Introduction
The principles of resistance training presented in this section apply to the use of both manual and mechanical resistance exercises for persons of all ages, but these principles are not “set in stone.” There are many instances when they may or should be modified based on the judgment of the therapist. Additional guidelines specific to the application of manual resistance exercise, proprioceptive neuromuscular facilitation, and mechanical resistance exercise are addressed in later sections of this chapter.

Examination and Evaluation
As with all forms of therapeutic exercise, a comprehensive examination and evaluation is the cornerstone of an individualized resistance training program. Therefore, prior to initiating any form of resistance exercise:
• Perform a thorough examination of the patient, including a health history, systems review, and selected tests and measurements.
• Determine qualitative and quantitative baselines of strength, muscular endurance, ROM, and overall level of functional performance against which progress can be measured.
• Implement testing procedures, such as manual muscle testing, determination of a repetition maximum, dynamometry, goniometry, quantitative functional performance tests, and assessment of the patient’s perceived level of disability.
• Interpret the findings to determine if the use of resistance exercise is appropriate or inappropriate at this time. Be sure to identify the most functionally relevant impairments, the goals the patient is seeking to achieve and the expected functional outcomes of the exercise program.
• Establish how resistance training will be integrated into the plan of care with other therapeutic exercise interventions, such as stretching, joint mobilization techniques, balance training, and cardiopulmonary conditioning exercises.
• Re-evaluate periodically to document progress and determine if and how the dosage of exercises (intensity, volume, frequency, rest) and the types of resistance exercise should be adjusted to continue to challenge the patient.

Is Resistance Training Appropriate? Questions to Consider
• Were deficits in muscle performance identified? If so, do these deficits appear to be contributing to limitations of functional abilities that you have observed or the patient or family has reported?
• Could identified deficits cause future impairment of function?
• What is the irritability and current stage of healing of involved tissues?
• Is there evidence of tissue swelling?
• Is there pain? (At rest or with movement? At what portion of the ROM? In what tissues?)
• Are there other deficits (such as impaired mobility, balance, sensation, coordination, or cognition) that are adversely affecting much of the performance?
• What are the patient’s goals or desired functional outcomes? Are they realistic in light of the findings of the examination?
• Given the patient’s current status, are resistance exercises indicated? Contraindicated?
• Can the identified deficits in muscle performance be eliminated or minimized with resistance exercises?
• If a decision is made to prescribe resistance exercises in the treatment plan, what resistance exercises are expected to be most effective?
• Should one area of muscle performance be emphasized over another?
• Will the patient require supervision or assistance over the course of the exercise program or can the program be carried out independently?
• What is the expected frequency and duration of the resistance training program? Will a maintenance program be necessary?
• Are there any precautions specific to the patient’s physical status, general health, or age that may warrant special consideration?

Preparation for Resistance Exercises
• Select and prescribe the forms of resistance exercise that are appropriate and expected to be effective, such as whether to implement manual or mechanical resistance exercises, or both.
• If implementing mechanical resistance exercise, determine what equipment is needed and available.
• Review the anticipated goals and expected functional outcomes.
• Explain the exercise plan and procedures. Be sure that the patient and/or family understands and gives consent.
• Have the patient wear nonrestrictive clothing and supportive shoes appropriate for exercise. If the patient is wearing a hospital gown, use a sheet to drape for modesty.
• If possible, select a firm but comfortable support surface for exercise.
• Demonstrate each exercise and the desired movement pattern.

Application of Resistance Exercises

NOTE: These general guidelines apply to the use of dynamic exercises against manual or mechanical resistance. In addition to these guidelines, refer to special considerations and guidelines unique to the application of manual and mechanical resistance exercises in the sections of this chapter that follow.

Warm Up
Prior to initiating resistance exercises, warm up with light, repetitive, dynamic, site-specific movements without applying resistance. For example, prior to lower extremity resistance exercises, have the patient walk on a treadmill, if possible, for 5 to 10 minutes followed by flexibility exercises for the trunk and lower extremities.

Placement of Resistance
• Resistance is typically applied to the distal end of the segment in which the muscle to be strengthened attaches. Distal placement of resistance generates the greatest amount of external torque with the least amount of manual or mechanical resistance (load). For example, to strengthen the anterior deltoid, resistance is applied to the distal humerus as the patient flexes the shoulder.
• Resistance may be applied across an intermediate joint if that joint is stable and pain-free and if there is adequate muscle strength supporting the joint. For example, to strengthen the anterior deltoid using mechanical resistance, a handheld weight is a common source of resistance.
• Revise the placement of resistance if pressure from the load is uncomfortable.

Direction of Resistance
During concentric exercise resistance is applied in the direction directly opposite to the desired motion, whereas during eccentric exercise resistance is applied in the same direction as the desired motion.

Stabilization
Stabilization is necessary to avoid unwanted, substitute motions.
• For non-weight-bearing resisted exercises, external stabilization of a segment is usually applied at the proximal attachment of the muscle to be strengthened. In the case of the biceps brachii muscle, for example, stabilization should occur at the anterior shoulder as elbow flexion is resisted. Equipment such as belts or straps are effective sources of external stabilization.
• During multijoint resisted exercises in weight-bearing postures, the patient must use muscle control (internal stabilization) to hold nonmoving segments in alignment.

Intensity of Exercise/Amount of Resistance
• Initially, have the patient practice the movement pattern against a minimal load to learn the correct pattern and the exercise technique.
• Have the patient exert a forceful but controlled and pain-free effort. The level of resistance should be such that movements are smooth and nonballistic or tremulous.
• Adjust the alignment, stabilization, or the amount of resistance if the patient is unable to complete the available ROM, muscular tremor develops, or substitute motions occur.

NOTE: The intensity of the exercise (submaximal to near-maximal) must be consistent with the intended goals of resistance training and the type of muscle contraction as well as other aspects of dosage.

Volume/Number of Repetitions and Sets and Rest Intervals
• In general, for most adults, use 8 to 12 repetitions of a specific motion against a moderate exercise load. This volume induces typical acute and chronic responses; that is, muscular fatigue and adaptive gains in muscular strength, respectively.
• Decrease the amount of resistance if the patient cannot complete 8 to 12 repetitions.
• After a brief rest, perform additional repetitions: a second set of 8 to 12 repetitions, if possible.
• For progressive overloading, initially increase the number of repetitions or sets; at a later point in the exercise program, gradually increase the resistance.

Verbal or Written Instructions
When teaching an exercise using mechanical resistance or when applying manual resistance, use simple instructions that are easily understood. Do not use medical terminology or jargon. For example, tell the patient to “Bend and straighten your elbow” rather than “Flex and extend your elbow.” Be sure that descriptions of resistance exercises to be performed in a home program are written and clearly illustrated.

Monitoring the Patient
Assess the patient’s responses before, during, and after exercise. It may be advisable to monitor the patient’s vital signs. Adhere to relevant precautions discussed in the next section of the chapter.

Cool Down
Cool down after a series of resistance exercises with rhythmic, unresisted movements, such as arm swinging, walking, or cycling. Gentle stretching is also appropriate after resistance exercise.

Buy the Book that holds this excerpt: Therapeutic Exercise: Foundations and Techniques (Therapeutic Exercise: Foundations & Techniques)

Related Articles