PT 153: Therapeutic Exercise 2
STRENGTHENING EXERCISE
AILA NICA J. BANDONG, PTRP
Instructor
Department of Physical Therapy
UP-College of Allied Medical Professions
Learning Objectives
At 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.
Power
Strength
Endurance
MUSCLE PERFORMANCE
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 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 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
• 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
Intensity:
Determining the Amount of Load
• Repetition Maximum
• Other methods
– Cable tensiometry
– Dynamometry (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 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
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
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 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:
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: closedchain 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
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
DeLorme
Oxford
Determination
of 10 RM
Determination of
10 RM
10 reps @ 50% of
10 RM
10 reps @100% of
10 RM
10 reps @ 75% of
10 RM
10 reps @ 75% of
10 RM
10 reps @ 100% of
10 RM
10 reps @ 50% of
10 RM
SETS REPETITIONS
AMOUNT OF
RESISTANCE
1
2
10
6
50% of 6 RM
3
Maximum
possible
Maximum
possible
100% 0f 6 RM
4
75% of 6 RM
100% of adjusted
working weight
Adjusted working weight (DAPRE)
Repetitions
in Set 3
Set 4
Next Exercise Session
0-2
5-10 lbs
5-10 lbs
3-4
0-5 lbs
5-6
Same weight
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
Exercise Regimens:
Circuit Weight Training
•
•
•
•
•
Bench press
Leg press or squats
Sit-ups
Upright rowing
Hamstring curls
•
•
•
•
•
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 phase
– Amortization phase: period of time between
stretch and shortening cycles
– Shortening 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 strength
– 90 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  fast
Short arc  full arc exercises
Concentric  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 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
Stabilization 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
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 (<60 y/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 (<60 y/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 Adaptations
VARIABLES
Max voluntary
strength
Evoked twitch force
Muscle cross-sectional
area
Neuromuscular
adaptation
Motor coordination
Body mass
Lean body mass
TRAINING
DETRAINING
Definite increase
Likely decrease
Likely increase
Likely no change
Unknown
Probable no change
(uncertain)
Probable decrease
(uncertain)
Unknown
Definite increase
Probable increase
(uncertain)
Definite no change
Unknown
Unknown
Body fat
Probable no change
(uncertain)
Likely no change
Stature
Likely no change
Unknown
Unknown
Potential Benefits and Risks
VARIABLES
EFFECTS
Sports Performance
Prevention of Injury
Improvements in performance
Diminished susceptibility in injuries
Recommended for girls as part of
osteoporosis prevention
Rehabilitation from Injury
Injury Risk (weightlifting)
Accelerated rehabilitation after injury
Moderate: unsupervised conditions and
during competitive lifting
Low: supervised and properly prescribed
programmes
Cardiorespiratory Illness
No effect or possible improvement depending
on the nature of the training programme
Not likely in properly-instructed, supervised
and prescribed programmes
No proven detrimental effect
Weightlifting Blackout
Resting Blood Pressure
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
Guidelines: Children and Adolescents
• 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 moderateintensity activity in most, if not all, days of the
week
• Encourage older children to participate in 2030 minutes of higher intensity activity at least
3x a week
Specific Guidelines
• 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
Precautions: Children and Adolescents
• 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
Documentation
_____ x ______ x _____ x ______, ______
type
mode or
form of
resistance
exercise
intensity # of reps # of sets frequency
amount of
load that
will be
used
number number number of
of times of bouts times the
the ex
in a day exercise
will be
to be
performed
performed
in a week
Documentation
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
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References
American 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.