Physical Rehabilitation: A Complete Guide

What Is Physical Rehabilitation?

The Core Types of Physical Rehabilitation

1. Physical Therapy (PT) / Physiotherapy

• Therapeutic exercise - isometric, isotonic, isokinetic, aerobic, and resistive training
• Manual therapy - joint mobilization, manipulation, soft tissue massage
• Electrotherapy - TENS (transcutaneous electrical nerve stimulation), neuromuscular electrical stimulation (NMES), ultrasound
• Thermal modalities - heat therapy (hot packs, diathermy), cryotherapy (ice packs)
• Hydrotherapy - aquatic exercises in a therapeutic pool
• Proprioceptive neuromuscular facilitation (PNF) - timed proprioceptive stimuli to improve neuromuscular response
• Gait training and balance retraining
• Postural education and ergonomics

• Orthopedic injuries (fractures, sprains, strains, ligament tears, tendinopathies)
• Post-surgical recovery (joint replacements, spinal surgery, cardiac/thoracic surgery)
• Chronic musculoskeletal pain (back pain, neck pain, arthritis, fibromyalgia)
• Neurological conditions (stroke hemiplegia, Parkinson's disease, multiple sclerosis, cerebral palsy)
• Sports injuries
• Cardiorespiratory conditions
• Pediatric developmental delays
• Balance disorders and fall prevention in the elderly

• Active deep vein thrombosis (DVT) - mobilization may dislodge thrombus
• Unstable fractures or recent surgical repairs not yet able to bear load
• Active infection at or near the treatment site
• Uncontrolled cardiovascular instability (severe arrhythmia, uncontrolled hypertension)
• Open wounds or active inflammatory flare-ups at the treatment area
• Severe osteoporosis with fracture risk (high-intensity resistance contraindicated)
• Thermal modalities are contraindicated over areas of impaired sensation, malignancy, implanted metal devices, or acute inflammation

2. Occupational Therapy (OT)

• Activities of Daily Living (ADL) training: bathing, dressing, feeding, grooming
• Instrumental ADL training: cooking, driving, managing finances, using technology
• Cognitive rehabilitation: memory, attention, problem-solving after brain injury
• Splinting and orthotic fabrication
• Adaptive equipment prescription (grab bars, modified utensils, wheelchairs)
• Home and workplace modification
• Fine motor skill retraining
• Sensory integration therapy (especially in pediatrics)
• Energy conservation techniques for fatigue management

• Stroke recovery (upper limb function, cognitive deficits, ADL dependence)
• Traumatic brain injury (TBI)
• Spinal cord injury
• Arthritis and joint disease limiting hand function
• Post-fracture (especially upper extremity)
• Neurodevelopmental disorders in children (autism, developmental coordination disorder)
• Mental health conditions affecting daily function (depression, schizophrenia)
• Burns and scar management
• Dementia and cognitive decline

• Medical instability preventing safe participation
• Severely uncontrolled psychiatric states that pose risk to staff or patient
• Active substance intoxication
• Severely reduced level of consciousness or coma (limits active participation)
• Acute infections with isolation precautions

3. Speech-Language Therapy (SLT) / Speech Pathology

• Articulation and phonological therapy
• Language therapy for aphasia (Broca's, Wernicke's, global aphasia)
• Voice therapy (vocal hygiene, pitch/volume exercises)
• Fluency therapy for stuttering
• Dysphagia management: diet texture modification, swallowing maneuvers (Mendelsohn, supraglottic swallow), oro-motor exercises
• Augmentative and Alternative Communication (AAC) device training
• Cognitive-communication therapy (after TBI)
• Resonance therapy for cleft palate

• Stroke with aphasia or dysarthria
• TBI with cognitive-communication disorders
• Parkinson's disease (hypophonia, dysphagia)
• Laryngeal cancer post-laryngectomy
• Head and neck cancer (post-radiation dysphagia)
• Cleft palate and craniofacial conditions
• Autism spectrum disorder
• Stuttering and voice disorders
• Neurodegenerative diseases (ALS, MS, Huntington's disease)
• Pediatric feeding and swallowing disorders

• Severe cognitive impairment preventing any participation
• Severe respiratory distress (dysphagia therapy requires controlled breathing)
• Medically unstable patients (defer until stabilized)
• Actively uncooperative or combative patient states

4. Cardiac Rehabilitation

1. Risk factor management
2. Aerobic and resistance exercise training
3. Patient education
4. Psychosocial interventions
5. Dietary counseling

• Typically 36 sessions, delivered 2-3 times/week over 12-18 weeks
• Can be center-based, home-based, or hybrid
• Three phases: Phase I (inpatient, early mobilization), Phase II (outpatient supervised exercise), Phase III (community-based maintenance)

• Following myocardial infarction (MI)
• Following coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI)
• Following valve replacement or repair
• Following cardiac transplantation
• Stable angina pectoris
• Peripheral vascular disease
• Heart failure with reduced ejection fraction (HFrEF)

• Unstable angina not yet stabilized
• Uncontrolled heart failure (decompensated)
• Severe symptomatic aortic stenosis
• Uncontrolled life-threatening arrhythmias
• Active myocarditis or pericarditis
• Recent pulmonary embolism or DVT
• Severe pulmonary hypertension
• Aortic dissection
• Uncontrolled systemic hypertension (resting BP >180/110 mmHg)

5. Pulmonary Rehabilitation

• Aerobic endurance training (walking, cycling)
• Strength/resistance training
• Breathing retraining techniques (pursed-lip breathing, diaphragmatic breathing)
• Airway clearance techniques (chest physiotherapy, oscillatory PEP devices)
• Inspiratory muscle training
• Nutritional counseling
• Psychosocial support
• Self-management education (action plans, inhaler technique)
• Supplemental oxygen therapy during exercise as needed

• Primary indication: COPD (any severity with functional limitation)
• Interstitial lung disease (ILD) including idiopathic pulmonary fibrosis (IPF)
• Pulmonary hypertension
• Asthma (moderate-severe)
• Cystic fibrosis
• Non-cystic fibrosis bronchiectasis
• Lung cancer (pre- and post-operative)
• Obesity hypoventilation syndrome
• Pre- and post-lung transplantation
• Post-COVID-19 respiratory sequelae

• Unstable cardiovascular disease (recent MI, uncontrolled arrhythmia)
• Severe orthopedic conditions preventing exercise participation
• Significant cognitive impairment preventing learning and cooperation
• Active substance abuse interfering with participation
• Severe pulmonary hypertension with high exercise risk
• Active infection with isolation requirements

6. Neurological Rehabilitation

• Constraint-Induced Movement Therapy (CIMT): Forcing use of the paretic limb by constraining the unaffected side; Adams & Victor's Neurology notes benefit through "functional expansion of the cortical motor representation into adjacent undamaged cortical areas."
• Mirror therapy: Creating visual illusion of paretic side moving; Cochrane meta-analysis shows modest motor benefit and reduced pain
• Task-specific training: Repetitive practice of specific functional tasks
• Neurodevelopmental techniques (Bobath concept)
• Robotic-assisted therapy and exoskeletons
• Functional electrical stimulation (FES)
• Treadmill training with body weight support
• Spasticity management (stretching, splinting, baclofen, botulinum toxin)
• Cognitive rehabilitation (attention, memory, executive function)
• Balance training and vestibular rehabilitation

• Passive range of motion exercises should begin within days of stroke completion to prevent contracture, especially at shoulder, elbow, hip, and ankles
• Patients should be mobilized to chair as soon as blood pressure is stable
• "Nearly all hemiplegic patients regain the ability to walk to some extent, usually within a 3-6 month period"
• Greater intensity of PT achieves better outcomes; an additional 30 min/day beyond conventional PT for 5 days/week over 20 weeks shows improved walking and dexterity

• Stroke (ischemic and hemorrhagic)
• Traumatic brain injury (TBI)
• Spinal cord injury (SCI)
• Multiple sclerosis
• Parkinson's disease
• Cerebral palsy
• Guillain-Barre syndrome
• Peripheral neuropathies
• Brain tumors (post-operative)
• Cerebellar ataxia

• Acute phase of neurovascular event where mobilization could be harmful (e.g., expanding hematoma)
• Severe raised intracranial pressure (ICP)
• Unstable spinal fracture (mobilization before stabilization)
• Active seizures or uncontrolled epilepsy
• Severe autonomic instability
• Medical instability (hemodynamic compromise, acute sepsis)

7. Orthopedic Rehabilitation

• Post-surgical rehabilitation protocols (TKA, THA, ACL repair, rotator cuff repair)
• Progressive range of motion exercises
• Strengthening and muscle re-education
• Proprioception and balance retraining
• Joint mobilization and manipulation
• Continuous passive motion (CPM) machines
• Orthotics and prosthetics fitting and training
• Sports-specific return-to-play programs
• Work-hardening programs

• Post-fracture management
• Post-arthroplasty (knee, hip, shoulder replacement)
• Sports injuries (ACL/PCL tears, meniscal repairs, shoulder instability)
• Spinal conditions (disc herniation, spinal stenosis, post-fusion surgery)
• Amputation (stump conditioning, prosthetic training)
• Tendon and ligament repairs
• Chronic osteoarthritis
• Osteoporosis management

• Active infection (osteomyelitis, septic arthritis)
• Unhealed or unstable fractures
• Severe cardiovascular instability
• Severe osteoporosis with imminent fracture risk from exercise
• Tumor/metastasis at the involved site (bone metastases are a specific concern)
• Deep wound or dehiscence preventing mobilization

8. Geriatric Rehabilitation

• Multidisciplinary team approach (physiatrist, PT, OT, dietitian, social worker, pharmacist)
• Emphasis on fall prevention programs (balance training, strength training, home modification)
• Management of osteoporosis-related fractures
• Post-acute care after hip fracture, joint replacement, or prolonged hospitalization
• Cognitive rehabilitation for mild cognitive impairment and early dementia
• Management of polypharmacy contributing to functional decline
• Delirium prevention and management

• Hip fracture (primary indication - early mobilization saves lives)
• Deconditioning after prolonged hospitalization
• Post-stroke in elderly
• Fall prevention in frail elderly
• Dementia with functional decline
• Post-cardiac or post-pulmonary events in older patients

• Severe cardiac or orthostatic instability
• Fractures requiring protected weight bearing
• End-stage dementia (limited capacity for participation)

9. Pediatric Rehabilitation

• Cerebral palsy
• Spina bifida (myelomeningocele)
• Down syndrome
• Brachial plexus birth palsy
• Developmental coordination disorder (DCD)
• Autism spectrum disorder
• Childhood cancer survivors
• Juvenile arthritis
• Acquired brain or spinal cord injury

• Sensory integration therapy
• Play-based therapeutic activities
• Hippotherapy (horse-assisted therapy)
• Constraint-Induced Movement Therapy for hemiplegic CP
• Adaptive sports and assistive technology
• Parent/caregiver training

10. Cancer Rehabilitation

• Post-mastectomy lymphedema management
• Post-surgical (lung, bowel, head-and-neck) deconditioning
• Chemotherapy-induced peripheral neuropathy
• Radiation fibrosis
• Cancer-related fatigue
• Pre-surgical optimization (prehabilitation)

• Thermal modalities and electrotherapy are generally contraindicated over areas of active tumor due to risk of promoting metastatic spread
• Electrotherapy contraindicated over areas with compromised lymphatic drainage
• High-impact exercise contraindicated in bone metastases (fracture risk)
• Aquatic therapy avoided with open wounds or port-a-cath sites

Summary Table: Indications & Contraindications

General Principles of Physical Rehabilitation

1. Multidisciplinary approach: Most rehabilitation programs combine PT, OT, SLT, nursing, social work, psychology, and medicine into an integrated team.
2. Goal-directed care: All rehabilitation is built around specific, measurable, achievable, realistic, and time-bound (SMART) goals negotiated with the patient.
3. Early initiation: Early mobilization consistently produces better outcomes. In stroke, ICU patients, post-cardiac surgery, and post-fracture management, early intervention prevents complications like contractures, DVT, pressure ulcers, and deconditioning.
4. Neuroplasticity: The injured nervous system retains capacity for reorganization. Repetitive, task-specific practice drives cortical remapping and functional recovery.
5. Restorative vs. Compensatory approach:
   • Restorative: Aims to improve actual impairments (e.g., strengthening a weak limb)
   • Compensatory: Adapts tasks or environment when full restoration is not possible (e.g., one-handed dressing techniques)
   • Preventive: Minimizes potential complications and secondary impairments
6. Dose-response relationship: Higher intensity and greater frequency of therapy generally produce better functional outcomes - demonstrated most clearly in stroke rehabilitation.

• Fuster and Hurst's The Heart, 15th Edition - Cardiac Rehabilitation chapter
• Murray & Nadel's Textbook of Respiratory Medicine - Pulmonary Rehabilitation chapter
• Adams and Victor's Principles of Neurology, 12th Edition - Physical Therapy and Rehabilitation
• Firestein & Kelley's Textbook of Rheumatology - Occupational and Physical Intervention Categories

Document Structure

Key clinical data included:

• Phase I: Day-by-day exercise progression table (Days 1-7)
• Phase II: Full FITT progression table (Weeks 1-3, 4-8, 9-12), Karvonen formula for training HR, resistance training protocol, HIIT evidence
• Phase III & IV: Weekly volume targets, AHA secondary prevention exercise targets
• Safety stats: 1 cardiac arrest per 116,906 patient-exercise hours (AHA data)
• Mortality data: 13% reduction per 1-MET improvement; 21-34% lower mortality in supervised CR participants

Document Overview

Question Distribution

What the Questions Cover

• Clinical contraindications and indications from ACC/AHA 2018
• Day-by-day Phase I exercise protocol with specific HR/BP/SpO2/MET parameters
• Karvonen formula calculations (including a worked example at Q91)
• HIIT criteria, HIIT protocols, and evidence (Ross, Martin, De Schutter studies)
• Risk stratification (Low/Moderate/High) and monitoring requirements
• Mortality statistics (exact numbers from AHA 2007 data)
• Special population adjustments (HFrEF, post-CABG sternal precautions, elderly, women)
• Nutritional targets (Na, saturated fat, LDL, BP, HbA1c goals)
• Psychosocial screening tools (PHQ-9, GAD-7)
• Landmark trials (HF-ACTION, De Schutter, Martin et al.)