Therapeutic Exercise: Muscle Performance and esistance Training

How is the appropriate exercise intensity for a given patient determined in PT intervention?

-Maximal effort vs submax -Repetition max test (1RM, 6RM, 10RM) -% of body weight -Dynamometry -BORG scale (perceived exertion) *Training zone (% of 1RM)* - Low 30-40% for sedentary and untrained - Healthy untrained, 40-60% - Very high >80% for highly training

What are the basic principles to using manual resistance?

1. Position pt appropriately (K&C pages 200-207). 2. Evaluate the pt's ROM & strength and explain exercise procedures to pt. Demonstrate movement to pt passively. 3. Apply resistance with full surface of your hand to distal portion of the joint segment in the direction opposite to that of the movement. 4. Stabilize to avoid substitute motions- generally applied at proximal attachment of muscle. 5. Apply the appropriate amount of resistance, to allow full ROM. *Avoid Valsalva's Maneuver (both pt & PT).*

What is isokinetic testing and when is it most frequently used?

Isokinetic devices measure muscle force production about a moment arm (torque) at a constant velocity and variable resistance. Components: Chair Dynamometer Computer

What is muscle endurance?

Muscular endurance is the ability of a muscle group to execute repeated contractions over a period of sufficient time to cause muscular fatigue, or to statically maintain a specific percentage of maximal voluntary isometric contraction for a prolonged period of time.

Which type of resistance is often contraindicated due to high impact?

plyometrics

What are the basic principles to using isometric resistance?

Principles 1. Hold contraction at least 6 seconds. 2. Load muscle > 60-80% of maximal voluntary contraction to develop strength. 3. Length of muscle directly effects maximal isometric tension (maximal tension changes through ROM). 4. Use multiple angle isometrics (every 20 degrees) to strengthen throughout joint ROM.

What are the limitations to mechanical isotonic resistance?

Prone to stronger muscle substitution/compensation. Machines based on average physical dimensions of population.

Alignment and Stabilization in resistance exercise refers to what?

Proper alignment for muscle action Consideration of gravity Ability to stabilize body or limbs appropriately

What is a limitation to isometric resistance?

Provides limited improvement in endurance.

What is a repetition maximum and how is it calculated?

Repetition maximum is the greatest possible weight lifted by a muscle group a specified # of times with correct form. 1-RM 10-RM Calculations 1 RM = 8.841 + (1.1828 x {7-10} RM)

Give an example of a plyometric LE exercise.

Repetitive jumping Bounding Box jumps Side jumps Hopping

How can we use a viscous medium to facilitate resistance exercise?

Resistance created by the viscosity or stiffness of a material. Examples include: Elastic bands & tubing (Theraband®) Putty (Theraputty) / rubber ball Water (Will be addressed separately)

What are rest intervales in resistance exercise training? Why are they important?

Rest is critical to allow body to recover from muscular fatigue and delayed onset muscle soreness. Rest is dependent on training regimen and patient response - Early rehab: As needed - Low activity: <2minutes - Moderate activity: 2-3 minutes after each set - High activity: >3 minutes

What is the reversibility principle?

Reversibility Principle: Adaptive changes in the body's systems are transient unless the improvements are used for functional activities or participates in a maintenance program.

What Muscle Strength Assessments (Specific Tests & Measures) can be used to assess patient strength? How are these used?

Specific tests: Repetition maximum (RM), Dynamometry, Manual muscle testing, Isokinetic testing How used?: BORG Scale of perceived exertion: Baseline if trying to improve with intervention Differential diagnosis of underlying pathology To determine if it is a cause of functional limitations

What is the specificity of training?

Specificity of Training: the adaptive effects of training (strength, endurance, power) are highly specific to the training method employed.

How should you progress balance training?

Start: Improve Posture > Alter Base of Support > Alter Support Surface> Add Additional body movements > Add Perturbations > Change Environment (moving or nonmoving) > Incorporate Functional tasks

T/F: Velocity specific training is fundamental to rehabilitation.

T

T/F: exercise can be harmful in the absence of correct form

T: Make sure patient uses proper biomechanics. Watch for improper joint alignment or incorrect movement that could precipitate or exacerbate injury.

What is the definition of advances strengthening exercise?

The use of functionally based and total body movement patterns against the resistance of body weight or an external load.

What is exercise duration?

Total number of weeks or months 2-3 week changes are from neural adaptation 6-12 weeks are needed for hypertrophy and changes in vascularization

What is the transfer of training principle?

Transfer of Training: carryover of training effects from one task/exercise to another. This is may be referred to as overflow, or cross-training effect.

What is manual muscle testing and what features make it a useful tool in patient assessment?

Uses a qualitative scale which is based on full ROM of a joint segment in an against gravity position, fair strength (3/5). Features Allows isolation of specific muscles. Can be used to quantify concentric or isometric (break test) muscle force. No equipment is needed. Useful for determining strength in weak muscles, with strength 3/5 of less. Can measure force in large & small muscles.

How are the ACSM intensity recommendations different from what we usually use in PT practice?

Usually higher than what we use in PT practice. *Novice to intermediate*- train with loads corresponding to 60-70% of 1 RM for 8-12 reps. - compared to 40-60% healthy untrained *Advanced*- use loading ranges of 80-100% of 1 RM. *Progression*- ↑ 2-10% when the individual can perform the current intensity for 1-2 reps over the desired # of reps on 2 consecutive training sessions.

Why is recent eye surgery a precaution to starting resistance exercise?

high BP can damage the healing surgery site

Define muscular strength.

refers to the maximal force that can be generated by a specific muscle or muscle group.

What is exercise frequency? How is it typically prescribed?

"Times per day or week" -The greater the intensity and volume, the greater the rest required -Optimal frequency has not been determined... 1. Low weight, low reps can be performed multiple times per day (early rehab) 2. Moderate intensity and volume, 2-3 times per week, or up to 5 times per week

What is periodization in terms of resistance exercise?

(aka periodized training) An approach to resistance training that partitions training program into specific time intervals and established systematic variation in intensity and reps, sets, or frequency. Typically used with highly training individuals.

What is the overload principle? how is it different between strength and endurance training?

*Overload Principle:* Progressively loading muscle by manipulating factors such as intensity and volume. - *Strength training:* the amount of resistance incrementally and progressively increased - *Endurance training:* an emphasis is placed on increasing the time of muscle contraction is sustained or the number of repetitions performed, rather than the amount of external resistance.

What is exercise volume? How is it different based on training goals?

*Repetitions:* RM percentage load, Goal based (power, endurance, strength) *Sets:* No set standard, 3-4 common. 1 set for early phase Multiple sets for advancing program *Strength:* 40-60% RM effort for healthy untrained 60-80% RM for 8-12 reps, 2-3 sets to elicit fatigue *Power:* 20-70% RM, explosive/ballistic movement. 3-4 sets, of 6-7 reps *Endurance:* 3-5 sets, 40-50 reps with submaximal load

What is manual resistance and what features make it useful in physical therapy practice?

*dfn:* "Active muscle contraction in which the resistive force is applied by the PT. " *Features* Accommodating resistance through the ROM., Useful for weak muscles., Useful when ROM needs to be controlled., Can be used for any type of contraction., No equipment is needed.,

Which of the following indicate that resistance is too high muscle? a. Tremors in contracting muscle(s) and or uncoordinated movement pattern. b. An increase in both SBP and DPB c. Inability to complete exercise through full range of movement. d. Substitute movements/compensating with other muscle groups e. more than one of the above

*e.* = a, c, and d, correct

Define Plyometrics.

- Activities for high demand occupations and sport activities require active burst of force and power that are not typically developed during most strength-building exercises. - Employs high-velocity eccentric to concentric muscle loading in functional movement patterns. - Body weight is usually used as the load but weights or elastic bands can also be incorporated. - Uses the series elastic properties of soft tissue and the stretch reflex to facilitate force production.

What is integration of function in terms of manual resistance exercise and why is it important?

- Balance of stability and active mobility - Balance of strength, power and endurance - Task-specific movement patterns with resistance incorporated.

What are the features of mechanical isotonic resistance (i.e. weights, exss machines) that make it useful in PT practice?

- Can include close-chain activities (less joint shear forces; more functional/ transferable). - Exercises multiple joints simultaneously. - Includes concentric & eccentric components. - Amount of resistance is limited to what the weakest point in ROM can acheive - Usually gravity dependent.

What are teh general principles of muscle setting?

- Muscle contracts isometrically against no external resistance. - Instruct patient to "squeeze" muscle and not to "push." - Make sure that little to no joint movement occurs. When would this be used clinically? (Examples)

In general, what determines the way that our body adapts to resistance exercise?

....

What should be your first steps in perscribing a resistance exercise program?

1. Assess indications, precautions, and contraindications for resistance exercise. 2. Identify patient impairments and functional limitations related to muscle weakness. 3. Determine the properties of muscle action in specific functions that are impaired. 4. Determine the type of exercise that best addressees the patients limitations: - Joint segment fixation: (Open-chain kinematic and Closed-chain kinematic) - Contraction type: (Concentric, Eccentric, Isometric)

What are the seven resistance loading methods?

1. Manual resistance, 2. Mechanical isotonic, 3. Viscous medium 4. Isometric 5. Muscle setting 6. Plyometrics 7. Isokinetic

Physiological Adaptations for Resistance Exercise iclude.... (5 categories)

1. Neural adaptations 2. Hypertrophy 3. Muscle fiber type adaptation 4. Vascular and Metabolic Adaptations 5. Connective tissue adaptations

What are the ten components to a resistance exercise perscription?

1. Type of resistance: isotonic, isometric, isokinetic 2. Amountof load: weight, band color... 3. Patient position: sitting (long vs short), standing, sidelying, hooklying, prone, supine, quadruped... 4. Joint movement: flex-ext, abd-add, IR-ER... 5. Number of reps: typically 1-25 6. Number of sets: typically 1-5 7. Frequency: 1-7 x week (usually 3-4) 8. Velocity: slow, moderate, or fast 9: Type of contraction: concentric, eccentric, isometric 10: plan for progression

Which of the following are general principles to resistance exercise training? a. Avoid breath holding / Valsalva maneuver. b. Perform warm-up activities. c. Balance flexion-dominant (pulling) exercises with extension-dominant (pushing) exercises. d. Move through full, available, and or pain-free ROM.

All

How long do patients need to recover between plyometric exercise bouts?

Allow adequate time for recovery with 48 to 72 hours between sessions. Stop an exercise if a patient can no longer perform the plyometric activity with good form and landing technique because of fatigue.

What are the features of resistance via viscous medium that make it useful to PT practice?

Any position can be used because resistance is not gravity dependent. Amount of resistance dependent on density of material & amount of stretch Facilitates exercising muscle groups that are difficult to resist against gravity. Portable, light weight, and inexpensive.

What should you do before imitating plyometric exercise?

Be sure the patient has adequate flexibility and strength before initiating. *Always warm-up with active exercise.*

What are the limitations to manual resistance?

Cannot be done independently by patient / time consuming for PT. Resistance cannot be measured quantitatively. Amount of resistance limited by strength of PT.

Give an example of a plyometric UE exercise?

Catching/throwing weighted ball Swinging a weighted object Push offs from wall or counter Clap push ups

What does it mean for an activity to be "closed chain"?

Closed-chain kinematic activities occur when the distal joint segment is fixed (usually with weight-bearing) and the proximal.

What are concentric contractions?

Concentric contractions involve tension development in a muscle that is shortening and producing approximation of joint segments.

What is a limitation of resistance via viscous medium?

Difficult to measure amount of resistance/ difficult to control total amount of exercise.

How should plyometric exercise training be progressed?

During jumping activities, emphasize learning techniques for a safe landing before progressing to rebounding. Progress reps before increasing resistance. For high-level, increase the rest intervals between sets and decrease the frequency of drills as the intensity of the drills increases.

What is dynomometry and how is it used?

Dynamometry measures the push or pull of force during muscle contractions. Many different types of dynamometers exist. (Hand grip dynamometer, Hand-held dynamometer, Cable tensiometry)

What are eccentric contractions?

Eccentric contractions involve tension development in a muscle that is elongating and producing separation of joint segments.

T/F: over fatiguing muscles is necessary for the overload principle to work

F: Avoid over fatiguing of muscles, allow adequate rest intervals between sets. Correct overuse as needed with verbal ques and or adjustment of exercise parameters.

What are the features of muscle setting?

Features - Maintains mobility between muscle fibers. - Can be used when active strong contraction of muscle is contraindicated. - Decreases muscle spasm and pain. - Possibly retards atrophy during early rehabilitation or joint immobilization. Limitation: DOES NOT increase muscle strength.

What is mode of exercise? What considerations should be made when selecting a mode?

Form of muscle exercise and type of muscle contraction. - Static: isometric - Dynamic: using concentric and/or eccentric - Isotonic: consistent tension throughout - Isokinetic: consistent speed throughout Resistance - Manual or mechanical - Accommodating resistance - Body weight Energy system - Aerobic - Anaerobic - Range of movement

What is muscle setting?

Gentle, static, unloaded (not against a resistance) contractions that produce internal shortening of sarcomeres.

What is exercise velocity?

How fast you are performing a movement/exercise. Slow and fast exercise velocities should be integrated into an exercise program Novice - slow -> moderate Advanced - fast

How should plyometric exercise be prescribed in pediatric and elderly patients?

If used in children or elderly, select only beginning-level stretch-shortening drills against light resistance.

What are isometric contractions?

Isometric contractions involve tension development in a muscle without an external change in muscle length of joint segments. With this type of contraction, sarcomeres shorten but the change in length is accommodated by stretching of the parallel elastic component and serial elastic component of the muscle.

What is exercise order? why is it important?

Large mm -> small muscles Multijoint -> single joint - training whole system as small muscles are active with large muscles and single joint muscles are active with multi joint muscles to facilitate coordination.

What types of resistances may be used when selecting an exercise mode?

Manual vs Mechanical Isometric - without change in length Dynamic (concentric/eccentric) Constant vs. Variable Resistance Isokinetic - without change in speed (research) Open vs closed chain

Write and exercise prescription for the following example: Patient needs mod A x1 for sit stand. Muscle groups? Contraction type? Open- vs closed-chain?

Muscle groups: Hip Extensors, Knee extensors, Contraction type: concentric Closed chain

Write and exercise prescription for the following example: Patient unable to push open exterior door of apartment building. Muscle groups? Contraction type? Open- vs closed-chain?

Muscle groups: Triceps, anterior deltiod, Wrist flexors Contraction type: concentric Closed chain

What is muscle power?

Muscular power is related to the strength and speed of movement and is defined as the work produced during muscle contraction per unit of time (force x distance/time).

What are the general Precautions/Contraindications to starting resistance exercise?

Neuromuscular inflammatory disorders Cardiovascular disorders Osteoporosis Children prior to epiphyseal fusion Bone metastasis Coagulation disorders Acute inflammation Exacerbation of joint pain Severe muscle soreness Fatigue/overwork Bone fracture-nonunion Rupture/surgical incision/repair of CT

What are the general precautions to resistance exercise?

Non-union fractures Medications that alter response to exercise History of Coronary Artery Disease (CAD) Myocardial Infarction (MI) Cerebrovascular Disorders Hypertension Eye Surgery Neurosurgery

What is isometric resistance and how is it useful?

Occurs when the load is greater than the strongest point in the muscle's ROM (using a weight that exceeds 1 RM). Pushing/pulling against an immovable object. Features Little / no equipment needed. Often used when joint movement is contraindicated. Can be applied manually or mechanically. Highly specific with ~ + 10 degree carryover.

What does it mean for an activity to be "open chain"?

Open chain kinematic activities occur when the proximal joint segment is fixed and the distal joint segment moves with muscle contraction.