Using the Thera-Ciser
The Reeducation part of Neuromuscular ReeducationTM may well be the most critical in terms of rehabilitation. You might be the best practitioner in your area, but if you don’t get a patient/client doing this work and being personally accountable for their complete recovery then it will only be a partial “fix” and they will wind up back in your office or somewhere else blaming you for their failure to be brought back to pre-injury status.
Although all exercise programs have their particular area of application, some forms are more often indicated and advantageous than others. Range of motion and isometric exercises are easy to perform, but self-limiting. They provide little motivation, as well as no way to measure improvement. Free weights do not promote patient compliance because they are either not available to the patient, too difficult to change and maneuver, or perhaps dangerous if not properly supervised. As stated earlier, exercise machines are often not available to the patient. Because of the advantage inherent with fast contractile exercises and the uniqueness of such, a prescription should include this type of exercise. One such system, which has proven to be successful both in the area of enhancing patient compliance and of producing good clinical results, is the Thera-Ciser Therapeutic Exercise System which is a unique combination of a versatile, simple-to-use Thera-Ciser and a series of bio-mechanical exercises (Figure 48).
Thera-Ciser exercises are arranged by body joints (e.g., shoulder, knee, ankle, etc.). Therefore, they can be followed in their entirety for total body conditioning, or only for selected joint rehabilitation. The Thera-Ciser Therapeutic Exercise System is not only challenging to the athlete but is compatible for any patient, whether young or old. In addition, through the use of the Thera-Ciser, the vast benefits of isokinetic exercise can be realized without the tremendous costs of expensive isokinetic Cybex machines which cost as much as $30,000.
Thera-Ciser Therapeutic Exercise System
The Thera-Ciser is a biomechanical isokinetic system of exercise for neuro-musculoskeletal conditions (Figure 49). It is comprised of exercise tubing with wrist and thigh Velcro adjustable straps and a retainer that attaches into the hinge side of a door (Figure 50). The patient can be instructed within minutes and then at home perform the prescribed exercises.
The wide range of application of the Thera-Ciser Therapeutic Exercise System is due in great part to the exercise tubing utilized. This permits movements throughout the joint’s total range of motion or only through a selected portion of that range. A wide variability of speeds can be achieved, from a very fast motion to a very slow sustained contraction. The resistance provided by the tubing can easily be altered from light to very heavy. Thus, you can understand how it can find rady application to any age or problem.
Another benefit of the Thera-Ciser Therapeutic Exercise System is its accompanying booklet. It is only 16 pages, with color motion photographs of each exercise and a simple description captioned below. This in itself will encourage many patients to make use of the exercises at home.
In addition, the booklet describes four phases of therapeutic exercise, allowing the doctor to easily and quickly identify the starting point for each patient. The patient can easily follow the instructions for each phase. This aspect of the booklet promotes compliance on the part of the doctor by reducing his instruction time to a minimum without jeopardizing the results of the exercise program. The phases are outlined below:
Phase 1 slow paced, short-range sessions will include benefits to the circulatory system, improving the venous and lympathic drainage, thus increasing the muscular pump and ridding the area of excess fluid. The connective tissue starts to conform to Davis’ Law as the fibroblasts align to tissue stress. Adhesions are less likely to form and those that do form will produce a small but flexible scar (Figure 51). The patient attaches the retainer to the door as the photograph and caption describe. The slack in the tubing is taken up and then the patient performs the exercise with small movements against minimal resistance.
Phase 2, because of the fast pace movement, will facilitate the collagen healing as well as facilitate the neurological pathway resulting in muscular tonus. Joint integrity starts to improve because of the increase in joint lubrication. Along with nourishing the articular cartilage, we prevent further adhesions because of the quick movement. This integrity of the joint forms the basis for further strengthening and endurance training (Figure 52).
Davies states that the short-range exercise does in fact facilitate the healing by Davis’ Law while not stressing the healing site (Figure 53). This Phase 2 is a very important portion of the Thera-Ciser program.
Initially, in an orthopedic injury there are some fundamental neurological components in force that are manifest by muscular weakness, and loss of joint integrity and stability. Second, in every trauma there is one paramount law of the nervous system that dominates. It is the Law of Facilitation. Briefly stated, see above, Figure 54.
In other words, the nervous system keeps a record of past history of the organism. An injury or joint requiring rehabilitation will demonstrate facilitated pathways that are viciously cyclic and are being manifest by muscle spasm, ischemia, hypoxia, pain, muscle weakness, and joint instability. These facilitated pathways must be resolved in order to obtain any degree of permanency in a rehabilitation program. If not, it is common for the patient to receive some relief initially, particularly after the adjustment; but returns to the office stating that he felt better for a while but the pain and problem returned.
The technique utilized is an active method of attempting to facilitate the normal neurological pathway that produces a muscle contraction. This procedure utilizes the exercise tubing to assist the exercise motion. There should be no pain occurring during the exercise regime. The fluctuation of impulse patterns from the CNS to the peripheral muscle and motoneuron is controlled by the speed of muscle contraction. Re-education of the neurological pathway of the involved muscle requires a quick contraction to the point of “neurological fatigue”. Due to the Law of Facilitation, a neurological impulse will take the same course on each successive occasion; and each time it traverses this path, the resistance will be less. Thus, we re-educate the pathway of muscle contraction.
This technique involves the patient attaching one end of the exercise tubing to a fixed position while the other end is grasped by the patient. The patient is then taught to stand far enough away so that the tubing is taut and not loose. The muscle is then taken through its concentric and eccentric contractions. The muscle is contracted at a short mid-range position as rapidly as possible to the point of complete fatigue. It must be emphasized to the patient that the technique is a very short contraction during which there is to be no pain. It would be helpful to discuss the concepts of green and red zones with the patient at this time: explain to the patient that where he or she experiences pain in the range of motion is thought of as the “red zone”, and that the patient is not to perform muscle contraction in this red zone. However, the contractions should be performed in the “green zones”, which are the pain-free areas on either side of the painful red zone. The clinician should generally instruct the patient with contractions beginning at the mid-range position of muscle motion. After this has been mastered the short contraction can be attempted at each end of the muscle range. By dividing the full range of muscle contraction into thirds, the patient initially exercises the muscle at its mid-range position, followed by contractions at each end. The concept of “overflow” should also be explained to the patient at this time: as the green zones are exercised and strengthened, the benefits of neurological re-education and strength development “overflow” into the painful red zone, and the area of pain gradually diminishes in degree of range. In review, in teaching this technique, the clinician must emphasize the following:
- Contraction at a very short range
- No pain during the contraction
- Contract the muscle as rapidly as possible
- Continue to the point of complete fatigue
This neurological law is important to understand and has significant implications. As the patient performs the Phase 2 exercise, the various neuro-logical pathways are facilitated resulting in “tonus”. Thus, as the patient performs the daily living activities of work, home, sports, etc., the neuro-muscular system is coordinated. This can be demonstrated by performing before and after manual muscle testing of the involved exercise motion. It will be found commonly that prior to the Phase 2 exercise upon manual muscle testing the involved muscles providing the exercise motion will respond in abnormal “tonus”, whereas immediately after the Phase 2 exercise the manual muscle test reveals a “normal tonus”.
Knapik has demonstrated when “tonus” is evaluated by manual muscle testing there is a 10-15 degree overflow on each side of the tested position which would apply to the results obtained. For example, if one were to completely assess shoulder flexion from 0 degrees to 180 degrees, the specific positions to perform manual muscle testing would have to be at 0, 30, 60, 90, 120, 150 and 180 degrees. This would evaluate the neurologic tonus throughout the range of motion via manual muscle testing. It cannot be assumed a range of motion is in normal tonus by testing only at one point in the plane of motion. Manual muscle testing provides the clinician with neurological “tonus” information. The Phase 2 exercise becomes the exercise to normalize every neuro-muscular position through an entire range of motion.
Larson states that these short-range exercises facilitate lubrication and fluid dynamics. Davies again reports that the short-range movement disperses the synovial fluid, helps nourish the cartilage, helps prevent its deterioration, prevents further adhesions by the quick movement, and prepares the joint for the demands of further exercise and rehabilitation (Figure 55). Cyriax points out that transverse friction massage can be applied with no results unless followed up with short-range movements. In other words, by simply massaging, the adhesions do not go away but will return without the short-range exercise (Figure 56).
Neurological Re-Education Prior to Strength Development
Moritani & DeVries indicate that this fast pace exercise plays a major role in strength development in the early stages. In other words, the first four to six weeks are primarily neurological preparation training followed by the morphological results (Figure 57).
Phase 3 beings the slow pace, full range exercise wherein we start to duplicate functional movements. Here we start to increase the strength and endurance capabilities of the particular joint (Figure 58).
Muscular strength is described functionally as the greatest peak tension a muscle group can generate dynamically during one contraction. Training the muscle for strength involves overloading the muscle through work-induced hypertrophy and hyperplasia. Studies conducted in animals demonstrate an increase in protein synthesis after only eight hours following an increase in muscle load. Physiologically, the increase in muscle size, which follows exercise is the manifestation of either an increase in the absolute size of the muscle fibers or, as recent observations in animals suggest, a result of an increase in the total amount of muscle fibers (hyperplasis) via a mechanism of muscle fiber splitting. In rat studies muscle inflammation was noted in response to exercise during early enlargement of skeletal muscle. Thus, there appears to be an early (within one hour) and later enlargement response (after eight hours) to increases in muscle load. A muscle may be overloaded by altering the amount of repetitions or the amount of resistance.
By stretching the Thera-Ciser in Phase 3 or Phase 4, the patient overloads the muscle by increasing the resistance and increases in strength are realized. Likewise, the velocity of limb movement may be held constant while increasing the number of repetitions. During the Thera-Ciser Phase 3 or Phase 4, the muscle can also be overloaded by increasing the intensity of muscular work by the addition of more repetitions.
This principal of strength is a physiological law attempting to accomplish a greater amount of peak tension in the involved muscle group. This is accomplished by contracting the involved muscle on an every-other-day regime to the point of complete peripheral fatigue. The muscle group being contracted must be totally fatigued. This point of fatigue is the enlargement process, involving muscular hypertrophy and hyperplasia. It is essential in strength training that the involved muscle not be contracted on consecutive days, as this will simply deteriorate muscle tissue instead of enlarging and strengthening.
Due to large amounts of muscle atrophy in some particular injuries there occurs a significant loss in muscle endurance. Thus, our final phase of rehabilitation would involve a period of fast contractile strength and endurance techniques (Figure 59). Thus, Phase 4 is the final phase and provides the full functional capabilities of strength, endurance and joint stability needed for daily living.
Muscle endurance involves the ability of the muscle to sustain continuous work at a moderate intensity. Endurance training involves the muscle contracting at a limb speed of approximately 50% intensity through full range motions until both neurological and peripheral fatigue occur. Due to traumatic injury, measurable endurance is lost. Studies measuring increases in muscular endurance also demonstrate strength increases up to 20%. Thus, endurance training can normally begin prior to the point of optimal muscle strength. Three sets to the point of fatigue will accomplish measurable endurance increases within the involved muscle over a period of four-eight weeks.
The general rule to apply prior to advancing to a higher phase of exercise is the ability of the patient to perform that phase without any pain. The patient generally spends two weeks per phase and if they do spend more than one week per phase, it is recommended that an every-other-day schedule be followed.
On the back page of every Thera-Ciser booklet is a progress chart; this chart is for the use of both the doctor and patient in evaluating the patient’s progress. The patient should be instructed to bring the progress chart along with every visit to the doctor’s office for his evaluation.
It is recommended that at the completion of each session the patient perform routinely an ice massage for 10-15 minutes to reduce any joint irritation which might be caused by the prescribed movement (Figure 60).
How Much–How Long to Exercise
A progress chart is provided on the back page of the Thera-Ciser booklet for the patient and chiropractor to assist progress. The patient generally spends two weeks per phase. It is generally suggested that the patient be categorized as a typical orthopedic or athletic case. The following suggestions are thus provided as to how long the patient should exercise in each phase.
The following guidelines are generally followed in difficult cases of rehabilitation. Some steps can be omitted if the patient already has optimum stability in that category.
- Linear Stability Prior to Rotational
All muscles whose primary responsibility is to provide linear integrity must reach optimum levels before muscles providing rotational control.
- Short Arc Movements Prior to Full Range of Motion
Initial exercise regimes must be selected that only minimally provide motion of the involved joint. After these areas have become stable, muscles providing greater motion at the joint are selected.
- Pain-Free Motion of Exercise
An exercise regime resulting in joint pain will aggravate the condition and inhibit strength gains.
- Stabilize Major Muscles Prior to Unstable
Strong areas are re-emphasized prior to slowly working toward weak areas. This provides the necessary “foundation” upon which the injured groups can build.
- Bilateral Exercise
The uninvolved extremity is exercised prior to the involved, to take advantage of the cross-education afforded.
- Combine and Exercise All Muscle Groups Providing Similar Function
Rehabilitation follows muscles providing similar action and function. Therefore all muscles providing similar stability should be optimized together. (For example, all muscles providing for function of Internal Rotation).
- (Option) Optimize Tone/Strength in One Muscle Before Advancing
In post-surgical and acute conditions optimal tone and strength must be achieved one muscle at a time.
As you can see, the Thera-Ciser Therapeutic Exercise System has been designed with both the health care professional and the patient in mind. With proper use of this system, some of the following results may be expected.
- Thera-Ciser produces beneficial contractions resulting in significant increases in both muscular strength and size.
- Through training, the time for a muscle to produce a maximal contraction will be significantly reduced, resulting in an increase in the velocity of muscular contraction.
- Through training the muscle will be able to sustain itself under endurance trials, resulting in an enhancement of the involved joint’s endurance.
- When a muscle is unable to produce an effective contraction as a result of disuse or incorrect use, the Thera-Ciser may be used to re-educate the proper use of the affected muscle group. The technique can be done in a manner to allow duplication of the proper muscle movement. This application may aid in reduction of habitual and unwanted substitute movements.
- Thera-Ciser reduces the effect of muscle atrophy and thus provides for facilitation of muscle contraction.
- Pain relief can be dramatic and appear rapidly.
- Stimulating muscles to work produces vasodilation, thus bringing more healing products to the injured area. Healing time in injured soft tissue is thus reduced.
- Thera-Ciser increases the muscle pump action to help rid an injured area of excess fluid build-up due to the patient’s reflex muscle inhibitions.
- By maintaining movement of tissues in the area of an inflammatory reaction, there will be a decrease in the amount of adhesions which will formed. In the case of pre-existing adhesions, Thera-Ciser can help loosen and stretch the contracting scar tissue, thus making for more efficient and pain-free range of motion.
A complete description of treatment and indicated exercises are contained in Clinical Chiropractic Biomechanics and Clinical Chiropractic Orthopedics for all of the various complaints entering the chiropractor’s office.
References:Thera-Ciser Professional Manual copyright 1986
Education Division, Foot Levelers, Inc, 518 Pocahontas Ave. N.E., PO BOX 12611, Roanoke, VA 24027-2611
Phone: 800-553-4860 Website: http://www.footlevelers.com/products/rehab-tools/theraciser