. For full range of hip extension, do not flex
knee full range, as two-joint rectus femoris would then restrict range.
Elongation of the Two-Joint Hamstring Muscle Group
o Place lower hand under pt heel and upper hand across anterior aspect of pt
knee.Keep knee in extension as hip is flexed. If knee requires support,
cradle patient's leg in your lower arm with your elbow flexed under calf and
your hand across the anterior aspect of the patient's knee. The other hand
provides support or stabilisation where needed.
o NOTE: If the hamstrings are so tight as to limit the knee from going into
extension, the available range of the muscle is reached simply by extending
the knee as far as the muscle allows and not moving the hip.

Elongation of the Two-Joint Rectus Femoris Muscle

o Position patient supine with knee flexed over edge of treatment table or
position prone. When supine, stabilize lumbar spine by flexing hip and knee
of opposite lower extremity and placing foot on treatment table (hook-
lying) When prone, stabilize the pelvis with the top hand
o Flex the patient's knee until tissue resistance is felt in the anterior thigh,
which means the full available range is reached.

Hip: Abduction and Adduction (Fig. 3.17)

o Support pt leg with upper hand under knee & lower hand under ankle.
o For full range of adduction, opposite leg needs to be in a partially abducted
position. Keep the patient's hip and knee in extension and neutral to rotation
as abduction and adduction are performed.

Hip: Internal (Medial) and External (Lateral) Rotation

Hand Placement and Procedure With the Hip and Knee Extended
o Grasp just proximal to patient's knee with top hand and just proximal to
ankle with bottom hand. Roll the thigh inward and outward.
Hand Placement and Procedure for Rotation With Hip and Knee Flexed
o Flex patient's hip and knee to 90°; support knee with top hand. If knee is
unstable, cradle thigh and support proximal calf and knee with bottom hand.

EXERCISE THERAPY
DEEPIKA DANGI

Rotate femur by moving leg like a pendulum. This hand placement provides
some support to knee but should be used with caution if there is knee
instability.

Ankle: Dorsiflexion
o Stabilize around malleoli with top hand. Cup the patient's heel with
the bottom hand and place the forearm along the bottom of the foot.
o Pull the calcaneus distalward with the thumb and fingers while
pushing upward with the forearm.
NOTE: If the knee is flexed, full range of the ankle joint can be obtained.
If the knee is extended, the lengthened range of the two-joint
gastrocnemius muscle can be obtained, but the gastrocnemius limits full
range of dorsiflexion. Apply dorsiflexion in both positions of the knee to
provide range to both the joint and the muscle.
Ankle: Plantarflexion
o Support heel with bottom hand. Place the top hand on the dorsum of
the foot and push it into plantarflexion.
NOTE: In bed-bound patients, ankle tends to assume a plantar-flexed
position from weight of blankets and pull of gravity, so this motion may
not need to be performed.

Subtalar (Lower Ankle) Joint: Inversion and Eversion

o Using the bottom hand, place the thumb medial and the fingers lateral
to the joint on either side of the heel.Turn heel inward and outward.
NOTE: Supination of the foot may be combined with inversion, and
pronation may be combined with eversion.

Transverse Tarsal Joint

o Stabilize pt talus and calcaneus with one hand. With other hand, grasp
around navicular and cuboid. Gently rotate mid-foot by lifting and
lowering arch.

Joints of the Toes: Flexion and Extension and Abduction and Adduction
(Metatarsophalangeal and Interphalangeal Joints)
o Stabilize bone proximal to joint that is to be moved with one hand,
and move distal bone with other hand. technique is same as for ROM
of the fingers. Several joints of toes can be moved simultaneously if
care is taken not to stress any structure.

CERVICAL SPINE
Stand at the end of the treatment table; securely grasp the patient's head by
placing both hands under the occipital region.

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Flexion (Forward Bending)

o Lift the head as though it were nodding (chin toward larynx) to flex
the head on the neck. Once full nodding is complete, continue to flex
the cervical spine and lift the head toward the sternum.

Extension (Backward Bending or Hyperextension)

o Tip the head backward. NOTE: If pt is supine, only head and upper
cervical spine can be extended; head must clear end of the table to
extend entire cervical spine. The patient may also be prone or sitting.

Lateral Flexion (Side Bending) and Rotation

o Maintain the cervical spine neutral to flexion and extension as you
direct the head and neck into side bending (approximate the ear
toward the shoulder) and rotation (rotate from side to side).
LUMBAR SPINE

Flexion
o Bring both of patient's knees to chest by lifting under knees (hip and
knee flexion). Flexion of spine occurs as the hips are flexed full range
and the pelvis starts to rotate posteriorly. Greater range of flexion can
be obtained by lifting under the patient's sacrum with the lower hand

Extension
o Position pt prone for full extension (hyperextension). With hands
under thighs, lift thighs upward until pelvis rotates anteriorly and
lumbar spine extends.

Rotation
o Position the patient in the hook-lying position with hips and knees
flexed and feet resting on the table.
o Push both of the patient's knees laterally in one direction until the
pelvis on the opposite side comes up off the treatment table. Stabilize
the patient's thorax with the top hand. Repeat in the opposite direction.

Self-Assisted ROM ————-

 Patient involvement in self-care should begin as soon as the individual is able to
understand and learn what to do.
 After surgery or traumatic injury, self-assisted ROM (S-AROM) is used to protect
healing tissues when more intensive muscle contraction is contraindicated.

MANUAL ASSISTANCE

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DEEPIKA DANGI

o With cases of unilateral weakness or paralysis or during early stages of

recovery after trauma or surgery, patient can be taught to use uninvolved
extremity to move involved extremity through ranges of motion.
o These exercises may be done supine, sitting, or standing.
o The effects of gravity change with patient positioning, so when lifting the part
against gravity, gravity provides a resistive force against the prime motion and,
therefore, the prime mover requires assistance.
o When the extremity moves downward, gravity causes the motion, and the
antagonists need assistance to control the motion eccentrically.

Arm and Forearm

Instruct patient to reach across body with uninvolved (or assisting) extremity and
grasp involved extremity around the wrist, supporting the wrist and hand.
 Shoulder flexion and extension. The patient lifts the involved extremity over
the head and returns it to the side
 Shoulder horizontal abduction and adduction. Beginning with arm
abducted 90°, pt pulls extremity across chest and returns it to side.
 Shoulder rotation. Beginning with arm at patient's side in slight abduction
and with elbow resting on a small pillow to elevate it or abducted 90° and
elbow flexed 90°, patient moves the forearm "like a spoke on a wheel" with
uninvolved extremity It is important to emphasise rotating humerus, not
merely flexing and extending elbow.
 Elbow flexion and extension. The patient bends elbow until hand is near
shoulder and then moves hand down toward the side of the leg.
 Pronation and supination of the forearm. Beginning with forearm resting
across body, the patient rotates the radius around the ulna. Emphasise to the
patient not to twist the hand at the wrist joint.

Wrist and Hand

The patient moves the uninvolved fingers to the dorsum of the hand and the thumb
into the palm of the hand.
 Wrist flexion and extension and radial and ulnar deviations. The pt moves
wrist in all directions, applying no pressure against fingers
 Finger flexion and extension. The patient uses the uninvolved thumb to
extend the involved fingers and cups the normal fingers over the dorsum of
the involved fingers to flex them (Fig. 3.28).
 Thumb flexion with opposition and extension with reposition. The pt cups
uninvolved fingers around radial border of thenar eminence of involved
thumb and places uninvolved thumb along palmar surface of the involved
thumb to extend it . To flex and oppose the thumb, the patient cups the
normal hand around the dorsal surface of the involved hand and pushes the
first metacarpal toward the little finger.

Hip and Knee

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DEEPIKA DANGI

 Hip and knee flexion. With pt supine, instruct pt to initiate motion by lifting
involved knee by slipping his or her normal foot under knee or with a strap
or belt under involved knee.pt can then grasp knee with one or both hands
to bring knee up toward chest to complete range. With pt sitting, he or she
may lift thigh with hands and flex knee to end of its available range.
 Hip abduction and adduction. It is difficult for weak pt to assist lower
extremities into abduction and adduction when supine owing to weight of
leg and friction of bed surface. It is necessary for individual to move a weak
lower extremity from side to side for bed mobility. To practice this
functional activity as an exercise, instruct pt to slide normal foot from knee
down to ankle and then move involved extremity from side-to-side. S-
AROM can be performed sitting by using hands to assist moving thigh
outward and inward.
 Combined hip abduction with external rotation. Pt sits on the floor or on a
bed with the back supported, the involved hip and knee flexed, and the foot
resting on the surface. The knee is moved outward (toward the table/bed)
and back inward, with assistance from the upper extremities
Ankle and Toes
 The patient sits with the involved extremity crossed over the uninvolved
one so the distal leg rests on the normal knee. The uninvolved hand moves
the involved ankle into dorsiflexion, plantarflexion, inversion, and eversion
and toe flexion and extension

WAND ( T-BAR) EXERCISES

 When a patient has voluntary muscle control in an involved upper extremity but
needs guidance or motivation to complete the ROM in the shoulder or elbow, a
wand (dowel rod, cane, wooden stick, T-bar, or similar object) can be used to
provide assistance
 The choice of position is based on the patient's level of function. Most of the
techniques can be performed supine if maximum protection is needed. Sitting or
standing requires greater control.
 Guide the patient through the proper motion for each activity to ensure that he or
she does not use substitute motions. The patient grasps the wand with both hands,
and the normal extremity guides and controls the motions.

 Shoulder flexion and return. The wand is grasped with the hands a shoulder
width apart. The wand is lifted forward and upward through the available
range, with the elbows kept in extension if possible. Scapulohumeral
motion should be smooth; do not allow substitute motions such as scapular
elevation or trunk movement.
 Shoulder horizontal abduction and adduction. The wand is lifted to 90°
shoulder flexion. Keeping the elbows extended, the patient pushes and pulls
the wand back and forth across the chest through the available range ). Do
not allow trunk rotation.
 Shoulder internal and external rotation pt arms are at sides, elbows are
flexed 90°. Rotation of arms is accomplished by moving wand from side to

EXERCISE THERAPY
DEEPIKA DANGI

side across trunk while maintaining elbows at side The rotation should
occur in the humerus; do not allow elbow flexion and extension. To prevent
substitute motions as well as provide a slight distraction force to the
glenohumeral joint, a small towel roll may be placed in axilla with
instruction to patient to "keep the roll in place."
 Shoulder internal and external rotation alternate position. patient's
shoulders are abducted 90°, and elbows are flexed 90°. For ext. rotation,
wand is moved toward pt head; for int. rotation,itis moved toward waistline.
 Elbow flexion and extension. Pt forearm may be pronated or supinated;
hands grasp wand a shoulder -width apart. Instruct pt to flex and extend elbows.
 Shoulder hyperextension. Pt may be standing or prone. He or she places
wand behind buttocks, grasps wand with hands a shoulder width apart, and
then lifts wand backward away from trunk. Pt should avoid trunk motion.
 Variations and combinations of movements. For example, the patient begins
with the wand behind the buttocks and then moves the wand up the back to
achieve scapular winging, shoulder internal rotation, and elbow flexion.

WALL CLIMBING
 Wall climbing (or use of a device such as a finger ladder) can provide the
patient with objective reinforcement and, therefore, motivation for
performing shoulder ROM.
 Wall markings also be used to provide visual feedback for height reached.
 The arm may be moved into flexion or abduction The patient steps closer to
the wall as the arm is elevated.
 PRECAUTION: The patient must be taught proper motions and not allowed
to substitute with trunk side bending, toe raising, or shoulder shrugging.

OVERHEAD PULLEYS
 If properly taught, pulley systems can be effectively used to assist an
involved extremity in performing ROM.
 The pulley has been demonstrated to utilize significantly more muscle
activity than therapist-assisted ROM and continuous passive motion
machines (described later in the chapter), so this form of assistance should
be used only when muscle activity is desired.
 For home use, a single pulley may be attached to a strap that is held in place
by closing the strap in a door. A pulley may also be attached to an overhead
bar or affixed to the ceiling. The patient should be set up so the pulley is
directly over the joint that is moving or so the line of pull is effectively
moving the extremity and not just compressing the joint surface together.
The patient may be sitting, standing, or supine.
 Shoulder ROM
o Instruct pt to hold one handle in each hand, and with normal hand, pull
rope and lift involved extremity forward (flexion), out to side (abduction),
or in the plane of the scapula (caption is 30° forward of the frontal plane).

EXERCISE THERAPY
DEEPIKA DANGI

o The patient should not shrug shoulder (scapular elevation) or lean trunk.
Guide and instruct the patient so there is smooth motion.
o PRECAUTION: Assistive pulley activities for the shoulder are easily
misused by the patient, resulting in compression of the humerus against
the acromion process. Continual compression leads to pain and decreased
function. Proper patient selection and appropriate instruction can avoid
this problem. If a patient cannot learn to use the pulley with proper
shoulder mechanics, these exercises should not be performed.
Discontinue this activity if there is increased pain or decreased mobility.

 Elbow Flexion
o With the arm sthbilized along the side of the trunk, the patient lifts the
forearm and bends the elbow.

SKATE BOARD / POWDER BOARD

 Use of a friction-free surface may encourage movement without resistance of
gravity or friction. If available, a skate with rollers may be used. Other methods
include using powder on the surface or placing a towel under the extremity so it
can slide along the smooth surface of the board. Any motion can be done, but most
common are abduction/adduction of the hip while supine and horizontal
abduction/adduction of the shoulder while sitting.

RECIPROCAL EXERCISES UNIT

 Several devices, such as a bicycle, upper body or lower body ergometer, or a
reciprocal exercise unit, can be set up to provide some flexion and extension to an
involved extremity using strength of normal extremity. Movable devices that can
be attached to a pt bed, wheelchair, standard chair
 A reciprocal exercise unit has additional exercise benefits in that it can be used for
reciprocal patterning, endurance training, and strengthening by changing the
parameters of exercise and monitoring heart rate and fatigue.

Continuous Passive Motion ————-

 Continuous passive motion (CPM) refers to passive motion performed by a
mechanical device that moves a joint slowly and continuously through a controlled
ROM.
 Continuous passive motion has beneficial healing effects on diseased or injured
joint structures and soft tissues in animal and clinical studies
 Benefits of CPM
o CPM has been reported to be effective in lessening the negative effects of
joint immobilisation in conditions such as arthritis, contractures, and intra-
articular fractures improved recovery rate and ROM, particularly early in
the recovery period after a variety of surgical procedures,

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o Preventing development of adhesions and contractures& joint stiffness

o Providing a stimulating effect on the healing of tendons and ligaments
o Enhancing the healing of incisions over the moving joint
o Increasing synovial fluid lubrication of the joint and thus increasing the rate
of intra-articular cartilage healing and regeneration
o Preventing the degrading effects of immobilisation
o Providing a quicker return of ROM
o Decreasing postoperative pain

 General guidelines for CPM

a) The device may be applied to the involved extremity immediately after
surgery while the patient is still under anaesthesia or as soon as possible
if bulky dressings prevent early motion
b) The arc of motion for the joint is determined. A low arc of 20° to 30° is
used initially and progressed 10° to 15° per day as tolerated. portion of
range used initially is based on the range available and patient tolerance.
The rate of motion is determined; usually 1 cycle/45 sec or 2 min is well
tolerated.
c) The length of time on the CPM machine varies for different protocols—
anywhere from continuous for 24 hours to continuous for 1 hour three
times a day, The longer period of time per day reportedly result in a
shorter hospital stay, fewer postoperative complications, and greater
ROM at discharge, although no significant difference was found in a
study comparing CPM for 5 hr/day with CPM for 20 hr/day.
d) the most gained range occurred with a CPM duration of 4 to 8 hours.
e) Physical therapy treatments are usually initiated during periods when the
patient is not on CPM, including active-assistive and muscle-setting
exercises.
f) The duration minimum for CPM is usually less than 1 week or when a
satisfactory range of motion is reached.
g) CPM machines are designed to be adjustable, easily con-trolled,
versatile, and portable. Some are battery operated (with rechargeable
batteries) to allow the individual to wear the device for up to 8 hours
while functioning with daily activities.

Functional ROM Activities ————-

 Grasping an eating utensil: utilising finger extension and flexion
 Eating (hand to mouth): utilising elbow flexion and forearm supination and
some shoulder flexion, abduction, and lateral rotation
 Reaching to various shelf heights: utilising shoulder flexion and
 Brushing or combing back of hair: utilising shoulder abduction and lateral
rotation. elbow flexion. and cervical rotation
 Holding a phone to the ear: utilising shoulder lateral rotation, forearm
supination, and cervical side bend

EXERCISE THERAPY
DEEPIKA DANGI

 Donning and doffing a shirt or jacket utilising shoulder extension, lateral

rotation, and elbow flexion and extension
 Reaching out a car window to an ATM machine: utilising shoulder abduction,
lateral rotation, elbow extension, and some lateral bending of the trunk
 Going from supine to sitting at the side of a bed: utilising hip abduction and
adduction followed by hip and knee flexion
 Standing up/sitting down and walking: utilising hip and knee flexion and
extension, ankle dorsi and plantarflexion, and some hip rotation
 Putting on socks and shoes: utilising hip external rotation and abduction. knee
flexion and ankle dorsi and plantarflexion. and trunk flexion

Normal ROM of joint ———

Shoulder
Flexion 0°-180 ° (150 °-180°) , Extension 0 °-45° (40 °-60 °)
Abduction 0 °-180° (150 °-180 °), Adduction 0 °
Internal rotation 0 °-90 ° (70 °-90 °) , External rotation 0°-90 ° (70 °-90 °)
Elbow
Flexion 0 °-135 ° (120 °-150 °), Extension 0 °
Forearm
Supination 0 °-90 ° , Pronation 0 °-90 °
Wrist
Flexion 0 °-90 ° (70 °-90 °) , Extension 0 °-70 ° (50 °-70 °)
Ulnar deviation 0 °-40 ° (25 °-40 °) , Radial deviation 0 °-20 ° (15 °-25 °)
MCP
Flexion 0 °-90 ° , Extension 0 °-20 ° (15 °-30 °)
Abduction 0 °-20 ° , Adduction 0 °
PIP
Flexion 0 °-110 ° (90 °-120 °) , Extension 0 °
DIP
Flexion 0 °-90 ° , Extension 0 °
Thumb
MCP flexion 0 °-45 °
HIP
Flexion 0 °-120 ° (110 °-130 °) , Extension 0 °-35 ° (25 °-40 °)
Abduction 0 °-55 ° , Adduction 0 °
External rotation 0 °-45 ° (35 °-50 °) , Internal rotation 0 °-35 ° (30 °-45 °)

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Knee
Flexion 0 °-120 ° , Extension 0 °
Ankle
Plantar flexion 0 °-45 ° , Dorsi flexion 0 °-20 °
Inversion 0 °-45 ° , Eversion 0 °-15 °
MTP
Flexion 0 °-40 °, Extension 0 ° 80 ° (10 °-90 °)
Abduction 0 °-15 °
Interphalangeal
Flexion 0 °-60 ° (50 °-70 °) , Extension 0 °

FUNCTIONAL RE-EDUCATION
o Education - the process of teaching and learning.
o Re-Education - Re-education means educating something, which is already
known by an individual.
o Functional Re-education Here the patient knows the activities or movements
that has to be performed but due to his ailment or diseased pathology he
could not perform it properly.
o "making the man independent" is the main motto for the functional re-
educational program.
o In the functional re-educational training, sequence of progressions of
position like the development of milestone of child from lying to walking.
o Depends on condition and level of independence program can be designed.
o Depending on the condition, sequence can be planned and multiple postures
may be overlapped Sequence can be varied from one patient to another.
o In the functional re-education training, sequence of progressions of position
like the development the milestone of the child-from the lying to walking.
o Re-education can be done on..
 On Mat
 On Re-education Board
 Using Parallel Bar
 Using Suspension Therapy
 Using Hydrotherapy

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PRINCIPLES
o Proper and thorough assessment
o Assessment of functional Ability needs special attention
o Rx should be Tailor made.
o Commands
o Treatment should be task specific.
o Never ever discourage the patient.
o Feedback should be taken from the pt and relatives.
o Treatment should be effective, that patient have to achieve physical
independence
o Reviews are needed to Record.

Benefits—
o Improve the coordination and balance.
o Increase the strength endurance of the muscle.
o Increase the pelvic stability.
o Increase the dynamic and static stability.
o Enhance the proprioception function.
o Improve the postural instability.
o Improve the ambulatory skill.
 The functional re-education training consists of perambulatory mat exercise
and ambulatory training.
o Rolling
o Supine to side lying
o Side lying to prone lying
o Prone to side lying Side lying to supine
o Elbow prone lying
o Hand prone lying
o Elbow side lying-quadruped position
o Side sitting
o Sitting
o Kneeling
o Kneel sitting
o Half-kneeling
o Standing
o Walking.

 In each and every posture many of the exercises can be practiced for the
progression and to improve the stability as well as mobility.

EXERCISE THERAPY
DEEPIKA DANGI

 This progressive exercise program in each position makes the patient master
in that particular posture and also gives more confident for the next
progressive posture.

SUPINE ( Progressive Activities in Supine)

Most of the exercises can be performed in the supine lying posture. Neck
stability and strengthening exercises , upper-limb and lower limb coordination
as well as strengthening programs , Trunk exercises , Postural drainage
techniques. And also supine position is the very much convenient posture to
adopt for long period. All the strengthening exercises starts with assisted
exercise progressed to assisted resisted ends with resisted exercises.
Assisted → Active → Assisted resisted → Resisted

BRIDGING

In supine lying both knees are flexed and feet are placed on couch. Patient is
asked to raise his trunk from the floor or couch. hip knee trunk aligns in straight
line.in hemiplegic's condition early weight bearing is made to practice to
improve independency. This is given hemiplegia and paraplegic cases.

I. This is important exercise has to be practiced to improve trunk

stability. It improves pelvic and trunk stability as well as facilitates hip
abductors and adductors.
II. Earlier it started with the assisted type, i.e. movement practiced with
the assistance support may be given for knee from falling apart.
III. Patient is made to practice independently without any support or
assistance to improve the ability to hold trunk for some time after
rising from the floor.
IV. Modification can be made to improve the stability and endurance.
Performing the bridging exercise with one lower extremity support
and another lower extremity with hip flexed and knee extended.Once
he masters in it, made to practice it with the manual resistance by the
therapist later with mechanical.

SUPINE TO SIDE LYING

Rolling can be practiced with the assistance. While rolling to left side below
sequences are performed.
o Right hand pulls the upper body i.e, upper trunk and pelvic towards left
side by holding bed end or beside bars in the left side .
o Right knee is flexed and with the foot , the pelvic and lower trunk pushed
towards left side
o Left leg can be hooked over the bed end and rotated-the lower trunk

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o Left hand may assist to turn the upper trunk by grasping the bed end

Uses
o Useful in bed making activities
o Useful in preventing bad source
o Easy to progress to the next posture

Uses in side lying - Some of the exercises like upper and lower extremities
strengthening exercises can be performed, coordination exercise can be
performed , postural drainage techniques can be performed , assistive
movements can be performed in the early stage, independent activities

SIDE LYING TO PRONE

o Left shoulder abducted and elbow extended , placed under body next line
o Right hand grasping head and besides bars or bed and rotates upper trunk
o Left upper extremity extended throughout
o Right knee flexed end with foot pushes the mat to the rotated lower
trunk

Progressive activities
o Next stability exercises can be performed mainly extension & flexion
movement, spinal extension exercises can be performed, upper lower
extremity exercise can be performed, assistant exercise and resistance
exercise can be performed

Uses - Bad activities, postural drainage , bed sores

PRONE TO SIDE LYING

o The right hand placed sideways and pressure applied over mat by which
upper trunk and head can be raised up
o Right knee flexed and pressure applied on mat to rotate the lower trunk
o Left hand holds bedsides bars or right side bed end and pushes body
towards left side . hence the total weight rotates 90 degrees now the left
hand goes down and right hand comes up.

SIDE LYING TO SUPINE

o Right hand hold bed and or the side bars and pulls the upper trunk
towards the back side
o Left lower limb hook bed and and pulls lower trunk towards front side
o Left hand applies pressure over bed or the bedside bars and pushes body
back side

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Above mentioned all the Rolling techniques done with assistance

in the early stage and it is progressed into in dependent rolling
Assisted— dependent— Resisted

ELBOW PRONE LYING

o Elbow and forearm support patient’s upper trunk and weight is
transmitted through the elbow this position is achieved from prone lying
o Position achieved are shoulder flexion and elevation, elbow flexion,
4:00 AM pronation, wrist hand extension, palm is flat supported by this
surface

Progressive activities
 Positions can be adopted with the help of assistance from
prone lying
 Progression can be made to maintain posture independently
 Manual approximation force can be applied towards one side
to the another may improve the dynamic stability of upper
extremity
 Elbow walking can be practiced
 Shifting the way towards one of side of the elbow and other
side of the elbow can be removed from the mat and swing
towards the weight bearing limb posteriorly. This may
improve the proprioception activity more over the shoulder
joint
 resistance can also be applied manually to improve the
strength
uses - Bed making, dressing activities patient can hold magazine and
read the during this position, these activities are more helpful for the
paraplegic patient to improve their upper limb stability

HAND PRONE LYING

o This position is same like elbow prone line next line in this position
the base of support decreases slightly and centre of gravity raises
comparatively with elbow prone line next line
o Instead of weight bearing on the elbow weight is transmitted through
the hand and the rest
o This is an intermediate position between elbow prone line and the
quadruped position
o Hyper extension of spine as well as hip joint occurs more which is
useful for postural alignment during ambulation in beginning of this
position assistance of therapist is required
o Progression activities can be performed

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Position- Shoulder- Elevation flexion and abduction , Elbow- Extension

Wrist- Hyperextension , Fingers- Extension , Forearm- Pronation

Progressive Activities
o Position may be achieved by the assistants and the support given to
maintain the posture during the early stage.
o Preparing pt to maintain posture independently without any assistants.
o Approximation can be applied in sideways, anteroposterior direction
by which we can achieve proximal muscle stability as well as
coordination.
o Weight shifting from one side to another can be practiced to increase
the muscle power as well as proprioception activities over shoulder
joint.
o Hand walking can be practiced to improve the dynamic stability over
the upper limb.
o Push-up exercise may helpful to improve the static as well as dynamic
stability of the upper limb.
o Pegboards can be used to improve the hand coordination.

Uses
o This position is helpful for the paraplegic patient to improve the upper
limb muscle power and strength. is used for dressing activities. Bed
mobility can be improved.

QUADRUPED POSITION
It is otherwise called as four-feeted position or animal position. In this position
the BOS decreases while comparative with the hand prone lying and the COG
increases. It is the first position in which the weight bearing through the hip
joint takes place in the reeducation training. It can be achieved from: (1) hand
prone lying, (2) side sitting.
o From hand prone lying - From hand prone lying hip and knees flexed
and the pelvic is taken up to the knee level and the body is raised with
the help of therapist support
o From side sitting - From side sitting trunk is rotated and raised up.
Both the upper limb is placed front and allowing weight bearing on
the knees and the hands
o Position- trunk- forward flexion , hip- flexed 90% , knee- 90% ,
elbow-extension , wrist- extension, shoulder- flexion and extension ,
forearm-pronation, palm- flat and placed on floor
o Progression activities —

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 This position is achieved from the prone on hand or side

sitting position with the help of the assistants.
 Active maintenance of the posture is practiced regularly to
maintain independence.
 Manual force is applied sideways and anteroposterior
direction to achieve the co-ordination as well as stability of
upper and lower limb.
 Weight shifting sideways and anteroposterior direction can
be practiced to improve the dynamic stability of the limb.
 Weight bearing on contralateral upper and lower extremities
practiced, which is helpful during upper limb swinging
walking.
 Crawling movement can be practiced to improve the
dynamic stability of the limbs It improves the neuromuscular
and proprioceptive activities over the joints.
 Weight bearing on three limbs. Two can be practiced which
may be increasing the static stability of the limbs.
 Forward and backward crawling movement can be practiced.
 'Cat and Camel' exercise for the trunk has to be practiced,
i.e. raising and lowering of the trunk in the quadruped
position
 ‘Elephant movement’ i.e, forward, backward and sideways
oscillatory movement of the body can be done in quadruped
position, which increases static and dynamic stability of limb
 Manual resistance can be applied to improve muscle
strength

o Uses- floor level activities like playing with kids, seeding , weeding,
and gardening activities, useful for patients who cannot walk to
ambulate in and out of house .

ELBOW SIDE LYING

This can be achieved from the side lying. The BOS is support-less and the COG
is high while comparing with the elbow prone lying. It is the very much
unstable and inconvenient for an individual to maintain for the longer period.
This posture can be supported with the opposite side hand placing over the mat
in front.
o Position - Same like the side lying but the elbow is flexed and placed
on the mat and the upper trunk weight is transmitted through the
weight-bearing elbow. Elbow- Flexion , Shoulder - Extension,
elevation and internal rotation.
o Progressive Activities

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 This position is achieved from the elbow prone lying with

the help of the assistant. Independently maintaining the
position also can be practiced.
 Creeping with help of elbow on mat is taught to improve
dynamic and static stability as well as proprioception
activities.
 Manual approximation force is applied to increase the
static stability over the upper limb.
 Resisted activities can be performed to improve muscle
power.

o Uses mat mobility activities, relaxed position for reading books and
watching television, Enroute for sitting positions

SIDE SITTING
This position can be achieved from the elbow side lying as well as from kneel
sitting. Here the BOS still reduces and the COG increases while comparing with
elbow side lying and it is more stable than kneel sitting posture . Both upper
extremities will be supporting posture
o From elbow side lying HIP and knee is flexed ,elbow extended, palm
is flat and placed on floor and trunk raised

o From kneel sitting hip and knee extended and one side of hip is placed
on floor with same side upper limb support

o Position Hip and knee are flexed and kept in side , weight is
transmitted through one upper limb and pelvis of one side , shoulder is
abducted and elevated , elbow is extended, lower hip is flexed ,
abducted and laterally rotated, upper hip is medially rotated and flexed

o Progression activities
 Earlier this position is adopted from the elbow side lying
and kneel sitting with the help of assistance of the
therapist. Therapist will be sitting side to the patient and
first flexing both the hip and knees, with extending
elbow.
 The patient is made to practice to maintain posture
without any support.Side sitting will be practiced for both
sides.
 Manual approximation force is given in anterior and
posterior as well as lateral direction also to improve static
stability of the trunk as well as the weight-bearing limb.

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 Weight shifting over upper limb will be practiced to

activate proprioceptors over shoulder and elbow joint
 Balancing ex.Will be practiced by removing upper limb
support
 Moving on mat by dragging buttocks and by support of
upper limb
 Opposing resisted force may be given over trunk to
improve trunk stability

o Uses – floor level household activities like cutting vegetables, eating,

garland making

LONG SITTING
It is a very stable position to maintain for longer period of time. This can be
achieved from side setting. The trunk muscles should have good power and
strength main tain trunk in the erect posture and is supported by both upper limb
by placing either side sometimes the upper limb may be placed posteriorly to
avoid back falling
o Position – spine- erect , shoulder- abduction and elevation, elbow-
extension, wrist- extension, hip-flexion and lateral rotation,knee-90*

o Progression activities
 Posture is achieved with the help of therapist. Therapist
grasping the drunk and making it straight
 Patient is made to maintain this posture with help of upper limb
support without any external support
 Balancing force can be applied inside as well as anteroposterior
direction
 Weight shifting from one upper extremity to another will be
practised to improve proprioception activity over shoulder
region
 Sum of drunk upper limb lower limb free strengthening exercise
can be performed
 Mat crunch exercise can be practiced with the help of crutches
 Hitching hiking both hip is lifted with the help of upper limb
support is called hitching. Forward backward and sideways
movements can be practiced in this position. Sand bags wooden
blocks or small size clutches can be used for performing
hitching . lifting the one of the pelvic up is called hiking.
Hiking is the most important movement should be practiced
because during the swing phase hip hiking is more or the most
to clear the foot from the floor

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 Patient is made to practice set without the support of upper

extremity.
 Walking on the buttocks can be practiced to improve dynamic
stability
 Sitting push ups can be performed with which gives more
stability and strength to the upper extremity sitting with leg
cross can be performed

KNEELING
Standing on both knees are called kneeling. This can be achieved from
quadruped position and side sitting. In this position base of support is decreased
and centre of gravity is raised. This is very much inconvenient poster to
maintain for long time. Stability in this posture also very less .
o From quadruped position Therapist standing back of patient grasping
the upper trunk and lifting trunk and upper extremity up. The posture
is maintained by help of back support by the therapist

o From side sitting Same like quadruped position therapist grasping the
upper trunk by standing back to the patient and lifting him in the
middle sometimes kneel siting also may be attained but it is on the
way process to kneeling position

o Progressive Activities
 Patient is assisted to maintain the posture in the beginning stage.
 Independent maintaining the posture can be practiced.
 Manual approximation force is applied in anteroposterior as
well as lateral directions to improve static and dynamic stability
of pt.
 Hip hiking can be practiced in this posture as said in long
sitting.
 Kneel walking may be encouraged to increase the dynamic
stability of the patient.
 Mat crutch activities can be practiced swing the upper extremity
by holding the crutches. Lifting the body by holding the
furniture or wall.
 Progression can be made to walk in side-ways.

o Uses For dressing activities, Useful for mobility , Useful to play with
kids , Improves the floor level activities.

HALF-KNEELING

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It is achieved from the kneeling, to achieve from the kneeling weight is

transmitted to one side knee and the opposite lower extremity is lifted and the
hip is flexed and the foot is placed front on the mat. In this posture the BOS is
more the COG is less while comparative to the kneeling posture and it is stable
than the kneeling. It is the intermediate posture between the kneeling and the
standing
o Position Weight bearing over one side knee another side hip and knees
are flexed and the foot is kept on the floor.

o Progressive Activities
 Assisted balancing approximation force weight shifting
activities can be performed as said in previous postures.
 Push-ups can be practiced to come out of this posture and go for
the standing posture with the help of the furniture or wall.

STANDING
Here the BOS is less and the COG increases more. So, this is the unstable
posture to maintain for prolonged time. This is the intermediate position
between the half-kneeling and the walking. It can be achieved from the half-
kneeling and the long sitting. This is the starting position for walking.

o Half-Kneeling Therapist is standing back to the patient and grasping

the upper trunk with both the hands and lifting the patient up. The
kneeling legs move forwards and the foot on the mat or the floor,
otherwise patient can hold the furniture or the wall and lift his body up
to reach standing with the help of the assistance.

FROM SITTING
From the sitting the therapist has to sit in front of the patient on the stool and
has to lock the patient's knee with his knees, while he is made to stand. The
therapist has to hold the pelvis of the patient and lift him, the patient by holding
the shoulder region of the therapist to avoid falling. Whenever the patient
allowed standing for first time, the therapist should be alert to complaint of
nausea, light-headedness due to the sudden drop of the BP.
o Progressive Activities
 Beginning patient is made to stand in corner of wall with
therapist support in front, so that pt cannot fall front, back, and
sideways.
 Independent maintaining the standing posture can be performed
to improve the static stability.
 Approximation force is applied in front, back, and lateral
direction to improve the lateral stability.

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 Weight shifting from one side to another will be carried out to

increase the proprioceptor and the balancing activity. It may be
started with the support of an object or the therapist.
 Crutch exercises may be performed in this posture to improve
the crutch activities.
 Many of upper and lower extremities exercises can be
performed.
 Forward, backward, and sideways stepping can be practiced to
improve the dynamic stability and to attain earlier walking.

PARALLEL BAR WALKING

As soon as the motor control is achieved in the standing posture the parallel bar
activities can be introduced. Before going for the parallel bar activities the
parallel bar should be adjusted depends on the patient's height. Normally, the
height of the parallel bar should be up to the level of the greater trochanter.

o General Instructions Proper instructions in parallel bar activities

should be given throughout the walking train-ing. It includes walking
pattern, progressive activities, turning techniques, stability, balance
and coordination. Generally, the verbal command improves or
facilitates the activities more. The support or assistance of therapist
will be given in the weaker side limb to increase more stability. In
some conditions like unstable knee, therapist should lock knee of
patient and body weight is transmitted through locked knee joint.

o Progressive Activities During the initial range of the parallel bar

activities the therapist should give support to the patient from falling.
Normally, the therapist has to stand towards the weaker side to give
the stability. Guarding belt or the towel tied over the waist is used to
guarding the patient from falling. During the initial standing the
therapist should be careful about the complaints Off the light
headedness, nausea due to postural hypotension. Patient can be
practised below mention progressive exercise to improve the
conditions

 Patient is made to stand with support of parallel bar without

therapist support in early stage
 weight shifting shifting the weight lateral, anterior posterior
sites without altering hand position in parallel bars
 One leg standing patient is recommended to stand with one leg
support and transmitted whole weight over supported leg

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 One hand support patient one hand is removed from parallel

bar and may him to stand with one hand support
 Hip hiking patient is asked to practise hip hiking movements
which is helpful to clear food from the ground and the forward
propulsion f body during ambulation
 Step forward and backward patient is practised to keep one leg
forward bring back to the normal position and one step
backward movement and bring back to the neutral position by
standing in the same place
 Parallel bar pushups patient's body is lifted with his upper
limb support on parallel bar is called parallel bar push up this is
to be practised to improve upper extremity strength and power
 Turning technique the turning in parallel bar is important and
useful while turning in the normal floor walking. Normally
patient is made to turn towards the normal side by avoiding the
abnormal side. Avoiding pivot is also most helpful to show easy
mastering in turning technique . for example while turning to a
right side right leg is raised and placed on the floor 90 degrees
to previous position and in same was followed by left foot and
kept parallel to right foot next to that left hand is removed from
left side and placed on right side parallel bar to attain perfect
support the therapist may help the patient to support him by
standing back to him
 Resisted towards progression resistance force is applied over
the chest region of the patient while walking in the parallel bar
 Backward walking can we practiced of the patient to get good
standing
 Side walking can be practiced to improve stability and balance
 Air cycling parallel bar pushups have to be done first followed
by cycling activity with lower extremity in the air next line step
up inside the parallel bar the step is placed and instructed the
patient to practice the step activity standing on one leg and
swing the opposite side unsupported lower extremity

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PYQS
DOMS
Delayed Onset Muscle Soreness (DOMS) is the muscle pain and stiffness that
occurs 12 to 72 hours after engaging in unfamiliar or intense physical activity.
Unlike acute muscle soreness, which occurs during or immediately after
exercise due to lactic acid buildup, DOMS is caused by microscopic damage to
muscle fibers.

Causes of DOMS

DOMS primarily results from eccentric muscle contractions, where the muscle
lengthens under tension. Examples include: Downhill running (quadriceps
lengthen while controlling descent), Lowering weights (eccentric phase of a
bicep curl), Jumping and landing (muscles absorb impact), Engaging in new
exercises (muscles are unaccustomed to the strain)These eccentric contractions
cause microscopic tears in muscle fibers, leading to an inflammatory response
and subsequent soreness.

Symptoms of DOMS

DOMS typically develops 12 to 24 hours post-exercise, peaks around 48 hours,

and gradually subsides over 3 to 7 days. Common symptoms include:

 Muscle stiffness and tenderness

 Reduced range of motion
 Swelling in the affected muscles
 Temporary loss of muscle strength
 Pain when touching or using the muscles

Mechanism of DOMS

1. Microscopic Muscle Damage – Eccentric exercise causes tiny tears in

muscle fibers.
2. Inflammatory Response – The body reacts by sending white blood cells
and fluids to repair the damage.
3. Pain Mediators – Substances like prostaglandins and bradykinin increase
pain sensitivity.
4. Fluid Accumulation – Swelling puts pressure on nerve endings,
contributing to discomfort.

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How to Manage and Reduce DOMS

Though DOMS is temporary and a natural part of muscle adaptation, several

strategies can help manage it:

1. Active Recovery- Light activities like walking, swimming, or yoga can

enhance blood flow and speed up recovery.

2. Hydration and Nutrition

 Protein supports muscle repair.

 Carbohydrates replenish glycogen stores.
 Antioxidants and Omega-3s (from fruits, vegetables, and fish) help
reduce inflammation.

3. Massage and Foam Rolling - Improves blood circulation and reduces muscle
tightness. Foam rolling may alleviate soreness by breaking up muscle
adhesions.

4. Cold and Heat Therapy

 Cold therapy (ice baths, cold packs) reduces swelling.

 Heat therapy (warm baths, heating pads) promotes blood flow for muscle
relaxation.

5. Stretching and Mobility Work - Gentle stretching can ease stiffness but won’t
prevent DOMS. Dynamic warm-ups before exercise help prepare muscles and
may reduce severity..

Preventing DOMS

While DOMS cannot always be avoided, you can minimise its severity by:

 Gradually increasing exercise intensity rather than jumping into high-

intensity workouts.
 Warming up properly to prepare muscles for exertion.
 Cooling down and performing light activity post-workout.
 Strengthening muscles through progressive resistance training.

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Benefits of correct therapist position —————-

1. Prevents Physical Strain and Injury for the Therapist

 Reduced Risk of Injury: Maintaining correct posture and body mechanics can prevent
overuse injuries, such as back pain, shoulder strain, or repetitive stress injuries. This is
especially important in professions like massage therapy, physical therapy, and
chiropractic care, where the therapist is physically involved in hands-on work.
 Energy Efficiency: Using proper body alignment allows the therapist to engage their
body weight and muscles more efficiently, minimising fatigue and conserving energy
over long sessions. This also helps avoid the therapist having to overuse their arms or
hands, reducing the risk of chronic strain.

2. Enhances Effectiveness of Treatment

 Improved Pressure and Technique: When the therapist positions themselves correctly,
they can apply appropriate pressure and use their body weight to provide more
effective treatment. For example, leaning into a treatment, using legs for support, and
keeping wrists straight can improve the depth and consistency of the therapy.
 Maximised Reach and Comfort: The therapist can work more comfortably and
efficiently when they are aligned with the client’s body, ensuring they can reach
different muscle groups or areas that need attention without unnecessary strain or
awkward movements.

3. Improves Client Comfort and Safety

 Stability and Support: A correctly positioned therapist is able to offer more stability
and safety to the client, especially when working with vulnerable or injured areas.
Proper body mechanics ensure that movements are smooth and controlled, which
reduces the risk of causing discomfort or harm during the session.
 Better Communication: A therapist in a well-supported, correct position can also
better observe the client’s responses (like facial expressions or body language) during
treatment. This allows for more accurate feedback and adjustments to the treatment to
ensure the client is comfortable.

4. Enhances Therapist Longevity in Practice

 Sustained Career: The ability to work in a proper ergonomic position can help a
therapist avoid the physical wear and tear that might lead to career-ending injuries.
Maintaining this posture over time can contribute to a longer, healthier career,
especially in physically demanding therapeutic practices.

5. Promotes Client Confidence and Trust

 Professionalism: A therapist who maintains a confident and professional posture is

more likely to install trust in the client. Proper positioning demonstrates knowledge of
technique and care for one’s own well-being, as well as respect for the client’s
comfort.

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Exercise to strengthen hip abductors ———-

Strengthening the hip abductors can improve stability, balance, and overall lower-body
strength. Here are four effective exercises:

1. Side-Lying Leg Raises

o Lie on your side with legs stacked and straight.
o Lift your top leg upward while keeping it straight.
o Slowly lower it back down without touching the other leg.
o Perform 10-15 reps per side.
2. Clamshells
o Lie on your side with knees bent at 90 degrees and feet together.
o Keeping your feet touching, lift your top knee while keeping your hips stable.
o Lower back down with control.
o Perform 10-15 reps per side.
3. Lateral Band Walks
o Place a resistance band around your thighs or ankles.
o Stand with feet hip-width apart and slightly bend your knees.
o Step sideways, maintaining tension in the band.
o Take 10-15 steps in one direction, then return.
4. Single-Leg Glute Bridge
o Lie on your back with one knee bent and the other leg extended.
o Push through the heel of the bent leg to lift your hips while keeping the
extended leg straight.
o Lower back down with control.
o Perform 10-12 reps per side.

Eccentric Exercise for hamstring muscle

Eccentric exercises for the hamstrings focus on lengthening the muscle under tension, which
helps build strength and reduce injury risk. Here are four effective eccentric hamstring
exercises:

1. Nordic Hamstring Curls

o Kneel on a soft surface with your feet secured (by a partner or under a sturdy
object).
o Slowly lower your upper body forward while keeping your core engaged.
o Control the descent as much as possible, then use your hands to push back up.
o Perform 6-10 reps.
2. Romanian Deadlifts (RDLs)
o Stand with a barbell or dumbbells in hand, feet hip-width apart.
o Slowly hinge at the hips, lowering the weight while keeping a slight bend in
the knees.
o Lower until you feel a stretch in the hamstrings, then return to standing.
o Perform 8-12 reps.
3. Slow Hamstring Curls (Machine or Stability Ball)

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If using a machine, set a lighter weight and lower the pad slowly after curling.
o
If using a stability ball, lie on your back with feet on the ball, bridge your hips,
o
then slowly extend your legs.
o Perform 10-12 reps.
4. Eccentric Sliding Leg Curls
o Lie on your back with your heels on sliders or towels on a smooth surface.
o Bridge your hips up and slowly extend your legs straight while controlling the
movement.
o Return to the starting position by resetting or pulling back with minimal
assistance.
o Perform 8-12 reps.

Exercise to strengthen pelvic floor muscle

Strengthening the pelvic floor muscles is essential for core stability, bladder control, and
overall pelvic health. Here are four effective exercises:

1. Kegel Exercises

 Sit or lie down comfortably.

 Contract the pelvic floor muscles as if stopping the flow of urine.
 Hold for 3-5 seconds, then relax for the same duration.
 Perform 10-15 repetitions, 2-3 times per day.

2. Bridge with Pelvic Floor Engagement

 Lie on your back with knees bent and feet flat on the floor.
 Engage the pelvic floor muscles and lift your hips toward the ceiling.
 Hold for 3-5 seconds, then lower slowly.
 Perform 10-15 reps.

3. Squats with Pelvic Floor Activation

 Stand with feet hip-width apart.

 Lower into a squat while engaging your pelvic floor muscles.
 Rise back to standing while maintaining the contraction.
 Perform 10-15 reps.

4. Bird Dog with Core and Pelvic Floor Engagement

 Start in a hands-and-knees position.

 Extend one arm and the opposite leg while engaging the pelvic floor.
 Hold for a few seconds, then return to the start.
 Perform 10 reps per side.

Pelvic floor muscle - Levator Ani Group (Main Pelvic Floor Muscles), Coccygeus
(Ischiococcygeus), Perineal Muscles (Supportive Muscles in the Pelvic Floor)

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Exercises to strengthen shoulder muscles —

Strengthening the shoulder muscles (deltoids, rotator cuff, and surrounding stabilizers)
improves mobility, stability, and overall upper-body strength. Here are four effective
exercises:

1. Overhead Shoulder Press

 Stand or sit with a dumbbell in each hand at shoulder height.

 Press the weights overhead until arms are fully extended.
 Slowly lower back to the starting position.
 Perform 8-12 reps.

2. Lateral Raises

 Hold a dumbbell in each hand by your sides.

 Raise both arms outward until they reach shoulder height.
 Lower slowly with control.
 Perform 10-15 reps.

3. Front Raises

 Hold dumbbells in front of your thighs.

 Raise one or both arms straight in front to shoulder height.
 Lower slowly with control.
 Perform 10-12 reps.

4. Face Pulls (Cable or Resistance Band)

 Attach a band or cable at head height.

 Pull the handles toward your face, keeping elbows high.
 Squeeze your shoulder blades together.
 Perform 12-15 reps.

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