may reduce coactivation of the hamstrings by

reciprocal inhibition.182-184 Advantages and

disadvantages of plyometric strengthening are
listed in Table 5-6.

progressively more resistance as they are

lengthened, whereas the force produced by a
muscle is greatest at midrange (see Fig. 5-3).
Water provides resistance proportional to the

Strengthening Against a Variable

Load. Strengthening exercise can also be

relative speed of movement of the patient and

the water and the cross-sectional area of the
patient in contact with water (Fig. 5-11).

performed against forces that provide varying

resistence, such as elastic bands or tubing or
water. Elastic materials provide progressively
more resistance as they are stretched and can
provide differing amounts of resistance,
depending on their composition and thickness.
FIG. 5-10 body push-up off the wall

Because resistance is a function of how much

the elastic material is elongated, to provide
consistent resistance the patient must always
grasp the band or tubing in the same place. 185
Resistance will increase if a shorter section of
band is used and decrease if a longer section is
used. Furthermore, elastic materials provide

INTERVENTION PROGRESSION
Several approach have been proposed for
progression of excercise to optimize muscle
performance. Two of the more popular and
earliest approach are the DeLorme technique
and the daily adjustable progressive resistive
exercise (DAPRE) technique. The DeLorme
technique was the first well-documented
approach to exercise progression for muscle
strengthening (Box 5-1).101 Using this
technique, exercise are performed as three sets
of ten repetition, starting with a load equal to

1/2 of the 10 RM and increasing to a load equal

to 3/4 of the 10RM for the second set and equal
to the full 10 RM for the final set of the ten
repetitions.
The DeLorme technique was followed by
the DAPRE technique, which was proposed to
be more adaptable progressive resistive

exercise program.186 With the DAPRE

technique, a 6 RM is used to establish the
initial working weight and the weight or load is
increased in future sessions based on the
performance during the previous training
session as shown in Table 5-7. The frequency

TABLE 5-6

Advantages and Disadvantages of Plyometric Strengthening

Advantages
Disadvantages
Utilizes the series elastic and stretch reflex More advanced technique requiring a high level
properties of the neuromuscular unit
of muscle performance capabilities prior to
initiation
Large potential influence on velocity of Higher risk of injury if not properly supervised
muscle contraction

Utilizes dynamic muscle co-activation for Usually reserved for more advanced patients
more balance between antagonistic muscle
group
Can involve lower extremities, upper
extremities, and trunk
Uses functional movements

FIG. 5-11 Water resistance property

And amount of weight increase are less

arbitrary with this technique than with the
DeLorme Technique.
Because muscle performance encompasses
three often very different components
(strength, power, and endurance), the training
for these components should reflect the needs
of each component. Training that focuses on
strength should involve progression of the
resistance, and training that focuses on power
should involve progressive changes in both
resistance and speed of movement. In general,
strength should be focused on before power
because power requires good strength.
Endurance training should use lower loads with
more repetition than strength or power training.
The speed of motion is also not a focus of
endurance training. Table 5-8 highlights the
recommended general training parameters for
each respective component of muscle
performance

Box 5-1 DeLorme Technique

Progressive Resistive Exercise

More
recently,
the
Norwegian
physiotherapist Oddvar Holten introduced the
medical exercise training (MET) approach to
muscle training.187 This approach involves use
of the Holten diagram to guide exercise
progression. This diagram depicts the
relationship between the maximum number of
repetitions that can be performed and the
percentage of maximal resistance in regard to
muscle strength , strength/endurance, and
endurance (Box 5-2). The diagram helpss
determine the muscular effort (alterations in
muscular strength, endurance, or both).156
According to the diagram, exercise is most
effective for improving endurance when 25 to
30 or more repetitions are performed at 60% to
65% of 1 RM or less and is most effective for
strengthening when contraction at 90% of 1
RM are used
In Summary, when selecting exercise to
improve muscle performance one should
consider the following:

Determine 10 RM
Patient then perform:
10 reps at 1/2 of 10 RM
10 reps at 3/4 of 10 RM
10 reps at the full of 10 RM
Built-in
TABLE
5-7warm-up
Daily adjustable resistive exercise (DAPRE) Technique
Strength
progressed
weeklyweight (6 RM)
Determine initial working

The patient then performs

Set 1: 10 reps of 1/2 working weight
Set 2: 6 reps of 3/4 working weight
Set 3: as many as possible with working weight
Set 4: as many as possible with adjusted working weight according to the number of reps
performed in set 3.*
The number of reps done in set 4 is used to determine the weight for the next day
Reps in Set
*Adjusted Working Weight for Next Exercise Session
Fourth Set
0-2
Decrease by 5 to 10 lb
Decrease by 5 to 10 lb
3-4
Same weight or decrease by 5 lb
Same weight
5-6
Same weight
Add 5 to 10 lb
7-10
Add 5 to 10 lb
Add 5 to 15 lb

>19

Add 10 to 15 lb

TABLE 5-8

Add 10 to 20 lb

Comparison of Training Characteristic for Developing Strength, Power, or

Endurance
Strength
Load/Intensity (%
of 1 RM)
Repetition
Sets
Rest
period
(minutes)
Speed
performance
Primary
source

of

energy

Power

Strength
and Endurance
Endurance
80-100%
Strength/force (70- 50-70%
Circuit training
100%) velocity (30(40-60%)
45%) or up to 10%
body weight
1-6
5-10
12-25
15-30+
3-5
4-6
2-3
2-5
3-6
2 to 4-6
30-60 seconds
45-90 seconds
(1:1 work-rest
ratio)
Slow
to Fast/explosive
Slow
to Medium
medium (Speed
medium
effort is as fast
(emphasize
as possible)
stabilization)
Phosphagen
Phosphagen
Anaerobic
Aerobic
Anaerob
glycolysis/aero
glycolysis
bic

Box 5-2 Holten Diagram

Dossage based off 1 RM = repetition maximum
Dossage: 100% = 1 RM
95% = 2 RM
90% = 4 RM strength
85% = 7 RM
80% = 11 RM
75% = 16 RM strength/endurance
70% = 22 RM
65% = 25 RM
Speed: >80% explosive
65%-80% breathing rhythm
<60% tissue related
Atrophy 30% 1 RM repetition as tolerated
Mobility10%-20% 1 RM high reps - 50
Endurance 70% 22 repetitions 3 sets
Stabilization 80% 11 repetitions 3 sets

The requirements of the activity to which

the patient is returning.
The patients goals for return to functional
abilities.
Advantages and disadvantages of various

types of exerciese.
General and patient-specific prevautions
and contraindications for the type of
exercise considered
ROM requirements for the activity and any
patient restrictions in ROM
The ideal approach to progression for
optimal functional benefit.
The patients motivation and social support
system.
Working weak muscles before strong
muscles in situation in which fatigue of the
target muscles could lead to synergistic
muscle compesation, especially when the
focus is rehabilitation of muscle weakness.
Developing strength and flexibility before
developing power.
Using simple exercise before initiating
more complex exercise
Developing proximal joint and trunk
stability and control before working on

extremity mobility
Starting exercise in more controlled
environment and then progressing to a less
controlled environment in regards to
stationary versus dynamic surface contact
and external stabilization. Initially using a
stationary, externally stabilized surface to
perform strengthening, and as the patient
progresses, using a less stable and more
dynamic surface area
Initiating horizontal or gravity eliminated
movements before vertical or antigravity
movement.
Initiating exercise in stress-free position
before stressful position.
Initiating unidirectional movements before
multidirectional movements.188
Progressing from isometric to eccentric to
concentric to plyometric types of exercise.
Incorporating activity-specific speeds of
movement in relation to the patients
functional goals
Ongoing reevaluation of the patient and
their needs and goals, as well as the
treatment plan, which is essential for
rehabilitation intervention to successfully
return patients with muscle weakness to
optimal function
CASE STUDY 5-1

SHOULDER PAIN AND

MUSCLE WEAKNESS

SCAPULAR

Examination
Patient History
HA is 21 years-old right-handed female college
volleyball player with a 2 month history of
right shoulder pain with overhead movements,
including serving and spiking. This pain started
2 months ago as a dull ache and has
progressively worsened. She has used
modalities such as ice, heat, electrical
stimulation, and ultrasound in the training
room, but none have helped. Radiographs and
past medical history are unremarkable, except

for a family history of high blood pressure

System Review
Integument was normal throughout
shoulder girdle and upper trunk

the

Tests and Measures

Musculoskeletal
Anthropometric Characteristics HA is
healthy, well-nourished muscular woman. She
has no visible muscle atrophy around shoulder
on either side but has slightly larger muscles on
the right
Posture HA sits with a slightly forward
head and bilaterally rounded shoulders. There
is positive sulcus sign with the arms at 0
degrees
of
abduction,
indicating
multidirectional laxity in both shoulders. This
is consistent with later findings that suggest
generalized ligamentous laxity
Range of Motion the AROM and PROM
of her cervical spine and bilateral upper
extremities is slightly excessive. She also has
several sign indicating generalized ligamentous
laxity. These include passive fifth finger
hyperextention past 90 degrees bilaterally, the
ability to oppose the thumb to the forearm
bilaterally, hyperextention greater than 10
degrees at the elbow bilaterally, and the ability
to touch the palms flat on the floor without
bending the knees. She has no discomfort with
passive overpressure to the cervical spine with
end ROM testing in all planes. Scapular
dyskinesis (medial scapular border winging) is
easily seen with AROM of the involved right
shoulder
Muscle Performance Strength testing
reveals several areas of muscle weakness on
the right including the shoulder external
rotators, scapular upward rotator, scapular
potractor muscles and scapular retractor
muscles. Each of these muscles is rated at 4/5
with manual muscle testing.Additionally,
manual muscle testing if the shoulder external
rotators produces some discomfort.
Reflex and Sensory Integrity sensation is

normal and symmetrical in both upper

extremities in all dermatomes. Deep tendon
reflexes at the bicepts, and tricepts and
brachioradialis are all normal and symmetrical
Special Testing HA has positive
impingement signs, including Neers test,
Hawkins-Kennedy,
and
the
coracoid
impingement sign

Evaluation, Diagnosis, and Prognosis

The finding from examination indicate that HA
most likely has impingement of her rotator cuff
caused by rotator cuff and scapula stabilizer
muscle fatigue. This fatigue is likely a result of
ligamentous laxity at the shoulder in
combination with the recent increased demands
from playing volleyball
Goals
Full return of muscle strength and endurance of
her dominant upper extremity and a return to
volleball pain-free
Prognosis
With rest and appropiate rehabilitation, this
injury will probably resolve without the need
for surgical stabilization of the shoulder.
Plan of Care
5 weeks of physical rehabilitation

Intervention
First, HA needs to incorporate relative rest into
her existing exercise program. She is therefore
instructed to avoid overhead lifting, serving,
setting, and spiking for serveral weeks while
continuing with other upper extremity exercise
that occur below shoulder level. Her initial
interventions included moist heat followed by
soft tissue mobilization to relax sore muscles
and decrease muscle spasm produced by pain
from overuse.
Once HAs shoulder pain subside, she
began muscular strength and enduracne
training exercise. First, she performed scapulan
and rotator cuff isometric at submaximal level

in position of comfort. Once HA could tolerate

isometrics, she was progressed to submaximal
isotonics in a limited arc with very light
resistance from dumbbells and elastic tubing.
As HA became able to stabilize her scapula
with overhead lifting of just her arm, she
gradually progressed to exercises that
incorporated resisted overhead activities at
different speeds.

Outcomes
After 5 weeks of physical rehabilitation, HA
had full muscle strength and endurance of her
dominant upper extremity and returned to
volleyball pain-free. She also had no scapular
winging on the right involved side. She
carefully progressed her volleyball practice and
playing intensity over several weeks to allow
her to return to full activity safely. She has had
no recurrence of symptoms
Please see the CD that accompanies this
book for a case study describing the
examination, evaluation and intervention for
patient with low back pain due to muscle
weakness

CHAPTER SUMMARY
Muscle tissue is the only type of soft tissue that
can generate tension enabling the skeletal
system to perform function such as maintaining
posture, respiration, moving limbs, and
absorbing ground reaction forces during the
gait cycle. A comprehensive examination must
be performed to determine the type and level of
muscle performance impairment. This complex
process of examination is important for many
facets of rehabilitation, including evaluation,
diagnosis, development of approapriate
treatment
plan,
and
selection
and
implementation of intervention to improve
muscle performance. Each aspect of muscle
performance, including strength, power, and
endurance, has its own unique characteristics
and must be trained accordingly with
appropiate specific intervention

GLOSSARY
A band: the densest portion of a sarcomere
Absolute strength: A measure of the maximal
amount of force generated in a movement or
exercise. This is indicated by the most weight an
individual can lift for 1 RM
Actin: The thin protein of myofibril that acts with
myosin to produce muscle contraction and
relaxation
Concentric contraction: A muscle action
involving shortening of the muscle length.

Delayed-onset muscle soreness (DOMS): Pain or

discomfort in muscles that comes on12-24 hours
after unaccustomed exercise, particularly exercise
involving eccentric muscle contraction
Eccentric contraction: A muscle action which
tension is developed as the muschle lengthens
Endomysion: the sheath that surrounds each
muscle fiber.
Endurance: the ability to perform low intensity,
repetitive, or sustained acivities over prolonged
period of time without fatigue
Epimysium: The dense outer fibrous sheath that
covers an entire muscle