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movement and velocity specific changes (Rutherford 1988). If training programs do not address the specific functional needs of the individual, the goal cannot be for challenging lunge and reach tasks. SMT has been used since the 1960s to challenge the balance system necessary for maintenance of the upright posture (Freeman 1965). SELF - HELP ADV ICE FOR THE CL IN IC I AN Craig Liebenson DC Fu nc tio na le xe rc is es achieved. In other words if trunk flexors are trained in the sitting position they become stronger there, but not in other positions such as standing. It has been shown that elite bicyclists in Europe do not realize functional gains on their bicycles following Of course, the ancient Tai Chi system has used this for perhaps thousands of years and now recent studies prove its value especially in the elderly (Wolf et al. 1996, Wolfson et al. 1996). It has been shown that SMT reduces falls in the elderly and knee and ankle injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Journal of Bodywork andMovementTherapies (2002) 6(2),108^116 This papermay bephotocopied for educational use. doi: 10.1054/jbmt.2002.0295, available online at http:// www.idealibrary.com on Private Practice 10474 Santa Monica Blvd., 202, Los Angeles, CA 90025, USA Correspondence to: C. Liebenson Tel: +1 310 470 2909; Fax: +1 310 470 3286; E-mail: cldc@flash.net 108 JOURNAL OF BODYWORK AND MOVEMENT THERAPIES APRIL 2002 Functional Introduction The goal of any fitness program is to improve an individual’s performance in their activities of daily living (ADLs), demands of employment (DE), or sports and recreational activities (SRAs). Many exercises are performed in ways which ‘‘isolate’’ problem areas, but do not mimic the actual way the individual uses their muscles. Such exercises may be important stepping stones in rehabilitation of functional ability, but they are not ends in themselves. This article will present a simple set of functional exercises representing a final common pathway which other exercises and manual therapies should aim to facilitate in our patient populations. It is well known in exercise science that the gains realized in training are usually limited to those positions or ranges of motion utilized. This is called the specific adaptation to imposed demands (SAID) principle (Sale 1981). Training leads to length, exercises seated knee extension progressive isotonic resistance exercise (Rutherford 1988). Six weeks of resistance training did not increase their torque output during knee extension on the bicycle. In fact, very few forms of exercise have been able to demonstrate that they can overcome this SAID principle. Therefore, exercises may begin for reasons of comfort or motor skills education in non- functional positions such as supine, but the goal of training people in ways which more closely mimics their ADLs, DE, or SRAs must be realized for actual improvements in performance to be achieved. Two excellent examples of functional training are the dynamic lunges or functional reach exercises introduced by Gary Gray, P. T. and the sensory-motor training (SMT) of Pr. Vladimir Janda (Gray 2001, Janda & Varova 1996). Gary has introduced a very detailed assessment and functional training program which utilizes a star matrix diagram can be assessed (see Fig. 1). Arm reaches can be added. Single leg squats, alone or with trunk twists and or arm reaches can be evaluated. Each movement is evaluated for its balanced excursion distance – the distance accomplished without loss of balance. The single leg squat is an ideal form of functional assessment of the lower extremity kinetic chain (Fig. 2). Table 1 shows the various dysfunctions which can be provoked by this test. While many clinicians may limit themselves to less provocative A B Fig. 2 Single-leg squat test. Self-help advice for the clinician Fu nc tio na le xe rc is es in professional European footballers (Caraffa et al. 1996, Seidler & Martin 1997, Tropp et al. 1995). SMT has also been shown to be an efficient way to build strength since balance training improved lower extremity strength more than four separate isotonic machine exercises (Balogun et al. 1992). The sensory-motor system has been addressed in a prior article in this ‘‘self-help’’ series, so this paper will focus on Gray’s work (Liebenson 2001). Assessment The goal of functional rehabilitation is to improve functional capacity so that it is sufficient to meet or exceed the physical demands of ADLs, employment, or sports and recreational activities. Symptomatic treatment alone such as with medication, massage, or manipulation rarely is sufficient to restore functional capacities. Active care methods which only focus on altering patterns of mechanical sensitivity such as the McKenzie system may be necessary but are not sufficient. Similarly, motor control reeducation programs, such as spinal stabilization methods, that do not train the patient in upright activities resembling their ADLs, DE and SRAs, will fall short of the goal of matching internal functional capacity to external demand. Most modern musculoskeletal treatment approaches focus on both reducing pain and restoring function. The Agency for Health Care Policy and Research in the United States in 1994 stated the modern goal of care: ‘‘The panel’s overall intent was to change the paradigm of focusing care exclusively on the pain of low back problems to one of helping patients improve their activity tolerance’’. (AHCPR 1994). In this regard it is important from day one of care to identify the ‘‘functional end points JOURNAL OF B of care’’ and establish a plan of treatment designed to achieve those goals. The means to reach these end points may include soft tissue and joint manipulation, floor exercises, and passive modalities, but the goal will be to restore functional integrity to meet the external demands of one’s environment. Thus, the common pathway of care must ultimately include controlled challenges of the motor control system in activities which mimic the ADLs, DE, or SRAs of the individual. In fact, if a clinician can safely train an individual to perform these functional tasks then training can be ‘‘fast tracked’’. Clinicians should be on guard for a tendency to ‘‘believe’’ that a particular dysfunction they have identified such as a trigger point or joint with poor ‘‘end feel’’ is decisive in interfering with a patient’s ability to perform a certain task with good stability. This approach adheres to the philosophy ‘‘begin with end in mind’’. For this reason activity intolerance questionnaires such as the Revised Oswestry and Neck Disability Index screens are excellent for goal setting (Bombardier 2000). Similarly, functional screens of an individual’s actual tasks is often more valid than tests of isolated impairments such as a voluntary strength deficit of a specific movement such as hip extension (Simmonds et al. 1998, Simmonds & Lee 2002). It has been shown that it is both reliable and valid to assess basic ‘‘core’’ tasks such as functional reach, loaded reach, timed up and go, distance walked, etc. (Simmonds et al. 1998, Simmonds & Lee 2002). A practical assessment method has been developed by Gray (2001). Asking patients to perform lunges in a variety of directions can reveal dysfunction in the foot, knee, hip and elsewhere. Forward, sideways, and back lunges utilizing a star 109 ODYWORK AND MOVEMENT THERAPIE 9:00 6:00 3:00 12:00 Fig. 1 Star diagram from Gray. S APRIL 2002 4 8 Liebenson Fu nc tio na le xe rc is es Table1 Single-leg squat dysfunctions K Subtalar hyperpronation K Early heel rise K Tibia torsion (internalrotation) K Femoral torsion (internal rotation) or valgus overstrain K Pelvic unleveling (Trendelenberg sign) K Excessive trunk flexion assessments such as analysis of gait, single-leg stance, or two-legged squat the advantage of the single-leg squat test is precisely its greater sensitivity for identifying dysfunction. For instance, if a patient has an inhibited gluteus medius, other tests may not reveal any pelvic unleveling whereas the single-leg squat almost surely will. Valgus overstrain of the knee with tibia torsion may also be missed. Shoulder and neck disorders related to elevation of the shoulder girdle, secondary to a pelvic or lower quarter imbalance may also be missed by the other less sensitive tests. Fig. 3 The relationship of knee and hip position. JOURNAL OF BO Table 2 Single-legsquat kinetic chain (see Figs Sign Early heel rise (see Fig. 4) Tibial torsion (see Fig. 6) Femoral torsion (see Fig. 6) Excessive knee valgus motion (see Fig. 6) Shoulder or pelvic unleveling (see Figs. 7 and Inability to maintain lumbar lordosis Poor control of knee extension when rising up It is usually not appreciated that knee function is ‘‘slaved’’ to the hip. For instance, in the frontal plane, knee position is dictated by eccentric control of the gluteus medius. Loss of the lateral pelvic brace results in knee valgus strain (see Fig. 3). In the sagittal plane control of hip flexion (eccentric gluteus maximus activity) along with lumbo-pelvic stability (neutral lordosis) are crucial to ‘‘bracing’’ the patello-femoral joint (see Fig. 9). In the transverse plane control of hip rotation – especially pelvis on femur – stabilizes torsional stresses on the knee (see Fig. 6). Table 2 summarizes the clinical decision making regarding finding the ‘‘key dysfunction link’’ in the kinetic chain. Fig. 4 Early heel rise. 110 DYWORK AND MOVEMENT THERAPIE ^9) Dysfunction Tight soleus Subtalar hyperpronation Hip or pelvic rotation dysfunction Gluteus medius insufficiency ) Gluteus medius insufficiency Gluteus maximus insufficiency Gluteus maximus insufficiency Training Functional training for each of the functional deficits identified above can be achieved. If there is poor control of the knee extensor mechanism when rising during the squat, going up stairs, or getting out of a chair a very simple exercise to isolate the gluteus maximus and quadriceps is to perform a step-up with the ankle fixed in plantar flexion. This is to reduce the input from the gastro-soleus while simultaneously reducing anterior shear of the femur on the tibia. This step-up can be performed as front, side and back step-ups (see Fig. 10). The frequency, repetitions, and intensity of motor control exercises Fig. 5 Subtalar hyperpronation. S APRIL 2002 Fig. 6 Excessive knee valgus with tibia torsion (internal rotation). Fig. 7 Pelvic unleveling (Trendelenberg sign). Self-help advice for the clinician JOURNAL OF B are quite different than for strength training. Greater frequency and repetitions and less intensity is Fig. 8 Shoulder unleveling. Fig. 9 Excessive trunk flexion. 111 ODYWORK AND MOVEMENT THERAPIE Fu nc tio na le xe rc is es required for motor control than strength training. As a rule of thumb 10–12 repetitions performed twice a day for up to 3 months are required. Resistance should be sub-threshold – at most 50% of an individual’s maximal capacity (Hoffer & Andreassen 1981, McArdle et al. 1991). If pelvic or shoulder unleveling are occurring then a single leg stance position can be maintained while performing arm reaches towards the inhibited gluteus medius or shifted pelvis (see Fig. 11). The key is to find an exercise which allows functional loading of the kinetic chain in a ‘‘stable’’ manner. Stable means with good equilibrium or control of the body’s center of mass over a stable base of support. A pioneer in stabilization training Morgan said, ‘‘After the patient has learned the limits of his or her functional range, conditioning and training for activities of daily living can safely begin. . . The patient must develop the coordination to control and feel the back position. Such coordination must become second nature so that the habit is maintained during all activities. . .’’ (Morgan 1988). Finding the exercise which is in a patient’s functional range requires observational skill to see if a movement is well stabilized. The goal is to find the most challenging and functional movement which is within a patient’s functional range. Gray refers to this as ‘‘attacking success’’ (Gray 2001). If a patient has good control of upright posture, then multiplanar movements are the most functional to train. Gray has taught an excellent lunge called the back lunge with a twist and arm reach (see Fig. 12). This simulates the functional movements involved in sporting activities such as throwing, the baseball or golf swing, the tennis forehand, backhand, overhead or S APRIL 2002 serving, and volleyball spiking, etc. This movement is the basic skill involved in simple reaching activities either behind or overhead. Anytime the upper quarter is being used a force transmission system is activated which transfers energy from the lower quarter through the trunk to the shoulder girdle. If a functional muscular sling is activated from the contralateral hip to the shoulder then the arm acts like a whip and does not have to generate much force on its own. This exercise trains this highly functional skill so that efficient transfer of energy can be trained and automatized. REFERENCES Agency for Health Care Policy and Research (AHCPR) 1994 Acute low-back problems in adults. Clinical Practice Guideline No. 14. US Government Printing, Washington, DC Bologun JA, Adesinasi CO, Marzouk DK A B C Fig. 10 Step-ups: (a) front; (b) side; (c) back. Liebenson 112 JOURNAL OF BODYWORK AND MOVEMENT THERAPIE Fu nc tio na le xe rc is es 1992 The effects of a wobble board Fig. 11 Single-leg squat with arm reach. S APRIL 2002 training. Journal of Bodywork and Movement Therapies 5: 21–28 McArdle WD, Katch FI, Katch VL 1991 Exercise Physiology, Energy, Nutrition and Human Performance, 3rd edn, chapter 20. pp. 384–417. Lea Febiger, Philadelphia Morgan D 1988 Concepts in functional training and postural stabilization for the low-back-injured. Topics in Acute Care Trauma and Rehabilitation 2(4): 8–l7 Rutherford OM 1988 Muscular coordination Self-help advice for the clinician exercise training program on static A Fig. 12 Back lunge with arm reach. balance performance and strength of lower extremity muscles. Physiotherapy Canada 44: 23–30 Bombardier C 2000 Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine 25: 3100– 3103 Carrafa A., Cerulli G, Projectti M, Aisa G, Rizzo A 1996 Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surgery Sports Traumatology and Arthritis 4(1): 19–21 Freeman MAR, Dean MRE, Hanham IWF 1965 The etiology and prevention of functional instability of the foot. Journal JOURNAL OF BO B Bone and Joint Surg (British) 47B: 678– 685 Gray G 2001 Rehabilitation Institute of Chicago. Functional approach to musculoskeletal system II Seminar, October Hoffer J, Andreassen S 1981 Regulation of soleus muscle stiffness in premamillary cats. Journal of Neurophysiology 45: 267–285 Janda V, Va’ vrova’ M 1996 Sensory motor stimulation. In Liebenson C (ed). Rehabilitation of the Spine: A Practitioner’s Manual. Lippincott/ Williams and Wilkins, Baltimore Liebenson CS 2001Advice for the clinician and patient: sensory-motor 113 DYWORK AND MOVEMENT THERAPIE Fu nc tio na le xe rc is es and strength training, implications for injury rehabilitation. Sports Medicine 5: 196 Sale D, MacDougall D 1981 Specificity in strength training: a review for the coach and athlete. Canadian Journal of Sport Science 6: 87 Seidler R, Martin PE I997 The effects of short term balance training on the postural control of older adults. Gait and Posture 6: 224–236 Simmonds MJ, Olson SL, Jones S, Hussein T, Lee CE et al. 1998 Psychometric characteristics and clinical usefullness of physical performance tests in patients with low back pain. Spine 23(22): 2412–2421 Simmonds MJ, Lee CE 2002 (scheduled publication) Physical performance tests: an expanded model of assessment and outcome. In Liebenson C (ed). Rehabilitation of Spine: A Practioner’s Manual. Lippincott/Williams and Wilkins, Baltimore Tropp H, Askling C, Gillquist J 1995 Prevention of ankle sprains. American Journal of Sports Medicine 4: 259–262 Wolf SL, Barnhart HX, Kutner NG et al. 1996 Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. JAGS 44: 489–497 Wolfson L, Whipple R, Derbe C et al 1996 Balance and strength training in older adults: intervention gains and Tai Chi maintenance. JAGS 44: 498–506 S APRIL 2002 Introduction Assessment Figure 1 Figure 2 Table 1 Figure 3 Table 2 Figure 4 Figure 5 Training Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 REFERENCES Figure 11 Figure 12
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