Partners R

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Partners gt RD

• University of North Carolina
• 1 School of public health
• Dr. Padua research expert
• Link to the Evidence Based Model

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NASM-OPT Training is a huge benefit. It has a
cumulative effect on your body. If your body is
more receptive every night, it is going to help
you over the long term. Steve Nash Two-Time
MVPGuard- Phoenix Suns
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Success Story Barry Zito

• NASM client Barry Zito, won the American League
  Cy Young Award after completing the 2002 season
  with a 23-5 record and 2.75 ERA in nearly 230
  innings.
• Barry Zito has never missed a start in the majors
  leagues.
• When asked in 2005 What are the most important
  factors that allow you to stay healthy? Zito
  responds I've just learned different stretches
  and so many different things through NASM, the
  National Academy of Sports Medicine, which is
  where I've been training in the off-season for
  the last six years.

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Unique gt Professional Sports Medicine Societies
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Uncovering Roadblocks Correcting Weak Links
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Presentation Overview

• This course will present an overview of the human
  movement system, human movement impairments and
  the best available evidence to support its
  concepts and implementation

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Learning Objectives

• Upon completion of this course the participant
  will
• Understand the concepts of the human movement
  system
• Understand common human movement impairments
• Have an awareness of the available evidence that
  supports HMS impairments
• Understand and be able to Identify common HMS
  impairments
• Understand and be able to Implement a
  comprehensive Corrective Exercise Strategy to
  alleviate common HMS Impairments

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Foot and Ankle Imbalances

• Lateral ankle sprains are the most common injury
  suffered in sports during sports participation
  (Safran, 1999)
• Denegar, et al 2002 in a retrospective study
  demonstrated altered arthrokinematic movement of
  the talus (decreased posterior glide) even though
  range of motion was restored

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Foot and Ankle Imbalances

• Friel, et al (2006) found ipsilateral hip
  weakness following inversion ankle sprains

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Foot and Ankle Imbalances

• Beckman et al demonstrated decreased gluteus
  medius muscle activation post ankle sprain
• If an athlete begins an integrated training
  program and has muscle imbalances in the hip
  complex secondary to an ankle sprain, then
  further compensations and possible injury may
  occur

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Foot and Ankle Imbalances

• Bullock-Saxton (1996) et al demonstrated
  decreased gluteus maximus muscle activation post
  ankle sprain
• If an athlete begins an integrated training
  program and has muscle imbalances in the hip
  complex secondary to an ankle sprain, then
  further compensations and possible injury may
  occur

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Knee and Hip Imbalances

• It has been recognized that the patellofemoral
  joint may be influenced by the segmental
  interactions of the lower extremity (Fredericson,
  Powers)
• Abnormal motions of the tibia and femur in the
  transverse and frontal planes are believed to
  have an effect on the patellofemoral joint (Ford,
  Nyland)
• This abnormal motion may be caused by weakness in
  the hip abductors and external rotators (Ireland)

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Knee and Hip Imbalance

• Recent kinetic analysis of running reveals that,
  although the knee joint primarily moves in the
  sagittal plane, the knee is also subject to
  significant frontal and transverse plane moments
  (McClay)
• In the absence of sufficient proximal hip
  strength, the femur may adduct and internally
  rotate, further increasing the lateral patellar
  contact pressure (Lee)

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Knee and Hip Imbalance

• Fredericson demonstrated that distance runners
  with ITB Syndrome had weaker hip abduction
  strength than the control group and their
  unaffected leg

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Knee and Hip Imbalance

• Ford and Hewett demonstrated that female athletes
  landed with greater total valgus (femur adduction
  and tibia abduction) than male athletes and may
  lead to ACL Tears

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Lumbo-Pelvic-Hip Complex Imbalance

• In a cross-sectional study of 100 patients
  (Cibulka) demonstrated unilateral hip rotation
  ROM asymmetry in patients with SI joint regional
  pain

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Lumbo-Pelvic-Hip Complex Imbalance

• Hodges and Richardson 1998 reported that slow
  speed of contraction of the transverse abdominus
  during arm and leg movements was well correlated
  with LBP

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Lumbo-Pelvic-Hip Complex Imbalance

• OSullivan et al 1997 found that synergist
  substitution of the rectus abdominus for the
  agonist transverse abdominus during the abdominal
  drawing-in maneuver suggesting less efficient
  intersegmental stabilizing mechanisms and greater
  shear forces at the intervertebral joints

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Lumbo-Pelvic-Hip Complex Imbalance

• Hides et al 1994 demonstrated unilateral atrophy
  of the multifidus in patients with low back pain

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Conceptual Paradigm ShiftThe Human Movement
System
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Human Movement System
Myofascial
Articular
Neural
Sensorimotor Integration
Neuromuscular Control
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Length-tension Relationship

• There is a direct relationship between tension
  development in a muscle and the length of the
  muscle
• There is an optimum length at which a muscle can
  generate maximum tension

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Force-couple Relationships

• Muscles work synergistically to reduce force,
  dynamically stabilize and concentrically produce
  force in all three planes of motion
• The CNS is designed to optimize the selection of
  muscle synergies

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Arthrokinematics

• Articular partners have predictable movement
  patterns
• Roll
• Slide
• Glide
• Translation
• These patterns are controlled by the CNS and the
  surrounding muscles of the kinetic chain

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Current Concepts in HMS

• Two distinct yet interdependent muscle systems
• Stabilization System (Stabilizers)
• Primarily involved in joint support
• Broad spectrum of attachments
• Prone to inhibition and weakness
• Movement System (Mobilizers)
• Superficial muscles associated with extremity
  movement
• Prone to overactivity and tightness
• Categorized into four common sub-systems

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Understanding Muscle Function

• Stabilizers
• Joint Stabilization
• Sensory Function
• Postural Control
• Isometric/Eccentric

• Mobilizers
• Joint Movement
• Angular Rotation and Torque Function
• Concentric

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Understanding Muscle Function

• Mobilizers
• Gastrocnemius
• Quadriceps
• Hamstrings
• Adductors
• Hip Flexors
• Rectus Abdominus
• Erector Spinae
• Latissimus Dorsi

• Stabilizers
• Gluteus Medius
• Transverse Abdominus
• Internal Oblique
• Multifidus
• Lower Trapezius
• Serratus Anterior
• Rotator Cuff
• Deep Neck Flexors

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Two Components of Spine Stability
Spine Stability Intervertebral Stability
Lumbopelvic Stability

• Intervertebral Stability
• Stability between two vertebrae (intervertebral
  joint)
• L1-L2, L2-L3, L3-L4, L4-L5, L5-S1
• Lumbopelvic Stability
• Stability between the lumbar spine and pelvis
• Need to achieve intervertebral stability to
  create lumbopelvic stability
• Lumbopelvic region is only as stable as the
  weakest link
• Link Intervertebral joint

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Spine Stability Intervertebral Stability
Lumbopelvic Stability
McGill Model
Hodges Model
Focuses on intervertebral stability
Focuses on lumbopelvic stability
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Dynamic Stabilizers

• Intervertebral Stabilizers
• Local musculature
• Transverse Abdominus
• Multifidus
• Pelvic Floor
• Diaphragm
• Lumbopelvic Stabilizers
• Global musculature
• External Oblique
• Internal Oblique
• Quadratus Lumborum

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Bracing
Drawing In
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Exercises to Facilitate Dynamic Stabilizers

• Abdominal Bracing
• Facilitates contraction of the Global
  Stabilizers
• Exercise to promote lumbopelvic stability
• Abdominal Drawing-In
• Facilitates contraction of the Local
  Stabilizers
• Also, facilitates contraction of the diaphragm
  and pelvic floor musculature
• Exercise to promote intervertebral stability

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Clinical Application

• Need to ensure both intervertebral and
  lumbopelvic stability to achieve spine stability
• Utilize both the drawing-in and bracing exercises
  to train the local and global muscles,
  respectively
• NOTE Must ensure intervertebral stability as
  lumbopelvic stability is not achieved without
  intervertebral stability
• RECOMMENDATION Begin with intervertebral
  stability training (drawing-in) and progress to
  lumbopelvic stability training (bracing)
• Want to have both the global and local muscles
  working together in the end

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HMS Efficiency
Normal Length-
Normal Force-
Normal
tension Relationship
couple Relationship
Arthrokinematics
Optimal
Senosorimotor integration
Optimal
Neuromuscular Efficiency
Optimal Tissue Recovery
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HMS Impairment
Altered Length-
Altered Force-
Altered
tension Relationships
Couple Relationships
Arthrokinematics
Altered Sensorimotor
Integration
Altered Neuromuscular
Efficiency
Tissue Fatigue
Initiation of the
Cumulative
Injury Cycle
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RESULTS OF HMS Impairments

• Reciprocal Inhibition
• Synergistic Dominance
• Arthrokinetic Inhibition
• Relative Flexibility
• Pattern Overload

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RECIPROCAL INHIBITION

• Increased neural drive or decreased extensibility
  of an antagonist will decrease the neural drive
  to the antagonist
• Leads to synergistic dominance

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SYNERGISTIC DOMINANCE

• The NMS phenomenon that occurs when synergists
  and stabilizers compensate for prime movers
  during functional movement patterns

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ARTHROKINETIC INHIBITION

• The process of inhibition that occurs from lack
  of proper joint arthrokinematics

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RELATIVE FLEXIBILITY

• The Kinetic Chain will take the path of least
  resistance

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PATTERN OVERLOAD

• Repetitive recruitment of the same muscle fibers,
  in the same ROM/Plane of motion and at the same
  speed creates tissue overload and eventually
  injury

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What is the solution?

• Static malalignments, poor muscle activation, and
  dynamic malalignments may all lead to Human
  Movement System Impairments
• Research has shown that a comprehensive
  Functional Profile was the most predictive of HMS
  Dysfunction
• Earl JE, Hertel J. Patterns of dynamic
  malalignment, muscle activation, joint motion,
  and patellofemoral-pain syndrom. J Sports
  Rehabil. 2005 14215-233

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Functional Profile

• Nadler et al 2002 in a Case Control Study of 213
  Division I NCAA athletes found that kinetic chain
  deficits existed long after symptomatic recovery
  from injury, resulting in functional deficits,
  which may be missed on a standard physical
  assessment
• This study may support residual functional
  deficits in athletes that suffer from a primary
  injury and are cleared for sports participation
• The above evidence helps to lead us to the
  conclusion that we may want to implement valid
  and reliable functional tests with our clients
  prior to initiating a comprehensive, integrated
  training program

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Uncovering Roadblocks

• Multiplanar vertical jump/hop
• Multiplanar horizontal jump/hop
• Shark skill test
• Multiplanar cone jump/hop test
• Speed tests
• Straight-ahead speed
• Lateral speed and agility
• Sport-specific
• Speed endurance

• Posture
• Gait
• Flexibility assessment
• Neuromuscular assessment
• Overhead-squat test
• Single-leg balance excursion
• Single-leg squat test
• Multiplanar lunge test
• Multiplanar step-up test
• Push-up test
• Overhead medicine-ball throw

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Integrated Assessment

• Movement Assessment
• Muscle Length
• Muscle Activation

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MOVEMENT ASSESSMENTS

• Overhead Squat
• A two-legged squat performed with the arms held
  overhead.
• It assesses total body structural alignment,
  dynamic flexibility, and neuromuscular control
  from a bilateral standing posture.
• Squatting requires optimal motion in the ankles,
  knees, and hips.
• Having the arms elevated overhead stresses the
  musculature surrounding the shoulder complex and
  increases the demand placed upon the core
  stabilizing muscles

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MOVEMENT ASSESSMENTS

• Single-leg Squat
• Assesses lower body dynamic flexibility,
  neuromuscular control and balance from a
  unilateral standing position
• The reduced base of support provides a greater
  challenge to the LPHC.
• The core and the proprioception mechanisms work
  harder than when squatting on two legs.
• Also assesses functionally applicable movements
  (squatting and balancing) used in everyday
  activities.

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Muscle Length

• The movement of a joint through its biomechanical
  ROM represents the integrated functioning of many
  systems primarily the muscular, articular, and
  nervous systems.

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Muscle Activation Assessment

• Optimum recruitment of muscles can only be
  achieved through the integrated functioning of
  many systems within the human body primarily the
  muscular, articular, and nervous systems.

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PROGRAM DESIGN

• Review Solutions Chart
• Develop class CET program
• Inhibit
• Lengthen
• Activate
• Integrate

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INHIBIT SMR

• Holding pressure on the tender areas of tissue
  (trigger point) for a sustained period of time,
  trigger point activity can be diminished.
• This will then allow the application of a
  lengthening technique (static stretching) to
  reset the muscle lengths and provide for optimal
  length-tension relationships.
• Subsequent use of activation and/or integration
  strengthening exercises will ensure an increase
  in intra- and inter-muscular coordination,
  endurance strength and optimal force-couple
  relationships that will produce proper
  arthrokinematics.

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LENGTHEN STATIC STRETCHING

• Static stretching is a flexibility technique used
  to increase the extensibility of muscle and
  connective tissue (lengthening) and thus ROM at a
  joint.
• Though, the exact mechanisms responsible for the
  efficacy of static stretching are not fully
  understood, it is believed that static stretching
  may produce both mechanical and neural
  adaptations that result in increased ROM

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ACTIVATE ISOLATED STRENGTHENING

• Isolated strengthening exercises are used to
  isolate a particular muscle to increase the force
  production capabilities through
  concentric-eccentric muscle actions.

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INTEGRATEINTREGRATED DYNAMIC MOVEMENT

• Integrated dynamic movement enhances the
  functional capacity of the human movement system
  by increasing multiplanar neuromuscular control.
• This is achieved by utilizing exercises that
  focus on the synergistic function of the
  stabilization and mobilization muscles of the
  body.

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If you see this.
Abnormal
Normal
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FEET Turn OutOveractive Muscles



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FEET Turn OutUnderactive Muscles






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FEET Flatten
Note the arch will drop or appear to flatten
and the lateral border may also appear to raise.
Collectively, this will usually cause an adducted
appearance of the crease at the junction between
the foot and lower leg.
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FEET FlattenOveractive Muscles



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FEET FlattenUnderactive Muscles




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We recommend this.
Inhibit
Integrate
Activate
Lengthen
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If you see this.
Normal
Abnormal
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KNEES Move InwardOveractive Muscles





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KNEES Move InwardUnderactive Muscles






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We recommend this.
Integrate
Activate
Inhibit
Lengthen
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If you see this.
Normal
Abnormal
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LPHC Excessive Forward LeanOveractive Muscles






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LPHC Excessive Forward LeanUnderactive Muscles






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We recommend this.
Inhibit
Lengthen
Activate
Integrate
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Putting it all together
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Demos 1 2 3
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THANK YOU