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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
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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
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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
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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
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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
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1992 The effects of a wobble board
Fig. 11 Single-leg squat with arm reach.
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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
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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
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Bone and Joint Surg (British) 47B: 678–
685
Gray G 2001 Rehabilitation Institute of
Chicago. Functional approach to
musculoskeletal system II Seminar,
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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
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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
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computerized balance training. JAGS
44: 489–497
Wolfson L, Whipple R, Derbe C et al
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498–506
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	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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