Table 2.
Sample of GEAR's exercise and rehabilitation exercises.
| Aerobic exercise | ||
|---|---|---|
| Given its high functional application, every patient is encouraged to participate in daily walking. If walking over ground is too challenging, patients can try the following: • Walk on a treadmill (with upper extremity support) • Walk in water (hydrotherapy) Other exercises include: • Upright, recumbent or semi-recumbent exercise bike • Elliptical trainer • Swimming • Rowing For patients with low physical activity levels, low activity tolerance, or low upright tolerance; patients can perform any of the following seated activities: *Note that seated activities should be repetitive/rhythmical in fashion, performed for at least 10 min, with an RPE of 3–6 (28) ° Marching ° Toe and heel tapping ° Reaching arms and legs to the side ° Arm ergometer ° Seated stepper/peddler *High impact activities such as running, stair climbing, and those with stop and go actions are not recommended if limited by lower body arthritis (28) |
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| Neuromuscular exercise | Resistance exercise | |
| Upper extremity | ||
| Neck | Deep Neck Flexor Activation with tactile and verbal cueing • Supine, blood pressure cuff/towel placed under the neck for feedback • Isometric holds avoiding accessory muscle use or breath holding Diaphragmatic Breathing Supine, Seated and Standing postural training awareness • Anterior, posterior and neutral pelvic tilt positions • Equal weight bearing through ischial tuberosities (ITs) in sitting (avoid sacral sitting) • Equal weight bearing through heel and ball of foot in standing • Thoracic extension If applicable, initiate Scapular Stabilizer Activation (see “Shoulder” Neuromuscular Exercises) If applicable, initiate Gaze Stability and Head-eye Coordination Exercises (as appropriate) Incorporate functional activities as able • Looking and walking |
Deep Neck Flexor Activation with: • Supine/seated/standing ° Resisted cervical spine isometrics (with/without band/ball) ° Lower c-spine flexion with cranio-cervical flexion • Plank/modified plank ° Resisted c-spine lateral flexion isometrics ° Lower c-spine extension to neutral Scapular Stabilization Exercises as appropriate (see Shoulder Exercises) Core Exercises as appropriate (see Low Back Exercises) |
| Upper/Mid back/Ribs | Start with “Neck Neuromuscular Exercise” and Costal Breathing Re-education Diaphragmatic Breathing Supine, seated and standing posture awareness Rotation/Dissociation Exercise • Segmental rolling in supine • Thoracolumbar control in 4-point kneeling |
Initiate Neck and Low Back Exercises (as appropriate) *Note if patient demonstrates rib flaring or excessive t-spine extension, encourage upper abdominal activation, control and posture • Bed/Wall Angel Exercise • A, W, T, Y, I Formation Exercices Introduce Additional Scapular Stabilization Exercises (see Shoulder Exercises) Seated/Standing Trunk Rotation • Uniplanar or multiplanar (proprioceptive neuromuscular facilitation pattern) • With/without resistance band/ball |
| Shoulder | Start with “Neck Neuromuscular Exercise” Scapular Stabilizer Activation with tactile and verbal cueing • Identification of “Scapular Setting” position (retracted and depressed) • Serratus Anterior Activation |
Scapular Stabilizer Activation with: • A, W, T, Y, I Exercices • Floor/Wall Angel Exercise • PNF Pattern Exercises with resistance band or pulleys – supine, seated, standing |
| • Side lying, supine or kneeling/plank positions as appropriate • Rotator Cuff Activation • Side lying against resistance • Trapezius, rhomboids, teres major, latissimus dorsi activation Remind patient of Supine, Seated and Standing postural training awareness |
•Scapular Protraction/Retraction ° Prone on elbows ° Serratus punch (band or free weight) ° Push-ups (wall, knees, full) ° High/Low/Bent over row with free weights • Rotator Cuff Exercises ° Isometric external rotation walk-outs ° Isotonic external rotation at 0 degrees and 90 degrees abduction +/- resistance band • Forward/Lateral raise to 90 degrees • Functional exercises as appropriate: ° Lifting, reaching overhead, ergonomics Introduce Neck and Shoulder Exercises as appropriate |
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| Elbow | Start with Neck Neuromuscular Exercises and/or Shoulder Neuromuscular Exercises if appropriate Triceps Activation: • Identification of “neutral” elbow position (avoiding hyperextension or valgus stresses) ° Wall push up or wall high plank ° Backward propped sitting position (no vision) • Teach self-facilitation with tapping/towel if appropriate |
Before performing elbow specific resistance exercises, ensure the patient has adequate neck and shoulder postural control and strength. Elbow Flexion/Extension: •Isometrics at different ranges • Isotonics with resistance band or dumbbell • Functional exercises as able: ° Triceps dip in chair or on bench ° Push up variations • Task specific exercises maintaining alignment: ° Lifting a bag, pushing/pulling a door, getting up from a chair etc. Elbow Pronation/Supination isometrics or isotonics with resistance band or dumbbell (if applicable) Wrist/Grip Activities if appropriate (see Wrist/Hands Exercises) |
| Wrist/Hands | Start with Neck, Shoulder and Elbow Neuromuscular Exercises where appropriate Determine the following: • Neutral Positions and avoiding hyperextension of: IP, MCP and radiocarpal/ulnocarpal positions. • Activation of: ° Lumbricals: “L Position” ° Finger Flexors/Extensors Introduce minimal weight bearing wrist extension maintaining alignment and activation • Weight bearing on a table with forward and backward weight shifting |
*Ensure the patient has adequate neck, shoulder and elbow postural control and strength. If proximal control is impaired, have the patient in more supported when performing hand specific training activities. Wrist Flexion/Extension and Radial/Ulnar Deviation • Isometrics, concentrics, eccentrics with resistance band or free weight • Clockwise and counterclockwise towel wringing • Radial/Ulnar Deviation with a hammer/dumbbell pronation/supination holding onto a hammer/dumbbell Weight bearing wrist extension ° Against a ball on the wall, alphabets, circles ° 4-point weight shifts Grip Strengthening with Putty or Elastics Functional Exercises • Farmer carries • Cooking—transferring plates, cups, chopping/cutting • Typing and pushing buttons |
| Lower extremity | ||
| Low Back | Core Activation with tactile and verbal cueing • Identify full range of motion by cueing anterior and posterior pelvic tilts • Identify neutral spine position • Transversus Abdominus activation with palpation medial to iliac crests • Practice grading TA activation—i.e., 100% and 50% of Maximum Voluntary Contraction determined. TA Activation with diaphragmatic breathing TA Activation with heel slides, fall outs, heel taps etc. |
Transversus Abdominus Core Activation with: • Positional holds (Dead Bug/Table Top Position) • Dead Bug with arm/leg movements • Bird Dog (4-point position) with arm/leg movements • Seated Pelvic Clock • High/low planks, side planks, leg lifts Supine/Seated/Standing Trunk Rotation (see Upper/Mid Back Exercises) |
| Hips | Start with “Low Back” Neuromuscular exercises. • Gluteal setting in supine or crook lying position • Supine marching, fall outs, adductor squeezes with ball • Partial sit-to-stand from perched sitting position (high surface with tap) encouraging proper alignment and muscular patterning |
Transversus Abdominus Core Activation with: • Hip Abduction (double crook or side lying +/- resistance band) • Glute Bridge • Hamstring Curl with exercise ball • Partial Sit-to-Stand from perched sitting position (high surface with tap) |
| Functional Exercises • Full Sit-to-Stand/Squat +/- hover • Squatting to pick objects off the floor |
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| Knees | Depending on posture, may be encouraged to start with “Low Back” Neuromuscular exercises. Isometric Quadriceps Activation • Place a rolled towel behind the knee in a supine or long sitting position for feedback • Teach self-facilitation/stimulation with tapping or a towel *Evaluate quadriceps activation, evaluate patellar mobility with activation Quads Over Roll +/– holds Straight Leg Raise +/– holds Functional Exercises • Full Sit-to-Stand/Squat/Hover • Stairs negotiation practice • Gait re-training exercises ° Forward/backward walking Side stepping (+/– resistance band) |
Transversus Abdominus Core Activation with: • Hamstring Curl on therapy ball • Partial Sit-to-Stand/Squat (see above) • Step Up with Tap Back (forward/lateral) • Sliding Lunges (backward and lateral) |
| Ankles/Feet | Foot Intrinsic Activation (“Short Foot” Exercise) • Start barefoot, in sitting (minimal WB position) • “Lift your toes off the ground to raise the arch of your foot. Now gently lower your toes, maintaining the arch of your foot” Progress length of holds, then to bilateral stance, then unilateral stance Functional Exercises • Tandem and Single Leg Stance practice • Gait re-training exercises (see above) • Heel/Toe/Tandem Walking • Dual tasking (i.e., walking and picking up an item off the floor) |
Dorsiflexion/Plantar Flexion/Inversion/Eversion • Resisted isometrics (against ball/wall/resistance band) • Isotonics through range (+/– resistance band) Foot Intrinsic Activation with: • Standing on a compromised surface (foam, pillow) • Barefoot Heel Raises |
*
Please note that exercises listed in the table above serve as a general guideline/framework for exercises provided to the patient and are dependent on which joint(s) the patient/clinician determine are problematic. This is not an inclusive list and are subject to changes and/or modifications.