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specified and that the exercise
prescription match the patient’s
functional needs.
A basic pillar of exercise science is
the SAID principle. This means that
accomplishes this force transmission
through its diagonal loops and slings
(oblique abdominal/pectorals,
gluteus maximus/latissmus dorsi)
linking the hip to the shoulder girdle
. . . . . . . . . . . . . . . . . . . . . . . . . . .
Journal of Bodywork and Movement Ther
6(4), 248^254
doi: 10.1054/jbmt.2002.0311, available online
http://www.idealibrary.com on
This paper may be photocopied fo
Craig Liebenson DC
Private Practice,
10474 Santa Monica Boulervard
CA 90025, USA.
Tel.: +1310 470 2909; Fax: +1
E-mail: cldc@flash.net
CL IN IC I AN ’ S INFORMAT ION FOR SELF - HELP PRO CEDURE S
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training causes ‘specific adaptation
to imposed demands’ (Sale &
MacDougall 1981). These
adaptations are specific to the
length, movement and speed of the
exercise trained (Rutherford 1988).
An example is that knee extensors
(quadriceps) trained on the seated
knee extension progressive
resistance machine do not become
stronger on a bicycle (Rutherford
(see Fig. 2).
The role of the trunk or ‘core’ in
force transmission should not be
underestimated. From the creeping
and crawling of an infant, to the
counter-rotation of pelvis and trunk
during gait, to the full coil of a
golfer diagonal, 3-D movements in
functional activities are the rule
(Lamoth et al. 2002). Yet, most
modern activities which are
202, Los Angeles,
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tional train
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Craig Liebenson
Introduction
Many exercises ‘isolate’ problem
areas, but is this an ‘integrated
isolation’ of functional activity
(Gray 2001)? If strength training
does not mimic the way muscles are
used in the patient’s functional
activities then it may have a
cosmetic effect, but not an injury
preventive or rehabilitative role. It is
important that the goal of training is
1988).
Gary Gray, PT has pioneered
functional exercises such as 3-D
lunges, single leg balance challenges,
and squats (Gray 2001, Risberg
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ing part 1:
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et al. 2001, Liebenson 2002). These
utilize a ‘star matrix’ floor pattern so
that tri-planar movement (sagittal,
frontal, and transverse) can be
trained (see Fig. 1).
Nearly all functional activities
involve the whole body. Therefore,
functional training should also
involve the entire locomotor system.
The trunk transmits the energy from
the lower quarter kinetic chain to
the upper quarter. The trunk
sedentary (e.g. sitting, standing,
slow walking), and even health club
exercises (e.g. sit-ups, biceps curls,
leg raises) predominately involve
only one plane of motion – the
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Clinician’s information for self-help procedures
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sagital plane. Therefore, in order to
‘drive’ function, it is imperative to
utilize full body motions utilizing
rotation. Such training will
automatically activate the deep
‘core’ trunk muscles such as the
transverse and oblique abdominal
muscles.
This article is the first in a series of
three on functional training. The
follow-up articles will provide brief
clinical notes and additional patient
pages based on this initial article.
Assessment
How does a practitioner know if a
patient’s stability during the
performance of daily tasks has
actually been improved? Can it be
assumed that if manual therapy
9:00
6:00
3:00
12:00
Fig. 1 The star matrix of Gary Gray, PT
(Liebenson 2002)
releases trigger points, restores joint
play, or improves range of motion
(ROM) that function is
automatically stabilized? Numerous
studies show that ROM
impairments correlate poorly with
activity intolerances or disability
(Klein et al. 1991, Waddell et al.
1992, Nattrass et al. 1999). Thus,
more direct measures should be
evaluated.
More direct measures include the
patients perception of their
functional disability (i.e. activity
intolerance questionnaires such as
Oswestry), and tests of actual
Fig. 2 Functional diagonal loops and slings. (A) Anterior chain and (B) posterior chain.
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functional tasks such as squatting,
lunging, balancing, loaded reaches,
etc. (Simmonds & Lee 2002). This
‘functional diagnosis’ can be
combined with the patient’s
structural diagnosis (e.g. pain
generator) to guide the clinician in
selecting what treatments are most
effective in patient care. For
instance, a patient with a structural
diagnosis of a herniated disc who
has a functional diagnosis of pain
with prolonged sitting and an
inability to perform a forward lunge
without flexing their trunk and hip
will require training which facilitates
lunging and kneeling while
maintaining the lumbar lordosis
(see Fig. 3).
The single leg squat will be
presented in detail as an example of
how the functional ability of the
lower quarter can be screened. Ask
the patient to perform a single leg
Asymmetry of depth indicates
any of the following: poor balance;
weakness of the quadriceps and
B
Liebenson 2002) and (B) Trendelenberg sign.
Fig. 5 Hip flexion (Liebenson 2002). Fig. 6 Tibial torsion.
Liebenson
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squat and compare one side to the
other looking for: asymmetry of
depth, Trendelenberg sign, hip
flexion, tibial torsion, or
hyperpronation (see Fig. 4).
Fig. 3 Forward lunge with hip and trunk
flexion.
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A
Fig. 4 (A) Single leg squat test (from Fig. 2 of
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Clinician’s information for self-help procedures
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gluteus maximus; or knee instability.
The Trendelenberg sign indicates
weakness of the lateral hip
stabilizers, in particular the gluteus
medius (see Fig. 4B). Hip flexion
indicates weakness of the hip
extensors (see Fig. 5). Tibial torsion
is a sign of knee instability and could
be secondary to either
hyperpronation in the subtalar
region or gluteus medius
insufficiency (see Fig. 6).
Fig. 7 Hyperpronation (Liebenson 2002).
Hyperpronation is a sign of subtalar
instability (see Fig. 7).
Training
The basics
It is important to have a way to
‘audit’ if your manual therapy has
successfully restored function. An
audit in the practice setting takes the
form of post-treatment checks of
relevant functional deficits that have
been identified. If manual therapy
does not restore function, then
functional training is indicated.
There are two basic principles to
follow when prescribing a new
exercise. The first is the McKenzie
principle that the movement should
centralize rather than peripheralize
This begins on the floor and then on
the Stability Trainer (see Fig. 9). It is
performed repetitively in the
direction on the Star Diagram
(front, side, and back) that
optimizes function (i.e. decreases
hyperpronation, tibial torsion, etc.).
When 12 repetitions can be
performed slowly without jerky
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symptoms (McKenzie 1981). If a
patient has symptoms of sciatica
that are aggravated by trunk flexion
movements then after performance
of 8–10 repetitions of a new exercise
the trunk flexion sensitivity should
be diminished.
Second, is the cognitive-behavioral
principle that ‘hurt does not
necessarily equal harm’ (Indahl et al.
1998). The patient should be
informed that light activity would
not injure them and that
deconditioned tissues are typically
uncomfortable to move because they
arestiff. The patient should be
regularly reassured with each visit
that increases in symptoms are not
signs of re-injury or confirmation of
pathological tissue. Rather, ‘flare-
ups’ are considered transient
‘spasms’ which will run a course and
are better with light stretching and
gentle activity than with
immobilization. Additionally, the
patient is educated that anxiety over
symptoms increases muscle tension
and reduces the pain threshold.
Therefore, it is best to learn how to
cope with symptoms by remaining
active.
Functional training involves a
variety of exercises which resemble
the functional activities the patient
engages in regularly. It requires very
little equipment and uses common
activities such as balancing,
reaching, kneeling, and squatting
as part of the exercise. Generally,
the training is performed in an
upright position with gravity as the
main form of resistance. However,
tubing, cables, hand weights and
other simple devices can also be
utilized.
Exercises are progressed from
simple uniplaner movements to
whole body tri-planer movements.
Examples of the exercises utilized
are shown in Table 1. Labile
surfaces such as gymnastic balls,
rocker boards, and stability trainers
are used to specifically challenge
stability mechanisms during these
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exercises. This amplifies the training
effects of the exercises (Janda &
Va’vrova’ 1996, Liebenson 2001).
Balogun demonstrated that by
exercising on a balance board lower
extremity strength improved more
than if four separate resistance
machine exercises are performed
(Balogun et al. 1992). Similarly,
Vera-Garcia showed that trunk
curl-ups on a gymnastic ball
increased the oblique abdominal
activity four-fold vs. floor training
(Vera-Garcia et al. 2000).
The Exercises
Single legbalance
The patient should start with his
eyes open and attempt to perform a
10 s hold. Six repetitions twice a
day is the goal. Arms should be
relaxed at their sides. If necessary
they can reach out for balance. This
can be progressed to performance
with eyes closed. The next
progression is to balance on one foot
on the Stability Trainer (see Fig. 8).
Again perform it first with eyes open
and then once mastered, with eyes
closed. Always progress to the next
level of exercise when six repetitions
with 10 s holds/repetition are
achieved.
Lunge
Table1Functionalmovements trained
K Single leg balancing
K Lunges
K Squats
K Whole body and ‘tri-planer’ exercises
K Functional activities such as tennis
backhand, golf swing, etc.
OCTOBER 2002
movements then it can be progressed
to lunging on the Stability
Trainer.
Squats
Training squats is valuable for
improving lower quarter and trunk
function. A seemingly difficult
exercise – the single leg squat – can
be modified so that it is performed
with appropriate stability. Weight
should be back on the heels and the
knees should not drive forward
beyond the toes. With fingertips on a
wall it becomes a novel way to
reeducate appropriate functional
movement patterns (see Fig. 10). It
should be performed with eyes open
until 12 slow repetitions can be
controlled, then it can be progressed
to eyes closed. Finally, it can be
performed on the Stability
Trainer.
Whole bodyand‘tri-planar’exercises
Single leg balance, lunge and squat
exercises can become ‘tri-planar’
exercises (movement in all three
planes of motion) by adding arm
reaches. The correct arm motion will
and should be searched for when
patients have difficulty stabilizing
any link (i.e. ankle, knee, etc.) in the
kinetic chain. As an example if a
person’s forward lunge occurs with
excessive hip or trunk flexion raising
the arms overhead will
automatically drive extension (see
Fig. 11). If subtalar hyperpronation
is present an arm reach across the
body during performance of an
oblique or lateral lunge will
automatically facilitate supination
(see Fig. 12).
The addition of arm movements
to a trunk or lower quarter exercise
instantly makes an exercise much
more functional. Punches teach
the patient to ‘learn’ how to transfer
their weight from back to front
leg (see Fig. 12). The weight
transfer facilitates the lower
quarter kinetic chain to generate
power which the trunk transmits to
Fig. 8 Single leg balance on the stability
trainer (Theraband stability trainer available
from The Gym Ball Store, San Diego,
www.gymball.com.).
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Fig. 9 Dynamic lunge on the Stability
Trainer.
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improve squat or lunge performance
Fig. 10 Single leg squat facing the wall.
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Fig. 11 Forward lunge with arms overhead.
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Fig. 13 (A and B) Punches.
Clinician’s information for self-help procedures
Fig. 12 Lateral lunge with arm reach.
the arm. Proprioceptive
neuromuscular facilitation (PNF)
patterns such as the ‘sword’ or
‘seatbelt’ are also utilized to
reeducate tri-planer coordination
(see Figs 13 and 14). Bands, cables
or hand weights are the only
equipment required.
Functionalactivities
The final common pathway for
functional exercises are movements
which mimic the sports or activities
an individual performs. The
Stability Trainer is ideal for
challenging the balance,
coordination, strength and
endurance of the individual in these
functional positions and movements
(see Fig. 15).
Summary
Improving stability during
performance of daily activities is
the final goal of rehabilitation.
Fig. 14 (A and B) Sword (Reproduced with permission from DeFranca C, Liebenson C. The
Upper Body Book, 2002, The Gym Ball Store, San Diego, www.gymball.com.).
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body movements coupled with
progressive balance challenges trains
the deep ‘core’ muscles.
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Gray G 2001 Rehabilitation Institute of
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Manual therapy and non-weight-
bearing exercises are frequently
catalysts in this process. However,
functional training does not
necessarily need to follow these
other approaches.
As the saying goes ‘begin with the
end in mind’. Functional whole
Fig. 15 Golfer exercise with stability trainer.
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Indahl A, Haldorsen EH, Holm S, Reikeras
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	Introduction
	Figure 1
	Assessment
	Figure 2
	Figure 3
	Figure 4
	Figure 5
	Figure 6
	Figure 7
	Training
	The basics
	Table 1
	The Exercises
	Figure 8
	Figure 9
	Figure 10
	Figure 11
	Figure 12
	Summary
	Figure 13
	Figure 14
	Figure 15
	REFERENCES