How to Eliminate Pathokinematics - Part IV

Last week we covered repetitions to substitution and lumbar-hip disassociation, two essential concepts to changing movement in our athletes.  This week let's continue the discussion by looking at proprioceptive training and concentric vs. eccentric training.

Proprioceptive Training

As defined by Wikipedia, proprioception is the sense that indicates whether the body is moving with required effort, as well as where the various parts of the body are located in relation to each other and in relation to space.  Proprioception is a sense provided by a combination of sensory receptors in the inner ear, the muscle spindle and the joint space that converge to give an overall sense of where the body is in space.  These inputs are sent to the higher centers of the brain (cerebellum) to compare the intended movement with the actual movement.  Once the intended and actual are compared (in the cerebellum) 
, minor adjustments can be made in the motor plan in the primary motor cortex of the brain in order to move the body into the desired position.

Proprioception provides us with a sense of where our body is in space which is an essential component in preventing injury and improving athletic performance.  Proprioception is something that can be learned, or re-learned, and is used extensively in rehabilitation settings to aid athletes in restoration of ability following injury.  However, current research suggests that training of this sense prior to injury also aids athletes in building the awareness of the lower kinetic chain during athletic activities, thereby improving performance.  Proprioceptive training is therefore an essential part of a program designed to aid in prevention of abnormal movement patterns or pathokinematics that can lead to injury and in improving overall athletic performance. 

In order to effectively use proprioceptive training, it is essential to ensure proper form and technique.  Due to the fact that you are attempting to train the “sense” of body position and how to maintain the correct body position, if done with improper form we are simply reinforcing bad movement patterns.  In the example here, if we let this athlete repeat this lateral shift during his squatting motion, then he will carry over this same poor movement patter when he does his squats with 225#.  Therefore, it is  important to keep in mind that multiple systems work together in the body to facilitate this sense of awareness.  Knowing this fact then, we can progress or regress this type of exercise by adding or removing some of the senses required to properly conduct them. 

Let’s look at an example to illustrate this point.  Vision is one way an athlete receives feedback about his or her current and desired body position.  An easier form of an exercise, requiring less proprioception, is to allow the athlete to watch themselves in a mirror while performing the desired movement.  As they progress in skill and endurance, you can have them do the exercise without the mirror (hence removing the visual input).  This is a technique that is often employed with the Squat Neuromuscular Retraining (SNMR) exercise, which will be discussed in a later blog. 

Another example is the sensation provided by receptors within the muscle spindle and joint space.  Performing exercises on an unstable surface (a Theraband Stability Trainer) can make it more difficult for this feedback system to provide input to the brain about body position and proper mechanics.  If combined with the removal of visual input, then a given exercise becomes increasingly difficult.  That said, as with any exercise, it is vital to first master the easiest levels of a given exercise prior to progressing to the next level, and in this case before removing or limiting other sensory input.

The purpose of proprioceptive exercise in our program is for the professional to teach the athlete to use his/her body to perform large movements while maintaining “healthy” alignment of the lower extremity, for example not allowing excessive internal rotation with valgus stresses at the knee and hip.  Considering the multiple senses involved, the athlete should start with one set of each exercise, performing the lowest number of repetitions recommended and slowly progress to 3 (or more as appropriate) sets of the highest repetitions recommended---using perfect form.  Progression is dictated by the athlete’s ability to perform the exercise with a moderate amount of effort without any decomposition of technique.

A final note is that proprioception should be considered throughout the entire program, during every exercise, and as part of every progression.  All too often we see professionals focus on proprioception during proprioceptive exercises and yet completely ignore it during dynamic stretches.  The dynamic valgus occurring during these stretches simply reinforces poor movement.  It is the proprioceptive sense that will enable the athlete to maintain the proper alignment of the lower limbs while performing many, if not all, of the exercises.  When and if movements revert to pathokinematic patterns, then we suggest revisiting proprioceptive retraining techniques such as the use of visual input, verbal cuing and regression of exercise to re-learn proper positioning.

Concentric Training vs. Eccentric Training

According to Merriam-Webster’s Medical Dictionary, (www.merriiam-webster.com) a concentric contraction is a type of muscle contraction in which the muscles shorten while generating force.  During an eccentric contraction, the muscle elongates while under tension due to an opposing force being greater than the force generated by the muscle.  Rather than working to pull a joint in the direction of the muscle contraction, the muscle acts to decelerate the joint at the end of a movement or otherwise control the repositioning of a load. 

This is the traditional understanding of concentric and eccentric contraction which has been applied to traditional training methodology.  However, the majority of training programs continue to focus solely on concentric strength training despite the abundance of evidence supporting the use of eccentric training protocols to improve performance and prevent injury.  Over the course of the last 10 years, LaStayo and others have done a tremendous amount of research on the benefits of eccentric strength training and the corresponding implications for improving strength and power.  In a 2009 study by LaStayo et al in Sport Health showed the strength gains that can be achieved with eccentric training versus concentric.  As such, these concepts have been widely used in rehabilitation settings and are beginning to be used in more frequently in performance training as well. 

In sports, our muscles act in both a concentric and eccentric fashions and therefore must be trained in both ways.  For example, when a basketball player is jumping for a jump shot, the quadriceps are functioning in a concentric fashion to generate enough force to produce a maximal vertical jump.  On the other hand, when a pitcher is pitching, the biceps acts in an eccentric fashion during deceleration phase to slow the arm.

We also know that in order to prevent injuries, we should train muscles in the fashion or similar contraction type that is similar to how they sustain injuries.  For example, sprinters often experience hamstring strains that occur during the eccentric phase (for the hamstring) of the running cycle.  Therefore training which focuses on concentric training of the hamstrings is less effective than training that focuses on training the hamstrings in an eccentric fashion.

In our program, we will describe exercises as having a concentric, eccentric or both concentric and eccentric focus.  The purpose is to train the muscles in the fashion that they perform during sport and to maximize the strength and power gains we achieve as a result.  However, it should be noted that caution must be used when incorporating more eccentric training protocols into established routines that have not traditionally used them, as these can lead to additional and/or new muscle work, resulting in more muscle soreness and/or injury if over used, or used before the body has a chance to adapt.  Close monitoring is required to ensure safety, proper form and to prevent overtraining.

Distal vs. Proximal Training

In exercise terminology, when we refer to distal placement of a weight or distal movement, we mean the weight or movement referred to is “far away” from the pivotal point or center of gravity.  When we use the word “proximal” we are referring to weight or movement that is closer to the joint, pivot point or center of gravity. 

Closed Chain vs. Open Chain Exercise

 

When we talk about ”open or closed chain” exercises, we are referring to the kinetic chain of the body, which is essentially the chain through which power is produced and off-loaded, resulting in movement and force attenuation.  Open chain exercises are those in which a given body part is free to move during the exercise as in a chest press, or leg extension.  These types of exercises usually isolate a single muscle, group or joint.  For example, during a leg extension exercise, the knee and quadriceps are isolated.  This type of exercise can be performed with or without added weight, but when weight is added, it is usually added distally (far away from the muscle group that is being isolated).  In this example, weight would be added at the ankle in order to maximally work the quadriceps in an open chain leg extension exercise.  Other types of open chain exercises in the gym might be biceps curls, hamstring curls, lat pull-downs and triceps kick-backs.

Closed chain exercises on the other hand are those that require your hands or feet to be in a fixed position during the exercise motion. The feet or hands are usually on the ground, but may also be fixed to a platform or other fixed machine or device.  Closed chain exercises work many joints and muscles at the same time.  An example of a closed chain exercise is the squat, which will be discussed in more detail later in this book.  The squat involves the knee, hip, and ankle joints and many muscle groups including the hamstrings, gluteal group (gluteus maximus, gluteus minimus, and gluteus medius), the quadriceps, the calf muscles, the lower back and abdominal muscles.  Different from open chain exercises, when additional weight is added to a closed chain exercise, it is placed in the proximal position, or closest to the center of gravity, where the core muscles can help control and move the weight safely.  In the squat example, additional weight, if added, would be placed on the shoulders or the front of the chest, versus a distal or “far away” placement of the weight. 


Of course, closed chain exercises can be performed very well without added weight, simply by using body weight.  They involve many more muscle groups, including smaller muscle fibers which are only recruited when balance and proprioception are required.   This makes closed chain exercises very efficient in that they work the most muscles in the body in the least amount of time.  They are also very effective in transferring strength and flexibility gains to activities of daily living and sports.  Consequently, they are often called “functional” exercises in that they help people gain fitness for all functions of life.  The picture to the right is a closed chain exercise (bottom leg) performed with poor technique.

Closed chain exercises more closely mimic real life movements as opposed to open chain exercises.  They are also usually safer for your joints, especially the knee, elbow and ankle.  If you remember our earlier discussion regarding forces to the joints and ligaments, you can see that closed chain exercises cause “compressive” force to the joints, which strengthen them over time.  Conversely, open chain exercises involve “shearing” forces, which stress the joint and can result in injury.  Other examples of closed chain exercises besides the squat are pull-ups, push-ups, and lunges.

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

How to Eliminate Pathokinematics - Part III

Last week, we covered the concept of symmetry and adaptation.  This week, we will take this discussion a step further in talking about repetitions to substitution.

Repetitions to Substitution (Regression of Exercise)

Understanding this concept is imperative to success of any program addressing movement.  As we know from previous blogs, when an athlete becomes fatigued and begins to modify his or her form, pathokinematics can emerge or worsen.  We also know that some athletes are “trained” to move in certain ways, or learned at an early stage to move in a certain way, and sometimes these habits are detrimental to sports performance and/or can lead to injury.  Ultimately, we are attempting to re-educate and retrain our clients in order to prevent poor movement patterns with this program.  In order to accomplish this objective, we must acknowledge and address the fact that there are both neurological and physiological components involved in the performance of movement.  Many poor movement patterns have been learned over many years—often over the lifetime of the subject--- and as a result have been carried over to training and then to performance of athletic activities.  Many subjects we see move in harmful ways simply during everyday life activities, such as gardening or house work or chores.

There is research available now that indicates that in order to change and/or prevent poor movement patterns or in order to create a new motor plan in the brain for movement (or better repetitive movement patterns) we must engage and involve the higher centers in the brain---primarily those in the primary motor cortex.  To create a change in the higher centers of the brain (primary motor cortex) requires between 3,000 and 30,000 repetitions of an activity.  A perfect example of this is the baseball pitcher who is trying to change his throwing mechanics.  To perfect a new movement pattern associated with pitching might take an entire season of training and constant attention to perfecting the technique.  Another example is the patient who tore her anterior cruciate ligament 6 months ago and has been limping ever since.  Getting this subject to ambulate or walk without a limp or a flexed knee can be very difficult and requires a lot of practice as well as continuing feedback.

Considering this, are we going to have athletes or clients do 30,000 reps?  No.  From the motor learning literature, we know there is techniques that can be employed or utilized that will aid in facilitating these changes in the primary motor cortex.  One of these is mental rehearsal.  Mentally rehearsing the movement results in similar synaptic firing and sequencing that occurs as if you did the movement.  Perfect example is the baseball player who mentally rehearses his throw in order to improve his pitch.  He rehearses it over and over again which results in the motor patterns being laid down for future reference when he does throw. 

Another technique is visual feedback.  Providing visual feedback into the system results in bringing in additional centers (visual cortex) into the equation which has the net result of improved synaptic firing.  In addition to this input, the athlete also becomes more aware of where their body is in space, begins to see and feel what the movement should feel like which results in synaptic sequencing of stabilizers and antagonist muscle groups which further facilitates the motor learning or changes within the primary motor cortex.  So, training in front of a mirror, use of video feedback or use of external visual devices (like motion guidance) become great tools to aid in this learning process.

Knowing then that movement patterns have a neurological motor learning aspect as well as a physiological aspect, we can see that performing repetitious movement with proper technique is vital to the success of this, or any, program.  Therefore, a vigilant eye to technique is critical to long term success.  Throughout this program we have listed a number of sets or an amount of time to perform a given exercise, but keep in mind that this is only a recommended goal.  The athlete should only perform the number of sets or repetitions for which they can maintain proper technique. 

Repetitions to substitution refers to the act of performing a given exercise only until there is an inability to maintain proper technique if one more repetition is completed.  In other words, we allow the subject to perform the exercise until a substitution of proper form occurs, or until the body begins to compensate for fatigue (or other physiological changes) or an inability to focus (or other neurological changes).  At the point of substitution during a repetitive set, the individual has exceeded his or her physiological and/or neurological ability to maintain proper support to the system.  When the subject can no longer maintain proper form, continuation simply reinforces the poor motor habits we are trying to eliminate or prevent, and further contributes to muscle weaknesses and the neurological patterns that caused or contributed to those poor movement patterns in the first place.

Poor technique = poor motor planning = poor performance

 

To illustrate this point, the above athlete (who is 6 months post operative) had been performing squats for over 3 months with a physical therapy provider at the point at which this photograph was taken.  Prior to being returned to sport, this athlete sought an evaluation due to lack of confidence with and strength on the involved side.  Obviously, if his technique had been corrected earlier in the recovery process he would not present with as much asymmetry in strength, endurance and proprioception this far in to the recovery process.  As much as you think this does not occur or that "I would see that" you would be surprise how much we see this even in professional and elite athletes being trained or rehabbed from the "best".

In the photographs below, we see a marked difference in performance results when testing vertical jump variance.  We can easily see nearly a 3 inch difference in quadriceps circumference when comparing the involved to the uninvolved legs.  This resulted in a strength measurement difference of 60% between the involved and the non-involved lower extremity.  At 6 months post operative, there should be a negligible difference between the involved and the uninvolved sides.  We can deduce in this example that form and technique were never addressed in this athlete’s rehabilitation and training and consequently, strength gains were not realized on the involved side.  Over time, if these deficits are not addressed, the athlete will continue to reinforce poor movement patterns, never fully regaining symmetry in the system or full use of that side of the lower extremity.

So what should happen at the point at which we see a substitution in form during an athlete’s exercise progression?  It is at this point, that the professional needs to “regress” the exercise routine.  Simply back it down to an easier form of the exercise.  There will be days or times during this program that an athlete will present with general fatigue, exhaustion or lack of focus.  The causes of pre-level exhaustion can be multi-factorial and can include, but are not limited to, any of the following:

1.     Prolonged practice (e.g., a 3 hour practice the day before)

2.     High intensity training (e.g., the day of or the day before)

3.     Poor sleeping patterns the night before

4.     Poor nutritional patterns

5.     Overtraining

6.     Depression

7.     Weight loss or gain

8.     Heat (high humidity or temperature days)

9.     Dehydration

In cases like this where the athlete presents with a pre-level exhaustion, it is important to remember that it is perfectly appropriate to regress exercises based on his or her stamina that day.  If you find that an athlete is not able to do the same level of exercises he or she was able to do the time before, regress the exercises.  The goal is to drive towards the set number but you should discontinue the set immediately once substitution starts.  Regression can be achieved in several ways:

1. Decrease the number of sets
2. Decrease the number of repetitions
3. Allow for longer rest periods between sets
4. Step back to a lower phase of the exercise
5. Reduce the total length of exercise time

Lumbar – Hip Disassociation

One of the essential components assessed during the a movement assessment is the athlete’s ability to perform some of the activities assigned using lumbar-hip disassociation. Lumbar-hip disassociation is crucial for athletes to master in order to prevent excessive stress on the lumbar spine as well as to enable them to develop strength and endurance of the lumbopelvic region.  Lumbar-hip disassociation refers to the athlete’s ability to discern the proprioceptive difference between lumbar spinal flexion and/or rotation and hip flexion and/or rotation.  Most young athletes tend to demonstrate spinal flexion and rotation with movements which require hip flexion and rotation.  This lack of an ability to discern between the two different types of movements leads to poor performance and can result in injuries to the hip, sacroiliac joint or lumbar spine.  Although not limited to females, the inability to tell the difference between hip and lumbar spine movement tends to be more prevalent in female athletes than male athletes, as well as in athletes who have undergone a recent and rapid growth spurt. 


Obtaining lumbar-hip disassociation will allow the athlete to perform hip flexion and/or rotation without lumbar movement which aids in maintaining stability of the lumbar spine with certain kinds of exercise.  This is an essential component to core development as well, and allows maximal force production, kinetic energy transfer and force attenuation along the kinetic chain.  Without the ability to disassociate between hip and lumbar spine movement/rotation, force production and transfer is lost along the kinetic chain, and there is increased stress to the lumbar spine and hip over time due to the repetitive forces that end there. 

The professional should continually maintain an awareness of the athlete’s ability to differentiate between movement at the lumbar spine and movement at the hip so that he/she can give feedback accordingly, and instruct the athlete throughout the course of the training program.  This will lead to better performance of the exercises within the protocol, greater strength and endurance gains, better outcomes, increased safety and ultimately, improved movement patterns.  There is a series of exercises included in the exercise program that will focus specifically on helping athletes obtain this “sense” or “awareness” called the Lumbar Hip Disassociation Prep Exercises.

If the athlete is allowed to train in postures without maintaining this lumbar-hip disassociation or in postures which further reinforce this poor movement patterns then we can anticipate this will be the movement pattern they will revert to during athletic activities.  As depicted in this picture, the variations may be slight but the impact that it has to motor unit recruitment and muscle sequencing is huge and should not be ignored. 


Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

How to Eliminate Pathokinematics - Part II

Last week, we started discussing some general concepts and terminology as it relates to training and movement.  This week, we will start our discussion on a very important concept of symmetry, adaptation and exercise progressions.

Symmetry

One of the easiest ways to maintain proper mechanics is to restore and/or maintain strength and endurance symmetry or balance between the right and left sides of the body.  We can see an excellent example of why this concept is important in athletic training if we take the example of a freshman college baseball pitcher.  By the time this athlete has reached this point in his athletic career, he has most likely been playing baseball since the age of 6 or 8 and pitching since age 8 or 9.  By the time he has reached college, he has been pitching (for the purpose of this example), right handed for 10 years.  Given this scenario, a significant amount of asymmetry or imbalance develops over time as a result of simply participating in the sport, but also and perhaps primarily, being “one side dominant” in that sport.  In most cases, this college aged individual will have increased tightness of the right pectoralis major, weakness of the right rhomboid, right lower trapesius, right serratus anterior and possibly the right rotator cuff.  He will also have more strength in his right gluteus maximus and right quadratus lumborum and multifidus than he has on the left side.  As a result of this asymmetry, he will begin to load his right shoulder and the left side of his lower back differently than the opposite side with every activity he does (including those during and before and after sporting activities).  This sets him up for right shoulder problems and lower back pain on the left over time.  Restoring symmetry to the system will balance loading of the tissues of the lower back, hip and shoulder.

In the medical field, making return to sport decisions often is determined by preference rather than   For example, my sports medicine specialist will rely on Cybex testing to determine if the athlete is ready to return to sport.  The general consensus is that the effected limb needs to be within ≥80% of the non-involved limb in order for the athlete to return to sport safely.  This same test has been used in the NFL for over a decade to determine if athletes are at risk for hamstring injuries.  However, in 2013, in the American Journal of Sports Medicine, Zvijac et al showed that the ability of this test to determine injury risk only had a predictive value of .513 and .524.  So 50% of the time it was right and 50% of the time it was wrong.  But when we consider the concept of specificity, does this really test specifically how the hamstrings function?  This is an open chain exercise and rarely do the hamstrings function in an open chain.  In athletics, the foot is in contact with the ground, the limb is fully loaded, the core is engaged and the hamstrings and quadriceps are function in co-contracted state.  The point is that specificity should apply not just to training and testing but also has a big application in determining when an athlete is ready to return to sport.  A well-constructed movement assessment should be one that not only identifies injury risk but which could also be used for determining return to sport calls.
what is truly supported by the science.

In addition to specificity, is this a true measure of symmetry or symmetry in movement or sport?  In 2001 in the Journal of Orthopedic and Sports Physical Therapy, Gaunt et al introduced the concept of limb symmetry index (LSI).  Simply stated, this is a measurement of variance between the right leg and left leg performance during functional testing.  In 2011, Ardern et al published a paper in the American Journal of Sports Medicine looking at LSI during functional activities for determining return to sport.  In this study and others, it is suggested that the limb being assessed should have a limb LSI of ≥85% of the contralateral limb.  Although we agree with this, we believe that this cannot and should not be determined by just one test but rather a sequence of tests that compares single limb performance.  Doing so in this manner allows stressing the limb in multiple planes of motion, brings in a level of fatigue to the testing and provides a more sensitive measure (due to accumulation of scoring from multiple tests) of LSI.


Adaptation

Most of us are very familiar with the concept of adaptation when dealing with exercise.  This is another of the six key “Principles of Conditioning” required to maximize the effectiveness of a given training program or plan.  Simply put, the body will adapt to the demands placed upon it.  As a direct result of the body’s ability to adapt to exercise, progressive resistance exercise (PRE) was developed.  Exercise physiologists have known for years that in order to see continued strength and endurance gains in athletes, they must have exercises that progressively increase physical demand.  If they do not continue to increase physical demand, then the body eventually adapts to the level of demand placed upon it and no longer makes strength or endurance gains.  This is one of the primary reasons that many exercise programs fail:  The athlete performs the same routine over and over again without increasing physical demands, which eventually results in performance plateaus.  Therefore, we know that a continually progressing exercise program is required in order to continue to see athletic performance improvement in terms of strength, speed and endurance gains.  So how do we do that?

The physical demands of exercise can be increased in several different ways.  You can increase the demands of a given exercise by:

1. Increasing the resistance or intensity of the exercise
2. Increasing the number of sets or duration of the training session
3. Increasing the number of repetitions within each set (or duration of the exercise)
4. Increasing or decreasing the speed of a given exercise, depending on load
5. Decreasing the base of support using
1. Unstable surfaces
2. Moving to single limb support
6. Increasing the number of joints involved in the exercise
7. Removing sensory input  - such as closing the eyes
8. Decreasing the rest time between sets/exercises – this is the concept of super setting which will be explained in more depth later in this chapter.

Exercise Progression

This is still another of the six key “Principles of Conditioning” needed to maximize the effectiveness of a given training program or plan.  In order to address the body’s natural adaptation response, we can increase the difficulty of an exercise as discussed above.  This is best done in a progressive format, beginning with easiest and moving to more difficult over time, so that as the body “super compensates,” or adapts to the current demands placed on it, future demands are continuously and systematically increased. 

There are several different ways to progress exercises.  Some programs use periodization.   Periodization is used primarily in sport-based performance training and enables an athlete to make strength and endurance gains up to his or her specific sport’s season and maintain those through a maintenance phase during the season, when sport specific training is the primary objective.  With this methodology the athlete participates in different kinds of training cycles throughout the year.

Our program, described in the future blog series, is designed to address pathokinematics in an individual which are identified using the movement assessment.  This takes into account still another of the “Principles of Conditioning”.  That is that all individuals are different and therefore require different training and exercise protocols in order to see improvement.  The Corrective Exercise Program we have designed to address and improve pathokinematic movement patterns allows customization based on the specific needs of the individual as seen in the movement assessment.  The methodology we use facilitates the progression of an individual athlete’s exercise regimen so that he or she is ultimately able to “normalize” pathokinematic movement by fully addressing deficits.  Once movement is “normalized,” many of our athletes will then move into more aggressive sport specific performance or power lifting types of periodization programs.


Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

How to Eliminate Pathokinematics - Part I

Throughout this blog we have been discussing pathokinematics and how we can use corrective exercises to address pathokinematics.  Now it is time to look more closely at specific exercise prescriptions for what we uncover in the movement assessment.  Although most of us have a thorough understanding of exercise physiology, it is imperative to establish a common framework for discussing these concepts so that we can examine how they impact movement or, more importantly here, re-training of movement so that we can achieve optimal outcomes.  We believe this is of such importance that this will consume several blog series.  So we encourage you to stick with us as this is the foundation of making permanent change in movement.  The following paragraphs review a few general exercise physiology terminology concepts that will be applied in the Corrective Exercise Program in the blogs that follows.  We plan to touch on the following terms and concepts:

 

§  Specificity

§  Symmetry

§  Adaptation

§  Exercise Progression

§  Repetitions to Substitution

§  Lumbar/Hip Disassociation

§  Proprioceptive Training

§  Concentric vs. Eccentric

§  Distal vs. Proximal training

§  Closed Chain vs. Open Chain Exercise

§  Supersets, Mega-Sets and Monster-Sets

§  Concept of Pre-Stretch: Proprioceptive Neuromuscular Facilitation (PNF)

§  Plyometrics

§  Squats and the Basics

§  Squat Neuromuscular Retraining (SNMR)

§  Full Squats and Jump Squats

§  Stretching and flexibility

§  Dynamic Stretches

§  Core

§  Role of Strength Training

§  Role of Cardiovascular Training

§  Rest and Recovery

§  Periodization

§  Period Based Nutrition

§  Psychology of Exercise

Specificity

In exercise physiology, specificity refers to a training effect that specifically targets the muscles, joints and other structures in the body (including the heart and lungs) in the ways that are involved in the activity for which you are training.  The training should target the pattern of muscle and joint involvement in the activity and also mimic the activity in terms of the specific duration and intensity demands it places on those muscles, joints and other structures.  This is one of the six key “Principles of Conditioning” that are required to maximize the effectiveness of a given training program or plan.  Specificity allows for the maximal amount of carryover from the training protocol to the activity for which you are training.  This improves the transfer of training gains, thus the outcome of training efforts is maximized.  In other words, the athlete will achieve maximum results in exchange for the time and energy expended.  For specificity to apply, a given training protocol must replicate the sport for which you are training in the following ways: 

·       anaerobic or aerobic demands

·       musculature involvement

·       type of contractions involved (concentric or eccentric)

·       number of joints used

·       length tension relationships

·       sequence of muscular contractions

·       flexibility demands

·       force, speed and endurance demands

Just like a football player would not train in the same fashion as a long distance runner, a soccer player would train with different demands than a volleyball player.  So, we must consider the athletic requirements of the sport when implementing a corrective exercise program, as well as the specific design, frequency and grouping of exercises that are appropriate for that athlete, in that sport.  The corrective exercise program discussed later will have maximal carry-over to the individual sport as long as we keep the concept of specificity in mind.

Ultimately, the measure of success of any training program is in its results.  If you are a runner, then the only measure of success is velocity.  After completing the training, can I run faster, farther and for a longer period of time, using the same or less energy, considering all environmental conditions (temperature, terrain, air quality, etc.)?  In this case, oxygen consumption is the measure used most frequency to assess running economy.  And even though we might see sports that use the same or nearly the same muscles, in similar ways as a given sport, like cross country skiing and running, we know that the aerobic demands of running and cross country skiing are actually quite different.  The specificity concept means that in order to become better at running, one must practice running.  The bottom line is: After I train, do I run faster in a race, and remain injury free?

Often times, training or an upbringing in one sport hurts athletes who want to migrate to another sport later in life.  The perfect example of this can be seen in the sport of triathlon.  Many times, triathletes are recruited from swimming backgrounds.  However, success in swimming is a terrible predictor of success in cycling or running.  In fact, swimming requires the exact opposite body position, body build and mechanics of the effective runner or cyclist.  In swimming, the chest is held high, the back is slightly arched to allow for the pressing of the body’s built-in floatation device (the lungs) which raises the hips and reduces drag.  The feet are fully plantar flexed, which results in poor plantar dorsiflexion over time, which is essential for running efficiency. Swimmers are often bigger, heavier athletes than runners, having more upper body muscle mass, particularly in the latissimus dorsi, pectorals and deltoids.  This body build is exactly opposite of what would be most conducive to running and cycling, which requires more propulsive muscle mass in the lower extremity and less muscle mass in the upper extremity.

Cyclists on the other hand, in order to generate power while remaining in the most aerodynamic position possible, end up becoming quite inflexible in the shoulders (required for an extended and efficient swim stroke) and in the hip flexors (critical for running).  Their range of motion is also sometimes limited by tightened hamstrings and overly developed vastus lateralis and gastrocnemius muscles.  For runners, on the other hand, we want the chest down, the body leaning forward beyond the center of gravity, the hip flexors and hamstrings loose to allow a full arc swing of the leg during the running stride, and small, light weight gastrocnemius muscles which can swing through the arc easily and quickly with less wear and tear on the hip, quadriceps and knees.  This is why rehabilitation strategies for running injuries using the bike are often detrimental to the return to running related sports because in fact they develop the system in ways that negatively impact the sport to which we are trying to return the athlete.  Thus, again we can see the case for increased and conscious specificity of training in both the rehabilitation and performance improvement training arenas.

Another concept related to specificity is the fact that there is little margin for variation or error in the planning and conduct of training.  This is especially true in multisport, but is usually also true in other kinds of sports.  Often, there is less strength available for related activities, less time for cross training, and ultimately athletes simply don’t have the time or luxury of introducing other disciplines with enough frequency to become proficient.  To refer back to the running example, elite runners run upwards of 120 miles per week.  Multisport athletes (as just one example) cannot spend that much time running and still be proficient in swimming and cycling.  Therefore, specificity becomes even more important in allocation of training hours. 

This being said, though, we can not negate the importance of including regular stretching, strengthening and some amount of cross training to prevent injury and facilitate healing of muscles used during the target sport(s), as well as isolation exercises to address specific weaknesses or asymmetries identified during movement.  Cross training provides a mental break, a change in athletic requirements and allows continuation of fitness levels in the most general sense when other factors require a change.

The concept of specificity also comes evident when looking at movement specific testing and   In 2012 in the American Journal of Sports Medicine, Grindem et al showed that single leg testing was a good predictor of injury risk in sport.   In 2013, Kristinaslund et al took it a step further showing that testing of single limb performance was a better indicator of injury risk than bilateral testing.  Considering the concept of specificity, then one should consider not only testing single limb performance but also training single limb performance.  Following the concept of specificity, if we train single limb performance and this improves then one can postulate that injury risk is then reduced and performance will improve.

training.

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is VP of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

 

 

How to Identify Pathological Movement - Part VI

Each of the Movement Tests (with the exception of the plank and side plank) we described is performed for multiple repetitions.  If you are unable to score every repetition and are only scoring one rep, then the score is based on the movement in which the most significant deviation is noted and which deviation is most pronounced.  Since many of these deviations become more pronounced with multiple repetitions, then it is the repetition(s) in which these become the most pronounced that are scored.  For example, in the Full Squat Test (FST), if the athlete has limited range of motion (60-90 degrees which would score him/her a 2/3) but a lateral shift of  >3” (which would result in a score of 1/3), then the score for the test would be based on the deviation resulting in the lower score (in this case 1/3 for the lateral shift >3”).  The philosophy behind this scoring method is that we want to reduce the magnitude of the deviations seen at their worst as well as those that are the most pronounced.  If an athlete presents with a lateral shift of 3 inches in the last 3 reps of the Full Squat Test (FST), then this is the area where we want to have the largest impact.  It is in the areas that have the greatest magnitude of deviation in which we can identify most significant risk of injury and which have a more pronounced impact on athletic performance.  Therefore using the Full Squat Test (FST) as an example, if the subject is able to perform 9 reps with a lateral shift of less than one inch but performs one rep with a lateral shift of >1 inch, the score for this test would be 2. 

For those tests in which the right and left are performed independently (Single Leg Squat Test & Side Plank test), then both the right and left are scored independently and compared to one another.  If you are scoring every rep, this will provide you with a clearer picture of variance right to the left.  This is referred to in the literature as limb symmetry index and if the variance is greater then 20%, we know this puts the athlete at greater risk for injury and performance issues.

Each test should be scored independently along with an explanation for the raw score.  For example:

• FST = 30/60 – 2” left lateral shift on 10/20 reps
• SLST = 48/60
• SLST R = 18/30 – hip adduction past midline right hip 6/10 reps
• SLST L = 30/30 – able to perform without deviation
• Plank – 22.5/30 with R hip drop at 45 seconds
• Side Plank R = 17.5/30 – 35 seconds – with R trunk rotation
• Side Plank L = 30/30 – 60 seconds

Total Score = 148/210 or 70%

R Score = 35.5/60 or 59%

L Score = 60/60 or 100%

Limb Symmetry Index = Lower score / Higher score = R Score / L Score = 35.5/60 = 59%

The best possible score on the MA is 210 points if each rep is scored independently.  The participant’s score is reported as XX/210.  Overall performance can be reported as raw score over total possible (148/210) or as a percentage (70%) as well as the limb symmetry index as a raw score over high score (35.5/60) or as a percentage (59%).

Pain

For all of the DMA tests described above, it is critical to determine if the athlete experiences pain during the testing as this will skew the results of the examination as well as the results obtained.  Many times, especially with the athletic population, pain will be denied even though they may be experiencing pain.  It is important to determine if this is the case due to the impact on the results of the assessment.  If they do experience pain, it is important to have them undergo a further orthopedic evaluation by a qualified health care professional (Medical Doctor, Certified Athletic Trainer, or Physical Therapist).  If pain is persistent enough to modify movement patterns or limit the athlete’s ability to perform these tests, then there is a high probability that the athlete will have pain with athletic activities and with a return to regular training.

Clearing Tests/Sport Specific Testing:

Part of the beauty of movement tests is that they can be implemented in any setting and with almost any population.  Whether they are performed as pre-participation physicals, on the field assessments, performance assessments or simply as a screening tool, you can get some valuable information from the movements you see.  With the advent of the MA, we have also come up with several sport specific tests that we use.  We use these tests for 2 specific reasons:

• Pre-participation Physical Clearing Tests – whether performing pre-participation physicals for high school, collegiate or professional athletes, efficiency of the testing protocols is absolutely essential.  Therefore, using the clearing tests can allow us to record some sport specific movements and immediately identify those that are at greatest risk and in need of further testing. During mass physicals, this then allows you to narrow down your group to make sure you are targeting those at greatest risk.  From an efficiency standpoint, this also prevents the movement screens from becoming a cumbersome addition to your physical process and preventing excessive wait times and prolonged physical process.
• Sports Specific Tests – with the addition of the sport specific tests (tests which incorporate movements that are specific to that sport) we can thoroughly assess the pathokinematics during sport specific movements and assess the impact of our treatment strategies on these specific movements.

The tests that we use are as follows:

• Jump Stop Test: during this test the subject is asked to sprint (starting from standing position) a distance of 10 yards (30 feet) and perform a jump stop.  They are recorded during the running phase as well as the jump stop.
• During this test, we are looking for:
• Pathokinematics
• Asymmetries
• Rational: during this test we are assessing mechanics during both sprinting and during the jump stop phase.
• Sport specific testing – as a sport specific test, this will provide us with a visual guide to the impact that our treatment strategies have on this particular movement.
• Clearing test – as a clearing test, this will allow us to identify those that are at greatest risk by how they present compared to all the subjects tested.
• Assessing Sprint cycle:
• Stride length – is there a variance
• Trunk – is there excessive forward flexion throughout or excessive trunk rotation
• Midstance – is there a trendelenburg on the stance leg, adduction or internal rotation at the knee
• Swing through – is there a circumduction with, decreased DF, knee contact
• Heel strike – where does initial contact occur, is there excessive pronation
• Assessing Jump Stop:
• Jump – what are the mechanics at push off
• Landing – what are mechanics and is it a hard or soft landing
• Sports – sports that these are commonly used with include:
• Basket Ball
• Volleyball
• Soccer
• Pole vaulting
• L – Test: during this test, the subject is asked to sprint 10 yards (30 feet) then cut off to the right.  This test is repeated again with cutting to the left.
• During this test, we are looking for:
• Pathokinematics
• Asymmetries
• Rational: during this test, we are assessing the mechanics during both the sprinting and during the cutting motion to the right and left.  There is also a comparison of the right side to the left for asymmetries. 
• Sport specific testing – as a sport specific test, this will provide us with a visual guide to the impact that our treatment strategies has on this particular movement.
• Clearing test – as a clearing test, this will allow us to identify those that are at greatest risk by how they present compared to all the subjects tested.
• Assessing Sprint cycle:
• Stride length – is there a variance
• Trunk – is there excessive forward flexion throughout or excessive trunk rotation
• Midstance – is there a trendelenburg on the stance leg, adduction or internal rotation at the knee
• Swing through – is there a circumduction with, decreased DF, knee contact
• Heel strike – where does initial contact occur, is there excessive pronation
• Assessing cutting motion:
• What are the mechanics with the rapid change in direction
• Sports – sports that these are commonly used with include:
• Basket Ball
• Volleyball
• Soccer
• Football
• Lacrosse
• Baseball
• Single Leg Squat Test: this test is used as clearing test only for our female athletes.  During this test, the subject is asked to perform 10 single leg squats as described above in the MA.  This test is repeated again on the opposite side.
• Assessing: during this test, we are assessing the mechanics similar to what we are doing in the MA.  There is also a comparison of the right side to the left for asymmetries. 
• Clearing test – as a clearing test, this will allow us to identify those that are at greatest risk by how they present compared to all the subjects tested.  This is only used as a clearing test for our female athletes as we have seen some common associations with failure of this test with increased risk for injury in the after mentioned sports.
• Sports – sports that these are commonly used with include:
• Basket Ball
• Volleyball
• Soccer
• Pole vaulting
• Scoring: The clearing tests are scored in the following manner with the exception of the SLST (which is scored according to scoring above):
• Scoring of the clearing tests are done in the following way
• 3 – no deviations noted
• 2 – notable deviations or compensation, need for further testing
• 1 – deviations/pain resulting in fall, pain or inability to perform, need for further testing

Primarily, these tests are used for clearing purposes as well as a base line measurement to assess the impact of our treatment or training strategies.  They are designed to assess the entire kinetic chain and when combined with Dartfish technology, provide you with a way to objectively measure these movements.  This will assist you in determining where movement is breaking down and more importantly how to address this with a training protocol. 

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis and author of a college textbook on this subject.  He serves as the National Director of Sports Medicine for Physiotherapy Associates, is a Safety Council Member for USA Cheer National Safety Council and associate editor of the International Journal of Athletic Therapy and Training.