THERAPEUTIC CONCEPTS

Intro to Therapeutic Concepts

Kinesiotherapy Training Module

Kinesiotherapy’s Role

• Kinesiotherapy provides a bridge between acute illness and physical
wellness for persons who are medically stable but have not yet achieved
maximal restoration of strength, endurance and mobility.

• Kinesiotherapists are qualified to implement exercise programs designed
to:
• Reverse or minimize the debilitating effects of disease, injury, or
prolonged illness.
• Enhance functional capacity.
• Restore the ability to perform daily tasks.
• Develop fitness characteristics to enhance healthy and functionally
independent living.

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• Essential skills required:
• Knowledge of normal body structures and movement patterns.
• Knowledge of how pathological disease processes affects normal
function.

• The intervention process includes :
• Development and implementation of a treatment plan.
• Assessment of progress toward goals.
• Modification of goals as necessary to achieve goals and outcomes, and
client education.

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• Kinesiotherapists must have a prescription from a qualified physician,
nurse practitioner and/or physician’s assistant who has been privileged to
make such referrals before administering therapeutic treatment.
• Protects the patient from receiving treatment from an unqualified
individual.
• Protects the therapist in that safe parameters for the patient are set.
• Provides other medical history, such as a pre-existing medical or
surgical condition, that was not reported by the patient during the
therapist’s evaluation.

• In collaboration with the patient/family, the Kinesiotherapist determines
the appropriate evaluation tools and interventions necessary to establish a
goal-specific treatment plan.
• A goal-specific treatment plan is based on anticipated outcomes for the
patient. What does the patient want to accomplish?

Therapeutic Concepts 4


• Basic guidelines for developing a rehab program include:
• Establish a baseline.
• Progression should be gradual and not cause excessive fatigue.
• Use the overload principle.
• Rhythmic/cyclic activity.

• Fundamental Modalities of Kinesiotherapy:
• Exercise
• Education

5

Therapeutic Concepts

• Physical Fitness – the ability to complete daily activities with vigor and
alertness, without undue fatigue, and with energy remaining to meet
unexpected activities.

• Rehabilitation – the restoration and/or maintenance of physical function to
the level that allows an individual to perform activities of daily living
(ADL) without incurring high levels of stress or fatigue.

• Activities of Daily Living (ADL) - the basic activities of typical human
life, including positioning, mobility, self-care/maintenance activities and
communication; examples include dressing, using eating utensils, daily
hygiene, getting up and down from a seated position, etc.

• Functional Limitations – the reduced ability of a person to perform basic
ADL activities in an efficient or typically expected manner.


Components of Physical Function

• Range of Motion (ROM) – the amount of angular motion allowed at the
joint between any two bony levers.

• Passive Range of Motion (PROM) – movement within the unrestricted
ROM for a segment that is produced entirely by an external force.

• Active-Assistive Range of Motion (AAROM) – movement through a ROM
that is completed by a voluntary muscle contraction along with the
assistance of an external force.

• Active Range of Motion (AROM) – movement within an unrestricted
ROM that is produced by an active contraction of the muscles crossing that
joint.



• Balance – the ability to maintain the body’s center of gravity over the
base of support.
• Static - the ability to hold a position without moving (ex. standing
on one leg).
• Dynamic - the ability to maintain equilibrium while moving through
space (ex. walking or running).

• Proprioception – perception of movement direction, amplitude, speed,
and tension based on information from tendon and muscle receptors,
joint receptors, and the vestibular system.

• Kinesthesia – awareness of weight, position, and movement of the body;
includes position sense (static position awareness); also from joint,
muscle and tendon receptors.

• Flexibility – the ability of muscle and other soft tissue to yield to a
stretch force.


• Coordination – the basis of smooth, efficient, and accurate movement that
results from using the appropriate muscles at the appropriate time with the
correct intensity.

• Muscular strength - the greatest measurable force that can be exerted by a
muscle during a single, maximum effort
• The relative strength of a muscle is represented by its ability to produce
a tension force in response to the demands placed on it
• Example – a maximum bench press, squat, deadlift.

• Muscular endurance - the ability of a muscle to:
• Resist fatigue during sustained contractions or repeated repetitions.
• Generate and sustain tension for an extended period of time
• Example – performing continuous reps of bench presses (16 or
higher) with a fixed resistance.



• Muscular power - work produced by a muscle per unit of time (force x
distance/time).
• Muscle power relates to the strength and speed of muscle performance.
• The greater the intensity of an exertion, the shorter the period of time
taken to generate the force, the greater the power output.
• Example - jumping movements, throwing movements.

• Cardiopulmonary Fitness – the ability of the heart and lungs to take in and
transport adequate amounts of oxygen to the working muscle, allowing
activities that involve large muscle groups to be performed over long
periods of time.



• Cognition - refers to the mental processes involved in gaining knowledge
and comprehension, including thinking, knowing, remembering, judging
and problem solving.
• These are higher-level functions of the brain.
• Includes short and long term memory, language, imagination,
perception, orientation, attention span, and planning.

• Sensation – the ability to perceive touch, temperature, pain, vibration.

• Hearing - perception of sound by conversion of sound waves and/or
vibration into nerve impulses.



• Vision – the act or power of sensing with the eyes.
• Includes visual acuity, depth perception, color vision, and peripheral
vision.

• Mobility – the ability to move in a variety of directions and carry out both
simple and complex motor tasks.
• Normal - the ability to move in one's environment with ease and
without restriction.
• Impaired - any limitation in independent, purposeful physical
movement of the body of one or more extremities.



• Posture – position of the body or body parts.
• Proper or neutral – normal spinal curves; the ears, shoulders, hips,
knees and ankles aligned as if a plumb line were running through them.
• Kyphosis – exaggeration of the posterior thoracic curve.
• Lordosis – exaggeration of the anterior cervical or lumbar curve.
• Scoliosis – lateral “S” or “C” curvature of the spine.

• Postural Control
• Equilibrium Reactions – reflexive reactions that enable a person to
maintain or regain balance during a shift in the center of gravity.

• Righting Reactions – the use of visual and vestibular input and
processing to place the head in correct position to maintain vertical
alignment of the head in relation to gravity.



• Pain – an unpleasant sensation induced by a noxious stimulus, received by
nerve endings and characterized by physical discomfort (ex. pricking,
throbbing, burning or aching).
• Occurs in varying degrees of severity, often as a consequence of injury,
disease, or emotional disorder.
• Can lead to physical, psychosocial and/or psychological distress.

• Acute Pain - sudden onset pain, that can be mild and last for a moment, or
be severe and last weeks or months; in most cases it does not last longer
than six months, and disappears when the underlying cause has been
treated.
• Primary goal of acute pain treatment is to diagnose the source and
remove it, since unrelieved acute pain can lead to chronic pain.



• Chronic pain - generally starts as acute pain, but continues beyond the
normal time expected for resolution of the problem.
• Can be mild or excruciating, episodic or continuous, merely
inconvenient or totally incapacitating.
• Nociceptive – arises from damage to tissues other than nerve fibers
• Neuropathic – occurs when nerves in the central nervous system
become injured, dysfunctional or damaged; often described as a
burning, stabbing, or tingling pain.
• Primary goals of treatment are to minimize pain and maximize
function.

• Idiopathic pain – pain for which a reasonable cause cannot be
determined.


Tests and Measurements

• Vital Signs - measures of various physiological processes used to assess
the most basic body functions; generally consist of blood pressure, heart
rate, respiratory rate and body temperature.

• Heart Rate (HR) – determined by the number of heartbeats per unit of
time, typically expressed as beats per minute (BPM).
• Normal resting heart rate ranges from 60 to 100 beats a minute in a
healthy adult.
• Many factors can influence heart rate, including: activity level,
fitness level, air temperature, body position (ex. standing , lying
down), emotions, body size, and/or medication use.
• Used to evaluate readiness for, as well as response to, exercise or
activity; best taken pre-, during and post-exercise.
• Can be measured at carotid, wrist, temple, elbow, or foot.



• Vital Signs (cont.)

• Blood Pressure (BP) - the force applied to the walls of the arteries as the
heart pumps blood through the body.
• Pressure is determined by the force and amount of blood pumped,
and the size and flexibility of the arteries.
• Can be affected by activity, temperature, diet, emotional state,
posture, physical state, medication use.
• Measured on the anteromedial aspect of the elbow at the brachial
artery.
• Systolic reading - the maximum pressure exerted when the heart
contracts; normal reading less than120mmHg.
• Diastolic reading - the minimum pressure in the arteries when the
heart is at rest; normal reading less than 80mmHg.



• Blood Pressure (cont.)
• Hypotension – low BP; of concern if symptomatic
(lightheadedness, dizziness, weakness or fainting).
• Hypertension –high BP; a consistently high blood pressure
exceeding 140/90mm/Hg.
• Orthostatic hypotension – a significant drop in pressure following a
change in body position resulting in low BP symptoms. Seen most
often when moving from lying to sitting or sitting to standing.

• Respiratory rate - number of breaths taken within a set amount of time.
• Average respiratory rate at rest for a healthy adult is usually given
as 12-18 breaths per minute.
• Note whether a person has any difficulty breathing.



• Pulse Oximetry – a non-invasive method for monitoring the oxygenation
of a patient's hemoglobin.
• Only measures oxygenation, not ventilation and is not a complete
measure of respiratory sufficiency.
• Normal range - 95-99.
• Abnormal – less than 89.

• Goniometer – a protractor with two extending arms that measures
joint range of motion.
• Pivot point is placed over the axis of the
joint.
• Arms are placed along the long axis of
the bones.



• Inclinometer – a device used to measure the range of motion of the spine.
• Measures angular displacement relative to gravity as opposed to arcs
like a goniometer.
• Inclinometers are used because the spine is composed of multiple joints
that function in unison to produce movement. A goniometer cannot
distinguish the difference between hip flexion, sacral flexion or lumbar
flexion when the subject is bending forward.



• Scoliometer – used to detect lateral spinal curvature (scoliosis).
• Flexometer – 360° gravity-type goniometer that is self-zeroing; straps to
body parts.


Average Ranges of Motion for the Upper Extremities
(in degrees from selected sources)
Joint Motion American Acad Kendall and American
of Orthopedic McCreary Medical Assoc
Surgeons

Shoulder Flexion 0–180 0-180 0–150
Extension 0-60 0–45 0-50
Abduction 0-180 0-180 0-180
Medial Rotation 0-70 0-70 0-90
Lateral Rotation 0-90 0-90 0-90

Elbow Flexion 0-150 0-145 0-140

Wrist Extension 0-70 0-70 0-80
Flexion 0-80 0-80 0-60
Radial Deviation 0-20 0-20 0-20
Ulnar Deviation 0-30 0-35 0-30


Average Ranges of Motion for the Lower Extremities
Surgeons

Hip Flexion 0-120 0-125 0-100
Extension 0-30 0-10 0-30
Abduction 0-45 0-45 0-40
Adduction 0-30 0-10 0-20
Lateral Rotation 0-45 0-45 0-40
Medial Rotation 0-45 0-45 0-50

Knee Flexion 0-135 0-140 0-150

Ankle Dorsiflexion 0-20 0-20 0-20
Plantarflexion 0-50 0-45 0-40
Inversion 0-35 0-35 0-30
Eversion 0-15 0-20 0-20


Average Ranges of Motion for the Spine
Surgeons

Cervical Flexion 0-45 0-45 0-60
Extension 0-45 0-45 0-75
Lateral Flexion 0-45 0-45
Rotation 0-60 0-80

Thoracic Flexion 0-50
Rotation 0-30
Thoracic/ Flexion 0-80

Lumbar Extension 0-25
Lateral Flexion 0-35
Rotation 0-45

Lumbo- Extension 0-25
Sacral Lateral Flexion 0-25



• End-Feel – a quality of resistance and/or sensation that is felt by the
examiner at the end point of the available range of motion. Each joint has
a normal end feel.
• Pathology is indicated when there is an incorrect end-feel at the terminal
range, or a correct end-feel before the terminal range.
• Passive range of motion should be used prior to performing a manual
muscle test, to determine if range is restricted, since the MMT grading
scale is based on the completion of the range of motion.


Normal (Physiological) End-Feels

End-feel Structure Example

Soft soft tissue approximation knee flexion (contact between the soft tissue of the
posterior leg and thigh)

Firm muscular stretch hip flexion with the knee straight (passive elastic
tension of hamstring muscles)
capsular stretch extension of metacarpophalengeal joints (tension
in the anterior capsule)
ligamentous stretch forearm supination (tension in the ligament in the
inferior radioulnar joint)

Hard bone contacting bone elbow extension (contact between the olecranon
process and olecranon fossa)


Abnormal (Pathological) End-Feels

End-feel Examples

Soft Occurs sooner or later in the ROM than is usual, soft tissue edema
or in a joint that normally has a firm or hard end- synovitis
feel; feels boggy

Firm Occurs sooner or later in the ROM than is usual, or increased muscular tonus
in a joint that normally has a soft or hard end-feel capsular, muscular,
ligamentous shortening

Hard Occurs sooner or later in the ROM than is usual, or chondromalacia, OA, loose
in a joint that normally has a soft or firm end-feel bodies in the joint, fx,
myositis ossificans

Empty No real end-feel because pain prevents reaching acute joint inflammation,
the end of ROM; no resistance is felt except the bursitis, abscess, fx
patient’s protective muscle splinting or muscle
spasm



• Manual Muscle Test (MMT) – assesses the extent and degree of muscular
weakness resulting from disease, injury or illness.
• Unaffected limb/side should be tested first – allows the tester to learn
what would be considered normal for that person.
• Proper positioning is essential for validity.
• Muscles and tendons should be palpated as a lack of tension helps
identify substitution by muscles other than the those being tested.
• Fatigued muscles should not be confused with weak ones.
• Grading system – system for recording results of manual muscle test.
• Several methods of recording exist.
• Considered to have both subjective and objective factors.



• MMT Grading System
• Normal or 5 or 100%– complete range of motion against gravity
with full resistance.
• Good or 4 or 75% – complete range of motion against gravity
with some resistance.
• Fair or 3 or 50% – complete range of motion against gravity.
• Poor or 2 or 25% – complete range of motion with gravity
eliminated.
• Trace or 1 or 5-10% – evidence of slight contractility, but no joint
motion.
• Zero or 0 or 0% – no evidence of contractility.



• Anthropometrics – measurement of body size and composition.
• Can include height, weight, body fat, circumference of any body
segment, and arm span.

• Sit and Reach – measures hip, low back and hamstring flexibility.

• Thomas Test – physical exam used to rule out a hip flexion contracture.
• Subject lies supine on the exam table; examiner passes a hand beneath the
person’s spine to identify lumbar lordosis.
• Unaffected hip is flexed until the thigh just touches the abdomen to
eliminate the lumbar lordosis.
• Angle between the affected thigh and the table is measured to detect any
fixed flexion deformity of the hip.



• Adams Forward Bend Test - used to screen for scoliosis.
• Subject bends forward with the feet together and knees straight while
dangling the arms; examiner stands behind subject, looking for
differences in rib cage height, or other deformities of the back.

• Get Up & Go – mobility test to assess risk for falls.
• Used mainly for the elderly population.
• Person must be able to walk independently with or without an assistive
device.
• A timed test that requires the individual to rise from a chair, stand
momentarily, walk 10 ft, turn around, walk back to the chair, turn
around and sit in the chair.



• Cardio/Respiratory – measures the ability of the circulatory and respiratory
systems to supply oxygen to skeletal muscles during sustained physical
activity.
• Six-Minute Walk – a self-paced test to measure functional exercise
capacity; the distance a person can walk on a flat, hard surface in a period
of 6 minutes.

• Leg length discrepancy – measure the length of each lower limb from the
anterior superior iliac spine to the medial malleolus; compare for
differences.



• Trendelenberg Sign – used to detect weak hip abductors, including gluteus
medius and minimus.
• Subject stands with feet shoulder width apart, lifts one foot
• Test is positive when the non weight-bearing limb shows pelvic drop;
indicates the hip abductors on the weight-bearing limb are weak and
cannot stabilize the pelvis.

• Electromyography – the measurement and analysis of muscle action
potential using surface or needle electrodes.


Therapeutic Interventions

• Therapeutic Exercise – the systematic and planned performance of bodily
movements, postures, or physical activities to:
• Remediate or prevent impairments.
• Improve, restore, or enhance physical function.
• Optimize overall fitness and health status.

• Four main types of therapeutic exercise:
• Passive – movement that is a result of an outside force.
• Active Assistive – some if not most of movement is assisted by an
outside force.
• Active – movement is performed without assistance.
• Resistive – movement is performed against an outside force.



• Codman’s or Pendulum Exercise –gravity assisted exercises for restoring
range of motion and function in the arm or shoulder.
• Performed by swinging a freely
hanging upper extremity in a pendulous
fashion
• Incorporates three distinct movement
patterns of the shoulder: circumduction,
flexion and extension, abduction and
adduction.



• Bobath or Neurological Development Treatment (NDT) – a system of
exercises, consisting characteristically of reflex-inhibiting postures and
maneuvers; an advanced hands-on approach to the examination and
treatment of individuals with disturbances of function, movement and
postural control due to a lesion of the central nervous system (CNS).

• Used primarily with children who have cerebral palsy (CP) and adults
with cerebral vascular accidents (CVA).

• Rehabilitation goals - to improve any or all of the following: postural
control, coordination of movement sequences, movement initiation,
optimal body alignment, abnormal tone or muscle weakness.



• Proprioceptive Neuromuscular Facilitation (PNF) - a system for promoting
the response of neuromuscular mechanisms by stimulating proprioceptors.

• Designed in the 1940s and 1950s by Kabat, Knott and Voss to
rehabilitate polio or other patients with paralysis.

• PNF techniques involve placing a demand where a response is
required.

• Specific parts of the body are stabilized with the hand or body of the
clinician, while the other hand is used to grip the extremity or relevant
part of the limb of the patient to offer highly specific patterns of
resistance.


• DeLorme Exercises - progressive resistance exercises usually called PRE,
in which the loads to be lifted increase progressively during one session as
well as during the course of training.

• Weight Bearing Exercise - an activity or exercise which requires that some
part of the body must resist gravity while supporting the weight of the rest
of the body.

• Williams Flexion Exercises - system of exercises intended to enhance
lumbar flexion, avoid lumbar extension, and strengthen the abdominal
musculature to manage low back pain non-surgically.
• While not the original intent, these exercises also stretch the back, hip,
gluteal, and hamstring musculature.



• Balance exercises – improve proprioception and kinesthesis, so as to
maintain both static and dynamic postures and balance.

• McKenzie Method or Mechanical Diagnosis and Therapy (MDT) - more of
an approach to back and neck pain rather than a specific set of exercises.

• Relies on therapist assessment, an algorithm to determine condition
categories that help pinpoint the mechanical source of a patient’s
historical pain, and active patient involvement in the diagnosis and
treatment prescription.

• Involves extension exercises , specified movements and positions, and
a strong focus on self treatment strategies and minimal use of manual
therapy procedures.



• Stretching exercises – exercises that lengthen and elongate muscles and
associated soft tissues.
• Static stretch - a stretch performed without joint movement where a
position is assumed and then held.
• Dynamic stretch - a stretch performed with joint movement where the
end position is not held.
• Ex. arms circles, side bends and exaggerated kicking action.
• Passive (or assisted) stretch - similar to a static stretch, however
another person or apparatus is used to help further stretch the muscles.
• Active (or active static) stretch - a stretch where a position is assumed
and then held with no assistance other than using the strength of the
agonist muscle(s). Tension of the agonist helps to relax the muscle(s)
being stretched (the antagonists) by reciprocal inhibition.



• Postural Drainage – an airway clearance technique that uses gravity to help
patients with respiratory illnesses clear mucus from the lungs.
• Uses various body positions to facilitate drainage from specific lung
segments.
• Often used in conjunction with chest percussion and vibration.

• Breathing exercises - techniques for learning to control the rate and
depth of breathing.
• Generally inhale through the nose, while expanding the chest, and then
exhale fully through the mouth, while contracting the abdominal
muscles.
• Used after chest surgery, by people with chronic obstructive pulmonary
disease, anxiety disorders, and asthma.



• Quad Cough – a technique to help clear secretions from the airway
• Generally used for patients with central nervous system disorders such
as spinal cord injury who are unable to generate sufficient force to
clear respiratory secretions.
• After a maximal inspiration, the patient coughs while an assistant
exerts gentle upward and inward pressure with both hands on the
abdomen; increased intra-abdominal pressure produces a more forceful
cough.

• Education – essential for the proper understanding of the disease, injury, or
illness and its effects, as well as the reasoning behind the treatment
program, proper technique and benefits of compliance.
• Can include verbal and written instruction, demonstration and
mentoring.


Medical Terminology

• Antalgic – counteracting or avoiding pain, as in a posture or gait assumed
so as to lessen pain.
• Ataxia -partial or complete inability to coordinate voluntary movements.
• Apraxia - total or partial loss of the ability to perform purposeful
movements or manipulate objects in the absence of motor or sensory
impairment.
• Aphasia – inability to communicate due to the disturbance of both
expressive and receptive language.
• Aneurysm – weak bulge in an artery.
• Clonus - a series of rapid involuntary muscle contractions associated with
upper motor neuron lesions.
• Contralateral – on or relating to the opposite side (of the body).


Medical Terminology

• Dyspnia – difficulty in breathing.
• Decubitus Ulcer – skin ulceration or sore frequently caused by prolonged
pressure.
• Drop Foot – the dropping of the forefoot due to weakness, damage to the
peroneal nerve or paralysis of the muscles in the anterior portion of the
lower leg.
• Dyskinesia – difficulty initiating movement.
• Edema –accumulation of fluid in the tissue spaces.
• Etiology – the source or origin of a symptom or disease.
• Fasciculation – small, local, involuntary muscle contraction and relaxation
which may be visible under the skin.
• Idiopathic – unknown cause.


Medical Terminology

• Ipsilateral – on or relating to the same side (of the body).
• Orthosis - an artificial or mechanical aid, such as a brace, to support or
assist movement of a weak or injured body part.
• Prosthesis – a device designed to replace a missing body part or to make a
part of the body work better.
• Syncope – fainting spell.


Abbreviations

• a - before
• AAROM – active assistive range of motion
• Abd - abduction
• ACL – anterior cruciate ligament
• Add - adduction
• ADL – activities of daily living
• AFO – ankle foot orthosis
• AK – above knee
• AROM – active range of motion
• BID, TID,QID – 2x/day, 3x/day, 4x/day
• BK – below knee
• BPH – benign prostatic hypertrophy


Abbreviations

• c - with
• CA – cancer
• CABG – coronary artery bypass graft
• CAD – coronary artery disease
• CCU – coronary care unit
• CHD – congestive heart disease
• CHF – congestive heart failure
• CKC – closed kinetic chain - ??? thoughts
• c/o – complains of
• COPD – chronic obstructive pulmonary disease
• CP – cerebral palsy
• CPM – continuous passive motion


Abbreviations

• CS – cervical spine
• CT – computerized tomography
• CVA – cerebral vascular accident
• D/C – discharge
• DDD – degenerative disc disease
• DM – diabetes melitis
• DVT – deep vein thrombosis
• Dx – diagnosis
• EKG/ECG – electrocardiogram
• EMG – electromyogram
• ERP – end range pain
• FWB – full weight bearing


Abbreviations

• Fx – fracture
• GM&S – general medical and surgical
• HEP – home exercise program
• HNP – herniated nucleus pulposus
• HTN – hypertension
• Hx – history
• ICU – intensive care unit
• ISOM – isometric
• Jt – joint
• LBP – low back pain


Abbreviations

• LE, UE – lower extremity, upper extremity
• LS – lumbar spine
• MI – myocardial infarction
• MMT – manual muscle test
• MS – multiple sclerosis
• MVA – motor vehicle accident
• N/A – not applicable
• NPO – nothing by mouth
• NSC, SC – non service connected, service connected
• NWB – non weight bearing


Abbreviations

• OA - osteoarthritis
• ORIF – open reduction internal fixation
• p - after
• PMH – past medical history
• PM&R – physical medicine & rehabilitation
• PRE – progressive resistive exercise
• PRN – as needed
• PVD – peripheral vascular disease
• PWB – partial weight bearing
• R/O – rule out
• Rx – prescription or treatment
• s – without
• SCI – spinal cord injury


Abbreviations

• SLR – straight leg raise
• SOB – shortness of breath
• S/S – signs and symptoms
• Sx – surgery
• THA – total hip arthroplasty
• TIA – transient ischemic attack
• TKA – total knee arthroplasty
• TTWB – toe touch weight bearing
• TURP – transurethral prostatectomy
• UTI – urinary tract infection
• WNL – within normal limits


THERAPEUTIC CONCEPTS

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