13.5 Range-of-Motion, Cardiovascular, Proprioceptive & Breathing Exercise

Range-of-Motion, Cardiovascular, Proprioceptive & Breathing Exercise

1. Completing the Therapeutic Exercise Blueprint

The therapeutic exercise area of the CKT blueprint (4–8% of questions) includes six competencies: stretching (13.1), range-of-motion exercises (3.3.b), strengthening (13.2), cardiovascular exercise (3.3.d), proprioception exercise (3.3.e), and exercise to restore capacity in activities of daily living (3.3.f). The massage techniques area also includes directing the client in diaphragmatic breathing (3.2.p). In BC, CCHPBC's scope explanatory statement describes therapeutic exercise for the purpose of home care as within massage therapy scope, while one-on-one yoga instruction and group exercise services are listed as out of scope, so the focus is on remedial home programs tied to the treatment plan.

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2. Range-of-Motion Exercise

Parameters: slow and controlled, within a pain-free or tolerable range, commonly 10 repetitions once or twice daily. ROM exercise maintains joint mobility and tissue length but does not build strength by itself. It is avoided or limited across unstable fractures, fresh surgical repairs (unless the protocol allows it), and acute inflammation where movement increases pain substantially.

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3. Cardiovascular (Aerobic) Exercise

Canadian Guidelines

Canada's 24-Hour Movement Guidelines for Adults (18–64 and 65+), developed by CSEP, recommend:

• At least 150 minutes per week of moderate-to-vigorous aerobic physical activity.
• Muscle-strengthening activities at least twice a week, plus balance challenges for older adults.
• Several hours of light activity, including standing, daily.
• Limiting sedentary time to 8 hours or less, including no more than 3 hours of recreational screen time, and breaking up long periods of sitting.
• 7 to 9 hours of good-quality sleep for adults aged 18–64 (7 to 8 hours for those 65 and older).

Prescribing Aerobic Activity in Remedial Care

• Screening: CSEP's Get Active Questionnaire helps identify clients who should speak with a qualified professional or physician before becoming more active. Known cardiovascular disease, chest pain, fainting, or uncontrolled blood pressure call for medical guidance first.
• Mode: Low-impact options such as walking, cycling, swimming, or water walking suit most musculoskeletal conditions.
• Intensity monitoring:
  • Talk test: at moderate intensity the client can talk but not sing; at vigorous intensity only a few words.
  • Rating of perceived exertion (RPE): for example, about 5–6 out of 10 for moderate effort.
  • Heart rate reserve (Karvonen method): target heart rate = (maximum heart rate − resting heart rate) × intensity + resting heart rate. Using the rough estimate of maximum heart rate = 220 − age, a 50-year-old with a resting heart rate of 70 has an estimated maximum of 170 and a reserve of 100; at 50% intensity the target is 50 + 70 = 120 beats per minute. Moderate intensity is about 40–59% of heart rate reserve.
  • Clients taking beta-blockers have blunted heart-rate responses, so RPE and the talk test are more reliable than heart-rate targets.
• Progression: Increase duration before intensity, by roughly 10% per week as tolerated.
• Stop signs: Chest pain or pressure, unusual shortness of breath, dizziness, palpitations, or nausea—stop and seek medical care.

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4. Proprioception and Balance Exercise

Proprioceptive training restores joint position sense and neuromuscular control after injury, especially ankle sprains and knee ligament injuries, and reduces fall risk in older adults. Balance training after an ankle sprain lowers the risk of re-spraining.

Progression principles (change one variable at a time):

1. Base of support: feet apart → feet together → tandem stance → single-leg stance.
2. Vision: eyes open → eyes closed.
3. Surface: firm floor → foam pad → wobble or balance board.
4. Task: static holding → arm or leg movements → catching a ball, perturbations, hopping, and sport-specific drills.

Safety comes first: practise beside a counter or in a corner, progress only when the current level is controlled for about 30 seconds, and avoid unstable surfaces for clients with severe neuropathy or high fall risk until they are supervised.

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5. Exercise to Restore Activities of Daily Living

Functional exercise rehearses the movements the client needs: sit-to-stand from a chair (leg strength and transfers), step-ups (stairs), reaching to shelves (shoulder elevation), carrying groceries close to the body (13.4), and floor-to-standing practice for older adults. These link directly to the ADL findings in 6.4 and the SMART goals in 11.1.

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6. Directing Diaphragmatic Breathing

Diaphragmatic breathing reduces sympathetic arousal, eases accessory-muscle overuse (scalenes, sternocleidomastoid, upper trapezius), helps clients with anxiety and pain, and supports lymphatic flow.

Teaching sequence:

1. Position the client supine with knees bent (or semi-Fowler for breathlessness).
2. Place one of the client's hands on the upper chest and the other on the abdomen just below the ribs.
3. Ask for a slow, gentle breath in through the nose, letting the abdominal hand rise while the chest hand stays relatively still.
4. Exhale slowly and fully, ideally longer than the inhalation; clients with COPD may use pursed-lip exhalation.
5. Practise for a few minutes at a comfortable, slow rate, avoiding forced deep breaths that cause dizziness (hyperventilation).
6. Progress to sitting, standing, and use during daily activities or stressful moments.

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7. Clinical Vignette

A 45-year-old client is 3 weeks past a grade II lateral ankle sprain and walks without a limp, but feels "unsteady" on uneven ground. Active ROM is nearly full and pain is minimal. After treatment, the therapist prescribes single-leg stance on the firm floor beside the kitchen counter (3 × 30 seconds, twice daily), progressing to eyes closed and then to a folded pillow once each level feels steady for 30 seconds. Because the client is deconditioned and wants to return to walking for fitness, the therapist also recommends building toward 150 minutes of brisk walking per week, using the talk test to keep the intensity moderate, and records both elements in the home care plan.