Chapter 6: Functional Movement Assessments and Exercise Programming for Apparently Healthy Participants

Instability training

-a method of training that challenges a client's ability to maintain balance while challenging the client's center of gravity -often accomplished by narrowing the client's base of support -by challenging posture this way, instability training is thought to improve feed-forward and feedback mechanisms by improving stability and proprioception -should involve low load tasks -client should be able to demonstrate some level of postural control, but at the same time require a great deal of concentration -once the client has mastered one level, they should progress to the next level of difficulty (mastered exercise on floor to the same exercise on an unstable surface then wobble board or bosu) (instability training progression chart ph 179)

How performance in unvaried or unidirectional movement patterns affect mobilizer and stabilizer muscles

-a tight and shortened agonist has a lowered activation threshold and is described as hypertonic (meaning it will not take much stimulus to activate the muscle) -hypertonic muscles suppress (decrease neural activity via reciprocal inhibition) the activity of lengthened antagonists and cause further weakening of that muscle -ex: hypertonic iliopsoas muscles often result from repeated hip flexion as seen in long distance cycling/running or prolonged seated postures; the hypertonicity of the hip flexors then contribute to the progressive weakening of the gluteus maximus via reciprocal inhibition

Age conflicts in proprioception, mobility, and stability

-adverse effects of aging on proprioception, mobility, and stability are well established and continuously increase in individuals over the age of 60 -the risk of falls due to diminished postural control and kinesthesia (awareness of the position and movement of the parts of the body by means of sensory organs) also increases with age

Assessment of static neutral posture

-although does not necessarily capture how an individual moves, static neutral posture assessments do provide the EP-C insight regarding specific muscle imbalances -this info can then be used in the selection of stabilization exercises and stretching and self-myofascial release (SMR) strategies -also help clients develop an awareness of neutral posture, which holds great relevance when clients perform dynamic movements requiring maintenance of neutral while under load -assessments include the plumb line assessment, wall test, and progressive approach to developing postural awareness

Wall Test

-assesses normal lumbar curvature and forward head posture -instruct the client to stand with his or her back against a wall and feet approximately 6 inches from the wall -ideally, the back of the head should be positioned against the wall and the assessor's hand should be able to fit snuggly between the client's lumbar spine and the wall -taken together, the wall test and plub line assessment expose areas of tightness and/or weakness

Self-myofascial release (SMR) and stretching

-based on a form of manual therapy believed to alleviate/manage the discomfort associated with tender spots (trigger points) within the myofascia and relax hypertonic areas within soft tissue -involves the compression of soft tissue using tools like foam rollers or tennis/target balls -compressive forces imposed on the myofascia stimulate various mechanoreceptors that reduce muscle-firing rates -mechanical pressure also may improve the viscous and fluid qualities of fascia (thixotropism) -reduces inflammation by increasing local blood flow

Suggested corrective exercise for the alignment fault of loss of cervical neutral

-chin tucks -isometric cervical exercise (i.e. using hands on forehead resisting neck flexion effort)

Hi-Lo Assessment

-client places one hand on his or her sternum and one hand on his or her upper abdomen -client is instructed to perform 10 breathing cycles -client reports which hand moved first at the beginning of the inhalation phase during the majority of the assessment -practitioner should also observe the hand movements

Progressive Approach to Developing Postural Awareness

-cue the client both manually and verbally to arch the low back and then flatten the low back, which should be repeated several times -the client should be asked to find the middle of the two extremes -once neutral alignment is found, the client should be instructed to hold this posture for several seconds and then lose neutral position by arching or flattening the low back, only to regain neutral position again -each stage should begin with eyes opened and then eyes closed -when more dynamic movements, like squatting, are introduced, a dowel placed along the spine provides valuable tactile feedback for the client -client should be encouraged to maintain 3 points of contact with the dowel: the back of the head, the upper thoracic spine, and the pelvis

Suggested corrective exercise for the alignment fault of anterior pelvic tilt

-curl-up -side plank/bridge

Importance of diaphragmatic control evaluation

-diaphragm muscles are the prime muscles of respiration and a vital muscle of core stabilization -if proper diaphragmatic control is not present, the generation of intra-abdominal pressure required to stabilize the spine during lifting tasks can be compromised -breathing pattern problems can occur from muscular imbalance, motor control alterations, and chronic low back pain -as any other muscle, improving the endurance of these muscles enables them to perform at higher capacities (leading to improved work capacity and prolonged time to fatigue) -poor diaphragmatic control leads to hyperventilation and the body exceeds the gas exchange needed for metabolism (over-breathing can drastically lower carbon dioxide levels which can raise pH levels) -alterations in breathing mechanics correlate with low scores on the Functional Movement Screen

Previous Injury and Pain conflicts in proprioception, mobility, and stability

-disturbances in the motor control system often follow injury and leave residual effects -alterations from injury lead to inappropriate magnitudes of muscle forces and stiffness across joints (allowing for a joint to buckle or undergo shear translation) -the loss of stability may be due to damage incurred to the passive structures of the joint (i.e. tendons, ligaments) where they can no longer support joint integrity -sensory receptors in the joints may be compromised, which results in the delay action of stabilizing muscles which can then change the order of muscle activation

Anterior pelvic tilt

-excessive arching of low back -weak gluteus medius and maximus -inhibited transverse abdominis

Suggested corrective exercise for the alignment fault of posterior pelvic tilt

-glute bridges -bird dogs

Loss of cervical neutral

-head positioned in front of the body or tilting up/down -weak deep cervical flexors

Assessment of rolling patterns

-ideally, the client should be able to roll with equal ease in all directions -the assessment observes the rolling strategy of the client in 8 different patterns, leading from all 4 quadrants of the body (assessment guidelines on pg 173)

Diaphragmatic Breathing Assessment

-ideally, the hand on the upper abdomen should rise before the hand on the chest, and the hand on the chest should move slightly forward and not upward towards the chin -the hi-lo assessment is used to correct the breathing pattern

Overall recommendations that address lifestyle issues known to perpetuate muscle imbalance

-improving the ergonomics of the work environment -setting a recurring alarm to serve as a reminder to stand and walk around the office -practice of diaphragmatic breathing -foam rolling while watching TV

Stabilization Strategies

-include feedforward strategies (postural adjustments) within the muscles to anticipate an event -managed at the subcortical level, where the generation of stability is somewhat automatic and requires quality proprioceptive input -the sensorimotor system is responsible for providing awareness, coordination, and feedback to maintain optimal positioning of joints to enhance the quality of movement and reduce the chance of injury -stabilizing muscles must be recruited with proper timing and speed and proper muscle patterns

Wall Plank-and-Roll (WPR)

-integrative assessment and corrections -assessment of lumbar stability and serves as an exercise to anhance lumbar torsional (anti-rotational) control -client instructed to face a wall with feet ~2 ft from the wall -elbows should be positioned on the wall with forearms lying one on top of the other -should then be instructed to "brace" or stiffen the trunk and pivot on the balls of their feet while pulling one elbow off the wall ending in a side plank position -client should be encourages to rotate the entire body as a single unit -no lumbar or pelvic motion should be observed during the pivot -once sufficient stability is demonstrated, progressions include side planks on the floor, initially performed on on the knees and then to a full body side plank position -to optimize the effectiveness of isometric endurance exercises like the side plank, it is recommended to perform repeated sets of short-duration holds (8-10 s)

Teaching How to Brace

-integrative assessment and corrections -client should be instructed to precontract, or brace, the abs prior to performing isometric exercises like a plank or isotonic like squats -use the cue of "pretend you are about to be hit in the stomach" -the intensity of the brace should be tailored to the relative intensity of the exercise, where resultant coactivation of the trunk muscles is ample to protect the spine during lifting tasks but does not encumber proper mobility (ex: performing a bodyweight squat may require a low level of bracing intensity, however a 1-RM squat should brace with closer to a maximal effort to maintain spinal integrity

Knee valgus

-knees collapsing inward towards each other -weak gluteus medius and maximus

Suggested corrective exercise for the alignment fault of knee valgus

-lateral band walks -clam shells -glute bridges -bird dogs

Posterior pelvic tilt

-loss of neutral lordosis (just the right amount of inward curve to be classified as good posture) in the lumbar spine or flattening of lumbar spine -weak gluteus medius and maximus -inhibited multifidus

Alignment faults

-many times verbal and manual cuing can correct the problem, however, alignment faults can be the result of low endurance, timing issues of the stabilizing muscles, and/or tightness in the mobilizing muscles -correct faults by incorporating isometric exercises applied at various joint specific angles for the weakened or inhibited muscles

Mobilizing vs Stabilizing Muscles

-mobilizing muscles: superficially located and responsible for controlling locomotion, alignment, and balancing forces imposed on the spine; also called global muscles and comprise long lever arms, allowing greater force production, torque, and gross multiplanar movements -stabilizing muscles: more centrally located and largely function to create stiffness across joints; are shorter in length and respond to changes in posture and extrinsic loads

Overwight/Obesity/Physical Inactivity conflicts in proprioception, mobility, and stability

-obesity and overweight has been shown to be associated with alterations in motor function and postural control (due to reductions in muscular strength and endurance, postural distortion, discomfort with movement, and the perception of stiffness) -obesity and overweight in growth and development stages is believed to contribute to aberrant motor patterning, which extends to adulthood

Motor Learning

-once motor patterns are integrated and stored, they become automatic and are fine-tuned by unconscious sensory feedback -the saving of motor patterns makes the neuromuscular system more efficient when the body is exposed to similar demands in the future

Everyday Posture and Limited Variety of Movement conflicts in proprioception, mobility, and stability

-repeated movements in one direction or sustained postures results in the remodeling of sarcomeres (adaptive muscle shortening represents a loss in sarcomeres, and lenghtening represents the addition of sarcomeres) and result in muscle imbalance -we stray from a neutral position and begin to adopt the posture that we are in most of the time -muscle length adaptations influence length tension and force-coupling relationships, motor control, and how we move -often seen in sedentary individuals, where muscles of the anterior torso and internal rotators of the shoulder tend to shorten -some athletes also experience faulty stabilization strategies and mobility (particularly in repeated unvaried or unidirectional movement patterns like cyclists or golfers)

Loss of thoracic extension

-rounding of the thoracic spine -weak middle and lower traps

SMR vs PMR and static stretching prior to exercise

-several recent investigations show that SMR elicits improvements in ROM without concomitant performance decrements when done prior to activity -PNF and static stretching have reported deleterious effects on performance prior to activity

Proprioception

-the sense of knowing where one's body is in space -composed of static (joint position sense) and dynamic (kinesthetic movement sense) -include info from machanoreceptors, and info collected from visual and vestibular centers further support proprioception -important mediator of joint stability and mobility and ultimately the calibration of movement

Stability

-the state of remaining unchanged, even in the presence of forces that would normally change the state of condition, or the state of a joint remaining or promptly returning to proper alignment through an equalization of forces -occurs through coordinated muscle coactivation, creating a suitable amount of stiffness to maintain joint alignment

Plumb Line Assessment

-use of a plumb line or static posture app is useful in identifying deviations from a neutral position -client should be barefoot, wear form-fitting clothing to identify bony landmarks, and be encouraged to assume their everyday, relaxed posture during the assessment -table 6.4: basic plumb line static postural assessment

Internal rotation of the shoulders

alignment fault associated with weak external rotators of the shoulder (infraspinatus)

Why establishing a movement baseline is important

assessment of a client's true movement baseline is important because you cannot just assume that the client already has sufficient proprioceptive acuity, mobility, and appropriate command of the stabilizing muscles to maintain optimal alignment (because assuming this and starting them out with simple bodyweight movements in a resistance program may cause injury)

Suggested corrective exercise for the alignment fault of internal rotation of the shoulders

band or dumbbell shoulder external rotation

Importance of rolling patterns

demonstration of efficient rolling patterns reveals proper recruitment sequencing of the core stabilizing muscles

What is Neutral Position, and why is it so important?

neutral position: the posture of the spine in which the overall internal stresses in the spinal column and muscular effort to hold the posture are minimal, and maintaining neutral is important because: -it organizes the body into its most biomechanically efficient posture -optimizes ideal muscle length-tension and force-coupling relationships -minimizes compressive and shear forces imposed on the joint -optimizes the timing and speed of contraction of stabilizing muscles

Reasons behind proprioceptive decline in elderly individuals

proprioceptive decline in elderly populations are because of: -a reduction in the number of joint mechanoreceptors -changes to the structure and sensitivity of mechanoreceptors -inadequate processing of proprioceptive input within the CNS

Suggested corrective exercise for the alignment fault of loss of thoracic extension

scapular retraction w/ no weight (progressing to seated rows)

Proprioceptive Acuity

sensory input that is gathered from specialized nerve endings (mechanireceptors) located in the skin, muscles, fascia, and joints

Joint Structure conflicts in proprioception, mobility, and stability

some clients will present structural anomalies that prohibit full ROM on certain exercises -ex: an individual's hip joint may have a capsular structure that prevents performing a deep squat with the feet pointed in a neutral alignment (in such cases, the EP-C should encourage movement that is most comfortable for the client and not attempt to stretch through this specific nonmodifiable limitation)

Propensity for Inhibition of Stabilizing Muscles

tendencies of certain muscles to weaken or tighten may lead to postural distortion and alterations in motor control (this may occur due to participation in sports involving repetitive actions, overtraining, poor ergonomics, sedentary lifestyle, trauma, or disease

Thixotropism

the fascia's ability to change from a more solid to a more gelatinous state and back, releasing tender spots/trigger points in muscle

Articular Geometry

the shape and depth of joints of which mobility and stability are partly derived from

Problems with muscle hypertonicity of agonists and weakening of antagonists via reciprocal inhibition

when an agonist muscle is weakened (gluteus maximus), the synergist muscle (hamstrings) will compensate for the primary movement (hip extension) which is problematic for 2 main reasons: -the pattern overworks the synergist (hamstrings), which increases the risk for injury -the compensatory pattern becomes etched within the sensorimotor system and will alter quality proprioception, mobility, and stability which tend to perpetuate further postural distortion (ex: hypertonic hamstrings from sedentary posture exert a downward force upon the proximal attachment site at the ischial tuberosity of the pelvis which rotates the pelvis posteriorly, which then reduces the neutral curvature of the lumbar spine (flattens the lower back)