Rehab & Scar Stretching & Progressive Resistance Training

DIAGNOSTIC INJURY MANAGEMENT

Rehabilitation & Scar Stretching.

Progressive Resistance TrainingSPTH01

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Introduction

Rehabilitation and Scar Stretching Scar Tissue Preparation for stretching Stretching routine – scar tissue Key points – healing process & rehabilitation

Progressive Resistance Training Resistance techniques Physiological changes of progressive resistance

exercises Designing a rehabilitation programme to develop

muscular strength, power & endurance Specific Progressive Resistance regimes

Rehabilitation & Scar Stretching. Progressive Resistance Training

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Phases of Healing

Phase I Acute Inflammatory Phase

2-4 days Protect, localise, prepare for healing & repair

Phase II Proliferation Phase

48 hours – 3-6 weeks Scar tissue formation

Phase III Remodelling Phase

Increase strength of repaired/replaced tissues First 3-6 weeks lays down collagen & strengthens fibres 3 months – 2 years – enhancement of scar tissue strength


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Scar Tissue

What is it? Also known as ‘Adhesions’ The body cannot re-create healthy tissue It creates new fibres which are not as

functional as the original tissue, but serve as a protective, useful barrier

A dead fibrotic tissue (very brittle, inflexible fibrous material) that forms mainly in muscles, tendons, ligaments, fascia & joints


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How is Scar Tissue formed?

Muscle, tendon or ligament is torn (sprained or strained) or nerve is damaged

Healing process – inflammatory response (acute inflammation, repair (proliferation) & remodelling)

Initial 72 hours – Redness, swelling, heat & pain

After 72 hours – Repair begins on damaged tissue Scar tissue formation rather than formation of

brand new tissueRehabilitation & Scar Stretching.


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How is Scar Tissue formed?

May also be formed in Repetitive Strain injuries – The muscle tightens up through repetitive

motion such as hitting a ball, or after it has been injured

Swelling occurs Swelling restricts the oxygen supply to the

muscles & connective tissues (hypoxia) The lack of oxygen causes scar tissue to

formRehabilitation & Scar Stretching.


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Formation of Scar Tissue

Fibrous material binds itself to damaged soft tissue fibres in an effort to draw the damaged fibres back together

Results is a bulky mass of fibrous scar tissue completely surrounding the injury site

May be seen & palpated as a bulky mass under the skin Scar tissue forming around an injury site is never as strong

as the tissue it replaces Contracts & deforms surrounding tissues, so not only is the

strength of the tissue diminished, but flexibility of the tissue is also compromised

Shortens the soft tissues resulting in a loss of flexibility. A weak spot forms within the soft tissues, which could easily result in further damage

Scar tissue will result in a loss of strength and powerRehabilitation & Scar Stretching.


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Rehabilitation & Scar Stretching Why do we need to rehabilitate scar tissue?

Scar tissue is : Weaker (50-80% as strong as original tissue) Less elastic More prone to further injury Up to 1000 times more pain sensitive than normal,

healthy tissue Need it to replicate surrounding healthy tissues (train

the collagen fibres to act like the healthy fibres) Rehab must take place in the presence of full

ROM after injury to avoid/reduce the formation of scar tissue


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Rehabilitation of Scar Tissue


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Where does it effect?

Scar tissue adheres itself to muscle fibres – preventing them sliding back & forth (sliding filament theory)

Scar tissue adheres itself to connective tissues which limits the flexibility of a muscle or joint

Scar tissue adheres itself to nerve cells which may lead to carpal tunnel syndrome, chronic back pain & other conditions


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Removing Scar Tissue

Deep tissue sports massage Ultrasound & heat will help the injured area, they will not

remove the scar tissue To start with, the area will be quite tender. Start with a light

stroke & gradually increase the pressure until you're able to use deep, firm strokes. The more you massage the effected area the harder & deeper you will be able to press

Use deep, firm strokes, moving in the direction of the muscle fibres. Concentrate your effort at the direct point of injury, & use your thumbs to get in as deep as possible to break down the scar tissue

Advise patient to drink plenty of fluid during their injury rehabilitation. The extra fluid will help to flush a lot of the waste products from their body


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Ultrasound in Tissue Repair

Ultrasound acts as “inflammatory optimiser “ to promote tissue repair (Mortimer & Dyson 1988, Nussbaum 1997, Leung et al 2004)

Stimulates proliferation phase (Mortimer & Dyson 1988, Ramirez et al 1997, Nussbaum 1997, 1998)

Enhances remodelling (Nussbaum 1998, Wang 1998)

Used with “Chronic” settings – continuous/1:1

Increases extensibility of scar tissueRehabilitation & Scar Stretching.


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Soft Tissue Release

Targets specific areas of a muscle to stretch – when performing a general stretch, the fibrous adhered area of the muscle is usually overlooked

Shorten Lock (take up the “slack”) Lengthen


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Progressive Resistance Training

Methods: Bodyweight Fixed weight machines Free weights

In groups, discuss the pro’s & con’s of each method of resistance training


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Bodyweight

Pro’s Use of body mass to create resistance e.g. Press-ups Appropriate in early stages of rehab – can be made

functional (unilateral/bilateral) Can be adapted easily to challenge proprioception, core

stability, plyometrics etc. No equipment required & performed anywhere

Con’s Can’t target all muscle groups for performance, prehab &

rehab Few exercises available to develop forces for

strength/power in advanced trainers Requires correct techniques to be effective


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Fixed weight machines

Pro’s Safety & little technique required Easy to control – no “spotter” required Attractiveness to those unfamiliar with exercise

Con’s Cost & size/benefit Adaptability to sport – predetermined

movement path Little or no scope for development of

core/functional stability


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Free weights

Pro’s Cost & Space Adaptability to sport Variety Develop stability – have to control own

movement path e.g. Bench press, squat, deadlift, row

Con’s Reputation Technique needs to be developed Requires “spotter”


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Sports Training Principles

Overload

ActiveInvolvement

Reversibility

Specificity

Individualism

Recovery

Variety Progression

Adaptation


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Resistance Training Guidelines


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Resistance Training Guidelines


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Training Goal Load (% 1 RM)

Goal Repetitions

Strength 85 & above 6 & below

Power 75 – 90 1 – 5

Hypertrophy 67 – 85 6 – 12

Muscular Endurance

65 & below 12 & greater

Training Goals & Reps


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Rest Periods


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Training Goal Rest Period Length

Strength 2 – 5 mins

Power 2 – 5 mins

Hypertrophy 30 secs – 1.5 mins

Muscular Endurance 30 secs or below

Physiological Changes of Progressive Resistance Training

Hypertrophy Primarily in Type II fibres

Increases in cross-sectional area (CSA) shown to correlate with increases in strength

Increase in actin & myosin synthesis, and increase in no. & size of myofibrils

Also a possible increase in non-contractile proteins e.g. collagen


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Fibre type changes Some evidence for Type I to Type II

and vice versa

Concurrent resistance and endurance training can lead to a reduction in the size of Type I fibres


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Skeletal Increase in bone mineral density, reduced risk

of fracture

Body Composition Decrease body fat, increase fat-free mass

Connective Tissue Ligament & tendon strength increases


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Rehab programmes to develop muscular strength, power & endurance

% 1 RM Reps Sets Rest

Muscular Strength

85+% 1RM 1 – 6 reps 2 – 6 sets 2 – 5 min rest

Power 75 – 90% 1 RM 1 – 5 reps 3 – 4 sets 2 – 5 min rest

Hypertrophy 67 – 85% 1 RM 6 – 12 reps 3 – 6 sets 30 – 90 secs rest

Muscular Endurance

Less than 67% 1 RM

12+ reps 2 – 3 sets 30 secs or less


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Can you design your own rehab/training programme for a particular athlete, considering their desires & needs using the guidelines mentioned above?

Specific Progressive Resisted Regimes

DeLorme and Watkins (1948) Zinovieff (Oxford) Technique McQueen Technique DAPRE System of Strength Progression


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DeLorme & Watkins (1948)

Initial sets begin light, & progressively add greater resistance into each subsequent set

Use 10 Repetition Max as a maximum strength figure

Popular in the 1950’s & 1960’s – proved significant gains during progressive short term training of 3 sets of 10 reps

Initially suggested 1st set of 10 reps at 50% of 10RM, 2nd set of 10 reps at 66% of 10RM & 3rd set of 10 reps at 100% of 10RM


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DeLorme & Watkins (1948)


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Current DeLorme & Watkins Strength Progression Guidelines

Zinovieff (Oxford) Technique (1951)

Revised Technique of the DeLorme & Watkins programme

Suggested that patients were too fatigued to complete the final set of 100% of 10RM

Reversed DeLorme system e.g. 10 reps at 100% of 10RM for the 1st set, 10 reps at 75% of 10RM for the 2nd set, 10 reps at 50% of 10RM for the 3rd set


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Zinovieff (Oxford) Technique (1951)

Current Zinovieff (Oxford) Technique Strength Progression Guidelines


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McQueen Technique (1954)

Based on the 10RM principle Developed individual

programmes for developing muscle power & hypertrophy

McQueen. I. (1954) Recent advances in the

Technique of progressive resistance

exercise. Brit. Med. J. 2:328-338.


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DAPRE System of Strength Progression (1985)

Daily Adjusted Progressive Resistive Exercise technique (Knight, 1985)

An objective method of increasing resistance as the individual's strength increases or decreases

Works on 10 RM principle Based on the concept that if the athlete meets

the targets, the weight is ideal. If they cannot meet the targets, the weight is too heavy, and if they can perform more than the set targets, the weight is too light & needs to be adjusted on a daily basis


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DAPRE System of Strength Progression


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Potentially Dangerous Resistance Exercises

Bouncing Squats Squats with knees tilting or rotating inwards Standing presses with back flexion, extension

or rotation Bench press with hips raised off bench Straight arm pullovers Rapid lumbar hyperextensions Squatting/jerking in running shoes Full ROM with rubber bands

Brukner and Khan (2006, p.743)Rehabilitation & Scar Stretching.


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Rehab & Scar Stretching & Progressive Resistance Training

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