**5. Techniques**

The techniques of exercise therapy used in treatment may be classified as follows [7].

#### **5.1. Passive movement**

#### *Passive movements*

Passive movements (Motion Therapy, Continuous Passive) provide continuous passive motion to the applied joint. The apparatus can be used immediately after the operation to improve the range of motion, reduce pain, discomfort, and healing. This machine is adjustable, easily controlled, versatile, and usually electrically operated.

#### *a) Relaxed passive movements*

The physiotherapist performed these movements for the patients. The physiotherapist needs knowledge of the anatomy of joints. The same direction and range of the movements are the same as those performed in the active movements. The physiotherapist moves the joint d through the existing free range and within the limits of pain.

#### *b) Accessory movements*

These movements are parts of any normal joint movement but may be absent or limited in abnormal joint conditions. They consist of rotational or gliding movements which cannot be separately performed as a voluntary movement but can be performed by the physiotherapist.

#### *Passive manual mobilization techniques*

#### *a) Mobilizations of joints*

The physiotherapist performed these movements which are usually small repetitive oscillatory, rhythmical, localized functional, or accessory in various amplitudes within the available range. These can be done quite strongly or very gently and are graded according to the part of the available range in which they are performed.

#### *b) Manipulations of joints*

#### *- Physiotherapists*

**f)** Sequence

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**h)** Feedback

**g)** Environment

**5. Techniques**

**5.1. Passive movement**

*a) Relaxed passive movements*

*b) Accessory movements*

*a) Mobilizations of joints*

*Passive manual mobilization techniques*

of the available range in which they are performed.

*Passive movements*

The therapist must continually monitor the exercise to determine the need for modification to increase or decrease difficulty to ensure continual progress is being made with minimal setbacks. In addition, exercise therapy can be complemented with adjunctive interventions if the additional intervention can lead to a higher level of functional outcome in a short time.

The techniques of exercise therapy used in treatment may be classified as follows [7].

able, easily controlled, versatile, and usually electrically operated.

through the existing free range and within the limits of pain.

Passive movements (Motion Therapy, Continuous Passive) provide continuous passive motion to the applied joint. The apparatus can be used immediately after the operation to improve the range of motion, reduce pain, discomfort, and healing. This machine is adjust-

The physiotherapist performed these movements for the patients. The physiotherapist needs knowledge of the anatomy of joints. The same direction and range of the movements are the same as those performed in the active movements. The physiotherapist moves the joint d

These movements are parts of any normal joint movement but may be absent or limited in abnormal joint conditions. They consist of rotational or gliding movements which cannot be separately performed as a voluntary movement but can be performed by the physiotherapist.

The physiotherapist performed these movements which are usually small repetitive oscillatory, rhythmical, localized functional, or accessory in various amplitudes within the available range. These can be done quite strongly or very gently and are graded according to the part The movements are performed by the physiotherapist. They are accurately localized, single, quick decisive movements, which have small amplitude and high velocity completed before the patient can stop it.

#### *- Surgeon/physician*

The movements are performed by a surgeon under anesthesia or physician to receive further range. The maintaining of the increase in movement must be performed by the physiotherapist.

#### *c) Controlled sustained stretching of tightened structure:*

The increase in range of movement can be done by passive stretching of muscles and other soft tissues. The stretching adhesions in these structures and lengthening of muscle increase the movement by inhibition of the tendon protective reflex.

#### **5.2. Active exercise**

Movement performed or controlled by the voluntary action of muscles, working in opposition to an external force

#### *Voluntary*

#### *a) Assisted active exercise*

In this type of exercise, the patient tries to perform the movement by himself/herself. However, his/her muscular action is insufficient for the production or control of full range of movement. To complete it, an external force needs to be added. If the muscle power increases, the assistance given must decrease.

#### *b) Free exercise*

Free exercises are those which are performed by the patient's own muscular efforts without the assistance or resistance of any external force, other that of gravity.

#### *c) Assisted-resisted exercise*

This type of exercise constitutes a combination of assistance and resistance during a single movement.

#### *d) Resisted exercise*

The external force may be applied to the body levers to oppose the force of muscular contraction and there will be increase in muscle power and hypertrophy.

Resisted exercise technique is classified into six major categories:


#### *Exercise preparation*

Before exercise training, a patient should be evaluated by a physician. It is important to exclude patients with ventricular hypertrophy, valvular heart disease, dangerous arrhythmias, and malignant hypertension. Other cardiac cases, and patients at risk, such as those with exercise‐induced asthma, obesity, or diabetes, should perform an exercise stress test under careful medical supervision. Blood pressure and heart rate and the electrocardiogram (ECG) must be monitored throughout the exercise to confirm their cardiovascular function.

#### *Aerobic or endurance training*

In endurance training program, there are three important variables, including frequency, intensity, and duration. The recommendations by the American College of Sports Medicine (ACSM) are as follows:


The duration of training is dependent on the intensity of the exercise. Thus, lower‐intensity exercise should be performed over longer duration (≥30 min), and conversely, higher levels of intensity should be performed at least 20 min or longer. Moderate‐intensity exercise of longer duration is recommended for untrained adults, because total fitness is more readily attained with exercise sessions of longer duration and because potential hazards and adherence problems are associated with high‐intensity activity.

#### *Exercise for healthy individuals*

Continuously aerobic exercises that use large muscle groups are recommended including western and eastern style:

Western style

Resisted exercise technique is classified into six major categories:

Before exercise training, a patient should be evaluated by a physician. It is important to exclude patients with ventricular hypertrophy, valvular heart disease, dangerous arrhythmias, and malignant hypertension. Other cardiac cases, and patients at risk, such as those with exercise‐induced asthma, obesity, or diabetes, should perform an exercise stress test under careful medical supervision. Blood pressure and heart rate and the electrocardiogram (ECG) must be monitored throughout the exercise to confirm their cardiovascular function.

In endurance training program, there are three important variables, including frequency, intensity, and duration. The recommendations by the American College of Sports Medicine

• Frequency—Appropriate frequency of the aerobic exercise should be 3–5 days per week. • Intensity of training—64/70—94% of maximum heart rate (HR max), or 40/50—85% of

• Duration of training—The appropriate duration of training should be intermittent or continuous aerobic exercise for 20–60 min (minimum of 10‐min bouts accumulated

The duration of training is dependent on the intensity of the exercise. Thus, lower‐intensity exercise should be performed over longer duration (≥30 min), and conversely, higher levels of intensity should be performed at least 20 min or longer. Moderate‐intensity exercise of longer duration is recommended for untrained adults, because total fitness is more readily attained with exercise sessions of longer duration and because potential hazards and adherence prob-

R) or heart rate reserve (HRR).

• Muscle stretching exercises (flexibility training)

• Body mechanics and awareness training

• Endurance training • Resistance training

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• Balance training

• Agility training

• Enhance function

*Exercise preparation*

*Aerobic or endurance training*

(ACSM) are as follows:

throughout the day).

• Gait and locomotion training

• Plyometric exercise (power training)

maximum oxygen uptake reserve (VO2

lems are associated with high‐intensity activity.

• Coordination training


Eastern style


The maximal HR can be calculated by the following formula: HR max = 220 – age.

The exercise session should consist of three periods. Starting with a warm‐up period of approximately 10 min which combines calisthenic‐type stretching exercises (without equipment). This follows by progressive aerobic activity that should increase the heart rate close to the prescribed heart rate for the session. Then, endurance training at the targeted heart rate for 20–60 min is performed and following by a cool‐down period of 5–10 min.

#### *Exercise for patients*

A less strenuous exercise training regimen must be used, with the training heart rate not exceeding 50–60% of maximum O2 uptake (VO2max) or a heart rate of 130 beats per minute (/ min). In elderly patients and patients at risk, the intensity, frequency, and duration of therapeutic exercise should be established for each patient individually with medical evaluation before.

**Figure 1.** Arm swing exercise.

**Figure 2.** Wand exercise.

Karvonen method should be employed to determine the target heart rate for the ill or elderly patient: Target HR = (220—age—resting heart rate × % intensity selected) + resting HR.

#### *Progression*

**Figure 1.** Arm swing exercise.

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**Figure 2.** Wand exercise.

In endurance training, progression can happen by increasing the intensity or the duration. Several factors affecting the suitable rate of progression including age, current activity levels, exercise goals, and physiologic limitations should be considered. Most importantly, progression rate should be used that results in long‐term participation. Being too aggressive can increase dropout rates because of injuries and/or perceived excessive discomfort. In addition, a progression of balance ability can be enhanced more by the exercise on the unstable support surface than exercise on the stable support surface.

#### *a) Special techniques There are many special techniques used in exercise therapy [6]*

