Craig Valency, CSCS
Part 6: Functional Rehabilitation
Prehab: Prevention is the Best Medicine
Life is full of enjoyable activities that aren’t always “functional” or optimal for human movement proficiency – but they sure are fun! If you like to race cars, play a round of golf, or shoot pool, you should do exercises that support those activities and help you excel. These exercises are not necessarily functional, but they are sport or activity-specific exercises.
Functional, or corrective exercises, should be used to correct imbalances that result from the asymmetric demands of your hobby, activity, sport, or job. These “prehabilitation” exercises are a great way to prevent a problem before it starts. You accomplish this by working the non-dominant arm or leg, if you play tennis for example, or by working the back side more than the front, if you are seated for hours a day, hunched over a computer at work.
Correct Use of Corrective Exercises: Isolate, Then Integrate
Many of these corrective exercises, which are designed to fix your body’s asymmetries, are single joint, isolation exercises. They can be effective in fixing a broken body, despite the fact that they are not functional, in terms of movements that involve the entire kinetic chain in a linked, natural manner. They can, however, address imbalances caused by your sport, activities of daily living, or occupation.
One way to enhance the effectiveness of these isolation exercises is to follow them up with a similar movement that integrates the entire kinetic chain. This reinforces proper neurological recruitment and sequencing of muscle firing patterns. In a sense, you are taking an isolated movement and putting it back into context so that your body recognizes and understands the movement.
For example, if you need to work the small shoulder rotator cuff muscles to increase joint integrity, you can do isolated dumbbell external rotations while lying on your side with your elbow fixed to your body. Immediately follow this exercise with something like a single leg squat and dumbbell “sword draw” movement. This now allows the shoulder to move in a spiral, diagonal pattern along with lower body integration. This is a more natural, linked, and recognizable pattern, based on how the muscles and fascia are attached. The isolation exercise addresses a specific muscle weakness or imbalance. Subsequently, the integration exercise re-educates the muscle’s ability to work synergistically with the rest of the body. Remember to first isolate, then integrate.
Rehab: Treat the Cause, Not the Symptom
Because the body is an integrated kinetic chain, an injury or chronic pain can be better addressed by looking at the links above or below the site of pain. By doing this, the cause of the problem can be treated rather than just the symptom. Traditional physical therapy has all too often focused on treating one body part to the exclusion of the rest of the body. This usually results in months or even years of therapy, during which patients complain that they only feel marginally better. Following are two examples of the most common areas of pain that people experience. Let’s view them through a treat the cause lens.
Low Back Pain
If your hips lack optimal mobility, than your low back has to rotate beyond its intended range of motion whenever you pick up a heavy box or play tennis. This can result in low back pain.
Now, excuse me while I geek out for just a moment. The low back, or lumbar spine, is not architecturally designed for much rotation. The lumbar facet joints face inward and literally bang into the adjacent joint with rotation of more than about 13 degrees. The facet joints of the thoracic spine (upper back) actually are faced posteriorally so that they glide in the transverse plane and allow up to 45 degrees of rotation.
Back to our regular programming. Treating the site of pain is fine for immediate relief and comfort, but your therapist should also do a comprehensive assessment to find the cause and treat it as well.
Individual strengthening of the small external rotators of the shoulder is important for posture and for joint integrity. But if you show up to the doctor with a rotator cuff impingement, it is silly for her to focus only on your shoulder and prescribe endless dumbbell or tubing external rotation exercises. A thorough exam might show that ankle mobility on one foot could be causing a chain reaction that creates compensation all the way up to the shoulder. If a locked and tight thoracic spine with some kyphosis (Hunchback of Notre Dame) is not treated, for instance, than no matter what you do to the shoulder, the cause of the impingement will always be there.
Our healthcare system is partly to blame for this revolving door of doctor visits, physical therapy prescriptions, and treatment of the symptom. Doctors write a physical therapy prescription for the body part that hurts. When you show up to therapy, your therapist is only “authorized” to treat that specific part, so the bombardment begins! Your painful appendage gets subjected to manual therapy, joint mobilizations, electrical stimulation, and ice, among many other modalities. It makes sense to the patient, but the point of pain is rarely the area most in need of treatment. Admittedly, if I went in for a headache, I would probably raise an eyebrow if the doctor performed mobilizations on my ankle. But now I know better!
Assess all of Me, Not Just my Parts!
The therapist should do a thorough, full body assessment to uncover any compensations or limitations in movements. He should evaluate the possible causes of the pain the patient is complaining about. The therapist must clearly communicate with the patient so that the patient understands why ankle and hip mobilizations are being done in order to treat a low back problem, for example.
Chuck Wolf, an influential innovator and leader in the fitness world, recently posted this “Insight of the Week” on his Facebook page. He speaks perfectly to this very topic. He explains, “In the majority of people presenting with low back pain, they usually have a limitation of motion in the foot/ankle complex, hips, and thoracic spine. Make sure these ‘Big Rocks’ have good range of motion to reduce compensations in the lumbar region.” Other impactful “treat the cause” leaders include Gray Cook, with his developmental approach, and Gary Gray, who was dubbed the “Father of Function” many years ago when the functional training movement was in its infancy. Their approach blurs the lines between therapy and training. Of course, countless physical therapists are also doing their parts to treat the cause.
Maybe you are in need of rehabilitation due to pain or discomfort. Perhaps you feel great when you start an exercise program or sport. Either way, it’s important to check for asymmetries as well as mobility or stability deficiencies. Start with prehabilitation so that you don’t need rehabilitation. Proper use of corrective exercises will help prevent a problem down the line that could result from compensations that occur once you start loading your body with weights at the gym, going on a backpacking trek, or just cleaning the backyard.
In Part 7, the final installment of “How Functional is Functional Training?” we put it all together with a glimpse into the life of one of my clients, Judy. You will go through a complete one-hour functional workout with her and see how it translates to the demands in her real life.
To read the complete series start here for part 1: From Muscles to Movements