STRENGTHENING EXERCISE

STRENGTHENING STRENGTHENING EXERCISEEXERCISE

AILA NICA J. BANDONG, PTRPInstructor

Department 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.

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 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 Principle

S pecific

A daptation to

I mposed

D 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 TrainingIncrease 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

• Gravity– Muscle 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 exercise– External– 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 Loading

Indications• 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 Loading

Indications• 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

• Repetition Maximum

• Other methods– Cable tensiometry– Dynamometry (hand-held, isokinetic)– Percentage body weight

Intensity:Determining the Amount of 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

Intensity:Calculating Initial Load

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

• Exercise protocols– De Lorme– Oxford– DAPRE

• 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

Volume:Training to Improve Strength

Exercise Order

• Refers to the sequence in which muscle groups are exercised during a session– Large muscle groups before small, isolated

muscles– Multi-joint muscles before single-joint

muscles– Higher 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:– Intensity– Volume– Patient’s goals– Health status– Previous participation in resistance exercise– Response 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 performed– For 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 exercise– Type of muscle contraction– Weight bearing vs Non-weight bearing– Energy system used– Short arc vs Full arc 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:Forms of Exercise

• Isometric or dynamic muscle contraction– Dynamic 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:Type of Muscle Contraction

• 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:Weight-bearing vs Nonweight-bearing

• 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:Energy Systems

• 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

Mode of Exercise:Short-arc vs Full-arc

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 contraction– Throughout the available ROM– Various 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

Adjusted working weight (DAPRE)Repetitions

in Set 3Set 4 Next Exercise Session

0-2 5-10 lbs 5-10 lbs

3-4 0-5 lbs Sameweight

5-6 Same weight 5-10 lbs

7-10 5-10 lbs 5-15 lbs

11 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

• Three phases– Stretch cycle: eccentric loading phase– Amortization phase: period of time between

stretch and shortening cycles– Shortening cycle : concentric phase

• Sources of resistance: body weight, external load


• 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 strength– 90 to 95% ROM


• 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


• 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


• Progression– Submaximal maximal– Intermediate and slow speed fast– Short arc full arc exercises– Concentric eccentric

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


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

• Muscle-setting exercise

• Stabilization exercise

• Multiple-angle isometrics

Types of Isometric Exercise

• Low intensity isometric exercise performed against little to no resistance

• Benefits:– Promotes relaxation and circulation– Decrease muscle pain and spasm after injury to

soft tissues during acute stage of healing– Maintains mobility between muscle fibers during

healing– Retard atrophy during immobilization

Muscle-setting Exercise

• Benefits:– Develop sub-maximal but sustained level of co-

contraction– Reduce instabililty– Enhance joint or postural stabililty

• Variations:– Rhythmic stabilization– Alternating isometrics– Dynamic stabilization

Stabilization Exercise

• 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

Multiple-angle Isometrics

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

• 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


• 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


• 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%

Guidelines: Older Adults (>60 y/o)

• 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

Resistance Exercise Among Pre-adolescents(Blimkie, C., 1993)

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 performancePrevention of Injury Diminished susceptibility in injuries

Recommended for girls as part of osteoporosis prevention

Rehabilitation from Injury Accelerated rehabilitation after injuryInjury 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 and 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


• 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


• 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

• Ensure safety as children are anatomically, physiologically, and psychologically immature– Use 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 environment– Limit strenuous prolonged exercise, provide

good hydration, and use appropriate clothing

Precautions: Children and Adolescents

Documentation

_____ x ______ x _____ x ______, ______

type intensity # of reps # of sets frequencymode or amount of number number number of

form of load that of times of bouts times the

resistance will be the ex in a day exercise

exercise used will be to be

performed performed

in a week

Example 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

Documentation

Example 2

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

Documentation

Example 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

Documentation

Example 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

Documentation

Example 5

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

Documentation

THANK YOU

FORLISTENING!

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.

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