This is an excerpt from Client-Centered Exercise Prescription-3rd by John C. Griffin.
Muscle Balance Prescription Model
Muscles that are too short are often strong and hold antagonists in a lengthened and weakened position. These muscles need to be lengthened and made more flexible through stretching. Muscles identified as weak and long need to be strengthened. This is best done through simple exercises that isolate and use the muscles in question. For muscle balance to be restored and maintained, therefore, therapeutic exercises to strengthen weak muscles should be combined with stretches for tight muscles.
The steps involved in the model for muscle balance prescription follow this approach. Client goals are established based on counseling concerns and assessment of posture, muscle tightness or joint ROM, and muscle weakness (see table 8.2). For each goal, a series of exercises is designed for flexibility of the tight muscles and strength of the weak side. Use form 8.2, Muscle Balance Prescription Worksheet, to record program recommendations and guidelines for safety and monitoring for each patient. The worksheet is a useful template to guide this program design process, ensuring that it is client centered and goal oriented. The two case studies at the end of the chapter demonstrate the use of the model and prescription worksheet.
For a client dealing with a weakness underlying muscular imbalance, refer to the detailed resistance training guidelines in chapter 7.
Step 1: Review Client Needs and Confirm Goals
Clients’ needs may be related to health or injury, fitness, or performance improvement. Their needs can also be identified by fitness assessments (posture, tightness, ROM, weakness) or an observed compensation in some movement patterns.
Clients are not going to say that they have muscle imbalance. But you can find out if they do by asking the right questions. Faulty body mechanics, as determined by postural screening, should be confirmed by the muscle tests. Select assessment items only after you and your client together have decided on priorities. Chapter 4 describes and interprets the following assessments:
● Postural assessments (including static and dynamic)
● Muscle length and flexibility assessments
○ Upper body: pectoralis minor, pectoralis major (sternal), shoulder internal rotators, shoulder external rotators, shoulder abduction ROM
○ Lower body: hip flexors (one and two joint), tensor fascia latae, hamstrings, hip internal rotators, hip external rotators, gastrocnemius, tibialis posterior, and soleus (ankle ROM)
○ Trunk: lumbar and cervical rotation ROM, sit-and-reach
● Strength assessments
○ Upper body: Push-ups (pectorals, serratus anterior), weightlifting 5RM (repetitions maximum) to 10RM (selected muscles)
○ Lower body: Weightlifting 5RM to 10RM (selected muscles)
○ Trunk: Biering - Sorenson (erector spinae), five-level sit-up (abdominal muscles), leg lowers (lower abdominal muscles), lateral lift (quadratus lumborum)
Postural analysis will indicate which muscle length and flexibility tests and strength assessments to perform. Interpretation of these tests will tell you what muscles need to be strengthened and which ones need to be lengthened.
Step 2: Select the Training Method
You must select the training method that best meets your client’s needs, time constraints, experience, and level of condition. Your design can become quite distinctive when you manipulate prescription factors within a given system. Training methods such as standard sets or a specific circuit may be appropriate for strengthening, whereas static stretching or PNF may be selected for tightness or ROM (presented in the earlier "Flexibility Training Methods" section).
There are two approaches to improving flexibility: decreasing the resistance to the stretch and increasing the strength of the opposing muscle. Decreasing resistance to the stretch can be accomplished by either increasing the connective tissue length or attaining a greater degree of relaxation or analgesic effect in the target muscle. Table 8.3 describes the appropriate stretching techniques for each approach.
Step 3: Select Exercises, Equipment, and Order of Performance
To restore and maintain muscle balance, combine therapeutic exercises to strengthen weak muscles with stretches for tight muscles. You must know the purpose and benefit of each exercise (and equipment, if used) and choose those that maintain muscle balance and retrain muscles that have been over- or underworked. Modifications may be necessary because of physical limitations and current or past injuries. Often there is no need for specialized equipment. Simple equipment that can be useful may include bands and tubing, pulleys, or other small equipment such as medicine balls and plyo balls, body bars, dumbbells, wobble boards, exercise balls, balance discs, BOSU trainers, and mats.
Order your selection of specific exercises using the following guidelines:
● Deal with each identified goal sequentially, as a unit of exercises.
● Work areas of weakness or imbalance while your client is still fresh.
● Have the client do a light warm-up and then stretch, followed by strengthening exercises and then any functional neuromuscular exercises.
● Select exercises for each related muscle group maintaining agonist - antagonist and bilateral symmetry, which promotes a balanced development.
● Choose exercises that are functional for the demands on the client; these often include exercises in more than one plane (see guidelines for functional exercise earlier in the chapter).
● Include stabilizers (e.g., lower spine muscles) later in the session.
A well-rounded flexibility or conditioning program should include at least one exercise for each major muscle group. Your prescription should include the stretch specific to the area of tightness, the proper positioning and execution of the stretch, and the method of stretching best suited to your client. Postural screening and muscle length testing may suggest greater emphasis on, or avoidance of, certain muscle groups.
Step 4: Set Intensity and Volume
Program strengthening recommendations may involve exercise load and volume. Exercise volume is one of the most important prescription factors. Volume is often described as sets \x\ reps \x\ load. The intensity or load must be heavy enough to cause temporary fatigue. If your client is using weights, strength and endurance improvements will come with 8 to 12 repetitions and a 75% load. Two sets are usually sufficient to produce excellent benefits. Frequency is sometimes more than 3 days per week for retraining an imbalance.
You can provide the appropriate overload for flexibility in the form of additional isolation stretches, more repetitions, longer duration, more frequent sessions, or a change of stretching technique. Heyward (2010) suggested 2 to 6 repetitions of each exercise for a minimum of 3 days a week, with the duration of stretch from 10 to 60 s. Covert and colleagues (2010) suggested one 30 s stretch per muscle group, but it is likely that longer periods or more repetitions are required in some people, for some muscle groups, or in the presence of injuries.
A stretch of relatively long duration and low force at elevated tissue temperatures will provide an effective permanent stretch (plastic deformation) (Sapega et al. 1991). If the duration of stretch is short, the intensity of force is high, and the tissue temperature is normal or cold, the muscle - tendon structure will return quickly to its original length (elastic deformation) and much of the benefit of the stretch will be lost.
Teach your clients to read their body’s feedback and make their prescription client centered:
- Stretch until you feel tension or slight pulling, but no pain.
- Hold that length of the muscle until there is a noticeable decrease in the tension (stress relaxation).
- Increase the muscle length until you feel the original tension level.
- Take a deeper breath and slowly exhale. Repeat steps 2 and 3 until no further increase.
Step 5: Design Progression and Monitoring
The universal principle of conditioning is progressive overload, that is, periodically raising the workload to increasingly challenge the muscle group. The object is to shape the overload to suit your client by manipulating the prescription factors according to the principle of specificity - namely, that gains in muscular fitness are specific to the muscle group, training method, and exercise volume.
To ensure safe and effective progression, modify only one volume factor at a time (e.g., increase reps up to about 15, then increase the load and drop the reps back down). Program cards that allow quick recording of these factors can save time and encourage regular recording. Visually monitor primary safety precautions and execution mechanics.
After constantly repeating a particular faulty movement pattern, clients need to be reprogrammed to perform the movement correctly. This can be difficult, because the faulty movement is by now ingrained in the central nervous system and has contributed to the muscle imbalance and poor posture. To address this condition, put your client’s kinesthetic and postural awareness to use. Have clients perform the exercises with little or no load initially. Once they can do the unloaded movement properly, add a TheraBand or tubing and continue to monitor the movement mechanics. There are several good examples of situations in which this has proven to be very effective:
● Clients with weak lower trapezius and overactive upper trapezius: Excessive scapular elevation can occur with dumbbell lateral raises. Start with light tubing and teach the client to pull outward, not upward, avoiding any shoulder shrugging.
● Clients who need to be aware of a neutral spine position: Promote postural awareness in a seated position on a stability ball. Establish awareness of what muscles are contracting to stabilize and then begin small movements in all directions while maintaining a good kinesthetic sense of the lumbar - pelvic position.
● Clients with winged scapulae that need to be stabilized against the rib cage: Teach clients to "set" their scapulae in proper alignment with your tactile feedback. Progress to a modified push-up and emphasize the involvement of the serratus anterior with fully protracted scapulae at the top of the exercise. Similarly, emphasize the rhomboids by pinching the scapulae in the lowered position.
Check your clients for alignment and compliment good form during their resistance exercises. Balance the number of push - pull movements in the maintenance prescription. Progress to more functional total-body exercises and identify the things clients do in everyday life that need the same degree of attention as their workout. Few of us are immune from these daily risks: the new mother who undergoes repeated spinal flexion with caring for her child, the career driver with a poor seat or poor core stability who has constant intervertebral compression, the office worker with his telephone wedged between his ear and shoulder, and the personal trainer who constantly stoops to pick up weights and leans over to spot clients.
Step 6: Design Warm-Up and Cool-Down
The warm-up and cool-down should reflect the type and magnitude of the work done in the training portion. After some warming, have the client statically stretch the muscle groups to be used in the workout. In the cool-down, relieve anticipated muscle tightness and have the client stretch tight postural muscles (e.g., anterior chest, hip flexors, hamstrings).
There has been some controversy about the merits of stretching, particularly as an element of the warm-up, and you must give your clients accurate information in this area. Warming up for stretching has replaced the notion of stretching to warm up. Besides simply raising tissue temperature, warm-up activity stimulates muscle calcium release and motor unit recruitment. However, warm-up without stretching does not increase ROM (Shrier and Gossal 2000). There is evidence that high strength and power outputs are negatively affected after a static stretching session. It is possible that long-lasting changes in the ability of a muscle to store elastic energy when stretched, as well as muscle excitability, can be negatively influenced by static stretching (LaRoche et al. 2008). This may suggest the avoidance of passive stretching before activities requiring high muscle force and power, with preference given to dynamic sport-specific muscle preparation. However, most clients who have tightness will benefit from a prewarmed, long, static stretch routine done frequently and without the ballistic effect of other activities.
Table 8.4 shows (for the lower body) the progression from postural assessment to the identification of probable areas of muscle imbalance, and it provides guidelines for exercise design. Depending on the exercise movement, every muscle, at some time, is a prime mover (agonist) in a specific action, and each muscle has an opposing muscle (antagonist). Refer to table 8.5 to determine muscle pairs and to aid you in designing exercises based on muscle testing.
When designing isolated corrective exercises, ensure that the resistance is light enough to prevent the client from compensating by using other muscles. As muscle balance improves, start to replace isolated exercises with more complex, functional movements. However, if the isolated weakness is not corrected, multijoint strengthening exercises will also tend to cause compensation and reinforce the imbalance or create new ones.
When a muscle has excessive tension, the stress should be relieved before you prescribe additional muscular work. There is often reduced neuromuscular input in these muscles. Roskopf (2001) suggested using isometric contractions to restimulate the muscle by increasing sensory input to the brain. Corrective isometrics can act as precursors to designing exercises to strengthen concentric contractions. Roskopf suggested a protocol using 6 repetitions of 6 s contractions progressing from 50% intensity to 70%, 100%, and maximal force on the last three contractions.
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