The human body reacts positively to the increased stresses placed upon it. As one of the basic tenets of physical rehabilitation, this is the whole reason we command muscles to lift more weight, tendons to pull more tension, and joints to undergo more movement. In order to develop and improve our physical capabilities, we place increased, yet controlled stresses on our bodies. Paradoxically, however, increased physical stress often is the cause of symptomatic conditions and physical breakdown. What is the difference? Actually, several have been identified.
Progressive overloading of responsive tissues is, in essence, the principle that underlies the benefits of exercise training. Benefits that accrue as the body's normal recuperative processes respond and improve in function include increased strength and endurance, better flexibility and improved coordination. Our goal is to stimulate these beneficial improvements while avoiding any errors that might place excessive strain on the involved tissues. Proper instruction, continued monitoring and specific corrections are necessary factors preventing overload injuries.
A Trio of Errors
There are three categories of exercise errors that indicate excessive loading of involved tissues. Most problems with exercises are associated with a "loss of form."1 This somewhat nebulous phrase can be defined as consisting of three problems: postural imbalance, misalignment and movement restriction. By paying attention to our patients as they perform their exercises, we can identify these problems early on and make the appropriate recommendations.
Postural Imbalance. Look for any abnormal or imbalanced postures during exercising. Whether the patient is strengthening, stretching or walking, hyperextensions and lateral shifts indicate an overload situation. This easily is seen during cervical training, when patients strain and push their heads forward instead of maintaining a balanced alignment throughout their specific exercises.
Misalignment. The more subtle deviation of misalignment during exercising relates primarily to the extremities. This can be noticed particularly in the feet (toe-out), ankles (excessive pronation), and knees (knock-knees). These are all indicators that additional exercising in these conditions likely will bring about a recurrence of symptoms, rather than improvement. Addressing the misalignments and asymmetries are paramount for progress and may require custom-made stabilizing orthotics.
Movement Restriction. Any limitation in range of motion during an exercise should prompt a search for the underlying cause. This may be a reasonable, self-protective response due to recent injury or (more commonly) an inappropriate fear response. It is also possible that the patient is placing excessive loads on sensitive tissues incapable of handling that amount of stress in their current state.
A Quintet of Solutions
Excessive loading, whether of resistance, flexibility, endurance, or proprioceptive exercises, is never helpful and can be counterproductive. There are Five solutions all starting with the letter "R." They are: Rest, Range, Rate, Resistance and Repetitions.2
Rest. By increasing the rest period between exercises or between sets, we allow the body to recharge and to handle better the overload. This is often the simplest of the solutions, as sufficient rest is frequently all that is needed to avoid rehab overload.
Range. Controlling the range of an exercise or a stretch may be needed, especially in the initial phases of rehab. Particularly after an injury, connective tissues may be easily aggravated by forcing too much range. This is where the body can often let us know when we have gone too far, since it will give us a pain message. Initially, we should recommend that exercises be performed only within a pain-free range of motion.
Rate. Slowing down the pace of an exercise and incorporating a relaxed breathing cycle often will reduce exercise stress significantly. In fact, slow and controlled exercising stimulates more neurologic control and retraining without overstressing tissues.
Resistance. Whether using exercise bands, weights or machines, careful control of the amount of resistance is important. Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation.3 However, excessive resistance can quickly produce the problems in posture, alignment and range of motion described above, resulting in a poor response to care.
Repetitions. Finally, one of the easiest ways we can overload our patients is to recommend too many repetitions of too many exercises. It is far better that a few repetitions of a few exercises be done regularly and consistently, interspersed with sufficient rest.
When we keep our eyes peeled for the three types of "loss of form," and then carefully control the "five Rs" of rehab training, we can avoid exercise overload and ensure a smooth response to chiropractic rehabilitation training.
References
- Mullineaux M. Strength conditioning: developing your teaching technique. Strength Cond J 2001;23:17-19.
- Mullineaux M, Rowe L. Manipulating training variables for safety and effectiveness. Strength Cond J 2003;25:33-36.
- Niesen-Vertommen SI, et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992;2:109-113.
