Combined Sections Meeting, 2017 – San Antonio
“We Stink at Loading: Exercise, Progression, Loading,
and Nutrition”
Lane Bailey
Ryan Jackson
Phil Page
Dan Lorenz
Rob Panariello
Tissue Repair: Rehabilitation Guideline
Lane Bailey, PhD, PT
DISCLOSURES
US-DOD: “METRC – REPAIR Study” - W81XWH-15-2-0067
US-DOD: “STaR Trial” OUTLINE
1. Briefly Review the Biology of Soft-Tissue Injury & Healing
Muscle
Tendon
Ligament
1. Applied Rehab Principles
Acute & Sub-Acute Injury Management
Post-Operative Exercise Progression
TISSUE INJURY
Prognosis based on several factors
Many Classification Systems Exist
MLG-R: Valle Sports Med 2016
mechanism of injury (M)
location of injury (L)
grading of severity (G)
number of muscle re-injuries (R)
More collective severity = Delayed/Poor Prognosis
MUSCLE INJURY
Muscle Force Thru ECM
Mechanical Connection
1. Epimysium
2. Perimysium
3. Endomysium
ECM Injury Linked to Prognosis
Central Tendon Injury = Poorer Outcomes
TENDON INJURY
Features of Injured Tendon
Disorganized collagen fiber arrangement
Increased non-collagenous ground substance
Increased number and rounded morphology of the tenocytes
Fatty deposits and ectopic ossification
LIGAMENT INJURY
Location Matters
i.e. Intra-articular vs Extra-articular
i.e. Intra-synovial vs Extra-synovial
Healing Requires a Provisional Scaffold (Blood Clot)
Synovial fluid washes away Clot Murray JOR 2013
LIGAMENT INJURY
Location Matters
Need for healing phases and blood supply is key
Murray JBJS 2000 & JOR 2007; Frank JOR 1983
ACL & MCL Fibroblast
Comparing in-vitro cell culture
Similar cell proliferation
LIGAMENT INJURY
Murray JBJS 2000 & JOR 2007; Frank JOR 1983
ACL & MCL Fibroblast
Comparing in-vitro cell culture
Similar cell proliferation
HEALING TIMELINES
Inflammation
Proliferation
Maturation
HEALING CAPACITY
Dependent Upon Injury Location & Blood Supply
Neovascularity – Not always good!
Signs of poor or compromised healing
Intra-articular vs extra-articular
Intra-synovial vs extra-synovial
HEALING CAPACITY
Blood Supply!!!
Use knowledge of tissue blood supply density
Neovascularity – Not always good!
Signs of poor or compromised healing
HEALING CAPACITY
SOFT-TISSUE HEALING
Muscle, Ligament & Tendon are mechanosensitive tissues
Mechanical Forces Converted To Biochemical Signals
Biochemical signals elicit cellular responses by the local cells
Similar mechanical and biological signals are involved in homeostasis, inflammation and repair
Understanding mechanobiology in tissue development, homeostasis and repair is critical to
designing therapies for soft-tissue injury
TENDON & LIGAMENT
Tendons are relatively hypocellular and hypovascular, with little or no intrinsic regenerative
capacity
Tendons consist primarily of collagen fibers (65-80%) oriented in the direction of tensile load.
Proteoglycans and glycoproteins combine to form a ground substance, accounting for 1-2% of
the dry mass of the tendon.
The ground substance surrounds the collagen fibers and plays an important role in cellular
interactions and collagen fibrillogenesis
HEALING TENDONS
Change in phenotype and ECM gene expression of endogenous cells and subsequent protein
synthesis are few factors associated with anabolic structural and compositional changes in
tendon repair sites
Changes cell phenotype
LOAD DEPENDANT
Avoid excessive or unloading
ACUTE MANAGEMENT
1. Protection, Rest, Ice, Compression, Elevation
2. Create an Ideal Healing Environment
Unloading of injured structures
Facilitate vascular mobility (dependent vs elevated position)
1. Avoid further damage
2. Begin with muscle activation in safe environment
3. GET PHASE 1 RIGHT!!!
PHASE 1
CHANGES IN LOAD
TOLERANCE
As tissue matures, it can tolerate greater load
Avoid Significant Increases in Tissue Load
EARLY MANAGEMENT
Allow the tissue to recover
Understand that the load capacity is compromised Mueller JOSPT 2002
Facilitate transition to the proliferative phase
Relative rest
Low load activity
Quad sets, scap retraction etc…table exercises are ok!
Have criteria to progression, no means don’t go!
EARLY POST-OP
MANAGEMENT
Allow the tissue to recover
Understand that the load capacity is compromised Mueller & Malluf
Facilitate transition to the proliferative phase
Relative rest
Low load activity
Quad sets, scap retraction etc…table exercises are ok!
Have criteria to progression, no means don’t go!
LOAD TOLERANCE
Use Lab & Basic science to determine tissue stress
Use physics & clinical judgement when no evidence available
Consider All Tissues Involved
What’s good for one tissue may not be for another
i.e. Graft vs Harvest Site
GRADED PROGRESSION
POST-OP STRENGTHENING BFR
POST-OP STRENGTHENING
Blood Flow Restriction Training
POST-OP STRENGTHENING
Blood Flow Restriction Training
POST-OP STRENGTHENING
Blood Flow Restriction Training
POST-OP STRENGTHENING
Blood Flow Restriction Training
SUMMARY
1. Understand healing principles of soft-tissues
2. Discuss guide rehab progression
3. Utili
Thank You
Nutritional and Supplementation Support for
Injuries
Ryan Jackson, MEd, RD, CSCS, SCCC
•
Goals of nutrition support of injuries
o Reduce muscle atrophy
o Increase collagen synthesis/tissue regeneration
o Manage inflammation
o Maintain optimal body compositionPromote optimal insulin sensitivity and glycemic
control*
•
Strategies to reduce muscle atrophy
o Frequent high protein feedings amounts throughout day, especially in and around
training/rehab
4-6 times per day every 2-4 hours
25-50 grams per feeding
• Leucine light switch for muscle protein synthesis(mTor)
o Creatine loading near the end of inflammation phase/onset of injury
20 g creatine/day for 7 days followed by 5-10 grams per day thereafter
throughout rehabilitation
Increase collagen synthesis/tissue regeneration
o Gelatin/Vitamin C supplementation at the onset of injury
5-15 grams gelatin+200-300 mg vitamin C 30-60 minutes before activity
Cells in tendons become less responsive after 10 minutes.
Turned back on after 6 hours.
If possible 2-3 rehab/training/movement sessions per day can maximize
o Vitamin A, E, Zinc, and Copper supplementation might play a role in assisting with
collagen synthesis and healing
Managing inflammation
o Remember inflammation is required for injury repair
o Optimal omega 3 to omega 6 balance (1:1-3 ratio)
Fish Oil @3-9g per day at onset of injury
Consume high amounts of avocados, nuts, seeds, olive oils, and grass fed animal
fat products
o Optimal micronutrient intake
Consume a wide variety of vegetables and fruits high in vitamin A, C, E, and D
Maintain optimal body composition
o Promote insulin sensitivity
Optimal protein feedings as listed above
Reduce overall calorie and specifically carbohydrate intake during initial phases
of injury and immobilization
Slowly reintroduce calories in form of carbohydrate as rehabilitation activity and
intensity increases
Keep carbohydrate feedings limited to in and around training
o Maintain glycemic control
•
•
•
The less lean an athlete is the more likely they might be at risk for poor glycemic
control
Poor glycemic control shown to decrease response/adaptation in tendons to
training
• I.e. association between diabetics and tendinopathy
Reconditioning/rehab=optimal time for retraining the body to better be fuel
adapted?
• Energy system training
• Utilize fat as a fuel source
• Train low/recover low strategies
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Dose and Prescription of Balance Training
Exercises
Phil Page, PT, PhD, ATC, CSCS, FACS
I.
II.
III.
IV.
Background
a. Postural stability: ability to maintain COG over BOS
i. Static & dynamic
ii. Visual, Vestibular, Proprioceptive
b. Sensorimotor System
i. 3 levels
ii. Motor Learning
Balance Training
a. Challenge systems that control postural stability
i. BOS
ii. COG
iii. Visual
iv. Vestibular
b. Different Unstable surfaces
c. Efficacy
i. Prevention
ii. Performance
iii. Rehab
Dosage
a. Why is dosage important?
i. Appropriate for training adaptation
ii. Specificity of training
iii. Individual prescription
iv. Progression parameters
v. Program replication
b. What is a ‘dose’ of exercise
i. Load
ii. Volume
iii. Duration
iv. Exercises
v. Progression
vi. Rest
Mega Review of Balance Training
a. Article selection
b. Results
i. Ankle Sprain
ii. ACL tear
iii. Athlete
iv. Older Adult
v. Chronic Disease
c. Limitations to ‘proper dose”
i. Pubmed search
ii. Lack of well-controlled dose-response studies
iii. Heterogeneity of studies / Inability to generalize findings
1. Populations, methods, outcomes, designs
iv. Lack of detail & parameters (esp. “Intensity”)
v. Balance often combined with other exercises
vi. Lack of quantification of balance ‘intensity’
vii. Moderate quality studies
d. Evidence-based dosing parameters
i. Load
ii. Volume
iii. Duration
iv. Exercises
v. Progression
vi. Rest
V.
e. Compliance
Future Research
Determining Resistance in Rehabilitation &
Dosing for Endurance, Hypertrophy, Strength,
& Power
Dan Lorenz, DPT, PT, ATC/L, CSCS
I. 1 RM Estimates in Rehabilitation
II. Principles of Progression
A. Progressive Overload
B. Specificity
C. Variation
a. Periodization
III. Endurance
A. Sets
B. Repetitions
C. Load
D. Rest Periods
IV. Hypertrophy
A. Sets
B. Repetitions
C. Load
D. Rest Periods
V. Strength
A. Types
a. Starting strength
b. Eccentric strength
c. Elastic strength
B. Sets
C. Repetitions
D. Load
E. Rest Periods
VI. Power
A. Sets
B. Repetitions
C. Load
E. Rest Periods
VII. Other training variables
A. Repetition velocity
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strength, power, and speed. J Strength Cond Res. 2002; 16: 75-82.
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differences of knee flexor and extensor isokinetic strength and multi-directional speed.
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implementation for athletic rehabilitation. Sports Health. 2010; 2: 509-518.
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resistance training, plyometric training, and complex training on measures of strength and
anthropometrics. J Strength Condit Res. 2012;26(2):422-431.
11. Reiman MP, Lorenz D. Integration of strength and conditioning principles into rehabilitation
programs. Int J Sports Phys Ther. 2011; 6(3): 241-53.
12. Simao R, De Salles BF, Figuueiredo T, Dioas I, Willardson JM. Exerise order in resistance
training. Sports Med. 2012;42(3):251-265.
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Exerc. 2009; 41(3): 687-708.
Metabolic Conditioning and Nutritional
Support
Ryan Jackson
•
•
•
•
Energy systems overview
The difference between nutritional/supplement fueling to adapt and fueling to perform.
o Nutrition and supplementation for conditioning should have two primary goals in this
order
1. Fuel to ADAPT
2. Fuel to PERFORM
Sub-Threshold Work and Supra-Threshold Work
o Sub threshold-Typically more aerobic
o Supra threshold-Typically more lactic and alactic
Sub-Threshold Work
o Endurance
Characteristics
• 65-80% HR max
• Continuous, long, easy in nature
Metabolic Goal
• Improve sub-threshold capacity thru both central and peripheral
adaptions
Nutrition/supplementation support
• Low carbtrain low strategies, fasted training
•
•
•
o
•
Caffeine
Beet root juice
Gelatin/Vitamin C supplementation
Threshold
Characteristics
• 80-90% HRmax
• Continuous long intervals @ threshold or very short, high effort
intervals @ or right below threshold
Metabolic Goal
• Delay onset of fatigue during high intensity repeated exercise i.e
THRESHOLD
Nutrition/supplementation support
• Low carbtrain low/fasted training
• Caffeine
• Beet root juice
• Beta-alanine/sodium bicarb
• Gelatin/Vitamin C supplementation
Supra-Threshold Work
o Capacity
Characteristics
• 90-100% HRmax
• Long to very short, high effort intervals, minimal rest
Metabolic Goal
• Improve maximal capacity of all systems
• Buffering capacity
• Fatigue tolerance
Nutrition/supplementation support
• Low carbrecover low/sleep low
• Creatine
• Caffeine
• Beta-alanine/sodium bicarb
o Power
Characteristics
• High Intensity, maximal intent, max effort
• Long to very short intervals with complete rest
Metabolic Goal
• Improve metabolic power
• Max capacity of all systems due to improved efficiency
• Intensity tolerance
Nutrition/supplementation support
o
• Creatine
• Protein
• Caffeine
Periodization Schemes in a perfect world
Block I Endurance/Threshold Block
Block 2 Capacity/Threshold Block
Block 3 Power/Endurance Block
Block 1 Endurance/Threshold
Block 2 Power/Threshold
Block 3 Capacity/Endurance
Block 1 Endurance
Block 2 Threshold
Block 3 Power or Capacity
Block 4 Capacity or Power
Long-Term Programming for Return to Play
Rob Panariello, MS, PT, ATC, CSCS
Risk Factors
Modifiable
• Physical Qualities
o ROM, Strength, Power, Elastic/Reactive Strength, Speed, etc.
• Skill Performance
o Deceleration, Cutting, Jumping/Landing from jumps, etc.
Non-Modifiable
• Knee Varus/Valgus, tibial slope, etc.
The Hierarchy of Athletic Development
•
Development of physical qualities necessary for return to sport
o Strength, Power, Elastic/Reactive Strength, Speed
o Each physical quality is dependent upon the optimal development of it’s
predecessor
•
Deficits found in the “return to play” ACL Athlete
o Strength
o Power
o Elastic Abilities
o Deceleration
o COD
o Speed
o Kinesiophobia
Athletic Performance
o Application of force into the ground surface area
o Force application must occur in short periods of time (amortization)
o Restoration/Development of the physical qualities for sports participation
o Contribution and inter-relationship of the physical qualities in a sport task
ACL Return to Play
o “Traditional” programs
o Professional Physical Therapy Return to Play Algorithm
o Review of sample testing results
o Return to Training
o Return to Practice
o Return to Play