Clients who are self-motivated to work hard are star pupils. But what do you do when a client, because of injury, overuse patterns or some other type of dysfunction, can’t quite make it out of the gate? Many people want and need help with reducing pain in addition to meeting functional fitness goals. One goal dovetails into the other, and being prepared to work with these objectives will set you apart from the crowd. Safe, effective corrective-exercise program design is the product of four main components: assessment skills, exercise sequencing, movement progression and regression, and client confidence (Price 2010).
The flow from point A to point B should be seamless. Assess the client’s history and musculoskeletal condition to determine which exercises will be most useful. Arrange the program in a logical format so the client will achieve the greatest benefit in the least amount of time. Regress and progress moves as needed. Finally, deliver your customized package (particularly at the initial stages) in a manner that increases the client’s confidence level.
This last factor is vital because a client in pain typically harbors a lot of fear and anxiety. Consequently, he is unsure of his ability to perform certain tasks and/or movements—and he needs your help (see the sidebar “Building Client Confidence”). This article outlines the most effective corrective exercises for alleviating chronic pain and explains how to incorporate them safely and effectively into your program design.
You wouldn’t drive a car across the country without first taking it to a mechanic for a tune-up, would you? The same concept applies when working with a client. Always conduct an initial consultation to gather baseline measurements and pertinent health history data. This is also your opportunity to learn about the client’s abilities and motivations—information that will help you be a more effective trainer and coach. The recommended way to conduct a consultation is to perform a verbal assessment first, followed by visual and hands-on assessments (American Council on Exercise 2010).
The verbal assessment helps you build rapport with your client as you gain insight into his particular issues, injuries and history. Do the verbal assessment at the beginning of the first appointment so the client can answer all your questions while seated and feeling at ease. Take notes and ask specific questions about the different aches and pains the person is experiencing and any activities that are exacerbating those conditions (for example, sitting for long periods at a desk, running with a sore knee, etc.).
The visual and hands-on part of the assessment helps you gain further insight into the causes of the client’s musculoskeletal imbalances. Although you may be interested in prodding and poking for hours to understand the misalignments, remember that your client will feel nervous standing in front of you. Make this portion of the process as smooth, quick and effortless as possible. As you perform each test, explain your actions so the client understands what you’re doing. Make a note of your findings, and conclude by reviewing the details in a clearly outlined proposal.
A successful corrective-exercise program includes self-myofascial-release (SMR) exercises at the beginning and throughout the program as needed. Once a client has adequately prepared the soft-tissue structures, you can progress to stretching and, further still, to strengthening exercises. It is very important to structure programs in this manner so that injured tissues have the chance to heal before the client attempts more complex strategies involving dynamic movements and/or exercises. SMR exercises (i.e., self-massage) regenerate and rejuvenate muscles and other soft tissues affected by chronic malalignment (Rolf 1989). As injured tissues adapt, the client can move on to various types of stretching to realign structures and increase blood flow and range of motion. Once the body finally begins to “let go” of dysfunctional patterns, the client will further progress to more complex strengthening exercises and multiplanar movements that challenge the entire body.
In addition to knowing what types of exercises to use and when, it is imperative to know how to both regress and progress each exercise—or the entire program, if needed. Regressions ensure that your client can perform each move safely and successfully, while progressions move the program toward the “big picture.” Regressions and progressions are crucial and creative keys in the corrective-exercise regimen; they are also your best ally in pain appeasement.
For example, let’s take an SMR exercise that utilizes a foam roller. You must know how to regress or progress that exercise based on the client’s feedback. If an individual tells you her shoulder hurts from holding her body on the roller, regress the exercise by having her perform a similar move lying on the ground with a tennis ball or a baseball. Alternatively, if a client has been performing the roller exercise regularly and begins to feel very little pressure, progress to a harder roller or a different exercise (a stretch or a strengthening move).
The following section contains 10 of the most effective exercises that can be incorporated into any health, fitness or athletic program in order to reduce chronic pain and improve function.
1. Golf Ball Roll (SMR)
Rationale. One of the most common musculoskeletal deviations that cause chronic pain is overpronation of the foot—in which the foot flattens and the weight collapses toward the midline of the body. Overpronation can cause the connective tissue that runs along the underside of the foot (plantar fascia) to become irritated and lose its ability to function correctly. Habitual overpronation can cause other structures in the body—like the ankles, knees and hips—to take up the slack caused by the foot not working properly. This can lead to overuse, pain and imbalances in those parts of the body as well.
Movement Cues. Place a golf ball on the underside of your foot. Roll it back and forth on any sore spots for at least 30 seconds to 1 minute once per day.
Progression. Perform the exercise standing up.
Regression. Perform the exercise with a tennis ball instead of a golf ball.
Tip. Encourage the client to perform this exercise while seated watching television.
Precaution. Avoid using too much pressure, as it can cause damage to the foot.
2. Foam Roller Quadriceps (SMR)
Rationale. There are four quadriceps muscles in the upper leg. Three of them run from the top of the leg to the kneecap. The fourth (rectus femoris) runs from the pelvis down to the kneecap and is responsible for helping with hip flexion. When the rectus femoris is tight or restricted, it can cause the hips to remain in flexion when a person attempts to extend the hips to stand upright. Consequently, the individual may hyperextend the lower back in an effort to pull the torso upright. This can place undue stress on the lumbar spine and may lead to chronic lower-back pain.
Movement Cues. Place the foam roller perpendicular to your thigh and lie over it. Find any sore spots and hold your body weight there for a few seconds until the tissues release. Roll each leg for about 1 minute once per day.
Progression. Add a stretch by bending the knee of the leg you are rolling.
Regression. Use a tennis ball on the thigh instead of a roller. Lie down and place the ball under the thigh muscles. Move the ball along the thigh to release different sore spots.
Tip. Focus attention toward the outside of the thigh, near the top (belly of the rectus femoris muscle).
3. Foam Roller Iliotibial Band (SMR)
Rationale. The iliotibial (IT) band attaches the gluteus maximus to the lower leg. When the body is working correctly, these structures work together to help control the leg as it rotates over the foot. However, overpronation causes the ankle and lower leg to rotate excessively over the foot toward the midline of the body (which in turn causes the entire leg to rotate inward). Since the IT band attaches to the lower leg, the excessive inward rotation of the leg can lead to irritation and inflammation in the IT band. This SMR exercise can rejuvenate and regenerate the IT band and take stress off the foot, ankle, knee, hip and lower back.
Movement Cues. Place the roller perpendicular to the side of your thigh and lie over it. Find any sore spots and hold your body weight there for a few seconds until the tissues release. Roll each leg from the side of your hip down to your knee for about 1–2 minutes once per day.
Progression. Stack the legs on top of each other to increase the pressure, or use a harder roller.
Regression. Perform the exercise lying on your side with a half roller (flat on one side).
Tip. A client who overpronates will likely find this exercise very painful at first. Start with a medium-firm roller and adjust as necessary.
Precaution. Do not roll over the knee joint.
4. Baseball on Gluteal Complex (SMR)
Rationale. In today’s environment, people spend more time than ever seated at a desk, watching television or driving cars. As a result of this sedentary lifestyle, the gluteal muscles do not have to work much throughout the day and can become quite dysfunctional and weak. This SMR exercise is designed to recondition the tissues of the gluteal complex to prepare them for progressing to a strengthening exercise later in the program (see “Lunge With Knee Pull”).
Movement Cues. Lie on your back on the floor with knees bent. Place a baseball under your butt on any sore spots you find. Hold the ball still on these spots for 10–20 seconds, for a total of about 1–2 minutes a day.
Progression. Place the ankle of the side you are massaging on the knee of your opposite leg.
Regression. Perform the exercise with a tennis ball instead of a baseball.
Tip. Ask the client to bring a baseball or tennis ball to the session so he can perform this exercise before working out, to loosen up the hips and lower back.
Precaution. Keep the knees bent to avoid hyperextending the lumbar spine.
5. Two Tennis Balls on Upper Back (SMR)
Rationale. One of the most common musculoskeletal deviations that cause chronic pain is excessive thoracic kyphosis (rounding of the upper back). This is usually caused by extended periods of sitting or by chronic stress. When the upper back is too rounded, the neck, head and shoulders fall out of alignment, and chronic pain can develop in any or all of these areas. Furthermore, in the standing position a rounded upper back places stress on the lower back, which tends to arch in order to pull the spine erect. This SMR exercise reconditions the muscles of the mid upper back and promotes extension in the thoracic spine.
Movement Cues. Take two tennis balls and place them on either side of your spine at about mid upper-back height. Bend the knees and support your head with a pillow as you lie over the balls. Gradually tilt your pelvis and flatten the lower back to the ground. Stay still on any sore spots for about 20–30 seconds until they release. Move the balls up your spine toward your neck and shoulders, pausing on any sources of tension.
Progression. Decrease the pillow height (without arching the neck).
Regression. Increase the pillow height or let the lower back arch slightly.
Tip. Have the client use the breath to control the amount of pressure (inhaling to increase pressure and exhaling to decrease pressure).
Precaution. If the client finds this exercise uncomfortable or painful, don’t force it. Begin with a large pillow to control the amount of pressure felt over the balls, and regress as necessary.
6. Calf Stretch (on BOSU® Balance Trainer)
Rationale. Activities such as walking, squatting or lunging require coordinated movement involving many areas of the body. The ankles must be able to bend to allow the legs to come forward over the feet, and the knees to bend when squatting or lunging. Restricted motion in an ankle can cause pain and dysfunction to any number of bodily structures as they compensate. Stretching the calf muscles in all three planes of motion can help the ankle dorsiflex (so the shin comes over the foot), thereby reducing the likelihood of painful compensations.
Movement Cues. Stand on a BOSU ball with one leg in front of the other. Push the heel of the back foot down into the BOSU ball as you stand erect. Keep the heel down and rotate the back leg outward. Now bend the knee of the back leg and rotate the leg inward (heel is still down). Perform 6–10 repetitions once per day on both sides.
Progression. Spread the toes, and push down with the big toe as you bend the knee to help strengthen the medial arch of the foot.
Regression. Perform the exercise standing on the floor.
Tip. Place the BOSU ball in front of a wall for balance.
Precaution. Begin slowly at first, to mobilize the ankle joint and warm up the muscles.
7. Hip Flexor Stretch
Rationale. The majority of muscles in the hip flexor group originate at the lumbar spine, cross the pelvis and attach to the top of the femur (an exception is the iliacus muscle, which originates on the pelvis). When these muscles become chronically shortened from constant hip flexion (prolonged sitting), the lumbar spine tends to be pulled toward the top of the leg and the pelvis drops down and forward. This disrupts correct functioning of the entire lumbopelvic hip girdle and can lead to pain in the lower back and hips. This exercise stretches the hip flexors so that the spine, hips and pelvis move back into alignment.
Movement Cues. Kneel on one knee, placing your other foot in front of you. Lift your torso upright as you tuck your pelvis and contract the gluteal muscles. Feel the stretch in the front of the hip and leg of the kneeling side. Perform this exercise at least once a day for 30 seconds to 1 minute on both sides.
Progression. Raise the arm on the same side as the kneeling leg.
Regression. Round the lower back slightly to reduce the arch in your lower back.
Tip. Keep the center of the hips aligned over the knee so the hips don’t shift to the side.
Precaution. Avoid arching the lower back as you lift the arm overhead.
8. Lying Rotations
Rationale. When a person is walking or playing tennis or golf, the torso should rotate as the arms swing across the body. If the torso does not rotate correctly, the shoulder girdle may experience stress because the arm has to move excessively in the shoulder joint during certain movements, such as the backswing in golf or tennis. This exercise targets the oblique muscles, which wrap around the torso. They originate on the rib cage and attach to the pelvis. This move stretches the obliques to improve torso rotation, thereby taking stress off the shoulder complex and arm.
Movement Cues. Lie on your back with knees bent. Place your arms out to the sides as you lift your legs up over your stomach. Drop your legs to one side while keeping the arms flat on the floor. Perform this stretch once a day for at least 30 seconds.
Progression. Pull down on your knees with your hand to help push your legs to the floor as you rotate.
Regression. Place a pillow between your knees as you drop your legs to one side.
Tip. Use a pillow to support the head and take stress off the neck.
Precaution. If you feel pain in the groin area, place a pillow between the knees.
9. Back Step With Arm Raise
Rationale. Once a client has addressed the localized restrictions in various parts of his body, it’s time to get him off the floor and teach him how to move correctly against the forces of nature (gravity and ground reaction forces). The ability to move correctly while in motion will ensure that the client can perform daily activities such as standing, walking and running without pain. This integrated exercise helps realign and retrain the entire body by combining the calf and hip flexor stretch while strengthening the muscles of the upper back and shoulders.
Movement Cues. Simultaneously step back with your right leg and lift your right arm over your head (make sure your heel hits the ground and try not to shrug your shoulders as you lift your arm). Stand in this position for a second or two as you tuck your pelvis under to help push your hips forward. Return to the starting position and repeat on the left leg while raising your left arm. Perform a total of 6–10 repetitions on both sides once per day.
Progression. Hold a light dumbbell (1–2 pounds) in your hand as you raise the arm.
Regression. Do not lift your arm over your head.
Tip. Keep the foot of your back leg facing forward as you step back.
Precaution. Do not overarch the lower back when raising the arm overhead. The motion should happen by extending the mid upper back.
10. Lunge With Knee Pull
Rationale. As you now know from the golf ball roll, many people with chronic pain have overly pronated feet. Overpronation may be due, in part, to weak gluteal muscles. A very important functional role of the gluteus maximus is to help slow down the leg as it rotates inward over the foot during all weight-bearing activities, such as walking, squatting, lunging and running. This exercise helps strengthen the gluteals so they are better able to slow down the transfer of weight over the foot, thereby reducing overpronation and lessening the pain and impact felt throughout the entire body as a result of weak gluteal muscles.
Movement Cues. Begin in a split stance with your right leg forward. Bend forward at your hips and grab the knee of your right leg with your left hand. Pull your right knee toward the center line of your body while keeping the spine erect and the right hip rotated back away from the right knee. Switch sides. Perform this exercise isometrically to get a feel for the correct movement before progressing to multiple repetitions with movement.
Progression. Rotate your right arm behind you to help rotate the torso.
Regression. Perform the “baseball on gluteal complex” or “foam roller iliotibial band” SMR exercises to prepare the muscles for this movement.
Tip. Rotate the right arm behind to help activate the gluteus maximus muscle on that side, and vice versa.
Precaution. If the hip does not rotate away from the knee, then the hip socket will not be aligned correctly. This may place stress on the hip and/or lower back, so coach the client to keep the hip rotated back as she pulls the knee inward.
Although clients may come to you eager to do plyometric box jumps on the first day, the professional and responsible thing to do is assess each individual’s unique needs. Pain can be an obstacle to movement. Use intelligent corrective-exercise program design to help clients understand and ease their pain as they progress gradually to strength and other advanced exercise parameters. This approach will encourage adherence and build trust in the journey toward optimum health and wellness.