Corrective Exercise and Rehab

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Optimizing healthy living through a systematic program of care ranging from pain relief, rehabilitation, corrective exercise and fitness should be your goal. Bridging the gap between rehabilitation and physical fitness can be a slippery slope if you are not familiar with the underlying principles of corrective exercise strategies.

Corrective Exercise and Rehab

  1. 1. Corrective Exercise Bridging the Gap between Rehab and Fitness Perry Nickelston, DC, FMS, SFMAChiropractic is not simply about pain relief, adjusting subluxations, and restoringspinal health. Your obligation as a frontline healthcare professional is to educate,teach, mentor, and transition your patient’s to an all inclusive healthy lifestyle.Optimizing healthy living through a systematic program of care ranging from painrelief, rehabilitation, corrective exercise and fitness should be your goal. Bridgingthe gap between rehabilitation and physical fitness can be a slippery slope if youare not familiar with the underlying principles of corrective exercise strategies.Ultimately you want clients to demonstrate functional movement patterns withbalance between proper mobility and stability before they engage in strenuousactivities. Without optimum balance and symmetry you are introducing a degreecompensation patterns with increased risk of injury. I am often quite surprised athow few health care professionals actually use corrective exercise in theirpractice. The exercise obtained by patients from performing everyday activitiesand functions is often inadequate. Many conditions treated by chiropracticadjustments could greatly benefit from exercise, as thousands of traumatic low-backache cases are treated annually by exercises alone.Corrective exercise is a form of exercise that strives to bring the body back intoperfect postural position. The body is designed to perform at its mostadvantageous level when it is in a position of ideal posture and bilateralsymmetry. Corrective exercise is designed to undo mobility and stabilityimbalances, thus guiding the body to work in synchronization without pain.Through Corrective exercise you will be working towards reeducating the body tomove as it was designed so that it can function at its best. Specific movementsimprove the body’s biomechanics and remove the negative micro-traumaticstresses which have lead to dysfunction. Through Corrective exercise youreintroduce proper function, which in turn restores correct structure. When thebody stops compensating for imbalances, clients are then able to move freelywithout restrictions and pain eventually disappears. It all comes down tomovement!
  2. 2. Each doctor will develop their own preferred way to look at movement issueswith specialized methods to arrive at solutions based on their practice paradigm.Unfortunately, highly specialized isolated movement examinations have been oneof the biggest errors in assessing global patterns of compensation. This isolationistthought process is then carried over into rehab, exercise and fitness. The bodyfunctions as a whole. The anatomy books have it wrong. The body does notsimply function with action from an origin to insertion point. Everything isinterconnected and one area of dysfunction will cause a compensation andmyriad of symptoms somewhere else. Correctives combine the scientificprinciples of biomechanics, physics, motor control and human physiology tocorrect the cumulative stress of life. Even very small structural changes, if theyoccur over time, alter the muscles and joints ability to perform properly. This isbecause no muscle works alone; each is connected to another part of the body.Because Corrective exercise focuses on fixing the cause of pain, instead of justaddressing symptoms, it works where many other remedies fall short. So even ifyou’ve tried everything else to help a client feel better, now is the time tointroduce an effective strategy to pain relief.Healthcare and fitness practices often neglect fundamental movement, payingtoo much attention to the superficial obvious. Weakness and tightness are oftenattacked with isolated and focused strengthening and stretching protocols thatdon’t work. The majority of musculoskeletal pain syndromes both acute andchronic are the result of cumulative micro-trauma from stress induced byrepeated movements in a specific direction or from sustained misalignments. Thebody develops a motor learning pattern for improper movement. Withoutcorrective exercise designed to teach the proper motor control patterns, patientswill often develop bad technique from inferior neuromuscular coordination andcompensation behavior. For example, when someone complains of chronic kneepain we are quick to find solutions to treat, rehab, and exercise the knee.However from a corrective exercise perspective we want to address movement inthe entire kinetic chain from, ankle, hip, core, thoracic spine and bilaterallysymmetry. This is a much more all inclusive full body system for exercise and longterm benefits of functional movement.The number one risk factor for musculoskeletal injury is a previous injury,implying that current rehab standards are missing something. Current medicaland rehabilitation programs can manage the pain and symptoms resulting froman initial injury, but they have less ability to influence the likelihood of a
  3. 3. recurrence. Don’t let this be you. Gray Cook, MSP, states, “Your commitmentshould be not only to manage the painful episode, but also target and contain therisk factors. It is important to separate pain with movement from movementdysfunction. It is possible to move poorly and not be in pain, and it’s possible to bein pain and move well. A licensed healthcare professional experienced inmusculoskeletal evaluation and treatment should address pain with movementregardless of fitness ability.” Corrective exercise is the great equalizer. It allowsyou to do exercise with clients in non-painful dysfunctional areas to help alleviatethe pain. Above all, we must remember that the muscle holds the skeleton inplace. Many conditions, both chronic and acute, cannot be permanently curedunless and until the damaged, distorted, or weak muscle is built up to normalstrength and tone.Many professionals do have an appreciation of function and yet they still persistin an anatomical approach to exercise by training bodyparts instead of movementpatterns. Choosing exercises based on symptoms is not alleviating the true cause.This is in agreement with the entire chiropractic paradigm of taking care of thewhole body, rather than simply isolating painful regions. When it comes tocorrective exercise and movement dysfunction not everything is as it appears.You cannot make assumptions about what the body is trying to tell you simply bylooking on the surface. You must think further outside of the proverbial box.For example:  What you see on evaluation as weakness may be muscle inhibition. So strengthening the weakness will make no lasting change in function. If anything you might worsen the condition.  There are always two sides to every coin. What you see as poor function in an agonist may actually be problems with the antagonist. If positive changes are not made within several visits flip the coin and look on the other side.  Weakness in a prime mover might be the result of a dysfunctional stabilizer. Don’t be so quick to blame the big muscles that are always in spasm. Look deeper at the underlying stabilizer culprits. A prime example is constant spasm in the upper trapezius from lack of stability in the scapulae.  Tightness and stiffness may be a neurological protective mechanism of the body to increase tone for stabilization. Stretching stiffness will often lead to further tightness and injury. The body will increase tightness as a guarding
  4. 4. mechanism or alternative to inadequate muscle coordination. Those hamstring muscles that are always tight, is a classic case of stiffness due to lack of stability elsewhere.Following are some essential paradigm components to understanding correctiveexercise.  The body follows the law of physics and takes the path of least resistance for motion, which contributes to hypermobility and lack of stability.  Joints tend to move in a specific direction which contributes to the development of movement patterns.  Your evaluation should include tests and assessments of ALL regions of the body, including determination of how all regions affect the movement of the painful joint because of the biomechanical interaction of the body.  Functional exercise is not about how it looks, it’s about the results you get from the movement. Keep it simple, basic, and foundational to make the largest impact.  The critical component is how the exercise is performed, not just performing it. Choose quality over quantity, by teaching ‘intent’ of movement. Explain to the client ‘why’ you are having them perform the exercise. Teaching a client how to move in patterns significantly reduces the chance of injury.  An exercise is not effective unless the exercise limits or corrects the movement at the painful joint and produces the desired appropriate movement at surrounding joints.Let’s take a look at some brief examples of the corrective exercise thoughtprocess in action.Shoulder pain: Performing the obligatory internal and external rotator cuffresistance exercises will do little to enhance shoulder stability. Instead focus onthoracic spine rotation and scapular stability.Knee pain: Knee extensions and hamstring curls are the pinnacle of isolationmovements. Instead focus on hip and ankle mobility. Pay special attention to hipstability and glutei muscle activation with rotational vector patterns.
  5. 5. Neck pain: Active range of motion exercises will only get you so far. Instead zeroin on thoracic spine extension and rotation patterns. Focus on pelvic rotationdetermining if there is an anterior or posterior shift compromising the kineticchain. Inner core exercises are paramount. And don’t forget the diaphragm.Back pain: It’s more to strengthening the back than just working the abdominals.Hip function is paramount to back mechanics. If you lack mobility and stability inthe hips your back will pay the price. Check the joints above and below for properfunctional control during basic patterns of movement. All corrective exercise forthe back should involve the hip and glutei.Principle Action Steps:Prioritize restoring and maintaining lumbo-pelvic stability. If you don’t, theadaptations up and down the kinetic chain will persist no matter what exercisesyou use with patients. Many times you will have to start simply with floorexercises in supine, quadruped, and sidelying to teach clients how to recruit thecore musculature, especially the external oblique, and hold pelvicposition/neutral lumbar spine. Most core exercises tend to be rectus abdominisdominant. This dominance often gets ignored because everybody wants strongabs and the faulty pattern gets reinforced.Emphasize the posterior chain since it is often a neglected component ofmovement. Deadlifts, low cable pullthroughs, and even back extensions can havecorrective properties if proper movement patterns such as hip extension arereinforced. Don’t be afraid of deadlifts either. When implemented at the righttime and with proper coaching of hip hinging a deadlift is one of the mosteffective exercises for injury prevention.Split stance exercises like split squats, Bulgarian split squats, and reverse lungesallow patients to work on hip mobility in hip flexion and extension as well asimproving stability. Asymmetrical loading is a great way to enhance trunkstiffness/pelvic stability that you’ll need to gain hip extension mobility. Alsoinclude a little bit single leg stance activity. It’s not about getting incredibly strongon a single leg but more about increasing stability. Your primary exercises shouldbe double leg, yet single leg movements add a nice unstable training variable.Start focusing more on function as opposed to structure. Karel Lewit, MD, said“The first treatment is to teach the patient to avoid what harms him.” Begin laying
  6. 6. your foundation for corrective exercise from the very first patient visit by notinghistory, work habits, activities of daily living and current fitness level. All of thesecomponents will be critical to the design matrix of your corrective exercisestrategy. Every exercise you prescribe is a test of how well your rehabilitationprogram has prepared the patient for movement. Remember the brain thinks interms of movements, not individual muscles so become attune to each patient asan individual. No cookie cutter exercise program will work for you in the world ofcorrective exercise, so take the necessary steps to learn proper application. Stopchasingpain.comReferences: 1. Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and Corrective Strategies. Santa Cruz, CA: On Target Publications, 2010. Print. 2. Sahrmann, Shirley. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines. St. Louis, MO: Elsevier/Mosby, 2011. Print. 3. Carey, Anthony. The Pain-free Program: a Proven Method to Relieve Back, Neck, Shoulder, and Joint Pain. Hoboken, NJ: J. Wiley, 2005. Print. 4. Hartman, Bill. Web. 20 Feb. 2011. Boston Sports Medicine and Performance Group on Sun, Jan 23, 2011 http://www.bsmpg.com/articles---resources-0/bid/51990/ 5. Liebenson, Craig. Rehabilitation of the Spine: a Practitioners Manual. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.

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