Author:Satya Khan

Crossfit – Not So Bad

There is a lot of conflicting information in the rehab and strength and conditioning world. Look no further than the message boards on any popular blog or facebook page and you will see disagreement. Sometimes it’s even hard to find conclusive information in the research. And for people who don’t spend their lives immersed in this field, it’s downright confusing. I’m here to tell that if you’ve ever given advice to someone, you were probably wrong.

While the healthy debate of ideas in our field is essential to growth, problems arise when conflicting information leaves people confused. It doesn’t help us reach a larger audience, get more people exercising, and positively influence our clients, athletes, and patients. I’m sick and tired of hearing people say “but my trainer said you *have* to do this…”

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Corrective Exercise

Remember when the term “corrective exercise” came into vogue? It was the smart man’s way to exercise. Trainers were energized by the wave of new information and everyone started looking for flaws that needed correcting. Although corrective exercise has it’s place, I’m going to look at the problems with a widespread focus on corrective exercise and use 17 articles to back my claims.

ALL exercise is corrective. When exercise is done correctly it causes positive adaptations.

Most everyday aches and pains respond well to non-specific exercise. We don’t always need complex corrective exercise plans based on biomechanic assumptions.

Cases that require actual corrective means should be referred to an injury specialist. While corrective exercise may be beneficial here, there may be potential deformities or pain that would benefit from manual therapy, medication, bracing, orthoses, or even surgery.

Don’t forget the KISS principle (keep it simple stupid!). Because sometimes exercise is as simple as strength, activation, and blood flow. All well programmed exercise is corrective. ALL OF IT!

For some populations, an exercise as simple as step-ups is “corrective” and helps to attenuate age related atrophy. Research on males 70 y/o has shown that increasing daily step frequency by adding in a high repetition low load unilateral resistance training program causes increases in muscle protein synthesis (1).

Now I’m not a big fan of the leg press, we don’t have one in our clinic. But for post-ACL patients, adding it to their program has been shown to be corrective. During ACL rehab, adding a functional squat machine from weeks 4-15 has been shown to increase week 15 measurements of quadriceps, hamstrings strength and increased score on functional measures such as single leg distance and vertical jump (2). To clarify, the functional squat machine does not qualify as a squat in my eyes.

Everyday movements and basic exercises are corrective when they are applied correctly. You don’t need to be Gray Cook to use corrective exercise.

Many aches and pains respond just as well to non-specific exercise programs. A recent study http://www.ncbi.nlm.nih.gov/pubmed/26247548 showed that rock climbing was an effective exercise to help reduce chronic back pain (4). I wonder if that ever occurred to the low back pain corrective exercise specialists? (drops mic and walks out…)

Research on low back pain has demonstrated previous lifestyle, exercise, and confidence in treatment to be large predictors of disability and function (5).

Although there are some well substantiated directional preference treatment approaches for low back pain, these fall under the category of rehabilitative or therapeutic exercise (3).
This is where the ever blurring distinction between therapy and training starts to come into play.

• The greatest predictor of non-specific chronic low back pain is exercise, and it’s not specific to core exercise (6). For sedentary workers, a 1-year walking program was shown to be a protective factor for reducing neck pain (7).
• So when you’re addressing pain, don’t always assume something structural needs correcting, sometimes you just need to get it moving.

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An example when correcting is actually necessary: chronic ankle instability.

• Chronic ankle instability is associated with neuromuscular changes and poor postural stability (10). Postural control exercises have shown benefit in the treatment of chronic ankle instability (9). Although this is a perfect case for corrective exercise, this athlete will likely benefit from other interventions beyond the scope of a trainer as well. And by the way, kinesiotape doesn’t help chronic ankle instability (13).
• For ankle instability as an example, a comprehensive approach to increasing ankle stability would be most beneficial. Prefabricated ankle orthoses can correct ankle dynamic stability and lead to a decrease in ankle sprains (8).
• Take a runner with pes planus (flat feet), he has a structural deformity. Now he might suffer from posterior tib pain at some point in his life. And although there are postural control exercises for addressing PTT, more severe cases may benefit orthotics and sometimes even surgery (11,12). All the corrective exercise in the world can’t correct his anatomy.

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K.I.S.S.

• Keep it simple, stupid. Because not all of your pre-conceived notions are correct.
• Some “corrective exercise” is a waste of time. For those who do not have proprioceptive deficits, unstable surface training does not allow enough progressive load to elicit optimal training effect (17).
• When addressing pain, not every exercise needs to be dynamic with a range of motion goal. You don’t always need to fix their perceived deficits. Isometric exercises can help with pain. A dose response relationship has been shown with the proposed effect of activation of high threshold motor-units involved in exercise-induced analgesia (14).
• Push-ups may be the best shoulder corrective exercise that exists. Upper extremity weight bearing exercises have advantages in providing increased joint proprioception, cuff co-contraction as well as reducing joint shearing forces (15,16).

In closing, don’t overthink corrective exercise. Everyday movements and basic exercise are corrective when applied correctly. And if problems arise that need actual correcting, refer them appropriately so that they can get the most beneficial treatments.

I have been positively influenced on this topic by Mike Reinold, Adam Meakins, Nick Tumminello, Greg Lehman, and many others.

-Teddy

References

1. Devries MC, Breen L, Von Allmen M. Low-load resistance training during step-reduction attenuates declines in muscle mass and strength and enhances anabolic sensitivity in older men. Physiol Rep. 2015 Aug;3(8).
2. Kınıklı GI, Yüksel I, Baltacı G. The effect of progressive eccentric and concentric training on functional performance after autogenous hamstring anterior cruciate ligament reconstruction: a randomized controlled study. Acta Orthop Traumatol Turc. 2014;48(3):283-9.
3. Surkitt LD, et al. Efficacy of directional preference management for low back pain: a systematic review. Physical Therapy. 2012; 92(5): 652-663.
4. Schinhan M, Neubauer B, Pieber K.Climbing Has a Positive Impact on Low Back Pain: A Prospective Randomized Controlled Trial. Clin J Sport Med. 2015 Aug 4. [Epub ahead of print]
5. Cecchi F, et al. Predictors of response to exercise therapy for chronic low back pain: result of a prospective study with one year follow-up. Eur J Phys Rehabil Med. 2014; 50:1-9.
6. Slade SC, et al. What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain?: A systematic review of qualitative studies. Clin J Pain. 2014; 30(11):995-1005
7. Sitthipornvorakul E, Janwantanakul P, Lohsoonthorn V. The effect of daily walking steps on preventing neck and low back pain in sedentary workers: a 1-year prospective cohort study. Eur Spine J. 2015 Mar;24(3):417-24.
8. Faraji E, Daneshmandi H, Atri AE. Effects of prefabricated ankle orthoses on postural stability in basketball players with chronic ankle instability. Asian J Sports Med. 2012 Dec;3(4):274-8.
9. Pourkazemi F, Hiller CE, Raymond J. Predictors of chronic ankle instability after an index lateral ankle sprain: a systematic review. J Sci Med Sport. 2014 Nov;17(6):568-73.
10. Hadadi M1 Ebrahimi I2 Mousavi ME. The effect of combined mechanism ankle support on postural control of patients with chronic ankle instability. Prosthet Orthot Int. 2015 Aug 13. [Epub ahead of print]
11. Madhav RT, Kampa RJ, Singh D. Cobb procedure and Rose calcaneal osteotomy for the treatment of tibialis posterior tendon dysfunction. Acta Orthop Belg. 2009 Feb;75(1):64-9.
12. Noll KH. The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin. 2001 Mar;6(1):25-36.
13. Kodesh E, Dar G. The effect of kinesiotape on dynamic balance following muscle fatigue in individuals with chronic ankle instability. Res Sports Med. 2015 Aug 17:1-12. [Epub ahead of print]
14. Hoeger Bement MK, Dicapo J, Rasiarmos R. Dose response of isometric contractions on pain perception in healthy adults. Med Sci Sports Exerc. 2008 Nov;40(11):1880-9.
15. Meakins, A. My top 5 shoulder rehab exercises. Accessible at https://thesportsphysio.wordpress.com/2014/02/14/my-top-5-shoulder-rehab-exercises/
16. Uhl TL, Carver TJ, Mattacola CG. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003 Mar;33(3):109-17.
17. Mate-Munoz JL, et al. Effects of instability training versus traditional resistance training on strength, power, and velocity in untrained men. J Sport Sci Med. 2014; 13:460-468