Clinical Decision Making in Therapeutic Exercise.

The purpose of this book, according to the authors, is to "aid the physical therapist in making the clinical decisions about the choice and progression of exercise procedures." The first chapter introduces a framework of clinical practice that consists of separate evaluation and intervention models. The evaluation model is comprehensive and considers environmental, psychological, nervous, and musculoskeletal factors and their interactions. The intervention model is a multidimensional matrix that characterizes what the authors believe are the essential components of normal movement: postures and movements (also called "activities"), stages of control, and parameters of movement capacity (eg, intensity, duration, frequency, and speed). Perhaps because each of these models is so comprehensive, I found their presentation confusing. The explanation of the elements of each model and the relationship between the evaluation and intervention models were not clear to me.

The second and third chapters attempt to explain components of the intervention model. Chapter 2 details the postures and movements that can be used in therapeutic exercise, which the authors refer to as "activities." Activities compose one of the three dimensions of the proposed intervention model. A systematic analysis of biomechanical and neural considerations of different postures is included. Progressions of activities are described for the supine, prone, and upright postures and for lower-trunk activity. The choices of postures and movements are heavily influenced by a pro-prioceptive neuromuscular facilitation (PNF) perspective to exercise.

Chapter 3, also heavily influenced by PNF principles, details the therapeutic exercise techniques that can be used to promote the stages of motor control. The stages of motor control compose the second of the three dimensions in the authors' intervention model and include mobility, stability, controlled mobility, and skill. The developmental nature of this framework and a section on "balancing the autonomic system" should probably be reexamined in the light of contemporary approaches to treatment.

The fourth chapter discusses evaluation in the general format of the proposed model. It represents a very brief overview of standard assessment procedures, with the exception that movement control is evaluated with regard to the four stages of control. In my opinion, this chapter should, but does not, clearly describe the relationship between the evaluation and intervention models.

The remaining chapters demonstrate the use of the framework in the therapeutic exercise treatment of patients with both musculoskeletal and neurologic dysfunction. A chapter that deals with improving ambulation ability in the elderly is also included. These chapters include many interesting ideas that can be incorporated into a therapeutic exercise program and are organized around the intervention model proposed by the authors. These chapters do not elucidate the link between the evaluation and intervention models.

This book was written for practicing physical therapists. I believe, however, that some of the material may be too basic for the intended audience. For example, the chapter on evaluation discusses many elementary concepts that would be more appropriate in a textbook for entry-level physical therapist students. The same might be said about the review questions that appear at the end of each chapter.

I believe that this book has numerous weaknesses, primarily concerning the proposed framework and the interrelationship of its parts. I do not believe that this book would be a good entry-level text for this reason and because of the organizational scheme used. Practicing physical therapists, however, will appreciate the extensive compilation of therapeutic exercise techniques for many common patient problems.

Ms Barker is assistant professor in the department of physical therapy and has taught courses on therapeutic exercise and neuroscience. She has authored a chapter on screening for nervous system disease and is currently enrolled in the doctoral program in biomedical science at Drexel University.