The Functional Approach to Rehab Exercise

S ELECTING IHli IDEAL EXERCISES FOR patients with back conditions re­quires judgment based on clinical experience and scientific evidence. There are several approaches to rehabilitation, and many different types of exercises are available; however, patients have a lim­ited amount of time, willingness, and en- thusiasm to exercise. Therefore, we must always try to give our patients the most effective exercises for their conditions. But, what are the "best" exercises for chiropractic patients? What to Look for The best exercises for a specific problem are those that will be rapidly effective, easy to learn and perform, and safe. The exercises must help the patient to regain nonnal alignment and easy, natural movement. And the end result should include a decreased chance of similar, recurring problems. A successful and appropriate rehabili­tative program can be designed without the need for expensive, joint-specific equipment. While isokinetic machines are useful in the research lab, current rehab concepts consider such equipment to be unnecessary. In fact, the low-tech ap­proach can be very effective for the treat­ment of most spinal conditions. Additional personnel, fancy equipment, more office space, and extra time are not necessary. With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, chiropractors can effectively rehab their patients with simple home ex­ercise equipment. Specific Adaptation to Imposed Demands The "SAID" concept is one of the un­derlying tenets of the strength and condi­tioning field.1 It describes the observa­tion that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bod- ies develop more muscle mass, and we become stronger. And, if we practice our balance and coordination, we improve our ability to function easier on an unstable surface (such as on a rolling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we be­come better at doing whatever it is that we do most often. It has taken quite a while for specialists in the treatment of spi­nal problems to incorporate this idea into neck and back rehab programs. Recently, some chiropractors have begun to use the same thought pro­cesses to design spinal exercises that we have used for decades to determine ap­propriate X-ray positions. We recognize that the spine functions very differently when it is not weight-bearing. We now know that the best way to help our pa­tients return to normal function is with exercises that imitate as closely as pos­sible the real conditions under which the spine must function day after day. That certainly must include the specific stress of gravity in the upright position. Kinetic Chain Exercises When the spine is bearing weight, it is part of a closed kinetic chain. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and sta­bilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Iso­tonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. More im- portant than the equipment used is whether the spinal support structures are exercised in an open or a closed-chain position. Open-chain exercises for the spine are done non-weight bearing, while either ly­ing on the ground or immersed in water (which removes much of the effect of grav­ity). Both floor-based and water-based exercises have some limited usefulness, primarily during the acute stage. A good example of this is a study com­paring closed vs. open kinetic chain exer­cises for the training of the thigh muscles. Augustsson, el ai, wanted to improve their subjects'vertical jump height.2 Two groups exercised twice a week at maximal resistance - one group doing closed-chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open-chain exercising). At the end of six weeks, both groups had gained considerable strength, but the closed-chain exercisers were the only ones who improved significantly in the vertical jump. Since jumping is a closed-chain activity, the SAID concept tells us to expect that closed-chain exer­cising will be more effective. Functional Position Exercise We know that the origins and insertions of many muscles change when going from standing to lying down. Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions. This is why it is so important to bring neck and back rehab exercises closer to real-life positions, and it explains why patients make much more rapid progress when they are taught to exercise in a functional (upright) position. By staying up off the floor, exercising in a weight-bearing position is actually easier for most patients. In addition to being ► ► more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities. Patients like the idea of doing exercises that clearly prepare them for better function during normal activities of daily life. The Value of Balance Exercises For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance. This means that about five-to-ten minutes of each workout should be spent exer­cising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board. The advantage of these balance exercises is seen when athletic pa­tients return to sports activities and can perform at high levels without consciously having to protect their backs. Back exer­cises done on a rocker board or while standing on one leg are considered more useful than those done on a gym ball, since the entire body is in a closed-chain position during the exercises. The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed during closed-chain exercising. This makes these types of exercises very valuable in the long run, particularly for competitive athletes. Functional Alignment Many chronic spinal problems develop secondary to an im­balance in weight-bearing alignment of the lower extremities. In fact, lower extremity misalignments—such as leg length discrep­ancies and pronation problems—are frequently associated with chronic pelvis and low back symptoms.3 Any of these that are present will need to be addressed in order to resolve the patient's current symptoms and to prevent future back problems. The effects of weight bearing and the alignment of the kinetic chain must be considered. Conclusion Selecting the best exercise approach for each patient's back problem is important. A well-designed exercise program allows the doctor of chiropractic to provide cost-efficient, yet very ef­fective rehabilitation care. Exercises performed with the spine upright (standing or sitting) specifically train and condition all the involved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their chiropractic care, Kim Chrislensen. DC. DACRB, CCSP. CSCS, is director of the Chiro­practic program at PeaceHealth Hospital in Longview Washington. He participates as a team physician and consultant to high school and university athletic programs. Dr. Chrislensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past presi­dent of the American Chiropractic Association Rehab Council. He is a "Certified Strength and Conditioning Specialist. " certified by the Na­tional Strength and Conditioning Association. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabili­tation and nutrition. He can be reached bv email at kchristenseniiQp.eaceliealth. org ■ References Fleck SJ. Kraemer WJ. Designing Resistance Training Programs. Champaign. 1L: Human Kinetics, 1987. Augustsson J. el at.. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance en­ hancement. J Orlhop Sports Phys Therap 1998; 27:3-8. Rothbart BA, Estabrook L. Excessive pronation: a major biomechani- cal determinant in the development of chondromalacia and pelvic lists. J Manip Physio! Therap 1988: 1 1:373-379. 4. Shrader JA. Nonsurgical management of the foot and ankle affected by rheumatoid arthritis. J Orlhop Sports Phys Ther 1999; 29(I2):7O3-717. 5. Wolfe MW. Uhl TL, Mattacola CG. McCluskey LC. Management of ankle sprains. Am Fain Physician 2001; 63( 1 ):93-104. 6. Lynch SA. Renstrom PA. Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment. Spoils Mcd 1999; 27(l):61-71. 7. Barkler EH, Magnusson SP, Becher K. Bieler T. el al. The effect of supervised rehabilitation on ankle joint function and the risk of recurrence after acute ankle distorsion. Ugeskr Laeger 2001: l63(23):3223-3226. 8. Holme E. Magnusson SP. Becher K. Bieler T. el al. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999; 9(2): 104-109. 9. Cleeman E. Flatow EL. Shoulder dislocations in the young patient. Ortltop Clin North Am 2000: 3 l(2):21 7-229. Hughes CJ. Hurd K. Jones A. Sprigle S. Resistance properties of tubing during shoulder abduction exercise. J Ortltop Sports Phys Ther 1999; 29:413-420. Mikesky AE. Topp R. Wigglesworth JK. Harsha DM. et al. Efficacy of a home-based training program for older adults using elastic tub­ ing. Eur J Appl Physiol Occup Physio! 1994: 69(4):316-320. ► Refereces continued on page 59...