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Functional training part 2:
integrating functional training
into clinical practice
. . . . . . . . . . . . . . . .
Craig Liebenson
Introduction
This reactivation approach consists
of four fundamental action steps
(see Table 1) (Liebenson 2003).
First, a detailed history of the
patient’s activity intolerances
associated with their pain. Second, a
thorough examination of the
functional pathology related to their
activity intolerances. Third, treatment
(advice, manipulation, and exercise)
directed to restoring function to the
‘key link’ believed to be responsible
for biomechanical overload of the
pain generating tissue. And, fourth
audit of the results.
Functional training is the
exercise which actually prepares
the patient for the functional
demands of their lifestyle,
occupation or sport. It is a
preventive approach which should
be integrated into the overall
management of the patient who
seeks care for a painful condition,
which is limiting activity. Functional
training is the final common
pathway for patient care.
Sometimes, it can even begin early in
care particularly if a ‘functional
range’ can be identified, which is
both relatively painless and where
motor control is appropriate.
History of activity
intolerances
The history should identify the
patient’s functional limitations,
specifically what activities aggravate
the patient’s symptoms. The basic
limitations are those that interfere
with activities such as sitting,
standing and walking. Eliminating
these intolerances can usually be
established as a mutually agreed
upon goal of care. This helps to
focus the patient on (dys)function
instead of pain.
Clinical challenge
Ask yourself if you can uncover
from the patient’s history what
specific activity intolerances are
present. Then try to achieve
agreement with the patient that
restoring these functions would be
a good goal for care?
Table1
Functional reactivation action steps
1. History of activity intolerance(s)
2. Assessment of relevant functional
pathology
3. Treatment of dysfunctional kinetic chain
4. Audit
CLINICIAN’S INFORMATION FOR SELF-HELP PROCEDURES
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Correspondence to: Craig Liebenson
Tel.: +1 310 470 2909; Fax: +1 310 470 3286;
E-mail: cldc@flash.net.
Craig Liebenson DC
Private Practice, 10474 Santa Monica Boulervard,
202, Los Angeles, CA 90025, USA
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Journal of Bodywork and Movement Therapies (2003)
7(1), 20^21
r 2003 Published by Elsevier Science Ltd.
This paper may be photocopied for educational use
doi:10.1016/S1360-8592(02)00104-3
S1360-8592/03/$ - see front matter
20
JOURNAL OF BODYWORK AND MOVEMENT THERAPIES JANUARY 2003
Assessment of relevant
functional pathology
Once the patient’s activity
intolerances are identified, then it is
necessary to find the functional
pathology which is responsible for
them. For instance, if the patient has
a walking intolerance, the feet
or sacro-iliac regions may
have relevant dysfunction that
is responsible for pain with
walking.
Clinical challenge
Ask yourself if you can find
the movement dysfunction
(pathokinesiology) which is
responsible for your patient’s
symptoms or activity intolerances.
Most patients have a vast ocean
of functional pathology. The object
is to focus on the source of
biomechanical overload which can
cause or perpetuate symptoms in the
pain generating or injured tissue. In
particular, that functional pathology
or dysfunctional kinetic chain,
which could lead to the specific
pattern of mechanical sensitivity
(i.e. activity intolerances) which the
patient has.
Treatment of the
dysfunctional kinetic chain
Advice, manipulation and exercise
are the three aspects of conservative
treatment of locomotor system
disorders (Liebenson 1996). They
constitute a continuum of care,
which has as its goal the
reassurance, reactivation, and return
to prior functional status of the
patient.
Advice begins with reassurance
to dispel the myth that ‘hurt
equals harm’. Promotion of
gradual resumption of activities as a
way to prevent deconditioning
and improve nourishment to the
painful tissues. Then specific
activity modification advice
regarding how to reduce
inappropriate biomechanical
loading of vulnerable tissues.
This consists of advice regarding
workstation ergonomics, sleep
posture and pillows, bending/
lifting/carrying, and pushing/
pulling.
Manipulation or manual therapy
serves as a catalyst to recovery.
If a tissue such as a joint or scar
is determined to be interfering
with function in a kinetic chain
related to the pain generator or
activity intolerance, then joint or
soft tissue manipulation would be
appropriate. For instance, a sitting
or forward bending intolerance may
be due to swelling of a disc and an
appropriate manual therapy
intervention may be lumbo-pelvic
traction.
Exercise serves a variety of
purposes in restoring function.
First, it may overlap with
manipulation as a catalyst to
recovery. McKenzie exercises
fit into this category (Hefner 2003).
Second, it may help to stabilize
the dysfunctional kinetic chain
by ‘grooving’ appropriate
movement patterns such as in
agonist–antagonist co-activation
or sensory-motor training.
Thirdly, it may help prevent
recurrences by reconditioning
functional patterns (i.e. functional
training), which mimick the
actual challenges faced by the
individual at home, work, or
sport.
Clinical challenge
Ask yourself if you can find
exercises which re-educate
movement patterns that are
responsible for biomechanical
overload in your patients home,
occupational, or sports activities?
Audit
This process of functional
reactivation and training should be
goal oriented (removal of activity
intolerances). These goals should be
measurable via reliable, valid, and
practical means. Finally, patient
status should be regularly re-
evaluated and goals adjusted as
needed.
A simple tool for measuring
activity intolerances associated with
low-back disorders is the Oswestry
questionnaire (Liebenson, 1996). A
similar tool for neck complaints is
the Neck Disability Index
(Liebenson, 1996).
REFERENCES
Hefner S, McKenzie R 2003 McKenzie
evaluation and treatment. In Liebenson
C (ed.), Rehabilitation of the Spine: A
Practitioner’s Manual, 2nd edn.
Lippincott/Williams & Wilkins,
Baltimore
Liebenson CS (ed.) 1996 Rehabilitation of the
Spine: A Practitioner’s Manual.
Lippincott/Williams & Wilkins,
Baltimore
Liebenson CS (ed.) 2003 Rehabilitation of the
Spine: A Practitioner’s Manual, 2nd edn.
Lippincott/Williams & Wilkins,
Baltimore
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JOURNAL OF BODYWORK AND MOVEMENT THERAPIES JANUARY 2003
Functional training
	Functional training part 2: integrating functional training into clinical practice
	Introduction
	History of activity intolerances
	Assessment of relevant functional pathology
	Treatment of the dysfunctional kinetic chain
	Audit
	Further Reading