Home Exercise Program

Introduction

Today, exercises are considered an integral part of patient management in manual medicine. The goal of treatment is to maximize patient function and independence, while minimizing pain and recurrences of pain by specifically addressing the structural, biomechanical and functional deficits arising from the various joint and tissue dysfunctions. In order to prescribe the appropriate exercise regimen for a particular patient, the specific structural and functional deficits need to be elucidated through a detailed structural and functional examination so as to determine the global, regional and specific segmental deficits. From the outset, patient goals and the various bio-psycho-social aspects should be considered when establishing the exercise prescription, including the final home exercise program.

There is ongoing discussion about the usefulness of manual medicine management and exercise therapy for various musculoskeletal disorders, either in isolation (one approach) or in combination (manual medicine and exercise combined). Supervised exercise therapy—i. e. “active” rather than passive therapy, modality-emphasized physical therapeutic measures—has become part of the most recent recommendations for the treatment of low back pain (Koes et al., 2006):

In the management of osteoarthritis, for instance, the Ottawa Panel (2005) recommend the use of therapeutic exercises, either alone or combined with manual therapy.

Beyond these and many other guidelines, there continues to be an ongoing discussion in the literature as to the advantages and disadvantages, indications, exercise types and preferences, mechanisms and outcomes of exercise in general (Hayden et al., 2005).

In addition to a generalized exercise regimen for aerobic cardiovascular and muscular conditioning, specific exercises to address muscle length (flexibility) and strength (power) are utilized in manual medicine. It is important that the exercise prescription for each patient is developed on an individual basis (specific selection of the particular exercises and their sequence, repetition and overall number of sets). The various exercises are a logical extension of and complement for the manual medicine treatment.

A number of various treatment regimens have been presented by various practitioners to improve flexion (Williams, 1953) and extension (McKenzie, 1981). Isaac and Bookhout (2002) make specific reference to McKenzie’s approach and specific non-neutral segmental (somatic) dysfunctions, in particular the flexion, rotation and side-bending dysfunctions (FRS-dysfunctions noted in the osteopathic literature). Bookhout presents a practical and rational approach to restoring normal neuromotor control by addressing the muscle imbalances associated with frequently observed abnormal movement patterns and specific segmental joint (somatic) dysfunctions.

Of particular importance in the concept of muscle imbalance are those presented by Janda (1980; 1977; 1986; 1994) and Lewit (1995).

This chapter contains a series of home exercises that can be given to patients. These exercises fall into two broad categories:

1. Those muscles or muscle groups that need to be stretched (typically the tonic, slow-twitch fiber muscles) and

2. Those muscles or muscle groups that need to be strengthened (typically the phasic, fast-twitch fiber muscles).

In general, it has been empirically learned and practiced (and thus awaits further good research, for instance) that when a muscle imbalance has been diagnosed the stretching of the shortened muscles should be done first before the strengthening. The rationale for this sequence is that abnormal muscle patterns may provide a negative-vicious-cycle feedback loop, where the strengthening of the already strong muscles is thought to further exacerbate the already existing muscle imbalance.

Some of the key points (no more than five) to remember when prescribing a home exercise program may include:

1. Have the patient perform the exercises under supervision until he is ready to perform them adequately and on his own.

2. Start low (one or two exercises to start with) and go slow (addition of new exercises).

3. Check to see what other exercises the patient may already be doing from previous treatment regimens (avoid duplication or exacerbation).

4. Evaluate patient’s ability to perform the exercises correctly over time, from visit to visit and then independently, with appropriate interval-based monitoring.

5. Assist with appropriate motivation for the patient to continue on an independent home exercise program.

As with many other aspects of health and function, it is often not one single factor that decides the outcome. It would be ideal if not only the medical aspects of the patient’s well-being are being addressed but also thorough consideration be given to dietary considerations, general fitness and physical performance, activities of daily living and vocational/ergonomic considerations, as well as the choice of appropriate and meaningful leisure activities.

Fig. 19.1 Overview of the tonic (postural) () and phasic () muscles.

1 Sternocleidomastoid

2 Scalene

3 Pectoralis major

4 Biceps brachii

5 Rectus abdominis

6 Abdominal oblique

7 Iliopsoas

8 Rectus femoris

9 Gracilis

10 Adductors

11 Vastus medialis

12 Vastus lateralis

13 Tibialis anterior

14 Longissimus cervicis

15 Trapezius (descending portion)

16 Levator scapulae

17 Rhomboid

18 Longissimus dorsi

19 Triceps brachii

20 Longissimus dorsi

21 Quadratus lumborum

22 Piriform

23 Gluteal

24 Biceps femoris

25 Semitendinosus

26 Tensor fasciae latae

27 Triceps surae

(soleus and gastrocnemicus)

The ideal outcome is one in which the goals of both patient and physician are congruent and can be fulfilled to the greatest possible extent, taking into consideration all aspects of the bio-psycho-social-spiritual model.

Exercise Section

Stretching of Shortened Muscles

Figs. 19.2–19.21

Fig. 19.2 Stretching of the posterior thigh muscles.

Instructions:

– Wrap towel around heel.

– With knee straight, bring leg up toward you as far as possible.

– Against resistance, push leg in opposite direction with maximal contraction.

– Bring leg further toward you.

Fig. 19.3 Stretching of the posterior thigh muscles and calf muscles.

Instructions:

– Wrap towel around the tip of the foot.

– With knee extended, bring leg up toward you as far as possible.

– Against resistance, push leg in opposite direction with maximal contraction.

– Bring leg further toward you.

Fig. 19.4 Stretching of the posterior thigh muscles.

Instructions:

– Bend leg at the knee and hold it in place with hands.

– Straighten leg to a point where a pulling type of pain sensation is perceived in the posterior muscles.

– Relax.

– Repeat further straightening.

Fig. 19.5 Stretching of the lateral thigh muscle.

Instructions:

– With the leg closest to the table bent, lie on one side across the table at an angle.

– Extend the other knee and drop that leg behind the posterior edge of the table.

– Bring leg back up.

– Relax and drop leg further.

Fig. 19.6 Stretching of the medial thigh muscles.

Instructions:

– Lie supine with buttocks and posterior thighs placed against the wall.

– With knees straight, let legs move apart slowly.

– Contract medial thigh muscles (as if wanting to bring legs together).

– Relax.

Fig. 19.7 Stretching of the medial thigh muscles.

Instructions:

– With the knee straight, place one leg to the side, push medial foot margin against the floor.

– Relax.

– Allow leg to glide further outward.

Fig. 19.8 Stretching of the deep gluteal muscles.

Instructions:

– Pull knee toward opposite hip.

– Against some resistance, push knee outward.

– Relax.

– Pull knee closer toward the opposite hip.

Fig. 19.9 Stretching of the deep gluteal muscles.

Instructions:

– Pull knee with hand toward the opposite shoulder.

– Against resistance, contract maximally as if wanting to move knee away from shoulder.

– Relax.

– Pull knee further toward the opposite shoulder.

Fig. 19.10 Stretching of the deep gluteal muscles.

Instructions:

– Pull knee toward opposite hip.

– Straighten upper body while inhaling simultaneously.

– While exhaling, lean forward with straight upper body.

– Further straighten trunk, again while inhaling.

– Repeat stretch.

Fig. 19.11 Stretching of the hip flexor muscles.

– Move pelvis forward over the extended support leg (the leg making contact with the floor).

Fig. 19.12 Stretching of the hip flexor and long knee extensor muscles.

Instructions:

– Pull leg up behind you.

– Against resistance, straighten knee.

– Relax.

– Pull leg up further.

Fig. 19.13 Stretching of the hip flexor and long knee extensor muscles.

Instructions:

– Pull leg up behind you.

– Drop head forward.

– Straighten knee against resistance.

– Relax.

– Pull leg up further.

Fig. 19.14 Stretching of the hip flexor and long knee extensor muscles.

Instructions:

– Assume position similar to that of starting for a sprint.

– Push straightened (posterior) knee toward the floor.

– Relax.

– Extend hip further.

Fig. 19.15 Stretching of the calf muscles.

Instructions:

– Lift heel of the posterior leg off the floor.

– Push heel flat against the floor.

– With the back straight, move trunk slowly forward.

– Lift heel off the floor, and then push it down again.

– Stretch further.

Fig. 19.16 Stretching of the lower back extensor muscles.

Instructions:

– Sit with legs slightly apart and feet raised (e. g., on books, etc.).

– Lean upper body forward.

– Inhale.

– Exhale while pulling the arms below the chair.

– Inhale and exhale.

– Pull arms further below the chair.

Fig. 19.17 Stretching of the lower back extensor muscles.

Instructions:

– Bring knees toward chin until pelvis begins to lift off the floor.

– Press thighs against arms and inhale.

– Exhale and relax.

– Bring knees further toward your chin.

Fig. 19.18 Stretching of the chest muscles.

Instructions:

– Walking position.

– Press hands against door frame.

– Relax.

– Lean upper body forward.

Fig. 19.19 Unilateral stretching of the chest muscles.

Instructions:

– Stand sideways to the door frame; rest forearm against the frame.

– Press forearm against door frame.

– Rotate trunk away (in small rotational steps) with the forearm remaining stationary.

Fig. 19.20 Stretching of the neck and shoulder muscles.

Instructions:

– Bend head to one side.

– Rotate arm outward and push it toward the floor.

– Inhale and lift shoulder.

– Exhale and pull arm toward the floor.

Fig. 19.21 Stretching of the neck and shoulder muscles.

Instructions:

– Bend head to one side (i. e., left) and hold in place with one hand.

– Grasp chair with the other hand.

– Lean trunk to the same side (i. e., left).

– Move back somewhat toward the original position and place hand on the chair closer to the floor.

– Repeat side-bending of the trunk.

Strengthening of Weak Muscles (Figs. 19.22–19.31)

Fig. 19.22 Strengthening of the shoulder blade muscles.

Instructions:

– Lean with shoulder blades against the wall at an angle.

– Push trunk off with the elbows, while maintaining normal lumbar lordosis (do not arch back).

Fig. 19.23 Strengthening of the shoulder blade muscles.

Instructions:

– Place fingertips against the wall at shoulder level.

– Push body off slightly.

– Maintain normal lumbar lordosis (do not arch back).

Fig. 19.24 Strengthening of the shoulder blade muscles.

Instructions:

– Rest on knees and hands.

– Slowly drop upper body between hands.

Fig. 19.25 Strengthening of the anterior thigh muscles.

Instructions:

– Rotate leg slightly outward.

– Keep knee straight.

– Pull great toe and foot toward you.

– Pull kneecap toward you.

– Contract anterior thigh muscles.

Fig. 19.26 Strengthening of the gluteal muscles.

Instructions:

– Lift one leg (with knee bent) up toward the horizontal while pushing the opposite leg under the table top.

Fig. 19.27 Strengthening of the gluteal muscles.

Instructions:

– Press heels together.

– Contract buttock muscles maximally.

Fig. 19.28 Strengthening of the gluteal muscles.

Instructions:

– Raise heels and rest them on support.

– Contract buttock muscles and simultaneously lift pelvis and lower back off the floor.

Fig. 19.29 Strengthening of the abdominal muscles.

Instructions:

– Push knees toward the ceiling.

– At the same time, lift pelvis slightly off the floor.

Fig. 19.30 Strengthening of the abdominal muscles.

Instructions:

– Pull toes toward you while pressing heels against the floor.

– Rotate arms slightly inward.

– Bend hands upward and push in direction of feet.

– Lift head and shoulders off the floor.

Fig. 19.31 Strengthening of the abdominal muscles.

Instructions:

– Bend knee and press against resistant hand.

– Lift head slightly off the floor.

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