One of the underlying principles in physical rehabilitation is that the body responds positively to the increased stresses placed upon it. This is the whole reason for asking muscles to lift more weight, for asking tendons to pull more tension, and for asking joints to undergo more movement. We have a mechanism for developing and improving our physical capabilities when we place increased, yet controlled, stresses on our bodies. On the other hand, increased physical stress is often the cause of symptomatic conditions and physical breakdown. What is the difference? Actually, several have been identified.
Gradual and paced overloading of res-ponsive tissues is the essential principle that underlies the benefits of exercise training. Benefits accrue as the normal recuperative processes of the body respond and improve in function; this includes more strength, better flexibility, increased endurance, and improved coordination. Our goal is to stimulate these beneficial improvements, while avoiding any excessive strain on the involved tissues. Proper instruction, continued monitoring, and specific corrections are necessary factors preventing overload injuries.
There are three categories of exercise errors that indicate excessive loading of involved tissues. By paying attention to our patients as they perform their exercises, we can identify these problems early on, and make appropriate recommendations. Most problems with exercises are associated with a “loss of form.”1 This somewhat nebulous problem can be defined as consisting of three problems, all of which are easily identified by a doctor of chiropractic. These include problems with posture, alignment, and range of motion.
Posture. Be on the lookout for abnormal or imbalanced postures during exercising. Whether the patient is strengthening, stretching, or walking, hyperextensions and lateral shifts indicate an overload situation. This is easily seen during cervical training, when patients strain and push their heads forward, instead of maintaining a balanced alignment throughout their exercise.
Alignment. The more subtle deviation of misalignment during exercising relates primarily to the extremities. This can be especially noticed in the feet (toe-out), ankles (excessive pronation), and knees (knock-knees). These are all indicators that additional exercising in these conditions will likely bring about a recurrence of symptoms, rather than improvement. Addressing the align-ments and asymmetries is paramount for progress, and may require custom-made orthotics.
Range of Motion. Any limitation in movement range during an exercise should prompt a search for the underlying cause. This may be a reasonable self-protective response due to recent injury, or (more commonly) an inappropriate fear response. It is also possible that the patient is placing excessive loads on sensitive tissues that are incapable of handling that amount of stress in their current state.
Excessive loading, whether of resistance, flexibility, endurance, or proprioceptive exercises, is never helpful, and can be counter-productive. Five solutions for this all start with the letter “R”: Rest, Range, Rate, Resistance, and Repetitions.2
Rest. By increasing the rest period between exercises, or between sets, we allow the body to recharge and to better handle the overload. This is often the simplest of the solutions, as sufficient rest is frequently all that’s needed to avoid rehab overload.
Range. Controlling the range of an exercise or a stretch may be needed, especially in the initial phases of rehab. Particularly after an injury, connective tissues may be easily aggravated by forcing too much range. This is where the body can often let us know when we have gone too far, since it will give us a pain message. Initially, we should recommend that exercises be performed only within a pain-free range of motion.
Rate. Slowing down the pace of an exercise and incorporating a relaxed breathing cycle will often reduce exercise stress significantly. In fact, slow and controlled exercising stimulates more neurologic control and re-training without overstressing tissues.
Resistance. Whether using exercise bands, weights, or machines, careful control of the amount of resistance is important. Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation.3 However, excessive resistance can quickly produce the problems in posture, alignment, and range of motion described above, resulting in a poor response to care.
Repetitions. And, finally, one of the easiest ways we can overload our patients is to recommend too many repetitions of too many exercises. It is far better that a few repetitions of a few exercises be done regularly and consistently, and be interspersed with sufficient rest.
When we keep our eyes peeled for the three types of “loss of form”, and then carefully control the five “R’s” of rehab training, we can avoid exercise overload and ensure a smooth response to chiropractic rehabilitation training.
Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.
He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at PeaceHealth Hospital by email at
1. Mullineaux M. Strength conditioning: developing your teaching technique. Strength Cond J 2001; 23:17-19.
2. Mullineaux M, Rowe L. Manipulating training variables for safety and effectiveness. Strength Cond J 2003; 25:33-36.
3. Niesen-Vertommen Sl, et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.