In part 1 of this article (Oct. 7 issue), I provided the corrective exercise/rehabilitation template I most often use in my office, which is based on the National Academy of Sports Medicine's (NASM) recommendations.A typical rehab prescription includes giving advice on proper posture while sitting and standing; teaching sternal lift and tall-spine concepts; training in proper respiration; use of various modalities including the deep-muscle stimulator and the class IV laser; mobilization/manipulation of hypomobile/fixed joints in the spine and extremities; training on how to use the foam roll daily at home; training on how to stretch/lengthen overactive muscles daily; training on how to perform isolated strength exercises for underactive muscles; and training on how to perform integrated whole-body exercises. This model of rehab is consistent with my treatment goals, which are as follows:
Prevent injuries in the actual training process. I need to minimize risk, look at the overall risk/benefit ratio and use sound exercise progressions. Have you ever had a patient get injured while you were trying to teach them a new exercise? If a client is under my watch while performing rehab exercises, I feel injuries suffered during training are my fault. The foam roll and stretching protocols will help prevent injuries. Hopefully no one ever gets hurt while re-training or working out in our offices.
Reduce the incidence of performance-related injuries. The number of injuries that athletes suffer is pretty high, so if I can reduce that, everyone is happy. Professional sports-team owners and coaches look at overall injury trends. They evaluate statistics such as "man games lost." An injured athlete simply can't play to their full potential.
Improve performance. It seems obvious, but keep training as safe as possible. Many times, I have to introduce simple, low-load exercises to re-establish efficient movement patterns. I can then add more complex movements and weight resistance exercises. Work to prevent/reduce injury potential, and then improve performance.
The ideal in-office program is designed with all of these goals in mind. A progressive exercise program minimizes exposure to undue stress and improves performance, but not at the expense of health. If a patient is scheduled for a one-hour rehabilitation session, time would be spent on movement therapy and strength therapy. Once the client enters the office and has signed in, have someone take their vitals. Most of my client's cardio work is done outside the office on their own time. If they want to use a bike or treadmill, I have them do that at the end of a session. Initially, you may need to help with cardio work, but eventually, they should be doing that on their own after you are done with the corrective exercises.
A typical professional athlete may have two to three hours a day to work out. They have a totally different time schedule than your average patient. Athletes can perform movement therapy for 60 minutes and strength training for an additional 60 minutes. A pro's workout will include warm-up, speed, plyos and conditioning. For example: warm up, 20 minutes; speed/plyo/medicine ball, 15 minutes; strength, 40 minutes; power/Olympic training, 20 minutes; and conditioning, 20 minutes.
The in-office session for patients is limited to 30 minutes. These sessions could take place in a small area in your office to perform the following: soft-tissue therapy (foam roll, deep muscle stimulator), static stretching of overactive muscles and activation of underactive muscles. Then there is the warm-up of the whole body. This includes lunges in different planes (sagittal, split legs), lateral lunges, rotational lunges, crossover lunges and hip-hinge range of motion. Finally, we get to lift weights. I recommend free weights or kettlebells.
A whole-body conditioning program can be divided into seven patterns. Any one of these can be emphasized, depending on the diagnosis and injury that needs rehabilitation.
Knee-dominant exercises include squats and variations. Static unsupported one-leg squats are the most difficult. Other examples include static supported split squats with one leg on a bench. Dynamic knee-dominant exercises include lunges and lunge variations.
Hip-dominant exercises include single-leg deadlifts, which really are a misnomer because the straight leg can have a 20 degree bend in it. Other choices include one- or two-leg stability ball leg curls and backward lunges where the back leg slides on a pad. Here are some other exercises to consider adding to your rehab program:
Vertical-pull exercises. These include chin-ups and rope pull-ups. Emphasize the eccentric portion and use alternating grips.
Horizontal-pull exercises. These include rows. Make sure clients reduce the upper trapezius dominance often displayed during rows. I recommend a 2:1 ratio with vertical pulls.
Horizontal-push exercises. These include bench presses. In the sagittal plane, the bench press is accomplished with a barbell, free weights or kettlebells. In the transverse plane, alternating dumbbell or kettlebell bench presses (resistance of transverse motion) are suggested.
Vertical-push exercises. These include overhead movements such as the overhead press or seated dumbbell raises, or kettlebell military raises. I also use alternating dumbbell or kettlebell raises, or half-kneeling dumbbell, front press, push press, and push-jerk moves.
Rotary/rotary stability/diagonal exercises. These include chops, lifts, rotations, push-pulls and diagonals.
In summary, the soft-tissue component of the workout includes foam roll instruction and therapy. The key areas I most often recommend are adductors/abductors, hip flexors, hips, thoracic spine and pectorals. The rolling decreases density, ironing out the muscles. Next, I use static stretching and the stability-ball stretching. The key areas include the hip flexors, abdominals, and spinal extensors. The foam roll and stretch portions last for 10 minutes.
I know that stretching may decrease immediate power, but the benefits clearly outweigh the losses. I want to keep my clients healthy now that I've gotten them this far. In the acute and subacute phase, I often restrict stretching because clients frequently aggravate themselves by overstretching. Static stretching is followed by active warm-up for about five minutes. Strength training, accomplished by performing one exercise in each of the seven categories discussed previously, occurs next and may take 15 to 35 minutes.
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