Hypervibe Vibration Therapy

Transcription

1 OFFICIAL GUIDE TO Hypervibe Vibration Therapy Created by GABRIEL ETTENSON, MS, PT

2 TABLE OF CONTENTS 1. Introduction to Hypervibe Vibration Therapy a. About the Hypervibe b. Other Platforms c. Setting the Hypervibe 2. Treatment Applications of the Hypervibe a. To Mobilize Mobilization Intensities b. To Strengthen Beginner G-Force Levels c. Exceptions to The Rules 3. Contraindications for Vibration Therapy 5. Positioning & Other Details 6. The Rehab Exercises a. Low Back Series b. Lower Extremity Strengthening c. Upper Extremity Strengthening d. Lower Body Mobility e. Upper Body Mobility f. Pelvic Floor & Core Strengthening g. Balance and Fall Prevention h. Advanced Balance i. Massage 4. Implementing Vibration Therapy Treatment a) Determining the Purpose of the Exercise b) Choosing appropriate exercise settings c) Progressing Vibration Therapy d) Additional Progressions for Training

3 Introduction to Hypervibe Vibration Therapy Since the inception of the industry in 1996, research has continued to grow in support of Whole Body Vibration (WBV) technology for providing an increasing number of therapeutic and fitness-related benefits. As a result, it has become quite clear that the Hypervibe can add significant value to medical, health and fitness facilities. Not only does using the Hypervibe provide a wide array of benefits, but provides them in a fraction of the time when compared to more traditional approaches. These benefits may include: > Increased muscle force and power > Improved flexibility > Improved joint and soft tissue mobility > Improved balance > Improved proprioception and postural stability > Improved functional performance > Improved blood flow > And much more Now, if you are asking how such a long list of benefits could possibly be attributed to something as simple as standing on a vibrating machine then you are not alone. Despite the tremendous amount of research supporting WBV s efficacy, this question, rooted in a limited understanding of the subtleties of this technology, continues to be the driving force behind the skepticism that has surrounded the industry for many years. However, as researchers are finding out, when you delve deeper into the scientific principles of not only the machine design, but how it works on the level of the body, it is a groundbreaking innovation with endless applications that can far exceed those that have been addressed up until now. As will be discussed below in further detail, here are a couple key points to focus on as we move forward in explaining how this technology works. 1. This technology was not created with the intention to shake an individual, but rather to simulate varying levels of hyper-gravity (greater than the strength of Earth s gravity) through mechanically induced, intermittent ground reaction forces. 2. The shaking or oscillating effects of a vibration platform on the body are secondary applications, but can provide tremendous therapeutic benefits. 3. Only around 5% of all vibration platforms on the market actually meet the criteria for providing evidence-based benefits of Whole Body Vibration. 4. Considering 99% of the time that a practitioner uses a vibration platform, the target is a localized region of the body, the term Whole Body Vibration is a misnomer and should eventually be thrown out as a term to describe this technology. 5. A vibration platform is significantly beneficial when used as a resistance training tool. However, instead of adjusting the variable of MASS (like traditional exercise), you are adjusting the variable of ACCELERATION (the rate at which you are falling due to Earth s gravity). This is the other side of Newton s FORCE equation (Force = Mass x Acceleration). 6. Strength training on the Hypervibe is best defined as a safer form of plyometric training. The unique principles upon which it is based, train the muscle system for power. 3

4 About the Hypervibe The Hypervibe is considered a pivotal, oscillating or side-alternating Whole Body Vibration platform. When looking at the three terms above (pivotal, oscillating, and side-alternating), while they may appear to be describing different things, all are simply referring to the same fundamental motion of the machine. This motion, like a teeter-totter, results in one side of the platform moving upward while the opposite side moves downward. In other words, it produces an alternating vertical motion (Figure 1). Figure 2 A lineal/vertical platform moves as one rigid unit across a fixed distance (amplitude). Similar to hopping on both feet, it moves both extremities up and down at the same time. While research does suggest that there are benefits associated with this type of machine, it s popularity it diminishing due to recent concerns over safety. Figure 1 The plate vibrates around a center fulcrum. The center fulcrum is a fixed point so the further away you travel from this point, the greater the vertical distance the platform will move. This refers to the increasing amplitude of the platform. The peak amplitude of the Hypervibe is 11mm at the outer edge. As you will learn later when discussing the origins of this technology, this type of movement pattern was based upon the desire to promote the movement of the pelvis, hips and spine associated with walking. Other Platforms While the majority of platforms on the market are built in a similar fashion to the Hypervibe, there does exist an alternative platform type referred to as a vertical or lineal platform. This platform moves up and down as one fixed unit, delivering a vertical force to both feet at the same time. Recent research has suggested that this particular platform not only has fewer treatment applications (limited mostly to strengthening), but also produces higher levels of force on the spine as well increased motion of the head. For these reasons, this type of machine is much less desirable for most clinical settings (Figure 2). Setting the Hypervibe: When using the Hypervibe for treatment, there are several unique variables that must be considered. Similar to using sets, repetitions, and weight with traditional resistance exercises, or using graded mobilization (I-IV) and varying pressure levels with manual therapy, these variables are selected according to the desired goal of the treatment. They are as follows: FREQUENCY Measured in Hz, frequency refers to the speed at which the platform vibrates. In other words, how many times per second the platform moves through its full upward and downward cycle of motion. For example, 20 Hz would equal 20 cycles / sec. The Hypervibe can vibrate with a frequency range of 0-28 Hz. The +/- buttons on the display panel of the Hypervibe allow the practitioner to move up and down in this range of frequencies (Figure 3). Figure 3 The display panel of the Hypervibe shows the frequency being used. The +/- buttons below the display allow it to be adjusted. 4

5 AMPLITUDE As described above in the graphic showing the movement of a pivotal platform, amplitude is measured in millimeters (mm) and refers to the distance the plate moves from the lowest point to the highest point. Often the term peak-to-peak displacement will be used interchangeably with the term amplitude for platforms that move with this particular type of motion. The Hypervibe has an amplitude (peak to peak displacement) range of 0-11mm. Because of the teeter-totter motion of the Hypervibe, the amplitude one selects is not done on the control panel, but rather by the foot position (or hand position with upper body ex s) on the plate. On the Hypervibe, a number system is used for the purposes of clear instruction and is broken down accordingly (Figure 4): Position Edge Actual Amplitude 0mm 2mm 4.2mm 6.6mm 9mm 11mm Figure 4 A sticker attached to the base of the platform shows the various positions to use when exercising. Each position corresponds to a particular amplitude (as indicated above the photo). In general, when selecting amplitude, the practitioner should use the big toe (lower body ex s) or the pointer finger (upper body ex s) as their marker. ACCELERATION OR G-FORCE Measured in G s, acceleration is the result of a specific frequency and amplitude selected by the practitioner. All frequency & amplitude combinations can be used to calculate a platform s g-force (Figure 5). FREQ Amp. #1 Amp. #2 Amp. #3 Amp. #4 Edge 2 mm 4.2 mm 6.6 mm 9 mm 11 mm 0 0.0g 0.0g 0.0g 0.0g 0.0g 1 0.0g 0.0g 0.0g 0.0g 0.0g 2 0.0g 0.0g 0.1g 0.1g 0.1g 3 0.0g 0.1g 0.1g 0.2g 0.2g 4 0.1g 0.1g 0.2g 0.3g 0.4g 5 0.1g 0.2g 0.3g 0.5g 0.6g 6 0.1g 0.3g 0.5g 0.7g 0.8g 7 0.2g 0.4g 0.7g 0.9g 1.1g 8 0.3g 0.5g 0.9g 1.2g 1.4g 9 0.3g 0.7g 1.1g 1.5g 1.8g g 0.8g 1.3g 1.8g 2.2g g 1.0g 1.6g 2.2g 2.7g g 1.2g 1.9g 2.6g 3.2g g 1.4g 2.2g 3.1g 3.7g g 1.7g 2.6g 3.6g 4.3g g 1.9g 3.0g 4.1g 5.0g g 2.2g 3.4g 4.6g 5.7g g 2.4g 3.8g 5.2g 6.4g g 2.7g 4.3g 5.9g 7.2g g 3.1g 4.8g 6.5g 8.0g g 3.4g 5.3g 7.3g 8.9g g 3.7g 5.9g 8.0g 9.8g g 4.1g 6.4g 8.8g 10.7g g 4.5g 7.0g 9.6g 11.7g g 4.9g 7.7g 10.4g 12.8g g 5.3g 8.3g 11.3g 13.8g g 5.7g 9.0g 12.3g 15.0g g 6.2g 9.7g 13.2g 16.2g g 6.6g 10.4g 14.2g 17.4g Figure 5 As demonstrated by the above chart, as the frequency and amplitude increases, the g-force produced by the plate increases. The variable of g-force is of paramount importance for using the platform for benefits related to developing muscle force & power as well as postural stability, balance, and overall functional performance. It relates to the amount of gravitational load that is being placed on the user while exercising on the plate. It is the resistance level being used when considering the Hypervibe a progressive resistancetraining tool (as opposed to a mobilization tool). 5

6 In general, when exercising on the platform, the gravitational load can be categorized accordingly (Figure 6): As the g-force level increases so does the level of resistance for the user. The Hypervibe can achieve a range of G s. The peak g-force of 17.4 G s is achieved with a high frequency of 28 Hz and the high amplitude of 11mm. Until a machine is made that displays the actual g-force a machine is producing, a practitioner must always select the appropriate level of resistance by choosing the amplitude and frequency settings that WILL RESULT IN the desired g-force level. This may be counterintuitive given the simplicity of selecting a weight or a specific exercise position when using more traditional methods. However, the addition of this element adds significant value to the exercise being performed on the platform and with time will become quite intuitive. Figure 6 As shown in the graph above, there are 5 fundamental categories for resistance with the Hypervibe. All categories correspond to a range of actual g-force. As strength training programs progress, so does the g-force level selected by the practitioner. TIME Time refers to the period of time that a vibration platform will continue to move. Depending on the overall purpose of the exercise, time may differ dramatically. This will be described in further detail below. 6

7 Treatment Applications of the Hypervibe When using the Hypervibe, a practitioner should first and foremost think about what their treatment goal is. From there, they will then decide which one of the two fundamental uses of the Hypervibe is best. The two primary ways to use the Hypervibe for treatment are: 1. TO MOBILIZE With this particular application, the Hypervibe platform is used to passively mobilize or oscillate a specific region(s) of the body. The fundamental goals of using this effect are to: > Improve local circulation > Improve soft tissue & joint mobility (Improve flexibility) > Improve or modify general sensation > Reduce pain perception > Reduce spasticity > Promote muscle relaxation > Improve basic balance responses Depending which of the above goal(s) one hopes to achieve with the platform during a given treatment, a level of mobilization intensity is selected by the practitioner. Like described above with g-force, this is determined by the frequency and amplitude settings and the level of intensity by which they are moving the body. It is important to note that while all amplitude and frequency setting combinations on the Hypervibe will correspond to a specific g-force no matter what the goal of treatment, in the case of mobilization, you are not focusing on that variable, but rather how rigorous the platform is moving the body. Additionally, the three mobilization intensity settings all create quite low g-forces and therefore do not induce sufficient levels of muscle activity. There are three mobilization intensities used on the Hypervibe: 1. LOW INTENSITY Low Intensity would be used for the following reasons: > Introducing a patient to the Hypervibe for the first time > Pain relief in acute and some subacute pain situations* > Reducing muscle guarding (acute) > Basic Balance training (platform is a wobble board) > Muscle relaxation in hypomobile clients > Grade 1-2 joint mobilization > Increasing circulation* > Reducing spasticity* > Improving or modifying sensation* 2. MEDIUM INTENSITY and High Amplitude (#2-4) Medium Intensity would be used for the following reasons: > Pain relief in subacute and chronic pain* > Muscle relaxation in hypermobile clients > Grade 3-4 joint oscillation > Conservative flexibility work > Reducing muscle guarding (subacute) > Advanced balance training (increasing wobble-board effect of platform) > Reducing spasticity* > Increasing circulation* > Improving or modifying sensation* 7

8 3. HIGH INTENSITY High Frequency (15-20 Hz) High Intensity would be used for: > Pain relief in chronic pain* > Advanced flexibility work > Releasing tight fascial tissue (i.e. ITB, Plantar Fascia) > Rigorous joint oscillation > Improving or modifying sensation* > Increasing circulation* > Reducing spasticity* High intensity mobilization is generally used when directly massaging an area of the body or when superimposing the vibration on a stretched muscle (Figure 7). Figure 7 These pictures demonstrate a massage position (calf massage) and a stretching position (hamstring). Both exercises are recommended to be performed with high mobilization intensities. * In many cases, where these treatment effects are desired, the most effective intensity will differ according to many variables. For example, in cases of chronic pain, a high intensity is THEORETICALLY the best option as it is likely to more rapidly alter nociceptive and non-nociceptive properties of the nerve receptors. On the other hand, the patient, having been in pain for so long, may be fearful of a more intense stimulus and therefore perceive the treatment as dangerous and ask to discontinue treatment. Overall, it is best to ere on the side of caution when starting out with the Hypervibe and start with more conservative treatment at first. As time progresses, intuition will take over. In general, when working on achieving benefits attributed to mobilizing a region of the body with the Hypervibe, a longer time frame is used. This is due to the fact that releasing connective tissue structures, promoting effective levels of circulation to promote mobility or relaxation, or closing the gate to pain will require more exposure time. In the exercise lists in this guide, the exercises that can be used to achieve effects related to using the platform for mobilization are marked with the symbol. Keep in mind that certain exercises in the program marked for mobilization may also be used for the second major effect of Hypervibe. This pertains to using the platform as a resistance tool in an attempt to strengthen the individual. 2. TO STRENGTHEN With this use of the Hypervibe, passive mobilization goals and the careful selection of a mobilization intensity becomes of less importance. Instead, the practitioner is more concerned about selecting a frequency and amplitude in order to generate a specific level of resistance or g-force. Focusing on the g-force of the platform is a key to working on: > Improving muscle power & force > Advancing balance training programs > Improving systemic circulation & VO2 Max > Increasing Growth Hormone production > Lowering Cortisol levels > Postural stability > Advanced Proprioception > Improving bone density > Improving functional performance (TGUG, Sit-Stand test etc.) To review, g-force (or acceleration) describes the amount of gravitational load that a platform, while moving vertically, places on the body. An increase in this 8

9 g-force when using the Hypervibe, like moving from 5 lbs. to 10 lbs. on a weight stack, would be referred to as increasing the resistance from 1g to 2g to 3g to 4g etc., where 1g = 1x the strength of Earth s gravity. Like ground reaction forces act on the body when walking, the increasing strength of the vertical motion of the platform while it vibrates serves to simulate varying levels of increased gravity or hypergravity. So then, much like adding weight to a person in order to increase their body mass and then have them move with this additional mass, here we have them move while feeling as if they are being pulled down harder. A way to further make sense of this concept, while also beginning the transition into actual treatment parameters, is to consider the original design of the first vibration platform. This machine, called the Galileo, was designed as a treatment for osteoporosis and theorized as a means to reproduce the effects of walking. The engineers intended to move the ground into the feet rather than the feet to the ground. For this reason the motion of the first platform, like the Hypervibe, mimicked a teeter-totter type motion therefore creating a functionally relevant reciprocal movement pattern. Additionally, the higher frequency and amplitude ranges of the Galileo platform were also carefully thought out so as to simulate both the neurophysiological and anatomical principles of walking. These included: > Placing the force of the platform on the user at a frequency rapid enough to cause reflexive muscle contractions via the stretch reflex. Much like the muscular responses to plyometric exercises, the rapid stretching of the muscles by the platform assured a higher level of muscle activity. > Have the platform be wide enough so as to allow the user to stand comfortably with proper alignment of the lower extremities. While anyone can develop strength by simply exercising on the Hypervibe (after all, it is a moving surface and this poses more of a challenge than being off of the platform), the ideal means to maximize muscle recruitment is to utilize higher g-force levels. For beginners, the following chart of specific frequency and amplitude combinations (Figure 8) are recommended for use with the Hypervibe. These setting combinations are also recommended as the best way to progress/regress exercises when need be. As time goes on and you become familiar with the relationship between these training variables, as well as how they are tolerated by the user, these settings can be manipulated according to the chart & graph provided earlier. Beginner G-Force Levels Resistance Level Frequency Amplitude Actual G-force Low G 12 #1 0.6 g s Low/Medium G 15 # g s Medium G 18 # g s Medium/High 22 # g s High G 25+ # g s + Figure 8 - Beginner Training Guidelines In contrast to mobilization, when using the Hypervibe as a resistance training tool, a shorter exercise time is recommended. This is due to the fact that the goal is to maximally challenge the individual in order to more rapidly produce the desired neuromuscular adaptations. In the exercise lists in this guide, the exercises that can be used to achieve effects related to using the platform for strengthening are marked with the symbol. EXCEPTIONS TO THE RULES Having defined these two primary applications, there does exist a grey area where these effects and their respective settings may crossover into each other s treatment categories. These situations, often dictated by the patient s overall status and the practitioner s specific treatment goals, will dictate these exceptions to the rules. 9

10 As an example, a severely deconditioned person whose goal of treatment may be functional and therefore requires muscle strengthening may not be able to tolerate even 12 Hz and the lowest amplitude setting. For this person, you would need to select a lower frequency for training. By definition, this lower frequency setting may be primarily used for mobilization, but here it will serve to strengthen. In another example, for aggressive stretching or to release tight connective tissue, a higher frequency is used. While this frequency may correspond to frequencies typically used for increasing muscle activity, here they serve to improve length or mobility of the fascia. In this example, the difference is the position of the clients on the platform. While there may indeed be some muscle activity as a result of the higher frequency, the fact that the muscle is lengthened during the exercise, results in flexibility changes rather than increased muscle tone (Figure 9). Figure 9 While high setting typically attributed to strengthening purposes of the Hypervibe are used here, the muscle is being stretched. This alters the extent of muscle activity and can therefore be viewed as a fascial release tool. 10

11 Implementing Vibration Therapy Treatment 1. Determining the Purpose of the Exercise: a. Mobilize: To increase mobility or achieve the therapeutic effects of passively vibrating / oscillating various tissues of the body. b. Strengthen: To improve muscle force or power development and the systemic responses associated with those improvements. 2. Choosing Appropriate Exercise Settings: a. For Mobilization, select the appropriate mobilization intensity b. For Strengthening, select the appropriate g-force level 3. Progressing Vibration Therapy: a. For Mobilization Exercises > Progress Time first (1 -> 3 minutes) > Then Intensity Level SAMPLE MOBILIZATION PROGRESSION: Exercise: Low Back Release Day 1 1 min., Level 1 Day 2 2 min., Level 1 Day 3 3 min, Level 1 Day 4 1 min., Level 2 b. For Strengthening exercises: > Progress Resistance Level or Time (Exercise Dependent) > Limit Exercises to < 2 minutes SAMPLE STRENGTHENING PROGRESSION: Exercise: Plank Day 1 1 min., Low G Day 2 2 min., Low G Day 3 1 min., Med G Day 4 1 min., High G Additional Progressions for Training: > Progress Lower Ext. ex s from bilateral to unilateral. > Progress Upper Ext. ex s from kneeling position to standard. > After max g-force is utilized with platform, add external weight. Contraindications for Hypervibe Training: The list below describes ABSOLUTE contraindications for Vibration Therapy. > Metal Implants placed within the past 1 year > Pregnancy > Acute Inflammation (joint, neural etc.) > Acute Infection > Metastatic Cancer > Kidney/Bladder/Gallstones > Epilepsy > Recent Fractures 11

12 Positioning & Other Details: Always keep the following variables in mind: > Maximize postural alignment during exercise. > Always flex knees and/or elbows approx (min). > Avoid excessive head vibration. Upper Body Exercises create increased head motion. They should be progressed slowly at the start. > Do not use shoes/sneakers unless absolutely necessary. Train with either bare feet or socks. > For upper body or lower body exercises being done with socks, use thin yoga mat on platform to avoid slippage. > Keep eyes open to avoid loss of balance. > For all balance exercises, use upper body support AS NEEDED. > For all balance programs, use mobilization intensity settings and progress them from low to high. In these programs the platform is being used as a wobble board. > Empty bladder before training for maximal comfort. > Strength Cord exercises use plate for balance effect only. Use low G & low/med G settings. > Exercises that involve being seated on the platform create more direct motion to the pelvis and spine. Use lower settings to introduce patients to these exercises regardless of the goal of the exercise. > With lighter patients or in situations where too high a g-force is being used, the user s feet may noticeably move around. In this case, use maximal g-force that ensures stability and then add external weight to progress. Other options include progressing the actual exercise (i.e. double leg squat to single leg squat etc.). Potential Side Effects: > Itching is normal after initial few sessions. This will subside. > Floaters indicate too much head vibration (repositioning needed) > Dizziness is typically a sign of Low blood sugar Vestibular issues after a head down pose is held for too long. > Tingling may occur in feet after initial session. This will subside. 12

13 the exercises 13

14 FREQ Amp. #1 Amp. #2 Amp. #3 Amp. #4 Edge 2 mm 4.2 mm 6.6 mm 9 mm 11 mm 0 0.0g 0.0g 0.0g 0.0g 0.0g 1 0.0g 0.0g 0.0g 0.0g 0.0g 2 0.0g 0.0g 0.1g 0.1g 0.1g 3 0.0g 0.1g 0.1g 0.2g 0.2g 4 0.1g 0.1g 0.2g 0.3g 0.4g 5 0.1g 0.2g 0.3g 0.5g 0.6g 6 0.1g 0.3g 0.5g 0.7g 0.8g 7 0.2g 0.4g 0.7g 0.9g 1.1g 8 0.3g 0.5g 0.9g 1.2g 1.4g 9 0.3g 0.7g 1.1g 1.5g 1.8g g 0.8g 1.3g 1.8g 2.2g g 1.0g 1.6g 2.2g 2.7g g 1.2g 1.9g 2.6g 3.2g g 1.4g 2.2g 3.1g 3.7g g 1.7g 2.6g 3.6g 4.3g g 1.9g 3.0g 4.1g 5.0g g 2.2g 3.4g 4.6g 5.7g g 2.4g 3.8g 5.2g 6.4g g 2.7g 4.3g 5.9g 7.2g g 3.1g 4.8g 6.5g 8.0g g 3.4g 5.3g 7.3g 8.9g g 3.7g 5.9g 8.0g 9.8g g 4.1g 6.4g 8.8g 10.7g g 4.5g 7.0g 9.6g 11.7g g 4.9g 7.7g 10.4g 12.8g g 5.3g 8.3g 11.3g 13.8g g 5.7g 9.0g 12.3g 15.0g g 6.2g 9.7g 13.2g 16.2g g 6.6g 10.4g 14.2g 17.4g 14

15 LOW BACK SERIES 1. Lumbosacral Release 2. Lumbar Massage 3. Standing Pelvic Tilts 4. Mini-Hip Circles 5. Lumbar Extension 6. Lumbar Rotation 7. Lumbar Sidebending 8. Assisted Lumbar Flexion 9. Squat 10. Modified / Standard Plank LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 15

16 LOWER EXTREMITY STRENGTHENING 1. Standing 2. Standing pelvic tilts 3. Standing Weight Shifts 4. Squat 5. Bridge 6. Lunge 7. Heel Raise 8. Step-Up 9. Standing Band Abduction 10. Lateral Step-Up LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 16

17 UPPER EXTREMITY STRENGTHENING 1. UE Weight Shifts 2. Cat/Camel 3. Plank 4. Dog-to-Plank 5. Scapular Depression 6. Push-Up 7. Triceps Dip 8. Str. Cord Shoulder ER 9. Str. Cord Shoulder Rows 10. Str. Cord Biceps Curls LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 17

18 LOWER BODY MOBILITY 1. Lumbosacral Release 2. Lumbar Massage 3. Calf Stretch 4. Posterior Chain Stretch 5. Hip Flexor Stretch 6. Tool-Assisted Plantar FasciaRelease 7. ITB/TFL Release LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 18

19 UPPER BODY MOBILITY 1. Shoulder Release 2. Cat/Camel Stretch 3. Latissimus Release 4. Cervical/Thoracic Release 5. Downward Dog 6. Pectoralis Stretch 7. Wrist Release LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 19

20 PELVIC FLOOR & CORE STRENGTHENING 1. Standing Kegel s (5 second holds) 2. Standing Pelvic Tilts 3. Standing Hip Circles 4. Plank 5. Short Range Crunch 6. Short Range Roll & Reach 7. Squat with Pelvic Tilts 8. Lunge 9. Seated Pelvic Massage LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 20

21 BALANCE & FALL PREVENTION 1. Normal Stance 2. Narrow Stance 3. Wide Side Stance 4. Narrow Side Stance 5. Tandem Side Stance 6. Alternating Knee Lift 7. Wide Stance with Head Turn 8. Narrow Stance with Head Turn For side-stance exercises, amplitude refers to back side of plate center point LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 21

22 ADVANCED BALANCE Normal Stance with Eyes Closed 2. Narrow Stance with Trunk Rotation 3. Narrow Side Stance with Trunk Rotation 4. Step Up 5. Step Up with Knee Lift 6. Lunge (S) 7. Side Step Up 8. Unsupported Heel Raise 3 4 For side-stance exercises, amplitude refers to back side of plate center point LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 22

23 MASSAGE Shoulder Massage 2. Cervical/Thoracic Massage 3. Hamstring Massage 4. Calf Massage 5. Gluteal Massage 6. Quad Massage 7. Lumbosacral Massage 8. Lumbar Massage LOW INTENSITY: MEDIUM INTENSITY: and High Amplitude (#2-4) Mobilization HIGH INTENSITY: High Frequency (15-20 Hz) Strengthening Resistance Level Frequency Amplitude Low G 12 #1 Low/Medium G 15 #1-2 Medium G 18 #2-3 Medium/High 22 #3-4 High G 25+ #4+ 23