Common Physical Therapy Mistakes #1: Poor Sequencing
Why Sequencing Matters in Physical Therapy
Effective physical therapy is crucial to successful recovery and rehabilitation after injury. Unfortunately, many PT programs are riddled with common physical therapy mistakes. Perhaps the most common is a lack of proper sequencing in exercise and treatment plans.
In this article, Dr. Gary Wang explains all you need to know about sequencing in physical therapy – and how sometimes just changing the order of exercises can make a big difference for you.
Physical Therapy Should Be Catered to Your Goals
Physical therapy should be tailored to your specific goals. For instance, the warm-up for a track athlete and runner differs significantly from that of a volleyball player or someone preparing for weightlifting. Therefore, a physical therapist should understand the demands of the activity that you are about to participate in order to prepare you for success.
This isn’t theory, either. There is a lot of scientific study to show that order of exercise makes a big difference to outcomes. For example, a 2019 study published in PubMed Central by Cardozo et. al concluded that, in circuit training, “It seems that exercise order should be considered when specific muscle weaknesses are a priority, so that these muscles are trained first within a circuit.”
Although this study was focused on circuit training for muscular strength and fitness, we often see that sequence of exercises matters more in rehab because of the presence of pain, injury and apprehension.
Common Physical Therapy Mistakes: The Order of Exercise is Important
When organizing a training session or workout, it is important to understand what the objective of the session is. The list of exercises can be the same for different goals, but the order in which they are conducted matters a lot.
Let’s say you have three exercises to do in a day:
Hamstrings curls and calf raises
Mobility work
Heavy squats
Let's say for example, you perform your heavy lifting and squats first, and then trained your hamstrings and calves, and lastly followed it up with mobility. There’s nothing inherently wrong with this but there may be more efficient and productive ways to sequence this workout (especially when rehabbing an injury)
The question is, what is your main focus? If it’s the squats, then the warm-up exercises and mobility work may prepare you for a better experience in the squats, because these will help you to build up to the squat.
Let’s say that we’re working with someone who is in pain or feeling apprehensive about getting back into lifting heavy, and squats are on the menu for the training session today – something that involves the whole body working together.
If we go right into the squats, things may or may not feel great. In this case, we can use the mobility work to first access and explore the body to see what is feeling tight or restrictive. We can then use some lower body and trunk exercises to build some awareness and confidence before putting it all together.
Essentially, what we are doing is taking the time to prepare for the main event: the squat. We need to take time to onboard the feet. We might do some calf raises, toe and foot rotting drills, and then work on the calves and hamstrings. When we start with a bottom-up approach, we make sure all the links in the chain are ready before putting it all together.
Educating Patients on Sequencing Benefits
Often, people come to us and say that they’ve done all the exercises on the internet, but are still experiencing pain and poor results. In many cases, it may be the actual load or intensity of the exercise that is the problem but that is for another article. If the load and intensity are within reason, then that’s when sequencing can play a huge role.
A good physical therapist will not only break down all the components of a movement; he or she will also explain why, and how they each play a role in the goal activity. The more you understand, the greater the buy-in to the correct way to achieve your goals.
What we do is help you find the hardest thing you can do well. We can then use this as the starting point for developing a tailored program for a successful rehab journey. This process is key in the long-term thinking of a successful exercise program. If we were to take you straight to the hardest thing you wish to do, we may be setting you up for failure.
Often, what we do is start you with an easier version of what they wish to do. This helps you build confidence and help you stack some small wins first. If you’re having a good experience and are developing strength, then we can move you on to greater challenges. As confidence, strength, and ability improves, we can begin to check things off the list and progress. At the heart of this progress, the sequence of exercise and programming progression is crucial.
Case Example: Addressing Knee Pain
Let’s put it all together with an example of someone who wants to work out but is dealing with knee pain. Often times, even though the pain is present in the knee, the root of the issue may actually be above or below the knee. When you treat the knee pain alone, you may receive knee massage, ice and stimulation, ultrasound, or an isolated exercise for the quads, hamstring, and so on. This doesn’t get to the root cause of the knee pain – it’s only treating the symptoms.
When you walk, run, squat, or jump, there’s a great amount of impact that has to travel through the knee. However, the first point of contact is your feet. If you’re not working well through your toes, arch, and feet, everything through the kinetic chain is affected – your arch, your Achilles, your calf, through your hips and back, and even up to your shoulders and neck.
So to look at just the knee when a patient is present with knee pain is simply not good enough. We need to look at their feet and how they produce forces. We need to understand how these forces translate through the entire body. We’re looking at how someone reacts to their feet hitting the ground, and how everything is working together efficiently. We cannot stress how crucial this is in the process and how in this case, working on the feet first can make a big difference for all the exercises that follow.
Simply put, physical therapy should be – it is – much more than focusing on one body part. When you understand this, then you understand why sequencing is so crucial to successful rehab.
The Reload Approach
I wish we could tell you that we have the perfect answer to pain. We don’t. No one does. Pain is complex, and unique to everyone.
What we do is take a scientific approach. It’s like a science experiment where we continue to make small changes and tweaks to exercise sequencing, overall programming, and regress and progress when necessary.
It’s a big-picture approach that enables us to develop a program of rehabilitation and exercise that makes the whole body stronger and healthier.
If you can’t handle the demands of strength training, for example, we may first need to start with some lifestyle modifications. This will help you become more active and build a level of fitness that enables you to add some strength training, knowing you’ll tolerate and recover better (don’t underestimate the importance of rest and recovery in fitness).
Going straight into heavy and intense lifting when you aren’t able to recover from it is a perfect example of how sequencing in macro programming (looking at the weeks and months) is just as important (if not more) than sequencing of exercises within a specific workout.
In conclusion, sequencing is not only important in the order of exercise you do within a workout session, but on a larger scale, sequencing can also play an important role in big picture planning for specific performance and health & fitness goals.
The first step to a new and complete you? Book a comprehensive 90-minute body evaluation with Reload.
