•  
  • corrective exercise
  • The most common targets for corrective exercise and rehabilitation: An introduction to a comprehensive exploration

The most common targets for corrective exercise and rehabilitation: An introduction to a comprehensive exploration

Tags: No Tags
Comments: 13 Comments
Published on: January 18, 2013

Purpose: To prop up for target practice 17 assumed dysfunctions in human movement.  Ideally, each “dysfunction” can be thoroughly critiqued to determine its relevance to ideal or painfree movement.

Why am I so critical?

I am critical of the strong.  There is no point in slamming ridiculous fitness guru’s or fish in the barrel weak-ass chiropractic/rehabilitation theories.  I want to critically evaluate the things that are closest to how I practice and those things that actually seem to dominate big swathes of evidence based practice.  I challenge the strong because the ideas should be able to take it.  If the “dysfunctions” in the post don’t hold up to scrutiny (and some don’t) then we are all the better for it.

Assessing function – the first step of corrective exercise

You can pick out a boatload of assumed dysfunctions.  You can use the FMS, you can use Kinetic Control, you could use Sahrmann’s tests, you can read Kendall and Kendall and test every muscle for strength, you can pull out your goniometer, fire up your 3D motion capture system and assess displacement, velocity, acceleration, summation of velocity across joints during a dynamic task, you can use an Ultrasound machine and determine some muscle thickness that seems aberrant,  you can steal my old EMG equipment (someone actually did this) and test muscle fatigue, muscle timing, muscle activation during functional tests or you can reincarnate Janda and put him to work. Whatever, its easy to find what someone in the world considers to be less than ideal function.  I’ve listed what I consider to be the most common ones that are regularly touted without any special equipment.

Assumed dysfunctions need to be examined in four areas

1. Their relationship to the occurrence of future injury (i.e. if you have one of these dysfunctions are you prone to getting injured in the future?)

2. Their relationship to performance.  If you have one of these assumed dysfunctions does it negatively influence objective performance variables (e.g. speed, power, force, running economy)

3. How do the existence of these dysfunctions relate to the person in pain? Are these dysfunctions defects or defenses? Is it necessary for the dysfunction to be corrected for a decrease in pain to occur? Does the dysfunction have to specifically addressed or is it “cleaned up” with other non-specific interventions?

4. If you think its relevant to correct these dysfunctions by what mechanism are they corrected if they can even be corrected

The most commonly reported “dysfunctions“:

1. Decreased ankle dorsiflexion: perhaps leading to increased pronation, knee valgus, hip IR and dysunction up the chain.  No one every says the decreased dorsiflexion encourages a more vertical tibia during the squat and therefore a greater reliance on the hip musculature and perhaps less knee loading.  Why not? It is just as plausible.

2. Decreased hip extension: perhaps  because of tight hip flexors due to our sedentary lifestyles or hip joint dysfunction

3. Weak gluteus maximus: perhaps causing hamstring, calf and spinal overload (this is often reported to be linked to tight hip flexors via some bastardized and probably wrong interpretation of reciprocal inhibition)

4. Increased pronation: either in terms of absolute amount or the time before pronation is reversed into supination.  We then tie this “dysfunction” into any kinetic chain abnormality we want

5. Altered timing or relative strength of the quadriceps muscle group

6. Tight hamstrings leading to spinal flexion

7. Tight hip flexors: perhaps leading anterior pelvic tilit and I have even heard the oppostie that it can lead to spinal flexion during a squat (this makes no mechancal sense but I hear it all time).

9.  Poor or inhibited activation of the deep trunk muscles with increases in the superficial global muscle’s activity (e.g a high threshold activity)

10.  Poor core strength, control or timing – this is diagnosed by any subtle movement of the spine away from neutral during any movement involving the lower limbs (e.g one leg glut bridge, single leg raise, prone leg extension, side lying hip abduction, side bridges, single leg squat)

11a. Poor pelvic control: perhaps manifesting as a Tredelenberg sign (pelvic drops to side during one leg activity) or as increased anterior tilt (perhaps secondary to weak gluts or tight hip flexors)

11b. Poor femoral control: perhaps manifested as increased knee valgus or increased hip internal rotation.  Rationale may be related to weak hip musculature, tight adductors, restricted ankle dorsiflexors, increased ROM of hip external rotators.

12. Poor breathing: you don’t breath through your belly, your diaghragm will suffer and you will lose core stability.  You might also see greater activity in the secondary muscles of respiration and neck and shoulder pain will result

13. Weak glutes leading to opposite arm movement dysfunction.  You will hear that during running the opposite arm might be abducted for balance or that the arm will be adducted to “cinch down” on the lumbodorsal fascia” to provide stability to the SI joint.

14. Poor scapular control- scapular dyskinesis, flying scapula, winging scapula, scapular malposition, medial border prominence, tight pectoralis minor.

15. Increased thoracic kyphosis or loss of thoracic extension or rotation leading to excessive strain on the lumbar spine, cervical spine or shoulder

16. Glenohumeral internal rotation deficit (GIRD) or loss of 180 degrees of shoulder rotation

17. Inhibited deep neck flexors leading to substitution by the scalenes and SCM

Alrighty, there are a bunch.  I won’t even get into joint arthrokinematics (i.e. stuck SI joint, upslips, loss of fibular head movement, thoracic ring dysfunctions etc).  These are some of the most common ones.  I hope to explore over the course of the year what we should do about these assumed dysfunctions.

Please leave any additions to the comment sections and I can even add them to the post.  Anyone up for writing a blog post about one of the specific dysfunctions.

Share this
13 Comments - Leave a comment
  1. Phil Gregory, PT, OCS, CSCS says:

    Timing patterns of hip extension? Thoracic extension deficits?

    • Greg Lehman says:

      Thanks Phil

      I think those were both in the list – the timing may have been bundled into Gmax inhibition. I’ve published a lot on the timing of the prone leg extension test. You might want to search the blog and look at the papers I published in BMC Musculoskeletal Disorders and Dynamic Medicine.

      greg

  2. Adam says:

    Greg,

    I would be up for writing a post about scapular position. I just got done an extensive literature review on the topic and am currently writing it up. I could do an abbreviated version for the blog. I am just starting a blog with a few colleagues so I wouldn’t mind posting it to both.

    I like your list so far.

    Adam

  3. Greg, great blog. How about the “link” (or supposed link) between poor posture and pain/dysfunction?

    • Greg Lehman says:

      For sure Sinead,

      That is my favourite area and is essentially what the whole post is about. We have posture (static) and form (dynamic). Can we now evaluate what is the RIGHT posture or form? I think all of the topics I listed are really asking what you are asking but are just being more specific.

      Personally, I tend to think the only poor posture is the one that people continue to use and have no options for variability. I’ve been teaching this since the 90s and still get huge resistance from the upright posture police. You know, “oh my god, you just bent over with your lower back to pick up a book off a chair. That’s terrible body mechanics”. This is a taste of things said to me when I went back to Physio school in 2009! Insane.

      that being said, I think posture can influence function. If you are doing bike fitting than I’m sure you can mess around with different postures to influence resting and working muscle lengths.

      Greg

  4. Keith Walker says:

    Hi Greg – I’m a keen follower of your blog – good stuff.
    If I may put my ‘two-penneth’ worth in on the subject of tight hamstrings; whilst I have observed from time to time that patients can respond to “loosening” the Hamstrings I have had a good look and come up with little literature support. Indeed,there seems to be a very limited evidential correlation between any physical characteristics and back pain. Below a few refs. to get anyone going on the Hamstring issue. My take – (+ve SLR’s aside) asymmetrically tight hams in adults maybe problematic, bilateral extreme tightness in teenagers needs to be investigated, otherwise only limited significance. As I say, only my take.

    Nourbakhsh, M.R., Arab, A.M. (2002) Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther, 32(9), 447-460.

    Halbertsma, J.P.K.,Goeken, L.N.H., Hof, A.L., Groothoff, J.W. & Eisma W.H. (2001) Extensibility and stiffness of the hamstrings in patients with nonspecific low back pain. Arch Phys Med Rehabil, 82(2), 232-238

    Hellsing, AL. (1988) Tightness of hamstring – and psoas major muscles. A prospective study of back pain in young men during their military service. Ups J Med Sci, 93(3), 267-276.

    Keith

    • Greg Lehman says:

      Thanks Keith,

      I tend to agree with you. A decade ago I was pretty anti-stretching and had a real hate-on for flexibility. Thought it was over rated. I still do when it comes to the painful state. I do think it probably has a role that is dependent upon our goal movement. If you need flexibility in your job as a gynmast then you better go get it. For the average person with low back pain I tend to see it more as defense rather than defect or completely not related.

      Thanks for the references. I only remember seeing the Halbertsma paper.

      Greg

      • Rosi says:

        Very interesting! I’m looking forward to reading your take on these. I think the answer in a lot of these cases may turn out to be “it depends”. Whether a particular dysfunction causes you a problem depends in part on what you’re trying to do with your body. What’s not a problem for someone sitting in an office 8 hours a day may well be a problem for a professional athlete. And vice versa. I also agree that the problems are more to occur with static postures and lack of movement, rather than with specific “bad postures”.

        • Greg Lehman says:

          Thanks Rosie,

          I think person specificity is key as well. Its like our love affair with movement screening (e.g. FMS). It might be predictive in a certain sport but it does not really make sense for a lot people. The screening movement has to match the demands of the goal task. If the screen is relevant in terms of kinematics, load, speed or context than it can’t really pick up a deficiency.

          Greg

  5. Rosi says:

    Incidentally, I have strong feelings about decreased dorsiflexion. In my opinion, that’s one of the big ones. One of the problems seems to be that it limits the ability to absorb force on landing. But I’m interested to read your take on it!

    • Greg Lehman says:

      Dorsiflexion is an interesting one. Probably sport dependent. With absorption though I would ask if the during a drop landing anyone actually ever comes close to 100% max dorsiflexion. If you are maybe its not because your tight but rather the movement strategy you choose to land. If you are knee dominant than you will flex more at the knees, have your centre of mass forward, have less hip flexion and because your knees are flexing without a lot of hip flexion you are probably having lots of dorsiflexion (e.g knees going well beyond toes). That movement strategy would require a lot of dorsiflexion to help absorb landing. But if you land with a hip dominant, hip hinging motion, your centre of mass is more posterior and you might not have a need for a lot of dorsiflexion. If your calves are stiff and strong they can then absorb impact without letting your heels just smack into the ground.

      Thoughts?

      greg

  6. Adam Meakins says:

    Greg, I love your brain!!!

    So good to meet (via social media and emails) a like minded critical thinker, all of the 17 are definitely worth investigating, I have another that would be good to look at… The ratio of GHJ IR v ER strength is there an ideal and can it predict risk of injury, I regularly use Isokinetic tests on the shoulder and see such a wide variation I’m at a loss here. Any thoughts or is 17 enough for one year….

    Regards

    Adam

Leave a comment

Your email address will not be published. Required fields are marked *


+ six = 9


*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Welcome , today is Wednesday, July 23, 2014