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What is Therapeutic Exercise?

08/01/2011, 11:00pm EDT
By Zach Webster, PT, DPT

Give Me Two Sets of Twenty

            Therapeutic exercise is defined as any exercise planned and performed to attain a specific physical benefit (via As physical therapists, therapeutic exercise is a vital aspect of treatment, as it helps patients to achieve maximal function, which is the ultimate goal.
            Throughout our undergraduate and graduate career we learn of the three different types of muscle contractions: concentric, isometric and eccentric. We learn of all the concentric actions of virtually every muscle in the body. It is easy to understand the isometric control of our muscles because the muscle essentially stays in a tonic, non-moving contractile position. However, why is the eccentric phase of muscles not stressed more? Being bipedal, locomotor systems, most of our everyday actions involve a series of open and closed chain actions. Muscles are constantly in a state of concentric contractions, eccentric contractions, or both all day long.
            All of us have learned of the origin and insertion of the peroneus longus (PL) muscle and that it plantarflexes and everts the foot as well as plantarflexes the 1st MT. This, however, is just half of the story. Sure we use this muscle concentrically when we are dressing, putting shoes on, lifting our foot up onto a step, or kicking a soccer ball with the outside of our foot, but one of it’s forgotten roles is what it does in a closed kinetic chain (CKC) system i.e. the stance phase of walking. With approximately 7200 steps (via taken per day, this CKC, eccentric muscle function, should be stressed more in school and in practice. The eccentric contractions of our muscles in everyday life are just as important as the concentric ones.
            The next time a client comes in for PT and brings to your attention their chief complaint; think about both the concentric and eccentric roles of muscles above and below the joint and how they might affect the complaint. Or when targeting a specific muscle for stretching or strengthening think about how it is used during the client’s specific function and strengthen/stretch it likewise. For example, if I have identified that a client is having plantar fasciitis because they are staying in the loading phase, or pronated throughout stance phase secondary to a dysfunctional PL muscle then I might want to keep the client in weight bearing and load the PL eccentrically, just as it is supposed to work in gait by decelerating dorsiflexion, and forefoot inversion (forefoot abduction occurs secondary to ground reaction forces which is a concentric action of PL). I’ll let you come up with the exercise!
            If we don’t question the other half of the muscle’s action we might be missing out on a huge part of our client’s function. If we are to truly maximize therapeutic exercise and plan exercises that are specific to our client’s physical benefit then we need to think about how the joints and muscles move/contract in the specific functional task and how we can maximally treat them within their functional role.
Who should train our clients?
            As PT’s, it is very important for us to be the masters of the musculoskeletal system and to be the clinician whom people come to when they have questions in this regard. We have done our profession a disservice and the potential people that we could possibly be helping by letting other scopes dominate this area. Of course there are great professionals in other professions, but right now PT’s are barely on the list or near the forefront of popping into people’s mind when it comes to training and maximizing functional mobility and movement. We are equipped with the tools and qualified to train individuals who want to get stronger, healthier, faster, more flexible, more toned etc. We should be very apt to training clients in all phases of their musculoskeletal development and desires.
            I understand the thin line that exists between training a client and providing physical therapy services, but this is easily avoided through what is advertised and what you do with/for the client. For example, a client comes into your PT clinic because they started exercising and developed Achilles tendonitis. Time after time after successfully treating your client they will ask you if you offer personal training services as they want to go beyond their prior level of function and reach a max level of function. Why shouldn’t we be the people who also train them and help them progress to their goals? With our knowledge, expertise and history with the client we know their potential areas of injury and impairments and we can specifically tailor any plan to help them reach their specific goals. Approaches like this have already been done in practices around the world, yet we need to continue to make the idea more mainstream and take it to the next level. In this new frontier of health care and the physical therapist’s place in it, there is much that can be lost if we do not act, and there is so much to be won if we do.  

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