Consider Adding “Pre-Habilitation” to Your Exercise Recommendations


At some point in life, 80% of the population will suffer from back pain, a primary cause of musculoskeletal degeneration and also one of the top reasons for visits to a physician.

What most people—including many doctors—do not realize is that a primary cause of problems like back pain is physical inactivity.

The truth is that long periods of time spent in sedentary postures in our cars, at our desks, in front of the computer or TV result in a progressive deterioration of muscle and joint function, and significantly compromise our ability to move with ease and fluidity. A sedentary way of life results in joint ailments, as well as over-used and abused muscles.

Yes, it is possible to overstrain muscles by sitting improperly and for too long!

fitnesscoachingTo compound the matter, a de-conditioned body is at much higher risk of injuries, so when sedentary people suddenly decide to exercise—for health, for enjoyment, or both—they are much more likely to strain and injure themselves.

Fitness professionals are increasingly aware of the need to help people with the basics of skillful movement before embarking on more intensive programs to build muscle, burn fat, or increase endurance.

In my experience as a personal trainer, I find that many clients are seeking exercise programs that bridge the gap between rehabilitation and conditioning. They want to age gracefully and improve fluidity in their everyday movement. Most of all, they want to prevent unnecessary non-contact injuries.


People are starting to understand the repercussions of poor form, poor posture, and decreased range of motion. They can really benefit from programs that focus on restoring freedom and ease of motion. This is a new and exciting direction in the fitness industry, one with important implications for physicians.

Think of it as “pre-habilitation” to prevent musculoskeletal pain, injury and long-term disability.

The consensus is that low to moderate intensity exercise is safe for the vast majority of people. That is true as long as we first address musculoskeletal imbalances so that strength does not get built on top of dysfunction. According to the National Academy of Sports Medicine (NASM), “the new mindset in fitness should cater to creating programs that address functional capacity, as part of a safe program designed especially for each individual person.”

Exercise can truly be therapeutic for a wide range of conditions and disorders, but the benefits can easily be overshadowed by injury. Step one of a sound training program is to create a solid foundation. This foundation phase involves corrective exercises for areas of the body that have limited range of motion (i.e. flexibility, mobility, and stability). If limitations in these areas are not addressed, pain will come knocking sooner than later.

The body will naturally choose the path of least resistance—whatever it may be– andnasm will try to keep moving in order to minimize energy expenditure. Over-facilitated or overactive muscles result in other muscles becoming under-active or inhibited (“shutting-off the muscle”). In turn, other sets of muscles will have to compensate for this loss of function. The combination of imbalances in the musculature plus the tendency toward momentum in the path of least resistance is a recipe for injury and pain.

Balancing Mobility & Stability

An initial assessment aimed at identifying musculoskeletal imbalances is essential for any therapeutic exercise program. Biomechanical assessments based on basic movement patterns can help identify the capabilities, competencies and limitations of each individual’s body.

This is a logical approach to movement evaluation that involves looking at what happens to the body during integrative (full body) movement. Can an individual properly execute a given movement? What is their range of motion capacity? Is one side of the body more dominant that the other? Is there any pain associated with that movement? From these observations, it is possible to determine if there are any alterations in joint mechanics and muscle recruitment.

Any weak links identified during the assessment should be the focus of the initial training program. In the realm of fitness it becomes obvious—sometimes painfully—that we are only as strong as our weakest link. So the initial phase of a therapeutic exercise program should entail exercises to help correct imbalances noted during the biomechanical assessment.

The joint-by-joint theory developed by renowned physical therapist and functional exercise training experts, Gray Cook and Michael Boyle, states that the body is a succession of mobile and stable joints. Each joint has a dynamic range of motion, which depends on flexibility as well as the ability of the neuromuscular system to control it efficiently in three planes of motion.

Loss of flexibility due to tightening (or shortening) of muscles or loss of neuromuscular control due to under-active (inhibited) muscles will result in a loss of mobility. This is why the sedentary lifestyle is so detrimental: it encourages tightening and shortening of certain muscles and the absence of neuromuscular activity speeds the decline.

Having full mobility leads to having full proprioceptive (sensory input) awareness. The body knows where it should and should not be and how to control its moving parts in the presence of change. This, too, is compromised by a life spent sitting in front of a screen.

Stability refers to efficient joint support during movement. It is achieved by firing of the right muscles, with the right force, at the right time and in the right sequence. Proper neuromuscular control is relative to stability. Without it, muscular compensations occur, leading to potential muscular disorders, pain, and potentially injury.

Corrective Exercises

One cannot think of building strength, which requires putting the joints under increased stress levels, without ensuring proper joint stabilization first. Imagine if one side of the body possesses proper mobility/stability patterns and the other does not. What happens? The result is equivalent to driving a car with one foot on the gas and one on the brake.

The joint by joint theory suggests that pain at one site stem from what is happening at the joint above or below the site of the pain. Take the spine for example. The atlanto-axial joint is mobile, the rest of the cervical spine is stable, the thoracic spine is mobile, and the lumbar spine is stable. Loss of mobility in the thoracic spine potentially results in increased mobility (ie, decreased stability) in the lumbar spine. A decrease in lumbar stability can lead to lower back pain and injuries.

The same can be applied to the limbs and the shoulder or pelvic girdles. Another primary example is pain at the knee, which is often the result of pain or dysfunction at the ankle or hip. The knee is expected to be a stable joint. Loss of hip mobility will result in the knee having to compensate by increasing its mobility, which can lead to pain and injury.

AnatomyTrainsCorrective exercises in the initial training phase are based purely on positively influencing the neuromusculoskeletal system. These exercises teach the mobilizers of the body to be more mobile and the stabilizers to be more stable.

Another main feature of corrective exercises is that they facilitate appropriate movement in all three planes of motion: the sagittal plane, frontal plane, and transverse plane

Only two joints in our bodies—the knees and the elbows–move preferably along one plane (sagittal). All other joints can and should be able to move in more than one plane of motion.

When it comes to strength training in the gym, most often we see people on weight machines. One of the big limiting factors with machines is that they keep the body constricted to one plane of motion. Therefore, if we forget or neglect to train (move) in all three planes, the body will lose its ability to control movement, potentially resulting in stress injuries due to the unnatural motions in the joints.

Another important reason to train in all three planes is the fact that the modern human body moves predominantly in the sagittal plane (forward and backward). Running and cycling, two of the most popular recreational activities are entirely based on repetitive forward motion. The legs always move sagittally. Serious runners and cyclists who do not cross train or participate in other activities, often develop ‘knock knees’ (knees turned in).

To break it down, ‘knock knees,’ also known as knee valgus, originate from underactive gluteus muscles and overactive hip adductors, hip flexors and hip internal rotation muscles. To restore proper knee function, one must focus on strengthening the gluteus muscles and attenuating the overactive muscles of the hip.

This is just one example of a common musculoskeletal imbalance that can potentially be prevented with a good biomechanical assessment and exercises directed at restoring balance. There are many others.

How does all of this apply in a medical practice?

Odds are, you’re already encouraging your patients to exercise. Certainly many people are looking for guidance on how to exercise and what forms are most appropriate. Any time the topic of exercise comes up in a clinical encounter, start thinking about the integrity of the individual’s movement patterns and posture.

If you’re already interested in exercise and fitness, and it is a major part of your practice, consider obtaining some training in biomechanics. Otherwise, help your patients find a physical therapist, movement specialist, or fitness professional specialized in biomechanics.

By referring to and collaborating with qualified fitness professionals you’ll spare your patients the difficulties—and injury risks—of going at it alone. You’ll also be able to feel confident that your patients’ exercise programs are based on the science of human movement.

This is not a one size fits all approach. It is tailored to each unique individual’s lifestyle, biomechanical function, movement capacity, and health goals. Going beyond the foundational phase in exercise programming, health and fitness professionals can work with you and your patients to design in-depth fitness programs.

The more integrated a training program can become, the better. For example, incorporating components such as flexibility, balance, cardiorespiratory training, and strength/resistance training will ensure that the client has a balanced program.

For further information and additional resources, I highly recommend two books: Anatomy Trains by Thomas Myers, and Movement by Gray Cook. These resources specialize in therapeutic and functional movement and provide practical application strategies.

Regardless of athletic or activity status, everyone needs to master fundamental and functional movement patterns. Exploration of these natural movement patterns results in the improved function of multiple organ systems, and in turn, improvement of overall health and quality of life.


Brittany Cushman holds a Master’s degree in Integrative Health Studies from the California Institute of Integral Studies. She currently works as a certified personal trainer at Equinox Sports Club in Los Angeles, CA where her passion is helping clients bridge the gap between rehabilitation and fitness conditioning.

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