Exercise prescription is at the heart of every rehab professional’s arsenal.  Whether you are prescribing a simple one such as a straight leg raise or something much more complex involving coordination of proprioception and plyometrics, you are intending to help your patients.  There’s a key component that is often missed during rehab however, and when it is, it can limit your effectiveness.  It may even drive your patients to report increased pain with treatment and in the worst cases, it prevents your patient from achieving their goals.

I don’t believe this is intentionally missed in rehab, but it’s something you will rarely see in research and a component rarely focused on in school.  Is your intervention aimed at the wrong impairment?

Let’s start with this example that’s easier to see and then we’ll move onto one that may be a bit less obvious.

Strength/Motor Control Exercise with a Range of Motion Limitation

Often, strength or motor control exercises are prescribed, not realizing the patient has a mobility restriction.  Let’s look at a couple of examples where this is commonly seen:

  • Wall Slide (Serratus Activation Overhead): When a patient performs a wall slide, they are moving into high degrees of flexion, often between 90 and 160 degrees.  In a patient with limited mobility or impingement, this can result in pain. Pain can inhibit muscle activationand therefore may negate the benefits of the exercise.  Even more so, if the patient is experiencing pain due to impingement and you are forcing them into impingement, this is analogous to putting the patient’s fingers in a doorway and repeatedly shutting the door on their fingers.  That’s just plain cruel!  These patients often perform an exercise like the wall wash because it has shown to activate the serratus anterior,but you must remember, these studies are typically performed in non-injured individuals.  It is not bad to prescribe this to a patient, but you need to check both their ROM and pain to properly prescribe it.  A little discomfort is OK, but causing symptoms which last or are more than just mild could slow down your progress.
  • Bird Dog (Opposite Arm Flexion and Hip Extension in Quadruped): Typically this is looked at as an exercise to build core control. It does a fantastic job of it and is thought to focus on improving multidi control.  The issue is, in the absence of further assessment, you may be prescribing it incorrectly!  Have you considered checking for adequate hip extension ROM?  Not just adequate, but good hip extension ROM.  Our bodies are smart and like to move the most efficient or comfortable way possible.  This means, if your hip extension is limited, instead of fighting through the limitation, you are more likely to use compensatory anterior pelvic tilting. You could continue to cue your patient to perform the exercise better, or you could help them return their hip extension motion, THEN cue them to perform it better.  Look at this picture here.  Does he lack hip extension or core control?  We can’t tell and we shouldn’t assume without testing it!
  • Bridges: Knowing what we just talked about for the wall wash and bird dog,
    what may occur with bridges? The same thing as with bird dogs!  When you lock out at the top, if you are lacking hip extension, you either can’t move through the full motion or you will tilt your pelvis and use an excessive lordosis

Bottom line, use exercises like the wall wash, bird dogs, and bridges but don’t make assumptions. If they don’t have the mobility and you can’t regain it quickly, limit the motion of the exercise through what motion they have.  Continue to address the mobility limitation and then immediately use the motor control exercise to reinforce the new motion.

You will see this same sequence with a number of other exercises.  What other exercises can you think of where this occurs?

Range of Motion Exercise with a Motor Control Impairment

What?  This seems to make no sense, right?  Shouldn’t this be obvious?  You’ve probably seen this and not realized it was staring right at you….We’ll cover this in my next post.

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References

  1. Ben-Yishay A, Zuckerman JD, Gallagher M, Cuomo F. Pain inhibition of shoulder strength in patients with impingement syndrome.  Orthopedics.  1994;17(8):685-688.
  2. Hardwick DH, Beebe JA, McDonnell MK, Lang CE. A comparison of serratus anterior muscle activation during a wall slide exercise and other traditional exercises.  J Orthop Sports Phys Ther. 2006;36(12):903-910.