Figure 1. Maintaining a plank position. Author Laura Keller, MPT, left, oversees client Olivia Ramsy.

When a physical therapist adopts the motto “Fitter, Faster, and Stronger,” they have a lot to live up to—especially when applying said motto to a world champion freestyle skier, a professional dancer, a collegiate athlete, as well as the grandmother who wants to return to gardening and playing with her grandchildren.

As a physical therapist, I approach each patient with the goal of not only returning them to function, but with the aspiration of giving them the treatment, tools, and knowledge to return to life beyond the functional. While some may argue this is not always a possible and attainable outcome, my rebuttal is that it is with this intention that a therapist must approach every patient—regardless of age or ability.

To reach beyond function, patients must have an intellectual understanding of the general kinesiologic principles of the core and the concept that every joint and muscle in the body works in three planes of motion. I find that patients often do not grasp this concept and that they are stuck in the uni-planar mind-set, not realizing that muscles never act in isolation without some concurrent foundation from the rest of the body.

Rehabilitation exercises and regimens should be geared toward asking the body to react to—and overcome—forces from all angles. The muscles must be coordinated well enough to mesh their individual abilities to overcome the forces acting upon the body (ie, gravity, cutting, twisting, and jumping). Traditional weight room exercises are certainly not obsolete. They can be important for building a base and helpful for an athlete to see objective progress. However, in order to make the most of the hard work one may put into the weight room, the neuromuscular system (the ability of the nerves to “talk to” the muscles) must be trained as well. In other words, the body is most efficient when groups of muscles work in unison. When someone trains a muscle in isolation (as do some weight machines), they are essentially training the muscle to do something new because it would rarely, if ever, function that way in daily life. One muscle will feed off another and produce an efficient and strong contraction when placed in an “action” situation much more easily than when put in isolation such as on a weight machine. Additionally, muscle produces the greatest force when put on a stretch or “wound up,” that is why we squat down first before attempting to jump our highest, that is why pitchers pull their arms and trunk so far back before a throw (the “windup”). Three-dimensional exercises use this property to get the most out of a muscle. The beauty of it is that this is exactly how the body would naturally attack an athletic task.

Want more information on core strengthening? Read “Getting to the Core“.

In my therapy practice, I have had the privilege of working with many professional and elite-level athletes; speaking at and contributing to conferences for professional women athletes; and touring as the PT for three different ski tours. I have also been the PT for several ballet companies. As part of the effort to return these athletes to their high level of activity, I used the same approach to their treatment that I use for all of my patients—I treat them all as if they were professional athletes, adjusting individual intensity levels and focusing on the patient’s ultimate goal. Also, I incorporate a philosophy of total body movement to gain full function and maximum fitness. This concept combines using “core” strengthening with more traditional lower extremity strengthening. The core is comprised of the localized and global muscles of the torso and pelvis, creating a foundation from which to utilize the extremities. One may look at it in an abstract way as a tree having a solid and sturdy trunk (the core) on which to support the branches (the limbs). Just as a tree will receive water and nutrients from its roots, we know that the human trunk houses our own nerve and blood supply and through core strengthening the neurologic and vascular output to the arms and legs is maximized.

Figure 2. Feet on exercise ball plank position. Keller guides Ramsy through the exercise.

In the past, rehabilitation meant gaining the range of motion and the strength only at the affected body part. Now, we argue that there is so much more than that to reach a patient’s maximal potential. Along with the focus at the injury, we look at the whole body, with the goal of integration. This is necessary because of the natural inhibition that the involved extremity will go through after any traumatic or chronic injury. For example, with a patient who has undergone anterior cruciate ligament surgery, the quadriceps will weaken and atrophy and the sense of proprioception is diminished. This inhibition is part of a neurological reflex that tries to protect the limb by not letting you use it. With exercises that involve the core along with the leg, the amount of disconnect is lessened. This is a principle that has deep roots in the rehabilitation of spinal cord injury and stroke victims, and physical therapists in the rehab arena for stroke and brain injured patients have been using a specialized version of the concept (proprioceptive neuromuscular facilitation and neuro-developmental treatment) since the 1940s. Standard care for these neurologic patients involves exercising all unaffected parts of the body, so surely the principle stands for orthopedic patients.

Plank Position Variations

(The accompanying series of images depicts several rehab clinic clients working through their regimens of core strengthening exercises based on the plank position.—Ed.)

Maintaining a Plank Position: A ballet dancer who is recovering from an ankle and foot injury should be bridging and going for her personal record in holding the plank position (see example in Figure 1).

Feet on Exercise Ball Plank Position: Have the client lie on their back, put their feet on an exercise ball, and rise up into a plank position with only the upper shoulders and head touching the ground. Hold a small weight (3 to 4 pounds) in each hand pointed toward the ceiling, then lower one weight to the ground, keeping that arm straight, while the other remains up. Then bring the weight back up and lower the opposite arm (see Figure 2).

Figure 3. Exercise band and flat-based exercise ball rotator cuff rotations.

Do not wobble and maintain the plank position!

Exercise Band and Flat-Based Exercise Ball Rotator Cuff Rotations: For a pitcher returning to a weekend recreational baseball team, any exercise band rotator cuff exercises should be done while holding a plank position or while standing on a flat-based exercise ball.

Stand in a split stance on the ball and take the arm up into horizontal abduction, pull exercise band into external rotation, and maintain balance (see Figure 3). The application of this viewpoint can also go toward spine patients. It may be stating the obvious to point out that a low back patient needs to be given core exercises. Yet it may not be so obvious to apply the whole body concept to spinal rehabilitation. For instance, along with traditional core exercises for the spine, the rehab program should advance to a stage where the client is squatting, properly using those very same core muscles that they used while bridging. When tolerable, the program should include step-ups and lunges, lifting medicine balls and doing push-ups to strengthen the arms. All of these extremity exercises need to be instructed with the clear concept that the core is engaged and assisting the movements, for I have never seen a low back patient who does not need to rise out of a chair, go up stairs, or lift an item onto a shelf. If they are not trained to incorporate the core with these functional movements, then they may risk reinjury or a worsening of their current symptoms.

The overall goal is easily achieved by incorporating a balance or tri-planar element to any traditional exercise by using flat-based exercise balls, balance discs, plyoballs, and free weights.

The Balance Move

The Semicircle Cup Touch: Place five cups in a semicircle about the diameter of the client’s arm span. Stand on one leg on a balance dot or any balance toy (if there is not access to one, then stand on a rolled up towel) and reach with the opposite hand to touch the cups. The client must touch and return to upright before touching the next cup. Then switch legs and do it again with the opposite hand (see Figure 4).

Figure 4. The semicircle cup touch.

Lower Body Move

Reverse Lunge on an Exercise Ball: This move incorporates balance, core, and leg strengthening. Stand on single leg with opposite leg behind you with the shin on an exercise ball. Lower the body into a lunge position by letting the back leg roll the ball away from the client. Then return to an upright position on the standing leg, rolling the ball back to the shin (see Figure 5).

Agility Move

Side Plank Rotations: The body is held in a side plank (a T-position); with the upper arm, reach high and to the ceiling, then bring the arm down slowly to wrap under the body, going into slight rotation at the trunk, then slowly unwind and reach up toward the ceiling again (see Figure 6). Repeat 8 to 10 times on each side.

Upper Body Move

Ball Push-ups: Lie over an exercise ball on stomach, walk out on hands into a push-up position, keeping hips up and not allowing the back to sag (see Figure 7). Do 10 push-ups.

By incorporating the three planes of motion along with the essentials of core training, we can all achieve the goal of making our patients Fitter, Faster, and Stronger!

Laura Keller, MPT, is the director of rehabilitation at The Stone Clinic (, San Francisco. For further information, please contact .

Figure 5. Reverse lunge on an exercise ball. Figure 6. Side plank rotations. Figure 7. Ball push-ups.