June 27 th , 2011 Assistant Professor of Physical Therapy at - - PowerPoint PPT Presentation

June 27th, 2011

 Assistant Professor of Physical Therapy at

Pacific University Oregon (near Portland, OR)

 Background: PT, ATC, CSCS; board certified

sports physical therapy

 Completing PhD dissertation currently

(RMUofHP)

 Wrote Core Assessment and Training; published

by Human Kinetics in 2010.

 Define the “core”  Functional assessment of core function in

athletes

 Exercise prescription for athletes  Examples from the literature

The core region consists

• f the muscles and

joints of : Lumbar spine Abdominals Hips

“Ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment (in activities)”.

Kibler et al Sports Med (2006)

 Lateral Musculature Test  Flexion Endurance Test  Back Extensor Test  Bunkie Test (de Witt)

 3 Tests

 Lateral Musculature Test  Flexor Endurance Test  Back Extensor Test

 Results from these tests will help to identify

muscular endurance capacity

 Why are these scores important? McGill SM (2002, 2007)

picture from McGill SM (2002) Low Back Disorders Human Kinetics

picture from McGill SM (2002) Low Back Disorders Human Kinetics

picture from McGill SM (2002) Low Back Disorders Human Kinetics

AVERAGE SCORES Back Extensor Test : 173 seconds Flexion Endurance: 134 seconds R Lateral Musculature: 83 seconds L Lateral Musculature: 86 seconds The Key: The Ratios Between Scores

McGill SM (2002)

 Right Lateral Test Score/ Left Lateral Test

Score should be ≤ 0.05

 Flexion Score/ Extension Score should be

≤ 1.0

 Lateral Test Score (either side)/ Extension

Score should be ≤ 0.75

McGill SM (2002)

• Study Compared 34 Year Old Males w/ No

Back Pain and 34 Year Old Males with a History of Disabling Back Pain

• Those With a History of Low Back Pain

Tested Worse Than Normals

• The 34-Ye

Year ar Old lds s Wit ith A His isto tory ry of LBP Were Asy symptoma mptomati tic c At t th the Tim ime of Test stin ing! g!!

McGill SM (2002)

 Decreased Performance Time  Changed Ratios  Patient Example:

Ext 6 sec, Flex 16 sec, RSB 7 sec, LSB 0 sec “BUT MY SPINE IS STRONG”

 A recently proposed

functional testing protocol for the core

 5 testing positions,

total of 10 tests

de Witt et al J Bodyw Move Ther 2009

de Witt et al recommends that endurance athletes should be able to hold each position for 40 seconds See case report later in discussion

de Witt et al (2009)

Hip Cross-over Step Down Single-legged squat STAR Lunge Squat

 Address muscular

endurance imbalances and movement pattern dysfunction (functional tests)

 Integrate core into

sport specific activities (e.g. plyometrics)

 CURL UPS  SIDE BRIDGING (Side

Plank)

 BIRD DOG

() aka Quadruped Opposite Arm and Leg Raise

McGill SM (2002)

SIDE BRIDGE (BEGINNER) SIDE BRIDGE

Step down – weakness glut max and medius Lunges – weakness of glut max and medius Squats – inability to assume neutral spine, poor muscular endurance of back extensors, weak glut max Single-legged squat – weakness of glut max and medius



Basic Quadruped Series



Prone Hip Extension



Bridging



Clamshell



Side-lying SLR



Straight Arm Pulldowns



Wall Lean



Cable Side Steps



Crunch



Side Bridge (Beginner)



Front Plank (Basic Position)

Starting position: Prone with both legs extended Movement: The client bends (flexes) one knee to 90º. Next, the client contracts the gluteus maximus and lifts the foot toward the ceiling by extending the hip. Common errors: The client compensates by extending through the lumbar spine. Considerations for rehab clients: This exercise may cause pain in patients with facet joint irritation or degenerative joint disease in the lumbar spine. Exercise the client may progress to next: Bridging exercises, bird dog.

CLAMSHELLS SIDE-LYING HIP ABD



Quadruped Opposite Arm and Leg Raise (Bird dog)



Side Bridge (or Side Plank)



Bridging with a March



Bridging with Leg Extension



Front Plank



Front Plank with Arm or Leg Extension



Front Plank with Opposite Arm and Leg Extension



Lunge



Lunge Twist



Backward Lunge



Lateral Lunge

This functional exercise strengthens the lower extremities and enhances core stability. Starting position: Standing with the hips shoulder-width apart Movement: The client steps (lunges) forward, flexing the lead hip and knee. The lead knee should be in alignment with the hip and foot, and the thigh should be parallel (or almost parallel) to the ground. The body is lowered toward the floor to the point where the trailing knee almost contacts the

• ground. The client then reverses the

movement, returning to the starting

• position. The client repeats the lunging

sequence with the opposite leg stepping forward.

Starting position: Same as the lunge Movement: When performing the lunge, the client rotates the trunk toward the side

• f the rear (trailing) leg.

The client returns to the starting position and repeats to the opposite side. Variation: The client can use a stick to help maintain balance.



Side-lying Bilateral Leg Raise



Jackknife on Physioball



Inverted Hamstring



Hang Twist



Prone Twist



V-Ups



Side Bridge with Hip Abduction



Side Bridge with Hip Flexion



Side Bridge with Shoulder External Rotation



Three Point Plank with Upper Extremity Exercise



Roman Chair



Roman Twist



Russian Twist



Russian Twist on Physioball

The inverted hamstring exercise addresses hamstring tightness, improves core stabilization, and incorporates balance training. Starting position: Balancing on one leg (with the knee in full extension) while maintaining optimal posture Movement: The client bends at the hips (not the waist) while maintaining a straight (neutral) spine. The client’s arms should be outstretched to the side to assist with balance. As the client leans forward, she will feel a stretching sensation in the hamstrings.

Starting position: Gripping a pull-up bar or the top of a squat rack with both hands using an underhand grip Movement: The client raises the knees toward the right shoulder until the thighs are parallel with the floor. The client holds the position for 1 or 2 seconds, then lowers the legs under

• control. The client then

repeats the movement to the opposite side.

Starting position: Same as the side plank (intermediate) Movement: While in the side plank position, the client abducts the top leg, lifting it off of the bottom leg approximately 6 to 8

• inches. Hold this

position for up to 5 seconds.

Starting position: Same as the side plank (intermediate) Movement: While in the side plank position, the client holds a light dumbbell with the shoulder and elbow in a 90°-90° position. Instruct the client to externally rotate the shoulder.

Brumitt & Dale NAJSPT 2009

Starting position: A three- point plank posture in which the client is supporting the body with both feet and one extended arm. Movement: While in the three-point plank position, the client performs an upper extremity exercise with the free arm. This exercise may be a shoulder flexion, shoulder horizontal abduction, shoulder row, or shoulder extension exercise.

Brumitt & Dale NAJSPT 2009

Starting position: Secured in a roman

• chair. The client’s feet should be

under the supports, and the chair should be adjusted to allow the client to bend completely forward at the waist. Movement: The client raises the torso from a flexed position to a neutral position. Considerations for rehab clients: Hyperextending the spine at the top

• f the movement is usually not

necessary and is contraindicated for patients with spondylolisthesis or degenerative joint disease. You must also weigh the risks of incorporating this exercise for an individual with a history of disc-related pain.

Starting position: Positioned on the roman chair as shown Movement: The client maintains the abdominal bracing contraction while slowly rotating the trunk and arms to the side. After rotating to the side, the client holds the position for up to 5

• seconds. The client then returns

to the starting position and repeats the movement to the

• pposite side.

Variation: To increase the challenge

• f the exercise, the client can hold

a medicine ball out with straight arms

Offer a dynamic, full body exercise Use of KB in our golf exercise programs May be useful for developing power

Brumitt et al NAJSPT 2010

 L sided low back pain during running  L side weakness hip extension, hip abduction

(MMT)

 Bunkie Test Brumitt J Bodywork & Movement Therapy (2011)

Bunkie Test Scores 1st Appt L R PPL 30 12pn APL 44 22 PSL 18 10 LSL 53 18 MSL 13 16

Home Exercise Program: 1-3 sets, high repetitions 15-25 Clamshells Side lying abduction Prone leg extension (knee bent) Lunges Squats (mini  progress)

1st Appt 8 days later L R L R PPL 30 12pn 52 59 APL 44 22 52 37 PSL 18 10 24 23 LSL 53 18 56 38 MSL13 16 16 23

Was able to run 4 miles pain free 1 week after initiating the training program

 21 y.o. female athlete  Diagnosed with Iron Deficiency w/ Anemia 2

years after initial decline in sports performance

 Ex: Ferritin level of 2 ng/mL, range should be

10-200; it is recommended that top athletes be at least 30-50 ng/mL.

 Continued to compete during this period

which led to low back, hip, and knee pain

Brumitt et al NAJSPT 2009

Core Weakness at Initial PT/ATC Eval Right Left Flexion 3+/5 3+/5 Abduction 3+/5 3+/5 Extension 4-/5 4-/5 ER 3+/5 3+/5 IR 4/5 4/5

Brumitt et al NAJSPT 2009

Ther Ex Program: Daily (1-2x a day, high repetitions) Clamshells Side lying hip abduction Side plank Front plank Squats Lunges Lower extremity stretching exercises

Brumitt et al NAJSPT 2009

Event Dist. 2006 2007

1

5000m

• 19:21.13

2

6000m 25:46 22:45.80

3

5000m 20:59.85 18:13.65

4

6000m 26:53.00 22.27

5

6000m 24:44.60 21:52.40

6

6000m

• 22:03.80

7

6000m

• 22.09

*Race #5 time is the 2nd fastest in school history (6000m) *Race #7 NCAA D-III National Championships *All-American Status

Brumitt et al NAJSPT 2009

HS female cross-country athletes have a higher incidence of injury than there male counterparts Poor core strength may be a contributing factor

Brumitt Ath Ther Today (2009) Rauh et al CJSM (2000) Rauh et al AJE (2006)

1st : address poor endurance capacity and poor endurance ratios 2nd : advance plank exercises high repetitions (2-3 sets x30 seconds)

Brumitt Ath Ther Today (2009)

 3 births in approx 2.5 yr  Wanted to return to

running, exercise

 Postpartum clients at

risk for:

 Back and leg pain  Incontinence  Headaches  Weight gain  Varicosities

Brumitt Physiother Theory Pract (2009)

Qualitative Assessment during Functional Tests

Squat Excessive spine flexion during the squat Single-legged squat Excessive knee valgum Single leg balance Bilateral pelvic drop reach test Lunge Excessive knee valgum

Brumitt Physiother Theory Pract (2009)

Pretest Core Endurance Scores and Ratios Extensor 6 sec Lateral Right 0 sec (unable to assume test position) Left 0 sec (unable to assume test position) Flexor 19 sec Flexor/Ext Ratio 3.16 All other ratios 0** (unable to assume test position)

Brumitt Physiother Theory Pract (2009)

 Core Program

 Basic  Intermediate Exercises over 8 weeks

 Running Program

 Walking  Running by 8 weeks

Brumitt Physiother Theory Pract (2009)

Pretest and Posttest Core Endurance Scores Day 1 Day 56 Extensor 6 sec 61 sec Lateral Right 0 sec 29 sec Left 0 sec 31 sec Flexor 19 sec 42 sec Flexor/Ext Ratio 3.16 0.69

Brumitt Physiother Theory Pract (2009)

During the golf swing: High shear, compression, rotation, and lateral bending forces Compression loads 8x

• ne’s bodyweight

Low back pain is the number one injury for pro and amateur golfers

Brumitt & Dale Athl Ther Today (2008) Meira & Brumitt Sports Health (2010)

Brumitt & Dale Athl Ther Today (2008)

Brumitt & Dale Athl Ther Today (2008)

Brumitt & Dale Athl Ther Today (2008)

Brumitt & Dale Athl Ther Today (2008) Fletcher et al J Str Cond Res (2004) Doan et al J Str Cond Res (2006)

 Bird dog

1-2 sets x10 reps

 Side planks

2-3 sets x10 second holds

 Crunches

1-2 sets x 25 repetitions

 Front Planks

1-2 sets x 10 second holds

Brumitt & Dale Ath Ther Today (2008)

 Hang Twist

2x15 reps

 Lunge Twist

2x15 reps

 Prone Twist

2x15 reps

 Roman Twist

2x15-20 reps

 Russian Twist

2x15-20 reps

 Lat pull down

3x4-6 reps

 Kettlebell squats

2x15 reps

 Plyometrics Brumitt & Dale Ath Ther Today (2008)

 Standing Horizontal Throws (each side)  Seated Horizontal Throws (each side)  Overhead Ball Throw  1-3 sets x10 reps each Brumitt & Dale Ath Ther Today (2008)

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