STRENGTHENING EXERCISEAILA NICA J. BANDONG, PTRP

InstructorDepartment of Physical Therapy

UP-College of Allied Medical Professions

PT 153: Therapeutic Exercise 2

LEARNING OBJECTIVESAt the end of the lecture, the students should be able

to: identify the factors affecting tension generation in

muscles. discuss the principles of resistance exercise aimed at

increasing strength. discuss the determinants of resistance exercise. differentiate the various forms of resistance exercise. identify guidelines to providing resistance exercise for

various age groups. discuss considerations for designing resistance exercise

for children. enumerate precautions and contraindications to

treatment using resistance exercise.

MUSCLE PERFORMANCE

Endurance

Power

Strength

STRENGTH Ability of contractile tissue

to produce tension and a resultant force based on the demands placed upon it

Greatest measureable force that can be exerted to overcome resistance in one maximum effort

STRENGTH TRAINING A systematic procedure of a muscle or

muscle group lifting, lowering, or controlling resistance for a particular number of repetitions or over a short period of time

PRINCIPLES OF RESISTANCE EXERCISE

Overload

SAID

Reversibility

OVERLOAD PRINCIPLE If improvements in muscle performance is

desired, the muscle must be challenged to perform at a level greater than that to which it is accustomed to

Progressive loading of muscle through increasing intensity or volume

SAID PRINCIPLES pecificA daptation to I mposedD emands

A framework of specificity is a necessary foundation on which exercise programs should be built

REVERSIBILITY PRINCIPLE Unless training-induced improvements

are regularly used or resistance exercises are maintained, adaptive changes are only temporary

Detraining begins at one to two weeks after cessation of exercise

EFFECT OF STRENGTH TRAINING

Increase in the maximum force-producing capacity of muscle due to physiological adaptations of the body to resistance

exercise

DETERMINANTS OF RESISTANCE EXERCISE

Alignment Stabilization Intensity Volume Exercise order Frequency

• Rest interval• Duration• Mode of exercise• Velocity• Periodization• Integration to

functional activities

ALIGNMENT Muscle Action

The direction of movement of a limb or segment of the body replicates the action of the muscle or muscle group being strengthened

GravityMuscle being strengthened should act

against the resistance of gravity and additional force provided by a device/equipment

STABILIZATION Refers to holding down a body segment

or keeping the segment/body steady during performance of exerciseExternal Internal

INTENSITY aka training load, exercise load Amount of resistance imposed on the

contracting during each repetition Should follow the overload principle

Intensity is greater than the usual load carried and progressively and gradually increased

INTENSITY:SUB-MAXIMAL LOADINGIndications At the beginning of exercise During early stage of soft tissue healing After immobilization Children and older adults Improvement of muscular endurance During warm up and cool down During slow-velocity isokinetic training

INTENSITY:MAXIMAL LOADINGIndications Goal to increase strength and power

and muscle size Healthy individuals in the advanced

phase of a rehab program Conditioning program for the well

population Training for competitive weight lifting

and body building

INTENSITY:DETERMINING THE AMOUNT OF LOAD

Repetition Maximum Other methods

Cable tensiometryDynamometry (hand-held, isokinetic)Percentage body weight

INTENSITY:CALCULATING INITIAL LOAD As a factor of repetition maximum

Sedentary individuals/untrained individuals/children/elderly:30% to 40% of 1RM

Patients with significant strength impairments:30% to 50% of 1RM

Highly trained individuals:80% to 95% of 1RM

INTENSITY:CALCULATING INITIAL LOAD As a factor of body weight (percentage)

Universal bench press: 30% body weight

Universal leg extension: 20% body weight

Universal leg curl: 10-15% body weight

Universal leg press: 50% body weight

VOLUME

Summation of the total number of repetitions and sets of a particular exercise during a single session

Inverse relationship between intensity and volume of resistance exercise

Repetitions vs. Sets

VOLUME:TRAINING TO IMPROVE STRENGTH Exercise protocols

De LormeOxfordDAPRE

Use an exercise load that cause fatigue after 6 to 12 repetitions for two to three sets; if fatigue no longer occurs, increase level of resistance

EXERCISE ORDER

Refers to the sequence in which muscle groups are exercised during a sessionLarge muscle groups before small, isolated

musclesMulti-joint muscles before single-joint

musclesHigher intensity exercise before lower

intensity (following an appropriate warm up)

FREQUENCY Number of sessions performed in a day

or in a week Dependent on the following factors:

IntensityVolumePatient’s goalsHealth statusPrevious participation in resistance exerciseResponse to training

FREQUENCY:GUIDELINES Low intensity, low volume: short sessions

performed daily or several times daily As intensity and volume increases:

frequency decreases to every other day or up to five sessions weekly

Frequency of two times weekly for maintenance programs

FREQUENCY:GUIDELINES

Prepubescent children and very old: frequency is two to three times/sessions weekly

Highly-trained athletes: high intensity and high volume performed 6 days per week

REST INTERVAL aka recovery period Rest between sets and exercise sessions Dependent on the intensity and volume

of exercise as well as status Active recovery is more efficient than

passive recovery to neutralize effects of fatigue

Decreasing rest interval between bouts and sessions as strategy to increase dosage

DURATION Total number of weeks or months that the

resistance exercise program is performedFor hypertrophy or increase in vascularization

to occur, at least 6 to 12 weeks of resistance training is needed

Depending on the nature of impairment, the training program may last from about a month or two to lifetime training to maintain optimal function

MODE OF EXERCISE The form or type of exercise or the

manner in which the exercise is carried out

Classification:Forms of exerciseType of muscle contractionWeight bearing vs Non-weight bearingEnergy system usedShort arc vs Full arc exercise

MODE OF EXERCISE:FORMS OF EXERCISE

Manual and mechanical resistance Constant or variable load through free

weights/weigh machines Accommodating resistance using

isokinetic dynamometer Body weight as resistance

MODE OF EXERCISE:TYPE OF MUSCLE CONTRACTION

Isometric or dynamic muscle contractionDynamic can be performed either

CONCENTRICALLY or ECCENTRICALLY Isokinetic contraction: speed of limb

movement is held constant by a device/equipment (controlled dynamic contraction)

MODE OF EXERCISE:WEIGHT-BEARING VS NONWEIGHT-BEARING

Nonweight-bearing with distal extremity moving: open-chain exercise

Weight bearing with body moving over a fixed distal segment/extremity: closed-chain exercise

MODE OF EXERCISE:ENERGY SYSTEMS Anaerobic exercise: high-intensity

exercise carried out for a limited number of repetitions and utilized as part of a strengthening exercise program

MODE OF EXERCISE:SHORT-ARC VS FULL-ARC Full-arc: develop strength throughout the

entire range of motion Short-arc: utilized to avoid painful motion

or a part of the range where the joint is unstable and to protect healing tissues following injury

VELOCITY Refers to the speed

with which an exercise is performed

Varies with concentric and eccentric muscle contraction

VELOCITY:IMPLICATION TO RESISTANCE TRAINING With free weights, slow to medium

speed/velocity of movement is safer and more effective as patient can maintain control of movement

Speed-specific training Plyometric training Isokinetic training

PERIODIZATION aka periodized training A method of designing a systematic

variation in exercise intensity and volume at regular intervals over a specified period of time

Used to limit overtraining and psychologic staleness

Designed for preparing athletes for competition

INTEGRATION TO FUNCTION Balance of stability and active mobility

Exercise program should address both static and dynamic strength of the trunk and extremitites

Balance of strength, power, and endurance

Progression of movement patterns Isolated strengthening, combined patterns,

task-oriented movement patterns

MANUAL RESISTANCE EXERCISE

A form of active-resistive exercise in which resistance is applied by the therapist to a dynamic or a static muscle contractionThroughout the available ROMVarious planes of motion Isolated muscle contraction or group of

muscles

MECHANICAL RESISTANCE EXERCISE

aka weight training, load-resisting exercise

Any form of exercise in which the resistance is applied by an equipment

EQUIPMENTS USED• Free weights• Elastic resistance• Weight-pulley system• Closed-chain training

equipments• Reciprocal exercise equipment• Isokinetic training equipment

EXERCISE REGIMENS Progressive Resistive Exercise Circuit Weight Training Plyometric Training Isokinetic Regimens

EXERCISE REGIMENS:PROGRESSIVE RESISTIVE EXERCISE Dynamic resistance training in which a

constant external load is applied to the contracting muscle and incrementally increased

Use of RM as basis for determining and progressing resistance

Determinationof 10 RM

10 reps @ 50% of 10 RM

10 reps @ 75% of 10 RM

10 reps @ 100% of 10 RM

DeLorme

Determination of 10 RM

10 reps @100% of 10 RM

10 reps @ 75% of 10 RM

10 reps @ 50% of 10 RM

Oxford

SETS

REPETITIONS

AMOUNT OF RESISTANCE

1 10 50% of 6 RM

2 6 75% of 6 RM

3 Maximum possible

100% 0f 6 RM

4 Maximum possible

100% of adjusted

working weight

ADJUSTED WORKING WEIGHT (DAPRE)Repetitions

in Set 3Set 4 Next Exercise

Session0-2 5-10 lbs 5-10 lbs3-4 0-5 lbs Same

weight5-6 Same

weight5-10 lbs

7-10 5-10 lbs 5-15 lbs11 or more

10-15 lbs 10-20 lbs

EXERCISE REGIMENS:CIRCUIT WEIGHT TRAINING Pre-established sequence of continuous exercises are

performed in succession at individual exercise stations that target a variety of major muscle groups (8-12) as an aspect of total body conditioning Minimum amount of rest interval between stations (15-20

seconds) Alternate among upper/lower extremity and trunk

musculature

Bench press Leg press or

squats Sit-ups Upright rowing Hamstring curls

Exercise Regimens:Circuit Weight Training

• Trunk extension

• Shoulder press

• Heel raises• Push-ups• Leg lifts or

lowering

EXERCISE REGIMENS:PLYOMETRIC TRAINING aka plyometrics, stretch-shortening drills,

reactive neuromuscular training A system of high-velocity resistance

training characterized by a rapid eccentric contraction followed by a rapid shortening contraction of the same muscle

EXERCISE REGIMENS:PLYOMETRIC TRAINING Three phases

Stretch cycle: eccentric loading phaseAmortization phase: period of time between

stretch and shortening cyclesShortening cycle : concentric phase

Sources of resistance: body weight, external load

EXERCISE REGIMENS:PLYOMETRIC TRAINING Appropriate only in the later stages of

rehabilitation of active individuals requiring high level of physical performance in high-demand activities

CRITEARIA for Plyometric Training:80 to 85% level of strength90 to 95% ROM

EXERCISE REGIMENS:ISOKINETIC REGIMENS Velocity Spectrum Rehabilitation

Performance of exercises at various velocities Limb is accelerated at the predetermined

speed/velocity then resistance is applied by the torque arm of the dynamometer through a small portion of the ROM

Performed without pain

EXERCISE REGIMENS:ISOKINETIC REGIMENS Training velocities

Medium angular velocity: 60/90-180 degrees/sec

Fast angular velocity: 180-360 degrees/sec Increments of 30 degrees/sec

Sub-maximal intensity/effort for a brief warm-up period maximal intensity

EXERCISE REGIMENS:ISOKINETIC REGIMENS One or two sets of 8-10 upto 20

repetitions of concentric contractions of antagonist muscle groups at multiple velocities

Rest of 15-20 seconds between sets and 60 seconds rest period between exercise speeds

Maximum frequency of 3x/week

EXERCISE REGIMENS:ISOKINETIC REGIMENS Progression

Submaximal maximal Intermediate and slow speed fastShort arc full arc exercisesConcentric eccentric

Eccentric performed to further challenge the individual muscle groups when strength deficits persist

EXERCISE REGIMENS:ISOKINETIC REGIMENS

Eccentric Isokinetic Training

ISOMETRIC EXERCISE aka static exercise Muscle contracts and produces force

without change in length of the muscle and without visible joint motion

Sources of resistance:Manually, weights, maintaining a position

against body weight, pushing/pulling an immovable object

RATIONALE AND INDICATIONS Prevent or minimize muscle atrophy when joint

motion is not possible due to external immobilization

Activate muscles to begin to re-establish control and protect healing tissues following soft tissue injury or surgery

Develop postural or joint stability Improve muscle strength if dynamic exercise

could cause joint pain and compromise joint integrity

Develop static muscle strength st particular points in the ROM needed for specific task-related needs

TYPES OF ISOMETRIC EXERCISE Muscle-setting exercise Stabilization exercise Multiple-angle isometrics

MUSCLE-SETTING EXERCISE Low intensity isometric exercise

performed against little to no resistance Benefits:

Promotes relaxation and circulationDecrease muscle pain and spasm after injury

to soft tissues during acute stage of healingMaintains mobility between muscle fibers

during healingRetard atrophy during immobilization

STABILIZATION EXERCISE Benefits:

Develop sub-maximal but sustained level of co-contraction

Reduce instabililtyEnhance joint or postural stabililty

Variations:Rhythmic stabilizationAlternating isometricsDynamic stabilization

MULTIPLE-ANGLE ISOMETRICS A system of isometric exercise where

resistance is applied manually or mechanically at multiple joint positions within the available ROM

Goals: Improve strength throughout ROM but

dynamic resistive exercise causes pain or not advised

CONSIDERATIONS Intensity: dependent on joint position Duration: held for 6-10 seconds to allow

for peak tension to develop and for metabolic changes to occur

Repetitive Contractions: decreases muscle cramping and increases effectiveness of the regimen

Joint Angle: resistance at 4-6 points in the available ROM

LIMITATIONS Improvements occur only at or closely

adjacent to the training angle Little or no carry-over of strength gains

to dynamic exercise Not as effective for developing muscle

endurance as resisted dynamic exercise

GUIDELINES: HEALTHY ADULTS (<60Y/O)

Perform warm-up activities followed by flexibility exercises prior to resistance training

For total body muscular fitness: perform dynamic exercises that target approx 8-10 muscle groups of the U/LE

Balance flexion-dominant (pulling) with extension-dominant (pushing) exercises

Move through the full, available, and pain-free ROM

Include both concentric (lifting) and eccentric(lowering) muscle actions

GUIDELINES: HEALTHY ADULTS (<60 Y/O)

Use moderate-intensity exercises at least 8-12 repetitions per set

Perform 1-3 sets of each exercise Include rest periods of 30-60 seconds

between sets Frequency of 2-3 times per week Use slow to moderate speeds of

movement Use rhythmic, controlled, non-ballistic

movements Cool down after the completion of

exercise

GUIDELINES: HEALTHY ADULTS (<60Y/O)

Exercises should not interfere with breathing: avoid valsalva maneuver

Increase intensity gradually (5% increments) as progression

Train with a partner for feedback and assistance, if possible

When re-initiating weight training after a period of exercise cessation (>1-2 weeks), reduce resistance and volume of exercise

GUIDELINES: OLDER ADULTS (>60 Y/O)

Perform at least 5-10 minutes of warm-up activities before each session of resistance exercises

Low to moderate levels at 10-12 repetitions for 6-8 weeks

Perform resistance training 2-3x weekly, allowing 48-hour rest periods between sessions

Avoid flexion-dominant resistance training that could emphasize postural changes

GUIDELINES: OLDER ADULTS (>60 Y/O)

Low intensity exercise to minimize excessive stress on the joints

Resistance training should be initiated with close supervision and minimal resistance

Maintain functional ROM Monitor vital signs, especially when the

program is progressed After a 1 to 2-week layoff, reduce the

intensity of weight training by 50%

RESISTANCE EXERCISE AMONG PRE-ADOLESCENTS(BLIMKIE, C., 1993)

Pre-adolescence: period between pre- and early puberty until 11 y/o (girls) and 13 y/o (boys)

Remained to be a debatable issue among the lay and scientific community

Positive correlation of strength gains and resistance training can not be generalized due to methodological flaws and limited literature

PHYSIOLOGIC ADAPTATIONSVARIABLES TRAINING DETRAINING

Max voluntary strength Definite increase Likely decrease

Evoked twitch force Likely increase UnknownMuscle cross-sectional area Likely no change Probable no change

(uncertain)

Neuromuscular adaptation Definite increase Probable decrease (uncertain)

Motor coordination Probable increase (uncertain) Unknown

Body mass Definite no change Unknown

Lean body mass Probable no change (uncertain) Unknown

Body fat Likely no change Unknown

Stature Likely no change Unknown

Potential Benefits and RisksVARIABLES EFFECTS

Sports Performance Improvements in performance

Prevention of Injury Diminished susceptibility in injuries Recommended for girls as part of osteoporosis prevention

Rehabilitation from Injury Accelerated rehabilitation after injury

Injury Risk (weightlifting) Moderate: unsupervised conditions and during competitive liftingLow: supervised and properly prescribed programmes

Cardiorespiratory Illness No effect or possible improvement depending on the nature of the training programme

Weightlifting Blackout Not likely in properly-instructed, supervised and prescribed programmes

Resting Blood Pressure No proven detrimental effect

GOALS Maintain activity Enjoy movement Develop lifelong activity habits

GUIDELINES: CHILDREN & ADOLESCENTS

No formal resistance training for children less than 6 to 7 years old

At age 6 to 7, introduce the concept of exercise initially without weights using light weights

Maintain close and continuous supervision by a trained personnel or a parent who has received instructions

Focus on proper form, exercise technique, and safety: alignment, stabilization, and controlled motion

Perform warm-up and cool down for 5 to10 mins Low exercise loads of at least 8 to 12 or 12-15

repetitions Perform 1 to 2 sets of each exercise allowing

rest periods of about 3 minutes between sets Frequency limited to 2 exercise sessions per

week Initial progression through increasing

repetitions, not resistance; or increasing the total number of exercise increase resistance by 5% at a time

Gradually progress activities

Guidelines: Children and Adolescents

Provide a variety of activities that target larger muscle groups, multi-joint, combined exercises

Focus on active, creative, enjoyable play in very young children

Encourage children >6 yrs to accumulate a minimum of 30 minutes of at least moderate-intensity activity in most, if not all, days of the week

Encourage older children to participate in 20-30 minutes of higher intensity activity at least 3x a week

Guidelines: Children and Adolescents

Encourage resistance training as only one of a variety of normal recreational and sport activities

Encourage using a variety of different training modalities (free weights, body weight, etc)

Discourage inter-individual competition, and stress the importance of personal improvement

Specific Guidelines

Discourage extremely high intensity (loading) efforts

Avoid isolated eccentric training Encourage a circuit system approach to

capitalize on possible cardiorespiratory benefits

Specific Guidelines

PRECAUTIONS: CHILDREN AND ADOLESCENTS Ensure safety as children are anatomically,

physiologically, and psychologically immatureUse appropriate equipment, match activity to

maturation or skill level, provide adequate skill preparation

Children are less tolerant to high heat load and increased susceptibility to hypothermia in a cold environmentLimit strenuous prolonged exercise, provide

good hydration, and use appropriate clothing

DOCUMENTATION_____ x ______ x _____ x ______, ______ type intensity # of reps # of sets

frequencymode or amount of number number number

ofform of load that of times of bouts times

theresistance will be the ex in a day

exerciseexercise used will be to be

performed performed in a week

DOCUMENTATIONExample 1

Resistance exercise of the right upper extremity muscles using free weights (dumbbell) x 10 lbs x 10 repetitions x 2 sets, thrice a week

DOCUMENTATIONExample 2

Manual resistance exercise of the left hip flexors x 8 repetitions x 2 sets, thrice a week

DOCUMENTATIONExample 3

Multiple angle isometrics of the right knee extensors x 7 seconds hold x 5 repetitions x 1 set, daily

Muscle setting exercise of both quadriceps x 10 seconds hold x 5 repetitions x 1 set, daily

DOCUMENTATIONExample 4

Resistance exercise of both lower-extremity muscles using elastic band (may specify initial color to use) x 10 repetitions x 3 sets, three times a week

DOCUMENTATIONExample 5

Progressive resistive exercise of both elbow flexors using De Lorme protocol x 3 sets, twice a week

THANK YOUFORLISTENING!

REFERENCESAmerican College of Sports Medicine (1998).

Guidelines for exercise testing and prescription (3rd ed). Baltimore: Williams and Wilkins.

Blimkie, C. J. R. (1993). Resistance training during preadolescence: Issues and controversies. Sports Medicine, 15(6), 389-407.

Kisner, C., Colby, L. (2007). Therapeutic exercise: Foundations and techniques (4th ed). Philadelphia: F. A. Davis Company.

Matos, N. and Winsley, R. J. (2007). Trainability of young athletes and overtraining. Journal of Sports Science and Medicine 6,353-367.