Mechanisms of Therapeutic Exercise Progression

Mechanisms Of Therapeutic Exercise Progression
Allan Besselink, PT, Dip.MDT Smart Life Project Austin, Texas
Background
Physiotherapist (1988) McKenzie Diploma (1998) USA Track and Field Endurance sports coach (running, triathlon)
2
Allan Besselink, PT, Dip. MDT
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)
Allan Besselink, PT, Dip. MDT 3
Why This Topic?

The vast majority of "treatments" have little to no confirmed scientific basis yet we claim to be focused on "evidencebased practice"
Why This Topic?

There are too many clinicians using yellow theraband forever ... yet we promote ourselves as the experts in therapeutic exercise
Why This Topic?

We have 50+ years of cellular physiology research and yet we choose to ignore it
Objectives
Identify and examine the current scientific literature on therapeutic exercise and tissue repair Identify the three primary components of RecoveryCentered Training and explain their relevance to therapeutic exercise progression
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
Objectives
Implement optimized therapeutic exercise progressions utilizing the critical parameters and dosage of various loading strategies
Overview
The Basics
Stimulus Response and Homeostasis Loading Strategies to attain Desired Response Tissue- And System-Based Symptomatic, Mechanical, And Functional
Mechanisms

Progressions
Overview
Traditional Approaches To Therapeutic Exercise
Optimal Critical Parameters? What Is The Role Of The PT?
Competent Self Care Is It Enough?
Summary
11
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
13
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
15
Evidence-Based Cellular Physiology

50+ years of research in cellular physiology Apply these wellestablished principles
16
Stimulus - Response
17
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"?
18
Balance Stimulus And Response
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Feedback Loops
20
SAID Principle
Specific Adaptation To Imposed Demands
Wolfe's Law
Form Follows Function Astronauts
21
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
22
Exercise Is Like Medicine
"Therapeutic Dose" is critical!
Critical parameters dosage, frequency, timing Exercise is no different enough for the desired response
23
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!
24
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
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

Scenarios
Stress reaction
Muscle strength
Osteoporosis
Osteoarthritis
Muscle endurance
Post-surgical ROM
Capsular tightness
Tendinopathy Derangement Weight loss
Neuromotor facilitation
Neuromotor inhibition Flexibility Aerobic capacity / deconditioning
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Mechanisms
29
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
31
Relationship Between Function And Cellular Activity

Cellular Level

Changes In ...
Protein synthesis Collagen synthesis Mitochondrial density
Tendon tensile strength
Muscle strength
Cartilage volume
etc
etc
It All Starts With The CNS
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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.
Mechanisms
Tissues

Connective Muscle Nervous
(Epithelial)
Systems
Traditional i.e. Cardiovascular
"Systems Thinking" (incl. MDT)

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)?
36
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 Tendon - tension Cartilage - compression Ligament - tension
Collagen

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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

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?

Building Capacity
Work = Force x Velocity x Time
Intensity is your friend, not your enemy
42
Critical Parameters
Tissues

Connective bone; cartilage; collagen Muscle
Nervous
RCT signs of under-recovery MDT directional preference
Systems

43
Scenarios
Stress reaction
Muscle strength
Osteoporosis
Osteoarthritis
Muscle endurance
Post-surgical ROM
Capsular tightness
Tendinopathy Derangement Weight loss
Neuromotor facilitation
Neuromotor inhibition Flexibility Aerobic capacity / deconditioning
44
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
46
Progression
Based on Symptomatic, Mechanical, and Functional Responses to Loading Strategies

Need benchmarks and baselines!
47
Responses To Loading Strategies
Symptomatic
Mechanical Functional
48
Progression
Progression will vary depending on the ability of the patient to adapt to the imposed demands

Age Metabolic state
49
Progression And Limiters
Be aware of the signs and symptoms of underrecovery (Recovery-Centered Training)
Mechanical
Cognitive Nutritional Hurt Not Harm
Safety
50
Traditional Approaches To Therapeutic Exercise
51
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
58
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/subscribe RunSmart: A Comprehensive Approach To Injury-Free Running
www.allanbesselink.com/slp
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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
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Mechanisms of Therapeutic Exercise Progression - TPTA Annual Conference 2011

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Allan Besselink, PT, Dip.MDT Smart Life Project Austin, Texas

Allan Besselink, PT, Dip. MDT

Educator (PT; PTA)

Why This Topic?

Allan Besselink, PT, Dip. MDT

Why This Topic?

Allan Besselink, PT, Dip. MDT

Why This Topic?

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Traditional Approaches To Therapeutic Exercise

Optimal Critical Parameters? What Is The Role Of The PT?

Competent Self Care Is It Enough?

Allan Besselink, PT, Dip. MDT

In groups of 3 to 5, discuss the scenario presented to you

What is the primary mode of therapeutic exercise required?

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Principles And Practices

Allan Besselink, PT, Dip. MDT

Stimulus Response Homeostasis Specific Adaptation To Imposed Demands

Allan Besselink, PT, Dip. MDT

Evidence-Based Cellular Physiology

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Balance Stimulus And Response

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Specific Adaptation To Imposed Demands

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Exercise Is Like Medicine

"Therapeutic Dose" is critical!

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

True Systems Thinking

Allan Besselink, PT, Dip. MDT

Central nervous system

Derangement, Dysfunction, Posture, Other

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Relationship Between Function And Cellular Activity

Protein synthesis Collagen synthesis Mitochondrial density

Tendon tensile strength

It All Starts With The CNS

Allan Besselink, PT, Dip. MDT

Connective Muscle Nervous

Traditional i.e. Cardiovascular

"Systems Thinking" (incl. MDT)

Mechanical Loading Strategies

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Allan Besselink, PT, Dip. MDT

Tension / Load / Resistance

CNS Recruitment Motor patterns Synaptogenesis Facilitation and inhibition

Allan Besselink, PT, Dip. MDT

In your original groups, discuss the scenario presented to you