Post-Rehabilitation and Medical Exercise

This is a good informative post about post rehabilitation and medial exercise and
is also an excerpt from my book.

Working with injuries

• “Make sure not to hyper-extend your back during _____ exercise.”
• “Don’t arch your back on Leg curl.”
• “Don’t use overhead press if you have a back injury.”
• “Don’t use lateral raise if you have a neck problem.”
• “Don’t use _____exercise if you have a shoulder problem.”

You’ve probably heard most of these statements, and more. They are all true, and not true. Many exercises irritate certain injuries. The same exercises will actually help those injuries. Many exercise instructors tell people not to do this or that exercise because it may hurt your back. They are probably wrong. Injury occurs when an exercise is performed incorrectly. Overhead press, for instance, should be avoided by people with lower-back pain. At least that’s what many therapists might tell us. They may not be aware that some equipment like the Medx overhead press is designed especially for patients with lower-back pain. The reactionary force of the exercise is transferred through the arms and shoulders into the back pad, not down the spinal column. Many exercises are now designed this way.

Post-Rehabilitation and Medical Exercise

The three part process to determining if an exercise is going to irritate an area:

1. Determine if the movement is tolerable to the injured area.

This is actually one of the purposes of the first workout. In order to test movement, you must eliminate the next two parts of the process. Make sure the resistance is light, but not so light as to make learning S.P.A.R.T.A. Training™ even more difficult to learn. We let the client know they will be exercising with a relatively light weight, performing only a few repetitions. Doing this will let us, the trainer, know if the movement only exacerbates an injury. If they have no adverse effects from this session, go on to the next part of the process. If they do have irritation to the area, you must decide what to do next. You have three choices. First, you can choose to change the settings, range, resistance, etc. on the current exercise. Second, you can choose to replace it with a similar exercise or an exercise that works the same body part in a different manner. Third, you can choose to eliminate the exercise completely.

2. Determine if the injured area has enough endurance.

This refers to muscular endurance. As long as the exercise was tolerated from the last session, increase the resistance slightly. The resistance should not be significant enough that the client will achieve momentary muscular fatigue, but the client should feel some fatigue in the area being exercised. Ideally, this procedure should be part of the second session. If the client has a chronic injury, we do not increase the resistance. The purpose of the exercise for this session will be to test if the injured area is irritated by too many repetitions. This way we can narrow down what actually is irritating to the client and what is beneficial and tolerable. We have the client begin the exercise. The client should continue the exercise as long as no irritations develop. We will stop the exercise after eight or ten repetitions. If the client tolerated ten repetitions, we attempt the third part of the process on the next session. If the client did not tolerate this phase of the process, you have two choices: First, you can eliminate the exercise. This is not necessary especially if the exercise is part of the general routine. Second, you can choose to redefine the point of termination of the exercise. If the client begins to feel anything in the area that is not muscular stress, terminate the exercise. After a few sessions, you should have a good idea how many repetitions occur when this happens. Once you have determined that, you can set the upper limit of repetitions for the exercise. For instance, if the client feels their shoulder on chest press after 6 repetitions, set the upper limit at 5 repetitions.

3. Determine if the resistance level is tolerable.

Estimate a resistance level that will sufficiently fatigue the muscle in about 10 repetitions. Early on in the post rehab program, the client’s only hope of muscular progress might be the miniscule benefit of performing multiple sets of the same exercise if more resistance is not tolerated. If they tolerate this session, they should have no trouble learning S.P.A.R.T.A. Training™.

No exercise needs to be avoided completely necessarily. It still may be very beneficial to perform a given exercise if you can just get the prescription right. Going into a little more depth, if it hurts too much to perform it, then the weight is probably too much initially, or the setting may be wrong. If it still hurts, then limit the range. You can try a hierarchy of techniques before eliminating an exercise completely. I usually use this protocol on a post-rehab client before eliminating exercises outright.

• Full range dynamic movement with lighter resistance
• Shortened pain free range
• Higher repetition ranges or TUL’s
• Negative only
• Static hold in pain free range
• Timed static contraction
• Multiple sets of either full range or limited

If none of these techniques work, then I eliminate the exercise completely and try to substitute with a similar one. Arching the lower back is not dangerous, unless it hurts to do so. In fact, some patients with certain lower back injuries feel better holding their back in an arched or extended position on different exercises. What will work for one client, may not work for the next one. Working with a client with an injury involves some trial and error training. The key to properly handling the situation is how you apply the trial, and how you handle and recovery from an error. Communication with the client is everything. We inform the client of what to say before the very first exercise. We must be sure the client knows what he/she may or may not feel. The client must be well informed and prepared for each exercise. S.P.A.R.T.A. Training™ uses these steps to safely and effectively work around injuries. We make sure to let the client know that we are not a rehabilitative therapist. That is beyond our scope of practice. We will do everything possible not to irritate the injury. The injury may get better during the course of the training, but we are not attempting to heal an injury. Rather, we are usually working around it to allow it to heal. Strengthening and producing integrity around an injured area may also be a continuing goal from their actual therapy program. For instance, a special routine I prescribe to work around an injury to my clients that have elbow tendonitis is below. It seems that about 25% of the clientele has it at all times due to various other activities like shoveling snow, tennis, or it may appear for no reason at all. They usually cannot grip or flex the elbow very forcefully before they feel pain. How can we work around this and not have to stop workouts for the entire body because of a very small, but painful injury? The routine looks something like this.

Calf raise
Leg press
Leg curl
Leg ext.
Chest fly (machine)
Chest press (machine with pressure on palms and no tight grip)
Super pullover (machine)
Tri. ext. (preferably machine no grip)
Lower back ext.
Abdominal crunch

As you can see, either the tendons on the medial or lateral side of the elbow are injured. Not once were those tendons engaged against any kind of resistance. The single joint upper body exercises successfully place the resistance on the pectoralis, deltoid, and latissimus by applying the resistance to the humerus bone well above where the elbow tendons originate from and are likely inflamed. We have successfully designed a routine that can work around the injury and still get 90-95% of the client’s body. With the use of several single joint exercises, the only major structure not worked would be the biceps and forearms. Perform this workout in a circuit, and they are performing quality cardiovascular work at the same time. There is no need to avoid exercise altogether for this client. It is a common injury many people have that most likely needs to rest and not be worked further. This routine can accomplish that.

As you can see, sometimes issues may get a little complicated. It is crucial that we have good communication with other health professionals like physical therapists and orthopedists so that we can have the clients continue to reach their health goals safely. Many times, we get a quick and cursory suggestion to do a given exercise, but not use more than 10 pounds. This is really not a helpful or descriptive suggestion. We are lacking several pieces of important information. If the client continues to use ineffective methods, they will never progress or reach their post rehab goals. A suggestion like that demonstrates lack of knowledge of equipment and techniques, but that is really within the realm of our scope of practice anyway. For instance, any given resistance amount means nothing by itself. In fact, there are two locations that we use and the same exercise in both locations is a 100 pound difference. If someone uses the Cybex VR3 Hip ABduction, they may use an average resistance of 80 pounds. If someone uses the Life Fitness Hip ABduction, they may use 180 pounds. Knowing appropriate and safe resistance levels requires knowledge of the equipment to be used. In addition, the resistance is not the same throughout the range of motion. Nautilus called this “dynamic variable resistance”. In order to match human biomechanics, the resistance was supposed to change depending on what position the body part is in at any point in the range of motion. This is not only true with regard to equipment, but also with body position in general. For example, I may prescribe a wall squat performed statically. If I have the client flex the knee to 90 degrees, that is easier and less difficult than having the client squat down to 110 degrees, but it is exactly the same body weight. What we are primarily concerned with is effective resistance. Complicating the issue even further is the speed of movement of any given exercise. We know that Force = Mass x Acceleration. We must consider all of these things when prescribing the right program. However, the real enemy, and many times the cause of, recent injury is the acceleration portion of the equation. You may have an exercise with resistance of 10 pounds, but depending on how fast you move it, it could help you strengthen and improve the area or it could send you back to the hospital depending on what you do with it. Many clients experience the exercise and are worried that it is too much resistance or that we are using “heavy weights” and rightly so. They don’t want to hurt themselves. On the contrary, that is the beauty of this methodology is that you can move slower, more controlled, use less resistance, and be placed in challenging, but very safe positions to maximize progress and minimize risk. The positions and movements may be challenging, but many times are less than a clients own body weight. And when a lower body injury is present, the post rehab exercise is the least of their worries. What people don’t realize is that many times they are exposed to more force walking up and down stairs to get into the facility or their home than they ever would be in a post rehab exercise situation. Proper prescription of post rehab exercise requires knowledge of several factors at once and it is an ever changing dynamic situation both short term during a workout and going forward in a progressive manner over time.

There are many other conditions and diseases in which S.P.A.R.T.A. Training™ is tolerable, and in many cases, beneficial. S.P.A.R.T.A. Training™ is safe and effective for clients who fall into the following special populations:

• Osteoporosis
• Rheumatoid/Osteoarthritis
• Orthopedic problems
• Lower back pain
• Neck pain
• Hypertension
• Obesity
• Cardiovascular/heart disease
• COPD
• Parkinson’s
• Fibromyalgia
• Thyroid and other Metabolic conditions
• Pre/post natal women
• Seniors
• Diabetes/Pre-diabetic
• Orthopedic problems
• Paralysis

We have had much success with lower back pain and neck pain. There is also quite a bit of research showing the effectiveness of strength training to combat insulin resistance. The hormone insulin is unable to do it’s job getting glucose into cells so exercise is the means to deplete glucose from muscle cells and then post workout, the cells pick up glucose from the blood readily.

Many times, people suffering from fibromyalgia can only tolerate slow, low-force exercise. It is challenging enough to stimulate strength and functional improvements, but will minimize any irritation to hot spots.

One of our greatest areas of success is osteopenia/osteoporosis. We have seen a magnitude of improvement of one % per month of training in bone mineral density. Many clients have even been brought out of osteoporosis.

Of course because S.P.A.R.T.A. Training&#153 is circuit training, the benefits of cardiovascular conditioning many and present even for those that are already diseased and rehabilitating from recent infarction.

There are few conditions or diseases where proper exercise is totally contraindicated. Something everyone should look into is the possibility of being reimbursed by your insurance company for your post rehabilitation training. I’ve had several clients obtain prescriptions from their doctor for strength training to stave off osteoporosis or other conditions. We even have a few insurance codes that may be useful for some clients depending on their conditions and insurance carriers. It’s worth looking into.

For more about these techniques and these specific conditions, take a look at our personal trainer store.