The Fitness Clinic for Physically Disabled: San Diego State University.The Fitness Clinic for Physically Disabled at San Diego State University San Diego State University (SDSU), founded in 1897 as San Diego Normal School, is the largest and oldest higher education facility in the greater San Diego area (generally the City and County of San Diego), and is part of the California State University system. , founded in 1983, has been successful in assisting individuals with a wide variety of physical and neuromuscular neuromuscular /neu·ro·mus·cu·lar/ (-mus´ku-ler) pertaining to nerves and muscles, or to the relationship between them.neu·ro·mus·cu·lar adj. 1. disabilities to improve their muscular strength, endurance, flexibility, overall health, and other motor abilities (Aufsesser, 1988). Experience with over 200 participants with disabilities has indicted INDICTED, practice. When a man is accused by a bill of indictment preferred by a grand jury, he is said to be indicted. that with improvement in fitness comes an improvement in functional independence. This is demonstrated when participants in the program with physical disabilities of various severity assume greater responsibility for their personal care and other activities in their daily routines. In some instances, the program has aided individuals with severely limiting conditions (quadriplegia quadriplegia: see paraplegia. and multiple sclerosis) in increasing their basic muscular strength, endurance, and balance allowing them more independence in their daily activities (Aufsesser & Burke, 1994). These activities include independent transfers, driving with hand controls, or showering unassisted. In other cases, individuals with conditions of varying severity have developed physical work capacities to seek employment and enable them to be more financially independent. Finally, for participants who are affected by neurodegenerative conditions, exercise can help in maintaining their physical work capacity and continued independence at home and in the work place. Goals the Fitness Clinic establishes for its participants are similar to those in mainstream programs--the difference is our program has been able to focus on functional improvement, as well as physical development. This varied approach has greatly enhanced the overall quality of the participants' lives. The number of physical activity programs for individuals with disabilities, especially physical disabilities, has increased tremendously since the legislation of the 1970s. Although professionals have realized since the 1960s that there is a link between physical work capacity, independence, and vocational success for individuals with physical disabilities, the past decade has brought the concept into clear focus (Burke, 1991; Lasko-McCarthey & Aufsesser, 1990). The Fitness Clinic, in its 14th year of operation, was established in September, 1983, with the assistance of a grant from the Office of Special Education and Rehabilitation Services. This grant support ended in May, 1986, and the Clinic has been self-supporting ever since. The Clinic was developed to provide adapted physical education Adapted physical education is a sub-discipline of physical education. It is an individualized program created for students who require a specially designed program for more than 30 days. and pre-physical therapy students with a needed practicum practicum (prak´tik  m),n See internship. site to work with individuals with a wide variety of physical disabilities. Since its inception, the Clinic has provided over 1,200 students with a quality laboratory setting in which to apply and hone their therapeutic and fitness related skills. This program has proven to be an essential learning experience for students in adapted physical education credential programs, athletic training athletic training Sports medicine The practice of physical conditioning and reconditioning of athletes and prevention of injuries incurred by athletes. See Athlete, Athletic trainer. , and pre-physical therapy. In the Clinic's 14 years, over 220 students have completed the adapted physical education credential, 40 have entered physical therapy schools, and hundreds have received their National Athletic Training Certification (NATA NATA National Athletic Trainers' Association NATA National Association of Testing Authorities (Australia) NATA National Air Transportation Association (Alexandria, VA, USA) ). Currently, 350 students seeking admission to physical therapy school are enrolled at San Diego State and will participate in the clinic as part of their undergraduate training. The Clinic has served over 200 individuals, ranging in age from 9 to 87 years, with a wide variety of disabilities. From a humble beginning with 19 participants in three classes, to the present (Spring 1997) with 65 community participants and 16 university students in eight sections, the Fitness Clinic provides individualized in·di·vid·u·al·ize tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es 1. To give individuality to. 2. To consider or treat individually; particularize. 3. fitness and wellness activities. In the 1996-97 year over 120 students assisted individuals with disabilities in the Clinic. The Fitness Clinic, utilizing students as practitioners, provides an excellent example of a dual training/service model program. In addition, the Fitness Clinic has begun a research program. Currently, a study utilizing two new objective manual muscle testing devices is being conducted with spinal cord spinal cord, the part of the nervous system occupying the hollow interior (vertebral canal) of the series of vertebrae that form the spinal column, technically known as the vertebral column. injured (SCI (Scalable Coherent Interface) An IEEE standard for a high-speed bus that uses wire or fiber-optic cable. It can transfer data up to 1GBytes/sec. (hardware) SCI - 1. Scalable Coherent Interface. 2. UART. ) individuals who are quadriplegic quadriplegic /quad·ri·ple·gic/ (-ple´jik) 1. of, pertaining to, or characterized by quadriplegia. 2. an individual with quadriplegia. . The Clinic has a medical advisory board consisting of four physicians, three physical therapists, and a registered nurse. The board meets annually and advises the Clinic staff on all medical and safety issues. Funding The Clinic's annual budget is supported by participant fees, donations, and a small contract for services with San Diego State University. The Clinic is an authorized service provider An Authorized Service Provider (ASP) is a third party person that has been cleared to work on a product that is still under warranty by another company without voiding the warranty. for both San Diego Regional Center and the California Department of Rehabilitation. In addition, the Clinic has received third party payments from insurance companies. In 1988 the Clinic established an endowment fund to help in assuring long-term financial stability of the program. Moreover, a second endowment fund was established in memory of a former client, Frank Parodi, who had amyotrophic lateral sclerosis amyotrophic lateral sclerosis (ALS) (ā'mīətrōf`ik, sklĭrō`sĭs) or motor neuron disease, (ALS Als (äls), Ger. Alsen, island, 121 sq mi (313 sq km), Sønderjylland co., S Denmark, in the Lille Bælt, separated from the mainland by the narrow Alensund. ), commonly known as Lou Gehrig's Disease Lou Geh·rig's disease n. See amyotrophic lateral sclerosis. . This fund supports work study in the clinic for students interested in careers working with individuals with disabilities. The future bodes well for additional sources of funding to support the Clinic's programs. The Clinic has been contacted by several administrators of rehabilitation hospitals to possibly provide exercise programs on a contract basis for clients after their release from rehabilitation programs. In addition, one major worker's compensation company director has contacted the clinic about the possibility of providing work hardening and fitness education programs for workers who are injured. Assessment The Fitness Clinic provides an individualized exercise program based on a medical screening and motor assessment. Medical release and advised consent forms are completed by participants and their physicians to ensure that a safe and appropriate program is designed. The assessment generally covers strength, muscular endurance, cardiovascular endurance, flexibility, ambulation am·bu·late intr.v. am·bu·lat·ed, am·bu·lat·ing, am·bu·lates To walk from place to place; move about. [Latin ambul , and balance. Goals are then formulated, and a program to attain these goals is developed and implemented. Participants in the clinic program are assigned student assistants who supervise them to ensure their exercise regime is properly completed. Prior to working in the Fitness Clinic, student assistants go through a ten-hour orientation in addition to taking a three-unit class in Corrective and Orthopedic Physical Education. The best way to describe the program's operation is to present case studies of participants and their exercise programs; discuss goals and needs of each individual prior to commencing the program and progress to this point; and discuss future goals and objectives. In some instances, participants' original goals were quickly achieved and new ones developed. In other cases, participants' programs needed to be modified to attain current goals. However, participants' programs are considered works in progress Kansas' sixth compilation album, Works in Progress is a combination CD/DVD release from the band Kansas, bringing together songs from the last ten years (1992-2002) of the band's career, featuring music from Live at the Whisky, Freaks of Nature , with goals and exercises being changed regularly. The ultimate goal of the program is to make participants as independent as possible within the limitations of their disabilities. Case Studies For the purpose of this article, the authors have established certain categories of severity for individuals with disabilities to assist the reader in understanding the manner in which the program is conducted. We believe that this approach will also provide the reader with useful information that can be applied in their programs. Categories Mild: A mild disability is a chronic condition, but not progressive in nature. The condition limits only the individual's motor function and has little impact on independent living skills. Examples could include single amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly , individuals with paresis paresis /pa·re·sis/ (pah-re´sis) slight or incomplete paralysis. general paresis paralytic dementia; a form of neurosyphilis in which chronic meningoencephalitis causes gradual loss of cortical , mild brain injury, or mild cerebral palsy cerebral palsy (sərē`brəl pôl`zē), disability caused by brain damage before or during birth or in the first years, resulting in a loss of voluntary muscular control and coordination. . Moderate: A moderate disability is a chronic condition and may or may not be progressive. The condition affects more than just motor performance and places greater limits on independence. Some of these limitations may be reduced with the utilization of assistive devices. Examples of this category include initial symptoms of neurodegenerative disorders, spinal cord injury Spinal Cord Injury Definition Spinal cord injury is damage to the spinal cord that causes loss of sensation and motor control. Description Approximately 10,000 new spinal cord injuries (SCIs) occur each year in the United States. (C7 to T12), acquired brain injury A neurological condition, Acquired Brain Injury (ABI) is damage to the brain acquired after birth. It usually affects cognitive, physical, emotional, social or independent functioning and can result from traumatic brain injury (i.e. accidents, falls, assaults, etc. , stroke, or cerebral palsy. Severe: A severe disability is associated with multiple chronic conditions that are often progressive. The condition severely limits the individual's functions including homeostasis homeostasis Any self-regulating process by which a biological or mechanical system maintains stability while adjusting to changing conditions. Systems in dynamic equilibrium reach a balance in which internal change continuously compensates for external change in a feedback , motor control, communication, behavior control, and cognitive abilities. Examples include higher level quadriplegia (SCI), severe acquired brain injury, severe stroke, and advanced neurodegenerative disorders (amyotrophic lateral sclerosis, and Parkinson's disease Parkinson's disease or Parkinsonism, degenerative brain disorder first described by the English surgeon James Parkinson in 1817. When there is no known cause, the disease usually appears after age 40 and is referred to as Parkinson's disease. ). Summary The intent of this article was to share what we believe is the prototype program of the future for developing the maximum physical work capacity of individuals with varying severities of physical and neuromuscular disabilities. The program's goal is to allow individuals with physical disabilities to maximize their abilities and be in the least restrictive environment As part of the U.S. Individuals with Disabilities Education Act, the least restrictive environment is identified as one of the six principles that govern the education of students with disabilities. . Legislation of the 1970s and rhetoric of the 1980s are now history. We need to move ahead and practice what we preach. It may sound trite, but children with disabilities grow up and become adults with disabilities. We hope these case studies provide you with some ideas that can be incorporated into your programs. If you train individuals in adapted or regular physical education, we hope you integrate this material into your training programs. The ultimate goal for all participants is to maximize their abilities within the limits of the disability. However, unless we press the limits, we will never really know how far we can go. We are amazed each day at the levels of function even those with severe disabilities reach--beyond what tradition and past practice tell us is attainable. Selected References Aufsesser, P.M. (1988). Fitness programs for the physically disabled, Proceedings. National Physical Activity for Exceptional Individuals Conference, Oakland, CA. Aufsesser, P.M., & Burke, J.P. (1994). The fitness clinic for physically disabled: Meeting the needs of the physically disabled into the 21st century. Proceedings, National Physical Activity Conference for Exceptional Individuals, Ontario, CA. Aufsesser, P.M., & Horvat, M. (1991). Cross training for the physically disabled, Clinic Kinesiology, 45, 18-23. Burke, J.P. (1991). Individualized fitness instruction for adults with disabilities, Proceedings, National Physical Activity Conference for Exceptional Individuals, Long Beach, CA. Lasko-McCarthey, P., & Aufsesser, P.M. (1990). Physical activity programs for disabled adults, Palaestra, 7(1), 18-29. Lasko-McCarthey, P., & Knopf, K. (1990). Adapted Physical Education for Adults with Disabilities, 3rd edition, Dubuque, IA: Bowers. RELATED ARTICLE: Case Study #1 The first individual, representing the mild category of disability, is a 29-year-old accountant who has cerebral palsy (spastic diplegia spastic diplegia A feature of cerebral palsy, which affects both legs, often unequally, characterized by hip flexion and internal rotation, due to the overactivity of the iliopsoas, rectus femorus, hip adductors; knee extension, due to overactivity of hamstrings, ). He is ambulatory and utilizes only ankle/foot orthotics orthotics /or·thot·ics/ (-iks) the field of knowledge relating to orthoses and their use. or·thot·ics n. and one Lofstrand crutch crutch (kruch) a staff, ordinarily extending from the armpit to the ground, with a support for the hand and usually also for the arm or axilla; used to support the body in walking. crutch n. . Medical History Primary Condition--Cerebral palsy (spastic diplegia) Onset--Congenital (forceps delivery forceps delivery n. The birth of a child assisted by extraction with a forceps designed to grasp the head. trauma) Primary symptoms: * Spastic spastic /spas·tic/ (spas´tik) 1. of the nature of or characterized by spasms. 2. hypertonic, so that the muscles are stiff and movements awkward. spas·tic adj. 1. muscle tone in lower extremity lower extremity n. The hip, thigh, leg, ankle, or foot. Also called inferior limb, pelvic limb. limited to hip flexors, hip adductors, hip internal rotators, and ankle plantar plantar /plan·tar/ (plan´tar) pertaining to the sole of the foot. plan·tar adj. Of, relating to, or occurring on the sole. flexors. * Postural abnormalities: lordosis lordosis /lor·do·sis/ (lor-do´sis) 1. the anterior concavity in the curvature of the lumbar and cervical spine as viewed from the side. 2. abnormal increase in this curvature. , rounded shoulders, and forward head. * Scissors gait. * Hypertrophy hypertrophy (hīpûr`trəfē), enlargement of a tissue or organ of the body resulting from an increase in the size of its cells. Such growth accompanies an increase in the functioning of the tissue. in shoulders, arms, and chest. * Tightness in abdominals, hip flexors, lumbar extensors, gluteals, hamstrings, hip adductors. Additional Symptoms: * Deep tendon reflexes deep tendon reflex n. Abbr. DTR Tonic contraction of the muscles in response to a stretching force, due to stimulation of muscle proprioceptors. Also called myotatic reflex. and tactile reflexes are hyperactive in the lower extremity. * Contractures Contractures Definition Contractures are the chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments, and tendons. and muscular adaptive shortening causing hip flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent. flex·ion n. 1. The act of bending a joint or limb in the body by the action of flexors. 2. , hip internal rotation internal rotation Medial rotation The act of turning about an axis passing through the center of the leg, which occurs with closed chain pronation; the talus acts as an extension of the leg in the frontal and transverse planes. Cf External rotation. , knee flexion, spinal hyperextension hy·per·ex·ten·sion n. Extension of a joint beyond its normal range of motion. hy  per·ex·tend , and
ankle plantar flexion.
* Balance disturbance due to hyperactive reflexive responses, loss of movement in torso and lower extremities. Secondary Conditions--Chronic low back pain secondary to excessive lordosis resulting from gait abnormality and tonus tonus /to·nus/ (to´nus) tone or tonicity; the slight, continuous contraction of a muscle, which in skeletal muscles aids in the maintenance of posture and in the return of blood to the heart. in lower extremity. Primary symptoms: * Localized pain around the fourth and fifth lumbar vertebrae Lumbar vertebrae The vertebrae of the lower back below the level of the ribs. Mentioned in: Spinal Instrumentation . * Tightness in gluteals. Additional Medical History: Pain and instability in both ankles. Goals and Objectives: * Improve gait by increasing active range of motion in hip flexion and lengthening stride. * Increase flexibility in lower extremity and torso. * Reduce and localize lo·cal·ize v. lo·cal·ized, lo·cal·iz·ing, lo·cal·iz·es v.tr. 1. To make local: decentralize and localize political authority. 2. back pain. * Improve stamina by increasing cardiovascular endurance. * Reduce postural deformity Deformity See also Lameness. Calmady, Sir Richard born without lower legs. [Br. Lit.: Sir Richard Calmady, Walsh Modern, 84] Carey, Philip embittered young man with club foot seeks fulfillment. [Br. Lit. . Individualized Fitness Program * Assessment of well-being: Resting heart rate, resting blood pressure, assessment of physical pain. This assessment allows the staff to monitor the vital signs and the physical condition of the participant on a daily basis. * Aerobic/Extended duration activities: leg cycle ergometry, arm crank ergometry, extended ambulation (walk on fitness trail). These activities are used to improve aerobic capacity, increase endurance, and promote options for daily health-related activity. * Balance development: Resisted postures (seated, standing, and kneeling). Standing on rocker board, physioball activities (seated, supine, and prone), stepping over obstacles, climbing over obstacles. These exercises create a challenge to the balance and proprioception proprioception Perception of stimuli relating to position, posture, equilibrium, or internal condition. Receptors (nerve endings) in skeletal muscles and on tendons provide constant information on limb position and muscle action for coordination of limb movements. centers of the brain and body. They are used to maintain or improve static and dynamic balance and increase kinesthetic kin·es·the·sia n. The sense that detects bodily position, weight, or movement of the muscles, tendons, and joints. [Greek k stimulation and awareness. * Muscular exercise and flexibility: Resistive resistive /re·sis·tive/ (re-zis´tiv) pertaining to or characterized by resistance. exercises for the upper extremity upper extremity n. The shoulder, arm, forearm, wrist, or hand. Also called superior limb, thoracic limb. . * Using wall pulleys, overhead pulley pulley, simple machine consisting of a wheel over which a rope, belt, chain, or cable runs. A grooved pulley wheel like that used for ropes is called a sheave. , dumbbells, Velcro weights and manual resistance; avoid any exercise that increases flexor flexor /flex·or/ (flek´ser) 1. causing flexion. 2. a muscle that flexes a joint. flexor retina´culum see entries under retinaculum. tone in elbow joints. * Independent stretching of upper extremity muscles. * Resistive exercise to increase strength of muscles that oppose the dominant tone in the lower extremity. * Passive maximal stretch of all muscles of the lower extremity dominated by tone. These exercises are performed to increase functional strength, oppose spastic muscle tone, and create better muscular balance. RELATED ARTICLE: Case Study #1 Participant - Case Study #1 Individual Fitness Program: DATE 5/2 5/4 5/9 1. RHR RHR Resting Heart Rate RHR Right Hand Reverse (door opening convention) RHR Residual Heat Removal (nuclear power) RHR Royal Highland Regiment (Black Watch) - 96 78 RBP RBP Retinol Binding Protein RBP Regular Baptist Press RBP Retinoblastoma Binding Protein RBP Risk-Based Pricing RBP Royal Black Preceptory (Loyal Orange Lodge Offshoot) RBP Rated Burst Pressure RBP Registered Biosafety Professional - 130/78 130/110 2. Flexiciser - 8 min X X X (OPTIONAL) Aerobics 3. UE Erg erg (ûrg), unit of work or energy in the cgs system of units, which is based on the metric system; it is the work done or energy expended by a force of 1 dyne acting through a distance of 1 centimeter. - 15 min X X X a) 2 min warmup/2 min cool down, at 0+ load b) 15 min at 1/4 kp load, 65 rpm c) Record HR at 6th min 4. Kinetron - 6-8 min or X X X LE ERG - 6-8 min 0 X 0 Muscular Exercise 5. Assistive - 2x10 rep Hips/knee - a) hip abd - (sup) X X X (no active add of hips!!!) b) hip ext. - X X X (Standing at table) c) knee ext - X X X (sup w/knee board) d) hip extrnl rot (bilat) X X X e) hip circumduction CIRCUMDUCTION, Scotch law. A term applied to the time allowed for bringing proof of allegiance, which being elapsed, if either party sue for circumduction of the time of proving, it has the effect that no proof can afterwards be brought; and the cause must be determined as it stood when X X X 6. PROM - 2x30 sec Hips - (sup) max stretch a) Hip fix (bent knee) X X X b) Hip abd (bilat) X X X c) Hip fix (contralat X X X w/bent knee) d) flip fix (straight knee) X X X e) Bilat extrnl rot (sup hook) X X X f) Lumbar traction X X X Facilitated Stretches h) HR - hip fixers 0 X 0 i) HR - hamstrings 0 X 0 j) HR - hip adductors 0 X 0 k) Low back PNF PNF, n proprioceptive neuromuscular facilitation, a manual resistance technique that works by simulating fundamental patterns of movement, such as swimming, throwing, running, or climbing. Methods used in PNF oppose motion in multiple planes concurrently. stretches 0 X 0 l) Hip flexor 0 X 0 7. PROM - 2x30 sec ankle dorsiflxn - (sup) 0 X 0 8. Active - 3x15 reps (do when time permits) Shoulders - (sit) record weight a) Bench press (universal) 65 65 75 b) sh abd - db 8 8 8 c) sh flx- db 8 8 10 d) let pull - (behind head) 90 90 100 e) elbow ext. w/lat bar 30 30 40 f) Abdominal crunches 2x60 2x60 2x60 (2x60 rep) 9. PROM - 2x30 sec Shoulders - (sit) max stretch a) Sh flx - (bilat) X X X b) Sh ab - X X X c) Sh horiz add - (bilat) X X X d) Sh horiz abd - X X X e) Sh diag abd - X X X Individual Fitness Program: DATE 5/11 5/16 5/18 1. RHR - 84 90 90 RBP - 132/102 2. Flexiciser - 8 min X X X (OPTIONAL) Aerobics 3. UE Erg - 15 min X X X a) 2 min warmup/2 min cool down, at 0+ load b) 15 min at 1/4 kp load, 65 rpm c) Record HR at 6th min 4. Kinetron - 6-8 min or X X X LE ERG - 6-8 min 0 X X Muscular Exercise 5. Assistive - 2x10 rep Hips/knee - a) hip abd - (sup) X X X (no active add of hips!!!) b) hip ext. - X X X (Standing at table) c) knee ext - X X X (sup w/knee board) d) hip extrnl rot (bilat) X X X e) hip circumduction X X X 6. PROM - 2x30 sec Hips - (sup) max stretch a) Hip fix (bent knee) X X X b) Hip abd (bilat) X X X c) Hip fix (contralat X X X w/bent knee) d) flip fix (straight knee) X X X e) Bilat extrnl rot (sup hook) X X X f) Lumbar traction X X X Facilitated Stretches h) HR - hip fixers X X X i) HR - hamstrings X X X j) HR - hip adductors X X X k) Low back PNF stretches X X X l) Hip flexor X X X 7. PROM - 2x30 sec ankle dorsiflxn - (sup) X X X 8. Active - 3x15 reps (do when time permits) Shoulders - (sit) record weight a) Bench press (universal) 75 85 85 b) sh abd - db 8 10 10 c) sh flx- db 10 10 10 d) let pull - (behind head) 100 100 100 e) elbow ext. w/lat bar 40 40 40 f) Abdominal crunches 2x70 2x70 2x70 (2x60 rep) 9. PROM - 2x30 sec Shoulders - (sit) max stretch a) Sh flx - (bilat) X X X b) Sh ab - X X X c) Sh horiz add - (bilat) X X X d) Sh horiz abd - X X X e) Sh diag abd - X X X LEGEND: ERG= Ergometer ergometer /er·gom·e·ter/ (er-gom´e-ter) a dynamometer. bicycle ergometer an apparatus for measuring the muscular, metabolic, and respiratory effects of exercise. LE = Lower Extremity MR = Maximal Resistance PNF = Proprioception and Neuromuscular Facilitation PROM = Progressive Range of Motion RBP= Resting Blood Pressure RHR = Resting Heart Rate UE = Upper Extremity RELATED ARTICLE: Case Study #2 The second individual, representing the moderate category of disability, is a 34-year-old male scientist who has Kugelberg-Welander form of spinal muscular atrophy Spinal Muscular Atrophy (SMA) is a term applied to a number of different disorders, all having in common a genetic cause and the manifestation of weakness due to loss of the motor neurons of the spinal cord and brainstem. . Though this disability is progressive and potentially life threatening, this participant is best described as being chronic stable. His independence would be severely limited if not for his novel and creative use of various assistive devices. He is currently non-ambulatory and relies on an electric wheelchair for locomotion locomotion Any of various animal movements that result in progression from one place to another. Locomotion is classified as either appendicular (accomplished by special appendages) or axial (achieved by changing the body shape). . Medical History Primary Condition--Spinal muscular atrophy muscular atrophy, n decrease in size and number of muscle fibers as a result of aging, reduction in blood supply, malnutrition, or denervation. See also innervation. (Kugelberg-Welander syndrome). Onset--This condition is congenital and neurodegenerative. Symptoms of flaccid flaccid /flac·cid/ (flak´sid) (flas´id) 1. weak, lax, and soft. 2. atonic. flac·cid adj. Lacking firmness, resilience, or muscle tone. muscle tone are present at birth. Primary Symptoms: * Flaccid muscle tone due to progressive muscular atrophy progressive muscular atrophy n. Atrophy of the cells of the anterior cornua of the spinal cord, resulting in the progressive wasting and paralysis of the muscles of the extremities and trunk. resulting from the degeneration of the motor neuron motor neuron n. A neuron that conveys impulses from the central nervous system to a muscle, gland, or other effector tissue. Motor neuron . Additional symptoms: * Loss of tendon and tactile reflexes. * Progressive loss of voluntary motor control. * Progressive loss of postural support and sitting balance. * Progressive loss of fine motor control. * Diminishing respiratory capacity respiratory capacity n. See vital capacity. . * Contractures and muscular adaptive shortening causing hip flexion, knee flexion, ankle planter flexion. Secondary Conditions--Muscular discomfort in neck and shoulders; Insomnia related to job stress. Additional Medical History: Unremarkable. Goals and Objectives: * Maintain strength and joint integrity in the upper extremity. * Develop the muscular endurance in hand and wrist strength to pilot sail planes. * Stand in standing frame every class meeting. * Develop functional manual wheelchair ambulation skills. * Increase endurance through extended duration activity. * Maintain or reduce contractures in lower extremity. Individualized Fitness Program * Assessment of well being: Resting heart rate, resting blood pressure, assessment of any physical pain. This assessment allows the staff to modify the program if vital signs are elevated, or to take measures to make preparations; to provide means. See also: measure to relieve any discomfort associated with muscular tightness. * Aerobic/Extended duration activities: Sports wheelchair propulsion and arm crank ergometry. Because of the severity of this individual's atrophy and loss of tone, these exercises are more geared to improve endurance than aerobic capacity. The wheelchair ambulation activity provides this individual, who normally uses an electric wheelchair, with an activity that is health related, functional, and easily duplicated at home. * Balance/Weight bearing activity: Supported standing (using standing frame), resisted postures (seated), and modified resisted rolling. The use of a standing frame has many benefits. Standing aids in maintaining bone density in the lower extremity, provides a pressure relief for the buttocks buttocks /but·tocks/ (but´oks) the two fleshy prominences formed by the gluteal muscles on the lower part of the back. , aids in bladder drainage, and is psychologically pleasing. The other exercises aid in developing muscular strength and control in the postural muscles of the torso. This improves sitting balance and sitting posture. * Muscular exercise and flexibility: Resistive exercises for upper extremity, using wall pulleys, overhead pulley, rickshaw and manual resistance; passive maximal stretch of muscles that move the shoulder joints; continuous passive motion continuous passive motion n. Abbr. CPM A technique in which a joint, usually the knee, is moved constantly in a mechanical splint to prevent stiffness and to increase the range of motion. of lower extremity, maximal stretch of muscles that move the hip joints; maximal stretch of thoracic torso and abdominal musculature musculature /mus·cu·la·ture/ (mus´kul-ah-cher) the muscular apparatus of the body or of a part. mus·cu·la·ture n. The arrangement of the muscles in a part or in the body as a whole. . These exercises maintain or increase strength, reduce the degree of existing contractures, and improve flexibility. RELATED ARTICLE: Case Study #2 Participant - Case Study #2 Individual fitness program: DATE 5/2 5/4 5/9 5/11 5/16 5/18 1. RHR - 76 0 78 72 76 0 2. RBP - 118/78 122/78 126/78 0 124/78 0 3. Standing frame - (15 min) 20 min 15 min 25 min 0 20 min 15 min (15 min) 4. Flexiciser - participant to determine duration * Gradually approach 40 rpms X X 0 X 0 X MUSCULAR EXERCISE (Seated in wheelchair) - 5. Active exercise of upper extremity * patient to determine duration a) Vertical pulleys X X X 0 0 X b) Basketball dribble X X X X X X c) Basketball catch and throw X X X X X X d) Shoulder press (over head using cane) 2x10 2x10 2x10 2x10 2x10 2x10 2x10 reps 6. Rickshaw - 3x10 reps a) Elevation/depression X 0 X X 0 0 b) Full shoulder movement X 0 X X 0 0 AEROBICS 7. UE Erg - 8-10 min X X X X X X * 0+ load 8. Wheelchair pushing - 10 min X X X X X X MUSCULAR EXERCISE (supine) 9. Assistive - 8-10 reps * Shoulder/elbow * Stretch maximally following last rep for 30 sec a) Sh horiz ate/add 0 X X X X 0 b) Sh Flx/ext (side) 0 X X X X 0 c) Sh abd (sup) 0 X X X X 0 d) Circumduction 0 X X X X 0 e) Elbow flx/ext w/MR 0 X X X X 0 10. Assistive - 15 x * Mobilize then stretch maximally for 30 sec after 15th rep a) Hip abd (powder board) 0 0 0 0 X X b) Hip flx/ext 0 0 0 0 X X c) Hip extrnl rot - 0 0 0 0 X X d) Hip circumduction 0 0 0 0 X X 11. PROM - 4 x * Maximal stretch a) Knee ext (w/hips neutral) X X 0 X X X b) Hip flx (straight knee) X X 0 X X X c) Hip flx (Contralat w/ bent (knee) X X 0 X X X d) Piraformas X X 0 X X X e) Gastrocs X X 0 X X X f) Lumbal traction X X 0 X X X RELATED ARTICLE: Case Study #3 The third individual selected, representing the severe category of disability, is a 35-year-old male who suffered severe brain injury and massive burns in an explosion. His disability ended his career as an electrical engineer and has completely compromised his independence. This participant relies on skilled nursing care 24 hours a day. In addition to the major problems described, this individual suffers from multiple related disorders, including comprehensive muscular rigidity and a severe form of anterior grade amnesia. He is non-ambulatory and needs full assistance. Medical History Primary Conditions--Acquired brain injury secondary to anoxia Anoxia Definition Anoxia is a condition characterized by an absence of oxygen supply to an organ or a tissue. Description Anoxia results when oxygen is not being delivered to a part of the body. . Severe burns over 95% of body (full thickness/massive scarring). Onset--Conditions resulted from exposure to an explosion at a hydroelectric plant, 1986. Primary Symptoms: * Severe muscular rigidity. * Severe short-term memory short-term memory n. Abbr. STM The phase of the memory process in which stimuli that have been recognized and registered are stored briefly. loss and anterior grade amnesia. * Loss of soft tissue and skin flexibility due to massive scarring. * Loss of speech due to damage and scarring of facial muscles facial muscles, n See muscles, facial. . Additional Symptoms: * Flexor contractures in hips and knees. * Severe balance disturbance. * Extreme tightness of anterior surface of body causing the following postural abnormalities: extreme kyphosis kyphosis (kīfō`səs): see hunchback. , forward head, rounding of shoulders, severe forward learn (tight abdominal and hip flexor muscles). * Extremely hyperactive tendon, stretch, and tactile reflexes. * Poor tactile discrimination. * Fluid accumulation in lungs. * Loss of hand function due to scarring. * Loss of ambulation without maximal assistance. * Incontinence. * Lack of attention span. * Poor proprioception. Secondary Conditions--Chronic urinary tract infections urinary tract infection (UTI), n infection in one or more of the structures that make up the urinary system. Occurs more often in women and is most commonly caused by bacteria. and chronic pulmonary complications. Goals and Objectives: * Increase passive range of motion in shoulder, spine/ torso, hip, and knee joints. * Increase flexibility of anterior torso. * Increase motor control of lower extremity. * Reduce forward postural lean. * Increase duration of maximally assisted walking. * Increase proprioception through muscular and tactile stimulation. Individualized Fitness Program * Assessment of well-being: resting heart rate, resting blood pressure, assessment of level of alertness (good, fair, poor). This assessment provides the staff with information about how this individual might perform this day. Vital signs are assessed not because this participant in hypertensive hypertensive /hy·per·ten·sive/ (-ten´siv) 1. characterized by increased tension or pressure. 2. an agent that causes hypertension. 3. a person with hypertension. , but to see if medications are suppressing function and mood. * Aerobic/Extended duration activities: Open floor assisted ambulation, Kinetron exerciser (modified stair climber). Because of severity of this individual's muscular rigidity, intensity of performance is always low. Aerobic capacity may not be greatly enhanced, but the extended nature of these activities does maintain and improve levels of local and overall endurance. Ambulation is very physically challenging, but severely limited. It fits better as an endurance type activity than a gait development activity. * Balance and ambulation development: Standing frame, partially assisted standing, resisted postures (seated). These exercises are used to improve sitting/standing balances and seated posture. They also help develop a greater degree of independence in transfer and mobility skills. * Active assistive and passive mobilization of shoulder and hip joints. Continuous passive motion of upper and lower extremity (cycling motion for legs, flexion/extension for shoulders). Using linear and rotational patterns that oppose dominant tone. * Maximal passive stretch of muscles that move the hip and shoulder joints. Especially those muscles that contribute to postural abnormalities or one dominated by rigidity. * Maximal stretch of thoracic torso and the abdomen. * Maximal stretch of lumbar spine Lumbar spine The segment of the human spine above the pelvis that is involved in low back pain. There are five vertebrae, or bones, in the lumbar spine. Mentioned in: Low Back Pain . * Prone lying. These exercises are done to improve flexibility, improve posture, increase independence, and maintain joint integrity. RELATED ARTICLE: Case Study #3 Participant - Case Study #3 Individual Fitness Program: DATE 5/1 5/3 5/8 5/10 5/15 5/17 1. RHR 68 70 70 68 72 72 2. Standing frame - 15 min X X X X X X * work on scapular scap·u·lar or scap·u·lar·y adj. Of or relating to the shoulder or scapula. scapular, adj pertaining to the region of the scapulae. scapular pertaining to the scapula. adduction adduction /ad·duc·tion/ (ah-duk´shun) the act of adducting; the state of being adducted. adduction ( w/MR 3. Backward wheelchair push 0 0 0 X X 0 4. Flexiciser- 10 min X X 0 X X X AEROBICS 5. Kinetron - 8-10 min duration at 80 speed setting * Verbally cue as little as possible * Encourage upright posture * Settings: Seat Height - 75 Stroke length - 30 Fore/Aft * during the 5th min record how many verbal prompts required to keep on task X X 0 X X X 6. Open floor ambulation/full assist a) forward steps 8 6 8 14 12 18 (record how many steps taken without verbal prompts) b) side steps X X X X X X MUSCULAR EXERCISE 7. Passive mobilization - 4 reps Shoulders - (supine) - Stretch maximally in each pattern a) fix- (unilat) X X X X X X b) abdct- (unilat) X X X X X X c) fix bilat w/cane X X X X X X d) diag abdct unilat X X X X X X e) Extrnl rot X X X X X X * stretch only - 2x30 sec f) Postural stretch - (thorasic X X X X X X pivots) g) arm off table - X X X X X X Assistive - 5 reps h) Scap add - (sup) X X X X X X 8. Passive Mobilization - 4 x Hips - (Supine) * movement is slow s/maximal stretch on 4th rep a) fix unilat X X X X X X b) extrn rot bilat X X X X X X * stretch maximally only - 2.30 sec a) Bilat abd X X X X X X b) Hip flx (straight knee) X X X X X X c) Hip flx X X X X X X (contralat w/bent knee) d) Legs off table - X X X X X X 9. Resisted roll (side - 10 min) X X X X X X Pelvic tilts - 25x X X X X X X Peter M. Aufsesser is the founder and Director of the Fitness Clinic for Physically Disabled at San Diego State University. His professional interests lie in assisting individuals with physical disabilities to be as independent as possible. James P. Burke is the Program Director of the Fitness Clinic. While his degree is in adapted physical education, he is also a registered kinesiotherapist. |
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