Corrective Exercise Program

 

Based on the concerns that have been identified on the postural assessement and the rest of test performed,  the client will be provided a corrective exercise program to improve muscular imbalances, muscular tightness, improve strenght on those weak muscles identified and improve his posture in general. Different methods will be applied, starting by an inhibition phase (myofascial release), lenghtening phase with static stretching and Proprioceptive neuromusuclar facilication (PNF) exercises, and strenghtening exercises.

1. Inhibit (Myofascial Release):

Self-myofascial release (SMR) is believed to be as effective as massages because it helps to restore muscles, relieve muscle stiffness and tension in tendons and ligaments, reduce muscle swelling, pain, and improve range of motion and flexibility (Chen et al., 2021; Mahbobeh et al., 2017; Schleip, 2003; Schroeder and Best, 2015). Furthermore, it has been implemented to reduce delayed onset muscle soreness (DOMS) (MacDonald et al., 2014) and to improve vascular and lymphatic circulation (Harrison et al., 2000). SMR involves using one's own body weight, typically on a foam roller (Healey et al., 2014), to exert pressure on the affected soft tissues by stimulating receptors located along the muscles, fascia, or connective tissue (The Golgi Tendon) that respond to tension (Beardsley and karabot, 2015; Clark et al., 2014). Maintaining the stretch until the tissue elongates and repeating the stretch until it is no longer felt (Liem et al., 2017). The applied pressure on the targeted area should range from 30-90 seconds (Clark et al., 2014).

Furthermore, SMR has been widely applied to rehabilitation treatments of musculoskeletal injureis such us ankle instability, back pain, neck pain, etc (Chen et al., 2021). Chen et al., (2021) systematic review of 8 randomized trial on 386 individuals, revealed that SMR decreased back disability in patients with lower back pain (p,0.04; SMD—0.35; ICC=-0.68, -0.02), but it not decreased pain (p>0.32) or improved lumbar ROM (p>0.92 vs p>0.70, right and left flexion, respectively. Contrary, Berdsley and Sharobot, (2015) systemeatic review found that SMR lead to acute incerases in acute flexibility and reduce DOMS.  Contradictory findindings may were due to differences in the pressure applied, repetitions, frequency  or the instructions used may affected the results. Evidence suggest to use SMR in conjuction to other techniques usch us statics stretching (Schroeder and Best, 2015).

Observation from the client’s postural assessment and posterior dynamic OH and SLS identified overactive muscles in the lowe limb extremities (gastrocnemius, soleus, tensor fascia latae and adductors) and upper body (Lattissimus dorsi, upper trapezius and quadratus lomborus). Therfore SMR techiniques were prescibed to release the trigger points found in the muscles shown in table 1. The client will perform the exercises daily after his training session (4 times/ week).

Table 1. Exercises implemented in inhibition phase of the corrective exercise program.

INHIBIT
Execise: SMR	Sets	Duration
Gastronemius/ Soleus	2	30 s
Rectus Femoris	2	30 s
TFL	2	30 s
Adductors	2	30 s
Lattissimus Dorsi	2	30 s
Quadratus Lomborus	2	30 s
Thoracic spine	2	30 s

Table 2. SMR exercise program images of the client performing each exercise.

Summary of exercised prescribed
1.	2.
3.	4.
5.	6.
7.

2. Lenghening: Statics Stretches (SS) and PNF:

Lengthening is the mechanical elongation of mechanically contracted muscle and connective tissue required to increase ROM at the tissue and joints (Clark et al., 2014). Static stretches (SS) have been shown to increase muscle tissue flexibility and ROM via neural and mechanical adaptations (Fukaya et al., 2021; Donti et al., 2018), whereas passive stretches (PS) maintain  joint and muscle stretching via the effect of an external force, utilising either proprioceptive stimulation for the strengthening (facilitation) or relaxation (inhibition) of muscle groups (Zaidi et al., 2023), such as a partner's push, wall, floor, or machine, which is applied to attain and hold the end position (Ruan et al., 2017).

Furthermore, Aslan et al., (2019) investigate the acute effect of dynamic and PNF stretches on hip flexor tightness on thirty-six students and observed that ROM improved in both groups (p< 0.001) but PNF technique resulted in a greater hip-extension ROM and dynamic balance (p< 0.004). Furthermore, Zaidi et al., (2023), investigated the immediate and long-term effect of SS and PNF on knee ROM and hamstrings flexibility in a randomized group of thirty males grouped in contract-relax group and passive stretching for 80-seconds. Results shown a statistical difference  between the PNF and control group (p< 0.01). SS  significant increased ROM and flexibility after 4-weeks intervention (p<0.001) but only improved ROM immediately post-treatment (p<0.007). Contrary, PNF significantly increased ROM and flexibility post-test (p<0.001) and after 4-weeks treatment (p<0.07, p<0.001)

For the purpose of this program, static stretches and PNF ( Hamstrings) will be implemented in the corrective exercise program  (Jhonson. 2012). The exercises were chosen based on the results obtained in the client’s previous assessments, revealing muscle tightness (erector spinae muscles, levator scapulae, upper trapezius, pectoralis major/minor, hip flexor, etc)  with the purpose of improving joint ROM, tissue lengthening, client posture and enhancing neuromuscular efficiency. 

Table 3.  Corrective exercise program implemented in the lengthening phase including stratic stretches and PNF.

LENGHTENING
Exercise	Sets	Reps
1. Banded ankle dorsiflexion	3	10 reps
2. Hamstrings PNF	2	3 reps
3. Periformis	3	30 sec
4. Static Kneeling hip flexor stretch + lateral flexion	3	30-60 sec
5.Trapezius, Levator scapulae, strenocleidomastoid standing stretches	1	30 sec
6. Cat-Camel	3	12  reps
7. Pectorales major/Minor	3	30-60 sec
8. Brussel’s Exercise with band	2	12 reps

Table 4.  Corrective exercise pictures of client perfoming the lengthening phase including stratic stretches and PNF.

Summary of Exercises Prescribed
1.	2.
3.	4.
5.	6.
7.	8.

* Videos of client executing some of the exercises implemented.

3. Strength exercises program:

The third phase of the corrective exercise continuum was the activation of the underactive muscles by isolated strengthening techniques (Clark et al., 2014). This phase was prescribed for 6 weeks/ three times a week  (Clark et al., 2014; Mendiguchia et al., 2020). Sets and repetitions were prescribed following Clark et al. (2014) guidelines (Table 5) and aimed to achieve an optimal motor unit  synchronization and optimal firing rate (Stull, n.d).

The strenghening programn consisted implementing exercises to different muscles groups. For instance, side lying adduction with shorter lever arm was selected based on the client expertise. Indeed, Haroy et al., (2018) investigated the effect of an adductor strength program in 35 soccer teams (n=313) with three progression levels of difficulty based on the Copenhagen Adduction exercise (CA) which has shown high activation  of the adductor longus magnus (Serner et al., 2014) and increases eccentric adduction strength gains when implemented (Haroy et al., 2017; Ishol et al., 2016). The exercises implemented were (easier, side-lying hip adduction, CA held from the knee and CA held from the ankle). Players performed the most difficult level and if experienced groin pain were performing easier levels. Results shown that the ASP reduced groin problems in competitive season by 41% (OR 0.59, 95%CI 0.40 to 0.86, p=0.008).

Furthermore, Mendiguchia et al., (2022) integrated a multimodal intervention program focus on the hip flexors, erector spinae, rectus femoris, thoracic region latissimus dorsi and specific lumbo-pelvic neuromuscular control training emphasized in the posterior pelvic tilt muscles and strengthening the hip extensors (Gluteus maximus and hamstrings) and found a decreased anterior pelvic tilt after 6-weeks training (p<0.001). Additionally, performing clams shells exercise will reduce hip rotator weakness minimising the potential risk of sustaining ACL injuries (Paterno et al., 2010).

Additionally,  hamstrings sliders were implemented to increase hamstrings activation as previously weakness was observed. Evidence has shown that eccentric hamstrings exercises are essential for rehabilitation programs because increase muscle strength and shift the peak torque angle to a longer length (Kilgallon et al., 2007; Orishimo and McHugh, 2015). Orishimo and McHugh, (2015) investigated hamstring activation on four hamstring-exercises revealing that hamstring activation was higher during sliders and resisted hamstring extension (108.5% MVIC vs 81.2% MVIC).

As it was observed in the postural assessment, gait analysis and Trendelenburg test, client had pelvic drop, commonly caused by weakness in the hip abductors and gluteus medius. Therefore, intervention will include strengthening of the gluteus medius (Lewis et al., 2018) and suitcase carry (SC) as it has shown to challenge the hip abductors muscles eccentrically (Neurmann, 1999). Graber et al., (2021) found that SC had higher hip abductor activity on the contralateral side of the handled-weight (p<0.01). Furthermore, McGill et al., (2009) investigated  trunk activation in different strongman exercises and found that SC is more effective on obliques than farmer’carry (left-side SC generated higher activation on right obliques (65.1 vs 50.40) and the right-side SC on the left obliques (61.65 vs 39.3)). Therefore, by adding this exercise, it will assist to train the torso stabiliser and improve stability hip, pelvic, and spinal stability (McGill et al., 2010).

Implementing these exercises has been demonstrated to be beneficial for activating essential muscles that support injury prevention, optimise posture, and athletic performance.

Table 5. Strenghtening program implemented 

STRENGHTENING
Exercise	Sets	Reps	Rest
Hamstings sliders	2	10 each leg	60 s
Walking lunges	2	12 each leg	60 s
Glute bridges	2	12	60 s
Glutes Clamshells	2	10	60 s
Side lying adduction	2	40 sec	45s
Ilipsoas March	2	10	60 s
Side plank	2	30	60 s
Deadbugs	2	12	60 s
Suitcase carry	2	12 m	60 s
Banded Shoulder external rotation	2	2	60 s

Table 6. Strenghening exercises peformed in the strenghtening phase of the corrective exercise treatment performed billateraly.

Summary of exercised prescribed
1.	2.
3.	4.
5.	6.
7.	8.
9.	10.

* Videos of client executing some of the exercises implemented.

B) Integration:  Integrated Dynamic Movement

The last technique included in the Corrective Exercise program is the use of integrated dynamic movement (IDM) (Clark et al., 2014), which enhances the client’s functional capacity by adding exercises that focus on muscle stabilization and mobilization, therefore increasing multiplanar neuromuscular control (Clark et al., 2014). IDM are complex movements in which muscles work eccentrically in the negative phase of the movement (Piri, 2019). Evidence has shown that eccentrical training has an equal or more capacity to increase flexibility compared to static-stretches exercises (Aijaz et al., 2011; Ferreira et al., 2007; Jank et al., 2014 ; Quddus, 2011). Client performed the exercises 3/week, 1 set and 12 repetitions (Clark et al., 2014). The integration exercises have been selected based on compensations found in previous tests. For instance, the ball squat to overhead press, as can teach proper hip hinging, lumbo-pelvic control, and challenge the core (Clark et al., (2014).

Table 8. Dynamic movements immplemented inteh integration phase of the strenghtening program phase.

Integration: Dynamic Movements
Exercise	Compensation	Set	Repetitions	Rest
1. Multiplanar Hop	Ankle instability Hip instability	1	4	60 s
2. Ball Squat to Overhead Press	Anterior Pelvic Tilt	1	12	60 s
3. Squat to row	Arms fall forward (OHS)	1	12	60 s
4. Standing one-arm Chest Press Cable	Scapula Winging	1	12	60 s

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2.

3.

4.

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