Manual resistance exercise is a form of active resistive exercise in which the resistance force is applied by the therapist to either a dynamic or a static muscular contraction.

• When joint motion is permissible, resistance is usually applied throughout the available ROM as the muscle contracts and shortens or lengthens under tension.

• Exercise is carried out in the anatomical planes of motion, in diagonal patterns associated with proprioceptive neuromuscular facilitation (PNF) techniques, or in combined patterns of movement that simulate functional activities.

• A specific muscle may also be strengthened by resisting the action of that muscle, as described in manual muscle-testing procedures.

• In rehabilitation programs, manual resistance exercise, which may be preceded by active-assisted and active exercise, is part of the continuum of active exercises available to a therapist for the improvement or restoration of muscular strength and endurance.

Advantages

• Most effective during the early stages of rehabilitation when muscles are weak (4/5 or less).

• Effective form of exercise for transition from assisted to mechanically resisted movements.

• More finely graded resistance than mechanical resistance.

• Resistance is adjusted throughout the ROM as the therapist responds to the patient’s efforts or a painful arc.

• Muscle works maximally at all portions of the ROM.

• The range of joint movement can be carefully controlled by the therapist to protect healing tissues or to prevent movement into an unstable portion of the range.

• Useful for dynamic or static strengthening.

• Direct manual stabilization prevents substitute motions.

• Can be performed in a variety of patient positions.

• Placement of resistance is easily adjusted.

• Gives the therapist an opportunity for direct interaction with the patient to monitor the patient’s performance continually.

Disadvantages

• Exercise load (amount of resistance) is subjective; it cannot be measured or quantitatively documented for purposes of establishing a baseline and exercise-induced improvements in muscle performance.

• Amount of resistance is limited to the strength of the therapist; therefore, resistance imposed is not adequate to strengthen already strong muscle groups.

• Little value for strong muscle groups.

• Speed of movement is slow to moderate, which may not carry over to most functional activities.

• Cannot be performed independently by the patient to strengthen most muscle groups.

• Not useful in home program unless caregiver assistance is available.

• Labor- and time-intensive for the therapist.

• Impractical for improving muscular endurance; too time-consuming.

Guidelines and Special Considerations

There are some special guidelines that are unique to manual resistance exercises that also should be followed when using this form of exercise. The following guidelines apply to manual resistance applied in anatomical planes of motion.

Body Mechanics of the Therapist. Select a treatment table on which to position the patient that is a suitable height or adjust the height of the patient’s bed, if possible, to enhance use of proper body mechanics. Assume a position close to the patient to avoid stresses on your low back and to maximize control of the patient’s upper or lower extremity. Use a wide base of support to maintain a stable posture while manually applying resistance; shift your weight to move as the patient moves his or her limb.

Application of Manual Resistance and Stabilization. Review the principles and guidelines for placement and direction of resistance and stabilization. Stabilize the proximal attachment of the contracting muscle with one hand, when necessary, while applying resistance distally to the moving segment. Use appropriate hand placements (manual contacts) to provide tactile and proprioceptive cues to help the patient better understand in which direction to move. Grade and vary the amount of resistance to equal the abilities of the muscle through all portions of the available ROM. Gradually apply and release the resistance so movements are smooth, not unexpected or uncontrolled. Hold the patient’s extremity close to your body so some of the force applied is from the weight of your body not just the strength of your upper extremities. This allows you to apply a greater amount of resistance, particularly as the patient’s strength increases. When applying manual resistance to alternating isometric contractions of agonist and antagonist muscles to develop joint stability, maintain manual contacts at all times as the isometric contractions are repeated. As a transition is made from one muscle contraction to another, no abrupt relaxation phase or joint movements should occur between the opposing contractions.

Verbal Commands. Coordinate the timing of the verbal commands with the application of resistance to maintain control when the patient initiates a movement. Use simple, direct verbal commands. Use different verbal commands to facilitate isometric, concentric, or eccentric contractions. To resist an isometric contraction, tell the patient to “Hold” or “Don’t let me move you” or “Match my resistance.” To resist a concentric contraction, tell the patient to “Push” or “Pull.” To resist an eccentric contraction, tell the patient to “Slowly let go as I push or pull you.”

Number of Repetitions and Sets; Rest Intervals. As with all forms of resistance exercise, the number of repetitions is dependent on the response of the patient. For manual resistance exercise, the number of repetitions of exercise is also contingent on the strength and endurance of the therapist. Build in adequate rest intervals for the patient and the therapist; after 8 to 12 repetitions, both the patient and the therapist begin to experience some degree of muscular fatigue.

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