Neuromuscular 2 Unit 5: Dosing principles for improving Strength, Aerobic capacity and endurance Flashcards
What is Physical Fitness?
A set of measurable health and skilled related attributes including: ability to carry out daily activities without undue fatigue
What is Physical Activity?
Any bodily movement produced by skeletal muscles that result in energy expenditure
What is exercise?
A subset of physical activity that is structured, planned and repetitive and has a final or intermediate objective for the improvement or maintance of physical fitness. Exercise is intentional.
Types of Exercise
With Exercise, what is the purpose for Strengthening Exercise?
- UMN: Challenge activity of descending
motor pathway - UMN: Challenge antagonist of a
hypertonic muscle
We must OVERLOAD!!!!!
Types of Exercise
With Exercise, how are strengthening exercises measured?
- %RM
- Reps in Reserve
Types of Exercise
With Exercise, what is the purpose fo Cardiovascular Exercise?
Challenge release of BDNF
Types of Exercise
With Exercise, how are Cardiovascular exercises measured?
- %HR Max
- % HRR Max
- % PRE
Types of Exercise
With Exercise, what is the purpose fo Balance Exercise?
Challenge posture control with motor learning principles
With Exercise, how are Balance exercises measured?
- Repetition is necessary
- Observational (is posture improving)
- Feedback Schedule
With Exercise, what is the purpose fo Coordination Exercise?
Challenge composition of movement with motor learning principles
With Exercise, how are Coordination exercises measured?
- Repetition is necessary
- Observational (is posture improving)
- Feedback Schedule
What are the Benefits of Physical Activity and Exercise?
- Improved motor performance
-BDNF and neuroplasticity - Improved functional mobility
-Fall reduction - Improved fitness
-Fatigue reduction - Improved cognition and mood
-Reduced depression - Improved QOL
- Reduced risk of chronic disease
-CVD, metabolic syndrome, stroke, osteoporosis
What is Brain Derived Neurotrophic Factor (BDNF)?
What is BDNF involved in?
- This is a key mediator or motor learning and “priming the brain” for neuroplasticity
- Its secreted by 2 mechanisms: Constructive and activity dependent pathways
- Evidence that 30 min at 60% maxHR is effective for increasing BDNF in pts with chronic disorders
Its involved in:
- Neuroprotection
- Neurogenesis
- Neuroplasticity
With Stroke, what are the Primary impairments for strength?
- Reduced force production, paresis or plegia
-Secondary impairment: disuse atrophy - Reduced voluntary motor output via corticospinal tract (Abnormal synergies: Flexor, Extensor)
- Abnormal muslce tone (Flaccidity, Hypotonia, Spasticity)
- Impaired sensory input
With Stroke, what are the Primary Impairments for Cardiopulmonary Function?
What are Secondary Impairments?
- Reduced cardiac output, cardia decompression, rhythm disorders
- Decreased vital capacity, pulmonary perfusion and lung volume
Limitations in cardiac and pulmonary function may limit rehabilitation potential
Due to deconditioning:
- Reduced CO, increased HR, increased BP, decreased O2 uptake, decreased vital capacity
With TBI, what are the Primary Impairments for Strength?
- Abnormal muscle tone
- Reduced motor output via impaired motor unit timing and recruitment
- Muscle paresis or plegia
- Impaired coordination
- Abnormal motor control resulting in synergistic movement
Secondary impairments: Disuse atrophy
With TBI, what are the Primary Impairments for Cardiopulmonary Function?
- Dysautonomia: This presents as Increased sympathetic
activity resulting in increased heart rate, respiratory rate, and blood pressure - Fatue, Poor sleep, increased cardiovascular disease risk
With MS, what are the Primary Impairments for Strength?
- Muscle paresis or plegia
- Decreased firing rate of motor units
- Impaired orderly recruitment of motor neurons
- Reduced force production, power, muscle endurance
- Abnormal motor control resulting in synergistic movement
- Spasticity, stiffness in muscle tone
Secondary impairment: Disuse atrophy and weakness due to inactivity
With MS, what are the Primary Impairments for Cardiopulmonary Function?
- Dysautonomia
- Reduced respiratory muscle function (weakness)
- Increased fatigue
Primary and Secondary:
- VO2 Max (aerobic power) may be reduced
Secondary impairment: Decreased work capacity, vital capacity and increased resting HR
With Parkinson’s, what are the Primary Impairments for Strength?
- Reduced and delayed motor recruitment
- Asynchronization of muscle contraction leading to issues with smoothly increasing firing rate
- Decreased amplitude of movement
- Troque production decreased at all speeds
Secondary impairment: Disuse and inactivity with progression of disease
Increased sense of effort, fatigue is common among those with PD
With Parkinson’s, what are the Secondary Impairments for Cardiopulmonary Function?
- Reduced rib cage compliance
- Rigidity
- Reduced chest wall mobility and expansion
- Reduced endurance, vital capacity, inspiratory and expriatory flow due to inactivity
What is the importance of screening neurological patients to exercise?
CDC recommends 150 min of Mod. intensity exercise
- With this, we must take a complete medial hx to ensure it is safe for the patient
- We assess strength, balance, cognition, behavior, and communication as well
- Assessment of vitals before, during and after must be done
-consider the position of the patient (Supine, sitting, standing)
- Submax testing may need to be performed to ensure proper prescription intensity
What is an Exercise Tolerance Test (ETT)?
This examines the ability of the cardiovascular system to accommodate to increasing metabolic demand, and ETT, stress test, or graded test is performed.
- All patients would qualify for recieving submax ETT as it helps guide the prescription of intensity of VO2 reserve 50-70% or HRMax 60-85%.
What are the different modes of submax ETT?
- Treadmill
- Recumbent leg cycle ergometer
- Recumbent stepper
- Upper extremity cycle ergometer
What are 3 different Graded ETT protocals with ecg?
- Bruce Protocal: Treadmill
- YMCA Protocal: Cycle Ergometer
- Total-body recumbent stepper protocol
What is a non-graded ETT?
6 minute walk test
How do we Examine Strength in Neurologic Populations?
With UMN Dx (Stroke, TBI, MS)
- MMT are not valid due to abnormal synergistic movement patterns. MMT are not valid in the absence of isolated movements
Strength Assessment
- Observation of strength though functional task (task analysis)
- Describe abnormal synergy
- MMT of isolated muslces only
- Self-report
With PD patients
- MMT
- Dynamometry
- Functional strength assessment (Task analysis of bed mobility, STS, stair climbing, etc)
How do we Examine Aerobic Capacity and Endurance in Neurologic populations?
Impairment based measures, activity based measures, RPE with exercise
Impairment based measures
- HR
- RR
- BP
- SpO2
- VO2 peak
- Ventilation parameters
Activity based measures
- 2 min walk test
- 6 min walk test
- 12 min walk test
RPE with exercise and/or functional activities
- BORG: 6-20
- Modified BORG: 0-10
Why does it matter to examine strength and aerobic capacity?
These results are required to individualize the plan of care and supply the patient with the appropriate dosage of activity
- Then we use the FITT Principle
Why was the FITT-CORRECT Principle created?
This revision resulted from recognizing the multitude of contextual factors applicable to the prescription of physical
activity and exercise to a variety of health conditions, such as those with neurologic diagnoses
What is the FITT-CORRECT Principle stand for?
Exercise Principles: Strength Specific
What is the Overload Principle?
- Muscles are to be progressively challenged to promote neuromuscular adaptation and gains in strength generation capabilities
- Intensity is needed to increase muscle capacity
Exercise Principles: Strength Specific
What is Specificity of Training?
- The Primary principle of neurologic rehabilitation
- Training effects are directly related to the type of training demands imposed on the muscle
- Changes specific to trainning are type and speed of contraction and length of muscle during training
Exercise Principles: Strength Specific
What is Cross-Training?
When exercise challenge range of muscle performance with varying speed, contraction type, endurance
Exercise Principles: Strength Specific
What is Reversibility?
- Don’t use it, you lose it
- Strength is not sustained unless activity leveles use the new gains and are continuously challenged
- Establish HEP and community fitness programs
What is the CDC Guideline for Strength: Older Adults Unsupervised and Special Populations?
- Minimum of 2 days/week
- At least 1 set of 8-12 reps (more benefit with 2-3 sets)
-rest 2-3 min between sets - Begin with no weight and re-assess bi-weekly
-If you can lift the weight > 12 times with good form, time to increase weight
-If you cant do ≤ 8 reps, reduce the weight - Work all major muscle groups
-Legs, hips, back, chest, abs, shoulder, arms - W/u 5-10 min
- Cood down with stretching (30-60 secs for older adults)
What is the ACSM Guideline for Strength: Sedentary OIder Adult and Special Populations?
- 1 set of 10-15 reps of each major muscle group
-40-50% of 1RM
-2-3 days/week - Rest ≥ 48 hours
- Gradual progression to:
-2-4 sets; with rest 2-3 min in between
-60-70% of 1RM novice to intermediate (moderate)
-70-90% (moderate to hard)
-≥80% of 1Rm for experienced (hard)
-< 50% 1Rm and 15-20 reps for endurance
How is 1RM calculated?
1RM = Weight / Coefficient Reps
Ex. If a patient performed 5 good reps at 35 lbs for paretic leg press, what is their 1RM?
- What is 50% of their 1RM?
5 Reps has a coefficient of .856
5 Reps has a coefficient of .856
35 / .856 = ~ 41lb (1RM)
- 41x50%= ~ 20lbs (50% of 1RM)
What are the different Types of strengthening?
Force-generation concentrically, eccentrically, isometrcially, and muscle power
- The torque velocity curve is altered after neurologic injury resulting in decreased torque production with increased speed (power is negatively impacted)
For those patients that are very weak (< 3/5), what type of strengthening should they do?
Isometrically and Eccentrically biased exercise may result in better gains.
- Eccentric strength is relatively more preserved than concentric, epecially those post-stroke
Who benefits from Cross-education training?
Cross education has been found to be successful in those with stroke and MS, this capatalizes on eccentric training of the less affected side to improve strength on the more affected side
What are some examples of Functional Task-Oriented LE Exercises?
- Repeated sit to stands (concentric) or stand to sit (eccentric). This can be progress by:
-weighted vest
-change seat height
-bias weaker extremity - Step ups/downs/lateral. Can be progressed by:
-weighted vest
-raised step height - Heel raises/toe raises
- Lunges
- Squats/mini squats
- ## Walking against resistance
Case Example
We want to train a patient at 50-60% of his 1RM with Functional activity due to being in the subacute phase of stroke and having prior sedentary lifestyle. The patient does a STS from a 18in chair and this was accomplished with CGA to Min A with heavy reliance of the less affected UE and LE throughout. The patient is unable to complete a 6th repwithout physical lifting assistance.
- How many reps should we aim for when performing at a low intensity for strength?
- What % of the 1RM is this patient currently performing?
- Must we modify the activity? How?
- We should aim for 15 reps, this will keep that patient at a low intensity for strength
- The patient has completed 5 good reps, using the coefficient table 5 reps = ~.856, so they ar working in their 86% 1RM
- Yes we must modify this by reducing the intensity by:
-Elevating the surface height incrementally and re-assess
-Shift towards eccentric focus
-Alter foot placement by placing the stronger limb posteriorly to begin
How can we use Functional Strength Training for the UE?
- Open chain reaching with or without support of the upper limb
-Manual support
-Pulley system support with suspension - Open chain reaching with or without load and resistance
-Theraband
-Holding free weight - Bimanual or unimanual task
- Closed Chain weight bearing
-Concentric: Push ups
-Eccentric: change tempo
-Isometric (prone on elbows, quadruped, modified plank)
What are General Precautions and Risk with Strength Training?
- MSK pain
- DOMS
- Falls
- Valsalva/Transient Hypertension
What are the Strengthening Considerations specific to Stroke?
- Strong evidence supports positive outcomes with progressive resistance training
- Strengthening does not exacerbate spasticity
- There is improved function as a result of strengthening programs, but results vary based on specificity and intensity of training
What are the Strengthening Considerations specific to TBI?
- Target improving force-production
- Limited evidence of direct benefits in this population - translate and apply evidence from other non-progressive dx such as stroke
What are the Strengthening Considerations specific to MS?
- Fatigue is a critical consideration in MS: Circuit training can improve work capacity
- 8 weeks of individualized PRE program can improve strength
- Consider closed chain activities to promote strength in the presence of ataxia
Overwork can cause a pseudo-exacerbation
What are the Strengthening Considerations specific to PD?
- Target antigravity extensor muscles as these contribute to poor posture, functional activity limitations, postural instability and falls
- Strength training improves muscle force, reduce bradykinesia, improves functional mobility, balance, gait, falls and QOL
- Not recommended to perform stength specific exercise program during “off” phase of medication
Isometric training is generally contraindicated and due to reduce torque production at all speeds power training should be considered for Parkinson’s, especially due to its correlation with falls
With Strength Training, what are the Key Considerations for the Neurologic Population?
- Specificity of training achieved through closed chain exercise and activity, as well as intensity are key ingredients to designing a program
- Estimate the 1RM with a challenging functional task
- Consider the presence of fatigue either as primary impairment of the disease itself or presence of fatigue with performance. Recognize when it’s occurring through compensatory movement, muscle substitution, and degradation of the quality of the movement.
- Rest minimum is 2 minutes
What are the benefits of working towards fatigue:
- Promotion of adaptaiton and gains
- Safely applies to TBI, Stroke, PD
- Caution when using with MS (Can be contraindicated)
- Can accomplish low-moderate intensity in multiple short bouts of exercise
What are the ACSM and CDC Guidelines of Aerobic Training for Older Adults and Special Populations?
- 30 min minimum per session of Moderate intensity, 5 days/week (150min/week)
OR - 20 min minimum per session of vigorous intensity, 3 days/week (60min/week)
- Multiple shorter sessions are also acceptable (at least 10 min bouts)
What are the Benefits of Aerobic Training?
- Supports accomplishing ADL and independence
- Improve exercise capacity
- Improve physical functional performance
- Improved fitness
- Reduction of chronic disease: cardiac disease, stroke (or second stroke)
- Improves QOL in areas of mental health, brain health and sleep
Using the FITT Principle, what is recommended for Aerobic Training?
Frequency
- 3-5 days/week
Intensities
- 40-70% HRR
- 55-80% HRmax
- 60-84% or 77-93% HRR and HR max for high-vigorous aerobic training
Time (per session)
- 20 min, 30 min, 60 min (pending intensity)
- Muliple 10 min bouts (for prior sedentary, greater fatigability)
Type
- Steady state versus interval training (Consider the mode of delivery)
What is the AHA/ASA Cardiovascular Guidelines for Stroke?
Frequency
- 3-5 day/week
Intensity
- 40-70% HRR pr 55-80% HRmax (11-14 or 14-16 RPE)
Time
- 20-60 min per session (or multiple 10 min sessions) (additional 5-10 min warm-up and coo down)
Type
- TM walking with BWS, recumbernt leg and/or arm ergometry
- Recumbent stepper is often the safest choice for those patients who may not be able to tolerate walking on a TM without support.
- Use of a harness for protection while on a TM is recommended, and this is functional as it relates to training for task specificity
- Recent protocal has been supporting HIITprotocals for chronic phase of stroke
What are the Precautions with Cardiovascular Training with Stroke patients?
- Blunted vital signs response due to medications
- Palpitations and irregular heart beats
- Sudden SOB
- Angina
- Fatigue and exhaustion
- Lightheaded or dizziness
- Imbalance and modification for motor performance
When any of these symptoms present become uncontrollable, or do not diminish with appropriate rest, then there will be a need to cease exercise and possibly call 911
What are the Intervention Guidelines for Cardiovascular Training for TBI patients?
Frequency
- 3-5 days/week
Intensity
- 60-90% age predicted HR max (208 - (.7 x age))
-This is in the vigorous zone
Time
- 20-40 min per session, depending on intensity
-Inverse relationship: higher the intensity, the less time needed
Type
- Traditional: walking, jogging, elliptical, cycling
- Circuit training
What are the Precautions with Cardiovascular Training with TBI patients?
- Fatigue
- Primary impairments of imbalance, ataxia, voluntary motor control
- Vital response must be monitored
- Cognitive function (Rancho Los Amigos)
When wanting to prescribe aerobic training at a vigorous intensity, you must properly screen and perform submax exercise tolerance testing for proper clearance. Patients with TBI are at risk for experiencing dysautonomia
What are the Intervention Guidelines for Cardiovascular Training for MS patients?
Frequency
- 3-5 days/week alternating days
Intensity
- 60-85% HRmax or 50-70% peak VO2
Time
- 30 consecutive min or three 10 min bouts
Type
- Cycling, walking, swimming, water aerobics, circuit training
What are the Precautions with Cardiovascular Training with MS patients?
- Signs of overwork
- Fatigue
-Contraindicted to “work to fatigue” - Type of MS
-RRMS vs PPMS - Core body temp
- Incoordination, spasticity, and imbalance
- Sensory impairment
- Cognitive and memory deficit
- CV dysautonomia
-HR and BP may be blunted
Cooling vest and fans are recommended
What are the Precautions with Cardiovascular Training with PD patients?
- Monitor vital signs and exertion:
-HR, BP, RR
-SpO2
-RPE
-Fatigue levels - Hypotensive responses
- Dyspnea
- Fall Risk
What are the Contraindications to Begin a Cardiovascular Exercise Program?
- Medical Instability of diabetes, angina, arrythmias
-Consult physician to establish stability - Uncontrolled HRrest > 100bpm or < 50 bpm
- Resting Systolic BP > 200mmHG or < 90mmHG
- Resting Diastolic BP > 110mmHG
- Oxygen Saturation < 90%
You should recommend formal submax ETT when indicated by patient factors.
What are the Indications to STOP Aerobic Exercise Training
- Lightheadedness or dizziness
- Chest heaviness, pain, or tightnes; angina
- Palpitations or irregular heartbeat
- Sudden SOB not due to increased activity
- Volitional fatigue and exhaution
- Abnormal response in BP values
- Chills, headaches, nausea, blurred vision
- Pain that does not improve
- Muscle burning
What are Alternative forms to deliver Aerobic Training?
- TM with or without BWS; Adapting for walking impairments, limited gait speed
-2mph at 3.5% grade = 3 METS or low to mod intensity exercise, at 7% grade = 4 METS etc
-3mph at 2.5% grade = 4 METS or mod intensity - Stroke Adaptive Cardiac Rehab Models
- VR gaming
- Robot assisted
- Seated cycle ergometers
- Recumbent bike
- Nu Step
Keep in mind, no matter how you deliver or modify the mode, it’s the intensity while performing that activity that matters
With Exercise Intensity, for HRR% and %PHR max, what is considered Low Intensity?
%HHR
- < 40%
%PHRMax
- < 64%
With Exercise Intensity, for HRR% and %PHR max, what is considered Moderate Intensity?
%HHR
- 40-59%
%PHRMax
- 64-76%
With Exercise Intensity, for HRR% and %PHR max, what is considered Vigorous Intensity?
%HHR
- 60-84%
%PHRMax
- 77-93%
What is the equation to get the Predicted HR max?
How about with patients that take Beta-Blockers?
Normal
- 207 - (0.7 x age)
Beta Blockers
- 164 - (0.7 x age)
What is the equation to find a patients Heart Rate Reserve (HRR)?
PHR Max - HR @ rest = HRR
What is the equation to find the Target Heart Rate (THR)?
HR @ rest + (%Intensity) x (HRR) = THR
Case Example:
- A patient is 77 years old, resting HR is 85 bpm. He is NOT on beta blockers. Use HRR% to calculate each range of targeted intensity?
Step 1: PHR Max = 207 - (.7 x 77) = 153.4
Step 2: HRR = 153.4 - 85 = 68.4
Step 3: THR
- Low: 85 + .39(68.4) = ~111
- Mod: 85 + .40(68.4) & 85 + .59(68.4) = ~112-125
- High: 85 + .6(68.4) & 85 + .89(68.4) = 126-146
