TherEx Unit 2

What factors must be considered when selecting the type of exercise?

*Cause , extent of primary and secondary impairments *muscle performance deficits, stage of healing *joint condition and tolerance to compression and movement *equipment availability *Patient's goals and intended outcomes

Discuss the general guidelines for rest intervals (recovery period).

*Higher intensity longer rest *Moderate intensity is recommended for 2-3 min after each set *3+ minutes for high intensity, large multi joint *Active rest: work another group in the same extremity or same group on opposite extremity *Moderate intensity requires 48 hours of rest interval

In what order should exercises be done?

Large muscle groups before small muscle groups and multi joint exercises before single joint exercises.

What neural adaptations occur in response to strength training?

Neural adaptations: due to motor learning and improved coordination ↑ recruitment, rate, and synchronization of motor units firing

What is the "limit" for intensity? How can cardiovascular risks be minimized?

Pain is indicative that the intensity is too great. Rhythmic breathing will minimize cardiovascular risks.

What are the risks associated with insufficient recovery?

Performance plateaus or deterioration. Fatigued muscles are more susceptible to acute strains.

What type of training manipulates the speed of movement?

Plyometric training or stretch shortening drills

Be sure you are familiar with the preparation and for resistance exercises.

Prep - picking the correct resistance, review goals, set up equipment, & explain procedure.

.Which is preferred for proprioception / kinesthesia training? Balance and postural control?

Proprioception/Kines = Closed- chain -- because multiple joints are moving, it triggers a bigger sensory response Balance & posture = Closed chain, because of upright WBing - better posture control.

What is the benefit of active versus passive recovery?

Recovery time can be decreased with active rest.

How, when and with what devices are multi-angle isometrics done? How much overflow occurs in any one position?

Resistance applied manually or mechanically at multiple points in ROM (this is for when motion is now permitted but strength training activities is un-advisable) Used when goal is to improve strength throughout ROM when motion is permitted but dynamic resistance is painful or inadvisable Overflow of +/- 10* Use 4-6 points through ROM

Why is velocity important in DCER and variable-resistance?

Slow velocities need to be used in order to avoid momentum and uncontrolled movement.

Compare tension potential and velocity.

Slow velocity with max loads eccentric will generate greater tension than concentric As velocity increases concentric tension decreases and eccentric tension will increase and then plateau under max load

application procedures and general precautions for resistance exercises-Intensity

Start minimal, adjust as patient needs - should be smooth, pain free mvmts.

What happens to strength at puberty? How do boys compare to girls?

Strength increases at puberty particularly in males. Males have a greater mass and are 10% stronger.

Define volume.

Summation of the total number of repetitions and sets of a particular exercise during a single exercise session multiplied by the exercise intensity.

What is velocity spectrum rehab? Describe the related joint compression forces

The VSR lets you train at different velocities. Using faster angular velocities generates less compressive forces and is overall more comfortable to the patient.

Define endurance

The ability to perform repetitive or sustained activities over a prolonged period of time.

What are the disadvantages of isokinetics?

The actual velocities of ADLs and sports cannot actually be obtained on these machines / it usually only focuses on one joint & one plane of mvmt / expensive machines / lots of set up

Define endurance training.

The practice of using muscle force to move a load for many reps or sustain a contraction for a period of time

Define strength training.

The systematic practice of using muscle force to raise, lower, or control heavy external loads for a low number of reps or over a short period of time.

Define duration

Total number of weeks or months that exercise program is carried out

Why is velocity specific training important?

Training induced gains occur only at the training velocity, must match functional activity

What factors must be considered in designing, implementing and progressing resistance exercises?

Underlying pathology, the severity and extent of muscle performance impairments, the presence of other deficits, the stage of tissue healing after injury or surgery, and the patient's age, overall fitness, and ability to cooperate and learn must be considered.

Once a baseline RM is determined, how is it used clinically?

Use a percentage of it to train the pt. Low/deconditioned = 30-40% highly trained pts =80% generally speaking it falls between 40-70%Use a percentage of it to train the pt. Low/deconditioned = 30-40% highly trained

application procedures and general precautions for resistance exercises-Clear Instruction

Use layman's terms - bend/straighten vs flex/ext

When is mechanical resistance useful?

Useful when resistance necessary exceeds manual abilities of therapist

How is variable-resistance exercise different? How is it done?

Variable resistance ex uses special equipment that is designed to maximally load at multiple points in the ROM. the patient is controlling the limb movement throughout the exercise. (ex: Cybex machine - uses hydraulics or weight cable system.)

What about strength levels in young/middle adult men versus women? What increases the rate of decline?

Young → Middle adults Strength max reached in 20's for women and 30's for men Inactivity ↑ rate of decline

application procedures and general precautions for resistance exercises-Know where to place the resistance

apply to distal end of segment where the mm being worked is attached (ex -if strengthening the deltoid - resistance should go at the distal end of humerus)

application procedures and general precautions for resistance exercises- warm up

dynamic stretching - 5-10 min on treadmill

What velocity is appropriate for free weights? How can faster velocities be safely achieved?

free weights are only safe and effective at slow to medium velocities *For faster velocities safer options: isokinetic dynamometer, pneumatic or hydraulic variable resistance machines, and elastic resistance

What are the signs of muscle fatigue and what is the appropriate response?

uncomfortable, pain, cramping, tremulous, unintentional slowing, jerky, inability to complete ROM, use of substitutes, inability to continue low intensity activity. Should change to another muscle group or decrease load.

How is hyperplasia different? When does it occur?

↑ # of mm fibers due to longitudinal splitting (growing new mm. fibers) Insignificant

How does ligament and tendon tensile strength change in response to exercise? Why is this beneficial? What type of resistance is best?

↑ in tensile strength, ↑ resistance to injury (may develop more rapidly with ecc).

Define hypertrophy. When does it occur? What type of exercise is required?

↑ size of mm fibers (type IIB) in 4-8 wks (2-3 wks with high-intensity training) Greatest with high-volume, mod resistance ecc

What is isokinetic exercise? What are the advantages?

"Accommodating Resistance" Velocity is being changed, rather than the load. The force applied is equal to the force that is given (i.e - it is pushing back as much as you are pushing it) Advantages = it accounts for fatigue - so even when the patient is tired, the machine still works to give resistance. Allows for quick reversal training / CON/ECC reversals.

What are the benefits of the SAID principle? How does it relate to Wolff's law?

(SAID)Specific Adaptation to Imposed Demands Guides the therapist to determine the exercise parameters that will create specific training effects to best meet the patient's functional needs and goals. It is an extension of Wolf's Law (body systems adapt over time to the stresses placed on them).

What should be happening while one muscle group rests?

*Active rest: work another group in the same extremity or same group on opposite extremity

How is manual resistance applied? When is it used?

*Applied by therapist or self- assisted *It is used in early stages with extremely weak and can overcome only min ---> mod resistance or when ROM needs to be carefully controlled *Limited only by strength of the therapist

Compare velocity to force in concentrics. Why does this occur?

*Concentrics: during max effort as velocity increases, the force the muscle can generate dec

Compare velocity to force in eccentrics. Why does this occur?

*During max effort as velocity increases the force the muscle can generate increases then levels off

Define mode. Give examples.

*Mode is a form of exercise, type of contraction, manner in which exercise is carried out EX: Dynamic vs. static WB vs NWB (open/ closed chain) Manual vs Mechanical Isometrics vs Isotonics vs Isokinetics Constant vs variable vs accommodating resistance Body weight resistance Short arc vs full arc

How is task-specific training done?

*Use simulated functional movements under controlled, supervised conditions allowing for safe return to independence *Begin pushing, pulling, holding activities against low-level resistance for limited reps *Gradually increasing resistance and supervision and increased use at home/work

How can body weight be used progressively?

*Wall push ups ---> countertop push ups --->horizontal push ups ---> head-down over ball

How are the 2 types of endurance different?

-Cardiopulmonary endurance is a total body endurance and is associated with repetitive, dynamic motor activities such as walking, swimming, cycling, or UE ergometry. Deals with large muscle groups. -Muscle endurance is a local endurance for 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.

What are the potential benefits of resistance exercise?

-Enhanced muscle performance through restoration -Improvement or maintenance of muscle strength, power, and endurance -Increased strength of connective tissue, tendons, ligaments, & intramuscular connective tissue -Increase bone mineral density and/or less bone demineralization -Decrease joint stress -Reduce risk of soft tissue injury -Improve balance -Improved capacity for repair and healing of damaged soft tissues & for remodeling -Enhanced physical performance -Positive changes in body composition (increased lean muscle muscle or decrease body fat) -Enhanced feeling of physical well-being -Positive perception of disability and quality of life

What factors affect mm performance

-Morphological qualities of muscle; neurological, biochemical, and biomechanical influences; & metabolic, cardiovascular, respiratory, cognitive, and emotional function.

What are the key elements for mm performance

-Strength, power, and endurance

Define muscle performance.

-The capacity of a muscle to do work (force x distance).

How can endurance be increased?

3-5 sets of 40-50 reps at a light weight.

Discuss some general guidelines for frequency

3-5 times a week with a rest interval of 48 hours when training major muscle groups.

How long does it take to regain the force-producing capacity of a muscle after exercise?

90-95% recovery in 3-4 minutes. Greatest recovery in first minute.

Define muscle strength.

A broad term that refers to the extent that contractile elements of muscles produce force.

Define sets

A predetermined number of consecutive reps grouped together.

What psychological factors negatively affect strength training?

Ability to develop/maintain mm. tension is negatively impacted by fear of P!/injury/reinjury, depression, impaired attention or memory (secondary to age, TBI, or meds)

How are reps and sets altered to increase strength?

According to DeLorme 3 sets accumulating 10 reps of a weight that is the 10 rep max. Others recommend 60-80% of 1 rep max for 3 sets of 8-12 reps.

Describe local muscle fatigue.

Acute diminished response to repeated stimuli. Normal, reversible and temporary leading to dec in strength.

Describe specificity of training. What factors must be considered?

Adaptive effects of training such as improvement of strength power and endurance are highly specific to the training method employed. Exercises incorporated in a program should mimic the anticipated function. For example if the desired functional activity requires greater endurance than strength, lower intensity exercises performed over a longer time should be emphasized. Consider mode, velocity, patient/limb position, movement pattern.

Define resistance exercise/training.

An activity in which dynamic or static muscle contraction is resisted by an outside force applied manually or mechanically.

Differentiate between anaerobic and aerobic power.

Anaerobic power is a single burst of high-intensity activity and Aerobic power is repeated bursts of less intense activity.

What are substitute motions? What impact do they have on exercise? How can they be avoided?

Appropriate positioning and alignment are essential to assuring correct mm is strengthened and to prevent substitute motions Substitute motions: compensatory firing patterns due to stronger adjacent agonists or synergists Use MMT positions to guide positions/alignment

What methods allow for partial weight bearing in closed chain exercises?

Aquatic therapy & Parallel bars - both allow for the unloading of the limb in standing

Why is attention important?

Attention is necessary for initial learning, independance in Ex program, safety, and optimal long-term training effects

What is the risk with isometrics and how can it be minimized? When are isometrics contraindicated?

Avoid valsalva (quick drop in BP followed by rapid increase) Emphasize rhythmic breathing and exhale during contraction High intensity contraindicated for CV disorders (cardiovascular)

How do closed-chain weight bearing activities enhance stability?

Because closed chain is WBing - it activates co-contraction of mm groups and promotes stability - (ex - in standing squats, the hams/quads co-contract to stabilize the hip & knee.

application procedures and general precautions for resistance exercises-Which direction the resistance should go

CON mvmt - resistance should be opposite of the motioned desired- (resist agaisnt it ECC - resist in the same direction it is going

What are some alternatives to a RM?

Cable tensiometry and isokinetic or handheld dynamometer.

What role do isometrics play?

Can be accomplished by maintaining an isometric contraction for an extended period of time.

Why are open-chain exercises important for individual muscle strengthening?

Closed chain ex are more likely to lead to substitute motions or compensatory motions that mimic strength gains ( fake progress) than open chain - so open is better for improvement.

How do you determine the load for manual resistance?

Completely subjective.

What is the difference between concentrics versus eccentrics? How can either be applied?

Concentrics- acceleration contraction Eccentric- deceleration (for sudden changes of direction or momentum; also shock absorber for high impact activities) Both use resistance forces such as body weight, free weight, pulley system, variable resistance machines, isokinetic machines

Discuss transfer of training as it relates to isometrics

Cross-exercise effect (a limited increase in strength of the contralateral unexercised mm group), as a result of transfer of training, has been observed with maximum isometric training

At what rate does strength decline during late adulthood? What can slow this? How do neuromuscular factors change? What other factors decline with age?

Declines 8% per decade after max (occurs later and slower in active adults) Tension generating decline accelerates to 15-20% in 60's and 70's and 30% each decade thereafter (significantly less in active elderly ~3% per decade) Correlates with ↓ functional abilities and ↑ falls NM: ↓ in mm mass, number of type I/II fibers, connective tissue, cross-section size, selective type II atrophy Change in length-tension relationship and loss of flexibility ↓ in strength, speed of mm contraction, endurance, ability to recover Also, decline in ability to generate power for activities requiring quick responses

What is included in dosage?

Dosage includes intensity, volume, frequency, duration of rest interval

How long should an isometric contraction be held?

Duration: 6-10 sec holds Repetitive contractions decrease cramping and increase effectiveness

What is DCER? What is the drawback of this?

Dynamic constant external resistance Weight does not change; torque and tension do Handheld or cuff weights/torque arm units/weight machines/weight pulley system Drawback: mm is max challenged at only one point

Why are eccentrics so important to rehab?

Essential component following musculoskeletal injuries/surgery/conditioning programs Reduces re injury risk associated with high intensity deceleration/quick direction changes/repetitive eccentric activities

What contributes to the negative effects of overtraining?

Excessive frequency, inadequate rest intervals, and progressive fatigue.

What is a Valsalva maneuver? When does it occur?

Expiratory effort against closed glottis - deep breath in, closed glottis & contraction of abdominal mm. -- causes a temporary increase in BP Often occurs with high level isometrics or dynamic contractions

How is general fatigue different? What factors cause it?

Full body diminished response due to prolonged activity. Cause by Decrease in blood sugar, glycogen stores and potassium.

Why is it important to include both OKC & CKC?

Functional activities involve many combinations of both - so we need to use both in order to successfully treat and challenge pts.

How is functional strength different than mm strength?

Functional strength relates to the ability of the neuromuscular system to produce/reduce or control the appropriate amount of force during functional activities in a smooth & coordinated manner. (Picking up a cup with the right amt. of force so as no to spill it by aggressive tilting vs. picking it up and not being able to tilt it.)

How can detraining be avoided?

Gains must be incorporated into daily functional activities as early as possible.

application procedures and general precautions for resistance exercises-Number of reps

Generally 8-12

application procedures and general precautions for resistance exercises- cool down

Gentle stretching, walking, stat bike

What factors influence the use of submaximal versus maximal loading? When do you choose one over the other?

Goals and expected functional outcomes of the exercise program, the cause and extent of muscle performance deficits, the stage of healing of the injured tissues, pt's age/general health/fitness level. In general the level of resistance is lower for those with impairments in comparison to those in a conditioning program.

What are the factors that influence fatigue?

Health status diet lifestyle abnormal onset with NM, CP, inflammatory, cancer, environmental factors cardiac or pulmonary disease MS: mid afternoon peak fatigue

Compare concentrics and eccentrics in terms of DOMS.

Higher incidence and severity in DOMS with repeated, rapidly progressed, high intensity eccentrics

Why is stabilization important? How can it be achieved?

Imperative to maintaining alignment, ensuring correct action, avoiding substitutions Can use body weight or stable surface External: therapist, belts, straps, surface Internal: isometric adjacent mm group

How are stabilization exercises done? What other terms are associated with this?

Improves postural or dynamic stability Uses midrange contractions against resistance (typically manual or body weight) in anti gravity positions and WB postures Terms: Rhythmic stabilization Alternating isometrics dynamic/core/segmental stabilization

What is the impact of the overload principle on endurance training?

In endurance training, emphasis is placed on increasing the time a muscle contraction is sustained or the number of reps performed rather than the amount of external resistance.

What is the impact of the overload principle on strength training?

In strength training, the amount of external resistance applied to the muscle is incrementally and progressively increased.

How can power be enhanced?

Increasing the work a muscle must perform during a specified period of time or reducing the amount of time required to produce the work. The greater the intensity and the shorter the time period, the greater the muscle power.

Define intensity. What factors influence intensity?

Intensity (Ex or training load) Amount of resistance imposed or extent to which the mm is loaded Amount of weight lifted, lowered, or held Must exceed loads normally encountered and then progressively ↑ Dependent upon volume, frequency, order of Ex, or length of rest intervals

What factors influence this(freq)?

Intensity and volume, as well as patient's goals/ general health status/ previous participation in exercise program/ and response to training.

What is intensity? How is volume different?

Intensity of resistance exercise refers to how much external resistance is imposed on the muscle, whereas volume of an exercise includes variables such as reps, sets, or frequency, any combination of which can be adjusted to progressively increase the demands on the muscle.

What is the relationship between reps and intensity?

Inverse relationship. Higher intensity = lower reps and sets. Lower intensity = higher reps and sets.

What are the benefits of isokinetics in terms of fatigue and painful arcs.

Isokinetics account for fatigue. If your patient is tired, the machine matches the amount of force they are putting out - and they are still getting a workout, even if it is light. If a patient experiences pain during this, isokinetic training works by reducing the external force placed on the limb - the external force goes away as soon as the pt stops pushing against it.

What is transfer of training? Other terms associated with it? What are the influencing factors?

It is also called overflow or a cross training affect. It can occur from an exercise limb to a non-exercised contralateral limb in a resistance training program. Strength training can moderately improve endurance (but not vice versa). Training one speed can result in improvement of higher or lower speeds.

Discuss the use of DeLorme's repetition maximum (RM)

It is used as a measurement of muscle strength which can then be used to determine loads used during the rest of the conditioning program.

What are the strength training principles, based on muscle physiology, that can be drawn from Table 6.1?

Larger diameter= greater force. Short Pennate and multi pennate = greater force. Long parallel equals higher rate of shortening, less force Type I: low and slow force development, resistance to fatigue type IIA and IIB: rapid and high force rapid fatigue Greatest force when near/at resting length.

How do you establish a patient's baseline threshold for fatigue?

Length of time a contraction is maintained or number of reps initially performed

Why and when are setting exercises used

Low intensity (can be max but typically low) contraction against little or no resistance Decreased p! And spasms, promotes relaxation and circulation during acute stages of healing Only improves strength in very weak mm but can retard atrophy and maintain mm fiber mobility during immobilization

Discuss the unique fatigue patterns of patients with MS versus those with cardiac dz, pulmonary dz, PVD, or CA.

MS: midafternoon fatigue Cardiac, etc: fatigue more rapidly and recover more slowly

Compare the loads of eccentrics versus concentrics. What impact does this have on maximal loading? On the initial phases of rehab? On the cardiovascular system?

Max concentric contraction produces less force than max eccentric in same conditions (greater loads can be lowered than lifted) Requires more effort to control same load concentrically than eccentrically Max concentric loading will not provide max eccentric loading Weak mm (< 3 / 5 ) eccentrics against gravity will strengthen and develop NM control (easier to control lowering against gravity) Greater CV stress with eccentric

What bone-related benefits are obtained through exercises in weight-bearing positions? How long must it be done?

Minimize or prevent age-related bone loss with ↓ risk of Fx (requires up to 9 months)

How can isometrics be done? Describe an evidence-based method.

Mm contraction without visible movement of the joint using resistant forces such as manual, maintained body weight (holding a push up), or trying to move an immovable object Protocol is 20 reps x6 secs. Less than 6 seconds does not provide enough force Cross exercise effect: limited increase in strength in contralateral, non exercised extremity

Why and when is isometric training important?

Mm endurance is more important than strength in maintaining postural stability and preventing injury during ADL's. Builds functional ability to hold resistance Indications: Minimize mm atrophy during immobilization Activate mm and protect healing structures when ROM is not advised, or when improving strength in a pt with poor joint integrity/p! Develop postural or joint stability Develop static mm strength for task specific functions

How can motivation be improved?

Motivation and adherence is improved with meaningful activities, periodic changes, charting progress, feedback and incorporating gains into functional use

In early childhood and preadolescence, what can generally be stated regarding strength & endurance? How do boys compare to girls? What is the risk of strength training at this stage? What is the appropriate emphasis for an exercise program? Based on the evidence, when and how should resistance training be done?

Muscle performance and endurance increase from birth to puberty boys: slightly greater mass and 10% stronger structured strength training not appropriate for toddler risk of epiphyseal and avulsion fractures.

Overload Principle

Muscle performance increases when load exceeds muscle capacity.

Define power

Muscle power (the rate of performing work) is related to the strength and speed of movement and is defined as the work (force x distance) produced by a muscle per unit of time (force x distance/time).

What are some of the advantages of endurance training over strength training?

Muscles adapt to endurance training which results in better delivery and use of oxygen; more impact on improved function, using lower levels of resistance minimizes potentially harmful joint reaction forces, produces less irritation to soft tissues, and is more comfortable for the patient than strength training.

What does proper alignment look like? How does it relate to gravity?

Must consider line of pull and fiber direction, replicate action of target mm/group Must consider pull of gravity and body weight

application procedures and general precautions for resistance exercises-Stabilizing

NWBing motions- stabilization is applied to proximal segment (i.e - stabilize the deltoid when resisting biceps) Wbing - pt uses mm activation to stabilize themselves

Define frequency

Number of exercise sessions per day or per week. Or the number of times a muscle group or a certain movement is exercised per week.

Define reps.

Number of times a particular movement is performed consecutively.

application procedures and general precautions for resistance exercises-Monitor

Observe closely and be ready to change if needed

Compare open-chain exercises to closed chain.

Open - distal segment is free - often performed in NWB positions - weight is applied to the moving distal segment. (ex - knee flexion) Closed - proximal segments move and the distal segment is stabilized on a surface - movement at one joint causes mvmt at the surrounding joints - performed in WBing positions - (ex - mini squat, push ups )

Why is open-chain important initially?

Open chain allows for more control in early phases - because you are focusing on a single joint