Practical Exercise Therapy

485 Pages·1999·11.43 MB·English

by  Margaret Hollis, Phyllis Fletcher Cook

Page i

Practical Exercise Therapy

Fourth Edition

Edited by

Margaret Hollis

MBE, MSc, FCSP, DipTP
Formerly Principal, Bradford
School of Physiotherapy

and

Phyl Fletcher-Cook

MEd, MCSP, Cert Ed
Senior Lecturer, Huddersfield
University

With contributions by

Sheila S. Kitchen
MSc, MSCP, DipTP
Course Co-ordinator, Physiotherapy Group
King's College, London

Barbara Sanford
DipPE (Lond. Univ.)
Formerly Lecturer in Physical Education
Bradford School of Physiotherapy

The late Patricia J. Waddington
BA (Hons), FCSP, DipTP
Formerly Principal, School of Physiotherapy
Manchester Royal Infirmary

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Page ii

© 1976, 1981, 1988, 1999 by
Blackwell Science Ltd
Editorial Offices:
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Blackwell Wissenschafts-Verlag GmbH
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Blackwell Science KK
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The right of the Author to be identified as the Author of this Work has been asserted in accordance with the
Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the
publisher.

First published 1976
Reprinted 1997
Second edition 1981
Reprinted 1983, 1984, 1985, 1987
Third edition 1989
Reprinted 1990, 1992, 1994, 1997
Fourth Edition 1999

Set in Sabon 10 on 13.5 pt
by Best-set Typesetter Ltd., Hong Kong
Printed and bound in Great Britain at
The Alden Press, Oxford

The Blackwell Science logo is a trade mark of Blackwell Science Ltd, registered at the United Kingdom
Trade Marks Registry

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A catalogue record for this title is available from the British Library

ISBN 0-632-04973-1

Library of Congress
Cataloging-in-Publication Data
Practical exercise therapy/edited by Margaret Hollis
and Phyl Fletcher-Cook; with contributions by
Sheila S. Kitchen, Barbara Sanford, the late
Patricia J. Waddington. —4th ed.
p. cm.
Includes bibliographical references and index.
ISBN 0-632-04973-1
1. Exercise therapy. I. Hollis, Margaret.
II. Fletcher-Cook, Phyl.
RM725.P73 1999
615.8'2—dc21 98-53120
CIP

For further information on
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Page iii

Contents

Preface
v

Acknowledgements
vii

1
Introduction
M. Hollis

1

2
Biomechanics
M. Hollis & S.S. Kitchen

9

3
Fundamental and Derived Positions
M. Hollis

47

4
Relaxation
M. Hollis

58

5
Passive Movements
M. Hollis

62

6
Respiratory Care – Basic Exercises
Phyl Fletcher-Cook

76

7
Apparatus: Small, Soft and Large
M. Hollis & B. Sanford

83

8
Suspension
M. Hollis

96

9
Springs, Thera-Bands, Pulleys, Weights and Water
M. Hollis

109

10
Re-education of Walking

134

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M. Hollis

11
Examination, Assessment and Recording of Muscle Strength
M. Hollis

145

12
Mobilization of Joints
M. Hollis

159

13
Assessment of a Patient's Suitability for Group Treatment
M. Hollis & B. Sanford

163

14
Group Exercise
B. Sanford

165

15
Preparation of Group Activities
B. Sanford

172

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Page iv

16
Exercises for Infants and Children
M. Hollis & B. Sanford

178

17
Special Regimes
M. Hollis

183

18
Neurophysiology of Movement
Phyl Fletcher-Cook

189

19
Proprioceptive Neuromuscular Facilitation (PNF)
P. J. Waddington

202

20
PNF Arm Patterns
P. J. Waddington

206

21
PNF Leg Patterns
P. J. Waddington

220

22
PNF Head and Neck, Scapular, and Trunk Patterns
P. J. Waddington

231

23
PNF Techniques
P. J. Waddington

241

24
Functional Activities on Mats
P. J. Waddington

248

25
Balance
P. J. Waddington

260

26
Gait
P. J. Waddington

269

Index
273

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Page v

Preface

In revising this book I have been greatly assisted by my co-editor Phyl Fletcher-Cook who has written new
chapters on basic techniques for respiratory care and the neurological basis of movement. Barbara Sanford
has checked and revised the chapters on which she worked originally but, sadly, Pat Waddington died in
1997. She gave her blessing to any revision we might make.

We have omitted some sections, notably some of the suspension and spring exercises, as these can now be
achieved in the more readily available therapeutic pools, and also the exercises for babies.

Much of the first edition of the book was based on our knowledge gained in practice both with patients and
in teaching students, so we have omitted the original bibliography which mostly related to those parts of the
book we have not altered. The two totally rewritten chapters each have their own references.

It was not necessary to revise the mechanics chapter as these concepts are eternal truths, as are many of the
concepts of movement and muscle action. The first edition became a 'latin primer' as I kept in mind that
recovery of movement and re-education of muscle could only be achieved in a limited number of ways. The
main principle that all students have to understand is that progression is of the patient, with the
physiotherapist constantly adapting techniques to the new needs and demands of the patient. Machines need
all the basic principles applied to their use and as more expensive forms of equipment become more freely
available in the developed world, there is still great need for the under-developed world to be able to carry
out exercise without modern gadgetry.

In this fourth edition we have stuck to the principle of producing a basic teaching book so that in the
different educational environments which prevail in some countries, students can still turn to simple
explanations

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Page vi

of the 'how' of 'therapeutic exercise'. We hope that future generations of students of all nationalities will find
this a book from which they can practise physiotherapeutic skills with the lesser guidance that now prevails.

Mr Peter Harrison AIMBI has again undertaken the photography and Janice Eccles has also again been able
to type the manuscript. We thank them for their work.

I would like to pay tribute to the contribution the late Pat Waddington made to the book and to thank
Barbara Sanford for her continued willingness to check and revise.

The staff at Blackwell Science continue to encourage me by wanting further editions of my books. I cannot
help feeling there must be a swan song sometime soon and in finding Phyl Fletcher-Cook I feel I have
assisted with continuity of the idea I first projected, of giving students a background knowledge based on
sound principles of mechanics, anatomy and physiology.

MARGARET HOLLIS
MBE, MSc, FCSP, DIPTP
BRADFORD

AND

PHYL FLETCHER-COOK
MEd, MCSP, CERT ED
BRADFORD

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Page vii

Acknowledgements

I am grateful to the following companies who lent photographs.

Days Medical Aids of Bridgend for Figs 10.2, 10.3, 10.5 and 10.6 of their walking aids.

Kirton Designs Ltd of Norwich for Fig. 7.1.

Nomeq of Redditch for provision of their extensive bibliography and articles on isokinetics and for Figs 7.2,
7.3, 7.4, 7.5, 7.6, 7.7, 9.29 and 10.1.

Portabell Keep Fit Systems Ltd for Fig. 9.38B.

Rank Stanley Cox for Fig. 8.3 of the Guthrie Smith suspension frame and Fig. 9.32 of their Variweight boot.

Fig. 9.3 is from the booklet issued by The Hygienic Corporation, to whom we are grateful.

Table 11.2 is modified from Skinner A. T. & Thomson A. M. (1983) Duffield's Exercise in Water, 3rd edn,
Baillière Tindall, London, with permission.

Our photographers were Mrs V. Cruse of Pudsey, Mr P. Harrison AIMBI of Bradford and Mr R. E. S.
Murray AIIP of Manchester to whom we owe our thanks for their patience and their expertise.

To our students
who, in learning from us,
teach us so much

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Page 1

Chapter 1—
Introduction

M. Hollis

The application of therapeutic exercise to a patient is a process which demands an initial examination of the
patient's needs and a constant reassessment of the situation in the light of progress or retrogression. It also
demands a knowledge of the condition from which the patient suffers, the potential recovery rate and
complications which may arise. In addition the therapist must constantly bear in mind the anatomy of the part
being treated and of the whole body; the physiological reactions of the body to all exercise and the particular
exercise she is applying at the moment; and the underlying mechanical principles associated with the exercise
and/or techniques applied.

Therapeutic exercise is also influenced by a psychological reaction in which the patient may or may not wish
to get better. If he wishes to improve he may be overeager to please and do too much or perform badly and in
haste. If he does not wish to improve it may be because he is afraid. He may be in pain and fear more pain,
he may be afraid his illness or accident may recur, or he may have a fundamental fear of the whole field of
medicine and hospitals in particular.

This barrier must be overcome and a rapport established between patient and therapist so that the therapist
may initiate the proceedings which will eventually lead to the patient achieving his maximum independent
potential.

To this end a few simple but important rules should be followed by the therapist. First, each patient should be
known by name and greeted and welcomed at each treatment session. Secondly, fear of more pain can be
overcome by working and teaching on parts which are not painful. Each action should be taught on the
soundest or least painful part, then on the afflicted part gradually working towards the part he most dreads
having treated. In this way he will not only be reassured but there will probably be less pain due to
facilitation of inhibition. As he relaxes he will relax his protective painful spasm and so have less discomfort.

Thirdly, his activities must always be harnessed to a goal which is within his potential of achievement. This
has two uses: it is a goal for which he can strive and a matter for congratulation when achieved. The
objective can be reset each day or each week or with no regularity at all, but it is most important that the
early goal is remarked upon when achieved as then the patient will gain confidence in his therapist as well as
in himself.

It is said that initially patients have a 'love–hate' relationship with their therapists. This may be so as the
therapist may have to insist on the patient performing an uncomfortable manoeuvre and he will not be
grateful for it until some time has elapsed. Examples of this situation arise when a patient

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Page 2

with an ineffective cough must be persuaded to cough more effectively to void his chest secretions in spite of
the pain of his abdominal incision; and when patients have to contract the quadriceps muscle group following
knee surgery. In both these cases patients freely admit later on that they hated the therapist at the time, but
are grateful now that they were persuaded to do their therapeutic exercise.

Therapists who work in this climate become accustomed to this attitude from their patients and learn to use
all their manual and psychological skills for the improvement of the patient.

With the patient who has a long-term problem, short-distance goal setting is even more important, and
knowledge of the medical history of the patient, his social background and his home and work environment
will be necessary to determine the sequence of the goals to be achieved. Personal independence should
usually be aimed for initially. This may be toileting, personal care and dressing, feeding or ability to get
about. Some go hand in hand. It is no use being able to undress and dress in the toilet if there is no possibility
of physically getting there.

It is essential that the therapist gradually withdraws what she does for the patient so that eventually he does
every task for himself. If this goal cannot be achieved then it is important to recognize that substitution must
occur, e.g. if independent walking is unsafe and not improving, the patient must come to terms with the
appropriate walking aid. Recognizing the moment when no further progress is being made is as important as
the first assessment of a patient. Failure to recognize this fact leads to false hopes on the part of the patient
and his family and a waste of the resources of the therapist, the tools of her work and the patient's time and
effort.

Physical Definitions of Muscle Performance

Force

The force output of a muscle, usually called its strength, is that which develops tension in the contracting
muscle so that it contracts to produce work.

Work is defined as the action of a force over a specific distance in space. In the human body it refers to the
product of muscular force exerted through a specific range of movement.

Power refers to a rate of doing work. In muscle action it is the output of the muscles at specific speeds of
contraction.

Endurance is the capacity to contract muscles at a specific rate (power) for a specific interval of time.

Muscles require to be able to do work at varying tempos and to maintain the work for a period of time;
failure to be able to produce satisfactory strength of muscle leads to weakness in one or more of the roles in
which muscles play their part in normal activities. The roles of muscles are dealt with later in this chapter.
Any failure of strength can lead to joint malfunction as well as functional incapacity in any of the daily
activities to which the human body is subject during normal living.

Types of Muscle Work

There are two main ways in which a muscle may work naturally. It may contract and produce no movement,
called isometric contraction, or it may produce movement during contraction, called isotonic contraction.
Both these types of contraction may be used therapeutically, but a third type of muscle action

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Page 3

may be applied to muscles to strengthen them. This uses isokinetic or accommodative resistance to achieve
isotonic contractions (see Chapter 9).

Isotonic Contraction

When a muscle works isotonically it contracts and the part of the body to which it is attached will move.
There are two types of isotonic contraction.

Isotonic Shortening.

When a muscle performs a contraction and its two attachments are approximating to one another, the
contraction is known as an isotonic shortening, e.g. when the arm is raised from the side and the abductors of
the shoulder contract, the contraction is one of isotonic shortening.

Isotonic Lengthening

When the attachments of a muscle move slowly away from one another and the muscle allows this
movement to occur in a controlled manner, the muscle action is one of isotonic lengthening, e.g. when the
body is in the upright position and the arm is lowered from abduction to adduction, the abductors of the
shoulder will control the movement and these abductors will be acting in isotonic lengthening.

Isotonic shortening can take place under any circumstances, i.e. whenever movement takes place in which
the attachments of a muscle approximate, the muscle work will be isotonic shortening. Isotonic lengthening,
however, may only be brought about if an outside force is applied to the component which is to be moved
and the body part is slowly moved so that the attachments of the muscle are moved away from one another.

Gravity may be the outside force which pulls body components towards the earth as in lowering the arm from
the abducted position to the side, or in sitting on the edge of a table lowering the outstretched leg to a right
angle at the knee. However, under many other circumstances, in order to work a muscle in isotonic
lengthening it is necessary for the therapist to be the outside force. The command given is 'resist slightly
whilst I move your leg', or arm as the case may be, to a new position. The patient offers slight resistance, the
therapist applies pressure which is greater than the resistance offered by the patient and is on the surface
which is on the same aspect as the muscles which are required to be worked in isotonic lengthening. For
example, if a patient is in side lying and the quadriceps are to be worked, the leg will be arranged straight at
the knee, one hand will be placed as a stabilizing hand on the thigh and to palpate the quadriceps. The other
hand will be placed on the anterior aspect of the leg and the command will be given 'resist slightly while I
bend your leg'. The patient resists, the therapist bends the leg and the quadriceps will be worked in isotonic
lengthening.

Many other examples of isotonic shortening and isotonic lengthening can be found and therapists should
attempt to work out the single movements of each of the joints of the body with and without resistance so
that they are able to identify isotonic shortening and isotonic lengthening. When therapists can identify these
two types of muscle work they should then try to apply the range of muscle work as described below.

Isometric Contraction

When a muscle works isometrically it shortens its muscular length and slightly lengthens its non-contractile
components and in doing so no movement occurs at any of the joints over

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