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Resistance exercise is an activity in which dynamic or static muscle

contraction is resisted by an outside force applied manually or
mechanically. Resistance exercise, also referred to as resistance training,
is an essential element of rehabilitation program for persons with
impaired function, also for those who wish to promote or maintain
health and physical well-being, enhance performance of motor skills and
reduce the risk of injury and disease.
Muscle performance primarily depends upon strength, power, and
endurance of the muscle that can be enhanced by resistance exercise.
a) Strength:
Practically muscle strength is the greatest measurable force that is
exerted by a muscle or muscle group to overcome resistance during
single maximum effort. Functional strength relates to the ability of
neuromuscular system to produce the appropriate amount of force,
during functional activities in a smooth and coordinated manner.
b) Power:
Muscle power is related to the strength and speed of movement and is
defined as the work (force × distance) produced by a muscle per unit
time. In other words, power is the rate of doing work. The force and
velocity are key factors that affect muscle power. Power can be gained
by either increasing the muscle work during specified period of time or
reducing the amount of time required to produce the work.

c) Endurance:
Primarily endurance refers to the ability to perform repetitive or
sustained activities over a prolonged period of time. Cardiopulmonary
endurance (total body endurance) is associated with repetitive, dynamic
motor activities like walking, cycling, swimming, etc., which involves
use of large muscles of the body. Muscle endurance is the ability of a
muscle to contract repeatedly against an external load, generate and
sustain tension and resist fatigue over an extended period of time. The
key parameters of endurance training are low intensity muscle
contraction, a high number of repetitions, and a prolonged time period.


Many factors determine whether a resistance exercise program is
appropriate, effective, and safe:
 Alignment of body segments during each unique exercise. To
strengthen a specific muscle or muscle group effectively and avoid
substitution, appropriate positioning of the body and alignment of
limb or body segment are essential.
 Exercise intensity is just the amount of external resistance applied
on contracting muscle during each repetitions of an exercise.
 Frequency in the resistance exercise is the number of exercise
sessions per day or week.
 Rest interval is necessary to allow time for the body to recuperate
from muscle fatigue or to offset adverse responses like muscle
soreness induced due to exercise.
 The type of muscle contraction, resistance, arc of movement used
and primary energy system utilized during exercise also
determine the benefits of exercise.


Manual Resistive exercises are used to:

1. To strengthen bones
2. To build muscle strength
3. To treat and prevent coronary heart diseases
4. To improve range of motion and endurance.
5. To improve muscle performance

6. To reduce risk of soft tissue injury

1. Observe the patient for signs of poor tolerance to
active exercise due to cardiovascular or pulmonary
2. Joint motion may be limited by chronic disease and
motion should be limited to available range of
3. Exercises can be modified to be performed sitting or
lying on the back.
4. Resistive exercises can be provided through manual
resistance supplied by the clinician or mechanically
with the use of equipment such as dumb bells,
resistive bands or ankle weights.
5. The patient should never hold their breath while
performing resistive exercise.
6. The amount of resistance applied should be
carefully monitored in those with osteoporosis.
7. Resistive exercise is contraindicated if a
Joint/muscle is inflamed or swollen.


1. Select ambient room atmosphere

2. Do not apply pressure to unstable joint or distal to fracture site.
3. Avoid Valsalva Manoeuvre
4. Prevent incorrect or compensatory motion.
5. Stop the exercise whenever the patient is experiencing pain or
unintended secondary stress on body or shortness of breath
6. Avoid overtraining or overwork and intensity of exercise should
be increased progressive.
7. Avoid too much resistance because patient will not be able to
the available joint motion and also he/she will feel excess
burden and pain on ligaments and muscle.


1. Acute Inflammation/ Acute disease

2. Pain
3. Severe Cardiopulmonary disease
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
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 anatomical planes of motion, in diagonal
patterns associated with PNF techniques, or in combined patterns
of movement that stimulate functional activities.
 A specific muscle may also be strengthened by resisting the action
of that muscle, as described in manual muscle testing procedures.

1) Prior to initiating the exercise:

a) Evaluate the patient’s range of motion and strength, and identify
functional limitations. Manual muscle testing and functional
tests will help the therapist establish a quantitative and
qualitative baseline level of strength and functional performance
against which progress can be measured. It will also help the
therapist determine the appropriate amount and type of
resistance that should be given in the exercise program.
b) Explain the exercise plan and procedures to the patient.
c) Patient should be placed in a comfortable position. The therapist
should assume a position next to the patient where proper body
mechanics can be used. Ensure that the region of the body in
which the exercise is to be done is free of restrictive clothing.
d) Demonstrate the desired motion to the patient by passively
moving the patient’s extremity through the motion.
e) Patient must be explained that he/she must perform the exercise
with a maximum but pain-free effort.
f) Ensure that the patient does not hold breath during maximum
effort to avoid the Valsalva maneuver.
2) During Manual Resistance Exercise:
a) Consider the site of application of exercise
Resistance is usually applied to the distal end of the segment
in which the muscle to be strengthened attaches. Distal
placement of resistance generates the greatest amount of
external torque with the least amount of effort from the
i) The site of application of resistance will vary depending on
the strength of the patient and the therapist as well as stability
of segment.
ii) Resistance may be applied across an intermediate joint if
that joint is stable and pain free and if there is adequate
muscle strength supporting the joint.
b) Determine the direction of resistance
Resistance is applied in the direction directly opposite to the
desired motion.
c) Provide stabilization:
To avoid compensatory motions when strengthening a
specific muscle, appropriate stabilization must be applied by
the therapist. Stabilization of a segment is generally applied
if proximal attachment of the muscle to be strengthened. For
example, in the case of biceps brachii muscle, stabilization
should occur at the anterior deltoid as elbow flexion is
d) Apply the appropriate amount of resistance
Initially have the patient practice the desired motion against
submaximal resistance to get the “feel” of the movement. To
increase strength, the optimal response from the patient
should be a maximum pain-free effort. In dynamic exercise
performed against resistance, the motion should be smooth,
not tremulous. The resistance applied should equal the
abilities of the muscle at all points in the range of motion.
Gradually apply and release resistance so that uncontrolled
movements do not occur.
e) Revise the site of application of resistance or decrease the
amount of resistance if:
i) The patient is unable to complete the full range of motion
ii) The site of application of resistance is painful.
iii) Muscular tremor develops.
iv) Compensatory motions occur.

3) Verbal Commands:
i) Coordinate the timing of the verbal commands with the
application of resistance to maintain control when the patient
initiates a movement.
ii) Use simple, direct verbal commands and use different verbal
commands to facilitate isometric, concentric or eccentric
4) Body Mechanics of Therapist
i) Select a treatment plinth 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.
ii) Assume a position close to the patient to avoid stresses on your
(therapist) lower back and to maximize control of the patient’s
treatment area.
iii) 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/her limb.
5) Number of Repetitions and Sets/Rest Intervals
i) As with all forms of resistance exercise, the number of
repetitions is dependent on the response of the patient.
ii) For manual resistance exercise, the number of repetitions also is
contingent on the strength and endurance of the therapist.
iii) In general, 8-10 repetitions of a specific motion will take the
patient to a point of muscular fatigue
iv) Additional repetitions may be carried out after an adequate
period of rest is allowed for recovery from fatigue.
Manual Resistance Procedures for Shoulder Movement
Shoulder Flexion:
1) Place the patient in supine position on the plinth.
2) Apply resistance to the anterior aspect of the distal arm or to the
distal portion of the forearm if the elbow is stable and pain-free
3) Command the patient to do shoulder flexion.
4) Stabilization of scapula and trunk is provided by the plinth.
Shoulder Extension:
1) Place the person in prone lying position on the plinth.
2) Apply resistance to the posterior aspect of the distal arm or the
distal portion of the forearm.
3) Command the patient to do shoulder extension.
4) Stabilization of scapula and trunk is provided by the plinth

Shoulder Abduction and Adduction:

1) Place the person in supine lying position on the plinth.
2) Apply resistance to the distal portion of the arm with the patient’s
elbow flexed to 90⁰.
3) To resist abduction, apply resistance to the lateral aspect of the
4) To resist adduction, apply resistance to the medial aspect of the
5) Command the patient to do shoulder abduction or adduction.
6) Stabilization is applied to the superior aspect of the shoulder, if
necessary, to prevent the patient from initiating abduction by
shrugging the shoulder.
Shoulder Internal and External Rotation:
1) Place the patient in supine position and place a towel below the
arm segment of the patient.
2) Flex the elbow to 90⁰ and position the shoulder in the plane of the
3) Apply resistance to the distal portion of the forearm during the
internal and external rotation.
4) Stabilize at the level of the clavicle during internal rotation while
the back and scapula are stabilized by the plinth during the external
5) Command the patient to do shoulder internal or external rotation.


1) Most effective during early stages of rehabilitation when muscles
are weak.
2) Effective form of exercise for transition from assisted to
mechanically resisted movements.
3) More finely graded resistance than mechanical resistance.
4) Resistance is adjusted throughout the ROM as the therapist
responds to the patient’s efforts or painful arc.
5) Muscle works maximally at all portions of ROM
6) The range of joint motion can be carefully controlled by the
therapist to protect healing tissues or to prevent movement into an
unstable portion of the range.
7) Useful for dynamic or static strengthening.
8) Direct manual stabilization prevents compensatory motions.
9) Can be performed in a variety of patient positions.


1) Exercise load is subjective; it cannot be measured or quantitatively
documented for the purposes of establishing a baseline and
exercise-induced improvements in muscle performance.
2) Amount of resistance is limited to the strength of the therapist;
therefore, resistance imposed is not adequate to strengthen already
strong muscle groups.
3) Speed of movement is slow to moderate, which may not carry over
to most functional activities.
4) Cannot be performed independently by the patient to strengthen
most muscle groups.
5) Laborious and Time intensive for the patient.
6) Not useful in home program unless caregiver assistance is