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Exercise Order and Sequencing for Corrective Exercise Programs


Learning Objectives:

  1. The reader will learn why it is important to structure corrective exercise programs in a sequential manner to help increase client confidence and adherence.
  2. The reader will learn the recommended exercise order for designing successful corrective exercise programs.
  3. The reader will learn how and when to progress a client’s corrective exercise program.

Many elements must be taken into consideration when designing successful corrective exercise programs. Knowing how to select and implement safe and effective exercises is important, but you must also incorporate the particular needs and capabilities of every client to promote adherence and minimize potential for discomfort. You must also structure programs in a logical sequence so clients can achieve the greatest benefits in the least amount of time and know when to progress and regress programs to maximize success.

Consider Your Client’s Needs

When clients first discuss their physical problems or movement issues with you, remember that they may have been feeling a lot of fear and anxiety regarding their pain, injury, and/or dysfunction – probably for quite some time. They may have lost confidence in their ability to perform certain tasks and will generally lack the self-assurance needed to perform complex motor tasks, especially those that require the use of the affected or painful area(s). To help boost client confidence at the outset of a corrective exercise program, choose easy-to-perform exercises that address the clients' imbalances and increase their own belief in the ability to perform the exercises/movements successfully. When a person attempts a new exercise and is able to perform it correctly, it increases self-confidence. This increased confidence will motivate them to repeat the action and also increase the likelihood they will be open to trying additional exercises.

The guiding principle of corrective exercise programming is the same as that of traditional fitness programs - gradual progression. Introducing concepts and exercises at a manageable pace for clients increases confidence, adherence and belief in their own abilities.

Corrective Exercise Order

Corrective exercise programs should address imbalances and deviations in a logical format. Damaged and stressed tissue structures must be reconditioned and rejuvenated before attempts at dynamic stretching or strengthening movements can be made. When designing a corrective exercise program, incorporate activities that accomplish the following goals in the order listed below:

  1. Regenerate and release the fascia, muscles and tendons,
  2. Realign and increase blood flow and range of movement to structures, and
  3. Strengthen the muscles and challenge the nervous system.

In other words, begin with the introduction of self-myofascial release (self-massage) techniques, progress to stretching, and then to strengthening exercises (Price, 2010). The remainder of this article will explain each of these techniques and activities.

Self-Massage

Self-massage regenerates and rejuvenates soft tissues that have become adversely affected by chronic malalignments (Abelson, 2003). These types of exercises are usually easier for clients to perform than more complex, movement-based exercises. Moreover, self-massage not only promptly reduces painful symptoms, but clients can also be successful when doing these techniques which helps build their confidence.

Two popular kinds of self-massage are:

  1. Self-Myofascial Release (SMR) Self-myofascial release is a massage technique of applying continual pressure to an area of the fascia that contains restrictions or lacks movement. The sustained pressure stimulates circulation to the area, reduces pressure build-up from sluggish blood flow, and restores suppleness to the myofascial tissue (Barnes, 1999).
  2. Trigger-Point Massage. Trigger point massage differs slightly from SMR in that it is intended to target a very specific area of a muscle (or the surrounding fascia). Trigger points are so-called because they trigger a painful response to the surrounding area when stretched, moved, or touched. Both techniques are very effective methods for preparing the soft tissue structures of the body for movement at the beginning of any corrective exercise program or exercise session.

Teach clients how to utilize foam rollers, tennis balls, golf balls, lacrosse balls, baseballs, racquetball balls, or trigger point therapy sticks, such as a Theracane®, electronic massage devices, and their hands and fingers to perform self-massage. Recommend techniques that clients can replicate at home, the office, or anywhere they feel completely comfortable.

An example of a self-massage technique would be using a tennis ball to help recondition the soft tissues of the buttock area (i.e., glutes and hip rotators) (see Figure 1).

Figure 1: Self-massage with a tennis ball

When to progress/regress between self-massage and stretching

You will know it is time to progress from self-massage to the stretching component of a program when the client no longer feels any tenderness when applying pressure to the target area or if the appropriate tissues have released enough to perform the desired progression (i.e., stretch) with correct technique. If a client is uncomfortable, experiences any type of pain, or finds the exercise too difficult, regress the self-massage technique being used. You can regress self-massage techniques by using a softer tool for applying pressure (e.g., a less dense roller or softer ball) or instructing clients to apply heat to the affected area instead.

Stretching

As deconditioned soft tissue structures become more fluid and healthy, it is time to increase the comfortable range of motion for the muscles, fascia, tendons, ligaments and joints. Stretching involves elongating and lengthening muscle fibers (and their accompanying soft tissues and fascia) in order to restore blood flow and elasticity to those structures (Walker, 2007). Many different types of stretching exercises can help facilitate flexibility/mobility and retrain movement in those parts of the body that have become dysfunctional as a result of chronic malalignment (Alter, 1996). Stretching also involves retraining the nervous system by moving the body in directions that mimic the way the body should move when it is working properly.

Three common stretching techniques are

  1. Passive Stretching
  2. Active Stretching
  3. Dynamic Stretching

Each technique should be utilized in the order listed above and offers a unique benefit to clients as they prepare for the next stage of their corrective exercise program.

Passive Stretching

Passive stretching involves holding a static position for a predetermined amount of time to achieve and increase range of movement around a joint or number of joints. Other muscles in the body are not being stimulated to a great extent to contract in a passive stretch and are, therefore, in a relatively passive state. Passive stretches are a good choice to use at the beginning of a stretching program. An example of a passive stretch would be a seated lower back stretch (see Figure 2).

Figure 2. Passive stretch - Seated lower back stretch

Active stretching

Active stretching involves a concept known as reciprocal inhibition, which is based around the notion that in order for one muscle group to relax, its antagonist muscle or muscle group must contract (e.g., contracting the quadriceps to enable the hamstrings to relax). Active stretching is a great way to begin integrating different functions of muscles or muscle groups to work together in a lengthening/contracting fashion. A passive stretch, such as a standing calf stretch (see Figure 3), can be turned into an active stretching exercise by activating the tibialis anterior (i.e., pulling the toes of the rear foot up toward the shin).

Figure 3. Passive stretch for the right calf

Note: This becomes an active stretch for the right calf when the toes of right foot are elevated towards the right shin.

Dynamic stretching

Dynamic stretching mimics functional movements. It involves the use of concentric activation (i.e., contraction) of certain muscles to move bones while other muscles eccentrically load (i.e., lengthen with tension like a bungee cord) to allow joint motion to occur with minimal stress to the joint. This type of stretching helps clients learn to perform a desired range of movement in a controlled and coordinated manner. An example of a dynamic stretch would be performing a step backward to the calf stretch pictured above. These types of stretches assist clients in progressing from the stretching to the strengthening components of their programs more successfully.

When to progress/regress between stretching and strengthening

Progress from stretching to strengthening when the muscles and soft tissue structures in the area(s) you are stretching are working correctly and/or it is appropriate to add a strengthening exercise as a client gains control of greater ranges of movement during a stretch. Regress a stretch if a client is in pain or discomfort, or has difficulty performing the exercise or remaining in control of the movement. You can regress stretching exercises by applying a self-massage technique instead or utilizing a less dynamic/more controlled stretch.

Strengthening

Once progress has been made toward improving the overall condition of a client’s dysfunctional soft tissue structures, begin incorporating strengthening exercises into the program.

There are many different kinds of strengthening exercises. Following are four effective corrective exercise strengthening strategies:

  1. Isometric
  2. Concentric
  3. Eccentric
  4. Kinetic chain multi-planar/dimensional

Follow the order detailed above to ensure your clients' benefit from each type of strengthening exercise as they progress through their corrective exercise program.

Isometric

Isometric contraction occurs when a muscle becomes activated, but stays the same length (i.e., it does not shorten or lengthen). This is the easiest type of movement for the nervous system to coordinate. Once the nervous system has generated an isometric muscle contraction, it is able to continually keep motor units firing to the muscle(s) involved in that contraction to maintain a state of activation. When a client’s muscles cannot activate correctly, or have shut down as a result of chronic malalignment issues, it is important to get those muscles firing again before attempting to engage them in dynamic movements. An example of an isometric exercise would be instructing your client to stand with their feet abducted and contracting their gluteus maximus to help outwardly rotate the leg (see Figure 4).

Figure 4. Isometric strengthening exercise contracting the gluteus maximus

Concentric

Concentric muscle action involves shortening a muscle to bring the origin and insertion points of that muscle closer together and results in the movement of a joint (e.g., contracting your biceps will bring your forearm closer to your shoulder and flex the elbow joint).

Eccentric

Eccentric muscle action involves the lengthening of a muscle to slow down parts of the body as they move (e.g., the biceps lengthen to slow extension of the elbow joint when lowering a heavy box from shoulder to waist height). Clients unable to perform an eccentric contraction correctly may experience more stress to a joint and/or pain if they attempt an eccentric movement. Therefore, concentric exercises are usually better choices when initially progressing corrective strengthening exercises from isometric to concentric/eccentric.

Both concentric and eccentric strengthening exercises can be performed using a single joint, or many joints (i.e., a multi-joint movement). Begin with single joint movements like a “Single Leg Lift” exercise (see Figure 5) that involves using the glutes to lift and lower the leg using just the hip joint (as long as the lower back does not arch and engage the lumbar erectors).

Figure 5. Concentric/Eccentric strengthening exercise - Single Leg Lift

Progress to multi-joint movements when you feel confident your client has control over each joint involved in the sequence (e.g., adding an opposite arm lift to the exercise above to incorporate spine extension).

Kinetic Chain and Multi-Planar/Dimensional Movements

Once a client can control a muscle or group of muscles both concentrically and eccentrically, and the joints those muscles cross, teach them how to use those muscle(s) as part of a kinetic chain (e.g., a series of motions or movements created by muscles working in sequence) (Whiting, 2006). For example, the gluteal complex, which includes the Gluteus Medius, Minimus, and Maximus, controls hip, leg and foot function (due to attachments of these muscles on the upper and lower leg). When working together as a kinetic chain, these muscles help slow forces to the feet, ankles, knees, and hips by transferring the weight of the body to these structures at the right speed and rate (e.g., “Side Lunge with Reach” picture below).

Figure 6: Side Lunge with Reach

When groups of muscles are working efficiently as part of a kinetic chain, progress to whole-body, multi-planar exercises that move the body in all different directions such as forward and backward (i.e., the sagittal plane), side-to-side (i.e., the frontal plane) and in rotation (i.e., the transverse plane). Performance of these types of exercises correctly and efficiently is the ultimate goal of corrective exercise programs. Clients that have progressed to this highest level should be free from pain, highly functional, and able to perform coordinated, dynamic movements.

When to progress/regress between strengthening exercises

Progress the type of strengthening exercises you are using when your client has reached a suitable level of competency and can do the movement well. Always regress a strengthening exercise if a client experiences any type of pain, has difficulty performing the movement, or reports excessive soreness the next day or later the same day after doing the exercises.

References

  1. Abelson, Dr. Brain and Abelson, Kamali. Release Your Pain. Calgary: Rowan Tree Books, 2003.
  2. Alter, M.J. Science of Flexibility (2nd ed.). Champaign, Ill.: Human Kinetics, 1996.
  3. Barnes, J.F. Myofascial Release. In: Hammer, W.I. (Ed.) Functional Soft Tissue Examination and Treatment by Manual Methods (2nd ed). Gaithersburg, Md.: Aspen Publishers, 1999.
  4. Price, J. The BioMechanics Method Corrective Exercise Educational Program. The BioMechanics Press, 2010.
  5. Walker, Brad. The Anatomy of Stretching. Chichester, England: Lotus Publishing, 2007.
  6. Whiting, W.C. & Rugg, S. Dynatomy: Dynamic Human Anatomy. Champaign, Ill.: Human Kinetics, 2006.