Corrective Exercise: Coming Full Circle
From medical gymnastics to proprioceptive neuromuscular facilitation to self myofascial release and beyond, corrective exercise continues to help humans with physical dysfunction.
The practice of corrective exercise is booming. At the 2007 IDEA World Fitness Convention™, more than 30 sessions were based on structural assessment and corrective exercise. All the top certifying organizations offer a bevy of continuing education courses on corrective exercise. Even clients are beginning to understand that their end goal may require customized corrective-exercise techniques, which may mean taking a step backward before moving forward.
It’s no wonder that corrective exercise is so popular. In the United States alone, musculoskeletal conditions account for approximately $254 billion a year in associated healthcare costs, lost productivity and medical research (United States Bone and Joint Decade 2002). This means that human dysfunction, malalignment and associated pain cost the U.S. more than $695 million per day. Certainly these conditions weigh heavily on the economy, but—more importantly—their profound and dramatic effects are causing many people to suffer.
The upside is that musculoskeletal pain issues are firmly and squarely in the spotlight. Consequently, more and more qualified professionals are entering the corrective-exercise and fitness arena. World-renowned physical therapists, exercise physiologists, doctors and biomechanics specialists are bringing quality research to the fitness and wellness industry—and as a result, business is booming.
Fitness professionals interested in exploring and/or expanding their involvement in corrective exercise can benefit from taking a look at its possible origins and at how it has developed over the years. From this solid foundation, it is easier to build for the future and continue to help clients improve their overall function.
Charles Darwin proposed that we have evolved as a species through a process of natural selection, by which favorable traits and characteristics are passed on from one generation to the next (Darwin 2002). This continual adaptation process ensures that humans are best suited to deal with their ever-changing environment.
Man began walking upright around 5–6 million years ago (Tomkins 1998). This accomplishment may have offered a more efficient way to hunt as the environment changed and food sources became scarce. Alternatively, it may have freed humans’ hands to use more advanced tools, or it may have been an attempt to reduce sun exposure. Although we may never be sure why man began walking upright, we do know that this adaptation made life easier and more efficient (Tomkins 1998).
Many important skeletal adaptations occurred as humans began to move upright on two limbs. We developed a lumbar curvature in our lower spine so that we could lift the torso on top of the pelvis. More weight on the pelvis and feet caused the back of the pelvis (ilium) to become thicker, flared and more stable. The talus bone in the ankle became more robust and solid. The foot developed a system of arches to further help the body absorb shock. The skull also changed to better accommodate an erect posture (Campbell 1973).
At the same time, the muscular system developed to assist with stability and propulsion. When apes stand on two legs, they cannot fully extend their hip/leg complex with their gluteus maximus muscles. They end up in a bent-hip and bent-knee position that resembles an awkward partial squat. However, as humans routinely began to stand on two legs, they had to extend—and sometimes hyperextend—their hips and legs. This resulted in a larger, more functional gluteus maximus muscle.
As humans became smarter and more efficient at using tools, they moved less and their specially adapted bodies started doing less of what they were designed to do.
People began to cultivate food, which meant less roaming and more repetition of the same movements in a sedentary position (Ishida et al. 2006; University of New Mexico 2007; Bridger 2003). As tasks became more specialized and the need for productivity increased, movements were further limited and postures were repeated continually throughout the workday. This resulted in humans becoming more physically dysfunctional.
Early civilizations recognized the potential harm such physical dysfunction could cause and took steps to counter it. One of the first structured methods of exercise—cong fu (a precursor to kung fu)—was developed in China around 2,600 BC as a form of medical gymnastics aimed at keeping the body conditioned (Rice 1958). People practiced various stances and poses to align the body, mind and spirit. Around the same time (or even earlier), in India, yoga emerged as a form of body-mind-spirit exercise. And the early Greeks also recognized the benefits of performing regular, structured exercise routines. What’s more, during these same periods in China, India and Greece, massage or therapeutic-touch techniques were developed to help treat disease, relieve stress and improve function (Cassar 2004). In the Persian Empire massage techniques were used to relieve the pain of certain conditions after diagnosis.
Over the 3,000–4,000 years after cong fu emerged, various forms of exercise continued to develop. However, exercise modalities designed to help with specific dysfunction did not become prominent until the late 19th and early 20th centuries (Dreeben 2007). These exercise forms, which laid the foundation for what we now call “corrective exercise,” became widespread largely in response to the Industrial Revolution and World War I (Hinshaw 1948).
World War 1 continued to increase the demand for automated production processes, but also brought the challenge of how to treat the many injured war veterans. The first “modern” practice of physical therapy was developed in London in 1896 in response to this need (Hinshaw, 1948). Soon thereafter, the shift from physical therapy to “corrective exercise” began in earnest.
Corrective-exercise techniques have developed over the years thanks to the work and influence of many people and methods. Here is a sampling of some of these influences.
Yoga and Tai Chi
Although yoga was not developed specifically for corrective means, its guiding principles are important to the teachings of corrective exercise (Claire 2003). Yoga poses are designed to facilitate an inward focus on breath and movement. This focused self-awareness is a fundamental tool used by experts today to retrain patterns and create movement awareness. Similarly, tai chi is based on softness of movement and on learning to yield to external forces. Tai chi also focuses on movement awareness, and it strives to teach the student to slow down the force of gravity so that movements flow and interact softly with the contact surface of the ground.
During World War I, Joseph Pilates, a German national interned in England, began developing a system of movements designed to help bedridden patients exercise against resistance. He crafted equipment out of springs from hospital beds, using principles that still underlie the spring tension system used in modern-day Pilates equipment (Isacowitz 2006).
Pilates drew from studies in Eastern practices, such as yoga and Zen, and was well trained in anatomy and physiology (Thompson 2007). He promoted the idea of a body-mind connection with an emphasis on breathing, control, precision and concentration. His methods stressed quality rather than quantity of movement. The exercises focused particularly on muscles such as the abdominals, pelvic stabilizers, gluteals and spinal extensors—much of the musculature that we refer to today as “the core.”
In 1926 Pilates moved to the United States and married Clara, whom he had met on the boat. Together they popularized his program, particularly among dancers. By the 1960s it was being used for warm-ups and dance training all over the U.S. Pilates had many followers and students who subsequently opened their own studios, adding their twists to the method along the way. Today, more than 10 million people worldwide practice Pilates (Thompson 2007).
As Pilates was gaining popularity, a technique developed by F.M. Alexander was also becoming known. Alexander was an Australian-born actor who had suffered from respiratory ailments as a child (Alexander 2000). In an attempt to cure his physical limitations—chronic hoarseness was interfering with his stage performances—he began paying close attention to his body and breath. He noticed that under stress the body reverted to unconscious movements that restricted breathing and other motor functions. Alexander was well educated in the workings of the brain and nervous system. This helped him develop a technique for consciously reprogramming movements by focusing on sending the right signals to the right muscles.
During the early to mid 1900s, Moshe Feldenkrais, who hailed from what is now Ukraine, developed an exercise system to retrain and correct movement imbalances. Feldenkrais practiced jujitsu and judo, and also devised his own self-defense techniques (Reese 2001). His method, based on “awareness through movement” (Shafarman 1997), taught people how to retrain injured or dysfunctional body parts by first becoming more mindful of their movement patterns. Feldenkrais had studied with Alexander and undoubtedly incorporated many of the Alexander principles into his own work.
Massage has been around for millennia. The medical community formally brought massage into its fold in the mid 1800s. Swedish massage became very popular, and many techniques from that time are still used today. Finnish and Russian influences further expanded the use of massage into sports and neuromuscular therapy.
In the 1950s Margaret Knott and Dorothy Vass developed an advanced stretching technique called proprioceptive neuromuscular facilitation (PNF), which helped improve flexibility and strength (McAtee & Charland 2007). When coupled with massage, PNF is a great technique for correcting movement imbalances and/or restrictions in the soft-tissue structures of the body.
One popular form of massage used for corrective means today is “self myofascial release.” This technique can be credited in part to Janet G. Travell, MD, White House physician during the Kennedy and Johnson administrations. Kennedy credited Travell with helping eliminate the terrible myofascial pain he experienced during his political career (Neckman 2007). Self myofascial release involves using a foam roller, a ball or some other specialized equipment to pinpoint and alleviate restrictions, pain or dysfunction in the muscular and fascial systems of the body.
Thomas Hanna, PhD
Thomas Hanna received training from Moshe Feldenkrais and became an expert in the teachings of the Feldenkrais Method®. In 1976, he developed Hanna Somatic Education®, which focuses on training body-mind integration (Hanna 2004). Somatic education teaches the individual to take responsibility for the process of retraining the body while learning to master both physical and mental stressors. Hanna, who died in a car crash in 1990, proposed that the body adapts to protect or ready itself against daily stressors and that over time our neuromuscular system can no longer relax (see the sidebar “Red Light, Green Light” below for more information).
Paul Chek, founder of the California-based C.H.E.K Institute, is a corrective and high-performance exercise coach who has developed a unique holistic approach to corrective exercise that considers physiological, biological, sociological and psychological factors. This is an advancement in the approach to corrective exercise, as it places primary emphasis on evaluating the underlying nonphysical causes of physical dysfunction (Chek 2005). In trying to scientifically prove the validity and effectiveness of corrective exercise, Chek developed and patented calibrating devices for measuring components of posture. This has helped prove the distinct benefits of corrective exercise.
Many other notable and respected fitness professionals are currently meeting the demand for corrective-exercise education and information. While by no means an exhaustive list, people such as Anthony Carey, MA; Gray Cook, MSPT; Gary Gray, PT; Lenny Parracino; Greg Roskopf, MA; and Chuck Wolf, MS, have added depth and integrity to this growing area of fitness and wellness with their well-researched and effective approaches.
We can extract several important lessons from the many years humans have used corrective-exercise modalities to relieve stress, improve function and decrease pain. As a group, fitness professionals who take the time to explore options and become better educated stand to make a lasting difference as people continue to need help with their dysfunctions. The following are key areas in the big picture of corrective exercise. Each stands on its own as an important aspect of training; combined, they form a powerhouse of knowledge and expertise.
Biomechanics. Evolution theories have suggested that as humans went from being quadrupedal to bipedal, certain biomechanical adaptations developed to make this progression possible. Whether one believes in evolution or not, the human body is designed to stand upright on two feet and to have an enormous degree of mobility. It is therefore essential for fitness professionals to understand human anatomy, physiology and biomechanics so that exercise can facilitate these basic human processes.
If you are applying biomechanics to corrective exercise, you should know the origin and insertion points for all the major muscle groups and be able to assess all the prime movements of the body. For example, when a client performs a squat, you need to be able to identify whether or not she is performing the movement correctly. Maybe one of her hips is “hiking” to one side, causing her knee to bow inward. If you know that the mobilizing muscles of the gluteals, quadratus lumborum, psoas major (a hip flexor muscle), abdominals, rectus femoris, adductors, tensor fasciae latae and lumbar-spine erectors (to name a few) are all responsible for both motion and stability during hip flexion, then you can design exercises that will address these muscles and correct the movement imbalance.
Assessments. Yoga and tai chi practitioners assessed both human and animal movements to better understand the most efficient and least stressful ways to move. In recent times, physical therapists and exercise physiologists have developed protocols to assess structure and movement. Today, these protocols are paramount to the success of any corrective-exercise program. An understanding of biomechanics teaches us where things should be, and an assessment tells us how far we are from that goal.
On a practical level, your assessment should include a verbal aspect so you can find out what a client has done in the past or is currently doing that may be aggravating his condition. You should then perform a visual assessment of all the major areas of the body (i.e., feet and ankles, knees, lumbopelvic-hip girdle, thoracic spine and shoulder girdle, and head and neck) to see what looks out of alignment. Next there should be a hands-on assessment to confirm or deny what you have seen during your visual assessment. Your hands-on assessment might include structural assessment protocols, tests for ranges of movement and muscle testing. If you feel comfortable performing movement or kinetic-chain tests, such as gait analysis, do this after you have assessed the individual structures during the hands-on portion of the assessment.
For example, perhaps a client presents with knee pain and you discover during the verbal assessment that he is an avid gardener and kneels for 6–8 hours per week. This could be irritating the patella and affecting the success of his corrective-exercise program. Furthermore, during the visual and hands-on assessment you discover that his foot overpronates, causing his knee to move toward the midline of his body. You note that this deviation would cause the knee to be out of alignment when he is walking or squatting in the garden. When you observe his gait pattern, you confirm that this does happen. Now you are armed with the information you require to begin designing exercises that will help correct these imbalances.
Exercise Principles. There are three basic components of corrective exercise, the values of which were established and recognized centuries ago: massage, stretching and strengthening (Alexander 2000; Coulter 2001; Shafarman 1997; Hanna 2004; Worthington 1982).
Massage is of utmost importance for helping restore soft tissue to a healthy state. Stretching facilitates range of movement and alignment. Coordinated strengthening exercises help reteach movement cues between the brain, the nervous system and the rest of the body.
For example, if a physical therapist has diagnosed plantar fasciitis in a client, you will probably identify some causal factors. When the foot flattens or pronates, the arch may collapse, placing stress on the underside of the foot. As a result, this client probably overpronates. When this happens, the heel of the foot will collapse inward, placing stress on the tissues that attach to the heel (i.e., the calf muscles by way of the Achilles tendon). Therefore, the first step would be to rejuvenate the damaged tissue on the underside of the foot by massaging it with a golf ball or similar massage tool. You could also teach the client how to self-massage the calf muscle. These massage techniques would be followed by stretching the calf and then by strengthening the arch of the foot and anterior calf to prevent the foot from collapsing and reinjuring the area. Eventually, you’d add coordinated weight-bearing exercises to address the entire lower-kinetic chain in order to keep the client aligned from the hips down to the feet.
Teaching Principles. Two very important teaching principles have been stressed throughout the history of corrective exercise: awareness and intention. Feldenkrais said, “If you know what you are doing, you can do what you want” (St. Cyr 1995). In essence, you can have all the best corrective exercises in the world, but if you don’t teach your client to feel what she should do and to have the intention to perform the movements correctly each time she does them, then your training will never be successful.
For instance, let’s say a hands-on foot and ankle assessment shows you that a client overpronates. You teach her how to perform the hands-on assessment for herself so she will know how to get her feet and ankles into a neutral position when you are not around to coach her. Armed with this skill she will soon become aware of what it feels like to have her arch slightly raised into a more neutral position, avoiding overpronation. In teaching the client how to find neutral, you also make her aware that as the foot overpronates, the knee buckles inward toward the center of the body. If this client had originally come to see you because of knee pain, she might now be more aware of how her overpronated foot was affecting her knee alignment. Now she has a reason and an intention to align her foot and ankle, because she knows that this directly impacts her knee.
Now that we know where corrective exercise has come from and what history has taught us, where do we go from here? Computer use, technological advances and improved efficiency mean we all attempt to perform beyond our means. This kind of pressure has devastating physiological and psychological ramifications. As a result, corrective-exercise specialists will continue to recognize the value of psychological assessments, and life-coaching is sure to become increasingly popular in future corrective-exercise programs. Life coaching’s current rise in popularity in the fitness setting is an excellent indication of how clients and fitness professionals alike are seeing the advantage of using coaching to improve function and performance—both physical and mental. Fitness professionals interested in specializing in corrective exercise stand to greatly enhance the effectiveness of their services by taking coaching courses or partnering with someone who is already certified as a coach.
Technological advances will also impact the corrective-exercise realm. It is likely that technology will be used to develop more accurate assessments and to help clients learn more quickly (through means such as body-imaging software and biofeedback equipment). A number of companies have already developed sophisticated Web-based assessment protocols designed specifically to address low-back pain and other chronic alignment conditions.
Although corrective exercise has been around for a long time, the journey is just beginning. It took humans millions of years to stand upright and only about 100 years to spend most of the day hunched over again at the computer, driving or watching television (Hinshaw 1948; Mokyr 1985). It is not unrealistic to assume that in the next 50–100 years most adults will require corrective-exercise strategies to prepare them for a regular exercise program. Corrective exercise will no longer be an adjunct to exercise, but a prerequisite.
In a sense, we have come full circle. We have become so efficient at not using our bodies for the purposes for which they were designed that we are almost back to where we started—learning to stand upright again! Lessons from history, however, have put us ahead of the game. Our industry provides us with the knowledge and expertise to keep people functioning and performing as nature intended. Continuing to develop our skills as teachers means that everyone will benefit.
Here are three very popular corrective exercises. Each exercise is described according to how it might have developed and how it is pertinent to helping clients achieve better alignment and function.
Foam Roller for Gluteals
Massage has long been used to help heal the soft-tissue structures of the body. So it’s not surprising that self myofascial massage techniques performed with a foam roller are very popular in the corrective-exercise setting. The increasing amount of time we spend in a seated position each day means we no longer fully extend our hips and legs as nature intended. Consequently, the posterior hip and gluteal musculature gets used incorrectly—some muscles are overworked, while others atrophy. Using a foam roller on the gluteal complex can rejuvenate this area and keep it healthier.
How to Do It: Sit on the foam roller with one ankle balanced on the opposite knee. Roll weight onto the buttock that’s on the side of the lifted leg and apply pressure to any sore spots in that buttock. Have clients perform this exercise once per day for 1–2 minutes each side.
Hip Flexor Stretch (With Rotation)
Hip flexor stretches have appeared in corrective-exercise programs since the origination of yoga and cong fu. For example, the warrior poses in yoga emphasize hip flexor flexibility as the student progresses through various planes of movement (Coulter 2001). Hip flexor stretches are particularly important in corrective-exercise programs because of the excessive amount of time we spend in hip flexion sitting down. Stretching the hip flexors can reduce the forward pull on the lumbar spine, thus reducing the possibility of excessive lumbar lordosis (a common cause of back pain).
How to Do It: Kneel on one knee with the other foot in front for balance. Tuck the pelvis under, using the gluteal muscles and abdominals to assist with the movement. Raise the arm on the same side as the kneeling leg to increase the stretch. Hug yourself around the shoulders, and rotate the torso over the front leg. Hold the stretch for about 30 seconds and repeat 6–8 times. Ask clients to do at least one set per day on each side.
Body-mind programs emphasize balance, coordination and weight transfer to correct movement deviations. Science has helped us better understand the body’s systems and the degree to which muscles need to coordinate with one another to facilitate balance and weight transfer. A good example of this is seen in the single-leg squat.
When someone squats on one leg, the gluteal muscles of the standing leg work eccentrically to slow down both hip and leg motion. As the person begins to rise out of the squat, the glutes extend the hip/leg complex in order to return the body to an upright position. At the same time, when the person lowers into a squat, weight is transferred forward in the foot and ankle, and as he stands up, weight settles back into the heel. It is imperative that you understand the coordination and timing of this movement so you can help clients learn to transfer weight properly—as is necessary, for example, when walking.
How to Do It: Stand on one leg and squat down by bending at the ankle, knee and hips. Slow the foot motion down with the muscles of the foot and calf, and the hip motion down by engaging the gluteal muscles. Extend the hips and legs and raise the arch of the foot back to its neutral position as you return to the starting point. Clients should perform 1–10 repetitions, 1–5 times per week, depending on the goal.
Thomas Hanna, PhD, who created Hanna Somatic Education, taught that the neuromuscular system has two basic responses to stress. He called these responses the “red-light reflex” and the “green-light reflex.” The red-light reflex, also known as the startle response, is the sustained adaptation of the neuromuscular system to negative stress. For example, if you feel threatened, your body draws inward to protect itself from the stressor. You tighten your abdominals, round your shoulders forward, clench your jaw, narrow your eyes and push your head forward. It’s as if you just had been punched in the stomach. The red-light reflex contracts the spinal flexors.
In contrast, the green-light reflex contracts the spinal extensors. It is responsible for readying the body and preparing it for action. An example would be a soldier standing as tall as possible, ready to respond to a challenge. It is important to be aware of these instinctual responses, as they demonstrate the need to incorporate stress reduction practices into corrective exercise.
Justin Price, MA, is a corrective-exercise specialist and the co-owner of The BioMechanics in San Diego. He was the 2006 IDEA Personal Trainer of the Year and serves as IDEA’s national personal training spokesperson. Price has taught thousands of people his assessment and corrective-exercise methods through his educational programs, presentations, writings and DVDs.
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