Designing an Exercise Rehab Program

By Perry Nickelston, DC, FMS, SFMA

I recently attended a workshop on fitness programming by master fitness expert Joe Dowdell, owner and founder of Peak Performance Gym in New York City and one of the most sought-after professionals in the country for program design.

His presentation got me thinking about how fitness programming principles can apply to chiropractic rehabilitation. Many of the points he stressed are vitally important to the treatments and protocols we provide to patients. There is an intricate connection between the world of fitness and exercise rehabilitation. The sooner we can bridge communication between the two disciplines, the more our patients will benefit. Implementing foundational systems that can be tailor-made for each patient is vital to success.

The Patient Comes First

The most important aspect of individual rehab programming is the goal of the patient/client. Every person is unique in their circumstances, history and capabilities. There are many tools available to help a person get well; however, knowing when and how much to use these tools is where the expertise lies. All too often, rehab programs fall into "cookie-cutter" designs – every patient gets the same exercises. When programs fail or success rates decline, it is most often the program design that is at fault.

The process of creating a treatment program starts by gathering information through the patient's history and the basic clinical examination. From the results, you will generate hypotheses that could explain the findings. Your expertise and clinical reasoning must play an important role, identifying which findings are important and which special tests must be performed to arrive at the correct diagnosis. Too many special tests waste time and confuse the assessment, while too few may be inconclusive or inaccurate.

In the fitness arena, you should never start someone on a program until you have performed an evaluation of their general physical preparedness (GPP); that means measuring their capabilities and abilities to perform physical activities. Exercise rehabilitation follows the same principles.

Right Tools, Right Time

Don't be so quick to blame the rehabilitation tool for not working; it may simply be a case of the right tool at the wrong time! Maybe it will be more effective further along in the treatment program. Falling prey to our own biased opinions on techniques, tools, systems and protocols is a mistake you don't want to make in clinical practice. There are positive benefits to almost every therapy system; it's up to you as health care professional to discover the ones that resonate with your philosophy and treatment paradigm.

Take a step back and reassess patient progress after implementing new tools and strategies. The body is brilliant in its feedback mechanisms and will react positively to what it likes and negatively to what it doesn't. I know that may seem like common sense (and it is), but sometimes we lose sight of the simple picture and find common sense is not so common. Learn to become attune to patient response, emotionally and physically, and change strategies appropriately.

Sample Rehab Template

Here is an example foundational template to follow. Remember to change systems accordingly based on individual circumstances.

Phase One

• Intake history
• Examination of symptomatic complaint
• Assessment of fundamental movement patterns
• Evaluation of functional and dysfunctional movement
• Global muscle testing and range-of-motion studies
• Patient education

Phase Two

• Chiropractic treatment based on technique specific protocols
• Progress toward proper mobility in joint structures first
• Establish sufficient stability to control movement under change and load
• Soft-tissue strategies to restore elasticity, flexibility and durability, with special attention to trigger points, fascial adhesions and muscle activation patterns
• Kinetic-chain function, ensuring primary movers and secondary stabilizers are maintaining their role
• Progression from unloaded to loaded variations of exercises
  
• Focus on attaining bilateral symmetrical movement
• Use a stable base and progress to an unstable base (tall kneeling, half-kneeling, in-line lunge, single-leg stance, etc.)

Phase Three

• Re-evaluation
• Increased loads, vectors and tempos of movement
• Core stabilization programs intensify
• Prescription of unsupervised, at-home exercises
• Functional motor programming movement patterning via neuromuscular challenges to balance and proprioception

Phase 4

• Final evaluation and discharge to wellness care
• Patient education

Patient education is a large component of the rehabilitation process. They must feel motivated to reach their goal and trust you as their doctor to guide them safely in that endeavor. Explain to the patient the nature of their program and stress any precautions specific to their situation:

• Discuss that exercise advancement is dependent upon successful completion of each phase and emphasize the need to follow the guidelines and to adhere to the precautions to avoid complications
• Outline the treatment plan and expected functional outcomes
• Emphasize the need to be an active participant in the rehabilitation process to prevent barriers in reaching functional goals
• Educate patient regarding activities of daily living
• Lay out the process from beginning to end so the patient has a roadmap for getting to their destination. Mark when re-evaluations will be done and make sure you hold true to allotted times

Corrective exercise is the end goal. Corrective exercise is designed to undo all imbalances and compensations, and guide the body to work without pain. Through corrective exercises, you will reintroduce proper function to the body, which in turn restores correct structure. Program design focuses on the foundations of optimum posture, quality movement, core coordination and kinetic function. It serves two major purposes: 1) a long-lasting solution for recurring injuries, aches, pains or joint problems; and 2) the missing link needed for exercise to improve fitness, health, well-being, quality of life and sporting performance.

Design your program so your patients/clients will begin to place emphasis on long-term rehabilitation and the prevention of future occurrences by looking beyond each symptom and seeking the underlying mechanical trigger. Musculoskeletal disorders should be approached in the context of the whole person, rather than focusing on body regions in isolation. This is the tenet of chiropractic, so let's get out there and walk the talk. It's what we do!

Resources

• Cook G. Athletic Body in Balance. Champaign, IL: Human Kinetics, 2003.
• Jones MA, Rivett DA. Clinical Reasoning for Manual Therapists. Edinburgh: Butterworth Heinemann, 2004.
• International Academy of Orthopedic Medicine: www.iaom-us.com
• Sahrmann SA, Caldwell C. Diagnosis and Treatment of Movement-Related Pain Syndromes Associated with Muscle and Movement Imbalances. St. Louis, MO: SSM Health Care, 1998.

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