RESISTANCE EXERCISE FOR IMPAIRED M.

PERFORMANCE ▪ relationships between force and

Muscle Performance – capacity of a muscle to do work
➢ Influenced by all body systems
➢ Factors that affect:
o Morphological qualities of muscle
o Neurological, biochemical, and biomechanical
influences
o Metabolic CV, respi, cogni, and emotional
function
➢ Key elements: strength, power, endurance
o If impaired = activity limitations and
participation restriction or increased risk of
dysfunction may ensue
Resistance exercise – dynamic or static muscle contraction is
resisted by an outside force applied manually or mechanically
➢ To promote or maintain physical health, enhanced
performance of motor skills, and reduce the risk of
injury and disease
➢ Consider these factors:
o Underlying pathology
o Extent and severity of muscle performance
impairments
o Presence of other deficits
o Stage of tissue healing after injury or surgery
o Pt/client age
o Overall level of fitness
o Ability to cooperate and learn
DEFINTIONS AND GUIDING PRINCIPLES
velocity
o anaerobic power – single burst of high-
intensity activity (performing a high jump)
o aerobic power (muscle endurance) – repeated
bursts of less intense activity (climbing stairs)
• Power training – muscle strength = develop muscle
power
o Can be gained through increasing the work a
muscle performs during a specified period of
time or reducing the amount of time required
to produce the work
Endurance – ability to perform repetitive or sustained
activities over a prolonged period of time
• Cardiopulmonary endurance – repetitive, dynamic
activities which involve use of the large muscles
• Muscle endurance – do not correlate w/ muscle
strength
• Endurance training/exercise – using muscle force to
control a light external load for many repetitions over
an extended period of time
o more positive impact on improving function
OVERLOAD PRINCIPLE
Description – guides the use of resistance exercise in
improving muscle performance
➢ “to improve a muscle performance, a resistance load
that exceeds the metabolic capacity of the muscle
must be applied” challenge muscle to a greater load
than what it is used to

Application of Overload Practice

➢ Strength, power, endurance can be enhanced by
resistance exercise ➢ Progressively loading muscle by manipulating factors
such as the intensity or volume of exercise
STRENGTH, POWER, AND ENDURANCE • Intensity of RE – how much external resistance is
Strength imposed on the muscle
• Volume of exercise – repetitions, sets, or frequency
• Muscle strength - extent that contractile elements of
(combination can progressively increase demands of
muscle produce force
muscle)
o Insufficient muscular strength = major
• Strength training program – amount of external
functional losses
resistance = incrementally and progressively
• Functional strength – produce appropriate amount of
increased
force during functional activities in a smooth and
• Endurance training program – increase time of
coordinated manner
sustained muscle contraction or number of
• Strength training – systematic practice of using
repetitions performance
muscle force to lift heavy loads for a relatively low
number of repetitions or over a short period of time’’
SAID PRINCIPLE
BOX 6.1 BENEFITS OF RESISTANCE EXERCISE
1. Enhanced muscle performance through
restoration, improvement or maintenance of ➢ To improve a specific muscle performance element,
muscle strength, power, and endurance the resistance program should match to that elements
2. Increased strength of connective tissues:
constructs
tendons, ligaments, and intramuscular connective
tissue o Ex. Increase muscle power = exercise
3. Increased bone mineral density and/or less bone programs should have interventions that
demineralization increase work demands while decreasing the
4. Decreased joint stress during physical activity time that work is accomplished
5. Reduced risk of soft tissue injury during physical ➢ Applies to all body systems
activity
➢ Extension of Wolff’s law
6. Improved capacity for repair and healing of
➢ Determine the exercise parameters that will create
damaged soft tissues and for tissue remodeling
7. Improved balance specific training effects to best meet the pt’s
8. Enhanced physical performance during daily functional needs and goals
living, occupational, and recreational activities ➢
9. Positive changes in body composition: ↑ lean
muscle mass or ↓ body fat Specificity of Training (Specificity of Exercise)
10. Enhanced feeling of physical well-being
11. Positive perception of disability and quality of life ➢ Adaptive effects of training are highly specific to the
training method employed
➢ Exercise should mimic the anticipated function (only
when possible)
Power
➢ Must always be emphasized
• Muscle power – rate of performing work
➢ Basis: related to morphological and metabolic
o work (force x distance) produced by a muscle
changes in muscle & neural adaptations to the
per unit of time (force x distance / time)
training stimulus associated with motor learning
o key factors that affect:
▪ rate at which a muscle produces a
force
Transfer of Training
➢ Carryover of training effects from one variation of
exercise or task to another also has been reported
(transfer of training, overflow or cross-training effect)
➢ Muscle strengthening program = transfer effect by
moderately improving muscular endurance
➢ Endurance training = little to no cross-training effect
on muscle strength
➢ Endurance + muscle = detrimental effect on the ability
to improve strength
REVERSIBILITY PRINCIPLE
➢ Adaptive changes from resistance training only lasts
for a short period of time (transient), unless
participates in a maintenance program
SKELETAL MUSCLE FUNCTION AND ADAPTATION TO RE
FACTORS THAT INFLUENCE TENSION GENERATION IN
NORMAL SKELETAL MUSCLE
Energy Stores and Blood Supply
➢ Adequate source of energy to contract and blood to
provide oxygen and nutrients
• Degree of vascularization – predominant fiber type
that constitutes tissue
Fatigue
1. Muscle (local) fatigue – diminished response of muscle
to a repeated stimulus
o when a muscle repeatedly contracts statically
or dynamically against imposed load
BOX 6.2 SIGNS AND SYMPTOMS OF MUSCLE FATIGUE
1. An uncomfortable sensation in the muscle, with
pain and cramping possible
2. Shaking or trembling of the contracting muscle
3. An unintentional slowing of contraction velocity
with successive repetitions of an exercise
4. Active movements are jerky or inconsistent
5. Inability to complete the movement pattern
through the full range of available motion during
dynamic exercise against the same level of
resistance
6. Use of substitute motions—that is, incorrect
movement patterns—to complete the activity
7. Inability to continue low-intensity physical
activity
8. Decline in peak torque during isokinetic testing
2. Cardiopulmonary (general) fatigue – systemic
diminished response to a stimulus as a result of
prolonged physical activity
o Related to body’s ability to use O2 efficiently
o Caused by:
▪ Decreased blood sugar levels
▪ Decreased glycogen store
▪ Depletion of K
3. Threshold for fatigue – level of exercise that cannot
be sustained indefinitely
o Length of time a contraction is maintained
• Factors that affect fatigue
o Patient’s health status
o Diet
o Lifestyle
Recovery from Exercise
➢ The body must be give time to restore itself to a state
that existed prior to the exercise
Age
BOX 6.3 SUMMARY OF AGE-RELATED CHANGES
Infancy, Early Childhood, and Preadolescence
• At birth, muscle accounts for about 25% of body
weight
• Total number of muscle fibers is established prior
to birth or early in infancy.
• Postnatal changes in distribution of type I and
type II fibers in muscle are relatively complete by
the end of the first year of life.
• Muscle fiber size and muscle mass increase
linearly from infancy to puberty.
• Muscle strength and muscle endurance increase
linearly with chronological age in boys and girls
throughout childhood until puberty.
• Muscle mass (absolute and relative) and muscle
strength is approximately 10% greater in boys
than girls from early childhood to puberty.
• Training-induced strength gains occur equally in
both sexes during childhood without evidence of
hypertrophy until puberty
Adolescence
• Rapid acceleration in muscle fiber size and
muscle mass, especially in boys. During puberty,
muscle mass increases more than 30% per year.
• Rapid increase in muscle strength in both sexes.
• Marked difference in strength levels develops
between boys and girls.
• In boys, muscle mass and body height and
weight peak before muscle strength peaks; in
girls, strength peaks
• before body weight peaks.
• Relative strength gains through resistance
training are comparable between the sexes, with
significantly greater muscle hypertrophy in boys
Young and Middle Adulthood
• Muscle mass peaks in women between 16 and 20
years of age; muscle mass in men peaks between
18 and 25 years of age.
• Muscle mass constitutes approximately 40% of
total body weight during early adulthood, with
men having slightly more muscle mass than
women.
• Muscle continues to develop into the second
decade, especially in men
• Muscle strength and endurance reach a peak
during the second decade, earlier for women
than men.
• Decreases in muscle mass begin to occur as early
as 25 years of age.
• Starting in the third decade, strength declines
between 8% and 10% per decade through the
fifth or sixth decade
 • Strength and muscle endurance decline less
rapidly in physically active adults.
• Improvements in strength and endurance are
possible with only modest increases in physical
activity.
Late Adulthood
• Muscle strength declines at a rate of 15% to 20%
per decade during the sixth and seventh decades
and declines at a rate of 30% per decade
thereafter.
• By the eighth decade, skeletal muscle mass will
have decreased by 50% compared to peak
muscle mass.
• Muscle fiber size (cross-sectional area), type I
and type II fiber quantity, and the number of
alpha motoneurons all decrease.
• Preferential atrophy of type II muscle fibers
occurs.
• Muscle contraction speed and peak power
production both decrease.
• Endurance and maximum oxygen uptake
gradually but progressively decrease.
• The force-producing capacity of muscle is
reduced.
• Performance of functional skills begins to decline
during the sixth decade.
• Significant deterioration in functional abilities by
the eighth decade is associated with a decline in
muscular endurance.
• With a resistance training program, significant
improvements in muscle strength, power, and
endurance is possible during late adulthood
Psychological and Cognitive Factors
1. Attention – pt must be able to focus on a given task to
learn how to perform it correctly (learning & carrying
out an exercise)
2. Motivation and feedback – willing to put forth and
maintain sufficient effort and adhere to the program
over time
o Maintain patient interest = use meaningful
activities that has potential usefulness
o Feedback – can have positive impact on pt
motivation
PHYSIOLOGICAL ADAPTATIONS TO RE
➢ Adaptation to overload create changes in muscle
performance determine the effectiveness of RE
Neural adaptations
➢ Initial rapid gain in the tension generating capacity is
attributed largely to neural responses (not in muscle
itself)
Skeletal Muscle Adaptations
1. Hypertrophy – increase muscle fiber d/t increase
myofibril volume
2. Hyperplasia – causes the portion of the muscle that
occurs with heavy RE to increase in size
3. Muscle Fiber Type Adaptation – transformation of
type IIb to type IIA common in endurance training
Vascular and Metabolic Adaptations
➢ High intensity, low volume = hypertrophy = decreased
capillary bed density (d/t increased num of
myofilaments)
Adaptations of CT
➢ RE for muscle strength = increase tensile strength of
tendons, ligaments, bones
• Tendons, ligaments, and CT in muscle – increased
tendon strength = musculotendinous junction
o Increased ligament strength = ligament-bone
interface
o Support the adaptive strength and size
changes of muscle = stronger ligaments and
tendons = less prone to injury
• Bone – bone mineral density is correlated with muscle
strength an level of physical activity
o Activities and exercises that minimize or
prevent age related bone loss, reduce risk of
fractures
DETERMINANTS OF RESISTANCE EXERCISE
BOX 6.4 DETERMINANTS OF RE PROGRAM
1. Alignment of body segments during each unique
exercise
2. Stabilization of proximal or distal joints to
prevent substitute motions
3. Intensity: the exercise load or level of resistance
4. Volume: the total number of repetitions and sets
in an exercise session
5. Exercise order: the sequence in which muscle
groups are exercised during a session
6. Frequency: the number of exercise sessions per
day or per week
7. Rest interval: the time allotted for recuperation
between exercise sets and sessions
8. Duration: total time committed to a resistance
training program
9. Mode: the type of muscle contraction, type of
resistance, arc of movement used, and primary
energy system utilized during exercise
10. Velocity: the rate at which each exercise is
performed
11. Periodization: the variation of intensity and
volume during specific periods of resistance
training
12. Integration of exercises into functional activities:
exercises that approximate or replicate
functional demands
Alignment - Determined by: fiber orientation, line of pull,
specific action
Stabilization - Holding down a body segment steady
• External stabilization – applied manually by PT or Pt
with equipment or gravity
• Internal stabilization – isometric contraction of an
adjacent muscle group that does not affect the
desired movement pattern but holds proximal body
segment of the muscle being strengthened firmly in
place
Intensity

Submaximal vs Maximal exercise loads

➢ factors:
o goals and expected functional outcomes of
the exercise programs
o cause and extent of muscle performance
deficits
o stage of healing of injured tissues
o pt age, general health and fitness level
➢ lower level of resistance if w/ impairment

Velocity of Exercise - prepare the patient for the variety of

functional activities that occur across the wide spectrum of
movement velocities

Force-Velocity Relationship – different during concentric and

Initial Exercise Loaf and Documentation of Training Effects eccentric muscle contraction

• Repetition Maximum (RM) – greatest amount of

weight or load that can be moved w/ control through
the full, available ROM
o Use of RM
▪ Identify an initial exercise load to be
used during exercise for a specified
number of reps
▪ Document a baseline measurement
of the dynamic strength of a muscle
or muscle group against which
exercise-induced improvements in
strength can be compared
o 1-Rm (greatest amount of weight a subject
can move through available ROM just one
time) as baseline measurement

BOX 6.5 % OF BODY WEIGHT AS AN INITIAL EX. LOAD TYPES OF RESISTANCE EXERCISE
• Universal bench press: 30% body weight
• Universal leg extension: 20% body weight
• Universal leg curl: 10% to 15% body weight
• Universal leg press: 50% body weight

Volume – summation of total num of reps and sets during a

single session x intensity of exercise

Exercise Order – sequence of RE during a session

Exercise Frequency – num of exercise session per day or week

Exercise Duration – total num of weeks or months of RE

Rest Interval – allow time for the body to recover

Mode of Exercise – form of exercise, type of muscle

contraction, manner

Type of muscle contraction

• Static contraction – isometric contractions done

internally (muscle setting) or against unmovable
external resistance
• Dynamic RE – concentric (muscle shortening) or
Manual Resistance Exercise
eccentric (muscle lengthening) or both
o Isokinetic contraction – velocity of a limb is ➢ Resistance is provided by a therapist
held consistent ➢ muscle to be strengthened is weak and can overcome
▪ Dynamic under controlled conditions only minimal to moderate resistance
Mechanical Resistance Exercise • Eccentric exercise - dynamic loading of a muscle
beyond its force-producing capacity, causing physical
➢ Resistance is applied through the use of equipment or
lengthening of the muscle as it attempts to overcome
mechanical apparatus
the load
➢ amount of resistance necessary is greater than what
the therapist can apply manually Characteristics Of Concentric and Eccentric Exercise

Isometric Exercise (Static Exercise)

➢ muscle contract and produces force without an

appreciable change in the length of the muscle and
without visible joint motion

Types of isometric exercise

1. Muscle-setting - Low-intensity isometric contractions

performed against little to no resistance
o decrease muscle pain and spasm and to
promote relaxation and circulation after
injury to soft tissues during the acute stage of
healing
o Does not improve muscle strength except in
very weak muscles.
o Can retard muscle atrophy and maintain
mobility between muscle fibers
2. Stabilization exercises - develop a submaximal but
➢ A maximum concentric contraction produces less
sustained level of co-contraction to improve postural
force than a maximum eccentric contraction under
stability or dynamic stability of a joint by means of
the same condition
midrange isometric contractions against resistance in
➢ Eccentric muscle contractions consume less oxygen
antigravity positions and in weight-bearing postures
and energy stores than concentric contractions
if weight bearing is permissible
➢ Repeated and rapidly progressed, high-intensity
3. Multiple-Angle isometrics - system of isometric
eccentric muscle contractions are associated with a
exercise in which resistance is applied, manually or
significantly higher incidence and severity of delayed
mechanically, at multiple joint positions within the
onset muscle soreness than occurs with high-intensity
available ROM
concentric exercise
o to improve strength throughout the ROM
when joint motion is permissible but dynamic Dynamic Exercise: Constant and Variable Resistance
resistance exercise is painful or inadvisable
➢ The most common system of dynamic resistance
Characteristics of Isometric Training training is progressive resistance exercise (PRE)
➢ a limb moves though a ROM against a constant
• Intensity of muscle contraction - Intensity (load) of at
external load, provided by free weights such as a
least 60% of a muscle’s maximum voluntary
handheld or cuff weight, torque arm units, weight
contraction (MVC) to improve strength
machines, or weight-pulley systems
• Duration of muscle activation - To achieve adaptive
changes in static muscle performance, an isometric Variable resistance exercise - imposes varying levels of
contraction should be held for 6 seconds and no more resistance to the contracting muscles to load the muscles
than 10 seconds more effectively at multiple points in the ROM
• Repetitive contractions - Use of repetitive
contractions Isokinetic Exercise/Accommodating RE
o held for 6 to 10 seconds each
➢ velocity of muscle shortening or lengthening and the
o decreases muscle cramping and increases the
angular limb velocity is predetermined and held
effectiveness of the isometric regimen
constant by a rate-limiting device known as an
• Joint angle and mode specificity - When performing
isokinetic dynamometer
multiple-angle isometrics, resistance at four to six
points in the ROM is typically recommended

Open-Chain and Closed-Chain Exercises

Open-chain exercises - distal segment (hand or foot) is free to

Dynamic Exercise: Concentric and Eccentric move in space, while the proximal segments are fixed
• Concentric exercise - f dynamic muscle loading in
which tension in a muscle develops and physical
shortening of the muscle occurs as an external force
(resistance) is overcome
 GENERAL PRINCIPLES OF RESISTANCE TRAINING
Examination and Evaluation

➢ cornerstone of individualized RE program

Preparation for Resistance Exercise

➢ Select and prescribe the forms of resistance exercise

Closed-chain exercises - body moves on a distal segment that
is fixed or stabilized on a support surface (weight-bearing
positions)
that are appropriate and expected to be effective,
such as choosing 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 with the patient.
➢ 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 possible, select a firm but comfortable support
surface for exercise.
➢ Demonstrate each exercise and the desired
movement pattern

Implementation of Resistance Exercises

Warm up - prior to resistance exercises using light, repetitive,

dynamic, site-specific movements without applying resistance

Placement of Resistance - most often applied to the distal end

➢ 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

Direction of Resistance

• Concentric exercise - resistance is directly opposite to

the desired motion
• Eccentric exercise - resistance is applied in the same
direction as the desired motion
➢ When using manual resistance, the force will be most
mechanically effective if applied perpendicular to the
segment through the entire arc of motion

Stabilization - necessary to avoid unwanted, substitute

motions

➢ nonweight-bearing resisted exercises - external

stabilization is applied to the proximal segment on
which the muscle to be strengthened attaches
➢ multijoint RE in weight bearing - patient must use
muscle activation and control to stabilize nonmoving
segments

Intensity of Exercise/Amount of Resistance

➢ Initially, have the patient practice the movement

pattern against a minimal load to learn the correct
exercise technique.
➢ Have the patient exert a forceful but controlled and
painfree effort. The level of resistance should be such
that movement performance is smooth and
nonballistic.
➢ 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

Number of Repetitions, Sets, and Rest Intervals

➢ In general, for most adults, use 8 to 12 repetitions of a

specific motion against a moderate exercise load. This
quantity typically induces the expected acute and
chronic responses of muscular fatigue and adaptive
gains in muscular strength.
➢ Decrease the amount of resistance if the patient
cannot complete the minimum target number of 8
repetitions.
 ➢ After a brief rest, perform additional repetitions—a Overtraining and Overwork
second set of 8 to 12 repetitions, if possible.
➢ deterioration in muscle performance and physical
➢ For progressive overloading, initially increase the
capabilities (either temporary or permanent) that can
number of repetitions or sets; at a later point in the
occur in healthy individuals or in patients with certain
exercise program, gradually increase the resistance
neuromuscular disorders
Verbal or Written Instructions - use simple instructions that
Overtraining - decline in physical performance in healthy
are easily understood
individual participating in high-intensity, high-volume strength
Monitoring the Patient - Observe the patient execute the and endurance training programs
exercises and modify any ineffective or incorrectly performed
Overwork - progressive deterioration of strength in muscles
techniques
already weakened by nonprogressive neuromuscular disease
Cool-Down - rhythmic, unresisted movements such as arm
Exercise-Induced Muscle Soreness
swinging, walking, or stationary cycling
➢ unaccustomed to exercise and if the program includes
Precautions for Resistance Exercise
Valsalva Maneuver eccentric exercise

➢ expiratory effort against a closed glottis, must be Acute Muscle Soreness - develops during or directly after
avoided during resistance exercise strenuous exercise performed to the point of muscle
exhaustion
BOX 6.10 General Precautions During RE
Delayed-Onset Muscle Soreness - With vigorous and
• Keep the ambient temperature of the exercise
unaccustomed resistance training or any form of muscular
setting comfortable for vigorous exercise.
overexertion, DOMS, which is noticeable in the muscle belly or
• Select clothing for exercise that facilitates heat
at the myotendinous junction develops approximately 12 to 24
dissipation and sweat evaporation.
hours after the exercise session
• Caution the patient that pain should not occur
during exercise.
• Do not initiate resistance training at a maximal
level of resistance, particularly with eccentric
exercise to minimize delayed-onset muscle
soreness (DOMS). Use light to moderate exercise
during the recovery period.
• Avoid use of heavy resistance during exercise for
children, older adults, and patients with
osteoporosis.
• Do not apply resistance across an unstable joint
or distal to a fracture site that is not completely
healed.
• Have the patient avoid breath-holding during
resisted exercises to prevent the Valsalva
maneuver; emphasize exhalation during exertion.
• Avoid uncontrolled, ballistic movements as they
compromise safety and effectiveness. Pathological Fracture
• Prevent incorrect or substitute motions by
➢ failure of bone already weakened by disease that
adequate stabilization and an appropriate level
results from minor stress to the skeletal system
of resistance.
➢ high risk for osteoporosis or osteopenia
• Avoid exercises that place excessive, unintended
o osteoporosis - a systemic skeletal disease
secondary stress on the back.
characterized by reduced mineralized bone
• Be aware of medications a patient is using that
mass
can alter acute and chronic responses to exercise.
• Avoid cumulative fatigue due to excessive Prevention of Pathological Fracture - physical activity that
frequency of exercise and the effects of includes resistance training
overtraining or overwork. Incorporate adequate
rest intervals between exercise sessions to allow BOX 6.14 Resistance Training Guidelines and Precautions
adequate time for recovery. to Reduce the Risk of Pathological Fracture
• Discontinue exercises if the patient experiences • Intensity of exercise. Avoid high-intensity, high-
pain, dizziness, or unusual or precipitous volume weight training. Depending on the
shortness of breath. severity of osteoporosis, begin weight training at
a minimal intensity (40% to 60% of 1-RM) and
progress to moderate-intensity (60% to <80% of
1-RM) only if indicated.
Risk Prevention During Resistance Exercise • Repetitions and sets. Initially, perform only one
set of several exercises, using 8 to 12 repetitions
➢ Caution the patient about breath-holding.
of each exercise for the first 6 to 8 weeks.
➢ Ask the patient to breathe rhythmically, count, or talk
• Progress intensity and volume (repetitions)
during exercise.
gradually; eventually work up to three or four
➢ Have the patient exhale when lifting and inhale when
sets of each exercise at moderate levels of
lowering an exercise load
intensity.
➢ Restrict high-risk patients from doing high-intensity
• Frequency. Perform resistance exercises two to
resistance exercises
three times per week.
Substitute Motions • Type of exercise. Integrate weight-bearing
activities into resistance training, but use the
➢ When the external resistance is too great for the following precautions:
target muscle to manage during exercise • Avoid high-impact activities such as jumping or
hopping. Perform most strengthening exercises in
 weight-bearing postures that involve low impact,
such as lunges or step-ups/step-downs against
additional resistance (handheld weights, a
weighted vest, or elastic resistance).
• Avoid high-velocity movements.
• Avoid trunk flexion with rotation and end-range
resisted flexion of the spine. Such combinations
can place excessive loading on the anterior
portion of the vertebrae, potentially resulting in
anterior compression fracture, wedging of the
vertebral body, and loss of height.
• Avoid lower extremity weight-bearing activities
that involve torsional movements of the hips,
particularly if there is evidence of osteoporosis of
the proximal femur.
• To avoid loss of balance during lower extremity
exercises while standing, have the patient hold
onto a stable surface such as a countertop. If the
patient is at high risk for falling or has a history
of falls, perform exercises in a chair to provide
weight bearing through the spine.
• In group exercise classes, keep participant-
instructor ratios low; for patients at high risk for
falling or with a history of previous fracture,
consider direct supervision on a one-to-one basis
from another trained person.
CONTRAINDICATIONS TO RESISTANCE EXERCISE
Pain
➢ severe joint or muscle pain during active movements
against no external load, dynamic resistance
exercises should not be initiated
Inflammation
➢ Dynamic and static resistance training
Severe Cardiopulmonary Disease
➢ associated with acute symptoms contraindicate
resistance training
➢ patients with severe coronary artery disease, carditis,
cardiac myopathy, congestive heart failure, or
uncontrolled hypertension or dysrhythmias should not
participate in vigorous physical activities, including a
resistance training program
MANUAL RESISTANCE EXERCISE
Definition and Use
➢ a form of active resistive exercise in which the
resistance force is applied to either a dynamic or a
static muscular contraction by the therapist
1. When joint motion is permissible, resistance is usually
applied throughout the available ROM.
2. Resistance is applied during exercise carried out in
anatomical planes of motion, in diagonal patterns
associated with PNF techniques, or in combined
patterns of movement that simulate functional
activities.
3. A specific muscle may also be strengthened by
resisting the action of that muscle, as described in
manual muscle-testing procedures
4. In rehabilitation programs, manual resistance
exercise, which may be preceded by active-assisted
and active exercise, is part of the continuum of active
exercises available to a therapist to improve or
restore muscular performance
Guidelines and Special Considerations
Body Mechanics of the Therapist
➢ Select a treatment table on which to position the
patient that is a suitable height or adjust the height of
the patient’s bed, if possible, to enhance use of proper
body mechanics.
➢ Assume a position close to the patient to avoid
stresses on your low back and to maximize control of
the patient’s upper or lower extremity.
➢ Use a wide base of support to maintain stability while
applying resistance; shift your weight to move as the
patient moves his or her limb
Application of Manual Resistance and Stabilization
➢ Review the principles and guidelines for placement
and direction of resistance and stabilization (see Figs.
6.12 and 6.13). Stabilize the proximal attachment of
the contracting muscle with one hand, when
necessary, while applying resistance distally to the
moving segment. Use appropriate hand placements
(manual contacts) to provide tactile and
proprioceptive cues to help the patient better
understand in which direction to move.251
➢ Grade and vary the amount of resistance to equal the
abilities of the muscle throughout the available ROM
➢ Gradually apply and release the resistance so
movements are smooth, not unexpected or
uncontrolled.
➢ Hold the patient’s extremity close to your body so
some of the force applied is from the weight of your
body not just the strength of your upper extremities.
This enables you to apply a greater amount of
resistance, particularly as the patient’s strength
increases.
➢ When applying manual resistance to alternating
isometric contractions of agonist and antagonist
muscles to develop joint stability, maintain manual
contacts at all times as the isometric contractions are
repeated. As a transition is made from one muscle
contraction to another, no abrupt relaxation phase or
joint movements should occur between the opposing
contractions
Verbal Commands
➢ Coordinate the timing of the verbal commands with
the application of resistance to maintain control when
the patient initiates a movement.
➢ use simple, direct verbal commands.
➢ Use different verbal commands to facilitate isometric,
concentric, or eccentric contractions.
o To resist an isometric contraction, tell the
patient to “Hold,” “Don’t let me move you,” or
“Match my resistance.”
o To resist a concentric contraction, tell the
patient to “Push” or “Pull.”
o To resist an eccentric contraction, tell the
patient to “Slowly let go as I push or pull you
Number of Repetitions and Sets/Rest Intervals
➢ As with all forms of resistance exercise, the number of
repetitions is dependent on the response of the
patient.
➢ For manual resistance exercise, the number of
repetitions also is contingent on the strength and
endurance of the therapist.
➢ Build in adequate rest intervals for the patient and
the therapist; after 8 to 12 repetitions, both the
patient and the therapist typically begin to
experience some degree of muscular fatigue
 TECHNIQUES: GENERAL BACKROUND Upper Extremity Diagonal Patterns
Upper Extremity
D1Flexion
Shoulder Flexion
D1Extension
Shoulder Extension
D2Flexion
Shoulder Hyperextension
D2Extension
Shoulder Abduction and Adduction
Lower Extremity Diagonal Patterns
Elevation of the Arm in the Plane of the Scapula
D1Flexion
Shoulder Internal and External Rotation
D1Extension
Shoulder Horizontal Abduction and Adduction
D2Flexion
Elevation and Depression of the Scapula
D2Extension
Protraction and Retraction of the Scapula
Mechanical Resistance Exercise
Elbow Flexion and Extension

Forearm Pronation and Supination

Wrist Flexion and Extension

Wrist Radial and Ulnar Deviation

Motions of the Fingers and Thumb

Lower Extremity

Hip Flexion With Knee Flexion

Hip Extension

Hip Hyperextension

Hip Abduction and Adduction

Hip Internal and External Rotation

Knee Flexion

Knee Extension

Ankle Dorsiflexion and Plantarflexion

Ankle Inversion and Eversion

Flexion and Extension of the Toes

Proprioceptive Neuromuscular Facilitation: Principles and

Technique

➢ combines functionally based diagonal patterns of

movement with techniques of neuromuscular
facilitation to evoke motor responses and improve
neuromuscular control and function