2002 Functional Design Systems

Transcription

1 1. The trunk is one of the most complicated areas of the body to functionally understand because it consists of so many core muscles. 2. The trunk is truly the crossroads of the body. 3. The trunk, and especially the back, has to deal with the rest of the body, and it has to do it in all three planes of motion. 4. We have to understand the trunk in function, and not through a single plane. 5. One of the key strategies in function is the strategy of attacking success. 6. One of the biggest goals in working with patients is to determine their threshold of success. 7. One of the key muscle groups that allows us to have a stable trunk are the abdominal muscles. 8. Often in analyzing the trunk, we want to determine what the hips are doing relative to the shoulders and where the patient is successful through the trunk. 9. Lunge tests are helpful in analysis of the trunk to evaluate the hip in all three planes. 10. To treat the back effectively, we want to treat other parts of the body that force the back to respond. 11. A primary focus with normal back pain is to mobilize the hips to turn the abdominals on and create motion through the trunk to help the back. 12. The opportunities for 3D walk warm-ups and core jogs to get the proprioceptors in the trunk turned on are endless. 13. As we exercise the trunk for better performance, we want to create eccentric lengthening (loading) leading to concentric production of force (unloading) through the trunk. 14. The miraculous nature of the body and its ability to transform itself is truly a grace gift. 15. The bookends of balance in golf are: 1) at the top of the full backswing, and 2) after completion of the downswing to a balanced follow-through. 16. Nonfunctional models that limit motion, isolate a body part and confuse the proprioceptors, and ignore the transverse plane are unproductive. 17. To get appropriate action and reaction of the musculoskeletal system, the proprioceptors have to be turned on the way they are in function Functional Design Systems

2 v1.2 THE TRUNK The Crossroads of Our Body By: Gary Gray, PT OBJECTIVES FOR THE TRUNK FUNCTIONAL GUIDE To assimilate up-to-date information and knowledge about the trunk. To learn how to apply effective functional techniques when testing, training and rehabilitating the trunk. To understand and appreciate the tri-plane Chain ReactionTM principles as they apply to the trunk. HOW TO USE THIS FUNCTIONAL GUIDE This functional guide can be used as a convenient summary of the program s contents to take with you after viewing. You can also use this guide as a notebook; space has been provided so that you can make notes on relevant tracts as you watch them.

3 One of the key strategies as we work with function is the strategy of ATTACKING SUCCESS ATTACKING SUCCESS Instead of starting with what patients or clients can t do, or where they are unsuccessful, what we want to do in function is attack success to more easily get them from Point A to Point B One of our biggest goals is to determine their threshold of success. In what activities, movements, planes are they successful and how far can they go We position our patients and clients for success by creating the right environment to make them more successful, through the use of different drivers, loads, activities, exercises, speeds, intensities... The key to attacking success is to understand why the body is successful to begin with; what is it in the body that allows it to be successful. EXAMPLES: ABDOMINALS IN ALL THREE PLANES One of the key muscles that allows us to have a stable trunk is the abdominal muscle. The strategy of attacking success first of all requires us to understand how the abdominals are successful to begin with. One of the ways to do this is analyzing what the abdominals are doing during gait, or ambulation. TRANSVERSE... as my right foot comes forward in gait, we see that the pelvis comes forward on the right and my shoulders are back on the right, which creates an eccentric elongation, a proprioceptive stimulation for the abdominal musculature in the transverse plane. So, if we simulate what happens in walking with activities that bring the pelvis forward and the shoulders back on the same side, the abdominals will have a huge ability to be successful.

4 FRONTAL... the abdominals are powerful in the frontal plane. As I step forward, the center of gravity translates from left to right. We get hip adduction on the right, and the hip has enough strength to allow it to be loaded. We will get eccentric lengthening of the left lateral abdominals and then a concentric pull to allow me my next step, and thus, loading to the opposite leg in the frontal plane for the abdominals. SAGITTAL... as my right foot enters the ground, I get a collapsing, or shock absorption. The pelvis rotates anteriorly. By keeping my body up, I begin to get the sagittal plane loading. If I get good hip extension on the left and a good stride on the right, and good tri-plane loading, my abdominals have a great opportunity to be lengthened in the sagittal plane. KEY POINT - the eccentric loading takes place when both feet are on the ground. However, the concentric production of force bringing the abdominals and pelvis back to allow the next step occurs when only one foot is on the ground. That s the swivel effect. This allows the pelvis to move freely in space, through all three planes, allowing successful loading to the abdominal musculature CONCLUSION - As we evaluate patients and clients, we want to know how the thing we re attacking becomes successful... and just how successful in all three planes, because that s exactly what we re going to mimic when we actually evaluate, test and train. We want to stimulate that body part the way it is designed to be stimulated. At times, as we evaluate, test, and train, we can facilitate one or two of those planes more significantly than a third to allow our patients to be more successful.

5 THE TRUNK - One of the most complicated areas in the body to functionally understand. It consists of so many different core muscles... from the abdominal muscles to the back muscles, to the hip muscles. THE BACK - A critical component of the TRUNK that truly is the crossroads of the body. The back has to deal with the rest of the body, what s going on in the upper trunk as well as the lower extremities. It has to deal with gravity, ground reaction force, and momentum. As the body does anything, the back has to deal with it... and it has to deal with it in all three planes of motion. WHAT DO WE SEE... As we take a look at the trunk and core, we realize the muscles are oriented to take advantage of the transverse plane. If we understand the back from a Chain Reaction approach, it literally becomes a torque converter. As one bone moves in the back area, the others are moving as well, and in all three planes. We have to differentiate between the motion of the bone in space relative to the motion of one bone compared to another bone. (ex: pelvis, hips and sacrum moving as a unit applied to L5). The abdominal muscles can create tremendous functional stability if stimulated properly. The hips can certainly make the back more or less successful. EXAMPLES: BONES AND THEIR MOVEMENT IN THE TRUNK DURING GAIT (AS RIGHT FOOT CONTACTS THE GROUND) TRANSVERSE... pelvis, sacrum, and L5 are all rotating to the left. Because of ground reaction and gravity, though, the sacrum is moving a bit faster and further than L5. Therefore, at the lumbar sacral junction. In reality, in function, we have right rotation, even though the motion of the bones themselves was rotation to the left.

6 FRONTAL... the pelvis translates from left to right and dips down on the left in so doing. The upper body stays relatively upright. L5 on top of the pelvis also rotates in like manner but not quite as fast or far. Relatively speaking L5 is rotating to the right and, therefore, we have lateral flexion to the right occurring at the lumbar sacral junction. SAGITTAL...the right foot goes through anterior rotation as the front leg is collapsing. The sacrum, as well as L5 on top of it, go through the anterior rotation, but because the lower segment is going a little faster, relatively speaking L5 is moving back on S1. This is rearward rotation or lumbar extension (L5-S1) ADDITIONAL POINTS The trunk is fascinating but we have to understand what is happening at the muscles and joints (because the actual motion described at the joint may be opposite of what the bones are doing). The proprioceptors are the key to success in function. We have to understand the trunk in function, not through a single planeness. As people come to us in pain, we have to understand the wisdom of looking at other parts of the body as causes and as compensators. Through a Chain Reaction functional approach, we have to look at how other parts of the body feed the back, and the rest of the trunk, and appreciate what the trunk and core have to do with the rest of the body.

7 THE FOCUS Because the trunk is the crossroads of the body, it s important that we look at the body from the ground up, from the top down, and also in all three planes of motion. It s important that we look at the foot and make sure the foot has the ability to load in all three planes. It s critical we understand what the hips are doing as well. And, in order to give us a place to start to understand success in the trunk, it s important that we appreciate the relation between the hip and the shoulder. It s the movement of the hip relative to the movement of the shoulder that creates a reaction through the trunk and it s three dimensional muscles. CASE STUDY: EVALUATION SCREENING OF THE TRUNK PURPOSE - to try to determine what the hips are doing relative to the shoulders and where the patient is successful through the trunk. Who within the body is helping the trunk properly and who is not. FUNCTIONAL SPECIALIZED TESTS (FOR THE CASE) (all lunge tests below alternate right foot to left foot) FIRST OBJECTIVE: to analyze the hip extension, to determine how much the patient s body has to actually come back, how much toe-out position there is, and to view the patient in the sagittal plane first. 1. POSTERIOR LUNGE Findings: It s more natural to toe-out for patient, which means the patient has a tight iliopsoas (which may inhibit the abdominals in the transverse plane). 2. POSTERIOR LUNGE WITH BILATERAL ARM POSTERIOR OVERHEAD REACH Findings: A good toe-out position, but in the sagittal plane, the patient is not getting good hip extension. And much of the extension is coming through the lumbar area and into the upper back. 3. ANTERIOR LUNGE WITH BILATERAL ARM POSTERIOR OVERHEAD REACH Findings: Patient is able to lift his heel off the ground, which releases the sagittal plane requirements of the hip flexor. Patient is more successful with the anterior lunge in the sagittal plane versus the posterior lunge.

8 SECOND OBJECTIVE: To see what happens in the transverse plane with the hips and shoulder. 4. ANTERIOR LUNGE WITH BILATERAL ROTATIONAL ARM REACH TO THE SAME SIDE Findings: Patient is getting good motion of the pelvis forward, the shoulders backward, and proprioceptively, the abdominals and back are being turned on nicely. 5. POSTERIOR LUNGE WITH BILATERAL ROTATIONAL ARM REACH TO THE SAME SIDE Findings: This simulates the previous reaction where the pelvis comes forward and the shoulder goes back. THIRD OBJECTIVE: To see what happens in the frontal plane. 6. ANTERIOR/LATERAL LUNGE; THEN WITH BILATERAL ARM OVERHEAD LATERAL REACH; THEN WITH ONE ARM OVERHEAD LATERAL REACH Findings: Abdominals are turned on nicely as pelvis dips down and arms are extended overhead. FOURTH OBJECTIVE: To see what happens once more in the transverse plane. 7. ANTERIOR LUNGE (WITH TOE-IN AND CROSSOVER) WITH SAME SIDE POSTERIOR OVERHEAD ROTATIONAL REACH Findings: We can give patient s rotators more of a load and provide functional stability through the trunk. SUMMARY - Through a series of quick tests, we can see what success the hips are having with the shoulders and visa versa. This will allow us to effectively turn on the core or trunk, especially through the abdominal muscles. In our case above, by giving some functional mechanical advantage to the hips, we can help the abdominals and back in the transverse plane, and then create some appropriate stretches and exercises to enhance the sagittal plane.

9 INTRODUCTION - Many times we get cases where we re concentrating so much on the back that we want to actually treat only the back. The most effective way to treat the back many times is to treat other parts of the body that feed the back the information. What we want to do is attack and create the right environment for proper rehabilitation. CASE BACKGROUND - We will look at a situation where we have a person with chronic back pain. Her locomotor system is good and she has decent motion through her hips. Her limitation is in her hip extension. Through her hips and shoulders she is not turning her abdominal muscles on. Our first goal is to find out where she s successful and build upon that success to design an environment to get the hips, shoulders, and abdominals moving properly in all three planes. CASE TREATMENT/EXERCISES: 1. Using the TrueStretch machine, the patient will keep their left foot back, place their right foot forward on the angle platform, place their hands forward on the bars, and slide the pelvis forward and back. At the same time, manual functional techniques are used on the hip to keep pressure off the back. RESULT: Patient is being helped to load anteriorly, is getting better thoracic extension, and is mobilizing the sagittal plane of the iliopsoas. 2. In the TrueStretch with feet in the same position, the patient places their hands to the left on different bars and continues to slide forward and back. Manual functional facilitation is used on the hips. RESULT: The patient is letting her shoulder and trunk wind the pelvis on the femur more effectively, so we get more transverse plane loading of the iliopsoas. We re continuing to mobilize the hips to turn the abdominals on. 3. In the TrueStretch with feet in the same position, this time the hands are placed to the right with the left arm and hand reaching overhead to the right. RESULT: The left hip actually gets loaded in the frontal plane affecting the iliopsoas, while there is sagittal plane and transverse plane loading going on. The abdominals are lengthening and taking advantage of the hips to create motion through the trunk to help the back. Bilateral hip swivel occurs if the same thing is done to mobilize the other hip in all three planes.

10 HOME EXERCISES 4. With a chair against a wall in a hallway or doorway where the patient has something to grab on to, similar exercises can be done by the patient. Keep the left foot back and place the right foot forward on the chair, and lean forward and back a few times. Then, with the left hand holding on to something, bring the right hand and arm back overhead as the body moves forward. Next, leaning forward, reach the right arm rotationally across the body to the left and come back. And finally, with the same forward glide, reach the right arm laterally to the right as the body goes forward. Each of these can be done several times. 5. The patient stands close to a wall with their left heel near the wall and their right foot forward in a normal ambulation base. They take the right shoulder back in a slight turn and touch the wall a few times and then with more speed. Do this looking straight ahead, then do it coming back near to the wall but not touching. If successful, take the right shoulder over and down to a further point to create more frontal plane load. Now, do that, just coming near to the wall. And finally, to guarantee motion through the hips and shoulders without pinching the back and to turn the abdominals on in the sagittal plane, take the shoulder directly back and touch the wall several times. CONCLUSION - Through various exercises, we were able to get the hips and shoulders moving to stimulate the abdominal musculature without impinging on the back. In a stance position of gait, the shoulders can be stimulated into extension, into lateral flexion and into rotation in order to functionally eccentrically load and facilitate the abdominals. An effective program can be designed to help ease the back pain of our patient.

11 GENERAL APPROACH - One of the exciting things as we learn more about the trunk is how to proprioceptively turn it on during our training. As we apply proper exercise, the trunk will appreciate the stimulation, and we ll get the eccentric lengthening and concentric production of force that allows us to move, balance, and enjoy our activities. We want to wake up our core and stimulate the nerves subconsciously. An ideal time to do this is during the warm-up as we go through a strategy to turn the trunk on in all three planes. The strategy of progressing from a walking program to a jogging program to a full stride program where we have legs and arms going in different planes will stimulate the trunk as all motion and action will meet at the trunk, the crossroads of our body. WHAT TO WATCH FOR - As exercises are performed, take a look at what the legs are doing, the arms, and how the trunk is dealing with it. Watch the eccentric loading, the loading of the proprioceptors, and the concentric production of force as the core is stimulated. The trunk functions at a subconscious level and receives information from the ground up and from the top down. So, we address it that way in all three planes to wake up the central core.

12 EXERCISES FROM VIDEO Sagittal plane forward strides, with arm punch matrix (in all three planes) Sagittal plane forward strides, with arms overhead in frontal plane rotation Sagittal plane backward strides, with arm punch matrix (in all three planes) Frontal plane strides, with forward punches (and then spin and side glide the opposite way) Sagittal plane backward strides, with bilateral arm posterior overhead throws Sagittal plane crossover strides, with bilateral arm transverse plane opposite reach Sagittal plane wide steps, with one-handed posterior overhead reach 360 Spin Walk 360 Spin Walk, with arms overhead, with cervical rotation Frontal plane strides, with bilateral arm sagittal plane drive into flexion and extension Frontal plane strides, with rotational spins and arms overhead DEMONSTRATION OF THE CORE JOG Examples from 3D Walk/Jog Matrix Video by Gary Gray, PT FOR DETAILED DEMONSTRATION OF THESE EXERCISES AND MORE, CONTACT: Functional Design Systems CLOSE - The opportunities for walk warm-ups and core jogs to get the trunk involved are endless. We can do long strides, short strides, wide strides, arms matrix, spin walks, etc. We can go backwards, forwards, reach, and rotate the head. The trunk can get turned on in all three planes and enhance the abilities and conditioning of our clients and athletes.

13 GRACE GIFT - When you take a look at the miraculous nature of the body, the ability of the body to accept things through the core and the trunk, take advantage of motion, take advantage of proprioceptive stimulation, and subconsciously react the right way, this transformation of the body is actually a grace gift. Transformation comes in the end not from an act of will but from an act of grace. We can only ask for it and keep asking. Phil Yancey, Reaching For the Invisible God In the game of golf, we can appreciate transformation by understanding the golf swing. How transformation occurs through the trunk and core, and what the arms and legs are doing in the swing allows us to create transformation at the top of the swing. If our muscles are properly loaded and proprioceptively turned on, and we have good balance, everything comes together and transformation takes place. Great golfers say it takes place automatically. BALANCE - Balance in golf, as in life, is a difficult thing to understand. As we start to understand the dynamics of functional balance, we begin to appreciate that it s not understood in stillness, but actually understood in motion. Golf gives us great examples through the entire swing of what balance really needs to be. Balance represents something desirable. It is a state of equilibrium where the parts of something offset those of another. There s a balance to most everything we do in life. In the golf swing, balance is the proper distribution of weight of the body before, during and after the swing. Jim Sheard & Wally Armstrong, In His Grip, Foundations For Life and Golf BOOKENDS OF BALANCE IN THE GOLF SWING The first is through the entire backswing until you get to that full backswing, that full load, and change directions. We call that point the transition or transformation. If everything has been done right to get fully loaded, the trunk will sense the shoulders and club head above and every thing below it, and have the balance to create the transformation. This transformation is the power that initiates the swing. The other bookend in the golf swing is after the downswing, or tri-plane unloading, that requires us at the other end to go through solid tri-plane loading or deceleration, to create a balanced follow-through.

14 FUNCTIONAL TESTING - Without the correct balance at either bookend, what happens in the middle is not going to be good. To help the golfer get to the right position, it will be helpful to test reach and balance (with something like the functional testing/measuring pole) at each bookend. It requires testing balance with that right hand driving off the right leg in the backswing direction, and with the left hand going off the right leg in more of a frontal plane with a little transverse plane. This would be repeated off the left leg as well. The other end of the bookend will put a lot of weight on the left foot, and again we ll determine through the follow-through how well our golfer can reach to the measuring pole. We ll do a balance test off the left leg with the left hand. Then we ll do a balance reach off the left leg with the right hand to see how far and how much in rotation and how high he can reach to the measuring pole. We ll do the same tests off the right leg in the same position we re in during the follow-through. The exciting thing about this is we can apply that functional understanding to any type of activity we desire. Wherever transformation takes place, that s where you will test their balance. That s where the eccentric load transforms to a concentric force of production to do what you want to do. GOLF BALANCE DRILLS (LEG DOMINANT DRILLS) With ball in normal position, take a step back, put most of the weight on the right leg (to create more flexion and loading) and hit the ball. With ball in normal position, come closer to the ball, put the weight on the right foot and hit the ball (body will be more upright in sagittal plane). Place right foot even with the ball (or have ball slightly behind the right foot), put most of the weight on the right leg, and go back, reach and hit the ball. This changes the angle of the body and tweaks the frontal plane. Do the same with the ball on the left side of the left foot with your weight on the left leg. For the transverse plane, toe the right foot out a lot, put your weight on the right leg and hit the ball. Then toe-in a lot with the right foot, weight on the right leg, and hit the ball. Repeat all the same drills with most of the weight on the left foot, i.e. left leg dominant. CLOSE - Transforming knowledge into the appropriate activity will create the right environment for patients and clients to find out where they re successful and then we can build upon that success.

15 OPENING - Dr. David Tiberio, friend and research specialist, helps add to our understanding of just how the trunk works through his experience and emphasis on research that supports function! The trunk and its understanding have been ignored through the years because it s hard to see just what goes on. And the things that have been tried have often failed, and we ve had trouble knowing why. HISTORICAL PERSPECTIVE - We ve taken a look at nonfunctional models that try to create artificial stability, to get the muscles to contract isometrically... and that has not worked. We ve tried to limit motion instead of facilitate it, spent too much time in the sagittal plane and ignored the transverse plane... and that has been unproductive. Now things are starting to make sense as we understand the trunk is a link in the body that works in all three planes, that muscles load before unloading, and other body parts have a direct effect on the trunk and on each other. IMPORTANCE OF RESEARCH - Hodges and Richardson have looked at a series of research projects that have shown us when the abdominals are functioning. They not only looked at motions of the trunk, but they made a point of looking at motions with the arm and with the leg. An article in 1977 in Experimental Brain Research showed that when you initiate arm motion in the sagittal or frontal planes, you get motion and muscle activity in the spine prior to the arm moving. This research is helpful because one of the reasons we failed in the past is we worked on restoring function in the trunk and core without recognizing forces that come from the arms down into the trunk from the top, and from the ground through the legs up into the trunk and spine. In this research, people were standing, they were upright relative to gravity, and they were able to experience forces from above and below. It was very functional. This is research that has been around a long time and demonstrates that the trunk really is the crossroads of the body. With the movement of the arms and legs in the research, the muscles of the abdominals were turned on.

16 ADDITIONAL THOUGHTS To get appropriate action and reaction of the musculoskeletal system, the proprioceptors have to be turned on the way they are in function. We have gotten away from true function... we have tried to make it simple and isolate too much. Programs have been created (from the research we have just described) that try to isolate the transverse abdominus muscle by itself, and do it in a position where the body is horizontal to gravity. With neither the arms nor legs functioning normally, forces below or above the trunk are absent. It s a functional dilemma. It would seem in the research that the arms and legs are what turned on the abdominals relative to momentum, gravity and body weight. If the hips, pelvis, or the trunk on the other hand are being stabilized artificially by the ground, gravity, the table... it seems like the proprioceptors that turn on the abdominal muscles would be confused. The core muscles turn on, in reality, before you move your arm because you need that stability first. Stability and mobility are linked with functional proprioception. The muscles will turn on... but not because someone is consciously trying to contract them in isolation. We often place the patient where we think it s more stabilizing to get the job done early on. This research is saying, though, to place them in the most functional position and let them go through the most functional motions in all three planes to get it done successfully. Let s get them in the posture that will get them moving in all three planes with the proper loads. CLOSE - We have to understand function to take advantage of the research that actually demonstrates function so it can be applied in our clinics functionally.