EVIDENCE-BASED ALTERNATIVES TO POPULAR EXERCISES by David Michael Jett, Jr., M.S., C.S.C.S., EP-C, PN; Jessica Gibb, M.S., CEP, EP-C, FMSC; and David E. Verrill, M.S., RCEP, CEP, PD, FAACVPR Apply it! Exercise selection for fitness clients is often based on tradition and experience of the fitness professional. With the growing prevalence of acute and chronic musculoskeletal injury, exercise selection practices should be updated and diversified to accommodate a diverse population. Evidence-based alternative exercises are presented for several traditional movements commonly used by fitness enthusiasts. These alternative exercises can be performed with minimal risk while promoting similar, and in some cases more beneficial, training effects. Key words: Overuse Injury, Low Back, Shoulder Impingement, Fitness, Musculoskeletal INTRODUCTION T he selection of client-appropriate exercises can be a challenging task for a fitness professional. For the novice fitness professional, exercise selection often is based upon exercises from textbooks or exercises that the individual has seen other trainers/trainees perform. In both cases, there may be alternative exercises for the fitness professional to use that better serve their client. When working with a client base that may be prone to chronic injury, as a growing number of middle-aged adults seem to be, alternative, evidence-based exercises may be a way to prevent injury. In 2013 alone, there were more than 10 million individual doctor’s office visits for both lower back pain and shoulder symptoms (28). Because overuse injuries can be difficult to diagnose, treat, and recover from (8), the task of safe and proper exercise selection becomes more important and may even assist with prevention of overuse injuries. Evidence exists indicating several exercises that were once fitness standards are now believed to either initiate a novel injury or exacerbate an existing injury (1,4,8–11,13,14,17–22,24–27). We have identified two anatomical locations — the shoulder joint complex and the lumbar spine — where the combination of previous injury and inappropriate exercise selection may escalate potential soft tissue damage. In an effort to avoid such a combination, it may be beneficial to select more modern, evidencebased alternative exercises, as opposed to some of the traditional fitness standards mentioned hereinafter. Because overuse injuries can be difficult to diagnose, treat, and recover from (8), the task of safe and proper exercise selection becomes more important and may even assist with prevention of overuse injuries. One area where the incorporation of alternative, evidence-based exercises may be of particular importance is the shoulder joint complex, due to this joint's relative importance for sporting activities and activities of daily living. Historically, exercises used to train this area often produce torque in extreme ranges of motion (ROMs), leading to shoulder capsule stress or nervous and ligament impingements (3,8,11,13,26). Some examples include the behind the neck lat pulldown, behind the neck shoulder press, and triceps bench dips. Specifically, an increased risk of anterior capsule instability, suprascapular neuropathy, and rotator cuff impingement has been shown with both the behind the neck lat pulldown and shoulder press (8,11,13,26). In addition, an increased risk of impingement syndrome and posterior capsule stress has been shown with triceps bench dips (8,11). As shown in the Table, there are several evidence-based alternative exercises that can illicit similar, if not better results, and do so with a decrease in risk of injury. For both the 20 ACSM’s Health & Fitness Journal ® November/December 2017 Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. TABLE: Benefits of Alternatives to Popular Exercises Popular Exercise Risks Alternative Exercise(s) Benefits BN lat pulldown 1. External rotation with abduction of glenohumeral joint through extreme ROM, exacerbated by horizontal abduction to avoid bar to head contact (8,11,13,26) A. Can lead to the following: - Rotator cuff instability (26) - Glenohumeral ligament stress (26) - Suprascapular neuropathy (8) - Rotator cuff impingement (13) - Stress anterior capsule (11) 2. Extreme cervical spine flexion and forward head tilt (8,11,13,25) A. Can lead to the following: - Transient upper extremity paralysis (11,13) - Transient brachial plexus nerve injury (8,13) 1. Anterior lat pulldown (8,11,13, 25,26) A. Performed in the scapular plane (8,11,13,25,26) B. Arms at 30-degree angle forward (8,11,13) C. Torso reclined at 30 degrees (13) (See Figure 1) 1. Better emphasis on lattimus dorsi, shoulder adductor, and scapular retractor muscles A. BN places more stress on elbow flexor complex (11,13, 25,26) 2. Eliminates risk of shoulder instability and anterior glenohumeral stress (11,13) 3. Better mechanical advantage, which allows for greater weight to be pulled (13,25) 4. Better sport specific applications (26) BN shoulder press 1. Repetitive abduction and external rotation producing torque in extreme ROM (8,11,13) A. Can lead to the following: - Suprascapular neuropathy (8) - Significant strain on anteroinferior glenohumeral ligaments (13) - Anterior capsule instability (11) 2. Stresses cervical spine because of excessive flexion in overhead position (13) 1. Anterior shoulder press (8,11,13) A. Arms at 30-degree angle forward (8) B. Performed in the scalpular plane (8,11) 1. Allows weights to be positioned in body’s center of gravity throughout lift (13) 2. Equal combination of shoulder flexion and abduction during concentric phase (13) 3. Assures shoulders avoid at-risk position throughout (11) 4. Better sport specific application (13) Triceps bench dips 1. Shoulder flexion performed with extreme internal rotation when arm reaches 90-degree angle (8) A. Can lead to the following: - Impingement syndrome (8) - Inflammation of subcoracoid bursa for friction with lesser tubercle, causes compression of surrounding soft tissue (8) 2. Posterior glenohumeral stress when weight borne through arm with shoulder and elbow flexion (11) 1. Traditional or modified push-up (3,15) (See Figure 2) 2. If posterior shoulder capsule is already unstable, body weight exercises may need to be avoided all together. Use a triceps cable machine pushdown as an alternative (8,11) 1. Appropriately strengthens scapular stabilizing muscles, such as the serratus anterior 2. Shown to have better activation of scapular stabilizing muscles than other exercises (3,15) 3. Enhances shoulder joint muscle activation (15) 4. Strengthening of shoulder stabilizers plays a role in rehabbing various shoulder pathologies (3) Hurdler’s stretch 1. May cause strain in the groin (20,27) 2. May cause laxity of the medial ligament of the bent knee and put stress on the ligaments of the knee joint (19,20,27) 3. May stress the cartilage of the bent knee (19,20,27) 1. Semistraddle (modified hurdler’s stretch) (7) (See Figure 3) 2. PNF hamstring stretch (2) 1. Does not force extreme internal rotation of the bent leg (27) 2. Does not induce medial stress on the ligaments/cartilage of the bent knee (9,27) 3. If available, PNF may be superior as it promotes muscular inhibition (2) (continues) Volume 21 | Number 6 www.acsm-healthfitness.org Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. 21 EVIDENCE-BASED ALTERNATIVE EXERCISES TABLE: Benefits of Alternatives to Popular Exercises (Continued) Popular Exercise Risks Alternative Exercise(s) Benefits 4. May cause discomfort at the hip joint because the femur of the leg that is tucked behind is in a position of extreme rotation of the joint angle (20,27) Loaded lumber rotation (e.g., Russian twist) 1. May cause/exacerbate degradation of intervertebral disks (21) 2. May be more dangerous when combined with lumbar flexion (10,14) 1. Lateral cable press (24) (See Figure 4) 2. Anti-rotation chop (See Figure 5) 1. Torsional challenge(s) that require the resistance of rotation and therefore lumbar stability as the arms are moved in different planes (24) 2. Trains core stability, specifically rotary stability, which will assist in producing and integrating force in the limbs (16) Loaded lateral flexion (e.g., dumbbell side bend) 1. Repeated flexion increases likelihood of disk herniation (4) 2. Lateral bending with compression may produce disk herniation (1) 1. Side plank or modified side plank (24) (See Figure 6) 2. Asymmetric loaded carry (24) (See Figure 7) 1. Trains the QL and lateral musculature (24) to assist in creating a stable base (16) for limb motion 2. Side plank improves trunk endurance without producing low back pain (12) 3. Isometric training superior to dynamic training for improving core stiffness (18) Straight leg sit-ups 1. Lumbar strain by not able to fully engage abdominal muscles 2. Increases stress on the low back muscles because of activity of the muscles that flex the hip (20,22,25) 3. Stretches abdominal muscles that may already be too long and weak 4. May result in nerve impingement and compression, as well as compression on the disks (19) 1. Bent knee sit-ups with arms folded on the chest (20,25) 2. Prone elbow plank (See Figure 8) 1. Helps stabilize the pelvis 2. Supports a neutral spine 3. Improves neuromuscular efficiency and intervertebral stability (5) 4. Strengthens rectus abdominus with less stress on the lumbar musculature Alternating crunches 1. May cause hip flexor strains 2. Strains the neck muscles and puts pressure on the cervical spine (20) 3. Hyperflexion of the neck 4. Aggravation of already thin disks in arthritic conditions (19) 1. Partial curl-ups with knees bent and hands across chest, with curling up motion until scapulae leave floor (19,20) 2. Prone elbow plank (See Figure 8) 1. Less neural activation of hip flexors and ancillary muscle groups that are not the focus of the exercise 2. Better pelvis stabilization 3. Reduced stress on cervical spine Back hyperextension or “Superman” 1. Extended posture results in intervertebral disk loading (23) 2. Lumbar region bears a high spinal compressive load as a result of the bilateral muscle activity. The load is transferred to the vertebral joints and can also crush the interspinous ligaments (23) 1. Single leg extension load with one knee on mat and rear leg and opposite arm extended (bird dog) (23) (See Figure 9) 2. Floor cobra exercise in a prone position with hips on floor, arms extended straight backwards, and toes pointed downward resting on floor (6) 1. Single leg extension exercise creates minimal external loads on the spine yet produces an extensor moment (and small isometric twisting moments) that results in extensor muscle activity (22) 2. Floor cobra exercise promotes isometric strengthening of gluteus maximus, hip flexors, and erector spinae BN, behind the neck; PNF, proprioceptive neuromuscular facilitation; QL, quadratus lumborum. 22 ACSM’s Health & Fitness Journal ® November/December 2017 Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. behind the neck lat pulldown and shoulder press, moving arms to 30 degrees forward in the scapular plane is suggested as a safer alternative. In addition, this placement allows for greater weight to be lifted, better mechanical advantage, and increased sport specificity (8,11,13,25,26). With respect to the triceps bench dip activity, there are two alternatives suggested within the research. First is a traditional push-up or modified pushup. By adjusting to this exercise, shoulder stabilization muscles, such as the serratus anterior, are better activated and strengthened (3,15). Second, it is suggested that if a client has any previous posterior shoulder capsule instability, body weight exercises are not recommended and a triceps pushdown exercise on a cable machine is the recommended alternative (3,8,11,15). A second anatomical area for which exercise selection may be important for injury prevention is the musculature surrounding the lumbar spine, popularly known as the “abs.” Exercises used to train this area often focus on dynamic efforts of lumbar extension, flexion, lateral flexion, and rotation — and these movements may or may not be loaded. The names of these exercises are familiar — the Russian twist (loaded lumbar rotation), the dumbbell side bend (loaded lateral flexion), straight leg sit-ups, alternating crunches (both lumbar flexion), and back hyperextension or “Superman” (lumbar extension). Evidence indicates that these exercises may exert one or multiple stressors on anatomical components of the lumbar spine. Specifically, interverbral disks are at increased risk of degradation during Photos courtesy of Frank Muntis, Greta Cesarz, and University of Louisville Student Recreation Center. Figure 1. Anterior lat pulldown. Volume 21 | Number 6 loaded lumbar rotation (21), increased risk of herniation during loaded lateral flexion (1,4), and increased compression during the straight leg sit-up exercise (19). In addition, ligaments within the spine may receive undo stress during repeated lumbar extension exercise (23). It is generally understood that the primary purpose of muscle is to produce joint movement, with a secondary purpose of joint stabilization. However, with respect to the core musculature (erector spinae, rectus abdominis, internal and external obliques), some exercise authorities believe that these functions should be reversed. McGill (24) asserts that the purpose of these muscles is to prevent motion rather than to produce motion, and Kibler et al. (16) contend that a well-conditioned core functions as a rigid cylinder that promotes lumbar spine stiffness. Consequently, these fitness professionals feel that core training programs should focus on static exercises that emphasize lumbar spine stability rather than on dynamic exercises that enable lumbar spine movements such as trunk flexion, trunk extension, trunk lateral flexion, and trunk rotation (Table). It is generally understood that the primary purpose of muscle is to produce joint movement, with a secondary purpose of joint stabilization. However, with respect to the core musculature (erector spinae, rectus abdominis, internal and external obliques), some exercise authorities believe that these functions should be reversed. Although the authors recommend static exercises to enhance core stabilization, we realize that many fitness trainers, trainees, and enthusiasts may choose to perform more traditional dynamic exercises. Therefore, we have included the best evidence-based versions of these two particular exercises to minimize injury risk for individuals who desire to use these movements. In addition, because low back pain is one focus of this article, and low back pain often is partially addressed by focusing on the improvement of hamstring flexibility, we have included a commonly used hamstring Figure 2. Traditional push-up. www.acsm-healthfitness.org Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. 23 EVIDENCE-BASED ALTERNATIVE EXERCISES Figure 4. Lateral cable press. Photos courtesy of Frank Muntis, Greta Cesarz, and University of Louisville Student Recreation Center. Figure 3. Semistraddle/modified hurdler’s stretch. Figure 5. Anti-rotation chop. stretch (the hurdler’s stretch), its potential risk, and an evidencebased alternative to this commonly used stretch (Table). CONCLUSIONS The process of appropriate program design can be complicated, but this practice can be simplified somewhat by considering the removal of specific exercises that may be inappropriate for many populations. Evidence was presented in this article to support the replacement of several exercises due to increased injury risk (1,4,8–11,13,14,17–22,24–27). Evidence-based alternatives to each movement were recommended and described. These Figure 6. Modified side plank. 24 ACSM’s Health & Fitness Journal ® November/December 2017 Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Figure 8. Prone elbow plank. Photos courtesy of Frank Muntis, Greta Cesarz, and University of Louisville Student Recreation Center. Figure 7. Asymmetric loaded carry. alternative exercises promote a similar, or in some cases, more beneficial training effect and also have a low injury risk. (2,3, 6–8,11,13,15,17,19,20,23–27). Practitioners are well served to choose exercises with a low risk-to-reward ratio, regardless of the health/injury status of the client or patient. Thus, there is nothing to lose by adding the alternative exercises suggested in Figure 9. Bird dog. this article to an exercise selection library and using them with both healthy and deconditioned populations. 1. Adams MA, Hutton WC. The relevance of torsion to the mechanical derangement of the lumbar spine. Spine (Phila Pa 1976). 1981;6(3):241–8. 2. Haff GG, Triplett NT. Essentials of Strength Training and Conditioning. 4th ed. Champaign (IL): Human Kinetics; 2016, p. 324–25. 3. Batbayar Y, Uga D, Nakazawa R, Sakamoto M. Effect of various hand position widths on scapular stabilizing muscles during the push-up plus exercise in healthy people. J Phys Ther Sci. 2015;27(8):2573–6. 4. Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. 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Available from: https://www.cdc.gov/nchs/data/ahcd/ namcs_summary/2013_namcs_web_tables.pdf Disclosure: The authors declare no conflict of interest and do not have any financial disclosures. D. Michael (Mike) Jett, Jr., M.S., C.S.C.S., EP-C, PN, earned a B.A. in history (2000) and an M.S. in exercise physiology (2004) from the University of Louisville. He is currently a full-time instructor at the University of Louisville in the Health and Sport Science Department. He is an NSCA Certified Strength and Conditioning Specialist, is an ACSM Certified Exercise Physiologist, and has the Level 1 Precision Nutrition 26 ACSM’s Health & Fitness Journal ® certification. He has more than 10 years of personal and group fitness training experience. Jessica Gibb, M.S., EP-C, CEP, FMSC, earned a B.S. in exercise physiology (2008) from Ohio University and an M.S. in exercise physiology with a concentration in strength and conditioning (2011) from the University of Louisville. She is currently a full-time instructor at the University of Louisville in the Health and Sport Sciences Department. She is a Certified Exercise Physiologist and Certified Clinical Exercise Physiologist through ACSM and has a Level 1 Functional Movement Screen certification. She has 10 years of personal and group fitness training experience. Dave Verrill, M.S., RCEP, CES, PD, FAACVPR, earned his B.S. in physical education (1979) from the University of Maine and his M.S. in exercise physiology (1982) from the University of South Carolina. He is currently a full-time instructor and laboratory director at the University of North Carolina at Charlotte in the Department of Kinesiology. He is an ACSM Certified Registered Clinical Exercise Physiologist, Clinical Exercise Specialist, and Preventive & Rehabilitative Exercise Program Director. He also is past president of the North Carolina Cardiopulmonary Rehabilitation Association (NCCRA) and the ACSM Clinical Exercise Physiology Association (CEPA). He has more than 35 years of experience in exercise testing, training, and prescription for apparently healthy, high-risk, and clinical populations. November/December 2017 Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.