The document discusses mechanisms of therapeutic exercise progression based on scientific evidence from cellular physiology research. It identifies three components of recovery-centered training: mechanical, neuro-musculoskeletal, and cardiovascular systems. Optimal therapeutic exercise requires applying principles of mechanical loading strategies and tissue-specific progressions based on symptomatic, mechanical, and functional responses to achieve desired cellular and tissue adaptations.

1. Mechanisms Of Therapeutic Exercise Progression Allan Besselink, PT, Dip.MDT Smart Life Project Austin, Texas

2. Background Physiotherapist (1988) McKenzie Diploma (1998) USA Track and Field Endurance sports coach (running, triathlon)

3. Background Educator (PT; PTA) Author - “RunSmart: A Comprehensive Approach To Injury-Free Running” (2008) Author (with Bridget Clark, PT) - “Running Injuries” chapter in 3 rd edition of ”Clinical Orthopedic Rehabilitation” (2011)

4. Why This Topic? The vast majority of "treatments" have little to no confirmed scientific basis … … yet we claim to be focused on "evidence-based practice"

5. Why This Topic? There are too many clinicians using yellow theraband forever … ... yet we promote ourselves as the experts in therapeutic exercise

6. Why This Topic? We have 50+ years of cellular physiology research … … and yet we choose to ignore it

7. Objectives Identify and examine the current scientific literature on therapeutic exercise and tissue repair Identify the three primary components of Recovery-Centered Training and explain their relevance to therapeutic exercise progression

8. Objectives Discuss the physiological mechanisms underlying tissue repair and development in the context of therapeutic exercise Define the principles of mechanical loading and their application to therapeutic exercise programs

9. Objectives Implement optimized therapeutic exercise progressions utilizing the critical parameters and dosage of various loading strategies

10. Overview The Basics Stimulus – Response and Homeostasis Mechanisms Loading Strategies to attain Desired Response Tissue- And System-Based Progressions Symptomatic, Mechanical, And Functional

11. Overview Traditional Approaches To Therapeutic Exercise Optimal Critical Parameters? Competent Self Care – Is It Enough? What Is The Role Of The PT? Summary

12. Discussion In groups of 3 to 5, discuss the scenario presented to you Assume no "red flags" are present What is the primary mode of therapeutic exercise required?

13. The Basics

14. Principles And Practices Principles = Why Practices = What

15. The Basics Stimulus – Response Homeostasis Specific Adaptation To Imposed Demands Wolfe's Law Building Capacity Critical Parameters

16. “ Evidence-Based Cellular Physiology” 50+ years of research in cellular physiology Apply these well-established principles

17. Stimulus - Response

18. Homeostasis "The maintenance of relatively stable internal physiological conditions under fluctuating environmental conditions" Are we ever "out of balance"? Do we ever really, by definition, have a "muscle imbalance"?

19. Balance Stimulus And Response

20. Feedback Loops

21. SAID Principle Specific Adaptation To Imposed Demands Wolfe's Law Form Follows Function Astronauts

22. Building Capacity Work = "the amount of energy transferred into or out of a system, not counting energy transferred by heat conduction" Work = Power x time Work = Force x Velocity x Time

23. Exercise Is Like Medicine "Therapeutic Dose" is critical! Critical parameters – dosage, frequency, timing Exercise is no different – enough for the desired response

24. Traditional Systems Cardiovascular / Aerobic system Endurance = the capacity to withstand physiological or psychological stressors over a sustained period of time The heart is a muscle!

25. True Systems Thinking Involves understanding the behavior of the system as a whole (Peter Senge "The Fifth Discipline") Recovery-Centered Training – A Model Of Human Performance Mechanical Diagnosis And Therapy (MDT)

26. Recovery-Centered Training Mechanical Neuro-musculo-skeletal Cardiovascular Cognitive Central nervous system Endocrine system Immune system Nutritional

27. MDT Mechanical Diagnosis and Therapy (MDT) A systems thinking approach to musculoskeletal care Mutually exclusive diagnostic categories based on system behavior (responses to repeated movements and sustained loading) Derangement, Dysfunction, Posture, Other

28. Scenarios Stress reaction Osteoporosis Osteoarthritis Capsular tightness Tendinopathy Derangement Weight loss Muscle strength Muscle endurance Post-surgical ROM Neuromotor facilitation Neuromotor inhibition Flexibility Aerobic capacity / deconditioning

29. Mechanisms

30. Mechanisms Mechanisms of Optimal Human Performance = Mechanisms of Injury Recovery = Mechanisms of Injury Prevention (Besselink 1992)

31. Mechanisms Stimulate appropriate cellular activity to attain desired cellular response Critical parameters of mechanical loading to attain desired cellular response Appropriate Symptomatic, Mechanical and Functional Responses

32. Relationship Between Function And Cellular Activity Cellular Level Protein synthesis Collagen synthesis Mitochondrial density etc Changes In ... Tendon tensile strength Muscle strength Cartilage volume etc

33. It All Starts With The CNS

34. Mechanotransduction Khan KM, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247-252. Kaneko D et al. Temporal effects of cyclic stretching on distribution and gene expression of integrin and cytoskeleton by ligament fibroblasts in vitro.Connect Tiss Res 2009; 50(4), 263-269.

35. Mechanisms Tissues Connective Muscle Nervous (Epithelial) Systems Traditional i.e. Cardiovascular "Systems Thinking" (incl. MDT)

36. Mechanical Loading Strategies What mechanical loading strategy is required to stimulate the desired cellular activity and to "turn on the gene"? Which mechanical loading strategy is required to attain the desired functional response(s)?

37. Critical Parameters Every training session/exercise has an intent – and a desired cellular response Critical parameters of dosage/potency and frequency

38. Connective Tissue Bone Tension, compression, shear Fluid flow Collagen Tendon - tension Cartilage - compression Ligament - tension

39. Muscle Tissue Number of muscle fibers recruited Velocity of muscle fiber recruitment Mitochondria = cellular powerhouse (active muscle fibers only) = endurance Tension / Load / Resistance

40. Nervous Tissue CNS Recruitment Motor patterns Synaptogenesis Facilitation and inhibition

41. Discussion In your original groups, discuss the scenario presented to you With what you now know, what is the primary mode of therapeutic exercise (mechanical loading strategy) required to attain the desired cellular response? What are the critical parameters necessary to do so?

42. Building Capacity Work = Force x Velocity x Time Intensity is your friend, not your enemy

43. Critical Parameters Tissues Connective – bone; cartilage; collagen Muscle Nervous Systems RCT – signs of under-recovery MDT – directional preference

44. Scenarios Stress reaction Osteoporosis Osteoarthritis Capsular tightness Tendinopathy Derangement Weight loss Muscle strength Muscle endurance Post-surgical ROM Neuromotor facilitation Neuromotor inhibition Flexibility Aerobic capacity / deconditioning

45. Tissue Repair And Remodeling Acute Phase = 1 to 3 days = "your friend, not your foe" Fibroplastic = up to 3 weeks = "prime time" for mechanical loading Remodeling = 6 weeks to 2 years = still very responsive to mechanical loading

46. Progressions

47. Progression Based on Symptomatic, Mechanical, and Functional Responses to Loading Strategies Need benchmarks and baselines!

48. Responses To Loading Strategies Symptomatic Mechanical Functional

49. Progression Progression will vary depending on the ability of the patient to adapt to the imposed demands Age Metabolic state

50. Progression And Limiters Be aware of the signs and symptoms of “under-recovery” (Recovery-Centered Training) Mechanical Cognitive Nutritional Safety Hurt Not Harm

51. Traditional Approaches To Therapeutic Exercise

52. Traditional Approaches Insufficient or inappropriate exercise parameters to elicit desired (or optimal) physiological response Garbage In, Garbage Out Modalities as a passive mechanical loading strategy

53. Woollard et al (2011) JOSPT "Change in Knee Cartilage Volume in Individuals Completing a Therapeutic Exercise Program for Knee Osteoarthritis" Loss of cartilage volume

54. Therapeutic Exercise Program Stretching, quadriceps setting, SLR Leg press at 70% of 1-RM: 3 x 10 PT 2x per week for 6 weeks HEP 2x per week for 4 weeks Based on the critical parameters, would I expect anything different?

55. Problem “ The inability to challenge our belief systems in the face of good scientific evidence is the primary limiting factor in the advancement of both health care and coaching, as well as human performance and injury prevention” (Besselink 2008)

56. Competent Self Care - Is It Enough?

57. Competent Self Care Can the patient perform the necessary loading strategies to promote optimal repair and remodeling on their own? What is the role of the PT? Competent self care and health mentorship is an opportunity for the PT profession

58. Summary

59. Challenge Your Thinking! “ We can't solve problems by using the same kind of thinking we used when we created them.” (Einstein)

60. For More Information: Smart Life Project www.allanbesselink.com/slp www.allanbesselink/subscribe “ RunSmart: A Comprehensive Approach To Injury-Free Running”

61. Move Forward (APTA) www.moveforwardpt.com

62. The Finish Line Is Upon Us!

63. Photo Credits http://www.flickr.com/photos/monsieurlui/ http://www.flickr.com/photos/emilianohorcada/ http://www.flickr.com/photos/pinksherbet/ http://www.flickr.com/photos/53921113@N02/ http://www.flickr.com/photos/panduadnyana/ Allan Besselink All others public domain or fair use Creative Commons