Functional, work-related exercises provide an effective paradigm for assessing and improving function.

One of the greatest challenges of industrial rehabilitation is ensuring long-term recovery and reducing the reoccurrence of injuries in a cost-effective manner. In today’s economy more than ever, time is money. This motto has become even more evident in workers’ compensation and industrial rehabilitation. Increased pressure on clinicians from case managers and employers makes it imperative to see patients quickly and return them to work as soon as possible.

Because of this urgency, return-to-work decisions can be largely focused on overall level of pain. If patients have little to no pain, they may be deemed ready to return to full duty regardless of their true functional abilities. Employers and case managers sometimes fail to see the negative long-term consequences of using decreased pain as the sole criterion for return to work. Patients may have little pain at rest, but lack the functional ability to perform their jobs due to the weakness and stiffness associated with their current injury. Part of our job in outpatient physical therapy is to shift the focus to function by integrating functional, work-related exercises.

The sports medicine model of the “four pillars of human movement” can be an effective approach for developing exercises that address work-related function. This article provides insight for therapists who want to break down job-related activities into the four pillars of movement and utilize exercises that help to build work-related function.

FOUR PILLARS OF HUMAN MOVEMENT

In most physical and occupational therapy education programs, students are taught three planes of movement: frontal, sagittal, and transverse. In contrast, the sports exercise field often refers to the concepts of the four pillars of movement popularized by Juan-Carlos Santana. The four pillars include: 1) push/pull; 2) change of elevation; 3) rotation; and 4) locomotion. Taken together, these four elements can provide an effective paradigm for assessing and improving function.

Push/pull involves any exercise that requires the upper or lower body to push weight away from or pull weight toward the body. Examples of pushing exercises would include chest press, overhead press, leg press, or pushing a sled.

Change of elevation involves any exercise that requires physically changing the body’s elevation. An example of change of elevation would include squats, deadlifts, step-ups, and lunges.

Rotation involves any exercise that requires a rotational component. Examples of rotation exercises include ball toss, wood chops, rotary torso, and repetitive trunk rotations.

Locomotion involves activities such as walking, stair climbing, bike riding, crawling, and sidestepping.

The more pillars of movement included in an exercise or exercise program, the more functional the exercise is for the patient. Some traditional straight plane exercise programs include push/pull or change of elevation but lack rotation and locomotion. Gym equipment typically uses only one pillar of movement and does not require balance, coordination, core stability, and overall functionality.

BREAKDOWN OF JOB-RELATED ACTIVITIES INTO FUNCTIONAL EXERCISES

With breakdown of any job-related activity into functional exercises, it is important to determine the activity demands. Does the activity require any dynamic materials handling such as floor-to-waist lifting, waist-to-eye level lifting, or pushing/pulling? Are the body positions required for the task static or dynamic? Does the lower body maintain a static position while the upper body is engaged in a dynamic task? Does the activity require any mobility such as walking, stair climbing, or repetitive trunk rotation? Does the activity require a high level of endurance? Job-related activities can require a combination of demands such as dynamic lifting combined with mobility and endurance.

Once the demands of the activity have been established, it is important to determine the pillar of human movement: push/pull, rotation, change of elevation, and locomotion. Most job-related activities involve multiple functional planes of movement. An example is the tarp-lift for a flatbed truck driver. This activity involves lifting a tarp from the floor to shoulder height along with transporting the tarp to the edge of the flatbed truck. Push/pull, change of elevation, rotation, and locomotion are all involved in a tarp-lift to a flatbed truck.

This activity can be performed using a power clean technique or a half-kneeling technique. The power clean lift technique can be broken down into five progressive parts with each part requiring at least one pillar of movement: 1) Deadlift (change of elevation); 2) Power Shrug (pull); 3) Upright Row (pull); and 4) Front Squat (change of elevation), then progressed into an over-the-shoulder carry (rotation and locomotion); and 5) press up on to the flatbed truck (push).

POWER CLEAN TARP-LIFT
  1. Deadlift—Keep arms fully extended, drive through legs, bringing tarp as close to the body as possible up to mid-thigh.
  2. Power Shrug—Keep arms fully extended, rise up on toes while shrugging shoulders toward ears.
  3. Upright Row—Lead with elbows, bring elbow out to side lifting tarp straight up toward shoulder, keeping tarp as close to the body as possible, finish with elbows higher than shoulders.
  4. Catch into Front Squat—Once tarp reaches chest height during the upright row, drop elbows down and in, while lowering body into a squat position. The speed of the lift should generate enough momentum to allow the patient to drop underneath the tarp. The squat is called a front squat because the weight is positioned in front of the body instead of behind on the shoulders.
  5. Firefighter Carry—Transition the tarp across either shoulder, support with opposite hand in front and same hand across the top of the tarp.

Using a half-kneeling technique changes the progressive parts into: 1) a lunge/split squat (change of elevation); 2) double hand hammer curl with alternating hand grip (pull and rotation); and 3) an over-the-shoulder carry/firefighter carry (locomotion).

HALF-KNEELING TARP-LIFT
  1. Starting Position—Half-kneeling position with either leg down and tarp standing in tall position.
  2. Split Squat/Lunge—With tarp across leg, lean forward, driving through front leg stand up.
  3. Double Hand Hammer Curl—On the way up into standing, transfer inside hand underneath and begin curling tarp up toward shoulder.
  4. Firefighter Carry—Transition the tarp across either shoulder, support with opposite hand in front and same hand across the top of the tarp.
SELECTING THE MOST APPROPRIATE TECHNIQUE

How to determine which technique is best for the patient? These techniques require different levels of skill. The power clean technique requires greater skill and coordination but allows the patient to generate a greater amount of force for heavier loads. The half-kneel technique requires less skill but does not allow the employee to create as much force. One disadvantage for using the half-kneel approach is that patients may have difficulty getting up off the floor due to obesity or knee pain. However, if a patient does not demonstrate adequate squat technique, the power clean technique should not be used. Poor technique can be due to factors such as lack of coordination, flexibility, balance, and/or strength. The therapist must be able to determine which factor(s) is preventing the patient from having success.

TEACHINIG PROPER SQUAT TECHNIQUE

Proper squat technique includes the following progression. 1) Start with feet shoulder width apart, weight on the heels, knees slightly bent, bottom out, shoulders back, chest out, and head up. 2) Slowly bend at the hips and knees maintaining body weight shifted on heels with shoulders back, chest out, and head up until reaching 90 degrees or the object to be lifted. This allows the patient to maintain a neutral to slightly extended spine and keeps the knees from going over the toes. If weight is shifted off the heels onto the forefoot or over the toes, then the center of gravity will occur primarily through the knees and less through the hips. This position can result in increased knee pain along with loss of balance and lack of core stability. 3) Once you have achieved a full squat, drive through the heels using hips first, then the knees, to return to the start/ready position. Driving through the heels and hips utilizes the hip extensors instead of just relying on the quadriceps and knees to do the work.

SQUAT TECHNIQUE

The split squat applies the same principles with the difference of an offset stance. The split squat is a variation of the lunge exercise. The front leg is the driving force of the lift just like a runner drives off the front leg in a race. The back is used for balance along with assistance but should not be used as the main driving force to lift the weight. Teaching a patient how to perform a lunge is the best way to prepare a patient for the half-kneeling technique. 1) Feet should be shoulder width apart with nondominant leg forward if possible and dominant leg back. Back leg should be at a comfortable distance and should not result in a stretch on the back leg. 2) Weight should be shifted to the nondominant leg during the squat.

SPLIT SQUAT/LUNGE TECHNIQUE

Using the example of the tarp-lift for a flatbed truck driver, the following exercises have been identified when using a power clean technique: deadlift, shrug, upright row, front squat, and push press with or without ambulation to be implemented in the exercise program. Each exercise should be performed separately in progressive order as follows: deadlift, shrug, upright row, front squat, and push press. With all exercises, progress weights on each exercise as appropriate as long as technique is not compromised. During each visit, component parts should be combined in a manner that progresses toward one fluid movement. The following sequence for progressing lifts into a full power clean should be used after one to two visits, which allows for learning and understanding individual exercise parts.

Suggested sequence for progressing into one full power clean:

  • Rep 1—Deadlift with shrug
  • Rep 2—Deadlift with shrug and upright row
  • Rep 3—Deadlift with shrug and upright row into a front squat
  • Rep 4—Deadlift with shrug and upright row into front squat finish with press up

Combining the component parts helps the patient transition into the full power clean technique using graded exposure. Practicing the whole sequence of movement as the last step reinforces learning. When combining component parts, weight progression should occur at a slower rate than the individual component exercises. Technique should always remain the focus when progressing weights. If the patient’s technique diminishes with increasing weight, then return to the previous weight and increase the repetitions. Once safe technique is demonstrated, patients will make strength gains rapidly. If the patient does not initially demonstrate the ability to perform certain aspects of the entire lift, the therapist should instead have the patient perform low-level functional exercises that promote success with the difficult task. For example, if patients cannot perform a full squat, have them instead perform mini-squats, wall sits, bridges, and sit-to-stand from an elevated sitting position.

CONCLUSION

Incorporating functional components and using the four pillars of human movement—with functional exercises that truly mimic job demands—help to maximize recovery and prevent reoccurrence of injuries. After mastering work-related function, the patient is truly ready to return to the job. With confidence knowing they have successfully performed job-related activities, fear of reinjury diminishes. Reinjury is less likely to occur because the employee has achieved the strength, flexibility, coordination, balance, and endurance to perform job-related tasks. Patients will have a better understanding of the biomechanics of their jobs and how to best approach the tasks at hand with proper technique. Since these functional tasks are addressed during the outpatient therapy phase of treatment, there is less need for formal work conditioning or transitional duty, and return to work is accomplished in a more cost-effective manner. This type of functional approach helps to differentiate a practice in a competitive field where it is sometimes difficult to achieve differentiation. And when all is said and done, both the patient and the employer come out ahead.

TABLE 1. Power Clean Technique
Functional Components Pillars of Movement Functional Exercise
Deadlift Change of Elevation/Pull Body Weight Squats, Wall Sits, Bridges, Leg Press, Side Steps with Theraband around ankles, Core Stablization
Power Shrug Pull Seated Shrugs, Walking Carrying Dumbbells at side
Upright Row Pull Side lateral raises, Rows, Low Rows
Front Squat Change of Elevation Sit to Stand with high low table, Bridging, Single leg eccentric lowering with step, Wood chops
Firefighter Carry Rotation/Locomotion Reverse Grip Curls, Lunges with Barbell, Core Stabilization
Push Press Push Shoulder Press, Curl to Press with Dumbbells, Core Stabilization

TABLE 2. Half-kneeling Technique/Split Squat
Functional Components Pillars of Movement Functional Exercise
Split Squat/Lunge Change of Elevation Pitcher lunge, Bridges, Step-ups
Double Handed Hammer Curl Pull Wide based Pile with DB, Single Arm Curl to Press with DB
Firefighter Carry Rotation/Locomotion Reverse Grip Curls, Lunges with Barbell

POWER CLEAN TARP-LIFT

1. Deadlift

2. Power Shrug

3. Upright Row

4. Catch into Front Squat

5. Firefighter Carry

  1. Deadlift—Keep arms fully extended, drive through legs, bringing tarp as close to the body as possible up to mid-thigh.
  2. Power Shrug—Keep arms fully extended, rise up on toes while shrugging shoulders toward ears.
  3. Upright Row—Lead with elbows, bring elbow out to side lifting tarp straight up toward shoulder, keeping tarp as close to the body as possible, finish with elbows higher than shoulders.
  4. Catch into Front Squat—Once tarp reaches chest height during the upright row, drop elbows down and in, while lowering body into a squat position. The speed of the lift should generate enough momentum to allow the patient to drop underneath the tarp. The squat is called a front squat because the weight is positioned in front of the body instead of behind on the shoulders.
  5. Firefighter Carry—Transition the tarp across either shoulder, support with opposite hand in front and same hand across the top of the tarp.

HALF-KNEELING TARP-LIFT

1. Starting Position

2. Split Squat/Lunge

3. Double Hand Hammer Curl

  1. Starting Position—Half-kneeling position with either leg down and tarp standing in tall position.
  2. Split Squat/Lunge—With tarp across leg, lean forward, driving through front leg stand up.
  3. Double Hand Hammer Curl—On the way up into standing, transfer inside hand underneath and begin curling tarp up toward shoulder.
  4. Firefighter Carry—Transition the tarp across either shoulder, support with opposite hand in front and same hand across the top of the tarp.

4. Firefighter Carry


TEACHING PROPER SQUAT TECHNIQUE

Proper squat technique includes the following progression. 1) Start with feet shoulder width apart, weight on the heels, knees slightly bent, bottom out, shoulders back, chest out, and head up. 2) Slowly bend at the hips and knees maintaining body weight shifted on heels with shoulders back, chest out, and head up until reaching 90 degrees or the object to be lifted. This allows the patient to maintain a neutral to slightly extended spine and keeps the knees from going over the toes. If weight is shifted off the heels onto the forefoot or over the toes, then the center of gravity will occur primarily through the knees and less through the hips. This position can result in increased knee pain along with loss of balance and lack of core stability. 3) Once you have achieved a full squat, drive through the heels using hips first, then the knees, to return to the start/ready position. Driving through the heels and hips utilizes the hip extensors instead of just relying on the quadriceps and knees to do the work.

Proper Squat Technique


Ryan Hunt, DPT, CSCS, is outpatient services manager for ErgoScience Inc, Birmingham, Ala.

Deborah Lechner, PT, MS, is founder and president of ErgoScience Inc. She has more than 25 years of clinical experience as well as an extensive research background. For more information, contact