Progressive exercise regimes

Therapists can devise tailored progressive exercise regimes only when they understand movement principles, Sean Fyfe argues

Sports therapists, in my experience, tend to stick to a very limited range of rehabilitation exercises, which means that they are some times unable to prescribe progressive training regimes with the kind of specificity that our clients need in order to make a full recovery that will return them to their sport and prevent a repeat of the injury.

The reasons for the limited repertoire are often, I believe, to do with practitioners’ underlying lack of knowledge of strength and conditioning training (see my argument in SIB57, March 2006). As I explain below, with an improved appreciation of mechanics, you should be able to design a far more comprehensive range of exercises, customised to the particular needs of individual clients.

At the beginning of the rehabilitation process, exercises should be simple, aimed at correct muscle activation and building up basic strength. But as athletes get further along the rehab path, they need more specific and more challenging exercises. If the athlete fails to achieve (or regain) high level training of their muscles in terms of strength, speed and type of activation, degree of muscle stretch and joint position, then they will remain susceptible to injury once they return to sport.

My own preferred approach is to start at the end. Determine an end point exercise that will convince you and your client that they are fully fit and safe to return to partici pation in their sport. Take into consideration not just the movement patterns involved, but also the sets and repetitions to be performed, based on the sportspecific requirement for that athlete (power, endurance, sustained speed, etc).

The kinetic chain is the key

Whatever your choice of exercise goal, it will involve a ‘kinetic chain’. The kinetic chain, in one useful definition, is:

‘a coordinated sequencing of activation, mobilisation, and stabilisation of body segments to produce an athletic activity’(1)

All kinetic chain movements will be either ‘open’ or ‘closed’. We call them open chain when there is free movement of the terminal segment; and closed when there is minimal movement at the end of the chain. Many athletic activities, such as a javelin throw, involve both closed and openchain move ments: the legs push against the ground (closed chain) and the arm throws into free space (open chain). Kinetic chain sequencing achieves three objectives, all of which need to be kept in mind when the therapist is designing a rehab regime:

Focused power: ‘Efficient generation and transfer of kinetic energy and force to the distal segment to move an object.’(1)

Joint control against damaging forces: Stabilisation and positioning of the body segments and joints to regulate and absorb the developed forces at the joints.’(2)

A stable base for action:‘Stabilisation of body posture to counteract the eccentric loads and destabilising effects of the athletic move ments.’(3)

From here you can work backwards. For your selected endpoint exercise, break the kinetic chain into its components and assess which element(s) you believe are breaking down. Isolate the individual component(s): this is your starting point, getting the client to retrain their muscular activation and control.

As you progress the exercise programme, you will gradually add back in the compo nents of the kinetic chain, and then train them under increasing load. Here are a couple of examples.

The sprinter

A young female sprinter is suffering from leftsided low back and upper gluteal pain. Briefly, assessment reveals left side posterior innonimate (hip/pelvis) rotation and poor movement, as well as L5/S1 stiffness in her spine. Functionally, discomfort is reproduced in repetitive singleleg jumping in a straight line. So this can be the exercise we select as our endpoint goal: five sets of eight maximal singleleg jumps in a straight line.

After considering what occurs in this kinetic chain and testing the components of the chain, I identify the main problem as poor activation and strength in gluteus maximus. The hamstring and erector spinae muscles are overactivating and the lack of glute activation is causing poor stability through the sacroiliac joint (SIJ).

The first step of the exercise rehabilitation programme is to isolate and retrain the failing component. A great way to achieve this is prone hip extension, beginning with glute activation and then extending the hip with neutral spine stabilisation. The sprinter can progress to singleleg squatting while concentrating on squeezing the glute and maintaining a neutral spine. This in turn can be progressed by deepening the squat and adding resistance (weights).

The eccentric component of the jumping can be trained by jumping down from a step and absorbing the shock by bending through the hip and knee, keeping a neutral spine. The glute should be squeezed just prior to landing. After that, we can begin singleleg jumping exercises on the spot, concentrating on neutral spine, glute activation and lower limb alignment. At first, jump height should be kept to a minimum, increasing gradually.

The athlete should land and balance before jumping again, until they have achieved maximum jump height with good control and posture. Jumps should then be done continuously, followed by forward, backward and sideways movement. I find it very helpful for clients to perform these types of exercises in front of a mirror. Gradually our aim of five sets of eight maximal single leg jumps in a straight line is achieved.

The tennis player

Shoulder pain associated with overhead or throwing sports is a very common sports injury. Yet too many rehabilitation programmes only ever include basic scapular stability exercises and external rotation strength in neutral. Without progressing the programme to challenge the kinetic chain, the job is only half done and you can expect to see your client back before long with a recurrence of their injury.

Throwing is the ultimate kinetic chain. Anterior shoulder instability is the product of the front of the shoulder not being able to withstand developed force. To give adequate protection to the structures of the joint, the following are particularly important:

* The scapular stabilisers need to be able to hold the shoulder blade in its correct posi tion and provide a stable base against which the rotator cuff can pull.

* The entire rotator cuff needs to activate to increase compression of the glenohumeral joint.

* The subscapularis muscle needs to be strong eccentrically when the glenohumeral joint externally rotates.

We have an elite 20yearold tennis player suffering from pain to the top of the shoulder at the front when serving. The pain is repro duced by drawing the humeral head forwards when the shoulder joint is forced into elevation and external rotation. Our tennis player demonstrates excessive external rotation and limited internal rotation.

For the endstage exercise we need to select an activity that repeatedly loads the anterior capsuloligamentous structures. I believe if the player can maximally throw a 1kg grippa ball (a weighted ball about the size of a tennis ball) 20 times, he should be able to serve at 100% capacity. But that will only happen if the three points above have been addressed.

To start with, we need exercises to isolate: * scapular strengthening with the arm elevated * eccentric control and strength of subscapu laris in the cocking position * external rotation strength in the cocking position.

Lying supine on a Swiss ball in a bridge position with the arm in a cocking position is a great way to achieve precise loading of the shoulder. You can then progress to fast eccentric/concentric contractions with a weight while maintaining a set scapular position. After that, drop a grippa ball from a selected height, so that the player has to pretense the shoulder, catch the ball without letting the shoulder move and then throw the ball back. You can progress the difficulty at this stage by increasing any or all of the drop height, weight of ball or speed of return throw.

The next progression is to do resisted throwing exercises, either with a cable machine or the grippa ball. At first the athlete should concentrate on just moving the upper limb; gradually they should link all the segments of the trunk and legs, by, for instance, undertaking controlled throwing of a grippa ball using leg drive and trunk rota tion. This should be progressed until we can achieve our endstage exercise.

Conclusion

My description of exercises here has been deliberately sketchy, to underline my point. What matters is the therapist’s under standing of the elements of the kinetic chain you are trying to fix, and how to approach the rehab programme. Once you have clarified that, you can be as creative as you like with your rehab equipment and exercise prescrip tion. Indeed you have to be, especially if you are working to return high level athletes to performance fitness.

References

1Putnam, CA (1993) ‘Sequential motions of body segments in striking and throwing skills’. J Biomech26:125135.

2 Cordo, PJ and Nashner, LM (1982) ‘Properties of postural adjustment with rapid arm movements’. J Neurophysiol47:287303.

3 Nieman, H, Niemei, J, Takala, EP, Viikari Juntara, E (1995) ‘Load sharing patterns in the shoulder during isometric flexion tasks’. J Biomech28(5): 555566.