Strength Training in Neurological Rehabilitation: Difference between revisions
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reduced Motor control, dextrity deficits, paresis(muscle weakness) and slowness of movment are well known charectristics of upper motor neurone syndorme. is a feature for upper motor neurone syndrome. | reduced Motor control, dextrity deficits, paresis(muscle weakness) and slowness of movment are well known charectristics of upper motor neurone syndorme. is a feature for upper motor neurone syndrome. | ||
Muscle weakness is a key physical impairement in neurological conditions limiting mobility. | Muscle weakness is a key physical impairement in neurological conditions limiting mobility. | ||
Feasibility studies started 15 years ago to improve mobility by introducing strength training to neurological rehabilitation. | Feasibility studies started 15 years ago to improve mobility by introducing strength training to neurological rehabilitation. | ||
Revision as of 23:55, 27 December 2019
Original Editor - Mariam Hashem
Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Tony Lowe, Lucinda hampton, Admin and Tarina van der Stockt
Evidence for Muscle Weakness[edit | edit source]
reduced Motor control, dextrity deficits, paresis(muscle weakness) and slowness of movment are well known charectristics of upper motor neurone syndorme. is a feature for upper motor neurone syndrome.
Muscle weakness is a key physical impairement in neurological conditions limiting mobility.
Feasibility studies started 15 years ago to improve mobility by introducing strength training to neurological rehabilitation.
A study by Cooke et al in 2010[1] compared the effect of functional strength training and conventional physiotherapy improve walking speed, distance and mechanics.
Resistance training was found to improve muscle strength[2] and was found to improve functional performance if resistance training was added to functional exercises[3].
Another systematic review by Kjølhede in 2012 reported strong evidence regarding progressive resistance training on muscle strength for people with MS but the mechanism of how strength training affecting strength needs more studies in the future[4].
Progressuve resistance exercises were strongly recommended by the Australian Stroke Foundation guidelines (2017) and the AHA guidelines (2010), however, the optimal strengthening approach is still unknown[5].
Despite being effective in musle strengthening but most of the applied studies failed to show improvement in walking capacity[6].
Current Evidence in Strength training[edit | edit source]
systematc review demoenstrated improvement in strength following resistance training but limited impact on walking[4][7][8][9][10].
A study by William et al [6] aimed to investigate task specifity of strength training for walking in neurological conditions.
Task Specific Criteria for Muscle Strengthning
Based on ACSM guidelines[11]:
- Role of the muscle
- Action of the muscle
- Type of contraction
- Active range and segmental alignement
- Load
- Speed of movement
The systematic review mainly found that quadriceps and hamstrings exercises were the most common used exercises in strength prevention in the selected studies so mainly targeting the kee joint. leg extension
Biomechanics of Gait
A good understanding of task specific gait parameters is needed to prescribe specfic exercises to improve walking.
Not only walking mechanics and transition through different phases of gait but also speed has a great effect on walking mechanics across hip, knee and ankle joints[12].
A thourough analysis of diffferent mechanics is important to undernstand normal gait and deviations from the normal pattern
Muscle power generation for walking
A imnimal level of strength is required in all muscles to generate the power for wlaking, however, not all muscles are created equally. Some muscles are more recruited throuout the walking cycle while other mscle contribute less. Knowing the important muscles is important to priotorize for Rx.
Three key events are important for power generation during walking cycle:
- 2-Ankle PF power generation at push-off at terminal stance
- 1-Hip extensor power generation at Initial Contact
- 3-Hip flexor power generation at toe-off to accelerate the leg through swing phase pre-swing
Key events at the knee for power absorption rather than power generation:
- Knee extensors at terminal stance
- Knee flexors at terminal swing to decelrate the leg.
At the stance phase, main power is genrated at the ankle at terminal stance key peak, liesser at the hip and a negative -[pwer absorption.
At terminal stance, small contribution from the calf muscle and the main is generated from the tendon-Achillies tendon. Breaking it down: most power is coming from the tendon-related to power storage and release[13]
Power vs strength:
Strength: reflects the maximum amount of force a muscle can produce
power: rate of force production
PRE: is the best method for improving the force production and muscle hypertrophy
changing resistance constantly is the key to improve strength
Ballistic /plyometric training dor power generation- power generation; stretch s cycle uses lighter loads and more repetitions
Heavy resistance training improves strength wheras ballistic training doesn't increase strength but it improves power genrations[5].
Task Specificity for Ankle PF/DF
Stance phase make up about 0.6 sec of the gait cycle, push off 0.15 seconds- that's where the achillies tendon is producing the power. Applied strength trainign/resistance trianing can increase the calf-tendon/muscle strength but not the power needed for the push off. improving the tendon fucntion is a key to improve walking mechanics at terminal stance utilizing the Achillies tendon power generation capacity.
Muscle Function for walking occurs at high angular velocities which means that we need to work on power generation at a targeted speed, consider ballistic strengthening training mostly at the ankle[5].
In williams study, only 16 studies included calf strengthning exercises out of?
However, looking at calf muscle exercises- it still has to be tailored to task specificity of walking. calf raises is the most common exercise but it is not task specific.
To improve walking nad power/fprce generated by calf
Leg slid vs Calf raises: table
Leg slid: is more effective in targeting task specific power genration?
Geeral strength training in the sudies haven't been
the testing performed on all these studies, though it's accurate dynamormetry. A change in joint mobility o for example strength of knee flexion/extension will not be refelcted on the walking abilities of this person.
RFD wasn't measure: rate if force develeopment.
Ballistic Strength Trianing
Most of the work done on healthy individuals
A 2017 study[14] evaluated the effect of functional high-velocity resistance training (power-training) to improve muscle strength and walking capacity of children with CP reported improvement in the muscle power sprint test (MPST), 1-minute walk test (1MWT), 10-m shuttle run test (SRT), gross motor function (GMFM-66), isometric strength of lower-limb muscles and dynamic ankle plantar flexor strength reflecting improvement on walking capacity. Significant improvemnet in all measures
Exercises: Task practice-targeting speed
- Running at 50-70% max speed with sled
- Walking at 50-70% max speed with sled
- Running at 50-70% max speed pushing a chair
- Stairs at 50-70% max speed with loaded vest
- Scooter 50-70% max speed with sled
- Sideways walking at 50-70% max speed wth sled
However, it was done on children not adult. and wasn't a traditional ballistic training, not an RCT design but yeilds promising evidence for fast strength training.
ballistic training was compared to conventional leg exercises by williams 2014. A single testing session : seated leg press performed conventionally compared to doing the same exercise with a jump. about 70% increase of concentric velocity in ballistic condition[15].
Conclusion
Power training is recommended over conventional strength/resistance training with considerations to gait biomechanics.Ballistic training improves power generation.
Exercises performed with speed.
Exercise also has to be specific to the muscles that genrates the power e g ankle plantar flexion. Making sure exercise is performed properly to ensure power is geenrated from the ankle. If pateint is unable to isolate the right muscle, apply some modifications to allo for proper performance.
ACSM guidelines:
PRT is the best method
Ballistic training improves power genration and considered superior to progressive resistance training for power generation.
Four Criteria to be considered:
- Maximum rate force production
- Lighter loads
- Stretch-shortening cycle
- Coordinated movement pattern/skill
Task Specific Criteria for Muscle Strengthning
Based on ACSM guidelines[11]:
- Role of the muscle
- Action of the muscle
- Type of contraction
- Active range and segmental alignement
- Load
- Speed of movement
Progression Principals:
- Progressive muscle overload
- Greater intensity
- Periodization
- Increasing total repetition & training volume
- Increasing speed of movement
- Reduce rest
- Hypertrophy
- Muscle Endurance
- Sports application
Improved walking ability asociated with compensations? leg can recover in rehabilitation[16]. Results?
Recovery of Walking:
Reduced distal power generaiton lead to proximal compensations[17]. greater hip flexor power generation to lift off and hip extensor to accelerate[5].
Williams et al: found reversed proximal compensation strategy after power generation training between ankle and hip
Clinical Implications:
focus on power genration rather than muscle strngth
unique calf role and stretch-shortening cycle.
Fast is better than nothing as higher RFD
Aiming for no contact phase but might need some assistance initially
Hopping or alternating on one leg
Leg slid alternatives
Needs to be specific
Trampoline -tramp pet
Claw: hip flexors? knee bent
Hip extensors
What about Quads? most commonly targeted, very important for standing upand stairs[18]. But might not be refelcting on gait function.
References[edit | edit source]
- ↑ Cooke EV, Tallis RC, Clark A, Pomeroy VM. Efficacy of functional strength training on restoration of lower-limb motor function early after stroke: phase I randomized controlled trial. Neurorehabilitation and Neural Repair. 2010 Jan;24(1):88-96.
- ↑ Royal College of Physicians Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd ed. London,UK: Royal College of Physicians; 2008.
- ↑ Olivetti L, Schurr K, Sherrington C, et al. A novel weightbearing strengthening program during rehabilitation of older people is feasible and improves standing up more than a nonweight-bearing strengthening program: a randomised trial.Aust J Physiother. 2007:53:147-153.
- ↑ 4.0 4.1 Kjølhede T, Vissing K, Dalgas U. Multiple sclerosis and progressive resistance training: a systematic review. Multiple Sclerosis Journal. 2012 Sep;18(9):1215-28.
- ↑ 5.0 5.1 5.2 5.3 Williams G, Strength Training in Neurological Rehabilitation Course, Physioplus 2019
- ↑ 6.0 6.1 Williams G, Kahn M, Randall A. Strength training for walking in neurologic rehabilitation is not task specific: a focused review. American journal of physical medicine & rehabilitation. 2014 Jun 1;93(6):511-22.
- ↑ Ada L, Dorsch S, Canning CG. Strengthening interventions increase strength and improve activity after stroke: a systematic review. Australian Journal of Physiotherapy. 2006 Jan 1;52(4):241-8.
- ↑ Morris SL, Dodd KJ, Morris ME. Outcomes of progressive resistance strength training following stroke: a systematic review. Clinical rehabilitation. 2004 Feb;18(1):27-39.
- ↑ Dodd KJ, Taylor NF, Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Archives of physical medicine and rehabilitation. 2002 Aug 1;83(8):1157-64.
- ↑ Van De Port IG, Wood-Dauphinee S, Lindeman E, Kwakkel G. Effects of exercise training programs on walking competency after stroke: a systematic review. American Journal of Physical Medicine & Rehabilitation. 2007 Nov 1;86(11):935-51.
- ↑ 11.0 11.1 American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Medicine and science in sports and exercise. 2009 Mar;41(3):687.
- ↑ Schwartz MH, Rozumalski A, Trost JP. The effect of walking speed on the gait of typically developing children. Journal of biomechanics. 2008 Jan 1;41(8):1639-50.
- ↑ Sawicki GS, Lewis CL, Ferris DP. It pays to have a spring in your step. Exercise and sport sciences reviews. 2009 Jul;37(3):130.
- ↑ Van Vulpen LF, De Groot S, Rameckers E, Becher JG, Dallmeijer AJ. Improved walking capacity and muscle strength after functional power-training in young children with cerebral palsy. Neurorehabilitation and neural repair. 2017 Sep;31(9):827-41.
- ↑ Williams G, Clark RA, Hansson J, Paterson K. Feasibility of ballistic strengthening exercises in neurologic rehabilitation. American journal of physical medicine & rehabilitation. 2014 Sep 1;93(9):828-33.
- ↑ Williams G, Schache AG. The distribution of positive work and power generation amongst the lower-limb joints during walking normalises following recovery from traumatic brain injury. Gait & posture. 2016 Jan 1;43:265-9.
- ↑ Williams G, Morris ME, Schache A, McCrory P. Observational gait analysis in traumatic brain injury: Accuracy of clinical judgment. Gait & posture. 2009 Apr 1;29(3):454-9.
- ↑ Canning CG, Shepherd RB, Carr JH, Alison JA, Wade L, White A. A randomized controlled trial of the effects of intensive sit-to-stand training after recent traumatic brain injury on sit-to-stand performance. Clinical rehabilitation. 2003 Jun;17(4):355-62.
