8/28/2013 1 Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach Eric J. Chaconas Morey J. Kolber Exercise Progression Strategies for the Knee & Shoulder Eric J. Chaconas, PT, DPT, CSCS, FAAOMPT Morey J. Kolber, PT, PhD, OCS,CSCS Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach Eric J. Chaconas Morey J. Kolber Course Objectives • Recall evidence-based implications for incorporating specific exercise strategies to the shoulder and knee in clinical practice. • Discuss the principles of exercise dosing and prescription. • Examine clinical and basic science research related to exercise progression at the shoulder and knee. • Recognize appropriate rehabilitation exercises for the shoulder and knee. Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach Eric J. Chaconas Morey J. Kolber Exercise • Load placed on the body in order to achieve a physiological response • Goal: functional movement pattern improvement – Motor Control – “Timing” “Activation” – Strength: eccentric, concentric, isometric – Hypertrophy – Power – Speed – Endurance
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8/28/2013
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Exercise Progression Strategies
for the Knee & Shoulder
Eric J. Chaconas, PT, DPT, CSCS, FAAOMPT
Morey J. Kolber, PT, PhD, OCS,CSCS
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Course Objectives
• Recall evidence-based implications for incorporating specific exercise strategies to the shoulder and knee in clinical practice.
• Discuss the principles of exercise dosing and prescription.
• Examine clinical and basic science research related to exercise progression at the shoulder and knee.
• Recognize appropriate rehabilitation exercises for the shoulder and knee.
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Exercise• Load placed on the body in order to achieve a
physiological response
• Goal: functional movement pattern improvement
– Motor Control
– “Timing” “Activation”
– Strength: eccentric, concentric, isometric
– Hypertrophy
– Power
– Speed
– Endurance
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber 4
Other Benefits to Consider
• Reversing pathophysiology
• Stress/injury tolerance
• Desensitization
• Reduce fear of movement
• Reducing systemic disease risk factors
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Treatment Progression
Mobility and Palliative Care
Motor Control, Strength, Proprioception
Endurance, Power, Functional
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber 6
Considerations
• Patient goals
• Tissue healing
• Bio-psychosocial variables (coping skills)
• Limitations (i.e. number of treatment sessions)
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Exercise Order
• Complex movements first– Fatigue will impair movement patterns
– Warm up exercises should be very short in duration
• Exercise order example: ACL rehab 6 weeks post surgery– Squat 2 x 8
– Leg Press 3 x 15
– Single leg proprioception training 3 x 45 seconds
– Side stepping with resistance band 30 feet x 4
– Side plank 2 x 1 minute
– Straight leg raise 3 x 25
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Intensity
• Inversely related to duration of rest period
• Can not increase intensity without sacrificing
some other parameter
– i.e. higher intensity = lower volume
• Intensity should be modified based upon
specific exercise goal
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Frequency
• Most common parameter that is arbitrarily chosen
– i.e. 3 times per week, home exercise program every day
• Total session volume
• Frequency must match the goal of the exercise
program
– Reversing inhibition
– Motor control/movement re-learning
– Strength development
– Power development
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Dosing Strategies
• What are your goals?
–Timing or activation?
–Strength vs. endurance vs. power vs. hypertrophy?
– Is there atrophy?
–What muscle fiber type needs to be recruited?
–What about bioenergetics?
–How will you know you are dosing correctly?
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Resistance Training Variables
Power Intensity:75-90% 1RM
Sets: 3-5
Repetitions: 1-5
Rest: 2-5 min
Strength Intensity:> 85%1RM
Sets: 2-6
Repetition: 6
Rest: 2-5 min
Hypertrophy Intensity:67-85%1RM
Sets: 3-6
Repetition: 6-12
Rest: 30-90 seconds
Endurance Intensity:< 67%1RM
Sets: 2-3
Repetition: 12
Rest: 30 sec
*Rest = between sets & exercises
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Muscle Performance Impairments
Ideal goals for exercise selection:
•Maximal activation
•Maximal isolation
Reality:
• Exercises that maximally activate: perpetuate imbalances
Early rehabilitation needs:
• Exercises that activate (timing) key muscles
• Minimize undesirable recruitment
Late rehabilitation:
• Maximal activation
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Shoulder Complex
• Weakness/Impairment
– External rotators
– Serratus anterior
– Lower trapezius
• Imbalances
– Internal/External rotation
– Abduction/External rotation
– Upper/Lower trapezius
– Upper trapezius/Serratus anterior
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Muscle Imbalances: Strength/Timing
Internal*/External RotationMacDermid et al, J Shoulder Elbow Surg, 2004; Marcondes et al, Rev Bras Fisioter, 2013;
Alderink et al, J Orthop Sports Phys Ther, 1986; Tata et al, J Orthop Sports Phys Ther, 1993
Abductor/External RotationReddy et al, J Shoulder Elbow Surg, 2000; Sharkey & Marder, Am J Sports Med, 1995
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Overhead Triceps Extension: TricepsModification: Biomechanics at End-Range
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber 52
KNEE
“You can’t control the knee at the knee”
• Weakness Impairment
– Hip external rotators and extensors
– Gluteus maximus and medius
– Quadriceps
• Applicable diagnoses
– PFPS (anterior knee pain)
– Knee osteoarthritis, ligament injury, patella
tendinopathy
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Step Down Test
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Step Down Trunk Control
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Drop Jump
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Glute Amnesia
• Common problem is
poor control of the
glutes with
overcompensation from
adjacent muscles
• Glute medius to tensor
fascia latae (TFL)
• Gluteus maximus to
hamstrings ratio
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Early Hip Control Principle
• Maximize abduction, external rotation and
extension motor control
• Optimize glute to TFL and glute to hamstring
ratio
• Minimize dynamic valgus
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
What doesn’t work?
• Why should we avoid ball between the knees?
• What is wrong with side lying hip abduction?
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Hip Movement Pattern Strategies
• Foundational motor control
• Tactile instruction
• Visual/cognitive
Exercise Gluteal to TFL Activation Index
Clam 115
Sidestep 64
Quadruped Hip Extension 50
Sidelying Hip Abduction 38
Step-up 32
Selkowitz 2013
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Clam
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Clam Plus
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Early Phase Gluteus Medius
• Side bridge (side plank)
– Endurance holds
• Side step progression
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Slow Eccentric
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Early Phase Gluteus Maximus
• Bridge with abduction
of hips to improve
glute/hamstring ratio
• Add resistance
• Unilateral
Kang 2013
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Extension Diagonals
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Boudreau 2009
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Side Bridge Progression
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Side Step Progression
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Single Leg Squat
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Single Leg Squat
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Single Leg Deadlift
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Squat Progression
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Step Up/Down
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Quadriceps
• Quadriceps inhibition in the presence of knee
pain
– Knee osteoarthritis
– Ligament Injury
– Knee joint effusion
– Patella femoral pain syndrome
– Most knee surgical procedures
• Does quadriceps weakness cause knee pain?
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Quadriceps Rehabilitation
• Open kinetic chain: straight leg raise, knee
extension
• Closed kinetic chain: Deeper knee flexion
angle = greater quadriceps activation
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Quadriceps
• NMES is effective
• Consider
– Electrode size
– Motor point
– Max intensity tolerated
• Diagnoses
– Total knee Stevens-Lapsley 2012
– Knee OA Vaz 2013
– ACL Kim 2010
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber 78
Home Program
• Patient adherence is the #1 concern
• Less is more
• Instruction: video, patient smartphone
• Adherence to an exercise program directly
associated with level of Self-determination
theory
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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
Self-determination Continuum
Lonsdale, 2012
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
5 A’s to Maximize Patient Self-
Determination
• Ask: Open ended questions, paraphrase, empathize– Gauge patient readiness to accept advice
• Advise: Provide rationale, request patient input and use autonomy focused phrases
– “Here are some things that will help you overcome”
• Agree: Active participation in goal setting, decide on objective, measurable and time based goals
• Assist: Identify barriers, identify solutions
• Arrange: Provide patient with a rehabilitation diary, follow up appointment and contact information for questions
Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach
Eric J. Chaconas Morey J. Kolber
References (Lower Quarter)• Boudreau, S.N., M.K. Dwyer, C.G. Mattacola, C. Lattermann, T.L. Uhl, and J.M. McKeon: Hip-muscle activation during
the lunge, single-leg squat, and step-up-and-over exercises. J Sport Rehabil 2009;18(1)91-103.
• Cambridge, E.D., N. Sidorkewicz, D.M. Ikeda, and S.M. McGill: Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises. Clin Biomech 2012;27(7)719-724.
• Kang SY, Jeon HS, Kwon O, Cynn HS, Choi B. Activation of the gluteus maximus and hamstring muscles during prone hip extension with knee flexion in three hip abduction positions. Man Ther 2013 Jan 8. [Epub ahead of print]
• Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. J Orthop Sports Phys Ther. 2010;40:383-391.
• McBeth, J.M., J.E. Earl-Boehm, S.C. Cobb, and W.E. Huddleston: Hip muscle activity during 3 side-lying hip-strengthening exercises in distance runners. J Athl Train 2012;47(1)15-23.
• McCurdy, K., E. O'Kelley, M. Kutz, G. Langford, J. Ernest, and M. Torres: Comparison of lower extremity EMG between the 2-leg squat and modified single-leg squat in female athletes. J Sport Rehabil 2010;19(1)57-70.
• Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus mediusactivation during rehabilitation exercises. Physiother Theory Pract 2012;28(4)257-268.
• Selkowitz, D.M., G.J. Beneck, and C.M. Powers: Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther201243(2):54-64.
• Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther 2012;92(2):210-26.
• Vaz MA, Baroni BM, Geremia JM, Lanferdini FJ, Mayer A, Arampatzis A, Herzog W. Neuromuscular electrical stimulation (NMES) reduces structural and functional losses of quadriceps muscle and improves health status in patients with knee osteoarthritis. J Orthop Res 2013;31(4):511-6.