Mechanisms Of Therapeutic Exercise Progression - TPTA Annual Conference 2011

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)


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)


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"


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 Recovery-Centered 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

Mechanisms Loading Strategies to attain Desired

Response Tissue- And System-Based

Progressions Symptomatic, Mechanical, And Functional


Overview

Traditional Approaches To Therapeutic Exercise

Optimal Critical Parameters? Competent Self Care – Is It Enough?

What Is The Role Of The PT? Summary


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?


The Basics


Principles And Practices

Principles = Why

Practices = What


The Basics

Stimulus – Response Homeostasis Specific Adaptation To

Imposed Demands Wolfe's Law Building Capacity Critical Parameters


“Evidence-BasedCellular Physiology”

50+ years of research in cellular physiology

Apply these well-established principles


Stimulus - Response


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"?


Balance Stimulus And Response


Feedback Loops


SAID Principle

Specific Adaptation To Imposed Demands

Wolfe's Law Form Follows Function Astronauts


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


Exercise Is Like Medicine

"Therapeutic Dose" is critical!

Critical parameters – dosage, frequency, timing

Exercise is no different – enough for the desired response


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!


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)


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 Osteoporosis Osteoarthritis Capsular tightness Tendinopathy Derangement Weight loss

Muscle strength Muscle endurance Post-surgical ROM Neuromotor facilitation Neuromotor inhibition Flexibility Aerobic capacity /

deconditioning


Mechanisms


Mechanisms

Mechanisms of Optimal Human Performance=

Mechanisms of Injury Recovery=

Mechanisms of Injury Prevention

(Besselink 1992)


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


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.


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)?


Critical Parameters

Every training session/exercise has an intent – and a desired cellular response

Critical parameters of dosage/potency and frequency


Connective Tissue

Bone Tension, compression, shear Fluid flow

Collagen Tendon - tension Cartilage - compression Ligament - tension


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


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


Critical Parameters

Tissues Connective – bone; cartilage; collagen Muscle Nervous

Systems RCT – signs of under-recovery MDT – directional preference


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


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


Progressions


Progression

Based on Symptomatic, Mechanical, and Functional Responses to Loading Strategies

Need benchmarks and baselines!


Responses To Loading Strategies

Symptomatic

Mechanical

Functional


Progression

Progression will vary depending on the ability of the patient to adapt to the imposed demands

Age Metabolic state


Progression And Limiters

Be aware of the signs and symptoms of “under-recovery” (Recovery-Centered Training)

Mechanical Cognitive Nutritional

Safety

Hurt Not Harm


Traditional Approaches ToTherapeutic Exercise


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


Woollard et al (2011) JOSPT

"Change in Knee Cartilage Volume in Individuals Completing a Therapeutic Exercise Program for Knee Osteoarthritis"

Loss of cartilage volume


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?


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)


Competent Self Care - Is It Enough?


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


Summary


Challenge Your Thinking!

“We can't solve problems by using the same kind of thinking we used when we created them.”

(Einstein)


For More Information:

Smart Life Project

www.allanbesselink.com/slp www.allanbesselink/subscribe “RunSmart: A Comprehensive

Approach To Injury-Free Running”

http://www.allanbesselink.com/slp


Move Forward (APTA)

www.moveforwardpt.com

http://www.moveforwardpt.com/


The Finish Line Is Upon Us!


Photo Credits

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Allan Besselink

All others public domain or fair use Creative Commons

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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/

Health & Medicine

Mechanisms Of Therapeutic Exercise Progression - TPTA Annual Conference 2011