การออกกำลังกายเพื่อเพิ่มความแข็งแรงและความทนทานของกล้ามเนื้อ (Strength and Endurance Exercise) เอกสารประกอบการสอนวิชา 514222 ผศ.ดร.ภัทรพร สิทธิเลิศพิศาล ภาควิชากายภาพบำบัด คณะเทคนิคการแพทย์ มหาวิทยาลัยเชียงใหม่

วัตถุประสงค์ อธิบายเทคนิควิธีการ ข้อบ่งใช้ ข้อระวัง ข้อห้าม ในเทคนิคการออกกำลังกายเพื่อการรักษาด้วยการออกกำลังกายเพื่อเพิ่มความแข็งแรงและความทนทานของกล้ามเนื้อได้อย่างถูกต้อง ประยุกต์การออกกำลังกายเพื่อเพิ่มความแข็งแรงและความทนทานของกล้ามเนื้อเพื่อการรักษาในกลุ่มเป้าหมายได้อย่างเหมาะสม

Functional limitation Disability Increase risk of dysfunction Injury Disease Immobilization Disuse Inactivity Therapeutic exercise Active exercise Resistance exercise Impaired Functional limitation Disability Increase risk of dysfunction Improve muscle performance Weakness Muscle atrophy

Patient management Free active exercise (FAE) Resistance exercise Strength gr. II-III Strength gr. IV up Select tests and measurements Muscle testing 1-RM Dynamometry Muscle performance problem (Kisner & Colby, 2007)

Guiding principles Overload principle Specific adaptation to imposed demands (SAID) principle Reversible principle

Overload principle A load exceeds the capacity of muscle Precaution Intensity: load or resistance Volume: repetition, set or frequency of exercise Strength training; amount of load Endurance training; time or repetition Precaution Applied underlying pathology, age, state of tissue healing, fatigue, ability and goal of pt Given time to adaptation of progressive loading

eccentric & concentric ex SAID principle Specificity of exercise Mode or type Velocity Limb position (joint angle) Movement pattern eccentric & concentric ex in WB

Reversible principle Adaptive changes in body’s systems are transient Detaining decrease muscle performance within 1-2 week

Free Active Exercise (FAE) Indications pt able to contract M. actively and move a segment (M. strength gr. II-III) Add in exercise program such as aerobic, yoga, Tai Chi etc. Limitations For strong muscles, FAE doesn’t maintain or increase strength FAE doesn’t develop skill or coordination except in the movement patterns used For brain damage pt. with unable to initiate mvt Muscle imbalance: compensation mvt Precautions and contraindications When motion is disruptive to healing process Acute tear, fracture and surgery Early controlled motion is used for decrease pain and increase rate of recovery; pt’s tolerance is monitored After myocardial infarction, coronary artery bypass surgery or percutaneous transluminal coronary angioplasty FAE of UE are tolerated under careful monitoring of symptoms

Patient preparation Communication & describe Free from restrictive clothing Position for patient; comfortable with proper alignment and stabilization Position for PT; proper body mechanics

Therapeutic effects Relaxation: pendulum Increase joint mobility Mainteinance elasticity and contractility Increase tension, strength (grade III – III+) Bone mineral sensory feedback Increase circulation, prevent thrombus formation Improve coordination and motor skill for functional activity Motivation Set in aerobic exercise program: promote cardiovascular response increase blood flow incraseO2 uptake in active tissue Capillary vasodilatation Increase venous return

Application of technique Demonstrate motion using PROM Patient perform motion PT’s guide pt if needed for smooth motion Motion is performed within available ROM Progression Type of muscle contraction; concentric, isometric, eccentric Change position Change liver arm of moment Decrease based of support Complex movement

(Kisner & Colby, 2007)

Specific FAE Six pack exercise Pendulum (Codman’s) exercise Passive Active Six pack exercise Quadriceps setting exercise (inner range) (Kisner & Colby, 2007)

Resistance exercise Any form of active exercise in which dynamic or static muscle contraction is resisted by an outside force applied manually / mechanically Resistance training Strength training Power training Endurance training (local endurance)

(Kisner & Colby, 2007)

(Kisner & Colby, 2007)

Model for Periodization Mesocycle 1 Mesocycle 2 Mesocycle 3 Mesocycle 4 Volume Intensity Technique Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Preparative Phase First Transition Competitive Phase Second Transition ( active rest ) Low load, high volume high load, low volume Decrease load & volume

Type of resistance training Manual resistance exercise Mechanical resistance exercise Free weight; dumbbell, barbell, velgo weight, springs, medicine ball Pulley systems resistance machines Elastic bands and tubing Pattern Isometric exercise Dynamic exercise Open-chain and closed chain exercise

Free Weight Springs Pulley Medicine ball

Isokinetic dynamometer Weight machine Isokinetic dynamometer Elastic band N-K table

Application of resistance exercise Warm up: site-specific dynamic mvt, stretching Placement of resistance: distal end Direction of resistance: opposite of motion for concentric Same direction for eccentric Stabilization: avoid substitution NWB resisted ex: proximal end WB resisted ex: muscle control (internal stabilization) to hold nonmoving segment (Kisner & Colby, 2007)

Order: large muscle before small muscle Intensity of ex or amount of resistance Submaximal, forceful but controlled and pain-free effort Manual resistance: PT adjusted equal pt ability Free weights and machines: RM, MVC Elastic bands: color Movement are smooth, nonballistic or tremulous Volume: number of rep, sets, rest interval Volume = set x rep 8-12 reps/set, 3 sets depend on goal strength/power/endurance Rest interval: ATP reproduction < 60 s very short rest periods 90-120 short periods 3 min Verbal or written instruction: simple Monitoring pt Cool down Frequency: FAE, isometric 5 days/wk, other 2-3 days/wk Progression: revaluate 2-4 wk, or 5% 2 wk (Kisner & Colby, 2007)

Medicine Ball

Precaution for resistance exercise Valsava maneuver (phenomenon) Intra-abdominal and thoracic pressure BP breath rhythmically, count/talk during ex Exhale with each resisted effort Substitute motions Appropriate resistance and stabilization

Overtraining or overwork repeated heavy resistance or exhaustive training muscle performance in healthy (overtraining) strength permanent or prolonged in NM disorder (overwork) Avoid overtraining: adequate rest interval not to rapid progression adequate diet and fluid intake trained by periodization overwork: monitor fatigue, not ex to exhaust, longer rest interval Exercise-induced muscle soreness Acute muscle soreness: lack of BF, O2, temporary build up metabolite Delayed-onset muscle soreness: 12-24 hr after vigorous ex Appropriate cool down; low intensity ex, active recovery Pathological fracture: osteoporosis and osteopenia

(Kisner & Colby, 2007)

(Kisner & Colby, 2007)

Pain: resistance, stop exercise Inflammation contraindication Severe cardiovascular disease Acute symptom contraindication Start after 12 wk of myocardial infraction, coronary artery disease bypass graft surgery

Manual resistance exercise PT position Body mechanic patient position Alignment Comfortable NWB Placement of resistance stabilization Intensity & V 8-12 rep, 3 sets Rest 3-5 min Strength Power Endurance Verbal command Simple & Timing Hold/Push/pull M. action order Type of contraction Static Dynamic Con/Ecc (Kisner & Colby, 2007)

Mechanical resistance exercise PT position patient position Placement of resistance stabilization Intensity & V Stregth Power Endurance Verbal command M. action order Type of contraction Static Dynamic Con/Ecc

Resistance training program Goal Load Repetition Speed Rest Maximum strength Heavy 80-100% 1RM (1-3 RM) Low 1-5 rep Slow Long Power 70-80% 1RM (4-6 RM) Medium 6-10 rep Fast medium Hypertrophy Medium to heavy 70-80%+ 1RM (6-12 RM) 8-12 rep Endurance Light 30-50% 1RM (12-20 RM) High 15+ rep Moderate Short (Kraemer et al. 1996)

Resistance training program จุดมุ่งหมายในการฝึก %ความหนัก จำนวนครั้ง จำนวนเซต เสริมสร้างความแข็งแรง 90%-100% 1-3 4-6 80%-89% 3-5 70%-79% 5-10 3-4 เสริมสร้างกำลังความเร็ว จังหวะการยกเร็ว 80%-90% 4-5 60%-69% 5-8 2-3 เสริมสร้างความอดทน 60%-70% 10-15 50%-59% 15-20 40%-49% 20-25 (เจริญ, 2545)

Progressive resistance exercise (PRE)

Circuit training (Howley & Franks 1997)

Isokinetic training

Neuromuscular training การฝึกที่กระตุ้นผ่านระบบประสาทและกล้ามเนื้อที่รวมเอาความแข็งแรงและการเคลื่อนไหวด้วยความเร็วเข้าไว้ด้วยกัน Plyometric training Explosive Power

Stretch-shortening cycle (SSC) To increase the power by using both the natural elastic components of muscle and tendon and the stretch reflex

Plyometric training Phase I Eccentric Phase II Isometric –Amortization- Phase III Concentric

References American College of Sports Medicine. ACSM’s guideline for exercise testing & prescription. 8th edition. Lippincott Williams & Wilkins, Philadelphia, 2010. Kisner C and Colby LA. Therapeutic exercise: foundations and techniques. 5th ed. F.A. Davis Company 2007.

Practices Manual Machine FAE Manual resisted exercise Resistance exercise with elastic band and medicine ball Machine Free weights: dumbbell, barbell, spring Weight machine, pulley, N-K table