Therapeutic Exercise Modalities in Clinical Practice for LE Rehabilitation

Kenneth C Ngwu Jr., SPT

INTRODUCTION

As a former collegiate athlete, I’ve had the pleasure of utilizing kettlebells for improvement of sports performance. I have also utilized them during many CrossFit workouts for maintenance of my overall health and fitness. My experience with kettlebells and observation of their use in PT practice at a previous rotation led to the development of my PICO question: For individuals participating in a highly active occupation, is a LE rehabilitation program with kettlebell training more effective than a traditional LE rehabilitation program without kettlebell training for resumption of prior level of activity? I was able to retrieve plenty of existing evidence regarding kettlebells as an exercise modality in clinical practice. After reviewing the evidence for critical analysis, I learned that kettlebells can serve as an effective adjunct to the rehabilitation of higher level functioning individuals with a lower body dysfunction. Later, I also explored evidence behind the utility of other exercise modalities such as the Total Gym, TRX Suspension System, and Swiss balls in clinical practice.

OVERVIEW

The selection of these modalities was mostly inspired from my previous clinical rotation with Advanced Physical Therapy Solutions (APTS) in Fayetteville, NC. At APTS, I was able to instruct and assist patients in utilizing these exercise modalities for the performance of therapeutic exercise. However, I remember initially not being aware of how some of the exercise modalities could be utilized for patient care. This made the process of selecting the appropriate therapeutic exercise and its associated modality a significant challenge especially for lower level functioning patients. Luckily, the mentorship provided by my CI and the clinical staff at APTS enabled me to overcome this challenge. This experience and recent knowledge of clinical evidence regarding each exercise modality inspired me to create an educational component for the Exercise Prescription class. The purpose of this component was to educate students about the existing clinical evidence and potential utility of kettlebells, Swiss Balls, TRX Suspension System, and the Total Gym as exercise modalities in the rehabilitation of individuals with a lower body dysfunction.

Below, I have briefly described each of the four exercise modalities and their related clinical evidence, which is further described in my CAPSTONE project.

• Swiss Ball (SB) exercises are often utilized in clinical practice as effective methods of lumbar stabilization and core strengthening. Existing evidence has supported its implementation as components into the POC for many patient populations. Many studies have already demonstrated the clinical efficacy of SB exercises for LBP patient populations. Other studies have also demonstrated the therapeutic effects of Swiss ball exercises for improvement of functional mobility and balance.
• TRX Suspension Training is an exercise modality with a single anchor system that supports or loads movements through multiple planes to enable a unique form of functional training.¹ This system allows for a wide range of bodyweight exercises to be appropriately modified and performed for the purposes of rehabilitation.¹ Lately, TRX has become increasingly utilized in clinical practice for closed chain exercise in lower extremity rehabilitation to allow progression from partial to full weight-bearing exercise.¹ Physical therapists have considered this exercise modality as a functional training tool that facilitates proprioceptive core stabilization and enhancement for a variety of patient populations.¹ However, there are only two published clinical studies related to the use of TRX for health and wellness efforts.
• The Total Gym is one of the more popular exercise modalities for functional and bodyweight training in conditioning and rehabilitation.² This exercise modality has been heavily recognized for allowing early partial weight bearing and closed kinetic chain rehabilitation of lower extremity dysfunction in patients receiving physical therapy care.² The Total Gym is considered one of the most effective and safe tools for functional rehabilitation that allows patients to progress safely with measurable results.² Ironically, the Total Gym has only one study related to its use in clinical practice.
• Kettlebells are cast iron weights resembling a cannonball-shaped orb with a handle attached to it.³This design creates an offset center of gravity that allows for its center of mass to extend beyond the gripping hand to facilitate full-body ballistic movements in kettlebell training.³ Strength and conditioning professionals have utilized kettlebell training exercises to improve muscular strength, endurance, power, and cardiorespiratory fitness.^3,4It has also been utilized in many clinical studies for lower extremity rehabilitation, LBP prevention and promotion of health and wellness.

Collectively, each of these four exercise modalities are capable of facilitating many dynamic body movements in therapeutic exercise necessary for functional rehabilitation. These capabilities can often be limited by a physical therapist’s creativity and their knowledge of biomechanics. They can also be significantly limited by a physical therapist’s unawareness of their potential utility in clinical practice. This can be prevented by provision of educational components with learning objectives similar to my CAPSTONE presentation, which are listed below:

• The learner will demonstrate awareness of existing clinical evidence regarding each of the therapeutic exercise modalities.
• The learner will be able to consider the age, lifestyle, and current condition of a patient when identifying what exercise modality is appropriate and safe in their plan of care.
• The learner will become familiar with common low level exercises that can be implemented with use of each of the four exercise modalities.
• The learner will become aware of how certain exercise modalities can facilitate efforts for the conditioning phase of rehabilitation and health and wellness.

PRODUCTS

The purpose of my CAPSTONE was facilitated by illustrating the use of each of the 4 exercise modalities in video clips embedded throughout my PowerPoint presentation, which you can download here. I highlighted some of the evidence behind each of the modalities, which are further described in my evidence table that you can download here.

I was able to present my CAPSTONE earlier this month to an audience of 30 first-year students in their Exercise Prescription class, as well as 2 faculty members. The presentation lead to some good class discussion as students were asked to determine how they could modify an illustrated exercise to be less challenging or more challenging according to a patient’s needs. They discussed how to determine which exercise and its associated modality were the most appropriate for each of the 4 mock patient scenarios provided at the conclusion of the presentation.

I also developed an extensive literature review to critique and analyze existing evidence related to the clinical efficacy of each of the four exercise modalities. You can download my literature review here.

EVALUATION

I administered a pretest and post-test to 30 first year students in attendance  for my presentation. The test results demonstrated significant improvements in the students’ knowledge and awareness of each of the four exercise modalities in clinical practice. I also provided a web survey to the two faculty members in attendance to retrieve feedback on my presentation and its content. You can download the feedback and test results here to view them.

ACKNOWLEDGEMENTS

I would like to give a special thanks to my committee members Amy Cecchini for her valued input from a clinical perspective and Mike Lewek for his guidance in developing my presentation. I would also like to thank Mike Gross, Karen McCullough, my mother and Mijo Cotic for their advisement and encouragement throughout the development of my CAPSTONE research and presentation. Lastly, I would like to say THANK YOU for visiting my CAPSTONE WikiSite. I would love to hear any of your comments or questions, which you can leave below or email to me at kenneth_ngwu@med.unc.edu.

REFERENCES

1.           Bettendorf B. TRX ® Suspension Training ® Bodyweight Exercise: Scientific Foundations and Practical Applications. San Francisco, CA; 2010:1–15.

2.           Our Story | Total Gym Physical Therapy. Available at: http://www.totalgymphysicaltherapy.com/our-team/. Accessed April 1, 2014.

3.           Lake JP, Lauder MA. Mechanical demands of kettlebell swing exercise. J Strength Cond Res. 2012;26(12):3209–16. doi:10.1519/JSC.0b013e3182474280.

4.           Otto WH, Coburn JW, Brown LE, Spiering BA. Effects of weightlifting vs. kettlebell training on vertical jump, strength, and body composition. J Strength Cond Res. 2012;26(5):1199–202. doi:10.1519/JSC.0b013e31824f233e.