RE lecture 2 strengthening/resistance exercises

Special Considerations cardiovascular

Arm exercises elicit different responses than leg exercises (arms<legs) Oxygen uptake Arms > Legs Myocardial efficiency Arms > Legs

Side Effects of Strengthening Exercises

Exercise induced muscle soreness DOMS Muscle fatigue

Risks of Strengthening Exercises

Muscle strain (mild - severe) Aggravate injury pain

How to achieve the overload principle

- Increasing Intensity (resistance/weight) - Increasing Volume (reps, sets, frequency)

Alignment

Determined by the muscle you are strengthening, and line of pull, to avoid recruitment of incorrect muscles or muscle group.

Stabilization

Holding down a body segment or holding the body steady to avoid unwanted substitute movement passive stabilization → active stabilization

AROM

Movement within the unrestricted ROM produced by active contraction of the mm crossing that joint

Body position

Variable, depending on pathology and impairments

Frequency

o Depends on intensity and volume o High intensity = less frequent (to allow for healing)

Reps/Sets

o Low Volume → High Volume o ↑load = ↓reps o ↓load = ↑reps

Range of Motion

o Short Arc → Full Arc o Stable portion of ROM → unstable portion of ROM

Endurance training

o key parameters are low intensity muscle contractions, large number of repetitions, and over a prolonged period of time. o Increasing the oxidative and metabolic capacities which allows for better delivery and use of Oxygen.

Order in which to do ROM as TEX

PROM→ AAROM → AROM

Speed of Movement

Slow → Fast

The maximum concentric contraction generates less tension than an eccentric contraction.

That means that greater loads can be lowered than lifted.

Strength

The ability of contractile tissue to produce tension and a resultant force based on the demands placed on the muscle.

Endurance

The ability to perform low-intensity, repetitive, or sustained activities over a prolonged period of time.

Maximum strength

The greatest measurable force that can be exerted by a muscle, or group of muscles, to overcome resistance during a single maximum effort.

Isometric resistance exercise

The muscle contracts but there is no change in muscle length and no joint movement Prevents/minimizes atrophy when joint movement is not possible (restrictive conditions, a cast, etc.) To re-establish neuromuscular control when joint movement is not advisable due to immobilization Helps develop postural and joint stability Helps train collagen fibres to orient along functional lines of stress Increases muscle strength when mobility is restricted

Plane of Movement

Uniplanar → Multi-planar

Karvonen's formula

[(Max.HR - Rest HR) + 60-70% (intensity level)] + Rest HR = Exercise HR

Eccentric exercise is associated with

a higher incidence of DOMS

The structure of a joint, as well as its integrity, and flexibility of the soft tissue that surround it

affect the amount of motion that can occur between any two bones.

When can strength/power/endurance be incorporated into ADLs

as early as possible in a rehabilitation program

AAROM

assistance is provided manually or mechanically by an outside force because the prime mover muscles need assistance to complete the motion.

Resistance exercise is integral in

conditioning programs for those who wish to promote or maintain health and physical well-being, enhance performance of motor skills and reduce the risk injury and disease.

Load for load concentric contractions

consume more oxygen/energy than eccentric contractions

Concentric and Eccentric training has shown to

create a cross-education effect resulting in a slight increase or maintenance in strength of the opposite unexercised limb.

Muscle fatigue

diminished response of a muscle to a repeated stimulus that causes temporary state of exhaustion that leads to a decrease in muscle strength

In rehabilitation, eccentric exercise may be

easier because they require less recruitment.

Greater stress is placed on the CV system during

eccentric training than concentric training.

Initiate an educational program that provides the patient with information about

effort symptoms and exercise precautions, monitoring the heart rate, and making modifications when indicated.

Increase the pace of the activity so the target heart rate can be maintained for 20 to 30 minutes.

fast walking, running, cycling, swimming, cross-country skiing, and aerobic dancing.

Eccentric training is integral to prevent

injury in activities that require high intensity deceleration or quick directional changes (sprinters, jumping, stop and go)

Muscle endurance

local endurance (one muscle that generates & sustains tension and resists fatigue over a long period of time)

To maintain normal ROM, the segments must be

moved through their available ranges (both joint and muscle ranges) periodically to maintain joint and soft tissue mobility and health.

Your Resting HR is

o 220 - ____ (Age) = ____ (establish max.HR) o _____ (max. HR) - _____ (Rest. HR) = _____ o _____ x .60 (Min. Intensity) + _____ (Rest. HR) = ______ Beats/Minute

Individualize the program of exercise.

o All people are not at the same fitness level and therefore, cannot perform the same exercises. o Any one exercise has the potential to be detrimental if attempted by someone not able to execute it properly. o During recovery following an injury or surgery, choose an exercise that does not stress the vulnerable tissue. o Begin at a safe level for the individual and progress as the individual meets the desired goals.

SAID principle

o In physical rehabilitation and sports training, the ... asserts that the human body adapts specifically to imposed demands. o given stressors on the human system, whether biomechanical or neurological, there will be a Specific Adaptation to Imposed Demands

Progression of Resistance Training

o Intensity o Body Position o Stabilization o Alignment o Reps/Sets o Order o Frequency o Type of Muscle Contraction o Range of Motion o Plane of Movement o Speed of Movement o Functional Movement Patterns

Order:

o Large muscle groups should be worked before small muscle groups o Multi joint exercises should be done before single joint exercises o ↑intensity before ↓intensity

Functional excursion

o Muscle ROM o the distance a muscle is capable of shortening after it has been elongated to its maximum. o directly affected by the joint(s) the muscle crosses.

Indications for strengthening exercises

o Muscle performance is impaired - to re-establish neuromuscular control o The need for rehabilitation due to immobilization is evident to prevent/minimize atrophy o To improve baseline level of strength/motor skills o If there is a potential risk of injury or re-injury o Postural or joint instability o During the subacute and chronic phases of healing to encourage better collagen alignment o Improve endurance and general physical well-being

Power training

o Power of a muscle or action can be enhanced by either increasing the load/resistance during a specific amount of time o by reducing the amount of time but maintain the weight/number of reps o Increase the load/resistance and reduce the amount of time, depending on your chosen focus for the exercise.

To avoid overuse syndromes in structures of the musculoskeletal system, proper warm-up and stretching of muscles to be used should be performed.

o Progression of activities should be within the tolerance of the individual. o Overuse commonly occurs when there is an increase in time or effort without adequate rest (recovery) time between sessions. o Increase the repetitions or the time by no more than 10% per week. o If pain begins while exercising or lasts longer than 2 hours after exercising, heed the warning and reduce the intensity.

Mobility and ROM

o ROM as you know it so far is used as an assessment/treatment technique o we will also explore it's uses as a TEX modality for it can be used for initiating movement in a rehabilitation program.

Functional Movement Patterns

o Simple → Complex o Single Joint → Multi Joint o Proximal Control → Distal Control

Type of Muscle Contraction

o Static → Dynamic o Concentric → Eccentric

Intensity

o Submaximal →Maximal o Light load → Heavy load

Power

o The work produced by a muscle per unit of time, or the RATE of performing the work. o Force x Distance / Time o Can be expressed by either a single burst of high intensity activity or by repeated bursts of less intense muscle activity

Cool down

o To encourage venous return post-exercise o allow a slow return to resting state

Warm up

o To prepare the body for exercise both physically and mentally. o should be gradual and sufficient enough to increase heart rate and the muscle temperature. o An increase in mm temperature will ↓ tissue viscosity and ↑nerve conduction. o should also include movements similar to what you will be doing in your activity

To determine Maximum Heart Rate you can do

o a Maximum Performance Multistage Test o Calculate 220 minus your age. This is less accurate but suitable for our needs as RMTs.

Strength Training

o a systemic procedure of a muscle (or muscle group) lifting, lowering, or controlling heavy loads for a relatively low number of repetitions or over a short period of time to increase the maximum force-producing capacity of a muscle. o leads to an increase in muscle strength as a result of neural adaptions, and increase in muscle fibre size.

Resistance exercise

o any form of active exercise in which dynamic or static muscle contraction is resisted by an outside force applied manually or mechanically. o an essential component of any rehabilitation program for people with impaired function

To avoid injuries, use appropriate equipment, such as

o correct footwear, for proper biomechanical support. o Avoid running, jogging, or aerobic dancing on hard surfaces such as asphalt and concrete.

Exercise induced muscle soreness

o develops during or immediately after exercise due to diminished blood flow, decrease oxygen, increase metabolic waste. o Often felt as a burning or aching sensation, generally subsides quickly as blood flow and oxygen is restored

(the dreaded) REVERSIBILITY PRINCIPLE

o if you don't use it, you lose it o Your increases in strength, power, and endurance are transient unless training-induced improvements are regularly used for functional activities or the person is involved in a maintenance-centred program.

DOMS

o pain in muscle belly or MT junction, peaks at 24-48 hours post exercise and can last as long as 10-14 days. o The etiology is unknown but current hypotheses connect microtearing to DOMS. o Most opinions on the prevention of DOMS are mostly conjecture and there is currently no evidence to prove that it can be prevented.

Determine the exercise heart rate

o response that can be safely reached using the Karvonen formula as a guide o accounting for medical conditions, medications, and the individual's perceived exertion.

Repetition maximum (RM)

o the greatest amount of weight a muscle can move through the available ROM a specific number of times before fatiguing. o A 1 RM = max. load in one rep, a 10 RM = max load in 10 reps (~75% of 1 RM). Not safe for people with joint impairments, recovering from or at risk of soft tissue injury, osteoporosis or CV pathology. o Once the 1 RM is established you use a percentage of that weight to determine your training zone for your resistance program. o For clients who are more sedentary or untrained start with 30-40% of 1 RM, for higher trained individuals you can use 40-70%, for highly trained individuals or athletes you can go as high >80%.

Cardiopulmonary endurance

o total body endurance o Systemic Endurance

An increase in mm temperature will

o ↓ tissue viscosity o ↑nerve conduction.

In a Strength training program, the amount of ... applied is progressively...

resistance, increased

Cool-down for 5 to 10 minutes

slow, total body repetitive motions and stretching activities.

Determining the maximum heart rate and exercise heart rate for training programs provides

the basis for the initial intensity of the exercise.

Rhabdomyolysis

the destruction of striated muscle cells

Passive Insufficiency

the point at which a muscle can lengthen no more due to joint(s) limitations

Active Insufficiency

the point at which a muscle can shorten no more due to joint(s) limitations

Joint ROM

the typical ROM

In an Endurance training program, the ... of sustained contraction or number of ... is ...

time, repetitions, increased

PROM limitations

true passive movement is not obtained while muscle is innervated

Initiate a program of activities for the patient that does not elicit a cardiovascular response over the exercise heart rate

walking, repetitive activities, easy calisthenics

Detraining can begin

within a week or two after exercise cessation and continues until training effects are lost. It is important for this reason that gains in

Clinical Signs and Symptoms of Muscle Fatigue

■ An uncomfortable sensation in the muscle, even pain and Cramping ■ Tremulousness in the contracting muscle ■ An unintentional slowing of movement with successive repetitions of an exercise ■ Active movements: jerky, not smooth ■ Inability to complete the movement pattern through the full range of available motion during dynamic exercise against the same level of resistance ■ Use of substitute motions—that is, incorrect movement patterns—to complete the movement pattern ■ Inability to continue low-intensity physical activity ■ Decline in peak torque during isokinetic testing

Guidelines for Initiating an Aerobic Exercise Program for the Deconditioned Individual and the Patient with Chronic Illness

■ Determine the exercise heart rate ■ Initiate a program of activities for the patient that does not elicit a cardiovascular response over the exercise heart rate ■ Provide patients with clearly written instructions about any activity they perform on their own. ■ Initiate an educational program that provides the patient with information

General Guidelines for an Aerobic Training Program

■ Establish the target heart rate and maximum heart rate. ■ Warm-up gradually for 5 to 10 minutes. ■ Increase the pace of the activity so the target heart rate can be maintained for 20 to 30 minutes. ■ Cool-down for 5 to 10 minutes ■ Aerobic activity should be undertaken three to five times per week. ■ To avoid injuries, use appropriate equipment ■ To avoid overuse syndromes in structures of the musculoskeletal system, proper warm-up and stretching of muscles to be used should be performed. ■ Individualize the program of exercise.

Clinical Signs and Symptoms of Delayed-Onset Muscle Soreness

■ Muscle soreness and aching beginning 12 to 24 hours after exercise, peaking at 24 - 48 hours, and subsiding 2 to 3 days later (or longer, as mentioned above) ■ Tenderness with palpation throughout the involved muscle belly or at the musculotendinous junction ■ Increased soreness with passive lengthening or active contraction of the involved muscle ■ Local edema and warmth ■ Muscle stiffness reflected by spontaneous muscle shortening before the onset of pain ■ Decreased ROM during the time course of muscle soreness ■ Decreased muscle strength prior to onset of muscle soreness that persists for up to 1 to 2 weeks after soreness has remitted

Benefits of Strengthening Exercises

Enhanced muscle performance: restoration, improvement or maintenance of strength, power and endurance. Increased strength of connective tissue Greater bone mineral density/ less demineralization Decreased stress on joints during activity Reduced risk of soft tissue injury Possible improvement in heal and repair capacity of soft tissue due to positive impact on tissue remodelling Improved balance and posture Enhanced physical performance in ADLs, occupation, athletics Body composition changes: ↑ lean muscle mass, ↓body fat Improved perception of ability/disability and quality of life Feels great!

Uses for PROM

Joint and tissue assessment To demonstrate what a client should be doing in an active exercise programs Preceding a passive stretch exercise

Concentric contraction

Overall muscle length decreases while muscle generates tension Internal force generated is greater than external resistance Accelerates a body segment Considered "Positive" work.

Eccentric contraction

Overall muscle length increases while the muscle generates tension Internal force generated is less than the external resistance Decelerates a body segment Absorbs shock Involved in most controlled movements in the direction of gravity (sitting down, descending stairs, putting something down) Considered "Negative" work

Contraindications for Strengthening Exercise

Pain - if a client experiences severe joint or muscle pain during active-free (AFROM) then Dynamic resistance exercise is contrainticated. Pain - if a client experiences pain during resisted isometric contraction, then static AND dynamic resistance exercise is contraindicated. Pain - if a client experiences pain that is not eliminated by reducing the resistance then the exercise is contraindicated. Inflammation - both static and dynamic resistance exercise is contraindicated in the presence of inflammatory neuromuscular disease (ie; Guillain-Barre, polymyositis, dermatomyositis) Inflammation - dynamic resistance exercise is contraindicated in the presence of an acute inflammation of a joint (gentle isometrics are ok) Severe Cardiopulmonary Disease - severe cardiac or respiratory diseases or disorders associated with acute symptoms contraindicate resistance training. (ie; coronary artery disease, carditis, cardiomyopathy, and congestive heart failure, or recent M.I., and bypass surgery until cleared by physician)

Prescription for ROM as TEX

Pain-free 7-10 reps 3 sets/day

PROM does not

Prevent atrophy Increase strength or endurance Assist circulation to the extent that active movement does

Precautions and CIs for ROM

- Do not do ROM if motion will disrupt the healing process - Do carefully controlled and slow movements PAIN FREE - Signs of too much of or the wrong movements include increased pain and inflammation - should not be done if client's response or condition is life threatening - PROM may be carefully administered to major joints with AROM to ankles and feet to minimize venous stasis and thrombus formation (bed rest) - After M.I., bypass surgery, or angioplasty, AROM of upper extremities and limited walking are usually tolerated under careful monitoring of symptoms

Special considerations

- Exercise in comfortable temperatures - Wear proper clothing for sweat dissipation - Pain does not equal gain - Always start resistance programs at minimal levels and progress from there - Avoid heavy resistance for children, the elderly, osteoporosis - Never apply resistance across unstable joints or distal to an unhealed fracture - Make sure client is breathing - Avoid ballistic movements - Prevent compensatory movements and momentum/swinging movements - Brace your core to avoid excess strain on the back - Medications, hydration and hunger/blood sugar levels may alter response to exercise - Avoid over training - Discontinue exercise if client experiences pain, dizziness or shortness of breath.

Indications for an Aerobic Exercise Program

- To maintain general muscular and joint health - Applicable to most populations - Can be incorporated into most daily activities - Can decrease the chance of developing health conditions (Heart disease, diabetes, osteoporosis) - Stress management, anxiety and depression - Improve balance, coordination and agility

PROM indications

- acute injury, inflamed tissue - active movement would be detrimental to healing process - immobilization d/t cast, coma, paralysis, bedrest, etc.

PROM goals

- decrease complications that can arise from immobilization - maintain joint and CT mobility - minimize contracture formation - maintain mechanical elasticity of mm - assist circulation and vascular dynamics - synovial movement and cartilage nutrition - decrease/inhibit pain -assist with healing process - maintain patient's awareness of movement

Using the S.A.I.D. Principle

- exercise programs should have specificity - exercises given should mimic the function you are trying to improve

AAROM and AROM limitations

- for strong muscles, AROM does not maintain or increase strength - only develops skill and coordination in the movement patterns used

AAROM and AROM goals

- in addition to the same goals for PROM - maintain physiological elasticity and contractibility of the participating muscle - provide sensory feedback from contracting muscle - provide stimulus for bone and joint tissue integrity - increase circulation and avoid thrombus formation - develop coordination and motor skills for functional activities

AAROM and AROM indications

- when a client is able to contract the muscles actively and move a segment with or without assistance - when a client has weak musculature and is not able yet to progress to resistance exercise - used on joints/segments above or below an immobilized segment to maintain normal function - can be used for aerobic conditioning and to relieve stress caused by sustained postures

The Exercise Heart Rate can be determined in 2 ways

1) as a percentage of the maximum heart rate depending on the level of fitness 2) Karvonen's Formula

PROM

An external force moves the limb/segment through the ROM (not synonymous with Passive stretching!)

Overload principle

If muscle performance is to improve, a load that exceeds the metabolic capacity of the muscle must be applied.

Warm-up gradually for 5 to 10 minutes.

Include lengthening and repetitive motions at slow speeds gradually increasing the effort.

Dynamic resistance exercise

Muscle contraction causes joint movement through available ROM (concentric and eccentric contraction).