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Preparing your patients for the game of life and sport:
Bridging the gap between physical therapy and performance
By: Dr. Arianne Missimer, PT, DPT, RD, RKC, CICS, CSCS, T.P.I. MP 3, K‐Vest 2
Owner CORE Fitness
Clinic Director Kinetic Physical Therapy
Performance
Physical Therapy
Nutrition
My MissionTo restore sustainable and optimal health in
individuals through proper nutrition, performance enhancement, and rehabilitation and bridge the gap between performance and
physical therapy.
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Gray Cook Lee Burton Mike Boyle Greg Rose Gary Gray Dr. Ed Thomas Athletes’ Performance Mike Clark Michol Dalcourt Thomas Myers Shirley Sarhman Vladmir Janda Pavel Kolar
Stuart McGill Dr. Mark Cheng Craig Leibenson Charlie Weingroff
NSCA!!
Special Thanks
Defining the GAP
Discuss pain’s effect on movement
Identify movement indicators as a means of a common language
Bridging the Gap…
Integrate quality, movement‐based training
Treat the WHOLE person
Form a Rehabilitation to Performance Continuum
Form a multidisciplinary team
Objectives
What is the GAP?
• Isolated vs. integrated
• Pain‐free vs. functional
• Movement‐based approach vs. impairment based
• Fitness/Performance vs. rehabilitation
• Injury prevention vs. treatment of injuries
• Common language
Global, comprehensive, movement‐based approach
• Insurance
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Movement Specialists….
• Need to understand :
– Effect of injury and pain
– Kinetic linking
– Force production
– Regional interdependence
• Need to have a:
– Movement‐based approach
– Common language
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Predictors of Injury:
• Previous Injury Ekstrand et al 2006, Murphy et al 2003
• Asymmetries Baumhauer et al 2001, Myer et al 2008, Nadler et al 2001,
Plisky et al 2006, Rauh et al 2007, Soderman et al 2001
Why do people sustain non‐contact injuries? 2‐17
Impairment focused?!?Normalize Enhance performancePain distorts motor controlHigh‐threshold strategies
What happens if we only get our patients pain‐free? 1
Movement changes after injury!!!
• Decreased proprioceptive input
• Movement patterns are lost due to:
– imbalances
– asymmetrical movement
– improper training
– incomplete recovery from injury
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We first need to understand movement
NervousMusculo‐skeletal
Kinetic Chain
Image adapted from Integrative Health
• “Muscles are discrete, while fascia is continuous.” Tom Myers
• Three dimensional matrix
• Dynamic structural support
Fascial System18
Anatomy Trains 18
• Superficial Back Line
• Superficial Front Line
• Lateral Line
• Spiral Line
• Arm Lines
• Functional Lines
• Deep Front LineAdapted from Anatomy Trains by Tom Myers
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Nervous System
Sensory
• Sense changes in either the internal or external environment
Integrative
• Analyze and interpret the sensory information to allow for proper decision making, producing the appropriate response
Motor• Neuromuscular response to the sensory info
Communication Network 19
Reflexes 20
• Primitive: Involuntary response to specific stimuli
• Postural: Allow adaptation of posture to changes in environment
• Locomotor:
MOVEMENTCompression and distraction
Neurodevelopment
• Fundamental activities of the human body revolve around simple and basic patterns of human movements
• Developmental sequence that starts at infancy and develops through childhood
(rolling crawling walking)
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• Mobility?
Motor Milestones
• Newborns move their head with their eyes
• 3‐5 months– Move their eyes I of their head
– Lift their head up with control
– Weight bear on their arms
to see toys
– Initiate rolling
(Postural reflex)
Motor Milestones 20
6‐8 months :
Sit upright without support
Crawling
(Locomotor reflex)
Motor Milestones
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• 10 to 12 months: develop the “S” curve
• 12-15 months:
– Stand briefly alone without support with high guard
– Deadlifting• 21 months‐24 months:
Deep squat to play
Stand on one foot with support briefly
Motor Milestones 20
Neurodevelopment initiation of motor planningChildren learn to balance themselves through feel
• Gravity begins to pull their ribs down, and their limber frames begin to develop stability
Motor Planning
• Motor plans are developed around your physical limitations
• Sound movement BEFORE performance enhancement
• Pain distorts motor
control
Motor Planning
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• Cognitive phase
• Associative phase
• Autonomous phase
Motor Learning
AutonomousAssociativeCognitive
Mobility and Stability
M bili d S bili /M C l
Mobility: freedom of movement; moving through a non‐restricted , pain‐free ROM
Stability/motor control: ability to maintain posture and/or control motion Coordination, sequencing, and timing
Static and dynamic Central Nervous System (CNS) organizes functional patterns
Adapted from Mike Boyle
Adapted from Mike Boyle
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Skill
Performance
Movement
Functional Performance Pyramid
Adapted from Gray Cook 2004
• Poor movement competency=compensation
• Poor durability
• Microtrauma
• Weakest link
• Inefficiency
We know what FUNCTIONAL is, so what is DYSFUNCTIONAL?
“As to the methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”
Ralph Waldo Emerson
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• If you could predict if you were 2‐3x more likely to get injured , wouldn’t want to know?
• How can we determine effectiveness of our treatment plans and training programs if we have nothing objectively measure?
• Screen foundational movements for a proactive approach to injury prevention
Establish a Movement Baseline
• Functional Movement System:
– Selective Functional Movement Assessment:Evaluation
– Functional Movement Screen: Checks risk
– Y Balance Test: Measures ability
Movement Indicators 1
Skill
Performance
MOVEMENTAdapted from Gray Cook 2004
• Reliable and reproducible screen• Identifies Physical imbalances, limitations, and weaknessesPotential cause and effect relationships of deficits and microtrauma/ chronic injuries
• Improves fundamental movement patterns with simple corrective exercises
• Great communication tool!!
Functional Movement Screen 1
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Corrective Algorithms ASLR SM RS TSP ILL HS DS
Mobility Stability Top 3 Asymmetries within the algorithm
Pain? Stop, begin SFMA or refer.
Corrective Algorithm
• <14 predicts risk for injury
• Standardizes movement
• Establishes appropriate goals
• Corrective strategies
• Prior to discharge
• Pre‐participation
• Communication and common language
Application/Benefits
• Screen, test, assess
• Posture and breathing
• Neuromuscular activation
• Corrective exercise
• Movement preparation
• Performance
• Recovery
• Re‐screen, test, assess
Preparing your patients/clients for the game of life and sport
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“You can teach a student a lesson for a day; but if you can teach him to learn by creating curiosity, he will continue the learning process as long as he lives.“ -- Clay P. Bedford
Computer Man
• Foundation for all movement
• Good posture=good habit=positive well‐being
• Ideal alignment=optimal movement
“Maintaining or restoring precise
movement of specific segments is the
key to preventing or correcting
musculoskeletal pain.”‐Sahrmann
Posture
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• Pillar Strength: Athletes Performance
– Foundation for kinetic linking
– Dynamic coordination of stability
– Production or transfer of force from LE to UE
via the pillar
• Proper stance for optimal movement
• Safely and effectively dissipate forces that move through the body
Posture
• Movement dysfunction is evident when breathing and postural control are compromised
• Cornerstone of optimal health and well‐being
• Optimal motor program
First movement
• What’s normal???
• 12‐15 breaths/minute (adult)
20,0000 breaths/day!!!
Breathing
Poor Breathing Increased sympathetic activity
Increased neural drive to global muscles
Inhibits local muscles Adopts a high‐threshold strategy
Proper Breathing: Increased parasympathetic activity
Improves recruitment patterns of the core for improved postural control
Optimizes respiratory function
Decreases risk of injuries, particularly upper quarter
Harmony , timing , sequencing, rhythm, coordination
Breathing
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Breathing
Mobility
• Mobility first???
• Quality stability is driven by quality proprioception
• If limitations in mobility exist,
quality proprioception is not
possible
• Gain mobility, then train stability
Improves flexibility, function, performance
Reduces injuries
Apply deep pressure into myofascialrestrictions to influence kinetic chain
Autogenic inhibition of muscle spindle
Search and Destroy!
Self‐Myofascial Release19
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Stability/Motor Control
• Stability does not equal strength
– Example: Tubing Shoulder ER
• Stability is reflex‐driven
• Neuromuscular and postural
control
• Sequencing and timing
• Static before dynamic
High‐Threshold Strategy
Inner Outer
Respiration ContinenceSegmental stability
Postural stabilityResists external loadMovement productionEnergy transfer
Neuromuscular Activation
• Core activation
• Activity‐dependent
• Problem‐specific
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• Progressions and regressions following the neuromotor developmental sequence
• Removing the dysfunctional pattern will improve stability/motor control
• Don’t correct the movement, correct the primitive things that came before that
• Eliminate counterproductive activities
Corrective Exercise
Rolling Patterns
• Practice makes perfect, right?
• Do a few things really well!
• Highest quality of motion with every repetition within a ROM that you can exhibit highest neural control
• Otherwise, the info is
INEFFICIENT!
Corrective Exercise
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• Soft Tissue Mobilization Active Isolated Stretching PNF
• Movement patterning
• Movement preparation
• Active rest
• Can correct in 2‐3 weeks
• Accountability: Homework!
Corrective Strategies
• Perception
• Verbal cueing???
• RNT
• Self‐limiting positions
• Quality vs. quantity
• Reps????
Proper Execution
20% greater speed and power output Increases core temperature Increases heart rate Increases blood flow to the muscles
Actively lengthens musclesActivates nervous system Prepares for the demands of the sport/activity
Movement Preparation 32
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Dancers, acrobats, martial artists Indian clubs, kettlebells Precision and fluidity Breathing Control BRAIN TRAINING
BE PRESENT!
Mindful Movement
Performance
• Functional training =core training=movement‐based training
• Primal movements
• Optimal loading the myofascial system in all 3 planes
• Life and sport
requirements
• What about
rotation?
Skill
PERFORMANCE
Movement
Any questions?
Image adapted from www.viprcanada.com
VS.
Image adapted from www.treadmill factory.com
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• Mindset
• Sleep
• Nutrition
• Active rest
• Soft‐tissue mobilization
Recovery
• Educate and empower!
– Posture/CORE 101
– Self soft‐tissue mobilization
– Neuromuscular Activation
– Corrective Exercise
– Movement Preparation
– Optimal Performance Program
– Regeneration/Recovery
• Teach sustainability
• Encourage Rehabilitation to Performance Continuum
For your patients/clients
Rehabilitation to Performance Continuum
Rehabilitation Return to activity/sport
• Multidisciplinary approach
Performance specialist/CSCS
Registered dietitian
Physical therapists/chiro’s
Mental health
Sports professionals/coaches
Physician
Performance Team
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• Ethical responsibility to screen before D/C
• Communication, understand each other’s role, and collaborate
• Develop a common language
• Goal: work together for the best interest of our patient/clients
Rehabilitation to Performance Continuum
• Age/Diagnosis
• Precautions
• Functional Movement Screen Score:
• Corrective Strategies
• Sport/Activity Specific
• Returned to full capacity : YES /NO
Rehabilitation to Performance Continuum
Yes/No Comments
CORE 101 Yes
Correctives Yes
Neuromuscular Activation Yes
Movement Preparation Yes
Strength Yes
Power, Speed, Agility No
Energy System No
Regeneration/Recovery Yes
Rehabilitation to Performance Continuum
Rehabilitation Return to Activity/Sport
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• Pain and injury alter movement
• Understand movement
• Functional Performance Pyramid
• Dysfunction = poor durability
• Establish a movement baseline
• Whole patterning is the rule
• Sport and life are movements!
• Establish a performance team
• Rehab to Performance Continuum
Key Points
Questions?
1. Cook G. Movement. Functional Movement Systems. Aptos, CA: On Target Publications; 2010.
2. Ekstrand J et al. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. British Journal of Sports Medicine. 2006: 40;767‐772.
3. Murphy D et al. Risk factors for lower extremity injury: a review of the literature. British Journal of Sports Medicine. 2003: 37;13‐29.
4. Baumhauer J. et al. Ankle ligament injury risk factors: a prospective study of college athletes. Journal of Orthopedic Medicine. 2001: 19; 213‐220.
5. Myer, G. et al. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinics in Sports Medicine. 2008: 7; 425‐448.
6. Myer G. et al. Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament regiment. Journal of Strength and Conditioning Research.2008: 22; 987‐1014.
7. Nadler et al. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil 2001; 80:572‐577.
8. Plisky P et al. Star excursion balance test as a predictor of lower extremity injury in high 9. school basketball players. Journal of Orthopaedic & Sports Physical Therapy. 2006: 36;
911‐919.
References
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References
9. Rauh M. et al. Quadriceps angle and risk of injury among high school cross‐country runners. Journal of Orthopedic & Sports Physical Therapy. 2007: 37; 725‐733.
10. Soderman, K. et al. Risk factors for leg injuries in female soccer players: a prospective investigation during one out‐door season. Sports Medicine. 2001:9; 313‐321.
11. McGuine T et al. Balance as a predictor of ankle injuries in high school basketball players. Clinical Journal of Sport Medicine. 2000: 10; 239‐244.
12. Tojian, T. and McKeag, D. Single leg balance test to identify risk of ankle sprains. British Journal of Sports Medicine. 2000: 40; 610‐613.
13. Wang, H. et al. Risk‐factor analysis of high school basketball‐player ankle injuries: a prospective controlled cohort study evaluating postural sway, ankle strength, and flexibility. Archives of Physical and Medical Rehabilitation. 2006: 87; 821‐825.
14. Hewett, T. et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in females athletes: a prospective study. American Journal of Sports Medicine. 2005: 33; 492‐502.
15. Zazulak, B. et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical‐epidemiologic study. The American Journal of Sports Medicine. 2007: 35; 1123‐1131.
References
16. McHugh M, et al. Risk factors for noncontact ankle sprains in high school athletes: The role of hip strength and balance ability. American Journal of Sports Medicine. 2006: 34; 464‐470.
17. McHugh M et al . Oversized young athletes: a weighty concern. Journal of Sports Medicine. 2010: 44; 45‐49.
18. Myers TW. Anatomy Trains. Myofascial Meridians Manual for Movement Therapists. Second Edition. Edinburgh, CA: Elsevier; 2009.
19. Clark, M., Luceh, S., Rodney, C., Cappuccio, R., Humphrey, R., Kraus, S., Titchenal, A., & Robinson, P. (2004). Optimum performance training for health & fitness professional. (2nd
ed.). USA: National Academy of Sports Medicine.
20. Cambell S.K. (2006). Physical Therapy for Children. (3rd ed.). St. Louis, Missouri: Saunders Elsevier.
21. Gray, GW. Wynn Marketing Inc; Adrian, MI: 1995. Lower Extremity Functional Profile.
22. Kiesel K, Plisky PJ, Voight ML. Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen? N Am J Sports Phys Ther. 2007 August; 2(3): 147–158
23. Hertel J, Miller SJ, Denegar CR. Intratester and intertester reliability during the Star Excursion Balance Tests. J Sport Rehabil. 2000;9:104‐116.
24. Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911‐919.
25. Kinzey SJ, Armstrong CW. The reliability of the star‐excursion test in assessing dynamic balance. J Orthop Sports Phys Ther. 1998;27(5):356‐360.
26. Chaiwanichsiri D., Lorprayoon E., Noomanoch L. Star excursion balance training: effects on ankle functional stability after ankle sprain. J Med Assoc Thai. Sep 2005;88 Suppl 4:S90‐94.
27. Olmsted LC, Carcia CR, Hertel J, Shultz S. Efficacy of the Star Excursion Balance Tests in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37(4):501‐506.
28. Hertel J, Braham RA, Hale SA, Olmsted LC. Simplifying the Star Excursion Balance Test: analyses of subjects with and without ankle instability. J Orthop Sports Phys Ther. 2006;36:131‐137.
29. Earl JE, Hertel J. Lower‐extremity muscle activation during the Star Excursion Balance Tests. J Sport Rehabil. 2001;10:93‐104.
References
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30. Gribble PA, Hertel J. Considerations for normalizing measures of the Star Excursion Balance Test. Measurement in Physical Education and Exercise Science. 2003;7(2):89‐100.
31. Sahrmann S A. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MS: Mosby; 2002.
32. Camhi, J. (2012). Lower quarter functional restoration workshop manual. Phoenix, AZ: Athletes Performance. DOI: www.athletesperformance.com/education
33. Cook, G. 2003. Athletic body in balance. Optimal movement skills and conditioning
for performance. Champaigne, IL: Human Kinetics
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