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With time being of the essence with patients, having a means to efficiently and effectively implement a therapeutic exercise routine can be challenging. Having a good comprehension of Total Gym’s mechanics has allowed me to create exercise routines that move a client through in as little as 15 minutes. To review these mechanics, see Total Gym Physical Therapy Video In-Service. Oftentimes the exercises look similar between clients, so the learning curve is less for both you and the patient, BUT the difference lies in the INTENT of the exercise. For example, squats may focus on leg activation or pelvic alignment and core activation depending on the needs of your client.
With low back being one of the most common diagnoses seen, this blog and the next two subsequent ones will address how to develop and progress a spinal stabilization program via enhancing mobility, core activation in varying positions, and postural awareness.
How to Develop a Spinal Stabilization Program – Part 1
Being a Physical Therapist, there lies an assumption that we all have a good foundation on neutral posture and core activation. When initiating a spinal stabilization program, I start with simplicity and then move into what I call “complex simplicity.” At first the movements are more linear allowing for the client to draw awareness of posture and core activation. Use this opportunity for you, as the PT, to observe if there are changes in form or activation with movements performed in sagittal, frontal or transverse planes. And, since the movements are less complex, reiterate that the focus is on the client learning about his/her posture to allow him/her to be able to achieve improved movement with ADLs. During this time, movements may also move from short to long levers, allowing the client to feel changes in level of activation. Can s/he feel the difference between a Lat Pulldown versus Lat Pullover? Using this movement, I will harness the opportunity to address levers in real life situations, like lifting groceries or children out and into the car.
Within this initial stage, remember that not all clients are comfortable with equipment, and time to learn how to move his/her body on the machine is needed to feel successful in the movement. The routine involves various positions to help train the body for the diverse movements of ADL. It is thus important, to teach the client how to transition between or enter and exit the machine safely between exercises.
Heel slides and/or marching
The intent is to teach pelvic and lower body dissociation, as well as pelvic stabilization with lower body movement, i.e. load transfer through the pelvis.
> Use socks on the rails or a towel under the shoes to allow for less friction.
> The inverted position helps to passively position the spine, which may be needed for stabilization as the lever increases in this exercise.
> If the lower ribs are hyper-extending, use a wedge or pillow to allow for more ideal alignment.
> If your client cannot tolerate the inverted position, the bring the board to parallel or incline.
Squats with or without monster band
The intent is to either maintain the pelvis in neutral with a squatting action, or with the buttocks off the edge of the glideboard, the pelvis moving from neutral into anterior tilt back to neutral.
> Ideally the buttocks is at the lower edge of the glideboard, however this may require strength to enter into the position, as well as move through this range of motion.
> Use of the theraband may allow for increased activation of the hip complex to help stabilize the pelvis and promote ideal knee tracking.
> Most clients want to push the low back into the glideboard to initiate the movement, especially moving from a squat to an upright position. Cue to activate core and lower body.
> For some, allowing the pelvis to naturally move into an anterior tilt may allow for less pain and improved activation. If able, have the client move the hips off the edge of the glideboard and let the buttocks drop in between the rails.
> To vary the exercise, have the client perform varying sets of squats with the feet in different positions. For example, neutral, externally rotated, staggered, or wide.
Lat Pulldown without or without bridge
The intent of the exercise is to draw awareness of how the upper body movement effects thoracic positioning. The supine position allows for the spine to be fully supported and provide feedback for when or if the lower ribs hyperextend.
When first teaching this exercise, teach it as two separate exercises to ensure the following
> The upper traps are not over activating. Cuing draw the scapula down the back assist with scapulohumeral rhythm and improved activation patterns.
> The lower ribs are remaining in contact with the glideboard, especially as the arms reach overhead.
> During Bridging, ensure the client is not riding back onto the cervical spine. Cuing for the knees to reach over the toes and keep the heels aligned with the sit bones and knees aligned with hips allow for improved activation and alignment.
The intent of the exercise is awareness of moving from short to long lever, and dissociation and stabilization between the trunk/spine and upper extremity.
> As the arms pullover, cue to end at the mid-thigh to maintain tension on the cables.
> Lengthening of the arms increases the lever, which changes the strength and flexibility demands.
> Watch for compensatory patterns such as pressing into the glideboard with the feet to over activate the glutes and not the core. Observe the rib cage as the arms move overhead toward the tower, as they may hyper-extend if the LATs are tight.
Low Chest Press
The intent of the exercise is to improve awareness of alignment in sitting, as well as increase strength of posture during upper body movement.
> Glideboard may be inclined or parallel allowing for changes in hamstring flexibility and spinal alignment. An incline board accommodates decreased hamstring flexibility.
> Alternate to begin and increase to bilateral chest press.
> Ensure shoulders are pulling away from the ears.
The intent of the exercise is to teach spinal stabilization as the arms are reaching overhead.
> Lean slightly forward to assist with balance. Note this will also require greater spinal work.
> Assess for excessive upper trap over activation.
> Alternate to begin and increase to bilateral chest press.
Upper back Extension
The intent of the exercise is to strengthen the upper thoracic spine to assist with posture.
> Allow the chest to lie at the top edge of the glideboard.
> The pulleys are allowing for a feedback mechanism of when to stop lifting.
> The focus is to press gently into the pulleys as the upper back extends. When the glideboard moves, this is the end of extension.
If a person cannot avoid initiating or over activating his/her low back, then use a pillow under the hips or enter a low kneeling position.
Pull up heel squeeze / gluteal activation
The intent of the exercise is to activate the posterior fascial sling for spinal stabilization.
> To first teach this exercise it can be broken into two parts
- Teach a pull up with focus on scapular depression and core engagement.
- Teach gluteal activation without over activation of the low back.With the hips externally rotated, knees bent and heels squeezing together, gently squeeze the heels together as the client pulls up and lowers down.
> The focus is on gluteal activation, however, some may hyper-extend the low back to compensate.
> The exercise can also be done with hips in parallel and/or extended.
Standing facing the tower, with or without squat stand.
The intent of the exercise is gaining the hip extension and while rolling through the ball of the foot.
> The client can be resting on his/her forearms or hands.
> The option of the squat stand is dependent on the client. Some clients prefer it off because it is more stable and requires less mobility. Other clients prefer the squat stand on as it allows for a greater surface area.
> Observe the alignment of the stationary leg as well, ensuring the knee and hip are alignment.
An incline glideboard will assist with upper body stabilization. If the glideboard is moved into a parallel position, then incline and squat stand height may have to be adjusted accordingly.
About the Author
Elizabeth Leeds, DPT, owner of Seaside Fitness and Wellness, combines her background in physical therapy, personal training and Pilates in her practice and teaching. As a pelvic floor physical therapist working at Comprehensive Therapy Services in San Diego, her passion for pregnancy and postpartum is seen in her mission to empower women with knowledge and understanding of their physical changes, and how to address them to prevent future issues. Additionally, Elizabeth is a Master Trainer and developer for Total Gym’s GRAVITY education.