Therapeutic Exercise: Moving Toward Function.

Therapeutic Exercise: Moving Toward Function

Hall CM, Brody LT, eds. Baltimore, MD 212001-2436, Lippincott Williams & Wilkins, 1999, hardcover, 786 pp, illus, ISBN: 0-397-55260-2, $64.95.

One of the greatest challenges for faculty in physical therapist education programs is to integrate therapeutic exercise into the curriculum. The subject is immense and students must learn to recognize, select, and use exercise interventions that are appropriate for a myriad of patient problems. It is hard to know where to begin and how to progress when teaching exercise applications. This new publication provides a road map that makes this journey of discovery easier for teachers and students alike.

Therapeutic Exercise: Moving Toward Function is designed as a textbook for use in physical therapist education programs. The editors' purpose is to provide a textbook with a "conceptual framework for learning how to make clinical decisions regarding the prescription of therapeutic exercise." The book is written in language that is consistent with the Guide to Physical Therapist Practice and presents exercise prescriptions and interventions in relation to the model of disablement used in the Guide.

The book is extensively illustrated and contains several other educational features in each chapter, including selected intervention features, boxes for self-management and patient-related instruction, key points, critical thinking questions, lab activities, and case studies. It is organized into 7 units.

Unit 1 covers exercise from the perspective of the chosen disablement model, patient management, and principles of self-management and exercise instruction. The modified disablement model that is developed in the unit helps organize the information according to impairment, functional limitations, and disability. A clinical decision-making model is introduced to show how to arrive at physical therapy diagnosis, prognosis, goals, and interventions that are efficient and effective.

Unit 2 contains 6 chapters that present comprehensive overviews of fundamental concepts of therapeutic exercise. Chapter 4 defines strength in terms of force, torque, work, and power and relates the development of strength to current knowledge of muscle physiology and biomechanics. The chapter also introduces strength training principles and exercise dosage. The next chapter introduces the application of exercise to cardiovascular and muscular endurance. Chapter 6 delineates the concepts of hypermobility and hypomobility, the effects of immobilization, and exercises to improve mobility. The next chapter discusses balance in relation to the aging process and provides guidelines for measurement and treatment of balance impairments. Therapeutic exercise is presented in chapter 9 as a cornerstone of treatment for pain impairment. Adjunctive physical agents are also discussed.

Unit 3 deals with therapeutic exercise applications in postsurgical and soft-tissue injuries, arthritic conditions, fibromyalgia and chronic fatigue, and obstetrics. Basic concepts, including viscoelastic characteristics, stress-strain relationships, and relaxation, creep, and hysteresis, are presented in chapter 10. It also covers stages of tissue healing and the SAID principle (specific adaptation to imposed demands) and describes therapeutic exercise applications to manage sprains, strains, contusions, and tendon and bony injuries within the context of anatomy and kinesiology. Chapter 11 discusses the therapeutic approaches used to manage rheumatoid arthritis and osteoarthritis, including exercise to improve joint movement and muscle strength, dynamic training, cardiovascular conditioning, and special precautions within exercise prescriptions for patients with arthritic conditions. Because fibromyalgia and chronic fatigue syndrome require special consideration, chapter 12 introduces exercise prescriptions that take into account fatigue and symptom exacerbation. Chapter 13 addresses the biomechanical changes in pregnancy and the therapeutic exercise approaches to counteract those changes.

Unit 4 introduces a variety of methods used in therapeutic exercise interventions. Proprioceptive neuromuscular facilitation is presented as a versatile manual therapy approach, which is based on improving function and using functions as goals, and as an application that works well in conjunction with other treatment approaches. Chapter 15 describes the characteristics of closed kinetic chain exercises and underscores how important an understanding of kinetics, kinematics, and kinesiology is in order to use this approach successfully. Chapter 16 presents an overview of Hellerwork, the Trager approach, Aston-Patterning, the Alexander technique, and the Feldenkrais method, all of which strongly emphasize education and improved self-awareness. Chapter 17 discusses the usefulness and effects of exercise in water as part of a total treatment strategy to improve function on land.

Units 5 and 6 address regional therapeutic exercise applications for the lower and upper extremities, respectively. Unit 5 contains chapters that cover lumbopelvic, pelvic floor, hip, knee, and ankle and foot. The biomechanics of the lumbopelvic region are presented in chapter 18 with examination and treatment parameters for this region. Chapter 19 explores the pelvic-floor musculature and its supportive, sphincteric, and sexual functions extensively, emphasizing self-assessment and guided self-management to improve the patient's quality of life. Chapter 20 underscores the importance of the muscles that cross the hip and the relationships that they have with the lumbopelvic region and the knee joint. This chapter presents treatment applications for osteoarthritis, total hip arthroplasty, and iliotibial band and piriformis syndromes, among other conditions. Chapter 21 addresses anatomic and physiologic impairments at the knee and patellofemoral joint and further discusses the interrelationships between the lower extremity and the lumbopelvic region. Chapter 22 presents examination and treatment applications related to ankle and foot function, especially during walking for shock absorption, load transmission, surface adaptation, and propulsion.

Unit 6 contains chapters on the temporomandibular joint; cervical and thoracic spine; shoulder girdle; and elbow, forearm, wrist, and hand. Chapter 23 offers therapeutic exercise applications that address both limited and increased mobility of the jaw and emphasizes the active involvement of patients in treatment. Chapter 24 presents examination and treatment for the craniovertebral complex, and chapter 25 covers thoracic spine considerations. Functional retraining to complement treatment of shoulder girdle impairments and scapular taping are discussed in chapter 26. Chapter 27 addresses impairments at the elbow, forearm, wrist, and hand and discusses the impact of factors such as work pace and lack of task variability in relation to carpal tunnel syndrome.

Unit 7 contains 11 case studies that are referenced throughout the text in the "Lab Activities" and "Critical Thinking Questions" sections. There are 2 appendixes, both of which deal with recognition of "red flags" or signs and symptoms that may indicate conditions that are beyond the scope of physical therapist practice. Appendix 1 discusses pathologies originating from sources other than neuromusculoskeletal sources, such as somatic and visceral pain. Appendix 2 addresses signs and symptoms occurring during exercise that may be associated with other medical conditions.

This book has several strengths. It is comprehensive and current. The chapters on the body regions, the pelvic floor, alternative movement-related therapies, and obstetric therapeutic exercise are thorough. Each chapter in the book presents a concise summary of anatomic and kinesiologic structure and function, followed by a systematic approach to examination, evaluation, and treatment planning. The reader is guided through a clinical decision making process through the use of case studies in the lab activities and critical thinking questions found at the end of many chapters. Each chapter is summarized in bulleted key points that help pull the essential content together.

The second strength of this book is that it is written to take into consideration the current health care system, and it is consistent with the Guide to Physical Therapist Practice. It is very important that beginning physical therapists are able to perform their essential functions effectively and efficiently. The emphasis that the book places on patient self-management, home exercise, and education is both timely and necessary in the managed care environment.

The authors achieve their purpose in providing guidelines for clinical decision making in the prescription of therapeutic exercise. They also advocate an open-minded and holistic approach in an area in which practice can sometimes be targeted at only part of a person. The reader never loses sight of the patient in this text. Extensive self-management and patient-related instruction sections and photographs keep the reader focused on the whole person. The text describes the relationship between patient and therapist as a cooperative relationship, which is aimed at setting and attaining common goals and functional outcomes.

This text is an excellent addition to the physical therapy curricula. I believe that it would be very useful to clinicians as well. Beginning physical therapists will find its current applications and thorough approach especially helpful. Clinical instructors will benefit from the many illustrations, examples, and case studies in their efforts to provide instruction to physical therapist students at all levels. Experienced clinicians will find the up-to-date content a valuable resource and adjunct to the Guide to Physical Therapist Practice as they continually add to and refine their clinical skills.

Mary Jean Gelsomino, PT Utica College of Syracuse University Utica, NY

Ms Gelsomino is Assistant Professor in the Physical Therapy Program.