There is something to do with our isometric contractions, our intensity of contraction, the duration of contraction that is able to somehow access and relatively easily that exercise-induced hyperalgesia, but it's just not that set three by 45 for every single thing. So it's not as homogenous as we would think.
SPEAKER_01:How effective are isometrics? This is what we explored with Stephen Collins. Now, Steve is a physiotherapist in Australia. He's titled with the ASCA Level 2 Strength conditioning coach. He also teaches a course and he's a really deep thinker. I love chatting to Steve about all things in the health professional field. Steve challenged us on using isometrics in many, many more ways than maybe what we originally thought for pain relief, for training, for stimulus, for robustness, different joint angles and specificity. So there are a lot of pearls in this one. Now we're going to attach Steve's blog and review in the show notes. Be sure to check that out. In the meantime, enjoy this episode. My name is Michael Risk and this is Physio Explained. Welcome, Steve, and thank you for joining us.
SPEAKER_02:Thank you very much, Michael. Glad to be here. Can't wait to help.
SPEAKER_01:We're reflecting on the blog you've written about isometrics, and we thought we would start at the start, which was this landmark paper by Ebony Rio, which kind of kicked off this huge thing of using isometrics for everything. Can we start there? Tell us about that research paper, what it meant, a deeper review of it, maybe how we've misinterpreted it and where you've landed with it.
SPEAKER_02:100%, mate. Actually, it's like a good exploratory paper and it's still very useful, but I came in 2016 and I definitely jumped on board as well. I was new into physio and pretty decent way into my strength and conditioning career and thought, hey, you know, they found this thing. If we load up a patella tendon, especially during season, 45 seconds, nice and heavy load, like 70% maximal contraction strength there that, yep, we're going to get this like massive, massive change to be able to allow our athletes to continue to kind of play and train pain-free and all of their tendon pain would be solved. But yeah, when you kind of got into the paper and everything a little bit more, and as I said, great paper, great exploratory paper. I think it was just the... clinicians and everything that kind of over-interpreted what you got out from it. And you got to look, it was only six participants in that paper. And I guess it hasn't been able to be reproduced very well. So when you look at another one time in the patellar tendon, it was done and it reproduced not to the same extent with a bigger cohort. And that was like, I think Peter Maliaris. But then again, another time it's come out to be like even a bigger cohort of people. And it was like, ah, does it really work? And then you looked at it with Achilles' tendinopathy, the same protocols of the three sets of the 45 seconds. And again, didn't do anything in Achilles tendinopathies. And then Bill Vincent Chino did it with the lateral elbow tendons and same protocol and didn't kind of work out. So it seems like that protocol, there was nothing kind of magic about that in particular. But there is actually other studies then that came on from there being like, okay, obviously, whatever he found there is onto something. And there were like really old studies that she drew on to get that. And which was that there is something to do with our isometric contractions, our intensity of contraction, the duration of contraction that is able to somehow access and relatively easily that exercise induced hyperalgesia, but it's just not that set three by 45 for every single thing. So it's not as homogenous as we would think, I guess is the big thing to get from that.
UNKNOWN:Yeah.
SPEAKER_01:This is a tangent. How do you think that happened, though, is a study with six people and it felt like within three months, the whole physio world anyway, the physio world that I had access to, we were literally doing isometrics for everything. That might even be a reflection on the current culture of health professionals.
SPEAKER_02:So I was only just into physio kind of at the time there, but I was very deep into the S&C world and the exact same thing happened. I think it was just that We want to help people. We want to have hope. And you have these conditions that during season are very hard to kind of manage and keep going. And you saw this paper that came out that showed, hey, these people had massive reductions in pain and big improvements in function. And you just thought, hey, this is something that I can solidly hang on to. But I think a lot of abstract reading and that type of stuff and then the sharing on, again, 2016, maybe a little bit of social media. It was early days of social media, but that's how I got onto it. It shared pretty quick. So, I guess there's probably things getting shared at that kind of surface level rather than looking a bit deeper and then also looking at the deeper underpinnings of hows and whys that would work.
SPEAKER_01:I'm putting you on the spot a bit. The biological rationale for that being pain relieving, did that go into that or have you read into that?
SPEAKER_02:Yeah. So, there's a few different mechanisms and it hasn't actually been amazingly fleshed out yep there's a few different mechanisms that work so there's a baroreceptor mechanism which is where they're thinking that like an intensity is important it's all just correlation and so correlation causation but it seems to be once our blood pressure gets to a certain kind of level that the baroreceptors go and that can trigger off our in those pain pathways trigger off the things that help to down regulate kind of pain so there's one way there another one was just getting into the same type of mechanism that you do with like your exercise-induced hyperalgesia with like your cardiovascular endurance training. So just your opioid kind of mechanism was saying that, but you could access it a bit earlier because you're kind of doing stuff that's a little bit more intense. So they were the two most hypothesized in Ebony's paper itself, references a little bit of that stuff, but didn't go super deep. It was more of like a pragmatic paper there.
SPEAKER_01:That's really cool. I'm enjoying watching your face light up when you talk about these biological mechanisms. So for the listeners who can't see it, I can tell how passionate you are about it. It's really nice to see. Talk to me about tendons, Steve. How are we dosing tendons for isometrics?
SPEAKER_02:This is where it comes for like our pain stuff versus what I look with isometrics now is I look at pain as not the primary goal. I look to actually try to get something from my isometric contractions. And usually... to get something from your isometric contractions, you reach the threshold to help with like pain relief. So either with our thresholds or the pain relief stuff, you're having to try to get into those type two or those higher motor units. So you're having to do things that's either high contraction force or long duration. So for our tendons, the cool thing with this is, and this is like, I always used to think plyometrics, plyometrics for tendons, that's the best kind of stimulus. But when you actually look at it, what a plyometric does versus like a isometric. A plyometric, you... land really quickly, the tendon and muscular tendons unit has to deform really quickly and you lose a lot of that energy to what's called hysteresis, which isn't actually going through the tendon to work on mechanotransduction. It's actually getting lost just to energy of deforming the tendon and bringing it back. Whereas isometric, I guess, with a plyometric, you are applying a big load, but you don't know exactly how much of that big load is going into helping a tendon adapt. Whereas with an isometric, because it's just holding the contraction in one standard point, you know exactly how much of that, or very, very close to, how much of that contraction is actually being used to make the tendon adapt. So then what you just do is just go into just general kind of strength training principles, which we'll kind of cover it later in the other question, instead of like, you know, basically how we're going to get our tendons adapted. is just to do normal either strength or hypertrophy type work in isometrics.
SPEAKER_01:That's super interesting to me, Steve. And just reading your blog, that's something that I never got to in my consulting career. And just with the view of the young physios at my clinics, I'm going to say not many of them think to use isometrics for adaptation. So could you touch more on that now? I think it's perfect.
SPEAKER_02:Yeah, 100%. So they have been found to be just as good for adaptation obviously like there's a few other caveats around that but in the studies where they've been compared to regular isotonic strength training they can be just as good for force production and for hypertrophy production and even for endurance the caveats are usually it's joint range of motion specific so it just goes by the said principle However, you can kind of get around that a little bit by if you're training isometrics at a larger joint angle, it's going to increase strength or hypertrophy through greater kind of ranges of motion. So through most of that whole arc, so say a knee extension at 90 degrees, well, then you're going to be getting strength most at 90 degrees, but you're still going to get quite a decent amount of strength through the whole thing versus if you did an isometric at 45 degrees. degrees, you're not going to really gain a lot of strength in any greater than kind of 45 degrees downwards. And our prescription parameters are pretty similar for time under tension to what we would for our regular kind of strength training so if you're looking like maximal strength work most sets take somewhere from 8 to 45 seconds you're looking something pretty similar for an isometric you're looking at doing one to five second contractions and then set with little micro breaks in between and then doing however many reps you need to make up that kind of 45 seconds for a set done for strength whereas Endurance or hypertrophy, sorry, is just going to be a little bit greater than that. So hypertrophy, about three seconds to kind of five second contractions. And you're looking, you could get up to total time under tension of about a minute, minute 30. So you could do that eight, 12, 15 reps, something like that. And endurance then is anything that's over that. So you're looking at our prolonged wall sits, all those other things, just maximal kind of length holds.
SPEAKER_00:This podcast is sponsored by Cliniko.
SPEAKER_01:Steve, do you have any cues that you give to patients while you're doing this? Are there external or internal cues that you find help? Do those cues actually change the tension or the load?
SPEAKER_02:100%. We innately do it in physio without maybe thinking about it, I guess, at this level, but There's two ways in which we can kind of cue a isometric contraction. We can either say an isometric contraction where we're getting someone to create positive work or try to create positive work into a system. So they're trying to push against something as hard as they can. So that's more in the SSC world would term that a push isometric. That's like your isometric mid-thigh pulls, an isometric deadlift, an isometric leg extension, an isometric bicep curl, something like that, where you're trying to pull on something as hard as you can. And then you also have like a pull type isometric, okay, or a hold type isometric. And one of those is going to be basically our old wall sits where you're trying to hold against negative work from the environment, whether or not you're holding your body up or you're holding like an isometric calf raise, you're holding a weight on your back for as long as you possibly can while it's trying to create some negative work down into the system.
SPEAKER_01:It's so interesting because until reading the blog and chatting to you, I was saying I've never really thought about using it for adaptation. The next question that came for me is, are there any specific instances in the research or for patients in your experience where you would choose isometrics over isotonics given that they have similar adaptations?
SPEAKER_02:Yeah, 100%. So for me, it's all coming across as times when like either A, the fatigue to kind of stimulus ratio is needing to be one where you're going a little bit more conservative, going, okay, I might not get as big of a stimulus because isometrics create less muscle damage. There's less C-reactive protein, less heat shock proteins as a response when they do blood tests, blood sample stuff from isometric training than there is from isotonic training. So If you're wanting to go, hey, I need a stimulus, but I kind of don't want that to be too fatiguing. So I use it a lot in say like some sort of neurological conditions where they have that fatigue debt kind of thing. I use isometric quite a bit there. So like you're looking with clinical conditions like MS, et cetera, as long as they have other things that are also indicated there. And then also, if I am looking to go work around a painful joint as well, so if they have a painful joint range of motion and going, okay, I don't want to expose into that range of motion, whereas a regular isotonic would, but hey, I might be able to do an isometric in and around that range of motion that also might get some pain relief. But if not, it definitely is going to give us that adaptive response. And Also, I was going to say before, there's a couple of different speeds so you can actually get power adaptations from isometrics as well because instead of just slowly taking up tension, we can also kind of rapidly take up tension and work on our rate of force development.
SPEAKER_01:Really cool because I think you also said before that even though we're working in a static range, you'll get the benefits through the range. So I'm now imagining all of these patients that had a painful movement or a movement arc, you could train them not in that arc, but still get the benefits through the arc. Is that right?
SPEAKER_02:Yep, the research would back that and that's useful in say like our ACLs early on when they can't do that work in that end range there. You'll see Mick Hughes does a lot of that type of stuff. We have rotator cuff related shoulder pains when they have that painful arc up through there, but you can get them doing isometrics up into less than 90 degrees, 45 degrees, wherever it is. I usually just do an isometric test like a dynamometer and then just prescribe based off that.
SPEAKER_01:Steve, there's so much value in today's episode. It's going to spark a lot of passion and curiosity for exercise prescription. My takeaway from this is I kind of want to do a practical on it. I want to try some of these dosages that you've suggested in the blog. So please, if you're listening to this, check out the blog, which we'll put in the show notes. And thank you so much for sharing all this knowledge tonight, Steve. Thank you very much, mate. I've loved it.