Physical Therapy

Micheal L. Reed

Updated 6/2014

Types of Phyiscal Therapy:

Aquatic Exercise

An option open to clinicians and patients for exercise and movement training is to use the buoyancy and non-weight bearing environment of a pool or other water-based environment. What is unique about this approach is the medium in which the therapy is administered as opposed to a difference in exercise techniques. That being said, the aquatic environment does provide some unique opportunities relative to temperature, resistance, speed, and position that cannot be achieved in other settings.

Cardio-Respiratory Conditioning

Aerobic conditioning of the cardiac and respiratory systems carry many beneficial effects. Among the more important include improved oxygenation of all biological tissues, enhanced endurance, better quality sleep, weight control, improved patient confidence and reduced fear avoidance. All of these benefits can help with a speedier and better quality recovery with diminished functional decline and disability.

The style of cardio-respiratory conditioning must be considered with respect to each specific patient and what positions trigger their symptoms.

Patients who have more symptoms while sitting: Avoid using a bicycle for aerobic training. These patients may do well with upright aerobic training tools such as walking and/or elliptical machines. They may also wish to swim, as the water’s buoyancy can be relieving.

Patients who have more symptoms when standing or walking: This group may find using an upright or recumbent bicycle for aerobic training is the better choice.

Patients who experience symptoms related to load bearing (sitting, standing, or walking): In this patient population, the better choice may be swimming.

Core Training

Since 1992, “core training” has become a very popular method of treatment for patients with spinal disorders. In fact, it is the most popular method of rehabilitation used in patients recovering from spine surgery.

Core training is an approach used to re-establish proper muscle tone and sequencing of small muscles that lie deep in the trunk and pelvic floor. In doing so, advocates profess that the spine becomes more stable, stiff, and connected to the extremities. This creates a firm foundation from which the larger trunk muscles and limbs can be used to move the body. Studies suggest that, for a specific population of patients with documented spinal instability, core training can result in a measurable and meaningful reduction in symptoms and improvement in function.

The application of a core training program begins with the process of making an accurate diagnosis of spinal instability and relating that disorder with the presentation of symptoms. Once that condition is established, trained clinicians will teach a patient, using various techniques, to activate the deep trunk and pelvic floor muscles. In a stepped progression, a patient will develop proficiency in using the correct stabilizing muscles at the most appropriate times to facilitate proper muscle sequencing and efficient movement patterns. As an end-point, a patient will be challenged to maintain their core activation and proper sequencing patterns during normal functional activities and, in some cases, with sport-specific challenges.

Neuromuscular Re-education & Movement Training

Neuromuscular re-education & movement training is somewhat related to core training. These approaches can be used to for patients with spine-related symptoms, or for those with an underlying condition who are working to prevent recurrences. These techniques require an understanding of the relationship between stabilizing and mobilizing muscles, proper sequencing and optimal biomechanical motion patterns for a variety of daily tasks, occupational activities and sports-specific physical performance.

In these approaches, tasks are broken down into their most simple component single-joint movement patterns. These patterns are perfected with proper alignment, breathing, and muscle stabilization in non-weight bearing postures using manual or mechanical assistance. As the specific single-joint component pattern is mastered, without symptoms, the training becomes more complex and might include one or more of the following advances:

  • Multi-joint movement

  • Non-linear motion (circular or diagonal)

  • Weight bearing postures

  • Proprioceptive challenges (eyes closed, unstable surfaces, etc…)

  • Progressive resistance

  • Variable speeds and durations

An assortment of techniques, tools and apparatus’ can be used to provide neuromuscular re-education and movement training including: one-to-one instruction, motion and task modeling, tactile cuing, taping and bracing, imagery, audiovisual aids, pressure biofeedback, EMG, assistive training environments such as Pilates or Gyrotonic, balance boards, dumbbells, and other devices.

The end goal with these types of approaches is to move a patient through a process that begins with:

  1. Unconscious movement incompetence (they don’t know what they don’t know), as it relates to efficiency and economy, to

  2. Conscious movement incompetence (they know what they don’t know), to

  3. Conscious movement competence (they learn through practice and repetition – this is the longest phase), and finally,

  4. A state of unconscious movement competence (Mastery). The last phase represents an integrated pattern of task performance that is safe and injury-resistant

Reactivation (Including Cognitive Behavioral Conditioning & Biometric Monitoring)

Many patients who suffer from spine-related symptoms quickly become deconditioned systemically (fatigue-resistance) and locally (disuse muscle deconditioning). These changes result from extended periods of rest and recuperation. In addition, deactivation of the body can lead to lower self-esteem, reduced confidence, poor body image, sleep disturbances, changes in appetite, fear and other problems.

Reactivation is a process of physical and mental stimulation in which a patient begins to perform normal physical activities, using proper body mechanics, in a dose-progressed manner. By grading the reactivation with recovery after bouts of effort, a patient can build their confidence, fatigue-resistance, and muscle conditioning. This should occur without uncomfortable delayed onset muscle soreness.

Small and controlled successes will lead to a graduated achievement of reactivation that permits reentry into typical daily activities, occupational demands, and recreational endeavors. Most importantly, a patient will realize the limitless capacity of their body to function at high levels without symptoms or without worsening their spine-related condition. This is a critical process through which a patient can achieve a full recovery.

Strategies for reactivation can include supervised training and guidance. In addition, remote monitoring devices can be worn on the wrists, ankles, and waist or attached to a garment. These devices record various biometrics such as number of steps taken, caloric expenditure, heart rate, and sleep patterns. The data collected can provide valuable feedback with respect to the patient’s activity levels during the day and the quality of their rest at night. This helps the health care provider gain a better understanding of their progress and activity tolerance.


Many patients with spine-related symptoms and functional deficits lose strength in specific muscles or groups of muscles for two reasons:

  1. neurological compromise caused by compression of the nerve roots or spinal cord or

  2. disuse and deconditioning when patients have a period of prolonged rest and convalescence.

Poor strength might be a contributing factor to the development of a spine-related disorder if the demands placed on the spine exceed a patient’s strength capacities.

Before starting any strengthening program, overload must be considered. Muscles must be taxed to their upper limits of capacity over a number of sessions so that they can get stronger. This process can take many months of effort. In the early phases of a recently initiated strengthening program, most of the gains are in learning and neuromuscular adaptation. Learning and neuromuscular adaptation lead to a better efficiency and economy of movement, which can quickly increase the load capacity of a muscle. While these early changes are exciting and encouraging, they are not necessarily associated with the kind of strengthening characteristic of muscular development.

Strength training, as part of a rehabilitation approach, can be used to restore muscle loss due to resolving neurological compromise or to reverse changes caused by disuse or deconditioning. In addition, strength training may be prescribed as a means of easing recurrent spine-related symptoms if pre-episode deficits are identified or suspected.

A strengthening program can be performed under the supervision of a trained medical professional, athletic trainer, personal trainer, or in a self-directed manner. Studies have shown that general strengthening can be beneficial in spine-related disorders. Further, for certain conditions and deficiencies, targeted strengthening that is customized for an individual patient can provide superior benefits to generalized strengthening.

Typically, strength training is performed 2-5 days per week. The program may be dosed and consist of any number of movement patterns performed 8-20 times over 2-4 sets. A tremendous amount of variability with respect to the loads, intensity, volume and duration can be utilized to achieve the desired results.

Various types of equipment can be utilized to assist in a strengthening program. Common elements include barbells and dumbbells, exercise machines, medicine balls and elastic cords.


Lack of flexibility in certain muscle groups and regions of the body has been linked to spine-related symptoms. A cause and effect relationship has not been clearly established; however, in some patients, improving the flexibility of the muscular or tendon tissue and connective tissue elements can enhance recovery and reduce focal areas of tension and stress.

Stretching can be integrated as part of a multi-faceted approach. Various techniques may be employed ranging from static, passive, low load, long duration strategies applied by a therapist to contract-relax tactics that enhance muscle reception to stretching. Programs can progress to ballistic muscle lengthening techniques used before sport participation.