Perturbation training with a roller board and platform is generally initiated first because this technique provides a more stable base of support. With this technique, the patient stands with one foot on the roller board and the other foot on the platform. The therapist asks the patient to stand with the knee flexed and to place equal weight on each foot during the training. During roller board/platform exercises, the patient is instructed to maintain the roller board in a steady position once the therapist starts moving it. While the therapist provides destabilizing force to the roller board, the patient is encouraged to develop muscle force that counteracts the destabilizing force. Patients are discouraged from overcoming the applied force and from co-contracting the thigh and leg muscles to maintain the roller board in one place. The therapist observes the patient’s thigh and leg muscles to ensure that the selective muscle contractions occur during training. Clinicians use their clinical reasoning skills to make decisions concerning the progression in difficulty throughout the perturbation training. The progression is guided by the patient’s tolerance to the activity and the presence of adverse responses, such as muscle soreness and joint effusion (Table 2).
To provide a more unstable surface, the stationary platform may be removed. During the roller-board-only perturbation training, the patient stands with single-limb support on the injured limb and the therapist moves the roller board in multiple directions to disturb the patient’s standing balance. The therapist moves the board in a random pattern and at different magnitudes according to the patient’s responses, with small displacement amplitudes for patients with poor balance responses and large amplitudes for patients demonstrating a minimal loss of balance. The therapist instructs the patient on the roller board to maintain his or her balance. The final technique is tilt board training. During the first three training sessions, the patient stands on a tilt board and the therapist applies anterior-posterior and medial-lateral oriented perturbation stimuli at random to challenge the patient’s balance. After the third training session, anterior-posterior perturbation stimuli are replaced with diagonal stimuli by moving the tilt board into a diagonal position. During tilt board exercises, the therapist instructs the patient to maintain balance during each of the destabilizing stimuli.
Table 2: Perturbation Training Program and Progression Guidelines Number of Sets/ Duration Perturbation Movement
Setup
Roller board/ stationary platform
• 2-3 sets • Each set for 1 minute
Begin with anterior-posterior and medial- lateral movements, and then progress to diagonal and rotation movements.
Patient stands with one foot on the roller board and the other foot on the platform. Patient is instructed to maintain the roller board in a steady position while the therapist moves the roller board. Begin with two-legged support, progressing to single-legged support on the injured limb. Begin with two-legged support, progressing to single-legged support on the injured limb.
Roller board
• 2-3 sets • Each set for 1 minute • 2-3 sets • Each set for 1 minute
Begin with anterior-posterior and medial- lateral movements, and then progress to diagonal and rotation movements. Begin with anterior-posterior and medial- lateral movements. After the third session, anterior-posterior movements are replaced by diagonal movements.
Tilt board
Instructions 1. The therapist moves the board in a block or random pattern and at different magnitudes and speeds according to the patient’s responses. 2. The patient is instructed to maintain his or her balance. 3. During sessions 1 through 4, unidirectional (anterior-posterior and medial-lateral) perturbation stimuli are provided with verbal cues about the movement directions at small amplitude and low speed. 4. During sessions 5 through 7, multidirectional (anterior-posterior, medial-lateral, diagonal, and rotational) perturbation stimuli are provided randomly at medium amplitude and moderate speed. 5. During sessions 8 through 10, multidirectional (anterior-posterior, medial-lateral, diagonal, and rotational) perturbation stimuli are provided randomly at large amplitude and high speed. In addition, activity-specific tasks should be added to the training sessions. Note. Reprinted with permission. ©2013, Zakariya Nawasreh. Muscle strengthening
2-minute rest periods between sets at a moderate velocity (Kraemer et al., 2002). Resistance progression follows a “+2 principle,” which dictates that if the patient is able to perform an extra two repetitions above the target repetition, then the load will be increased in the next training session (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010). For patients who fail to restore quadriceps strength to the injured limb within 80% of the uninjured limb, strength training may be augmented with neuromuscular electrical stimulation (NMES) training (Fitzgerald, Axe, & Snyder-Mackler, 2000c; Snyder-Mackler et al., 1995). The therapist must consider the patient’s sport and occupational needs and individualize strengthening programs for each patient accordingly. Additionally, patients are encouraged to start a fitness strengthening program once they finish their rehabilitation program. The aims of the fitness strengthening program are to maintain muscular strength and to minimize quadriceps strength asymmetry between limbs.
Patients receive a progressive exercise program to restore muscle strength that is required for participation in high- level activities (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010). The goal of the strengthening program is to maximize the quadriceps force production by using high-intensity and low-repetition principles. Strengthening programs should include single-limb exercise for the injured limb, including knee extension, knee flexion (leg curl), and leg press exercises. Patients may also perform single-limb squats, two-limb support squats with weights, and lateral and forward step-downs using different step heights. The American College of Sports Medicine (ACSM) guidelines for the resistance training progression to induce muscle hypertrophy in healthy individuals recommend that loads corresponding to 1 to 12 repetition maximums (RM) be used (with emphasis on the 6 to 12 RM zone) in a periodized fashion using 1- to
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