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Background
Physiotherapist (1988) McKenzie Diploma (1998) USA Track and Field Endurance sports coach (running, triathlon)
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Background
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
Allan Besselink, PT, Dip. MDT 10
Mechanisms
Progressions
Overview
Summary
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Discussion
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The Basics
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The Basics
Wolfe's Law
Building Capacity Critical Parameters
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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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Feedback Loops
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SAID Principle
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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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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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
Nutritional
Allan Besselink, PT, Dip. MDT 26
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)
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
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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
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Changes In ...
Muscle strength
Cartilage volume
etc
etc
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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
(Epithelial)
Systems
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 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
Nervous Tissue
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Discussion
Building Capacity
Work = Force x Velocity x Time
Intensity is your friend, not your enemy
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Critical Parameters
Tissues
Nervous
RCT signs of under-recovery MDT directional preference
Systems
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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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Progressions
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Progression
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Symptomatic
Mechanical Functional
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Progression
Progression will vary depending on the ability of the patient to adapt to the imposed demands
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Mechanical
Cognitive Nutritional Hurt Not Harm
Safety
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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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"Change in Knee Cartilage Volume in Individuals Completing a Therapeutic Exercise Program for Knee Osteoarthritis" Loss of cartilage volume
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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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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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www.allanbesselink.com/slp
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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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