Strength Training in Neurological Rehabilitation: Difference between revisions

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== Strength Training for Muscle Weakness ==
== Strength training in Evidence  ==
Paresis (muscle weakness) is a  is a key physical impairment in neurological conditions limiting mobility<ref name=":2" />.  
Paresis (muscle weakness) is a  is a key physical impairment in neurological conditions limiting mobility<ref name=":2" />.  


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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<ref name=":2">Williams G, Strength Training in Neurological Rehabilitation Course, Physioplus 2019 </ref>.  
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<ref name=":2">Williams G, Strength Training in Neurological Rehabilitation Course, Physioplus 2019 </ref>.  


Despite being effective in musle strengthening, most of the applied studies failed to show improvement in walking capacity<ref name=":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.</ref>.     
Differnet systematc reviews<ref name=":0" /><ref>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.</ref><ref>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.</ref><ref>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.</ref><ref>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.</ref> demoenstrated improvement in strength following resistance training but showed limited impact on walking parameters<ref name=":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.</ref>


== Current Evidence in Strength training ==
A study by Williams et al <ref name=":1" /> aimed to investigate task specificity of strength training for walking in neurological conditions.The systematic review mainly found quadriceps and hamstrings exercises to be the most common used exercises in neuroligical rehabiilitaton.  
Differnet systematc reviews<ref name=":0" /><ref>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.</ref><ref>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.</ref><ref>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.</ref><ref>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.</ref> demoenstrated improvement in strength following resistance training but showed limited impact on walking parameters.


Task Specific Criteria for Muscle Strengthning
== Biomechanics of Gait ==
A good understanding of gait parameters is needed to prescribe proper exercises for walking.  


Based on ACSM guidelines<ref name=":3">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.</ref>: 
Muscle recruitment and speed influence walking mechanics across hip, knee and ankle joints<ref>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.</ref>.  
* Role of the muscle
* Action of the muscle 
* Type of contraction 
* Active range and segmental alignement
* Load
* Speed of movement 
 
A study by Williams et al <ref name=":1" /> aimed to investigate task specificity of strength training for walking in neurological conditions.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 mnimal level of strength is required in all muscles to generate the power for walking, however, not all muscles are reqruited equally.  
 
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<ref>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.</ref>.
 
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:   
Three key events are important for power generation during walking cycle:   
* 2-Ankle PF power generation at push-off at terminal stance   
# Hip extensor power generation at Initial Contact 
* 1-Hip extensor power generation at Initial Contact 
# Ankle PF power generation at push-off (terminal stance)  
* 3-Hip flexor power generation at toe-off to accelerate the leg through swing phase pre-swing
# Hip flexor power generation at toe-off to accelerate the leg through the swing phase
Key events at the knee for power absorption rather than power generation:  
At the knee joint, muscles generate force for power absorption:
* Knee extensors at terminal stance
* Knee extensors at terminal stance
* Knee flexors at terminal swing to decelrate the leg.  
* 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 the stance phase, <u>the main</u> power is genrated <u>at the ankle.</u>  
 
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<ref>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.</ref>
 
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<ref name=":2" />.
 
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<ref name=":2" />. 
 
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<ref>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.</ref> 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<ref>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.</ref>.   


Conclusion   
A study analyzed the power generated at the ankle joint and found that Achillies tendon produced the highest peak of force.<ref>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.</ref>


Power training is recommended over conventional strength/resistance training with considerations to gait biomechanics.Ballistic training improves power generation.     
== Is it just about strength? ==
'''<u>Strength reflects the maximum amount of force a muscle can produce Whearas power is defined as the rate of force production</u>'''


Exercises performed with speed.    
Progresive Resistance Exercises ( PRE) are considered the best method for improving the force production and muscle hypertrophy. Changing resistance constantly is the key to improve strength<ref name=":2" />.  


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.     
Heavy resistance training improves strength wheras ballistic (lighter loads and high repetitions) training doesn't increase strength but it improves power genrations<ref name=":2" />.


ACSM guidelines:     
Stance phase make up about 0.6 sec of the gait cycle, push off 0.15 seconds- that's when the achillies tendon is producing most of the power. Strength training can increase the muscle-tendon strength but not the power needed for the push off. 


PRT is the best method   
Speed is another factor that influence gait mechanics as muscle power genration during walking occurs at high angular velocities. Applying the principals of ballistic training at a tageted speed at the ankle joint can be the key to better gait parameters <ref name=":2" />. 


Ballistic training improves power genration and considered superior to progressive resistance training for power generation.    
In williams et al systematic review<ref name=":1" />, most studies did not include exercises relating to all three main power events important for walking. Instead, strength testing and strengthening exercises were prioritized for the knee extensors and flexors, despite their minor role played in normal gait cycle.  


Four Criteria to be considered:    
A 2017 study<ref>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.</ref> evaluated the effect of functional high-velocity resistance training (power-training) to improve muscle strength and walking capacity of children with Cerebral Palsy reported significant improvement in the muscle power sprint test, 1-minute walk test (1MWT), 10-m shuttle run test (SRT), gross motor function , isometric strength of lower-limb muscles and dynamic ankle plantar flexor strength reflecting improvement on walking capacity.   
* Maximum rate force production   
* Lighter loads   
* Stretch-shortening cycle     
* Coordinated movement pattern/skill   


Task Specific Criteria for Muscle Strengthning
Ballistic training was compared to conventional leg exercises by williams <ref>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.</ref>. A single testing session seated leg press performed conventionally compared to doing the same exercise with a jump found 70% increase of concentric velocity in ballistic condition.     


Based on ACSM guidelines<ref name=":3" />:
== Clinical Applications ==
Considerations for exercises prescriptions: 
* Power training is recommended over conventional strength/resistance training with considerations to gait biomechanics.
* Ballistic training improves power generation.
* Exercises should be performed with speed     
* Exercise has to be specific to the muscles that genrates the power (ankle plantar flexor)     
* Exercise has tobe performed properly to ensure power is genrated from the ankle. If pateint is unable to isolate the right muscle, apply some modifications to allow for proper performance.     
Task specificity principals based on ACSM guidelines<ref name=":3">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.</ref>:    
* Role of the muscle  
* Role of the muscle  
* Action of the muscle   
* Action of the muscle   
Line 182: Line 113:
Hip extensors
Hip extensors


What about Quads? most commonly targeted, very important for standing upand stairs<ref>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.</ref>. But might not be refelcting on gait function.    
What about Quads? most commonly targeted, very important for standing upand stairs<ref>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.</ref>. But might not be refelcting on gait function.                        


== References  ==
== References  ==

Revision as of 00:00, 29 December 2019

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Tony Lowe, Lucinda hampton, Admin and Tarina van der Stockt


Strength training in Evidence[edit | edit source]

Paresis (muscle weakness) is a is a key physical impairment in neurological conditions limiting mobility[1].

Muscle weakness.

Resistance training was found to improve muscle strength[2] and functional performance when added to functional exercises[3].

A systematic review by Kjølhede in 2012 reported strong evidence regarding progressive resistance training on muscle strength for people with Multiple Sclerosis[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[1].

Differnet systematc reviews[4][5][6][7][8] demoenstrated improvement in strength following resistance training but showed limited impact on walking parameters[9]

A study by Williams et al [9] aimed to investigate task specificity of strength training for walking in neurological conditions.The systematic review mainly found quadriceps and hamstrings exercises to be the most common used exercises in neuroligical rehabiilitaton.

Biomechanics of Gait[edit | edit source]

A good understanding of gait parameters is needed to prescribe proper exercises for walking.

Muscle recruitment and speed influence walking mechanics across hip, knee and ankle joints[10].

A mnimal level of strength is required in all muscles to generate the power for walking, however, not all muscles are reqruited equally.

Three key events are important for power generation during walking cycle:

  1. Hip extensor power generation at Initial Contact
  2. Ankle PF power generation at push-off (terminal stance)
  3. Hip flexor power generation at toe-off to accelerate the leg through the swing phase

At the knee joint, muscles generate force for power absorption:

  • Knee extensors at terminal stance
  • Knee flexors at terminal swing to decelrate the leg.

At the stance phase, the main power is genrated at the ankle.

A study analyzed the power generated at the ankle joint and found that Achillies tendon produced the highest peak of force.[11]

Is it just about strength?[edit | edit source]

Strength reflects the maximum amount of force a muscle can produce Whearas power is defined as the rate of force production

Progresive Resistance Exercises ( PRE) are considered the best method for improving the force production and muscle hypertrophy. Changing resistance constantly is the key to improve strength[1].

Heavy resistance training improves strength wheras ballistic (lighter loads and high repetitions) training doesn't increase strength but it improves power genrations[1].

Stance phase make up about 0.6 sec of the gait cycle, push off 0.15 seconds- that's when the achillies tendon is producing most of the power. Strength training can increase the muscle-tendon strength but not the power needed for the push off.

Speed is another factor that influence gait mechanics as muscle power genration during walking occurs at high angular velocities. Applying the principals of ballistic training at a tageted speed at the ankle joint can be the key to better gait parameters [1].

In williams et al systematic review[9], most studies did not include exercises relating to all three main power events important for walking. Instead, strength testing and strengthening exercises were prioritized for the knee extensors and flexors, despite their minor role played in normal gait cycle.

A 2017 study[12] evaluated the effect of functional high-velocity resistance training (power-training) to improve muscle strength and walking capacity of children with Cerebral Palsy reported significant improvement in the muscle power sprint test, 1-minute walk test (1MWT), 10-m shuttle run test (SRT), gross motor function , isometric strength of lower-limb muscles and dynamic ankle plantar flexor strength reflecting improvement on walking capacity.

Ballistic training was compared to conventional leg exercises by williams [13]. A single testing session seated leg press performed conventionally compared to doing the same exercise with a jump found 70% increase of concentric velocity in ballistic condition.

Clinical Applications[edit | edit source]

Considerations for exercises prescriptions:

  • Power training is recommended over conventional strength/resistance training with considerations to gait biomechanics.
  • Ballistic training improves power generation.
  • Exercises should be performed with speed
  • Exercise has to be specific to the muscles that genrates the power (ankle plantar flexor)
  • Exercise has tobe performed properly to ensure power is genrated from the ankle. If pateint is unable to isolate the right muscle, apply some modifications to allow for proper performance.

Task specificity principals based on ACSM guidelines[14]:

  • 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[15]. Results?

Recovery of Walking:

Reduced distal power generaiton lead to proximal compensations[16]. greater hip flexor power generation to lift off and hip extensor to accelerate[1].

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[17]. But might not be refelcting on gait function.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Williams G, Strength Training in Neurological Rehabilitation Course, Physioplus 2019
  2. ↑ Royal College of Physicians Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 3rd ed. London,UK: Royal College of Physicians; 2008.
  3. ↑ 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. ↑ 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. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 9.0 9.1 9.2 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
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