Exercise prescription presentation 08.10.16

PowerPoint Presentation

@Physiocouk #manchesterphysio facebook.com/physiocouk

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Exercise Prescription for Sports and Massage Therapists

With: Richard Gregory - Msc (hons) Physiotherapy; Bsc (hons) Sport Science)

Katie Emmett - Bsc (hons) Sports Therapy@Physiocouk #manchesterphysio facebook.com/physiocouk

Welcome

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Katies LinkedIn: www.linkedin.com/katieemmett Twitter: @KatiePhysiocouk

Richs LinkedIn: www.linkedin.com/in/richard-gregory-60712887 Twitter: @RichPhysiocouk

Who are we?

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Website: www.physio.co.uk

Twitter: @physiocouk

Facebook: www.facebook.com/physiocouk

Lets connect

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10.00 - 10.30 - Induction / Arrival10.30 - 11.30 - Theory: exercise prescription11.30 -11.45 Break11.45 - 12.30 - Practical: Lower Limbexercise prescription12.30 13.00 Lunch13.00 -13.45 - Practical: UpperLimbexercise prescription13.45- 15.00 - Case Studies: upper and lower limb

Itinerary

@Physiocouk #manchesterphysio facebook.com/physiocoukAims of today

To discuss the physiological and neurological effects of detraining

To understand specific exercise prescription in terms of volume, load, rest, training days per week

End-stage rehab

Returning to previous level of activity or becoming specifically conditioned for an activity

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@Physiocouk #manchesterphysio facebook.com/physiocoukThree pure fibre types can be identified based on their contractile/metabolic characteristic.TYPE ITYPE IIATYPE IIBFurther intermediate hybrid fibres result in continuum ranging from slowest to fastest (Fry 2004).

I IC IIC IIAC IIA IIAB IIB(SLOWEST) (FASTEST)Muscle Fibre Types

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@Physiocouk #manchesterphysio facebook.com/physiocoukCOSTILL ET AL (1976)Untrained individuals: 50/50 ratio between slow-twitch/fast-twitchLong/middle distance runners: 60-70% slow-twitchSprinters: 80% fast-twitchMuscle Fibre Types

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What happens to injured individuals?

@Physiocouk #manchesterphysio facebook.com/physiocouk2 WEEKSDecrease in VO2 max (up to 7%; Coyle, 1984)No reductions in strengthNo muscle atrophy

The Exercise Detraining Effect

@Physiocouk #manchesterphysio facebook.com/physiocouk 2-3 WEEKSFurther decrease in VO2 max (9%)Decrease in capillary density (Blomquist et al 1983)Muscle atrophy (6.4% in CSA; Bangsbo & Mizuno, 1987)58% elevation in HGH (Houston et al 1979)19.2% elevation in testosterone (Houston et al 1979)No reduction in strength (uninjured population)


@Physiocouk #manchesterphysio facebook.com/physiocouk4-8 WEEKS

Decrease in eccentric strength (Hortobagyi et al 1993)6% reduction in 1RM (Hakkinen et al 2000)Fibre type switching: Slow twitch to fast twitch (5% FTB to 19% FTB after 56 days detraining in cyclists; Hakkinen et al 2000). Implications to antigravity/postural muscles.


@Physiocouk #manchesterphysio facebook.com/physiocouk8-12 WEEKSAlmost complete loss of increased VO2 max among those training at lower intensities7-12% loss in strength (Hakkinen et al, 2001)Maximal neural innervation activity reduced (Hakkinen et al, 1985)


@Physiocouk #manchesterphysio facebook.com/physiocoukSpecific Exercise Prescription

@Physiocouk #manchesterphysio facebook.com/physiocouk.

GETTING THE BASICS RIGHT:S.P.O .R .T .

F .I .T .T .Training Principles

@Physiocouk #manchesterphysio facebook.com/physiocoukIntensity of effortLoadRepetitionsRest intervalsVolumeRange of motionContraction types

Variables to Consider

@Physiocouk #manchesterphysio facebook.com/physiocoukForce Velocity Curve

Which type of contraction elicits maximum strength?

Answer = EccentricTherefore should incorporate low velocity eccentric contractions for strength training

@Physiocouk #manchesterphysio facebook.com/physiocoukPain Management

Some of our tools.

R.I.CEManual Therapy (Grade II/III)R.O.M (synovial sweep)Therapeutic Massage DTFM

Specific exercise prescription to reduce pain

Tendons love Isometrics

Naugle et al (2012): Isometric exercise exerts a generalized pain inhibitory response.

Cook and Purdam (2013): 40-60 second holds, 4-5 times, several times a day. In highly irritable tendons, a bilateral exercise, shorter holding time and fewer repetitions per day may be indicated.

@Physiocouk #manchesterphysio facebook.com/physiocoukHow does White Goodman do it?

Training for Strength

@Physiocouk #manchesterphysio facebook.com/physiocoukPERIPHERAL FACTORS

The peripheral factors that might affect strength gains include:HypertrophyHyperplasiaMuscle fibre type shiftsConceptual Basis For Strength Gains

Conceptual Basis For Strength Gains

@Physiocouk #manchesterphysio facebook.com/physiocoukMUSCLE HYPERTROPHY AND HYPERPLASIA Acute: Sarcoplasmic Hypertrophy (Fluid content)Chronic: Myofibrilar hypertrophy (increased myofibrils)Hyperplasia: Increase in the number of muscle fibres


Occurs when protein synthesis is greater than protein degradationFollowing resistance training, protein synthesis remains elevated for up to 48 hours

@Physiocouk #manchesterphysio facebook.com/physiocoukCENTRAL FACTORS

The central factors that might affect strength gains include:

Inter-muscular co-ordinationMotor unit recruitmentMotor unit firing frequency



Training For Strength- Intensity

@Physiocouk #manchesterphysio facebook.com/physiocoukKEY FOR STRENGTH = HIGH LOAD, HIGH VOLUMELOAD:Novice: 60-70% 1RMAdvanced: 80-100% 1RMVOLUME:Novice: 1-3 sets, 8-12 repetitionsAdvanced: 2-6 sets, 1-8 repetitionsACSM (2013)Training For Strength-Load and Volume

@Physiocouk #manchesterphysio facebook.com/physiocoukACSM (2013):2-3 minutes for intense exercises with heavy loadROBINSON ET AL (1995): 3 minutes more beneficial than 1 minute for improving squat 1RMWILLARDSON AND BURKETT (2008)Benefits in strength with 2 minute rest. No further improvement with 4 minute restTraining For Strength- Rest Intervals

Training For Strength- Rest Periods


Training For Strength- Frequency

@Physiocouk #manchesterphysio facebook.com/physiocoukACSM (2013):

Novices: 2-3 times per week working entire bodyAdvanced: 4-6 workouts a week, still only working each muscle group 2-3 times a week.

Rozier (1981): No difference between training 3 or 5 times a week (trend to improving more with 3 times)

Farinatti (2013): Compared training muscle groups 1, 2, or 3 times a week.

Result:

Bench press and calf raise 10RM = no difference between groupsKnee extension 10RM = favoured 3 times a week

Training For Strength- Frequency

Do we over prescribe in this respect?

Protein synthesis is elevated for 48 hours post exercise

Why are we prescribing exercises every day? Recovery is needed. 27


THE ABILITY OF A MUSCLE TO EXERT SUBMAXIMAL FORCE REPEATEDLY OVER TIME.

Training For Muscular Endurance

@Physiocouk #manchesterphysio facebook.com/physiocoukLOADLess than 70% of 1RM (ACSM 2013)VOLUME2-4 Sets10-25 Repetitions (ACSM 2013)20-28 Repetitions (CAMPOS 2002)Training For Muscular Endurance

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@Physiocouk #manchesterphysio facebook.com/physiocoukREST PERIODSACSM (2013)30 Seconds to 1 minute between setsISSA (2010)1:1 Ration (Exercise:Rest)WHY?Creates high lactate levels in exercising muscles, causing body to improve ability to buffer accumulating lactate (improves lactate threshold)

Training For Muscular Endurance

ISSA international sport sciences association

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@Physiocouk #manchesterphysio facebook.com/physiocoukADAPTATIONS:Fibre shifting: decrease in type 2B fibres; increase in type 2AB fibres (Campos 2002)Hypertrophy (Fisher 2013)Angiogenesis (Katch 2011)Arteriogenesis (Yang et al 2008)Mitochondrial BiogenesisTraining For Muscular Endurance


Training For Motor Control

Often effects:

Stabilising musclesRotator cuffCorePostural muscles

The most common causes of compensation and poor processing (in other words, things that negatively affect motor control) include:Sedentary or deconditioned state (if you dont use it, you lose it)Previous injury, instability, or structural deformityPredisposition to hypermobility (the joints dont communicate as tightly with the muscles)These things lead to poor movement and poor motor programming.This is why we need to intervene and train proper motor control to stay injury resilient and to rehab from any current injuries.

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@Physiocouk #manchesterphysio facebook.com/physiocoukLOAD 30-50% 1RMVOLUME20-25 Repetitions3-5 Sets per muscle group FREQUENCY5-7 Days per week(SHUMWAY-COOK, 2007)Training For Motor Control

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Training For Power

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@Physiocouk #manchesterphysio facebook.com/physiocoukLOAD30-60% 1RM VOLUME1-3 Sets3-6 RepetitionsREPETITION DURATIONShort/explosiveACSM (2013)Training For Power

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@Physiocouk #manchesterphysio facebook.com/physiocoukREST PERIODS

2-3 Minutes for high intensity exercises using heavy loads1-2 Minutes for low intensity exercises using light loads

FREQUENCYNovices: 2-3 times per week working entire bodyAdvanced: 4-6 workouts a week, still only working each muscle group 2-3 times a week.

Training For Power

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@Physiocouk #manchesterphysio facebook.com/physiocoukCoffee Break

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@Physiocouk #manchesterphysio facebook.com/physiocoukPracticalExercise Prescription: Lower Limb

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@Physiocouk #manchesterphysio facebook.com/physiocoukHamstring Exercises

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection - Hamstrings

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@Physiocouk #manchesterphysio facebook.com/physiocoukGlute Max/Glute Med Exercises

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Gluteus Maximus

Reiman et al (2012)42

@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Gluteus Medius

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Gluteals

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@Physiocouk #manchesterphysio facebook.com/physiocoukHip adductors

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Adductors

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@Physiocouk #manchesterphysio facebook.com/physiocoukLunch

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@Physiocouk #manchesterphysio facebook.com/physiocoukPracticalExercise Prescription: Upper Limb

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@Physiocouk #manchesterphysio facebook.com/physiocoukRotator Cuff Exercises

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Rotator Cuff

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection RC : Infraspinatus

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@Physiocouk #manchesterphysio facebook.com/physiocoukSerratus Anterior Exercises

'bound down' by tight fascia. In addition, pain can also be generated from damaged myofascial tissue itself, sometimes at a 'trigger point' where a contraction of muscle fibers has occurred. In either case, the restriction or contraction inhibits blood flow to the affected structures, thus accentuating the contraction process further unless the area is treated.52

@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Serratus Anterior

PNF D1 Flexion and adductionPNF D2 Flexion and Abduction53

@Physiocouk #manchesterphysio facebook.com/physiocoukUpper/Lower Trap Exercises

'bound down' by tight fascia. In addition, pain can also be generated from damaged myofascial tissue itself, sometimes at a 'trigger point' where a contraction of muscle fibers has occurred. In either case, the restriction or contraction inhibits blood flow to the affected structures, thus accentuating the contraction process further unless the area is treated.54

@Physiocouk #manchesterphysio facebook.com/physiocoukExercise Selection Upper/ Lower Trapezuis

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Return to Sport

@Physiocouk #manchesterphysio facebook.com/physiocoukADVANTAGEDISADVANTAGEOPEN CHAIN Joint compression

Exercise in non-WB position

Exercise through ROM

Able to isolate muscle Joint translation

FunctionalityCLOSED CHAIN Joint forces

Joint translation

Functionality

Improved muscle activity through co-activation Joint compression

Not able to work through ROM

Not able to isolate muscles

Return to Sport

Traditionally: Closed chain considered safer due to decreased joint translation/forces and increased functionality


Sport-specific Explosive Power

With MET is it important to know how the muscle is contracted and how muscle energy tehcniques work

Important to mention

Sport-specific Explosive Power

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@Physiocouk #manchesterphysio facebook.com/physiocoukExercises designed to reach maximal force in shortest time possibleAims to increase power of subsequent movements by using elastic properties of muscle and tendon and stretch reflexWhen used correctly, plyometric training has consistently been shown to improve production of muscle force and power (Hewett et al, 1996; Lachance 1995)Plyometrics


Stretch-shortening Cycle

During plyometric exercises, the muscle spindles are stimulated by a rapid stretch causing a reflexive muscle action.

When muscle spindles are stimulated, it sends an input to the spinal cord via Type Ia nerve fibres. After synapsing with the alpha motor neurons in the spinal cord, impulses travel to the agonist extrafusal fibres, causing a reflexive muscle action

The reflexive response increases to force output of the agonist muscle.

GOLGI TENDON ORGAN:

Function: detects tension. If tension is too high will cause muscle to relax

In plyometrics golgi tendon is inhibited/de-sensitised.

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Needs to be a fast transition phase: If the amortization phase lasts too long, the energy stored during the eccentric phase dissipates as heat, and the stretch reflex will not increase muscle activity during the concentric phase

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@Physiocouk #manchesterphysio facebook.com/physiocoukREST INTERVALS5-10 seconds between repetitions2-3 minutes between sets (ACSM 2013)FREQUENCY1-3 sessions per week (Baechle and Earle, 2008)RECOVERY TIME48-72 hours between training sessions (CHU, 1998)

Plyometrics - Prescription

Volume measured in feet

Beginner 80-100 per session Intermediate 100-120Advanced 120-140

DOMS is intense, hence 1-3 sessions per week (eccentric)

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Plyometrics Upper Limb

boxing, rugby hand-off, gymnastics

Throwing sports/overhead activities

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Plyometrics Lower limb

Sport football, basketball, rugby etc

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@Physiocouk #manchesterphysio facebook.com/physiocoukPain freeNo effusionFull (optimal) AROMBetween 90% - 100% strengthCan perform sport specific functional tests

Return to Sport Guidelines

@Physiocouk #manchesterphysio facebook.com/physiocoukIn-Line / Off-Line Rehab

Consider the specific demands of the sport

Most sports (particularly invasion sports) do not only work in a frontal plane

Need to return to off-line movements before the are match ready

@Physiocouk #manchesterphysio facebook.com/physiocoukSherry and Best (2004)

Hamstring rehab protocol:

1 minute side steps1 minute karaoke1 minute fast-feet

3 sets, 2 min rest between sets

Resulted in significant reduction in hamstring re-injury rates when compared to control

Insert evidence

@Physiocouk #manchesterphysio facebook.com/physiocoukCase Studies

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@Physiocouk #manchesterphysio facebook.com/physiocoukUpper Limb

Tennis player - rotator cuff impingement

Stage 1

Ax:1/52 post injury 7/10 VASPain arcPain on resisted abduction/ER. +ve HK

Stage 2

Ax: 8/52 post injuryPain free ROM-ve HK-ve pain on ER5/5 strength

Consider:

What main requirement is? Motor Control and explosive power in upper limbWhat deficits may be?Specific exercisesPrescription of repetitions, sets, load etc

Tennis player - rotator cuff impingement

Stage 1

Ax:1/52 post injury 7/10 VAS, reduced movement. Pain on resisted abduction/ER. Answers:Isometricsreduce pain isometric: stationary against the wall/ theraband/ 5x daily 45 sec x 5 hold / research

Stage 2 (8/52 post injury)Ax:Pain free ROM, -ve HK, -ve pain on ER, 5/5 strengthAim: retraining motor control or Power (plyometrics)?

Answer:25-30 reps3-5 sets5-7 times weeklyFunctional exercises? Rotator cuff?

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@Physiocouk #manchesterphysio facebook.com/physiocoukLower Limb

Rugby player: Back (winger). Grade 2 Hamstring injury

Stage 1:

Ax: 3/52 post injuryFull pain-free range of motion. No pain on resisted testingMild tenderness on palpation of bicep femoris MTJ4/5 oxford scale strength in knee flexors4+/5 oxford scale strength in gluteals, knee extensors

Stage 2:

Ax: 6/52 post injury5/5 oxford scaleNo tenderness on palpation

Rugby player: Back (winger). Grade 2 Hamstring injury

Stage 1: 3/52 post injury

Rx/Answer: Strength orientated training to address strength deficit::HamstringsQuadsGlutes8-12 reps, 80% 1 RM

Stage 2: 7/52 post injury

- PlyometricsAsk: what other functional exercise stuff, agility work (Sherry and best protocol)

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In Summary

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Healthcare

Exercise prescription presentation 08.10.16