{
  "resourceType": "ActivityDefinition",
  "id": "neuromuscular-exercise-knee",
  "url": "https://bodyiq.dev/fhir/ActivityDefinition/neuromuscular-exercise-knee",
  "version": "1",
  "name": "NeuromuscularExerciseKnee",
  "title": "Neuromuscular Exercise (Step-Downs / Single-Leg Balance)",
  "status": "draft",
  "experimental": true,
  "description": "Neuromuscular exercises improving sensorimotor control, functional stability, and fall risk in knee OA. Includes step-downs from various heights, single-leg balance, and perturbation training. Addresses proprioceptive deficits and mimics activities of daily living.",
  "useContext": [
    {
      "code": {
        "system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
        "code": "user"
      },
      "valueCodeableConcept": {
        "text": "difficulty: intermediate"
      }
    }
  ],
  "topic": [
    {
      "coding": [
        {
          "system": "https://bodyiq.dev/fhir/CodeSystem/exercise",
          "code": "neuromuscular-exercise-knee",
          "display": "Neuromuscular Exercise (Step-Downs / Single-Leg Balance)"
        }
      ]
    }
  ],
  "bodySite": [
    {
      "coding": [
        {
          "system": "https://bodyiq.dev/fhir/CodeSystem/exercise",
          "code": "knee",
          "display": "Knee"
        },
        {
          "system": "http://snomed.info/sct",
          "code": "129159008",
          "display": "Structure of femorotibial joint"
        }
      ],
      "text": "Knee"
    },
    {
      "coding": [
        {
          "system": "https://bodyiq.dev/fhir/CodeSystem/exercise",
          "code": "hip",
          "display": "Hip"
        },
        {
          "system": "http://snomed.info/sct",
          "code": "24136001",
          "display": "Structure of hip joint"
        }
      ],
      "text": "Hip"
    }
  ],
  "kind": "ServiceRequest",
  "dosage": [
    {
      "text": "Progressive program over 12 weeks; step-down height and balance surface progress"
    }
  ],
  "usage": "Evidence: strong.",
  "note": [
    {
      "text": "Stable hip, level pelvis — glute med locks the alignment",
      "authorString": "focus:internal"
    },
    {
      "text": "Lower the trailing heel slowly to kiss the floor",
      "authorString": "focus:external"
    },
    {
      "text": "Keep the kneecap aimed over the second toe",
      "authorString": "focus:external"
    },
    {
      "text": "Hand on standing hip — feel it stay level",
      "authorString": "focus:tactile"
    }
  ],
  "relatedArtifact": [
    {
      "type": "citation",
      "label": "kisner-therapeutic-2017",
      "citation": "Kisner C, Colby LA, Borstad J. (2017). Therapeutic Exercise: Foundations and Techniques"
    },
    {
      "type": "citation",
      "label": "acsm-guidelines-2021",
      "citation": "American College of Sports Medicine. (2021). ACSM's Guidelines for Exercise Testing and Prescription",
      "document": {
        "url": "https://doi.org/10.4135/9781412994149.n165"
      }
    },
    {
      "type": "citation",
      "label": "sharma-knee-oa-2021",
      "citation": "Sharma L. (2021). Osteoarthritis of the Knee",
      "document": {
        "url": "https://doi.org/10.1007/s40883-021-00226-x"
      }
    },
    {
      "type": "citation",
      "label": "zeng-exercise-knee-oa-2022",
      "citation": "Zeng CY, Zhang ZR, Tang ZM, Hua FZ. (2022). Benefits and Mechanisms of Exercise Training for Knee Osteoarthritis",
      "document": {
        "url": "https://doi.org/10.3390/ijms232314953"
      }
    },
    {
      "type": "citation",
      "label": "roos-neuromuscular-2025",
      "citation": "Roos EM, Kroman S, Ageberg E. (2025). An Exercise Therapists' Guide to Neuromuscular Exercise for People With Knee or Hip Osteoarthritis",
      "document": {
        "url": "https://doi.org/10.1097/WNR.0000000000002248"
      }
    },
    {
      "type": "citation",
      "label": "flaxman-knee-synergies-2021",
      "citation": "Flaxman TE, Shourijeh MS, Smale KB, et al.. (2021). Functional Muscle Synergies to Support the Knee Against Moment Specific Loads While Weight Bearing",
      "document": {
        "url": "https://doi.org/10.1016/j.jelekin.2020.102506"
      }
    },
    {
      "type": "citation",
      "label": "yan-knee-oa-exercise-modalities-2025",
      "citation": "Yan L, Li D, Xing D, et al.. (2025). Comparative Efficacy and Safety of Exercise Modalities in Knee Osteoarthritis: Systematic Review and Network Meta-Analysis",
      "document": {
        "url": "https://doi.org/10.1136/bmj-2025-085242"
      }
    },
    {
      "type": "successor",
      "label": "Progress single-leg balance/step-down control to a full single-leg squat.",
      "display": "Single Leg Squat / Pistol Squat",
      "resource": "ActivityDefinition/single-leg-squat-pistol"
    }
  ],
  "extension": [
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Quadriceps Femoris"
        },
        {
          "url": "role",
          "valueCode": "primary"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "21989003"
          }
        }
      ]
    },
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Gluteus Medius"
        },
        {
          "url": "role",
          "valueCode": "primary"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "78333006"
          }
        }
      ]
    },
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Hamstrings (Group)"
        },
        {
          "url": "role",
          "valueCode": "secondary"
        }
      ]
    },
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Gastrocnemius"
        },
        {
          "url": "role",
          "valueCode": "stabilizer"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "35616000"
          }
        }
      ]
    },
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Soleus"
        },
        {
          "url": "role",
          "valueCode": "stabilizer"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "78376008"
          }
        }
      ]
    }
  ]
}