Tag Archives: corrective exercise

Resistance Training Guidelines & Exercise Progression in Injury Rehabilitation

Adjusting resistance level of inverted rows (No, that’s not me – notice no bald spot!)

As rehab and fitness professionals, it is crucial that we know why we do what we do. Always be able to answer if someone asks “why?”. One of the awesome things about our profession is that, in rehabilitation and strength training, there are many successful approaches to obtaining great outcomes. Throughout my career I have seen a wide variety of rehabilitative approaches used by the physical therapists and athletic trainers I’ve worked with and known. It is very true that there is no “one way” to obtain positive results with your patients. The art of successful injury rehabilitation is not only “what” you know, but more importantly how you apply what you know (i.e you bridge the gap between knowledge and application). I also believe that, out of fear of increasing pain and setting back the healing process, many times rehab clients may not “pushed” and stressed as much as they could be in terms of developing strength and power (safely, of course, without increasing pain or dysfunction). This concern can be solved by reviewing evidence-based basic resistance training guidelines. I’m going to review an evidence-based approach that I used successfully, specifically in regards to rehabilitating athletes and persons looking to return to the healthy lifestyle they had prior to the injury. Bear in mind, however, that most of these principles are not just appropriate for “athlete” rehab. The four components I wish to discuss are:

  1. Preparing the body for reconditioning (the “dynamic warm up”)
  2. Sequence of Exercise Modes
  3. Work:Rest Ratios
  4. Resistance Training Load Prescription

Preparing the body for reconditioning (the “dynamic warm up”)

Dynamic warm up (DWU) for movement/exercise preparation actively readies the body tissues for the demands about to be placed upon them. In other words, it provides a “wake up” and “rehearsal” for the body. In doing so, you stimulate both a neuromuscular and cardiovascular response. Proper DWU raises core body temperature, increases muscle elasticity, decreases inhibition of antagonist muscles, and stimulates the nervous system. Additionally, especially in the case of athletes, there is an emotional and psychological stimulus for increased levels of activity. There is plenty of research demonstrating the use of a proper DWU:

Rationale:

  • Improves flexibility, coordination, balance, proprioception, and movement speed
  • Decreases chance of injury during training/competition
  • It serves as an excellent tool for concentrating on teaching movement/skill technique (i.e. this is where your “corrective exercises” come in)
  • On the contrary, static stretching has been shown to decrease muscle strength/force production at both slow and fast velocities, anywhere from 10 mins-24 hrs later, as well as plyometric abilities

Gradual progression example in a rehab setting*^:
Low intensity non-impact general warm up (i.e. bike/UBE) → Core/Neuromuscular activation → Joint mobility/dynamic flexibility → Dynamic movement prep → “Build Up” Agilities/Plyometrics (i.e. General linear prep → General multidirectional prep).

*Gradual progression within this from low intensity → high intensity
^ When warranted, modalities and manual therapies are performed prior to starting (as well as when isolated concerns arise during training, i.e. ankle dorsiflexion mobilizations to improve a squat pattern dysfunction)

Sequence of Exercise Modes

In order to obtain the most benefit from utilizing various modes of exercises in rehabilitation, it is important to have an idea of the recommended proper sequence based on research and rationale. If client has 1 or 2 areas (of the distinct areas listed below) of impairment or disability, it is recommended to focus on these areas first, and then supplement “accessory areas” afterwards. If taking a more global approach, a more specific progressive approach as I’ll outline has been shown to be effective in maximizing the cumulative benefits gained through each method of exercise towards the overall goal(s) of your rehabilitation. In other words, you are less likely for one preceeding exercise to have a detrimental or “limiting” affect on a following exercise. Example: you don’t run a long distance workout before performing a plyometric power workout if your goal is to improve power– your power “output” will suck.

Progression guidelines*

*NOTE:  These are after/not including the DWU.  Not all of these areas need to be addressed in every rehabilitation session. This provides a logical sequence to administer therapeutic exercises as appropriate in the event that all were performed in one session.

1) Dynamic Mobility/Warm-up (as outlined above).  For specific example, see here.

2) Agilities
– Motor learning/technique work (i.e. functional agilities such as stops, ladder footwork)
– Linear  (Assisted/BW → Resistance)
– Multi-directional (45 deg COD → 90 deg COD → 135 deg COD → 180 deg COD)
– Assisted/BW → Resistance
– Practical agilities (i.e. real-life movement and situational drills, planned à unplanned               reactions)

3) Resistance exercises/plyometrics for power

4) Resistance exercises for strength
a) Power → Non-power exercises
b) Large muscle areas → Small muscle groups
c) Multi-joint exercises → Single-joint exercises

Muscular Endurance Exercises
a) Large muscle areas → Small muscle groups
b) Multi-joint exercises → Single-joint exercises

5) Balance/Proprioception
– Static → adjust plane of movement → adjust speed of movement → add dynamic external stimulus → change terrain

6) Static Stretches

Work:Rest Ratios

Newsflash:  3 x 10 with 30 second rests, all the time/every session does not cut it. Please read that 3 x 10 times today. Your client will not gain muscle strength and functional power with this approach, setting them up for future re-injury. We need to recondition strength and power, not just muscle hypertrophy and endurance. Proper reps, set, and rest period prescription can have a huge impact on successful outcomes. It is important to remember that rest periods differ based on your training goal (i.e. strength/power vs. muscle endurance). Typically, rest periods are inversely related to load: heavy load = longer rest period. I’ve heard the argument that “I don’t want my patient just sitting around that long between sets – I have to maximize their time in the session”. Well, I agree. That’s why we prescribe “accessory” exercises to perform using different body regions/neuromuscular systems to serve as “active rest”. Superset that . An example would be using a single-leg Romanian deadlift coupled with a plank variation, or a balance/proprioception exercise between shoulder strengthening sets. Treat the body, not just the body part

Rest Period Length Based on the Training Goal
Training Goal Rest Period Length b/t Sets*
Strength 2-5 minutes
Power 2-5 minutes
Hypertrophy 30 – 90 seconds
Muscular Endurance 30 seconds or less

* Multi-joint requires longer rest than single-joint

Training Specific Energy Systems
% of Max Power Primary Energy System Stressed Typical Exercise Time Work:Rest Ratios
90-100 Phosphogen 5-10 sec 1:12 to 1:20
75-90 Fast Glycolysis 15-30 sec 1:3 to 1:5
30-75 Fast Glycolysis and Oxidative 1-3 min 1:3 to 1:4
20-35 Oxidative > 3 min 1:1 to 1:3

In terms of day-to-day rest, here are some recovery guidelines*. When performing plyometrics, lower intensity drills can be performed 3-4x/week (minimum 24 hrs recovery time; example = technique drills or jumping rope). Moderate intensity plyometric drills can be performed 2-3x/week (36-48 hrs recovery time; example = medicine ball throws or band resisted exercises).  Higher intensity, high shock drills should be performed no more often than 2x/week (72 hours recovery time; ex: high box jumps or max effort bounding). *Disclaimer – it’d be fine to do upper extremity plyos one day and lower extremity the next day – rest times are referring to a specific muscle group/body region being stressed). With regard to resistance training, training for strength should be performed on non-consecutive days for muscle group. When training for balance, proprioception, core stability, and muscular endurance, it is typically fine to perform these on a daily basis without concern for overtraining.

Resistance Training Load Prescription

In addition to proper rest periods, variation and progression of load is also key to successful outcomes. This is especially important when the client is strength training on a regular basis.  Every day should not be a “heavy stress” day (100% of the load). In order to avoid overtraining and plateaus, it is important to mix in some “medium stress” days (90 % of the load) and “light stress” days (80% or less of the load). In terms of progression of the training load, I typically follow the “2-for-2” progression rule. Let’s use this example: goal is 3 sets of 8 reps for a dumbbell bench press. I will increase resistance load when patient demonstrates the ability to perform 10 reps on the third set for 2 consecutive instances.

There is also some debate about the use of multiple sets vs single sets. Single sets may be more appropriate for untrained individuals and when performing a muscular endurance/high rep set. Multiple sets are more appropriate for intermediate/advanced persons, showing better long-term gains. Studies have also shown that multi-set without failure tends to be more effective over time vs. single set to failure.

Load and Repetition Assignments Based on Training Goal
Training Goal Load (% 1RM) Goal Repetitions
Strength 85+ < 6
Power:        Single-effort eventMultiple effort event 80-9075-85 1-23-5
Hypertrophy 67-85 6-12
Muscular Endurance < 67 > 12

Repetition Max Continuum (Baechle & Earle, 2000)

rep max continuum

One of my most common recommendations I make to athletic trainers and physical therapists is for them to take a portion of their annual CEUs through courses geared towards fitness/performance training. I’ve personally learned a ton this way, much of which I have worked in cohesively with my sports medicine/rehab background to improve my outcomes! Challenge yourself by questioning the rationale behind your approach. This is the best way to continually improve!

P.S. I apologize for the length of time between this and my last post.  Baby #3 joined the family recently, so I’ve been both sleep deprived and busy 🙂

Thanks for reading!
Ryan

RStevensATC@gmail.com

References:

  • Annaccone AR.  Balance of Power.  Adv for Dir Rehab.  21-24; Aug 2007.
  • Baechle, T.R., & Earle, R.W. (2nd ed.). Essentials of Strength and Conditioning. Champaign IL, USA: Human Kinetics. 2000.
  • Chu DA, Cordier DJ.  Plyometrics – Specific Applications in Orthopaedics.
  • Fredrick GA, Szymanski DJ.  Baseball (Part I): Dynamic Flexibility.  Strength & Cond J.  Vol 23 (1): 21-30; 2001.
  • Groner C.  Stretching…Out?  Biomechanics.  Oct 2004.
  • Howard RL.  Plyometric Concepts Reinvent Lower Extremity Rehabilitation.  Biomechanics.  Sept 2004.
  • McClellan T.  Big Jumps.  Training & Cond.  Vol 3 2007.
  • McMillian DJ, Moore JH, Hatler BS, Taylor DC.  Dynamic vs. Static-Stretching Warm-up:  The Effect on Power and Agility Performance.  J of Strength & Cond.  20(3): 492-499; 2006.
  • Myer GD, Paterno MV, Hewett TE.  Back in the Game.  Rehab Management.  Oct. 2004.
  • NSCA Certification Commision.  Essentials of Strength Training and Conditioning. 2005.
  • Pitney WA, Bunton EE.  The Integrated Dynamic Exercise Advancement System
  • Technique for Progressing Functional Closed Kinetic Chain Rehabilitation Programs.  J of Athletic Training.  Vol 29 (4): 297-300; 1994.

 

5 essential components for developing agility

Are you quick?  I’m not talking 100 meter dash time.  I’m talking “5-10-5” time.  That person who fears nobody 1 on 1, and who nobody wants to defend.  You create separation on offense and close the gap on defense.  Do you want to be that athlete (or develop that athlete)?  He are 5 essential components you must include in your training program if you wish to develop your agility.

*Addendum: This blog was written with the intention of these being ideas for someone who has no major imbalances/deficits/asymmetries needing correction – I.E. they have a good functional movement and mobility assessment with solid movement patterns.

ScreenShot2013-09-28at10.49.40PM_crop_exact

1) Core Stability

Amazing agility takes great control of your center of gravity.  You have to be able to resist motion and momentum in order to change direction quickly.  Core stability is the foundation for deceleration (which is the foundation for change of direction).   For the following exercises, I like to aim for 30 reps in a set done well before increasing difficulty.  As you improve, you can increase speed of movements with the side plank and bridge (as long as your trunk is stable).  Here are some things I use:

    • Side plank with extremity movements (1:16 mark on the video).  Get creative with your extremity movements to up challenge.
    • Bird dogs (video).  Also try these ipsilaterally!single leg bridge marching
    • Single-leg bridge with marching: Perform these slow and controlled – keep your trunk in one place while flexing one hip as in the picture.  Work up to 2 sets of 30 reps each side.  Unlike the picture, with these place your arms like you are “under arrest” (since you’ll soon be breaking the speed limit).
    • Anti-rotation exercises (video thanks to Martin Norum).  Slow and controlled is the key here.

2) Strength (Glutes, Quads, Adductors, Calves)

Strength is the foundation of power (see below).  By improving your lower body and hip strength, you’ll be able to produce more power into the ground, thus propelling you the opposite direction while making your opponent look foolish.  Periodize your strength program properly, with rep # appropriate for the phase you are in.  Here are some exercises I use:

      • Deadlift: 2 versions to work on.  Traditional (video thanks to Eric Cressey) and Single leg RDL (video thanks to Angel Stone).  When doing traditional deadlifts, if you have bumper plates focus on a strong lift, then drop from tall.
      • Goblet lunges (multi-direction): “Goblet”-style hold increases posture muscle stress, challenging core.  Forward, lateral (like in the video – thanks Eric Cressey), diagonal (forward AND backward), and retro should all be performed.  Work on the “push back” version in place like in the video to develop eccentric strength, and the walking versions for strengthening the concentric component of cutting.lateral band walk
      • Mini-band lateral walking:  Band around the knees = easy, around ankles = harder.  Avoid knees buckling towards each other while you step.  Great exercise to use in superset on an upper body day.
      • Calf raises: Off of a step to increase stretch reflex.  Do lots of them.

3) Lateral/Rotational Power (Plyometrics)

You have to use your core stability and strength in an explosive manner.  Here are some ideas from what I use:

      1. Medicine ball throws: Rotational, “punches”, “Granny toss” or underhand overhead, and overhead forward with follow-through to RDL (see above).  Perform sets of 6-8.
      2. Single-leg bounding (multidirection): First work on doing these in place (off of one foot and landing in the same spot on the other). Imagine hoping over a low fence. These can also be performed forward, lateral, diagonally, and backwards. Perform sets of 6 on each leg.
      3. Broad jumps (multidirection):  In addition to jumping forward, also try lateral and diagonal.  Sets of 6.  (thanks to Nike Training)
      4. Quick hops:  Channel your inner MC Hammer.  Less foot contact time on the ground is better! Perform in place, or moving back and forth forward, lateral, or diag (2- or 1-legged). Two versions: Standing tall or perform while staying in “athletic position”.  15-30″ sets, depending on your training phase.

4) Acceleration and Deceleration (planned)

Simple fact: in order to change direction, you have to be able to slow down and stop (temporarily).  Too often athletes only focus on developing speed and power, but neglect to spend much time on deceleration training.  Stop faster than your opponent, and you’ll be changing direction faster than your opponent.  After you decelerate and stop, you have to move quickly in a new direction.   Gain speed quickly.  BOOM! Like being shot out of a cannon.  Here are some drills I use:

      • Lateral step Med ball fake throw I learned this from Lee Taft (thanks Lee!)
      • Lateral/diagonal bounds with med ball (video thanks to Nike Training).  The next level up from Med ball fake throws, now you cover more ground with your bounds
      • Med ball catches: Perform the above drills, but instead of holding the med ball, have some one toss it to you so that you catch it just before you land in your “cut” position.
      • Push Shuffle and Carioca: Perform for footwork and for speed. To push shuffle, a) do not cross shoes, and b) move laterally by pushing the ground away from you through your back shoe. When doing carioca with or without ladder, focus on a good hip turn and pump arms “athletic” rather than “dance-style”. (Thanks to King Sports Training for video) 
      • Low box shuffle/crossover: check out these two great videos on low box training that I use for agility.  Shuffle (thanks Lee Taft) and crossover (Thanks RPI Strength)
      • Spider drill (video thanks to QuickBoard).  Use both a “shuffle only” version as well as a natural crossover version
Chicago Bulls v Utah Jazz

Poor defender had no chance…

5) Reaction (unplanned)

Making a planned change of direction is one thing.  Reacting and making an unplanned change of direction is true agility.  The final crucial component to developing your agility is to work on your reaction skills.  Here are some drills I use:

    • Tennis ball catch reaction(Thanks to Joe Hos for video)
    • Reaction cuts (variable cues): Work on performing quick starts and 45/90/180 degree change of direction skills while reacting to variable cues. Visual instruction (coach points), verbal (clap/whistle), or movement (go after tossed ball).
    • Partner Mirror Drill:  Get creative with rules.  “Use only shuffle”, “Can use crossover”, “Anything goes”.  Can also be performed using forward, backward and lateral movements in 4 planes of motion. (Thanks RPI Strength for video)

5 components to work on, all important in developing agility.  Ready to become a human highlight reel?  Now go dominate.

RS

Questions or additional recommendations? Leave a comment.

Ryan Stevens, MPS, LAT/ATC, CSCS
RStevensATC@gmail.com