Warm-Up Techniques and their Place in Patient Education

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Robert Stalker, MD
Warm-Up Techniques
and their Place in Patient Education
SUMMARY                                                           RESUME
Warm-up has been poorly studied                                   Malgre le peu d'etudes scientifiques concernant le
scientifically, but there is a growing body of                    rechauffement,les preuves s'accumulent pour
evidence to suggest that if properly executed,                     suggerer que, lorsque 1'exercice est bien fait, il
                                                                   apporte des b1nefices psychologiques et physiques.
it benefits the exerciser both psychologically                    Le medecin de famille se doit d'etre familier avec les
and physically. The family practitioner should                    principes et les etapes du rechauffement s'il veut en
be familiar with the principles and phases of                     informer correctement ses patients, le tout dans un
warm-up in order to instruct athletic patients                    but de prevention des blessures
properly, with the purpose of preventing                          musculo-squelettiques.
musculoskeletal injury. (Can Fam Physician
1988; 34:177-181.)
Key words: sports medicine, warm-up exercise, patient education

  Dr. Stalker is the Director of the        ity, strengthening, mechanical mala-          Warm-up is defined as the "indi-
Dalhousie University Sport                  lignment, and the use of appropriate vidual optimal psychophysical pre-
Medicine Clinic and is a member of          equipment.                                 paration for strenuous motor exertion
the College of Family Practice.                It is widely recognized that one of in training and contests'.' It is
Requests for reprints to: Dr.               the most common causes of overuse widely reported that warm-up may en-
Robert Stalker, Dalhousie                   injuries is improper training. Trying hance athletic performance and de-
University Health Service, Halifax,         to do too much, too soon, and too crease musculoskeletal injury. This
N.S. B3H 4J5                                quickly are common errors. The ath- concept has never been adequately
                                            lete, when asked why he was injured, tested scientifically, because of the
                                            often suggests that he had not warmed multiple factors that influence muscu-
  T HE FITNESS EXPLOSION has                up properly. The warm-up is believed loskeletal injury and that are difficult
     resulted in a new population of        to be an important component of pre- to control in the scientific model. In-
patients for many family practitioners.     paring for an athletic event. A coach or tuitively, most sports-medicine scien-
These patients seek appropriate treat-      a physician would never suggest that tists consider that warm-up is of bene-
ment for a variety of musculoskeletal       an athlete perform a 100-metre sprint fit, and that the lack of hard scientific
injuries and want expert advice on in-      or compete in a pole-vaulting competi- data should not deter the physician
jury prevention. The importance of          tion or, for that matter, take part in any from promoting the concept.
preventive education cannot be over-        vigorous sporting event without an ap-
stressed, as many sports-medicine ex-       propriate period of preparing the body Physiological Effects
perts believe that most athletic inju-      for these activities. The physician of Warm-Up
ries are preventable. The physician          should educate the athlete about the
 should discuss with the athlete the im-     benefits and proper techniques of            Chart 1 lists a number of the bene-
 portance of proper training, flexibil-      warm-up.                                  fits of warming-up, and this list can be
CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988                                                                                   177
used in the education process.2 In-         General Warm-Up Phase                        ence swimmer's shoulder during the
creasing the body temperature and, in                                                    swim season. His predictions were
particular, the temperature of the mus-        The general component of warm-up          93% accurate, showing a strong cor-
cles and soft tissues is probably the       can be active or passive in nature. Ac-      relation between lack of flexibility
most important componenrt of warm-          tive warm-up should be encouraged.           and soft-tissue shoulder injury.8 Re-
Up.3 Athletes who are informed that         Advocate the use of an aerobic activity      ports from professional basketball
warming up for strenuous activities         using the large muscles, such as light       teams who incorporated flexibility ex-
may benefit their physical perfor-          jogging, calisthenics, or bicycling.         ercises into their training programs
mance and not just loosen up stiff mus-     This method is more effective in rais-       showed significant decreases in the
cles will be more likely to take the        ing the core temperature than are pas-       number of muscle injuries.9 DeVries'
time to do the warm-up properly.            sive activities such as massage, heat-       studies found that stretching increased
                                            ing pads, or sitting in a sauna.             flexibility and was very helpful in the
                                               The activity should be continued          prevention of muscle soreness and the
Components                                  until the core temperature is raised by      reduction of muscle tension. '0 Chart 2
of the Wann-Up Period                       one to two degrees centigrade. Clini-        lists several of the benefits of flexibil-
   Warm-up can be divided into three        cally, this is the temperature rise nec-     ity exercises.
phases: general, flexibility, and spe-      essary to bring on a light to moderate
cific activities. The purpose of the        sweat. The activity should be begun at       Methods of Stretching
warm-up is to increase the temperature       a low intensity and gradually increased
                                             to a vigorous or moderate intensity. As        There are a number of stretching
of the body. This is best achieved by                                                    techniques. Stretching exercises have
gradually stimulating the cardiore-          the athlete becomes better condi-
                                             tioned, the body's thermoregulatory         been found superior in increasing
spiratory system, which increases the                                                    flexibility in the lower extremities as
blood flow to the working muscle.            system becomes more efficient, and so
                                             a longer or more intense w,arm-up will      compared to general warm-up and
The rise in temperature results from                                                     massage. 1 I This finding would sug-
the dissipation of heat produced by          be required to raise the core tempera-
                                            ture.f6                                      gest that an active approach to flexi-
friction from sliding filaments during                                                   bility is necessary to obtain benefit. It
muscular contraction.4                                                                   is necessary to stretch on a regular
    Stressing the body by gradually in-     Flexibility Phase                            basis, as well. It is a difficult task to
creasing the intensity of the activity is                                                ensure that athletes stretch regularly.
important. Overwhelming the heart              The purpose of performing an activ-
                                            ity to raise the core temperature is to      This activity is often sacrificed be-
with a very strenuous activity may                                                       cause the athlete is late for practice or
carry with it some risk. Barnard5 did       make the muscles more elastic and, of
                                            course, to protect the heart. This initial   the coach wants more time for spe-
 an interesting study: subjects per-                                                     cific activities. Most athletes, when
 formed a treadmill run at moderate in-     period should be followed by a period        questioned, claim that they stretch be-
 tensity with no prior warm-up. At the      of flexibility exercises. Muscle tight-
                                            ness is thought to predispose athletes       fore each activity. Levine found,
 end of the test, 30% of the subjects                                                    however, that only 30% of men and
 displayed abnormal electro-cardio-         to certain injuries.7 It would follow
                                            that developing flexible soft tissues        58% of women on varsity teams actu-
 grams. If these same subjects had done                                                  ally stretched, and many did not
 two minutes of easy jogging before         might reduce injuries.                       stretch following the activity.7 His
 their run, the ECG abnormalities were         While research has not been pub-          study found that many important soft-
 eliminated or reduced. The heart needs     lished to substantiate the claim that         tissue areas were neglected. The phy-
 warming up.                                flexibility exercises are beneficial in       sician should try to obtain specific in-
                                            reducing the incidence of soft-tissue         formation from patients about what
                                            injuries, the typical physician's im-        areas are stretched and, just as impor-
 Chart 1                                    pression would be that an athlete who
 Beneficial Effects of Warm-Up                                                           tant, what areas are ignored.
                                            stretches regularly seems to sustain             Flexibility exercises can be simply
 1. The break-down of oxyhemoglobin         fewer injuries. Gripp studied a group
    for the delivery of oxygen to the       of elite swimmers and after assessing
    working muscle is increased.                                                          Figure 1
                                            their shoulder flexibility tried to pre-      Static Stretch for Gastrognemus
 2. The release of oxygen from              dict the number who would experi-
    myoglobin is increased.
 3. The activation energy for vital
    cellular metabolic chemical              Chart 2
    reactions is lowered.                    Benefits of Flexibility Exercises
 4. Muscle viscosity is reduced,
    producing an improvement in              1. Increased range of motion about a
    mechanical efficiency.                       joint
 5. Nervous impulses travel more             2. Retention of muscle elasticity
    rapidly, and the sensitivity of nerve    3. Reduced risk of injury
    receptors is augmented.                  4. Reduced muscle soreness and
 6. Blood flow to muscle is increased.           fatique
 7. The cardiovascular response to           5. Enhanced athletic performance by
    sudden strenuous exercise is                improving the efficiency of motor
    improved.                                    function
                                             6. Enhanced ability to generate power
 Source: See Reference 2.
 178                                                                                       CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988
categorized as follows: static, ballistic,
                                      couraged as the initial method of            ponents. There is a greater risk of in-
and proprioceptive neuromuscular fa-  stretching. This method involves rapid       jury in using this technique if it is not
cilitation (PNF). Any method used     changes in direction and velocity. This      done properly, and communication be-
should be preceded by general warm-   can lead to overstretch on the Golgi         tween the participants is vital for pre-
up. The athlete wants to take advan-  apparatus within the muscle and result       venting injury.
                                      in contraction of the muscle and strain.
tage of the increase in tissue elasticity                                             Stretching should follow the com-
                                      It must be realized, however, that most
that follows elevation of the core tem-                                            pletion of any strenuous activity.
perature. The flexibility program mustathletic activities consist of a series of   DeVries suggests that stretching exer-
be individualized for each athlete, and
                                      ballistic movements. After the soft tis-     cises held for two minutes or more
it is helpful for the physician to be-sues are prepared through general            after strenuous activity were beneficial
come familiar with the demands of the warming up and static and PNF stretch-       in reducing or eliminating muscle
patient's sport. Attention should be  ing, ballistic stretching, if performed      soreness.18 Muscle tightness usually
concentrated on the soft-tissue areas carefully can be included in the spe-        follows activity and can last up to two
                                      cific warm-up phase.
that will be under stress during the ac-                                           to three days after the exercise period.
tivity. The particular flexibility exer- PNF flexibility techniques can pro-       Stretching after the activity has been
cise should be designed to isolate andduce dramatic increases in range of          shown by a number of authors to elim-
stretch the specific muscle group in- motion. If the athlete's activity re-        inate this tightness.
volved. Any areas that have been in-  quires great ranges of motion to per-           There are a number of stretches in
jured need careful attention, but     form the sport successfully, this tech-      common use that should be dis-
stretching of all the principal musclenique is to be recommended. It is            couraged because of the risk of injury
groups should be encouraged, as flex- more effective for increasing flexibil-      that they entail. The athlete can be
ibility is specific to a joint.12     ity than are other techniques.16 Con-        taught a safe stretch for the same area.
   Static stretching should be pro-   sider the ranges of joint motion re-         Figures 6 to 8 present examples of in-
moted as the initial flexibility tech-quired by the following athletes:            correct and correct techniques.
nique performed in the warm-up        ballerina, gymnasts, ice-hockey goa-
period. Research by Moore and col-    lie, and high jumper.                        Specific Wann-Up
leagues indicates that static stretching There are a number of different PNF
                                      techniques, including hold-relax, anta-
produces less tension and resistance in                                               In this phase of the warm-up, the
the soft tissue than do other tech-   gonist-contraction-relax, and slow-          emphasis is on rehearsing the specific
niques and may be less likely to result
                                      reversal-hold-relax techniques. Figure       movements that will be used in the
in injury."3 This technique can be    5 demonstrates the hold-relax tech-          actual athletic activity, but keeping
adapted to any of the major muscle-   nique.17 The muscle to be stretched is       the intensity at a reduced level. This
tendon units. Figures 1-4 show ex-    passively stretched by the partner.          activity improves co-ordination and
amples. This technique can be done    This movement is followed by a 3-6-          balance and may reduce the chance of
unassisted.                           second isometric contraction of the          injury. Rehearsals also increase mus-
   Athletes performing static stretch-same muscle while the athlete uses the       cle strength by enlarging neurological
ing should use slow controlled move-  partner for resistance. The contraction      recruitment and increasing muscular
ment. They should stretch the soft tis-
                                      should build up to a maximal contrac-        response time. This phase should in-
sue to the point of perceived tension tion. This movement is followed by a         clude a short rest period of about 10
but not pain. The area being stretchedperiod of passive static stretch per-        minutes. During this period the ath-
should be relaxed. The stretch posi-  formed by the partner.                       lete may visualize the upcoming ac-
tion should be maintained for as long    PNF techniques are ideal for athletes     tivity and "psych up."
as possible, ideally about 30-60 sec- involved in team sports or those who
onds.14 Repetitions may be done as    have a training partner. The disadvan-       Psychological Aspects
long as the above principles are fol- tage is that the athlete must have a         of Wann-Up
lowed. The effect of stretching may   partner who is familiar with the tech-          A number of coaches and sport sci-
last for up to three hours as long as nique and can provide enough resis-          entists believe that the benefits of
the core temperature remains ele-     tance to support the isometric compo-        warm-up are related to its psychologi-
vated.15                              nents and be careful enough to not           cal aspects. Massey did a study that
   Ballistic stretching is to be dis- overstretch the area for the static com-     would suggest that psyching up is the

                                             Figure 3
Figure 2                                     Static Stretch                        Figure 4
Static Stretch for Hip Abductors             for Posterior Rotator Cuff            Static Stretch for Low Back

CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988                                                                               179
most important component.'9 He hyp-       tion of elite athletes for competition,  race plan. She practices starts and then
notized athletes who had warmed up        and the scientific aspects of this new   returns to land and retreats to a quiet
to forget that they had done so, and      application of psychology are begin-     place where she uses mental imagery
he found no measurable improvement        ning to be published.                    to "'psych up" for the event or goes
in their physical performance. Ma-                                                 through relaxation techniques to re-
lareki found that athletes who thought    Specific Example                         lieve anxiety. Fifteen minutes before
they had warmed up performed bet-         of a Warm-Up Routine                     the race begins, she is on the course
ter.20 Thus the warm-up period may                                                 doing short accelerations but at a low
be an important means for athletes to        An athlete is to compete in the na- intensity to avoid any anaerobic activ-
decrease their anxiety levels. The area   tional finals for canoe racing in the ity which would lead to lactic-acid
of sport psychology is becoming in-       1000-metre event. The athlete's warm- build-up in the muscles.
creasingly important in the prepara-      up begins at the competition site,
                                          where she starts by preparing and References
                                          checking all of her equipment. Next 1. Kreiie V, Koch P. Warming-up as a pre-
Figure 5                                  she runs along side the course for five liminary to training and competitive sport.
PNF Stretch for Hamstrings                minutes, working up a light to moder- Muscle and tendon injuries in athletes.
                                          ate sweat. She is instructed to keep on Stuttgard: Georg Thieme Publishers, 1979;
                                          her sweatsuit to maintain an elevated 76.
                                          core temperature, and she begins to 2. Shellock FG. Physiological benefits of
                                          stretch on dry land, concentrating on warm-up. Phys Sportsmed 1983;
                                          static and PNF stretches for the low- 10:136-9.
                                          back rotators and the rotator cuff of 3. Asmussen E, Boje 0. Body temperature
                                          the shoulder. This exercise can be fol- and capacity for work. Acta Physiol Scand
                                                                                    1945; 10:1-22.
                                          lowed by ballistic stretches for the
                                                                                   4. Elam R. Warm-up and athletic perfor-
                                          same areas, while the athlete goes mance: physiological analysis.
                                          through a mental rehearsal of the event Strength aand Conditioning Assoc National
                                                                                                                     J 1986;
                                          ahead. The athlete goes out on the 2:30.
                                          water 75 minutes prior to race time and 5. Barnard RJ. The heart needs warm-up
                                          paddles two to four kilometres, con- time. Phys Sportsmed 1976; 1:40.
                                          centrating on the feel of the boat and 6. Astrand PO,
                                          on correct alignment and technique. Work Physiology.Rodahl K. Textbook of
                                                                                                       New York: McGraw
                                          This period is followed by periods of Hill, 1977.
                                          short sprints as she builds up accelera- 7. Levine M, Lombardo J, McNeely J, et
                                          tion, progressing from half-speed to al. An analysis of individual stretching pro-
                                          full speed. The event is rehearsed by grams of intercollegiate athletes. Phys
                                          completing the 1000 metre distance in Sportsmed 1987; 3:130-9.
                                          the appropriate lane, simulating the 8. Greipp JF. Swimmer's shoulder: the in-

                                          Figure 6a                                 Figure 7a
                                          Improper Stretch for Low Back             Improper Stretch for Quadriceps

                                                                                     Fibure 7b
                                                                                     Proper Stretch for Quadriceps

                                          Figure 6b
                                          Proper Stretch for Low Back

180                                                                                  CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988
 fluence of flexibility and weight training.
 Phys Sportsmed 1985; 8:92- 105.
 9. Beaulieu JE. Stretching for all sports.
 Pasadena: Athletic Press, 1980.                  College of Family Physicians of Canada
 10. DeVries H. Prevention of muscle dis-
 tress after exercise. Research Quarterly
 1961; 32:177- 85.
 11. Wiktorsson-Moller M, Oberg B, Ek-
 strand J, et al. Effects of warming up, mas-
 sage, and stretching on range of motion
 and muscle strength in the lower extremity.
Amer JSport Med 1983; 4:249-53.
 12. Harris M. Flexibility: review of the lit-
                                                 Annual Scientific Assembly
 erature. Phys Ther 1969; 49:591-601.
 13. Moore MA, Hutton RS. Electromyo-
 graphic investigation of muscle stretching
                                                 Montreal, 15-18 May 1988
 techniques. Medicine and Science in Sport
and Exercise 1980; 5:322-9.
 14. Beaulieu JE. Developing a stretching
 program. Phys Sportsmed 1981;
                                                 CALL FOR PAPERS
 15. Hansen TO. Selected effects of stretch-
 ing on flexibility. Master's Thesis Univer-     A feature of the College's 1988 Annual Scientific
sity of California at Los Angeles, 1962.         Assembly, to be held in Montreal, will be the
 16. Holt LE, Travis RM, Okita T. Com-           presentation of freestanding papers on a variety of
parative study of three stretching tech-         topics. CFPC and AAFP members are invited to submit
niques. Perceptual and Motor Skills 1970;
31:611-6.                                        abstracts of proposed papers, which will be judged by
 17. Holt LE. Scientific Stretching for          the Scientific Program Committee for possible
Sport (3-s) Dalhousie University, 1974.          presentation.
 18. DeVries H. Physiology of exercise for
physical education and athletics. Dubu-          ABSTRACTS
que, Iowa: William C. Brown Co., 1974.             Abstracts should include:
 19. Massey BH, Johnson WR, Kramer GF.           * a brief statement of thepurpose of the study;
Effect of warm-up exercise upon physical         * a statement of the methods used;
performance using hypnosis to control the        * a summary of the results, presented in sufficient detail
psychological variable. Research Quar-
terly 1961; 32:63-71.                            to support the conclusions;
20. Malareki I. Investigation on physiolog-      * a statement of the conclusions reached. It is not
ical justification of so-called warming-up.      satisfactory to state, "The results will be discussed", or
Acta Physiologica Poland 1954; 5:543-6.          "Other data will be presented."
Figure 8a                                        FORMAT
Improper Abductor Stretch                           Each speaker will have 10 minutes for presentation,
                                                 including 35 mm slides, if desired, plus five minutes
                                                 discussion time. Papers may cover any research, or any
                                                 clinical, political, economic, philosophical or historical
                                                 area of direct relevance to family medicine.
                                                    Abstracts will be considered only if submitted on
                                                 official abstract forms and accompanied by a completed
Figure 8b                                        registration form for the Assembly, together with the
Proper Stretch for Hip Abductors                 registration fee. Forms and additional information are
                                                 available from:
                                                           Director of Administration
                                                           College of Family Physicians of Canada
                                                           4000 Leslie Street
                                                           Willowdale, Ont. M2K 2R9
                                                  Deadline for submission of abstracts: March 21, 1988

CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988                                                                     181

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Description: Many people start to do not like when the warm-up exercise, that can save time. But the fact so that you waste time burning calories, adequate warm-up exercise can increase your body temperature, increase fat burning activity. Exercise increases your body temperature once each of your cells about 13% corresponding increase in metabolic rate. Before the campaign to make a simple to moderate-intensity warm-up exercise at least 5 minutes, gradually increase your heart rate, muscle activity you up, your breathing speed up, your body's metabolism and energy consumption will be greatly enhanced.