Therapeutic Exercise and

Assistive Device for

Musculoskeletal Disorders
 01 THERAPEUTIC EXERCISE

TYPE OF THERAPEUTIC
02
EXERCISE
TABLE OF
CONTENTS 03 ORTHOSES

04 ASSISTIVE DEVICES

SPECIFIC MUSCULOSKELETAL
05 DISORDERS
01

THERAPEUTIC
EXERCISE
 THERAPEUTIC EXERCISE

is the systematic, planned performance of physical

movements, postures, or activities intended to provide a
patient/client with the means to :

▪ Remediate or prevent impairments of body

functions and structures.
▪ Improve, restore, or enhance activities and
participation.
▪ Prevent or reduce health-related risk factors.
▪ Optimize overall health, fitness, or sense of well-
being.

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
COMPONENT OF HUMAN FUNCTION
RELATED TO
HUMAN MOVEMENT

Therapeutic Exercise
Interventions
• Aerobic conditioning and reconditioning
• Muscle performance exercises: strength, power, and
endurance training
• Stretching techniques including muscle-lengthening
procedures and joint mobilization/manipulation
techniques
• Neuromuscular control, inhibition, and facilitation
techniques and posture awareness training
• Postural control, body mechanics, and stabilization
exercises
• Balance exercises and agility training
• Relaxation exercises
• Breathing exercises and ventilatory muscle training
• Task-specific functional training
Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 COMMON BODY FUNCTION
IMPAIRMENTS MANAGED BY
THERAPEUTIC EXERCISE

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
02

TYPE OF
THERAPEUTIC
EXERCISE
 TYPE OF
THERAPEUTIC EXERCISE

Stretching ROM Exercise

(Fullest ROM
(Increase mobility)
possible)

Strengthening
(Increase Muscle
Aerobic
Strength) (Physical Fitness)
 STRETCHING EXERCISE

Increase soft tissue extensibility with the intent of improving flexibility and ROM by
elongating (lengthening) structures that have adaptively shortened and have become
hypomobile.

Potential Benefits and Outcomes of Stretching

▪ Increased flexibility and ROM
▪ General Fitness
▪ Injury prevention and reduced post-exercise muscle soreness
▪ Enhanced performance

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 TYPES OF STRETCHING
Types of Stretching
• Static stretching
• Intermittent stretching
• Ballistic stretching
• Proprioceptive neuromuscular facilitation
stretching procedures (PNF stretching)

• Manual stretching Self-stretching PNF Stretching

• Mechanical stretching Static and active
• Self-stretching stretch
• Passive stretching
• Active stretching

Ballistic stretching
Mechanical stretching

Self-stretching

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
DETERMINANTS OF STRETCHING INTERVENTIONS

• Alignment: Positioning a limb or the body such

that the stretch force is directed to the appropriate
muscle group
• Stabilization: Fixation of a bony segment that
has an attachment of the muscle to be stretched
• Intensity of stretch: Magnitude of the stretch Recommendation:
force applied
• Duration of stretch: Length of time the stretch ❑ a low intensity
force is applied during a stretch cycle ❑ < 60 seconds
• Speed of stretch: Rate of initial application of the ❑ Slow rate
stretch force ❑ Min. 2x/week (for
• Frequency of stretch: Number of stretching
sessions per day or per week healthy individual
• Mode of stretch: Form or manner in which the
stretch force is applied (static, ballistic, or cyclic),
degree of patient participation (passive, assisted,
or active), or the source of the stretch force
(manual, mechanical, or self)

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 INDICATION AND CONTRAINDICATION OF
STRETCHING
Bony block limiting joint motion

Contraindication
Limited ROM due to adhesions,
contractures and scar tissue Recent fracture or incomplete
union
Restricted motion  structural
Indication

deformities
Inflammation
Muscle weakness & shortening of
opposing tissue  limited ROM Sharp, acute pain with joint
movement/ muscle elongation
Component of program to prevent
injuries
Hematoma/ tissue trauma
Prior to & after vigorous exercise 
reduce muscle soreness
Existing hypermobility

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 ROM EXERCISE
Neurological Surgical or
Simply
Systemic Joint or muscular traumatic Immobilization
inactivity
diseases insults

Can lead to decreased

▪ The full motion possible is called ROM
the range of motion (ROM).
▪ All structures in the region are Segments must be moved
affected: muscles, joint surfaces, through their available ranges
synovial fluid, joint capsules, periodically
ligaments, fasciae, vessels, and
nerves.
ROM exercise (P-AA-A)

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 ROM EXERCISE
INDICATION GOAL
• Acute inflammation • Maintain joint & connective tissue mobility
• Unable/not supposed • Minimize effects of contracture formation
to move segment • Maintain mechanical elasticity
Passive ROM •
•
Assist circulation
Enhance synovial movement, assist healing

INDICATION GOAL
Active-assistive • Able to contract muscles actively • Maintain physiological elasticity &
ROM & move segment with/without
assistance
contractility of participating
muscles
• Immobilized segment of body for • Provide sensory feedback from
period of time  used above and contracting muscles
below region of immobilized • Provide stimulus for bone &
segment tissue integrity
Active ROM • A-AROM is used to provide enough • Develop coordination & motor
assistance for weak musculature skills for functional activities
that is unable to move a joint
through desired range

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 ROM EXERCISE
Summary of Precautions and Contraindications
to Range of Motion Exercises
ROM should not be done when is disruptive to the
healing process
• Carefully controlled motion within the limits of pain-
free motion during early phases of healing has been
shown to benefit healing and early recovery
• Signs of too much or the wrong motion include
increased pain and inflammation
ROM should not be done when the patient’s response
or the condition is life-threatening Shoulder Wrist Lumbar flexion
• PROM may be carefully initiated to major joints and
AROM to ankles and feet to minimize venous stasis
and thrombus formation.
• After myocardial infarction, coronary artery bypass
surgery, or percutaneous transluminal coronary
angioplasty, AROM of upper extremities and limited
walking are usually tolerated under careful monitoring
of symptoms

• NOTE: ROM is not synonymous with stretching

Hip & knee flexion MTP & IP joints Self-assisted hip flexion

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 STRENGTHENING
▪ Essential element for those with
impaired function
▪ Integral component of
conditioning programs for
promoting/ maintaining health
& physical well-being
▪ Potentially enhance
performance of motor skills
▪ Reduce risk of injury and
disease
Acute Inflamation
Severe joint or muscle
Contraindications pain during active-free
(unresisted) movements
Severe cardiac or
respiratory diseases or
disorders associated with
acute symptoms
Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 PRINCIPLE AND TYPES OF STRETCHING
OVERLOAD
•To improve muscle performance, load applied should exceed
metabolic capacity of muscle
•E.g 2kg  4 kg  6 kg, etc
•Adding intensity/ volume of exercise

SAID (SPECIFIC ADAPTATION TO IMPOSED DEMANDS)

•Extension of Wolff's law: body systems adapt over time to the
stresses placed on them
•E.g desired functional outcome ability to ascend & descend stairs,
exercise should be performed eccentrically & concentrically in a
weight-bearing pattern and progressed to the desired speed.
Isokinetic

REVERSIBILITY
•Detraining: reduction of muscle performance begins within a week or
two after the cessation of resistance exercises & continues until
training effects are lost  gains in strength and endurance must be
incorporated into daily activities ASAP in a rehabilitation program

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 AEROBIC EXERCISE

Cardiorespiratory endurance exercise

• Ability of the circulatory & respiratory system to supply Frequency Intensity
oxygen during sustained physical activity

Purpose Time Type

• Increase endurance

Land-based or water based Volume Progression

• Aquatic exercise: treatment options that may otherwise be
difficult/ impossible to implement on land.

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
AEROBIC EXERCISE – WATER BASED
Rheumatoid Arthritis
• Higher temperatures are recommended (except in acute stage)
Spasticity or for those whose immersion time lasts 20
to 45 minutes
• Lower temperatures are recommended
General flexibility, strengthening, gait training, and
relaxation
•Temperature range may be between 26°C and 35°C
•Temperature at 33°C  beneficial for patients with acute painful musculoskeletal
injuries

Cardiovascular training and aerobic exercise

•Water temperatures between 26°C and 28°C maximizes exercise efficiency,
increases stroke volume, and decreases heart rate

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
AEROBIC EXERCISE – LAND BASED

Kisner, Carolyn. 2018. Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis
Company: Philadelphia.
 03

ORTHOSES
any externally applied device
used to modify structural and
functional characteristics of the
neuromuscular
 ORTHOSES
Splints and orthotics are used to:
- Decreasing inflammation and pain by
unweight joints, stabilize joints, decrease joint
motion
- Function improvement by support joints in a
position of maximal function
- Increase joint motion (i.e., dynamic splint)
- Minimizing deformity for patients at different stages
Splints may be prefabricated but are best when molded
to fit the individual patient.

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010.
Braddom’s Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
 ORTHOSES - UPPER EXTREMITY

Mallet Finger Boutonnière Deformity Swan Neck Deformity

tube Custom-ordered
silver ring orthosis

Capener Serial cast

custom

Custom low-
Ulnar Splint temperature
thermoplastic (LTT) Prefabricated
- Easy to on and off
orthosis polypropylene
- Can be applied if the person warrants more Oval 8 orthosis
protection on the ulnar side of the hand, such as
with sports injuries, Carpal tunnel syndrome
(CTS) or ulnar wrist pain
DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s
Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
ORTHOSES - LOWER EXTREMITY
Knee Brace
Braces for the knee maybe used for
pain relief, instability caused by
ligamentous laxity, significant
quadriceps weakness, or excess
recurvatum

Control of pronation by bringing the

calcaneus perpendicular to the floor
often relieves pain and helps to
balance the weight-bearing column

If pronation is not controlled by a

shoe, a hindfoot orthotic has been
shown to improve gait and reduce
pain

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s
Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
ORTHOSES - SPINAL
Biomechanics
Restrict flexion and extension  (with posterior bar) 
Indication
Low back pain, herniated disks and lumbar muscle strain. To
control gross trunk motion for pain control

Contraindication
Unstable fractures, fractures / kondisi patologis lain diatas regio
lower lumbar 

Special consideration
Long term use: increase movement vertebrae movement above
lumbar. Muscle atrophy >>> risk of injury. Psychological
dependence
DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s
Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
04

ASSISTIVE
DEVICES AND
ADAPTIVE AIDS
 ASSISTIVE DEVICES AND ADAPTIVE AIDS
Energy-
efficient
▪ Assistive devices and adaptive aids
ambulation
& hand
function
compensate for limited ROM and pain,
and help promote independence and Maintenance
of proper
Appropriate
adaptive aids
lesser impairment, and disability for posture & clothing

arthritic patients. CONSERVING

ENERGY
▪ RD is most often accompanied by fatigue, Proper orthotics &
assistive devices
so conserving energy to maximize function
Maintenance Proper
is an important part of the arthritic patient’s of ROM &
strength
environment
al design
lifestyle
Rest periods
throughout
the day

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins;
2010.
ASSISTIVE DEVICES AND ADAPTIVE AIDS

Lateral wedge:
for flexible
varus calcaneus

Medial wedge:
for flexible
valgus calcaneus
 prevent overpronation

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010.
 ASSISTIVE DEVICES AND ADAPTIVE AIDS

Increased leverage or
enlarged handles to
decrease effort and
dexterity demands

Broad-handle utensils

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010.
 AMBULATORY AIDS
If joint pain is a problem, secondary to loss of cartilage, effusion, or active synovitis, the painful joint needs to be unloaded.

Body Weight Transmission

An unilateral cane
Forearm or arm cane
opposite the affected
 40% to 50%
side  20% to 25%

✔ Improve balance
✔ Redistribute and extend the weight-
Bilateral crutches  Walker  up to bearing area
up to 80% 100% ✔ Reduce lower limb pain
✔ Provide small propulsive forces
✔ Provide sensory feedback

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s
Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
05

SPECIFIC
MUSCULOSKELETAL
DISORDER
 KNEE OSTEOARTHRITIS
Isotonic quadriceps

ROM exercise proceed to

Prevent ROM loss
Stretching
Knee Osteoarthritis

Isometric 5-10 reps daily,

hold 6 seconds
Muscle weakness esp
quadriceps and hamstring
Isotonic and closed chain
exercise Isometric quadriceps

Knee brace

Orthosis

Lateral wedge shoes

Assistive devices Cane

Isotonic Hamstring

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s Physical
Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
 RHEUMATOID ARTHRITIS

Orthoses Resting splint

Acute stage

Inflammatory joints :
TENS, cold packs
Modalities
Severe spasm : local hot
packs, massage

AROM/AAROM 3x10
reps, 1-2x/day
Exercise
Isometric exercise with
submaximal effort

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s
Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
 RHEUMATOID ARTHRITIS
Splints, foot orthoses, or assistive devices can be
Orthoses prescribed if indicated.

Subacute/chronic stage Modalities Local cold therapy  hot therapy if swelling of the joint
subsides.

Isotonic exercise  added gradually (increases in

repetition and resistance.)

Exercises
If patient condition improves  endurance training,
aerobic exercise, and recreational exercise can be added

Assistive A forearm support crutch or cane  more preferable

devices

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins; 2010. Braddom’s
Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
RHEUMATOID ARTHRITIS

Braddom’s Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
 STENOSING FLEXOR TENOSYNOVITIS (TRIGGER FINGER)

▪ Reduce inflammation, decrease local

pressure, make appropriate worksite
changes
▪ Rest from provocative activities &
immobilization of affected digit for 4-6
weeks using a splint or buddy taping to
an adjacent finger.
▪ Splinting  reduce pressure & tension
on the flexor tendon, maintaining the
MCP joint at 10º of flexion while
Soft splint Custom hand-based splint permitting active IP joint motion.
more functional use ▪ Persistent symptoms >6 weeks: local
steroid injection into synovial sheath
(level of the A-1 pulley)
AAOS Atlas of Orthoses and Assistive Devices,4th ed. Mosby, 2008. pg. 292-3
DEQUERVAIN’S TENOSYNOVITIS

Forearm-based Hand-based
thumb spica thumb spica
splint splint

AAOS Atlas of Orthoses and Assistive Devices,4th ed. Mosby, 2008. pg. 292-3
Braddom’s Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
 RESTRICTED MOTION – NECK AND SHOULDER

Forward Head : Postural Correction Exercise Pendulum exercise: flexibility, increase ROM, reduce pain

Isometric strengthening exercise (Forward, Backward,

Lateral) Finger ladder exercise: increase shoulder flexion & abduction

Braddom’s Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
 RESTRICTED MOTION – BACK

William ▪ Open the intravertebral foramen McKenzie ▪ Reduce discogenic pain by decreasing pressure at
▪ Stretch back extensors, hip flexors, & facets posterior annulus fibrosus
Flexion ▪ Strengthen abdominal & gluteal muscles Extension ▪ Return to normal functioning in ADL
▪
Exercise Mobilize lumbosacral junctions
Exercise ▪ Minimize risk of recurring pain

Braddom’s Physical Medicine & Rehablitation. 5th ed. Philadelphia: Elsevier; 2016.
NECK PAIN – UPPER TRAPEZIUS SPASM

Walker B. The Anatomy of Stretching: Your Illustrated Guide to Flexibility and Injury Rehabilitation.
3nd Ed. Chicester : Lotus Publishing; 2021.
 ANKYLOSING SPONDYLITIS (AS)

a rheumatic and most frequently recorded disease with unknown etiology among seronegative spondyloarthropathies

Education : proper or "functional" posture

before the spine become ankylosed

Gentle manipulations such as massage for

pain modulation
AS
Segmental and global trunk stabilization
and scapular stabilization exercises

Stretch to maintain hip extension and

shoulder flexion

Kisner, Carolyn..Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis Company:
Philadelphia.. 2018.
 ANKYLOSING SPONDYLITIS (AS) - EXERCISES

Trunk-Lumbar Rotation

Pelvic Tilt Exercise

Postural Correction
Bridge Exercise
Single-Double Knee to Chest

Kisner, Carolyn..Therapeutic Exercise Foundation and Techniques. 7th Ed F.A. Davis Company:
Philadelphia.. 2018.
FUNCTIONAL EVALUATION – RHEUMATOID DISEASE

DeLisa’s Physical Medicine & Rehabilitation. 5th ed. USA: Lippincott Williams & Wilkins;
2010.
THANK YOU