Optimizing healthy living through a systematic program of care ranging from pain relief, rehabilitation, corrective exercise and fitness should be your goal. Bridging the gap between rehabilitation and physical fitness can be a slippery slope if you are not familiar with the underlying principles of corrective exercise strategies.

1. Corrective Exercise
Bridging the Gap between Rehab and Fitness
Perry Nickelston, DC, FMS, SFMA
Chiropractic is not simply about pain relief, adjusting subluxations, and restoring
spinal health. Your obligation as a frontline healthcare professional is to educate,
teach, mentor, and transition your patient’s to an all inclusive healthy lifestyle.
Optimizing healthy living through a systematic program of care ranging from pain
relief, rehabilitation, corrective exercise and fitness should be your goal. Bridging
the gap between rehabilitation and physical fitness can be a slippery slope if you
are not familiar with the underlying principles of corrective exercise strategies.
Ultimately you want clients to demonstrate functional movement patterns with
balance between proper mobility and stability before they engage in strenuous
activities. Without optimum balance and symmetry you are introducing a degree
compensation patterns with increased risk of injury. I am often quite surprised at
how few health care professionals actually use corrective exercise in their
practice. The exercise obtained by patients from performing everyday activities
and functions is often inadequate. Many conditions treated by chiropractic
adjustments could greatly benefit from exercise, as thousands of traumatic low-
backache cases are treated annually by exercises alone.
Corrective exercise is a form of exercise that strives to bring the body back into
perfect postural position. The body is designed to perform at its most
advantageous level when it is in a position of ideal posture and bilateral
symmetry. Corrective exercise is designed to undo mobility and stability
imbalances, thus guiding the body to work in synchronization without pain.
Through Corrective exercise you will be working towards reeducating the body to
move as it was designed so that it can function at its best. Specific movements
improve the body’s biomechanics and remove the negative micro-traumatic
stresses which have lead to dysfunction. Through Corrective exercise you
reintroduce proper function, which in turn restores correct structure. When the
body stops compensating for imbalances, clients are then able to move freely
without restrictions and pain eventually disappears. It all comes down to
movement!

2. Each doctor will develop their own preferred way to look at movement issues
with specialized methods to arrive at solutions based on their practice paradigm.
Unfortunately, highly specialized isolated movement examinations have been one
of the biggest errors in assessing global patterns of compensation. This isolationist
thought process is then carried over into rehab, exercise and fitness. The body
functions as a whole. The anatomy books have it wrong. The body does not
simply function with action from an origin to insertion point. Everything is
interconnected and one area of dysfunction will cause a compensation and
myriad of symptoms somewhere else. Correctives combine the scientific
principles of biomechanics, physics, motor control and human physiology to
correct the cumulative stress of life. Even very small structural changes, if they
occur over time, alter the muscles and joints ability to perform properly. This is
because no muscle works alone; each is connected to another part of the body.
Because Corrective exercise focuses on fixing the cause of pain, instead of just
addressing symptoms, it works where many other remedies fall short. So even if
you’ve tried everything else to help a client feel better, now is the time to
introduce an effective strategy to pain relief.
Healthcare and fitness practices often neglect fundamental movement, paying
too much attention to the superficial obvious. Weakness and tightness are often
attacked with isolated and focused strengthening and stretching protocols that
don’t work. The majority of musculoskeletal pain syndromes both acute and
chronic are the result of cumulative micro-trauma from stress induced by
repeated movements in a specific direction or from sustained misalignments. The
body develops a motor learning pattern for improper movement. Without
corrective exercise designed to teach the proper motor control patterns, patients
will often develop bad technique from inferior neuromuscular coordination and
compensation behavior. For example, when someone complains of chronic knee
pain we are quick to find solutions to treat, rehab, and exercise the knee.
However from a corrective exercise perspective we want to address movement in
the entire kinetic chain from, ankle, hip, core, thoracic spine and bilaterally
symmetry. This is a much more all inclusive full body system for exercise and long
term benefits of functional movement.
The number one risk factor for musculoskeletal injury is a previous injury,
implying that current rehab standards are missing something. Current medical
and rehabilitation programs can manage the pain and symptoms resulting from
an initial injury, but they have less ability to influence the likelihood of a

3. recurrence. Don’t let this be you. Gray Cook, MSP, states, “Your commitment
should be not only to manage the painful episode, but also target and contain the
risk factors. It is important to separate pain with movement from movement
dysfunction. It is possible to move poorly and not be in pain, and it’s possible to be
in pain and move well. A licensed healthcare professional experienced in
musculoskeletal evaluation and treatment should address pain with movement
regardless of fitness ability.” Corrective exercise is the great equalizer. It allows
you to do exercise with clients in non-painful dysfunctional areas to help alleviate
the pain. Above all, we must remember that the muscle holds the skeleton in
place. Many conditions, both chronic and acute, cannot be permanently cured
unless and until the damaged, distorted, or weak muscle is built up to normal
strength and tone.
Many professionals do have an appreciation of function and yet they still persist
in an anatomical approach to exercise by training bodyparts instead of movement
patterns. Choosing exercises based on symptoms is not alleviating the true cause.
This is in agreement with the entire chiropractic paradigm of taking care of the
whole body, rather than simply isolating painful regions. When it comes to
corrective exercise and movement dysfunction not everything is as it appears.
You cannot make assumptions about what the body is trying to tell you simply by
looking on the surface. You must think further outside of the proverbial box.
For example:
 What you see on evaluation as weakness may be muscle inhibition. So
strengthening the weakness will make no lasting change in function. If
anything you might worsen the condition.
 There are always two sides to every coin. What you see as poor function in
an agonist may actually be problems with the antagonist. If positive
changes are not made within several visits flip the coin and look on the
other side.
 Weakness in a prime mover might be the result of a dysfunctional
stabilizer. Don’t be so quick to blame the big muscles that are always in
spasm. Look deeper at the underlying stabilizer culprits. A prime example is
constant spasm in the upper trapezius from lack of stability in the scapulae.
 Tightness and stiffness may be a neurological protective mechanism of the
body to increase tone for stabilization. Stretching stiffness will often lead to
further tightness and injury. The body will increase tightness as a guarding

4. mechanism or alternative to inadequate muscle coordination. Those
hamstring muscles that are always tight, is a classic case of stiffness due to
lack of stability elsewhere.
Following are some essential paradigm components to understanding corrective
exercise.
 The body follows the law of physics and takes the path of least resistance
for motion, which contributes to hypermobility and lack of stability.
 Joints tend to move in a specific direction which contributes to the
development of movement patterns.
 Your evaluation should include tests and assessments of ALL regions of the
body, including determination of how all regions affect the movement of
the painful joint because of the biomechanical interaction of the body.
 Functional exercise is not about how it looks, it’s about the results you get
from the movement. Keep it simple, basic, and foundational to make the
largest impact.
 The critical component is how the exercise is performed, not just
performing it. Choose quality over quantity, by teaching ‘intent’ of
movement. Explain to the client ‘why’ you are having them perform the
exercise. Teaching a client how to move in patterns significantly reduces
the chance of injury.
 An exercise is not effective unless the exercise limits or corrects the
movement at the painful joint and produces the desired appropriate
movement at surrounding joints.
Let’s take a look at some brief examples of the corrective exercise thought
process in action.
Shoulder pain: Performing the obligatory internal and external rotator cuff
resistance exercises will do little to enhance shoulder stability. Instead focus on
thoracic spine rotation and scapular stability.
Knee pain: Knee extensions and hamstring curls are the pinnacle of isolation
movements. Instead focus on hip and ankle mobility. Pay special attention to hip
stability and glutei muscle activation with rotational vector patterns.

5. Neck pain: Active range of motion exercises will only get you so far. Instead zero
in on thoracic spine extension and rotation patterns. Focus on pelvic rotation
determining if there is an anterior or posterior shift compromising the kinetic
chain. Inner core exercises are paramount. And don’t forget the diaphragm.
Back pain: It’s more to strengthening the back than just working the abdominals.
Hip function is paramount to back mechanics. If you lack mobility and stability in
the hips your back will pay the price. Check the joints above and below for proper
functional control during basic patterns of movement. All corrective exercise for
the back should involve the hip and glutei.
Principle Action Steps:
Prioritize restoring and maintaining lumbo-pelvic stability. If you don’t, the
adaptations up and down the kinetic chain will persist no matter what exercises
you use with patients. Many times you will have to start simply with floor
exercises in supine, quadruped, and sidelying to teach clients how to recruit the
core musculature, especially the external oblique, and hold pelvic
position/neutral lumbar spine. Most core exercises tend to be rectus abdominis
dominant. This dominance often gets ignored because everybody wants strong
abs and the faulty pattern gets reinforced.
Emphasize the posterior chain since it is often a neglected component of
movement. Deadlifts, low cable pullthroughs, and even back extensions can have
corrective properties if proper movement patterns such as hip extension are
reinforced. Don’t be afraid of deadlifts either. When implemented at the right
time and with proper coaching of hip hinging a deadlift is one of the most
effective exercises for injury prevention.
Split stance exercises like split squats, Bulgarian split squats, and reverse lunges
allow patients to work on hip mobility in hip flexion and extension as well as
improving stability. Asymmetrical loading is a great way to enhance trunk
stiffness/pelvic stability that you’ll need to gain hip extension mobility. Also
include a little bit single leg stance activity. It’s not about getting incredibly strong
on a single leg but more about increasing stability. Your primary exercises should
be double leg, yet single leg movements add a nice unstable training variable.
Start focusing more on function as opposed to structure. Karel Lewit, MD, said
“The first treatment is to teach the patient to avoid what harms him.” Begin laying

6. your foundation for corrective exercise from the very first patient visit by noting
history, work habits, activities of daily living and current fitness level. All of these
components will be critical to the design matrix of your corrective exercise
strategy. Every exercise you prescribe is a test of how well your rehabilitation
program has prepared the patient for movement. Remember the brain thinks in
terms of movements, not individual muscles so become attune to each patient as
an individual. No cookie cutter exercise program will work for you in the world of
corrective exercise, so take the necessary steps to learn proper application.
Stopchasingpain.com
References:
1. Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and
Corrective Strategies. Santa Cruz, CA: On Target Publications, 2010. Print.
2. Sahrmann, Shirley. Movement System Impairment Syndromes of the Extremities, Cervical
and Thoracic Spines. St. Louis, MO: Elsevier/Mosby, 2011. Print.
3. Carey, Anthony. The Pain-free Program: a Proven Method to Relieve Back, Neck,
Shoulder, and Joint Pain. Hoboken, NJ: J. Wiley, 2005. Print.
4. Hartman, Bill. Web. 20 Feb. 2011. Boston Sports Medicine and Performance Group on
Sun, Jan 23, 2011 http://www.bsmpg.com/articles---resources-0/bid/51990/
5. Liebenson, Craig. Rehabilitation of the Spine: a Practitioner's Manual. Philadelphia:
Lippincott Williams & Wilkins, 2007. Print.