Anna is a 30-year-old former dancer, she is hypermobile, her level is intermediate. She has had a knee replacement 3 months ago had has adequate but not complete recovery yet. She also has minor joint instability particularly T 11-T12 and L1 which cause minor discomfort.
GENERAL CONSIDERATIONS AND COMMENTS.
Since Anna is hypermobile and a former dancer, her tendency will be to overextend and overstretch, simply because she can. The delicate balance in working with Anna is to strengthen and stabilize, and at the same time stretch the muscles enough to keep them from seizing up but NOT to promote flexibility. The distinction between appropriate stretching and end range extending a move which would promote flexibility, is a distinction that Anna needs to learn, and in the beginning, she is going to feel “reined in”, so we will avoid exercises where Anna’s tendency will be to overstretch, and train her in other exercises as to where is the appropriate place in the motion to stop.
GOALS OF TREATMENT – The primary goal of treatment is to strengthen and stabilize Anna and avoid flexibility exercises since she is hypermobile. Most of Anna’s exercises will be done either supine which takes the pressure off her back or sitting or side-lying. The goal will focus on complete powerhouse stability. Anna could also do some exercises standing up, keeping her core on and spine straight.
After Anna’s knee surgery it is important to remember that knees are designed purely for flexion and extension, so we will cautiously be exploring exercises to strengthen abductors, adductors, hamstrings, gluteal muscles, and hip flexors as Anna more completely recovers from her surgery ( about 6 months). No exercises will be done that cause “pain tweaks”. It is critically important not to over push the pace of remedial knee exercises.
EXERCISES TARGETING HYPERMOBILITY AND THORACIC INSTABILITY
NON REFORMER EXERCISES
These are simple but excellent exercises for Anna to include in her home program. Deceptively simple but effective reminders for Anna as to where she needs to focus her muscle awareness.
1. Roll up – mat exercise. Prone, legs and arms flat to start. This exercise will engage Anna’s core and encourage thoracic stability as she rolls up and back down, becoming aware of each vertebra. X 5 reps
2.Single leg circle – mat exercise. This exercise encourages Anna’s powerhouse stability. X 5 reps each leg.
3.Single Leg Stretch – Mat exercise. Pulling one leg in and bend. This is a good exercise to engage the core while making sure Anna’s back is flat to the carriage. X 5 reps
4. Saw – Mat exercise. Legs are flat and in an open V position. Anna will be reaching across to touch alternative toes. Abdominals will be engaged. While the twist is good for Anna, I would be careful with this exercise NOT to encourage too much flexion forward in the back muscles. This is an exercise which Anna could overdo. X 3 reps for each side
5. Spine Twist – Mat exercise. Sitting with legs out straight and arms to the sides. An excellent exercise for engaging the core and underarm muscles, while twisting from the waist. Anna needs to be able to do these kinds of motions in real life while maintaining stability throughout her lower and upper spine. X 5 reps for both sides
6. Pushups – Mat exercise. Since Anna’s level is Intermediate, I am going to presume that this is within her range of ability and is excellent for strong core engagement while keeping the entire back line straight. 3-5 reps, this can increase and also the number of counts to hold can be increased.
7. McGill Crunch – chest lift with no rotation. The goal here is pelvic stability and abdominal strengthening. 3-5 reps and hold for 10.
8. Upright standing for arms and torso rotation. Simple Twist focusing on core and upper thoracic control and stability while twisting from obliques. This is also a good exercise to do for Anna’s knee recovery as she needs to learn how to twist without jamming her knee. X 5 reps
9. Side lying – swinging one straight leg back and forth. Each side. This will require abdominal control and upper thoracic stability. It also engages the hip flexors and abductors. I would be careful since Anna is hyper-mobile, not to let her legs swing too far in either direction. This exercise can also be done in leg straps which would help with Anna’s control of her hyper-mobility. X 3-5 reps each leg
Most of the exercises recommended for Anna are supine as this is the easiest position to ensure her spinal stability as she is working on increasing core strength and overall stability.
Footwork Series: Foot work on the reformer was chosen because it is supine and alleviates pain that Anna may feel in the T11-12 and L1 area. It also is the easiest position and set of exercises to work on core strength and spine stability. The goals for this series include hip extensor strength, knee extensor strength, and ankle plantar flexor strength. Overall, Anna will be working her hamstrings and quadriceps as well as working to strengthen the muscles around the si joint. Time permitting in each session, a good variety of these footwork exercises would always be included in Anna’s program. Given her recent knee surgery, we would always be asking for feedback as to whether any exercise causes any knee twinges, in which case we would back off and do other exercises until the knee had further recovered. As Anna recovers from her knee surgery we can up the tension level on the springs. Any series of repetitions can be repeated.
1. Parallel Closed Heels x8-10 reps
2. Parallel Closed Toes x8-10 reps
3.V position open Toes, heels touching x 5 reps
4. Open 2nd Position parallel Toes x8-10 reps
5. Wide toes turned out, but be careful not to add this exercise until Anna’s knee recovers.x8-10 reps
6. Calf Stretch on both feet toes together, lowering with straight legs, and lower heels.
7. Running in place, alternating feet. Stretches calf muscles.x 10 reps
8. Single-Leg Heels and Toes. Since Anna is an intermediate client these can safely be added to her program to challenge her and add strength and test her stability. However, you would not do them until Anna’s knee is stronger. X 5 reps each leg
Other Reformer Exercises
- Lunges – Eve’s lunge would be a good exercise for Anna, especially the modified versions with one foot on tension bar cover or higher on foot bar because it keeps Anna’s back straight, and works IT band and hips flexing, but I would not include it at the beginning of Anna’s regimen because she would have a tendency to overextend and possibly hurt her knee. X 8-10 reps
- Bridging – which encourages pelvic and lumbar stabilization, and hamstring control. This gets Anna to start thinking about engaging other muscles to support her back. Adding a block between her legs for this exercise helps to focus more on the hamstrings as she squeezes the block to raise her pelvis off the mat. As Anna progresses with this exercise, I would move from a fixed carriage position to one where she bridges using tension springs. The more advanced Anna becomes, I would make the tension springs lighter. x 5 Reps and hold for 10.
- Frog – in leg straps-Target adductors ( inner thighs), hamstrings and hip flexors, while keeping Anna’s spine flat and still. X5 reps
- Leg Circles – in straps.Targets adductors ( inner thighs), hamstrings and hip flexors. X 5-10 Reps
- Modified Mermaid for Side Reach: Sitting Position. The muscle focus being the abdominals with obliques emphasis. The exercise objectives are abdominal control, oblique stretch, shoulder adductor stretch, maintaining flexion in lumbar, and a stable pelvis when reaching back. We are using the modified version so that Anna does not have to bend her knee. X5 reps on each side.
- Down stretch – The Movement is in the shoulder girdle and the arms will be engaged as Anna presses out against the springs. This exercise puts the back into extension, while Anna, in particular, needs to be maintaining a flat back. x 5 reps
- Short Box: Seated. Using tension bar, reps both vertically and at 45 degrees. The goal here is to engage Anna’s core, spinal lift, while maintaining control of the bar speed in both directions. Control is more important than spring tension. X 5 reps.
- Rowing Front. As Anna progresses, I would like to see her do some seated rowing. In this exercise, Anna is sitting straight and tall and will encourage torso stabilization. It will strengthen her abdominals, hip flexors, and stabilize her scapula including the serratus anterior, trapezius and rhomboids as well as Teres minor and major. It will stretch her hamstrings and improve her coordination. It also will strengthen her shoulder and rotator cuff muscles including pectoralis major, deltoid and latimus dorsi. X 8-10 reps
- Long stretch on the Reformer. Hands on foot bar and press out with straight back only (no arched back) x 5-6 reps
- Long box arms in pulling straps in prone position. There are different variations of this exercise but it strengthens the back of the body including latissimus dorsi, Teres Major, lower trapezius, erector spinal, glut Maximus. It strengthens the abdominals, increases scapular stability and improves leg and torso alignment. Building to X 8-10 reps.
EXERCISES TARGETING KNEE
Note that Anna is still in the relatively early stages of knee recovery, so it is important that she constantly gives feedback if she experiences any pain/ twinges.
1. Footwork – for strength and alignment of the lower body from hips to feet (see above for recommended list)
2. Bridging – for strengthening gluteal muscles and hamstrings, and stabilizing the back of the knee. The first phase is accomplished with fixed carriage on the Reformer, with legs on spring plate or foot bar but graduating eventually to a higher challenge to springs while keeping carriage stable as Anna bridges up. The lighter the springs become, the more core strength control is needed. See exercise also referenced in the above section.
3. Side lying legs – pendulum swings, which requires core strength for controlled execution. X10 Reps.
4. Feet in Straps- target adductors (inner thighs), hamstrings and hip flexors. Frog and leg circles as listed in the prior section.
EXERCISES TO START AND COMPLETE A WHOLE BODY WORKOUT
These exercises are good to do at the beginning and a fewer number at the end of any exercise session. They loosen up joints and muscles so that exercises on the Reformer can be better accomplished and they also give any client, including Anna, some very simple exercises to do at home. With Anna, she would need to be shown the difference between an appropriate stretch and avoiding end range of motion. Our goal is stability not flexibility.
- Pelvic Clock – Supine. Rolling pelvic area back and forth. Legs bent to loosen the base of the spine while keeping glutes and legs inactive. X 5 reps
- Knee sways – for upper thigh stretch and modest gluteal stretch X 5 reps
- Knee Folds. Supine, knees bent, feet flat. Clasp one leg at a time, moving closer to the chest. Alternate legs. Engage the core but do not move the Pelvis. X 5 reps
- Leg Slides (Supine Hip Extension) Supine, Legs Bent feet on the floor, to lengthen leg out from thigh, and feel hamstring stretch. Stretch out one leg at a time. Add variation of ankle rotation and toes wiggling. X 5 reps
- Stretch Supine, knees bent and feet flat. One leg crossed over the other. Take a knee in the opposite hand, pull stretch over for 3 inhalations/ exhale, outer thighs and gluteal and piriformis stretch. X 5 reps
- Supine One leg/ knee bent. Other Leg straight up vertical in the air for small circles, 5 in each direction (clockwise and counter-clockwise). Loosens the hips and works adductors. X 5 reps
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