Post on 27-May-2015
description
Mechanisms Of TherapeuticExercise Progression
Allan Besselink, PT, Dip.MDTSmart Life Project
Austin, Texas
Allan Besselink, PT, Dip. MDT 2
Background
Physiotherapist (1988)
McKenzie Diploma (1998)
USA Track and Field
Endurance sports coach (running, triathlon)
Allan Besselink, PT, Dip. MDT 3
Background
Educator (PT; PTA)
Author - “RunSmart: A Comprehensive Approach To Injury-Free Running” (2008)
Author (with Bridget Clark, PT) - “Running Injuries” chapter in 3rd
edition of ”Clinical Orthopedic Rehabilitation” (2011)
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Why This Topic?
The vast majority of "treatments" have little to no confirmed scientific basis …
… yet we claim to be focused on "evidence-based practice"
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Why This Topic?
There are too many clinicians using yellow theraband forever …
... yet we promote ourselves as the experts in therapeutic exercise
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Why This Topic?
We have 50+ years of cellular physiology research …
… and yet we choose to ignore it
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Objectives
Identify and examine the current scientific literature on therapeutic exercise and tissue repair
Identify the three primary components of Recovery-Centered Training and explain their relevance to therapeutic exercise progression
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Objectives
Discuss the physiological mechanisms underlying tissue repair and development in the context of therapeutic exercise
Define the principles of mechanical loading and their application to therapeutic exercise programs
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Objectives
Implement optimized therapeutic exercise progressions utilizing the critical parameters and dosage of various loading strategies
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Overview
The Basics Stimulus – Response and Homeostasis
Mechanisms Loading Strategies to attain Desired
Response Tissue- And System-Based
Progressions Symptomatic, Mechanical, And Functional
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Overview
Traditional Approaches To Therapeutic Exercise
Optimal Critical Parameters? Competent Self Care – Is It Enough?
What Is The Role Of The PT? Summary
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Discussion
In groups of 3 to 5, discuss the scenario presented to you
Assume no "red flags" are present What is the primary mode of therapeutic
exercise required?
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The Basics
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Principles And Practices
Principles = Why
Practices = What
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The Basics
Stimulus – Response Homeostasis Specific Adaptation To
Imposed Demands Wolfe's Law Building Capacity Critical Parameters
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“Evidence-BasedCellular Physiology”
50+ years of research in cellular physiology
Apply these well-established principles
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Stimulus - Response
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Homeostasis
"The maintenance of relatively stable internal physiological conditions under fluctuating environmental conditions"
Are we ever "out of balance"?
Do we ever really, by definition, have a "muscle imbalance"?
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Balance Stimulus And Response
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Feedback Loops
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SAID Principle
Specific Adaptation To Imposed Demands
Wolfe's Law Form Follows Function Astronauts
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Building Capacity
Work = "the amount of energy transferred into or out of a system, not counting energy transferred by heat conduction"
Work = Power x time
Work = Force x Velocity x Time
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Exercise Is Like Medicine
"Therapeutic Dose" is critical!
Critical parameters – dosage, frequency, timing
Exercise is no different – enough for the desired response
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Traditional Systems
Cardiovascular / Aerobic system
Endurance = the capacity to withstand physiological or psychological stressors over a sustained period of time
The heart is a muscle!
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True Systems Thinking
Involves understanding the behavior of the system as a whole (Peter Senge "The Fifth Discipline")
Recovery-Centered Training – A Model Of Human Performance
Mechanical Diagnosis And Therapy (MDT)
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Recovery-Centered Training
Mechanical
Neuro-musculo-skeletal Cardiovascular
Cognitive
Central nervous system Endocrine system Immune system
Nutritional
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MDT
Mechanical Diagnosis and Therapy (MDT)
A systems thinking approach to musculoskeletal care
Mutually exclusive diagnostic categories based on system behavior (responses to repeated movements and sustained loading)
Derangement, Dysfunction, Posture, Other
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Scenarios
Stress reaction Osteoporosis Osteoarthritis Capsular tightness Tendinopathy Derangement Weight loss
Muscle strength Muscle endurance Post-surgical ROM Neuromotor facilitation Neuromotor inhibition Flexibility Aerobic capacity /
deconditioning
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Mechanisms
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Mechanisms
Mechanisms of Optimal Human Performance=
Mechanisms of Injury Recovery=
Mechanisms of Injury Prevention
(Besselink 1992)
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Mechanisms
Stimulate appropriate cellular activity to attain desired cellular response
Critical parameters of mechanical loading to attain desired cellular response
Appropriate Symptomatic, Mechanical and Functional Responses
Relationship Between Function And Cellular Activity
Cellular Level Protein synthesis Collagen synthesis Mitochondrial density
etc
Changes In ... Tendon tensile
strength Muscle strength Cartilage volume
etc
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It All Starts With The CNS
Mechanotransduction
Khan KM, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247-252.
Kaneko D et al. Temporal effects of cyclic stretching on distribution and gene expression of integrin and cytoskeleton by ligament fibroblasts in vitro.Connect Tiss Res 2009; 50(4), 263-269.
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Mechanisms
Tissues Connective Muscle Nervous
(Epithelial) Systems
Traditional i.e. Cardiovascular "Systems Thinking" (incl. MDT)
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Mechanical Loading Strategies
What mechanical loading strategy is required to stimulate the desired cellular activity and to "turn on the gene"?
Which mechanical loading strategy is required to attain the desired functional response(s)?
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Critical Parameters
Every training session/exercise has an intent – and a desired cellular response
Critical parameters of dosage/potency and frequency
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Connective Tissue
Bone Tension, compression, shear Fluid flow
Collagen Tendon - tension Cartilage - compression Ligament - tension
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Muscle Tissue
Number of muscle fibers recruited
Velocity of muscle fiber recruitment
Mitochondria = cellular powerhouse (active muscle fibers only) = endurance
Tension / Load / Resistance
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Nervous Tissue
CNS Recruitment
Motor patterns
Synaptogenesis
Facilitation and inhibition
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Discussion
In your original groups, discuss the scenario presented to you
With what you now know, what is the primary mode of therapeutic exercise (mechanical loading strategy) required to attain the desired cellular response?
What are the critical parameters necessary to do so?
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Building Capacity
Work = Force x Velocity x Time
Intensity is your friend, not your enemy
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Critical Parameters
Tissues Connective – bone; cartilage; collagen Muscle Nervous
Systems RCT – signs of under-recovery MDT – directional preference
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Scenarios
Stress reaction Osteoporosis Osteoarthritis Capsular tightness Tendinopathy Derangement Weight loss
Muscle strength Muscle endurance Post-surgical ROM Neuromotor facilitation Neuromotor inhibition Flexibility Aerobic capacity /
deconditioning
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Tissue Repair And Remodeling
Acute Phase = 1 to 3 days = "your friend, not your foe"
Fibroplastic = up to 3 weeks = "prime time" for mechanical loading
Remodeling = 6 weeks to 2 years = still very responsive to mechanical loading
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Progressions
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Progression
Based on Symptomatic, Mechanical, and Functional Responses to Loading Strategies
Need benchmarks and baselines!
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Responses To Loading Strategies
Symptomatic
Mechanical
Functional
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Progression
Progression will vary depending on the ability of the patient to adapt to the imposed demands
Age Metabolic state
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Progression And Limiters
Be aware of the signs and symptoms of “under-recovery” (Recovery-Centered Training)
Mechanical Cognitive Nutritional
Safety
Hurt Not Harm
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Traditional Approaches ToTherapeutic Exercise
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Traditional Approaches
Insufficient or inappropriate exercise parameters to elicit desired (or optimal) physiological response
Garbage In, Garbage Out
Modalities as a passive mechanical loading strategy
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Woollard et al (2011) JOSPT
"Change in Knee Cartilage Volume in Individuals Completing a Therapeutic Exercise Program for Knee Osteoarthritis"
Loss of cartilage volume
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Therapeutic Exercise Program
Stretching, quadriceps setting, SLR Leg press at 70% of 1-RM: 3 x 10 PT 2x per week for 6 weeks HEP 2x per week for 4 weeks Based on the critical parameters, would I
expect anything different?
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Problem
“The inability to challenge our belief systems in the face of good scientific evidence is the primary limiting factor in the advancement of both health care and coaching, as well as human performance and injury prevention”
(Besselink 2008)
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Competent Self Care - Is It Enough?
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Competent Self Care
Can the patient perform the necessary loading strategies to promote optimal repair and remodeling on their own?
What is the role of the PT?
Competent self care and health mentorship is an opportunity for the PT profession
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Summary
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Challenge Your Thinking!
“We can't solve problems by using the same kind of thinking we used when we created them.”
(Einstein)
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For More Information:
Smart Life Project
www.allanbesselink.com/slp www.allanbesselink/subscribe “RunSmart: A Comprehensive
Approach To Injury-Free Running”
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Move Forward (APTA)
www.moveforwardpt.com
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The Finish Line Is Upon Us!
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Photo Credits
http://www.flickr.com/photos/monsieurlui/
http://www.flickr.com/photos/emilianohorcada/
http://www.flickr.com/photos/pinksherbet/
http://www.flickr.com/photos/53921113@N02/
http://www.flickr.com/photos/panduadnyana/
Allan Besselink
All others public domain or fair use Creative Commons