All Posts tagged Rehab Exercises

What’s New In Cervical Spine Rehab

 

Rehab

 

By Dr. Jeffrey Tucker

 

My personal in-office experience of patients that present with pain after a motor vehicle injury is consistent with a 2010 study by Hincapié CA, et al. I find most patients report pain in multiple body areas and that isolated neck pain is extremely rare. Hincapié CA, et al report 86 percent of 6481 Saskatchewan residents that responded reported posterior neck pain, 72 percent indicated head pain, and 60 percent noted lumbar back pain. Ninety-five percent of claimants reported some pain within the posterior trunk region, comprising the posterior neck, shoulder, midback, lumbar, and buttock areas.

Regarding cervical rehab for these patients, in the past I’ve used everything from bodyweight isometrics and elastic Thera-Bands to strengthen the neck; dumbbells and kettlebells to strengthen the upper body; low load exercises for strength and motor control concepts performing 10 repetitions of deep neck flexor activation against an inflatable blood pressure cuff and a whole lot more.

All of these are effective at reducing acute and chronic neck pain. Oh, I can’t forget teaching patients all the foam rolling, stretching, warm-ups and cool downs I can get them to do. I can probably do an entire seminar on rehab compliance at this point.

My treatment choice has always depended on the individual patient, whether they are young or old, active or inactive, conditioned or deconditioned. Truthfully I don’t see a significant difference between the different treatment  modalities. Most patients obtain clinically important improvements at 6 weeks after the beginning of treatment and exercise programs. I think that is in line with what most practitioners were taught to expect. However, I still see that 10% (plus or minus) or so of clients take a lot longer than 6 weeks to resolve and have on-going residual complaints and problems. On the other hand, I love treating chronic pain patients that come into my office that were not originally treated by me – those who had previous chiropractic care, acupuncture, medical care or physical therapy without active rehab (they just received passive modalities). With some new tweeks on rehab, I expect good results with these individuals. My hands-on treatment over the past few years seems to include more cervical mobilization (stair-stepping technique), lower cervical manipulation (rather than upper cervical manipulation), thoracic manipulation, and I continue to do a lot of specialized deep soft tissue therapy for pain reduction. The deep tissue work is especially valuable to the upper cervical region. Over the last few years, I’ve added warm laser, but it is so unpredictable who will benefit and change and who doesn’t, I’m losing interest in the whole “laser” thing for the cervical region.

One of the most helpful things I’ve learned in the last five to six years is Dr. Kim Christensen’s Neuromobilization technique. If you have a patient with radiculitis, this technique can produce some clinically important reduction of pain immediately posttreatment. The biggest changes in my cervical treatment come in my rehab. Helpful strategies in the past several years include using the NASM protocol for the ‘overhead squat’ as a diagnostic tool and treatment guide, and using the Functional Movement Screen (FMS) as a predictor of risk for injury.

My latest rehab management strategies for MVA & cervical spine patients:

 

 

 

 

 

Manual therapy: lot of personal thought and patient time figuring out manual maneuvers and stretches to influence the fascia – that thin fibrous layer consisting of longitudinal and transverse connective tissue fibers. Restrictions seem to show up everywhere. Along the sacrotuberous ligament, the thoracolumbar fascia, the latissimus dorsi muscle, the spinous processes of all of the thoracic vertebrae, the angles of ribs, the serratus muscle, the splenius capitis muscles and the deep fascia of the neck. 

Balancing (sensorimotor training) exercises as early as possible. I start patients standing with a narrow stance, progressing to tandem stance and single leg stance. The progression includes the use of foam under each foot to augment postural instability. Manipulate visual inputs (focusing on a point 2 meters away on the wall at eye level and under, with eyes open (EO) plus eyes closed (EC) conditions). I use 30 second bouts. 

 

Stretching exercises is still part of many cervical rehab programs but dynamic stretching and mobility of the thoracic spine to influence the cervical spine is enhancing rehab routines. Mobility needs to be taught before stability. We have to reduce neck/shoulder stiffness and enhance neck range of motion. The static stretches for the levator scapulae, suboccipitals, SCM, pectoralis minor, and scalenes continue to be at the top of the list. I am enjoying using the stretch strap from Theraband.

 

 

 

Strengthening exercises after the deep neck flexors (DNF): Sometimes I begin with the head positioned against gravity to enhance isometric strength of the neck extensor muscles. I still do typical strengthening exercises for the paraspinal muscles and shoulder girdle muscles (upper and middle trapezius, rhombo-serratus). These exercises help increase the sustained isometric effort tolerance of the neck muscles. Progression includes unstable surface 

 

 

 

and escalating resistance and movement pattern improvement. I begin my corrective exercise strategy with bodyweight, progress to Therabands resistance, then progress to free weights and kettlebells.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oculomotor and head/eye exercises

 

 

 

: In the upright, sitting and supine positions I teach patients eye tracking while moving the head. This involves coordination exercises and re-establishing proper movement patterns.

The progression includes increasing neck rotation amplitude, instability on a stability ball and augmenting neck muscle activity with the head in a weight-dependent position. For the past few years I’ve been using the overhead squat for cervical evaluation. Dr. Christensen and I wrote a chapter on the cervical spine in Mike Clark’s new book. In the past we used the overhead squat as a movement pattern to evaluate the ankles, knees, and lumbopelvic-hip complex. Now we use it to evaluate the cervical spine as well. Just think of it as closely rel ated  to the supine cervical flexion movement pattern. Have the patient perform the overhead squat. Observe them from the front and side. The normal pattern would be for them to lead with the posterosuperiour aspect of head. If the SCM’s and subocciptals are dominating, they will lead with their chin. This is a faulty pattern. Remember these muscle actions:

 

Antomical action of longus capitus and colli (cranio-cervical flexion) nods the chin.

 

 

 

 

 

 

SCM extends the cranio-cervical region and flexes the neck.

Scalenes are neck flexors.

During the overhead squat I seem to find a lot of overactive SCM, anterior scalene, and suboccipital muscles.

 

Here are a couple of corrective exercises:

 

 

 

Hyoid Stretch

 

Scalenes and hyoids can be short, limiting cervical extension. Hyoid stretch: teeth touching – extend the neck – open mouth and your head extends further. The stretch is close the mouth = fascial stretch of hyoids. To find out if it‘s articular, perform the chin tuck and extend the cervical spine over the upper thoracic region.

 

 

 

 

 

4 Point Kneeling: The head and neck are passively positioned in neutral alignment, then the patient actively moves (turning side to side, looking up and down) and attempts to return to neutral position. Perform this procedure twice. Notice if they can come back to the neutral position. Score: Good  = the patient accurately and  confidently returns to the neutral position both times without making adjustments. Average  = the patient returns to neutral position with reasonable accuracy but lacks confidence – may need to make several adjusting movements or is “not quite sure.” Poor

= the patient cannot return to the neutral position and is often very unsure of the correct position as evidenced by the vacant facial expression that frequently is associated with performing this test.

I’m sure there are dozens of specific treatments, exercises, and natural remedies out there for our patients. I’d be interested to know about them, but if you’re following the rehab model in all its facets – manipulation/mobilization, modalities, diet, activity, exercise, leisure, sleep, stress prevention – I think you’ll find we do so much good!

 

 

 

 

 

I have new material to share with you.

Dr. Jeffrey Tucker can be contacted at:

11600 Wilshire Blvd. #412, Los Angeles,

CA 90025, phone 310.473.2911

and on the web at www.DrJeffrey-

Tucker.com

 

 

1. J Occup Environ Med. 2010 Mar 30. Whiplash

Injury is More Than Neck Pain: A Population-

Based Study of Pain Localization After

Traffic Injury. Hincapié CA, Cassidy JD, Côté P,

Carroll LJ, Guzmán J.

2. Comerford lecture notes 2009.

 

 

 

Dr. Tucker completed Chiropractic training at Los Angeles College of Chiropractic.

He has a post graduate Diplomate degree in Rehabilitation and is certified in

chiropractic spinal trauma. He is a past-president of the Santa Monica Chiropractic

Society. Dr. Tucker served on the Chiropractic Rehabilitation board. He is a

member of the California Chiropractic Association and the American Chiropractic

 

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Core Training On Stability Balls Part 1

 Are you seeing more people train on balls while working out in the gym? Training with unstable surfaces such as Thera-Band® exercise balls, stability trainers, and balance boards do promote activation of core muscles. The “core” can be defined as the axial skeletal and its muscular and fascial attachments, including the pelvic and shoulder girdle.

Canadian researchers David Behm PhD and colleagues published a comprehensive review on the use of instability to train the core. Research has shown that exercises performed on unstable surfaces produce higher levels of muscle activation in both the core and extremity muscles compared to stable surfaces. However, force and power outputs are decreased while exercising on unstable surfaces, sometimes up to 70%. Interestingly, increasing levels of core muscle activation can also be achieved with free weight exercises such as squats and Olympic lifts without added instability.

In their article, the authors made several recommendations for both athletes and non-athletic conditioning based on their review of the literature. Dr. Behm et al. noted that athletes should emphasize “higher-intensity ground-based lifts” (such as Olympic lifts, squats and deadlifts) while including resistance exercises with unstable devices, as well as unilateral exercises that provide “transverse stress to the core musculature.” Furthermore, they stated that “unstable exercises should not be used when hypertrophy, absolute strength, or power is the primary training goal.”

Similar recommendations were made for the general population, noting the benefits of both free weight and instability training on promoting spinal stability. It’s important to remember to decrease resistance loads on exercises performed on unstable surfaces.

During rehabilitation, unstable surfaces can be effective at improving muscle reaction time and co-contractions that protect joints. In addition, resistance training on unstable may provide localized muscle endurance training, beneficial for the high proportion of Type I “aerobic, slow-twitch” muscle fibers found in core muscles. Dr. Behm and colleagues recommend core endurance training exercises generally be performed at higher repetitions (greater than 15 per set), while athletes requiring more strength and power perform less than 6 repetitions per set. The authors further noted that unstable surfaces can provide musculoskeletal health benefits such as decreased injury risk and increased spinal stabilization as opposed to using free weights.

In summary, unstable exercise devices such as Thera-Band Exercise Balls and Stability Trainers should be included as part of a well-rounded conditioning program for athletes and non-athletes, but not for increasing primary strength and power. In addition, resistance exercises performed on an unstable surface should be performed at a reduced intensity level because of the reduction in force output.

REFERENCES:
Behm DG, et al. The use of instability to train the core musculature. Appl Physiol Nutr Metab. 2010 Feb;35(1):91-108.

Behm DG, et al. Canadian Society for Exercise Physiology position stand: The use of instability to train the core in athletic and nonathletic conditioning. Appl Physiol Nutr Metab. 2010 Feb;35(1):109-12.

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Sample Kettlebell Program

The first kettlebell maneuver I teach my clients is the swing. It is the most common kettlebell exercise. The swing should be viewed as the foundation exercise and I like to see clients master the swing before other kettlebell exercises are introduced.

Once clients can perform the 2-handed swing, this is a typical progression I teach my clients in the office:

One-Arm Swing. Grasp the handle with one hand in overhand grip with slight elbow bend. Position feet slightly wider than hip width, and assume athletic stance. Upper body should be upright, with chest lifted and shoulder blades retracted. Free arm should be out to side of body. Rotate body slightly, allowing kettlebell to hang between legs. Initiate swing by rocking hips (versus using shoulders to lift bell). Raise bell upward with momentum, and give forceful hip thrust at top of movement. Bell should go no higher than eye level, with bell pointed away from body at end of arm. Allow gravity to bring bell downward in controlled manner. Keep spine at neutral, rather than rounded, at bottom of movement. Perform 10 repetitions in each hand.

One-Arm Alternating Swing. Repeat steps above (one-arm swing), but switch to other hand at top of movement. Perform 10 repetitions in each hand.

Around-the-Body Pass (at waist level). Grasp handle with both hands in overhand grip with slight elbow bend. Position feet slightly wider than hip width apart, and assume athletic stance. Upper body should be upright, with chest lifted and shoulder blades retracted. Release one hand from bell, allowing opposite hand to bring bell behind body. Free hand should grasp bell at back of body and complete the rotation. Grasp kettlebell firmly to avoid dropping it. After 10 repetitions in one direction, repeat 10 reps in the opposite direction.

Figure Eight (between the legs). Grasp handle with right hand in overhand grip with slight elbow bend. Position feet slightly wider than hip width apart, and assume athletic stance. Upper body should be upright, with chest lifted and shoulder blades retracted. Left arm should be out to side and ready to accept kettlebell. Begin movement by handing bell from right hand to left hand through legs from front of body to back. Left hand then brings bell around from back of body to front of body. Continue this figure-eight pattern by passing bell through legs again from left hand to right hand. After desired number of repetitions, repeat in opposite direction.

These exercises provide a good cardio and fat-loss workout, creating a great foundation for other exercises. After a full-body warm-up, perform each exercise for approximately 30 seconds or 10 reps. Do one exercise after another and rest at the end. Repeat the circuit 2 or 3 times depending on your condition and the amount of time you have to train. 

For a one-on-one in-depth kettlebell session, please call my office at 310-473-2911.

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Principles of a Rehab Specialist: From Fat Loss to Performance Ready, Part 1

by Jeffrey H. Tucker, DC, DACRB

This article is a real story about a client of mine, Sheldon, whom I am proud to call a very good friend. Last year, I was excited to find out that he was invited to play in the 2007 Maccabi Games (www.jccmaccabigames.org).

I want to personally share his story with you while educating you on the principles of rehab at the same time. Sheldon was given an opportunity to live a dream of playing in a basketball competition that few will ever experience. He came to me feeling confident with our past experiences I could help him recover from a serious injury and get him in shape for the tournament in about 12 weeks’ time. Like every client, Sheldon’s recovery and therapy required customization.

In mid-September 2007, Sheldon, a 49-year-old male presented to my office with left lower-posterior leg and ankle pain made worse with walking. He indicated to me that the pain was in the Achilles tendon region and attachments at the calcaneus. He had been recently invited to play for the U.S. basketball team at the 11th Pan American Maccabi Games in Buenos Aires, Argentina, in December 2007. He decided to make the trip to Argentina a family vacation. Sheldon was not unfit, yet he was not in condition for a world-class competition. The ankle injury had occurred as a result of his overexertion in preparing for the tournament.

He came to my office with an immediate goal of pain relief so he could practice basketball again. His bigger goal was a structured exercise program to get him ready for Argentina. The patient was diagnosed with pre-insertional Achilles tendonitis with a partial tear. His past history was remarkable for low back pain and previous diagnosis as a pre-diabetic. The goals of a complete chiropractic/rehabilitation training program for this client were to: decrease pain and body fat, increase strength, endurance, flexibility, lean muscle mass and performance; and prevent injury.

Sheldon’s treatment was guided by measurements such as bioelectrical impedance analysis (BIA), weight loss, heart rate, exercise intensity, ratings of perceived exertion, interval training timing and meal plans. The tools I used to decrease his pain as quickly as possible were a class IV, high-powered warm laser, sound-assisted soft-tissue mobilization (SASTM) as taught by David Graston, joint mobilization/manipulation and myofascial therapy. I had his MD prescribe ketoprofen cream, an anti-inflammatory used to massage into the Achilles area.

As part of his overall program to achieve the above goals, I recommended and initiated food plans, supplementation and a corrective exercise program. Diet is the best tool for fat loss. I have found the Mediterranean diet is easy for clients to follow and offers the best results.

The need for supplements depends upon the individual sitting in front of you. However, there are specific nutrients we can recommend for each individual to take on a daily basis. For example, Sheldon was instructed to take 3 grams of EPA/DHA per day for pain relief and to support joint and bone health, glucose and insulin homeostasis, and the integrity of neurological cells. He was instructed to take daily essential vitamins and minerals, and to increase his protein intake using a bioactive, pure whey protein powder concentrate.

Exercise creates changes in the musculoskeletal system, increasing strength and performance, along with stimulating physiological processes. However, we may not all agree on the best type of exercise to make such changes. In this article and the next, I will discuss these topics and much more, clarifying the connections between fat loss, fat-free mass, exercise and performance.

Measurement and Weight-Loss Basics

Within three weeks, Sheldon was walking without pain. At the end of the third week, he could jog with slight to moderate pain after 10 to 15 minutes of intermittent stops and starts, as in playing basketball. Once his pain diminished enough that he could jog, it was time to get serious and implement a corrective exercise program. We all recognize the value in measuring blood pressure, height and weight. As part of my workup before starting an exercise progression or before starting a weight-loss program, I measure body fat percentage and lean body mass. When I ask a client, “How much do you weigh today?” I often hear remarks such as, “10 pounds too much.” Then I ask, “But how much do you weigh now?” and get the usual response of, “I don’t know, I never weigh myself.”

Maintaining a healthy body weight includes maintaining healthy functioning immune, hormonal and reproductive systems without any traces of an eating disorder. It is also a weight that you can realistically reach and maintain with healthy lifestyle efforts. To effectively manage body weight and body composition, it is important to know your daily caloric requirements. A BIA test can tell us body composition and basal metabolic rate. Accurate assessments using BIA allows me to determine each client’s unique personal caloric requirements and to better plan and evaluate weight management/exercise programs. As mentioned above, I utilize therapeutic lifestyle changes (TLC) including food plans, supplements, exercise and relaxation that can be evaluated using objective measures before and after beginning my nutritional and/or exercise program.

Body Composition Measurements

In my practice, I use a body composition machine, which is a portable, battery-powered bioimpedance analyzer. Patient assessments are conducted using a connection between the analyzer and the wrist and ankle of the patient. Connections to the patient are through standard ECG sensor pad electrodes. Resistance and reactance, the two components of impedance, are measured directly from the body.

On Sheldon’s initial office visit, he was 78 inches tall and weighed 215 pounds. A look at some of the results from Sheldon’s BIA test revealed the following:

Fat Mass (FM) 20.8%
Fat-Free Mass (FFM) 79.2%
Body Mass Index (BMI) 25.5
Intracellular Water (ICW) 56.4%
Extracellular Water (ECW) 43.6%

Body Weight

Body weight is the sum of your body fat or fat mass (FM) and your lean body mass or fat-free mass (FFM). FFM consists of dry lean mass and total body water (TBW). TBW is divided into water inside the cells (intracellular water – ICW) and water outside the cells (extracellular water – ECW). TBW is the sum of intracellular water and extracellular water (ICW + ECW = TBW). Keeping these components appropriately balanced is the key to staying fit and healthy. Compositional imbalance in the body is closely related to obesity, malnutrition, edema and osteoporosis. It also will contribute to suboptimal athletic performance.

Body Mass Index

Body mass index (BMI) is a common measure expressing the relationship (or ratio) of your body weight to your height. BMI is more highly correlated with body fat than any other indicator of height and weight, but it is not recommended for use as the sole measurement of your body composition. It does not apply to infants, children, adolescents, pregnant/breastfeeding women or adults over 65 years of age.1

BMI Measurements and Ranges: You can calculate your BMI using the formula: BMI = weight (kg)/[height (m)].2

BMI <18.5: This calculation may indicate an underweight status and may be associated with health problems for some people. This client may need to have a consult regarding diet or other health-related issues.

BMI of 18.5 – 24.9: This zone is the preferred range as it is associated with the lowest risk of illness. The client is living life in a way that improves health.

BMI of 25 – 27: This zone may be fine if you are physically active. You likely have lots of muscle mass and may be overweight but not overly fat. However, a BMI over 25 may be associated with health problems for inactive people. This client will need to consult with a doctor.

BMI of 27 – 29.9: This is a health risk zone and is associated with increased risk of heart disease, high blood pressure and diabetes. At this point diet, nutrition and exercise must be implemented.

BMI > 30: This is obesity. Clients must be provided with a program of balanced eating, supplements, regular exercise and reduction of stress.

Sheldon’s BMI was 25.5, putting him between 25 and 29.9. Although he is only 0.5 over, this still falls within the overweight range. Being overweight increases your risk for heart disease, diabetes and other serious health problems. I was not concerned about Sheldon being overweight, but I was concerned that he would be under stress from the workouts ahead and was on a tight time schedule to get ready for Argentina. Within the first week of treatment, I had discussed the Mediterranean food plan with Sheldon to promote healing and increase strength.

Table 1: Risks of cardiovascular disease relative to body mass index and waist circumference3

Body Mass Index (BMI) Waist Circumference
Men = 102 cm (40 inches)
Women = 88 cm (35 inches)
Waist Circumference
Men > 102 cm (40 inches)
Women > 88 cm (35 inches)
Underweight = <18.5 Increased Risk? Increased Risk?
Normal weight = 18.5-24.9 Low Risk Low Risk
Overweight = 25-29.9 Increased Risk High Risk
Obese = 30-34.9 High Risk Very High Risk
Obese = 35-39.9 Very High Risk Very High Risk
Extremely obese = 40+ Extremely High Risk Extremely High Risk

The BMI ranges are based on the relationship between body weight and disease and death.4 Overweight and obese individuals are at increased risk for many diseases and health conditions, including hypertension, coronary heart disease, stroke, type 2 diabetes, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, some cancers (endometrial, breast and colon), and dyslipidemia (high LDL cholesterol, low HDL cholesterol or high levels of triglycerides).

Muscle Mass

There are three types of muscle: cardiac, visceral and skeletal muscle. The quantity of skeletal muscle is most affected by exercise, particularly by strength-training programs. By comparing the percentage of body fat mass and skeletal muscle mass in each body component, the level of fatness or obesity can be measured in a more proactive and exact manner. An essential part of my program is to teach my clients how to train and lift free weights. By teaching Sheldon corrective exercises and a free-weight training program, I expect his muscle mass to increase and the body fat to decrease.

We will follow Sheldon’s progress in part 2 of this series and look at metabolism and the benefits of interval training.

References

  1. Mei Z, Grummer-Strawn LM, Pietrobelli A, et al. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. Am J Clin Nutr, 2002; 75(6):978-85.
  2. Garrow JS, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obesity, 1985;9:147-53.
  3. Gallager DG, Heymsfield SB, Heo M, et al. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr, 2000;72(3):694-701.
  4. Prentice AM, Jebb SA. Beyond body mass index. Obesity Rev, August 2001;2(3):141-7.
  5. Gallagher D, Visser M, Sepúlveda D, et al. How useful is BMI for comparison of body fatness across age, sex and ethnic groups? Am J Epidemiol, 1996;143(3):228-39.
  6. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series. Geneva: World Health Organization, 1995.
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Principles of a Rehab Specialist: Kettlebells 101

by Jeffrey H. Tucker, DC, DACRB

There is a lot of excitement and “buzz” about kettlebells in the weight room and the rehab setting these days, so I want to make sure everyone is familiar with this valuable piece of fitness equipment. A “kettlebell” or girya is a traditional Russian cast-iron weight that looks like a cannonball or bowling ball with a handle. The kettlebell goes way back: The term first appeared in a Russian dictionary in 1704. So popular were kettlebells in Tsarist Russia that any strongman or weight-lifter was referred to as a girevik or “kettlebell man.”

Kettlebells come in several sizes/weights, from 5 lbs all the way up to 105 lbs. You can do standard weight-training exercises with kettlebells, including bench presses, overhead presses, curls, squats and rows. However, the unique value of kettlebells is derived from ballistic (fast exercise) work such as snatches, swings, cleans and jerks.

For those of you who don’t know me, I really do prescribe exercise in my practice. Exercise is a natural drug. We need to deliver the right drug, at the right dose, at the right frequency to get the right result. Learning to make good exercise selections is purposeful and designed to decrease pain, prevent injury, decrease body fat, and increase lean muscle mass, strength, endurance, flexibility and overall athletic performance. Currently, I am using kettlebells in my small-group exercise classes to achieve the above goals.

I became intrigued by the claims of the advantages of kettlebells, so I decided I wanted to learn how to use them. I met a well-known kettlebell expert and took workshops from him. I also met with Pavel Tsatsouline, the person responsible for popularizing kettlebells in the U.S. He taught me some of his stretching routines. Once I learned about kettlebells, I immediately realized the benefits to my rehab practice.

The All-in-One Workout Tool

Kettlebells develop all-round fitness and teach kinetic linking. For example, the kettlebell “swings” makes the deadlift functional. It gets you connected to the ground, draws energy from the ground and transfers energy through the shoulder. Kettlebells enhance awareness of posture, position, breath and grip.

Here is a short list of workout equipment the kettlebell replaces: barbells, dumbbells, belts for weighted pull-ups and dips, thick bars, lever bars, medicine balls, grip devices and cardio equipment. The good news is you don’t need to spend thousands of dollars on expensive equipment. For most of your clients, all you need are two or three kettlebells of varying weights. They do not take up much space, so you can train in a small area. In the office, you can get a great workout in a limited space while improving strength, agility and stamina.

I especially like the cardio benefits clients can get from kettlebells. It’s easy to use interval training principles (go slow, go fast, repeat). I have been teaching a twice-weekly exercise class for the past four years. When I first started the class, we used body-weight exercises, balance balls and bands. Each year since starting the class, I’ve introduced a more challenging tool or device. Last year I added telescopic stick/band training to the class, which provided great variety and core work with bands. In January 2008, I started using kettlebells. The participants in my class are noticing more dramatic changes in body composition from kettlebell training than from anything else we’ve done in the past. Kettlebells develop shoulders, back muscles, arms, forearms, a cut-up midsection and strong legs.

Ballistic Drills

Ballistic kettlebell drills involve a snapping action of the hips, and I have found this movement targets the gluteals better than bridges and are as good as squats. Once my clients can perform 50 consecutive bridges in a variety of poses, they are ready for the kettlebell swings. Whatever rehab techniques you use in your office, I always teach and recommend that you start and concentrate on functional asymmetries (right/left differences). Accumulation of asymmetries over time can lead to significant injury.

Most of us have learned something from the Janda method of movement pattern analysis. Kettlebell exercises are movement-based, not just lifting-based. You’re getting movement training with weight instead of weight training with single-plane movement. We’re not just trying to hypertrophy muscles like a bodybuilder; we’re trying to groove movement patterns throughout the body that are both strong and stable.

For sports, you need explosive hips, stable joints and quick hands. Kettlebell training develops those attributes. Most of the moves are done standing (bilateral or single-leg stance), and many moves are done lying supine. Multi-joint movements comprise most of the drills. Kettlebells complement core stabilization, body-weight exercises and telescopic stick/band exercises. Many are characteristic of work, sports, and activities of daily living. With kettlebells, we don’t need machines, so we have more room in our workout areas!

Building Muscle, Losing Fat

With kettlebells, your clients will build muscular endurance when performing high repetitions, and with proper nutrition they will lose fat. Ballistic exercises are not the only exercises to help accomplish this; the Turkish get-up, press and windmill will develop hard midsections and increase shoulder flexibility and stability. Some of my favorite kettlebell exercises include the clean and press, front squat, renegade row, swings and the double clean (holding a kettlebell in each hand).

I love free weights and try to get most of my clients on a free-weight program, but you really can’t do the above exercises with dumbbells. I think kettlebells are actually more challenging than dumbbells. Kettlebell handles are much thicker and will give you a vice grip in no time. Also, the off-centered weight of a kettlebell will force you to use more stabilizer muscles and work the targeted muscles through a longer range of motion.

Progressive, Whole-Body Training

Kettlebell rehab exercise progressions are the same as with other exercise programs. Progress from slow to fast – start a skill at a speed that allows success. Slow down to gain control, and then once it can be mastered, progress to explosive speed. Progress from simple to complex. Finally, build from stable to unstable: a client does not belong in single-leg stance, on a ball or on any unstable surface if they cannot stabilize on the ground with both feet first. Only progress to a less stable environment when the initial exercise is completely mastered and no longer provides a training effect.

I want my clients to get out of pain as quickly as possible so I can begin to train them for fitness. Being fit is a means toward an end, not an end in itself. I use kettlebells to develop complementary motor skills and abilities, and couple effort with execution. Power, flexibility, agility, speed and endurance are the elements of athleticism. Each is trainable, but they must be trained collectively because they are parts of a larger whole. None is a separate entity or more important than another. Sometimes we need to train isolated muscles, but most of the time we train movement patterns, not individual muscles. Kettlebells help achieve this.

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