The Functional Approach
by K.D. Christensen DC, CCSP, DACRB
Selecting the ideal exercises for patients with back conditions requires judgment based on clinical experience and scientific evidence. There are several approaches to rehabilitation, and many different types of exercises are available; however, patients have a limited amount of time, willingness, and enthusiasm to exercise. Therefore, we must always try to give our patients the most effective exercises for their condition. But, what are the “best” exercises for Chiropractic patients?
The best exercises for a specific problem are those that will be rapidly effective, easy to learn and perform, and are safe; that is, they don’t worsen the current condition or aggravate other problems. The exercises must help the patient to regain normal alignment and easy, natural movement. And the end result should include a decreased chance of similar, recurring problems.
A successful and appropriate rehabilitative program for the back and/or neck can be designed without the use of expensive, joint-specific equipment. While rehab type machines can be very useful, current active care concepts consider such equipment not an absolute requirement. In fact, the low-tech approach can be very effective for the treatment of most spinal conditions. Additional personnel, fancy equipment, more office space, and extra time are not always necessary. With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, doctors of Chiropractic can effectively rehab their patients with timely in-office instruction and patient performance followed by simple home exercise procedures .
Specific Adaptation to Imposed Demands
The “SAID” concept is one of the underlying tenets of the strength and conditioning field.  It describes the observation that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bodies become stronger. And, if we practice balance and coordination skills, we improve our ability to function easier on unstable surfaces (such as on an incline, rolling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.
It has taken quite a while for those specialists in the treatment of spinal problems to incorporate the SAID concept into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As Chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that an ideal way to help our patients return to normal function is with exercises that imitate as closely as possible the real conditions under which the spine must function day after day. That certainly must include the specific stress of gravity in the upright position.
Kinetic Chain Exercises
When the spine is bearing weight it is part of a closed kinetic chain. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Perhaps more important than the equipment used is whether the spinal support structures are also exercised in an open or a closed-chain position.
Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity). Both floor-based and water-based exercises have some specific usefulness, primarily during the acute stage.
A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles. Augustsson et al. wanted to improve their subjects’ vertical jump height.  Two groups exercised twice a week at maximal resistance – one group doing closed-chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open-chain exercising). At the end of six weeks both groups had gained considerable strength, but the closed-chain exercisers were the only ones who improved significantly in the vertical jump. Since jumping is a closed-chain activity, the SAID concept tells us to expect that closed-chain exercising will likely be more effective.
Functional Position Exercise
We know that the functional origins and insertions of many muscles change when changing position from standing to lying down. Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions. This is why it is also important to bring neck and back rehab exercises closer to real-life positions, and it explains why patients make rapid progress when they are taught to exercise in a functional (upright) position.
Patients initially may need to exercise when lying down. However, continual floor-based exercises do not train muscles and joints to function in upright functional postures. The neurological patterns that are developed on the floor or in a pool may not resolve problems encountered in upright activities. Generally, continually learning new skills and habits on the floor doesn’t translate to better functioning during upright activities And, some patients don’t like to get down onto the floor to exercise, anyway.
By staying up off the floor, exercising in a weight-bearing position is actually easier for most patients. In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities. Patients accept the idea of doing exercises that clearly prepare them for better function during normal activities of daily life.
How to Spot a “Sham” Exercise
When investigators want to test treatments, they always require a “control” group, which is given a treatment that is known to be ineffective. A 1998 study on back pain published in the respected journal Spine taught several popular low back exercises to the control group. As with other studies, the researchers found no improvement using these exercises.  The six exercises considered a “sham” treatment included: knee-to-chest stretches, partial sit-ups (”ab crunches”), pelvic tilts, hamstring stretches, “cat and camel”, and side leg lifts. The problem with these and most other commonly recommended back exercises is that the joints, discs, muscles, and connective tissues are not bearing weight during the exercise; therefore, the movements performed while exercising do not prepare or retrain these structures for daily activities. On the other hand, exercises performed with the spine upright (standing or sitting) against resistance specifically train and condition all involved structures to work together smoothly. Thus, effective exercises are ones that are performed upright, in a closed kinetic chain.
The Value of Balance Exercises
For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance. This means that about five to ten minutes of each workout should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board. The advantage of these balance exercises is seen when athletic patients return to sports activities and can perform at high levels without consciously having to protect their backs. Back exercises done on a rocker board or while standing on one leg can be more useful than those done on a gym ball, since the entire body is in a closed-chain position during the exercises. The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed during closed-chain exercising. This makes these types of exercises very valuable in the long run, particularly for competitive athletes.
Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities. In fact, lower extremity misalignments — such as leg length discrepancies and pronation problems — are frequently associated with chronic pelvis and low back symptoms.  Any of these that are present will need to be addressed in order to resolve the patient’s current symptoms and to prevent future back problems. The use of adjustments, exercises, and custom, flexible orthotics for the lower extremities is especially critical when a functional approach is taken. The effects of weight bearing and the alignment of the kinetic chain must be considered.
Selecting the best exercise approach for each patient’s back problem is important. A well-designed exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitative care. Exercises performed with the spine upright (standing or sitting) specifically train and condition all the involved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their Chiropractic care. Except for brief periods in patients who are acute, caution must be heeded for continual exercises that don’t place patients in real-life, functional positions. While this may require a change in standard procedures, it is consistent with Chiropractic philosophy and treatment approaches. When you persist with this, you will experience dramatic improvements in patient outcomes.
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2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.
3. Snook SJ et al. Reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion — a randomized controlled trial. Spine 1998; 23:2601-2607.
4. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.
Published on www.ccptr.org July 26th, 2003. For more about the author go to http://www.ccptr.org/rehabilitation-specialist/kim-christensen-d-c/