1. Muscle and exercise
physiology

2. The muscle cell is called
• Myofibril
• Muscle fiber
• Sarcomere
• Fascicle

3. Lecture plan
• Muscle structure
• Muscle types
• Exercise physiology
• Types of exercise
• Prescribing exercises

5. Muscle fiber structure

6. Structural unit of myofibril is a
Sarcomere

8. Structure of Sarcomere

9. Muscle proteins
• Sarcomere proteins
– Actin
– Myosin
– Titin
– Nebulin
– Tropomyosin
– Troponin
• Extra fiber proteins
– Vinculin
– Dystrophin

10. Clinical significance
• Myosin: Cardiomyopathy, Coeliac disease, Gluten
enteropathy, Chaga’s disease
• Actin: Cardiomyopathy
• Troponin T: Cardiac disease, COPD
• Troponin I : Renal Disease, Inflammatory muscle
disease
• Vinculin: Autoimmune skin and liver disease,
Duchenne
• Dystrophin: Muscular dystrophies
• Nebulin: Nemaline Myopathy

11. Muscle fiber types
• Type 1 (Slow Oxidative) 50%
• Type ll A (FOG) Red 35%
• Type ll B (Fast Glycosylated) White
15%

15. Muscle physiology

16. What is the difference between the muscles
of a sprinter vs a long distance runner

17. Types of contraction
• Isometric
• Eccentric
• Concentric
(Tension developed is most in eccentric
then isometric then concentric)

19. Frank Starlings law
• Force of contraction is proportional to the
stretch

20. Length
Tension

21. Define
• Hyperplasia
• Hypertrophy

22. Exercise physiology

23. What is therapeutic exercise?
• Customised exercise prescribed for
specific therapeutic benefit
Vestibular exercises, abdominal exercises

24. Types of exercises
• Strength building (bulk)
• Endurance building
• Mobility improving (ROM)
• Aerobic exercises
• Relaxing (TROM)
• Proprioception and balance improving
Special exercises
Stability improving

25. Examples
• Strength- weight training
• Endurance- repetitive exercises (cycling,
jogging, swimming)
• Mobility- ROM exercises, stretching
• Relaxing- Yoga
• Aerobic – rhythmic dance
• Proprioception- Swedish ball, Theraband,
inclined plane etc
Stabilisation- core Stabilisation

26. Composite exercise programmes
• Combine the benefits of all above
• Grade them sequentially
– Start with strength, endurance, stabilisation
and ROM
– Upgrade to proprioception
– Relaxation last
• Ensure that exercise programme is
continued

27. Which is ideal?
– Structured therapeutic exercise
– Playing basket ball

28. Rational of exercise therapy
GASS
• Generalized well being and weight reduction
removes illness behaviour
• Aerobic activity increases circulation and
psychological well being
• Stretching of muscle and ligaments so that they can
stretch with less pain
• Strengthening the guy ropes and cantilevers so that
they can bear more load
Am. Academy Neuro Surgeons

29. Examples
• ACL reconstruction-Goals
– Improve range of movement
– Strengthen the dynamic stabilisers of the
knee
– Improve proprioception of the reconstructed
and natural ligaments
Priority=Stabilization

30. ACL reconstruction
• ROM: active and passive/ assisted
stretching
• Strengthening: increasing weights-Quads,
Hams, Gastroc
• Proprioceptive: wobble board, Swedish
ball, inclined plane, beech games

31. Total shoulder replacement
• ROM: active and passive/ assisted
stretching
• Strengthening: increasing weights-Deltoid,
Spinatii, Subscap, Lats, Pecs, Trapezius
• Endurance: increasing cycles for above
• Proprioceptive: classical dancing
• Priority=Stabilization: limiting TROM

32. Designing an exercise regime
Time
Intensity
aerobic
strength
endurance
proprioception

33. • What is the rationale for doing exercises
for IVDP?

34. • Do you recommend Flexion or extension
exercises for IVDP?

35. • Flexion exercises- Williams
• Extension exercises-McKenzie, Cyriax,
Maitland
• Core stabilisation exercises

37. Foraminal
stenosis

38. Guy rope Cantilever

41. Prescribing exercises for low back
pain
• Depends on pain pattern
– Fatigue endurance
– Mechanical pain stabilisation
– TROM pain and stiffness stretching
• Depends on Pathology
– Spondylolisthesis no extension
– IVDP sciatic stretch

42. Goals of exercise therapy in LBP
• Increase stable zone
• Improve mobility
• Improve strength
• Improve endurance (effort tolerance)
• Increase proprioception (prevent injury)
• Empower the patient to help himself
• Prevent deconditioning

43. Exercise therapy do’s and don’t’s
• Avoid bending
• Avoid lifting
• Sleep on hard bed
• Avoid pillow
• Avoid 2 wheelers

44. Can back pain patients bend?
References
• Mercer
• Turek
• Campbell
• Apley
• Bridwell et al
• White et al
• Frymoyer
• Aebi et al
• S Rengachary
• Youman
• Benzel E
• McCullough
• Harrison
• Price
• Davidson

46. “Basic biomechanics of the musculoskeletal
system”
Frankel and Nordin; 2001

47. What bed

48. Lifting, lying,
extension
Pain avoidance
behaviour

50. Pillow ?

51. Exercise in low back pain
• Should be tailored to the type of pain
pattern
• And the pathology
• Eg:
– Effort intolerance type of pain
– Spondylolisthesis

52. Effort intolerance
• Example: doing house work; standing for
long, sitting for long

53. Extensor strengthening without
extension
• Example: extension of the spine causes
impingement of the facets- spondylolysis
• Yet extensor strengthening is important for
spondylolisthesis
• How to achieve this?
• Diagonal lifts; Dying bug exercises

54. Postural LBP

55. Postural back pain
Bad posture causing back pain is best
treated by postural corrective devices (car
seat back rest)
Yes
No

56. Postural LBP
• Of the chronic 80% are P.LBP
• Does not mean bad posture
• Means bad postural muscles
• Reflects urban life style and stressful
living

57. Sagittal trunk alignment

60. Postural LBP
the person
• Young adult (male> female)
• Obese/ asthenic
• Sedentary employment
• Stressful life style
• Lack of physical activity
• 2 wheeler travel

61. Postural LBP
Pain pattern
• Dull aching
• Increased by sitting/ standingIncreased by sitting/ standing
• Decreased by walking
• Not aggravated by bending/ squatting
• Bilateral para-spinal pain
• No Radiculopathy
• Normal or non-contributary
investigations

62. Therapy
• Enhance strength and ENDURANCE of
the postural muscles

63. Core stabilisation exercises
• Improve pain free range of movements
• Prevent recurrent injury by strength and
proprioception

64. Summary
• Exercise therapy is not a random act of
ignorance
• Customised, carefully planned, scientific

65. THANK YOU

66. Deconditioning syndrome

67. Illness behaviour