Slow heavy resistance training: A 2020 case study

: In today's episode, slow heavy resistance training, a 2020 case study. Welcome to the podcast helping you overcome your proximal hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments and of course bust the widespread misconceptions. My name is Brody Sharp. I'm an online physiotherapist, recreational athlete, creator of the Run Smarter series and a chronic proximal hamstring tendinopathy empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Thanks for joining me on another episode. Today we are going through a paper which I stumbled across on a Facebook group. And the title of the paper is the management of proximal handshake tendinopathy in a competitive power lifter with heavy slow resistance training. So it's a case report that is a 2020 paper that came out looking at one case study and it was by Kayla. Kruger Nicholas Washmith and Tyler Williams and I Scoured through it and it came up with a ton of lessons. So I thought I would bring it forth on the podcast and talk through the actual paper what they discussed and talk about sort of my key takeaways at the end because This is a case study about a power lifter, but there is a lot of tangible takeaways and a lot of things that tie in really well that no matter what type of athlete you are, recovering from PhD, you can learn a ton of lessons. So I thought I'd start with the background and the purpose of this study. So the paper says proximal hamstring tendinopathy is a chronic overuse condition that develops as a result of repetitive mechanical loading at the proximal hamstring tendon. Nothing new there. PHT is most commonly diagnosed in athletes such as middle and long distance runners or individuals who routinely perform exercises. and activities that contribute to tensile and compressive loading of the proximal hamstring tendon. Examples of these include squatting, lunging, leaning forward, stairs, uphill running, and sitting for long periods of time. And this is kind of what I see as well. Not only do I see a lot of runners with PHT, but it might be say someone who loves ju- doing gym classes that just involve a lot of squatting or lunges, those form of exercises and that pretend has the risk to overload the proximal hamstring tendon. They go on. Traditional treatment strategies of PHT are almost always conservative, so not requiring surgery, and focus on the progressive loading of the tendon within a pain monitoring framework in order to reduce pain, restore function, and prevent re-injury. However, recent evidence suggests that not all patients with tendinopathy respond to this intervention. In one study, up to 45% of patients with Achilles tendinopathy did not improve with eccentric exercise with an eccentric exercise regime. Mechanisms underlying the effectiveness of eccentric training alone are poorly understood and the management has seldom been compared to other forms of load based management. So what they're saying here is eccentric only exercises are very popular, but lacks evidence when it's faced with other loading exercises such as concentric or eccentric and concentric, a whole bunch of those. So it doesn't reign superior as a loading management technique. They go on. Heavy slow resistance training, which contains both the concentric and eccentric phases, increases the loading time and time under tension experienced by the tendon compared to eccentric training only. So if you were to do a squat, the down phase is most considered the eccentric phase where lengthening the muscles under tension but the concentric phase is when you come back up and you're using your strength to shorten your muscles and so this slow heavy resistance training is slow and heavy but contains both of those concentric and eccentric phases. So you're doing slow loading through both of those phases. The focus of this heavy slow resistance training is to perform slow, fatiguing, progressive exercises with both the concentric and eccentric components, increasing the tendon's time under tension and leading to greater tendon adaptation. So if we do these slow repetitions, that means that the tendon is spending more time under tension and therefore has more time to adapt is the theory. Researchers yet to examine the effectiveness of this heavy slow resistance training on PHT specifically. The purpose of this case report is to describe the outcome of a power lifter with PHT who responded favorably to this rehab program management failed to alleviate symptoms. So let's, let's go into this actual case description. Who was this person and what was their history? So the subject was a 31 year old male, competitive powerlifter who was referred to physical therapy with the diagnosis of left PHT. The subject stated that prior to seeking recent treatment of this condition, his medicine physician referred him to physical therapy for static and dynamic hamstring stretching, hamstring soft tissue mobilization, dry needling, general hamstring strengthening exercises, and exercises that eccentrically loaded the hamstring using body weight or manual resistance applied by the treating therapist. So that's what he had in the past. And this subject reported that he self discharged from physical therapy after nine visits due to a lack of progress. So just wasn't seeing any improvement symptoms. So just didn't go back. Approximately 60 days after discharging from physical therapy, the patient opted to receive a left PHT tonotomy and PRP. So platelet rich plasma injection. After the PRP procedure was performed without complication, the subject was referred to a different PT for the ongoing treatment of his left PHT. Treatment at this facility included left hip joint self mobilizations, so kind of like stretches, active release techniques of the ischial tuberosity, proximal hamstring cupping, free weighted exercises that included kettlebell Romanian deadlifts and modified trap bar deadlifts. After four sessions, the subject did not see improvements of symptoms and self discharged from PT due to a continued lack of progress. person's gone through the ring, I've tried a whole bunch of different things that is not seeing outcomes. The subject's primary complaint was pain that worsened with activities that required hip flexion while maintaining a neutral spine. So examples would be deadlifting, squatting, lifting, picking up objects off the floor. His previous PT advised him to keep loading hip extension movements during his weight lifting. that should be pain free by limiting the load and reducing the range of movement, which resolved some of his symptoms. However, the subject continued to have pain with prolonged sitting and driving. So the PT advised, okay, just don't lift as heavy and just don't go through a great range of movement, which settled symptoms somewhat, but didn't carry over into the functional. functional load such as sitting and driving, which makes sense. The subject rated his pain as an 8 out of 10 with prolonged sitting and driving. This affected the subject's ability to meet his expectations for his job. The subject's primary goal was to decrease pain and functional activities such as sitting and return to competitive power lifting. So this is the gentleman, this 31 year old that they then started the intervention and While I say that, let's talk about the intervention. So that's the next section of this article. The subject performed three weekly sessions, so three times a week, each of which consisted of two, his choice of two bilateral exercises and choice of one unilateral exercise. So bilateral exercises mean you're on two feet, unilateral means that you're just balancing on one leg. So he had a choice of In these three sessions a week, each session, he would choose to do two of these bilateral exercises. So they included low bar back squats, sumo deadlifts, Romanian deadlifts, conventional deadlifts, trap bar deadlifts, good mornings, loaded barbell hip thrusts, and lying leg curls. So a prone hamstring curl, I'll assume. So a lot of deadlift variations in there. Um, and then he also had the choice to do one unilateral exercise, which included single leg Romanian deadlifts, single leg hamstring curls or reverse dumbbell lunges. So each session, three times a week, he got to just choose the, um, from two bilateral exercises and from one of those unilateral exercises. These symptoms were selected in collaboration by the subject due to the response, uh, the reproducibility of his symptoms and the subject was familiar with all of these movements. So that's why they kind of gave him this list of, uh, exercises to do. The subject was instructed to spend three seconds completing each of the concentric and eccentric phases. So each repetition would take. six seconds. So if he was doing a deadlift, he would go down one, two, three, come up one, two, three, and that would be one rep. So down three seconds, up three seconds. The subject initially performed all resistance exercises at an RPE, so a rate of perceived exertion, or how difficult the exercise is out of 10. So 10 is the most difficult. So he's asked to perform these exercises at an RPE of 7, which is quite high, and progressed, would eventually progress the RPE to 9 as the subject became more accustomed to the protocol in order to accommodate for this muscular adaptation. So doing, eventually getting up to very, very high, very intense exercise. The subject was told that moderate pain during the exercise was acceptable and encouraged. but pain and discomfort was not to increase following end of the training session. So RPE of seven to nine was used to ensure adequate loading intensity during these progressive loading exercises and the tendon during this rehab exercises. So as the tendon got stronger, as the person got stronger, that RPE, the rate of perceived exertion would reduce. And so they needed to increase the weight in order to continue to operate at an RPE very, at very high amounts. So that's seven to nine out of 10. The follow-up conversations with the therapist. So just following up with phone calls and emails and things, um, focused on monitoring of the program compliance, collecting data related to pain, sitting tolerance, and the weightlifting tolerance. I should say here as well. Um, taken out chunks of the paper that I read just found the most relevant stuff and put that in there. But I should mention that this case study opted to do all of his exercises at home. He didn't want to go to a clinic every time he had to do these sessions and do the exercises. So he chose to do it at home. So that's why the follow up with the therapist was done via call and via email, those sort of things. I think you know where we're going with this next. We're gonna look at the outcome of this case study. This podcast episode is sponsored by the Run Smarter Physiotherapy Clinic, which is my own physio clinic where I help treat a wide range of PHT sufferers, both locally in person and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, close to 70% of my entire caselo has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, you can always schedule a free 20 minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes. to be taken to my online calendar to book in a time. So now we have the outcome. Following a 12 week independent rehab program utilizing this heavy slow resistance training, the subject showed functional improvement and was able to return to competitive powerlifting with minimal pain. Additionally, prolonged sitting and driving was no longer an aggravating activity for the subject. During the fourth week, this is important, during the fourth week of this 12 week heavy slow resistance protocol, the subject noted that his pain decreased a meaningful amount both while lifting and during prolonged sitting. The subject reported that this improvement provided encouragement to maintain compliance with the remainder of the protocol. So improvement in both power lifting and improvement in both sitting. 12 weeks and throughout those 12 weeks in the first four weeks there was a significant improvement or shown what they called a meaningful improvement. The discussion throughout this by the authors, they said that this case report describes the clinical reasoning and the physical therapy management of the subject with chronic PHT who was not able to return to his prior level of functioning with previous interventions soft tissue and joint mobilization, dry needling, low load and low intensity, hamstring exercises, eccentric exercises using the subject's body, cupping and PRP injections. The primary goal of the tendinopathy rehab is improving the capacity of the tendons to manage load. That is something like the language that I use almost in every episode. I'll say that again. The primary in tendinopathy rehab is improving the capacity of the tendon to manage load. There is evidence that tendons are highly responsive to diverse active loading strategies while there is minimal evidence to support the efficacy and the use of manual therapy for the management of tendinopathy. So manual therapy would just be the list of all the things I mentioned above. Because previous physical therapy and medical interventions have not been effective for this subject, a slow... A heavy slow resistance program was proposed in an attempt to increase the load intensity of the rehab program, as well as the PHT's time under tension in order to reduce pain and restore function. Within four weeks of starting this program, the subject noted a meaningful decrease in pain, which helped to provide motivation in remaining compliant through the entire 12-week program. This supports the goal of increasing his load intensity in the rehab, although a case report of a single subject does not infer cause and effect relationship, just talking about. the nature of it being a case report, it's only n equals one. However, a meaningful change within four weeks of starting the program and continue to improve throughout the remainder of the 12 weeks. And in fact, the outcomes remained 12 months after the completion of the program suggests that the increase in load strategy with this heavy slow resistance program was helpful. So the subject went on to remain successful 12 months after the completion of this program, which shows the long-term effectiveness of it. So I thought I'd write five little key takeaways here after reading this particular paper and thought I'd share with you now. So, number one, tendons love slow heavy load. I say it quite often, I say it with my patients all the time when they're a little bit fearful about increasing their exercises or they're a bit fearful to progress or they're just keeping to body weight because of discomfort, I always tell them tendons love slow heavy load and when they start to apply heavier load than what they were thinking and the tendons get a lot better, the symptoms get a lot better, they're wondering why, and I repeated again, tendons love slow, heavy load. The second point that I have here is just be progressive. Make sure that your program includes slow, heavy load, but then make sure that we don't just maintain that same load four weeks in a row. make sure that we continue to progress that load in order for you to see progress with your rehab. Number three, progress with double leg exercises and single leg exercises. So I ran through a whole list of those there, I can go through them again. So the double leg exercises were low bar back squats, sumo deadlifts, Romanian deadlifts, conventional deadlifts, trap bar deadlifts, good mornings, load. a loaded barbell hip thrust and prone hamstring curls. The unilateral ones, so one legged, were single leg Romanian deadlifts, single leg, the single leg RDLs were with dumbbells, so obviously with weights, single leg hamstring curls and reverse dumbbell lunges. So make sure that we include both the double leg and the single leg. Number four, pain during exercise is okay. That's the same advice that they had for this particular case study. Um, not only did they say that pain is okay, they said pain is actually encouraged provided that there was no ongoing lingering pain afterwards. So very important to know. And the last one I have written down is that there should be for most cases, uh, a change, a meaningful change in around about four to six weeks of a program. If not, if you are continuing a strength program for six weeks and you're not seeing benefits, then you need to change something. It might not be changing the exercise, but changing the load outside of exercise, changing your running, changing your sitting habits, changing something. You should see a meaningful change in four to six weeks. Otherwise, if you continue doing that, continue doing what you're doing for another six weeks, the likelihood of you becoming, like reducing your symptoms, improving your symptoms is quite low. So I'll repeat those again. Tendons love slow, heavy load. Be progressive with your exercises. Do double leg and single leg exercises. Pain during the exercise is encouraged and there should be a meaningful change in four to six weeks. Otherwise, change your management somehow. That's what I have for today. Um, hope you enjoy it. Hopefully you take away these lessons. Um, if you've listened to all these episodes, uh, these are nothing revolutionary, nothing new, but sometimes communicating it in a different way. Sometimes just really resonates with someone. So hopefully it's resonated with you. We'll be back next week and until then, good luck with your rehab. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future. And remember, knowledge is power.