What We Do: Therapeutic Exercise
Therapeutic exercise refers to a wide range of physical activities that focus on restoring and maintaining strength, endurance, flexibility, stability and balance. It is prescribed to correct impairment, improve musculoskeletal function or maintain a state of well-being. Therapeutic exercise may vary from highly selected activities restricted to specific muscles or parts of the body. The goal of therapeutic activities is to return an injured patient to a fully functioning, pain-free state.
A physical therapist begins by conducting a thorough evaluation of an individual’s physical capabilities through both a medical history and physical assessment. The physical therapist then uses his/her knowledge to shape a treatment care plan containing a slowly progressing exercise program that is appropriate to each individual’s needs. The physical therapist monitors progress, assists with some physical movements and continuously modifies the plan as the patient recovers.
sEMG (Surface Electromyography) biofeedback techniques augment, not replace, physical therapy and therapeutic exercise. sEMG should never be provided alone. It should be supplemented with exercise and functional training. As an adjunctive technique sEMG biofeedback can supply specific information to speed motor learning. Unlike a therapist’s verbal technique, sEMG biofeedback permits patients to develop their own strategies and test them against specific electronically amplified kinesiological variables. sEMG biofeedback is a logical adjunct to therapeutic exercise and because most exercises require contraction or relaxation of muscles, it is especially popular in rehabilitation.
Torticollis-sEMG biofeedback is the treatment of choice for spasmodic, idiopathic torticollis. Most therapists teach spasmodic torticollis patients to relax their contralateral sternocleidomastoid (SCM) and contract the ipsilateral SCM with one or two channel sEMG. Once relaxation of the contralateral SCM can be achieved reliably, several sessions of general relaxation may be offered to assist in generalizing the treatment results.
Weakness-Probably the most obvious use of sEMG in orthopedics is for muscles with less than Fair plus “strength”. Such muscles cannot produce enough force to exercise against graded resistance such as weights, yet these patients need some indicator of progress and incentive to continue the sometimes boring repetitious contractions. sEMG biofeedback is very useful for surgically induced weakness as well as for postfracture or disuse atrophy. Using widely spaced electrodes to maximize the area of motor unit sampling, the patient is requested to increase the amplitude as much as possible which, in turn, increases muscle force. When the patient can exercise against weight, sEMG biofeedback should be discontinued in favor of other resistive exercises.
Contractures-Many orthopedic patients have joint contractures. Used as an adjunctive tool, sEMG biofeedback can be used to relax the antagonist muscle and can improve joint mobilization techniques. One of the requisite conditions of joint mobilization in particular and passive ROM in general is that the patient relax those muscles that resist that motion.
Anterior Cruciate Ligament Reconstruction (ACL)-Regular use of sEMG biofeedback in conjunction with strengthening exercises significantly improves the rate of functional recovery of the quadriceps femoris muscle activity following major ligament reconstruction. Easily incorporated into an ACL rehabilitation protocol, sEMG is most useful when the patient exhibits signs of poor quadriceps femoris motor control or when the patient does not appear to be contracting the muscle maximally. The device enables the patient to exercise and monitor each repetition without assistance. Patients consistently report that using sEMG biofeedback during exercise makes them better aware of whether they are exercising correctly and increases their feelings of muscle control during exercise.
VMO/VL Deficiency-This is one of the commonest conditions presented to clinicians involved in the management of sports injuries. Overuse injuries abound in the patellofemoral region because the patellofemoral joint is essentially a soft tissue joint, very much reliant on the soft tissue structures to determine the position of the patella on the femur. Poor medial quadriceps activity is a major finding in patients with this deficiency, so appropriate muscle training is imperative to ensure the patella position is optimized. Muscle training is more effective when a surface sEMG device is monitoring the activity of the agonist (vastus medialis oblique) and antagonist (vastus lateralis) muscles because immediate information about the amount and timing of the vastus medialis oblique (VMO) compared with the vastus lateralis (VL) enhances the recovery of patients with VMO/VL deficiency.
Uninvolved/Involved Muscle Pairs
Neurological inhibition resulting from pain and effusion has been demonstrated in patellofemoral patients and this phenomena is likely to occur in any patient who has undergone trauma to a synovial joint. The result of such motor inhibition can have profound effects on patterns of motor activity during functional activities. The neuromuscular system is extremely adaptable and is permissive of substitution of inappropriate motor activation in order to accomplish functional tasks.
From a rehabilitation perspective, the result is that despite the use of functional strengthening activities, the patient may substitute uninhibited muscles for those that are inhibited and thus, strengthen all muscle groups EXCEPT the one functional strengthening activity is meant to target. For example, patients who have undergone knee surgery or injury often exhibit gross inhabitation of the quadriceps femoris muscles secondary to pain and inflammation. The problem is that the patient may not be able to actively recruit the quadriceps muscle group, and therefore may complete rehabilitation activities only by substitution of other muscle groups. Anyone who has worked with knee patients recovering from surgery is familiar with the scenario of the patient who works very hard in the clinic yet fails to show much improvement in quadriceps strength as measured objectively via isokinetics or otherwise. This may be explained by abnormal recruitment patterns of muscle activity during functional rehabilitation.
This phenomena may occur whenever joint pathology is present, whether it be at the knee, hip, ankle or shoulder joint. After injury or surgery patients often develop muscle substitution patterns which are difficult or impossible to recognize without the use of surface sEMG. Therefore, it is helpful to the patient to periodically evaluate the pattern of muscle activity on the uninvolved versus the involved side during the course of rehabilitation. This permits the patient and the physical therapist to distinguish the difference between an inappropriate and appropriate motor pattern. Once that has been achieved the physical therapist can use facilitation techniques and motor training activities assisted by surface sEMG in order to reinforce normal motor patterns.