Few can resist resistance training. Ross Nakaji, PT, OCS, SCS, ATC, CSCS, clinic director of Los Gatos Orthopedic Sports Therapy Inc (LGOST) of Los Gatos, Calif, estimates that resistance training is integrated into the programs of 90% to 95% of his patients. "I would say everyone has a similar level of benefit from resistance training. The same exercise can be customized for the patient in terms of intensity, the level of resistance, the number of repetitions, and so on," Nakaji says.

LGOST's patients range in age from 3 to 70 years old. The practice specializes in outpatient orthopedic physical therapy, offering rehabilitation for ACL tear and reconstruction patients; spinal training; biomechanical evaluations, such as flexibility assessments, gait analyses, and neurological screening; and performance enhancement. The practice also treats work-related injuries and offers off-site athletic training coverage. "I would say the largest percentage of patients are treated for their knees, with shoulders, backs, necks, and feet following," Nakaji says, adding that his brother-in-law is a podiatrist whose practice is located in the same building.

Most of these patients will be prescribed resistance training. "The program doesn't vary with the diagnosis as much as with the patient's goals and the demands of those goals," Nakaji says. A patient who wants to "walk without pain" will require a different program than one who wants to return to a sport or sprint 100 yards.

NOT TOO HEAVY

Exercises and dosage (resistance load) are tailored to the patient. "Every structure in the body has a certain tolerance to stress, or the resistance load. So if you overwork a muscle, it will get bigger but risks tearing. If you underwork it, it will atrophy and shrink. But if you stress it correctly, it will get stronger and grow," Nakaji says.

It is the PT's job to optimize the patient's load, finding the correct balance between pushing too hard or too little. The ultimate goal is better function, and in some instances, a broad approach can reveal other areas for treatment. "As physical therapy advances, the more important it is to look at the patient in the big picture. What is causing that hip to hurt? Is it the hip or the SI [sacroiliac] joint? How is everything working together, and how can we make it function better?" Nakaji asks.

The progression occurs in steps, from simply isolating the muscle to training with high resistance and/or high repetitions. Nakaji typically starts with isometrics, involving muscle contractions that do not change the length of the muscle or the joint angle. "Isometrics are a great way to initiate muscle recruitment and muscle tone," Nakaji says.

Nakaji also works the muscle with isotonic contractions, concentric contractions, and eccentric contractions before adding load. "There are different ways to accomplish the goals before you actually apply a resistance load. Many times, a patient cannot figure out how to get an isolated muscle to work, so we teach them to isolate first and then integrate," Nakaji says.

NOT TOO LIGHT

A resistance load may be created first with gravity. "We want the patient to maintain a particular position against gravity for a specific duration," Nakaji says. For instance, a knee patient in early rehab would be required to work the quadricep muscle with full leg raises. Another example includes the popular plank pose: maintaining it can help strengthen core muscles as well as the arms.

Once gravity has been conquered, manual resistance is added. The application of force by the patient in a specific direction isolates muscle groups while repetitive patterns integrate them. As patients grow stronger, more resistance and eventually weights can be used. Many of the items used to create a resistance load can be found in the local gym: stretch bands (Nakaji uses products from Lifeline and Thera-Band), stability balls and medicine balls ("at the appropriate size for the patient," Nakaji says), balance boards (wooden wobble boards are used at LGOST), free weights, and pulley weights, such as those available on the Total Gym by Total Gym Inc of San Diego.

Nakaji considers all of these tools must-haves. The smaller items (balls, bands, and boards) are easily affordable—LGOST tends to give away gym balls and Thera-Band products to patients for stability and core-exercise training. The Total Gym requires a greater investment but is available in four models, ranging from an at-home unit to a motorized model (all rely on body weight to create resistance). Nakaji uses the GTS model.

If patients do not have access to any of these instruments, Nakaji will teach them how to work with household items, such as pillows and blankets. The point, however, is not the equipment but the work. LGOST therapists aim to have their patients sweating. "Patients are definitely on the road to recovery when they sweat because they are functioning at a higher level of exercise," Nakaji says.

JUST RIGHT

The patient assumes a side, or lateral, plank position for lateral trunk stability and strength, as Ross Nakaji, PT, OCS, SCS, ATC, CSCS, provides multi-directional rhythmic stabilization to her left arm.

To keep momentum going for advanced patients, the facility will use its more complex equipment, which Nakaji also considers must-haves. Upper-body cycles are key for patients who cannot, or should not, work their lower bodies, such as postsurgical knee patients. Stationary bikes are good for patients who can work their lower extremities. Nakaji prefers the Star Trac Johnny G Spinner Elite bike model, by Star Trac of Irvine, Calif, for its heavier flywheel. Three of the four models weigh in at 43 pounds. "The heavier flywheel provides a more realistic feel as well as continuous resistance that permits the patient to stand out of the saddle and sprint," Nakaji says.

Among treadmills, Nakaji is impressed by those available from Woodway, Waukesha, Wis, which employ a patented technology that reduces the friction created by conventional devices. The transportation system is based on ball bearings rather than a conveyor belt and uses a 3¼8-inch-thick vulcanized rubber T-slat for shock absorption.

The modifications create a comfortable running surface as well as a longer life. Nakaji thinks the main benefit is the ability to get a truer speed than is possible on more conventional models. "Patients can also freewheel—lean forward into the rail and sprint as fast as they can run—which can't be done on belt treadmills," Nakaji says. The one drawback is cost. Nakaji suggests a Woodway model can cost two to three times as much as a high-quality but conventional treadmill.

Another expensive but highly valued piece of equipment at LGOST is the Impulse trainer, commercialized by Impulse Training Systems, Newnan, Ga. The system uses weights, pulleys, a slide track, horizontal movement, and inertia to teach patients coordinated movements and eventually increase speed. The weight moves horizontally, creating little resistance through gravity. "Patients are instructed to move the weight in one direction, and then to slow it down, speed it up, and/or reverse it," Nakaji says.

The pattern will cycle the patient through concentric and eccentric movement as well as the transition between them. The energy is controlled by the patient. As he or she advances, the weight is gradually decreased from a high of about 17 pounds, enabling the movement to become quicker over time. Nakaji has found the machine particularly useful when treating patients recovering from shoulder injuries. He notes famous users include pitchers Nolan Ryan and Curt Schilling.

PICKING UP SPEED

The patient performs manually resisted abdominal crunches on a Gymball for stability and uses a medicine ball for resistance to her adductors.

"A lot of the things we do in physical therapy are generally focused on recruiting fast-twitch muscle fibers, which are the first to atrophy when there is an injury or surgery," Nakaji says. This is in part because many athletes actually perform with these muscles and movements. "Most plays in tennis and basketball are six seconds or less, so if you want to play an anaerobic sport, you have to train that way," Nakaji says.

But this movement requires different training exercises than the typical endurance programs many rehabilitation patients have been prescribed. For athletes particularly, Nakaji notes a trend away from the fat-burning, steady aerobic conditioning ("riding a bike for 30 minutes," Nakaji says) to sugar-burning interval-type training (sprints, for example). Higher loads, quick durations, and fewer repetitions characterize this latter type of resistance training.

FULL SPEED AHEAD

Nakaji shared a typical program for one of his most common patients: one recovering from knee surgery. The major goal in postoperative knee rehabilitation is to increase the strength and bulk of the quadricep muscles, which do not work well when the knee is in pain. Therefore, an early goal is to restore normal contraction of the quadriceps. Corresponding exercises would include isometric quad sets, held for a minimum of 6 to 10 seconds. "The literature shows that holding it for one second will not benefit the muscle tone," Nakaji says.

Next, Nakaji would have the patient work on straight-leg raises to the front, side, and/or back. Then, range of motion permitting, a number of other similar exercises are performed with a hi-lo table, including more leg raises and bridges. As swelling and pain are reduced, the patient would perform exercises with a greater range of motion using the Total Gym. "We can stay at a light increment of weight here if needed. Patients typically start at about 20 to 30 percent of their body weight," Nakaji says.

Eventually, squats supporting 100% of the body weight are integrated along with equipment, such as balls, and movements, such as chopping. Balancing exercises are also prescribed and can be as simple as balancing on one leg or throwing and catching balls. Lunges are combined with pivots and arm movements, then give way to pseudo-hopping and then regular hopping. Weights come next.

Not every patient will perform every exercise; some movements may be contraindicated for an individual, but the guidelines provide a foundation from which to start.

Nakaji expects future equipment to optimize the difficulty so rehabilitation produces a result that is measurable and accomplished in a shorter time. Equipment that goes beyond endurance training will become more mainstream for both rehabilitation and performance-enhancement training. Examples include the inertia training of the Impulse trainer and the Acceleration Training vibration technology of the Power Plate machines from Power Plate International Ltd/Power Plate North America, Inc, Northbrook, Ill.

But again, it isn't the instrumentation but the work itself. LGOST does perform modality services, such as ultrasound and electrical stimulation, but Nakaji prefers the more active approach of resistance training. At LGOST, "sweat is magical" and resistance is futile.

Renee DiIulio is a contributing writer for Physical Therapy Products. For more information, contact .