Chinese Proverb. He who asks a question is a fool for five minutes; he who does not ask a question remains a fool forever. What do we Fix?

Transcription

1 Robert H. Rowe, PT, DPT, DMT, MHS, FAAOMPT Director Brooks Institute of Higher Learning Chinese Proverb He who asks a question is a fool for five minutes; he who does not ask a question remains a fool forever. What do we Fix? Weakest Link in Chain Goals of Rehabilitation

2 A. Smoking B. Diabetes C. Obesity D. Poor Fitness Answer = D Excessive Force (stress) Too Little Force (stress) Optimal Loading

3 To Increase the Tissue Tolerance for Activities of Daily Living Tissue Regeneration (providing the tissues OSR) Endurance Control/Coordination Strength Flexibility Mobilization Stabilization Other Considerations (power, speed, etc) Resistance Heavy Repetitions Few Functional Qualities Power Strength Volume Light Many Speed Endurance Coordination

4 Apparatus Starting Position Repetitions Resistance Speed Range of Motion Sets Breaks Con/Ecc/Iso Frequency Resting Intervals Endurance Cardiopulmonary system Musculoskeletal system Immune System Central Nervous System Strength Musculoskeletal System Balance (i.e. Coordination) Neuromusculoskeletal System Flexibility Musculoskeletal System *National Institute of Aging at NIH AKA Aerobic Exercise Goal is to increase and/or maintain the health of systems as well as promote the ability of the tissue to perform over a prolonged period of time. Also beneficial to restore the health of debilitated tissue. Typically Utilizes: Organized classes such as traditional aerobic classes Spinning classes Individual running or utilizing machines Swimming Dancing

5 AKA Weight Training Goal is to increase the strength of the muscles and other connective tissues. Typically Utilizes: Dumbbells Machines Elastic Bands Also known as Coordination Exercise. Goal is to improve/maintain the ability to effectively and efficiently move within our environment during functional activities. Typically Utilizes: Functional Training Tai Chi Balance Training Programs (Stepping On) Goal is to improve/maintain the ability to safely and effectively move our trunk and limbs through normal movement patterns. Primarily related to the ability of the muscle to lengthen. Increased flexibility is NOT inherently healthier! Typically Utilizes: Traditional Stretching Yoga Dynamic Stretching

6 These programs offer a combination of exercise types within one program. May Include: CrossFit Kickboxing Cross Training Pros provides opportunity to perform exercise within each of the 4 types of exercise. Cons Potential for over training in one area. Endurance low resistance and high reps. 3 sets of 25 reps Aerobic Activity 150 minutes per week. 10 minute sessions. Strength high resistance and low reps. 3 sets of 10 reps Balance/Coordination many, many reps with functional resistance. 3 to 5 sets of appropriate resistance. Flexibility slow prolonged stretch. Hold stretch for 30 seconds several times per day. 3 minutes of dynamic training. Taylor described many options for trunk strengthening and flexibility, though most of a general nature, including all planes of motion and tri-planar motions. EFFECT. This movement is strongly felt at the side of the hip which is under at the time, and acts throughout the whole extent of the side of the body. It also affects the back.

7 Many of today s exercise programs can be traced back to hundreds of years to previous authors a few examples of diagonal pattern exercise, lumbar extension exercise and functional squat training. The Goldie s exerciser, the precursor to the modern Total Gym, allowed for decreasing the load from gravity as well as assisted exercise. Examples of a) self assisted exercises for shoulder elevation and b) sling exercises for gravity eliminated exercises to the hip.

8 Exercise specific approach (Taping, S-EMG) Muscle isolation (i.e. VMO training, transverse abdominus) Muscle imbalance approach (long and short muscles) General weight training approaches (DeLorme) Equipment based approaches (Isokinetics, Nautilus, MET, Swiss Ball, Aquatics, MedEx) Movement Pattern approaches (Feldenkrais, PNF, Functional Exercise, Yoga, Pilates, Bobath, Tai Chi) Diagnosis driven approaches (Protocols, Spinal Stabilization, McKenzie, Case Study) Functional Training (work hardening, sport training) Stay Active - Physiatrist approach to general exercise Evidenced Based Medicine (vs Authority Based) Specific therapeutic dosing is the use of dosage and exercise progressions to achieve specific functional qualities with training. Specific therapeutic dosing is not limited to use of pulleys and free weight equipment.

9 70% 30% Reserve Work Capacity Demand Percent of Physical Work Capacity 125% Normal 100% 75% 50% Reserve 25% Demand Illness Or Inactive Reserve Demand Trained Reserve Demand

10 Exercise Principles are the Same in Athletes as in Patients, the Difference is in Dosage and Specificity Objective and Measurable Adjusted to Tissues Participating Physiologic Based on the work of Delorme & Holten. Specific # of reps for each type of exercise (e.g. 60% of 1 RM = Endurance Training). Dose is based on # of Reps. The dose is a clinical judgment (guestimate).

11 If the patient obtains 11 repetitions with 2lb., then 60% of 1 R.M. = STEP 1: X = 2 lb. 60% 80% STEP 2: X = STEP 3: X = 3 2 STEP 4: X = 1.5 lb. 60% of 1 R.M. = 1.5 lb Regeneration/Revascularizat ion Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program Work at 40% to 50% of 1 RM to revascularize and wash out waste metabolites from muscles which are either in guarding and/or have not been activated for a prolonged period. The patient would work at the level of 3 sets times 50 reps per set.

12 Regeneration/Revascularization Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program 60% 1 RM (3 x Reps) to continue revascularization, to improve endurance, to increase protein synthesis of the muscle, provide compression/decompression and gliding to the articular cartilage. Also to provide modified tension in the line of stress to the weakened tendons, ligaments, and capsule. Increasing the strength (ability to tolerate loading and tensile forces) of the collagenous based tissues and articular cartilage. Regeneration/Revascularization Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program 60% 1 RM (3 x Reps) to improve coordination. Increasing the efficiency of muscle contraction. In Task Vs Out of Task Consider synergistic force couples. Regeneration/Revascularization Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program 80% 1 RM (3 x 11 Reps) in order to develop dynamic stability within functional patterns. Rests between sets should last 1-2 minutes to allow homeostasis to be maintained. Continue exercises in functional patterns being specific to patient's occupation/adl requirements.

13 Regeneration/Revascularization Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program Warm Up is Not! Warm Up is! Intensity 50% of Conditioning Cool Down Elastic Region AKA toe phase or clinical range. Plastic Region Permanent deformation occurs due to destruction of collagen chemical bonds. Yield Point Transition between elastic and plastic regions.

14 Regeneration/Revascularization Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program Regeneration/Revascularization Endurance Exercise Coordination Exercise Strengthening Exercise Stretching Exercise (Flexibility) Benefits Vs. Harm Warm Up Aerobic Exercise Home Exercise Program Patient's home program will consist of exercises to reinforce the clinical program. Important to get in enough reps to have an effect on the: Articular cartilage. Collagenous based structures. Muscle coordination and endurance. Dynamic stability within functional patterns. Neurophysiological: dorsal horn inhibition, coordination, motor learning, balance, posture. Histological: Fiber (tissue repair) and GAG (nutrition/lubrication) production - emphasis on open chain for tissue loading. Biomechanics: joint play, axis of motion, posture. Biochemical: edema reduction, O 2, hormone production, protein synthesis. Psychological: positive experience with exercise, compliance, posture.

15 Pathology and tissue tolerance Primary and Secondary Model of dysfunction End Goal - Functional level to return to Exercise Back Ground / Equipment Availability Patient s Learning Style Insurance Coverage Acute versus chronic Patient not performing the correct dose. Developing Muscular Imbalances Exercise Program Lack of Balance Progression Too Much Too Little Pt s age, status, pathology, & background. Signs and Symptoms Stages of Tissue Healing Physiologic Basis for Exercise Functional Requirements Patient Goals

16 Begin with the end in mind! Muscle Vs Other Connective Tissues Signs of Harmful Progression No Pain; No Gain! Provide optimal stimulus of regeneration (OSR). Normalize guarded pattern if present. Normalize motor patterning (up-train / downtrain concepts). Establish normal joint and/or fascial mobility. Progress patient specific treatment goals. Increased Pain Increased Edema and/or Temperature Decrease active range of motion Delayed Onset Muscle Soreness (DOMS) Decreased weight bearing status Decreased position tolerance

17 No positive changes in patients subjective comments. No objective changes in physiologic findings of the tissues. Focus on Physiologic Effects Low resistance and high reps. Always look to work in task, but not at the expense of rebuilding the foundation. Commonly performed in conjunction with manual techniques. May last 1-4 weeks.

18 Initiate pre-functional activities. Focus on endurance, coordination, and eventually strength. Transition all exercises/activities to in task. May last 3-12 weeks. Tissues are prepared for functional activities. Activities performed are related to patients specific tasks. May begin as early as week 3 and last for many weeks/months. 3 Phases are a continuum with some gray during the transitions. Move from Impairments to Actions to Tasks to Activities Always try to be in task. Go out of task when necessary. Don t ALWAYS have to start with Phase I

19 Begin with the end in my mind. Phase 3 What does the patient want to attain based on their goals/psfs. Phase 2 What physiologic components need to be modified to safely and effectively perform Phase 3 activities. Phase 1 What tissues have to be regenerated, revascualrized, up trained, down trained, etc to safely and effectively perform Phase 2 activities.