Episode 1: Welcome to The ProActive Perspective!

Episode 1: Welcome to the ProActive Perspective Podcast!

The following blog posts are transcripts composed from the audio podcast. It is computer generated (with a little editing on my part), but it follows my flow of thought and reads like a spoken conversation. None of it should be considered medical advice as it is general information regarding rehab and strength and conditioning. Enjoy!

Welcome to the Proactive Perspective. My name is Daniel Bodkin and I'm the owner of Proactive Athletic Performance in Georgia, in this Episode I want to talk about isokinetics as a whole and give you a little introduction to who I am and what we do at Proactive.

My career started out in the US Army where I shot rockets out of tanks for four years and that allowed me to have a couple of years overseas in both South Korea and in Iraq as well as two years spent in the United States in Oklahoma. After getting out, I actually stayed in the National Guard where they had the same MOS, 13M, shooting rockets out of tanks, but I also was able to attend the University of South Florida, where I graduated the athletic training and physical therapy programs. While I was an athletic training student, I learned isokinetics at one of my rotations with John Hisamoto.

And then, after I graduated with my bachelor's degree and during PT school, I worked for him two days a week as a PT tech and my job there was essentially setting up the two different isokinetic machines that we had for patient care. So essentially, he would say, “Hey, set up the Kincom for a left knee and go set up the Cybex for right shoulder”. So I was just doing patient setups and wiping tables, two days a week after classes for three years, but then I worked for him for four years as a physical therapist before my wife's medical training, took us out of town.

Now, this also allowed me to develop a relationship with Csmi and Csmi is the maker of the Humac NORM isokinetic system. It's owned by two brothers, Rob and Rich Potash. And one day, while I was there, one of the brothers came to town just to have a visit with us. And while I was there, we kind of showed him some of the things that we had been doing with some of the different testing and treatment protocols that we were using the machine with. We weren't coming up with new science, we were just taking a lot of the background foundational science of rehab and injury recovery and rehab and applying it to their equipment. And they really liked what we were coming up with so they invited me to go to the NFL combine with them. And so I did that for I think six years. It was 2013 through 2018 and each year it was about a week long we would test about 80 athletes a day and these are all guys that are trying out for the National Football League. And each year, I would either go a day earlier or stay a day late to help break down the machines or build the machines. And so that combined with John's teaching that he did because we'd always have therapists and physios from usually Asia or Europe, come and spend a few days with us and we would do a live course with them. Those two things kind of led them (CSMi) to ask me to do some installs and trainings for them.

And then when I left the clinic world in 2019 to move to Atlanta, this is also during the covid time, their installer had to leave the company. So they asked if I wanted to take on that role. Also, in this time, leading up to that, I decided I wanted to make the course that we were doing with John and turn it into a virtual course that we could teach in the United States, for physical therapists and athletic trainers and actually get it credentialed for a ceu hours. So this role with them as their clinical education director and installer just kind of organically happened.

I'm still working with Csmi between one and five trips or installs a month. I fly into a city, install the equipment in the morning and train their staff and then fly back at night. So I'm still very active in the education world with Csmi and also helping them to bring some of the new rehab principles and techniques to their equipment.

For Proactive Athletic Performance, my clinic, we actually just opened up this year in 2024 and my goal for this clinic wasn't too just have my patients that would come in and see me and give them access to the equipment. I wanted to make it to where all the physical therapist, athletic trainers, the surgeons and doctors, their patients could have access to it without them having to have the equipment itself. Because, unfortunately, the biggest barrier to entry to having this equipment is just the cost. An isokinetic machine brand new will run you about $50,000. And I also have a force plate technology, which is about $15,000 a year because it's a subscription program. So it takes a lot to have this from the financial standpoint but there's also a big issue of space because the equipment does take up space.

Most clinics don't have access to this, and so that was my goal, to have a testing center that local PT’s and athletic trainers and the docs could refer their patients in to get testing and then they can use this data and helping to either establish a baseline, monitor their patient's progress, or help them in the planning. Whether it's planning that next phase of their rehab, determining if they're ready for discharge, and then where they should go after discharge. Whether that's more strength/conditioning, whether it's getting back onto the field for the return to sport training, or if they're actually ready for full return to play.

So that's who we are here at Proactive. Now for today's episode, I just want to give a brief overview of isokinetics because it's something that we learn about in school and when I say learn about it, it’s basically we end up reading a chapter in our textbooks and unfortunately the chapter in our textbooks is pretty outdated. It doesn't cover a lot of the newer techniques that can be taught and it's always taught from a very sciency standpoint and usually by the time you're through the first couple of pages, a lot of the students tune out and that was one of my big roles as an educator of isokinetics is I wanted to make it to where it could be understood by most clinicians. I try to break it down to a level that's very easy to follow. And that's what I want to cover in these upcoming episodes. I want to take different aspects of isokinetics and how we can apply it to different stages of injury or stages of return to play or different injuries. Today, let's just talk a little bit about what it is.

These machines were developed in the 70s and 80s and really, it was they were trying to find a way to measure strength and initially, it started out as isometric, meaning that the machine doesn't move, and the person would push or pull into it and the dynamometer would register how much force occurred. And that's really good way of getting measurements. And we actually saw a big resurgence of isometrics lately with handheld dynamometers or inline dynamometers.

The problem with that is that it only measures strength at one point in the range of motion and there's not as much inputs from the body going in, so you don't have as much neurologic input to it. So you're not getting as much information. Then the developers of this equipment were trying to find a way of measuring strength through the entire range of motion.

What they came up with is isokinetic dynamometry and ISO means same and KINETIC is speed. So what they found is that if you can set the speed on these machines from a robotic or computerized control, and then, that allows for the resistance to accommodate. Because we have different points in our range of motion where we're really strong, it's usually kind of in the mid-range of a joints range of motion, but we also have points in the range of motion where we're very weak. So, by keeping the speed fixed, that allows the resistance to accommodate. And essentially, the machine is going to match the output that you put in. So where you're weaker in the range of motion, it's going to give you less resistance but where you're stronger in the range motion, it's going to give you more resistance.

This allows us to get maximum muscle capacity, whether it's through testing or exercise training.

If we're talking testing, it gives us even more information because then we can use force tracings that the machines show. Nowadays, it's all computerized but it used to be done with papers and styluses. But it's going to outline and draw torque shape curves and you can analyze those curves to give you a qualitative information about a muscles strength capacity. It also gives us a precise numbers. So we can measure what the peak outputs are or just the total output for the entire range of motion. And we have some standards that we know patients should be able to hit. They're based upon just, years and years of study. It's funny because most of the studies that even talk about this are so old that it's even hard to find the references. People aren't really studying these normative values that much anymore because it's so well established.

But we can take what a muscles output is and we can compare that to the patient's body weight, Because we know, for example, your quadricep, it should be able to produce one foot-pounded of torque for every one pound that you weigh. That's just our normative standard. So if somebody is, significantly less than that, then we know that muscles capacity is far below what it should be, but if it's close to it or even exceeding, that tells us that muscle is, nearly recovered or fully recovered or recovered beyond normal strength and now is an athletic level strength.

Theu also gives us the ability to compare a muscle or a limb side to side. So I can take your surgical quadriceps and compare that to your non-surgical quadriceps and see how much you've recovered based upon what that other side is.

It also gives us the ability to measure muscle balance within a limb and we have normative values for this as well. The quadriceps should be stronger than your hamstrings. Your hamstrings, it's going to be about 60% that of what your quadriceps, so I can do testing, and I can see what your quadriceps are hitting and what numbers your hamstrings are hitting. I can also base it upon on your other limb and your body weight on normative values to see exactly which muscles are deficient, by how much as a percent. And that has implications on your progress you're making toward your return to sports and activity, but also on your performance as well.

It used to be that you would find these devices in just about every hospital system, or you'd have multiple machines in most major cities. This is back in the 80s and 90s. But unfortunately in the 1990s, when the healthcare laws changed, we (physical therapists), we used to be able to bill for what we did. So if I put you on one of my isokinetic machines, I could charge you more for that than if I had you doing a squatting exercise.

But in the 90s, the healthcare laws changed and we could no longer bill for what we did. We (physical therapists), we had to start billing for our time so whether I put you on a $50,000 machine for that 15 minute block, or had you doing body weight exercises or exercises with a dumbbell, a kettlebell or ankle weight, I would get paid the same. So when these machines started to break down (they last about 15 to 20 years), instead of clinics replacing them, they just got rid of them all together so it's hard to find these machines. Even in Atlanta, aside from mine. There's only two other locations in the clinical setting. Then we have one further out outside of the city and there's also one at the university. Unfortunately, these clinics and the university, they're just using them on their small group of patients that they come through. And if you're wanting to get tested you have to become part of their system. They won't, test you from outside their organization.

And also with that, recently we've had a bit of a resurgence with isokinetics. One thing is that a lot of the studies that came out during that time period of the late 90s and early 2000s was kind of against, the open kinetic chain for the knee or against isolated muscle strengthening or testing. And it started to move toward that functional testing, but that also kind of fed into that reimbursement model that we have in the US. But recently a lot of studies have come out showing that by isolating the muscle and the joint for testing and training and you combine that with some of the compound movements the functional rehab and testing, that's what's going to give you the most benefit. So we've had a big resurgence in it from that standpoint

The other is that the machines have been modernized. When they first came out in the seventies and they weren't computerized and then they started to get computerized in the 80s but we had a big boom in our technology in the 90s and 2000s so that will really allowed for an expansion of our testing and our training. So, we've seen a big resurgence of the machines in the United States. Now they've stayed popular throughout the rest of the world, especially in Europe and Asia and Australia. They've stayed really popular there just the United States that they kind of died away. But they've made a big resurgence lately.

Next, I want to talk about the difference between isometric, isotonic, and isokinetic. And these are different exercise modes. With isometric exercise, the joint angle is held constant. So this is like doing a wall sit or if you're just going to pick up a dumbbell and do a bicep curl and hold it. There's no movement occurring. Now that allows for really good beginning rehab and also some tendon loading. But it's really limited and what it can do for the big picture. We also have isotonic and with isotonic exercise the load is held constant and this is your typical exercise. So the load is constant, but the patient is going to control how fast to move it and what direction it's going to be moving. And this is most of your exercise. Like I mentioned, whether it's a squat, any exercise machines at the gym, bicep curls, when you go there, you're picking up a given weight and you're moving it through your range of motion. The nice thing about is, it's pretty inexpensive, and it's easily accessible, and it doesn't take a whole lot of skill to learn how to either teach the exercise or do yourself. The downside with that, as I mentioned when I was talking about testing is that you have different strength capacities at different ranges of motion. So, for example, everybody thinks of the bicep curl, if I'm doing a bicep curl and I want to go heavier and heavier, if I pick up a weight that's too heavy for me, I'll be able to curl it for about the first half of the motion but then I get stuck, right? You get those sticking points and the reason for that is you've reached a point in the range of motion where you're weaker than the load that you're trying to lift. So you're really limited to the weakest points in your range of motion. You have to go to a lighter weight so that you can perform the full range. That's where the advantage of isokinetic machines comes in because what we'll do on the isokinetic machine is set a constant speed based upon certain things, the range of motion available, your stage of rehab, or our goal for the day. So we'll set the speed constant and by doing that the resistance accommodates. So, where I'm weaker on the range of motion, I'm going to get less resistance but where I'm stronger in the range of motion, I'm going to get more resistance. And that allows us to maximize the muscle capacity through the entire range of motion.

Now it's really effective in getting neurologic adaptations to occur, to get hypertrophy and strength capacity built up, but that by itself isn't going to give you a full rehab, it's when you combine the isokinetic and the isolated training and testing with our other techniques. So if we're working on a knee, we would want to also do squatting, lunging, hinging, and a lot of your traditional exercises and rehab and in strength conditioning. But we would also combine that with the isokinetics to really isolate that joint and get the most effective and efficient training right to the weakest link of your system.

So that's a good introduction to isokinetics and also what we do here at Proactive Athletic Performance and my role with Isokinetics and CSMi. In the upcoming episodes I want to break down different components of isokinetics, of force plate testing and training, and rehab in general. But I want to kind of keep these episodes to maybe 20-25 minutes that way you can just consume it on your drive to work or, while you're making your errands around town, or doing chores. So that's everything for today. And I look forward to going on this journey with you. Thank you all very much.

 

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Episode 2: Tests that we use at ProActive